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It is the study of the nature, cause, control and determinants of the frequency and distribution of disease, disability and death in human populations. (Timreck, 1994) It is the study of the distribution and determinants of disease frequency in human populations. (MacMahon and Trichopoulos, 1996)
Epidemiology is an investigative method used to detect the cause or source of diseases, disorders, syndromes, conditions or perils that cause pain, illnesses, injury, disability or death in human populations or groups. (Timreck, 1994) Epidemiology is a discipline that describes, quantifies and postulates causal mechanisms for health phenomena in the population. (Friis and Sellers, 1996)
A study of the distribution and determinants of healthrelated states or events in specified populations, and the application of this study to control of health problems. (Last, 1988)
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Population of interest are human populations Describes distribution of health and disease (by person, place and time variables) Identifies determinants of health and disease (risk factors, causes) Health and disease (injury, illness, disability or death)
Hippocrates in 400 BC in his On Airs, Waters and Place the role of the environment in health and disease among men John Graunt, in 1662, published Natural and Political Observations Made Upon the Bills of Mortality which recorded descriptive characteristics of birth and death data, including seasonal variations, infant mortality, excess of male over female deaths, and other findings. He was the first to employ quantitative methods in describing population vital statistics.
John Snow investigated a cholera epidemic in mid-19th century in London. His work featured various techniques in epidemiologic inquiry such as spot map of cases, tabulations of cases and deaths, development and testing of hypotheses that contaminated water may be associated with cholera outbreaks. Koch in late 1800s espoused the concept that diseases are caused by living organisms and made possible more refined classification of disease by specific causal organisms through his postulates for disease causation.
The history of epidemiologic methodology is largely the history of the development of five ideas:
Human disease is related to the environment in which we live; Counting of natural phenomena may even be more instructive than just observing them; natural experiments can be utilized to investigate disease etiology; Natural experiments occur more frequently than we think and reflect the tremendous heterogeneity of human experience; true experiments may be conducted in human populations in some circumstances.
Framingham Heart Study began in 1949 for its pioneering investigations of risk factors for coronary heart disease. After World War II, the work of Doll and Peto identified the strong association between smoking and lung cancer. Eradication of smallpox
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Universal political commitment Clear and specific goal with precise timetable Well-trained and committed staff Flexible strategy Features of the disease that made its elimination possible Availability of an effective and stable vaccine
Genetic Factors
`
Causation
Genetic Factors
Environmental factors (including lifestyle)
Ill health
Death
`
Natural History
Good health
Subclinical changes
Proportion with ill health, change over time, change with age, etc.
Good health
Ill health
Time
Evaluation of intervention
Good health
Health promotion Preventive measures Public health services
Ill health
` Prevention
It is interdisciplinary
Draws from biostatistics and other social and behavioral sciences as well as from medically-related fields of toxicology, pathology, virology, genetics, microbiology, parasitology and clinical medicine.
Definition of epidemic:
Attacking many people at the same time, widely diffused and rapidly spreading, excessive occurrence of disease (Dictionary) The occurrence in a community or region of cases of illness clearly in excess of normal expectancy (Benenson, 2000)
Describe the different models of disease causation (triangle, wheel, lever, web)
Explain the criteria that supports causal inference Describe the natural history of disease Explain the use of classification of diseases and disability
Factor
Disease
Statistical dependence between two variables, that is, the degree to which the rate of disease in persons with a specific exposure is either higher or lower than the rate of disease among those without that exposure.
OR Exposed: lower rate of disease Unexposed: higher rate of disease
Epidemiology does not determine the cause of a disease in a given individual. Instead, it determines the association between a given exposure and frequency of disease in population.
Studies are undertaken to demonstrate a link (association) between F and D.
We infer causation based upon the association and several other factors
Causal association between categories of events/characteristics (F and D) in which an alteration in the frequency or quality of one category is followed by a change in the other Non-causal association of both categories of events (F and D) with a third category
C A B
C A B A
C
If: Alter A, expected change in B Alter C, no expected change in B
A B
A
Tubercle bacilli
B
TB
A
Tampons
V
Staph organism
B
Toxic shock syndrome
no association F D
direct F D
indirect F V D
The organism must be present in every case of the disease The organism must be able to be isolated and grown in pure culture The organism must, when inoculated into a susceptible animal, cause the specific disease The organism must then be recovered from the animal and identified
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A particular disease has one cause A particular cause results in one disease
BUT not true for many diseases (Ex. Smoking causes many diseases; CAD has multiple causes)
Cause cannot be established by means of Kochs postulates since many factors act together to cause diseases
Biomedical scientists elucidate pathogenic causes/mechanisms (cellular/subcellular processes) Epidemiologists investigate other less specific factors (env, behavioral, etc.) --- risk factors that are associated with an increased risk of becoming diseased
Risk factor
(+)
F D
`
Preventive factor
(-)
F D
Examples:
Cig smoke lung cancer (health education) Use of tampons toxic shock syndrome (removed from market) Washing of hands infections (OB should wash their hands)
Necessary cause
A cause is termed necessary if a disease cannot develop in its absence If A is a necessary cause of B, then B will only occur if preceded by A (absolutely necessary) A necessary condition is one that must be satisfied for the result to happen
The presence of A does not ensure that B will occur, but the presence of B ensures that A must have occurred (all cases are exposed) If A is absent, B cannot occur
Cause
Necessary: 16 years old Necessary cause: tubercle bacilli Sufficient cause: jumping Sufficient cause: vaccination
Effect
Drivers license Tuberculosis Feet off the ground Immunity
Factor (-) b
(-)
Cause
Necessary: 16 years old Necessary cause: tubercle bacilli Sufficient cause: jumping Sufficient cause: vaccination Sufficient cause: ____________
Effect
Drivers license Tuberculosis Feet off the ground Immunity ______________________
Cause of any effect consists of a constellation of components that act in concert to produce disease Ex. Disease X occurs in the ff. 3 situations:
U A B A
U E B
U A B A
U E B
Step 1 determine presence of validity of statistical association. Exclude chance, bias, confounding Step 2 Determine causality
Experiment (not always possible) Non-experiment consideration (set of criteria) Strength of association Time sequence Biologic credibility Consistency with other studies Dose-response relationship
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Random variability Determined by sample size Extent of chance: p-value, confidence interval Epi Assumption draw an inference about the experience of an entire pop based on study of only a sample (ex. Prevalence of malnutrition among 06 y.o., province X)
Effect of extraneous variable (confounder) that distorts the relationship between E and D Non-comparable study groups (confounder) Presence/extent of confounding
Stratified and regression analysis
It is associated with the exposure but is not a consequence of the exposure ( ) It is a risk factor for the study disease ( )
C
(1) (2)
? Exposure
Disease
Ex. Age and gender (potential confounders) related to most diseases and to the presence of many exposures
Age
(1) (2)
? Exercise MI
(1) Younger tend to exercise (2) Younger lower MI
Cases (+MI) A C
Controls (-MI) B D
Age
(1) (2)
? Exercise
(1) Younger tend to exercise (2) Younger lower MI If controls are younger than cases
MI
Cases (+MI)
Controls (-MI)
Smoking
(1) (2)
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(1) Smoking is associated with alcohol (2) Smoking is a risk factor of heart disease
Step 1 determine presence of validity of statistical association. Exclude chance, bias, confounding Step 2 Determine causality (criteria)
Consistency of findings Strength of association Biologic gradient Temporal sequence Plausibility and coherence Specificity of the association
Relationships that are demonstrated in multiple studies are more likely to be causal Look for consistent findings
Across different populations In differing circumstances With different study designs
Strong associations are less likely to be caused by chance or bias A strong association is one in which the relative risk is ery high or very low
Dose response (change in level of cause associated with changes in disease frequency)
Standardized Mortality Ratios (Lung Cancer) Dose (cigs/day) 10 10-20 40 Study 1 1.3 2.8 4.7 Study 2 1.8 2.3 3.7 Study 3 1.4 2.4 6.3
Exposure must precede disease Exposure must precede the latent period (disease onset detection)
The proposed causal mechanism should be biologically plausible Is there a mechanism of action; evidence from animal studies
Note: lack of plausibility may simply reflect lack of medical knowledge
Causal mechanism must not contradict what is known about the natural history and biology of the disease
An exposure leads to a single or characteristic effect, or affects people with a specific susceptibility
Easier to support causation when associations are specific, but This may not always be the case x Many exposures cause multiple diseases
Association Bias
Yes
No
Chance
Yes
No
Confounding
Yes
No
Association
Association
Strength of association
Higher RR, likely causal
Biologic gradient (dose response amt, duration gradient of risk associated with degree of exposure)
Temporal sequence
Exposure precedes disease
Plausibility/coherence
Not contradict K re natural history/biology of disease
No single study is sufficient for causal inference Causal inference is not a simple process
Consider weight of evidence Requires judgment and interpretation
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Demonistic Theory Devilisitic Theory Tridoshas Theory Four Humours Theory Yang and Yin Principles Germ Theory Epidemiological Triad Multifactorial Theory
Ecology the study of the relationship of organisms to each other as well as to other aspects of the environment Ecologic models: interrelations of factors
The triangle The lever The wheel The web
AGENT
HOST
ENVI
HOST
AGENT
ENVIRONMENT
Social Environment
Biological Environment
Host (Man)
Genetic cure
Physical Environment
High HDL
Coronary heart disease (Web of causation of CHD by Dr. Sherwin, University of Maryland
There is no single cause Causes of disease are interacting Illustrates the interconnectedness of possible causes
susceptibility
adaptation
presymptomatic
clinical disease
disability/recovery death/chronicity
exposure
onset
clinical horizon
Time
Disease has not developed Interaction of agent, host, envi Groundwork for disease has been laid due to the presence of factors that favor its occurrence
Factors whose presence is associated with an increased probability that the disease will develop later Ex. Smoking, alcohol drinking, multiple sex partners all risk factors will develop the disease
Not
Vit D
Rickets
Salmonella
Typhoid
Changes in the organs have occurred sufficiently to show signs and symptoms of the disease Classification of disease is important
For better management of cases For epidemiologic study grouping of disease reduces variation; for evaluation of intervention and for internal comparisons May be used on morphologic (cancer), functional (heart), therapeutic (heart), etc
Disability any temporary or long-term reduction of a persons activity as a result of an acute or chronic condition
Induction period causal action to disease initiation (cause effect) Latent period disease occurrence to detection (effect on body detection)
Induction period
Latent period
cause
effect
detected
Basis natural history of disease Obj: halt or reverse the disease process; prevent pathologic process from evolving further 4 levels: primordial, primary, secondary, tertiary
Tissue changes
Prepathogenesis
Pathogenesis
Stage of disease
Susceptibility
Presymptomatic
Clinical disease
Disability/reco very
Levels of prevention
Primary
Secondary
Tertiary
Mode of intervention
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Early diagnosis and prompt treatment Screening surveys are designed to uncover asymptomatic diseases and to alter the natural history of the condition detected Possible to either cure disease or slow its progression, prevent complications, limit disability Early treatment of persons with infectious diseases may protect others from acquiring the infection
Limitation of disability and rehabilitation Where disease has already occurred and left residual damage PT of an affected limb to restore motion
Latest phase to be recognized as a result of the increasing knowledge of the epidemiology of specific disease (ex. Cardiovascular disease) The aim is to avoid the emergence and establishment of the social, economic and cultural patterns of living that are known to contribute to elevated risk of disease Ex. urban air pollution and its global effects (the greenhouse effect, acid rain, ozone depletion)
A national policy and program on nutrition involving the agricultural sector, the food industry, and the food import/export sector Non-smoking promotion policy A program for prevention of hypertension A program to promote regular physical activity
Prepathogenesis Period
Period of Pathogenesis
HEALTH PROMOTION
Good standard of nutrition adjusted to develop-mental phases of life Attention to personality development Provision of adequate housing, recreation, and agreeable working conditions Marriage counseling and sex education Genetics Periodic selective examinations
SPECIFIC PROTECTION
REHABILITATION
Provision of hospital and community facilities for retraining and education for maximum use of remaining capacities Education of the public and industry to utilize the rehabilitated As full employment as possible Selective placement Work therapy in hospitals Use of sheltered colony
Case-finding measures, individual and mass Screening surveys Selective Examinations Objectives: To cure and prevent disease processes To prevent the spread of communicable diseases To prevent complications and sequelae To shorten period of disability
Attention to personal hygiene Use of environmental sanitation Protection against occupational hazards Protection from accidents Use of specific nutrients Protection from carcinogens Avoidance of allergens
DISABILITY LIMITATION
Adequate treatment to arrest the disease process and to prevent further complications and sequelae Provision of facilities to limit disability and to prevent death
Primary Prevention
Secondary Prevention
Tertiary Prevention
Development of Disease Underlying conditions leading to causation Specific causal factors Early stage of disease
Phase of Prevention
Target Population
Primordial
Primary
Secondary
Tertiary
Patients
Goal of epidemiology
ID of causal factors serve as causal criteria for grouping of ill persons
Grouping of ill persons Arrangement of the disease entities into groups having common characteristics
Criteria ` Manifestational
Signs and symptoms Biochemical/physiologic/anatomic/behavioral changes A combination Ex. DM, musculoskeletal, mental retardation, cancer
Absence/lack of understanding of etiology, diseases are classified based on manifestations of the disease rather than by its etiology
Tuberculosis
International Classification of Diseases, 10th revision (ICD-10); assigning codes and classification of mortality data International Classification of Diseases, 10th revision, Clinical modification (ICD-10-CM); assigning codes to diseases, OPD, in-patients International Classification of Functioning, Disability and Health (ICF); approved May 22, 2001
Endorsed by WHA in 1990 (used in 1994) Latest in a series with its origin in 1850s First ed.: International List of Causes of Deaths
Organization/Year
Bertillon Classification of Causes of Death Intl Statistical Institute, 1893 International List of Causes of Death
5 revisions
WHO, 1948
WHO
10th revision
International standard diagnostic classification Diseases and other health problems are categorized into disease entities Assigns a three character alphanumeric code to every major condition. Often a fourth character is added for more exact specification
Ex. ICD C92 is myeloid leukaemia, which may additionally be specified as C92.0 (acute) or C92.1 (chronic). Broader groupings are readily formed Ex. ICD C81-C96 consists of all malignant neoplasms of lymphatic and haematopoietic tissue
Provide consensual, meaningful and useful framework which governments, providers and consumers can use as a common language Facilitate the storage, retrieval, analysis and interpretation of data for clinical and epi purposes Permit the comparison of data within populations over time and between populations at the same point in time as well as the compilation of nationally consistent data
Used for:
Monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected