Epidemiology

Epidemiology
Epi = upon
Demos = people
Logos = science
"the study of what is (only) upon the people".

According to WHO (2017) ‘…. epidemiology is the study of the distribution and
determinants of health-related states or events (including disease), and the
application of this study to the control of diseases and other health problems.….’
 Epidemiology: Terminology

A disease is a particular abnormal condition, a disorder of a

Disease structure or function, that affects part or all of an organism.

is the rapid spread of infectious disease to a large number of people in a

Epidemic given population within a short period of time, usually two weeks or less.
Syndemic study of the interaction of diseases in a population

is the invasion of an organism's body tissues by disease-causing agents,

their multiplication, and the reaction of host tissues to these organisms and
Infection the toxins they produce.
transmissible disease or communicable disease, is illness resulting from an
Infectious disease infection.

Immunity Inherited, acquired, or induced resistance to infection by a specific pathogen

Epidemiology: Application/Scope

To determine, describe, and report on the natural course of disease, disability, injury, and death

To aid in the planning and development of health services and programs

To provide administrative and planning data

To study the cause (or etiology) of disease(s), or conditions, disorders, disabilities, etc.

To determine the primary agent responsible or ascertain causative factors

To determine the characteristics of the agent or causative factors

To determine the mode of transmission

To determine contributing factors

To identify and determine geographic patterns

 Epidemiology: Types / Methods

• examining the distribution of disease in a

Descriptive epidemiology population, and observing the basic features of
its distribution

• investigating a hypothesis about the cause of

Analytic epidemiology disease by studying how exposures relate to
disease

Descriptive epidemiology is antecedent to analytical epidemiology.

Analytical epidemiology • know where to look

studies require • know what to control for
information to ... • develop viable hypotheses
 Epidemiology: Descriptive Epidemiology

Three essentials characteristics of disease that we look for in descriptive epidemiology are ….

What = health
issue of
concern

Why/how =
causes, risk
Person
factors, modes Who = person
of transmission
5W

Time Place
When = time Where = place
Epidemiology: Descriptive Epidemiology

Three essentials characteristics of disease that we look for in descriptive epidemiology are ….

• age, gender, ethnic group

• genetic predisposition
• concurrent disease
Person • diet, physical activity, smoking
• risk taking behavior
• SES, education, occupation

• presence of agents or vectors

Geographic Place
• climate
• geology
• population density
• economic development
• nutritional practices
• medical practices
Epidemiology: Descriptive Epidemiology

Three essentials characteristics of disease that we look for in descriptive epidemiology are ….

• Calendar time
• Time since an event
• Physiologic cycles
Time • Age (time since birth)
• Seasonality
• Temporal trends
Epidemiology: Descriptive Epidemiology

Three essentials characteristics of disease that we look for in analytic epidemiology are ….

Key feature of analytic epidemiology = Comparison group

• Demographic factor such as age, race, or sex;

• Constitutional factor such as blood group or immune
status;
Characteristic • Behavior or act such as smoking or having eaten salsa;
or
• Circumstance such as living near a toxic waste site.

Identifying factors associated with disease help health officials appropriately target public health
prevention and control activities

It also guides additional research into the causes of disease.

Epidemiology: Epidemiological Studies

• investigator determines through a controlled process the

exposure
• tracks the individuals or communities over time to detect
Experimental the effects of the exposure.
• For example, in a clinical trial of a new vaccine
• Follow-up

• Observes the exposure and disease status of each

Observational study participant.
• Examples: Cholera in a place observational studies
Epidemiology:
Epidemiological
Studies
Types of
Observational
Studies
•Study on each
participant is
exposed or not
Cohort studies •Tracks the
participants to see if
they develop the
disease of interest
•A group of people
with disease
Case-control •Comparison group
studies to compare previous
exposures between
thesample
•A two groups
of persons
from a population
•Tends to assess the
Cross-sectiona presence
(prevalence) of the
l studies health outcome
•For example, in a
cross-sectional
study of diabetes
 •Epidemiology : The Epidemiologic Triangle

Epidemiologic
Triangle is a
mode
l or
tool
for
studyi
ng
Time
•The epidemiologichealth
triangle is made up of three parts: agent, host and
probl
environment (there are three factors to study the causes of a disease,
ems
in analytic epidemiology:
•Agent i.e.,
•Host how a
•Environment diseas
e
sprea
ds
and
how
 •Epidemiology : The Epidemiologic Triangle

•that causes the disease (the

“what” of the Triangle) • Types of Agents
•The agent is the • Biological (micro-organisms)
microorganism that
actually causes the disease • Physical (temperature, radiation, trauma, others)
Agent in question. • Chemical (acids, alkalis, poisons, tobacco, others)
•An agent could be some
form of bacteria, virus, • Environmental (nutrients in diet, allergens, others)
fungus, or Protozoa • Psychological experiences, stress, crime
(parasite).

•Bacteria •Protozoa
•are single-celled organisms. •Virus •Fungi •Protozoa are very small
•Fungi are like plants made up of •Most live in water
•Capable to reproduce themselves, by •A virus may have a spiny outside layer,many cells. They are not called
themselves. called the envelope. plants because they cannot produce •They are parasites, which
•They are larger than viruses (but still •Viruses have a core of genetic material,their own food from soil and water. means they live off other
much too small to be seen with the naked but no way to reproduce it on their own. organisms, in some cases
•Instead, they live off animals, humans.
eye). •Viruses infect cells and take over their including people, and plants.
•They are filled with fluid and may havereproductive machinery to reproduce. •Mushrooms and yeast are fungi. •Malaria is a parasitic
threadlike structures to move themselves, protozoan, as is Giardia.
like a tail.
 •Epidemiology : The Epidemiologic Triangle

•organism harboring the disease (the

“who” of the Triangle)
•The agent infects the host, which is
the organism that carries the disease.
•A host doesn’t necessarily get sick;
hosts can act as carriers for an agent
without displaying any outward
symptoms of the disease.
•Hosts get sick or carry an agent
Host because some part of their physiology
is hospitable or attractive to the agent.
•The “host” heading also includes
symptoms of the disease.
•Different people may have different
reactions to the same agent.
•For example, adults infected with the
virus varicella (chickenpox) are more
likely than children to develop
serious complications.
 •Epidemiology : The Epidemiologic Triangle

•those external factors that cause or allow

disease transmission (the “where” of the
Triangle)
•The environment includes any factors that
affect the spread of the disease but are not
directly a part of the agent or the host.
•Some diseases live best in dirty water.
Others survive in human blood.
Environment • For example, the temperature in a given
location might affect an agent’s ability to
thrive, as might the quality of drinking
water or the accessibility of adequate
medical facilities.
•Still others, like E. coli, thrive in warm
temperatures but are killed by high heat.
Other environment factors include the
season of the year
 •Epidemiology : The Epidemiologic Triangle
•In the center of the
Triangle is time.
•Most infectious diseases
have an incubation
period—the time between
when the host is infected
and when disease
symptoms occur.
Time •Time may describe the
duration of the illness or
the amount of time a
person can be sick before
death or recovery occurs.
•Time also describes the
period from an infection to
the threshold of an
epidemic
Epidemics occur when… foragent
host, a population.
and environmental factors are not
in balance.

•due to new agent

•due to change in existing
•agent (infectivity, pathogenicity, virulence)
•Due to change in number of susceptible in the population

AGENT
• HIV is a viral infection that
targets a person’s immune
system, making it more
vulnerable to other forms of
infection.
• Because the virus targets the
immune system itself, the body
cannot effectively fight HIV on
its own.
• HIV is communicated through
direct contact with an infected
person’s bodily fluids, and it
primarily spreads through sexual
contact or shared needles.
•Epidemiology : The Epidemiologic Triangle Example-1
HIV
HOST
• HIV was originally carried by
chimpanzees and that humans
who hunted these chimpanzees
for meat became infected with a
mutated form of the virus upon
contact with the chimpanzees’
blood.
• HIV can be transmitted when a
bodily fluid such as blood comes
into contact with a mucous
membrane or damaged tissue
(such as an open wound or the
mucous membranes found inside
the mouth).
ENVIRONMENT
• There are a number of
socio-economic factors that can
impact the spread of HIV within
a community.
• Communities with higher
concentrations of sexually
transmitted diseases (STD) and
lower incidences of reporting due
to social pressure or otherwise
allow HIV to flourish.
• Poverty limits access to care and
treatment, and discrimination can
discourage individuals from
being tested or seeking care.
 •Epidemiology : The Epidemiologic Triangle Example-2

Smoking Related Disease

AGENT HOST ENVIRONMENT

• Unlike the agent in many
epidemiologic triangles,
cigarettes and other forms of
tobacco are not microbes, and
smoking is not contagious in
the usual sense.
• It is not transmitted from
person to person,
though second-hand smoke is
dangerous.
• However, a carcinogen in the
smoke of a cigarette is an
agent.
• People become a potential host
for smoking-related diseases
when they smoke cigarettes or
when they inhale second-hand
smoke.
• A host can then suffer a variety
of ailments, from lung cancer to
heart disease to diabetes.
• Not all people who smoke
suffer the same effects at the
same rates; genetics play a part
here, as do environmental
factors.
• The reasons people smoke are almost
entirely social.
• Pressure from peers or friends, a need to
fit in, or susceptibility to the marketing
efforts of tobacco companies are all
factors that can lead to smoking and,
consequently, smoking-related diseases.
• In addition, environmental factors such as
the frequency at which people smoke and
the length of time they remain a smoker
can affect their chances of contracting a
smoking-related disease.
• Because cigarettes and other tobacco
products are highly addictive, individuals
are likely to continue to smoke once they
start.
Epidemiology:
Disease

The study of disease is called pathology which includes the

study of cause.

Disease is associated with specific symptoms and signs.

It may be caused by external factors such as pathogens, or

it may be caused by internal dysfunctions.

Does not allow the body to function normally.

Can affect individual organs or an entire body system.

Epidemiology:
Types of Disease

•Based
•Acute on are
diseases
those conditions in
symptom /effect appearance
which the peak severity
of symptoms occurs
within three months
(usually sooner), and
recovery in those who
survive is usually
Acute Diseases complete
•Example:
•Chronic
Asthma
diseases or
attack; Broken
conditions are bone;
those in
Bronchitis;
which Burn;
symptoms
Common
continue cold; Flu;
longer than
Heart
three attack;
months and in
Pneumonia;
some cases for the
Respiratory
remainder infection;
of the
Strep throat
person’s life. Recovery
is slow and sometimes
incomplete.
Chronic Diseases •Examples:
Alzheimer’s disease;
Arthritis; Chronic
obstructive pulmonary
disease (COPD);
Depression; Diabetes;
Epidemiology:
Types of Disease

•Based on symptom /effect appearance

Acute Chronic
Definition An acute disease is a disease A chronic condition is a human health condition or disease
with a rapid onset and/or a short that is persistent or otherwise long-lasting in its effects.
course.
Appearance of Sudden Usually gradual
symptoms
Duration Short; a few days to a week or Extended period of time; usually six weeks or more, often
two. months or years.
Nature of Pain Starts suddenly as a reaction to Develops gradually out of habitual diet, posture or other
an injury or something else. condition. Continues beyond expected period of recovery.
Examples Breaking a bone, burn, strep Osteoporosis, asthma, frequent migraines, consistent back
throat, flu, asthma pain, heart disease, kidney disease.
attack, heartburn.
Epidemiology:
Types of Disease

•Based on Transmission

Diseases for
which
biological
1. Communicable (Infectious) Diseases agents or their
products are
The disease
the cause and
process
which are begins
when the
transmissible
causative
from one
agent is able
individual toof
The
to process
lodge and
another and
lodgment
grow or
growth
reproduceof a
microorganis
within the
m or virus in
body
Examples:
the host is
Carbapenem-
termed
Resistant
infection
Enterobacteria
Epidemiology:
Types of Disease

•Based on Transmission

Those
diseases or
illnesses
2. Non-communicable (Noninfectious) that cannot
Diseases/Illnesses Several,
be or
even many,
transmitted
factors
from anmay
contribute
infected to
The
the
person to a
contributing
developmen
susceptible,
factors
thealthy may
of a given
one
be genetic,
non-commu
Examples:
environment
nicable
Cancer;
al, or
health
Diabetes;
behavioral
condition
Hypertensio
in nature
n;
Epidemiology:
Types of Disease

Acute Diseases
Communicable Common cold, pneumonia, mumps, measles, pertussis, typhoid
fever, flu

Non-communicable Appendicitis, Poisoning, Trauma (e.g., due to automobile

accidence, fires, etc.)

Chronic Diseases
Communicable Lyme disease, Tuberculosis, AIDS, Syphilis, rheumatic fever
following Streptococcal infections, Herpes

Non-communicable Diabetes, coronary heart disease, osteoarthritis, cirrhosis of the

liver due to alcoholism, hypertension
Epidemiology:
Path/Way/Course
Infectious of Disease

Some
Terminologies

Exposure •Invasion of Host

•period of time
between exposure
and onset of
symptoms -- e.g.,
interval between
Incubation HIV infection and
development of
AIDS can be as
long as 10-15
•Disease runs
years --
course
treatment,
Host reaction recovery/death
(most people don’t
die from infectious
diseases)
Epidemiology:
Path/Way/Course
Infectious of Disease

•Varies by disease
•Salmonella -- 12-72 hours after infection;
symptoms usually resolve in 5-7 days,
unless infected person is in a very
weakened health status
•Measles (rubeola) -- approx. 10-12 days
(prodomal -- i.e., interval between the
earliest symptoms and the appearance of
INCUBATION PERIOD the rash or fever -- rash onset, on average,
14 days
•HIV -- 6 weeks upward to months; interval
between HIV infection and development of
AIDS can be as long as 10-15 years
•2-6 weeks after infection in many, but not
all, diseases, most people develop
antibodies against reinfection
Epidemiology:
Chain/Path/Way/Course
Infectious of Disease

Infection is the
invasion
and growth
of bacteria,
For an or
viruses,
infection
parasites to
develop,
that are not
each link of
typically
the chain
existing
must
withinbethe
connected.
body.
Breaking
any link
•The spread of infection follows of chain
a strict
consisting of six elements / the chain
stages.
can stop the
transmissio
n of
infection!
Epidemiology:
Chain/Path/Way/Course
Infectious of Disease

•Stage 1: INFECTIOUS DISEASE

•Any microorganism that can cause a disease such as a bacterium, virus, parasite, or
fungus. Reasons that the organism will cause an infection are virulence (ability to
multiply and grow), invasiveness (ability to enter tissue), and pathogenicity (ability to
cause disease).

•Stage 2: RESERVOIR
•The place where the microorganism resides, thrives, and reproduces, i.e., food, water,
toilet seat, elevator buttons, human feces, respiratory secretions.
Epidemiology:
Chain/Path/Way/Course
Infectious of Disease

•Stage 3: PORTAL OF EXIT

•The place where the organism leaves the reservoir, such as the respiratory tract
(nose, mouth), intestinal tract (rectum), urinary tract, or blood and other body fluids.

•Stage 4 : MODE OF TRANSMISSION

•The means by which an organism transfers from one carrier to another by either
direct transmission (direct contact between infectious host and susceptible host) or
indirect transmission (which involves an intermediate carrier like an environmental
surface or piece of medical equipment).
Epidemiology:
Chain/Path/Way/Course
Infectious of Disease

• Stage 5: PORTAL OF ENTRY

•The opening where an infectious disease enters the host’s body such as mucus
membranes, open wounds, or tubes inserted in body cavities like urinary catheters or
feeding tubes.

• Stage 6: SUSCEPTIBLE HOST

• The person who is at risk for developing an infection from the disease. Several
factors make a person more susceptible to disease including age (young people
and elderly people generally are more at risk), underlying chronic diseases such
as diabetes or asthma, conditions that weaken the immune system like HIV,
certain types of medications, invasive devices like feeding tubes, and
malnutrition.
Epidemiology: Mode of
Communicable Disease
Transmission

•Immediate transfer of the disease agent by

direct contact between the infected and the
susceptible individuals
•Occurs through such acts as touching, biting,
kissing, sexual intercourse, or by direct
Direct Transmission projection (droplet spread) by coughing or
sneezing within a distance of one meter
•Examples of diseases for which transmission is
usually direct are AIDS, syphilis, gonorrhea,
and the common cold

•May be one of three types:

Indirect •air-borne
Transmission •vehicle-borne
•vector-borne
 Indirect Transmission
•transmission of microbial aerosols to a
suitable port of entry, usually the
respiratory tract
•Microbial aerosols are suspensions of dust
or droplet nuclei made up wholly or in
Air-borne transmission part by microorganisms -- may be
suspended and infective for long periods
of time
•Examples of air-borne diseases include
•contaminated
tuberculosis, materialshistoplasmosis,
influenza, or objects (fomites)
serve
and as vehicles, nonliving objects by which
legionellosis
communicable agents are transferred to a
susceptible host
•The agent may or may not have multiplied or
developed on the vehicle
•Examples of vehicles include toys,
handkerchiefs, soiled clothes, bedding, food
Vehicle-borne transmission service utensils, and surgical instruments
•Also considered vehicles are water, milk,
food (e.g., common vehicles), or biological
products such as blood, serum, plasma,
organs and tissues
•Almost any disease can be transmitted by
vehicles, including those for which the
primary mode of transmission is direct, such
 Indirect Transmission
•disease transfer by a living organism, such as a
Vector-borne transmission
mosquito, fly, or tick
•Transmission may be mechanical, via the
contaminated mouth parts or feet of the vector,
or biological, involving multiplication or
developmental changes of the agent in the
vector before transmission occurs
•In mechanical transmission, multiplication and
development of the disease do not usually
occur -- e.g., organisms that cause dysentery,
polio, cholera, and typhoid fever have been
isolated from such insects as cockroaches and
house flies and could presumably be deposited
on food prepared for human consumption
Indirect Transmission

In biological transmission

•multiplication and/or developmental changes of the disease agent occur in

the vector before transmission occurs
•Biological transmission is much more important than mechanical
transmission in terms of its impact on public/community health
•Examples of biological vectors include mosquitoes, fleas, ticks, lice, flies
and other insects
Mosquitoes

•are extremely important vectors of human diseases

-- e.g., they transmit the viruses that cause yellow
fever and dengué fever as well as 200 other
viruses -- they also transmit malaria, which infects
100 million people in the world each year (most in
Ticks
tropical areas), killing at least 1 million of them
each year
•are another important biological vector,
transmitting Rocky Mountain spotted fever,
relapsing fever, and Lyme disease
 Outcomes of Infection

•(i) infection without illness;

Microbes differ in their ability to •(ii) infection with illness; (with or
produce the different outcomes of without long-term sequelae) and
infection: •(iii) infection, illness and then
death
Outcomes

•all cause
•Disease-s
Mortality /pecific
cause-spe
indicators
cific
/ General
Morbidit indicators
: clinic
y use,
hospitaliz
Quality of •General
ation, /
Disease-s
medicatio
life pecific
n use

Costs
The Iceberg Concept:
As Applied to Virus
Infections
 Epidemiology: Iceberg of Disease

The concept of the "iceberg phenomenon of disease "gives an idea

of the progress of a disease from its sub-clinical stages to overt or
apparent disease state.

1 Diseased, diagnosed & controlled

2 Diagnosed, uncontrolled
Diagnosed
disease

3 Undiagnosed or wrongly

diagnosed disease Undiagnosed or

4 Risk factors for disease wrongly diagnosed disease

5 Free of risk factors

 Epidemiology: Iceberg of Disease

The submerged portion of the iceberg represents the hidden mass of the disease (e.g., subclinical cases,
carriers, undiagnosed cases).

The floating tip represents what the physician sees in his practice/chamber/hospital etc. and are
recognized as cases (diseased persons).

The vast submerged portion of the iceberg represents the hidden mass of the disease that is unrecognized/
latent/ inapparant / pre-symptomatic/ undiagnosed cases and carriers in the community.

The water line represents the demarcation between clinical and subclinical or undiagnosed patients.

In some cases (for example, hypertension, diabetes, anemia, malnutrition and mental illness) the
unknown morbidity (represented by submerged portion of iceberg) far exceeds the known morbidity.

Thus detection and control undiagnosed reservoir of disease is a challenge to modern technique.
DISEASE AND INJURY PREVENTION AND CONTROL

• Prevention
• Includes individual, clinical, or personal health services such as
immunizations, screening for high blood pressure and follow-up services, or
the use of Pap smears to detect the precursors to cancer of the cervix

• Protection
• Includes the activities of organizations, both public and private, to reduce
exposure to hazards such as polluted water, contaminated food, traffic
accidents, mosquitoes, or use of electric saws without safety devices
PREVENTION OF COMMUNICABLE DISEASES

• Primary Prevention
• In the chain of infection model, primary prevention strategies are evident at
each link of the chain
• Successful application of each strategy can be seen as weakening the link --
with the ultimate goal of interrupting the disease transmission cycle
• Community measures -- e.g., chlorination of the water supply, inspection of
restaurants, immunization programs that reach all citizens, maintenance of a
well-functioning sewer system, proper disposal of solid waste, and control of
vectors and rodents
• Personal/Individual actions -- hand washing, proper cooking of foods,
adequate clothing and housing, use of condoms, obtaining all of the available
immunizations against specific diseases
PREVENTION OF COMMUNICABLE DISEASES
(cont’d.)
• Secondary Prevention
• Community effort includes measures taken to control or limit the extend of a
disease outbreak/epidemic -- e.g., maintaining records of cases and compliance
with regulations requiring the reporting of notifiable diseases, investigating
cases and contacts, those who may have become infected through contact with
cases
• Individual effort includes either (1) self-diagnosis and self-treatment with
nonprescription medications or home remedies, or (2) diagnosis and treatment
with an antibiotic or other physician-prescribed medicine
PREVENTION OF COMMUNICABLE DISEASES
(cont’d.)
• Occasionally, secondary disease control measures may include isolation or
quarantime
• Isolation = separation, for the period of communicability, of infected persons
or animals from others so as to prevent the direct or indirect transmission of
the communicable agent to a susceptible person/host
• Quarantine = limitation of the freedom of movement of well persons or
animals that have been exposed to a communicable disease until the incubation
period has passed
• Further measures may include disinfection -- the killing of communicable
agents outside the the host, and mass treatment with antibiotics
• Public health education and health promotion should also be used as both
primary and secondary preventive measures
PREVENTION OF COMMUNICABLE DISEASES
(cont’d.)

• Tertiary Prevention
• Convalescence from infection, recovery to full or partial health, and return to
normal activity
• In some cases, such as paralytic polio, return to normal activity may not be
possible, even with extensive physical therapy
• At the community level, proper removal of infected items such as clothing,
disinfection, and burial of the dead, for example
• Tertiary prevention may also involve the reapplication of primary and
secondary measures to prevent further cases -- e.g., in Japan and South Korea,
people with colds or flu wear gauze masks in public to reduce the spread of the
disease
 TOOLS AVAILABLE TO THE “STATE” FOR THE
CONTROL OF COMMUNICABLE DISEASE
• REPORTING -- Physicians and other health professionals must report specified
diseases to a designated authority, usually to local or state health authority
• LABORATORY REPORTING -- In many states, licensed laboratories must report
positive results for certain diseases to the health department, even though a diagnosis
may not have been established
• SURVEILLANCE -- The systematic measurement of health status and risk factors
• MONITORING -- Involves the ongoing assessment of a condition after intervention has
been initiated
• LABORATORY ANALYSIS -- Involves public health laboratories with authority for
the study and detection of infectious diseases
• CONTACT INVESTIGATION -- Once a case of a particular disease has been
diagnosed, personnel from the health department are authorized to interview the victim to
establish a list of possible contact. (A practice of considerable debate recently because of
AIDS.)
TOOLS AVAILABLE TO THE “STATE” FOR THE
CONTROL OF COMMUNICABLE DISEASE
• TREATMENT -- Public health agencies are required to provide treatment services for
specified infectious diseases. (In many cities, special hospitals were built for this
purpose.) Local health departments are also required to provide services for people
infected with sexually transmitted diseases or tuberculosis. These services are not
regarded as welfare services but rather as tools to prevent the spread of dangerous
communicable diseases. It is important to note, however, that the state cannot require
treatment. The state can only force treatment if it can prove that the victim is (1)
gravely disabled, and (2) a danger to self or others because of the disability
• ISOLATION -- Means separation of infected people from non-infected people during
the period of communicability. Follows the “least restrictive” principle
• IMMUNIZATION -- All states have requirements for the immunization of children
against certain infectious diseases -- most common are diphtheria, pertussis (whooping
cough), tetanus, rubella (German measles), and polio. The controlling agency is usually
the school system, which is required to prevent entry of any child who has not been
properly immunized
TOOLS AVAILABLE TO THE “STATE” FOR THE
CONTROL OF COMMUNICABLE DISEASE
• INVESTIGATION -- In addition to the specific authorities noted above, most
health departments are required to investigate unusual occurrences of disease or
injury. This includes the authority to review medical records, to perform
laboratory investigations, to examine patients, and to interview both patients and
others who may have been exposed to the disease or injury. (The public health
authorities may require court authorization to undertake these investigations.)
Stay Safe…☺
Thank You