Epidemiology and prevention control

CLS 351
Outline
• Defining & comparing prevention, control &
eradication.
• Recognizing and comparing different levels of
prevention
• Differentiate between screening and diagnostic tests.
• Discuss criteria for effective screening.
• Conclude characteristics of ideal screening test.
• Define and calculate sensitivity and specificity.
• Define and calculate predictive values of disease.
The goals of epidemiology are to:
• Prevent,
• Control,
• Eradicate diseases and injuries (in rare cases).

 Prevention “planning and taking action to prevent

(forestall) occurrence of an undesirable event”
• It is more desirable than intervention, where the
action is taken during an event.
For example, immunizing is preferable than taking
antibiotics.
Control:
• Containment of a disease.
• Include both prevention and intervention
measures.
• Often used to mean limiting transmission of a
communicable disease in a population.
Significant control of certain diseases has been
achieved through specific preventive measures
Example: Decline in T.B. mortality in England &
Wales (1840-1968), was attributed to improved
nutrition & sanitation.
Eradication:
• Uprooting or total elimination of a
disease from the population.
• Rarely achieved in public health.
• BUT, Smallpox is the only
communicable disease that has
been eradicated (WHO certified
eradication of smallpox in 1979).
Epidemiology can play a central role in prevention
by identifying modifiable causes of disease.

Prevention is gaining acceptance in all countries

due to:
• Limitations of modern medicine in curing
diseases.
• Increasing costs of medical care.
Types (levels) of Prevention
I - Primary prevention:
A - Health promotion.
B - Specific protection.
II-Secondary prevention.
III-Tertiary prevention.
 Primary Secondary Tertiary
Prevention Prevention Prevention
Cur
Healthy Biologica Clinical e Chronic
individua l Course of Disability disease
onset of disease
l
disease
Deat
h
Functional
Risk Asymptomati Symptoms Status

Factors c and
signs signs

Rehabilitatio
Immunizatio Screening Diagnosis
n
n Health Surveillan Treatment Support
Education ce Complianc
e
Prophylaxis
Adherence
The levels of prevention in relation to natural
history of disease
Types (levels) of Prevention
I - Primary prevention:
In this level, actions are taken prior to the onset of
disease with an objective to prevent disease
occurrence in a healthy person.
It is done in the stage of pre-pathogenesis of the
natural history of disease.

It comprises:
A - Health promotion.
B - Specific protection.
A - Health promotion:
It is the top most level of health (positive health). It
is not directed to a specific disease, but it is
intended to strengthen the host by improving the
general health and the quality of life for individuals
and communities.
It can be achieved by:
• Improving food distribution and nutrition.
• Basic sanitation (safe drinking water, waste disposal,
control of insects and rodents…..etc).
• Personal hygiene.
• Health education.
• Family planning.
B - Specific protection:
Aims to avoid occurrence of specific diseases and
conditions. Basic approach of primary prevention is
identifying weak points and break weakest link in
chain of transmission.

For example: immunization against specific

diseases.
II - Secondary prevention:
Early diagnosis and treatment of diseases before they
become advanced and disability becomes severe.

Health screenings
• Their goal is not to prevent the onset of disease,
but to detect its presence during early
pathogenesis, permitting early treatment to reduce:
• Risk of developing a clinical disease.
• Severity of the disease (limiting disability).
• Death due to the disease.
Definition of screening:

“Application of a test or procedure to asymptomatic,

apparently well individuals, to classify them as likely
or unlikely to have a particular disease.”
• Those who test positive (appear likely to have the
condition) will be sent for further evaluation by a
subsequent diagnostic test or procedure to
determine whether they do in fact have the disease
(reach a final diagnosis).
 Screening tests Diagnostic tests
Done to those who are Done to those with suggestive
apparently healthy or signs or symptoms
asymptomatic
Applied to a group of Applied to a single person
individuals
Results are based on one Results are based on the
criterion evaluation of a number of
symptoms, signs and
investigations
Results are not conclusive Results are conclusive and final
Less accurate More accurate
Less expensive More expensive
Not a basis for treatment Basis for treatment
N.B. With few exceptions, some tools are both screening and diagnostic.
Types of screening
There are different types of screening, each with
specific aims:
 Mass screening aims to screen the whole
population;
 Multiple or multiphasic screening uses several
screening tests at the same time;
 Targeted screening of groups with specific
exposures, e.g. workers in lead battery factories, is
often used in environmental and occupational health;
 Case-finding or opportunistic screening is aimed at
patients who consult a health practitioner for some
other purpose.
Criteria for screening

(Bonita, 2006)
Characteristics of ideal
screening test
• The screening test itself must be cheap, easy to
apply, acceptable to the public, reliable and valid.
• Being simple and rapid, we expect a screening test
to have some errors. We use methods of evaluation
of screening tests: reliability and validity.
• A test is reliable if it provides consistent results, and
valid if it correctly categorizes people into groups
with and without disease, as measured by its
sensitivity and specificity.
Sensitivity and
specificity
• Sensitivity is the proportion of people with the
disease in the screened population who are
identified as ill by the screening test. (When the
disease is present, how often does the test detect
it?)
• Specificity is the proportion of disease-free people
who are so identified by the screening test. (When
the disease is absent, how often does the test
provide a negative result?)
Two by two tables
True Disease State
Screening
Test Result AFFECTED UNAFFECTED TOTAL

True False Screen positives

POSITIVE positives positives
a b

False True Screen negatives

NEGATIVE negatives negatives
c d
TOTAL Affected Unaffected Total Screened
individuals individuals
Validity of a screening test
Sensitivity of a test is defined as the percentage
of persons with the disease of interest who
have positive test results.

= True positives X 100

True positives + False negatives

= a/(a+c) X100
 Sensitivity – true positive rate
How good is this test at picking up people who have
the condition?
Validity of a screening test
Specificity of a test is defined as the percentage of
persons without the disease of interest who have
negative test results.

= True negatives x 100

True negatives + False positives

= d/(d+b) X100
 Specificity – True negative rate
How good is this test at correctly excluding people
without the condition?
 Overall validity

= True positive + True negative X100

True positive + false positive +false negative+ true negative

a d

 X 100
a bcd
Example:
• The “gold standard” for breast cancer diagnosis is
the histopathological confirmation of cancer in a
surgical specimen.
• To calculate how accurate mammography test for
detecting breast cancer is, screening test
(mammography) results are compared with findings
from surgical excision biopsies in women without
palpable breast masses .
Calculate sensitivity & specificity of mammography,
prevalence of breast cancer:

Gold standard
(Surgical biopsy)
Total
Cancer No cancer
Positive 14 8 22
(Mammograph
Screening test

Negative 1 91 92
y)

Total 15 99 114
Sensitivity = True positives X 100
True positives + False negatives
= a/(a+c) X100 = 14/(14+1) x100 = 93.3%

Specificity = True negatives x 100

True negatives + False positives
= d/(d+b) X100 = 91/(91+8) x100= 91.9%

Overall validity = True positive + True negative X100

True positive + false positive +false negative+ true negative

= (a+d)/(a+b+c+d) X 100 = 92.1%

• The higher the sensitivity AND specificity the better
the test.
• The lower the false positive and false negative rates
the better the test.
Sensitivity should be increased
At the expense of specificity when the penalty
associated with missing a case is high, such as:
• When the disease is serious and definitive treatment
exists so that it can be treated effectively in early
stages.
• When the disease can spread (syphilis and
gonorrhea).
• When subsequent diagnostic evaluations of positive
screening tests are associated with minimal cost and
risk (further series of blood pressure readings to
ascertain hypertension).
Positive and negative predictive values

Sensitivity and specificity describe the accuracy of

a test.
Two measures that directly address the probability
of disease:
• The positive predictive value (PV+) and,
• The negative predictive value (PV -).
 Positive predictive
value (PV+)
• Is defined as the % of persons with positive test results
who actually have the disease of interest.
• The PV+ therefore, allows one to estimate how likely
the disease is present if the test is positive.
• PV+ is calculated as follows:
True positive
Positive predictive value  X 100
True Positives  False positives

= a/(a+b) X100
Negative predictive
value (PV-)
• Is defined as the % of persons with negative test
results who actually don’t have the disease of
interest.
• The PV- therefore, allows one to estimate how likely
the disease is absent if the test is negative. PV- is
calculated as follows:
True negatives
Negative predictive value  X 100
True negatives  False negatives

= d/(c+d) X100
Calculate the positive predictive
value and negative predictive value
Gold standard
(Surgical biopsy)
Total
Cancer No cancer
Positive 14 8 22
(Mammograph
Screening test

Negative 1 91 92
y)

Total 15 99 114
 True positive
Positive predictive value  X 100
True Positives  False positives

= a/(a+b)x100 = 14/22 x100= 63.6%

True negatives
Negative predictive value  X 100
True negatives  False negatives

= d/(d+c) x100= 91/92 x100= 98.9%

• A high PV- is expected in screening for rare diseases,
because the vast majority of those screened will be
disease free.
• PV+, or yield of cases, of a screening test can be
increased by increasing the prevalence of the pre-
clinical disease.
• This is done by applying the screening test to
individuals who are at high risk of developing the
disease.
(Bonita, 2006)
Examples of
screening
programs
1- Hypertension
Screening test: Measurement of blood pressure
Diagnostic test: Measurement of blood pressure 3
times over 3 minutes period in sitting position
Types of screening
Mass screening: Adults above 35 years of age (in
communities with high prevalence)
Selective screening:
• Persons with positive family history of disease
• Diabetic patients
Value:
• Launch of early treatment (anti-hypertensive)
• Education about diet modification (Salt intake)
2- Breast cancer
Screening test:
• Breast self-examination
• Mammography
Diagnostic test: Biopsy and pathological exam
Types of screening:
Mass screening: Adult females
Selective screening: Family history, Unmarried/ non
lactating
Value: Early treatment/ reduces mortality
III - Tertiary prevention:

It refers to prevention of the disease consequences

and disability. It is the final level of prevention.
Actions are done during the stage of pathogenesis.
III - Tertiary prevention:

It comprises:
• Disability limitation: patients come late in the
pathogenesis phase. It aims to halt the
disease process by giving appropriate
treatment to limit disability, prevent further
complications and if possible prevent or
postpone death.
• Rehabilitation: It attempts to restore an
affected individual to a useful, satisfying and
self-sufficient role in the society (becomes a
productive unit of the community).
(Gordis, L., 2013)
Essential reading

• Basic epidemiology ,Bonita, pages: 4-11.

• Basic epidemiology ,Bonita, pages: 110-114.
• Gordis, L., 2013. Epidemiology. Pages 5-6