Epidemiology

Dr. Roshan Dhakal

MD Community Medicine
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 Epidemiology

Epi (among)
Demos (people)
Logos (doctrine)

Doctrine of what is happening to the people

 Epidemiology
The study of distribution and determinants of
health related states or events in a specific
population and application of this study to the
control of health problems (John M. Last).
 Distribution

Epidemiology

Determinants Frequency
 • Pattern of occurrence of disease in
Distribution the community with reference to
(Descriptive time, place and person.
Epidemiology)

Disease Frequency: Measuring the magnitude or extent of

health related events or health problem in the community,
in terms of morbidity rates such as incidence and
prevalence and also in mortality rates.

Determinants • Etiological or risk factors related to

particular disease.
(Analytical
epidemiology)
 Epidemiological studies(Methods)

Observational Experimental
Studies Studies

Randomized
Descriptive controlled trial

Field Trials

Analytical
Community
Trials
 Types of epidemiological study
1) Observational study
a. Descriptive (Hypothesis formulation)
b. Analytical (Hypothesis testing) Unit of Study
i. Ecological or Correlational ------------------population
ii. Cross-sectional or Prevalence -------------Individual
iii. Case- Control ---------------------------------Individual
iv. Cohort or Follow up-------------------------Individual
2) Experimental Study (Hypothesis confirmation)
a) RCT---------------------------------------------Patient
b) Field Trials------------------------------------Healthy People
c) Community Trials---------------------------Communities
d) Clinical trial ----------------------------------Patients
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Measurements in Epidemiology:
Tools of measurement in epidemiology

• Rate: Numerator is a part of denominator and multiplier is 1000 or

10,000 or 100,000

• Ratio: Numerator is not a part of denominator and BOTH

numerator and denominator are unrelated

• Proportion: Numerator is a part of denominator and multiplier is

100, Proportion is always expressed in percentage (%)

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Examples of Tools of Measurement in
Epidemiology

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 Descriptive epidemiology
(Time, Place and Person)
Time Distribution:

1) Short term fluctuations

2) Periodic fluctuations

3) Long-term or secular trends

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 Time Distribution of Disease
1) Short Term Fluctuations (Epidemic)
• Occurrence of no. of cases of a disease „clearly in excess of normal
expectancy‟
– Normal expectancy (NE): looking at average of no. of cases of the
disease in previous 3-5 years in that geographical area
– If NE = zero, „even one case is considered epidemic‟

• Occurrence of a new disease in a population (as NE = Zero)

• Reoccurrence of an eliminated/eradicated disease in a population (as NE
= Zero)

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 Time Distribution of Disease
Types of epidemics:
• Common-source epidemics:
– Single exposure or „Point source‟ epidemics
– Continuous or multiple exposure epidemics

• Propagated epidemics:
– Person-to-person
– Arthropod vector
– Animal reservoir

• Slow (modern) epidemics

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Single exposure or „Point source‟ epidemics:
– Epidemic curve: „Sharp rise and sharp fall‟ in no. of cases
– „Clustering of cases‟ in a narrow interval of time
– All „cases develop within one incubation period‟ of the disease
– Eg: Food poisoning, Measles, Chicken pox, Cholera, Bhopal Gas
tragedy, Minamata disease in Japan

Common source‟, continuous or repeated exposure epidemics:

– „Sharp rise‟ in no. of cases
– Fall in no. of cases is interrupted by „Secondary waves/ peaks
– Eg: Contaminated well in a village

Propagated epidemics:
– „Gradual rise and gradual fall‟ over a long time (Tail off)
– Results from „person-to-person transmission
– Eg: Epidemics of Hepatitis A and Polio
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 2) Periodic Fluctuations
• Seasonal trends: Is seasonal fluctuation in occurrence of a disease:
– Due to vector variation, environmental factors and change in herd
immunity
– Eg:
• Measles (early spring)
• Upper respiratory infections (winters)
• Gastrointestinal infections (summers)
• Cyclical trends: Is occurrence of a disease in cycles spread over short
periods of time, which may be days, weeks, months or years:
– Eg:
• Automobile accidents during weekends
• Measles (every 2-3 years)
• Rubella (every 6-9 years)
• Influenza pandemics (every 10-15 years)

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 Long Term Fluctuations [Secular Trends]
• Implies changes in occurrence of a disease (progressive increase or
decrease) over a long period of time, generally several years or
decades
• Eg:
– Communicable diseases (Poliomyelitis, Diphtheria, Pertussis)
are reducing in past few decades
– Non-communicable diseases (Diabetes, Hypertension, Obesity)
are increasing in past few decades.

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 Morbidity Measurements
 Incidence:
• Is defined as the „no. of new cases‟ occurring in a defined population
during a specified period of time for a given period
• No. of Incidence = New cases of a disease in a year ×1000
Total population at risk
• It is a rate
• Incidence is the best measure of disease frequency in etiological studies
• Incidence can be determined from: Cohort study

 Special types of incidence rates:

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 Attack rate

• Number of people at risk in whom a

certain illness develops X 100
Total number of people at risk

• Useful for comparing the risk of disease in groups with different

exposures.

Primary Attack Rate :

Rate at which the disease is spreading
and attacking the people in the
community (i.e. extent of the
epidemic).
 Secondary Attack Rate
• Percentage of exposed persons, developing the disease following
exposure to a primary case, within the range of incubation period.
• For E.g.:

1 child
develops
Family of 6 persons chickenpox
consisting of 2 parents and after SAR
(already immune) and sometimes, 2 = 2/3X100
4 children, susceptible children
to chickenpox develop = 66 %
among 3
children
 Prevalence
Prevalence: Is total current (Old + New) cases in a given population over a
point or period of time.
Prevalence= No. of total (new + old) cases of a disease in a year *100
Total population

Prevalence is a proportion (NOT a ratio)

Prevalence can be determined from: Cross Sectional Study

• Types of prevalence:

– a point of time (Point Prevalence)

– a period of time (Period Prevalence)

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 Types of Epidemiological study
Synonyms of names of epidemiological studies
 Cohort study
• Prospective study
• Forward looking study
• Cause to effect study
• Risk factor to disease study
• Exposure to outcome study
• Follow-up study
• Incidence study
 Cross sectional study
• Prevalence study
• “Snapshot” of population study
 Case control study
• Retrospective study
• Backward looking study
• Effect to cause study
• Disease to risk factor study
• Outcome to exposure study
 Ecological study
• Co-rrelational study
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Clinical relevance of different studies
 Evidence Based Medicine/ Practice

• Is considered „Gold standard for clinical practice

• Aims to apply best available evidence gained from scientific

method to clinical decision making

• Highest importance is given to strongest epidemiological studies:

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Clinical relevance of different studies

 Evidence-Pyramid in
Research
1. Meta-analysis (Highest
clinical relevance/gold
standard)
2. Systematic review
3. Cohort study
4. Case control study
5. Case series
6. Case report

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Relationship between Incidence
and Prevalence:

Prevalence = Incidence × Mean duration of the disease

P= I × d
– Prevalence describes balance between incidence, mortality and
recovery

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 Cross-Sectional Study
• Is based on the single examination of a cross-section of a population „at
one point of time‟, results of sample are then projected to whole
population
• Is simplest form of observational epidemiological study
• Also known as Prevalence study
• Advantages:
– Provides „Prevalence of the disease‟ under study
– Gives „Snapshot of a population‟
– More useful for chronic diseases
• Disadvantages:
– Tells about distribution of a disease, „rather than its etiology‟
– Provides little information about natural history of disease or
incidence

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 Cohort Study
• Is a type of analytical (observational) study used for „hypothesis testing‟

• Types of cohort studies:

1. Prospective cohort study:

• Known as „Current cohort‟ or „Concurrent cohort‟ study
• Outcome has not yet occurred when the study has begun: Only
exposure has occurred; we look for development of same disease
in both exposed and non-exposed groups
Examples:
Doll & Hills prospective study on smoking and lung cancer

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 Cohort Study
2. Retrospective cohort study:
• Known as „Historical ‟ or „Non-concurrent‟ cohort study
• Combines advantages of both Cohort study and Case control study
• Both exposure as well as outcome have occurred when the study has
begun:
First we go back in time and take only exposure into consideration
(cohorts identified from past hospital/ college records)
Then look for development of same disease in both exposed and
non-exposed groups
• Examples:
1. Effect of fetal monitoring on neonatal deaths

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 Case Control Study
• Cases are diseased individuals, Controls are those free from the disease
under study
• Controls must be similar to cases, as much as possible except for the
absence of disease under study

• Sources of controls :
– Hospital controls: are often a „source of selection bias‟
– Neighborhood controls: provide similar socio-economic and living
conditions
– Relatives: Sibling controls are unsuitable in genetic studies
– General population: by choosing a random sample

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 Strength of Association in Cohort Study
 Relative risk (RR) = Incidence among exposed
Incidence among non-exposed

Interpretation: Incidence of lung disease among exposed is ........ many times higher as
compared to that among non-exposed

 Attributable risk (AR)

= (Incidence among exposed – Incidence among non-exposed) × 100
Incidence among exposed

Interpretation: ..........much disease can be attributed to exposure

 Population attributable risk (PAR)

= (Incidence among total – Incidence among non-exposed) × 100
Incidence among total
Interpretation: If risk factor is modified or eliminated, there will be ......... annual reduction in
incidence of disease in the given population 30
 Strength of Association in a CCS
• in a case control study, we calculate „an estimate of relative risk‟,
known as „odds ratio‟ (cross product ratio)
• correct table construction in a case control study: table will have
disease at the top (row) and history of exposure/ risk factor on the
left (column)
• odds ratio in a 2 × 2 table for a case control study:

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Cohort Studies versus Case Control Studies

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Useful Parameter(s) obtained by
epidemiological studies:

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RCT( Randomized Controlled Trial)
• Types:
1. Concurrent parallel design: Comparisons between 2 groups:
• Experimental group: exposed to specific medication or intervention
• Reference group: not exposed to specific medication or intervention

2. Crossover design: Comparisons between 2 groups:

• Experimental group: exposed to specific medication or intervention
• Reference group: not exposed to specific medication or intervention
– Then the groups are crossed-over
– Cross-over design RCT helps removing ethical concerns
• Intention to treat trial: Implies that the results of a RCT are unaffected by
attrition (loss to follow up) or change over of study subjects from one group
to another

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 Randomization in RCT
Randomization in RCT is a statistical procedure by which participants are
allocated into either of 2 groups: Experimental Group‟ & „Reference Group‟

• Randomization is best done by „Random number tables‟

• The essential purposes of randomization is:
– Participants have „Equal and Known Chance ‟ of falling into either
„Experimental Group‟ or „Reference Group‟
– To eliminate selection bias
– To eliminate confounding
– To ensure comparability among two groups
– To have „similar prognostic factors‟ among two groups

• Randomization „removes both confounding and bias‟

• Randomization is superior to Matching

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 Potential Errors in Epidemiological
Studies
 Random errors: Sampling errors

• Random error „cannot be completely eliminated‟

• Random errors can be reduced by: careful measurement of exposure and

outcome, thus making individual measurements precise

• Best way of reducing sampling errors (increasing precision): Increase the

sample size in the study

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 Potential Errors in Epidemiological
Studies
Systematic errors: Biases
• Bias is any „systematic error‟ in an epidemiological study, occurring
during data collection, compilation, analysis and interpretation

• Predominantly biases are of 3 types:

– Subject bias: Error introduced by study subjects. Examples:
• Hawthorne effect
• Recall bias
– Investigator bias: Error introduced by investigator
• Selection bias
– Analyzer bias: Error introduced by analyzer

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 Some Important Types of Biases
• Attention bias (Hawthorne effect): Study subjects may systematically
alter their behaviour when they know they are being observed

• Berkesonian bias (Admission rate bias): Bias due to hospital cases and
controls being systematically different from each other

• Interviewer bias: Interviewer devotes more time of interview with cases

as compared to controls

• Memory/ Recall bias: Cases are more likely to remember exposure more
correctly than controls

• Neymann Bias (Prevalence-incidence bias): Bias due to missing of fatal

cases, mild/ silent cases and cases of short duration of episodes from the
study 38
Minimization of Biases in RCT

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 Confounding
• Any factor associated with both exposure and outcome, and has an
independent effect in causation of outcome is a confounder
– It is found unequally distributed between the study and control groups
– Has an independent effect in causation of outcome (thus is a risk
factor itself

Smoking CHD
E O

C
Alcohol

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Exposure Disease
(alcohol drinking) (lung cancer)

Confounding Variable
(smoking)

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Methods Used to Control Confounding

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 Matching
•Process of selecting controls in a such a way that they are similar to cases
(with regard to certain pertinent selected variables which may influence the
outcome of disease, thereby distorting the results)

•Matching eliminates confounding: Matching distributes known confounding

factors equally in two groups

Remember:
• Randomization is Superior to both matching and blinding
• Blinding: Removes bias
• Matching: Removes known Confounding
• Randomization: Removes selection bias, known and unknown
confounding

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 Pre-Clinical & Clinical Trials

• Phase III is a RCT: Comparison of a new drug with an existing old drug
• New drug is launched in market after: Phase III
• Longest phase of a trial: Phase IV
• Post-marketing surveillance: Phase IV
• Maximum tolerated dose (MTD) of a drug: Phase I

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1. Iceberg phenomenon differentiates:
a) Apparent and Inapparent c) Symptomatic and Asymptomatic
b) Cases and Carriers d) Diagnosed and Undiagnosed
2. Seasonal trend is due to:
a) Vector variation c) Environmental factors
b) Change in herd immunity d) All of the above
3.True about point source epidemic is
a) Occurs in more than 1 incubation period
b) Occurs in one incubation period
c) The exposure is continuous
d) Epidemic curve falls very slowly
4.Bhopal gas tragedy is an example of
a) Point source epidemic c) Continuous epidemic
b) Propagated epidemic d) Slow epidemic
5.Long term fluctuation is seen with
a) cyclic trends c) epidemics
b) secular trends d) seasonal trends
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6) “Epidemic curve” is
1. A graph of the person distribution of epidemic cases
2. A graph of the place distribution of epidemic cases
3. A graph of the time distribution of epidemic cases
4. A graph of the number of cases distribution of epidemic cases

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7.Epidemiology deals with the study of?
a. Distribution of disease c. Determinant of disease
b. Disease frequency d. All of the above

8.The numerator is not a part of denominator in ?

a. Rate b. Ratio c. Proportion d. None of the above

9.Total number of cases at a given point of time in a given population is

a. Incidence b. Prevalence c. Epidemiology d. Attack rate

10.Case control studies are:

a. Prospective studies c. Retrospective studies
b. Cross Sectional studies d. None of the above

11.Prevalence of the disease is estimated form

a. Case control study c. Cross sectional study
b. Cohort study d. Randomized trial
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12.All of the following statement about cross sectional study are true except
a. Many outcomes are possible
b. Lesser time is required
c. Relationship between cause and effect can be established
d. Less expensive

13. All the following are advantages of case control study except
a. Useful in rare disease
b. Relative risk can be calculated
c. Odds ratio can be calculated
d. Cost effective and inexpensive

14. Denominator while calculating the secondary attack rate include:

(a) All the people living in next fifty houses
(b) All the close contacts
(c) All susceptible amongst close contact
(d) All susceptible in the whole village
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15.Study of time, place and person is called
a. Experimental Epidemiology c. Analytical epidemiology
b. Descriptive epidemiology d. Randomized clinical trial

16.Case control studies are used for

a. Study of common diseases c. Finding of multiple risk factors
b. Finding incidence rates d. Finding relative risk

17. Denominator for calculating incidence rate is

a. Total Population c. Mid Year Population
b. Population at risk d. Previous Population

18. Which of the following can be expressed in ratio:

a. Case Fatality Rate c. Proportion mortality
b. Infant Mortality d. Maternal Mortality

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