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Learning Objectives
1. 2. 3. 4.
Describe the origins of epidemiology Define epidemiology Describe the scope of epidemiology Discuss the contribution of epidemiology in the control of diseases
Learning Objective
5. Define health and disease 6. Identify the stages of disease 7. Compute the measures of disease frequency given a set of data
Definition of Epidemiology
Hippocrates in 400 BC in his On Airs, Waters and Place the role of the environment in health and disease occurrence. John Graunt, in 1662, published Natural and Political Observations Made Upon the Bills of Mortality which recorded characteristics of birth and death data, including seasonal variations, infant mortality, excess of male over female deaths, and other findings. He was the first to employ quantitative methods in describing population vital statistics.
2.
John Snow investigated a cholera epidemic in mid-19th century in London. His work featured various techniques in epidemiologic inquiry such as a spot map of cases, tabulations of cases and deaths, development and testing of hypotheses that contaminated water may be associated with cholera outbreaks.
Table. Deaths from cholera in districts of London supplied by two water companies, 8 July to 26 Aug1854 (Source: Snow, 1855)
The history of epidemiologic methodology is largely the history of the development of five ideas:
a. b.
c.
d.
e.
Human disease is related to the environment in which we live; Counting of natural phenomena may even be more instructive than just observing them; natural experiments can be utilized to investigate disease etiology; Natural experiments occur more frequently than we think and reflect the tremendous heterogeneity of human experience; true experiments may be conducted in human populations in some circumstances
The epidemiological approach of comparing rates of diseases in subgroups of the human population became increasing used in the late 19th and early 20th centuries.
The main applications were to communicable diseases. This method proved to be a powerful tool for showing associations between environmental conditions or agents and specific diseases.
Definition of Epidemiology
Definitions of Epidemiology
1.
It is 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)
2.
It is the study of the distribution and determinants of disease frequency in human populations. (MacMahon and Trichopoulos, 1996)
Definitions of Epidemiology
3.
Epidemiology is an investigative method used to detect the cause or source of diseases, disorders, syndromes, conditions or perils that cause pain, injury, illness, disability or death in human populations or groups. (Timreck, 1994) Epidemiology is a discipline that describes, quantifies, and postulates causal mechanisms for health phenomena in the population. (Frils and Sellers, 1996)
4.
3.
4.
Population of interest are human populations. Describes distribution of health and disease (by person, place and time variables). Identifies determinants of health and disease (risk factors, causes) Health and disease (injury, illness disability or death)
This emphasizes that epidemiologists are concerned not only with death, illness and disability, but also with more positive health states and with the means to improve health.
Scope of Epidemiology
Herd immunity
A vaccine provides herd immunity if it not only protects the immunized individual, but also prevents that person from transmitting the disease to others, causing decline in prevalence of the organism in the population.
Uses of Epidemiology
1.
Causation
Ill health
Uses of Epidemiology
2.
Explain local disease patterns - By utilizing what is already known about the etiology of a particular
health problem, epidemiologist may be able to explain and deal, e.g. with a particular outbreak, and formulate preventive measures suitable to a specific community.
Uses of Epidemiology
3. Describe the natural history of disease
- To identify factors related to the course of the disease once the
disease is established; - It is useful to know how the duration of a disease and the probability of various outcomes (e.g., recovery, death, complications) vary by age, gender, geography, etc.
Death Natural history Good health Subclinical changes Clinical disease Recovery
Uses of Epidemiology
4. Provide guidance in the administration and evaluation of health services. - Estimation of number of hospital beds required for patients with
specific diseases (e.g., mental illness) or for a given segments of the population (e.g., prematurely born infants, disabled elderly) will require knowledge of the frequency and natural history of particular diseases or of all diseases in the affected segments of the population.
Uses of Epidemiology
4. Provide guidance in the administration and evaluation of health services.
- The planning of efficient research (diagnostic, therapeutic, or preventive) will require knowledge of how many cases of a particular disease are likely to be found in a given population during a given period. - Knowledge of the relative frequency of disease in population subgroups is useful if it enables intervention programs to target these populations e.g.,screening programs.
Uses of Epidemiology
Treatment/medical care
Evaluation of Intervention
Ill health
Achievements in Epidemiology
1.
Smallpox
1790s: cowpox infection conferred protection against smallpox virus (only after 200 years were benefits of the discovery applied and accepted) 1967: 10-year eradication program of WHO ( 10-15M new cases; 2M deaths annually in 31 countries) 1976: 2 countries 1977: last naturally occurring smallpox US$ 200M outlay estimated to result in savings of US$ 1500M a year. Factors for success: universal political commitment, a definite goal, a precise timetable, well-trained staff and a flexible strategy. And an effective heat-stable vaccine.
Achievements in Epidemiology
2. Methylmercury poisoning
1950: Mercury released with water discharged from a factory in Minamata, Japan, into a small baysevere poisoning in people who ate fish contaminated with methylmercury. 1st case DDx as infectious meningitis 121 patients residents close to Minamata Bay; main occupation fishing. People visiting affected families who ate little fish did not suffer disease. Conclusion: something in the fish had poisoned the patients; not communicable or genetically determined.
Achievements in Epidemiology
3. Rheumatic fever (RF) and rheumatic heart disease (RHD)
-
Associated with poverty, poor housing, overcrowding: factors favoring spread of streptococcal URTIs. In developed countries, decline of RF started on 20th century, before introduction of sulfonamides and penicillin. In developing countries, among socially and economically disadvantaged groups, RHD is one of the most common forms of heart disease. Epidemiology: understanding RF and RHD development of methods for prevention of RHD role of social and economic contributing factors for outbreaks of RF and spread of strep throat infxn
Achievements in Epidemiology
4. Iodine deficiency diseases
- 16th century: Goiter and cretinism first described in detail - 1915: endemic goiter named as easiest to prevent; - 1989, Hetzel: use of iodized salt for goiter control proposed in Switzerland - 1990s: large-scale trials in Akron, Ohio, USA, on 500 girls, 11-18 yo. - Epidemiology: identification and solving iodine-deficiency problems effective preventive measures methods of monitoring iodization programmes
Achievements in Epidemiology
5. High blood pressure
- in both developed and developing countries; - 20% of people aged 35-64 years in USA and parts of China - Epidemiology: defined extent of the problem established the natural history of the condition and health consequences of untreated HPN demonstrated the value of treatment helped determine most appropriate BP level at which treatment should begin
Achievements in Epidemiology
6. Smoking, asbestos and lung cancer
- 1930s: dramatic increase in occurrence of lung cancer in industrialized countries - 1950: first epidemiological studies linking lung cancer and smoking - Main cause of increasing lung cancer: tobacco smoking - Other causes: asbestos dust and urban air pollution. - Smoking and asbestos interact, creating high lung Ca rates for workers who both smoke and are exposed to asbestos dust. Epidemiology: provide quantitative measurements of the contribution to disease causation of different environmental factors.
Achievements in Epidemiology
7. Hip fractures
- Epidemiological research on injuries, ie hip fractures due to fall, involves collaboration between scientists of epidemiology and in the social and environmental health fields. - implication s for the health service needs of aging population. - Epidemiology: vital in examining both modifiable and non-modifiable factors to reduce the burden of fractures.
Achievements in Epidemiology
8. AIDS
- 1981: first identified as a distinct disease entity in USA - 1992 April: 484,148 cases have been reported (USA-45%, Europe-13%, Africa-30%, Asia and other areas-12%) - True extent of the cases is likely to be much higher than reported. - 50% of people with HIV infection likely to develop AIDS within the years. - Of those with AIDS, more than 50% die within 18 months of diagnosis. - In USA, AIDS is already a more important cause of premature death than COPD and DM. - Epidemiology: identification of epidemic determination of pattern of AIDS spread identification of risk factors evaluation of interventions (treatment, prevention, control)
Definitions of health and disease Measures of disease frequency Use of available information
WHO, 1984: health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity World Health Assembly, 1977: - main target of Member States of WHO: By year 2000 all people attain a level of health permitting them to lead socially and economically productive lives.
The development of criteria to establish the presence of a disease requires definition of normality and abnormality. (difficult)
Stages of Disease
1.
The development and expression of a disease occur over time and can be divided into 3 stages: Predisease stage - (before the pathologic process begins) - early intervention may prevent exposure to the agent of disease (e.g.,lead, trans-fatty acids, or microbes) preventing the disease process from starting: PRIMARY PREVENTION
2. Latent stage - (when disease process has begun, but is still asymptomatic) - screening and appropriate treatment may prevent progression to symptomatic disease: SECONDARY PREVENTION
Stages of Disease
3. Symptomatic stage - (when disease manifestations are evident) - intervention may slow, arrest, or reverse the progression of disease: TERTIARY PREVENTION
Based on fundamental concepts of prevalence and incidence Note: calculation of measures of disease frequency depends on correct estimates of the people under consideration (potentially susceptible to the disease studied): POPULATION AT RISK Population at risk can be defined on basis of demographic or environmental factors: e.g., occupational injuries = workforce
brucellosis = people handling animals (farms and slaughterhouses)
A rate is calculated by dividing the number of cases by the corresponding number of people in the population at risk, and is expressed as cases per 10 people.
Decreased by:
Shorter duration of disease High case-fatality rate from disease Decrease new cases (decrease incidence) In-migration of healthy people Out-migration of cases Improved cure rate of cases
2.
3.
Assess the need for health care and the planning of health services/project medical case needs Measure the occurrence of conditions with gradual onset of disease (e.g., maturity-onset DM, RA) Assess the PH impact of a disease
person-time incidence rate - most accurate way of calculating Incidence rate (Last,1988) - Each person in the study population contributes one person-year to the denominator for each year of observation before disease develops or the person is lost to follow-up.
SOURCES OF DATA
Session Objectives
1.
2. Describe the integrity and comparability of data, and identify gaps in data sources
Epi Data
1. 2. 3.
Disease status Exposure status (intrinsic and extrinsic factors) Others - vital event - socio-demographic/ cultural data - health resources - services
Types of data
1. 2.
Sources
Primary data: 1. Observation (direct measurement) 2. Query (interview or questionnaire)
Sources
Secondary data 1. Vital records (birth/death certificates) 2. Reportable disease statistics 3. Disease Registries 4. Morbidity Surveys 5. Screening Surveys 6. Patient Records (hospitals, private clinics)
Seatwork:
1.
2.
Identify the epi data that can be derived from each of the following sources Give your comment on the quality of data (completeness/accuracy) that can be obtained from each source
Seatwork:
Data Sources
1. Vital stats 1.1 Death certificate 1 2 Birth certificate 2. Reportable Disease Stats 3. Disease Registries 4. Morbidity Surveys 5. Screening Surveys 6. Patient records (hospital/MD practice)
Key Info
2.
3.
4.
Nature of data -- routinely collected (registration system), survey data, hospital or clinic cases, MDs records Availability -- ad hoc (prn)? Periodic? (weekly, annual, etc) Completeness of population coverage (thoroughness) -- Are all cases identified? Value and Limitation -- Utility of data, accuracy of information
1. Vital Records
1.1 Death Certificate (Mortality Statistics)
Information
1. Fact of death
Completeness/accuracy
Satisfactory (deaths unlikely to go unrecorded) Not satisfactory
2. Cause of death
1. Vital Records
1.1 Death Certificate: Issues/Problems Diagnostic inaccuracy Unavailability of cause of death statement Lack of standardization of diagnostic criteria ( What constitutes a cause of death? acceptable cause of death?)
1.
2.
3.
1. Vital Records
1.1 Death Certificate: Causes of Problems
1. 2.
3.
Medically unattended deaths (verbal autopsy) Lack of training of certifying MDs on cause of death certification/ access to guidelines Attitude of MDs
Research Findings: Completeness and Acceptability of cause of death statement in death certificates
19% completely filled up Of the 19%, only 12 were filled up in an acceptable manner Among the items, underlying cause was the least filled up (28%)
(Immediate cause=92%, Antecedent cause=57%)
5% underlying cause are unacceptable entries (Cardiac arrest, respiratory arrest, CR arrest, heart failure, DOA, Shock)
1. Vital Records
1.2 Birth Certificate/fetal death
Information
1. Fact of birth
Completeness/accuracy
Satisfactory
(births unlikely to be recorded)
2. Condition of child at birth (weight, abnormality, etc) 3. Condition of mother during pregnancy/delivery
Satisfactory
Not satisfactory
(recall)
Not all will seek medical attention; asymptomatic Failure of MDs to fill out the required reporting forms MDs concern over confidentiality of information WHO: reluctance to admit occurrence of certain diseases
Neonatal Tetanus Non-neonatal tetanus Meningococcal infection Paralytic shellfish poisoning Rabies Typhoid and paratyphoid fever Pertussis
Acute Flaccid Paralysis Acute Hemorrhagic Syndrome Acute Lower Respiratory Tract Infection and Pneumonia Acute watery Diarrhea Acute Bloody Diarrhea Food Poisoning Chemical Poisoning
3. Registries
-- centralized database for collection of information about a disease (cancer, trauma, etc) -- newly recognized cases are entered and maintained in a file until recovery, death, or migration -- Source of data for: duration of illness outcome of illness (Case fatality) incidence and prevalence natural history of disease -- Satisfactory source of data only for some diseases
4. Morbidity Surveys
Sample population (representative sample) National Demographic and Health Survey (NSO) --every 5 years National Nutrition Survey (FNRI) -- every year National weighing,Operation Timbang (DOH) --on-going (15 years) Prevalence Surveys (periodic)-TB, Disability, STD
5. Screening Surveys
Sample population (non-representative sample)
6. Hospital Data
In-patient and out-patient records Does not represent a specific population Type of information is not standardized
Agreement between medical record and interview is variable Excellent agreement (inherent features of patients clinical condition surgical procedures, family history of cancer) Poor agreement (pharma use)
DOH - Phil. Morbidity and Mortality Report (quarterly) - Field Health Service Information System (FHSIS)
a. stat indicators of health programs,DOH b. vital stats, by province, city, region
2.
- Philippine Health Statistics (including notifiable diseases) NSO - Vital events (births, deaths, marriages) - National Demographic Survey (every 5 years,2003)
--demographic, maternal and child health stats
3.
1. Denominator data: define the population at risk; Census statistics 2. Numerator data: define the events/conditions of concern; statistics from health, disease, birth, and death registries and surveys
fact and cause of death, age, sex, DOB, place of residence Useful only if data are complete and accurate Not in all countries: no resources for routine death registers, not reported due to cultural or religious reasons. International Classification of Diseases (WHO,1992b) revised at regular intervals used for coding causes of deaths; account of the emergence of new diseases and changes in criteria for established diseases
Number of deaths in a specified period Crude mortality rate = ____________________________________ (x 10 ) Average total population during that period Disadvantages: No account of fact that the chance of dying varies according to age, sex, race, socioeconomic class, and other factors. Not appropriate for comparing different time periods or geographical areas.
IMR as an indicator of the level of health in a community: based on the assumption that IMR is particularly sensitive to socioeconomic changes, and to health-care interventions. High IMR should alert health professionals to the need for investigation and preventive action on a broad front.
Based on deaths of children aged 1-4 years. Common in this age group: accidental injuries, malnutrition and infectious diseases.
Life expectancy:
Defined as: the average number of years an individual of a given age is expected to live if current mortality rates continue.
Life expectancy (years) at selected ages for four countries Age Birth 45 years 65 years Mauritius 65.0 25.3 11.7 Bulgaria 68.3 27.3 12.6 USA 71.6 30.4 15.0 Japan 75.8 32.9 16.2
1960
1970
1980
40 45 70
Impairment: any loss or abnormality of psychological, physiological or anatomical structure or function. Disability: any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.
2.
Session Objectives
1. 2. 3.
4.
Define cause of a disease Determine the types of factors of disease Describe the different risk factors of disease using the BEINGS model Discuss how to establish the cause of disease in terms of temporal relationship, plausibility, consistency, strength, doseresponse relationship, reversibility and study design
Epidemiology
A major goal of epidemiology is to assist in the prevention and control of disease, and in the promotion of health by discovering the causes of disease and the ways in which they can be modified.
This session will describe the epidemiological approach to causation.
Example 2: TB: tubercle bacillus as the necessary cause. Susceptible host: Infection
TB
Exposure to bacteria
Tissue invasion
The organism must be present in every case of the disease; The organism must be able to be isolated and grown in pure culture; The organism must, when inoculated into a susceptible animal, cause the specific disease; The organism must then be recovered from the animal and identified.
Anthrax- first disease demonstrated to meet these rules; proven useful with some other infectious diseases.
Factors in Causation:
Four types of factor play a part in the causation of disease. All may be necessary but they are rarely sufficient to cause a particular disease or state:
Predisposing factors, such as age, sex, previous illness, may create a state of susceptibility to a disease agent. Enabling factors, such as low income, poor nutrition, bad housing, and inadequate medical care, may favor development of disease.
Factors in Causation
3. Precipitating factors, such as exposure to a specific disease agent or noxious agent, may be associated with the onset of a disease or state. 4. Reinforcing factors, such as repeated exposure and unduly hard work may aggravate an established disease or state.