Subject:- Community

Health Nursing

Topic:- Epidemiology

PRESENTED BY,
MR. KAILASH NAGAR
ASSIST. PROF.
DEPT. OF COMMUNITY HEALTH NSG.
DINSHA PATEL COLLEGE OF NURSING, NADIAD
1. Introduction to Epidemiology

2
 Definitions

Health: A state of complete physical, mental and social well-

being and not merely the absence of disease or
infirmity (WHO,1948)

Disease: A physiological or psychological dysfunction

Illness: A subjective state of not being well

Sickness: A state of social dysfunction

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 Definitions…

Public health

The science & art of

Preventing disease,
prolonging life,
promoting health & efficiency
through organized community effort (Winslow, 1920)

4
 Definitions…

Epidemiology

It is the study of frequency, distribution, and

determinants of diseases and other health-related
conditions in a human population
and
the application of this study to the prevention of
disease and promotion of health

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 Components of the definition

1.Study: Systematic collection, analysis and

interpretation of data

Epidemiology involves collection, analysis and

interpretation of health related data

Epidemiology is a science

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 Components…

2. Frequency: the number of times an event occurs

Epidemiology studies the number of times a disease

occurs

It answers the question How many?

Epidemiology is a quantitative science

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 Components…

3. Distribution: Distribution of an event by person,

place and time

Epidemiology studies distribution of diseases

It answers the question who, where and when?

Epidemiology describes health events

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 Components…

4. Determinants: Factors the presence/absence of

which affect the occurrence and level of an event

Epidemiology studies what determines health events

It answers the question how and why?

Epidemiology analyzes health events

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 Components…

5. Diseases & other health related events

Epidemiology is not only the study of diseases

The focus of Epidemiology are not only patients

It studies all health related conditions

Epidemiology is a broader science

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 Components…

6. Human population

Epidemiology diagnoses and treats

communities/populations

Clinical medicine diagnoses and treats patients

Epidemiology is a basic science of public health

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 Components…

7. Application

Epidemiological studies have direct and practical

applications for prevention of diseases &
promotion of health

Epidemiology is a science and practice

Epidemiology is an applied science

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 History of Epidemiology

Seven land marks in the history of Epidemiology

1. Hippocrates (460BC): Environment & human

behaviors affects health
2. John Graunt (1662): Quantified births, deaths
and diseases
3. Lind (1747): Scurvy could be treated with fresh
fruit

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 History…

4. William Farr (1839): Established application of vital

statistics for the evaluation of health problems
5. John Snow (1854): tested a hypothesis on the origin
of epidemic of cholera
6. Alexander Louis (1872): Systematized application of
numerical thinking (quantitative reasoning)

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 History…

7. Bradford Hill (1937): Suggested criteria for

establishing causation

Epidemiological thought emerged in 460 BC

Epidemiology flourished as a discipline in 1940s

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 Scope of Epidemiology

Originally, Epidemiology was concerned with

investigation & management of epidemics of
communicable diseases

Lately, Epidemiology was extended to endemic

communicable diseases and non-communicable
infectious diseases

Recently, Epidemiology can be applied to all

diseases and other health related events
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 Purpose/use of Epidemiology

The ultimate purpose of Epidemiology is prevention

of diseases and promotion of health

How?
1. Elucidation of natural history of diseases
2.Description of health status of population
3. Establishing determinants of diseases
4. Evaluation of intervention effectiveness

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 Types of Epidemiology

Two major categories of Epidemiology

1.Descriptive Epidemiology

Defines frequency and distribution of diseases

and other health related events

Answers the four major questions: how many,

who, where, and when?

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 Types…

2. Analytic Epidemiology

Analyses determinants of health problems

Answers two other major questions: how? and

why?

Generally, Epidemiology answers six major

questions: how many, who, where, when, how
and why?

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 Basic Epidemiological assumptions

1.Human diseases doesn’t occur at random or by

chance

2. Human diseases have causal and preventive

factors

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 Basic features of Epidemiology

1. Studies are conducted on human population

2. It examines patterns of events in people
3. Can establish cause-effect relationship without
the knowledge of biological mechanism
4. It covers a wide range of conditions
5. It is an advancing science

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2. Communicable disease
Epidemiology

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 Disease causation

The cause of a disease

An event, a condition or a characteristic that comes

before the disease and without which the disease
wouldn’t occur

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 Theories of disease causality

What causes a disease?

Ninetieth century theories
1. Contagion theory
2. Supernatural theory
3. Personal behavior theory
4. Miasma theory

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 Theories…

Twentieth century theories

1. Germ theory
2. Lifestyle theory
3. Environmental theory
4. Multi-causal theory

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 Necessary Vs Sufficient

Necessary: the disease will not occur without the

presence of the factor
Example: Mycobacterium TB for TB

Sufficient: the presence of the factor always result

in disease
Example: Rabies virus for rabies

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 Etiology of a disease

The sum of all factors contribution to the

occurrence of a disease

Agent factors +Host factors +Environmental factors

= Etiology of a disease

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 Disease models

How do diseases develop?

Three best known models

1.Epidemiological triangle
The interaction of an agent and host in an appropriate
environment results in disease

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 Disease models…

2. Web of causation
Complex interaction of factors results in disease

3. Wheel model
The hub (host) having a genetic make up as its core,
surrounded by an environment schematically divided in
to biological, physical and social

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 Natural history of disease

The progression of disease process in an individual

overtime in the absence of intervention

Four stages in the natural history of a disease

1.Stage of susceptibility
Presence of factors
No disease

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 Natural history…

2. Stage of sub-clinical disease

Presence of pathogenic changes (biological onset)
No disease manifestations

3. Stage of clinical disease

Presence of sign and symptoms (clinical onset)

4. Stage of recovery, disability,or death

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 Levels of disease prevention

Three major levels of disease prevention

1. Primary prevention
Targeted at healthy people

Objectives are Promotion of health

Prevention of exposure and
Prevention of disease

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 Levels of disease…

2. Secondary prevention

Targeted at sick individuals

Objective is to stop or slow the progression of

disease and to prevent or limit permanent damage
through early detection & treatment

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 Levels of disease…

3. Tertiary prevention

Targeted at people with chronic diseases &

disabilities that can’t be cured

Objective is to prevent further disability or death and

to limit impacts of disability through rehabilitation

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 Infectious disease process

There are six components of the infectious disease

process constituting chain of disease transmission

1.The agent 2. Its reservoir

3. Its portal of exit 4. Its mode of transmission
5. Its portal of entry 6. Susceptible host

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 The agent
Possible outcomes of exposure to an infectious agent

Infection: invasion & multiplication in the host

Infectivity: the proportion of exposed who becomes

infected
Infection rate= Infected/exposed
Disease: A clinically apparent infection

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 The agent…

Pathogenicity:the proportion of infected who develop

clinical disease
Clinical-to-Subclinical ratio
Virulence: the proportion clinical cases resulting in
severe clinical disease
Case fatality & hospitalization rate
Immunogenecity:the infection’s ability to produce
specific immunity

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 Reservoir Vs Carrier

Reservoir
An organism or habitat in which an infectious
agent normally lives, transforms, develops and/or
multiplies

Carrier
A person who doesn’t have apparent clinical
disease, but is a potential source of infection to
other people

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 Types of carriers

1.Incubatory carriers: transmits the disease during

incubation period
Example: Measles, mumps

2. Convalescent carriers: transmits the disease during

convalescent period
Example: Typhoid fever

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 Types of carriers…

3. Asymptomatic carriers: transmitting the disease

without showing manifestations
Example: polio, Amoebiasis

4. Chronic Carriers: transmitting the disease for long

time/indefinite transmission
Example: Viral hepatitis, typhoid fever

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 Importance of carriers

1. Number- carriers may outnumber cases

2. Difficulty in recognition- carriers don’t know that
they are infected
3. Mobility- carriers are mobile, cases are restricted
4. Chronicity- carriers re-introduce infection and
contribute to endemicity

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 Effect of carriers on disease transmission

• Ice-berg effect in temperate zone

• Hippopotamus effect in tropical zone

These are the fact that carriers constitute a hidden

reservoir of infection and that they may outnumber
actual cases

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 Modes of disease transmission
1.Direct transmission
Direct contact: physical contact with body part of
infected person: Touching, kissing,biting,sex
Example: HIV
Direct projection: projection of saliva droplets
while coughing, sneezing,spitting,talking,singing
etc
Example: Common cold
Transplacental: Transmission from mother to
fetus through the placenta
Example: Syphilis
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 Modes of disease…

2. Indirect transmission
Vehicle-borne: transmission through inanimate
objects/non-living substances e.g HIV by needles

Air-borne: transmission by dust or droplet nuclei

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 Modes of disease…

Vector-borne: infectious agent is conveyed by an

arthropod to host
Biological: there is multiplication and/or
development in the vector
Salivarian: Injects infected saliva e.g mosquito
Stercorarian: infects by infected feaces e.g louse
Mechanical: simple transfer without biological
stages in the vector e.g flies

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 Importance of mode of transmission

• A disease often has several modes of transmission

• It is important to distinguish between the

predominant mode of transmission and those of
secondary importance

• Identifying primary and secondary modes of

transmission is important to identify most
effective prevention and control measures

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 Herd immunity

It is host resistance at a population level

It is defined as the resistance of a community

(group) to invasion and spread of an infectious
agent, based on immunity of high proportions of
individuals in the community.

It has implications on vaccination programs

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 Conditions under which herd immunity best
functions
1. Single reservoir
2. Direct transmission
3. Total immunity
4. No carrier state
5. Uniform distribution of immunes
6. No overcrowding

Seldom all fulfilled

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 Time course of an infectious disease

Pre-patent period: between biological onset

and first shedding

Incubation period: between biological onset

and clinical onset

Communicable period: time during which

agent is being shed
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 Time course of…

Latent period: between recovery and relapse in clinical

disease

Convalescent period: between recovery and time when

shedding stops

Generation period: between exposure/infection and

maximum communicability of exposed host

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 Application of time periods
• Pre-patent period
– When should we investigate?
• Incubation period
– When was time of exposure?
• Communicable period
– When should we take care of infectiousness?
• Latent period
– When would relapse occur?
• Convalescent period
– When,after recovery an individual becomes non-infectious?
• Generation time
– When is the maximum risk for contacts?

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Factors which influence the development of
disease
Strain of the agent
Dose of the agent
Route of infection
Host age, nutritional status, immune status
Influence of treatment
Influence of season

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3. Measures of disease
occurrence

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What are measures of disease occurrence?

These are measurements of the

frequency/magnitude/amount
of disease
in populations

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 How do we measure diseases?

Four quantitative descriptors

• Numbers
• Ratios
• Proportions
• Rates

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 Descriptors

Numbers: Use of actual number of events

e.g 100 cases of TB in community A

Ratios: Quantifies the magnitude of one occurrence X,

in relation to another event Y as X/Y
e.g Ratio of TB cases in community A to B is 1:10

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 Descriptors

Proportions: a ratio in which the numerator is

included in the denominator
e.g proportion of TB cases in community A is 10%

Rates: a proportion with time element

It measure the occurrence of an event overtime
e.g U5 measles cases in 2000/U5 population in 2000

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Which community is more affected?

Community A has 100 cases of disease X

and
Community B has 1000 cases of disease X,

which community is more affected?

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 When we call..

• When we call a measure a ratio, we mean a non-

proportional ratio

• When we call a measure a proportion, we mean a

proportional ratio that doesn’t measure an event
overtime

• When we call a rate, we mean a proportional

ratio that does measure an event in a population
overtime

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 Types of rates
1. Crude rates: Apply to the total population in a
given area

2. Specific rates: Apply to specific subgroups in the

population (age, sex etc) or specific diseases

3. Standardized rates: used to permit comparisons

of rates in population which differ in structure
(e.g age structure)
Two methods of standardization:Direct, indirect
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 Morbidity rates
Morbidity rates are rates that are used to quantify
the magnitude/frequency of diseases

Two common morbidity rates

Incidence rates(Cumulative incidence, incidence
density)
Prevalence (Period prevalence, point prevalence)

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 Incidence rate
The proportion of a population that develops a
disease overtime

The risk/probability of an individual developing a

disease overtime

The rapidity with which new cases of a disease

develop overtime

The proportion of unaffected individuals who on

average will contract the disease overtime

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 Cumulative incidence

Number of new cases of a

Cumulative = disease during a specified period
Incidence Population at risk in the same
Period

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Practical challenges in measuring incidence rate

1. Identification of population at risk

Population at risk constitutes all those free of
the disease and susceptible to it

2. Population is not static/it fluctuates/as a result

of births, deaths and migration

3. People are at risk only until they get the disease

and then no more at risk

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 Practical solution to the challenges

1. Use the total population as a denominator

This gives an estimate of the incidence rate and not
the actual incidence rate

2. Use person-time at risk

Incidence density=number of new cases of a
disease over a specified period/person-time at risk

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 Prevalence rate

It measures the proportion of a population with a

disease during a specified period or at a point in
time

Two types
1. Point prevalence rate
2. Period prevalence rate

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 Point prevalence rate
Measures the proportion of a population with
a disease at a point in time

Point prevalence rate=All persons with a

disease at a point in time/Total population

It is not a rate, but a true proportion

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 Period prevalence rate

Measures the proportion of a population with a

disease in a specified time period

Period prevalence rate=All persons with a

disease overtime period/Average(mid-
year)population in the same period

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 Incidence Vs prevalence

Incidence rate considers only new cases of a disease

Prevalence rate considers all (new + old) cases of a disease

Incidence rate considers population at risk as a denominator

Prevalence rate considers total population as a denominator

Incidence & period prevalence rates require follow up

studies

Point prevalence rate requires cross- sectional study

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 Relationship between prevalence & incidence
rates
Prevalence α incidence
Prevalence α Average duration
Prevalence α Incidence X Average duration

An increase in prevalence rate may not necessarily be

due to an increase in incidence rate, it could due to
an increase in average duration of a disease due to
decrease in death and/or recovery rates

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 Mortality rates

These rates measures magnitude of deaths in a

community

Some are crude like the crude death rate

Others are cause-specific mortality rate

Some others are adjusted like standardized

mortality ration

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 Common Mortality rates

• Crude death rate • Perinatal mortality rate

• Age-specific mortality rate • Neonatal mortality rate
• Sex-specific mortality rate • Infant mortality rate
• Cause-specific mortality rate • Child mortality rate
• Proportionate mortality ratio • Under-five mortality
• Case fatality rate rate
• Fetal death rate • Maternal mortality ratio

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4. Measures of association

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 2X2 table
Disease

Yes (+) No (+) Total

Exposure Yes (+) a b a+b

No (+) c d c+d

Total a+c b+d a+b+c+d

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 Cells

A= Exposed, and diseased

B= Exposed, Not diseased
C= Not exposed, diseased
D= Not exposed, Not diseased

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 Totals

Marginal totals
a+b= Exposed
c+d= Non-exposed
a+c= Diseased
b+d= Non-diseased

Grand total
n = a+b+c+d

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 Chi-square statistics

Chi-square tests whether there is an association

between two categorical variables

Ho: There is no association between row & column

variables
Ha: There is an association between row and column
variables
Chi-square statistic has a degree of freedom (r-1)(c-
1), where r is number of rows & c number of
columns
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 Chi-Square…
Χ 2= Σ (O - E)2
E
O: Observed cells
E: Expected cells

Expected value = (Row total)X(Column total)

Grand total
For a 2X2, table
Χ2= (/ad-bc/-n/2)2n
(a+b)(a+c)(c+d)(b+d)

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 Importance of Chi-square

If the calculated chi-square value is greater than the

critical or P<0.05 we say that there is association

Chi-square statistics tells only whether there is

association. It doesn’t tell us how much strong an
association is.

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 Relative risk (RR)

Expresses risk of developing a diseases in exposed

group (a + b) as compared to non-exposed group (c + d)

RR= Incidence (risk) among exposed

Incidence (risk) among non-exposed

RR= a/(a+b)
c/(c+d)

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 Interpretation of relative risk

What does a RR of 2 mean?

Risk in exposed =RRX Risk in non-exposed

RR of 2 means
Risk in exposed=2X Risk in non-exposed

Thus a relative risk of 2 means the exposed group is

two times at a higher risk when compared to non-
exposed

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 Strength of association

In general strength of association can be

considered as:

High if RR>3
Moderate if RR is between 1.5 & 2.9
Weak if RR is between 1.2 & 1.4

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 Odds ratio (OR)

Odds ratio is the ratio of odds of exposure among

diseased to odds of exposure among non-diseased

Odds of an event E is the ratio of probability of the

event to its complement

Odds=P(E)/P(E’)=P(E)/(1-P(E))

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 Odds ratio…
Odds of exposure among exposed=a/c
Odds of exposure among non-diseased=b/d

OR = Odds of exposure among diseased

Odds of exposure among non-diseased

OR= (a/c)/(b/d)
OR= ad/bc (it is also called cross-product ratio)

Interpretation of OR is the same as that of RR

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 Odds ratio…

RR can be best estimated by OR if the following

conditions are fulfilled

1. Controls are representative of general population

2. Selected cases are representative of all cases
3. The disease is rare

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 Attributable Risk (AR)
AR indicates how much of the risk is due to
/attributable/ to the exposure

Quantifies the excess risk in the exposed that can be

attributable to the exposure by removing the risk of
the disease occurred due to other causes

AR= Risk (incidence) in exposed- Risk (incidence) in non-

exposed

AR= {a/(a+b)} / {c/(c+d)))}

Attributable risk is also called risk difference
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 Interpreting AR

What does attributable risk of 10 mean?

10 of the exposed cases are attributable to the

exposure

By removing the exposure one can prevent 10 cases

from getting the disease

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 Attributable risk percent (AR%)

Estimates the proportion of disease among the

exposed that is attributable to the exposure

The proportion of the disease in the exposed that can

be eliminated by eliminating the exposure

AR%= (Risk in exposed – Risk in non-exposed)X100%

Risk in non-exposed

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 Interpretation of AR%

What does AR% of 10% mean?

10% of the disease can be attributed to the exposure

10% of the disease can be eliminated if we avoid the

exposure

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 Population Attributable Risk (PAR)

Estimates the rate of disease in total population that

is attributable to the exposure

PAR = Risk in population – Risk in unexposed

PAR = ARX prevalence rate of exposure

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 Population attributable risk percent (PAR%)

Estimates the proportion of disease in the study

population that is attributable to exposure and thus
could be eliminated if the exposure were eliminated

PAR%= Risk in population – Risk in unexposed

Risk in population

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Possible outcomes in studying the relationship
between exposure & disease

1. No association
RR=1
AR=0
2. Positive association
RR>1
AR>0
3. Negative association
RR<1 (fraction)
AR<0 (Negative)
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 Risk Vs Preventive factors

A risk factor is any factor positively associated with a

disease (RR>1)
It is associated with an increased occurrence of a
disease
A preventive factor is any factor negatively
associated with a disease (RR<1)
It is associated with a decreased occurrence of a
disease
Risk and preventive factors may (not) amenable to
change (e.g. Smoking, age)

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5. Evaluation of Evidence
(Judgment of causality)

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 Association Vs Causation

The existence of an association doesn’t itself

constitute a proof of causation

An observed association could be a fact or an artifact

Hence, an association is a necessary but not a

sufficient condition for causation

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Possible explanations for observed association

1. Chance
2. Bias
3. Confounding
4. Reverse causation
5. Reciprocal causation
6. Cause-effect relationship

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 Accuracy of measurement

Accuracy = Validity + Precision

Validity is the extent to which a measured

value actually reflects truth

There are two types of validity

– Internal validity
– External validity

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 Types of validity

Internal validity:
Is the degree to which a measured value is true within
the sample

External validity:
Is the extent to which a measured value apply beyond
the sample

This is related to generalizability

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 Precision

Precision is the extent to which random error alters

the measurement of effects

Threats to validity of study:

Random error (chance): is sampling error
Systematic error (bias): is error in the conduct of
the study

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 Judgment of causality

Judgment of causality has two steps

1. Check whether the observed association

between exposure and disease is Valid (Rule
out chance, bias and confounding)

2. Check whether the observed association is

causal (Does the totality of evidence supports
the findings)
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 Role of chance

The role of chance as an alternative explanation for

an association emerges from sampling variability

Evaluation of the role of chance is mainly the

domain of statistics and involves

1. Test of statistical significance

2. Estimation of confidence interval

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 1. Test of statistical significance

P-value quantifies the degree to which chance

accounts for observed association

P-value is the probability of obtaining a result at

least as extreme as the observed by chance alone

P<0.05 indicates statistical significance for medical

research

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 Test of statistical…

A very small difference may be significant if you have

large sample

A large difference may not achieve statistical

significance is you have small sample

One can’t make a definite decision based on p-value

only

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 2. Estimation of confidence interval

Confidence interval represents the range within which

true magnitude of effect lies within a certain degree
of assurance

It is more informative than p-value because it reflects

on both the size of the sample and the magnitude of
effect

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 Role of bias

Bias is any systematic error in the design, conduct or

analysis of an epidemiologic study that results in an
incorrect estimate of association between
exposure and disease

Unlike chance bias can’t be statistically evaluated

There are two major types of bias
1. Selection bias
2. Information bias

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 Selection bias
Any systematic error that arises in the process of
identifying the study population
It affects the representativeness of the study
It occurs when there is a difference between
sample and population with respect to a variable

Examples of selection bias:

1. Diagnostic bias
2. Volunteer bias
3. Non-response bias
4. Loss to follow-up bias

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 Information/observation/bias

Any systematic error in the measurement of

information on exposure or disease

Examples of information bias:

1. Interviewer bias/observer bias
2. Recall bias / Response bias
3. Social desirability bias
4. Placebo effect

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 Ways to minimize bias

1. Choose study design carefully

2. Choose objective rather than subjective
outcomes
3. Blind interviewers whenever possible
4. Use close ended questions whenever
possible
5. Collect data on variables you don’t expect to
differ between two groups
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 Role of confounding

Confounding refers to the mixing of the effect of an

extraneous variable with the effect of the exposure
and disease of interest

Characteristics of a confounding variable

1. Associated with disease in absence of exposure
2. Associated with exposure but not as a consequence of exposure
3. The frequency of the confounding variable vary between the
groups that are compared
Example: In association between smoking and lung cancer alcohol
drinking suspected as a confounding

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 Effect of confounding

Totally or partially account for the apparent effect

Mask an underlying true association

Reverse the actual direction of association

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Control of confounding variables

During designing stage:

– Randomization
– Restriction
– Matching

During analysis stage

– Standardization
– Stratification/pooling
– Multivariate analysis

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Criteria to asses the strength of evidence for
cause and effect relationship
Observational studies have many biases and
confounding. Experimental studies if properly done
can show cause-effect relationship. But they are not
usually feasible due to ethical issues

In the absence of an experimental trail, the following

criteria (Bradford Hill criteria) are used to asses the
strength of evidence for a cause and effect
relationship

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 Criteria to asses the strength…
1. Strength of association: The stronger the
association the more likely it is causal

2. Consistency of association: The more consistent,

the more likely it is causal

3. Specificity of association: If single exposure

linked to single disease more likely

4. Temporal relationship: The exposure must come

before the disease
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 Criteria to asses the strength…

5. Dose-response relationship: risk of disease increase

with increasing exposure with factor

6. Biological plausibility: Knowledge of association

coherent with biology and descriptive epidemiology
of the disease

7. Reversibility: Eliminating the exposure should be

followed by a decrease in the incidence rate of the
disease

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6. Epidemiologic Study Designs

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 Study design

Study design is the arrangement of conditions for

the collection and analysis of data to provide the
most accurate answer to a question in the most
economical way.

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 Types of Epidemiologic study designs

I. Based on objective/focus/research question

1. Descriptive studies
– Describe: who, when, where & how many

2. Analytic studies
– Analyse: How and why

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 Types…

II. Based on the role of the investigator

1. Observational studies
– The investigator observes nature
– No intervention

2. Intervention/Experimental studies
– Investigator intervenes
– He has a control over the situation

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 Types…

III. Based on timing

1. One-time (one-spot) studies

– Conducted at a point in time
– An individual is observed at once

2. Longitudinal (Follow-up) studies

– Conducted in a period of time
– Individuals are followed over a period of time

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 Types…

IV. Based on direction of follow-up/data collection

1. Prospective
– Conducted forward in time

2. Retrospective
– Conducted backward in time

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 Types…

V. Based on type of data they generate

1. Qualitative studies
– Generate contextual data
– Also called exploratory studies

2. Quantitative studies
– Generate numerical data
– Also called explanatory studies

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 Types…

VI. Based on study setting

1. Community-based studies
– Conducted in communities
2. Institution-based studies
– Conducted in communities
3. Laboratory-based studies
– Conducted in major laboratories

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 Types…

VII. Standard classification

1. Cross-sectional studies
2. Case-control studies
3. Cohort studies
4. Experimental studies

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 Cross-sectional studies
In this study design information about the status of
an individual with respect to presence/absence of
exposure and diseased is assessed at a point in time.

Cross-sectional studies are useful to generate a

hypothesis rather that to test it

For factors that remain unaltered overtime (e.g. sex,

race, blood group) it can produce a valid association

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 Cross-sectional…

• Comparison groups are formed after data collection

• The object of comparison are prevalence of exposure
or disease
• Groups are compared either by exposure or disease
status
• Cross-sectional studies are also called prevalence
studies
• Cross-sectional studies are characterized by
concurrent classification of groups

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 Cross-sectional…

Advantages of cross-sectional studies

• Less time consuming

• Less expensive
• Provides more information
• Describes well
• Generates hypothesis

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 Cross-sectional…

Limitations of cross-sectional studies

• Antecedent-consequence uncertainty
“Chicken or egg dilemma”
• Data dredging leading to inappropriate comparison
• More vulnerable to bias

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 Cross-sectional…

Types of cross-sectional studies

1. Single cross-sectional studies
– Determine single proportion/mean in a single population
at a single point in time
2. Comparative cross-sectional studies
– Determine two proportions/means in two populations at
a single point in time
3. Time-series cross-sectional studies
– Determine a single proportion/mean in a single
population at multiple points in time

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 Cross-sectional…

In general, cross-sectional studies are

– Simplest to conduct
– Commonest to find
– Least useful to establish causation

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 Case-control studies

• Subjects are selected with respect to the presence

(cases) or absence (controls) of disease, and then
inquiries are made about past exposure

• We compare diseased (cases) and non-diseased

(controls) to find out the level of exposure

• Exposure status is traced backward in time

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 Case-control…

Steps in conducting case-control studies

I. Define who is a case
– Establish strict diagnostic criteria
– All who fulfil the criteria will be “case population
– Those who don’t fulfil will be “control population”
II. Select a sample of cases from case population
– This sample must be representative of the case
population

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 Case-control…

Sources of cases
1. Hospitals (Health institution)
– Cost-less
– Bias-more

2. Population (Community)
– Cost-more
– Bias-less

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 Case-control…

III. Select controls from a control population

– Should be representative of control population
– Should be similar to cases except outcome
– Should be selected by the same method as cases
Sources of controls
1. Hospital (Health institution) controls
– Readily available
– Low recall bias
– More cooperative

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 Case-control…

However, hospital controls are

– Less representative
– More confounding
2. Population (community) controls
– More representative
– Less confounding
– Costly and time consuming
– More recall bias
– Less cooperative

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 Case-control…

IV. Measure the level of exposure in cases & controls

– Review or interview for exposure status
– Use same method for case and controls

V. Compare the exposure between cases & controls

– Prepare 2X2 table
– Calculate OR
– Perform statistical tests

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 Case-control…

Types of case-control studies

I. Based on case identification

1. Retrospective case-control
– Uses prevalent cases
– Increased sample size
– Difficult to establish temporal sequence
– Useful for rare outcomes

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 Case-control…

2. Prospective case-control
– Uses incident cases
– Establish temporal sequence
– Recall is not a serious problem
– Records are easily obtainable

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 Case-control…

II. Based on matching

Matching: Relating cases and controls with respect to
certain variable

1. Matched case-control studies

2. Unmatched case-control studies

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 Case-control…

Advantages of case-control studies

• Optimal for evaluation of rare diseases

• Examines multiple factors of a single disease
• Quick and inexpensive
• Relatively simple to carry out
• Guarantee the number of people with disease

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 Case-control…

Limitations of case-control studies

• Inefficient for evaluation of rare exposure

• Can’t directly compute risk
• Difficult to establish temporal sequence
• Determining exposure will often rely on memory

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 Cohort studies

• Subjects are selected by exposure and followed to

see development of disease

• Two types of cohort studies

1. Prospective (classical)
– Outcome hasn’t occurred at the beginning of the study
– It is the commonest and more reliable

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 Cohort…

2. Retrospective (Historical)

• Both exposure and disease has occurred before the

beginning of the study
• Faster and more economical
• Data usually incomplete and in accurate

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 Cohort…

Steps in conducting cohort studies

1. Define exposure
2. Select exposed group
3. Select non-exposed group
4. Follow and collect data on outcome
5. Compare outcome b/n exposed & non-exposed

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 Cohort…

Advantages of cohort studies

• Valuable when exposure is rare

• Examines multiple effects of a single exposures
• Temporal relationship is known
• Allow direct measurement of risk
• Minimize bias in ascertainment of exosure

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 Cohort…

Limitations of cohort studies

• Inefficient for evaluation of rare disease

• Expensive
• Time-consuming
• Loss to follow-up creates a problem

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 Experimental studies

• Individuals are allocated in to treatment and control

groups by the investigator

• If properly done, experimental studies can produce

high quality data

• They are the gold standard study design

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 Experimental…

Experimental studies can be

1. Therapeutic trials
– Conducted on patients
– To determine the effect of treatment on disease

2. Preventive trials
– Conducted on healthy people
– To determine the effect of prevention on risk

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 Experimental…

Three different ways of classifying intervention studies

I. Based on population studies
– Clinical trial: on patients in clinical settings
– Field trial: on healthy people in the field
– Community trial: on the community as a whole
II. Based on design
– Uncontrolled trial: no control (self-control)
– Non-randomized controlled: allocation not random
– Randomized control: Allocation random

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 Experimental…

III. Based on objective

– Phase I: to determine toxic effect
– Phase II: to determine toxic effect
– Phase III: to determine applicability

Challenges in intervention studies

• Ethical issues
– Harmful treatment shouldn’t be given
– Useful treatment shouldn’t be denied

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 Experimental…

• Feasibility issues
– Getting adequate subjects
– Achieving satisfactory compliance

• Cost issues
– Experimental studies are expensive

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 Experimental…

• The quality of “Gold standard” in experimental

studies can be achieved through

– Randomization
– Blinding
– Placebo

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 Experimental…

Randomization: random allocation of study subjects in

to treatment & control groups

Advantage: Avoids bias & confounding

Increases confidence on results

Blinding: Denying information on treatment/control

status

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 Experimental…

Single blinding: study subjects don’t know to which

group they belong
Double blinding: Care givers also don’t know to
which group study subjects belong
Triple blinding: data collectors also don’t know
allocation status

Advantage: Avoids observation bias

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 Experimental…

Placebo: an inert material indistinguishable from active

treatment

Placebo effect: tendency to report favourable response

regardless of physiological efficacy

Placebo is used as blinding procedure

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7. Screening

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 Screening

Screening refers to the presumptive identification of

a disease/defect by application of tests, examinations
or other procedures in apparently healthy people.

Screening is an initial examination

Screening is not intended to be diagnostic

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 Aims of screening program

• Changing disease progression efficiently

• Altering natural course of disease
• Protecting society from contagious disease
• Allocating resources rationally
• Selection of healthy people for job
• Studying the natural history of disease

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 Criteria for selecting diseases for screening

Severity- The disease should be serious

Treatment- Early treatment should be more
beneficial
Prevalence- Pre-clinical Prevalence should be high

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 Criteria for establishing screening program

The problem should have public health importance

There should be accepted treatment for positives
Diagnostic & treatment facilities should be available
Recognized latent stage in the time course
Test is acceptable, reliable & valid
Natural history of the disease well understood
Case-finding is economical and continuous

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 Screening tests

The performance of a screening test is evaluated

against a diagnostic test in 2X2 table

Diagnostic test
D+ D-
Screening test T+ a b a+b
T- c d c+d
a+c b+d n
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 Definitions of cells

True positives (a): Diseased identified by test as diseased

False positives (b): Disease free falsely labelled as disease
False negatives (c): Diseased falsely labelled as disease free
True negatives (d): Disease free identified as free

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 Definition of totals

D+ (a+c): total subjects with a disease

D- (b+d): total subjects without disease
T+ (a+b): total test positives
T- (c+d): total test negatves

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 Test performance

Validity of a test

The ability of a test to differentiate correctly those

who have the disease and those who don’t

• It is a function of sensitivity and specificity

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 Test performance

A. Sensitivity of a test
• The ability of a test to correctly identify those who
have the disease
• The probability that a diseased individual will have
a positive test result
• The proportion of people with a disease who have
a positive test result
• True positive rate (TPR)

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 Test performance

Sensitivity (TPR)= P(T+|D+)

=TP/(TP + FN )
= a/(a+c)
False negative rate (FNR)=P(T- |D+)
= c/(a+c)
Sensitivity= 1- FNR

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 Test performance

B. Specificity of a test
• The ability of a test to correctly identify those who
don’t have the disease
• The probability that a disease-free individual will
have a negative test result
• The proportion of people without the disease who
have a negative test result
• True negative rate (TNR)

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 Test performance

Specificity (TNR)= P(T-|D-)

=TN/(TN + FP )
= d/(d+b)
False positive rate (FPR)=P(T+ |D-)
= b/(b+d)
Specificity= 1- FPR

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 Test performance

Predictive value of a test

The ability of a test to predict the presence or

absence of disease

Two type: Positive & negative predictive values

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 Test performance

A. Predictive value positive (PVP)

√ The ability of a test to predict the presence of
disease among who test positive
√ The probability that a person with a positive test
result has a disease
√ The proportion of diseased individuals in a
population with a positive test result
√ Prior/post-test probability
PVP=P(D+ | T+)
= a/(a+b)

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 Test performance

A. Predictive value negative (PVN)

 The ability of a test to predict the absence of
disease among who test negative
 The probability that a person with a negative test
result is disease-free
 The proportion of disease-free individuals in a
population with a negative test result
 Prior/post-test probability
PVN=P(D- | T-)
= d/(c+d)

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 Test performance

Prevalence of a disease
 The proportion of individuals with a disease
 Prior/pre-test probability of a disease
Prevalence = P (D+)
= (a+c)/n

Yield of a test
Proportion of cases detected by the screening program
Yield = a/n

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 Multiple testing

Parallel testing:
– Tests are given concurrently
– At least one positive indicates disease
– Results in
• Greater sensitivity
• Increased PVN
• Decreased specificity

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 Multiple testing

Serial testing:
– Tests are administered sequentially
– All positive indicates disease
– Results in
• Lower sensitivity
• Increased specificity
• Increased PVP

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 Reliability of a test

• Ability of a test to give consistent results up on

repeated measurements

• Two major factors affect reliability

– Method variation
– Observer variation
– Inter-observer variation
– Intra-observer variation

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 Reliability of a test

Reliability can be classified as:

– Internal reliability
• Internal consistency reliability
– External reliability
• Alternate test reliability
• Test-retest reliability

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 Evaluation of a screening program

Evaluation of a screening program involves

consideration of two issues

1. Feasibility: Determined by acceptability of the

screening program

2. Effectiveness: Determined by the outcome of the

screening program

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 In general

In general, a screening test should be

– Reliable & valid

– Sensitive & specific
– Simple & acceptable
– Effective & efficient

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Thank you!

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