HK 56700 Fall 2014 Sample

Fall 2014
HK 56700
David R. Black, PhD, MPH
Michael A. Johnson
Center for Social
Problem Solving,
Measurement,
and Research,
Inc.
Custom for HK 56700 at Purdue University, August 25, 2014

Copyright 2014 by Center for Social Problem Measurement.

All rights reserved. Manufactured in the United States of America. No part of this document
may be reproduced or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without prior written permission of the Center for
Social Problem Measurement.

Printed in Oshtemo, MI, United States
Table of Contents

Chapter Title Page
Material covered in Exam 1 4
1 Syllabus and Supporting Information 6
2 Epidemiological Statistics 25
3 Welcome to HK 56700 28
4 Introduction 53
5 What is Epidemiology 56
6 Disease Prevention 74
7 History of Epidemiology 80
8 Roots of Modern Epidemiology 93
9 Epidemiologic Investigation 106
10 Indices of Morbidity 112
11 Ratios: Rates, Ratios, and Proportions 123
12 Incidence, Prevalence, & Duration Exercises 136
13 Duration 141
14 Indices of Mortality 145
15 Prenatal & Infant Life 159
16 Additional Mortality Formulas 175
17 Adjusted Standard Mortality Rates (SMR) 181
18 SMR Direct Example 186
19 SMR Indirect Example 192
Material Covered in Exam 2 201
20 Investigating Outbreaks 203
21 Demography 243
22 Methods of Surveillance 256
23 Problems with Data Collection 280
Material Covered in Exam 3 307
24 Study Designs 309
25 Experimental Study Designs 312
26 Observational Study Designs 318
27 Calculating Risk 334
28 Causality 349

Center for
Social
Problem
Measurement
David R. Black Handbook for Epidemiology for Public Health Practice 8/25/2014
4
Exam 1 Study Guide*

Know the:

1. Definition of epidemiology
2. Objectives of epidemiology
3. Key terms related to the definition of epidemiology.
4. SKIT and differences among types of prevention.
5. Differences between rates, ratios, and proportions (all classified under ratio).
6. Formulas for all ratios presented and how to interpret them.
7. Differences in person, place, and time variables.
8. Terms related to distribution (e.g., outbreak, epidemic, pandemic, etc.).
9. Importance of John Snows study and its relevance for epidemiology today.
10. Calculation of duration.
11. Differences between incidence, incidence rate, prevalence, and prevalence rates.
12. Interpretation of or how to interpret graphs.
13. Standardized Mortality Rate (SMR) Direct and Indirect Methods
14. Key points covered in Homeworks and Assignments and be ready to list formulas and
calculate problems.
*Note: Knowing the exact definitions of terms and formulas should have been accomplished
via the Quizzes and Homeworks. You will be tested on precision of knowledge and
application.
5
Center for
Social
Problem
Measurement
6

Principles of Epidemiology
HK 56700

David R. (Randy) Black, PhD, MPH, HSPP, CHES, CPPE, FASHA, FSBM, FAAHB, FAAHE
Professor of Health and Kinesiology; Adjunct Appointment in Health Sciences; Nutrition Sciences; Nursing and Professor and
Associate Director of Purdue Homeland Security

Instructors Contact Information
Office: LAMB 106A
Email: dblack@purdue.edu (best means of contact)
Phone: 765-743-4001 (M-F 8 AM 5 PM)
Course Information
Course Number: HK 56700
Semester/ Year: Fall 2014
Meeting Days, Time: ONLINE COURSE,
Lecture videos are posted on Tuesdays and
Thursdays on YouTube.

Office hours
By appointment, contact Professor Black to schedule a time for an in-person meeting or telephone call.

Important Notes:

This course is cross-listed with HK 44500. The Blackboard Learn course that we will be using for the entire
semester is Fall-2014-HK-56700-001-XLST.

DO NOT SCHEDULE TRAVEL on the exam dates or until the University releases the final exam
schedule. I do NOT make accommodations for travel unless it is for a funeral or emergency medical care.
Also, exam and quiz dates will not be changed to accommodate athletes. There are no exceptions to this
policy.

Important Policy

NOTE: WE FOLLOW THE SYLABUS TO THE LETTER. RARELY DO WE DEVIATE FROM IT.
YOU WILL FIND ANSWERS TO MOST EVERY QUESTION YOU HAVE ABOUT THE COURSE
AND COURSE POLICIES BY REVIEWING THE SYLABUS CAREFULLY BEOFRE CONTACTING
THE INSTRUCTOR. IF YOUR PARTICULAR ISSUE IS NOT ADDRESSED, PLEASE CONTACT US
AND WE WILL HAPPILY ANSWER YOUR QUESTION. OFTEN WHEN WE REPLY TO
QUESTIONS, WE COPY VERBATIM THE PART OF THE SYLABUS THAT APPLIES THAT
ADDRESSES AND PROVIDES THE ANWWER TO THE QUESTIONS YOU ASKED OR THE
ISSUE OF CONCERN. WE HAVE EXPENDED GREAT EFFORT ON THE SYLLABUS TO MAKE
SURE THAT YOU UNDERSTAND THE COURSE, WHAT WILL HAPPEN UNDER VARIOUS
CIRCUMSTANCES, AND WHAT IS EXEPECTED OF YOU. WE HAVE PROVIDED INORMATION
IN DETAIL TO PROTECT AND PRESERVE YOUR RIGHTS AND TO HELP YOU. KNOWLDEGE
GIVE YOU CONTROL.
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Trained Peer Helpers

There are Trained Peer Helpers for this course. As a prerequisite to serving as a Peer Helpers, each individual
has been certified by the University in the handling and protecting private student information protected by
the Family Educational Rights and Privacy Act (FERPA) pertaining to educational information. The Peer
Helpers fully understand their legal and ethical obligation to protect the confidentiality of student data. Their
email addresses will be posted to Blackboard.

Qualifications of Trained Peer Helpers:
Taken the course the semester before and received a grade no lower than an A-
Have exceptional verbal and written communication skills
As a prerequisite to serving as a Peer Helpers, each individual has been certified by the University in
the handling and protection of private student information protected by the Family Educational
Rights and Privacy Act (FERPA) educational information. The Peer Helpers fully understand their
legal and ethical obligation to protect the confidentiality of student data. Successfully complete the
FERPA (Family Educational Rights and Privacy Act) certification at
https://www.purdue.edu/webcert and provided a copy of their certification to the instructor
Signed and provided to the instructor a copy of the Confidentiality Agreement for Trained Peer
Helpers (in the textbook after this syllabus)
Received individual instruction from the instructor about the importance of maintaining
confidentiality
Commit not to share under any circumstances information about you with anyone other than the
instructor or the other Trained Peer Helpers

Duties of Trained Peer Helpers may include:
Course planning
Tutoring
Lead help sessions
Review exams, quizzes, and homeworks
Peer-mentoring, for example by
answering questions during office hours
or by email
Carrying out other duties similar to these

Duties will not include:
Serve as independent instructors for
courses
Assign and submit official course grades
Present course content that has not been
authorized by the faculty course
instructor

Prerequisites

STAT 301 or equivalent.

Restrictions

Freshman: 0 14 hours
Freshman: 15 - 29 hours
Sophomores: 30 44 hours

Students that have accumulated the following credits and fall within one of the 3 categories above, should plan
to take the course later in their academic careers when they have more background.
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Class Structure

Lecture will be on YouTube with links mailed out each week and quizzes and exams will be given online on
Blackboard Learn (https://mycourses.purdue.edu). Lectures on YouTube should be listened to as you follow
along in the required book noted below. Homeworks are on BlackBoard Learn along with the correct
answers. Complete the homeworks! They will help prepare you for quizzes and exams. Quizzes will only be
available from 12:01 AM to 11:59 PM each Thursday. The quizzes will cover the material from the Thursday
of the prior week and Tuesday of the current week lectures. Required equipment will be listed below under
Required Textbooks and Tools.

Lectures are uploaded to YouTube for Tuesdays and Thursdays. They may vary in length as we try to divide
the information by topics, not length. Some may be short and others may be longer. We try to keep lectures
to no more than 2.5 hours per week, which is equivalent to the amount of lecture time that you would
receive, if you attended a class on campus. Some weeks you may put in a little more time than others, but
usually the time required the next week will be less. It should all balance out. Some, depending on skills,
experiences, and ability to assimilate the materials, may have to spend a lot more time.

Course Goals and Learning Objectives

Students successfully completing this course will be equipped to meet the core competencies associated with
a Master Degree of Public Health. Consequently, HK 56700 aims to address the following content domains
and competencies outlined by the Association of Schools and Programs of Public Health (ASPPH):

Domain A. Biostatistics
Domain C. Epidemiology

At the conclusion of this course, students will be able to:

Biostatistics
A.9. Interpret results of statistical analyses found in public health studies.
A.10. Develop written and oral presentations based on statistical analyses for both public health
professionals and educated lay audiences. (You will not be held responsible for this
competency because of the size of the class and the material that is covered.)

Epidemiology
C.1. Identify key sources of data for epidemiological purposes.
C.2. Identify the principles and limitations of public health screening programs.
C.3. Describe a public health problem in terms of magnitude, person, place, and time.
C.4. Explain the importance of epidemiology for informing scientific, ethical, economic, and
political discussions of health issues.
C.5. Comprehend basic, ethical, and legal principles pertaining to the collection, use, and
dissemination of epidemiological data.
C.6. Apply the basic terminology and definitions of epidemiology.
C.7. Calculate basic epidemiology measures.
C.8. Communicate epidemiologic information to lay and professional audiences.
C.9. Draw appropriate inferences from epidemiologic data.
C.10. Evaluate the strengths and limitations of epidemiologic reports.

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Course Description

Epidemiology is the cornerstone of many different disciplines. HK 56700 is a methods course, which is
requisite for many health-related fields. The design of the course is to teach thinking and problem-solving
skills. The course does not focus on teaching you what to think; rather, it teaches how to think. The
course does require memorization of formulas and studying for quizzes. Application of knowledge and
concepts is the main emphasis. As a professional, people do not bring you answers. They bring you questions
that may take the full extent of your knowledge in a discipline to answer the question. The instructional
design of the course should provide a foundation pertaining to the skills you will need to answer examination
questions, and will encourage thinking, problem solving, and application. Additional study and completing
practice problems are not required, but are strongly recommended. Additional problems can be found in the
Supplemental Reading List books on p. 13 below. Some of the these books may be in the Purdue Library
system.

The course is designed to focus on the introduction and application of basic/rudimentary terms and
epidemiologic descriptive and analytic statistics. Provided is a fundamental understanding of the nature of
epidemiologic study as related to human morbidity, mortality, and injury (disability). Examples of other topics
to be presented include the utility of public health, vital statistics, concepts of disease transmission, risk
management by restricting the spread of disease, injury, types of epidemiological studies, screening, causality,
etc. (see topic outline). Approximately 18 universities across the country teach undergraduate epidemiology.
Future thinking is that epidemiology will be a required course for all students across the nation who enter
college. Epidemiology has universal application and is discussed daily in the news and routinely by
government agencies. Paid positions are available to students after successfully completing this one course
alone.

This is a medical course (physicians are able to pass their medical boards in epidemiology by taking the course
or via private tutoring) so it is unwise to underestimate the courses difficulty. If medical courses were
easy, everyone would be a physician. Nevertheless, many students consider this an easy course because it is
listed under the Department of Health and Kinesiology. Do NOT deceive yourself into thinking the course is
substandard or simple. Regrettably, some students have had to retake the course more than once because they
did not take it seriously or the learning style required was different from what they were used to in other
courses. Above average quantitative skills are advantageous.

Instructors Philosophy

I respect and prize students! I consider it an honor and privilege to instruct some of the brightest minds in
the country/world. I believe students in my course will make significant contributions to society and will be
leaders and supervisors in the future. I realize that the students I teach will make the world a better place to
live and inventions and changes will come from those I have had the pleasure to instruct.

My commitment to students is to try to teach the material as simply as possible. Sometimes, there may be
redundancy because some concepts are difficult and important and are worthy of repetition or because of
editing of videos and portions of the videos that should have been eliminated. This happens by mistake, but
also because we want to present to you the latest information.

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I want every student to learn the material. I hate assigning low course grades. Never do I pride myself in
failing students, but wonder how I might have reached students who have not performed well. I recognize
that grading influences future opportunities and poor grades may eliminate key opportunities. I know it is
important that students meet me halfway, and do all they can to learn the materials, as well as seek help early
if they are struggling. I have taught the course more than 110 times (in one form or another) during the
course of my career. I am familiar with the subject matter. Slides are updated regularly to attest to the
relevance and utility of epidemiology. Again, there are variations between the slides in the course manual and
the presentations used in classes previously due to updates and topic of significance being added. We
apologize in advance for any confusion or inconvenience this may cause.

I want students to succeed. Success is not a confirmation of the intelligence quotient (IQ). It seems that some
have an affinity or genetic determinants or skills for the topic and others do not. Perhaps, it is similar to being
a basketball player. You can practice routinely, but if you do not possess some abilities, you will not make the
team or do well in the class.

Important University and Course Policies

It is imperative that you follow the policies listed in the syllabus and reviewed in the first lectures. At
least 1 of the first 2 lectures will be devoted to policies. You will be quizzed on the lecture about policies and
the syllabus. There will be a Student Information Sheet quiz on Blackboard Learn Thursday of the first week.
Complete it online and you will be given full credit. Questions about course policies should be directed to the
instructor.

The syllabus will be used to answer questions pertaining to policies. You will be able to anticipate
answers in advance if you study the policies. Many problems and student complaints/ disappointments are
due to being unaware of policies that are already explained in the syllabus. One way to avoid uncomfortable
situations and feelings of unfair treatment, frustration, or favoritism is to publish policies in advance. We
want to meet your expectations and for you to feel comfortable, respected, and equitably treated. One way to
do that is for you to know what is expected of you. The purpose for having and following policies is civility,
equity, and so you will not be surprised about requirements of the class or those of the University.

All decisions about class conduct are based on university policies, which will be followed to protect
student rights. Classroom Behavior: Students at Purdue University are expected to be at all times in
compliance with the Campus Code of Conduct. Failure to abide with this code will not be tolerated in this course.

Communications

We take pride in answering student emails/calls promptly. Generally, emails or calls are responded to within 4
hours during the business day, but sometimes because of extenuating circumstances, it will take 24-48 hours
to reply. Students should email questions about absences and grading to the instructor and all involved in
operating the course. The best communication method is email, but sometime using the phone is far more
expedient.

Resolving Conflicts

If you have concerns/worries about the materials presented, course objectives, lecture materials, or any other
class related issues, contact me. Normally, every issue can be resolved.

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Getting Help

IF YOU DID NOT DO WELL ON THE QUIZZES OR EXAM 1, GET HELP IMEDIATELY.
DO NOT WAIT, AND ESPECIALLY, DO NOT WAIT UNTIL THE END OF THE COURSE/
SEMESTER. I CANNOT DO ANYHING FOR YOU THEN. THERE IS ABSOLUTELY NO
EXTRA CREDIT OPPORTUNITIES. AFTER EXAMINATION 3 OR BEFORE FINAL
GRADES ARE SUBMITTED, THERE ARE NO EXCEPTIONS TO THE RULE FOR EXTRA
CREDIT AND GRADES WILL NOT BE CHANGED FOR ANY REASON WHATSOVEVER
(UNLESS THERE IS A COMPUTATIONAL OR CLERICAL ERROR, WHICH IS A RARITY
BECAUSE A COMPUTER PERFORMS THE CALCULATIONS). IF I GIVE SPECIAL
CONSIDERATION TO ONE PERSON, I MUST GIVE SPECIAL CONSIDERATION TO
EVERYONE, WHICH NEGATES THE REASON FOR DEVELOPING A GRADING
STANDARD IN THE FIRST PLACE, WHICH IS INEQUITABLE AND A BASIS FOR GRADE
APPEAL

Helping Yourself

Study before and after each lecture. Make note cards. I recommend the supplemental books listed toward
the end of the syllabus. If you need clarification about a definition of a term, use the index (not the Table of
Contents). There are other practice problems in these books and answers. The books are provided as
reference material. Chapter reading assignments will not be given because that is not how the course operates.
The course is taught by topic/concept, not by chapter. Sometimes an entire chapter will apply; most of the
time it will not. The course is taught using a medical school model; the slides and the notes you take
next to the slides in your textbook are vital and important to your success on quizzes and exams.

If you think you are going to have trouble in the course, buy all the books or review them at the library. The
costs of the 1 required book is produced at the lowest price possible. Sometimes students pay hundreds of
dollars for books for a course. This not the case in this course.

Use the discussion forums on Blackboard Learn. The trained peer helpers and Dr. Black will be
monitoring them to answer your questions.

Discussion Forums
You are expected to participate in the Discussion Forums on Blackboard Learn to help answer questions
from the undergraduate students in HK 44500 as well as your fellow graduate students. The undergraduate
students may post questions anonymously; however, graduate students must post non-anonymously so we gauge
your participation. HK 56700 students will be on a rotating schedule of who is responsible for monitoring
and helping answer questions in the forums for that week. You will be informed when it is your turn to be
moderator. The trained peer helpers and Dr. Black also will monitor the forums.

Help Sessions

Online help sessions are optional and are held only at the request of the class. Help sessions will be
telephonic and graphics/slides will be shown. Attendance at help sessions is optional/voluntary. You do not
have to attend, but it is advisable. If requested, directions for how to participate will be provided to the class.
While attendance will not be taken, we may request in advance how many people will be participating as it
may affect choice of the delivery method used for the help session. Trained Peer Helpers lead the help
sessions and answer the questions, along with the instructor and our IT expert.
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Help sessions will be scheduled at a time that accommodates the most students, if any student requests a help
session. It is impossible to accommodate everyones schedule. We will consider any day and time including
weekends.

Let Professor Black know if you would like a help session.
If nobody requests a help session, one will not be held.

You may request a help session at any time. This way you can receive
clarification when you need it, not just before an exam.

Academic Dishonesty

Purdue prohibits "dishonesty in connection with any University activity. Cheating, plagiarism, or knowingly
furnishing false information to the University are examples of dishonesty." [Part 5, Section III-B-2-a,
University Regulations]. Furthermore, the University Senate has stipulated that "the commitment of acts of
cheating, lying, and deceit in any of their diverse forms (such as the use of substitutes for taking examinations,
the use of illegal cribs, plagiarism, copying during examinations, communicating with someone outside the
classroom via text message) is dishonest and must not be tolerated. Moreover, knowingly to aid and abet,
directly or indirectly, other parties in committing dishonest acts is in itself dishonest." [University Senate
Document 72-18, December 15, 1972]. Also, see http://tinyurl.com/qcglxym .

Your webcam will be used to monitor test-taking behavior and your computer will be locked down
so files may not be opened and computer programs such as a calculator cannot be accessed.

Examples of academic dishonesty include, but are not limited to
Giving or receiving answers by use of signals during an exam.
Copying with or without the other persons knowledge during an exam.
Doing quizzes or exams for someone else.
Using unauthorized notes during an exam.
Using programmable devices to answer test questions.
Using any electronic means as a help line to receive answers.
Sitting together to take exams or quizzes is observable via your webcam. Exams and quizzes
are to be complete by yourself.

Important disclosure

We will be enabling Respondus Monitor for all quizzes and the final exam. Respondus Monitor is a video
recording stored for future viewing to detect cheating. If you do not have a webcam connected to your
computer before you launch Respondus Lockdown Browser, you will not be able to access the quizzes or the
final exam. Respondus Lockdown Browser contains Respondus Monitor to observe behaviors during
examinations and quizzes. If Respondus Lockdown Browser is not installed, you will not be able to access the
quizzes and exams. If you do not have a webcam, they can be purchased for minimal cost at most box stores
or stores that sell computer. Installation is not difficult.
Turn off your phone if possible or otherwise set it to silent. If you must answer an emergency call, please exit
the Respondus Lockdown Browser and record your reason for exiting the quiz or exam. After your
emergency situation is resolved, contact Dr. Black at dblack@purdue.edu or 765-743-4001 and your quiz
attempt or exam will be reset at Dr. Blacks discretion.
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Do not take any quiz or exam in any location where there could be the inadvertent disclosure of
confidential information. Remember, you have control over when and where you take the quizzes and
exam because of the amount time allotted (see below under Attendance).

Use of Copyrighted Materials

Among the materials that may be protected by copyright law are the lectures, notes, transcripts, and other
material presented in class or as part of the course. Always assume the materials presented by an instructor
are protected by copyright. Students enrolled in Purdue University courses are permitted and encouraged to
take notes, which they may use for individual/group study or for other non-commercial purposes reasonably
arising from enrollment in the course or the University generally.

Notes taken in class are, however, generally considered to be derivative works of the instructors
presentations and materials, and they are thus, subject to the instructors copyright in such presentations and
materials. No individual is permitted to sell or otherwise barter notes, either to other students or to any
commercial concern, for a course without the express written permission of the course instructor. Dr. Black
has chosen to not grant such permission.

Attendance

Course attendance policy. Attendance is taken by completion of exams and quizzes.

You ARE expected to watch every lecture. Attendance is 5% of your grade and is based on completing the
online quizzes and exams. Quizzes are only available on Blackboard Learn. There is no makeup of
quizzes or exams. You are allowed to miss 1 quiz with no penalty to your attendance grade. You will still get a
zero (0) on the quiz or exam. After the 2
nd
absence demonstrated by not taking a quiz or exam, your
attendance grade drops to 2.5%. After the 3
rd
absence, your attendance grade drops to 0%. The only
exceptions to this are excused absences with proper documentation verified by the Office of the Dean of
Students.

Your lowest quiz score will be dropped before final grades are calculated. Dropping this quiz will not affect
your attendance grade.

University attendance policy. Students are expected to be present for every meeting of the classes in which they are
enrolled. Only the instructor can excuse a student from a course requirement or responsibility. When conflicts or absences can be
anticipated, such as for University sponsored activities and religious observations, the student should inform the instructor of the
situation as far in advance as possible. For unanticipated or emergency absences when advance notification to an instructor
is impossible, the student should contact the instructor as soon as possible by email, or by contacting the Health and Kinesiology
main office at 765-494-3170. When the student is unable to make direct contact with the instructor and is unable to leave word
with the instructors department because of circumstances beyond the students control, and in cases of bereavement, the student or
the students representative should contact the Office of the Dean of Students at 765-494-1747.

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Additional Information about the Universitys Grief Absence Policy:

Purdue University recognizes that a time of bereavement is very difficult for a student. The University therefore provides the
following rights to students facing the loss of a family member through the Grief Absence Policy for Students (GAPS). GAPS
Policy: Students will be excused for funeral leave and given the opportunity to earn equivalent credit and to demonstrate evidence
of meeting the learning outcomes for misses of assignments or assessments in the event of the death of a member of the students
family. It is very important that you contact the Office of the Dean of Students at 765-494-1747 to report absences under
this policy.

Emergencies and Health

In the event of a major campus emergency, course requirements, deadlines, and grading percentages are
subject to changes that may be necessitated by a revised semester calendar or other circumstances beyond the
instructors control. Relevant changes to this course will be posted on the course website or can be obtained
by contacting the instructor via email or phone.

You are required to read your @purdue.edu email daily.

The following are personal actions you should take if an emergency occurs:

1. To report an emergency, call 911. To obtain updates regarding an ongoing emergency, sign up for
Purdue Alert text messages, view www.purdue.edu/ea .
2. There are nearly 300 Emergency Telephones outdoors across campus and in parking garages that
connect directly to the PUPD. If you feel threatened or need help, push the button and you will be
connected immediately.
3. If we hear a fire alarm during class, we will immediately suspend class, evacuate the building, and
proceed outdoors. Do not use the elevator.
4. If we are notified during class of a Shelter in Place requirement for a tornado warning, we will
suspend class and shelter in the basement.
5. If we are notified during class of a Shelter in Place requirement for a hazardous materials release, or a
civil disturbance, including a shooting or other use of weapons, we will suspend class and shelter in
the classroom, shutting the door and turning off the lights.
6. Please review the Emergency Preparedness website for additional information.
http://tinyurl.com/keow3tg

Students with Disabilities

Purdue University is required to respond to the needs of the students with disabilities as outlined in both the Rehabilitation Act
of 1973 and the Americans with Disabilities Act of 1990 through the provision of auxiliary aids and services that allow a
student with a disability to fully access and participate in the programs, services, and activities at Purdue University.

If you have a disability that requires special academic accommodation, please email me within the first 3
weeks of the semester in order to discuss any adjustments. It is imperative that we talk about this at the
beginning of the semester. It is the student's responsibility to notify the Disability Resource Center
(http://www.purdue.edu/drc) of an impairment/condition that may require accommodations.

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Harassment

Harassment will not be tolerated and will not be part of this course. You will always be treated with respect
and our team expects the same in return. Respect is part of learning to become a professional.

Harassment is defined in Purdue University's Anti-Harassment (III.C.1) policy: http://tinyurl.com/ohbhaxj

Conduct towards another person or identifiable group of persons that has the purpose or effect of:
1. Creating an intimidating or hostile educational environment, work environment or environment for
participation in a University activity;
2. Unreasonably interfering with a person's educational environment, work environment or
environment for participation in a University activity; or
3. Unreasonably affecting a person's educational or work opportunities or participation in a University
activity.
Use of the term Harassment includes all forms of harassment, including Racial Harassment and Sexual
Harassment.
Sexual Harassment
A. Any act of Sexual Violence.
B. Any act of Sexual Exploitation.
C. Any unwelcome sexual advance, request for sexual favors or other written, verbal or physical conduct
of a sexual nature when:
1. Submission to such conduct is made either explicitly or implicitly a term or condition of an
individual's employment, education, or participation in a University activity;
2. Submission to, or rejection of, such conduct by an individual is used as the basis for, or a
factor in, decisions affecting that individual's employment, education, or participation in a
University activity; or
3. Such conduct has the purpose or effect of unreasonably interfering with an individual's
employment or academic performance or creating an intimidating, offensive, or hostile
environment for that individual's employment, education, or participation in a University
activity.
Missed or Late Work

Missed or late work will not be accepted. No quizzes or exams may be made up except under the GAPS policy
outlined above. If you have a schedule conflict due to other activities or course field trips, please let Dr. Black know as soon as
possible.

Examinations

All exams are non-cumulative and will test the application of concepts beyond what is required or expected in
completing homework, assignments, and quizzes. Exams are a test of knowledge and application and are not
simply a test of information that has been memorized. Relying strictly on memory is ineffective in this
course. You must think and apply confidently what you have learned. The course requires higher-order
reasoning and cognitive processes expected of an upper division class person at a Big 10 university.

Homework, assignments, and quiz answers will not be discussed in the recorded lectures, but feel free to
contact Dr. Black or any member of the to get help or answers about the reason you received what grade you
did.
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Exams are taken on Blackboard Learn. Exams are closed book, note, and are to be completed alone.

I reserve the right to change any exam to be proctored on campus. If you are a Distance Learning
student with no on-campus courses, please let Dr. Black know the first week of classes and we will
work out arrangements in the event we move any exam to a proctored environment.

We are interested in accuracy in grading above all else. The first grade posted in Blackboard may
not be your final score. Scores for exams and quizzes may be adjusted at any time during the
semester if responses are found to be inaccurate.

Number of Examinations

Three (3) non-cumulative examinations will be administered during the course. The exams will include
True/False, multiple choice with multiple answers, matching, and fill in the blank (filling in missing entries in
tables like in some of the homeworks on BlackBoard Learn) questions. Exams will cover lecture materials,
homework, assignments, and quizzes. ONLINE exams are scheduled throughout the semester. Dates are
listed below:

Academic Calendar - Fall Semester 2014

August
Monday 25 Classes Begin
September
Monday 1 Labor Day (No Classes)
Monday 8 Last Day to Cancel a Course Assignment Without It Appearing on Record
Monday 22
Last Day to Withdraw a Course With a Grade of W or to Add/Modify a Course With
Instructor and Advisor Signature
October
Monday 6 Last Day For Grade Correction for 2014 Spring Semester and Summer Session
Thursday 9 Exam I
Monday - Tuesday 13 - 14 October Break
Wednesday 29 Last Day to Withdraw From a Course With a W or WF Grade
Wednesday 29 Last Day to Add/Modify a Course With Instructor, Advisor and Department Head Signatures
November
Thursday 20 Exam II
Wednesday - Saturday 26 - 29 Thanksgiving Vacation
December
Saturday 13 Classes End
Monday - Saturday 15 - 20
Final Exams
Exam III
See the final exam schedule at http://www.smas.purdue.edu .
Do not schedule travel until the final exam schedule is released.
Saturday 20 Semester Ends
Tuesday 23 Grades Due
17

Equipping Yourself for Examinations

Study materials. PowerPoint is used to present lecture materials (see Required Text). Use Foundations of
Epidemiology as you listen to and view the lectures. Be sure to take notes next to the slides.

Tips for success on examinations.
Study
Complete the homeworks in on BlackBoard Learn and refer to the answers provided.
Study in groups, if possible, to test your knowledge before the test (3 people seems to be the right
group size.)
Be prepared when you meet as a group
Do not let something go that you do not understand
You also may do problems in the supplemental textbooks
Please contact Professor Black or any member of the instructional team with any questions.

Observations. Students who do well on tests often make flash cards. Cramming for exams does not work!

Examination day. All students must take exams online on the scheduled date. Dates of exams are
published in advance (see above). The final will be given online on the date and time that it is
officially scheduled by the university.

Equipment. Purchase a 4-function calculator. DO NOT USE A PROGRAMMABLE CALCULATOR
OR YOUR CELL PHONE CALCULATOR. ADDITIONAL REQUIREMENTS ARE LISTED
UNDER REQUIRED TEXT AND TOOLS.

Grade determination. The highest score sets the curve, not the total number of possible points. Non-
differentiating items will be eliminated after reviewing a computer generated item analysis. Your score on
quizzes and exams may change slightly if the item analysis does not detect a problem with the question, but
we do.

Quizzes and homework. Normally, a quiz will be given every Thursday. As you would expect, quizzes may
vary in difficulty and format depending on the content examined. Homeworks are on BlackBoard Learn
along with answers, but will not be scored. Answers will be reviewed during help sessions, if students desire.

Grading

Scale: A+ = 97% - 100%
A = 93% - 96.99%
A- = 90% - 92.99%
B+ = 87% - 89.99%
B = 83% - 86.99%
B- = 80% - 82.99%
C+ = 77% - 79.99%
C = 73% - 76.99%
C- = 70% - 72.99%
D+ = 67% - 69.99%
D = 63% - 66.99%
D- = 60% - 62.99%
F = 59.99% and BELOW

18

Basis for Grades: Percentage
Exam I 21.66%
Exam II 21.66%
Exam III 21.67%
Quizzes 15%
Moderating the discussion forums 10%
Attendance (denoted by completion of quizzes and exams) 5%
Total 100%

Required Text and Tools
Note: Available only on Lulu.com.
Black, D.R.*, & Johnson, M.A.* (2014). Handbook for foundations of epidemiology. Oshtemo, MI: Center for Problem Solving and
Measurement Press. A link to purchase this book will be provided via email on your Purdue email account and posted to Blackboard
Learn.
A 4-function calculator that is not on a phone, tablet, or other device.
o Scientific, graphing, phone, tablet, or other calculators are not permitted.
Four function calculators have no more buttons than the example on the
right.
o Generally, when required, an onscreen calculator will be provided during
exams and quizzes.
A computer meeting these minimum requirements:
o Windows: 8, 7, Vista
o Mac: OS X 10.6 or higher
o Internet Explorer (Windows) or Safari (Mac) must function properly on
the computer
o Adobe Flash Player
o A reliable broadband Internet connection.
A webcam. It may be built-in to your computer or may be external. You dont need a high-end webcam. Webcams can be
purchased online or from any big box store. We have tested cameras from Logitech and Microsoft as well as cameras built
into Dell and Toshiba laptops.

Quizzes and exams will not be extended to accommodate unreliable Internet connections or unreliable computers. If you have an
issue due to an unforeseen power outage due to a storm, contact Dr. Black at dblack@purdue.edu or 765-743-4001 as soon as possible.
If the problem is on Purdues end, we will make adjustments.
Most ITaP labs should meet these requirements. The LAMB 122 lab is not an ITaP lab and should not be used for exams or quizzes.
Respondus Lockdown Browser. Links for this program will be posted to Blackboard Learn. You will not be able to take quizzes or
exams without this program. No makeups and a zero (0) will be recorded.

Supplemental Readings (Optional Textbooks)

Note: The books below are available on Amazon.com and you should be able to review them at 1 of
the Purdue libraries.

Aschengrau, A., & Seage, G. R. (2014). Epidemiology in public health. (3
rd
ed.). Boston, MA: Jones and Bartlett
Publishers. ISBN: 978-1284028911 (paper).
19

Merrill, R.M. (2013). Introduction to epidemiology (6
th
ed.). Burlington, MA: Jones & Bartlett Learning. ISBN: 978-
1449665487 (paper).
Gordis, L. (2013). Epidemiology (5
th
ed.). Philadelphia, PA: Elsevier Saunders.
ISBN-13: 978-1455737338.
Heymann, D.L. (2013). Control of communicable diseases manual (20
th
ed.). Washington, D.C.: American Public
Health Association. ISBN: 978-0875530185.
Porta, M., (Ed.) (2008). A dictionary of epidemiology (5
th
ed.). New York: Oxford University Press. ISBN: 978-
0195314502.

Which Books to Purchase

Buy all of them if you are having difficulty in the course. These books are all EXCELLENT reference guides,
independent of the field employment you select for your lifes career.

For Your Information: Other Public Health Books by the Instructor (Not used in this course)

Diet, J.E, & Black, D.R. (Eds.) (under contract/in progress). Large event security planning and emergency
management. New York, NY: CRC Press: Taylor & Francis Group.
Dietz, J.E., & Black, D.R* (Eds.) (2012). Pandemic planning. New York, NY: CRC Press: Taylor & Francis
Group. ISBN#: 978-1439857656.
Black, D.R.*, Foster, E.S*, & Tindall, J.A.* (2012). Evaluation of peer and prevention programs: A blueprint for
successful design and implementation. New York, NY: Routledge: Taylor & Francis. ISBN# 978-
0415884785.
Black, D.R.*, Leverenz, L.L., Coster, D.C., Larkin, L.L., & Clark, C.A. (2010). Physiological screening test (PST)
manual for eating disorders/disordered eating among female collegiate athletes. Monterey, CA: National Athletic
Trainers Association/Heath Care for Life & Sports. ISBN: 978-1606790694.
Tindall, J.A.*, & Black, D.R.* (2009). Peer programs An in-depth look at peer programs: Planning, implementing, and
administration (2
nd
ed.). New York: Routledge, Taylor & Francis. ISBN # 978-0415962360
http://tinyurl.com/TindallBook . Reprinted with permission:
Tindall, J.A.*, & Black, D.R.* (2009). Highlights of the peer resource literature (Chapter 5). Perspectives in Peer
Programs, 21(2), 69-84.
20

COURSE OUTLINE
FALL 2014
HK 56700

I. Epidemiology, History and Definitions
A. What is Epidemiology and Why is it Important?
1. Human Population (Magnitude, Person, Place, Time)
2. Distribution of Disease
3. Disease Cycles
a) Sporadic
b) Endemic
c) Epidemic
d) Pandemic
e) Holoendemic
f) Hyperendemic
4. Determinants
5. Prevention of Disease
a) Primary
b) Secondary
c) Tertiary
B. History
1. Medicine
a) Infectious Disease Epidemiology
b) Snow and Cholera
c) Pasteur/Koch
d) Graunt
2. Behavioral Epidemiology
3. Leading Causes of Death
C. Objectives of an Epidemiological Investigation
1. Steps in Studying Disease Etiology

II. Incidences of Morbidity and Mortality
A. Incidences of Morbidity
1. Duration, Incidence, and Types of Prevalence: For example
a) Point Prevalence
b) Period Prevalence
c) Lifetime Prevalence
B. Ratios: Rates, Ratios, and Proportions
1. Crude Rates (Birth and Death)
a) Category-Specific Rates
b) Birth Mortality Rates (Infant, Neonatal, and Maternal)
c) Cause Specific Rate
d) Cause-Fatality Rate
e) Proportionate Mortality Rate (PMR)
C. Adjustments-Standardize Mortality Ratio (SMR)
1. Direct Method
2. Indirect Method

21

III. Sources of Health Data
A. Investigating Outbreaks
1. Direct and Indirect Transmission
2. Case
a) Index
b) Primary
c) Secondary
3. Incubation vs. Duration
B. Demography
1. Age and Sex
2. Sex Ratio, Sex Specific Death Rate
3. Life Expectancy
C. Problems with Data Collection
1. Survey
2. Interview Survey
3. Hospital Data Problems
4. Morbidity Report Problems
a) Under-numeration
b) Misreporting
5. Sources of Mortality Data

IV. Competency: Key Sources of Data for Epidemiological Purposes
A. U.S. Census Bureau
B. CDC
C. Secondary Data Sources
D. Additional Data Sources

V. Methods of Surveillance
A. Surveillance
B. Screening
1. When to Screen
2. When not to Screen
C. Sensitivity and Specificity
1. Positive Predicated Value
2. Negative Predicated Value
D. Repeat Screenings
E. Relationships

VI. Study Designs
A. Types of Study Designs: Observational and Experimental
1. Experimental
a) Community
b) Clinical
2. Observational
a) Case- control
b) Cross-Sectional
c) Historical Prospective
d) Prospective/Longitudinal

22

VII. Assessing Risk
A. Direct Measure of Risk (Prospective)
1. Absolute Risk
2. Attributable Risk
3. Preventive Risk
4. Relative Risk
B. Indirect Measure of Risk (Retrospective and Cross- Sectional)
1. Odds Ratio
2. Matched Sample

VIII. Epidemiological Studies Related to Casualties
A. Causality
B. Confounding Variables
C. Error
1. Random
2. Systematic

D. Bradford Hills Criteria
1. Strength of Association
2. Dose- Response Relationship (Biological Gradient)
3. Temporal Relationship
4. Specificity of Association
5. Consistency of Association
6. Biological Plausibility
7. Coherence
8. Experimentation to Rule Alternative Explanations
9. Analogy

23

Confidentiality Agreement for

Date: ______/______/2014

I, _______________________________, (PID#: _________-_________ DOB: _____/______/______),
agree not to disclose any information pertaining to individuals enrolled in HK56700, Principles of
Epidemiology, except with the professor, Dr. Black, or fellow peer helpers. I have completed the Family
Educational Rights and Privacy Act of 1974 (FERPA; https://www.purdue.edu/webcert) training and test and
have a certificate to indicate that I know what is confidential information and how to manage it. I provided the
instructor a copy of the certificate.

I take my position and this agreement seriously and know that a breach of confidentiality could result in serious
consequences to the instructor, Purdue University, and to me personally. I realize by signing this form that I
share in the responsibility and the liability of disclosing unauthorized information. I have read this form and all
questions have been answered to my satisfaction. I will willingly and voluntarily execute these duties and
responsibilities and realize that is what my signature indicates. I have been given a signed copy of this form.

I understand that my participation is an educational opportunity for me and that my participation as a Trained
Peer Helper is voluntary and that I will receive no compensation.

_____________________________________________
Students Printed Name

_____________________________________________
Students Signature

Dr. David R. Black______________________________
Instructors Printed Name

_____________________________________________
Instructors Signature

Last updated: August 18, 2014
24
Center for
Social
Problem
Measurement
25
Epidemiological Statistics
Infant Mortality Rate
1
=
# o] dcuths undc 1 cu
# o] Ic bths
1,000

Neonatal Mortality Rate
1
=
# o] dcuths undc 1 month
# o] Ic bths
1,000
Usually reported annually
Compares infants both Numerator and Denominator

Maternal Mortality Rate
1
=
# o] mutcnuI dcuths ]om chIdbth
# o] Ic bths
10,000
Compares deaths of mothers with live births
# deaths within 90 days of delivery related to pregnancy
Count all deaths related to pregnancy not just childbirth

Note: The denominator (D) is the same for both neonatal and maternal mortality. The K value is
different: Neonatal (1,000), Maternal (10,000).

Problems with Maternal Mortality Formula
1. Denominator excludes all pregnancies which do not result in a live birth (stillborns, induced
abortions, spontaneous abortions, ectopic pregnancies).
2. Debate about how soon after delivery death can be attributed to childbirth

Crude Death Rate =
# o] dcuths
popuIuton
1,000
Tells nothing about age or sex. It is a general comparison

Sex-Specific Death Rate =
# o] dcuths o] mcn o womcn
popuIuton o] thut gcndc
1,000
It is more specific than CDR and tells which gender is affected more

Cause Specific Death Rate =
# o] dcuths duc to u spcc]c cuusc
totuI popuIuton
1,000/10,000/100,000
Tells proportion of total population dying from a particular disease.
Tells how much of a public health priority it is.

Case Fatality Rate =
# o] dcuths ]om u dscusc
cuscs o] thut dscusc
100
Tells how likely death is from a disease
Usually a %
Indicates how deadly a disease is once you get it

Proportionate Mortality Ratio
=
# o Jcotbs rom o spcciic cousc in o JcincJ populotion
totol # o Jcotbs cxcpcctcJ rom tbis conJition in o stonJorJ populotion
100
Usually a %
26
Variables of Population:
Note: Crude rates can be changed to specific rates by focusing on any # of independent variables or
determinants. The limitation of using specific rates are (1) data may not be available and (2) costs due
to collection, entry, and storage of data.

Example of Variables:
Age
Sex
Race or Ethnicity
Cause of Death
Socioeconomic
Status
Occupation
Marital Status
Geographic
Location

Age and Sex

Most basic characteristics of a population
Every population has a different age and sex composition

Sex Ratio =
muIcs
]cmuIcs
100

Sex Specific Death Rate =
# o] dcuths o] ]cmuIcs
# o] uII ]cmuIcs

OR

Sex Specific Death Rate =
# o] dcuths o] muIcs
# o] uII muIcs

1
= NOT A TRUE RATE
27
Center for
Social
Problem
Measurement
28
Welcome to HK 56700
Epidemiology for Public Health Practice
Fall 2014
David R. Black, PhD, MPH, HPPE, CHES,
CPPE, FASHA, FSBM, FAAHB, FAAHE
Professor of Health and Kinesiology; Nursing; Health Sciences; Nutrition Sciences
Professor and Associate Director of the Purdue Homeland Security Institute
1
Dr. Blacks Contact Information
Phone: 765-743-4001 (8 AM 5 PM M-F)
Fax: 765-496-1239
E-mail: dblack@purdue.edu
Office Hours: By appointment, email or call to set up a time.
Time and Class Location:
Online. Lecture videos are posted on Tuesdays
and Thursdays with quizzes on Thursdays
covering the previous 2 class lectures.
2
29
There are Trained Peer Helpers for this course. As a
prerequisite to serving as a Peer Helpers, each individual
has been certified by the University in manageing and
protecting private student information protected by the
Family Educational Rights and Privacy Act (FERPA)
educational information system. The Peer Helpers fully
understand their legal and ethical obligation to protect the
confidentiality of student data. Their email addresses will
be posted to Blackboard. Their office hours are by
appointment and you may email them and/or telephone
them, if they provide their phone number. You can always
contact me.
3
Qualifications to be a Trained Peer Helper
Taken the course previously and received a grade no lower than an A-
Have exceptional verbal and written communication skills
As a prerequisite to serving as a Peer Helpers, each individual has been certified
by the University in managing and and protecting private student information
protected by the Family Educational Rights and Privacy Act (FERPA) educational
information system. The Peer Helpers fully understand their legal and ethical
obligation to protect the confidentiality of student data. Completed the FERPA
(Family Educational Rights and Privacy Act) certification at
www.purdue.edu/webcert and provided a copy of their certification to the instructor
Signed and provided to the instructor a copy of the Confidentiality Agreement for
Trained Peer Helpers (located in the textbook after the syllabus)
Received individual instruction from the instructor about the importance of
maintaining confidentiality
Committed not to share under any circumstances information about you with
anyone other than the instructor or the other Trained Peer Helpers
4
30
Duties of a Trained Peer Helper
Course planning
Tutoring
Lead help sessions
Review exams, quizzes, and homeworks
Peer-mentoring, for example, by answering
questions during office hours, by email, and/or by
phone
Carrying out other duties similar to these
5
Trained Peer Helpers do not:
Serve as independent instructors for courses
Present course content that has not been
authorized by the faculty course instructor
Assign and submit official course grades
6
31
Teaching Assistant
There is also a teaching assistant for this course.
Teaching assistants have the same requirements
and duties as Trained Peer Helpers, however, they
are assigned and are paid by the department.
7
Required Course Manual
A DIRECT LINK TO PURCHASE THE BOOK
WILL BE POSTED TO BLACKBOARD AND
SENT VIA EMAIL TO THE CLASS.
8
32
ONLY REQUIRED TEXT
Black, D.R., & Johnson, M.A.
(2014). Handbook for Epidemiology
for Public Health Practice.
Oshtemo, MI: Center for Problem
Solving and Measurement, and
Research.
The current edition has a background of Theres More Than
Corn in Indiana and yellow text on the cover. Updates have
been made throughout the book. Do not purchase earlier
versions of the book. The older versions are not the same as
newer version.
The text is $75 for the spiral bound edition and $85 for the
hard cover edition. They are identical inside.
9
REQUIRED TOOLS
4 Function Calculator
May NOT use a scientific, graphing, phone, tablet, or similar calculators
An on-screen calculator will be provided during exams and quizzes when necessary.
Windows or Macintosh Computer; Linux computers are not compatible with required software.
Webcam and Microphone
May be integrated into your computer or external. We have had good experiences in the past with
Logitech and Microsoft cameras. You do not need the most expensive camera. A $20-50 camera is
sufficient. The microphone may be integrated into the computer or camera. Most cameras already
have microphones.
Reliable broadband Internet access. Time for quizzes and exams will not be extended due to
unreliable Internet access. If you live in an area with shared Internet access such as an
apartment complex, sorority, or fraternity and your connection is not reliable or stable, you
may wish to use an ITaP lab or other reliable connection.
Adobe Flash Player
Respondus Lockdown Browser and Respondus Monitor. See links on Blackboard Learn.
These are academic integrity tools that we use to allow for convenient examinations, while still
maintaining fairness to all students.
NOTE: The LAMB 122 computers are NOT an ITaP computers and will not meet your needs
for this class. ITaP labs do not have cameras, but most USB cameras that we have tried in
the past will connect fine to ITaP computers and function automatically. You may need to
arrive at the lab about 15 minutes before you wish to begin the quiz or exam to allow the
software for your camera to install.
10
33
4 Function Calculators
You may only you a simple 4-function
calculator on quizzes and exams. A 4-
function calculator should not have any
more buttons than this.
Generally, an on-screen calculator will
appear on your computer when
calculations are required.
11
1
2
3
4
Supplemental Textbook
Merrill, R.M. (2013). Introduction
to epidemiology (6
th
ed.).
Burlington, MA: Jones & Bartlett
Learning.
ISBN: 978-1-4496-6548-7.
12
34
Aschengrau, A., & Seage, G. R.
(2014). Epidemiology in public health.
(3rd ed.). Boston, MA: Jones and
Bartlett Publishers.
ISBN: 978-1284028911 (paper).
13
Gordis, L. (2013). Epidemiology (5
th
ed.).
Philadelphia, PA: Elsevier Saunders.
ISBN: 978-1455737338.
14
35
Heymann, D.L. (2014). Control of communicable
diseases manual (20
th
ed.). Washington, D.C.:
American Public Health Association.
ISBN: 978-0875530185.
No cover image available.
15
For Your Information (FYI)
Dietz, J.E., & Black, D.R. (Eds.). (under
contract and in progress). Large event
security planning and emergency
management. New York, NY: CRC Press:
Taylor & Francis Group.
No cover image of the book available yet.
16
36
Porta, M. (Ed.). (2008). A dictionary
of epidemiology (5
th
ed.). New York,
NY: Oxford University Press.
ISBN: 978-0195314502.
17
For Your Information (FYI)
Public Health Books by the Instructor:
Dietz, J.E., & Black, D.R (Eds.) (2012). Pandemic
planning. New York, NY: CRC Press: Taylor & Francis
Group (ISBN: 978-1439857656).
18
On the Taylor
and Francis Best
Seller List.
37
FYI
Black, D.R., Foster, E.S., & Tindall, J.A. (2012). Evaluation of
peer and prevention programs: A blueprint for successful design
and implementation. New York, NY: Routledge: Taylor & Francis
(ISBN#: 978-0415884785).
19
FYI
Tindall, J.A., & Black, D.R., (2009). Peer programs An in-depth
look at peer programs: Planning, implementing, and
administration (2
nd
ed.). New York, NY: Routledge: Taylor &
Francis (ISBN#: 978-0-415-96236-0). Reprinted with permission:
Tindall, J.A., & Black, D.R. (2009). Highlights of the peer resource
literature (Chapter 5). Perspectives in Peer Programs, 21(2), 69-
84.
20
38
FYI
Black, D.R., Leverenz, L.J., Coster, D.C., Larkin, L.L., & Clark,
R. (2010). Physiological screening test (PST): Manual for eating
disorders/ disordered eating among female collegiate athletes.
Dallas, TX & Monterey, CA: National Athletic Trainers
Association and Healthy Learning (ISBN: 978-1606790694).
21
HK 56700 Course Description
HK 56700 is a requisite for most health-related
fields, and the course focuses on the introduction
and application of basic epidemiologic principles.
Epidemiology is the cornerstone of many different
disciplines.
22
39
Use the terms person, place, and time to describe public
health problems
Calculate basic epidemiologic statistics
Communicate epidemiologic information to both public and
professional audiences
Identify sources of epidemiologic data
Learn the basics of screening programs
23
Source: Association of Schools and Programs of Public Health (ASPPH). MPH Core Competency Development Project.
http://www.ASPPH.org/document.cfm?page=851. Accessed May 19, 2009.
ASPPHs MPH Core
Competencies
Apply epidemiology terms and definitions
Comprehend the legal principles involved in using and
distributing epidemiologic data
Make inferences from epidemiologic data
Evaluate strengths and weaknesses of epidemiologic
reports
Explain the applications of epidemiology to medicine
and other topics such as environmental, occupational
health, and disaster preparedness
24
ASPPHs MPH Core
Competencies
40
Course Goals
To understand the basis and origin of the
epidemiologic thought and problem-solving
To apply epidemiologic concepts to evaluate the
distribution, determinants, and frequency of
mortality, morbidity, injury, and disability in human
populations
KNOW THIS DEFINITION, WHICH IS A CLASSIC
DEFINITION OF EPIDEMIOLOGY
25
Course Goals (cont.)
To compute various morbidity and mortality, risk
determinants, and foodborne screening statistics
To interpret and evaluate epidemiologic data
To understand epidemiologic research designs and
basic investigative procedures
To comprehend causality and other related criteria
for confirming causality
26
41
Learning Methods and Materials
The material in class is presented as illusively simple, but
dont be fooled.
The application of epidemiologic principles is challenging. This
is what makes the course difficult.
This is a medical course. The slides and notes you take are
vital. If you suspect you are going to have trouble with the
course, buy all the books.
Physicians are able to pass medical boards in epidemiology by
only taking this 1 course. Often they receive Cs or Bs and
feel fortunate to receive that letter grade.
27
Homework and Assignments
Assignments and homework are not collected or graded.
The assignments are selected to reinforce basic
principles presented in lecture.
Homework and assignments provide excellent practice
for the test, but are not exact duplicates of what will be
on tests. They are designed to initiate thinking and
problem solving and imagine different ways questions
might be asked.
The emphasis is not telling you what to think, but
teaching you how to think. 28
42
Homework and Assignments
Homework and assignments build a minimum
understanding and knowledge of concepts so
students can perform at a higher level of cognitive
reasoning and apply what they know.
Exams are not a regurgitation of the material
presented in class. This course requires memory,
but the main focus is on appliction of what you have
learned.
29
Homework, Assignments, and Help Sessions
Homework and assignments will not be discussed during recorded lectures, but
may be discussed during help sessions, discussion formum, or office hours, if so
desired.
Help sessions will be requested by students or no help session will be offered.
A help session may be requested at any time during the semester by any student.
Request are annonymous and the name of the student making the request will not
be shared with the other students.
Help sessions are lead by the Trained Peer Helpers and monitored by the
instructior and IT Expert.
Electronic attendance at help sessions is optional, not required, and attendance is
not taken. I would advise attending, if one of you requests a session.
We may send out some form of survey to determine how many people are
planning to attend the help session as it may affect the electronic medium we use
to conduct the session.
30
43
Best Practices for Success
The slides do not contain all of the class information that you
must know; additional note-taking is prudent.
The manual is provided to help you learn the fundamentals of
Epidemiology.
Be sure to have the slides with you as you watch each lecture to
enhance your understanding and knowledge of the material.
It is a good idea to review past slides that have been presented
previously and ones for the current lecture and future lectures.
Note cards may be advantageous for some.
Study and review after each class session is imperative. Dont
get behind. Cramming does not work for this course.
31
Progressive Learning
The course begins with the definition of epidemiology and
the focus is descriptive. As the course progresses, the
emphasis is on both descriptive and analytic methods. You
will learn epidemiologic calculations and investigative
methods. You also will learn valuable lessons from history,
which are still applicable today. History should help to
reinforce current epidemiological thought processes and
problem solving and procedures. This helps to provide a
mental set for the course.
The course relies on concepts learned earlier in the course.
So it is important that you learn them as we progress.
32
44
Course Requirements
Attendance is taken by completing exams and quizzes. Quizzes
will be given on Thursdays between 12:01 AM and 11:59 PM.
Once you start, you will have 20 minutes to complete each quiz.
The quiz will not be available to you again. There are no
makeups for quizzes or exams except under the GAPS (Grief
Absence Policy for Students) policy.
If there are any technical issues taking a quiz or exams, contact
the instructor immediately by phone so the issue can be
corrected. You will not be penalized for technical issues on
Purdues end.
Your lowest quiz score will be dropped at the end of the semester.
This dropping will not affect your attendance score.
33
Getting Help
If you do not understand lecture material, homework and
assignments, exams, and/or quizzes, contact the instructor
ASAP.
With this online format, you can watch the videos endless
times until you understand. This is different from an in-class
lecture where you only hear it once.
Get help early.
Do not wait until the end of the class to indicate you are
having trouble; nothing can be done at that point.
No additional work can be completed after the exam or prior
to grades being submitted in hopes of raising your grade or to
acquire additional points.
34
45
How to Succeed
To be successful in the course, students must do the following:
Watch every lecture in its entirety
Attend optional help sessions or participate in the discussion forums.
The discussion forums will be monitored by the entire teaching team.
2 graduate students will be assigned as a weekly moderator. An email will
be sent that week to the assigned moderators. The moderators will be
responsible for attempting to answer questions from the HK 44500 and HK
56700 students and the teaching team will also review and weigh in as
necessary.
Seek help early
Make flash cards
There is no substitute for studying.
35
Exams and Quizzes
There is 1 non-cumulative exam for each section of the
textbook, 3 exams in total.
Exam and quiz questions are as follows: true/false,
multiple choice, multiple answer, matching, and math
problems (as multiple fill in the blank questions).
They will cover material from the lectures, homework,
assignments, quizzes, and handouts.
All in the prior bullet will be distributed through
Blackboard Learn according to the schedule in the
syllabus. 36
46
Exams and Quizzes
The exams and quizzes require higher-order reasoning and
cognitive processing, which are expected of students at a Big 10
university.
A 4-function calculator, Respondus Lockdown Browser,
Respondus Monitor (accessed through the Lockdown Browser),
webcam, and microphone will be required to take exams and
quizzes. Links for these programs will be posted to Blackboard
Learn. You will not be able to take quizzes or exams without these
programs and a webcam.
No makeups and a zero (0) grade will be recorded.
The format may be changed to a proctored (on campus) exam at
Dr. Blacks sole discretion. If you are a Distance Learning student
and have no on campus classes, please let Dr. Black know during
the FIRST week of classes so we can make alternate
arrangements for evalualtion, if necessary.
37
Exams and Quizzes
Exams and quizzes are self-explanatory.
Vocabulary is part of the exam or quiz and vocabulary development is
expected of students and persons who are formally educated. You
must know terms precisely and how to apply them.
Definition of terms will not be provided or verified during an exam or
quiz.
Students should not expect help on examinations or quizzes from Dr.
Black or others helping with the proctoring of the exam other than
asking questions about the instructions.
All exams and quizzes are closed book, note, and friend/enemy
are not to be consulted for help.
You are NOT to work together on exams and quizzes. Monitoring
technology will be used during all quizzes and exams to ascertain who
is doing what .
38
47
Grades & Course Evaluations
SEE SYLLABUS FOR BREAKDOWN OF
GRADES. WE WILL USE A + AND - SYSTEM.
We follow Blackboard Learns rounding. An
89.99% will remain a B+, for example. We must
follow a standard to be equitable to all students.
BE SURE TO PERUSE THE SYLLABUS.
Purdues Course Evaluation will be distributed via
email by the University.
39
Academic Decorum
Purdue students should adhere to the Campus Code of
Conduct.
Academic dishonesty will not be tolerated in the course.
Examples of cheating include, but are not limited to the
following: giving or receiving aid during exams, or copying
from another persons exam during the test.
If you see cheating, please report it to Dr. Black. Your
report will be kept confidential. If you are uncomfortable
with Dr. Black knowing your identity for reporting the
cheating, you also may report it to the departmental
secretary who will pass on the report anonymously.
40
48
Academic Decorum
Cheating or other forms of dishonesty that are
discovered by the instructor will result in at least a
failing grade on the given quiz/test for all involved.
More severe cases will result in a failing grade for
the course; cases of academic dishonesty also may
be referred to the Dean of Students Office.
41
Academic Decorum
Please contact Dr. Black if you have any questions
pertaining to academic honesty. Also, you are
encouraged to review the Dean of Students
Website for more information on academic honesty
and integrity.
Civility is expected and will always be provided in
return.
42
49
Academic Decorum
Please read the following websites:
http://www.purdue.edu/ODOS/osrr/conductcode.htm
http://www.purdue.edu/ODOS/osrr/academicdishonesty.htm
You will be accountable for knowing the information on
the websites.
Knowledge helps to preserve your rights and to prevent
serious unwanted personal consequences that could
jeopardize your degree and your entire professional
future. 43
Students with Disabilities
Purdue accommodates students who have disabilities;
students should notify Dr. Black within the first 3 weeks
of class to determine an appropriate course of action.
Verification with the Disability Resource Center
(www.purdue.edu/drc) is required. Additional details
are in the syllabus.
In certain circumstances, there may be no alternative
course of action; however, every effort will be made to
help the student meet course requirement to receive a
satisfactory grade.
44
50
Emergency Preparedness
In the event of a major campus emergency, course
requirements, deadlines and grading percentages
are subject to changes that may be necessitated by
a revised semester calendar or other modifications.
Information about course changes will be
communicated via BlackBoard Learn or e-mail. You
also may contact Dr. Black preferably by email.
45
To report an emergency, call 911. To obtain updates regarding an ongoing emergency,
sign up for Purdue Alert text messages, view www.purdue.edu/ea .
There are nearly 300 Emergency Telephones outdoors across campus and in parking
garages that connect directly to the PUPD. If you feel threatened or need help, push the
button and you will be connected immediately.
If we hear a fire alarm during class we will immediately suspend class, evacuate the
building, and proceed outdoors. Do not use the elevator.
If we are notified during class of a Shelter in Place requirement for a tornado warning, we
will suspend class and shelter in the basement.
If we are notified during class of a Shelter in Place requirement for a hazardous materials
release, or a civil disturbance, including a shooting or other use of weapons, we will
suspend class and shelter in the classroom, shutting the door and turning off the lights.
Please review the Emergency Preparedness website for additional information:
http://tinyurl.com/keow3tg
EMERGENCY PREPAREDNESS
A MESSAGE FROM PURDUE
46
51
Harassment
Harassment will not be tolerated and will not be part of this course.
Harassment is defined in Purdue University's Anti-Harassment (III.C.1)
policy: http://tinyurl.com/ohbhaxj . Use of the term Harassment includes
all forms of harassment, including Racial Harassment and Sexual
Harassment.
Sexual Harassment
Any act of Sexual Violence.
Any act of Sexual Exploitation.
Any unwelcome sexual advance, request for sexual favors or other written, verbal
or physical conduct of a sexual nature when:
Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's
employment, education, or participation in a University activity;
Submission to, or rejection of, such conduct by an individual is used as the basis for, or a factor in,
decisions affecting that individual's employment, education, or participation in a University activity; or
Such conduct has the purpose or effect of unreasonably interfering with an individual's employment or
academic performance or creating an intimidating, offensive, or hostile environment for that individual's
employment, education, or participation in a University activity. 47
Due on Thursday by 11:59 PM:
Student Information Sheet
It gathers important contact and demographic
information and is an agreement to follow all of
the policies and requirements outlined in the
syllabus.
Quiz over the syllabus.
48
52
Center for
Social
Problem
Measurement
53
49
Introduction
50
Underlying Assumption of
Public Health
We are caught in an inescapable network of
mutuality, tied in a single garment of destiny.
Whatever affects one directly, affects us all
indirectly.
-Dr. Martin Luther King, Jr.
54
51
55
Center for
Social
Problem
Measurement
56
53
What is Epidemiology?
Definition of Epidemiology
Epidemiology: The study of the distribution and
determinants of disease frequency and injury and
disability in human populations.
Epi = upon
Demos = people
logy = study of
54
57
55
A Few Applications of Epidemiology
To study the etiology of diseases, disorders, and
disabilities
To identify agents associated with diseases
To assist in the development of health initiatives,
services, and programs (e.g., policies about
smoking and seatbelt laws)
To prevent/protect and control diseases
Use the terms magnitude, person, place,
and time to describe public health problems
ASPPHs MPH Core Competency
56
58
57
Distribution: First Key Word of the
Person: Refers to demographic variables such as
age, gender, race, sex, socio-economic, and
marital status
Place: A specific geographic location
Time: A specified period of time
Nations With Confirmed Cases of H5N1
Avian Influenza (February, 2007)
http://www.pandemicflu.gov/
Person
Time
Place
58
59
Person = ?
Place = ?
Time = ?
Source: Scrimshaw, N. S. (n.d.). Nutrition and health from womb to tomb. Retrieved from http://archive.unu.edu/unupress/food/V181e/p10.gif
Originally from NutritionToday 1996; 31(2): 55-67
59
What type of best fit line seems to summarize the relation between DMF
and Time?
DMF = Decayed, Missing, and False Teeth
Who = ?
Where = ?
When = ?
3
4
5
6
7
8
9
1970 1977 1984
N
u
m
b
e
r

o
f

D
M
F

T
e
e
t
h
Time variable indicates causal relationship between decline in dental caries and the introduction of fluoride
in New Zealand.
60
60
Water Fluoridation: National Fluoridation Report (CDC)
Percentage of state Public Water Service population receiving fluoridated water - 2006
61
62
Terms Related to Distribution
I. Sporadic
II. Endemic
III. Hyperendemic
IV. Holoendemic
V. Outbreak
VI. Epidemic
VII. Pandemic
61
63
Sporadic
Sporadic: An event that occurs irregularly or
haphazardly (variable).
N
u
m
b
e
r

o
f

C
a
s
e
s
Time
Number of Cases of a Disease at a Specific Time
64
Endemic
Endemic: The constant presence of a disease or infectious
agent within a population (steady state).
N
u
m
b
e
r

o
f

C
a
s
e
s
Time
62
65
Hyperendemic
Hyperendemic: A disease that is constantly
present at high incidence or prevalence.
N
u
m
b
e
r

o
f

C
a
s
e
s
Time
66
Hyperendemic
Disease present constantly at a high rate
& in all parts of the population
Incidence of Malaria, World Malaria Report 2005, WHO
63
Holoendemic
Holoendemic: The disease is more prevalent in kids than
adults (kids infect kids).
Examples: Measles, Mumps, and Chickenpox
Age
Children Adults
Time Time
N
u
m
b
e
r

o
f

C
a
s
e
s
N
u
m
b
e
r

o
f

C
a
s
e
s
N
u
m
b
e
r

o
f

C
a
s
e
s
Age Distribution
67
68
Foodborne Outbreak
Outbreak: An event of acute illness that does not reach pandemic or
epidemic distributions. Outbreaks are confined (e.g., restaurants,
schools, hotels, single buildings, or a small geographic location).
CDC defines a foodborne outbreak as well as waterborne outbreaks
as 2 or more cases. The first case is the endemic state.
Outbreaks are usually caused by exposure to pathogens (e.g.,
waterborne disease that is conducive to Legionella growth include
warm water temperatures, stagnation, scale and sediment, and low
biocide levels). Waterborne diseases can be circulated through
ventilation systems.
64
Second Wave of SARS Outbreak in Toronto
Example of a Disease Outbreak
69
70
Epidemic
Epidemic: The number of observed diagnosed cases in a
community, state, or region (for example, the Midwest) is greater
than the expected number of cases.
N
u
m
b
e
r

o
f

C
a
s
e
s
Time
Number of Cases of a Diagnosed Disease at a Specific Time
Expected number
65
71
Pandemic
Pandemic: The number of cases observed in a population is greater
than the expected number of cases, and a large geographic area is
affected (e.g., country, continent, or world).
Country One Country Two
N
u
m
b
e
r

o
f

C
a
s
e
s
N
u
m
b
e
r

o
f

C
a
s
e
s
N
u
m
b
e
r

o
f

C
a
s
e
s
Time Time Time
No. of Cases at a Specific Time
Expected number
Pandemic
Epidemic occurring over wide
geography and affecting large
portion of population
1918-1919 Influenza
Pandemic infected over 50%
of the WORLDS population
and killed >20 million
An Emergency Hospital for Influenza
Patients Source:
http://virus.stanford.edu/uda/
72
66
Deaths in Major Cities: 1918-1919 Pandemic
73
74
Comparing Distributions
Pandemic
Epidemic
Outbreak
67
Term Distribution Criteria
Outbreak Localized
(confined)
Two or more cases (foodborne/waterborne)
# of observed cases are greater than expected (all
other transmission modes)
Epidemic Community
State
Region
# of observed cases are greater than expected
Pandemic Country
Continent
World
# of observed cases are greater than expected
75
Classifying Terms
76
Misuse of Terminology (CDC)
A large multi-state outbreak of infectious
Avian influenza outbreaks among poultry occur worldwide
from time to time
Mumps Outbreak, United States, 2006
1951 Influenza Epidemic, England and Wales, Canada, and
the United States
Influenza Epidemics in the United States, France, and
Australia, 1972-1997
68
Application of Terms
77
Might be considered what?
What term could we use?
Expected could
be called what?
78
About Disease
Two fundamental assumptions:
Diseases do not occur at random
Diseases have causal (determinants/agents) factors, which often
make them preventable and controllable so the public can offer
themselves protection.
Disease varies due to:
Culture
Society
Genetics
Environment
Determinants
69
79
80
Determinants: The Second Key Word in the
Determinants are variables that affect the distribution of a
disease.
Examples of determinants:
1. Age
2. Sex
3. Genetics
4. Biology
5. Environment
6. Seasons
Person
Place
Time
Note: Determinant implies a cause and effect relationship
as does pre-disposing factors from the social sciences.
70
Determinants
Identifying determinants primary goal of
epidemiologists
Identifying risk factors for health-related states
or events
Risk factor = behavior, environmental
exposure, human characteristics
81
Examples of Risk Factors
Behaviors
Cigarette smoking, physical inactivity, not wearing a
helmet when riding a motorcycle
Environmental exposure
Air pollution from Staleys wet corn milling facilities,
loud music or noises
Human characteristics
Age, gender, race/ethnicity
82
71
83
Frequency: The Third Key Word in
the Definition of Epidemiology
Determinants are related to disease frequency (f)
What does f tell us?
How often a disease occurs during a specified period of time.
f tells us the magnitude of the disease at any given point.
f can help us identify determinants, too.
Why is f important?
f tells us whether we have an outbreak, epidemic, or
pandemic.
Trends and patterns lead to hypotheses about cause,
prevention/protection, control, and treatment/ intervention
strategies.
Example: Frequency
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$18,000
$20,000
Sri Lanka Egypt Thailand Chile Mexico Argentina Sweden USA
60
70
80
90
100
110
120
130
140
G
N
P
P
e
r

1
0
0
,
0
0
0

P
o
p
u
l
a
t
i
o
n
Crude Injury Mortality Rates in Males by Level of Economic Development
Rate (right axis)
GNP (left axis)
84
72
Events in the U.S.
Disease Time Number of Cases
Influenza 1917-1919 >20 million killed
(1-2% of world pop)
St. Louis Encephalitis 1975 1,815
Legionnaires Disease in Philadelphia 1976 182
29 died
Lyme Disease 1982-1992 49,872
AIDS 1981-1993 315,000
85
86
Summary
What is Epidemiology?
The study of the distribution and determinants of disease frequency
and injury/disability in human populations.
What terms have we covered thus far?
Epidemiology
Distribution (i.e., person, place, and time)
Outbreak, epidemic, pandemic, etc.
Determinants
Frequency
73
Center for
Social
Problem
Measurement
74
87
Disease Prevention
88
Levels of Disease Prevention
Primary Prevention
Stop the disease before it happens
Secondary Prevention
Keep the disease from getting worse
Tertiary Prevention
Treat the disease once it has developed
75
89
SKIT
You can recall the levels of prevention easily by a
mnemonic called SKIT.
STOP it from happening.
KEEP IT from getting worse.
TREAT it once it has developed.
90
Primary Prevention
Stop the disease from happening.
Examples include immunization, health promotion
interventions, and reducing your exposure to
environmental disease-causing agents.
How about fluoridation of drinking water?
76
91
Primary Prevention
What are some primary prevention strategies for breast
cancer?
Knowledge of family history
Regular self-examinations
Regular check-ups with your doctor
Blood tests
Imaging (e.g., x-rays and/or a sonogram)
Minimizing your exposure to radiation (UV light)
Healthy eating (e.g., eliminate sugar and fat).
Exercise
NOTE: Some of the examples may be used under more than 1
term on the next slides.
92
Modifies the extent or severity of a disease by early
detection and prompt treatment.
What are examples of secondary prevention strategies
for breast cancer?
Sonograms
PET (Positron Emission Tomography)
CT (Computed Tomography) scans
Blood tests
Diet and exercise
Segmental Mastectomy
Lumpectomy
77
93
American Indian/Alaska Native and Asian/Pacific Islander populations were not broken out into their own categories for the 1987 data.
Source: National Center for Health Statistics. National Health Interview Survey in Health, United States, 2005 with Chartbook on Trends in the Health of Americans.
-5
5
15
25
35
45
55
65
75
1987 1994 2000 2003
30
61
71
70
24
64
68
70
0
66
47
63
0
56
54
58
19
52
61
65
Year
% of U.S. Women 40 Years and Older Who Have Had a Mammogram in the Last 2 Years
by Race and Ethnicity
White Black American Indian/AK Native* Asian/Pacific Islander* Hispanic
94
Source: National Center for Health Statistics. National Health Interview Survey in Health, United States, 2005 with Chartbook on Trends in the Health of Americans.
0
10
20
30
40
50
60
70
80
1987 1994 2000 2003
18
48
58 58
31
61
70
68
38
70
76
75
% of U.S. Women 40 and Older Who Have Had a Mammogram in the Last 2 Years by
Education Level
Less than High School High School Graduate Some College or More
78
95
Tertiary Prevention
Damage control
The disease has already occurred.
What some are examples of tertiary prevention strategies for
breast cancer?
Blood tests
Chemotherapy
Radiation
Oral medications
Blood transfusions
Group counseling or public meetings
Diet and exercise and supplements
79
Center for
Social
Problem
Measurement
80
97
History of Epidemiology
98
Brief History of Epidemiology
Hippocrates (460-377 BC)
First epidemiologist
Observed and described behaviors
Linked clean air and water to longevity
John Graunt (1620 - 1674)
Famous for work involving record keeping and association
Systematically recorded and analyzed morbidity and
mortality data
81
99
John Graunt
Developed the Bills of Mortality, which listed
possible causes of death during the Black Plague
during 1347-1350
Analyzed demographic variables and their
relationships to mortality
Calculated life tables and life expectancy
Coined the terms acute and chronic
100
Founders of Modern Epidemiology
John Snow
Ignaz Semmelweis
Reasons
Introduced hypothesis testing, analyses, and
explanation. This is the analytic part of
epidemiology.
82
101
John Snow, MD
English physician
The founder of Anesthesiology
In 1853-1854, London beset with a Cholera epidemic.
Miasma Theory suggested Cholera was spread by
pollution (bad air; e.g., poisonous gases)
However, Snow hypothesized that drinking water was
contaminated with fecal waste.
102
John Snow, MD
Snow conducted a famous study by
walking door-to-door to inquire about
where consumers obtained their water.
The procedure of going door-to-door is
known as shoe-leather epidemiology.
83
103
Approximate Distribution of Infected Residents, London, 1855
Place
Time
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Number of Deaths: 500 within 10 days
Population at Risk: 300,000 residents
= Diagnosed Cholera Case
.
104
Vibrio cholerae
Source: http://remf.dartmouth.edu/images/bacteriaSEM/source/1.html. T.J. Kirn, M.J. Lafferty, C.M.P Sandoe and R.K. Taylor, 2000, "Delineation of pilin
domains required for bacterial association into microcolonies and intestinal colonization", Molecular Microbiology, Vol. 35(4):896-910
84
105
John Snow, MD
In 1854, Snow concluded the
Broad Street water pump was
the main source of Cholera.
Snow later removed the handle
and the epidemic ended.
106
John Snow, MD
Many people were skeptical because Cholera incidence rate was
already declining.
In 1855, nearly 300,000 residents confirmed their water originated
from a common source.
In 1855, Snow published On the Mode of Communication of
Cholera.
John Snow died in 1858 at the age of 45.
85
107
On the Mode of Communication of Cholera.
by
John Snow, M.D.,
Member of the Royal College of Physicians,
Fellow of the Royal Med. And Chir. Society,
Fellow and Vice-President of the Medical
Society of London.
Second Edition, Much Enlarged.
London: John Churchill, New Burlington
Street.
M.DCCC.LV.
108
London Times, July 3, 1849
86
109
More Information
More information about John Snow can be
found at the following website:
http://www.ph.ucla.edu/epi/snow.html
110
Robert Koch, MD
In 1883, Vibrio cholera was isolated by Robert
Koch, a German bacteriologist.
Koch won the Nobel Prize for his knowledge of
biology and the mode of transmission of vibrio
cholera. He also developed procedures for
preventing and controlling Cholera epidemics.
87
111
Ignaz Semmelweis (1818-1865)
Improved hospital hygiene
Worked in maternity ward at General Hospital in Vienna
Puerperal (childbirth) fever killed 50% of mothers in General
Hospital
Death rate 3 times higher in ward staffed by medical students
112
Ignaz Semmelweis (1818-1865)
Hypothesis
Students did not wash hands after working with cadavers and
patients
Test
Soak hands in a chlorinated lime solution
Result
Maternal mortality decreased from approximately 120
deaths/1,000 live births to 12 deaths/1,000 live births in just 7
months
Medical community still favored Miasmic Theory
88
113
Proper Hand Washing
1. Wet your hands and wrists with warm water. Then
apply antibacterial soap. Lather well.
2. Scrub all surfaces, including the backs of hands,
wrists, between fingers and under fingernails.
3. Rub your hands together for at least 1 min. Friction
also helps to kill germs.
Source: http://www.mayoclinic.com/health/hand-washing
114
Proper Hand Washing
4. Dry your hands with a clean towel.
5. Use a towel to turn off the faucet and to open the
bathroom door.
6. Use your hind quarters to open the door if the design
of the bathroom allows it.
7. Keep hands away from face.
8. Cough into your sleeve.
Note: Alcohol-based hand cleaners (e.g., Purell) are
thought to be effective, if used properly.
89
115
Typhoid Mary
Real name Mary Mallon
She was a cook in NY during the early 1900s
Mary was infected with Salmonella typhi and
many of the people who ate her food became
sick and died
Led to the tracking of disease carriers and strict
laws for food handlers
116
U.S. Public Health Timeline
1639: Massachusetts and Plymouth colonies
mandated the use of vital statistics.
1701: Massachusetts passed legislation isolating
smallpox patients from the rest of the healthy
population (i.e., quarantine).
1842: Henry W. Rumsey wrote, Essays on State
Medicine, which emphasized the importance of health
promotion and disease prevention.
90
117
1850: Lemuel Shattuck wrote, Report of the
Massachusetts Sanitary Commission, which marked
the beginning of community health.
Shattucks report recommended the following:
State and local health departments;
A systematic collection of vital statistics;
Sanitation inspections;
School health programs; and
Controlling mental illness, alcohol abuse, and TB.
118
Massachusetts established the first Board of Health in
1869 followed by CA in 1870.
The board focused on the following:
Inspection of housing;
Public education and hygiene;
Investigation of diseases;
Regulating slaughterhouses;
Monitoring prisons;
Healthcare for the poor.
91
119
1947: Statistics originated in IA after WWII.
1950: The U.S. government, for the first time,
published national mortality statistics.
92
Center for
Social
Problem
Measurement
93
121
Roots of Modern
Epidemiology
122
Roots of Modern Epidemiology
Epidemiology emerged out of the infectious
diseases specialty and was associated with an
epidemic.
What is the purpose of clinical practice?
To treat people with a disease; primarily, one person at
a time. Diagnosis should be primary/mandated.
What is the purpose of Epidemiology?
To prevent/protect and control diseases in human
populations.
94
123
Epidemiologists vs. Clinicians
Epidemiologists Clinicians
Study populations and distributions Examine and diagnose patients
Population-based Patient-based
Prevent, protect, and control Treat and cure
124
Why Do We Need Epidemiology?
Epidemiology fills the gap between clinical practice and
laboratory studies; alone, neither specialty represents a
true picture of what causes or cures most diseases.
Descriptive epidemiology relies heavily on
Clinical observations
Descriptions (trends and patterns)
Abnormalities/anomalies
Descriptive statistics This is an area where you want to
develop expertise. It is not simple. It requires higher-order
reasoning.
95
125
Behavioral Epidemiology
Scientists suggest that all diseases are not due to
genetics alone; there are often social, behavioral,
and environmental factors.
1980s: Social scientists began focusing on AIDS
initiatives when they learned that AIDS could be
prevented and controlled through behavior
modifications (e.g., bleaching needles, wearing
condoms, and abstaining from sex).
126
Behavioral Epidemiology: The study of the
distribution and determinants of disease frequency
and injury/disability in human populations related to
engaging in unhealthy behaviors and making
behavioral choices deleterious to ones health.
The theme is personal responsibility, which society
resists.
96
127
Examples of poor health habits guided by human
choices include the following: cigarette smoking,
eating sodium-rich foods, high fatty foods,
inadequate exercise, excessive exposure to UV
light, stress, alcohol abuse and/or misuse, and licit
(not forbidden by law) and illicit (forbidden by law)
drug use.
Licit, not illicit drugs, are the biggest problem in this
country (nicotine, alcohol, and caffeine).
128
There are 3 relationships to assess:
Determinants of behavior
Behavior
Disease
Determinant Behavior Disease
Type of Cigarette No. of cigarettes smoked Heart Disease/Cancer
Stress Poor/maladaptive response to workload Heart Disease/ Stroke/Cancer
No. of Partners Sexual intercourse without condoms STDs, STIs, and AIDS
UV Light Exposure Using tanning beds Skin Cancer
Sharing Needles No. of times sharing AIDS
97
Examples of Risk Factors
Behaviors
Cigarette smoking, physical inactivity, not wearing a
helmet when riding a motorcycle
Environmental exposure
Air pollution from Staleys wet corn milling facilities,
loud music
Human characteristics
Age, gender, race/ethnicity
129
What Do Epidemiologists Do?
Identify health risk factors
Describe etiology of a
disease
Identify populations at risk
Prioritize public health
threats by demographics
130
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W
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Q
A
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.

101
Skills & Background for
Effective Epidemiologist
Population perspective
Basic biology
Physical ecology
Social ecology, sociology, social psychology
Economics
Above all, an epidemiologist has statistical and
quantitative skills!
133
Ecological Perspective
Interaction of organisms & their environment
Includes both physical & social ecology
In public health, concerned with interaction
between environments & disease
134
102
Physical Ecology
How does the physical
environment relate to
disease states?
Biology
Geology
Meteorology
Eastern Tree Hole Mosquito (Ochlerotatus triseriatus),
vector for La Crosse Encephalitis
Ochlerotatus triseriatus (Say 1823). TaxonConcept
Knowledge Base, editor Peter J. DeVries, Available from
http://lod.geospecies.org/ses/iuCXz.html. Accessed 13
August 2014
135
Social Ecology
Relationship between
behavior & disease
Examples
Sexually transmitted
infections (STIs)
Organizational culture
of hospitals & medical
errors
35
40
45
50
55
60
65
P
e
r
c
e
n
t

R
e
s
i
s
t
a
n
c
e
Year
Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA)
among ICU Patients, 1995-2004
Source: National Nosocomial Infections Surveillance (NNIS) System
136
103
Sociology & Behavioral Epidemiology
Sociology: study of social systems and their influence on
human behavior
Behavioral epidemiology: study of the relationship
between human behaviors and the distribution and
determinants of disease and injury frequency in a human
population
Social Science Informs Epidemiology
137
Research Questions Addressed by Social &
Behavioral Epidemiologists
How does the social environment result in
differences in quit rates between teen and adult
smokers?
What is the relationship between SES and health
status?
How does neighborhood SES and social capital
impact rates of obesity?
138
104
Non-Academic Roles
Public Health Agencies
Pharmaceutical and Medical Technology Firms
Health Insurers
Occupational Health and Safety
Hospitals
139
105
Center for
Social
Problem
Measurement
106
Epidemiologic Investigation
141
Spectrum of Disease
Disease inception
Prepathogenesis
Factors that initiate disease
Pathogenesis
Mechanisms by which etiological agents produce a disease
Pathological progression
Clinical response
Mild
Moderate
Severe
142
107
Spectrum of Disease
Sequalae of disease
Remission
Reoccurrence
Unremitting progression
Death
143
A case is defined differently based on the
model of disease and the availability and
sensitivity of the assessment method.
Exposure Pathological progression
Signs & symptoms Disease onset
Progression or reversal Disorder/disease
Death
-- The italicized text appears repetitive
-- Also, not everyone with a disease dies from the disease;
not all diseases cause death (be careful). The chart is
misleading.
Spectrum of Disease
144
108
Case vs. Noncase
What is a case?
A case is what you define it to be.
A case is defined for diagnostic purposes.
It implies a binary distinction (yes/no)
Must have a diagnosis
What is a noncase?
Someone who doesnt meet the case criteria.
145
Example
Maritally Happy vs. Relatively
Happy vs. Distressed
Marital Adjustment Scale (MAS)
>100 = Maritally happy
<99 86 = Relatively happy
<85 = Distressed
146
109
Problems with Case Definition
Sometimes criteria change
What are the implications?
Counts in the past may not be comparable to present counts
[This is incorrect: Counts should not be compared; a
denominator (population or person-time at risk) is always
necessary]
May give inflated or reduced count
Difficult to make trend comparisons
May not be able to tell if interventions are working
Do not know what implications to draw or what to do
147
Steps of an Epidemiologic
Investigation
1. Determine the magnitude of disease problems in the
community.
Like Cholera example, in terms of casualties
(distribution, determinants, and frequency), diagnosis,
incidence, and prevalence
2. Investigate the etiology of diseases and modes of
transmission.
Cholera caused by Vibrio cholerae bacterium
3. Study the natural history of the disease.
Snow studied Cholera for 5 years
148
110
Steps of an Epidemiological
Investigation
4. Develop a prevention program.
Snow removed pump handle
5. Evaluate new preventative measures and modes of
healthcare delivery.
Snow removed handle, incidence decreased
6. Provide a system for implementing environmental
regulatory decisions or policies.
Purify drinking water
Water collection restricted to 1 well that was not contaminated
149
150
Calculate basic epidemiologic statistics
ASPPHs MPH Core Competency
111
Center for
Social
Problem
Measurement
112
Indices of Morbidity
151
Indices of Morbidity and Mortality
Morbidity Rates
Risks of illnesses
Mortality Rates
Deaths from illnesses
Birth Rates
152
113
Measuring Morbidity and Mortality
Correctly measuring morbidity and mortality is a
matter of understanding the relationships
between the numerator, denominator, and
constant.
153
K
154
114
Morbidity
The three units of morbidity are as follows:
1. People who are ill
2. Periods of illness that people experience
3. Duration of illness
Morbidity is measured by incidence and prevalence.
Incidence and prevalence are different terms and dont
mean the same thing.
Incidence rates and prevalence rates do not mean the
same thing as incidence and prevalence.
155
Incidence and Incidence Rates
Incidence alone is a count (integer). How many
people are diagnosed as sick/ill?
Incidence Rate (IR): The ratio that new cases
appear in a population.
Note: Incidence is usually annual, but can be for shorter time periods
(e.g., half year, quarter, or a 2 week interval). If not specified, assume
annual incidence. A diagnosis is always required. Whether a count or a
ratio, incidence is annual.
156
115
U.S. Population = 318,646,736 (as of
8/13/2014). Based on 1 birth every 7 seconds,1
death every 13 seconds, and 1 international
migrant every 40 seconds. This results in a net
gain of 1 person every 12 seconds.
World population:
7,185,167,500 (as of 8/13/2014)
Source: U.S. Census Bureau http://www.census.gov/popclock/
157
Population as of 8/13/2013 1:04 AM EDT
Estimated Population in 2050 (3 scenarios)
158
116
Midyear
Denominator is the midyear for the population.
Midyear is synonymous with median.
For example
2009, 2010, 2011 (Midyear = 2010)
2008, 2009, 2010, 2011, 2012 (Midyear = 2010)
159
Prevalence
Prevalence alone is a count (integer)
Prevalence Rate: The ratio of the total number of
individuals who have a disease during a specific
time divided by the population at risk and multiplied
by K.
Prevalence considers new, existing, and
recurring cases
Assume point prevalence, if not told or specified
otherwise, whether it is a count or ratio.
160
117
Recurring
When to include a case in the numerator:
If a disease is recurrent, you can count it in the
numerator more than once.
Person must become sick and then completely get over
the disease each time. They are cured.
For example, influenza could be counted in the
numerator more than once because the disease could
recur in the same individual during a specified time
period.
161
Prevalence
There are four main types of prevalence:
Point Prevalence
Period Prevalence
Annual Prevalence
Lifetime Prevalence
Prevalence varies according to time
The same time periods as above also apply to
incidence.
162
118
Point Prevalence Rate
Point Prevalence Rate (PR): The ratio of the number of
people with a disease during a specified time; similar to
a snapshot (1, 24-hour day) of the disease in time.
*If not specified, always assume Point Prevalence
Denominator could be a unique population, U.S. population,
or world population.
163
Period Prevalence Rate
Period Prevalence Rate (PPR): The ratio of the total number of
people who had a disease during a specified period within a year
(e.g., 3, 6, or 9 month period, less than a year).
164
119
Annual Prevalence Rate
Annual Prevalence Rate (APR): The ratio of the
total number of persons with the disease at any
time during a 1 year period.
165
Lifetime Prevalence Rate
Lifetime Prevalence Rate (LPR): The ratio of the
number of people known to have had the disease at
least once during their lifetime.
Lifetime is considered to be 65 years.
Recurrence is not taken into account; only count
whether the person has ever had a disease once in
his/her lifetime.
166
120
Prevalence Summary
Reflects the number of new, existing, and recurring
cases in a population
Prevalence includes incidence.
Prevalence alone is a count.
Prevalence rates vary by time and have a special
notation (e.g., 7/100,000 population).
K is the reference group that usually make the numerator
a whole intriguer.
167
Communicate epidemiologic information to both
public and professional audiences
ASPPHs MPH Core
Competency
168
121
Which K Should You Use?
Depends on whether studying (a unique) group, U.S. or World
population is the focus.
Study Group Results or General Public Audiences
K determined by population size
4/1,000 is easier to understand than 0.4/100
Use the smallest reference group that will enhance public understanding.
K are hypothetical reference groups.
Professional/Scientific Audiences
Generally use the standard statistical values established by the
U.S. Bureau of Statistics. Use a K appropriate for a study group,
U.S., or World population. 169
122
Center for
Social
Problem
Measurement
123
Ratios
Rates, Ratios, and Proportions
171
Categories of Measurement
Epidemiology uses 3 types of ratios (all 3 are called ratios):
Rates
Ratios
Proportions
Rates, ratios, and proportions are all subsets of ratios because they
have a numerator and denominator; hence are a ratio (i.e., one # is
divided by another; hence that makes it a ratio; often time we express
it as a 3:1 ratio).
172
Ratio =
Numerator
Denominator
* K
124
Distinguishing Formulas
Focus on the Denominators
Rate (Related)
Denominator contains all people at risk.
Ratio (Separate and Distinct)
Denominator contains a different group.
Proportion (Repeated)
Denominator contains people from the numerator and
remaining members of the pop.
Proportions do not require time.
173
Numerator is related to the denominator.
In a population at risk, a rate measures the
occurrence of an event with respect to time.
The denominator is the study group, the U.S., or
the world population at risk.
Rates
174
125
Ratios
The numerator and denominator of a ratio are
separate and distinct.
A ratio expresses a relationship between a
numerator (A) and a denominator (B). The items in
A are not counted in B.
175
Proportion
The value in the numerator is repeated in the
denominator.
176
126
Examples Differentiating Rates, Ratios,
and Proportions: Example I
Data
N = 59
N = 5 smokers
Use Attack Skills
1. Write down formula
2. Insert numbers into formula
3. Compute calculation
4. Draw conclusions
177
Example I
1. What is the rate of smokers?
2. What is the ratio of smokers to nonsmokers?
3. What is the proportion of the students who
smoke?
178
127
Smokers in Unique Study Group
Information
59 population at risk
5 smokers
Formula
Rate = (X/Y) x K
Rate = (5/59) x 100 = 8.5/100
8.5/100 smokers out of every 100 people in this
unique study group 179
Ratio of Who Smokes
Information
5 smokers
54 nonsmokers
Formula
Ratio = (A/B) x K
Ratio = (5/54) x 100
Ratio = 9.2 smokers /100 individuals
180
128
Proportion Who Smoke
Information
5 smokers
54 nonsmokers
Formula
Proportion = A/(A + B) x 100%
Proportion = 5/(5+54) x 100% = 8.47%
181
Consider the following statement:
The prevalence rate of TB in the United States for a 1 year
period was 700/100,000 population.
Why is this a rate?
Simply because it says it is? Incorrect
Numerator is cases of TB. Correct
Numerator is a subset of the population at risk. Correct
K is per 100,000. Correct
Time is specified (1 year). Correct
Example
182
129
Example II
What proportion of
TB cases in 2008
were foreign-born
people?
183
Problem Exercise
You need a proportion. Why?
Numerator is a subset of the denominator.
Denominator is the whole.
184
130
Problem Exercise
How many foreign-born TB cases are there compared to US-
born cases in 2008?
You need a ratio. Why?
Numerator is foreign-born
Denominator is separate and distinct.
185
Rate Cannot Be Calculated
Recall Formula: Rate = (X/Y) x K
Related: The denominator is the population at risk or a specific
study group.
A rate measures the occurrence of an event with respect to time.
We dont have information for the population at risk or the total
population for the U.S. It isnt given. We cant fractionate it.
Where would you get it? Perhaps, from the U.S. Population
Clock or government resources. Remember, this is a unique
study. We might assume that these are Purdue students. Then
we would use the total number of Purdue students in the
denominator or the total number of freshman to seniors.
186
131
Rate, Ratio, or Proportion?
The comparison of one population subgroup to
another subgroup in the same population (e.g., 95
males/100 females in the U.S. in 2010).
This is a ___________.
Ratio
187
Why?
Traditionally, males are not a subset of females;
the 2 groups are separate and distinct.
Ratio = (A/B) x K
Sex gets into biological, social, political, religious,
and legal/constitutional issues.
188
132
The frequency of live births in a population during a
specified time period (e.g., 15.5 live births/1,000
population in the U.S. in 2000).
This is a ___________.
Rate
189
Why?
Numerator - Live births is outcome of interest
Denominator Population at large or unique group
study population at risk
Time is involved - year 2000
Information is based on time, and it is used to make
population comparisons.
N and D Related
190
133
The relation of a population subgroup to the entire
population: that is, a population subgroup divided
by the entire population (e.g., 60% of the total U.S.
population age 15 and over were currently married
in 2000).
This is a ___________.
Proportion
191
Why?
Numerator is a subset of the denominator.
N = Age 15 and over and married
D = All U.S. people age 15 and over who married
and are unmarried (single, separate, divorced, and
widowed)
Answer is a proportion
The value in the N is repeated first in the D.
192
134
Additional Information About Rates
You should convert awkward fractions and
decimals into whole numbers, if you can.
Rates, ratios, and proportions are all classified as
ratios because one number is divided by another
number and multiplied by K, which may vary
depending of the numerator and what is easiest to
communicate and the type of formula (i.e., a
proportion is * 100%).
193
How to Express Rates and Ratios
Rates often can be presented as follows:
Per a power of 10
Rare diseases are often reported per million (e.g.,
4/million).
194
135
Center for
Social
Problem
Measurement
136
Incidence, Prevalence,
and Duration Exercise
195
196
Reports of Cancer, Plumcoulee, Manitoba
Pt Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
1 X
2 D X
3
4 X
5 D C
6 D X
7 C
8 D
9 D X
10 D
11 D C
12 D X
D = First Diagnosis = With Disease C = Cured X = Died
Roht, L.H. Principles of Epidemiology. Academic Press, INC, San Diego, CA. 1982: pg. 112.
196
137
Incidence and Incidence Rates
Incidence REQUIRES a diagnosis.
Incidence alone is a count (integer).
Incidence Rate (IR): The ratio of new cases that
appear in a population.
Note: Incidence is usually annual, but can be for shorter time periods (e.g.,
half year, quarter, or 2 week intervals). If not specified, assume annual
incidence. A diagnosis is always required.
197
IR=
Number of new cases during a specified time
Total population at risk
K
Calculating Incidence Rate
What is the incidence rate of cancer?
Count number of Ds (diagnosed new cases)
IR = (8 cases/12 patients at risk) x 100
IR = 67 cases/100 individuals
Usually annual. Recall it can be for shorter time
periods (e.g., half year or quarter)
Remember, if not specified, it is an annual
incidence rate.
198
138
Reports of Cancer, Plumcoulee, Manitoba
Pt Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
1 X
2 D X
3
4 X
5 D C
6 D X
7 C
8 D
9 D X
10 D
11 D C
12 D X
D = First Diagnosis = With Disease C = Cured X = Died
199
Prevalence Rate Example
What is the prevalence rate for cancer on 7/1
Recall point prevalence rate
Prevalence rate = (7 cases/12 patients at risk) x 100
Prevalence rate = 58.3 cases/100 individuals
200
PR=
Total individuals with disease at a specific point in time
Total population or study group at risk
* K
139
Prevalence/Incidence Summary
Prevalence reflects the number of new, existing, and
recurring cases in a population and is more comprehensive
than incidence.
Prevalence includes incidence.
Prevalence alone is a count.
Prevalence rates vary by time and have special notation
depending on whether we are working with a special
population, larger geographic area, or the nation (e.g.,
7/100,000 population).
K is the reference group that usually makes the numerator a
whole integer.
201
140
Center for
Social
Problem
Measurement
141
203
Duration
Duration
Once patients have been diagnosed with the
disease, how long do their signs and symptoms
last? Duration answers that question.
Note: Be sure the constants for prevalence rate and incidence rate
are equal so they cancel.
204
Duration=
Point Prevalance Rate
Incidence Rate
142
What Factors Influence Duration?
Rarity of Disease
Rare diseases can influence the numerator and the
denominator
A low incidence and short duration of an illness decreases
prevalence
Note: When calculating duration, use point prevalence
rate (not the period prevalence rate) and the annual
incidence rate.
205
Duration=
Incidence Rate
Solving for Incidence and
Prevalence Using Duration
206
Duration=
Incidence Rate
Incidence Rate=
Duration
Point Prevalence Rate = Duration Incidence Rate
143
Calculating Duration
The incidence rate and prevalence rate must have equal
constants so they cancel
Recall from the previous examples:
PR = (7cases/12 patients at risk) x K
IR = (8 cases/12 patients at risk) x K
207
144
Center for
Social
Problem
Measurement
145
Indices of Mortality
209
Crude Rates
Derived from minimal data or information
Crude rates allow comparisons between different
populations, but they fail to show differences
between subgroups.
Two most common crude rates:
Crude Death Rate (CDR)
Crude Birth Rate (CBR)
210
146
Crude Death Rate
CDR is a summary statistic.
CDR summarizes the death rate of a population.
CDR is crude because it includes the entire population
(not divided based on specific demographics such
age, race, and sex).
CDR can be calculated from a minimum amount of
information (i.e., total number of deaths based on
death certificates and midyear population ideally from
the census or perhaps from the U.S. Population
Clock).
211
What Do Crude Death Rates Tell Us?
Clues for changes in death patterns
Note time and trends across years
Planning purposes
Plan prevention, protection, and control strategies
Inexpensive method of surveillance
Death records available (required by law) and most countries have
this information, and at times no other information.
Leading causes of deaths
Can compare different death rates for different reasons to help set
priorities (e.g., Healthy People 2020).
212
147
Standard Statistical Terms
Infant Mortality Rate (IMR)
Maternal Mortality Rate (MMR)
Cause-Specific Death Rate (CSDR)
Case-Fatality Rate (CFR)
Morbidity Rate
213
Standard Statistical Terms for a
Population
Crude Death Rate (CDR): The ratio of the number of
deaths divided by the number of people at risk
multiplied by 1,000.
K = 1,000 or 10,000 or 100,000
214
148
Making Crude Rates Specific
Crude rates can become specific rates when considering
the following information:
Age
Marital Status
Single
Married
Divorced
Geographic Location
City
State
Region
Country
Sex
Male
Female
Race or Ethnicity
Whites
Blacks
Hispanics
Asians
Socioeconomic Status
Occupation
215
216
149
217
Computing Crude Death Rates
Population A Number Deaths
Ages 45-54 1,000 2
Ages 55-64 4,000 20
Total 5,000 22
Population B
Ages 45-54 5,000 8
Ages 55-64 2,000 5
Total 7,000 13
Population C
Ages 45-54 6,000 6
Ages 55-64 4,000 12
Total 10,000 18
218
150
Rates, Ratios, Piopoitions, & Inuices:
Noibiuity, Noitality, & Natality
General
Name Presentation Numerator (X) Denominator (Y) Expressed Per
Number At Risk (K)
Death Rate 1. Crude rate
2. Specific rates by:
Cause
Age
Race
Gender
Occupation
Other
Total number of deaths reported during a
specified time period.
Estimated mid-period
population.
1,000
10,000
100,000
Incidence Rate 1. Crude rate by cause
Age
Race
Gender
Socioeconomic status
Disease stage
Other
Number of new cases of a specified
disease reported during a specified time
period.
population at risk.
100
1,000
10,000
100,000
1,000,000
Attack Rate 1. Crude rate by cause
Age
Race
Gender
Residence area
Other
Number of new cases of a specified
disease reported during a specified time
period.
Susceptible population
at risk during the same
time period.
100
1,000
10,000
100,000
1,000,000
Secondary Attack
Rate
1. Crude rate by cause
Age
Race
Gender
Households
Families
Other
Number of new cases of a disease
occurring within the incubation period of
that disease reported following
identification of an index case in a
household, family or other appropriate
epidemiological unit.
Susceptible number of
persons exposed to the
index case during the
same time period.
100 (usually)
Point Prevalence
Rate
Age
Race
Gender
Disease stage
Other
Number of current cases of a specified
disease existing at a specific point in time.
Estimated population at
risk at the same point in
time.
100
1,000
10,000
100,000
1,000,000
151

Rates, Ratios, Proportions, & Indices (continued)
Number At Risk (K)
Period Prevalence
Rate or Case-Load
Ratio
Age
Race
Gender
Disease stage
Other
Number of current cases of a specified
disease existing during a specified time
period.
population at risk at the
same point in time.
100
1,000
10,000
100,000
1,000,000
Proportionate
Mortality Ratio
1. Crude ratio
2. Specific ratios by:
Age
Race
Gender
Occupation
Other
Number of deaths assigned to a specified
cause.
Total number of deaths
from all causes reported
during the same period.
100
1,000
Case-Fatality Rate
or
Death-To-Case
Ratio
1. Crude rate
Age
Gender
Race
Other
Number of deaths assigned to a disease. Number of cases of
that disease during the
same time period.
100

152

Maternal and Natality
Number At Risk (K)
Birth Rate 1. Crude rate
2. Specific death rates by:
Maternal age
Gender of child
Marital status
Other
Number of live births reported
during a specified time period.
Estimated mid-period population. 1,000
Low Birth Weight
Ratio
Crude rate
Specific death rates by:
Maternal age
Race
or area
Other
Number of live births under
2,500 grams (or 5 lbs)
during the same time period.
100
Infant Mortality
Rate
1. Crude rate
Age of infant
Race
Prenatal care
Marital status
Cause of death
Other
Number of deaths under 1
year of age reported during a
specified time period, usually a
calendar year.
1,000
Fertility Rate Crude rate
Specific death rates by:
Maternal age
Race
Area
Other
Theoretical
during a specified time period
from mothers aged 15-44
years.
Estimated number of women in
age group 15-44 years at mid-
period.
1,000
General Use
Estimated number of women in
age group 15-44 at mid-period.
1,000
Maternal Mortality
Rate
1. Crude rate
Age
Race
Cause of death
Other
Number of deaths 90 days
of delivery, assigned to causes
related to pregnancy during a
specified time period.

1,000
Fetal Death Rate 1. Crude rate
Maternal age
Race
Marital status
Cause of death
Other
General Use
Number of fetal deaths of 28
weeks or more gestation
reported during a specified
time period, usually a calendar
year.
weeks or more gestation reported
during the same time period plus
the number of live births occurring
1,000
(Use if early fetal death reporting is good)
time period, usually a calendar
year.
weeks or more gestation reported
during the same time period plus
the number of live births occurring

1,000
153

Number At Risk (K)
Fetal Death Ratio
(sometimes
mistakenly called
Fetal Death Rate)
1. Crude rate
Maternal age
Race
Prenatal care
Cause of death
Other
General Use
time period.
1,000
Number of fetal deaths of
20 weeks gestation reported
1,000
Neonatal Mortality
Rate

1. Crude rate
Maternal age at birth
Race
Birth weight
Cause of death
Other
Number of deaths 28 days
of age reported during a
specified time period, usually a
calendar year.
1,000
Perinatal Mortality
Rate

1. Crude rate
Maternal age
Race
Prenatal care
Cause of death
Other
General Use
Number of reported fetal
deaths 28 weeks gestation
plus the reported number of
infant deaths within 7 days of
live during a specified time
period.
Number of reported fetal deaths
of 28 weeks gestation plus the
number of live births reported
1,000
Number of reported fetal
deaths of 20 weeks
gestation plus the reported
number of infant deaths within
7 days of life during a specified
time period.
Number of reported fetal deaths
of 20 weeks gestation plus the
number of live births reported
1,000
Post-neonatal
Mortality Rate
1. Crude rate
Maternal age at birth
Race
Cause of death
Theoretical
Number of deaths from 28
days of age up to, but not
including 1 year of age,
reported during a specific time
period, usually a calendar year.
during the same time period less
the number of deaths < 28 days of
age.
1,000
General use
Number of deaths from 28
days of age up to, but not
including 1 year of age,
reported during a specific time
period, usually a calendar year.
1,000

Source: Roht LH, Selwyn BJ, Holguin AH,. Christensen BL. Principles of Epidemiology: A self teaching guide. New York: Academic Press. 1982; pp. 139-143.
154
1. What is the CDR for population A?
2. What is the CDR for population B?
3. What is the CDR for population C?
4. What would calculating other ratios tell us (e.g., a
specific rate and/or a proportion)?
219
1. CDR for population A
CDR = (22/5,000) x 1,000
CDR = 4.4 deaths/1,000 individuals
2. CDR for population B
CDR = (13/7,000) x 1,000
3. CDR for population C
CDR =(18/10,000) x 1,000
220
155
(CDR)
4. Compute the proportions of people between the ages 55 and 64. What
do the following calculations tell us about the 3 populations?
A. Pop. A = 4000/(4000+1000) x 100% = 80%
B. Pop. B = 2000/(2000+5000) x 100% = 28%
C. Pop. C = 4000/(4000+6000) x 100% = 40%
Population A has the highest proportion of people ages 55-64.
Hypothesis is that older people are more likely to die than younger
people.
What are they more likely to die from?
221
Crude Birth Rate (CDR)
Crude Birth Rate (CBR): The ratio of the number of
live births divided by the total population at risk
multiplied by 1,000.
222
156
223
Calculating Crude Birth Rate
No. of Live Births Year Population
240 1970 11,920
180 1980 12,212
250 1990 14,100
409 2000 16,271
Computing Crude Birth Rate
1. What is the CBR for each decade?
CBR (1970) = 240/11,920 = 0.0201 x 1,000 = 20.1/1,000
CBR (1980) = 180/12,212 = 0.0147 x 1,000 = 14.7/1,000
CBR (1990) = 250/14,100 = 0.0177 x 1,000 = 17.7/1,000
CBR (2000) = 409/16,271 = 0.0251 x 1,000 = 25.1/1,000
2. Is there a trend?
3. What factor(s) may be responsible for the baby boom in 2000?
Perhaps historical, sociological, and/or economic factors. People have more
confidence in the future when times are prosperous (e.g., bullish market; low
unemployment rate; confidence in leadership, especially at the federal level).
Sometimes these factors are disregarded, if a bad economy is protracted.
224
157
Data Trends
The line to the right is
called U or J
shaped; it is very
common in epi.
Other types of trends:
Linear
Exponential
Logarithmic
Time (yrs.) x-axis
B
i
r
t
h
s

p
e
r

1
,
0
0
0

y
-
a
x
i
s
Number of Births From 1970-2000
225
Interpreting CBRs
Dependent variables are always located on the y-axis
(births/1000), whereas independent variables (time) are
located on the x-axis.
Linear, exponential, logarithmic, and curvilinear lines
can be used to express trends in data.
Often best fit regression lines are used to model
relationships between the independent and the
dependent variables as are other statistics (e.g., time-
series programs). 226
158
Center for
Social
Problem
Measurement
159
Prenatal and Infant Life
227
Important Rates
Why focus on the above rates?
These rates estimate the health and wealth of a
community or nation. Poor economy is directly connected
to lower birth rate and lower migration to the US from
other countries.
These rates relate to the confidence in the future.
228
160
Early Fetal
Period
20 weeks
Late Fetal
Period
20 weeks
B
I
R
T
H
Neonatal
Period
First 4
weeks of
life
Postnatal
48 Weeks
Periods of Prenatal & Infant Life
Prenatal
Perinatal
Infancy
I
N
S
T
A
N
T
229
C
o
n
c
e
p
t
i
o
n
I
N
S
T
A
N
T
1. How long is the Infancy Period?
2. How long is a Neonatal Period?
3. How long is the Prenatal Period?
4. How long is the Perinatal Period?
5. When do most deaths occur?
6. When is a death certificate required?
230
161
Indiana Standards
In Indiana, if gestation is 19 weeks, a death
certificate is filed with the State. Gestation =
PERIOD OF INTRAUTERINE FETAL
DEVELOPMENT FROM CONCEPTION TO BIRTH.
If the baby takes a breath, it is considered a viable
birth, and a birth certificate is filed.
On the same or on the next day, both a birth and
death certificate maybe filed.
231
Race and
year Infant
Under 28
days
Under 7
days
Postnatal
Fetal
mortality
rate
Late fetal
mortality
rate
Perinatal
mortality
rate
All Races
1950 29.2 20.5 17.8 8.7 18.4 14.9 32.5
1960 26.0 18.7 16.7 7.3 15.8 12.1 28.6
1970 20.0 15.1 13.6 4.9 14.0 9.5 23.0
1980 12.6 8.5 7.1 4.1 9.1 6.2 13.2
Race of Child: White
1950 26.8 19.4 17.1 7.4 16.6 13.3 30.1
1960 22.9 17.2 15.6 5.7 13.9 10.8 26.2
1970 17.8 13.8 12.5 4.0 12.3 8.6 21.0
1980 11.0 7.5 6.2 3.5 8.1 5.7 11.9
Race of Child: Black or African American
1950 43.9 27.8 23.0 16.1 32.1 - - - - - -
1960 44.3 27.8 23.7 16.5 - - - - - - - - -
1970 32.6 22.8 20.3 9.9 23.2 - - - 34.5
1980 21.4 14.1 11.9 7.3 14.4 8.9 20.7
*Statistics from the CDC
232
162
Gestational Age
Measured from last normal menstrual period
When period stops, gestation starts
Preterm
<37 weeks; 9.25 months
Term
37-41 weeks;10.25 months
Post Term
42 weeks; 10.5 months
233
This graph shows the decline in U.S. maternal mortality rates from the end
of WWII. The rate for the white population dropped steadily from over 900 in
1918 (not shown in graph), the decline for the nonwhite population has been
even more dramatic.
Maternal Mortality Rates, By Race, 1915-1971
1.What are the reasons for the decline in
MMR?
2.What is the crude rate?
3.What is the specific rate?
4.What is the difference in information you
can get from the crude rates and specific
rates?
5.What subgroup adds most to the crude
rate?
U.S. Maternal Mortality Rates, By Race, 1915-1971. Omran (1977), figure 8
234
163
Infant Mortality Rate: The ratio of the number of
deaths of children under 1 year old per 1,000 live
births in the same year multiplied by 1,000.
1 year = 365 days or 366 for a leap year
235
Calculate the following:
1. What was the # of infant deaths in 1980?
2. What was the # of births in 1980?
3. What are the # of births and deaths both occurring in
1980?
4. What is the infant mortality rate for 1980?
5. Is IMR a true rate?
236
164
237
True Rate
What is a true rate?
Sometimes, cases are taken into account in the numerator, but not in
the denominator.
For example, case #13 is taken into account in the numerator, but
not in the denominator. Cases 2 and 9 were included in the
denominator, but not in the numerator.
As was demonstrated, the numerator is not totally a subset of the
denominator. Of course, to meet the definition of a rate, this is a
requirement: cases must be considered in both the numerator
and the denominator to be a true rate.
Therefore, IMR is not a true rate.
238
165
Ways to Reduce Infant Mortality
Adequate prenatal care
Abstain from alcohol, smoking, and other drugs
(ATODs)
Reduce chemical exposure
Immunizations
Proper sanitation and infection control
Adequate nutrition
Proper Hygiene
239
Neonatal Mortality Rate: The ratio of
the number of deaths of babies under 1
month (28 days) of age/1,000 live
births.
240
166
241
Neonatal Mortality Rate (NMR)
Neonatal mortality rate for 1980.
You need to know:
How many infants died within 28 days of birth in 1980?
What was the total number of births in 1980?
What can you conclude?
Is NMR a true rate?
Is there a case where it might not be?
242
167
Neonatal Mortality Rates Due to
the Following
1. Low birth weight = # 1 cause
2. Poor prenatal care
3. Infections
4. Lack of proper medical care
5. Injuries
6. Prematurity
7. Congenital birth defects
8. Functional health illiteracy and poverty.
Why?
243
244
Conclusion
1/3 of all infant deaths occur during the
neonatal period.
Prevention Strategies
Focus especially on prenatal and then the
postnatal care; time period immediately before
and after pregnancy.
Health education for mothers.
Changes in policies pertaining to access.
Changes in laws.
168
Maternal Mortality Rate: The ratio of the
number of deaths of mothers related to
pregnancy or childbirth per 10,000 live
births.
245
246
169
Calculate the MMR and NMR for 1980.
What conclusions do you draw?
What prevention strategies could be used?
Would you focus on mothers or infants? Why based
on the data?
247
Information
2 maternal deaths
200 live births
Calculation
MMR = (2/200) x 10,000
MMR = 100 deaths/10,000 live births
248
170
Count any death connected to pregnancy, not just deaths
connected to childbirth.
Deaths in the numerator are deaths arising from pregnancy
or from puerperal causes within 42 days, 90 days, or even up
to 1 year after child birth (different organizations have
different standards).
The WHO standard is 42 days.
Puerperium: pertaining to, caused by, or related to childbirth
Maternal Mortality: What Do We Count in the
Numerator?
249
Maternal vs. Neonatal Rate
Compare and contrast the formulas for NMR and
MMR.
Same: Denominator = Number of live births
Different: K = 1,000 vs. 10,000
Conceptually, what is the difference between the
two formulas?
Neonatal: Comparing infants in both N and D
Maternal: Comparing deaths of mothers in N with live
births of infants in the D
250
171
Maternal deaths can be subdivided into two groups:
Direct obstetric deaths
Result from obstetric complications during the pregnant
state (e.g., death of mother due to surgery to remove a
diseased or stillborn baby in womb).
Indirect obstetric deaths
Result from preexisting conditions not associated with direct
obstetric cause (e.g., diabetes, hypertension/ cardiovascular
diseases as well as debilitating psychosocial issues pre-
and post-delivery). 251
Examples of Puerperal (Related to
Childbirth) Deaths
Ruptured uterus
Puerperal fever (running high fever during pregnancy)
Stroke due to baby
Gestational (carrying young in the uterus)
For example, hypertension/cardiovascular disease, stroke, and
diabetes
Ignaz Semmelweis was called the Savior of Mothers after he
discovered that hand washing prevented puerperal fever.
Risse, G.B., Semmelweis, Ignaz Philipp. Dictionary of Scientific Biography (C.C. Gilespie, ed.). New York: Charles
Scribner's Sons, 1970-1980.
252
172
Weaknesses of MMR
Denominator excludes all pregnancies that do not result in live
births (e.g., stillborns, induced abortions, miscarriages, and
ectopic pregnancies).
Ectopic pregnancies = a complication of pregnancy in which
the embryo implants outside the uterine cavity.
Public health officials still debate how long after delivery a
maternal death can be attributed to childbirth.
253
Selected Health Status Indicators for CA and the US
= 5.51156 lbs.
*State of California Department of Health Services September 1987
254
173
Analyses
Teenage birth rate declining (CA > U.S.)
Need to increase % of mothers who seek medical care during 1
st
trimester (CA = U.S.)
Number of Cesarean births rising (CA < U.S.)
Life expectancy; women still outlive men (CA = U.S.)
Infant death rate dropping (CA = U.S.)
Death Rates:
Heart Disease
Cancer
Stroke
Unintentional Injury
Suicide
Homicide
What are your priorities/hypotheses?
Are your political representatives addressing these issues?
CA better than U.S.
CA better than U.S.
CA better than U.S.
CA worse than U.S.
CA worse than U.S.
CA worse than U.S.
255
174
Center for
Social
Problem
Measurement
175
Additional Mortality
Formulas
257
Cause-Specific Death Rate
Cause-Specific Death Rate (CSDR): The ratio of
the number of deaths from a specific cause
divided by the total population at risk multiplied by
100,000.
258
176
259
CSDR
Age Population Deaths
<15 5,000 50
16-44 10,000 200
45 5,000 250
Total 20,000 500
Observing Mortality for Leukemia in Community A, 2005
CSDR of Leukemia Population
<15 years old
CSDR = (50/5,000) x 100,000
CSDR = 1,000/100,000
16-44 years old
CSDR = (200/10,000) x 100,000
CSDR = 2,000/100,000
45 years old
CSDR = (250/5,000) x 100,000
CSDR = 5,000/100,000
Total Leukemia deaths in Population
CSDR = (500/20,000) x 100,000 = 2,500/100,000
260
177
Age-Specific CSDR
If you calculate the age-specific CSDR for each
age group, what can you tell about the pattern of
this disease?
What variables may you want to learn more
about?
Sex
Other differences among groups (e.g., social
economic status, educational level, health literacy,
race, etc.).
261
Proportionate Mortality Rate (PMR): The ratio of the
number of deaths from a particular cause divided by
the deaths from all causes multiplied by a constant.
K = 100 or 1,000
Shows the ranking of diseases or their priority among diseases rather than their
occurrence of the disease in the total population.
Proportionate Mortality Rate
(PMR)
262
178
Case Fatality Rate
Case Fatality Rate (CFR): The ratio of the number of
deaths from a specific cause divided by the number of
cases multiplied by 100.
Shows the killing power of that particular disease in
relationship to those who have the disease.
263
Case Fatality Rate
Example:
CFR = (60,000/120,000) x 100
CFR = 50 deaths/100 cases
or 50% of the cases will die.
264
179
The State of Indiana reported 11,620 tobacco related
deaths last year (the influences of primary). There are
1,374,566 smokers in Indiana based on statistics that
21.2% of Hoosiers smoke and the State population is
6,483,802 people.
.845/100 smokers will die or 8.45/1,000 will die
Which is the better K value?
Case Fatality Rate
265
Review
Morbidity
Incidence Rate
Prevalence Rate
Mortality
Infant Mortality Rate (IMR)
Neonatal Mortality Rate (NMR)
Case Fatality Rate (CFR)
Cause-Specific Death Rate (CSDR)
Proportionate Mortality Ratio (PMR)
Every rate is a crude rate, but can be a specific rate by taking into account
demographic and other variables.
266
180
Center for
Social
Problem
Measurement
181
Adjusted Standard
Mortality Rates (SMR)
Direct method
Indirect method
267
Standard Mortality Rate (SMR)
Standard Mortality Rate: The ratio of the number of
deaths observed in the study population to the
number that would be expected if the study
population had the same distribution as the
standard population.
Last JM, ed. A Dictionary of Epidemiology. 4th ed. New York, NY: Oxford University Press; 2001.
268
182
SMR for the subpopulation or preferred population
is based on the standard population.
Can we assume the distribution of the
subpopulation is like the standard population? The
answer is NO.
The direct method cannot be used without age-
specific death data for the subpopulation; you
must have mortality data for each age group.
Calculating SMR
Direct
269
Standard Mortality Rate (SMR)
A technique to remove, as far as possible, the
effects of differences in age or other demographic
variables when comparing populations.
SMRs have fewer limitations than crude rates.
Age is the most commonly adjusted variable.
270
183
Confounding Variable
Any characteristic, trait, or factor that can distort the results of an
investigation, if not taken into account.
Confounding is bias or error, which should be minimized or
eliminated, if possible.
Confounding literally means the effects of variables mixed
together.
In science, the goal is to identify valid (true) scores without errors
or bias.
271
Why Use Standardized Mortality Rates?
To offset the effects of skewness or bias (e.g.,
more college students or more seniors in a
community).
Note differences in distributions to determine
whether skewness exists.
Skewness may be examined, for example, by
determining whether there are more people in a
particular age group than the corresponding age
group in the gold standard population.
272
184
Calculating SMR
Direct Method
Best indication of how a subpopulation compares to a
total population:
1. Find the total standardized population of the reference
group (always look for the summary value),
denominator of SMR
2. Find age-specific death rate for subpopulations
273
Calculating SMR
3. Find expected deaths for reference population
4. Add expected deaths of standard population.
5. Calculate Direct SMR
274
185
Center for
Social
Problem
Measurement
186
SMR Direct Example
275
In 1980, there were 228 deaths from lung cancer in the resident population of Honolulu
City and County in Hawaii. The population in mid-1980 was 762,565 giving a crude rate
of 29.9 per 100,000 population. In 1980, the crude rate for the U.S. for lung cancer was
47.9 per 100,000 population (given). In order to control for age effects on these crude
rates, age-adjusted rates can be computed by the direct or the indirect method.
Note: Death rate is per 100,000 in smaller populations
DIRECT METHOD
Honolulu County, 1980 United States, 1980
Age Groups
(in years)
a
Population
T
Lung Cancer
Deaths
t
Death
Rates
Z
(z=t/T)
Standard
Population
B
Expected
Deaths
b
(b=B x Z)
<24 334,539 0 --- 93,777,167 ---
25-44 232,786 6 62,716,549
45-64 139,872 93 44,502,662
65-84 51,360 114 23,309,360
85+ 4,008 15 2,240,067
Total 762,565 228 226,545,805
276
187
DIRECT METHOD
Age Groups
(in years)
a
Population
T
Lung Cancer
Deaths
t
Death
Rates
Z
(z=t/T)
Standard
Population
B
Expected
Deaths
b
(b=B x Z)
<24 334,539 0 --- 93,777,167 ---
25-44 232,786 6 62,716,549
45-64 139,872 93 44,502,662
65-84 51,360 114 23,309,360
85+ 4,008 15 2,240,067
Total 762,565 228 226,545,805
.0000257
.0006648
.0022196
277
SMR
(Direct)
= 40.3 deaths/100,000 individuals
DIRECT METHOD
Age Groups
(in years)
a
Population
T
Lung Cancer
Deaths
t
Death
Rates
Z
(z=t/T)
Standard
Population
B
Expected
Deaths
b
(b=B x Z)
<24 334,539 0 --- 93,777,167 ---
25-44 232,786 6 .0000257 62,716,549
45-64 139,872 93 .0006648 44,502,662
65-84 51,360 114 .0022196 23,309,360
85+ 4,008 15 .0037425 2,240,067
Total 762,565 228 226,545,805
1,612
29,585
51,737
8,383
91,317
278
188
Example of Calculating Expected
Deaths for Honolulu County
Age Honolulu Lung Death U.S. Expected
Group Population Cancer Rate 10
5
Standard Deaths
Deaths Population
<24 NOT SHOWN BECAUSE OF ZERO (0) LUNG CANCER DEATHS
25-44 232,786 6 2.57 62,716,549
25-44 232,786 6 .0000257 62,716,549 1,612
2.57/100,000
Calculations
6/232,786 = .0000257 x 62,716,549 = 1,612
Note: If you see a death rate that is 2.57 and it says the death rate is 10
5
right above it as it indicates in this
example, then divide by 100,000 (if has not already been done as it is in this case) to make it into a
fraction. In this instance, it would be .0000257. If you multiplied 2.57 x 62,716,549, your Expected Deaths
would = 61,181,530. Ultimately, your total Expected Deaths would exceed the size of the U.S. population,
which would not make sense and you would know immediately that your answer is incorrect.
279
Example of Calculating % and Testing for
Skewness
Age Honolulu %
Group County
<24 334,539/762,565 43.8
25-44 232,786/762,565 30.5
45-64 139,872/762,565 18.3
65-84 51,360/762,565 6.7
85 + 4,008/762,565 0.5
Total Population of Honolulu County = 762,565
Note: Now figure % for U.S. 1980 using the same process. Next
slide presents those % and the differences to detect if there is
skewness or not (i.e., whether Honolulu and the U.S. have the
same distribution). They did NOT!
280
189
% Differences in Age Dist. Among Two
Populations
Age
Group
X
Honolulu
County
Y
United
States
Z
% Difference
(Y-Z)
<24 43.8 41.4 +2.4
25-44 30.5 27.7 +2.8
45-64 18.3 19.6 -1.3
65-84 6.7 10.3 -3.6
85+ 0.5 1.0 -0.5
If the sum of % differences were 0, then you would not calculate
SMR
(direct).
281
Summary of Differences for Selected
Age Categories
Combined Ages Sum of % Differences
<24-44 +5.2
45-85+ -5.4
These small % differences are significant
If the sum of % differences were ~ 0, then you would not calculate SMR
(direct)
Conclusion: The distributions of age-specific categories for Honolulu
are different from the U.S. There are 5.4% fewer elderly people (45-
85+), and 5.2% more younger people in Honolulu than the U.S.
There is 10.6% total difference, when you disregard signs.
282
190
Cancer of the Lung
Original Conclusion
CDR (Honolulu) = 29.9 deaths/100,000 (given in problem)
CDR (U.S.) = 47.9 deaths/100,000 (given in problem)
Reaction: Lets move to Honolulu County.
New Conclusion after Calculating SMR (direct):
CDR (Honolulu) = 40.3 deaths/100,000
CDR (U.S.) = 47.9 deaths/100,000
Conclusion: CDR for Honolulu County may be better than
the U.S. population; however, it is not 18/100,000 less, only
7.6/100,000 less.
283
191
Center for
Social
Problem
Measurement
192
SMR Indirect Example
285
SMR Indirect Method
Note: 228 is from the direct method initial problem statement.
286
193
Indirect Method Process
1. Calculate the cause specific/crude (in this case it
is age-specific death rate) death rate for the
standard U.S. population.
2. Find expected death rates of the standard
population.
287
When do you use SMR
(indirect)
?
When you dont have age-specific death rates for the
preferred population of interest.
What about skewness?
There must be skewness. You would not calculate
SMR
(indirect)
if the sum of % differences was 0.
If any skewness is expected, calculate SMR
(indirect)
to
determine how much the answer changes.
Accept the SMR
(indirect)
answer.
288
194
Indirect method uses the rates of larger
reference populations and the application to
smaller populations.
Indirect method is used when deaths by age
group are unavailable or unreliable.
There also must be skewness which is the same
requirement for Direct method.
Indirect Method
289
Direct & Indirect Method
Cannot compare indirect & direct results because
they are calculated differently.
Indirect method used for within, not between
communities (e.g., diseases for a given city not
between cities).
There must be skewness between the gold
standard and the study population to use
SMR
(indirect)
.
290
195
Direct or Indirect?
Depends on the type of data available.
If age-specific death counts are available for the
standard population, but not the study population,
your only option is to use the indirect SMR or
SMR
(indirect)
.
291
1. Calculate the age-specific death rates (Z) of the
standard population.
2. Multiply the death rates from the standard
population by their corresponding age-specific
population sizes in the study population [(Z)*(T)]
3. Sum the expected deaths in the study population
(t)
292
196
3. Find expected death rates/age group in the
population of interest.
4. Sum expected deaths.
5. Calculate age-adjusted rate.
SMR
(indirect)
expressed as a %.
Also expressed as a rate in the example.
Only SMR
(indirect)
expressed in these 2 forms: % and
rate.
293
SMR Indirect Method
INDIRECT METHOD
United States, 1980 Honolulu, 1980
Age Groups
(in years)
a
Standard
Population
B
Lung Cancer
Deaths
b
Death
Rates
Z
(z=b/B)
Population
T
Expected
Deaths
t
(t=T x Z)
<24 93,777,167 88 .0000009 334,539 0
25-44 62,716,549 2,756 .0000439 232,786 10
45-64 44,502,662 45,215 .0010160 139,872 142
65-84 23,309,360 57,304 .0024584 51,360 126
85+ 2,240,067 4,134 .0018455 4,008 7
Total 226,545,805 762,565 285
294
197
INDIRECT METHOD
Age Groups
(in years)
a
Standard
Population
B
Lung Cancer
Deaths
b
Death
Rates
Z
(z=b/B)
Population
T
Expected
Deaths
t
(b=B x Z)
<24 93,777,167 88 334,539
25-44 62,716,549 2,756 232,786
45-64 44,502,662 45,215 139,872
65-84 23,309,360 57,304 51,360
85+ 2,240,067 4,134 4,008
Total 226,545,805 762,565
.0000009
.0000439
.0010160
.0024584
.0018455
295
Note: 228 is from the direct method initial problem statement.
INDIRECT METHOD
Age Groups
(in years)
a
Standard
Population
B
Lung Cancer
Deaths
b
Death
Rates
Z
(z=b/B)
Population
T
Expected
Deaths
t
(b=B x Z)
<24 93,777,167 88 .0000009 334,539
25-44 62,716,549 2,756 .0000439 232,786
45-64 44,502,662 45,215 .0010160 139,872
65-84 23,309,360 57,304 .0024584 51,360
85+ 2,240,067 4,134 .0018455 4,008
Total 226,545,805 109,497 762,565
0
142
126
7
10
285
296
198
SMR Indirect Method
Answers differ between direct and indirect
methods
Direct method = 40.3 deaths/100,000
Indirect method = 38.7 deaths/100,000
Close but not the same. REMEMBER, THEY
WERE CALCULATED DIFFERENTLY.
297
How to Interpret SMR (indirect) % Values
When expressed as a %, 100% is the null
hypothesis.
An SMR(indirect) of 80% is 20% less than the
standard or what might be expected in deaths.
An SMR(indirect) of 110% is 10% above the
standard or expected in deaths.
SMR(indirect) is used frequently in Canada and
Europe.
298
199
Crude Death Rate vs.
Age-Adjusted Death Rate
Crude and Age-Adjusted Death Rates for
Hyperglycemic Crises as Underlying
Cause per 100,000 Diabetic Population,
United States, 19802009
Both the crude and age-adjusted death
rates for hyperglycemic crises as
underlying cause decreased from 1980 to
2009. Declines in the crude and age-
adjusted rates were similar. The age-
adjusted rate decreased 64% from 48.4 per
100,000 diabetic population in 1980 to 17.3
per 100,000 diabetic population in 2009.
Data Source: Division of Vital Statistics (data from the National Vital Statistics System) and
Division of Health Interview Statistics (data from the National Health Interview Survey).
299
181.8
107.9
26.7
109.7
62.6
25.8
0
20
40
60
80
100
120
140
160
180
200
Cardiovascular Disease Coronary Heart Disease Stroke
R
a
t
e
s

p
e
r

1
0
0
,
0
0
0
All Races
Asian Americans - Pacific Islanders
Selected 1995 Age-Adjusted Death Rates (U.S.)
Source: Anderson, 1998.
300
200

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