SESI 1_Pengantar Epidemiologi 2009 Final

7/27/2019 SESI 1_Pengantar Epidemiologi 2009 Final

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Epidemiologi

Departemen Epidemiologi

Fakultas Kesehatan Masyarakat Universitas Indonesia

1


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Definisi (1)

Tidak ada definisi tunggal

Epidemiologi

Dari bahasa Greek.

Epi= atas, pada,

demos= penduduk,

logi= studi

Studi distribusi dan determinan peristiwa

kesehatan dalam populasi manusia.

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Definisi (2)

Hirsch(1883)

Suatu gambaran kejadian, distribusi, dan tipe penyakit

manusia, ..

Frost (1927)

Ilmu fenomena masal penyakit infeksius, atau seperti

riwayat alamiah penyakit infeksius suatu ilmu induktif

yang tidak hanya mendeskripsikan distribusi penyakit,melainkan kesesuaiannya dalam suatu filosofi yang

konsisten

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Definisi (3)

Greenwood ( 1934)

Epidemiologi adalah studi penyakit sebagai

fenomena massal

Lilienfeld(1957)

Epidemiologi boleh didefinisikan sebagai studi

distribusi suatu penyakit atau kondisi dalampopulasi dan faktor yang mempengaruhi

distribusi ini

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Definisi (4)

Taylor (1963)

Studi kesehatan atau penyakit dalam populasi

McMahon, Pugh, dan Ipsen (1970)Studi distribusi dan determinan frekuensi

penyakit pada manusia distribusi (epidemiologi deskriptif) dan determinan dari

distribusi yang tercatat (epidemiologi analitik)

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Epidemiology Defined Greek roots

epi = upon (as in epidermis)demos = the people (as in demography)

ology = to speak of, to study

Literally - study of epidemics

Modern definitionsof epidemiologyrefer to

distributionsin populations (statistical)

determinants (pathophysiological, environmental,behavioral)

control of health problems(biological, social,

economic, political, administrative, legal)Gerstman Chapter 1 6


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Epidemiology compared

to medicineMain unit of concern in epi population

Main unit of concern in medicineindividual

public healthEpidemiologystudy of

Public healthorganized effort Epi said to be methodologic backbone of public

health

Gerstman Chapter 1 8


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Definisi (5) Suatu ilmu dasar dari kedokteran pencegahan dan

kesehatan masyarakat yang mempelajari:

Penyakit(atau status kesehatan)

Frekuensi(enumerasi jumlah yang ada atau tingkat

perkembangan dalam periode waktu spesifik)

Determinan(faktor yang mempengaruhi distribusi)

Metode(proses yang dilakukan untuk mendeskripsikanfrekuensi dan distribusi, rasional ilmiah yang digunakanuntuk menentukan kausal distribusi penyakit dalam

populasi

Populasi(populasi manusia tertentu) 9


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EpidemiologiIlmu dasar semua aspek

kesehatan masyarakat: (1)

Penyakit infeksi

Penyakit kronis

Cedera intensional dan tidak intensional

Kesehatan mental

Nutrisi

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EpidemiologiIlmu dasar semua aspek

kesehatan masyarakat: (2)

Pendidikan dan promosi kesehatan

Perencanaan kesehatan

Administrasi kesehatan masyarakat

Pelayanan pengobatan medis

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Ruang lingkup

Definisi penyakit

Kejadian penyakit

Penyebab penyakit

Keluaran penyakit

Pengelolaan penyakit dan pencegahanpenyakit

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Aktivitas epidemiologi (1)

1. Pengumpulan dan analisis pencatatan vital

(kelahiran dan kematian)

2. Pengumpulan dan analisis data morbiditas

dari rumah sakit, lembaga kesehatan, klinik,

dokter dan industri

3. Pemantauan penyakit dan masalah

kesehatan komunitas yang lain13


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Aktivitas epidemiologi (2)4. Investigasi kejadian luar biasa yang

mengarahkan program pemberantasan ataupencegahan epidemik dan masalah kesehatankomunitas yang lain

5. Merancang dan melaksanakan penelitiankesehatan

6. Merancang dan melaksanakan registrasikesehatan untuk masalah yang menjadiperhatian seperti: cacat lahir, insidens kanker,

atau penggunaan napza 14


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Aktivitas epidemiologi (3)7. Skrining (penapisan) untuk penyakit

8. Penilaian efektivitas keberadaan pengobatan

yang baru

9. Mendeskripsikan riwayat alamiah penyakit

10. Identifikasi individu atau kelompok padapopulasi umum terhadap peningkatan risiko

perkembangan penyakit tertentu

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11. Identifikasi keterkaitan etiologi penyakit

12. Identifikasi masalah kesehatan masyarakat

dan pengukuran besar distribusi,

frekuensi, atau dampak pada kesehatan

masyarakat

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13. Penilaian program kesehatan

14. Menyediakan data yang diperlukan untuk

perencanaan kesehatan atau pembuatan

keputusan oleh badan administrasi

kesehatan atau pembuat kebijakankesehatan

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Who is an epidemiologist ?

A professional who strives to studyandcontrolthe factors that influence the

occurrence of disease or health-relatedconditions and events in specified populationsand societies, has an experience in populationthinkingand epidemiologic methods, and is

knowledgeable about public healthand causalinferencein health(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)


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Epidemiologists are required to have someknowledge of:

Public health:because of the emphasis on disease prevention

Clinical medicine:because of the emphasis on disease classification and

diagnosis (numerators)

Pathophysiology:because of the need to understand basic biological

mechanisms in disease (natural history)

Biostatistics:because of the need to quantify disease frequency and its

relationships to antecedents (denominators, testing hypotheses)

Social sciences:because of the need to understand the social context in

which disease occurs and presents (social determinants of health

phenomena)


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1.4 Selected Historical Figuresand Events

Understanding medical history is animportant part of epidemiology

This section divided into three eras

400BC 1850

1850 - 1900

Twentieth century epi


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Gerstman Chapter 121

Historical Figures & Events

400BC 1850

Hippocrates (400BCE)

Age of enlightenment (17th& 18thcenturies)

John Graunt (1620 1674)

1850 -1900

John Snow (1813 1858)

Germ Theory (mid 19

th

century)

Twentieth century epi

Modern epidemiology


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Sejarah perkembangan epidemiologi

Ahli epidemiologi pertama

Hippocrates460377 SM

Ahli Epidemiologi yang pertama Menjelaskan terjadinya penyakit dari dasar yang

rasional

Buku yang ditulis: Epidemic I, Epidemic II, On Airs,

Waters, and Places Memperkenalkan istilah epidemicdan endemic

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The First Epidemiologists

Hippocrates 460 B. C. to 377 B.C.

attempted to explain disease

occurrence on a rational basis instead

of from a supernatural view point

Three major booksEpidemic I

Epidemic II

On Airs, Waters, and Places


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24

H ippocrates (1)

Recognized the association

of various diseases with

environmental factors

place

water conditions

climate

eating habits

housing


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25

Hippocrates (2)

Introduced

epidemic

endemic


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26

H ippocrates (3)

Theory about the cause of disease

personal observation

Greek thinking Disease is the imbalance of body

humors

phlegmblood

yellow bile, black bile


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Galen 129

199 M

Ahli bedah tentara romawi

Bapak Fisiologi Eksperimental

Faktor Prokatartik (cara hidup orang) dan temperamenmempengaruhi kesehatan dan penyakit

Pengaruh lingkungan (geografi dan iklim)miasma(istilah umum untuk partikel dalam udara)

Malariaudara buruk Teori miasma

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28

Galen (1)

129 - 199 A.D. Father of experimental physiology

Health and Disease influenced by

Procataritic factors

the way of life a person led

life style

Temperament

the innate qualities of the body

personality


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29

Galen (2)

Disease caused by Miasma

particles in the air

from sources waste

stagnant water

decaying animals

theory used to explain the great

plague epidemic in Europe


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Age of enlightenment (17th& 18thcenturies)

Thomas Sydenham (16241689)

Hippocrates InggrisBapak Epidemiologi

Atmosfer mengakibatkan perubahan konstitusiepidemik

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Thomas Sydenham (1)

1624 - 1689

Father of Epidemiologyinsisted that observationshould have

precedence over theory in the study

of the natural history of disease


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Demographic Approach(pp. 1214)

John Graunt (1620 1674)


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Sejarah perkembangan epidemiologiDEMOGR PHIC PPRO CH Kelahiran vital statistik

John Graunt

Analisis data mortalitas dalam tahun 1662

Melakukan kuantifikasi yang pertama dari pola

kelahiran, kematian dan kejadian penyakit

Mencatat perbedaan laki-laki dan perempuan,kematian bayi yang tinggi, perbedaan urban-

rural, dan variasi musiman


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Demographic Approach17thCentury Life Table

Age % surviving

6 64

16 40

26 25

36 16

46 10

56 6

60 3

76 1

80 0

John Graunt

(162074)


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Epidemiology (Schneider)

Life Table of Deaths in London

Age Deaths Survivors

0 -- 100

6 36 64

16 24 40

26 15 25

36 9 16

46 6 10

56 4 666 3 3

76 2 1

80 1 0Source: Graunts Observations1662


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Epidemiology (Schneider)

Graunts Observations

Excess of male births

High infant mortality

Seasonal variation in mortality


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37


Willian Farr

Melakukan pengumpulan data secara sistematik

dan statistik kematian di Inggris

Bapak Statistik vital moderen dan surveilens

Memperluas analisis data morbidtas dan

mortalitas epidemiologi

Melihat efek status perkawinan, pekerjaan danketinggian


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Sejarah perkembangan epidemiologiKonsep kontagion dan Teorigermpenyakit

Hieronymous Frascastorius (14781553) Sastrawan dan dokter dari Italia

Penyakit disebabkan oleh germ

Penyakit ditransmisikan dari orang ke orang melalui suatu

partikel yang sangat kecil

Igmatz Semmelweis (18181865)

Ahli Obstetri dari Hungaria

Demam nifas dapat direduksi jika para dokter mencuci tangan

sebelum menolong persalinan

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Downloaded from: StudentConsult (on 29 August 2009 12:10 AM)

2005 Elsevier


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Downloaded from: StudentConsult (on 29 August 2009 12:10 AM)

2005 Elsevier


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Edward Jenner Mendukung teori Fracastorius

Menerima teori germ penyakit

Penemu vaksin cacar (akhir tahun 1700)

Louis Pasteur Berkontribusi dalam menguatkan teori germ penyakit

dengan mendemonstrasikan efektivitas imunisasi padapencegahan rabies dalam tahun 1885

Belum mampu mengisolasi virus rabiesmenghalauteori miasma

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Studi epidemiologi klasik awalJames Lind

Melakukan studi epidemiologi ekperimen pada

etiologi dan pengobatan scurvy (1753) Makan jeruk merupakan obat untuk scurvy

P L Panum

Studi epidemiologi klasik tentang penyakit campak dipulau Faroe (1875)

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John Snow (18131858)

Ahli anestesi

Melakukan serial investigasi kolera di London

Bapak Epidemiologi Lapangan

Melakukan studi epidemik kolera (1854)

43

h d


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Snows Methods

Ecological studies compared cholera rates by region

Cohort compared cholera rates in exposed and

non-exposed individuals

Case-control compared water source in cases and

controls

Snows


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Snow s

Ecological

Analysis Southwark Water

Company

neighborhoods

high rates

Mixed service

intermediate rates

Lambeth Water Co.neighborhoods

no cases


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46

Deaths from Cholera per according to water company

supplying subdistricts of London, 1853-1854

Water Company Population in1851

Deaths fromCholera

Deaths rateper 100,000

living

Southwark and Vauxhall

Company

Lambeth Company

Both Company

167,654

14,632

301,149

192

0

182

114

0

60


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The Grand Experiment

A retrospective study

X

O

X


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48

Deaths from Cholera per 10,000 according to water company supplying

actual houses, London - 1854

Water Supply Number of

Houses

Deaths from

Cholera

Deaths in Each

10,000 Houses

Southwark and Vauxhall

Company

Lambeth Company

Rest of London

40,046

26,107

256,423

1,263

98

1,422

315

37

59

Source: Snow (55)


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Snows Cohort Study (Table 1.7, p. 25)

Cholera mortality per 10,000 household and water

source

Rate Southwark & Vauxhall= 1263 / 40,046

10,000 = 315 Rate Lambeth= 98 / 26107 10,000 = 37.5

Southwark & Vauxhall drew water from fecal

contaminated water region

Supporting evidence for water-borne transmissiontheory

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Snows Cohort AnalysesWater Source Cases Homes

Rate per

10,000

Southwark 1263 40,046 315*

Lambeth 98 26,107 37

Both 1422 256,423 59

* Rate, Southwark = 1263 / 40,046

= .0315 = 315 / 10,000


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Snows Case-Control Study

Epidemic area of Golden Square area (1854 epidemic) Interviewed cases and non-cases to determine water source

Cases

61 used water from Broad St. pump 6 did not use Broad St. pump

6 could not determine if used Broad St. pump

Controls were less likely to use Broad St. pump water

e.g., Among Brewer workers (non-cases), the men were allowed a

certain quantity of malt liquor, and Mr. Huggins [the proprietor]believes they do not drink water at all

Map showing proximity to pump and no. of cases (next slide)

51

Cholera Deaths

Broad St. Outbreak


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Snows Map (Fig 1.14)

Vis ali ation S ccess Stories


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54

Visualization Success Stories

From Visual Explanations by Edward Tufte,

Graphics Press, 1997

Illustration of John

Snows

deduction that a choleraepidemic

was caused by a bad

water pump, circa 1854.

Horizontal lines indicate

location of deaths.

John Snow: A Classic Epidemiologic


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55

John Snow: A Classic Epidemiologic

Study

The Father of field epidemiology

investigating the outbreak of cholera in Gloden Square of London

descriptive epidemology --> hypothesis generation --> hypothesis

testing ---> public health application

G S C O S


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Golden Square Cholera Outbreak: John Snow(2)

Theory

Hypothesis

Hypothesis

test

Public Health

Application

Action

Water was the source of

disease

Correlation of the

distribution of cholera case

households and the location

of water pumps

Removed the handle of the

pump in Broad Street

London Cholera Outbreak: John Snow (3)


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57

London Cholera Outbreak: John Snow(3)

TheoryHypothesis

Hypothesis

test

Public

Health

Application

ActionWater served as vehicle for

transmitting choler

based on time, place, and

person; compared groups

are comparable

changing the location ofwater intake to avoid water

contamination


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Studi epidemiologi klasik awal James Lind

Melakukan studi epidemiologi ekperimen

pada etiologi dan pengobatan scurvy (1753)Makan jeruk merupakan obat untuk scurvy

S j h k b id i l i


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S j h k b id i l i


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S j h k b id i l i


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S j h k b id i l i


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62


Goldberger (1923) Menggunakan studi epidemiologi

observasional dan eksperimen tentang

pellagra (defisiensi asam nikotinat)

J h G ldb (1874 1929)


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Joseph Goldberger (1874-1929)

used observational and experimentalepidemiologic methods to identifyvitamin deficiency as the cause ofpellagra;

identified diets high in cereals andcanned food as a risk factor; provedsources of fresh animal protein and

legums were effective in prevention;first nutritional epidemiologist.

S j h k b id i l i


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Hill, Doll, Wynder, Cornfield and other Post world warII epidemiologists. World War II is a convenientwatershed to mark the risk of the "modernepidemiologists", since this coincides with theemergence of chronic disease as major causes ofmorbidity and mortality;

focuses on individual risk factors; hallmarked bystudies on :

smoking and lung cancer, The SurgeonGeneral's Report on Smoking and Health,

the Framingham heart studies, water fluoridation trials, and

the poliomyelitis field trials of 1954.

Maturation of Epidemiology


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atu at o o p de o ogy(1910 - 1945)

Key methodologic developments include theadvancement of epidemiologic theory,

outbreak investigation methods,

methods to study non-infectiousdiseases (case-control and cohortmethods),

the introduction of randomized clinicaltrials, and new survey methods

developed by Goldberger in the study ofpellagra).

Also, changes in the education ofphysicians and health care took place inthe 1910s and 1920s, respectively

Last half of 20th Century


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y("Modern Epidemiology")

The epidemiologic transition from acutecontagious to chronic non-contagiouscauses of morbidity effected the wayepidemiologists studied disease

Illustrative examples

British Doctors Study (Doll & Hills studiesof the effects of smoking)

Framingham Heart Study (risk factors forheart disease, many investigators)


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Doll dan Hill (1950) Studi Merokok dan kaitannya dengan kanker paru dan studi penyakit

kardiovaskular pada penduduk Framingham, Massachusetts

(Dawber, Kannel, dan Lyell, 1963. Gordon, Castelli,Hjortland, Kannel, dan Dawber, 1977) Riset epidemiologi pada penyakit kronik

(Freedman, Chear, Srinivasan, Webber, dan Berenson, 1985)

Bogalusa Heart Study

(Stamler, Wentworth, dan Neaton, 1986) Multiple Risk Factor Intervention Trial


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Doll and Hill, 1952

Lung cancer

cases

Controls OR

Smoke 25+ per

day

331 (24%) 166 (12%) 17.4

Smoke 5-24 per

day

1019 (75%) 1130 (83%) 7.8

Non-smoker 7 (1%) 61 (5%) 1

Estimated 10-Year CHD Risk in55 Year Old Adults According to Levels of


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55-Year-Old Adults According to Levels of

Various Risk Factors Framingham Heart Study

A B C D

Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90

Total Cholesterol (mg/dL) 200 240 240 240

HDL Cholesterol (mg/dL) 50 50 40 40

Diabetes No No Yes Yes

Cigarettes No No No Yes

5

13

25

58

20

27

37

0

5

10

15

20

25

30

35

40

A B C D

Esti

mated10-YearRate(%

)

Men

Women

Estimated 10-Year Stroke Risk in 55-Year-Old Adults

A di l f V i Ri k F


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2.6 4

5.4

8.4

1.1 2

19.1

22.4

14.8

27

6.3

3.5

0

5

10

15

20

25

30

A B C D E F

Estimated10-YearRate

(%)

Men W omen

According to Levels of Various Risk FactorsFramingham Heart Study

A B C D E F

Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148Diabetes No No Yes Yes Yes Yes

Cigarettes No No No Yes Yes Yes

Prior Atrial Fib. No No No No Yes Yes

Prior CVD No No No No No Yes

Sou rce: Stro ke 1991;22:312-318. *BP in millimeters of mercury (mmHg)

22 4

27

25

30

(%)


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2.6 4

5.4

8.4

1.1 2

19.1

22.4

14.8

6.3

3.5

0

5

10

15

20

25

A B C D E F

Estimated10-YearRate

Men W omen

A B C D E F

Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148

Diabetes No No Yes Yes Yes Yes

Cigarettes No No No Yes Yes Yes

Prior Atrial Fib. No No No No Yes Yes

Prior CVD No No No No No Yes

Estimated 10-year stroke risk in 55-year-old adults

according to levels of various risk factors (FHS).Source: Wolf et al., Stroke.1991;22:312-318.

*BP in millimeters of mercury (mmHg)

Offspring CVD Risk by Parental CVDSt t F i h St d


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Status: Framingham Study

0

0,5

1

1,5

2

2,5

MEN WOMEN

NONE

MATERNAL

PATERNAL

Risk Ratio

2.5

2

1.5

1

0.5

0Men Women

1.0

1.7

2.2

1.0

1.7 1.7

Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI

Parental CVD


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Aplikasi

EpidemiologiAudit

Pelayanan

Kesehatan

Keluaran

dan

Prognosis

LingkunganGenetikLife styleRisikoPenyakit

Riset

Pelayanan

Kesehatan

EtiologiPenyakit

Kebutuhan

kesehatan

penduduk

EPIDEMIOLOGI


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Kontribusi epidemiologi (1)

Penyelidikan modus transmisi penyakit baru

Penentuan sebab-sebab penyakit yang dapat dicegah

Penentuan riwayat alamiah penyakit Pengamatan spektrum penyakit


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Kontribusi epidemiologi (2)

Penilaian intervensi kesehatan komunitas

Penyusunan prioritas pemberantasan penyakit

Perbaikan diagnosis, pengobatan dan prognosispenyakit klinis

Peningkatan riset pelayanan kesehatan

Penyediaan saksi ahli dalam pengadilan

History of Epidem iology


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y p gy

HIPPOCRATES (400 BC): On A irs, Waters, and

Places Hypothesized that disease might beassociated with the physical environment,including seasonal variation in illness.

JOHN GRAUNT (1662): Nature and Pol i t icalObservat ion s Made Upon the Bi l ls ofMortal i ty First to employ quantitativemethods in describing population vitalstatistics.

JOHN SNOW (1850): Formulated naturalepidemiological experiment to test thehypothesis that cholera was transmitted by

contaminated water.

Histo ry o f Epidem iology (cont .)


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Histo ry o f Epidem iology (cont .)

DOLL & HILL (1950): Used a case-controldesign to describe and test the associationbetween smoking and lung cancer.

FRANCES at al. (1950): Huge formal field trialof the Poliomyelitis vaccine in schoolchildren.

DAWBER et al. (1955): Used the cohortdesign to study risk factors forcardiovascular disease in the FraminghamHeart Study.

Brief History of Epidemiology


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Spring, 1999

Jan

Risser,

PhD

WillRisser,


Classical Infectious Diseases Epidemiology

Edward Jenner (1749-1823)

developed a vaccine against smallpox using cow pox

160 years before virus was identified

John Snow (1813-1858)

described the association between dirty water and cholera

44 years before vibrio was identified

Ignaz Semmelweis (1818-1865)

described the association between childbed fever andphysicians unclean hands

32 years before causal agent was discovered



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Spring, 1999

Jan

Risser,

PhD

WillRisser,


Classical Nutritional Epidemiology

James Lind (1716-1794) conducted an experiment which showed that scurvy could

be treated and prevented with limes, lemons, and oranges

ascorbic acid was discovered 175 years later

Joseph Goldberger (1874-1927)

identified that pellagra was not infectious but nutritional

in origin and could be prevented by increasing the amount

of animal products in the diet and substituting oatmeal for

corn grits niacin was discovered 10 years later



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Spring, 1999

Jan

Risser,

PhD

WillRisser,


Epidemiology of Chronic Diseases

Observational Studies:R Doll & AB Hill. Early case-control study. Smoking and

carcinoma of the lung: Preliminary report. [Br. Med. J. 2:739, 1950]

Cohort Studies:

An approach to longitudinal studies in a community: theFramingham study. 10,000 residents gave baseline

information. Follow-up is now 50 years. [Annals New YorkAcademy of Sciences 107:539;1963]



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Spring, 1999

Jan

Risser,

PhD

Will

Risser,



Experimental Studies:

Hypertension Detection and Follow-up Program Cooperative

Group. 10,500 subjects randomly assigned to two groups:

1. stepped care - antihypertensive therapy increased stepwise to achieve

and maintain blood pressure reduction to goal.

2. Referred care - subjects were referred to their primary care physician and

treated as usual.

mortality stepped care 9.0/100 referred care 9.7/100

final blood pressure 84.1 in stepped care 89.1 in referred care



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Spring, 1999

Jan

Risser,

PhD

Will

Risser,



Physician Health Study

randomized, placebo-controlled, double-blind clinical trial

conducted entirely through the mail

22,071 male physicians enrolled to study the effects of aspirin on

cardiovascular disease and the effects of beta-carotene on cancer randomly assigned to one of four groups

aspirin beta carotene

active active

active placebo

placebo active

placebo placebo


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ROOTS OF MODERN EPIDEMIOLOGY

1. ACUTE DISEASE INVESTIGATION

----- Emphasis on empirical systematic

investigation, biology, and

environment/host manipulation

2. MEDICINE

----- All early epidemiologists were

physicians.



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3. STATISTICS

----- Emphasis on the scientific method,

quantification and measurement,

and hypothesis testing. In 1960s, many

epidemiologists were statisticians.

4. SOCIAL SCIENCES

----- Investigation of human behavior in

relation to disease, and methods of

data collection (surveys, etc.)



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5. COMPUTER SCIENCES----- Emergence of chronic disease

epidemiology required the ability to

handle large amounts of data and to

perform complex analyses.

6. MANAGERIAL SCIENCES

----- Management principles for acquisitionof grants, research collaboration, and

management of clinical trials.



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7. GENOMICS----- 2001 marked first publication of

draft sequences of the human

genome. Intensive investigations beingconducted to identify disease

susceptibility genes gene-

environment interactions, and

gene-gene interactions.

Classical e s s Mode n


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Classical versus Modern

Applications

Classical:descriptive, observational, field,analytical, experimental, applied,

healthcare, primary care, hospital, CD,NCD,environmental, occupational,psycho-social, etc

Modern:risk-factor, molecular, genetic,life-course, CVD, nutritional, cancer,disaster, etc

SESI 1_Pengantar Epidemiologi 2009 Final

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Transcript of SESI 1_Pengantar Epidemiologi 2009 Final