Descriptive Epidemiology Lecture Note-1

Basic Epidemiology
1

EPIDEMIOLOGIC VARIABLES

In descriptive epidemiology data is organized
according to time, place and person. These
three characteristics are sometimes called
epidemiologic variables.

Compiling data by time, place and person is
done in order to:
Become familiar with the data and the extent
of the problem.

2
EPIDEMIOLOGIC VARIABLES
Provide a detailed description of the health of
a population that is easily communicated.

Identify the population at greater risk of
acquiring a particular disease. This
information provides important clues to the
causes of a disease, and these clues can be
turned into testable hypotheses.
3

Some details on Epidemiologic Variables:

TIME:
In Epidemiology knowing the time where the
diseases occurred will help to define:

Epidemic period
Secular trends
Seasonality

4
How do you represent the change in disease
rates over time?
The change in disease rates over time is
usually shown on a graph, with number or
rate of cases or deaths on the vertical axis and
the time period in a horizontal axis.

5
We can thereby define:
The epidemic period: is a period during which
the number of cases reported is greater than
normal. The epidemic curve is generally
represented by a histogram.
Secular trends: Which are long term trends in
disease incidence (over years)?
Secular trends are useful to predict the future
and to evaluate policies and programs.

6
Seasonality: Seasonality in diseases distribution
can be identified by graphing the occurrence
of a disease by week or month over the course
of the year.
Seasonal patterns may suggest hypotheses
about how an infection is transmitted,
behavioral risk factors, or other possible
contributing factors.

7
PLACE:
By analyzing data by place, we can get an idea
where the disease agent occurs, what may
carry it, and how it spreads.

8
Where the occurrence of a diseases is associated
with a place, we can infer that factors which
increase the risk of a disease are present in either
the persons living there (HOST FACTOR) or in the
environment(ENVIRONMENTAL FACTOR), or both.

A spot map may be used to represent the location of
each cases home or workplace, or where we believe
cases were exposed.

9
PERSON:
Person data may be shown in tables or graphs and
may reflect the inherit characteristics of people
(age, gender, ethnic group) their acquired
characteristics (educational, marital, immune or
nutritional status), their activities (Occupation,
leisure time activities, use of alcohol, tobacco,
medication), or the condition in which they live
(socio economic status, access to health)

10
AGE: Age is probably the single most important
person attribute in descriptive
epidemiology. Data should be analyzed by age
groups which are narrow enough (often 5
years) to detect any age related patterns.

SEX: sex related differences in diseases
incidence can provide important clues to
causes of disease.

11
ETHNIC GROUP AND SOCIO ECONOMIC
STATUS: These are also important variables in
descriptive epidemiology.

These differences may also be related to other
factors, such as living conditions, behavioral
patterns, or access to health care which may
also affect patterns of health and diseases.

12

Measures of Disease Occurrence

The number of cases in a given community
can give more epidemiologic sense if they are
related to the size of the population.

Such tie of the number of cases with the
population size can established by calculating
ratios, proportions, and rates.
13
Measures of Disease Occurrence
These measures provide useful information
about the probability of occurrence of health
events and population at a higher risk of
acquiring the disease. They are also
important in designing an appropriate public
health interventions.

14
What is a variable?
A VARIABLE is a characteristic of a person,
object or phenomenon which can take on
different values. These may be in the form of
numbers (e.g., age) or non-numerical
characteristics (e.g., sex).

(Handout)

15

RATIOS, PROPORTIONS AND RATES:

Frequencies for specific variables may be
expressed in frequency distributions for
ORDINAL (with values ranked in a graded
order) variables.

ORDINAL scale data may be further
summarized with measures of central
location and measures of dispersion.

16
Many NOMINAL (with names or categories)
variables have only two categories (e.g., alive
or dead, sick or well, exposed or unexposed).

The frequency measures we use with such
dichotomous variables are rates, ratios and
proportions.

17
All the three measures use the same formula.
Ratio, proportion and rates = x x 10
n

y
Relate the number of cases to the size of the
population in which they occurred.

They reflect the probability of occurrence of a
particular event.

18
Use of such measures:
In health and public health fields:
Help to identify high risk groups which can be
targeted for special interventions. These
groups can be studied to identify risk factors
which are related to the occurrence of
diseases.

19
RATIO:
A ratio is the expression of the relationship
between a numerator and denominator which
may involve either an interval in time or may
be instantaneous in time. The ratio is the
form:
X: Y or x x k
Y

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Where
X = number of events or items counted and not
necessary a portion of y
Y = number of events or items counted and not
necessary a population of persons exposed to
the risk.
K= a base, as in the case of the rates, but usually
1 or 100 for the purpose of expressing ratios.

21
In ratio, the value of x and y may be completely
independent, or x may be included in y.
Example: The sex of children attending an
immunization clinic could be compared in either of
the following ways.
( 1) female/male (2) female/all
In the first option x (female) is completely independent
of y (male). In the second, x (female) is included in y
(all).
Both examples are ratios.

22
PROPORTION:
A proportion is the second type of frequency
measure used with dichotomous variables, is ratio in
which x is included in y or in other words. It s an
expression in which the numerator is always included
in the denominator, and the base is equal to 100.

Therefore proportion is always expressed in as a
percent.

23
RATE:
The third type of frequency measure used with
dichotomous variables, rate, is often a proportion.
With an added dimension.

Rate measures the occurrence of an event in a
population over time.
A rate is often expressed in the form of:
X x k
Y

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Where:
X = number of times an event has occurred during a
specific interval of time.
Y = number of persons exposed to the risk of the event
during the same interval
K= some round number (100, 1000, 10,000, 100,000
etc) or base depending upon the relative magnitude
of x and y.

25
The basic formula for a rate is as follows:

Rate = Number of cases or events occurring during a given time period X 10
n

Population at risk during the same period

26
Notice the three most important aspects of this formula:
The persons in the numerator must reflect the
population from which the cases in the denominator
arose.
The counts in the numerator and denominator
should cover the same time period.
In theory, the persons in the denominator must be
at risk for the event, that is, it should have been
possible for them to experience the same or similar
event.
27
Points to consider about rates, ratios and proportions:

When we call a measure a ratio we usually mean a
non proportional ratio.

When we call a measure a proportion we usually
mean a proportional ratio that does not measure an
event over time.

When we use the term rate, we frequently refer to
a proportional ratio that does measure an event in
a population over time.

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INDEX:
An index is the best available approximation to the
true rate. This usually occurs when we are unable to
count directly the number at risk (the denominator)
and use something else which we can count to give
us an impression of the number at risk.

29
Example: The calculation of MMR
The MMR calculated with approximation of a
denominator is not at all a rate in a strict
sense, but is nevertheless a useful index which
gives an impression of the risk of dying
associated with pregnancy.

30

Exercise
31

Use of RATIOS, PROPORTIONS, and RATES

In public health, we use ratios and
proportions to characterize populations by
age, sex, race, exposures and other variables.

We also use ratios, proportions, and most
important rates to describe three aspects of
the human condition: morbidity (diseases),
mortality (death) and natality.

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Condition: Morbidity (disease)
Ratios: Risk ratio (relative risk)
Rate ratio
Odds ratio

Proportions: Attributable proportion
Point prevalence

33
Rates: Incidence rate,
Attack rate,
Secondary attack rate,
Person time rate,
Period prevalence

34
Condition: Mortality (death)
Ratios: Date to case ratio
Maternal mortality rate
Proportionate mortality ratio
Post neonatal mortality ratio
Proportions:
Proportionate mortality
Case fatality rate

35
Rates: Crude mortality rate
Case specific mortality rate
Sex specific morality rate
Age specific morality rate
Race specific morality rate
Age adjusted morality rate
Neonatal morality rate
Infant mortality rate
Years of potential life lost rate

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Condition: Natality (birth)
Ratios:
Male to female ratio at Birth
Proportions:
Low Birth Weight Ratio
Rates:
Crude Birth Rate
Crude Fertility Rate
Crude Rate of Natural Increase

37
MORBIDITY FREQUENCY MEASURES:
To describe the presence of disease in a
population, or the probability (risk) of its
occurrence, we use one of the morbidity
frequency measures.

In public health terms, disease includes
illnesses, injuries, or disability.

38
Morbidity rates measure the frequency of
illness within specific populations.
In morbidity rates, time and place must
always be specified
The most commonly used morbidity rates
include point prevalence, period prevalence,
and incidence and attack rate.

39
Frequently used measures of morbidity
INCIDENCE: Incidence is a measure of the frequency
with which an event, such as a new case of
illnesses, occurs in a population over a period of
time.
These new cases of a disease occur either through
the onset of the disease on current members of the
population or through immigration of persons
already ill in the population.

40
Incidence rates are the most common way of
measuring and comparing the frequency of
disease in a population.

Incidence rate expresses the probability or
risk of an illness in a population over a period
of time.

41
Since incidence rate is a measure of risk,
when one population has a higher incidence
of diseases than another, we say that the first
population is at higher risk of developing
disease than the second, all other factors
being equal. We can also express this by
saying that the first population is a high risk
group relative to the second population.

42

Incidence rate: New cases occurring during a given period x 10
n

Population at risk during the same time period
Numerator (x):
Number of new cases of specified disease reported
during a given time interval
Denominator (y):
Average population during time interval
Expressed per number of Risk (10
n
):
Varies 10
n
where n=2,3,4,5,6

43

Exercise 2
44
PREVALENCE:
Prevalence, sometimes referred to as
prevalence rate, is a proportion of persons in
a population who have a particular disease or
attribute at a specified point in time or over a
period of time.
Prevalence measures the frequency of all
current cases of diseases (old and new) and is
of two types:

45
The general formula of prevalence is:

Prevalence = all new and pre existing cases during a given time period x 10
n

Population during the same time period

The formula for prevalence of an attribute is:
Prevalence = Persons having a particular attribute during a given period of time x 10
n

Population during the same time period
The value of 10
n
may be 1,000, 100,000, or even 1,000,000 for rare traits and
for most diseases.

46
Prevalence is commonly of TWO types:

Point Prevalence: Point Prevalence measures the
frequency of all current cases of diseases (old and
new) at a given instant in a time.

Point prevalence would help us to know how much of a
particular disease is present in a population at a
single point in time. To get a snap shot look at the
population with regard to that diseases.

47
Measure: (Point prevalence)
Numerator (x):
Number of current cases (new and old) of a
specified disease at a given point in time
Denominator (y):
Estimated population at the same point in time
n
):
Varies 10
n
where n=2,3,4,5,6

48
Period Prevalence: Period Prevalence measures the frequency
of all current cases of diseases (old and new) for a prescribed
period of time.
Measure: (Period prevalence)
Numerator (x):
Number of current cases (new and old) of a specified disease
over a given time interval
Denominator (y):
Estimated population at mid interval
n
):
Varies 10
n
where n=2,3,4,5,6

49
Some points to note:
A case is counted in prevalence until death or
recovery occurs.
Prevalence is based on incidence (risk) and duration
of disease. High prevalence of a disease within a
population may reflect high risk or prolonged
survival without cure. Conversely low prevalence
may reflect low incidence, a rapidly fatal process, or
rapid recovery.

50
Some points to note:
We often use prevalence rather than
incidence to measure the occurrence of
chronic diseases such as osteoarthritis which
have long duration and dates of onset which
are difficult to pin point.

51
ATTACK RATE: Attack rate is an incidence rate
usually expressed as a percent, used for particular
populations (the population at risk), and observed
for limited period of time, as an epidemic. The
attack rate is usually expressed as a percent, so 10n
equals 100.

Attack rate = Number of new cases among the population during the period x 100
Population at risk at the beginning of the period

52
Measure: (Attack Rate)

Numerator (x):
Number of new cases of specified disease reported during
an epidemic period

Denominator (y):
Population at the start of the epidemic period

n
):
Varies 10
n
where n=2,3,4,5,6

53
Points to note:
Attack rate is a proportion the person in the
numerator is also in the denominator. This
proportion is a measure of probability or risk of
becoming a case.

54
Secondary Attack Rate:
A secondary attack rate is a measure of the
frequency of new cases of a disease among
the contacts of known cases.
55
S-Attack rate = Number cases among contacts of primary cases during the period x 10
n

Total number of contacts

Numerator (x):
Number of new cases of specified disease among contacts of
known cases

Denominator (y):
Size of contact population at risk
n
):
Varies 10
n
where n=2,3,4,5,6

56
Person Time Rate:
A person time rate is the type of incidence rate that
directly incorporates time into the denominator.
Typically, each person is observed from a set
beginning point to an established end point (onset
of disease, death, migration out of the study, end of
the study). The numerator is still the number of
new cases, but the denominator is a little different.
The denominator is the sum of the time each
person is observed, totaled for all persons.

57
Person Time Rate = Number of cases during observation period x 10
n

Time each person was observed, totaled for all persons

For example, a person enrolled in a study who
develops the disease of interest 5 years later
contributes 5 person years to the denominator. A
person who is disease free at one year and who is
then lost to follow up contributes just that one-
person year to the denominator.

58
Person time rates are often used in cohort (follow up
studies) studies of disease with long incubation or latency
periods, such as some occupationally related diseases, AIDS
and Chronic diseases.

The attack rate is more useful when we are interested in the
proportion of a population at risk who becomes ill over a
brief period, particularly during the course of an epidemic.
The person-time rate is more useful when we are interested
in how quickly people develop illness, assuming a constant
rate over time.

59
Day Three
Morbidity and mortality measurements that are
useful to measure strength of Association between
exposure and outcomes:
Risk Ratio or Relative Risk
Odds ratio
Attributable risk
Attributable risk proportion

60
Relative Risk (RR) expresses the risk of
developing a certain disease in people
exposed to a certain factors as compared to
the risk of disease in people not exposed to
that factor.

61
Since the risk of developing disease is measured by
incidence rate, the relative risk is calculated as
follows:
RR = Incidence rate among exposed
Incidence Rate among non Exposed

The relative risk, as in all measures of associations,
can also be used to compare risk of death, accident
or any other possible outcome of an exposure.
62
Relative risk, compares the risk of some
health-related event such as diseases or death
in two groups.
The two groups are typically differentiated by
demographic factors such as sex (e.g., males
versus females) or by exposure to a suspected
risk factor (e.g., consumption of potato salad
or not).
63
Often, you will see the group of primary interest
labeled the exposed group, and the comparison
group labeled the unexposed group.

In calculating RR, we place the group that we are
primarily interested in the numerator; we place the
group we are comparing them with in the
denominator:

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A risk ratio of 1.0 indicates identical risk in the two
groups.

A risk ratio greater than 1.0 indicates an increased
risk for the numerator group,

While a risk ratio less than 1.0 indicates a decreased
risk for the numerator group (perhaps showing a
protective of the factor among the exposed
numerator group.

65
A general guideline as to how the strength of
association measured

66
Relative Risk (Risk Ratio) Strength of Association
1.2-1.4 Weak
1.5-2.9 Moderate
3.0-10 or more Strong
One limitation of relative risk is that it shows the risk
of developing a disease associated with an exposure
only in relation to the absence of the exposure.

It does not show the actual or absolute risk of
developing a disease, which is measured by
incidence rate.
67
Rate Ratio:
A rate ratio compares two groups in terms of
incidence rates, person-time rates, or mortality rates.

The rate ratio quantifies the relative incidence of a
particular heath event into specified population (one
exposed to a suspected causative agent, one
unexposed) over a specified period.

68
Rate Ratio:
Like the risk ratio, the two groups are typically differentiated by
demographic factors or by exposure to a suspected causative
agent. The rate for the group of primary interest is divided by
the rate for the comparison group.

Rate ratio = Rate for group of primary interest x 1
Rate for comparison group

The interpretation of the value of rate ratio is similar to that of
the risk ratio.

69
Odds Ratio:

An odds ratio is another type of measure of
association, which quantifies the relationship
between an exposure and health outcome from a
comparative study.

70
Odds ratio:
The design of a case control study does not allow the
determination of incidence rate, therefore the direct
calculation of relative risk is not possible in such
studies.

An indirect estimate of the relative risk in case control
studies is given by odds ratio (OR)

71
The odds ratio is calculated using the following formula :
Odds ratio = ratio of diseased to non diseased in exposed
ratio of diseased to non diseased in unexposed
Odds ratio = ad
bc
a = number of persons with disease and with exposure of
interest
b = number of persons without disease, but with exposure of
interest

72
c= number of persons with diseases, but without exposure of
interest
d= number of persons without diseases, but without exposure
of interest
a+c= total number of persons with disease (cases)
b+d= total number of persons without disease (controls)

Note that in the two- by-two table, under the pellagra
example , the same letters (a, b, c, and d) are used to label the
four cells in the table.
73
The odds ratio is some times called the cross-
product ratio, because the numerator is the product
of cell a and cell d, while the denominator is the
product of cell b to cell c (for the denominator)
creates and x or cross on the two- by-two table.

74
Example of
To quantity the relationship between pellagra and
sex as shown in example in the Goldburg study, the
odds ratio is calculated as:
Odds ratio:
46x 1,401
= 2.5

1,438x18

Notice that the odds ratio of 2.5 is fairly close to the
risk ratio of 2.4. That is one of the attractive
features of the odds ratio.

75
Example 5:

The odds ratio can be used as an estimate of relative
risk only if certain conditions are met. What are
those conditions?

76
Attributable risk:
The attributable risk (AR) measures the component of
the incidence rate of a certain outcome which can be
attributed to certain exposure, assuming the
exposure is a cause of the outcome.

AR= Incidence rate of outcome among exposed - Incidence rate of outcome among
non exposed
77
Taking the example of smoking and lung cancer:

Incidence rate of lung cancer among non smokers = Incidence rate due to all
risk factors other than smoking

Incidence rate of lung cancer among smokers = Incidence rate among
smokers due to smoking + Incidence rate due to all risk factors other than
smoking

Incidence rate of lung cancer among smokers = AR+ Incidence rate among
non-smokers
AR= Incidence rate among smokers - Incidence rate among non-smokers
78
Point to note:
Unlike the relative risk, which is dimensionless, as a type of
incidence rate, AR is expressed per a certain population size
per unit time.
While the relative risk is better for quantifying strengthen of
association, the attributable risk is more useful from the
public health point of view, in that it tells us how many cases
of disease in exposed people could have been prevented by
eliminating the exposure assuming the exposure is the causal
agent for the disease.
Example 6 question 1
79
Attributable Proportion

The attributable proportion, also known as the
attributable risk percent, is a measure of the public
health impact of a causative factor.
In calculating this measure, we assume that the
occurrence of disease in a group not exposed to the
factor under study represents the baseline or
expected risk for that disease; we will attribute any
risk above that level in the exposed group to their
exposure.

80
Thus, the attributable proportion is the proportion
of disease in an exposed group attributable to the
exposure. It represents the expected reduction in
disease if the exposure could be removed (or never
existed).
For two specified subpopulations, identified as
exposed or unexposed to a suspected risk factor,
with risk of a health event recorded over a specified
period,

81

Attributable Proportion= (Risk for exposed group)- (Risk for unexposed group)x 100

Risk for exposed group

82
Table : Death rates and rate ratios from lung cancer by daily cigarette consumption, Doll
and Hill physician follow- up study, 1951-1961

83
Cigarettes per
day
Date rates per
1000 per year
Attributable
proportion
0 (none smokers) 0.07
1-14 0.57
15-24 1.39
25+ 2.27
Mortality Frequency Measures
Mortality Rates
A mortality rate is a measure of the frequency of
occurrence of death in a defined population during
a specified interval. For a defined population, over a
specified period of time.

When mortality rates are based on vital statistics (e.g., counts
of death certificates), the denominator most commonly used
is the size of the population at the middle of the time period.
84

85
Neonatal- birth up to 28days
Post neonatal- from 28 up to 1years period
Infant = one years old and below
Age-specific mortality rate
neonatal,
postneonatal, and
infant mortality rates.
86
Infant mortality rate
The infant mortality rate is one of the most
commonly used measures for comparing
health services among nations.
87
Maternal mortality rate
The maternal mortality rate is really a ratio
used to measure mortality associated with
pregnancy.
The numerator is the number of deaths
assigned to causes related to pregnancy
during a given time period.
The denominator is the number of live births
reported during the same time period.

88
Sex-specific mortality rate
A sex-specific mortality rate is a mortality rate
among either males or females.
Both numerator and denominator are limited
to the one sex.
Race-specific mortality rate
A race-specific mortality rate is a mortality
rate limited to a specified racial group.
Both numerator and denominator are limited
to the specified race.
89
Combinations of specific mortality rates
Mortality rates can be further refined to
combinations that are cause-specific, age-
specific, sex-specific, and/or race-specific.
For example, the mortality rate attributed to HIV
among 25- to 44-year-olds in the United States in
1987 was 9,820 deaths among 77.6 million 25- to
44-yearolds, or 12.7 per 100,000. This is a cause-
and age-specific mortality rate, because it is
limited to one cause (HIV infection) and one age
group (25 to 44 years).
90
Age-adjusted mortality rates
Often, we want to compare the mortality experience of
different populations. However, since mortality rates increase
with age, a higher mortality rate in one population than in
another may simply reflect that the first population is older
than the second.
Statistical techniques are used to adjust or standardize the
rates in the populations to be compared which eliminates
the effect of different age distributions in the different
populations.
Mortality rates computed with these techniques are called
age-adjusted or age-standardized mortality rates.
91
Death-to-case ratio
The death-to-case ratio is the number of
deaths attributed to a particular disease
during a specified time period divided by the
number of new cases of that disease
identified during the same time period:

the death-to-case ratio is a ratio but not a
proportion.
92
Case-fatality rate
The case-fatality rate is the proportion of
persons with a particular condition (cases)
who die from that condition.
The formula is:

the case-fatality rate is a proportion and
requires that the deaths in the numerator be
limited to the cases in the denominator.
93
Proportionate mortality
Proportionate mortality describes the proportion of deaths in
a specified population over a period of time attributable to
different causes.
Each cause is expressed as a percentage of all deaths, and the
sum of the causes must add to 100%.
These proportions are not mortality rates, since the
denominator is all deaths, not the population in which the
deaths occurred.
For a specified population over a specified period,
94
Years of Potential Life Lost and YPLL
Rate
YPLL is a measure of the impact of premature
mortality on a population.
It is calculated as the sum of the differences between
some predetermined end point and the ages of
death for those who died before that end point.
The two most commonly used end points are age 65
years and average life expectancy.
Because of the way in which YPLL is calculated, this
measure gives more weight to a death the earlier it
occurs.
95
Calculating YPLL from a line listing
1. Eliminate the records of all persons who died
at or after the end point (e.g., age 65 years).
2. For each person who died before the end
point, identify that individuals YPLL by
subtracting the age at death from the end
point.
3. Sum the YPLLs.
96
Calculating YPLL from a frequency
distribution
1. Ensure that age groups break at the end point (e.g., age 65
years). Eliminate all age groups older than the end point.
2. For each age group younger than the end point, identify the
midpoint of the age group

3. For each age group younger than the end point, identify that
age groups YPLL by subtracting the midpoint from the end
point.
4. Calculate age-specific YPLL by multiplying the age groups
YPLL times the number of persons in that age group.
5. Sum the age-specific YPLLs.
97
Years of Potential Life Lost Rate
The Years of Potential Life Lost Rate represents years of
potential life lost per 1,000 population below the age of 65
years (or below the average life expectancy).
YPLL rates should be used to compare premature mortality in
different populations, since YPLL does not take into account
differences in population sizes.
The formula for a YPLL rate is as follows:

We use YPLL rates to compare YPLL in populations of different
sizes.
Because different populations may also have different age
distributions, we commonly calculate age-adjusted YPLL rates to
eliminate the effect of different age distributions in the populations to
be compared.
98
Natality Frequency Measures
Natality measures are used in the area of
maternal and child health and less so in other
areas.
99

100
Summary
Counts of disease and other health events are
important in epidemiology.
Counts are the basis for disease surveillance
and for allocation of resources.
However, a count alone is insufficient for
describing the characteristics of a population
and for determining risk.
For these purposes we use ratios, proportions,
and rates as well as measures of central
location and dispersion.
101
Ratios and proportions are useful for
describing the characteristics of populations.
Proportions and rates are used for quantifying
morbidity and mortality.
From these proportions we can infer risk
among different groups, detect high-risk
groups, and develop hypotheses about
causesi.e., why these groups are at
increased risk.
102
The two primary measures of morbidity are
incidence rates and prevalence.
Incidence rates reflect the occurrence of new
disease in a population;
Prevalence reflects the presence of disease in
a population.
To quantify the association between disease
occurrence and possible risk factors or causes,
we commonly use two measures, relative risk
and odds ratio.
103
Mortality rates have long been the standard
for measuring mortality in a population.
Recently, years of potential life lost and years
of potential life lost rates have gained in
popularity because they focus on premature,
and mostly preventable, mortality.
104
All of these measures are used
when we perform the core
epidemiologic task known as
DESCRIPTIVE EPIDEMIOLOGY
105

Descriptive Epidemiology Lecture Note-1

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Basic Epidemiology

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