Centers for Disease Control and Prevention Global Health Odyssey Museum Tom Harkin Global Communications Center June 6-10, 2011

1
Day 2
Teach Epidemiology
Professional Development Workshop
Centers for Disease Control and PreventionGlobal
Health Odyssey MuseumTom Harkin Global
Communications Center
June 6-10, 2011
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Teach Epidemiology
Teach Epidemiology
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Time Check 815 AM
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Teach Epidemiology
Teach Epidemiology
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Time Check 845 AM
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Teach Epidemiology
Teach Epidemiology
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Teachers Team-Teaching Teachers (TTTT)
Existing Lesson   Team leads other workshop
participants
in
a portion of a selected existing epidemiological
lesson.
Teach Epidemiology
11
Epi Grades 6-12
Metacognition
They can then use that ability to think about
their own thinking to grasp
how other people might learn.
They know what
has to come first,
and they can
distinguish between foundational concepts
and elaborations or
illustrations of those ideas. They realize
where people are likely to face
difficulties developing
their own comprehension,
and
they can use that understanding
to
simplify and clarify complex topics for others,
tell the right story, or raise a powerfully
provocative question. Ken Bain, What the Best
College Teachers Do
Teach Epidemiology
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Enduring Epidemiological Understandings
Teach Epidemiology
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Time Check 930 AM
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Teach Epidemiology
Teach Epidemiology
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Teachers Team-Teaching Teachers (TTT)
Teach Existing Epidemiological Lessons (EL) (4
Groups)   Team leads other workshop participants

in a portion of a
selected existing epidemiological lesson.
Teach Epidemiology
17
Epi Grades 6-12
Metacognition
They can then use that ability to think about
their own thinking to grasp
how other people might learn.
They know what
has to come first,
and they can
distinguish between foundational concepts
and elaborations or
illustrations of those ideas. They realize
where people are likely to face
difficulties developing
their own comprehension,
and
they can use that understanding
to
simplify and clarify complex topics for others,
tell the right story, or raise a powerfully
provocative question. Ken Bain, What the Best
College Teachers Do
Teach Epidemiology
18
Enduring Epidemiological Understandings
Teach Epidemiology
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Time Check 1015 AM
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Teach Epidemiology
Teach Epidemiology
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Time Check 1100 AM
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Teach Epidemiology
Teach Epidemiology
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Teachers Team-Teaching Teachers (TTT)
Teach Existing Epidemiological Lessons (EL) (4
Groups)   Team leads other workshop participants

in a portion of a
selected existing epidemiological lesson.
TTTT 3 EL
Teach Epidemiology
26
Epi Grades 6-12
Metacognition
They can then use that ability to think about
their own thinking to grasp
how other people might learn.
They know what
has to come first,
and they can
distinguish between foundational concepts
and elaborations or
illustrations of those ideas. They realize
where people are likely to face
difficulties developing
their own comprehension,
and
they can use that understanding
to
simplify and clarify complex topics for others,
tell the right story, or raise a powerfully
provocative question. Ken Bain, What the Best
College Teachers Do
Teach Epidemiology
27
Enduring Epidemiological Understandings
Teach Epidemiology
28
Time Check 1015 AM
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(No Transcript)
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Teach Epidemiology
Teach Epidemiology
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Time Check 1030 AM
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Teach Epidemiology
Teach Epidemiology
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Teachers Team-Teaching Teachers (TTT)
View a News Item from an Epidemiological
Perspective   Team leads other workshop
participants

in the analysis of a news item from an
epidemiological perspective.
Teach Epidemiology
35
Epi Grades 6-12
Metacognition
They can then use that ability to think about
their own thinking to grasp
how other people might learn.
They know what
has to come first,
and they can
distinguish between foundational concepts
and elaborations or
illustrations of those ideas. They realize
where people are likely to face
difficulties developing
their own comprehension,
and
they can use that understanding
to
simplify and clarify complex topics for others,
tell the right story, or raise a powerfully
provocative question. Ken Bain, What the Best
College Teachers Do
Teach Epidemiology
36
Enduring Epidemiological Understandings
Teach Epidemiology
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Time Check 1130 AM
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(No Transcript)
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Teach Epidemiology
Teach Epidemiology
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Time Check 1230 PM
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Teach Epidemiology
Teach Epidemiology
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http//prezi.com/ghtd8j_zll-w/now-for-something-a-
little-different/
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Epi Grades 6-12
Metacognition
They can then use that ability to think about
their own thinking to grasp
how other people might learn.
They know what
has to come first,
and they can
distinguish between foundational concepts
and elaborations or
illustrations of those ideas. They realize
where people are likely to face
difficulties developing
their own comprehension,
and
they can use that understanding
to
simplify and clarify complex topics for others,
tell the right story, or raise a powerfully
provocative question. Ken Bain, What the Best
College Teachers Do
Teach Epidemiology
45
Enduring Epidemiological Understandings
Teach Epidemiology
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Enduring Epidemiological Understandings
Teach Epidemiology
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Time Check 115 PM
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Teach Epidemiology
Teach Epidemiology
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Teach Epidemiology
EPI-501
Marian R Passannante, PhD Associate
Professor University of Medicine and Dentistry of
New Jersey New Jersey Medical School School of
Public Health
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Epidemiology
Enduring Epidemiological Understandings

• Descriptive
• concentrates on examining the distribution of
  diseases in the population in terms of person,
  (who gets the disease), place (where they get the
  disease) and time (when they get the disease)
• Generates hypotheses

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Descriptive Epidemiology
Enduring Epidemiological Understandings

• Person

Source Reported Tuberculosis in the United
States, 2009 http//www.cdc.gov/tb/statistics/surv
/surv2009/slides/surv9.htm
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Descriptive Epidemiology
Enduring Epidemiological Understandings

• Place
• Reference
• Hootman JM, Pan L, Helmick CG, Hannan C.
  State-specific trends in obesity prevalence among
  adults with arthritis, Behavioral Risk Factor
  Surveillance System, 20032009.MMWR
  201160(16)509-513.

                                                
                                             
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Descriptive Epidemiology
Enduring Epidemiological Understandings

• Time

 source http//www.cdc.gov/chronicdisease/resourc
es/publications/aag/osh.htm                       
                                                  
                                                  
               
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Epidemiology
Enduring Epidemiological Understandings

• Descriptive
• Analytic

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• What is the relationship between physical
  activity and health status among high school
  students?
• Define outcome and how it will be measured.
• Define the exposure and how it will be measured.

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• What is the relationship between physical
  activity and health status among high school
  students?
• Define outcome and how it will be measured.
• Health status absenteeism
• Define the exposure and how it will be measured.
• Physical Activity participation in varsity
  sports

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ecological Studies
• Information is collected on groups, not
  individuals
• Often called correlation studies
• Easy to perform- data often already available

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ecological Study
• High school
• Absenteeism Rate
• Number of lost school days due to
• absence /(Number of students) x
• (Number of schooldays) x 100
• of high school
• students on varsity sports teams

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ecological Studies
• Advantages
• Information is collected on groups, not
  individuals
• Easy to perform- data often already available
• Disadvantages
• Doesnt control for other factors (confounders)
• Individual associations may not be the same as
  group associations

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Epidemiology
Enduring Epidemiological Understandings

• Analytic
• concerned with studying the relationship between
  an exposure and an outcome
• test hypotheses
• Includes a comparison group

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Outcomes
• Health or Disease outcomes
• Dependent variable
• Y variable
• Exposures
• Risk or Protective Factor
• Independent or Predictor variable
• X variable

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Analytic Epidemiology

• Outcome

Exposure -
A B
- C D
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Epidemiology
Enduring Epidemiological Understandings

• Analytic
• Observational
• Cross-Sectional
• Case-Control
• Cohort
• Experimental
• Behavioral Trials
• Clinical Trials

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Cross-Sectional Studies
• Data on possible risk factors and disease
  outcomes are collected at the same time.
• These studies are sometimes called prevalence
  studies since the information collected can be
  used to provide prevalence (the proportion in a
  population with a particular outcome).

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you measure the exposure and outcome?
• Physical Activity Health Status

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you measure the exposure and outcome?
• Physical Activity Health Status
• 1. Participation in organized sports 1. Days
  Absent
• 2. Amount of daily/weekly exercise 2. Body Mass
  Index
• 3. Amount of vigorous exercise 3. Blood Pressure

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cross sectional study of
• Physical Activity Health Status
• among high school students? Health
  Status (BMI)

Physical Activity Obese - Non-Obese
High A B
- Low C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cross sectional study of
• Physical Activity Health Status
• among high school students? Obesity
• Conduct a Survey asking
• questions about current
• Physical activity, height and
• Body weight.

Physical Activity -
A B
- C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cross sectional study of
• Physical Activity Health Status
• among high school students?
  
• Obesity
• Conduct a Survey
• Calculate Prevalence of Health Outcome
• In both Physical Activity Groups
• A/AB and C/CD
• Calculate a Prevalence Ratio to compare groups
• (A/AB)/(C/CD)

Physical Activity -
A B
- C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cross sectional study of
• Physical Activity Health Status
• among high school students?
  
• Advantages
• Good for generating prevalence Obese
• Can be done over a short period of time
• Disadvantages
• Survey data difficult to verify
• Can not provide information on causal
  associations
• Unclear whether exposure or disease came first
• (e.g. Are students obese because they are less
  physically
• active or are they less physically active
  because they are
• obese?)

Physical Activity -
A B
- C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a case-control study of
• Physical Activity Health Status
• among high school students?
• Obesity
• 1) Identify cases and controls
• 2) Interview cases and control to ask
• about physical activity during the past
• 4 years
• 3) Fill in the 2 x 2 table and calculate
• The Odds Ratio

Physical Activity case - control
A B
- C D
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What is an odds ratio?

• A measure of association used to quantify the
  relationship between an exposure and an outcome.
  It is also called the cross-products ratio.
• Outcome obesity
• Exposure physical activity
• The ratio of the odds that cases (obese) were
  exposed to a particular risk factor (physical
  activity) as compared with the odds that the
  controls (non-obese) were exposed to that same
  risk factor (physical activity).
• In a case-control study the odds ratio
• Odds that a case was exposed / Odds that a
  control was exposed

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What is an odds ratio?

• Can be calculated using a simple 2-by-2
  contingency table.
• Odds of that a case was exposed a/c
• Odds of that a control was exposed b/d
• Ratio of the odds or Odds Ratio (a/c)/(b/d)
• ad/bc (cross-products ratio)

• Outcome
• Exposure Case Control
• yes a b
• no c d

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a case-control study of
• Physical Activity Health Status
• among high school students?
• Identify those with high and low health status
• ( of cases and controls may or may not be the
  same)
• Ask them questions about prior physical activity
  level
• Calculate a measure of risk Odds Ratio
• A x D 12 x 178 2136 .507
• B x C 183 x 23 4209
• Odds that obese students were physically active
  were about 50 lower than the odds that
  non-obese students were physically activity.

Physical Activity Case Obese Controls Non-obese
A 12 B 23
- C 183 D 178
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Interpretation of the Odds Ratio source
modified from Jekel et al. Epidemiology,
Biostatistics and Preventive Medicine, pg 93.

• - 4.0 (4/1)
• - 2.0 (2/1)
• ----------------1.0 (1/1) equal odds in two
  groups
• - 0.5 (1/2)
• - 0.25 (1/4)

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Interpretation of the Odds Ratio source
modified from Jekel et al. Epidemiology,
Biostatistics and Preventive Medicine, pg 93.

• - 4.0 (4/1) Odds that cases were exposed are 4
  times higher than
• the odds that controls were
  exposed
• - 2.0 (2/1) (the exposure is positively
  related to the disease)
• ----------------1.0 (1/1) equal odds in two
  groups
• (the exposure is not related to the disease
  )
• - 0.5 (1/2)
• - 0.25 (1/4) Odds that cases were exposed
  are
• 25 as high or 75
  lower
• l than the odds that controls were exposed
• (the exposure is negatively
  related to the disease)

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a case-control study of
• Physical Activity Health Status
• among high school students?
• Obesity
• Advantages
• Good for studying rare outcomes
• Do not need very large sample
• Disadvantages
• Can not calculate incidence rates
• Must estimate relative risk using the odds ratio
• Estimates may be affected by recall bias

Physical Activity -
A B
- C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cohort study of
• Physical Activity Health Status
• among high school students? Obesity

Physical Activity -
A B
- C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cohort study of
• Physical Activity Obesity
• among high school students?
  Obesity
• 1) Identify students with high and low activity
  level
• who are not obese at the start of high school
• 2) Follow them over time and calculate BMI
• 3) Calculate Incidence of obesity in both
  exposure groups
• 4) Calculate Relative Risk (incidence in exposed
  group
• divided by incidence in unexposed group)
• (A/ AB) / (C/CD) 10/500
  .50
• 
  20/500
• The risk of obesity is 50 lower in those who had
  high levels of physical activity compare d to
  those who did not.

Physical Activity -
A 10 B 490
- C 20 D 480
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Interpretation of the Relative Risksource
modified from Jekel et al. Epidemiology,
Biostatistics and Preventive Medicine, pg 93.

• - 4.0 (4/1) Risk of outcome is 4 times higher
  among those with the
• factor as compared to those without the
  factor
• - 2.0 (2/1)
• ----------------1.0 (1/1) equal risk in two
  groups
• - 0.5 (1/2)
• - 0.25 (1/4) Risk of outcome is 25 as high or
  75 lower among
• those with the factor as compared to those
  without the factor

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• How would you design a cohort study of
• Physical Activity Health Status
• among high school students?
• Advantages Health Status
• Allow for the direct calculation of incidence
  rates
• Good for studying rare exposures
• Allows investigators to assess the progression
  from exposure
• to disease
• Disadvantages
• Need a large sample
• Can take a long time to complete the study
• More costly and labor intensive than other
  studies
• Those who are lost to follow-up can bias the
  outcome

Physical Activity -
A B
- C D
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Epidemiologic Study Designs Experimental
Enduring Epidemiological Understandings

• How would you design a behavioral trial of
• Physical Activity Health Status
• among high school students? Health Status

Physical Activity -
A B
- C D
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Epidemiologic Study DesignsExperimental
Enduring Epidemiological Understandings

• How would you design a behavioral trial of
• Physical Activity Health Status
• among high school students?
• Obesity
• Random assignment of normal weight students
• to different activity level
• 2) Follow groups over time to calculate
  incidence of
• health status outcome (blind evaluation)
• Calculate Relative Risk (incidence in exposed
  group
• divided by incidence in unexposed group)
• Would this be ethical?

Physical Activity -
A B
- C D
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Epidemiologic Study DesignsExperimental
Enduring Epidemiological Understandings

• How would you design a clinical trial of
• Vitamin C Health Status
• among high school students?
  
• Health Status
• Random assignment of healthy to Vitamin C
• Follow groups over time to calculate incidence of
  
• health status outcome (blind evaluation)
• Calculate Relative Risk (incidence in exposed
  group
• divided by incidence in unexposed group)
• Would this be ethical?

Vitamin C -
A B
- C D
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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Minimizing Risks and Maximizing Benefits
• Informed Consent
• Confidentiality of information
• Respect for Human Rights
• Scientific Integrity

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Minimizing Risks and Maximizing Benefits
• Physical
• Emotional
• Especially in vulnerable populations

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Informed Consent
• Investigators must provide clear and complete
  information regarding a research project so that
  potential participants area able to decide
  whether or not to be part of the study..
• Source Coughlin S, Ethical issues in
  epidemiologic research and public health practice
  . Emerging Themes in Epidemiology 2006, 316
  open access

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Confidentiality of Information
• Limiting access to study data
• Study records locked away
• Limit/delete identifying information on data
  collection forms and in computer files
• Encrypting of computer databases
• Limit geographic detail
• Source Coughlin S, Ethical issues in
  epidemiologic research and public health practice
  . Emerging Themes in Epidemiology 2006, 316
  open access

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Confidentiality of Information
• Certificate of Confidentiality Certificates
  protect against compulsory legal demands, such as
  court orders and subpoenas, for identifying
  information or identifying characteristics of a
  research participant.
• Source http//grants.nih.gov/grants/policy/coc/fa
  qs.htm

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Respect for Human Rights
• Individual rites
• Right of the Population

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• Scientific Integrity
• Research sponsorship
• Appearance of conflict of interest
• Possible conflict of interest
• Conducting and reporting research honestly

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Epidemiologic Study Designs
Enduring Epidemiological Understandings

• Ethical Issues
• The institutional review board system (IRB)
• United States, federal regulations to protect
  human research subjects (45 CFR 46) have
  resulted in a complex IRB system. Similar
  safeguards exist in many other countries.
• We recommend that students doing epidemiologic
  research
• Login to the NIH Protecting Human Research
  Participants training modules (http//phrp.nihtrai
  ning.com/users/login.php).
• Complete three of the seven training modules
  History, Codes and Regulations, and Respect for
  Persons.
• Source Coughlin S, Ethical issues in
  epidemiologic research and public health practice
  . Emerging Themes in Epidemiology 2006, 316
  open access

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Epidemiologic Study DesignsBreak
Enduring Epidemiological Understandings
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Enduring Epidemiological Understandings
Analytic Observational Study Type Main Feature Outcome Measure
Cross-sectional Exposure and outcome assessed at the same time Prevalence Prevalence Ratio
Case-Control Assemble Cases and Controls Ask about prior exposure Odds Ratio
Cohort Assemble cohort based on exposure All free of outcome at beginning Follow over time to assess outcome Incidence Rate Relative Risk
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Epidemiologic Measures of Morbidity
Identifying Patterns of Health and Disease and
Formulating Hypotheses

• Incidence refers to the occurrence of new cases
  of disease or injury in a population over a
  specified period of time.

• Prevalence refers to the proportion of persons in
  a population who have a particular disease or
  attribute at a specified point in time or over a
  specified period of time.

Teach Epidemiology
Source of Definitions Principles of Epidemiology
in Public Health Practice Third Edition , U.S.
DHHS, CDC
97
Cross-Sectional Studies

• Data on exposure and outcome are collected at
  the same time.
• Prevalence Ratio
• Prevalence of Outcome among those who have the
  exposure
• A/AB
• Prevalence of the Outcome among those who did not
  have the exposure C/CD
• Calculate a Prevalence Ratio to compare groups
  (A/AB)/(C/CD)

Outcome Outcome -
Exposure A B
Exposure - C D
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Outcome measures

• Case-Control Study
• Odds Ratio A x D
• B x C
• aka Cross-Products Ratio

• Cohort study
• Relative Risk

Exposure Case Control
Yes A B
No C D
Exposure Disease No Disease
Yes A B
No C D
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Analytic Epidemiology
Enduring Epidemiological Understandings
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Analytic Epidemiology
Enduring Epidemiological Understandings

• Self Check

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Source Principles of Epidemiology in Public
  Health Practice Third Edition , U.S. DHHS, CDC

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Answer A and E
• Experimental Clinical Trial

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Source Principles of Epidemiology in Public
  Health Practice Third Edition , U.S. DHHS, CDC

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Answer A and E
• Experimental Clinical Trial

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Source Principles of Epidemiology in Public
  Health Practice Third Edition , U.S. DHHS, CDC

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Answer B and C
• Observational Cohort Study

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Analytic Epidemiology
Enduring Epidemiological Understandings
Source Principles of Epidemiology in Public
Health Practice Third Edition , U.S. DHHS, CDC
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Teach Epidemiology
108
Analytic Epidemiology
Enduring Epidemiological Understandings
108
Teach Epidemiology
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Analytic Epidemiology
Enduring Epidemiological Understandings
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Teach Epidemiology
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Analytic Epidemiology
Enduring Epidemiological Understandings

• OR (32x60) 12
• (8 x 20)
• Source Principles of Epidemiology in Public
  Health Practice Third Edition , U.S. DHHS, CDC

Storage Case Control
inside 32 20
- outside 8 60
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Analytic Epidemiology
Enduring Epidemiological Understandings

• What is the appropriate measure of risk?
• Calculate this measure.
• Source Principles of Epidemiology in Public
  Health Practice Third Edition , U.S. DHHS, CDC

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Analytic Epidemiology
Enduring Epidemiological Understandings

• Relative Risk
• Incidence of illness in exposed group (those
  who ate cake) 50/53 .943 6.1
• Incidence of illness in
  non-exposed group (did not eat cake) 4/26
  .154
• Source Principles of Epidemiology in Public
  Health Practice Third Edition , U.S. DHHS, CDC

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Analytic Epidemiology
Enduring Epidemiological Understandings

• A cross-sectional study was conducted among
  1000 high school students. Students were asked to
  provide information on their gender and whether
  they had smoked more than 1 cigarette during the
  past week. The study data are provided in the
  table below.
• What is the prevalence of smoking
• Among males? Among Females?
• Calculate a Prevalence Ratio.

Gender Smoked Didnt smoke
Male 40 380
Female 30 570
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Analytic Epidemiology
Enduring Epidemiological Understandings

• A cross-sectional study was conducted among
  1000 randomly selected high school students.
  Students were asked to provide information on
  their gender and whether they had smoked more
  than 1 cigarette during the past week. The study
  data are provided in the table.
• What is the prevalence of smoking
• Among males? 40/400 10
• Among Females? 30/600 5
• Prevalence Ratio 10/5 2

Gender Smoked Didnt smoke
Male 40 360
Female 30 570
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Time Check 245 PM
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Time Check 300 PM
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Teach Epidemiology
Teach Epidemiology
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Tours
Teach Epidemiology
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Tours
Broadcast Studios
Teach Epidemiology
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Tours
Emergency Operation Center
Teach Epidemiology
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Time Check 400 PM
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Extra Slides
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