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Chapter 1

Basic Epidemiologic Concepts and

 Study of something that affects a population
 Study of factors that determine the
occurrence & distribution of disease in a
 One of the ways in which disease, injury and
clinical practice are studied
Classical Vs. Clinical

 Classical  Clinical
 Population oriented  Use of research designs
studies of the community and statistical tools to
origins of health study patient in health
problems. care setting
Stages of Disease
 Pre-disease Stage: No disease present

 Latent Stage: Asymptomatic; disease is in


 Symptomatic Stage: Manifestation of disease

 Defined:  Examples:
 Insects, arthropods and  Mosquitoes = West Nile
animals which aid in the Virus
spread of disease by  Tick = Lyme Disease
themselves being a host  Rats = Bubonic Plague
capable of transmitting
disease causing  Mosquitoes = Canine
organisms to the host Heartworm
they are living on  Snail = Haemonchus
contortus (nematode)
Risk Factors for Diseases

 Biological/Behavioral
 Environmental
 Immunological (Herd Immunity)
 Nutritional
 Genetics (Genetic Susceptibility)
 Services, Social Factors, Spiritual Factors
Genetic Susceptibility

Evaluation of which of the following potentially

preventable causes of disease is most likely to
raise ethical concerns?
(A) Dietary intake
(B) Genetic susceptibility
(C) Immunization status
(D) Smoking history
(E) Social support networks
Chapter 2
Epidemiologic Data Sources and
Types of Data Used in Health Studies

 Numerator Data
 A definition of the events or conditions of concern
 Example: Lung Cancer
 Denominator Data
 A definition of the population at risk
 Example: Smokers at risk for lung cancer
Epidemiological Measurements
 Frequency – deals with numbers
 Incidence – number of occurrences (well: ill or
live: dead)
 Prevalence – number of cases within a population
at a given time
 Risk – deals with proportion of people
unaffected at the beginning of a study
Epidemiological Measurements
 Rates: Frequency of events that occur
in/during a defined period of time.
 Generally the following rules are in play
 Numerator: rate of the frequency of event
 Denominator: number of people at risk during period
being studied/considered
 Constant multiplier: usually 100 in order to get a
percentage; 1000, 10,000 or 100,000 used for numbers
less than “1”. Not used a lot.
Methods of Data Collection

 United States Census

 Takes place every 10 years
 Also collects continuously data on births and deaths
through the Dept. of Vital Statistics

 U.S Vital Statistics

 Basically deals in birth and death of the population
 Local and state officials collect information
 Federal government collates the information after it is
Maternal and Fetal Associated Rates
Live birth is the delivery of a product of conception that shows any
sign of life after complete removal from the mother.

 Infant mortality rates: death of infants born alive

 Neonatal and Post-neonatal Mortality Rates: death of infants a)
during first 28 days of life (neo=new) and b) from 28th day to 1
year of life (post=after event).
 Perinatal mortality rates: deaths that occur around the time of
birth (i.e. stillborn)
 Maternal mortality rates: death of a pregnant woman as a result
of pregnancy related health issue
Chapter 3
Epidemiologic Surveillance &
Outbreak Investigation
Types of Surveillance
 Passive Surveillance  Active Surveillance
 Routine data collection  Periodic reports
 Physicians  By phone or visit
 Clinics  Labor intensive
 Laboratories  Health departments
 Hospitals  Example: The insuring
 Example: Infant Mortality that TB patients are
rate in Duval County, taking their medications
Florida in January 2008 as directed
Things to Know About Outbreaks
 Epidemic: Occurrence of disease at an
unusual frequency
 Syndromic Surveillance: Surveillance which
is looking for unlikely symptoms that may
identify possible bio-terrorist activity using
Elementary my dear Watson…
 Investigating an Epidemic:
 Establish a common diagnosis
 Establish a case definition (criteria of the disease)
 Establish a given number of diagnosed cases
 This is somewhat predicated by the number of cases of
the disease normally seen in the area at the same time
of the year
 Establish Time, Place and Person
 index case—the case that introduced the organism into
the population.
Chapter 4
Causation in Epidemiologic Investigation
& Research
 The first and most basic requirement for a
causal relationship to exist is that there must
be an association between the outcome of
interest (e.g., a disease or death) and the
presumed cause.
Pitfalls to Causal Research

 There are many things that can slow or interfere with

validating research into cause and effect
 Bias (differential error): Most dangerous as it is a deviation
or distortion of data or interpretation that goes in one
 Random Error: Something that happens randomly and
unexpectedly for no reason, and appears as unexpected
highs or lows in the statistical analysis
 Confounding: Confusion of two variables in such a way as
to not be able to discern which is which, causing the data to
be discarded
More Still…

 Synergism: an interaction of two variables

that produces an effect that is greater
together then than the separate effect of the
 Effect Modification: Appearance of an
unexpected third variable which affects the
performance of the two accounted for
Chapter 5

Common Research Designs of

 To generate a workable hypothesis
 To test the hypothesis
 Identify variables that may cause an effect to
 Identify risk factors
 Minimize aforementioned pitfalls from
occurring (i.e. bias, confounding, etc.)
Research Design

 Generating Hypothesis
 Cross sectional surveys (interviews)
 Cross sectional ecological surveys (behavior)
 Longitudinal ecologic studies (on-going
Hypothesis Testing

 Prospective cohort studies:

 The identification of a group of people/individuals on whom
baseline (initial) data is collected after which the same data
is collected over a long period of time
 Ex: Framingham Heart Study – a study that has been on-
going since 1950.
 Can be expensive and time-consuming
 Retrospective Cohort Study
 Choosing a group of people in which something has
already occurred and reviewing what their lives were like
after the event.
 Ex: Study of people exposed to radiation after Chenobyl
incident in Russia
More Hypothesis Testing

 Case-Control Studies
 Randomized Controlled Clinical Trials
(therapeutic in nature)
 Randomized Controlled Field Trials
(preventive in nature)
Chapter 6

Assessment of Risk and Benefit

in Epidemiologic Studies
Attributable Risk (AR)
 Defined: An estimate of the amount of risk
which is attributable to the risk factor

 Formula:
AR = [a/(a+b)] – [c/(c+d)]
Relative Risk
 Defined: This is somewhat of a comparison of
the ratio of risk in an exposed group to the
ratio of risk in the unexposed group.
 Formula:

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

Hint: Notice that we are dividing the two sets of numbers not subtracting them
as we did with AR

 Defined: An estimate of a odds ratio

 Formula:
OR = (a/c) / (b/d)
HINT: Do not use the step in the book that instructs you to convert the above
formula to OR = ad/bc. The reason is because the numbers sometimes
become too large to work with and muddy the waters.
Chapter 7

Understanding the Quality of Data in

Clinical Medicine
Key Concepts
 Accuracy: Ability of a measurement to be correct on
the average
 Precision: Ability of a measurement to give the
same results with repeated measurements of the
same thing

Both of these are necessary in statistics and neither

takes a back seat to the other
False is False and True is True
Or is it?

 Type I Error
 Also known as a false-positive error or Alpha error
 The error is in the fact that a positive reading is
registered when the results are actually negative

 Type II Error
 Also known as a false-negative error or a beta
 The error is in the fact that a negative reading is
registered when the results are actually positive
Sensitive Vs. Specific

 Sensitivity – Ability of a test to detect the

disease when present
 Specificity – Ability of a test to indicate non-
disease status when no disease is present
Chapter 8

Improving Decisions in Clinical Medicine

Bayes Theorum
 A somewhat convoluted theory that is used in
the mathematical exercise of determining

 If a patient has symptom A what is the probability

that the symptom is caused by a certain disease?
Evidence Based Medicine
 A form of medical practice that:
 Bases a diagnosis on symptoms + prevalence
 Relies heavily on the use of Bayes Theorum
 Must perform tests to rule out diseases as part of the
diagnostic process
 Uses a sequential approach to tests
 Begin with most sensitive test for fastest and most accurate
 Continues with other tests in a sequence until a satisfactory
answer is arrived at (i.e. diagnosis)
Decision Trees
 A method of improving decision making in
times of uncertainly
 A way of outlining ones thoughts and rationale
concerning a medical dilemma
 Create a decision tree
 Identify/set limits to the problem
 Diagram options
 Obtain information on each option
 Compare the values
 Perform sensitivity analysis to arrive at an answer