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SCHOOL OF PUBLIC HEALTH

COURSE CODE: MPH5101

COURSE TITLE: FOUNDATION OF EPIDEMIOLOGY

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COURSE OUTLINE
WEEK TOPIC LECTURES

1 Introduction to Epidemiology Concepts,historical evolution,uses ,principles

of epidemiology
2 Disease Causation Concepts, theories of diseases causation
,factors of diseases causation, natural history
of a disease ,incubation period mode of
transmission
3 Levels of Prevention Premordial,primary,secondary and Tertiary
4 Disease Outbreak Concepts,Steps in investigating disease
outbreak
5 Population Screening Concepts,Principles, purpose,stages of
screening
6 CAT 1 CAT 1
7 Measures of Disease Mortality
8. Measures of Diseases Morbidity
9 Measures of Association Concepts of risks,relative risks,Odds
ratio,Attributable risks ,Applications in
Epidemiology
10 CAT 2 CAT 2
11 Sampling Methods Probability and Non Probability Sampling
Methods
12 Ethics in Epidemiology Principles of Ethics
Ethics and Professional issues in
Epidemiology
13 Epidemiological Studies Types,Experimental,Observational,Cohort,case
control,Advantages and Disadvantages
14 Epidemiological Studies Cross-sectional,Advantags and Disadventages

15&16-Exams
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LECTURE 1

INTRODUCTION OF EPIDEMIOLOGY

Lecture Overview

Epidemiology is a basic science of public health. It addresses questions about distribution,

causation and prevention of diseases in human populations. This lecture will discuss
introductoryconcepts in epidemiology,historical development ,principles and disease distribution.

By the end of this lecture you should be able to :-

i.define Epidemiology
ii.Dsecribe the historical development of Epidemiology
iii.Describe the uses of Epidemiology
iii.Review principles of Epidemiology
iv.Describe diseases distribution.

Epidemiology is the study of the distribution and determinants of health-related states or events
(including disease), and the application of this study to the control of diseases and other health
problems.(WHO)

Epidemiology is considered a basic science of public health. Epidemiology is:

a) a quantitative discipline built on a working knowledge of probability, statistics, and sound

research methods

b) a method of causal reasoning based on developing and testing hypotheses pertaining to

occurrence and prevention of morbidity and mortality; and

c) a tool for public health action to promote and protect the public's health based on science, causal
reasoning, and a dose of practical common sense

“Epidemiology is the study of the distribution and determinants of health-related states or events in
specified populations, and the application of this study to the control of health problems.”

“Epidemiology is the study of the distribution and determinants of disease frequency in man.”

These definitions of epidemiology include several terms which reflect some of the important
principles of the discipline:
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Study - Epidemiology is a scientific discipline and has at its foundation, sound methods of
scientific inquiry.

Distribution - Epidemiology is concerned with the frequency and pattern of health events in a
population.

Frequency includes not only the number of such events in a population, but also the rate or risk of
disease in the population.

Pattern refers to the occurrence of health-related events by time, place, and personal characteristics.

 Time characteristics include annual occurrence, seasonal occurrence, and daily or even
hourly occurrence.
 Place characteristics include geographic variation, urban-rural differences, and location of
work sites or schools, for example.
 Personal characteristics include demographic factors such as age, race, sex, marital status,
and socioeconomic status, as well as behaviors ( such as occupation or risk-taking activity)
resulting in environmental exposures.

Determinants - Epidemiology is often used to search for causes and other factors that influence the
occurrence of health-related events such as diseases, syndromes, and injuries. Analytic
epidemiology attempts to provide the Why and How of such events by comparing groups with
different rates of disease occurrence and with differences in demographic characteristics, genetic or
immunologic make-up, behaviors, environmental exposures, and other so-called potential risk
factors. Under ideal circumstances, epidemiologic findings provide sufficient evidence to direct
swift and effective public health control and prevention measures.

Health-related states or events - Originally, epidemiology was concerned with epidemics of

communicable diseases. The discipline was extended to endemic communicable diseases and
noncommunicable infectious diseases. Modern epidemiology has been applied to chronic diseases,
injuries, birth defects, maternal-child health, occupational health, and environmental health. Now,
even behaviors related to health and well-being (amount of exercise, seat-belt use, etc.) are
recognized as valid subjects for applying epidemiologic methods. The term "disease" refers to the
range of health-related states or events.

Historical Evolution of Epidemiology

Although epidemiology as a discipline has blossomed since World War II, epidemiologic thinking
has been traced from Hippocrates through John Graunt, William Farr, John Snow, and others. The
contributions of some of these early and more recent thinkers are described below

Circa 400 B.C.

Epidemiology's roots are nearly 2500 years old.

Hippocrates attempted to explain disease occurrence from a rational rather than a supernatural
viewpoint. In his essay entitled “On Airs, Waters, and Places,” Hippocrates suggested that
environmental and host factors such as behaviors might influence the development of disease.

1662
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Another early contributor to epidemiology was John Graunt, a London haberdasher and
councilman who published a landmark analysis of mortality data in 1662. This publication was the
first to quantify patterns of birth, death, and disease occurrence, noting disparities between males
and females, high infant mortality, urban/rural differences, and seasonal variations.

1800

William Farr built upon Graunt's work by systematically collecting and analyzing Britain's
mortality statistics. Farr, considered the father of modern vital statistics and surveillance, developed
many of the basic practices used today in vital statistics and disease classification. He concentrated
his efforts on collecting vital statistics, assembling and evaluating those data, and reporting to
responsible health authorities and the general public.

1854

In the mid-1800s, an anesthesiologist named John Snow was conducting a series of investigations
in London that warrant his being considered the “father of field epidemiology.” Twenty years
before the development of the microscope, Snow conducted studies of cholera outbreaks both to
discover the cause of disease and to prevent its recurrence.

Snow conducted one of his now famous studies in 1854 when an epidemic of cholera erupted in the
Golden Square of London. He began his investigation by determining where in this area persons
with cholera lived and worked

Because Snow believed that water was a source of infection for cholera, he marked the location of
water pumps on his spot map, then looked for a relationship between the distribution of households
with cases of cholera and the location of pumps.

Snow's second investigation reexamined data from the 1854 cholera outbreak in London.

19th and 20th centuries

In the mid- and late-1800s, epidemiological methods began to be applied in the investigation of
disease occurrence. At that time, most investigators focused on acute infectious diseases. In the
1930s and 1940s, epidemiologists extended their methods to noninfectious diseases. The period
since World War II has seen an explosion in the development of research methods and the
theoretical underpinnings of epidemiology. Epidemiology has been applied to the entire range of
health-related outcomes, behaviors, and even knowledge and attitudes. The studies by Doll and Hill
linking lung cancer to smoking and the study of cardiovascular disease among residents of
Framingham, Massachusetts two examples of how pioneering researchers have applied
epidemiologic methods to chronic disease since World War II. During the 1960s and early 1970s
health workers applied epidemiologic methods to eradicate naturally occurring smallpox
worldwide.This was an achievement in applied epidemiology of unprecedented proportions.

In the 1980s, epidemiology was extended to the studies of injuries and violence. In the 1990s, the
related fields of molecular and genetic epidemiology (expansion of epidemiology to look at
specific pathways, molecules and genes that influence risk of developing disease) took root.
Meanwhile, infectious diseases continued to challenge epidemiologists as new infectious agents
emerged (Ebola virus, Human Immunodeficiency virus (HIV)/ Acquired Immunodeficiency
Syndrome (AIDS)), were identified (Legionella, Severe Acute Respiratory Syndrome (SARS)), or
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changed (drug-resistant Mycobacterium tuberculosis, Avian influenza). Beginning in the 1990s and
accelerating after the terrorist attacks of September 11, 2001, epidemiologists have had to consider
not only natural transmission of infectious organisms but also deliberate spread through biologic
warfare and bioterrorism.

Today, public health workers throughout the world accept and use epidemiology regularly to
characterize the health of their communities and to solve day-to-day problems, large and small.

Thacker SB. Historical development. In: Teutsch SM, Churchill RE, editors. Principles and
practice of public health surveillance, 2nd ed. New York: Oxford University Press; 2002.

USESOF EPIDEMIOLOGY

1. To study the history of the health of populations, and of the rise and fall of diseases and changes
in their character.

2. To diagnose the health of the community and the condition of the people.

3. To study the working of health services with a view to their improvement.

4. To estimate from the group experience what are the individual risks on average of disease,
accident and defect, and the chances of avoiding them.

5. To identify syndromes by describing the distribution and association of clinical phenomena in

the population.

6. To complete the clinical picture of chronic diseases and describe their natural history: by
including in due proportion all kinds of disease.

7. To search for causes of health and disease by computing the experience of groups defined by
their composition, inheritance and experience, their behaviour [sic] and environments.
opportunity and sometimes by planned experiments.

Activity 1.1

Highlight the uses of Epidemiology.

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PRINCIPLES OF EPIDEMIOLOGY

Principles Used in Epidemiology

The principles and methods used in epidemiology can describe the health of populations, to detect
causes of health problems; to quantify the association between ill health and risk factors; to test
treatment and public health interventions; and to monitor changes in states of health over time.

In epidemiology, the health professionals must be able to describe the distribution and determinants
of health states and events. Distribution of health states or events refers to the description of the
frequency and patterns of health events in a population. Frequency is measured by rates and risks
of health events in a population; the pattern refers to the occurrence of health related events by
time, place and personal characteristics. Determinants are causes and other factors that influence
the occurrence of health related events. These include death, illness and disability as well as
positive health states and the means to improve health. Epidemiology seeks to identify the
determinants of health and disease.

The principles of the approach used in epidemiology revolve around studying health related events
by asking the following questions:
a. What? This is the case definition. It is the standard criteria for deciding whether or not a person
has a particular disease or health related event. A case definition consists of clinical criteria,
sometimes with limitations on time, place and person. The clinical criteria includes confirmatory
laboratory tests, if available, or a combination of symptoms (complaints) and signs (physical
findings), and other supportive evidence. e.g. acute onset of flaccid paralysis of one or more limbs
with decreased or absent tendon reflexes in the affected limbs, without other apparent cause and
without sensory or cognitive loss (Center for Disease Control on definition of paralytic
poliomyelitis). Application of these standard criteria ensures that every case is diagnosed in the
same way regardless of when and where it occurred. This allows for comparison of rates of
occurrence between populations overtime.
b. Who? Individual counting the number of persons involved in a health event is one of the basic
steps of epidemiological investigation. Simple count of cases does not adequately compare the
occurrence of disease in different populations or during different times so these are converted to
rates. These relate to the number of cases in the size of the population. Since personal attributes are
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often associated with health events, differences in the distribution of these factors should also be
considered while comparing occurrence of health events between populations.
c. Where? Place. Health events are described by the location in order to gain insight into the
geographical difference or the extent of the event. The place can be that of residence, birth or
employment, a district, state or country of a health event. Analyzing data by place can also give
clues to the source of agents that cause disease and their mode of transmission e.g., in identifying
the source of the causal agent while investigating an outbreak, a spot map may be used.
d) When? Time. Rates of occurrence of disease often change with time. Long-term or secular
trends can be plotted over time as annual rates. The trends can be used to suggest or predict the
future incidence of a disease and to evaluate programmes or policy decisions, to suggest what
caused an increase or decrease in the occurrence of a disease. This can be displayed as a graph.
e) Why? Causes. Besides describing the levels and patterns in occurrence of health events by
person, place and time, epidemiology is concerned with the search for causes and effects. This can
quantify association between potential determinants and health events, and test hypothesis about
causal relationships. The various epidemiological study designs have the basic principle of making
unbiased comparison between a group with and without the determinants or health event under
investigation.

Activity 1.2

Describe disease distribution in terms of person, place and time.

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You
have come to the end of the Lecture where you have covered the following:-
Definition of Epidemiology

Historical
 evolution of epidemiology
uses of Epidemiology
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Principles of Epidemiology


Explain how Epidemiology is Art and Science.

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Goordis,Leon(2004) Epidemiology(3rd Edition)Elservier Saunders,Philedelphia.

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LECTURE 2
DISEASE CAUSATION

Lecture Overview

In the previous lecture we have introduced Epidemiology and its concepts where we have seen that
it deals with prevention and control of diseases amongst other factors. But then how does a disease
came about? This lecture will look at the disease causation ,natural history,prognosis of disease .

By the end of the lecture you should be able to:-

I.Describe different models of disease causation.
ii.Outline factors of disease causation
Ii Explain natural history of disease.
iiiDescribe prognosis of disease.
iv.Explain the mode of transmission

Concepts of Disease Occurrence

A critical premise of epidemiology is that disease and other health events do not occur randomly in
a population, but are more likely to occur in some members of the population than others because
of risk factors that may not be distributed randomly in the population. As noted earlier, one
important use of epidemiology is to identify the factors that place some members at greater risk
than others.

Causation

A number of models of disease causation have been proposed. Among the simplest of these is the
epidemiologic triad or triangle, the traditional model for infectious disease. The triad consists of an
external agent, a susceptible host, and an environment that brings the host and agent together. In
this model, disease results from the interaction between the agent and the susceptible host in an
environment that supports transmission of the agent from asource to that host. Two ways of
depicting this model are shown in Figure 1.
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.
Agent, host, and environmental factors interrelate in a variety of complex ways to produce disease.
Different diseases require different balances and interactions of these three components.
Development of appropriate, practical, and effective public health measures to control or prevent
disease usually requires assessment of all three components and their interactions.

Agent originally referred to an infectious microorganism or pathogen: a virus, bacterium, parasite,

or other microbe. Generally, the agent must be present for disease to occur; however, presence of
that agent alone is not always sufficient to cause disease. A variety of factors influence whether
exposure to an organism will result in disease, including the organism’s pathogenicity (ability to
cause disease) and dose. Over time, the concept of agent has been broadened to include chemical
and physical causes of disease or injury. These include chemical contaminants (such as the L-
tryptophan contaminant responsible for eosinophilia-myalgia syndrome), as well as physical forces
(such as repetitive mechanical forces associated with carpal tunnel syndrome). While the
epidemiologic triad serves as a useful model for many diseases, it has proven inadequate for
cardiovascular disease, cancer, and other diseases that appear to have multiple contributing causes
without a single necessary one.

Host refers to the human who can get the disease. A variety of factors intrinsic to the host,
sometimes called risk factors, can influence an individual’s exposure, susceptibility, or response to
a causative agent. Opportunities for exposure are often influenced by behaviors such as sexual
practices, hygiene, and other personal choices as well as by age and sex. Susceptibility and
response to an agent are influenced by factors such as genetic composition, nutritional and
immunologic status, anatomic structure, presence of disease or medications, and psychological
makeup.

Environment refers to extrinsic factors that affect the agent and the opportunity for exposure.
Environmental factors include physical factors such as geology and climate, biologic factors such
as insects that transmit the agent, and socioeconomic factors such as crowding, sanitation, and the
availability of health services.
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Component causes and causal pies

Because the agent-host-environment model did not work well for many non-infectious diseases,
several other models that attempt to account for the multifactorial nature of causation have been
proposed. One such model was proposed by Rothman in 1976, and has come to be known as the
Causal Pies. This model is illustrated in Figure 2. An individual factor that contributes to cause
disease is shown as a piece of a pie. After all the pieces of a pie fall into place, the pie is complete
— and disease occurs. The individual factors are called component causes. The complete pie,
which might be considered a causal pathway, is called a sufficientcause. A disease may have more
than one sufficient cause, with each sufficient cause being composed of several component causes
that may or may not overlap. A component that appears in every pie or pathway is called a
necessary cause, because without it, disease does not occur. Note in Figure 2 that component
cause A is a necessary cause because it appears in every pie.
Figure 2 Rothman’s Causal Pies
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The component causes may include intrinsic host factors as well as the agent and the environmental
factors of the agent-host environment triad. A single component cause is rarely a sufficient cause
by itself. For example, even exposure to a highly infectious agent such as measles virus does not
invariably result in measles disease. Host susceptibility and other host factors also may play a role.
At the other extreme, an agent that is usually harmless in healthy persons may cause devastating
disease under different conditions. Pneumocystis carinii is an organism that harmlessly colonizes
the respiratory tract of some healthy persons, but can cause potentially lethal pneumonia in persons
whose immune systems have been weakened by human immunodeficiency virus (HIV). Presence
of Pneumocystis carinii organisms is therefore a necessary but not
sufficient cause of pneumocystis pneumonia. In Figure 2, it would be represented by component
cause A.
As the model indicates, a particular disease may result from a variety of different sufficient causes
or pathways. For example, lung cancer may result from a sufficient cause that includes smoking as
a component cause. Smoking is not a sufficient cause by itself, however, because not all smokers
develop lung cancer. Neither is smoking a necessary cause, because a small fraction of lung cancer
victims have never smoked. Suppose Component Cause B is smoking and Component Cause C is
asbestos. Sufficient Cause I includes both smoking (B) and asbestos (C). Sufficient Cause II
includes asbestos without smoking, and Sufficient Cause C includes smoking without asbestos. But
because lung cancer can develop in persons who have never been exposed to either smoking or
asbestos, a proper model for lung cancer would have to show at least one more Sufficient Cause
Pie that does not include either component B or component C.

Note that public health action does not depend on the identification of every component cause.
Disease prevention can be accomplished by blocking any single component of a sufficient cause, at
least through that pathway. For example, elimination of smoking (component B) would prevent
lung cancer from sufficient causes I and II, although some lung cancer would still occur
through sufficient cause III.
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Natural History and Spectrum of Disease

Natural history of disease refers to the progression of a disease process in an individual over time,
in the absence of treatment. For example, untreated infection with HIV causes a spectrum of
clinical problems beginning at the time of seroconversion (primary HIV) and terminating with
AIDS and usually death. It is now recognized that it may take 10 years or more for AIDS to
develop after seroconversion.Many, if not most, diseases have a characteristic natural history,
although the time frame and specific manifestations of disease may vary from individual to
individual and are influenced by preventive and therapeutic measures.

Figure 3 Natural History of Disease Timeline

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The process begins with the appropriate exposure to or accumulation of factors sufficient for the
disease process to begin in a susceptible host. For an infectious disease, the exposure is a
microorganism. For cancer, the exposure may be a factor that initiates the process, such as asbestos
fibers or components in tobacco smoke (for lung cancer), or one that promotes the process, such as
estrogen (for endometrial cancer). After the disease process has been triggered, pathological
changes then occur without the individual being aware of them. This stage of subclinical disease,
extending from the time of exposure to onset of disease symptoms, is usually called the incubation
period for infectious diseases, and the latency period for chronic diseases. During this stage,
disease is said to be asymptomatic (no symptoms) or inapparent. This period may be as brief as
secondsfor hypersensitivity and toxic reactions to as long as decades for certain chronic diseases.
Even for a single disease, the characteristic incubation period has a range. For example, the typical
incubation period for hepatitis A is as long as 7 weeks. The latency period for leukemia to become
evident among survivors of the atomic bomb blast in Hiroshima ranged from 2 to 12 years, peaking
at 6-7 years.44 Incubation periods of selected exposures and diseases varying from minutes to
decades are displayed in

Corona virus Syndrome (SARS) 3–10 days, usually 4–6 days

Varicella-zoster virus Chickenpox 10–21 days, usually 14–16 days
Treponema pallidum Syphilis 10–90 days, usually 3 weeks
Hepatitis A virus Hepatitis - 14–50 days, average 4 weeks
Hepatitis B virus Hepatitis - 50–180 days, usually 2–3 months
Human immunodeficiency virus AIDS <1 to 15+ years
Atomic bomb radiation (Japan) Leukemia 2–12 years
Radiation (Japan, Chernobyl) Thyroid cancer 3–20+ years
Radium (watch dial painters) Bone cancer 8–40 years

Although disease is not apparent during the incubation period, some pathologic changes may be
detectable with laboratory, radiographic, or other screening methods. Most screening programs
attempt to identify the disease process during this phase of its natural history, since intervention at
this early stage is likely to be more effective than treatment given after the disease has progressed
and become symptomatic.
The onset of symptoms marks the transition from subclinical to clinical disease. Most diagnoses are
made during the stage of clinical disease. In some people, however, the disease process may
never progress to clinically apparent illness. In others, the disease process may result in illness that
ranges from mild to severe or fatal. This range is called the
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spectrum of disease. Ultimately, the disease process ends either in recovery, disability or death.
For an infectious agent, infectivity refers to the proportion of exposed persons who become
infected. Pathogenicity refers to the proportion of infected individuals who develop clinically
apparent disease. Virulence refers to the proportion of clinically apparent cases that are severe or
fatal.
Because the spectrum of disease can include asymptomatic and mild cases, the cases of illness
diagnosed by clinicians in the community often represent only the tip of the iceberg. Many
additional cases may be too early to diagnose or may never progress to the clinical stage.
Unfortunately, persons with inapparent or undiagnosed infections may nonetheless be able to
transmit infection to others. Such persons who are infectious but have subclinical disease are called
carriers. Frequently, carriers are persons with incubating disease or inapparent infection.
Persons with measles, hepatitis A, and several other diseases become infectious a few days before
the onset of symptoms. However carriers may also be persons who appear to have recovered from
their clinical illness but remain infectious, such as chronic carriers of hepatitis B virus, or persons
who never exhibited symptoms. The challenge to public health workers is that these carriers,
unaware that they are infected and infectious to others, are sometimes more likely to unwittingly
spread infection than are people with obvious illness.
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Activity 2.1

Explain the agent-host –environment interaction in disease causation.

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MODES OF TRANSMISSION
An infectious agent may be transmitted from its natural reservoir to a susceptible host in different
ways. There are different classifications for modes of transmission. Here is one classification:
• Direct
Direct contact
Droplet spread
• Indirect
Airborne
Vehicleborne
Vectorborne (mechanical or biologic)

In direct transmission, an infectious agent is transferred from a reservoir to a susceptible host by

direct contact or droplet spread.
Direct contact occurs through skin-to-skin contact, kissing, and sexual intercourse. Direct contact
also refers to contact with soil or vegetation harboring infectious organisms.
Thus, infectious mononucleosis (“kissing disease”) and gonorrhea are spread from person to person
by direct contact. Hookworm is spread by direct contact with contaminated soil.
Droplet spread refers to spray with relatively large, short-range aerosols produced by sneezing,
coughing, or even talking. Droplet spread is classified as direct because transmission is by direct
spray over a few feet, before the droplets fall to the ground. Pertussis and meningococcal infection
are examples of diseases transmitted from an infectious patient to a susceptible host by droplet
spread.
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Indirect transmission refers to the transfer of an infectious agent from a reservoir to a host by
suspended air particles, inanimate objects (vehicles), or animate intermediaries (vectors).

Airborne transmission occurs when infectious agents are carried by dust or droplet nuclei
suspended in air. Airborne dust includes material that has settled on surfaces and become
resuspended by air currents as well as infectious particles blown from the soil by the wind. Droplet
nuclei are dried residue of less than 5 microns in size. In contrast to droplets that fall to the ground
within a few feet, droplet nuclei may remain suspended in the air for long periods of time and may
be blown over great distances. Measles, for example, has occurred in children who came into a
physician’s office after a child with measles had left, because the measles virus remained
suspended in the air.

Vehicles that may indirectly transmit an infectious agent include food, water, biologic products
(blood), and fomites (inanimate objects such as handkerchiefs, bedding, or surgical scalpels). A
vehicle may passively carry a pathogen — as food or water may carry hepatitis A virus.
Alternatively, the vehicle may provide an environment in which the agent grows, multiplies, or
produces toxin — as improperly canned foods provide an environment that supports production of
botulinum toxin by Clostridiumbotulinum.
Vectors such as mosquitoes, fleas, and ticks may carry an infectious agent through purely
mechanical means or may support growth or changes in the agent. Examples of mechanical
transmission are flies carrying Shigella on their appendages and fleas carrying Yersinia pestis, the
causative agent of plague, in their gut. In contrast, in biologic transmission, the causative agent of
malaria or guinea worm disease undergoes maturation in an intermediate host
before it can be transmitted to humans.

Portal of entry
The portal of entry refers to the manner in which a pathogen enters a susceptible host. The portal of
entry must provide access to tissues in which the pathogen can multiply or a toxin can act.
Often, infectious agents use the same portal to enter a new host that they used to exit the source
host. For example, influenza virus exits the respiratory tract of the source host and enters the
respiratory tract of the new host. In contrast, many pathogens that cause gastroenteritis follow a so-
called “fecal-oral” route because they exit the source host in feces, are carried on inadequately
washed hands to a vehicle such as food, water, or utensil, and enter a new host through the mouth.
Other portals of entry include the skin (hookworm), mucous membranes (syphilis), and
blood(hepatitis B, human immunodeficiency virus).

Figure 4. Portal of Entry. See below.

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Host
The final link in the chain of infection is a susceptible host. Susceptibility of a host depends on
genetic or constitutional factors, specific immunity, and nonspecific factors that affect an
individual’s ability to resist infection or to limit pathogenicity. An individual’s genetic makeup
may either increase or decrease susceptibility. For example, persons with sickle cell trait seem to be
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at least partially protected from a particular type of malaria. Specific immunity refers to protective
antibodies that are directed against a specific agent. Such antibodies may develop in response to
infection, vaccine, or toxoid (toxin that has been deactivated but retains its capacity to stimulate
production of toxin antibodies) or may be acquired by transplacental transfer from mother to fetus
or by injection of antitoxin or immune globulin. Nonspecific factors that defend against infection
include the skin, mucous membranes, gastric acidity, cilia in the respiratory tract, the cough reflex,
and nonspecific immune response. Factors that may increase susceptibility to infection by
disrupting host defenses include malnutrition, alcoholism, and disease or therapy that impairs the
nonspecific immune response.

Implications for public health

Knowledge of the portals of exit and entry and modes of transmission provides a basis for
determining appropriate control measures. In general, control measures are usually directed against
the segment in the infection chain that is most susceptible to intervention, unless practical issues
dictate otherwise.
For some diseases, the most appropriate intervention may be directed at controlling or eliminating
the agent at its source. A patient sick with a communicable disease may be treated with antibiotics
to eliminate the infection. An asymptomatic but infected person may be treated both to clear the
infection and to reduce the risk of transmission to others. In the community, soil may be
decontaminated or covered to prevent escape of the agent.
Some interventions are directed at the mode of transmission. Interruption of direct transmission
may be accomplished by isolation of someone with infection, or counseling persons to avoid the
specific type of contact associated with transmission. Vehicle-borne transmission may be
interrupted by elimination or decontamination of the vehicle. To prevent fecal-oral transmission,
efforts often focus on rearranging the environment to reduce the risk of contamination in the future
and on changing behaviors, such as promoting hand washing. For airborne diseases, strategies may
be directed at modifying ventilation or air pressure, andfiltering or treating the air. To interrupt
vectorborne transmission, measures may be directed toward controlling the vector population, such
as spraying to reduce the mosquito population. Some strategies that protect portals of entry are
simple and effective. For example, bed nets are used to protect sleeping persons from being bitten
by mosquitoes that may transmit malaria. A dentist’s mask and gloves are intended to protect the
dentist from a patient’s blood, secretions, and droplets, as well to protect the patient from the
dentist. Wearing of long pants and sleeves and use of insect repellent are recommended to reduce
the risk of Lyme disease and West Nile virus infection, which are transmitted by the bite of ticks
and mosquitoes, respectively.
Some interventions aim to increase a host’s defenses. Vaccinations promote development of
specific antibodies that protect against infection. On the other hand, prophylactic use of
antimalarial drugs, recommended for visitors to malaria-endemic areas, does not prevent exposure
through mosquito bites, but does prevent infection from taking root.
Finally, some interventions attempt to prevent a pathogen from encountering a susceptible host.
The concept of herd immunity suggests that if a high enough proportion of individuals in a
population are resistant to an agent, then those few who are susceptible will be protected by the
resistant majority, since the pathogen will be unlikely to “find” those few susceptible individuals.
The degree of herd immunity necessary to prevent or interrupt an outbreak varies by disease. In
theory, herd immunity means that not everyone in a community needs to be resistant (immune) to
prevent disease spread and occurrence of an outbreak. In practice, herd immunity has not prevented
outbreaks of measles and rubella in populations with immunization levels as high as 85% to 90%.
One problem is that, in highly immunized populations, the relatively few susceptible persons are
often clustered in subgroups defined by socioeconomic or cultural factors. If the pathogen is
introduced into one of these subgroups, an outbreak may occur.
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In this Lecture we have looked at Diseases causation.Having had enoyed this lecture answer the
following:-

1.With an aid of an illustration, explain natural history of a disease.

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

2.Describe different models of diseases causation.

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

3.Explain factors of diseases causation.

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Goordis,Leon(2004) Epidemiology(3rd Edition)Elservier Saunders,Philedelphia.

 40

LECTURE 3
LEVELS OF DISEASE PREVENTION

Lecture overview

The primary mandate in public health is prevention of diseases. This lecture looks at levels of
diseases prevention.

By the end of the lecture you should be able to ;

i. Describe levels of disease prevention
41
42
43
44
45
46
47
48
49
50
51
52
 53

This has been a good lecture knowing how diseases are prevented which equips you to answer tha
following question:

Prevention is better than cure” Discuss

 54

_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________

LECTURE 4

INVESTIGATION OF DISEASE OUTBREAK

Lecture Overview

Welcome to lecture four. In the previous lecture we looked at levels of disease prevention. If
diseases are not prevented, they may result into influx of community members suffering from
disease .This lecture will look at disease outbreak.

Activity 4.1

Define an outbreak.

_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________

STEPS IN INVESTIGATIONG AN OUTBREAK

1: Prepare for Field Work

Anyone about to embark on an outbreak investigation should be well prepared before leaving for
the field. Preparations can be grouped into three categories: (a) investigation, (b) administration,
and (c) consultation. Good preparation in all three categories will facilitate a smooth field
experience.

(a)Investigation
First, as a field investigator, you must have the appropriate scientific knowledge, supplies,
and equipment to carry out the investigation. You should discuss the situation with
someone knowledgeable about the disease and about field investigations, and review the
applicable literature. You should assemble useful references such as journal articles and
sample questionnaires. Before leaving for a field investigation, consult laboratory staff to
ensure that you take the proper laboratory material and know the proper collection, storage,
and transportation techniques. Arrange for a portable computer, tape recorder, camera, and
othersupplies.

(b) Administration
 55

Second, as an investigator, you must pay attention to administrative procedures. You may
need to take care of personal matters before you leave, especially if the investigation is
likely to be lengthy.

LECTURE 5

SCREENING POPULATION
Lecture Overview

Population screening, as defined by the World Health Organisation (WHO), is presumptive

identification of unrecognised disease or defects by means of tests,examinations or other
procedures that can be applied rapidly. Screening is intended for people who do not have the
symptoms of the disease, or condition being screened and can identify a pre-disease abnormality or
early disease.

The aim of screening for a disease is to reduce the burden of the disease, mortality and morbidity
in the community. Screening does not guarantee that disease will not occur, or if it occurs, that it
can be cured.

Screening involves a test being offered to all individuals in an eligible group, usually defined by
age, as part of an organised program. The group is eligible because there is strong scientific
evidence that they are at most risk and will get the most health benefit from screening. No
screening test is 100 per cent accurate .For a screening program to succeed there must be evidence
that early diagnosis and treatment increases the chance of successfully treating or managing the
disease.

Population screening is planned and coordinated with the aim of bringing maximum health benefits
to the community, with a focus on equity of access and health outcomes.

By the end of the lecture you should be able to:

iDefine screening.

ii.Describe the principles of screening.

iii.Outline the purpose of screning

iv.Describe the process of screening

WHO Principles of screening

 56

Condition
•The condition should be a significant health problem
•There should be a recognisable or early symptomatic stage.
•The natural history of the condition, including development from latent to declared disease should
be adequately understood.

Test
•There should be a suitable test
•The test should be acceptable to the population

Treatment

There should be accepted treatment for patients with recognised disease .

Screening program

There should be an agreed policy on whom to treat as patients

Facilities for diagnosis and treatment should be available

The cost of case finding should be economically balanced in relation to possible

expenditure on medical care as a whole

•Case finding should be a continuing process and not a 'once and for all' project
It is important to distinguish between population-based screening and opportunistic case-finding.
Population-based screening is where a test of offered systematically to all individuals in the defined
target group within the framework of agreed policy, protocols, quality management monitoring and
evaluation.

Opportunistic case-finding occurs when a test is offered to an individual without

symptoms.

PURPOSE OF SCREENING

1.It enables to identifty risk factors.

2.Helps in early disease detection
3.Helps in implementation of effective treatment as soon as possible
4.Helps in disease prevention and maintain good health
5.Helps to promote health and prevent health complication
 57

The Screening Process

DEFINED TARGET POPULATION
 58

Congratulations .You have successfully completed this lecture on population screening where you
have defined screening,principles of screening,purpose of csrening and its process.This knowledge
has equipped you to answer the following:-

1.Describe the process of screening

_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________________________________

2.Explain the WHO principles of screening.

 59

LECTURE 6

Lecture Overview
MEASURES OF DISEASE

Mortality and Morbidity

These are indicators of health status in a population.
Death is a unique and universal event, and as a final event, clearly defined Age at death and cause
provide an instant depiction of health status. In high mortality settings, information on trends of
death (by causes) substantiate the progress of health programs

By the end of the lecture you should be able to:-

i.Distiquish between mortality and morbidity
iiOutline major sources of mortality
iii.Explain measures of mortality
iv.Calculations on measures of disease
v.Highlight the importance of these measures in epidemiology.

Major Sources of Mortality Information

�National vital registration systems -a major source in developed countries

�Sample registration systems (e.g., in China and India)
�Household surveys -to estimate infant and child mortality
�Special longitudinal investigations (e.g., maternal mortality studies)

Vital Registration or vital Statistics

Systems

Features
�Universal coverage of the population
�Continuous operation

Death Registration:
 60

Counting the Events

This is an official notification that a death has occurred usually a legal requirement before
burial/cremation. Counts (rates) by age, sex, location and time provide invaluable health data.
Concurrent registration is essential for good cause of death determination .

Data Collection for Vital Registration

�Events are collected by a local registration office, usually a government agency.
�Who reports to registration office?
–Individual citizens, local officials, physicians, hospital employees, etc.
�Main advantage is universal coverage
�Disadvantages are late or never reporting

Special Problems of Vital Registration in Developing Countries

�Laws vary dramatically across the countries

�Public compliance poor
�Definitions of vital events varies
�Inadequate resources
�Lack of trained personnel to collect data
�Data infrequently analyzed
�Underutilization of data

Measures of Mortality

 Crude Death Rates

 Age-Specific Death Rates
 Life Table Estimates
 Life expectancy
 Survivorship (by age)
 Cause-Specific Death Rates
 Special Indicators
 Infant and maternal mortality rates

Crude Mortality Indicators

Crude Death Rate

(CDR)
Number of deaths in a given year per 1000 mid-year population.

No of deaths per year

_______________--
Mid year population*1000

Crude Death Rates

N/B
�Risks of death change by age, so CDR is affected by population age structure
�Aging populations can have rising CDRs, even as the health conditions are improving
 61

�LDCswith very young populations will often have lower CDRsthan MDCseven though their
overall health conditions are poorer .

Age Specific Death Rates (ASDR)

Number of deaths per year in a specific age (group) per1000persons in

the age group.
=Da
Pa *1000
Where Da= Number of deaths in age group a
Pa= Midyear population in age a

IMPORTANCE OF AGE SPECIFIC AGE RATES

-Can compare mortality at different ages.

-Can compare mortality in the same age groupsover time and /or between countries and areas.
-Can be used to calculate life tables to create an age-independent measure of mortality (life –
expectancy).

THE LIFE TABLE

A powerful demorgraphic tool used to stimulate the life time mortality experience of a
population,by taking that population’s age specific death rates and applying them in a hypothetical
population of 100,000 people born at the same time.

LIFE EXPECTANCYAT BIRTH

This is the number of years lived among a cohort of births experiencing deaths at each year at age
throughout their remaining life time according to a specific schedule of age pecific mortality rates.
N/B This measure of mortality is independent of the age structure of the population.
This is the most commonly cited life-expectancy measure
It is a good indicator of current health conditions.

LIFE EXPECTANCY
This is the estimate of the average number of additional years a person could expect ti live if the
age-specific death rates for a given year prevailed for the rest of his or her life.

INFANT MORTALITY RATE

This is the number of deaths of infants under the age 1per year per 1000 lives in the same year.

IMR=No of deaths of infants ina given year *

Total live births in that year
 62

It is a major determinant of life expectancy at birth.

The IMR is sensitive to levels and changes in social economic conditons of a population.

MATERNAL MORTALITY
This is the death of woman while pregnant or within 42 days of termination of pregnancyor from
any caouse related to,or aggravated by the pregnancy or its management.

Maternal Mortality Ratio

Is the number of women who die as a result of complications of pregnancy or child bearing ina
given year per 100,000live births in that year.

=No of maternal deaths*100,000

No of live births

Maternal Mortality Rate

Number of women who die asa result of complications of pregnancy or childbearing ina given year
per 100,000 women of childbearing in the population.
=No of maternal deaths*100,000
No of women ages 15-49

With the following formulas you should be in a position to calculate any mortality and morbidity
rates.

MORBIDITY

Morbidity refers to the diseases and illness, injuries, and disabilities in a population.
Data on frequency and distribution of a illness can aid in controlling its spread and, in some cases,
may lead to the identification of its causes.

The major methods for gathering morbidity data are through surveillance systems and sample
surveys which are both costly procedures and therefore are used only selectively in developing
country setting to gather data on health problems of major importance

Morbidity -Indicators
Incidence Rate-Number of persons contracting a disease during a given time period per 1000
population at risk.
-Refers only to new cases during a defined period.

Example
Incidence for malaria will be given by: No of persons developing malaria during a given time
period divided by population at risk multiplied by constant(k)

Prevelance rate- Number of persons who have a particular disease/condition at a given point in
time per 1,000 population. A Snapshot of an existing health situation and Includes all known cases
of a disease that have not resulted in death, cure or remission
 63

Congratulation you are done with this interesting lecture.We have discussed different mortality
tates and ratios,sources of mortality information and challenges of vital registration in developing
countries.

1.Outline the sources of mortality data.

_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________

2 Describe challenges of vital registration in developing countries.

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3.Differntiate between the following terms
I crude death rate and age specific death rate
ii.infant mortality rate and maternal mortality rate
iii.incidence and prevalence

4.What is the importance of Age specific rate.

_______________________________________________________________________________
______________________________________________________________________________
5.What is the importance of incidence and prevalence in control of communicable diseases.
_______________________________________________________________________________________________________________________
_____________________________________________________________________________________________
 64

Olsen,Jorn.Saracci,Rodolfo,Trichoponlos,Dimtrios (2001) Teaching Epidemiology(2nd

ed),OUP, Oxford

Goordis,Leon(2004) Epidemiology(3rd Edition)Elservier Saunders,Philedelphia.

 65

LECTURE 7

MEASURES OF ASSOCIATION

By the end of the lecture you should be able to:

Ii Differentiate between relative risk,odds ratio and attributable risks

iiiDifferentiate between incidence and prevalence
iv calculate the on these measues
vExplain the application of these measures in epidemiology

RISKS
Risk can be defined as the probability of an event.( such as developing a disease )occurring.
RELATIVE RISK
I s the probability of an event (developing a disease)occurring in the exposed people compared to
the probability of an event in non exposed people or as the ratio of the two probabilities.

Relative risk =Risk in exposed

Risk in non exposed

INTERPRETING THE RELATIVE RISK

There are three possibilities.

1.If the relative risk is equal to 1,the numerator equals the denominator and the risk in exposed
persons equals the risk in non exposed persons hence NO evidence exists for any increased risk
in exposed individuals or for any association of the disease with the exposure in question.

2.If the risk is greater than1, the numerator is greater than the denominator and the risk in the
exposed is greater than the risk in non exposed persons. This is evidence of a positive
association and may be causal.
3.If the relative risk is less than 1,the numerator is less than the denominator, and the risk in
exposed persons is less than the risk in non exposed persons. This is an evidence of a negative
 66

association and it maybe indicative of a protective effect.

CALCULATING RELATIVE RISK

CHD DEVELOPS CHD DOES NOT TOTALS

DEVELOP
SMOKE 84 2916 3000
CIGARATTES
DO NOT SMOKE 87 4913 5000
CIGARATTES

Incidence among exposed= 84/3000=28.0per 1000

Incidence among the non exposed=87/5000=17.4per 1000

RR=Incidence in exposed
Incidence in non xposed
=28.0/17.4
1.61

Hence there is evidence that smoking cigarette is associated with coronary heart disease.

Activity 7.1

What is the application of relative risk in epidemiology.

_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________

ODDS RATIO
Is the ratio of the no.of ways the event can occur to the number of ways the event cannot occur.

Odds=probabilitity
1-pobability
=P/1-P

EXAMPLE
Suppose we are betting on a horse(Epi beauty) which has a 60%probability of winning the race(P)
Epi has a40% probability oflosing(1-P)
 67

Odds=P/1-P

=60%/40%
=1.5 winning.

Develops disease Do not Develop Totals

disease
Exposed 200 9800 10,000
Not Exposed 100 9900 10,000

Calculate the
i. Relative Risk
ii. Odds Ratio

Relative Risk=200/10,000
100/10,000

=2

Activity 7.2

Explain the interpretation.

_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________

Odds Ratio=200*9900
100*9800
=2.02
 68

Congratulation for going through lecture 7.We have discussed relative risks and odds ratio and
their applications in Epidemilogy.

From the table below calculate the Relative Risk and Odds Ratio respectively.

Develop disease Do not develop disease

Exposed 50 50
Not Exposed 25 75

. Sauvaget C, Nagano J, Allen N, et al. Intake of animal products and stroke mortality in the
Hiroshima/Nagasaki Life Span Study. International Journal of Epidemiology. 2003;32:536–543.

Last JM, ed., et al. A Dictionary of Epidemiology. 4th ed. New York: Oxford University Press;
2000.
Gordis L, Epidemiology. 2nd ed. Philadelphia: WB Saunders; 1996.
 69

LECTURE 8

MEASURES OF ASSOCIATION

By the end of the lecture you should be able to:

i.Define Attributable risk
ii.calculate attributable risks
iii.Describe the applications of attributable risk in Epidemiology.

ATTRIBUTABLE RISK (AR)

Lecture overview

Many diseases are caused by more than one exposure. For example, lung cancer is caused by
exposure to smoking, asbestos, radiation or some chemical products. Public health programs to
prevent disease are directed toward reducing or eliminating such causal exposures.

Epidemiologic research not only focuses on the identification and assessment of risk factors but
also is concerned with planning and evaluating public health interventions or control measures
to reduce the incidence of disease in the population. Being able to predict the impact of remov-
ing a particular exposure on the risk of developing a disease is an important public health con-
sideration. It allows those who are responsible for protecting the public’s health to make deci-
sions about allocating scarce resources (time, energy, money and political capital) where they
will have the most impact. It helps them answer the following questions:

1. What amount of the risk of developing a disease is attributable to a particular exposure?

2. By what percent would the risk of developing disease be reduced if the exposure were
eliminated?
 70

If smoking were eliminated, what would happen to the incidence of lung cancer? Would smokers’
risk of lung cancer disappear if they stopped smoking?

For public health decision-making purposes, it is valuable to be able to answer these questions
from two perspectives: from the perspective of the impact of eliminating the exposure on only
those who are exposed and from the perspective of the impact of eliminating the exposure on
the entire population, those who are exposed and those who are not exposed.

Note that for purposes of this teaching unit risk and incidence rate (or incidence) can be
considered interchangeable. Strictly speaking, however, incidence rate (or incidence) denotes
the rate of new cases per unit time whereas risk denotes the rate of new cases in a fixed interval
of time.

Measures of Attributable Risk in the Exposed

Attributable risk (AR): AR is the portion of the incidence of a disease in the exposed that is
due to the exposure. It is the incidence of a disease in the exposed that would be eliminated if
exposure were eliminated.
 71

The AR is calculated by subtracting the incidence in the unexposed (Iu) from the incidence in the
exposed (Ie):

AR = Ie − Iu
Attributable risk percent (AR%): AR% is the percent of the incidence of a disease in the
exposed that is due to the exposure. It is the proportion of the incidence of a disease in the
exposed that would be eliminated if exposure were eliminated.

The AR% is calculated by dividing the attributable risk (AR) by the incidence in the exposed (Ie)
and then multiplying the product times 100 to obtain a percentage:

Ie − I
AR% = × 100
u
Ie
or
AR
AR% = × 100
Ie

Measures of Attributable Risk in the Population

Population attributable risk (PAR): PAR is the portion of the incidence of a disease in the pop-
ulation (exposed and nonexposed) that is due to exposure. It is the incidence of a disease in the
population that would be eliminated if exposure were eliminated.

The PAR is calculated by subtracting the incidence in the unexposed (Iu) from the incidence in
total population (exposed and unexposed) (Ip):

PAR = Ip − Iu

Population attributable risk percent (PAR%): PAR% is the percent of the incidence of a dis-
ease in the population (exposed and nonexposed) that is due to exposure. It is the percent of
the incidence of a disease in the population that would be eliminated if exposure were eliminated.

The PAR% is calculated by dividing the population attributable risk (PAR) by the incidence in the
total population and then multiplying the product times 100 to obtain a percentage:

Ip − I
PAR% = × 100
u
Ip
or
PAR
PAR% = × 100
Ip
 72

Example

The preventive advantages of eating fish have been reported in numerous studies. A recent
cohort study1 reported that not eating fish increased the risk for stroke. The table below
shows the results of this study:

Eating Fish and Stroke

Cases Noncases
Eating Fish of Stroke of Stroke Total
Never 82 (a) 1,549 (b) 1,631
Almost daily 23 (c) 779 (d) 802
Total 105 2,328 2,433

Incidence in the exposed (Ie): a/a b 82/1,631 0.0503, or 5.03 per 100
Incidence in the unexposed (Iu): c/c d 23/802 0.0287, or 2.87 per 100
Incidence in both combined (Ip): a c/(a b c d) 105/2,433
0.0432, or 4.32 per 100
Incidence in the exposed a/a + b
RR = =
Incidence in the unexposed c /c + d
a(c + d )
RR = = 5.03/2.87 = 1.75
c (a + b)

Applying the formulas above to these data (and disregarding the fact that some members of the
population may eat fish more than “never” and less than “almost daily”) results in the following
measures of attributable risk.

AR = I e − I = 5.03 − 2.87 = 2.16 per 100

u
AR% = (AR /I e ) 100 (2.16/5.03) 100 = 43%
=
PAR = I p − I u = 4.32 − 2.87 = 1.45 per 100
PAR% = (PAR /I p ) = (1.45/4.32) 100 = 33.6%
100
Assuming that this and many other studies present enough evidence about the preventive advan-
tages of eating fish to reduce stroke, we could interpret the above data as follows:

• Those who never eat fish have 1.75 times as much risk (higher incidence) as those who eat
 73

fish almost daily (RR = 1.75).

 74

• If those who do not eat fish change their eating habits and begin to eat fish
almost daily, their incidence of strokes will decrease by 2.16 per 100
individuals (AR = 2.16 per 100), which would represent a 43% reduction of
their stroke incidence (AR% = 43%).

• A reduction of 1.45 new cases of stroke per 100 population (exposed and
unexposed) is expected if everybody eats fish almost daily (PAR = 1.45 per
100). Such reduction represents a 33.6% reduction of the incidence in the
population (PAR% = 33.6%).
!

With the following formulas you should be in a position to calculate any Attributable
risks.

You have come to the end of another lecture where we discussed about
definition ,calculations and applications of attributable risk.

Outline the applications of attributable risk in Epidemiology.

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

. Sauvaget C, Nagano J, Allen N, et al. Intake of animal products and stroke

mortality in the
Hiroshima/Nagasaki Life Span Study. International Journal of Epidemiology.
2003;32:536–543.

Last JM, ed., et al. A Dictionary of Epidemiology. 4th ed. New York: Oxford
University Press; 2000.
Gordis L, Epidemiology. 2nd ed. Philadelphia: WB Saunders; 1996.
 75

LECTURE 9

SAMPLING METHODS

Lecture Overview

In research, sampling is concerned with the selection of a subset of individuals from

within a statistical population to estimate characteristics of the whole population.

By the end of the lecture you should be able to:

1.Define sampling.

2.Explain the sampling process

3.Differentiate between probability and non probability sampling

methods.

4.Describe types of probability sampling methods giving their merits

and demerits.

Activity

Outline the advantages of sampling

_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________________

Each more properties (such as weight, location, color) of observable bodies

distinguished as independent objects or individuals. In survey sampling, weights can
be applied to the data to adjust for the sample design, particularly stratified sampling
(blocking). Results from probability theory and statistical theory are employed to
guide practice. In business and medical research, sampling is widely used for
gathering information about a population.

The sampling process comprises several stages:

 Defining the population of concern

 Specifying a sampling frame, a set of items or events possible to measure
 76

 Specifying a sampling method for selecting items or events from the frame
 Determining the sample size
 Implementing the sampling plan
 Sampling and data collecting

Population definition

 Successful statistical practice is based on focused problem definition. In

sampling, this includes defining the population from which our sample is
drawn.
 A population can be defined as including all people or items with the
characteristic one wishes to understand. Because there is very rarely enough
time or money to gather information from everyone or everything in a
population, the goal becomes finding a representative sample (or subset) of
that population.
 Sometimes that which defines a population is obvious. For example, a
manufacturer needs to decide whether a batch of material from production is
of high enough quality to be released to the customer, or should be sentenced
for scrap or rework due to poor quality. In this case, the batch is the
population.
 Although the population of interest often consists of physical objects,
sometimes we need to sample over time, space, or some combination of these
dimensions. For instance, an investigation of supermarket staffing could
examine checkout line length at various times, or a study on endangered
penguins might aim to understand their usage of various hunting grounds over
time. For the time dimension, the focus may be on periods or discrete
occasions.
 In other cases, our 'population' may be even less tangible. For example, Joseph
Jagger studied the behaviour of roulette wheels at a casino in Monte Carlo, and
used this to identify a biased wheel. In this case, the 'population' Jagger wanted
to investigate was the overall behaviour of the wheel (i.e. the probability
distribution of its results over infinitely many trials), while his 'sample' was
formed from observed results from that wheel. Similar considerations arise
when taking repeated measurements of some physical characteristic such as
the electrical conductivity of copper.
 This situation often arises when we seek knowledge about the cause system of
which the observed population is an outcome. In such cases, sampling theory
may treat the observed population as a sample from a larger 'super population'.
For example, a researcher might study the success rate of a new 'quit smoking'
program on a test group of 100 patients, in order to predict the effects of the
program if it were made available nationwide. Here the super population is
"everybody in the country, given access to this treatment" - a group which
does not yet exist, since the program isn't yet available to all.
 Note also that the population from which the sample is drawn may not be the
same as the population about which we actually want information. Often there
is large but not complete overlap between these two groups due to frame
issues etc. (see below). Sometimes they may be entirely separate - for instance,
we might study rats in order to get a better understanding of human health, or
 77

we might study records from people born in 2008 in order to make predictions
about people born in 2009.
Time spent in making the sampled population and population of concern precise is
often well spent, because it raises many issues, ambiguities and questions that would
otherwise have been overlooked at this stage.

Sampling frame

In the most straightforward case, such as the sentencing of a batch of material from
production (acceptance sampling by lots), it is possible to identify and measure every
single item in the population and to include any one of them in our sample. However,
in the more general case this is not possible. There is no way to identify all rats in the
set of all rats. Where voting is not compulsory, there is no way to identify which
people will actually vote at a forthcoming election (in advance of the election). These
imprecise populations are not amenable to sampling in any of the ways below and to
which we could apply statistical theory.

As a remedy, we seek a sampling frame which has the property that we can identify
every single element and include any in our sample. The most straightforward type of
frame is a list of elements of the population (preferably the entire population) with
appropriate contact information. For example, in an opinion poll, possible sampling
frames include an electoral register and a telephone directory.

Probability and nonprobability sampling

A probability sampling is one in which every unit in the population has a chance
(greater than zero) of being selected in the sample, and this probability can be
accurately determined. The combination of these traits makes it possible to produce
unbiased estimates of population totals, by weighting sampled units according to their
probability of selection.

Example: We want to estimate the total income of adults living in a given street. We
visit each household in that street, identify all adults living there, and randomly select
one adult from each household. (For example, we can allocate each person a random
number, generated from a uniform distribution between 0 and 1, and select the person
with the highest number in each household). We then interview the selected person
and find their income. People living on their own are certain to be selected, so we
simply add their income to our estimate of the total. But a person living in a
household of two adults has only a one-in-two chance of selection. To reflect this,
when we come to such a household, we would count the selected person's income
twice towards the total. (The person who is selected from that household can be
loosely viewed as also representing the person who isn't selected.)

In the above example, not everybody has the same probability of selection; what
makes it a probability sample is the fact that each person's probability is known. When
every element in the population does have the same probability of selection, this is
known as an 'equal probability of selection' (EPS) design. Such designs are also
referred to as 'self-weighting' because all sampled units are given the same weight.
 78

Probability sampling includes:

 Simple Random Sampling,

 Systematic Sampling,
 Stratified Sampling,
 Probability Proportional to Size Sampling, and
 Cluster or
 Multistage Sampling. These various ways of probability sampling have two
things in common:
1. Every element has a known nonzero probability of being sampled and
2. involves random selection at some point.

Non probability sampling is any sampling method where some elements of the
population have no chance of selection (these are sometimes referred to as 'out of
coverage'/'undercovered'), or where the probability of selection can't be accurately
determined. It involves the selection of elements based on assumptions regarding the
population of interest, which forms the criteria for selection. Hence, because the
selection of elements is nonrandom, nonprobability sampling does not allow the
estimation of sampling errors. These conditions give rise to exclusion bias, placing
limits on how much information a sample can provide about the population.
Information about the relationship between sample and population is limited, making
it difficult to extrapolate from the sample to the population.

Example: We visit every household in a given street, and interview the first person to
answer the door. In any household with more than one occupant, this is a
nonprobability sample, because some people are more likely to answer the door (e.g.
an unemployed person who spends most of their time at home is more likely to answer
than an employed housemate who might be at work when the interviewer calls) and
it's not practical to calculate these probabilities

Nonprobability sampling methods include

 accidental sampling,
 quota sampling and
 purposive sampling. In addition, nonresponse effects may turn any probability
design into a nonprobability design if the characteristics of nonresponse are
not well understood, since nonresponse effectively modifies each element's
probability of being sampled.
Sampling methods

Within any of the types of frame identified above, a variety of sampling methods can
be employed, individually or in combination. Factors commonly influencing the
choice between these designs include:

 Nature and quality of the frame

 Availability of auxiliary information about units on the frame
 Accuracy requirements, and the need to measure accuracy
 Whether detailed analysis of the sample is expected
 Cost/operational concerns
 Cost/operational concerns
 79

Simple random sampling

 In a simple random sample (SRS) of a given size, all such subsets of the frame
are given an equal probability. Each element of the frame thus has an equal
probability of selection: the frame is not subdivided or partitioned.
 Furthermore, any given pair of elements has the same chance of selection as
any other such pair (and similarly for triples, and so on).
 This minimises bias and simplifies analysis of results. In particular, the
variance between individual results within the sample is a good indicator of
variance in the overall population, which makes it relatively easy to estimate
the accuracy of results.
 However, SRS can be vulnerable to sampling error because the randomness of
the selection may result in a sample that doesn't reflect the makeup of the
population.
 For instance, a simple random sample of ten people from a given country will
on average produce five men and five women, but any given trial is likely to
overrepresent one sex and under represent the other. Systematic and stratified
techniques, discussed below, attempt to overcome this problem by using
information about the population to choose a more representative sample.
 SRS may also be cumbersome and tedious when sampling from an unusually
large target population. In some cases, investigators are interested in research
questions specific to subgroups of the population. For example, researchers
might be interested in examining whether cognitive ability as a predictor of job
performance is equally applicable across racial groups.
 SRS cannot accommodate the needs of researchers in this situation because it
does not provide subsamples of the population. Stratified sampling, which is
discussed below, addresses this weakness of SRS.
 Simple random sampling is always an EPS design (equal probability of
selection), but not all EPS designs are simple random sampling.
Systematic sampling

 Systematic sampling relies on arranging the target population according to

some ordering scheme and then selecting elements at regular intervals through
that ordered list. Systematic sampling involves a random start and then
proceeds with the selection of every kth element from then onwards. In this
case, k=(population size/sample size).
 It is important that the starting point is not automatically the first in the list, but
is instead randomly chosen from within the first to the kth element in the list.
A simple example would be to select every 10th name from the telephone
directory (an 'every 10th' sample, also referred to as 'sampling with a skip of
10').
 As long as the starting point is randomized, systematic sampling is a type of
probability sampling. It is easy to implement and the stratification induced can
make it efficient, if the variable by which the list is ordered is correlated with
the variable of interest. 'Every 10th' sampling is especially useful for efficient
sampling from databases.
 For example, suppose we wish to sample people from a long street that starts
in a poor area (house No. 1) and ends in an expensive district (house No.
1000).
 A simple random selection of addresses from this street could easily end up
with too many from the high end and too few from the low end (or vice versa),
 80

leading to an unrepresentative sample. Selecting (e.g.) every 10th street

number along the street ensures that the sample is spread evenly along the
length of the street, representing all of these districts.
 (Note that if we always start at house #1 and end at #991, the sample is
slightly biased towards the low end; by randomly selecting the start between
#1 and #10, this bias is eliminated.
 However, systematic sampling is especially vulnerable to periodicities in the
list. If periodicity is present and the period is a multiple or factor of the
interval used, the sample is especially likely to be unrepresentative of the
overall population, making the scheme less accurate than simple random
sampling.
 For example, consider a street where the odd-numbered houses are all on the
north (expensive) side of the road, and the even-numbered houses are all on
the south (cheap) side.
 Under the sampling scheme given above, it is impossible to get a
representative sample; either the houses sampled will all be from the odd-
numbered, expensive side, or they will all be from the even-numbered, cheap
side.
 Another drawback of systematic sampling is that even in scenarios where it is
more accurate than SRS, its theoretical properties make it difficult to quantify
that accuracy. (In the two examples of systematic sampling that are given
above, much of the potential sampling error is due to variation between
neighbouring houses - but because this method never selects two neighbouring
houses, the sample will not give us any information on that variation.)
 As described above, systematic sampling is an EPS method, because all
elements have the same probability of selection (in the example given, one in
ten). It is not 'simple random sampling' because different subsets of the same
size have different selection probabilities - e.g. the set {4,14,24,...,994} has a
one-in-ten probability of selection, but the set {4,13,24,34,...} has zero
probability of selection.
 Systematic sampling can also be adapted to a non-EPS approach; for an
example, see discussion of PPS samples below.
Stratified sampling

 Where the population embraces a number of distinct categories, the frame can
be organized by these categories into separate "strata."
 Each stratum is then sampled as an independent sub-population, out of which
individual elements can be randomly selected.
There are several potential benefits to stratified sampling.

o First, dividing the population into distinct, independent strata can

enable researchers to draw inferences about specific subgroups that
may be lost in a more generalized random sample.
o Second, utilizing a stratified sampling method can lead to more
efficient statistical estimates (provided that strata are selected based
upon relevance to the criterion in question, instead of availability of the
samples). Even if a stratified sampling approach does not lead to
increased statistical efficiency, such a tactic will not result in less
efficiency than would simple random sampling, provided that each
stratum is proportional to the group's size in the population.
 81

o Third, it is sometimes the case that data are more readily available for
individual, pre-existing strata within a population than for the overall
population; in such cases, using a stratified sampling approach may be
more convenient than aggregating data across groups (though this may
potentially be at odds with the previously noted importance of utilizing
criterion-relevant strata).
o Finally, since each stratum is treated as an independent population,
different sampling approaches can be applied to different strata,
potentially enabling researchers to use the approach best suited (or
most cost-effective) for each identified subgroup within the population.
There are, however, some potential drawbacks to using stratified sampling.

o First, identifying strata and implementing such an approach can

increase the cost and complexity of sample selection, as well as leading
to increased complexity of population estimates.
o Second, when examining multiple criteria, stratifying variables may be
related to some, but not to others, further complicating the design, and
potentially reducing the utility of the strata.
o Finally, in some cases (such as designs with a large number of strata,
or those with a specified minimum sample size per group), stratified
sampling can potentially require a larger sample than would other
methods (although in most cases, the required sample size would be no
larger than would be required for simple random sampling.
A stratified sampling approach is most effective when three conditions are met

1. Variability within strata are minimized

2. Variability between strata are maximized
3. The variables upon which the population is stratified are strongly correlated
with the desired dependent variable.

Advantages over other sampling methods

1. Focuses on important subpopulations and ignores irrelevant ones.

2. Allows use of different sampling techniques for different subpopulations.
3. Improves the accuracy/efficiency of estimation.
4. Permits greater balancing of statistical power of tests of differences between
strata by sampling equal numbers from strata varying widely in size.

Disadvantages

1. Requires selection of relevant stratification variables which can be difficult.

2. Is not useful when there are no homogeneous subgroups.
3. Can be expensive to implement.

Poststratification
 Stratification is sometimes introduced after the sampling phase in a process
called "poststratification".
 This approach is typically implemented due to a lack of prior knowledge of an
appropriate stratifying variable or when the experimenter lacks the necessary
information to create a stratifying variable during the sampling phase.
 82

 Although the method is susceptible to the pitfalls of post hoc approaches, it

can provide several benefits in the right situation.
 Implementation usually follows a simple random sample. In addition to
allowing for stratification on an ancillary variable, poststratification can be
used to implement weighting, which can improve the precision of a sample's
estimates.
Oversampling

Choice-based sampling is one of the stratified sampling strategies. In choice-based

sampling, the data are stratified on the target and a sample is taken from each stratum
so that the rare target class will be more represented in the sample. The model is then
built on this biased sample. The effects of the input variables on the target are often
estimated with more precision with the choice-based sample even when a smaller
overall sample size is taken, compared to a random sample. The results usually must
be adjusted to correct for the oversampling.

Probability-proportional-to-size sampling

 In some cases the sample designer has access to an "auxiliary variable" or

"size measure", believed to be correlated to the variable of interest, for each
element in the population. These data can be used to improve accuracy in
sample design. One option is to use the auxiliary variable as a basis for
stratification, as discussed above.
 Another option is probability-proportional-to-size ('PPS') sampling, in which
the selection probability for each element is set to be proportional to its size
measure, up to a maximum of 1.
 In a simple PPS design, these selection probabilities can then be used as the
basis for Poisson sampling. However, this has the drawback of variable sample
size, and different portions of the population may still be over- or under-
represented due to chance variation in selections. To address this problem,
PPS may be combined with a systematic approach.
Example: Suppose we have six schools with populations of 150, 180, 200, 220, 260,
and 490 students respectively (total 1500 students), and we want to use student
population as the basis for a PPS sample of size three. To do this, we could allocate
the first school numbers 1 to 150, the second school 151 to 330 (= 150 + 180), the
third school 331 to 530, and so on to the last school (1011 to 1500). We then generate
a random start between 1 and 500 (equal to 1500/3) and count through the school
populations by multiples of 500. If our random start was 137, we would select the
schools which have been allocated numbers 137, 637, and 1137, i.e. the first, fourth,
and sixth schools.

 The PPS approach can improve accuracy for a given sample size by
concentrating sample on large elements that have the greatest impact on
population estimates.
 PPS sampling is commonly used for surveys of businesses, where element size
varies greatly and auxiliary information is often available - for instance, a
survey attempting to measure the number of guest-nights spent in hotels might
use each hotel's number of rooms as an auxiliary variable.
 In some cases, an older measurement of the variable of interest can be used as
an auxiliary variable when attempting to produce more current estimates.
Cluster sampling
 83

 Sometimes it is more cost-effective to select respondents in groups ('clusters').

 Sampling is often clustered by geography, or by time periods. (Nearly all
samples are in some sense 'clustered' in time - although this is rarely taken into
account in the analysis.) For instance, if surveying households within a city,
we might choose to select 100 city blocks and then interview every household
within the selected blocks.
 Clustering can reduce travel and administrative costs. In the example above,
an interviewer can make a single trip to visit several households in one block,
rather than having to drive to a different block for each household.
 It also means that one does not need a sampling frame listing all elements in
the target population. Instead, clusters can be chosen from a cluster-level
frame, with an element-level frame created only for the selected clusters. In
the example above, the sample only requires a block-level city map for initial
selections, and then a household-level map of the 100 selected blocks, rather
than a household-level map of the whole city.
 Cluster sampling generally increases the variability of sample estimates above
that of simple random sampling, depending on how the clusters differ between
themselves, as compared with the within-cluster variation. For this reason,
cluster sampling requires a larger sample than SRS to achieve the same level
of accuracy - but cost savings from clustering might still make this a cheaper
option.
 Cluster sampling is commonly implemented as multistage sampling. This is a
complex form of cluster sampling in which two or more levels of units are
embedded one in the other.
 The first stage consists of constructing the clusters that will be used to sample
from. In the second stage, a sample of primary units is randomly selected from
each cluster (rather than using all units contained in all selected clusters). In
following stages, in each of those selected clusters, additional samples of units
are selected, and so on. All ultimate units (individuals, for instance) selected at
the last step of this procedure are then surveyed. This technique, thus, is
essentially the process of taking random sub samples of preceding random
samples.
 Multistage sampling can substantially reduce sampling costs, where the
complete population list would need to be constructed (before other sampling
methods could be applied). By eliminating the work involved in describing
clusters that are not selected, multistage sampling can reduce the large costs
associated with traditional cluster sampling.

NON PROBABILITY SAMPLING

Quota sampling

 In quota sampling, the population is first segmented into mutually exclusive

sub-groups, just as in stratified sampling.
 Then judgement is used to select the subjects or units from each segment
based on a specified proportion. For example, an interviewer may be told to
sample 200 females and 300 males between the age of 45 and 60.
 It is this second step which makes the technique one of non-probability
sampling. In quota sampling the selection of the sample is non-random.
 84

 For example interviewers might be tempted to interview those who look most
helpful. The problem is that these samples may be biased because not
everyone gets a chance of selection. This random element is its greatest
weakness and quota versus probability has been a matter of controversy for
many years.
Accidental sampling

 Accidental sampling (sometimes known as grab, convenience or opportunity

sampling) is a type of nonprobability sampling which involves the sample
being drawn from that part of the population which is close to hand. That is, a
population is selected because it is readily available and convenient.
 It may be through meeting the person or including a person in the sample
when one meets them or chosen by finding them through technological means
such as the internet or through phone.
 The researcher using such a sample cannot scientifically make generalizations
about the total population from this sample because it would not be
representative enough. For example, if the interviewer were to conduct such a
survey at a shopping center early in the morning on a given day, the people
that he/she could interview would be limited to those given there at that given
time, which would not represent the views of other members of society in such
an area, if the survey were to be conducted at different times of day and
several times per week.
This type of sampling is most useful for pilot testing. Several important
considerations for researchers using convenience samples include:

1. Are there controls within the research design or experiment which can serve to
lessen the impact of a non-random convenience sample, thereby ensuring the
results will be more representative of the population?
2. Is there good reason to believe that a particular convenience sample would or
should respond or behave differently than a random sample from the same
population?
3. Is the question being asked by the research one that can adequately be
answered using a convenience sample?

In social science research, snowball sampling is a similar technique, where existing

study subjects are used to recruit more subjects into the sample. Some variants of
snowball sampling, such as respondent driven sampling, allow calculation of selection
probabilities and are probability sampling methods under certain conditions.

Line-intercept sampling

Line-intercept sampling is a method of sampling elements in a region whereby an

element is sampled if a chosen line segment, called a "transect", intersects the
element.

Panel sampling

Panel sampling is the method of first selecting a group of participants through a

random sampling method and then asking that group for (potentially the same)
information several times over a period of time.
 85

Therefore, each participant is interviewed at two or more time points; each period of
data collection is called a "wave". The method was developed by sociologist Paul
Lazarsfeld in 1938 as a means of studying political campaigns.

This longitudinal sampling-method allows estimates of changes in the population, for

example with regard to chronic illness to job stress to weekly food expenditures. Panel
sampling can also be used to inform researchers about within-person health changes
due to age or to help explain changes in continuous dependent variables such as
spousal interaction. There have been several proposed methods of analyzing panel
data, including MANOVA, growth curves, and structural equation modeling with
lagged effects.

Sampling errors and biases are induced by the sample design. They include:

1. Selection bias: When the true selection probabilities differ from those
assumed in calculating the results.
2. Random sampling error: Random variation in the results due to the elements
in the sample being selected at random.

Non-sampling error

Non-sampling errors are other errors which can impact the final survey estimates,
caused by problems in data collection, processing, or sample design. They include:

1. Overcoverage: Inclusion of data from outside of the population.

2. Undercoverage: Sampling frame does not include elements in the population.
3. Measurement error: e.g. when respondents misunderstand a question, or find
it difficult to answer.
4. Processing error: Mistakes in data coding.
5. Non-response: Failure to obtain complete data from all selected individuals.

After sampling, a review should be held of the exact process followed in sampling,
rather than that intended, in order to study any effects that any divergences might have
on subsequent analysis.

A particular problem is that of non-response.

Two major types of nonresponse exist: unit nonresponse (referring to lack of

completion of any part of the survey) and item nonresponse (submission or
participation in survey but failing to complete one or more components/questions of
the survey).

In survey sampling, many of the individuals identified as part of the sample may be
unwilling to participate, not have the time to participate (opportunity cost), or survey
administrators may not have been able to contact them. In this case, there is a risk of
differences, between respondents and nonrespondents, leading to biased estimates of
population parameters. This is often addressed by improving survey design, offering
incentives, and conducting follow-up studies which make a repeated attempt to
contact the unresponsive and to characterize their similarities and differences with the
rest of the frame. The effects can also be mitigated by weighting the data when
 86

population benchmarks are available or by imputing data based on answers to other

questions.

Nonresponse is particularly a problem in internet sampling. Reasons for this problem

include improperly designed surveys, over-surveying (or survey fatigue), and the fact
that potential participants hold multiple e-mail addresses, which they don't use
anymore or don't check regularly.

Well done ,you are done with this lecture. We discussed about the sampling methods
and non sampling methods

Critique probability and non probability sampling techniques.

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LECTURE 9

Ethical issues in epidemiology

Lecture Overview

Ethical issues can facilitate the effective planning, implementation, and growth of a
variety of public health programs and research activities. Public health ethics is
consistent with the prevention orientation of public health. Ethical concerns can be
anticipated or identified early and effectively addressed through careful analysis and
consultation.We will discuss the ethical issues in Epidemiology.

By the end of the lecture you should be able to:-

i.Discuss Ethics in Epidemiology.

Activity 9.1

What is Ethics?

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

ETHICAL PRINCPLES

There are four Ethical prinnciples namely:

1.Beneficence

2. Nonmaleficence

3.Justice

4.Respect for autonomy

The principles of beneficence, nonmaleficence, autonomy, and justice, seek to reduce

morality to its basic elements and to provide a useful framework for ethical analysis in
the health professions. The principles do not provide a full philosophical justification
for decision making, however. In situations where there is conflict between principles,
it may be necessary to choose between them or to assign greater weight to one.
 88

Practical problems in public health ethics require that these principles be made more
applicable through a process of specification and reform.

The ethical principle of beneficence requires that potential benefits to individuals and
to society be maximized and that potential harms be minimized . Beneficence
involves both the protection of individual welfare and the promotion of the common
welfare. This principle underlies ethical rules and norms that require that public health
institutions act in a timely manner on the information they have and that they
expeditiously make the information available to the public .

The principle of nonmaleficence requires that harmful acts be avoided. However, the
principle of nonmaleficence does not preclude balancing potential harms against
potential benefits .

The principle of autonomy focuses on the right of self-determination. Respect for the
individual which grants importance to individual freedom in political life, and to
personal development.

Principles of justice emphasize a mixture of criteria so that public utility is

maximized. From this perspective, a just distribution of benefits from public health
programs or research is determined by the utility to all affected. Each person should
share equally in the distribution of the potential benefits of health care resources such
as screening services.

Specific ethical issues arising in epidemiologic research and public health practice
that have been highlighted in ethics guidelines include minimizing risks and providing
benefits, informed consent, avoiding and disclosing conflicts of interest, obligations to
communities, and the institutional review board system.

Minimizing risks and providing benefits

Epidemiologists have ethical and professional obligations to maximize the potential

benefits of studies to research participants and to society, and to minimize potential
harms and risks. In addition, these obligations are often legal or regulatory
requirements.

The risks of epidemiologic studies and practice activities can be minimized by

rigorously protecting the confidentiality of health information. Although the risks
posed by epidemiologic studies are often minor compared with those that may be
associated with clinical trials and other experimental studies, participants in
epidemiologic studies may be burdened by a loss of privacy, by time spent completing
interviews and examinations, and by possible adverse psychological effects such as
enhanced grief or anxiety.

Such risks and potential harms can be minimized by careful attention to study
procedures and questionnaire design, for example, by limiting the length of interviews
or by scheduling them on a date that is less likely to result in adverse psychological
effects.

Minimizing risks and potential harms and maximizing potential benefits are
particularly important in epidemiologic studies of vulnerable populations. Examples
 89

include studies of children, prisoners, some elderly people, and populations that are
marginalized or socioeconomically disadvantaged.

A further obligation is the need to ensure that the burdens and potential benefits of
epidemiologic studies are distributed equitably. The potential benefits of
epidemiologic research are often societal in nature, such as obtaining new information
about the causes of diseases, or identifying health disparities across groups defined by
race, ethnicity, socioeconomic status, or other factors. Research participants may
receive direct benefits from participation in some studies, such as when a previously
unrecognized disease or risk factor is detected during examinations. The balance of
risks and potential benefits of epidemiologic studies are considered not only by
individual researchers but also by members of human subjects .

Avoiding and disclosing conflicts of interest

Other ethical issues that arise in the professional practice of epidemiology relate to
how best to deal with potential conflicts of interest, in order to maintain public trust in
epidemiology and sustain public support for health research.. Conflicts of interest can
affect scientific judgment and harm scientific objectivity. Studies have suggested that
financial interests and researchers' commitment to a hypothesis can influence reported
research results . To address such concerns, funding agencies and research institutions
have taken steps such as adopting new training programs that encourage researchers to
avoid or disclose conflicts of interest, and revising or strengthening institutional rules
and guidelines. Researchers should disclose financial interests and sources of funding
when publishing research results. It may also be important to disclose information
about potential or actual financial conflicts of interest when obtaining informed
consent from research participants. A related issue is that health researchers should
avoid entering into contractual agreements that prevent them from publishing results
in a timely manner . Communicating research results in a timely manner, without
censorship or interference from the funder, is essential for maintaining public trust .

Obligations to communities

These obligations include communicating the results of epidemiologic studies at the

earliest possible time, after appropriate scientific peer review, so that the widest
possible audience stands to benefit from the information. Epidemiologists should
strive to carry out studies in a way that is scientifically valid and interpret and report
the results of their studies in a way that is scientifically accurate and appropriate. In
addition, epidemiologists should respect cultural diversity in carrying out studies and
in communicating with members of affected communities.

Informed consent

Informed consent provisions in public health studies ensure that research participants
make a free choice and also give institutions the legal authorization to proceed with
the research Investigators must disclose information that potential participants use to
decide whether to consent to the study. This includes the purpose of the research, the
scientific procedures, anticipated risks and benefits, any inconveniences or
discomfort, and the participant's right to refuse participation or to withdraw from the
research at any time.
 90

. Informed consent requirements may be waived in exceptional circumstances when

obtaining consent is impractical, the risks are minimal, and the risks and potential
benefits of the research have been carefully considered by an independent review
committee. Risks and potential harms in such studies may be very low, and risks may
be further reduced by omitting personal identifiers from the computer databases.

Privacy and confidentiality

One important way in which public health researchers reduce potential harms and
risks to participants in epidemiologic studies is by rigorously protecting the
confidentiality of their health information. Specific measures taken by researchers to
protect the confidentiality of health information include keeping records under lock
and key, limiting access to confidential records, discarding personal identifiers from
data collection forms and computer files whenever feasible, and training staff in the
importance of privacy and confidentiality protection .

Other measures that have been employed to safeguard health information include
encrypting computer databases, limiting geographic detail, and suppressing cells in
tabulated data where the number of cases in the cell is small .

1. -Crofts; 1986. pp. 1867–77.

Discuss Ethics in Epidemiology

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_____________________________________________________________________
_____________________________________________________________________
_________________
Explain the major thical principles.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________

Lappe M. Ethics and public health. In: Last JM, editor. Maxcy-Rosenau's public
health and preventive medicine. 12. Norwalk, CT: Appleton-Century
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 92

LECTURE 10

EPIDEMIOLOGICAL STUDIES

Lecture overview

Epidemiological studies may deal merely with the distribution of diseases/conditions

in human populations (descriptive surveys), and/or with the factors influencing the
distribution and the frequency of diseases (analytic surveys: cross-sectional, case-
control, cohort, quasi-experiment and experimental studies).

By the end of the lecture you should be able to:

i.Explain types of episemiological study designs.
ii.Critique cohort and case control study designs.

Descriptive survey

population in relation to sex, age, or other characteristics.

Analytical survey (explanatory study)
• Tests hypotheses
• Looks for associations based on: a) groups (ecological/correlation studies,
trend studies); b) based on individuals (cross-sectional, case-control, cohort,
experiments and quasi-experiments).
This is the most classical way of classifying the epidemiological inquiries. However,
this classification has little practical value in itself, since the same study could be both
descriptive and analytic or, in principle, all studies could be regarded as analytic (e.g.
the distribution of a certain condition by sex or age could be regarded as a sort of
implicit analysis rather than just description of the observed facts).
 93

The most important way of classifying the epidemiological studies is the one which
accounts for the role/control of the researcher over the study. According to this, a
major distinction is being made of: a) observational studies, and b) experiments.
Observational studies
• The investigator observes the occurrence of the condition/disease in population
groups that have assigned themselves to a certain exposure.
• Often most practical and feasible to conduct.
• Carried out in more natural settings – representative of the target population.
• Often, there is little control over the study situation – results are susceptible to
distorting influences.
Experimental approach
• The most powerful study design for testing ethiological hypothesis.
• The investigator exercises control over the allocation of exposure, its
associated factors and observation of the outcome.
• For obvious ethical and practical reasons, the possibilities of conducting
experiments in human populations are very limited.

Direction of Study Question

According to the direction of inquiry, epidemiological studies are classified as
follows:
Prospective (forward-looking) approach – in which (disease free) people who are
exposed and non exposed are followed up and compared with respect to the
subsequent development of the disease/outcome under study.
Retrospective (backward-looking) approach – in which people with the disease are
compared with people without the disease, to determine whether they differ in their
past exposure to the (hypothesized) causative factor.
Non-Directional Design – the investigator observes simultaneously the exposure and
disease status in the study population.
Ambispective Design – one primary variable/factor is measured prospectively and
the other one retrospectively, or one primary variable/factor is measured both
prospectively and retrospectively.
 94

Direction of Data Collection

Retrolective – data collected before the study design (not necessarily for the purpose
of the actual study).
Prolective – data collected after study design (for the purpose of the actual study)
 95

Three major types of epidemiological studies

1) Cohort Studies. The design of a cohort study is sketched below:

Disease

Exposed

No disease
People without
Population the disease
“at risk”

Disease

Not exposed

No disease
 96

• The essence of cohort studies is the identification of a group of subjects about

whom certain exposure information is collected. The group is then followed up in
time to ascertain the occurrence of disease/condition of interest.
• For each individual prior exposure can be related to subsequent disease
experience.
• Since the first requirement of such studies is the identification of the
individuals forming the study group – COHORT, prospective or longitudinal
studies are usually referred to as cohort studies.
Advantages of cohort studies
1. Measure incidence and thus permit direct estimation of risk of disease.
2. Do not rely on memory for information about exposure status, hence avoid bias
due to selective recall.
3. Since cohort studies begin with people free of disease, potential bias due to
selective survival is eliminated.
4. Cohort studies provide a logical approach to studies of causation or effects of
treatment.
5. Cohort approach can yield information on associations of exposure with
several diseases.
Disadvantages of cohort studies
1. Require large samples to yield the same number of cases that could be studied
more efficiently in a case-control study.
2. Particularly inefficient for studies of rare diseases.
3. Logistically difficult – long follow-up period, often serious attrition to study
subjects.
4. Direct observation of participants may cause changes in health behavior.
5. Possible bias in ascertainment of disease due to changes over time in criteria
and methods.
6. Very costly.

An alternative strategy to the costly and time consuming prospective cohort design is
the historical cohort study. A cohort is identified (enumerated) as of some historical
point in time and is then followed over past time to the present. Disease rates and
relative risk (RR) can be derived from this type of study as well. The retrospective
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(historical) cohort approach is particularly amenable to the study of exposure-disease

relationship for which the exposure group is unusual in some way, e.g. many
occupational or environment exposure-disease relationships
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2) Case-Control Studies. The design of a case-control study is sketched below:

Exposed

Cases
Not exposed

Population

Exposed
Controls

Not exposed

TIME
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The case-control study begins with a group of cases of a specific disease. This (the disease) is the starting
point of the study, unlike cohort studies where the interest is in drawing a contrast between exposed and
non-exposed subjects. So, the case-control approach is directed at the prior exposures, which caused the
disease and thus proceeds from effect (outcome) to cause (exposure).
Advantages of case-control studies
1. Highly informative compared to other designs: several exposures or potential causal agents can be
examined.
2. Efficient designs (low cost per study) primarily because few subjects are needed to obtain stable
estimate of RR.
3. Particularly appropriate for studies of rare diseases (e.g. a case-control study with 100 cases of a
disease having an annual incidence of 1/1000. A cohort design for this disease would require 1000
persons to be followed up for 100 years or 10000 persons to be followed up for 10 years in order to
yield the same number of cases).
Disadvantages of case-control studies
1. The absolute frequency of a disease can not be determined. No counts are made of population at-
risk, thus there are no denominators available to obtain the incidence rates. Lacking absolute risks, it’s
not possible to compare disease rates among different studies, nor is it possible to estimate the
attributable risk.
2. Particularly subject to bias: selection bias in choosing controls and recall bias (cases may recall
better prior exposures than controls).
3. “Philosophically” difficult to interpret: the antecedent-consequent relationship (exposure-outcome)
is subject to considerable uncertainty.
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Congratulations for successfully completeing this lecture.We have looked at types of epidemiological
studies ,cohort and case-control studies.

1.Identify major classes of epidemiological studies.

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______________________________________________________________________________________
______________________________________________________________________________________
2.Critiques cohort and case control studies
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1. Gordis L. (1996). Epidemiology. W.B.Sounders Company, Philadelphia.

2. Abramson JH, Abramson ZH. (1999). Survey methods in community medicine. Churchill
Livingstone, New York.
3. Lilienfeld AM, Lilienfeld DE. (1980). Foundations of epidemiology. Oxford University Press, New
York.
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LECTURE 11
EPIDEMIOLOGICAL STUDIES
CROSS SECTIONAL STUDY DESIGN

By the end of the lecture you should be able to:

i.Critique cross sectional studies.

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3) Cross-Sectional Studies. The design of a cross-sectional study is sketched below:

Population

Information on both exposure and disease

Exposed Exposed, Not Not

and have do not exposed, exposed,
The have the have the do not
Disease disease disease have the
disease
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Cross-sectional design is referred to as non-directional or one point in time survey,

where data is collected on both outcome and exposure status of the individuals under
study. Such studies are useful to describe characteristics of study population and can
generate new ethiological hypothesis. This study design involves disease prevalence.
Cross-sectional studies can evaluate the impact of changes in health services during an
intervening period. This can be accomplished by conducting a cross-sectional study
twice: before and after the intervention.
Advantages of cross-sectional studies
1. Describe the distribution of both exposure and outcome in a population
(particularly useful for studying frequent outcomes of long duration).
2. Provide estimates of the magnitude of a disease problem in a community,
which might be very important for planning of health services.
3. Compared with other studies are relatively quick and inexpensive. Often,
involve only one-time survey.
4. Largely applicable: provision of health care services as well as generation of
ethiological hypothesis.
Disadvantages of cross-sectional studies
1. Do not measure risk, because this would require incidence data.
2. Can not determine cause-effect relationship.
3. Current exposure status may be due to changes that have occurred as a result of
the disease rather than having led to the disease.
4. Diseases of short duration may be missed. Thus, cross-sectional studies are
best applied to the study of chronic or persistent conditions.

Congratulations for successfully completing this lectur which we have discussed cross
sectional studies.
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Critique cross sectional studies.

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Gordis L. (1996). Epidemiology. W.B.Sounders Company, Philadelphia.

Abramson JH, Abramson ZH. (1999). Survey methods in community medicine.
Churchill Livingstone, New York.
Lilienfeld AM, Lilienfeld DE. (1980). Foundations of epidemiology. Oxford
University Press, New York.
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5. Kleinbaum DG, Kupper LL, Morgenstern H. (1992). Epidemiologic research: principles and
quantitative methods. Lifetime Learning Publications, Belmont, California.
6. Abramson JH, Feinleib M, Detels R, Greenberg RS, Ibrahim MA. Oxford Textbook of Public
Health. (1985) vol 3: investigative methods in public health. Oxford University Press, Oxford.