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Use of GIS in Epidemiology: A Case Study in Istanbul

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Journal of Environmental Science and Health Part A, 41:2013–2026, 2006
Copyright
C Taylor & Francis Group, LLC
ISSN: 1093-4529 (Print); 1532-4117 (Online)
DOI: 10.1080/10934520600780636

Use of GIS in Epidemiology:

A Case Study in Istanbul
Necla Ulugtekin,1 Seval Alkoy,2 Dursun Z. Seker,1 and
Cigdem Goksel1
1
ITU, Istanbul Technical University, Faculty of Civil Engineering, Dept. of Geodesy
and Photogrammetry Engineering, Istanbul, Turkey
2
District Health Directorate, Statistics and Communicable Disease Control Unit,
Kagithane, Istanbul, Turkey

In this study, the procedure of using GIS for tracking the distribution of measles in
a district of Istanbul was performed. The aim of the study is to present the available
questionnaire data, which were collected during the measles epidemic, by means of
maps. The designed maps show the relation and the distribution of individual cases on
time and spatiality. A database is designed according to the questionnaires. Geo-spatial
distribution of measles cases was analyzed. The obtained results were discussed and
presented.

Key Words: Epidemiology; GIS; Spatial; Diseases; Thematic maps.

INTRODUCTION
Epidemiology is the scientific study of the spread and control of diseases as a
function of time and location. Epidemiology follows the patterns of a disease
on people in their healthy and un-healthy periods; and tracks their history
of illness especially paying attention to when and where they have it.[1,2]
Geographic information system (GIS) is a tool for the collection of data from
many sources by various methods, which is also capable of organizing, storing,
retrieving, analyzing and presenting the spatial data. Spatial data integration
and visualization are the two most powerful specifications of GIS.[3–6]
Epidemiologists have traditionally used maps while analyzing the rela-
tionship between location, surrounding environment, and the disease. GIS
has been used in the surveillance and monitoring of vector-borne as well as
water-borne diseases, and the ones in relation to the environmental health,

Address correspondence to Necla Ulugtekin, ITU, Istanbul Technical University, Fac-

ulty of Civil Engineering, Department of Geodesy and Photogrammetry Engineering,
34469 Maslak, Istanbul, Turkey; E-mail: ulugtek@itu.edu.tr
2013
2014 Ulugtekin et al.

disease policies and planning, the existing health situation in the area,
generation and analysis of research hypotheses, identification of high-risk
health groups, planning and programming of activities, and monitoring and
evaluation of interventions.[2,7,8] GIS has enabled researchers to determine
locations of high prevalence areas and populations at risk.[9,10] It forms an
intersection between the spatial data regarding health and the environment.
GIS has been an excellent tool for the monitoring of the spatial, temporal
and environmental factors associated with diseases. Many geo-statistical tests
have been developed to explore patterns of geographical clustering of the data
on diseases under question.[11,12]
GIS software is created to enhance the tracking, routing, documentation,
monitoring, analysis, management and mapping of the resources of health and
environmental. GIS has the potential to assist the health organizations to
accomplish majority of the tasks that they are entitled to, ranging from daily
operations to long-term planning and updating. Effective implementation of
GIS allows the realization of this potential while offering efficient ways to
perform the functioning, storage and sharing of data between the organiza-
tional units, and their integration with other technologies. The geographical
distribution of any disease could be mapped by means of GIS. It supports
public health programs from small to large scales, varying from management
of the departmental functions that run the day-to-day operations of a health
organization to epidemiological mapping performed by the public health
officials.[2,11]
Environmental epidemiology studies require interdisciplinary expertise
and adherence to the fundamental principles of geospatial, environmental, and
epidemiological sciences.[7,8,13] GIS is known to be the best-suited system to
design a special database for querying and analyzing geospatial, environmen-
tal and epidemiological structure. It plays a critical role in determining where
and when to intervene, improving the quality of care, increasing accessibility
of service, finding more cost-effective delivery modes, and preserving patient
confidentiality while satisfying the needs of the research community in terms
of data accessibility.
Spatial data have also become an essential component of the diseases
information system. Spatial data, together with other thematic information
has been used for the decision-making purposes for the control of epidemic
and non-epidemic diseases.[14,15] Spatial variation of the health related data
is well known, and its study is a fundamental aspect of the epidemiology
science.[2,9,12,14] However, decision-making has become more challenging due
to the substantial increase in the amount of available information.
GIS allows environmental and epidemiological data to be stored, analyzed,
and displayed spatially. Data collection can be accomplished by importing the
data in tabular or digital forms, which are referenced with map coordinates
that define their geographical positions. The data are entered into a database
 GIS Epidemiology Study on Measles in Istanbul 2015
where they are stored in the form of a map with a specified theme. Tabular
(attribute) data corresponding to the theme can be stored at each data
layer. Analytical functions within the software can be used to process and
manipulate both the map (graphic or geographic) and the attribute (semantic)
data through linkages established within the GIS.[6] Two types of output
are common; one of them is the tabular form such as the line-by-line data,
statistics, and reports whereas the other one is the cartographic form such
as maps, map files, and map overlays.[13] Representation and identification
of spatial patterns play an important role in the formulation of public health
polices.[9] Maps can also be used to present the epidemiological information.
In this study, the tracking of measles distribution in Gaziosmanpasa
district of Istanbul has been realized. A GIS study incorporating the epidemi-
ological data was designed, and the goals, approaches and progress routes
for both current and prospective studies were determined and geographic
distributions of the cases of measles were analyzed. The data on the incidence
and resulting complications of the disease, together with time and number
of inoculations were obtained and visualized on the map using different
techniques, and temporal as well as spatial comparisons were carried out.
Furthermore, the relationship between health and the environment regarding
its suitability for spatial analysis were discussed in the manuscript.

METHOD AND MATERIAL

GIS is the visualized form of information presented by means of maps. Maps
are used to communicate the geographical information. They enable to observe
both the attribute and geographical relationships at once. The map is an
efficient tool to explore the geographical relationships between earth obser-
vations. This is an easy way to rapidly browse relationships between many
variables. Data can be presented on the maps by different methods: dot-density
maps, proportional circles, proportional spheres, grey-scale (choropleth) maps,
contour (isopleths) maps, cartograms and 3D surface plots.[6,16] Maps have also
been successfully used to visualize the patterns in disease distributions.
Using GIS for epidemiological studies in Turkey is a relatively new ap-
proach. Even though there are many GIS projects, which have been performed
previously, there are hardly any researchers involved with epidemiological
studies. Epidemiologists are still using conventional methods in their studies.
This study is believed to initiate the exchange of ideas and cooperation between
epidemiologists and GIS specialist in Turkey.

Study Area
In this study, the Gaziosmanpasa District, which is selected as study area,
is given in Figure 1. This area has become a highly urbanized district of
2016 Ulugtekin et al.

Figure 1: Study area.

Istanbul in the last few decades. The reasons for selecting this district as
study area in this study were mainly the data availability and easy access
to the data regarding to area. Another strong reason for the selection was that
300 out of 3000 cases of measles encountered in the city of Istanbul, having
a population of more than 12 million people, occurred in this district which
constitutes only 10% of the overall population. The district composed of 41
sub-districts also receives the highest migration as well as experiencing the
highest population growth, lowest income rates and hence has become a major
unplanned urbanization zone as to city planning. The crime rates in addition
to rates of death and disease occurrences are also quite high in this district.
During their investigations on measles epidemics in the entire city of
Istanbul, the epidemiologists have concluded that the district was the most
striking one as; there were reported cases of deaths resulting from measles;
the epidemic was best investigated in this district; the cases were confirmed
by investigations carried out in laboratories; majority of the cases among the
unvaccinated aged under 5 occurred in this district, and it was intervened with
a 2-week vaccine campaign to stop the epidemic. The occurrence of 5 cases
resulting in measles-related deaths has also lead to the consideration of this
particular site for this study.

Collecting and Using Data in the Study Area

Data used in this study were obtained from the “Provincial Health Direc-
torate, Epidemiology Division, Statistics and Communicable Diseases Control
 GIS Epidemiology Study on Measles in Istanbul 2017
Unit.” While the measles cases were reported for more than 3,000 children in
the entire city, 320 cases were reported from the study area.
The data on measles were gathered for the time period from 04.02.2001
until 27.07.2001. The data collection was accomplished via the questionnaires
filled in the health centers. Among the gathered data for the 320 cases from
the district, only 195 cases were considered appropriate for the evaluation,
and hence used in this study. After collection, the questionnaires were sent
to a single health center by fax where the data referred in this study were
obtained.
A portion of the addressees provided in the questionnaires collected from
the street had incorrect information where the sub-districts or streets claimed
were actually located in another district. As there is no standard that is exist
for address indications the data were collected on the basis of statements. The
questionnaires were prepared for the whole districts of Istanbul; however, the
data were collected separately from each district. In the case of prolongation
of the GIS studies to cover other districts in the further stages, it would be
possible to find new data on the studied district of Gaziosmanpasa.

Questionnaire Data
The questionnaire data, which was related with the epidemic studies car-
ried out in Turkey, were used as tabular data. Although location information
was collected within the questionnaires, the tabular usage of such data will
significantly decreases the advantages such as integration of various mapable
data, understanding the relationships between cases and rapid decision mak-
ing for pre-cautions. In this study, questionnaire data of 320 measles cases
were evaluated, visualized by using location information, being maps. These
data were obtained from the 25 health institutions for the Gaziosmanpasa
district. The items asked in the questionnaire were transferred to the database
established for the GIS. The following are the examples of the data asked in
the questionnaire:

(i) Identity of the patient, name of mother and father (The system of
providing Identity Numbers is being newly employed in Turkey after
the year of 2002),
(ii) Date of birth (arbitrary filled),
(iii) Sex,
(iv) Permanent address, city, district, sub-district, street, and number (arbi-
trarily filled, hence causing extensive data loss),
(v) Contact telephone numbers (asked to track the state of sickness, not
every patient has it),
2018 Ulugtekin et al.

(vi) In the case of students, the name of the school and class (since the names
of the schools were not reported in a standard way, they have been re-
arranged in the database),
(vii) Information on the disease in terms of the dates of prodromes and skin
eruptions, and consult to the health center (It was also asked if the
patient was treated in the hospital but only 7 such cases were reported),
(viii) Data regarding the medical treatment such as fewer, spots, complica-
tions and their types,
(ix) Information on vaccination as available, not available, and unknown
(Vaccine prosecution forms were also asked but the answers were not
satisfactory),
(x) The place and dosage of vaccination (data were considered as unreli-
able),
(xi) Epidemiological relations (as school, family, environment, etc.),
(xii) The Health center filling the questionnaire,
(xiii) Name and Surname of the reporting doctor and his/her signature, and
(xiv) Date of reporting.

Spatial Data and Database

A private company has provided the geometric data used in this study. The
geometric data used were at ED 50 datum and at Gauss Kruger projection. As
the data were detailed to indicate the streets and the buildings, the cases were
positioned with respect to the building door numbers stated in the addresses.
As well as the geometric data, the required specific data such as the type of
building use were also present. In this study, MapInfo Professional 7.8 GIS
software was used. The database was formed with the semantic data and has
been related to the geometric data (Fig. 2).

RESULTS
In this study, an epidemiological GIS was designed and goals, approaches
and progresses for its understanding were determined. The ultimate goal of
the study was to define the measles epidemic in the study area that has
already been reported to affect 320 children. Geographical distributions of
the cases were analyzed and the incidences and complications of the disease,
time and number of inoculations were obtained and visualized on the map
using different techniques, and temporal and spatial comparisons were done.
Statistical results of the field work were also evaluated and vaccination
programs were planned according to obtained results.
 GIS Epidemiology Study on Measles in Istanbul 2019

Figure 2: Relation between the database and geometric data.

Measles epidemics are commonly encountered in late winter and early

spring periods. The cases in the selected area have also occurred and reported
in this period. The first cases began to be reported in March and the 2-week
vaccination campaign covering all the kids aged 6 months to 7 years old
was started in the 3rd week of April to stop the epidemic and 3–4 weeks
after the campaign the number of reported cases have decreased considerably.
Nevertheless, a few cases continued to occur until July.
As the number of cases is investigated at certain time intervals, it is
observed that, at the early stages of the epidemic, the cases tend to be single
whereas the new cases then start to show up as the previous cases infect the
ones in their vicinity, causing significant extension in the number of cases and
their spatial distribution. Hence the actual epidemic break-out occurs. At the
third stage the number of cases fall and the epidemic dies out. The table of
the tracked epidemic in Gaziosmanpasa revealed a typical epidemic profile as
demonstrated in Figure 3.
The cases were determined with respect to the sub-districts. Upon a
general evaluation of the data it was found that 12 sub-districts out of the total
of 41, there had been no reported cases. The number of cases was reported
to be 1–5 in 18 sub-districts, 6–15 in 8 sub-districts and more than 15 in
3 sub-districts (Fig. 4). The three sub-districts having the highest numbers
2020 Ulugtekin et al.

Figure 3: Measles distribution of Gaziosmanpasa district with respect to number of cases.

Figure 4: The sub-districts experiencing highest occurrences.

 GIS Epidemiology Study on Measles in Istanbul 2021
of cases were the 50.Yıl sub-district with 28 cases, Karadeniz sub-district
with 27 cases and the Esentepe sub-district with 19 cases. The average ages
of the patients have also been observed. The numbers determined in the
study revealed that there were 11 reported cases of measles for babies up to
11 months, 68 cases for children aged 1 to 5, 104 cases for children aged 5 to
15 and 12 cases for the ones aged over 15. The distribution of the cases with
respect to ages was presented in Figure 5.
The timing of the consults to the health centers were investigated and
given in Figure 6. The condition for consult to a health institution was highly
related to the educational, social and economical state of the family. The
ratio of the cases where the time between when symptoms of the disease
first appeared and the date of consultation to a health institution reached
2 weeks (16 cases) and where these dates are not known (31 cases) provide

Figure 5: Distribution of cases with respects to age.

2022 Ulugtekin et al.

Figure 6: The time periods for the applications to the health centers.

some clues on the socioeconomical structure of the region. One of the most
important problems faced during the transfer of these data into the digital
format was that the people escorting the patient did not know the date of
birth of the patient. During the arrangement of these data, the table was
filled with the estimated dates of birth according to the reported ages by
the escorts and questionnaire date. However, the software could not detect
the daily differences but the yearly ones; therefore, a code was written with
MapBasic and the daily calculations were performed as well.
Another parameter that has been investigated in this study was the
state of vaccination in the reported cases. It is worth noting that half of the
cases occurred in the vaccinated patients. 96 of the measles cases had been
vaccinated before, whereas 92 cases were not and in 7 cases there was no
 GIS Epidemiology Study on Measles in Istanbul 2023

Figure 7: Vaccinated and unvaccinated cases.

information regarding vaccination. The distribution reflecting this situation

was demonstrated in Figure 7.
The sub-districts where the highest numbers of cases were reported,
namely Karadeniz and 50.yıl, have been further investigated (Fig. 4). The
results of the analyses performed by GIS and the use of building information
of high accuracy revealed that a portion of these cases occurred in the same
buildings in these sub-districts, which turn out to be a rather striking point
from the epidemiological viewpoint (Fig. 2).
It is quite expressive that the cases tended to cluster in neighboring
areas (Fig. 8). This could be explained with the fact that, one of the basic
characteristics of the measles disease is that it can spread to the 8 persons
in the closest circle, whom in such cases most commonly happen to be the
neighbors or relatives. In addition, as the sites were visited to investigate the
2024 Ulugtekin et al.

Figure 8: Neighboring in dense sub-districts.

epidemic, it was determined that for each of the reported case of measles there
existed 5–6 more cases in the same house or in the neighborhood that were not
reported. Hence, the reported number of cases does not reflect the enormity
of the situation, which also was an interesting and important finding of the
study.

CONCLUSIONS
Many different analysis and queries can be realized with the assistance of GIS.
However, analysis of such cases investigated in this study may only be achieved
with the use of reliable and satisfactory data. This study, once again, revealed
that the data was the most important component of the GIS applications.
Portions of the obtained results were visualized only to provide perspec-
tives for the researchers. These shall be evaluated as thematic maps. The lack
of data to be mapped encountered in the study was identified to be the main
problem to be solved at the data collection stage.
The lacking of standards is another problem that has been faced even
during the data collection stage. It is necessary to have a standardization
regarding the data to be collected. These data for such cases may be acquired
via reliable databases that are to be jointly formed and used by the health in-
stitutions. This could be established parallel to the simultaneous improvement
of the geographical, health and society related consciousness both in the health
personnel and the society itself.
 GIS Epidemiology Study on Measles in Istanbul 2025
The relationship between the data that can be mapped should be estab-
lished previously and it should already be known what class and type of data
will be collected at the data gathering stage. Apart from the collection of data,
geomatics-based GIS specialists have to be engaged in the establishments of
databases not only for statistical purposes but also for the acquisition data that
can be mapped.
By means of the analysis performed by GIS, the regions of dense occur-
rences, schools and even the buildings can be identified and simultaneously
provided with health care services. Similar studies should be carried out also
for the other communicable diseases in order to enable taking the required
precautions prior to the spread of the disease. This study will provide a route
for successive similar research.
The integration of GIS and the epidemiological methods need to be
developed as a common work of the technical and social sciences. This has
just started to be considered and the process will be long. This study is a
representative and creative piece of research with the collaboration of GIS
specialists and epidemiologists, and the results will surely be beneficial for
public services.

ACKNOWLEDGMENTS
The authors would like to thanks to Basar Computer Systems and Communi-
cation Technologies Industrial and Commercial Ltd. Co. and Provincial Health
Directorate, Epidemiology Division, Statistics and Communicable Diseases
Control Unit for their contributions. The efforts of students for creating digital
format from the analog query forms are also acknowledged.

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