EPIDEMIOLOGY :

(History, Scope & Principal)

Prof.Dr.Soeharyo Hadisaputro, dr.Sp.PD-KPTI

Theories of Disease Causation
• Supernatural Theories
• Hippocratic Theory
• Miasma
• Theory of Contagion
• Germ Theory (cause shown via Henle-
Koch postulates)
• Classic Epidemiologic Theory
• Multicausality and Webs of Causation
(cause shown via Hill’s postulates)
 PERKEMBANGAN ILMU
KEDOKTERAN/KESEHATAN
* Ilmu Kedokteran
(Medical Sciences)
Kel. I. Sosial Kel. I. Perilaku

Ilmu Farmasi Ilmu Keperawatan

Ked.Gigi Ilmu Kebidanan
Ilmu Kes. Ilmu GIZI
Masyarakat

* Ilmu Kedokteran

EPIDEMIOLOGI
 ILMU EPIDEMIOLOGI &
PERKEMBANGANNYA

* Ilmu Epidemiologi
(Epidem. Sciences)

Biostatistics

Behaviour

Clinical Epidemiology
Field
Epidemiologiy

General Epidemiolgy
Disaster
Nutritional Epidemiologi
Managerial
Epidemiology
Epidemiology
 EPIDEMIOLOGI
• Epidemiologi : merupakan dasar ilmu
kesehatan masyarakat.
• Asal kata : Epidemi dan logy (peduli hanya
pada penyakit menular)
• Epi (atas); Demos (penduduk) dan Logos
(ilmu)  peduli terhadap tak hanya penyakit
menular saja, juga penyakit tidak menular &
kronis  non penyakit (disaster, family
planning, behaviour dll)
5
 EPIDEMIOLOGI
• Kata kunci : distribusi, determinan dan control
terhadap kejadian
• Istitute of medicine (1988) : Kesehatan
masyarakat adalah usaha2 komunitas yg
terorganisir yg berguna bg pencegahan
penyakit dan promosi kesehatan. Berkaitan dg
banyak disiplin ilmu lain dan menjadi inti
sadar dasarnya adlh epidemiologi. (Konsep
WINSLOW)
6
 PUBLIC HEALTH (Winslow, 1920)
Public Health is the science and art of (1) preventing
disease, (2) prolonging of life, and (3) promoting of health
and efficiency through organized community effort for (a)
the sanitation of the environment (b) the control of
communicable infections © the education of the individual
in personal hygiene (d) the organization of medical and
nursing service for the early diagnosis and preventive
treatment of disease (e) the development of the social of
living adequate for the maintenance of health, so
organizing these benefits and enable every citizen to
realize his birthright of health and longevity.
 SENIOR EPIDEMIOLOGIST IN
THE WORLD

• (1) ANTONIO V.LEUWENHOEK (1632)

• (2) ROBERT KOCH (1882)
• (3) MAX VAN PATTERNKOFER
• (4) JOHN SNOW (1854)
• (5) PERVICAL POTT
• (6) JAMES LIND (1747)
• (7) DOLL and HILL (1950)
 400 B.C. HIPPOCRATES

• Perkembangan penyakit pada manusia

berhubungan dengan faktor gaya hidup dan
keadaan lingkungan (environment).
• Bukunya : “On Airs, Waters, an Places”. 9
• Dilahirkan tahun 460 BC di pulau Greek island of Kos
(Cos), menjadi sangat terkenal dalam bidang
kedokteran yang menentang infrastruktur kuat di
daerah Greece.
• Menjadi oposisi selama 20 tahun di penjara, dia
menulis buku-buku yang terkenal yaitu The
Complicated Body, Air, Water and Place
• Orang pertama yang menyatakan bahwa penyakit
disebabkan oleh ‘naturraly’ bukan karena
supernatural dan kutukan Tuhan.
• Dianggap sebagai "Father of Medicine“, karena
memberikan kontribusi revolusioner kearah
kedokteran praktis yang terus berkembang setelah
beliau wafat. 10
1600s. Bacon
• Mengembangkan prinsip
logika induktif, sebagai dasar
filosofi pada penelitian
epidemiologi.
• Francis Bacon, 1st Viscount
St. Alban,[ (22 January 1561 –
9 April 1626) seorang
ilmuwan dan filosof, ahli
hukum. Ia terkenal akibat
kerjanya sebagai advocat
filosof dsan praktisi sebagai
the scientific method selama
revolusi scientific.
11
 1624-1689 : Thomas Sydenham
Dikenal sebagai
tokoh kedokteran
klinik (clinical
medicine) dan
epidemiologi.
Yang menekankan
secara mendetail
observasi pasien &
akurasi pencatatan
(reporting)
12
 1662 : JOHN GRAUNT
• John Graunt (24 April 1620 –
18 April 1674) salah seorang
pelopor pertama
demographers, yang semula
sebagi seorang penjual
pakaian laki-laki
• Menganalisis kelahiran dan
kematian di London dan
kuantifikasi penyakit di
populasi

13
• Graunt, bergaul dengan William Petty, yang
mengembangkan pertama kali human
statistical dan metoda census yang
selanjutnya digunakan untuk kerangka kerja
demografi modern. Ia diakui sebagai orang
yang mengembangkan pertama kali membuat
life table, yang memberikan kemungkinan
probabilitas kehidupan pada kelompok umur.
Graunt juga dianggap the first experts bidang
dalam bidang epidemiology, sejak membuat
buku yang terkenal yang menyajikan sebagaian
besar statistik public health. 14
1747 : LIND
James Lind FRSE FRCPE (4
October 1716 in
Edinburgh – 13 July 1794
in Gosport), seorang
dokter Scotland, sebagai
seorang pioneer naval
hygiene di Royal Navy. Ia
melakukan pertama kali
clinical trial, yang
mengembangkan teori
bahwa citrus fruits cured
scurvy.
15
• Scurvy adalah penyakit yang saat ini dikenal
disebabkan karena kekurangan Vitamin C, tetapi
waktu itu konsep mengenai vitamins belum
diketahui. Vitamin C diperlukan untuk
mempertahankan kesehatan jaringan.
• In 1740 adanya bencana besar hasil dari Anson's
circumnavigation yang menarik perhatian di
Eropa, dari 1900 laki-laki, 1400 di antaranya
meninggal, yang sebagain besar diduga
menderita scurvy. Menurut Lind, scurvy sebagai
penyebab kematian terbesar di armada Inggris.

16
 1749-1823 : Edward Jenner
 Sebagai pioner uji klinik untuk vaksinasi dalam rangka
pengendalian penyebaran penyakit cacar (smallpox)
 Jenner's work influenced many others, including
Louis Pasteur who developed vaccines against rabies
and other infectious diseases

17
 1839 WILLIAM FARR
• Berhasil
pertama kali
menyusun
suatu sistem
sebagai
ringkasan rutin
penyebab
kematian
18
• Sebagai contoh, ia pertama kali menunjukkan
mortality rates of different occupations to be
compared. In 1839, he joined the Statistical Society
(now called the Royal Statistical Society).
• There was a major outbreak of cholera in London in
1849 which killed around 15,000 people. Early
industrialisation had made London the most
populous city in the World at the time, and the River
Thames was heavily polluted with untreated sewage.
Farr subscribed to the conventional theory that
cholera was carried by polluted air rather than water
– the miasmic theory.
19
 Some historic pandemics
• Plague of Justinian: 541 - 750, 50% - 60% Europe's
population killed

• The Black Death: 1347 - 1352: killed 25 million in

Europe over 5 years (25% - 50% of the populations of
Europe)

• The introduction of smallpox, measles and typhus to

the Americas by European explorers: 15th - 16th century
caused epidemics among the native inhabitants.
Between 1518 and 1568 these diseases caused the
population of Mexico to fall from 20 million to 3 million.
 Some historic pandemics
• Smallpox killed ~ 60 million
Europeans during the 18th century
(~ 400,000/year). Up to 30% died,
among children <5 80%. 1/3 of
the survivors went blind.

• In 19th century, tuberculosis

killed ~ 25% of the adult
population of Europe; by 1918
one in six deaths in France were
still caused by TB.
Three cases highlighted

• Semmelweis
• John Snow
• Spanish influenza
 1840’s : Ignas Semmelweis
 Pioneered hand-
washing to help
prevent the spread of
septic infections in
mothers following
birth

23
 Puerperal fever in two obstetric wards
(1846)

Ward 1 Ward 2
Mortality rate: 9,9% Mortality rate: 3,4%
(7,7-15,8%) (2-7,5%)

Explanation: epidemics through atmospheric influences

Semmelweis: atmospheric influences would equally affect

both wards, no evidence of clustered cases -> not a
contagious disease -> endemic disease -> cause of the
difference must be found inside the clinic
 Hypotheses
• Position of beds ?
• Social background of patients ?
• In ward 1 only male health care workers,
in ward 2 some female assistents ?
• Ventilation ?
• Food ?
 March 1847
• Dr. Kolletschka (friend of Semmelweis)
dies from wound sepsis, from a knife-
wound attracted during autopsy
• Symptoms similar to puerperal fever
• Is there a connection between
contamination at autopsy and puerperal
fever ?
• Bacteria were not yet discovered!
 Puerperal fever in two obstetric wards
(1846)

Ward 1 Ward 2
Mortality rate: 9,9% (7,7- Mortality rate: 3,4% (2-
15,8%) 7,5%)
Medical students Midwife students

Medical students assist during autopsy!

Medical students must disinfect their hands after autopsy
from May 1847 on.
Mortality rates: June/Dec 1847 3%, 1848 1,3%
 1849-1854 : SNOW
• Membuat dan
menguji
hipotesis ttg
penyebab
cholera di
London –
salah satu
studi analitik
epidemiologi 29
 Spanish influenza
• The Spanish Influenza Pandemic of 1918
killed ~50-100 million people (about 2% of
world population of 1.7 billion). Today
Influenza kills ~ 250,000 to 500,000
worldwide each year.
• In western world, 1% of infected people
died
• Relatively less attention
• W-shaped mortality curve
W-curve
1920 : Joseph Golberger
• Publikasi studi
lapangan deskriptif
yg menunjukkan
kekurangan zat
gizi/makanan pada
penyakit pellagra

32
1950 : Doll & Hill

• Studi kasus
kontrol
pertama –
hubungan
merokok
sigaret dg
kanker paru
33
• Sir Austin Bradford Hill FRS (8 July 1897
– 18 April 1991), English epidemiologist
and statistician, pioneered the randomized
clinical trial and, together with Richard Doll,
was the first to demonstrate the connection
between cigarette smoking and lung
cancer. Hill is widely known for pioneering
the "Bradford Hill" criteria for determining a
causal association.

34
1954 : Field Trial Salk
• Jonas Edward Salk
(October 28, 1914 – June
23, 1995) was an American
medical researcher and
virologist, best known for his
discovery and development
of the first polio vaccine. He
was born in New York City
to parents from Ashkenazi
Jewish Russian immigrant
families. Although they did
not have much formal
education, his parents were
determined to see their
children succeed.
35
1959 : Mantel & Haenszel
Mengembangk
an prosedur
statistik
untuk
menganalisis
stratifikasi pd
studi kasus
kontrol

36
1960 : McMahon
• Membuat
publikasi buku
teks
epidemiologi
pertama dg
fokus sistematik
pd rancangan
studi 37
 1949: Framingham Heart Study
• Studi kohort pertamakali.
• The Framingham Heart Study is a long-term,
ongoing cardiovascular study on residents of the
town of Framingham, Massachusetts. The study
began in 1948 with 5,209 adult subjects from
Framingham, and is now on its third generation of
participants. Prior to it almost nothing was known
about the "epidemiology of hypertensive or
arteriosclerotic cardiovascular disease“. Much of
the now-common knowledge concerning heart
disease, such as the effects of diet, exercise, and
common medications such as aspirin, is based on
this longitudinal study.
38
 Epidemiology

The study, and more precisely, the

quantification of the relationship
between determinants with the
occurrence of an illness.
 FINAL DEVELOPMENT OF
EPIDEMIOLOGY DEFINITION

Originally, epidemiology was concerned with

epidemics of communicable diseases.
More recently, epidemiologic methods have
been applied to chronic diseases, injuries,
violence, birth defects, maternal-child
health, occupational health, environmental
health, disaster, family planning, etc.
 •
DEVELOPMENT OF EPIDEMIOLOGY
DEFINITION

LAST (Final Definition)

Epidemiology is study of the
distribution and determinants of
health-related states or events
is specified populations and
the application of this study to
control health problems.
 USES OF EPIDEMIOLOGY
GENETIC FACTORS
1. Causation

GOOD HEALTH HEALTH

ENVIRONMENTAL FACTORS Death

(incluiding lifestyle)
2. Natural history Subclinical Clinical
Good health changes disease

3. Description of health status Recovery

of populations
Good health
Propotion with III health,
change over time, change III
with age, etc. health Time

Treatment medical care

4. Evaluation of Good health III health

Intervention
Health promotion
Preventive measures
Public health services
 SPECTRUM OF DISEASE

Exposure DEATH
Etiologic Sympton
Pathologic Diagnosis
Agent Changes Time

Subclinical Clinical RECOVERY

Manifestation Manifestation
 CONCEPT OF HEALTH STATUS

•(1) THE TRADITIONAL (ECOLOGICAL) MODEL : (a)

Agent (b) Host © Environment
• (2) THE HEALTH FIELD CONCEPT (HL
Lamframboise, 1973) : (a) Environment (b) Life
style © Biological (d) System of health service.
• (3) THE ENVIRONMENT OF HEALTH (H.L.Blum,
1974; The Force field and wellbeing paradigms of
health) : (a) Environment (b) Behaviour (Life style)
© Health service and (d) Heridity.
 Epidemiologic Triad

Disease is the
result of forces
within a dynamic
system consisting
of:
Agent
Host
Environment
 Triad Cont’d - Determinants

• Agent factors: pathogenicity; virulence

• Host factors: age, gender; education;

behaviors; culture.

• Environmental: climate; geography;

biological; socioeconomic, political, and
cultural
 AGENT OF HOST
DISEASE
FULCRUM

ENVIRONMET OF
LIFE

BIOLOGY PHYSIC SOCIAL ECONOMIC

Leavell’s diagram of balanced of gondition

Little agent More Agent Weaknes of

(not more) Healthy of and very
host host
virulent

Good Bad
Environment Environment

DIAGRAM : Balance of Health DIAGRAM : Imbalance of Health

BIOLOGICAL INTERACTION