Descriptive

Epidemiology
Dr. KANUPRIYA CHATURVEDI

How we view the world..
Pessimist: The glass is
half empty.

Optimist: The glass is
half full.

Epidemiologist: As
compared to what?
Epidemiology is...
Epidemiology is...
"The worst taught course in Medical
school."
Medical Student
Epidemiology is...
"The science of making the obvious
obscure."
Clinical Professor
Epidemiology is...
"The science of long division....

I'=[(480)(log2)(10E6)]/[(9.1)(0.955po)+0.45
n]"

Statistician
Definition of Epidemiology*
"The STUDY of the DISTRIBUTION and
DETERMINANTS of HEALTH-
RELATED STATES in specified
POPULATIONS, and the application of this
study to CONTROL of health problems."
*Last, J.M. 1988. A Dictionary of Epidemiology, 2nd ed.
Epidemiology: Definition
Dynamic study of the
Determinants
Occurrence
Distribution
Control
Pattern
Of health and disease in a population
Epidemiology
EPI DEMO LOGOS
Upon,on,befall People,population,man the Study of
The study of anything that happens to
people
That which befalls man
Definition of Epidemiology
A quantitative basic science, built on a working
knowledge of probability, statistics and sound
research methods.

A method of causal reasoning, based on
developing and testing biologically plausible
hypothesis pertaining to occurrence and
prevention of morbidity and mortality.

A tool for public health action to promote and
protect the public's health based on science, causal
reasoning, and a dose of practical common sense.
Epidemiology is a Quantitative
Discipline
Measures of frequency
Counts and rates
Measures of association
Relative risk
Odds ratio
Statistical inference
P-value
Confidence limits

Clinician Epidemiologist
Patients
diagnostician

Investigations

Diagnosis

Therapy

Cure


Communitys
diagnostician

Investigations

Predict trend

Control

Prevention

Epidemiology
Describes
health events
cause and risk factors of disease
clinical pattern of disease
Identify syndromes
Identify control and/or preventive measures

So, Epidemiology
Is the basic science of public health

Provides insight regarding the nature, causes,
and extent of health and disease

Provides information needed to plan and target
resources appropriately

Kinds of Epidemiology
Descriptive

Analytic

Experimental
Further studies to determine the
validity of a hypothesis concerning
the occurrence of disease.
Deliberate manipulation of the
cause is predictably followed
by an alteration in the effect
not due to chance
Study of the occurrence and
distribution of disease
Overview of epidemiologic design
strategies
Descriptive
Populations{Correlational studies}
Individual
Case report
Case series
Cross sectional studies
Analytic studies
Observational
Case control
Cohort
Retrospective
Prospective
Interventional/Experimental
Randomized controlled trial
Field trial
Clinical trial
Descriptive vs. Analytic Epidemiology
Descriptive
Used when little is
known about the
disease

Rely on preexisting
data

Who, where, when

Illustrates potential
associations

Analytic
Used when insight about
various aspects of disease is
available

Rely on development of new
data

Why

Evaluates the causality of
associations
Both are important!
Descriptive Studies
Relatively inexpensive and less time-consuming
than analytic studies, they describe,

Patterns of disease occurrence, in terms of,
Who gets sick and/or who does not
Where rates are highest and lowest
Temporal patterns of disease

Data provided are useful for,
Public health administrators (for allocation of resources)
Epidemiologists (first step in risk factor determination)

Descriptive Epidemiology
Correlational studies

Case reports

Case series

Cross sectional studies
Correlational Studies (Ecological Studies)
Uses measures that represent characteristics of
entire populations
It describes outcomes in relation to age, time,
utilization of services, or exposures

ADVANTAGES
We can generate hypotheses for case-control studies and
environmental studies
We can target high-risk populations, time-periods, or
geographic regions for future studies
Correlational Studies
LIMITATIONS
Because data are for groups, we cannot link disease and
exposure in individual

We cannot control for potential confounders

Data represent average exposures rather than individual
exposures, so we cannot determine a dose-response
relationship

Caution must be taken to avoid drawing inappropriate
conclusions, or ecological fallacy

Patterns of disease Occurrence :
Correlation of Population statistics
Ecologic ( correlation ) studies

Used as first step in determining association
plot : disease (population) burden [ Y axis ]
vs. prevalence of risk factor [ X axis ]
e.g. smoking vs. lung cancer

-- correlation coefficient : r ; + 1 to -1
Quantifies linear relationship between exposure & disease


Case Reports (case series)
Report of a single individual or a group of
individuals with the same diagnosis
Advantages
We can aggregate cases from disparate sources to generate
hypotheses and describe new syndromes
Example: hepatitis, AIDS
Limitations
We cannot test for statistical association because there is no
relevant comparison group
Based on individual exposure {may simply be coincidental}

Case report/Case series(contd.)
Important interface between clinical medicine &
epidemiology

Most common type of studies published in
medical journals{1/3
rd
of all}

e.g. Frisbee finger , break dancing neck

AIDS ~ b/w oct1980-may81, 5 cases of P.carinii
pneumonia were diagnosed among previously healthy
young homosexual males in L.A.




Cross-Sectional Studies (prevalence studies)
Measures disease and exposure simultaneously in a
well-defined population

Advantages
They cut across the general population, not simply those
seeking medical care
Good for identifying prevalence of common outcomes, such
as arthritis, blood pressure or allergies

Limitations
Cannot determine whether exposure preceded disease
It considers prevalent rather than incident cases, results
will be influenced by survival factors
Remember: P = I x D

Cross-Sectional Studies
Can be used as a type of analytic study for testing
hypothesis, when;

Current values of exposure variables are unalterable over
time

Represents value present at initiation of disease

E.g. eye colour or blood group

If risk factor is subject to alterations by disease, only
hypothesis formulation can be done
The epidemiologic approach:
Steps to public health action
MEASURES
Counts
Times
Rates
Risks/Odds
Prevalence

METHODS
Design
Conduct
Analysis
Interpretation
ALTERNATIVE
EXPLANATIONS
Chance
Bias
Confounding

INFERENCES
Epidemiologic
Causal
ACTION
Behavioural
Clinical
Community
Environmental
DESCRIPTIVE
What (case
definition)
Who (person)
Where (place)
When (time)
How many
(measures)

ANALYTIC
Why (Causes)
How (Causes)
Key questions
Why now?
Why here?
Why in this group?



Descriptive Epidemiology
Study of the occurrence and distribution of
disease
Terms:
Time
Place
Person

What are the three categories of
descriptive epidemiologic clues?

Person: Who is getting sick?
Place: Where is the sickness occurring?
Time: When is the sickness occurring?

PPT = person, place, time
Time
Secular

Periodic

Seasonal

Epidemic

Secular Trend

The long-time trend of disease
occurrence

Tetanus by year, USA, 1955-2000
During 2000, a total of 35 cases of tetanus were reported. The percentage of cases among persons aged 25-59 years
Has increased in the last decade. Note: A tetanus vaccine was first available in 1933.
0
100
200
300
400
500
600
700
800
900
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
Year
Possible Reasons for Changes in
Trends
Artifactual
Errors in numerator due to
Changes in the recognition of disease
Changes in the rules and procedures for
classification of causes of death
Changes in the classification code of causes of
death
Changes in accuracy of reporting age at death
Errors in the denominator due to error in the
enumeration of the population
Possible Reasons for Changes in
Trends (cont.)
Real
Changes in age distribution of the population
Changes in survivorship
Changes in incidence of disease resulting
from
Genetic factors
Environmental factors
Other phrases
Cyclic trends ~ recurrent alterations in
occurrence , interval or frequency of disease
Secular cyclicity
Levels of immunizations
Build up of susceptibles
e.g. Hep A-7 yr cycle,Measles-2yr cycle
Short term cyclicity
Chickenpox,salmonella(yearly basis)





Periodic Trend

Temporal interruption of the general
trend of secular variation

Whooping Cough - Four-monthly
admissions, 1954-1973
Seasonal
A cyclic variation in disease frequency
by time of year & season.

Seasonal fluctuations in,
Environmental factors
Occupational activities
Recreational activities

Seasonal Trend
Pneumonia-Influenza Deaths By year,
1934-1980
Epidemic
An increase in incidence above the expected
in a defined geographic area within a
defined time period

Endemic, Epidemic and Pandemic
Endemic - The habitual presence (or usual occurrence) of a
disease within a given geographic area
Epidemic - The occurrence of an infectious disease clearly in
excess of normal expectancy, and generated
from a common or propagated source
Pandemic - A worldwide epidemic affecting an exceptionally
high proportion of the global population
Number
of Cases
of
Disease
Time
Time clustering
Time Place Cluster/disease cluster
A group of cases occur close together
& have a well aligned distribution
pattern {in terms of time and place}

Cluster analysis-used for rare or special disease
events.
Time/Place clustering analysis using the
Poisson model
{Poisson spatial/nearest neighbor distribution}

Poisson probability distribution is an inferential statistics probability
measure.

Describes objects/events as they are distributed geographically.

Geographical area divided into a series of equal square areas.

Randomization i.e. each case has equal probability of falling into each
square.

If clustering occurs, probability of cause-effect relationship goes up &
vice versa.


Place
Diagnosis is Made


Contact occurred
between agent
and host

Source became
infected

Geographic Area Example Action Level
Home Patient ill

Restaurant Food
Eaten

Farm Eggs Infected
Investigation

Control


Prevention

Person
Age Hobbies
Sex Pets
Occupation Travel
Immunization status Personal Habits
Underlying disease Stress
Medication Family unit
Nutritional status School
Socioeconomic factors Genetics
Crowding Religion

Descriptive epidemiology :
Patterns of Disease Occurrence
distribution of disease in populations
numerator ( event count ) / denominator ( group at
risk )

by person : age , race / ethnicity , gender ,
occupation , education , marital status , genetic
marker , sexual preference

by place : residence (urban vs. rural) , worksite ,
social event

by time : week , month , year ; sporadic , seasonal
, trends
--- incubation period ; latency

Sources of information
Census data
Vital statistical records
Employment health examinations
Clinical records from hospitals
National figures on food consumption ,
medications, health events etc
Epidemiologic ( scientific ) Approach

1. Identify a PROBLEM :
clinical suspicion ; case series ; review of medical literature


2. Formulate a HYPOTHESIS ( asking the right question ) ;
good hypotheses are: Specific, Measurable, and Plausible


3. TEST that HYPOTHESIS ( assumptions vs. type of data )


4. always Question the VALIDITY of the result(s) :
Chance ; Bias ; and Causality
Epidemiologic Study: threats to Validity

Chance : role of random error in outcome measure(s)
( p - value ; power of the study and the confidence interval )
--- largely determined by sample size

Bias : role of systematic error in outcome measure(s)


Selection bias - subjects not representative

Information bias - error(s) in subject data / classification

Confounding - 3rd variable (causal) assoc. w/ both X and Y
What is a hypothesis?

An educated guess

an unproven idea

based on observation or reasoning, that can be
proven or disproven through investigation.

What goes into a hypothesis?
Characteristics of the disease
The illness
Established modes of transmission

Distribution
In time
By place
By person

Hypothesis formulation
4 methods {derived from 5 canons of inductive
reasoning by John Stuart Mill}

Method of difference
Method of agreement
Method of concomitant variation
Method of analogy

Measures
Morbidity: Refers to the presence of disease in a
population

Mortality: Refers to the occurrence of death in a
population

Methods for Measuring
How do we determine disease frequency for a
population?

Rate = Frequency of defined events in specified
population for given time period

Rates allow comparisons between two or more
populations of different sizes or of a population
over time

Compute Disease Rate
Number of persons at risk = 5,595,211

Number of persons with disease = 17,382

Rate = 17,382 persons with heart disease
5,595,211 persons
= .003107 heart disease / resident / year

Rates
Rates are usually expressed as integers and
decimals for populations at risk during specified
periods to make comparisons easier.

.003107 heart disease / resident / year x 100,000

= 310.7 heart disease / 100,000 residents / year

Prevalence vs. Incidence

Prevalence is the number of existing cases of
disease in the population during a defined
period.

Incidence is the number of new cases of
disease that develop in the population during a
defined period.
Incidence
Incidence rate is a measure of the
probability of the event among persons at
risk.

Incidence Rates
Population denominator:

IR = # new cases during time period X K
specified population at risk


Example (Incidence Rate)
During a six-month time period, a total of 53 nosocomial
infections were recorded by an infection control nurse
at a community hospital. During this time, there were
832 patients with a total of 1,290 patient days. What is
the rate of nosocomial infections per 100 patient days?

Mortality Rates
A special type of incidence rate

Number of deaths occurring in a specified
population in a given time period

Use of Mortality rates
Mortality rates are used to estimate disease
frequency when
incidence data are not available,

case-fatality rates are high,

goal is to reduce mortality among screened or
targeted populations

Mortality Rates: Examples
Crude mortality: death rate in an entire
population
Rates can also be calculated for sub-groups within
the population

Cause-specific mortality: rate at which deaths
occur for a specific cause

Mortality Rates: Examples
Case-fatality: Rate at which deaths occur from a
disease among those with the disease

Maternal mortality: Ratio of death from
childbearing for a given time period per number
of live births during same time period

Mortality Rates: Examples
Infant mortality: Rate of death for children less
than 1 year per number of live births

Neonatal mortality: Rate of death for children
less than 28 days of age per number of live
births
Prevalence
Prevalence: Existing cases in a specified
population during a specified time period (both
new and ongoing cases)

Prevalence is a measure of burden of disease or
health problem in a population

Prevalence
Prevalence: The number of existing cases in the
population during a given time period.

PR = # existing cases during time period
population at same point in time

Prevalence rates are often expressed as a percentage.


Factors Influencing Prevalence
Increased by:
Longer duration of the
disease
Prolongation of life of
patients without cure

Increase in new cases
(increase in incidence)

In-migration of cases

Out-migration of
healthy people
In-migration of
susceptible people

Improved diagnostic
facilities
(better reporting)
Decreased by:
Shorter duration of
disease

High case-fatality
rate from disease

Decrease in new
cases (decrease in
incidence)

In-migration of
healthy people

Out-migration of
cases

Improved cure rate
of cases
Basic Measures of Association
Relative risk& odds ratio

We often need to know the relationship between
an outcome and certain factors (e.g., age, sex,
race, smoking status, etc.)

Used to guide planning and intervention
strategies

2 x 2 contingency table for Calculation of
Measures of Association
Outcome
Exposure Present Absent TOTAL
Present a b a+b
Absent c d c+d
TOTAL a+c b+d a+b+c+d
Note: Exposure is a broad term that represents any
factor that may be related to an outcome.
Relative Risk
Ratio of the incidence rates between two groups
Can only be calculated from prospective studies
(cohort studies)
Interpretation
RR > 1: Increased risk of outcome among exposed
group
RR < 1: Decreased risk, or protective effects, among
exposed group
RR = 1: No association between exposure and
outcome

Calculation of Relative Risk
incidence rate among exposed
RR =
incidence rate among non-exposed

Calculation of Relative Risk
Outcome
Exposure Present Absent TOTAL
Present a b a+b
Absent c d c+d
TOTAL a+c b+d a+b+c+d
Relative Risk =
a
a b
c
c d
+
|
\

|
.
|
+
|
\

|
.
|
Relative Risk Case Study
Birth Weight
Smoking status <2500 g >2500 g TOTAL
Smoker 120 240 360
Non-smoker 60 580 640
TOTAL 180 820 1000
Smoking and low birth weight
Answers to Relative Risk Case Study
1. Incidence of LBW among
smokers


2. Incidence of LBW among
non-smokers


3. Relative risk for having a
LBW baby among smokers
versus non-smokers


= =
120
360
1000 3333 x , .
= =
60
640
1000 938 x , .
= ~
3333
938
36
.
.
.
Understanding Probability and Odds
Probability: Chance or risk of an event occurring (a
proportion)
Probability= no. of times an event occurs
no. of times an event can occur

Odds: ratio of the probability of an event occurring to
the probability of an event not occurring

Odds = P/(1-P)
Calculation of Odds Ratio
Outcome
Exposure Present Absent TOTAL
Present a b a+b
Absent c d c+d
TOTAL a+c b+d a+b+c+d
Odds Ratio =
ad
bc
Odds Ratio
The odds ratio (OR) is a ratio of two odds.

The OR can be calculated for all three study
designs
Cross-sectional
Case-control
Cohort.

Various approaches to Odds ratio

Cross product/odds ratio
2 x 2 contingency table (ad/bc)

Prevalence odds ratio
cross sectional studies

Exposure odds ratio( odds of exposure in diseased vs. nondiseased)
In rare cases or exotic diseases

Disease odds/Rate odds ratio(odds of getting a disease if exposed
or unexposed)
Cohort & cross sectional

Risk odds ratio
Cross sectional ,cohort & case control
Odds Ratio
For cohort & cross sectional studies: OR is a
ratio of the odds of the outcome in exposed
persons to the odds of the outcome in non-
exposed persons.

For case-control studies: OR is a ratio of the
odds of exposure in cases to the odds of
exposure in controls.

Provides an estimate of the relative risk when
the outcome is rare

Interpretation of Odds Ratio
OR > 1: Increased odds of exposure among those
with outcome

OR < 1: Decreased odds, or protective effects,
among those with outcome

OR = 1: No association between exposure and
outcome


Keeping the Terms Straight
Risk ratio = relative risk

Relative odds = odds ratio

Remember the key is recognizing the terms
risk and odds

Appropriateness of Measures
Remember that the relative risk can only be
calculated in prospective studies

Odds ratio can be calculated for any design
Cohort / prospective
Case-control
Cross-sectional

Inference
The relative risk and odds ratio provide the
magnitude of difference between some factor
and an outcome

How do we know if the magnitude is statistically
significant?

Confidence Intervals
A confidence interval is a range of values that is
likely (e.g., 95%) to contain the true value in the
underlying population


The 10 Steps of Outbreak Investigation
Prepare for field work
Establish the existence of an outbreak
Verify the diagnosis
Define & identify cases
Perform descriptive epidemiology
Develop hypotheses
Perform analytic epidemiology
Refine hypotheses & conduct additional studies
Implement control & prevention measures
Communicate findings
Objectives of Descriptive Epidemiology
To evaluate trends in health and disease and allow
comparisons among countries and subgroups within
countries

To provide a basis for planning, provision and
evaluation of services

To identify problems to be studied by analytic methods
and to test hypotheses related to those problems