Epidemiology Final Exam Study Guide

Introduction & History of Epidemiology

Epidemic: “the occurrence, in a community or region, of cases of an illness, specific health-
related behavior, or other health-related events clearly in excess of normal expectations”
Endemic: the constant presence of a disease or infectious agent within a given geographic area
or population
Pandemic: “an epidemic occurring worldwide or over a very wide area crossing international
boundaries and usually affecting a larger number of people”
Epidemiology: “…Distribution and determinants of health and diseases, morbidity, injuries,
disability, and mortality in populations”
Some history of epidemiology
James Lind: 1747- Scurvy experiment on navy ships
John Snow: “Father of Epidemiology”, cholera outbreak
Edward Jenner: Smallpox
Pellagra: caused by a lack of nicotinic acid or its precursor tryptophan in the diet and lead to
dermatitis, diarrhea, and mental disturbance, and is often linked to overdependence on corn as
a stable food
Robert Koch: verified that human disease was caused by a specific living organism

Descriptive Date
Descriptive epidemiology: used to identify a health problem that may exist. Characterize the
amount and distribution of disease by person, place, and time
Describe general differences between point epidemics, secular trends, cyclical trends and
clustering
Point epidemics: may indicate response to a common source of exposure
- Tuberculosis outbreak at elementary school in SC
- Hepatitis/HIV outbreak at OK dental clinic
- Cancer among persons exposed to radiation at the Chernobyl Nuclear Power Plant
explosion
Secular Trends: Gradual change in frequency of disease over period of time
- Increased rate of resistance of Staphylococcus aureus in hospitals over time

Cyclic Trends (seasonal): Increased and decreases in frequency over time.

Season Affective Disorder (SAD) is the increase in depressive symptoms. Typically starts in the
fall and lasts through the winter.

Clustering: “A closely grouped series of events or cases of a disease or other health-related

phenomena with well-defined distribution patterns in relation to time or place or both”

Sources of Data/Surveillance
Raw: you sort and analyze it yourself. You can collect raw data yourself, find it through
publically-available resources
Processed: Reported in text, tables/figures. You can find processed data in popular, scholarly,
or professional literature.
Primary Data: Data collected by the researcher
Secondary Data: Data utilized for analyses that was collected by others.
Population-based surveys:
- BRFSS
- HINTS
- NHANES
Registries:
- Cancer
- Births and deaths
Insurance claims:
- Medicare and Medicaid
- Blue Cross Blue Shield
Medical or administrative records

Behavioral Risk Factor Surveillance System (BRFSS): collects data on cigarette smoking, alcohol
use, physical activity, diet, hypertension, and seatbelts to examine premature morbidity and
mortality among adults.

Surveillance: initially used to describe monitoring of persons who, because of an exposure,

were at risk of developing disease
- If they exhibited evidence of disease, they could later be quarantined to prevent its
spread
Immediate Surveillance Data:
Important for- epidemics, newly emerging health problems, changes in health practices,
changes in antibiotic resistance

Annual Surveillance Data:

Annual Disseminiation:
- Estimate the magnitude of a health problem and its cost
- Assess effectiveness of control activities
- Set research priorities
- Facilitate planning
- Monitor risk factors
- Monitor changes in health practices

Archival Surveillance Data:

Archival information for:
- Describing natural history of diseases
- Facilitating epidemiologic and laboratory research
- Validating use of preliminary data (provide a baseline)
- Setting research priorities
- Documenting distribution and spread of disease
Passive Surveillance: health-care providers send reports to a health department on the basis of
a known set of rules and regulations (provider-initiated).
- EX. Reporting of cancer cases to registry
Active Surveillance: less commonly, health department staff may contact health care providers
to solicit reports. It is usually limited to specific diseases over a limited period of time, such as
after a community exposure or during an outbreak (health department-initiated).

Circadian Biology in Epidemiology

Circadian rhythms: are physical, mental and behavioral changes that follow a roughly 24-hour
cycle, responding primarily to light and darkness in an organism’s environment. Your body’s
natural rhythm in the absence of an external cues
Diurnal rhythms: your body’s rhythms under the pressure of 24-hour changes in the
environment.

Rates and Ratios

3 Categories of rates: crude, specific, adjusted
Crude death rate: Number of deaths in a given year X 1,000
Population at midpoint of the year
Crude natality rates:
- Birth rate
- Fertility rate
- Infant mortality rate
- Neonatal morality rate
- Post-neonatal mortality rate
- Fetal death rate

Crude birth rate: Number of live births within given period X 1,000
Population at midpoint of that period

Fertility rate: Number of live births within a year X 1,000

Number of women aged 15-44 at midpoint of year

Infant morality rate: Number of infant deaths during the year X 1,000
Number of live births during the year

Neonatal morality rate: # of infants under 28 days who died during the year X 1,000
# of live births during the year

Post-neonatal morality rate: # of infants 28-365 days old who died during the year X1,000
# of live births during the year

Fetal death rate: # of fetal deaths after 20+ weeks gestation X 1,000
Total # of fetal deaths (20+ weeks) plus total # of live births
 Late fetal death rate: # of fetal deaths after 28+ weeks gestation X 1,000
Total # of fetal deaths (28+ weeks) plus total # of live births

Age-specific rates:
# of deaths among those aged 15-24 years during given time period X 1,000
# of persons aged 15-24 years during given time period

Cause-specific rates:
# of deaths from given disease during given time period X 1,000
Population size at midpoint of given time period

Proportional Mortality Ratio (PMR) %:

Mortality due to a specific cause during a time period X 1,000
Mortality due to all causes during the same time period

Adjusted rates: summary measures of the rate of morbidity and mortality in a population in
which statistical procedures have been applied to remove the effect of differences in
composition of various populations
- Necessary for comparison of rate across groups
- Example: comparison of heart disease death rates across states

Incidence and Prevalence

Know the relationship between incidence and prevalence
Be able to calculate prevalence
Understand how to set up a 2x2 table
Prevalence: number of existing cases of a disease over total population
Incidence:
- Numerator= the number of new cases
- Denominator= the population at risk
- Time= the period during which the cases occur
Prevalence vs. Incidence
If the duration of disease is short and incidence is high, prevalence becomes similar to incidence
Short duration- cases recover rapidly or are fatal
Example: common cold

If duration of disease is long and incidence is low, prevalence increases greatly relative to
incidence
Example: HIV/AIDS prevalence

Point Prevalence: # of person’s ill

Total # in the group

RCT
Describe design of RCT: an epidemiological experiment in which participants selected from a
population are randomly assigned into 2 or more groups, usually called treatment and control
groups, to receive or not to receive an intervention.
Key features:
- Equipoise
- Selection of subjects
- Baseline measurements
- Randomization of intervention
- Blinding
- Follow-up
- Intention to treat
- Validity
- Ethical considerations

Interpret results of RCT

List strengths and weakness of RCT
Strengths:
- Randomization makes groups comparable
- Results provide evidence for causality
- Direct clinical implications
Limitations:
- Limited generalizability of study results (external validity)
- May be costly depending on sample size
- Results comprised if: sample size too small, follow-up not complete, no blinding,
randomization unsuccessful

Cohort studies
Describe design of cohort studies: Two groups are compared: one group HAS the EXPOSURE of
interest and a comparable group DOES NOT HAVE the exposure
Interpret results of cohort studies
Advantages:
- Permit direct observation of risk
- Exposure factor is well defined
- Can study rare exposures
- The temporal relationship between risk factor and outcome is known
Disadvantages:
- Expensive and time consuming
- Complicated and difficult to carry out
- Subjects may be lost to follow-up during the course of the study
Attributable Risk (AR):
A/(A + B) – C/(C + D)

Relative Risk (RR):

Incidence of disease in the exposed
Incidence of disease in the unexposed

If RR = 1: risk in exposed equal to risk in unexposed- no association

If RR >1: risk is exposed is greater than risk in unexposed- positive association (possibly causal)
If RR <1: risk in exposed is less than risk in unexposed- negative association (possibly protective)

Case-control Studies
Describe design of case-control studies: start with people with the disease (cases) and people
without the disease (controls)
OR:
Odds of exposure among cases
Odds of exposure among controls

If OR=1: odds of exposure do not differ by disease status- no association

If OR >1: odds of exposure higher in diseased- positive association
If OR <1: odds of exposure lower among diseased
Advantages:
- Tend to use smaller sample size than cohort prospective studies
- Relative to cohort studies, quicker and easier to complete
- Typically, are low in cost
- Useful for studies of rare diseases, when little is known about the disease, or diseases
with long latency periods (cancer)
Disadvantages:
Recall bias
- Exposure measurements may be inaccurate

Cross-sectional studies
Describe design of cross-sectional studies: participants are selected without any consideration
of their exposure or outcome status
Interpret results of cross-sectional studies:
Interpretation: the prevalence of (depression) is (NUMBER) times among those who are
(physically active) compared to those who are not
Advantages:
- Can be done in a short period of time
- Provides prevalence data
- Provides trend data
- Hypothesis generating
Disadvantages:
- Don’t know temporal sequence
- Don’t count those who died quickly from disease- selective survival
- Not true risk calculation

Calculate and interpret prevalence ratio

PR: a / (a+b)
c/ (c+d)

Ecological studies:
Describe design of ecological studies:
Observational study in which variables are measured at the group level
Appropriate for initial investigation of causal hypothesis
Descriptive: Examines trends in population-level outcomes
Analytic: Examines relationship between exposure and disease with population-level
(aggregate) rather than individual-level data

Advantages:
- Quick, easy and inexpensive
- Usually rely on easily available existing data
- May suggest new hypotheses
- Explore neighborhood-level and macro-level exposures
Disadvantages:
- Crude exposure measure
- Ecologic Fallacy: can observe association with aggregate data but not at the individual
level

Infectious diseases
Epidemiological triangle
Agent (virulence, infectivity of a pathogen

Environment Host:
(sanitary conditions, social context) (genetic susceptibility, resiliency, nutritional status
Characteristics of infectious agents
Examples:
- Bacteria (Tuberculosis and salmonellosis common diseases caused by bacteria)
- Viruses (a microorganism composed of a piece of genetic material surrounded by a
protein coat. To replicate, a virus must infect a living cell. (Viral Hepatitis A, herpes, and
influenza are caused by viruses)
- Rickettsia (A genus of bacteria that can grow within cells. Fleas, lice, ticks)
- Fungi (Mycoses) (ringworm, athletes foot)
- Protozoa (Microscopic single-cell organisms, malaria)
- Parasites (Organisms found most frequently in moist, tropical areas, pinworms)
- Prion (Protein particles that are forms of normal cellular protein, minus nucleic acid,
that causes disease when it accumulates the brain, mad cow disease)
Direct transmission: person to person
Indirect: vehicle-borne, airborne, vector-borne
Vehicle Borne: infectious result from contact with vehicles, which are contaminated,
nonmoving objects
Formites: classroom doorknob, towels in locker room
Foodborne: caused by ingestion of contaminated food
Waterborne: caused by infectious agents which contaminate the water supply
Airborne: involve the spread of droplet nuclei (particles) that are present in the air
Vector-borne: living insect or animal involved in transmitting disease agents

Public Health Policy

Know process from evidence to policy
Stage 1: in the car
- Traditional role of epidemiologists as researchers)
- Findings communicated primarily in the academic
- Few other passengers in the journey
- Screening procedures in the early development
- Limited policy application
Stage 2: in the bus
- Epidemiologists take on broadened roles (conduct research & communicate to public,
serve as consultants or content experts)
- More complicated research (clinical trials)
- Many more participants in the journey (includes participants from other fields)
- More mature evidence of etiology and potential
Stage 3: in the train
- Epidemiologists are among many disciplines (continue previous roles, act as
spokesperson for policy or scientific positions)
- Incremental changes require large studies
- Mature scientific and policy environment
- The journey is now being made by multitude (debate has shifted into the media)

Causality
Be able to interpret a confidence level: A range of values that with a certain degree of
probability contain the population parameter
Know Hills criteria
Strength: strong associations give support to causal relationship

Replication of Findings: association observed repeatedly in different study designs, different

populations
- EX. Smoking and lung cancer has been observed in dozens of studies among various
populations

Biological Gradient: Dose-response: linear relationship between exposure and disease

 - EX. Lung cancer risk increases with the number of cigarettes smoked per day

Plausibility: association biologically plausible

- EX. Radiation for sunlight exposure can damage DNA in skin cell leading to skin cancer

Consideration of Alternative Explanations: researchers have ruled out alternative explanations

for the observed association

Consistency with other knowledge: corresponding between known association and one that is
being evaluated for causality
- EX. Passive smoking and lung cancer due to known association of active smoking and
lung cancer or smoking leading to lung cancer in men AND women

Cessation of the Exposure: does the prevention of the exposure affect the frequency of the
outcome
- EX. Stopping a chemical exposure reduces frequencies of acute dermatitis

Outbreak Investigation
Attack rate = ill X 100
Ill + well

Number sick per 100 persons

Screening Tests
Sensitivity: The ability of the test to identify correctly all screened individuals who actually have
the disease A/(A+C)

Specificity: The ability of the test to identify only nondiseased individuals who actually do not
have the disease D/(B+D)

Positive predictive value: the proportion of individuals screened positive by the test who
actually have the disease (A/A+B)

Negative predictive value: the proportion of individuals screened negative by the test who do
not have the disease (D/C+D)
Reliability: (Precision) the ability of a measuring instrument to give consistent results on
repeated trials
Validity: (Accuracy) the ability of a measuring instrument to give a true measure. This can be
evaluated only if an accepted and independent method for confirming the test exists.

Confounding and Bias

Define and identify confounding: distorts the estimate of association between exposure and
outcome (perhaps reverse relationship)
- Must be a risk factor for outcome
- Must be associated with exposure
- Must not be an intermediate step in causal path between exposure and outcome
Identify approaches to control for confounding:
- Remove the effect of the confounder on the relationship between exposure and
outcome
- In most cases, cannot adjust unmeasured or unknown factors
- Cannot completely adjust for imprecisely measured factors
Effect modification: association between exposure and outcomes CHANGES within levels of this
factor

Bias: deviation of results or inferences from the truth, or processes leading to such deviation.
Any trend in the collection, analysis, interpretation, publication, or review of data that can lead
to conclusions that are systematically different from the truth

Selection bias: refers to distortions that result from procedures used to select subjects and
from factors that influence participation in the study
Arises when the relation between exposure and disease is different for those who participate
and those who theoretically would be eligible for study but do not participate

Information Bias: Can be introduced as a result of measurement error in assessment of both

exposure and disease

Exposure Identification Bias:

Recall bias: this bias is more of a concern for case-control studies. Cases may be more likely to
report or critically think of past exposures that lead to development of their conditions,
whereas controls may not do this

Results of information bias: misclassification

Non-differential misclassification: where the degree of misclassification between your two
main comparison groups is about the same. This will bias your results to the null value.
Differential misclassification: where the degree of misclassification is different for your two
main comparison groups. This could bias your results away or towards the null, there is no way
to be sure which way the bias will occur.

Ethics in Epidemiology
Know the historical milestones associated with ethical guidelines
Nuremberg Code: (1946)- drafted to judge physicians/scientists who had conducted biomedical
experiments on Nazi concentration camp prisoners
10 Standards:
1. Voluntary and informed consent is essential
2. Experiment should yield fruitful results for society, unprocurable by other means
 3. Based on results of animal experimentation and knowledge of natural history of disease
4. Conducted to avoid all unnecessary physical and mental suffering
5. If there is reason to believe death or disabling injury will occur, experiment should not
be done
6. Proper preparations made to protect subjects against possibility of injury, disability or
death
7. Conducted by scientifically qualified persons
8. Subject should be able to withdraw from the study at will throughout the study
9. The scientist should be prepared to terminate the experiment at any stage if he/she
believes the experiment is likely to results in injury, disability, or death
Declaration of Helsinki: 1964- The world medical association developed the statement
primarily for physicians doing research involving human subjects or identifiable human
material/data. Updated 7 times, most recently in October 2013.
Example principles:
- Informed consent
- Privacy and confidentiality
- Use of placebo only when no proven intervention exist
- Protection of vulnerable populations
- Duty to make results of research publically available
- Research must be approved by research ethic committee before the study begins
- Research must conform to scientific principles and be based on scientific literature
- Importance of the research must outweigh the risks to subjects
Belmont Report- 1978

Belmont report
Respect for persons:
- Individuals should be treated as autonomous agents (freedom to deliberate and choose
actions)
- Individuals with diminished autonomy are entitled to protection (prisoners)
Beneficence:
- “Do no harm” (Hippocratic Oath)
- Maximize possible benefits and minimize possible harms
Justice:
- Individuals should be treated equally (benefits and burdens are distributed fairly)
- Selection of subjects should not be based on convenience and manipulability (welfare
patients)