EpiMidterm

Incidence:Thenumberofnewcasesthatbecomeilloveracertainperiodoftime.
IncidenceRate:Newcasesoccurringduringagivenperiodoftime/Populationatriskat
thebeginningoftimeperiodx100
Prevalence:Numberofcasesofdisease,infectedpersons,orconditionpresentata
particulartimeinrelationtothesizeofthepopulationfromwhichitisdrawn;Types:
Point(pointintime),Period(certaintimeperiod),Annual,lifetime,andoneyear.
PrevalenceRate:Totalnumberofpeopleinapopulationthathaveaconditionata
specifictime;Numberofcasespresentinthepopulationinaspecifictime/Numberof
peopleinthepopulationatthatspecifiedtimex100
Studydesigns:Descriptive:Ecological,CaseStudy/CaseSeries,CrossSectional.
Analytical:Observational;CaseControl,Cohort,CrossSectional;Experimental:
Experiment,RandomizedClinicalTrial,RandomizedCommunityTrial.
Experiments:Manipulationofoneormoreindependentvariablestomeasureeffecton
dependentvariable
Screeningwhen,what,types:Secondaryprevention,catchingdiseasesinpreclinical
phasesinordertominimizedamage;identifieshighriskgroups.Elementsofagood
screeningtest:Validityandreliability,sensitivityandspecificity,precisionandaccuracy,
reproducibility.Forascreeningtesttobesuccessful:Suitabledisease(earlydetection,
longlatentperiods,serioushealthconsequences,progressive,treatmenteffectiveatan
earlystage,prevalenceofdetectablepreclinicalphasemustbehigh),suitabletest
(inexpensive,easy,leastinvasive,benefitfromearlydetection,valid&reliable,good
predictivevalue,suitablescreeningprogram.
Exposureandoutcomeinrelationtostudydesign:Exposurefirst:Cohort.Disease
(outcome)first:Casecontrol
Parametricvs.nonparametric:Parametricdata:Interval&ratioscales,assumes
distributionisnormalandsamplingwasrandom,largedatasets,statisticallymore
powerful.Nonparametric:Nominal&ordinalmeasurement,assumesrandomnessbut
determinesdistributionaccordingtostudypopulation,goodforsmalldatasets(lessthan
30),notaseasytointerpret.
Endemic,pandemic,epidemic:Endemic:Constantpresenceofdiseaseinageographic
area.Epidemic:Occurrenceofdiseaseinageographicareathatisinexcessofwhatis
normallyexpected.Pandemic:Anepidemicthatcrossesinternationalborders;usually
infersworldwideevent.
Bookquestions
EcologicalFallacy:Inaccurateinferencefrompopulationorcommunityresultstothe
individual.
3typesofprevention:Primary:Actiontopreventadisease(Healthylifestyles,dietary
counseling,vaccinations,useofsunscreen,healtheducation,contraception,
pasteurizationofmilk.Secondary:Detectthediseasebeforeitisapparent,preclinical
(earlydetection,screeningprograms,stooltestingforcolorectalcancer,mammograms,

testingforHIV/AIDS).Tertiary:Preventingadiseasefrombecomingworseinthosewho
aresymptomatic(treatmenttherapies,rehabilitation,developmentofnew
treatments/medicines.)
Assumptions&definitionsofepi:OurDefinition:Thestudyofthedeterminantsand
distributionofdisease.WHODefinitionofHealth:Astateofcompletephysical,
mental,andsocial(andemotional,environmental,behavioral,occupational)wellbeing
andnotmerelytheabsenceofdiseaseorinfirmity.Assumptions:1.Disease,illness,and
illhealthareNOTrandomlydistributed,2.Eachindividualhascharacteristicsand
behaviorsthatpredisposeusto,orprotectusagainst,avarietyofdifferentdiseases,3.
Humandiseasehascausalandpreventivefactorsthatcanbeidentified.
Measuresofcentraltendency&ofdispersion:CentralTendency:Median(middle
number)preferredbecauseitdisregardsoutliers.Mode:Numberthatoccursmostoften.
Mean:Basicaverage,affectedbyoutliers.Dispersion:Range,variance,standard
deviation.
Single,double,andtripleblindstudies:Single:Subjectunawareofgroupassignment.
Double:Subjectandresearcherunawareofassignment.Triple:Subject,researcherand
peopleadministeringthetreatmentallunawareofassignment.
CasefatalityRate:Numberofdeathsfromaspecificcause/Totalnumberofcasesof
thatdiseaseinagiventimeperiodx100
CrudeDeathRate:Numberofdeathsinagivenyear/Population(usuallyatmidyear)
AgeSpecificMortalityRates:Numberofdeathsamongaspecificagegroup/Numberof
peopleinthatspecificagegroup(midyear)x100,000
ProportionalMortalityRate:Numberofdeathsfromaspecificcauseinaspecifictime
period/Alldeathsduringthesametimeperiodx100
CauseSpecificMortalityRate:Numberofdeathsduetoaspecificdisease/Reference
Population(midyear)
AttackRate:akaIncidenceRate;Newcasesoccurringduringagivenperiodof
time/Populationatriskatthebeginningofthetimeperiodx100
SecondaryAttackRate:Newcasesamongcontactsofprimarycasesduringashort
period/(Populationatthebeginningofthetimeperiod)(primarycases)x100.The
proportionofpeopleexposedtoprimarycaseswhobecameilloutofallpeopleexposed
toprimarycases.
Kappastatistic:Consistsoftwoquestions:1.Howmuchbetterareoverlapping
observationsbetweentwoobserversthatwhatwewouldexpectbychangealone?2.
Whatsthemostwecanexpectthestudytoimprovetheirobservationratherthanwhat
wewouldexpectbychancealone?Measures:InterRaterReliabilitybychanceHow
muchofthevariationinresultsisduetodifferenceinobserversorresearchersandnotby
chancealone?
Sensitivity:Abilityofatesttocorrectlyidentifythosewhohavethedisease.100%
sensivitywouldfindalltheill.a/a+c(truepositives/truepositives+falsenegatives)
Specificity:Abilityofatesttocorrectlyidentifythosewhodonothavethedisease.
100%specificitywouldfindallthehealthy.d/b+d(truenegatives/falsepositives+true
negatives)

SequentialvsSimultaneousTesting:Sequential:NetLossinSensitivity,NetGainin
Specificity.Simultaneous:NetGaininSensitivity,NetLossinSpecificity.
PPV:Positivepredictivevalue.Numberoftruepositives/Totalwhotestedpositive(true
andfalsepositives).a/a+b.Moreinfluencedbyspecificitythanbysensitivity.The
higherthespecificity,thehigherthePPV.
PPV&Prevalence:Thehighertheprevalence,thehigherthePPV.
NPV&Prevalence:Thehighertheprevalence,thelowertheNPV.
NPV:Negativepredictivevalue.Numberoftruenegatives/Totalofpeoplewhotested
negative(trueandfalsenegatives).d/c+d.
TypeIandTypeIIerrors:TypeI:FalsePositive.TypeII:FalseNegative.
Alpha,beta,power:Alpha:indicatestheprobabilityofmakingaTypeIerror;setsthe
confidencelevel;setatapleveloflessthanorequalto.05or.01.Beta:Indicatesthe
probabilityofmakingaTypeIIerror;setseffectsize;usuallysetat0.2or0.1.Power:1
Beta;usuallysetat80%or90%;indicatescorrectlyidentifyingadifference,orthe
probabilityofdetectingadifferencebetweengroupswhenadifferencedoesinfactexist.
Samplesizeselection:5factors:1.Thedifferenceinresponseratesthatistobedetected;
2.Anestimateofresponserateinoneofthegroups;3.Levelofstatisticalsignificance
(alpha);4.Valueofpowerdesired(Beta;1Beta);5.Whetherthetestshouldbeonesided
ortwosided.
Directandindirectstandardizationdifferences:Standardization:Themathematical
adjustmentbetweentwopopulationstoensurecomparability.DirectStandardization:
Whenagespecificmortalityratesfor2+populationsAREknown.Indirect
Standardization:Whenallweknowiswhatthemortalityrateforaparticularconditionis
inthegeneralpopulationandwewanttoknowifthemortalityrateforthatconditionina
specificpopulationisthesameasforthegeneralpopulation.Agespecificmortalityrates
forpopulationofinterestareNOTknown.UseaStandardizedMortalityRatio(SMR):
Observed(actual)Deaths/ExpectedDeathsx100.SMR=1:Noeffect.SMR<1:
ProtectiveEffect.SMR>1:IndicativeofRisk.
Calculatevaluesinlifetable
Active&passiveSurveillance:Active:Actuallygoingoutandgettingdata;more
expensivebutmoreeffective.Passive:Regular,systematicprocessofreporting
conditions(e.g.regularphysiciancasereporting);generally,lessexpensivebutmaymiss
events.Syndromic:Monitoringofsyndromessuchasinfluenza;e.g.Ebola.
Primaryandsecondarydata:
HistoricalBros:Hippocrates:Fatherofmedicine.Graunt:BillsofMortality,
precursorofmodernvitalrecords;deathrecordsbygender,timeofyear,location,etc.
Lind:Scurvy.Goodepidemiologicaldesign.Jenner:Vaccination,smallpox,Fatherof
Immunization.Farr:Createdmodernvitalrecordsbycompilingannualbirths,marriages,
anddeathrecordsandconductingextensivetestingandassociationswiththefindings.
Vector/Hostdeterminant:Agent:Causeofadisease.Host:Harborsdisease/pathogen,
notnecessarilysick.Environment:Conditionsthatallowfordiseasetransmission.
Vector:Interactionbetweenhost,agent,andenvironment(akatheTriangleof
Epidemiology).

Validity&Reliability:Validity:Abilityofatesttodistinguishwhohasa
condition/diseaseandwhodoesnotDoesthetestaccuratelymeasurewhatitis
supposedto?Reliability:Abilityofatesttogiveconsistentresultseverytime
(consistency)Doesitprovidethesameresulteverytime?(repeatability)
Probability5yearsurvival,allyearsorjustoneyear?Pfiveyears=P1xP2xP3xP4x
P5;probabilityforallfiveyearsisPfiveyears,whileprobabilityforyearfiveisP5.
Necessary&SufficientCauses:Necessaryneededtoproducedisease.Sufficientis
itenoughalonetoproducedisease,ormustitbeinconjunctionwithanotherfactor?
NNT,NNH,ARR:NNT:NumberthatNeedtobeTreated:1/ARR.Rateofexperimental
outcomeinthetreatedandnontreatedgroupsHowmanypeoplewouldneedtobe
treatedtopreventundesiredoutcome?NNH:NumberNeededtoHarm:1/ARR.Rateof
sideeffectMeasureofriskofharmingonepersom;Howmanypeoplewouldneedto
betreatedtoincuronesideeffect?ARR:AbsoluteRiskReduction:|(Rateinuntreated
group)(RateintreatedGroup)|.RateinuntreatedgroupalsocalledCER(ControlEvent
Rate);RateintreatedgroupalsocalledEER(ExperimentalEventRate).
Efficacy&Effectiveness:Efficacy:Reductionofrisk;expressedastherateofdiseasein
thetreatmentgroupascomparedtotherateofdiseaseinthecontrolgroup:(Placeborate)
(Treatmentrate)/(Placeborate).Efficacymeasureshowwelltheinterventionworks
underidealconditions(invitro).Effectiveness:Howwelltheinterventiondoesinreal
life(invivo).