EPIDEMIOLOGY

Dr. Vijayalaxmi Gurung

EPIDEMIOLOGY

Epidemiology is the basic science of preventive and social medicine. It cover not only study of disease distribution and causation but also health and health related events occurring in human population. Modern epidemiology has entered the most exciting phase of its evaluation

By identifying risk factors of chronic disease, evaluating treatment modalities and health services, it has provided new opportunities for prevention, treatment, planning and improving the effectiveness and efficiency of health services.

Epidemiology is derived from the word epidemic, which is very old word dating back to the 3th Century B.C. Epidemiology means: Epi= among Demos= people Logos= study

Epidemiology
EPI
Among

DEMO
People, population,man

LOGOS
The Study of

The study of anything that happens to people

That which befalls man

DEFINITION

There appears to be almost as many definition of epidemiology as there are authors who have written on the subject, ranging from Hippocrates to those of the present day. A short list is given below: That branch of medical science which treats of epidemics Parkin, 1873

1.

2.

The science of the mass phenomena of infectious diseases- Frost, 1927 The study of disease, any disease, as a mass phenomenon- Greenwood, 1934 The study of the distribution and determinants of disease frequency in man- macMohan,1960

3.

4.

Definition of Epidemiology*
The STUDY of the DISTRIBUTION and
DETERMINANTS of HEALTH-RELATED STATES in specified POPULATIONS, and the application of this study to CONTROL of health problems."

*Last, J.M. 1988. A Dictionary of Epidemiology, 2nd ed.

Although there is no single definition to which all epidemiologist subscribe, three components are common to most of them. Studies of disease frequency Study of the distribution

1.

2.

3.

Study of determinants

Clinician
Patients diagnostician Investigations Diagnosis Therapy Cure

Epidemiologist
Communitys diagnostician Investigations Predict trend Control Prevention

AIMS OF EPIDEMIOLOGY
a. b.

c.

According to the International Epidemiological Association (IEA), epidemiology has three main aims: To describe the distribution and magnitude of health and disease problems in human populations To identify etiological factors in the pathogenesis of disease; and To provide the data essential to the planning, implementation and evaluation of service for the prevention, control and treatment of disease and to the setting up of priorities among those services.

The ultimate aim of epidemiology is to lead to effective action: To eliminate or reduce the health problem or its consequences; and To promote the health and well-being of society as a whole.

a.

b.

Kinds of Epidemiology
Descriptive Analytic
Study of the occurrence and distribution of disease
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

Methods of epidemiological studies

Observational study Descriptive study Cross-sectional study Longitudinal study Analytical study Case control study Cohort study Experimental study RCT NRCT

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

Age Sex Occupation Immunization status Underlying disease Medication Nutritional status Socioeconomic factors Crowding

Person

Hobbies Pets Travel Personal Habits Stress Family unit School Genetics Religion

Steps of Descriptive Epidemiology

Defining the population

Defining the disease

Describe the disease Measurement of disease Comparing with known indices Formulation the hypothesis

Incidence
Incidence

rate is a measure of the probability of the event among persons at risk.

Incidence Rates

Population denominator:

IR = Number of new cases during time period XK specified population at risk

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 =Number of existing cases during time period population at same point in time

Prevalence rates are often expressed as a percentage.

iv) As a surrogate for longitudinal descriptive studies : say, for weight charting of children from birth till 5 years age, on a monthly basis, ideally, we should collect a group of (say 1000) children born recently, and follow them up for next 5 years, recording their weight every month.

This is the ideal, but often a difficult way (longitudinal descriptive study).

To overcome the problems of follow up, what we can do is that we can take a cross sectional sample of say, 100 children each of ages 1, 2, 3 and so on, till 60 months and weigh them; the average weights could be used for making a growth chart as would have been done by a longitudinal study. Excellent and easy though it may look, the method has a flaw.

Cross Sectional Descriptive Studies

Such descriptive studies are done on a sample of the total population and may be community based or hospital based. They are mainly directed to work out the : i) Prevalence of a factor of interest, e.g. prevalence of leprosy among general population, i.e. community based, or prevalence of nosocomial Pseudomonas infection in renal units, i.e. hospital based.

ii) Mean of a factor of interest (e.g. Hb% level in ladies in the community; or serum protein levels among patients admitted with open pulmonary TB). iii) Description of a Pattern (e.g. pattern of antibiotic prescription in an Acute Medical Ward; or knowledge, attitudes and practices regarding contraceptives in a community).

The children whom we take up in such a study at different age groups are the ones who have survived to this age. It is quite possible that malnourished (under weight) children might have been dying progressively more, and not reaching the next month of age.

If this were true, a chart based on cross sectional study would show higher mean values as compared to a (more correct) chart based on longitudinal descriptive study.

Longitudinal Descriptive Studies

In contrast to a cross sectional descriptive study, a longitudinal descriptive study follows up a single group of subjects over a defined period of time. These studies are more scientific than cross sectional ones but at the same time more costly and time consuming.

These studies are undertaken with the following general objectives : i) To see the incidence of a disease (e.g. the incidence of poliomyelitis among children in the community or the incidence of acute glomerulonephritis among children admitted in hospital, with acute sore throat). ii) To describe the natural history of a disease (e.g. the clinical progression of cases of AIDS in hospital; or the clinical progression of cases of viral hepatitis in a community).

iii) To describe a health related natural phenomena (e.g. the examples of weight charting of children given earlier). iv) To study the trend of a disease (e.g. to see whether the incidence of TB is rising or falling in a community). v) To study the trend of a health - related phenomena (e.g. to see whether the blood pressure of children from well - to - do families rises progressively; or whether the level of knowledge regarding prevention of AIDS is

The basic difference between a cross sectional and a longitudinal descriptive study can be appreciated by the essential difference that in a cross sectional study the researcher examines every subject only once; while in a longitudinal study each subject is examined at least twice.

For this reason, a cross sectional study gives us

the prevalence while a longitudinal study gives us the incidence.

Use of descriptive epidemiology

To provides data- magnitude of diseases

Formulation of etiological hypothesis

Data for planning, organizing and evaluating preventive and curative services Help to conduct the research

Analytical epidemiology

Second type of epidemiological studies

Helps to test the hypothesis

Individuals are evaluated in analytical studies Always two groups- study and control Uses a comparison group to establish an association between cause and effect

Use of analytical epidemiology

Incidence can be calculated Estimation of odd ratio and relative risk

Case control study

Kind of analytical study It is a retrospective study

First approach to test causal hypothesis

Definition

A case control study is defined as an epidemiological approach in which the researcher starts by picking up cases who have already developed a particular disease or outcome of interest, and a comparison group (controls) of subjects who, except for the fact that they have not developed the particular disease, are otherwise similar to the cases.

Having assembled the two groups, the investigator finds out the presence (or the history) of the particular exposure which she thinks is a risk factor and compares the two groups (cases and controls) as regards the presence (or history) of exposure.

3 Distinct Features

Both exposure and outcome have occurred before start the study Proceeds backward from effect to cause

Use the control group to refute or support the hypothesis

Case-control study design

Exposure Disease Observer

?
Choose groups with and without disease, look back at what different exposures they may have had

Case control studies

Attempt to make inference from existing observations (retrospective) Compares patients with outcome/disease with those without and attempts to identify factors that influenced that outcome (or caused that disease)

Important concept: start with the result (disease) and

work backwards for the cause

Steps of case control

Selection of cases and control Matching

Measurement of exposure, and

Analysis and interpretation

Selection of cases
Definition of cases Diagnostic criteria Eligibility criteria Sources of cases Hospital General population

Diagnostic Criteria
The diagnostic criteria of the disease and the stage of the disease to be included in the study. Ex-Breast of cancer Histologically the cases should be of same group. The diagnostic criteria should not be changed till the study is over.

Eligibility Criteria

Only the newly diagnosed cases within the specific period of time are eligible than the old cases.

Sources of cases
Hospitals: The cases may be drawn from a single hospital or a network of hospitals, admitted during the specific period of time. The entire case series or a random sample of it is selected for the study. Advantage - convenient

General Population: In a population based case control study, all the cases of the study disease occurring within a defined geographic area during a specific period of time are ascertained. EX: The disease registry or the hospital network

Selection of control
Free from the disease Must be similar to the cases as possible except for the absence of the disease under the study. Selection of the cases is difficult if the disease under investigation occurs in a subclinical form.

Sources of control Hospital control Relatives Neighborhood General population

Matching

Frequency matching: Selecting the controls in such a manner, so that the proportion of controls with the certain characteristics is identical to the proportion of cases with the same characteristics. Paired matching: For each case selected for the study ,a control is selected ,who is similar to the case in terms of specific characteristics

Measurement of exposure
By questionnaire Interviews Hospital records Employment records

Analysis

Exposure rates: The exposure rate among cases The exposure rate among the controls

Odds ratio: Aim: To assess the relationship between the disease and its possible exposures

Odds ratio
The probability that a particular event will occur divided by the probability that a event will not occur. It is also termed as a cross product ratio.

Strengths of case-control design

Best study when have rare disease or outcome Relatively quick and inexpensive Low cost Relatively efficient Feasible Several exposures Data are ready made.

Cont..
No ethical problems Conclusion can be drawn quickly by the nested case control study.

Weaknesses (potential biases)

Difficult to select the appropriate controls Do not establish the risk(only odds ratio) More chance of bias. Reliance on recall or records to determine the exposures. Less analytical compares to cohort study

Selection (confounding) bias: controls must be as similar to cases as possible Representativeness bias: cases should be typical

Recall bias: cases may be able to remember events better because of its significance or may be prompted to remember by investigators

Ways to combat weakness

Matching: for each case, find a control that

looks just like him/her in all other possible ways except for the disease (same age, race, economic class, etc.)

Blinding: individual assessing exposures

should be blinded to whether the person is a case or control

Nested case control study

It is type of a case control study that draws its cases and the controls from a cohort population that has been followed for a time period. A nested case control study depends on the pre-existence of a cohort.

Nested case control study

Cohort population-All are free from the diseases

Follow up for the years

Some develop the disease and some will not develop the disease

The investigator identifies the cases of disease that occurs in the cohort during the follow up period as well as the disease free individuals within the cohort to serve as controls.