Epidemiology

Epidemiology
An introduction.....

Dinesh Chaudhary

Epidemic
The occurrence in a community or region of
cases of an illness, specific healthrelated
behaviour,, or other healthbehaviour
health-related events
clearly in excess of normal expectancy.
- JM Last : A Dictionary of Epidemiology

Epidemiology derives from "epidemic," a

term which provides an immediate clue to
its subject matter. Epidemiology originates
from the Greek words,
epi = upon
demos =people
logy = study of

Evolution of Definitions
Applied exclusively to epidemic
Historical Definition:

The science or doctorine of epidemics.

- New standard Dictionary of English

The branch of medical science which treats of

epidemics.
- Parkin 1873

The science of the mass phenomena of

infectious diseases.
- Frost, 1927

Evolution
Epidemilogy is the study of the pattern of
diseases and the factors that cause disease in
man.
Centre of Disease Control, US Public health Service

Epidemiology is the study of the distribution

and determinants of disease frequency in
man.

Evolution
The study of the distribution and
determinants of health related states
and events in specified populations
and the application of this study to
control of health problems
problems
John M. Last, A Dictionary of Epidemiology

MacMahon,
MacMahon, 1960

Key Aspects of This Definition

Determinants

Determinants
Distribution
Population
Health problems

Factors or events that are capable of

bringing about a change in health.

Examples of Determinants
Biologic agents--bacteria
Chemical agents--carcinogens
Less specific factors--stress, drinking,
sedentary lifestyle, or high-fat diet

Population
Epidemiology examines disease occurrence
among population groups, not individuals.
Epidemiology is often referred to as
population medicine.
The epidemiologic description indicates
variation by age groups, time, geographic
location, and other variables.

Distribution
Frequency of disease occurrence may vary
from one population group to another.
Example: Hypertension more common
among young black men than among
young white men.

Health Problems
Epidemiology investigates many different
kinds of health problems/outcomes:
Infectious diseases
Chronic diseases
Disability, injury, limitation of activity
Mortality
Active life expectancy
Mental illness, suicide, drug addiction

Components of Epidemiology
Disease frequency: Rate, ratio, proportion
Distribution of disease: with relation to time,
place, person
Determinants of disease: agent, host and
environment

Ultimate Aim of Epidemiology

To eliminate or reduce the health problems
or its consequences
To promote the health and well being of
society as a whole

Uses of epidemiology cont.

3.Look at risks of individuals as they affect
groups or population.
-What are the risks factors, problems, behavoiur
that affects group?
-Risk factor assessment done: health screening,
medical exams, disease assessments.
4. Planning and evaluation:
-How well do public health and health services
meet the problems and needs of the population
or group?

Aims of Epidemiology
To describe the distribution and magnitude of
health and disease problems in human population
To identify etiological factors (risk factors) in the
pathogenesis of disease
To provide the data essential to the planning,
implementation and evaluation of services for the
prevention, control and treatment of disease, and
to the setting up of priorities among those services

Uses of epidemiology
1.To study the history of disease:
-Trends of a disease for the prediction of trends.
-Result are useful in planning for health services
and public health.
2.Community diagnosis:
-What are the diseases, conditions, injuries,
disorders, disabilities, defects causing illness,
health problems or death in a community or
region?

Uses of epidemiology cont.

5.Completing the natural history of disease:
-Identification and diagnosis process to establish that
a condition exists or that a person has a specific
disease.
6.Identification of syndromes:
Help to establish and set criteria to define syndromes.
7. Searching for causes and risk factors:
-Findings allow for control, prevention, and
elimination of the causes of disease, conditions,
injury, disability and death

Branch of Epidemiology

Comparison between
Epidemiology and Clinical Medicine
Subjects

1. Descriptive Epidemiology

Epidemiology

1. Unit of study

2. Analytical/Etiological Epidemiology
3. Experimental Epidemiology
4. Serological Epidemiology
Immunological studies
Biochemical studies
5. Clinical Epidemiology
6. Operational Epidemiology

Defined population or
population at risk

Clinical Medicine
Case or cases

2. Examination

Survey of particular community Patients

3. Concerns with

Both sick and healthy people

Cases with disease pattern

4. Diagnosis

People/community diagnosis
by survey

Patient diagnosis with the help of

signs and symptoms, laboratory
and radiological tests

5. Objectives

To identify particular source of To diagnose, prognosis and

infections, mode of
prescribe specific treatment for the
transmission, etiological factors diseases within the limited time.
and ways to control these
problems and continuous
follow up

Comparison between
Epidemiology and Clinical Medicine.....
Subjects

Epidemiology

Clinical Medicine

6. Relationship

Epidemiology goes to the

community to find and
solve health problem

Patients come to the doctor

for treatment

7. Area concern

Concern with preventive

and promotive measures

Concern with curative

measures

8. Concept

Biostatistical

Biomedical

9. Result

Symbolized in the form of

tables and graphs

Symbolized as medical and

laboratory report

10. Time

Sustainable and long

process

Quick and short results

Historical Antecedents
Environment and disease
Use of mortality counts
Use of natural experiments
Identification of specific agents of disease

History
of
Epidemiology

The Environment
Hippocrates wrote On Airs,
Waters, and Places in 400 BC.
He suggested that disease
might be associated with the
physical environment.
This represented a movement
away from supernatural
explanations of disease
causation.

Use of Mortality Counts

John Graunt, in 1662, published Natural

and Political Observations Made upon the

Bills of Mortality.

Use of Natural Experiments

John Snow was an
English physician and
anesthesiologist.
He investigated a cholera
outbreak that occurred
during the midmid-19th
century in Broad Street,
Golden Square, London.

John Graunts Contributions

Recorded seasonal variations in births and
deaths.
Showed excess male over female
differences in mortality.
Known as the Columbus of
biostatistics.

Snows Contributions
Linked the cholera epidemic to
contaminated water supplies.
Used a spot map of cases and
tabulation of fatal attacks and deaths.

Snows Natural Experiment

Two different water companies supplied water
from the Thames River to houses in the same
area.
The Lambeth Company moved its source of
water to a less polluted portion of the river.

John Snows Cholera Map

Snow noted that during the next cholera

outbreak those served by the Lambeth
Company had fewer cases of cholera.

Natural Experiment
Definition: The epidemiologist does not
manipulate a risk factor but rather observes
the changes in an outcome as the result of a
naturally occurring situation.

Examples of Contemporary
Natural Experiments
Seat Belt LawLaw--Did seat belt use reduce
fatalities from motor vehicle accidents?
Tobacco TaxTax--Did the increase in cigarette
price decrease the sale of cigarettes?
Helmet LawLaw--Did requiring the use of
helmets by motorcyclists reduce the number
of head injuries sustained?

Other Historical Developments

Alexander Langmuir established CDCs
Epidemiologic Intelligence Service.
Wade Hampton Frost was the first
professor of epidemiology in the U.S.
Joseph Goldberger discovered the cure
for pellagra.

Contemporary Natural Experiments

Currently, natural experiments may be the
result of legislation, policy changes or
environmental interventions.

Koch's Postulates

Microorganism must be observed in every case of the

disease.
 Microorganism must be isolated and grown in pure

culture.
 Pure culture must, when inoculated into a susceptible

animal, reproduce the disease.

 Microorganism must be observed in, and recovered
from, diseased animal.

Recent Applications of Epidemiology

Framingham Heart Study (since 1949)
investigates coronary heart disease risk factors.
Smoking and lung cancer; e.g., Doll and Petos
study of British doctors smoking.
AIDS, chemical spills, breast cancer screening,
secondhand smoke.

Additional Applications of Epidemiology

Infectious diseases
Environmental health
Chronic diseases
Lifestyle and health promotion
Psychiatric and social epidemiology
Molecular and genetic epidemiology

Level of Health and Disease

Positive health
Better health
Freedom from sickness
Unrecognized sickness
Mild sickness
Severe sickness
Death

Determinants of Health

Spectrum of Health
The concept of health and disease spectrum emphasizes
that the health or disease of an individual is not static
static:: it is
a dynamic phenomenon and a process of continuous
change, subject to frequent subtle variations.
variations.
According to the concept health and disease lie along a
continuum, and there is no single cut off point, the lowest
point on the health disease spectrum is death and the
highest point corresponds to the WHO definition of positive
health..
health
It is thus, spectrum declare that health fluctuates within a
range of optimum wellwell-being to various level of dysfunction
till death.
death.

Determinants of Health
Health is multimulti-factorial.
The factors which influence health lie both
within the individual and externally in the
society in which he or she lives.
These factors interact and these
interaction may be health promoting or
deleterious.

Determinants of Health
1. Biological determinants
2. Behavioural and sociosocio-cultural conditions
3. Environment
4. Socio
Socio--economic conditions
5. Health services
6. Aging of the population
7. Gender
8. Other factors

1. Biological determinants
The physical and mental traits of every human being
are to some extent determined by the nature of his
genes at the moment of conception.
A number of diseases are now known to be
genetic origin, e.g. chromosomal anomalies,
errors of metabolism, mental retardation, some
types of diabetes etc.
Therefore; the state of health depends partly on the
genetic constitution of man.

3. Environment
Environment is classified as internal and
external.
The internal environment of man pertains to
each and every component part, every tissue,
organ and system and their harmonious
functioning within the system.
The external environment consists of those
things to which man is exposed after
conception. It can be divided into physical,
biological and psychosocial components, any or
all of which can affect the health of man and
his susceptibility to illness.

6. Aging of the Population

Major concern of rapid population aging is the
increased prevalence of chronic diseases and
disabilities both being conditions that tend to
accompany the aging process and deserve special
attention.

7. Gender
The Global Commission on Womens Health drew
up an agenda for action on womens health
covering nutrition, reproductive health, the health
consequences of violence etc.

2. Behavioral and sociosocio-cultural conditions

It is composed of cultural and behavioural patterns and
lifelong personal habits e.g. smoking, alcoholism that
have developed through process of socialization.
Life styles are learnt through social interaction with
parents, peer groups, friends and siblings and through
school and mass media.
In the developed countries coronary heart disease, obesity,
lung cancer, drug addiction etc. are associated with
lifestyle change.
In developing countries where traditional life styles still
persist, risks of illness and death are connected with
lack of sanitation, poor nutrition, personal hygiene,
customs and cultural patterns.

4. SocioSocio-economic conditions
Socioeconomic conditions have long been known to influence
human health.
Health status is determined primarily by their level of
socioeconomic development, e.g. per capita income,
education, employment, housing, the political system of the
country etc.

5. Health services
The term health and family welfare services cover a
wide spectrum of personal and community services for
treatment of disease, prevention of illness and promotion
of health.
The purpose of health services is to improve the health status
of population.

8. Other factors
Other contributions to the health of population
derive from systems outside the formal health
care system, i.e. health related systems (e.g.
food and agriculture, education, industry, social
welfare, rural development) as well as adoption of
policies in the economic and social fields that would
assist in raising the standards of living.

Mode of transmission
Two types
Direct transmission
Indirect Transmission

Indirect transmission
Vehicle-borne
VehicleVector--borne
Vector
Air
Air--borne
Fomite--borne
Fomite
Unclean--hand & fingers
Unclean

Direct Transmission
Direct contact: contact from skin to skin, mucosa to
mucosa or mucosa to skin by touching, kissing, sexual
contact. Eg
Eg.. HIV, Gonorrhea, Hep B, eye infection etc.
Droplet infection: Size < 5 mm of droplet can
penetrate into alveoli/ spread at distance 30 to 60
cm/eg
cm/
eg.. Common cold, Diptheria,
Diptheria, TB etc
Contact with soil: eg.
eg. Hookworm, tetanus etc
Inoculation into skin or mucosa: Eg rabies virus
by dog bite, HIV & Hep B through contaminated
needles & syringe
Trans placental route: Syphilis, Hep B, Malaria etc

Vehicle--borne
Vehicle
Vehicles refer to water, food, blood, serum, plasma
and other biological products such as tissues/organ,
which transmit disease like diarrhoea,
diarrhoea, food
poisoning, hepatitis A & B, enteric fever etc.

Vector-- borne
Vector
An insect or orthopodes that transports agent are
called vector i.e. Mosquitoes, housefly, sandfly,
sandfly,
ticks etc. They are responsible for the transmission
of variety of infections such as malaria, encephalitis
etc

Air
Air--borne
Air
Air--borne diseases are transmitted through the
droplet nuclei & dust. Droplet nuclei are the tiny
particles range from 1 to 10 micron. Eg disease
transimitted through droplet nuclei are TB, measles,
pneumonia, influenza etc

Fomite borne
Articles or substances which contain infectious
discharge of disease person, may capable of
transmitting an infectious agent is known as fomite
i.e. Clothes, towels, cups, spoon etc & the disease
caused by these are dysentry,
dysentry, intestinal worms,
typhoid etc.

Unclean hand and fingers

Unclean hand and fingers are most ommon
mode of transmission of infectious agent for
example agent transfers to food or vehicles
directly or indirectly through skin, nose,
boewl.. Dysentry,
boewl
Dysentry, intestinal worms, typhoid
etc.

Natural history of disease

Natural history of disease consist of two
phases-phases

TIME
Death
Clinical
disease

Infection
Susceptible
host

Recovery
No infection

PrePre-pathogenesis phase (i.e. the process in

environment)
Pathogenesis phase (i.e. the process in man)

Incubation period
Latent

Non-infectious

Infectious

Exposure

Onset

PrePre-pathogenesis Phase
the process in environment
Refers to the period preliminary to the onset of
disease in man.
The disease agent has not yet entered man but the
factors which favour the onset are already existing
in the environment.

Causative factors of Disease

Three factors referred as epidemiological
triad-- agent, host and environment.
triad
Operating in combination, these factors
causes not only single case to epidemics,
but also the distribution of disease in
community.

Pathogenesis phase

Begins with the entry of the disease agent in

the susceptible host.

The infection in the host may be clinical, subsubclinical; typical or atypical or the host may
become carrier with or without having
developed disease. (e.g. diphtheria, poliomyelitis)

The disease progresses through incubation

period,early and late pathogenesis.
Final outcomeoutcome- recovery, death, disability.

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Agent factors
Agent is defined as a substance ,living or nonnonliving, or a force tangible or intangible, the
excess presence or relative lack of which may
initiate or perpetuate a disease process.
Classified as:
Biological agents:
Viruses, Rickettsiae,fungi,bacteria,protozoa
and metazoa.

Nutrient agents:
Proteins, fats, carbohydrates, vitamins,minerals,
and water.
Any excess or deficiency of the intake of nutritive
elements may result in nutritional disorder .eg.
PEM, anemia, goiter, obesity and vitamin
deficiencies.
Physical agents:
Heat, cold,humidity,pressure,radiation,electricity,
sound, etc.
Excessive exposure may result in illness.

Chemical agents:
(i) Endogenous: some chemicals produced in

body as result of derangement of

function.eg:urea,serum bilirubin,ketones,uric
acid,calcium carbonate.
(ii)Exogenous: outside human body
eg. Allergens, metals,fumes, dust, gases,
insecticides,etc.

Host factors

Mechanical agents:
Chronic friction and other mechanical forces may
result in crushing,tearing,sprains,dislocations,etc
crushing,tearing,sprains,dislocations,etc..

Absence or insufficiency or excess of a factor

necessary to health:
i)
ii)
iii)
iv)
v)
vi)

Chemical factors like hormones

Nutrient factors
Lack of structure like thymus
Lack of part of structure like cardiac defect
Chromosomal factors
Immunological factors

Plays major role in determining outcome.

Classified as:
(i) Demographic characteristics: age, sex, ethinicity
ethinicity..
(ii) Biological characteristics: genetics, biochemical,
enzymes, blood groups.
(iii) Social and economic characteristics:
SES,education,occupation,stress,, marital status,housing
SES,education,occupation,stress
status,housing..
(iv) Lifestyle factors: alcohole
alcohole,, smoke,drugs,etc
smoke,drugs,etc..

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Environmental factors
The external or macro environment is defined
as all that which is external to the individual
human host, living and nonnon-living, and with
which he is in constant interaction.

Iceberg of disease
What the
physician sees

community

Symptomatic disease

Eg
Eg:: air, water, food, housing,etc
housing,etc..
What the
Physician
does not see

Distribution of Disease
Time
Place
Person

I. ShortShort-term fluctuations
The best known shortshort-term fluctuation in the occurrence of
a disease is an epidemic.

Types of epidemics
Three major types of epidemics may be distinguishec

A. Common - source epidemics

a. Single exposure or "point source" epidemics.
b. Continuous or multiple exposure epidemics

B. Propagated epidemics
a. (a) PersonPerson-toto-person
b. (b) Arthroood vector
c. (c) Animal reservoir

C. Slow (modern) epidemics

Presymptomatic
disease

Time Distribution
The pattern of disease may be described by the time of
its Occurrence
It raises questions whether the disease is seasonal in
occurrence; whether it shows periodic increase or
decrease; or whether it follows a consistent time trend.
It yields important clues about the source or aetiology of
the disease, thereby suggesting potential preventive
measures.
Epidemiologists have identified three kinds of time trends
or fluctuations in disease occurrence.
I. Short
Short--termfluctuations
II. Periodic fluctuations, and
III. Long
Long--term or secular trends

II.. Periodic fluctuations

I. Seasonal trend : Seasonal variation is a wellwell-known characteristic

of many communicable diseases. For example, measles is

usually at its height in early spring and so is varicella.
varicella. ARI
frequently show a seasonal rise during winter months.
Gastrointestinal infections are prominent in summer months
because of warm weather and rapid multiplication of flies. The
seasonal variations of disease occurrence may be related to
environmental conditions (e.g., temperature, humidity, rainfall,
overcrowding, life cycle of vectors, etc.) which directly or
indirectly favour disease transmission.
II. Cyclic trend : Some diseases occur in cycles spread over short
periods of time. For example, measles in the prepre-vaccination era
appeared in cycles with major peaks every 22-3 years and rubella
every 66-9 years. This was due to naturally occurring variations
in herd immunity. Influenza pandemics are known to occur at
intervals of 77-10 years, due to antigenic variations

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III. LongLong-term or secular trends

The term "secular trend" implies changes
in the occurrence of disease (i.e., a
progressive increase or decrease) over a
long period of time, generally several
years or decades.
Coronary heart disease, lung cancer and
diabetes which have shown a consistent
upward trend in the developed countries
during the past 50 years or so

PERSON DISTRIBUTION
In descriptive studies, the disease is further
characterised by defining the person who
develop disease by age, sex, occupation,
martial status, habits, social class and
other host factors.
These factors do not necessarily represent
aetiological factors, but they contribute a
good deal to our understanding of the
natural history of disease.

Place Distribution
a. International variations
b. National variations
c. Rural - urban differences
d. Local distributions

ICD
The International Classification of Diseases (ICD) is the standard
diagnostic tool for epidemiology, health management and
clinical purposes.
This includes the analysis of the general health situation of
population groups.
It is used to monitor the incidence and prevalence of diseases
and other health problems, proving a picture of the general
health situation of countries and populations.
populations.
ICD is used by physicians, nurses, other providers, researchers,
health information managers and coders, health information
technology workers, policypolicy-makers, insurers and patient
organizations to classify diseases and other health problems
recorded on many types of health and vital records, including
death certificates and health records.

ICD....
In addition to enabling the storage and retrieval of diagnostic
information for clinical, epidemiological and quality purposes, these
records also provide the basis for the compilation of national
mortality and morbidity statistics by WHO Member States. Finally,
ICD is used for reimbursement and resource allocation decisiondecisionmaking by countries.
All Member States use the ICD which has been translated into 43
languages. Most countries (117) use the system to report mortality
data, a primary indicator of health status.
ICD--10 was endorsed by the FortyICD
Forty-third World Health Assembly in
May 1990 and came into use in WHO Member States as from 1994.
ICD is currently under revision, through an ongoing Revision
Process, and the release date for ICDICD-11 is 2017.

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