DISEASE SURVEILLANCE CAT.

1. Giving examples explain:

i. Cohort study.
A cohort study is a type of epidemiological study where the investigator compares an exposed
group of individuals to an unexposed (or less exposed) group of individuals to determine if the
outcome of interest is associated with exposure. The unexposed group serves as a comparison
group, providing an estimate of the baseline or expected amount of disease occurrence in the
community. If the disease rate is substantively different in the exposed group compared to the
unexposed group, the exposure is said to be associated with the illness.
In a cohort study a group of individuals with a common characteristic is followed overtime to
find how many reach a certain health outcome of interest (disease, condition, event, death or a
change in health status or behavior). A cohort is defined as a group of persons usually 100 or
more in size, who share a common characteristic e.g., people born in the same year or all
enrollees of a specific health insurance plan. There are two types of cohort studies: prospective
and retrospective cohort studies. Prospective studies follow a cohort into the future or forward in
time for health outcome while retrospective studies trace back in time for exposure information
after the outcome has occurred. Both types of cohort studies are referred to as longitudinal or
follow up studies.
Examples of cohort study.
a. The Framingham study is a well-known cohort study that has followed over 5,000
residents of Framingham, Massachusetts since the early 1950s to establish the rates and
risk factors of heart disease.
b. The Nurses Health study I and Nurses Health study II are a cohort study established in
1976 and 1989 respectively that have followed over 100,000 nurses each and have
provided useful information on oral contraceptive, diet and lifestyle risk factors.
c. A longitudinal cohort study by Hoepner et al., (2016) that looked at whether exposure to
bisphenol A (BPA) early in life affects obesity levels in children later in life.
ii. Case-control study.
A case control study is used to determine if there is an association between an exposure and a
specific health outcome. These studies proceed from effect (e.g., health outcome, condition,
disease) to cause (exposure). Case control studies assess whether exposure is a
disproportionately distributed between the cases and controls, which may indicate that the
exposure is a risk factor for the health outcome under study. Case control studies are used for
studying rare health outcomes or diseases such as uveal melanoma.
Investigators start by enrolling a group of people with disease (cases) and a people without
disease (controls) as a comparison group; then compare previous exposures between the two
groups. The control group provides an estimate of the baseline or expected amount of exposure
in that population. If the amount of exposure among the case group is substantially higher than
the amount you would expect based on the control group, then illness is said to be associated
with that exposure. The key in a case control study is to identify an appropriate control group,
comparable to the case group in most respects in order to provide a reasonable estimate of the
baseline or expected exposure.
Examples of case control study.
a. A case control study by Togha et al., (2018), that compared serum Vitamin D levels in
individual who experience migraine, headaches with their matched controls studied over
a period of thirty days, individuals with higher levels of serum Vitamin D was associated
with lower odds of migraine headaches.
b. A case-control study by Boubekri et al., (2014), explored the impact of exposure to
daylight on the health of office workers (measuring well-being and sleep quality
subjectively, and light exposure, activity level and sleep-wake patterns via actigraphy).
Individuals with windows in their workplaces had more light exposure, longer sleep
duration, and more physical activity. They also reported a better score in the areas of
vitality and role limitations due to physical problems, better sleep quality and less sleep
disturbances.

iii. Retrospective cohort study.

In retrospective cohort study both the exposures and outcomes have already occurred. The
investigator calculates and compares rates of disease in the exposed and the unexposed groups.
Retrospective studies are conceived after some people have already developed the outcomes of
interest. The investigator goes back in time to identify a cohort or group of individuals at a point
in time before they had developed the outcomes of interest and they establish their exposure
status at that point in time. They then determine whether the subjects subsequently developed the
outcomes of interest.
In essence the investigator jumps back in time to identify a useful cohort which was initially free
from disease and at risk of developing the outcome. They then use whatever records are available
to determine each subject’s exposure status at the beginning of the observational period and
ascertain what subsequently happened to the subjects in two or more exposure groups.
Retrospective cohort studies are longitudinal because they examine health outcomes over a span
of time.
Retrospective cohort studies are commonly used in investigations of disease in groups of easily
identified persons such as workers at a particular factory or attendees at a wedding.
EXAMPLE: A retrospective cohort study was used to determine the source of infection of
cycloporiasis, a parasitic disease that caused an outbreak among members of a residential facility
in Pennsylvania in 2004. The investigation indicated that consumption of snow peas was
implicated as the vehicle of the cycloporiasis outbreak.
2. Describe the advantages and disadvantages of cohort and case-control studies.
I. Cohort study.
Advantages of cohort study.
 a. Clarity of Temporal Sequence: Cohort studies more clearly indicate the temporal
sequence between exposure and outcome, because in a cohort study, subjects are known
to be disease-free at the beginning of the observation period when their exposure status is
established. In case-control studies, one begins with diseased and non-diseased people
and then ascertains their prior exposures. This is a reasonable approach to establishing
past exposures, but subjects may have difficulty remembering past exposures, and their
recollection may be biased by having the outcome (recall bias).
b. Allow Calculation of Incidence: Cohort studies allow you to calculate the incidence of
disease in exposure groups, so you can calculate: Absolute risk (incidence), Relative risk
(risk ratio or rate ratio), Risk difference and Attributable proportion (attributable risk %)
c. Facilitate Study of Rare Exposures: While a cohort design can be used to investigate
common exposures (e.g., risk factors for cardiovascular disease and cancer in the Nurses'
Health Study), they are particularly useful for evaluating the effects of rare or unusual
exposures, because the investigators can make it a point to identify an adequate number
of subjects who have an unusual exposure, e.g.,
 Exposure to toxic chemicals (Agent Orange)
 Adverse effects of drugs (e.g., thalidomide) or treatments (e.g., radiation treatments
for ankylosing spondylitis)
 Unusual occupational exposures (e.g., asbestos, or solvents in tire manufacturing)
d. Allow Examination of Multiple Effects of a Single Exposure
e. Avoid Selection Bias at Enrollment: Cohort studies, especially prospective cohort studies,
reduce the possibility that the results will be biased by selecting subjects for the
comparison group who may be more or less likely to have the outcome of interest,
because in a cohort study the outcome is not known at baseline when exposure status is
established. Nevertheless, selection bias can occur in retrospective cohort studies (since
the outcomes have already occurred at the time of selection), and it can occur in
prospective cohort studies as a result of differential loss to follow up.

Strengths
 Multiple outcomes can be measured for any one exposure.
 Can look at multiple exposures.
 Exposure is measured before the onset of disease (in prospective cohort studies).
 Good for measuring rare exposures, for example among different occupations.
 Demonstrate direction of causality.
 Can measure incidence and prevalence.

Weaknesses
 Costly and time consuming.
 Prone to bias due to loss to follow-up.
 Prone to confounding.
 Participants may move between one exposure category.
 Knowledge of exposure status may bias classification of the outcome.
 Being in the study may alter participant's behaviour.
 Poor choice for the study of a rare disease.
 Classification of individuals (exposure or outcome status) can be affected by changes in
diagnostic procedures.
Disadvantages of Prospective Cohort Studies
1. You may have to follow large numbers of subjects for a long time.
2. They can be very expensive and time consuming.
3. They are not good for rare diseases.
4. They are not good for diseases with a long latency.
5. Differential loss to follow up can introduce bias.

Disadvantages of Retrospective Cohort Studies

1. As with prospective cohort studies, they are not good for very rare diseases.
2. If one uses records that were not designed for the study, the available data may be of
poor quality.
3. There is frequently an absence of data on potential confounding factors if the data was
recorded in the past.
4. It may be difficult to identify an appropriate exposed cohort and an appropriate
comparison group.
5. Differential losses to follow up can also bias retrospective cohort studies.

B. CASE-CONTROL STUDY.

Advantages:
 They are efficient for rare diseases or diseases with a long latency period between
exposure and disease manifestation.
 They are less costly and less time-consuming; they are advantageous when exposure
data is expensive or hard to obtain.
 They are advantageous when studying dynamic populations in which follow-up is
difficult.

Disadvantages:
 They are subject to selection bias.
 They are inefficient for rare exposures.
 Information on exposure is subject to observation bias.
 They generally do not allow calculation of incidence (absolute risk).