sesi 1_pengantar epidemiologi.ppt

EpidemiologiIntermediateDepartemen EpidemiologiFakultas Kesehatan Masyarakat Universitas Indonesia*

Definisi (1)Tidak ada definisi tunggal Epidemiologi Dari bahasa Greek. Epi = atas, pada, demos = penduduk, logi = studi

Studi distribusi dan determinan peristiwa kesehatan dalam populasi manusia.

*

Definisi (2)Hirsch (1883)Suatu gambaran kejadian, distribusi, dan tipe penyakit manusia, ..

Frost (1927)Ilmu fenomena masal penyakit infeksius, atau seperti riwayat alamiah penyakit infeksius suatu ilmu induktif yang tidak hanya mendeskripsikan distribusi penyakit, melainkan kesesuaiannya dalam suatu filosofi yang konsisten*

Definisi (3)Greenwood ( 1934)Epidemiologi adalah studi penyakit sebagai fenomena massal

Lilienfeld (1957)Epidemiologi boleh didefinisikan sebagai studi distribusi suatu penyakit atau kondisi dalam populasi dan faktor yang mempengaruhi distribusi ini*

Definisi (4)Taylor (1963)Studi kesehatan atau penyakit dalam populasi

McMahon, Pugh, dan Ipsen (1970)Studi distribusi dan determinan frekuensi penyakit pada manusia distribusi (epidemiologi deskriptif) dan determinan dari distribusi yang tercatat (epidemiologi analitik)*

Epidemiology DefinedGreek rootsepi = upon (as in epidermis)demos = the people (as in demography)ology = to speak of, to study

Literally - study of epidemics

Modern definitions of epidemiology refer to distributions in populations (statistical)determinants (pathophysiological, environmental, behavioral)control of health problems (biological, social, economic, political, administrative, legal)*

Public Health DefinedDefinitions of public health refer to organized effort (activity)reduction of morbidity & mortality improvements in health

Main public health competency areas epidemiology biostatisticshealth administrationbehavioralenvironmental health science*

Epidemiology compared to medicineMain unit of concern in epi populationMain unit of concern in medicine individual public healthEpidemiology study ofPublic health organized effortEpi said to be methodologic backbone of public health

*

Definisi (5)Suatu ilmu dasar dari kedokteran pencegahan dan kesehatan masyarakat yang mempelajari:

Penyakit (atau status kesehatan)

Frekuensi (enumerasi jumlah yang ada atau tingkat perkembangan dalam periode waktu spesifik)

Determinan (faktor yang mempengaruhi distribusi)

Metode (proses yang dilakukan untuk mendeskripsikan frekuensi dan distribusi, rasional ilmiah yang digunakan untuk menentukan kausal distribusi penyakit dalam populasi

Populasi (populasi manusia tertentu)*

Epidemiologi Ilmu dasar semua aspek kesehatan masyarakat: (1)Penyakit infeksi Penyakit kronisCedera intensional dan tidak intensionalKesehatan mentalNutrisi

*

Epidemiologi Ilmu dasar semua aspek kesehatan masyarakat: (2)Pendidikan dan promosi kesehatanPerencanaan kesehatanAdministrasi kesehatan masyarakatPelayanan pengobatan medis*

Ruang lingkupDefinisi penyakitKejadian penyakitPenyebab penyakitKeluaran penyakitPengelolaan penyakit dan pencegahan penyakit*

Aktivitas epidemiologi (1)Pengumpulan dan analisis pencatatan vital (kelahiran dan kematian)

Pengumpulan dan analisis data morbiditas dari rumah sakit, lembaga kesehatan, klinik, dokter dan industri

Pemantauan penyakit dan masalah kesehatan komunitas yang lain*

Aktivitas epidemiologi (2)Investigasi kejadian luar biasa yang mengarahkan program pemberantasan atau pencegahan epidemik dan masalah kesehatan komunitas yang lain

Merancang dan melaksanakan penelitian kesehatan

Merancang dan melaksanakan registrasi kesehatan untuk masalah yang menjadi perhatian seperti: cacat lahir, insidens kanker, atau penggunaan napza*

Aktivitas epidemiologi (3)Skrining (penapisan) untuk penyakit

Penilaian efektivitas keberadaan pengobatan yang baru

Mendeskripsikan riwayat alamiah penyakit

Identifikasi individu atau kelompok pada populasi umum terhadap peningkatan risiko perkembangan penyakit tertentu*

Aktivitas epidemiologi (4)Identifikasi keterkaitan etiologi penyakit

Identifikasi masalah kesehatan masyarakat dan pengukuran besar distribusi, frekuensi, atau dampak pada kesehatan masyarakat*

Aktivitas epidemiologi (5)Penilaian program kesehatan

Menyediakan data yang diperlukan untuk perencanaan kesehatan atau pembuatan keputusan oleh badan administrasi kesehatan atau pembuat kebijakan kesehatan

*

Who is an epidemiologist ?A professional who strives to study and control the factors that influence the occurrence of disease or health-related conditions and events in specified populations and societies, has an experience in population thinking and epidemiologic methods, and is knowledgeable about public health and causal inference in health (Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)

*

Epidemiologists are required to have some knowledge of: Public health: because of the emphasis on disease preventionClinical medicine: because of the emphasis on disease classification and diagnosis (numerators) Pathophysiology: because of the need to understand basic biological mechanisms in disease (natural history) Biostatistics: because of the need to quantify disease frequency and its relationships to antecedents (denominators, testing hypotheses) Social sciences: because of the need to understand the social context in which disease occurs and presents (social determinants of health phenomena)

*

1.4 Selected Historical Figures and EventsUnderstanding medical history is an important part of epidemiology

This section divided into three eras400BC 18501850 - 1900Twentieth century epi*

*Historical Figures & Events400BC 1850Hippocrates (400BCE)Age of enlightenment (17th & 18th centuries)John Graunt (1620 1674)

1850 -1900John Snow (1813 1858)Germ Theory (mid 19th century)

Twentieth century epiModern epidemiology

Sejarah perkembangan epidemiologi Ahli epidemiologi pertama

Hippocrates 460 377 SMAhli Epidemiologi yang pertamaMenjelaskan terjadinya penyakit dari dasar yang rasionalBuku yang ditulis: Epidemic I, Epidemic II, On Airs, Waters, and PlacesMemperkenalkan istilah epidemic dan endemic*

*The First EpidemiologistsHippocrates460 B. C. to 377 B.C. attempted to explain disease occurrence on a rational basis instead of from a supernatural view point Three major books Epidemic I Epidemic II On Airs, Waters, and Places

*Hippocrates (1)Recognized the association of various diseases with environmental factors place water conditions climate eating habits housing

*Hippocrates (2)Introduced epidemic endemic

*Hippocrates (3)Theory about the cause of disease personal observation Greek thinking Disease is the imbalance of body humors phlegm blood yellow bile, black bile

Sejarah perkembangan epidemiologi Galen 129 199 M

Ahli bedah tentara romawiBapak Fisiologi EksperimentalFaktor Prokatartik (cara hidup orang) dan temperamen mempengaruhi kesehatan dan penyakitPengaruh lingkungan (geografi dan iklim) miasma (istilah umum untuk partikel dalam udara)Malaria udara burukTeori miasma*

*Galen (1)129 - 199 A.D. Father of experimental physiology Health and Disease influenced by Procataritic factors the way of life a person led life style Temperamentthe innate qualities of the body personality

*Galen (2)Disease caused by Miasmaparticles in the air from sources waste stagnant water decaying animals theory used to explain the great plague epidemic in Europe

Sejarah perkembangan epidemiologiAge of enlightenment (17th & 18th centuries)

Thomas Sydenham (1624 1689)

Hippocrates InggrisBapak EpidemiologiAtmosfer mengakibatkan perubahan konstitusi epidemik

*

*Thomas Sydenham (1)1624 - 1689 Father of Epidemiology insisted that observation should have precedence over theory in the study of the natural history of disease

Demographic Approach(pp. 1214)John Graunt (1620 1674)*

*Sejarah perkembangan epidemiologi DEMOGRAPHIC APPROACHKelahiran vital statistikJohn Graunt

Analisis data mortalitas dalam tahun 1662Melakukan kuantifikasi yang pertama dari pola kelahiran, kematian dan kejadian penyakitMencatat perbedaan laki-laki dan perempuan, kematian bayi yang tinggi, perbedaan urban-rural, dan variasi musiman

*Demographic ApproachJohn Graunt (162074)

17th Century Life TableAge% surviving6641640262536164610566603761800

Epidemiology (Schneider)

Life Table of Deaths in LondonSource: Graunts Observations 1662

AgeDeathsSurvivors0--1006366416244026152536916466105646663376218010

Epidemiology (Schneider)

Graunts ObservationsExcess of male birthsHigh infant mortalitySeasonal variation in mortality

*Sejarah perkembangan epidemiologiWillian Farr

Melakukan pengumpulan data secara sistematik dan statistik kematian di InggrisBapak Statistik vital moderen dan surveilensMemperluas analisis data morbidtas dan mortalitas epidemiologiMelihat efek status perkawinan, pekerjaan dan ketinggian

Sejarah perkembangan epidemiologi Konsep kontagion dan Teori germ penyakit

Hieronymous Frascastorius (1478 1553)Sastrawan dan dokter dari ItaliaPenyakit disebabkan oleh germPenyakit ditransmisikan dari orang ke orang melalui suatu partikel yang sangat kecil

Igmatz Semmelweis (1818 1865)Ahli Obstetri dari HungariaDemam nifas dapat direduksi jika para dokter mencuci tangan sebelum menolong persalinan*

Downloaded from: StudentConsult (on 29 August 2009 12:10 AM) 2005 Elsevier *

Sejarah perkembangan epidemiologi Edward JennerMendukung teori FracastoriusMenerima teori germ penyakitPenemu vaksin cacar (akhir tahun 1700)

Louis PasteurBerkontribusi dalam menguatkan teori germ penyakit dengan mendemonstrasikan efektivitas imunisasi pada pencegahan rabies dalam tahun 1885Belum mampu mengisolasi virus rabies menghalau teori miasma*

Sejarah perkembangan epidemiologiStudi epidemiologi klasik awalJames LindMelakukan studi epidemiologi ekperimen pada etiologi dan pengobatan scurvy (1753)Makan jeruk merupakan obat untuk scurvy

P L PanumStudi epidemiologi klasik tentang penyakit campak di pulau Faroe (1875)*

Sejarah perkembangan epidemiologi John Snow (1813 1858)

Ahli anestesiMelakukan serial investigasi kolera di LondonBapak Epidemiologi LapanganMelakukan studi epidemik kolera (1854)*

Snows MethodsEcological studiescompared cholera rates by region

Cohortcompared cholera rates in exposed and non-exposed individuals

Case-controlcompared water source in cases and controls*

*Snows Ecological AnalysisSouthwark Water Company neighborhoods high ratesMixed service intermediate ratesLambeth Water Co. neighborhoods no cases

*

Deaths from Cholera per according to water company supplying subdistricts of London, 1853-1854

Water Company

Population in 1851

Deaths from

Cholera

Deaths rate per 100,000 living

Southwark and Vauxhall Company

Lambeth Company

Both Company

167,654

14,632

301,149

192

0

182

114

0

60

The Grand Experiment A retrospective studyXOX*

*

Deaths from Cholera per 10,000 according to water company supplying actual houses, London - 1854

Water Supply

Number of Houses

Deaths from

Cholera

Deaths in Each

10,000 Houses

Southwark and Vauxhall Company

Lambeth Company

Rest of London

40,046

26,107

256,423

1,263

98

1,422

315

37

59

Source: Snow (55)

Snows Cohort Study (Table 1.7, p. 25)Cholera mortality per 10,000 household and water sourceRate Southwark & Vauxhall = 1263 / 40,046 10,000 = 315Rate Lambeth = 98 / 26107 10,000 = 37.5Southwark & Vauxhall drew water from fecal contaminated water regionSupporting evidence for water-borne transmission theory*

Snows Cohort Analyses* Rate, Southwark = 1263 / 40,046 = .0315 = 315 / 10,000*

Water SourceCasesHomesRate per 10,000Southwark126340,046315*Lambeth9826,10737Both1422256,42359

Snows Case-Control StudyEpidemic area of Golden Square area (1854 epidemic)Interviewed cases and non-cases to determine water sourceCases61 used water from Broad St. pump 6 did not use Broad St. pump6 could not determine if used Broad St. pumpControls were less likely to use Broad St. pump watere.g., Among Brewer workers (non-cases), the men were allowed a certain quantity of malt liquor, and Mr. Huggins [the proprietor] believes they do not drink water at allMap showing proximity to pump and no. of cases (next slide)

*

Cholera Deaths Broad St. Outbreak*

Snows Map (Fig 1.14)*

*Visualization Success StoriesFrom Visual Explanations by Edward Tufte, Graphics Press, 1997Illustration of John Snowsdeduction that a cholera epidemicwas caused by a bad water pump, circa 1854.

Horizontal lines indicate location of deaths.

*John Snow: A Classic Epidemiologic Study The Father of field epidemiology investigating the outbreak of cholera in Gloden Square of London descriptive epidemology --> hypothesis generation --> hypothesis testing ---> public health application

*Golden Square Cholera Outbreak: John Snow (2)Theory Hypothesis Hypothesis testPublic Health Application

Action Water was the source of disease Correlation of the distribution of cholera case households and the location of water pumps Removed the handle of the pump in Broad Street

*London Cholera Outbreak: John Snow (3)Theory Hypothesis Hypothesis testPublic Health Application

Action Water served as vehicle for transmitting choler based on time, place, and person; compared groups are comparable changing the location of water intake to avoid water contamination

*Sejarah perkembangan epidemiologi Studi epidemiologi klasik awalJames LindMelakukan studi epidemiologi ekperimen pada etiologi dan pengobatan scurvy (1753)Makan jeruk merupakan obat untuk scurvy

Sejarah perkembangan epidemiologi

*Sejarah perkembangan epidemiologi Goldberger (1923)Menggunakan studi epidemiologi observasional dan eksperimen tentang pellagra (defisiensi asam nikotinat)

Joseph Goldberger (1874-1929)used observational and experimental epidemiologic methods to identify vitamin deficiency as the cause of pellagra;

identified diets high in cereals and canned food as a risk factor; proved sources of fresh animal protein and legums were effective in prevention; first nutritional epidemiologist.

Sejarah perkembangan epidemiologi Hill, Doll, Wynder, Cornfield and other Post world war II epidemiologists. World War II is a convenient watershed to mark the risk of the "modern epidemiologists", since this coincides with the emergence of chronic disease as major causes of morbidity and mortality;

focuses on individual risk factors; hallmarked by studies on :

smoking and lung cancer, The Surgeon General's Report on Smoking and Health, the Framingham heart studies,water fluoridation trials, and the poliomyelitis field trials of 1954.

Maturation of Epidemiology (1910 - 1945)Key methodologic developments include the advancement of epidemiologic theory,

outbreak investigation methods,

methods to study non-infectious diseases (case-control and cohort methods),

the introduction of randomized clinical trials, and new survey methods developed by Goldberger in the study of pellagra).

Also, changes in the education of physicians and health care took place in the 1910s and 1920s, respectively

Last half of 20th Century ("Modern Epidemiology")The epidemiologic transition from acute contagious to chronic non-contagious causes of morbidity effected the way epidemiologists studied disease

Illustrative examples British Doctors Study (Doll & Hills studies of the effects of smoking)Framingham Heart Study (risk factors for heart disease, many investigators)

*Sejarah perkembangan epidemiologi Doll dan Hill (1950)Studi Merokok dan kaitannya dengan kanker paru dan studi penyakit kardiovaskular pada penduduk Framingham, Massachusetts(Dawber, Kannel, dan Lyell, 1963. Gordon, Castelli, Hjortland, Kannel, dan Dawber, 1977)Riset epidemiologi pada penyakit kronik(Freedman, Chear, Srinivasan, Webber, dan Berenson, 1985)Bogalusa Heart Study(Stamler, Wentworth, dan Neaton, 1986)Multiple Risk Factor Intervention Trial

Doll and Hill, 1952*

Lung cancer casesControlsORSmoke 25+ per day331 (24%) 166 (12%)17.4Smoke 5-24 per day1019 (75%)1130 (83%)7.8Non-smoker7 (1%)61 (5%)1

Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study

A B C DBlood Pressure (mm Hg)120/80140/90140/90140/90Total Cholesterol (mg/dL)200 240 240 240HDL Cholesterol (mg/dL) 50 50 40 40Diabetes No No Yes YesCigarettes No No No Yes

*

Chart15

55

138

2520

3727

Men

Women

Estimated 10-Year Rate (%)

Sheet1

CVDCVD2001 CVD total mortalityLCD BLACK M/F, 2001LCD AM. INDIAN M/F, 2001AgesMenWomenMenWomenNHES IIINHANES INHANES III

MalesFemales145,908141,80125-442.02.8A2.61.1Non-Hispanic WhitesNon-Hispanic BlacksMexican AmericansWhite Males163163155% of Men using PA to lose weight% of Men meeting PA guidelines% of Women using PA to lose weight% of Women meeting PA guidelinesNumber of TransplantsEST. COST OF CV DISEASES 2004

1979500469MALESFEMALESMALESFEMALES45-546.75.5B4.02.0Black Males171165166Whites66.522.863.520.1196823

80510490Coronary Heart Disease54502,18954CVD+cong.A33.5CVD+cong.A40.1D of H/St.A24.4D of H/St.A25.455-6413.18.4C5.43.5Awareness69.573.957.8White Females170166163Blacks70.122.662.816.9197010Heart Disease238.6

81500484Stroke18163,53818CancerB22.4CancerB20.8CancerB17.1CancerB19.165-7417.711.1D8.46.3Treatment60.163.040.3Black Females172174168Hispanics63.817.152.714.3197522Coronary Heart Disease133.2

82495484Congestive Heart Failure652,8286AccidentsC5.9DiabetesF5.1Acc.C14.0Acc.C8.275+18.616.1E14.819.1Control, Treated55.644.644.0Others68.423.063.520.6198057Stroke53.6

83498494High Blood Pressure546,7655Assault(Homicide)D4.6Nephritis, etc.G2.9C. Liver D.D4.8DiabetesE6.7F22.427.0Control, All Hypertensives33.428.117.7Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex and Race and Survey1985719Hypertensive Disease55.5

84491493Diseases of the Arteries439,4044HIV(Aids)E3.7AccidentsC2.8DiabetesE4.3C. Lower res.D.F4.1Prevalence of Coronary Heart Disease by Age and SexNHES III, NHANES I, NHANES III: 1966-70, 1971-74 and 1988-94Leisure-time Physical Activity (PA) Patterns Among Overweight Adults by Race/Ethnicity and Sex19902,107Congestive Heart Failure28.8

85491498Rheumatic Fever/Rheumatic Heart Disease0.43,4890.4NHANES III: 1988-94Estimated 10 Year Stroke Risk in 55 Year Old AdultsBRFSS: 199819952,363Total CVD*368.4

86481498Congenital Cardiovascular Defects0.44,1090.4Leading Causes of Death for Black or African American Males and FemalesLeading Causes of Death for American Indian/Alaska Native Males and FemlaesAccording to Levels of Various Risk FactorsExtent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity20002,199

87475499Other13118,78613United States: 2001United States: 2001Framingham Heart StudyNHANES IV: 1999-200020022,154Estimated Direct and Indirect Costs (in Billions of Dollars) of Cardiovascular Diseases and Stroke

88476504100.8931,108100.0United States: 2004

89456486Trend in Heart Transplants

90448478Percentage Breakdown of Deaths From Cardiovascular DiseasesUnitedStates: 1968-2002

91447479United States:2001

92444479

93457500

94452498

95455505

96453506

97450503

98446504

99446513

00439507Non-Hispanic WhitesNon-Hispanic BlacksMexican Americans

01432499YearMalesFemales12% of high school students who participated in vigorous or moderate physical physical activity in past 7 daysMen5.47.68.1

70779597Whites76.644.218.2Women4.79.511.4

Cardiovascular Disease Mortality Trends for Males and FemalesMales71851628Blacks26.724.116.4Non-Hispanic White MalesNon-Hispanic White FemalesNon-Hispanic Black MalesNon-Hispanic Black FemalesHispanic MalesHispanic FemalesMalesFemales

United States: 1979-2001Males72935693ABCDEFCHF PREVALENCEMexican Americans34.317.317.5Vigorous73.759.872.447.868.852.4Non-Hispanic Whites12.45.3Prevalence of Age-Adjusted (2000) Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity

73982725Blood Pressure*95-105138-148138-148138-148138-148138-148MalesFemalesModerate29.824.723.716.525.918.5Non-Hispanic Blacks17.514.6NHANES III: 1988-94 NHANES III

741030756DiabetesNoNoYesYesYesYes20-240.10.1Prevalence of Current Smoking for Men Ages 18-24 by Education and Race/EthnicityHispanics21.38.8

751043789Cigarette SmokingNoNoNoYesYesYes25-340.10.1NHANES III: 1988-94Prevalence of Students in Grades 9-12 Who Participated in Sufficient Vigorousu.s. 1979-00

Prevalence of CVD, U.S. 1988-94 NHANES III761087843Prior AFNoNoNoNoYesYes35-440.70.5or Moderate Physical Activity During the Past 7 Days by Race/Ethnicity and SexPercentage of Overweight Among Students in Grades 9-12 by Sex and Race/EthnicityCatheterizationsOpen-HeartBypassPTCAEndarterectomyPacemakers

771111852Prior CVDNoNoNoNoNoYes45-541.81.3United States: 2001United States: 200119792991721145442

AgeMalesFemales78111084455-646.23.4803501971375544

20-245.54.6791014724* - Closest ranges for women are : 95-104 and 115-124.65-746.86.6814162221597326

25-3410.44.280104973775+9.89.7824732401708231

35-4417.413.6811095765MenWomen835122601919525

45-5434.228.982116084120-349.80.0Prevalence of Congestive Heart Failure by Age and Sex8457627820210339

55-6451.048.183122985235-4417.116.0NHANES III: 1988-948569030823010740

65-7465.265.284104484045-5432.330.5867863702848332

75+70.779.085120584655-6444.153.0878794093321568189

86125088965-7459.970.38894445735321170120

Females87126890175+68.884.18999846836824370107

Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and SexFemales8812208309010465013922666897

NHANES III :1988-94MenWomen891174819Prevalence of High Blood Pressure in Americans Age 20 and Over by Age and Sex91105751840730367121

DR FOR WOMEN, CV AND CANCER 2001A55901151795United States: 1999-200092108459046836791113

LCD HISPANIC M/F, 2001B138911146806WhitesBlacksMexican Americans93107860648536989123

White FemalesBlack Females63,31747,082C252092124788612

Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart StudyABCDEFSystolic BP*95-105130-148130-148130-148130-148130-148DiabetesNoNoYesYesYesYesCigarettesNoNoNoYesYesYesPrior Atrial Fib.NoNoNoNoYes YesPrior CVDNoNoNoNoNoYesSource: Stroke 1991;22:312-318.*BP in millimeters of mercury (mmHg)*

Chart2

2.61.1

42

5.43.5

8.46.3

14.819.1

22.427

Men

Women


Sheet1












88476504100.8931,108100.0United States: 2004




92444479

93457500

94452498

95455505

96453506

97450503

98446504

99446513



70779597Whites76.644.218.2Women4.79.511.4










25-3410.44.280104973775+9.89.7824732401708231

35-4417.413.6811095765MenWomen835122601919525


55-6451.048.183122985235-4417.116.0NHANES III: 1988-948569030823010740

65-7465.265.284104484045-5432.330.5867863702848332

75+70.779.085120584655-6444.153.0878794093321568189

86125088965-7459.970.38894445735321170120

Females87126890175+68.884.18999846836824370107






ABCDEFSystolic BP*95-105130-148130-148130-148130-148130-148DiabetesNoNoYesYesYesYesCigarettesNoNoNoYesYesYesPrior Atrial Fib.NoNoNoNoYes YesPrior CVDNoNoNoNoNoYesEstimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318.*BP in millimeters of mercury (mmHg)*

Chart2

2.61.1

42

5.43.5

8.46.3

14.819.1

22.427

Men

Women


Sheet1












88476504100.8931,108100.0United States: 2004




92444479

93457500

94452498

95455505

96453506

97450503

98446504

99446513



70779597Whites76.644.218.2Women4.79.511.4










25-3410.44.280104973775+9.89.7824732401708231

35-4417.413.6811095765MenWomen835122601919525


55-6451.048.183122985235-4417.116.0NHANES III: 1988-948569030823010740

65-7465.265.284104484045-5432.330.5867863702848332

75+70.779.085120584655-6444.153.0878794093321568189

86125088965-7459.970.38894445735321170120

Females87126890175+68.884.18999846836824370107






Offspring CVD Risk by Parental CVD Status: Framingham StudyRisk Ratio2.521.510.50MenWomen1.01.72.21.01.71.7Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMIParental CVD

*Aplikasi Epidemiologi

*Kontribusi epidemiologi (1)Penyelidikan modus transmisi penyakit baruPenentuan sebab-sebab penyakit yang dapat dicegahPenentuan riwayat alamiah penyakitPengamatan spektrum penyakit

*Kontribusi epidemiologi (2)Penilaian intervensi kesehatan komunitasPenyusunan prioritas pemberantasan penyakitPerbaikan diagnosis, pengobatan dan prognosis penyakit klinis Peningkatan riset pelayanan kesehatanPenyediaan saksi ahli dalam pengadilan

History of EpidemiologyHIPPOCRATES (400 BC): On Airs, Waters, and Places Hypothesized that disease might be associated with the physical environment, including seasonal variation in illness.

JOHN GRAUNT (1662): Nature and Political Observations Made Upon the Bills of Mortality First to employ quantitative methods in describing population vital statistics.

JOHN SNOW (1850): Formulated natural epidemiological experiment to test the hypothesis that cholera was transmitted by contaminated water.*

History of Epidemiology (cont.)DOLL & HILL (1950): Used a case-control design to describe and test the association between smoking and lung cancer.

FRANCES at al. (1950): Huge formal field trial of the Poliomyelitis vaccine in school children.

DAWBER et al. (1955): Used the cohort design to study risk factors for cardiovascular disease in the Framingham Heart Study.*

Brief History of EpidemiologyClassical Infectious Diseases EpidemiologyEdward Jenner (1749-1823)developed a vaccine against smallpox using cow pox160 years before virus was identifiedJohn Snow (1813-1858)described the association between dirty water and cholera 44 years before vibrio was identifiedIgnaz Semmelweis (1818-1865) described the association between childbed fever and physicians unclean hands 32 years before causal agent was discovered

Brief History of EpidemiologyClassical Nutritional EpidemiologyJames Lind (1716-1794) conducted an experiment which showed that scurvy could be treated and prevented with limes, lemons, and orangesascorbic acid was discovered 175 years laterJoseph Goldberger (1874-1927)identified that pellagra was not infectious but nutritional in origin and could be prevented by increasing the amount of animal products in the diet and substituting oatmeal for corn gritsniacin was discovered 10 years later

Brief History of EpidemiologyEpidemiology of Chronic DiseasesObservational Studies:R Doll & AB Hill. Early case-control study. Smoking and carcinoma of the lung: Preliminary report. [Br. Med. J. 2:739, 1950]Cohort Studies:An approach to longitudinal studies in a community: the Framingham study. 10,000 residents gave baseline information. Follow-up is now 50 years. [Annals New York Academy of Sciences 107:539;1963]

Brief History of EpidemiologyEpidemiology of Chronic DiseasesExperimental Studies:Hypertension Detection and Follow-up Program Cooperative Group. 10,500 subjects randomly assigned to two groups: 1. stepped care - antihypertensive therapy increased stepwise to achieve and maintain blood pressure reduction to goal.2.Referred care - subjects were referred to their primary care physician and treated as usual.

mortalitystepped care 9.0/100 referred care 9.7/100final blood pressure84.1 in stepped care89.1 in referred care

Brief History of EpidemiologyEpidemiology of Chronic DiseasesPhysician Health Studyrandomized, placebo-controlled, double-blind clinical trialconducted entirely through the mail22,071 male physicians enrolled to study the effects of aspirin on cardiovascular disease and the effects of beta-carotene on cancerrandomly assigned to one of four groupsaspirinbeta caroteneactiveactiveactiveplaceboplaceboactiveplaceboplacebo

ROOTS OF MODERN EPIDEMIOLOGY1. ACUTE DISEASE INVESTIGATION-----Emphasis on empirical systematicinvestigation, biology, and environment/host manipulation2. MEDICINE-----All early epidemiologists werephysicians.*

ROOTS OF MODERN EPIDEMIOLOGY3. STATISTICS-----Emphasis on the scientific method,quantification and measurement,and hypothesis testing. In 1960s, manyepidemiologists were statisticians.4. SOCIAL SCIENCES-----Investigation of human behavior inrelation to disease, and methods ofdata collection (surveys, etc.)*

ROOTS OF MODERN EPIDEMIOLOGY5. COMPUTER SCIENCES-----Emergence of chronic diseaseepidemiology required the ability tohandle large amounts of data and toperform complex analyses.6. MANAGERIAL SCIENCES-----Management principles for acquisition of grants, research collaboration, and management of clinical trials.*

ROOTS OF MODERN EPIDEMIOLOGY7. GENOMICS-----2001 marked first publication of draft sequences of the human genome. Intensive investigations being conducted to identify disease susceptibility genes gene-environment interactions, and gene-gene interactions.*

Classical versus Modern ApplicationsClassical: descriptive, observational, field, analytical, experimental, applied, healthcare, primary care, hospital, CD, NCD, environmental, occupational, psycho-social, etcModern: risk-factor, molecular, genetic, life-course, CVD, nutritional, cancer, disaster, etc *

*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w**dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*Snow first used vital statistic from the registrar general that compared mortality by source of water by subdistricts. In the subdistricts in which supply was from Lambeth only, there was no death while in the subdistrict while the supply was mostly by Sothwark&Vauxhall, the death rate was very high. Gaining permission from the Registrar General, Snow was supplied with addresses of persons who died from Cholera. He went into the subdistrict of Kensington One and Two and found that 38 out of 44 deaths in this subdistrict received their water from Southwark and Vauxhall Company.

dewi wdewi w*dewi wdewi w*A report to the parliament based on the continuation of the work of Snow. Dr. Snow finally able to prove his hypothesis, that is, the circumstances of the cholera poison passing down into the river, being drawn from the river and distributed through miles of pipes into peoples homes produces a specific disease throughout the community.dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*mm Hg = millimeters of mercurymg/dL = milligrams per deciliter of bloodSource:Circulation 1998;97:1837-1847.

dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*For a brief history of epidemiology:Edward Jenner (1749 to 1823) - observed that persons who had been infected with cow pox - were not likely to get small pox. He used a vaccine from cow-pox effluence to inoculate against small pox - and it worked.dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w*dewi wdewi w

sesi 1_pengantar epidemiologi.ppt

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