Applications of

Epidemiology in the
Communities

Joedo Prihartono
Department of Community Medicine FKUI

Modified from Kimberly Carter, PhD, RN

 Epidemiology
The study of the distribution of health
and of the determinants of deviations
from health in populations

What
Who, Where, When
Why, How
Purpose of Epidemiology

To obtain necessary data to prevent and

control disease through Community Health
Intervention

Epi - on or upon
Demos - the people
Logos - Knowledge
 DESCRIPTIVE ANALYTIC
EPIDEMIOLOGY EPIDEMIOLOGY

Incidence Risk Factors

Prevalence

Triad Epidemiology Diagnostic Tools

HA-E

Holistic Diagnosis
CLINICAL EPIDEMIOLOGY /
(BIOPSYCHOSOSIAL)
EBM
( Clinical Trial, Etiologic/
Diagnostic/Therapy/Prognostic
Meta Analysis) Therapy, Prognosis
 Uses of epidemiology
Search for cause/causes of diseases
Discover the health status of population or groups

Discover and bridge gaps in Natural History of

Diseases
Controlling diseases to break transmission

Planning of health programs on evidence basis and

health priority
Evaluate health programs and interventions

Determine the chances or probability of occurrence

of disease/deaths/disability
Support better management of health services and
hospital services
 Epidemiologic Models

Models to describe the factors necessary

to make an epidemiologic event happen

Web of Causation
Ecological (or epidemiologic) Model
 Example of a Web of Causation
Overcrowding Malnutrition

Exposure to
Mycobacterium

Susceptible Host Infection Tuberculosis

Tissue Invasion
and Reaction

Vaccination Genetic
 Host:
Intrinsic factors, physical factors,
psychological factors, immunity

Health
or
Illness
?

Agent:
Amount, infectivity, pathogenicity, Environment:
virulence, chemical composition,
Physical, biological, social
cell reproduction
CAUSATIVE STEPS
A B

Significant Not Significant

Causal Coincidence

Direct Indirect
 Examples of Agents of Disease
Nutritive excesses or deficiencies (Cholesterol,
vitamins, proteins)
Chemical agents ( CO2, drugs, medications)
Physical agents (Ionizing radiation)
Infectious agents (hookworm, malaria, tuberculosis)

Examples of Host Factors

Genetic (Thallasemia)
Age, Gender, Ethnicity
Physiology state (pregnancy, puberty, fatigue)
Prior immunologic experience (immunization, prior
infection)
Human behavior (life style, food handling, hygiene)
Examples of Environmental
Factors
Physical environment (geology, climate)

Biologic
environment (population density,
sources of food, influence of vertebrates and
arthropods)

Socioeconomic (exposure to chemical agents,

urban crowding, tensions/ pressures, cooperative
efforts in health education, wars, floods)
 Epidemiology within the
Health Care System
Curative

Medicine Epidemiology

Individual Community

Community Health
Basic Nursing
Nursing/Public Health

Preventive
 Levels of Prevention
Primary: Activities to decrease the probability
of specific illnesses or dysfunctions No Disease
Present
Secondary: Early Diagnosis and prompt
intervention allowing early return to ADLs.
Disease has occurred
Tertiary: A defect or disability is fixed, stabilized
or irreversible. Rehabilitation. Disease has
advanced

HEALTHY PARADIGM
Natural History of Disease
The process by which diseases
occur and progress in humans
Exposure to Agent
Symptom
Development
Pre-exposure
Preclinical
Stage:
Stage:
Factors present
leading to Exposure to Clinical
causative
Resolution
problem Stage: Stage:
development agent: no
symptoms Symptoms Problem resolved.
present present Returned to health
or chronic state or
death

Primary Secondary Tertiary

Prevention Prevention Prevention
 Epidemiologic Control
Measures
Rapid identification of isolated
disease outbreaks
in community, hospital, school, other institution

Notification to local health authority

Sub-district (kecamatan)
District
Province
National
WHO
 Epidemiologic Measures

Rates : Events / Population at risk

Mortality rate ( Infant MR, Under-5 MR, Cause
specific MR, Standardize MR )

Ratio : Events / Events

Maternal Mortality Ratio
Sex Ratio
Dependency Ratio
 Relative Risk (Risk Ratio)

Theratio of the risk of developing disease among

those exposed to a factor to the risk among those
not exposed.

Incidence of disease in exposed group

= ------------------------------------------------------------------------
Incidence of disease in non exposed group
Calculating Relative Risk

Daily avg # drinks Cirrhosis Cases Relative Risk

(per 1,000)
0 7 7/7 = 1.0

1 26 26/7 = 3.7

2-3 48 48/7 = 6.9

4+ 40 40/7 = 5.7
 Attributable Risk

Attributable Risk: Rate of a disease among

exposed individuals that can be attributed to the
exposure and not to other causes

rate of outcome (incidence or mortality) among

exposed - rate among the unexposed per constant
Calculating Attributable Risk

Daily avg # drinks Cirrhosis Cases Attributable Risk

(per 1,000) to level of drinks

0 7 7-7 = 0.0

1 26 26-7 = 19.0

2-3 48 48-7 = 41.0

4+ 40 40-7 = 33.0
 Basic Definitions

Morbidity

Mortality

Epidemic

Endemic

Pandemic
 Rates

Allows comparison between populations

Frequency in numerator (X)

Comparison population in denominator (Y)

X/Y x Constant (C)

Usually per 1,000 or 100,000 (NOT %)

 Incidence
# of new cases of disease in a place from Time 1 to Time 2
-------------------------------------------------------------------------------------------------- x C
# of at risk persons in a place at midpoint of time period

Prevalence
# of existing cases in a place at a given time
----------------------------------------------------------------------- x C
# of persons in a place at midpoint of year
Crude Mortality Rate

# of deaths during a year

-------------------------------------------------------------
Average (midyear) population

/ per 100,000 population

Cause-Specific Mortality Rate

# of deaths from a stated cause in a year

----------------------------------------------------------------------------------
Average (midyear) population

/ per 100,000 population

Age-specific mortality rate
Infant MR
Under 5 MR

# of deaths of a given age group in a year

-------------------------------------------------------------------------------------
Average (midyear) population of same group

/ per 100,000 population

Standardized Mortality Rates
Adjusts for differences in populations so that
comparisons are interpretable.

Age-adjusted
Race-adjusted
Gender-adjusted
Education
Socio-economic
Religion
etc
Maternal Mortality Ratio

# of maternal deaths during a year

-------------------------------------------------------------------
# of live births in same year

/ per 100,000 live births

Case Fatality Percentage

# of deaths from specific disease

--------------------------------------------------------------------
# of cases

TIMES 100%
 Fertility Rate
Crude Birth Rate : No of birth / population
General Fertility Rate : No of birth / women 15-49

Age Specific Fertility Rate :

No of birth to women sp age group/ women of sp age group

Total Fertility Rate : Average no of live children at age 49

Gross Reproductive Rate :

Average no of Female children at age
 Interpreting Epidemiological
Information

Indices of population change are fertility, mortality,

and migration

Indices of overall health status are IMR and MMR

To plan for future health needs, look at age

distribution, at-risk groups, screening protocols,
treatment modalities, and referral mechanisms
 Screening Validity

Sensitivity
Specificity
Positive and Negative Predictive Values
 The Ideal Screening Test
Normal Diabetic

Blood Glucose
 Sensitivity

Tests ability to identify correctly those who do have

disease

= True positives/All those with the disease

= TP /TP + FN
 Specificity

Tests ability to identify correctly those who do not

have disease

= True negatives/All without the disease

=TN/ TN + FP
Indices to evaluate accuracy of
Screen or diagnostic test

Test Disease Present Disease Absent

Positive Result A B
(True positives) (False positives)

Negative Result C D
(False Negatives) (True negatives)

Totals A+C B+D

Application of Sensitivity & Specificity
Blood Glucose Level (mg/100 Actual diabetics; (n=70) Actual non-diabetics; (n=510)
ml) using screening test

80 100.0 (n=1) 1.2 (n=6)

90 98.6 (n=1) 7.3 (n=31)
100 97.1 (n=3) 25.3 (n=91)
110 92.9 (n = 3) 48.4 (n=116)

120 88.6 (n=4) 68.2 (n=101)

130 81.4 (n= 5) 82.4 (n=71)
140 74.3 (n=7) 91.2 (n=45)
150 64.3 (n= 6) 96.1 (n=25)
160 55.7 (n= 3) 98.6 (n=12)
170 52.9 (n=2) 99.6 (n=5)
180 50.0 (n=4) 99.8 (n=6)
190 44.3 (n=5) 99.8 (n=0)
200 37.1 (n=26) 100.0 (n=1)
 Application (Continued)

Blood Glucose Level True Diabetics (%) True Non-diabetics (%)

(mg/100 ml)

All over 110mg/100 ml are 88.6% 52.2%

classified as diabetics
(True positives) (False positives)

All under 110mg/100 ml are 11.4% 47.8%

classified as non-diabetics
(False Negatives) (True negatives)

Totals 100.0% 100.0%

 Application (Continued)

Sensitivity = 62/70 x 100% = 88.6%

Specificity = 244/510 x 100% = 47.8%

 Predictive Values

Determines relationship between sensitivity,

specificity, and prevalence
When prevalence is low, even a highly specific test
will give a relatively large number of false positives
because of the many non-diseased persons being
tested.
 Positive Predictive Value

Likelihood that an individual with a positive test has

the disease
TP / (TP + FP) = 62 / (62 + 266) = 18.9%
 Negative Predictive Value

Likelihood that an individual with a negative test does

not have the disease
TN / (TN + FN) = 244 / (244 + 8) = 98.8%
Benefits and disadvantages of screening
Benefits Disadvantages
Improved prognosis for some cases Longer morbidity in cases where
detected by screening prognosis is unaltered
Less radical treatment for some early Over treatment of questionable
cases abnormalities
Reassurance for those with negative False assurance for those with false
test results negative results
Increase information on natural Anxiety and sometimes morbidity for
history of disease and benefits of those with false positive results
treatment at early stage Unnecessary intervention for those
with false positive results
Hazard of screening test
Diversion of resources to the
screening program
 DM Screening at Primary Health Care
Patients criteria:
Aged 45 yrs Suggested to check for blood glucose (with or
without risk factor)
Aged between 17 to < 45 yrs Check for weight, height, and blood
pressure.
If BMI > 25 kg/m2 , Check for risk factors
Family history of DM
Blood pressure 140/90 mmHg or under treatment
Having been diagnosed with cardiac disease or stroke
HDL cholesterol < 35 mg/dl and / or Triglyceride > 250 mg /dL or under
treatment
History of having baby > 4 kg or being diagnosed with Gestasional DM
Woman with PCOS (polycystic ovary syndrome)
History of GDPT (Glukosa Darah Puasa terganggu) / TGT (Toleransi
Glukosa Terganggu)
Low physical activity

Buku protokol DM di pelayanan primer

 Result of DM Screening
Accidental and fasting blood glucose as screener and
diagnosis of DM
Table: Accidental and fasting blood glucose as screener and diagnosis
of DM
Type of examination Non DM Suspect DM DM

Accidental blood plasma vena < 100 100 - 199 > 200
glucose

Capillary blood < 90 90 - 199 > 200

Fasting blood plasma vena < 100 100 -125 > 126
glucose

Capillary blood < 90 90 - 99 > 100

Buku protokol DM di pelayanan primer

Considerations for Selection of
Screens

Prevalence
Financial
Availability/ Feasibility of
Treatment
Relative costs of classifying
persons as FN and FP
 Surveillance
Epidemiologic Surveillance is an ongoing and systematic
data collection, analysis and interpretation of health data in
the process of describing and monitoring a health event
(CDC). Data collected through health institution using
International Classification of Disease (ICD) 10

Objective of surveillance : determine incidence of diseases,

geographical distribution, identify population at risk,
monitor trend of disease, assess the disease burden in the
community or health needs, etc.

The information is used for planning, implementation and

evaluating public health interventions and programs
 Epidemic : Outbreak (Wabah / KLB)

Outbreak (Wabah / Kejadian Luar Biasa) is a significant

increase in incidence of a disease in a specified time

Indonesia : Wabah /KLB:

a. Increase more that 2 times in the same length period
b.Incidence of a new disease (HIV)
c. Incidence of a disease that was no longer exist (polio)

Wabah occur in a greater area than KLB (several kabupaten)

in a province. If a disease is declared as wabah, then the
national government should support. In KLB, the local
government is responsible.
Using Epidemiology To Identify
The Cause Of Diseases
Cohort studies

Case control & Cross sectional Studies

Estimating Risk

Association vs causation

Identifying the roles of Genetic and Environmental

Factors in Disease Causation
 Applying Epidemiology to
Evaluation and Policy
Using Surveillance

Using Epidemiology in Intervention of Outbreaks

Using Epidemiology in Community Diagnosis

Using Epidemiology in Quality Assurance

Using Epidemiology in Program Evaluation (ie ANC,

FP, Immunization, TB)

Using Epidemiology in Public Policy

 From study to policy

Policy
Why non iodinated salt is still in the market?
A cross sectional study on endemic goiter
revealed that its prevalence in the mountainous
area is higher than coastal area
PLACE
The cause of endemic goiter is deficiency of
iodine that highly available in the sea fishes
Sea fishes are not available for people in the
mountain
 Findings of a cross sectional study could be used for
health program planning such as:
Planning of health personnel
Determining target population for education or
prevention programs

Findings of an analytical study causal relationship

Smoking habit and lung cancer, cardiac disease,
negative effect to fetus, etc warning sign at the
cigarette box
From study to disease management

Management of breast cancer.

A study among 1,079 breast cancer patients has
compared radical mastectomy, total mastectomy
with radiation, and only total mastectomy for
patients without metastasis, and also comparison
between radical mastectomy to combination of
total mastectomy with radiation for patients with
metastasis

The findings reveal that radical mastectomy is not

significantly different to total mastectomy for
disease-free survival, relapse-free survival, distant-
disease-free survival and overall survival. 4
 Source of material

Kimberly Carter PhD, RN

Buku Protokol DM di Pelayanan Primer

Sunder Lala. Adars, Pankaj. Textbook Community

Medicine, Preventive and Social Medicine. New Delhi.
2 nd ed, 2009

Gordis l. Epidemiology Elsevier Saunders, 3 rd ed,

2004
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