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Epidemiology

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the study of the distribution and determinants of health-related events or states in population groups and the application of the study to control health problems

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Population focus

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the focus of epidemiology is on the occurrence of the health and disease in the population

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population

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all the inhabitants of a given country or area considered together

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epidemiology is sometimes called

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population medicine

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the clinician

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Deals with patients Takes a history Conducts a physical Makes a diagnosis Proposes a treatment Follows up the patient

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the epidemiologist

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Deals with populations Frames the question Investigates Draws conclusions Gives recommendations Evaluates programmes

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distribution

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The occurrence of diseases and other health outcomes varies in populations, with some subgroups of the populations more frequently affected than others.

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determinants

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Any factor that brings about change in a health condition or other defined characteristic."

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the determinants of health include

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the social and economic environment, the physical environment, and the person's individual characteristics and behaviors.

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examples of determinants include

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social support network genetics income gender street lights education

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exposures

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pertain either to contact with a disease-causing factor or to the amount of the factor that impinges upon a group or individuals.

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examples of exposures

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second hand smoke. amount salmonella, how much

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outcomes

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"All the possible results that may stem from exposure to a causal factor..."

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how are outcomes expressed

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mortality or morbidity

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morbidity

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illnesses due to a specific disease or health condition

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mortality

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death

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quantification

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Refers to counting the cases of illness or other health outcomes Denotes the use of statistics to: describe the occurrence of health outcomes and measure their association with exposures

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Epidemiology aids with

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health promotion alleviation of adverse health outcomes prevention of disease

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Examples of health problems to be controlled:

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infectious and communicable diseases chronic diseases

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three types of prevention

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primary secondary tertiary

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Primary Prevention

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before the disease occurs

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Secondary Prevention

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during progression of the disease

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Tertiary Prevention

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during later stages of the disease. Reduction of disability and prompt rehabilitation

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Observational science

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is a science where it is not possible to construct controlled experiments in the area under study. It is more of a seeing and watching science.

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Epidemiology is an ____________________ that capitalizes upon naturally occurring situations in order to study the occurrence of disease.

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observational science

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Descriptive epidemiology

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refers to epidemiologic studies concerned with characterizing the amount and distribution of health and disease within a population. Person- sex, age, race/ethnicity Place- countries, regions, localized patterns of disease Time- decade, year month week, hours

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Analytic epidemiology

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examines causal (etiologic) hypotheses regarding the association between exposures and health conditions.

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Epidemiologists are hired by

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State and local health departments Federal government agencies such as the National Institutes of Health, Department of Health and Human Services, and the Centers for Disease Control and Prevention Private companies like Bristol-Myers Squibb, British Airways, Chevron Corporation, Dow Corning Corporation, Dupont, and Eli Lilly and Company International agencies such as the World Health Organization Consulting firms; and Medical centers (Infection Preventionist)

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Hippocrates (460 BC-370 BC)

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Greek authority departed from superstitious reasons for diseases and disease outbreaks and was the founder of Western Medicine Hippocratic Oath Wrote On Airs, Waters, and Places in 400 BC Suggested disease might be associated with environmental factors

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Plague

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Of great significance for epidemiology Thought to be caused by a bacterial infection of Yersinia pestis transmitted via flea bites Three pandemic plagues in history Characterized by: Swollen lymph nodes Fever Appearance of black splotches on the skin

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John Graunt (1620- 1674)

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First to employ quantitative methods to describe birth and death data, seasonal variations, and infant mortality Known as the Columbus of statistics Natural and Political Observations Mentioned in a Following Index, and Made Upon the Bills of Mortality (1662)

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Sir Percival Pott (1714-1788)

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is thought to be the first person to describe an environmental cause of cancer. Observed that chimney sweeps had high incidence of scrotal cancer

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Edward Jenner (1749-1823)

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developed the first vaccine in 1796 for smallpox.

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John Snow and cholera in London during the mid- 19th century

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Over the centuries, cholera has inspired great fear because of the dramatic symptoms and mortality that it causes. Untreated cholera outbreaks can kill more than one-half of affected cases. Cause is Vibrio cholerae bacterium. Level of fatality is often less than 1% when the disease is treated.

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John Snow (1813-1858)

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An English anesthesiologist who innovated several of the key epidemiologic methods that remain valid and in use today Believed that cholera was transmitted by contaminated water and was able to demonstrate this association.

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Snow's Natural Experiment

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Broad Street, London, had a major cholera outbreak in 1849. Two different water companies supplied water from the Thames River to houses in the same area. In 1852, the Lambeth Company relocated its sources of water to a less polluted portion of the river. Snow noted that during a later cholera outbreak in 1854, those residents served by the Lambeth Company had fewer cases of cholera than residents served by the other water company (Southwark and Vauxhall Company).

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John Snow's Contributions

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Powers of observation and written expression Application of epidemiologic methods Used mapping (spot maps of cases) Used data tables to describe infectious disease outbreaks Recommended a public health measure to prevent disease

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William Farr (1807-1883)

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Developed a more sophisticated system that recorded the cause of death. Examined possible linkage between mortality rates and population density (defined as number of persons per square mile)

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Robert Koch (1843-1910)

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a German physician. his postulates demonstrated the association between a microorganism and a disease.

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Koch's Postulates:

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1.The organism must be observed in every case of the disease. 2.It must be isolated and grown in pure culture. 3. The pure culture must, when inoculated into a susceptible animal, reproduce the disease. 4.The organism must be observed in, and recovered from, the experimental animal.

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Pandemic influenza (1918-1919

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aka Spanish Flu Killed 50 to 100 million persons globally Estimates suggest that one-third of the world's population became infected and developed clinically observable illness. Infected young adults

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Discovery of penicillin

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Alexander Fleming (1881-1955) discovered the anti-microbial properties of the mold Antibiotic avaliable toward end of WWII

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Framingham Study

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investigates risk factors for coronary heart disease.

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Historical use of Epi

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documents the patterns, types, and causes of morbidity and mortality over time. Example: Decline in infectious disease mortality Epidemiologic Transition Describes a shift in the patterns of morbidity and mortality from causes related primarily to infectious and communicable diseases to causes associated with chronic, degenerative diseases

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Community health use Epi

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To diagnose the health of the community and the condition of the people, to measure the true dimensions and distribution of ill-health in terms of incidence, prevalence, disability and mortality;..." Characteristics that maybe measured are: age and sex distribution, race/ethnicity, SES, employment/unemployment, access to health care, pop density, residential mobility.

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Disease Management

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Refers to a method of reducing healthcare costs by providing integrated care for chronic conditions. Examples include integrated care for: Heart disease Hypertension Diabetes

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risk

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The probability that an event will occur..."

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risk factor

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an exposure that is associated with a disease, morbidity, mortality, or adverse health outcome.

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risk assessment

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a methodology used to provide quantitative measurements of risk to health. Helps us create PH policy

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disease causality use

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To search for causes of health and disease by computing the experience of groups defined by their composition, inheritance and experience, their behavior and environments." One of the most important uses of epidemiology

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graphical Presentations

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Used to summarize key aspects of the data set Types of graphs: Bar chart Line graph Pie chart

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How to make a graph: the title should include ________

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Description of the data Location Date

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Bar Chart

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Is a type of graph that shows the frequency of cases for categories of a categorical (discrete) variable such as a Yes/No variable.

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Histogram

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chart used for continuous variables

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Continuous Variable

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A variable that could have an infinite number of values along a continuum.

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examples of continuous variables

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height, weight, and blood sugar level, time.

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Pie Chart

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A circle that shows the proportion of cases according to several categories

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Spot maps and rate maps

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display geographical locations of cases or rates

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__________ are slightly different in that geographical areas are shaded according to the differences in values; prevalence, incidence or mortality are often shown on rate maps. Areas with the highest rates are typically shaded with the darkest shades or the brightest colors

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rate maps

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Epidemic

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"The occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess of normal expectancy."

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Pandemic

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"An epidemic occurring worldwide, or over a very wide area, crossing international boundaries, and usually affecting a large number of people."

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examples of pandemics

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1918 spanish flu 2009 h1n1

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Endemic

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The habitual presence of a disease within a given geographic area.

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Epizootic

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An epidemic outbreak of disease in an animal population in a given geographic area, often with the implication that it may extend to humans

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Ratio

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The value obtained by dividing one quantity by another."

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examples of ratios

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rates proportions percentages

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Proportion

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A type of ratio in which the numerator is part of the denominator

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_________________ Indicate how important a health outcome is relative to the size of the group

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proportions

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________________May be expressed as a percentage

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proportions

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A/(A+B)

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calculation of a proportion

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Percentage

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A proportion that has been multiplied by 100.

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(A/A+B) X 100

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formula for a percentage

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Rate

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Also a type of ratio, a _____ differs from a proportion because the denominator involves a measure of time.

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calculation of a rate

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x/ change in time

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Epidemiologic measures provide the following types of information:

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the frequency of a disease or condition associations between exposures and health outcomes strength of the relationship between an exposure and a health outcome

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__________________________ are useful in epidemiology to characterize the occurrence of disease, morbidity, and mortality in populations.

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quantitative terms

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Quantitative terms include:

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Counts Incidence Prevalence

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Count

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Refers to the number of cases of a disease or other health phenomenon being studied

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Incidence

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Refers to the occurrence of new disease or mortality within a defined period of observation (e.g., a week, month, year, or other time period) in a specified population.

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Population at Risk

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The members of the population who are capable of developing the disease or condition being studied are known as ____________

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Incidence Rate

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A rate formed by dividing the number of new cases that occur during a time period by the number of individuals in the population at risk

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Attack Rates

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used as a synonym for risk. It is the risk of getting the disease during a specified period, such as the duration of an outbreak. A variety of attack rates can be calculated.

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Overall attack rate

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the total number of new cases divided by the total population.

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A food-specific attack rate

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is the number of persons who ate a specified food and became ill divided by the total number of persons who ate that food.

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secondary attack rate

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sometimes calculated to document the difference between community transmission of illness versus transmission of illness in a household, barracks, or other closed population.

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Prevalence

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The number of existing cases of a disease or health condition, or deaths in a population at some designated time.

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Point Prevalence

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All cases of a disease, health condition, or deaths that exist at a particular point in time relative to a specific population from which the cases are derived.

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point prevalence formula

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Number of persons ill at a point in time/ Total number in the group

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Period Prevalence

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All cases of a disease within a period of time

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Lifetime Prevalence

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Cases diagnosed at any time during the person's lifetime

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Factors that cause prevalence to increase

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Increase in incidence Longer duration of the case In-migration of cases Prolongation of life of patients without a cure

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Factors that cause prevalence to decrease

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Decrease in incidence Shorter duration of disease In-migration of healthy people Improved cure rate of disease

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Four measures of morbidity (illness) and mortality (death) are:

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crude rates case fatality rates proportional mortality ratio cause-specific rates

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Crude Rate

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A type of rate that has not been modified to take account of any of the factors such as the demographic make-up of the population that may affect the observed rate Includes a time period during which an event occurred.

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crude rate calculation

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frequency of disease over a specified period of time/ unit size of population

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___________ Aid in making comparisons but have limitations

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crude rate

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Crude Death Rate

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Can be expressed in terms of any unit size of a population that is convenient. For example, infant mortality is expressed per 1,000 live births and cancer rates are expressed per 100,000 population.

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crude death rate calculation

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# of deaths in given year/ reference population (midpoint) all multiplied by 100,000

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Reference Population

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The population from which cases of a disease have been taken

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Case Fatality Rate (CFR)

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The number of deaths due to a disease that occur among persons who are afflicted with that disease.

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calculation of case fatality rate

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# of deaths due to disease "x"/ number of cases of disease "x" all multiplied by 100 during a time period expressed as a percentage

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Proportional Mortality Ratio (PMR)

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The number of deaths within a population due to a specific disease or cause divided by the total number of deaths in the population

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PMR formula

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mortality due to a specific cause during a time period/ mortality due to all causes during the same time period all multiplied by 100 expressed as a percentage

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Cause-Specific Rate

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A measure that refers to mortality (or frequency of a given disease) divided by the population size at the midpoint of a time period times a multiplier.

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cause specific rate calculation

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mortality/population at midpoint size of time period all multiplied by 100,000

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Age-Specific Rate (R)

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The number of cases per age group of population during a specified time period

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R=

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number of deaths among those aged 15-24yo/ number of persons who are aged 15-24 (during time period) all per 100,000

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Sex-Specific Rate

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The frequency of a disease in a gender group divided by the total number of persons within that gender group during a time period times a multiplier all per 100,000

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Adjusted Rate

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A rate of morbidity or mortality in a population in which statistical procedures have been applied to permit fair comparisons across populations by removing the effect of differences in the composition of various populations Age is a factor

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disability-adjusted life years (DALYs)

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It is a measurement that combines the burden of mortality and morbidity into a single number.

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the sum of ______across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

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DALYS

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DALYs for a disease or health condition are calculated as the sum of the_________ due to premature mortality in the population and the _________ for people living with the health condition or its consequences

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Years of Life Lost (YLL) Years Lost due to Disability (YLD)

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DALY =

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YLL + YLD

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Quality

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is determined by the sources used to obtain the data and how completely the data cover the reference population.

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The quality of data affects the permissible ________________ of the data and the types of statistical analyses that may be performed.

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applications

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Ask the following questions when choosing a data set:

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What is the nature of the data, including sources and content? How available are the data? HIPPA protected information How complete is the population coverage? What are the appropriate and inappropriate uses of the data?

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Representativeness

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Also known as external validity

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Refers to the generalizability of the findings to the population from which the data have been taken.

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representativeness

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U.S. Bureau of the Census

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provides data that can be used to define the denominator in rates with respect to official estimates of total population size and subdivisions of the population by geographical area.

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The American Community Survey (ACS)

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is an ongoing survey that collects data every year -- giving communities the current information they need to plan investments and services.

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Vital events

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are deaths, births, marriages, divorces, and fetal deaths.

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US Mortality data

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are almost totally complete because deaths are unlikely to go unrecorded in the United States.

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National Center for Health Statistics (NCHS)

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compiles and publishes national mortality and morbidity rates.

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WHO Mortality Database

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only 1/3 of adults are included

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Death certificate data in U.S. include the following information:

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demographic characteristics (e.g., age, sex, race) date and place of death (e.g., hospital, home) cause of death (e.g., immediate cause and contributing factors)

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Note that the specified cause of death may not be entirely accurate.

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Primary cause of death sometimes unclear. Diagnostic criteria may lack consistent standards Some conditions may be unreported because of stigma (HIV, TB, alcoholism, drug addict)

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The International Classification of Diseases (ICD)

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is the classification used to code and classify mortality data from death certificates

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The International Classification of Diseases, Clinical Modification

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is used to code and classify morbidity data from the inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys."

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Birth Statistics

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Include live births and fetal deaths Presumed to be nearly complete Used to calculate birth rates Helpful in understanding birth defects, length of gestation, birth weight, and demographic background of the mother Affected by mother's failure to recall events during pregnancy May miss conditions that were not detected at birth

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Life expectancy

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number of years that a person is expected to live, at any particular year (e.g., at birth)

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Additional Measures of Disease Occurrence

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Maternal mortality rate Infant mortality rate Fetal mortality Fetal death rate Late fetal death rate Birth rate (e.g., crude birth rate) General fertility rate Perinatal mortality rate

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Maternal Mortality

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Encompasses maternal deaths that result from causes associated with pregnancy.

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Maternal Mortality Rate

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number of deaths assigned to causes related to childbirth/ number of live births X 100,000 live births

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Infant Mortality Rate

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Number of infant deaths among infants aged 0-365 days during a year divided by the number of live births during the same year (expressed as rate per 1,000 live births) Related to inadequate health care and poor environmental conditions. Substantial racial and ethnic variations.

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Fetal Mortality

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Death of the fetus when it is in the uterus and before it has been delivered

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Fetal death rate-

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death after 20 weeks

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Late fetal death rate-

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death after 28 weeks

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fetal death rate calculation

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number of fetal deaths after 20 weeks or more gestation/ number of live births + number of fetal deaths after 20 weeks or more gestation X 1,000

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late fetal death rate calculation

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number of fetal deaths after 28 weeks or more gestation/ number of live births + number of fetal deaths after 28 weeks or more gestation X 1,000

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Crude Birth Rate

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Number of live births during a specified period such as a year per the resident population during the midpoint of the year Affects the size of the population.

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crude birth rate calculation

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number of live births within a given period/ population size at the middle of that period X 1,000 population

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General Fertility Rate (Fertility Rate)

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Number of live births reported in an area during a given time interval divided by number of women aged 15-44 years in the area Expressed as rate per 1,000 women aged 15-44 years.

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general fertility rate calculation

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# of live births within a year/ # of women aged 15-44 during midpoint of the year X 1,000 women aged 15-44

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Perinatal Mortality

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Defined as the number of late fetal deaths after 28 weeks or more gestation plus infant deaths within 7 days of birth divided by the number of live births plus the number of late fetal deaths during a year. Expressed as rate per 1,000 live births and fetal deaths.

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Public Health Surveillance

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The ongoing systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The final link in the surveillance chain is the application of these data to prevention and control."

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PH surveillance information is used to:

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Assess public health status Track conditions of public health importance Define public health priorities Evaluate programs Develop public health research

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Passive Surveillance

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(initiated by the source of the data, often a health care provider or clinical laboratory rather than the health department) - refers to data supplied based on a known set of rules or regulations that require reporting (e.g., VAERS, notifiable disease reporting).

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Active Surveillance

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health agency solicits reports from various providers. Most commonly implemented in epidemic settings.

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World Health Organization (WHO)

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Provides global infectious disease surveillance Yields data on health indicators Collects mortality data

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European Union

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Public health data include social and health inequalities and determinants of health.

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Pan American Health Organization (PAHO

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Disease information from Central and South America

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Three examples are surveillance systems for the following:

answer

Communicable and infectious diseases Non-infectious diseases Risk factors for chronic diseases

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Reportable and Notifiable Disease Statistics

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By legal statute, physicians and other health-care providers must report cases of certain diseases, known as reportable and notifiable diseases, to health authorities.

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Sentinel" Surveillance

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Use of a subset of a population to serve as "early warning" of Public Health events

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advantages of sentinel surveillance

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surveillance can be targeted to specific populations or geographies - less resource intensive

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Sentinel Chicken (Arboviral) Surveillance

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Used to detect the presence of arboviruses within certain geographical areas Targeted interventions

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Syndromic Surveillance

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Monitoring of hospital emergency department chief complaints (CC) "Syndromes" based on CC Generally represent potential prodromal stages of infectious diseases Bioterrorism events Naturally occurring outbreak

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Reportable and Notifiable Disease Statistics

answer

Deficiencies of these statistics: Population coverage may be incomplete. No information is available about persons who develop the disease and do not seek medical attention. Physicians and other providers may fail to fill out the proper forms or know which diseases are currently reportable.

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Behavioral Risk Factor Surveillance System (BRFSS)

answer

State-based telephone surveillance system designed to collect data on: Individual risk behaviors Preventive health practices Information from the survey is used for health planning, program evaluation, and monitoring health objectives Examples of data collected relate to: Health risk behaviors Preventive health practices Health care access

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Youth Risk Behavior Survey

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School-based confidential survey of Florida's public high school students Administered in odd-numbered years to students in 9-12 grade levels Topics of YRBS cover: Unintentional injuries & violence Tobacco, alcohol, and drug use Sexual behaviors Dietary behaviors Physical activity

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Florida Youth Tobacco Survey

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Tracks indicators of tobacco use and exposure to second-hand smoke among public middle and high school students Provides data for monitoring and evaluating tobacco use

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Statewide Cancer Registry

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Legislatively mandated, population-based, statewide cancer registry Demographic data, diagnosis, stage of disease at diagnosis, medical history, laboratory data, tissue diagnosis, and initial course of treatment

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Data from the National Center for Health Statistics (NCHS)

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Scope of information is extensive. Examples of surveys and data collection systems include: The National Health Interview Survey National Health and Nutrition Examination Survey (NHANES) The Vital Statistics System

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Chronic Disease Surveillance: Asthma as an example

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Asthma surveillance programs provide data necessary for the development and evaluation of healthcare services for afflicted persons. National data is available on asthma prevalence, activity limitation, days of work or school lost, rescue and control medication use, asthma self-management education, physician visits, emergency department visits, hospitalizations due to asthma, and deaths due to asthma.

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The field of _________________ classifies the occurrence of disease according to the following variables: person (who is affected) place (where the condition occurs) time (when and over what time period the condition has occurred)

answer

descriptive epidemiology

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A____________________ is one that is ...concerned with characterizing the amount and distribution of health and disease within a population.

answer

descriptive epidemiologic study

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Descriptive Epi Provides valuable information for the following activities:

answer

Prevention of disease Design of interventions Conduct of additional research (Analytic studies: case control, cohort)

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Uses of Descriptive Epidemiologic Studies

answer

Permit evaluation of trends in health and disease Provide a basis for planning, provision, and evaluation of health services Identify problems to be studied by analytic methods and suggest areas that may be fruitful for investigation

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Types of Descriptive Epidemiologic Studies

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Case reports Case series Cross-sectional studies

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Case Reports (Case Studies)

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Accounts of a single occurrence of a noteworthy health-related incident or of a small collection of such events Tracks people with a known exposure or looks back via medical records for a common exposure and health outcome. Can be prospective or retrospective studies

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Retrospective-

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Looking back at events that have already taken place. Criteria are established for selecting cases from historical records for inclusion in the study.

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Prospective-

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Looking forward at events that are likely to occur in the future. Criteria are established and cases fitting the criteria are included as they become available.

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In comparison with a case report, a _______________ is a larger collection of cases of disease, often grouped consecutively and listing common features, e.g. characteristics of affected patients.

answer

case series

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Cross-Sectional Studies

answer

A type of investigation ...that examines the relationship between diseases (or other health-related characteristics) and other variables of interest as they exist in a defined population at one particular time. A type of prevalence study Example: the Behavioral Risk Factor Surveillance System (BRFSS)

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Epidemiologic Inferences from Descriptive Data

answer

Descriptive epidemiology and descriptive studies provide a basis for generating hypotheses. Descriptive epidemiologic studies connect intimately with the process of epidemiologic inference. Epidemiologic inference is initiated with descriptive observations.

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Person Variables: Examples

answer

Marital Status Nativity (place of origin) Migration Religion Age Sex Race/Ethnicity Socioeconomic Status

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Age

answer

Perhaps the most important factor to consider when describing occurrence of disease or illness

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Examples of Age Associations

answer

The incidence of and mortality from chronic diseases increase with age. Some infections, e.g., mumps and chickenpox occur more commonly during childhood. The leading cause of death among young adults is unintentional injuries. Maternal age is associated with rates of diabetes and related complications.

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Sex

answer

Epidemiologic studies have shown sex differences in a wide scope of health phenomena including morbidity and mortality. Examples: All cause age-specific mortality rates higher among males Differences in cancer rates, e.g., cancers of the genital system

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Five major race categories in Census 2010:

answer

White Black or African American American Indian and Alaska Native Asian Native Hawaiian and other Pacific Islander

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Ethnicity-

answer

Non-hispanic or Hispanic

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Race/Ethnicity: Other Considerations

answer

Somewhat ambiguous classification Tends to overlap with nativity and religion Some scientists propose that it is a social construct rather than a biological construct. Used to track various health outcomes

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Nativity

answer

Place of origin of the individual or his or her relatives Subdivisions include: Foreign-born Native-born

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Examples of racial/ethnic differences in health characteristics include the following:

answer

Lower frequency of asthma reported among Hispanics. Incidence of gonorrhea is higher among non-Hispanic blacks than other groups.

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Socioeconomic Status (SES)

answer

Defined as a "Descriptive term for a person's position in society,..." Often formulated as a composite measure of the following dimensions: A person's income level Education level Type of occupation A single dimension of SES (e.g., poverty level) may be used. The social class gradient Strong, inverse association of SES with levels of morbidity and mortality Those in lowest SES positions are confronted with excesses of morbidity and mortality from numerous causes.

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Your percent poverty

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Percent poverty: 100%, 200%, 400% Ratio of income to poverty threshold (government decides

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Health Disparities

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Differences in the occurrence of diseases and adverse health conditions in the population

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Place variables

answer

Morbidity and mortality vary greatly with respect to place. International National (within-country) Urban-rural differences Localized patterns of disease

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International Variables

answer

World Health Organization (WHO) studies: Both infectious and chronic diseases show great variation from one country to another. Climate, cultural factors, national dietary habits, and access to health care affect disease occurrence. Variations in life expectancy (U.S. ranked number 42 in 2013).

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National (Within-Country)

answer

Regional differences may affect the prevalence and incidence of disease. Factors include: Climate Latitude Environmental pollution Example: Regional variations in stroke

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Urban-Rural Differences

answer

Urban and rural sections of the United States show variations in morbidity and mortality related to environmental and lifestyle issues. Urban example: elevated occurrence of lead poisoning among children who live in older buildings. Rural example: pesticide exposure and farming injuries among agricultural workers.

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Localized Patterns of Disease

answer

Associated with specific environmental conditions that may exist in a particular geographic area. Examples: Cancer and radon gas Naturally occurring arsenic in water supply Presence of disease vectors

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Time Variables

answer

Secular trends Cyclic (seasonal) trends Point epidemics Clustering

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Secular Trends

answer

Refer to gradual changes in the frequency of disease over long time periods. Examples: Yearly suicide rates of U.S. females—firearm-associated suicides decreased, but those by hanging increased. Age-adjusted prevalence of hypertension (no secular trend shown).

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Cyclic (Seasonal) Trends

answer

Cyclic trends are increases and decreases in the frequency of a disease or other phenomenon over a period of several years or within a year.

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A_________________ may indicate the response of a group of people circumscribed in place to a common source of infection, contamination, or other etiologic factor to which they were exposed almost simultaneously. Example: outbreak of Vibrio infections following Hurricane Katrina in 2005

answer

point epidemic

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Clustering

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"A closely grouped series of events or cases of a disease or other health-related phenomena with well-defined distribution patterns in relation to time or place or both...." Often used to describe aggregation of uncommon conditions such as leukemia or cancer. Clustering may reflect: Common exposure to an etiologic agent Chance occurrences

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spatial clustering

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refers to aggregation of events in a geographic region

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Temporal clustering

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denotes the occurrence of events related to time.

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