Public Health Information Network (PHIN) Series I

is for Epi
Epidemiology basics for non-epidemiologists

Series Overview
Introduction to: The history of Epidemiology Specialties in the field Key terminology, measures, and resources Application of Epidemiological methods

Series I Sessions
Title Epidemiology in the Context of Public Health An Epidemiologists Tool Kit Descriptive and Analytic Epidemiology Surveillance Epidemiology Specialties Applied Date January 12 February 3 March 3

April 7
May 5

What to Expect. . .
Today
Understand the basic terminology and measures used in descriptive and analytic Epidemiology

Session I V Slides
VDH will post PHIN series slides on the following Web site:
http://www.vdh.virginia.gov/EPR/Training.asp

NCCPHP Training Web site: http://www.sph.unc.edu/nccphp/training

Site Sign-in Sheet

Please submit your site sign-in sheet to: Suzi Silverstein Director, Education and Training
Emergency Preparedness & Response Programs

FAX: (804) 225 - 3888

Series I Session III

Descriptive and Analytic Epidemiology

Todays Presenter
Kim Brunette, MPH Epidemiologist North Carolina Center for Public Health Preparedness, Institute for Public Health, UNC Chapel Hill

Session Overview
1. Define descriptive epidemiology 2. Define incidence and prevalence 3. Discuss examples of the use of descriptive data 4. Define analytic epidemiology 5. Discuss different study designs 6. Discuss measures of association 7. Discuss tests of significance

Todays Learning Objectives

Understand the distinction between descriptive and analytic Epidemiology, and their utility in surveillance and outbreak investigations Recognize descriptive and analytic measures used in the Epidemiological literature Know how to interpret data analysis output for measures of association and common statistical tests

Descriptive Epidemiology
Prevalence and Incidence

What is Epidemiology?
Study of the distribution and determinants of states or events in specified populations, and the application of this study to the control of health problems
Study risk associated with exposures Identify and control epidemics Monitor population rates of disease and exposure

What is Epidemiology?
Looking to answer the questions: Who? What? When? Where? Why? How?

Case Definition
A case definition is a set of standard diagnostic criteria that must be fulfilled in order to identify a person as a case of a particular disease Ensures that all persons who are counted as cases actually have the same disease Typically includes clinical criteria (lab results, symptoms, signs) and sometimes restrictions on time, place, and person

Descriptive vs. Analytic Epidemiology

Descriptive Epidemiology deals with the questions: Who, What, When, and Where
Analytic Epidemiology deals with the remaining questions: Why and How

Descriptive Epidemiology
Provides a systematic method for characterizing a health problem Ensures understanding of the basic dimensions of a health problem Helps identify populations at higher risk for the health problem Provides information used for allocation of resources Enables development of testable hypotheses

Descriptive Epidemiology What?

Addresses the question How much? Most basic is a simple count of cases
Good for looking at the burden of disease Not useful for comparing to other groups or populations Race Black White # of Salmonella cases 119 497
http://www.vdh.virginia.gov/epi/Data/race03t.pdf

Pop. size 1,450,675 5,342,532

Prevalence
The number of affected persons present in the population divided by the number of people in the population

# of cases Prevalence = ----------------------------------------# of people in the population

Prevalence Example
In 1999, Virginia reported an estimated 253,040 residents over 20 years of age with diabetes. The US Census Bureau estimated that the 1999 Virginia population over 20 was 5,008,863. 253,040

Prevalence=
5,008,863

= 0.051

In 1999, the prevalence of diabetes in Virginia was 5.1% Can also be expressed as 51 cases per 1,000 residents over 20 years of age

Prevalence
Useful for assessing the burden of disease within a population Valuable for planning Not useful for determining what caused disease

Incidence
The number of new cases of a disease that occur during a specified period of time divided by the number of persons at risk of developing the disease during that period of time # of new cases of disease over a specific period of time Incidence = ------------------------------------------# of persons at risk of disease over that specific period of time

Incidence Example
A study in 2002 examined depression among persons with dementia. The study recruited 201 adults with dementia admitted to a long-term care facility. Of the 201, 91 had a prior diagnosis of depression. Over the first year, 7 adults developed depression. Incidence =

= 0.0636

110 The one year incidence of depression among adults with dementia is 6.36% Can also be expressed as 63.6 (64) cases per 1,000 persons with dementia

Incidence
High incidence represents diseases with high occurrence; low incidence represents diseases with low occurrence Can be used to help determine the causes of disease Can be used to determine the likelihood of developing disease

Prevalence and Incidence

Prevalence is a function of the incidence of disease and the duration of disease

Prevalence and Incidence

Prevalence

= prevalent cases

Prevalence and Incidence

New prevalence

Incidence
Old (baseline) prevalence

No cases die or recover

= prevalent cases

= incident cases

Prevalence and Incidence

= prevalent cases

= incident cases

= deaths or recoveries

Time for you to try it!!!

Descriptive Epidemiology
Person, Place, Time

Descriptive Epidemiology Who? When? Where?

Related to Person, Place, and Time Person
May be characterized by age, race, sex, education, occupation, or other personal variables

Place
May include information on home, workplace, school

Time
May look at time of illness onset, when exposure to risk factors occurred

Person Data
Age and Sex are almost always used in looking at data
Age data are usually grouped intervals will depend on what type of disease / event is being looked at

May be shown in tables or graphs May look at more than one type of person data at once

Data Characterized by Person

http://www.vahealth.org/civp/Injury%20in%20Virginia_Report_2004.pdf

Data Characterized by Person

http://www.vdh.virginia.gov/std/AnnualReport2003.pdf

Data Characterized by Person

http://www.vdh.virginia.gov/epi/cancer/Report99.pdf

Data Characterized by Person

http://www.vahealth.org/chronic/Data_Report_Part_3.pdf

Time Data
Usually shown as a graph
Number / rate of cases on vertical (y) axis Time periods on horizontal (x) axis

Time period will depend on what is being described

Used to show trends, seasonality, day of week / time of day, epidemic period

Number of cases

10

12

Epi Curve for E.Coli outbreak n=108

Date of onset

Data Characterized by Time

http://www.dhhs.state.nc.us/docs/ecoli.htm

10 /1 1/ 20 05 10 /1 3/ 20 05 10 /1 5/ 20 05 10 /1 7/ 20 05 10 /1 9/ 20 05 10 /2 1/ 20 05 10 /2 3/ 20 05 10 /2 5/ 20 05 10 /2 7/ 20 05 10 /2 9/ 20 05 10 /3 1/ 20 05 11 /2 /2 00 5 11 /4 /2 00 5 11 /6 /2 00 5 11 /8 /2 00 11 5 /1 0/ 20 05

Data Characterized by Time

http://www.vdh.virginia.gov/std/HIVSTDTrends.pdf

Data Characterized by Time

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5153a1.htm

Data Characterized by Time

http://www.health.qld.gov.au/phs/Documents/cdu/12776.pdf

Place Data
Can be shown in a table; usually better presented pictorially in a map Two main types of maps used: choropleth and spot
Choropleth maps use different shadings/colors to indicate the count / rate of cases in an area Spot maps show location of individual cases

Data Characterized by Place

http://www.vdh.virginia.gov/epi/Data/region03t.pdf

Data Characterized by Place

http://www.vdh.virginia.gov/epi/Data/Maps2002.pdf

Data Characterized by Place

http://www.vahealth.org/civp/preventsuicideva/epiplan%202004.pdf

Data Characterized by Place

http://www.vahealth.org/civp/preventsuicideva/epiplan%202004.pdf

Data Characterized by Place

Source: Olsen, S.J. et al. N Engl J Med. 2003 Dec 18; 349(25):2381-2.

5 Minute Break

Analytic Epidemiology
Hypotheses and Study Designs

Descriptive vs. Analytic Epidemiology

Descriptive Epidemiology deals with the questions: Who, What, When, and Where
Analytic Epidemiology deals with the remaining questions: Why and How

Analytic Epidemiology
Used to help identify the cause of disease Typically involves designing a study to test hypotheses developed using descriptive epidemiology

Borgman, J (1997). The Cincinnati Enquirer. King Features Syndicate.

Exposure and Outcome

A study considers two main factors: exposure and outcome Exposure refers to factors that might influence ones risk of disease

Outcome refers to case definitions

Case Definition
A set of standard diagnostic criteria that must be fulfilled in order to identify a person as a case of a particular disease Ensures that all persons who are counted as cases actually have the same disease Typically includes clinical criteria (lab results, symptoms, signs) and sometimes restrictions on time, place, and person

Developing Hypotheses
A hypothesis is an educated guess about an association that is testable in a scientific investigation Descriptive data provide information to develop hypotheses Hypotheses tend to be broad initially and are then refined to have a narrower focus

Example
Hypothesis: People who ate at the church picnic were more likely to become ill
Exposure is eating at the church picnic Outcome is illness this would need to be defined, for example, ill persons are those who have diarrhea and fever

Hypothesis: People who ate the egg salad at the church picnic were more likely to have laboratoryconfirmed Salmonella
Exposure is eating egg salad at the church picnic Outcome is laboratory confirmation of Salmonella

Types of Studies
Two main categories:
1. Experimental 2. Observational

1. Experimental studies exposure status is assigned 2. Observational studies exposure status is not assigned

Experimental Studies
Can involve individuals or communities Assignment of exposure status can be random or non-random The non-exposed group can be untreated (placebo) or given a standard treatment Most common is a randomized clinical trial

Experimental Study Examples

Randomized clinical trial to determine if giving magnesium sulfate to pregnant women in preterm labor decreases the risk of their babies developing cerebral palsy Randomized community trial to determine if fluoridation of the public water supply decreases dental cavities

Observational Studies
Three main types: 1. Cross-sectional study 2. Cohort study 3. Case-control study

Cross-Sectional Studies
Exposure and outcome status are determined at the same time Examples include:
Behavioral Risk Factor Surveillance System (BRFSS) - http://www.cdc.gov/brfss/ National Health and Nutrition Surveys (NHANES) http://www.cdc.gov/nchs/nhanes.htm

Also include most opinion and political polls

Cohort Studies
Study population is grouped by exposure status Groups are then followed to determine if they develop the outcome
Exposure Outcome

Prospective
Retrospective

Assessed at beginning of study

Assessed at some point in the past

Followed into the future for outcome

Outcome has already occurred

Cohort Studies
Study Population
Exposure is self selected
Exposed Non-exposed

Follow through time

Disease No Disease Disease No Disease

Cohort Study Examples

Study to determine if smokers have a higher risk of lung cancer Study to determine if children who receive influenza vaccination miss fewer days of school Study to determine if the coleslaw was the cause of a foodborne illness outbreak

Case-Control Studies
Study population is grouped by outcome Cases are persons who have the outcome Controls are persons who do not have the outcome Past exposure status is then determined

Case-Control Studies
Study Population

Cases

Controls

Had Exposure

No Exposure

Had Exposure

No Exposure

Case-Control Study Examples

Study to determine an association between autism and vaccination Study to determine an association between lung cancer and radon exposure

Study to determine an association between salmonella infection and eating at a fast food restaurant

Cohort versus Case-Control Study

Classification of Study Designs

Source: Grimes DA, Schulz KF. Lancet 2002; 359: 58

Time for you to try it!!!

5 Minute Break

Analytic Epidemiology
Measures of Association and Statistical Tests

Measures of Association
Assess the strength of an association between an exposure and the outcome of interest Indicate how more or less likely one is to develop disease as compared to another Two widely used measures:
1. Relative risk (a.k.a. risk ratio, RR) 2. Odds ratio (a.k.a. OR)

2 x 2 Tables
Used to summarize counts of disease and exposure in order to do calculations of association

Outcome

Exposure
Yes

Yes
a

No
b

Total
a+b

No
Total

c
a+c

d
b+d

c+d
a+b+c+d

2 x 2 Tables
a = number who are exposed and have the outcome b = number who are exposed and do not have the outcome c = number who are not exposed and have the outcome d = number who are not exposed and do not have the outcome

*********************************************************************** a + b = total number who are exposed c + d = total number who are not exposed a + c = total number who have the outcome b + d = total number who do not have the outcome a + b + c + d = total study population

Relative Risk
The relative risk is the risk of disease in the exposed group divided by the risk of disease in the non-exposed group RR is the measure used with cohort studies a RR = a+b c c+d

Relative Risk Example

Escherichia coli? Pink hamburger Yes No Total Total Yes 23 7 30 No 10 60 70 33 67 100

RR =

a / (a + c) c / (c+ d)

23 / 33 7 / 67

= 6.67

Odds Ratio
In a case-control study, the risk of disease cannot be directly calculated because the population at risk is not known

OR is the measure used with case-control studies axd

OR = bxc

Odds Ratio Example

Autism MMR Vaccine? Yes No Total Total Yes 130 120 250 No 115 135 250 245 255 500

OR =

axd bxc

130 x 135 115 x 120

= 1.27

Interpretation
Both the RR and OR are interpreted as follows: = 1 - indicates no association > 1 - indicates a positive association < 1 - indicates a negative association

Interpretation
If the RR = 5
People who were exposed are 5 times more likely to have the outcome when compared with persons who were not exposed

If the RR = 0.5
People who were exposed are half as likely to have the outcome when compared with persons who were not exposed

If the RR = 1
People who were exposed are no more or less likely to have the outcome when compared to persons who were not exposed

Tests of Significance
Indication of reliability of the association that was observed Answers the question How likely is it that the observed association may be due to chance? Two main tests:
1. 95% Confidence Intervals (CI) 2. p-values

95% Confidence Interval (CI)

The 95% CI is the range of values of the measure of association (RR or OR) that has a 95% chance of containing the true RR or OR One is 95% confident that the true measure of association falls within this interval

95% CI Example
Disease Odds Ratio 95% CI

Gonorrhea
Trichomonas Yeast

2.4
1.9 1.3

1.3 4.4
1.3 2.8 1.0 1.7

Other vaginitis
Herpes Genital warts

1.7
0.9 0.4

1.0 2.7
0.5 1.8 0.2 1.0

Grodstein F, Goldman MB, Cramer DW. Relation of tubal infertility to history of sexually transmitted diseases . Am J Epidemiol. 1993 Mar 1;137(5):577-84

Interpreting 95% Confidence Intervals

To have a significant association between exposure and outcome, the 95% CI should not include 1.0

A 95% CI range below 1 suggests less risk of the outcome in the exposed population
A 95% CI range above 1 suggests a higher risk of the outcome in the exposed population

p-values
The p-value is a measure of how likely the observed association would be to occur by chance alone, in the absence of a true association A very small p-value means that you are very unlikely to observe such a RR or OR if there was no true association

A p-value of 0.05 indicates only a 5% chance that the RR or OR was observed by chance alone

p-value Example
Disease Gonorrhea Trichomonas Yeast Odds Ratio 2.4 1.9 1.3 95% CI 1.3 4.4 1.3 2.8 1.0 1.7 p-value 0.004 0.001 0.04

Other vaginitis
Herpes Genital warts

1.7
0.9 0.4

1.0 2.7
0.5 1.8 0.2 1.0

0.04
0.80 0.05

Grodstein F, Goldman MB, Cramer DW. Relation of tubal infertility to history of sexually transmitted diseases . Am J Epidemiol. 1993 Mar 1;137(5):577-84

Time for you to try it!!!

Questions???

Epidemiology Pocket Guide: Quick Review Any Time!

Measures of Disease Frequency Classification of Study Designs 2 x 2 Tables Measures of Association Tests of Significance

http://www.vdh.virginia.gov/EPR/Training.asp

Session III Slides

Following this program, please visit the Web site below to access and download a copy of todays slides:
http://www.vdh.virginia.gov/EPR/Training.asp

Site Sign-in Sheet

Please submit your site sign-in sheet to: Suzi Silverstein Director, Education and Training
Emergency Preparedness & Response Programs

FAX: (804) 225 - 3888

References and Resources

Centers for Disease Control and Prevention (1992). Principles of Epidemiology: 2nd Edition. Public Health Practice Program Office: Atlanta, GA. Gordis, L. (2000). Epidemiology: 2nd Edition. W.B. Saunders Company: Philadelphia, PA. Gregg, M.B. (2002). Field Epidemiology: 2nd Edition. Oxford University Press: New York.

Hennekens, C.H. and Buring, J.E. (1987). Epidemiology in Medicine. Little, Brown and Company: Boston/Toronto.

References and Resources

Last, J.M. (2001). A Dictionary of Epidemiology: 4th Edition. Oxford University Press: New York. McNeill, A. (January 2002). Measuring the Occurrence of Disease: Prevalence and Incidence. Epid 160 lecture series, UNC Chapel Hill School of Public Health, Department of Epidemiology.

Morton, R.F, Hebel, J.R., McCarter, R.J. (2001). A Study Guide to Epidemiology and Biostatistics: 5th Edition. Aspen Publishers, Inc.: Gaithersburg, MD.
University of North Carolina at Chapel Hill School of Public Health, Department of Epidemiology, and the Epidemiologic Research & Information Center (June 1999). ERIC Notebook. Issue 2. http://www.sph.unc.edu/courses/eric/eric_notebooks.htm

References and Resources

University of North Carolina at Chapel Hill School of Public Health, Department of Epidemiology, and the Epidemiologic Research & Information Center (July 1999). ERIC Notebook. Issue 3.
http://www.sph.unc.edu/courses/eric/eric_notebooks.htm

University of North Carolina at Chapel Hill School of Public Health, Department of Epidemiology, and the Epidemiologic Research & Information Center (September 1999). ERIC Notebook. Issue 5.
http://www.sph.unc.edu/courses/eric/eric_notebooks.htm

University of North Carolina at Chapel Hill School of Public Health, Department of Epidemiology (August 2000). Laboratory Instructors Guide: Analytic Study Designs. Epid 168 lecture series. http://www.epidemiolog.net/epid168/labs/AnalyticStudExerInstGuid2 000.pdf

2005 PHIN Training Development Team

Pia MacDonald, PhD, MPH Director, NCCPHP Jennifer Horney, MPH Director, Training and Education, NCCPHP

Kim Brunette, MPH Epidemiologist, NCCPHP

Anjum Hajat, MPH Epidemiologist, NCCPHP Sarah Pfau, MPH Consultant