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FINAL EXAM
REVIEW INTRODUCTION TO
NSG 522: Applied Epidemiology and
EPIDEMIOLOGY
Biostatistics for Nursing Practice
Rush University, College of Nursing

What is Epidemiology? Core Epidemiological Functions

Epidemiology is… 1. Surveillance

2. Field investigations
“The study of the distribution and determinants of heath- 3. Analytic studies
related states or events in specified populations, and the 4. Evaluation
application of this knowledge to the control of health 5. Linkages
problems.” 6. Policy

CDC, 2006

Epidemiology is a Quantitative Science 5 W’s of Epidemiology

• Epidemiology is a quantitative science
• What?
• When?
• Measurement is an essential feature of epidemiology
• Where?
• Who?
• Measurement focuses on
• Why?
- Distribution of health-related states and events
- Determinants of health-related states and events

• Epidemiology is a story about health related states and

events supported with data

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Epidemiology Descriptive Epidemiology

Two components of epidemiology Describes the WHEN, WHERE and WHO

- Descriptive - Time
- Analytic - Place
- Person

• Descriptive epidemiology studies the DISTRIBUTION of

health related states and events

• Descriptive epidemiology studies the FREQUENCY and

PATTERN of health related states and events

Analytic Epidemiology Descriptive vs. Analytic Epidemiology

Analytic epidemiology • Descriptive epidemiology describes the

- Why-- Cause and Effect - Distribution of health-related events
- Frequency and pattern of events
- Analytic epidemiology quantifies the association between - The ‘who, where, and when’
exposures and outcomes to determine causal - The ‘person, place, and time’
relationships
- The ‘why’ examines potential etiologies (helpful or
harmful) for the health-related event • Analytic epidemiology describes the
- The ‘why’ explains the causes of the health-related state - Determinants of health-related events
or event - The ‘why’
- Analytic epidemiology studies the DETERMINANTS of - The ‘cause(s)’
health related states and events

The Role of the CDC

DETERMINANTS
OF HEALTH

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Determinants of Health Biological Sources of Disease

• Biological • Congenital
• Environmental • Hereditary
• Social • Infectious
• Health behaviors • Inflammatory
• Metabolic
• Nutritional
• Tumors
• Vascular

Environmental Sources of Disease Social Determinants of Health

• Allergens
• Chemical exposures
• Infectious organisms
• Nutrition
• Physical agents
• Trauma

Health Behaviors
• Nutrition
• Physical activity
• Rest and relaxation MECHANISMS
• Tobacco use
• Alcohol use OF
• Illicit substance use
• Immunizations DISEASE CAUSATION

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Multicausality The ‘Causal Pie’ Model

• Causative agent or event
• Every causal mechanism involves the joint action of a
• Characteristics of the person
multitude of component causes
• Characteristics of the environment
• The etiology of all diseases is multifactorial, even with a • Presence of preventative factors
simple infectious disease • Action of catalysts or additive factors
• Mediating and moderating factors
• Some disease have very complex etiologies (e.g., • Interaction between the factors
cardiovascular disease)

Bradford Hill Criteria for Causation

• Strength of association
• Consistency
• Specificity
• Temporal relationship MODELS OF
• Biological gradient
• Plausibility DISEASE CAUSATION
• Coherence
• Analogy
• Experimental evidence

Etiology of Disease Epidemiological Triad or Triangle

Occurrence of disease can be understood using 3 models:
- Epidemiological Triad or Triangle
- BEINGS Model
- Web of Causation

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BEINGS Model of Disease Causation Web of Causation

B – Biological, Behavioral
E – Environmental
I – Immunological
N – Nutritional
G – Genetic
S – Services, Social, Spiritual

Spectrum of Disease
• Describes the severity of disease
• Can vary from mild to fatal
SPECTRUM AND
NATURAL HISTORY
OF DISEASE

Natural History of Disease Stage of Susceptibility

• Natural history of a disease describes the progression of
the disease process over time in an untreated individual

• Describes the stages of disease

- Stage of susceptibility
- Stage of preclinical, subclinical, presymptomatic, or
latent disease
- Stage of clinical disease
- Stage of recovery, disability, or death

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Stage of Subclinical Disease Stage of Clinical Disease

• Not apparent or asymptomatic
• Onset of symptoms
• Pathological changes occur
• Diagnosis usually occurs during this stage
• Pathology may be detected by screening
• Incubation period for infectious diseases
• Latency for chronic disease

Stage of Recovery, Disability, or Death

LEVELS OF
PREVENTION

Primary Prevention Secondary Prevention

• Used during the stage of susceptibility • Used during the preclinical (subclinical, presymptomatic,
• Protects against the disease latent) and early clinical stages of disease
- Place the host in good health • Early detection and prompt intervention to control the
- Protects against disease or other health-related disease and minimize or eliminate complications
events (e.g., immunization)
- Public health measures

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Levels of Prevention and the

Tertiary Prevention Stages of Disease
• Stage of susceptibility
• Used during the advanced stage of clinical disease or
- Primary prevention
when disability has occurred
• Measures aimed at reducing the long term impact of
• Stage of preclinical, subclinical, presymptomatic, or latent
disease and disability
disease
- Secondary prevention

• Stage of clinical disease

- Secondary prevention during early part of stage
- Tertiary prevention during more advanced disease

• Stage of recovery, disability, or death

- Tertiary prevention

Prevention and the

Natural History of Disease

COMMUNICABLE
DISEASES

Communicable Disease Chain of Infection

• The ability of a disease to • Reservoir
- Be transmitted from one person to another -or – • Portal of exit
- To spread through the population is called • Transmission
communicability - Direct
- Indirect
- Airborne
• Portal of entry
• Susceptible host

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Reservoir Portal of Exit

• Reservoir • Portal of exit from the reservoir
- Habitat in which the agent grows and lives - Respiratory tract
- Blood
• Reservoirs can be - Semen
- Human - Other body fluids
- Animal - Crossing the placenta (mother-to-fetus)
- Invertebrates (insects, arachnoids) - Blood sucking mosquitos
- Environment

Mode of Transmission Portal of Entry

• Direct transmission
- Direct contact (kissing, sexual intercourse, soil contact) • Portal of entry into the host
- Respiratory tract
• Indirect transmission - Mouth
- Vehicleborne (food, water, bedding, instruments) - Break in the skin or mucous membrane
- Vectorborne (mosquitos, fleas, ticks) - Surgical sites
- Catheters
• Airborne transmission
- Droplet (direct mode of transmission)
- Droplet nuclei (indirect mode of transmission)

Susceptible Host
• Susceptible host
- Immune status
- Overall health PREVENTION
- Nutritional status
AND CONTROL
OF INFECTION

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Primary Prevention for Infection Active and Passive Immunity

• Used during the stage of susceptibility • Active immunity
• Protects against the disease - Body produces its own antibodies in response to
having been vaccinated or having a specific disease
• Includes activities pathogen invade the body
- Eliminate or sanitize the reservoir
- Eliminate or cover the portal of exit • Passive immunity
- Eliminate or cleanse the transmission mode - Administration of immune globulin
- Cover or filter the portal of entry - Transplacental transfer of immune globulins to the
- Place the host in good health and immunize when fetus
available - Transfer of antibodies and other immunoprotectant in
human milk

Herd Immunity Cocooning

• Viewed as the resistance a population has to the invasion • Used to protect infants from communicable diseases
and spread of an infectious disease • Only family and friends who are fully immunized are
• Based on the notion that if a population or group is allowed to be around the infant
mostly protected from a disease by immunizations (85%
or more), then the chance of a major epidemic occurring
is reduced

Host-Related Control and Prevention

• Isolation
- Used for persons who are known to be ill with a
contagious disease
- Used in inpatient settings (hospitals or nursing
homes) DESCRIPTIVE
- State laws as well as accrediting organizations
require one or two beds to be designated and as EPIDEMIOLOGY
isolation beds

• Quarantine
- Used for persons who have been exposed to a
contagious disease but may or may not become ill

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Using Tables to Describe Person

Descriptive Epidemiology
• Descriptive epidemiology describes the
- Frequency of events
- Pattern of events
- Who (person)
- Where (place)
- When (time)

Using a Population Pyramid to Describe Person Using Maps to Describe Place

Using Event Timelines to Describe Time

HEALTH
SURVEILLANCE

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Public Health Surveillance Health Indicator

• Defined as the “ongoing, systematic collection, analysis,
and interpretation of health-related data essential to Markers of health status
information for the planning, implementation, and of - Physical or mental illness
public health practice, closely integrated with the timely - Impairments or disabilities
dissemination of these data to those responsible for
- Social well being
prevention and control” (CDC)
- Service provision
- Resource availability
• Public health surveillance uses data to monitor health
problems to facilitate their prevention or control

• Information gained from surveillance can be used for

- Planning disease control and prevention programs
- Policy-making

Notifiable Diseases in the United States

• Many infectious disease must be reported so that
appropriate control measures can be implemented
• Other diseases are also reported
• Federal and state mandated reporting
MEASURES OF
• Notifiable diseases are those of considerable public
health importance because of their seriousness.
DISEASE
- Cause serious morbidity or death OCCURANCE
- Have the potential to spread
- Can be controlled with appropriate intervention

Measures of Disease Occurrence Ratios

• Counts • Ratios compare two things
- Number (n)
- Frequency (f) • Divide the numerator by the denominator
• Ratios
• Proportions • Expressed as X/Y or X:Y
• Percentages
• Rates • Numerator may or may not be part of the denominator

• The numerator and denominator may or may not be

related

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Proportions (p) Percentages (P)

• Numerator is always a part of the denominator • Numerator is always a part of the denominator
• Just a proportion multiplied by 100!!!
• Calculated as p= A e.g., 1/8 =.125 = 12.5%

A+B
• Calculated as P = A * 100
A+B
• Usually calculated as a decimal e.g., 1/8 =.125

Rates
• Frequency of an event in a population in a specified
period of time

• Population is always specified VITAL

• Time period is always specified STATISTICS

Vital Statistics Mortality

• Three major categories of vital statistics • A mortality rate is a measure of the frequency of
- Mortality occurrence of death in a defined population during a
specified interval. (CDC, 2006)
- Morbidity
- Natality
Deaths during a given time period × 10n*
Size of the population in which the deaths occurred

* (usually 1,000 or 100,000)

CDC, 2006

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Crude (All Cause) Mortality Rate

Infant Mortality Rate
• The crude mortality rate is the mortality rate from all
causes of death for a population • Infant mortality rate
• Also called the “All Cause” Mortality Rate - Deaths of infants < 1 year of age
- Denominator is number of live births in the given time
• Example period
- In 2003, there were 2,419,921 deaths in the USA - Live birth has a specific definition
- The estimated population was 290,809,777 - Per 1,000 live births
- The crude mortality rate was
2,419,921 ⁄ 290,809,777 × 100,000 = • Single most widely used health indicator to compare
nations
832.1 deaths per 100,000 population

Neonatal Mortality Rate Maternal Mortality Rate

• Neonatal mortality rate
• Maternal mortality rate
- Deaths of infants < 28 days of age
- Deaths of women due to pregnancy related causes
- Denominator is number of live births in the given time during pregnancy or during the first 42 days after
period pregnancy termination, regardless of the duration of
- Per 1,000 live births the pregnancy
- Denominator is number of live births in the given time
period
- Per 100,000 live births

Morbidity Incidence and Prevalence

• A morbidity rate is a measure of the frequency of
• Incidence and prevalence are the two major measures of
occurrence of disease or injury in a defined population
during a specified interval. disease frequency

Cases during a given time period × 10n*

Size of the population in which
the cases occurred

* (usually 1,000 or 100,000)

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Prevalence Prevalence
• Prevalence refers to the status of disease, not the onset • Prevalence is calculated as a proportion

• Prevalence measures the frequency of a disease at a • Prevalence =

particular point in time Number of individuals who have a disease at a particular point in time
Total population at risk at the specified time

• Prevalence measures all cases (old and new) at a

specified period of time
• Point prevalence = assessed at one specific point in time

• Period prevalence = assessed during a certain period

Incidence Incidence Proportion

• Incidence measures the rate at which people without a
disease develop the disease during a specified period • Incidence Proportion =
Number of new cases of a disease in a specified time period
• Incidence is a measure of the onset of disease Population at risk of the disease at the start that time period

• Incidence measures the appearance of disease • Also called

- Risk
• Incidence means new - Attack rate
- Probability of developing a disease

Incidence Rate

• Incidence Rate =
Number of new cases of a disease in a specified time period
Time that each person was observed, totaled for all persons
EPIDEMIOLOGIC
• Also known as “”Person-Time Rate”
STUDY DESIGNS
• Most accurate estimate of risk
• More difficult to calculate
• Accounts for incomplete data

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Levels of Evidence Systematic Reviews: Meta-Analyses

• Study of studies
Systematic reviews • Method used in Cochrane Reviews and AHRQ Reviews
Randomized controlled trials • Very powerful methodology
• Stringent criteria for inclusion in the analysis
Nonrandomized trials
• Quantitative analysis to combine and compare results of
Cohort studies the studies
Case-control studies
Cross-sectional studies
Case reports and case series
Opinion, experience, and theory

Study Designs in Epidemiology Study Designs in Epidemiology

• Prospective
• Experimental studies
- Randomized controlled trails
- Randomized trials
- Quasi-experiments (non-randomized trials)
- Non-randomized trials (quasi-experiments)
- Prospective cohort studies

• Observational studies
• Retrospective
- Cohort studies
- Retrospective cohort studies
- Case-control studies
- Case-control studies
- Cross-sectional studies
• Cross-sectional

Prospective Study Designs Prospective Cohort Studies

• Randomized clinical trials • A group (cohort) of disease-free individuals is identified at
- Randomization to treatment groups one point in time and then followed over a period of time
to determine whether whether the outcome (disease)
- Control of the intervention
occurs

• Non-randomized clinical trials (quasi-experiments)

- No randomization to treatment groups
- Comparison group may be different from the
intervention group
- Control of the intervention

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Retrospective Cohort Studies Case-Control Studies

• Retrospective study that have a historical perspective • Retrospective study design
- Requires access to information about the subjects
• Studies people who already have the disease and looks
before the exposure to disease causing factors and backward at exposures
the onset of disease occurs
- Often able to accomplish this when there are • Two groups of individuals are studied
comprehensive medical records - A group that has the disease under study (cases)
- A group that does not have the disease under study
• Also known as historical cohort studies (controls)

• Their health information is then examined to determine

whether there are risk factors that may be related to their
current disease

Cross-sectional studies
• A population is studied at a single point in time

• Participants are asked about their current disease state

and their exposures to certain factors RISK:
• Also known as prevalence studies
WHAT IS IT?
• Weakest study design

Calculation of Risk Absolute and Attributable Risk

• The probability that an event will occur • Absolute Risk
- The overall incidence of the disease in a specified
• Risk is calculated as a proportion
population
- Calculated the same as the incidence proportion
• Risk is the same as the incidence proportion

• Risk is presented as a probability and can vary from 0 to 1.0 • Attributable Risk
- The amount of disease associated with a causative
Risk = Number of people who get the disease during a designated period factor in a specified population
Population of interest at the start of the designated time period

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Measures of Association Relative Risk (RR)

• Measures of association are used to compare the
occurrence of disease in one group with the occurrence • Relative risk is a measure of association between the
of disease in another group exposure to a particular factor and the risk of a particular
disease or outcome
• Commonly used measures are
- Risk Ratio or Relative Risk (RR) • Can only be calculated from prospective studies
- Odds Ratio (OR)
Relative Risk = Incidence rate among the exposed
Incidence rate among the non-exposed

Odds Ratio Interpretation of the Risk and Odds Ratios

• Is used to estimate the Relative Risk when the RR cannot RR or OR = 1

be calculated - Risk/Odds in the exposed is equal to the risk/odds in
the non-exposed group
• Used in case-control and other retrospective studies
RR of OR > 1
Odds ratio = The odds that a case was exposed - Risk/Odds in the exposed group is greater than the
The odds that a control was exposed risk/odds in the non-exposed group

RR or OR < 1
- Risk or Odds in the exposed group is less than the
risk/odds in the non-exposed group

Risk Ratios: Confidence Intervals Confidence Intervals

• Risk ratios and odds ration are estimates are the actual • If the CI includes 1, there is not a difference between the
population risk and odds ratios exposed and unexposed groups
• Confidence intervals are calculated for risk and odds - RR or OR = 1.5 [CI: 0.8, 2.2]
ratios
• If the confidence interval includes 1, the risk ratio is not • If the CI does not include 1, there is a difference between
statistically significant and that means the exposure did the groups
not significantly increased or decreased the risk of - RR or OR = 1.5 [CI: 1.1, 1.9]
disease
• If there is a difference between the groups, you have to
• If the confidence interval does not include 1, the risk ratio determine whether the difference is increased or
is statistically significant and that means the exposure decreased
significantly increased or decreased the risk of disease

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Confidence Intervals
• The exposure group (RR) or the cases (OR) are always
in the numerator and the comparison (non-exposed or
control) groups are always in the denominator

• If the RR or OR is greater than 1 and the CI does not HEALTH

include 1, that means there is a greater risk in the
exposed group RR or OR = 3.3 [CI: 2.0, 4.6] SCREENING
• If the RR or OR is less than 1 and the CI does not include
1, that means there is a reduced risk in the exposed
group OR = 0.72 [CI: 0.54, 0.92]

Health Screening Screening as Secondary Prevention

• Screening is used to promote detection of diseases in • Health screening activities are used to identify disease
their earliest stages, when treatment has the greatest during the preclinical (subclinical, presymptomatic, latent)
chance of working, in order to reduce morbidity and stage of disease
mortality

Stage of Subclinical Disease

• Not apparent or asymptomatic
• Pathological changes occur and some can be detected
by screening
• Incubation period for infectious diseases CHARACTERISTICS
• Latency for chronic disease
OF
SCREENING TESTS

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Sensitivity Sensitivity
• Probability that a person with the disease will test
People in the Population of Interest
positive for the disease (true positive)

Screening Test Disease Present No Disease

• The ability of the test to correctly identify those with the
disease
A
Positive Test True Positive B

• Probability of correctly identifying the disease C

Negative Test False Negative D

Sensitivity = A / (A+C)

Specificity Specificity
• Probability that a person who does not have the disease People in the Population of Interest
will test negative for the disease (true negative)
Screening Test Disease Present No Disease
• The ability of the test to correctly identify those without
the disease B
Positive Test A False Positive

D
Negative Test C True Positive

Specificity = D / (B+D)

Positive Predictive Value Positive Predictive Value

• Probability that a person who has a positive test actually People in the Population of Interest
has the disease
Screening Test Disease Present No Disease

• Proportion of people with a positive test result who have A B

Positive Test
the disease True Positive False Positive

C D
Negative Test False Negative True Negative

Positive Predictive Value = A / (A+B)

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Negative Predictive Value Negative Predictive Value

• Probability that a person who has a negative test does People in the Population of Interest
not have the disease
Screening Test Disease Present No Disease

• Proportion of people with a negative test result who do A B

not have the disease Positive Test True Positive False Positive

C D
Negative Test False Negative True Negative

Negative Predictive Value = D / (C+D)

INVESTIGATION
OF AN TERMINOLOGY
OUTBREAK

Cases: Definitions Cases: Definitions

• Case • Secondary cases
- An individual who has the disease, disorder, injury, - Cases that became ill after the disease was
health behavior, or health event of interest introduced into the population and become infected
from the primary case
• Primary case
- First case of the disease or condition or behavior • Suspect case
- An individual who has all of the signs and symptoms of
• Index case a disease or condition, yet not diagnosed
- First case brought to the epidemiologists attention
(not necessarily the primary case) • Confirmed
- All criteria are met

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Terminology Epidemic, Outbreak, and Pandemic

Endemic Epidemic
- Amount of disease usually present in a community - An increase in the number of cases above what is
expected in the population in that area
Hyperendemic
Outbreak
- Persistent high levels of disease
- An epidemic but in a limited geographic area
Sporadic
Pandemic
- Occurs infrequently and irregularly
- Epidemic that has spread over several countries or
continents

Spread of Epidemics
• Common source
- Attributed to a specific source
- Point sources
- Intermittent sources
- Continuous sources STEPS IN AN
• Propagated INVESTIGATION
- Transmitted from person to person

• Mixed epidemic
- Starts with a common source
- Then spread by person-to-person contact

Steps in a Field Investigation Establish Criteria for Case Identification

1. Establish the existence of an epidemic (or outbreak)
2. Confirm the diagnosis • Standard clinical criteria (what)
3. Establish criteria for case identification • Loose case definition vs. strict case definition
4. Search for missing cases • A case may be further characterized by
5. Count cases
- Who
6. Orient the data according to person, place, and time
7. Classify the epidemic - Where
8. Determine who is at risk of becoming a case - When
9. Analyze the data
10. Formulate a hypotheses
11. Test hypotheses
12. Develop reports and inform those who need to know
13. Execute control and prevention measures
14. Administration and planning activities

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Case Definitions Case Definitions

Count Cases Examine the Data by Person, Place, and Time

• Person
- Inherent characteristics (age, race/ethnicity, sex)
• Use standard descriptive statistics - Acquired characteristics (immunity or marital status)
• Exposure status and disease frequency need to be - Activities (occupation, leisure, use of medications)
determined and compared with the appropriate at-risk - Conditions (socioeconomic state, access to health care)
• Place
population
- Residence
- Birthplace
- Place of employment
- School district, hospital unit
- Country
- State
- County
- Census tract
- Street address
- Map coordinates
• Time
- Epidemic curve

Classify the Epidemic Analyze the Data

• Use an epidemic curve to classify the epidemic • Descriptive analysis

- Common source - Descriptive statistics
- Propagated • Graphic display
- Mixed - Spot Map
- Epidemic Curve
• Testing for relationships
- Associations
- Correlations

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Implement Control and Prevention Measures

• Immunization programs
• Risk factor prevention
• Behavior change programs

Good Luck!

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