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Epidemiology: Principles and Methods

Prof. dr. Bhisma Murti, MPH, MSc, PhD Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret

Definitions in Epidemiology
1. 2. 3. Definition and aims of epidemiology Study designs used in epidemiology Measures of Disease Frequency
Incidence (Cumulative Incidence and Incidence Density) Prevalence

4. 5. 6. 7. 8.

Measures of Association Bias Confounding Chance Causal Inference

A study of the distribution of disease frequency in human population and the determinants of that distribution Epidemiologists are not concerned with an individuals disease as clinicians do, but with a population distribution of the disease Distribution of disease by person, place, time Assumption:
Disease does not occur randomly Disease has identifiable causes
which can be altered and therefore prevent disease from developing

Definition of Epidemiology
The study of the distribution and determinants of health-related states or events in specified population, and the application of this study to control of health problems.
Determinants: physical, biological, social, cultural, and behavioral factors that influence health. Health-related states or events: health status, diseases, death, other implications of disease such as disability, residual dysfunction, complication, recurrence, but also causes of death, behavior, provision and use of health services.
[source: Last (ed.) Dictionary of Epidemiology, 1995]

Aims of Epidemiologic Research

1. Describe the health status of a population 2. To assess the public health importance of diseases 3. To describe the natural history of disease, 4. Explain the etiology of disease 5. Predict the disease occurrence 6. To evaluate the prevention and control of disease 7. Control the disease distribution

Descriptive epidemiology

Analytic epidemiology Applied epidemiology

Descriptive and Analytical Epidemiology

1. Descriptive epidemiology
Describes the occurrence of disease (crosssectional)

2. Analytic epidemiology:
Observational (cohort, case control, crosssectional, ecologic study) researcher observes association between exposure and disease, estimates and tests it Experimental (RCT, quasi experiment) researcher assigns intervention (treatment), and estimates and tests its effect on health outcome

Epidemiologic Study Designs

Epidemiologic Study Designs

Study Design and Its Strength of Evidence

1. 2. 3. 4. 5. 6. Systematic review, meta-analysis: secondary data analysis Randomized Controlled Trials (RCT) Cohort: prospective or retrospective
Quasi experiment
Strongest evidence

Case control: prospective or retrospective Cross sectional Case Reports / Case Series

Weakest evidence

Which Disease if More Important to Public Health? Measure of Disease Occurence

Hypothetical Data




Children exposed Children ill

Attack rate

251 201

238 172

218 82

Attack rate =

Number of Ill persons (new cases) Population at risk exposed

Attack rate is a Cumulative Incidence; it shows the risk (probability) of disease to occur in a population In regard to risk, measles is the most important disease to public health while rubella being the least

Description of Disease Distribution in the Population

Disease affects mostly people under five years of age

Disease affects people living alongside the river

Disease reaches its peak in frequency in Week 6

Natural History of Disease

Index the first case identified Primary the case that brings the infection into a population Secondary infected by a primary case Tertiary infected by a secondary case
Susceptible Immune P S S T


Timeline of Infectiousness
Dynamics of infectiousness

Latent period

Infectious period



Dynamics of disease

Incubation period

Symptomatic period



Measure of Disease Frequency

1. Cumulative Incidence (Incidence, Risk, I, R)= Number of new case over a time period Population at risk at the outset - Indicates the risk for the disease to occur in population at risk over a time period. Value from 0 to 1.


Incidence Density (Incidence Rate, ID, IR)=

Number of new case over a time period Person time at risk Indicates the velocity (speed) of the disease to occur in population over a time period. Value from 0 to infinity


Prevalence (Point Prevalence):

Number of new and old cases at a point of time Population Indicates burden of disease. Value from 0 to 1.

Endemic vs. Epidemic

Number of Cases of a Disease

Endemic Time


Levels of Disease Occurence

Sporadic level: occasional cases occurring at irregular intervals Endemic level: persistent occurrence with a low to moderate level Hyperendemic level: persistently high level of occurrence Epidemic or outbreak: occurrence clearly in excess of the expected level for a given time period Pandemic: epidemic spread over several countries or continents, affecting a large number of people

Factors Influencing Disease Transmission

Infectivity Pathogenicity Virulence

Weather Housing Geography

Antigenic stability Survival

Occupational setting
Air quality Food


Age Sex Genotype Behaviour Nutritional status Health status

Measures of Infectivity, Pathogenecity, Mortality

Infectivity (ability to infect)
(number infected / number susceptible) x 100

Pathogenicity (ability to cause disease)

(number with clinical disease / number infected) x 100

Virulence (ability to cause death)

(number of deaths / number with disease) x 100

All are dependent on host factors

Preventable Causes of Disease

Biological factors and Behavioral Factors Environmental factors Immunologic factors Nutritional factors Genetic factors Services, Social factors, and Spiritual factors
[JF Jekel, Epidemiology, Biostatistics, and Preventive Medicine, 1996]

Types of Cause: Necessary cause: Mycobacterium tuberculosis Sufficient cause: HIV Contributory cause: Sufficient-Component Cause

Causal Model of Risk Factors for CVD

Morbidity and Mortality

(Stroke, MI)


Biological Risk Factors

(Hypertension, Blood Lipids, Homocysteine)

Proximate cause

Genetic Risk Factors

Behavioral Risk Factors

(Family History)

(Cigarette, Diet, Exercise)

Intermedi ate cause

Environmental Factors

(Socioeconomic Status, Work Environment)

Distal cause

To Study Disease Etiology

Kuartil asupan buah dan sayur

Kuartil asupan buah dan sayur

To Study Prognosis (Survival)

Validity of Estimated Association and Causation

OR = 7.3

Lung Cancer

True association
causal non-causal

Bias? Confounding? Chance?


The Role of Bias, Confounding, and Chance in The Estimated Association

Association ?
present absent

Selection Bias and Information Bias?



False association

Confounding ?
unlikely likely

Chance ?

True association

Systematic errors in selection of study subjects, collecting or interpreting data such that there is deviation of results or inferences from the truth.
Selection bias: noncomparable procedure used to select study subjects leading to noncamparable study groups in their distribution of risk factors. Example: Healthy worker bias Information bias: bias resulting from measurement error/ error in data collection (e.g. faulty instrument, differential or non-differential misclassification of disease and/ or exposure status. Example: interviewer bias, recall bias)

1. A mixing of effects
between the exposure, the disease, and a third factor associated with both the exposure and the disease such that the effect of exposure on the disease is distorted by the association between the exposure and the third factor

2. This third factor is so called confounding factor

Cases of Down syndroms by birth order

Cases per 100 000 live births 180 160 140 120 100 80 60 40 20 0 1 2 3 4 5

Birth order

Observed (but spurious) association, presumed causation

Birth Order

Downs syndrome
True association

Unobserved association

Maternal age

Apakah Ada Hubungan antara Urutan Kelahiran dan Risiko Sindroma Down?

[Biomedical Bestiary: Michael, Boyce & Wilcox, Little Brown. 1984]

Observed (but spurious) association, presumed causation


Cancer Smoking, Alcohol, other Factors

Unobserved association

True association

Hills Criteria for Causation

1. 2. 3. 4. 5. 6. 7. 8. 9. Strength of association Specificity Temporal sequence Biologic gradient (dose-response relationship) Biologic plausibility Consistency Coherence Experimental study Analogy