EPIDEMIOLOGY

By :
dr. Siswanto, M.Sc.
EPIDEMIOLOGY

By :
dr. Siswanto, M.Sc.
INTRODUCTION OF
EPIDEMIOLOGY
Why does a disease develop in
some people and not in others ?

The disease and health problems

are not randomly distributed in a
population.
 DEFINITION
● The study of the distribution and determinants of
health related states or events in specified
populations, and the application of this to the
control of health problems.
● The study of the distribution and change in
diseases.
● The study of the distribution and determinants of
disease in human population
● “Study of disease and other health related phenomena in

group of persons. (Kramer MS, 1988)

● A science concerned with describing the pattern of disease

occurrence in population and determining the factors which

influence disease prevalence and distribution with the

ultimate objective of providing the basis of control and

prevention
● The characterization of the distribution of
health-related state or events is one broad
aspect of epidemiology called descriptive
epidemiology.
● Epidemiology is also used to search for
causes and other factors that influence the
occurrence of health-related state or events.
The latter is called analytic epidemiology
● Descriptive epidemiology provides the What,
Who, When and Where.
WHAT is the health problem , disease or event and what are its
manifestations and characteristics ?
WHO is affected with reference to age ,sex, social
class, ethnic, occupation, heredity and personal habits ?
WHEN does it happen, in terms of days, months, seasons or
years ?
WHERE does the problem occur, in relation to place of residence,
geographical distribution and place of exposure ?
 ● Analytic epidemiology attempts to provide the Why, How
and So What
HOW does the health problem, disease or event occur, and what is its
association with specific conditions, agents, vectors, sources of infection,
susceptible groups and other contributing factors ?
WHY does it occur, in terms of the reasons for its persistence or occurrence ?
SO WHAT interventions have been implemented as a result of the information
gained and what was their effectiveness ? Have there been any improvements
in health status ?
 What questions
Can be answered by
Epidemiological Approach ?
● How many peoples influenced by the
disease? Since when the disease started,
and do the number of cases tend to
increase or decrease by time?
● Do the disease burdened on a specific
group of Age, gender, place, occupation,
religion, economic status groups, marriage
status, education?
● What is the probable cause or risk factor
that make the disease frequency?
● Which of the cause / risk factors
manageble?
● What are the effective solution to control
the disease ?
Case definition is a set of
standard criteria for deciding a
person has a particular disease
(health related condition) or not
A Case definition consists of
clinical criteria include :
(symptoms/subjective
complaints, signs/objective
physical finding and laboratory
test)
● For example : in an outbreak of bloody diarrhea
caused by infection with E coli O 157:H7,
investigators defined cases in the following three
classes :
● Definite case : E coli O157:H7 isolated from a
stool culture with gastrointestinal symptoms
● Probable case : Bloody diarrhea with
gastrointestinal symptoms
● Possible case : Diarrhea and gastrointestinal
symptoms
 What kind of epidemiological
technique needed in Community Diagnosis
● The Disease Frequency
measurement:
○ Prevalence and Incidence rate
● The trends of Prevalence &
Incidence
● The distribution of prevalence or
incidence rate by age, sex,
occupation, socio-economic groups,
place, religions
● Formulate Hypothesis about the risk
factors (use la londe model)
● Test hypothesis
 SCHEME FOR AN EPIDEMIOLOGICAL
STUDY CYCLE

DESCRIPTIVE
STUDIES
ANALYSIS OF RESULTS,
SUGGEST MODEL BUILDING
FURTHER-DESCRIPTIVE FORMULATION OF
AND NEW HYPOTHESIS HYPOTHESIS

TEST HYPOTHESIS

ANALYTICAL STUDIES EXPERIMENTAL STUDIES :

- X - SECTIONAL
- CASE-CONTROL - CLINICAL TRIALS
STUDY - FIELD TRIALS
 RESEARCH DESIGN IN EPIDEMIOLOGY

THE EPIDEMIOLOGY STUDY

OBSERVATIONAL STUDIES
EXPERIMENTAL STUDIES
(NO CONTROL OVER
(INFESTIGATOR DETERMINE)
EXPOSURE)
WHO EXPOSED OR NOT
EXPOSED

NO COMPARISON GROUP COMPARISAN

GROUP

DESCRIPTIVE ANALYTIC

CASE SURVEILLANCE SURVEY CROS SEC CASE COHOR

REVIEW TIONAL CON TROL T
STUDY STUDY STUDY
5 CRITERIA CAUSAL ASSOCIATION

1.TEMPORAL RELATIONSHIP --> means exposure to the

causal factor (risk factor) must precede development of
the disease (effect)

2. STRENGHT OF ASSOCIATION (RR> 4) --> Strength

refers to the size/magnitude of RR (not the p value or
degree of statistically significance which can be
increased by increasing the sample size).

3. CONSISTENCY (C) AND REPLICATION (R)

C--> means different studies resulted in the same
association
R--> means repetition of the same study resulted
in the same association.
 ● SPECIFICITY/DOSE-RESPONSE RELATIONSHIP

Measures the degree to which one particular exposure produces

one specific disease.

● COHERENCE WITH EXISTING KNOWLEDGE (BIOLOGICAL

PLAUSIBILITY)

Support for the causal of an association exist if a causal

interpretation is plausible in term of current knowledge about the

factor and the disease.

 PRINCIPLES OF CAUSALITY
(SEVEN POINTS)
1. There should be evidence of a strong
association between the risk factor and the
disease ( Relative risk, odds ratio and
prevalence ratio)
2. There should be evidence that exposure to the
risk factor preceded the onset of disease
3. There should be a plausible biological
explanation
4. The association should be supported by other
investigations in different study setting
5. There should be evidence of reversibility of the
effect. ( That is, if the “cause” is removed the
“effect” should also disappear, or at least be less
likely)
6. There should be evidence of a dose response
effect.( That is, the greater the amount of exposure
to the risk factor, the greater the chance of
disease)
7. There should be no convincing alternative
explanation. ( For instance, the association should
not be explainable by confounding)
 NATURAL HISTORY OF DISEASE

Natural history of disease refers to the progress of a

disease process in an individual over time, in the
absence of intervention.
The process begins with exposure to or accumulation of
factors capable of causing disease. Without medical
intervention, the process ends with recovery, disability, or
death
 NATURAL HISTORY OF DISEASE

ONSET
OF
SYMPTO
USUAL
MS TIME
PATHOLOG
IC OF
DIAGNOSIS
CHANGES
EXPOSU
RE SPECTRUM OF
DISEASE

STAGE OF STAGE OF STAGE OF STAGE OF

SUSCEPTIBILI SUBCLINICAL CLINICAL DISABILITY OR
TY DISEASE DISEASE ● RECOVE
DEATH
WITHOUT MEDICAL
RY
INTERVENTION
● DISABILI
 NATURAL HISTORY OF DISEASE

● For infectious disease, the exposure usually is

microorganism. For infectious disease the period of
subclinical is called the incubation period
● For cancers, the critical factors may require both
cancer initiators, such as asbestos fibers or
components in tobacco smoke (for lung cancer) and
cancer promoters, such as estrogens (for
endometrial cancer). For chronic disease the period
of subclinical is called the latency period
 DISEASES CAUSATIONS

● MOSTLY MULTIFACTORIALS (> 1 factor)

● 2 THEORY :
○ EPIDEMIOLOGICAL TRIANGLE MODEL;
○ LA LONDE (Henry L Blum) MODEL.
 EPIDEMIOLOGICAL TRIANGLE
MODEL
● The arising disease, is always a result of total
interaction of 3 factors:
○ The Destructive power of AGENT OF DISEASE,
as an absolute factor that must be exist as the
cause.
○ The Defensive Power of HUMAN HOST as the
target of agent of disease, and
○ The Supporting Power of the ENVIRONMENT to
destructive power of agent of disease or to
protective power of human host
 DETERMINANT OF HEALTH
EPIDEMIOLOGICAL TRIANGLE MODEL

Resistance of
Human host
Destructive against disease
power of Agent
of
diseases
Environment
 AGENT OF DISEASES

● Physical agent: Temperature, dust, gas, light,

noise, radiation, etc
● Chemical Agent : Acid, Base, metal, Organic
compound, food aditive, etc
● Biological agent : Bactery, Insect, Allergen,
Animal’s bites, etc
● Intrinsic agent : Gen, hereditary disorders;
● Psychologial agent : Mental Stress;
DESTRUCTIVE POWER OF AGENT OF
DISEASE
DETERMINED BY :
● Quantity of agents;
● Duration of contact with agent of disease;
● Area of contact between agent of disease and
body of human host;
● Basic characteristic of agent of disease :
Corosive, Allergen, Toxic, Carcinogenic,
Mutagenic, Invasive, etc;
● Tissue resistance of human host against agent of
disease
 HOST RESISTANCE
● Host resistance against destructive
power of agent of disease,
determined by :
○ Genetic factors;
○ Mental & Spiritual stability
○ Nutritional status;
○ Physical fitness;
○ Immunity;
 ENVIRONMENTAL FACTORS

● EFFECT AGAINST AGENT OF DISEASE :

○ Increase /decrease number of agent of disease,
duration of contact, area of contact and destructive
power of agent of disease;
○ ex High air temperature lower the body indurance
● EFFECT AGAINST HUMAN RESISTANCE :
○ Increase / decrease psicho-bio-physical indurance ;
○ ex Food production determine the nutritional status
of population.
 DETERMINANT OF HEALTH
LA LONDE MODEL
PSYCHO-BIOL
OGICAL
ENDURANCE

HEALTH
SERVICE
PROGRAMS
Healt
h
prob
ENVIRONMENT lem
● Biological
● Social

LIFE STYLE
Three terms are used to describe an infectious
disease according to the various outcomes
● Infectivity refers to the proportion of exposed
persons who become infected.
● Pathogenicity refers to the proportion of infected
persons who develop clinical disease
● Virulence refers to the proportion of persons with
clinical who become severely or die
 Chain of infection

● Transmission of disease occur when the agent

leaves its reservoir or host through a portal of exit,
and is conveyed by some mode of transmission, and
enters through an appropriate portal of entry to
susceptible host. The process is called the chain of
infection.
 RESERVOIR

● The reservoir of an agent is the habitat in which an

infectious agent normally lives, grows and
multiplies.
● Reservoir include human, animal and the
environment
 Two type of human reservoir

● Carrier is person without apparent disease who is

capable of transmitting the agent to others.
Asymptomatic carriers , who never show symptom
during the time they are infected.
Incubatory or convalescent carriers who are capable of
transmission before or after they are clinical ill
 Two type of human resevoir

Chronic carriers is one who continues to harbor an

agent for extended time (months or years).
Exp : Hepatitis B, typhoid fever)
● Symptomatic persons are usually less likely to
transmit infection widely because their symptom
increase their likelihood of being diagnosed and
treated.
 Portal of exit

The path by which an agent leaves the source host.

The portal of exit usually corresponds to the site at
which the agent is localized.
Examp : tubercle bacilli and influenza virus exit the
respiratory tract, cholera vibrios in feces.
 Modes of transmission
● Direct
Direct contact (kissing, sexual intercourse)
Droplet spread ( refers to spray with relative
large. Sneezing, coughing even talking)
● Indirect ( an agent is carried from a reservoir to
a susceptible host by suspended air particle,
vector and vehicle)
Airborne (The nuclei less than 5 μ/micron)
Vehicleborne
Vectorborne : Mechanical, Biologic
 Portal of entry

An agent enters a susceptible host through a portal of

entry.
RESEARCH DESIGN IN
EPIDEMIOLOGY
 DESCRIPTIVE STUDIES
● Information is collected only on those
individuals with a health problem or a
particular exposure. There is no
comparison group. Much useful
information can be derived from these
studies but no definite analysis of
cause-effect association can be made
from these information
● TIME
Disease rates change over time.
Some of these changes occur regularly
and can be predicted.
Example : the seasonal increase of
influenza cases with the onset of cold
weather is a pattern that is familiar to
everyone
Malaria by year, United States, 1930 - 1990
● Place
We describe a health event by place to gain insight
into the geographical extent of the problem.
For place, we may use place of residence,
birthplace, place of employment, hospital unit,
urban and rural etc, depending on which may be
related to the occurrence of the health event.
● Person
When we organize or analyze data by “person”
there are several person categories.
Inherent characteristics of people ( age, race, sex),
acquired characteristics ( immune, marital status),
their activities ( occupation, use of tobacco, drugs),
the conditions under which they live (
socioeconomic, access to medical care)
● Example : Sex
● For some disease, this sex-related difference is
because of genetic, hormonal, anatomic, or
other inherent differences between the sexes.
● Premenopausal women have a lower risk of
heart disease than man of the same age. This
difference is attributed to higher estrogen level in
women.
PERTUSSIS (WHOOPING COUGH) INCIDENCE
BY AGE GROUP,
UNITED STATES, 1989
 ANALYTIC STUDIES
1. CROSS-SECTIONAL STUDY
The comparison is made between a group of
persons who has the disease and a group
that does not have the disease, but the
characteristic and/ or exposure of the two
groups are observed in the same time
 ADVANTAGES
● Quick and easy to perform

● Straight forward data analysis

● Loss to follow up –
 DISADVANTAGES
● Difficult to interpret association in terms
of cause and effect
● Not suitable for the rare disease, since
sample size requirement will have to be
large.
 CASE-CONTROL
STUDY

THE STUDY MOVE BACKWARD FROM

DISEASE ( EFFECT) TO RISK FACTOR
(CAUSE).
PERSON WITH AND WITHOUT DISEASE
ARE IDENTIFIED AND THEN THE
PRESENCE OR ABSENCE OF PREVIOUS
EXPOSURE TO THE RISK FACTOR IS
DETERMINED
 STUDY DESIGN OF
CASE-CONTROL
Risk factor +

Risk factor - CASES

POPULATIO
N
Risk factor +

CONTROLS
risk factor -
 ADVANTAGES
● Efficient for the study of rare diseases
● Efficient for the study of chronic disease
(diseases with a long latency)
● Tend to require a smaller sample size than other
designs.
● Less expensive than other designs
5. Many risk factors can be studied simultaneously
 DISADVANTAGES
● Risk of disease cannot be estimated directly
● Not efficient for the study of rare exposures
● More susceptible to selection bias
4 Information on exposure may be less accurate
than other design ( memory bias)
5 Can investigate only one disease outcome
 COHORT STUDY

The study move forward from risk factor

(cause) to disease (effect).
Population exposed and not exposed to a
risk factor are identified and then both
population were followed to determine the
frequencies of health problems.
 STUDY DESIGN OF COHORT
Disease +

Risk factors +
Disease -

population
Disease +
Risk factors -

Disease -
 ADVANTAGES
● Direct calculation of relative risk
● May yield information on the incidence of
disease
● Clear temporal relationship between exposure
and disease
● Particularly efficient for study of rare exposure
● Can examine multiple effect of a single exposure
● Minimizes bias
● Strongest observational design for
establishing cause and effect relationship
 DISADVANTAGES
● Time consuming
● Often requires a large sample size
● Expensive
● Not efficient for the study of rare diseases
● Lost to follow-up
● Changes in exposure
● Ethic
 USES
● Population or community health assesment.
To do this, we must find answers to many questions : What
are the actual and potential health problems in the
community ?, Where are they ?, Who is at risk ?, Which
problems are declining over time ?, Which ones are
increasing or have the potential to increase ?, How do
these patterns relate to the level and distribution of services
available ?.
● Individual decisions. People may not realize that they
use epidemiologic information in their daily decisions.
● Completing the clinical picture.
When studying a disease outbreak, epidemiologists
depend on clinical physicians and laboratory scientists for
the proper diagnosis of individual patients. But
epidemiologist also contribute to physicians, understanding
of the clinical picture and natural history of disease.
● Search for causes.
Much of epidemiologic research is devoted to a search for
causes, factors which influence one,s risk of disease.
● Health Status
For example : Prevalence, Incidence
● Evaluation of intervention.
To assess the effectiveness of preventive and
therapeutic treatments.
To assess the impact of health-care services
To predict future health care needs
TERIMAKASIH
INTRODUCTION OF
EPIDEMIOLOGY
Why does a disease develop in
some people and not in others ?

The disease and health problems

are not randomly distributed in a
population.
 DEFINITION
● The study of the distribution and determinants of
health related states or events in specified
populations, and the application of this to the
control of health problems.
● The study of the distribution and change in
diseases.
● The study of the distribution and determinants of
disease in human population
● “Study of disease and other health related phenomena in

group of persons. (Kramer MS, 1988)

● A science concerned with describing the pattern of disease

occurrence in population and determining the factors which

influence disease prevalence and distribution with the

ultimate objective of providing the basis of control and

prevention
● The characterization of the distribution of
health-related state or events is one broad
aspect of epidemiology called descriptive
epidemiology.
● Epidemiology is also used to search for
causes and other factors that influence the
occurrence of health-related state or events.
The latter is called analytic epidemiology
● Descriptive epidemiology provides the What,
Who, When and Where.
WHAT is the health problem , disease or event and what are its
manifestations and characteristics ?
WHO is affected with reference to age ,sex, social
class, ethnic, occupation, heredity and personal habits ?
WHEN does it happen, in terms of days, months, seasons or
years ?
WHERE does the problem occur, in relation to place of residence,
geographical distribution and place of exposure ?
 ● Analytic epidemiology attempts to provide the Why, How
and So What
HOW does the health problem, disease or event occur, and what is its
association with specific conditions, agents, vectors, sources of infection,
susceptible groups and other contributing factors ?
WHY does it occur, in terms of the reasons for its persistence or occurrence ?
SO WHAT interventions have been implemented as a result of the information
gained and what was their effectiveness ? Have there been any improvements
in health status ?
 What questions
Can be answered by
Epidemiological Approach ?
● How many peoples influenced by the
disease? Since when the disease started,
and do the number of cases tend to
increase or decrease by time?
● Do the disease burdened on a specific
group of Age, gender, place, occupation,
religion, economic status groups, marriage
status, education?
● What is the probable cause or risk factor
that make the disease frequency?
● Which of the cause / risk factors
manageble?
● What are the effective solution to control
the disease ?
Case definition is a set of
standard criteria for deciding a
person has a particular disease
(health related condition) or not
A Case definition consists of
clinical criteria include :
(symptoms/subjective
complaints, signs/objective
physical finding and laboratory
test)
● For example : in an outbreak of bloody diarrhea
caused by infection with E coli O 157:H7,
investigators defined cases in the following three
classes :
● Definite case : E coli O157:H7 isolated from a
stool culture with gastrointestinal symptoms
● Probable case : Bloody diarrhea with
gastrointestinal symptoms
● Possible case : Diarrhea and gastrointestinal
symptoms
 What kind of epidemiological
technique needed in Community Diagnosis
● The Disease Frequency
measurement:
○ Prevalence and Incidence rate
● The trends of Prevalence &
Incidence
● The distribution of prevalence or
incidence rate by age, sex,
occupation, socio-economic groups,
place, religions
● Formulate Hypothesis about the risk
factors (use la londe model)
● Test hypothesis
 SCHEME FOR AN EPIDEMIOLOGICAL
STUDY CYCLE

DESCRIPTIVE
STUDIES
ANALYSIS OF RESULTS,
SUGGEST MODEL BUILDING
FURTHER-DESCRIPTIVE FORMULATION OF
AND NEW HYPOTHESIS HYPOTHESIS

TEST HYPOTHESIS

ANALYTICAL STUDIES EXPERIMENTAL STUDIES :

- X - SECTIONAL
- CASE-CONTROL - CLINICAL TRIALS
STUDY - FIELD TRIALS
 RESEARCH DESIGN IN EPIDEMIOLOGY

THE EPIDEMIOLOGY STUDY

OBSERVATIONAL STUDIES
EXPERIMENTAL STUDIES
(NO CONTROL OVER
(INFESTIGATOR DETERMINE)
EXPOSURE)
WHO EXPOSED OR NOT
EXPOSED

NO COMPARISON GROUP COMPARISAN

GROUP

DESCRIPTIVE ANALYTIC

CASE SURVEILLANCE SURVEY CROS SEC CASE COHOR

REVIEW TIONAL CON TROL T
STUDY STUDY STUDY
5 CRITERIA CAUSAL ASSOCIATION

1.TEMPORAL RELATIONSHIP --> means exposure to the

causal factor (risk factor) must precede development of
the disease (effect)

2. STRENGHT OF ASSOCIATION (RR> 4) --> Strength

refers to the size/magnitude of RR (not the p value or
degree of statistically significance which can be
increased by increasing the sample size).

3. CONSISTENCY (C) AND REPLICATION (R)

C--> means different studies resulted in the same
association
R--> means repetition of the same study resulted
in the same association.
 ● SPECIFICITY/DOSE-RESPONSE RELATIONSHIP

Measures the degree to which one particular exposure produces

one specific disease.

● COHERENCE WITH EXISTING KNOWLEDGE (BIOLOGICAL

PLAUSIBILITY)

Support for the causal of an association exist if a causal

interpretation is plausible in term of current knowledge about the

factor and the disease.

 PRINCIPLES OF CAUSALITY
(SEVEN POINTS)
1. There should be evidence of a strong
association between the risk factor and the
disease ( Relative risk, odds ratio and
prevalence ratio)
2. There should be evidence that exposure to the
risk factor preceded the onset of disease
3. There should be a plausible biological
explanation
4. The association should be supported by other
investigations in different study setting
5. There should be evidence of reversibility of the
effect. ( That is, if the “cause” is removed the
“effect” should also disappear, or at least be less
likely)
6. There should be evidence of a dose response
effect.( That is, the greater the amount of exposure
to the risk factor, the greater the chance of
disease)
7. There should be no convincing alternative
explanation. ( For instance, the association should
not be explainable by confounding)
 NATURAL HISTORY OF DISEASE

Natural history of disease refers to the progress of a

disease process in an individual over time, in the
absence of intervention.
The process begins with exposure to or accumulation of
factors capable of causing disease. Without medical
intervention, the process ends with recovery, disability, or
death
 NATURAL HISTORY OF DISEASE

ONSET
OF
SYMPTO
USUAL
MS TIME
PATHOLOG
IC OF
DIAGNOSIS
CHANGES
EXPOSU
RE SPECTRUM OF
DISEASE

STAGE OF STAGE OF STAGE OF STAGE OF

SUSCEPTIBILI SUBCLINICAL CLINICAL DISABILITY OR
TY DISEASE DISEASE ● RECOVE
DEATH
WITHOUT MEDICAL
RY
INTERVENTION
● DISABILI
 NATURAL HISTORY OF DISEASE

● For infectious disease, the exposure usually is

microorganism. For infectious disease the period of
subclinical is called the incubation period
● For cancers, the critical factors may require both
cancer initiators, such as asbestos fibers or
components in tobacco smoke (for lung cancer) and
cancer promoters, such as estrogens (for
endometrial cancer). For chronic disease the period
of subclinical is called the latency period
 DISEASES CAUSATIONS

● MOSTLY MULTIFACTORIALS (> 1 factor)

● 2 THEORY :
○ EPIDEMIOLOGICAL TRIANGLE MODEL;
○ LA LONDE (Henry L Blum) MODEL.
 EPIDEMIOLOGICAL TRIANGLE
MODEL
● The arising disease, is always a result of total
interaction of 3 factors:
○ The Destructive power of AGENT OF DISEASE,
as an absolute factor that must be exist as the
cause.
○ The Defensive Power of HUMAN HOST as the
target of agent of disease, and
○ The Supporting Power of the ENVIRONMENT to
destructive power of agent of disease or to
protective power of human host
 DETERMINANT OF HEALTH
EPIDEMIOLOGICAL TRIANGLE MODEL

Resistance of
Human host
Destructive against disease
power of Agent
of
diseases
Environment
 AGENT OF DISEASES

● Physical agent: Temperature, dust, gas, light,

noise, radiation, etc
● Chemical Agent : Acid, Base, metal, Organic
compound, food aditive, etc
● Biological agent : Bactery, Insect, Allergen,
Animal’s bites, etc
● Intrinsic agent : Gen, hereditary disorders;
● Psychologial agent : Mental Stress;
DESTRUCTIVE POWER OF AGENT OF
DISEASE
DETERMINED BY :
● Quantity of agents;
● Duration of contact with agent of disease;
● Area of contact between agent of disease and
body of human host;
● Basic characteristic of agent of disease :
Corosive, Allergen, Toxic, Carcinogenic,
Mutagenic, Invasive, etc;
● Tissue resistance of human host against agent of
disease
 HOST RESISTANCE
● Host resistance against destructive
power of agent of disease,
determined by :
○ Genetic factors;
○ Mental & Spiritual stability
○ Nutritional status;
○ Physical fitness;
○ Immunity;
 ENVIRONMENTAL FACTORS

● EFFECT AGAINST AGENT OF DISEASE :

○ Increase /decrease number of agent of disease,
duration of contact, area of contact and destructive
power of agent of disease;
○ ex High air temperature lower the body indurance
● EFFECT AGAINST HUMAN RESISTANCE :
○ Increase / decrease psicho-bio-physical indurance ;
○ ex Food production determine the nutritional status
of population.
 DETERMINANT OF HEALTH
LA LONDE MODEL
PSYCHO-BIOL
OGICAL
ENDURANCE

HEALTH
SERVICE
PROGRAMS
Healt
h
prob
ENVIRONMENT lem
● Biological
● Social

LIFE STYLE
Three terms are used to describe an infectious
disease according to the various outcomes
● Infectivity refers to the proportion of exposed
persons who become infected.
● Pathogenicity refers to the proportion of infected
persons who develop clinical disease
● Virulence refers to the proportion of persons with
clinical who become severely or die
 Chain of infection

● Transmission of disease occur when the agent

leaves its reservoir or host through a portal of exit,
and is conveyed by some mode of transmission, and
enters through an appropriate portal of entry to
susceptible host. The process is called the chain of
infection.
 RESERVOIR

● The reservoir of an agent is the habitat in which an

infectious agent normally lives, grows and
multiplies.
● Reservoir include human, animal and the
environment
 Two type of human reservoir

● Carrier is person without apparent disease who is

capable of transmitting the agent to others.
Asymptomatic carriers , who never show symptom
during the time they are infected.
Incubatory or convalescent carriers who are capable of
transmission before or after they are clinical ill
 Two type of human resevoir

Chronic carriers is one who continues to harbor an

agent for extended time (months or years).
Exp : Hepatitis B, typhoid fever)
● Symptomatic persons are usually less likely to
transmit infection widely because their symptom
increase their likelihood of being diagnosed and
treated.
 Portal of exit

The path by which an agent leaves the source host.

The portal of exit usually corresponds to the site at
which the agent is localized.
Examp : tubercle bacilli and influenza virus exit the
respiratory tract, cholera vibrios in feces.
 Modes of transmission
● Direct
Direct contact (kissing, sexual intercourse)
Droplet spread ( refers to spray with relative
large. Sneezing, coughing even talking)
● Indirect ( an agent is carried from a reservoir to
a susceptible host by suspended air particle,
vector and vehicle)
Airborne (The nuclei less than 5 μ/micron)
Vehicleborne
Vectorborne : Mechanical, Biologic
 Portal of entry

An agent enters a susceptible host through a portal of

entry.
RESEARCH DESIGN IN
EPIDEMIOLOGY
 DESCRIPTIVE STUDIES
● Information is collected only on those
individuals with a health problem or a
particular exposure. There is no
comparison group. Much useful
information can be derived from these
studies but no definite analysis of
cause-effect association can be made
from these information
● TIME
Disease rates change over time.
Some of these changes occur regularly
and can be predicted.
Example : the seasonal increase of
influenza cases with the onset of cold
weather is a pattern that is familiar to
everyone
Malaria by year, United States, 1930 - 1990
● Place
We describe a health event by place to gain insight
into the geographical extent of the problem.
For place, we may use place of residence,
birthplace, place of employment, hospital unit,
urban and rural etc, depending on which may be
related to the occurrence of the health event.
● Person
When we organize or analyze data by “person”
there are several person categories.
Inherent characteristics of people ( age, race, sex),
acquired characteristics ( immune, marital status),
their activities ( occupation, use of tobacco, drugs),
the conditions under which they live (
socioeconomic, access to medical care)
● Example : Sex
● For some disease, this sex-related difference is
because of genetic, hormonal, anatomic, or
other inherent differences between the sexes.
● Premenopausal women have a lower risk of
heart disease than man of the same age. This
difference is attributed to higher estrogen level in
women.
PERTUSSIS (WHOOPING COUGH) INCIDENCE
BY AGE GROUP,
UNITED STATES, 1989
 ANALYTIC STUDIES
1. CROSS-SECTIONAL STUDY
The comparison is made between a group of
persons who has the disease and a group
that does not have the disease, but the
characteristic and/ or exposure of the two
groups are observed in the same time
 ADVANTAGES
● Quick and easy to perform

● Straight forward data analysis

● Loss to follow up –
 DISADVANTAGES
● Difficult to interpret association in terms
of cause and effect
● Not suitable for the rare disease, since
sample size requirement will have to be
large.
 CASE-CONTROL
STUDY

THE STUDY MOVE BACKWARD FROM

DISEASE ( EFFECT) TO RISK FACTOR
(CAUSE).
PERSON WITH AND WITHOUT DISEASE
ARE IDENTIFIED AND THEN THE
PRESENCE OR ABSENCE OF PREVIOUS
EXPOSURE TO THE RISK FACTOR IS
DETERMINED
 STUDY DESIGN OF
CASE-CONTROL
Risk factor +

Risk factor - CASES

POPULATIO
N
Risk factor +

CONTROLS
risk factor -
 ADVANTAGES
● Efficient for the study of rare diseases
● Efficient for the study of chronic disease
(diseases with a long latency)
● Tend to require a smaller sample size than other
designs.
● Less expensive than other designs
5. Many risk factors can be studied simultaneously
 DISADVANTAGES
● Risk of disease cannot be estimated directly
● Not efficient for the study of rare exposures
● More susceptible to selection bias
4 Information on exposure may be less accurate
than other design ( memory bias)
5 Can investigate only one disease outcome
 COHORT STUDY

The study move forward from risk factor

(cause) to disease (effect).
Population exposed and not exposed to a
risk factor are identified and then both
population were followed to determine the
frequencies of health problems.
 STUDY DESIGN OF COHORT
Disease +

Risk factors +
Disease -

population
Disease +
Risk factors -

Disease -
 ADVANTAGES
● Direct calculation of relative risk
● May yield information on the incidence of
disease
● Clear temporal relationship between exposure
and disease
● Particularly efficient for study of rare exposure
● Can examine multiple effect of a single exposure
● Minimizes bias
● Strongest observational design for
establishing cause and effect relationship
 DISADVANTAGES
● Time consuming
● Often requires a large sample size
● Expensive
● Not efficient for the study of rare diseases
● Lost to follow-up
● Changes in exposure
● Ethic
 USES
● Population or community health assesment.
To do this, we must find answers to many questions : What
are the actual and potential health problems in the
community ?, Where are they ?, Who is at risk ?, Which
problems are declining over time ?, Which ones are
increasing or have the potential to increase ?, How do
these patterns relate to the level and distribution of services
available ?.
● Individual decisions. People may not realize that they
use epidemiologic information in their daily decisions.
● Completing the clinical picture.
When studying a disease outbreak, epidemiologists
depend on clinical physicians and laboratory scientists for
the proper diagnosis of individual patients. But
epidemiologist also contribute to physicians, understanding
of the clinical picture and natural history of disease.
● Search for causes.
Much of epidemiologic research is devoted to a search for
causes, factors which influence one,s risk of disease.
● Health Status
For example : Prevalence, Incidence
● Evaluation of intervention.
To assess the effectiveness of preventive and
therapeutic treatments.
To assess the impact of health-care services
To predict future health care needs
TERIMAKASIH