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Basic Epidemiology

Dr Harry Tagbor
What is Epidemiology
The study of the distribution and
determinants of health-related states or
events (including disease) in human
populations, and the application of this
study to the control of diseases and other
health problems.
What is Epidemiology

Epidemiologists often ask "what is the


denominator?" - meaning, what is the
population from which the cases arose?

By counting the number of health-related


events which occur within a specified time
in different populations we can make
estimates of the frequency of these
events, which we can compare in different
populations.
What is Epidemiology?
For example, we can compare the infant
mortality rate in different countries and at
different times.
In England and Wales the infant mortality rate
was 6.6 per 1000 live births in 1992. The
corresponding figure for Brazil was 36.
What is Epidemiology
The fundamental things we need to know about
a disease in a population are who, where, and
when. In other words, we are interested in
describing the distribution of a disease in terms
of time, place and person.
What is Epidemiology?
Exercise
Highlight the time, place, and person in the
statements below.

"The prevalence of HIV infection among pregnant


women of all ages in Elubu, Ghana in 1995 was 3%.

"The incidence of lymphoblastic leukaemia among


children aged under 15 years in Tamale between
1951 and 1960 was 3.1 per 100 000 person-years."
Exposures & outcomes
The two key elements that we measure in
most epidemiological studies are the
exposure and the outcome.
The exposure is the risk factor that we are
investigating, which may or may not be the
cause.
The outcome is the disease, or event, or
health-related state, that we are interested in.
Exposures & outcomes
An exposure can be any factor that may
influence the outcome.

List some exposures that may be relevant


to whether or not an individual develops
lung cancer.
Exposures & outcomes
Possible exposures to lung cancer
Smoking habits
Exposure to asbestos
Doctor's advice on smoking
Cultural background
Region of residence
Socio-economic class
Government legislation on tobacco advertising
Price of cigarettes
Exposures & outcomes
The outcome can be any health-related event or
state - or it can be a risk factor for, or a precursor
to, a disease.
Example
In a study of the effect of cigarette smoking on lung
cancer, cigarette smoking is the exposure, or risk
factor, that we are interested in, and the outcome is
lung cancer.
However, in a study of the effect of cigarette
advertising on smoking, the exposure of interest is
cigarette advertising, and cigarette smoking is the
outcome.
Exposures & outcomes
Exercises

In a study of the influence of advice from a


midwife on whether a mother breast-feeds or
not, is breast-feeding the exposure or the
outcome?

In a study of the effect of breast-feeding on


diarrhoeal disease in childhood, is breast-
feeding the exposure or the outcome?
Exposures & outcomes
Note, the outcome need not be a disease. For
example:

growth

intelligence

multiple pregnancy

fertility
Role of epidemiology
The first of these functions is to describe
differences in the distribution of health and
disease within and between populations.
With descriptive epidemiology, we can
measure the burden of illness within a
population.
Role of epidemiology
For example, we may use descriptive
epidemiology to
examine how the birth-weight of babies has
changed in Ghana over the last 10 years,
or to describe differences in the prevalence of
hypertension between men and women,
or to compare the incidence of tuberculosis in
different regions of Ghana.
Role of epidemiology
The second function is to interpret the
differences we have described.
With analytical epidemiology, we can
investigate risk factors for a disease or an
outcome.
Here we ask the question "does the pattern of
exposure to certain risk factors among
individuals with or without a specific disease
help us to work out the cause of the disease?"
Role of epidemiology
For example, we might look at the effect of
different levels of dust exposure on the risk of
developing of industrial lung disease.
However, be careful in how you interpret your
findings:
In analytical epidemiology, we measure
associations between exposures and outcomes.
If we demonstrate an association, that does
NOT necessarily mean that the exposure
caused the outcome.
Role of epidemiology
For example
The rate of heart attack varies considerably by
geographical region, even within a single country.
The rate of heart attack is higher in Scotland than
in England. This does not necessarily mean that
living in Scotland causes heart attacks: it is more
likely that people living in Scotland are exposed to
other factors which are more direct causes of heart
disease.
Role of epidemiology
In some cases we can suggest appropriate
public health action even if we do not know the
precise biological cause of a disease.
Suggest reducing the risk of lung cancer by not
smoking cigarettes, even if we do not know exactly
what it is in cigarettes that causes cancer.

Suggest reducing the risk of getting diarrhoea from


contaminated water by boiling it, even if we do not
know exactly which pathogen in the water causes the
disease.
Role of epidemiology

The third major function of epidemiology is to


apply our results, and then to evaluate the
effectiveness of interventions and strategies of
health-care delivery.
With observational epidemiology, we can assess the
impact of health services on the health of a
community.
We could look at the differences in maternal mortality
rates in communities with and without access to
antenatal care.
With interventional epidemiology, we can assess the
effect of a specific health intervention.
Application
Different methods are used in carrying out
an epidemiological investigation:
surveillance and descriptive studies are used
to study distribution
analytic studies are used to study
determinants (causes, risk factors)
The Three Axes of Epidemiologic
Research Design

The design of a study can be considered from


three aspects related to the recording of
exposure and outcome, as follows:
the direction e.g. looking forward (prospective) from
exposure to outcome, or backwards (retrospective)
from outcome to exposure, or mixed (cross-sectional)
when exposure and outcome get measured together.
sample selection e.g. by exposure, by outcome, or by
other criteria.
Historical, concurrent or mixed, depending on the
calendar timing of measurement of exposure and
outcome, and the actual time of conducting the study.
Axes of Epidemiologic Research
Design
Direction
Direction refers to the order in which exposure and
outcome are investigated. Forward from exposure to
outcome; backward from outcome to exposure; or
simultaneously where exposure and outcome are
determined at the same time.

Sample selection
This refers to the criteria used to choose study
subjects; it can be based on exposure or outcome or
other criteria.
Axes of Epidemiologic Research
Design
Timing

Timing refers to the relation between the time


of the study and the calendar time of
exposure and outcome. Thus, historical
means that both exposure and outcome
occurred before the study; concurrent means
that exposure and outcome are occurring at
the same time as the study; or mixed timing.
Axes of Epidemiologic Research
Design
In most studies the researcher is attempting to
demonstrate that a process begins with an agent acting and
an outcome or event happens, as shown in the diagram
below:
Basic epidemiologic research designs

Descriptive study
A study in which the distribution of an
exposure and/or an outcome are examined
without any attempt by the investigator to
influence them.
Interventional Study
A study designed to test a hypothesis by
modifying an exposure within the study
population.
Basic epidemiologic research
Descriptive
designs
Observational Explanatory Experimental
Document Seek causes, Examine Evaluate efficacy
experience, predictors, aetiology, of therapeutic
observations, risk factors. efficacy or cause and other
unusual Researcher using strategy interventions.
events, observes of comparison
programmes, phenomenon
treatments without
intervention.

Begin search for


explanations.
Examples: Examples: Examples:
Case Reports or - Case-control - Clinical trials
Series studies - Educational
- Prevalence - Cohort studies interventions
Studies - Health care
- Surveys interventions.
Cross-Sectional Study
A study in which the prevalence of an exposure
and/or an outcome are measured in a given
population at a specified point in time. The data may
be analysed to look for an association between the
exposure and the outcome.
Example: the prevalence of onchocerciasis in a
particular community could be determined by a
descriptive cross-sectional survey. If data on
possible risk factors for onchocerciasis are collected
from the same people at the same time then they
could be used in an analytic study to look for
associations between the risk factors and the
disease.
Case control study
A study in which individuals with and without the outcome
of interest are identified. Their status with respect to
exposures of interest is then determined in order to look
for associations between these exposures and the
outcome of interest.

For example: we could use a case-control study to


determine risk factors for diarrhoeal disease among
children. We would identify children with and without
diarrhoea and obtain information concerning exposures
of interest (breast-feeding, water supply etc). We would
then analyse the data to see if breast-feeding or water
supply was associated with diarrhoea.
Cohort study
A study in which one or more groups of individuals
are followed up over a period of time to determine
the frequency of a particular outcome in the
group(s).

For example, in a cohort study of the effect of


smoking on fatal diseases was studied by
determining the smoking habits of a large group of
doctors, and then following them up to determine
the causes of death. The frequency of specific
causes of death (such as lung cancer and heart
disease) could then be compared between
smokers and non-smokers.
The Role of Epidemiology
Epidemiology has three major functions:
to describe patterns of health and disease
within populations
to interpret these differences
to apply our results to public health practice,
and to evaluate the effect of health-related
interventions