EPIDEMIOLOGY

Crisbert I. Cualteros, M.D. http://crisbertcualteros.page.tl

DEFINITION
Study of the distribution and determinants of health and disease among populations and the application of such study to the prevention and control of health problems. Determination of the nature, extent and determinants of disease or health problems

COMPONENTS OF EPIDEMIOLOGY
I. Descriptive Epidemiology

study of the distribution of disease variables commonly examined are descriptive of person, place and time

II.

Analytic Epidemiology

use of epidemiologic methods to explain disease occurrence or elucidate causal mechanisms

CHARACTERISTICS / FEATURES OF EPIDEMIOLOGY

It is a quantitative science. It is an applied science. Its methods are generally observational. Its focus is the group or community of persons. Its methods are systematic and orderly.

DESCRIPTIVE EPIDEMIOLOGY
I. Definition
II. Uses

study the amount and distribution of

disease within a population

evaluate trends in health and make

comparisons health planning identify problems to be studied by analytical methods = hypothesis

DESCRIPTIVE EPIDEMIOLOGY
III. Community Reaction to Disease
1.

Absence of disease
No

cases on current record Disease absent from the beginning or has been eradicated
2. 3. 4.

Sporadic
Occurrence

of few and unrelated cases

Endemic
Constant

occurrence of disease

Epidemic
Occurrence

of a number of cases of disease in excess of the normal expectancy

IV. Descriptive Variables

A. Person 1. Age

DESCRIPTIVE EPIDEMIOLOGY
Different diseases show different age patterns

Disease Characteristic Pattern of Magnitude Confers long lasting immunity decreasing with age Degenerative diseases or increasing with age w/ long latency Reflects low resistance high at extreme ages of young and old

VARIABLES OF PERSON
2. Sex

Difference in sexual constitutional, e.g. hormonal balance Greater exposure of males due to habits, recreation, occupation, lifestyle Greater health consciousness of females:
Early

consultation, diagnosis and treatment Better compliance with treatment More cases recorded artifactual reason

VARIABLES OF PERSON
3. Civil Status
Differences in lifestyle that are causally related to particular diseases Self-selection Concordance between marital partners Greater family support among the married 4. Socio-economic class affects state of nutrition, level of health awareness or knowledge, etc

5. Genetics

DESCRIPTIVE VARIABLES
B. Place
1. Variables Of Place
climate,

geographic divisions physical environment

altitude, soil, vegetation, fauna biological environment: infectious disease agents, animal reservoirs, vectors socio-cultural-political-economic environment related to level of development

VARIABLES OF PLACE

population characteristics
density urban vs. rural mobility herd immunity

PLACE
2. Etiology of Disease Variations
in risk

Real Causes - reflect true increase

deteriorating

Artifactual Causes
reliability

or improving environment quality, availability and distribution of medical care

of diagnosis completeness of reporting and recording of diseases, births and deaths

DESCRIPTIVE VARIABLES
C. Time

Temporal variations changes /

fluctuations in disease frequency with the passage of time

1. Types of Temporal Variations:

Secular Trends Cyclic Fluctuations Short-term Irregular e.g. Epidemics / outbreaks

TEMPORAL VARIATIONS
Secular Trend
Fluctuations Measure of frequency Mortality rates Rates Nature of change regular rises Increase or decrease Period of observation 10 years or days, weeks, longer (5) hours, months, years

Cyclic
Incidence

Almost

TIME
2. Reasons for Changes in Mortality Rates
Artifactual or non-etiologic
Error

in the numerator

oguess diagnosis / misdiagnosis oinaccurate counting ochange in the International Classification of Diseases
Error

in the denominator

oover or underestimate of the population

TIME

Change in Case Fatality Rate, w/o

change in Incidence Rate
change

in availability or utilization of health care services change in treatment modalities change in risk to superimposed infections

TIME

Change in Incidence Rate, w/o change

in Case Fatality Rate
Artifactual

or non-etiologic Real or etiologic

o change in disease agent o change in herd resistance o change in the environment

TIME
3. Types of Cyclic Fluctuations

Cyclic Intrinsic Fluctuation

change/s

Cyclic Extrinsic Fluctuation (seasonal

variation)
change

in the host change in herd resistance accumulation of susceptibles

in the environment change in the disease agent

Analytic Epidemiology
I. Definition

study the determinants of disease or

reasons for low and high frequency in specific groups employs Epidemiologic Methods:
Definition

of the problem Appraisal of existing facts Formulation of hypothesis Testing of hypothesis Conclusion and practical application

ANALYTIC EPIDEMIOLOGY
II. Principal Uses

Community diagnosis Investigation of epidemics Determination of disease etiology Evaluation of community intervention
and programs

COMMUNITY DIAGNOSIS
I. Definition of the Problem
Determining the extent and magnitude of the problem using statistical indices Comparison of the statistical indices with those of other places and other diseases computation of economic burden of disease: cost of losses due to disability, death, treatment and prevention

COMMUNITY DIAGNOSIS
II. Appraisal of Existing Facts

Determining the:
state

of knowledge of disease or health problem etiology distribution of the disease/ problem in terms of person, place and time factors associated with the disease/ problem

COMMUNITY DIAGNOSIS
III. Formulation of Hypothesis

Explanations for the existence and magnitude of the disease / problem

IV. Testing of Hypothesis V. Conclusion and Practical Solutions to the Problem

EPIDEMICS
I. Definition

the occurrence of any number of cases of a disease clearly in excess of the normal expectancy or what usually prevails

EPIDEMICS
II. Causes of Epidemics flare up of an old or existing disease
increased

virulence of existing strain introduction of a new strain of the existing agent increased capacity to multiply decreased resistance of the population dilution of herd resistance with a susceptible population changes in the environment favoring disease transmission, e.g. calamities destroying health facilities, factors favoring survival and multiplication of vectors, changes in climate, temperature, etc.

Causes of Epidemics

new disease
introduction

of a disease not previously present in the community disease previously affecting lower animals affecting man for the first time recognition for the first time of previously occurring disease known by another name

EPIDEMICS
III. Classification of Epidemics according to:
1. Onset (of epidemic)

explosive, abrupt, sudden majority

of cases occurring within one incubation period staggering, insidious, gradual

2. Exposure (of cases)

mass or simultaneous exposure

occurred about the same time progressive cases were exposed one after the other from a primary case

CLASSIFICATION OF EPIDEMICS
3. Transmission
exposure propagated

common vehicle single or multiple

contact-transmitted: person to person vector-transmitted

CLASSIFICATION OF EPIDEMICS
4. Epidemic Curve

classical short ascending, long

descending limbs; water-borne

inverted long ascending, short

descending limbs; vector-borne

Epidemic Curve

bell-shaped ascending and descending limbs about equal, peak is rounded; contact-transmitted

point - ascending and descending limbs about equal, peak is pointed; food poisoning

EPIDEMICS
IV. Termination of Epidemics

eradication / killing of disease agents at

the source or reservoirs interruption or closure of transmission exhaustion of susceptibles

EPIDEMICS
V. Steps in the Investigation of Epidemics
1. Definition of the problem

verify the diagnosis establish existence of an epidemic

2. Appraisal of existing facts

characterize the distribution of cases

by person, place and time

INVESTIGATION OF EPIDEMICS
3. Formulation of hypothesis

as to source of infection, mode of

transmission, factors that may have given rise to the epidemic

4. Testing of hypothesis
control)

conduct an epidemiological investigation (case

5. Conclusion and recommendations for control

DETERMINATION OF DISEASE ETIOLOGY

I. Types of Epidemiologic Studies
A. Descriptive Studies
1. Uses

determination of distribution of disease according

to person, place and time delineation of syndrome as a disease entity establishment of the natural history of disease classification of disease manifestational: pathologic and symptomatic experiential: based on similarity of experience

Descriptive Studies
2. Types

Case report
unit

of study: single person with a disease limitation: based on experience of a single person provides first clues in the identification of a disease or adverse effects of exposure

TYPES OF DESCRIPTIVE STUDIES

Case series
unit

of study: group of persons with a similar disease Uses:

formulation of criteria for diagnosis o formulation of indications for treatment o identification of prognostic factors o determination of survival rates
o

CASE SERIES
Limitation
o

limited generalizability because of unrepresentativeness of subjects and absence of comparison group

TYPES OF DESCRIPTIVE STUDIES

Prevalence/Cross-sectional/
Surveys
measures

event information about exposure and outcome are obtained simultaneously in a well-defined population

prevalence of disease or an

PREVALENCE/CROSSSECTIONAL/ SURVEYS

Uses
determination of prevalence of risk factors determination of frequency of prevalent cases determination of health status and health needs

PREVALENCE/CROSSSECTIONAL/ SURVEYS

Advantages
quick

and easy to perform

Disadvantages
temporality cannot be ascertained selects for longer-lasting and indolent cases

TYPES OF DESCRIPTIVE STUDIES

Ecological Studies
crude

way of exploring relationship between environment or occupation and disease unit of study: populations or groups of people rather than individuals hypothesis generating rather than hypothesis testing

ECOLOGICAL STUDIES

Advantage

simple to conduct

Disdavantage
individual

link between exposure and effect cannot be made (ecologic fallacy)

Types of Epidemiologic Studies

B. Analytic Studies 1. Use

to determine whether a factor is causally

associated with disease to test epidemiologic hypotheses

2. Categories

observational/ non-experimental
observes

natural course of events case control study, cohort study, crosssectional study

CATEGORIES OF ANALYTIC STUDIES

Experimental/ Interventional
exposure

to the factor or treatment under study controlled by investigator randomized clinical trial (rct), community trial, laboratory trial

ANALYTIC STUDIES
3. Types

Case-control Studies
cases

(with disease) and controls (no disease) are selected from a chosen population both are questioned or records are reviewed about presence or absence of a suspected cause/risk factor in the past

CASE-CONTROL STUDIES
1. Uses

to test risk factors preferred if disease is rare preferred if several factors are

associated with disease of interest

CASE-CONTROL STUDIES
2. Requirements for valid results

Cases must be representative of all

those with disease and clearly defined.

Controls must be representative of all

those without the disease and come from same community or source as the cases.

CASE-CONTROL STUDIES
3. Analysis

Odds Ratio (OR)

proportion

of those with history of exposure to the factor among the cases (a/a+c) is compared to those with history of exposure (b/b+d) to the factor among the controls = ad/bc

OR

ANALYSIS OF CASE CONTROL STUDIES

+ -

Outcome (Disease)

Exposure (Factor)

+ -

a c
a+c

b d
b+d

outcome exists if (a/a+c) (b/b+d)

* statistical

association between factor and

CASE-CONTROL STUDIES
4. Advantages

more economical smaller sample size required suitable for rare diseases suitable for diseases associated with
multiple exposures

CASE-CONTROL STUDIES
5. Disadvantages

more susceptible to bias of recall estimate of risk is indirect controls more difficult to assemble temporal relationship between factor
and outcome cannot be ascertained

TYPES OF ANALYTIC STUDIES

Cohort Studies
groups

of subjects are chosen on the basis of having been exposed to a factor or not groups are followed up to identify those who develop the disease or outcome

COHORT STUDIES
1. Uses

to test prognostic factors to directly measure risk of development

of disease or outcome provide more definitive information about disease etiology preferred for study of rare exposures

COHORT STUDIES
2. Requirement for valid results

Similarity of comparison groups

3. Types

concurrent

Subjects are free of disease or outcome of interest at the time of initiation of the study. Investigator follows-up the groups or cohorts from exposure to appearance of disease or outcome.

TYPES OF COHORT STUDIES

. Non-concurrent
Subjects

who are free of the disease or outcome of interest at some point in the past are identified in terms of their exposure level. Disease or outcome status is determined through existing records. At the time the study is conducted, the specified follow-up period has elapsed.

COHORT STUDIES
4. Analysis

Relative Risk or Risk Ratio(RR)

proportion of subjects with the disease or outcome among the exposed (a/a+b) is compared to proportion of subjects with the disease or outcome among the unexposed (c/c+d) = a/a+b c/c+d

RR

ANALYSIS OF COHORT STUDIES

+ -

Outcome (Disease)

Exposure (Factor)

+ -

a c
a+c

b d
b+d

outcome exists if (a/a+b) (c/c+d)

* statistical

association between factor and

ANALYSIS OF COHORT STUDIES

Attributable Risk (AR)

estimate

of the amount of risk that is attributable to the risk factor = a/(a+b) - c/(c+d)

AR

COHORT STUDIES
5. Advantages provides direct estimate of risk temporality can be ascertained (for concurrent
less biases of recall and observation allows for determination of population-based
rates controls easier to assemble variations in exposure can be followed-up unsuspected effects of the exposure may be observed

studies)

COHORT STUDIES
6. Disadvantages

more expensive follow-up period may be long high attrition rate large sample size required change in exposure rates over long
periods of time

CHARACTERISTICS OF CASE CONTROL AND COHORT STUDIES

Case Control
Starting population group diseased group

Cohort
exposed

Control Group unexposed

non-diseased

Information Sought frequency of disease rate exposure to risk factor Principal bias knowledge of knowledge of

CHARACTERISTICS OF CASE CONTROL AND COHORT STUDIES

Case Control
Time to Complete usually long Study Measure of Relative Risk Association short

Cohort

Odds Ratio

TYPES OF ANALYTIC STUDIES

Experimental Studies

Requirement for validity: complete comparability of comparison groups

Clinical Trial - Randomized

Controlled Trial (RCT)
investigator

1. Types

randomly places the subjects to one of the intervention groups ex. drug or surgical trials used if strong evidence for association already exists

TYPES OF EXPERIMENTAL STUDIES

Field or community trials

are people in the general population who are disease-free but are presumed to be at risk
ex. subjects

trials of preventive measures, e.g. immunization

FIELD OR COMMUNITY TRIALS

Requirements
high incidence of disease under study availability of facilities for observation accessibility of subjects availability of resources for precise diagnosis and follow-up

EXPERIMENTAL STUDIES
2. Analysis

comparison of disease or outcome rate

in experimental (P1) = (a/a+c) and control groups (P2) = (b/b+d)

ANALYSIS OF EXPERIMENTAL STUDIES

Therapeutic / Preventive Measure +

+
Disease/ Outcome -

a
c a+c b+d

b
d

ANALYSIS OF EXPERIMENTAL STUDIES

Protective Value = P2 P1
P2

EXPERIMENTAL STUDIES
3. Advantage

Provide the strongest evidence for

testing hypothesis

4. Limitation
trials

ethical issues, especially for clinical

Determination of Disease Etiology

II. Assessment of Results
1. determine if statistical association between factor and outcome occurs 2. if association exists, determine if due to:

chance

extraneous or confounding variables

matching specification or restriction standardization of rates stratified analysis

perform significance testing

Assessment of Results

if association exists, determine if due to:

causal relationship
o

criteria: 1. measures of strength of association OR, RR, Protective Value 2. temporality exposure occurred prior to outcome 3. dose-response relationship

CRITERIA FOR CAUSAL ASSOCIATION

4. specificity factor associated with only 1 or limited number of diseases 5. consistency of association distribution of factor and disease is similar in different sub-groups 6. biologic plausibility consistency with existing knowledge