Introduction of Epidemiology

Epidemiology
DR. SOURAB KUMAR

DAS
What Is Epidemiology?
 Simply :
 It is the study of health and disease in human populations.
 Comprehensively :
 It is the study of the distribution and determinants of disease frequency in
human populations.
HISTORY
The word epidemiology consists of the Greek words
EPI = Among, Upon

DEMOS = People
LOGOS = Doctrine
Thus means the doctrine of what is among or happening to

people
DEFINITION OF 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
control of health problems (Last, 1988)
Distribution
 Person: demographic (i.e., age, gender, race) and other personal
characteristics of the population under study.
 Place: region, residence, workplace topography or location of rooms,

buildings or other structures
 Time: seasonal patterns, secular trends, or acute changes in disease

occurrence.
Description By Person
Description By Place
Rocky Mountain Spotted Fever, by county, 1993 .
o Clear clustering of cases of RMSF along

the east coast and in the south central U.S.
o Disease is not randomly distributed.
Description By Time
Trends in infectious disease mortality in the U.S. from 1900 to 1996
With the exception of the influenza pandemic of 1918, death rates due to infectious
diseases decreased until around 1980, at which time several factors (including HIV
related mortality and antibiotic resistance) caused these rates to rise.
Determinants
by means of:
 The necessary causes and enabling factors
 agent factor - necessary factors
 host factors : age, sex, race, genetic makeup, pregnancy, previous

immunologic experience
 Environmental factors : family size and composition, crowding, hygienic

conditions, geographic, climatic and seasonal circumstances, “lifestyle”
-qualities of society
Health- related states and events
 Diseases
 Causes of death
 Behavior: Tobacco, Alcohol, Drug use
 Reactions to preventive regimens, etc.

Epidemiology may be used for
o Identifying risk factors
o Evaluating the impact of treatment and impact of interventions or

health services
o Planning of prevention, treatment, and improving the effectiveness

and efficiency of health services
FIVE main objectives of Epidemiology
 1. To identify the cause of disease and its risk factors

 2. To determine the extent of disease found in the
community
 3. To study the natural history and prognosis of disease
 4. To evaluate new preventative and therapeutic
measures
 5.To provide a foundation for developing public policy.
FUNCTIONS OF EPIDEMIOLOGY
1. To discover the agent, host and environmental factors which affect
health, in order to provide the scientific basic for the prevention of
disease and injury and promotion of health
2. To determine the relative importance of causes of illness, disability and

death, in order to establish priorities for research and action
FUNCTIONS OF EPIDEMIOLOGY
3. To identify those sections of the population which have greatest risk
from specific causes of ill health, so that the indicated action may be
directed appropriately
4. To evaluate the effectiveness of health programs and services in

improving the health of the population
EPIDEMIOLOGICAL APPROACH:
• The epidemiological approach of health and disease have two major

foundations-
• A)Asking questions.
• B)Making comparison
 ASKING QUESTIONS MAKING COMPARISONS
 Related to health events: Exposure and Risk

(Disease)
 Who?(who are effected) Before and After

(Intervention)
 What?(what is the magnitude)
 When?(when did it happen?)
 Where?(where did it happen?)
 Why?(why did it happen)
 How
Related to health events:
1. what can be done to reduce this problem and its
consequences?
2. How can it be prevented in the future?
3. What action should be taken by the community? By the
health services? by other sectors? Where and for whom
these activities be carried out?
4. What resources are required? How are the activities to be
organized?
5. What difficulties may arise, and how might they overcome?
The Global Burden of some Tropical Diseases
Points People People Infected Annual Morbidity No. of countries

at risk (millions) (millions) Mortality Disability Affected
Leishmaniasis 350 12 Visceral: VL : very high 88

100,000 CL : multiple
Cutaneous: very lesions
low
Lymphatic 1,100 120 Excess mortality 44 million with 73
filariasis among those chronic
with disability
elephantiasis
Malaria 2,300 300-500 1.5-2.7 million 300-500 million 100
clinical cases
Onchocerciasis 120 18 Excess mortality 270,000 blind 34

among the blind
Determine great public health Problems
1954-1998
900
800
700 Others Injuries & poisoning

CDR（1/100,000）
600
500
400
300
Non-communicable diseases
200
100 Communicable,
maternal and
child diseases
0
1954 1957 1963 1975 1980 1985 1990 1995 1998
BASIC MEASUREMENT OF EPIDEMIOLOGY
1. Measurement of mortality.
2. Measurement of morbidity
3. Measurement of disability
4. Measurement of the presence, absence or distribution of the
characteristic or attributes of the disease.
5. Measurement of natality
6. Measurement of medical needs, health care facilities, utilization of
health services and other health related events.
7. Measurement of the presence , absence or distribution of the
environment and other factors suspected of causing the disease.
8. Measuring demographic variables.
BASIC TOOLS OF MEASUREMENT OF
EPIDEMIOLOGY
 MEASURE OF DISEASE FREQUENCY
 RATE
 A measure of some event, disease, or condition in relation to a unit of population
 Rate= Numerator(X)/Denominator(Y) × Multiplier (K)
 Eg.
o Death rate=Number of deaths in one year / mid year population×1000.
• A rate comprises the following elements- Numerator, denominator, time

specification and multiplier.
• The time dimension usually a calendar year.
• K=is a convenient number or bases to express the relation of X and Y.
• It is usual expressed per 1000 or some other round figure(10,000;100,000).
BASIC TOOLS OF MEASUREMENT OF
EPIDEMIOLOGY
 MEASURE OF DISEASE FREQUENCY
 RATE
• Types:
• Crude rates: Actual observed rate-e.g crude birth rate, crude death rate.
• Specific rates: Actual observed rates
a) Due to specific cause(e.g TB)
b) Occurring in specific groups( e.g. 5-10 years boys)
c) During specific time(e.g. July, 2000) periods.
• Standardized rates: directly or indirect method of standardization or
adjustment.
 Ratio
 Another measure of disease frequency is ratio. It expresses a relation in
size between two random qualities.
 It expresses in the form of x:y or x/y.
o Example:1
• The ratio of white blood cell relative to red cell is 1:600 or 1/600, meaning
that for each white cell there are 600 white cell.
o Example 2:
 The number of children with scabies at certain time ⁄ The number of
children with malnutrition at certain time.
 Other examples include : sex-ratio, doctor-population ratio, child –
women ratio etc.
 Proportion
 A proportion is a ratio which indicates the relation in magnitude of part of

the whole.
 Example:
o The number children with scabies at a certain time ⁄ The total number of
children in the village at the same time ×100.
Q. In a urban community, a total 250 children aged 3 years

have been suffering from measles, 35 children died among
them. What rate should be calculated about the disease?
• Ans-
• Rate should be calculated:
• =Numerator(X)/Denominator(Y)×Multiplier(K)
• =35/250×1000
• =140 per 1000 affected children.
• Q. In a slum there are 50 children with PEM

out of 500 children. Total 2000 people live in
that slum. Calculate proportion of PEM among
the children.
• Ans- calculation of proportion:

• A) proportion of the PEM within the children:
• proportion
• =the number children with PEM/total number of children ×100.
• 50/500×100
• =10%
• B)proportion of PEM within total population:
• Proportion=the number of children with PEM/total number of

population ×100
• =50/2000×100
• =2.5%
• Measures of Disease Occurrence
• PREVALENCE
• INCIDENCE
 PREVALENCE
 The propotion of persons in a given population who have a particular
disease at a point or interval time.
 Prevalence: Quantifies the “burden” of disease.

- Point Prevalence
- Period Prevalence
POINT PREVALENCE RATE
Number of existing cases of disease at

a point in time
P =---------------------------------------------------------
Total population
At that point in time
 “Point” Prevalence
 Example:
o On June 30, 1999, neighborhood A has:
 Population of 1,600
 29 current cases of hepatitis B
 So, P = 29 / 1600 = 0.018 or 1.8%

“Period” Prevalence
Number of existing cases

Pp = --------------------------------
Total population
During a time period
(i.e. May 1 - July 31, 1999)
Includes existing cases on May 1, and those

newly diagnosed until July 31.
 “Period” Prevalence
 Example:
o Between June 30 and August 30, 1999, neighborhood A has:
 Average population of 1,600
 29 existing cases of hepatitis B on June 30
 6 incidence (new) cases of hepatitis B between July 1 and August 30
 So, Pp = (29 + 6) / 1600 = 0.022 or 2.2%.

 Prevalence is used
 To determine the existing disease situation
 By epidemiologists and health administrators to plan for the health
facilities and manpower

 INCIDENCE
o The number of new cases of the disease occuring in a defined
population during a specified period of time.
 INCIDENCE
Number of new cases of disease during a given time period

--------------------------------------------------------------------
Population at risk during that period
For example,If there had been 500 new case of illness in a population of
30,000 in a year, the incidence rate would be:
=500/30,000 × 1000
=16.7 per 1000 per year.
Incedence rate must include the unit of time used in the final expression, if
you wrote 16.7 per 1000 , this would be inadequate. The correct
expression is 16.7 per 1000 per year.
Incidence
oIncidence quantifies the “development” of disease, that is , if the incidence

rate is increasing, it indicate failure or ineffectiveness of the current control
programmes.
oTypes:
- Cumulative incidence (CI)/

“Incidence proportion”/Risk.
- Incidence rate (IR)

(“Incidence density”)
 Cumulative Incidence (CI) /Risk
 PROPORTION of individuals who become diseased during a specified period
of time.
No. of new cases of disease during a given period of time

 CI = ------------------------------------------------------------------------------
No. Of individual in the population at the begining of that given
period
 Example: During a 1-year period, 10 out of 100 “at risk” persons develop the
disease of interest.
10
 CI = ---------- =0.10 or 10.0%
100
 Incidence Rate (IR)
No. new cases of disease during a specified period

 IR =
------------------------------------------------------------------------------------
Sum of the length of time each person in the population is at risk
of contracting the disease.
 EXAMPLE:
 A hypothetical cohort of 6 patients were enrolled into a study and the

occurrence of disease was observed over a period of time. Patient A
developed the disease 2 years after entry. Similarly Patients B, C, D, E, F
contributed 2, 3, 7, 2, and 6 years, respectively. Patients A and C
developed disease. What is the cumulative incidence and incidence rate of
the disease?
 CUMULATIVE INCIDENCE(RISK)
2/6=33%
Incidence density (INCIDENCE RATE)
 No. of new cases/person-time.

o The number of new cases = 2
o Person time = 2+2+3+7+2+6=22 person years
IR = 2/22 = 0.09 CASES/PERSON YEAR
OR
9 CASES/100 PERSON -YEARS
(2/22 × 100)
Mortality rates and ratios:

1. Crude date rate:
The simplest measure of mortality is the crude “date death
rate”. It is defined as “the number of death(from all
causes)per 1000 estimated mid-year population in one year,
in a given place.”
The crude death rate calculated from the following formula:
Number of deaths during the year/Mid- year population×1000.
2.Specific death rates:

The specific date rates may be cause or disease specific –e.g.,
tuberculosis-
• Number of deaths from tuberculosis during a calendar
year/Mid-year population×1000.
• Specific death rate for males
=Number of deaths among males during a calendar year/Mid-
year population of males×1000.
• Specific death rate in age group 15-20 years
=Number of deaths among males during a calendar year/mid-
year population of person aged 15-20×1000
3.Case fatality rate(ratio)

= Total number of deaths due to a particular disease/
Total number of cases due to the same disease×100.
• Case fatality rate represents the killing power of a disease. It is
simply the ratio of death to cases.
• Case fatality rate typically used in acute infectious disease(e.g.
food poisoning, cholera, measles).
4.Propotional mortality rate:

It is sometimes useful to know what proportion of total death are
due to a particular cause(e.g., cancer) or what proportion death
are occurring in a particular age group(e.g., above the age of
50 years). Proportional mortality rate expresses the “number
of deaths due to a particular cause(or in a specific age group)
per 100 (or per 1000) total deaths”
a) Proportional mortality from specific disease:

Number of deaths from the specific disease in a year/ total deaths from all causes in
that year × 100.
b) under-5 proportionate mortality rate:
Number of deaths under 5 years of age in the given year/Total number of deaths during
the same period×100.
c)Proportional mortality rate for aged 50 years and above:
Number of deaths of persons aged 50 years and above/total deaths of all age group in
that year×100.
5. Survival rate it is the proportion of survivor in a group,(e.g.,

of patients ) studied and followed over a period ( e.g., a 5 year
period).
• It is method of describing prognosis in certain disease
conditions.
• Survival rate = total number of patients alive after 5 years/
total number of patient diagnosed or treated ×100.
Measures of Association
• In epidemiology, we measure association between a disease
and an exposure
• To determine association, we must determine whether there is
an excess risk of disease relating to certain exposure.
Definition
What is Association?
• Two factors are associated when the occurrence of one is
related to the occurrence of the other .
What is Risk?
• Risk refers to an individual’s likelihood or probability for
developing a disease or untoward effect.
Example
CHD and oral contraceptives (OC) in women age 35
years or more
CHD Non-case
30 30
OC 60
20 70
No OC 90
50 100 150
Overall risk of CHD is 50/150= 0.33

Among OC users, risk of CHD is 30/60=0.50
Among No OC users, risk of CHD is 20/90=0.22
Comment: There is an association between OC use and CHD.
Breast cancer and use of oral contraceptives
(OC)
Cancer Non-case
15 30
OC 35 70
45
Overall risk of breast cancer is 50/150= 0.33

No OC
Among OC users, risk of breast cancer is 15/45=0.33
Among No OC users, risk of CHD is 35/105=0.33
105
Comment: There is no association between OC use and breast cancer
 Measure of disease association
1. Realative risk(RR)
=incidence in exposed group/incedence in non exposed group.
2.Attributed fraction(AF)
=Incedence in exposed group—incedence in non exposed
group/incedence in exposed group.
3.Attributable Risk (AR)
• = Risk in exposed– Risk in non-exposed
Interpretation of Relative Risk (RR)
Three possibilities
• RR=1, the risk in exposed persons EQUALS
to the risk in non-exposed persons
• RR > 1, the risk in exposed persons is
GREATER than the risk in non-exposed
persons
• RR <1, the risk in exposed persons is LESS
than the risk in non-exposed persons
Example of (AF)
CHD No CHD Total
Incidence
(/1000/yr) Smoking
84 2916
3,000 28.0
No smoking 87 5,000 4919 17.4
AF = (28.0-17.4)/28.0 = 0.379 = 37.9%
37.9% of the morbidity from CHD among smokers may be attributable to smoking and
could be prevented by eliminating smoking
An example or AR
» Group A: 1000 smokers give rise to 100 lung cancer
» Group B: 1000 nonsmokers give rise to 20 lung cancer
» Therefore, (100-20)=80 lung cancer among smokers due to smoking
Concept of Odds Ratio (OR)
• The ratio between two probabilities of a event is known as
odds ratio.
• In epidemiology, same population has two probabilities
– Probability of disease and probability of no disease
• Two probabilities add to 1
– Probability of disease (p), probability of no disease (1-p)
• Odds of disease =
Probability of diseases (p)
Probability of no disease (1-p)
Concept of Odds Ratio (OR)
IHD
Case control
• exposed
• Not exposed a b
c d
• Probability of a cell (p1)=a/a+b

• Probability of b cell (p2)=b/a+b
• Odds1=probability of getting heart disease/probability of not getting heart
disease=p1/p2=a/b (odds of exposure)
• Probability of c cell(p3)=c/c+d
• Probability of d cell(p4)=d/c+d
• Odds2 =p3/p4=c/d (Odds of non exposure group)
• p1/p2
• So odds ratio =p3/p4
• =ad/bc
• Suppose , OR=3.5
• There is probability of getting lung cancer 3.5 times more among smoker
than the non smokers.
Characteristics of risk, prevalence, and incidence rate
Characteristics Risk Prevalence Incidence rate
What is measured Probability of Percent of Rapidity of

disease population disease
with disease occurrence.
Units
None None Case/Person-time
Time of diagnosis
Newly diagnosed Existing Newly diagnosed
Synonyms
cumulative Incidence density
Incidence ---------------------
----
Types of epidemiological study
 Two different classes of epidemiological studied are
mentioned;
Epidemiological study
Observational Experimental
Descriptive Analytical
OBSERVATIONAL Vs. EXPERIMENTAL
1.Based on: Observation 1.Based on: Experiment.

(Natural Experiment).
2. Nature affects the outcome. 2. Researcher intervenes to affect the

outcome.
3. Investigator measures only 3. Investigator intervenes &

measures.
4. Demonstrates association; may or 4. May prove causation.

may not imply causation.
5. Ethical problem: Less. 5. Ethical problem: More.

e.g. Health hazards of Tsunami victims. e.g. Drug trial.
6. Chance of Bias – more. 6. Less – Extraneous variables are

relatively tightly controlled.
Observational study
• Observational study allow nature to take its own course, the
investigator measure but does not intervene.
OBSERVATIONAL
RESEARCH
DESCRIPTIVE ANALYTICAL
Cross sectional Cohort study

Case report Case control
Ecological report Follow-up/
Longitudinal study
DESCRIPTIVE Vs. ANALYTICAL
1.Simply describes the disease 1. Explains the disease occurrence.
occurrence with general information.
Distribution of disease Determinants of disease.
2. More diffuse & superficial. 2. Narrow down to answer specific

questions.
3. No attempt to analyze the link 3. Exposure and outcome relationship is

between exposure and outcome. analyzed.
4. Usually no hypothesis testing. 4. Hypothesis testing usually done.

DESCRIPTIVE STUDIES
 First phase of epidemiological investigation
 Descriptive study is limited to a description of the occurrence of a disease

in a population.
 Identifying the characteristics with which the disease in question seems
to be associated with in order to formulate a hypothesis.
Questions Asked
 When is the disease occurring?

(Time Distribution)
 Where is it occurring?
(Place Distribution)
 Who is getting the disease?

(Person Distribution)
Procedures in Descriptive Studies
 Defining the population to be studies
 Defining the disease under study
 Describing the disease by
o time
o place
o person
 Measurement of disease
 Comparing with known indices
 Formulation of etiological hypothesis
ANALYTICAL
EPIDEMIOLOGY
 Second major type of epidemiological studies
 The subject of interest is the individual within the population
 The objective is to test hypotheses
 The inference made is to the population from which the sample was
drawn
2.EXPERIMENTAL STUDIES
(Intervention studies)
a)Randomized or Clinical with patient

Controlled trials trials as unit of study
b)
Field trial or Community with healthy
intervention people as
study unit of study
c)Communiry with communities

trials as unit of study
EPIDEMIOLOGIC APPROACH
1. To recognize the • Cross-sectional DESCRIPTIVE

problem study EPIDEMIOLOGY
2. To set up the • Longitudinal study
hypothesis • Retrospective study
3. To demonstrate the • Cohort study ANALYTIC

factors EPIDEMIOLOGY
4. To demonstrate the • Case-Control
cause and effect (Comparison) study
EPIDEMIOLOGIC APPROACH
5. To test the
effectiveness of
control measure in
small scale project
6. To evaluate, correct,
modify
Intervention APPLIED
study EPIDEMIOLOGY
7. To test the
effectiveness of
control measure in
large scale project
THANK U

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Introduction of Epidemiology

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Epidemiology

DR. SOURAB KUMAR

EPI = Among, Upon

Thus means the doctrine of what is among or happening to

 Place: region, residence, workplace topography or location of rooms,

 Time: seasonal patterns, secular trends, or acute changes in disease

o Clear clustering of cases of RMSF along

 The necessary causes and enabling factors

 agent factor - necessary factors

 host factors : age, sex, race, genetic makeup, pregnancy, previous

 Environmental factors : family size and composition, crowding, hygienic

 Behavior: Tobacco, Alcohol, Drug use

 Reactions to preventive regimens, etc.

o Evaluating the impact of treatment and impact of interventions or

o Planning of prevention, treatment, and improving the effectiveness

 1. To identify the cause of disease and its risk factors

2. To determine the relative importance of causes of illness, disability and

4. To evaluate the effectiveness of health programs and services in

• The epidemiological approach of health and disease have two major

 ASKING QUESTIONS MAKING COMPARISONS

 Related to health events: Exposure and Risk

 Who?(who are effected) Before and After

Points People People Infected Annual Morbidity No. of countries

Leishmaniasis 350 12 Visceral: VL : very high 88

Onchocerciasis 120 18 Excess mortality 270,000 blind 34

700 Others Injuries & poisoning

• A rate comprises the following elements- Numerator, denominator, time

 A proportion is a ratio which indicates the relation in magnitude of part of

Q. In a urban community, a total 250 children aged 3 years

• Q. In a slum there are 50 children with PEM

• Ans- calculation of proportion:

• Proportion=the number of children with PEM/total number of

• Measures of Disease Occurrence

 Prevalence: Quantifies the “burden” of disease.

POINT PREVALENCE RATE

Number of existing cases of disease at

 So, P = 29 / 1600 = 0.018 or 1.8%

Number of existing cases

Includes existing cases on May 1, and those

 So, Pp = (29 + 6) / 1600 = 0.022 or 2.2%.

 To determine the existing disease situation

 By epidemiologists and health administrators to plan for the health

facilities and manpower

Number of new cases of disease during a given time period

oIncidence quantifies the “development” of disease, that is , if the incidence

- Cumulative incidence (CI)/

- Incidence rate (IR)

No. of new cases of disease during a given period of time

 Incidence Rate (IR)

No. new cases of disease during a specified period

 A hypothetical cohort of 6 patients were enrolled into a study and the

Incidence density (INCIDENCE RATE)

 No. of new cases/person-time.

Mortality rates and ratios:

2.Specific death rates:

3.Case fatality rate(ratio)

4.Propotional mortality rate:

a) Proportional mortality from specific disease:

b) under-5 proportionate mortality rate:

c)Proportional mortality rate for aged 50 years and above:

5. Survival rate it is the proportion of survivor in a group,(e.g.,

Overall risk of CHD is 50/150= 0.33