Académique Documents
Professionnel Documents
Culture Documents
Medunsa, Pretoria
14-18 February 2011
• Introduction to Epidemiology
- Basic concepts and uses in Public Health
• Inferential Statistics:
- Theoretical Population and Sampling
- Estimation or Hypothesis testing
• Basic epidemiological study designs
- Diagnostic, Prognostic, Interventional, Etiognostic
- Error: precision and validity
• Summarizing and presenting data in tables
and graphs
1
Scheme, continued
• Inferential statistics for one group, two groups
and more than two groups
- Parametric and non-parametric
• Regression, multiple regression basic
concepts:
- Linear
- Logistic (Binary-)
- Cox
• Advanced Statistics as input for research
design
• Intervention Research and RCT
2
Introduction to Epidemiology:
Basic concepts and uses of
Epidemiology in public Health
Medunsa, Pretoria
14-18 February 2011
4
History of Epidemiology
Where do we come from?
John Snow?
5
History of Epidemiology
William Farr (1807-1883)
Hygology (Hygiene)
Vital Statistics
Cholera epidemic
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History of Epidemiology
William Farr (1807-1883)
‘Miasma Theory’
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History of Epidemiology
John Snow (1813-1858)
‘Germ Theory’
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History of Epidemiology
John Snow (1813-1858)
Mapping
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History of Epidemiology
John Snow (1813-1858)
‘Southwark and
Vauxhall company’
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History of Epidemiology
John Snow & William Farr
Analysis by Farr
district water supply Population Deaths due to Cholera mortality
cholera pro mille
Southwark & Vauxhall Cy 167.654 844 5,0
Lambeth Cy 19.133 18 0,9
Both companies 300.148 652 2,2
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History of Epidemiology
What is striking?
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History of Epidemiology
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History of Epidemiology
John Snow (1813-1858)
Explanation:
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History of Epidemiology
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History of Epidemiology
Janet Lane-Claypon (1877-1967):
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Epidemiology, nowadays…
• Epidemiology is no longer the exclusive
activity for the Public Health Professional
• Clinical Epidemiology
• Genetic Epidemiology
• …
17
Epidemiology, Quo vadis?
• Epidemiology: where are we going?
• EBM
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Evidence Based Medicine (EBM)
BMJ 1996;312:71-72 (13 January)
David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W
Scott Richardson
Editorials
Evidence based medicine: what it is and what it isn't
Evidence based medicine is not restricted to randomised trials and meta-
analyses. It involves tracking down the best external evidence with which to
answer our clinical questions. To find out about the accuracy of a diagnostic test,
we need to find proper cross sectional studies of patients clinically suspected of
harbouring the relevant disorder, not a randomised trial. For a question about
prognosis, we need proper follow up studies of patients assembled at a uniform,
early point in the clinical course of their disease. And sometimes the evidence
we need will come from the basic sciences such as genetics or immunology.
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EBM
It is when asking questions about therapy that we should try to avoid the non-
experimental approaches, since these routinely lead to false positive conclusions
about efficacy. Because the randomised trial, and especially the systematic
review of several randomised trials, is so much more likely to inform us and so
much less likely to mislead us, it has become the "gold standard" for judging
whether a treatment does more good than harm. However, some questions about
therapy do not require randomised trials (successful interventions for otherwise
fatal conditions) or cannot wait for the trials to be conducted. And if no
randomised trial has been carried out for our patient's predicament, we must
follow the trail to the next best external evidence and work from there.
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EBM
Levels of evidence
Level Therapy (prevention) Prognosis Diagnosis
Aetiology (harm)
1 RCT (SR/ind.) Inception cohort study Level1 diagnostic
(SR/ind.) study/ cohort study
4 Case series (poor cohort or case Case series (poor cohort Case control study
control study) study)
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List of study design features
Q-
RC RC NR CB PC RC HC NC
T T CT A S S T C CC XS BA CR/CS
Was there a comparison:
between two or more groups receiving
different interventions? Y Y Y Y Y Y Y Y Y Y N N
with the same group over time? P P N Y N N N N N N Y N
Were participants allocated to groups by:
Concealed randomization? Y N N N N N N N N N na na
Quasi-randomization? N Y N N N N N N N N na na
By other action of researchers? N N Y P N N N N N N na na
Time differences? N N N N N N Y N N N na na
Location differences? N N P P P P P na na na na na
Treatment decisions? N N N P P P N N N P na na
Patient preferences? N N N P P P N N N P na na
On the basis of outcome? N N N N N N N Y Y P na na
Which parts of the study were prospective:
Identification of participants? Y Y Y P Y N P* Y N N P P
Assessment of baseline and treatment
allocation? Y Y Y P Y N P* Y N N na na
Assessment of outcomes? Y Y Y P Y P P Y N N P P
Generation of hypotheses? Y Y Y Y Y Y Y Y P P P na
On what variables was comparability
between groups assessed:
Potential confounders? P P P P P P P P P P N na
Baseline assessment of outcome
variables? P P P Y P P P N N N N na
Y=Yes; P=Possibly; P*=Possible for one group only; N=No; na=not applicable. NB. Note that ‘possibly’ is used in the table to indicate cells
where either ‘Y’ or ‘N’ may be the case. It should not be used as a response option when applying the checklist; if uncertain, the response
should be ‘can’t tell’.
RCT=Randomized controlled trial; Q-RCT=Quasi-randomized controlled trial; NRCT=Non-randomized controlled trial; CBA=Controlled
before-and-after study; PCS=Prospective cohort study; RCS=Retrospective cohort study; HCT=Historically controlled trial; NCC=Nested
case-control study; CC=Case-control study; XS=Cross-sectional study; BA=Before-and-after comparison; CR/CS=Case report/Case series
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The Principles of The Cochrane
Collaboration
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Epidemiology, Quo vadis?
• Epidemiology: where are we going?
• EBM
• Poor concepts
• Illness, disease, sickness
• Frequencies
• Study object
• Study design
• Model analysis versus data analysis
24
Epidemiology, Quo vadis?
• Epidemiology: where are we going?
• EBM
• Poor concepts
• Urge for publications and PhD-theses
• Quantity vs Quality
• …
25
Epidemiology, Quo vadis?
• Epidemiology: where are we going?
• EBM
• Poor concepts
• Urge for publications and PhD-theses
26
‘Epidemiology, Quo vadis?’
Eur J Epidemiol. 2004;19(8):713-8.
Miettinen OS.
In our etiologic research, we epidemiologists need to leave behind the concepts of 'cohort' study
and 'case-control' study and adopt that of the etiologic study as the singular substitute for these.
We then need to realize that the etiologic study is well suited to be viewed as paradigmal for
intervention studies. We finally need to become serious about object design before methods
design in both etiologic and intervention research. Once these developments have occurred,
we'll be ready for truly meaningful research to advance the knowledge base of both types of
causality-oriented 'gnosis' in the practice of clinical medicine, etiognosis and intervention-
prognosis; and descriptive-prognostic study we'll see as inherent in any intervention-prognostic
study. As for diagnostic research, then, we need to come to see it as nothing but a special case
of our familiar descriptive prevalence research. Because of this readily attainable theoretical
readiness peculiar to us research epidemiologists, and for other reasons besides, only we can
assume the central role in the production of the knowledge base for scientific medicine. We
consequently have the obligation to assume this larger and higher, meta-epidemiologic mission--
and some even higher ones besides.
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Object design before study design
Meta-epidemiology:
DIA GNOSTIC
ETIO GNOSTIC
PRO GNOSTIC
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Object design before study design
• Diagnosis
• Etiognosis
• Prognosis
Questions:
• Symptomatic (sick) person: is illness
present ?
• Person with illness: why ?
• Person with illness: will he be cured ?
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Object design before study design
Examples:
Measuring
Database
Statistical test (t-test)
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Object design before study design
Examples:
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Object design before study design
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Object design before study design
Sampling
What is sampling?
How would you sample?
Measuring
Analysis
Presentation of results
33
Object design before study design
Mean of
systolic BP
(mm Hg), P
150
P = 100mmHg + (1 mm Hg/yr).A
100
50
0
0 20 40 60
Age (yr), A
34
Object design before study design
LEEFTIJD vs. SBD
SBD = 97,775 + ,55625 * LEEFTIJD
Correlation: r = ,47883
180
160
140
SBD
120
100
80 Regression
15 25 35 45 55 65 75 95% confid.
LEEFTIJD
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Object design before study design
Presentation of results
36
Object design before study design
Presentation of results
37
Object design before study design
‘Study objects’ (questions):
What are the questions (clinical, public health) that need for scientific
answers (abstract, objective, rational):
Will the patient still be alive in five years from now, when choosing for this
intervention?
What are the causes of relapse/death in this patient and what was the
contribution of the intervention?
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Directionality
‘Study Objects’ (Questions):
PROGNOSIS
Future, taking into account the present, the past en when interventional
conditional on part of the future
DIAGNOSIS
Present, taking into account the present and the past
ETIOGNOSIS
Present, taking into account the past
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Epidemiological outcomes
‘Study methods’ (type):
PROGNOSIS
Cumulative incidence
Surviving probability
Incidence density
DIAGNOSIS
Prevalence
Comparison: ROC, area under the curve
ETIOGNOSIS
Incidence density, (Cumulative incidence, Prevalence?)
Do not over-simplify...
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Directionality
‘Study methods’ (type):
PROGNOSIS
Cumulative incidence
Paradigm: RCT: Experimental cohort study
DIAGNOSIS
Prevalence study
Cross-sectional study
ETIOGNOSIS
Incidence density study, Prevalence study
Case-control study
Do not over-simplify...
41
Object design before study design
Meta-epidemiological study objects:
DIAGNOSTIC
Current prevalence (T0) as a descriptive function of diagnostic
indicators (current, past)
ETIOGNOSTIC
Current incidence (T0) as a causal function of exposure in the past
(risk-indicators)
PROGNOSTIC
Interventional: Future (post-T0) incidence/prevalence as a causal
function of future intervention
Otherwise: Future (post-T0) incidence/prevalence as a descriptive
function of prognostic indicators (current)
42