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EPIDEMIOLOGY

Epidemiology ...is the study of the distribution and


determinants of health-related states or events in
specified populations and the application of this
study to control of health problemshow disease is
distributed in populations and of the factors that
influence or determine this distribution (A
Dictionary of Epidemiology 1988)

Epidemiology is the study of distribution and determinant of the


diseases Frequency in man ( Mac.Mahon 1970)
Kata epidemiologi berasal dari kata dalam bahasa Yunani :
Epi : pada
Demos : masyarakat
Logos : ilmu pengetahuan, doktrin, sains
Dengan demikian, epidemiologi dalam artian luas adalah studi terhadap efek dari
berbagai hal pada masyarakat.

Ruang Lingkup Epidemiologi


1. Geografik Patologi
2. Epidemiologi Klinik
3. Identifikasi Agent Penyebab Penyakit
4. Statistical Epidemiology
5. Epidemiologic Field Survey
6. EpidemiologicLongitudinal Study
7. Epidemiologi Eksperimental
8. Tracing Reservoir Epidemiology
9. Epidemiologic Control Program
Macam Macam Epidemiologi

1. Epidemiologi Deskriptif ( Apa,Siapa,Dimana & Kapan)


2. Epidemiologi Analitik ( Faktor Kausal dengan Uji Hipotesa)
3. Epidemiologi Operasional
3.1. Investigasi Wabah
3.2. Penatalaksanaan pencegahan & kontrol penyakit
3.3. Mendukung kegiatan praktis petugas kesehatan
4. Epidemiologi Eksperimental
1. 4.1. Clinical trial
2. 4.2. Field trial
3. 4.3. Community trial
old --- Study of epidemics.

most --- Analyses of the distributions and determinants of disease/


injury ( health-related states ) frequency in populations , and the
application of this study to the control of health-related problems.

new --- Systematic approach to answer any health-related questions.

Epidemiology is a basic science of medicine.


Objectives of Epidemiology
identify the etiology (cause) of disease and the
the factors that increase a persons risk for a
disease
determine extent of disease found in the
community
study the natural history and prognosis of
disease
EPIDEMIOLOGI

Adalah ilmu yang mempelajari distribusi dan determinan penyakit


Yang sering terjadi pada manusia

Determinan adalah paparan atau intervensi pada populasi atau


Individu yang dapat berupa Faktor kausal yang terjadi pada
manusia

Determinan ada 2 bentuk

1. Determinan genetik
2. Determinan lingkungan
Determinan Lingkungan

Paparan : Substansi Toksik lingkungan


misalnya sampah,polusi udara dll
Intervensi : Program penyuluhan KesMas
Vaksinasi

Determinan genetik

Paparan genetik yang didapat oleh faktor keturunan


Klasifikasi Epidemiologi

1. Epidemiologi deskriptif adalah bagian dari Epidemiologi


Yang menjelaskan distribusi penyakit didalam populasi
Berdasarkan faktor Tempat,Waktu dan Individu
(Place .Time & Person) dengan menggunakan ukuran ukuran
Deskriptif Epidemiologi.

2. Analitik Epidemiologi adalah bagian dari epidemiologi


Yang bertujuan mencari dan membuktikan faktor kausal
Dengan memakai ukuran ukuran analitik Epidemiologi
DESKRIPTIF EPIDEMIOLOGI

DESKRIPSI KEJADIAN PENYAKIT BERDASARKAN


1. PLACE/TEMPAT
2. PERSON/ORANG
3. TIME/WAKTU

UKURAN UKURAN
DESKRIPTIF DESKRIPTIF
BIOSTATISTIK EPIDEMIOLOGI

INTERPRETASI KEJADIAN PENYAKIT


Descriptive epidemiology :
Patterns of Disease Occurrence

distribution of disease in populations

numerator ( event count ) / denominator ( group at risk )

by person : age , race / ethnicity , gender , occupation ,


education , marital status , genetic marker , sexual preference

by place : residence (urban vs. rural) , worksite , social


event

by time : week , month , year ; sporadic , seasonal , trends


--- incubation period ; latency
Pattern of All - cause Mortality ; by person :
Age groupings

0.16

0.14

0.12
Rate per year

0.1

0.08

0.06

0.04

0.02

0
<1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 > 84
Age Group (years)

Age-specific death rates for deaths from all causes. USA;1991


Source: National Center for Health Statistics;1993
Pattern of disease Occurrence ; by Person:
race / ethnicity
Tuberculosis ; incidence rates / 100,000 ; United States , 1992

50

40

30 CDC.
MMWR
20 1993; 42:696
10

0
W Bl na Hi As
hi ac ti v sp ia
te k e an n
,n ,n Am ic /P
-H -H ai
er fi c
Pattern of disease Occurrence ; by place
Rocky Mountain Spotted Fever

cases
Reported

Rocky Mountain Spotted Fever. Counties reporting cases: U.S.; 1993


CDC Summary of notifiable diseases. USPHS; 1994
Pattern of disease Occurrence : by time
Percentage change in US tuberculosis incidence rates

15

10

-5

-10 CDC; MMWR.


1993; 42:68
-15

-20
1981-83 1983-85 1985-87 1987-89 1989-91

3-year intervals in the United States, 1981 - 91.


Pattern of disease Occurrence :
by Time
Patterns of disease Occurrence :
Correlation of Population statistics

Ecologic ( correlation ) studies

--- plot : disease (population) burden [ Y axis ]


vs. prevalence of risk factor [ X axis ]

-- correlation coefficient : r ; + or -
-- r-squared : % variability in Y explained by X

is only a hypothesis-generating study design

* beware of ecologic fallacy when reading results


Scatterplot of incidence of reported AIDS & TB. 15 states ; US , 1993
correlation (ecologic) study: CDC, MMWR. 1993; 42:4

25 *
*
20
*
*
15
* * *
* * *
10
*
* *
5
* *
0
0 10 20 30 40 50 60 70 80 90 100
Incidence of AIDS per 100,000
Relationship between # dental carries & fluoride content of public water
adapted from - Dean HT , et al. 1942. Pub Hlth Rep 57:1155-79

*
100
*
90
**
80
* *
70 ** *
60 *
50 * *

40 *
*
30
* * ** *
20
* ** *
10

0.0 0.5 1.0 1.5 2.0 2.5 3.0


Fluoride content (ppm) of public water supply
Relative risk of cancer mortality : various Japanese men ,
compared with white men living in California

Relative risk ( compared with California whites )

Japanese Japanese immigrants Immigrant Japanese sons


cancer Sites in Japan in California in California

Stomach 8.4 3.8 2.8


Liver 4.1 2.7 2.2
Colon 0.2 0.4 0.9

Adapted from - Buell P and Dunn JE. 1965. Cancer 18:656.


Descriptive epidemiology : pattern of occurrence
Prevalence of HIV+ and community Mosquito index

20 r = .83 r - squared = .92 *


p < .001 p < .001 * *
15
* *

10
* *
* * * * *
5 * * *

0
HIV+

0 2 4 6 8 10 12 14 16 18 20 22

Index of community mosquito infestation


ANALITIK EPIDEMIOLOGI

UKURAN
INFERENSIAL
EPIDEMIOLOGI
BIOSTATISTIK
ANALITIK

FAKTOR KAUSAL/PROTEKTIF
Analytic epidemiology :
Case-control study; HIV carried by mosquitoes ?

Mosquito exposure No exposure

HIV + 158 17 175

Controls 247 143 390

405 160 565


O.R. = 5.38
Analytic epidemiology : stratification for confounding ;
Case-control study. HIV carried by mosquitoes ?

Mosquito Exposure No exposure

Females HIV + 3 2

Mosquito Exposure 166 133

Males HIV + 155 15


304
controls 81 10 O.R. = 1.21

O.R. = 1.27 261


APPLIKASI EPIDEMIOLOGI DALAM
KESEHATAN MASYARAKAT

1. Pengumpulan dan analisa data data kelahiran kematian(Vital


Record) dan penyakit ( Morbidity)
2. Monitoring penyakit dan permasalahan kesehatan masayarakat
3. Penyelidikan wabah/outbreak didalam masyarakat dilanjutkan
dengan kontrol dan tindakan pencegahan wabah pada
masyarakat lainnya.
4. Mengidentifikasi permasalahan kesehatan masyarakat yang ada
dan menaksir seberapa parah pengaruhnya terhadap kesehatan
masyarakat secara keseluruhan
5. Mengevaluasi program Kesehatan
6. Menyediakan data yang diperlukan untuk perencanaan
program kesehatan masyarakat atau data yang diperlukan oleh
Dinas Kesehatan untuk mengambil keputusan
APPLICATIONS of epidemiology
in the practice of Medicine

disease Surveillance (medical intelligence)

searching for Causes

comparing Diagnostic Techniques

discovering the Natural History of a medical condition

recognizing Prognostic Factors

evaluating new Procedures / Treatments


Topik Epidemiologi

1. Epidemiolgi Penyakit Menular


2. Epidemiologi Kesehatan Lingkungan
3. Epidemiologi Penyakit tidak menular dan Penyakit Menahun
4. Sosial Epidemiologi
5. Genetik Epidemiologi
6. Neuroepidemiologi
7. Molekuler Epidemiologi
8. Farmako Epidemiologi
9. Psiko Epidemiologi
Ruang Lingkup

Endemik : Suatu keadaan dimana angka kejadian penyakit


tertentu menetap pada prevalen tertentu di suatu wilayah tertentu
Dengan catatan prevalen rate daerah endemis lebih tinggi dari
Daerah non Endemis. Contoh Malaria di Lampung,Jambi dan
Irian Jaya.

Epidemik: Adalah suatu keadaan angka kejadian penyakit


meningkat lebih tinggi dari angka kejadian biasanya . Biasanya
dipakai patokan Gausian rata rata + 2 Sd dan dapat juga dipakai
kriteria KLB untuk menyatakan suatu Epidemik

Pandemik : Adalah suatu keadaan dimana terjadi peningkatan


Angka kejadian penyakit tertentu yang meluas penyebarannya
Secara Global
Angka Kematian pada masyarakat oleh penyakit Typhus
Abdominalis 5 tahun terakhir tahun 1999 - 2004 5 per 100,000
per tahun 0.5 dengan interval 4 - 6 per 100,000 per tahun Pada pengamatan
tahun 2005 ini didapatkan angka kematian Typhus Abdominalis 6.5 per
100,000

Epidemik

Angka Kematian pada masyarakat oleh penyakit Typhus


Abdominalis di Palembang 15 tahun terakhir tahun 5 per 100,000
per tahun 0.5 dengan interval 4 - 6 per 100000 pertahun Sedangkan
angka kematian di Kabupaten lainnya pada propinsi sumatera
Selatan rata rata 2 per 100,000 per year 0.3
Maka Palembang dinyatakan sebagai daerah endemis Typhus Abdominalis

ENDEMIK
Epidemiology - Basic ASSUMPTIONS

Health events do not occur randomly.

Natural history of disease/injury is a continuum : includes both causal


and preventive factors.

[ # susceptible > # exposed > # subclinical > # clinical illnesses ]


( # of mild illness > # of severe illness > # of fatalities )

Hallmark of epidemiologic inference : unbiased comparison

Constant goal : science - based intervention(s)


Natural history of illness ; the continuum

Dead
number of clinical Illnesses
number Infected

number Exposed to sufficient cause


number of Susceptibles

TOTAL Population
Prevalence estimates of illness ; pyramid of health care

1000 adults at risk in a given geographic region

750 adults report at least one illness or


injury / month

250 adults
consult doctor
each month
9 hosp

1
the Classic Epidemiologic TRIAD
of disease Causation

Environment

Agent Host
the pyramid of disease Natural History ;
elements involved in causation

Environment

vector

Agent time
Host
The Web of disease Causation

atherosclerosis

coronary occlusion thrombotic tendency

MYOCARDIAL INFARCTION lack of collateral circulation lack of exercise

stress obesity hypertension cigarette smoking

social pressures diabetes hereditary factors personality & stress

lipids, triglycerides, cholesterol

hereditary factors
Rothmans Causal Pie

A = necessary cause
J K
B, C, D, E, H, I, J, & K A
E
= contributing causes
D A

D B
C
C
H
J
I E III
A

B
II

Necessary cause(s) + contributing cause(s) = SUFFICIENT CAUSE


Natural history model of cervical carcinoma

Infection:
Normal
bacterial &/or viral

Invasive
Dysplasia : mild cancer

moderate
cancer
severe in situ
Web of Causation ; Sufficient Cause(s)

[ susceptible ]

undiagnosed (subclinical) outcome


[ pathology ]

Diagnosed (clinical ) outcome


[ sequelae ]

recovery , disability , death


Levels of Prevention
( Natural History of disease )

PRIMARY SECONDARY TERTIARY


Prevention Prevention Prevention

clinical horizon SICK ;

curative
Health Case Rehab
promotion finding medicine medicine

WELL Time -------->


The general Epidemiologic ( scientific ) Approach

1. Identify a PROBLEM :
clinical suspicion ; case series ; review of medical literature

2. Formulate a HYPOTHESIS ( asking the right question ) ;


good hypotheses are: Specific, Measurable, and Plausible

3. TEST that hypothesis ( assumptions vs. type of data )

4. always Question the VALIDITY of the result(s) :


Chance ; Bias ; and Causality