Professional Documents
Culture Documents
by Fisaha.H(BSc. Mphil)
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Learning Objectives
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Measurements in Epidemiology
Measures of disease occurrence
Prevalence
Incidence
Mortality
Rates, Proportions, Ratios
Measures of Association
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Epidemiologic Measures of association
Quantifies or expresses the strength of the
relationship between an "exposure" and
“outcome” of interest
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Measures of association…
Event
– e.g., injury from land mine
Condition
– e.g., blindness
Death
Others
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Description of Relationships
• Variables can be related or unrelated to another
description
• If related, variables can be
• Statistically significant
But remember:
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"Every epidemiologic study can be
summarized in a 2-by-2 table.“
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two-by-two table….
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two-by-two table…..
Disease
Yes No Person-time
units
a -
Exposure
Yes c - PY1
No PYo
a+c PY1 + PYo
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Risk
= "Attack rate“
= Probability of getting disease
= Risk of disease
= Cumulative incidence
= Incidence proportion
1. Relative Risk
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Relative Risk
Risk: The probability of an event occurring
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RR…
Indicate the likelihood of developing the disease in the
exposed group relative to those who are not exposed
RR = R e / Rè Disease
Yes (+) No (-)
K
Exposure a b a+b n
Yes (+)
. a . c d o
c+d
RR = w
No (-)
. a+b
n
.
. c .
– It is a directcmeasurement
+d of a risk
Bacteruria
Yes No Total
Current OC use
Yes 27 455 482
No 77 1831 1908
Total 104 2286 2390
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Relative Risk…
RR = a/(a+b) =27/482 =1.4
c/(c+d) 77/1908
• Interpretation – OC users had 1.4 times the risk or
were 40 percent (i.e 1.4 minus the null value of 1.0)
more likely to develop bacteruria than nonusers
• For cohort studies with person-time units of
follow-up, the RR is calculated analogously as the
ratio of the incidence density in those exposed to
that among those non exposed.
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Example conti….
Postmenopausal
hormone use
Yes 30 - 54,308.7
No 60 - 51,477.5
Total 90 105,786.2
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Example Conti….
RR = Ie =IDe = a/PY1 = 30/54,308.7 = 0.5
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Exercises
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Interpretation of RR
A RR of 1 indicates no association
considered:
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Odds ratio
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Odds ratio, cross product ratio…
b/d bc
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OR…
Example
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Example cont…
Table 3: Data from a case-control study of current oral
contraceptive (OC) use and MI in premenopausal female
nurses
Myocardial infarction
Yes No Total
Current OC use
Yes 23 304 327
No 133 2816 2949
Total 156 3120 3276
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Example cont…
OR = ad = (23)(2816) = 1.6
bc (304)(133)
Interpretation: women who had MI were 1.6
times more likely to use OCP than individuals
with out MI.
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OR can be used as a valid estimate of
the RR
When the disease is uncommon;
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When Can the Odds Ratio be Used
to Approximate the Relative Risk?
D+ D- Total Risk
E+ a b a+b a/a+b
E- c d c+d c/c+d
a a
RR = a+b ≈ b ≈ ad = OR
c c bc
c+d d
For a rare disease, a <<< b, so a+b ≈ b
c <<< d, so c+d ≈ d
Example of the “Rare Disease” Assumption
D+ D- Total Risk
E+ 90 499,950 500,040 0.00018
E– 10 499,950 499,960 0.00002
OR = ad = (90)(499,950) = 9.0
bc (499,950)(10)
Example of the “Rare Disease” Assumption
D+ D- Total Risk
E+ 90 50 140 0.643
E- 10 50 60 0.167
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Attributable Risk
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Attributable Risk (AR) or (RD)
provides information about the absolute effect of
the exposure AR = Ie – Io
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AR/RD…
AR quantifies disease burden in exposed
group attributable to exposure
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Attributable Risk
I exposed – I unexposed
I = Incidence
AR cont…
For example in the study of OC use and
bacteruria:
AR=27/482 – 77/1908 = 0.01566 = 1566/105
Interpretation: the excess occurrence of
bacteruria among OC users attributable to
their OC use is 1566 per 100,000.
AR is used to quantify the risk of disease in the
exposed group that can be considered
attributable to the exposure by removing the risk
of disease that would have occurred anyway due
to other causes (the risk in the non-exposed).
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AR cont…
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AR cont…
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Interpretation
No
0
Negative Positive
AR = 0
No Association
AR > 0
Positive association
AR < 0
Negative association
4.Attributable Risk Percent (AR%)
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Attributable Risk Percent (AR%)
Also called, attributable fraction/ etiologic fraction.
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AR%...
estimate the proportion of the disease among the
exposed that is attributable to the exposure, or
the proportion of the disease in that group that
could be prevented by eliminating the exposure
AR% = AR x 100 = (Ie – Io) x 100
Ie Ie
Example: In the cohort study of OC use and
bacteruria,
AR% = 1566/105 x 1OO = 27.96%
27/482
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AR% …
Interpretation:
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AR% …
For most case-control studies, the AR cannot be
calculated because the incidence rates among the
exposed and non exposed groups are not
available.
It is, however, possible to calculate the AR% using
the following formula
AR% = (OR – 1) x 100
OR
Example: From the data on OC use and MI, the
OR of MI associated with current OC use was 1.6,
yielding AR% of 37.5%
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AR% cont…
Interpretation
If OC use causes MI, nearly 38% of MIs among
young women who used OCs could be
attributable to that exposure or could be
eliminated if they were to stop using OCs
If the exposure is preventive, so that Ie is less
than Io, the AR is meaningless.
-However, an analogous measure, the
Preventive Fraction (PF)****, can be defined
PF = Io – Ie
Io
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5. Population Attributable Risk (PAR)
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Population Attributable Risk (PAR)
It is measure of the excess rate of a disease in total study
population which is attributable to an exposure
Calculated by multiplying the attributable risk by the
proportion of the population exposed.
It can also be calculated by the rate of the disease
among the total population minus the rate in non-
exposed group.
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PAR…
Example: the PAR of bacteruria associated with OC use
(Table 1) is:
Or alternatively
316/105/year
• -Thus, if OC use were stopped, the excess annual
incidence rate of bacteruria that could be eliminated among
women in this study is 316 per 100,000. 59
6.Population Attributable Risk Percent (PAR
%)
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4. Population Attributable Risk Percent
(PAR%)
It measures the proportion of disease in a total
population that is attributable to an exposure.
IT
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PAR%...
4351.5