ASSIGNMENT

SUBJECT
EPIDEMIOLOGY (MPH 501)
TOPIC
WITH THE USE OF EXAMPLES, DISCUSS HOW MEASURES OF DISEASE
FREQUENCY AND MEASURES OF ASSOCIATION ARE APPLIED IN
EPIDEMIOLOGY ET AL.

NAME
JERRY SELASE SIFA
LECTURER
DR FRANK BAIDEN

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1.0 Introduction
Epidemiology is the study of the distribution and determinants of health-related states or events in
specified populations and the application of this study to control of health problems(CDC, 2012).
Epidemiology studies the frequency of diseases in relation to populations, and their relation to the
population size. It also examines the occurrences of the diseases in relation to time and place. In
other words, epidemiologists provide answers to questions such as who gets a disease, how much
of the disease there is, and what makes the person (population) vulnerable to the disease?
(Macfarlane, n.d.). In assay to address such questions, epidemiologists embark on activities to
measure disease occurrence and measure association of exposure and outcomes of health events.
2.0 Fractions used for describing diseases- Ratio, Proportion and Rate
2.1) Ratio
Ratio is a comparison of two values that are not required to be related. In other words, it is a
fraction which the numerator is not a subset of the denominator. Ratio is used by epidemiologists
as a descriptive and analytical tool(CDC, 2012). As a descriptive tool, ratio is used to describe the
relations items or variable. As analytical tool, it is used to estimate and compare health event
outcomes such as diseases, injuries and deaths across time, person and place. In epidemiology,
ratio manifests in the forms such as risk ratio (relative risk), rate ratio, and odds ratio(CDC,
2012). It is mathematically expressed as:
a
n
b 10

To illustrate: A country has a population size of 27, 000,000 and 100, 000 public toilets. To
determine the public toilet population ratio. I do the following:
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100,000
27,000,000 1000 = 3.7

Interpretation: 3.7 public toilets per 1000 people or 1 public toilet for 270 people
2.2 Proportion
Proportion is a fraction that compares a part to the whole. Put differently, it is the fraction that has
its numerator being part of its denominator. This may be expressed as a decimal, a fraction, or a
percentage. It is very useful to epidemiologists because, it offers them the opportunity to make
comparisons that are not possible with raw numbers. It is also used for descriptive purpose such
as describing the relation of an exposure to health outcome. It is mathematically expressed as:
Number of personsevents with a particular characteristic
n
Total number of personsevents , of which the numerator is a subse 10

Assuming Dr Frank Baiden assigns first year MPH students to find out the proportion of men in
Ghana living with HIV/AIDS. The students went to Ghana AIDS Commission (GAC) and found
that 100,000 men are living with HIV/AIDS. The students went to Ghana Statistical Service and
were informed there are 8, 000,000 men in Ghana. To determine the proportion, they did the
following:

100,000
8,000,000 100= 1.25%

2.3 Rate

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CDC (2012) describes rate as A rate is a measure of the frequency with which an event occurs in
a 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 locations, at different times, or among different groups of persons with
potentially different sized populations; that is, a rate is a measure of risk. A rate has a numerator,
a denominator and a stated time period: for example, 10 suicides per 100,000 persons per year.

3.0 Measures of Disease Frequency (Incidence and Prevalence) and Epidemiology

Incidence and Prevalence are two basic measures of disease frequency in epidemiology. They
describe important part of the natural course of disease, in that, Incidence indicate transition from
health to ill health, and Prevalence focuses on period of time a person (population) lives with a
disease. As mentioned, incidence rate indicate new occurrences of a disease in a population over a
specified period of time. It is used by epidemiologists to measure risk, exposure level, and
vulnerability of a population to a disease; as well as, the effectiveness of disease prevention
measures. To illustrate Incidence:
Assuming there is an outbreak of chicken pox in Ensign College of Public on 6 th October,
2016, which started with a second year male MPH student who made it habit of hugging
ladies. As on 9th October, 11 new cases were recorded at the colleges infirmary.
Meanwhile, the nurse had mentioned 3 existing cases who have been quarantined prior 6 th
October, 2016. Of the 15 new and existing cases, 12 cases were in their second year of
MPH progamme, and 3 cases were in their first year. Going through records, ECOPH
bears population of 150(both students and teaching staff).

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In such as case, an epidemiologist would want to go beyond the mere number of occurrences to
determine the rate of new disease occurrences using the mathematical formula below:
Number of people who got chicken pox

6 thOctober 2016 10th Oct . 2016

Population at risk at the start of the period

10n

Substituting with numbers:

Incidence (new occurrences) from 6th October to 10th October, 2016 = 12
Population at risk as at the start of the period (6th October, 2016) = 148

Cumulative Incidence =

12
148

102 = 8 per 100 people from 6th October, 2016 to 10th October,

2016, suffered chicken pox in the college.

Assuming the incidence increased from 8 per 100 people to 12 per 100 people on 12 th October,
2016, it would suggest an increase in incidence due to factors such as poor prevention
intervention measures, change in mode of transmission, increased risk factor, or increased
vulnerability among population at risk(CDC, 2012).
Another way epidemiologists calculate incidence is the use of incidence density. Incidence
density offers epidemiologists the opportunity to calculate the time individual cases contributed to
the population at risk over specific period of time. This approach according to WHO is the most
accurate way of calculating incidence(Beaglehole, 1993). To illustrate this using an example from
the book, Principle in Epidemiology in Public Health
Investigators enrolled 2,100 women in a study and followed them annually for four years
to determine the incidence rate of heart disease. After one year, none had a new diagnosis
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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 new diagnoses of heart disease, and 793 had been lost to follow - up.
After four years, another 8 had new diagnoses with heart disease, and 392 more had been
lost to follow - up.
Number of new cases of heart disease
Time each person was observed , totaled for all persons
Numerator = number of new cases of heart disease

= 0 + 1 + 7 + 8 = 16

Denominator (person-years of observation) = (2,000 + x 100) + (1,900 + x 1 + x 99) +

(1,100 + x 7 + x 793) +

Incidence Density=

(700 + x 8 + x 392)

= 6,400 person-years of follow-up

16
6,400 1000 = 2.5 cases per 1,000 person-years

3.1 Prevalence
The prevalence of disease is the proportion number of individuals in a population with a disease
or other personal attribute. It is used by epidemiologists to ascertain the burden of a disease and it
serves as a point of planning and allocating resources. To illustrate:
A questionnaire was distributed to the workforce of a company producing bottled water
for Ensign College of Public Health on a particular working day. Of the 1534 workers,
178 reported headaches on the survey day.

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Prevalence=178 cases

Prevalence (proportion) =

178
1534

100

= 0.12 or 12 per 100 workers have head ache.

4.0 Measures of Disease Association and Epidemiology

A major function of epidemiology is to ascertain the causes of adiseases. Epidemiologist start this
journey by first identifying exposures and the outcomes precipitated by the exposures. By this,
they use epidemiological tools such as Relative Risk, Attributable Risk and Odds Ratio.
4.1 Relative Risk (Risk Ratio)
It is a ratio of the prevalence of disease (or cumulative incidence) in two population groups.
Relative risks are applied to cross-sectional and cohort studies. It is expressed in mathematical
terms as:
Risk of disease(incidence proportion , attack rate)group of primary interest
Risk of disease ( incidence proportion, attack rate ) comparison group

A cross-sectional study in a small town collected information from individuals on recent

gastrointestinal symptoms and the source of their household water supply. Amongst those
with source A, the prevalence (risk) of diarrhoea was 0.11 while the prevalence amongst
individuals with source B was 0.04.

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0.11
0.04 =2.75

Interpretation
Values above 1 indicate a greater risk in A, values below 1 indicate a greater risk in B, while a
value of 1 implies equal risk in both groups. In this case the risk of suffering gastrointestinal is
2.75 times higher in source A than source B.
4.2 Odd ratio
Basically, odd ratio is the comparison of two odds. That is, odds of exposure in a group is the
number exposed in a group divided by the number not exposed. Epidemiologists use it in a casecontrol study and cross sectional to determine association of exposure with an outcome. If the
ratio for instance is above 1, epidemiologists interpret that cases are more likely to be exposed to
a particular factor than controls, and if the ratio is less than 1, the opposite is true. If the ratio is
close or equal to 1 it implies that the odds of exposure are very similar in the two groups.
Exposure to smoking
Smokers
Non smokers
10,000

Cancer
100 (a)
80 (c)

No cancer
1,900 (b)
7,920 (d)

Total
2,000
8,000

Odds ratio = ad / bc

100 (7,920)
80 (1,900) =5.2

Interpretation
This implies that those who smoke are 5.2 times likely to have been exposed to smoking.

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4.3 Attributable Risk

Attributable risk. According to CDC (2012), is a measure of the public health impact of a
causative factor. The calculation of this measure assumes that the occurrence of disease in the
unexposed group represents the baseline or expected risk for that disease. It further assumes that if
the risk of disease in the exposed group is higher than the risk in the unexposed group, the
difference can be attributed to the exposure. Thus, the attributable proportion is the amount of
disease in the exposed group attributable to the exposure.
In another study of smoking and lung cancer, the lung cancer mortality rate among nonsmokers
was 0.07 per 1,000 persons per year. The lung cancer mortality rate among persons who smoked
114 cigarettes per day was 0.57 lung cancer deaths per 1,000 persons per year. Calculate the
attributable proportion.
Attributable Risk
Risk exposed groupRisk unexposed group
= Attributable Risk
Risk exposed group
(0.57 0.07) / 0.57 x 100% = 87.7%
Interpretation
About 88% of the lung cancer among smokers of 1-14 cigarettes per day might be attributable to
their smoking. The remaining 12% of the lung cancer cases in this group would have occurred
anyway.

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QUESTION TWO (2)

Match each definitions below with one of the following terms:
(A) Prevalence
(B) Incidence
(D) Risk Ratio
(E) Risk Difference
(F) Attributable Fraction
a. _Risk Ratio -This statistic describes the excess in risk associated with an exposure in relative
terms. When it is 1, there is no additional risk associated with the exposure.
b. Prevalence -This statistic describes the probability that someone selected at random from the
population will have the disease in question.
c. Risk Difference This statistic describes the excess in risk in absolute terms. It shows the
additional number of cases expected per m exposures.
d. Incidence This statistic is used to estimate the risk of acquiring a disease. It may be measured
as a rate or a proportion.

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Question Three (3)

The College recently held a retirement reception but due to budget cuts had to go with the cheaper
caterer. After the event, 90 of the 120 attendees reported having severe gastroenteritis for the
weekend. The epidemiologist in you wanted to figure out which food(s) at the event might be
responsible, so you interviewed all of the attendees: Of 60 people who recalled eating mini beef
Wellingtons, 50 of them reported getting sick. Of 100 people who recalled eating spicy chicken
satay, 85 reported getting sick. Of 40 people who recalled having vegetables with ranch dressing
dip, 35 reported getting sick. Based on these interviews, which food is most likely responsible for
the gastroenteritis outbreak?
Food Specific Attack Rate
Ate
Mini Beef Wellingtons
Spicy chicken satay
Vegetables with ranch

Mini Beef Wellingtons

50
60

100 =83.3

Sick
50
85
35

Total
60
100
40

Attack Rate (%)

83.3
85
87.5

Spicy chicken satay

85
100

100 =85

Vegetables with ranch

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35
40

100 =87.5

Mini Beef Wellingtons

50
60

100 =83.3

Interpretation:
Vegetables with ranch of 87.5% Attack Rate is most likely responsible for the gastroenteritis
outbreak.

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Chapter four (4)

A study was conducted to determine the association between heart disease and smoking. Of the
8,000 people who joined the study, 3,000 smoked cigarettes. Among the smokers, 84 developed
heart disease and of the nonsmokers, 87 developed heart disease.
a) Write a report to how you determined the association between the exposure and the outcome
b) Assuming 35% of the population smoked, what is the attributable risk in the total population?
Solution
4a.) Write a report to how you determined the association between the exposure and the
outcome
Exposure to smoking
Smokers
Non smokers
8000

Cancer
84
87

No cancer
2,916
4,913

Total
3,000
5000

Relative Risk is used because the study suggests Prospective Study (Cohort Studies).
Relative Risk = Formulae
Risk in the exposed:
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84
100 = 2.8%
3000

Risk in the unexposed group:

87
5000 100 =1.7%

Relative Risk (Risk Ratio):

0.028
0.017 =1.6

Interpretation
It is observed that those who smoked are 1.6 times likely to develop cancer than those who do not
smoke.

4b.) Assuming 35% of the population smoked, what is the attributable risk in the total
population?
Exposure to smoking
Smokers
Non smokers
8000

Cancer
84
87

No cancer
2,716
5,113

Total
2,800
5200

If 35% of the population smoked, then the new number of those who smoked is 2,800.

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35
8000=2,800
100
Calculating Attributable Risk
Risk exposed groupRisk unexposed group
= Attributable Risk
Risk exposed group
Risk in exposed group:
84
=0.03
2,800
Risk in unexposed group
87
=0.017
5200

Attributable Risk
Risk exposed groupRisk unexposed group
= Attributable Risk
Risk exposed group
0.030.017
=0.433 100= 43.3%
0.03

Interpretation:
This implies that 43.3% of cancer found among those who smoke is due to their exposure to
smoking.

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REFERENCES
Beaglehole, R. B. R. K. T. (1993). Basic Epidemiology. Geneva: World Health Organisation.
CDC. (2012). Principles of Epidemiology in Public Health Practice: An intro to Applied
Epidemiology and Biostatistics.
Macfarlane, S. J. A. & M. J. G. (n.d.). Epidemiological Studies: A Practical Guide.

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