Workshop Molecular Epidemiology – Lima 2013

Conceptos básicos de
Epidemiología

Larissa Otero MD MPH

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Objetivos

•  Pensamiento Epidemiológico

•  Beneficios de una fuerte interacción

epidemiológicaßà biólogo molecular en
todas las etapas de la investigación

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 Workshop Molecular Epidemiology – Lima 2013

•  Inferencia
•  Validez
•  Diseño de estudios
•  Fiabilidad y reproductibilidad de una
prueba

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Qué es la epidemiología
Es el estudio de la ocurrencia y distribución de
los eventos de salud que se relacionan y sus
determinantes

Evidencia científica directa de los

determinantes que permite prevenir y controlar
la enfermedad

à Es la herramienta de la Salud Pública

Porta 2008
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Qué es la epidemiología
•  Cuantificar la frecuencia de una enfermedad en la
población
–  Es prioritaria para la intervención en programas de salud?

•  Entre quien es mas frecuente y por qué?

–  Es prioritaria para la intervención en programas de salud en
ciertos grupos?

•  Conocer la causa de la enfermedad

–  Por qué una enfermedad ocurre y por qué es persistente en la
comunidad?

•  Contribuye a la selección de estrategias que

probablemente contribuyen al control de una enfremedad
en particular

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Tobaco y cancer
•  Compuestos carcinogenos en el tobaco
•  Cancer de pulmón en animales de
experimentación cuando se les forza a
inhalar humo del cigarrillo
Pero:
•  El Cancer de pulmón ocurre más a menudo
en funadores que en no fumadores?
•  A menudo, es suficiente para reducir el
riesgo de cancer el NO fumar?

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Tobaco y cancer
•  En los años 20, se sospechó de una relación ente
el fumar cigarrillos y el cancer pulmonar en UK

•  1947, Richard Doll

–  Estudio de caso-control
–  Historia de fumadores de pacientes hospitalizados
con cancer pulmonar vs. un grupo similar sin cancer
de pulmon

•  1951, A.B. Hill

–  Estudio de cohorte
–  Midio el Cancer pulmonar y las muertes entre los
doctores británicos que fumaban vs. aquellos que no
fumaban
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Virus del Ebola

•  Muchas muertes en el Congo
•  Pacientes con fiebre y hemorragía

Investigación de la epidemia
•  Determinó cuantos mas muertos
•  Donde se relacionaban?
•  Qué es lo que pudo haber cocacionado?

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•  Inferencia
•  Validez
•  Diseño de estudio
•  Fiabilidad y reproductibilidad de una
prueba

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Inferencia
•  Extrapolar los resultados de una muestra
a la población
•  Ex. Fumar causa cancer pulmonar?
•  Necesitamos ser capaces de INFERIR
que los resultados de EL grupo estudiado
pueda ser extrapolado a otros fumadores
y no fumadores
•  Los resultados que obtenemos son
reales?
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•  Los resultados que obtenemos

son reales?

•  Cuál es la precision de las

medidas de nuestro estudio?

•  Cuál es la validez de las

medidas en nuestro estudio?
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Precisión and validez

IMPRECISO
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 Workshop Molecular Epidemiology – Lima 2013

Precisión and validez

Es preciso pero
NO VALIDO

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Precisión se mide por:

Significancia de las
pruebas estadísticas

Intervalos de
confianza
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Precisión
Prevalencia del HIV entre trabajadoras
sexuales (TSex) es del 6.9%

Prevalencia del HIV en la población en

general es del 1.5%

Es la prevalencia alta en las TSex?

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Precisión
•  Prevalencia del HIV entre Tsex es del
6.9% (95% confidence interval (CI)
2.8-10.9)

•  Podemos decir que, al 95% de

confiabilidad, la prevalencia de HIV entre
Tsex se encuentra entre 2.8% y 10.9 %

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Interpretation

Prevalencia del HIV

Entre TSex, 6.9% (95%CI 2.8-10.9)

2.8 6.9 10.9

0.7 1.5 2.3

En la población en general, 1.5% (0.7-2.3)

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Intervalos de confianza y
valores p
•  Ambos muestran la precisión de una
estimación pero,

•  CI provee información inmediata del

tamaño de muestra
–  Amplio CI en tamaños de muetras pequeñas
–  estrecha CI en tamaño de muestras grandes

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Intervalos de confianza
HIV Entre TSex
• Estudio con un tamaño de muestras de 146
TSex, 10 son HIV +
–  6.9% (2.8%-10.9%)

• Estudio con un tamaño de muestras de

4380 TSex, 300 son HIV +
–  6.9% (6.1-7.6)

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Precisión
•  Un cálculo apropiado del tamaño de
muestra para cualquier evento que
queramos medir es la clave para tener
una buena precisión

•  Precisión es requerida para poder

extrapolar nuestros resultados a un grupo
más amplio o a la población

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•  Inferencia
•  Validez
•  Diseño de estudios
•  Fiabilidad y reproductibilidad de una
prueba

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Precisión and validez

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Validez

•  Inferencia estadística

•  Validación interna

•  Validación externa

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 Población externa Workshop Molecular Epidemiology – Lima 2013

Validación externa

Población objetivo

Validación interna

Población origen

Inferencia estadística

Población en estudio
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Validez

1.  Sesgos
•  Selección
•  Información
à Mala clasificación

2.  Confusión

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 Sesgos Workshop Molecular Epidemiology – Lima 2013

Estudio de Cohrte del Tabaco y el cancer

•  Cuestionarios vía correo electonico a

59,600 médicos
•  Estado Fumador: actual / ex-fumador / no
fumador
•  Respuestas recividas de 40,637 (68%) de
los médicos
•  Cómo cree usted que el 68% de las
respuestas puede afectar a los
resultaados del estudio?
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Sesgos de selección
•  Si la distribución al factor de exposición
(fumar) en que respondieron (68%) vs a los
que no respondieron (32%) es diferente…

•  Ejm. Si la mayoría no respondieron que

fumaban y pocos respondieron que fumaban
à La verdadera asociación entre fumar y el
cigarrillo podría no ser una vrdadera estimáción

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Sesgos de selección
•  Los 40,637 que respondieron y entraton al
estudio fueron seguidos por 5 años
•  Al final de los 5 años, se pudo rastrear a
15,848 (39%) participantes para ver si
ellos desarrollaron cancer de pulmón

•  Cómo el seguimiento del 39% podría

afectar a los resultados del estudio?

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Sesgo de selección
•  En general, tasas de respuesta /
seguimiento del 80% o más
•  Determinar si los que no respondieron o
se perdieron durante el seguimiento
difieren de los que si respondieron o
fueron seguidos en los factores
importantes
•  Valorar la posibilidad de un sesgo de
selección in el estudio desde el diseño,
la conducción, el análisis y el reporte
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Sesgos de información
•  La información de los dos gupos se
colecta de manera diferente

•  Causas de la mala clasificación de la

información
–  Differential misclassification: level of
misclassification is different in the two groups
–  Non-differential misclassification: level of
misclassification is the same in the two groups

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Information bias
•  Questionnaire could be applied in different
manners if the interviewer knows the
outcome of the participant

•  Recall bias
–  Mothers of children with congenital
malformations

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 How to prevent information Workshop Molecular Epidemiology – Lima 2013

bias?
•  Standardising data collection forms
•  Training interviewers and health workers
•  Use more than one source of information
•  Conceal exposure or disease status from
interviewers
•  Assess the possibility of information bias in the
study

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Confounding

•  Association between two variables does

not reflect the truth because a third
variable is masking it

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Confounding

Exposure Disease

Confounding
factor

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Confounding

Matches Lung
cancer

Smoking

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How to prevent confounding?

•  Study design
•  Data analysis
–  Multivariable analysis
–  Stratification
–  Standardisation

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 Summary Workshop Molecular Epidemiology – Lima 2013

•  Precise results depend largely on a well calculated sample

size

•  Precison can be reported with statistical tests or much more

informative confidence intervals

•  Sample size is irrelevant if the study is not valid

•  Valid results depend on a good assesment and control of bias

and confounding from the study design, to the conduction and
data analysis

•  Validity can be easily overlooked and if not reported, the

reader cannot see it
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•  Inference
•  Validity
•  Study design
•  Validity and reproducibility of a test

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Types of studies designs

•  Experimental/observational

•  Descriptive/analytic

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Usual sequence of studies in Workshop Molecular Epidemiology – Lima 2013

humans
Clinical observations

Available routine data

Case-control studies

Cohort studies

Randomized trials

Systematic reviews/ meta-

analysis
 Cohort and case control
Workshop Molecular Epidemiology – Lima 2013

Study start

Exposed

t
Cohor
patients
Disease ?
Non exposed
patients

Case- control
Diseased
patients
Exposure ?
Non diseased
patients

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 Cohort and case control Workshop Molecular Epidemiology – Lima 2013

Study starts

How

Cohort
40,637 doctors many will
Smokers and get lung
Non smokers cancer in
each
group?

control
Case-
1357 patients
How many with lung
smoked in each cancer
group? 1357 patients
withouth lung
cancer

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 Summary Workshop Molecular Epidemiology – Lima 2013

Cohort Case Control

How are participants selected On exposure On outcome

What is measured Outcome Exposure

Duration of study Long Short

Sample size Large Small

Logistics Complex Simple

Costs Expensive Less expensive

Danger of selection bias Low High

Loss to follow up Frequent No

Information bias Possible Recall bias

Need to control confounding Yes Yes

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•  Inference
•  Validity
•  Study design
•  Validity and reproducibility of a test

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Validity and reproducibility of a test

•  Correct interpretation of the results
provided by a test

•  Understand the consequences of false

positive and false negative results

•  Assess reproducibility

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 Is the result of a diagnostic test saying the
Workshop Molecular Epidemiology – Lima 2013

truth?

Validity: what we want to measure and what

we are actually measuring

Reproducibility: probability that if the test is

repeated it will give the same results

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 Performance of a test Workshop Molecular Epidemiology – Lima 2013

•  Sensitivity: capacity to correctly identify

diseased persons
–  A diseased person may have:
•  a positive test-result (“true positive”)
•  a negative test-result (“false negative”)

•  Specificity: capacity to correctly identify non-

diseased persons
–  A non-diseased person may have
•  a negative test-result (“true negative”)
•  a positive test-result (“false positive”)

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 Sensitivity and specificity Workshop Molecular Epidemiology – Lima 2013

Disease No
disease

Test + True False

positives positives

Test - False True

negatives negatives

Sensitivity:
Number of diseased persons testing positive / Number of
diseased persons

Specificity:
Number of non-diseased persons testing negative / Number of
non-diseased persons

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 Performance of a test Workshop Molecular Epidemiology – Lima 2013

When interpreting the results of a test, one

wants to know:
• If the test is positive, is the person truly
diseased?
• If the test is negative, can the disease be
truly ruled out?

How much does the test predicts the reality?

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 Positive and negative predictive value
Workshop Molecular Epidemiology – Lima 2013

•  The PPV of the test is the probability that a

person with a positive test truly has the
disease:
–  No. of diseased persons testing positive / No. of
persons testing positive

•  The NPV of the test is the probability that a

person with a negative test is truly free from
that disease:
–  No. of persons free from the disease testing
negative / No. of persons testing negative

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Validity and reproducibility of a test

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 Exercise Workshop Molecular Epidemiology – Lima 2013

•  A shopkeeper in Cuzco coughing for 3 weeks has a

positive result in a test for TB Xpert MTB Rif.
•  Prevalence of TB in Cuzco is low, and among patients
coughing for 3 weeks it is 1%.

•  In North Lima, where prevalence of TB among people

coughing > 3 weeks can be up to 20%, a housewife gets
a positive result in Xpert MTB Rif.

•  Sensitivity of Xpert MTB Rif : 95%

•  Specificity Xpert MTB Rif : 99%

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 Questions Workshop Molecular Epidemiology – Lima 2013

•  If the test is positive, is the person truly diseased?

•  If the test is negative, can the disease be truly ruled out?

1.  What is the positive predictive value of the new test in

the shopkeeper and in the housewife?

2.  What is negative predictive value of the new test in the

shopkeeper and in the housewife?

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North Lima Cuzco

Prev TB among TB suspects Prev TB among TB suspects 1
20% %

TB NO TB NO TB
TB

TEST +
TEST +

TEST -
TEST -

Sensitivity: N° of diseased persons testing positive / N°of diseased persons = 95%

Specificitiy : N°of non diseased persons testing negative / N° of diseased persons =

99%

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North Lima Cuzco

Prev TB among TB suspects Prev TB among TB suspects 1
20% %

TB NO TB NO TB
TB

TEST +
TEST +

TEST -
TEST -

PPV: N° with a positive test that have the disease / N° with a positive test
NPV: N° with a negative test that do have the disease / N° with a negative test

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 Conclusion Workshop Molecular Epidemiology – Lima 2013

For a test 95% sensitive and 99% specific test:

•  A positive result has a very high, 95%, probability of

being truly positive in a high prevalence area

•  And a low, 49%, probability of being truly positive in a

low prevalence area

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 PPV Workshop Molecular Epidemiology – Lima 2013

•  Probability that a person with a positive

test truly has the disease

•  Depends on sensitivity but also on the

prevalence of the disease in the
population tested

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 PPV and prevalence Workshop Molecular Epidemiology – Lima 2013

During dry season in Burkina Faso, a RDT

for P. falciparum had a PPV of 9%

In the rainy season, the PPV ranged from

38% in adults to 82% for infants

Bisoffi et al 2010
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 What consequences will the test result have?
Workshop Molecular Epidemiology – Lima 2013

For the individual For the

community/health
services
False Anxiety, stigma. Burden on health
positives Inconveniences, risks of services
further tests. Waste of
Inconvenience or risks resouerces
linked to treatment
Unnecessary expenses
False Correct diagnosis missed, Transmission
negatives delayed diagnosis, Late diagnosis, less
suffering, death effective treatment
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 Exercise Workshop Molecular Epidemiology – Lima 2013

•  A nurse notices that someone is coughing in the waiting

room. What is the probability that this patient has TB?
The nurse says he should take a sputum sample to the
TB lab.

•  If we would have had information on duration of cough,

to what extent would this affect the probability of TB?

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 Exercise Workshop Molecular Epidemiology – Lima 2013

•  Data from a study in health centers in North Lima:

–  249 out of 2166 people with cough for 2 weeks or

more had a positive smear result, compared to 84 out
of 2749 people with cough for less than 2 weeks.

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 Exercise Workshop Molecular Epidemiology – Lima 2013

•  If cough > 2 weeks was a test, we would

like to know its characteristics
–  Sensitivity
–  Specificity
–  PPV
–  NPV

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 2 x 2 table Workshop Molecular Epidemiology – Lima 2013

DISEASE
(TB)

Present Absent

Cough for two

Present 249 1917 2166
weeks

Absent 84 2665 2749

333 4582 4915

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Characteristics of the test “cough>2wks”
Workshop Molecular Epidemiology – Lima 2013

•  Sensitivity: 249/333 = 75%

•  Specificity: 2665/4582 = 58%

•  PPV: 249/2166 = 11%

•  NPV: 2665/2749 = 97%

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 Conclusion Workshop Molecular Epidemiology – Lima 2013

The very high negative predictive value indicates that

somebody with a “negative test” (not coughing for > 2
weeks) has a very high probability of NOT having TB

àDon´t test people coughing for < 2 weeks in a high

prevalence setting!

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 Reproducibility Workshop Molecular Epidemiology – Lima 2013

•  Capacity of a test to give the same result -

positive or negative, whether correct or
incorrect - on repeated application in a
person with a given level of disease
(Rothmann)

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The Kappa coefficient (κ)

Chance-corrected agreement measure
0 indicates agreement no better than chance
1 indicates perfect agreement
-1= perfect disagreement

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STARD initiative Workshop Molecular Epidemiology – Lima 2013

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STARD checklist Workshop Molecular Epidemiology – Lima 2013

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Note on missing values

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 Missing values: things to Workshop Molecular Epidemiology – Lima 2013

consider
Risk of bias?

• Selection bias (people excluded because of

missing data?)

• Information bias (more data missing in one

group (D or E) than in the other?)

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 Missing values: things to Workshop Molecular Epidemiology – Lima 2013

consider
•  Why are data missing?
–  Random or not?
•  How many data are missing? ~ 20%
•  For which variables?

•  Impact of missing data on analysis?

Depends on statistical tests

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Missing values: things you can doWorkshop Molecular Epidemiology – Lima 2013

•  Assess risk of (selection) bias: compare

everything you do know between included
and lost subjects
•  Imputation: replace missing values by mean,
previous value, a value from the distribution
of the available data,...
•  Sensitivity analysis: assess different
scenarios
•  Be transparent & discuss risk of bias because
of missing data

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Molecular epidemiology Workshop Molecular Epidemiology – Lima 2013

•  Molecular tools enhance measures of diagnosis,

prognosis and exposure, reduces misclassification and
increases the power of the study

•  To properly enhance classic epidemiological studies,

design, procedures, analysis and interpretation have
to follow strong epidemiological methods

•  To apply findings from laboratory models in invididuals

and populations, results have to come from studies
from individual and/or population using
epidemiological methods

Foxman
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References

• Rothman. Modern Epidemiology

• Foxman. Molecular epidemiology and
infectious diseases
• Riley. Molecular epidemiology of infectious
diseases. Principles and practices
• Epistat text MDC, ITM, Antwerp

Acknowledgements

• Tine Verdonck
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