1

Course Topics
Class 1
1. Introduction to Epidemiology & Its Role in Public
Health (Chapter 1, p1 -> p6)
2. Measuring Health and Disease (Chapter 2, p15 -> p31)
3. Types of Studies (Chapter 3: p39-p51)
Class 2
4. Causation in Epidemiology (Chapter 5: p89-p96)
5. Epidemiology and prevention: chronic
noncommunicable diseases (Chapter 6: p99-p113)
6. Communicable diseases: epidemiology surveillance
and response (Chapter 7: p117-p127)
Class 3
7. Understanding & Managing Errors in Studies (Chapter 3:
p51-p57)
2
8. Basic Biostatistics: concept and tools (Chapter 4: p63-p69)
 Assessment components
ØUsing a 10-point scale for all assessment.
ØOngoing Assessment: Attendance 10% + In-class
individual exercises 10% = 20%
ØMid-term Assessment: Presentation 10% + Mid-
term exams 10% = 20%
ØFinal Exams: 60%
üMinimum passing point: 4/10

3
 Class attendance (10%)
ØArriving late by 15 minutes: no points deducted
ØArriving late by more than 15 minutes but less than 1
hour: 25% deduction
ØArriving late by 1 hour or more: 50% deduction
ØMissing a class without permission: NOT allowed to
take the semester exam.

4
 In-class individual exercises
ØFor each speech you make, you will receive 1
bonus point.
ØThe class monitor will compile the bonus points at
the end of the class and send them to me.

5
 Presentation 10% (Class 2)
Group 1: Causation in Epidemiology
Group 2: Epidemiology and prevention: chronic
noncommunicable diseases
Group 3: Communicable diseases: epidemiology
surveillance and response
ØThe groups submit their list of members after
playtime.
ØEach group has 15-20 minutes for presentation, 5-
10’ Q&A.
ØPlease send your presentations to me 1 days
before class; students should prepare their own 6
laptops/computers.
 Presentation score
6 points Content aligns with the textbook
+1 point Demonstrates creativity: content, visuals,…
+1 point Exhibits presentation skills
+1 point Capable of answering questions

7
 Mid-term exams (10%) (Class 3)
- Take the test on Google Forms, 15 multiple choice
questions/15 minutes
- Please remember to bring your phone to class

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Textbook

9
 NGUYEN TAT THANH UNIVERSITY
NURSING FACULTY

Lesson 1: Introduction to Epidemiology &

Its Role in Public Health

Ph.D. To Thi Lien

email: ttlien@ntt.edu.vn
Date: March 2024
10
 Objectives
üUnderstanding the historical context of
epidemiology
üUnderstanding the definition and scope of
the field
üUnderstanding the basics of disease
causation and natural history
üApplying epidemiological methods in public
health
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12
 Historical Context

Hippocrates John Snow Now

(c. 460–c. 370 BC) (1813–1858) • Explore and act
• Environmental • Ending the upon the social
factors influence cholera outbreak determinants of
the occurrence of in London in 1854 health and
disease. • Infection theory disease 13
 What is Epidemiology?

“The study of the distribution and determinants of

health-related states or events in specified
populations, and the application of this study to the
prevention and control of health problems”(Last)
14
15
Two years of
COVID-19 have
created a second
silent pandemic
— one of grief
16
The Most Destructive Pandemics
and Epidemics In Human History

17
18
 Purposes Of Epidemiology

1. Identify causes (etiology) and risk factors

for disease.
2. Determine the extent of disease in the
community.
3. Study natural history and prognosis of
disease.
4. Evaluate preventive and therapeutic
measures
5. Provide foundation for public policy
(Gordis: Epidemiology, p. 3-4)
 Scope
üA common population used in epidemiology is one
selected from a specific area or country at a specific
time.

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 Causation of Disease

Figure 1.1. Causation

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 Natural History of Disease
üEpidemiology is also concerned with the course and
outcome (natural history) of diseases in individuals and
groups.

Figure 1.2. Natural history

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 Natural history of disease
ØStage of susceptibility
ØStage of pre-symptomatic (sub-clinical) disease
ØStage of clinical disease
ØStage of recovery , disability or death

Risk factors

Death

Normal Disease recover

disabled
23
 Epidemiology VS Clinical medicine

Epidemiology Clinical medicine

Population People (Case)
Prevention and control Treatment
Epidemiologist Case
Healthy in population Healthy in people
 NGUYEN TAT THANH UNIVERSITY
NURSING FACULTY

Lesson 2: Measuring Health and Disease

Ph.D. To Thi Lien

email: ttlien@ntt.edu.vn
Date: March 2024
25
 Objectives

üDefining and understanding the scope of

health and disease in epidemiology
üDifferentiating and calculating key
epidemiological measures
üUnderstanding the use and limitations of
health data
üInterpreting epidemiological data to inform
public health decisions
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 Definition of Health
ØWHO defined health as a complete state of
physical, mental and social well being and not just
the absence of disease or infirmity, leading to an
ability to lead a socially and economically
productive life.

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 Definition of Health
ØEpidemiologists are required to have some
knowledge of the disciplines of public health,
clinical medicine, pathophysiology, statistics, and
the social sciences.

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 Diagnostic Criteria
üDiagnostic criteria are usually based on symptoms,
signs, history and test results.

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30
üDiagnostic criteria can change rapidly with
advancing knowledge and improving techniques,
as well as based on the context of their
application.

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 Measuring Disease Frequency
Population at risk
üThe people who are susceptible to a given disease, and
can be defined by demographic, geographic or
environmental factors.

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 Incidence and Prevalence

ü The incidence is the rate of occurrence of NEW cases

arising in a given period in a specified population
ü Prevalence is the frequency of EXISTING cases in a
defined population at a given point in time. 33
 ü Common cold:
high incidence,
low prevalence

ü Diabetes: Low
incidence, high
prevalence

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 Attack Rate and Rates

!"#$%& '( )%')*% +((%,-%.

• Attact Rate = -/% !"#$%& %0)'1%.
Øduring outbreaks to see how fast a disease is
spreading in a small group.

• Rate =
!"#$%& '( ,+1%1
,'&&%1)'!.2!3 !"#$%& '( )%')*% 2! -/% )')"*+-2'! +- &214

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 Prevalence
Øhow common a disease is in a specific group at a particular
time, a "snapshot" of a disease in a community.
!"#$%& '( )%')*% +,-. -.% /,0%10% '& 2'3/,-,'3 1- 1 0)%2,(,%/ -,#%
P= !"#$%& '( )%')*% ,3 -.% )')"*1-,'3 1- &,04 1- -.% 0)%2,(,%/ -,#%
(x10n)

P is the: Point Prevalence

• Period Prevalence
• Lifetime Prevalence
Question Type of measure
Do you currently have asthma? Point prevalence

Have you had asthma during the last 2 years? Period prevalence

Have you ever had asthma? Cumulative incidence

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 Prevalence
Factors:
• the severity of illness
• the duration of illness
• the number of new cases
ØMeasures of prevalence are helpful in assessing the
need for preventive action, healthcare and the
planning of health services.

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 Incidence
!"#$%& '( 3%+ %5%3-0 ,3 1 0)%2,(,%/ )%&,'/
I= (x10 n)
!"#$%& '( )%&0'30 %6)'0%/ -' &,04 /"&,37 -.,0 )%&,'/

Cumulative Incidence
!"#$%& '( )%')*% +.' 7%- 1 /,0%10% /"&,37
1 0)%2,(,%/ )%&,'/
= !"#$%& '( )%')*% (&%% '( -.% /,0%10% ,3 -.% )')"*1-,'3 (x10 n)

1- &,04 1- -.% $%7,33,37 '( -.% )%&,'/

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Incidence and Prevalence
40
 Health Data
Mortality

Standard death certificate: age, standard diagnostic

sex, and place of residence classification for epidemiology
and health management. 41
 Mortality
Limitations

Lack of resources to establish Limitations of vital registration

routine vital registration systems systems 42
 Mortality
Crude mortality rate=
!"#$%& 8( 9%1-.0 9"&,37 :)%2,(,%/ ;%&,'/
(x10n)
!"#$%& '( )%&0'30 1- &,04 '( /<,37 /"&,37 -.% 01#% )%&,'/

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 Mortality
Age-Specific Death Rates

='-1* 3"#$%& '( /%1-.0 '22"&&,37 ,3 1 0)%2,(,2 17% 13/ 0%6 7&'")
'( -.% )')"*1-,'3 ,3 1 /%(,3%/ 1&%1 /"&,37 1 0)%2,(,%/ )%&,'/
>0-,#1-%/ -'-1* )')"*1-,'3 '( -.% 01#% 17% 13/ 0%6 7&'") (x10 n)

'( -.% )')"*1-,'3 ,3 -.% 01#% 1&%1 /"&,37 -.% 01#% )%&,'/
Proportionate Mortality
A ratio: the number of deaths from a given cause per 100 or
1000 total deaths in the same period.

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 Mortality

ØInfant mortality rate=

!"#$%& '( )%*+,- ./ * 0%*& '( 1,.23&%/ 2%-- +,*/ 4 0%*& '( *5%
(x10n)
!"#$%& '( 2.6% $.&+,- ./ +,% -*#% 0%*&
ØChild Mortality rate is based on deaths of children aged 1–4 years,
and is frequently used as a basic health indicator.
ØMaternal mortality rate=
!"#$%& '( #1-%&31* /%1-.0 ,3 1 7,5%3
7%'7&1).,2 1&%1 ,3 1 7,5%3 <%1& n)
!"#$%& '( *,5% $,&-.0 -.1- '22"&&%/ 1#'37 -.% )')"*1-,'3 '( (x10
-.% 7,5%3 7%'7&1).,2 1&%1 /"&,37 -.% 01#% <%1&

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 Mortality

ØThe adult mortality rate is the probability of dying

between the ages of 15 and 60 years per 1000
population.
ØLife Expectancy: Average number of years a person
is expected to live based on current death rates.
ØAge-Standardized Rates: Adjusts death rates to
make them comparable across different age
structures.
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 Morbidity
ØHow often people get sick.
ØOther sources include:
• Hospital records (who gets admitted and
discharged)
• Visits to the doctor
• Specialist clinics (like where you get stitches)
• Disease lists (like a cancer register)
No of clinically ill
Morbidity rate = Population

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 NGUYEN TAT THANH UNIVERSITY
NURSING FACULTY

Lesson 3: Types of Studies

Ph.D. To Thi Lien

email: ttlien@ntt.edu.vn
Date: March 2024
48
 Objectives

üUnderstanding the differences between

observational and experimental studies.
üIdentifying the characteristics, purposes, and
limitations of various observational study designs.
üRecognizing the principles and methodologies of
experimental studies.
üAnalyzing the appropriateness and limitations of
different study designs for specific public health
research questions.
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50
51
 Observational Studies
üDescriptive Studies just describe what is happening
with a disease in a group of people. Think of it as taking
a "snapshot" of the disease's presence.
E.g. You see statistics about how many people got the flu
this year.
• survey: time, place, person
• Case report, case series

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The 5W's of descriptive epidemiology

• What = health issue of concern

• Who = person
• Where = place
• When = time
• Why/how = causes, risk factors,
modes of transmission

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 Observational Studies
üAnalytical Studies: look at the relationships between a
health status and other factors.
E.g. Trying to find out if people who smoke are more
likely to get lung cancer.

• Cross-sectional
• Cohort
• Case-control

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 Analytic epidemiology
Tests hypotheses about:
• Why
• How

Comparing groups with different rates of disease

occurrence and with differences in demographic
characteristics, genetic or immunologic make-up,
behaviors, environmental exposures, and other
potential risk factors

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 Experimental studies
üExperimental studies involve actively attempting
to change a disease determinant or its progression
through treatment.
• Randomized control trial
• Clinical trial
• Community trial

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57
 Epidemiology study

Distribution Risk factors

Descriptive study Analytic study

Descriptive epidemiology

Time

Descriptive study Distribution Place

Person
Epidemiology

Analytic study Risk factors Etiology

 Descriptive Studies

ØExamining the distribution of a disease in a

population, and observing the basic features of its
distribution in terms of time, place, and person.

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Person

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 Time
• Changing or stable?

• Seasonal variation.

• Clustered (epidemic) or evenly

distributed (endemic)?

• Point source or propagated.

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 Place
• Geographically restricted or widespread
(pandemic)?

• Relation to water or food supply.

• Multiple clusters or one?

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64
 Ecological Studies
ØThe units of analysis are groups of people rather
than individuals.
ØThese studies compare populations in different
places at the same time or, in a time series, or one
place at different times.
ØThe shorter the time being studied, the less likely
other factors will confuse the results.

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66
 Limitations
ØDifficult to interpret since it is seldom possible to
examine directly the various potential explanations
for findings.
ØData on different exposures and on socioeconomic
factors may not be available.
ØThe unit of analysis is a group, the link between
exposure and effect at the individual level can not
be made.
ØThe ecological fallacy/bias occurs.

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 Cross-sectional Studies
ØCross-sectional studies take a "snapshot" of a
group at a specific time.
ØThese studies measure the prevalence of disease -
prevalence studies.
ØThey measure both the exposure and disease at
the same time.

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 Pros and Cons
ØAdvantages:
• quick to conduct and cost is moderate
compared with other study designs.
• useful for the health care needs of populations,
sudden outbreaks of disease
ØDisadvantages:
• cannot provide information on the incidence of
disease in a population only an estimate of
prevalence
• Difficult to investigate cause and effect
relationships
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72
 Case-control Studies
ØCase-control studies investigate causes of diseases.
ØThey include people with a disease (cases) and without
a disease (control/comparison/reference) group.
ØThe study compares the occurrence of the possible
cause in cases and in controls.

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Ø The investigators collect data on disease occurrence at one
point in time and exposures at a previous point in time.

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Ø Case-control studies are longitudinal, in contrast to
cross-sectional studies
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 = timing of data collection

Ø Case-control studies also called retrospective

studies since the investigator is looking backward
from the disease to a possible cause.
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 Case-control Studies
ØCases are selected on the basis of disease, not
exposure.
ØControls are people without the disease.
ØThe choice of controls and cases must not be
influenced by exposure status.
ØThe exposure status of the cases is determined
after the development of the disease (retrospective
data) by direct questioning of the affected person
or a relative or friend or using tests or checking
records.
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Ø Proportionately more people who had the disease (50 of
61 cases) reported prior meat consumption than those
who were not affected
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 Odds Ratio (OR)
ØOdds ratio (OR) is the ratio of the odds of exposure
among the cases to the odds of exposure among
the controls.
• OR = 1, there's no link.
• OR > 1, the exposure might increase the risk.
• OR <1, the exposure might decrease the risk.

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 OR=(50/11)÷(16/41)= (50 × 41)/(11 × 16)= 11.6
Ø The cases were 11.6 times more likely than the
controls to have recently eaten meat. 80
 Pros and Cons
ØAdvantages:
• an efficient method for studying rare diseases
• subjects have experienced the outcome of interest
at the start of the study
• quick to run and cheaper than other study
ØDisadvantages:
• Can not provide information on the disease
incidence in a population
• Reliant on the quality of past records or recollection
of study participants
• Difficult to ensure an unbiased selection of the
control group 81
 Cohort Studies
ØBegin with a group of healthy people are classified
into subgroups according to exposure to a potential
cause of disease and followed up to see how the
subsequent development of new cases in the
groups with and without exposure.
ØFollow-up or incidence studies

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Ø the data on exposure and disease refer to different
points in time, cohort studies are longitudinal, like
case- control studies 83
 Pros and Cons
ØAdvantages:
• monitored over time for disease occurrence
• estimates of the absolute incidence of disease in
exposed and non-exposed
ØDisadvantages:
• long follow-up period
• case of rare diseases large groups are necessary
• Losses to follow-up
• expensive

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 follow up study
participants for a long
time

current exposure can

be collected at the time
the cohort
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Ø the Framingham study – a
cohort study that began in
1948 – has investigated the
risk factors for a wide range
of diseases, including
cardiovascular and
respiratory diseases and
musculoskeletal disorders

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confuse
89
 Experimental Studies
ØIntervention/experimentation involves attempting to
change a variable in one or more groups of people.
• The elimination of a dietary factor thought to cause
allergy
• testing a new treatment on a selected group of patients
ØThe effects of an intervention are measured by
comparing the outcome in the experimental group with
that in a control group.
ØEthical considerations are of paramount importance in
the design of these studies.

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 Randomized controlled trials
Ø An epidemiological experiment designed to study
the effects of a particular intervention, usually a
treatment for a specific disease (clinical trial).
ØSubjects are randomly allocated to intervention
and control groups, and the results are assessed by
comparing outcomes.

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 Field Trials
ØField trials involve people who are healthy but
presumed to be at risk.
ØData collection takes place “in the field,” usually among
non-institutionalized people.

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 Field Trials
ØField trials are often logistically complicated and
expensive endeavours. E.g.
ØField trials can be used to evaluate interventions
aimed at reducing exposure without necessarily
measuring the occurrence of health effects. E.g.
ØSuch intervention studies involve a smaller scale,
and at lower cost, since lengthy follow-up or
measurement of disease outcomes.

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The Salk polio vaccine

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 Community Trial
ØThe treatment groups are communities rather than
individuals.
ØThis is particularly appropriate for diseases that are
influenced by social conditions, and for which
prevention efforts target group behaviour.

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 Limitations of community trials
ØOnly a small number of communities can be
included and random allocation of communities is
usually not practicable.
ØOther methods are required to ensure that any
differences found at the end of the study can be
attributed to the intervention rather than to
inherent differences between communities.
ØIt is difficult to isolate the communities where
intervention is taking place from general social
changes that may be occurring.

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 Limitations of community trials
ØDesign limitations, especially in the face of
unexpectedly large, favourable risk factor changes
in control sites, are difficult to overcome.
ØAs a result, definitive conclusions about the overall
effectiveness of the community-wide efforts are
not always possible.

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