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BASIC CONCEPT OF EPIDEMIOLOGY

Oleh : Dr. Siswanto, M.Sc.

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 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

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)

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

THE SISTEMATIC THINKING OF CAUSAL ASSOCIATION


Statistical association present Bias absent Conclude the suspected factor is not implicated in etiology Conclude association is artifactual (sporious)

present

absent
Apply 5 criteria satisfied Conclude Association is causal (Source : Morton and Hebel, 1980)

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)

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

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 -) SPECTRUM 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 DISEASES


PRE PATOGENESIS PATOGENESIS CONVALESCENS

NATURAL HISTORY OF DISEASES

DEAD
VITAL LIMIT

CACAT
CLINICAL HORIZON

SEMBUH PENC PRIMER PENC SEKUNDER PENC TERSIER

3 TINGKATAN UPAYA PENCEGAHAN

Malaria by year, United States, 1930 - 1990

Contoh : Penelitian bertujuan untuk mengetahui Kwalitas kegiatan belajar mengajar. Agar diperoleh data yang lengkap yang bisa menggambarkan kwalitas diatas maka ditentukan beberapa segi yang harus diamati Mis : dari Guru, siswa, kegiatan waktu belajar, sarana dan hasil pelajaran

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)

JENIS DATA DAN UJI HIPOTESIS YANG SESUAI (SATU VARIABEL BEBAS) VARIABEL METODE Bebas Tergantung Nominal Nominal Kai-kuadrat Uji Mutlak Fischer Nominal Numerik Uji t, Independen, (dikotom) berpasangan Nominal Numerik Anova (>2 nilai) Numerik Numerik Regresi/korelasi

METODE STATISTIK UNTUK VARIABEL BEBAS > 1


VARIABEL Bebas Tergantung Nominal Numerik Numerik Numerik multipel Nominal & Nominal logistik Numerik (dikotom) METODE Anova Regresi Regresi

CLINICAL EPIDEMIOLOGY

Clinical epidemiology is the application of epidemiology principles and methods to problems encountered in clinical medicine

Clinical Issues and Questions in the Practice of Medicine ISSUE


Normality/abnormality

QUESTION
Is a person sick or well? What abnormalities are associated with having a disease? How accurate are diagnostic tests or strategies used to find a disease? How often does a disease occur? What factors are associated with an increased likelihood of disease? What are the consequences of having a disease?

Diagnosis

Frequency Risk

Prognosis

ISSUE Treatment

QUESTION How does treatment change the future course of a disease? Does intervention on people without disease keep disease from arising? Does early detection and treatment improve the course of disease? What conditions result in disease? What are the pathogenetic mechanisms of disease?

Prevention

Cause

TERIMAKASIH