advanced course in field epidemiology health protection surveillance centre ireland
DESCRIPTION
Advanced course in field epidemiology Health Protection Surveillance Centre Ireland. Objectives To strengthen understanding of various epidemiological studies available in field epidemiology. James Stuart & Alain Moren, June 2006. Presentations on methods. Study design Reference group - PowerPoint PPT PresentationTRANSCRIPT
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Advanced course in field epidemiology
Health Protection Surveillance Centre Ireland
Objectives
To strengthen understanding
of various epidemiological studies available in field epidemiology
James Stuart & Alain Moren, June 2006
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Presentations on methods
Study design Reference group Counfounding and effect modification Matching Mesures or impact Alternative designs Introduction to multivariable analysis How to interpret data How to make an oral scientifi presentation
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Case studies Smoking and lung cancer Trichinosis Toxic shock syndrom Tiramisu
Presentations from participants
One each day
Evening session?
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Epidemiological studies
Two types Observation Experiment
James Stuart & Alain Moren, June 2006
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Experiment
Exposed
Not exposed
Disease occurrence
Unethical to perform experiments on people if exposure is harmful
Exposure assigned
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RandomisedControlledTrial
BlindedDosesTime periodRisk - effectNo bias
If exposure not harmful
TreatmentPreventive measure (vaccination)
If not possibleLeft with observation of experiments designed by Nature
Cohort studiesCase control studies
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Cohort studies marching towards outcomes
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What is a cohort?
One of 10 divisions of a Roman legion Group of individuals
- sharing same experience - followed up for specified period of time
Examples- birth cohort- cohort of guests at barbecue- occupational cohort of chemical plant workers- EPIET cohort 10
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follow-up period
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Calculate measure of frequency:
Cumulative incidence- Incidence proportion- Attack rate (outbreak)
Incidence density
end of follow-up
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Cohort studies
Purpose- Study if an exposure is associated with outcome(s)?- Estimate risk of outcome in
exposed and unexposed cohort- Compare risk of outcome in two cohorts
Cohort membership- Being at risk of outcome(s) studied- Being alive and free of outcome
at start of follow-up
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unexposed
exposed
Cohort studies
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unexposed
exposed
Incidence amongexposed
Incidence amongunexposed
Cohort studies
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ate ham
did not ham
ill not ill
49 49 98
4 6 10
Presentation of cohort data: 2x2 table
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Population Cases (f/u 2 years)
HIV + 215 8HIV - 289 1
Presentation of cohort data: Population at risk
Does HIV infection increase risk of developing TB among a population of drug users?
Source: Selwyn et al., New York, 1989
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Person-years Cases
Smoke 102,600 133
Do not smoke 42,800 3
Presentation of cohort data: Person-years at risk
Tobacco smoking and lung cancer, England & Wales, 1951
Source: Doll & Hill
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Presentation of data: Various exposure levels
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time
Exposure Study startsDisease
occurrence
Prospective cohort study
time
ExposureStudy startsDisease
occurrence
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Retrospective cohort studies
Exposure
time
Diseaseoccurrence Study starts
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Recipe: Cohort study
Identify group of - exposed subjects- unexposed subjects
Follow up for disease occurrence Measure incidence of disease Compare incidence between exposed and
unexposed group
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Our objective is to compare:
an incidence rate in an exposed population
to the rate that would have been observed
in the same population, at the same time
if it had not been exposed
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Principle of case control studies
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Exposed
Unexposed
Source population
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CasesExposed
Unexposed
Source population
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CasesExposed
Unexposed
Source population
Sample
Controls
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CasesExposed
Unexposed
Source population
Controls =Sample of the denominatorRepresentative with regard to exposure
Controls
Sample
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Intuitively
if the frequency of exposure is higher among cases than controls
then the incidence rate will probably be higher among exposed than non exposed.
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Case control study
DiseaseControls
Exposure
??
Retrospective nature
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Cases Controls
Exposed a b
Not exposed c d
Total a + c b + d
% exposed a/(a+c) b/(b+d)
Distribution of cases and controls according to exposure in a case control study
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Oral Myocardialcontraceptives Infarction Controls
Yes 693 320
No 307 680
Total 1000 1000
% exposed 69.3% 32 %
Distribution of myocardial infarction cases and controls by oral contraceptive use
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Physical Myocardialactivity Infarction Controls
>= 2500 Kcal 190 230
< 2500 Kcal 176 136
Total 366 366
% exposed 51.9% 62.8 %
Distribution of myocardial infarction cases and controls by amount of physical activity
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Water Cases ControlsConsumption
YES 150 ?
NO 50 ?
Total 200 200
Volvo factory, Sweden, 3000 employees, Cohort study200 cases of gastroenteritis
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Two types of case control studies
ExploratoryNew diseaseNew risk factorsSeveral exposures"Fishing expedition"
AnalyticalPrecise a single hypothesisDose response
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unexposed
exposed
Incidence amongexposed
Incidence amongunexposed
Cohort studies
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Absolute measures
- Risk difference (RD) Ie - Iue
Relative measures- Relative risk (RR)
Rate ratio Risk ratio
Effect measures in cohort studies
Ie
Iue
Ie = incidence in exposedIue= incidence in unexposed
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ate ham
did not eat ham
ill not ill Incidence
49 49 98 50 %
4 6 10 40 %
Risk difference 50% - 40% = 10%
Relative risk 50% / 40% = 1.25
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Exposure Population (f/u 2 years)
Cases Incidence
(%) Relative
Risk
HIV +
215
8
3.7
11
HIV - 298 1 0.3
Does HIV infection increase risk of developing TB among drug users?
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Vaccine efficacy (VE)
Status Pop. Cases Cases per
1,000 RR
Vaccinated 301,545 150 0.49 0.28
Unvaccinated 298,655 515 1.72 Ref.
Total 600,200 665 1.11
VE = 1 - RR = 1 - 0.28
= 72%
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Population Cases Incidence
a1High N1 I1
cUnexposed NneIue
at riskExposurelevel
a2Medium N2 I2
a3Low N3 I3
Various exposure levels
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Population Cases Incidence RR
a1High N1 I1
cUnexposed NneIue
at riskExposurelevel
a2Medium N2 I2
a3Low N3 I3
RR1
RR2
RR3
Reference
Various exposure levels
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Cohort study: Tobacco smoking and lung cancer, England & Wales, 1951
Source: Doll & Hill
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A cohort study allows to calculate indicators which have a clear, precise meaning.
The results are immediately understandable.
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Cohort studies
Rate Rate difference Rate Ratio (strength of association)
No calculation of rates Proportion of exposure
Case control studies
Any way of estimating Rate ratio ?
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I1 = a / P1
I0 = c /P0
E
E
a
c
P1
P0
PopulationdenominatorCases
E
E
a
c
P1 /10
P0 /10
PopulationsampleCases
a/P1
I1/ I0 = ------
c/P0
}
aI1 = --------
P1/10
cI0 = --------
P0/10
} a/P1
I1/ I0 = ------
c/P0
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I1 = a / P1
I0 = c /P0
Cases Controls
E
E
a b
c d
E
E
a
c
P1
P0
Source population
Pop.Cases
P1 b--- = ----P0 d
= sample
a/P1
I1/ I0 = ------
c/P0
}
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I1 = a / P1
I0 = c /P0
Cases
= sample
E
E
a b
c d
Since d/b = P0 / P1
E
E
a
c
P1
P0
Source population
Pop.Cases
a/P1 a . P0 a . d I1 / I0 = ------ = ------- = ----- = c/P0 c . P1 c . b
}Controls
P1 b
--- = ----
P0 d
a / c------b / d
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Case control study design
Cases Controls
E
E
a b
c d
a b a x d---- --- = --- ---- c d b x c
Odds ratio
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Exp
Unexp.
Radiation Total Cases Rate RR
Breast cancer
28010 41 14.6 1.9
19017 15 7.9 Ref.
Source: Rothman
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Exp
Unexp.
Radiation Total Cases Rate RR Controls OR
Breast cancer
28010 41 14.6 1.9 280 1.9
19017 15 7.9 Ref. 190Ref.
Source: Rothman
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Oral Myocardialcontraceptives Infarction Controls OR
Yes 693 320 4.8
No 307 680 Ref.
Total 1000 1000
% exposed 69.3% 32 %
Distribution of myocardial infarction in cases and controls by recent oral contraceptive use
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Physical Myocardialactivity Infarction Controls OR
>= 2500 Kca l 190 230 0.64
< 2500 Kcal 176 136 Ref.
Total 366 366
% exposed 51.9% 62.8 %
Distribution of myocardial infarction in cases and controls by amount of physical activity
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Distribution of cases of endometrial cancer by estrogen use
Estrogen use Cases Controls Odds ratio
High a1 b1 a1d/b1c
Low a2 b2 a2d/b2c
None c d Reference
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Relation of Hepatocellular Adenoma to duration of oral contraceptive use in 79 cases and 220 controls
Months ofOC use Cases Controls Odds ratio
0-12 7 121 Ref.13-36 11 49 3.937-60 20 23 15.061-84 21 20 18.1>= 85 20 7 49.7Total 79 220
Source: Rooks et al. 1979
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Limitations of case-control studies
Cannot compute directly relative risk Not suitable for rare exposure Temporal relationship exposure-disease
difficult to establish Biases +++
- control selection- recall biases when collecting data
Loss of precision due to sampling
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Disadvantages of cohort studies
Large sample size Latency period Lost to follow Exposure can change Multiple exposure = difficult Ethical considerations Cost Time consuming
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Advantages of case control studies
Rare diseases Several exposures Long latency Rapidity Low cost Small sample size Available data No ethical problem
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Strengths of cohort studies
Can directly measure - incidence in exposed and unexposed groups- true relative risk
Well suited for rare exposure Temporal relationship exposure-disease is clear Less subject to selection biases
- outcome not known (prospective)
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Can examine multiple effects for a single exposure
population outcome 1 outcome 2 outcome 3
exposed Ne Ie1 Ie2 Ie3
unexposed Nne Iue1 Iue2 Iue3
RR1 RR2 RR3
Strengths of cohort studies
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The cohort study
is the gold-standard
of analytical
epidemiology
CASE-CONTROL STUDIES HAVE THEIR PLACE IN EPIDEMIOLOGY but if cohort study possible,
do not settle for second best
Alain Moren