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STRATEGIES IN EPIDEMIOLOGY July 01, 2015
Dr. A. Abat

KINDS OF EPIDEMIOLOGIST
OUTLINE Descriptive Study of the occurrence and distribution of
I. EPIDEMIOLOGY
disease
A. KINDS OF EPIDEMIOLOGIST
B. PURPOSEOF EPIDEMIOLOGIC STUDY Analytic Further studies to determine the validity of
II. HYPOTHESIS hypothesis concerning the occurrence of disease
A. FEATURES OF GOOD HYPOTHESIS Experimental Deliberate manipulation of the cause is
B. METHODS OF FORMULATING HYPOTHESIS predictably followed by an alteration in the effect
1. Method of DIFFERENCE not due to chance
2. Method of AGREEMENT
3. Method of CONCOMITANT VARIATION
PURPOSE OF EPIDEMIOLOGIC STRATEGY
4. Method of ANALOGY
o To describe the distribution and elucidate the etiology of disease
C. SOME CONSIDERATIONS IN FORMULATING
in a population
HYPOTHESIS
D. EVALUATION AND SELECTION OF HYPOTHESIS
AKA: Epidemiologic approach, Cycle of epidemiologic reasoning
III. STUDY DESIGN
A. DESCRIPTIVE EPIDEMILOGY
HYPOTHESIS
1. CASE REPORTS and CASE SERIES
o An assertion or proposition about the relationship between two or
2. CROSS-SECTIONAL STUDIES
more variables, adopted to explain facts and to guide in the
3. CORRELATIONAL (ECOLOGIC) STUDIES
investigation of others
B. ANALYTIC STUDIES
o Supposition arrived at from observation or reflection that leads to
1. OBSERVATIONAL studies
refutable predictions
2. CROSS-SECTIONAL studies
o Should be specific, observable, and measurable
3. CASE CONTROL studies
o Tells the direction of your research
4. COHORT studies
o Guides the investigator
C. EXPERIMENTAL STUDIES
o Limits the area of investigation
1. CLINICAL Trials
o Sensitizes the researcher to relevant data and relationships
2. COMMUNITY Trials
o Provides a unifying concept between the variables being
IV. THE EPIDEMIOLOGIC APPROACH
investigated
EPIDEMIOLOGY FEATURES OF A GOOD HYPOTHESIS
A.POPULATION (target population)
 To whom the hypothesis will apply.
 The relevant pop. characteristics should be specified.
B. ‘CAUSE’
 Suspected risk factor being investigated is usually a
particular environmental exposure (physical, chemical,
biologic, and even psychological factor)
C. OUTCOME
 Quantitative basic science  Usually the disease or condition of interest.
D. DOSE-RESPONSERELATIONSHIP
- built on a working knowledge of probability, statistics, and
sound research methods.  Amount of exposure necessary for the disease or
 Method of causal reasoning condition to develop
E. TIME-RESPONSE RELATIONSHIP
- based on developing and testing biologically plausible
hypothesis pertaining to occurrence and prevention of  Time period between the exposure and the
morbidity and mortality. development of the outcome
 Tool for public health  This concept is synonymous to the incubation period
- action to promote and protect the public’s health based on for infectious diseases and latency period for non-
science, causal reasoning, and a dose of practical common infectious diseases.
sense. Example:
 Among adults with previous exposure to typhoid fever, the
Clinician Epidemiologist ingestion of ten million viable typhoid bacilli will result in an
attack rate of typhoid fever of 50% within a period of 30 days.
Patient’s diagnostician Community’s Diagnostician o Population: adults with previous exposure of typhoid
Investigations Investigations fever
Diagnosis Predict trend o Cause: ingestion of viable typhoid bacilli
Therapy Control o Outcome: typhoid fever
o Dose-response: 10 million viable typhoid bacilli
Cure Prevention o Time-response: 30 days
Page 1 of 3
TRANSCRIBERS: Delos Santos, I., Galang
 Strategies in Epidemiology
Weak associations, even if statistically significant, are rarely
immediately productive of strong hypothesis.
METHODS OF FORMULATING HYPOTHESIS
1. METHOD OF DIFFERENCE C. Observed changes in the frequency of disease, especially if the
 “If 2 different circumstances gave rise to marked differences in change occurs over a relatively short span of time, can lead to
disease frequency and a particular factor can be identified in 1 very productive hypothesis.
circumstance but not in the other, then the presence of this factor Example:
(or its absence) may be a cause of the disease.” o Rapid increase in the number of unusual congenital
 Disadvantage: the potentially large number of hypotheses which malformations during 1959-1961 due to thalidomide
are consistent with or are suggested by the observed differences exposure.
 Examples:
o Differences in the frequency of diseases between population D. An isolated or unusual case should receive particular attention in
with low socio-economic status vs. high socio-economic forming hypothesis.
stratum. Example:
o Difference between disease frequency between males and o Paying a particular attention to persons living in areas or
females; USA vs India communities in which the diseases are absent.
o Correlation of cigarette smoking and lung cancer both by
gender and overtime E. Observations that appear in conflict or those which present a
paradox should be considered.
2. METHOD OF AGREEMENT Example:
 “If a factor is common to a number of different circumstances o Pellagra was associated with diet since asylum workers did
that have been found to be associated with presence of the not develop the disease even if they were in close contact
disease factor may be a cause of the disease.” with inmates who had pellagra)
 Example:
Injecting drug use, sexual intercourse and transfusion of EVALUATION AND SELECTION OF HYPOTHESIS
blood and blood products are all associated with HIV A. The value of a hypothesis is inversely related to the number of
infection acceptable alternatives. The hypothesis becomes more valuable
and productive if the number of acceptable alternatives becomes
3. METHOD OF CONCOMITANT VARIATION fewer in number.
 Involves identifying a factor whose frequency or strength varies
with the frequency of the disease. B. It is useful to make deliberate search for specific demographic
 Inductive reasoning information that may be relevant to it.
 Involves quantitative approach Example:
 Example: o Low rate of cervical cancer among Jewish women. (No
Increase in the sale of salt and the death due to cancer of difference in cervical rates in Lebanon[Moslems circumcised
the esophagus in the province of China; fluoride VS not circumcised Christians])
concentration in drinking water w/ prevalence of dental
caries. C. A hypothesis need not be consistent with all existing
observations. It is possible to have multiple causes of the same
4. METHOD OF ANALOGY disease. It is also possible that disease classifications are still
o “How a disease/ condition distributed in the population may be crude thereby lumping diseases or conditions which are
sufficiently similar to that of some other disease that has been etiologically heterogeneous.
more or less completely and successfully studied to suggest that
certain causes may be common to both.” STUDY DESIGN
o Checks for variation  A specific plan or protocol for conducting the study, which allows
o Deductive reasoning – epidemiologic principles already the investigator to translate the conceptual hypothesis into an
established are applied to other situations operational one. (Mandil A., University of Alexandra)
o Example
o The observation that the geographic distribution of Burkitt’s DESCRIPTIVE VS ANALYTIC EPIDEMIOLOGY
lymphoma is similar to that of malaria and yellow fever which Descriptive Analytic
prompted people to hypothesize that just like these 2
diseases, an insect vector may be involved in the etiology of Used when little is Used when insight
this particular type of lymphoma. known about the about various aspects
o Association of diseases occurring in certain parts of the disease of disease is available
world during summer months with vector transmission.
Rely on pre-existing Rely on development of
SOME CONSIDERATIONS IN FORMULATING HYPOTHESIS data new data

A. New hypothesis are commonly formed by relating observations Who, where, when Why
from several different fields. In the area of disease causation,
“epidemiologic findings are most profitable viewed in the light of Illustrates potential Evaluates the quality of
clinical, pathologic, and laboratory observations.” associations associations
B. The stronger the statistical association between the exposure and
the disease, the more likely it is to suggest a causal hypothesis. BOTH ARE IMPORTANT!

TRANSCRIBERS: Delos Santos, I., Galang Page 2 of 3

 Strategies in Epidemiology
 Usually done last due to possible ethical issues
A. DESCRIPTIVE EPIDEMIOLOGY 1. CLINICAL TRIALS
1. CASE REPORTS AND CASE SERIES
 Individual subjects
 Report of a single individual (Case Report) or a group of
individuals (Case Series) with the same diagnosis 2. COMMUNITY TRIALS
 Describe only those with the disease  Among population
 Example:
AIDS - Between Oct. 1980 – May 1981, 5 cases of P. carinii THE EPIDEMIOLOGIC APPROACH:
pneumonia were diagnosed among previously healthy young STEPS TO PUBLIC HEALTH ACTION
homosexual males in LA
Descriptive Measures Alternative Action
2. CROSS SECTIONAL STUDIES
Explanations
 Aka Prevalence study
 Measures disease and exposure simultaneously in a well-defined What (cause Counts -Chance Behavioral
population definition)
Times -Bias Community
3. ECOLOGIC (CORRELATIONAL) STUDIES Who
Rates Confounding Environmental
 Data being used are secondary on population aggregates
Where
 Use measures that represent characteristics of entire Risk Odds
populations. When (time)
 Example: Prevalence
Occurrence of respiratory diseases among urban vs rural How many
Incidence
secondary to air pollution (measures)

B. ANALYTIC STUDIES Analytic Methods Inferences

1. OBSERVATIONAL STUDIES
 The investigator simply observes the natural course of events, Why (causes) Design Epidemiologic
noting who is exposed and who is not exposed and who has not
developed the outcome of interest How (causes) Conduct Causal

2. CROSS SECTIONAL STUDIES Analysis

 Measurements of cause and effect related to the same point in Interpretation
the study of member’s lives
 Limited to studies of causes that are long standing characteristics
of the individual
 Measure of association: Prevalence Ratio THE EPIDEMIOLOGIC APPROACH
 Example:  The number of cycles depend on the number of the hypothesis.
o Association of Backpack Use with Back Pains among Grade
5-6 Students in Sta. Ana Elementary School

3. CASE CONTROL STUDIES

 Identify a group of subjects who already have the
disease/condition and a comparison group who do not have the
disease/condition
 Information on past exposure are then obtained and compared
between the cases and controls
 Measure of association: Odds Ratio
 Start with the disease, then determine exposure
 retrospective

4. COHORT STUDIES
 The members of the population at risk are classified in terms
whether that had been exposed or unexposed to the factor of
interest and followed up to determine who will develop the
disease/condition being investigated
 Measure of association: Relative Risk
 Get exposures, then follow up
 Forward directionality

C. EXPERIMENTAL STUDIES
 The investigator assigns the study subjects to the exposure
status usually in a random manner
 “manipulative studies”

TRANSCRIBERS: Delos Santos, I., Galang Page 3 of 3