Introduction to Epidemiology and the Epidemiology Modules

1. Introduction to Epidemiology and the Epidemiology Modules Tasha E. Fingerlin Colorado School of Public Health University of Colorado Denver July 17, 2008

2. Today What is Epidemiology? Measures that are important in all of epidemiology Why I never believe anything I read in the newspaper The three modules and how they fit into the big picture

3. What is Epidemiology? Greek (English) epi (among) demos (people) logy (study)

4. What is Epidemiology? The study of the distribution and determinants of health and disease related states in populations, and the application of this study to control health problems. (John M. Last)

5. What is Epidemiology? The study of the distribution and determinants of health and disease related states in populations, and the application of this study to control health problems. “the product of [epidemiology] is research and information and not public health action and implementation”. (Atwood et al. 1997) “epidemiology’s full value is achieved only when its contributions are placed in the context of public health action, resulting in a healthier populace.” (Koplan et al. 1999)

6. “Epidemiology . . . is a Greek word that means to put people to sleep with charts and graphs.” - Dr. Mark Johnson In testimony before the House Judiciary Committee on the spread of HIV

7. “Epidemiologists . . . Are like bookies of disease, stalking the globe to determine point-spreads on which groups of people are most likely to get which diseases. Part detective and part statistician, part anthropologist and part physician, epidemiologists hope to track down the agents of illness by deducing which of the differences between peoples lie at the root of their distinctive disease patterns.” (H. Shodell, Science ’82, September, p. 50)

8. Functions of Epidemiology (Schoenback and Rosamond)

9. What are the health problems of the community? What are the attributes of these illnesses? Etiology, prognosis and program evaluation ANALYTIC Why? How? Epidemiologic approaches DESCRIPTIVE Health and disease in the community What? Who? When? Where? How many people are affected? What are the attributes of affected persons? Over what period of time? Where do the affected people live, work or spend leisure time? What are the causal agents? What factors affect outcome? By what mechanism do they operate?

10. Forms of Epidemiology • Clinical Epidemiology • Descriptive Epidemiology • Predictive Epidemiology • Etiologic Epidemiology • Genetic Epidemiology • Occupational Epidemiology • Social Epidemiology • Spatial Epidemiology • Surveillance • etc…

11. Academia The Colorado School of Public Health As of July 1st!

12. Government Agencies • Local health departments • State health departments • Office of the Surgeon General of the United States • FDA • Centers for Disease Control (CDC) • World Health Organization (WHO) Julie Gerberding, MPH, MD

13. Industry • Occupational epidemiologists – monitor and investigate effects of worker exposures • Pharmaceutical companies – mostly clinical trials of drugs, but also follow-up epidemiologic studies • Contract research organizations (CRO)– design and implement epidemiologic studies for government or other industries

14. A Brief History of “Modern” Epidemiology John Snow (1813-1858) Public Health intervention Late 1800s -> 1950s The “hey day” of infectious disease epidemiology and prevention John Ryle (1899-1950) The Institute of Social Medicine Doll & Hill (1954) Smoking and Lung Cancer Archie Cochrane (1909-1988) Evidence-based medicine Mary-Claire King (1946- ) BRCA1 gene and Breast Cancer

15. What is Epidemiology? The study of the distribution and determinants of health and disease related states in populations, and the application of this study to control health problems. (John M. Last)

16. What are “disease” and “health”? Dorland's Illustrated Medical Dictionary (28th ed.): Disease – "any deviation from or interruption of the normal structure or function of any part, organ, or system (or combination thereof) of the body that is manifested by a characteristic set of symptoms and signs . . .". Health – "a state of optimal physical, mental, and social well-being, and not merely the absence of disease and infirmity."

17. What is “disease” Manifestional criteria: Manifestational criteria refer to symptoms, signs, and other manifestations of the condition. Defining a disease in terms of manifestational criteria relies on the proposition that diseases have a characteristic set of manifestations. This defines disease in terms of labeling symptoms. Causal criteria: Causal criteria refer to the etiology of the condition, which, must have been identified in order to be employed. This defines disease in terms of underlying pathological etiology.

18. Manifestational Criteria The Acquired Immunodeficiency Syndrome (AIDS) was initially defined by the CDC in terms of manifestational criteria as a basis for instituting surveillance. The operational definition grouped diverse manifestations – Kaposi's sarcoma outside its usual subpopulation, PCP and other opportunistic infections in people with no known basis for immunodeficiency. This was based on similar epidemiologic observations (similar population affected, similar geographical distribution) and a shared type immunity deficit (elevated ratio of T-suppressor to T-helper lymphocytes).

19. Causal Criteria Human immunodeficiency virus (HIV, previously called human lymphotrophic virus type III) was discovered and demonstrated to be the causal agent for AIDS. AIDS could then be defined by causal criteria.

20. Challenges with Disease Classifications • A single causal agent may have multiple clinical effects. • 2. Multiple etiologic pathways may lead to apparently identical manifestations, so that a manifestationally-defined disease entity may include subgroups with differing etiologies. • 3. Multi-causation necessitates a degree of arbitrariness in assigning a causative versus a contributing factor to a disease. • 4. Not all persons with the causal agent develop the disease.

21. The Natural History of Disease cause specific mortality onset of disease diagnosis of disease Physiologic Abnormalities Underlying Genetic Susceptibility Clinical disease Sub-clinical disease X Environmental & Behavioral Factors

22. Measures of Disease Occurrence • To study disease, need measures of its occurrence • Some measures of disease occurrence • Counts • Prevalence • Incidence • Mortality

23. What are the health problems of the community? What are the attributes of these illnesses? Epidemiologic approaches DESCRIPTIVE Health and disease in the community What? Who? When? Where? How many people are affected? What are the attributes of affected persons? Over what period of time? Where do the affected people live, work or spend leisure time? Each of the measures can be calculated for different combinations of “What? Who? When? and Where?” Each of the W’s needs to be defined carefully to get comparable measures across state, nation, world

24. Prevalence • The prevalence of a disease is the proportion of individuals in a population with disease (cases): • Prevalence is a proportion – range of 0 to 1 • Removes the effect of total population size – makes estimates from different populations or over time more comparable.

25. Prevalence • Often expressed as a percent (%) – Prevalence *100 • Also often expressed as the prevalence per 1,000 or 10,000 or 100,000. • Prevalence * 1,000 = prevalence per 1,000.

26. Obesity Trends* Among U.S. AdultsBRFSS, 1991-2006 1991 1995 2002 2006 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

27. Prevalence – Salmonella Cases infected with the outbreak strain of Salmonella Saintpaul, as of July 15, 2008 9pm EDT

28. Incidence • Incidence is a measure of risk of developing disease • Often multiplied by 100,000 (or 1000 or 100) and reported as “Incidence per 100,000” If population size is 3.81 million, then

29. Incidence – Salmonella Incidence of cases of infection with the outbreak strain as of July 15, 2008 9pm EDT

30. Prevalence and Incidence – Salmonella Cases infected with the outbreak strain of Salmonella Saintpaul, as of July 15, 2008 9pm EDT

31. Incidence and Prevalence • Incidence and prevalence measure different aspects of disease occurrence PrevalenceIncidence Numerator: Denominator Measures: Most useful: All cases, no matter how long diseased Only NEW cases All persons in population Only persons at risk of disease Presence of disease Risk of disease Risk, etiology Resource allocation

32. Mortality Rate – Incidence of death • Numerator • Number of deaths • Denominator • Number of individuals in population • Time interval • 1-year: Annual Mortality Rate • Typical to use annual rate • Specifier • age, sex, race, etc.

33. Mortality rates

34. Case Fatality “Rate” • Cumulative incidence of death among those who develop an illness • Technically not a rate, but a proportion • Time period should be stated • Example • 15/300 persons died in 30 days after surgery • CFR = 0.05 x 1,000 = 50 per 1,000 • Risk of dying within 30 days of surgery is 50 per 1,000 surgeries, or 5%

35. Importance of defining numerator and denominator • For each of the measures, carefully defining both the numerator and denominator crucial for interpretation • In order for measures to be comparable across studies, need consistent definition and reporting strategies for numerator • Also need consistent approaches for counting (or estimating) the persons or person-time for the denominator

36. Prevalence Numerator – case definition From Gordis Text

37. Prevalence Numerator – case definition AIDS cases, United States 1984-2000 Result of new definition 1st Quarter of 1993: Expansion of surveillance case definition Gordis: Fig 4-17

38. Incidence Denominator – Who is at risk?

39. Importance of looking at multiple measures

40. The “demi” in Epidemiology Understanding population dynamics is crucial to epidemiology. Demography = the study of population dynamics including fertility, mortality and migration denominator…denominator…denominator…denominator…denominator…denominator…

41. Comparing rates between two different populations What is your guess regarding the incidence of HIV/AIDS in Kenya compared to Denmark?

42. Comparing rates between two different populations Crude Incidence of HIV/AIDS, 2005 Rate / 1,000 Kenya data from UNAIDS/WHO, Denmark data from UNICEF

43. Comparing rates between two different populations HIV/AIDS by Age % of cases Age (years) (from CDC, U.S. 2001-04)

44. Potential problems in interpretation of rates over time • Numerator • diagnostic abilities • diagnostic criteria • reporting completeness • payment schemes (affecting items above) • others . . . • Denominator • census methods for classification • age misclassification • removal of persons at risk • cohort effects (changes in exposure/prognosis or other confounding variables over time) • others . . .

45. Age / Period / Cohort Effects

46. Age / Period / Cohort Effects

47. The Three Epidemiology Modules • Imperfect testing • Pass it on • Computer modeling of disease outbreaks

48. Imperfect Testing Scientific questions that require or are made easier to answer by binary tests • Diagnosis of disease in a clinical setting • Screening individuals to identify those who might need further testing to determine disease status • Surveillance for - Cancer and other diseases - Infectious disease outbreaks - Bioterror agents • Identifying sequence characteristics across the genome

49. Imperfect Testing • Focus on medical testing, but applicable to all sorts of testing scenarios • Follows story of a woman who gets a positive mammogram and wants to know the implications – does she have breast cancer? • She goes on to get tested for some of the known breast cancer genes – and learns what that means for her daughter • Emphasis on understanding the implications of the results from imperfect tests – and the personal decisions that are often necessary. • Uses simple and conditional probabilities and concepts of relative risk (ratio of risk for those with and without genetic risk factor)

50. Pass it On/Modeling of Outbreak Some questions we might want to ask about infectious disease spread and epidemics • How many individuals (or what proportion) will become infected? • Will a given disease become epidemic? How far will it spread? • How long will the disease or pathogen persist in the population? • Would vaccination prevent an epidemic? If so, what type of vaccination program is most efficient? • What other measures could be taken to prevent an epidemic?