Epidemiology Applications

SOUTH CAROLINA

AHEC

OBJECTIVES
q

applications of epidemiologic method

SOUTH CAROLINA

AHEC

Assessing Risk and Burden of Disease
q q q

Relative Risk Odds Ratio Attributable Risk

SOUTH CAROLINA

AHEC

Relative Risk
q

q

Calculated to identify differences in disease rates between exposed and unexposed groups. Risk of disease among exposed ÷ risk of disease among unexposed
v RR

= 1, no difference v RR > 1, association between exposure and disease
SOUTH CAROLINA

AHEC

Odds Ratio
q

q

Calculated to identify likelihood of exposure to a risk when comparing two groups, one with and one without disease. Exposure odds in disease group ÷ exposure odds in non-disease group
v Ratio

= 1, no association v Ratio > 1, association between exposure and disease
SOUTH CAROLINA

AHEC

Attributable Risk
q

q q

Calculated to identify the proportion of disease among exposed people that actually results from the exposure Individual attributable risk = RR - 1 / RR Population attributable risk = Pe (RR 1) / 1 + Pe (RR - 1), where Pe = proportion of population exposed
SOUTH CAROLINA

AHEC

Epidemiology in Action
q q q

Outbreak and Cluster Investigations Public Health Surveillance Community Screening Programs

SOUTH CAROLINA

AHEC

Outbreaks and Clusters
q

q

Outbreak: an epidemic limited to a localized increase in the incidence of a disease Cluster: an aggregation of relatively uncommon events or diseases in space and/or time in amounts believed or perceived to be greater than expected by chance
SOUTH CAROLINA

AHEC

Characteristics of Outbreak Investigations
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q

q q

Infectious disease or condition Etiologic agent is transmissible organism Short time frame for investigation (hours, days) Moderate to large effect estimates Moderate to high exposure levels
SOUTH CAROLINA

AHEC

Characteristics of Outbreak Investigations, cont.
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Acute exposure period (hours, days) Laboratory confirmation common Moderate to high possibility of establishing cause and effect Most common study design: retrospective cohort

SOUTH CAROLINA

AHEC

Characteristics of Cluster Investigations
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q

q q

Non-infectious disease or condition Often unknown or combined etiologic agents Longer time frame for investigation (weeks or months) Weak to moderate effect estimates Low exposure levels
SOUTH CAROLINA

AHEC

Characteristics of Cluster Investigations, cont.
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q q

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Chronic exposure period (years or decades) Laboratory confirmation uncommon Low possibility of establishing cause and effect Most common study design: casecontrol
SOUTH CAROLINA

AHEC

Challenges of Cluster Investigations
q q q q

Active or passive approach Epidemiology or public health education Data sources and denominators Costs and yields

SOUTH CAROLINA

AHEC

Public Health Surveillance
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q

Ongoing systematic collection, analysis and interpretation of outcome-specific health data Closely integrated with the timely dissemination of those data to those responsible for preventing and controlling disease or injury
SOUTH CAROLINA

AHEC

Sources of Surveillance Data
q q q q q q

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Reports of health events Reporting from laboratories Registries Vital statistics Periodic surveys Information on environmental exposures Information from other organizations AHEC
SOUTH CAROLINA

Uses of Surveillance Information
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Immediate detection Annual dissemination Archival information

SOUTH CAROLINA

AHEC

Community Screening Programs
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Defining the target population Setting priorities among diseases and conditions Choosing effective screening tests Assessing the effectiveness of screening programs

SOUTH CAROLINA

AHEC

Screening Tests
Disease Status Test Results Positive Negative Total Positive Negative Total A B true (+) false (+) C D false (-) true (-) A+C B+D A+B C+D

SOUTH CAROLINA

AHEC

Hypothetical Example

Disease Status Test Results Positive Negative Total Positive Negative 900 100 1,000 4,950 94,050 99,000 Total 5,850 94,150 100,000

SOUTH CAROLINA

AHEC

Sample Data
q q q

AIDS Syphilis Diabetes

SOUTH CAROLINA

AHEC

Estimated Incidence of AIDS and Deaths of Adults with AIDS*, 1985 - June 1998, United States
25,000

Number of Cases/Deaths

AIDS Deaths

20,000

1993 definition implementation

15,000

10,000 5,000 0

*Adjusted for reporting Quarter-Year of Diagnosis/Death delays

1985 1986 19871988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
SOUTH CAROLINA

AHEC

AIDS Cases by Age and Sex Reported 1981-1998, United States
35,000 30,000

Number of Cases

25,000 20,000 15,000 10,000 5,000
0 0 10 20

Male N=574,783 Female N=113,414

Age at Diagnosis
3

30

40

50

60

70

80

90

SOUTH CAROLINA

AHEC

Estimated Number of Persons Living with AIDS
250 200

1993 -1998, by Sex, United States
Men

Thousands

150 100 50 0 1993

Women

1994

1995

1996

1997
SOUTH CAROLINA

1998

Year

AHEC

Estimated Number of Persons Living with AIDS 1993 - 1998, by Race/Ethnicity, United States
140 120

Thousands

100 White, not Hispanic 80 60 40 20

Black, not Hispanic Hispanic Asian/Pacific Islander
1994 1995 1996

American Indian/ Alaska Native
1997
SOUTH CAROLINA

0 1993

1998

Year

AHEC

Estimated Number of Persons Living with AIDS 1993 - 1998, by Race/Ethnicity, United States
2,500 2,000

Persons

Asian/Pacific Islander
American Indian/ Alaska Native

1,500 1,000 500 0 1993

1994

1995

Year

1996

1997
SOUTH CAROLINA

1998

AHEC

Estimated Number of Persons Living with AIDS 1993 -1998, by Region, United States
12 0 10 0

Thousands

8 0 6 0 4 0 2 0 0

South

Northeast

West

Midwest

U.S. dependencies and possessions
1994 1995

1993

Year

1996

1997
SOUTH CAROLINA

1998

AHEC

Proportion of AIDS Cases, by Race/Ethnicity Year of Report,1985-1998, United States
70 60 50 40 30 20 10 0

Percent of Cases

White, not Hispanic Black, not Hispanic Hispanic American Indian/ Asian/Pacific Islander Alaska Native
1987 1989

1985

Year of Report

1991

1993

1995
SOUTH CAROLINA

1997

AHEC

AIDS Cases by Exposure Category and Year of Report, 1985-1998, United States
8 0 7 0 6 0 5 0 4 0 3 0 2 0 1 0 0

Percent of Cases

Men who have sex with men (MSM)

Injection drug use (IDU)

Heterosexual contact
MSM & IDU
1985 1987 1989 1991 1993 1995 1997

Year of Report
SOUTH CAROLINA

udes cases with other or unreported risk pending medical record review and reclassification.

AHEC

AIDS Rates per 100,000 Population Reported in1998
7.8 3.3 6.2 2.6 1.2 14.8 17.3 6.6 7.9 2.0 4.3 4.8 8.5 20.1 4.7 13.5 PR 44.3 VI 29.6
SOUTH CAROLINA

0.9 4.0 3.9 2.6 10.8 8.1 8.0 15.1 11.1 21.8 7.3
8.2 6.1

3.4 VT 2.5 47.9 14.5 4.7 7.1 12.8 14.7
NH 3.5 MA 15.0 RI 12.9 CT 20.3 NJ 26.3 DE 23.4 MD 31.9 DC 189.1

10.4

13.8

12.0

20.3 16.9 36.5

Rate per 100,000 <5 5 - 14.9 15+

AHEC

AIDS Cases Reported in 1998 and Estimated 1998 Population, by Race/Ethnicity, United States
AIDS Cases N=48,269*
33%
<1 1 % %

Population
71%

N=274,766,00

45% 20%

13% 12%

1 % 4 %

White, not Hispanic Black, not Hispanic Hispanic

*Includes 211 persons with unknown race/ethnicity

Asian/Pacific Islander American Indian/ Alaska Native
SOUTH CAROLINA

AHEC

AIDS in Adult/Adolescent Men by Race/Ethnicity per 100,000 Population, Reported in 1998 United States
Race/Ethnicity
White, not Hispanic Black, not Hispanic Hispanic Asian/Pacific Islander American Indian/ Alaska Native Total*

Cases
14,027 14,740 7,511 329 117 36,886

Rate
18 125 58 9 16 34
SOUTH CAROLINA

Includes 162 men whose race/ethnicity is unknown. *

AHEC

AIDS by Region & Size of Place of Residence Reported in 1998, United States
NonMetropolitan Metropolitan metropolitan area 500,000 area 50,000population 499,999 population area
Northeast N=14,399 North Central N=4,317 South N=19,474 West N=8,121

% 93.1

% 4.5

% 2.4

76.3 75.6 86.7

14.4 13.5 8.2

9.3 10.9 5.0 SOUTH CAROLINA AHEC

P r im a r y a n d s e c o n d a r y s y p h ilis - R a te s b y s ta te : U n ite d S ta te s a n d o u tly in g a r e a s , 1 9 9 7
0 .3 0 .3 0 .0 0 .1 0 .6 1 .2 0 .0 0 .2 0 .4 0 .0 0 .1 0 .3 1 .1 3 .5 3 .5
0 .2 0 .1
P u e r to R ic o 6 .7 V ir g in Is . 1 .8

0 .2 0 .3 1 .7 0 .2 2 .1 1 .6 2 .0 3 .5
0 .1

0 .8 1 .0

3 .7 2 .6

3 .0
G u a m 0 .0

0 .5

3 .5 9 .8 1 4 .0 6 .9 1 0 .2 R a te p e r 1 0 0 ,0 0 0 p o p u la tio n 1 4 .4 9 .6 7 .0 < 4 (n = 4 2 ) 8 .4 4 .1 -1 2 (n = 7 ) > 12 (n = 3 ) 2 .1

VT 0 .0 N H 0 .0 M A 1 .3 RI 0 .2 C T 1 .9 NJ 1 .9 D E 3 .0 M D 1 7 .6

N o t e : T h e t o t a l r a t e o f p r im a r y a n d s e c o n d a r y s y p h ilis f o r t h e U n it e d S t a t e s a n d o u t ly in g a r e a s ( in c lu d in g G u a m , P u e r t o R ic o , a n d V ir g in I s la n d s ) w a s 3 . 3 p e r 1 0 0 , 0 0 0 p o p u la t io n . T h e H e a lt h y P e o p le y e a r 2 0 0 0 o b je c t iv e is 4 . 0 p e r 1 0 0 , 0 0 0 p o p u la t io n

SOUTH CAROLINA

AHEC

P r im a r y a n d s e c o n d a r y s y p h ilis - C o u n tie s w ith r a te s a b o v e a n d c o u n tie s w ith r a te s b e lo w th e H e a lth y P e o p le y e a r 2 0 0 0 o b je c tiv e : U n ite d S ta te s , 1 9 9 7

R a te p e r 1 0 0 ,0 0 0 p o p u la t io n <4 >4 (n = 2 ,7 0 2 ) (n = 4 1 3 )

SOUTH CAROLINA

AHEC

SOUTH CAROLINA

AHEC

SOUTH CAROLINA

AHEC

SOUTH CAROLINA

AHEC

SOUTH CAROLINA

AHEC

SOUTH CAROLINA

AHEC

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