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Studi Kohort

Cohort in epidemiology:

a group of people who share a


common experience or condition

Experimental vs. Cohort


In experimental studies, individuals are

ASSIGNED to a group and the exposure


is FORCED upon them

In a cohort study, the exposure is

NATURAL and individuals are NOT


ASSIGNED to a group; they are in a
group either by their own choosing
(smoking vs. not) or by chance
(exposure to radiation leak or not)

Cohort definition
- People living in a geographical area
Members of all worker ever employed in
one factory
- Cohort of workers from different plants
but engage the same industrial process
- Member of professional organization

Cohort Definition
Advantage of first option, restricting the

cohort to a place:
Characterization of exposure is more
consistent and precise
Pooling cohort members from multiple
facilities increases the study size

Closed vs. Dynamic


Closed cohort

study subjects are observed continuously


from the time joining the study forward.
It assumes no subject enter or exit when
the study is defined
Dynamic (open population)
allows the member enter or exit from the
study. person-time experiences
accumulate from a changing of individual

TIME

Disease
Exposed
Population

No disease

People
Without
disease

Disease
Not exposed
No disease

Groups are classified on the basis of

presence or absence of exposure


Free of outcome of interest at the start of
follow-up
Subjects are followed to assess outcome

Types of Cohort Study


Retrospective cohort

Both exposure and outcome have already


occurred

Prospective cohort

Exposure may or may not have occurred


but the outcome have not

Prospective Cohort

Exposure
x
o
Retrospective Cohort

Exposure Disease
x
?
o
?

Disease
?
?

Retrospective cohort vs.


Prospective cohort
Factors to be considered

Scientific
Does

available data provide adequate detail


information on risk factors?

Logistic

Planning a Cohort Study


Is the study cohort sufficiently large to

yield statistically reliable data?


Will the cohort have an adequate length
of follow-up for studying delayed effects
or rare disease?
Are exposure data suitable for assessing
exposure-response relationship?

Selection of exposed
population
Is the exposure common or rare in the

population?
Does it allow complete and accurate

exposure and follow-up information on


all study participants?

Special exposure population

Industrial-based (Occupational)
Living near suspected hazardous environment
Being present at given event (hiroshima
population, veteran of vietnams war)

Groups of people that provide adequate

information
Health insurance, profession, student

Population in specific geographic

Selection of comparison
population
Groups being compared should be as

similar as possible in terms of


Other risk factors of outcome
Exposure assessment
Outcome assessment

Selection of comparison
population
Internal comparison

Levels of exposure
Smoking among physician

General population ( SMR analysis)

Outcome occurrence in study population is


compared to that in general population

Special comparison

E.g. Groups are compared based on different task

Multiple comparison

Defining Exposure
Quality of exposure assessment

determine validity of environmental


epidemiology study

Yes/no or high/low
nonhomogenous
within group
Ordinal
dose-response
Continuous from relevant time
increases sensitivity

Measuring Exposure
Interviews, questionnaires, structured diaries
Measurements in external media

(macroenvironment) from existing records or


conducted for epidemiologic investigation
Concentrations in the personal or
microenvironment
Individual doses
Biologic monitoring

substance (blood lead)


biologic marker (phenol as urinary metabolite of
benzene)

Exposure variable
Intensity = magnitude of the amount of a

substance that potentially can enter the


body
Duration = length of time during which a
given intensity is maintained
Cumulative exposure (CE) = I x D

Sources of Data
Exposure

Records
Questionnaire, Interview
Physical examination
Direct measurement

Outcome

Hospital or clinic records


Death certificate
Periodic health examination
Questionnaire, interview

Follow-up of the Cohort


Update interview, resend questionnaire,

update physical exam, exposure


measurement, outcome
Sketch diagram on how to follow-up the
subjects
Develop a guide on how to search
losses of follow-up. It should not be
related to exposure or outcome.

Issues in Analysis
Bias

Losses to follow-up
Misclassification of exposure
Nondifferential: a similar proportion
of inaccuracy occurs in each study
group
Differential

Measure of association
Absolute measure

Risk difference (RD) = Ie - Iue

Relative measure

Risk ratio
Rate ratio
Incidence exposed
Incidence unexposed

Data analysis

Perhitungan RR untuk CI
Outcome (+)

Outcome (-)

E (exposed)

a+b

NE (unexposed)

c+d

Total

a+c
b+d
(a + b + c + d)

Total

CI pada populasi exposed (E) --- a/(a + b)


RR=
CI pada populasi unexposed (NE) --- c/(c + d)

Data analysis

Perhitungan RR untuk IR
Outcome (+)

Person-time

E (exposed)

N1

NE (unexposed)

N0

Total

a+c

IR pada populasi exposed (E) --- a/N1


RR=
IR pada populasi unexposed (NE) --- c/N0

SMR analysis

Study Cohort

Age

(1)
Obs

(2)
P-Y

40-49
50-59
60-69
70-79

6
27
98
48

1200
2340
3750
975

Total

179

Reference
population
(3)
Rate
per 1000

(4)
Exp = SMR =
(2) x (3) (1) : (4)

2.5
6.1
12.4
25

3
14.27
46.50
24.38

2
1.89
2.11
1.97

88.15

2.03

of
users?

Does HIV infection increase risk


developing TB among drug

Exposure

Population
(f/u 2 years)

Cases

Incidence
(%)

Relative
Risk

HIV +

215

3.7

11

HIV -

298

0.3

Various Levels Exposures


Exposure levels

Population
at Risk

Cases Incidence

RR

High

N1

a1

I1

RR1

Medium

N2

a2

I2

RR2

Low

N3

a3

I3

RR3

None

N0

a0

I0

Ref

Presentation of data:
Various exposure levels

Strengths
Design of choice to study rare exposure
Can examine multiple outcomes of a

single exposure
Can elucidate temporal relation between
exposure and outcome
Minimize bias of exposure assessment
Direct measurement of incidence

Limitations
Inefficient to study rare disease
If prospective, costly and time

consuming
If retrospective, requires adequate
records
prone to losses to follow-up threat
validity of the result

A
B
C
D
E
F
G
H

Plant open

Cohort
enumeration

Jan 1,1940 Jan 1, 1950

1960

1970

T1
End of follow-up
Dec 31, 1984