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T torial

Tutorial
:Epidemiology
E id i l
and
d
Bi t ti ti for
Biostatistics
f NT
Dr. Chanon Kongkamol
Occupational Health Unit,
Community Medicine,
PSU

Epidemiology is the study of the distribution and


determinants of disease in populations.

(Mac Mahon & Pugh, 1970)

STEP I : 10 % = 30

1. Fundamental concepts
p of measurement
2. Fundamental concepts of study design
3. Fundamental concepts of hypothesis testing
and statistical inference

1.1 FFundamental
d
l concepts off MEASUREMENT

Scales of measurement
Distributions,
Di ib i centrall tendency,
d
variability, probability
Disease prevalence and
incidence
Disease outcomes
(eg.
Fatality rate)

Associations (eg. Correlation and


covariance)
Health impact (eg. Risk differences
and ratio)
py ((eg.g
Efficacyy of drugg therapy
Number needed to harm)
Sensitivity, specificity, predictive
values

2. Fundamental concepts of

st d design
study

Types of experimental studies (eg.


Clinical trials
trials, field trials,
trials
community intervention trials)
Type of observational studies (eg.
Cohort, case-control)
Sampling and sample size

Subject selection and exposure


allocation (eg.
(eg Randomization,
Randomization
systemic assignment)
Outcome assessment
Internal and external validity
Level of evidence

3.3 Fundamental concepts of

Hypothesis testing and statistical inference

Confidence
C fid interval
it l
Statistical significance and Type I error
Statistical power and Type II error

Part I :
Fundamental concepts of
MEASUREMENT
MEASUREMENT

1.1 FFundamental
d
l concepts off MEASUREMENT

1. Scales of measurement
2.2 Distributions,
Di t ib ti central
t l tendency,
t d
variability, probability
3. Disease prevalence and incidence
((eg.g
4. Disease outcomes
Fatality rate)

5. Associations (eg. Correlation and


covariance))
6. Health impact (eg. Risk differences and
ratio)
7. Efficacy of drug therapy (eg. Number
needed to harm)
8. Sensitivity, specificity, predictive values

QQ.11

Ratio
A.
B.
C.
D
D.
E.

A.
B.
C.
D
D.

E.


a)
b)
c))
d)
e)

a) Ratio
b) Nominal
N i l
c)) Ordinal
O di l / NNominal
i l
d) Nominal
e) Nominal

1.1 FFundamental
d
l concepts off MEASUREMENT
1. Scales of measurement
2.2 Distributions,
Distributions central tendency
tendency,
variability, probability
3. Disease prevalence and incidence
4. Disease outcomes
(eg.
Fatality rate)

5. Associations (eg. Correlation and


covariance))
6. Health impact (eg. Risk differences and
ratio)
7. Efficacy of drug therapy (eg. Number
needed to harm)
8. Sensitivity, specificity, predictive values

Q2.


M di = 180,
Median
180 Q1 = 150,
150 Q3=
Q3 200


Extreme
A.
B.
C.
D
D.
E.

A. 360
B. 340
C. 330
D 20
D.
E. 10
13

BOX Plot

180(150,200)
IQR = 200-150 = 50
Upper = Q3 + 1.5
1 5 IQR
= 200 +1.5*50 = 275
Lower = Q1- 1.5 IQR
= 150 - 1.5*50 = 75
Upper Outlier = Q3 + 3IQR
= 200 + 3(50) = 350
Lower Outlier = Q
Q1 - 3 IQR
Q
= 150 - 3 (50) = 0

350
275

75
0
15

Q3. Hct% 60


Gaussian distribution

A.
B
B.
C
C.
D.
E.

A .Median
B Mean
B.
M
C Median
C.
D. Mean
E. Mode

S.D.
SD
S.D.
Q1 Q3
Q1,Q3
Q1,Q3
Q1,Q3


Normal distribution
Mean + S.D.

1.1 FFundamental
d
l concepts off MEASUREMENT
1. Scales of measurement
2.2 Distributions,
Distributions central tendency
tendency,
variability, probability

3. Disease prevalence and


incidence
4. Disease outcomes
Fatality rate)

(eg.

5. Associations (eg. Correlation and


covariance))
6. Health impact (eg. Risk differences and
ratio)
7. Efficacy of drug therapy (eg. Number
needed to harm)
8. Sensitivity, specificity, predictive values

- 400,000
400 000
- 40 130,000
- 48 450 15
- 49 = 80 49
A.
B
B.
C.
D
D.
E.

80/ 400,000
80 / 130,000
130 000
450 / 130000
80 / (130000-450)
(130000 450)
80 / (130000-450-15)
(
)


Incidence = new cases / pop at risk
80 / (130000-450-15)

A. 35
1000
B.


20

1000
C. 50
1000
D
D.


35

100
E. 50
100



35 100
pop at risk

Incidence HIV

A.

AIDS

B
B.

HIV

C.

D.

AIDS

E
E.

HIV


HIV


???

60 1,000 DM 200

DM
50
incidence

A.
A
B.
C.
D.
E
E.

5%
6.25%
20%
25%
50%


Incidence = new cases / pop at risk
I = 50 / (1000 200 )
I = 6.25 %


1. 50 1000
2.
500 1000
3.3

250 1000

A.
B
B.
C.
D.
E.

> >
> >
> >
> >
> >

1.1 FFundamental
d
l concepts off MEASUREMENT
1. Scales of measurement
2.2 Distributions,
Distributions central tendency
tendency,
variability, probability
3. Disease prevalence and incidence

4. Disease outcomes
Fatality rate)

((eg
eg.g.

5. Associations (eg. Correlation and


covariance))
6. Health impact (eg. Risk differences and
ratio)
7. Efficacy of drug therapy (eg. Number
needed to harm)
8. Sensitivity, specificity, predictive values

4.0 //
0.2
case fatality rate
A.
B
B.
C.
D.
E.

0.005 %
0 05 %
0.05
5%
0.2 %
5


Case fatality
y rate is
The proportion of individuals
contracting
t ti a disease
di
who
h di
die off
that disease.
/
0.2

4
CFR = 0.2*100 / 4 = 5%

Jap. B encephalitis
- 500 serology
- 300

- 100
- 50
- 5
fatality rate

A. 5/50
B. 5/150
C 5/155
C.
D. 5/500


Case fatality rate is
The proportion of
individuals contracting a disease who die of that disease.
5

100
100+50+5
50 5
CFR = 5/155

Mortality rate
250/1000
50/1000

AA. Indirect adjusted rate

B. Direct adjusted rate 500


C.

5
D.
50


Indirect / SMR

Standard Mortality ratio = All dead


allll expected
t d dead
d d
SMR = 250/ 50 = 5

ER






A.
B.
C
C.
D
D.
E.

Odds Ratio
Relative risk
M
Mortality
li rate
Prevalence

Incidence


F Strength of Association
Case Control Study

Odds Ratio

1.1 FFundamental
d
l concepts off MEASUREMENT
Scales of measurement
Distributions,
Distributions central tendency
tendency,
variability, probability
Disease prevalence and incidence
Disease outcomes
(eg.
Fatality rate)

Associations
(eg Correlation and
(eg.
covariance)
Health impact (eg. Risk differences
and ratio)
Efficacy of drug therapy (eg. Number
needed to harm))
Sensitivity, specificity, predictive
values


...

Q :
%

39

A.
B.
C
C.
D
D.
E
E.

Row percent n(%)


Column percent n(%)
R percent
Row
Column percent

40

Bradford-Hill criteria
Strength
Consistency
Specificity
S
ifi it
Temporality
Biological gradient
Plausibility
Coherence
Experiment
E
i
t
Analogy

The strength
g of association
Same Question Answer
Same pop factor- disease
Exposure Disease
D
Dose-response
relationship
l ti
hi
Biological knowledge
Lab and epidemiologic study
p
confirmation
Experimental
Acommonly accepted phenomenon
in one area can be applied to
another area.

Systemic review A, B
causal association
A.
B.
C
C.
D.
E.

Temporality
Reversibility
Consistency
Dose-effect
Biological plausibility

microalbuminuria
HbA1C 7
HbA1C 7

Mentel Haensel OR

Crude OR 1.39
ORMH 1.22


A.
B.
C.
D.
E.

43

Crude
C d OR = 1.39
1 39
ORMH = 1.22
1 22
= ((1.38-1.22)) *100 / 1.38 = 12%

15 %

2 model

Case-control study :

Odds Ratio
(Crude)

95% CI

(Crude)

Odds Ratio
(
(Adjusted)
)

95%
CI
(Adjusted)
j

5.62

3.79-8.33

4.48

2.88-6.98

2-4

2 94
2.94

1 92-44.51
1.92
51

1 51
1.51

0 93-22.46
0.93
46

>4

4.43

2.26-8.68

1.86

0.89-.386


A
A.

2-4
B.
2-4

2 4

C. 2-4

D. 4

E.

46

AA.
B.
C.
D.
E.

Errors
Random errors
Neyman bias
Berkson bias
Confounder
47

S l ti bi
Selection
bias
Neyman bias
Berkson bias
Exposure suspicious bias
Detection signal bias
Non respondent bias
Susceptibility bias

II IInformation/Observation
II.
f
ti /Ob
ti Bi
Bias
Recall bias
Interviewer bias
Misclassification bias
Loss to follow up bias


cuff

A.
B.
C
C.
D.
E.

Bias
Confounder
Contamination
Co-intervention
Ethics

50

1.1 FFundamental
d
l concepts off MEASUREMENT

Scales of measurement
Distributions,
Di ib i centrall tendency,
d
variability, probability
Disease prevalence and
incidence
Disease outcomes
(eg.
Fatality rate)

Associations (eg. Correlation and


covariance)

Health impact (eg. Risk


diff
differences
andd ratio)
ti )
Efficacy of drug therapy (eg. Number
needed to harm)
Sensitivity, specificity, predictive values

case control study 1,000


600 control 2
400
A.
B.
C.
D.
E
E.

3
4
6
8
12

600

400

1000

400

1600

2000

1000

2000

3000

OR = (600*1600) / (400*400) = 6

Case

C control
t l study
td

Caffeine

NO
YES

YES
40
60

NO
200
100

240
160

100

300

400

OR

OR

A.
B.
C
C.
D.
E.

0.2
0.33
06
0.6
2
3

55

Case

C control
t l study
td

Caffeine

NO
YES

YES
40
60

NO
200
100

240
160

100

300

400

OR = (60*200) / (40*100) = 3

Cohort study

A 30,000
A
5
. 10,000
10 000

10

8

5 .
A.
B.
C.
D.
E.

2
2.5
3
5
7.5


RR = Ie/Io
RR = (10/10,000) / (8/20,000)
RR = 2.5
25

odds ratio = 23/207 incidence


exposed = 10% relative risk

A.
A
B.
C
C.
D.
E.

0.18
0
18
0.19
0 20
0.20
0.21
0.25

59
59

Method 1 : manual
OR = 23/207
D+

E+

230

E01
0.1

D-

2300-230
=2070
0.1

2300

0.2

RR=Ie / Io = (230/2300) / (0.1/0.2) = 0.1/0.5 = 0.2


60

http://www.physicsforums.com/showthread.php?t=3
9140
61

A. A 0.05
B. A 0.1
C
C.

Date


D. 5
E. 10

62
62

Strong Association

Exp 0.05, 0.1,1,5,10


Change to 20, 10,1,5,10
Ans: 0.05
0 05
63
63

1-5
Percent Attribution Risk Percent Population
Risk
malnutrition = 25 and 10 %

- Percent Attribution Risk = 25 %


- Percent Population Risk = 10 %
A
A.

1.5
1 5

B.

15

C.

25 %

D.

15%

E.

10 %

1.1 FFundamental
d
l concepts off MEASUREMENT
1. Scales of measurement
2.2 Distributions,
Distributions central tendency
tendency,
variability, probability
3. Disease prevalence and incidence
4. Disease outcomes
(eg.
Fatality rate)

5. Associations (eg. Correlation and


covariance)
6. Health impact (eg. Risk differences and
ratio)
7. Efficacy of drug therapy (eg
(eg..

Number needed to harm)

8. Sensitivity, specificity, predictive values


8
2

A.
B.
C.
D
D.
E.

4
6
10
17
25
67

Ie = 8%
Io = 2%
AR = (8-2) /100 = 6/100
NNH = 16.67 = 17

68

Vaccine X X

Vaccine

30,000
,

350

Vacc
Vaccinee

45,000
5,000

1200
00

A.
B
B.
C.
D.
E
E.

44.75
51 00
51.00
53.75
56.25
98 83
98.83

(Io-Iv) * 100
Io
((1200/45000) (350/30000)) *100) / (1200/45000)
56.25

1,500
1,500 250
300 Number need to treat
A.
A
B
B.
C.
D.
E
E.

10
20
30
40
50


AR = 300/1500 250/1500 = 50/1500
NNT =1/AR = 1500/50 = 30

relative risk XXX 0.80 incidence


XXX 4%/
number needed to treat

A 25
A.
B. 50
C. 75
D. 100
E. 125


NNT = 1/AR
AR = CER - EER

BUT
RR = Ie / Io
0.8 = 4 / x
X=5

AR = 4/100 5/100 =
1/100
NNT = 100/1 = 100

relative risk XXX 0.50 incidence


XXX Vaccine 1/1000/year

Vaccine
A 25
A.
B. 50
C. 75
D. 100
E. 125


RR = Ie / Io
0.5
0 5 = 0.001
0 001 / Io
I
Io = 0.002
Efficiency
Effi i
= (Io-Ie)*100
(I I )*100 / Io
I
)
/ 0.002
= ((0.002-0.001)*100
= 50 %

1.1 FFundamental
d
l concepts off MEASUREMENT
1. Scales of measurement
2.2 Distributions,
Distributions central tendency
tendency,
variability, probability
3. Disease prevalence and incidence
4. Disease outcomes
(eg.
Fatality rate)

5. Associations (eg. Correlation and


covariance)
6. Health impact (eg. Risk differences and
ratio)
7. Efficacy of drug therapy (eg. Number
needed to harm)

8. Sensitivity, specificity, predictive


values
l

General representation of a diagnostic test


Disease status
Test

Positive

Negative

Total

Positive

a+b

Negative

c +d

a + c

b + d

Total

We can give names to the four cells:


Test

Disease status

Name

True positive

False positive (b)

False negative (c)

True negative (d)

(a)

The quantities defined and discussed earlier are


S
Sensitivity
iti it

= a// ((a + c))

Specificity

= d/ (b + d)

Positive predictive value

= a/ (a + b)

Negative predictive value = d/ (c + d)

LR+ = Sn / (1
(1-Sp)
Sp)
LR- = (1 Sn) / Sp
Accuracy =

a+d

a + b+ c+ d

Bayes theorem
Bayes
PPV

NPV

sensitivity X prevalence
sensitivity
iti it X prevalence
l +( 1-specificity)X
1 ifi it )X (1
(1-prevalence)
l )
specificity X (1-prevalence)

= (1-sensitivity) X prevalence + specificity X (1-prevalence)

Interpretation of Kappa
K
<0
0 - 0.19
0.20- 0.39
0.40- 0.59
0 60- 0.79
0.600 79
0.80- 1.00

Interpretation
No agreement
Poor agreement
Fair agreement
Moderate agreement
Substantial agreement
Almost perfect agreement

Landis JR
JR, Koch GG
GG. Biometrics 1977; 33:159-174.
33:159 174

0
1-3
4-6
7-9
10-12
13 15
13-15

Sensitivity
100
96
90
88
65
52

Specificity
0
50
60
80
93
97


Sensitivi Specifici LR+
LR
LR
ty
ty Sn/1-SP 1-Sn / Sp

Prev

PPV

NPV

1 00
1.00

0 00
0.00

1 00
1.00

#DIV/0!

0 30
0.30

0 30
0.30

#DIV/0!

0<=3

0.96

0.50

1.92

0.08

0.30

0.45

29.52

4<=6

0.90

0.60

2.25

0.17

0.30

0.49

14.42

7<=9

0.88

0.80

4.40

0.15

0.30

0.65

16.12

10<=12

0.65

0.93

9.29

0.38

0.30

0.80

6.85

13<=15

0.52

0.97

17.33

0.49

0.30

0.88

5.39

PPV

((Goal standard))

37
10

48
55

85
65

47

103

150

PPV =

test test
PPV = 37/85

1000

250
50

100
600

350
650

300

700

1000

Specificity


Specificity =

(600*100)
100) / 700 = 86 %
Sp = (600


cut off -



sensitivity
sensitivity Specificity
Cost effective
B

2. Fundamental concepts of

st d design
study

Types of experimental studies (eg.


Clinical trials, field trials,
community intervention trials)
Type
T pe of observational
obser ational ststudies
dies (eg
(eg.
Cohort, case-control)
Sampling and sample size

Subject selection and exposure


allocation (eg.
(eg Randomization,
Randomization
systemic assignment)
Outcome assessment
Internal and external validity
Level of evidence

1.

Type
yp of Studies

2. +
3. Intervention

Case-control Study
disease
Observed
cause

Experimental Study
observed
assigned
disease
exposure

Retrospective cohort Study


observed
cause
di
disease

Prospective Cohort Study


observed
natural
di
disease
exposure

XXX YYY

incidence
YYY ZZZ

XXX

A.
B.
C.
D.
E.

Case-control studyy
Cohort study
Experimental study
Cross-sectional studyy
Descriptive study

1.
2. +
3. Intervention

Cohort study

Observational
Prospective Analytic study

Prospective Cohort Study


observed
natural
disease
p
exposure

Hep.
H A

A incidence Hepp A

A.
B.
C.
D
D.
E.

Cross-sectional study
y
Cohort study
Case control study
Meta analysis
Meta-analysis
Clinical trials



exposure disease
Retro cohort

1
AA.
B
B.
C.
D.
E.

clinical
li i l trials
il
Cohort study
Case series
Case control study
Cross sectional study



N
For causation Case Control

clinical trial

AA.
B.
C.
D.
E.


100%


Randomized
comparable

A

Cli i l ttrials
Clinical
i l phase
h
A.
A
B
B.
C.
D.
E
E.

Preclinical
P
li i l
Phase 0
Phase 1
Phase 2
Ph
Phase
3
100

Phases of Clinical Trial


Pre-clinical :

studies and trials on animal populations

Phase 0
:
human microdosing studies =
pharmacokinetics + pharmacodynamics
Phase I

a small (20-80) group of healthy

volunteers will be selected for safety


Phase II

on larger groups (20-300) = how well the


drug works, safety assessments

Phase III

RCT multicenter trials on large patient


groups

Phase IV

Post Marketing Surveillance Trial

st d design
study

2. Fundamental concepts of

Types of experimental studies (eg.


Clinical trials, field trials,
community intervention trials)
Type
T pe of observational
obser ational ststudies
dies (eg
(eg.
Cohort, case-control)

Sampling and sample size

Subject selection and exposure


allocation (eg
(eg. Randomization,
Randomization
systemic assignment)
Outcome assessment
Internal and external validity
Level of evidence

.


1000
100 10


10

100

A.
B.
C.
D
D.
E
E.

Cluster sampling
Simple random sampling
Systematic random sampling
St tifi d random
Stratified
d sampling
li
Purposive sampling


Systematic random sampling


120

350

A.
B.
C.
D.
E.

Cluster sampling
Accidental sampling
p g
Purposive sampling
Stratified random sampling
Systematic random sampling


Systematic random sampling

A.
B.
C.
D.
E.

Cluster sampling
Simple random sampling
Stratified sampling
Multi-stage sampling
Systemic sampling


Multi-stage sampling

st d design
study

2. Fundamental concepts of

Types of experimental studies (eg.


Clinical trials, field trials,
community intervention trials)
Type
T pe of observational
obser ational ststudies
dies (eg
(eg.
Cohort, case-control)
Sampling and sample size

Subject selection and exposure


allocation (eg. Randomization,
systemic assignment)
Outcome assessment

Internal and external


validity
Level of evidence


A.
A
B.
C.
D.
E
E.

Sampling technique
Allocation
Internal Validity
S
Statistical
Analyses
Ethics
110

Internal validity


External validity

2. Fundamental concepts of

st d design
study

Types of experimental studies (eg.


Clinical trials, field trials,
community intervention trials)
Type
T pe of observational
obser ational ststudies
dies (eg.
(eg
Cohort, case-control)
Sampling and sample size

Subject selection and exposure


allocation ((eg.g Randomization,,
systemic assignment)
Outcome assessment
Internal and external validity

Level of evidence

L l off evidence
Level
id
A

Meta-analyses, Systematic reviews best RCTs

Systematic reviews CTs, not well RCT but strong

Systematic reviews descriptive studies, not well RCT/CT

consensus

L l off recommendation
Level
d ti
1

L l off recommendation
Level
d ti
1A

1B

1C

L l off recommendation
Level
d ti
0A

0B

0C

3.3 Fundamental concepts of

Hypothesis testing and statistical inference

Confidence
C fid interval
it l
Statistical significance and Type I error
Statistical power and Type II error

Basic Biostatistics

Point estimation
OR = 3,
3 Diff = 10

Confidence interval
OR(95% CI) = 0.5 -10
10
Diff (95% CI) = 1 - 20

P-value = 0.08
P-value = 0.04

Point & CI

odds ratio



A.
B.
C
C.
D.
E.

0.5
1
5
100



Point
P i t estimation
ti ti

Confidence interval or P-value

2.5
95% CI = 0.9 6.2
A.
B.
C
C.
D.
E.

Sensitivity diagnostic tests

A.
B.
C
C.
D.
E.

Chis square
T-test
Normal distribution
Binomial
ANOVA

Binomial
Bayer's
Bayer s law
P(B/A)
(
) = P(Bi)P(A/Bi)
( ) (
)
P(A)


84
95 % CI = 79-87
99 % CI = 78
78-88
88
10,000
78-88
A.
A
B
B.
C.
D.
E
E.

9900
9500
500
100
99

Prevalence of HBsAg
g

A.
B.
C
C.
D.
E.

Chi-square
Student t-test
Analysis of variance
Paired t-test
Linear regression



Proportion
P
ti ttestt
Chi-square
q

A.
B.
C
C.
D.
E.

Regression
Correlation
Anova
Student t-test
Chi-square

Predict Regression
= correlation

= 1.25 + 0.8()


90 3

A.
B
B.
C
C.
D.
E.

Z-test
Tt t
T-test
Anova
Chi-square
Multiple regression


Repeated ANOVA

T pe I & II Errors
Type

Type I error =
Type II error =


Type
I error =5, Type II error = 20
Ho

error
A.
B
B.
C.
D.
E.

5
10
15
20
25


Ho
..



=== Type II error
20

4/1000
P-value = 0.9
09
ppower = 93%

A.
A
B.
C.
D
D.
E
E.

Type I error = 0.07


0 07
Type II error = 0.07
Type I error = 0.1
T
Type
II error = 0.1
01
Type I error = 0.9
09



Power 1- Beta
1-0.93
0.07


50

(
)



()
Type II error

A.
B.
C
C.
D.
E.

P < 0.05
0 05
P < 0.01
0 01
P < 0.05 P < 0.10


??

case control
t l
aspirin
i i

MI OR = 0.7 (95 % CI = 0.3 -1.3)

1.3)

2 95% confidence interval


A.
A
B.
C.
D.
E
E.

0.3
0
3 1.3
13
0.3 - 0.7
0.5 - 0.9
0.1 - 1.1
1 3 - 2.9
1.3
29





OR = 0.7
0 7 95 % CI = 0.3
0 3 -1.3
13
sample
p size 95 % CI

95 % CI = 0.5 - 0.9

1.
2.
3.
4
4.
5
5.

143

1.
2.
3.
4.
5.

(Cholera)

12.
(Typhus)

(Plague)
13.
((Variola Smallpox)
p )
14.
(Yellow fever)
15.
((Meningococcal
g
16.
Meningitis)
17.
6. (Diphtheria)
7 (Tetanus
7.
(T t
18.
neonatorum)
8
8.
(Poliomyelitis)
9. (Influenza)

10. (Encephalitis)
11. (Rabies)

(Tuberculosis)
((Anthrax))
(Trichinosis)
((Yaws))

(Acute flaccid
paralysis)
(
p
y
Severs Acte Respiratory
Syndome)

144

24
.. 2551
1. SARS
meningitis

7
7.


2. Cholera
8. Encephalitis
p
3. Acte Severely ill or 9. -AFP
death of unknown 10.
10


etiology)

4 Cluster
4.
Cl t off diseases
di

with unknown
11
11.
etiology
12.
5 Anthrax
5.
145
6. Meningococca


1 .. 2551
1.
2 Influenza
2.
Infl en a
3.
4.
5
5.
(Hand food Mouth

Diseases)
6. Leptospirosis
6
L
i i
( y
y)
7. (Dysentery)
8. .
9
9.

146

1.
2
2.

3.
y
y
4.


5
5.

6.
7.
y

147

WHO Pandemic Phase

148

WHO Pandemic Phase


Stage 1 : Ind. Animal
Stage 2 : Among Animals.
Stage 3 : Few to human
Stage 4 : Local Among human

Stage 5 : Regional among


human

Stage 6 : Global

Epidemiology

E id i l SSurveillance
ill


Epidemiology
E id i l SSurveillance
ill
Target

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