Analytic Epidemiology

EPIDEMIOLOGY AND RISK ANALYSIS

ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Define analytic epidemiology

• List three types of observational study
designs
 OVERVIEW

• Review of descriptive vs. analytic

epidemiology
• Components of analytic epidemiology
• Types of analytic study designs
TYPES OF STUDIES

Lancet 2002; 359: 57–61

 DESCRIPTIVE VS. ANALYTIC
EPIDEMIOLOGY

Descriptive Analytic
epidemiology epidemiology
Questions • Who/Which • Why
• What • How
• When
• Where
Comparison
No Yes
Group?
 ANALYTIC EPIDEMIOLOGY

• Used to help identify the cause or

causes of disease
• Typically involves designing a study to
test one or more hypotheses
Source: Borgman, J (1997). The Cincinnati Enquirer. King Features Syndicate.
COMPONENTS OF ANALYTIC
EPIDEMIOLOGY
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 EXPOSURE AND OUTCOME

• Exposure:
• Any factor that might influence the risk of
disease
• Outcome:
• Disease or condition, standardized using
case definitions
 CASE DEFINITION

Standard diagnostic criteria that must be

fulfilled to identify an individual as a case of a
particular disease
• Clinical (laboratory results, symptoms, signs)
• Restrictions on individual, place, and time

Ensures that all individuals who are counted

as cases actually (likely) have the same
disease
 DEVELOPING HYPOTHESES

• An hypothesis is an educated guess about

an association that is testable in a scientific
investigation
• Descriptive data provide information to
develop hypotheses about disease
causation
• Hypotheses tend to be broad initially and
are then refined as more data are gathered
 HYPOTHESIS EXAMPLES:
BROAD, EARLY IN INVESTIGATION

Hypothesis: People who ate

at the food cart were more
likely to become ill
• Exposure: eating at the
food cart
• Outcome: illness – this would
need to be defined: e.g., any http://mmm-yoso.typepad.com
person with the acute onset
of diarrhea and fever (on a
specific date or days)
 HYPOTHESIS EXAMPLES:
SPECIFIC, ETIOLOGY DETERMINED
• Hypothesis: People who ate
the bahn mi from the food
cart were more likely to have
laboratory-confirmed
Salmonella
• Exposure is eating bahn mi
from the food cart
www.foodiemommy.com
• Outcome is laboratory
confirmation of Salmonella
TYPES OF ANALYTIC STUDIES
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 ANALYTICAL STUDIES

Three main study designs:

1. Cross-sectional study
2. Cohort study
3. Case-control study
 CROSS-SECTIONAL STUDIES

• Exposure and outcome status are determined

at the same time
• “Snapshot” of population being studied

• Also includes most opinion and political polls

 CROSS-SECTIONAL STUDIES

Can be descriptive and analytical design

Investigate the association between a putative risk factor and a

health outcome

Risk factors and outcome are measured simultaneously

Difficult to determine whether the exposure proceeded or followed

the disease

Limited ability to draw conclusions about association between a risk

factor and health outcome
 COHORT STUDY DESCRIPTION

Study population is grouped by exposure status

Groups are then followed over time to determine if they

develop the outcome of interest

Exposure Outcome
Prospective Assessed at Followed into the
beginning of study future for outcome
Retrospective Assessed at some Outcome has
point in the past already occurred
COHORT STUDY DESIGN

Study
Population

Exposure is
self selected

Exposed Non-exposed
 COHORT STUDY DESIGN

Study
Population
Exposure is
self selected
Exposed Non-exposed

Follow through
time

Disease No Disease Disease No Disease

CASE-CONTROL STUDY DESCRIPTION

Study population is grouped by outcome

Cases are individuals who have the outcome of interest

Controls are individuals who do not have the outcome of interest

Past exposure status is then determined

CASE-CONTROL STUDY DESIGN

Study
Population

Select based
on disease
status
Cases Controls
CASE-CONTROL STUDY DESIGN

Study
Population
Select based
on disease
status Controls
Cases

Look back in
time

Exposed Not Exposed Exposed Not Exposed

 COHORT VS. CASE-CONTROL
Cohort Study Case-Control Study
Preferred • Population members are • Identifying and/or
study design easily identifiable and accessing entire
when… accessible cohort would be too
costly or time
• Exposure is rare
consuming
• There may be multiple
• Illness is rare
diseases involved

Study group Exposed individuals Individuals with illness

(cases)
Comparison Non-exposed individuals Individuals without the
group illness (controls)
 SUMMARY

Analytic epidemiology addresses “why” and “how” a

health problem occurs

In experimental studies investigators assign exposures

to participants

In observational studies investigators observe exposures

and outcomes already occurring in the population

Commonly designs are cohort studies and case-control

studies
SUMMARY OF STUDY DESIGNS
Statistical Measures in
Epidemiology
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Define the most common statistical

frequency measures used in infectious
disease epidemiology
• Construct a frequency distribution
 LEARNING OBJECTIVES

• Calculate and interpret the following statistical measures

• Ratios
• Proportions
• Incidence rates: attack rates & secondary attack rates
• Prevalence
• Mortality rates
• Relative risk and odds ratio
• Choose and apply the appropriate statistical measures
 USING STATISTICAL MEASURES

• Statistics summarize the data collected through

disease surveillance or an outbreak
investigation, so we can learn from these data
Calculating statistics helps us to:
• describe risk
• make comparisons
• identify high-risk groups
• develop hypotheses about the cause(s) of disease
 WHY DO WE NEED TO DESCRIBE
AND COMPARE RISK?
• Differences in risk among different populations
can provide clues for investigation of what
caused one group to have a higher risk
• If specific factors (including behaviors) with
higher risk can be identified, then perhaps
effective prevention and control measures can
be identified
 FREQUENCY MEASURES

• The most common statistical measures used in

field epidemiology are “frequency measures,”
which are simply ways of counting cases and
comparing their characteristics.
• In contrast with statistics used in
epidemiological research, frequency
measures are relatively easy to calculate and
use.
 FREQUENCY DISTRIBUTION

• When we collect data about disease cases, we must put

them in some kind of order. The most basic way to do
this is to organize a “line listing”

• A line listing is actually a simple data base, in which

each row represents a case of the disease we are
investigating. Each column contains information about
one characteristic, called a “variable.”
 FREQUENCY MEASURES

Three kinds of frequency measures are

used with two-category (dichotomous)
variables
• Ratios
• Proportions
• Rates
 RATIOS, PROPORTIONS, RATES

• All three measures are based on the same formula:

Ratio, proportion, rate = x/y x 10 ⁿ

• In this formula, x and y are the two quantities that are

being compared.
• The formula shows that x is divided by y.
• 10 ⁿ is a constant that we use to transform the result of
the division into a uniform quantity.
 RATIOS, PROPORTIONS, RATES

• 10 ⁿ is a constant that we use to transform the result of

the division into a uniform quantity.
• The size of 10 ⁿ may equal 1, 10, 100, 1000 and so on
depending on the value of n.
• Examples:
102 = 10 x 10 = 100

103 = 10 x 10 x 10 = 1000

105 = 10 x 10 x 10 x 10 x 10 = 100,000
 FREQUENCY MEASURES OF
DISEASE
• Several standard measures are used to
measure and describe the frequency of
disease (morbidity)
• Each measure has its appropriate uses,
depending on the situation and the
information available to the epidemiologist.
• The two main types of rates are:
• incidence
• prevalence
 INCIDENCE RATES

• The most common way of measuring and

comparing the frequency of disease in
populations
• Incidence is a measure of risk
• When…
Incidence Population A > Incidence Population B
We can say that
Risk Population A > Risk Population B
 INCIDENCE
• The number of new cases of a disease that occur
during a specified period of time divided by the
number of individuals at risk of developing the
disease during that period of time

# of new cases of disease

over a specific period of time
Incidence =
# of persons at risk of disease
over the specified period of time
 INCIDENCE EXAMPLE

A study is examining factors related to schistosomiasis

in community-dwelling children. During the study
period, 77,719 children aged 5-10 years were
followed, and 612 developed schistosomiasis.
612
Incidence =
77,719
 INCIDENCE EXAMPLE

612
Incidence = = 0.0079
77,719

• The one year incidence of schistosomiasis among

children aged 5-10 years is 0.79%
• Can also be expressed as 79 cases per 10,000
persons (children) aged 5-10 years
 INCIDENCE

• High incidence represents

diseases with high occurrence;
low incidence represents
diseases with low occurrence
• Can be used to help determine
the causes of disease
• Can be used to determine the
likelihood or risk of developing
disease
 RATE RATIOS

• A rate ratio is another tool that is useful for

comparing rates between groups
• A rate ratio compares the rates of disease in
groups that differ by demographic characteristics
or exposure history
• The rate for the group of primary interest is
divided by the rate for a comparison group.
• Rate ratios may be calculated for incidence rates
or for mortality rates, discussed later
 PREVALENCE RATES

• The proportion of individuals in a population

with a particular disease at a specified point
in time, or over a specified period of time
• The numerator includes not only new cases,
but also old cases (individuals who remained
ill during the specified point or period in time).

• A case is counted in prevalence until death or

recovery occurs.
 PREVALENCE RATES

• Prevalence differs from incidence, as

incidence includes only new cases in the
numerator.
• Prevalence is most useful for measuring the
burden of chronic diseases such as
tuberculosis, malaria, HIV, brucellosis, etc.,
in a population.
 PREVALENCE

The number of affected individuals (e.g. ill persons or

“cases”) present in the population divided by the total
number of individuals in the population

Prevalence

= # all new & pre-existing cases in a time period x 10n

# of individuals in the population in the same period

 PREVALENCE EXAMPLE

• In 2010, a US state reported an estimated

253,040 residents over 20 years of age with
diabetes. The US Census Bureau estimated that
the 2010 population over 20 years of age in that
state was 5,008,863.

Prevalence = 253,040
5,008,863
 PREVALENCE EXAMPLE

• In 2010, a US state reported an estimated

253,040 residents over 20 years of age with
diabetes. The US Census Bureau estimated that
the 2010 population over 20 in that state was
5,008,863.
Prevalence = 253,040 = 0.051
5,008,863
• In 2010, the prevalence of diabetes was 5.1%
• Can also be expressed as 51 cases per 1,000
residents over 20 years of age
PREVALENCE

• Useful for assessing the burden

of disease within a population
• Valuable for planning
• Not useful for determining
what causes disease
 PREVALENCE AND INCIDENCE
Prevalence is a function of the incidence of disease
and the duration of the disease
 PREVALENCE AND INCIDENCE

= prevalent cases

Prevalence
 PREVALENCE AND INCIDENCE

= prevalent cases

New
prevalence
Incidence
Old (baseline)
prevalence

= incident cases
No cases die
or recover
 PREVALENCE AND INCIDENCE

= prevalent cases

= incident cases
= deaths or
recoveries
 PRACTICE SCENARIO

A town has a population of

3600. In 2013, 400 residents of
the town are diagnosed with a
disease. In 2014, 200
additional residents of the town
are diagnosed with the same
disease. The disease is lifelong
but it is not fatal.
• What is the prevalence in
2013? In 2014?
• What is the incidence in 2014? www.adventurealive.com
PRACTICE SCENARIO ANSWERS
• Population: 3600
• 2013: 400 diagnosed with a disease
• 2014: 200 additional diagnosed with the disease
• No death, no recovery

Prevalence Prevalence Incidence

(2013) (2014) (2014)
Numerator 400 600 ?
Denominator 3600 3600 ?
11.1% 16.7% ?
 PRACTICE SCENARIO ANSWERS

• Population: 3600
• 2013: 400 diagnosed with a disease
• 2014: 200 additional diagnosed with the disease
• No death, no recovery

Prevalence Prevalence Incidence

(2013) (2014) (2014)
Numerator 400 600 200
Denominator 3600 3600 3200
11.1% 16.7% 6.3%
 MORTALITY RATES

• Mortality rates measure the frequency of

occurrence of death in a defined population
during a specified interval.

• To calculate a simple mortality rate, we need

to know the number of deaths in a given
population during a specified time period, and
the size of the population in which the deaths
occurred.
 MORTALITY RATES

Mortality rate =

deaths occurring during a given time period x 10n

size of population in which the deaths occurred

 CRUDE MORTALITY RATES

• The crude mortality rate is the mortality rate

from all causes of death for a population
during a specified time period.
• The denominator is the population at the mid-
point of the time period.
• For example, the crude mortality rate for
Malaysia for 2011was 500 deaths per 100,000
population data.worldbank.org/indicator/SP.DYN.CDRT.IN
 CAUSE-SPECIFIC MORTALITY RATES

• This is the mortality rate from a specified cause

for a population during a specified time period.
• The numerator is the number of deaths from that
cause, and the denominator remains the size of
the population at the mid-point of the time
period.
• For example, the HIV/AIDS death rate for the US
in 2007 was 7 per 100,000 people.
 RELATIVE RISK OR RISK RATIO (RR)

• Compares the risk of disease or death in two groups.

• The two groups may be defined by a demographic factor (for
example, domestic vs. wild, male vs. female).
• More commonly, they are defined by a difference in their
exposure to a suspected risk factor for disease (for example, ate
potato salad or didn’t).
• Often, the group of primary interest is labeled “exposed,” and the
comparison group is called “unexposed.”
• The group of primary interest goes into the numerator, and the
comparison group is the denominator.
 RELATIVE RISK OR RISK RATIO (RR)

• The number of affected individuals present in the

population divided by the total number of individuals in
the population:
Risk for group of primary interest x1
RR =
Risk for comparison group

• “Risk” is defined as an incidence rate or attack rate of

the disease in each group
• To calculate RR, a two-by-two table is set up
as shown on the next screen:
RELATIVE RISK OR RISK RATIO (RR)
RELATIVE RISK OR RISK RATIO (RR)
 ODDS RATIO (OR)

• The odds ratio is used in case/control studies

• In a case/control study, ill individuals’ characteristics
and exposures are compared with those of well individual
(“controls”) selected from the same
population in which the outbreak occurred.
• Example: In an outbreak due to possible contaminated
food at a restaurant, the types of food consumed by ill
persons (“Cases”) is compared to those foods consumed by
non-ill persons (“Controls”) at the restaurant the same day.
This could be done even if we did not know exactly how
many people ate at the restaurant that day.
ODDS RATIO (OR)
 ODDS RATIO (OR)

• The OR in this example is:

Odds Ratio = (46 x 40) / (25 x 18) = 1840 / 450 = 4.1

• So those who became ill were 4.1 times as likely to have

eaten the tuna casserole.
We should probably look a little more
closely at that tuna casserole!
• We would still need to subject this result to a test of statistical
significance (just like we do with the RR) to judge the
probability that the result could have occurred by chance
alone
 SUMMARY

Commonly used measures in descriptive

epidemiology are prevalence and incidence

Other common measures include ratios of

incidence and prevalence in different
populations of interest – risk ratio, odds ratio
PECOT: A METHOD FOR
CRITICAL APPRAISAL
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
CAN WE TEACH CRITICAL APPRAISAL
in 30 minutes!
‘THE GATE APPROACH’

Adapted from Rod Jackson, Center for Evidence

Based Medicine, University of Oxford,UK and University
of Auckland, NZ
http://www.cebm.net/index.aspx?o=1083
 GATE: A GRAPHIC APPRAISAL
TOOL FOR EPIDEMIOLOGY

1. Picture
2. Formulas
3. Acronyms
 A PICTURE: THE GATE FRAME

the shape of every epidemiological study

A PICTURE: THE GATE FRAME

the shape of every epidemiological study

THE PECOT ACRONYM: THE 5 PARTS OF
EVERY EPIDEMIOLOGICAL STUDY

Participants P

Exposure Group E C Comparison Group

O Outcomes
Time
T
All epidemiological studies can be hung on the GATE
 2 FORMULAS: STUDY ANALYSES

1. Occurrence of disease
= Numerator ÷ Denominator ÷ Time

2. Random error (95% Confidence Interval)

= 1.96 x Standard Error
D

N
 GATE FRAME PICTURE & PECOT
ACRONYM

Participants P

Exposure Group E C Comparison Group

O Outcomes
Time
T
Describe a study’s design by hanging PECOT on the frame
 PARTICIPANTS

Study Setting

Eligible Participants

P
Participants
 FILL IN FOR

Deep-vein thrombosis (DVT) in long-haul flights.

Lancet 2001; 357:1485-9
DVT in long-haul flights: Lancet 2001;357:1485-9
PARTICIPANTS
Study Setting: Volunteers, UK, ?1990s

Eligible Participants: no previous DVT, > 50 yrs,

planned economy air travel, 2 segments > 8
hours

Participants: 200, mean age 61-62 years

 EXPOSURE & COMPARISON GROUPS

Exposure or Comparison or
Intervention Group EG CG Control Group
(EG) (CG)
 FILL IN FOR
Deep-vein thrombosis (DVT) in long-haul flights.
Lancet 2001; 357:1485-9
 EXPOSURE & COMPARISON GROUPS

115 116
Exposure or Comparison or
Intervention Group Control Group
(EG): 100 100 (CG):
Below knee no stockings
compression
stockings
 OUTCOMES (O)

yes a b
Disease O Outcomes (O)
no c d
OUTCOMES (O)

100 100

a= b=
yes 0 12
DVT O Outcomes (O)
no c d
incidence TIME (T)

prevalence

T
 FILL IN FOR
Deep-vein thrombosis (DVT) in long-haul flights.
Lancet 2001; 357:1485-9
 TIME (T)

Outcome:
number with
DVTs
0 12
prevalence
T = post-flight
(<48 hrs)
STUDY DESIGN: GATE FRAME & PECOT

Participants P

Exposure Group E C Comparison Group

O Outcomes
Time
T
Every epidemiological study hangs on the GATE frame
 DVT in long-haul flights: Lancet 2001;357:1485-9

Setting: UK volunteers – 479 considered

Eligible: > 50 yrs, no DVT, flying > 8 hrs
Participants 231

115 116
Exposure Group: 100 100 Comparison Group:
stockings no stockings

0 12 Outcomes:
Time:
at post flight assess DVT
2 FORMULAS: STUDY ANALYSES

1. Occurrence of disease
= Numerator ÷ Denominator ÷ Time

2. Random error (95% Confidence Interval)

= 1.96 x Standard Error
D

N
 All epidemiological studies involve
measuring the OCCURRENCE of disease
Occurrence = Numerator ÷ Denominator

N Numerator (Outcomes)

O = N÷D
D Denominator (Participants)
 GATE STUDY ANALYSES
Participants = P Overall Denominator

Denominator 1: Denominator
Exposure EG CG 2:
Comparison
Group (EG) Group (CG)

Numerator a b Numerator 2:
1: a O b
c d

Describe a study’s analyses by hanging the numbers

on the frame
 OCCURRENCE = N ÷ D

Denominator 1: Denominator 2:
Exposure Group EG CG Comparison Group
EG CG

Numerator 1: a b Numerator 2:
a O b
c d

Exposure Group Occurrence: Comparison Group Occurrence:

EGO = a ÷ EG CGO = b ÷ CG
CALCULATE EGO & CGO FOR THE OUTCOME
‘DVT’ POST LONG-HAUL FLIGHT

Denominator 1: Denominator 2:
Exposure Group EG CG Comparison Group
EG = 100 CG = 100

Numerator 1: a b Numerator 2:
a = 3* O b = 12
c d

EGO = 3/100 people at CGO = 12/100= people

post flight assessment at post flight assessment
* a = 0 but have used 3 to illustrate calculations on next
DESCRIBING DIFFERENCES BETWEEN
OCCURRENCES

Relative difference or Relative Risk =

EGO ÷ CGO

Absolute Difference or Risk Difference =

EGO - CGO

Number Needed To Treat (NNT) =

1 ÷ RD
 FILL IN FOR

Deep-vein thrombosis (DVT) in long-haul flights.

Lancet 2001; 357:1485-9
 DESCRIBING DIFFERENCES BETWEEN
OCCURRENCES
Relative difference or Relative Risk = EGO ÷ CGO

= 3/100 ÷ 12/100 = 3/12 = 0.25

Absolute Difference or Risk Difference = EGO -
CGO
= 3/100 - 12/100 = - 9/12 = - 7.5 /100

Number Needed To Treat (NNT) = 1 ÷ RD

= 1 ÷ (- 7.5 /100) = - 100/7.5 = 13.3
 ANALYSES

it’s all about

EGO & CGO
 ASSIGNMENT

PECOT approach to this article

Introduction to Surveillance
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Explain the surveillance “feedback loop” of data

and information flow through local, state, and
federal channels

• Describe characteristics of three different methods

of surveillance: active, passive, and syndromic

• List 5 applications of public health surveillance

 OVERVIEW

• How surveillance works

• Passive, active, and syndromic
surveillance
• Applications of surveillance data
• Surveillance limitations and
challenges
 SURVEILLANCE

“…the continuous, systematic collection,

analysis and interpretation of health-
related data needed for the planning,
implementation, and evaluation of public
health practice. ”

World Health Organization

SMART SURVEILLANCE

Strategic
Measurable
Adaptable
Responsive
Targeted
 SURVEILLANCE INFORMATION, USE,
DISSEMINATION, AND REPORTING
• Physicians, Standardized data collection Local & district/provincial
veterinarians, health departments &
nurses national health agency
• Laboratories Dissemination to those analyze data
• Community who need to know
health clinics

Public health Dissemination

evaluation to those who
need to know
Change in health Public health planning
• Public health officials
practice (vaccination, and intervention
• Health directors
reduction of risk • Health policy officials
factors, medical • The public
intervention, etc.)
 INTERNATIONAL SURVEILLANCE
AND REPORTING SYSTEMS
WHO reportable pandemic and epidemic diseases
(linked to International Health Regulations, IHR)
• Viral hemorrhagic fevers, influenza (avian, seasonal,
pandemic), cholera, Nipah/Hendra, leptospirosis,
meningitis, plague, Rift Valley fever, SARS and coronavirus,
smallpox and human monkeypox, tularemia, viral hepatitis,
yellow fever
• WHO Global Influenza Surveillance and Response System
http://www.who.int/influenza/gisrs_laboratory/en/
• Global Outbreak Alert and Response Network (GOARN)
http://www.who.int/csr/outbreaknetwork/en/
 INTERNATIONAL SURVEILLANCE
AND REPORTING SYSTEMS
• OIE/FAO listed animal diseases
• Includes 85+ diseases of terrestrial vertebrates, 6 of bees, and
28 diseases of aquatic animals (fish, mollusks, crustaceans, and
amphibians)
• www.oie.int/animal-health-in-the-world/oie-listed-diseases-
2014/
• World Animal Health Information System (WAHIS)
• EMPRES Animal Health – Global Animal Disease Information
System http://empres-i.fao.org/eipws3g/
SOURCES OF SURVEILLANCE DATA

Mortality reporting
• Legally required as part of vital statistics programs
in most countries

Morbidity reporting
• Notifiable disease reporting (legally required) or
specially created systems
SOURCES OF SURVEILLANCE DATA

• Surveys
• Epidemic reporting/cluster
investigation
• Laboratory investigations and reporting
• Individual investigations
 MANAGEMENT OF
SURVEILLANCE DATA

Reliability and validity of data

• Timeliness
• Completeness
• Accuracy

Analysis of surveillance data

• Trends
• Clusters
• Patterns
SURVEILLANCE DATA GRAPHS
 SURVEILLANCE
METHODS
PASSIVE, ACTIVE, AND SYNDROMIC
 PASSIVE SURVEILLANCE

Laboratories, veterinarians, physicians, nurses,

community animal and human health workers or other
health care providers regularly report cases of disease
to the local, provincial, or national health departments
based on a standard case definition of that particular
disease.
Higher level authorities
collate and analyze data,
and provide feedback to
provincial and local health
professionals.
 EXCERPT: 2011 RECOMMENDED
REPORTABLE DISEASES
• Anthrax • Botulism
• Arboviral neuroinvasive and • Botulism, foodborne
non-neuroinvasive diseases • Botulism, infant
• For example, Eastern • Botulism, other (wound
equine encephalitis virus & unspecified)
disease, St. Louis • Chancroid
encephalitis virus disease,
West Nile virus disease • Chlamydia
trachomatis infection
• Babesiosis
• Cholera
• Brucellosis
Specific reportable diseases and conditions are mandated by state
law, and can differ for every state.
 ACTIVE SURVEILLANCE

Local or state health departments

initiate the collection of information
about specific cases of disease from
laboratories, veterinarians, physicians,
nurses, community animal and
human health workers or other health
care providers
ACTIVE SURVEILLANCE
APPLICATIONS

• Outbreak investigations
• Other times when complete
case ascertainment is desired
• Research study
• Incomplete information reported
• During planned priority activities
linked to eradication (e.g., polio
eradication), or elimination
(e.g., malaria) activities
ADVANTAGES AND LIMITATIONS

Passive Surveillance Active Surveillance

• Advantages: • Advantages:
• Inexpensive • Complete data
• Low data collection • Flexible
burden for health
department

• Limitations: • Limitations:
• Under-reporting • Costly, labor-
• Missing information intensive
• Can be slow
 SYNDROMIC SURVEILLANCE

The ongoing, systematic collection, analysis,

interpretation, and application of real-time
indicators for disease that allow for detection
before human and veterinary public health
authorities would otherwise identify them.
WHAT ARE “INDICATORS OF DISEASE?”

• Clinical signs that we can categorize into

syndromes
• Not a specific diagnosis

Example:
Cough + Sore throat + Fatigue + Fever =
“Influenza-like illness”
SYNDROMIC SURVEILLANCE
Daily temperatures and GP visits for heat
syndrome, Bordeaux, 1 June – 31 Aug, 2006

www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18905
 COMMON SYNDROMES
UNDER SURVEILLANCE

Influenza-like Meningitis /
Gastroenteritis
illness (ILI) Encephalitis

Rash / Fevers
Botulism Hemorrhagic
of unknown
syndrome syndromes
origin (FUO)
WHY DO SYNDROMIC SURVEILLANCE?

• Early detection
• Ideally automated

• Outbreak characterization
• Magnitude, rate of spread,
effectiveness of control
measures

• Detection of unexplained
deaths
LIMITATIONS OF SYNDROMIC
SURVEILLANCE

Limited by available
data
• False alarms
• Inconsistent
reporting sources
• IT failure
 LIMITATIONS OF SYNDROMIC
SURVEILLANCE (2)

Inadequate sensitivity: failure to detect

outbreaks or emergencies
• Outbreak is too small
• Population disperses
after exposure,
cluster not evident
 LIMITATIONS OF SYNDROMIC
SURVEILLANCE

Costly
• Infrastructure and staff
• Complicated data use
agreements
• Not specific for
an individual
infectious agent
 SURVEILLANCE APPLICATIONS

Establish public Aid in determining Assess public health

health priorities resource allocation programs
•Facilitate research

Detect epidemics
•Estimate magnitude of
Determine baseline the problem
level of disease •Determine geographical
distribution
ESTABLISH PUBLIC HEALTH
PRIORITIES

Frequency Severity
• Incidence, • Case fatality rate,
prevalence, mortality, hospitalization,
years of life lost disability

Costs
• Direct, indirect
SURVEILLANCE DATA MAPS
ASSESS PUBLIC HEALTH PROGRAMS
Laboratory Confirmed Cases of Meningococcal
Meningitis C, England and Wales, 1998 - 2010
1200
Number of Laboratory
Confirmed Cases

1000

800

600

400

200

Year
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1234859709051?p=1201094595391
 DETERMINE BASELINE RATES
TB Case Rates in U.S.-born vs. Foreign-born Persons United
States, 1993–2009*
40
Cases per 100,000

30

20

*Updated as of July 1, 2010.

10

0
1993 1995 1997 1999 2001 2003 2005 2007 2009
U.S.-born Foreign-born U.S. Overall
EARLY DETECTION OF EPIDEMICS
Boston, MA
200

Number of flu patients by month

150
100
N50
0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
SURVEILLANCE LIMITATIONS
AND CHALLENGES
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 SURVEILLANCE LIMITATIONS

• Uneven application of information

technology
• Paper-based versus electronic

• Timeliness
• Reporting time requirement
• Reporting burden
 SURVEILLANCE LIMITATIONS

Completeness
• Unreported cases
• Incomplete reports
• Consistency of
reporting
 LIMITATIONS: MULTIPLE SYSTEMS

Program Specific Reports and MMWR Annual

MMWR Weekly Tables
Summaries Summaries

Statistical Surveys
for Chronic
National Diseases, Injuries
HARS STD* TIMS NNDSS EIP PHLIS
and Other Public
Health Problems
MIS Systems

Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc.

State Reporting by
Paper Form,
Data
HARS EIP Telephone & Sources
STD*MIS TIMS NETSS PHLIS
Systems Fax
Physicians
Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc.

Chart Review

Local HARS STD*MI TIMS NETSS EIP PHLIS

Lab Reports

S Systems
*
* EIP Systems (ABC, UD,
Foodnet)
STD*MIS TIMS
(Optional (Optional
at the at the
Clinic) Clinic)
 SURVEILLANCE CHALLENGES

• Assessing quality of the data

• Using case definitions
• Translating data into information and
action
 QUALITY OF THE DATA

• Completeness of case ‘Tip of the iceberg’

ascertainment Reported
• Assessment of Diagnosis is
completeness, made
accuracy, and
Individual cases are
timeliness of reports seen by human/animal
healthcare provider

Sick human or animal

 SURVEILLANCE CHALLENGES BY
DEFINITION

• Clinical vs. surveillance case definitions

• Cases ‘worked’ vs. cases ‘counted’
• Place of exposure, residence, or diagnosis
• Re-infection or duplicate report
• Frequencies by date of onset, date of
diagnosis, or date of report
 TRANSLATING DATA INTO
INFORMATION
• Provides the basis for
public health action
• Requires sound analysis
and interpretation
• Extracts meaningful,
actionable findings
• Requires clear
presentation of
complex issues
 SUMMARY

Public health surveillance is the ongoing collection,

analysis, interpretation of health data and dissemination
of information

Surveillance data are used for planning,

implementation, and evaluation of veterinary and
human public health practice

Surveillance data collection can be passive, active, or

syndromic - each type presents unique advantages
and limitations
Disease Risk Analysis: The Basics
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Understand the purpose and basic

terminology of risk analysis
• Describe the components of the risk analysis
process
• Give some applications of risk analysis for
zoonotic infectious diseases
• Explain some of the commonly recognized
and used risk analysis frameworks
WHAT IS DISEASE RISK ANALYSIS?

• A logical process to support decision-making under

uncertain conditions, when information is
incomplete
• Adds science to policy, to help minimize risk and its
impacts
• Communicate risk to stakeholders

Risk = Likelihood X Magnitude

of something happening of the negative consequence
WHAT IS DISEASE RISK ANALYSIS?

• Disease Risk Analysis addresses the

differences between:
• Perception vs. Reality
– Does the perceived or identified risk really
matter?
– If yes, how much does it matter?
– Zero risk is not realistic

• Fate vs. Probability

 Brief History of Fate vs Probability

“Before risk, there was fate.”*

Concept of risk developed in the 16th
and 17th centuries, studied and
advanced by gamblers – who took economic
risks in pursuit of winning
•“risk” from Italian risicare, “to dare”
• ca. 1526: Girolamo Cardano, physician,
astrologer, gambler, wrote Liber de Ludo
Aleae (Book on Games of Chance). Included
the first systematic treatment of probability, as
well as a section on effective cheating
methods!
• 1654: Pascal & de Fermat discover probability
theory
*Bernstein PL (1996) Against the Gods: The Remarkable Story of Risk, Wiley: New York.
WHAT IS DISEASE RISK ANALYSIS?

• Organized approach to a problem

• Recognize that it is a simplification of real world
• Transparent, including about uncertainty
• Should increase communication (though it does not
always succeed at this)
• Multidisciplinary stakeholders
• Helps identify data gaps and research needs
• Cyclical / Iterative process
RISK ANALYSIS COMPONENTS

Risk assessment

Risk Risk
communication management
Assessment Management Communication

© S Harris
 CONCEPTS

• Hazard or Threat: An agent, substance or action that

has the potential to cause an undesired event

• Risk: The probability of an undesired event and its

consequences
What is happening here?
What are cause – effect relationships?
 Exposure
Hazard

Hazard
Collision?

Level of effect?

Risk
 RISK ANALYSIS PROCESS –
NOT SCARY!
• Formulate a question
• Identify the hazards / threats related to your question
• Establish criteria for ranking /prioritizing these
• Draw a picture to visualize the “system” of interest
• Identify critical control points
• Develop a model – mathematical…or not
• Identify and evaluate data sources
• Input data (collected from monitoring or surveillance efforts,
published studies, expert opinions, etc.)
• Run model
• Assess results and effects of data quality
• Sensitivity analysis and uncertainty
• Collect more data
• Rerun model
 APPROACHES

Formalized / Codified
• Specific standardized processes that are supported by
policy
o OIE/IUCN (animal movement)
o Hazard analysis and critical control points (HACCP, food safety)
o Codex alimentarius (WHO/FAO international food safety)
o Invasive species (UN Convention on Biological Diversity)
Inherent
• Assessing risk without labeling it as such
o Engineering
o Business, insurance
o Ecology, epidemiology
OIE RISK ANALYSIS FRAMEWORK(1)
OIE RISK ANALYSIS FRAMEWORK (2)
Decision-Making Framework for Identifying, Processing and Managing Health Risks
(source: Health Canada)
Collect Assumptions to Input in Model:
-Published literature
-Expert consensus
Identify the Issue
and Its Context

Monitor and
Evaluate Results Assess Risks Run Model Calculations
and Timelines

INVOLVE INTERESTED
AND
AFFECTED PARTIES

Implement Identify and

the Strategy Analyze Options
Consideration of other
Parameters outside of
Select a
Strategy
Model, by decision-makers
 Risk Analysis Framework A brief description of the situation
Product or commodity involved
The values expected to be
1. Assessment of effectiveness of Risk Management placed at risk
measures taken (e.g. human health, economic
2. Review risk management concerns)
and/or Potential consequences
assessment as necessary A. Risk Evaluation Consumer perception of the risks
The distribution of risks and
benefits

D. Monitoring and review

1. Identification of problem/potential problem
2. Establishment of a risk profile Value judgements
Risk 3. Ranking of the hazard for risk assessment and policy choices
for the risk
Communication 4.
and risk management priority
Establishment of the risk assessment policy assessment process
for
C. Implementation of conduct of risk assessment
5. Commitment of resources
management /policy 6. Commissioning of risk assessment
decision 7. Consideration of risk assessment result Hazard identification
Hazard characterisation
Exposure assessment
Risk characterisation

Risk perception
Value judgement
B. Risk management and Precautionary
option assessment principle
Benefits/ costs Risk Assessment
Other technical
factors
1. Identification of available management/policy
options
2. Selection of preferred management /policy
option,
Regulatory or other control
3. Final management /policy decision
measures
Courtesy D. Travis, UMN
 Initiating event - Policy
P
O Science based decision
L
I
Risk Analysis
C
Y Outputs
Model and
Decision
Model inputs (data)
D
A
Surveillance/monitoring
T
A
Public health, conservation
projects, agricultural projects
Courtesy D. Travis, UMN
SURVEILLANCE AND DISEASE RISK
ANALYSIS
Disease • Scientific collection of standardized data over
monitoring time
• Monitoring evaluates trends over time
and • Surveillance watches for new diseases in order
to respond
surveillance

• Science-based decision making

Risk • What is the risk of leptospirosis, drug-resistant

tuberculosis, Plasmodium knowlesi
Analysis emergence?
• Use best data available to make decisions,
reduce risk, evaluate, and try again
RISK ANALYSIS COMPONENTS

Risk Risk
assessment management

Risk
communication
START WITH A TESTABLE QUESTION

What is the risk of leptospirosis outbreaks occurring

during the rainy season in Thailand?

What is the risk of the global emergence of P. knowlesi

from macaques into humans?

What is the risk of moving avian diseases around

through commercial poultry trade?

What are the infectious disease risks of having a pet

monkey?
 RISK ASSESSMENT

• A systematic approach to
the measurement of the
risk derived from a given
hazard/threat of interest
• Based on
scientific/objective
evidence, clearly
documented
• May be quantitative
or qualitative
 HAZARD IDENTIFICATION

• What can go wrong?

• Example, what pathogens are spread by live poultry trade?
• How can it go wrong?
• Example, via live bird importation?
• Ranking/Prioritization
• Link defining question to potential hazards/threats
• Listing all diseases potentially important to the question or
issue
• Establish criteria for importance based upon the question
• Model high priority hazards
 HAZARD CHARACTERIZATION

• What are effects of

the hazard/threat?
• When do the effects
occur? How long do
they last?
• Any dose/response
effect?
• Exposure P McMullin. Practical Illustrations of risk assessment and risk
assessment – how management in the Poultry Industry. www.poultry-health.com

can the hazard

reach the host?
 RISK ASSESSMENT

Hazard Pathway
WHAT HOW

Assumptions
Model Rating scale
Uncertainty

Risk Characterization

What is the EXTRA risk to the population from this hazard?

Courtesy D. Travis, UMN

 DEVELOP A MODEL

• Pathway
characterization
• Visualize and draw the
question
• Identify critical control
points - areas where
disease risk changes
(↑ or ↓)
• Identify data gaps
• Refine questions

www.fao.org
 ADD REALITY

• Qualitative data
• Appropriate for a
“rough draft” or
when no data are
available
• Visual-based,
expert opinion
• Low/medium/high
 ADD REALITY

Semi-Quantitative
• Ranking, categorical scoring, etc.
PERHAPS ECONOMIC IMPACT IS MOST IMPORTANT…

Marsh 2008
 ADD REALITY

Quantitative
• Deterministic (point estimates)
• Stochastic (range of probabilities)
o @RISK ad-on for Excel, Monte Carlo simulation models
The Risk Interconnection
Map 2013

Source: World Economic Forum

 SOLUTIONS FOR LACK OF DATA

Collaborate with Communicate

Get more data mathematical uncertainty to
modelers decision makers
• Active • Use methods that • Leverage that for
surveillance, work well with more funding,
research imperfect data better programs
and uncertainty
DATA AVAILABILITY & QUALITY

Quantitative data (numbers) not required to start the model!

RISK ANALYSIS COMPONENTS

Risk Risk
assessment management

Risk
communication
 RISK MANAGEMENT

The process of deciding upon and

implementing measures to achieve the
appropriate level of protection versus the
undesired risk
 RISK MANAGEMENT

Understanding where the

important variables are
that have the greatest
• Sensitivity analysis
effect on the risk

Understanding scenarios
that are most cost • Cost-Benefit analysis
effective

• Repeat the cycle, it’s an iterative process

Adaptive management
STEPS OF RISK MANAGEMENT

Risk assessment

Monitoring and Develop strategies,

Evaluatuion policies

Innovation
RISK ANALYSIS COMPONENTS

Risk Risk
assessment management

Risk
communication
 RISK COMMUNICATION

• Timely, transparent sharing of information

among risk assessors, risk managers and
stakeholders (including the public)
• Helps the timely updating of risk
assessment to appropriately respond to
changes in the probability of the undesired
event of interest, and the adjustment of
management options
PURPOSE OF RISK COMMUNICATION

• Enhance the participation of the risk analysis

stakeholders
• Enhanced knowledge of the decision -
making process and risk management
• Help policy maker to make transparent,
consistent and effective decisions
RISK ANALYSIS STAKEHOLDERS

Individuals and
populations
Communities Governments
(humans and
animals)

Research
International
Industries centers and
organizations
academics

Communication
And others…
media
 OPTIONAL ACTIVITY

You have a research article that applies Disease Risk

Analysis. Please read it and answer questions below:
• What is the framing question?
• What is/are the hazard/hazards identified?
• What are risks?
• Is the risk analysis qualitative, quantitative, or both?
• Who are the stakeholders identified?
• Who will be informed of the results?
• How could results be applied?
 SUMMARY

Risk analysis is a logical, structured, evidence-based

approach that integrates science and policy

Supports decision-making in uncertain conditions

Aids decision makers to consider an evidence-based range

of options for prevention and mitigation of disease risks

Three main components are risk assessment, risk

management, and risk communication

Risk analysis may be qualitative, semi-quantitative, or

quantitative
Risk Analysis: A Field Exercise
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 INSTRUCTIONS

• If you as a class instructor are planning to carry out

the optional field trip as described in the facilitator
guide, please develop a brief (5-10 slides)
presentation on the community you will be visiting
• The presentation should includes basic information
on community geographic location, human
population size, significant animal populations
(domestic and wildlife), proximity to major industry,
proximity to national parts/protected areas, major
occupations, any known human and animal
disease problems
 INSTRUCTIONS

• Also include an agenda for the day (departure

time, major events, return time, travel time)
• Include a description of the activities the students
are to undertake
• Ensure that you have the necessary human and
animal subjects protection approvals from you
institution
• Ensure that you have made prior contact and have
approvals from the relevant community leaders and
local/district authorities
 Module Review
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 ONE THING..

• That you liked/felt was a strength of

the module.
• That you would suggest we change.

Thank you.
This publication was made possible in part through the support
provided by the United States Agency for International Development.
The opinions expressed herein are those of the author(s) and do not
necessarily reflect the views of the US Agency for International
Development or the US Government. USAID reserves a royalty-free
nonexclusive and irrevocable right to reproduce, publish, or otherwise
use, and to authorize others to use the work for Government purposes.