Measurment of Health Edited PDF
Measurment of Health Edited PDF
Measurment of Health Edited PDF
disease
UNIVERSITY OF GONDAR
COLLAGE OF MEDICINE AND HEALTH SCIENCE
INSTITUTE OF PUBLIC HEALTH
DEPARTMENT OF EPIDEMIOLOGY AND
BIOSTATISTICS
Alemneh M. (BSc, MPH)
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Course objective
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Course contents
Chapter one: Introduction to public health
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Chapter Five: measurements of
association
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Chapter One
Introduction to Public health
Definitions of terms:
Health is a difficult concept to define.
WHO in 1948 defined health as “A state of complete
physical, mental and social well being and not merely
the absence of disease or infirmity.”
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Clinical versus community medicine:
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Methods of Community
Diagnosis:
Discussion with community leaders
and health workers
Survey of available health records
Field survey.
Compilation and analysis of the data.
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It is impossible to address all the identified
problems at the same time because of
resource scarcity.
Therefore the problems should be put in
the order of priority using a set criterion.
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Criteria for priority setting
Magnitude (amount or frequency) of the
problem
Severity (to what extent is the problem
disabling, fatal)
Feasibility (availability of financial and
material resource, effective control
method)
Community concern (whether it is a felt
problem of the community)
Government concern (policy support,
political commitment)
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Health p1 2 3 4
Magnitude
Severity
Feasibility
Community
concern
Gov’t
concern
Total
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EPIDEMIOLOGY
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Components of the
definition
“Population” the focus of epidemiology is
mainly on the population rather than
individuals.
“Frequency” shows epidemiology is
mainly a quantitative science.
Epidemiology is concerned with the frequency
of diseases and other health related
conditions.
Frequency of diseases and deaths are
measured by morbidity rates and mortality
rates.
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“Health related conditions” are
conditions which directly or indirectly
affect or influence health. These may be
injuries, vital events, health related
behaviors, social factors, economic
factors etc.
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The part of epidemiology concerned with
the frequency and distribution of diseases
by time, person and place is named
Descriptive Epidemiology.
.
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Determinants” are factors which
determine whether or not a person will get a
disease.
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Scope of Epidemiology
Originally, epidemiology was concerned with
epidemics of communicable diseases
and epidemic investigations.
Later it was extended to endemic
communicable diseases and non-
communicable diseases
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At present epidemiologic methods are
being applied to:
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Purpose/Use of
Epidemiology
The ultimate purpose of Epidemiology is
prevention and control of disease, in an effort
to improve the health status of populations.
This is realized through:
1. Elucidation of the natural history of disease
4. Evaluation of intervention
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Fundamental Assumptions in
Epidemiology
There are two basic assumptions in
epidemiology.
1. Non random distribution of diseases
i.e. the distribution of disease in human
population is not random or by chance
2. Human diseases have causal and
preventive factors that can be
identified through systematic
investigations of different populations.
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Risk factors could be:
Factors related to the agent: Strain difference
Factors related to the human host: Lack of
specific immunity.
Factors related to the environment:
Overcrowding, Lack of ventilation
Risk factors may further be classified as:
• Factors susceptible to change: smoking
habit, alcohol drinking habit
• Factors not amenable to change: age, sex,
family history
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In order to be able to prevent disease, it is
vital to identify factors that can be changed.
For some diseases, the specific causes are
not known. In such cases it is very
important to identify risk factors, especially
those that can be changed and act on them.
Epidemiology is mainly interested in those
risk factors that are amenable to change as
its ultimate purpose is to prevent and
control disease and promote the health of
the population.
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Chapter Two
Epidemiological concept of disease
causation
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HOW THE DISEASE IS CAUSED?
2. Ecological theory
3. Germ theory
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25
25
1. SUPERNATURAL THEORY OF DISEASE
• At least 10% of the people in developed countries
and 30% in developing countries still believe in
supernatural origin
• Even today superstitions are becoming major
obstacles in disease control
• Most of the literates view that disease is the result of
microbes
• Most of the uneducated people (90%) believe that
disease is due to bad physical environment
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26 26
2. ECOLOGICAL THEORY
• Around 463 BC, hippocrates is the first
epidemiologist who advised to search the
environment for the cause of the disease.
• Mckeown has pointed out, improved health
owes less to advances in medical science
than to the operation of natural ecological
laws
• He rightly advised to search air, water and
places for the cause of a disease
• In ecological approach an agent is
considered necessary but not sufficient
cause
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of a disease.
27
27
3. GERM THEORY
Germ theory: Microbes
(germs) were found to be
the cause for many known
diseases.
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1. The epidemiologic triangle
Agent
Host
Environment
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Epidemiological triad model con’t…
• An agent is a factor whose presence or
absence, excess or deficit is necessary for a
particular disease or injury to occur.
• General classes of disease agents include;
1. Chemicals such as benzene, oxygen, and
asbestos;
2. Microorganisms such as bacteria, viruses, fungi,
and protozoa; and
3. Physical energy sources such as electricity and
radiation.
• Many diseases and injuries have multiple agents.
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• The environment includes all external
factors, other than the agent, that can
influence health. These factors are further
categorized according to whether they
belong in the social, physical, or
biological environments.
• The social environment including
availability of medical care and health
insurance; cultural “dos” and “don’ts”
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• The physical environment:- climatic
conditions, pollution…
• The biological environment:- vectors,
humans and plants and animals acting as
a reservoir
• The host is the actual or potential
recipient or victim of disease or injury.
Although the agent and environment
combine to “cause” the illness or injury if
the host is not susceptible disease will not
occur.
• According to this model Disease and injury
occur only when the interaction between
the three factors is altered.
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2. The web of causation model
Hormones physical
inactivity
Smoking obesity
heredity
Blood clotting hardening of arteries
Heart disease stroke hypertension
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3. The Wheel model The wheel consists of a
hub (the host or human), which has genetic makeup
as its core. Surrounding the host is the environment.
The size of each part varies according to the type of
disease shown.
Social
Physical environment
environment
Host
(man)
vc
Genetic
core
Biologic
environment
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Natural History of Disease
and Levels of Prevention
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Natural history of disease
Is the course of a disease over time
without any treatment or
intervention.
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There are four stages in the natural
history of a disease.
These are:
Stage of susceptibility/exposure
Stage of pre-symptomatic (sub-clinical)
disease
Stage of clinical disease and
Stage of disability or death
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1. Stage of susceptibility
Disease has not yet developed, but there
are factors that favor its occurrence
Examples:
A person practicing casual and
unprotected sex has a high risk of
getting HIV infection.
An unvaccinated child is susceptible to
measles.
High cholesterol level increases the risk
of coronary heart disease.
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2.Stage of Pre-symptomatic
(sub-clinical) disease
In this stage there is no manifestation of
the disease but pathogenic changes have
started to occur.
There are no detectable signs or symptoms.
The disease can only be detected through
special tests.
Examples:
Detection of antibodies against HIV in an
apparently healthy person.
Ova of intestinal parasite in the stool of
apparently healthy children.
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3. The Clinical stage
By this stage the person has developed signs and
symptoms of the disease.
The clinical stage of different diseases differs in
duration, severity and outcome.
The outcomes of this stage may be recovery,
disability or death.
Examples:
Common cold has a short and mild clinical stage
and almost everyone recovers quickly.
Polio has a severe clinical stage and many patients
develop paralysis becoming disabled for the rest
of their lives.
Rabies has a relatively short but severe clinical
stage and almost always results in death.
HIV/ AIDS has a relatively longer clinical stage and
eventually results in death.
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4. Stage of disability or death
The disease has occurred and left
damage to the body that limits the
activity of the victim(disability) or has
ended with the death of the victim
Examples:
Trachoma may cause blindness
Meningitis may result in blindness,
deafness or death.
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Healthy person
Recovery
Clinical disease
Recovery Death
Disability
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Disease Prevention
The major purpose in investigating the
epidemiology of diseases is to learn how to
prevent and control them.
Disease prevention means to interrupt or
slow the progression of disease.
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Levels of disease prevention
1. Primary
health promotion
Prevention of exposure
Prevention of disease
2. Secondary prevention
Screening
Early detection and treatment
3. Tertiary prevention
Rehabilitation
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1. Primary prevention
Is aimed at preventing healthy people from
becoming sick.
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1.2 - Prevention of
exposure
is the avoidance of factors which may
cause disease if an individual is
exposed to them.
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1.3 - Prevention of
disease
Is the prevention of disease development
after the individual has become exposed
to the disease causing factors.
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2. Secondary prevention
Detecting people who already have the
disease as early as possible and treat
them.
It is carried out after the biological onset
of the disease, but before permanent
damage sets in.
The objective of secondary prevention is
to stop or slow the progression of
disease and to prevent or limit
permanent damage.
Examples:
Prevention of blindness from Trachoma
Early detection and treatment of breast
cancer to prevent its progression to the
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invasive stage
3. Tertiary prevention
Is targeted towards people with chronic
diseases and disabilities that cannot be
cured.
Tertiary prevention is needed in some
diseases because primary and secondary
prevention have failed, and in others
because primary and secondary prevention
are not effective.
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Tertiary prevention
cont’d
It has two objectives:
Treatment to prevent further disability or
death and
To limit the physical, psychological,
social, and financial impact of disability,
thereby improving the quality of life.
This can be done through rehabilitation,
which is the retaining of the remaining
functions for maximal effectiveness.
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Level of prevention Point of intervention
Natural history of disease
Primary Health promotion
Prevention of exposure
Clinical
onset
Early treatment
(prevention of permanent damage
)
Rehabilitation (prevention of
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Exercise -1
for each of the following intervention , indicate what
level of prevention is involved
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Thank you!
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CHAPTER THREE
Measurement of Disease and
Death
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Measurements of Disease
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Incidence Rate
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CI = Number of new cases of a disease
during a given period of time
X 1000
Total population at risk
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2. Incidence Density
An incidence rate whose denominator is calculated
using person-time units.
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2. Prevalence rate
Prevalence rate measures the number of
people in a population who have a disease
at a given time.
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1. Period prevalence rate
Period Prevalence rate measures the
proportion of a population that is affected with
a certain condition during a specified period of
time.
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Point Prevalence rate
Measures the proportion of a population
with a certain condition at a given point in
time.
This is not a true rate; rather it is a simple
proportion.
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Exercise 1
Each horizontal line in the next figure
represents one of 10 persons who had
giardiasis (a parasitic intestinal
infection which doesn’t confer
immunity against subsequent
infections) in a population of 100.
The date of onset and duration of
each episode indicated by a line of
X’s .the vertical lines indicate specific
dates.
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a. Population at risk for giardiasis on Jan 1, 1990
b. Incidence rate of giardiasis in 1990
c. Point prevalence rate of giardiasis on Jan 1 1990
d. The period prevalence of giardiasis in 1990
e. The point prevalence of giardiasis on July1, 1990
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• A=98
• B=6/98*1000=6.1per1000
• C=20per 1000
• D=80per 1000
• E=40per 1000
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Relationship between incidence and point prevalence
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Factors influencing prevalence
rate
a) severity of illness - for highly fatal
(lethal) diseases the prevalence rate is
low.
b) duration of illness - short duration of
disease leads to low prevalence rates.
c) the number of new cases - the higher
the number of new cases the higher will
be the prevalence.
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Prevalence can be increased by
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Prevalence can be
decreased by
Shorter duration of disease
High case - fatality rate
Decrease in new cases
In-migration of healthy people
Out-migration of cases
Improved cure rate of cases
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Prevalence rate is not a helpful measure to
provide strong evidence of causation and
risk of development of a disease.
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Incidence rate is important as
A fundamental tool for etiologic studies
of acute and chronic diseases
A direct measure of risk
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Limitations of prevalence
studies
Prevalence studies favor inclusion of
chronic over acute cases.
Disease status and attribute are measured
at the same time; hence, temporal
relations cannot be established.
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Measurements of Death
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Crude Death rate (CDR)
CDR= Total no. of deaths reported X
1000
during a given time interval
Estimated mid interval
population
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Age- specific mortality rate
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Sex- specific mortality rate
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Cause- specific mortality rate
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Proportionate mortality ratio
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Case Fatality Rate
CFR= No. of deaths from a sp. disease during a given
time x 100
No. of cases of that disease during the same
time
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Perinatal Mortality Rate
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Neonatal Mortality Rate
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Infant mortality rate
IMR= No. of deaths under 1 yr during a given time
X 1000
No. of live births in the same area& during
the same yr
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Child mortality rate
= No. of deaths of 1-4 yrs of age during a given
time X 1000
Average (mid-interval) population of same age at
same time
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Maternal Mortality Ratio
MMR=Total no of female deaths due to complications of
pregnancy,
child birth & puerprium in an area in a year x
100,000
No. of live births in the same area & year
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When calculating (using) mortality rates it is
important to understand their interpretations and
how they differ from each other.
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The case fatality rate asks the question: “what
proportion of the people with the disease
die of the disease?”
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SCREENING AND SCREENING
PROGRAM EVALUATION
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Definition
• Screening is the search for unrecognized disease or
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Case finding (diagnosis)
• Occurs when clinicians search for diseases with
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Objective of Screening Tests
• To lower morbidity and mortality of the
disease in a population.
• Screening provides access to the medical
care system which is not an actual goal of
screening, but is a benefit.
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An ideal screening test should be
1. Inexpensive,
2. Easy to administer,
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Validity of a screening test
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Sensitivity and Specificity of a screening test
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Test Definitive diagnosis
resul Diseased Non Total
t diseased
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• Sensitivity: The probability of testing
positive if the disease is truly present
Sensitivity = a / (a + c)
= TP X 100
TP+FN
• Specificity: The probability of screening
negative if the disease is truly absent
Specificity = d / (b + d)
= TN X100
TN + FP
• Accuracy= a+d/a+b+c+d
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Predictive Value of a Screening Test
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– Predictive Value of a Negative Test
(PVNT) or Negative Predictive Value
Shows the degree of confidence the
disease can be ruled out by using this
specific test.
PVNT = TN X 100%
TN+FN
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• Predictive value of a test is determined by
Sensitivity, Specificity and the Prevalence of the
disease.
• The higher the prevalence, the more likely it is that a
positive test is predictive of the diseases i.e. PVPT will
be high.
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Reliability (Precision) of Screening Test
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1. The variability of a method- depends
on such factors as the stability of the
reagents used and fluctuation in the
substance being measured ( e.g in
relation to meals, diurnal variation).
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Evaluation of screening program
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Feasibility
The feasibility of a screening program is
determined by
• The acceptability of the program to the
potential screenees,
• Cost-effectiveness,
• The subsequent diagnosis and treatment
of individuals who test positive,
• The yield of cases.
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Feasibility
Total screened
• Yield = TP X 100
TP + FN + TN + FP
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Effectiveness
The evaluation of the effectiveness of a
screening program must be based on
measures that reflect the impact of a
program on the course of a disease.
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Exercise Diagnostic(Gold
standard Test)
Positive Negative Total
350 50 400
Screeni Positive
ng Test
150 450 600
Negativ
e
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THANK YOU!
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CHAPTER FOUR
EPIDEMIOLOGIC STUDIES
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Epidemiological design
strategies
o Epidemiology is primarily concerned with the
distribution and determinants of disease in
human populations
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122 122
Epidemiologic approaches
1. DESCRIPTIVE
Used to describe health and disease in the
community
What? by….Who? When? Where?
What are the How many Over what Where do the
health problems people period of affected
of the community? are affected? time? people
live, work or
spend leisure
2. time?
ANALYTI
Used to identify etiology, prognosis and for
C Why? evaluation
program
How?
What are the causal By what
agents? mechanism
What factors affect
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operate? 123
outcome?
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124 124
Descriptive studies
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125 125
What?
Cases
Person Time
Place
Who? Where?
When?
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126 126
Category of descriptive
studies
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127 127
Case report
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129 129
Example 1:-
Both
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case report and case series are able to
132 132
Disadvantages of case reports and
series
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134 134
Strength
Can be done quickly and inexpensively, often using
available data.
environmental exposures, eg
- Do heat waves increase death rate?
- Does soft drinks increase heart disease?
- Do economic recessions increase suicide rate?
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135 135
Limitation
1. Inability to link exposure with disease.
- Data on exposure and outcome are not linked at the
individual level;
- Correlation found with aggregate data may not apply
to individuals (this is referred as ecological fallacy)
2. Lack of ability to control for effects of potential
confounding factors
- A correlation found between the high per capita
color TV and mortality from CHD, again here it is
obvious that color TV owning is not a good reason for
increased mortality from CHD
3. It may mask a non-linear relationship between
exposure and disease while it is exist
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136 136
Cross sectional study
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Cross-sectional studies
It is also called prevalence study (survey study)
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140 140
Advantages
Good design for hypothesis generation
Highly generalizable
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141 141
Disadvantage
Impractical for rare diseases and rare exposure – because we
need to take very large sample size
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142 142
Analytical Study
Designs
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143 143
Learning objectives
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144 144
Introduction to analytic
Application: studies
To search for cause - effect relationship and
mechanism
o Why?
o How?
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Analytic studies...
Observational studies
o An investigator observes the natural course of an
event
o An investigator measures but does not intervene
Interventional studies
o An investigator assigns study subjects to exposed
and non-exposed and follows to measure for
disease occurrence
o An investigator manipulates the intervention
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148 148
Observational analytic studies
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149 149
Case-Control Studies
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150 150
Definition of case-control
studies
A case control study is one in which persons
with a condition (“cases”) and suitable
comparison subjects (“controls”) are
identified, and then the two groups are
compared with respect to prior exposure to
risk factors
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151 151
Definition of case-control
studies…
o The investigator looks back in time to measure
exposure of the study subjects to the risk factors
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154 154
What is case?
o It is the outcome of interest under study
o It can be:
– A disease
E.g. HIV status, malaria status
– A behavior
E.g. Alcohol drinking habit(yes/no),
cigarette smoking(yes/no)
- Event – traffic accident
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155 155
What is control?
o It is the comparison group (reference)
under study)
– Incidents cases
–11/14/19
Chronic/prevalent cases
157 157
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158 158
Measuring exposure of
interest
o Exposure status could be ascertained by interview
(patient, relative), hospital records, laboratory
analysis etc…
o May include analysis of pre-diagnostic biological
specimens (nested case-control approach)
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159 159
Common bias in case-control
studies
o Information bias
- recall bias
- non-response bias
o Selection bias
controls
- the probability of selecting a real case and
control
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160 160
Strengths of case-control studies
o To investigate rare disease (less than 10%)
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163 163
Learning objectives
o Immigration cohort
o Treatment cohort
o Exposure cohort
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165 165
Definition of cohort studies
A cohort study is an observational research design
which begins when a cohort initially free of disease
(outcome of interest) are classified according to a
given exposure and then followed (traced) over time
The investigator compares whether the sub-sequent
development of a new cases of disease (other
outcome of interest) differs between the exposed and
non-exposed cohorts
For example if a researcher want to investigate
weather drinking more than five cup of
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166 166
Design of cohort studies
= == > If we want to know weather exposure to
drinking coffee during pregnancy will result in abnormal
birth Diseased
Exposed Give abnormal
Drink more baby
than five cup of
Coffee per day Not diseased
People
without Give normal baby
Population
at risk the Diseased
outcome Not Exposed Give abnormal
Pregnant baby
Not drink
mothers any coffee
Not diseased
Give normal baby
Time
Direction of enquiry
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167 167
Basic features of cohort studies
“Disease free” or “without outcome” population at entry
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168 168
Types of cohort studies
Cohort studies can be classified depending
on the temporal relationship between the
initiation of the study and the occurrence of
the outcome of interest
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169 169
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170 170
1. Prospective cohort studies
o Study participants are grouped on the basis of past
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171 171
2. Retrospective cohort studies
o What
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173 and
173
Which type of cohort studies
should be used?
The decision to conduct a retrospective or
prospective study depends on:
–
o Exposure is any risk factor that can associated with the
interview
o Death certificate
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176 176
Follow up period of cohort studies
o The follow-up is the most critical and demanding part
of a cohort study.
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178 178
Strength of cohort studies:
o Particularly efficient when exposure is rare
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179 179
Limitation of cohort studies:
o Costly and time consuming if disease is rare and/or
records
o Exposure status may change during the course of
study
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180 180
Experimental
(Intervention studies)
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Definition
An experiment is a set of
observations,
conducted under controlled
circumstances,
in which the scientist
manipulates the
conditions to ascertain what
effect such
manipulation has on the
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Key Features of
Experimental Design
1) Investigator manipulates
the condition under study
2) Always prospective
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Types of intervention studies
Eligible B P
R
Individuals With
outcome
Not-
received
Without
Interventi outcome
on
R=randomization B=double blinding P=placebo
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Prevention Trial
With
outcome
Vaccinate
d Without
outcome
Health B P
R
Individuals With
Not- outcome
Vaccinate
Without
d outcome
C.1 Phase I
Trial on small number of subjects to
test a new drug with small dosage to
determine the toxic effect
C.2 Phase II
Trial on small group of people to
determine the therapeutic effect
C.3 Phase III
• Study on large population
• Usually randomized controlled trial
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Problems of intervention studies
1. Ethical problem
• An independent group must be
established.
• Purpose:
– Safety of subjects
– Maintaining the quality of the study
– Maintain objectivity
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2)Cost
• Loss to follow-up
– Select population who are both interested and reliable.
– Arrange frequent contacts with individuals
– Use incentives, such as providing medical information
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Main steps in an RCT
1. Identify new
drug/intervention/prevention
2. Identify comparison – e.g standard
treatment versus placebo
3. Define eligible patient population/
exclusions (i.e the sampling frame)
4. Define the outcomes and how to
assess them
5. Write the protocol
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Main steps in an RCT cont…
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Assessment of
compliance
• Self-report
• Pills count
• Biochemical tests
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Stopping Rules
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The Quality of “Gold
Standard"
• Randomization
• Blinding
• Use of Placebo
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Chapter Five
MEASURES OF ASSOCIATION
AND EVALUATION OF EVIDENCE
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Learning objectives
• After the end of this session, students will
be expected to:
– List common measures of association and
measures of public health impact
– Calculate and interpret
• relative risk
• odds ratio
• attributable and population attributable risk
and their percent
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Definition of association
An association is said to exist between two
variables when a change in one variable parallels
or coincides with a change in another ones
An association is said to be causal when it can be
proved that a change in the exposure variable
produces a change in the outcome variable
More appropriately, a causal relationship exists
when exposure enters into the causation of disease
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o Statistical relationship between two or
more variables
o A causal association exists when the risk
factor causes change in the disease
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Measuring an association
Quantifies the strength of the relationship
between an "exposure" and “outcome” of
interest
Quantifies the difference in occurrence of
disease or death between two groups of
people who differ on “exposure status”
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Two main options for comparison
Calculate ratio of two measures of
disease frequency
o Relative comparison
o Strength of relationship between
exposure and outcome
Calculate difference between two
measures of disease frequency
o Absolute comparison (attributable risk)
o Public health impact of exposure
(population attributable risk)
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How strong is the association?
The strength of the association is
commonly measured by the relative risk,
odds ratio, attributable risk and population
attributable risk and their percents
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1. Relative Risk (RR) or Risk Ratio
RR shows the magnitude of association
between exposure & disease
Indicates the likelihood of developing the
disease in exposed group relative to those
who are not exposed
RR can also be used to compare risks of
death, injury, and other possible outcomes
of the exposure.
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.
RR Incidence of a disease among exposed (a/
(a+b))
= Incidence of a disease among non-
exposed (c/(c+d)) Disease
. a .
Yes (+)
Exposu
RR = a+b re
Noa(-) b
a+
Yes (+)
.
b
.
.
.
c .
.
c d
c +d No (-) c+
d
– It is a direct measurement of a risk to
develop the outcome of interest
– It is usually used in cohort and
experimental studies
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209
Example
Table 1: data from a cohort study of oral
contraceptive (OC) use and bacteruria
among women aged 16-49 years
Bacteruria
Yes No Total
Current OC use
Yes 27 455 482
No 77 1831 1908
Total 104 2286 2390
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Calculate RR??????? Ans:- 1.4
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Interpretation
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• Values of RR less than one 1 indicate a
negative association between the risk
factor and the disease.(i.e. protective )
• In general the strength of association can
be considered:
• High - if the RR is 3.0 or more
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2. Odds Ratio (OR)
o Odds: The ratio of the probability of an
event's occurring to the probability of its
not occurring
o Odds Ratio: The ratio of two odds
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Cont’d…
In case control studies, it is usually not possible
to calculate the rate of development of disease
in the exposed and non-exposed group.
Hence, it is difficult to calculate the RR.
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• Odds Ratio: Odds of case being
exposed
Odds of control being exposed
OR = a/c = ad
b/d bc
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Example
Table 3: Data from a case-control study of
current oral contraceptive (OC) use and MI in
pre-menopausal female nurses
Myocardial infarction
Yes No Total
Current OC use
Yes 23 304 327
No 133 2816 2949
Total 156 3120 3276
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Calculate OR
OR = ad = (23) (2816) = 1.6
bc (304) (133)
11/14/19 218
Interpretation of the Odds
Ratio…
• OR = 1 then exposure Not related to
disease
• OR >1 then exposure Positively
related to disease
• OR <1 then exposure Negatively related
to disease
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Interpretation
• The odds of having the disease in question
are OR times greater among those
exposed to the suspected risk factor than
among those with no such exposure.
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Exercise
• Suppose study was conducted in US in order to find
out weather mother’s use of hormone during
pregnancy influenced her son’s risk of testicular
cancer in later life. Investigator selected 500 peoples
with cancer and 1000 without cancer. The study
found 90 mothers in cases and 50 mothers in controls
had used hormones during pregnancy.
• What study design were used
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Odds Ratio as estimator of
Relative Risk
OR is a valid estimator of RR if:
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• What is the excess risk among
exposed individuals?
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Absolute Measures of Risk
o Absolute risk: a measure of association
indicating on an absolute scale how much
greater the frequency of diseases is in an
exposed group than in an unexposed group,
assuming the association between the
exposure and disease is causal
o Attributable risk is also known as risk
difference or excess risk among exposed
groups
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Attributable Risk (AR) / Risk
Difference (RD)
Provides information about the absolute effect of
the exposure or the excess risk of disease in those
exposed compared with those non exposed.
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Cont’d…
AR=0 no association
AR > 0 indicates positive association
the number of cases of the disease among
the exposed that can be attributable to
the exposure itself, or
alternatively, the number of cases of the
disease among the exposed that could be
eliminated if the exposure were eliminated
Thus, the AR can be useful as a measure
of the public health impact of a
particular exposure.
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• What proportion of cases is
attributed to the actual exposure
among exposed people?
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Attributable Risk Percent (AR
%)
Estimates the proportion of the disease among
the exposed that is attributable to the exposure,
or
• AR % = 1566/100,000 X 100
27/482
= 27.96 %
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Population Attributable Risk
(PAR)
Public health planners want to be able to
anticipate the effect of eliminating the
exposure on the population as a whole,
rather than just on the exposed part of the
population.
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• PAR = AR X prevalence rate of the
exposure
Interpretation:
In a population of 100,000 smokers, 18 deaths from
lung cancer per year could have been avoided by
preventing them from smoking (this refers to AR).
In a general population of 100,000 with a prevalence
rate of cigarette smoking of 20 %, about 18 deaths
from lung cancer per year would be prevented by
eliminating cigarette smoking (this refers to PAR).
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Both AR and PAR are used to estimate the
effect on disease incidence of eliminating a
given risk factor, but while AR estimates
reduction in disease incidence only in
those exposed, PAR estimates
reduction in disease incidence in the
population as a whole.
The alternative formula for PAR is:
PAR = Incidence rate in total population
minus incidence rate in non-exposed
population
PAR = IT - Io
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• What proportion of cases is
attributed to the actual exposure
among the general population?
11/14/19 240
Population Attributable Risk
Percent (PAR %)
Expresses the proportion of disease in the study
population that is attributable to the exposure and
thus could be eliminated if the exposure were
eliminated.
PAR% is the percent of the incidence of a disease in
the population (exposed and non exposed) that is
due to exposure.
PAR % = PAR X100
incidence rate in total population
Example:
PAR = 17.8 per 100,000 per year
Mortality rate in non-smokers = 7 per 100000
Mortality rate in the total population = 24.8 per 10 5
per year
Calculate PAR %
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• PAR % =17.8 per 105 per year X100
24.8 per 105 per year
=71.8%
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Possible Outcomes In Studying The
Relationship Between Disease And
Exposure
1. No association between exposure and
disease
AR=0, RR=1 ,OR=1
2. Positive association between exposure
and disease (more exposure, more
disease)
AR>0, RR>1 ,OR>1
3. Negative association between exposure
and disease
(more exposure, less disease)
AR<0 (negative), RR
<1(fraction)OR<1
11/14/19 243
Exercise
There is some hint that coffee drinking causes
peptic ulcer. One epidemiologist wanted to
make sure whether this is true.
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EVALUATION OF EVIDENCE
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Brain storming
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Association Vs Causation
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Accuracy
=
Validity + precision
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Validity of epidemiological studies
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Types of validity
Internal validity:
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Precision
Precision measures the extent by which our study
result is similar (consistent) with other previous
studies published on the area by different scholars
in different population, area and methods.
Precision is the extent to which random error alters
the measurement of effects
Threats to validity of study:
- Random error (chance): is sampling error
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The Bradford Hill Criteria
o It is the statement of epidemiological criteria
of a causal association formulated in 1965 by
Sir Austin Bradford Hill
1. Strength of association
2. Consistency of findings with other studies
3. Temporality
4. Biologic gradient
5. Biologic plausibility
6. Specificity of the association
7. Experimental evidence
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Bradford……….
1. Strength of the Association - The stronger the
association, the more likely that it is causal.
2. Consistency of the Relationship - The same
association should be demonstrable in studies with
different methods, conducted by different
investigators, and in different populations.
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
This works more to most living organisms as causes.
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Bradford…….
11/14/19 257
7. Biological plausibility
Hypothesis should be coherent with what is
known about the disease; both biologically
and using laboratory.
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Which Hill’s criteria are essential?
There are no completely reliable criteria for
determining whether an association is causal or not
In judging the different aspects of causation; not all
criteria must be fulfilled to establish scientific
causation
The correct temporal relationship is more essential
risk factor/cause ---------------------
outcome/effect
=== Once this has been found, weight should be
given to:
– Strength of the association
– Biologic plausibility
– Consistency
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– Dose-response relationship
CHAPTER SIX
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Learning Objectives
After this session, students will be expected to:
system
Systematic, ongoing…
– Collection
– Analysis Health action
– Interpretation
investigation
– Dissemination
…of health outcome control
data prevention
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Components of Surveillance and
Public Health Action
Public Health
Component of Action
Surveillance Priority setting
o Collection Planning,
o Analysis implementing and
o Interpretation
evaluating disease
o Dissemination
occurrence in that
community
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Purpose of Surveillance
I. To be able to identify diseases, injuries,
hazards and other health related factors as
early as possible. prediction and early
detection of outbreaks.
II. To provide scientific baseline data and
information for priority setting, planning,
implementing and evaluating disease
control program for both communicable
and non-communicable health problems.
III. To define the magnitude and distribution of
diseases by time, person and place
dimension
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Types of Surveillance
1. Active surveillance
2. Passive surveillance
3. Sentinel surveillance
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Active Surveillance
activities
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Preconditions to institute an active surveillance
system.
For periodic evaluation of an ongoing program
For programs with limited time of operation such
as eradication program.
In unusual situations such as .
– New disease discovery
– New mode of transmission
– When a high-risk season/year is recognized.
– When a disease is found to affect a new
subgroup of the population.
– When a previously eradicated disease reappears
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Passive Surveillance
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Sentinel Surveillance Con’t...
The advantages of sentinel surveillance data are
that they can be less expensive to obtain than those
gained through active surveillance of the total
population, and the data can be of higher quality
than those collected through passive systems.
In developing countries, sentinel surveillance
provides a practical alternative to population-based
surveillance
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Main Purposes of Sentinel Surveillance
To detect changes
11/14/19 273
Advantages of sentinel surveillance
Relatively inexpensive
Provides a practical alternative to population-
based surveillance
Can make productive use of data collected for
other purposes
Disadvantages:
The selected population may not be
representative of the whole population
Use of secondary data may lead to data of lesser
quality and timeliness
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Process of Public Health Surveillance
11/14/19 275
Criteria for selecting and prioritizing health
conditions for surveillance system
includes:
Public health importance of the problem:-
• incidence, prevalence,
• severity, sequela, disabilities,
• mortality caused by the problem,
• socioeconomic impact,
• communicability,
• potential for an outbreak,
• public perception and concern, and
• international requirements.
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If disease has epidemic potential
If required internationally
programs
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Basic Principles of Surveillance
11/14/19 278
Elements of Surveillance
• Case definition
• Cycle of surveillance
• Confidentiality
• Incentives
11/14/19 279
A) Case Definition
11/14/19 280
Standard case definition
If the use of case definition is agreed by
everyone in the country or across boundaries
or continents it is standard case definition
o Surveillance using less specific criteria is
sometimes referred as syndromic surveillance
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Types of Case Definition
Confirmed case
o A case with laboratory verification
Probable case
o A case with typical clinical features of the
disease without laboratory confirmation
Suspected case/possible
o A case presented with fewer of the typical
clinical features of the disease without
laboratory confirmation
11/14/19 282
Advantages of Case Definition
1) Facilitate early detection and prompt
management even if diagnosis is not
confirmed by laboratory
3) Observation of trends
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B) Population Under Surveillance
11/14/19 284
C) Cycle of Surveillance
11/14/19 285
D) Confidentiality
• Personal identifying information is necessary to:
11/14/19 287
Public Health Emergency Management (PHEM)
Public health emergencies are events or disasters that
threaten the health of communities at large
11/14/19 290
Preparedness
Actions taken before an emergency to prepare for
response
11/14/19 291
Response
Activities to address immediate and short-
term effects of a disaster
– Implement emergency management plan
o Save lives
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Recovery
Restore essential functions and normal operation
community
11/14/19 293
Limitations of Surveillance System In Ethiopia
o Under reporting
o Lack of representativeness
o Lack of timeliness
o Lack of motivation
11/14/19 294
List of Priority Reportable Diseases In Ethiopia
11/14/19 296
Learning objectives
After the end of this session, students will be able to:
11/14/19 297
Level of disease
occurrences
• Diseases occur in a community at different levels at a
particular point in time.
Occurrence at expected levels
• Endemic: Presence of a disease at more or less stable level.
--==Malaria is endemic in the lowland areas of Ethiopia.
• Hyper endemic: Persistently high level of disease occurrence.
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Excess of what is expected
• Epidemic: The occurrence of health related
condition/disease in excess of the usual frequency
• Outbreak: Epidemics of shorter duration covering
a more limited area.
• Cluster: is an aggregation of cases in a given area
over a particular period without regard to whether
the number of cases is more than expected.
• Pandemic: An epidemic involving several
countries or continents affecting a large number
of people.
example : HIV/AIDS is a pandemic.
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What is outbreak
occurrence?
11/14/19 300
What does outbreak
investigation & control?
It is the process of identifying:
o The cause of the epidemic
11/14/19 302
What are the objectives for
outbreak investigation? Or reason
to investigate
1)To initiate control & prevention measures/to
evaluate existing preventive strategies i.e.
vaccine
The most important public health reasons for
investigating an outbreak are to help guide disease
prevention and control strategies.
These disease control efforts depend on several factors,
Including
knowledge of the agent,
The natural course of the outbreak,
The usual transmission mechanism of the disease,
and
Available control measures
11/14/19 303
2) Research and training
opportunity
o Each outbreak should be viewed as an experiment
waiting to be analyzed
o It presents a unique opportunity to study the
natural history of the disease
o It could be a good opportunity to gain additional
knowledge on
– The impact of prevention and control measures
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3) Public, political and legal
obligations
o Politicians and leaders are usually concerned with
control of the epidemic or address public concern
about the outbreak.
o Politicians and leaders may sometimes override
scientific concerns
o The public are more concerned in cluster of
disease and potentials of getting medication
o It is the right of the community to get
treatment/service and it is government and our
11/14/19 305
duty to protect the community
4) Program
considerations
o Occurrence of an outbreak notifies the
presence of a program weakness
o This could help program directors to change
or strengthen the program’s effort in the
future to prevent potential episodes of
outbreak occurrence
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Goals of investigation
Identify the etiologic agent
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1. Common source
It occurs as a epidemic
result of the exposure of a group of
population to a common source (etiological agent)
o It can result from a single source/ exposure of
the population to the agent
E.g: contaminated water supply, or food in a
certain restaurant
Three types
1. Point common source
2. Continuous common source
3. Intermittent common source
11/14/19 309
A) Point common source
epidemic
o Single/ones/limited time exposure to the source
o All exposed hosts will develop disease within one
incubation period
o The epidemic usually decline after a few
generations, either because the number of
susceptible hosts fall below some critical level, or
because intervention measures become effective
o A rapid rise and gradual fall of an epidemic curve
suggests a point source epidemic
11/14/19 310
E.g. Food borne outbreak in a
wedding feast
Commonly due to
infectious diseases or
May be from
environmental
pollution Features of epidemic curve:
1-Rises and falls rapidly, no
secondary waves.
2-Tends to be explosive, with
clustering of cases within narrow
interval of time. 3-All cases
develop within one incubation
period.
11/14/19 311
B) Continuous common source
epidemic
If exposure to a common source continues over
time for days, weeks
The epidemic curve has a plateau (multimodal
epi curve)/ long peak
Range of exposures and range of incubation
periods is different
1-The exposure from the same
source may be prolonged-
continuous, repeated or
intermittent
2-No explosive rise in number
of cases.
3-Cases occur over more than
one incubation period.
11/14/19 312
C) Intermittent common source
epidemic
11/14/19 313
2. Propagative /progressive
o
epidemic
It occurs as a result of transmission of an
infectious agent from one person to another
directly or indirectly
o There is a successive generations of cases
11/14/19 315
Typical Propagated Epidemic Curve
Of infectious origin, with person to person transmission (hepatitis A,E and polio epidemics).
Gradual rise and tails off over longer period of time. Transmission continues till depletion of
susceptible or susceptible individuals are no longer exposed to source of infection. Communicability
(speed of spread) depends on herd immunity among exposed and opportunities for contact with
infective dose and secondary attack rate.
11/14/19 316
3. Mixed Epidemic
o It shows the features of both types of epidemics
11/14/19 317
11/14/19 318
Steps of outbreak investigation and control
1.Prepare to field work
2.Establish the existence of outbreak
3.Verifying the diagnosis
4.Case definition and case finding
5.Perform descriptive epidemiology
6.Formulate hypotheses
7.Testing hypotheses
8.Refine hypothesis and additional studies
9.Implementing prevention and control activities
10.Communicate findings
In practice, however, several steps may be done
at the same time, or
The circumstances of the outbreak may dictate
that a different order be followed
11/14/19 319
Step 1: Prepare for field
work
Before leaving for the field, an investigator
must be well prepared to under take the
investigation:
o Investigation (Knowledge in epidemiology
and the disease of concern is important)
o Administrative (Logistics, administrative
procedures, travel arrangements)
o Consultation (Health workers should know
their role, and should participate in the
planning phase)
11/14/19 320
Step 2: Establish the existence of
outbreak
o An outbreak is the occurrence of more cases of
disease than expected level
o The investigator has to compare previous case
load with the current to assure the existence
of the outbreak
o But be careful, excess cases may not always
indicate an outbreak occurrence rather it may
be because:
Change in population size
Change in case definition
Change in reporting procedure
11/14/19 321
Step 3: Verifying the diagnosis
o The initial report may be spurious and arise from
misinterpretation of the clinical features
o Review clinical and laboratory findings to establish
diagnosis
o Goals in verifying the diagnosis includes:
11/14/19 322
Step 4: A. Case definition and
case finding
• Define cases ( Establish case definition):
11/14/19 323
Step 4: Case definition and case
finding Cont…d
11/14/19 324
Define cases ( Establish case definition):
1)Possible (suspected)
Having fewer sign and symptoms
2) Probable
Having typical sign and symptoms
3) Definite (confirmed)
Laboratory confirmed
Example : A patient hospitalized in the ICU from
24th November 2017, with new or worsening of
cough, Fever >38, with suggestive X-ray changes
and cultures identify a respiratory microorganism.
11/14/19 325
B. Identify cases (line listing)
o Identifying information
e.g. Hospital admission number, unit, name, address,
phone.
o Demographics
e.g. Age, sex, date of admission, date of surgery.
o Risk factor information
e.g. Type of surgery, co morbidity, catheters, implants
o Clinical data
• e.g. Onset of symptoms and signs, frequency and
duration of clinical features, treatments, devices, etc
11/14/19 326
11/14/19 327
Step 5: Performing Descriptive
Epidemiology
o Once data is collected, it should be analyzed by time, place and
person
11/14/19 328
1. Analysis of epidemic by time
11/14/19 329
Epidemic curve
Point source
11/14/19 330
2. Analysis of epidemic
byisplace
– A spot map a simple and useful
technique for illustrating where cases
live, work or may have been exposed
– Area map if large area is affected
11/14/19 331
John Snow’s spot map of the distribution of cholera
cases Golden London square August-September 1848
11/14/19 332
3. Analysis of epidemic
by person
o Characterizing an outbreak occurrence by person is how we
determine what populations are at risk for the disease
o Host characteristics: age, race, sex, or medical status and
exposures-occupation, leisure activities, use of medications,
tobacco and drug use etc…
o These influence susceptibility to disease and opportunities
for exposure to risk factors
o We use attack rates to identify high risk groups
11/14/19 333
Attack rate
11/14/19 334
Step 6: Formulating Hypothesis
Depending on the outbreak, the hypothesis may address
o The exposures that caused the disease
o The agent and its reservoir
o Risk factors that caused disease
o The mode of transmission
Using :
1. Subject-matter knowledge
2. Descriptive epidemiology
3. Talking with patients
4. Talking with local officials
The hypotheses should be testable
11/14/19 335
Step 7: Testing the hypothesis
Evaluate the credibility of your hypotheses
11/14/19 336
Factors that should also be
considered when evaluating
possible causality:
• Testing statistical significance
• Consistency with other studies
11/14/19 337
Step 8: Refining hypotheses and
o
additional studies
When analytic epidemiological studies do not confirm
11/14/19 338
Step 9: Implementing control and
prevention
In outbreak investigation, the
primary goal is to control and
prevent the outbreak.
Implementing control measure
should be done as soon as possible
It should go in parallel to
investigating the outbreak
11/14/19 339
Source/ Mode of Transmission
Causative
Agent
11/14/19 340
Control measures (do early)
1. Measures Directed Against the Reservoir:
– Reduce contact rate
– Reduce infectious sources- destruction of infected animal
/isolation
– Reduce infectiousness- early treatment
- Immunization
11/14/19 342
DAY
11/14/19 343
Step 10: Communicating
findings of investigation
The final responsibility of the investigative team is to prepare a written report to document the
investigations, findings and the recommendations
The written report should follow the scientific reporting format which includes:
o introduction
o methods
o results
o discussion
o conclusion, and
o Recommendations
11/14/19 344
Summary of the investigation and control
of an epidemic considering procedure
11/14/19 345
Post-Epidemic
Surveillance
o The efficacy of control measures should be assessed day to
day during the outbreak, a final assessment being made
after it has ended
o This will provide a logical basis for post-epidemic
surveillance, and preventive measures aimed at avoiding
similar outbreaks in the future
o Develop long term early warning system
11/14/19 346
The End!
11/14/19 347