MODULE 6

BIOSTATISTICS AND
EPIDEMIOLOGY IN THE
CONTEXT OF PUBLIC HEALTH
ELPIDIO A. CADUT. III, RMT, GCP
 KEY FACTS:
• Noncommunicable diseases (NCDs) kill 41 million people each year worldwide, equivalent to
71% of all deaths globally.
• Each year, 15 million people -2.2 million die from a NCD between the ages of 30 and 69 years;
over 85% of these "premature" deaths occur in low- and middle-income countries.
• Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually,
followed by cancers (9.0 million), respiratory diseases (3.9million), and diabetes (1.6 million),
globally.
• These 4 groups of diseases account for over 80% of all premature NCD deaths.
• Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase
the risk of dying from a NCD.
• Detection, screening and treatment of NCDs, as well as palliative care, are key components of
the response to NCDs.
◦
 Philippine context:
◦ NCDs account for 68% of all deaths in the Philippines, and the probability of dying
between the ages of 30 and 70 years from one of the four main NCDs is 29% in the
Philippines
◦ The economic cost of NCDs to the Philippine economy is PHP 756.5 billion per year,
which is equivalent to 4.8% of the country’s annual gross domestic product.
◦ • NCDs in the Philippines are causing a surge in health-care costs and social care and
welfare support needs and are contributing to reduced productivity.
◦ • The economic modelling for the return on investment analysis suggests that the
intervention with highest economic benefit in Philippines is the package of salt-
reduction interventions, followed by reducing tobacco consumption and increasing
physical activity in the population.
◦ • A national multisectoral NCD coordination mechanism needs to be established that
can bring together and strengthen existing cross-agency initiatives on NCDs.
RISK FACTORS:
Prevention and Control of NCDs
Global Response to Address NCDs
66th World Health Assembly endorsed the WHO Global Action Plan
for the Prevention and Control of NCDs 2013-2020 (resolution
WHA66.10)

The global action plan offers a paradigm shift by providing a road map and a menu of policy options for
Member States, WHO, other UN organizations and intergovernmental organizations, NGOs and the
private sector which, when implemented collectively between 2013 and 2020, will attain 9 voluntary
global targets, including that of a 25% relative reduction in premature mortality from NCDs by 2025.
Global Response to Address NCDs
This initiative is built on the previous Global Strategy endorsed in 2000 which had:
◦
1. To map the emerging epidemics of non-communicable diseases
and analyze their social, economic, behavioral and political
determinants.
2. To reduce the level of exposure of individuals and populations to the
common risk factors for non-communicable diseases and their
determinants.
3. To strengthen health care for people with non-communicable diseases.
GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020

◦ Vision:
◦ A world free of the avoidable burden of noncommunicable diseases.
◦ Goal:
◦ To reduce the preventable and avoidable burden of morbidity, mortality and
disability due to noncommunicable diseases by means of multisectoral
collaboration and cooperation at national, regional and global levels
GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020

◦ Overarching principles:
◦ • Life-course approach
◦ • Empowerment of people and communities
◦ • Evidence-based strategies
◦ • Universal health coverage
◦ • Management of real, perceived or potential conflicts of interest
◦ • Human rights approach
◦ • Equity-based approach
◦ • National action and international cooperation and solidarity
◦ • Multisectoral action
GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
◦ OBJECTIVES:
◦ 1. To raise the priority accorded to the prevention and control of noncommunicable
diseases in global, regional and national agendas and internationally agreed
development goals, through strengthened international cooperation and advocacy.
◦ 2. To strengthen national capacity, leadership, governance, multisectoral action and
partnerships to accelerate country response for the prevention and control of
noncommunicable diseases.
◦ 3. To reduce modifiable risk factors for noncommunicable diseases and underlying
social determinants through creation of health-promoting environments.
◦ 4. To strengthen and orient health systems to address the prevention and control of
noncommunicable diseases and the underlying social determinants through people-
centered primary health care and universal health coverage.
◦ 5. To promote and support national capacity for high-quality research and
development for the prevention and control of noncommunicable diseases.
◦ 6. To monitor the trends and determinants of noncommunicable diseases and
evaluate progress in their prevention and control.
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
◦ VOLUNTARY GLOBAL TARGETS
◦ (1) A 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or
chronic respiratory diseases
◦ (2) At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context
◦ (3) A 10% relative reduction in prevalence of insufficient physical activity
◦ (4) A 30% relative reduction in mean population intake of salt/sodium
◦ (5) A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years
◦ (6) A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised
blood pressure, according to national circumstances
◦ (7) Halt the rise in diabetes and obesity
◦ (8) At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to
prevent heart attacks and strokes
◦ (9) An 80% availability of the affordable basic technologies and essential medicines, including generics,
required to treat major noncommunicable diseases in both public and private facilities
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 1
◦ • Raise public and political awareness, understanding and
practice about prevention and control of NCDs Contribute to all 9
◦ • Integrate NCDs into the social and development agenda and voluntary global
poverty alleviation strategies
targets
◦ • Strengthen international cooperation for resource mobilization,
capacity-building, health workforce training and exchange of
information on lessons learnt and best practices
◦ • Engage and mobilize civil society and the private sector as
appropriate and strengthen international cooperation to support
implementation of the action plan at global, regional and national
levels
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 2
◦ • Prioritize and increase, as needed, budgetary allocations for
prevention and control of NCDs, without prejudice to the Contribute to all 9
sovereign right of nations to determine taxation and other policies
voluntary global
◦ • Assess national capacity for prevention and control of NCDs
targets
◦ • Develop and implement a national multisectoral policy and plan
for the prevention and control of NCDs through multistakeholder
engagement
◦ • To strengthen national capacity including human and
institutional capacity, leadership, governance, multisectoral action
and partnerships for prevention and control of noncommunicable
diseases
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 3
◦ • TOBACCO USE
◦ Reduce affordability of tobacco products by increasing tobacco A 25% relative
excise taxes reduction in overall
◦ Create by law completely smoke-free environments in all indoor mortality from
workplaces, public places and public transport cardiovascular
◦ Warn people of the dangers of tobacco and tobacco smoke diseases, cancer,
through effective health warnings and mass media campaigns
diabetes or chronic
◦ Ban all forms of tobacco advertising, promotion and sponsorship
respiratory diseases
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 3
◦ • HARMFUL USE OF ALCOHOL At least a 10% relative reduction
◦ Strengthening awareness of alcohol-attributable burden in the harmful use of alcohol, as
appropriate, within the national
◦ Regulating commercial and public availability of alcohol context
◦ Restricting or banning alcohol advertising and promotions A 25% relative reduction in the
◦ Using pricing policies such as excise tax increases on alcoholic prevalence of raised blood
beverages pressure or contain the
prevalence of raised blood
◦ Reducing the public health impact of illicit alcohol and informally
pressure according to national
produced alcohol by implementing efficient control and
circumstances
enforcement systems
A 25% relative reduction in
overall mortality from
cardiovascular diseases, cancer,
diabetes or chronic respiratory
diseases.
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 4 -At least 50% of eligible
◦ Cardiovascular disease and diabetes people receive drug
therapy and counselling
◦ Drug therapy (including glycaemic control for diabetes mellitus
and control of hypertension using a total risk approach) and (including glycaemic
counselling to individuals who have had a heart attack or stroke control) to prevent heart
and to persons with high risk (≥ 30%) of a fatal and nonfatal attacks and strokes.
cardiovascular event in the next 10 years. -A 25% relative reduction in
◦ • Acetylsalicylic acid for acute myocardial infarction. the prevalence of raised
◦ Detection, treatment and control of hypertension and diabetes, blood pressure or contain
using a total risk approach. the prevalence of raised
◦ Treatment of congestive cardiac failure with ACE inhibitor, beta- blood pressure, according
blocker and diuretic. to national circumstances
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 4 -At least 50% of eligible
◦ Cancer people receive drug
therapy and counselling
◦ Prevention of liver cancer through hepatitis B immunization.
(including glycaemic
◦ Prevention of cervical cancer through screening (visual inspection
control) to prevent heart
with acetic acid [VIA] (or Pap smear (cervical cytology), if very
attacks and strokes.
cost-effective), linked with timely treatment of pre-cancerous
lesions. -A 25% relative reduction in
◦ Population-based colorectal cancer screening, including through the prevalence of raised
a fecal occult blood test, as appropriate, at age >50, linked with blood pressure or contain
timely treatment. the prevalence of raised
◦ Oral cancer screening in high-risk groups (e.g. tobacco users, blood pressure, according
betel-nut chewers) linked with timely treatment. to national circumstances
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 4 -At least 50% of eligible
◦ Chronic Respiratory Disease people receive drug
therapy and counselling
◦ Access to improved stoves and cleaner fuels to reduce indoor air
pollution Cost-effective interventions to prevent occupational lung (including glycaemic
diseases, e.g. from exposure to silica, asbestos control) to prevent heart
attacks and strokes.
◦ Treatment of asthma based on WHO guidelines
◦ Influenza vaccination for patients with chronic obstructive
-A 25% relative reduction in
pulmonary disease the prevalence of raised
blood pressure or contain
the prevalence of raised
blood pressure, according
to national circumstances
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 5
◦ • Develop and implement a prioritized national research agenda
for noncommunicable diseases. Contribute to all 9
◦ • Prioritize budgetary allocation for research on noncommunicable voluntary global
disease prevention and control.
targets
◦ Strengthen human resources and institutional capacity for
research
◦ • Strengthen research capacity through cooperation with foreign
and domestic research institutes.
 GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL
OF NONCOMMUNICABLE DISEASES 2013–2020
Menu of policy options Voluntary global targets
◦ Objective 6
◦ Develop national targets and indicators based on global
monitoring framework and linked with a multisectoral policy and Contribute to all 9
plan
voluntary global
◦ • Strengthen human resources and institutional capacity for
targets
surveillance and monitoring and evaluation
◦ • Establish and/or strengthen a comprehensive noncommunicable
disease surveillance system, including reliable registration of
deaths by cause, cancer registration, periodic data collection on
risk factors, and monitoring national response
◦ • Integrate noncommunicable disease surveillance and monitoring
into national health information systems
LIFESTYLE-RELATED DISEASES
VISION-MISSION
◦ VISION:
◦ A Philippines free from the avoidable burden of NCDs

◦ MISSION:
◦ Ensure sustainable health promoting environments and accessible,
cost-effective, comprehensive, equitable and quality health care
services for the prevention and control of NCDs, and guided by the
principle of “Health in All, Health by All, Health for All” .
 OBJECTIVES:
1.To raise the priority accorded to the prevention and control of non-communicable
diseases in national, regional and local health and development plans
2.To strengthen leadership, governance, and multisectoral actions for the prevention and
control of non-communicable diseases
3.To reduce modifiable risk factors for non-communicable diseases and underlying social
determinants through creation of health-promoting environments
4.To strengthen health systems and increase access to quality medicines, products and
services, especially at the primary health care level, towards attainment of universal health
coverage
5.To promote and support research and development for the prevention and control of
non-communicable diseases
6.To monitor the trends and determinants of non-communicable diseases and evaluate
progress in their prevention and control
Program
Components
1. Cardiovascular Disease
2.Diabetes Mellitus
3.Cancer
4.Chronic Respiratory Disease
Policies and Laws
1.AO No. 2011-0003 or The National policy on Strengthening the Prevention and Control of
Chronic Lifestyle Related Non-Communicable Diseases
2.AO No. 2012-0029 or The Implementing Guidelines on the Institutionalization of Philippine
Package of Essential NCD Interventions (PhilPEN) on the Integrated Management of
Hypertension and Diabetes for Primary Health Care Facilities
3.AO No. 2013 – 0005 or The National Policy on the Unified Registry Systems of the
Department of Health (Chronic Non-Communicable Diseases, Injury Related Cases, Persons
with Disabilities, and Violence Against Women and Children Registry Systems)
4.AO 2015-0052: “National Policy on Palliative & Hospice Care in the Philippines
5.AO 2016-0001: “Revised Policy on Cancer Prevention and Control Program
6.AO 2016 – 0014 - Implementing Guidelines on the Organization of Health Clubs for Patients
with Hypertension and Diabetes in Health Facilities
(Administrative Order-2011-0003 National Policy On Strengthening the
Prevention and Control of Chronic Lifestyle Related Non-Communicable
Diseases)
Relevant Statistics
◦ National Nutrition Survey – Food and Nutrition Research Institute (20years old
and above):
Prevalence of Hypertension (2015): 23.9
Prevalence of High Fasting Glucose (2013): 5.6
Prevalence of High total Cholesterol: 18.6
Prevalence of Binge Drinking (2015): Males: 58.8, Female: 41.9
Prevalence of Insufficiently Physically Active Adults (2015): 42.5
Prevalence of Overweight and Obese and Adult (2013): Males: 27.6, Females: 34.4

Global Adult Tobacco Survey 2015:

Prevalence of Current Tobacco Use: 23.8
 Program Accomplishments/Status
1.Finalization of the Philippine Multi-sectoral Strategic Plan for the Prevention and Control of NCDs (2017 – 2025)
2.The Philippine Package of Essential NCD Intervention for the integrated management of hypertension and
diabetes is being implemented nationwide. This is being supplemented by developing the DOH Hypertension and
Diabetes Health Clubs in primary health care facilities which will ensure continuity of care and provision of NCD
drugs. A registry of hypertensives and diabetics was also developed and is maintained by the department.
3.Training on Diabetes management using Insulin for Regional Offices and LGUs
4.Provision of NCD drugs through the Medicine Access Programs (Breast Cancer, Childhood Cancer, Colon and
Rectum Cancer, Insulin, NCD maintenance medicines for hypertension and diabetes)
5.Training on cervical cancer screening using visual inspection using acetic acid (VIA) among health care workers
started in 2013 and on-going. Monitoring of trained institutions started in 2014.
6.NCD indicators are integrated in existing DOH current performance reporting systems like Field Health Service
Information System, Local Government Unit scorecard
7.DOH support for proposed legislative bills focusing on addressing the harmful effects of alcohol consumption, and
integrating palliative and hospice care into the health care system
 Calendar of Activities
◦ Goiter Awareness Week
◦ National Cancer Consciousness Week ◦ Nutrition Month
◦ Philippine Heart Month ◦ Thyroid Cancer Awareness Week
◦ International Childhood Cancer Day
◦ Obesity Awareness and Prevention
◦ Hypertension Awareness Month Week
◦ Cervical Cancer Consciousness Month ◦ Breast Cancer Awareness Month
◦ International Thyroid Awareness Week ◦ World Diabetes Day
◦ World No Tobacco Day
◦ National No Smoking Month
Epidemiology of Infectious disease
• The incubation period—Diseases caused by either an infectious agent
or a noninfectious agent, such as a toxin or carcinogen, have an
intrinsic incubation period after contact with the agent before disease
occurs.

• Resistance—Some individuals may have immunity or resistance to

infection on a biologic basis, such as from previous infection,
immunization, or because of host genetics, and remain uninfected
after exposure.

◦ The control, treatment, and prevention of an epidemic usually involves the

cooperative efforts of all three groups of specialists: clinicians, microbi- ologists,
and epidemiologists.
OUTBREAKS OF DISEASE
EPIDEMIC CURVE
◦ An epidemic curve is a plot of the number of cases against the time
of onset of disease, with time on the horizontal x-axis and the
number of new cases on the vertical y-axis

◦ There are three basic types of epidemic curves:

◦ Point source outbreaks or epidemics
◦ Continuous common source epidemics
◦ Propagated or progressive
◦ source epidemics.
EPIDEMIC CURVE
◦ POINT SOURCE OUTBREAKS (EPIDEMICS)

Example: Graph from a Hepatitis A outbreak

EPIDEMIC CURVE
◦ CONTINUOUS COMMON SOURCE EPIDEMICS
Graph from cholera
outbreak in the Broad
Street area of London in
1854 that was
investigated by Dr. John
Snow.
EPIDEMIC CURVE
◦ PROPAGATED (OR PROGRESSIVE SOURCE EPIDEMIC)
MEASURES OF DISEASE OUTBREAK
◦ Attack rate (AR): proportion of people in a population who develop a particular
condition during an outbreak (specified time period); also called crude attack rate.
◦ Case Fatality rate (CFR): proportion of people with a particular condition who die
from it in a specified time period.
◦ Secondary Attack rate (AR): are used in infectious disease investigations when a
limited timeframe exists and the infectious agent has a short incubation period.
◦ Basic Reproductive Ratio/Basic Reproduction Number (R0): measure of the number
of infections produced on average by an infected individual in the early stages of an
epidemic when virtually all contacts are susceptible.
◦ Positivity rate: percentage of people who tested positive in a particular disease.
◦ Recovery rate: proportion of people who recovered from a particular disease
◦ RECOVERY RATE:
◦ Case recovered X 100
◦ Total case

◦ AVERAGE ATTACK RATE:

◦ ((Cases from recent 1-2 weeks/14)
◦ population)) X 100,000

◦ DAILY POSITIVTY RATE:

◦ Positive result X 100
◦ Total No. of test done

◦ CASE-FATALITY RATE:
◦ Total No. of death X 100
◦ Total No. of case
FIELD INVESTIGATIONS AND PUBLIC
HEALTH SURVEILLANCE
Step 1. Prepare for Field Work
◦ Step 2. Confirm the Diagnosis
◦ Step 3. Determine the Existence of an Outbreak
◦ Step 4. Identify and Count Cases
◦ Step 5. Tabulate and Orient the Data in Terms of Time, Place, and Person
◦ Step 6. Consider Whether Control Measures Can Be Implemented Now
◦ Step 7. Develop and Test Hypotheses
◦ Step 8. Plan One or More Systematic Studies
◦ Step 9. Implement and Evaluate Control and Prevention Measures
◦ Step 10. Communicate Findings
 FIELD INVESTIGATIONS AND PUBLIC
HEALTH SURVEILLANCE
◦ PUBLIC HEALTH SURVEILLANCE
◦ is “the ongoing, systematic collection, analysis, and interpretation of health-related data essential to
planning, implementation, and evaluation of public health practice closely integrated with the timely
dissemination of these data to those responsible for prevention and control.”

◦ GOAL OF PUBLIC HEALTH SURVEILLANCE

◦ To identify patients and their contacts for treatment and intervention
◦ To detect epidemics, health problems, changes in health behaviors
◦ To estimate magnitude and scope of health problems
◦ To measure trends and characterize disease
◦ To monitor changes in infectious and environmental agents
◦ To assess effectiveness of programs and control measures
◦ To develop hypotheses and stimulate research
PUBLIC HEALTH SURVEILLANCE PROCESS
Thank you!
 “The struggle you’re in
Today is developing the
strength you need for
Tomorrow”