EPIDEMIOLOGY

By :

dr. Siswanto, M.Sc.

INTRODUCTION OF EPIDEMIOLOGY

Why does a disease develop in some people and not in others ?

The disease and health problems are not randomly distributed in a population.

DEFINITION
The study of the distribution and determinants of health related states or events in specified populations, and the application of this to the control of health problems. The study of the distribution and change in diseases. The study of the distribution and determinants of disease in human population

Study of disease and other health related phenomena in group of persons. (Kramer MS, 1988)

A science concerned with describing the pattern of disease occurrence in population and determining the factors which influence disease prevalence and

distribution with the ultimate objective of providing the

basis of control and prevention

 The characterization of the distribution of health-related state or events is one broad aspect of epidemiology called descriptive epidemiology. Epidemiology is also used to search for causes and other factors that influence the occurrence of health-related state or events. The latter is called analytic epidemiology

 Descriptive epidemiology provides the What, Who, When and Where.

WHAT is the health problem , disease or event and what are its manifestations and characteristics ? WHO is affected with reference to age ,sex, social class, ethnic, occupation, heredity and personal habits ? WHEN does it happen, in terms of days, months, seasons or years ? WHERE does the problem occur, in relation to place of residence, geographical distribution and place of exposure ?

Analytic epidemiology attempts to provide the Why, How and So What

association with specific conditions, agents, vectors, sources of infection, susceptible groups and other contributing factors ? WHY does it occur, in terms of the reasons for its persistence or occurrence ? SO WHAT interventions have been implemented as a result of the information gained and what was their effectiveness ? Have there been any improvements in health status ?
HOW does the health problem, disease or event occur, and what is its

What is hospital epidemiology?

The fundamental roles of hospital epidemiology are to: Identify problem Identify risks Understand risks Eliminate or minimize risks

What questions Can be answered by Epidemiological Approach ?

How many peoples influenced by the disease? Since when the disease started, and do the number of cases tend to increase or decrease by time? Do the disease burdened on a specific group of Age, gender, place, occupation, religion, economic status groups, marriage status, education? What is the probable cause or risk factor that make the disease frequency? Which of the cause / risk factors manageble? What are the effective solution to control the disease ?

Case definition is a set of standard criteria for deciding a person has a particular disease (health related condition) or not

A Case definition consists of clinical criteria include : (symptoms/subjective complaints, signs/objective physical finding and laboratory test)

For example : in an outbreak of bloody diarrhea caused by infection with E coli O 157:H7, investigators defined cases in the following three classes : Definite case : E coli O157:H7 isolated from a stool culture with gastrointestinal symptoms Probable case : Bloody diarrhea with gastrointestinal symptoms Possible case : Diarrhea and gastrointestinal symptoms

What kind of epidemiological technique needed in Community Diagnosis

The Disease Frequency measurement:

Prevalence and Incidence rate

The trends of Prevalence & Incidence The distribution of prevalence or incidence rate by age, sex, occupation, socio-economic groups, place, religions Formulate Hypothesis about the risk factors (use la londe model) Test hypothesis

SCHEME FOR AN EPIDEMIOLOGICAL STUDY CYCLE

DESCRIPTIVE STUDIES
ANALYSIS OF RESULTS, SUGGEST FURTHERDESCRIPTIVE AND NEW HYPOTHESIS TEST HYPOTHESIS MODEL BUILDING FORMULATION OF HYPOTHESIS

ANALYTICAL STUDIES - X - SECTIONAL - CASE-CONTROL STUDY - COHORT

EXPERIMENTAL STUDIES :

- CLINICAL TRIALS - FIELD TRIALS

RESEARCH DESIGN IN EPIDEMIOLOGY

THE EPIDEMIOLOGY STUDY

OBSERVATIONAL STUDIES (NO CONTROL OVER EXPOSURE)

EXPERIMENTAL STUDIES (INFESTIGATOR DETERMINE) WHO EXPOSED OR NOT EXPOSED

NO COMPARISON GROUP

COMPARISAN GROUP

DESCRIPTIVE

ANALYTIC

CASE SURVEILLANCE REVIEW

SURVEY

CROS SEC TIONAL STUDY

CASE CON TROL STUDY

COHORT STUDY

5 CRITERIA CAUSAL ASSOCIATION

1.TEMPORAL RELATIONSHIP --> means exposure to the causal factor (risk factor) must precede development of the disease (effect) 2. STRENGHT OF ASSOCIATION (RR> 4) --> Strength refers to the size/magnitude of RR (not the p value or degree of statistically significance which can be increased by increasing the sample size). 3. CONSISTENCY (C) AND REPLICATION (R) C--> means different studies resulted in the same association R--> means repetition of the same study resulted in the same association.

SPECIFICITY/DOSE-RESPONSE RELATIONSHIP Measures the degree to which one particular exposure produces one specific disease.

COHERENCE WITH EXISTING KNOWLEDGE (BIOLOGICAL PLAUSIBILITY) Support for the causal of an association exist if a causal

interpretation is plausible in term of current knowledge about

the factor and the disease.

PRINCIPLES OF CAUSALITY (SEVEN POINTS)

1.

2. 3.

4.

There should be evidence of a strong association between the risk factor and the disease ( Relative risk, odds ratio and prevalence ratio) There should be evidence that exposure to the risk factor preceded the onset of disease There should be a plausible biological explanation The association should be supported by other investigations in different study setting

5. There should be evidence of reversibility of the effect. ( That is, if the cause is removed the effect should also disappear, or at least be less likely) 6. There should be evidence of a dose response effect.( That is, the greater the amount of exposure to the risk factor, the greater the chance of disease) 7. There should be no convincing alternative explanation. ( For instance, the association should not be explainable by confounding)

NATURAL HISTORY OF DISEASE

Natural history of disease refers to the progress of a disease process in an individual over time, in the absence of intervention. The process begins with exposure to or accumulation of factors capable of causing disease. Without medical intervention, the process ends with recovery, disability, or death

NATURAL HISTORY OF DISEASE

ONSET OF SYMPTOMS
PATHOLOGIC CHANGES EXPOSURE
SPECTRUM OF DISEASE

USUAL TIME OF DIAGNOSIS

STAGE OF STAGE OF STAGE OF STAGE OF SUSCEPTIBILITY SUBCLINICAL DISEASE CLINICAL DISEASE DISABILITY OR DEATH
WITHOUT MEDICAL INTERVENTION RECOVERY DISABILITY DEATH

NATURAL HISTORY OF DISEASE

For infectious disease, the exposure usually is microorganism. For infectious disease the period of subclinical is called the incubation period For cancers, the critical factors may require both cancer initiators, such as asbestos fibers or components in tobacco smoke (for lung cancer) and cancer promoters, such as estrogens (for endometrial cancer). For chronic disease the period of subclinical is called the latency period

DISEASES CAUSATIONS

MOSTLY MULTIFACTORIALS (> 1 factor)

2 THEORY :

EPIDEMIOLOGICAL TRIANGLE MODEL; LA LONDE (Henry L Blum) MODEL.

EPIDEMIOLOGICAL TRIANGLE MODEL

The arising disease, is always a result of total interaction of 3 factors: The Destructive power of AGENT OF DISEASE, as an absolute factor that must be exist as the cause. The Defensive Power of HUMAN HOST as the target of agent of disease, and The Supporting Power of the ENVIRONMENT to destructive power of agent of disease or to protective power of human host

DETERMINANT OF HEALTH EPIDEMIOLOGICAL TRIANGLE MODEL

Destructive power of Agent of diseases

Resistance of Human host against disease

Environment

AGENT OF DISEASES

Physical agent: Temperature, dust, gas, light, noise, radiation, etc Chemical Agent : Acid, Base, metal, Organic compound, food aditive, etc Biological agent : Bactery, Insect, Allergen, Animals bites, etc Intrinsic agent : Gen, hereditary disorders; Psychologial agent : Mental Stress;

DESTRUCTIVE POWER OF AGENT OF DISEASE

DETERMINED BY : Quantity of agents; Duration of contact with agent of disease; Area of contact between agent of disease and body of human host; Basic characteristic of agent of disease : Corosive, Allergen, Toxic, Carcinogenic, Mutagenic, Invasive, etc; Tissue resistance of human host against agent of disease

HOST RESISTANCE

Host resistance against destructive power of agent of disease, determined by :

Genetic factors; Mental & Spiritual stability Nutritional status; Physical fitness; Immunity;

ENVIRONMENTAL FACTORS

EFFECT AGAINST AGENT OF DISEASE : Increase /decrease number of agent of disease, duration of contact, area of contact and destructive power of agent of disease; ex High air temperature lower the body indurance EFFECT AGAINST HUMAN RESISTANCE : Increase / decrease psicho-bio-physical indurance ; ex Food production determine the nutritional status of population.

DETERMINANT OF HEALTH LA LONDE MODEL

PSYCHOBIOLOGICAL ENDURANCE

HEALTH SERVICE PROGRAMS

Health problem
ENVIRONMENT Biological Social

LIFE STYLE

Three terms are used to describe an infectious disease according to the various outcomes

Infectivity refers to the proportion of exposed persons who become infected. Pathogenicity refers to the proportion of infected persons who develop clinical disease Virulence refers to the proportion of persons with clinical who become severely or die

Chain of infection

Transmission of disease occur when the agent leaves its reservoir or host through a portal of exit, and is conveyed by some mode of transmission, and enters through an appropriate portal of entry to susceptible host. The process is called the chain of infection.

RESERVOIR

The reservoir of an agent is the habitat in which an infectious agent normally lives, grows and multiplies. Reservoir include human, animal and the environment

Two type of human reservoir

Carrier is person without apparent disease who is capable of transmitting the agent to others. Asymptomatic carriers , who never show symptom during the time they are infected. Incubatory or convalescent carriers who are capable of transmission before or after they are clinical ill

Two type of human resevoir

Chronic carriers is one who continues to harbor an agent for extended time (months or years). Exp : Hepatitis B, typhoid fever) Symptomatic persons are usually less likely to transmit infection widely because their symptom increase their likelihood of being diagnosed and treated.

Portal of exit
The path by which an agent leaves the source host. The portal of exit usually corresponds to the site at which the agent is localized. Example : tubercle bacilli and influenza virus exit the respiratory tract, cholera vibrio in feces.

Modes of transmission

Direct Direct contact (kissing, sexual intercourse) Droplet spread ( refers to spray with relative large. Sneezing, coughing even talking) Indirect ( an agent is carried from a reservoir to a susceptible host by suspended air particle, vector and vehicle) Airborne (The nuclei less than 5 /micron) Vehicleborne Vectorborne : Mechanical, Biologic

Portal of entry
An agent enters a susceptible host through a portal of entry.

RESEARCH DESIGN IN EPIDEMIOLOGY

DESCRIPTIVE STUDIES

Information is collected only on those individuals with a health problem or a particular exposure. There is no comparison group. Much useful information can be derived from these studies but no definite analysis of causeeffect association can be made from these information

TIME Disease rates change over time. Some of these changes occur regularly and can be predicted. Example : the seasonal increase of influenza cases with the onset of cold weather is a pattern that is familiar to everyone

Malaria by year, United States, 1930 - 1990

Place We describe a health event by place to gain insight into the geographical extent of the problem. For place, we may use place of residence, birthplace, place of employment, hospital unit, urban and rural etc, depending on which may be related to the occurrence of the health event.

Person When we organize or analyze data by person there are several person categories. Inherent characteristics of people ( age, race, sex), acquired characteristics ( immune, marital status), their activities ( occupation, use of tobacco, drugs), the conditions under which they live ( socioeconomic, access to medical care)

Example : Sex For some disease, this sex-related difference is because of genetic, hormonal, anatomic, or other inherent differences between the sexes. Premenopausal women have a lower risk of heart disease than man of the same age. This difference is attributed to higher estrogen level in women.

PERTUSSIS (WHOOPING COUGH) INCIDENCE BY AGE GROUP, UNITED STATES, 1989

50

REPORTED CASES PER 100.000 POP

40 30 20 10 0 < 1 TH 1-4 TH 5-9 TH 10-14 TH 15-19 TH 20+TH

AGE GROUP (YEARS)

ANALYTIC STUDIES
I.

CROSS-SECTIONAL STUDY The comparison is made between a group of persons who has the disease and a group that does not have the disease, but the characteristic and/ or exposure of the two groups are observed in the same time

D+

D-

TOTAL

FR +

A+B

FR -

C+D

TOTAL

A+C

B+D

A+B+C+D

ADVANTAGES
1 2 3

Quick and easy to perform Straight forward data analysis Loss to follow up

DISADVANTAGES
1

Difficult to interpret association in terms of cause and effect Not suitable for the rare disease, since sample size requirement will have to be large.

CASE-CONTROL STUDY
THE STUDY MOVE BACKWARD FROM DISEASE ( EFFECT) TO RISK FACTOR (CAUSE). PERSON WITH AND WITHOUT DISEASE ARE IDENTIFIED AND THEN THE PRESENCE OR ABSENCE OF PREVIOUS EXPOSURE TO THE RISK FACTOR IS DETERMINED

STUDY DESIGN OF CASECONTROL

Risk factor +

Risk factor -

CASES
POPULATION

Risk factor +

CONTROLS
risk factor -

ADVANTAGES
1 2

Efficient for the study of rare diseases Efficient for the study of chronic disease (diseases with a long latency) Tend to require a smaller sample size than other designs. Less expensive than other designs

5. Many risk factors can be studied simultaneously

DISADVANTAGES
Risk of disease cannot be estimated directly 2 Not efficient for the study of rare exposures 3 More susceptible to selection bias 4 Information on exposure may be less accurate than other design ( memory bias) 5 Can investigate only one disease outcome
1

COHORT STUDY

The study move forward from risk factor (cause) to disease (effect). Population exposed and not exposed to a risk factor are identified and then both population were followed to determine the frequencies of health problems.

STUDY DESIGN OF COHORT

Disease +

Risk factors +
Disease -

population Risk factors -

Disease +

Disease -

ADVANTAGES

Direct calculation of relative risk May yield information on the incidence of disease Clear temporal relationship between exposure and disease Particularly efficient for study of rare exposure Can examine multiple effect of a single exposure

Minimizes bias Strongest observational design for establishing cause and effect relationship

DISADVANTAGES

Time consuming Often requires a large sample size Expensive Not efficient for the study of rare diseases Lost to follow-up Changes in exposure Ethic

USES

Population or community health assesment. To do this, we must find answers to many questions : What are the actual and potential health problems in the community ?, Where are they ?, Who is at risk ?, Which problems are declining over time ?, Which ones are increasing or have the potential to increase ?, How do these patterns relate to the level and distribution of services available ?. Individual decisions. People may not realize that they use epidemiologic information in their daily decisions.

Completing the clinical picture. When studying a disease outbreak, epidemiologists depend on clinical physicians and laboratory scientists for the proper diagnosis of individual patients. But epidemiologist also contribute to physicians, understanding of the clinical picture and natural history of disease. Search for causes. Much of epidemiologic research is devoted to a search for causes, factors which influence one,s risk of disease.

Health Status For example : Prevalence, Incidence Evaluation of intervention. To assess the effectiveness of preventive and therapeutic treatments. To assess the impact of health-care services To predict future health care needs

TERIMAKASIH