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INTRODUCTION TO EPIDEMIOLOGY

Dr. M. Fahdhy, SpOG, MSc

Obstetric and Gynecology department, Faculty of Medicine
North Sumatra University
 OBJECTIVES

 Introduction
 Patient profile
 Person, place and time
 The epidemiologic approach
 The application of epidemiology
 Summary

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 INTRODUCTION

 Epidemiology :

 Basic medical science that focuses on the

distribution and determinants of disease
frequency in human population

 Concerned with understanding the factor that

risk, cause, prevent, intervene, and reduces
diseases by studying associations between
disease out comes and suspected determinants
in human population
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 INTRODUCTION

 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

 Determine of disease frequency or occurrence

 The disease does not develop at random
 Certain persons are at comparatively high risk by virtue of their personal
characteristics and environment
 The repeated occurrence of AIDS in homosexual men suggested that had an
increased risk of AIDS
 Other high risk group for AIDS were identified including hemophiliac and
intravenous drugs users
 Medical research is devoted to investigating the biologic element of disease
development, the microbiologist tends to focus on the infectious agent (HIV-
1=human immunodeficiency virus), immunologist concentrates on the mechanism
of immune dysfunction and the epidemiologist on views disease from both biology
and social perspective

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 THE EPIDEMIOLOGIC APPROACH

 Medical research is motivated by a desire to prevent or control human illnesses

 the epidemiologic approach are
1. The focus on human population
2. Heavy reliance on nonexperimental observation
 The epidemiologist actually observes the patterns of exposure and disease
development as they naturally occur within human population
 It is not necessary to characterize the molecular properties of HIV-1 in order to
recognize that AIDS is a contagious disease that spread through certain
interpersonal behaviours
 One can recommend measures to prevent the spread of AIDS by reducing the
frequency of high risk practices

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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

 In the United State between February 1990 to January 1991 16.4

cases of AIDS were reported for every 100,000 persons
 The rapidity of disease occurrence is referred to as an incidence rate
 Characteristic pattern of disease occurrence, incidence rates may be
determined for subgroups define by geographic area
 Surveillance data usually are limited to general characteristics of
affected persons such as age, race, gender, and place of residence
 Variation in incidence can lead to identification of high risk group and
call for more in depth investigation into personal characteristics,
behaviors, and environments

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 Searching for Causes

 Epidemiologist often rely upon interview, record review, and laboratory

examination
 The associations between these characteristics and the occurrence of disease
can occur by coincidence, by cause and effect or by non causal linkage
 Determination of disease development also known as risk factors
 Identification risk factors can result better understanding of pathway leading to
disease acquisition and thereby suggest preventive strategies
 The association can be investigated by case control study
 Cases were persons who are affected with disease
 Controls were persons who are unaffected with disease
 To look backward in time identify characteristic that may have contributed
to disease development
 Comparisons of historical exposures reported by cases and control can provide
suggestive evidence of a cause and effect relation ship

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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

 To obtain objective evidence of the presence or absence of particular condition

 The evidence can be obtained to detect disease at its earliest stages among
asymptomatic persons in general population as screening
 Used in order to confirm a diagnosis among persons with existing signs or symptom of
illness
 Ideally, a diagnostic test would correctly distinguish affected persons from unaffected,
Unfortunately most diagnostic test are not perfect
 False positive : positive test result in an unaffected persons
 False negative : negative test result in an affected persons
 Sensitivity as the percentage of persons with the disease who have positive result
 Specificity as the percentage of persons without the disease who have negative result
 A good diagnostic testing has high sensitivity (low false negative) and high specificity (low
false positive)

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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

 Survival analysis can be employed to identify subgroup of

patients with favorable or unfavorable clinical outcome
 These factors may involve
 demographic characteristic (age, race and gender)
 Younger patient with AIDS tended to survive longer than older one
 White race and male gender are also favorable prognosis
 Clinical signs and symptom
 Laboratory test result

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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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