1 a) Short notes on Iceberg phenomenon and its public health importance

Visible cases
(Diagnosed diseases)
Diseased, diagnosed, controlled
- Dead cases
- Hospitalised cases
- Clinic Cases Diagnosed, uncontrolled

Undiagnosed or wrongly
diagnosed disease

Risk factors for disease

Invisible cases
(Undiagnosed or wrongly diagnosed
disease)
- mild cases
- carriers Free from risk factors
- asymptomatic infection

Definition of iceberg phenomenon:

The variation in severity of a disease process is referred to as the iceberg phenomenon (Moris
1967). The iceberg concept describes that the tip of the iceberg, which corresponds to active
clinical disease accounts for a relatively small proportion of the disease.

Example:
An outbreak investigation of diphtheria in Alabama (1963). The outbreak caused two deaths, 12
children were down with clinical symptoms of diphtheria. It also caused asymptomatic infection
in 32 children discovered via an extensive campaign of culturing the throats of all school-
children in the outbreak area. Fourteen cases of diphtheria were visible but the 32 carriers would
have remained invisible without the extensive use of culturing and epidemiological surveillance.

(Lilienfield & Stolley, 1994) For tuberculosis, approximately 1 in 10 people developed clinical
disease, 9 in 10 people infected with measles have clinical signs, about 2 in 3 people infected
with mumps and about 1 in 10 people infected with poliomyelitis.
Other examples: Hepatitis B carriers, Cholera carriers, HIV/AIDS, Prostate cancer (Bhopal,
2003)

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Importance of the concept:
In an outbreak - Considering only the clinically ill in the midst of an outbreak is a grave
mistake. Instead of addressing the intervention (preventive and control activities) only to
the clinically affected people it should be applied to all susceptible, exposed people in the
neighborhood. Interpreting the absence of clinical cases as the absence of the disease in
any form is a mistake. Many infections are able to occur and enter a population such as
importation of a subclinical chronic carrier, and this infection could spread for weeks.
Interpreting the decline of clinical cases over time as evidence that certain applied
intervention were effective may sometimes not be true. Recognize that this decline is the
natural history of most infectious disease outbreaks without any interventions. For
most outbreaks of infectious disease, the highest number of clinical cases usually occurs
early in the natural course of the disease, and then decline as the people respond to the
infection and the pool of susceptible declines. Clinical cases may disappear altogether
even thou the infection is still widespread in the community. This natural decline is then
mistaken as evidence of effective intervention.
Disease does not equal infection and diseased people do not always show signs of disease
Provide reasons why it is difficult to control disease transmission in population
Studying ONLY symptomatic cases or individuals may produce a misleading picture of a
disease pattern & its severity.
Inaccurate data for Public Health programs. There is a specific and minimal level of
healthcare need at each level. Eg.:
Level 1 vigilance and continuity of high quality care through follow-up
Level 2 Review and attemps to deliver effective and acceptable care
Level 3 A need for opportunistic or targeted screening for people with early disease
Level 4 Screening and health education
Level 5 Health promotion to maintain this desirable state for people
Epidemiological studies of the causes and consequences of disease should, ideally be or
representative cases. Studies based on selected cases from the tip of the iceberg may give
an erroneous view.

1b. Sensitivity and specificity of a screening test

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Definition of screening:

The presumptive identification of unrecognized disease or defect by the application of

tests, examinations or other procedures which can be applied rapidly. Screening tests sort
out apparently well persons who probably have the disease from those who probably do
not.

To asses the performance of a screening test four measures can be used:

Sensitivity
Specificity

In a perfect world, medical tests would always be correct. In reality, however this does
not happen. Consider a test that has only positive or negative results. Example:

Screening test # Disease (true/definitive test) Total

Present Absent
Positive a (TP) b (FP) a+b
Negative c (FN) d (TN) c+d
Total a+c b+d a+b+c+d
# Disease status is said to be the true status of the person based either on a definitive (gold standard)
series of tests or observation, often made over long period of time (possibly checked via postmortem)

Sensitivity : the proportion of diseased people who were correctly identified as positive
by the test.

Equation : a / (a + c) or TP / (TP + FN)

The greater the sensitivity of a test the more likely the test will detect persons with the
disease of interest. Test with great sensitivity are useful clinically to rule out the presence
of a disease, that is a negative test would virtually exclude the possibility that the patient
has the disease of interest.

Specificity : the proportion of non-diseased people who were correctly identified as

negative by the test

Equation : d / (b + d) or TN/ (FP + TN)

The greater the specificity of a test, the more likely it is that persons without the disease
of interest will be excluded from consideration of having the disease. Very specific tests
often are used to confirm the presence of a disease. This is because a highly specific test
is rarely positive in the absence of a disease, i.e gives few false positive results.

Sensitivity of the test should be increased

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 when the penalty with missing a case is high (serious disease and definitive
treatment exists)
when the disease can spread
when subsequent diagnostic evaluation of positive screening tests are associated
with minimal risk and cost

Specificity of the test should be increase
when the false positive results can harm patient physically, emotionally or
financially
when the costs or risks associated with further diagnostics techniques are
substantial

The above examples are mainly from dichotomous classification of clinical findings
negative, positive. However not all test are interpreted in this manner. (i.e serum alkaline
phosphatase level is on a continuous scale, blood sugar tests) If this is so, as much as it is
desirable to have a test that is both highly sensitive and highly specific, there is a trade-
off between the sensitivity and specificity of a test (cut-off).

Another way to express this relationship between sensitivity and specificity for a given
test is to construct a curve called a (ROC) receiver operator curve. Plotting the true
positive (sensitivity) against the false positive rate ( 1-specificity)

1 c. Observational and Experimental Study Designs

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Main classification of epidemiological study designs

Features of observational study:

investigator allows nature to take its course
observes and measures the characteristics of interest to the study
does not intervene or control factors related to the exposure or outcome
low cost, minimal ethical issues involved
Few issues: Disease are not investigated directly as investigators cannot
manipulate exposure, residual confounding is also a problem

Features of an experimental study:

Investigator actively manipulates the characteristics / variable under study
Investigator monitors the outcome
Studies how subject / phenomenon reacts to the manipulated conditions
Investigator controls study population and factors to which the population is
exposed
Have advantaged over controlled conditions BUT ethical problems of
experimenting on humans.

In general, in an observational study the investigator watches as subjects themselves

choose which group they will be in (exposed or unexposed), in an experimental study, the
investigator assigns participants in their exposure groups.

Epidemiological
Studies

Observational Experimental
Study Study

Descriptive Study: Randomized Control Trial

e.g
Surveillance
Case report
Case series
Cross Sectional

Analytical Study:
Case control
Cohort

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In observational study, two components:

a) Descriptive component
describes the occurrence and distribution of disease in a population
pre-requisite of any systematic investigation of pattersn of disease occurrence in
human population
Hypothesis generating

b) Analytical Conponent
analyse the relationship between exposure and outcome under natural conditions

In experimental study:
a) Therapeutic randomized controlled clinical trials, treatment allocated to individuals,
b) Intervention efficacy trial, effectiveness trial

c) Preventive

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2. Mortality data are more useful than morbidity data in assessing the health needs of the
population. Discuss this statement, using examples to illustrate your points.

Framework:

- Definition of mortality data with examples

- Definition of morbidity data with examples
- Agree with statement giving appropriate reasons
- Disagree with statement giving appropriate reason

Discuss investigate or examine by argument, debate, giving reasons, pro and con
Describe give detailed or graphic account of.

Epidemiology is a population science studies health patterns, depends heavily upon

data to achieve its goal, findings are drawn upon and applied to the groups of people.

Mortality data
death data, identifies serious health problems,
gives some indication of size of a problem
gives useful information about the number of people who have died
enables comparison between figures across time and place.
The mortality rate is the number of deaths in a population in a specific period of
time in relation to the total number in the population. Deaths are usually reported
in the form of rates, i.e. the proportion of a population that dies during a period of
time.
Examples of mortality data : IMR, NMR, PNMR, Perinatal MR, Stillbirth MR,
etc (CDR, ASDR, SDR)
Sources : vital statistics registration, Hospital records, Government health
institution, Police, Community etc

Morbidity data
Morbidity departure, subjective or objective, from a state of physiological or
mental well-being, whether due to disease, injury or impairment.
important to establish and describe more directly size of problem in a population.
The morbidity rate is defined as the proportion of the population that becomes
diseased during a period of time.
Example: Cancer registry, Cataract Surgery registry etc.
Sources :notifications of infectious diseases of public health importance, registries
of other diseases such as cancer, birth defects; hospital discharge statistics; health
insurance claims; and health surveys.

Mortality data are more useful than morbidity data in assessing the health needs of the
population.
Reason being:
Coverage issues : Mortality data legally required

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 Event is unlikely to be missed
Coverage is more
Morbidity data no single source of data can provide comprehensive picture.

Morbidity data - issues in ascertaining its validity (variation in perception of

illness and illness behaviour)
Problems of definition
Criteria of ill health,
problems of diagnosis
Iceberg concept

Morbidity data are more useful than mortality data in assessing the health needs of the
population.

mortality data provides useful information about the patterns of death of the
population,

the picture it provides on health is limited because it describes our health status as
it was, not what it is at present.

A health spectrum exists in any population from healthy persons through a
continuum of ill-health to persons who a close to dying. To answer questions
about the health of the population along the health spectrum, we have to rely on
morbidity data that gives us information about disease occurrence rather than
mortality data.

Mortality data - can be unreliable (Msian scenario - 40 % are legally certified)

Mortality data becoming less reliable as window on illness

ICD classification - 9 th / 10th

Quality of Life - impact of disease

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