EPIDEMIOLOGICAL

STUDY-II
MEENA GYAWALI
MPH, MPRHGD, PhD (Candiate)
 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 study
• Advantages:
– Provides ‘Prevalence of the disease’ under study
– Gives ‘Snapshot of a population’
• Disadvantages:
– Tells about distribution of a disease, ‘rather than its etiology’
– Cannot establish causality as ‘does not establish time sequence
– Provides little information about natural history of disease or incidence
 Case Control Study
• Starts with diseased population
• Doesnot determines the incidence or prevelance of
diseases.
• It is a retrospective study.
• The study goes from effect -> cause.
• Help to interperiate:
– Odd’s ratio: OR= ad/bc
– Tells us the assosication between risk factors and diseases
occurance.
 Strength of Association in a Case Control Study

• Case Control Study cannot provide with incidences nor Prevalance

• So in a Case Control Study we calculate ‘an estimate of Relative Risk’, known as ‘Odds
Ratio’ (CROSS PRODUCT RATIO)
• Odds Ratio in a 2 × 2 table for a case control study:

Disease Present Disease absent

Exposure (+) a b
present

Exposure (-) c d
absent

Odd Ratio (Cross product ration) = ad/bc

 CASES CONTROLS TOTAL
(Lung Cancer) (Without Lung Cancer)

SMOKERS 33 (a) 55 (b) 88 (a+b)

NON-SMOKERS 2 (c) 27 (d) 29 (c+d)

TOTAL 35 (a+c) 82 (b+d) N= a+b+c+d

Odds Ratio (cross product ratio)= ad / bc

• Odds Ratio = 33 x 27 /55 x 2 = 8.1
• Smokers have risk of developing lung cancer 8.1 times higher than
non-smoker.
• It is estimation of risk of disease associated with exposure.
 Case control study
Advantages of case control study:
• Useful in rare diseases
• Odds ratio can be calculated
• Cost-effective and inexpensive
 Example
• 100 patient with lung cancer and 100 patient without
lung cancer were enrolled in a study. They were
questionned about smoking habit over the past 20
years. 90 of the lung cancer patients reported they
used to smoke and 10 of the patients who did not
smoke have lung cancer.
Lung
Cancer
No Lung
cancer OR: ad/bc
Smoking (+)present a
90
b
10 90*90/10*10 OR = 81
Non Smoking (-) c d
absent 10 90
=8100/100
 Calculate
• In a study, a resercher has examined the association
between the patient who were exposed to estrogen and
endometrial cancer.
• Among total 330 patient who were exposed 274 didnot
develop endometrial carcinoma where as out of 408
patients who were not exposed 18 of them developed
carcinoma.
• Calculate the odd ratio.
 Answer
Endometrial No Endometrial
Cancer cancer
Estrogen exposure yes a b
56 274
Estrogen exposure No c d
18 390

OR: ad/bc
56*390/274*18
=21840/4932
= 4.42
 Prevalence VS Incidence
• Prevalence = the number of cases of a
disease in a specific population at a particular
timepoint.
• Incidence = the rate of new cases of a
disease occurring in a specific population over
a particular period of time
 Cohort study
• Is a type of analytical (observational) study used for
‘hypothesis testing’
• Prospective study
• The cohorts must be free from
• Forward looking study
the disease under study.
• Cause to effect study
• Exposure to outcome study
• Risk factor to disease study
• Determines the incidence of the diseases
• Follow up study
Strength of Association in Cohort Study
• Strength of association in a cohort study is
evaluated by:
– Relative risk (RR)
– Attributable risk (AR)
– Population attributable risk (PAR)
– Incidence rates
Strength of Association in Cohort Study
• Relative risk (RR) = Incidence among exposed/ Incidence
among non-exposed
– RR = I exposed/ I non-exposed
– Interpretation of RR: Incidence of lung disease among exposed IS SO
MANY TIMES HIGHER as compared to that among non-exposed
• Attributable risk (AR) = (Incidence among exposed – Incidence
among non_exposed)/ Incidence among exposed × 100
– AR = (I exposed – Inon-exposed)/ I exposed × 100
– Interpretation of AR: So much disease can be attributed to exposure
 Strength of Association in Cohort Study
(Conti..)
• Population attributable risk (PAR) = (Incidence among
total – Incidence among non_exposed)/ Incidence
among total × 100
– PAR = (Itotal – Inon-exposed)/ Itot × 100
– Interpretation of PAR: If risk factor is modified or eliminated,
there will be so much annual reduction in incidence of
disease in the given population.
 Strength of Association in Cohort Study
(Conti..)
Incident :
• Total no of diseases/ total number of exposure
Interpretation of Relative Risk (RR)
RR Interpretation Example

Risk Factor Disease

RR > 1 I exp > Inonexp So many times Smoking Lung
chances/incidence of disease Cancer
development is more among
exposed as compared
to non-exposed
(Positive Association)

RR = 1 Iexp = Inonexp Chances/incidence of disease Smoking HIV/AIDS

development is same among
exposed as compared to non-
exposed
(No Association)

RR < 1 Iexp < Inonexp Chances/incidence of disease Vitamin-A Epithelial

development is less intake cancers
among exposed as compared to
non-exposed
(Negative Association)
 Relative Risk (RR) Versus Odds
Ratio (OR)
Relative risk (RR) Odds Ratio (OR)

Synonyms Risk ratio Cross product ratio

Utility Estimates strength of Estimates strength of association

association in a cohort study in
a case control study

Measure of strength of More accurate estimate Less accurate (only an estimate of

association RR

Calculation Iexposed/ Inon-exposed ad/ bc

 Useful Parameter(s) obtained by
epidemiological studies
Epidemiological studies Useful parameter(s)

Cohort Incidence, Relative risk, Attributable risk (AR), Population

AR

Case control study Odds ratio

Cross sectional study Prevalence

 QN1
• Cause to effect progression is seen in all except:
(a) Case control study
(b) Descriptive study
(c) Cohort study
(d) Randomized control trial

(b) Descriptive study

 QN2
Incidence rate can be calculated from:
• (a) Cohort study
• (b) Case control study
• (c) Cross sectional study
• (d) Descriptive study

(a) Cohort study

 QN3
The ratio between the incidence of disease among exposed
and non-exposed is called:
• (a) Causal risk
• (b) Relative risk
• (c) Attributable risk
• (d) Odds ratio

(b) Relative risk

 QN4
• A study compared 150 children with a particular disease
with 300 disease free children to examine past
experiences that may contribute to the development of
the illness. What kind of study is this?
• (a) Cohort
• (b) Controlled clinical trial
• (c) Case series
• (d) Case control
(d) Case control
 QN5

• The table given below shows cases of breast cancer occurring in a

randomized clinical trial of a new drug designed to prevent the disease. In
this study, 1000 healthy women between the ages of 60 and 65 were given
the drug and 1000 were given the placebo for 5years.
Breast ca No Breast Ca Total

Placebo 40 960 1000

New drugs 10 990 1000

What is the relative risk of breast cancer in patients exposed to drug?

(a) 25%
(b) 50%
(c) 75% 10/40*100
(d) 100%
(a) 25%
 QN6
• The physical examination records of the entire incoming freshman
class of 1935 at the University of Minnesota were examined in
1977 to see if their recorded height and weight at the time of
admission to university was related to their chance of developing
CHD. This is an example of:
(a) Cross sectional study
(b) Descriptive study
(c) Retrospective cohort
(d) Clinical trial
(c) Retrospective cohort
 QN7
All the following are advantages of case control studies
except:
• (a) Useful in rare diseases
• (b) Relative risk can be calculated
• (c) Odds ratio can be calculated
• (d) Cost-effective and inexpensive

Relative risk can be calculated

 QN8
Which of the following statements is not correct?
• (a) A cohort study is more expensive in comparison to case control study
• (b) A cohort study starts with people exposed to risk factor or suspected cause while case
control study starts with disease
• (c) A long follow-up period often needed with delayed results in a cohort study whereas a
case control study yields relatively quick results
• (d) A cohort study is more appropriate when the disease or exposure under investigation is
rare, in comparison to case control study

(d) A cohort study is more appropriate when the disease or exposure

under investigation is rare, in comparison to case control study
 QN9
• Which is not an analytical study?
(a) Case control
(b) Cohort study
(c) RCT
(d) Cross sectional

(c) RCT
 QN10
• In a study done to establish smoking as a risk factor for a
disease, 30 out of 50 smokers developed the disease
while 10 out of 50 non-smokers developed the disease.
Odds ratio is? [DNB December 2010]
• (a) 3 (b) 6
• (c) 5 (d) 10

(b) 6
 Disease Present Disease absent

Exposure (+) a(30) b(20)

present

Exposure (-) c(10) d(40)

absent

OR=ad/bc
30*40/20*10= 1500/200
ans: 6
THANK YOU