MATRIKULASI

DASAR DASAR EPIDEMIOLOGI

OLEH

DADI S ARGADIREDJA,dr. DTM&H, MPH

DEFINITIONS
HEALTH :
- WHO 1948 Health is a state of complete physical,
mental and social well-being and not merely the absence
of disease or infirmity.
- ACT no 23 ,1992 ( UU Kesehatan )
Keadaan sejahtera dari badan jiwa an sosial yang
memungkinkan setiap orang hidup produktif secara
sosial dan ekonomis
- LAST, 1987 A state of equilibrium between humans,
and the physical , biologic, and social environment
compatible with full functional activity

Definitions................cont
PUBLIC HEALTH:
WINSLOW 1920 the state and the art of 1) of
preventing disease 2) prolonging life and 3) promoting
physical health and efficiency through organized
community effort for: a)the sanitation of the environment
b) control of community infections. c)the
educations of the individuals in personal hygiene d) the
organization of medical and nursing service for the early
diagnosis and preventive treatment and e) development
of social machinery which will ensure to individuals in the
community a standard of living with adequate for the
maintenance of health.
to organizing these benefits as to enable every citizen to
realize his birthright of health and longivity.

Definitions...................cont
LAST 1988 ;effort organized by society to
prevent, promote, and restore the peoples
health. It is the combination of science,
skills and beliefs that is directed to the
maintenance and improvement of the health of
all people through collective or social actions.
IOM 1988 what we as a society do collectively to
assure the conditions for people to be
healthy.

Definitions.....................cont
EPIDEMOLOGY:
Mausner & Bahn 1974 ;
the study of the distribution and determinats of
diseases and injuries in human populations
LAST 1995,WHO 1993.
The study of distribution and determinants of
health-related states or events in the specified
populations and the applications of the study to
control of health problems.

definitions.................cont
HARFIAH:
Epi = di,pada Demos = masyarakat dan
Logos = ilmu
Epidemi = wabah, outbreak ,Logos= ilmu

HISTORY
2000 years ago : Hypocrates environment influence
the occurance of disease.
1848 John Snow cholera related with contaminated
water.
1906 Sinclairrelationship b/w occupational
environment and disease/injuries.
1959 Doll & Hill relationship b/w cigarette smoking and
lung cancer.
Now communicable disease epidemiology remain of
vital importance in developing and developed countries.
Noncommunicable disease epidemiology is also
important in the future.

DEVELOPMENT OF
EPIDEMIOLOGY AS A SCIENCE
Before 1950 acute onset epiemiology.
In 1950 Doll & Hill tobacco smoking and lung
cancer landmark finding of modern
epidemiology
In 1960s -1970s developed
quicklycodification of methodologies specific
to the study of chronic , emerging,
reemerging disease
In 1990s specialities in epidemiology eg
nutritional epidemiology,environmental
epidemiology, occupational epidemiology etc.

Development................cont
More recently epidemiology has focused not
only on the study of chronic disease but also on
the emerging and re-emerging
diseases such as : HIV-AIDS, Ebola,
Tuberculosis, Dengue hemorrhagic fever, West
nile, Mad-cow, Severe acute respiratory
syndrome (SARS).
Epidemiologist have been called upon to
participate in a wide variety of activities related to
homeland security,disease surveillance. Food
and water supply protection ,bioterorism

Development.............cont
Beside understand biology,medicine,and
pathology ,epidemiologist should know
foundation in a number of other field.What did
each of the following fields contribute to the
development of epidemiology?
Statistics:
epidemiology is population based,study group of
people rather than individual the data
collected need statistical analyses.

Development.......................cont
Social sciences(sociology. Psychology,
anthropology) are foundational field for
epidemiology because the vast majority of
epidemiologic studies are observational.
Epidemiologist must understand process and
forces in community.
Computer technology:
Some time epidemiologist study large group of
people and collect numerous data over time for
each person. need software capable of
storing,managing and analyzing large amount of
data.

Development..............cont
Managerial science:
-epidemiologist study volunteersmust
manage volunteer process .The right of
human subjects should be potected.
-Study consist of many teams so
epidemiologist should have managerial
skill .

 THE SCOPE OF EPIDEMIOLOGY:

-for many yearsrestricted to infectious disease.
-After infectious disease was satisfactory
controled disease of later life
(vascular,arthritides,malignancy)
-centuries ago non infectious
- Mid 18 th century lead poisoning,scurvy
- Now all diseases ,conditions, and health related
events mental illnes, suicide, drug addiction,and
injury.

NATURAL HISTORY OF DISEASE

It is important to understand natural history of
disease in order to understand different
approaches to prevention and control. Each
disease has its own life history.
1.Stage of susceptibility:
In this stage disease has not developed, but the
groundwork has been laid of factors which
favors to its occurance (fatigue.alcoholism. High
serum cholesterol etc) Factor is called Risk
factor.

Natural....................cont
2.Stage of presymptomatic disease
In this stage no manifest disease, but usually
pathogenic changes have started to occur. The
changes are below clinical horizon Example of
thisi presymptomatic disease are atheroscerotic
changes in coronary vesels before any sign and
symptoms of illnes.
3. Stage of clinical disease
In this stage sufficient anatomic and functional
changes have occurred, so that there are
recognizable signs and symptoms.

Natural .....................cont
4.Stage of disability
- some diseases run their course and then
resolve completely, either spontaneously or
under the influence of therapy.
- give rise to a residual defect of shot or long
duration.
- disease with self-limited chronic disability.
-disability = limitation of a persons activities

LEVEL OF PREVENTION
Primary prevention;
prevention of the occurance of disease consist of
two major measures :
- General health promotion like healthy living
(good nutrition, adequate clothing, shelter, rest
and recreation),
- Specific protective measures like immunization,
sanitations, protection against accidents and
occupational hazards

LEVELS..................CONT.
Secondary prevention
-with early detection and prompt treatment of
disease, it is sometimes posible to either cure
disease at the earliest stage possible or slow its
progression, prevent complication.
- on a community basis, early treatment of person
with infectious disease may protect others from
acquiring infection and thus provides at once
secondary protection for the infected individuals
and primary prevention for their potential
contacts.

Levels.....................cont
Tertiary prevention
-This consists of limitation of diasability and
rehabilitation. So in this stage we prevent
disability and dependency

Variations in severity of disease

Inapparent infection frequent:
Inapparent

mild

mod sv ftl

tbc

Clinical disease common

In mild

moderate

Infection usually fatal

sv

ftl

measles
rabies

Sv

fatal

USES OF EPIDEMIOLOGY
Causation :

genetic factor

good health --------ill-health

environment
factor (including
behavior)

Natural history

death

good health - subclinical -clinical---recovery

Uses of.....................cont
Description of status of populations.
proportion with ill health change over
time ,change with age etc.
Evaluation of intervention:
treatment/med care
good health

ill health

heath promotion
promotive measures
PH services

DETERMINANTS OF HEALTH

DADI S ARGADIREDJA,dr,DTM&H, MPH

Program Studi Ilmu kesehatan Masyarakat
Fakultas Kedokteran
UNPAD

DETERMINANTS OF HEALTH
ENVIRONMENT DETERMINANTS
-Prior to industrial revolution sanitary measurement
had limited impact on the incidence of desease in
society. society were susceptible to waterborne,
foodborne. But caused by limitted size of town and
cities no epidemic
-during industrial revolution housing for worker were
bad (dwelling) class difference,
- Prior 18 th century class difference in mortality < .
- 1970 -1985 in developed countries categorical
pollutants removed from the air (lead.CO, SO etc)
housing were also improved.

Determinans..............cont
Environmental factors that affect health include
- Life support food,water, Air.
- Physical factors Mechanical,
Accoustical, Electrical, Thermal,
Ionizing Radiation.
-Biologic factors Microorganism,toxin.
biologic wastes, Biologic antagonist, animals
Plant, Allergen.
- Psychosocial crowding, demands,physical
time.
- Chemical factors Inorganic, organic, products
complexes

Product complexes such as :

. Combustion products
. Macromolecular products
. Industrial wastes
. Agricultural wastes including fertilizer
, pestisides. And herbicides
The environmental field is full of hazard .Their
complexity is increasing as technology provides
us with new products and processes

Determinants...............cont
LIFE-STYLE
- smoking- lung ca, peptic ulcers
- substance / drug abuse . addiction
- Exercise /physical activity heart disease
diabetes, osteoporoses.
- Diet coronary heart disease. Stroke,
colon cancer.
- Unprotected sex STD, HIV-AIDS, Hepatitis,
Unwanted pregnancies, Cervical Ca

Determinants...........cont
BIOLOGY
-in earlier centuries biologic phenomenons
were the dominant determinants of health
-Biology as determinants of health not just
a matter of pathogenic microorganism
.Interactions of microorganism with environment
and lifestyle had decreased infectious disease
but in other side produce new disease eg : HIVAIDS, Legionnairs disease,Lyme disease, Toxic
shock syndrome

- Genetic.
-arthritic histocompatibility locus of
chromosome
-alzheimer caused by protected genes
turned off
-Now reseacher can examine the chromosomal
structure of cell from the amniotic fluid genetic
marker. At the present time it is not possible to
alter genetic structure in human.

Gender ;
Female : breast ca ,ca colon,
Man : hemophilia, motorcycle accident

SOCIO-ECONOMIC
- Race Black White, Hispanic
- Poverty
In every determinants low income people always at
disadvantages
Government conduct program Safety-net

-social ;
children live in family with social stress
greater risk of illnes and injuries
people live socially isolateddeath rates
2 -4 X higher
- income disparity

HEALTH RISK

DADI S ARGADIREDJA,dr,DTM&H,MPH
Program Studi Ilmu Kesehatan Masyarakat
Fakultas Kedokteran
UNPAD

HEALTH RISK
Risk means
- A probability
- A factor that raises the probability of
an adverse outcome.
- A consequences.
- A potential adversity of threat.
Focus on risk to health>
-is key to preventing disease and injury
-many health risk are result of deliberate decision by
individuals consciously trying to make the best choices
for themselves
- to make decision wisely

Health risk...............cont
- health risk is the key for research priorities
- prioritization for health policy and research
-public perception of risk plays a role in risk
analyses
-Risk assesment,communication, risk
management. Cost effectiveness and policy
development form focus of the report.

RISK ASSESMENT
- Definition :is the systematic scientific
characterization of potential adverse
health effects resulting from human exposures to hazardous agents and
situation.
hazard = intrinsic toxic properties
RISK MANAGEMENT:
Refer to the process by which policy actions are chosen to deal with
hazards identified in the risk
assesment/ risk characterization
RISK COMMUNICATION
Is the challenging process of making risk assesment and risk
management information comprehensible to community
group,lawyer,politician, judges,business-man, labour and environmentalis

Risk assessment

Root of risk assessment Environment sector

Analog with assessing population attributable risk in epidemiology.

Four elements of risk assessment:

1 .Hazard identification chemical X cause liver damage
2 Dose response assessmenthealth affect depend on amount
of exposure.
3 Exposure assessment.distribution and concentration of pollution
in the env combine w/behavior and physiology estimate amount of
polutant in which humans are exposed.
4 Risk characterization combines risk exposure and dose
responsecalculate the estimated health risk.

Risk perception..........cont
Risk had different meaning different group of people,
Be influenced by larger social and cultural context.
Often lead to intense public controversy.
These differences have to be understand and resolve
Risk perception are being influenced by 3 factors:
-power/influence of special interest group
-increasing influence of global mass-media
-globalisation increase risk in middle and low income countries
CIRI GLOBALISASI: KEMAJUAN TRANSPORTASI, INFORMASI,
TEKHNOLOGI

Risk communications
Have 6 main components 1) the aims and
objectives, 2) framing the contents and
messages.3)population and target
audience.4)sources and presentation of
information. 5) the distribution and flow of
information, 6) mechanism of dialog and conflict
resolutions.
Designed for a health program to be
implemented by an expert regulatory body.
More successful if better dialogue b/w parties.
Influence by powerful interest group outside the
government.

DISTRIBUTIONS
TIME:
-Hour distribution incubation period very
short, toxic substance.
- Daily
- Weekly for surveillance epidemiology.
- Monthly
- Seasonal summer,Rainy season.
- Yearly
- Cyclic changes annual or other periodicity
eg measles epidemic every 3 years.
- Secular trends long periods, years or decades
DIGAMBARKAN DENGAN : TABLE DAN GRAFIK

Distributions..............cont
PLACE :
- Natural boundariescharacterized by particular
environment and climate (Temp, humidity, rainfall,water
supply, mineral in soil etc)
- Physical boundaries
- Political subdivision National, provinces,
District,municipals, sub district, villages etc
- Mapping of environmental factor.
- Rural-urban differences.
- DIGAMBARKAN DENGAN : TABLE, GRAFIK, SPOT MAP

Distributions...............cont
- tnternational comparison.
- study on migrants = PERPINDAHAN PENDUDUK

PERSON :
-

Age :measles,chickenpox,mumps occur mainly in children (disease w/

life-long immunity)
Sex death rate M>F but morbidity rate F>M.
Mammae ca F>M, Depression F>M.
Etnic group and color Black have higher death rate than Hispanic and
white.
Social-class white collar(PEKERJA KTR), blue collar(PEKERJA KSR)
Occupation asbestosis, lung fibrosis,injury.
Marital status
Other family variables family size, birth order, maternal age, parental
deprivation (PARENTAL DEPRIVATION)

EPIDEMIOLOGIC MODELS
The Epidemiologic triangle.
host
agent

environment

The Web of causation

Epid...................cont
The Wheel
Genetic
core
host
environment

 Ecologic mOdel - inter-relation of

factors
MA
NU
SIA

 Ecologic models

MULTIPLE CAUSATION
AGENT :
- Biologic microorganism virus,
bacteria, ricketzia, protozoa,
fungi, metazoa
-Physical Lead (TIMAH), asbes, CO etc
-Social Maternal deprivation.

Multiple

.............cont

HOST (Intrinsic factors)

-genetic factors
-immunity
-personality
ENVIRONMENT (extrinsic factors)
-Biological environment
Agents of disease, reservoir(perantara), vectors (tempt bibit
peny.berkembang biak) & ada transmitter(co/lalat yang hanya
ditempeli bibit peny. Diare), plants and animal(source of food),
-Social environment.
eating habits, the way of cooking
- Economic environment
low income, health service payment,

Multiple...............cont
-ideology and politics
social conflict, war death ,injuries
-physical environment :
heat, light, air, water radiation,gravity
atmoshpheric pressure, chemical

MEASURES OF DISEASE
FREQUENCY
Poplation at risk:
the part of population which is susceptible to a
disease;( Ca cervix)

Man

woman

Total Population

woman

all woman

pop at risk
woman age
25-69

 Prevalence & Incidence

Prevalence rate :E existing cases/tot pop
Incidence rate : E new cases/ pop at risk
P=Ixd
d =duration
P .> I Diabetes
P < I Influensa

 Factors influencing prevalence rate

Increased by :
-longer duration of disease.
-prolongation of life of patient w/o cure
- increase of new cases
- in migration case
- out migration of healthy people
- in migration of susceptible people
- improved diagnostic

 Decreased by:
-shorter duration of disease.
-High case fatality rate
-Decrease of new cases
-In migration healthy people
-Out migration of cases
-Improve cure rate.

 Prevalence rates are influenced by so many

factors ,
- unrelated to disease causation
- dont usually provide strong evidence
of causality.
- helpful in assesing the need for health
care and planning of health services.
- often used to measure the occurance
of conditions for which the onset of disease
maybe gradual( ex maturity onset of DM)

 Incidence rate.
number of new cases/ population at risk

Last (1995) most accurate way to calculate

incidence person-time incidence rate
no of people who get a disease in spesified period / sum of
the length of time during which person in the populatioh is
at rik

Cumulative incidence rate or Risk

is the simpler measure of occurance of a disease or
health status

CI= number of people who get disease during a specified

period / number of people free of the disease in the
population at riask at the beginning of the period.

CI used :
-often cases /1000 population.
-probibility/risk of individual in the popula
tion getting the disease during specified
period.
-period can be of any length but usually
years or a whole life time

 Case Fatality
number of death from a disease in specified period / numbr of
diagnosed casesof thedisease at the same period

- in percent(%)
- a measure of the severity of a disease.
- strictly speaking ; fatality/case ratio but is often
called case fatality rate.
Interrelasionship
Pr rate = Inc rate x averageduration of
disease

 Calculation of disease occurance :

1.----------------------------------------2.----------------------------------------3---------xxxxxxxxxxxx D
4-----------------------------------------5-----------------???????????????
6---------xxxxxxxxxxxxxxxxxxxxxxx
7----------------------------- xxxxxxxxx
.1........2.......3......4......5.....6... .7

7.yrs
7 yrs
2 yrs
7 yrs
3 yrs
2 yrs
5 yrs
years ob

 Notes

---------- healthy period

xxxxxxx disease period
?????? Lost of follow up
D
death
Calculation :

I ncidence rate = 3 / 33 9.1cases /

100 person-years

Cumulative incidence rate = 3 / 7 43

cases pe 100 persons during 7 yrs
Average duration of disease = 10 / 3
3.3 years.
Prevalence rate at 4th year = 2 / 6
33 cases per 100 persons.
Prevalence rate = 9,1 x 3.3 30 cases
per 100 population

 Mortality:
- crude death/mortality rate = number of
of death in specified period / Ave
rage of population during that pe
riod
- Age and sex death rate = number of death
occuring in a specific age and sex group
of population in a defined area during
specified period / Estimated total popu

lation of the same age and sex group

of the population in the same area
during the same period
- Infant mortality rate = number of death children < 1 year / number of live birth in the same
year.
Countries can be devided into : High income
countries ,Medium income ; Low income countries
Notes : China and Sri Lanka (low income countries
have low infant mortality rate. (38, 19 /1997

-Maternal mortality rate = maternal pregnancy

related death in one year / Total birth in
the same year.
- Life expectancy = the average number of
years an individual of a given age is ex
pected to live if current mortality rates
continue.
life expectancy at birth (E o )
life expectanct at 60 ( E 60 )

- QALYs = quality adjusted life years\

- DALYs = disability adjusted life years
for esimate cost effectiveness of various
procedure
Standardized rates
Age standardized death rates = age adjusted
rate
Standariation direct
indirect disease rates in
standard population

- applied in population being

compared. Indirect> direct
can compare for mortality or morbidity.
MORBIDITY
Death rate is useful for investigating disease with high
case fatality rate. In low
CFR morbidity is more useful
The source of data
- Notifiable disease report
- Hospital admission rate
- Cause routin data not accurate collecting new
data need screening and questionair.

DISABILITY : WHO definition

Impairment= any loss or abnormality of
psychological,physiological or anatomical
structure or function.
disability = any restriction or lack of ability
to perform an activity in the maner or within the range
considered normal for a human being.
handicap = a disadvanted for agiven individual
resulting from impairment or a disability that prevent the
fulfilment of a role that is normal for that individual,
COMPAIRING DISEASE OCCURANCE :

a. Absolute comparison
- Risk difference = Exess risk
= Absolut risk
a difference in rates of occurance
b/w exposed and non exposed
groups
- Atributable fraction (exposed)
= Etiological fraction

risk diference / rate of occurance

among the exposed population.
Atributable fraction is useful for asses
ing priorities for P.H action
- Population attributable risk (PAR)
= insidence of a disease in population
that iassociated with (attributable to)
an exposure to risk factor(Last 1995

useful for determining the relative

importance of exposure for entire po\
pulation would be reduced if exposure
were eliminated
PAR = Ip-Iu / Ip
Ip = incidence rate of the
disease in total population
Iu= incidence rate of the
disease among unexpose
group

Relative comparison.= risk ratio

is the ratio of the occurance of a disease
among exposed people to that among
the unexposed. Risk ratio is better indica
tor of an assciation than risk difference.
is used in assesing the likelihood that an
association represents a causal relation
ship.
The standardized mortality ratio is the special
type of risk ratio

Types of study
----------------------------------------------------------------------------------------Type of study
alterative name
unit of study
----------------------------------------------------------------------------------------------------------------OBSERVATIONAL
- Descriptive
- Analytic
. Ecological
correlational
populations
. Cross sectional
prevalence
individuals
Case control
case referece
individual
. Cohort
follow up
individual
EXPERIMENTAL
Randomized ctrl
Field trials
community trial

INTERVENTION STUDY
Clinical trial
patients
healthy people
Comm intervntion
communities
study
-----------------------------------------------------------------------------------------------------------------.

Observational studies :
- descriptive studies
+ based on routinely available data or data obtain
in special survey.
+ in many countries undertaken by center of
health statistic.
+ no attempt to analyse the links b/w exposure
and effect.
+ usually based on death statistics and may exa
mine pattern of death by age,sex,and ethnicity
during soecified time periods or in various countries

Ecological studies:
+ initiate epidemiological process
+ unit analyes is population or group.
+ Socioeconomic confounding is
potential problems in this study.
+ Simple, attractive, but difficult to inter
prate.
+ individual link b/w exposure and effect
cannot be made,
+ An ecological fallacy or bias results if inappropriate
conclusions are drawn on the basis of ecological
data.

 Cross sectional studies.

+ measure prevalence of disease.
+ often called as prevalence study.
+ It is not easy to assess the reason for
assosiation in this study.
+key question whether the exposure
preceeds or follow the effect.If E before
any effect analysis like cohort.
+ easy and economic.
+ investigating E that are fixed characteristic

+ several countries conduct regular

cros section study.
+ helpful in assesing health care need
+ attention must be given to the
purpose of survey, questionaire must
be well design and sample chosen
must be appropriate.

Case control studies.

+relative simple and economical
+used to investigatecauses of disease
especialy rare disease.
+ include people with disease and people
unaffected by disease.
+ called retrospective study.
+ the dificult task is to select control
+ Ideally Case should be new cases
+ Can be prospective.

 Association b/w E and disease calculate

Odd ratio
Exposure
+
+
a
b
A
Disease
c
d
B
C
D
E

OR : ad/bc
OR ; risk ratio
Cohort studies
+ called follow up studies / incidence std
+ begin with people free of disease,
devide into Exposed and non Exposed
+ Follow whether disease develop or not

+ called prospective study

+ provide best information about caution of
disease and the most direct measure
ment of the risk of developing disease.
+ simple but need long time
+use to investigate late/ chronic effect.
+ difficulty meassuring exposure

+ cost can be reduced using hystorical

cohort.
+ At start using healthy people posible
to examine a range of outcome (example Framingham study investigate risk
factor not only for cardio vascular but
also for respiratory and musculoskelet
al.

Application of different observational study

design
----------------------------------------------------------------------Eco CS
CC
Investigation of rare disease
Investigation of rare cause
Testing multiple effect of cause
Study of multiple E or determinant

Meassurement of time relationship

Direct incidence of incidens
Investigation of long latent period
+ = suitable

- = not suitable

++++
++
+
++

++
++

++
-

++++
++++

+*
+*
+++

Co
++++
++++
++++

++++
++++
-

* if prospecyive/ population base

Advantage and disadvantage

----------------------------------------------------------------------------------------------Eco
CS
CC
Co
Probibility of :
selection bias
NA
med
high
low
Recall bias
NA
high
high low
loss to follow up NA
NA
low
high
confounding
high
med
med
low
Time acquired
low
med
med
high
Cost
low
med
med
high
NA = not applicable

Experimental epidemiology
1. Randomized controlled trial:
- = randomized clinical trial
- is an epidemiological experiment to
study a new preventive or therapeutic
regimen.
- Subjects in population are randomly
allocated to treatment & control group.
- result are assessed by comparing the
outcome of two or more groups

example :
- early discharge (3 dys) of patient w/
myocard infarction.
-glucose-based of Oral rehydration solu
tion can be raplace by rice-based.
2, Field trials
-contrast to clinical trial.
-involve people who are disease free but pre
sume to be a risk.

the purpose is to prevent the occurance

of disease that may occure w/ relatively
low frequency.
- Need majo logistic and budget.
- Example :
trial of Salk vaccine toprevent polio
field trial of vaccine against New World
cutaneus leishmaniasis

3. Community trials
- the treatment group not individual but
communities.
- appropiate for disease that have their
origins in social conditions which in turn
can most easily be influence by inter
vention directed at group behavior as
well as individual

Potential error in epidemiological studies

1. Random error
=divergence due to chance aloneof an ob
servation on a sample from the true
population value, leading to lack of per
cission in the measurement of an asso
ciation
- Three major source of random error
(individual bio;ogical variation, campling error
and measurement error)

2.Sample size calculations

-the desireble size of proposed study
can be assessedusing standard formula
- before using formula information on
following variables is inquired,(required
level of statistical significance, accepta
ble chance of missing a real effect,
magnitude of the effect under investigation
, amount of disease in the population and re
lative size of the groups being compared.)

- the percision of the study can also be improved

by ensuring that the groups are of appropiate
relative size.
- Usually become an issue in case-control study
(control size)
3 Systematic error
- systematic error (or Bias) occur when there is a
tendency to produce results that differ in a
systematic manner from the true values.

- study with small systematic error = high accuracy. Accuracy is not affected by sample size
- There are more than 30 specific type of bias .
- the principal biases are Selection bias and
measurement / classification bias.

Selection bias
- Occur when there is a systematic difference b/w
characteristics of people selected for a study
and of those who are not

example :
people who participate in study on the affect
of smoking differ in smoking habit with habit
in non responder.
- cohort of newborn follow up for 12 month
varied according to income level of parents
- study of efect of formaldehyde in feactory
sick worker has gone out of the factory

Measurement bias,
- occur when the individual measurement or
classification of disease/exposure are
inaccurate
- example study using lab examination. Different
lab different result.
- A form of measurement bias of particular impor
tance in retrospective case-control studies
known as recall bias.

- this occurs when there is a differential recall of

information by cases and control

Confounding:
In the study of association b/w E to a cause/risk
factor and the occurance of disease,
confounding can occur when another E exist to
the study population and is associated both with
the disease and the E being studied.

-confounding occurs when the effects of two E/

risk factor have not separated and it is there
fore incorrectly concluded that the effect is
due to one rather than to the other variable
- example study association of smoking w/ lung
cancer age become confounding factor.
- Age and social class are often confounder

confounding coffee drinking, cigarette

smoking and coronary heart disease
Exposure
Disease
(coffee drinking)
(heart disease)

Confounding variable
(cigarette smoking)

Control of confounding
- control confounding in study design :
by randomization, restriction and matching,
- control at analysis stage by stratification and
statistical modelling,

 VALIDITY
Is an expression of the degree to which a test
is capable of measuring what it is intended to
measure.;
Valid if its results correspond to the truth ; there
is no systematic error and random error should
be as small as possible

 Validity and reliability

Validity
high
low
-------------------------------------------------------measured value
measured value
! !!!!!!!!
!!!!!!!!!
high
^
^
true value
true value
Reliability
measured value
measured value
! ! ! ! ! ! !
! ! !!!!!
low
^
^
true value
true value

 With low reliability but high validity the measured value

are spread out but the mean of the measured value is
close to the true value.
A high reliability (repeatability) of the measurement
doesnot ensure validity since they may all be far from the
true value
There are two type of validity (internal and external)
- External validity=generalizebility the extent
to which the results of the study apply to people not in
it for example laboratory not involve in it.
Need externel quality control of measurement and
judgement about the degree to which the result of the
study can be extrapolated.

- Internal validity

is the degree to which the results

of an observation are correct for the particular group

of people being studied. Example :measurements of
Hb must distinguish accurately [articipants with
anemia as defined in the study. Analysis by other lab
may produce different result caused by systematic
error

Reliability
- = Percision
- test which give consistent results when
the test is performed more than once on
the same individual under the same
condition
- Influenced by inherent variation in the
method and observer variation

Basic statistics

check Biostatistics

Causation in epidemiology
A major goal of epidemiology is to assist
in the prevention and control of disease
and in the promotion of health by discovering
the cause of disease and the ways in which they
can modified .
Concept of cause
-the concept of cause is not only for
prevention but also for diagnosis and correact
treatment
-The concept of cause has different meaning in

different context and no definition is equaly

apprropriate in all science
- A cause of a disease is an event, condition. Characteris
tic or a combination of those factor which play an
important role producing the disease .
- A sufficient cause is not usually a single factor but often
comprises several components.In general it is not
necessary to identified all the components of a sufficient
cause before efective prevention can take place ,since
the removal of one component may interfere with the
action of the other and this prevent the disease.

Each sufficient cause has a necessary cause

as a component Example : In food-borne outbreak it maybe found that chicken salad and
creamy dessert were both sufficient cause of
salmonella diarrhoea. Adanya salmonella is a
necessary cause of this disease. Simillarly
many in tuberculosis there are different com
ponents in causation of tuberculosis but tuber
cle bacillus is a necessary cause.

 Cholera
genetic factor

expposure to
contaminated
water

effect of cholera
toxin on bowel
wall cells

malnutrition
crowding
poverty

increased
ingestion
cholera
suscepti
cholera
bility
vibrio
o----------RISK FACTOR-------------------o-------mechanism for CH


genetic factor

exposure to
bacteria

tissue
invasion

malnutrition

crowding

Susc
host

inf

tuberculosis

poverty
o-----risk factor of tbc--------------o--------mechanisms of tbc--

 Single and multiple causes

-Pasteur work on microorganism led to the formu
lation, first by Henle and then by Koch the
following rules for determining whether a specific
living organism causes particular disease:
-the organism must be present in every case
of the disease.
-the organism must be able to be isolated and
grown up to pure culture

- the organism must, when inoculated into a

susceptible animal cause the specific disease
- the organism must then be recovered from
the animal and identified
-First example for these rules was Anthrax
-For most diseases (infectious and non infectious) Kochs rules for determining causation are
inadequate.Many causes are usualy operating
and single factor(ex: sigaret smoking )

but no causative organism appear.

- Kochs rules are of value only when:
. The specific cause is an overpowering in
fectious agent.
. Uncommon situation suceptibility due to
other factor.
. Sufficient amount of the agent (infective
dose )

 Factors in causation;
Four type of factor play a part in causationof disease. All
maybe necessary but they are rarely sufficient to cause
a particular disease or state:
- Predisposing factors such as age, sex and previous
illness may create a stae of susceptibility to disease
agent.
- Enabling factors such as low income,poor nutrition,
bad housing and inadequate medical care may favour
development of disease

Conversely circumtances that assist in recovery from

illness or in the maintenance of good health could
also be called enabling factors.
- Precipitating factors such as exposure to a specific
disease agent or noxious agent may be assosiated
with the onset of disease or state
-Reinforcing factors such as repeated exposur and
unduly hard work may aggravate an established
disease or state.
The term risk factor is commonly used to describe

factors that are positively associated with the risk of development of a disease but are not sufficient to cause of
disease. Some risk factors( e.g tobacco smoking) are
associated with several disease. Epidemiological study
can measure the relative contribution of each factor to
disease occurance , and corresponding potential reduc
tion in disease from the elimination of each risk factor.

Interaction :
the effect of two or more causes acting together is often
greater than would be expected on the basisof summing

the individual effect. This phenomenon is called Interaction . Example :High risk of lung cancer in a people
who smoke and exposed to asbestos dust.

Establishing the cause of disease:

Causal inference is the term for the process of determin
ing whether observed assiciation are likely to be causal.
Before an association is assessed for the possibility that
it is causal bias and confounding should be excluded

assessing the relationship b/w a possible cause and an

outcome
observed association
could it be due to selection
or measurement bias
coud it be due to confounding
could it be a result of chance
could it be causal

apply guidelines and make

judgement

 Temporal relationship
temporal relationship is crucial the cause must
preceed the effect. This usually self-evidence ,although
difficult may arise in case-control and cross sectional
study when measurement of the possible cause and
effect are made at the same time and the effect may in
fact after the exposure. In cases where the cause is an
exposure that can be at different levels it is essential that
high enough level be reached before the disease occur
for the correct temporal relationship to exist
repeated measurement (time&place) trengthen the
evidence

 Guidelines for causation

Temporal relation does the cause preceede the effect (essential)
Plausibility
is the association consis tent w/ other knowledge
( mech of action evidence from exp animals)
Consistency
have similar results been shown in other studies
Strength
what is the strength of association b/w the cause
and effect ( relative risk )
Dose-response is increase exposure to the possible cause
relationship
increase effect.
Reversibility
removal of possible cause reduction of risk
Study design
evidence based on strong study design
Judging the
how many lines of evidence lead to the conclution

 Plausibility :
an association is plausible and that more likely to be
causal. If consistent with other knowledge.eg laboratory
experiments. Example predominant view of cholera in
1830 was miasma but Snow showed that evidence
was contagion Lack of plausability may simply reflect
lack of medical knowledge example sceptism that still
exist about therapeutic effect of acupuncture and homeeopathy cause by absence of information about a plausi
ble biological mechanism.

 Consistency
consistency is demonstrated by several studies giving
the same result.This is particulary important when a
variety of design are used in different setting.
- Technique Metaanalyses (combines the result of a
number of well-design trials each of which deal with a
relatively small sample, in order to obtain a better overall
estimate of effect.

 Strength
-a strong association b/w possible cause and effect as
measures by the size of the risk ratio is more likely to be
causal than is a weak association
- relative risk greater than 2 can be consider strong
- the fact that an association is weak does not preclude it
from being causal

Dose-response relationship
- a dose response relationship occurs when changes in
level of possible cause are associated with changes in

prevalence or incidence of the effect

- the demonstration of a clear dose response relation
ship in unbiased studies provides strong evidence for
a causal relationship b/w exposure or dose and
disease.

Reversibility
When the removal of a possible cause result in reduced
disease risk, the likelihood of the association being
causal is strengthen

 Study design
the ability of a study design to prove causation is a most
important consideration. The best evidence comes from
well-designed, competency conducted randomized
control trial.
- Other experimental studies such as field and community
trials are seldom used to study causation
- Evidence comes most often from observational studies
- Cohort studies ae the next best design because when well
conducted, bias is minimized,
- Although case control studies are subject to several forms
of bias the result from large well-design investig

of this kind provide good evidence for a causal nature of an

association
- ecological study provide the least satisfactory type of evidence on
causality because of danger of incorrect extrapolation to individuals
from data on regions and countries
Relative ability of studies to prove causation
randomized controlled trials-------------------strong
Cohort studies------------------------------------moderate
Case control studies-----------------------------moderate
Cross section studies--------------------------- weak
Ecological studies ------------------------------- weak

 judging the evidence

Regrettably there are no completely reliable
criteria for determining whether an association is
causal or not . Causal inference is usually
tentative and judgement must be made on the
basis of the available evidence uncertainly
always remain

Communicable disease
epidemiology
Communicable =infectious
Communicable disease is an illness caused by
transmission of the specific infectious agent or its toxic
product from infected person or animal to a susceptible
host either directly or indirectly
In developed countries acute upper respiratory
infection (ARI) are responsible for a great deal of
morbidity and time off work
In developing countries communicable disease are still
the major cause of both morbidity and mortality

 There are emergence of new diseases eg

- Lhasa fever (Viral disease, transmitted by rodent, first
recognized in Nigeria in 1969 )
- Legionnaires (Gram negative bacillus ,first described
after an outbreak of pneumonia following a meeting of
American Legionnaire in Philadelphia 1976. was traced
to the contamination of air-conditioning equipment.
- AIDS is the most devastating of the new communicable
disease.

 Epidemic and endemic disease

- Epidemic : is the occurrence in a community
or region of a disease that is usually large and
unexpected for the given place and time
- Epidemic are usually either point source or
contagious.
- Endemic ; is one that is usually present in a
given geographical area or population group at
relatively high prevalence and incidence rate in

comparison with other area or populations

- Endemic disease become a major problems
in developing countries .If condition changes
either in host or the environment an endemic
disease may become epidemic.
Spectrum of illness from communicable

disease
in apparent infection mild disease se
vere disease death

 Chain of infection
-Communicable disease occur as a result of the
interaction of the agent, the transmission
process and the host. All of this are influence by
the environment.
-Knowledge of each factor in a chain of infection
maybe required before effective intervention can
take place

-The infection agent o

.A large number of microorganism cause disease
in human.
.Infection is not equivalent to disease. Some
infection do not produce clinical disease.
.Pathogenicity ability of the agent to produce
disease . Measure by the ratio of the number
of person developing clinical illness to the
number exposed to infection.

.Virulence - a measure of severity of disease.

- can vary from low to high.
- virus attenuated and have low
virulence for immunizations
.Infectivity the ability of the agent to invade
and produce infection in the host
.Infection dose the amount required to cause
infection in susceptible subject

.Reservoir the natural habitat of the

infectious agent, can be human
animal or environment source
.The source of infection is the person or
object from which the host
acquires the agent.
.Carrier infected person who shows no
evidence of clinical disease.

 Transmission
-is the spread of an agent
through the environment or to another
person.
-Transmission maybe direct or indirect.

 Direct transmission

Indirect Tr

--------------------------------------------------------------------------------------------Touching
Vehicle borne(food water
tool,etc
Kissing
Vector borne
Sexual intercourse
Airborne long distance
Other contact(breast feeding
Parenteral
medical procedure etc)
Airborne short distance
Tranplacenta
Transfusion

 Host
The person or animal that provide a suit
able place for infectious agent to grow
and multiply under natural condition
-Reaction of the host to infection is
extremely variable,depend on interaction
of host, agent and transmission factor

 Incubation period
-the time between entry of the infectious
and the appearance of first sign or symptom of disease
- The outcome of infection is the degree of
natural or vaccine-induce resistance or
immunity of the host

 Environment
- The environment plays a critical role in
the development of communicable
disease
- General sanitation, temperature, air
pollution, water quality,
- Social economic like population density,
overcrowding, and poverty

 Investigation and control C.D epidemic

- Purpose of investigating epidemic is to
identify its cause and the best mean to
control it
- Step : preliminary investigationio ,
Identification of cases, collection and analyses
data, implementation of control

measure and follow up

- preliminary verify D/ ,confirm epidemic +
formulation of hypothesis
- Surveillance is essential part of disease
control
- Sentinel health information system
- Management of an epidemic treating cases
,preventing spread of the disease, and
monitoring result of control measure

 Control measures can be directed against :

- source
- spread of infections.
- protecting people exposed to it.
Once control measures has been implemented
surveillance must continue to ensure their
acceptability and effectiveness.
systematic immunization program can be very
effective in certain diseases

CLINICAL EPIDEMIOLOGY
Definition is the application of epidemiological
principal and methods to the practice of clinical
medicine.
Clinical epidemiology is one of the basic medical
sciences although in most medical schools this is
not yet recognized.
The central contents of clinical epidemiology are
definition of normal and abnormal, accuracy of
diagnostic test, natural history&prognosis of
disease, effectiveness of Th/ and prevention in
clinical practices.

 Definition of normality and abnormality;

The first priority in any clinical consultation is to
determine whether the patients symptoms, sign
and D/ test result are normal or abnormal. This
is necessary before further action can be taken
whether this be investigation, treatment or
observation. It would be easy if there were
always clear distinction b/w frequency
distribution of observation on normal and
abnormal

 There are three types of criteria have been used to help

clinician make practical decisions:
1. Normal as common
Usually used in

clinical practice is to consider frequency

occurring value as normal and those occurring infrequently as
abnormal. The arbitrary cut off point on the frequency distribution
( mean +or-2 SD) as normal and beyond that as abnormal. This is
called as operational definition of abnormality. If the distribution in
fact Gaussian (statistical normal) cut-off point =2,5% of the populatio
is abnormal.
As alternative approach 95% of population is normal and 5%of
population as Abnormal

.
2, Abnormality associated w/ disease

based on the distribution s for both healthy and

diseased people and attempts to define a cut-of points
that clearly separate the two groups ,A comparison of
two frequency distributions often shows considerable
overlaps .Choosing a cut-off point that nearly separate s
cases from non cases is clearly impossible. there are
always some healthy people on the abnormal side of the
cut-off point and some true cases on the normal side.
Abnormal as treatable
The difficulties in distinguishing b/w normal and

abnormal using the above criteria led to the use of

criteria determined by evidence from randomized
controlled trials, which indicate the level at which T/
does more good than harm. Unfortunately this
information is only rarely available in clinical
practice. The example of this is treatment of hypertension. Treating patient with high diastolic pressure
(>120mmHg) was beneficial . 95 mmHg is cut-off
point whether treated or not

Treatment of hypertension ;changing criteria overtime

pharmacological T/ introduced (125)

veteran administration trial

(110/100)

Australian trial (100)

T/ not recommended

1955

1965

US trial (90)

1975

1985

 Diagnostic test
-first objective in a clinical sitution is to
diagnose any treatable disease present.
-diagnostic test will help that,
-usualy involve laboratory investigation
microbiological,biochemical, physiologi
cal, anatomical.etc

 Value of the test

a disease maybe either present or
absent
and the test maybe pos or negative/
Relationship B/w diagnostic test result
and the occurrence of disease

disease
present
absent
pos true pos

false pos

neg

true neg

Test
false neg

sensitivity? Specificity ?
pos predictive value? Neg predictive
value ?
Natural history and prognosis;

 Effectiveness of treatment
Prevention in clinical practice