OVERVIEW OF EPIDEMIOLOGY

Definition of Epidemiology
Epi meaning on or upon; demos meaning people; logos meaning the study of. Epidemiology is the study
of the distribution and determinants of health-related states or events in specified populations, and the
application of this study to the control of health problems
1. Study
Epidemiology is data-driven and relies on systematic and unbiased approach to the collection,
analysis, and interpretation of data
Need careful observation and use of valid comparison group
Include surveillance, observation, hypothesis testing, analytic research and experiments
2. Distribution
Frequency refers not only to the number of health events in population, but also to the
relationship of that number to the size of the population
Pattern refers to the occurrence of health-related events by time, place, and person. Time
patterns may be annual, seasonal, weekly, daily, hourly, weekday vs weekend, etc. Place
patterns include geographic variation, urban or rural differences, and location of work sites or
schools. Personal characteristics include demographic factors such as age, sex, marital status,
socioeconomic status, behaviours, and environmental exposures
3. Determinants
Any factor that influence the occurrence of disease and other health-related events. It can be
biological, chemical, physical, social, cultural, economic, genetic, behavioural
Epidemiologist assume that illness does not occur randomly in population but happens only
when the right accumulation of risk factors or determinants exists in individual
4. Health-related States or Events
Refer to diseases, causes of death, behaviours such as use of tobacco, positive health states,
reactions to preventive regimens, and use of health services
The shorterm is disease
5. Specified Populations
Include those with identifiable characteristics such as occupational groups
The clinicians patient is individual and the epidemiologists patient is the community
6. Application
Apply the knowledge gained by the studies to community-based practice to promote, protect,
and restore health
The epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well
as experience, judgement, and understanding of local condition
Apakah Kedokteran Komunitas ?
Kedokteran komunitas adalah cabang ilmu kedokteran yang mempelajari tentang kesehatan
anggota komunitas dengan memusatkan pada diagnosis dini, identifikasi faktor risiko, dan
pencegahan penyakit
Kedokteran klinis adalah cabang ilmu kedokteran yang mempelajari tentang berbagai pelayanan
kesehatan untuk mengobati dan mencegah penyakit pada individu

Kedokteran Klinis Kedokteran Komunitas

Seseorang yang sakit dan sehat,
Klien Seseorang yang sakit
anggota komunitas
Multiple factor
Konsep penyebab Penyebab tunggal Prioritas pada faktor risiko
perilaku, sosial, dan lingkungan
Individu, keluarga, komunitas,
Level penyebab Individu
dan lingkungannya
Promotif, preventif, kuratif, dan
Jenis pelayanan
Kuratif rehabilitatif. Prioritas pada
kesehatan
promotif dan preventif
Tingkat pelayanan
Pelayanan spesialis Pelayanan kesehatan primer
kesehatan
Level intervensi Individu Individu dan komunitas
Tujuan pelayanan Penyakit hilang dan perbaikan
Penyakit hilang
kesehatan kualitas hidup
Kesehatan semua anggota
Dampak kesehatan komunitas
Kesehatan individu
yang ingin dicapai Produktivitas dan
pembangunan sosial ekonomi
 Tanggung jawab Dokter dan tenaga Dokter, tenaga kesehatan
kesehatan kesehatan profesional profesional, dan komunitas

Core Epidemiologic Functions Major Task in Epidemiology

1. Public Health Surveillance
Surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of
health data to help guide public health decision making and action
Common sources of data are morbidity and mortality reports submitted by health-care
providers, infection control practitioners, or laboratories
2. Field Investigations
The investigation may be as limited as phone call to the health-care provider or it requires the
coordinated efforts of dozens of people. The objectives are :
Identification of additional unreporter or unrecognized ill persons who might otherwise
continue to spread infection to others
Identification source or vehicle of infection that can be controlled or eliminated
Learn more about the natural history, clinical spectrum, descriptive epidemiology, and risk
factors of the disease before determining the appropriate intervention
3. Analytic Study
The hallmark of an analytic epidemiologic study is the use of valid comparison group

4. Evaluation
Evaluation is the process of determining the relevance, effectiveness, efficiency, and impact of
activities with respect to established goals
Effectiveness refers to the ability of program to produce the intended or expected results
Efficiency refers to the ability of the program to produce the intended results with minimum
expenditure of time and resources
5. Linkages
Epidemiologist usually work in multidisclipinary team such as laboratorians, sanitarians,
infection control personnel, nurses or other clinical staff, computer information specialists
Need to maintain relationship to promote current and future collaboration
6. Policy Development
Provide input, testimony, and recommendations regarding disease control strategies, reportable
disease regulations, and health-care policy

Descriptive Epidemiology
1. 5Ws of Descriptive Epidemiology
What are the actual and potential health problems in the community ?
Who is ill ?
Where are they occuring ?
When did they become ill ?
Why / how did they become ill ? causes, risk factors, models of transmission
2. Time
Secular (long-term) trends
Seasonality
Day of the week and time of day
3. Place
Determine the geographic extent and geographic variation
Refers to place of residence and any geographic location relevant to disease occurrence
Can be specific or non specific location such as urban or rural, domestic or foreign, institutional
or noninstitutional
4. Person
Age, usually use age groups that are narrow enough to detect any age-related patterns
Sex
Ethnic and racial groups such as race, nationality, religion, tribes
Socioeconomic status such as occupation, family income, educational achievement
MEASURING THE OCCURRENCE OF DISEASES

Basic Concepts
1. Defining Health and Disease Case Definition
Case definition is set of standard criteria for classifying whether a person has particular disease,
syndrome, or other health condition. It is must be clearly stated, and easy to use and measure in
standard manner in wide variety of circumstances by different people
Components : Combination of symptoms, signs, confirmatory laboratory tests. Case definitions
for outbreak investigations are more likely to specify limits on time, place, and or person than
those used for surveillance
The criteria may change quite rapidly as knowledge increases or diagnostic technique improve

2. Issues on Terminology
Proportion : Comparison of part to the whole, numerator is included in the denominator

+
Ratio : Comparison of any two values, the numerator and denominator need not be related. For
example sex ratio, risk ratio, ratio of number of residents with number of hospitals


 Rate : Frequency with which an event occurs in defined population over specified period of
time. It also means how fast something is happening or going
Population at risk : People who are susceptible to a given disease. For example, occupational
injuries occur only among working people, so the population at risk is the workforce

Prevalence : Extent to which something exists. It counts of new and old cases at specific period
of time in defined population
Incidence : The act of happening and the extent of occurrence. It counts of new cases at specific
period of time in defined population
Incidence Prevalence
Number of new cases of disease during Number of existing cases of
Numerator
specified period of time disease at given point of time
Denominator Population at risk Population at risk
Whether the event is new case Presence or absence of disease
Focus
Time of onset of the disease Time period is arbitrary
Estimates the propability of
Expesses the risk of becoming ill
the population being ill at the
The main measure of acute disease
period of time
Uses or conditions, but also used for
Useful in the study of the
chronic disease
burden of chronic diseases and
More useful for studies of causation
implication for health services

Measuring Disease Frequency (Morbidity)

1. Incidence Proportion
a. Definitions and Formula
 Proportion of an initially disease-free population that develops disease, becomes injured or
dies during specified period of time
Synonyms : Attack rate, risk, probability of developing disease, cumulative incidence
b. Formula
No. of new cases of disease or injury during specified period
Incidence Proportion =
Size of population at start period
c. Properties and Uses
Measure of the risk of disease or the probability of developing disease during specified
period. It includes only new cases of disease in the numerator
All of the individuals must have been observed (at risk) for the entire period
Time period must be clearly specified such as 1 week, 1 month, 5 years, etc

2. Incidence Rate
a. Definitions
Ratio of the number of cases to the total time the population is at risk of disease
Each person is observed from an established starting time until one of four end points is
reached i.e. onset of disease, death, lost to follow-up, or the end of the study
Synonym : Person-time rate
b. Formula
No. of new cases of disease or injury during specified period
Incidence Rate =
Time of each person was observed, totaled for all persons
In long-term follow-up study of morbidity, each study participant may be followed or
observed for several years. One person observed for 5 years = 5 person-years (py) but 5
people observed for only 1 year also = 5 person-years
Persons lost to follow-up contribute 0,5 year to the denominator. For example, someone
lost to follow-up in year 3 and someone diagnosed with the disease in year 3, each
contribute 2,5 person-years
 Denominator is the sum of all of the person-years for each study participants
c. Properties and Uses
Describes how quickly disease occurs in population
Because person-time is calculated for each subject, it can accommodate persons coming
into and leaving the study
Person-time assumes that the probability of disease during the period is constant. But, this
assumption is often not valid due to risk of many chronic disease with increasing age
Report the person-time with something more understandable. For example, 2,5 per 1000
person-years is reported as 2,5 of new cases per 1000 person per year
3. Prevalence Rate
a. Definitions
Proportion of persons in population who have particular disease at specified period of time
Includes all cases, both new and preexisting
Point Prevalence Period Prevalence
 Prevalence measured at Prevalence measured
Definitions
particular point in time over an interval of time
Number of cases during
Numerator Number of cases at one time
period of time
Denominator Population at risk Population at risk
Do you currently have Have you had asthma
Example question
asthma ? during the last one year ?
b. Formula
No. of people with disease or condition on particular date
Point prevalence =
Total number of people in the population
No. of people with disease or condition at any time during interval
Period prevalence =
Total number of people in the population
c. Properties and Uses
The numerator for prevalence includes all persons ill from specified cause during specified
time regardless of when the illness begin
Cover both incidence and duration of illness. High prevalence might reflect high incidence or
proloned survival without cure or both. Whereas low prevalence might indicate low
incidence, rapidly fatal process, or rapid recovery
Often used for measuring chronic diseases such as diabetes mellitus or osteoarthritis
Measure of the burden of disease in community Assessing the need for preventive action,
healthcare and the planning of health service

EXAMPLES : Calculating Prevalence Rate

 Point prevalence in January is 2/20 = 10% (case numbers 1 and 15)
Point prevalence in July is 4/20 = 20% (case numbers 1, 3, 15, 18
Period prevalence in one year is 5/20 = 25% (case numbers 1, 3, 12, 15, 18)

4. Application of Prevalence and Incidence

a. Sources of Statistics
Disease reporting : Communicable diseases, cancer registries
Data accumulated as by-product of insurance and prepaid medical care plans
Tax-financed public assistance and medical care plans : Armed Forces, Veterans
Administrations, State medical care plans
Hospitals and clinics
Absenteeism records : Industry and schools
Pre-employment and periodic physical examination in industry and schools
Case-finding programs
Records of military personnel
Morbidity surveys on population samples such as National Health Survey
b. Identifying New Cases
Screened for the disease at baseline to define prevalent case. Those who do not have the
disease at baseline are followed for the specified time, such as 1 year. They are rescreened to
see if they have developed the disease. Any person that were free of disease at the beginning of
the year and developed disease during 1-year period serve as incident case
c. Correlation of Incidence and Prevalence
The tap inflow is the incidence, the bath water is the prevalence (pool of cases).
The prevalence pool is changed by the rate of inflow (incidence), death, recovery, or
emigration (outflow). The population reservoir is enhanced by births and immigration and
diminished by deaths and emigration
Some incident case die before reaching the prevalence pool, such as sudden infant death
syndrome. The recovered cases rejoin the main population reservoir unless they are by
definition chronic and lifelong problems
d. Choice of Incidence or Prevalence
Choice of Incidence
Cause of disease
Burden of disease of short
duration such as measles,
influenza, diarrhea, TIA, sprains
Choice of Prevalence
Burden of chronic disease, even
when these are rare
Health behaviours and other
disease risk factor
Measuring Mortality Frequency
1. Mortality Rate
a. Crude Mortality Rate (Crude Death Rate)
Mortality rate from all causes of death for a population
 The main disadvantage is that it does not take into account the fact that the chance of dying
varies according to age, sex, race, socio-economic class, and other factors
Total no. of deaths at specific period of time
Crude mortality rate = 1000
Mid-interval population
b. Cause-specific Death Rate
Mortality rate from specified cause for a population
No. of deaths due to specific cause during time interval
Cause-specific death rate = 1000
Mid-interval population
c. Age-specific Death Rate
Mortality rate limited to particularr age group
Note that in putting restrictions, the same restriction must apply to both the numerator and
the denominator
No. of deaths in the age group during time interval
Age-specific death rate = 1000
No. of persons in that age group in the population
d. Infant Mortality Rate
Mortality rate in children during the first year of life
It is widely used to measure health status among nations because it reflects the health of
the mother and infant during pregnancy and the year thereafter such as prenatal care,
prenatal health behaviors, postnatal care and behavior, sanitation, infection control
No. of deaths in children < 1 year during time interval
Infant mortality rate = 1000
No. of live birth during the same time interval
e. Neonatal Mortality Rate
No. of deaths in children < 28 days during time interval
Neonatal mortality rate = 1000
No. of live birth during the same time interval
f. Child Mortality Rate
No. of deaths in children aged 1 - 4 years during time interval
Child mortality rate = 1000
No. of children aged 1 - 4 years during the same time interval
g. Maternal Mortality Rate
Refers to the risk of mother dying from causes associated with delivering babies, complications
of pregnancy or childbirth
No. of maternal death during time interval
Maternal mortality ratio = 1000
No. of live birth during the same time interval
No. of maternal death during time interval
Maternal mortality rate = 1000
No. of women in reproductive age (15 - 49 years)
2. Case-fatality Ratio (CFR)
Proportion of persons with particular condition who die from that condition
It is common measure of the short-term severity of acute disease and allows direct assessment
of the effectiveness of intervention
No. of cause-specific deaths among the incident cases
Case-fatality ratio = 1000
No. of incident case
3. Proportionate Mortality
Proportion of deaths in specified population over period of time attributable to different causes
Each cause is expressed as percentage of all deaths and the sum of the causes must add to 100%
The interpretation can be misleading because they are not based on mortality rates. A low
cause-specific mortality rate can elevate the proportionate mortalities for all of the other cause
No. of death due to specific cause during time interval
Proportionate Mortality Ratio = 100
No. of death from all causes during time interval