MDGs

The Millennium Development Goals (MDGs) & Targets to be achieved by 2015 come from Millennium Declaration, signed by 191 countries, in September 2000.

The Eight Millennium Development Goals are

To eradicate extreme poverty and hunger; To achieve universal primary education; To promote gender equality and empower women; To reduce child mortality; To improve maternal health; To combat HIV/AIDS, malaria, and other diseases; To ensure environmental sustainability; and To develop a global partnership for development.

Achieving MDGs in Pakistan

For attainment of 8 Millennium Goals the UN Millennium Declaration had fixed 18 Targets and 48 Indicators

Pakistan has adopted 16 Targets and 37 Indicators

MDGs Pakistan
MDGs
1 2 3

Targets
2 1 1

Indicators
3 3 4

Eradicate Extreme Poverty and Hunger Achieve Universal Primary Education Promote Gender Equality & Women Empowerment Reducing Child Mortality Improving Maternal Health Combating HIV/AIDS, Malaria and other Diseases Ensuring Environmental Sustainability Develop a Global Partnership for Development*

4 5 6

1 1 2

6 5 5

7 8

3 5 16

8 7 37

Achieving MDGs in Pakistan Health (Goal 4, 5 and 6)

Target 5 Target 6 Target 7 Target 8
{Under-five Mortality, Health and Care}

{Maternal Mortality} {HIV/ AIDS}

{Malaria, TB and Other Major Diseases}

Goal 4: Reduce Child Mortality

Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Targets Pakistan Target for 2010
Under-5 mortality rate is 84 Infant mortality rate 71 Proportion of fully immunized Children against Measles 80%
UNICEF 2010

77 65 90 %

Goal 5: Improve Maternal Health

Targets a) Reduce by three-quarters between 1990 and 2015, the Maternal Mortality ratio; B) Achieve universal access to reproductive health by 2015. Maternal Mortality Ratio 2009 -10 is : 272 (UNICEF 2010) Target 2009-10 : 300 Proportion of births attended by skilled birth attendants : 45 Target 2009-10 : 60

Goal 5: Improve Maternal Health

Contraceptive Prevalence Rate: 30 Target 2009-10 : 51

Total Fertility Rate Target 2009-10

:3.8 :2.7 (UNICEF-2010)

 Target 7: Have halted by 2015, and begun to reverse, the spread of HIV/AIDS Target 8: Have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases Proportion of TB cases detected and cured under
DOTS(Direct Observed Treatment Short Course)

Goal 6: Combating HIV/AIDS, Malaria and Other Diseases

in 2009 2010 =80 cases Target 2009 2010 =85cases

Goal 6: Combating HIV/AIDS, Malaria and Other Diseases

Incidence of tuberculosis per 100,000 population 2009- 2010 = 175 cases (National TB Control Program , Ministry of Health) Target 2009 2010 130 cases HIV prevalence per 100,000 0.1 (National Aids control program, Ministry of Health)

Attaining the MDGs in Pakistan

Security issues, financial crunches and certain other domestic and international issues have undermined the efforts of Pakistan in attaining the Millennium Development Goals (MDGs). For the past few years, a security paradigm has replaced the development paradigm in the country In spite of the unfavorable circumstances, the Government of Pakistan is resolved to fulfill its commitment of achieving MDGs.

Descriptive and Analytic Epidemiology

Descriptive Epidemiology
Prevalence and Incidence

What is Epidemiology?
Study of the distribution and determinants of states or events in specified populations, and the application of this study to the control of health problems
Study risk associated with exposures Identify and control epidemics Monitor population rates of disease and exposure

What is Epidemiology?
Looking to answer the questions: Who? What? When? Where? Why? How?

Descriptive vs Analytic Epidemiology

Descriptive epidemiology deals with the questions: Who, What, When, and Where
Analytic epidemiology deals with the remaining questions: Why and How

Descriptive Epidemiology
Provides a systematic method for characterizing a health problem Ensures understanding of the basic dimensions of a health problem Helps identify populations at higher risk for the health problem Provides information used for allocation of resources Enables development of testable hypotheses

Descriptive Epidemiology What?

Addresses the question How much? Most basic is a simple count of cases
Good for looking at the burden of disease Not useful for comparing to other groups or populations Race Black White # of Salmonella cases 119 497 Pop. size 1,450,675 5,342,532

http://www.vdh.virginia.gov/epi/Data/race03t.pdf

Prevalence
The number of affected persons present in the population divided by the number of people in the population

# of cases Prevalence = ----------------------------------------# of people in the population

Prevalence Example
In 1999, a US state reported an estimated 253,040 residents over 20 years of age with diabetes. The US Census Bureau estimated that the 1999 population over 20 in that state was 5,008,863. 253,040 Prevalence= = 0.051 5,008,863 In 1999, the prevalence of diabetes was 5.1% Can also be expressed as 51 cases per 1,000 residents over 20 years of age

Prevalence
Useful for assessing the burden of disease within a population Valuable for planning Not useful for determining what caused disease

Incidence
The number of new cases of a disease that occur during a specified period of time divided by the number of persons at risk of developing the disease during that period of time # of new cases of disease over a specific period of time

Incidence =

# of persons at risk of disease over that specific period of time

Incidence Example
A study in 2002 examined depression among persons with dementia. The study recruited 201 adults with dementia admitted to a long-term care facility. Of the 201, 91 had a prior diagnosis of depression. Over the first year, 7 adults developed depression. Incidence = 7 = 0.064

110 The one year incidence of depression among adults with dementia is 6.4% Can also be expressed as 64 cases per 1,000 persons with dementia

Incidence
High incidence represents diseases with high occurrence; low incidence represents diseases with low occurrence Can be used to help determine the causes of disease

Can be used to determine the likelihood of developing disease

Prevalence and Incidence

Prevalence is a function of the incidence of disease and the duration of disease

Prevalence and Incidence

Prevalence

= prevalent cases

Prevalence and Incidence

New prevalence

Incidence
Old (baseline) prevalence

No cases die or recover

= prevalent cases

= incident cases

Prevalence and Incidence

= prevalent cases

= incident cases

= deaths or recoveries

Practice Scenario
A town has a population of 3600. In 2003, 400 residents of the town are diagnosed with a disease. In 2004, 200 additional residents of the town are diagnosed with the same disease. The disease is lifelong but it is not fatal. How would you calculate the prevalence in 2003? In 2004? How would you to calculate the incidence in 2004?

Practice Scenario Answers

Population : 3600 2003: 400 diagnosed with a disease 2004: 200 additional diagnosed with the disease No death, no recovery Prevalence Prevalence Incidence (2003) (2004) (2004) Numerator Denominator 400 3600 11.1% 600 3600 16.7% 200 3200 6.3%

Descriptive Epidemiology
Person, Place, Time

Descriptive Epidemiology
Who? When? Where?

Related to Person, Place, and Time Person

May be characterized by age, race, sex, education, occupation, or other personal characteristics

Place
May include information on home, workplace, school

Time
May look at time of illness onset, when exposure to risk factors occurred

Person Data
Age and Sex are almost always used in looking at data
Age data are usually grouped intervals will depend on what type of disease / event is being looked at

May be shown in tables or graphs May look at more than one type of person data at once

Data Characterized by Person

70

Overweight and obesity by age: United States, 1960-2002

60

50

Overweight including obese, 20-74 years

Percent

40

30

Overweight, but not obese, 20-74 years

20

Obese, 20-74 years

10

Overweight, 6-11 years

Overweight, 12-19 years

1960- 196365 62

196670

197174

197680

Year

198894

19992002

SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Examination Survey and National Health and Nutrition Examination Survey.

Data Characterized by Person

Data Characterized by Person

Emergency Room Visits for Consumer-product Related Injuries among the Elderly (65 years and older), 2002
Packaging and containers, 35,020

Home workshop tools, 38,210

Bathrooms, 85,630

Yard / garden equipment, 41,780

Personal use items, 58,220 Sports, 57,120

Housewares, 52,990

Time Data
Usually shown as a graph
Number / rate of cases on vertical (y) axis Time periods on horizontal (x) axis

Time period will depend on what is being described Used to show trends, seasonality, day of week / time of day, epidemic period

Data Characterized by Time

Epi Curve for E.Coli Outbreak, n=108
12
10
Number of cases

6 4
2 0 10/11 10/14 10/17 10/20 10/23 10/26 10/29 11/1 11/4 11/7 11/10

Date of onset

http://www.dhhs.state.nc.us/docs/ecoli.htm

Data Characterized by Time

http://www.hivclearinghouse.org/0Surveillance%203rd%20Quarter%20Report.pdf

Data Characterized by Time

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5153a1.htm

Data Characterized by Time

http://www.health.qld.gov.au/phs/Documents/cdu/12776.pdf

Place Data
Can be shown in a table; usually better presented pictorially in a map Two main types of maps used: choropleth and spot
Choropleth maps use different shadings/colors to indicate the count / rate of cases in an area Spot maps show location of individual cases

Data Characterized by Place

Data Characterized by Place

Spot map of men who tested positive for HIV at time of entry into the Royal Thai Army, Thailand, November 1991May 2000.
http://www.cdc.gov/ncidod/EID/vol9no7/02-0653G1.htm

Data Characterized by Place

Source: Olsen, S.J. et al. N Engl J Med. 2003 Dec 18; 349(25):2381-2.

Analytic Epidemiology
Hypotheses and Study Designs

Analytic Epidemiology
Used to help identify the cause of disease Typically involves designing a study to test hypotheses developed using descriptive epidemiology

Exposure and Outcome

A study considers two main factors: exposure and outcome Exposure refers to factors that might influence ones risk of disease

Outcome refers to case definitions

Developing Hypotheses
A hypothesis is an educated guess about an association that is testable in a scientific investigation Descriptive data provide information to develop hypotheses Hypotheses tend to be broad initially and are then refined to have a narrower focus

Example
Hypothesis: People who ate at the picnic were more likely to become ill
Exposure is eating at the picnic Outcome is illness this would need to be defined, for example, ill persons are those who have diarrhea and fever

Hypothesis: People who ate the egg salad at the picnic were more likely to have laboratory-confirmed Salmonella
Exposure is eating egg salad at the church picnic Outcome is laboratory confirmation of Salmonella

Types of Studies
Two main categories:
1. Experimental 2. Observational

1. Experimental studies exposure status is assigned 2. Observational studies exposure status is not assigned

Experimental Studies
Can involve individuals or communities Assignment of exposure status can be random or non-random The non-exposed group can be untreated (placebo) or given a standard treatment Most common is a randomized clinical trial

Experimental Study Examples

Randomized clinical trial to determine if giving magnesium sulfate to pregnant women in preterm labor decreases the risk of their babies developing cerebral palsy Randomized community trial to determine if fluoridation of the public water supply decreases dental cavities

Observational Studies
Three main study designs: 1. Cross-sectional study 2. Cohort study 3. Case-control study

Cross-Sectional Studies
Exposure and outcome status are determined at the same time Examples include:
Behavioral Risk Factor Surveillance System (BRFSS) - http://www.cdc.gov/brfss/ National Health and Nutrition Surveys (NHANES) http://www.cdc.gov/nchs/nhanes.htm

Also include most opinion and political polls

Cohort Studies
Study population is grouped by exposure status Groups are then followed to determine if they develop the outcome
Exposure Outcome

Prospective
Retrospective

Assessed at beginning of study

Assessed at some point in the past

Followed into the future for outcome

Outcome has already occurred

Cohort Studies
Study Population
Exposure is self selected
Exposed Non-exposed

Follow through time

Disease No Disease Disease No Disease

Cohort Study Examples

Study to determine if smokers have a higher risk of lung cancer Study to determine if children who receive influenza vaccination miss fewer days of school Study to determine if the coleslaw was the cause of a foodborne illness outbreak

Case-Control Studies
Study population is grouped by outcome Cases are persons who have the outcome Controls are persons who do not have the outcome Past exposure status is then determined

Case-Control Studies
Study Population

Cases

Controls

Had Exposure

No Exposure

Had Exposure

No Exposure

Case-Control Study Examples

Study to determine an association between autism and vaccination Study to determine an association between lung cancer and radon exposure

Study to determine an association between salmonella infection and eating at a fast food restaurant

Cohort versus Case-Control Study

Classification of Study Designs

Source: Grimes DA, Schulz KF. Lancet 2002; 359: 58

Measures of Association and Statistical Tests

Measures of Association
Assess the strength of an association between an exposure and the outcome of interest Indicate how more or less likely a group is to develop disease as compared to another group Two widely used measures:
1. Relative risk (a.k.a. risk ratio, RR) 2. Odds ratio (a.k.a. OR)

2 x 2 Tables
Used to summarize counts of disease and exposure in order to do calculations of association Outcome

Exposure
Yes

Yes
a

No
b

Total
a+b

No
Total

c
a+c

d
b+d

c+d
a+b+c+d

2 x 2 Tables
a = number who are exposed and have the outcome b = number who are exposed and do not have the outcome c = number who are not exposed and have the outcome d = number who are not exposed and do not have the outcome

***************************************************** ************* a + b = total number who are exposed c + d = total number who are not exposed a + c = total number who have the outcome b + d = total number who do not have the outcome Outcome a + b + c + d = total study population
Yes Yes Exposure No

No

a c

b d

Relative Risk
The relative risk is the risk of disease in the exposed group divided by the risk of disease in the nonexposed group RR is the measure used with cohort studies
Outcome Yes No Yes Exposure No Total

a c

b d

a+b c+d

Risk among the exposed Risk among the unexposed

a a+b
RR = c c+d

Relative Risk Example

Escherichia coli? Pink hamburger Yes No Total Total Yes 23 7 30 No 10 60 70 33 67 100

RR =

a / ( a + b) c / ( c + d)

23 / 33 7 / 67

= 6.67

Odds Ratio
In a case-control study, the risk of disease cannot be directly calculated because the population at risk is not known

OR is the measure used with case-control studies axd

OR = bxc

Odds Ratio Example

Autism MMR Vaccine? Yes No Total Total Yes 130 120 250 No 115 135 250 245 255 500

OR =

axd bxc

130 x 135 115 x 120

= 1.27

Interpretation
Both the RR and OR are interpreted as follows: = 1 - indicates no association > 1 - indicates a positive association

< 1 - indicates a negative association

Interpretation
If the RR = 5
People who were exposed are 5 times more likely to have the outcome when compared with persons who were not exposed

If the RR = 0.5
People who were exposed are half as likely to have the outcome when compared with persons who were not exposed

If the RR = 1
People who were exposed are no more or less likely to have the outcome when compared to persons who were not exposed

Tests of Significance
Indication of reliability of the association that was observed Answers the question How likely is it that the observed association may be due to chance? Two main tests:
1. 95% Confidence Intervals (CI) 2. p-values

95% Confidence Interval (CI)

The 95% CI is the range of values of the measure of association (RR or OR) that has a 95% chance of containing the true RR or OR One is 95% confident that the true measure of association falls within this interval

95% CI Example
Disease Odds Ratio 95% CI

Gonorrhea
Trichomonas Yeast

2.4
1.9 1.3

1.3 4.4
1.3 2.8 1.0 1.7

Other vaginitis
Herpes Genital warts

1.7
0.9 0.4

1.0 2.7
0.5 1.8 0.2 1.0

Grodstein F, Goldman MB, Cramer DW. Relation of tubal infertility to history of sexually transmitted diseases. Am J Epidemiol. 1993 Mar 1;137(5):577-84

Interpreting 95% Confidence Intervals

To have a significant association between exposure and outcome, the 95% CI should not include 1.0 A 95% CI range below 1 suggests less risk of the outcome in the exposed population A 95% CI range above 1 suggests a higher risk of the outcome in the exposed population

p-values
The p-value is a measure of how likely the observed association would be to occur by chance alone, in the absence of a true association A very small p-value means that you are very unlikely to observe such a RR or OR if there was no true association A p-value of 0.05 indicates only a 5% chance that the RR or OR was observed by chance alone

p-value Example
Disease Gonorrhea Trichomonas Yeast Odds Ratio 2.4 1.9 1.3 95% CI 1.3 4.4 1.3 2.8 1.0 1.7 p-value 0.004 0.001 0.04

Other vaginitis Herpes

Genital warts

1.7 0.9
0.4

1.0 2.7 0.5 1.8

0.2 1.0

0.04 0.80
0.05

Grodstein F, Goldman MB, Cramer DW. Relation of tubal infertility to history of sexually transmitted diseases. Am J Epidemiol. 1993 Mar 1;137(5):577-84

Summary
Descriptive Epidemiology
Answers: Who, what, where, when Key Terms: Prevalence, person, place, time Hypothesis-generating

Analytic Epidemiology
Answers: Why, how Key Terms: Measure of association Hypothesis-testing