Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease

Professor in Community and Preventive Medicine

Meysamie@tums.ac.ir

Epidemiologic Orientation to
In the name of the Almighty
Health and Disease
Alipasha Meysamie, MD, MPH
Professor in CPM

Epidemiology; Definition Epidemiology; Definition

• Study of • Disease not randomly distributed
– Distribution and determinants of throughout a population,
• Diseases and injuries in human populations. – Subgroups differ in
– Concerned with • Frequency of different diseases.
• Frequencies and types of illnesses and injuries – Uneven distribution
• In groups of people • Used to investigate causal factors
• And with the factors that influence their • Groundwork for programs of prevention and
distribution. control.

Population Medicine and

Epidemiology; Definition
Epidemiology
• Contribution of epidemiology to advance • Knowledge about human health and
of medical science disease
– Beyond the bounds of direct observation. – Sum of a large number of disciplines
– Chains guide investigation to the facts of the • Anatomy, microbiology, pathology, immunology,
future; clinical medicine, radiology
• Grouped according to methods and
underlying concepts
– Three major categories,
• All highly interrelated
• Each has its major locus of activity and specific
methods.

١
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Population Medicine and Population Medicine and

Epidemiology Epidemiology
• Basic sciences • Clinical medicine
– (e.g., Biochemistry, physiology, pathology), – Focuses largely on the medical care of individuals.
• Typically, sick people seeking help;
• Clinical sciences • Need for examination of apparently well people
– (e.g., Adult medicine, neonatology, obstetrics – To detect disease in early stages.
and gynecology, urology), • Population medicine
• Population medicine. – Community replaces the individual patient
– Community medicine, preventive medicine, • Evaluate the health of a defined community,
• Including those would benefit from, but do not seek, medical
or social medicine, or, more traditionally, care.
public health. • This approach requires specific techniques and skills in
• Concerned with the study of health and disease in addition to clinical practice.
human populations.

Population Medicine and Population Medicine and

Epidemiology Epidemiology
• Correct diagnosis in an individual patient • Correct diagnosis in an individual patient
– Patient's history, – Example,
– Physical findings, and • Cancer of pancreas,
– More probable in an elderly smoker than in an
– Laboratory data, also adolescent.
– Knowledge of the distribution of diseases by – Information about the illnesses prevalent
such factors as in the community
• Age, sex, ethnicity, and socioeconomic status. • A patient with fever and respiratory disease,
– Influenza epidemic is in progress or a recent upsurge in
streptococcal isolations.

Population Medicine and Population Medicine and

Epidemiology Epidemiology
• The level of occurrence of a disease in a • Tuberculosis,
population
– Dependent on – Basic sciences
• The accuracy of the diagnoses on individual patients and • Various aspects of the tubercle bacillus
• The completeness of report
– Structure and antigenic composition,
– Lead to containment of
– Growth in different media, and
• An outbreak resulting from contamination of food or water or
– Resistance to specified antibiotics
– Need for an intensified immunization against measles.
• Accuracy of both individual diagnoses and • Host responses,
epidemiologic assessment – Extent of becoming walled off by fibrous tissue.
– Dependent on
• Adequate laboratory support.
• Require special techniques for isolation and identification, such
as Legionella,

٢
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Population Medicine and Population Medicine and

Epidemiology Epidemiology
• Tuberculosis, • Tuberculosis,
– Clinical study – As a community problem,
• Diagnosis, • High occurrence in particularly susceptible
• Estimation of the extent and activity of disease, groups,
– Infants, alcoholics, and recent immigrants;
• Choice of therapy,
• Appraisal of the patient's response, and • Follow up household contacts of cases; and
• Adequate follow-up of chemotherapy. • Assurance of chemotherapy continuing for an
adequate period.
– Outpatient chemotherapy,
– DOTS Strategy

Population Medicine Population Medicine

• Largely based on observational studies, • Information from
– Gathered from a variety of sources – Systematic studying
• To develop a comprehensive picture of health • Patterns of occurrence of disease in a
problems in the community. community and
– Information from • Patterns of delivery of medical care,
– Services offered both influence and are influenced by
• Records of clinical facilities;
» The amount and nature of disease
– Vary in accuracy and completeness.
» The changes in modes of therapy.
• Surveys of samples of the population.
• Epidemiology is the discipline provides this
– Information about health problems and
systematic approach.
– Needs of all segments of the population,

Health and Disease Health and Disease

• Epidemiology defined in terms of disease • Health
– Central concern is maintenance of health – Amplified to include the quality of life, socially and
• Through the prevention of disease. economically productive life.
• Easier to define and measure – To achieve maximum well-being for
• All segments of the population.
– Disease, disability, and death
– Than operational definition of health. • Ideal state of well-being
• Health – Through the complete elimination of disease,
– Merely as the absence of disease and disability • Attempts to quantity health status
– World health organization – Focus primarily on measurement of morbidity and
• A state of complete physical, mental and social well-being mortality
and not merely the absence of disease or infirmity. • Ultimate goal is a more positive one.

٣
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

The Need for Rates The fallacy of looking the numbers

• Rate
instead of rates
– Measurement of disease • Looking only at numbers of cases
– Identification of high-risk groups in a population,
• Relating cases or events to a population base. – Without relating them to the population from
– The numerator of a rate which the cases derive
• The number of people with the disease being counted
• The number of people to whom something happens; – The number of deaths associated with two
– The denominator modes of transportation,
• the population at risk of the disease or event.
• Everyone in the denominator must be at risk of entering the • Automobiles and
numerator
• Private aviation:
– Morbidity rates
• Rates of disease Numberofevents
– Mortality rates;
Rate =
• Rates of death,.
Numberofpo pulationat risk

The fallacy of looking the numbers The fallacy of looking the numbers
instead of rates instead of rates
two modes of Automobiles Private • Clinically oriented studies usually focus
transportation Aviation only on the numerator, such as
Number of 1,000 50 – The fatalities in the chart, or
fatalities per – The number of sick persons who seek
year medical care.
Number 100,000 1,000
exposed to
risk
Rate of fatal 0.01 0.05
injury

The fallacy of looking the numbers

instead of rates
• Two reports on ulcer disease.
– A clinical report
• "problem of the gastric ulcer reviewed: study of
1,000 cases" (Smith et al., 1953).
– An epidemiologic study of gastric ulcer
indicated
• Annual incidence rates of 44 per 100,000 persons
aged 15 years and older (Bonnevie, 1975),
• In contrast to earlier studies, gastric ulcer is now
more common in males than in females.
Low vs. High Rates of Disease
• Low as well as high rates of disease
– Useful clues to etiology.
• Absence of pellagra in attendants in mental
hospitals
– At a time when it was prevalent in patients
» Reject the popular hypothesis that pellagra is of
infectious origin
» In favor of a hypothesis of nutritional deficiency.
• The virtual absence of carcinoma of the cervix
among nuns in contrast to the high rate among
prostitutes
– Sexual activity was probably an important etiologic
factor.

٤
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

THE NATURAL HISTORY OF

The main function of epidemiology
DISEASE
• Discover groups in the population with
• The development of disease
high rates of disease, and with low, – Often an irregularly evolving process,
– So that causes of disease and of freedom – Labeling "diseased" rather than "not diseased"
from disease can be postulated • May be arbitrary.
– Relating diseases to the ways of living of • Natural life history, "Natural History"
different groups, – Especially chronic disease
• To unravel "causes" of disease • Last years or decades.
– Great advantage – Course of disease over time, unaffected by
• Applicable prevention in the early stages of treatment.
diseases, – Factors favoring development of chronic disease often
• To disrupt the pattern of causation before the are present early in life,
intimate nature of diseases • Antedating the appearance of clinical disease by many years.

THE NATURAL HISTORY OF

Health status spectrum
DISEASE
• Each disease in each patient has its
Undiagnosed own life history,
Healthy Disease
Overt Disease
• No general formulation
Insusceptible Susceptible No irreversible Irreversible – Useful to develop a schematic picture of the
Morbidity Morbidity
(Disability) (Disability) natural history of disease
– As a framework
• Within which to understand
– Different approaches to
» Prevention and control.

Stage of Susceptibility :
Stage of Susceptibility
Risk factors
• Disease has not developed but • Factors whose presence
– The presence of factors that favor its occurrence. – Associated with an increased probability
– For example, • That disease will develop later.
• Fatigue and acute and chronic alcoholism
– Heighten susceptibility to pneumonia; • The need to identify such factors
• Inadequate maternal nurturing
– More apparent
– Predisposes to emotional illness;
• High serum cholesterol levels • Because chronic diseases represent our major
– Increase the probability of overt coronary heart disease; health challenge.
• Immune suppression • Epidemiologic Transition
– Increase the risk of developing cancer.

٥
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Stage of Susceptibility : Stage of Susceptibility :

Risk factors Risk factors
• Immutable, • Even when there is a strong statistical
– Major determinants of risk association
• Age, sex, race, and family history,
– Not subject to change, – Between a risk factor and a disease,
• Susceptible to change, – Does not mean that all individuals with the
– As smokers risk factor
• can be persuaded to give up smoking. • Will necessarily develop the disease
• Not now amenable to change, but
– For identifying persons who deserve close medical
supervision.

Stage of Pre-symptomatic
Stage of Clinical Disease
Disease
• No manifestation of disease, • Sufficient end-organ changes have
– But pathogenetic changes have started to occur. occurred
• Changes below – Recognizable signs or symptoms of
– The level of the "clinical horizon," disease.
– The imaginary dividing line
• Above which disease manifests itself
• Several possible bases for classification
– Through detectable signs or symptoms. of this stage
– Examples – Based on
• Atherosclerotic changes in coronary vessels
• Morphological subdivision or
– Prior to any signs or symptoms of illness,
• Pre-malignant and malignant alterations in tissue. • Functional or
• Therapeutic considerations.

Stage of Clinical Disease Stage of Clinical Disease

• Cancer : • The importance of staging for prognosis of
– Classified on morphological grounds cancer,
– Five-year relative survival rates
• The location of the tumor • For cancer of different organs
• Histological type and extent. • According to localized or regional spread at the time of
– A commonly used procedure : diagnosis.

1. Localized, – Prognoses vary according to the different sites of

cancers,
2. With regional metastases, or
– But uniformly , better for localized cases than with
3. With generalized spread.
regional involvement.
– Stage is the major influence on prognosis.

٦
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

regional spread localized

Stage of Clinical Disease
Ute rus -Corpus 35
88
• Functional and therapeutic classification
Ute rus -Ce rvix 39
81 – Categorization of cardiac disease
38
• Of the New York heart association (1964).
Pros tate 75 • Functional classification
– Class I
Ovary 20
81 » No limitation of physical activity because of discomfort
– Class II
Lung- Bronchus 4
39 » Slight limitation of physical activity;
» Patient comfortable at rest but ordinary activity produces
Colon-Re ctum 28 discomfort
75
– Class III
47 » Marked limitation of physical activity;
Bre as t 87 » Comfortable at rest but less than ordinary activity causes
discomfort
Bladde r 11
66 – Class IV
» Inability to carry out any physical activity without
0 20 40 60 80 100 discomfort

Stage of Clinical Disease Stage of Clinical Disease

• Functional and therapeutic classification • Functional and therapeutic classifications

– Categorization of cardiac disease – Do not always parallel each other.
• Therapeutic classification • A patient with a recent heart attack or active
– Class A rheumatic carditis
» Physical activity need not be restricted in any way
– Not have symptoms upon physical exertion, but
– Class B
– Advised to remain at complete rest (class I, E).
» Ordinary physical activity need not be restricted, but
patient is advised against severe efforts
– Class C
» Ordinary physical activity should be moderately restricted
– Class D
» Ordinary physical activity should be markedly restricted
– Class E
» Complete bed rest advised; patient confined to bed or
chair

Stage of Clinical Disease Stage of Clinical Disease

• Classification,
– Great importance for epidemiologic study.
• No complete understanding of the natural
history of many diseases.
– Effective grouping reduces variability,
• Yielding relatively homogeneous subgroups. • An individual with a number of risk
• Important for evaluation of factors, not progress to clinical disease.
– The effect of prophylactic or therapeutic agents; – Follow-up of large groups over time
– For comparative studies of disease in different groups,
• Longitudinal studies
» International, regional, occupational, and so on;
– And for clinical management of patients.

٧
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Stage of Disability Stage of Disability

• Disability
– Any limitation of a person's activities, including
• Self-limited psychosocial role as parent, wage earner, and
– Diseases resolve completely, member of his community.
– Any temporary or long-term reduction of a person's
• Spontaneously or under therapy. activity as a result of an acute or chronic condition
• Loss of function rather than structural defect
• Chronic disability • Individuals vary widely in reaction to physical impairment.
– Residual defect of short or long duration, • Two persons with the same amount of tissue damage from
heart disease,
• Leaving the person disabled – Marked differences in their resultant level of disability.
• A small proportion of cases of measles – Substantial amount of disability associated with acute
– Subacute sclerosing panencephalitis (SSPE),
illness,
» a progressive neurologic disorder.
– Protracted disability from chronic illness
• Of greater significance for society.

Death
Clinical F
Health status spectrum Disease E Chronicity

Clinical Horizon
D Residual
B In apparent
In apparent or Disability
A Abortive Condition C
Undiagnosed Sub clinical No
Healthy Disease
Overt Disease Condition Disability
Stage of Pre Disability or
Disease Susceptibility symptomatic Clinical disease
Recovery
Insusceptible Susceptible No irreversible Irreversible
Morbidity Morbidity Tissue Resolution or
Pre Pathogenesis Pathogenesis
(Disability) (Disability) Changes Sequel

Level of Secondary
Prevention Primary
Tertiary
Early
Mode of Health Promotion diagnosis Treatment & Rehabilitation
Intervention Specific protection Prompt Limitation of disability
treatment

LEVELS OF PREVENTION LEVELS OF PREVENTION

• To push back the level of detection and • Primary prevention
– Appropriate in the stage of susceptibility
intervention to the precursors and risk • Prevention of disease by altering susceptibility or reducing
factors of disease. exposure for susceptible individuals;

• Emphasis on preventive rather than • Secondary prevention

– Applied in early disease, i.e.,
curative medicine. • Preclinical and clinical stages
• Prevention – Early detection and treatment of disease;

– Inhibiting the development of a disease • Tertiary prevention

– Appropriate in the stage of advanced disease or
before it occurs. disability
– Include measures that interrupt or slow the • The alleviation of disability resulting from disease and
attempts to restore effective functioning.
progression of disease.

٨
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Primary Prevention Primary Prevention

• Prevention of the occurrence of disease • Specific protective measures
– Two major categories: – Immunizations,
• General health promotion and – Environmental sanitation (e.g., Purification of water
• Specific protective measures. supplies), and
• General health promotion – Protection against accidents and occupational
– Provision of conditions at home, work, and school that hazards.
favor healthy living, e.g., – The past successes of public health in developed
• Good nutrition, countries
• Adequate clothing, • Accomplished largely by primary prevention of infectious
• Shelter, disease
• Rest, and – Through environmental protection and immunization.
• Recreation. • The most pressing problem today
• Broad area of health education, – Chronic disease whose prevention requires both
– Hygiene, • Knowledge of new environmental hazards related to
– Sex education, advances in technology and
– Anticipatory guidance for children and parents, and • Modification of deeply rooted individual behavior, such as
– Counseling in preparation for retirement. – Dietary patterns, physical activity, and the use of alcohol and
tobacco.

Primary Prevention Primary Prevention

• Ill effects of some of these behavior patterns • Deaths and injuries from accidents,
– Accumulate: – Especially motor vehicle crashes.
• Alcoholism as – Efforts at primary prevention
– Cirrhosis of the liver and
– Increased rates of certain cancers
• Attempts to influence individual behavior and
– Fetal alcohol syndrome (FAS) • Environmental controls
» As a consequence of alcohol ingestion during pregnancy
» Mental retardation, microcephaly, deficiency in length and
– E.G., Reduced exposure to asbestos in the
weight both pre- and post-natal and a set of characteristic workplace,
facial abnormalities.
– An increased risk of spontaneous abortion among women
– Passive restraints in cars,
» Who took as little as one to two drinks daily. – Altered composition of dietary fats at the
social level

Secondary Prevention Secondary Prevention

• Early detection and prompt treatment of • Inability to prevent certain diseases,
disease. – Efforts at control of many chronic diseases
– Possible to either center primarily around secondary prevention.
• Cure disease or • Diabetes,
• Slow its progression,
• Hypertension,
• Prevent complications, limit disability, and
• In situ carcinoma of the cervix, and
• Reverse communicability of infectious diseases.
• Glaucoma.
– On a community basis,
• Early treatment of infectious diseases (e.G.,
Sexuallytransmitted infections)
– Protect others from acquiring the infection
• Secondary prevention for the infected individuals
and primary prevention for their potential contacts.

٩
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Secondary Prevention Tertiary Prevention

• Primary prevention and secondary • Limitation of disability and rehabilitation
prevention – Where disease has already occurred and left
residual damage.
– Responsibility of physicians both in
• Private practice and
– Early physiotherapy to
• An affected limb to restore motion and prevent
• Community posts. contractures for the limitation of disability.
– Screening surveys • To restore an affected individual to a useful,
• By health departments and other community satisfying, and self-sufficient role in society,
agencies rehabilitation.
– To uncover asymptomatic disease and – Major theme
– To alter the natural history of the condition detected. • Maximal utilization of the individual's residual
capacities,
– With emphasis on remaining abilities rather than on
losses.

Tertiary Prevention Tertiary Prevention

• Modern rehabilitation includes
– Psychosocial and vocational as well as
medical components,
• Good teamwork from a variety of professions,
• Also require extensive physical facilities such as
– Special vehicles and
– Modifications of the home setting and
• Sufficient funding
– To provide a variety of services over a prolonged period
of time.
• The different levels of prevention
– Fully understood only in relation to the natural
history of disease.
– The clearer under-standing of the natural
history of a disease,
• The greater the opportunities for developing
effective points of intervention.
• The interrelations between natural history and
levels of prevention will be illustrated by a specific
example, stroke.

Death
Clinical F
Disease E Chronicity

Clinical Horizon
D Residual
B In apparent
In apparent or Disability
Sub clinical A Abortive Condition C
No
Condition Disability
Stage of Pre Disability or
Disease Susceptibility symptomatic
Clinical disease
Recovery

Tissue Resolution or
Pre Pathogenesis Pathogenesis
Changes Sequel

Level of Secondary
Prevention Primary
Tertiary
Early
Mode of Health Promotion diagnosis Treatment & Rehabilitation
Intervention Specific protection Prompt Limitation of disability
treatment

١٠
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Application Of Prevention And Application Of Prevention And

Natural History: Stroke Natural History: Stroke
• Stroke, • The third leading cause of death in the
– Symptom complex of neurologic deficit lasting united states,
at least 24 hours,
– 200,000 deaths annually.
• Results from damage to the brain by blood supply
alteration . • Major contributor to disability.
– A manifestation of cerebrovascular disease • The National Center for Health Statistics
(CVD).
– Variable effects depend on – In 1975
• The extent and • Over 300,000 non institutionalized people
paralyzed as the result of a stroke.
• Location of the damage to nervous tissue;
• Impairment of speech or cerebration, or paralysis.

Application Of Prevention And Application Of Prevention And

Natural History: Stroke Natural History: Stroke
• Mechanisms of stroke: • Older persons ,
– Large artery thrombosis. • Without warning ,
– Lacunae (small infarcts deep in the brain), • Without relation to health status in earlier life.
– Embolism, • Elevated blood pressure ,
– at high risk of hemorrhagic stroke,
– Intracranial hematoma,
• But infarction, unpredictable.
– Subarachnoid hemorrhage, and
• Prevention?
– Aneurysm and arteriovenous mal-formations
• Cerebral thrombosis accounts for more than half of • A modest concern for rehabilitative measures.
all strokes.

Application Of Prevention And Application Of Prevention And

Natural History: Stroke Natural History: Stroke
• Importance of the extra-cranial vessels • Epidemiology
– Stroke does not occur at random but
(carotids and the vertebral-basilar system) • Factors identifiable in earl life
in the production of stroke, – Influence the probability that stroke will occur years later.
– Derived from populations placed under observation
• Anticoagulant therapy many years ago,
• Technical achievements in vascular • For the study of coronary heart disease (CHD).
• Frarningham, Massachusetts,
surgery and • 5200 people was followed biennially since 1948
– history, physical examination, chest x-ray, EKG. and blood
• Diagnostic radiology. determinations.
– Major finding ,
• Importance of hypertension as a precursor
– To cerebral thrombosis as well as to hemorrhage.

١١
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Application Of Prevention And

Natural History: Stroke
• For both brain infarction and hemorrhagic
stroke,
– The morbidity ratio much higher for persons
with hypertension than for those with normal
blood pressure on initial examination.
– Additional factors contributing to risk are
cardiac abnormalities (i.e., Left ventricular
hypertrophy on electrocardiogram or cardiac
enlargement on x-ray).
– The contribution of factors such as elevated
blood lipids, glucose intolerance, obesity, and
cigarette smoking not clearly defined.

Application Of Prevention And

Natural History: Stroke
• Transient ischemic attacks (TIA).
– A focal neurologic deficit
• Abrupt onset
• Brief duration
• Complete recovery.
– Useful indicator of impending stroke?
• Lead to surgical or pharmacologic intervention.
• Even though 40 percent of TIA
– Will have a stroke within five years,
• TIAs occur uncommonly among all stroke patients.
• Only about 10 per cent of cerebral infarction
– Had had a TIA before their stroke.

Application Of Prevention And Application Of Prevention And

Natural History: Stroke Natural History: Stroke
• Primary and secondary prevention.
• The late or final manifestation of a long – Secondary prevention
chain of events. • Through recognition and treatment of tia
– Identification of high blood pressure
• Tertiary prevention, • As a major risk factor
– Series of intervention trials.
– Rehabilitation after stroke – The Veterans Administration (VA),
• Male veterans antihypertensive treatment
• Early physical therapy – Reduced morbidity and mortality from high blood pressure
– To prevent contractures and muscle atrophy, • Beneficial results from treating diastolic blood pressure (DBF)
between 115 and 129.
• Early ambulation – In subsequent trials,
– To prevent thromboembolic complications, and • Intervention at lower levels of blood pressure.
– Lowered morbidity and mortality,
• Active occupational and psychologic rehabilitation. – Test the effects of antihypertensive therapy on the general
population
• People of both sexes, all races, and younger as well as middle-aged
adults.

١٢
Alipasha Meysamie, MD, MPH Epidemiologic Orientation to Health and Disease
Professor in Community and Preventive Medicine
Meysamie@tums.ac.ir

Application Of Prevention And

Natural History: Stroke
• Two largest and most ambitious
– The Hypertension Detection and Follow-up Program
(HDFP),
• Screened almost 200,000 persons in 1973 and 1974.
• Discovered over 10,000 dbf of 90 mm hg or above.
• Designated as hypertensive,
• Enrolled in the study,
• Randomized into one of two groups:
– One received a rigid course of care (stepped care, or sc);
– Other referred to usual source of care (referred care, or rc).
• Followed for five years;
• The endpoint :
– Total mortality (all causes).
• Five-year mortality was 17 per cent lower for the SC than for
the RC,
• The difference was 20 per cent greater for the group with
DBF of 90 to 104 mm Hg.

Application Of Prevention And Application Of Prevention And

Natural History: Stroke Natural History: Stroke
• Two largest and most ambitious • A decline in the mortality from stroke in recent
– The Multiple Risk Factor Intervention Trial years
(MRFIT), – At least in part, a decrease in occurrence.
• Select for intervention ; unusually high risk for – The introduction of antihypertensive agents.
vascular disease – But in recent years mortality has been falling faster,
– Because of multiple risk factors
• By about 4 to 5 per cent per year,
» High blood pressure,
– Reasonable to widespread screening of the population
» Elevated blood lipids, and
» Initiated in the 1970s,
» Cigarette smoking.
– the systematic use of antihypertensive drugs,
• Both the experimental and the control groups
– Developed a decline in risk factor levels. • Auxiliary methods to understand and control
– Non significant difference of CHD mortality between the – The influence of stress and lifestyle on blood
groups pressure.

SUMMARY
• Rates
– Presented as fundamental tools in epidemiology.
• Model of the natural history of disease
• Risk factor
– Increase the likelihood of disease development
• Personal and societal impacts of the stages of
disability.
• Levels of prevention
– Primary, secondary and tertiary
– Outlined and developed in relation to the natural
history

١٣