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 Surveillance
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Epidemiology
It is the study of the distribution &determinants of health- related -1
states or events in specified populations &the application of this study
to the control of health problems
It is data-driven &relies on a systematic &unbiased approach to -2
collection, analysis, &interpretation of data
It is concerned with the frequency &pattern of health events in -3
population by careful observation and use of valid comparison groups
to assess whether what was observed, such as the number of cases of
diseases in a particular area during a particular time period or the
frequency of an exposure among persons with disease, differs from
what might be expected
Pattern: - It is refers to the occurrence health related events by
time, person, and place
Time may be annual, seasonal, weekly, daily, hourly, weekday -1

versus weekends or any other breakdown of time that may influence

.disease or injury occurrence

Place: - Geographic variation, urban\rural differences, &location -2

of work sites or schools
Person: - age, sex, marital status &socioeconomic status as well as -3
behaviors & environmental exposures
In simple terms the epidemiologist Counts, Divides, Compares
Counts cases or health events, and describes them in terms of time,
person& place
Divides the number of cases by an appropriate denominator to
calculate rates
Compares these rates over time or for different groups of people
 Epidemiological studies
Descriptive epidemiology
Describes disease &exposure &may consist of calculating rates
incidence and prevalence without using control groups & can only
generate hypothesis not test them, characterizing health events by
time, person and place(cross-sectional study)
Analytical epidemiology
A) Observational studies (Case control & cohort studies)
b) Experimental studies (clinical trials)
The main feature of analytical studies is using a control group
&mostly used as hypothesis testing studies
Statistical terms
Measures of averages -1
Locate the center point of a group of data (mean- node – median)
Measures of distribution -2
Range – Variance – Standard deviation
Frequency measures -3
Ratio – Proportion - & Rate
Ratio
:

It Is the relative magnitude of two quantities or a comparison of any

two values, It is calculated by dividing one interval by the other .the
numerator and denominator need not to be related .therefore, one
compare apples with oranges or apples with number of physician visits
Proportion
 It is the comparison of a part to the whole. It is a type of ratio in which
the numerator is included in the denominator. A proportion may be
expressed as a decimal, fraction, or a percentage
Rate
Is a measure of the frequency with an event occurs in defined
population over a specified period of time. Because rates put disease
frequency in the perspective of the size of the population, rates are
particularly useful for comparing disease frequency in different
location, at different time, or among different groups of persons with
potentially different sized population, that is a rate is a measure of risk
Rate
Measures that are expressed per unit time (how quickly disease occurs
in a population)
Incidence, &prevalence rate •

Incidence-1 •
Occurrence of new cases of diseases or injury in a population over •
.specified period of time

Two types of incidence are commonly used - •

)incidence proportion & incidence rate( •
A) incidence proportion(attack rate – cumulative •

incidence- risk – probability of getting disease

Is the proportion of an initially disease-free population that develops
disease or become injured, or dies during a specified (limited) period
of time
o calculate it by dividing number of new cases of disease per size of
pulation at risk at start period
B) Incidence rate (Person- time rate or incidence density)
It must incorporate time directly into the denominator. A person-time
rate is generally calculated from a long-term cohort follow-up study
where in enrollees are followed over time &occurrence of new cases
of disease is documented. Each person is observed from an
established starting time until one of four (end points) is reached
Onset of disease – death – migration out of the study (lost to
follow up) – the end of the study
It is the number of new cases identified during the period of
observation .the denominator is the sum of the time each
person was observed totaled for all persons this denominator
represents the total time the population was at risk of and
being watched for disease so incidence is a ratio of the number
of cases to the total time the population at risk
-:NB
If our study is to follow up patients for 5 years and we fail to
observe one patient after 2 years or become diseased we
consider that we follow him for 2.5 years to calculate
denominator (total time)
-:Example
Investigators enrolled 2,100 women in a study & followed
them annually for 4 years to determine the incidence rate of
heart disease .after one year non had a new diagnosis of heart
disease but 100 had been lost to follow-up after two years one
had a new diagnosis of heart disease and another 99 had been
lost to follow –up after three years another seven had a new
diagnosis of heart disease and 793 been lost to follow-up after
4 years another 8had a new diagnosis of heart disease and 392
more were lost to follow up after 4 years leaving 700 women
.who were followed for four years & remain heart disease free
Calculate the incidence rate of heart disease among this cohort
Assume that persons with new diagnosis of heart disease and
those lost to follow up were free for half the year & thus
.contribute 0.5 year to the denominator
:The answer
Numerator = number of new cases of heart disease
16 =0+1+7+8 =
Denominator = person – years of observation
0.5x100+( 1,900 + 0.5x1+ 0.5x 99 +( 1100+0.5 x 7 + 2,000( =
+ 0.5x 793)+ ( 700 +0.5 x 8+ 0.5 x 392)= 6400 person\years of
follow-up
Or
= Denominator = person\ years of observation
793 x (+)99 x 1.5( + )100 x 0.5( + )8x 3.5( + )7x 2.5( + )1x1.5(
6400 person\years of follow up =)700x 4(+)392x 3.5(+)2.5
=Incidence rate= 16\6400 = 0.0025 cases per person\year
cases per 1000 person\ years 2.5
In contrast the Incidence proportion can be calculated as
16\2100 = 7.6 cases per 1000 population during the 4-year
period, or an average of 1.9 cases per 1000 per year (7.6
divided by 4years). The Incidence proportion underestimates
the true rate because I ignores persons lost to follow-up, and
.assumes that they remained disease free for all 4 years
:2ry attack rates
We divide no of cases among contacts of primary cases x 10n\
.total no of contacts
Often, the total no of contacts in the denominator is calculated
as the total population in the house holds of the primary cases
– the no of primary cases for the 2ry attack rate, 10n usually is
100%

Consider an outbreak of shigellosis in which 18 person in 18

different households all became if the population of the
community was 1000 then the overall attack rate was 18\1000
x 100% = 1.8% one incubation period later , 17 persons in the
same households as these primary cases developed shigellosis.
If the 18 households included 86 persons, calculate the 2ry
.attack rate
x 100%) = 25%)17\68 ( = )x 100% )86-18(\17(
:Prevalence
It is 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
Prevalence differs from incidence is that prevalence includes
all cases , both new and pre existing , in the population at the
specified time , whereas incidence is limited to new cases
.only
Prevalence is a good measure of the overall burden of
infections of a facility, expressing how common infections
.are?. Prevalence is often expressed as a percentage
Point prevalence refers to the prevalence measured at a
particular point in time. It is the proportion of persons with a
.particular disease or attribute on a particular date
Period prevalence refers to prevalence measured over an
interval of time. It is the proportion of persons with a
.particular disease or attribute at any time during the interval
In limited- duration prevalence, prevalence is looked at
retrospectively. That is, it counts all those alive at a point in
time that, during a prescribed duration of time (past 5 years,
for example) had a particular disease. Complete \life time
prevalence, on the other hand, counts all those alive at a
particular point in time that had the disease at any time in the
past or present, whether cured or in current treatment, usually
expressed as a ratio of those with the disease compared to a
.given population
Prevalence= all new and pre existing cases during a given time
.period x 10n\ population during the same time period
:Measures of association
A measure of association quantifies the relationship 
.between exposure and disease among the 2 groups
In this perspective exposure is used to mention any 
characteristics associated with one group of people and
not with the other including but not limited to (exposure
to food and communicable diseases, immunization status,
age, sex, socioeconomic level.)
Examples of measures of association include risk ratio 
(relative risk, rate ratio and odds ratio.)
:Risk ratio (relative risk)
Compares the risk of a health event (disease, injury, risk
factor, or death) among one group with the risk among another
group. It does so by dividing the risk (incidence proportion,
attack rate) in group one by the risk (incidence proportion,
attack rate) in group two. Often the group of primary interest
is labeled the exposed group and the comparison group is
.labeled the unexposed group
RR = risk of disease in group of primary interest\ risk of
.disease in comparison group
Risk ratio of 1.0 indicates identical risk among the 2 
.groups
Risk ratio greater than one indicates an increased risk for 
.the group in the numerator, usually the exposed group
A risk ratio less than one indicates a decreased risk for 
the exposed group indicating that perhaps exposure
.actually protects against disease occurrence
:Example 
In an outbreak of varicella, varicella was diagnosed in 18 of
152 vaccinated children compared with 3 of 7 unvaccinated
.calculate the relative risk or risk ratio
.Risk of varicella among vaccinated = 18\152 =0.118= 11.08%
Risk of varicella among unvaccinated children =
3\7=0.429=42.9%
RR= 0.118\0.429 = 0.28
The risk is less than one; indicate a decreased risk or
.protective effect for the exposed (vaccinated) children
The risk ratio of 0.28 indicates that vaccinated children where
only a proximately one\ force as likely to develop varicella as
.where Unvaccinated children
:Rate Ratio
It compares the incidence rate, person\time rates or mortality
.rates of 2 groups
Rate Ratio= Rate for group of primary interest\ rate for
.comparison group
The interpretation of the value of rate ratio is similar to that of
.risk ratio
:Odd Ratio (O R)
It quantifies the relationship between an exposure with 2
.categories and health outcome
O R = ad\bc
.The O R is the measure of choice in case control study
The no of persons in the control group is usually decided by
.the investigator
The size of the population from which the case-patients came
is not known. As a result, risks, rates, risk ratio or rate ratios
can't be calculated from the typical case-control study
however, You can calculate an odds ratio and interpret it as an
approximation of the risk ratio particularly when the disease is
.uncommon in the population
:Example
In the previous example (that of varicella) calculate the OR of
the used data
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Exposed (A) 18- diseased non exposed (B) 3- non diseased
Exposed (C) 134- Non diseased Non exposed (D) 4
OR = (18 x 4) \ (3x 134) = 0.179

Case-Control Studies
In a case-control study, the investigator compares one group among whom
a problem is present (cases) with another group, called a control or
comparison group, where the problem is absent to find out what factors
.have contributed to the problem
Strengths and Limitations

Strengths (advantages)
Evaluation of diseases with long latent period-1
.Evaluation of rare diseases-2

.Examine multiple etiologic factors for a single disease -3

.Quick and inexpensive-4

Limitations (disadvantages.)
.Inefficient for the evaluation of rare exposures-1
.Cannot directly compute incidence rates of disease -2

.Difficult to establish the temporal relationship -3

.Prone to recall and selection bias compared to other analytical studies -4

:Issues in the design and conduct of case-control studies

.Definition and selection of cases -

Selection of controls-
.Ascertainment of disease and exposure status -

Selection of cases
Prevalent (existent at a point in time) OR -
.Incident (newly diagnosed) cases -
Selection of controls
Selection of control group is made for a particular group of cases and
:involves consideration of a number of issues including

The characteristics and source of cases •

The need to obtain comparable. Information from both cases and •
.controls

Practical and economic considerations •

Sources of control subjects
Hospital controls •
2General population controls
3Special groups: friends, neighbors, or relative of cases

Hospital controls
Patients seeking care for conditions other than the disease of interest at the •
.facilities where the cases are identified

.Best to choose patients with a variety of diseases •

Patients with diseases thought to be related to the exposure of interest are •

.excluded

Advantages and disadvantages of selection controls from hospital

Advantages
Easy and less costly •
Less recall bias •
More eager to participate compared with general population controls •
Disadvantages
Not representative of the general population •

General population
Controls: If cases recruited from a well defined population the best control group
is a random sample of the same source of population to achieve comparability
.between both groups
Controls consist of special groups: May not be possible to examine risk factors that
are closely linked to socio-economic or environmental exposures because cases and
.controls are too similar

Odds ratio (OR) =ad/cb

Cohort studies
Definition of cohort study
The cohort study is defined as an analytic epidemiologic research design in •
which the study population is composed of individuals who are classified as
. particular risk factor (comparison groups) exposed or not exposed to

In designing a cohort study, investigators should clearly state the research •

hypothesis and specify the expected relationship between the exposure and the
.health problem of interest

Types of cohort study

Cohort study may be either prospective or retrospective (historical): In a •
prospective cohort study, exposure status is determined when the study begins
and the exposed and unexposed groups are followed forward in time to observe
.whether they develop the study outcome
In historical cohort study the exposure and the health problem is determined from In
cohort studies, investigators can examine more than one health problems that may be
the result of the exposure under study
Relative risk is the most common used measure of association between •
.exposure to a particular factor and risk of specified outcome

Relative risk is the incidence of the outcome among the exposed study subjects •
.divided by the incidence of the outcome among the unexposed subjects

Cumulative incidence relative risk (CIR): it measures the risk of the study •
subject developing the health problem during study period
Person-time Incidence density relative risk (IDR) •
Some studies use person-time as the denominator in the relative risk
.calculation instead of the number of persons enrolled in the study

Advantages and disadvantages of cohort studies

Advantages
Describe the natural history 2-Study rare exposure-1
Temporal sequence 4-Multiple outcome 5-Calculate -3
relative risk
Disadvantages: 1-Large number 2Long term of follow up -3-Loss to follow up 4-
Expensive 5- Change of exposure during the study

Epidemic curves
•The character of an epidemic is determined by an epidemic
curve. This is a graph in which cases are plotted according to
the time of onset of illness.
•The reasons for constructing an epidemic curve include:
1-To determine whether the source of infection was
common, propagated, or both; the shape of the curve is
determined by the epidemic pattern.
2-To identify the probable time of exposure of the cases to
the source(s) of infection
3-To identify the probable incubation period.
4-To determine if the problem is ongoing.
•Characteristics of an epidemic curve:
1-An epidemic curve is a histogram.
2-Cases are plotted by date of onset of illness.
3-Time intervals (on the X axis) must be based on the
incubation or
Latency period of the disease and the length of the period
over which cases are distributed.
Types of epidemic curves
1- Point source: is characterized by a rapid rise and fall of cases
which are located within one incubation period. They are
caused by a common source with a very short exposure time.
2- Common source: is one in which people are exposed
intermittently or continuously to a common harmful source.
In case of intermittent exposure a multi-peak epidemic curve
that extends over more than one incubation period will result
while in case of continuing common source a curve with a
gradual increase in cases and possibly a plateau will be
observed.
propagated source : is usually resulting from a person to person -3
transmitted disease and the typical curve will extend over more
than one incubation period and will show a gradually increasing
multiple peaks
Bar Chart & Run Chart
Special cause (Trend - Shift)
Bar-Chart
.