Descriptive Epidemiology

Dr. Arulita Ika Fibriana M.Kes

Epidemiology: Definition
Dynamic study of the
Determinants
Occurrence
Distribution
Control
Pattern

Of health and disease in a population

Epidemiology
Describes
health events
cause and risk factors of disease
clinical pattern of disease
Identify syndromes

Identify control and/or preventive

measures

Epidemiology is a Quantitative
Discipline
Measures of frequency
Counts and rates

Measures of association
Relative risk
Odds ratio

Statistical inference
p-value
Confidence limits

Two Broad Types of

Epidemiology
Descriptive Epidemiology
Examining the distribution of
disease in a population, and
observing the basic features of its
distribution

Analytic Epidemiology
Testing a hypothesis about the
cause of disease by studying how
exposures relate to the disease

Kinds of Epidemiology

Descriptive

Study of the occurrence and

distribution of disease

Analytic

Further studies to determine the

validity of a hypothesis concerning
the occurrence of disease.

Experimental

Deliberate manipulation of the

cause is predictably followed by
an alteration in the effect not due
to chance

Epidemiologic Activities
Descriptive epidemiology person,
place & time
Demographic distribution
Geographic distribution
Seasonal patterns etc.
Frequency of disease patterns

Useful for:
Allocating resources
Planning programs
Hypotheses development

Epidemiologic Activities
Analytic epidemiology
analysis of the relationship
between two items
Exposures
Effects (disease)

looking for determinants or

possible causes of disease
useful for
hypothesis testing

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
Analytic

Descriptive

Used when insight

about various aspects
of disease is available

Rely on
preexisting data

Rely on development
of new data

Who, where, when

Why

Evaluates the
causality of
associations

Used when little is

known about the
disease

Illustrates
potential
associations

Both are

Descriptive Studies
Relatively inexpensive and less timeconsuming 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)

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

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, timeperiods, or geographic regions for future
studies

Correlational Studies
LIMITATIONS
Because data are for groups, we cannot link disease
and exposure in individual
Example: Percentage of teenagers taking drivers education and
fatal teenage car accidents study done by National Safety
Council

We cannot control for potential confounders

Data represent average exposures rather than
individual exposures, so we cannot determine a doseresponse relationship
Caution must be taken to avoid drawing inappropriate
conclusions, or ecological fallacy

Breast Cancer Mortality and Dietary Fat

Intake

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{1/3rd of
all}
e.g. Frisbee finger , break dancing neck
AIDS, 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
DESCRIPTIVE

What (case
definition)
Who
(person)
Where
(place)
When
(time)
How many
(measures)

ANALYTIC

Why
(Causes)
How
(Causes)

MEASURES

Counts

Times

Rates

Risks/Odds

Prevalence

ALTERNATIVE
EXPLANATION
S

Chance

Bias

Confounding

METHODS

Design

Conduct

Analysis

Interpretation

INFERENCES

Epidemiologic

Causal

ACTION

Behavioural

Clinical

Community

Environmental

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, 19552000

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.
900
800
700
600
500
400
300
200
100
0

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

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

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

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.

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

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 subgroups 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
Decreased by:

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)

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

Absent

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 nonexposed

Calculation of Relative Risk

Outcome

Exposure

Present

Absent

TOTAL

Present

a+b

Absent

c+d

TOTAL

a+c

b+d

a+b+c+d

Relative Risk =

a b
c

c d

Relative Risk Case Study

Smoking and low birth weight

Smoking
status

Birth Weight
<2500 g >2500 g

TOTAL

Smoker

120

240

360

Non-smoker

60

580

640

TOTAL

180

820

1000

Answers to Relative Risk Case

Study
1. Incidence of LBW
among smokers

120

x 1 , 0 0 0 3 3 3 .3
360

2. Incidence of LBW
among non-smokers

60

x 1 , 0 0 0 9 3 .8
640

3. Relative risk for

having a LBW baby
among smokers versus
non-smokers

3 3 3 .3

3 .6
9 3 .8

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

Absent

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