EPIDEMIOLOGY:

PRINCIPLES AND METHODS

Department of Public Health,

Faculty of Medicine,
Tggl 1 September 2016
20 Pasien datang ke puskesmas pada saat yang berbeda
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Epidemiology
• A study of the distribution of disease frequency in
human population and the determinants of that
distribution
• Epidemiologists are not concerned with an individual’s
disease as clinicians do, but with a population’
distribution of the disease
• Distribution of disease by person, place, time
• Assumption:
• Disease does not occur randomly
• Disease has identifiable causes
• which can be altered and therefore
• prevent disease from developing
Definition of Epidemiology
• The study of the distribution and determinants of
health-related states or events in specified
population, and the application of this study to
control of health problems.
[source: Last (ed.) Dictionary of Epidemiology, 1995]
• Determinants: physical, biological, social, cultural,
and behavioral factors that influence health.
• Health-related states or events: health status,
diseases, death, other implications of disease such
as disability, residual dysfunction, complication,
recurrence, but also causes of death, behavior,
provision and use of health services.
Aims of Epidemiologic Research
1. Describe the health status of a Descriptive
population epidemiology
2. To assess the public health
importance of diseases
3. To describe the natural history of
disease,
4. Explain the etiology of disease Analytic
5. Predict the disease occurrence epidemiology
6. To evaluate the prevention and
control of disease
7. Control the disease distribution Applied
epidemiology
Descriptive and Analytical Epidemiology

1. Descriptive epidemiology
• Describes the occurrence of disease (cross-sectional)
2. Analytic epidemiology:
• Observational (cohort, case control, cross-sectional, ecologic
study) – researcher observes association between exposure
and disease, estimates and tests it
• Experimental (RCT, quasi experiment) – researcher assigns
intervention (treatment), and estimates and tests its effect on
health outcome
Epidemiologic Study Designs
Epidemiologic Study Designs
Study Design and Its Strength
of Evidence
1. Systematic review, meta-analysis: Strongest
evidence
secondary data analysis
2. Randomized Controlled Trials (RCT)
3. Cohort: prospective or retrospective
Quasi experiment
4. Case control: prospective or
retrospective
Weakest
5. Cross sectional evidence
6. Case Reports / Case Series
Which Disease if More Important to Public
Health? Measure of Disease Occurence
Hypothetical Data
Measles Chickenpox Rubella
Children exposed 251 238 218
Children ill 201 172 82

Attack rate 0.80 0.72 0.38

Attack rate = Number of Ill persons (new cases)

Population at risk exposed

Attack rate is a Cumulative Incidence; it shows the risk (probability) of

disease to occur in a population
• In regard to risk, measles is the most important disease to public
health while rubella being the least
Description of Disease Distribution in the
Population

Disease affects Disease affects Disease reaches its

mostly people under people living peak in frequency in
five years of age alongside the river Week 6
Natural History of Disease
Transmission
Cases
 Index – the first case identified
 Primary – the case that brings the infection into a population
 Secondary – infected by a primary case
 Tertiary – infected by a secondary case
T
S
Susceptible P
S
Immune
S
T
Sub-clinical

Clinical
Timeline of Infectiousness
Dynamics of Latent Infectious Non-infectious
infectiousness period period

Susceptible
Time

Dynamics of Incubation Symptomatic Non-diseased

disease period period

Susceptible
Time
Measure of Disease Frequency
1. Cumulative Incidence (Incidence, Risk, I, R)=
Number of new case over a time period
Population at risk at the outset
- Indicates the risk for the disease to occur in population at risk over a time
period. Value from 0 to 1.
2. Incidence Density (Incidence Rate, ID, IR)=
Number of new case over a time period
Total Person time at risk
Indicates the velocity (speed) of the disease to occur in population over a
time period. Value from 0 to infinity
3. Prevalence (Point Prevalence):
Number of new and old cases at a point of time
Population
Indicates burden of disease. Value from 0 to 1.
Endemic vs. Epidemic
Number of Cases of a Disease

Endemic Epidemic

Time
Levels of Disease Occurence
Sporadic level: occasional cases occurring at
irregular intervals
Endemic level: persistent occurrence with a low to
moderate level
Hyperendemic level: persistently high level of
occurrence
Epidemic or outbreak: occurrence clearly in
excess of the expected level for a given time period
Pandemic: epidemic spread over several countries
or continents, affecting a large number of people
Factors Influencing Disease Transmission

Agent Environment
• Infectivity • Weather
• Pathogenicity • Housing
• Virulence • Geography
• Immunogenicity • Occupational setting
• Antigenic stability • Air quality
• Survival • Food
Host • Age
• Sex
• Genotype
• Behaviour
• Nutritional status
• Health status
Measures of Infectivity, Pathogenecity,
Mortality
•Infectivity (ability to infect)
(number infected / number susceptible) x 100

•Pathogenicity (ability to cause disease)

(number with clinical disease / number infected) x 100

•Virulence (ability to cause death)

(number of deaths / number with disease) x 100

All are dependent on host factors

Preventable Causes of Disease
“BEINGS”
• Biological factors and Behavioral Factors
• Environmental factors
• Immunologic factors
• Nutritional factors
• Genetic factors
• Services, Social factors, and Spiritual factors
[JF Jekel, Epidemiology, Biostatistics, and Preventive Medicine, 1996]

Types of Cause:
• Necessary cause: Mycobacterium tuberculosis
• Sufficient cause: HIV
• Contributory cause: Sufficient-Component Cause
Causal Model of Risk Factors for CVD
Morbidity and Mortality
Disease
(Stroke, MI)

Biological Risk Factors Proximate

cause
(Hypertension, Blood Lipids, Homocysteine)

Genetic Risk Factors Behavioral Risk Factors Intermedi

(Family History) (Cigarette, Diet, Exercise) ate cause

Environmental Factors Distal

cause
(Socioeconomic Status, Work Environment)
 Validity of Estimated Association
and Causation
Smoking Lung Cancer
OR = 7.3

True association Bias?

causal Confounding?
non-causal
Chance?

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 Surveilans Kesehatan

Suatu proses pengamatan terus menerus dan

sistematik terhadap terjadinya penyebaran
penyakit serta kondisi yang memperbesar
risiko penularan dengan melakukan
pengumpulan data, analisis, interpretasi dan
disesiminasi serta tindak lanjut perbaikan dan
perubahan

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 Tujuan Surveilance
• Memonitor kecenderungan penyakit
• Mendeteksi perubahan mendadak insidensi
• Memantau kesehatan populasi
• Menentukan kebutuhan kesehatan prioritas
• Mengevaluasi efektivitas program
• Mengidentifikasi kebutuhan riset

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Jangkauan pelaksanaan surveilans yang
meliputi aspek:

Surveilans penyakit menular,

Surveilans penyakit tidak menular. Surveilans
masalah kesehatan, dan Surveilans Lingkungan
dan Perilaku.

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 Kegunaan surveilans yang penting adalah :

• Mengamati kecenderungan dan memperkirakan besar

masalah kesehatan.
• Mendeteksi serta memprediksi adanya KLB.
• Mengamati kemajuan suatu program pencegahan dan
pemberantasan penyakit yang dilakukan.
• Memperkirakan dampak program intervensi yang ada.
• Mengevaluasi program intervensi.
• Mempermudah perencanaan program pemberantasan

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