Epidemiologicstudies 160723192425
Epidemiologicstudies 160723192425
Epidemiologicstudies 160723192425
Dalia El-Shafei
Lecturer, Community Medicine Department, Zagazig
University
http://www.slideshare.net/daliaelshafei
Epidemiology is derived from the Greek,
Epi: On or upon.
Demos: people.
Logos : the study of
1- Case Report:
Example:
Intestinal obstruction was reported in a young child.. Documents
showed that this child received Rota virus vaccine three months ago. A
detailed report about this unusual event and exposure was published
in a medical journal. The investigator formulated a hypothesis that
Rota virus vaccine may have been responsible for the rare occurrence
of this event.
The features of the Case Report:
80
+ve Correlation (r = +1)
60
40
20
0
10°C 15°C 20°C 25°C 30°C 35°C 40°C
60
40
20
0
3 4 5 6 7 8 9
Parasitic Infection
Pattern of Diet
Mothers Awareness
Mothers Education
(Confounding factors)
4- Cross sectional study (Prevalence study):
Questions:
Draw the flow chart.
Tabulate the data.
Write the title of the table.
Consumption of high
caloric diet with obesity
n=20
The flow Chart:
Consumption of high
Caloric diet without obesity
n=60
Secondary Sample
school pupils n=400
No consumption of high
Caloric diet with obesity
n=16
No consumption of high
Caloric diet without obesity
n=304
Distribution of the studied sample of secondary school
pupils in the city X during the year 2004 according to
consumption of high caloric diet & obesity.
Consumption With Without Total
of high caloric obesity obesity
diet
Yes 20 60 80
No 16 304 320
Total 36 364 400
Prevalence of obesity among those consumed high caloric diet (P1 ) =
20 X 100 = 25%
80
16 X 100 = 5%
320
The prevalence rate =
The total number of all cases (old and new) in certain area at a given time X 100
The total number of population in the same area and time
The uses of cross-sectional study:
E Case Controls
s
Present
X DISEASE Absent
Prospective
(Cohort(
P
O
S
Present
Exposed a b
U
R
E
Absent
Not exposed c d
Mausner, 1985
Total Total
Design of a Case-Control Study
Case Control studies
The features of case control Study
1- Suitable :
to test the hypothesis that the disease of interest is caused by
an exposure.
for diseases with long latency period.
to study rare diseases
2- Easy, rapid, & cheap (compared withy prospective cohort)
3- Requires few subjects.
4-Can examine multiple exposure factors for a single disease.
5-Estimation of the risk (odds Ratio)
6-Minimal ethical problems.
7- No attrition problem.
Limitations of case control study:
Types of Bias:
•Recall bias.
•Bias due confounding factors.
•Selection bias.
Selection bias: The cases may not represent
those in the general population.
Example:
The health awareness about the association
between CHD and smoking influences the
selection of cases. Smokers at the time of onset of
CHD are more likely to attend the health care
facilities than those with similar symptoms who
are non smokers. This results in an artificially high
proportion of cases of CHD among smokers.
Confounding factors:
Factors other than the studied one that disturb
relation between the studied exposure &
disease of interest.
Parasitic Infection
Pattern of Diet
Mothers Awareness
Mothers Education
(Confounding factors(
Recall (Interview( Problems
Limitations in recall
Recall bias
One group (e.g., mothers with child with
birth defect) may clearly remember (recall)
an event (e.g., mild respiratory infection)
Other group (e.g., mothers with healthy
child) may not recall any such event
Matching
Concern that cases & controls may differ in
characteristics or exposures other than that
observed in the study
To overcome this problem, we can match cases in
controls in regard to potential factors of concern
Matching selects controls that are similar to cases
in characteristics such as age, race sex,
socioeconomic status, occupation, etc.
Matching
Group matching (frequency matching)
proportion of controls with a given
characteristic (variable) is identical to
proportion of cases with the same characteristic
Example:
An investigator selected 200 patients with basal cell carcinoma (BCC)
admitted to X hospital during the year 2004, and 200 subjects free from
the disease as a control from general population. Both groups were
interviewed to obtain information on history of exposure to sunrays
Those with history of exposure were 120 among cases and 40 among
the control .
Past
Present
The Independent variable :
The Exposure to Sun Rays .
Prospective study
Longitudinal study
Incidence study
Cohort
Cause
Effect
RF
(Disease)
exposure
Case control
Cohort Studies
Retrospective
(Case-Control)
A fourfold table
E Case Controls
s
Present
X DISEASE Absent
Prospective
(Cohort)
P
O
S
Present
Exposed a b
U
R
E
Absent
Not exposed c d
Mausner, 1985
Total Total
Prospective cohort
Persons developed
Persons not exposed to BCC )n=4(
Sunrays
n=400
Persons don't develop
BCC )n=396(
Present Future
Direction of the study
Tabulation of data:
)I0( 400
Calculation of Risk:
1- Relative Risk )RR(.
2-Attributable risk percent )ARP(.
Estimation of risks:
ARP = ( Ie - I0 )X100
(Ie)
10
Design:
Children exposed and not exposed tobacco smoke in their
homes Follow them in time for disease
occurrence.
Start Outcome
Family smoker Diseased
500 children 300
Exposed
Children Not diseased
(yrs 12)> year 1 200
1000 Family non- Diseased
smoker 120
500 children
Not exposed
Not diseased
380
Rate: Incidence rate
60
24 = 2.5
Relative Risk:
Smoking
- Lung Cancer mortality: RR=18.57
- Myocardial infarction mortality: RR=1.35
Group of persons
years follow up 20
30 – 62yrs outcome
6,500
Both sexes
:Information
S. cholest.level
Bl.pressure , weight
Cig. Smoking
Occupation Based Studies to study
effect of exposures
a( Clinical trials:
It is usually used to assess efficacy of a new line of ttt (a
new drug for example) or to compare 2 types of ttts:
surgical or medical.
Diseased subjects are randomly allocated into 2 groups,
"ttt” group (who are given the new drug) and "control
group" (who are given the usual ttt or no ttt in placebo).
Results are assessed by comparing health improvement
of the 2 groups at end of trial.
Example: surgical or medical treatment of peptic ulcer
EXPERIMENTAL STUDY
Random Allocation ?
Yes No
Randomized Non-Randomized
Controlled trial Controlled trial
(RCT)
Randomization: assigned to ttt & control group.
Matching: matched pair design to arrange ttt &
control groups similar for the main variables such
as age, sex. Matching determine data analysis.
Cross–over design: In a clinical trial of short term
benefits it may be appropriate to use participants as
their self-controls.
Single & double–blind designs: single blind when
the participants don’t know the preparation while in
double blind method, both investigator &
participants do not know, only (designer) knows.
“Triple blind: subjects & investigators &
statisticians”
b( Community trials:
Involve people who are not diseased (but presumed likely
to be at risk) and the sample is drawn from the community.
Data collection takes place in the field.
For example: in studies carried out to assess the efficacy
of new vaccines. The participants are divided into 2
groups: one who is the experimental group (will take the
new vaccine) and the 2nd is the control group (will not take
the vaccine).
The participant will be followed to compare the level of
occurrence of the disease in both groups. Therefore, these
groups should be alike as much as possible in all aspects
other than ttt /intervention received.
Hierarchy of major study designs
RCT Interventional
Cohort Observational
Case control
Cross sectional
Validity
Exercise1:-
Description of 35 patients with thyroid cancer
are regarding past history of exposure to
radiation and response to surgical treatment
Feedback:-
Case series
Exercise2:-
Patients admitted for uterine prolapse were age
and social class-matched with fellow patients
without prolapse and surveyed as to chronic
constipation history to assess the possible
association of chronic constipation and
uterine prolapse.
Feedback 2:-
Case-control study
Exercise3:-
A 39-year old man who presents with mild sore
throat, fever, malaise and headache was treated
with penicillin for presumed streptococcal
infection.
He returned after a week with hypotension, fever and
abdominal pain .
A diagnosis of Rocky Mountain spotted fever was
made and he responded good to chloramphenicol.
Feedback 3:-
Case report
Exercise4:-
A total of 298 who have minor operations during
March 1980 in one hospital, half of them are
known and recorded to be exposed to hepatitis B
contaminated vials discovered and half of them to
vials free of this pollution are followed up starting
from July 2000 till 2010 to diagnose liver cancer.
Feedback 4:-
Retrospective cohort
Exercise 5:-
500 patients were classified according to their
body mass index (obese or not) and
simultaneously according to having knee
osteoarthrosis
Feedback of Exercise5:-
Prospective cohort
study
Exercise 7:-
An oncologist determined that 75 out of 100
randomly selected leukemia patients had
experienced exposure to ionizing radiation while
60 out of 100 randomly selected healthy
individuals who did not differ from patient with
respect to age or sex had experienced exposure to
ionizing radiation .
Feedback of Exercise7:-
Case-control study
Exercise 8:-
In one of two capital cities of two adjacent
governorates, health education & strict application
of helmets use for motorcycle drivers were done
& in the other city no application of such
awareness or law & then the incidence of head
injury among motorcycle drivers was found for a
year
Feedback 8:-
Community trial
Exercise 9:-
A team of clinical researchers decide to investigate
if ovarian cancer responds better to Taxol than to
conventional chemotherapy. They choose suitable
patients & randomize to Taxol & control groups
(subjects are alike, apart from the exposure to
which therapy).