Types of epidemiology

 Prospective Study - looks forward, looks to the future,

examines future events, follows a condition, concern or disease
into the future

Types on time
frame basis

time

Study begins here

EXAMPLE
  Retrospective Study - “to look back”, looks back in time to
study events that have already occurred

Types on time
frame basis

time
Study begins here
EXAMPLE
 Observational

Types

experimental
 Epidemiology

Further Observational Experimental

classification
Randomized Community
Descriptive Analytical Field trials
control trials trials

Case series Cross

Case Reports Ecological Case control cohort
sectional
Observational Studies that do not involve any
intervention or experiment.
epidemiology
  First phase of epidemiological studies
 Concerned with the distribution of disease and health
Descriptive related characteristics in human population
studies  Identify the characteristics with which the disease in
question is seem to be associated
  Defining the population to be studied
 Defining the disease understudy
 Describe the disease by
Steps in Time

descriptive Place
Person
study  Measurement of disease
 Comparing with known indices
 Formation of an etiological hypothesis
 Time distribution Short term
fluctuation
Single source or
pin point
epidemics
Periodic Common source
fluctuation epidemics
Continuous or
multiple exposure
Long term or epidemics
secular fluctuation
Time
Person to person
distribution Short term
fluctuation

Propagated
Arthropod vector
epidemics

Slow (modern)
Animal reservoir
epidemics
 Age
Place distribution International variation

Person distribution
Sex
National variation ethnicity
Martial status
Urban rural variation
Occupation
Local distribution Social class
Behavior
Stress
Migration
  Disease load
 Available in terms of morbidity, mortality, disability
Measurement  Measurement of
of disease  Prevalence (longitudinal studies)
 Incidence rate (cross-sectional studies)
  Related to disease etiology
Should specify :
 The population- characteristics of the person to whom the
hypothesis applies
 The specific cause of being considered
 The expected outcome-disease
Formulation of  The dose-response relationship
hypothesis  The time-response relationship.
 Case Reports
 Detailed presentation of a single
Types of case or handful of cases
 Generally report a new or unique
descriptive finding
epidemiology  e.g. previous undescribed
disease
 e.g. unexpected link
between diseases
 e.g. unexpected new
therapeutic effect
 e.g. adverse events
Case Series
 Experience of a group of patients
with a similar diagnosis
 Assesses prevalent disease
 Cases may be identified from a
single or multiple sources
 Generally report on new/unique
condition
 May be only realistic design for
rare disorders
  Look at the entire population
 To test the hypothesis
Analytical Used to determine:
epidemiology  Whether or not a statistical association exist between a disease
and suspected factor
 If one exist, then the strength of association
  An “observational” design that surveys exposures and disease status at
a single point in time (a cross-section of the population)

 Often used to study conditions that are relatively frequent with long
duration of expression (nonfatal, chronic conditions)
Cross-sectional  It measures prevalence, not incidence of disease
study  Example: community surveys
 Not suitable for studying rare or highly fatal diseases or a disease with
short duration of expression
 Disadvantages
• Weakest observational design, (it
Cross-sectional Design measures prevalence, not incidence of
disease). Prevalent cases are survivors
• The temporal sequence of exposure and
factor present effect may be difficult or impossible to
No Disease determine
factor absent • Usually don’t know when disease
Study occurred
population • Rare events a problem. Quickly
factor present emerging diseases a problem
Disease
factor absent

time
Study only exists at this point in time
  Retrospective studies
Features:
1. Both exposure and outcome(disease) has been occurred before the start
of study
2. The study precedes backwards from the effect to cause
Case-control 3. It uses a control or comparison groups to support or refute the
study interference
Basic steps
4. Selection of cases and controls
5. Matching
6. Measurement of exposure
7. Analysis and interpretation
Case-Control Design
factor present
Cases
factor absent (disease) Strengths
Study • Less expensive and less time consuming
population • Efficient for studying rare diseases
factor present Controls
Limitations
(no disease)
factor absent • Inappropriate when disease outcome for a
present specific exposure is not known at start of
past study
• Exposure measurements taken after
disease occurrence
• Disease status can influence selection of
time subjects

Study begins here

 Analysis

Case-control
study
Relative risk:
The estimation of risk associated with the exposure is
obtained by an index called as relative risk
Aka relative ratio, defined as the ration b/w incidence of the
disease among exposed person and incidence among non
exposed
Practice question
  Prospective and retrospective study
 Cohort- is defined as a group of people who share a common characteristic
or experience with in a defined time period.
 For example: people who are exposed to particular vaccine or drugs.
Features:
Cohort studies 1. Cohorts are identified prior to the appearance of disease under
investigation
2. study groups so defined observed over a period of time to determine the
frequency of disease among them
3. Study proceed forward from cause to effect
 disease
Factor Strengths
Study present no disease • Exposure status determined before
population disease detection
free of • Subjects selected before disease
Factor disease
Cohort Design

disease detection
absent • Can study several outcomes for each
no disease
exposure
present
future
Limitations
• Expensive and time-consuming
• Inefficient for rare diseases or
diseases with long latency
time
• Loss to follow-up
Study begins here
  These are studies where exposure data relating to a place (say
hardness of water, which could be collected on individuals) are
correlated with health data collected on individuals but summarised
by place.
Ecological  What is missing: relationship between exposure and outcome at the
study design individual level
 Most ecological analyses are based on population case-series.
 Ecological analyses are subject to the ecological fallacy.
  Ecological fallacy, also called ecological inference fallacy, in 
epidemiology, failure in reasoning that arises when an inference is
made about an individual based on aggregate data for a group.

Ecological
fallacy
Example
  A study in which a population is selected for a planned trial of a regimen,
whose effects are measured by comparing the outcome of the regimen in the
experimental group versus the outcome of another regimen in the control
group.
Experimental
study design  Such designs are differentiated from observational designs by the fact
that there is manipulation of the study factor (exposure), and
randomization (random allocation) of subjects to treatment (exposure)
groups
 1. Provide stronger evidence of the effect (outcome) compared to
observational designs, with maximum confidence and assurance
2. Yield more valid results, as variation is minimized and bias
controlled
Why performed? 3. Determine whether experimental treatments are safe and
effective under “controlled environments” (as opposed to “natural
settings” in observational designs), especially when the margin of
expected benefit is doubtful / narrow (10 - 30%)
 RANDOMIZATION outcome

Intervention
no outcome

Experimental Design
Study
population
outcome
Control

no outcome

baseline
future

time
Study begins here (baseline point)
Types of  Randomized control trials- involving random allocation

experimental  Field trials- done on healthy people as unity of study

study design  Community trials- are done with communities as unit of study
  A design with subjects randomly assigned to “treatment” and
“comparison” groups

 Provides most convincing evidence of relationship between

exposure and effect

Randomized  Not possible to use RCTs to test effects of exposures that are
control trials expected to be harmful, for ethical reasons
Basic steps:
(RCTs) 1. Drawing up a protocol
2. Selecting reference and experimental population
3. Randomization
4. Intervention
5. Follow up
6. Assessment outcome
The “gold standard” of research
designs. They thus provide the most
convincing evidence of relationship
between exposure and effect.
Example:
trials of hormone replacement
therapy in menopausal women
found no protection for heart
disease, contradicting findings of
prior observational studies
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