Cohort Study

Definition

A study design where one or more samples (called cohorts) are followed prospectively and subsequent status evaluations
with respect to a disease or outcome are conducted to determine which initial participants exposure characteristics (risk
factors) are associated with it. As the study is conducted, outcome from participants in each cohort is measured and
relationships with specific characteristics determined. A cohort study is useful for estimating the risk of disease, the
incidence rate and/or relative risks. Non-cases may be enrolled from a well-defined population, current exposure status
determined, and the onset of disease observed in the subjects over time. The data may be displayed as follows:
Do not Total
Developed the
Developed the
disease
disease
Exposed to risk a+b
a b
factor

Un Exposed to c+d
c d
risk factor
Measures of disease frequency and effect or association can be calculated from these data:
Incidence Density (Incidence Rate):
 Among Exposed: a / a + b
 Among Non exposed: c / c + d
Risk Ratios; Relative Risk: It estimates the magnitude or strength of association between exposure and disease
and indicates the likelihood of developing the disease in the exposed group relative to the non-exposed group.
a / a + b over c / c + d
Attributable Risk: Incidence rate in exposed - Incidence rate in unexposed

Types of Cohort Studies

The simplest cohort design is prospective, i.e., following a group forward in time, but a cohort study can also be
'retrospective'. In general, the descriptor, 'prospective' or 'retrospective', indicates when the cohort is identified
relative to the initiation of the study and not to the relationship between exposure and effect
1. Prospective cohort (concurrent; longitudinal study) - An investigator identifies the study population at the
beginning of the study and accompanies the subjects through time. In a prospective study, the investigator begins
the study at the same time as the first determination of exposure status of the cohort. When proposing a
prospective cohort study, the investigator first identifies the characteristics of the group of people he/she wishes to
study. The investigator then determines the present case status of individuals, selecting only non-cases to follow
forward in time. Exposure status is determined at the beginning of the study.
2. Retrospective cohort study (historical cohort; non-concurrent prospective cohort) - An investigator
accesses a historical roster of all exposed and non exposed persons and then determines their current case/non-
case status. The investigator initiates the study when the disease is already established in the cohort of individuals,
long after the original measurement of exposure. Doing a retrospective cohort study requires good data on
exposure status for both cases and non cases at a designated earlier time point.

3. Combination of retrospective & prospective cohort studies.

Advantages

 Allow complete information on the subject’s exposure, including quality control of data, and experience thereafter.
 Provide a clear temporal sequence of exposure and disease (Time-to-event analysis is possible).
 Give an opportunity to study multiple outcomes related to a specific exposure.
 Permit calculation of accurate incidence rates (absolute risk) as well as relative risk.
 Methodology and results are easily understood by non-epidemiologists.
 Enable the study of relatively rare exposures.
 Magnitude of a risk factor’s effect can be quantified
 Selection and information biases are decreased

Disadvantages

 Not suited for the study of rare diseases because a large number of subjects is required.
 Not suited when the time between exposure and disease manifestation is very long, although this can be overcome in
historical cohort studies.
 Exposure patterns and Unexpected environmental alteration may change during the course of the study and make the
results irrelevant.
 Maintaining high rates of follow-up can be difficult.
 Expensive to carry out because a large number of subjects is usually required.
 Baseline data may be sparse because the large number of subjects does not allow for long interviews
may influence the association
 Non-response, migration and loss-to-follow-up biases
 Sampling, ascertainment and observer biases are still possible

Example

 A cohort study was designed to assess the impact of sun exposure on skin damage in beach volleyball players.
During a weekend tournament, players from one team wore waterproof, SPF 35 sunscreen, while players from the
other team did not wear any sunscreen. At the end of the volleyball tournament players' skin from both teams was
analyzed for texture, sun damage, and burns. Comparisons of skin damage were then made based on the use of
sunscreen. The analysis showed a significant difference between the cohorts in terms of the skin damage.

 To determine the long-term effectiveness of influenza vaccines in elderly people, cohorts of vaccinated elderly
and unvaccinated community-dwelling elderly were studied. The results suggest that the elderly who are
vaccinated have a reduced risk of hospitalization for pneumonia or influenza

Think About It!

How does a retrospective cohort study differ from a case-control study? Suppose you are
investigating the possibility of an environmentally-linked cancer among students at a
university. How would the sample selected for a case-control study differ from those included in a
retrospective cohort study?
 Attributable Risk (Risk difference)

The risk difference, also called attributable risk, is the difference in rates of occurrence between exposed and
unexposed group.

Risk difference= I E – I U

Significance:

It is a useful measure of the extent of the public health problem caused by the exposure.

Attributable fraction

The Attributable fraction or etiological fraction is determined by dividing the risk difference by the rate of
occurrence among the exposed population.
For example the attributable fraction of smoking for stroke in the women smokers is
((49.6 – 17.7)/49.6) X 100=64% where IE=49.6 & IN=17.7
In the above example, one would expect to achieve a 64% reduction in the risk of stroke among the women
smokers if smoking were stopped, on the assumption that smoking is both causal and preventable. Attributable
fraction is a useful tool for assessing priorities for public health action.
Significance:
 when an exposure is believed to be a cause of a given Disease, the attributable fraction is the proportion
of the disease in the Specific population that would be eliminated in the absence of exposure.
 It will help determine the priority health actions to be taken by the health planners.

Population attributable risk :

The Population attributable risk or population attributable fraction is a measure of the excess rate of disease in
a total study population which is attributable to an exposure.
It is calculated by:
Where IP is the incidence rate of the disease in the total population and IU is the incidence rate of the disease
among the unexposed group. The population attributable risk or population attributable fraction is Calculated
as
AFP = 30.2 – 17.7 =0.414 (Corresponding to 41.4%)
30.2
Significance:
1. This measure is useful for determining the relative importance of exposures for the entire population.
2. It is the proportion by which the incidence rate of the outcome in the entire population would be reduced
if exposure were eliminated.
3. It is useful for the health planners.