Teach Epidemiology

Centers for Disease Control and PreventionGlobal Health Odyssey Museum

Tom Harkin Global Communications Center June 8-12, 2009

Teach EpidemiologyProfessional Development Workshop

Day5

2Teach Epidemiology

Teach Epidemiology

Welcome to

Web Sites

Teach Epidemiology

Teach Epidemiology

Teach Epidemiology

Teach Epidemiology

Teach Epidemiology

Welcome to

Teach Epidemiology

Teach Epidemiology

Teach Epidemiology

6

Time Check

9:15 AM

7Teach Epidemiology

Teach Epidemiology

8Teach Epidemiology

Teaching Epidemiology

Group 5

9Teach Epidemiology

Teach Epidemiology

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Enduring Epidemiological Understandings

Scenario 1 - Guilt by Association

Wendy

Mark

WendyNot Observed

Empty Beer Bottles

MarkCause

Scenario 1- Guilt By Association

Association Cause

XObserved

Confounding

Definition

A situation in which an association between a given exposure

and an outcome is observed as a result of the influence of a third unobserved factor, called a confounder.

Confounding

Review

A situation in which an association between a given exposure (Mark) and an outcome (empty bottles) is observed as a

result of the influence of a third unobserved factor, called a confounder (Wendy)

Obviously we should have spoken to Wendy.

Cause

Association Cause

XObserved

Not Observed Confounder

Match-Carrying

Lung Cancer

Review - Diagram of Confounding

Smoking

Epi Teams

Confounding 1

Cause

Association Cause

XObserved


Coffee Cancer

Confounding 2

Cause

Association Cause

XObserved


Drinking Alcohol during Pregnancy

Low Birth Weight

Babies

Confounding 3

Cause

Association Cause

XObserved


Eating Pretzels

Auto Accidents

Confounding 4

Cause

Association Cause

XObserved


Watching TV

Acne

Confounding 5

Cause

Association Cause

XObserved


Playing Volleyball

Skin Cancer

Confounding 6

Cause

Association Cause

XObserved


Driving Motorcycles

Hepatitis C

Confounding 7

Cause

Association Cause

XObserved


Playing Baseball

Oral Cancer

Confounding 8

Cause

Association Cause

XObserved


SandSkin

Cancer

Confounding 9

Cause

Association Cause

XObserved


Eating Ice Cream

Drowning

Scenario 2

Died Not Died

Scenario

Had Bedsores

No Bedsores 90

b

d

a

c

Risks Relative Risk

79

286

745

8,290

824

8,576

9%

3%

Total

X 3

Individuals with bedsores are 3 times more likely to die than those without bedsores.

DeathGetting

bedsores

“The study establishes a clear

progression beginning with

patients getting bed sores and ending

with death.”

“If we can keep our patients from

getting bedsores, then we can go a long way towards

preventing hospital deaths.”

Cause

Scenario 2

Confounding

Is cause the only possible

association between the

two?

1. Cause

2. Chance

3. Bias

Reverse Time Order

4.

5. Confounding

?Not Observed

DeathsBedsoresCause

Scenario 2

Association Cause

XObserved

Scenarios

?

Not Observed

DeathBedsoresCause

Association Cause

XObserved

Wendy

Not Observed

Broken Beer Bottles

MarkCause

Association Cause

XObserved

Scenario 1 Scenario 2

Scenario 2

?Not Observed

DeathBedsoresCause

Association Cause

XObserved

Confounder

Scenario 2

?

DeathBedsoresCause

Association Cause

XObserved

Severity of Medical

Condition

Not Observed Brainstorm

Stratification

Definition

A procedure which creates strata based on categories of the suspected confounding variable and examines the exposure-disease association within each stratum (subgroups).

Stratification

Died Not Died

Scenario 2 Stratified

Had Bedsores

No Bedsores 90

b

d

a

c

Risks Relative Risk

55

5

51

5

106

19

51.9%

50.0%

Total

Patients with

High Medical Severity

x1

There is no association!!

Died Not Died

Scenario 2 Stratified

Had Bedsores

No Bedsores 90

b

d

a

c

Risks Relative Risk

24

281

694

8,285

718

8,566

3.3%

3.3%

Total

Patients with

Low Medical Severity

There is no association!!

x1

Died Not Died

Scenario 2 Adjusted

High Severity

Low Severity 90

b

d

a

c

Risks Relative Risk

60

305

56

8,979

116

9,284

51.7%

3.2%

Total

All Patients Based on Severity of Illness ONLY

x16

The high relative risk show that severity of illness is a CONFOUNDER.

Scenario 2

Summary – Relative Risk of Death

Bedsore vs. No Bedsore 3

Bedsore vs. No Bedsore

(High Severity Illness)1

Bedsore vs. No Bedsore (Low Severity Illness)

1

High Severity vs. Low Severity Illness

16

Severity of Illness

Group Practice

Confounding

Is the association due to confounding?

1. Cause

2. Chance

3. Bias

Reverse Time Order

4.

5. Confounding



44

National Research Council , Learning and Understanding

Teach Epidemiology


Knowledge that “… is connected and organized, and … ‘conditionalized’ to specify the context in which it is applicable.”

45

Time Check

10:00 AM


Teach Epidemiology



Group 6

TYPES OF BIASTYPES OF BIAS

Using the definitions of the Using the definitions of the types of bias given, match the types of bias given, match the

following phrases with the following phrases with the appropriate bias.appropriate bias.

Name the BiasName the Bias

epidemiologist asks specific epidemiologist asks specific questions to casequestions to case

Information BiasInformation Bias


better memory recallbetter memory recall

Recall BiasRecall Bias


Heightened knowledge of riskHeightened knowledge of risk

Awareness BiasAwareness Bias


spends more time on casespends more time on case



error in sampling processerror in sampling process

Selection Bias Selection Bias


time lapsetime lapse



PublicityPublicity



less recallless recall



MagazinesMagazines



MemoryMemory



Higher focus on past behaviorsHigher focus on past behaviors



more than one disease presentmore than one disease present

Berkson’s BiasBerkson’s Bias


fabrication of informationfabrication of information



probes for more with caseprobes for more with case



unbalanced in comparison to target unbalanced in comparison to target populationpopulation



Social stigmaSocial stigma



hospital admissionhospital admission



mediamedia


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Teach Epidemiology



68

Time Check

10:45 AM


Teach Epidemiology



Group 7

92


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93

Time Check

11:30 AM

94


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Teach Epidemiology - 501 (Monday) CDC June 2009

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John Snow, MD

(1813-1858)

Father of Epidemiology

“On the Mode and

Transmission of Cholera”

Identifying Patterns and Formulating Hypotheses


99



A Mysterious Ailment

By Jerry Bishop, Staff Reporter of the Wall Street Journal

A mysterious, often fatal illness is breaking out in epidemic proportions among young homosexual men and drug users. More than 180 cases of the strange illness have been reported since last summer to the federal Center for Disease Control in Atlanta. As of last Friday, at least 74 of the victims have died. All the victims are men and 90% of them are either homosexual or bisexual. Many of the victims are drug users. The illness is characterized by months of fever, malaise, and drastic weight loss. In almost all cases the patients develop overwhelming infections of one or more of a dozen different viruses, bacteria or protozoa. The infecting microbes are types that do not ordinarily cause overt human disease. Many of the patients also develop a rare type of cancer. To the astonishment of medical scientists, most of the patients appear to have recently developed a defect in their immune systems that prevents them from fighting off infections. The infections are extremely difficult to control with antibiotics and antiviral drugs. "We are reasonably confident that this is, in fact, a new medical problem," said Dr. Harold Jaffe, an epidemiologist on a new task force organized by the Center for Disease Control to search for the cause of the illness. In an effort comparable to that launched last year to unravel the mystery of toxic shock syndrome, the center's task force is trying to find out whether a new germ has emerged or whether something in the environment has changed to account for the sudden outbreak of the illness. For example, the task force is checking into the use of sexual stimulants by the victims on the possibility these chemicals can impair the immune system and leave the user vulnerable to infections. Among such stimulants are chemicals that are inhaled. These include amyl nitrate sold in glass vials, known by the street name "poppers" and isobutyl nitrate sold as "liquid incense." First hints that some unusual illness was breaking out came earlier this year when researchers in New York and Los Angeles reported cases of both a rare kind of pneumonia and a rare cancer called Kaposi's sarcoma occurring in a few young men. The men were either homosexual or drug users or both. The disease center alerted doctors and health officials around the country last summer to the strange ailment. This week's New England Journal of Medicine, published today, devotes three articles to describing 19 of the patients, six of whom died. Publishing three lengthy articles on the same illness is unusual for the medical



101

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2006

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



Answer the Question

Teach Epidemiology


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Whistles

What’s My Hypothesis?

Teach Epidemiology



Group 1



Group 2


107


Teach Epidemiology





Ken Bain, What the Best College Teachers Do

“… they can distinguish between foundational concepts and elaborations or illustrations of those ideas.”



Teach Epidemiology - 501 (Tuesday) CDC June 2009

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111

Risk of

Negative Heroin

Test

Nothing

Bupe

Total

Trial 1 Trial 2

Trial 3 Trial 4

Bupe

No Bupe

Bupe

No Bupe

Bupe

TotalRelative

Risk

No Bupe

TotalRelative

Risk

Total

Tested Negative

for Heroin

Tested Positive

for HeroinRelative

Risk

Risk of

Negative Heroin

Test

Tested Negative

for Heroin

Tested Positive

for Heroin

Risk of

Negative Heroin

Test

Tested Negative

for Heroin

Tested Positive

for Heroin

Risk of

Negative Heroin

Test

Tested Negative

for Heroin

Tested Positive

for Heroin

10021 7990

or 21%21

10010021 79

90or 21%

21

100

10021 7990

or 21%21

10010021 79

90or 21%

21

100

10021 7990

or 21%21

100

Bupe is not associated with having a negative tests for heroin.

1

10062 3890

or 62%62

100

Bupe is associated with having a positive test for heroin!

.34

1006 9490

or 6%6

100

Bupe is associated with having a negative test for heroin.

3.5

Nothing

Compared to what?

Making Group Comparisons and Identifying Associations

Teach Epidemiology

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Buprenorphine

Buprenorphine & Naloxone

Placebo


Teach Epidemiology

DrugEpi 3-5 Fundamentals of Study Design

Controlled Trial

Healthy People

-

Healthy People

E

Random Assignment

E

DZ

DZ

DZ

DZ

Cohort Study

Healthy People

-

Healthy People

E

E

DZ

DZ

DZ

DZ

Cross-Sectional Study

-

E

E

DZ

DZ

Case-Control Study

-

DZ

DZ

E

E

E

E


Teach Epidemiology


Teach Epidemiology

Test the hypothesis:

People who watch more TV eat more junk food.


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Group 3


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Group 4


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Explaining Associations and Judging Causality

122

Relative Risks

Greater than 1 Less than 1

1

By ChanceBy Chance

25 cards25 cards25 cards25 cards

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Group 7

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Group 6

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Group 8

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Hypothesis

Total Risk Relative Risk

a b

c d

or %

or %Exposure Outcome

?Turned Up Together

Healthy People

-

Healthy People

E

E

DZ

DZ

DZ

DZ

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1.

2.

3.

4.

5.

6.

7.

8.

.

Empowers students to be scientifically literate participants in the democratic decision-making process concerning public health policy.

Empowers students to make more informed personal health-related decisions.

Increases students’ media literacy and their understanding of public health messages.

Increases students’ understanding of the basis for determining risk.

Improves students’ mathematical and scientific literacy.

Expands students’ understanding of scientific methods and develops their critical thinking skills.

Provides students with another mechanism for exploring important, real world questions about their health and the health of others.

Introduces students to an array of career paths related to the public’s health.

Top 8 Reasons to Teach / Learn about Epidemiology

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Workshop Goal

Teach Epidemiology

To increase the frequency with which epidemiology is taught to students in grades 6-12

Teach Epidemiology

Innovation

… an idea, practice or object that is perceived as new by an individual or other unit of adoption.

Everett M. Rogers, Diffusion of Innovations

Workshop Goal

Diffusion

The process by which an innovation is communicated through certain channels over time among the members of a social system

(with the aim being to maximize the exposure and reach of innovations, strategies, or programs.)

Everett M. Rogers, Diffusion of Innovations

Teach Epidemiology

Workshop Goal

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137

Explore Public Health Career Paths

http://www.asph.org/document.cfm?page=1038

Teach Epidemiology

What do you mean - Teach Epidemiology?

138

Leverage the Young Epidemiology Scholars Competition

http://www.collegeboard.com/yes/

Teach Epidemiology


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Leverage the Science Olympiad Competition

http://soinc.org/

Teach Epidemiology


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Show and Discuss Is Epidemiology in Your Future?

http://www.rwjf.org/pr/product.jsp?id=26931#content

Teach Epidemiology


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Infuse Epidemiology into Existing Lesson about Something Else

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Teaching Existing Epidemiology Lessons

http://www.collegeboard.com/yes/ft/iu/units.html

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http://ccnmtl.columbia.edu/projects/epiville/

Teach Epidemiology


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http://www.diseasedetectives.org/

Teach Epidemiology


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http://www.cdc.gov/excite/

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http://www2a.cdc.gov/epicasestudies/

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http://www.cdc.gov/excite/ScienceAmbassador/ScienceAmbassador.htm

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http://www.buffetbusters.ca/

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http://www.montclair.edu/Detectives/

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http://www.montclair.edu/drugepi/

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View a News Item from an Epidemiologic Perspective

http://www.nationalacademies.org/headlines/

Teach Epidemiology


Teach Epidemiology

During the coming school year, participate in an online Teach Epidemiology In the News - Social Network

and teach epidemiology.



Pre-Workshop Assessment

Pre-Workshop Assessment

Teach Epidemiology

Workshop Process Evaluation

Teach Epidemiology

Teach EpidemiologyProfessional Development Workshop

Day5

Thank You

Documents

Teach Epidemiology