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EPIDEMIOLOGY What is epidemiology? o Epidemiology is often called the science of public health Main impact is on the community, vs clinical medicine which is on the individual patients o The study of the distribution and determinants of disease risk in human populations (demos) The 4 Ds. Patterns and trends are seen, not unpredictable o The study of the frequency of occurrence of disease and why it happens. o Study: surveillance, observation, hypothesis testing, analytic research, and experiments o Distribution: analysis by time, place, and person o Determinants: physical, biological, social, cultural, and behavioral factors that influence health o Health-related states or events: diseases, causes of death, behavior, reactions to preventive regimens, and provision and use of health o Morbidity- looking at disease prevention o Mortality- prevention of bad outcomes o Integral part of basic description of a disease like the clinical findings and pathology Determinants of a differential diagnosis: - Likelihood - Severity of untreated outcome - Treatability o Diverse range of health conditions o Impact that various exposures have on the manifestation of disease o Central concern of epidemiology: the maintenance of health through the prevention of the occurrence of disease and prompt treatment of the disease in people who already have the disease What do epidemiologists do? o Epidemiologists come from a variety of backgrounds and specialize in many types of health research o Epidemiologists study an unlimited number of conditions that influence health from academic, governmental and private industry positions o Within academic institutions, research topics include: Infectious disease Chronic diseases Cancer Reproductive and perinatal epidemiology Cardiovascular disease Occupational epidemiology Environmental epidemiology Clinical epidemiology Genetics Pharmacoepidemiology - How drugs are beings used o Within government institutions, research topics include: Health services research Health outcomes research Health technology assessment Health economics Health policy formulation and implementation - 10-90 gap: 90% of people with the disease do not have access to treatment of the disease, inequity o Within specific institutions, epidemiologic investigations include: Sports Medicine Space Medicine Trauma and other injuries Toxicology o In addition to research, the government maintains departments of health that perform surveillance and prevention work and conducts health research and investigation a agencies affiliated with the Public Health Service What are the uses of epidemiology? o Determining the natural history of the disease discovering the agent, host and environmental factors which affect health in order to provide the scientific basis for the prevention of disease and injury and the promotion of health o Evaluation of determinants to disease Includes patterns of disease distribution Investigation of nature of associations or relationships between disease and determinants - Risk factor disease promoter Not necessarily a cause - Protective factor disease prevention

o Determining the relative importance of causes of illness, disability and death, in order to establish priorities for research and action o Identify those sections of the population which have the greatest risk from specific causes of ill health, in order that the indicated action may be directed appropriately o Evaluating effectiveness of health programs and services in improving the health of the population o Providing evidence-based guides to the management of patients in whom disease has already developed (Clinical Epidemiology) o Clinical Epidemiology Diagnostic testing Screening populations at risk Testing new treatments Searching for prognostic factors 5 determinants to Clinical Outcome (Of recovery, chronicity, disability or death; and due to some combination of all the foregoing) o The illness (due to a specific disease and of a specific severity and prognosis) o Diagnostic tests (of varying accuracy and utility) o Potential treatments (of varying efficacy and toxicity) o Clinical performance (competence + motivation - barriers) Clinical competence - Do you have the knowledge and skills to do it correctly? Motivation - Do you want to do it correctly Barriers - Will circumstances permit you to do it correctly o Patient compliance (With Rx and advice of varying degree and cadence) Success stories of Epidemiology: Smoking and Lung Cancer o Establish direct, consistent, strong, specific, temporally appropriate and coherent relationship between smoking and lung cancer o Result to series of public health efforts to control tobacco use o Policy changes Advertising restrictions, clean indoor air policies o Clinical interventions Physician advice to patients for smoking cessation o Smoking prevention programs in organizational settings Curricula in schools that focus on effective prevention strategies Modern Challenges and Opportunities in Epidemiology o Applying advances from molecular biology o Moving beyond risk factor epidemiology to affect change o Measuring and communicating weak associations o Measuring outcomes and quality of health care o Setting priorities and measuring progress o Investigating public health outbreaks o Preventing chronic diseases and other modern epidemics o Measuring the effects of community-level risk and interventions o Informing public health policies o Increasing epidemiologic capacity in applied settings Priority Areas in Healthy People in 2010 o Millennium goals o Access to quality health services o Arthritis, osteoporosis, and chronic back conditions o Cancer o Chronic kidney disease o Diabetes o Disability and secondary conditions o Educational and community-based programs o Environmental health o Family Planning o Food safety o Health communication o Heart disease and stroke o HIV o Immunizations and infectious diseases o Injury and violence prevention o Maternal, infant and child health o Medical product safety o Mental health and mental disorders o Nutrition and weight o Occupational safety and health

o Oral health o Physical activity and fitness o Public health infrastructure o Respiratory diseases o Sexually transmitted diseases o Substance abuse o Tobacco use o Vision and hearing Descriptive Epidemiology o Patterns of disease distribution Person - Age, sex, ethnic group, race, social class, occupation, marital status, family variables, other personal variables - Family variables family size, birth order, maternal age and parental deprivation - Other personal variables blood type, environmental exposures and personality traits Place - Natural boundaries - Political subdivision - Mapping of environmental factors (GIS) - Urban-rural differences - International comparisons - Study of migrants Time - Secular trends refers to changes over a long period of time, years or decades - Cyclic changes refers to recurrent alterations in the frequency of disease Seasonal Other periodicity year cycles What is health? o Elastic Concept of Health Defined either as absence of disease and disability or be given a positive meaning: o WHO definition State of complete physical, mental and social well-being and not merely the absence of disease or infirmity o Health is not the absence of disease but rather the process by which individuals maintain their sense of coherence (ie. That life is comprehensible, manageable, and meaningful) and ability to function in the face of changes in themselves and their relationships with their environment Aaron Antonovsky Disease Concepts: o Multiple Causation of Multifactorial Etiology Epidemiologic Triangle: host-agent-environment interaction - All given equal importance The Wheel: host with genetic core as center of disease The Web: interconnecting chains of causation o Host factors Responsible for the degree to which the individual is able to adapt to the stressors produced by the agent - Host resistance - Persons genotype - Nutrition status and body mass index - Immune system - Social behavior/social class membership - Personality o Environmental factors 3 major types of environment - Biological environment - Social environment - Physical environment - Each of these factors interact with each other Biologic environment - Infectious agents of disease - Reservoirs of infection: other human beings, animals and soil - Vectors that transmit the disease - Plants and animals Social Environment - The overall economic and political organization of a society by which individuals are integrated into the society at various stages in their lives - Social customs - General level of receptivity to new (health-related) ideas

- Extent of social integration Physical Environment - Heat/cold - Light - Air - Water - Kinetic energy - Radiation - Gravity - Atmospheric pressure - Chemical agents - Noise Agent factors Biologic agents Chemical agents Physical agents Social and psychological stressors Epidemiologic Triangle

Epidemiologic Triad

The Web of Causation

o The Wheel

Risk Factors for Disease: BEINGS Model o Biologic factors and Behavioral factors o Environmental factors o Immunological factors o Nutritional factors o Genetic factors o Services, Social factors, and Spiritual factors

Natural History of the Disease Stages of the disease o Stage of Susceptibility o Pre-Symptomatic Stage o Stage of Clinical Disease o Stage of Disability or Recovery Tissue Changes o Pre-pathogenesis o Pathogenesis o Resolution or Sequelae Levels of Prevention o Primary Prevention o Secondary Prevention o Tertiary Prevention Modes of Intervention o Health Promotion and Specific Protection o Detection, Early Diagnosis and Prompt Treatment o Treatment and Rehabilitation, Limitation of Disability

Methods of Primary Prevention General Health Promotion o Most fundamental sources of health: Adequate nutrition Safe environment Prudent behavior o Nutritional factors Overnutrition (Obesity) - Sedentary lifestyle - Energy-dense, nutrient dilute food - Increased risk for cardiovascular diseases Undernutrition - Cultural factors - Political factors preventing fair distribution of resources - Increased risk for infections due to lowered immunity

Environmental and occupational factors Major Sources of Environmental Hazard - Air Pollution

Types of Air Pollutants Particulate matter Metal fumes Gases Dusts Ozone Environmental tobacco smoke: most common and most serious indoor air pollutant - Water pollution - Solid wastes - Electromagnetic radiation - Contaminated food o Behavioral factors Counseling of women before and during pregnancy Counseling of parents Counseling of patients with risk factors Counseling of patients addicted to substance abuse o Societys Contribution to Health Opportunities for safe employment Control of environmental systems (water supply and sewage disposal) Regulation of environment, commerce and public safety Sustain social support systems such as families, neighbors and houses of worship Specific Protection o Major goals of primary prevention by specific protection Prevention of specific diseases (using vaccines and antimicrobial prophylaxis) Prevention of specific deficiency states (iodized salt and fluoridation of water) Prevention of specific injury and toxic exposures (helmets, goggles, filters and ventilation systems) o Prevention of iatrogenic diseases and injuries Nosocomial infections Medical errors Unnecessary surgery Surgical and medical errors o Prevention of Diseases by Use of Vaccines Intact immune system in health well-nourished individual provides basic protection Intact immunity implies normal immune system at birth and has not suffered damage from: - Any disease (infection with HIV) - Any medications (cancer chemotherapy, steroids) Types of Immunity - Passive immunity Protection against an infectious disease provided by circulating antibodies Maternal antibodies Administration of human immune globulin Anti-toxin - Active immunity Stimulation of the production of antibodies within the body by an exogenously administered substance Stimulation of either humoral (blood) antibody or cell-mediated immunity Provides both individual immunity and herd immunity Far superior to passive immunity because: It lasts longer (lifetime in some cases) Rapidly stimulated to high levels by a re-exposure to the same or closely related antigens Types of Vaccines - Inactivated (killed) organisms Older pertussis and typhoid vaccines - Live attenuated (altered) Injectable Influenza and polio vaccines - Toxoids (inactivated or altered bacterial exotoxins) Bacillus Calmette-Guerin (BCG), oral polio, measles Immunization Goals - Eradication of disease Small pox eradication - Regional elimination of disease Control of poliomyelitis in Western Hemisphere - Control of disease to reduce morbidity and mortality Reduction in cases of measles and chickenpox Immunization Schedules

- Infant (Expanded Programme of Immunization) (DOH and CDC sites) - Early Childhood - Teenagers and young adults - Adults to elderly o Protection Using Antimicrobials Prophylaxis therapy - Presurgical prophylaxis - Antivirals for influenza for exposed persons - Penicillin for rheumatic fever patients - INH for 9-12 months for recent converters for TB Ceftriaxone for syphilis or gonorrhea - Rifampicin for meningococcal exposures o Prevention of Deficiency states Vitamin and mineral supplementation of food - Vit. B and Folic acid in cereals - Vit. A and D in milk products - Iodine in salt - Vit. A and Iron in noodles and snack foods (Sangkap Pinoy) - Fluoridation of water o Prevention of Injuries and Toxic Exposures Food regulation agencies (BFAD, FDA, Bureau of Agriculture and Bureau of Fisheries) Government laws protecting land, sea and air transportation (speed limits, helmets, maximum limits of air time or driving time) Local regulations regarding building codes (ramps for the elderly, toxic fumes and fire alarms) Occupational Safety and Health Administration (OSHA) - Chemical safety Safe storage and positioning of chemicals - Biological safety Immunization of workers and biologic hoods - Physical safety Protection against harmful levels of noise, heat, repetitive injuries Methods of Secondary Prevention Outline o Early detection Screening Case Finding o Prompt treatment Screening in Secondary Prevention o Process of identifying a subgroup of people in whom there is a high probability of finding asymptomatic disease or a risk factor for developing a disease or becoming injured o Usually occurs in a community setting o Minimum requirements: Disease requirements Screening test requirements Health care system requirements o Not intended to be diagnostic will require confirmatory tests for diagnostics o May be virtually diagnostic if results are so clearly abnormal (pre-test probability of disease is >90%) Case Finding in Secondary Prevention o The process of searching for asymptomatic diseases and risk factors among people in a clinical setting (under medical care) o The process of identifying a disease in patients presenting with signs and symptoms under medical care Disease Requirements for Screening in the Community o The disease is serious o Effective treatment exists o Natural history of disease is well understood o Disease occurs frequently o Other diseases or conditions may be detected Screening Test Requirements for Screening in the Community o Quick to perform o Easy to administer o Inexpensive o Safe o Acceptable to participants o Sensitivity, specificity and other operating characteristics of the test are acceptable Health Care System Requirements for Screening in the Community

o o o o o o Follow-up must be available for those who test positive Before undertaken, treatment should already be available Individuals screened and diagnosed as positive for disease must have access to treatment Treatment should be acceptable to those screened Population to be screened should be clearly identified Clarification of issues to include: Who is responsible for the screening What cutoff points are to be used for defining a positive test result How the findings will become part of a participants medical record at his usual place of care (ie. HIV and drug abuse and other conditions that may result in stigma) Objectives of Screening Program Target Objective Example Disease `Treatment to reduce mortality Cancer Disease Treatment to prevent complications Hypertension Disease Treatment to eradicate infection and Gonorrhea, syphilis or TB prevent its spread Disease Change in diet and lifestyle Coronary artery disease or DM type 2 Behavioral Change in lifestyle Cigarette smoking or unsafe sexual risk factor practices Environmental Change in occupation COPD form work risk factor Metabolic risk Treatment or change in diet and Elevated serum cholesterol levels factors lifestyle Test Operating Characteristics o Validity closeness to true state (disease vs. non-disease) Sensitivity Specificity Positive Predictive value Negative Predictive Value o Reliability (Precision) o Yield the amount of previously unrecognized disease that is diagnosed and brought to treatment due to screening Test validity Characteristics o Sensitivity the proportion of patients with the disease who test positive o Specificity the proportion of patients without the disease who test negative o Positive Predictive Value the proportion of test-positive patients who truly have the disease o Negative Predictive value the proportion of test negative patients who truly are disease-free Derivation of Test Characteristics Gold Standard Diagnostic Test (+) (-) (+) a B (-) c D o A true positive o B false positive o C false negative o D true negative Sensitivity: o a/a+c Specificity: o d/b+d Positive Predictive Value: o a/a+b Negative Predictive Value o d/c+d When patient comes to see you: sensitivity and specificity When they come back with the result: positive, negative predictive value SPin High specificity, rule in disease SNout High sensitivity, rule out disease Likelihood ratio for a positive test result (LR+) the probability of a positive test result for a person with the disease divided by the probability of a positive test result for a person without the disease Likelihood ratio for a negative test result (LR-) the probability of a negative test result for a person with the disease divided by the probability of a negative test result for a person without the disease Nomogram


o o >80% or <20% prior probability, no need to take diagnostic test o Ex. Only in children will UTZ for appendectomy be required o Likelihood ratio of a positive test will always be whole numbers o Likelihood ratio of a negative test will always be decimals o Posterior probability >90, definite treatment Receiver Operating Characteristic (ROC) Curve o Used for tests that produce results along a continuous scale of measurement o There are many options about where to set the cutoff point between a positive and a negative test result resulting in varying sensitivity and specificity o The area under the curve serves as an overall measure of test performance

o Screening o Refers to the use of tests to detect the presence of a disease at an earlier time that it hould be detected through routine methods o The presumptive identification of unrecognized disease or defect by the application of tests, examinations or other procedures which can be applied rapidly to sort out apparently well persons who probably have a disease from those who probably do not o A screening test is not intended to be diagnostic o Persons found positive in a screening test will need to undergo a confirmatory test o Distorting effects:

Lead-time bias Length-biased sampling Patient self-selection bias Lead-Time Bias The interval between the time a condition is detected through screening and the time it would normally have been detected by the reporting of symptoms or signs Screening test detects cases in which the disease occurs earlier in the clinical course therefore survival time may appear to be longer, even though the time of death is the same as if no screening has occurred

Length-Biased sampling Occurs when the screening test preferentially detects slowly progressive disease that is less likely to cause death or may result in a delayed death Slow-growing cancers vs. fast aggressive cancers o Patient Self-Selection bias Volunteers who choose to participate in early detection programs may differ from those who do not in characteristics that may be related to survival Participants may generally have better healthy living practices making them more healthconscious and more compliant. With prescribed preventive regimen Methods of Tertiary Prevention Disability limitation goal of halting the progress of the disease or limiting the damage caused by an injury (prevention of further impairment) Rehabilitation focuses on reducing the social disability produced by a given level of impairment by strengthening the patients remaining functions Levels of Intervention

o o


o Public Health Framework for a Scientific Approach to Prevention Tools and Processes What is the problem? Public Health Surveillance What is the cause? Etiologic Research What is a solution? Intervention Research/ Policy change/ Evidence Reviews How do you do it? Program Planning Did it work? Process & Outcome Evaluation Surveillance o Definition: The process that is used to collect, manage, analyze, interpret and report reliable information about the status of those diseases or their antecedents in populations o Surveillance systems: Networks of people and activities that maintain the process and may function at local to international levels o Locally- surveillance may provide the basis for identifying people who need treatment, prophylaxis or education o More broadly, surveillance can: Inform the management of public health programs Inform the direction of public health policy Uses of Surveillance Information o Primary objectives: To monitor the incidence or prevalence of specific health problems Document their effect in defined populations Characterize affected people and those at greatest risk Objectives of Surveillance o Descriptive epidemiology (person, place, time) of health problems (for needs assessment) o Links to service provides aggregate data for health planners and serves to initiate individual preventive or therapeutic actions (ex. Tuberculosis) o Links to research provides clues for further investigation and identifies people who may participate in research studies, hence permitting comparisons among different groups (ex. Toxic Shock Syndrome resulting from use of tampons) o Evaluation of interventions provide comparatively inexpensive and sufficient assessment of the effect of intervention efforts (ex. Effect of use of condoms on decreasing incidence of HIV and other STIs) o Planning and projections observed trends in disease incidence combined with other information about the population at risk of the natural history of a disease can be used to anticipate the effect of a disease or the need for care (ex. WHO prediction of global trends in road traffic injuries by 2020 3rd leading contributor) o Education and policy educational value: Alerts clinicians to community health problems Informs health policy makers about the need for prevention or care resources Ex: AH1N1 influenza

Local surveillance identifies the onset of influenza season and prevalent influenza strains Clinicians are alerted and provided timely guidance on evaluation and management of patients with respiratory illness - Globally guide vaccine development Uses of Surveillance Information o Organized based on 3 categories of timeliness Immediate Annual Archival o Immediate detection of Epidemics (AH1N1, typhoid) Newly emerging health problems New disease manifestations - (Jacqueline L. Dee, The WHO Dengue Classification and Case Definitions: Time for a Reassessment. The Lancet, Vol368, Issue 9530, Pages 170-173,2006.) Changes in health practices (Harmful effects: Vit. E and prostate cancer; calcium and Cardiovascular Disease) Changes in antibiotic resistance (MRSA, MDR-TB) o Annual dissemination for: Estimating the magnitude of the health problem, including cost Assessing control activities Setting research priorities Testing hypothesis Facilitating planning Monitoring risk factors Monitoring changes in health practices Documenting distribution and spread o Archival information for: Describing natural history of the disease Facilitating epidemiologic and laboratory research Validating use of preliminary data Setting research priorities Documenting distribution and spread Elements of a Surveillance System o Case definition o Population under surveillance o Cycle of surveillance information has to get to the right people in time to be useful o Confidentiality Protecting physical security and confidentiality of surveillance records is ethically mandated Laws that mandate reporting ideally provide concomitant protection and sanctions to prevent inappropriate release of identifying information HIPAA Health Insurance Portability and Accountability Act of 1996 strictly regulates use of electronic health data yet allowing for legitimate access for public health surveillance o Incentives to participation o Surveillance ethics Sources and Collection of Public Health Surveillance Data o Reports of health events o Reporting from laboratories and other health care facilities o Registries o Vital statistics o Information on health status, risk factors and experience of populations o Information on potential exposure to environmental agents o Information from other organizations o The health care system and the impact of the health care system on health Selected Data Source Use Vital Statistics Portray trends in disease and health Immunization registries Evaluate control measures Reporting from laboratories Monitor changes in infectious diseases Notifiable diseases Estimate magnitude of health problems Hospital discharge data Monitor health practice Risk factor surveillance Plan public health practice Cancer registries Test hypothesis Steps in Automated Reporting of Infectious Disease Data -


o Elements in establishing a Surveillance system o Establish goals o Develop case definitions o Select appropriate personnel o Acquire tools and clearances for collection, analysis and dissemination o Implement surveillance system o Evaluate surveillance activities Approaches to Surveillance o Active cs. Passive surveillance Active organization conducting surveillance initiates procedures to obtain reports - Obtains primary data - More expensive Passive the organization conducting surveillance does not contact potential reporters and leaves the initiative for reporting to others - Obtains secondary data o Notifiable disease reporting o Laboratory-based surveillance o Volunteer providers o Registries o Surveys o Information systems o Sentinel events 1st ever or 1st reported o Record linkages o Combination of surveillance methods Outbreak and Cluster Investigations Outbreak (epidemic): epidemic limited to a localized increased in the incidence of a disease (usually refers to infectious disease) Cluster: aggregation of relatively uncommon events or diseases in space and/or time in amounts that are believed or perceived to be greater than could be expected by chance Endemic vs. Epidemic vs. Pandemic o Endemic: a disease that exists permanently in a particular region or population o Epidemic: An outbreak of disease that attacks many people at about the same time and may spread through one or several communities o Pandemic: When an epidemic spreads through the world Endemic o The constant presence of a disease or infectious agent within a geographic area or population group o The usual prevalence or rate of occurrence of a given disease with an area o Greek: within the population o Low to moderate normal base level rate of occurrence in the population o Malaria in Palawan, Amebiasis in Cebu, Schistosomiasisin Leyte, Substance abuse in Cebu Epidemic o The unusual (dramatic) occurrence of disease o The occurrence in a community or region of a group of illness of similar nature, clearly in excess of normal expectancy >20% of previous years o The occurrence in a community or region of cases of an illness, specifically o May encompass any time period o Few hours: chemical intoxication (radiation disaster in Chernobyl, Ukraine and organophosphate disaster in Bohol involving school children) or bacterial food poisoning during a social event o Few weeks: influenza or hepatitis o Several years: drug addiction

More definitions: o Sporadic: individual cases of disease in widely separated geographic areas or otherwise independent cases o Pandemic: disease involves numerous communities spanning across continents (global distribution) Outbreak Characteristics o Problem is unexpected o Immediate response is required o Field investigation necessary to solve the problem o Extent of investigation likely to be limited because of the need for timely investigation Types of Outbreaks (Epidemics) o Common Source Epidemic Outbreaks caused by exposure of a group of persons to a common noxious influence Exposure to common source is often at the same time or within a brief period of time Resultant cases all develop within one incubation period Median incubation period: the time at which 50% of cases have occurred on the epidemic curve o Propagative or Progressive Epidemic Result from transmission either direct or indirect of an infectious agent from one susceptible host to another Direct person-to-person spread Spread indirectly through vectors Epidemic period extends over a number of incubation periods o Mixed epidemics The epidemic begins with a single, common source of an infectious agent with subsequent propagative spread Exemplified by many foodborne pathogens o Epidemic Curves


Propagative spreads out, not as severe as common source Airborne has the widest spread Epidemic Surveillance Concepts o Incubation period time between exposure and first detectable symptom o Latency period time when disease is concealed (hidden or inactive) o Infectious period time during which the disease can be transmitted with or without contact o Subclinical infection infection with no or minimal clinical manifestations o Well carriers of disease subclinically infected individuals with no symptoms who carry and shed the infectious agent o Reservoirs the living organisms or inanimate matter in which an infectious agnet normally lives o Generation time the period between the receipt of infection by a host and maximal communicability of that host When quarantine is done o Herd Immunity the resistance of a group to invasion and spread of an infectious agent, based on the immunity of a hoigh proportion of individual members of the group o Index Case The case that brings a household or other group to the attention Time course of Common Infections (all in days) Disease Incubation period Latency period Infectious period Measles 8-13 6-9 6-7 Mumps 12-26 12-18 4-8 Pertussis 6-10 21-23 7-10 Rubella 14-21 7-14 11-12 Diphtheria 2-5 14-21 2-5 Varicella 13-17 8-12 10-11 Hepatitis B 50-110 13-17 19-22 Poliomyelitis 7-12 1-3 14-20 Influenza 1-3 1-3 2-3 Common Source of Epidemic Diseases Disease Anthrax sheep, horses Bacillary Dysentery Botulism Brucellosis sheep, horses Cholera Giardiasis Hepatitis Paratyphoid Causative Agent Bacillus anthracis (B) Infection Sources Milk or meat from infected animals Fecal contamination of food and water Soil-contaminated food Milk or meat from infected animals Fecal contamination of food and water Fecal contamination of water Infected humans Fecal contamination of food and water Reservoirs Cattle, swine, goats,

Shigella dysenteriae (B) Clostridium botulinum (B) Brucella melitensis (B)

Humans Soil Cattle, swine, goats,

Vibrio cholerae (B) Giardia spp. (P) Hepatitis A,B,C,D,E (V) Salmonella paratyphi (B)

Humans Wild mammals Humans Humans

Typhoid Fever Salmonella typhi (B) Fecal contamination of food and water Infection Sources Human cases and carriers; infected food and fomites Inhalation of contaminated fecal material Human cases and carriers Human carriers Sputum from human cases; contaminated milk Human cases Human cases Human cases Human cases Humans

Host-to-host Epidemics Disease Causative Agent Respiratory Diseases Diphtheria Corynebacterium diphtheriae (B) Hantavirus pulmonary syndrome Meningicoccal meningitis Pneumonococcal pneumonia Tuberculosis Hantavirus (V)

Reservoirs Humans


Neisseria meningitidis (B) Streptococcus pneumoniae (B) Mycobacterium tuberculosis (B) Bordetella pertussis (B) Rubella virus (V) Influenza virus (V) Measles virus (V)

Humans Humans Humans, cattle

Whooping cough German measles Influenza Measles Sexually transmitted diseases HIV-Disease Chlamydia Gonorrhea Syphilis Trichomoniasis Vector-borne diseases Epidemic typhus Lyme disease Malaria Mosquito Plague Rocky Mountain spotted Fever Direct-contact diseases Psittacosis or bird excrement Rabies Tularemia

Humans Humans Humans, animals Humans

HIV (V) Chlamydia trachomatis (B) Neisseria gonorrheae (B) Treponema pallidum (B) Trichomonas vaginalis (P) Rickettsia prowazekii (B) Borrelia burgdorferi (B) Plasmodium spp. (P) Humans, mosquitoes Yersinia pestis (B) Rickettsia rickettsii (B)

Infected body fluids, blood, semen, etc. Urethral, vaginal, and anal secretions Urethral and vaginal secretions Infected exudate or blood Urethral, vaginal, prostate secretions Bite by infected louse Bite from infected tick Bite from infected Anopheles Bite by infected flea Bite by infected tick

Humans Humans Humans Humans Humans

Humans, lice Rodents, deer, ticks

Wild rodents Ticks, rabbits, mice

Chlamydia psittaci (B) Wild and domestic birds Rabies virus (V)

Contact with birds Bite by carnivore Wild and domestic carnivores Rabbits

Franciscella tularensis Contact with rabbits (B) Steps in outbreak Investigation Process on the Community Setting o Determine the existence of an epidemic o Confirms the diagnosis o Define a case and estimate the nuber of cases o Orient the data in terms of time, place and person o Determine who is at risk of having the health problem o Develop an explanatory hypothesis o Compare the hypothesis with the established facts o Plan and execute a more systematic study o Prepare a written report o Execute control and prevention measures Periods, phases, stages, and intervals


o Outbreak Analytic Study Designs Case-control studies o Cases of diseased individuals are evaluated against a matched control and rate of exposure is compared between both groups Retrospective cohort studies o The outcomes (disease or health condition) have all occurred prior to the start of the investigation and the experience of cohorts is reconstructed through existing records Study Designs in Epidemiologic Research o Observational (Non-experimental) Descriptive - Case Report About one person, one case - special - Case Series One group with similar characteristics Cohort of individuals that experience a strange or unusual characteristics Cannot calculate risk factors - Descriptive Cross Sectional Simply splicing the population at the moment in time Specify time frame, looking at one population 1 big group divided into 4, those with exposure, without exposure and with disease and no disease Analytical - Analytical Cross Sectional Calculate measures of association - Case-Control Ideal design for determination of odds risk - Cohort Associated with relative risk - Ecologic o Interventional (experimental) Quasi-Experimental Clinical vs. Community - Based Clinical Trials (Randomized Controlled Trial) Field Trials Community Intervention and Cluster Randomized Trials Non-experimental studies o Investigator observes the effect of previous intervention assignment by other people or by the subject himself o Exposure or outcome may have already occurred at the time the study is initiated

o Observational, subject has exposure, investigator does not allocate exposure, experimental assigns exposure o Prospective, exposure already has happened or investigator will allocate the exposure o Ambispective increase the sample size, uses both prospective and retrospective o Four main types of non-experimental studies: Case-Control cases arising from a source population and a sample of the source population are classified according to their exposure history Cohort all subjects in a source population are classified according to their exposure status and followed over time to ascertain disease incidence Cross-sectional studies - Exposure and disease or outcome status as of a particular time is ascertained - Includes prevalence studies Ecologic studies the units of observation are groups of people Cross-sectional studies o A study that includes all persons in the population at the time of ascertainment o A representative sample of all such persons, selected without regard to exposure or disease status o Prevalence study: cross-sectional study conducted to estimate prevalence o Exposure is ascertained simultaneously with the disease o Different exposure subpopulations are compared with respect to their disease prevalence Case-Control Studies o Conducted by defining a source population at the outset and by identifying a single disease of interest o Cases are identified and their exposure status is determined o A control group of study subjects is sampled from the entire source population that gave rise to the cases o Purpose of the control group is to determine the relative size of the exposed and unexposed denominators with the source population o Cardinal requirement of control selection: controls must be sampled independently of their exposure status o Measure of association between disease outcome and exposure: Odd Risk (OR) o Recall bias: cases report more detail than control o Case Control Study Design

o Cohort Studies o Investigator defined two or more groups of people (study cohorts) that are free of disease and that differ according to the extent of their exposure to a potential cause of disease: o Common design is to evaluate 2 groups: Exposed or index cohort Unexposed or reference cohort o The disease or outcome may (retrospective cohort) or may not (prospective cohort) have occurred o Groups are identified on the basis of exposure status NOT on disease or outcome status o Measure of association exposure and disease outcome: Relative Risk (RR) o Harmful studies are usually determined by observational study designs

o Cohort Study Designs

o Measures of Disease Frequency o Incidence number of new cases among number at risk Depends on natural history of the disease If it has a well-defined starting point, ex. measles o Prevalence number or existing case among number at risk Important to identify time frame Point prevalence - Short point in time maximum is one year Period prevalence - More than 1 year Higher than incidence If there is no defined starting point, ex. diabetes Measures of Association o Correlation Coefficient Measure association between dependent and independent variable o Spearman Rank Correlation Measure association between dependent and independent variable o Odds Ratio Case Control: the odds of having been exposed o Relative Risk (Risk Ratio) Cohort/Experimental: the probability of incidence among the exposed relative to the probability of incidence among the unexposed Odds Ratio o Also referred to as OR o Defined as the odds in favor of disease among exposed individuals divided by the odds in favor of disease among the unexposed o Interpreted as the odds of having been exposed o Case Control Study Design Cases Controls Exposed a b Not Exposed c d o OR=ad/bc Relative risk (Risk Ratio) o Also referred to as RR o Ratio of incidence in exposed persons to incidence in non-exposed persons o Calculated only from a cohort study o Cohort Study Desing Disease Non-disease Exposed a b Not Exposed c d o RR=IE/I


o o o o o

RR of 1.0 indicates identical probabilities of disease in both the exposed and non-exposed groups RR>1 implies that there is an increase risk of disease among those with the exposure RR<1 suggests that there is a decreased risk of developing disease among the exposed individuals Do not use P values, use 95% confidence interval A. 37(0.7-5.0) B. 37 (2.5-4.6) C=3.7 (1.01-4.6) Significant: B and C, B has less variation A, risk factor for some, protective for others 95% confidence interval should not cross 1 Here, should not be >1 P value tell - How much possibility was due to chance - Alpha error less than chance The higher the value away from 1, the stronger the association Ecologic Studies o The unit of observation is a group of people rather than individuals o Also referred to as aggregate studies o Only requirement is that information on the populations studied is available to measure the exposure and disease distributions in each group o Research goal is to estimate effects of group-level exposures on group-level outcomes o Useful for detecting associations of exposure distributions with disease occurrence o May be classified on two dimensions: Method of exposure measurement Method of grouping by place or by time - Exploratory: there is no specific exposure of interest or the exposure of potential interest is not measured - Etiologic: the primary exposure variable is measured and included in the analysis o Rationale for ecologic studies Low cost and convenience Measurement limitations of individual-level studies (ex. Environment al epidemiology) Design limitations of individual-level studies little exposure variation within the study area Interest in ecologic effects Simplicity of analysis and presentation Levels of measurement: - Aggregate measures summaries of observations derived from individuals in each group (proportion of smokers, median family income) - Environmental measures physical characteristics of the place in which members of each group live or work (air pollution level and hours of sunlight) - Global measures attributes of groups, organizations or place for which there is no distinct analog at the individual level (population density, level of social disorganization, existence of specific law or type of health care system) Experimental studies o A set of observations conducted under controlled circumstances in which the investigator manipulates the conditions to ascertain what effect, if any, such manipulation has on the observations o Epidemiology: exposure manipulations or interventions in which all exposure assignments are expected to cause NO HARM o The design is guided by the objectives of: Reducing variation in the outcome attributable to extraneous factors Accounting accurately for the remaining extraneous variation o Generally 2 or more forms of intervention o Random sampling while recruiting o Intervention assignments determined by the investigator by applying a randomized allocation screen o Purpose of random allocation: create groups that differ only randomly at the time of allocation with regard to subsequent occurrence of the study outcome o Ideally, experimental groups are identical with respect to extraneous factors that affect the outcome of interest so that if treatment had no effect, identical outcomes would be observed across the groups o Biologic variation is kept minimal o Quasi-experiment: controlled studies in which exposure was assigned by the investigator witout using randomization o Community Intervention and Cluster Randomized Trials Extension of the field trial that involves intervention on a community-wide basis

o o o Ex: vaccination vs. water fluoridation Cluster randomized trials: Field trials in which the treatment is assigned randomly to groups of participants Clinical trial Experiment with patients as subjects Goal is to evaluate potential cure for a disease or to find a prevention of disease sequelae Field trials Subjects are not defined by presence of disease or by presentation for healthcare Randomized Controlled Study Design

Retrospective vs. Prospective Studies o Retrospective Studies Advantages - Inexpensive to carry out - Fewer number of subjects - Ideal for rare diseases - May be the only feasible way to accumulate cases Disadvantages - Needed information about past events may not be available from routine records - Needed information may be inaccurately recorded - Biased Information o Prospective Studies Advantages - Cohort is classified according to exposure before the disease develops - Permit calculation of incidence rates among exposed and unexposed allows for determination of attributable risk Disadvantages - Main disadvantage: usually long, expensive and large-scale undertaking - Outstanding problem of attrition loss of patients from follow-up due to lack of interest, migration or death Criteria for Judging Causal Associations o Strength of the association Dose-response relationship o Consistency of the association o Temporally correct association o Specificity of the association o Coherence with existing information (Biological plausibility) Epidemiology of Infectious Disease Common Source Epidemic Diseases Disease Anthrax Causative Agent Bacillus anthracis (B) Infection Sources Reservoirs Cattle, swine, goats, Milk or meat from infected animals sheep, horses Fecal contamination of food and water Humans

Bacillary Dysentery Shigella dysenteriae (B)

Botulism Soil Cattle, swine, goats, Brucellosis Brucella melitensis (B) Milk or meat from infected animals sheep, horses Cholera Vibrio cholerae (B) Fecal contamination of food and water Humans Giardiasis Giardia spp. (P) Fecal contamination of water Wild mammals Hepatitis Hepatitis A,B,C,D,E (V) Infected humans Humans Paratyphoid Salmonella paratyphi (B) Fecal contamination of food and water Humans Typhoid Fever Salmonella typhi (B) Fecal contamination of food and water Humans Propagative host to host Disease Respiratory Diseases Diphtheria Causative Agent Corynebacterium diphtheriae (B) Hantavirus (V) Infection Sources Reservoirs Humans Rodents Humans Humans Humans, cattle Humans Humans Humans, animals Humans Humans Humans Humans Humans Humans Clostridium botulinum (B) Soil-contaminated food

Human cases and carriers; infected food and fomites Hantavirus pulmonary Inhalation of contaminated fecal syndrome material Meningicoccal meningitis Neisseria meningitidis (B) Human cases and carriers Pneumonococcal Streptococcus pneumoniae Human carriers pneumonia (B) Tuberculosis Mycobacterium Sputum from human cases; tuberculosis (B) contaminated milk Whooping cough Bordetella pertussis (B) Human cases German measles Rubella virus (V) Human cases Influenza Influenza virus (V) Human cases Measles Measles virus (V) Sexually transmitted diseases HIV-Disease HIV (V) Chlamydia Gonorrhea Syphilis Trichomoniasis Vector-borne diseases Epidemic typhus Lyme disease Malaria Human cases

Infected body fluids, blood, semen, etc. Chlamydia trachomatis Urethral, vaginal, and anal (B) secretions Neisseria gonorrheae (B) Urethral and vaginal secretions Treponema pallidum (B) Infected exudate or blood Trichomonas vaginalis (P) Urethral, vaginal, prostate secretions Rickettsia prowazekii (B) Bite by infected louse Borrelia burgdorferi (B) Bite from infected tick Plasmodium spp. (P) Bite from infected Anopheles Mosquito Bite by infected flea Bite by infected tick

Plague Yersinia pestis (B) Rocky Mountain spotted Rickettsia rickettsii (B) Fever Distribution of Clinical severity by Class of Infection

Humans, lice Rodents, deer, ticks Humans, mosquitoes Wild rodents Ticks, rabbits, mice

o Relationship of Disease Statistics to Severity of Illness


o o Diseases that are less apparent, underdetected o Sometimes, if disease is inapparent, give time for disease to progress step back Components of the Infectious disease Process o Infectious agents o Intrinsic properties of infectious agents Causing infection Causing virulence Causing transmission o Host-parasite interactions o Pathogenic mechanisms o Reservoirs o Mechanisms of transmission of infection Intrinsic Properties of Infectious Agents o Morphology o Size o Chemical character o Antigenic make-up o Growth requirements o Ability to survive outside a host o Ability to produce toxins o Ability to become resistant to antibiotics o Ability to acquire new genetic information for survival Host-Parasite Interactions o Infectivity ability of an agent to invade and multiply or produce infection in a host o Pathogenicity ability to produce clinical apparent illness o Virulence proportion of clinical cases resulting in severe clinical manifestations (including sequelae) o Immunogenicity the infections ability to produce specific immunity Pathogenic Mechanisms o Direct tissue invasion o Production of a toxin o Immunologic enhancement or allergic reaction leading to damage to the host o Persistent or latent infection o Enhancement of host susceptibility to drugs of otherwise minimal toxicity o Immune suppression Reservoir o The living organisms or inanimate matter in which an infectious agent normally lives and multiplies: Humans Animals (zoonosis refers to infections transmissible under natural conditions from vertebrate animals to man) Environmental sources (soil, water) Types of Carriers o An infected person who does not have apparent clinical disease but is nevertheless a potential source of infection to others o Includes persons whose infection remains inapparent (asymptomatic) through-out, as well as those for whom the carrier state precedes or follows manifest disease Type of Carrier Examples Inapparent throughout Polio virus, meningococcus, hepatitis viruses

Incubatory carrier Viruses of chickenpox, measles and hepatitis Convalescent carrier C. diphtheriae, hepatitis B virus and Salmonella species Chronic carrier S. typhosa, hepatitis B virus Transmission of Infection: The Chain of Infection

o o Cut one link in the chain stop the transmission Disease Concepts The Chain of Infection

o Mechanisms of Transmission of Infection o Direct Transmission o Indirect Transmission Vehicle borne Vector borne Airborne - Droplet nuclei - Dust Direct Transmission o Consists of essentially immediate transfer of an infectious agent from an infected host or reservoir to an appropriate portal of entry o Ex. Kissing, sexual intercourse o Spray by droplets through sneezing and coughing onto the mucous membranes of others (occurs over short distances) o Includes exposure of susceptible tissues to fungal agents, bacterial spores or parasites Breaking the Chain of Infection


Vital Statistical Rates and Ratios Health Indices o Frequency of health-related events within an identified base population o Measured as rates of specific events within a specific base population Not enough to do absolute counts, has to be rates. o Used to: Assess status of health conditions for an identified base population Assess sufficiency of health programs for an identified base population o Categories of rates of health related-events: Crude Rates- total population of a given geographical areas in a given time frame - Midyear population - Crude death rate, crude birth rate Specific Rates o Crude rates: denominator is the total population within a specified geographical area o Specific Rates: events happening to a specific group are related only to the corresponding segment of the population Can be made specific according to: - Age - Sex - Occupation - Marital Status - Race - Exposure Fertility Rates o Crude Birth Rate (CBR): measures how fast people are added to the population through births o General Fertility Rate (GFR): births are related to the segment of the population deemed to be capable of giving birth (women in the reproductive age group) Crude Birth Rate o Factors that affect CBR: Fertility/marriage patterns Sex and age composition of a population number of females Birth registration practice factitiously alters value o Crude rate since it includes members of the base population who are incapable of giving birth (men, children, elderly women) General Fertility Rates o Constituents of the base population within a given country will depend of the definition of the age of reproduction of that country o Can be made more specific by computing for different categories of maternal variables to be allowed for more meaningful comparisons across populations: Age of mother Educational attainment Occupation Fertility Rates o Crude Birth Rates (CBR) (for crude rates, always x 1000) General Fertility Rates (GFR)

Mortality Rates o Crude Death Rate o Specific Mortality Rate o Cause of Death Rate o Infant Mortality Rate Neonatal Mortality Rate Postnatal Mortality Rate o Maternal Mortality o Proportionate Mortality Ratio o Swaroops Index o Case Fatality Rate Crude Death Rate o Rate with which mortality occurs in a given population o Factors that affect CDR Age and sex composition of the population Environmental and occupational conditions Peace and order conditions

o o Widely used due to general availability of data for computation Used to compare populations with similar structure

o Specific Mortality Rate o Rates of dying in specific population groups o Can be made specific according to: Age Sex Occupation Education Exposure to risk factors o Graph of age-specific mortality rates generally show a J-shaped (developed countries, more reaching older age) or U-shaped curve whereby mortality rates are higher with extremes of age Cause-of-Death Rate o Crude rate since denominator is midyear population o Can be made specific by relating the deaths from a specific cause and group to the mid-years population of that specified group o Ten leading causes of death are determined using thing measure o Factors that affect cause-of-death rate are: Completeness of registration of deaths Composition of the population Disease ascertainment level in the community Other Mortality Rates o Specific Mortality Rate

(F = multiple of 10 until value is a whole number) Cause of Death Rate

Infant Mortality Rate (IMR) o The number of deaths among infants < 1 yr. age in a calendar year per one thousand livebirths in the same period o A sensitive index of level of health in the community o Subdivided into: Neonatal Mortality Rate usually due to congenital or poor maternal care Post-neonatal Mortality Rate usually due to environmental or infectious diseases o High IMR means low levels of health standards which may be due to: Poor maternal and child health care Malnutrition Poor environmental sanitation Deficient health service delivery o May be artificially lowered by improving registration of births Increases the denominator, does not mean health services improved o o

Categories of Infant Mortality Rates Neonatal Mortality Rate

Post-neonatal Mortality Rate

Subdividing IMR into 2 categories is due to different causes of death in these two age group categories Neonatal Mortality Rate - Prenatal of genetic causes Post-Neonatal Mortality Rate - Environmental, genetic, nutritional or infectious causes Maternal Mortality Rate (MMR) o

o o o Measures the number of deaths due to diseases directly related to pregnancy, deliver and puerperium Ideal denominator should have been number of pregnancies but often underreported May be affected by: Maternal health practices Diagnostic assessment Completeness of Registration of births

o Proportionate Mortality Ratio (PMR) o Proportion of total deaths occurring in a particular population group or from a particular cause o Denominator is total number of deaths, Not population size o Affected by the proportion of deaths due to other causes within the same time period o Swaroops Index o Special kind of proportionate mortality ratio o Also a sensitive indicator of the standards of health care o Developed countries have higher Swaroops index than less developed countries o o The higher, the better the health index of the country Case Fatality Rate o Proportion of cases which end up fatally o Tells how much of the afflicted die from the disease o High CFR more fatal disease o Time element is usual duration of the disease o Depends on: Natural history of disease itself Diagnostic ascertainment Level of reporting in the population o

Occupational Epidemiology The study of health effects of factors to which people are exposed in the workplace environment Factors may be: o Chemical o Physical heat, noise, radiation or mechanical energy o Biological o Psychological Contributory factors o Training o Workplace layout o Environment o Working practices o Lack of maintenance o Lack of guidance The kind of occupational illness and the health hazards encountered are directly related to: o The means of economic activity that prevail o Type of technology available Health concerns associated with worksite exposures o Carcinogenesis o Chronic Diseases respiratory, neurologic and cardiovascular o Reproduction Primary goal in occupational epidemiology is the identification or confirmation of new occupational disease and the study of dose-response characteristics in order to prevent illness Ecological studies provide a crude way of exploring associations between occupation and disease The group, not the individual, is the unit of comparison Disease rates in various groups are being compared Ecological studies: (Observational) o Case Report o Case Series o Cross-sectional o Case-control o Cohort Has an important role notably in: o Establishing the causes and determinants of this ill-health, o Ensuring adequate recognition and quantification of this, and o Determining appropriate occupational exposure limits Criteria for Causal Association o Strength of association calculate odds risk or relative risk o Dose-response relationship o Consistency of the association\ o Temporally correct association o Specificity of association o Coherence with existing information o Reversibility Linked to Environmental Epidemiology: o Environmental epidemiology involves the use of epidemiologic tools to study communities that may be exposed to pollution, hazardous waste, radiation through air, water or food contamination o Occupational by-products mostly affects the environment Hazards and Risk in the Workplace o Hazard is the potential to cause harm o Risk is a measure of the likelihood of a specified harmful effect in a specified circumstances Physical Hazards o Non-ionizing radiation e.g. microwaves, infrared, visible and ultra-violet light o Ionizing radiation e.g. X-rays, gamma rays, beta particles, alpha particles from radon daughters o Noise (usually measured in decibels dB) and vibration; o Temperature, humidity etc. o Ergonomic: Posture, movement (e.g. keyboard operation), load bearing (e.g. patient handling) Chemical Hazards o Inorganic e.g. lead, arsenic, silica o Organic e.g. solvents, resins, glues, fluxes (vapors and gases are usually expressed in concentrations of parts per million or per billion: ppm or ppb) Biological Hazards o Allergens of biological origin: laboratory animals, insects, mites, wood and other plant material, fungal spores o Infections: Bacteria: Tuberculosis, Brucella, Leptospica etc. o Viruses: eg. Hepatitis B from needlestick injuries Psychological Hazards

o Stressors in the Workplace Recent promotion beyond capacity Conflicts due to multiple responsibilities Too many demands on time A tiring shift pattern, excess overtime Too little or boring work New technology A new or unreasonable boss Increased productivity targets Threat of redundancy Sexual harassment or bullying High sickness absence in colleagues Prevention of Occupational Stress o Focus on individual behavior by support and advice, to help coping with the stress o Identify situations which include potential stressors, assess the risk of stress, and then take steps to reduce the stressors so as to reduce the stress. Preventing psychological distress Occupational Exposure o A measure of the intensity and/or extent to which the human body experiences a particular hazard o For a given hazard, the greater the exposure the greater the risk of an adverse effect on health. This is because of the exposure-response relationship. Skin o Eczema/dermatitis This can be irritant e.g. caused by detergents, or allergic e.g. caused by certain rubber chemicals Cancer e.g. from skin exposure to pitch/tar, or to excessive sunlight o Lungs Asthma e.g. from glutaraldehyde in healthcare workers, other causes of may include flour, or other agents in bakeries, or di-isocyanates in twin-packspray painting Allergic alveolitis e.g. Farmers lung from fungal spores Pneumoconiosis e.g. silicosis caused by inhaling quartz Cancer e.g. from asbestos inhalation o Musculoskeletal Tenosynovitis and similar conditions Back pain from manual handling o Nervous and Mental Peripheral neuropathy e.g. caused by lead or n-hexane Nerve deafness induced by noise Mental ill-health e.g. caused by stress, or by chemical exposures such as mercury o Blood/Marrow Anemia e.g. caused by lead, which may impair the synthesis of normal hemoglobin Aplastic anemia may be caused by high exposures to benzene Leukemia caused by benzene o Genitourinary and endocrine Kidney damage solvent exposures, or by cadmium Bladder cancer beta naphthylamine, generally aromatic amines Infertility caused by some chemical exposures e.g. male infertility caused by DBCP (dibromochloropropane) Endocrine dysfunction and/or effects on reproduction phthalates, glycerol ethers, and organophosphates o Liver Hepatitis Cancer Responsibilities of Employer and Company Physician o Assessment of Health risks Created by Work Identification of hazards Assessment of exposure, work practices, etc o Prevention or Control of Risks Elimination of hazards Substitution of hazards Enclosure/Segregation so as to reduce exposure Local exhaust ventilation if appropriate Personal protection e.g. gloves, goggles, masks, footwear Appropriate work organization and practice o Monitoring and Evaluation Checking of control measures Environmental monitoring: personal and background Appropriate health surveillance o Consultation, Information, Instruction & Training

o Record Keeping and Reporting

Demography Derived from Greek words synos meaning the people and ypagly meaning to draw or write The empirical, statistical and mathematical study of human populations Focus of attention: o Population size o Population composition or structure o Distribution of the population within a given location Population Size o Number of people within a given time and place o Projections of changes in population size in the future o Affected by living (health, political, environmental, social) conditions of a given time Population Composition o Pertains to all the measureable characteristics of the people o Most common: age and sex o May identify other characteristics of the population depending on the purpose for which the description is being made o Related to the number of births, deaths and migration activity in the area o Also influenced by existing living conditions within a given place and time (selection process) o Affects selection of types of intervention (health services) for a given type of population Population Distribution o Pertains to where members of a given population are located o Related to prevailing conditions o Affects distribution of health services o Measures of population distribution Urban-rural distribution Population density - Number of persons per area Crowding index - Number of persons divided by the total number of rooms in the house Uses of Demography o For identification and characterization of health problems within a given community o For prioritization of health programs given the limited resources o For identification of determinants or reasons for occurrence of specific health problems o To predict future developments and possible consequences Sources of Demographic data o Censures De jure assigns individuals to the place of their usual residence De facto allocation of individuals to areas where they were physically present at the census date o Sample Surveys o Vital Registration Systems o Continuing Population Registers Tools of Demography o Ratio numerator not part of denominator o Proportion numerator part of denominator o Rate element of time, numerator part of denominator Age composition o Median age o Age-dependency ratio Relates the size of the dependent segment of the population to the economically productive age-group of the population o The higher the age dependency ratio, the more people unemployed or less people in productive age group Sex Composition o Sex Ratio Compares the number of male individuals to the number of females in the population o Sex structure Computing for the sex ratio of each age group Population Pyramid o Graphic form of describing the age and sex composition of the population at the same time o Used for describing and explaining demographic trends of population over time o Various type of population pyramid Formulas for Computing Various Aspects of Population Estimation Using Different Mathematical Assumptions Unknown Arithmetic Geometric Exponential

Future Population (Pt) Past Population (P0) Absolute Increase per year (b) or annual rate of growth (r) Time (t) Doubling time (t*)