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EPIDEMIOLOGIC METHODS/STUDIES

TYPE OF
STUDY

OBSERVATIONAL STUDIES

ALTERNATIVE
NAME

A. DESCRIPTIVE STUDIES
B. ANALYTICAL STUDIES
1. Ecological

Co-rrelational

2. Cross sectional

Prevalence

3. Case control

Case reference

4. Cohort

Follow up

EXPERIMENTAL/
INTERVENTIONAL STUDIES

A. RANDOMIZED CONTROLLED
TRIALS (RCT)
B. NON RANDOMIZED CONTROLLED
TRIALS

Clinical Trials

DESCRIPTIVE EPIDEMIOLOGY
Describes the distribution of disease patterns
according to time, place and person.
PROCEDURES IN DESCRIPTIVE STUDIES

1. Defining the population


2. Defining the disease under the study
3. Describing the disease by time, place & person
4. Measurement of disease
5. Comparing with known indices
6.Formulation of etiological hypothesis

1. DEFINING THE POPULATION TO BE


STUDIED
Whole population/sample/group
Large enough
Stable community
Visitors should not be a part of study
Study population should not be very different
from other populations

Defining the population at risk

2. DEFINING THE DISEASE UNDER STUDY


Operational definition
By which the disease/condition can be identified
& measured accurately in the defined population
Precise, valid, applicable, acceptable
Clinicians definition of Tonsillitis
Inflammation of tonsils by infection usually, S.pyogens
Operational definition of Tonsillitis
Presence of enlarged, red tonsils with white exudate which
on throat swab culture grow predominantly S.pyogens
Definition framed by Epidemiologist
When there are no pathognomic signs & symptoms of
disease

WHO CASE DEFINITION OF AIDS (>12 yr)


At least 2 major signs and 1 minor sign
Signs not known to occur with condition not related to AIDS

Major signs

Minor signs

Weight loss >10 % of body wt.

Persistent cough >1 month

Chronic diarrhoea >1 month

Generalized pruritic dermatitis

Prolonged fever >1 month

History of herpes zoster

(intermittent or constant)

Oropharyngeal candidiasis
Chronic progressive or
disseminated herpes simplex
infection
Generalized lymphadenopathy

3. DESCRIBING THE DISEASE BY TIME, PLACE & PERSON


TIME

PLACE

PERSON

Year, season Climatic zones Age

Birth order

Month, week

Gender

Family size

Marital
status

Height

Day,

Country,
region
Urban/rural

Hour of
onset
Duration

Towns, cities, Occupation Weight


institutions

Social
status
Education

B.P.
Blood
cholesterol
Personal
habits

TIME DISTRIBUTION
Time trends/fluctuations
I.

Short term fluctuation

II.

Periodic fluctuation

III. Long term fluctuation

I. SHORT TERM FLUCTUATION


COMMON SOURCE
EPIDEMIC

PROPAGATED
EPIDEMIC

Single
exposure
(Point source)

Person to person

Multiple/Continuous
/repeated exposure

Animal reservoir

Arthropod vector

EPIDEMIC CURVE
Graph of time distribution of epidemic cases
Shows time relationship with exposure to
a suspected source

SINGLE EXPOSURE (POINT SOURCE) EPIDEMIC


Exposure is brief & simultaneous

Features of epidemic curve


Curve rises and falls rapidly
One peak (No secondary waves)
Clustering of cases within a
short time interval (explosive)

Number of cases

Median Incubation period:


Time required to develop 50% cases

Time

Cases develop within a single incubation period

Causative factors
Infectious agent
Chemical contamination
Examples:
Salmonella food poisoning
Bhopal gas tragedy, India (MIC gas)
Minamata disease, Japan (methyl mercury in fish)

COMMON SOURCE MULTIPLE


(CONTINUOUS/REPEATED)EXPOSURE EPIDEMIC
Common source
Continuous, repeated or intermittent exposure
More than one incubation period
Extended or irregular
8
6
Series1

4
2

17

15

13

11

0
3

1. Water source contamination


2. Vaccine contamination
3. Legionnaires disease outbreak
in 1976 (Philadelphia)

10

Examples:

PROPAGATED EPIDEMIC
Usually person to person transmission of
an infectious agent
(Epidemics of Polio & Hepatitis A, Measles)
Gradual rise and gradual fall
Speed of spread depends upon
1.Herd immunity
2.Opportunities for contact
3.SAR

Susceptible
Source/vector
Immunity

( Susceptibles )
Gradual
rise

Gradual
fall

Propagated Epidemic

II. PERIODIC FLUCTUATION


A. Seasonal trend B. Cyclic trend
SEASONAL TREND
Disease

Peak

Measles

Early spring

Upper Respi. Tract Inf.

Winter

GIT Inf.

Summer

Sunstroke

Summer

Seasonal Trend
PNEUMONIA

DIARRHOEA
15

10

Series1

5
0

NO. OFCASES

NO. OFCASES

15

10

Series1

5
0

J F M A M J J A S O N D

J F M A M J J A S O N D

MONTH

MONTH

SEASONAL FLUCTUATIONS ARE DUE TO:


Temp., humidity, rainfall,
overcrowding, life cycle of vectors

B. CYCLIC TREND
Disease at regular time intervals/cycles
(days, weeks, months, years)
Measles

(Prevaccination era)
Rubella

years
6-9 years Variation in herd
immunity

Influenza pandemics

7-10
Antigenic
years
variation
Weekends -

Automobile accidents
in US

Variation in herd
immunity

MEASLES (CYCLIC TREND)

NO. OF CASES

MEASLES
10
8
6
4
2
0

Series1

1 2 3 4 5 6 7 8 9 10 11
YEARS

III. LONG TERM OR SECULAR TREND


Changes (Increase/Decrease) in disease occurrence over
a long time (years)
During last 50 years, in developed countries:
Diabetes,
Lung Cancer,
Coronary
Heart Disease

Tuberculosis,
Polio,
Diphtheria

SMR

TB mortality in England
1400
1200
1000
800
600
400
200
0

BCG, DRUGS

1871

1891

1911

1931

years

1951

1971

PLACE DISTRIBUTION
Geographical pathology: Study of geography of disease
I.INTERNATIONAL VARIATIONS
Japan

Stomach Cancer

India

Oral cavity Cancer, Carcinoma Cervix

Japan

Lowest level of Breast Cancer

Western
countries
Developed
countries
Developing
countries

Highest level of Breast Cancer


More Cardiovascular diseases
Less Cardiovascular diseases

II.NATIONAL VARIATIONS
Some parts of a country are affected more
than other parts
e.g. Lathyrism, Malaria, Leprosy,
Nutritional deficiency diseases
BIMARU states

NATIONAL VARIATION IN POLIO

III.RURAL-URBAN VARIATIONS
RURAL:
Helminthic diseases,
Skin Inf.,
Zoonotic diseases
High IMR and MMR
URBAN:
Accidents, Lung cancer,
Cardiovascular diseases,
Mental illness, drug abuse
CAUSES FOR VARIATION:
Difference in population density, Social class, medical care,
education, sanitation, environmental factors

IV.LOCAL DIFFERENCES
Variation between outer and inner city areas
Spot map/shaded map
Shows at a glance areas of high & low frequency,
boundaries & patterns of disease distribution
Clustering of cases in map
Common source of inf./Common risk factor

JOHN SNOWS EXPERIMENT


Investigation of Cholera epidemic (1854)
In Golden Square district of London
Two water companies in London
Sources of water
1.down stream from sewage,
2.from up stream
Snow identified the source of Inf.
Common water pump in Broad street
Snow gave the hypothesis
Cholera is a water borne disease

Snows Cholera Map

OTHER EXAMPLES OF SPOT MAPS


AIDS:
Case clustering based on sexual contact and blood
products provided the clue that AIDS is an Infectious
disease

CLASSICAL EXAMPLES OF PLACE RELATED DISEASES


Yellow fever: In Africa & Americas but not in Asia
Schistosomiasis: Middle East and Africa
Sleeping sickness: Africa
ALL DISEASES HAVE SOME SPECIFIC GEOGRAPHIC DISTRIBUTION

IMPORTANCE OF GEOGRAPHIC VARIATION


Relating the variations to agent, host & env. factors
Clues to source and spread of disease
Formulation of etiological hypothesis
Clinician also get clues for diagnosis based on
geographic distribution of diseases

MIGRATION STUDIES
To evaluate the role of possible genetic and environmental
factors in disease causation
A.
Comparison of disease and death rates in migrants with
those of their kins who stayed at home
(Genetically similar groups, under different environments)
If the rates (after some years) are similar to country of
adoption
Change in the environment
Study of twins in two different environments

B.
Comparison of migrants with local population of host
country
(Genetically different, under same environment)
If rates of disease and deaths are similar to the country
of origin
Genetic factors responsible
Examples of Migration studies:
1. Japanese living in USA have a higher coronary heart
disease than Japanese in Japan
2. Japanese in USA have similar (to USA) rate of
stomach and colon cancer

PERSON DISTRIBUTION
1.AGE: Childhood-Measles
Middle age-Cancer
Old age-Atherosclerosis
Chronic diseases show progressive increase with
age (Cumulative exposure to some risk factors)
Bimodality:
2 separate peaks in age incidence curve
Hodgkins disease, leukaemia, Breast Cancer in females
Indicates 2 distinct set of causal factors may be present
Only small number of observations

Hodgkin's disease
8
Rate

6
4
2
0
0

10 20 30 40 50 60 70 80 90
Age

Bimodal peak

2.SEX
In males: Coronary heart disease, Lung Cancer
In females: Diabetes, Hyperthyroidism, Obesity
Causes:
Basic biological differences including sex linked genetic
inheritance, Cultural and behavioral differences
(smoking, automobiles use, alcoholism)
3.ETHNICITY
Diabetes - Asians
Congenital adrenal hyperplasia - Eskimos
Tay sachs disease - Jews
Causes: Genetic/Environmental factors

4.MARITAL STATUS
For married persons: Less mortality
Less morbidity
Less mental illness
Less suicide rate
More Sexually Transmitted Diseases
More Cancer cervix
(Hypothesis from the studies which
shows that Cancer cervix is rare in nuns)

Why lower morbidity & mortality in married persons ?


Those who are healthy are more likely to get married
Sober life

5.OCCUPATION
Altered Habits
Sedentary workers: Heart disease
Occupational diseases
Coal miners: Silicosis
Bysinossis: Cotton dust
Occupation accidents

6.SOCIAL STATUS
High Social Class
Better health,
Better nutritional status,
longer life expectancy
Coronary Heart Disease, Hypertension, Diabetes
Low Social Class
More Infectious diseases and Alcoholism

7.BEHAVIOUR
Smoking, sedentary life style,
Over eating, drug abuse,
Mass movements (in pilgrimages)-Infections, STDs
8.STRESS
Susceptibility to diseases
9.MIGRATION
Migration from rural to urban areas
(Increase in malaria, filaria, leprosy)

4. MEASUREMENT OF
DISEASE

To know the disease load

A. Cross sectional studies:

Prevalence study
More useful for chronic disease
Distribution pattern may suggest causal hypothesis

B. Longitudinal studies:

Repeated observations of same population over


a long time period by means of follow up examinations

Uses of longitudinal studies:

To study natural history of disease


For identifying risk factors
For finding the incidence rate

5. COMPARING WITH KNOWN INDICES


Comparisons with
different populations
or
with subgroups in the same population
Uses:
Clues to disease etiology
Identify groups at risk

6. FORMULATION OF A HYPOTHESIS
Hypothesis is a supposition ,arrived at from
observation. It can be accepted or rejected,
using the analytical studies
Hypothesis should specify:

1.Population: Characteristics of the persons to


whom the hypothesis applies
2.Specific cause
3.Expected outcome-disease
4.Dose response
5.Time response

Hypothesis:

Smoking of 30-40 cigarettes per day causes lung cancer in


10% of smokers after 20 years of exposure

USES OF DESCRIPTIVE EPIDEMIOLOGY


1.Provide data regarding the magnitude of the disease load
and types of disease problems (morbidity and mortality)
in the community
2.Provide clues to disease etiology
(Possible causal association between a factor & a disease)
3.Provide data for planning, implementing and evaluating
preventive and curative services
4.Contribute to research by describing variations
in disease occurrence by time, place and person