2/11/2020

You can’t manage

Measurement of Exposure what you can’t
measure!
Youssef Farag, MD, PhD, MPH
Co-Director, Egypt CSRT
Faculty Director, Postgraduate Medical Education
Harvard Medical School

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Measurement Measurement
The procedure of applying a standard scale to The procedure of applying a standard scale
a variable or to a set of values to a variable or to a set of values

Exposure Exposure
The variable whose causal effect (or The variable whose causal effect (or
association) is to be estimated association) is to be estimated

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Methods of Measurements
• Laboratory scientists
• Geneticists
• Clinicians
• Nurses
• Radiologists
• Histopathologists
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How do they contribute?
Clinicians
• identify what’s clinically
meaningful or useful
exposure variable
• inform the utility and
feasibility of an exposure
variable
• connect between what’s
measured and what they
want to know
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Measurements
X Y
• Exposure
• Predictor
• Risk factor
• Independent variable
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How do they contribute?
• Behavioral & social ..with each field having its own standards,
scientists
terminology, conventions, and other peculiarities
• Economists
• Medical Students
• Admin staff
• Billing department
• Security
• And many more …
Measurements
Epidemiologists
• understand and evaluate
• measurement accuracy
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• methods to improve
measurement
• Incorporate all of the
above to interpret the
results
Measurement of Exposure
• Individual vs. group exposures
• Outcome • Direct vs. indirect (surrogate) exposure
• Response • Duration and/or dose
• Event • Choice of scale
• Dependent variable • Fixed vs. time-varying exposures
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Measurement of Exposure Measurement of Exposure

• Individual vs. group exposures
• Direct vs. indirect (surrogate) exposure
• Duration and/or dose
• Choice of scale
• Fixed vs. time-varying exposures
• Individual-level exposures:
• Measured for each participating person in the study e.g.
Height, weight, blood pressure
• Group-level (aggregate) exposures:
• Aggregating attributes among individuals
• Average income
• Physical characteristics of a location
• Neighborhood or geographic characteristics
• Describing interactions of individuals
• Social network

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Exposure: Neighborhood racial and income composition

Brancati et al, Am J Prev Med 2008

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Healthy Food Availability Index

Measurement of Exposure
• Individual vs. group exposures
• Direct vs. indirect (surrogate) exposure
• Duration and/or dose
• Choice of scale
• Fixed vs. time-varying exposures

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Measurement of Exposure
• Direct exposures:
• the actual agent that may be influencing the
occurrence of disease
• Indirect (Surrogate) exposures:
• an agent that may not be directly causing harm but
may be:
• Associated (correlated) with true exposure
• In the chain of events that lead to disease (‘mediators’)
• ‘Biomarker’: biological (often blood) measurements

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Figure 1. Distribution of serum cotinine concentrations 
and selected receiver operating characteristic (ROC) and 
other operating characteristics of cutpoint rules among 
adult smokers and nonsmokers aged 20–85 years, overall 
and by gender and race/ethnicity, National Health and 
Nutrition Examination Survey, 1999–2004. The solid and 
open bars represent the self‐reported distributions of 
smokers and nonsmokers, respectively; a heavy dotted 
line is drawn at the optimal ROC cutpoint; and a lighter 
dotted line is drawn at the common fixed cutpoint of 14 
ng/mL. ‘‘Overall Population, %’’ on the y‐axis refers to 
the percentage of all smokers or nonsmokers in the 
respective groups. ‘‘ROC’’ is the optimal cutoff point 
derived using the ROC curve, which is the representation 
of the tradeoffs between sensitivity and specificity. All 
percentages of nonsmokers with serum cotinine levels of 
0.035 ng/mL or less are cropped at 16%.

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Measurement of Exposure Measurement of Exposure

• Individual vs. group exposures
• Direct vs. indirect (surrogate) exposure
• Duration and/or dose
• Choice of scale
• Dose:
• Administered dose (intake):
• amount of agent coming in contact with an individual in a
defined time interval
• Internal dose (uptake):
• amount of agent actually absorbed or deposited in the body

• Fixed vs. time-varying exposures • Active or biologically effective dose:

• amount of agent that actually interacts with target sites in the
body

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Measurement of Exposure Measurement of Exposure

• Individual vs. group exposures • Choice of Scale:
• Direct vs. indirect (surrogate) exposure • Continuous:

• Duration and/or dose • Categorical:

• Choice of scale • Dichotomous
• Multiple Categories
• Fixed vs. time-varying exposures

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Measurement of Exposure Measurement of Exposure

• Individual vs. group exposures • Fixed exposures:
• Direct vs. indirect (surrogate) exposure Don’t change over the follow-up duration
• Example:
• Duration and/or dose • Gender
• Choice of scale • Date of birth
• Status at time ‘t’
• Fixed vs. time-varying exposures

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Measurement of Exposure Measurement of Exposure

• Time-varying exposures:
Time-dependent, modifiable, change over time
• Example:
• Behaviors (e.g., smoking, alcohol use, diet, medications)
• Clinical characteristics (e.g. weight, blood pressure)
• Environmental/occupational exposures (e.g. lead)
• Infection status (e.g., STIs, hepatitis) Fixed exposure Time‐varying exposure
• Biomarkers (e.g., cholesterol, glucose) Solid ‐ Exposed
Dotted ‐ Not exposed 

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Measurement of Exposure
• How to summarize/present Time-varying
exposures:
• Average exposure
• Cumulative exposure
• Maximum exposure
• Time since exposure
1        2        3        4        5        6         7        8       9      10     11
Start End

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Journal of the National Cancer Institute, Vol. 92, No. 14, July 19, 2000

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Time at risk
Time at risk
(years)

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Start 1        2        3        4        5        6         7        8       9      10     11 End Start 1        2        3        4        5        6         7        8       9      10     11 End

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Measurement of Exposure

Summary
• Individual vs. group exposures
• Direct vs. indirect (surrogate) exposure
• Duration and/or dose
• Choice of scale
• Fixed vs. time-varying exposures

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Questions Thank You!

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