DAVAO DOCTORS COLLEGE

MEDICAL LABORATORY SCIENCE DEPARTMENT

STUDENT NOTES: Biostatistics and Epidemiology

EPIDEMIOLOGY i. Specific agent, specific disease
(Agent -- Disease)
a. Study of distribution and determinants of health-related b. Multiple Causation
events i. Interplay of different components
b. Components 1. Susceptible host +
i. Descriptive (Goal: generate hypothesis) Pathogenic Agent +
1. Distribution of health-related space Environment = disease
2. Describes the pattern of disease as to ii. Sufficient component cause
a. P – Person 1. Each component should be
b. P – Place present
c. T – Time 2. C1+C2+C4+C5=Disease
3. Designs a. Sufficient cause
a. Case Report b. Component cause
b. Case studies c. Necessary cause
c. Ecologic studies 3. Hierarchy of Cause
d. Prevalence studies a. Indirect cause IC
ii. Analytic (Goal: test hypothesis) b. Direct cause
1. Determination of health-related states c. Disease
a. Understanding the causes of risk a. +DC=Disease
factors that lead to the disease 2. Risk Factors (it is not the cause but only
2. Designs the “enabler”)
a. Cross-sectional a. Personal behavior/ lifestyle/ practices
b. Longitudinal b. Environmental exposure
i. Prospective c. Genetic make-up (predisposing factor)
1. Observational: Cohort study 3. Association
2. Interventional: Experimental a. Identifiable relationship
ii. Retrospective b. Associated variables mean that they
1. Case control co-exist
c. Functions c. Does not necessarily imply cause and
i. Describe health status effect relationship
ii. Explain causes 4. Confounders
iii. Predict a. Extraneous variables whose effect
d. Disease Causation may influence the relationship of the
i. History variables to be studied on
1. Hippocrates b. It has to be “controlled” since it has an
2. Miasmic Theory influence to both cause and effect;
3. John Snow – shoe leather theory “without the confounder, the causation
4. Robert Koch – Germ theory (Koch’s will not push thru”
postulate)
5. Legionnaire’s disease – pneumonia among Case
American Legion Convention attendees in a.Set of standard criteria for deciding whether an individual has a
Philadelphia Hotel (1976) disease or health event of interest
6. Toxic Shock Syndrome – use of tampons b.Criteria
among menstruating women (1980) i. Manifestational Case – e.g. Syndromes; Chronic
7. Framingham Heart study – Thomas Drawber; and Psychiatric Diseases
risk factors for development of Coronary i. S/Sx
Heart Disease (1948) ii. Laboratory findings
8. British Doctors Study – R. Doll and R. Peto iii. Onset, course
(1951) – smoking and death among british iv. Prognosis
docs – harmful effects of during smoking v. Treatment response
ii. Theories of Disease Causation ii. Causal – e.g. Infections
1. Causation – linearity, cause precedes the i. Identifying the disease based on its cause/ etiology
effect
a. Specific Causation
Natural History of Disease viii. Method of hypothesis testing
a. Good health > ill health > Good health (Recovery) a. Method of Agreement (Commonality)
> ill health >> Death o There is a common circumstance in
b. Exposure to symptom agreement with all instance
i. Initiation – infectious disease o E.g. common factor X results to
ii. Induction – non-infectious disease disease Y
c. Exposure to time of diagnosis b. Method of Difference
i. Latency o Disease A = has factor X Y Z; Disease
d. Prevention A = W Y Z; therefore Disease A is not
Level Phase of Goal caused by Factor X
Disease c. Concomitant variation
Primordial Underlying Minimize o Level of severity
o Eg. More factor X results to Severe
economic/ hazard
form of disease than those with less
social/
factor X
environmental d. Analogy
conditions o Example
leading to  Disease V is common in place Z
causation and is caused by Factor X
e.g. helmet  Disease W is common in place Z
use/ wash of and is caused by Factor X
hands  Disease Y is common in place Z
 Therefore, Factor X is the cause of
Disease Y
Primary Specific causal Reduce Descriptive Epidemiology
factor incidence a. Descriptive Studies
Eg. HPV of disease i. Case report
vaccine a. Detailed account of a patient’s
experience and clinical manifestation
that comprise a new or an atypical
Secondary Early Stage of Reduce health event or disease
disease prevalenc i. Eg. VACTRL syndrome
e of ii. Case Series
disease a. Multiple case reports in one disease
by iii. Prevalence Studies (Existing Case)/ Incidence
shortening (New Case)
duration a. Determine proportions of individuals
Tertiary Late stage Reduce with the disease or a heath event in a
the defined population at a given time
number b. E.g. parasitism among children
iv. Ecological Study
and
a. Aka correlational study
impact of
b. Correlation of factors in different
complicati groups
on
Analytical Epidemiology
a. Analytical Studies
Epidemiologic Approach
i. Counterfactual Scenario/ Alternative History
a. Flow
a. The “what if” in epidemiology
i. Examine existing facts
b. An alternative parallel timeline that differ
ii. Generate new hypothesis
from reality
iii. Test hypothesis
ii. Contingency table
iv.Conclude/ generate new facts
b. Components of an Epidemiologic hypothesis Disease Present Disease Absent
ii. Cause is considered
iii. Anticipate the effect Factor Present A B A+B
iv. Characterize the population Factor Absent C D C+D
v. Exposure-response is established
vi. Time-response relationship A+C B+D
vii. Example of Epidemiologic Hypothesis
a. Men who would exercise 30 minutes a day iii. Measurement of exposure and outcome variables
for 6 months will lose weight by 50% compared at one time point
to those who do not
 a. Measured at one point of time– Cross-
sectional
b. Cannot be measured at one point of time-
Longitudinal
i. Measurement of Outcome variable
1. YES – Prospective study
2. NO – Retrospective
ii. Assigning or manipulating the exposure
variable
1. Observational – no intervention
(Cohort)
2. Experimental – with intervention
iv. Designs
a. Cross-sectional
i. Aka Prevalence study
ii. E.g. survey of group with exposure and
without
b. Cohort Study
i. Prospective study between with exposure
and without exposure
c. Retrospective Cohort Study
i. Aka historical cohort study
ii. Retrospective study between group with
or without exposure and its present
outcome (with or without the disease)
d. Case-control study
i. Aka trohoc study
ii. Outcome is measured at present time
and E of the participants in the past is
estimated
iii. Subjects should be the same
1. Eg. All should be 7 yrs old, same
outcome
e. Experimental Study
i. A cohort study with manipulation of
exposure or non exposure with
randomization
ii. Cohorts are randomly assigned
Measurements in Epidemiology
a. Measures of Disease Frequency
i. Quantification of disease occurrence
1. Size of population
2. Time period from which data was
collected
ii. Ratio – “a/b”
1. Proportion
a. Type of ratio in which who are
included in the numerator are also
included in the denominator
b. a/a+b
2. Rate
a. There is a distinct relationship
between the numerator and
denominator
b. Time – included in the
denominator
b. Measure of Occurrence
i. Incidence – new cases
ii. Prevalence – present cases
c. Population
i. Closed population
1. Aka cohorts
2. no gains for members after it is
established but may be reduced due to
losses e.g. death
3. if members are no longer at risk hence
called now a case
ii. Open population
1. Aka dynamic
2. Adds new members through birth and
immigration and lose through death and
emigration
3. Through time, the open population may
grow, remain constant or decline
d. Measures of incidence
i. Number of new cases that develop in a population
at risk during a specified time interval
1. Numerator – measure of events –
transition from diseased state, thus can
be a measure of risk
2. Denominator
a. Individuals who are at risk and who
was at risk and now acquired the
disease state
3. incidence proportion = (no.of new cases
given a period of time)/(total population at
risk)
4. incidence rate = (no.of new case during
a period of time)/(total person time of
observation)
e. Person time
i. Amount of time a person is observed during the
study, and is counted only when a person is at risk
of being detected as a case
ii. Not counted after
1. The person develops the disease under
investigation
2. The person withdraws from the study
3. The study ends
iii. Add the time of every case until the person
developed the disease
iv. Individual Person time is KNOWN
1. Sum of individual’s time at risk or time
each person remained under observation
and free from disease
v. Individual Person time is NOT-KNOWN
1. Total person time = average population
size x length of follow-up periods
2. Average population = population at start
+ population at the end/2
f. Prevalence
i. Quantifies the proportion of individuals in a
population who have the disease a specified time
1. Prevalence = (no.of existing cases)/(total
population) x 100
2. Point in time
a. Specific point in calendar eg.
Onset of menopause
ii. Relationship between prevalence ad incidence
1. P = I x D
a. Assumptions
a. Incidence of the disease is
constant over time
 b. Duration of disease is 1. Standard set of criteria
constant over time 2. Components
c. Prevalence of the disease is a. Clinical criteria
low <10% b. Exposure to risk factors
3. Stratification of cases
Outbreak Investigation a. Confirmed
I. Definition of terms b. Probable
a. Outbreak – upsurge of cases in a defined geographic c. Possible
region or easily defined sub-population; more cases than 4. Search for additional cases
expected given area, group of people and period of time a. Local clinics, hospitals and labs
b. Epidemic – outbreak on a larger area b. Direct from doctors, institutions and
c. Disease cluster – aggregates of cases in an given area, groups
group of people and period of time regardless if the c. Reports from media
number of cases is more than expected d. Surveys if the population
II. Factors affecting to mount outbreak investigation 5. Information collection
a. Number of cases is significantly higher than expected a. Case ID
b. Scale and severity b. Demographic info
c. Potential for spread i. Age
d. Political and public health consideration ii. Sex
e. Resource availability c. Reporter information
III. Agencies d. Clinical information
a. Local health departments e. Risk factor information
b. Higher level health agencies f. Denominator data
IV. Objectives vi.Conduct Descriptive Epidemiologic studies
a. Assess the extent of the outbreak 1. Range and extent of outbreak
b. Reduce the number of cases associated with the outbreak 2. Exposure, MOT, incubation period,
by identifying and eliminating the source environmental contribution, host risk factors
c. Identify new diseases syndromes and agent characteristics
d. Assess efficacy of employed prevention strategies 3. Generate hypothesis
e. Address liability concerns, measures damage 4. Describe time epidemic curve
f. Train epidemiologists a. Display magnitude and time trend
g. Provide good public relations and public education i. Epidemic vs endemic
V. Steps ii. Y axis = cases
a. Prepare field work iii. X axis = time
i. Administrative b. Information obtained
1. Travel arrangements i. Probable period of exposure
2. Supplies, equipment, logistics 5. Present/ Analyze Data
3. Administrative and scientific contacts a. Epidemic Curve
ii. Personal i. Point source epidemic
1. Knowledge updates 1. Exposed to the same
2. Understanding of role in the field time in a short period of
3. Familiarity of the chain of authority involved time
in the process 2. peak
b. Establish outbreak ii. Continuous common source
i. Confirm reported cases epidemic
ii. Compare observed rate of occurrence with 1. plateau
1. National surveys iii. Sporadic Curve
2. Data from localities 1. common intermittent
3. Published literatures source
iii. Consider 2. curve is jagged
1. Random fluctuations in occurrence iv.Propagated epidemic
2. Seasonal variation 1. Disease spread is
3. Change in reporting practices or case person to person with
definition increasing number of
4. Diagnostic bias cases in each generation
5. Publicity bias 2. Progressively taller
iv.Verify diagnosis of cases peaks
1. Review clinical findings and lab results b. Epidemic Maps
2. Check consistency with what is known i. Dot maps
clinically and epidemiologically 1. Geographical extent
v. Establish case definition and search for additional 2. Evidence of clustering
cases vii. Develop hypothesis
 viii. Evaluate Hypothesis
ix.Reconsider refine hypothesis and conduct
additional studies
x. Communicate Findings

REFERENCES:
 Bluman, A. G. (2012). Elementary statistics: a step by step
approach (8th ed.). 1221 Avenue of the Americas,New York,
NY 10020: McGraw-Hill Companies
 Daniel, W. W. (2005). Biostatistics: A foundation for analysis
in the health sciences (8th ed.). Philippines: Mindmover
Publishing. doi:570.15195/D221
 Nuevo, J. M. (2019). Biostatistics and epidemiology.
Powerpoint presentation.