BASICS OF

EPIDEMIOLOGY
FATHER OF EPIDEMIOLOGY

JOHN SNOW (1813-1858)

CONTEXT

Epidemiology is derived from the word epidemic.

Epi = among
Demos = people
Logos = study
The foundation of epidemiology was laid in 19th century.

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 60 p
DEFINITION

Epidemiology has been defined by John M Last as

“ The study of the occurrence and distribution of health related events,
states, and processes in specified populations, including the study of
determinants influencing such processes and the application of this
knowledge to control relevant health problems.”

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 60 p
 FURTHER ELABORATION OF DEFINITION

BONITA R, BEAGLEHOLE R, KJELLSTORM T. basic epidemilogy. 2nd ed. Geneva, WHO Library Cataloguing-in-Publication
Data: WHO; 2006. 4 p.
 COMPONENTS
1-Study of disease frequency :-
Inherent in the definition of epidemiology is the measurement of frequency of disease, disability
or death, and summarizing this information in the form of rates and ratios or proportions..
2-Study of distribution of disease :-
Disease is not uniformly distributed in human populations. An important function of the
epidemiology is to study the distribution in the various subgroups of the population by time, place,
and person
3-Study of determinants of disease:-
A unique feature of epidemiology is to test etiological hypothesis and identify the underlying
causes of disease. This requires the use of epidemiological principles and methods (analytical
epidemiology).

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 61 p
AIMS OF EPIDEMIOLOGY
According to International Epidemiological Association (IEA) –
Three main aims :-
1. To describe the distribution and magnitude of health and diseases
problems in human population
2. To identify etiological factors in the pathogenesis of disease.
3. To provide the data essential to the planning, implementation and
evaluation of health services and to set up priorities between
services
Ultimate aim :-
To eliminate or reduce the health problems / consequences
To promote health and well-being of society as a whole

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 61 p
EPIDEMIOLOGIC APPROACH

First ask
Who has the disease?
How many have it?
Which area is affected?
When it is happening?
What is causing it?
Then compare
Does incidence vary with age? gender? Season? Occupation….
What epidemiologist measures..?Tools

1. RATE ( ‘ / ’ )
It is a fraction of two different variables
Numerator is a subset of the denominator
It gives how fast an event is happening, time is included
Eg : Crude death rate =  
2. RATIO (‘ : ‘)
It is the fraction of two different and independent variables,
Numerator is not a component of denominator
Eg: Ratio of deaths due to TB : Leprosy = 2:1
3. PROPORTION (‘%’)
It is a fraction of two variables, both of which measure same
physical quantity
The numerator is a subset of denominator
Eg: Case fatality rate=  ×100

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 63 p
CONCEPT OF NUMERATOR AND
DENOMINATOR IN EPIDEMIOLOGY
Numerator :
It refers to the number of times an event (sickness, birth, death,
episodes of sickness etc) has occurred in a population , during a
specified time period.
Denominator
Epidemiologists love denominators
the epidemiologist has to choose an appropriate denominator by
calculating a rate
It may be a) Related to the population
b) Related to the total events
 To calculate the proportion, we divide the number of numerator
events among exposed individuals by the total number of exposed
individuals.
Eg:- Proportion of eaters of potato salad at a picnic who were
diagnosed with a salmonella infection during the ensuing 48 hours.
To calculate the rate we use a person – time denominator
Eg:- Rate of lung cancer in persons who have been employed in a
given industry

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 63 p
CONCEPTS OF INCIDENCE AND
PREVALENCE
 INCIDENCE PREVALENCE

It is the number of new cases occurring in It refers specifically to all current cases (old + new)
a defined population during a specified existing at a given point or over a period in time in
period of time a given population

=  ×1000 =  ×100
Rate Proportion
Cohort Cross-sectional
Special incidence rate Prevalence
Attack rate Secondary attack rate Point prevalence Period prevalence
RELATIONSHIP BETWEEN PREVALENCE AND
INCIDENCE

Prevalence = Incidence × Mean duration

Longer the duration of the disease , greater its prevalence
FACTORS AFFECTING INCIDENCE AND PREVALENCE

BONITA R, BEAGLEHOLE R, KJELLSTORM T. basic epidemilogy. 2nd ed. Geneva, WHO Library Cataloguing-in-
Publication Data: WHO; 2006. 19 p.
 EPIDEMIOLOGICAL STUDY DESIGNS

NO Any intervention YES

OBSERVATIONAL STUDY EXPERIMENTAL STUDY

DESCRIPTIVE ANALYTICAL RANDOMIZED NON-RANDOMIZED

STUDY STUDY TRIALS TRIALS
:- Case report :- Case control :- RCT :- Pre- post study
:- Case series :- Cohort :- Field trial :- Uncontrolled trial
:- Cross sectional :- Ecological :- Community trial :- Natural experiment
:- Cross sectional :- Quasi experimental

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 70 p , 88 p
 LEVEL OF EVIDENCES
Meta analysis
&
Systematic review

RCT

Cohort study

Case control study

Cross- sectional study

Ecological

Kazemi Y, Stringer H, Klee T. Study of child language development and disorders in Iran: A systematic review of
the literature. J Res Med Sci Off J Isfahan Univ Med Sci. 2015 Jan;20(1):66–77.
DESCRIPTIVE STUDIES

It describes the state of a disease in terms of time, place and person

and does not ask why

Procedures in descriptive studies

1. Defining the population to be studied
2. Defining the disease under study
3. Describing the disease by : Time , Place , Person
4. Measurement of disease
5. Comparing with non indices
6. Formulation of an aetiological hypothesis
 CASE REPORT
Publishing clinical findings of a new case

CASE SERIES
Publishing clinical findings of a group of cases
INVESTIGATION OF CHOLERA EPIDEMIC
BY JOHN SNOW
In 1854 in the Golden Square district of London , He was able to
focus attention on the common water pump in Broad street as a
source of infection.
Consequently, the removal of the handle led to cessation of the
epidemic.
Based on his descriptive findings , Snow was able to Hypothesize
that cholera was a water-borne disease, long before the birth of
bacteriology.

Tulchinsky TH. John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and
Now. Case Stud Public Health. 2018;77–99.
SPOT MAP OF CHOLERA EPIDEMIC IN LONDON
ANALYTICAL STUDY
ECOLOGICAL STUDY

Also known as correlational study

Unit of of study : Population
Weakest study design
Drawback – Ecological fallacy- characters ascribed to a population
may or may not be possessed by an individual.
 Example :-
To prove relation between Ca breast and per capita meat consumption ,
a Public Health Specialist had collected records of incidence of Ca
breast and of red meat consumption from every countries.

Incidence USA
of Ca
breast

India

Per capita meat consumption

CROSS SECTIONAL STUDY

Prevalence
Also known as snap shot study
It shows distribution
Cause and outcome - both are present, but we cannot comment on
association
No follow-up
Natural history of disease cannot be studied
Temporal association cannot be studied
Example : -

Anemia in girls in a school

X X X X X X X X X
X X X X X X X X X
X X X X X X X X -Hb %
H/o Diet
Rural/Urban
Age, caste
CASE CONTROL STUDY

EXPOSED CASES
NON
TIME(WITH
DISEASE) POPULATIO
EXPOSED DIRECTION OF INQUIRY
N

EXPOSED CONTROLS
(WITHOUT
NON DISEASE)
EXPOSED

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot; 2023. 78 p
 Eg : Oral contraceptives and thromboembolic disease
In 1968-69 , Vassey and Doll reported the findings of their case control
studies in which they interviewed women who had been admitted to
hospitals.

Studies confirmed that taking the pill and having thromboembolic

disease co existed more frequently than would be expected by
chance.
 It is often called retrospective studies
Backward looking study

Basic steps
1. Selection of cases and controls
2. Matching:- selecting controls in such a way that they are similar to
cases with regard to certain pertinent selected variables. eg: age
3. Measurement of exposure
4. Analysis and interpretation
Advantages
Less time and money consuming
Suitable for rare diseases
Multiple risk factors can be studied
Disadvantages
Recall bias, Selection bias, Interviewer’s bias, Confounding bias
Natural history of disease cannot be studied
Temporal association cannot be studied
 NESTED CASE CONTROL STUDY
The nested case control design makes cohort study less expensive
The cases and control are both chosen from a defined cohort
It is done when tests are expensive

Disease Cases

People
without
Population disease

No disease Sample Controls

BONITA R, BEAGLEHOLE R, KJELLSTORM T. basic epidemilogy. 2nd ed. Geneva, WHO Library
Cataloguing-in-Publication Data: WHO; 2006. 49 p .
ODD’S RATIO/ CROSS PRODUCT RATIO
It is the measure of strength of association between risk factor and
outcome

Disease (yes) Disease (no)

Exposed

Non exposed

Odd’s ratio = (  ) / (  ) = 
 COHORT STUDY
TIME
DIRECTION OF INQUIRY

DISEASE

EXPOSED
NO DISEASE
POPULATIO PEOPLE WITHOUT
N DISEASE

DISEASE
NOT
EXPOSED NO DISEASE

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot;
2023. 78 p
 It is known by variety of names- Prospective study,
Longitudinal study, Incidence study, Forward looking study
Advantages
Natural history of disease can be studied
Temporal association can be studied
Can find incidence
Single exposure causing multiple disease can be studied
Disadvantages
More time and money consuming
Attrition bias (Loss to follow up)
Hawthorne bias ( people change behavior when they know
they are observed)
Types of cohort study
1. Prospective cohort study- is one in which the outcome has not yet
occurred at the time the investigation begins
2. Retrospective cohort studies- is one in which the outcomes have
all occurred before the start of investigation. Mixture of case control
and Cohort study.
3. Ambispective / Mixed Cohort study- it is the mixture of
prospective cohort and retrospective cohort
EXPERIMENTAL STUDIES
RANDOMISED CONTROL TRIAL

Randomization – heart of RCT

It ensures selection bias
Each participant has equal chance of group allotment
Ensures comparability
Example – New drug for HTN ( Intervention)
Random sampling
select target population sample population (1000)
(10000- HTN) randomization

experimental control
group group Parallel RCT

New drug (a) Old drug (b)

Manipulation and follow up

Assessment
wash out period

a b
Cross over RCT Manipulation and follow up

Assessment
NON RANDOMIZED EXPERIMENTAL
STUDIES
Uncontrolled trial
Trials with no control group
Historical controls- ( experience of earlier untreated patients
affected by same disease )
Eg: Pap test in cervical cancer when it was introduced in 1920s
Natural experiments
When experimental studies not possible in human population, we
seek natural circumstances that mimic as experiment.
Eg:-
John snow’s discovery that Cholera is a water borne disease
Atomic bomb radiation
Pre-post study
Compare findings before and after intervention
Eg: - Intervention for obese people – diet plan
CONFOUNDING
It is the third variable which is associated with cause and outcome
and independently causes outcome
It is also called as indirect association
Eg:
High altitude ………… Goitre

iodine deficiency

Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s Banasidas Bhanot;
2023. 96 p
USES OF EPIDEMIOLOGY

1. To study historically the rise and fall of the disease in the population
2. Community diagnosis
3. Planning and evaluation
4. Evaluation of individuals risks and chances
5. Syndrome identification
6. Completing the natural history of disease
7. Searching for cases and risk factors
SUMMARY

Epidemiology is the study of distribution and determinants of health

related events
The aims and uses of epidemiology
Concepts of incidence and prevalence
Epidemiological approach to causation
Classification of epidemiological study designs
Strength and limitations of epidemiological study designs
The contribution of epidemiology to the prevention of disease and
the promotion of health
Hierarchy of evidences
EPIDEMIOLOGICAL EXERCISES
A recent study observed that 1 in 20 persons with cancer were
diagnosed with a second cancer. In the general population, the life
time probability of being diagnosed with cancer is considerably
greater. Is this evidence of immunity developed as a result of the
first cancer?
In a randomized controlled trial of screening for two forms of cancer (breast and
colon), more than 150,000 men and women were recruited to take part. Follow-up
of these individuals took place over an average of 5 years for cancer incidence and
cause-specific mortality.
In an analysis unrelated to those bearing on the efficacy of screening, incidence and
mortality rates in all trial participants combined were compared to those of
demographically comparable individuals in the population as a whole. The
incidence of cancer (Excluding cancer of the breast and colon) in the trial
participants was 89% that of the general population , whereas the corresponding
figure for cancer mortality was 56%.
Because of the large number of events, chance is a highly unlikely explanation
for the difference between the relative risk for cancer incidence (0.89) and that for
cancer mortality (0.56). What do you believe to be the most likely explanation for
the difference.?
Epidemiologist in California observed that about 65% of infants who died of
sudden infant death syndrome (SIDS) typically were put to sleep in the prone
position, in contrast to 60% of control infants. Most other studies of SIDS
and sleeping position have found a considerably greater case control
difference. Commenting on this result, an editorialist wrote , “One reason
that prone sleeping may not have been observed as a strong risk factor for
SIDS (in this study) is that it is difficult to measure risk for a characteristic
present in 60 % of the population“ Do you agree with this assertion ? If yes,
why ? If not, why not?
A case control study of the relationship between asthma and a history of
pertussis among children ( 2 years of age) was carried out in one
community. Although overall participation was good, not all parents of
cases and controls could be interviewed. A difference in the percentage
interviewed based on case/control status and on day care enrollment was
noted .Only 63% of control parents with a child enrolled in day care could
be interviewed, versus 82% of control parents with a child who was not
enrolled in a day care. In all 93% of case parents were interviewed a
percentage that was the same for parents of children who were and were not
enrolled in day care.
In this study , under what circumstance would “ enrollment in day care “
confound the association between asthma and pertussis vaccination?
REFERENCES

1. Park K. Preventive and social medicine. 27th ed. Jabalpur: M/s

Banasidas Bhanot; 2023. 60 p.
2. Bonita R, Beaglehole R, Kjellstorm T. basic epidemilogy. 2nd
ed. Geneva, WHO Library Cataloguing-in-Publication Data: WHO;
2006. 4 p.
3. Kazemi Y, Stringer H, Klee T. Study of child language
development and disorders in Iran: A systematic review of the
literature. J Res Med Sci Off J Isfahan Univ Med Sci. 2015
Jan;20(1):66–77.
4. Tulchinsky TH. John Snow, Cholera, the Broad Street Pump;
Waterborne Diseases Then and Now. Case Stud Public Health.
2018;77–99.
THANK YOU