Ron Christian G.

Sison, RMT, MPH

Originates from the Greek words:

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

Literal translation: That which befalls man (epidemics)

It is the study of the nature, cause, control and determinants of the frequency and distribution of disease, disability and death in human populations. (Timreck, 1994) It is the study of the distribution and determinants of disease frequency in human populations. (MacMahon and Trichopoulos, 1996)

Epidemiology is an investigative method used to detect the cause or source of diseases, disorders, syndromes, conditions or perils that cause pain, illnesses, injury, 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. (Friis and Sellers, 1996)

A study of the distribution and determinants of healthrelated states or events in specified populations, and the application of this study to control of health problems. (Last, 1988)

` ` ` `

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)

Hippocrates in 400 BC in his On Airs, Waters and Place the role of the environment in health and disease among men John Graunt, in 1662, published Natural and Political Observations Made Upon the Bills of Mortality which recorded descriptive 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.

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

Framingham Heart Study began in 1949 for its pioneering investigations of risk factors for coronary heart disease. After World War II, the work of Doll and Peto identified the strong association between smoking and lung cancer. Eradication of smallpox

` ` ` ` `

Universal political commitment Clear and specific goal with precise timetable Well-trained and committed staff Flexible strategy Features of the disease that made its elimination possible Availability of an effective and stable vaccine

Elucidate disease etiology

May also identify the determinants of outcomes of illness Other outcomes of interest biologic processes like growth, multiple pregnancy, intelligence and fertility

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, for example, with a particular outbreak, and formulate preventive measures suitable to a specific community

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 (recovery, death, complications) vary by age, gender, geography, etc.

Provide guidance in the administration and evaluation of health services

Estimation of number of hospital beds required for patients with specific disease (e.g. mental illness) or for 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

Provide guidelines in the administration and evaluation of health services

The planning of efficient research (diagnostic, therapeutic, 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)

Genetic Factors
`

Causation

Genetic Factors
Environmental factors (including lifestyle)

Ill health

Death
`

Natural History

Good health

Subclinical changes

Clinical Disease Recovery

Description of health status of populations

Proportion with ill health, change over time, change with age, etc.

Good health

Ill health

Time

Treatment, Medical care

`

Evaluation of intervention

Good health
Health promotion Preventive measures Public health services

Ill health

` Prevention

of Disease ` Maintenance of Health

It is interdisciplinary
Draws from biostatistics and other social and behavioral sciences as well as from medically-related fields of toxicology, pathology, virology, genetics, microbiology, parasitology and clinical medicine.

Use of population research techniques and requires quantification of relevant factors

E.g. the presence or absence (or the amount) of exposure and the magnitude of the outcome

Use of special vocabulary

Definition of epidemic:
Attacking many people at the same time, widely diffused and rapidly spreading, excessive occurrence of disease (Dictionary) The occurrence in a community or region of cases of illness clearly in excess of normal expectancy (Benenson, 2000)

Ron Christian G. Sison, RMT, MPH

Explain concepts of disease causation Define and differentiate

Association vs. causation Necessary vs. sufficient cause Direct vs. indirect cause

Describe the different models of disease causation (triangle, wheel, lever, web)

Explain the criteria that supports causal inference Describe the natural history of disease Explain the use of classification of diseases and disability

Concept of Cause Natural History of Disease Classification of Disease and Disability

Event/condition/characteristic that plays a role in producing occurrence of a disease

Factor

Disease

Association identifiable relationship between an exposure and disease

Association does not always indicate that there is cause-effect relationship

Causation presence of a mechanism that leads from exposure to disease

Statistical dependence between two variables, that is, the degree to which the rate of disease in persons with a specific exposure is either higher or lower than the rate of disease among those without that exposure.
OR Exposed: lower rate of disease Unexposed: higher rate of disease

Exposed: higher rate of disease Unexposed: lower rate of disease

Epidemiology does not determine the cause of a disease in a given individual. Instead, it determines the association between a given exposure and frequency of disease in population.
Studies are undertaken to demonstrate a link (association) between F and D.

We infer causation based upon the association and several other factors

Causal association between categories of events/characteristics (F and D) in which an alteration in the frequency or quality of one category is followed by a change in the other Non-causal association of both categories of events (F and D) with a third category

C A B

A = mothers age B = low birth weight C = fathers age

C A B A

C
If: Alter A, expected change in B Alter C, no expected change in B

A B

Direct Cause: immediate

A
Tubercle bacilli

B
TB

Indirect Cause (intermediate stage) predisposing cause

A
Tampons

V
Staph organism

B
Toxic shock syndrome

association F ---- D causal F D V non-causal F D

no association F D

direct F D

indirect F V D

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

` `

A particular disease has one cause A particular cause results in one disease
BUT not true for many diseases (Ex. Smoking causes many diseases; CAD has multiple causes)

Cause cannot be established by means of Kochs postulates since many factors act together to cause diseases

Develop intervention methods Formulate prevention strategies

Biomedical scientists elucidate pathogenic causes/mechanisms (cellular/subcellular processes) Epidemiologists investigate other less specific factors (env, behavioral, etc.) --- risk factors that are associated with an increased risk of becoming diseased

Risk factor
(+)

F D
`

Preventive factor
(-)

F D

Effective Rx and Preventions

Epi research provided info that has formed the basis for public health decisions long before the mechanism of a particular disease was understood

Examples:
Cig smoke lung cancer (health education) Use of tampons toxic shock syndrome (removed from market) Washing of hands infections (OB should wash their hands)

Necessary cause
A cause is termed necessary if a disease cannot develop in its absence If A is a necessary cause of B, then B will only occur if preceded by A (absolutely necessary) A necessary condition is one that must be satisfied for the result to happen

The presence of A does not ensure that B will occur, but the presence of B ensures that A must have occurred (all cases are exposed) If A is absent, B cannot occur

Sufficient Cause (satisfying condition)

A cause is termed sufficient when it inevitably produces or initiates a disease If A is a sufficient cause of B, the presence of A guarantees B. However, other events may also cause B, and thus Bs presence does not ensure the presence of A If A is present, B will always occur

Cause
Necessary: 16 years old Necessary cause: tubercle bacilli Sufficient cause: jumping Sufficient cause: vaccination

Effect
Drivers license Tuberculosis Feet off the ground Immunity

Disease (+) (+) a

Factor (-) b

(-)

Necessary cause: b = 0 Sufficient cause: c = 0

Cause
Necessary: 16 years old Necessary cause: tubercle bacilli Sufficient cause: jumping Sufficient cause: vaccination Sufficient cause: ____________

Effect
Drivers license Tuberculosis Feet off the ground Immunity ______________________

Sufficient Cause (satisfying condition)

A cause is termed sufficient when it inevitably produces or initiates a disease If A is a sufficient cause of B, the presence of A guarantees B. However, other events may also cause B, and thus Bs presence does not ensure the presence of A If A is present, B will always occur A set of minimum conditions that produce disease

Cause of any effect consists of a constellation of components that act in concert to produce disease Ex. Disease X occurs in the ff. 3 situations:

U A B A

U E B

Sufficient Cause (satisfying condition)

A cause is termed sufficient when it inevitably produces or initiates a disease If A is a sufficient cause of B, the presence of A guarantees B. However, other events may also cause B, and thus Bs presence does not ensure the presence of A If A is present, B will always occur Means a complete causal mechanism (a set of minimum conditions/events/charac that inevitably produces disease)

U A B A

U E B

Step 1 determine presence of validity of statistical association. Exclude chance, bias, confounding Step 2 Determine causality
Experiment (not always possible) Non-experiment consideration (set of criteria) Strength of association Time sequence Biologic credibility Consistency with other studies Dose-response relationship

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Random variability Determined by sample size Extent of chance: p-value, confidence interval Epi Assumption draw an inference about the experience of an entire pop based on study of only a sample (ex. Prevalence of malnutrition among 06 y.o., province X)

Systematic error (aspects of study design) Types:

Selection bias Misclassification bias

Presence/extent of bias: stat approaches

Effect of extraneous variable (confounder) that distorts the relationship between E and D Non-comparable study groups (confounder) Presence/extent of confounding
Stratified and regression analysis

It is associated with the exposure but is not a consequence of the exposure ( ) It is a risk factor for the study disease ( )
C
(1) (2)

? Exposure


Disease

Ex. Age and gender (potential confounders) related to most diseases and to the presence of many exposures

Age
(1) (2)

? Exercise MI
(1) Younger tend to exercise (2) Younger lower MI

Exercise (+) (-)

Cases (+MI) A C

Controls (-MI) B D

Age
(1) (2)

? Exercise
(1) Younger tend to exercise (2) Younger lower MI If controls are younger than cases

MI

Factor (Exercise) (+) (-)

Cases (+MI)

Controls (-MI)

Example: Exercise andMI

Confounder: age

If controls are younger than cases:

Result: relationship between E and MI Thus: those who have MI are less likely than controls to exercise (apart from any effect of exercise, the association is simply a consequence of the greater proportion of younger individuals in the control group)

Smoking
(1) (2)

? Alcohol Heart disease

` `

(1) Smoking is associated with alcohol (2) Smoking is a risk factor of heart disease

Step 1 determine presence of validity of statistical association. Exclude chance, bias, confounding Step 2 Determine causality (criteria)
Consistency of findings Strength of association Biologic gradient Temporal sequence Plausibility and coherence Specificity of the association

Relationships that are demonstrated in multiple studies are more likely to be causal Look for consistent findings
Across different populations In differing circumstances With different study designs

Strong associations are less likely to be caused by chance or bias A strong association is one in which the relative risk is ery high or very low

Dose response (change in level of cause associated with changes in disease frequency)
Standardized Mortality Ratios (Lung Cancer) Dose (cigs/day) 10 10-20 40 Study 1 1.3 2.8 4.7 Study 2 1.8 2.3 3.7 Study 3 1.4 2.4 6.3

Exposure must precede disease Exposure must precede the latent period (disease onset detection)

The proposed causal mechanism should be biologically plausible Is there a mechanism of action; evidence from animal studies
Note: lack of plausibility may simply reflect lack of medical knowledge

Causal mechanism must not contradict what is known about the natural history and biology of the disease

An exposure leads to a single or characteristic effect, or affects people with a specific susceptibility
Easier to support causation when associations are specific, but This may not always be the case x Many exposures cause multiple diseases

Association Bias
Yes

No

Chance

Yes

No

Confounding

Yes

No

Association

Association

Consistency with other investigators

Diff designs, diff pop, diff investigators

Strength of association
Higher RR, likely causal

Biologic gradient (dose response amt, duration gradient of risk associated with degree of exposure)

Temporal sequence
Exposure precedes disease

Plausibility/coherence
Not contradict K re natural history/biology of disease

Specificity (not always the case)

Exposure leads to single effect

No single study is sufficient for causal inference Causal inference is not a simple process
Consider weight of evidence Requires judgment and interpretation

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Demonistic Theory Devilisitic Theory Tridoshas Theory Four Humours Theory Yang and Yin Principles Germ Theory Epidemiological Triad Multifactorial Theory

Multiple causation or multi factorial etiology

More than one factor should be present for disease to develop

Factors affecting the development of disease

Host factors (intrinsic): affect susceptibility to disease Environmental factors (extrinsic): influence exposure and sometimes indirectly affect susceptibility as well

Ecology the study of the relationship of organisms to each other as well as to other aspects of the environment Ecologic models: interrelations of factors
The triangle The lever The wheel The web

AGENT

HOST

ENVI

HOST

AGENT

ENVIRONMENT

Social Environment

Hub = host with genetic make up as core

Biological Environment

Host (Man)

Genetic cure

Physical Environment

Genotypic LDL level

Sat fat and chol in diet Stress Oral contraceptive Obesity

Polyunsaturated fat in diet

Physical inactivity Low HDL Diabetes Hypertension

Higher Phenotypic LDL level

High HDL

Salt Smoking Stress

Coronary artery disease

Physical activity Estrogens Oral Contraceptives

Coronary heart disease (Web of causation of CHD by Dr. Sherwin, University of Maryland

There is no single cause Causes of disease are interacting Illustrates the interconnectedness of possible causes

Possible to interrupt the causation of disease by cutting the chains

Course of disease over time unaffected b y treatment or prevention

Earliest Stage Prepathogenesis Phase

Termination (Recovery, Disability, Death)

Unaffected by treatment or prevention

susceptibility

adaptation

presymptomatic

clinical disease

disability/recovery death/chronicity

exposure

onset

clinical horizon

Prepathogenesis (interaction of agent, host, env)

Pathogenesis (reaction of host to stimulus)

Time

Natural History of Disease

Disease has not developed Interaction of agent, host, envi Groundwork for disease has been laid due to the presence of factors that favor its occurrence

Factors whose presence is associated with an increased probability that the disease will develop later Ex. Smoking, alcohol drinking, multiple sex partners all risk factors will develop the disease

 Not

Factor whose presence/absence causes a disease

Vit D

Rickets

Salmonella

Typhoid

Biologic, physical, chemical, social/psychological

Human in whom an agent produces diseases Susceptible

Immunity Inherent resistance

Genetic Past environmental exposures

Past immunization Natural infection

Personality Social class

Provide reservoirs of agents (live/multiply), mode of transmission

Environment factors (extrinsic factors)

Biological environment Social environment access to medical care, social customs affecting health Physical environment heat, light, air, water, etc.

No manifestation, no signs nor symptoms Pathologic changes have started to occur

Changes in the organs have occurred sufficiently to show signs and symptoms of the disease Classification of disease is important
For better management of cases For epidemiologic study grouping of disease reduces variation; for evaluation of intervention and for internal comparisons May be used on morphologic (cancer), functional (heart), therapeutic (heart), etc

Disability any temporary or long-term reduction of a persons activity as a result of an acute or chronic condition

Induction period causal action to disease initiation (cause effect) Latent period disease occurrence to detection (effect on body detection)

Induction period

Latent period

cause

effect

detected

Basis natural history of disease Obj: halt or reverse the disease process; prevent pathologic process from evolving further 4 levels: primordial, primary, secondary, tertiary

Tissue changes

Prepathogenesis

Pathogenesis

Stage of disease

Susceptibility

Presymptomatic

Clinical disease

Disability/reco very

Levels of prevention

Primary

Secondary

Tertiary

Mode of intervention

Health Promo Specific protection

Detection Early Dx Prompt Rx

Rx and Rehab Limitation of disability

General health promotion

Provision of conditions at home, work and school that favor healthy living; e.g. good nutrition, adequate clothing, shelter, rest and recreation Encompasses health education

Specific protective measures

Includes immunization, environmental sanitation and protection against accidents and occupational hazards

` `

Early diagnosis and prompt treatment Screening surveys are designed to uncover asymptomatic diseases and to alter the natural history of the condition detected Possible to either cure disease or slow its progression, prevent complications, limit disability Early treatment of persons with infectious diseases may protect others from acquiring the infection

Limitation of disability and rehabilitation Where disease has already occurred and left residual damage PT of an affected limb to restore motion

Latest phase to be recognized as a result of the increasing knowledge of the epidemiology of specific disease (ex. Cardiovascular disease) The aim is to avoid the emergence and establishment of the social, economic and cultural patterns of living that are known to contribute to elevated risk of disease Ex. urban air pollution and its global effects (the greenhouse effect, acid rain, ozone depletion)

A national policy and program on nutrition involving the agricultural sector, the food industry, and the food import/export sector Non-smoking promotion policy A program for prevention of hypertension A program to promote regular physical activity

The Natural History of Any Disease of Man

Interrelations of Agent, Host, and Environmental Factors Production of Stimulus

Reaction of the HOST to STIMULUS

Early Pathogenesis Discernible early lessons Advanced Disease Convalescence

Prepathogenesis Period

Period of Pathogenesis

HEALTH PROMOTION
Good standard of nutrition adjusted to develop-mental phases of life Attention to personality development Provision of adequate housing, recreation, and agreeable working conditions Marriage counseling and sex education Genetics Periodic selective examinations

Use of specific immunizations

SPECIFIC PROTECTION

EARLY DIAGNOSIS and PROPT TREATMENT

REHABILITATION
Provision of hospital and community facilities for retraining and education for maximum use of remaining capacities Education of the public and industry to utilize the rehabilitated As full employment as possible Selective placement Work therapy in hospitals Use of sheltered colony

Case-finding measures, individual and mass Screening surveys Selective Examinations Objectives: To cure and prevent disease processes To prevent the spread of communicable diseases To prevent complications and sequelae To shorten period of disability

Attention to personal hygiene Use of environmental sanitation Protection against occupational hazards Protection from accidents Use of specific nutrients Protection from carcinogens Avoidance of allergens

DISABILITY LIMITATION

Adequate treatment to arrest the disease process and to prevent further complications and sequelae Provision of facilities to limit disability and to prevent death

Primary Prevention

Secondary Prevention

Tertiary Prevention

Levels of Application of Preventive Measures

Development of Disease Underlying conditions leading to causation Specific causal factors Early stage of disease

Phase of Prevention

Target Population

Primordial

Total population/selected groups Total population/selected groups/individuals Patients

Primary

Secondary

Late stage of disease

Tertiary

Patients

Grouping/formation of classes Allow generalizations regarding features of the members of a class

Pre-requisite of epidemiologic study

Inference about association (can be made only when the elements of the association are considered in groups or classes) Measuring disease frequency in a population requires the stipulation of diagnostic criteria To achieve standardization, therefore comparability, in mortality and morbidity data

Goal of epidemiology
ID of causal factors serve as causal criteria for grouping of ill persons

Grouping of ill persons Arrangement of the disease entities into groups having common characteristics

Criteria ` Manifestational
Signs and symptoms Biochemical/physiologic/anatomic/behavioral changes A combination Ex. DM, musculoskeletal, mental retardation, cancer

Causal and etiologic

Cause of illness Ex. Birth trauma, lead poisoning

Absence/lack of understanding of etiology, diseases are classified based on manifestations of the disease rather than by its etiology

Early 19th century

Scrofula White plaque

(cervical lymph gland) (lungs)

Late 19th century (role of tubercle bacillus)

Tuberculosis

International Classification of Diseases, 10th revision (ICD-10); assigning codes and classification of mortality data International Classification of Diseases, 10th revision, Clinical modification (ICD-10-CM); assigning codes to diseases, OPD, in-patients International Classification of Functioning, Disability and Health (ICF); approved May 22, 2001

Endorsed by WHA in 1990 (used in 1994) Latest in a series with its origin in 1850s First ed.: International List of Causes of Deaths

William Farr (England)

5 classification of causes of death (1864) x Epidemic disease x Local diseases (by anatomic site) x General diseases x Developmental diseases x Diseases as a direct result of violence Basis of the International List of Causes of Death

Organization/Year

Disease Classification System

Bertillon Classification of Causes of Death Intl Statistical Institute, 1893 International List of Causes of Death
5 revisions

WHO, 1948

International Classification of Diseases, Injury, & Causes of Death (6th revision)

7th, 8th, 9th revisions

WHO

ICD-10 ICD-10-CM ICD

Endorsed by WHA in 1990 Used by member state 1994

10th revision

International standard diagnostic classification Diseases and other health problems are categorized into disease entities Assigns a three character alphanumeric code to every major condition. Often a fourth character is added for more exact specification

Ex. ICD C92 is myeloid leukaemia, which may additionally be specified as C92.0 (acute) or C92.1 (chronic). Broader groupings are readily formed Ex. ICD C81-C96 consists of all malignant neoplasms of lymphatic and haematopoietic tissue

Provide consensual, meaningful and useful framework which governments, providers and consumers can use as a common language Facilitate the storage, retrieval, analysis and interpretation of data for clinical and epi purposes Permit the comparison of data within populations over time and between populations at the same point in time as well as the compilation of nationally consistent data

Used for:

Analysis of the general health situation of population groups

Monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected