2 - Epidemiology: Amira Shaheen, PHD Abdulsalam Khayyat, PHD Hamzeh Alzabadi, PHD

2nd_Epidemiology
Amira Shaheen, PhD

Abdulsalam Khayyat, PhD
Hamzeh AlZabadi, PhD
What is Epidemiology?
Origins:
 Over 2000 years ago, epidemiology used
to be recognize as environmental factors
that can influence the occurrence of
disease “Hippocrates and others”
 In the nineteenth century start to be
defined as the distribution of disease in
specific human population groups
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What is Epidemiology
Origins:
 This was the time when John Snow observed that
the risk of cholera, in London, was related to the
drinking of water supplied by a particular company
(Southwark company)
 Snow’s discovery led to encourage improvements
in the water supply long before discovering the
organism responsible for Cholera
 His research has a direct impact on public policy
with an emphasize on communicable diseases
where associations between environmental
conditions or agents and specific diseases were
investigated
3
What is Epidemiology
Modern Epidemiology:
 Starts with the work that was done by
Doll and Hill in 1950s
 Both studied the relationship between
cigarette smoking and lung cancer
 This research expand epidemiological
interest to chronic diseases
4
Figure 1: Distribution of cholera cases in the Golden Square
area of London, August-September 1854
According to Snow, the Broad Street pump was the source of
the epidemic
5
Definition of Epidemiology
Epidemiology: “Is the study of the
distribution and determinants of
health-related states or events in
specified populations, and the
application of this study to control of
health problems” (Last, 1988)
6
Introduction
 From the definition: epidemiology can be divided
in two:
1. Descriptive epidemiology: what, who,when and
where? It describes the frequency and pattern of
health events in a population (rate, time, place
and personal characteristics, describe
transmission, distribution and Natural history of
disease)
2. Analytical epdemiology: why and how?

Determinants, causes, and factors that influence
the occurance of the health-related events
(Establish determinates and causes of disease
7
Scope of epidemiology
 The target of a study in epidemiology is a human
population
 A population can be defined in geographical or
other terms, e.g.:
1. Specific group of hospital patients
2. Factory workers
 The most common population used in
epidemiology is that in a given area or country at
a given time
 Demographic factors such as age, sex, ethnicity
should be taken into consideration while doing
epidemiological analysis
8
Using of epidemiology in public health:
 Can lead to the identification of preventive
methods
 Epidemiology lends strong support to both
preventive and clinical medicine
 Epidemiology is often used to describe the
health status of population groups and thus
helps policy makers in identifying priority
health programes for prevention and care
9
 Epidemiologist can be involved in
effectiveness and efficiency of health
services through:
1. The value of treating high blood pressure
2. The efficiency of sanitation measures to
control diarrheal diseases
3. The impact on public health of reducing
lead additives in petrol, and so on
10
Achievements in epidemiology
 Smallpox: The elimination of smallpox
from the world contributed greatly to
the health and well being of millions of
people, mainly in the poorest countries
 The last naturally occurring case of
smallpox was reported in 1977
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Achievements in
epidemiology_Smallpox
 Several factors contributed to the success
of the program:
1. Universal political commitment
2. Definite goal
3. Precise timetable
4. Well trained staff
5. Flexible strategy
6. In addition to the availability of an
effective heat-stable vaccine
12
Methyl-mercury poisoning: in 1950,

mercury compounds were released
with the water discharged from a
factory in Minamata, Japan, into a
small lake. This led to the
accumulation of methyl-mercury in
fish, causing sever poisoning in people
who eat them (WHO, 1976)
13
Achievements in epidemiology_
Methyl mercury poisoning
A reported epidemic of disease caused
by environmental pollution
 The first cases thought to be infectious
meningitis
 Through observation they found that
121 infected patients were living near
the Minamata lake
14
Achievements in epidemiology_
Methyl mercury poisoning
 A survey was done to investigate the causes.
The results showed that:
 Victims were exclusively members of families
whose main occupation was fishing
 People visiting these families and family
members who ate small amounts of fish did not
suffer from the disease
 It was concluded that something in the fish
poisoned the patients and the disease was not
communicable or genetically determined
15
Rheumatic fever and rheumatic heart disease:
 Is associated with poverty, particularly poor
housing and overcrowding, where streptococcal
upper respiratory tract infections favor to spread
 In many developed countries the decline in
rheumatic fever started at the beginning of
the 20th centaury, long before the
introduction of effective drugs such as
sulfonamides and penicillin
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Rheumatic fever and rheumatic heart disease:
 Today the disease has almost disappeared from
developed countries except in few areas among
socially and economically disadvantage groups
 Today, RHD is the most common forms of heart
disease in developing countries
 Epidemiological studies have highlighted the role
of social and economic factors that contribute to
outbreaks of rheumatic fever and to the spread
of streptococcal throat infection
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Iodine deficiency: It associated by the
loss of physical and mental wellbeing
that is caused by inadequate
production of the iodine_containing
thyroid hormone
 Only in 1915 effective prevention and
control was applied through the use of
iodized salt to cure from Goiter
18
Iodine deficiency:
 In 1924, a large trials with iodine were carried out in
Ohio/USA, on 5000 girls aged between 11-18 years. The
prophylactic ad therapeutic effects were impressive and
iodized salt was introduced on a community scale
 This prevention is effective because salt is used by all
sections of society roughly the same level throughout the
year
 Success depends on the effective production and
distribution of the salt and requires legislative
enforcement, quality control and public awareness
 However, there was unnecessary delay in adopting this
strategy in the developing countries where iodine
deficiency is still endemic
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Epidemic Disease Occurrence
 Level of disease:
 The baseline level of a disease in a community is

often considered as the expected level of the disease
 Example: over the past 4 years the number of

reported cases of poliomyelitis has ranged from 5 to
9. Therefore, assuming there is no change in
population, we would expect to see approximately 7
reported cases next year
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Level of disease:
• Endemic: when the disease is maintained in the

population without the needs for external outputs
(A persistent level of occurrence with a

low to moderate disease level is
referred to as an endemic level)
• An irregular pattern of occurrence, with

occasional cases occurring at irregular
intervals is called sporadic
21
Level of disease:
• Epidemic (Outbreak): occurs when new cases

of a disease, in a given human population, and
during a giving period of time, substantially
exceed what is expected based on recent
experience in an area
• Pandemic: if an epidemic spreads to other

countries or continents and affects substantial
number of people
22
Uses of epidemiology in public health
practice
1. Health surveillance
2. Disease investigation
3. Analytic studies
4. Program evaluation
23
Descriptive Epidemiology
24
Descriptive epidemiology
 In descriptive epidemiology, we
organize and summarize data
according to time, place, and
person. They are sometimes
called the epidemiological
variables
25
Descriptive epidemiology; Time
 Health problem rate exchange over time
 Depending on our interests: we might
describe the pattern in years, months,
weeks….etc! and we can here identify the
epidemic period.
 We can use for example « secular-long
term-trends » by graphing annual cases or
rate of a disease over a period of years (Fig.
2)
26
Figure 2: Malaria by year, United States,
1930-1990
27
Descriptive epidemiology; Time
 We can use also « seasonality » by graphing
the occurrence of a disease by week or month
over the course of a year or more (Fig. 3)
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Descriptive epidemiology; Place
 To gain insight into the geographical extent
of the problem
 We may use place of residence, birthplace,
place of employment, school district,
hospital unit..etc!!
 Sometimes we may find it useful to analyze
data according to place categories such as
urban or rural, refugee camps..etc!!
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Descriptive epidemiology; Place
By analyzing data by place, we

can get an idea of where the
agent that causes a disease
normally lives and multiplies
What may carry or transmit it,
and how it spreads
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Descriptive epidemiology; Person
 We may use inherent characteristics of people (for
example, age, race, sex)
 Their acquired characteristics (immune or marital
status)
 Their activities (occupation, foods, use of
medications/tobacco/drugs)
 Or the conditions under which they live
(socioeconomic status, access to medical care)
 These categories determine who is at greatest risk
of experiencing some health condition
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Analytical Epidemiology
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Analytical epidemiology
 Analytical epidemiology is concerned with the
search for causes and effects, or the why and
the how.
 Identifying factors that are associated with
disease helps us identify populations at
increased risk of disease
 Identifying risk factors also provides keys to
direct research activities into the causes of a
disease, hence prevention
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Analytical epidemiology; Bradford Hill
 Bradford Hill (1965) criteria of causation;
Suggested that the following aspects of an
association be considered in attempting to
distinguish causal from non-causal
associations: NEXT SLIDE
34
 Bradford Hill (1965) criteria of causation;
1. Temporal relationship
2. Strength of the association
3. Biological plausibility
4. Dose–response relationship
5. Replication of the findings
6. Effect of removing the exposure (reversibility)
7. Study design
8. Consistency with other knowledge
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1. Temporal Effect:
Exposure must precede disease
Essential criterion for causality
Knowledge of:
– Latency period
– Incubation period
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2. Strength of association;
Strong associations are more likely to be
causal than weak ones
Smoking > 20 cigarettes/day lead to higher

risk of lung cancer
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3. Biologic plausibility; is consistent with current
biological and medical common knowledge.
Smoking
Ingesting of chemicals and known carcinogens
Lung cancer
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4. Dose-response relationship;
Risk increases with more intense/more
frequent exposure
The more cigarettes are smoked, the greater
the risk of lung cancer.
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5. Consistency with other knowledge;

Association is supported by the results of
different disciplines
 e.g:
– Animal studies
– Other data sets
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6. Study design….
Chance?
Mistakes?
Alternative hypothesis?
41
7. Replication of the findings; similar findings
found in:
Different areas
Different populations
By using different study designs
42
8. Effect of removing the exposure;
A decrease in the
outcome of interest E.g How improving road would influence
is seen when the The occurrence of road traffic crashes?

exposure is removed
43
Specificity of the association is also important
 Strengthens evidence if the cause has ONLY
one effect.
Asbestos exposure
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Causation
A cause of a disease is an event, condition,
characteristic, or combination of these factors
which plays an important role in producing
the disease
A cause could be sufficient or necessary
45
Sufficient and component cause
A sufficient cause is a set of minimal conditions or events that inevitably produce
disease
Potato chips
Y
W Obesity
No exercise High
A
cholesterol
C
T
Genes
X B
Smoking
Stress
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Risk Factors
The term risk factors refers to those
factors that have a direct link to the
cause of the disease but are not
sufficient to cause the disease
They increase the chance of
contacting a health condition but
themselves not enough. e.g. poverty,
education, smoking... etc.
47
Analytical Epidemiology
Analytical epidemiologic studies fall into
two categories: experimental
(intervention) and observational
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Epidemiological Study Designs
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Descriptive Vs Analytical designs
 Data that obtained from descriptive
epidemiological study designs help
in generate hypothesis
 Data that obtained from analytical

epidemiological study designs help
in testing hypothesis
50
Epidemiological study design
Hypothesis formation
Descriptive
Ecological Case report Case series
epidemiology
Analytic
epidemiology
Clinical
Hypothesis testing
trials
Case-
Cross-
Cohort control
sectional
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Descriptive Study Designs
52
Descriptive study designs
Descriptive study designs include case reports,
case series, and ecologic studies.
The case report is the most elementary study

design in the literature. It generally describes
an injury or injuries to one or two individuals
that have been identified in a medical setting.
There is also usually a unique feature to the
noted chronic disease.
53
 The case series design is an extension of the case
report. In a case series, a number of events are
described. These events usually have been
observed over a set period of time (such as one
year) and are identified from one reporting source
(e.g. a hospital).
 The ecologic study is a hypothesis generating study.

Usually using group-level data, it examines if two
factors are correlated with each other.
54
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Ecological Study design
 Basic observational study
 Studies population/groups/ clusters rather than
individuals
 At least one variable is measured at the group
(not individual) level
 Suitable for hypothesis generation not cause
and effect
56
Ecological studies
 Associations on population levels might not
reflect associations on individual levels
 Example; do not know individuals who are
obese tend also to be depressed
 Ecologic Fallacy; incorrectly assuming that an
association on a population level reflect an
association on an individual level
57
Ecological Fallacy; example
 Imagine a study of coronary heart disease rate in the capital
cities of the world relating the rate to average income
 Within the cities studied, CHD is higher in the richer cities
than in the poorer ones
 We might predict from such a finding that being rich
increases your risk of heart disease
 In the industrialized world the opposite is the case; within
cities such as London, poor people have higher CHD rates
than rich one
 The ecological fallacy is usually interpreted as a major
weakness of ecological analyses
 Ecological analyses, however, informs us about forces which
act on whole populations
58
Analytical Study Designs
59
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Cross-sectional studies
An “observational” design that surveys
exposures and disease status at a single point
in time (a cross-section of the population)
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63
64
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Cross-sectional design_Uses
 Often used to study conditions that are relatively
frequent with long duration of expression
(nonfatal, chronic conditions)
 It measures prevalence, not incidence of disease
 Example: community surveys
 Not suitable for studying rare or highly fatal
diseases or a disease with short duration of
expression
66
Cross-sectional design
 Limitations;
-Weakest observational design, (it measures
prevalence, not incidence of disease).
Prevalent cases are survivors
-The temporal sequence of exposure and effect
may be difficult or impossible to determine
-Usually don’t know when disease occurred
-Rare events a problem. Quick recovery is also a
problem
67
Case_control design_uses
An “observational” design comparing
exposures in disease cases vs. healthy
controls from same population
Exposure data collected retrospectively
Most feasible design where disease
outcomes are rare
68
Case-control design_feature
Cases: Disease
Controls: No disease
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Case-control design
 Strengths;
– Less expensive and less time consuming
– Efficient for studying rare diseases
72
Case-control design
 Limitations;
– Inappropriate when disease outcome for a
specific exposure is not known at start of
study
– Disease status can influence selection of
subjects
73
Cohort Study
 An “observational” design comparing individuals
with a known risk factor or exposure with others
without the risk factor or exposure
 Looking for a difference in the risk (incidence) of
a disease over time
 Best observational design
 Data usually collected prospectively (some
retrospective)
74
Timeframe of Studies
Prospective Study; looks forward, looks to
the future, examines future events, follows a
condition, concern or disease into the future
time
Study begins here
75
Timeframe of studies
Retrospective Study; “to look back”, looks
back in time to study events that have
already occurred
time
Study begins here
76
Prospective cohort studies
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Cohort studies
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Cohort studies
Prospective vs. Retrospective
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Cohort studies
Prospective vs. Retrospective
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Reminder: Cohort vs. Case
Control studies
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The difference between a retrospective
cohort and a case-control study is as follows:
In a case control study we separate groups by

disease status and then look backwards for
exposures.
In a retrospective cohort we separate groups

by exposure and then look at disease status.
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Cohort Study
Strenghts;
– Exposure status determined before disease
detection
– Subjects selected before disease detection
– Can study several outcomes for each exposure
89
Cohort Study
Limitations
– Expensive and time-consuming
– Inefficient for rare diseases or diseases with

long latency
– Loss to follow-up
90
Experiment_ RCTs
The “Gold Standard” of research design
RANDOMIZATION outcome
Intervention
no outcome
Study
population
outcome
Control
no outcome
baseline
future
time
Study begins here (baseline point)
91
Randomized control trial_Intervention
 The “Gold Standard” of research design

- Trials of hormone replacement therapy in menopausal
women found no protection for heart disease,
contradicting findings of prior observational studies
- It is not unexpected to find that observational studies find
different results than for clinical trials. For example there have
been 100 of observational studies demonstrating that
hormone replacement was protective for women. However,
when this was put to a clinical trail, the surprising result was
that hormone replacement was not protective
92
Phases of the clinical trials
 Phase I trials: Initial studies to determine the metabolism
and pharmacologic actions of drugs in humans. May
include healthy participants and/or patients." Drug is tested
in a small group (8-80) to evaluate its safety and to explore
possible side effects and the doses at which they occur.
 Phase II trials: Describes these as "Controlled clinical

studies” conducted to evaluate the effectiveness of the
drug for a particular indication or indications in patients
with the disease or condition under study and to determine
the common short-term side effects and risks." The new
treatment might be tested in a somewhat larger group (80-
200).
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Phases of the clinical trials
 Phase III trials: "Expanded controlled and uncontrolled
trials” after preliminary evidence suggesting effectiveness
of the drug. Intended to evaluate the overall benefit-risk
relationship of the drug and provide adequate basis for
physician labeling." Conducted in larger groups (200-
40,000) to formally test effectiveness and establish the
frequency and severity of side effects compared to no
treatment, or, compared to currently used treatments
("usual care")
 Phase IV trials: Post-marketing "surveillance" to collect
information regarding risks, benefits, and optimal use. This
phase can be particularly important for identifying rare, but
potentially devastating side effects.
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Used to assess efficacy and safety of a new
treatment or preventive intervention
Compare alternative treatment
Evaluate the effectiveness and efficiency of different

forms of service provision
Provide direct evidence that exposure to a suspected

agent causes disease or that its removal prevents or
reduces the frequency of disease
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The use of this design is limited primarily by ethical
constraints
In principle similar to cohort study
Volunteers are not acceptable
Subject must be allocated at random to test against

control group
Stratification is sometimes desirable
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Ideally, neither the subject nor the

assessor know to which gp the
participant belongs (double blind)
If the patient the does not know the
treatment this is called single blind
If both: double blind
If patient, assesser and analyser (triple
blind)
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 Limitations;
–Very expensive
– It may be unethical, for example, to assign
persons to certain treatment or comparison
groups
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In Summary …
 Choice of study design depends on;
1. Nature of the disease

2.Type of exposure
3.Available resources
4.Logistic of time
5.Availability of documentation
6.Results of previous studies
7.Gaps in knowledge that remained to be filled
99
Measures of Frequency
100
Introduction
 In epidemiology, many nominal variables have
only two possible categories: alive or dead;
case or control; exposed or unexposed.
 Such variables are called “dichotomous”.
 The frequency measures we use with

dichotomous variables are ratios, proportions,
and rates.
101
Introduction
 All three measures are based on the same
formula:
 X and y are the two quantities that are being
compared
 The size of 10n may equal 1, 10, 100, 1000
and so on depending upon the value of n. For
example:
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Ratio, and rate
 In the formula , if x is not included in y, this
is called ratio. If x is included in y, this is
called proportion.
 The rate, is often a proportion: it measures the

occurrence of an event in a population over
time. The basic formula for a rate is as follows:
103
Ratio, and rate
 In rate formula:
 Persons in the denominator must reflect the

population from which the cases in the
numerator arose
 The counts in the numerator and denominator
should cover the same time period
 Persons in the denominator must be “at risk” for
the event (possible for them to experience the
event)
104
Uses of Ratio, and rate
Ratios and rates are used to characterize
populations by age, sex, race, exposures,
and other variables
Ratios and rates are also used to

describe three aspects of the human
condition: morbidity (disease), mortality
(death) and natality (birth)
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Frequency measures
106
Incidence Vs Prevalence
107
Incidence Vs Prevalence
108
Incidence, prevalence, Duration
109
Relationship between prevalence and
incidence
110
Incidence Rate
 The most common way of measuring and
comparing the frequency of health problem
in populations
 It is the probability or risk of having the
health problem in a population over a
period of time “mid-time point”
 Sometimes referred as incidence
 The formula for calculating an incidence
rate :
111
Incidence rate
 E.g.
In 1989, 733,151 new cases of gonorrhea were
reported among the United States civilian
population. The 1989 mid-year U.S. civilian
population was estimated to be 246,552,000. For
these data we will use a value of 10x5 for 10xn.
Solution:
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Cumulative Incidence
When the denominator is the
size of the population at the
start of the time period, the
measure is sometimes called
cumulative incidence
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Person_time rate
A person-time rate is a type of incidence

rate that directly incorporates time into
the denominator.
Typically, each person is observed from a

beginning point to an end point (onset of
disease, death, migration out of the
study, or end of the study).
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Person_time rate
The numerator is still the number of

new cases, but the denominator is a
little different.
The denominator is the sum of the time
each person is observed, totaled for all
persons.
Formula:
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Person_time rate
 For example:
 A person enrolled in a study develops the

disease 5 years later contributes 5 person-
years to the denominator.
 A person who is disease-free at one year

and who is then lost to follow-up
contributes just that 1 person-year to the
denominator.
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Person_time rate
Person-time rates are often used in
cohort (follow-up) studies of diseases
with long incubation or latency periods,
such as some occupationally related
diseases, AIDS, and chronic diseases.
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Frequency measures/prevalence
 Prevalence or “prevalence rate”:
The proportion of persons in a population who have

a particular disease at a specified point in time or
over a specified period of time.
The formula is:
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Point vs. period prevalence
 Point Prevalence: how much of a particular
disease is present in a population at a single
point in time
 Period Prevalence: how much of a particular
disease is present in a population over a longer
period
 Example: In a survey of patients at a sexually
transmitted disease clinic, 180 of 300 patients
interviewed reported use of a condom at least
once during the 2 months before the interview.
The period prevalence of condom use over the
last 2 months is:
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Comparison of prevalence and incidence
Numerator of Incidence = new cases

occurring during a given time period
Numerator of Prevalence = all cases

present during a given time period
Prevalence is based on both incidence

(risk) and duration of disease
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High prevalence of a disease within a

population may reflect high risk, or it
may reflect prolonged survival without
cure
Conversely, low prevalence may indicate

low incidence, a rapidly fatal process, or
rapid recovery
122
We often use prevalence rather than

incidence to measure the occurrence of
chronic diseases such as osteoarthritis
which have long duration and dates of
onset
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Measures of Associations
124
Risk ratio “relative risk” or rate
ratio: RR
 Measure of association quantifies the relationship
(association) between the exposure (e.g. sex, etc…)
and health outcome (e.g. pellagra)
 Compares the risk of some health-related event

such as disease or death in two groups
 The two groups are typically differentiated by

demographic factors such as sex (e.g., males versus
females) or by exposure to a suspected risk factor
(e.g., consumption of potato salad or not)
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ratio: RR
Typically we usually have an “exposed
gp” in the numerator and an “unexposed
gp” in the denominator (comparison gp)
Formula:
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ratio: RR
E.g.
Calculate the (relative risk; RR) or risk ratio of pellagra for

females versus males??
127
ratio: RR
 Solution:
RR=
Interpretation: The risk of pellagra in females

appears to be 2.4 times higher than the risk in males
128
Relative Risk (RR)
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Relative Risk
 RR=1; the risk in exposed is identical to that
in non-exposed group
 RR > 1; the exposed group is at higher risk of
developing the health outcome compared to
non-exposed group
 RR < 1; the exposed group is at lower risk of
developing the health outcome compared to
non-exposed group (protective effect)
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Measure of association; Odds Ratio
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Odds ratio calculation
133
Odds ratio
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Odds ratio
 OR is usually used in cross-section, and case-
control studies
 The best study design to measure a rare

health outcome association with the exposure
is the case-control study. In this case, the RR
is almost equal to the OR.
135
Summary
Study Design Measure of Measure of
frequency association
Cross-Sectional Prevalence Odds Ratio
Cohort Study Incidence Relative Risk
Case-Control Prevalence Odds Ratio
RCT Incidence Relative Risk

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Measures of Impact
137
Attributable Risk (AR)
 Risk difference = attributable risk
 Used when the outcome and exposure are
dichotomous/ binary
 AR= Risk among exposed – Risk among non-
exposed
 AR= 0, this indicates no difference in risk between
exposed groups
 AR is positive; indicated that exposure increases
the risk
 AR is negative; indicates a reduced risk
138
Measures of potential impact
 These measures predicted
impact of removing a
hazardous exposure from the
population
 Two types
– Attributable fraction in
exposed cases
– Attributable fraction in the
population as a whole
139
 Attributable Proportion or “attributable risk
percent”: the proportion of disease in an
exposed group attributable to the exposure
 Formula:
 Attributable proportion can be calculated for

rates in the same way
11/07/2018 140
 Example: calculate the attributable proportion
for persons smoked 1-14 cigarettes/day :
 Solution:
11/07/2018 141
11/07/2018 142
In Exposed gp:
In total population:
11/07/2018 143
Attributable Fraction Exposed
Cases (AFe)
Proportion of exposed cases averted with
elimination of the exposure
RR  1
Formula : AFe 
RR
144
Afe; Example
RR of lung CA associated with moderate
smoking is approx. 10.4. Therefore:
RR  1 10.4  1
AFe    .904
RR 10.4
Interpretation: 90.4% of lung cancer in
moderate smokers would be averted if they
had not smoked.
145
Attributable Fraction, population (AFP)
Proportion of all cases averted with

elimination of exposure from the population
R  R0
Definitional formula : AFp 
R
where
R  overall rate
R0  rate in nonexposed population
146
Attributable Fraction, population
(AFP)
AFp equivalent formulas;
AF p  AFe  pc
where pc  proportion of cases that are exposed
pe ( RR  1)
AF p 
1  pe ( RR  1)
where pe  prevalence of exposure in population
147

2 - Epidemiology: Amira Shaheen, PHD Abdulsalam Khayyat, PHD Hamzeh Alzabadi, PHD

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2 - Epidemiology: Amira Shaheen, PHD Abdulsalam Khayyat, PHD Hamzeh Alzabadi, PHD

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2nd_Epidemiology

Amira Shaheen, PhD

2. Analytical epdemiology: why and how?

Methyl-mercury poisoning: in 1950,

 The baseline level of a disease in a community is

 Example: over the past 4 years the number of

• Endemic: when the disease is maintained in the

(A persistent level of occurrence with a

• An irregular pattern of occurrence, with

• Epidemic (Outbreak): occurs when new cases

• Pandemic: if an epidemic spreads to other

By analyzing data by place, we

Smoking > 20 cigarettes/day lead to higher

Ingesting of chemicals and known carcinogens

5. Consistency with other knowledge;

is seen when the The occurrence of road traffic crashes?

 Data that obtained from analytical

The case report is the most elementary study

 The ecologic study is a hypothesis generating study.

Study begins here

In a case control study we separate groups by

In a retrospective cohort we separate groups

– Subjects selected before disease detection

– Can study several outcomes for each exposure

– Inefficient for rare diseases or diseases with

 The “Gold Standard” of research design

 Phase II trials: Describes these as "Controlled clinical

Compare alternative treatment

Evaluate the effectiveness and efficiency of different

Provide direct evidence that exposure to a suspected

In principle similar to cohort study

Volunteers are not acceptable

Subject must be allocated at random to test against

Stratification is sometimes desirable

Ideally, neither the subject nor the

1. Nature of the disease

 Such variables are called “dichotomous”.

 The frequency measures we use with

 The rate, is often a proportion: it measures the

 Persons in the denominator must reflect the

Ratios and rates are also used to

A person-time rate is a type of incidence

Typically, each person is observed from a

The numerator is still the number of

 A person enrolled in a study develops the

 A person who is disease-free at one year

The proportion of persons in a population who have

The formula is:

Numerator of Incidence = new cases

Numerator of Prevalence = all cases

Prevalence is based on both incidence

High prevalence of a disease within a

Conversely, low prevalence may indicate

We often use prevalence rather than

 Compares the risk of some health-related event

 The two groups are typically differentiated by

Calculate the (relative risk; RR) or risk ratio of pellagra for

Interpretation: The risk of pellagra in females

 The best study design to measure a rare

Cross-Sectional Prevalence Odds Ratio

Cohort Study Incidence Relative Risk

Case-Control Prevalence Odds Ratio

RCT Incidence Relative Risk