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Epidemiologi

Intermediate
Departemen Epidemiologi
Fakultas Kesehatan Masyarakat Universitas Indonesia

Definisi (1)
Tidak ada definisi tunggal
Epidemiologi

Dari bahasa Greek.


Epi = atas, pada,
demos = penduduk,
logi = studi
Studi distribusi dan determinan peristiwa
kesehatan dalam populasi manusia.
2

Definisi (2)
Hirsch (1883)
Suatu gambaran kejadian, distribusi, dan tipe penyakit
manusia, ..

Frost (1927)
Ilmu fenomena masal penyakit infeksius, atau seperti
riwayat alamiah penyakit infeksius suatu ilmu induktif
yang tidak hanya mendeskripsikan distribusi penyakit,
melainkan kesesuaiannya dalam suatu filosofi yang
konsisten
3

Definisi (3)
Greenwood ( 1934)
Epidemiologi adalah studi penyakit sebagai
fenomena massal

Lilienfeld (1957)
Epidemiologi boleh didefinisikan sebagai studi
distribusi suatu penyakit atau kondisi dalam populasi
dan faktor yang mempengaruhi distribusi ini

Definisi (4)
Taylor (1963)
Studi kesehatan atau penyakit dalam populasi

McMahon, Pugh, dan Ipsen (1970)


Studi distribusi dan determinan frekuensi
penyakit pada manusia distribusi
(epidemiologi deskriptif) dan determinan dari
distribusi yang tercatat (epidemiologi analitik)

Epidemiology Defined
Greek roots
epi = upon (as in epidermis)
demos = the people (as in demography)
ology = to speak of, to study
Literally - study of epidemics
Modern definitions of epidemiology refer to
distributions in populations (statistical)
determinants (pathophysiological, environmental,
behavioral)
control of health problems (biological, social,
6
economic, political, administrative, legal)

Public
Health
Defined
Definitions of public health refer to
organized effort (activity)
reduction of morbidity & mortality
improvements in health
Main public health competency areas
epidemiology
biostatistics
health administration
behavioral
environmental health science
7

Epidemiology compared
to

medicine

Main unit of concern in epi population


Main unit of concern in medicine individual

public health
Epidemiology study of
Public health organized effort
Epi said to be methodologic backbone of public
health
8

Definisi (5)
Suatu ilmu dasar dari kedokteran pencegahan dan
kesehatan masyarakat yang mempelajari:
Penyakit (atau status kesehatan)
Frekuensi (enumerasi jumlah yang ada atau tingkat
perkembangan dalam periode waktu spesifik)
Determinan (faktor yang mempengaruhi distribusi)
Metode (proses yang dilakukan untuk mendeskripsikan
frekuensi dan distribusi, rasional ilmiah yang digunakan
untuk menentukan kausal distribusi penyakit dalam
populasi
Populasi (populasi manusia tertentu)

Epidemiologi Ilmu dasar semua aspek


kesehatan masyarakat: (1)
Penyakit infeksi
Penyakit kronis
Cedera intensional dan tidak intensional
Kesehatan mental
Nutrisi

10

Epidemiologi Ilmu dasar semua aspek


kesehatan masyarakat: (2)
Pendidikan dan promosi kesehatan
Perencanaan kesehatan
Administrasi kesehatan masyarakat
Pelayanan pengobatan medis

11

Ruang lingkup

Definisi penyakit
Kejadian penyakit
Penyebab penyakit
Keluaran penyakit
Pengelolaan penyakit dan pencegahan
penyakit
12

Aktivitas epidemiologi (1)


1. Pengumpulan dan analisis pencatatan vital
(kelahiran dan kematian)
2. Pengumpulan dan analisis data morbiditas
dari rumah sakit, lembaga kesehatan, klinik,
dokter dan industri
3. Pemantauan penyakit dan masalah
kesehatan komunitas yang lain

13

Aktivitas epidemiologi (2)


4. Investigasi kejadian luar biasa yang
mengarahkan program pemberantasan atau
pencegahan epidemik dan masalah kesehatan
komunitas yang lain
5. Merancang dan melaksanakan penelitian
kesehatan
6. Merancang dan melaksanakan registrasi
kesehatan untuk masalah yang menjadi
perhatian seperti: cacat lahir, insidens kanker,
14
atau penggunaan napza

Aktivitas epidemiologi (3)


7.

Skrining (penapisan) untuk penyakit

8.

Penilaian efektivitas keberadaan pengobatan


yang baru

9.

Mendeskripsikan riwayat alamiah penyakit

10.

Identifikasi individu atau kelompok pada


populasi umum terhadap peningkatan risiko
perkembangan penyakit tertentu
15

Aktivitas epidemiologi (4)


11. Identifikasi keterkaitan etiologi penyakit
12. Identifikasi masalah kesehatan masyarakat
dan pengukuran besar distribusi,
frekuensi, atau dampak pada kesehatan
masyarakat

16

Aktivitas epidemiologi (5)


13. Penilaian program kesehatan
14. Menyediakan data yang diperlukan untuk
perencanaan kesehatan atau pembuatan
keputusan oleh badan administrasi
kesehatan atau pembuat kebijakan
kesehatan
17

Who is an epidemiologist ?
A professional who strives to study and
control the factors that influence the
occurrence of disease or health-related
conditions and events in specified
populations and societies, has an
experience in population thinking and
epidemiologic methods, and is
knowledgeable about public health and
causal inference in health
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)
18

Epidemiologists are required to have some


knowledge of:
Public health: because of the emphasis on disease prevention
Clinical medicine: because of the emphasis on disease
classification and diagnosis (numerators)
Pathophysiology: because of the need to understand basic
biological mechanisms in disease (natural history)
Biostatistics: because of the need to quantify disease
frequency and its relationships to antecedents (denominators,
testing hypotheses)
Social sciences: because of the need to understand the social
context in which disease occurs and presents (social determinants
of health phenomena)
19

1.4 Selected Historical


Figures and Events
Understanding medical history is
an important part of epidemiology
This section divided into three eras
400BC 1850
1850 - 1900
Twentieth century epi
20

Historical Figures &


Events

400BC 1850
Hippocrates (400BCE)
Age of enlightenment (17th & 18th centuries)
John Graunt (1620 1674)

1850 -1900
John Snow (1813 1858)
Germ Theory (mid 19th century)

Twentieth century epi


Modern epidemiology
21

Sejarah perkembangan epidemiologi


Ahli epidemiologi pertama
Hippocrates 460 377 SM
Ahli Epidemiologi yang pertama
Menjelaskan terjadinya penyakit dari dasar yang
rasional
Buku yang ditulis: Epidemic I, Epidemic II, On Airs,
Waters, and Places
Memperkenalkan istilah epidemic dan endemic

22

The First Epidemiologists


Hippocrates
460 B. C. to 377 B.C.
attempted to explain disease
occurrence on a rational basis instead
of from a supernatural view point
Three major books
Epidemic I
Epidemic II
On Airs, Waters, and Places

23

Hippocrates (1)
Recognized the association
of various diseases with
environmental factors

place
water conditions
climate
eating habits
housing
24

Hippocrates (2)
Introduced
epidemic
endemic

25

Hippocrates (3)
Theory about the cause of disease
personal observation
Greek thinking

Disease is the imbalance of body


humors
phlegm
blood
yellow bile, black bile
26

Sejarah perkembangan epidemiologi


Galen 129 199 M
Ahli bedah tentara romawi
Bapak Fisiologi Eksperimental
Faktor Prokatartik (cara hidup orang) dan temperamen
mempengaruhi kesehatan dan penyakit
Pengaruh lingkungan (geografi dan iklim) miasma
(istilah umum untuk partikel dalam udara)
Malaria udara buruk
Teori miasma

27

Galen

(1)

129 - 199 A.D.


Father of experimental physiology
Health and Disease influenced by
Procataritic factors
the way of life a person led
life style

Temperament
the innate qualities of the body
personality

28

Galen

(2)

Disease caused by Miasma


particles in the air
from sources
waste
stagnant water
decaying animals

theory used to explain the great


plague epidemic in Europe

29

Sejarah perkembangan epidemiologi


Age of enlightenment (17th & 18th centuries)

Thomas Sydenham (1624 1689)


Hippocrates Inggris
Bapak Epidemiologi
Atmosfer mengakibatkan perubahan konstitusi
epidemik

30

Thomas Sydenham

(1)

1624 - 1689
Father of Epidemiology
insisted that observation should have
precedence over theory in the study
of the natural history of disease
31

Demographic Approach
(pp. 1214)

John Graunt (1620 1674)


32

Sejarah perkembangan epidemiologi


DEMOGRAPHIC APPROACH

Kelahiran vital statistik


John Graunt
Analisis data mortalitas dalam tahun 1662
Melakukan kuantifikasi yang pertama dari pola
kelahiran, kematian dan kejadian penyakit
Mencatat perbedaan laki-laki dan perempuan,
kematian bayi yang tinggi, perbedaan urbanrural, dan variasi musiman
33

Demographic Approach

John Graunt
(162074)

17th Century Life Table


Age
% surviving
6
64
16
40
26
25
36
16
46
10
56
6
60
3
76
1
34
80
0

Life Table of Deaths in London


Age

Deaths

Survivors

--

100

36

64

16

24

40

26

15

25

36

16

46

10

56

66

76

80

Source: Graunts Observations 1662


Epidemiology (Schneider)

Graunts Observations

Excess of male births

High infant mortality

Seasonal variation in mortality

Epidemiology (Schneider)

Sejarah perkembangan epidemiologi

Willian Farr
Melakukan pengumpulan data secara
sistematik dan statistik kematian di Inggris
Bapak Statistik vital moderen dan surveilens
Memperluas analisis data morbidtas dan
mortalitas epidemiologi
Melihat efek status perkawinan, pekerjaan
dan ketinggian
37

Sejarah perkembangan epidemiologi


Konsep kontagion dan Teori germ penyakit

Hieronymous Frascastorius (1478 1553)


Sastrawan dan dokter dari Italia
Penyakit disebabkan oleh germ
Penyakit ditransmisikan dari orang ke orang melalui suatu
partikel yang sangat kecil

Igmatz Semmelweis (1818 1865)


Ahli Obstetri dari Hungaria
Demam nifas dapat direduksi jika para dokter mencuci tangan
sebelum menolong persalinan

38

39
Downloaded from: StudentConsult (on 29 August 2009 12:10 AM)
2005 Elsevier

40
Downloaded from: StudentConsult (on 29 August 2009 12:10 AM)
2005 Elsevier

Sejarah perkembangan epidemiologi


Edward Jenner
Mendukung teori Fracastorius
Menerima teori germ penyakit
Penemu vaksin cacar (akhir tahun 1700)

Louis Pasteur
Berkontribusi dalam menguatkan teori germ penyakit
dengan mendemonstrasikan efektivitas imunisasi pada
pencegahan rabies dalam tahun 1885
Belum mampu mengisolasi virus rabies menghalau
teori miasma
41

Sejarah perkembangan epidemiologi

Studi epidemiologi klasik awal


James Lind
Melakukan studi epidemiologi ekperimen pada
etiologi dan pengobatan scurvy (1753)
Makan jeruk merupakan obat untuk scurvy

P L Panum
Studi epidemiologi klasik tentang penyakit campak di
pulau Faroe (1875)

42

Sejarah perkembangan epidemiologi

John Snow (1813 1858)

Ahli anestesi
Melakukan serial investigasi kolera di London
Bapak Epidemiologi Lapangan
Melakukan studi epidemik kolera (1854)

43

Snows Methods
Ecological studies
compared cholera rates by region

Cohort
compared cholera rates in exposed
and non-exposed individuals

Case-control
compared water source in cases and
controls
44

Snows
Ecological
Analysis

Southwark Water
Company
neighborhoods
high rates
Mixed service
intermediate rates
Lambeth Water Co.
neighborhoods
no cases
45

Deaths from Cholera per according to water company


supplying subdistricts of London, 1853-1854
Water Company

Population in
1851

Deaths from
Cholera

Deaths rate
per 100,000
living

Southwark and Vauxhall


Company

167,654

192

114

Lambeth Company

14,632

Both Company

301,149

182

60

46

The Grand Experiment


A retrospective study

O
X

47

48

Snows Cohort Study (Table 1.7, p. 25)


Cholera mortality per 10,000 household and water
source
Rate Southwark & Vauxhall = 1263 / 40,046 10,000 = 315
Rate Lambeth = 98 / 26107 10,000 = 37.5

Southwark & Vauxhall drew water from fecal


contaminated water region
Supporting evidence for water-borne transmission
theory
49

SnowsCohortAnalyses
WaterSource
Southwark
Lambeth
Both

Cases
1263
98
1422

Homes
40,046
26,107
256,423

Rateper
10,000
315*
37
59

* Rate, Southwark = 1263 / 40,046


= .0315 = 315 / 10,000
50

Snows Case-Control Study


Epidemic area of Golden Square area (1854 epidemic)
Interviewed cases and non-cases to determine water source

Cases
61 used water from Broad St. pump
6 did not use Broad St. pump
6 could not determine if used Broad St. pump

Controls were less likely to use Broad St. pump water


e.g., Among Brewer workers (non-cases), the men were allowed a
certain quantity of malt liquor, and Mr. Huggins [the proprietor]
believes they do not drink water at all
Map showing proximity to pump and no. of cases (next slide)
51

Cholera Deaths Broad St. Outbreak

52

Snows Map

(Fig 1.14)

53

Visualization Success
Stories
Illustration of John
Snows
deduction that a cholera
epidemic
was caused by a bad
water pump, circa 1854.
Horizontal lines indicate
location of deaths.

From Visual Explanations by Edward


Tufte, Graphics Press, 1997
54

John Snow: A Classic Epidemiologic


Study
The Father of field epidemiology
investigating the outbreak of cholera in Gloden Square of London
descriptive epidemology --> hypothesis generation --> hypothesis
testing ---> public health application

55

Golden Square Cholera Outbreak: John Snow (2)

Theory

Action

Hypothesis
Hypothesis
test
Public Health
Application

Water was the source of


disease
Correlation of the
distribution of cholera case
households and the location
of water pumps
Removed the handle of the
pump in Broad Street
56

London Cholera Outbreak: John Snow (3)

Theory
Hypothesis
Hypothesis
test
Public
Health
Application

Action
Water served as vehicle for
transmitting choler
based on time, place, and
person; compared groups
are comparable
changing the location of
water intake to avoid water
contamination
57

Sejarah perkembangan epidemiologi


Studi

epidemiologi klasik awal

James

Lind

Melakukan

studi epidemiologi ekperimen


pada etiologi dan pengobatan scurvy (1753)
Makan jeruk merupakan obat untuk scurvy

58

Sejarah perkembangan epidemiologi

Sejarah perkembangan epidemiologi

Sejarah perkembangan epidemiologi

Sejarah perkembangan epidemiologi


Goldberger

(1923)

Menggunakan

studi epidemiologi
observasional dan eksperimen tentang
pellagra (defisiensi asam nikotinat)

62

Joseph Goldberger (18741929)


used observational and experimental
epidemiologic methods to identify
vitamin deficiency as the cause of
pellagra;

identified diets high in cereals and

canned food as a risk factor; proved


sources of fresh animal protein and
legums were effective in prevention;
first nutritional epidemiologist.

Sejarah perkembangan epidemiologi

Hill, Doll, Wynder, Cornfield and other Post

world war II epidemiologists. World War II is a


convenient watershed to mark the risk of the
"modern epidemiologists", since this coincides
with the emergence of chronic disease as
major causes of morbidity and mortality;

focuses on individual risk factors; hallmarked


by studies on :

smoking and lung cancer, The Surgeon

General's Report on Smoking and Health,


the Framingham heart studies,
water fluoridation trials, and
the poliomyelitis field trials of 1954.

Maturation of Epidemiology
(1910 - 1945)

Key methodologic developments include

the advancement of epidemiologic theory,

outbreak investigation methods,


methods to study non-infectious

diseases (case-control and cohort


methods),

the introduction of randomized clinical


trials, and new survey methods
developed by Goldberger in the study
of pellagra).

Also, changes in the education of

physicians and health care took place


in the 1910s and 1920s, respectively

Last half of 20th Century


("Modern Epidemiology")
The

epidemiologic transition from acute


contagious to chronic non-contagious
causes of morbidity effected the way
epidemiologists studied disease

Illustrative

examples
British Doctors Study (Doll & Hills studies
of the effects of smoking)
Framingham Heart Study (risk factors for
heart disease, many investigators)

Sejarah perkembangan epidemiologi


Doll dan Hill (1950)
Studi Merokok dan kaitannya dengan kanker paru dan studi
penyakit kardiovaskular pada penduduk Framingham,
Massachusetts

(Dawber, Kannel, dan Lyell, 1963. Gordon, Castelli,


Hjortland, Kannel, dan Dawber, 1977)
Riset epidemiologi pada penyakit kronik

(Freedman, Chear, Srinivasan, Webber, dan Berenson,


1985)
Bogalusa Heart Study

(Stamler, Wentworth, dan Neaton, 1986)


Multiple Risk Factor Intervention Trial
67

Doll and Hill, 1952


Lung cancer
cases

Controls

OR

Smoke 25+ per


day

331 (24%)

166 (12%)

17.4

Smoke 5-24 per


day

1019 (75%)

1130 (83%)

7.8

Non-smoker

7 (1%)

61 (5%)

1
68

Estimated 10-Year CHD Risk in


55-Year-Old Adults According to Levels of
Various Risk Factors Framingham Heart Study

Blood Pressure (mm Hg)

120/80 140/90 140/90 140/90

Total Cholesterol (mg/dL)

200

240

240

240

HDL Cholesterol (mg/dL)

50

50

40

40

Diabetes

No

No

Yes

Yes

Cigarettes

No

No

No

Yes

69

Estimated 10-Year Stroke Risk in 55-Year-Old Adults


According to Levels of Various Risk Factors
Framingham Heart Study

A
Systolic BP*
95-105
Diabetes
No
Cigarettes
No
Prior Atrial Fib. No
Prior CVD
No

B
C
D
E
F
130-148 130-148 130-148 130-148 130-148
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
Yes

Source: Stroke 1991;22:312-318.

70

*BP in millimeters of mercury (mmHg)

A
Systolic BP*
95-105
Diabetes
No
Cigarettes
No
Prior Atrial Fib. No
Prior CVD
No

B
C
D
E
F
130-148 130-148 130-148 130-148 130-148
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
Yes
*BP in millimeters of mercury (mmHg)

Estimated 10-year stroke risk in 55-year-old adults


according to levels of various risk factors (FHS).
Source: Wolf et al., Stroke.1991;22:312-318.

71

Offspring CVD Risk by Parental CVD


Status: Framingham Study
Parental CVD <55
men, <65 Women

Risk Ratio

2.5
2
2.2

1.5

1.7

1.7

1.7

1
1.0

1.0

0.5
0

Men

Women

Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
72

Aplikasi
Epidemiologi

Audit
Pelayanan
Kesehatan

Keluaran
dan
Prognosis

Kebutuhan
kesehatan
penduduk
Etiologi
Penyakit

EPIDEMIOLOGI

Lingkungan
Genetik
Life style

Riset
Pelayanan
Kesehatan

Risiko
Penyakit

73

Kontribusi epidemiologi (1)


Penyelidikan modus transmisi penyakit baru
Penentuan sebab-sebab penyakit yang dapat
dicegah
Penentuan riwayat alamiah penyakit
Pengamatan spektrum penyakit

74

Kontribusi epidemiologi (2)


Penilaian intervensi kesehatan komunitas
Penyusunan prioritas pemberantasan penyakit
Perbaikan diagnosis, pengobatan dan
prognosis penyakit klinis
Peningkatan riset pelayanan kesehatan
Penyediaan saksi ahli dalam pengadilan

75

History of Epidemiology
HIPPOCRATES (400 BC): On Airs, Waters, and
Places Hypothesized that disease might be
associated with the physical environment,
including seasonal variation in illness.
JOHN GRAUNT (1662): Nature and Political
Observations Made Upon the Bills of Mortality
First to employ quantitative methods in
describing population vital statistics.
JOHN SNOW (1850): Formulated natural
epidemiological experiment to test the
hypothesis that cholera was transmitted by
contaminated water.
76

History of Epidemiology (cont.)


DOLL & HILL (1950): Used a case-control
design to describe and test the association
between smoking and lung cancer.
FRANCES at al. (1950): Huge formal field trial
of the Poliomyelitis vaccine in school
children.
DAWBER et al. (1955): Used the cohort design
to study risk factors for cardiovascular
disease in the Framingham Heart Study.
77

Brief History of Epidemiology


Classical Infectious Diseases Epidemiology
Edward Jenner (1749-1823)
developed a vaccine against smallpox using cow pox

160 years before virus was identified

John Snow (1813-1858)


described the association between dirty water and cholera

44 years before vibrio was identified

Ignaz Semmelweis (1818-1865)


described the association between childbed fever and
physicians unclean hands

32 years before causal agent was discovered

Brief History of Epidemiology


Classical Nutritional Epidemiology
James Lind (1716-1794)
conducted an experiment which showed that scurvy could
be treated and prevented with limes, lemons, and oranges

ascorbic acid was discovered 175 years later

Joseph Goldberger (1874-1927)


identified that pellagra was not infectious but nutritional
in origin and could be prevented by increasing the amount
of animal products in the diet and substituting oatmeal for
corn grits

niacin was discovered 10 years later

Brief History of Epidemiology


Epidemiology of Chronic Diseases

Observational Studies:
R Doll & AB Hill. Early case-control study. Smoking and
carcinoma of the lung: Preliminary report. [Br. Med. J. 2:739, 1950]
Cohort Studies:
An approach to longitudinal studies in a community: the
Framingham study. 10,000 residents gave baseline
information. Follow-up is now 50 years. [Annals New York
Academy of Sciences 107:539;1963]

Brief History of Epidemiology


Epidemiology of Chronic Diseases

Experimental Studies:
Hypertension Detection and Follow-up Program Cooperative
Group. 10,500 subjects randomly assigned to two groups:
1. stepped care - antihypertensive therapy increased stepwise to achieve
and maintain blood pressure reduction to goal.
2. Referred care - subjects were referred to their primary care physician and
treated as usual.

mortality
final blood pressure

stepped care 9.0/100


84.1 in stepped care

referred care 9.7/100


89.1 in referred care

Brief History of Epidemiology


Epidemiology of Chronic Diseases

Physician Health Study


randomized, placebo-controlled, double-blind clinical trial
conducted entirely through the mail
22,071 male physicians enrolled to study the effects of aspirin on
cardiovascular disease and the effects of beta-carotene on cancer
randomly assigned to one of four groups
aspirin
beta carotene
active
active
active
placebo
placebo
active
placebo
placebo

ROOTS OF MODERN EPIDEMIOLOGY


1. ACUTE DISEASE INVESTIGATION
----- Emphasis on empirical systematic
investigation, biology, and
environment/host manipulation
2. MEDICINE
----- All early epidemiologists were
physicians.
83

ROOTS OF MODERN EPIDEMIOLOGY


3. STATISTICS
----- Emphasis on the scientific method,
quantification and measurement,
and hypothesis testing. In 1960s, many
epidemiologists were statisticians.
4. SOCIAL SCIENCES
----- Investigation of human behavior in
relation to disease, and methods of
data collection (surveys, etc.)
84

ROOTS OF MODERN EPIDEMIOLOGY


5. COMPUTER SCIENCES
----- Emergence of chronic disease
epidemiology required the ability to
handle large amounts of data and to
perform complex analyses.
6. MANAGERIAL SCIENCES
----- Management principles for
acquisition
of grants, research collaboration, and
management of clinical trials.
85

ROOTS OF MODERN EPIDEMIOLOGY


7. GENOMICS
----- 2001 marked first publication of
draft sequences of the human genome.
Intensive investigations being
conducted to identify disease
susceptibility genes geneenvironment interactions, and genegene interactions.
86

Classical versus Modern


Applications

Classical: descriptive, observational,


field, analytical, experimental,
applied, healthcare, primary care,
hospital, CD, NCD, environmental,
occupational, psycho-social, etc
Modern: risk-factor, molecular,
genetic, life-course, CVD, nutritional,
cancer, disaster, etc
87