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CPH QUIZ 3

EPIDEMIOLOGY

Definition (demography sociology statistics)
The study of the distribution and determinants of health-related states or events in
specified populations. (App : the control of health problems)
The science that forms the basic for PH and unites PH professions.
A scientific discipline and has its foundation, sound methods of scientific injury.

Study Surveillance, observation, hypothesis testing, analytic research &
exp.
Distribution Analysis of times, persons, places and classes of people affected.
Frequency (rate/risk of disease) and pattern of health events in a
population.
Determinants Factor influencing health: biological, chemical, physical, social,
cultural, economic, genetic, behavioral.
Health related
states and
events
Diseases, causes of death, behavior (tobacco use), positive health
status, reaction to preventive regimes and provision and use of
health services.
Specified
populations
Those with identifiable char. (occupational groups)
App to
prevention and
control
The aims of PH : To promote, protect and restore health.

2 fundamental assumptions
Disease dont occur by chance
Disease are not distributed randomly in populations (HOW, WHY)

BASIS OF DEMOGRAPHY
Demography : the scientific study of human population.

5 Aspects of Human population (CD SP SE)
Composition Stratification of population
(Age, sex, literacy, occupation, income, religion)
Distribution How people are distributed in the country.
(Regions, Urban/Rural/Desert, Natives/Foreigners, Race)
Size To know the #all persons in the community.
(Census/Est. population)
CENSUS = Enumeration of all persons in the community.
(Periodically 10 years, high cost)
Factors affecting size : Births, Deaths, Migration
Population
dynamics
Study of processes that influence the char of population marriage,
births, deaths, migration, social mobilization.
Socio economic determinants and consequences of population change

LANDMARKS IN EPIDEMIOLOGY
Vital
statistics
Official registration records
(Births, deaths, marriages, divorces, adoption)
City, country, state health dept.
Compare with prev. years, provide indicators of population growth or
reduction
Supply info about #birth & deaths, reg certificate record, cause of
death = to determine Morbidity and mortality trends.
To assess community health status.
Infectious
Dse (IED)
Epidemiolog
y
Study of prevalence, incidence, determinants of infection
One of the most important causes of morbidity and mortality in the
world.
Implement and evaluate interventions at individual and community
level
--1prevention = prevent infection
--2prevention = prevent disease development
--3prevention = prevent dse associated death & disability
Noninfectiou
s Dse
Epidemiolog
y
Major cause of death and disability:
Cancer, heart dse, lung dse, diabetes.
Responsible for 63% deaths worlwide (double #ID, maternal and
perinatal, nutritional def)
Causes of premature death from NCD : Tobacco, poor diet, physical
inactivity, harmful alcohol consumption.
Social
Epidemiolog
y
Study of relationships b/w health
Study a broad range of social factors (race, social class, gender, social
policies)
Sruveillance (descriptive relationships b/w social factors and health,
tracking of health inequalities)
Etiology (causal effects of social exposures on health)

Health policy Epi Infectious Dse Epi
1883 Bismarck : workers compensation, Nat.health
insurance
1796 Jenner : cowpox to vaccinate smallpox
1917 Semashko : soviet state health system 1854 Snow : water transmission of cholera in london
1948 UK: Nat. health service 1882 Koch : TB and cholera organism
1978 Declaration on Alma-Ata and Health for all 1978 Eradication of smallpox
1979 US surgeon gen. healthy people and health targets 1980 HIV and other infectious dse
1990 Managed care revolution in US 2000 Elimination of yaws, poliomyelitis, leprosy,
dracunculiasis, measles
Non Infectious Dse Epi Social Epi
1747 Lind : prevention of scurvy by citrus fruits 1662 Graunt : natural and political observations made
upon bills of mortality
1775 Pott : excess cancer of scrotum in chimney sweeps 1836 Registrar gen. office : UK parliament
1914 Goldberger : nutritional cause of pellagra 1842 Chadwick report sanitary condition of labouring
pulation of great britain
1950 Doll and Hill : Cigarette smoking Lung cancer 1848 Virchow : medicine is a social sc ience
1954 Framingham : heard dse risk factors 1858 Simon : mortality by district (social, environmental)
1960 Reducing mortality from CVD, trauma 1982 Black : social class differences in mortality in UK
1990 Infections as causes of chronic dse : MDR
organism
1995 Beijing conference on women : empowerment of
health of women and children

SNOW ON CHOLERA
Dr. John Snow
Talents in math
14 yo : medical apprenticeship with william hardcastle
1832 Exposed to cholera px in killingworth
Study in london MD (westminster medical society president)
Royal college of physicians, London Epidemiological society (founding member)
Anesthesiology (ether, chloroform, less risk of overdose)
Original concept of anesthesia : boston
Worlds first professional anesthetist
Royal medical and chirurgical society : more extensively conversant w/its operation and
more successful in administering it than any living person.

British Cholera Epidemics
1831-1832 1
st
modern outbreak in britain
23000 deaths
Helped to launch the sanitary reform movement
1848-1849 250k cases , 53k deaths
Prompted snow and others to investigate the case

London Cholera Epidemics (Sep 1848 Aug 1849)
Human + animal excrement + garbage cesspits or river cesspits filled and
overflowed draining into the river
Hypotheses A GI disease (causal agent = ingested)
Diarrhea = most prominent symptom (causal agent : left the body by this
route)
Cholera excretion + river drinking water dissemination of disease
Causal
hypothesis
Sewage contaminated drinking water (causal agent for cholera
epidemic)

Snow didnt have exact info on the sources of water for the districts
East and South = water supplies from polluted parts of Thames River
London = water from uncontaminated source (no sewage)

The Broad Street Pump Outbreak
Golden square, adjoining streets
250 yards of Cambridge streets + broad street = 500 cholera attacks in 10 days
Snow hypothesis:
Sewage water contamination cause of cholera
Working knowledge of the cluster area (soho)

Difficulties of exposure assessment
Piped water = no sewage contamination
All goldern square water sample has visible purities except Braod street
Small flocculent particles (white flecks) in broad street

Case series evaluation
Cases in those who use broad street pump
No cases in those who did not use broad street pump

Controversies
Snows cholera VS Britishs Miasma (bad air theory)
Henry whitehead (Gods divine intervention) VS outbreak
Robert Koch : vibrio cholerae = poison behind outbreak
Dr. john snow = pioneer in PH research (EPIDEMIOLOGY)

MIASMA THEORY AND GERM THEORY
MIASMA cause of Cholera outbreak (Air)
Spread through the stench of decay
Source of odor
Preventive approach : cleansing and scouring
Dr. william farr
Soil at low elevations contain much organic matter MIASMATA
GERM John snow
Cholera was caused by a germ cell
Transmission : drinking water
Modified by Louis Pasteur and Robert Koch about biomedical .

HOST AGENT ENVIRONMENT PARADIGM
Paradigm that interact with each other to form a condition that favors ill health or
disease to occur.
Harmful AGENT contact specific HOST through a sympathetic ENVIRONMENT
HOST Person with risk of specific disease
Intrinsic char (influence individual susceptibility to dse)
AGENT Organism/ direct cause of disease
Health hazard : biological, chemical, Ergonomics, physical,
psychological
ENVIRONMENT External factors
Influence the host/his susceptibility to the agent.

HOST AGENT ENVIRONMENT
Age
Sex
Genes
Psychology
Lifestyle
Edu
Biological
Genetic
Nutritional
Chemical
Physical
Mechanical
Biological
Genetic
Physical
Social situation
Economic
Trauma
Social situation
Occupation
PH essence : intervention to change the chain.

DEFINITIONS
Epidemiology Basic science of PH concerened with
distribution, determinants of health and
diseases, morbidity, injuries, disability,
mortality.
Monitoring reports
of communicable
diseases in the
community
Epidemic Occurrence of a community/region of cases of
an illness, specific health related behaviour or
health related events in excess of normal
expectancy
Food borne dse,
salmonella
Epidemiologist Evaluates new preventive measures, program,
treatments designed to promote good health.
Monitor the effectiveness of intervention
program
John Snow (father
of modern
epidemiology)
Endemic A disease or infectious agents habitually
present in a community, geographic area, or
population group.
Maintains a low but continuous incidence
Plague of rodents in
western US.
Pandemic Worldwide epidemic, crossing international
boundaries,.
Influenza

LIFE SPAN & LIFE EXPECTANCY
Life span Average length of life of a kind organism in a particular environment
underspecified cirumstances
Life
expectancy
Average #years of a person can expect to live
Estimate the equivalent years in full health that a person can expect to
live on.
The basis of the current mortality rates and prevalence distrubution of
health states in the population

Risk factors of Life expectancy
Physical Age, genetic, gender, race
Emotional Stress, anxiety, mood, anger
Intellectual Cognitive abilities, edu background
Environmental Sanitation, climate, air, water
Socio cultura Lifestyle, culture, practices
Spiritual Spiritual beliefs, values
Others Developmental disabilities, chem exposures, vices, diseases,
accidents, lifestyle, environmental, economic status

RATE AND RATIO
RATE A measure of risk
Measure the occurance of an event in a particular population in a
specified period of time




RATIO A relationship b/w 2 values or quantities




DIFFERENCE RATE
Possess time dimension
Subject : included in population
RATIO
No time dimension
Subject : 2 distinct quantities

MORTALITY AND MORBIDITY
MORTALITY MORBIDITY
Death itself Illness or causes of death

Relevance to Epidemiology
Help define health status of a population
Explain etiology of a disease
Predict disease occurrence (intervention, allocation of HC resources)
Controls disease distribution
Helps in disease eradication

Philippine Std. certificate of Death
Demographic : Name, age, gender
Time, place, date of Death
Attendant (MD, admin of hospital)
Corpse disposal : autopsy, burial, cremation permit

INCIDENCE RATE & PREVALENCE RATE
INCIDENCE RATE PREVALENCE RATE
#New cases of diseases occuring in a
specific population in a specified time
period
#Disease cases, infected person/condition
at a particular time
Useful to determine the need for initiation
of preventive measures

Meaningful measure for acute & chronic Special for chronic.. can also be for acute

Importance in epidemiology
To assess and explain the impact of PH control measures, prevention program, clinical
intervention, health services on disease.
Observe the occurences and frequencies of disease in population
To analyze further contribution in assessment and control of health problems in
community.
To illustrate changing disease trends (analyze and observe disease occurrence and
other health related behavior in population over time)

BURDEN OF DISEASE
Overall impact of disease and injuries at the individual level, societal level, or economic
cost of disease.
GBD : Global burden of disease = WHO & World Bank study : measure the total loss
of health resulting from disease and injuries.
Generates the most comprehensive and consistent estimates of mortality and morbidity
by age, sex, region.
Infectious disease 43% of global burden
A measure of the gap between current health status and ideal situation where everyone
lives into old age, free of diseases and disability.

Measurement of Burden of Diseases
DFE
Disability Free Expectancy


DALYs
Disability Adjusted Life Years
Health gap measures
Impact of premature death + disability + non
fatal health outcomes
HALE
Health Adjusted Life Expectancy

Equivalent #years a person can expect to live in
full health
LE
Life Expectancy
Average #years a person is expected to live.
PE YLL
Potential & Expected Years of Life
lost
Indicator of loss from premature mortality
(early death from average LE in a developed
country)
QALYs
Quality Adjusted Life years
Magnitude of the weighs assigned to different
helath conditions (highly subjective)
Ex: new radical treatment that increase LE by
10years but associated with side effects

YEARS OF POTENTIAL LIFE LOST (YPLL)
Measure the impact of premature mortality on a population.
End point = 65 yo

Calculation
Eliminate all age group > endpoint
Identify midpoint of age group younger than the end point




Sum the Age specific YPLL

Age group deaths Age midpoint Age group YPLL Age Specific YPLL
0-4 125 2.5 62.5 7813
5-14 316 10 55 17380
15-24 472 20 45 21240
25-34 471 30 35 16485
35-44 767 40 25 19175
45-54 1459 50 15 21885
55-64 2611 60 5 13055
65+ 15277 -
Not stated 0 -
TOTAL 21498 117033

DALYs DISABILITY ADJUSTED LIFE YEARS
Summary measure of population health widely used in disease burden assessment
studies and cost utility analysis.
Incident number of healthy life years lost due to disease or disabiliity
(fatal, non fatal outcome )
(years of life lived with disability YLD + Years of life lost due to premature death YLL)
Indicator of burden of disease in a population

YLD = Morbidity component (~ incident cases and severity of disease)

YLL = Mortality component (~ #deaths and average age of death)


COST EFFECTIVENESS ANALYSIS BY DALY




HALE HEALTH ADJUSTED LIFE EXPECTANCY
Based on LE at birth + adjustment for time spent in poor health.
Equivalent of years an individual can expect to live in full health.
HALE = LE 6 or 8 (male)
HALE = LE 7 or 10 (female)


INDICATORS FOR MEASURING MORTALITY
CDR (Annual Crude death Rate)
Universally used
A generalized indicator of health
population




ASDR (Age specific Death Rate)
Compare mortality at different ages
Compare mortality in the same age
group over time b/w countries and
areas




CSDR (Cause specific death rate)




SPECIAL INDICATORS
MATERNAL MORTALITY RATES
#deaths assigned to puerperal
causes in given year divided by #live
births in that year with the quotient
multipled by 100-




SPECIAL INDICATOR
INFANT MORTALITY RATES
#deaths of persons of age 0-1 in a
calendar year divided by #live births
in that year, with the quotient
multiplied by 1000