Debre Markos University College of Health Science Department of Public Health Epidemiology For 2 Year BSC in Medical Laboratory Science Students by Mengistie Kassahun (MPH in Field Epidemiology)

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Debre Markos University

College of Health Science


Department of Public Health
Epidemiology for 2nd year BSc in Medical
Laboratory Science
students
By
Mengistie Kassahun(MPH in Field
Epidemiology)

July, 2021
Debre Markos,
Ethiopia
.

Natural history of diseases


Natural history of diseases
• The natural history of disease refers to the
progression of a disease process in an individual
absence of intervention
over time, in the
Stages in the natural history of disease
stages in the natural history of a disease
There are four stages in the natural history of a disease.
1. Stage ofsusceptibility
2. Stage ofpre-symptomatic (sub-clinical) disease
3. Stage ofclinical disease and
4. Stage ofdisability or death
Stage ofsusceptibility
 In this stage, disease has not yet developed ,
 but the groundwork has been laid by the presence of
factors that favor its occurrence.
 Examples:
 A person practicing casual and unprotected sex has a
high risk of gettingHIV infection.
 Anunvaccinated child is susceptible to measles.
Stage of Pre-symptomatic (sub-clinical) disease
 In this stage there isno manifest disease but
pathogenic changes have started to occur.
 There are no detectable signs or symptoms.
 The disease can only be detected through special
tests.
 Example:
Detection of antibodies against HIV in anapparently
healthy person.
Stage of Pre-symptomatic…
 Ova of intestinal parasite in the stool of apparently
healthy children
 The pre-symptomatic (sub-clinical) stage may lead to
the clinical stage, ormay sometimes end in recovery
without development of any signs or symptoms
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
The Clinical stage…
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
Stage of disability or death
 Some diseases run their course and thenresolve
completely either spontaneously or by treatment.
 In others the disease may result in a residual defect,
leaving the persondisabled for a short or longer
duration.
 Still, other diseases will end indeath .
Stage of disability or death
 Disability is limitation of a person's activities including
his role as a parent, wage earner, etc…
Examples
 Trachoma may cause blindness
 Meningitis may result inblindness ordeafness .
 Meningitis may also result indeath .
. Healthy person

•.
Sub clinical disease

Recovery
Clinical disease

Recovery Death
Disability
Levels of Disease Prevention
• Disease prevention means to interrupt or slow
the progression of disease

• Epidemiology plays a central role in disease


prevention by identifying those modifiable
causes.

• There are three levels of prevention


1. Primary prevention
• The main objectives of primary prevention are
promoting health, preventing exposure and preventing
disease
• keeps the disease process from becoming established
by eliminating causes of disease or increasing
resistance to disease
• Has 3 components.
A. Health promotion:- consists of general non-specific
interventions that enhance health and the body's ability to
resist disease
• Improvement of socioeconomic status, provision of
adequate food, housing, clothing, and education are
examples of health promotion
Primary prevention…
B. Prevention of exposure:- is the avoidance of
factors which may cause disease if an individual
is exposed to them.

• Examples can be provision of safe and


adequate water, proper excreta disposal, and
vector control
Primary prevention…
C. Prevention of disease:- is the prevention of
disease development after the individual has
become exposed to the disease causing factors
• Immunization is an example of prevention of
disease.
• Immunization acts after exposure has taken place
• Immunization does not prevent an infectious
organism from invading the immunized host, but
does prevent it from establishing an infection.
• If we take measles vaccine, it will not prevent the
virus from entering to the body but it prevents the
development of infection/disease
2. Secondary prevention
• its objective is to stop or slow the progression of
disease so as to prevent or limit permanent damage.
• It can be achieved through detecting people who
already have the disease as early as possible and
treat them.
• It is carried out before the person is permanently
damaged.
• Examples:
• Prevention of blindness from Trachoma
• Early detection and treatment of breast cancer to
prevent its progression to the invasive stage, which is
the severe form of the disease
3. Tertiary prevention
• is targeted towards people with permanent
damage or disability.
• It is needed in some diseases because primary and
secondary preventions have failed, and in others
because primary and secondary prevention are not
effective.
• It has two objectives:
1. Treatment to prevent further disability or death
2. To limit the physical, psychological, social, and
financial impact of disability
It can be done through rehabilitation
Retraining of the remaining functions for maximal
effectiveness.
Tertiary prevention…
• Example: When a person becomes blind due to
vitamin A deficiency, tertiary prevention
(rehabilitation) can help the blind or partly blind
person learn to do gainful work and be
economically self supporting.
.

Screening
Learning objectives
• Define screening

• Identify types of screening

• Identify Criteria of screening

Identify and describe factors affecting validity


and reliability of screening tests
Screening
The presumptive identification of unrecognized
disease or defect by the application of tests,
examinations, or other procedures which can be
applied rapidly in apparently healthy individuals
A screening test is not intended to be diagnostic
Screening is an initial examination only, and positive
responders require a second, diagnostic examination
Definition

Screening

24
Diagnostic test Vs screening test
Screening tests
are tests done in individuals with no such 
symptoms or signs

Diagnostic tests

tests performed in persons with a symptom  or a
sign of an illness

25
Differentiate Between Screening and
Diagnostic Tests
Screening Diagnostic
Asymptomatic Suggestive clinical
picture
Large group Single subject
Less accurate Accurate
Not conclusive Conclusive
Less expensive Expensive
Not basic for treatment Basic to treatment
26
Uses of Screening
Uses of Screening

Case Detection Perspective Screening

Case / Disease Control Prospective Screening

Research Natural History of Disease

Health Education Public Awareness

27
Purpose of Screening
Reducing disease burden

Classifying people to likelihood of having a particular


disease

Means of identifying high risk groups who warrant further


evaluation

28
Aims of screening program
Changing disease progression efficiently

Altering natural course of disease

Protecting society from contagious disease

Allocating resources rationally

Selection of healthy people for job

Studying the natural history of disease

29
Principles for Screening Programs
1. Condition should be an important health problem
2. There should be a recognizable early or latent
stage
3. There should be an accepted treatment for persons
with condition
4. screening test is valid, reliable, with acceptable
yield
5. The test should be acceptable to the population to
be screened
6. Cost of screening & case finding should be
economically balanced in relation to medical care
as a whole
8/12/2021 30
Criteria for selecting diseases for screening

Severity- The disease should be serious

Treatment- Early treatment should be more


beneficial

Prevalence- Pre-clinical Prevalence should be


high

31
Criteria For Successful Screening Test:
Criteria for Disease:
Present in population screened
High burden & of high public health concern
Screening +Intervention must improve outcome
Known natural history of the disease

32
Criteria For Successful Screening Test:
Criteria for Test:
Reliable
Valid
Simple and inexpensive
Very safe
Acceptable to subjects and providers
Cost-effective
Exit strategy
33
Criteria For Successful Screening Test:
 Exit strategy:
 Facilities for diagnosis and appropriate
treatments should be available for positive
subjects
 Ethically not acceptable to offer screening
without available management

34
Criteria For Successful Screening Test:
Definition of Reliability:
• Repeatability, Precision
• Getting the same results, when the test
repeated in same target individuals in the
same settings

35
Criteria For Successful Screening Test:
Causes of unreliability:
• Observer variation
• Subject variation – Biological
• Technical method variation

36
Criteria For Successful Screening Test:
ACCEPTABILITY :
• The test should not be:
• Painful
• Unsafe
• Discomforting /Embarrassing
• Socially/ believes not accepted

37
Criteria For Successful Screening Test:
VALIDITY:
Ability of the test to distinguish between who
has the diseases and who does not

38
Types of screening
1. Selective Vs Mass.
Selective – screening of people with selective exposure
Mass – screening of people without reference to specific
exposure
2. Multiple-Parallel Vs Series
Parallel testing – applying two screening tests and a positive
result on either test is sufficient to be labeled as positive
 These tests are given concurrently
E.g. – Breast cancer screening
 Results in
- greater sensitivity
- increased PVN
-decreased specificity
39
Cont’…

Serial testing – applying two screening tests


and both must be positive in order to prompt
action
 These tests are administered sequentially
 Increase specificity of the test
E.g. – HIV testing, Syphilis

40
Validity of a categorical test: four possible
relationships b/t a diagnostic test & actual
presence of disease
Screening Disease status or Diagnostic test
or Reference Test
Test result (Gold standard)
Positive Negative
Positive True + (a) False + (b) ?
Negative False - (c) True - (d)
?

? ?
Definitions of cells

True positives (a): Diseased identified by test as


diseased

False positives (b): Disease free falsely labelled as


disease

False negatives (c): Diseased falsely labelled as


disease free

True negatives (d): Disease free identified as free


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Definition of totals
D+ (a+c): total subjects with a disease

D- (b+d): total subjects without disease

T+ (a+b): total test positives

T- (c+d): total test negatives

43
Sensitivity
DISEASE TOTAL

No
Diseased disease
Test a b a+b
Ability of thetest +ve

TEST
to truly identify
those who have Test c d c+d
the disease -ve

TOTAL a+c b+d a+b+c


+d

True Sensitivity=
Positive a/(a+c)

44
Sensitivity
[A 90% Sensitivity means that 90% of the diseased

people screened by the test will give a “true positive”


and the remaining 10% a “false negative results”]

45
Specificity DISEASE TOTA
L
No
The ability of the Diseased diseas
e
test to correctly
Test a b a+b
identify those who

TEST
+ve
do not really have
the disease Test c d c+d
-ve

TOTAL a+c b+d a+b+


c+d

True Specificity=
Negative d/(b+d)

46
Specificity
[[A 90% Specificity means that 90% of the non
diseased people screened by the test will give a “true
negative” result, and the remaining 10% a “false
positive results”]]

47
Example
Assume a population of 1,000 people among
these 100 have a disease and 80 of them are
confirmed by the test. Totally the screening test
reported that 180 people identified as positive
during the test.
calculate sensitivity and specificity?

48
Cont’……

Sensitivity = 80/ 100 X 100= 80%


Specificity = 800/ 900 X 100 = 88%

49
Specificity and sensitivity
Increased sensitivity decreases the specificity
• Leads to more false positives
• people wrongly diagnosed as having the
disease
• unnecessary panic among people & Health
workers
• Unnecessary exposure for treatment
• Unnecessary wastage of resource (human, time,
drug, etc)
• Unnecessary stress on the health system
• Wrong negative implication external relation

50
Specificity and sensitivity
Increased specificity decreases the sensitivity
• Leads to more false negatives
• people wrongly diagnosed as not having
the disease
• delay in diagnosis
• Negative implication on prognosis of
disease
• Unnecessary wastage of resource
(human, time, drug, etc) for sever disease
• Unnecessary stress on the health system

51
Predictive value
DISEASE TOTA
L
No
Diseased diseas
Positive Negative e
Predictive Predictive
value value Test a b a+b

TEST
+ve
Proportion of Proportion of
Individuals with Individuals with Test c d c+d
positive test really negative test
have the disease really have no -ve
disease

TOTAL a+c b+d a+b+


c+d
PPV=a/(a+b) NPV= d/(c+d)

52
Effects on Predictive Values

Prevalence PPV Increases; NPV Decreases


Increases
Prevalence PPV Decreases; NPV Increases
Decreases

Specificity Increases PPV increases

Sensitivity Increases NPV increases

53
Cont’....
Prevalence of a disease
The proportion of individuals with a disease
Prior/pre-test probability of a disease
Prevalence = P (D+)
= (a+c)/n
Yield of a test
Proportion of cases detected by the screening
program
Yield = a/n
54
.

Thank you

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