H Soori, Prof.

of Epidemiology

Measurements in epidemiology

1
 Epidemiology is a scientific discipline focused on quantifying and understanding
health and disease within human populations and groups.
 The accuracy of measurements, standardization of measurement techniques, and
reduction of measurement errors are crucial for facilitating meaningful data
comparisons.
 In epidemiology, the collection of data pertaining to measurements should
prioritize simplicity and accuracy.
 These data should be fit for the intended purposes of their collection, adhering to
standardized and operational definitions.
 Additionally, raters should receive appropriate and comprehensive training to
ensure the accuracy of the data they produce.
 To enhance the utility of epidemiological data, it is important to continuously
publish and present the findings, incorporating feedback as necessary.

2
Primary, secondary and third-party data
 Primary data: refers to the original data collected firsthand by researchers
specifically for their research objectives. This data is obtained through direct
observation, interviews, surveys, experiments, or other data collection
methods. Primary data is considered to be the most reliable and accurate
because it is collected for a specific purpose and is directly relevant to the
research question at hand.
 Secondary data: Secondary data refers to data that has already been collected
by someone else for a different purpose but can be used by researchers for
their own studies. This data is typically obtained from published sources,
government agencies, research institutions, or other researchers' studies.
 Third-party data refers to information collected and obtained from external
sources that are not directly involved in the research or data collection
process. It is data that is generated by entities other than the researcher or the
organization conducting the research.

3
Information sources of health and disease

• WHO
• Global Health Database (GHO)= https://www.who.int/data/gho
• U.S. government website- https://www.data.gov/
• European Data Portal- https://www.europeandataportal.eu/
• World Bank Open Data - https://data.worldbank.org/
• UN Data- https://data.un.org/
• OpenDataSoft- https://www.opendatasoft.com/
• Open Data for Africa- https://data.afdb.org/
• Canadian Open Data- https://open.canada.ca/en/
• Ministries oh Health
• Research centers
• Forensic medicine, hospitals, clinics, laboratories, police, health centers,
social security
• Surveillance systems
• Registration systems 4
 Criteria for good measurements
1. Clarity of definitions, indicators, etc.
2. Precision
3. Reliability
4. Consistency
5. Meaning Adequacy
6. Feasibility
7. Utility
8. Validity
9. Consensus
10. Ethical considerations (e.g. Privacy, Confidentiality-Anonymity)

5
Stages in the development and validation of
criterion-referenced measures.
1. Specify the conceptual model of the measure.
2. Specify the purpose(s) of the measure.
3. Clarify objective(s) or the domain definition.
4. Prepare test specifications including:
a. Method of administration
b. Number or proportion of items that will focus on each objective or subscale

c. Type of items and how they will be created

d. Test restrictions and givens
e. General scoring rules and procedures
5. Construct the measure including:
a. Develop a pool of items or tasks matched to the objective(s) or subscales
b. Review items or tasks to determine content validity and their
appropriateness
c. Select items after editing or deleting poorly developed items from the item
pool
d. Assemble the measure
6. Set standards or cut score for interpreting results. 6
7. Field-test or administer the measure.
8. Assess reliability and validity of measure
Statistical Analyses for Measurement of Precision, Accuracy

7
Statistical Analyses for Measurement of Errors

8
 Measurement errors:
Measurements are an important part of daily activities in
medical services and research.
Important points in measurement errors:
 Case Definition
 Severity scales
 Unreported OR Unrecorded Cases
 Duplicated OR Replicated Cases
 Misclassifications

9
 Misclassification
 Misclassification results from errors in measuring the study data.
 Any type of study data can potentially be misclassified.
 A useful approach to judging misclassification in a clinical research
article is to ask the following questions:
(1) Based on the data collection methods, what study elements may have
been misclassified?
(2) Is misclassification likely to be differential or non-differential?
(3) What is the expected impact of misclassification on the study results?

Differential and non-differential misclassification is only related to

analytical studies.

10
 Differential Misclassification
Misclassification that occurs preferentially or systemically within a
particular subset of the study population is called differential
misclassification.
Differential misclassification can change relative risk estimates toward or
away from 1.0, depending on the particular situation.
1. Differential misclassification occurs when:
a. there is misclassification of the exposure that differs among
subjects who experience or do not experience the outcome or
b. there is misclassification of the outcome that differs among
subjects who are exposed or unexposed
2. Differential misclassification can result in observing a relative risk that
is closer to or further from 1.0, depending on the particular situation.

11
 Non-differential /Random Misclassification

 Misclassification that occurs randomly or roughly equally throughout a study

population is called non-differential or nonselective misclassification.
 Examples of non-differential misclassification include use of a standard cuff to
measure blood pressure, administration of a questionnaire to determine the
presence of diabetes, and use of a variable laboratory assay to measure serum
triglyceride levels.
 The impact of non-differential misclassification of the study outcome differs
when there is under diagnosis of the disease.
1. Non-differential misclassification of the outcome occurs when error in
measuring the outcome is similar among exposed and unexposed subjects.
2. Non-differential misclassification of the outcome may result in bias toward the
null or no change in the observed relative risk.
In summary, non-differential misclassification of either the exposure or the
outcome typically results in observing a relative risk that is closer to 1.0,
than the true relative risk that would be obtained if the study data were
measured perfectly.
12
Information Bias (cont.)

Misclassification bias – errors are made in

classifying either disease or exposure status
 Types of Misclassification Bias

 Differential misclassification – Errors in measurement are one way only

 Example: Measurement bias – instrumentation may be inaccurate,
such as using only one size blood pressure cuff to take
measurements on both adults and children
 Misclassification Bias (cont.)
True Classification
Cases Controls Total
Exposed 100 50 150
Nonexposed 50 50 100
150 100 250

OR = ad/bc = 2.0; RR = a/(a+b)/c/(c+d) = 1.3

Differential misclassification - Overestimate exposure for 10 cases, inflate
rates

Cases Controls Total

Exposed 110 50 160
Nonexposed 40 50 90
150 100 250

OR = ad/bc = 2.8; RR = a/(a+b)/c/(c+d) = 1.6

 Misclassification Bias (cont.)
True Classification
Cases Controls Total
Exposed 100 50 150
Nonexposed 50 50 100
150 100 250
OR = ad/bc = 2.0; RR = a/(a+b)/c/(c+d) = 1.3

Differential misclassification - Underestimate exposure for 10 cases, deflate

rates
Cases Controls Total
Exposed 90 50 140
Nonexposed 60 50 110
150 100 250

OR = ad/bc = 1.5; RR = a/(a+b)/c/(c+d) = 1.2

 Misclassification Bias (cont.)
True Classification
Cases Controls Total
Exposed 100 50 150
Nonexposed 50 50 100
150 100 250
OR = ad/bc = 2.0; RR = a/(a+b)/c/(c+d) = 1.3

Differential misclassification - Underestimate exposure for 10 controls,

inflate rates

Cases Controls Total

Exposed 100 40 140
Nonexposed 50 60 110
150 100 250
OR = ad/bc = 3.0; RR = a/(a+b)/c/(c+d) = 1.6
 Misclassification Bias (cont.)
True Classification
Cases Controls Total
Exposed 100 50 150
Nonexposed 50 50 100
150 100 250

OR = ad/bc = 2.0; RR = a/(a+b)/c/(c+d) = 1.3

Differential misclassification - Overestimate exposure for 10 controls,

deflate rates

Cases Controls Total

Exposed 100 60 160
Nonexposed 50 40 90
150 100 250

OR = ad/bc = 1.3; RR = a/(a+b)/c/(c+d) = 1.1

 Misclassification Bias (cont.)

 Non-differential (random) misclassification – errors in

assignment of group happens in more than one direction
 Misclassification Bias (cont.)
True Classification
Cases Controls Total
Exposed 100 50 150
Nonexposed 50 50 100
150 100 250
OR = ad/bc = 2.0; RR = a/(a+b)/c/(c+d) = 1.3

Non-differential misclassification - Overestimate exposure in 10

cases, 10 controls – bias towards null

Cases Controls Total

Exposed 110 60 170
Nonexposed 40 40 80
150 100 250
OR = ad/bc = 1.8; RR = a/(a+b)/c/(c+d) = 1.3
 Modalities of measurement
 There are three basic modalities of measurement:
1. Self-report
2. Physiological measurement
3. Behavioral measurement
 behavioral observation
 content analysis and archival research

21
 Self-report measures

 You ask a participant to describe his behavior, to express

his opinion or characterize his experience in an interview
or by using a questionnaire with ratings
 Positive aspects
 Only the individual has direct access to information about his state
of mind
 More direct measure
 Negative aspects
 Participants may distort the responses to create a better self-image
or to please the experimenter
 The response can also be influenced by wording of the questions
and other aspects of the situation

22
 Physiological measures
 Physiological manifestations of the underlying construct
 e.g. EEG, EKG, MRI
 advantages
 provides accurate, reliable, and well-defined measurements that
are not dependent on subjective interpretation
 disadvantages
 equipment is usually expensive or unavailable
 Presence of monitoring devices may create unnatural situation
 question: Are these procedures a valid measure of the construct
(e.g. increase in heart rate to fear, arousal)

23
 Behavioral measures
 Behaviors that can be observed and measured (e.g. reaction time,
reading speed, focus of attention, disruptive behavior, number of words
recalled on a memory test)
 How to select the right behavioral measure?
 Depends on the purpose of the study

 In clinical setting the same disorder can reveal itself through

different symptoms
 In studying memory we want to have the same measure for all
subjects to be able to compare them

Beware of situational changes in behavior (e.g. disruptive behavior in

school vs when observed) and different behavioral indicators of a construct

24
 Other aspects of measurement
 Multiple measures
 Sometimes you can use two (or more) different procedures to
measure the same variable (e.g. heart rate and questionnaire as a
measure of fear)
 Problems (the two variables may not behave in the same way)
 e.g. a specific therapy for treating fear may have large effect on

behavior but no effect on heart rate

 The lack of agreement between two measures is called
desynchrony
 One measure can be more sensitive than other

 Different measures may indicate different dimensions of the

variable and change at different times during the treatment

25
Some Limitations of Hospital Data
 Hospital admissions are selective in relation to
Personal characteristics
 Severity of disease
 Associated conditions
 Admission policies
 Hospital records are not designed for research. They may be
 Incomplete, illegible, or missing
 Variable in diagnostic quality
 Population(s) at risk (denominator) is (are) generally not defined

26
 Measures in Epidemiology

 Numbers of cases  Relative risk

 Proportional mortality  Odds ratio
 Proportional mortality ratio  Attributable risks
 Actual/Crude prevalence and  Numbers needed to treat and
incidence rates prevent
 Specific prevalence and  Life years lost
incidence rates  Disability adjusted life year
 Standardised rates (DALY)
 Standardised ratios  Quality adjusted life year
(QALY)
The most important measurements in epidemiology

 Measurement of death/Mortality
 Measurement of Morbidity
 Measuring disability
 Birth/Fertility measurement
 Measuring the presence, absence, or distribution of factors related or
attributable to the disease
 Measuring medical needs, health care, health service costs and other
factors related to health
 Measuring the presence, absence, or distribution of environmental
factors and other factors that are effective in causing the disease
 Measurement of demographic variables

28
 In order to value the raw epidemiological measurements, they
should be converted into proportions, ratios, or rates in order
to gain a more correct understanding of them.

 Proportion= Division of two related numbers, numerator is a

subset of denominator
 Ratio= Division of two unrelated numbers

 Rate= Division of two numbers; time is always in denominator

29
 Rates
Important measures in epidemiology mainly include 3 groups:

1. Birth rates (such as raw birth rate, or birth rate),

2. Morbidity rates (such as incidence rate, prevalence rate or disease

attack rate), and

3. Mortality rates (such as crude death rate, cause-specific death rate,

maternal death rate, fatality rate, lost years of life, death rate).

30
 Crude birth rate
equal to:
the number of live births in a certain population and a certain period of
time (for example, one year) divided by the average number of the total
population multiplied by 1000.
The size of this index is different in different countries, but due to its
rawness, it cannot provide a comprehensive picture of the situation of
births in different societies.
For example, in 2020, the crude birth rate in the world was 18.8 per
thousand

31
 Fertility rate
 Fertility rate is presented as general fertility rate and total fertility rate.
 General fertility rate is equal to the annual number of live births in a certain
population for every one thousand women of reproductive age in that society.
 Women of reproductive age are usually considered to be 15 to 49 years old and
sometimes 15 to 44 years old.
 Total Fertility Rates is the average number of live babies born to women in a
community during their reproductive period.
 This rate includes the total number of women's age-specific fertility rate in
different ages of their reproductive period.
 The total fertility rate in 2021 was 2.44 in low-income countries and 1.56 in
high-income countries. This amount in the world was about 2.32.
 If this amount is less than 2.1 in a society, it indicates the trend of decreasing
population growth, and if it is more than this value, it indicates the increasing
trend of population in that society.
 It was 6.82 in Niger, and 0.75 Hong Kong 2021.
32
 Disease Incidence Rate
 It refers to the measure of the number of new cases of a specific disease that
occur within a defined population over a given time period.
 It is a measure of the occurrence of new cases of a disease in a population at risk.

 The applications of this amount are in determining the probability of the spread of
a certain disease in a certain period of time, for example one year, and searching
for the causative factors of the disease.
 The incidence rate can be used/calculated in analytical studies (e.g. Cohort
studies).
 This is a measure that is used in the comparison between two societies and is
important for studies related to control and prevention.
 The incidence rate is more applicable for diseases that have a short period.

33
Types of incidence rates
 Point Incidence Rate: Point incidence rate refers to the incidence of new
cases of a disease within a specific time interval, usually a single point in
time.
It is calculated by dividing the number of new cases within that time interval by
the population size at that time.
 Cumulative Incidence Rate: The cumulative incidence rate measures the
proportion of individuals who develop a specific disease or condition within
a defined population over a specified time period.
It is calculated by dividing the number of new cases of the disease by the total
population at risk at the beginning of the time period and multiplying by a
constant (usually 1,000 or 100,000) to express the rate per unit of population.
 Person-time incidence rate (Incidence density) is a measure used in
epidemiology to estimate the rate of new cases of a disease or event per
unit of person-time at risk.
It takes into account the varying lengths of time that individuals are at risk of
developing the disease.

34
 Example
Suppose we want to calculate the cumulative incidence rate of a specific disease in a
population over a one-year period. We start with a population of 1,000 individuals who are
initially disease-free. Over the course of the year, 50 new cases of the disease are diagnosed.
 Point incidence rate = (Number of new cases / Total at risk) x Constant
Point incidence rate = (25 new cases / 250 person-years) x 1,000
Point incidence rate = 100 per 1,000
 Cumulative incidence rate = (Number of new cases / Total person-time at risk) x
Constant
Cumulative incidence rate = (50 new cases / 1,000) x 1,000
Cumulative incidence rate = 50 per 1,000
 Person-Time Incidence Rate OR Incidence density:
Let's consider a cohort study in which a group of 500 individuals is followed for a period of 2
years to assess the incidence of a specific disease. During this time, 20 individuals develop
the disease. for the entire 2-year duration, resulting in a total person-time of 1,000 person-
years (500 individuals x 2 years).
Person-time incidence rate = (20 new cases / 1,000 person-years) x 1,000
Person-time incidence rate = 20 per 1,000 person-years

35
 Person-time occurrence rate is synonymous
with distance Incidence density

Nominator=0 Nominator=1 Nominator=2 Nominator=3

1st year 2nd year 3rd year 4th year

Denominator=19.5 Denominator=28
Denominator=10 Denominator=35.5

Incidence rate=2/28
Incidence rate= 0/10
Incidence rate=1/19.5 Incidence rate= 3/35.5
36
 Comparison of incidence based on person (cumulative
incidence) and incidence based on person-time (incidence
density)
cumulative incidence person-time (incidence density)
It is between zero and one. It can be between zero and infinity.
It measures the absolute risk. (For It does not provide an absolute risk value (for
example, 50 cases in 1000 people is example, it says 50 cases per 1000 person-
equal to 5 percent) years of disease).
It is calculated by dividing the number It takes into account the varying lengths of time
of new cases by the total population that individuals are at risk of developing the
at the beginning of the time period. disease.
It is useful for understanding the risk It is useful for comparing disease occurrence
of disease occurrence in a rates across different populations or time
population. periods, taking into account variations in the
length of observation.
commonly used in studies where the useful in studies where the observation period
focus is on the risk of disease within varies for different individuals or when
a specific time period, such as cohort individuals enter or leave the study population
studies or clinical trials. at different times. It is often used in cohort
studies or other longitudinal study designs.
37
 It should be noted that
the amount of risk, which is sometimes taken as equivalent to cumulative
incidence, has differences with this rate.
 First, the risk of morbidity or death in a person in a certain time or age
range is pre-determined.
 Second, risk has no unit, unlike the rate of occurrence, whose unit is
person-time.
 Thirdly, in risk measurement, the probability of disease occurrence is
measured, but the incidence rate measures the speed of disease
occurrence.

Risk is the possibility of harm

38
 Disease Prevalence Rate
 Prevalence rate is the number of cases of a disease in a population at risk,
which can be in the form of point prevalence (prevalence at a certain
point or moment), period prevalence (prevalence in a certain period of
time) and or Lifetime prevalence (the proportion of those who have had
the disease throughout their lifetime to the population at risk at the
beginning of that time period).

 The applications of the prevalence rate are in measuring the amount of

disease in the society, and determining the health care needs in the society.

39
 Disease Prevalence Rate
The formula for calculating prevalence rate is as follows:

Prevalence rate = (Number of individuals with the disease / Total population) x Constant

For example, if a survey conducted in a community of 1,000 individuals finds that

100 individuals have a back pain, the prevalence rate would be calculated as:

Prevalence rate = (100 individuals with the disease / 1,000 total population) x 100

Prevalence rate = 10%

40
 For example, in response to the following questions, different
measures of prevalence rates can be measured:

 Do you currently suffer from back pain: (Point prevalence)

 Have you ever had back pain in the past year? (Periodic prevalence)
 Have you had back pain in your life? (Lifetime prevalence)

41
 Births
Recoveries
Population reservoir Immigration

Incident cases
Emigrant cases,
Prevalent cases unmeasured cases
occurring abroad, and
deaths
Emigrant and non-
Recoveries measured cases, deaths
Examples of Point and Period Prevalence and
Cumulative Incidence in Interview Studies of Asthma

Interview Question Type of Measure

"Do you currently have asthma?" Point prevalence

"Have you had asthma during the last (n)

Period prevalence
years?"

"Have you ever had asthma?" Cumulative incidence

43
Information needed to calculate incidence and prevalence rates:
1. Incidence Rate:
• Number of new cases: This refers to the number of individuals who develop the disease or
experience the event of interest during a specific time period. Numerator

• Total person-time at risk: This is the sum of the time each individual in the population was
under observation or at risk of developing the disease during the specified time period. It takes
into account the varying lengths of time individuals were followed or exposed to the risk.
Denominator
• Constant: A constant may be used to adjust the incidence rate to a specific population size or
time unit if necessary.
2. Prevalence Rate:
• Number of individuals with the disease: This refers to the total number of individuals in the
population who have the disease at a specific point in time. Numerator
• Total population: This is the size of the population under consideration at the specific point in
time. Denominator
• Constant: A constant may be used to express the prevalence rate as a percentage or per a
specific population size if desired.

44
Some important points of prevalence and
incidence rates:
 They are considered very important measures in epidemiology.
 It is measured in the rate of incidence of people who were not sick before, but
have contracted the disease in a certain period of time, but in the rate of
prevalence, the proportion of the number who are sick in a population is
measured. In other words, incidence is equivalent to new cases and prevalence is
equivalent to old and new cases (all cases) of the disease.
 A period of time may mean a year, a certain period of time, or a moment in time.
 The prevalence of the product is the sum of the cases in the past periods of time
that are still affected by the disease.
 Measuring prevalence is easier and cheaper than incidence.
 In measuring the rate of incidence, first of all, a population should be determined,
and they should be followed up in a certain period of time, so that the cases of
incidence are revealed.
 Using the rates of incidence and prevalence, the average duration of the disease
can also be determined.
In fact, the average duration of the disease is equal to the proportion of the
prevalence divided by the incidence of the same disease.
In other words, the prevalence rate of the disease is equal to the incidence rate of the
disease by the average duration of the disease.
45
Excercise
 In this example,
What is the numerator for
incidence in 2004?
What about the numerator for
point prevalence in Jan 2004
and Dec 2004?

46
 Incidence and prevalence and preferences
 For studies of the causes of disease the incidence rate is preferred.
Why?
 For studies of the burden of diseases of short duration e.g. measles
incidence is also preferred. Why?
 The prevalence rate is generally preferred as the measure of burden for
long-lasting diseases. Why?
 For health behaviours and other disease risk factors prevalence is the
preferred measure (even in studies of disease causation). Why?
 Disease Attack Rate
 Attack rate is the proportion of a population that develops a specific
disease during an outbreak or a defined period of time. It provides an
estimate of the risk of acquiring the disease within the population during
the specified period.

 Disease attack rate includes the number of new cases of a specific

disease in a population at risk, which is expressed as a percentage.

 This amount is determined by identifying clinical or sero-epidemiological

cases.

 In this, usually the time dimension is not clear. Measuring this amount is
very important in confirming the existence of epidemics (related
explanations have been provided before).

48
 Survival rate
 This rate is the number of survivors of a disease during a period of time
(for example, a period of 5 years) to all patients in the same period of
time.
 This amount is mainly used to evaluate standards related to treatment
methods.
 This time is usually calculated from the date of diagnosis of the disease
or the start of treatment, and it is used especially in cancer treatments.
Therefore, the survival rate is: the number of patients surviving a disease
after 5 years, divided by the total number of diagnosed or treated
patients multiplied by 100.
 For example, the latest UK data shows the 5-year age-standardised survival rate
for breast cancer – that is, the percentage of people who are alive 5 years after
diagnosis – is over 80%. It is 88% in the Netherlands
 However, some cancers, such as lung cancer, have a 5-year survival rate of less
than 20%. It ‘s 21% in the Netherlands 49
 Proportion Surviving (95% Confidence)
0.6 0.7 0.8 0.9 1.0

100
5
Survival Time
Kaplan Meier Curve

15
20

50

50
 Crude Mortality Rate
 The average annual number of deaths during a year per 1,000
population at midyear; also known as crude death.
 In 2021:
Qatar: 1.22 per 1000
Bulgaria: 18.0
Iraq: 5.24
Iran:5.57
Turkey: 6.38

World 2021: 8.98

51
 Case fatality rate
 Case fatality rate is a mathematical quantity that
describes the severity of a disease Y.
 Usually applied to acute diseases, it is the
proportion of persons diagnosed with a disease Y
who actually die from disease Y during the period
of observation:

No. of dying from disease Y in population p

CFR in population p =
No. with disease Y in population p

52
 Mortality Rates
Mortality is the incidence of death from a disease.
Some special rates
Number of infant (< 1 year) deaths
Infant mortality rate ________________________________________
Number of live births

Number of intrauterine deaths after 28 weeks

____________________________________
Stillbirth rate
Total births

Number of stillbirths + deaths in 1st week of life

_____________________________________
Perinatal mortality rate
Total births

NB These rates are usually related to one year 53

Mortality rate, infant (per 1,000 live births)

2021
World: 28
Sierra Leone: 78
Monaco: 1
Iran: 11
Iraq: 21

Low income: 47
High income: 2

54
 Ratios
 One of the most important measurements in epidemiology are ratios.
 Ratio is a value obtained by dividing one measure or quantity by
another quantity.
 Ratio is a general term that includes proportion, and percentage.
 The important difference between Ratio and proportion is that in Ratio
the fraction is integrated in the denominator of the fraction, while in
proportion it is not required.
 Ratios are sometimes expressed as percentages (such as the
mortality ratio) and sometimes as the ratio of the amount, which is the
ratio of two amounts (such as the ratio of the amount of an event in
exposure to the amount of the same event in non-exposure).
 There are important ratios such as sex ratio, independent ratio, Odds
ratio, relative risk.

55
Odds & Odds Ratio:
 One of the most important ratios is the odds ratio (OR).
 Odds ratio = dividing the odds of exposed group by the odds of
non-exposed group.
 Odds is the probability of an event occurring rather than not
happening.
 odds are the proportion of people who have been exposed to a
pathogen or risk factor and become ill to the number of people who
have been exposed to the same agent but have not become ill.
 The odds ratio is actually equivalent to the proportion of the odds
of exposed to the odds of not exposed.
 Odds ratio can be obtained in case-control studies.

56
 For example, in the following table: a. the number of exposed
population and got sick, b. number of exposed population and
not got sick, c. number of not exposed and got sick, and d. ...

Disease

- +

a+b b a + Exposure

c+d d c -

b+d a+c

Based on this, the odds in exposed is equal to a/b, and the odds in non-exposed
is equal to d/c. In this case, the odds ratio will be equal to the ratio of these two
and equal to a*d divided by b*c. 57
 If the odds ratio is equal to one, it means that the chance of the disease
occurring in the exposed group is the same as in the non-exposed group,
or in other words, other people have the same chance of getting sick
whether they are exposed to this particular factor or not.
 The value obtained for the odds ratio is greater than one, it indicates a
greater increase in the chance of the occurrence of the disease in the face
of that factor compared to the absence of exposure.
 Obviously, if the value of the odds ratio is less than one, it will indicate
the protective effect of exposure to that factor.
When we calculate the odds ratio in epidemiological studies using
sampling, it is necessary to calculate and report the 95% confidence
limits for the odds ratio.

58
 Relative risk
 The relative risk is the ratio of the risk of morbidity or death in the
exposure to the same risk in the non-exposed group, in other words,
the relative risk is the ratio of the (cumulative) incidence rate in the
exposed group to the (cumulative) incidence rate of the disease in
the non-exposed group.
 Relative risk, telling us how much risk of disease there is when
exposed to a factor compared to a person who has not been
exposed to that factor, also shows the strength of a causal
relationship.

59
Relative risk
Disease

- +

a+b b a + Exposure

c+d d c -

b+d b+c

𝑎
𝑎 +𝑏
𝑅𝑒𝑙𝑎𝑡𝑖𝑣𝑒 𝑅𝑖𝑠𝑘 =
𝑐
𝑐 +𝑑 60
 Like incidence rate, relative risk cannot be measured in a cross-
sectional study.
 If the relative risk value is equal to one, it means that the probability
of the disease in the exposed group is not the same as in the non-
exposed group, or in other words, whether people are exposed to
this particular factor or not, they will have the same probability of
getting sick.
 The higher the relative risk value is greater than one, the greater
the increase in the probability of disease occurrence in the face of
that factor compared to the absence of exposure, as well as the
greater strength of their relationship.
 If the relative risk value is less than one, it will indicate the
protective effect of exposure to that factor in the occurrence of the
disease.
When we calculate relative risk in epidemiological studies using
sampling, it is necessary to calculate and report 95% confidence limits
for it.
61
In case-control studies, the relative risk cannot be measured, but if the
following conditions are met, the odds ratio can be a suitable
approximation of the relative risk in the society:
1. When the desired disease in the study does not have a high
prevalence in the society.
2. When the studied cases are the real representatives of all the people
with the disease in the selected population in terms of exposure
history.
3. When the studied witnesses are the real representatives of all non-
patients in the population selected for the study in terms of exposure
history.

62
 Attributable risk
The attributed risk is also a ratio and it is the difference between the
incidence of the disease in the exposed group to the non-exposed group,
provided that causes other than the cause under investigation have similar
effects in the two groups.
 To calculate attributable risk, you would typically need the following
information:
1. Incidence rate among the exposed group: This refers to the rate at which the
disease occurs in individuals who have been exposed to the risk factor.
2. Incidence rate among the unexposed group: This refers to the rate at which the
disease occurs in individuals who have not been exposed to the risk factor.
The formula for calculating attributable risk can be expressed as follows:
Attributable Risk = Incidence rate among the exposed group - Incidence rate
among the unexposed group

63
 Attributable fraction risk in population
 The attributable risk of the population or the attributable component of the
population is the ratio that if the exposure is eliminated, the incidence rate of the
outcome will decrease in the entire population.
 The following method is used to estimate this size:
 AFp is equivalent to the attributed part of the population, Ip is the incidence rate
of the desired disease in the entire population.
 And Iu is also the incidence of disease in the non-exposed group.
Attributable Fraction (AF) = (Prevalence of exposure × (Relative Risk - 1)) /
(Prevalence of exposure × (Relative Risk - 1) + 1) OR
Ip  Iu
AFp 
Ip

64
 Attributable fraction risk in population
 For example, suppose a study finds that the prevalence of smoking (the
exposure) in a population is 30%, and the relative risk of lung cancer
associated with smoking is 5. The attributable fraction can be calculated as
follows:
 Attributable Fraction (AF) = (0.3 × (5 - 1)) / (0.3 × (5 - 1) + 1)
Attributable Fraction (AF) = 0.12 / 0.52
Attributable Fraction (AF) ≈ 0.23 or 23%

This indicates that approximately 23% of lung cancer cases in the population can
be attributed to smoking.

65
Population Attributable Risk percentage (PAR)

When extrapolating the results of a study to a community or population of

individuals with and without a risk factor, we need to use another measure of
risk known as the population attributable risk percentage (PAR%). If a cause-
and-effect relationship is present, the PAR% tells us the percentage of the risk
in a population that can potentially be eliminated.
To calculate the PAR%, we must know more than the relative risk (expressed as
>1). It requires that we know or be able to estimate the proportion of individuals
in the population who possess the risk factor (ranging from 0 to 1) that is we
need to know the prevalence of the risk factor.

where Prev. of RF = Prevalence of the risk factor or the proportion

of the population=(A + B)/(A + B + C + D)

66
 Population Attributable Fraction (PAF):
 The Population Attributable Fraction (PAF) is a measure used in epidemiology to
estimate the proportion of disease occurrence in a population that can be attributed
to a specific risk factor or exposure. It represents the population-level impact of the
risk factor on the disease burden.
 In fact, it is to answer the question that "If the effect of the causal factor in
the population is removed, how much will the burden of disease or the
incidence of disease in the population be reduced?«

 PAF = (Prevalence of exposure × (Relative Risk - 1)) / (1 + (Prevalence of exposure × (Relative Risk - 1))) OR

 OR  1 
PAF  P   
 OR 
 For example, suppose a study finds that the prevalence of smoking (the exposure) in a population is
30%, and the relative risk of lung cancer associated with smoking is 5. The Population Attributable
Fraction can be calculated as follows:
PAF = (0.3 × (5 - 1)) / (1 + (0.3 × (5 - 1)))
PAF = 0.12 / 1.48
PAF ≈ 0.081 or 8.1%
 This indicates that 8.1% of lung cancer cases in the population can be attributed to smoking. 67
Exposure

68
What is Exposure?
 Exposure is contact. No matter how dangerous a
substance or activity, without exposure, it cannot
harm you.
 Exposure is defined as the contact between an agent
and a target.

 where E is exposure, C(t) is a concentration that

varies with time between the beginning and end of
exposure.

69
Comparative Risk of Death by Exposure

Number of
Lifetime Risks
Deaths / Year
Motor vehicle
accidents 1240000 1/65

Home accidents
675000 1/130

Lung cancer
2160000 1/12
deaths in smokers
Research and
Data Collection

Risk
Assessment

Risk
Management
 Measurement of exposure
 In many epidemiological activities, there is a need to determine the
exposure of individuals or population groups to a pathogenic or
dangerous agent or agents.
For example, sometimes it is necessary to know whether those who
deal with lead suffer from anemia more often. To find the answer, the
situation of exposure to lead should be investigated.
 Exposures are classified in three ways: dichotomous, continuous,
and ranked.

72
Amount of exposure:

The greater the amount of a substance a person is

exposed to, the more likely that health effects will
occur.
 Duration
 Frequency

73
 Most exposures are binary (such as whether a person smokes or does not
smoke, deals with lead or not).
 In the rank exposure, which is mostly used for people's activities, or job
exposure, the exposure is examined more precisely.
For example, a person smokes, is exposed to other people's cigarette smoke, and
does not smoke, or exposure to very high amounts of lead, moderate amounts of
lead, low amounts of lead, and no exposure to lead (which, of course, for each of
these groups there will be a certain operational definition).
 Continued exposure explores more details about Exposure.
For example, daily consumption of zero to n cigarettes per day, exposure to zero
to n micrograms of lead per day, and so on.

Exposure to different factors can also be classified based on statistical patterns

or using standard criteria.
For example, lead exposure was divided into three groups based on the lower
third of the data, the middle third, and the upper third, or based on standard
criteria (allowed exposure values).

74
 Exposure information usually includes the following:
 Intensity: The level or volume of exposure to a pathogen or risk factor
 Duration of the exposure period: the length of time the exposure
occurred
 Exposure graph (Profile): Whether the exposure occurred continuously
and uniformly, or with fluctuations with the period of exposure and non-
exposure.
 Time period: biological period related to exposure
 The effect of environmental factors that can have a double effect on the
role of the exposure factor.
 The tools used to collect information related to exposure are also diverse
and include such things as interviews, use of questionnaires, health-
medical documents and documents, direct measurement of environmental
factors, measurement of biological markers that have been affected by
exposure.

75
Routes of exposure
There are three major means by which a toxic
substance can come into contact with or enter
the body. These are called routes of exposure.
 Inhalation (breathing) of gases, vapors, dusts or
mists is a common route of exposure.
 Direct contact (touching) with the skin or eyes is
also a route of exposure.
 Ingestion (swallowing) of food, drink, or other
substances is another route of exposure.

76
 Length of exposure:

 Short-term exposure is called acute

exposure. Long-term exposure is called
chronic exposure.

77
 Sensitivity:

All people are not equally sensitive to chemicals, and

are not affected by them in the same way.
There are many reasons for this:
 genetic differences
 allergic
 age,
 illness,
 diet,
 alcohol use,
 pregnancy and
 medical or non-medical drug use
can also affect a person's sensitivity to an exposure.
78
Exposure assessment
&
Risk assessment

79
 Exposure assessment
 Exposure assessment depends on the nature and size of the exposed
population and the volume and length of the exposed period.

 Exposure assessment should be related to the past and present

exposures, as well as the prediction of future exposures.

80
 Human Exposure Evaluation

 How many people will be exposed?

 Through which routes?
 Who is exposed?
 What is the magnitude, duration, and timing of the
exposure?
 Risk assessment
 The process of measuring exposure should be aware of its short-term
and long-term effect on individuals or groups, and special and
appropriate techniques should be used.

 In risk assessment, attention should be paid to the mutual effects of

exposure to environmental hazards in humans.

 Risk assessment is done to predict and analyze the ecological impact

of exposure to hazards on human health that may be caused by the
use of a technology, pathogenic or hazardous agent, or a process.

 Health risk assessment determines the probability or severity of injury,

illness or death in humans.

82
How is risk measured?
 Risk assessment is a process of quantitative measurement
of the probability of harm to individuals or populations that
occurred from a specific activity.
In risk estimation, two steps should be considered:
 Hazard Identification
 Exposure Quantification

83
Risk Assessment
Dose-Response
Assessment

Hazard Risk
Identification Characterization

Exposure
Assessment
Dose-response
 Dose-response is a term used in epidemiology and toxicology to
describe the relationship between the magnitude of exposure to a risk
factor (such as a chemical, drug, or radiation) and the resulting effect
or response in an organism or population.
 It explores how changes in the amount or intensity of exposure are
associated with changes in the incidence or severity of an outcome,
such as disease occurrence or biological response.
 Dose-response assessment is modeling for a relation between exposure
to an identified hazard at different dose levels and the disease risk it
induces.

85
 Key characteristics and interpretations of dose-
response relationships include:
1. Threshold: Some dose-response relationships exhibit a threshold, below which
there is no observable effect or response. This means that a certain minimum level
of exposure is required to produce a response. Above this threshold, the response
increases with increasing dose.
2. Linear: In a linear dose-response relationship, the response increases
proportionally with increasing dose. This suggests that there is no threshold
below which there is no effect, and every increment in exposure contributes to an
incremental change in the response.
3. Non-linear: Non-linear dose-response relationships do not follow a straight line.
They can take various shapes, such as exponential, sigmoidal, or U-shaped. These
relationships indicate that the response changes at a non-constant rate as the dose
increases.
Understanding the dose-response relationship is important in various fields,
including pharmacology, toxicology, and environmental health. It helps in
determining safe exposure levels, establishing dose guidelines, assessing risks, and
developing interventions or regulations to mitigate adverse effects. 86
?Any Question ِ

87