INTRODUCTION TO EPIDEMIOLOGY
Introduction
Patient profile
Person, place and time
The epidemiologic approach
The application of epidemiology
Summary
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INTRODUCTION
Epidemiology :
Clinical Epidemiology :
The science of making prediction about individual
patients by counting clinical events in similar patients,
using strong scientific method for studies of groups of
patients to ensure that the predictions are accurate
The purpose is to develop and apply methods of clinical
observation that will lead to valid conclusions by avoiding
being misled by systematic error and chance, to make
good decisions in the care of patients
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PATIENT PROFILE
In June 1981, A 29 year old previously healthy man was referred to UCLA Medical
center with a history of fever, fatigue, lymph node enlargement, and weight lost of
almost 25 lb (11-12 kg) over the preceding 8 month. He had a temperature of 39.5
°C, appeared physically wasted and had swollen lymph node. Laboratory result a
depressed level of peripheral blood lymphocytes. The patient suffered from
simultaneous infections involving Candida albicans in his upper digestive tract,
cytomegalovirus in his urinary tract, and pneumocystis carinii in his lungs.
Although antibiotics therapy was administered, the patient remained chronically ill
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PATIENT PROFILE
Why a healthy young man would suddenly develop concurrent infections of three different
organ systems involving three different microorganisms.
Parasite P carinii was known to cause illness in persons with impaired immune responses
that he did not had underlying causes of immune dysfunction such as cancer, severe
malnutrition, and use immune suppressing drugs
Three other similar patients had been examined within the preceding 6 month
Why were four such patients appearing at about the same time in the same location?
Was this new appearance of rare and life threatening from pneumonia confined to UCLA
Medical center, or were physician elsewhere observing similar patient?
Recognizing the potential for widespread emergence of this new, unexplained, and
debilitating condition, the CDC (center for disease control) established a special task force
to collect more detail information on the affected person.
Between June and November 1981 a total 76 cases of P carinii were identified
A few month later the disease was named the acquired immune defisiency syndrome
(AIDS)
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PERSONS, PLACE, AND TIME
The story of the first few AIDS patients also called “ Sentinel cases”.
In 1981, no one could have predicted that more than 150,000 persons in the
United states would be diagnosed with AIDS during the following decade, more
than 100,000 deaths from AIDS would be reported
By 1990. AIDS had become the second most common cause of death after
accidental trauma among men aged 25-44 in United States
3 dimensions – persons, place, and time are the features traditionally used to
characterize patients of disease occurrence.
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THE EPIDEMIOLOGIC APPROACH
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THE EPIDEMIOLOGIC APPROACH
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THE APPLICATION OF EPIDEMIOLOGY
Disease Surveillance
Searching for causes
Diagnostic testing
Determining the Natural History
Searching for prognostic factors
Testing new treatment
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Disease Surveillance
Frequency of disease
The number of persons who acquire the disease (cases) over a specified period
of time and the size of the unaffected population (risk)
To defined the occurrence of disease depend on the state of knowledge and the
new diagnostic test
In 1982 AIDS is A disease at least moderately indicative of a defect in cell
mediated immunity, occurring in a persons with no known cause for
diminished resistance to that disease
In 1987 AIDS is a patient with specific clinical manifestations that occur in
conjunction with a positive antibody test for HIV-1 infection
Such change in diagnostic criteria can have a profound effect on the apparent
frequency of disease
A rapid and dramatic increase the frequency of disease within a particular
population is referred to as an epidemic
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Disease Surveillance
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Searching for Causes
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Searching for Causes
Information from case control study may be distorted (biased) differing abilities of
cases and control to recall exposure
Such bias could be avoided by using a cohort study design
Exposure is assessed among unaffected persons and subjects are then observed
for subsequent development of illness
A cohort of 2507 homosexual men without antibodies to HIV-1 (seronegative)
were questioned about their sexual practices and then followed for development
of antibodies to HIV-1 (seroconversion). Within 6 month, 95 men (3,8 %)
seroconverted and the risk of developing HIV-1 was found to be related to anal
intercourse
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Diagnostic Testing
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Diagnostic Testing
A number of different laboratory tests for the presence of HIV-1 infection have
been introduced
The logic of this strategy requires two assumptions :
That HIV-1 infected persons have detectable antibodies
The person with detectable HIV-1 antibodies are infected with HIV-1
Among 74 patients have AIDS, 72 patients (97%) had detectable antibodies, 2
patients (3%) was false negative
Among 261 healthy blood donors , 257 (98%) had no detectable antibodies, 4
(2%) was false positive
Interpretations of results most account for the possibility of an incorrect
diagnosis
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Determining the natural history
The prediction of patient with the disease always involve an element of the unknown
because the actual sequence of event can vary widely among patients
The best guidance for predictions is the experience of other patients
Since the Patients with AIDS the chance for recovery are virtually nil, so focused on the
anticipated duration of survival
By noting the timing of critical event for each patient (dates of diagnosis, development
further manifestation, and death), the progression of the disease can be summarized as
natural history of the illness
Case fatality rate : the percentage of the patient with a disease who die within specified
period ( From 1985 to 1991 among 10,233 patient with AIDS, 9248 were known have died
(90,4%)
Survival : the probability of remaining alive for a specific length of time
Median survival time: The duration that was a half patient with the disease (AIDS) still alive
was found 11 month. Only 18% of patients remained alive at 2 years following diagnosis
Improvement in clinical management, the survival experience of AIDS patient has
improved
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Searching for Prognostic factors
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Testing New Treatment
All new medications must be proved effective before introducing into routine clinical care
The standard approach used to evaluate treatment effectiveness is the randomized
clinical control trial, that mean a comparison the patients who receive the new medication
against patients who receive an inactive substance (placebo) or standard treatment
Randomized refers to a method of treatment assignment that is determined by chance
rather than patient preference or physician selection
AZT is a thymidine analogue with the ability to inhibit replication of HIV-1 in laboratory test
in 1986
Among 282 patients with AIDS had been randomized assignment in the allocation of 145
patients to AZT and 137 to the placebo. The two study group were similar with clinical
characteristics at the onset of treatment. After 4 month observations among The AZT
treatment only 1 death compared to 19 deaths among the placebo group
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Summary
We have seen how epidemiologic research has contributed to basic knowledge about
AIDS
The techniques of surveillance were used to determine the pattern Of AIDS by person,
place, and time
Comparison of affected and unaffected person led to the identification of risk factors and
ultimately the suspicion an infectious agent was responsible
Evaluation of test for antibodies to HIV-1 allowed improved diagnosis and prevention of
spread by contaminated blood product
Studies of natural history help to define the clinical course of the illness
Prognostic factors were determined through comparison of patients with favorable and
unfavorable outcome
Improvement in treatment was demonstrated through randomized control trial
Epidemiologic research has been pivotal in gaining insight into many different disease
Ultimately this information can be used to help control the impact of disease through
preventive or improve clinical management
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Thank you
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Progress of labor
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