DEBRE TABORE UNIVERSITY

COLLEGE OF HEALTH
SCIENCE

Module: Measurement of health and

disease

Mekonnen Assefa (MPH in Epidemiology &

Biostatistics)
 Introduction to
Epidemiology
Objectives:
• Define epidemiology and discuss
components
• Discuss the history of epidemiology
• Describe the scope and purpose of
epidemiology
• Identify & distinguish between clinical
and community medicine
• Discuss the chain of disease transmission
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Epidemiology: Definition:
• Epidemiology is the study of the
 frequency,
 distribution and
 determinants
of diseases and other health related
states or events in specified
populations, and the application of this
study to the promotion of health, and to
the prevention and control of health
problems.
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3
Disease
Components of Definition
• Population - the focus of epidemiology is
mainly
on the population rather than individuals.
• Frequency - epidemiology to be mainly a
quantitative science and Epidemiology is
concerned with the frequency of diseases and
other health related conditions.
• Health related conditions-are conditions
which directly or indirectly affect or influence
health such as injuries, vital events, health related
behaviors, social factors, economic factors etc.

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 Components of
Definition…
• Distribution.
Person- Who :
Young Vs Old, Female Vs Male, Rich Vs Poor,
etc.
Place .Where:
Lowland Vs Highland, Urban Vs Rural
Time - When:
Seasonal Variations, Long term variations
• Descriptive epidemiology is concerned
with it.
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 Components of Definition…

• Determinants- How: mechanism-

Mode of transmission
• Why: cause-
Genetic Vs environmental, Social and
cultural conditions
• Analytical Epidemiology deals
with it

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Purpose of Epidemiological
Information
• Community need assessment- setting
priority
• Individual decisions-
preventing/avoiding risky behaviors
• Understanding clinical presentations
• Identify cause of diseases
• Completing the clinical picture of
disease
• Identifying new syndromes
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 Purpose of Epidemiology…

• Determining effectiveness of
therapeutic and preventive measures
e.g. Mammograms, clinical trials
• Monitoring the health of a community,
region, or nation
e.g. Surveillance, accident reports
• Studying trends over time to make
predictions for the future
e.g. Smoking and lung cancer
• Estimating health services needs
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 Epidemiology: Scope
• Originally,
epidemics of communicable
diseases and epidemic
investigations.
• Later,
• endemic communicable diseases
and non-communicable diseases.

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 Scope….
At present
• Infectious and non • Cancer
infectious diseases • Occupational health
• Injuries and accidents
• Environmental health
• Nutritional deficiencies
• Health behaviors
• Mental disorders
• Maternal and child health • Violence, etc.
• Congenital anomalies  All disease
conditions and
 READ:- History of other health related
epidemiology events.

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Epidemiology: Basic
Assumptions
• Non random Occurrence of
diseases

• Human diseases have causal and

preventive factors that can be:
• identified through systematic
investigations of populations or
group of individuals in different places
or at different times.
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 Epidemiological concepts of
disease causation
• A cause of a disease can be defined as a
factor (characteristic, behavior, event,
etc.) that influences the occurrence of disease.
• Not all associations between exposure and
disease are causal
• If disease does not develop without the factor
being present, then we term the causative
factor "necessary“
• If the disease always results from the factor,
then we term the causative factor "sufficient".

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 Factors involved in
disease causation
• Host factors (intrinsic factors):
influence exposure, susceptibility or
response to the agents
– Age
– Sex
– Ethnic group
– Immunity and immunologic response
– Genetic factors e.g. sickle cell anaemia
– Physiological status e.g. pregnancy, puberty,
stress, etc.
– Human behaviour e.g. personal hygiene,
dietary habit, occupation, utilization of health
services, sexual activity, etc.
– Concurrent or pre-existing disease: e.g. HIV,
diabetes, etc.Measurment of Health and Disease 13
 Factors involved in
disease causation…
• Extrinsic (environmental)
factors
– Physical environment (heat, cold,
chemicals)
– Biologic environment (infectious
agents of disease, vectors, plants and
animals)
– Social environment (economic,
political, culture)

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 Factors involved in
disease causation…
• Risk factors
– Factors that increase occurrence of adverse health
outcome
– E.g. – smoking cigarette
• Agent – a specific factor in whose absence a disease
wouldn’t develop; also called necessary cause E.g. – M. tb
for tuberculosis
Examples of agents
– Living organisms (infectious agents)
– Chemical agents (e.g. poison, allergens)
– Psychological factors and stress
– Nutritive elements
– Physical agents (e.g. radiation)
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 Factors involved in
disease causation…
• The environmental factors are closely
related to each other and to host
factors
• If the existing balance of forces is
precarious, disease develops
• Different epidemiologic models
have been developed to depict the
ways in which these interactions
influence the occurrence of disease
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 Conceptual Models of
Causation
• Depict multi factorial causation,
confounding, interdependence of
effects, direct and indirect effects,
levels of causation, and systems or
webs of causation
• Models – the epidemiologic triangle,
web of causation, wheel model,
sufficient-component cause model

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 Epidemiologic Triangle

• The epidemiologic triangle or

triad is the traditional model
of infectious disease
causation.
• It has three components :
Agent, Host, and
Environment

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Epidemiologic Triangle…
• Was widely used for many years and
still referred frequently in
epidemiological literature
• Each component must be analyzed
and understood for prediction of
patterns of a disease
• This model highlights the agent of
disease as a separate component

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EPIDEMIOLOGIC TRIANGLE AND
TRIAD (BALANCE BEAM)

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 The Web of Causation
• Effects never depend on single
isolated causes, but rather develop
as the result of chains of
causation in which each link is the
result of “a complex genealogy of
antecedents”

• E. g. the web of causation underlying

coronary heart disease
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 The Wheel Model
• Consists of a hub (the host or human), which
has genetic make-up as its core,
surrounded by the environment, schematically
divided into the three sectors - biological,
social, and physical
• The relative size of the different components of
the wheel depend upon the specific disease
problem under consideration
– Hereditary disease - genetic core is relatively
large
– Measles - state of immunity of the host &
biological sector of the environment is large
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Wheel Model…

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 Sufficient-component cause pie model

• Causal pie is one of the models that take

into account multiple factors which are
important in causation of disease.
• In the causal pie model, the factors
are represented by pieces of the pie
called component causes
• In disorders with multi-factorial causation
often no specific causes are known,
• many factors appear to be important,
and mechanisms of causation are not
apparent.
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Rothman's Causal Pies: Conceptual
Scheme for Disease Causation

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 GROUP DISCUSSION
Use the two models (Agent-Host-
Environment and Causal Pies) to
describe the following :
a. Use the Agent-Host-Environment model to
describe the role of the human
immunodeficiency virus (HIV) in AIDS.
• Agent:
• Host:
• Environment:
b. Some of the risk factors for heart disease
are smoking, hypertension, obesity,
diabetes, high Measurment
cholesterol,
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inactivity and 26
 DISCRIPTIVE
EPIDEMIOLOGY
• In descriptive epidemiology, we
organize and summarize data
according to time, place, and
person.
• These three characteristics are
sometimes called the
epidemiologic variables.
• Not intended to confirm
causes/determinants.
Measurment of Health and Disease 27
 DISCRIPTIVE
EPIDEMIOLOGY…
• To describe the occurrence of a
disease fully, the following questions
must be answered.
• Who is affected?
• Where? and
• When do the cases occur?
• How many?

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 PERSON
• PERSON: indices of person
include: basic demographic factors:
as age, sex, race, marital status,
or occupational status
• life-style variables: the consumption
of various foods or medication use
• This answers the question of who
is/ is not most affected?.

Measurment of Health and Disease 29

 Place characteristics
• A health event is described by place to
gain insight into the geographical
extent of the problem.
• For place, we may use place of
residence, birthplace, place of
employment, school district,
hospital unit, etc., depending on
which may be related to the occurrence
of the health event.

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 Spot maps
• Plot location of each case of a
disease, usually by residence or
workplace
• Traditionally used to investigate
outbreaks of disease
• Density of spots can be related to
density of population or workplaces,
obscuring source of problem

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Distribution of cholera cases
in the Golden Square area of
London, August-September
1854

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 Time

• With regard to time,

descriptive studies may
examine seasonal patterns in
disease onset or compare the
frequency recent time with that
of previous years.

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There are three kinds of changes in
disease occurrence over time

a. Secular trend: slow and gradual

changes over long period of time.
b. Periodic or cyclic changes:
recurrent alternations in the frequency
of diseases.
c. Sporadic: refers to the occurrence
of individual cases or outbreaks of
disease at irregular and
unpredictable interval.
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 Establishing causation
• Causal inference should not be
made until certain requirements
have been satisfied, which relate
to two major questions:
• Is there actually an association?
• If there is an association, is it
likely to be causal?

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 Process of establishing
causation
• Develop Hypothesis
• Testing Hypothesis , assess presence of
association
• Use criteria to establish association,
Bradford hills criteria
1. Developing a hypothesis
• From descriptive studies
– Suggest possible determinants
2. Testing the hypothesis
• Using analytic studies
– Assess presence of association
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36
 Does association imply
causation?
• An observed association could be
– Non-causal
• Artifactual
– Sampling error
– Confounding
– Bias , which could be selection, information,
measurement
– Reverse causality-bias, the effect may result the
cause, take Vitamin A and Diarrhoeal disease
association.
• Coincidence
– Other causes
– Causal
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 3. Use criteria for
establishing causation
• How to separate causal from non-
causal associations in
epidemiology?
• Setting criteria
• Offered by Bradford Hill
– Guides, not rules
– Strength, consistency,
specificity, temporality,
biologic gradient, plausibility,
coherence, experimental
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 Natural History and Spectrum
of Disease
• The progress of a disease process in an
individual over time, in the absence of
intervention.
• Without medical intervention, the process
ends with recovery, disability, or death.
• With a particular individual, the usual
course of a disease may be halted at
any point in the progression by
preventive and therapeutic measures,
host factors, and other influences.
Measurment of Health and Disease 39
 Natural history of
disease

Figure . Natural History of Disease

Measurment of Health and Disease 40

 Natural history of
disease…
• Three terms are used to describe an infectious
disease according to the various outcomes
that occur after exposure to its causative
agent
 Infectivity: refers to the proportion of
exposed persons who become infected.
• Pathogenicity: refers to the proportion of
infected persons who develop clinical disease.
• Virulence: refers to the proportion of
persons with clinical disease who become
severely ill or die

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 Natural history of
disease…
• The natural history and spectrum of disease
presents challenges to the clinician and to the
public health worker.
• Because of the clinical spectrum, cases of illness
diagnosed by clinicians in the community often
represent only the “tip of the iceberg.”
• For the public health worker, the challenge is
that persons with in apparent or undiagnosed
infections may nonetheless be able to transmit
them to others. Such persons are called
carriers
Measurment of Health and Disease 42
Natural history of
disease…

Measurment of Health and Disease 43

 Chain of Infection
Components of infectious process
• Agent
• Reservoir
• Portal(s) of exit from the reservoir
• Mode(s) of transmission
• Portal(s) of entry in to the new host
• Presence of susceptible host.

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 Agent
• An organism that causes the
infections or infectious process
Classification:
a. metazoa- multi cellular organisms
b. Protozoa- unicellular organisms e.g.
amoebae
c. Bacteria-T. pallidum, M.tuberclosis
d. Fungus-e.g. c. alibicans
e. Virus-e.g. chicken pox, polio etc
Measurment of Health and Disease 45
 The reservoir:
• is an organism or habitat in which an
infectious agent normally lives,
transforms, develops and/or
multiplies.
Usual reservoirs:
- human beings
- vertebrate animals,
- invertebrates (arthropods, molluscs) and
-environmental sources (plants, soil, water,
etc)
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 Reservoir…
• Usually the human host is the
only reservoir for: measles,
diphtheria, pertussis, poliomyelitis,
syphilis and gonorrhea.
• As a general rule, the greater the
number of different reservoirs for a
given disease, the greater the
difficulty in controlling that disease.
(e.g., malaria)
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 Carrier:

• An infected person without manifestations of

disease, but capable of transmitting the
infection to others.
• There are four types of carriers:
a. Incubatory carrier: measles, chicken pox,
mumps etc
b. Convalescent carrier: diphtheria, hepatitis
c. Asymptomatic carrier: polio, amoebiasis
d. Chronic carrier: typhoid fever
• Importance: number, recognition, chronicity,
mobility
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 Portal(s) of Exit
All body secretions and discharges:
• mucus, saliva, tears, breast milk;
• vaginal, cervical and urethral
discharges; semen, pus, exudates
from wounds.
• Other routes: exhalation, talking and
coughing, through excretions,
• blood and tissues (placenta).

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 Modes of Transmission
1. Direct transmission
a. Direct contact: (Biting in rabies,
Passage through birth canal)
b. Direct projection: saliva droplets
by expiratory activities, coughing,
sneezing, spitting, talking and singing.
 has to be with in one meter proximity.
c. Trans-placental: maternal to fetus
with passage through the placenta
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 Modes of Transmission…
2. Indirect transmission
a. Airborne: e.g. pulmonary tbc
 Droplet nuclei
 Dust re-suspended droplets
b. Vehicle borne
A vehicle: is non living substance or object by which an
infectious agent can be transported into a host through
a suitable portal of entry
e.g. food, milk, water, soil, blood, fomites etc
c. Vector borne
• Mechanical
• Biologic

Measurment of Health and Disease 51

 Portal of Entry
• Determines whether or not the
agent will succeed in establishing
an infection.

E.g. Cl. tetani requires an injury to

enter and cause infection. If
ingested it is harmless.

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Susceptible Human Host
• Defn:- A person lacking sufficient resistance
to a particular pathogenic agent to prevent
disease if exposed .
• The concept of host susceptibility or
resistance can be seen at two level,
individuals and that of the population
• Host resistance at the population level is
called herd immunity
• Immunity: - is the state of defence carried
out by specific immunological reaction in the
body
Measurment of Health and Disease 53
 Human Host: Types of
Immunity
1. Inherited
• natural resistance of a species or race
2. Acquired
• A. Natural
(i) Active: Infection by an agent stimulates
the host to produce antibodies
(ii) Passive: Antibodies produced by the
mother cross the placenta into the blood
stream of the fetus i.e. Maternal antibodies
Measurment of Health and Disease 54
 Types of Immunity…..
• B. Artificial
(1) Active: Host is stimulated to
produce antibodies by the injection
of an attenuated pathogen (antigen)
i) Killed vaccine
ii) Modified live vaccine
(2) Passive: Host receives antibodies
produced elsewhere.
Measurment of Health and Disease 55
 Time Course of Infectious
Diseases
o Prepatent period: is the time interval between
infection (or biological onset), and the point at
which the infection can first be detected, as
measured by the time of first shedding of the
agent by the host.
*window period for HIV/AIDS
o Incubation period: between the biological and
clinical onset.
o Communicable period
o Latent period- The time interval between
recovery and the occurrence of a relapse or
recrudescence
Measurment of Health and Disease 56
 Time Course….

Figure : Time Course of a Disease in Relation to Its

Clinical Expression and Communicability
Measurment of Health and Disease 57
PRINCIPLES OF COMMUNICABLE
DISEASES CONTROL
1. Attacking the source (reservoir) of infection
a. Treatment of cases and carriers.
b. Isolation and quarantine
c. mass vaccination and killing/ burning (rabies,
anthrax).
d. Active surveillance of contacts
2. Interrupting the chain of transmission.
• Personal hygiene, Vector control, Disinfection and
sterilization
3. Reducing host susceptibility.
• Immunization ,Better and improved nutrition, Health
education, Chemo prophylaxis, Person protection
(mosquito nets, clothing repellents, shoes, etc.)
Measurment of Health and Disease 58
 Levels of Disease
Prevention
1. Primary prevention: before occurrence of disease
• (Health promotion, Prevention of exposure,
• Prevention of disease)
2. Secondary prevention:-
• prevention after biological onset but before permanent
damage to stop or slow the progression of disease
• screening and case detection and treatment
3. Tertiary prevention: disease has already
• occurred and left residual damage to limit the
• impact of that damage.
 Rehabilitation: retaining of remaining functions for
maximal effectiveness.
 Limitation of disability

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Levels of Disease
Prevention

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 Screening and diagnostic tests
• is the presumptive identification of
unrecognized disease or defect by
means of rapidly applied tests,
examinations or other procedures in
apparently healthy individuals.
• Screening is a public health intervention
intended to improve the health of a
precisely defined target population
• Screening tests sort out apparently well
persons who probably have a disease from
those who probably do not
Measurment of Health and Disease 61
 Screening….
• A screening test is not intended to be
diagnostic and is an initial examination only;
positive responders require a second,
diagnostic examination.
Aim of screening program
 To reverse, halt, or slow the progression of
disease
 To alter the natural course of disease for a
better outcome for individuals affected
 Protect society from contagious disease
 Rational allocation of resources
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 Screening...
Diseases Appropriate for
Screening:
• Serious
• Treatment given before symptoms
should be more beneficial in terms of
reducing morbidity or mortality than
that given after disease
• High prevalence of preclinical disease

Measurment of Health and Disease 63

Criteria for establishing
screening program
• Important health problem
• Accepted treatment for patients with
recognized disease
• Facilities for diagnosis and treatment
• Recognized latent or early
symptomatic stage
• Suitable test with high validity
• Test acceptable to the population
Measurment of Health and Disease 64
 Criteria…
• Adequately understood natural
history
• Balanced cost of case-finding
with medical care as a whole.
• Case finding should be a
continuous process and not a
once and for all project

Measurment of Health and Disease 65

 Evaluation of Screening
Tests
For a successful screening the
test should ideally be:
▪ inexpensive
▪ easy to administer
▪ impose minimal discomfort on
the patients.
▪ valid
▪ reliable
Measurment of Health and Disease 66
 Validity of a Screening Test

• is the ability to differentiate accurately

between those who have the disease
and those who do not.
A. Sensitivity - is the ability of a test to
identify correctly those who have the
disease

B. Specificity - is the ability of a test to

identify correctly those who do not have
the disease
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 The contingency table
• Condition According
to Gold Standard
• Present• Absent • Total

a = True
• Positive b= a+ b
positives False
• Test positi
• Result ves
c= d=
• Negative False True
c+ d
negati negat
• Total ves
a+c bives
+d
Grand
Total
a+b+c
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 Validity….

• SENSITIVITY= TP *100
TP+FN

• SPECIFICITY = TN *100
TN+FP

Measurment of Health and Disease 69

 Predictive Value of a
Screening Test
• is the ability of a test to predict the presence
or absence of disease from test results.
1. Predictive Value of a Positive Test
(PVPT) or Positive Predictive Value
(PPV)
• shows the probability that the person tested
positive by this specific test truly has the
disease.
• PVPT = TP *100
TP + FP
Measurment of Health and Disease 70
 Predictive Value…
2. Predictive Value of a
Negative Test (PVNT) or
Negative Predictive Value
• Shows the degree of confidence
the disease can be ruled out by
using this specific test.
• PVNT = TN X 100
TN+FN
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 Reliability (Precision)

• one that gives consistent results

when the test is performed more
than once on the same individual
under the same conditions.
• Two major factors affect
consistency of results:
a) variation inherent in the method
b) observer variation (observer error).

Measurment of Health and Disease 72

 Reliability…
1. The variability of a method-
• the stability of the reagents used
• fluctuation in the substance being
measured (e.g. in relation to meals,
diurnal variation).
2. Observer variation
• inter-observer variation
• intra-observer variation
These variations can usually be
reduced by:
1. careful standardization of procedures
2. intensive trainingMeasurment
period for all observers
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 Evaluation of screening
program
Involves consideration of:
1) Feasibility :
• acceptability, cost-effectiveness,
treatment, and yield (Y).
Y= TP/(TP+TN+FP+FN)
2) Effectiveness: reduction of
morbidity, mortality and disability

Measurment of Health and Disease 74

 Quiz /Exercise On Screening

Case: To evaluate a new laboratory for accuracy in

conducting urine drug tests, 1,209 urine samples
were obtained from individuals who volunteered
for a drug-avoidance program and were analyzed
by the new lab. 416 samples contained evidence
of cocaine use, and of these, the new lab reported
that 150 were positive for cocaine use. 793
samples did not contain evidence of cocaine use,
and of these, the new lab reported that 8 were
positive for cocaine use.
Calculate the positive predictive value, the
negative predictive value, the sensitivity,
the specificity and yield. construct 2x2 table
Measurment of Health and Disease 75
Introduction to
Epidemiological
Study Designs

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 Session Objectives
• Describe well all types of epidemiological study
designs
• Explain the uses of the various study designs.
• Express well the characteristics of descriptive
study designs and how hypothesis is
generated.
• Determine when to proceed with an analytic
study for further test of the hypothesis
• Describe the characteristics and design of
observational and experimental design
• Describe the concepts, merits, demerits
and application of various epidemiological
study designs Measurment of Health and Disease 77
 Broad categories of epidemiologic
designs

I. Observational
– investigator simply observes

• without having the power of assigning or

allocating the factors to the study participants
– can be descriptive or analytic

II. Interventional
– investigator assigns factors

– are special type of analytic designs and termed as

evaluative
Measurment of Health and Disease 78
 Specific types of epidemiologic
designs

• Observational
– Descriptive
• case-report, case-series, cross-sectional,
ecological
– Analytic
• Case-control, cohort
• Interventional
– Experimental
• Clinical trials, field trials, community
trials
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 Epidemiological studies…
Populati Ecologic
on
Descriptive Case report, case-
series
Individu Descriptive Cross-sectiona
Observati als
onal
Comparative Cross-sectiona

Analytical Case-control
Ep.
Designs Prospective
Cohort
Clinical Retrospective
Intervent trials
Community trials
ion
Field trials
Measurment of Health and Disease 80
 Descriptive study
designs
Purpose and characteristics
• mainly concerned with the distribution of
diseases
• useful for health managers to allocate
resources.
• hypothesis generation.
• less time consuming and less expensive
(use routinely collected information).
• most common study designs used by
epidemiologists.
Measurment of Health and Disease 81
 Descriptive study designs: types

Correlational (ecological) studies

• Observational studies conducted at a
population level rather than an individual level.
• Examine characteristics of entire
populations(unit of analysis is population)
Example: 1. Examination of state data on
• tobacco sales and mortality from CHD.
2. Fluoride content of water and dental
caries
– Prevalence of people with dental caries in
villages Vs Fluoride content of water in villages
Measurment of Health and Disease 82
 Correlational studies….
Strength
• Quick and inexpensive, can be used as first
step in investigating a possible exposure-
disease relation ship.
• It is useful in giving a fruitful start for more
detailed epidemiological studies.
Limitation
• Doesn't link specific persons exposure with
specific outcome
• Risk of ecological fallacy
• Can't control for potential confounding factors
Measurment of Health and Disease 83
 Case Reports and Case Series

• Describes single patient or group of

patients experience
• Most common form of study published in
medical journals.
• Presents an unusual disease or unusual
presentation of a disease or Useful for
the recognition of new diseases
• Useful for constructing of the natural
history of a disease,
• Useful to formulate a hypothesis and to
detect an epidemic
Measurment of Health and Disease 84
 Case report

• It is the study of health profile of a single

individual using a careful and detailed
report by one or more clinicians.
• It is common form that is published in articles
• Report is usually documented if there is
unusual medical occurrence, thus it may
be first clue for identification of a new disease
It is made using: Simple history,
Physical examination
and
Lab. / radiologic
investigation.
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 Case series
• Individual case report can be expanded to a
case series which describes characteristics
of a number series, of patients (usually 5-
12) with a similar disease.
• Similar to case report, it is usually made on
cases having new and/ or unusual disease
(giving interest to clinicians)
• It is often used to detect the
emergence of new disease or an
epidemics.
Measurment of Health and Disease 86
Case Report/Series studies…

Strengths
• May lead to formulation of new
hypotheses
• Important link between clinical
medicine and epidemiology
Limitation
• Cannot be used to test hypotheses

Measurment of Health and Disease 87

 Case report/series studies:
Examples
E.g. case report: A 40-year old
premenopausal woman developed
pulmonary embolism 5 weeks after
beginning to use an oral contraceptive
preparation to treat endometriosis.
E.g. case series: Five young, previously
healthy homosexual men were diagnosed
as having pneumocystis carinii
pneumonia at 3 Los Angeles hospitals
during a 6 month period in 1980 to 1981.
Measurment of Health and Disease 88
 Cross-Sectional (prevalence)
Studies
• Exposure and disease status are
simultaneously assessed in a population
• Information about the status of an
individual with respect to the presence
or absence of exposure and disease
is assessed at the same point in time.
• Cross-sectional surveys could provide
information about the frequency of a
disease by furnishing a ‘snapshot’ at
a specified time.
Measurment of Health and Disease 89
 Cross-Sectional
studies….
• May be useful first step in longitudinal
studies.
• Data are obtained only once
• Measures of association is made using
odds ratio.
Strength
• Provides information about the frequency
and characteristics of a disease.
• decision making and priority setting

Measurment of Health and Disease 90

 Cross-Sectional
studies….
• prevalence of disease or other health
outcome in special groups (e.g.
occupations)
• investigates exposures that are fixed
characteristics of individuals,
( ethnicity and blood groups).
Limitation
• Can’t determine whether exposure
preceded or occurred as a result
of the disease (chicken and egg
Measurment of Health and Disease 91
Analytic epidemiological
studies
Objectives /aim
• To test hypothesis about causal relationship
• To search for cause and effect. Why???
How???
• To compare treatment regimens / prevention
programs
• To assess diagnostic tests
• To quantify the association between
exposure and outcome
 Measure of association

Measurment of Health and Disease 92

 Analytic Studies…
• Explicit comparison of exposure and
disease
• Appropriate comparison/control group
• Hypothesis testing
Two types
• Observational - natural course of
events
• Intervention - investigator allocates
exposure and follows subjects
Measurment of Health and Disease 93
 Case-Control Studies
Properties
• suitable for identifying risk factors for
rare diseases
Design
• Selection of cases (disease) and
controls (no disease) based on
disease status
• Exposure status is unknown
• lacks temporality
Measurment of Health and Disease 94
Steps in conducting case control
studies
1: Define cases
• is establishment of strict diagnostic
criteria and definition of the disease
or outcome of interest.
2: Select cases
sources:
1. Hospitals (health institutions)
2. Population (community)

Measurment of Health and Disease 95

 Steps…
3: Select controls
• consider comparability, practicability and
economic impact.
• controls should be similar with the cases except
the disease or other outcome of interest.
Sources of controls
1. Hospital controls
2. General population controls
Advantages:
• Generalization is possible
 If cases are selected from the population, it is
good to select controls from the population
too.
Measurment of Health and Disease 96
 Steps…
4. Check the exposure status
• Information regarding the exposure
status can be obtained by interview or
from different records.
5: Analysis
• Prepare 2X2 table
• calculate Odds Ratio (OR)
• Perform statistical tests to check
whether there is significant association.
Measurment of Health and Disease 97
 Case- control studies…
Advantages
• Uniquely suited to diseases with long
incubation periods
• More efficient in terms of time and money
• Good for study of rare disease
• Can look at multiple exposures for a single
disease
Disadvantages
• Inefficient for evaluation of rare exposures
• Cannot directly compute incidence rates of
disease Measurment of Health and Disease 98
 Cohort studies
Types of cohort studies
• Classification is based on the temporal
relationship between the initiation of the study
and the occurrence of the disease.
1. Prospective cohort study
• the outcome has not yet occurred at the
beginning.
• is the commonest type.
• unless specified cohort study refers to the
prospective type of cohort
• more reliable than the retrospective
Measurment of Health and Disease 99
Fig. prospective cohort studies
Measurment of Health and Disease 100
Types of cohort studies…
2. Retrospective (Historical) cohort
study
• the investigation is initiated at a point
in time after both the exposure and
disease have already occurred.
• less costly and less time consuming
• often uses data collected for other
purposes, hence information obtained
might be incomplete and non
comparable for all subjects
Measurment of Health and Disease 101
Retrospective or Prospective

Measurment of Health and Disease 102

 Steps in conducting cohort study
1: Define exposure
2: Select exposed group
3: Select controls (non-exposed)
• control groups should be comparable to the exposed
group
4: Identify sources of data for exposure and outcome
Possible sources of exposure data:
• pre-existing records
• conducting interview
Possible sources of outcome data:
• routine surveillance
• death certificate
• periodic health examination
• hospital records etc.
Measurment of Health and Disease 103
 Steps…
5: collect data
6: Analyze data
• prepare 2X2 table
• calculate Relative Risk (RR)
• perform statistical tests to check
whether there is statistical significant
association

Measurment of Health and Disease 104

 Cohort (Cont…)
Advantages
• Can measure incidence and thus
relative risk
• No recall bias
• Exposure precedes disease
• Can study several diseases
• Can be very efficient for rare
exposure
Measurment of Health and Disease 105
 Cohort (Cont…)
Disadvantages
• Large number of subjects/participants
• Inefficient for rare diseases
• Long follow-up period
• Subjects may change health behaviors
during course of study
• Possible changes over time in
ascertainment of disease
• Very costly
Measurment of Health and Disease 106
Advantages and limitations of cohort
and case control studies
Case control Cohort
Advantages:  valuable when exposure is rare
 optimal for evaluation of rare  can examine multiple effects
Disease of a single exposure
 can examine multiple factors  temporal relationship is known
for a single disease  allows direct measurement of risk
 Quick & inexpensive  minimize bias in ascertainment of
 relatively simple to carry out exposure
 guarantee the number of persons with
a disease

Limitations:  inefficient in evaluation of

 inefficient in evaluation of rare rare diseases
exposure  and
Measurment of Health expensive
Disease 107
Experimental/Intervention studies

• Individuals are allocated into

experiment or control group by the
investigator.
• can produce high quality data.
• Experimental study is the gold
standard study design compared
to other designs.

Measurment of Health and Disease 108

 Experimental Studies

The investigator through randomization

allocates subjects
to different categories of exposure.
Randomization: An allocation
procedure that assigns
subjects into (one of the) exposure groups
being compared Measurment of Health and Disease 109
Classification of Intervention Studies

A. Classification based on the

population studied
1. Clinical trial: usually performed in the
clinical setting and the subjects are patients
2. Field trial: used in testing medicine for
preventive purpose. Subjects are healthy
peoples
E.g. vaccine trial
3. Community trial: unity study is group of
people/community
E.g fluoridation of water to prevent dental caries
Measurment of Health and Disease 110
 Classification of
Intervention Studies…
B. Classification based on
design
1. Uncontrolled trial
No control group. Control will be past
experience
2. Non randomized controlled:
There is a control group allocation to
either group is not randomized
3. Randomized controlled: there is
control group
Measurment of Health and Disease 111
 Problems related to experimental
studies
 Ethical issues:
• harmful should not be used in this
study.
• beneficial treatment should not be
withheld from any affected
individuals.
 Feasibility / practical issues
• subject recruitment
• difficult to achieve satisfactory
compliance. Measurment of Health and Disease 112
Measures of Disease and Death
Frequency
• Counts, Proportions, ratios, rates
• Measures of disease frequency -
measures disease risk or burden in a
population
• Prevalence ( point, period, lifetime)
 burden
• Incidence( CI)
risk

Measurment of Health and Disease 113

 Measures of Frequency….
Ratio
• occurrence of one event in relation to the
other
• Ratio=A/B ; A:B
 Used to compare two quantities
• ratio of female to male births
• Age dependency ratio,
• maternal mortality ratio
• the ratio of people with tuberculosis to
those without tuberculosis.
Measurment of Health and Disease 114
 Measures of
Frequency….
Proportion:
• is a type of ratio which quantifies
occurrences in relation to the population
in which these occurrences take place
( i.e. denominator includes the
numerator).
• P=A/A+B
e.g. proportion of TBC cases among
inhabitants of a certain locality.
Measurment of Health and Disease 115
 Measures of
Frequency….
Rates
• Special form of proportion that
includes a specification of time
• Most commonly used in epidemiology
because it most clearly expresses
probability or risk of disease or
other events in a defined population
over a specified period of time.
• Rate=A/A+B + time element
Measurment of Health and Disease 116
 Measures of Morbidity
1. Incidence
• Measure of new cases of disease
(or other events of interest) that
develop in at risk population during a
specified period of time.
• Measure of the probability that
IR= (no of people who developed a
unaffected persons will develop the
certain condition during a specified
disease.
period of time) / (population at risk for
the condition)
Measurment of Health and Disease 117
 Incidence….
• Population at risk: those
individuals who are not having the
disease currently but capable of
developing it.

E.g. There were 70 cases of breast

cancer developed over the five years
follow up of 3,000 women.

 Calculate the IR of breast

Measurment of Health and Disease 118
 Measures of Morbidity…
2. prevalence
• Proportion of individuals in a
population with disease at a specific
point of time
Provides an idea of how severe a
problem may be
 Useful of
P=number forexisting cases
planning of disease
health at a
services
given pt/pd in time
(facilities,
Totalstaff)
population at risk
Measurment of Health and Disease 119
 Types of prevalence
1. Period prevalence rate: measures the
proportion of a population that is affected
with a certain condition during a specified
PPR= notime
period of of people with a
condition during a specified
period of time / total population
2. Point prevalence: number of cases that
exist at a given point in time
Point prevalence rate is directly proportional to
both the incidence rate and the average
duration of disease
Point prevalence rate ~ IR*D
Measurment of Health and Disease 120
 Types of prevalence….
3. Lifetime prevalence: proportion
of the population that has a history
of a given disorder at some point in
time
Factors determining
prevalence
 Severity of illness
 Duration of illness
 The number of new cases
Measurment of Health and Disease 121
 Measure of Mortality
• Mortality rate and ratio measure the
occurrence of death in a population
using different ways.
• Rate whose denominator are the
total population are commonly
calculated using either the mid –
interval or the average population.
• This is due to population size
fluctuation over time due to birth,
death and migration
Measurment of Health and Disease 122
Measure of Mortality…..
Three types of rates:
» Crude rates
» Specific rates
» Adjusted rates

Measurment of Health and Disease 123

 Crude rates
• are summary rates based on the actual
number of events (births, deaths,
diseases) in the total population over a given
time period.
• most widely used in description of
populations are the crude birth rate (CBR) and
the crude death rate (CDR).
# Of deaths in a year
CDR = ------------------------------------------X
1000
Average (mid-year) population.
Measurment of Health and Disease 124
 Crude rates …..
Advantages:
• Actual summary rates
• Calculable from minimum information
• Widely used despite limitations
Disadvantages:
• Difficult to interpret due to variation in
composition (e.g.: age)
• Obscure significant differences in risk
between subgroups.
Measurment of Health and Disease 125
 Specific rates
Apply to specific subgroups in the population, such as :
 Age-specific rates
 Gender-specific rates
 Race-specific rates
 Cause-specific rates
 Place-specific rates
Examples: Infant Mortality Rate (IMR), Neonatal Mortality
Rate (NMR), Maternal Mortality Ratio (MMR), Sex
specific mortality rate
# Of deaths from a specified cause in a year
CSDR=------------------------------------------------------x
1000
Average population in the same period
Measurment of Health and Disease 126
 Specific rates…
Advantages:
• The rates apply to homogenous
subgroups
• The rates are detailed and useful for
epidemiological and public health
purposes.
Disadvantages:
• It is cumbersome to compare many
subgroups of two or more
populations Measurment of Health and Disease 127
Commonly used mortality measures
Crude Death rate (CDR) = Total no. of deaths reported during a
given time interval X 1000
Estimated mid interval population
Age- specific mortality rate = No. of deaths in a specific age group
during a given time X1000
Estimated mid interval population of sp. age
group
Sex- specific mortality rate = No. of deaths in a specific sex during
a given time X 1000
Estimated mid interval population of same
sex
Cause- specific mortality rate = No. of deaths from a specific cause
during a given time X 100,000
Estimated mid interval population

Measurment of Health and Disease 128

 mortality measures….
Proportionate mortality ratio = No. of deaths from
a sp. cause during a given time x 100
Total no. of deaths from all other causes in
the same time
Case Fatality Rate (CFR) = No. of deaths from a sp.
disease during a given time x 100
No. of cases of that disease during
the same time
Perinatal Mortality Rate = No. of fetal deaths of 28
wks or more gestation Plus no. of infant deaths
under 7 days x1000 .
no. of live births during the same
period.
Measurment of Health and Disease 129
 mortality measures….
Neonatal Mortality Rate = No. of deaths under 28 days of age
reported during a given time x 1000
No. of live births reported during the same time
Infant mortality rate (IMR) = No. of deaths under 1 yr of age
during a given time X 1000
No. of live births reported during the same time interval
Child mortality rate (CMR) = No. of deaths of 1-4 yrs of age
during a given time X 1000
Average (mid-interval) population of same age at same time
Under- five mortality rate = No. of deaths of 0-4 yrs of age
during a given time X 1000
Average (mid-interval) population of the same age at same time
Maternal Mortality Ratio = No. of pregnancy associated
deaths of mothers in a given time x 100000
No. of live births in the same time
Measurment of Health and Disease 130
Measures of Association
• Epidemiological data are often
presented in the forms of two by
two (contingency) table

• 2x2 table contain 4 cells a , b , c , d

• The strength of association assessed

by calculating relative risk(RR),
odd ratio or other measure of
association Measurment of Health and Disease 131
Measures of
Association…

Measurment of Health and Disease 132

Measures of Association…

Measurment of Health and Disease 133

 Measures of
Association…
TESTS
1. Showing mainly the presence
or
absence of association. E.G.
Chisquare.
2. Showing the strength of
association: Relative Risk
(RR),Odds Ratio (OR) or other
measures of association.
Measurment of Health and Disease 134
 A. Relative Risk (RR) or
Risk Ratio

 shows the magnitude of

association between exposure
& disease
 Indicates the likelihood of
developing the disease in
exposed group relative to those
who are not exposed
Measurment of Health and Disease 135
 Relative risk

Example: Cohort study of oral

contraceptive (OC) use and
bacteruria among women aged 16-
49 years (table:2)
Measurment of Health and Disease 136
 Bacteruria
Oral
contrace Yes No Total
ptive
(OC) Yes 27 455 482
Use
No 77 1831 1908

Total 104 2286 2390

Table:2 Calculate RR ???? 1.4

Interpretation: Women who used oral contraceptive
had 1.4 times higher risk of developing bacteruria than
non users
Measurment of Health and Disease 137
 Odds Ratio (OR)
• RR can be estimated by calculating
the ratio of the odds of exposure
among the cases to that among
the controls i.e. the OR.
• Difficult to calculate RR
OR = a/c ad
b/d bc

Measurment of Health and Disease 138

 Odds Ratio (OR)…
Example: Table 3: this table shows
from case control study of oral
contraceptive (OC) use and
myocardial infarction in pre
menopausal female nurse. Calculate
Myocardial
OR???? Interpretation????
infarction
Oral
contrac Yes No Total
eptive Yes 23 304 327
(OC)
Use No 133 2816 2949
Total Measurment
156 3120
of Health and Disease
3276 139
 Attributable risk(AR)
 AR or RD is a measure of association that
provides information about the absolute
effect of the exposure or the excess risk
of diseases in those exposed
compared with those non exposed
AR= incidence among exposed-
incidence among non exposed (Ie-Io)

 Example: In the study of OC use and

bacteruria (table: 2), the attributable risk
Measurment of Health and Disease 140
Interpretation: the excess
occurrence of bacteriuria among
OC users attributable to their OC
use is 1566 per 100,000.

Measurment of Health and Disease 141

 Attributable risk
•
percent(AR%)
Estimate the proportion of the disease among
the exposed that is attributable to the
exposure, or the proportion of the disease
in the exposed group that could be
prevented by eliminating the exposure

AR%= (Ie- Io)x100

Ie
• Interpretation: if OC use cause bacteriuria,
for AR% of 28 % about 28% of bacteriuria
among women who use OC can attributed to
their OC use and can be eliminated if the they
did not use oral contraceptive.
Measurment of Health and Disease 142
 POSSIBLE OUTCOMES IN
STUDYING THE
RELATIONSHIP BETWEEN
DISEASE AND
1. No association EXPOSURE
between exposure and
disease
• AR=0, RR=1
2. Positive association between exposure
and disease (more exposure, more disease)
• AR>0, RR>1
3. Negative association between exposure
and disease (more exposure, less disease)
• AR<0 (negative), RR <1(fraction)

Measurment of Health and Disease 143

Thank you
Measurment of Health and Disease 144
QUESTION

Measurment of Health and Disease 145