Epidemiology - what is it?

•epi - upon
•demos - people or population
•logos – science
•‘That which befalls the population’
•The study of the distribution and determinants of
disease frequency in human populations
(MacMahon and Pugh, 1970)
MEASURING HEALTH AND DISEASE

1.Definitions
2. Measurement (general issues)
4. Measures of disease frequency
3. Routinely available information
(e.g., mortality, morbidity)
5. Measures of effect
Population Health
™Conceptual framework for thinking why some
people are healthier than others
•Policy development for resource allocation
ƒMaintenance of health
ƒHealth research
™Social structures and processes that contribute to
health
™Epidemiology addresses health at the population
level
DEFINITIONS OF HEALTH AND DISEASE
REQUIRE DEFINITIONS OF NORMALITY:
• Common (frequent)
• Statistical (within a range)
• Pragmatic (related to risks)
• Practical (related to benefits)
DEFINITIONS ARE BASED ON
• Signs
• Symptoms
• Results of tests
Defining health
•The absence of disease
•A feeling of well-being
•Freedom from the risk of disease and untimely death
•Many definitions
WHAT IS HEALTH?
"Health is a state of complete
physical, mental social well-being
and not merely the absence of
disease or infirmity."
(WHO.1948)
Define disease
™Case definition is the set of criteria that differentiate
normal (non-diseased) from abnormal (diseased).
™Case definition may be based on symptoms
„sometimes the absences of symptoms
™Case definition may be complicated because there:
„Are no tests;
„Tests are expensive; or
„Test are impractical.
It is important that case definitions are frequently
reviewed
Case definition
™Case definition should consider how cases will be
detected.
™Things to consider:
„Is there a registry of cases?
„Are all cases likely to be recorded on the registry?
„Are cases seen by a medical practitioner?
„Are all cases likely to be seen by a medical
practitioner
The Jones criteria (revised) for guidance in the
diagnosis of acute rheumatic fever
A high probability of rheumatic fever is indicated by the presence
Of two major, or one major and two minor manifestations,
if supported by evidence of a preceding Group A streptococcal infection.

Major manifestations Minor manifestations

Carditis Clinical:
Fever,
Polyarthritis arthralgia (joint pains),
previous rheumatic fever
Chorea or rheumatic heart
disease
Erythema marginatum
Laboratory:
Subcutaneous nodules acute-phase reactants:
abnormal erythrocyte
sedimentation rate,
C-reactive protein,
leukocytosis
prolonged P-R interval
MEASUREMENT OF HEALTH AND DISEASE
IS REGUIRED FOR:

• Preventing disease
• Promoting health
• Planning health services

THE CENTRAL TOOL OF EPIDEMIOLOGY

IS THE COMPARISON OF RATES:

Rate = Numerator x 10n

Denominator
INDICATORS OF A POSITIVE HEALTH STATE (DIRECT
MEASURES)
PHYSICAL DEVELOPMENT INDICATORS ‐ measures physical growth outcomes.
These indicators include a variety of anthropometric dimensions, the most common being  
height,weight.
PHYSICAL FITNESS INDICATORS – different tests‐e.g. 
•Youth Fitness Test, which is composed by the Sit-Ups, Shuttle-run, Standing
Long Jump, 50-Yard dash, 12- Minute Run,
•the time it took to walk 6 m at a normal pace,
•the best of 3 trials of grip strength,
•the best of 3 trials of forced expiratory volume of air from the lungs in 1 second
(FEV1)
EXERCISE TOLERANCE INDICATORS ‐ The exercise tolerance tests are used to 
determine how efficiently the different  systems are  working. It can be performed on both 
healthy individuals or on someone who may be suspected of having a disease, during
treatment or rehabilitation.
•Treadmill exercise testing
•Stationary bicycle exercise testing
•Harvard Step Test
NEGATIVE HEALTH INDICATORS
(MEASURES)

Always calculated as

Rate = Numerator
Denominator
Defining the population
•Populations may be defined by:
„Location
„Age
„Sex
„School
 Population at risk in a study of carcinoma of the cervix
Total population All women (age groups) Population at risk

For any epidemiogical analysis defining the population at risk improves accuracy since the will not be "diluted" by including people
who cannot contract the disease in the denominator.
For cancer, neither men (because they have no cervix), nor young or very old women (because they are unlikely to develop
the disease) are included in the population at risk
–Study population
–the population of individuals selected to participate 
in the study (regardless of whether they participate) 
–Target population
–Target population = population to which the results 
will apply
 Target

Sample 
Study population

Study population = the population of individuals selected to participate in the study 
(regardless of whether they participate) 
 Target

Sample 
Study population

Sample population = the population that is actually sampled (may = study population).
 Sampling
• Method of sampling determines if results can
be extrapolated to the target population.
• A number of methods may be employed to
sample the population including:
– Randomly select a sub-set (e.g. draw 10 house
numbers from a hat)
– Non-randomly select a sub-set (e.g. all even
number houses in a street)
 Defining timeframe

• Study time
–Period of time over which the study is
conducted
–Usually calendar time
–Sometimes specified by event at which
data collection commenced e.g. birth to
school age
 Defining time frame

• Risk period
–Time during which the individual could
develop disease
–Does not always equal the study time
• e.g. a person is a risk of work place
accident only when working.
 Introduction

• It is important to describe the

frequency of disease in
numeric terms.
 Prevalence

• Proportion of population at a defined

point in time that are suffering from the
disease.
• Case becomes an prevalent case until
recovery, death or it leaves the population
• Calculated as the:
Number of individuals with attribute at a
specified point in time X10n
Total population at the given point in time
Factors influencing observed prevalence rate
 Prevalence

If population is in a ‘steady state’

then prevalence depends:
¾Incidence
¾Duration of disease
Therefore prevalence may increase if
survival rate improves and incidence
stays the same
Incidence rate
I 10n
IR= X 

PT
•Where:
I = number of cases
PT = Person time a risk

•Theoretical range zero to infinity

Person time at risk

•An individual contributes time at risk until
„Loss to follow‐up
„Death from another cause
„Change in risk status (e.g. hysterectomy 
eliminates risk of uterine cancer
What is person time at risk?
•Person‐time at risk is the denominator for rates of 
disease
•1000 person‐years at risk =
„1000 people followed for 1 year
„500 people followed for 2 years
„10,000 people followed for 1/10 of a year
„100 people followed for 10 years
Calculating person time at risk

•Exact method

„Sum up the total person time at risk

 Steady state population

births deaths
Population at risk
Immigration Emigration

cases
 Estimating time at risk

–All cases, losses to follow-up and

additions occur half way through
the study period
• Alternatively, ½ the cases occur
at the beginning and ½ at the
end
• Uses the formula
(No. at start - ½ no. sick – ½ no.
lost + ½ no. add)×length of study
Cumulative incidence
I
CI =
N0

•Where:
„I = Number of cases during a time period
„N0 = Disease free people at time zero
•Theoretical range 0 to 1
•Probability that an individual will become
diseased over specified period
 Attack ‘rate’
• Is equivalent to the cumulative density
– i.e. number of cases/number at risk at
start
• Is a proportion not a rate
• Typically used in reports of point
source epidemics
 Case fatality ‘rate’
• Is cumulative incidence of number of
people infected that died.

• The proportion of individuals contracting

a disease who die of that disease.

• Problem is the ‘true’ number of infected

people may be unknown.
 When do I use each
measure?
• Risk-based measure (i.e. prevalence and
cumulative incidence) are best if:
–Risk period is short relative to the study
period
–There is no recovery and no deaths
–No/small losses to follow-up
–All people at-risk for the same length of
time
 When do I use each measure?

• Rate based (Incidence rate) measures are

best if:
–Risk period is long compared to the
study period
–Recovery or high death rate
–Repeat events
–People at risk for varying lengths of time
ROUTINE INFORMATION
MORTALITY (DEATH) DATA:
(Coded according to the ICD 10)

CRUDE MORTALITY RATE (CMR)

Total # people dying

CMR = ___________

Total # people
*AGE-SPECIFIC RATES
*SEX-SPECIFIC RATES
*CAUSE-SPECIFIC RATES
*AGE-STANDARDIZED RATES (Also called age-adjusted rates)
•Standardization: 
„The process by which you derive a 
summary figure to compare health 
outcomes of groups
„The process can be used for mortality, 
natality, or morbidity data
Infant mortality

The infant mortality rate is defined as the number of infant deaths (deaths in
the first year of life) to those born in a particular year per 1000 live births in
that year.
Method of Calculation

Infant Mortality Rate

Total number of deaths for live born
infants (364 days or younger)
Total number of live births
x 1,000

Neonatal Mortality Rate

Total number of deaths for live born
infants (27 days or younger )
Total number of live births
x 1,000

Postneonatal Mortality Rate

Total number of deaths for live born
infants (28 days to 364 days)
Total number of live births

Early Neonatal Mortality Rate

Total number of deaths in live born
infants 6 days of age or younger
Total number of live births
x 1,000
LIFE EXPECTANCY
Average number of years of life remaining at
specified ages if current mortality trends continue

EXAMPLE: New Zealand life expectancy at birth

(years)
Men Women
European 71 77
Maori 67 71
Definitions:
Impairment, disability, handicap

Impairment: Any loss or abnormality of psychological,

physiological, or anatomical structure or function

Disability: Any restriction or lack (resulting from an impairment)

of ability to perform an activity the manner or within the range
considered normal for a human being

Handicap: A disadvantage for a given individual, resulting from

an impairment or a disability, limits or prevents the fulfillment of a
role that is normal (depending on age, sex, social and cultural
factors for that individual)