The Occurrence of Disease I. Disease Surveillance and Measures of
Morbidity Surveillance A fundamental role of public health Can monitor changes in disease frequency and levels of risk factors Most often used for infectious disease but increasingly used to monitor changes in other types of conditions including cancer, injuries and illnesses after natural disasters, completeness of vaccination coverage and prevalence of drug-resistant organisms Defined by CDC as ongoing systemic collection, analysis and interpretation of health data essential to the planning, implementation and evaluation of public health practice closely integrated with the timely dissemination of these data to those who need to know Provides decision-makers with guidance for developing and implementing the best strategies for programs for disease prevention and control Importance of standardized definitions of disease and diagnostic criteria Passive and Active Surveillance Passive surveillance/reporting: available data on reportable diseases are used, or in which disease reporting is mandated or requested, with the responsibility for the reporting often falling on the health care provider or district health officer o Quality of data depends on individual or staff who may not receive any additional funds or resources, i.e. reporting is not their primary responsibility o Underreporting or lack of completeness are likely o Reporting instruments must be simple and brief o Less expensive Active surveillance: staff recruited to carry out a surveillance program by making periodic field visits to health care facilities such as clinics and hospitals to identify new cases of a disease or deaths from the disease that have occurred (case finding) o Involves interviewing physicians and patients, reviewing medical records, surveying villages/towns to detect cases o Reporting is more accurate because staff are specially trained for the position o More expensive
Challenge of disease surveillance using mortality data is differing
estimates of mortality o Malaria mortality estimates vary greatly in developing countries due to difficulties in obtaining reliable data in the absence of a standardized surveillance system, vital registration and diagnostic testing Surveillance can also be used to assess changes in levels of environmental risk factors for disease
Stages of Disease in an Individual and in a Population
Healthy->disease onset->symptoms->seek care->diagnosis>treatment->outcome: cure, control, disability, death Sources of data: interviews, physician records, hospital records o The data source influences the rate calculated for the frequency of disease (i.e. hospital records dont include people who died prior to seeking care) Rate: how fast the disease is occurring; proportion: the fraction of the population affected Measures of Morbidity Incidence rate: number of new cases of a disease during a specific period of time in a population as risk of developing the disease o Incidence rate per 1,000 = No. of new cases of a disease occurring in the population during a specified period of time / No. of persons who are at risk of developing the disease during that period of time x 1000 o Incidence rate is a measure of risk o Denominator must only include people at risk of disease (i.e. for uterine cancer, only women are included in denominator) o 2 types of denominators: people at risk who are observed throughout a defined time period if incidence is calculated using period of time during which all the individuals in the population are considered at risk then it is cumulative risk when all people are not observed for the full time period, person-time, or units of time when each person is observed person-time is the units of time that each individual at risk was observed
Ex. 1 person at risk observed for 5 years = 5
person-years (py) If people at risk are observed for different periods of time, the incidence rate is: Incidence rate per 1000 = no. of new cases of a disease in a population during a specified time / total person-time x 1000 o Identifying new cases in order to calculate incidence Define and screen population for the disease at a baseline; of those who do not have the disease, follow-up after a period of time; of those who develop the disease in the time period = new incident cases Attack rate: the number of people exposed to a suspect food who became ill divided by the number of people exposed to that food (not a true rate, really a proportion of all people who ate a certain food who became ill) Prevalence: number of affected persons present in the population at a specific time divided by the number of persons in the population at that time (i.e. the proportion of the population affected by the disease at that time), prevalence per 1000 = No. of cases of a disease present in the population at a specific time / No. of persons in the population at that specified time x 1000 o Point prevalence: prevalence of the disease at a certain point in time o Period prevalence: people who had the disease at any point during a certain time period o Incidence vs. prevalence: prevalence is a snapshot in time of those who have disease vs, those who dont, whereas incidence is new cases of the disease for a given population Point prevalence: Do you currently have asthma? Period prevalence: Have you had asthma during the last [n] years? Cumulative incidence: Have you ever had asthma? o Prevalence can only be lowered by death or cure, so when insulin became available the prevalence of diabetes increased because those who formerly would have died now survived o Prevalence is very important for public health planning Problem with incidence and prevalence measurements o Problems with numerators Defining who has the disease Ascertaining which persons to include in the numerator (i.e. finding cases)
o Problems with denominators
Selective undercounting of certain groups in the population Deciding who to include in denominator (i.e. should women with hysterectomies be included in the denominator for uterine cancer?) o Problems with hospital data Hospital admissions are selected Records designed for patient care not research Defining denominators is difficult because most hospitals do not have defined catchment areas Relationship between incidence and prevalence o Prevalence = incidence x duration of disease o Spot map: does not take population density into consideration
Conclusion o Important role of epidemiology is surveillance of disease and surveillance of morbidity in planning and development of health services o Different approaches to measuring morbidity