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EPIDEMIOLOGY-MCH 101

ANA LIZA CARPIO-JABONERO, MD, MPH


Local Health Support Division
Department of Health-Center for Health Development Davao Region

Learning Objectives
1. 2. 3. 4.

Describe the origins of epidemiology Define epidemiology Describe the scope of epidemiology Discuss the contribution of epidemiology in the control of diseases

Learning Objective
5. Define health and disease 6. Identify the stages of disease 7. Compute the measures of disease frequency given a set of data

Definition of Epidemiology
  

Historical context Definition and scope of epidemiology Achievements in epidemiology

Historical Context: Origins


1.

Hippocrates in 400 BC in his On Airs, Waters and Place the role of the environment in health and disease occurrence. John Graunt, in 1662, published Natural and Political Observations Made Upon the Bills of Mortality which recorded characteristics of birth and death data, including seasonal variations, infant mortality, excess of male over female deaths, and other findings. He was the first to employ quantitative methods in describing population vital statistics.

2.

Historical Context: Origins


3.

John Snow investigated a cholera epidemic in mid-19th century in London. His work featured various techniques in epidemiologic inquiry such as a spot map of cases, tabulations of cases and deaths, development and testing of hypotheses that contaminated water may be associated with cholera outbreaks.

Table. Deaths from cholera in districts of London supplied by two water companies, 8 July to 26 Aug1854 (Source: Snow, 1855)

Water supply company Southwark Lambeth

Population 1851 167,654 19,133

No. of deaths from cholera 844 18

Cholera death rate per 1000 population 5.0 0.9

Historical Context: Origins


4.Koch, in late 1800s, espoused the concept that diseases are caused by living organisms and made possible more refined classification of disease by specific causal organisms through his postulates for disease causation.

The history of epidemiologic methodology is largely the history of the development of five ideas:
a. b.

c.

d.

e.

Human disease is related to the environment in which we live; Counting of natural phenomena may even be more instructive than just observing them; natural experiments can be utilized to investigate disease etiology; Natural experiments occur more frequently than we think and reflect the tremendous heterogeneity of human experience; true experiments may be conducted in human populations in some circumstances

The epidemiological approach of comparing rates of diseases in subgroups of the human population became increasing used in the late 19th and early 20th centuries.

The main applications were to communicable diseases. This method proved to be a powerful tool for showing associations between environmental conditions or agents and specific diseases.

Historical Context: Modern epidemiology


5. Framingham Heart Study began in 1949 for its pioneering investigations of risk factors for coronary heart disease. 6. After WW II, in 1950s, Doll, Hill and others studied the relationship between cigarette smoking and lung cancer. 7. A long-term follow-up of British doctors indicated a strong association between smoking habits and the development of lung cancer.

Historical Context: Modern Epidemiology


For many diseases, a number of factors contributed to causation. Some factors were essential for the development of a disease- and some just increased the risk of developing it. New epidemiological methods were required to analyse these relationships. Today, communicable disease epidemiology remains of vital importance in developing countries where malaria, schistosomiasis, leprosy, poliomyelitis and other diseases remain common.

Definition of Epidemiology


Etymology originates from the three Greek words


- Prefix: - Root: - Suffix: epi (on, upon, befall) + demos (people, population, man) + logy (study of)

Literal translation --- that which befalls man (e.g., epidemics)

Definitions of Epidemiology
1.

It 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 problems. (Last, 1988)

2.

It is the study of the distribution and determinants of disease frequency in human populations. (MacMahon and Trichopoulos, 1996)

Definitions of Epidemiology
3.

Epidemiology is an investigative method used to detect the cause or source of diseases, disorders, syndromes, conditions or perils that cause pain, injury, illness, disability or death in human populations or groups. (Timreck, 1994) Epidemiology is a discipline that describes, quantifies, and postulates causal mechanisms for health phenomena in the population. (Frils and Sellers, 1996)

4.

Anatomy of the Definition


1. 2.

3.

4.

Population of interest are human populations. Describes distribution of health and disease (by person, place and time variables). Identifies determinants of health and disease (risk factors, causes) Health and disease (injury, illness disability or death)

This emphasizes that epidemiologists are concerned not only with death, illness and disability, but also with more positive health states and with the means to improve health.

Scope of Epidemiology


Scope: human population


Population defined in geographical or other terms e.g. a specific group of hospital patients or factory workers can be a unit of study. Most common population: in a given area or country at a given time basis for defining subgroups with respect to sex, age group, ethnicity, etc.

Herd immunity


A vaccine provides herd immunity if it not only protects the immunized individual, but also prevents that person from transmitting the disease to others, causing decline in prevalence of the organism in the population.

Uses of Epidemiology
1.

Elucidate disease etiology


- May also identify the determinants of outcomes of illness.. leading to identification of preventive methods. (Epidemiology as a basic medical science with goal of improving health) - Other outcomes of interest --- biologic processes like growth, multiple pregnancy, intelligence, and fertility
Genetic factors

Causation

Good health Environmental factors (including lifestyle)

Ill health

Uses of Epidemiology
2.

Explain local disease patterns - By utilizing what is already known about the etiology of a particular
health problem, epidemiologist may be able to explain and deal, e.g. with a particular outbreak, and formulate preventive measures suitable to a specific community.

Uses of Epidemiology
3. Describe the natural history of disease
- To identify factors related to the course of the disease once the
disease is established; - It is useful to know how the duration of a disease and the probability of various outcomes (e.g., recovery, death, complications) vary by age, gender, geography, etc.
Death Natural history Good health Subclinical changes Clinical disease Recovery

Uses of Epidemiology
4. Provide guidance in the administration and evaluation of health services. - Estimation of number of hospital beds required for patients with
specific diseases (e.g., mental illness) or for a given segments of the population (e.g., prematurely born infants, disabled elderly) will require knowledge of the frequency and natural history of particular diseases or of all diseases in the affected segments of the population.

Uses of Epidemiology
4. Provide guidance in the administration and evaluation of health services.
- The planning of efficient research (diagnostic, therapeutic, or preventive) will require knowledge of how many cases of a particular disease are likely to be found in a given population during a given period. - Knowledge of the relative frequency of disease in population subgroups is useful if it enables intervention programs to target these populations e.g.,screening programs.

Uses of Epidemiology
Treatment/medical care

Evaluation of Intervention

Good health Health promotion Preventive measures Public health services

Ill health

Achievements in Epidemiology
1.

Smallpox
1790s: cowpox infection conferred protection against smallpox virus (only after 200 years were benefits of the discovery applied and accepted) 1967: 10-year eradication program of WHO ( 10-15M new cases; 2M deaths annually in 31 countries) 1976: 2 countries 1977: last naturally occurring smallpox US$ 200M outlay estimated to result in savings of US$ 1500M a year. Factors for success: universal political commitment, a definite goal, a precise timetable, well-trained staff and a flexible strategy. And an effective heat-stable vaccine.

Achievements in Epidemiology
2. Methylmercury poisoning
1950: Mercury released with water discharged from a factory in Minamata, Japan, into a small baysevere poisoning in people who ate fish contaminated with methylmercury. 1st case DDx as infectious meningitis 121 patients residents close to Minamata Bay; main occupation fishing. People visiting affected families who ate little fish did not suffer disease. Conclusion: something in the fish had poisoned the patients; not communicable or genetically determined.

Achievements in Epidemiology
3. Rheumatic fever (RF) and rheumatic heart disease (RHD)
-

Associated with poverty, poor housing, overcrowding: factors favoring spread of streptococcal URTIs. In developed countries, decline of RF started on 20th century, before introduction of sulfonamides and penicillin. In developing countries, among socially and economically disadvantaged groups, RHD is one of the most common forms of heart disease. Epidemiology: understanding RF and RHD development of methods for prevention of RHD role of social and economic contributing factors for outbreaks of RF and spread of strep throat infxn

Achievements in Epidemiology
4. Iodine deficiency diseases
- 16th century: Goiter and cretinism first described in detail - 1915: endemic goiter named as easiest to prevent; - 1989, Hetzel: use of iodized salt for goiter control proposed in Switzerland - 1990s: large-scale trials in Akron, Ohio, USA, on 500 girls, 11-18 yo. - Epidemiology: identification and solving iodine-deficiency problems effective preventive measures methods of monitoring iodization programmes

Achievements in Epidemiology
5. High blood pressure
- in both developed and developing countries; - 20% of people aged 35-64 years in USA and parts of China - Epidemiology: defined extent of the problem established the natural history of the condition and health consequences of untreated HPN demonstrated the value of treatment helped determine most appropriate BP level at which treatment should begin

Achievements in Epidemiology
6. Smoking, asbestos and lung cancer
- 1930s: dramatic increase in occurrence of lung cancer in industrialized countries - 1950: first epidemiological studies linking lung cancer and smoking - Main cause of increasing lung cancer: tobacco smoking - Other causes: asbestos dust and urban air pollution. - Smoking and asbestos interact, creating high lung Ca rates for workers who both smoke and are exposed to asbestos dust. Epidemiology: provide quantitative measurements of the contribution to disease causation of different environmental factors.

Achievements in Epidemiology
7. Hip fractures
- Epidemiological research on injuries, ie hip fractures due to fall, involves collaboration between scientists of epidemiology and in the social and environmental health fields. - implication s for the health service needs of aging population. - Epidemiology: vital in examining both modifiable and non-modifiable factors to reduce the burden of fractures.

Achievements in Epidemiology
8. AIDS
- 1981: first identified as a distinct disease entity in USA - 1992 April: 484,148 cases have been reported (USA-45%, Europe-13%, Africa-30%, Asia and other areas-12%) - True extent of the cases is likely to be much higher than reported. - 50% of people with HIV infection likely to develop AIDS within the years. - Of those with AIDS, more than 50% die within 18 months of diagnosis. - In USA, AIDS is already a more important cause of premature death than COPD and DM. - Epidemiology: identification of epidemic determination of pattern of AIDS spread identification of risk factors evaluation of interventions (treatment, prevention, control)

MEASURING HEALTH AND DISEASES

Measuring health and disease


  

Definitions of health and disease Measures of disease frequency Use of available information

Definition of Health and Disease




WHO, 1984: health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity World Health Assembly, 1977: - main target of Member States of WHO: By year 2000 all people attain a level of health permitting them to lead socially and economically productive lives.

Definition of Health and Disease




Epidemiologists: health states defined as disease present or disease absent

The development of criteria to establish the presence of a disease requires definition of normality and abnormality. (difficult)

Stages of Disease


1.

The development and expression of a disease occur over time and can be divided into 3 stages: Predisease stage - (before the pathologic process begins) - early intervention may prevent exposure to the agent of disease (e.g.,lead, trans-fatty acids, or microbes) preventing the disease process from starting: PRIMARY PREVENTION

2. Latent stage - (when disease process has begun, but is still asymptomatic) - screening and appropriate treatment may prevent progression to symptomatic disease: SECONDARY PREVENTION

Stages of Disease
3. Symptomatic stage - (when disease manifestations are evident) - intervention may slow, arrest, or reverse the progression of disease: TERTIARY PREVENTION

Measures of Disease Frequency


 

Based on fundamental concepts of prevalence and incidence Note: calculation of measures of disease frequency depends on correct estimates of the people under consideration (potentially susceptible to the disease studied): POPULATION AT RISK Population at risk can be defined on basis of demographic or environmental factors: e.g., occupational injuries = workforce
brucellosis = people handling animals (farms and slaughterhouses)

Measures of Disease Frequency


Prevalence and incidence
The prevalence of a disease is the number of cases in a given population at a specified point in time. The incidence of a disease is the number of new cases arising in a given period in a specified population.

Measures of Disease Frequency


These are fundamentally different ways of measuring occurrence, and the relation between prevalence and incidence varies between diseases. High prevalence and low incidence: Diabetes Low prevalence and high incidence: common colds
(Colds occur more frequently than diabetes but last only a short time, Once contracted, Diabetes is permanent.)

Measures of Disease Frequency


Prevalence and Incidence are more useful if converted into rates.

A rate is calculated by dividing the number of cases by the corresponding number of people in the population at risk, and is expressed as cases per 10 people.

Measures of Disease Frequency: Prevalence rate


The prevalence rate (P) for a disease is calculated as:
Number of people with the disease or condition at a specified time P = ______________________________________ (x 10 ) Number of people in the population at risk at the specified time
Data on the population at risk are not always available; may use total population as an approximation. P is often expressed as cases per 1000 or per 100 population. In this case, P has to be multiplied by the appropriate factor 10 .

Measures of Disease Frequency: Prevalence rate


point prevalence rate = if the data have been collected for
one point in time.

period prevalence rate = the total number of persons known


to have had a disease or attribute at any time during a specified period, divided by the population at risk of having the disease or attribute midway through the period.

Measures of Disease Frequency: Prevalence rate


Example:
In a large industrial concern employing 10,000 people on January 1,2004, 50 people have diabetes. An additional 100 cases of diabetes were diagnosed between January 1,2004 and January 1,2005. During the year, no employees moved out of the company due to retrenchment or retirement; neither were new employees hired. The prevalence of diabetes as of January 1,2004 is:

x 1000 = 5 cases/1000 employees P = 50 10,000

Measures of Disease Frequency:

Factors influencing observed prevalence rate:


Increased by:
Longer duration of the disease Prolongation of life of patients without cure Increase in new cases (increase in incidence) In-migration of cases Out-migration of healthy people In-migration of susceptible people Improved diagnostic facilities (better reporting)

Decreased by:
Shorter duration of disease High case-fatality rate from disease Decrease new cases (decrease incidence) In-migration of healthy people Out-migration of cases Improved cure rate of cases

Measures of Disease Frequency: Prevalence rate: Uses


1.

2.

3.

Assess the need for health care and the planning of health services/project medical case needs Measure the occurrence of conditions with gradual onset of disease (e.g., maturity-onset DM, RA) Assess the PH impact of a disease

Measures of Disease Frequency: Incidence rate


Numerator: number of new events that occur in a defined period Denominator: population at risk of experiencing the event during this period

person-time incidence rate - most accurate way of calculating Incidence rate (Last,1988) - Each person in the study population contributes one person-year to the denominator for each year of observation before disease develops or the person is lost to follow-up.

Measures of Disease Frequency: Incidence rate


Number of people who get a disease in a specified period I = ______________________________ (x 10 ) Sum of the length of time during which each person in the population is at risk The numerator strictly refers only to first events of disease. The units of I must always include a dimension of time (day, month, year, etc)

SOURCES OF DATA

ANA LIZA CARPIO-JABONERO, MD, MPH


Local Health Support Division Department of Health-Center for Health Development Davao Region

Session Objectives
1.

Identify sources of epidemiologic data

2. Describe the integrity and comparability of data, and identify gaps in data sources

Epi Data
1. 2. 3.

Disease status Exposure status (intrinsic and extrinsic factors) Others - vital event - socio-demographic/ cultural data - health resources - services

Types of data
1. 2.

Primary data Secondary data

Sources
Primary data: 1. Observation (direct measurement) 2. Query (interview or questionnaire)

Sources
Secondary data 1. Vital records (birth/death certificates) 2. Reportable disease statistics 3. Disease Registries 4. Morbidity Surveys 5. Screening Surveys 6. Patient Records (hospitals, private clinics)

Seatwork:
1.

2.

Identify the epi data that can be derived from each of the following sources Give your comment on the quality of data (completeness/accuracy) that can be obtained from each source

Seatwork:
Data Sources
1. Vital stats 1.1 Death certificate 1 2 Birth certificate 2. Reportable Disease Stats 3. Disease Registries 4. Morbidity Surveys 5. Screening Surveys 6. Patient records (hospital/MD practice)

Key Info

Completeness & Accuracy

Quality and Utility of Data


1.

2.

3.

4.

Nature of data -- routinely collected (registration system), survey data, hospital or clinic cases, MDs records Availability -- ad hoc (prn)? Periodic? (weekly, annual, etc) Completeness of population coverage (thoroughness) -- Are all cases identified? Value and Limitation -- Utility of data, accuracy of information

1. Vital Records
1.1 Death Certificate (Mortality Statistics)

Information
1. Fact of death

Completeness/accuracy
Satisfactory (deaths unlikely to go unrecorded) Not satisfactory

2. Cause of death

1. Vital Records
1.1 Death Certificate: Issues/Problems Diagnostic inaccuracy Unavailability of cause of death statement Lack of standardization of diagnostic criteria ( What constitutes a cause of death? acceptable cause of death?)

1.

2.

3.

1. Vital Records
1.1 Death Certificate: Causes of Problems
1. 2.

3.

Medically unattended deaths (verbal autopsy) Lack of training of certifying MDs on cause of death certification/ access to guidelines Attitude of MDs

Research Findings: Completeness and Acceptability of cause of death statement in death certificates

  

19% completely filled up Of the 19%, only 12 were filled up in an acceptable manner Among the items, underlying cause was the least filled up (28%)
(Immediate cause=92%, Antecedent cause=57%)

5% underlying cause are unacceptable entries (Cardiac arrest, respiratory arrest, CR arrest, heart failure, DOA, Shock)

1. Vital Records
1.2 Birth Certificate/fetal death

Information
1. Fact of birth

Completeness/accuracy
Satisfactory
(births unlikely to be recorded)

2. Condition of child at birth (weight, abnormality, etc) 3. Condition of mother during pregnancy/delivery

Satisfactory

Not satisfactory
(recall)

2. Reportable Disease Statistics (Notifiable)


MDs/health facilities legally required to report cases of certain diseases to health authorities System of reporting is in place Issues/Problems:
   

Not all will seek medical attention; asymptomatic Failure of MDs to fill out the required reporting forms MDs concern over confidentiality of information WHO: reluctance to admit occurrence of certain diseases

--Unsatisfactory source (incomplete population coverage)

Notifiable Diseases (2001, FHSIS)

Anthrax Cholera Diphtheria Viral enceph Leprosy Leptospirosis Malaria Measles

Neonatal Tetanus Non-neonatal tetanus Meningococcal infection Paralytic shellfish poisoning Rabies Typhoid and paratyphoid fever Pertussis

Notifiable Diseases ( Syndromes )

Acute Flaccid Paralysis Acute Hemorrhagic Syndrome Acute Lower Respiratory Tract Infection and Pneumonia Acute watery Diarrhea Acute Bloody Diarrhea Food Poisoning Chemical Poisoning

3. Registries
-- centralized database for collection of information about a disease (cancer, trauma, etc) -- newly recognized cases are entered and maintained in a file until recovery, death, or migration -- Source of data for: duration of illness outcome of illness (Case fatality) incidence and prevalence natural history of disease -- Satisfactory source of data only for some diseases

4. Morbidity Surveys
Sample population (representative sample)  National Demographic and Health Survey (NSO) --every 5 years  National Nutrition Survey (FNRI) -- every year  National weighing,Operation Timbang (DOH) --on-going (15 years)  Prevalence Surveys (periodic)-TB, Disability, STD

5. Screening Surveys
Sample population (non-representative sample)
 

Neighborhood screening clinics Health fare, civic groups

-- not satisfactory source

6. Hospital Data
  

In-patient and out-patient records Does not represent a specific population Type of information is not standardized

Research Findings: Comparison of data from multiple sources

Agreement between medical record and interview is variable Excellent agreement (inherent features of patients clinical condition surgical procedures, family history of cancer) Poor agreement (pharma use)

Agencies concerned with collection, management, and publication of health data:


1.

DOH - Phil. Morbidity and Mortality Report (quarterly) - Field Health Service Information System (FHSIS)
a. stat indicators of health programs,DOH b. vital stats, by province, city, region

2.

- Philippine Health Statistics (including notifiable diseases) NSO - Vital events (births, deaths, marriages) - National Demographic Survey (every 5 years,2003)
--demographic, maternal and child health stats

3.

FNRI - National Nutrition Survey

USE OF AVAILABLE INFORMATION

Use of Available Information


Epidemiology rely on a variety of sources for obtaining data to analyze health-related rates and risks. Data can be discussed in terms of:

1. Denominator data: define the population at risk; Census statistics 2. Numerator data: define the events/conditions of concern; statistics from health, disease, birth, and death registries and surveys

Use of Available Data: A. Mortality


Death Certificate:
  

fact and cause of death, age, sex, DOB, place of residence Useful only if data are complete and accurate Not in all countries: no resources for routine death registers, not reported due to cultural or religious reasons. International Classification of Diseases (WHO,1992b) revised at regular intervals used for coding causes of deaths; account of the emergence of new diseases and changes in criteria for established diseases

Use of Available Data: MORTALITY

Number of deaths in a specified period Crude mortality rate = ____________________________________ (x 10 ) Average total population during that period Disadvantages:  No account of fact that the chance of dying varies according to age, sex, race, socioeconomic class, and other factors.  Not appropriate for comparing different time periods or geographical areas.

Use of Available Data: Mortality


Age-specific and sex-specific death rate:
Total number of deaths occurring in a specific age- and sex-group Of the population in a defined area during a specified period _____________________________________________________ (x 10 ) Estimated total population of the same age- and sex-group of the Population in the same area during the same period

Proportionate mortality rate: (ratio)


Number of deaths from a given cause/ 100 (or 1000) total deaths in the same period

Use of Available Data: Mortality before and just after birth


Infant Mortality Rate
Number of deaths in a year of children less than 1 year of age = _________________________________________________ x 1000 Number of live births in the same year

IMR as an indicator of the level of health in a community: based on the assumption that IMR is particularly sensitive to socioeconomic changes, and to health-care interventions. High IMR should alert health professionals to the need for investigation and preventive action on a broad front.

Use of Available Data: Mortality before and just after birth

Other measures of mortality in early childhood:


Fetal death rate Stillbirth or late fetal death rate Perinatal mortality rate Neonatal mortality rate Postnatal mortality rate

Precise guidelines on the definition is found in ICD.

Use of Available Data: Mortality before and just after birth

Child Mortality Rate:


-

Based on deaths of children aged 1-4 years. Common in this age group: accidental injuries, malnutrition and infectious diseases.

Household survey questions used, if without accurate death registers:


During the last 2 years,have any children died who were aged 5years or less? How many months ago did the death occur? How many months of age was the child at death? Was the child a boy or a girl?

Use of Available Data:


Maternal mortality rate:
Maternal pregnancy-related deaths in one year = ______________________________________ (x 10 ) Total births in same year

Life expectancy:


Another frequently used summary measure of the health status of a population.

Defined as: the average number of years an individual of a given age is expected to live if current mortality rates continue.

Life expectancy (years) at selected ages for four countries Age Birth 45 years 65 years Mauritius 65.0 25.3 11.7 Bulgaria 68.3 27.3 12.6 USA 71.6 30.4 15.0 Japan 75.8 32.9 16.2

Use of Available Data: MORBIDITY

Morbidity: -the frequency of illness


-useful for investigating diseases with low case-fatality e.g., RA, chicken pox, mumps -helpful in clarifying the reasons for particular trends in mortality: changes in death rates could be due to changes in morbidity rates.
Because population age structures change with time, time-trend analysis should be based on age-standardized morbidity and mortality rates.

Use of Available Data: MORBIDITY


The morbidity data are collected to meet legal requirements e.g., notifiable diseases: quarantinable diseases (cholera), AIDS Notification = depends on patients seeking medical advice, the correct diagnosis being made, and the notifications being forwarded to the public health authorities. Many cases may never be notified. For diseases of major public health importance, notifications are collated by the WHO, and published in the Weekly epidemiological record.

Use of Available Data: MORBIDITY

Other sources of information on morbidity


1. data on hospital admissions and discharges 2. OPD and primary health care consultations 3. specialist services (e.g, accident treatment) 4. registers of disease events, i.e CA, congenital malformations.

Use of Available Data: MORBIDITY


Factors influencing Hospital Admission Rates:
1. 2. 3. 4.

Morbidity of the population Availability of beds Admission policies Social factors

Hospital admission rates for asthma per 100,000 by age (Auckland,NZ)

Age group (years) 0 14 15 44 45 - 64

1960

1970

1980

40 45 70

160 115 115

450 200 220

Use of Available Data: MORBIDITY


The morbidity data are collected to meet legal requirements e.g., notifiable diseases: quarantinable diseases (cholera), AIDS Notification = depends on patients seeking medical advice, the correct diagnosis being made, and the notifications being forwarded to the public health authorities. Many cases may never be notified. For diseases of major public health importance, notifications are collated by the WHO, and published in the Weekly epidemiological record.

Use of Available Data: DISABILITY

Measurements of occurrence, also of persistence of the consequences of disease, WHO, 1980b:


1.

Impairment: any loss or abnormality of psychological, physiological or anatomical structure or function. Disability: any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.

2.

Use of Available Data: DISABILITY


3. Handicap: a disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual.
Measurement of the prevalence of disability presents problems also, and is affected by extraneous social factors. It is important in societies with increasing number of aged people.

ASSOCIATION AND CAUSATION

Session Objectives
1. 2. 3.

4.

Define cause of a disease Determine the types of factors of disease Describe the different risk factors of disease using the BEINGS model Discuss how to establish the cause of disease in terms of temporal relationship, plausibility, consistency, strength, doseresponse relationship, reversibility and study design

Epidemiology
A major goal of epidemiology is to assist in the prevention and control of disease, and in the promotion of health by discovering the causes of disease and the ways in which they can be modified.
This session will describe the epidemiological approach to causation.

The concept of cause


A cause of a disease is an event, condition, characteristic or a combination of these factors, which plays an important role in producing the disease. Logically, a cause must precede a disease. A cause is termed sufficient when it inevitably produces or initiates a disease. A cause is termed necessary if a disease cannot develop in its absence.

The concept of cause


A sufficient cause is not usually a single factor; comprises several components. It is not necessary to identify all the components of a sufficient cause before effective prevention can take place. The removal of one component may interfere with the action of the others, and thus prevent the disease. Example: cigarette smoking 1 component of the sufficient cause of lung cancer. Smoking is not sufficient in itself to produce the disease. However, the cessation of smoking reduces the number of cases of lung cancer in a population even if the other component causes are not altered.

The concept of cause


Each sufficient cause has a necessary cause as a component.
Example 1: Outbreak of foodborne infection:
- chicken salad and creamy dessert-both sufficient causes of salmonella diarrhea - occurrence of salmonella is a necessary cause of disease.

Example 2: TB: tubercle bacillus as the necessary cause. Susceptible host: Infection
   

TB

Genetic factors Malnutrition Crowded housing Poverty

Exposure to bacteria

Tissue invasion

The concept of disease


Kochs postulate: rules for determining whether a specific living organism causes a particular disease.
 

The organism must be present in every case of the disease; The organism must be able to be isolated and grown in pure culture; The organism must, when inoculated into a susceptible animal, cause the specific disease; The organism must then be recovered from the animal and identified.

Anthrax- first disease demonstrated to meet these rules; proven useful with some other infectious diseases.

Factors in Causation:
Four types of factor play a part in the causation of disease. All may be necessary but they are rarely sufficient to cause a particular disease or state:


Predisposing factors, such as age, sex, previous illness, may create a state of susceptibility to a disease agent. Enabling factors, such as low income, poor nutrition, bad housing, and inadequate medical care, may favor development of disease.

Factors in Causation
3. Precipitating factors, such as exposure to a specific disease agent or noxious agent, may be associated with the onset of a disease or state. 4. Reinforcing factors, such as repeated exposure and unduly hard work may aggravate an established disease or state.