Advanced Epidemiology

lecture notes for Epidemiology MPH.

Students
By
Getachew Hailu

(BSC in PH, MPH in Epidemiology, Asst. Prof. of Epidemiology)

Epi. & Biostat. Dept., SPH, MHSC, BDU

Geatchewmph35@gmail.com 1
BDU, MHSC, SPH, EBD, Advanced Epidemiology
Course outline and Schedule for MPH in
Epidemiology students.
Day Time Week One Instructor/
presenter
3:00-6:15 Introduction to Advanced Epidemiology Getachew H.
Monday Home take assignments-I
8:30-11:15 All students
3:00-6:15 Introduction to Advanced Epidemiology Getachew H.
Tuesday
8:30-11:15 Individual study All students
3:00-6:15 Cross-Sectional Study design Zelalm A.
Wednesday
8:30-11:15 Home take assignments-II All students
3:00-6:15 Cohort study design Zelalm A.
Thursday
8:30-11:15 Individual study All students

Geatchewmph35@gmail.com 2
BDU, MHSC, SPH, EBD, Advanced Epidemiology
Course outline and Schedule for MPH in
Epidemiology students.
Day Time Week One Instructor/
presenter
3:00-6:15 Case-Control Study Getachew H
Friday
8:30-11:15 Individual study All students
3:00-6:15 Experimental (interventional) TBA
Monday
8:30-11:15 Individual study All students
3:00-6:15 Assessment of cause effect relationship TBA
Tuesday Individual study
8:30-11:15 students
3:00-6:15 Causal inferences TBA
Wednesday Individual study
8:30-11:15 students
3:00-6:15 Critical appraisal of epidemiological studies Zelalem A.
Thursday
8:30-11:15 Individual study All students
Geatchewmph35@gmail.com 3
 BDU, MHSC, SPH, EBD, Advanced
Epidemiology Course outline and Schedule for
MPH in students.
Time Week two Instructors/
Presenters
3:00-6:15 Systematic Review & Meta Analysis Getachew H.
Friday
8:30-11:15 Individual study All students
Monday 3:00-6:15 Individual presentation in the class Students
8:30-11:15 Group Assignment presentation 50% Students
Tuesday 3:00-6:15 Individual study Students
8:30-11:15 Final Exam (50%) All instructors

Geatchewmph35@gmail.com 4
 Course Objectives
• At the end of this course, students will:
– Familiarize themselves with current topics in the
field of epidemiology.
– Have deeper understanding of epidemiological
methods and concepts.
– Acquire skills of critically reviewing Epidemiologic
studies
– be able to conduct evaluation of evidence and
perform causal inferences
– Have some understanding on systematic
review/meta-analysis
– Have the capacity to apply epidemiological
knowledge in disease prevention and control
Geatchewmph35@gmail.com
 Introduction to Advanced
Epidemiology
• Session contents
• Epidemiology and public health
• Features and functions of advanced epidemiology
• Different fields of Epidemiology
• Epidemiologic transition/phases of Epidemiology.
• Traditional and modern epidemiologic concepts

Geatchewmph35@gmail.com 6
Epidemiology and public health

Public health

The science & art of

Preventing disease,
prolonging life,
promoting health & efficiency
through organized community effort (Winslow, 1920)

Geatchewmph35@gmail.com 7
Epidemiology and public health
• Epidemiology
• is a scientific discipline with sound methods of scientific
inquiry at its foundation.
• is data-driven and relies on a systematic and unbiased
approach to the collection, analysis, and interpretation of
data.
• is not just a research activity but an integral component
of public health,
• provides the foundation for directing practical and
appropriate public health action based on causal
reasoning.

Geatchewmph35@gmail.com 8
Epidemiology and public health

• In fact, Epidemiology is often described as the basic

science of public health due to;
• First, it is a quantitative discipline that relies on a
working knowledge of probability, statistics, &sound
research methods.

• Second, it is a method of causal reasoning based on

developing and testing hypotheses grounded in such
scientific fields as

• biology, behavioral sciences, physics, and ergonomics to explain

health and health-related behaviors, states, and events.

Geatchewmph35@gmail.com 9
Steps in the Paradigm of Public Health

1. Define the problem

2. Measure its magnitude
3. Understand the key determinants
4. Develop intervention/prevention strategies
5. Set policy/priorities
6. Implement and evaluate

Geatchewmph35@gmail.com 10
Quantitative Methods in public health

• Public health investigations use quantitative methods,

which combine the two disciplines of epidemiology and
biostatistics

• Epidemiology is about the understanding of disease

development and the methods used to uncover the etiology,
progression, and treatment of the disease

• Information (data) is collected to investigate a question

• The methods and tools of biostatistics are used to analyze the
data to aid decision making
Geatchewmph35@gmail.com 11
Role of Quantitative Methods in Public Health

1. Address a public health question

2. Conduct a study
3. Collect data
4. Describe the observations/data
5. Assess the strength of evidence for/against a
hypothesis; evaluate the data
6. Recommend interventions or preventive programs

Geatchewmph35@gmail.com 12
 Purpose of Epidemiology

The ultimate purpose of Epidemiology is

prevention of diseases and promotion of health

How?
1. Elucidation of natural history of diseases
2. Description of health status of population
3. Establishing determinants of diseases
4. Evaluation of intervention effectiveness
Geatchewmph35@gmail.com 13
 Basic Epidemiological assumptions

1.Human diseases doesn‟t occur at random or by

chance

2. Human diseases have causal and preventive

factors that can be identified by systematic
investigation

Geatchewmph35@gmail.com 14
 Features of advanced
Epidemiology
• The Six striking features which differentiate
epidemiology from other sciences are the following
1. Epidemiology is centrally concerned with finding
out about causation, either for its own sake or to
make a prediction. It is not at all concerned with

• discovering “laws of nature”,

• developing grand theoretical frameworks,
• measuring constants or anything else.

Geatchewmph35@gmail.com 15
 Features …

2. Theory does not feature prominently in

epidemiology.
• It does not have a proper domain of theory,
• where theory is understood as making claims about the
nature of the world.
• Instated epidemiology develops methods.
• The expertise of an epidemiologist is methodological.

3. Experiment does not feature prominently.

Geatchewmph35@gmail.com 16
 Features…

4. The methods of epidemiology are domain

insensitive.

• Epidemiologists count things and then draw conclusions

by comparing the results of different counting exercises.

• The limits of what we can count and compare are well

outside the limits of what is medically significant.

Geatchewmph35@gmail.com 17
 Features…

5. The centrality of population thinking.

• Populations (and not just individuals making up those populations)

are thought of as bearing health-related properties.

6. The stakes are high.

• The cost of failing to make a correct inference may be as high as

the cost of making an incorrect inference.

• This is in contrast to many other sciences where the cost of making

correct inference is merely slow progress.

Geatchewmph35@gmail.com 18
Core epidemiologic functions

1. Public health surveillance

2. Field investigation (survey/study)
3. Analytic studies
4. Evaluation (efficiency, effectiveness, efficacy)
5. Linkages (multidisciplinary approach)
6. Policy development
• Differentiate Efficiency, effectiveness and efficacy
• Give an example for each core epidemiologic function?

Geatchewmph35@gmail.com 19
What is the appropriate core function to
each of the statements below?
1. Reviewing reports of test results for Chlamydia trachomatis from
public health clinics Surveillance
2. Meeting with directors of family planning clinics and college
health clinics to discuss Chlamydia testing and reporting Linkage
3. Developing guidelines/criteria about which patients coming to
the clinic should be screened (tested) for Chlamydia infection policy
4. Interviewing persons infected with Chlamydia to identify their
sex partners Field Investigation
5. Conducting an analysis of patient flow at the public health clinic
to determine waiting times for clinic patients Evaluation
6. Comparing persons with symptomatic versus asymptomatic
Chlamydia infection to identify predictors Analytic study

Geatchewmph35@gmail.com 20
 Types of Epidemiology
Types Component Objectives/ concerns
Descriptive Distribution  Frequency/distribution of health events
epidemiology by person, time and place „
 Generate cause-effect hypothesis
Analytic Determinants  Search for causes or risk factors
epidemiology  Response to a study of hypothesis
 Use various epidemiologic methods
Disease-specific Health, disease,  All health outcomes „
epidemiology or injury  CDC,NCD, Chronic Diseases, CVD,
molecular, genetic, Nutrition, mental,
occupation, GIS, RH, injury, ca, etc
Applied Application  Monitoring and evaluation
epidemiology  Planning and policy making
 Prevention and promotion of health
Geatchewmph35@gmail.com 21
 Fields of Epidemiology
• Epidemiology
• as a basic public health science, its principles and
concepts are applied to different fields of public health
including;
• Occupational Epidemiology -----
• Reproductive Health Epidemiology-----Meseret Manaye
• Nutrition Epidemiology-------Woynshet Getachew
• Molecular Epidemiology---
• Genetics Epidemiology-----
• Clinical Epidemiology-------
• Field Epidemiology---------
Geatchewmph35@gmail.com 22
 Fields of Epidemiology
• Communicable diseases Epidemiology-------
• Chronic Diseases Epidemiology------- Robel Demelash
• Infectious Diseases Epidemiology------ Endeshaw Habitamu
• Tropical Diseases Epidemiology-----
• Cancer Epidemiology---------
• Injury Epidemiology--------Kefyalew Wondemnew
• GIS Epidemiology---------
• Risk Factors Epidemiology------

Geatchewmph35@gmail.com 23
Epidemiologic transition
• Health Transition
• is a conceptual description of the change in disease
patterns that occur during socio-economic development.

• is composed of two interlinked components:

• epidemiologic transition and
• demographic transition.

• Epidemiologic transition
• A transition from infectious disease to chronic,
degenerative, or man-made diseases as the primary
causes of mortality.

Geatchewmph35@gmail.com 24
Causes of Epidemiologic Transition

1. Socioeconomic development
• brings better nutrition, better housing, increased
literacy, safe water and sanitation, and better
living conditions.

2. Modern health technology,

• access to vaccines and antibiotics.

3. Cultural and behavior factors

• affecting hygiene, use of health service, tobacco,
alcohol, safe sex, etc.
Geatchewmph35@gmail.com 25
Theory of Epidemiologic Transition
The theory consists of the following premises:
1. Mortality is a fundamental factor in population dynamics.

2. During the transition, a long-term shift occurs in mortality

and disease patterns whereby pandemics of infection are
gradually displaced by degenerative and man-made diseases
as the chief form of morbidity and primary cause of death.

3. During the epidemiologic transition the most profound

changes in health and disease patterns obtain among
children and young women.

4. The shift in health and disease patterns that characterize the

epidemiologic transition are closely associated with the
demographic and socioeconomic transition that constitute
the modernization complex.
Geatchewmph35@gmail.com 26
 Phases of epidemiologic transition

A) The Stage of Pestilence and Famine

• Is the feature of today‟s collapsed countries,
• Sierra Leone, Somalia, and Afghanistan.
• Is the stage when
• Mortality is high,
• Group-I conditions are the main causes of mortality,
• Plague and smallpox were spread in epidemics
• Fertility rates are high,
• Population growth is slow or nonexistent
• Average life expectancy at birth is low and variable,
( ranging from 20-40 years old)

Geatchewmph35@gmail.com 27
Phases of epidemiologic transition

B) The Stage of Receding Pandemics

• Is the feature of today‟s low income countries:
• Especially those in Sub-Saharan Africa.
• Is the stage when
• Mortality declines
• Fertility remains high,
• Population growths exponentially
• Larger epidemics become less frequent
• Group-I conditions remains main cause of mortality
• Average life expectancy at birth increases steadily from
about 30 to about 50 years.
• low and middle-income countries entered at end of 1940s.
Geatchewmph35@gmail.com 28
Phases of epidemiologic transition

C. The Stage of Non-Communicable diseases

• Is the feature of today‟s middle-income countries
• Most middle-income countries entered this stage now
• Is the stage when
• Mortality due to infectious diseases declined
• Life expectancy at birth increased to ≥70 years of age
• Socio-economic development, improved living
conditions contributed for this stage entry .
• An ageing population is observed,
• Infectious diseases changes to chronic & NCD.

Geatchewmph35@gmail.com 29
Phases of epidemiologic transition

D. The Stage of delayed Degenerative Diseases

• Is the feature of today‟s high-income countries
• Is the stage when
• Mortality due to IHD and cancer start to decrease.
• Low fertility far less than 2 children per women
• Tobacco smoking and dietary fat intake is reduced
• Mortality is mainly from Alzheimer‟s disease.
• suffering from heart attack and COPD reduced
• Survival increases to 10 years longer
• Suffering from osteoporosis, allergy, eating disorders,
psychosocial diseases and chronic fatigue syndrome.
Geatchewmph35@gmail.com 30
The Demographic Transition
• The transition of a country from high birth rate and high
death rates to low birth rate and low death rates.

• Demographic transition is a theory that explains

population change.

• It is a three stage pattern of population change that

occurs as societies industrialize and urbanize.

• Demographic transition model is based on the change in

crude birth rate (CBR) and crude death rate (CDR) over
time.

Geatchewmph35@gmail.com 31
Stages of demographic transition
Stage CBR CDR Growth Rate Example
I High High Slow Ethiopia, Angola, and Nigeria
II High low skyrocketing Today‟s Third World countries
III Low Low Stable Most Europe, Japan, and USA

Stage Justifications
I Both high rates counter balanced resulting slow natural increase because
of poor health conditions, medicine, food, etc
II Death rates decline because of better health conditions, improved
medicine, better food, etc.
III keep families small (2/woman), in part, because children become an
economic burden in advanced industrial societies,

Geatchewmph35@gmail.com 32
Demographic Transition
• Most developed countries are beyond stage three of
the model.

• The majority of developing countries are in stage

two or stage three.

• The major (relative) exceptions are (in stage one)

• Some poor countries, mainly in Sub-Saharan Africa, and
• Some Middle Eastern countries, which are poor or
affected by government policy or civil war
• such as Pakistan, Palestine, Yemen and Afghanistan.

Geatchewmph35@gmail.com 33
Patterns of Demographic Transition
• Three different patterns have been described as:
A) The Classical or Western model.
• Socio-economically driven.
• Occurred over a period of almost 200 years.
• Describes the gradual, progressive transition from high
to low rates of mortality and fertility.
• Characterized by slow population growth rate.
• Is most Western European societies demographic model
• Example: England and Wales.

Geatchewmph35@gmail.com 34
Patterns of Demographic Transition
B) The Accelerated model
• Medicine and technology driven.
• Lasted less than one century.
• Characterized by lower mortality and birth rates.
• Example: Japan.
C) The Delayed model
• Population growth and medical advances driven.
• Non-rapid, low mortality and birth rates
• kept the population growth high.
• Example: Sir Lanka.

Geatchewmph35@gmail.com 35
Demographic Transition

Geatchewmph35@gmail.com 36
Traditional and Modern

Epidemiologic concepts

Geatchewmph35@gmail.com 37
Traditional Epidemiology

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
(Last, 1988)

1. Germs and miasmas

2. Risk factor epidemiology
3. Epidemiology in the 21st century

Geatchewmph35@gmail.com 38
Snow on Cholera
Water Deaths From Death
Supplier Population Cholera Rate/1000

Southwark 167,654 844 5.0

& Vauxhall

Lambeth 19,133 18 0.9

Both 300,149 652 2.2

Geatchewmph35@gmail.com 39
Snow‟s Cholera Map

Geatchewmph35@gmail.com 40
Social and Economic Factors and Health

• Just as social changes were the major cause of

decline in infectious diseases last century,

• social changes are also likely to be the most

effective means of reducing chronic diseases such as
heart disease and cancer.

Geatchewmph35@gmail.com 41
Epidemiology is a Population Science

• “Traditional” epidemiology starts at the population

level and the first step is to ascertain variations in
the occurrence of disease within and between
populations

• “Populations” include not only countries, but

geographical regions, demographic groups,
communities, extended families, etc

Geatchewmph35@gmail.com 42
Examples of the “Top Down” Approach

• Cancer Incidence in Five Continents

• Global comparisons of CHD
• Global comparisons of asthma prevalence

• The European Community Respiratory Health Study

(ECRHS)

• The International Study of Asthma and Allergies in

Childhood

Geatchewmph35@gmail.com 43
Levels of Analysis:
“Top-down” Versus “Bottom-up”
Populations Social science/
Groups epidemiology
Individuals Clinical
Organs Pathology/
Cells biology
Molecules Molecular biology

Geatchewmph35@gmail.com 44
The “Top-down” Approach
• Starts at the population level in order to ascertain
the main factors that influence health status within
the population.

• Uses a structural model of causation, rather than a

behavioral model or a biomedical model.

• Causation is seen as resulting from processes and

mechanisms that are internal between externally-
related independent objects.

Geatchewmph35@gmail.com 45
“Modern” Epidemiology
“The study of the occurrence of illness”

“A systematic body of epidemiologic principles by

which to design and judge [epidemiologic] studies
has begun to form only in the last two decades”
(Rothman, 1986)

Geatchewmph35@gmail.com 46
“Modern Epidemiology”

• Epidemiology is a generic method

• The word “populations” is not necessary for its
definition
• The focus is on measuring individual exposure-
disease associations
• Certain study designs are most valid
• We should focus on hypotheses that fit these study
designs

Geatchewmph35@gmail.com 47
“Modern” Epidemiology
• Concentrates on studying individual “risk factors”
for disease
• “Clinical trial” paradigm comparing “exposed” with
“non-exposed” individuals
• Emphasis on “analytical” rather than “descriptive”
studies
• Emphasis on individuals rather than populations
• Increasing emphasis on molecular biology

Geatchewmph35@gmail.com 48
The “Bottom Up” Approach

• Focuses on understanding the individual components

of a process at the lowest possible level and

• using this information as the “building blocks” to

gain knowledge about higher levels
• “A vast stockpile of almost surgically clean data
untouched by human thought”

Geatchewmph35@gmail.com 49
The Decline of Population Epidemiology

There is currently little interest in the population

approach because:

• It is regarded as “too political”, “old fashioned” and

uninteresting
• There is a lack of support and funding
• The “success” of “risk factor” epidemiology

Geatchewmph35@gmail.com 50
Problems of the Risk Factor Approach:
Tobacco
• The limited success of legislative measures in
industrialized countries has led the tobacco industry to
shift its promotional activities to developing countries so
that more people are exposed to tobacco smoke than ever
before.

• Thus, on a global basis the “achievement” of the public

health movement has often been to move public health
problems from rich countries to poor countries, and from
rich populations within the industrialized countries.

Geatchewmph35@gmail.com 51
Problems of the Risk Factor Approach:
Tobacco
• When a public health problem is studied in individual
terms (eg. tobacco smoking)
• rather than in population terms
(eg. tobacco production, advertising and distribution, and the social
and economic influences on consumption)

• then it is very likely that the solution will also be defined

in individual terms and the resulting public health action
will merely move the problem rather than solve it.

Geatchewmph35@gmail.com 52
Problems of Modern Epidemiology:
Biomarkers
“We are in the era of molecular research ... The use
of molecular markers represents a quantum leap in
the evolution of epidemiologic ideas”
(Schulte, 1993)

Geatchewmph35@gmail.com 53
Problems of Modern Epidemiology:
Scientific Limitations of Biomarkers
• Historical exposures
• Individual temporal variation
• Study size
• What does a biomarker measure?
• Increased likelihood of confounding

Geatchewmph35@gmail.com 54
Problems of “Modern” Epidemiology

• Epidemiology has largely ceased to function as part

of a multidisciplinary approach to understanding
the causation of disease in populations and has
become a set of generic methods for measuring
associations of exposure (“risk factors”) and disease
in individuals.

• If epidemiology is just about measurement then it

can never claim to be a science.

Geatchewmph35@gmail.com 55
Problems of “Modern” Epidemiology
• Recent changes in the epidemiologic paradigm have
changed, and have reflected changes in, the way in
which epidemiologists think about health and
disease.

• The key issue has been the shift in the level of

analysis from the population to the individual.

Geatchewmph35@gmail.com 56
Epidemiology in the 21st century
• The importance of context
• Problem-based epidemiology
• Appropriate technology
• Epidemiology as a population science

Geatchewmph35@gmail.com 57
Context is Important
• The “populations” which epidemiologists study are not
just collections of individuals which are conveniently
grouped for the purposes of study, but are instead
historical entities.

• Every population has its own history, culture, organisation,

and economic and social divisions which influences how
and why people are exposed to particular factors, and how
they respond.

Geatchewmph35@gmail.com 58
Context is Important
• Even when focusing on individual-level hypotheses,
epidemiology is inevitably entangled with society and it is
unscientific to study disease in the abstract.

• To understand the causation of disease in a population it is

essential to understand the historical and social context.

Geatchewmph35@gmail.com 59
Problem-based Epidemiology
• The approach of “problem-based” medicine can be
used in the teaching and practice of epidemiology

• The appropriate methods should be chosen to fit the

problem rather than letting the methods define the
problem

Geatchewmph35@gmail.com 60
Appropriate Technology: theories
• New theories or hypotheses may require new
methods of measurement

• As attention moves “upstream” existing

epidemiologic methods will become inappropriate

Geatchewmph35@gmail.com 61
Appropriate technology: methods
• It cannot be simply assumed that high-tech methods
such as “molecular epidemiology” will be more
valid than traditional questionnaires

• There is a need for an “evidence-based” approach to

the teaching and conduct of epidemiology

Geatchewmph35@gmail.com 62
Appropriate Technology: methods
• Just as case-control studies were developed for “risk
factor” epidemiology, new methods need to be
developed for “ecoepidemiology”

• We should focus on the important public health

issues and use appropriate technology to address
them

Geatchewmph35@gmail.com 63
Appropriate technology: Strategies
• It cannot be simply assumed that a “bottom-up”
approach will be more effective, particularly since
the “top down” approach has been effective in the
past

Geatchewmph35@gmail.com 64
Epidemiology in the 21st century

• The current danger for epidemiology is not the use

of new techniques or micro-level analyses, but that
these techniques may define which hypotheses are
acceptable for study

Geatchewmph35@gmail.com 65
All of the Different Levels of Analysis
Are Important
• Population level studies are complementary to
studies at the individual and micro-levels

• Individual and micro-level studies have had some

real successes

• It is legitimate that people should work at the level

appropriate to their training and interest

• A multi-level approach may be particularly effective

Geatchewmph35@gmail.com 66
Epidemiology in the 21st century

• Susser suggests that epidemiology has been through

three major phases and is now entering a fourth:

• miasma theory epidemiology (“traditional”)

• germ theory epidemiology (“traditional”)
• “black box” epidemiology (“modern”, “risk factor”)
• global epidemiology (ecoepidemiology)

Geatchewmph35@gmail.com 67
Epidemiological Paradigms
“Traditional” “Modern”
• Branch of “public health” • Branch of “science”
• Demography/social science • Clinical trial paradigm
paradigms
• Population level • Individual/molecular level
• Top down (structural, • Bottom up (reductionist
dialectical) positivist)
• Intervention “upstream” • Intervention “downstream”

Geatchewmph35@gmail.com 68
Epidemiology in the 21st century
• We need to reintegrate epidemiology into public
health and restore the population perspective

• This requires not just multi-level analysis but rather

“multi-level thinking”

• This multi-level thinking can be encouraged and

fostered by a problem-based and evidence-based
approach.

Geatchewmph35@gmail.com 69
Occupational Epidemiology

Advanced Epidemiology 1
1 August 2022
Getachew Hailu

Geatchewmph35@gmail.com 70
 Objectives
• By the end of this session students will be able to:
• Define the scope of occupational epidemiology

• Describe the study design issues specific to occupational

epidemiology

• Outline methods of occupational exposure measurement

Geatchewmph35@gmail.com 71
 Occupational Epidemiology
• Definitions
• History
• Epidemiological tools and issues
– Study designs
– Exposure measurement
– Specific biases
• Primary prevention
• Occupational epidemiology in Ethiopia

Geatchewmph35@gmail.com 72
 Definitions
• Occupational Epidemiology
– Is the systematic study of illness and injuries
related to the workplace environment
(Checkoway 2004).

– Is application of epidemiological tools to the

identification, prevention and treatment of
workplace injury and disease (Levy, 1995)

Geatchewmph35@gmail.com 73
 History
– 1713. First description of occupational diseases &their
causes (Ramazzini).
– 1753. scurvy in sailors (Lind).
– 1775. Scrotal cancer in chimney sweeps (Potts).
– 1879. Respiratory cancer in metal miners.
– 1895. Bladder cancer in dye workers.

• Elucidated through careful investigation of case

series by clinicians (and employees) rather than the
use of epidemiological instruments.
Geatchewmph35@gmail.com 74
 Examples of occupational diseases
associations from epidemiological studies
– Cancer & broad ranges of carcinogens in dye, rubber
and petroleum industries.
– Sub-fertility & chemicals used in agriculture, dry
cleaning and other industries.
– Pneumonoccosis & mineral dusts from mining and
grinding industries.
– Infections from agents acquired by health, agriculture
and abattoir workers (Nosocomial and zoonotic).
– CHD and insulin resistance & occupational stress;
– Hearing loss & noise level in medium and large scale
industries.
– Injuries & construction industries and imperfectly
mechanized industries.
Geatchewmph35@gmail.com 75
 Global Picture
– Annually, 1.1 million deaths from work related
injury and diseases worldwide.
– Economic loss average 4% of GNP.
– Thousands of deaths years lost to occupational
injury, 1990 Murray & Lopez. WHO, 1994.
EMEs FSEs India China Other Asia SSA MEC LAC Total
Deaths 8.6 13.3 35.5 23.9 18 15.5 9.1 13.3 137.2
YLD* 16 25 41 46 28 18 14 21 208

Geatchewmph35@gmail.com 76
 Epidemiological Tools-1
• Study designs are as for any other area of epidemiology
• Ecological
– Use routine data sources to generate SMRs,
– But problems with numerator-denominator bias

– Eg. A man is entitled to the army for 3 years (national

service), but then retires from the army to open a bar. On a
10-year census he is included as a publican/civil.
– Where as when his death is registered, his wife registers him
as „Major‟ (shaleka), and the clerk coding his death assumes
he is in the armed forces.
– This man‟s death appears in a different numerator category
to the denominator category he fulfilled in life.
Geatchewmph35@gmail.com 77
 Epidemiological Tools-2
• Cross-sectional
– Good for generating hypothesis
– Quick and relatively cheep, but
• Prone to response bias
• Inclusion of active workers only (healthy workers
effect)
• Reverse causality

Geatchewmph35@gmail.com 78
 Epidemiological Tools-3
• Cohort
– Good for follow-up (records, registers), But
– Expensive, time consuming if prospective
– Inadequate exposure and confounder measurement

• Nested case-control (subset of whole cohort)

– Useful for exposures not related to single industry
– Include mortality odds ratio studies (CF, PMR)
Geatchewmph35@gmail.com 79
 Exposure Measurment-1
• Move from classification by job type to actual
measurement of exposure to specific agents,
including dose where possible.

• Job-Exposure Matrices.
– Cross-classification of job titles with lists of
potential exposure agents.
– Reached through a combination of deterministic
modeling and expert review.
– Can be used Semi-quantitatively.

Geatchewmph35@gmail.com 80
 Exposure Measurment-2
• Dose-Response analysis.
– Dose may be estimated from measurements of
exposure (Duration and Intensity) and
Knowledge of uptake and clearance.

– Use of molecular “internal dose” markers

(Protein or DNA Adducts) may give a more
helpful measure of effective exposure.

Geatchewmph35@gmail.com 81
 Biases specific to Occupational
Epidemiology
• Healthy Worker Effect
– Healthy hire effect
– Healthy worker survival effect

• Controlling for the healthy worker effect

– Restrict analysis to long term survivors
– Exclude recent (<10 years) exposures
– Adjust for current employment status

Geatchewmph35@gmail.com 82
 Primary prevention
• Avoiding or limiting exposure to chemicals,
dusts, infectious agents or psychological
stressors through:
– Enclosing parts of production process
– Requiring protective clothing, masks or breathing
apparatus to be worn by workers.
– Banning production of certain toxins.
– Limiting time any individual is exposed.

• Legislation to enforce these is essential!

Geatchewmph35@gmail.com 83
 Occupational Epidemiology in
Ethiopia
• Pocket studies so far
– Onchocerciasis in Teppi coffee plantation workers;
– Podoconiosis in subsistence farmers in Wolaitta Zone;
– Child Labour and emotional disorder in Addis Ababa;
– Occupational Safety and sanitary practices of small
business enterprises in Jimma;
– Noise-induced hearing loss among textile workers.

• Data from most industries and large-scale employers

are routinely compiled by MOLSA, but some
sectors may be omitted
Geatchewmph35@gmail.com 84
 Sources
– Occupational Health- Recognizing and preventing work-
related disease. Levy BS, Wegman DH. 1995 3rd edition.
Little brown & co. Boston.
– Handbook of epidemiology. Ahrens & Pigeot, eds. 2005 1st
edition. Springer-Verlarg Berlin Heidelberg.
– Williams GM, Najiman JM, Clavarino A. Correcting for
numerator-denominator bias when assessing changing
inequalities in occupational class mortality, Australia. 1981-
2002. Bull WHO 2006; 84:198-203.
– McMichael AJ. Standardized mortality ratios and the
healthy worker effect: scratching beneath the surface. Occ
Med.1976; 18: 165-168.
– Murray CJL, Lopez AD. Global comparative assessments in
the health sector. WHO Geneva, 1994.
Geatchewmph35@gmail.com 85
Thanks

Geatchewmph35@gmail.com 86