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EPIDEMIOLOGY

What is epidemiology?
o Epidemiology is often called the science of public health
Main impact is on the community, vs clinical medicine which is on the individual patients
o The study of the distribution and determinants of disease risk in human populations (demos)
The 4 Ds.
Patterns and trends are seen, not unpredictable
o The study of the frequency of occurrence of disease and why it happens.
o Study: surveillance, observation, hypothesis testing, analytic research, and experiments
o Distribution: analysis by time, place, and person
o Determinants: physical, biological, social, cultural, and behavioral factors that influence health
o Health-related states or events: diseases, causes of death, behavior, reactions to preventive
regimens, and provision and use of health
o Morbidity- looking at disease prevention
o Mortality- prevention of bad outcomes
o Integral part of basic description of a disease like the clinical findings and pathology
Determinants of a differential diagnosis:
- Likelihood
- Severity of untreated outcome
- Treatability
o Diverse range of health conditions
o Impact that various exposures have on the manifestation of disease
o Central concern of epidemiology: the maintenance of health through the prevention of the
occurrence of disease and prompt treatment of the disease in people who already have the disease
What do epidemiologists do?
o Epidemiologists come from a variety of backgrounds and specialize in many types of health
research
o Epidemiologists study an unlimited number of conditions that influence health from academic,
governmental and private industry positions
o Within academic institutions, research topics include:
Infectious disease
Chronic diseases
Cancer
Reproductive and perinatal epidemiology
Cardiovascular disease
Occupational epidemiology
Environmental epidemiology
Clinical epidemiology
Genetics
Pharmacoepidemiology
- How drugs are beings used
o Within government institutions, research topics include:
Health services research
Health outcomes research
Health technology assessment
Health economics
Health policy formulation and implementation
- 10-90 gap: 90% of people with the disease do not have access to treatment of the disease,
inequity
o Within specific institutions, epidemiologic investigations include:
Sports Medicine
Space Medicine
Trauma and other injuries
Toxicology
o In addition to research, the government maintains departments of health that perform surveillance
and prevention work and conducts health research and investigation a agencies affiliated with the
Public Health Service
What are the uses of epidemiology?
o Determining the natural history of the disease

discovering the agent, host and environmental factors which affect health in order to provide
the scientific basis for the prevention of disease and injury and the promotion of health
o Evaluation of determinants to disease
Includes patterns of disease distribution
Investigation of nature of associations or relationships between disease and determinants
- Risk factor disease promoter
Not necessarily a cause
- Protective factor disease prevention

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Determining the relative importance of causes of illness, disability and death, in order to establish
priorities for research and action
o Identify those sections of the population which have the greatest risk from specific causes of ill
health, in order that the indicated action may be directed appropriately
o Evaluating effectiveness of health programs and services in improving the health of the population
o Providing evidence-based guides to the management of patients in whom disease has already
developed (Clinical Epidemiology)
o Clinical Epidemiology
Diagnostic testing
Screening populations at risk
Testing new treatments
Searching for prognostic factors
5 determinants to Clinical Outcome (Of recovery, chronicity, disability or death; and due to some
combination of all the foregoing)
o The illness (due to a specific disease and of a specific severity and prognosis)
o Diagnostic tests (of varying accuracy and utility)
o Potential treatments (of varying efficacy and toxicity)
o Clinical performance (competence + motivation - barriers)
Clinical competence
- Do you have the knowledge and skills to do it correctly?
Motivation
- Do you want to do it correctly
Barriers
- Will circumstances permit you to do it correctly
o Patient compliance (With Rx and advice of varying degree and cadence)
Success stories of Epidemiology: Smoking and Lung Cancer
o Establish direct, consistent, strong, specific, temporally appropriate and coherent relationship
between smoking and lung cancer
o Result to series of public health efforts to control tobacco use
o Policy changes
Advertising restrictions, clean indoor air policies
o Clinical interventions
Physician advice to patients for smoking cessation
o Smoking prevention programs in organizational settings
Curricula in schools that focus on effective prevention strategies
Modern Challenges and Opportunities in Epidemiology
o Applying advances from molecular biology
o Moving beyond risk factor epidemiology to affect change
o Measuring and communicating weak associations
o Measuring outcomes and quality of health care
o Setting priorities and measuring progress
o Investigating public health outbreaks
o Preventing chronic diseases and other modern epidemics
o Measuring the effects of community-level risk and interventions
o Informing public health policies
o Increasing epidemiologic capacity in applied settings
Priority Areas in Healthy People in 2010
o Millennium goals
o Access to quality health services
o Arthritis, osteoporosis, and chronic back conditions
o Cancer
o Chronic kidney disease
o Diabetes
o Disability and secondary conditions
o Educational and community-based programs
o Environmental health
o Family Planning
o Food safety
o Health communication
o Heart disease and stroke
o HIV
o Immunizations and infectious diseases
o Injury and violence prevention
o Maternal, infant and child health
o Medical product safety
o Mental health and mental disorders
o Nutrition and weight
o Occupational safety and health

o Oral health
o Physical activity and fitness
o Public health infrastructure
o Respiratory diseases
o Sexually transmitted diseases
o Substance abuse
o Tobacco use
o Vision and hearing
Descriptive Epidemiology
o Patterns of disease distribution
Person
- Age, sex, ethnic group, race, social class, occupation, marital status, family variables,
other personal variables
- Family variables family size, birth order, maternal age and parental deprivation
- Other personal variables blood type, environmental exposures and personality traits
Place
- Natural boundaries
- Political subdivision
- Mapping of environmental factors (GIS)
- Urban-rural differences
- International comparisons
- Study of migrants
Time
- Secular trends refers to changes over a long period of time, years or decades
- Cyclic changes refers to recurrent alterations in the frequency of disease
Seasonal
Other periodicity year cycles
What is health?
o Elastic Concept of Health
Defined either as absence of disease and disability or be given a positive meaning:
o WHO definition
State of complete physical, mental and social well-being and not merely the absence of
disease or infirmity
o Health is not the absence of disease but rather the process by which individuals maintain their
sense of coherence (ie. That life is comprehensible, manageable, and meaningful) and ability to
function in the face of changes in themselves and their relationships with their environment
Aaron Antonovsky
Disease Concepts:
o Multiple Causation of Multifactorial Etiology
Epidemiologic Triangle: host-agent-environment interaction
- All given equal importance
The Wheel: host with genetic core as center of disease
The Web: interconnecting chains of causation
o Host factors
Responsible for the degree to which the individual is able to adapt to the stressors produced
by the agent
- Host resistance
- Persons genotype
- Nutrition status and body mass index
- Immune system
- Social behavior/social class membership
- Personality
o Environmental factors
3 major types of environment
- Biological environment
- Social environment
- Physical environment
- Each of these factors interact with each other
Biologic environment
- Infectious agents of disease
- Reservoirs of infection: other human beings, animals and soil
- Vectors that transmit the disease
- Plants and animals
Social Environment
- The overall economic and political organization of a society by which individuals are
integrated into the society at various stages in their lives
- Social customs
- General level of receptivity to new (health-related) ideas

- Extent of social integration

Physical Environment
- Heat/cold
- Light
- Air
- Water
- Kinetic energy
- Radiation
- Gravity
- Atmospheric pressure
- Chemical agents
- Noise
Agent factors
Biologic agents
Chemical agents
Physical agents
Social and psychological stressors
Epidemiologic Triangle

Epidemiologic Triad

The Web of Causation

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The Wheel

Risk Factors for Disease: BEINGS Model

o Biologic factors and Behavioral factors
o Environmental factors
o Immunological factors
o Nutritional factors
o Genetic factors
o Services, Social factors, and Spiritual factors

Natural History of the Disease

Stages of the disease
o Stage of Susceptibility
o Pre-Symptomatic Stage
o Stage of Clinical Disease
o Stage of Disability or Recovery

Tissue Changes
o Pre-pathogenesis
o Pathogenesis
o Resolution or Sequelae
Levels of Prevention
o Primary Prevention
o Secondary Prevention
o Tertiary Prevention
Modes of Intervention
o Health Promotion and Specific Protection
o Detection, Early Diagnosis and Prompt Treatment
o Treatment and Rehabilitation, Limitation of Disability

Methods of Primary Prevention

General Health Promotion
o Most fundamental sources of health:
Adequate nutrition
Safe environment
Prudent behavior
o Nutritional factors
Overnutrition (Obesity)
- Sedentary lifestyle
- Energy-dense, nutrient dilute food
- Increased risk for cardiovascular diseases
Undernutrition
- Cultural factors
- Political factors preventing fair distribution of resources
- Increased risk for infections due to lowered immunity

Environmental and occupational factors

Major Sources of Environmental Hazard
- Air Pollution

Types of Air Pollutants

Particulate matter
Metal fumes
Gases
Dusts
Ozone
Environmental tobacco smoke: most common and most serious indoor air
pollutant
- Water pollution
- Solid wastes
- Electromagnetic radiation
- Contaminated food
o Behavioral factors
Counseling of women before and during pregnancy
Counseling of parents
Counseling of patients with risk factors
Counseling of patients addicted to substance abuse
o Societys Contribution to Health
Opportunities for safe employment
Control of environmental systems (water supply and sewage disposal)
Regulation of environment, commerce and public safety
Sustain social support systems such as families, neighbors and houses of worship
Specific Protection
o Major goals of primary prevention by specific protection
Prevention of specific diseases (using vaccines and antimicrobial prophylaxis)
Prevention of specific deficiency states (iodized salt and fluoridation of water)
Prevention of specific injury and toxic exposures (helmets, goggles, filters and ventilation
systems)
o Prevention of iatrogenic diseases and injuries
Nosocomial infections
Medical errors
Unnecessary surgery
Surgical and medical errors
o Prevention of Diseases by Use of Vaccines
Intact immune system in health well-nourished individual provides basic protection
Intact immunity implies normal immune system at birth and has not suffered damage from:
- Any disease (infection with HIV)
- Any medications (cancer chemotherapy, steroids)
Types of Immunity
- Passive immunity
Protection against an infectious disease provided by circulating antibodies
Maternal antibodies
Administration of human immune globulin
Anti-toxin
- Active immunity
Stimulation of the production of antibodies within the body by an exogenously
administered substance
Stimulation of either humoral (blood) antibody or cell-mediated immunity
Provides both individual immunity and herd immunity
Far superior to passive immunity because:
It lasts longer (lifetime in some cases)
Rapidly stimulated to high levels by a re-exposure to the same or closely related
antigens
Types of Vaccines
- Inactivated (killed) organisms
Older pertussis and typhoid vaccines
- Live attenuated (altered)
Injectable Influenza and polio vaccines
- Toxoids (inactivated or altered bacterial exotoxins)
Bacillus Calmette-Guerin (BCG), oral polio, measles
Immunization Goals
- Eradication of disease
Small pox eradication
- Regional elimination of disease
Control of poliomyelitis in Western Hemisphere
- Control of disease to reduce morbidity and mortality
Reduction in cases of measles and chickenpox
Immunization Schedules

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- Infant (Expanded Programme of Immunization) (DOH and CDC sites)
- Early Childhood
- Teenagers and young adults
- Adults to elderly
o Protection Using Antimicrobials
Prophylaxis therapy
- Presurgical prophylaxis
- Antivirals for influenza for exposed persons
- Penicillin for rheumatic fever patients
- INH for 9-12 months for recent converters for TB
Ceftriaxone for syphilis or gonorrhea
- Rifampicin for meningococcal exposures
o Prevention of Deficiency states
Vitamin and mineral supplementation of food
- Vit. B and Folic acid in cereals
- Vit. A and D in milk products
- Iodine in salt
- Vit. A and Iron in noodles and snack foods (Sangkap Pinoy)
- Fluoridation of water
o Prevention of Injuries and Toxic Exposures
Food regulation agencies (BFAD, FDA, Bureau of Agriculture and Bureau of Fisheries)
Government laws protecting land, sea and air transportation (speed limits, helmets, maximum
limits of air time or driving time)
Local regulations regarding building codes (ramps for the elderly, toxic fumes and fire
alarms)
Occupational Safety and Health Administration (OSHA)
- Chemical safety
Safe storage and positioning of chemicals
- Biological safety
Immunization of workers and biologic hoods
- Physical safety
Protection against harmful levels of noise, heat, repetitive injuries
Methods of Secondary Prevention
Outline
o Early detection
Screening
Case Finding
o Prompt treatment
Screening in Secondary Prevention
o Process of identifying a subgroup of people in whom there is a high probability of finding
asymptomatic disease or a risk factor for developing a disease or becoming injured
o Usually occurs in a community setting
o Minimum requirements:
Disease requirements
Screening test requirements
Health care system requirements
o Not intended to be diagnostic will require confirmatory tests for diagnostics
o May be virtually diagnostic if results are so clearly abnormal (pre-test probability of disease is
>90%)
Case Finding in Secondary Prevention
o The process of searching for asymptomatic diseases and risk factors among people in a clinical
setting (under medical care)
o The process of identifying a disease in patients presenting with signs and symptoms under medical
care
Disease Requirements for Screening in the Community
o The disease is serious
o Effective treatment exists
o Natural history of disease is well understood
o Disease occurs frequently
o Other diseases or conditions may be detected
Screening Test Requirements for Screening in the Community
o Quick to perform
o Easy to administer
o Inexpensive
o Safe
o Acceptable to participants
o Sensitivity, specificity and other operating characteristics of the test are acceptable
Health Care System Requirements for Screening in the Community

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o
o
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Follow-up must be available for those who test positive

Before undertaken, treatment should already be available
Individuals screened and diagnosed as positive for disease must have access to treatment
Treatment should be acceptable to those screened
Population to be screened should be clearly identified
Clarification of issues to include:
Who is responsible for the screening
What cutoff points are to be used for defining a positive test result
How the findings will become part of a participants medical record at his usual place of care
(ie. HIV and drug abuse and other conditions that may result in stigma)
Objectives of Screening Program
Target
Objective
Example
Disease
`Treatment to reduce mortality
Cancer
Disease
Treatment to prevent complications
Hypertension
Disease
Treatment to eradicate infection and
Gonorrhea, syphilis or TB
prevent its spread
Disease
Change in diet and lifestyle
Coronary artery disease or DM type 2
Behavioral
Change in lifestyle
Cigarette smoking or unsafe sexual
risk factor
practices
Environmental Change in occupation
COPD form work
risk factor
Metabolic risk Treatment or change in diet and
Elevated serum cholesterol levels
factors
lifestyle
Test Operating Characteristics
o Validity closeness to true state (disease vs. non-disease)
Sensitivity
Specificity
Positive Predictive value
Negative Predictive Value
o Reliability (Precision)
o Yield the amount of previously unrecognized disease that is diagnosed and brought to treatment
due to screening
Test validity Characteristics
o Sensitivity the proportion of patients with the disease who test positive
o Specificity the proportion of patients without the disease who test negative
o Positive Predictive Value the proportion of test-positive patients who truly have the disease
o Negative Predictive value the proportion of test negative patients who truly are disease-free
Derivation of Test Characteristics
Gold Standard
Diagnostic Test (+)
(-)
(+)
a
B
(-)
c
D
o A true positive
o B false positive
o C false negative
o D true negative
Sensitivity:
o a/a+c
Specificity:
o d/b+d
Positive Predictive Value:
o a/a+b
Negative Predictive Value
o d/c+d
When patient comes to see you: sensitivity and specificity
When they come back with the result: positive, negative predictive value
SPin High specificity, rule in disease
SNout High sensitivity, rule out disease
Likelihood ratio for a positive test result (LR+) the probability of a positive test result for a person
with the disease divided by the probability of a positive test result for a person without the disease
Likelihood ratio for a negative test result (LR-) the probability of a negative test result for a person
with the disease divided by the probability of a negative test result for a person without the disease
Nomogram

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o >80% or <20% prior probability, no need to take diagnostic test
o Ex. Only in children will UTZ for appendectomy be required
o Likelihood ratio of a positive test will always be whole numbers
o Likelihood ratio of a negative test will always be decimals
o Posterior probability >90, definite treatment
Receiver Operating Characteristic (ROC) Curve
o Used for tests that produce results along a continuous scale of measurement
o There are many options about where to set the cutoff point between a positive and a negative test
result resulting in varying sensitivity and specificity
o The area under the curve serves as an overall measure of test performance

o
Screening
o Refers to the use of tests to detect the presence of a disease at an earlier time that it hould be
detected through routine methods
o The presumptive identification of unrecognized disease or defect by the application of tests,
examinations or other procedures which can be applied rapidly to sort out apparently well persons
who probably have a disease from those who probably do not
o A screening test is not intended to be diagnostic
o Persons found positive in a screening test will need to undergo a confirmatory test
o Distorting effects:

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Lead-time bias
Length-biased sampling
Patient self-selection bias
Lead-Time Bias
The interval between the time a condition is detected through screening and the time it would
normally have been detected by the reporting of symptoms or signs
Screening test detects cases in which the disease occurs earlier in the clinical course therefore
survival time may appear to be longer, even though the time of death is the same as if no
screening has occurred

Length-Biased sampling
Occurs when the screening test preferentially detects slowly progressive disease that is less
likely to cause death or may result in a delayed death
Slow-growing cancers vs. fast aggressive cancers
o Patient Self-Selection bias
Volunteers who choose to participate in early detection programs may differ from those who
do not in characteristics that may be related to survival
Participants may generally have better healthy living practices making them more healthconscious and more compliant. With prescribed preventive regimen
Methods of Tertiary Prevention
Disability limitation goal of halting the progress of the disease or limiting the damage caused by an
injury (prevention of further impairment)
Rehabilitation focuses on reducing the social disability produced by a given level of impairment by
strengthening the patients remaining functions
Levels of Intervention

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Public Health Framework for a Scientific Approach to Prevention
Tools and Processes
What is the problem?
Public Health Surveillance
What is the cause?
Etiologic Research
What is a solution?
Intervention Research/ Policy change/ Evidence Reviews
How do you do it?
Program Planning
Did it work?
Process & Outcome Evaluation

Surveillance
o Definition: The process that is used to collect, manage, analyze, interpret and report reliable
information about the status of those diseases or their antecedents in populations
o Surveillance systems: Networks of people and activities that maintain the process and may
function at local to international levels
o Locally- surveillance may provide the basis for identifying people who need treatment,
prophylaxis or education
o More broadly, surveillance can:
Inform the management of public health programs
Inform the direction of public health policy
Uses of Surveillance Information
o Primary objectives:
To monitor the incidence or prevalence of specific health problems
Document their effect in defined populations
Characterize affected people and those at greatest risk
Objectives of Surveillance
o Descriptive epidemiology (person, place, time) of health problems (for needs assessment)
o Links to service provides aggregate data for health planners and serves to initiate individual
preventive or therapeutic actions (ex. Tuberculosis)
o Links to research provides clues for further investigation and identifies people who may
participate in research studies, hence permitting comparisons among different groups (ex. Toxic
Shock Syndrome resulting from use of tampons)
o Evaluation of interventions provide comparatively inexpensive and sufficient assessment of the
effect of intervention efforts (ex. Effect of use of condoms on decreasing incidence of HIV and
other STIs)
o Planning and projections observed trends in disease incidence combined with other
information about the population at risk of the natural history of a disease can be used to anticipate
the effect of a disease or the need for care (ex. WHO prediction of global trends in road traffic
injuries by 2020 3rd leading contributor)
o Education and policy educational value:
Alerts clinicians to community health problems
Informs health policy makers about the need for prevention or care resources
Ex: AH1N1 influenza

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Local surveillance identifies the onset of influenza season and prevalent influenza strains
Clinicians are alerted and provided timely guidance on evaluation and management of
patients with respiratory illness
- Globally guide vaccine development
Uses of Surveillance Information
o Organized based on 3 categories of timeliness
Immediate
Annual
Archival
o Immediate detection of
Epidemics (AH1N1, typhoid)
Newly emerging health problems
New disease manifestations
- (Jacqueline L. Dee, The WHO Dengue Classification and Case Definitions: Time for a
Reassessment. The Lancet, Vol368, Issue 9530, Pages 170-173,2006.)
Changes in health practices (Harmful effects: Vit. E and prostate cancer; calcium and
Cardiovascular Disease)
Changes in antibiotic resistance (MRSA, MDR-TB)
o Annual dissemination for:
Estimating the magnitude of the health problem, including cost
Assessing control activities
Setting research priorities
Testing hypothesis
Facilitating planning
Monitoring risk factors
Monitoring changes in health practices
Documenting distribution and spread
o Archival information for:
Describing natural history of the disease
Facilitating epidemiologic and laboratory research
Validating use of preliminary data
Setting research priorities
Documenting distribution and spread
Elements of a Surveillance System
o Case definition
o Population under surveillance
o Cycle of surveillance information has to get to the right people in time to be useful
o Confidentiality
Protecting physical security and confidentiality of surveillance records is ethically mandated
Laws that mandate reporting ideally provide concomitant protection and sanctions to prevent
inappropriate release of identifying information
HIPAA Health Insurance Portability and Accountability Act of 1996 strictly regulates use
of electronic health data yet allowing for legitimate access for public health surveillance
o Incentives to participation
o Surveillance ethics
Sources and Collection of Public Health Surveillance Data
o Reports of health events
o Reporting from laboratories and other health care facilities
o Registries
o Vital statistics
o Information on health status, risk factors and experience of populations
o Information on potential exposure to environmental agents
o Information from other organizations
o The health care system and the impact of the health care system on health
Selected Data Source
Use
Vital Statistics
Portray trends in disease and health
Immunization registries
Evaluate control measures
Reporting from laboratories
Monitor changes in infectious diseases
Notifiable diseases
Estimate magnitude of health problems
Hospital discharge data
Monitor health practice
Risk factor surveillance
Plan public health practice
Cancer registries
Test hypothesis
Steps in Automated Reporting of Infectious Disease Data

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Elements in establishing a Surveillance system
o Establish goals
o Develop case definitions
o Select appropriate personnel
o Acquire tools and clearances for collection, analysis and dissemination
o Implement surveillance system
o Evaluate surveillance activities
Approaches to Surveillance
o Active cs. Passive surveillance
Active organization conducting surveillance initiates procedures to obtain reports
- Obtains primary data
- More expensive
Passive the organization conducting surveillance does not contact potential reporters and
leaves the initiative for reporting to others
- Obtains secondary data
o Notifiable disease reporting
o Laboratory-based surveillance
o Volunteer providers
o Registries
o Surveys
o Information systems
o Sentinel events
1st ever or 1st reported
o Record linkages
o Combination of surveillance methods
Outbreak and Cluster Investigations
Outbreak (epidemic): epidemic limited to a localized increased in the incidence of a disease (usually
refers to infectious disease)
Cluster: aggregation of relatively uncommon events or diseases in space and/or time in amounts that
are believed or perceived to be greater than could be expected by chance
Endemic vs. Epidemic vs. Pandemic
o Endemic: a disease that exists permanently in a particular region or population
o Epidemic: An outbreak of disease that attacks many people at about the same time and may
spread through one or several communities
o Pandemic: When an epidemic spreads through the world
Endemic
o The constant presence of a disease or infectious agent within a geographic area or population
group
o The usual prevalence or rate of occurrence of a given disease with an area
o Greek: within the population
o Low to moderate normal base level rate of occurrence in the population
o Malaria in Palawan, Amebiasis in Cebu, Schistosomiasisin Leyte, Substance abuse in Cebu
Epidemic
o The unusual (dramatic) occurrence of disease
o The occurrence in a community or region of a group of illness of similar nature, clearly in excess
of normal expectancy
>20% of previous years
o The occurrence in a community or region of cases of an illness, specifically
o May encompass any time period
o Few hours: chemical intoxication (radiation disaster in Chernobyl, Ukraine and organophosphate
disaster in Bohol involving school children) or bacterial food poisoning during a social event
o Few weeks: influenza or hepatitis
o Several years: drug addiction

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More definitions:
o Sporadic: individual cases of disease in widely separated geographic areas or otherwise
independent cases
o Pandemic: disease involves numerous communities spanning across continents (global
distribution)
Outbreak Characteristics
o Problem is unexpected
o Immediate response is required
o Field investigation necessary to solve the problem
o Extent of investigation likely to be limited because of the need for timely investigation
Types of Outbreaks (Epidemics)
o Common Source Epidemic
Outbreaks caused by exposure of a group of persons to a common noxious influence
Exposure to common source is often at the same time or within a brief period of time
Resultant cases all develop within one incubation period
Median incubation period: the time at which 50% of cases have occurred on the epidemic
curve
o Propagative or Progressive Epidemic
Result from transmission either direct or indirect of an infectious agent from one susceptible
host to another
Direct person-to-person spread
Spread indirectly through vectors
Epidemic period extends over a number of incubation periods
o Mixed epidemics
The epidemic begins with a single, common source of an infectious agent with subsequent
propagative spread
Exemplified by many foodborne pathogens
o Epidemic Curves

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Propagative spreads out, not as severe as common source

Airborne has the widest spread
Epidemic Surveillance Concepts
o Incubation period time between exposure and first detectable symptom
o Latency period time when disease is concealed (hidden or inactive)
o Infectious period time during which the disease can be transmitted with or without contact
o Subclinical infection infection with no or minimal clinical manifestations
o Well carriers of disease subclinically infected individuals with no symptoms who carry and
shed the infectious agent
o Reservoirs the living organisms or inanimate matter in which an infectious agnet normally lives
o Generation time the period between the receipt of infection by a host and maximal
communicability of that host
When quarantine is done
o Herd Immunity the resistance of a group to invasion and spread of an infectious agent, based
on the immunity of a hoigh proportion of individual members of the group
o Index Case The case that brings a household or other group to the attention
Time course of Common Infections (all in days)
Disease
Incubation period Latency period Infectious period
Measles
8-13
6-9
6-7
Mumps
12-26
12-18
4-8
Pertussis
6-10
21-23
7-10
Rubella
14-21
7-14
11-12
Diphtheria
2-5
14-21
2-5
Varicella
13-17
8-12
10-11
Hepatitis B
50-110
13-17
19-22
Poliomyelitis 7-12
1-3
14-20
Influenza
1-3
1-3
2-3
Common Source of Epidemic Diseases
Disease
Anthrax

Causative Agent
Bacillus anthracis (B)

Infection Sources
Milk or meat from
infected animals

Reservoirs
Cattle, swine, goats,

sheep, horses
Bacillary Dysentery

Shigella dysenteriae (B)

Fecal contamination of
food and water
Soil-contaminated food

Humans

Milk or meat from

infected animals

Cattle, swine, goats,

Fecal contamination of
food and water
Fecal contamination of
water
Infected humans
Fecal contamination of
food and water

Humans

Botulism
Brucellosis

Clostridium botulinum
(B)
Brucella melitensis (B)

sheep, horses
Cholera

Vibrio cholerae (B)

Giardiasis

Giardia spp. (P)

Hepatitis
Paratyphoid

Hepatitis A,B,C,D,E (V)

Salmonella paratyphi
(B)

Soil

Wild mammals
Humans
Humans

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Typhoid Fever

Salmonella typhi (B)

Host-to-host Epidemics
Disease
Causative Agent
Respiratory Diseases
Diphtheria
Corynebacterium
diphtheriae (B)
Hantavirus pulmonary
syndrome

Hantavirus (V)

Meningicoccal
meningitis
Pneumonococcal
pneumonia
Tuberculosis

Neisseria meningitidis
(B)
Streptococcus
pneumoniae (B)
Mycobacterium
tuberculosis (B)

Whooping cough
German measles
Influenza
Measles
Sexually transmitted
diseases
HIV-Disease

Bordetella pertussis (B)

Rubella virus (V)
Influenza virus (V)
Measles virus (V)

Chlamydia

Chlamydia trachomatis
(B)
Neisseria gonorrheae
(B)
Treponema pallidum (B)

Gonorrhea
Syphilis
Trichomoniasis
Vector-borne diseases
Epidemic typhus
Lyme disease
Malaria
Mosquito
Plague
Rocky Mountain spotted
Fever
Direct-contact diseases
Psittacosis
or bird excrement
Rabies
Tularemia

HIV (V)

Trichomonas vaginalis
(P)
Rickettsia prowazekii
(B)
Borrelia burgdorferi (B)
Plasmodium spp. (P)
Humans, mosquitoes
Yersinia pestis (B)
Rickettsia rickettsii (B)

Chlamydia psittaci (B)

Wild and domestic birds
Rabies virus (V)

Fecal contamination of
food and water

Humans

Infection Sources

Reservoirs

Human cases and

carriers; infected food
and fomites
Inhalation of
contaminated fecal
material
Human cases and
carriers
Human carriers

Humans

Sputum from human

cases; contaminated
milk
Human cases
Human cases
Human cases
Human cases

Humans, cattle

Infected body fluids,

blood, semen, etc.
Urethral, vaginal, and
anal secretions
Urethral and vaginal
secretions
Infected exudate or
blood
Urethral, vaginal,
prostate secretions

Humans

Bite by infected louse

Humans, lice

Bite from infected tick

Bite from infected
Anopheles

Rodents, deer, ticks

Bite by infected flea

Bite by infected tick

Wild rodents
Ticks, rabbits, mice

Rodents

Humans
Humans

Humans
Humans
Humans, animals
Humans

Humans
Humans
Humans
Humans

Contact with birds

Bite by carnivore

Franciscella tularensis
Contact with rabbits
(B)
Steps in outbreak Investigation Process on the Community Setting
o Determine the existence of an epidemic
o Confirms the diagnosis
o Define a case and estimate the nuber of cases
o Orient the data in terms of time, place and person
o Determine who is at risk of having the health problem
o Develop an explanatory hypothesis
o Compare the hypothesis with the established facts
o Plan and execute a more systematic study
o Prepare a written report
o Execute control and prevention measures
Periods, phases, stages, and intervals

Wild and domestic

carnivores
Rabbits

18

o
Outbreak Analytic Study Designs
Case-control studies
o Cases of diseased individuals are evaluated against a matched control and rate of exposure is
compared between both groups
Retrospective cohort studies
o The outcomes (disease or health condition) have all occurred prior to the start of the investigation
and the experience of cohorts is reconstructed through existing records

Study Designs in Epidemiologic Research

o Observational (Non-experimental)
Descriptive
- Case Report
About one person, one case - special
- Case Series
One group with similar characteristics
Cohort of individuals that experience a strange or unusual characteristics
Cannot calculate risk factors
- Descriptive Cross Sectional
Simply splicing the population at the moment in time
Specify time frame, looking at one population
1 big group divided into 4, those with exposure, without exposure and with disease
and no disease
Analytical
- Analytical Cross Sectional
Calculate measures of association
- Case-Control
Ideal design for determination of odds risk
- Cohort
Associated with relative risk
- Ecologic
o Interventional (experimental)
Quasi-Experimental
Clinical vs. Community - Based
Clinical Trials (Randomized Controlled Trial)
Field Trials
Community Intervention and Cluster Randomized Trials
Non-experimental studies
o Investigator observes the effect of previous intervention assignment by other people or by the
subject himself
o Exposure or outcome may have already occurred at the time the study is initiated

19
o

Observational, subject has exposure, investigator does not allocate exposure, experimental assigns
exposure
o Prospective, exposure already has happened or investigator will allocate the exposure
o Ambispective increase the sample size, uses both prospective and retrospective
o Four main types of non-experimental studies:
Case-Control cases arising from a source population and a sample of the source population
are classified according to their exposure history
Cohort all subjects in a source population are classified according to their exposure status
and followed over time to ascertain disease incidence
Cross-sectional studies
- Exposure and disease or outcome status as of a particular time is ascertained
- Includes prevalence studies
Ecologic studies the units of observation are groups of people
Cross-sectional studies
o A study that includes all persons in the population at the time of ascertainment
o A representative sample of all such persons, selected without regard to exposure or disease status
o Prevalence study: cross-sectional study conducted to estimate prevalence
o Exposure is ascertained simultaneously with the disease
o Different exposure subpopulations are compared with respect to their disease prevalence
Case-Control Studies
o Conducted by defining a source population at the outset and by identifying a single disease of
interest
o Cases are identified and their exposure status is determined
o A control group of study subjects is sampled from the entire source population that gave rise to
the cases
o Purpose of the control group is to determine the relative size of the exposed and unexposed
denominators with the source population
o Cardinal requirement of control selection: controls must be sampled independently of their
exposure status
o Measure of association between disease outcome and exposure: Odd Risk (OR)
o Recall bias: cases report more detail than control
o Case Control Study Design

o
Cohort Studies
o Investigator defined two or more groups of people (study cohorts) that are free of disease and that
differ according to the extent of their exposure to a potential cause of disease:
o Common design is to evaluate 2 groups:
Exposed or index cohort
Unexposed or reference cohort
o The disease or outcome may (retrospective cohort) or may not (prospective cohort) have
occurred
o Groups are identified on the basis of exposure status NOT on disease or outcome status
o Measure of association exposure and disease outcome: Relative Risk (RR)
o Harmful studies are usually determined by observational study designs

20
o

Cohort Study Designs

o
Measures of Disease Frequency
o Incidence number of new cases among number at risk
Depends on natural history of the disease
If it has a well-defined starting point, ex. measles
o Prevalence number or existing case among number at risk
Important to identify time frame
Point prevalence
- Short point in time maximum is one year
Period prevalence
- More than 1 year
Higher than incidence
If there is no defined starting point, ex. diabetes
Measures of Association
o Correlation Coefficient
Measure association between dependent and independent variable
o Spearman Rank Correlation
Measure association between dependent and independent variable
o Odds Ratio
Case Control: the odds of having been exposed
o Relative Risk (Risk Ratio)
Cohort/Experimental: the probability of incidence among the exposed relative to the
probability of incidence among the unexposed
Odds Ratio
o Also referred to as OR
o Defined as the odds in favor of disease among exposed individuals divided by the odds in favor of
disease among the unexposed
o Interpreted as the odds of having been exposed
o Case Control Study Design

Cases Controls
Exposed
a
b
Not Exposed
c
d
o OR=ad/bc
Relative risk (Risk Ratio)
o Also referred to as RR
o Ratio of incidence in exposed persons to incidence in non-exposed persons
o Calculated only from a cohort study
o Cohort Study Desing
Disease Non-disease
Exposed
a
b
Not Exposed
c
d
o RR=IE/I

21

o
o
o
o
o

RR of 1.0 indicates identical probabilities of disease in both the exposed and non-exposed groups
RR>1 implies that there is an increase risk of disease among those with the exposure
RR<1 suggests that there is a decreased risk of developing disease among the exposed individuals
Do not use P values, use 95% confidence interval
A. 37(0.7-5.0)
B. 37 (2.5-4.6)
C=3.7 (1.01-4.6)
Significant: B and C, B has less variation
A, risk factor for some, protective for others
95% confidence interval should not cross 1
Here, should not be >1
P value tell
- How much possibility was due to chance
- Alpha error less than chance
The higher the value away from 1, the stronger the association
Ecologic Studies
o The unit of observation is a group of people rather than individuals
o Also referred to as aggregate studies
o Only requirement is that information on the populations studied is available to measure the
exposure and disease distributions in each group
o Research goal is to estimate effects of group-level exposures on group-level outcomes
o Useful for detecting associations of exposure distributions with disease occurrence
o May be classified on two dimensions:
Method of exposure measurement
Method of grouping by place or by time
- Exploratory: there is no specific exposure of interest or the exposure of potential interest
is not measured
- Etiologic: the primary exposure variable is measured and included in the analysis
o Rationale for ecologic studies
Low cost and convenience
Measurement limitations of individual-level studies (ex. Environment al epidemiology)
Design limitations of individual-level studies little exposure variation within the study area
Interest in ecologic effects
Simplicity of analysis and presentation
Levels of measurement:
- Aggregate measures summaries of observations derived from individuals in each
group (proportion of smokers, median family income)
- Environmental measures physical characteristics of the place in which members of
each group live or work (air pollution level and hours of sunlight)
- Global measures attributes of groups, organizations or place for which there is no
distinct analog at the individual level (population density, level of social disorganization,
existence of specific law or type of health care system)
Experimental studies
o A set of observations conducted under controlled circumstances in which the investigator
manipulates the conditions to ascertain what effect, if any, such manipulation has on the
observations
o Epidemiology: exposure manipulations or interventions in which all exposure assignments are
expected to cause NO HARM
o The design is guided by the objectives of:
Reducing variation in the outcome attributable to extraneous factors
Accounting accurately for the remaining extraneous variation
o Generally 2 or more forms of intervention
o Random sampling while recruiting
o Intervention assignments determined by the investigator by applying a randomized allocation
screen
o Purpose of random allocation: create groups that differ only randomly at the time of allocation
with regard to subsequent occurrence of the study outcome
o Ideally, experimental groups are identical with respect to extraneous factors that affect the
outcome of interest so that if treatment had no effect, identical outcomes would be observed across
the groups
o Biologic variation is kept minimal
o Quasi-experiment: controlled studies in which exposure was assigned by the investigator witout
using randomization
o Community Intervention and Cluster Randomized Trials
Extension of the field trial that involves intervention on a community-wide basis

22

o
o
o

Ex: vaccination vs. water fluoridation

Cluster randomized trials: Field trials in which the treatment is assigned randomly to groups
of participants
Clinical trial
Experiment with patients as subjects
Goal is to evaluate potential cure for a disease or to find a prevention of disease sequelae
Field trials
Subjects are not defined by presence of disease or by presentation for healthcare
Randomized Controlled Study Design

Retrospective vs. Prospective Studies

o Retrospective Studies
Advantages
- Inexpensive to carry out
- Fewer number of subjects
- Ideal for rare diseases
- May be the only feasible way to accumulate cases
Disadvantages
- Needed information about past events may not be available from routine records
- Needed information may be inaccurately recorded
- Biased Information
o Prospective Studies
Advantages
- Cohort is classified according to exposure before the disease develops
- Permit calculation of incidence rates among exposed and unexposed allows for
determination of attributable risk
Disadvantages
- Main disadvantage: usually long, expensive and large-scale undertaking
- Outstanding problem of attrition loss of patients from follow-up due to lack of interest,
migration or death
Criteria for Judging Causal Associations
o Strength of the association
Dose-response relationship
o Consistency of the association
o Temporally correct association
o Specificity of the association
o Coherence with existing information (Biological plausibility)
Epidemiology of Infectious Disease
Common Source Epidemic Diseases
Disease

Causative Agent

Anthrax

Bacillus anthracis (B)

Bacillary Dysentery Shigella dysenteriae (B)

Infection Sources

Reservoirs
Cattle, swine, goats,
Milk or meat from infected animals
sheep, horses
Fecal contamination of food and water Humans

23
Botulism

Clostridium botulinum (B) Soil-contaminated food

Soil
Cattle, swine, goats,
Brucellosis
Brucella melitensis (B)
Milk or meat from infected animals
sheep, horses
Cholera
Vibrio cholerae (B)
Fecal contamination of food and water Humans
Giardiasis
Giardia spp. (P)
Fecal contamination of water
Wild mammals
Hepatitis
Hepatitis A,B,C,D,E (V) Infected humans
Humans
Paratyphoid
Salmonella paratyphi (B) Fecal contamination of food and water Humans
Typhoid Fever
Salmonella typhi (B)
Fecal contamination of food and water Humans
Propagative host to host
Disease
Respiratory Diseases
Diphtheria

Causative Agent

Infection Sources

Corynebacterium
diphtheriae (B)
Hantavirus (V)

Human cases and carriers; infected

food and fomites
Hantavirus pulmonary
Inhalation of contaminated fecal
syndrome
material
Meningicoccal meningitis Neisseria meningitidis (B) Human cases and carriers
Pneumonococcal
Streptococcus pneumoniae Human carriers
pneumonia
(B)
Tuberculosis
Mycobacterium
Sputum from human cases;
tuberculosis (B)
contaminated milk
Whooping cough
Bordetella pertussis (B) Human cases
German measles
Rubella virus (V)
Human cases
Influenza
Influenza virus (V)
Human cases
Measles
Measles virus (V)
Sexually transmitted diseases
HIV-Disease
HIV (V)

Human cases

Reservoirs
Humans
Rodents
Humans
Humans
Humans, cattle
Humans
Humans
Humans,
animals
Humans

Infected body fluids, blood, semen,

etc.
Chlamydia trachomatis
Urethral, vaginal, and anal
(B)
secretions
Neisseria gonorrheae (B) Urethral and vaginal secretions
Treponema pallidum (B) Infected exudate or blood
Trichomonas vaginalis (P) Urethral, vaginal, prostate
secretions

Humans

Vector-borne diseases
Epidemic typhus
Lyme disease

Rickettsia prowazekii (B) Bite by infected louse

Borrelia burgdorferi (B) Bite from infected tick

Malaria

Plasmodium spp. (P)

Humans, lice
Rodents, deer,
ticks
Humans,
mosquitoes
Wild rodents
Ticks, rabbits,
mice

Chlamydia
Gonorrhea
Syphilis
Trichomoniasis

Bite from infected Anopheles

Mosquito
Bite by infected flea
Bite by infected tick

Plague
Yersinia pestis (B)
Rocky Mountain spotted Rickettsia rickettsii (B)
Fever

Distribution of Clinical severity by Class of Infection

o
Relationship of Disease Statistics to Severity of Illness

Humans
Humans
Humans
Humans

24

o
o Diseases that are less apparent, underdetected
o Sometimes, if disease is inapparent, give time for disease to progress step back
Components of the Infectious disease Process
o Infectious agents
o Intrinsic properties of infectious agents
Causing infection
Causing virulence
Causing transmission
o Host-parasite interactions
o Pathogenic mechanisms
o Reservoirs
o Mechanisms of transmission of infection
Intrinsic Properties of Infectious Agents
o Morphology
o Size
o Chemical character
o Antigenic make-up
o Growth requirements
o Ability to survive outside a host
o Ability to produce toxins
o Ability to become resistant to antibiotics
o Ability to acquire new genetic information for survival
Host-Parasite Interactions
o Infectivity ability of an agent to invade and multiply or produce infection in a host
o Pathogenicity ability to produce clinical apparent illness
o Virulence proportion of clinical cases resulting in severe clinical manifestations (including
sequelae)
o Immunogenicity the infections ability to produce specific immunity
Pathogenic Mechanisms
o Direct tissue invasion
o Production of a toxin
o Immunologic enhancement or allergic reaction leading to damage to the host
o Persistent or latent infection
o Enhancement of host susceptibility to drugs of otherwise minimal toxicity
o Immune suppression
Reservoir
o The living organisms or inanimate matter in which an infectious agent normally lives and
multiplies:
Humans
Animals (zoonosis refers to infections transmissible under natural conditions from
vertebrate animals to man)
Environmental sources (soil, water)
Types of Carriers
o An infected person who does not have apparent clinical disease but is nevertheless a potential
source of infection to others
o Includes persons whose infection remains inapparent (asymptomatic) through-out, as well as those
for whom the carrier state precedes or follows manifest disease
Type of Carrier
Examples
Inapparent throughout Polio virus, meningococcus, hepatitis viruses

25

Incubatory carrier
Viruses of chickenpox, measles and hepatitis
Convalescent carrier
C. diphtheriae, hepatitis B virus and Salmonella species
Chronic carrier
S. typhosa, hepatitis B virus
Transmission of Infection: The Chain of Infection

o
o Cut one link in the chain stop the transmission
Disease Concepts The Chain of Infection

o
Mechanisms of Transmission of Infection
o Direct Transmission
o Indirect Transmission
Vehicle borne
Vector borne
Airborne
- Droplet nuclei
- Dust
Direct Transmission
o Consists of essentially immediate transfer of an infectious agent from an infected host or reservoir
to an appropriate portal of entry
o Ex. Kissing, sexual intercourse
o Spray by droplets through sneezing and coughing onto the mucous membranes of others (occurs
over short distances)
o Includes exposure of susceptible tissues to fungal agents, bacterial spores or parasites
Breaking the Chain of Infection

26

27
Vital Statistical Rates and Ratios
Health Indices
o Frequency of health-related events within an identified base population
o Measured as rates of specific events within a specific base population
Not enough to do absolute counts, has to be rates.
o Used to:
Assess status of health conditions for an identified base population
Assess sufficiency of health programs for an identified base population
o Categories of rates of health related-events:
Crude Rates- total population of a given geographical areas in a given time frame
- Midyear population
- Crude death rate, crude birth rate
Specific Rates
o Crude rates: denominator is the total population within a specified geographical area
o Specific Rates: events happening to a specific group are related only to the corresponding segment
of the population
Can be made specific according to:
- Age
- Sex
- Occupation
- Marital Status
- Race
- Exposure
Fertility Rates
o Crude Birth Rate (CBR): measures how fast people are added to the population through births
o General Fertility Rate (GFR): births are related to the segment of the population deemed to be
capable of giving birth (women in the reproductive age group)
Crude Birth Rate
o Factors that affect CBR:
Fertility/marriage patterns
Sex and age composition of a population number of females
Birth registration practice factitiously alters value
o Crude rate since it includes members of the base population who are incapable of giving birth
(men, children, elderly women)
General Fertility Rates
o Constituents of the base population within a given country will depend of the definition of the age
of reproduction of that country
o Can be made more specific by computing for different categories of maternal variables to be
allowed for more meaningful comparisons across populations:
Age of mother
Educational attainment
Occupation
Fertility Rates
o Crude Birth Rates (CBR)

(for crude rates, always x 1000)

General Fertility Rates (GFR)

Mortality Rates
o Crude Death Rate
o Specific Mortality Rate
o Cause of Death Rate
o Infant Mortality Rate
Neonatal Mortality Rate
Postnatal Mortality Rate
o Maternal Mortality
o Proportionate Mortality Ratio
o Swaroops Index
o Case Fatality Rate
Crude Death Rate
o Rate with which mortality occurs in a given population
o Factors that affect CDR
Age and sex composition of the population
Environmental and occupational conditions
Peace and order conditions

28
o
o

o
Specific Mortality Rate
o Rates of dying in specific population groups
o Can be made specific according to:
Age
Sex
Occupation
Education
Exposure to risk factors
o Graph of age-specific mortality rates generally show a J-shaped (developed countries, more
reaching older age) or U-shaped curve whereby mortality rates are higher with extremes of age
Cause-of-Death Rate
o Crude rate since denominator is midyear population
o Can be made specific by relating the deaths from a specific cause and group to the mid-years
population of that specified group
o Ten leading causes of death are determined using thing measure
o Factors that affect cause-of-death rate are:
Completeness of registration of deaths
Composition of the population
Disease ascertainment level in the community
Other Mortality Rates
o Specific Mortality Rate

Widely used due to general availability of data for computation

Used to compare populations with similar structure

(F = multiple of 10 until value is a whole number)

Cause of Death Rate

Infant Mortality Rate (IMR)

o The number of deaths among infants < 1 yr. age in a calendar year per one thousand livebirths in
the same period
o A sensitive index of level of health in the community
o Subdivided into:
Neonatal Mortality Rate usually due to congenital or poor maternal care
Post-neonatal Mortality Rate usually due to environmental or infectious diseases
o High IMR means low levels of health standards which may be due to:
Poor maternal and child health care
Malnutrition
Poor environmental sanitation
Deficient health service delivery
o May be artificially lowered by improving registration of births
Increases the denominator, does not mean health services improved
o
o

Categories of Infant Mortality Rates

Neonatal Mortality Rate

Subdividing IMR into 2 categories is due to different causes of death in these two age group
categories
Neonatal Mortality Rate
- Prenatal of genetic causes
Post-Neonatal Mortality Rate
- Environmental, genetic, nutritional or infectious causes
Maternal Mortality Rate (MMR)
o

Post-neonatal Mortality Rate

29
o
o
o

Measures the number of deaths due to diseases directly related to pregnancy, deliver and
puerperium
Ideal denominator should have been number of pregnancies but often underreported
May be affected by:
Maternal health practices
Diagnostic assessment
Completeness of Registration of births

o
Proportionate Mortality Ratio (PMR)
o Proportion of total deaths occurring in a particular population group or from a particular cause
o Denominator is total number of deaths, Not population size
o Affected by the proportion of deaths due to other causes within the same time period
o
Swaroops Index
o Special kind of proportionate mortality ratio
o Also a sensitive indicator of the standards of health care
o Developed countries have higher Swaroops index than less developed countries
o
o The higher, the better the health index of the country
Case Fatality Rate
o Proportion of cases which end up fatally
o Tells how much of the afflicted die from the disease
o High CFR more fatal disease
o Time element is usual duration of the disease
o Depends on:
Natural history of disease itself
Diagnostic ascertainment
Level of reporting in the population
o

30
Occupational Epidemiology
The study of health effects of factors to which people are exposed in the workplace environment
Factors may be:
o Chemical
o Physical heat, noise, radiation or mechanical energy
o Biological
o Psychological
Contributory factors
o Training
o Workplace layout
o Environment
o Working practices
o Lack of maintenance
o Lack of guidance
The kind of occupational illness and the health hazards encountered are directly related to:
o The means of economic activity that prevail
o Type of technology available
Health concerns associated with worksite exposures
o Carcinogenesis
o Chronic Diseases respiratory, neurologic and cardiovascular
o Reproduction
Primary goal in occupational epidemiology is the identification or confirmation of new occupational
disease and the study of dose-response characteristics in order to prevent illness
Ecological studies provide a crude way of exploring associations between occupation and disease
The group, not the individual, is the unit of comparison
Disease rates in various groups are being compared
Ecological studies: (Observational)
o Case Report
o Case Series
o Cross-sectional
o Case-control
o Cohort
Has an important role notably in:
o Establishing the causes and determinants of this ill-health,
o Ensuring adequate recognition and quantification of this, and
o Determining appropriate occupational exposure limits
Criteria for Causal Association
o Strength of association calculate odds risk or relative risk
o Dose-response relationship
o Consistency of the association\
o Temporally correct association
o Specificity of association
o Coherence with existing information
o Reversibility
Linked to Environmental Epidemiology:
o Environmental epidemiology involves the use of epidemiologic tools to study communities that
may be exposed to pollution, hazardous waste, radiation through air, water or food contamination
o Occupational by-products mostly affects the environment
Hazards and Risk in the Workplace
o Hazard is the potential to cause harm
o Risk is a measure of the likelihood of a specified harmful effect in a specified circumstances
Physical Hazards
o Non-ionizing radiation e.g. microwaves, infrared, visible and ultra-violet light
o Ionizing radiation e.g. X-rays, gamma rays, beta particles, alpha particles from radon daughters
o Noise (usually measured in decibels dB) and vibration;
o Temperature, humidity etc.
o Ergonomic: Posture, movement (e.g. keyboard operation), load bearing (e.g. patient handling)
Chemical Hazards
o Inorganic e.g. lead, arsenic, silica
o Organic e.g. solvents, resins, glues, fluxes (vapors and gases are usually expressed in
concentrations of parts per million or per billion: ppm or ppb)
Biological Hazards
o Allergens of biological origin: laboratory animals, insects, mites, wood and other plant material,
fungal spores
o Infections: Bacteria: Tuberculosis, Brucella, Leptospica etc.
o Viruses: eg. Hepatitis B from needlestick injuries
Psychological Hazards

31
o

Stressors in the Workplace

Recent promotion beyond capacity
Conflicts due to multiple responsibilities
Too many demands on time
A tiring shift pattern, excess overtime
Too little or boring work
New technology
A new or unreasonable boss
Increased productivity targets
Threat of redundancy
Sexual harassment or bullying
High sickness absence in colleagues
Prevention of Occupational Stress
o Focus on individual behavior by support and advice, to help coping with the stress
o Identify situations which include potential stressors, assess the risk of stress, and then take steps to
reduce the stressors so as to reduce the stress.
Preventing psychological distress
Occupational Exposure
o A measure of the intensity and/or extent to which the human body experiences a particular hazard
o For a given hazard, the greater the exposure the greater the risk of an adverse effect on health. This
is because of the exposure-response relationship.
Skin
o Eczema/dermatitis This can be irritant e.g. caused by detergents, or allergic e.g. caused by
certain rubber chemicals
Cancer e.g. from skin exposure to pitch/tar, or to excessive sunlight
o Lungs
Asthma e.g. from glutaraldehyde in healthcare workers, other causes of may include flour, or
other agents in bakeries, or di-isocyanates in twin-packspray painting
Allergic alveolitis e.g. Farmers lung from fungal spores
Pneumoconiosis e.g. silicosis caused by inhaling quartz
Cancer e.g. from asbestos inhalation
o Musculoskeletal
Tenosynovitis and similar conditions
Back pain from manual handling
o Nervous and Mental
Peripheral neuropathy e.g. caused by lead or n-hexane
Nerve deafness induced by noise
Mental ill-health e.g. caused by stress, or by chemical exposures such as mercury
o Blood/Marrow
Anemia e.g. caused by lead, which may impair the synthesis of normal hemoglobin
Aplastic anemia may be caused by high exposures to benzene
Leukemia caused by benzene
o Genitourinary and endocrine
Kidney damage solvent exposures, or by cadmium
Bladder cancer beta naphthylamine, generally aromatic amines
Infertility caused by some chemical exposures e.g. male infertility caused by DBCP
(dibromochloropropane)
Endocrine dysfunction and/or effects on reproduction phthalates, glycerol ethers, and
organophosphates
o Liver
Hepatitis
Cancer
Responsibilities of Employer and Company Physician
o Assessment of Health risks Created by Work
Identification of hazards
Assessment of exposure, work practices, etc
o Prevention or Control of Risks
Elimination of hazards
Substitution of hazards
Enclosure/Segregation so as to reduce exposure
Local exhaust ventilation if appropriate
Personal protection e.g. gloves, goggles, masks, footwear
Appropriate work organization and practice
o Monitoring and Evaluation
Checking of control measures
Environmental monitoring: personal and background
Appropriate health surveillance
o Consultation, Information, Instruction & Training

32
o

Record Keeping and Reporting

Demography
Derived from Greek words synos meaning the people and ypagly meaning to draw or write
The empirical, statistical and mathematical study of human populations
Focus of attention:
o Population size
o Population composition or structure
o Distribution of the population within a given location
Population Size
o Number of people within a given time and place
o Projections of changes in population size in the future
o Affected by living (health, political, environmental, social) conditions of a given time
Population Composition
o Pertains to all the measureable characteristics of the people
o Most common: age and sex
o May identify other characteristics of the population depending on the purpose for which the
description is being made
o Related to the number of births, deaths and migration activity in the area
o Also influenced by existing living conditions within a given place and time (selection process)
o Affects selection of types of intervention (health services) for a given type of population
Population Distribution
o Pertains to where members of a given population are located
o Related to prevailing conditions
o Affects distribution of health services
o Measures of population distribution
Urban-rural distribution
Population density
- Number of persons per sq.km. area
Crowding index
- Number of persons divided by the total number of rooms in the house
Uses of Demography
o For identification and characterization of health problems within a given community
o For prioritization of health programs given the limited resources
o For identification of determinants or reasons for occurrence of specific health problems
o To predict future developments and possible consequences
Sources of Demographic data
o Censures
De jure assigns individuals to the place of their usual residence
De facto allocation of individuals to areas where they were physically present at the census
date
o Sample Surveys
o Vital Registration Systems
o Continuing Population Registers
Tools of Demography
o Ratio numerator not part of denominator
o Proportion numerator part of denominator
o Rate element of time, numerator part of denominator
Age composition
o Median age
o Age-dependency ratio
Relates the size of the dependent segment of the population to the economically productive
age-group of the population
o The higher the age dependency ratio, the more people unemployed or less people in productive
age group
Sex Composition
o Sex Ratio
Compares the number of male individuals to the number of females in the population
o Sex structure
Computing for the sex ratio of each age group
Population Pyramid
o Graphic form of describing the age and sex composition of the population at the same time
o Used for describing and explaining demographic trends of population over time
o Various type of population pyramid
Formulas for Computing Various Aspects of Population Estimation Using Different Mathematical
Assumptions
Unknown
Arithmetic Geometric Exponential

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Future Population (Pt)
Past Population (P0)
Absolute Increase per year (b) or annual rate of growth (r)
Time (t)
Doubling time (t*)