PERSONS Causes 1) stage of development -congenital anomalies can only result from intrauterine exposure to dangerous influences as drugs,

radiation & viruses -children lack in immunity, if not protected by specific vaccines they will suffer more from infectious disease -children are growing continuously exposed to infections. They are more liable to malnutrition -sexually transmitted diseases more common among sexually active adolescents & young adults - adults are exposed to occupational diseases -women in reproductive age are at risk from reproduction especially if their fertility behaviour is not properly planned -older people are more exposed to fractures due to osteoporosis 2) degree of exposure, susceptibility & duration of immunity -chicken pox is a disease of childhood because of long lasting immunity 3) hormonal changes -breast cancer shows two peaks. 1st(40-49)-ovarian dysfunction, 2nd(65+)-adrenal oestrogen imbalance 4) cumulative effects -chronic & degenerative diseases-atherosclerosis tend to increase with age reflects cumulative effect of exposure to environmental influences 1) Anatomical difference- eg: cancer prostate in males, cancer uterus in females 2) Sex-linked genetic inheritance- eg: haemophilia 3) hormonal factors- eg: CHD affects young men frequently due to protective action of oestrogen 4) differences in habits, social relationships & other aspects of life- eg: tetanus more in males 1) Mortality rates are lower for married persons because -people who live dangerously tend to live single -persons who have poor health tend to remain single -differences in way of live of single & married people 2) suicide & mental illness are more likely to affect single persons 3) breast cancer-females remain single/marry late , cancer cervix-females marry young 4) spouses usually develop same disease Importance 1) severity of disease -pneumococcus tends to produce severe disease in very young & very old -fracture neck femur is serious in elderly while cancer is more severe in young 2) clicical type of disease -crenitism in childhood & myxoedema in adults 3) age distribution curve can show one peak or Bimodality-eg: different mechanisms as in Hodgkins disease & female breast cancer

Marital status

sex

age

Occupation

Related to disease in several ways 1) exposure to several type of disease 2) association between occupation & social class 3) certain occupation select certain types of workers-eg: army or police forces

Important epidemiological factor because : 1) most sensitive measure of social class 2) indicates influences of working condition-eg: exposure of physical, chemical & biological factors 3) alter general pattern of life of employees-eg: night shift alter sleep pattern of nurse

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Social status

1) Low social class -tb, RHD, chronic bronchitis, malnutrition -infants, maternal, preschool mortalities 2) upper social class -obesity, gout, CHD, atherosclerosis -longer life expectancy

Measured by : 1) educational level 2) type of occupation 3) income 4) residence 5) housing conditions

Behaviour

Important behavioural factors include -cigarette smoking -sedentary life -eating habits -drug abuse 1) Moslems do not suffer from Taenia solium and alcoholic liver cirrhosis 2) Cancer cervix is less among Jewish & Moslems women attributed to personal hygiene & male circumcision 1) hypertension high frequency in blacks 2) tb low frequency among European Jews but not Arab Jews

risk factor in many disease as -CHD, cancer, accidents, obesity

Religion

Ethnics group = Group of persons who lived together for a sufficient length of time to have acquired common characteristics whether by biological or social mechanism

Ethnics

Differences may be due to: -hereditary factors -religion -food habits -common exposure to social & environmental factors

TIMES 1) Short term fluctuations / epidemics = occurrence in a community or region of cases of an illness, in excess of normal expectancy. Point source epidermics -exposure of susceptible disease agent is brief & essentially simultaneous -explosive number of resultant cases -all cases develop within short period of time, eg:water borne of typhoid & cholera 1) epidemics curve rises & falls rapidly with no secondary waves 2) epidemics tend to be explosive, there is clustering cases within a short period of time 3) all cases develop within one incubation period Propagated / contagious epidemics -infectious agent is propagated in community by passage from person to person -eg: epidemic of measles 1) epidemic curve rises & falls gradually 2) cases occur over a much longer period 3) cases occur within more than one incubation period

Main features

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DESCRIPTIVE STUDIES DESCRIPTIVE STUDIES on frequency& distribution of known& possible of known& posible causes of disease in populations 1)provide information on the frequency of health states&possible causes 2)planning health promotion 3)planning health services & preventions Population Correlation -1 (negative correlation 0 (no correlation) +1 (positive correlation) Positive correlation 1) average consumption of meat and rate of cancer colon in women 2) per capita cigarettes sales and mortality from lung cancer 3) consumption of pork meat and number of cases of breast cancer Negative correlation -percentage of mortality from cancer cervix and percentage in number of women screen for cervical cancer Case report Describes a new unusual or interesting phenomenon in a single case Case In 1961, pulmonary embolism found in 40 years pre-menopausal female after 5 days using oral contraceptives. (PE usually occurs among post menopausal females). Adenocarcinoma of vagina was reported in a young girl that was exposed to oestrogen during fetal life. (this tumour is rare & usual victim is >50 years) Hypothesis oral contraceptive pills might be responsible for occurrence of PE in premenopausal females. fetal exposure to oestrogen may have responsible for rare occurrence of this tumour. Case series Describes new unusual or interesting phenomenon collected from individual case reports Case 1In 1981, 5 cases of pneumocystitis carinii pneumonia reported among young previously healthy, homosexual men in LA within 6 months. (pneumonia only in older cancer patients). Kaposi sarcoma reported among adult homosexual men. (KS disease of old age) Hypothesis Sexual behaviour could be related to AIDS Individual-based Cross sectional (prevalence study) Exposure (E) and disease (D) status are assessed simultaneously among individuals in a well-defined population. 1) IHD in relation to high fat diet 2) Obesity in relation to diabetes mellitus 3) Thrombophlebitis in relation to use of oral contraceptives 4) Health interview questionnaire inquires into all health & health relatedproblems Analysis & interpretation of the results a) Tabulation of data Condition Characteristic cases controls Yes no total b) Flowchart Characteristic + condition Characteristic + no condition sample No characteristic + condition No characteristic + no condition b) Prevalence rates = total number of all cases (new+old) x 100 = a/(a+b) x 100 total number of population = c/ (c+d) x 100 a c a+c b d b+d Uses Concept Type

total a+b c+d a+b+c+d

proved later on suffering from AIDS

Examples

OR

c) Interpretation prevalence rate of (condition) among (characteristics) is more than among (characteristics)

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1) easy, cheap & quick 2) use information already available 3) useful in formulating hypothesis

1) Easy, cheap 2) Useful in formulating hypothesis 3) Individual in case series may serve as cases in a case control study

1) Quick, easy & cheap 2) Reveals the distribution of health & disease status 3) Direct case finding 4) Estimates prevalence rate in relation to exposure 5) Shows case load 6) Provides information for planning & evaluation of health services 7) Generates hypothesis 1) Not useful for rare condition 2) Not useful in acute condition 3) Deals only with survivors (survival bias) 4) Fails to demonstrate the temporal relationship (Chicken-egg dilemma)

Disadvantages

Advantages

1) Inability to link a particular exposure to a particular individual 2) Inability to control for *confounding factors

1) Based on experience of a single individual 2) Might be coincidence 3) Problem of finding a suitable comparison group

ANALYTICAL STUDIES

ANALYTICAL STUDIES type Case control Propspective Individuals are selected on the basis of having the disease (case) or not having thed disease (control) and then compared in relation presence or absence of particular exposure 1) selection of cases a) set the selection criteria b) sources of cases i) hospital selection bias ii) general population generalization but v.costly 2) selection of controls a) set the selection criteria b) sources of controls Hospital Steps -accessible -share same criteria -abolish recall bias -willing to cooperate -over presentation of risk factors among selected subjects -sick by definition Selection of individuals on basis of being exposed or non-exposed and follow them for a certain duration of time to determine whether or not the disease developed 1) selection of population a) selection of exposed i) common exposure- from general population ii) rare exposure- from specific population (subgroups/occupation b) selection of non-exposed or comparison group i) heterogenous internal comparison eg: exposure to smoking in the population ii) homogenous external comparison eg: cohort of radiologists is compared with a cohort of ophthalmologists Special group -healthy -share same characteristics -willing to cooperate 2) Obtain data on exposure -subjects themselves -medical records -medical examination -laboratory examination -environmental surveys 3) Follow up two cohort for the whole latency period Cohort studies Retrospective Goes back years to select the study subjects (exposed to suspected factor, Ee) and the comparison group (not exposed to suspected factor, Eo) from existing records. *useful for occupational exposures-records are available

Concept

General population -healthy

Adv

-time consuming -very costly -population list may be not available -recall bias -non response bias

Disadv

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c) matching process which selects the controls that similar to cases with regard to certain confounding factors which are known to influence the outcome of disease d) size of control choose at least one. Increasing size increasing results precision. However 4 controls increase the cost with little increase in precision 3) Determine the exposure using same methodology for both cases or controls 4) Analysis & interpretation of the results a) Tabulation of data disease status Exposure cases controls Yes no total b) Exposure rates i) Rate of exposure among cases = number of those exposed among the cases x 100 = a/(a+c ) x 100 total number of cases ii) Rate of exposure among controls = number of those exposed among the controls x 100 = b/(b+d) x 100 total number of controls c) Estimation of risk associated with exposure (Odds Ratio) = a x d -measure of the strength of association between the risk c x b ssa s factor and disease. If the value of odds is: >1 = exposure is a risk =0 = no relation between exposure and disease <1 = exposure is protective OR It is (Odds value) times more likely among (esposure) to have (disease a c a+c b d b+d

4) Obtain data on outcome -death records -medical records -medical examination -laboratory investigations 5) Analysis and interpretation a) Tabulation of data Exposure Yes no disease status cases a c controls b d total a+b c+d

b) Calculation of incidence rate i) Incidence rate among exposed = a / (a+b) x constant ii) Incidence rate among non exposed = c / (c+d) x constant c) Calculation & interpretation of relative risk (RR) = incidence rate among exposed (Ie) Incidence rate among non-exposed (Io) Interpretation of RR >1 = exposure is a risk =0 = no relation between exposure and disease <1 = exposure is protective d) Calculation & interpretation of attributable risk (ARP) = Ie Io x 100 Ie Interpretation of ARP = (ARP) & of the (diseasa) among (person exposed) is attributed to (exposure)

Past

Present

Present

Future

Past

Present

Exposure Disease Non-exposure Exposure Flowchart Non-exposure Non-disease

Exposure

Disease Non-disease

Non-exposure

Disease Disease

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Popective cohort Exposure may/may not occured at that time but disease definitely didnt occur Main differences Begins in the present and continue in the future Times consuming Expensive Not suitable for evaluation of rare diseases -loss of experienced staff, loss of funds -change in environmental factors -change in standard diagnostic methods or criteria of diseases -study may alter participants behaviour -attrition problem (loss of participants) during follow up -ethical problems -expensive & time consuming

Retrospective cohort Both exposure and disease have occurred and the investigator has to make sure that the exposure occured before the disease status Begins in the past and continue to the present Saves time Cheap

Limitations

-records are not available & incomplete -not accurate

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SOURCES OF EPIDEMIOLOGY Sources Population census Population estimates Utilities / uses Denominator for mortality, morbidity & fertility rates Outdated ten year census data Denominator for : i) infant mortality & morbidity rates ii) maternal mortality & morbidity rates Numerator for : -fertility rates i) determining the number of deaths ii) calculating mortality rates and ratios iii) determining causes of deaths i) forward incidence data (new cases) ii) indicates fluctuations of occurrence of diseases iii) predicts the occurrence of epidemics iv) allows for tracing sources of infections, mode of transmission & identification of person-place-time v) provides data for planning & evaluation of control or prevention intervention i) good source for accurate information on -incidence & prevalence rates -duration of disease -cure, mortality & disability rates ii) facilitates studies of environmental hazards i) diagnose is correct ii) good source for studying serious & severe conditions iii) source for studying nosocomial infections Diagnosis is correct Limitations

POPULATION STATISTICS

Birth registration VITAL RECORDS

Death registration International reporting a) require international measures eg : cholera, plague, yellow fever) b) under international surveillance eg: louse borne typhus, relapsing fever, poliomyelitis National reporting -primary infectious disease -eg: measles, meningitis, typhoid DISEASE REGISTERS Eg: tuberculosis, cancer, mental disoreders HOSPITAL RECORDS -most accurate source -include inpatient & outpatient records SPECIAL SUBGROUPS RECORDS Include records of : -maternal & child health record -health insurance records may be : -cross-sectional surveys -retrospective surveys -prospective surveys RECORD LINKAGE = process by which medical record from two/more different sources are brought together to provide a single file for individual Eg: - linking record of all family members together - linking school medical record to occupational - linking maternity medical records to newborn -school health services -others MORBIDITY SURVEYS

NOTIFICATION OF INFECTIOUS DISEASES

i) number of cases notified is usually much lower than exists ii) not all health problems are notifiable

i) expensive ii) need active research program iii) not all diseases are registered Information may not be completed ii) not representative of population iii) usually deal with severe condition Not representative of population

Refer to analytic epidemiology

i) brings together information of events occurring to single person together from different records. so full course of an illness occurring in life of individual provided ii) provides information on -natural history of specific disease or morbidity -family & genetic diseases -chronic history of specific diseases or morbidity -use of health survices

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MORBIDITY RATES Measure INCIDENCE RATE -most common way of comparing the frequency of disease in populations -adjust for differences in population sizes -express probability of risk illness in a population over period of time ATTACK RATE -incidence rate applied to a narrow defined population observed for a limited of time SECONDARY ATTACK RATE PREVALENCE RATE Point prevalence = proportion of people affected by a disease at a particular time = old + new cases x 10n population formula = new cases x 10n population *disease affecting whole community (cholera, tb) use mid-year population as denominator = new cases x 10n population = cases among contact of 1ry x 10n cases during 1 incubation period contacts Utilities i) important in planning & priotizing health problems ii) indicator for evaluation of efficiency of preventive program iii) measure absolute risk from the total sample iv) use to calculate -relative risk -attributable risk & attributable risk percent i) epidemics ii) restricted to special age group or time eg: attack rate of puerperal sepsis i) measures ease of communicability ii) directs case finding activities i) indicates amount of cases required care ii) planning health services

Factors increasing incidence rate 1) increase in proportion who has risk factor 2) improved case finding & reporting of disease Factors reducing incidence rate 3) change in balance of etiological factors (mutation) 4) quality of preventive program

Period prevalence = particular disease is present in a population over a longer period of time

-measure of frequency of new cases of disease among contact -length of incubation period is important -immune individuals & primary case are excluded from denominator Depends on: i) incidence rate ii) duration of disease (cure, care, death) Factors affecting prevalence rate Increase by Decrease by -longer duration of disease -shorter duration of disease -prolongation of life without cure -high case-fatality rate increase in new cases -decrease in new cases -out-migration of healthy people -out-migration of cases -in migration of susceptible people -improved diagnostic facilities -improved cure rate (better reporting)

RECOVERY RATE

= recoveries from certain disease x 100 disease

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MORTALITY RATES Measure CRUDE DEATH RATE Formula = all deaths mid-year population

x 1000

AGE SPECIFIC DEATH RATE

= death in specified age x 1000 total live birth = death in specified sex x 1000 population = deaths due to pregnancy, delivery, puerperium & associated condition x 10n Total live birth *10n = 10 000 (not common) = deaths of specific cause x 10n mid-year population *10n><100 000 = deaths of certain disease x 100 person have same disease = deaths from given cause x 100 deaths from all causes

SEX SPECIFIC DEATH RATE

MATERNAL MORTALITY RATIO

CAUSE SPECIFIC DEATH RATE

CASE FATALITY RATE

PROPORTIONATE MORTALITY RATE

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