Dr.

Faran Emmanuel
University of Manitoba
BASIC VS APPLIED EPIDEMIOLOGY
▪ Basic Epidemiology course
▪ Basic Biostatistics course

WHY ANOTHER COURSE OF EPIDEMIOLOGY?

EPIDEMIOLOGY
IN THE CLASS ROOM
▪ Most difficult subject in MSPH
course - Extremely demanding …
its like a foreign language
▪ Too many concepts –confusion
on how all those topics connect
▪ Improves reasoning, investigation
skills, understanding of data and
numbers
▪ enhances ability to analyze public
health problems
EPIDEMIOLOGY
IN REAL WORLD
▪ Science of Public health programs
▪ Investigates public health issues
and generates scientific evidence
▪ Develops a science based platform
for program development
▪ Tracks disease trends
▪ Monitors and evaluates public
health response
FOCUS OF THIS COURSE
▪ Basic concepts – some revision
▪ How all these different concept connect
with each other
▪ In a real life situation …… How are these
concepts used
▪ How does Epidemiology and Biostatistics
support each other
▪ Data analysis using SPSS
▪ Conduct basic analysis of data set
EPIDEMIOLOGY
IN THE PRE-COVID ERA
 I AM AN EPIDEMIOLOGIST

The usual 03 responses you get

“You're WHAT?”
“Oh… so you are a skin specialist?”
“Uh-huh… OK… And what do you do?”
 I AM AN EPIDEMIOLOGIST

That’s wonderful… I was looking for

someone like you
Do you have time to answer a few
questions?
WHAT EPIDEMIOLOGISTS DO
• Epidemiologists are public health scientists
• They are the investigators: they investigate diseases
• They tell which diseases are there, how they spread,
who is affected in a population
• They tell us how to prevent them
• …… and what is the best way to deal with it
• Epidemiology deals with health of POPULATIONS

“thats quite a job … isnt’it ???

EPIDEMIOLOGY - DEFINITION

“The study of the distribution and determinants of disease

frequency in human populations and the application of this study
to control health problems”

John M. Last, Dictionary of Epidemiology

 EPIDEMIOLOGY - DEFINITION

“The study of the distribution (who has the disease, where

and when did they acquire the disease) and determinants of
disease frequency in human populations (a group of people with a
common characteristic such as residence, age, gender), and the
application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

 EPIDEMIOLOGY - DEFINITION

“The study of the distribution and determinants (what

causes the disease… in epi terms this is a study of all exposures)
of disease frequency in human populations (a group of people
with a common characteristic such as residence, age, gender), and
the application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

EPIDEMIOLOGY - DEFINITION

“The study of the distribution and determinants of disease

frequency (counting the number of cases of a disease in a
population over a specific period of time … in epi terms disease
could be regarded as OUTCOME) in human populations and the
application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

EPIDEMIOLOGY - DEFINITION

“The study of the distribution and determinants of disease

frequency in human populations (a group of people with a
common characteristic such as residence, age, gender), and the
application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

EPIDEMIOLOGY - DEFINITION

“The study of the distribution and determinants of

disease frequency in human populations and the
application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

APPLICATION OF THIS DEFINITION
You must have encountered questions like ……

▪ What is the Epidemiology of Hepatitis C in Pakistan

▪ What is the Global Epidemiology of COVID 19 infection

▪ A review of HIV/AIDS Epidemiology

“Lets use the example of COVID19 to understand

how concepts of epidemiology are used
AN EPIDEMIOLOGIST’S APPROACH

I keep six honest serving-men

(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling (1865–1936)

 CORE EPIDEMIOLOGICAL CONCEPTS
DISEASE WHAT
Descriptive

WHO PERSON

DISTRIBUTION WHEN TIME

WHERE PERSON
PLACE

WHY RISK FACTORS

Analytic

DETERMINANTS
HOW MANY?
HOW
DYNAMICS?
 CORE EPIDEMIOLOGICAL CONCEPTS
DISEASE WHAT
Descriptive

WHO PERSON

DISTRIBUTION WHEN TIME

WHERE PERSON
PLACE

WHY RISK FACTORS

Analytic

DETERMINANTS
HOW MANY?
HOW
DYNAMICS?
 AN EPIDEMIOLOGICAL INVESTIGATION

WHAT – DEFINING THE DISEASE”

In very simple terms, an epidemiologist:
COUNTS : cases or health events, and describes them in terms of time, place, person;
DIVIDES: the number of cases by an appropriate denominator to calculate rates; and
COMPARES: these rates over time or for different groups of people.

Before counting cases, however, we must decide what are we dealing with
“WHAT IS THE DISEASE” or “WHO IS THE CASE”
This is done by developing a case definition.

In an epidemiological investigation defining every variable of interest is the key

AN EPIDEMIOLOGICAL INVESTIGATION

WHAT – DEFINING THE DISEASE”

Case definitions can also change over time as more

information is obtained. The first case definition for
SARS, based on clinical symptoms and either contact
with a case or travel to an area with SARS
transmission, was published in CDC's (MMWR) on
March 21, 2003. Two weeks later it was modified
slightly. On March 29, after a novel coronavirus was
determined to be the causative agent, an interim
surveillance case definition was published that
included laboratory criteria for evidence of infection
with the SARS-associated coronavirus. By June, the
case definition had changed several more times. In
anticipation of a new wave of cases in 2004, a
revised and much more complex case definition was
published in December 2003.
 AN EPIDEMIOLOGICAL INVESTIGATION

WHAT – DEFINING THE DISEASE”

EXPOSURES – definition of all exposures is also important

e.g., in an epidemiological investigation of HPV spread among female sex

workers, define the following exposures:

• Female sex worker

• Client vs regular sex partner
• Safe sex
• Drug use
• Socio-economic class
 CORE EPIDEMIOLOGICAL CONCEPTS
DISEASE WHAT
Descriptive

WHO PERSON

DISTRIBUTION WHEN TIME

WHERE PERSON
PLACE

WHY RISK FACTORS

Analytic

DETERMINANTS
HOW MANY?
HOW
DYNAMICS?
AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – PLACE - WHERE

Distribution of disease by place provides
insight into the geographic extent of the
problem and its geographic variation. Sometimes
place refers not to a specific location at all but to
a place category such as urban or rural, domestic
or foreign, and institutional or non-institutional.

YOU ALL KNOW JOHN SNOW? WHAT DID HE

DO ?
 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – PLACE - WHERE

SPOT MAPS

New cases per 100,000 people in preceding two weeks

Circles are sized by county or territory population.
 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – PLACE - WHERE

Figure 1. Distribution of COVID-19 confirmed cases across countries and territories.
DISTRIBUTION MAPS
 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – PLACE - WHERE

HEAT MAPS

Global Population Density

 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – TIME - WHEN

• The occurrence of disease changes over time. Displaying the patterns of disease occurrence by
time is critical for monitoring disease occurrence in the community and for assessing whether the
public health interventions made a difference.

• Time data are usually displayed with a two-dimensional graph. The vertical or y-axis usually shows
the number of cases; the horizontal or x-axis shows the time periods such as years, months, or
days – THE EPI CURVE
ENDEMIC – EPIDEMIC - PANDEMIC
EPIDEMIC TYPES
Point source In a point source outbreak cases are
infected at the same time by a single source or single
exposure e.g., Food Outbreaks. The number of cases
rises rapidly to a peak and decline gradually.

Continuous source People are exposed continuously or

intermittent to a common harmful source.

Propagated (Also known as person-to-person) The

casual agent is spread person to person. For this reason,
the epidemic may last longer and is more complicated
to contain.
AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – TIME - WHEN

Seasonality

Disease occurrence can be graphed by

week or month over the course of a
year or more to show its seasonal
pattern. Some diseases such as
influenza and West Nile infection are
known to have characteristic seasonal
distributions. Seasonal patterns may
suggest hypotheses about how the
infection is transmitted, what behavioral
and environmental factors increase risk.
 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – TIME - WHEN

Day of week and time of day.

For some conditions, displaying data by day of the

week or time of day may be informative. Analysis at
these shorter time periods is particularly appropriate
for conditions related to occupational or
environmental exposures e.g., Road Traffic Accidents
AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – TIME - WHEN

Long term trends
1900 2000
Studying rate of a disease over a
period of years shows long-term or
secular trends in the occurrence of 1. Pneumonia 1. Heart Disease
the disease. Health officials use 2. TB 2. Cancer
3. Diabetes & Enteritis 3. Stroke
these rates to assess the prevailing
4. Heart Disease 4. Chronic lower RTI
direction of disease occurrence
5. Chronic Nephritis 5. Accidents
(increasing, decreasing, or
6. Injury 6. DM
essentially flat), help them evaluate
7. Stroke 7. Influenza
programs or make policy decisions
 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – PERSON – WHO

▪ Because personal characteristics may affect illness, organization and analysis of data by
“person” may use inherent characteristics of people (for example, age, sex, race), biologic
characteristics (immune status), acquired characteristics (marital status), activities
(occupation, leisure activities, use of medications/tobacco/drugs), or the conditions under
which they live (socioeconomic status, access to medical care).

▪ Age and sex are the two most commonly analyzed “person”characteristics. However,
depending on the disease and the data available, analyses of other person variables are
usually necessary.

▪ Sometimes, two variables such as age and sex can be examined simultaneously. Person
data are usually displayed in tables or graphs.
 AN EPIDEMIOLOGICAL INVESTIGATION

DISTRIBUTION – PERSON – WHO

▪ Analysis by Age
5-year age groups

▪ Analysis by Gender

▪ By Socio-economic class

▪ By geography
 CORE EPIDEMIOLOGICAL CONCEPTS
DISEASE WHAT
Descriptive

WHO PERSON

DISTRIBUTION WHEN TIME

WHERE PERSON
PLACE

WHY RISK FACTORS

Analytic

DETERMINANTS
HOW MANY?
HOW
DYNAMICS?
AN EPIDEMIOLOGICAL INVESTIGATION

DETERMINANTS – WHY/HOW?
A major goal of Epidemiology is to identify risk factors of a disease

Association ??
Exposure Disease
Causal relationship
Temporal relationship
Strength of association

▪ Epidemiology begins with Observation - DESCRIPTIVE EPIDEMIOLOGY

▪ Determine association and prove causation – ANALYTICAL EPIDEMIOLOGY
AN EPIDEMIOLOGICAL INVESTIGATION

DETERMINANTS

HILL’S
CRITERIA
 THE BACKBONE OF EPIDEMIOLOGICAL CALCULATIONS

THE 2 X 2 TABLE A 2X2 table is used for most

core Epi concepts and
calculations
OUTCOME
▪ Hypothesis testing (errors)
Diseased Non diseased
(+ve) (-ve) ▪ Sensitivity/Specificity

▪ Predictive values
Exposed
(+ve) Total exposed ▪ Attack rates
EXPOSURE

▪ Relative risk

▪ Attributable risk
Non Exposed
(-ve) Total Non
▪ Odds Ratio
exposed

Total Total Non

Diseased diseased
NATURAL HISTORY OF DISEASE

Incubation period

Primary Prevention Secondary Prevention Tertiary Prevention

Early detection Treatment and Rehabilitation
NATURAL HISTORY OF DISEASE – COVID 19
EPIDEMIOLOGIC
TRIAD OF DISEASE
vector
EPIDEMIOLOGIC TRIAD OF DISEASE
COVID-19
COUNT, PROPORTIONS, RATIO & RATES
▪ These are the measures used by epidemiologists to describe disease
in a population.

▪ Each measures in Epidemiological investigation is either a

proportion, a ratio or a rate.

▪ While these are basic arithmetic functions and fairly simple to

calculate, it is important to understand how they are used, how they
differ and how to interpret them.
COUNT, PROPORTIONS, RATIO & RATES
▪ Counts, also called frequencies, are fairly straightforward.

▪ Counts are the total number of events that occur in a defined period
of time. No denominator…

▪ Every epidemiological investigations starts with Count data

▪ The total number of cases COVID 19 cases in a day or a week

 COUNT, PROPORTIONS, RATIO & RATES
▪ Proportion is a type of measure in
which the numerator is included in the
denominator; describe a fraction of
people who developed a condition

▪ A proportion may be expressed as a

decimal, a fraction, or a percentage

▪ Number of people living with HIV

globally.
 COUNT, PROPORTIONS, RATIO & RATES
▪ A ratio is the relative comparison of any two values.

▪ It is calculated by dividing one variable by the other. The numerator and denominator need
not be related. Therefore, one could compare apples with oranges.

▪ Ratios are common descriptive measures, used as both descriptive measures and as
analytic tools.
▪ As a descriptive measure, ratios can describe the male-to-female ratio of participants
in a study, or the ratio of controls to cases
▪ As an analytic tool, ratios can be calculated for occurrence of illness, injury, or death
between two groups. These ratio measures, including risk ratio (relative risk), rate
ratio, and odds ratio, are described later in this lesson.
 COUNT, PROPORTIONS, RATIO & RATES
▪ In epidemiology, a rate is a measure of the frequency with which an event
occurs in a defined population over a specified period of time.

▪ To a non-epidemiologist, rate means how fast something is happening or

going. Rate is always reported per some unit of time e.g., person years
WHY MEASURE MORTALITY RATES
▪ Death is the final common outcome of all health and nutrition problems

▪ Strongest indicator which can signal a broad range of health problems and the overall
health status of a society

▪ It is easily defined and information on deaths is often already collected by authorities.

Vital statistics systems record certain information on each death, such as name, age at
death, and cause of death, then sum the number of deaths periodically to calculate
mortality rates.

▪ Unfortunately, in many less-developed countries, vital statistics systems are very

incomplete. Even in countries with well-functioning systems, such systems often break
down early in settings of armed conflict.
WHAT
WE
DIE
OF?
WHAT
WE
DIE
OF?
GLOBAL DEATHS: APPROXIMATE TOTALS FOR
SELECTED CAUSES

Ebola in West Africa

total in 2015/16 ~10,000

Per week
Malaria (mostly children) ~10,000
Smoking ~100,000
Vascular disease ~350,000
COVID 19 ~42,000
Source: UN, 2000
LARGE GAPS IN MORTALITY EVIDENCE
➢ 48 million infants are not registered each
year (~ 40%)

➢38 million deaths are not registered (2/3 of

all deaths globally)

➢ 85 countries have zero or unreliable cause

of death information
▪an additional 52 countries have low-quality data
 Nationwide Mortality Studies:
Indian Million Death Study (MDS)
1. Visit 1.4 M homes (“true snapshot” of India) in the “SRS” with a
recent death & ask standard questions and get a local language
narrative (adapted WHO tool)
2. 800 non-medical surveyors (now electronic entry + GPS)
3. Web-based double coding by 400 doctors (guidelines, +
adjudication and other strict quality control)
4. Study all diseases, work with RGI/census dept, keep costs <$1 per
home
5. Indian totals to date: ~0.8M deaths
6. Nationwide mortality studies
expanding to Sierra Leone, Ethiopia
and Mozambique

Gomes et al, Health Affairs, 2017

VARIOUS MORTALITY MEASURES

We may not always be interested in a rate for the entire

population; perhaps we are interested only in a certain age
group, in men or in women, or from a specific disease.

Deaths from a certain disease, that is, a disease-specific or a

cause-specific rate. E.g., mortality from lung cancer,

of all deaths, what proportion was caused by a specific disease.

e.g., proportionate mortality from Cancer. Increase in PM doesn’t
always mean a high mortality from that disease…

In the case-fatality rate, however, the denominator is limited to

those who already have the disease. Thus, case fatality is a
measure of the severity of the disease.

Deaths within a specific age group..

CHILD
MORTALITY
MEASURES OF MORBIDITY
Two major measures of disease occurrence in populations:

• Prevalence: Count of existing cases (deals with “status” not with “change”)

How many have the disease

• Incidence: Rate at which new events occur in population

What is the risk of disease and how fast it could happen

PREVALENCE
▪ In epidemiology, a big question is “what is the burden of the disease”

▪ Prevalence sometimes also called Prevalence rate is a “snapshot” or “a

slice” through the population at a point in time to determine who has the
disease and who does not.

▪ Cannot determine when disease developed or risk of getting that disease.

▪ Cross sectional studies… prevalence studies

 Point Prevalence of the disease at a certain POINT in time. The word
prevalence used generally refers to point prevalence
prevalence “ are you currently having asthma”
Prevalence

“On your last injection, did you share a syringe/needle with an IDU”

Prevalence of the disease within a certain time PERIOD. e.g., within

a year, within 6 months, last 5 years. The period needs to be clearly
defined.
Period “ did you have an attack of asthma in the last 6 months”
prevalence “In the last month, did you share a syringe/needle with another IDU”
INCIDENCE
▪ Incidence of a disease is defined as the number of NEW cases of a disease that
occur during a specified period of time in a population at risk for developing the
disease.

▪ Incidence is a measure of events—development of a disease. Because incidence is a

measure of events, incidence is a measure of risk.

▪ The denominator of an incidence rate represents the number of people who are at
risk for, developing the disease. Any individual included in the denominator must
have the potential to become part of the numerator.

▪ Cohort studies
 Incidence proportion is a measure of the risk of disease or the probability of developing
the disease during the specified period. As a measure of incidence, it includes only new
Cumulative
cases of disease in the numerator. The denominator is the number of persons in the
Incidence, population at the start of the observation period. Because all of the persons with new
Incidence cases of disease (numerator) are also represented in the denominator, CI is also a
Proportion, proportion.
Cumulative In = New cases / Pop at risk (*1000)
INCIDENCE

Incidence rate or person-time rate is a measure of incidence that incorporates time

directly into the denominator, called person-time. Generally calculated from cohort
follow-up study, wherein enrollees are followed over time and the occurrence of new
cases of disease is documented. Each person is observed from an established starting
Incidence Rate, time until one of four "end points" is reached: Disease, Death, Lost to follow-up, or end
of the study. Numerator of the incidence rate is the number of new cases developed,
Incidence
however, the denominator differs. The denominator is the sum of the time each person
Density was observed, totaled for all persons. This denominator represents the total time the
population was at risk. Thus, incidence rate is also a ratio of the number of cases : total
time the population is at risk.
In Rate = New cases / Total Person Time (*1000)
 ILLUSTRATION Corn =
INCIDENCE & PREVALENCE Person at risk

Speed of Popping = Incidence Rate

Popped Corn = Diseased Individual

Popcorn In Bowl = Prevalence

Eaten Popcorn = Recover / Died

Period Prevalence for the period between 2010 to 2014
Point Prevalence Cumulative Incidence Incidence Rate

2011 2012 2013 2014

EXAMPLES: PROPORTIONS, RATIO & RATES
Condition Ratio Proportion Rate
Morbidity • Risk ratio • Attack rate • Person-time incidence rate
(Disease) (Relative risk) (Incidence proportion)
• Rate ratio • Point prevalence
Odds ratio • Attributable
proportion

Mortality • Death-to-case ratio • Proportionate • Crude mortality rate

(Death) • Maternal Mortality mortality • Case-fatality rate
ratio • Cause-specific mortality rate
• Age-specific mortality rate
• Infant mortality rate

Natality • Crude birth rate

(Birth) Crude fertility rate
WHEN IS INCIDENCE & PREVALENCE SAME?
▪ There is an important relationship between incidence and prevalence.

▪ In a steady-state situation, in which the rates are not changing and in-migration
equals out-migration, the following equation applies:

Prevalence = Incidence × Duration of disease

▪ Thus if the duration of the disease is short Prevalence and Incidence are the same..
E.g., Diseases with a very high Case Fatality Rate… Tetanus. Rabies

▪ Diseases with long term survivals have different prevalence and incidence rates..
e.g., Diabetes, Cancers, Hepatitis
PRACTICAL USE OF INCIDENCE & PREVALENCE
PRACTICAL USE OF INCIDENCE & PREVALENCE
 CORE EPIDEMIOLOGICAL CONCEPTS
DISEASE WHAT
Descriptive

WHO PERSON

DISTRIBUTION WHEN TIME

WHERE PERSON
PLACE

WHY RISK FACTORS

Analytic

DETERMINANTS
HOW MANY?
HOW
DYNAMICS?
 THANKS
PLEASE READ THESE BASIC CONCEPTS….

will be happy to answer any questions

faran.emmanuel@umanitoba.ca