Epidemiology 2011

SESSIONS-II & III

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Dr. Arshad Sabir A.P

Learning Objectives
At the end of this session students should be able describe to; 1. Definition & concept of epidemiology, 2. O3 basic concepts/Components of epidemiology 3. Measurements in epidemiology 4. Measurement of Mortality 5. Understand, Types and Standardization of Mortality rates 6. Incidence and Prevalence Rates.
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Epidemiology
The study of the distribution and determinants of a disease, health related states or events in specified populations and the application of this study to the control of health problems. (John M.Last 1988) Study of a disease a disease as a mass phenomenon. (Green wood 1934) Medical Science which treats Epidemics
(Perkins 1873)

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Epidemiology ?
A scientific process that detects, investigates causes of health problems, designs & evaluates the interventions to control these problems. Is a both, a field of research to advance scientific understanding of health & disease and application of knowledge to control disease and advance public health. It is primarily an observational science
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Epidemiology is characterization of health problem by time place and person, in order to explain the causes of the problems in terms of Agent-Host & Environmental factors.
Host (Person)

Agent

Environment (Place)

Epidemiology uses an ecological approach.

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DETREMINANTS OF DISEASES (CHD)

Obesity Increased catecholamine thrombotic tendency Hyperlipidemia Changes in walls of arteries Changes in Life style Smoking Abundance of Food Lack of Physical activity Emotional disturbances Aging and Other factors Stress

Hypertension

Coronary artery atherosclerosis

Coronary Heart Diseases

03 Basic Concepts
1. Study of Disease Frequency
(Quantitative science).

what to measure? (Mortality & Morbidity) Disease & its consequences Health related states & Events
(Health demands/Needs, Health Services & Facilities,

Human behaviors, Health related variables.

How to measure ? By using statistical tools of measurement. { RATES, RATIO, and PROPORTION} WHY ? For Public health purposes, Comparison/
Analysis etc etc (Clues to diseases etiology)
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03 Basic Concepts..
2. Study of disease distribution:

Fact: Health/Disease is not uniformly distributed in human population, But in Patterns and epidemiology is the study these distribution patterns. In terms of ! TIME, PLACE & PERSON. TIME: whether there has been an increase or decrease of disease over time. PLACE: whether there is higher concentration of disease in one geographic area than in other places. PERSON: whether disease occurs more often in people of a certain age group (sex, profession, race, social etc) than in other age groups. Like infants vs. adults. (Analytical thinking, Comparison, Generation of Etiological Hypothesis )
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03 basic concepts..

3-Study of Determinants of disease.

Scientific description of the Problem Analysis Testing etiological Hypothesis ANALYTICAL EPIDEIOLOGY It is real substance of EpidemiologyAgent Host Environment

HOW! Use of statistical principles & Methods

Help to identify;
Risk factors/ causes of the disease (Determinants) Best preventive, therapeutic & diagnostic modalities Best public health approaches.
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ANALYSIS (comparison)
Important differences and similarities in host and environmental conditions between of those who are affected and, not affected are identified and compared. (under Statistical methods ) Important associations are identified & quantified and tested for significance It provides scientific explanation of the causes of disease occurrence over the individuals and the populations.
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Basic measurements in Epidemiology

Mortality: (Mortality Rates) Natality: Pop. growth Rates, Morbidity: Disease, Injury, disability,
Disease occurrence in populations --Incidence Prevalence Rates Disease affects----Disability Rates Disease severity-----Fatality Rates Disease infectivity-----Attack Rates

Demographic and other relevant variables:

Social & environmental, attitude & behavioral factors. All factors health of the people factors Bio-statistics is basic tool of measurements in Epidemiology
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Basic measurements in epidemiology

I. Measurement of disease & consequences of disease, its magnitude (Quantitative epidemiology). II. Measurement of Distribution of Disease & Health related states, phenomenon in populations. (Descriptive Epidemiology) III. Measurement of Determinants of Disease ( Analytical Epidemiology ) Bio-statistics is basic tool of measurement in Epidemiology
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Rates, Ratio & Proportion.

( Basic tools of measurements)

RATE
Is measure of occurrence of a particular condition in a certain population in a given period of time. It is a statement of risk of developing a particular condition. Elements of Rate
I. II. III. IV.
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Numerator Denominator Multiplier Time specification

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Numerator & Denominator

Numerator.
Event/Entity under consideration whose occurrence is being measured .e.g No. of deaths or births, No. of Doctors, No. of spell of illness etc.

Denominator.
It is the total No. people or total No. of events in which the numerator (Event/Entity) is being measured.

Types of denominator
a. Related to population. b. related to events

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a. Related to population.
1. Mid year population (1st July) 2. Population at risk (Exposed) 3. Person time denominator (Pearl index) b. Related total No. of events. Examples; IMR, MMR, Case fatality rates.
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Ratio
A ratio expresses relationship in size between two random quantities. It is obtained by dividing one quantity with other quantity. Numerator is not part of denominator but both have some logical association. Examples. Male to Female ratio, Population per Healthcare facility ratio. Maternal Mortality Ratio (MMR)
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Proportion
A ratio which indicates relation in magnitude of a part to the whole.
- Numerator is always included in denominator - Expressed in percentage. Examples: Proportion of males in Rawalpindi city .
= Total No. of males in the City -------------------------------------- X 100 Total No. of male & female population in the city

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Measurement of Mortality
DEATH RATES: (deaths certification 1. Crude Death Rate
and recording issues)

Actual observed rates without any specification. It is single figure. (CDR Pakistan 10/1000) Benefit &Limitations

2. Specific Death Rates

Actual observed rates in population with some specification like age (IMR, U5-MR), sex (MMR), & cause(deaths due to T.B), Ethnic class(deaths in Hindu). Economic class.. Uses: comparison, High risk/target groups identification etc limitations (need certified, each death recording)
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Types of death rates

3. Case fatality Rates:

Reflect killing power of a diseases/virulence. e.g. Rabies, Typhoid, food poisoning. Time interval is not specified.

4. Proportional Mortality Rates:

Tell what proportion of total deaths is occurring in a particular (age & sex) group or due to a specific disease or in a particular age group (when detailed statistics, demographic details are not available). EXAMPLE: Prop. MR due to TB: No. of deaths due to TB in a year ----------------------------------------- X 100 Total No. of deaths from all causes in the same year
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Types of death rates

5. Survival Rates ( reflect disease prognosis) 6. Adjusted/Standardized Rates.

Crude rates are standardized with some mathematical procedures for their meaningful use. For meaningful Comparison

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Adjustment can be made for age, sex, race etc . Crude Rate is single figure.
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Crude Death Rates

when compared over populations City CDR Age specific Death Rates per 1000 population 0-1y 1-4y 5-7y 8-44y 45-64 65plus

London

15.2 13.5

0.6

0.4

1.5

10.7

59.7

Lahore

9.9

22.6

1.0

0.5

3.6

18.8

61.1

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Methods of standardization of M.Rates

A. Direct standardization
Steps; I. Have a standard population II. Have age & sex specific rates of both populations to be compared. III. Apply crude pop: specific rates to the standard pop: and expected No. of deaths will be obtained. IV. Divide the total No. of expected deaths by total No. of standard population to get the standardized Rate.
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Crude Death Rate for Pop. A (CDR=8.4)

Age groups 0-5y 6-15y 16-19y 20-60y Mid year pop. 3000 7000 8000 10000 Deaths in a year 80 50 20 40 Age Sp: Death Rates per 1000 80/3000 x 1000 50/7000 x 1000 20/8000 x 1000 40/10000x100 0 26.6 per 1000 7.1 2.5 4

60y and above

5000

90

90/5000 x 1000

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CRUDE DEATH RATE =

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TOTAL POP: 33000

TOTAL DEATHS = 280

Dr. Arshad Sabir A.P

280/33000 X 1000

= 8.4 PER 1000

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Standard population and CD-Rates Adjustment

Age groups Mid ypop Age Sp: Death Rates of Pop. A 26.6 per 1000 7.1 Expected number of deaths

STANDARDI SED DEATH RATE

Standardized Death Rate

0-5y 6-15y

2000 8000

26.6/1000 x 2000 7.1/1000 X 8000

= 53.2 = 56.8

16-19y
20-60y 60y and above

10,000
12,000 5000 Total Pop. = 38000

2.5
4 18

2.5/1000 X 10000
4/1000 X 12000 18/1000 X 5000 Total deaths

=25
= 48 = 108 = 291

= 291/38000 X 1000 = 7.6 deaths per 1000

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B. Indirect standardization
Standardized Mortality Ratio n (SMR)
Mortality rates adjustment for their purposeful use. Basically a Ratio of total No. of deaths in a certain group to that in standard pop: expressed in percentage. Compares mortality in a certain occupation with Mortality in general population. Measure of likely excess risk of dying in the study pop: Observed deaths SMR = -------------------------X 100 Expected deaths SMR above 100 means this much % mortality is in excess Little details are required. Basis of fund allocation.
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Measuring Morbidity
Incidence:
Occurrence of new cases of a disease in a given population.

INCIDENCE RATE:
Defined as; Number of new cases of a disease occurring in a defined population during a specified period of time .e.g. Incidence of malaria in Pakistan? Incidence of Tuberculosis in Pakistan? 10 cases of malaria in a year in a town with population of 100,000.
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Incidence Rates

Incidence rates refer to;

Only new cases During given time period Specified population May also refer to episodes or new spells of illness of the same disease(.e.g.common cold,ARI,Malaria, etc

Incidence rate;
tells the rate at which new cases are occurring is not influenced by duration of disease Usually used for acute conditions

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Incidence Rate

No. of new cases of specific disease during a given time period Incidence Rate = _____________ X 1000
Pop. at risk of having the disease during that period of time

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Incidence Rates

Special Incidence Rates

i. Attack rate: Is an incidence rate (expressed in %) used only when population exposed to risk for a limited period of time (epidemic). This rate reflect the extent of epidemic. ii. Secondary Attack Rate: Number of exposed persons developing the disease within the range of incubation period following exposure to primary case. It tell us about rate of spread of disease. useful: to evaluate the efficacy of a, preventive measures (vaccine, isolation etc)
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Prevalence
Total No. of individuals who have the disease or attribute of the disease (New & old cases) at a particular time/period in a population at risk of having the disease or attribute at this point or during this period of time. 02 types : 1. Point prevalence 2. Period prevalence

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Prevalence Rate (PR)

No. of all current cases (New &Old ) of a disease existing at / during a given time PR = __________________ Estimated population at risk of disease during the same time

X 100

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Prevalence = Incidence X Prevalence

PR is influenced by following factors; 1. 2. 3. 4. 5. 6. 7. Duration of illness Prolongation of life without cure Increase/decrease in incidence (New cases) In/out -migration of cases Migration of healthy people Improved diagnostic facilities Improved disease reporting

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OSPE-1
A total number of 3000 people died due to cardiac diseases in year 2008
1. Is this statement cab taken as epidemiological Rate ?

If No; 2. What elements should be added to convert this into a rate? 3. Calculate the RATE.
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OSPE-2
Crude death rate of a town-x was 10 per thousand population in a given year but in the same year 5000 deaths occurred in Kachiabadi having population of 100,000 of the same town-x. Q. 1. Standardize the Mortality experience of the Kachi-abadi. Q. 2. what public health decision can be taken the obtained SMR?
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Key: OSPE-1
1. No ( it gives no useable meanings) 2. i. Place specification ( Say Rawalpindi) ii. A constant /Multiplier ( Say 100, 1000 etc.) iii. Denominator ( Midyear population in year 2008) 3. 3000/1500000 X 1000 = 2 per 1000 pop.
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Key: OSPE-2
Ans:1.
Mortality in town-x = 10 / 1000 pop. (CDR) Mortality in Kachi-abadi = 1500 per 100,000 pop. Crude Death rate in Kachi-abadi = 1500 / 100000 x 1000 Crude Death rate in Kachi-abadi = 15 / 1000 pop. SMR = 15/10 x 100 = 200 SMR = 150 50

Ans: 2
Mortality in Kachi-abadi is 50% high as compare to whole town. Situation demands allocation of more funds for health development of people of Kachi-abadi.

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