Community Medicine
Dr. Nasih Lec: -1-
27-Sep-06
Basic Epidemiological concepts
Definition of epidemiology
The study of the distribution and determinants of health-related states or events in
specified populations and the application of this study to control of health
problems. (Last)
Keywords in the definition
• Specific populations:
– Epidemiology is about populations not individuals, a population
which is clearly defined.
• Health-related events
– Epidemiology is not only about diseases but all health related
events such as smoking, breast-feeding, road traffic accidents
• Distribution: how disease varies by
– Place
– Person
– Time
• Determinants
– What factors cause the problem or are associated with the problem
• Application
– Findings of the epidemiologic studies are used to help control
health-related problems
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Historical Background
Hippocrates’s “epidemiologic” advice to doctors
Whoever wants to investigate medicine properly should proceed thus: in the
first place to consider the seasons of the year and what effects each of them produces.
Then the winds, the hot and the cold, especially such as are common to all countries,
and then such as are peculiar to each locality. In the same manner, when one comes
to one city to which he is a stranger, he should consider its situation, how it lies as to
the winds and rising of the sun; for its influences is not the same whether it lies to the
north or to the such, to the rising sun or to the setting sun. one should consider most
attentively the waters which the inhabitants use, whether they be marshy and soft or
hard and running from elevated and rocky situations, and then if saltish and unfit for
cooking; and the ground whether it be naked and deficient in water or wooded and
well watered, and whether it lies in a hollow, confined situation or is elevated and
cold; and the mode in which inhabitants live, and what are their pursuits, whether
they are fond of drinking and eating to excess and given to indolence or are fond of
exercise and labor.
Epidemiology = Study of things that happen upon people
• First appearance of the word in English: 1850 (London epidemiological
society)
• Hippocrates(born around 460 BC): called diseases resident in community
endemeion and diseases that come from time to time epidemeion
• Hippocrates described the distribution of diseases by season, age, climate
and personal behavior
• John Graunt published a book on weekly reports of births and deaths of
London (1662)
• William Farr given responsibility for medical statistics for England and
Wales, he set up a system for the routine collection of data on mortality of
England and Wales (1839).
• Farr used this data to compare the mortality rates among different
populations.
John Snow and cholera: he investigated the mortality of 1853 outbreak in
London and found an association between the water source and death
from cholera.
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Exposure and Outcome
The two key elements that we measure in most epidemiological studies
• The exposure
– is the risk factor that we are investigating, which may or may not
be the cause.
• The outcome
– is the disease, or event, or health-related state, that we are
interested in.
Example:
• In a study of the effect of cigarette smoking on lung cancer, cigarette
smoking is the exposure, or risk factor, and the outcome is lung cancer.
• But in a study of the effect of cigarette advertising on smoking, the exposure
of interest is cigarette advertising, and cigarette smoking is the outcome.
Measures of Occurrence
The basis of all epidemiological research is the quantification of the occurrence
of health-related outcomes (cases) in specified populations
• Incidence risk
Incidence risk is the proportion of new cases that occur in a population
during a specified period of time.
Incidence = no. of new cases in time period / population at risk at start of
period
• Incidence Rate
The incidence rate is the number of new cases that occur in a specified time
period in relation to the total person-time at risk.
Incidence rate = number of new cases in a defined time period / total person-time at
risk
• Prevalence
The prevalence is the proportion of persons in a defined population that
has the outcome under study at a specific point in time. So:
Prevalence = Number of existing cases/ study population
Stratum-Specific Measures
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We can also measure the occurrence of an outcome in different subgroups, or
strata, of the population such as sex, age, residence or any characteristic of
interest.
Incidence in stratum= no. of new cases in time period in stratum/ stratum
population at risk at start of period
Prevalence in stratum= Number of existing cases in stratum/ stratum study
population
• The number of cases is the numerator and the total population at risk is the
denominator
• Measures of prevalence and incidence are meaningless unless we define:
– What we mean by a case
– The population at risk of becoming cases
– The time frame, where this is: a specific point in time (for
prevalence) or an interval of time (for incidence)
• Prevalence depends on:
– Incidence: more new casesà more existing cases à higher
prevalence BUT…
– Duration of disease: less duration à less existing cases à lower
prevalence . Duration depends on nature of disease, access to
treatment and death.
Prevalence= incidence * duration
Measures of prevalence and incidence are meaningless unless we
define:
• What we mean by a case à case definition
• The population at risk of becoming cases
• The time frame, where this is: a specific point in time (for prevalence) or
an interval of time (for incidence)
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Sources of error in prevalence and incidence
1) The numerator
– Is the case definition clear and standard? More or less cases may
have been included. Over- or under-estimation
– Have all cases been identified and included? Has data collection
been effective in accounting for all cases? Underestimation.
2) The denominator
– Do we have a reliable estimate of the population at risk?
Underestimation of populationà overestimation of
prevalence/incidence
– Have we included all strata in the data collection? High risk/ low
risk groups?
3) Random error
– Are we calculating from routine data? Many limitations and
sources of error
– Are we calculating from a fresh survey? Have we used proper
sampling technique?
Case definition
A set of standardized criteria used to identify cases.
A good case definition should enable us to clearly identify whether a person or
event would be classified as a case or not
A good case definition must include information on:
• The methods to identify a case: clinical, histological, laboratory
• The boundaries of a case: what is the dividing line between a case and a
non-case? Invasive cancer-preinvasive cancer
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• The unit of analysis: what is the unit of a case? One episode-several
episodes of diarrhea? Breast tumor-tumor in both breasts
Objectives of epidemiology (uses of epidemiology)
1- Assessment of the health situation
Collect basic data about diseases and health-related problems in the
community
2- Study natural history and etiology of disease
Help understand risk factors and natural history of disease
3- Control and prevention
Provide recommendations for control and prevention of health problems
in the population
4- Planning health interventions
Provide data for developing health policy and sound planning
5- Evaluation of health interventions
Assess the impact of health programmes and interventions
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Written By:
Rand Aras Najeeb