EPIDEMIOLOGY

BY PROFESSOR Dr. NAHEED HUMAYUN SHEIKH

Learning objectives

Scope of Measurement in Epidemiology

Measurement of Mortality Measurement of Morbidity Measurement of Disability Measurement of Natality Measurement of the presence, absence or distribution of the characteristics of the disease.

Scope of measurement in Epidemiology (cont)

Measurement of medical needs, health care facilities, utilization of health services etc Measurement of the presence, absence or distribution of the environment and other factors Measurement of demographic variables

Measures of Disease Frequency

Rates Ratios Proportions RATE: A rate measures the occurrence of some particular event in a population during a given time period. e.g Death rate=Number of deaths in one yr x 1000
Midyear population

Elements of Rate
Numerator Denominator Time specificationUsually a calendar year Multiplier---1000, 10,000, 100,000.

Categories of Rates
Crude rates (Unstandardized rates): Actual observed such as the birth and death rates. Example: Crude Death Rate =No. of deaths during the year x1000 Mid year population

Specific Rates
Actual observed rates due to specific causes---tuberculosis Occurring in specific groups---e.g.. age-sex groups During specific time periods e.g. annual, monthly or weekly rates.

Examples of Specific rates

Specific death rate due to tuberculosis: =No. of deaths from tuberculosis
during a calendar year x1000

Mid-year Population

Standardized rates
Obtained by direct or indirect method of standardization or adjustment.
Example: Age and sex standardized rates.

RATIO
It expresses a relation in size between two random quantities. Numerator is not a component of the denominator The numerator and denominator may involve an interval of time or may be instantaneous in time.

RATIO
Example 1: The ratio of white blood cells to red cells is 1:600 Example 2:
No. of children with scabies at a certain time No. of children with malnutrition at a certain time

PROPORTION
It is a ratio which indicates the relation in magnitude of a part of the whole or it expresses the number of cases of a particular disease relative to the total cases of all diseases e.g. proportional morbidity or mortality rates

Proportion
Numerator is always included in the denominator It is expressed as a percentage

Important Proportions
Case fatality Proportionate morbidity Proportionate mortality

(Proportions (%) Case Fatality Rate

Number deaths from a disease during a specified period of time
x 100

Case Fatality Rate =

Number of diagnosed cases of disease in the same period of time

Proportionate mortality
Number of deaths from a disease during a specified period of time
x 100

Proportionate mortality =

Number of death due to all diseases in the same period of time

Concept of Numerator and Denominator

Numerator: It refers to the number of times an event has occurred in a population, during a specified time period. An event may be sickness, births, deaths, episodes of sickness. Denominator: An appropriate denominator is needed. Numerator has no value without denominator

Denominator
Denominator is : 1.Related to the population 2.Related to total events

Denominator related to the population

a) Mid year populationMidpoint refers to the population estimated as on the first of July of a year. b) Population at risk: It is restricted to those who are capable of having or acquiring the disease or condition in question.

Denominator related to the Population

Examples: In case of food poisoning, all those who ate the food are at risk of having the disease.
In calculating the General fertility rate, the denominator is women of childbearing age.

Denominator related to the population

c) Person-Time:

-Persons may enter the study at different times as in Cohort studies, thus they are under observation for various time periods.

Examples: --Person-year (Most frequently used) --Person- month --Person-week --Man-hours

Denominator related to Population

d) Person Distance: --A variant of person-time. Example is passenger-miles.
e) Subgroups of the Population: Age, sex, occupation etc.

Denominator related to events

The denominator is related to total events instead of the total population e.g. Infant mortality rate(L.B) In case of accidents, the number of accidents per thousand vehicles, or per million vehicles miles will be more useful.

Measurement of Morbidity in terms of frequency

Disease frequency is measured by Incidence and Prevalence rates. INCIDENCE: It is defined as the number of new cases of a disease during a specified period of time among number of persons at risk of contracting the disease.

INCIDENCE
Two specific types of Incidence measures: Cumulative Incidence/Risk Incidence Density/Rate: CUMULATIVE INCIDENCE/RISK Def. It is the proportion of the people who become diseased during a specified period of time and is calculated as:

Cumulative Incidence
No. of new cases of a disease CI= during given period of time x1000 Total population at risk
CI provides an estimate of the probability, or risk that an individual will develop a disease during a specified period to time

INCIDENCE RATE OR DENSITY

It is defined as the number of new cases occurring in a defined population divided by the sum of the time periods at risk for all individuals in the population. This sum of individual periods of observation is known as person-time at risk.

Incidence density/rate
Formula:
No. of new cases of disease Incid.Rate= in as specified period of time

_____________________ X1000

Total person time of observation

SENARIO
06 acquired disease out of 20 exposed in village A & B observed for 30 days for appearance of -----

Calculations for I.D

Person time for A=06x 15 days = 90 days Person time for B=6x 30 days =180 days I. Density in A=6/90x 100 =6.66% I. Density in B=6/180x 100=3.33% Cumulative incid.=6/20x 100=30%

Incidence rate or Density

POPULATION A X X X X X X X X POPULATION B

X X

X
X

Time

Time

Incidence Rate
In the above example, the persontime at risk in population A is clearly smaller than that for population B resulting in the incidence rate for A being greater than for B. Note however that the cumulative incidence/risk at time t is the same in A and B.

Special Incidence rates

Attack rate (case rate) Secondary attack rate Hospital admission rate Age specific rate

Secondary attack rate

Formula:
No. of exp., develop disease within S.A.R= inc. period _____________________ X100 Total person susceptible/expo or person -weeks of exposure

Uses of Incidence Rate

It is useful for taking action: a) To control the disease b) For research into etiology and pathogenesis, distribution of diseases and efficacy of preventive and therapeutic measures.

PREVALENCE
It refers specifically to all current cases old and new) existing at a given point in time or over a period of time in a given population. --It is usually expressed as a percentage or, when number is very small, as per 1000 population.

Types of Prevalence
Point Prevalence: It is defined as the number of all current cases (old& new) of a disease at a point in time in relation to a defined population. The point consists of a day, several days or even a few weeks depending upon the time it takes to examine the population sample It can be made specific for age, sex and other relevant factors

Point Prevalence
Number of people with disease or having vital event at a given point in time x1000 Point Prevalence = Total number of persons at risk in that point in time

Period Prevalence
It measures the frequency of all current old and new) existing during a defined period of time (e.g. annual) expressed in relation to a defined population. It includes cases arising before but extending into or through to the year as well as those cases arising during the year

Formula of period prevalence

Number of people with disease or having vital event at a specified time period
Prevalence Rate = Total population at risk in the middle of the time internal

x 10n

Incidence and Prevalence

Jan 2006
Case 2 Case 3 Case 4

31 Dec 2006

Case 1

Case 5
Case 6 Case 7 Case 8

The cases for incidence rate during year 2006? The case for point prevalence on 1st Jan? The cases for point prevalence at 31st Dec? The cases for period prevalence?

Example to calculate Incidence and Prevalence

In a population of 1671 children <5 years of age,48 children were found to be severely malnourished. Prevalence= 48 x1000 =28/1000 1671 Incidence: Population at risk of developing malnutrition is: 1671-48=1623

Example-----Cont.
During the specified period of time, determine all new cases of severe malnutrition. Suppose 100 new cases are registered.
Incidence= 100 x1000=62/1000 1623

Uses of Prevalence
It helps to estimate the magnitude of health or disease problems (burden of disease) in the community and identify high risk populations Useful for administrative and planning purposes e.g. manpower needs, rehabilitation facilities.

Relationship between prevalence and Incidence

Given the assumption that the population is stable and incidence and duration are unchanging, the relationship between incidence and prevalence is: P=IxD Conversely, incidence and duration can also be calculated: Incidence=P/D Duration=P/I

Factors that increase the observed prevalence

Longer duration of disease Choronicity of the disease Increase in new cases In migration of cases Out-migration of healthy people In-migration of susceptible people Improved diagnostic facilities

Factors that decrease observed prevalence

Short duration of the disease High case fatality rates Decrease in new cases In-migration of health people Out migration of cases Improved cure rate

Adjusted or Standardized Rates

One of the main difficulties in the comparison of crude rates among various geographical areas or over a period of time is that the basic characteristics of the population may differ substantially, particularly with regard to age and sex.

Adjusted or Standardized Rates

When we are doing: Comparison of incidence or prevalence of some condition in two or more populations. Comparison of death rates in two or more populations Comparison of changes in death rates, measures of success of some treatment or procedure etc in the same or two populations in the same or two different time periods Comparison of disease rates in two or more populations

Adjusted or Standardized Rates

Use of a single index is very helpful. This index is called Standardized Rates. Two methods of deriving standardizing rates are: 1.Direct Standardization 2.Indirect Standardization

Direct Standardization
Define a STANDARD POPULATION'. It is defined as one for which the numbers in each age and sex group are known. Apply the age (etc) specific rates of the study population to the number in the standard population. This gives the EXPECTED number of cases in the standard population Add these expected numbers over the age groups to obtain the total number of expected cases (in the standard population).

Direct Standardization
Divide the total number of expected cases by the total number in the standard population to give a crude rate called the standardized incidence rate or standardized mortality/morbidity rate of the index population.

Requirements for the standardized rate

Availability of age-specific rates in each of the population groups under study
The designation of a standard population age distribution.

Indirect Age Standardization

The simplest form of it is known as Standardized Mortality/Morbidity Ratio (SMR). The age-sex adjusted mortality (morbidity) rates from the standard population are applied to each of the index populations to give standardized mortality (morbidity) ratios.

Indirect Standardization:
Does not require the knowledge of age specific rates in the study population Less sampling error is expected here as compared to the direct method using small number of specific rates. Requires the information on the number of persons and the number of deaths in a population for which the standardized mortality ratio is needed.

Indirect Standardization:
Select a series of standard death rates at all ages from a standard population. Apply these rates to the number in the study population (all ages) to calculate the expected deaths in each age group.

Indirect Standardization
The Standard mortality ratio is a ratio (usually expressed as a percentage) of the total number of deaths that would have been expected to occur if that study group had experienced the death rates of the standard population. Thus SMR compares the mortality in an occupational group with the mortality that the occupational group would have had if they had experienced national mortality rates.

Indirect Standardization
In this method, the more stable rates of larger population are applied to the smaller study group. It gives a measure of the likely excess risk of mortality due to the occupation. Observed Deaths SMR=Observed Deaths x100 Expected Deaths

Epidemiological Research

Descriptive Research

Analytic Research
Observational Analytical studies

Experimental/ interventional Studies

Design Strategies in Epidemiological Research

Classification
DESCRIPTIVE STUDIES 1. 2. 3. 4.

Study designs
Cross-sectional studies Longitudinal studies Population Correlations Case reports

OBSERVATIONAL ANALYTICAL EXPERIMENTAL OR INTERVENTIONAL STUDIES

1. Case control study designs 2. Cohort study design 1. Therapeutic or drug trials 2. Preventive trials

Epidemiological components and objectives

Type of Epidemiology Descriptive Epidemiology Study designs
Cross-sectional Correlation Case Reports

Area of Questions to exploration be answered

Frequency Distribution Developing the hypothesis How much?
(Rate, ratio and proportion)

Who? (Persons) Where? (Place) When? (Time)

Analytic Epidemiology
Experimental Epidemiology

Case control Cohort

Testing the hypothesis (Association)

Confirmation the association (Establishment
of cause)

What is the cause? (host, agent and

environment)

Preventive trials Clinical trials

Confirmation of Association (Establishing the

cause)

DESCRIPTIVE EPIDEMIOLOGY
First phase of an epidemiological investigation. Type: Observational studies. Describe the pattern of disease occurrence or health related events in relation to time, place and person.

Descriptive Epidemiology
Such studies basically ask the question:
a) Where is the disease occurring?Time Distribution b) Where it is occurring?--------- Place Distribution c) Who is getting the disease----Person Distribution

Steps to be followed in Descriptive Studies

1. Defining the population to be studied 2. Defining the disease under study. 3. Describing the disease by: a) time b) place c) person 4.Measurement of disease 5.Comparing with known indices 6.Formulation of an etiological hypothesis

Defining the Population.

Define the population, not only in terms of the total number but also its composition in terms of age, sex, composition, cultural characteristics etc. Defined population can be the whole population in a geographic area or a representative sample taken from it.

Defining the Population

Defined population can also be esp. selected group such as age and sex groups, occupational gps., hospital patients. It needs to be large enough so that age, sex and other specific rates are meaningful.

Defined Population
Community should be stable.
Defined population (population at risk) serves as a denominator for calculating rates which are essential to measure the frequency of disease, and study its distributions and its determinants.

Defining the Disease Under Study

To obtain an accurate estimate of the disease in a population, an epidemiologist needs a definition that is both precise and valid to enable him to identify those who have the disease from those who do not.

Defining the Disease under Study

The diagnostic methods for use must be acceptable to the population to be studied and applicable to their use in large populations. Thus an Operational definition is needed by which the disease or health event can be identified and measured in the defined population with a degree of accuracy.

Example:Tonsillitis
For a clinician, it can be defined as an inflam. of the tonsils caused by streptococcus pyogenes. For an epidemiologist, op.def. will be that a case of tonsillitis would include the presence of enlarged, red tonsils with white exudates which on throat swab culture grow predominantly S. pyogenes.

Describing the Disease in relation to time, person and place.

Time Distribution: It represents the temporal distribution of onset of disease after exposure to an etiologic agent.
May be described by the time of its occurrence i.e. by week, month, year, the day of the week, hour of onset etc.

Time Distribution:
Three types of time trends or fluctuations: o Short term fluctuations o Periodic fluctuations o Long term and secular trends

SHORT TERM FLUCTUTATIONS

Found in epidemics of infectious diseases. EPIDEMIC: The occurrence in a community or region of cases of disease/ health related events clearly in excess of normal expectancy.

PERIODIC FLUCTUTATIONS
Seasonal trend: Examples: Measles more common in early spring. ARI common during winter months. Gastrointestinal infections in Summer months

Periodic fluctuatations
Cyclic Trends: It refers to the recurrent alterations in the frequency of disease. Cycles may be annual or have some other periodicity. Measles epidemics used to occur every two or three years in the prevaccination era.

LONGTERM OR SECULAR TRENDS

It refers to the changes in the occurrence of diseases over a long period of times, generally several years or decades. Consistent change in one direction ( a progressive increase or decrease) Such trends are observed both for infectious and non infectious diseases.

Periodic Fluctuations
Influenza pandemics are known to occur at intervals of 7-10 years due to antigenic variations.
Non-infectious e.g. Accidents more common in US in weekends.

Secular trends
Examples: Coronary heart disease, lung cancer and diabetes have shown an upward trend in the developed countries over a period of 40-50 years.

Use of studying Time trends

The epidemiologists seeks to provide guidelines to the health administrator in matters of prevention or control of disease.

PLACE DISTRIBUTION
It is the frequency distribution of disease occurrence in relation to the place(s) or geographical areas that are defined/ separated either by natural barriers such as mountain ranges, rivers, deserts or political boundaries

Place Distribution:
Natural boundaries: Disease frequency may vary in areas defined by natural boundaries, because of influences of :
Environmental factors Climatic conditions Genetic inheritance or social customs

Place Distribution
Geographical regions have also differ regarding
economic activities and growth. Transport facilities Access to medical care.

Study of migrant population are carried out to distinguish between genetic factors and environmental factors related to disease.

Place Distribution
These geographical variations can be classified as :
International variations National variations Rural urban differences Local distribution

PERSON DISTRIBUTION
This refers to the characteristics of individuals that may influence their exposure to and /or susceptibility to the disease in question. People can be described in terms of their genetic and acquired characteristics of age, sex, ethnic group or race, occupation habits etc.

Person Distribution:
Most frequently described characteristics of person described by the epidemiologists are :
Age Sex Race Social class Occupation

MEASUREMENT OF DISEASE
To have a clear picture of the amount of disease (disease load) in the population, this information can be available in the form of morbidity, mortality, disability rates etc. Morbidity ---Incidence and Prevalence.

Cross-sectional Studies(Prevalence studies)

Based on a single examination of a cross-section of a population at one point in time. More useful for chronic diseases e.g. hypertension. Tells us about the distribution of disease in population rather than its etiology.

LONGITUDNAL DISEASES:
Observations are repeated in the same population over a period of time by means of follow up examinations. Useful:
To study the natural history of disease and its future outcome. For identifying risk factors of disease and For finding out incidence rate or rate of occurrence of new cases of disease in the community.

COMPARING THE KNOWN INDICES

Helps to find out the disease etiology.

Can identify groups who are at increased risk for certain diseases.

FORMULATION OF HYPOTHESIS
A hypothesis is a supposition, arrived at from observation or reflection. In descriptive epidemiology, hypothesis can be formulated about the disease etiology. It can be accepted or rejected , using the techniques of analytical epidemiology.

Criteria of Epidemiological Hypothesis:

The populationcharacteristics of persons to whom the hypothesis applies. The specific cause being considered. The expected outcome Dose-response relationship Time response relationship

Hypothesis:
Example: Cigarette smoking causes Lung Cancer.

USES OF DESCRIPTIVE EPIDEMIOLOGY

Provide data regarding the magnitude of the disease load and type of disease problems in the communitymorbidity and mortality rates and ratios. Provide clues to Disease Etiology. Provide background data for planning, organizing and evaluating preventive and curative services Contribute to research by describing variations in disease occurrence by time, place and person.