Public Health and Epidemiology:

Lecture 1a:

Ø 3 pillars of public health practice:

1. Health services: organization + delivery of high-quality services for prevention, treatment and care
2. Health protection: measure to control infectious disease and environmental hazards (+ readiness to face public health emergencies)
3. Health improvement: services aimed at promoting health and tackling determinants of health inequality
Lecture 1b:
Ø What is burden of disease?
- Concept that describes death and loss of health due to disease, injuries and risk factors for the whole world
Equations:
Incidence: rate of new cases in a specified population in a given period
Used to measure acute disease, and studies of causation
Cumulative incidence: risk that an individual will develop disease in Incidence rate: how frequently/fast a disease occurs in a population
a given time interval
Measures Cumulative incidence = # #$ %&' ()*&* +% ) ,+-& .&/+#0 # 56 789 :;<8< =7 ; >=?87 @8A=5B
Incidence rate = C5D;E @8A<57 D=F8 56 5G<8A?;D=57< 9H=E8 ;D A=<I =7 ; >=?87 D=F8 @8A=5B
# #$ ..1 +%+,+)112 $/&& #$ )%0 ), /+*3 #$ ,4& 0+*&)*&
of
morbidity
*DON’T INCLUDE PPL LOST TO FOLLOW UP OR PPL WHO DEVELOP *If person time not available we use mid-year population
DISEASE DURING OBSERVATION *
Prevalence: frequency of existing cases in a population at a given point in time
Used to see burden of chronic diseases and implication for health services
Point prevalence: prevalence at a particular point in time Period prevalence: prevalence measured over an interval of time
# 8J=<D=7> :;<8< 56 B=<8;<8 ;D ; >=?87 𝐩𝐨𝐢𝐧𝐭 56 D=F8
Point prevalence= P5@QE;D=57 ;D DH8 <;F8 >=?87 @5=7D =7 D=F8

Ø Relation between incidence and prevalence:

- Common cold: high incidence and low prevalence
- T2D: low incidence and a high prevalence
Ø What factors increase prevalence?
1. Longer duration of disease
2. Increased frequency of new cases
3. Improved diagnosis and thus better reporting
4. Emigration of healthy ppl and or immigration of susceptible ppl
Ø What factors decrease prevalence?
1. Shorter disease duration
 2. Decreased incidence of new cases
3. Emigration of cases
4. Immigration of healthy ppl
Ø What is HALE (Health Adjusted Life Expectancy)
- Average number of years that a person can expect to live in full health by taking into account years lived in less than full health due to disease and or
injury
- Obtained by subtracting years of ill health from standard life expectancy
Ø What are QALYs (quality adjusted life years)?
- A measurement that gives us an idea of how many extra months or years of life of reasonable quality a person might gain as result of treatment
- 1: perfect health 0: death/bad health
- Estimated through questionnaires
Ø What are DALYs (Disability adjusted life years)?
- A measure of the overall burden of disease DALYS = YLD + YLL
- YLD: Years lived with disability
- YLL: Years of Life lost
- 1 DALY = Loss of 1 year full of health

Ø What is disability weight?

- Value of time lived in non-fatal health status à opposite of Q
- 0:perfect health 1: death

Ø Compare QALYs and DALYs:

Lecture 1c:
Mortality rates:
R
#$ 0&),4* +% ) 0&$+%&0 .#.S1),+#% 0S/+%T ) T+U&% ,+-& .&/+#0
Crude mortality rate =D5D;E @8A<57 D=F8 56 5G<8A?;D=57< ;D A=<I 56 BV=7> WX F=B V8;A =7D8A?.@5@QE;D=57 Total number of deaths in a population during a time interval
# B8;DH< =7 ;7 ;>8 >A5Q@ =7 ; >=?87 D=F8 @8A=5B
Age specific mortality rate = *+Z& #$ .#.S1),+#% #$ ,4), )T& T/#S.
SEE: neonatal, postnatal and infant mortality rates
# 0&),4* 0S& ,# ) *.&(+$+( ()S*& 0S/+%T ) ,+-& +%,&/U)1
Cause specific mortality rate = -+0 2&)/ +%,&/U)1 .#.

Ø What is direct standardization?

- Answers the Q of what would be the mortality rate in a standard population, if this had the same age specific mortality rates of countries A& B?
- We use standardization to compare mortality rates more accurately

Ø What is indirect standardization?

- Answers the Q of what would be the mortality rate in country A and B if they would have the same age-specific mortality rates of a standard
population? è we do this when we don’t have the age specific mortality rates
*more suitable for studies with s,all number or when rates are unstale

Ø Comparison of direct &indirect standardization:

Lecture 2a:
- What is the difference between descriptive and analytic studies?
Ø Descriptive: generate hypothesis
Ø Analytic: test hypothesis about exposure-outcome hypothesis è include a comparison group
A. Observational or
B. Experimental
- What is the difference between case report and case series?
Ø Case report: describes the experience of a single patient
Ø Case series: describe a set of patients who show similar symptoms or outcomes
- What are ecological studies?
Ø Studies where the unit is a GROUP instead of an individual example: measuring the association between mean number of minutes exercised by people
living in different parts of the country and compare it with the average body weight measured in a health survey covering the same geographical areas
instead of measuring the minutes an individual exercises and relate this to his body weight
Cross-sectional study:
• To learn about the characteristicsof a population or a trend in a specific point in time à i.e. a SNAPSHOT
• Often done as a survey (no comparison group)
• Small defined group OR a sample from a bigger group à that should represent the whole pop
•

Cohort studies: longitudinal follow up studies [exposure occurs BEFORE outcome = exposure à outcome]
• Well define group of individuals who share a common characteristic or experience (e.g. born same year, went to same event)
• Used to find multiple outcomes from a single exposure
• Participants classified according to exposure status and followed up over time [participants are always free of disease initially]
Prospective Vs Retrospective cohort studies:
Case-control study: slide 25
• Examines multiple exposures related to a SINGLE outcome
• Participants selected based on OUTCOME STATUS [except the control subjects don’t have any outcome]

• Participant selection: 1st step= the case definition should be clearly defined to make sure that all cases are based on the same diagnostic criteria [the
criteria specified should include:
1. Person: patient characteristics (age, sex, race, occupation, exclusion criteria)
2. Place
3. Time (period associated with illness onset)
4. Clinical features
Ø Control group: random sample from the general population that gives rise to the cases è recruiting >1 control per case may improve the statistical
power of the study [more than 4 controls per case is not considered to be more efficient]
 Lecture 2b:

COHORT STUDIES: MEASURES OF ASSOCIATION CASE CONTROL STUDIES: MEASURES OF ASSOCIATION

• Risk ratio: binary categorical outcome aka relative risk • Odds ratio: categorical exposures
**Binary outcomes are those that can take only one of two values, such as treatment failure or Ì Odds= the probability of an event occurring vs the
success, or mortality (dead or alive) probability of it not occurring
**Categorical outcomes: These are dependent variables that have mutually exclusive outcomes.
That is, the choice of one outcome means non-use of the other outcome
• Mean difference: numerical exposures
• Rate ratio: biary/categorical outcomes à used when person years can be Ì Mean of exposure in case group – mean of exposure in
calculated control gotup
!! In case control studies the outcome is ALWAYS binary !!
Ì Compares the rates of disease in 2 groups that differ by demographic
characteristics by exposure history
• Mean difference: categorical exposure Vs numeric outcome
/+*3 +% &[.#*&0 # %&' ()*&* )/(
Risk ratio= /+*3 +% S%&[.#*&0 Rate ratio= .#.S1),+#% ,+-& ), /+*3 Mean difference = Odds ratio: = d/0
mean of outcome in
Example:
exposed – mean of
To find risk in exposed or
outcome in
unexposed you do:
# #$ %&' #S,(#-& #((S/&%(&* unexposed
Risk= PWP\]^C_W` ^C X_ab

Risk ratio interpretation: Rate ratio interpretation: Odds ratio interpretation:

• >1: exposed have an • =1: exposed & non-exposed have same odds of developing the
increased risk of outcome outcome (exposure is not associated w/ outcome)
• <1: exposed have decreased • >1 exposed have greater odds/ likelihood of developing outcome
risk of outcome (exposure= risk factor)
• =1: exposed & non-exposed >1 exposed have fewer odds of developing the outcome
have the same risk of the (expo=protective factor)
outcome3
Lecture 2c:

- What are the characteristics of a confounder?

is a variable that influences both the dependent variable and independent variable, causing a spurious association
1. Variable independently associated with the outcome
2. Variable must be associated with exposure in the source population
3. Should not lie in the causal pathway between the 2

- When smth fulfils the criteria of a potential confounder what do we do to test if indeed it confounds the exposure-disease relationship
à Calculate crude estimate à stratify and calculate the crude estimate in each strata = pooled risk ratio aka adjusted estimate
è IF the adjusted estimate differs from the crude by 10 % or more then we consider it a confounder
Example:

- How do we control for confounding at the design stage?

• Randomization
• Restriction
• Matching
- What do we mean by matching?
The selection of study participants so that potential confounding variables are evenly distributed in the 2 groups being compared
Example: in a case control study of exercise and CHD, each patient with HD is matched with a control of the same age group and sex to ensure that
confounding by age and sex doesn’t occur
*If the matching criteria are too many and too strict = called overmatching

- What do we mean by restriction?

We mean the use of inclusion/ exclusion criteria to limit the study to ppl who have particular characteristics
 Example: in a study on the effects of coffee on CHD,participation in the study should be restricted to non-smokers à removing any potential effect of
confounding

- Even after the above techniques we can still have some ‘residual confounding’. What are the causes?
Ø Unmeasured confounding (i.e. not all parameters are taken into consideration)
Ø Some confounding categories are too broad
Ø Missclassification in measure of confounder

- What is overadjustment?

- Summary:
 - What is bias?
Any systematic error in a study that results in an incorrect estimate of the association between exposure and risk of the disease
2 categories of bias:
1. Information bias
2. Selection bias

- What is information bias? What are the types?

Ø Results from systematic differences in the way data on exposure or outcome are obtained from the various study groups (measurement error)

- What is selection bias? What are the types?

Selection bias occurs when there is a systematic difference in characteristics between either those participating in the study and those who do not, or those
in the treatment arm of a study and those in the control group
When these characteristics are related to either the exposure or outcome under investigation

- What is internal validity?

If the results of the study are valid for the sample of patients who were actually studied.
[High internal validity comes at the expense of ability to be generalized]
- What does internal validity depend on?
1. Chance (random error)
2. Confounding
3. Bias (systematic error)
- What is external validity?
If the results of the study are valid for the population from which the sample in the study was drawn
Lecture3a:
Mini summary of week 1 & 2 (measures of frequency and measures of association respectively:

- What is the attributable risk?

Ø Measures the amount of a health outcome in the exposed that can be attributed to a specific exposure
Ø Incidence in exposed – Incidence in non-exposed è risk difference
Ø Note: can be calculated from cumulative incidence, incidence rate, mortality rates, DALY rates à broad concept

- What is attributable risk percent or fraction?

Ø It’s the attributable risk divided by the population exposed so we express it as a proportion
Ì Proportion I can prevent if we eliminate the risk factors (the proportion of the disease incidence inn the exposed that would be eliminated if
exposure were eliminated)
Ì If we don’t have information on the incidence, we can use the RR for cohort studies and the OR for case control studies:
Ì

Example:
 - What is the population attributable risk?
Ø Is the risk in the population that would be eliminated if the exposure were eliminated [PAR= Risk in population – risk in nonexposed]
We change the ‘exposed’ component with the population
Ø If we don’t know the risk in the population à PAR = AR X Proportion of exposed

- What is the population attributable risk percent or fraction?

Don’t remember these formulas

Example:
 - What is the number needed to treat (NNT)?
= The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.). For
example, if a drug has an NNT of 5, it means you have to treat 5 people with the drug to prevent one additional bad outcome.
è the higher the NNT the less effective is the treatment because more ppl need to receive the treatment to see a benefit in one person
e
NNT = fgg

Example:

- What is the number needed to harm (NNH)? (Aka number needed to treat in order to harm)
= The number of individuals who must be treated so that one of them presents an adverse reaction accountable to treatment
è It should be high as this indicated lesser likelihood of harm relative to the comparator
Example:
- What do we mean by the term efficacy?
à Efficacy is what is measured in trials è can it work?

- What is effectiveness?
à Whether the treatment achieves its goals in real life è does it work in the real world?

- What factors can affect the cost effectiveness of an intervention?

Time, place

- What are the 3 types of economic analyses?

1. Cost effectiveness analysis: how can I get the biggest effect for every euro spent? [ measured in non-monetary single natural unit]
2. Cost utility analysis: measured in terms of utility (indicator used in QALYs e.g., u measure how much money you spend for every 1 point increase in
QALY)
3. Cost benefit analysis: completely measure in terms of money: if an intervention costs an X amount of money how much money am I getting back à
does this cost us money or save it in the long run?

- What is vaccine efficacy vs effectiveness?

-
Lecture 3b: Statistical testing of a hypothesis
• Sample estimate: our ‘best guess’ (derived from single sample) about
population parameter
• Sample estimates contain some error because we didn’t investigate the entire
population à aka sampling error or random error
• Sampling error ¯ with sample size è the more our sample approaches the
population size the smaller the error àThe smaller the uncertainty about
population parameter
• Standard error: an estimate of sampling error from a single sample è so from
a single sample we get the best guess (sample estimate) and how wrong we
can be when we only take 1 sample (standard error)
• 95 % CI = Sample estimate +/- 1.96 SE à provides an interval in which we
expect the population parameters to be with high probability è the 95% CI will
contain the population with 95% probability

When the 95 % CI doesn’t include 0 à we can say that this is statistically significant
SOS:
Lecture 3b: Part II Statistical testing of hypothesis

- What is the p value?

Ø The probability of obtaining an association as strong (or stronger) as the one observed in our sample, if in fact there is no association present in the
source population (i.e. the null hypothesis H0 is true)
! the smaller the p value the stronger the evidence to reject the null hypothesis Mostly set at 0.05
 When the 95% CI doesn’t include 1 (in case of a RR)è
this already means that the p value will be smaller than
0.05 (but we don’t know how low this probability is)

§ Generally the stronger the association the smaller

the p value

- How do we calculate the p value?

o Chi square test: if both depend on and independent variable are categorical
o T test: if independent variable is categorical and the dependent variable is continuous (e.g. does the mean fasting blood glucose level vary
between 2 groups e.g. high vs low physical activity
o ANOVA: 3 or more groups
o Linear regression:test hypothesis when looking at association between 2 numerical variables
Conceptual errors in hypothesis testing and associated probabilities:
Ø Type 1a: False positive in reality there’s no difference but the study
suggested there is a significant difference àwe rejected the null
hypothesis when in fact it was accurate
Ì The max. rate of type I error is governed by α

Ø Type 2: false negative: u miss a difference àthere is a difference in

the population, but you say
there is none
Ì Β is the probability of
type 2 error: depends
on sample size, effect
size and a (alpha)
Ì The bigger the sample
the bigger the power
Post hoc testing, subgroup analyses and the risk of multiple comparisons
 Interventional study design: aka Clinical trials [assign the exposure rather than assessing it]
• Can investigate binary (incidence) OR numerical (BP) outcome
Lecture 4a: • Involves:
A. A group that receives intervention (treatment) à Intervention study arm
B. A group that receives control treatment à Control study arm
• Always prospective (i.e. there is follow-up)
• Types:
A. Randomized Controlled trials (RCTs)
Ì Parallel
Ì Crossover
B. Non-randomized/non-controlled trials (quasi experimental)
1. Point of randomization: DON’T confuse with random sampling à this has to do with. How we recruit our sample
from the source population [randomization has to do with how we split that sample into 2 identical groups]
o Eliminates allocation bias (type of selection bias) à ensures that the way participants are split into groups
and whether they will receive intervention or control is completely random
o Ensures equal distribution of participant characteristics in the groups à minimizes confounding

2. Presence of control group: allow for the study of the effectiveness of the intervention beyond any placebo effects
- In the absence of a control / placebo group à we call it active control (old/conventional treatment) or if we
want to compare doses the control/active group will be the ones receiving the lowest dose

3. Point of blinding ensures elimination of allocation bias as well as response bias

o Single blind: if only the participants are not aware of the group they are in
o Double blind: if both participants and researchers don’t know which category they are in

Crossover design: removes patient variation à we can investigate the participants response to either active
intervention AND the control intervention i.e a specific type of RCT where you assess 2 or more interventions. In this
design, all participants receive all the interventions, but the order in which they get the interventions is randomisedè
more study power (precise and efficient results)
- If the wash out period is not adequately performed = carry over effects
- In cross over designs participant drop out increases because participants are followed up over a longer period
of time
When can we NOT use cross over RCTs?
Ø When the treatment cures or totally alleviates the symptom
Ø Treatment persists or has long term effects (leading to carry over effects)
Ø Disease / symptoms have slow or delayed response to treatment
Ø When the outcome is a self-limiting condition
Cluster randomization trials: instead or randomizing individuals we randomize clusters like hospitals, schools,
worksites etc. à used in public health and general practice research (not so much in investigating medical
Lecture 4b: treatments)
Ø Non-randomized trials: only difference with RCT: 2 groups are not created from the sample using
randomization
Ø Non-controlled: only intervention arm (no control group)
3 types of RCTs: [RCTs mainly test therapeutic interventions]
1. Superiority trial: we want to show that the intervention is superior than the standard or control group)
2. Equivalence: shows that 2 treatments are not too different in efficacy
3. Non-inferiority: when we are looking for new treatments that have the same efficacy but demonstrate better quality in other aspects à to show non
inferiority margin: we look at the upper limit of the 95 % CI
In order to prove superiority etc. we need to a have a margin of clinical significance à i.e. the threshold for which the study can claim
superiority/equivalence/non-inferiority

Example of superiority trial:

• In order to have statistical significance the 2 confidence intervals should NOT overlap

Example of noninferiority trial:

Community trial example:

Allocation concealment: how we implement the randomisation (happens during randomization)
 Ì Important in preventing selection bias
Ì Done by: either letting a 3rd party do the randomisation OR give the groups in opaque files

Blinding: reduces observation and measurement bias

Ì Who should be blinded? Patients, caregivers, collectors of and adjudicators of outcome date
Ì When blinding is not possible à it’s called open label trials

Placebo controls: a way of blinding

Ì Goal is to reduce measurement bias

Hawthorne effect: aka observer bias à when study participants change their normal behavior because they know they are being observed
[minimized by observing participants discretely]

Lecture 4c:
 What helps us formulate a good clinical Q?
PICO: Population/Population Intervention Comparator and Outcome
P: patient problem à most important characteristic of the patient
(primary problem, disease, or coexisting condition) sometimes gender,
race and age are also relevant

I: which intervention, prognostic factor or exposure is considered

C: comparison: what is the main alternative to compare with the

intervention? If we are trying to decide between 2 drugs, a drug and no
medication or placebo, 2 diagnostic tests
• Our clinical Q might not always include comparison

O: outcome: what can you hope to accomplish, measure, improve or

affect
- Patient oriented or
- Disease oriented
 When it comes to appraisal of studies instead of appraising each study publication on its own we
can look at a number of studies as part of a systematic review and appraise by OUTCOME
4 Levels of evidence:

Systematic reviw: you are systematically reviewinbg and summarizing evidence around a topic à have pre-defined inclusion and exclusion criteria, asses the
quality of included studies, presents the findings etc in a more sophisticated way
Ì Systematic reviews highlight consistency
Strengths of systematic reviews:

Steps for conducting a systematic review:

How to conduct a
systematic review
Week 5:
- What information does a population pyramid give us?
à The count or percentage of a population by age and sex
à Can also be used to display other data such as disease or a health characteristic by age and sex

• When the base is wide = high birth rate

• When the top is very narrow = increased death rate
• Sides of pyramids vertical = life expectancy is longer

- Which parameters are used to describe demographic transition?

1. Death rate
2. Birth rate

- 5 stages of demographic transition:

1. High fluctuating: in least developed countries and less economically develop countries
o High death rates: diseases, famines, poor medical knowledge
o High birth rate: religious values, children required in farming + manufacturing, lack of contraceptives
2. Early expanding (youthful)
o high BIRTH RATE:
o Death rate: decreases significantly
3. Late expanding (countries like India, Brazil)
o Birth rate: decreasesà failing infant mortality, laws against child work,
improved medical care and diet
o Death rate: decreases slowly à improvement in medical care
(sterilization, vaccines), better sewers, water supply and sanitation,
improved food supply and medication
4. Low fluctuating: countries like Russia, Germany, Japan
o Birth rate: low à emancipation and education in women, later
childbirth, later & fewer marriages, much more family planning options
o Death rate: low à medical advances (transplants, heart operations),
better food supply, preventative medicine
5. Decline (ageing): countries like Russia, Germany, Japan
o Birth rate: very low à same as stage 4
o Death rate: low à same as stage 4
- What factors drive the speed of the transition?
Ageing population • Proportion of older people has increased worldwideè declines in fertility and infant mortality
• As many NCDs show an exponential increase with age, their rise has become one of the major global health challenges
• Greater number of older people è of who will support and care for their needs?? few countries are introducing universal
pensions for older people or other mechanisms for ensuring their rights
Greater urbanization • Urbanisation has important health effects through changes in the social and physical environment

Negative effects of urbanisation:

• Adverse lifestyle changes:
• poor diets, less physical activity; alcohol and recreational drug use; and high risk sexual behaviour
• Physical environment: over-crowding, traffic hazards, air pollution, greater risk of bacterial and vectorborne diseases through
lack of potable water and good sanitation and risk of food poisoning
• Social effects: marginalisation and isolation which can lead to depression
• Ecological effects:ecological footprint (from greenhouse gases, waste), lack of recreational space and time wasted in
attempting to move around (commuting)

Positive effects of urbanisation:

• Socioeconomic: Positive health benefits from improvements in socioeconomic circumstances
• Access: Better access to facilities such as education and health care

Migration People migrate for a range of ‘push’ (natural disasters, war, poverty) and ‘pull’ factors (education and economic prospects

Process of migration itself causes psychosocial stress and physical danger

Migration facilitates transfer of infectious agents
Others, such as disease-carrying mosquitoes, travel in the passenger cabin or luggage of jets, causing tropical infections in
temperate countries when they bite airport workers or those who live nearb

Globalization
Epidemiology of major chronic conditions I: cardiometabolic and cerebrovascular conditions:

FOR RECORDED LECTURE: FOCUS ONLY ON THE RESPIRATORY PART

Atherosclerosis:
Modifiable causes:
1. Smoking
2. HTN
3. Dyslipidemia
4. Obesity
5. Diabetes mellitus
6. CKD
 Week 7 Lecture 7a&b:

Lower resp. tract infections:

A. Pneumonia
B. Bronchiolitis
C. Tracheitis

What does a PAR [population attributable risk] of 55% mean?

à 55% of deaths among ppl with LRI are due to this risk factor/exposure i.e., childhood wasting
àBy removing childhood wasting we can prevent 55% of deaths among children with LRI

SUMMARY:
HIV & AIDS:
Week 8:
Lecture 8a: Infectious disease transmission I
- What characteristics helps us determine the nature of an infection?
Infectivity Ability of an agent to establish an infection in the host, given that the host is exposed to the agent
à refers to the proportion of exposed persons who become infected
Pathogenicity The ability to cause disease in an infected host
à refers to the proportion of infected individuals who develop clinically apparent disease
Virulence Measures the severity of the disease, which can vary from low to high
à Case fatality ratio or Proportion of severe cases out of all cases
Infective dose Amount required to cause infection in susceptible individuals
Reservoir The natural habitat of the agent (humans, animals, environmental sources)
- Human reservoir: variola virus
Source of The person or object from which the host acquires the agent
infection

- What is a carrier?
A person with inapparent infection but who is able to transmit the pathogen to others

- What are the different type of carriers?

Asymptomatic or healthy Never experience symptoms despite being infected
Incubatory Transmit the agent during the incubation period before clinical iloness begins
Convalescent carriers Have not recovered from their illness but still capable of transmitting it to others
Chronic carriers Continue to harbor a pathogen e.g. salmonella typhi in the gallbladder

- What are the 2 types of vectors?

Ì Mechanical: animal carries a pathogen without being infected itself
Ì Biological: the pathogen goes through part of its reproductive cycle in the vector
- What are vehicles and what are the 3 types? - What are the 2 modes of transition?
Vehicles are contaminated objects or elements of the environment A. Vertical: mother to child (transplacental OR at birth)
Ì Airborne: dust particles B. Horizontal: direct (via contact or spread) or indirect (vectors and
Ì Foodborne: water, milk, food vehicles)
Ì Waterborne

- What is the basic reproduction number? R0

A measure of the average number of secondary cases produces by 1 primary case in a wholly susceptible population à indicates how contagious and
infectious an agent is

- What is the effective reproductive number? Rt

It is the average number of secondary cases produced by 1 primary case in a population made up of both susceptible and non-susceptible hosts

- What parameters can reduce the rate of spread of an epidemic?

A. Transmission probability per contact
B. Contact rate
C. Duration of infectiousness

- What does the persistence of an epidemic depend on?

a. Births
b. Migration

- What is cocooning?
à immunizing people who are likely to come into contact with a susceptible person so that the susceptible person is unlikely to be exposed to the
pathogen e.g., adults that will come in contact with newborns < 2 months are advised to take the pertussis vaccine
 Lecture 8b: Infectious disease transmission II
- What is public health surveillance?
Public Health Surveillance is the ongoing, systematic collection, analysis, and interpretation of health-related data
Goal: provide information to be used for public health action
- What are the 4 types of surveillance?

- What are the key elements of a surveillance system?

Why?
- High morbidity, high severity/mortality, high socioeconomic cost?
- Do prevention or control measures exist?
What/Who?
- Clear and simple based on clinical, biological, and epidemiological criteria

- What’s the difference between ‘outbreak’ ‘epidemic’ and ‘pandemic’?

Ø Epidemic: occurrence of cases more than what is normally expected in a community or region
o We must specify time period, geographical region and where in the population the disease occurs
Ø Outbreak: used more specifically to refer to an epidemic in a geographically or demographically localized population
Ø Pandemic: worldwide epidemic
 - What are some surveillance system attributes?

- What are the 10 steps in an outbreak investigation?

Aka descriptive epidemiology

Aka analytical epidemiology?

- Step 5:
Ø Time: epidemic curves (describe start, peak, end and
Outliers [shape of distribution can give info on the
Nature of disease & mode of transmission]
Ø Place: residence, possible exposure, maps/areas
of risk
Ø Person: distribution of cases by age, sex, exposures
 - Step 6: Develop + test hypothesis on pathogen, mode of transmission, source of outbreak, period of interest
à Analytical epidemiology: case control investigations or retrospective cohort investigations
• Case control: compares people with illness with a sample of people without the illness à cannot directly calculate attack rates
• Cohort study: includes all individuals in a confined setting and compare those who were exposed with those not exposed à can calculate attack rate

- What is the attack rate?

Ì Risk of getting the disease during a specified period (can be calculated for everyone at risk or for people who had a specific exposure)

- Step 8: verify the hypothesis with additional tests Step 9: communicate results Step 10: implement control
measures
Lecture 8c: Infection control
- Where do infections occur?
Ø Health care associated infections (HAI): occurs in a patient in a healthcare facility that is not present or incubating at the time of admission à includes
infections that only become apparent after discharge & occupational infections of staff
Risk factors:
o Very young people (premature babies and very sick children) o Hand washing techniques (inadequate hand washing by
and Very old people (the frail and the elderly) hospital staff, visitors, and patients)
o Present comorbidities o Antibiotics (resistant bacteria)
o Immunocompromised o procedures/Equipment (urinary catheters, central/peripheral
o Length of stay in a healthcare facility Surgery and Wounds venous catheters, respiratory devices)
o High-risk patient care areas (ICU, NICU)

- What are the steps to tackle AMR (antimicrobial resistance)?

- What precautions are taken to prevent and control infections?

ü Hand hygiene: most important part of infection control à Hand ü Decontaminating equipment and patient care devices: cleaning,
washing (40-60s) before any contact with patients, after any disinfection and sterilisation
activity that contaminates the hands, after removing protective ü Maintain a clean clinical environment
clothing, after using the toilet and before handling food ü Handle and dispose of sharps safely
ü Sanitizer: but not effective against spores (clostridium dificile) ü Manage linen safely
ü Use of PPE (personal protective equipment): gloves, apron, eye ü Dispose of contaminated waste safely
protection, face masks ü Managing blood and body fluids: spillages and transport of
ü Respiratory hygiene: cough etiquette specimens
ü Appropriate patient placement (isolation rooms, scheduled ü Prevent occupational exposure to infection
appointments)
 - What are some transmission based precautions?
for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission
Contact precaution Droplet precaution Airborne precaution
used for infections, diseases, or germs that are used for diseases or germs that are spread in —used for diseases or very small germs that are
spread by touching the patient or items in the room tiny droplets caused by coughing and sneezing spread through the air from one person to another
MRSA, VRE, diarrheal illnesses, open wounds, RSV pneumonia, influenza, whooping cough, tuberculosis, measles, chickenpox
bacterial meningitis

- What are the responsible teams for organization of infection control?

Hospital (Infection prevention control IPC team), community (Health protection team: nursing, residential homes, nurseries, schools etc)

- What are the members of an IPC team?

AIM of IPC team: containment of infection and prevent the spread of infectopm with health care facilities
Infection Control Doctors: General physician, Infectious disease specialist,Clinical microbiologist ,Epidemiologist
Infection control nurses
Clerical / admin support

- What is the role of the local health protection team (HPT)?

1. Determine the likelihood of transmission Give advice / prophylaxis to close contacts
2. Determine whether public health action is necessary / conduct risk assessment
3. Infection control advice and support to nursing and residential homes, schools etc (see slide 30)

- Notification of infectious diseases: Registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local
health protection team (HPT) of suspected cases of certain infectious diseases. [ κατάλογος υποχρεωτικά δηλουμένων λοιμωδών νοσημάτων]
Week 9: Epidemiological paradigms: Adult life risk factors, Early Life programming, Life course epidemiology
Adult life risk factors approach
Early life programming
• See examples:14-
Ø Chronic disease is the result of adult behaviors and risk factors
Account for almost 50% of burden of disease
• Smoking
• Poor diet
• Exercise
• alcohol consumption)
- How does the WHO measure burden of disease?
Ø Disability adjusted life years = years of life lost due to early death + yeas spent living with disability
- Men, younger ppl, lower social classes, lower educational level à more likely to exhibit multiple risks
Limitations:
- Approach fails to explain many of the geographical and social differentials in chronic disease
- Emphasized an individuals lifestyle as a cause and solution of health problems but ignores broader
determinants of health
Early life = duration of pregnancy and first 3 years of life
Ø Fetal origins of adult disease hypothesis: period of gestation has significant impacts on developmental health
and wellbeing outcomes for an individual ranging from infancy to adulthood
• Stimulus/insult at sensitive period of developmentà permanent effects on structure, physiology +
metabolism è predispose to chronic diseases
Ø Barker hypothesis: intrauterine growth retardation, low birth weight and premature birth have a causal
relationship to the orrigins of HTN, CAD and non-insulin dependent diabetes à early life exposure influence
diseases that occur later in life
Ø Thrifty phenotype hypothesis: in settings in which fetal environment does not match the adult environment à
catch up growth and disconnection between foetal programming à adult environment can predispose adult to
metabolic disease, including obesity and T2D
Potential mechanisms: how can an exposure in utero or postnatal increase risk for a chronic disease in midlife
- Structural changes in organs. – hormonal changes - epigenetic modifications
!! Intergenerational transmission of programmed effects à these effects may be transmitted non-gnomically to
subsequent generations (mechanisms unknown)
Limitations:
- Potential confounders: people whose growth was impaired in untero may continue to be exposed to an
adverse environment in childhood or adulthood
- Later adverse env. May increase the rates of specific chronic disease and not the effects of programming
 Life Course epidemiology Ø Long term effects on later health of physical or social exposures that occur during gestation, childhood,
See examples:18 adolescence, young adulthood and later adult life à integrates both biological and social risk processes in all life-
course stages
Ø Critical period model: sees the time window of exposure as key à looking at a particular period of time where
an exposure would lead to [permanent devastating developmental changes while in another period it wouldn’t
have the same severity e.g., fetal alcohol syndrome
o Fetal origins of adult disease hypothesis: one example of critical period model
Ø Accumulation of risk model: adverse exposure early in life increases risk has an additive effect with adverse
influences in later life à focuses mostly on accumulation of exposure throughout life-course
A. Uncoorelated: exposures that have an independent effect on disease risk irrespective of later exposures
B. Coorelated: when exposures are ‘clustered’ or ‘chains of risks’
1. Risk clusteringà accumulation of exposures related to the # of other exposes (often connected to
socioeconomic factors)
2. Chain of risk à sequence of linked exposures that raise disease risk because one negative exposure à
leads to another etc

Week 10.1: Primary prevention
Types of prevention:
PRIMARY SECONDARY TERTIARY
è eliminates the causes of disease or increases resistance to è Interrupts disease process before it Limits the physical &social consequences of
disease à keeps the disease process from being established becomes symptomatic symptomatic disease

- Efforts of primary prevention directed at:
A. Whole population: ‘the population strategy’ è aims to reduce average risk à by shifting the
population to the left
✅ don’t have to identify high risk population

❌ doesn’t give sufficient benefit to high risk population

B. People at high risk: ‘the high-risk individual strategy’ èaims to protect susceptible ppl as a result
of a particular exposure
✅ efficient for ppl at greatest risk of a specific disease
❌ requires screening programs to identify high risk (time and costly)

*Sometimes the 2 strategies are combined

- Primary prevention can be implemented via:
I. Health promotion: activities and interventions directed at individuals, families, communities or whole pop à enables them to take greater
control over their health
o Medical or preventive: aim to reduce morbidity and mortality, involves health professionals
o Behavioral change: encourage ppl to adopt healthy behaviors
o Educational: gives knowledge and information, and skills so ppl can make informed choices about their health behaviour
o Empowerment: helps ppl identify their concerns and gain skills and confidence to act upon them
o Social changes: aim is to change the physical, social and economic environment to promote health










- What are the most common theoretical models of behavioral change?
1. Health belief model: before seeking preventive measures, people must believe
§ Severity: disease is serious if acquired
§ Susceptibility: I or my children are at risk of disease
§ Perceived benefit: this measure will prevent the disease
§ Perceived barriers: there are no serious risks or barriers involved in obtaining the preventive measure
è this is used to promote screening
2. Transtheoretical model: ppl don’t change their behaviour dramatically in 1 moment à change is a process and patients have different
counselling and informational needs depending on where they are in this process








3. Theory of planned behavior: explores how ppl form intentions for behaviour change
These intentions are influenced by a person’s attitude and beliefs, the presumed attitudes and beliefs of other important individuals (subjective norms),
and perceived behavioural control

II. Specific protection:
o Diseases: e.g., vaccines, antimicrobial prophylaxis
o Deficiency states: fluoride to prevent dental caries,
o Injuries & toxic exposures: helmets and goggles or other protective equipment
Week 10.2: Secondary disease prevention
- What is secondary prevention?
Interrupts disease process before it becomes symptomatic à aims to reduce the impact of disease or injury that has already occurred by detecting
and treating disease or injury ASAP or slow its progression
Examples:
• regular exams and screening tests to detect disease in its earliest stages (e.g., mammograms to detect breast cancer)
• daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes

- How is early detection of disease achieved in secondary prevention?
I. Screening: occurs in community setting and applied to a population
II. Case finding: occurs in a clinical setting and applied to an individual
àTargeting resources at individuals or groups at high risk of a particular disease à actively searching systematically for at risk people rather
than waiting for them to present with signs or symptoms of active disease
Ø Periodic health examination: Annual checkups: medical Hx, physical exam, FBC, urinalysis, CXR, ECG
Ø Lifetime health monitoring: the idea of modifying the periodic examination to focus only on the conditions that would be most likely to be found
in a person of a given age, gender and family Hx
Ø Health protection packages: Gender and age-appropriate immunisations, screening, and counselling à Performed when patients attend for unrelated
symptoms rather than for a specific preventive purpose
Exceptions requiring specific preventive visits: Pregnant women Babies, infants, children Elderly

- What are health risk assessments?
à Use questionnaires or computer programmes to elicit and evaluate information concerning individuals in a clinical or occupational medical practiceè
these computer algorithms calculate a persons risk age è serve to raise awareness
Data collected include: weight, height, BP, Cholesterol level, previous and present conditions, family Hx, social Hx

- What is a risk age?

The age at which the average individual would have the same risk of dying as the person being assessed. If older than the chronological age, the person
would be at higher risk of dying than someone of the same chronological age.

- What are some examples of case finding strategies?

A. Communicable disease control:
sexual partner ascertainment in syphilis outbreaks - household/work contacts in food-borne outbreaks
B. Health systems data: used to identify ‘’missed risk groups’’ à example: Registered GP patients over 50
years of age with a BMI>30 who may not be on the register of people at risk for coronary heart disease
Examples of such health systems data: Index of Multiple Deprivation, or PARR: patients at risk of
rehospitalization
 Week 10.3: Tertiary and quaternary prevention

- What is tertiary prevention? à Limits the physical &social consequences of a symptomatic disease
- The sooner tertiary prevention is initiated, the better the chance of preventing significant impairment
Categories:
i. Disability limitation: prevention of further impairment (slow progression or limit damage)
o symptomatic stage prevention: therapy + attemps to limit future progression
§ strategies include: diet modification, behavior + environment, screening frequently for complications, treating any complications

ii. Rehabilitation: aims to strengthen the patient’s remaining functions and to help the patient learn to function in alternative ways
§ Beginning rehabilitation early tends to increase the
cooperation of patients and family members
§ Should be tailored to meet the physical, emotional,
psychological, and occupational needs of the individual as well as
the patients illness perceptions
• Members of rehabilitation team: Coordinator Physiotherapists
Occupational therapists Psychiatric / emotional counsellors
Spiritual counsellors Consultants / specialists in rehabilitation

- What’s the difference between disease, disability and illness?
Disease Disability Illness
medical adverse impact of the adverse impact on subjective
condition or disease on objective functioning àinfluenced by patients’
diagnosis itself physical, perceptions of their disease, its
(e.g. diabetes, psychological and duration severity, and expectations
COPD) social functioning for a recovery

- Describe the new additional levels of preventionà primal, primordial and quaternary prevention:
PRIMAL PRIMORDIAL QUATERNARY
Support parents to Prevent the onset of wider determinants of disease (social,economic,cultural) Aim to Identify a patient or a
optimize the health of Example of interventions: population at risk of
their child’s early life Ø Multisectoral collaboration to increase access and affordability of healthy food overmedicalisation àProtect them
Ø Laws banning smoking in public places from invasive medical interventions
Ø Built environment interventions to promote physical activity and reduce air pollution à Provide ethical care
Week 11: Screening

- What level of prevention does screening refer to?

Secondary

- What is the aim of screening?

1. reduce mortality
2. reduce the incidence of a condition by identifying and treating its precursors;
3. To reduce the severity of a condition by identifying people with the condition and offering effective
treatment
4. To increase choice by identifying conditions or risk factors at an early stage in a life- - What are the types of screening?
course when more options are available A. Opportunistic: patient asks doctor to be referred for screening, or
doctor sends px for screening because he has a risk profile à
- What are some examples of screening? usually not free
§ Cancer (bowel, breast, cervical) Infectious diseases in pregnancy (e.g. TORCH) B. Organized screening: Targeted (selective) screening of groups with
§ Foetal anomalies (e.g. trisomies) Newborn (physical exam, blood spot, hearing specific exposures (high risk)
e.g. workers in lead battery factories (used in environmental
tests)
and occupational health)
§ Diabetic eye (retinopathy) screening Abdominal aortic aneurysm Mass screening è screen the whole population (or sub-
- What are the NSC criteria for screening? When is screening important? group) e.g., Mammography in women aged 50-70 every three
Criteria for appraising the viability, effectiveness and appropriateness of a screening years (UK) à usually free of charge
programme under four headings:
1. The condition: shouls be an important public health problemà There should be a detectable risk factor or disease marker (basis for screening test)
The condition should have a latent period or early symptomatic stage (with good prognosis)
2. The test: simple, safe, precise and validated screening test, non-invasive and thus acceptable by population
§ There should be an agreed policy on the further diagnostic investigation of individuals with a positive test result
and on the choices available to those individuals
3. The intervention: There should be an effective treatment for patients identified through early detection
§ There should be evidence that earlier treatment leads to better outcomes for the screened individual compared
with usual care
4. The screening program:
§ There should be evidence from high quality RCTs that the screening programme is effective in reducing mortality and morbidity
§ There should be evidence that the complete screening programme (test, diagnosis and treatment) is clinically, socially and ethically acceptable to
health professionals and the public and that the benefits outweigh the harms
§ The cost of the screening programme should be economically balanced in relation to medical care expenditure as a whole
§ There should be a plan for monitoring the screening programme
- What’s the difference between screening & confirmatory / diagnostic testing?
§ Adequate staffing and facilities prior to commencement • Confirmatory tests are also called diagnostic tests
• As part of screening programmes, if a person tests positive following
screening, confirmatory tests are used to establish the presence or
absence of disease In the absence of screening, this would be called
‘diagnostic testing’, which establishes the presence of disease as a basis
for treatment decisions in symptomatic individuals

- When evaluating the effectiveness of screening programmes,

what types of bias should be considered?
Ø Length bias:
o The length of the detectable preclinical phase (DPCP) can
vary substantially from person to person (e.g., prostate
cancer is a very slow growing tumour in many men, but very
rapidly progressing and lethal in few others)
o These differences in DPCP exaggerate the apparent benefit
of screening (i. e. overestimation of survival), because there
is a greater chance that screening will detect subjects with
long DPCPs (i.e. slow growing disease)
Ø Overdiagnosis-bias:
o extreme form of length-time bias
o Overestimation of survival duration among screen-
detected cases caused by inclusion of pseudodisease—
subclinical disease that would not become overt before
the patient dies of other causes E.g. recent increase in
thyroid cancer incidence reflects overdiagnosis of
clinically unimportant lesions due to the rise in the use of
neck ultrasonography
Ø Lead-time bias: The gain from screening is the difference
between the time a disease would have been diagnosed by
clinical symptoms and when it is detected with a screening
procedure.
o Overestimation of survival duration among screen-
detected cases due to earlier detection by screening than
clinical presentation
o Lead time bias is not the exception but the rule that comes
with any successful effort to detect disease early
Week 11: Screening (and Diagnostic) Test Performance Statistics
- How can we evaluate test performance?
We use a benchmark test: gives definitive classification of people in ‘affected’ and ‘not
affected’ by disease
SOS: 2X2 Table [caution: False negative]
- How do we measure the performance of screening (and diagnostic) tests?
Ø Sensitivity : when the disease is present how well do I detect it à you can derive False
negative rate

SENSITIVITY & SPECIFICITY LOOK AT COLUMNS

ARE NOT FUNCTIONS OF PREVALENCE à they are test

specific UNLIKE PPV and NPV are affected by test +
population
Ø Specificity: only for those that don’t have the disease à ou of all ppl not having the disease how many test negative

• SEE clinical implications slides 15-17

What is the probability that the patient has/does not have the disease having tested positive/negative?
Ø Positive predictive value :if test was positive how well can I predict the presence of disease PREDICTIVE VALUES LOOK AT ROWS

Ø Negative predictive value: From all ppl who tested neg on the screening how many are unaffected
When we increase cut off:
decrease the false positives
(specificity increases),
increase false negatives
(decreases sensitivity)
When we decrease cut off:
increase the false positives
(specificity decreases),
decrease false negatives
(increases sensitivity)
See example: 29-30
 Week 12: Predicting and modifying health- related behavior in population groups II: targeting wider determinants
Social epidemiology: branch of epidemiology that studies the social distribution and social determinants of states of health
- What socio-structural factors affect health?
• Social class
• Gender Race/ethnicity

- 4 concepts in social epidemiology:

Biopsychosocial Diseases are products of the interaction between social, individual, and biological factors
paradigm
Population An individual’s risk of disease cannot be isolated from the disease risks of the population to which s/he belongs
perspective
Advance 2 explanations of the effects of socio-structural factors on:
statistics A. Compositional: A group includes different types of individuals; differences among those individuals account for the observed differences
between groups à differences between individual at individual levels
B. Contextual: Social level factors, such as features of physical and social environments, influence health either in addition to, or in interaction with,
individual characteristics à differences at social level
Use of theory Use of theory to build hypotheses and interpret results
Example: modelling social class and congenital heart disease (CHD)
Ø In the statistical model, controlling for smoking implicitly assumes that social class has a direct effect on CHD independent of smoking
Ø If a statistical association between social class and CHD disappears when smoking behaviour is accounted for, the hypothesized theory will tell
us whether the effect of social class on CHD is spurious, or mediated by smoking behaviour\
Social selection: A person’s health status determines his or her social class, rather than vice versa
Ø A person with poor health is likely to be in a low social class because his chance to hold a job may be limited due to his poor health status
However, this theory has not been supported by evidence
Socio-biological translation theory: Social class influences biological functions through several paths that, in turn, affect health status
• Physical environment: exposing people to carcinogens and other environmental hazards (Poor may live and work in more hazardous
environments, such as polluted neighbourhoods and unsafe working conditions)
• Social environment: provides vulnerability to interpersonal aggression or violence to some Vs Access to social resources and support to others
• Socialization and experiences: Social experiences are hypothesized to influence psychological development, ongoing mood, and cognition,
which, in turn, impact health status
• Health behaviours: Many risky health behaviours for chronic diseases, such as smoking, physical inactivity, and dietary fat intake, are more
prevalent in lower social class groups
- Even when an individual is interested in improving their health behaviour, it may be difficult to accomplish in unfavourable social conditions
- People in low social classes tend to have more barriers to behaviour change in their social conditions compared with those in high social
classes, which might lead to differences in health status between classes
 Health need assessments: aka HNAs
Types of needs:
Ø Normative need: based on professional judgement
Ø Felt need: individual's perceptions of variations from normal health (e.g: people want to know
their blood cholesterol levels, or the gender of their unborn child)
Ø Expressed need: vocalisation of need or how people use services
Ø Comparative need: based on judgements by professionals as to the relative needs of different
groups Examples: workers in company A has health policies about smoking at work and
provides healthy food but the company B doesn’t provide it , the workers in company B are in
need

Approaches to conducting HNAs:

Epidemiological
- Epidemiology of the condition
- Current service provision
- Effectiveness and cost-effectiveness of
interventions and services
Comparative
- compares service provision between different
populations
- Large variations in service use may be
influenced by a number of factors, and not just
differing needs
Corporate
Based on eliciting the views of stakeholders on what
services are needed
- May include professionals, patients and service-
users, the public and politicians
- Community engagement and user involvement are
important in informing local policy

Summary of HNA approach:

Health Impact Assessments (HIAs):

Approach that gets people to think about what they are doing, and how it may alter people’s health.
Imagine someone was planning to build a new motorway
An HIA would answer
• ‘How would this new development affect people’s health?’
• Would the motorway increase or decrease noise, air or light pollution?
• How would the motorway affect local businesses and jobs?
• Would the new motorway reduce or increase the stress for local people?
• How would a new motorway change the local infrastructure needs - and would this be good or bad for local people?
HIAs can be carried out prospectively, concurrently or retrospectively