INTRODUCTION TO EPIDEMIOLOGY FPMD 6300 Fall SEMESTER 2010

Instructor:

Joseph L. Lyon, M.D., M.P.H.

Copyright 2005, Joseph L. Lyon, M.D., M.P.H. All rights reserved Revised December 2005 FPMD 6300

PREFACE This syllabus was developed from the lecture notes used to teach the introductory epidemiology course to students in the Master of Science in Public Health of the Department of Family and Preventive Medicine. The stimulus for this syllabus was the notes taken by Jeffrey Johnson, the course teaching assistant, from the lectures given between 1983 and 1987. The influence of one of the master teachers of epidemiology, Kenneth Rothman, is also evident in much of the material. This is deliberate and reflects his influence on Jeff and me during our summer course with him in 1984 and 1985. Other faculty of the division has also contributed to this syllabus. Dr. D.W. West provided several of the examples used in the rate adjustment section, and Dr. Mary Catherine Schumacher and Dr. Catherine Schuman provided several of the examples used in the sections on confounding and matching. I am grateful to them for these contributions. Finally, thanks are in order to all the students who have struggled through the lectures, raised questions, and generally helped me to clarify many of the concepts and examples. I look forward to further questions.

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INTRODUCTION TO EPIDEMIOLOGY FPMD 6300 COURSE OUTLINE Credit Hours: Time/Day: Location: Goal: 3 9:00 AM 10:20 AM Monday & Wednesday

375 Chipeta Way, Room 203 To provide skills necessary to measure disease occurrence and its relationship to excess risk and those necessary to evaluate cause-effect relationships in human populations.

Grading Requirements: In-class Quizzes: Online Quizzes: Final Exam: Total Possible: 400 points (8 quizzes 50 points each). I will replace your lowest quiz score with a 50. 50 points 150 points (comprehensive final exam) 600 points

Grading criteria for this course as follows: 90% of the total points is the cut off for an A80% of the total points is the cut off for a B70% of the total points is the cut off for a CBy the fourth quiz, you should have a picture of your standing in the course. Any examination grade below 80% is a failing score for students in the MPH/MSPH program. An average on all your quizzes below 80% means you are failing the class. If you find yourself in this position you are responsible for contacting the instructor or one of the TAs for recommendations on additional readings or problem sets that may help you in improving your grade. We do not offer any extra credit for outside work to offset a failing course grade. If your final grade in the course is below a B-, you will have to repeat the course to remain in the MPH/MSPH program. The examinations will consist of questions that will consist of multiple choice questions, short answer, or setting up and solving a problem from data provided. We give partial credit for setting up the problem correctly and will grade story problems as follows. If your answer is correct, you receive full credit. If your answer is not correct we will check the set up of the problem. If you set up the problem correctly, but obtain the answer wrong, you will receive half credit. If you did not set up the problem correctly, or we cannot determine how you set up the problem, you will receive no credit. A WORD OF WARNING-A FINAL ANSWER WITH NO UNITS OR INCORRECT UNITS WILL COST YOU ONE POINT. You will be taught many mathematical formulae in this course. You need to know them, and demonstrate this knowledge by applying the formulae to data, but we do not expect you to memorize them. We will provide you with the written formulae necessary to complete each quiz.

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Required text: The syllabus is the primary text for the class. We are recommending that students also buy the Epidemiologic Methods: Studying the Occurrence of Illness by Thomas D. Koepsell and Noel S. Weiss. This book contains many examples of epidemiologic studies that have relevance to public health, and presents the studies in question and answer format. This text will be our main text in lab. We are also recommending Workbook of Epidemiology by Staffan E. Norell. We will use some of the examples from the Norell book in class and lab, and will recommend sections in the text for supplemental reading. Additional Reading: an addition of text that is helpful for students in understanding epidemiology is entitled, Making Sense of Data, by Abramson. A copy may be obtained from the instructor or purchased at the bookstore. Required Texts: Syllabus for course available for cost of photocopying, or can be downloaded from the website A calculator capable of doing addition, subtraction, multiplication, division, and finding natural logarithms (log to base e, ln, or e) is essential for examinations, homework, assignments, and labs. Kleinbaum, Kupper, Morgenstern: Epidemiologic Research, Belmont, CA: Lifetime Learning Publications, 1982. Rothman, K., Epidemiology An Introduction. Oxford University Press, 2002. MacMahon, B. Pugh T., Epidemiology, Principles and Methods, Boston: Little, Brown & Company, 1998. *You will also need to read assigned articles, which can be accessed by Electronic Reserve and the Marriott Library Reserve Desk.

Calculator:

Additional Reading:

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EPIDEMIOLOGY LAB Time/Day: Location: INSTRUCTOR: Wednesday, 10:30 AM 11:15 PM 375 Chipeta Way Classroom 203 Joseph L. Lyon, M.D., M.P.H. Office: 375 Chipeta Way, Suite A Telephone: 587-3350 Email: joseph.lyon@utah.edu Office Hours: Monday, 10:30 11:30 AM, or by appointment Jill Briggs Office: 375 Chipeta Way, TA cubes Telephone: 750-1601 Email: jill.s.briggs@aruplab.com Office Hours: Monday, 10:30-11:15 AM, or by appointment

TEACHING ASSISTANT:

*A quiz on the lecture material will be given during the first part of the class. Answers will be given immediately after the quiz. The instructor will thoughtfully consider any protests about your understanding of the meaning of a word versus the instructor. This class, different form most you have taken at the University level, offers your partial credit for a response of I dont know on true/false or multiple-choice questions. We operate on the theory that you are less dangerous stating your ignorance rather than trying to fake it when you get in to the real world. This option is not available on problem solving questions, though wished for by many students. Make-up quiz policy: We will allow you to take 2 make-up quizzes. Make-up quizzes must be taken within one week of the scheduled quiz. These quizzes will be taken in the Testing Center (extension 1-8744; located in 498 SSB). There is a $5 fee for using Testing Center services. You will be required to supply a photo ID before being allowed to take the test. Testing Center hours are: M, W, F T, Th 8:00 AM 3:00 PM 5:00 PM 8:30 PM

Any exceptions to this policy will require consultation and approval from the course instructor and TAs. ADA Policy: The University of Utah seeks to provide equal access to its programs, services, and activities for people with disabilities. If you will need accommodations in this class, reasonable prior notice need to be given to the instructor and the Center for Disability Services, 581-5020 (Voice or TDD; located in 162 UNION) to make arrangements for accommodations. All written information for this course can be made available in the alternative format with prior notification. Passing the TOEFL test indicates readiness to take courses at the University of Utah.

Introduction to Epidemiology Fall 2010 - Course Schedule ***Subject to change at discretion of Dr. Lyon*** Date 23-Aug-10 25-Aug-10 30-Aug-10 1-Sep-10 6-Sep-10 8-Sep-10 13-Sep-10 15-Sep-10 20-Sep-10 22-Sep-10 27-Sep-10 29-Sep-10 4-Oct-10 6-Oct-10 11-Oct-10 13-Oct-10 18-Oct-10 20-Oct-10 25-Oct-10 27-Oct-10 1-Nov-10 3-Nov-10 8-Nov-10 10-Nov-10 15-Nov-10 17-Nov-10 22-Nov-10 24-Nov-10 29-Nov-10 1-Dec-10 6-Dec-10 8-Dec-10 Syllabus Section Class Intro, Section 1 Section 1 Section 2 Section 2 Section 3 Section 3 Section 3 Section 4 Section 4 Section 4 Section 5 Section 5 Section 5 Lab Assignment Lab Intro Lab 1 Labor Day Holiday Lab 2 Quiz 1 Lab 3 Quiz 2 Lab 4 Lab 4 Quiz 3 Lab 5 Fall Break Section 6 Section 6 Section 6 Section 7 Section 7 Section 7 Section 8 Section 8 Section 8 Section 9 Section 9 Section 9 Section 10 Section 10 Causation Quiz 4 Lab 6 Lab 7 Quiz 5 Lab 8 Quiz 6 Lab 9 Lab 10 Quiz 7 Lab 11 Quiz 8 Lab 12, Review Final Quiz .

Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed Mon Wed

Fall 2010 Dates to Remember: Classes Begin Last Day to Drop Labor Day Tuition Due Fall Break Last Day to Withdraw Thanksgiving Break Last Day of Classes Grades Available

Mon, August 23 Wed, September 1 Mon, September 6 Tue, September 7 Mon-Sat, Oct 11-16 Fri, October 22 Thu-Fri, November 25-26 Fri, December 10 Tue, December 28

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Assigned Reading: Section: Additional Readings:

Available on the Web:

Available on Electronic Reserve through the Marriott Library: X X X X X X X X X X

Introduction Section 1 Section 1 Section 1 & 2 Section 2 Section 2 Section 3 Section 3 Section 4 Section 4

Section 4 Section 4 Section 4

Trends in Cancer Mortality by Primary Cancer Site, 1992-2001 Nations Leading Alarmists Excited about Bird Flu Risk of Myocardial Infarction and Stroke after Acute Infection or Vaccination Plasma Organochlorine Levels and the Risk of Breast Cancer Transmission of Norwalk Virus During a Football game Bovine Spongiform Encephalopathy in U.S. Estimates of global and regional potential health gains from reducing multiple major risk factors In-Hospital Mortality Chart Multiplicity in randomised trials I: endpoints and treatments Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injuryoutcomes at 6 months Noncardiovascular Disease Outcomes During 6.8 Years of Hormone Therapy Failure of Estrogen Plus Progestin Therapy for Prevention Risks and Benefits of Estrogen Plus Progestin

http://www.theonion.com/news /index.php?issue=4105&n=1

http://jama.amaassn.org/cgi/content/full/28 8/1/58 http://jama.amaassn.org/cgi/reprint/288/3/3 66.pdf http://jama.amaassn.org/cgi/reprint/288/3/3 21.pdf

X X X

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Section 4 Section 4 Section 4 Section 4 Section 4 Section 4 Section 4 Section 4 Section 4 Section 5 Section 5

Mortality in Relation to Smoking The Lancet: Saturday 13 August 1988 Plasma Organochlorine Levels and the Risk of Breast Cancer Extended Work Shifts and the Risk of Motor Vehicle Crashes among Interns Epi 2: Compared to what? Finding controls for case-control studies Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with HPV types 16 and 18 in YW Endometrial cancer and hormonereplacement therapy in the Million Women Study Meta-Analysis: High-Dosage Vitamin E Supplementation May Increase All-Cause Mortality Oral Erythromycin and the Risk of Sudden Death from Cardiac Causes Risk of Community-Acquired Pneumonia and Use of Gastric Acid-Suppressive Drugs Major Risk Factors for Aneurysmal Subarachnoid Hemorrhage in the Young Are Modifiable

http://bmj.bmjjournals.com/cgi/content/ full/328/7455/1519

X X X X X X X X X

http://stroke.ahajournals.org/cgi/ reprint/34/6/1375?maxtoshow=&HITS=10&hits =10&RESULTFORMAT=&fulltext=Subject+ Features+and+Risk+of+Aneurysmal+SAH&searched =1092338817115_4946&stored_search=&FIRSTINDEX =0&search_url=http%3A%2F%2Fstroke.ahajournals.org %2Fcgi%2Fsearch&journalcode=strokeaha

Section 5

Section 5 Section 6

Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial Risk of Community-Acquired Pneumonia and Use of Gastric AcidSuppressive Drugs The Canadian C-Spine Rule versus the

http://jama.ama-assn.org/cgi/content/full/292/16/1955 http://content.nejm.org/cgi

X X

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Section 6 Section 6 Section 6 Section 9 Section 9 Section 9 Section 10 Section 10 Section 10 Section 10 Section 10

Additional Readings: Additional Readings: Additional

NEXUS Regression of low-grade squamous intraepithelial lesions in young women Efficacy of MRI and Mammography for Breast-Cancer Screening in Women with a Familial or Genetic Predisposition Refining clinical diagnosis with likelihood ratios Estrogen Plus Progestin and the Incidence of Dementia and Mild Cognitive Impairment in Postmenopausal Women The Environment and Disease: Association or Causation? Comparison of Causes of Death During 1994-1998 Between LDS and non-LDS in Utah The Empire of Alarmists Strike back CDC detectives study obesity outbreak in West Virginia Endometrial cancer and hormonereplacement therapy in the Million Women Study Risk Factors for Autism: Perinatal Factors, Parental Psychiatric History, and Socioeconomic Status Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebocontrolled trial Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis Associations between breast cancer risk factors and religious practices in Utah Impact of the LDS Churchs Health

/content/abstract/349/26/2510 X X http://jama.ama-assn.org/cgi/reprint/289/20/2651.pdf X X X http://www.techcentralstation.com/060805E.html http://www.kentucky.com/mld/kentucky/11803022.htm X X X X X

http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6T1B4DH1SM9-133&_cdi=4886&_user=990933&_orig=search&_coverDate=10%2F09%2F2004&_qd =1&_sk=996350557&view=c&wchp=dGLbVtzzSkWW&md5=21d1d8c791e8a334b7e782a65fe55094&ie=/sdarticle.pdf

X X

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Readings:

Doctrine on Deaths from Diseases and Conditions Associated with Cigarette Smoking

Articles may be accessed from home. If you have Internet Access follow these steps: 1. 2. 3. 4. Type www.t-proxy.lib.utah.edu or https://t-proxy.lib.utah.edu into your address bar web browser: i.e. Internet Explorer Netscape Safari etc. Use your Network ID (NID) (this is the same I.D. and password you use to register, check your grades and log into the computers in the Multi-Media Center). An alphabetized list of databases will be displayed. E-Reserve materials are listed as Marriott Library E-Reserves. The Reserve Catalog is displayed for you to type in your Course or Professor. If you have problems, please call the Multi-Media Center, 581-6494 or 581-4808. They will be happy to assist you.

Table of Contents

Section 1: Epidemiology as a Science............................................................................................................2 Section 2: Disease Diagnosis and Classification.......................................................................................20 Section 3: Measurements of Disease............................................................................................................33 Section 4: Study Design...............................................................................................................................54 Section 5: Measurement and Interpretation of Risk.....................................................................................84 Section 6: Screening for Disease and the Effects of Misclassification of Exposure and Disease..............116 Section 7: Identifying Extraneous Factors and Controlling for Factors that Change Relative Risks.........135 Section 8: Matching....................................................................................................................................174 Section 9: Linear Models, Multiple Levels of Exposure and Logistic Regression....................................190 Section 10: Causation and Statistical Significance.....................................................................................211