PHC 2 - Tools in Community Diagnosis

A. Application of Public Health Tools in Community
Diagnosis
1. Demography
a. Sources of Demographic Data
b. Population Size
c. Population Composition
d. Population Distribution
10/25/2018Mary Aretha D. Rocha 2

2. Health Statistics, Health Indicators and
Implications
a. Crude Birth Rate
b. Crude Death Rate
c. Specific Rates of Mortality
d. Leading Causes of Mortality
e. Leading Causes of Morbidity
f. Life Expectancy

B. Philippine Health Situation
1. Demographic Profile
2. Health Profile
C. Epidemiology and the Nurse
1. Definition of Related Terms
2. Aspects of Epidemiology
3. Natural Life History of Disease
4. Epidemiological Triangle
5. Epidemiological Process and Investigation

▪ is the scientific and statistical study of population
 It includes the size, structure, composition and
distribution of these populations and spatial and/or
temporal changes in them in response to time, birth,
migration, ageing, and death
 Greek: demos = the people
grapho = writing

1. Social Observation
2. Family Records
3. Population Census
4. Registration of Vital Data
5. Health Survey
6. Studies and Researches

1. Social
Observation
2. Family Records
3. Population
Census
4. Registration of
Vital Data
5. Health Survey
6. Studies and
Researches
 study of the social and physical
order in urban neighborhoods

1. Social
Observation
2. Family
Records
3. Population
Census
4. Registration of
Vital Data
5. Health Survey
6. Studies and
Researches

1. Social
Observation
2. Family Records
3. Population
Census
4. Registration of
Vital Data
5. Health Survey
6. Studies and
Researches
 the procedure of systematically
acquiring and recording information
about the members of a given
population.
 it is a regularly occurring and official
count of a particular population

1. Social
Observation
2. Family Records
3. Population
Census
4. Registration of
Vital Data
5. Health Survey
6. Studies and
Researches
 types of census:
◦ De jure –people are assigned
to a place where they usually
live regardless of where they
are at the time of the census
◦ De facto –people are
assigned to a place where
they are physically present at
the time of the census

1. Social
Observation
2. Family Records
3. Population
Census
4. Registration
of Vital Data
5. Health Survey
6. Studies and
Researches
 is an administrative system used by
the government to record vital
events which occur in the
population; live births, stillbirths

1. Social
Observation
2. Family Records
3. Population
Census
4. Registration of
Vital Data
5. Health
Survey
6. Studies and
Researches
 are nationally-represented household
surveys that provide data for a wide
range of monitoring and impact
evaluation indicators in the areas of
population, health, and nutrition.

 is the number of individual organisms in a population
 denoted as N

• refers to the combined
demographic characteristics
of persons within a
geographic area.
• is the description of a
population according to
characteristics such as:
• age
• sex
• population pyramid

The distribution within a
group of people of specified
individual attributes such as:
 sex
◦ sex ratio
 age
◦ age distribution
◦ median age
◦ age dependency ratio
 marital status
 other characteristics
◦ educational attainment
◦ occupational group
◦ economic group
◦ ethnic group
◦ religion

 the arrangement or
spread of people living
in a given area; also,
how the population of
an area is arranged
according to variables
such as age, race, or
sex.

 Urban – Rural
 Crowding Index – indicates the ease by which a
communicable disease can be transmitted from one
host to another susceptible host
 Population Density – determine the congestion of
the area/place

Health Statistics
Health Indicators
& Implications

❑ refers to the systematic study and the
application of statistical measurements
to vital events such as births, illnesses,
marriages, divorces/ separations and
deaths that is utilized to gauge the
levels of health, illness and health
services of a community
❑ a government database recording the
births and deaths of individuals within
that governments jurisdiction

1. A tool for planning, implementing, and evaluating
health programs.
2. Serves as indexes of the health condition obtained
in a community or population group.
3. Provide variables as to the nature of health
services or action needed.
4. Serves as basis for determining the success or
failure of such services or actions.

▪ a list of information which determine the health of a
particular community, specifically the population.
Types of Health Indicators:
▪ Fertility
▪ Morbidity
▪ Mortality

 Fertility rate
◦ Crude birth rate
◦ General fertility rate
 Morbidity rates
◦ Incidence rate
◦ Prevalence rate
 Mortality rates
◦ CDR
◦ Maternal mortality rate
◦ Neonatal mortality rate
◦ Post-neonatal rate
◦ Infant mortality rate
◦ Specific mortality rates

▪ Fertility
▪ Morbidity
▪ Mortality
1. Crude Birth Rate (CBR)
▪ Overall total reported births
▪ Formula:
CBR = Overall Total Reported Births x 1000
Population

▪ Fertility
▪ Morbidity
▪ Mortality
▪ is a measure of the risk of developing some
new condition within a specified period of
time
▪ illnesses affecting the population group
1. Incidence Rate (IR)
▪ reported new cases affecting the
population group
▪ Formula:
IR = new cases of disease x 100
Population

▪ Fertility
▪ Morbidity
▪ Mortality
2. Prevalence Rate (PR)
▪ determine sum total of new + old cases
of diseases per percent population.
▪ Formula:
PR = new cases + old cases x 100
Population

▪ Fertility
▪ Morbidity
▪ Mortality
▪ Reports causes of death
1. Crude Death Rate (CDR)
▪ overall total reported death
▪ Formula:
CDR = overall total deaths x 1000
Population

MORTALITY: TEN (10) LEADING CAUSES
NUMBER AND RATE/100,000 POPULATION
Philippines
5-Year Average (2004-2008) & 2009
CAUSES
5-Year Average
(2004-2008)
2009*
Number Rate Number Rate
1. Diseases of the Heart 82,290 94.5 100,908 109.4
2. Diseases of the Vascular System 55,999 64.3 65,489 71.0
3. Malignant Neoplasms 43,185 49.6 47,732 51.8
4. Pneumonia 35,756 41.1 42,642 46.2
5. Accidents** 34,704 39.9 35,990 39.0
6. Tuberculosis, all forms 25,376 29.2 25,470 27.6
7. Chronic lower respiratory diseases 20,830 24.0 22,755 24.7
8. Diabetes Mellitus 19,805 22.7 22,345 24.2
9.Nephritis, Nephrotic syndrome and Nephrosis 11,612 13.4 13,799 15.0
10. Certain conditions originating in the perinatal period 12,590 14.5 11,514 12.5
Note: Excludes ill-defined and unknown causes of mortality
* reference year
** External causes of Mortality 10/25/2018Mary Aretha D. Rocha 29

▪ Fertility
▪ Morbidity
▪ Mortality
2. Maternal Mortality Rate (MMR)
▪ maternal deaths due to maternal causes
▪ Formula:
MMR = number of maternal deaths x
1000
Registered Live Births

MATERNAL MORTALITY: BY MAIN CAUSE
Number, Rate/1000 Livebirths & Percent Distribution
Philippines, 2009
CAUSE Number Rate Percent*
TOTAL 1,599 0.9 100.0
1. Complications related to pregnancy occurring
in the course of labor, delivery and puerperium
655 0.4 41.0
2. Hypertension complicating pregnancy,
childbirth and puerperium
513 0.3 32.1
3. Postpartum hemorrhage 286 0.2 17.9
4. Pregnancy with abortive outcome 142 0.1 8.9
5. Hemorrhage in early pregnancy 3 0.0 0.2
*Percent share to total number of maternal deaths

▪ Fertility
▪ Morbidity
▪ Mortality
3. Neonatal Mortality Rate (NMR)
▪ number of deaths among neonates
(newborn 0-28 days or less than 1
month)
▪ Formula:
NMR = number of neonatal deaths x 1000

▪ Fertility
▪ Morbidity
▪ Mortality
4. Infant Mortality Rate (IMR)
▪ number of infant deaths 0-12 months or
less than 1 year old
▪ Formula:
IMR = number of infant deaths x 1000

INFANT MORTALITY: TEN (10) LEADING CAUSES
NUMBER AND RATE/per 1000 live births AND PERCENTAGE DISTRIBUTION
Philippines, 2009
Cause Number Rate Percent
1. Bacterial sepsis of newborn 3,082 1.8 14.2
2. Pneumonia 2,452 1.4 11.3
3. Respiratory distress of newborn 2,438 1.4 11.3
4. Disorders related to short gestation and low birth eight, not
elsewhere classified
1,609 0.9 7.4
5. Congenital malformations of the heart 1,523 0.9 7.0
6. Congenital pneumonia 1,052 0.6 4.9
7. Neonatal aspiration syndrome 1,038 0.6 4.8
8. Diarrhea and gastroenteritis of presumed infectious origin 971 0.6 4.5
9. Other congenital malformations 940 0.5 4.3
10. Intrauterine hypoxia and birth asphyxia 883 0.5 4.1

▪ Fertility
▪ Morbidity
▪ Mortality
5. Swaroop’s Index (SI)
▪ deaths among individuals in the age
group 50 and above
▪ formula:
SI= number of deaths (individual >50 years old) x 100
Total Deaths

2010
Diseases Number Rate
1. Acute Respiratory Infections 1, 289, 168 1371. 3
2. Acute Lower Respiratory Tract Infection and
Pneumonia
586, 186 623. 5
3. Bronchitis/ Bronchiolitis 351, 126 373. 5
4. Hypertension 345, 412 367. 4
5. Acute Watery Diarrhea 326, 551 347. 3
6. Influenza 272, 001 289. 3
7. Urinary Tract Infection 83, 569 88. 9
8. TB Respiratory 72, 516 77. 1
9. Injuries 51, 201 54. 5
10. Diseases of the Heart 37, 589 40. 0

Philippine Health Situation

Population 107,668,231 (July 2014 est.)
Age structure 0-14 years:
▪ 33.7% (male 18,493,668/female 17,753,359)
15-24 years:
▪ 19% (male 10,416,358/female 10,044,724)
25-54 years:
▪ 37% (male 20,031,638/female 19,796,545)
55-64 years:
▪ 5.8% (male 2,882,719/female 3,372,485)
65 years and over:
▪ 4.5% (male 2,103,596/female 2,773,139) (2014 est.)

Dependency ratios total dependency ratio: 60.7 %
youth dependency ratio: 54.3 %
elderly dependency ratio: 6.4 %
potential support ratio: 15.6 (2014 est.)
Median age total: 23.5 years
male: 23 years
female: 24 years (2014 est.)
Population growth
rate
1.81% (2014 est.)

Net migration
rate
-1.23 migrant(s)/ 1,000 population (2014 est.)
Urbanization Urban population: 48.8% of total population
(2011)
Rate of urbanization: 2.16% annual rate of
change (2010-15 est.)
Major cities -
population
MANILA (capital) 11.862 million;
Davao 1.565 million;
Cebu City 855,000;
Zamboanga 884,000 (2011)

Nationality noun: Filipino(s)
adjective: Philippine
Ethnic
groups
Tagalog 28.1%, Cebuano 13.1%, Ilocano 9%,
Bisaya/Binisaya 7.6%, Hiligaynon Ilonggo 7.5%, Bikol 6%,
Waray 3.4%, other 25.3% (2000 census)
Religions Catholic 82.9%
▪ Roman Catholic 80.9%, Aglipayan 2%,
Muslim 5%
Evangelical 2.8%
Iglesia ni Kristo 2.3%,
Other Christian 4.5%
Other 1.8%, unspecified 0.6%, none 0.1% (2000 census)

Languages Filipino (official; based on Tagalog) and English (official)
Eight major dialects - Tagalog, Cebuano, Ilocano, Hiligaynon or
Ilonggo, Bicol, Waray, Pampango, and Pangasinan
Literacy definition: age 15 and over can read and write
total population: 95.4%
male: 95%
female: 95.8% (2008 est.)
School life
expectancy
(primary to
tertiary
education)
total: 11 years
male: 11 years
female: 12 years (2009)
Education
expenditures
2.7% of GDP (2009)

Population
growth rate
1.81% (2014 est.)
Birth rate 24.24 births/1,000 population (2014 est.)
Death rate 4.92 deaths/1,000 population (2014 est.)

Sex ratio at birth: 1.05 male(s)/female
0-14 years: 1.04 male(s)/female
55-64 years: 1 male(s)/female
65 years and over: 0.76 male(s)/female
total population: 1 male(s)/female (2014 est.)

Mother's mean age
at first birth
23.1
note: median age at first birth among
women 25-29 (2008 est.)
Infant mortality rate total: 17.64 deaths/1,000 live births
male: 19.99 deaths/1,000 live births
female: 15.17 deaths/1,000 live births
(2014 est.)
Life expectancy at
birth
total population: 72.48 years
male: 69.52 years
female: 75.59 years (2014 est.)

Total fertility rate 3.06 children born/woman
(2014 est.)
Contraceptive prevalence rate 48.9% (2011)
HIV/AIDS - adult prevalence
rate
0.1% (2012 est.)
HIV/AIDS - people living with
HIV/AIDS
14,800 (2012 est.)
HIV/AIDS - deaths 300 (2012 est.)

Drinking water source improved:
urban: 92.5% of population
rural: 91.2% of population
total: 91.8% of population
unimproved:
total: 8.2% of population (2012 est.)
Sanitation facility access improved:
total: 74.3% of population
unimproved:
total: 25.7% of population (2012 est.)

Major infectious
diseases
degree of risk: high
food or waterborne diseases: bacterial
diarrhea, hepatitis A, and typhoid fever
vector-borne diseases: dengue fever
and malaria
water contact disease: leptospirosis
(2013)

Maternal mortality rate 99 deaths/100,000 live births (2010)
Children under the age of 5
years underweight
20.2% (2011)
Health expenditures 4.1% of GDP (2011)
Physicians density 1.15 physicians/1,000 population (2004)
Hospital bed density 1 beds/1,000 population (2011)
Obesity - adult prevalence
rate
6.3% (2008)

▪ the study of distribution of disease or physiologic
condition among human population and the factors
affecting such distribution
▪ the study of the pattern of occurrence and distribution of
health conditions such as disease, death, deformities or
disabilities on human populations

Susceptible population
 at risk to develop, acquire or experience the disease
Immune Population
 those that did not experience the disease, usually
individuals develop resistance against the disease

a. prevention of disease
b. prolong life
 promote physical health and efficiency through organized
community efforts
Importance of Epidemiology in Public Health:
▪ serve as the backbone of the prevention of diseases

 to study the history of the health population and
the occurrences of disease
 to diagnose the health of the community and the
condition of people
 to study the work of health services with a view
of improving them
 to estimate the risks of disease, accidents,
defects and the chances of avoiding them

PATTERNS SUSCEPTIBLE
POPULATION
IMMUNE
POPULATION
Epidemic 80% (more than
50%)
20%
Endemic 50% 50%
Sporadic 20% 80%
Pandemic ---- ----

 Epidemic
 Endemic
 Sporadic
 Pandemic
 disease occurs in short duration of time
or season.
 Example: measles, chickenpox,
dengue
 greater than 50% of the population are
susceptible or affected by the occurring
disease

 Epidemic
 Endemic
 Sporadic
 Pandemic
 places where the disease occurs
regularly, habitually, constantly affecting
the population group
 2 local endemic diseases where
causative agent is available on those
places
▪ Malaria: Palawan & Mindanao
▪ Schistosomiasis: Samar, Leyte,
Mindoro, Davao

 Epidemic
 Endemic
 Sporadic
 Pandemic
 The pattern of occurrence of disease
is on & off where:
On = available causative agent
Off = no available causative agent
 It’s intermittent (unpredictable) in
occurrence
 example: rabies, tetanus

 Epidemic
 Endemic
 Sporadic
 Pandemic
 the disease occurs worldwide,
international, universal, global in
occurrence like in AIDS, Hepatitis B,
PTB, measles, mumps, diphtheria,
pneumonia
 SARS is categorized by WHO as an
OUTBREAK only because out of 191
nations, only 33 countries are reported
to have it.

▪Epidemiologic Triad
▪Transmission
▪ Incubation period
▪ Herd immunity

▪ The triad consists of an external agent, a host and
an environment in which host and agent are brought
together, causing the disease to occur in the host.
▪ A vector is an organism which
transmits infection by
conveying the pathogen from
one host to another without
causing disease itself, may be
part of the infectious process.

Transmission
• in the traditional epidemiologic triad model, transmission
occurs when the agent leaves its reservoir or host
through a portal of exit
• is conveyed by a mode of transmission to enter through
an appropriate portal of entry to infect a susceptible host

1. Direct Transmission
▪ Direct contact refers to close contact that results in
exposure to skin and body secretions.
▪ Organisms can be transmitted from one part of a
person's body, such as their skin or an infected wound, to
another part of their own body or to another individual.
▪ direct contact: host-to-host
droplet spread from one host to another

1. Direct Transmission
▪ Some diseases that are transmissible by direct contact
include:
• Athlete's foot
• Impetigo
• Syphilis (on rare occasions, if an uninfected person
touches a chancre)
• Warts
• Conjunctivitis

2. Indirect Contact
▪ the transfer of an infectious agent from a reservoir to a
susceptible host by suspended air particles, inanimate
objects (vehicles or fomites), or animate intermediaries
(vectors)
▪ occurs when organisms from an infected host or other
reservoir are transmitted to a susceptible host via an
inanimate object or fomite

2. Indirect Contact
▪ in the hospital environment fomites which can become
contaminated and act as sources of infection include
medical equipment such as endoscopes, clothing,
bedding, dressings and sinks
▪ gastrointestinal pathogens such as Salmonella can be
transmitted in this way

3. Droplet Infection
▪ the transmission of infectious agents in droplets from
respiratory secretions by coughing, sneezing or talking, is
another form of contact transmission.
▪ Pathogens that are transmitted in this way are the cold
and influenza viruses and the bacteria responsible for
tuberculosis.

▪ Diseases that are commonly spread by coughing or
sneezing include:
◦ Bacterial Meningitis
◦ Chickenpox
◦ Common cold
◦ Influenza
◦ Mumps
◦ Strep throat
◦ Tuberculosis
◦ Measles
◦ Rubella
◦ Whooping cough 10/25/2018Mary Aretha D. Rocha 68

4. Oral Transmission
▪ diseases that are transmitted primarily by oral means
may be caught through direct oral contact such
as kissing, or by indirect contact such as by sharing a
drinking glass or a cigarette.
▪ diseases that are known to be transmissible by kissing
or by other direct or indirect oral contact :
✓Cytomegalovirus infections
✓Herpes simplex virus (especially HSV-1)
✓Infectious mononucleosis

5. Fecal-oral transmission
▪ Direct contact is rare in this route, for humans at least.
▪ More common are the indirect routes; foodstuffs or water
become contaminated (by people not washing their
hands before preparing food, or untreated sewage being
released into a drinking water supply) and the people
who eat and drink them become infected.

▪ In developing countries most sewage is discharged into the
environment or on cropland as of 2006
▪ even in developed countries there are periodic system
failures resulting in unsanitary sewer overflow
▪ This is the typical mode of transmission for the infectious
agents:
✓Cholera
✓Hepatitis A
✓Polio
✓Rotavirus
✓Salmonella
✓Parasites e.g. Ascaris lumbricoides

6. Sexual Transmission
▪ refers to any disease that can be caught during sexual
activity with another person, including vaginal or anal
sex or (less commonly) through oral sex.
▪ Transmission is either directly between surfaces in
contact during intercourse or from secretions (semen or
the fluid secreted by the excited female) which carry
infectious agents that get into the partner's blood stream
through tiny tears in the penis, vagina or rectum (this is a
more usual route for viruses).

 anal sex is considerably
more hazardous since
penis opens more tears in
the rectum than the
vagina, as the vagina is
more elastic and more
accommodating
 Some diseases
transmissible by the
sexual route include:
▪ HIV/AIDS
▪ Chlamydia
▪ Genital warts
▪ Gonorrhea
▪ Hepatitis B
▪ Syphilis
▪ Herpes
▪ Trichomoniasis

7. Oral sexual transmission
▪ Sexually Transmitted Diseases such as HIV and Hepatitis
B are thought to not normally be transmitted through
mouth-to-mouth contact, although it is possible to transmit
some STDs between the genitals and the mouth,
during oral sex.
▪ In the case of HIV this possibility has been established. It is
also responsible for the increased incidence of herpes
simplex virus 1 (which is usually responsible for oral
infections) in genital infections and the increased incidence
of the type 2 virus (more common genitally) in oral
infections.

8. Vertical transmission
▪ This is from mother to child, often in utero or
during childbirth (also referred to as perinatal infection). It
occurs more rarely via breast milk.
▪ Infectious diseases that can be transmitted in this way
include: HIV, Hepatitis B and Syphilis.

9. Iatrogenic transmission
▪ Transmission due to medical procedures, such
as injection or transplantation of infected material.
▪ Some diseases that can be transmitted iatrogenically
include:
▪ Creutzfeldt-Jakob Disease by injection of contaminated
human growth hormone.
▪ MRSA infection is often acquired as a result of a stay in
hospital

10. Vector-borne transmission
▪ A vector is an organism that does not cause disease itself
but that transmits infection by conveying pathogens from
one host to another.

▪ the period from the moment of exposure to an
infectious agent until signs and symptoms of
the disease appear

▪ also called as “Community Immunity”
▪ the principle of community immunity applies to control a
variety of contagious diseases, including influenza,
measles, mumps, rotavirus, and pneumococcal disease
▪ describes a form of immunity that occurs when the
vaccination of a significant portion of a population (or herd)
provides a measure of protection for individuals who have
not developed immunity

 proposes that, in contagious diseases that are transmitted
from individual to individual, chains of infection are likely to
be disrupted when large numbers of a population are
immune or less susceptible to the disease
 the greater the proportion of individuals who are resistant, the
smaller the probability that a susceptible individual will come
into contact with an infectious individual

▪ applies only to diseases that are contagious. *
 It does not apply to diseases such as tetanus (which is
infectious, but is not contagious), where the vaccine
protects only the vaccinated person from disease. Nor does
it apply to the IPV poliomyelitis vaccine that protects the
individual from viremia and paralytic polio but does not
prevent the fecal-oral spread of infection.

▪ herd immunity should not be confused with contact
immunity. *
▪ Contact immunity - wherein a vaccinated individual can
'pass on' the vaccine to another individual through contact.

Disease Transmission R0
Herd immunity
threshold
Diphtheria Saliva 6–7 85%
Measles Airborne 12–18 92–94%
Mumps Airborne droplet 4–7 75–86%
Pertussis Airborne droplet 12–17 92–94%
Polio Fecal-oral route 5–7 80–86%
Rubella Airborne droplet 5–7 80–85%
Smallpox Social contact 6–7 83–85%
^ - R0 is the basic reproduction number, or the average number of secondary infectious cases
that are produced by a single index case in completely susceptible population

 The proportion of immune individuals in a population above
which a disease may no longer persist is the herd immunity
threshold.
 Its value varies with the virulence of the disease, the efficacy
of the vaccine, and the contact parameter for the population.

 Team Organization
 Epidemiological Investigation
 Collection of Laboratory Specimens
 Treatment of Patients and Contacts
 Immunization Campaign
 Environmental Sanitation
 Health Education
 Involvement of Other Agencies
 Reporting

 Establish fact of presence of epidemic
 Establish time and space relationship of the
disease
 Relate to characteristics of the group in the
community
 Correlate all data obtained

 Establish fact of
presence of epidemic
 Establish time and space
relationship of the disease
 Relate to characteristics of
the group in the
community
 Verify diagnosis
 Reporting
 Is there an unusual
prevalence of the disease

 Establish fact of presence
of epidemic
relationship of the
disease
the group in the community
 Are the cases limited to or
concentrated in a particular
area?
 Relation of cases by days
of onset to onset of the first
known cases (usually done
in weeks)

of epidemic
 Relate to
characteristics of the
group in the community
 Relation of cases to age,
groups, sex, color,
occupation, school
attendance, past
immunization.
 Relation of sanitary facilities
 Relation to milk and food
supply
 Relation of cases to other
cases and known carriers if
any

of epidemic
the group in the community
 Correlate all data
obtained
 Summarize the data
 Draw final conclusion
 Establish source of
epidemic and the manner
of the spread
 Make suggestions as to
the control and
preventions of future
outbreaks

Thank You ☺

PHC 2 - Tools in Community Diagnosis

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