Epidemiology and Public Health

Epidemiology is a science that studies the causes and effects of

health-related events as they occur in populations. Disease, defined
as a deviation from health, is one such health-related event of
concern to epidemiologists, so in that regard, epidemiology is often
thought of as the study of disease in populations.

Although the historical origins of epidemiology as a science are

investigations of epidemics of infectious disease, modern
epidemiology has expanded to not only include contagious diseases,
but also environmental connections to disease states and even
accidental injuries. Epidemiologists gather data on the frequency of
various diseases in populations, and correlate risk factors associated
with disease development.

The information compiled by epidemiologists provides the

foundation for the concept of “public health.” The focus of public
health is to prevent and manage diseases, injuries, and other
conditions that threaten human helath. Keeping track of the number
of people who acquire or have a particular health-related condition
guides the deployment of interventions, distribution of grant funding
for research on particular diseases, and development of public
health policy.

In the United States, the Centers for Disease Control and Prevention
(CDC) is the arm of the federal government responsible for
promoting and protecting public health. On the infectious disease
front, the CDC receives reports on the occurrence of certain
infectious diseases, called notifiable diseases, from regions in the
United States and its territories. The data received from state and
local health agencies each week is compiled into a large searchable
database called the National Notifiable Diseases Surveillance
System (NNDSS) and published in the Morbidity and Mortality
Weekly Report (MMWR), which is available in both print and
electronic formats.

The data maintained within the NNDSS tables is available for

retrospective analysis and also used to predict trends in disease
occurrence in populations by time and place.
Two important measurements of disease occurrence and distribution
are morbidity (illnesses due to a disease) and mortality (deaths
due to a disease). The morbidity of a specific disease is defined as
the number of susceptible people in a population that have the
disease during a specific period of time, and is usually expressed as
a rate. Mortality may also be expressed as a rate, and reflects the
number of deaths due to a particular disease in a population over
time.

Frequency of Disease in a Population

The frequency at which a disease occurs in a population is a way to
assess risk and disease impact. One way to measure disease
frequency is to simply count how many people are afflicted with it in
a given period of time. However, using simple counts prevents
comparison among populations, which may vary vastly in size.
Therefore, disease frequency is usually expressed as a proportion of
the number of people affected by the disease to the population size,
over a specified time period.

Two specific statistical measures widely used in epidemiological

investigations are incidence and prevalence. Incidence is a
measure of the number of NEW cases of a disease during a specific
time period. Incidence is used as a way to understand risk factors,
such as the cause of a health-related event or concern for disease
spread. Prevalence refers to the total number of both new and
existing cases in a population over time, and provides an indication
of the overall health of the population during a time period.

Both of these statistics are measures of disease over time. For this
reason, they are often expressed as a rate:

Incidence rate = Number of new cases of a disease in a

population ÷ Number of at-risk people during a time period

Prevalence rate =Number of cases of a disease in a

population ÷ Number of at-risk people during a time period

Because the number of cases of any disease may be small, and the
size of the population under study may be very large, the resulting
number may be so exceptionally small that it is perceived to be of
no consequence. Therefore, these measures are often expressed as
a percent, or multiplied by a factor of 100, 1,000, or even 100,000
so that the rates are expressed in number of people per 100, 1,000,
or 100,000 individuals, respectively. For example, if over the course
of one year, five women in a study population of 200 women (5/200)
develop breast cancer, then the calculated incidence of breast
cancer in this population is 0.025. Such a small number might lead
some people to presume their disease risk is also small. Therefore,
the incidence may be expressed as a percent (2.5%), or a multiplier
can be used to express the disease rate as 25 breast cancer cases
per 1,000 women per year.

Prevalence estimates the likelihood that someone in a group will

have a disease, and is often used as an indicator of the overall
healthcare burden of a disease. Prevalence is highly dependent on
the duration of the morbidity associated with the disease. The
prevalence of chronic diseases will continually increase as the cases
accumulate over time since it is a measure of both new and existing
cases.

For example, a survey asking about personal experience with colon

cancer was provided to 80,000 people, with 2,400 responding that
they had been recently diagnosed with the disease, and 7,000
people responding that they’d had the disease for more than a year.
The prevalence rate for colon cancer in this population can be
determined by adding new and existing cases (9,400) and dividing
by the size of the population (80,000). Therefore, the prevalence of
cancer in this population is 0.1175, which can be expressed as
11.75%, or 118 colon cancer cases per 1,000 people.

Incidence and prevalence are two fundamentally different statistics.

Keeping track of new cases of a disease requires an extensive
network of reporting, while prevalence can be determined by
surveying members of a population at a given point in time.
Although there are limitations, if the disease is fairly stable in the
population, has an average time of duration, and is not irreversible,
incidence can be estimated using the prevalence data, and vice
versa, using the following relationships (where Time refers to the
average amount of time a person is sick with the disease):

Prevalence rate = Incidence x duration (in days, weeks, or

months) of the disease
Incidence rate = Prevalence / duration (in days, weeks, or
months) of the disease
Example: A prevalence survey conducted in upstate New York in
2013 revealed that 200 people in a study population of 16,000
Saratoga County residents were diagnosed with anaplasmosis, a
bacterial disease transmitted to humans by ticks. For appropriately
treated patients, the average amount of time that a person is sick
with this disease is approximately four weeks.

1. What is the prevalence of anaplasmosis in Saratoga County,

expressed per 1,000 people?

2. What is the estimated annual incidence of anaplasmosis per

1,000 Saratoga County residents? (Hint: Because this asks for the
annual incidence, time should be expressed in years.)

3. In 2013, there were 223,865 people living in Saratoga County.

Therefore, how many of those people would be expected to have
anaplasmosis in 2013?

Measures of Association
Measuring the frequency of health-related events in populations is a
useful way to assess and compare the health status of people in a
population at one time, at different times, among subgroups of the
population, or between populations. However, knowing how
frequently a disease occurs in a single group does not indicate
whether being a member of that group increases a person’s risk of
experiencing a specific health-related event.
Therefore, identifying the cause of a health-related event in
epidemiology usually includes comparing disease rates between
groups of people who differ by exposure. By measuring and
comparing the frequency of health related events between groups
where one is exposed and one is not, it is possible to evaluate if
there is an association between a particular risk factor (such as
smoking) and a positive or negative impact on health (such as
cardiovascular disease).

For cohort studies which involve a group of people who share the
same experiences, epidemiologists may make comparisons of
disease frequency by calculating ratios of the variables. The risk
ratio (also known as relative risk) gives an indication of
the strength of the association between a factor and a
disease or other health outcome. To calculate the relative risk,
the incidence of the health-related event in a group that was
exposed to the condition or variable is divided by the incidence of
the same variable in the group that was not exposed. In general, a
calculated risk ratio equal to or close to one indicates that there is
no difference in risk, because the incidence is approximately equal
in both groups. Ratios greater than or less than one suggest higher
or lower risk, respectively.

To calculate relative risk in a study involving a cohort, the

conventional method is to organize the data in a format known in
statistics as a “2 x 2” table. An example is shown in Table 1:

Table 1. Standard 2 x 2 table for relative risk calculation.

Outcome

Yes No Total Incidence of outcome

Exposed 16 108 124 16/124 = 0.13

Not Exposed 14 341 355 14/355 = 0.04

Relative risk is calculated by dividing the incidence of the health

event for the exposed group by the incidence of the health event in
the unexposed group:

RR = incidence of outcome in exposed group / incidence of

outcome of non-exposed group

RR = 0.13/0.04 = 3.25

In this case, because the calculated value is more than one, there is
an increased risk associated with exposure to the risk factor.
Specifically, the people in the exposed group were 3.25 times more
likely to have the health event than those in the non-exposed group.

Example: To determine if patients who take prophylactic antibiotics

before surgery are more or less likely to develop a hospital-acquired
infection (HAI) of the wound, two groups of surgery patients were
compared. One group with eighty participants took an antibiotic
prior to surgery, and a second group of seventy patients did not
take the antibiotic. Six people in the antibiotic group developed an
HAI after surgery, and nine people in the no antibiotic group ended
up with an HAI. Calculate the relative risk for this health-related
event.

Table 2. Relative Risk Example

Outcome
 HAI No HAI Total Incidence of outcome

Antibiotic 6 74 80 6/80 = 0.075

No antibiotic 9 61 70 9/70 = 0.13

RR = incidence of HAI for exposed group / incidence for non-

exposed group

RR = 0.075/0.13 = 0.58

Because the relative risk is less than one, there is a reduced risk for
a patient of getting a hospital-acquired infection if they are given an
antibiotic before surgery. Specifically, someone who gets a pre-
surgery antibiotic has 0.58 times the risk of an HAI, meaning that
taking a pre-surgery antibiotic cuts the risk of HAI by almost half.

Another option to compare frequencies of health events is to

calculate the risk difference, in which the difference between the
two measures is determined by subtraction. The risk difference
provides a measure of the public health impact of the risk factor
and indicates how the health event might be prevented if the risk
factor were eliminated.

The cohort study above examined if prophylactic antibiotics reduced

the risk of getting a hospital acquired infection for patients. Note
that the incidence of HAI in the antibiotic group was 75 per 1,000
people, and the incidence of HAI in the no antibiotic group was 130
per 1,000. The difference between these two values (55) indicates
the number of HAI cases that could be prevented through
prophylactic antibiotics before surgery. In this case, HAI would be
prevented for 55 people (per thousand) if they are given an
antibiotic before surgery.
Example: To determine if people who take a proton-pump inhibitor
to combat heartburn are more or less likely to develop
gastroesophogeal reflux disease (GERD), two groups of patients
were compared. One group with 43 participants took the PPI daily,
and a second group with 39 patients did not. After 3 months, 6
people in the PPI group developed GERD, while 5 people in the no
PPI group developed GERD. Calculate the risk difference and
indicate whether taking a PPI reduces the risk for GERD.

Using a case-control (as opposed to a cohort) study, relative risk is

also a way for epidemiologists to track risk factors associated with
disease outbreaks and potentially assign a cause, such as during a
sporadic outbreak of a food-borne disease.

Example: On February 12, 2014 a forty-three-year-old man in New

York was hospitalized with a one-week history of diarrhea and
vomiting followed by fever, neck pain, and headache. This was the
first reported (index) case of a sporadic outbreak of listeriosis, a
disease caused by the bacterium Listeria monocytogenes. Almost
everyone who is diagnosed with listeriosis has an invasive infection,
meaning that the bacteria spread from their intestines to their
bloodstream or other body sites, including the central nervous
system.

An epidemiological investigation of this event identified 630

laboratory confirmed listeriosis cases across 11 states. To identify
the source of the bacteria, a case-control study was conducted to
compare the foods eaten by 52 of the patients with
confirmed cases, with a group of 48 healthy controls who were
matched to the case patients by gender, age, and geographic
location. All 100 people were asked to complete a questionnaire
about the foods they had eaten just prior to the index case report.
The data is illustrated in Table 3.
Table 3. Questionnaire data

Ate food Did not eat food

Food item: Sick Not Sick Sick Not Sick

Weiner brand hot dog 24 28 22 26

Raggle brand sausage 20 32 29 19

Dairydelish yogurt 38 14 13 35

Yummyum ice cream bar 28 24 23 25

So… which food was contaminated? Calculate the relative risk for
each food, and the highest number wins. Start by calculating the
incidence for each group (first food item is shown):

Weiner hot dogs Incidence exposed 24/52 = 0.46 RR: 0.46/0.5 = 0.92

Incidence not exposed 22/48 = 0.5

Raggle sausage Incidence exposed RR:

Incidence not exposed

Dairydelish Incidence exposed RR:

Incidence not exposed

Yummyum Incidence exposed RR:

Incidence not exposed

Based on your calculations, which food is associated with this food-

borne outbreak of Listeria?

Epidemiology Problem
On July 30, 2013, the New York State Department of Health received
a complaint from a person who said that he and his entire family
had become very ill with vomiting and diarrhea after eating at a
particular restaurant. He went on to say that his two-year-old son,
Devin, became so dehydrated that he required hospitalization. After
rehydration therapy, Devin was well enough to return home. A
specimen taken from Devin’s stool was cultured on several types of
media, including Sorbitol-MacConkey (SMAC) Agar, Salmonella-
Shigella (SS) Agar, and Mannitol Salt Agar (MSA). Pink colonies grew
on the SMAC plates, but no colonies appeared on the MSA plate.
Pertinent results and additional tests are provided in Table 4, or
your instructor may provide you with the actual media containing
the cultures you should use in this analysis.

Table 4. Laboratory results for bacteria cultured from stool specimen.

Gram
MacConkey Agar Catalase Oxidase TSI
stain

Pink Colonies were Bubbles formed No color change when

K/A H2S
single translucent and when H2O2 was smeared on a DrySlide
gas
bacilli beige colored added Oxidase card

Based on the laboratory results, what bacterial genus is the most

likely cause of Devin’s illness?

_____________________________________________________________________
______

What is the name of the gastrointestinal disease caused by

infection with this bacterium?

_____________________________________________________________________
______

Over the next 10 days, the hospital where Devin had been treated
saw an additional 19 cases of rapid-onset gastroenteritis in people
who dined at the same restaurant as Devin and his family. The
Department of Health initiated an investigation, which included
interviewing restaurant staff and people who had eaten there at
some point over the previous two weeks. Samples of food taken
from the restaurant at the time of the interviews did not test
positive for any harmful bacterial agents.

To determine what food item might have been contaminated, a

case-control study was conducted with the 19 people who
developed food poisoning after dining at the restaurant matched
with 20 controls, who had eaten at the restaurant but did not get
sick. The responses were compiled and the data is shown in Table 5.

Table 5. Data from the case-control study

Exposed Not Exposed

Food item: Sick Not Sick Sick Not Sick

Hamburger 8 11 9 11

Hot dog 7 12 8 12

Fried chicken 9 10 12 8

French fries 10 9 11 9

Potato salad 16 3 4 16
Soda 11 8 11 9

Water 9 10 6 14

Beer 10 9 10 10

Can a particular food item be associated with the occurrence of

disease among the people that ate at the restaurant? If yes, which
food?

_____________________________________________________________________
____

Epidemiologists were interested in knowing if this was a sporadic

outbreak or an indication of a disease becoming more common in
the upstate New York region. Therefore, a quick analysis was
performed by comparing the incidence of this disease at 4 times
throughout the year of 2013, at weeks 12, 26, 40, and 52. Retrieve
this data from the NNDSS database (you can find it at cdc.gov →
MMWR → State Health Statistics → NNDSS Tables → Search
Morbidity Tables).

Week 12: Number of reported cases __________

Week 26: Number of reported cases __________

Week 40: Number of reported cases __________

Week 52: Number of reported cases __________

In this case, the size of the population would be considered the

same for each of the weeks, therefore it is possible to compare the
number of reported cases without calculating the incidence. From
this data, what can you conclude overall about the occurrence of
this disease in upstate New York? Is there any indication that we are
on the verge of an epidemic of this disease?
_____________________________________________________________________

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