Mekelle University

College of health science

School of public health
Department of
Epidemiology
5/20/16

MU-CHS-SPH-D.
Epidemiology

EPIDEMIOLOGY FOR 2nd

/3rd

YEAR
PUBLIC

HEALTH

and

Environmental STUDENTS
BY:-KIDANU G. (BSc in public health, MPH in
Epidemiology)

GOOD LUCK!!
MU-CHS-SPH-D.
5/20/16

Epidemiology

SAVE LIFE !!
PROMOTE TO
HEALTH FOR ALL!
HEALTHY PEOPLE!

5/20/16

Basic concepts of community health

Health has two model for its definition. These are
1)Negative model-it indicates that health is
complete absence of a disease , disability

&

death.
2)Positive model- it has similar meaning with
WHO definition i.e.
Health is a state of complete physical,
mental,&

social

wellbeing

not

absence
of disease MU-CHS-SPH-D.
or infirmity.
5/20/16
Epidemiology

merely
4

 Disease :- it is the opposite of ease

literally .
- It is psychological & physiological
dysfunction.

Illness:- is subjective feeling of

an individual who feels aware of
not being well.
Sickness:-it is a state of social
dysfunctional role that an individual
assumes ill.
MU-CHS-SPH-D.
5/20/16

Epidemiology

 Risk factor:- a factor that increases or

decreases the probability of a

disease occurrence. E.g. the RF of
lung cancer is smoking. it can be
classified as
1. Modified RF:- a factor i.e.
susceptible to change with time .e.g.
RF for lung Ca is smoking.
2) Non modified RF :-factors that
cant be amenable to change from
time to time.eg sex, age, familiy
MU-CHS-SPH-D.
history.
Epidemiology
5/20/16

Cont....

Four types of factors play a part in the

causation of disease.
1. PREDISPOSING FACTORS- Such as
age, sex and previous illness, may
create a state of susceptibility to the
disease agent.
2. ENABLING FACTORS- Such as low
income, poor nutrition, bad housing and
inadequate medical care may favor the
development of disease. Conversely,
circumstances that assist in recovery
from illness or in the maintenance of
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RF........

3. PRECIPITATING FACTORS- Events which

favor exposure to specific disease agent or
noxious agent may be associated with the
onset of the disease or state.
4. REINFORCING FACTORS- Such as repeated
exposure and unduly hard work may
aggravate an established disease or state.

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clinical medicine vs community medicine.

Clinical medicine:- focus on diagnosing
&treating disease of individual person.
Techniques to assess clin. medicine of an
individual are 1.History taking
2.Phisical examination
3.Investigation
4. Establishing differential diagnosis
5.Treatment
6.Follow up
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MU-CHS-SPH-D.
Epidemiology

Community Medicine:Focuses on diagnosing and investigating

the health
related problem of
the
community.
It is also referred as:
population medicine
,
Preventive medicine ,
Social medicine, &
Public health medicine.
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MU-CHS-SPH-D.
Epidemiology

10

Cont

Techniques for diagnosing

community medicine

1. Discussion with the community

member.
2. Document review
3. Field survey
4. Community diagnosis
5. Intervention
6. Monitoring & Evaluation
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MU-CHS-SPH-D.
Epidemiology

11

Selecting Criteria For Prioritization in

community diagnosis
Magnitude of the problem
Degree of severity
Feasibility
Sustainability
Community concern
Political & social acceptability with
consideration of equity
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MU-CHS-SPH-D.
Epidemiology

12

 Community diagnosis :- It is descriptive

identification of health and health related
events of the community using a set of
criteria.

Community diagnosis provides basis for decision on:

The need for intervention
Type of intervention needed
Target group at whom intervention
should be directed
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Public health concept

Defn Is the science and art of preventing
diseases, prolonging life and promoting
health
by
community
efforts
and
governments action.

Aims of public Health

Preventing disease
Prolonging life
Improving quality of life
Eliminating health inequalities
Organizing community to promote active
participation
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14

Public h....cont
CORE FUNCTIONS OF PUBLIC HEALTH

1. Assessment- of health need, by conducting

surveillance and specific studies
2. Leadership - program design, resource allocation
and social mobilization
3. Provision of services- assure availability of quality
& comprehensive health services through accessible
outlets

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15

DESIRED
CHARACTERISTICS
INFORMATION IN PUBLIC HEALTH

OF

Timely
Dynamic
Context related (behavior)
Reliable
Unbiased

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16

Primary health care(PHC):

is defined as: essential health care

made universally accessible to individuals
and acceptable to them, through their full
participation and at a cost the community
and the country can afford.

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17

PHC....
Primary health care (PHC) concept was
evolved based on 4 concepts:
1. Equitable distribution of health care
facilities
2. Community participation
3. Multi-sect oral approach
4. Appropriate technology

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18

PHC...........
PHChas 8 aims/ essential elements:
1. Promotion of food supplies and nutrition
2. Providing health education about health
problems and their control
3. Provision of safe water and sanitation
4. Promotion of maternal and child health
and family planning
5.Providing immunization against infectious
diseases
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19

PHC Cont....
6. Prevention and control of locally endemic
diseases
7. Treatment of common diseases and
injuries
8. Provision of essential drugs

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20

The subject mater of Epidemiology

The word epidemiology originates

from three Greek words i.e.
Epi up on
demos population
logile study ,so its
definition goes to the study of up on
population.
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21

History of Epidemiology
It is as all as medicine , however , it is a flourish
(grow) till 1940s.
Some key
contribute for the devt of
epidemiology like
1) John Grunt(1962):-is the 1st contributor that
publishes

political & natural observation on

the bill of mortality. He was the first to quantify

patterns of birth, death and disease occurrence,
noting sex disparities, high infant mortality,
residence differences, and seasonal variations.
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22

History of Epide........Con
2. Lind (1747s) :-He had used an "experimental"
approach to prove the cause of scurvy by
showing it could be treated effectively with
fresh fruit.
3) Pietrecher & louts (1787 1872) :- They
show systematic application of numerical
thinking.
4) Williams fair ( 1839s):- He takes the
responsibility of medical statistics & extended
the epidemiological analysis (morbidity &
5/20/16
23
mortality).

5) John snow(1854) :- he tried to

relate the cause of cholera to
death & water supply.
6) Brand for hill(1937s):- He
worked on principle of medical
statistics and suggested the
criteria for establishing disease
causation.
7)1950s-1970s:-Modern Epidemiology
began. The method of epidemiology for
chronic disease ,injury, birth defect, hygiene
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24

 Epidemiology:- is originally the

word was applied to the study of
acute infectious disease & it was
defined
as
the
study
of
epidemic.But currently :
It is the study of frequency,
distribution, and determinants of
health related state or events in the
specific population & the application
of this study to the control of health
problems.
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25

Frequency:-The rate of occurrence of a

disease
Distribution:-

The

occurrence

of

disease by PPT.
Determinant: Causes,predisposing factors, etiologies,
precipitating factors etc.
The domain of Analytic Epidemiology.
The response for how and why questions.
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26

Scope of Epidemiology: In the past

the scope was restricted to

infectious disease or epidemic but this

concept is no longer true today.
Currently

the

scope

includes

both

infectious & non infectious disease.

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27

PURPOSE OF EPIDEMIOLOGY: For diagnostic purpose

For identification of determinants of disease
For evaluation of disease control strategy.
For observation of the natural history of a
disease.
For classification of disease
For evaluation of the effectiveness
intervention

of

Define standards and ranges for normal

5/20/16
values
of biological and social measures.

28

Epidemiological concept of disease

There are 2 basic assumptions in
Epidemiology. These are
1. Non random distribution of a
disease:A disease does not occur in one
community by chance or randomly
distributed.
2. Human disease has causative &
preventive factor that can be identified
by investigation on a population.
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29

Cont

Type of epidemiology
1. Descriptive epidemiology:-

It describes the frequency & distribution of any health

related problems in terms of PPT.

It answers: Who is affected? Where& When it

occurs?
2. Analytical

epidemiology:-

It analyzes determinants of any health related problem.

It answers: Why and How
5/20/16
occur?

health related problem

30

Cont..

Epidemiological aspects of communicable

disease
Definition:-

It

is

disease/illness

due

to

infectious agent or its toxic products which

arise through transmission of that agent or its
products from an infected person, animal, &
inanimate reservoir to a susceptible host either
directly or indirectly through an intermediate
plant , animal host ,vector & /in animate
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environment
.

31

Principle of disease causation

There are two basic principle of disease
causation. these are
1) Single germ theory
2) Ecological approach
1) Single germ theory:- it explains that
the cause of a disease is a single entity or
factor.
2) Ecological approach:Ecology is the study of the r/p between
organism to each other &to the
environment.
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32

Cont..
This approach says that the cause of
disease is not a single entity or factor.
Factors can be classified based on causal
pie
Sufficient factor
Necessary factor

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33

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34

1. Etiology of disease

All factors that contribute for the

development of a disease. These factors
are related to the agent , host, &
environment.
1.1. Agent factor are factors that cause a
disease.eg
a) Nutrient
b) Chemical agent
c) Physical agent
d) Infectious agent
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35

1.2. Host Factor(intrinsic factor)

Factors
that
influences
exposure
,susceptibility,& response of the host or
person to the agent that depends on
1) Genetic factor
2) Age
3)Sex
4) Physiological
Factors
5) Socioeconomically Status
6)Ethnicity

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36

Cont.

1.3. Environmental factor

It Contributes or influences the
existence of the infectious agent,
exposure & susceptibility of the host
. This factor depends on
a) Biological
b) Social
c) Physical
d) Chemical
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Environment

37

Cont
Disease causation model
1) Epidemiological triangle Model(triad
model)
This state that factors are in a balanced
state but if there is a change in these
factor, there is chance to increase or
decrease the occurrence of a disease.
Envt
Host
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Agent
38

2)

The web model:-

The cause of a disease is not a single

entity rather it depends on the chain
of disease causation.

E.g.DM HTN choronary

heart

disease

3) Wheel model:-describe the

cause of a disease depends on the
relation ship of the size of each
host like with biological , physical or
social envt.
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39

Causal concepts of a disease

1) Not all association b/n factor & disease
are causes
2) Any cause must precede the disease
3)

The cause is

necessary

when the

disease doesn't develop in its absence.

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40

Criteria of cause - effect relation ship

(brand for hill criteria)
1) Strength of the association
2) Consistency of the relation ship
3) Specificity of the association.
4) Temporary relation ship
5) Dose response relation ship
6) Biological plausibility(Credibility or
experimented)
7) Experimental confirmation
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41

1.Strength of the Association - The stronger

the association, the more likely that it is causal.
2.Consistency of the Relation shipThe same association with different methods,
by d/t investigators, and in d/t populations.
3. Specificity of the Association - The
association is more likely causal if a single
exposure is linked to a single disease.
4. Temporal Relationship - The exposure to
the factor must precede the onset of the
disease.
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42

Causal .......
5.Dose-response Relationship - The risk
of disease often increases with increasing
exposure to a causal agent.
6.Biological Plausibility - The hypothesis
for causation should be coherent with
what is known about the biology and the
descriptive epidemiology of the disease.
7.Experimental
confirmationConfirmation that the risk of disease
often increases with increasing exposure
to a causal agent by manipulating
exposure level
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43

Natural history of a disease

Defn:- is the progression of the disease
process in an individual over time with out
any intervention or treatment.
It has four stages, these are
1) Stage of susceptibility
2) Stage of subclinical(pre-symptomatic)
3) Stage of clinical disease
4) Stage of disability or death

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44

Cont.
1) Stage of susceptibility :
Is a person who have no sufficient resistance/immunity to
prevent infection.
2) Stage of pre-symptomatic:There is no clinical manifestation but there is a pathogenic
changes. This stage may leads to clinical stage &/
recovery with out any manifestation .

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45

3)Clinical stage:During this period; the person has already developed

clinical manifestation & the result of this stage may be
recovery , disability , or death.
4) Stage of disability or death:during this stage the person has developed
complications like death or disability.
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46

 Exposure to an infectious agent does

not necessarily lead to infection
An infection does not necessarily
lead to disease
Infection may remain asymptomatic
or sub-clinical, or may lead to overt
clinical disease

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47

Cont.

Generally
Healthy person but exposed for some
exposure
Immunized
Susceptible
sub clinical disease

Recovery

Recovery

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clinical disease

disability

death

48

5/20/16

49

 Disease prevention
It has level of prevention ,
stage, and target population

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50

Levels of Disease Prevention

It is important for implementing interventions

that
prevent infections or ameliorate
infections.

It involves the interruption or slowing of

disease
progression through appropriate intervention.

Epidemiology plays a central role in disease

prevention by identifying modifiable causes of
disease and their risk factors
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51

Level of
preventi
on

Stage of disease

target
populati

primordi there is underline condition for General

al
the occurrence of disease like
populati
socioeconomic status ,culture
of the
commun
y
Primary The objectives here are to
Healthy
preventi promote health, prevent
people
exposure, and prevent
on

5/20/16

occurrence of disease.
Prevent healthy people from
being sick
Using
vaccination
,
vector
control, Safe water supply,
Health
education,
adequate
housing, Safe disposal of human

52

Cont
3

Secondar
y
preventio
n

Interventions
that
act
after the biological onset of
a
disease,
but
before
permanent damage sets in.

patie
nt

The objective here is to

stop or slow the progression
of disease and to prevent or
limit permanent damage.
Strategy at this stage is
through early detection and
treatment of disease.

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53

Cont
Detection by
physical examination
4

Tertiary
preventi
on

Intervention that acts after

permanent damage has set
in, and the objective is to
limit the impact of that
damage.

patie
nt

The
impact
can
be
physical,
psychological,
social (social stigma or
avoidance by others), and
financial.
5/20/16

Strategy at this stage in

54

 Components of infectious process in

the chain of disease transmission

There are six major components of

the infectious disease. these are
1) Agent
2) Reservoir
3) Portal of exit
4) Mode of transmission
5) Portal of entry
6) Human host
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55

5/20/16

56

The chain of disease transmission are

Reservoir

Agent

portal of exit

MOT
portal of entry

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new host.

57

1) Infectious agent

Any disease causing living organism

or

micro

OM

,chemical

toxic

substance/ & inanimate subs that

can cause disease. e.g. biological
agent like bacteria, virus &inanimate
agent like chemical subs.

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58

Cont

The out come of exposure to Infectious

agent depends on :1) Infectivity of the agent
2) Pathogenesity of the agent
3) Virulence of the disease
4) Immunogenicity

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59

Cont
1) Infectivity:- the ability of the infectious
agent to invade & multiply in the host.
2) Pathogenesity :- the ability of the
infectious agent to produce clinically
apparent disease .i.e. the ability to
produce Sign & symptom of the disease.

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60

3) Virulence:- The proportion of the clinical

cases resulting to sever clinical cases or
The ability to cause sever out come of the
disease . e.g. disability, death.

4) Immunogenicity:- the ability of the

infection to produce specific immunity.
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61

5/20/16

62

Cont.
Virulence =case fatality rate = No of fatal case
X100
(CFR)
total no of case
=Hospitalization Rate = No of admitted
caseX100
total no of case
eg. There are 500 patients in one area: 150 +ve
for PF, 50 +ve for PV,10 death, then calculate
the CFR. So CFR= total death X100 i.e. 10x 100
=2%
total case
500
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63

2) Reservoir :- is any OM or habitat in

which infectious agent can live
normally ,transform, develop or multiply.
Eg man , animal, nonliving subs.
3) Portal of exit:- it is the site in which the
infectious agent can escape or leave from
infected person. such as all body
secretion like saliva, breast milk , viginal ,
cervical discharged , etc
4) Mode of transmission:- mechanism by
which infectious agent is transmitted
from the reservoir to new host.
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64

Cont.
There are 2 type of MOT. these are
A) direct transmission:-can be direct
contact, direct projection of saliva, intra
placental,
B) indirect transmission:- Can be
Air borne( IA transmitted through dust or
droplets nuclei.)
Vehicle borne( any subs that help to carry
&transfer infectious agent.)
Vector borne (transmission of IA through
vector)
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65

5) Portal of entry :- is the site where an

Infectious agent enter to the new host.
6) New host:- is final chain of the infectious
agent which highly acquire infection.
Herd immunity:-is the resistance of the

community to invasion& spread of the

infectious

agent

or

development

of

immunity at the population level.

Herd immunity is less effective for air born
disease.
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66

Cont..

The pre-requisite for herd immunity

Single reservoir
Total immunity
Uniform distribution of the immunity.
No shading of the agent by immune host(no
carrier state)
Direct transmission of a disease.
No over crowding of the community
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67

Timeline course of infection

1) pre patent period:-is time interval b/n
biological

onset

till1st

shading

of

an

infectious agent.
2) Incubation period:- is time interval b/n
biological onset & clinical onset.
3) Communicable period :- is a period where
an infected host transmit infection to other .
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68

Cont...
4) Latent period :- is a time interval b/n
recovery & relapse phase in clinical
disease.
5) Predormal period:- is time interval b/n
symptom onset & sign onset.
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69

5/20/16

70

Disease carrier

It is an infected person or animal that

transmits infection with out any clinical
manifestation.
Types of carriers :-

1) Incubatory carrier:- a carrier that

transmits the infectious agent during
incubation period. eg. measles, mumps

2) Convalescent carrier:-a carrier that

transmits the infectious agent during
recovery.eg Typhoid fever
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71

Cont.....
3) Asymptomatic carrier :- Carrier that
transmits disease with out ever showing
any clinical manifestation. E.g. Polio ,
Amoebiasis
4)Chronic carrier:- a carrier stayed for a
long period of time.

E.g

V/ hepatitis ,

Typhoid fever
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5/20/16

73

Methods of controlling
communicable disease
1) Protection of the susceptibility
2) Interruption of the transmission
3) Elimination of the reservoir but not
for all
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74

If Human is act as a reservoir

Early detection & Treatment

Isolation: is separation of infected

persons

from

non-infected

for

the

period of communicability.

Quarantine: is

limitation of freedom

of movement of apparently healthy

persons or animals who have been
exposed to a case of infectious disease.

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75

If animal act as a reservoir

Vaccination(reducing susceptibility)
Interruption of the transmission
Killing
2) Chemoprophylaxis like for malaria &
meningitis
1)

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76

Measurement in Epidemiology

Basic measurements are:

1) Measurement of association (r/n b/n factor
& disease) is done by rate , ratio , ecological
fraction
2) Measure of disease occurrence (frequency) is
done by prevalence & incidence
3) Standardization( adjustment)
4) 5/20/16
Variation in disease occurrence & association
77

Cont..
Measurement of morbidity & mortality
Basic measurements are:1) Absolute number
2) Ratio , Proportion, Rate
1) Absolute number : Is a simple count of events with out stating
the size of popn.
It has no denominator i.e. 1
Is not used for comparison purpose.
It is a basic measure for frequency
measurement.
78
It is used for public plan5/20/16

Conts.
2) Ratio, Proportion,& Rate: Are a relative figures
Used for comparison purpose
Used
to assess distribution
determinants of a disease

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&

79

Ratio :It quantifies the magnitude of one occurrence

or condition in relation to the other.
It express the relation ship b/n two items (No
)in the form of X:y => X/y x100
During the calculation, take x & y at the
same time.
E.g. The no of female & male students are 20&
80 respectively; Calculate the ratio of F to M
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80

Cont..

So/n R= F x100 , 20x100 = 1/4= 25%

M
80
This indicates that 1 Female is to 4 male
student or 25% female is to 75% male
student

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81

Proportion :It is specific type of ratio.

The numerator includes in the denominator.
i.e.

x 100 ,always express in %

X+Y
E.g. F=20, M=80, find the proportion of M to
F
P= 80
x 100 =80%
80+20
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82

Rate :is the no of cases per unit popn per unit

time.
It is special form of proportion.
It is a basic measure of disease occurrence.
To calculate rate, you must need
1) No of people with disease(event) (X).
2) No of people with out disease(Y) but at
risk.
The numerator (x) & denominator (X+Y)
Rate = No of diseased (event) in a specified period
xK
total popn at risk in specific period;
K=100,1000,10000
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83

Population at risk :-The group of people who

have the potential of getting the disease.
The advantage of rate over the absolute no

is enable to make comparison of frequency

of ds or death In d/t pop. or in the same pop.
at d/t time
e.g.
Years
T. popn
No of death
1920
10000
600
1960
40000
1800
1980
60000
2000
From
this death is high at -------5/20/16

death rate
60
45
33
84

Cont

Rate can be classified as

1) Crude rate
2) Specific rate
3) Adjusted rate or standard rate

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85

1. Crude Rate :-

It is the actual summery rate in a total

pop. over a given time.

It depends on the probability of dying

people

&

age

distribution

of

the

population.
It is difficult to interpret .
CR= total no of events(Bor D)over specified time X K; k=1000
total no of population at risk
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86

2) Specific rate : It is a detailed type of rate not a summery rate .

It

uses

for

epidemiological

&

public

health

purpose.
It applies to a specific subgroup of popn such as
age specific rate, sex specific , & marital status
rate etc. E.g. IMR, NMR, MMR ,CMR
It is a cumbersome rate if there are many groups.
Control homogenous group .
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87

3) Adjusted rate:It is a summery rate but needs statistical

transformation to permit fair comparison
b/n group
Control confounder variable .
The most common variable which needs
adjustment is age.
It permits group discussion.
It is fictious rate(false type of rate)
It depends on standard population for its
magnitude.
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88

Cont...
There are two method of adjustment.
These are
1) Direct method if total standard
population is given
2) Indirect method if the ASDR is given

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89

Cont.
Direct method:- it require
1) Age Specific Rate for the Sample (ASMR)
2) Age Structure of the standard of the pop.
(AS).
Age adjusted rate = Expected no of death
X1000(K)
(AAR)
total no of standard
population
Expected Death rate=ASMR X standard
popn./1000
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90

Indirect method:It requires

Age structure of the sample population at
risk.
Total cases in the sample population.
Age specific rate of the standard
population.
Standard mortality ratio(SMR)
SMR =Observed case x100(k)
expected case
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91

Cont
AAR =Total no of expected death of a given pop
x1000
total standard pop
if it is direct method use it. But if it is indirect
method use the following
Age Adjusted Rate =adjusted death rate of A X
1000
adjusted death rate of B
adjusted death rate(AorB)=total no
ofexpectedD.x100
total standard pop
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92
Expected
D.=ASMR x standard pop /1000

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93

Measures of Morbidity
It is a measure of disease occurrence in a
given

population

at

specified

time

period(PPT).
Measure of morbidity is more difficult than
mortality Because

Illness may not easily recognized

It rapidly occur in one person.
A person may suffer from d/t
5/20/16

94

Cont....
There are two basic measure of morbidity .
1)

Incidence rate(IR)=> It assess new

case
2)Prevalence rate(PR)=>It assess old &
new case.

5/20/16

95

Incidence rate
Is the probability that healthy individual will
develop a specific disease during specific time.
It is a measure of the number of new cases in a
popn. over a given period of time.
IR=No of new case of disease in specific period x
K
people at risk during the given period of
time
i.e. the probability of healthy individual that
develop a disease.
5/20/16

96

Cont...
IR (illness)= the no of illness that newly occurs at a
timex k

pop. at risk during the given period of time

i.e. The number of people with disease to

be expected among the group of people at
specific period of time.

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97

Cont

There are two type of incidence rate.

These are
1) Cumulative incidence rate(CIR)
2) Incidence density rate(IDR)
N.B. CIR is calculated from a popn. who
are more or less stable and by taking the
popn. at the beginning period of time as
denominator.
CIR=
No of new case
x k
no of popn at the beginning of time
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98

Incidence density
It is an alternative name for IR whose
denominator is
calculated
by using
person time unit
ID is used commonly for disease which
have long incubation period.
ID= No new case (X) of disease during time
period x K

total person-time-unit(Y)(time of each person

was observed &total for all)

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99

CONT.

E.g. 5 person observed for 2 years

=5x2=10
2 person observed for 3 years =3x2=6
3 person observed for 4 years
=3x4=12
1 person observed for 5 years =1x5=5
11(X)
(Y)33 pyr is total for all
ID=x/yx100= 11/33 x100=33.3/100

5/20/16

100

E.g.
5p-----------1--------------->2(+ve),0 dead
2p-----------1---------------2--------->3(+ve),0
dead
3p-----------1---------------2-----------3----->4(+ve),0dead
1p-----------1---------------2-----------3-------4------>5(+ve),0 dead
ID=x/yx100= 11/33 x100=33.3/100

5/20/16

101

Cont..

Que2
investigator enrolled 2100 male in a study & follow them
over four years to determine heart ds. the follow up date
provided below , calculate the p-time-unit incidence rate
of a disease.
We assume that person dxed with disease & those lost to
follow up , where ds free for year & contribute half
years to denominator.
Initial enrolment 2100 male free of disease.
after 1 yr, 2000 ds free ,0 with ds, 100 lost to follow up.
After 2 year, 1900disease free, 1with ds, 99lost to follow
up, &
after 3 years ,1100ds free, 7 with ds,793lost to follow up.
after 4 yrs 700ds free,8 with ds,392 lost to follow up.
find 1)total new case 2) p-t-unit 3) ID
5/20/16

102

Numerator = number of new cases of heart

disease
= 0 + 1 + 7 + 8 = 16
Denominator = person-years of observation
= (2,000 + x 100) + (1,900 + x 1 + x
99) + (1,100 + x 7 + x 793) +(700 +
x 8 + x 392)
= 6,400 person-years of follow-up or
Denominator = person-years of observation
= (1 x 1.5) + (7 x 2.5) + (8 x 3.5) + (100 x
0.5) + (99 x 1.5) + (793 x 2.5) +(392 x 3.5)
+ (700 x 4)
= 6,400 person-years of follow5/20/16

103

So/n
lost to follow up & disease free has contribution
by year to denominator , So
1) Total cases are 0+1+ 7+8 =16
2) p-t-u 1st add all disease free peri.e2000 + 1900
+ 1100 +700=5700
2nd lly (0+1+7 +8) x = 8 this are cases that
have a contribution by year to denominator.
3rd lly (100+99+793+392) x =692
finally disease free +lost to follow up +with
disease
5700 +692 +8 =6400
3) ID = total new
cases/total for all of p-t-u x 100 = 16/6400 x100
5/20/16
104
=0.25/100

Basic requirement for IR : knowledge of the health status of the

population.
Time onset of a disease
Period of observation.
Specification of numerator
Specification of denominator

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105

Prevalence rate: The amount of disease that is present already

in a popn.
Indicates the number of existing cases in a

pop.
It estimates disease burden.
Used to describe the distribution (PPT).
Commonly

misleading
5/20/16
illnesses..

used
for

for
acute

chronic

diseases

episodes

of

but

chronic
106

Prevalence is affected by:

1. New and effective treatment

2. Increased survival despite incidence
unchanged or even decreasing
3. Prevalence decreases due to new
curative therapy, despite more people
acquiring disease
4. Population movement
Types of prevalence:- 1) Period prevalence
rate
2) Point
5/20/16

107

Con't

1.Period prevalence:- measure the proportion

of pop. that are affected with a certain ds
during a specific time period
PP= no of individual with ds during specific time
xK
total pop. at mid interval(middle year)
2) Point prevalence:-is measures the
proportion of people with disease at given
point of time.
it is not a true rate but a simple proportion.
PP= no of indi. with ds during specific time point
x K estimated pop. at the same point of time
5/20/16

108

Reasons for high prevalence rate

Increases in survival(Prolongation of life

of cases without cure)
Improvement of medical care.
Slow cure of a disease.
High incidence rate(Increase in new
cases)
Long duration of the disease
In-migration of cases
Migration of healthy people
In-migration of susceptible individuals
e.g. aged
5/20/16

109

Cont.
Reason for low prevalence of a disease

Rapid and High fatal processes of a

diseases.
Rapid cure and Short duration of a disease.

low in incidence rate(decrease in new

cases).
In-migration of healthy individuals
Migration of cases
Improved cure rate of cases

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110

Prevalenc
e

5/20/16

111

The relation b/n incidence rate & point

prevalence
pp includes both new & old case
it is directly related with incidence rate.
if incidence stay the same & duration
become
shorter,
prevalence
also
decrease.
if incidence increases & duration stay the
same prevalence rate also increases.

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112

Measure of mortality.

Mortality rate & ratio measures the

occurrence of deaths in a population
using d/t ways.
The denominators are the total mid
interval popn or average population.
These are 1) Crude rate(CDR)
2) Specific rate(SDR)
3) Standardize /adjusted
rate(ADR)
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113

1) CDR is a summery rate.

= no of death in a given popn in a calendar
year x K
average popn in the same calendar year
2) SDR is the number of death in a specific group
of popn.
) It can specify by age, sex, & disease etc.
e.g. 1) ASDR
2) SSDR
3) DSDR
SDR=No of death in a specific group in a year x K
average popn in the same calendar year
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114

Some commonly used specific death rate are

1) Specific rate related to infant & children like
IMR,NMR,PNMR,CMR,U5MR
1.IMR=No of death of infant under 1 yrs of age in a yr x k

total no of live birth in the same period

2.NMR=No of death upto28days of age in a
yearx1000
total no of live birth during the same
period
3.PNMR=no of infant death b/n 28dys-1yrs in a
timexk
total no of live birth during the same
period
5/20/16

115

Cont.
4.CMR=no of death of children 1-4yrs in a year x
k
total no of children(1-4) in the same yr
5.U5MR=no of death U5childern in a given yr x
k(100)
total no of death in the same year
= CMR +IMR
Note.IMR is a best indicator of health status of a
given community because
It is sensitive indicator of availability,
utilization & effectiveness of health care.
It is mostly related to perinatal care.
5/20/16

116

Specific rate related to pregnancy &peuprium.

1) Still birth rate
2) Perinatal mortality rate
3) Maternal mortality rate
1) Still birth rate:- it is no of the fetal death
after28 weeks of gestational age .
it is not an abortion.
SBR=No of f/death of 28or more completed wks in a
yrx1000

total no of birth(still birth &alive birth)

2)PMR=No of stillbirth & infant
death(<7days)x1000
total no of birth (live birth + still birth)
5/20/16

117

3. MMR
Maternal
women
pregnant

death:at

child

is No of death of
bearing

age

while

or with in 2-4 days post

partum(end of px) irrespective of duration

& site of pregnancy from any cause or
aggravated by pregnancy but not from
accidental cause .
MMR=no of maternal death due to p x ,
childbirth,
puerperal condition x 1000
5/20/16

118

Other specific
specific ds

rate=no

in a given year

of
x

death

from

k(1000)

total no of population
in a cal/year
Case fatality rate= No of death x100
total no of cases

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119

Measure of associations
association is a r/n s/p of events
it quantifies the r/n s/p b/n the so called
exposure & disease(cause effect r/n s/p)
Common measurements of associations are
1) Relative risk(RR)
2) Attributable risk(AR) or risk difference(RD)
3) Attributable risk percent(AR%)
4) Population attributable risk(PAR)
5) Population attributable risk(PAR%)
6)Odds ratio(OR)
5/20/16

120

CONT

1) Relative risk- it is an estimation of risk

It measures the magnitude(strength) of
association
It indicates the likelihood(possibility) of
developing of the disease in the exposed
group relative to the non exposed group.
It is used in cohort & experimental study
RR=risk of disease in exposed group
risk of disease in non exposed
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121

 Eg

+
exposed + a
c
total
a+c

Cont
-

b
d
b+d

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

RR= Risk in exposed

= IR in exposed
risk ds in none exp
IR in disease in none exp
i.e RR = a/ (a + b) = a(c + d)
= X
c /( c + d)
c ( a + b)
N.B, If RR is x times more likely to develop the disease as an
exposed or the exposed group is higher by x% than the non
exposed group.

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122

Cont..
a= individual who are exposed & have
disease
b= individual who are exposed but do not
have a disease.
C= individual who are not exposed but
have a disease.
d= individual who are not exposed & do
not have a disease
a + b =total no of individual who are
exposed.
C + d= total no of individual who are not
exposed
5/20/16

123

Cont
Eg.
CA
+
Ca
Smoker
112
nonsmoker 88
total
200

176
224
400

total with
288
312
600

find RR=?

5/20/16

124

Cont..

so/n RR= risk in exposed/risk in non exposed

112/288 = 112 x
312 = 1.38
88/312
288
88
The exposed group for smoking is 1.38 times
more likelihood to develop the ds (Ca) as
compared with non exposed group to smoking.
Or the exposed group to smoking is higher than
by 38% of developing Ca than the non exposed
group.
Generally the strength of the association can be
conceder :
High if RR >or=3
Moderate if RR = 1.5-2.9
5/20/16 Weak
125
if RR= 1.2-1.4

2) AR(attributable risk) or RD(risk difference)

It indicates how much the risk is

attributable (as a result) or due to the
exposure.

it is called excess risk

Used to measure the public impact of the
exposure
AR= risk of disease in exposure - risk of
disease in non exposure .
5/20/16

126

Cont
It quantifies the risk of disease or excess
risk in the exposed group that can be
consider as a result or attributable to
the exposure by removing the risk of
the disease that would have occurred any
way due to other causes.
AR= a
c
= 112 - 88 =
0.11=11%
a +b
c+d
288
312
The exposure increase the probability of
disease by .11 than the non exposed.
5/20/16

127

Cont
3) Attributable risk percent (AR%):-it
measures the proportion of disease among the
exposed group i.e. attributable to the
exposure or
The proportion of disease that can be prevented
by eliminating the exposure .
AR%=risk In exposed group- risk in non exposed
groupx100
risk in exposed group
=
a
c
a+b
d +c
a/a + b
AR%=
AR X100
=
RR-1 X100
5/20/16
Risk in exposed
RR

128

4) Population attributable risk(PAR):- it is the

difference b/n risk of ds in total pop. & risk in non
exposed group i.e.
PAR= risk of ds in total pop - risk in non exposed
= AR x proportion of exposed group. or AR x
prevalence rate of the exposure.
eg if 1/5 of total pop is non exposed grp then , PAR=ARX
4/5
5) PAR% :- it estimates the proportion of disease in the
study population i.e. attributable to the exposure & this
could be eliminated If the exposure were eliminated.
PAR% = Risk in in total pop- risk in non exposed x100
Risk in total popn
= PAR
X100 = y
Risk in total pop
y is a disease that can be prevented by elimination of
5/20/16
129
exposure
of the disease.

Generally,
1) If PAR is 0, RR=1
There is no association b/n exposure & disease
Risk of ds in exposure=risk of ds in non exposure
Exposure is not risk factor
2)If AR<0There is negative association b/n expo& ds
RR<1 risk of ds in exposed<risk in non exposed
exposure reduces the disease means it is a protective
factor.
3) if AR>0 There's +ve association b/n exposure &d/s
RR>1 Risk of ds is higher in exposed than in non
exposed
exposure is risk factor for the devt of disease.)
5/20/16

130

Cont..

6) Odds ratio(chance ratio) :- it is the

ratio of the chance of exposure among
diseased group with that of control group.
it concerned in cases & control group.
it is inversely related to RR (OR=1/RR)
It is across product ratio( a x d/b x c)
OR= odds of exposure among cases
odds of exposure among control
case
control total
ex
+
a
b
a+b
OR=a
/c = ad
5/20/16

131

Eg
OC
uses

YES

cx ca
YES
40

NO
400

TOTAL
440

NO
160
800
960
total 200
1200
1400
OR = ad/bc=40x800/160x400= .5
this indicates that women who uses OC
had 0.5 times higher risk of developing
cervical ca than non OC user.
. Control groups are almost similar to total
population
5/20/16

132

Cont..

RR can be estimated by OR if
1) the controls are representative of the
general Population.
2) The selected cases are representative of
all cases
3) The disease is rare.

5/20/16

133

Eg a cohort study was conducted on

10,000 individual in order to asses the
association b/n cigarette smoking & lung
Ca. as data indicated ,the study analyzed
among 7000 smoker& 73 lung Ca cases.
The data also show as out of the smoker
in the study 70 smoker developed the
disease.
1) Calculate incidence of lung Ca among
smoker
2) //
//
//
//
non smoker
3) Calculate RR & its interpretation.
5/20/16

134

So/n
smoker
non smoker
total

lung ca control
70
6930
3
2997
73
9927

total
7000
3000
10000

1) IR =total new case in smoker xk( 1000)

total pop
= 70/10000 x1000= 7
2)
IR = Total no of cases in nonsmoker x 1000
Total popn at risk
= 3/10000X 1000=0.3 = 3/1000
3) RR= Risk of disease in exposed =
Risk of disease in non exposed
5/20/16

135

CONT..
70/7000 = 10
3/3000
Interpretation, Group of people who are
exposed to smoking is 10 times more
likely than non exposed Group for the
development of lung CA .
4) AR= Risk of disease in exposed risk of
disease in non exposed
= 70 - 3
=
0.009
7000
3000
5) AR% =Risk in exposed- risk in non
exposed x100
5/20/16

136

Cont..

AR% = AR
X
100
=
RR-1 X100
Risk of exposed group
RR
= 0.009 X100 = 90%
= 10-1 X100= 90%
70/7000
10
INTE . Lung CA can be prevented by 90% if smoking
is eliminated in a given sample population.
6) OR = odds of exposure among cases
odds of exposure among control
= 70x2997 =209790 = 10.1
6930x3
20790
Inter , lung CA is 10 times higher in smoker than
non smoker in a given sample population.
5/20/16

137

Source of data in community health

There are different source of
epidemiological data like
1) census
2) vital statistics
3) Health service records
4) disease registration
5) Morbidity & mortality survey.
5/20/16

138

Census :it is simply an enumeration of population.

there are two method of census. These
are
1) De facto
2) De jure

5/20/16

139

Cont
A) De facto is an enumeration of persons at the place where
they found at the time of enumeration but excludes those
who are temporarily away .
B) De jure is a counting of population according to their
usual place of residence& excludes temporarily visitors.
Uses of census:1) For Health planning & programming.
2) for accurate description of the health status of population
3) principal source of denominator for rate of disease &
death.
Limitation of census
1) it is expensive in terms of money & time.
2) it can not assess updated change in every year b/c
census takes place every 10 year in Ethiopia context.
5/20/16

140

2)Vital statistics
Are data calculated from an ongoing registration of
vital events like birth , death, marriage , & divorce
data.
The data drive from birth & death registration
serve as numerator for calculating rates like CBR
& CDR.
It serve as a denominator to calculate MMR.
it serve as a source of numerator for IMR,
stillbirth rate , perinatal mortality rate.
3) Health service records
includes 1) monthly morbidity rate.
2) quaternary & annual report.
3) reports of notifiable disease
5/20/16
141
4)epidemic report

Types of data used for

epidemiological study
1) demographic data obtained by using
census.
2) vital statistics
3) surveillance data
4) socio economic data
5) utilization data like health service
utilization
6) health status & behavioral data
Method of data collection
1) self administer questioner.
5/20/16

142

EPIDEMIOLOGICAL SURVEILLANCE
It

is a systemic collection, analysis,

interpretation &dissemination of health

related data in an ongoing bases.
WHO, surveillance is the continuous
scrutiny of the factors that determine the
occurrence& distribution of disease &
other health related events through a
systematic collection of data.
5/20/16

143

 Public
health
surveillance
is
the
continuous
systematic
collection,
analysis,
interpretation,
and
dissemination of health data for the
purpose:
Describing and monitoring health events,
Setting priorities,
Assisting the planning, implementation,
And evaluation of public health interventions
and programs (FMoH, 2002).

5/20/16

144

Figure
1: surveillance cycle
5/20/16

145

Survi....cont
It provides information for action.
It is used to investigate, prevent,&
control disease.
It can be done globally, regionally,
nationally or institutional level.
.
5/20/16

146

Cont

why analysis is done for surveillance?

Analysis ( monitoring & evaluation
health events) of surveillance.

To detect sudden onset of disease.

To follow secular(long terms) trends
& patterns of a disease.
To identifies changes in agent or host
factor.
To detect any changes of health
practice
5/20/16

147

Interpretation of surveillance data

Information

helps as a base to formulate

hypothesis.
It stimulate community health research.
To test hypothesis

5/20/16

148

Criteria for identifying disease for surveillance

Frequency ( Incidence, Prevalence, Mortality)
Severity
Case fatality ratio
Hospitalization rate
Disability rate
Years of potential life lost
Quality adjusted life years lost

Cost
Preventability
Communicability
Public Interest
5/20/16

149

Objective of surveillance
1. Monitoring health trends:
detection of an increase in adverse health
events can alert for further investigation
E.g,

5/20/16

150

Cont....

2. Link to services:
It provides aggregated data for health planners
and serves to initiate individual preventive
actions
By describing where most cases of disease
occur for targeting public health interventions

5/20/16

151

Cont.....

3. Links to research:

It can provide an important bridge to

researchers by providing clues for further
investigation & by identifying individuals who
may be subjects in specific research.

5/20/16

152

Cont.....

4. Evaluation of interventions:
It may provides a comparatively inexpensive
and sufficient assessment of the impact of
intervention.

5/20/16

153

Cont......

5.projections:
Observed trends in disease pattern
combined with other information about
the population at risk can be used to
estimate future trends

5/20/16

154

Steps in Planning Surveillance

1. Establish objectives
2. Develop case definitions
3. Determine data source or data collection
mechanisms
4. Develop data collection instruments
5. Field test methods
6. Develop and test analytic approach
7. Develop dissemination mechanism
8. Ensure use of analysis and interpretation

5/20/16

155

Cont
Types of surveillance
There are three types in general these are
1.Passive surveillance.
It is a routine type of surveillance.
Public health officers contact health service
provider to collect reports of disease or events.
The data is generated with out intervention or
contact by health agency carrying out the
surveillance.
It5/20/16
is a diseases out break surveillance report.156

Cont
It is cheap, cover a wide area,& wide range of
problems
It does not require special arrangement.
The information is not available on time & may

not get as a desire .

The information generated is to large extent,

unreliable ,incomplete, & inaccurate.

It lacks representativeness & feedback system
5/20/16

157

2) Active surveillance
It is a method of data collection usually on a
specific disease for limited period of time.
Health officials mostly go out reach & collect data.
It is not used as a routine purpose .
The data are complete , accurate & timely
available.
It requires good organization & skilled man power .
It is expensive & directed to ward specific problem.
It is not a continuous process rather than for a short
5/20/16
period
of time.

158

Cont
Conditions in which active surveillance is appropriate

a. For periodic evaluation of on going program.

b. For programs which have timeline of operation.
E.g small pox.
C . In unusual situation such as

5/20/16

New disease recovery.

New mode of transmission.
When high risk season is recognized
When previously eradicated disease has reappear.

159

Cont

3) Sentinel surveillance.
Is used a pre arranged information.
Use data from a few selected sites rather
than data from all sites.
Is done on a broad level

The information represents a given

people but it is a sample. Eg HIV
prevalence.
It uses secondary data & leads to less
quality.
It is relatively cheap.
5/20/16

160

Cont

Characteristics of surveillance system

1) Sensitivity.*
2) Simplicity
3) Dynamicity.
4) Representativeness *
5) Positive predictive value *
6) Timelines
7) Flexibility
8) Cost of the system.
5/20/16

161

Cont

Activities in surveillance.
1) Data collection & recording
2) Data compilation, analysis &
interpretation
3) Reporting & notification
4) Dissemination of information.
5/20/16

162

Source of data for surveillance.

Morbidity & Mortality registration.
Epidemic reporting
Reports of laboratory Utilization
Reports of epidemic field Investigation
Inform.

on

animal

reservoir

&

vector

distribution.
Report of drug utilization.
Knowledge of the population & environment.
5/20/16

163

Cont

Purpose of surveillance
For early recognition of acute or emergency
disease that demands urgent action.
To recognize seasonal change .
To serve as a guide for
planning
implementation
monitoring
of health program.
evaluation
For proper assessment of priority in health
program.

5/20/16

164

Constraints of surveillance.

Non recording
Failure to report timely
Late report for notifiable disease &
inconsistency of case detection
Inadequate data analysis.
Inadequate lab involvement for case
detection.
Lack of feed back & motivation
Lack of advanced communication

Shortage of techniques &skill staff.

5/20/16

165

Cont

Notifiable disease at international level

1) Cholera
2) Plague
3) Yellow fever
4) Ebola
Diseases under global surveillance
5) Relapsing fever
6) Influenza
7) Malaria
8) Meningococcal meningitis
9) Epidemic typhus.
5/20/16

166

Cont

Disease under EPI program.

1) Measles
2) Tetanus
3) Pertusis
Disease under regional interest
4) Diarrhea
5) Congenital meningitis
6) Trepanomiasis
7) Infectious hepatitis
8) HIV
5/20/16

167

Cont
Current surveillance system in
Ethiopia (IDSS)
IDSS is a new strategy which helps to
detect the priority communicable disease
& most functional at woreda level.
It

helps

to

strengthen

the

national

disease surveillance system.

5/20/16

168

Objective of IDSS

To strengthen the capacity of woreda to

conduct effective surveillance activity.
To integrate multiple surveillance system.
To improve the use of inform. for decision
making
To improve the flow surveillance information
To strengthen the laboratory capacity.
To improve the participation of health
worker in a surveillance system .
helps to participate the community in the
surveillance system.
5/20/16

169

Cont
Core activity of IDSS guideline
1) case detection
2) Case registration
3 ) confirmation of cases
4) report
5) analysis & interpretation of data
6) Ix of additional cases& confirmation of
suspected cases.
7) Response with respect to the report
8) Provide feed back
9) Monitoring & evaluation system
5/20/16

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Cont
Priority disease according to the IDSS In Ethiopia
there are 21 disease for IDSS in Ethiopia .but
According to
1) Epidemic prone disease(11).
2) Disease targeted for eradication &
elimination(4)
like acute flaccid poliomyelitis
-Guinea worm
-leprosy
-neonatal tetanus

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Cont
3) Disease based on public health
importance.(6)
Like1) U5 pneumonia
2) U5 diarrhea
3) new AIDS case
4) oncocerciasis
5) STI
6) TB

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Case definition :- is a clinical criteria used to detect

with laboratory or with out laboratory
Classification of case definition
1) Confirmed:

case

with

laboratory

verification.
2) probable: a case with typical cf but

without laboratory confirmation.

3) possible/suspected: a case with fewer

of typical clinical features.

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5/20/16

174

Study design
It is the process that guides researchers
on how to collect, analyze and interpret
data.
It is a logical model and structure of
the research.
It is the blue print of research that lays
out the strategy and frame work for the
conduct of research
It is the "glue" that holds all of the
elements in a research project together
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Selection of study design

In selecting the design of the study,
consider:
The state of knowledge about the problem
The type of information you want to obtain
The nature of the problem and its
environment
The resources available for the research
The knowledge and creativity of the
researcher
Sample to be taken
Method of analysis to be used
Purpose of the research

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Types of epidemiological study

1.Descriptive type of study
Characterize disease occurrence by PPT.

Generate testable Hypothesis as to the cause o

disease.
It uses for resources allocation.
Used to describe the natural history of disease.
It is less time consuming & less expensive.

Most

common

study

designs

used

by

epidemiologist.

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Answer
the question When, Who and Where

Descriptive type of study.

It has three classification. these are
a) Case report/case series
b) Correlation/ecological
c) Cross- sectional study.

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2.Analytical type of study

Concerned with the search for causes and
effects.
Test hypothesis about association b/n exposure
& outcome
It answers the question Why & How it occur?
1.1.Observational study
a) cohort study
b) case control
c) Comparative cross-sectional
1.2. Experimental ( interventional )
Has three classification. these are
a) community b) clinical
c) Field trial
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5/20/16

180

Cont

Types of descriptive study.

1) Co-relational study
it is concerned with the pattern of a disease
among the population not an individual.
The source of information is the general
population.
Incidence & prevalence rates are commonly
used to quantify disease occurrence in group.
It needs average exposure status of the
community not exposure status of each
individual.
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2) case report/case series

It describe the experience of
single/group of patients with similar
diagnosis.
it consists of a careful , detailed report
by one or more clinicians of a single
patient profile.
it more focus on unusual disease finding.
it is important for hypothesis generation.
There is no comparison group.
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3) Cross sectional study.

A study that examine people in a
definitive population at a point in
time.
information on exposure & disease
status of an individual is find out at
the same time.
It provide evidence of a valid
statistical association b/n exposure &
disease not for testing hypothesis.
It is one step & time collection of
data.
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183

Cont

it is less expensive & easy to conduct

it shows relative distribution of health
related condition in a given group &
population
it is concerned on majority of the
population not on individual that needs
treatment.
it is difficult to asses which one is occur
1st ,the exposure or the disease.
if the sample size is too small, there is
insignificant cause effect relation ship.
Analysis is employed through OR
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184

5/20/16

185

Cont..

Analytical type of study.

It uses control group(comparison group) to
asses the determinants(cause) of a disease.
It is used to test hypothesis.
1) Cohort study
) it is group of people w/h have similar
characteristics in in a defined population.
) Study subjects are selected by exposure stat
) It can examine multiple effects of a single
exposure.
) It is expensive & time consuming.
) 5/20/16
It is inefficient in evaluation of rare disease.
186

Cont

if there is lost to follow up ,there is a problem in

result of the study.
it allows direct measurement of risk factor.
There is temporal relation ship b/n exposure &
disease
It asses exposure status at base line & ds status
at follow up of the study.
It is taken in order to asses the association b/n
exposure & disease.
e.g exposure out come(yes or no)
Is there
a DS ?
non exposure out come(yes or no)
Analysis is done by RR&AR
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187

Cont
Type of cohort
Classification is based on temporal r/n ship b/n the
initiation of the study & the occurrence of the
disease.
Both designs classify subjects in the study on the
basis of presence or absence of exposure
a) Prospective
it is forward looking type of study like incidence &
follow up study
at the beginning of the study the out come has
not yet developed .
it is the commonest type of cohort study.
It is more reliable than retrospective cohort.
. 5/20/16
188

Prospective ....

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189

Cont.

b) Retrospective
It is back ward type of study
The study is initiated at a point in time
after both exposure & disease have
already occurred.
it is less costly & less time consuming.
it commonly used secondary data that is
not a representative of all subjects.
e.g? Is there exposure disease +
exposure (outcome)
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Retrospective ....

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191

Cont
Indication of cohort study
when there is a good evidence of
exposure& disease.
for rare exposure but the incidence of
disease is higher among those who are
exposed.
If follow up is easy.
when there is available of ample funds.
.
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General consideration while in the cohort study selection

1.At the time the exposure status is

defined, all potential subjects must be
free from the disease under investigation
2)Both
cohort
groups
are
equally
susceptible to ds.
3) Both cohort groups are comparable
group.
4)Should have to present with diagnostic &
eligibility criteria to select cohort group
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193

Cont

Elements of cohort study

1) Select study subject a representative sample
from a general population or special group like
proficienal or occupational group.
2) Obtain data on exposure status through
environment survey
by interview
by review of recording
by medical examination periodically
by routine surveillance.
3) Selection of comparison group
4) Follow up
194
5) 5/20/16
Analysis (RR & AR)

Cont

Strength of cohort study

it asses incidence rate & risk factor
it establishes cause & effect relation ship
it is important to find out risk of rare exposure.
it minimize selection & information bias of the
study.
Weakness of cohort study
loss to follow up
it needs large sample ,is expensive &
conceders ethical issue.
it is ineffective for rare disease
it takes long time to complete the study
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2) Case control study

Definition
Subjects are selected on the basis of
whether they do(cases) or do not
(controls) have a particular disease
under study
Groups are then compared with respect
to the proportion having a history of an
exposure or characteristics of interest
It is good for studying rare diseases &
diseases with very long latency periods,
After identifying cases & controls
investigators look backward in time to
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196

Cont..

Retrospective case control study:- If all

the cases of the disease have been
diagnosed at the time the investigators
initiates the study
a prospective case control study:- If the
study is begun and all new cases that are
diagnosed within the next period of time
are included.
The unite of observation & analysis is an
individual not group or general population
it is only a practical approach to identify
risk factor for rare disease.
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Cont

it can examine multiple factors for a

single disease.
it is easy to complete & quick.
it is inexpensive in terms of cost &
logistics
it needs a smaller study population as
compared with cohort study.
it is inefficient in analysis of rare
exposure.
it cant provide a direct estimation of
risk.
it has selection & recall bias in the study
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Cont..
Selection of cases
1) Hospital or medical care facility
this approach is referred to as hospitalbased case control study
is more common because it is relatively easy
& inexpensive to conduct
2) General population
Referred as population-based case
control study
At base line ,selection of cases ,control &
5/20/16
199
exposure
status( unknown)

Cont
cases may be located from clinic,
hospital, or disease registration.
incidence cases are preferable to prevent
cases for reducing recall bias & over
representativeness of cases of long
duration.
the most desirable way to obtain cases is
to include all incidence cases in a defined
population

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200

Cont
2) Experimental study: it is type of epidemiological study which
produce high quality data.
it is called gold standard study design as
compared to other designs.
Investigator assigns subjects to exposure
and non-exposure and makes follow up to
measure for the occurrence of a disease.

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201

Generally considered either therapeutic or

preventive
1. Therapeutic (secondary prevention)
trials
conducted among patients with a
particular disease to determine the ability
of an agent or procedure to diminish
symptoms, prevent recurrence, or
decrease risk of death from that disease

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202

Preventive (primary prevention)

trial
involves the evaluation of whether
an agent or procedure reduces the
risk of developing disease among
those free from that condition at
enrollment
can be studied among either
individuals (Field trial) or entire
populations (Community trial).
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203

Cont..
Classification.
a) Clinical trial :- it is called randomized
control trial.
) it is used to test the efficiency of drug ,
procedure, or intervention on the
patient.
)usually performed in clinical settings
)the subjects are patients
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204

5/20/16

205

b) Community trial
It is type of trial which analyze or asses
the effect of drug, intervention, or
procedure of the community not at
individual level.
Unit of the study is group of
people/community e.g. fluoridation of
water to prevent dental caries

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5/20/16

207

C) Field trial : Used in testing medicine for preventive

purpose
Subjects are healthy people e.g. vaccine
trial

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5/20/16

209

5/20/16

210

Q1
1) Write the objective of current surveillance
system in Ethiopia at least 7 objective.(3pt)
2) List the type of data used for
epidemiological study at least 6 data.(3pt)
3) List the limitation of surveillance system at
least 8(4pt).
4) List the prerequisite criteria during cohort
study subject selection at least 4 criteria.
(2pt)
5) Explain the d/c b/n active & passive
surveillance
with respective to their advantage
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211
&disadvantage at least 6 character. (3pt)

SCREENING
Defn: it is a presumptive identification of
unrecognized
disease or defect to the
application of tests , examination or other
health related procedures in apparently
healthy individual.
Identification people with disease can be takes
place through
1) Screening
2) Clinical diagnosis
3) Survey
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212

Cont..
Out comes of screening are
1)Negative
2) Positive:- it requires additional diagnosis
)It is not absolute intended to be diagnostic
) It is one of the most practical application of epidemiology
used to promote health and prevent disease
)It should be innocuous
rapid enough
cost wise

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213

Main difference
Screening

Diagnosis

Applied to asymptomatic
groups

Applied to symptomatic
individuals

Lower cost per test

Higher cost; all necessary

tests applied to identify
disease

Lower yield per test

Higher probability of case

detection

Lower adverse
consequences of error

Failure to identify true

positives can delay treatment
and worsen prognosis

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214

Criteria for establishing screening program

Disease -Serious
-High prevalence of preclinical stage
-Natural history understood
-Long period b/n first signs and overt
disease
Diagnostic test -sensitive and specific
-Simple and cheap
-safe and acceptable
-Reliable
Treatment
-Facilities are adequate
-Effective, available, acceptable,
and safe
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WHO Criterion for Screening

Is it a health problem?
Is there treatment?
Are there facilities in place?
Is it detectable pre-clinically?
Is there a suitable screening test?
Is the screening test acceptable to people?
Is the natural history of disease understood?
5/20/16 the costs acceptable?
Are

216

Purpose of screening

To slow or halt the progress of disease.

To alter the natural course of a disease.
To apply research on natural history of
disease

To prevent community from contagious

disease.
To allocate resource
5/20/16
To
select healthy people

217

Screening cont
Type of screening
1) Selective screening: Screening of people
with selective exposure
2) Mass screening: screening of people without
reference to specific exposure
Principles of screening
There are three basic tools used in screening
test. These are
1) Validity
2)Reliability
3) Yield
5/20/16

218

Cont

1)Validity of the test:- It detects those

who have disease or not using sensitivity
& specificity .
Sensitivity and specificity are affected by
Degree of skill
Equipment
Reagent
Severity, range of manifestation of disease
Presence of other disease

2) Yield of the test :it detects total amount

of previously un recognized disease
brought to Rx as a result of screening
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219

3)Reliability of the test :- It gives consistent result

when the test is conducted more than ones on the
same individual under the same condition.
Intra-observeragreement among measurements
made by the same observer
Inter-observer agreement among measurements
made by different observers
Test-retest agreement among measurements on
the same subject at different times

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220

2-by 2 table for the calculation of validity

of screening tests
Definitive Diagnosis
Screening Diseased Non
Total
Test
Diseased
TP(a)
FP(b)
TP+FP(a+
Positive
b)
FN(c)
TN(d)
FN+TN(c+
Negative
d)
Total
TP+FN(a+ TN+FP(b+ TP+FP+T
c)
d)
N+FN
(a+b+C+
d)
5/20/16

221

Cont

Measure of validity :- Validity is

measured with
Sensitivity :-the proportion of people with a ds
who have +ve test among those who have a disease
or
It is the ability of a test to identify
accurately among those who have
disease.
If there is high sensitivity there is low
false negative
Sensitivity = TP
5/20/16

; a/a+c x 100

TP+FN

222

2) Specificity :-the proportion of people

without the ds who have -ve test or
It is the ability of a test to identify
correctly among those who have not a
disease (TN).
If there is high specificity there is low
false +ve.
Specificity = TN

; d/b+d x 100

TN +FP
NB. Sensitivity and specificity are
affected by the cut-off value of
measure at which a test is defined as
positive.
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223

Consequences of false positive in

screening
Patients are started on treatment
unnecessarily
Treatment is continued longer than
necessary
Medications will be wasted
Patients lose confidence in the
programme
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224

Predictive Value of a Screening

Test

Predictive value is the ability of a test to

predict the presence or absence of
disease from test results.
1. Positive Predictive Value (PPV)
It is the probability of the presence
of the ds in a person with a
positive test result.
i.e. PVPT =
5/20/16

TP
TP+FP

X 100
225

Cont
2. Negative Predictive Value(NPV)
It is the probability of not having
the disease when the test result
is negative
i.e. PVNT = TN
X 100
TN+FN

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226

Calculate sen., spec. ,PVTP

,PVTN
Test result
disease
No disease
total
+
total

5/20/16

8
10
18

6
4
10

14
14
28

227

Conti....
So/n Sen= TP/TP+FN X100
= 8/18X100= 44.4%
Specif.= TN/TN+FP X100
= 4/10 x100=40%
PVTP =TP/TP+FP x100
= 8/14x100=57.1%
PVTN =TN/TN+FNx100
=4/14x100=28.6%
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228

Evaluation of screening
program

1)Feasibility or acceptability.
Effectiveness of the test

1)

(Reducing

morbidity & mortality)

2) Efficiency of the test

) Minimal inconvenience & discomfort
) Reasonable cost

3)Quality of the program

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229

It

Yield

is the amount of previously

unrecognized disease or defect i.e.
diagnose & brought to treatment as a
result of screening.
Yield=
TP
*
100
TP+FP+FN+TN

Eg.

5/20/16

8/28 *100= 28.6%

230

Conti....
Factors affecting the yield are
Sensitivity
Prevalence of disease
Multiphase of screening
Frequency of screening
Participation in screening & follow up

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231

Establishing screening program should be

acceptable intervention
feasible & available intervention
Suitable test
Natural history of a disease should
be adequately understood.
should be agree policy
Be ongoing not one time.
Cost should be reasonable

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232

Out break investigation & management

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233

level of disease occurrences

Epidemic :- occurrence of ds in excess of the usual
frequ.
Out break:-the occurrence of ds in excess of the
usual frequency in a limited area in small no of
cases .
Cluster :- is an aggregation of cases in a given area
over a particular period of time irrespective of the
no of cases.
Endemic :- the occurrence of ds at more / less stable
level ( Incidence=Prevalence)
Sporadic:- the occurrence of ds at irregular or
occasional
Pandemic :- the occurrence of disease at world wide
level
5/20/16
Index
cases :- the 1st case during epidemic period234.

Investigation
It is the process of identifying

the cause,

source, mode of transmission and preventive/

control measures of the epidemic.
1)It provides useful knowledge about the disease
2) It helps in the future to prevent out break
3) It helps to understand the natural history of a
disease.

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235

Limitation during out break investigation.

1) if out break is an on going at the time of

investigation , it needs great urgency
2) If the number of the study is limited ,the
statistical power of the study is weak.
3)Early media report may be bias to the
response of person.
4) If detection of out break is delayed ,some
useful clinical & envital sample may
difficult to obtain.
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236

Epidemic

It is the occurrence disease in a

community in excess of the normal
frequency.
To define epidemic, the number of
cases depends on
Infectivity of the agent
Size & type of the population exposed by
the ds.
Previous experience of a disease in a given
area.
Time & place of occurrence of a disease.
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237

Occurrence of Epidemics cont.

Recent increase in amount or virulence of
the agent
Recent introduction of the agent into a
settings
Enhanced mode of transmission
Change in the susceptibility of the host
response
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238

Cont..
NB a single case can be epidemic b/c of
long absent from the population or 1st
investigated
It may include any kind of disease or
injury.
If the number of cases exceeds the
expected level on the basis of the past
experience of the particular population,
then it is an epidemic
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239

 An epidemic may cover a small area

within a city, or an entire nation or
may have a worldwide distribution.
It may encompass any time period
ranging from few hours (chemical
intoxication,
bacterial
food
poisoning), a few weeks (influenza,
hepatitis) to several years (AIDS).

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240

Types of epidemics
Epidemics (outbreaks) can be classified
according to the method of spread or
propagation, nature and length of
exposure to the infectious agent, and
duration.
A. Common Source Epidemic.
Disease occurs as a result of exposure of
a group of susceptible persons to a
common source of a pathogen, often at
the same time or within a brief time
period.
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241

Type of epidemic cont

When the exposure is simultaneous, the

resulting cases develop within one
incubation period and this is called a
point source epidemic.
The epidemic curve in a point source
epidemic will commonly show a sharp
rise and fall.
E.g. Food borne epidemic following an
event where the food was served to many
people.
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242

Types of epidemics cont

If the exposure to a common source continues
over time it will result in a continuous
common source epidemic.
E.g A waterborne outbreak that is spread
through a contaminated community water
supply
The epidemic curve may have a wide peak b/c
of the range of exposures& the range of IP.

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243

Types of epidemics cont

B. Propagative / Progressive
Epidemics.
infectious agent is transferred from one host to
another.
It can occur through direct / indirect
transmissions.
Propagative spread usually results in an
epidemic curve with a relatively gentle upslope
and somewhat steeper tail.
E.g outbreak of malaria.
It will have successive generations of cases.
5/20/16

244

C. Mixed Epidemics.
The epidemic begins with a single,
common source of an infectious
agent with subsequent Propagative
spread.
Many food borne pathogens result in
mixed epidemics.

5/20/16

245

Steps for epidemic investigation

1) Verify the diagnosis by
take detail history of the patient
Establish ddx
Make arrangement
Confirm the diagnosis
2) Verify the existence of epidemic
By comparing the usual ,previous,& current
number of cases .
5/20/16

246

Steps for epidemic investi. cont..

3)Identification of the affected people &

diagnosis.
By establishing case definition
Case definition is a standard set of
criteria to differentiate b/n cases and non
cases. it can be:
Confirmed / definite: A case with laboratory
verification.

Probable: A case with typical cf but without

laboratory confirmation.

Possible: A case with fewer of typical clinical

5/20/16

247

Steps for epidemic investigation cont ..

4) Descriptive analysis
Searching of frequency, distribution &
determinants of a disease using epidemic
curve(time),personal
factors(person),place(spot map).
5) Formulate & test hypothesis
6) Management of the epidemic
treatment of cases
prevent & control of spread of disease.
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248

Steps for epidemic investigation cont ..

writing a scientific report which include

like
factors leading to epidemic
evaluation of measures used for the
control of the epidemic.
recommendations for the prevention of
similar episodes in the future.
Managing outbreak/epidemics
Continued survey in order to search
additional cases
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249

Management of epidemics
Management of epidemics
requires an urgent and intelligent use
of appropriate measures against the
spread of the disease.
Action to be taken is dependent on
the type of the disease as well as the
source of the outbreak.

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250

Management of epidemics cont..

Measures directed against the reservoir
Understand the nature of the reservoir.

E.g. Domestic animals as reservoir:

Immunization
Testing of herds
Destruction of infected animals
Example: brucellosis and bovine tuberculosis.

Wild animals as reservoir:

post-exposure prophylaxis
Example: rabies
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251

Management of epidemics cont..

Humans as reservoir
Removal of the focus of infectione.g. cholecystectomy for Typhoid fever.
Isolation of infected persons.
-This is separation of infected persons
from non-infected for the period of
communicability.

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252

Management of epidemics
Treatment to make them noninfectiouse.g., tuberculosis.
Disinfection of contaminated objects.
Quarantineis the limitation of freedom of movement
of apparently healthy persons or animals
who have been exposed to a case of
infectious disease.
Cholera, Plague, and yellow fever are
the three internationally quarantinable
diseases by international agreement
5/20/16

253

Management of
epidemics cont..
Measures that interrupt the
transmission of organisms
Action to prevent transmission of
disease by ingestion:
Purification of water
Pasteurization of milk
Inspection procedures designed to ensure
safe food supply.
Improve housing conditions.
5/20/16

254

Management of
epidemics cont..
Measures that reduce host
susceptibility
-Active immunization
-Passive immunization
-Chemoprophylaxis

5/20/16

255

Judgment of causality
Definition of Epidemiology
. and determinants of diseases and
other health related problems in human
population and the application ..
One of the major purposes of
epidemiological studies
Discovering the causes of disease
Judge whether an association of an exposure
and a
disease is causal or not.
5/20/16

256

Cont..
Epidemiological studies are
conducted in human beings,

It is difficult to achieve total control

of
study subjects than lab. based
studies.

5/20/16

257

Inference
When we find an OBSERVATION
(e.g. an association), we should ask ourselves:
Is it true in the sample? (Data quality)
Is it true in the source population? (Chance/Bias)
What can be concluded about cause and effect?
(Confounding and beyond )

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258

Establishing a Causal
Association
Observed association

Could it be due
to Bias?
Could it be due to
Confounding?

No

No
Could it be due to
Chance?
No
Could it be
Cause
5/20/16

Apply Judgment of causality259

Bias
Any systematic error in an epidemiologic
study that results in an incorrect estimate
of the association between exposure and
risk of disease.
It describes error arising from the design
or execution of a study

5/20/16

260

We should minimize introduction of Bias

Choose appropriate study design
Use
strict
procedure

and

randomized

sampling

Follow the activities in a protocol strictly.

Choose and stick to standardized questioner/
ascertaining instrument
Train and blind your interviewers( single,
double, triple)
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261

Types of bias
1. Selection bias
a. Berksonian bias: there is a difference
in the probability of selecting cases and
control with exposure.
b. Response bias: there is a difference
b/n those who volunteer and refuse the
study.
2. Information bias
a. Interviewer bias: there is a difference
in the knowledge of the interviewer
/examiner that influence the response of
5/20/16

262

Cont....
b. Observer bias: observation may have
preconceived expectation of what they
should find in an examination.
c. Recall bias: those with a particular
exposure/ out come may remember
events more clearly than other.
d. Lost follow up: the result of the study
may affect by those who lost to follow
than those who followed the entire study.
5/20/16

263

Cont....
E. How thorn effect: it is a natural
condition that people differently acting if
they know they are being
watered/examined .
F. Survival bias: it is different among
group with known out come /exposure
followed more closely than other.

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Confounding
Confounder is a variable that associated
with exposure independently.
It is the mixing of the effect of an
extraneous variable with the effects of
the exposure and disease of interest.
It is characterized by:
a. Associated with the disease of interest in
the absence of exposure.
b. Associated with the study exposure but
not as a consequence of the exposure.
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Effect of confounder
1. Totally or partially accounts for the
apparent effect
2. Mask an underlying true association
3. Reverse the actual direction of the
association

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In the design confounding could be

minimized by:
Randomization
Restriction
Matching
Evaluation of confounding in the analysis
by:
Standardization
Stratification/pooling
Multivariate analysis
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Chance

To rule out chance;

1. During designing
Increase the sample size (the Power)
2. Do statistics
Hypothesis testing, P-values role
(Chi square, Students-t-test, F-test, etc. )
Confidence interval determination

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Bradford-Hill criteria

It is the statement of epidemiological

criteria of a causal association formulated
in 1965 by Austin Bradford Hill (18971991)
1.Strength of the Association - The
stronger the association, the more likely that it is
causal.
2.Consistency of the Relation shipThe same association with different
methods, by d/t investigators, and in d/t
populations.
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Cont...
3. Specificity of the Association - The
association is more likely causal if a single
exposure is linked to a single disease.
Single exposure
single disease
4. Temporal Relationship - The exposure
to the factor must precede the onset of the
disease
5.Dose-response Relationship - The risk
of ds often increases with increasing
exposure to a causal agent.
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Cont...
7.Biological Plausibility - The hypothesis
for causation should be coherent with
what is known about the biology and the
descriptive epidemiology of the disease.
6.Experimental
confirmationConfirmation that the risk of disease
often increases with increasing exposure
to a causal agent by manipulating
exposure level

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8. Study design

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thank
you!!
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Quiz. Answer the following questions.

1) what are the factors that affect the out come of the
exposure of infectious agent to susceptible host? (3)
2) Write types of carrier with respect to their defn?(3)
3) what is herd immunity &precondition to be functional
immunity.(3)
4) what is natural history of disease & its stage?(2)
5. Why measurement of morbidity is more difficult than
measurement of mortality rate.(3pt)
6. Explain the d/c b/n active & passive surveillance
with respective to their advantage &disadvantage at least 6
character(2)
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Q3
1) write the basic requirements of IR at least five.
(5 pt)
2) Write at least two measurements of disease
frequency.(2 pt)
3)List the characteristics of specific & adjusted
rate.(5pt)
4) Why measurement of morbidity is more
difficult than measurement of mortality rate.
(3pt)
5) what is maternal death in full definition? (2pt)
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