Causality in epidemiologic Study

 At the heart of epidemiology is the notion of causality

 One of the central concerns of epidemiology is to be able to assert that a causal

association exist between an eksposure factor and disease (or other adverse outcome)
in the host

AB

 nonscientists : Generally mean that the first event preceded the second in time and
seemed to be related to its occurrence

 Scientists :

 need to be a little clearer

 need to know if exposure to a toxin always makes people sick or only sometimes

 need to understand if a nasty symptom can be caused by one virus or several

It's not enough to simply say that one thing causes another; scientists have to be able to
describe the nature of that association. they have developed terminology to describe the causal
relationship between two events. They say that causes are necessary, sufficient, neither or
both.

Necessary vs Sufficient

 If one thing is a necessary cause of another, then that means that the second thing can
never happen without the first. (Sebab yang harus ada bila penyakit yang terjadi –
Outcome--.Namun sebab itu dapat ada tanpa kejadian penyakit)

 In contrast, if something is a sufficient cause, then every time it happens the outcome
will follow. (Jika sebab itu ada penyakit harus terjadi. Namun, penyakit dapat terjadi
tanpa sebab yang sedang ada tersebut)

Type of causality(First event)

 Both necessary and sufficient

 Necessary but not sufficient

 Sufficient but not necessary

  Neither necessary nor sufficient

Necessary But Not Sufficient

A person must be infected with HIV before they can develop AIDS. HIV is therefore a necessary
cause of AIDS; however, since every person with HIV does not develop AIDS, it is not sufficient.

Sufficient But Not Necessary

Decapitation is sufficient to cause death; however, people can die in many other ways

Neither Necessary Nor Sufficient

Gonorrhea is neither necessary nor sufficient to cause pelvic inflammatory disease, because
you can have gonorrhea without ever developing PID and PID without ever having been
infected with gonorrhea

Both Necessary And Sufficient

A gene mutation associated with Tay-Sachs is both necessary and sufficient for the
development of the disease, since everyone with the mutation will eventually develop Tay-
Sachs and no one without the mutation will ever have it

Risk Factor

 A factor that associated with the increased probability of a human health problem

 Although a risk factor is not necessarily sufficient to cause disease, its presence does
increase the chance of developing the disease

 Risk factor --- at-risk behavior --- predisposing factor

 At-risk factor : an activity performed by person who are healthy, but are at greater risk
of developing a health-related state or event because of the behavior

 Predisposing factor : are those existing factors or conditions that produce a

susceptibility or disposition in a host to a disease or condition without actually causing it

Causal inference

 Is a conclusion abaut the presence of a health-related state or event and reasons for it’s
existence

 The connection between human health and physical, chemical, biological, social, and
psychosocial factors in the environment is based on causal inference

 Something is true or highly probably 

 Expectation : hypothesis, theories or prediction

  Experience ; results, observation or data

Faktor-faktor Penyebab

 Predisposing factors

 Reinforcing factors

 Enabling factors

 Prescipitating factors

Predisposing factors

The factors of conditions already present in a host that produce a susceptibility or disposition
to a disease or condition without actually causing it

Ex : age, immune status

if the host :

 Natural resistance  respond by not getting the disease

 Not protected respond by getting the disease

 Sensitife to a condition  respond accordingly

Reinforcing factors

Reinforcing factors have the ability to support the production and transmission of disease or
conditions, support and improve a population’s health status, and help control disease and
conditions

 Negative reinforcing  the factors that help aggravate and perpetuate disease,
conditions, disability or death, ex : occupation  stress

 Positive reinforcing those that support, enchance, and improve the control and
prevention of the causation of disease, ex : occupation  hobby (refresh)

Enabling factors

Can effect health through an environmental factor in either a positive or negative way

 These factors include : services, living conditions, program, societal support, skills, and
resources that facilitate a health outcome’s occurance

Ex : bad nutrition, bad sanitary, health service

Prescipitating factors

Are essential to the development of disease, conditions, injuries, disabilities, and death
(Eksposur pada penyakit atau agen berbahaya)

Ex : infectious agent, which is associated with the definitive onset of disease ; lack of seat belt
use in car, dringking and driving, and lack of helmet use by motorcycle riders

Teori-teori penyebab penyakit

 Teori supernatural

 Teori Hippocratik

 Teori miasma

 Teori Kontagion

 Teori Germ (sebab ditunjukkan melalui postulat Henle – Koch)

 Teori Epidemiologik klasik

 Teori multikausal dan jaring penyebab (sebab ditunjukkan melalui postulat Hill)

Teori supernatural

 Terjadinya penyakit karena kekuatan supernatural

Teori Hippocrates (1) (460 SM – 377 SM)

 Berbagai penyakit ada hubungan dengan faktor tempat (geografi), kondisi air, iklim,
kebiasaan makan dan perumahan

 Teori tentang sebab penyakit didominasi oleh pendapat medis lebih dari 2000 tahun

 Penyakit terjadi akibat ketidakseimbangan cairan tubuh (phlegm = lendir, darah,

empedu kuning, dan empedu hitam)

Teori Hippocratic (2)

 Prinsip utama teori Hippocrates tentang sebab penyakit adalah “konstitusi” mempunyai
pengaruh pada keseimbangan cairan tubuh

 “Konstitusi” merujuk pada geografi, iklim, makanan,gerakan bintang dan planet

terutama meteor dan komet.

Teori Miasma (oleh Galen 129 -199 M)

 Miasma

Istilah umum untuk partikel yang ada dalam udara

 Miasma yang buruk (seperti penguapan dari sampah, air yang macet, pembusukan
binatang) dipikirkan sebagai penyebab penyakit
Teori Kontagion oleh Hieronymus Fracastorius (1478 – 1553)

 Penyakit ditransmisikan dari satu orang ke lain orang melalui partikel yang sangat kecil
untuk dapat dilihat.

 Proses transmisi penyakit ini disebut Kontagion  penularan

Teori Germ (kuman) (1)

 Penyakit disebabkan oleh suatu kuman

 Penemuan mikroskop oleh Leewenhook telah membantah teori miasma.

 Pendukung teori germ

 Edward Jenner  penemu vaksin cacar

 Louis Pasteur  penemu vaksin rabies

Teori Germ (kuman) (2)

 Sebab ditunjukkan oleh postulat Henle – Koch (kadang-kadang disebut “determinisme

murni”

 Postulat Henle-Koch

 Agen harus ada pada setiap kasus penyakit

 Agen tidak terjadi pada penyakit lain sebagai kebetulan atau parasit
nonpatogenik (satu agen satu penyakit)

 Agen dapat diisolasi dan jika dikenakan pada subjek yang sehat akan
menyebabkan penyakit yang bersangkutan

Teori epidemiologik klasik

 Digambarkan dengan Triad epidemiologik

 Penyakit adalah hasil dari kekuatan dalam suatu sistem dinamik yang terdiri dari

 Agen infeksi

 Manusia (host)

 Lingkungan

Teori Multikausalitas dan Jaring kausal

Sebab ditunjukkan oleh postulat (kriteria) Hill

Causal criteria
 • John Stuart Mill (Philosopher), 1856 Three methods of hypothesis formulation in
disease etiologi

• Sir Austin Bradford Hill, 1965  Mill’s postulates abaut causality – nine criteria that
could be used to determine wheter statistical association were causal association

John Stuart Mill (Philosopher), 1856

Three methods of hypothesis formulation in disease etiologi

1. Method of difference

2. Method of Agreement

3. Method of concomitant variation

4. (Method of Analogy)

Method of difference

 The frequency of disease occurance is extremely different under different situation or

condition

 If a risk factor can be identified in one condition and not a second, it may be that factor,
or the absence of it, that cause the disease

Ex : Valley Fever (coccidioidomycosis) occurs only in the desert of the South-western US

Method of Agreement

 If risk factors are common to a variety of different circumstance and the risk factors
have been positively associated with a disease,then the probability of that factor being
the cause is extremely high

 (Adanya kemiripan distribusi suatu penyakit dengan penyakit lain yang telah banyak
diteliti secara lebih mendalam, mengindikasikan adanya kemungkinan penyebab yang
sama)

Ex : increasing trends in cigaratte smoking is directly associated with increasing trends in lung
cancer in many different place througout the world

Method of concomitant variation

 The frequency of strength of a risk factor varies with the frequency of the disease or
condition

Ex : Mortality rate penyakit jantung koroner (PJK) meningkat sejalan dengan peningkatan
tingkat konsumsi rokok rata-rata per kapita. Rokok penyebab PJK?

Method of Analogy
  Adanya kemiripan distribusi suatu penyakit dengan penyakit lain yang telah banyak
diteliti secara lebih mendalam, mengindikasikan adanya kemungkinan penyebab yang
sama.

Ex : Kemiripan distribusi geografis lymphoma Burkit di Afrika dengan penyakit malaria dan
demam kuning (yellow fever), memunculkan dugaan bahwa vektor serangga turut berperan
dalam menimbulkan lymphoma ini

Sir Austin Bradford Hill, 1965

Mill’s postulates abaut causality – nine criteria that could be used to determine wheter
statistical association were causal association

 Strength of association

 Consistency of association

 Specificity

 Temporality

 Biologic Gradient

 Biological plausibility

 Analogy

 Coherence

 Experimental evidence

Strength of association

Research problem  research hypothesis (expected association between variables) 

select design study  statistical test  significant or not  does the measured
association represent the “truth”????

 A strong statistical association between an exsposure and health outcome provides

greater evidence of there being a causal association because it is more likely to be real
(valid)

Consistency of association

This occures when associations are replicated by different investigators in different

setting with different methods

Ex :the 1964 report of US Surgeon General identifying a causal association between

cigaratte smoking and lung cancer was based on 29 case-control studies and 7
prospective cohort studies
Specificity

 Means an exsposure is associated with only one disease or the disease is associated
with only one exsposure

Ex : specificity in Koch’s Postulates published in 1880

 a specific association is one that is consentrained to a particular disease-exposure

relationship

Temporality

 In order for an exposure to cause a disease, the exposure must precede the disease

Ex : it has been established that mosquito bites precede malaria

Biological Gradient

 An increasing amount of exposure increases the risk of disease

Ex : Studies have identified direct association between pask-years of smoking and age-
related macular degeneration, providing evidence that smoking may be causally related
to blindness

Biologic Plausibility

 Biological often involves experiments ini contolled labolatory environment

Ex : tobacco smoke is known to contain over 60 carcinogens, including fiomaldehde and

benzoprene

Coherence

 Causal inference is consistent with known epidemiologic patterns of disease

Analogy

 Analogous situations with previously demonstrated causal association provide support

of there being a causal association

Experimental evidence

The randomized, double-blind experimental study design is the best for establishing
cause-effect relationship