March 14, 2023 – Tuesday

Basic Epidemiology Course

Dr. Eugenia Mercedes R. Canal

TOPIC I: Public Health Approach

Surveillance – > Risk Factor Identification – > Intervention Evaluation - > Implementation
(Problem) (Cause) (What Works) (Response)

Core Sciences:
1. Prevention Effectiveness
2. Surveillance
3. Informatics
4. Epidemiology
5. Laboratory
6. Public Health

Epidemiology:
- Study of distribution and determinants of health-related states among specified
populations and he application of that study to the control of health problems.

Purposes:
- Discover the agent, host, and environmental factors that affect health.
- Determine the relative importance of causes of illness, disability, and death.
- Identify those segments of the population that have the greatest risk from specific
cause of ill health.
- Evaluate the effectiveness of health programs and services in improving population
health.

Solving Health Problems:

- Step 1: Data Collection - > Surveillance, Determine time, place and person
- Step 2: Assessment - > Inference (a conclusion reached on the basis of evidence)
- Step 3: Hypothesis Testing - > Determine how and why
- Step 4: Action - > Intervention

Key Terms:
- Epidemic: Clustering of causes
- Endemic: Present in a population
- Rate: Number of cases occurring during a specific period
- Pandemic: Disease that spreads across regions
- Cluster: Group of cases in a specific time and place that might be more than
expected
Rates:
- Help us compare health problems among different populations that include two or
ore groups who differ by a selected characteristic.

Rate Formula:
1. The number of cases of the illness
2. Size of population at risk
3. The period during which we are calculating the rate in an outbreak

Rate (%) = Number of Cases / Population at Risk X 100

Epidemiology Study Type:

- Experimental
- Observational
o Descriptive
o Analytic

Descriptive:
- When was the population affected?
- Where was the population affected?
- Who was affected?

Analytic:
- How was the population affected?
- Why was the population affected?

Data Sources and Collection Methods:

1. Individual Persons – Questionnaire and Survey
2. Environment
3. Health Care Providers
4. Nonhealth-related Sources

Conducting Study:
- Studies are conducted in an attempt to discover associations between an exposure
or risk factor and a health outcome.

Cross-Sectional Study:
- Subjects are selected because they are members of a certain population subset of a
certain time.

Cohort Study:
- Subjects are categorized on the basis of their exposure at one or more time.
Case Control:
- Study that compares population with versus without the disease.

Laboratory:
- Working in collaboration with other arms of the nation’s public health system, PHLs
provide:
o Clinical diagnostic testing
o Disease surveillance
o Advanced skills in laboratory practice

Goal:
1. Protect and improve public health by testing samples, providing expertise, and
communicating scientific information.

1:100,000 – One confirmed case is considered as an outbreak of Measles

Core Functions:
1. Disease prevention, control, and surveillance
2. Integrated data management
3. Reference and specialized testing
4. Environmental health and protection
5. Food safety
6. Laboratory improvement and regulation
7. Policy development
8. Public health preparedness and response
9. Public health-related research
10. Training and education
11. Partnerships and communication

System Infrastructure:
- State and Territories
- Federal
- Environmental
- Private

Using PHL Results:

- Data are used to monitor trends and detect changes
- Identify or confirm an outbreak
- Guide public policy
- Determine disease history
- Prioritize resource allocation
- Provide a baseline for epidemiologic research, and
- Identify environmental hazard and exposures
Informatics:
- Public health informatics is the systematic application of the information, computer
science, and technology to public health practice, research, and learning.

Informatician:
- Envisions innovative scenarios
- Understands ideas
- Understands capabilities, opportunities, and limitations

Building Your Public Health Information System:

1. Programmer
2. Database Administrator
3. Network Administrator
4. Web Designer
5. Security Specialist

Surveillance:
- Ongoing systematic collection, analysis and interpretation of health-related data
essential to planning, implementation, and evaluation if public health practice
closely integrated with timely dissemination of health-related data.

Goal:
- Used for health action by public health personnel, govt leaders, and the public to
guide public health policy and programs.

P - Prevent
D - Detect
I - Isolate
T - Treat
R - Reintegrate
M – Mainstream

Types and Attributes:

Passive Surveillance:
1. Diseases are reported by the HC providers
2. FSHIS
3. Simple and inexpensive
4. Limited by incompleteness of reporting

Active Surveillance:
1. PIDSR and ESR
Sentinel Surveillance:
- Reporting of health events by health professionals who are selected to represent a
geographic area or a specific reporting group.
- Active or Passive

Syndromic Surveillance:
- Focuses on one or more symptoms

Process:
- Data Collection
- Data Analysis
- Data Interpretation
- Data Dissemination
- Link to Action – End goal is to influence the decisions of the leader

Data Sources:
1. Reported diseases or syndromes
2. Electronic health records
3. Vital records
4. Administrative Data Systems

Value of an Epidemic Curve:

- Shows the magnitude of the outbreak
- Shows the time course of the outbreak

In data interpretation, by identifying the person, protocol, and risk, you can more easily
determine how and why the health event occurred.

TOPIC II: IMRaD REPORTING

Introduction, Methods, Results and Discussion

- It is often used for lab reports as well as for reporting any planned, systematic
research in the different sciences.

Introduction:
- Why did you start?
Methods:
- What did you do?
Results:
- What did you find?
Discussion:
- What does it mean?
Conclusion and Recommendation
Introduction:
- Brief, clear, to the point
- Write in present tense
- State the aim or objective of the study
- Learn about the disease:
o Sufficient background information

Background:
- Detailed yet brief information of the said illness or condition

Method:
- What as all done?
- How was it done?
- When was it done?
- Who did it?
- How were the results analyzed?
- Did you have ethical clearance to do so?

Methodology:
- Descriptive Study
- Analytic Study

Results:
- Collate the data (n – proportion of the total number; N – total number)
- Prepare tables, and figures - Epidemic Curve, and Age and Sex Distribution (One
table)
- Analyze
o List all the findings
o Identify the important ones
- Text - Story
- Tables – Meat
- Figure – Drama
- Should not include:
o Any methods
o Data for which methods are not included
o No interpretation of data, and references

Discussion:
- Answers “so what?”
o What do these results tell you?
o What use is the information?
o Do you have suggestions for the future generation?
 - This is the place for you to speculate what you found
- Explain the meanings and implications of the results
- Relate the results to the questions that were set out in the introduction
TOPIC III: Case Definition

Case Definitions and Line Lists

Case Definition
- Uniformly applied set of criteria for deciding whether to classify a person as having a
particular disease, injury or other health related condition.

Applications:
- For clinical diagnosis and management
- Surveillance
- Outbreak investigation
- Analytic studies

Cholera:
- Suspected Case:
o A patient of more than or equal of 5 years if age with severe dehydration or
death from acute watery diarrhea
- Confirmed Case:
o Vibrio cholerae 01 or 0139 isolated

Purpose of Surveillance Case Definition:

- Ensure that cases are classified in a consistent way
- To be guided what to, and not to report
- To determine whether the case to reported or not

Characteristics of Surveillance Case Definition:

- Clinical Features: Signs, Symptoms, Lab Results
- Demographic Criteria (Age, Gender, Address, etc.)
- Many are tiered:
o Suspect
o Probable or possible (Epi-Linking Method)
o Confirmed

Chikungunya:
- Suspected Case:
o Any person with acute onset of fever > 38.5 deg C and severe arthralgia or
arthritis
- Confirmed Case:
o A suspected case with laboratory confirmation
Measles:
- Suspected Case:
o Fever
o Generalized maculopapular rash
o Cough, coryza and/or conjunctivitis

Why is uniform use of case definitions important?

- Ensure comparability of disease numbers and patterns across geographic areas
- Ensure comparability of disease numbers and patterns over time
- Many case definitions are stratified to reflect that certainty of the diagnosis
- No case definition is perfect - - some cases will not be captured, and some non-cases
will be

Line Lists or Line Listing:

- Ensures that comparable data are collected for each case
- Convenient and helpful too for organizing data about cases
- Table used for public health surveillance or epidemiologic investigation that includes
limited information about each person, organized into rows and columns.
o One row per person
o One column per variable

Categories of the Information in a Line List:

- Identifying information (Case Name, Initials, UIC)
- Demographic information (Age, Sex, DOB, Location)
- Clinical information
- Risk factors (usually for outbreaks)

TOPIC IV: Data Collection

Detect - > Data Collection

Reporting Sources:
- Health Care Providers
- Laboratories
- Pharmacists
- Media Reports
- Sick persons, family, relatives, neighbors
- Other (Death Certificate)
Notifiable Disease:
- Varies by country
o Lists of diseases (20-80+)
o Case definitions
o How to report
o How quickly to report
o How much detail to provide
- What are the surveillance requirements in this country?
o Ordinance
o Manpower
o Trained personnel in ESR, PDSR, and Basic Epidemiology
o Office

Passive Data Collection:

- It relies on others
- Healthcare provider initiates
- Usually adequate for monitoring trends over person, palce and time

Active Data Collection:

- Requires assertive action
- Health agency solicits information
- Usually reserved for diseases of special interest

Aggregate:
- Number of cases
- By age or sex
- Weekly or monthly

Case Based (Individual):

- Each case reported individually
- Line list or case report

Zero Reporting:
- Report of zero cases when no cases are observed within specific time frame
- Distinguishes between report stating no cases were observed and and report not
being submitted
- Is a key feature of surveillance systems
- Silent DRU

Role of the Laboratory:

- Important public health partners in a district
- Laboratory confirmation is essential to:
o Rule in or diagnose a specific disease
 o Rule out (or exclude) a specific disease
o Confirm a case of a reportable disease
o Verify the cause of a suspected outbreak
- Acute laboratory results require a specimen that is:
o Collected at the proper time during a person’s illness
o Collected from the proper source
o Placed in the correct transport media
o Handled, stored, and transported properly
 Diarrhea – Cary Blaire Transport Medium
 Pertussis – Regan Lowe Transport Medium
 COVID19 – Universal Transport Medium

Limitations of the Reporting Systems:

- Underreporting, incomplete reporting
- Lack of timeliness
- Inconsistent use of case definition

Ways to Improve Reporting:

- Improve awareness
- Reduce reporting burden – simplify reporting and conduct surveillance
- Monitor and conduct validation of data

Data Quality:
- The level of accuracy and completeness of data in a dataset
o Accurate, Complete and Timely (ACT)
- Do the data accurately reflect reality, so that the data serve the intended purpose?

Data Quality Issues:

- Individual Records:
o Missing Data
o Incorrect Data
o Unreadable Data
- Data System:
o Delated Records
o Missing Records
o Duplicate Records

When Do Data Quality Issues Occur?

- Data Collection

Common Types of Data Entry Errors:

- Transposition
- Copying
 - Coding
- Consistency
- Range

Causes of Poor Quality Data:

- During Data Collection
o Poorly designed forms
o Patient inability or refusal to provide information
o Language barriers
o Health provider inability or refusal to collect data
o Missing or inaccurate facility records
o Late collection and/or reporting
- During Data Entry, Management, Analysis
o Transcription errors
o Calculation errors
o Data handling errors (lost data, lost files, wrong files)

Impact of Poor Surveillance Data Quality:

- Distorted picture of disease occurrence
- Inadequate monitoring and evaluation of program effectiveness
- Reduced confidence and support

Steps to Promote Better Data Quality:

- Used standardized forms, procedures, and terms
- Distribute written guidelines to all reporting sites
- Provide training in importance of surveillance
- Conduct regular data quality check

TOPIC V: Displaying and Interpreting Data

Displaying Data
- Collect - > Compile and Analyze

Age and Sex of Case Patient (Line List)

Case Number Date of Onset Age Sex

1 21 Nov 2022 9 M
2 21 Nov 2022 39 M
3 21 Nov 2022 29 F
Why Organize and Display Data?
- Summarize when dataset has too many records to review individually
- Become familiar with the data before analysis
- Identify errors
- Identify and display
o Patterns
o Trends
o Relationships
o Exceptions

Methods for Summarizing Data

- Tables
- Graphs
- Maps

Types of Tables:
- 1-Variable Table (Frequency)
o Multiple Table
- 2-Variable Table
o All called as cross tab or contingency table
- Frequency Distribution Table
- Composite or Combination Table

Graphs:
- Line Graph
- Histogram
- Bar Graph

Variables:
- Quantitative – Line graph, or Histogram
- Qualitative – Bar graph

Why is distinction important?

- Because we summarize different variable types with different summary methods.

Histogram:
- Commonly used for outbreaks
- Quantitative
- Epidemic curve
- X-axis usually time (date of symptom onset or date of diagnosis)
- Y-axis represents frequency or number of reported cases
- No need to rearrange
Bar Graphs:
- Used for qualitative data
- Can be vertical or horizontal
- Gender, symptoms
- Rearrange order of columns
- Have the same width
- Have spaces or gaps

Maps:
- Describe the geographic distribution of disease.
o The two most common types are:
 Spot maps
 Area Maps

TOPIC VI: Interpreting Data:

Interpretation
- Process of assigning meaning to observation and analysis results

Aspects of Interpreting Surveillance Data:

1. Explain epidemiologic and statistical measures and findings in plain language
2. Compare the observed data to each threshold
a. Threshold – level of disease occurrence at which public health officials should
prepare and take action
i. Alert Threshold
ii. Epidemic Threshold
iii. Action Threshold
3. Compare the observed to expected values
a. Observed
b. Expected
i. Endemic – Ongoing presence of an agent or health condition within a
geographic area,
ii. Epidemic – Sudden increase of number within a geographic data
4. Consider the quality data
a. Completeness
b. Timeliness
c. Accuracy
5. Consider possible explanations in apparent increase of cases:
o True increase in disease occurrence:
 Outbreak
 Seasonal pattern
 Sudden increase in size of population
o Change in reporting procedures
o Change un case definition
 o Increase or improvement in laboratory setting
o Increased awareness of disease
o Increased access to health care
o New health care provider, reporter or clinic
o Laboratory or diagnostic error
o Batch reporting

6. Make inferences
- A conclusion reached on the basis of evidence and reasoning/judgment.
March 15, 2023 – Wednesday

Investing an Epidemic: Steps of an Epidemic Investigation

Epidemic
- An increase, of sudden, in the number of cases of disease above what is normally
expected in a given area.
Outbreak

Criteria:
1. If the disease is priority
2. Disease exceeds the usual expected frequency
3. Cases are due to common sources
4. When the disease seems to be more severe
5. When a disease has not previously occurred for a long time in a place

Steps of an Outbreak Investigation:

Step 1: Prepare for Field Work