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Epidemiology Applications

SOUTH
CAROLINA AHEC
OBJECTIVES

● applications of epidemiologic method

SOUTH
CAROLINA AHEC
Assessing Risk and Burden of
Disease
● Relative Risk
● Odds Ratio
● Attributable Risk

SOUTH
CAROLINA AHEC
Relative Risk

● Calculated to identify differences in

disease rates between exposed and
unexposed groups.
● Risk of disease among exposed ÷ risk
of disease among unexposed
▲ RR = 1, no difference
▲ RR > 1, association between exposure and
disease
SOUTH
CAROLINA AHEC
Odds Ratio
● Calculated to identify likelihood of
exposure to a risk when comparing two
groups, one with and one without
disease.
● Exposure odds in disease group ÷
exposure odds in non-disease group
▲ Ratio = 1, no association
▲ Ratio > 1, association between exposure
and disease
SOUTH
CAROLINA AHEC
Attributable Risk

● Calculated to identify the proportion of

disease among exposed people that
actually results from the exposure
● Individual attributable risk = RR - 1 / RR
● Population attributable risk = Pe (RR -
1) / 1 + Pe (RR - 1), where Pe =
proportion of population exposed

SOUTH
CAROLINA AHEC
Epidemiology in Action

● Outbreak and Cluster Investigations

● Public Health Surveillance
● Community Screening Programs

SOUTH
CAROLINA AHEC
Outbreaks and Clusters

● Outbreak: an epidemic limited to a

localized increase in the incidence of a
disease
● Cluster: an aggregation of relatively
uncommon events or diseases in space
and/or time in amounts believed or
perceived to be greater than expected
by chance
SOUTH
CAROLINA AHEC
Characteristics of Outbreak
Investigations
● Infectious disease or condition
● Etiologic agent is transmissible
organism
● Short time frame for investigation
(hours, days)
● Moderate to large effect estimates
● Moderate to high exposure levels
SOUTH
CAROLINA AHEC
Characteristics of Outbreak
Investigations, cont.
● Acute exposure period (hours, days)
● Laboratory confirmation common
● Moderate to high possibility of
establishing cause and effect
● Most common study design:
retrospective cohort

SOUTH
CAROLINA AHEC
Characteristics of Cluster
Investigations
● Non-infectious disease or condition
● Often unknown or combined etiologic
agents
● Longer time frame for investigation
(weeks or months)
● Weak to moderate effect estimates
● Low exposure levels
SOUTH
CAROLINA AHEC
Characteristics of Cluster
Investigations, cont.
● Chronic exposure period (years or
● Laboratory confirmation uncommon
● Low possibility of establishing cause
and effect
● Most common study design: case-
control

SOUTH
CAROLINA AHEC
Challenges of Cluster
Investigations
● Active or passive approach
● Epidemiology or public health education
● Data sources and denominators
● Costs and yields

SOUTH
CAROLINA AHEC
Public Health Surveillance

● Ongoing systematic collection, analysis

and interpretation of outcome-specific
health data
● Closely integrated with the timely
dissemination of those data to those
responsible for preventing and
controlling disease or injury

SOUTH
CAROLINA AHEC
Sources of Surveillance Data

● Reports of health events

● Reporting from laboratories
● Registries
● Vital statistics
● Periodic surveys
● Information on environmental
exposures
● Information from other organizations
SOUTH
CAROLINAAHEC
Uses of Surveillance
Information
● Immediate detection
● Annual dissemination
● Archival information

SOUTH
CAROLINA AHEC
Community Screening
Programs
● Defining the target population
● Setting priorities among diseases and
conditions
● Choosing effective screening tests
● Assessing the effectiveness of
screening programs

SOUTH
CAROLINA AHEC
Screening Tests

Disease Status
Test
Positive Negative Total
Results
A B
Positive A+B
true (+) false (+)
C D
Negative C+D
false (-) true (-)
Total A+C B+D

SOUTH
CAROLINA AHEC
Hypothetical Example

Disease Status
Test
Positive Negative Total
Results
Positive 900 4,950 5,850
Negative 100 94,050 94,150
Total 1,000 99,000 100,000

SOUTH
CAROLINA AHEC
Sample Data

● AIDS
● Syphilis
● Diabetes

SOUTH
CAROLINA AHEC
Estimated Incidence of AIDS and Deaths of Adults
with AIDS*, 1985 - June 1998, United States
25,000
AIDS 1993 definition
implementation
Number of Cases/Deaths

20,000 Deaths

15,000

10,000

5,000

0
1985 1986 19871988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
delays of Diagnosis/Death
SOUTH
CAROLINA AHEC
AIDS Cases by Age and Sex
Reported 1981-1998, United States
35,000

30,000
Male N=574,783
Number of Cases

25,000 Female N=113,414

20,000

15,000

10,000

5,000

0
0 10 20 30 40 50 60 70 80 90
Age at Diagnosis
SOUTH
CAROLINA AHEC
3
Estimated Number of Persons Living with AIDS
1993 -1998, by Sex, United States
250

200
Men
Thousands

150

100

50
Women

0
1993 1994 1995 1996 1997 1998
Year SOUTH
CAROLINA AHEC
Estimated Number of Persons Living with AIDS
1993 - 1998, by Race/Ethnicity, United States
140

120
Thousands

80 Black, not Hispanic

60
Hispanic
40
American Indian/
Asian/Pacific Islander
0
1993 1994 1995 1996 1997 1998
Year SOUTH
CAROLINA AHEC
Estimated Number of Persons Living with AIDS
1993 - 1998, by Race/Ethnicity, United States
2,500

2,000
Persons

Asian/Pacific Islander
1,500

American Indian/

500

0
1993 1994 1995 1996 1997 1998
Year SOUTH
CAROLINA AHEC
Estimated Number of Persons Living with AIDS
1993 -1998, by Region, United States
12
0
10
0
Thousands

8 South
0 Northeast
6
0
4
0
West
Midwest
2
0 U.S. dependencies and possessions
0
1993 1994 1995 1996 1997 1998
Year SOUTH
CAROLINA AHEC
Proportion of AIDS Cases, by Race/Ethnicity
Year of Report,1985-1998, United States
70

Percent of Cases

50

40 Black, not Hispanic

30
Hispanic
20

10 American Indian/
Asian/Pacific Islander
0
1985 1987 1989 1991 1993 1995 1997
Year of Report
SOUTH
CAROLINA AHEC
AIDS Cases by Exposure Category and
Year of Report, 1985-1998, United States
8
0
7
Men who have sex with men (MSM)
Percent of Cases

0
6
0
5
0
4 Injection drug use (IDU)
0
3
0
2 Heterosexual contact
0
1 MSM & IDU
0
0
1985 1987 1989 1991 1993 1995 1997
Year of Report
udes cases with other or unreported risk pending medical record review and reclassification.
SOUTH
CAROLINA AHEC
AIDS Rates per 100,000 Population
Reported in1998
7.8
3.3 3.4 VT 2.5
0.9
6.2 4.0
2.6 NH 3.5
2.0 3.9 47.9 MA 15.0
1.2 7.3 RI 12.9
2.6 14.5 CT 20.3
14.8 4.3
8.2 6.1 NJ 26.3
6.6 10.8 DE 23.4
7.9 4.7
17.3 4.8 MD 31.9
14.7
8.1 7.1 DC 189.1
10.4
8.5 12.8
13.8 12.0
8.0 20.3
15.1 11.1 16.9
20.1
Rate per 100,000
21.8 36.5
<5
4.7 5 - 14.9
13.5 15+
PR 44.3 VI 29.6
SOUTH
CAROLINA AHEC
AIDS Cases Reported in 1998 and Estimated 1998
Population, by Race/Ethnicity, United States
AIDS Cases Population
N=48,269*
N=274,766,00
33% 71%

<1 1
45% 1
% %
4
20% %
13% %
12%

White, not Hispanic Asian/Pacific Islander

Black, not Hispanic American Indian/
*Includes 211 persons with unknown race/ethnicity
SOUTH
CAROLINA AHEC
per 100,000 Population, Reported in 1998

United States
Race/Ethnicity Cases Rate
White, not Hispanic 14,027 18
Black, not Hispanic 14,740 125
Hispanic 7,511 58
Asian/Pacific Islander 329 9
American Indian/
Total* 36,886 34

* 162 men whose race/ethnicity is unknown.

Includes
SOUTH
CAROLINA AHEC
AIDS by Region & Size of Place of Residence
Reported in 1998, United States

Metropolitan Metropolitan Non-

area 500,000 area 50,000- metropolitan
population 499,999 population area
% % %
Northeast
N=14,399 93.1 4.5 2.4

North Central
N=4,317 76.3 14.4 9.3

South
N=19,474 75.6 13.5 10.9

West
N=8,121 86.7 8.2 5.0
CAROLINA AHEC
SOUTH
P r im a r y a n d s e c o n d a r y s y p h ilis - R a te s b y s ta te :
U n ite d S ta te s a n d o u tly in g a r e a s , 1 9 9 7
0 .3
0 .0 0 .0 0 .2
0 .3 0 .3 VT 0 .0
0 .1 N H 0 .0
0 .1 1 .7 0 .8 M A 1 .3
0 .0 1 .6 RI 0 .2
0 .3 0 .2 1 .0 C T 1 .9
0 .6 2 .0
0 .2 0 .4 3 .7 2 .6 NJ 1 .9
1 .2 0 .1 D E 3 .0
1 .1 2 .1 3 .5 3 .5
M D 1 7 .6
1 4 .0 9 .8
3 .0 3 .5
0 .5 6 .9 1 0 .2
G u a m 0 .0
R a te p e r 1 0 0 ,0 0 0
1 4 .4 9 .6 7 .0 p o p u la tio n
3 .5 < 4 (n = 4 2 )
0 .2 8 .4 4 .1 -1 2 (n = 7 )
2 .1 > 12 (n = 3 )
0 .1
V ir g in Is .
P u e r to R ic o 1 .8
N o t e : T h e t o t a l r a t e o f p r im a r y a n d s e c o n d a r y s y p h ilis f o r t h e U n it e d S t a t e s a n d o u t ly in g a r e a s 6 .7
( in c lu d in g G u a m , P u e r t o R ic o , a n d V ir g in I s la n d s ) w a s 3 . 3 p e r 1 0 0 , 0 0 0 p o p u la t io n .
T h e H e a lt h y P e o p le y e a r 2 0 0 0 o b je c t iv e is 4 . 0 p e r 1 0 0 , 0 0 0 p o p u la t io n

SOUTH
CAROLINA AHEC
P r im a r y a n d s e c o n d a r y s y p h ilis - C o u n tie s w ith r a te s a b o v e a n d c o u n tie s w ith
r a te s b e lo w th e H e a lth y P e o p le y e a r 2 0 0 0 o b je c tiv e : U n ite d S ta te s , 1 9 9 7

R a te p e r 1 0 0 ,0 0 0
p o p u la t io n
<4 (n = 2 ,7 0 2 )
>4 (n = 4 1 3 )

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CAROLINA AHEC
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CAROLINA AHEC