UNIT 4 INTRODUCTION TO

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Objectives Introduction . Epidemiological Concepts 4.2.1 Epidemiological Trends and Definition 4.2.2 Aims of Epidemiology Epideiniological Aspects of Disease and Health 4.3.1 Epidemiological Models of Causation of Disease 4.3.2 Epidemiological Model of Determinants of Health 4.3.3 Natural History of Disease 4.3.4 Spectrum of Diseasc 4.3.5 Ice-berg of Disease 4.3.6 Levels of Prevention of Disease Epidemiological Methods 4.4.1 DescriptiveEpidemiology 4.4.2 Analytical Epidemiology 4.4.3 ExperimentalEpidemiology Epidemics 4.5.1 Concepts of Epidemics 4.5.2 Investigation of an Epidemics Preventive Epidemiology 4.6.1 Health Surveys 4.6.2 Screening of Disease I 4.6.3 rSurveillance 4.6.4 Monitoring and Evaluation Epidenliology and N~~rsing Let Us Sum Up Key Words

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4.10 Answers to Check Your Progress

4.0 OBJECTIVES
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After going through this unit, you should be able to: define the science of epidemiojogy; describe the epidemiological trends and explain the modern concept of
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state the aims and scope of epidemiology; discuss epide~niological theories of disease causation; discuss epidemiological models of health determinants;

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definq natural history af disease and discuss its process;

Principles and Practice of Community Health Nursing

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explain levels of prevention of disease; describe epidemiological methods; define different types of epidemic and describe investigation of epidemics; describe interventions of preventive epidemiology; and identify the role of a nurse in epidemiological process.

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4.1

TRODUCTION

Community health is the field concerned with the study of health and diseases in human population and its goal is to provide comprehensive need based health care services to the entire community to achieve the goal of Heal For All. The health worker, therefore, need to have some basic knowledge and skills which will help her1 him to identify health need, health problem, the related etiology and plan, implement and evaluate health care services. The science of epidemiology helps health workers to develop such knowledge and skills.Tn this unit we shall discuss about, concepts of epidemiology, epidemiological concepts of disease causation, epidemiological methods, Epidemics monitoring and evaluation of role of nurse in epidemiology.

4.2 EPIDEMIOLOGICAL CONCEPTS
The science of epidemiology deals with the study of health related states and events occurring in a population. The origin of this science has been traced to the time of Hippocratres who tried to explain the causative factors of discases. But it flourished rapidly during the last three decades of the present century and contributed extensively in the field of medicine and community health. As a science and academic field, epidenliology not only helps in understanding the health concepts, natural history of disease and disease causation, it also helps in planning, implementing and evaluating effective and efficient health care services.

4.2.1 Epidemiological Trends and Definition
The term "epidemiology" is derived from the term "Epidemic". The literal meaning of the term is "study among people" (Epi = among, demos = people, logos = study). The foundation of the epidemiology was laid in the 19th century when infections and communicable diseases like cholera, typhoid, plague etc., were most prevalent in the world in the form of epidemics and pandemics. During the late 19th century and the early 20th century, the study of frequency, distribution and determinants of infections and communicable diseases and their peventionand control were the primary focci of epideiniologists. There has been considerable reduction in the morbidity and mortality from these diseases as a result of epidemiological studies and improved methods of diagnosis, prevention and control. However, the threat of communicable disease is still present, specially in developing countries, because of substandard environmex~tal conditions, poor socio-econo~nic status and inadequate resources. It may also be defined as the study of frequency, distribution and determinants of health related states and events and disease in human populations. Frequency Distribution
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rates, ratio, normal ranges time, place and person

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accidents etc. etc. Thus. any disease. incidence rate. and the application of this study to control health problems (Last.aetiological hypothesis e. ... . = .disease or health related events in different places..female ratio. not only on communicable diseasQ but also on these new emergent and chronic diseases. as a mass phenomenon (Greenwood. The measurements are done in the form of rates.~ ~ i d e m i ois l the o ~ study ~ of the distribution and determinants of disease frequency in man (MacMohan?1960) 5) Epidemiology is the stbdy of frequency. health needs.' ' w Testing of etiological hypothesis derived from descriptive study of diseases and health related events.All diseases and health-related diseases . 1983) From these various definitions it is learnt that modern epidemiology deals with: Measurement of occurrence of health related statesland events iie. "Smoking of 15-20cigarettes per day over a p&bd of 10-15 yearsais associated with lung cancer in men and women occurrence of diarrhea is more frequent in non-breast fed infants than in breast fed infants of low sgcio-economic population".. place and person.From the above definition and concepts it can be said that it includes three important elements: 4 - Introduction to Epidemiology . non-communicable Populations Ecological approach.by time. These problems include cardio-vascular diseases. several definitions have been given by various authors based on their experience background and changing trends which are listed below: 1) The epidemiology is that branch of medical science which deals with epidemics (Parkin. and measurement of frequency of disease. ratios and propo&on e. I t ' * ' Distribution of disease pattern in a community . These problems are taking the form of epidemic. In fact. whether the occurrence is more in man than in woman and in what particular age and with particular life style etc. health demands. male . health related stateslevents.g. Rates. This'iaspect of epidemiological s&es help in establishing cause and effect relationship dnd it refers to analytical and experimental epidemiology. This aspect of epidemiology refers to descriptive epidexnialogy.g. The epidemiologist examines whether there is increase or decrease of disease or health related Bvents over time. the epidemiologists study all those conditions that affe'ct the health of a population at any given time. whether there is high or lower concentration of . disability or death. events and morbidity patterns in population. . many new problems have come up in the 20th century. 1927) 3) Epidemiology is the study of disease. diabetes. percentage of children with malnutrition etc. cancer. ' - While communicable diseases continue to be serious public health problems. ratios and proportions can help in making comparison of different population different time with re'spect to occurrence of disease. 1873) 2) Epidemiology is the science of m a s phenomena of infectious diseases (Frost. 1934) 4) . The focus of epidemiologists is now. distribution and determinants of health related states. blood cholesterol level.both communicable and .

To plan and evaluate health services. . e 4. a . ' 3) to provide information on health related states and events for planning. 2) to identify aetiological factors in the pathogenesis of diseases. implementation and evaluation of health care services. diagnosis. 'TO estimate individuals risk and chance.. e To complete the natural history of disease. To define and redefine syndromes. implementation and evaluation of comprehensive health care services to ded with health problems and promote health and well being of the society as a whole. ' The uses of epidemiology are: e e 9 9 To study the health history of popylation and their disease trends.2 Aims of ~pidemiology \I . To arrive at community.three main aims have been identified by InternationalEpidemiologicalAssociation: 1) to describe.the occurrence and distribution of disease problems in human population.2.Principles and Practice of Community Health Nursing e Planning of health card services based on the studies. . Based on the concept of epidemio1ogy. To search for causes of health and disease by employing epidemiological methods.

.. But this'theory has mariy limitations. Tuberculosis due to tuberculosis bacilli.. ..Disease .Man. . .. susceptible and lived in slum got the disease. ..1: Epidemiological Methods of Causation of Disease .. ... 4. . Therefore....1. . diphtheria due to mycobacterium diphtheria etc....3 EPZDEMIOLOGICALASPECTS OF DISEASE AN'D With the progress of civilization from the primitive period to modern time the concept of disease and health have changed from supra-natural to multifactorial causes and holistic health approach. ..1 Epidemiological Models of Causation of Disease Before the discovery of micro-organisms in 19th century diseases Cvere associated wi& supranatural and spiritual forces... ' Disease agent.For example every one exposid to disease agent did not get the disease say like tuberculosis. .. . it is important to clarify the concept of health and disease... The ge&i theory became popular during the 19th and early part of 20th century. ] ~ x a m ~ l are: es .4... cholera due to cholera vibrio. According to this..'. theory there is one single specific causative agent to every disease as shown in the model given below.... This means in addition to specific causative' agent there are many other factors related to host and environment which contribute to causation of disease as shown in the Fig. .. only those who were undernourished...... Agent and ..... . . Epidemiological Biad Agent Host I Environment Epidemiological concept of interaction of Host.3. Introduction to Epidernioloe 4.. ...Environment Fig... 4. But these old concepts still preyail among people in the world who are under-developed..

host and environment which is shown in the model Fig. The Web of Causation.1. poor.for Myocardial Infarction I . According to this model disease is caused hy the interactionofagent. This refer to state of health equilibrium and is represented in the following model of Alten Dever (see Fig. for example cancer.3: . .) ' . immunization . exercise Smoking Emotional Disturbances . cardiac diseases. This means the disease will occur only when the host is'weak. dark and dingy environment is conductive to the prevalence af tuberculosis on patiqnts.2. diqbetes. 4. curative. / ' Changes in ' Ii"i"\ / -I . mental disorders. 4. and environmental sanitation. the organisms must enter through respiratory tract and in sufficient amount. . Coronary Occlwsion # I I I Myocardial lsekaemia' Myocardial Infarction ~ g4. Fig. nephroitic syndrome.hrombotic Tenrny Coronary atherasclerosis - Changes in walls of arteries . These diseases could not be prevent@ and controlled by the traditional methods of isolation. etc. 1 I 1 Hyperlipidaernia . the host should not have specific resistance and should have weak general body resistance.Principles and Practice of Community Health Nursing This model 'is known as_Epidemio_~ogical Triad. This model in ~ t h ewords r implies that disease will not occur without the optimal interaction of these three factors and remain in balanced state. etc. 4. For example for pulmonary tuberculosis. the agent is strong and enters the host through the right channel and in sufficient amount and when environment conditions facilitate the interaction of host and agent. Stress Overeating lack of physical . tncreased.2: Ecological Model of Health Equilibrium I This model is applicable to'infectious diseases and not to new types of chronic and degeAerative diseases which are a result of modern civiiization.

etc.4: Model of D~terminantsof Health 4. 4.I It has been epidemiologically recognized that these diseases are caused due to complex interaction of multiple factors related to life style. s&. host and environmental factors as shown in the model ~~idemiblogical Triad (Fig. 4. for prevention and controlsf cardio-vascular diseases. regular health check ups. It also suggeits variety of intervention e.. physiological status. unhygienic habits and health behavior. traditional practices and biological factors i. Prepathogenisis Phase . climate condition and prevalence of insects.4..e. It starts with the interaction of agent. epidemiological triaa as discussed earlier. 4. human behaviour and the environmental conditions as shown in model Fig.5). poor physical environment..3. etc. This model suggests clusters of cases and combinations of effects related to each other. marital status.g.1 and Fig. This model refers to health force field model as suggested by Blum.. Of late the epidemiologist proposed a model for analysis of health of people rather than analysis ofksease among the people..3. 4.. genetic traits..3 Natural History of Disease In the absence of any intervention (i. The disease agent has yet not entered the host (&an).e.2 Epideqiological Model of Determinants of Health 4 . Agent is regarded as an integral part of total environment. host and environment i. 4. The disease process in man depends on the characteristics of these three factors. According to this model. diet control.g.. Epidemiologists try to analyze these factors to study the health status. human biology and health and health allied resources as shown in the model Fig. cardio-pulmonary diseases. 4. .e. exercise. The natural histo* of disease has'two phases: (i) Prepathogenisis phase and (ii) Pathogenesis phase. we h e always exfiosed to k e risk to disease but disease process in man starts only when there is interaction m o n g agent.3. prevention or treatment) almost all disease follow a natural course of events which refers to "natural history of disease". health is influenced by a v d e t y of factors which are classified as life style. morbidity and mortality pattern in any community. etc. 4 Health allied resources I Environment ( Hg.5) e. avoidance of smoking. environment. But the factors that favour its (agents) interaction with the human host exist in the environment (Fig. pests and rodents. Introduction to Epidemiology 4. p his phase is before the onset of disease in man and it is in the environment. This refers to web of causation as suggested by MacMohan and Pugh. etc. These four categories of factors are related to an affect one another and interact with each other. age.

These variations are due to susceptibility of the host. etc. in case of measles virus. skin ashes all over the body in measles.5.e. the visus grow and multiply and bring in physiological changes in the body. the signs and symptoms usually become clear cut and clinical diagnosis can be made with ease e.4 Spectrum of Disease whenever any disease occurs in the community everyone does not get sick. The end results of disease. This period is called as incubation period. @ The graphic representation of these variations in disease occurrence refer t. 4. The signs and symptoms are vague during the first few days (1 to 4 days ) of illness e. Many people get the infection but remain sub-clinical i.. From this discussion of pathogenesis phase of a disease we learn that each disease has a series of stages as shown in the Fig. clinical signs and symptoms of the disease are absent. The host remains apparently healthy and arnbulant.6). chronic state or death. The severity of the sicbess also varies ranging from mild to severe. As the agent e.'After a lapse of some period.Defection early ' disease vescence escence Disease Pathogenisis Incubation period Fig. This stage of pathogenesis (disease process) refer to Fastegium. in measles.. the respiratory tract. running nose.g..is diseasec Agent Period of Pathogeniss . 4. This period is called as prodromal period and it is early prepathogenesis phase. 'measles virus' enter the body through appropriate channel e.. the signs and symptoms of disease begins to appear. Its duration varies from disease to disease and in case of same disease in different people depending upon the virulence of causative agent and the susceptibility' of human host. the agent in this case i. But as the disease advances.g.g. virulence of the agent and the various environmental factors which influence the host agent interaction.Principles and Practice of Community Health Nursing Prepathogenisis Period Before man. .. the health equilibrium within the body is dislurbed. 4.g.do not show recognizable signs and sylnptoms but remain as carriers of infection. watering of ejres.e. It is only some people who get sick who show' clinical signs and symptoms of the disease.o spectryrh o f disease which is like a spectrum of sunlight having different shades of colors froin one end to the other.. v The course of disease in human "OSt Death + Fastegium t Environment clinical Horizon Early Discernible Advanced Defer. 4..3.e.Conval . At one end of the spectrum are sub-clinical cases whereas i t the other end ase very serious and fatal cases (see Fig. They are a source of risk to others and create public health problems. which difIer in various diseases. pwcess may be complete recovely which refers to defervescence and convalescence or it may end into some kind of disability1 defect. These changes are sub-clinical i. .5: Prepathogenisis and Pathogenisis Periods of Natural History Pathogenesis Phase This phase begins with the entry of the disease agent in the human host.

Preventive measures during this period of a disease process prevent the occusrence of disease and promote health.P. It includes early identification of cases and their contacts and giving them timely treatment 'and follow-up e. cholera. Health protnotive measures are equally applicable to thc prcvention of chronic and non-communicable diseases such as casdiovasculas. increase or decrease of specific nutrient in diet'and or supplelnenting it e. (iii) Tertiary Prevention.6 Levels of Prevention of Disease We are all familiar with a vely popular phrase "Prevention is better than cure". According to natural histo~y of disease. Plague. They are: (i) Pri~nary Prevention. dysentery.3. iron rich diet and supplementing with iron tablets in case of prevention of anaemia. Specific Protection: I1 refers to actions to protect from a particular disease or group of disease.4. and restore health.3. healthf~~l these aspects ase directly related to socio-economic and cultural status of the fanlily which rnusl be . He is not able to recognize a large number of sub-clinical or presymptomatic and missed. pertusis and tetanus. imnzunization for tuberculosis. cases which remain hidden like the vast submerged portion of the ice-berg as shown in the Figure. like B. It is also economical because preventive .T. Secondary preventive measures pre~ent'disabilit~ or defects. It does not require sophisticated infrastmcture.mnproved. Similarly. It is because of the i'act that prevenlion helps to promote and preserve health and minimizes the sulfcrings and distress. equipmenls and material. three levels of prevention have been identified. Introduction to Epidemiology 4. etc.g. The hidden cases we much more8thanknown cases and they are a source of infection beca~~se they ase casriers of infection. These measures we classified as: e Health Promotion: Health promotive factors include wholesome nutritious life-style and adequate resources.G.. have been reduced due to these preventive measures.' prevents the occurrence of new cases and controls old cases.e. (ii) Secondary Prevention.. Above all it is a positive appmach L o healthful living. measures can be followed and practiced by all at the village and ho~lle level. * 2) Secondary Level of Prevention: Seconday level of prevention refers to * measures taken during pathogenesis period to control.g. tuberculosis. for diphtheria. D. the concept of prevention is broad based.C. during the prepathogenesis phase of disease.e.. safc environmnent to live. Primary prevention is given major emphasis in health care and it is identified with health education because it is considered as the responsibility of the individual. accidents. I) Primary Level of Prevention: It refers to prevenlive measures taken before the qccurrence of a disease i. the progress of disease in man to stop or control the spread of disease in the community. diabetes. 85 . Thus secondary level of prevention reduces prevalence rate of the disease i. The detection and control of hidden cases is a challenge for health personnel in the field of community health. family and coinxnunity. early diagnosis and treatment of high blood pressure will help in the lxevention of possible cardiovascular emergencies.. leprosy etc. Much of the morbidity and nlortality due to conz~nunicable diseases such as typhoid. These actions help in early recovery prevent cavilation and consolidation of the affected p a t of the lungs and also prevent further sprgad of the tuberculosis in community.. All food. early diagnosis and treattnent of all cases of tuberculosis and their contacts.5 Ice-berg of Disease From the spectrum of disease we 1ea1-n that when a disease occurs in a co~nmunity the physician will be able to recognize only clinical cases which is like the floating tip of the ice-berg which is visible on the surface of water. Epidemiologically.

. deep breathing exercise.. .g.. etc. for efficient lung expansion. in case of patients with pulmonary tuberculosis. vocational and psychosocial rehabilitation e. meditation.. The measures included are physical.Principles and Practice of Community Health Nursing d 3) Tertiary Level of Prevention: The purpose of tertiary level prevention is to limit the disability and help the individual adjust to permanent impairment and disabilities so as to lead a useful life. guidance and training to learn new vocation and guidance and counseling for restoration of family and social relations. etc.

Introduction to Epidemioloj!y .

its analysis. cancer. place and time. Descriptive and analytical methods or studies are also known as observational studies because the investigator does not intervene. . place and time.. month..1 Descriptive Epidemiology Descriptive epidemiology is concerned with the study of frequency and distribution of disease and health related events in population in terms of person. social class. It consists of two type of observational studies: (i) Case Control Study. etc.4. 0 Thus. and (ii) Cohart Study.. periodic fluctuation..2 Analytical Epidemiology You have learnt that descriptive studies yield etiological clues for various diseasqs which helps in making a guess or formulation of hypothesis for further vigorous study or testing e.4 EPHDENIPOLOGICAL The epidemiologist and comtnunity health workers are interested in the study of the health status of the population at large. low concentration and spotting of cases in the map. This method gives information about who all are affected by a particular disease or health related problems. determine the factors affecting health and disease and utilize this infonllation in planning to provide need based health care services. income. 3) planning.g. Thus. This refers to statistical i~iformation of a problem and are given in the table for you to learn to coinpute. The data is collected about: 1) Perso~ial characteristics such as age. purpose is to provide and overview of the extent of health problems and to give a clue to possible etiological factors involved. etc. descriptive epidemiology provides information for: 1) making community diagnosis i. dietary pattern with obesity.. occupation. 2) Place distiibution of cases i.4. etc. raC%. sex. rates and ratios. social class. description of health needs and health problems. Such information gives clues to possible associated factors such as age with specific disease e. seasonal variation. idenlify morbidity and mortality patterns. diphtheria. These type of hypothesis are further studied and tested by analytical studies to determine the association of cause with the effect. measles. describing the nature of diseases or problems and measuring their extent in terms of incidence/prevalencerate. sex.e. where the cases occur and when they occur. Such epidemiological study requires systematic collection of health data. 4. dietary pattern habits. mortality rates. season. (iii) Experimental method. areas of high concentration. Its . The data collected are analyzed and presented in terms of percentage.g. organizing mid implementation of health care services to deal with these problems. day and hour of onset I of the disease. in early childhood. by age. pertusis. marital status.e. education. 3) Time distribution/trends such as year. occupation. "cigarette smoking (10 to 20) in a day causes lung cancer in 10 to 15 percent of smokers after 20 years of exposure". he or she makes an observation of the frequency and distribution of the disease by person. weak. analytical epidemiology goes beyond the descriptive epidemiology. (ii) Analytical method. 2) providing ch~es to etiology of disease for further rigorous investigation and confrontation of the causes. 4.Principles and Practice o f Commui~ity Health Nursil~g Iti 4. identification of factors associated with the probleins and stating the hypothesis which are: (i) Descriptive method.

Rubella in mothers during early pregnancy in the cause of congential deformities in children. He reviews the records. a group of prople say in the same age group and who are exposed to a certain risk factor say cigarette smoking (study group) and who are not exposed to the risk factors (contribi group). Intraduction to Epidemiology 2) Cohart Study: A cohart is a specilic group of people. oha art study is prospective in nature because the group under study is free from the disease but exposed to risk factor. These trials do involve medical.3 Experimental Epidemiology Experimental studies are similar in approach to cohart studies expect that conditions are under the caref~~l control of the investigator. The prospective study is expensive and time consuming but it has its advantages over retrospective method.istics to that of cases but they are free from the problem under study (controls). Both the groups are followed up for several years and observations are made with reference to frequency and distribution of the suspected disease (in this example lung cancer) over a period of time. Usually these experiments are done in the laboratoly animals.. couple married in the same year (marriage cohart). interviews the cases and their family members. These conclusions are based on repeated case control studies.4. Experimental studies are done to confirm the cause and effect association of the efficacy of preventive or therapeutic agent or procedure. people born on the same day or the sane year (birth cohart). This method can help in studying the natural history of disease. the disease has already occurred and the epidemiologist goes back in time.. therefore. estimating incidence rates.1) Case Control Study: In this method a group of people who have been diagnosed as having a particular problem (cases) are compared with a group of people who are similar in charactei.e. e. 4. sharing common charactegstics or experience e. risk factor under study to other diseases or problems e. a class of nursing students (experience cohart). The data is statistically analysed and comparisons are done between the incidence among smokers and non-smokers to determine the association of risk factors to the disease. He then observes and analyze the outco~nes using statistical methods and confirm the cause of diseases. This approach has helped in identification of causative factors of many diseaseslproblems. people with same occupations (occupational cohart) etc.g. cardio-vascular problems etc. .e. iodine deficiency associated with hyperthyroidism. is called as retrospective method. ethical and moral issues. and establishes the efficacy or preventive measures and drugs under study. The data thus collected about the suspected factorlfactors is analyzed statistically to determine the extent of its association with the disease. Case control studies are easy to organize and are less expensive..g. But clinical and community trials are done to determine efficacy of preventive or therapeutic laboratory animals. This method.g. Here the approach used is retrospective i. etc. but not to the control group which is similar to the experimental in all its aspects. In these studies the investigator administers and does investigatiodgives treatment to the experimental group which is either exposure to caGsative agent or preventive/therapeutic agent. In this method of study the epidemiologist selects a cohart i. cigarette smoking and high blood pressure. smoking associated with lung cancer. at a certain time..

g.5.Principles and Practice of Community Health Nursing In 1994 we read a great deal in the newspaper about plague epidemic in our country. What is an epidemic? 4. . outbreak of influenza in ..1 Concepts of Epidemics Epidemic is defined as the occurrence of a disease for more than normal expectancy in a cqnmunity or region during a specific time period e.

In this the exposure to infection is continuous repeated or intermittent but may not be at the same time or place e. i. there is a clustering of cases (i. Laboratory examination is done wherever necessary and applicable. Transmission continues as long as susceptible people are there in the community and are exposed to infected people. If the frequency is more than normal e'xpectancy in the community then it is considered as an epidemic. milk supply or contaminated well water. 2 Investigation of an Epidemic Investigation of epidemic is essential to determine the particular condition or factors which are responsible for the outbreak.g. The epidemic flares up gradually depending upon the herd immunity. I) Common Source Epidemic: Most of the time the epidemic occurs due to exposure to an infectious agent from common source. e 2) Propagated 'Epidemic: this epidemic results from person to person contact and mostly due to infectious agent. opportunity for contact. The common source epidemic can be due to: 0 Introduction to Epidemiology Single exposure or point source infection: In single exposure or point source infection. - Demographic study which includes total population composition.. Investigation of epidemic is a systematic process and goes thraugh orderly steps which are discussed as under: 1) Verfication of Diagnosis of Disease: The first step is to diagnose the disease and is done on the basis of clinical examination of cases. etc. morbidity and mortality rates and proportions.e. This information is necessary for calculating epide~niological measurement e. These epidemics are irregular. 4. Examples of epidemic include influenza. 3) Defining the Population at Risk: It includes: Obtaining or preparing a map of the area. the exposure to the agent is brief and simultaneous. (ii) Propagated epidemic. cholera in s u F etc. namely: (i) Common source epidemic. epidemic of cholera or infective hepatitis or any other such problem due to unsafe water supply.g. hepatitis. The resultant cases develop the problem within one incubation prior to the disease. The map should show the landmarks. develop within one incubation period because the exposure to infection is only one time. . There are mainly two types of epidemics.. The classical example is for a brief period. The epidemic is explosive. cases occur in one particular location usually) within a short period one incubation period. etc. the epidemic rises and falls rapidly as shown in the Fig. 5 . epidemic of STDs through infected prostitutes. sections and locations of all dwelling units.7. roads. Multiple exposure or continuous exposure: Multiple exposure or continuous exposure is common source epidemic. 2) Confirmation of the Existence of an Epidemic: This is done on the bases of the frequency of the disease. cholera.e. food poisoning. contaminated air. Bhopal Gas tragedy. Often such comparison is not required because there is sudden increase in number of cases within a short period which happens with common source epidemic of cholera.. food. hepatitis. food poisoning cases. 4 . extended over a period of time and continued beyond the range of one incubation period. It tails off gradually bver a long period of time.Delhi in a large number in November-December. Often health team at the grass root level is made responsible to investigate and plan and implement the intervention to control the epidemic. soil. first time and all those who have to develop the problem. water.

time of the onset of the disease. Ultimately the investigator is able to formulate the hypothesis. This information will help in identification of the planning of preventive and control measures.Principles and Practice of Community Health Nursing . the epidemiologist / health worker prepared a programme of prevention and control of the epidemic not only the present but also for its prevention in future. place and time distribution. . Spot maps are prepared to find out the geographical distribution of cases. sex. piuties attended. agent factors and host. A complete list of cases by chronological order is prepared to show the beginning of the epidemic. information contacts. food eaten sources of w ~ t e retc. Description of the cases in terms of person. An attempt is made to identify the first case and follow its movements to trace the source and spread of infection. occupation. 7) Formulation of Hypothesis: Analysis of data will reveal the possible causes of epidemic and the inode of the spread of infection. 8) Recommendation for Prevention and Control: Based on the information revealed about the epidemic.g. signs and symptoms. 6) Data Analysis: The data analysis is the same as in descriptive epidemiology. movements. Concentration of cases (clustering) will indicate the common source of infection. 5 ) Study of Ecological Factors: It includes investigation of all those ecological factors. 4) Identification of all Cases and their Characteristics: This can be done by organizing house to house search till the area is free of epidemic and medical examination of population at risk.factors. information on common source of infection according to the disease under investigation e. An epidemiological sheet is prepared for every case. . history of immunization. It includes basic information on age..

e. e.. Selective or high risk screening i. kidney diseases. These are not diagnostic tests eg mass chest screening by miniature X-rays. anaemia.In this a number of tests for different condition are krouped together to screen for a number of condition at one and the same time eg test for lung cancer. General health survey is not a regular practice in our country.2 Screening of Diseases Screening of disease is defined.. Similarly pap smear for cancer of the cervix.e. . This will help in detecting lesions which may or may not be tubercular and hence require further investigation. Longitudinal. Screening. rapid and inexpensive because they are meant for large population. women 35 + and lower social group have more chances of cancer of cervix and if they are screened for that. screening of only those who are at high risk to have a particular problem or disease. those who have high possibility of having the disease under study. surveys provide v'aluable information about the natural history of diseases. diabetes.e. The health surveys provide comprehensive data about health and sickness status of the whole community.g. diabetes. screening of the whole population or the subgroups whet]ner or not exposed to the risk of having the disease under study. then there are more chances of detecting the cases.9 4. Similarly people having a family history of diabetes. i. There are three types of screening. but are difficult to organize and are time consuming etc. etc. Surveillance and Monitoring. The basic purpose of screening for disease protection is to separate from a large group of apparently healthy population.6. 4.1 Health Surveys Health surveys are investigations to identify health problems in health and disease in a community. It is not advisable under the present limited resources.6. Cross-sectional surveys provide data about the prevalence and distribution of illness and the state of health of a community at one point in time. Health surveys help in making community diagnosis. Special and specific health surveys deal with the investigation of selected health problems e. ji) iii) Multiple screening . visual and audio defects are grouped together. It has only been done once or twice in our country. namely: i) Mass screening i. breast cancer should be screened for such problems. The screening test are usually very simple. examination or procedures in an apparently healthy population". The important point is that we must concentrate on the early detection of those diseases for which early treatment is available and it is effective eg tuberculosis. as "The search for unrecognized diseases by means of rapidly applied tests. Whether general or specific health surveys can be cross-sectional or longitudinal. brought to treatment. Mudaliar. cardiovascular diseases. mild and symptomatic diseases.. determinants. Screening helps to detect persons with early mild and symptomatic diseases. cancer of cervix and the breasts.e. filarial malaria or tuberculosis etc. Once I 1946 by the Health Survey *and Development Committee headed by Sir Joseph Bhore and again in 1962 by Health Survey and Development committee headed by Dr. Introduction to Epidemiology 4.6 PREVENTIVE EPIDEMIOLOGY Preventive epidemiology is concerned with those measures at the community level which help in identification of population at risk and environmental factors leading to ill health and detection of persons with early. cancer of the breast and uterus. so that they may undergo further investigation and if diseased. occurrence and distribution and the factors affecting health and disease i.. These measures include: Health surveys. incidence and prev&nce of diseases and the underlying causes.g.

Monitoring is ongoing. implementation of active and passive surveillance for the prevention and control of malaria. 4.3 Surveillance The literal meaning or surveillance is supervision or close watch specially on suspected person Epidemiologically surveillance means continuous scrutiny of the factors that determine the occurrence. typhoid cases and carriers. The main steps involved are : collection of relevant information about the disease under surveillance. dissemination of this information to the concerned authority for decisions and actions leading to prevention and control of diseases. The epidemiological surveillance can be: i) ii) Individual Surveillance .and distribution of diseases and other conditions of ill health It is more than simple reporting of cases. Epidemiologically it is a specific and essential part of surveillance. routes of transmission. It includes identification of missed and suspected cases and contacts..6.4 Monitoring and Evaluation The literal meaning of monitoring is maintaining regular surveillance. finding out source of infection. Local Population Surveillance .it includes surveillance of an infected person as long as he is the source of infection to others e.e. iii) National Surveillance .. This implies maintaining records of surveillance activities performed and reporting deviation to authority to take corrective measures.g. polio.surveillance of some of the important diseases like influenza. day-to-day follow-up of surveillance activities which are to. This information will help in planning and implementing prevention and control of diseases in the community.g.be implemented as planned. iv) International Surveillance .. analysis and interpretation of this information. surveillance of small pox after its eradication.g. their confirmation by laboratory investigations.~rinciples and Practice of Community Health Nursing 4.e. .6. malaria done by WHO and it provides information to the countries in the world to take timely action.

.......................... ... i) A nurse working in the community deals with the people in various settings and h d p them to solve their health problems. .. ................ 11............................ A nurse makes use of epidemiological ......................................Introduction to Epidemiology 5) Defixie surveillance and monitoring? ................................................................................................................................. ..................... < ...............................................................................................................................1 ........................ 6) What are the differet~t: types of' surveilllmcel? The science of epidemiology is basic to profession 01nursing wherever it is practiced............................. ..... ..................................................................................

etc. E. e e Notification of certain specific diseases like measles. formulates alternative interventions and implements the prevention and control of problem and evaluates the effectiveness of the intervention. Health education of. the secaid is in human host which start with the interaction of agent and host undqr a favorable environment and refers to 'pathogenesis'. hepatitis.# ranges from mild to severe. method of spread of infection. not only those who are working in the community setting. community diagnosis.people in general. you have learnt that epidemiology is the basic science of community health. She may deal with the problem independently especially when there are minor ailments or simple health conditions and she is the only health worker in the health agency. accidents. mental health problems. Epidemiologically there are three major categories of factors i. Identify the source of infection. diphtheria.. keep them under surveillance. But chronic and degenerative diseases are caused due to complex interaction of multiple factors related to life style. iniplementing and evaluation. She participates in data collection data analysis. tetanus. through health education and helping people in their life style. cancer. Kiowledge of the basic concepts involved in the epidemiological process is essential for any nurse. One phase is in the environment before the onset of disease and refers to 'pre pathogenesis'.Principles and Practice of Community Health Nursing process in solving t h e problem i. surveillance activities and screening-etc. Trace the contacts. occurrence of any epidemic or community level general health survey or specific health survey. analytical and experimental are useful for greater understanding of population health. and necessary background information which helps in planning and implementing effective health services to prevent and control various health and health related problems including infectious. rabies. having two phases.e. human behavious and environmental condition known as " web of causation". ii) a Nurses in the community have an active role in prevention and control of communicable disease which include: Participation in early diagnosis and treatment i. identification of all cases. environment which interact to cause various diseases. She may pmicipate as one of the team members especially when it is large scale investigation. 4. mild undiagnosed cases remain hidden and become a source of infection to others. The sub clinical. host and . They also participate in its investigations. agent. planning.g.8 LET US SUM UP After going through this unit. non infectiobs and chronic diseases. ' . .e. In the absence of any intervention almost all diseases follow a natural cause of event which refers to the natural history of disease. Nurses play a key role in prevention and control of diseases as well as in restoring and maintaining optimum health wherever they practice. ' e iii) The nurses should take notice of any uliusual occurrence of any disease in large numbers and report the same to the authority. she identifies and investigates the problems. h e severity of illness . iv) Nurses in the community have an important role in prevention and control of chronic and non-infectious problems such as cardio-vascular conditions.e. Epidemiological methods such as descriptive. STD to the health authority.

they may be physical. chemical or physical in nature. Clustering Communicable Ecology : Grouping offcolony oflcrowding of. Environment : The aggregated of all external conditions that may Epidemic : The occurrence in a community or region of an illness or. It is very important to do systematic investigations not only to deal with the existing problem of the epidemic but also to deal with the problem in the future. enhance or inhibit the interaction between host and agent. - The occurrence of disease more than nor~nal expectancy in a community during a specific time is known as an epidemic which can be due to common source of infection' or due to spread of infection from one person to another. 97 . 4. Tertiary level prevention to limit viability and help individual to adjust the permanent impairment by physical. Preventive measures which can be planned and implemented at the community level to prevent and control diseases are: i) conduct of health service. : Able to be transmitted from one host to another. Endemic . cultural and economical. monitoring and evaluation. analysis and interpretation of these information. Epidemiology is a basic requirement for preparation of community health nurse and all othe'r members of health team to function effectiverly in the community. to determine health needs and problems.f According to natural history of disease there are &ee levels of prevention which include: Introduction to Epidemiology - Primary level prevention to prevent the occurrence of disease which includes health promotion and specific protection. biological. Community health nurses play an important role in epidemiological studies of human population and their problems by way of collection of information. vocational and psychological rehabilitation.- : Habitual or usual presence of a disease or infectious agent within a defined geographical area. which may be biological.a group of illness of similar nature clearly in excess of normal expectation. social. Secondary level prevention includes measures taken during the pathogenesis phase to stop or control the spread of disease by early detection and treatment. : A branch of biological science concerned with the study of interrelationship of organism and their environment.9 KEYWORDS Agent : Causative factor invading a susceptible host through a favorable environment to produce disease. Etiology : Cause of a disease condition. ii) screening for disease or detect persons with early mild and symptomatic diseases. iii) suweillance.

2) 'To determine the morbidity pattern. This theory differed from germ theory which explains t$t there is one shingle specific causative agent to every disease i.e. 1 Susceptible Host : Sensitive host i.10 ANSWERS TO CHECCK YOU PROGRESS Check Your Progress 1 1) Epidemiology is the study of frequency. : Measurement of all cases (old or new) of disease or other conditions present in a population at a given time. Hypothesis Immunity Incidence Statement showing relationship of one factor with the other. : Death.. Morbidity Mortality : Illness or some other conditions. determinants of health. health related States and events and their determinants for the. not synonymous to disease.one effect whereas according 98 . distribution ahd determinants. Insusceptibility to disease or condition. : An epidemic over a wide geographical area. : Close or detailed exsunination. web of causation. evaluating and monitoring bf health services. not including . the host who does not 'have imm.implemeriting. It also deals with planning.Principlqs and Practice of Community Health Nursing Host A vertebrate or invertebrate species (human. . one cause .e.a population during a given period. etc) capable of being infected or affected by an agent. animals. 3) Modern epidemiology not only deals with study of frequency. Infection : The entry and development or multiplication of an infectious agents in the body of host. 4. critical gaze. death. 2) Epidemiological triad theory explains that the disease is caused due to interaction of three categories of factors which include host. Scrutiny . dishbution and determinants of health related states/events ai~d morbidity patterns in population and the applications of this study to control health problems. disabilities Ad mortality among people but also those hkalth related conditions and events and situation which have direct or indirect effect on-health of the people. Check Your progress 2 1) Germ theory : epidemiologicid dlad. A measurement of the number of new cases of a disease or other event occurring in..unity. or Pandemic Prevalence even worldwide. may be natural or acquired. agent and environment.purpose of planning and implementing comprehensive health care services.

In that case disease process goes through series of stages as shown in Fig 4.e. d) Health and health allied resources. sex education. disability limitations adequate treatment. During the prepathogenesis period the disease has yet not occurred. to know the details of the problem in question. avoidance of allergens. adequate housing.e.. recreation. Tertiary Level Prevention .Health promotion i. These factors are in state of equilibrium. Measures taken at this stage will help monitoring the health ecluilibrium of agent. occupational theory. Secondary level prevention .Facilities for retraining and education for ~naximum use of remaining capacities. personal hygiene. genetics. 4.. Pathogenesis : This phase begins with the entry of agent in human being.to epidemiological triad in addition to one single specific cause there are othe~ factors which are responsible for causing disease i. good nutrition.5 in the text. 8) Occurrence of disease is compared with the ice berg because only in a few which is like floating up clinical diagnosed cases are known to the epiden~iologist of the ice berg which is visible on the surface. periodical selective screening. personalily development. Introduction to Epidemiology 4) a) Human biology. b) Life style. Check Your Progress 3 1) There are two major approaches to the epidemiological study of any disease or health problem i. 99 . specific protection i..e. 7) Spectrum of disease refers to graphic represenlation of the variation of disease occurrence in people. there has not been optimal interaction of agent. host and environment and thus prevent optimal interaction of these factors and hence prevent the occurrence of the disease. host and environment. more than one disease and there is complex interaction among the causative factors. screening selective examinations. three categories of causative factors to cause a disease. provision of facilities. (a) investigation . 5) See the definitions given in the text. Draw your own figure. host and environtnent.e. protection from occupational accidents etc.e. 10) Primary Level Prevention . Draw your own figure. environtnental sanitation. health education. whereas majority of the subclinical presympton~atic. The disease will occur only when there is optimal interaction of agent. disease have occurred in man. making observations through records etc. enhance the quick and conlplete recovery and prevent disability and premature death. n~easures taken during this period will prevent the occurrence of disease to others. See Fig. 9) Three levels of prevention of disease are bascd on the stages of natural history of disease. Agent has yet not entered in the human host i. 3) Web of causation means that there are multiple causes which have multiple effects i. use of specific nutrition. imnlunization.Early diagnosis and prompt treatment which includes case finding.~nissed cases are unknown like the hidden portion of the ice berg under the water. marriage counseling. During the pathogenesis period the state of equilibrium is lost.e.means asking questions. These measures refer to secondary level prevention and tertiary level of prevention. 6) Prepathogenesis is the first phase of disease and it is before the occurrence of disease in man. good working conditions.6. c) Environment.

determine health deficits.Principles and Practice of Community Health Nursing (b) making comparison of two different groups one with the problem and other without the problem and to find why it is so? i. the direction is from cause to effect. the direction is from effect but to cause. Check Your Progress 4 1) See the definition given in the text.e. the disease have yet not occur~ed people are exposed to the iisk factor under study. Comparison can also be made of two groups .e. these studies go beyond descriptive studies and help in determining the causative factors. The investigator administers an interventionltreatme~ltto the o the experimental group but not in the control group which is similar L experimental group in all its characteristics. find out all cases. This method helps to know he community health status and make diagnosis i. In this. The health surveys can be general and 1 specific and these can be cross-~ect~iional and longitudinal. In propagated epidemics.e.- Check Your Progress 5 1) Health Surveys are investigations to identify problems of health and disease in a i comnunity and the factors affecting them.e. If it is due to continuuus or extended over a repeated exposure. 3) Investigation of epide&c help to: - confirm the existence of epidemic. there is clustering and sudden explosion of the cases and rapid fall in case. Whereas in case of cohart study. I I I . epidemic are not explosive.regulas ~md period of time i. It gradually fall off. The investigator makes observation over a long period of time of the expected outcomes. Thus this method have contributed in of the disease. the condition under careful control of investigator. know the population at risk. the epidemic is due to porlion to person contact. It flares gradually depending upon herd immunity. but il. studies are done on the basis of etiological clues obtained by 3) ~nalytical descriptive studies i. 2 ) Descriptive epidemiology is a method of study of occurrences and distribution of disease and health related events in a population by person. Experimental studies are comparative studies like analytical studies but are different from analytical studies in their design. I 100 4 . and foilnulation and implementation of alternative actions that will help prevent and control of the existing epidemic and epidemic in future. opportunity for contact. beyond the range of one incubation period. In experimental studies. time and place. understanding the causative factors and natural h s t o ~ y 4) Case control method is retrospective i. health threats and foreseeable crisis situation and possible associated factors as discussed in community identification unit. the factor causing the problem. understand underlying factors causing epidemic. the disease have already occurred and the investigator investigates the etiological factor i. Cohslrt study is prospective in nature. 5 ) Experimental studies are impostant because these studies help to (a) confirm the cause and effect association of the disease.one exposed to the risk factor and the other not exposed to the risk factor and to observe the effect over a period of time. 2) In common source epidemic it if is due to single exposure.e. and (b) evaluate or assess the efficacy of preventive or therapeutic agent or procedure.e.

d) Conforming the cause and effect relationship.national surveillance and Individual surveilla~lce. e) Evaluating and assessing the efficacy of the prevention and therapeutic agents. people at risk and accordingly plan and ilnpleinent services.screening only those people who are at high risk of problem under study. . c) Study of natural history of diseases.e. international surveillance. foreseeable crisis situation and possible association of factors.screening of whole population. local population surveillance. who have high possibility of having a disease under study.See definition given in the text. b) Planning and evaluation and monitoring of health care services. The purpose to identify persons from normal population.. 7) a) Identificatibn of conlrnunity health stalus and making diagnosis i. ' Introduction to Epidemiology b) Selective or high risk screening . determination of health deficits. See the definition in the text. health threats. a) Mass screening . Identification of epidemics. c) Multiple screening.