28/11/2019

Epidemiology in
Healthcare
Marsha Ivey, MSc (Stats) MSc (PH)
Lecture Public Health - PHPC Unit

Learning Objectives
1. List the uses of epidemiology in healthcare
2. Describe the differences between clinical medicine
and epidemiology
3. Describe use of epidemiology in healthcare
associated infections (HAI)

December 1, 2013 2

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Health Systems Thinking

• Systems thinking is an approach to problem solving that view
‘problem’ as part of a wider dynamic system.
• Systems thinking involves much more than a reaction to present
outcomes or events.
• It demands a deeper understanding of the linkages, relationships,
interactions and behaviors among the elements that characterize the
entire system.

Epidemiology and the Clinical Picture

• Epidemiology supplements the clinical picture
• Asks questions that cannot be asked in clinical medicine about the
health of the community and of sections of it, present and past:
• Provides a different view of the world of medicine
• Clinical problems are set in a community perspective; health
problems are revealed and indication may be given where among the
population they might best be studied.
• Epidemiology provides the evidence base for action at all levels

Smith - https://doi.org/10.1093/ije/30.5.1146

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Epidemiologic
Model for Health
Systems

Epidemiology before Clinical Medicine

• 400 B C –Hippocrates |occurrence of human disease to environment.
• 1747 -James Lind |treatment of scurvy by oranges.
• 1768 -Edward Jenner | Small pox vaccine.
• 1850 - Ignaz Semmelweis | reducing incidence puerperal fever –
hand washing.
• 1853 – John Snow |cholera epidemic control.
• 1950s -Doll and Hill | causation - smoking causes lung cancer.

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Evolution of Epidemiology
Medical science was individual oriented BUT
Better human health achieved by prevention of diseases rather
than by cure.

1. Historical/Trend Study

In historical study of the health of the community and of the rise and
fall of diseases in the population; useful ‘projections' into the future
may also be possible.

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NATURAL HISTORY OF DISEASE

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Trend Study
1. Studying the past history for rise and fall

2. Studying its changing behaviour

3. Making future predictions

4. Giving early warnings or feedback

5. Planning health services and public health

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2. Community Diagnosis

For community diagnosis of the presence, nature and distribution of

health and disease among the population, and the dimensions of these
in incidence, prevalence, and mortality; taking into account that
society is changing and health problems are changing.

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Comparative prevalence of diabetes in adults (20-79 years) in countries with high prevalence (≥ 10%).
Data from International Diabetes Federation Diabetes Atlas, 6th ed, 2013.

Global prevalence 8.3% (382 million people)

198m M vs 184m F; expect > 592 million by 2035; 10.1% global prev.

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Community Diagnosis
• Social anatomy: race, age and sex composition, socio economic
status, population at risk, resources available.

• Social physiology: positive & negative lifestyles, occupation, health

services awareness and utilization, nutritional polices, labour.

• Social pathology: morbidity, mortality, disability, alcoholism, smoking,

crime & violence, risk prone behaviour.

ONION PRINCIPLE
Just like the layers of the onion, the old
diseases wane and give place to new ones.
Infectious ones will be replaced by non–
infectious ones to be replaced later by
personal and behavioral problems.

One must be aware of this phenomenon before

diagnosing the community health

OLD DISEASES

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3. Health Services Evaluation

To study the workings of health services. This begins with the

determination of needs and resources, proceeds to analysis of services
in action and, finally, attempts to appraise.

Such studies can be comparative between various populations.

Health Services Evaluation cont’d

Locations for epidemiological research: the laboratory, the clinical
encounter and the population
• Accurate information socio demo profile,the diseases, health
facilities
• Evaluation of a programme for its impact
• Evaluate policies implemented/adopted by government; policies
that relate to health, curtailment of smoking, to changes in our diet,
to elimination of trans-fats and fatty foods from our diet, and the
elimination of sugary snacks from schools, and so forth.
Health planning for
• Appropriate, Cost effective, Community need based
• Judicial mix of preventive, promotive, curative, rehabilitative and
public health services

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4. Individual Risk/Chance
To estimate, from the common experience, the individual's chances and risks
of disease.

The individual’s risk affects risk of population/groups

INDIVIDUAL RISK

GENERAL POPUTLATION RISK

PROGNOSIS FOR BY PHYSICIAN

Factors associated with prolonged length of stay following cardiac

surgery in a major referral hospital in Oman: a retrospective
observational study
Almashrafi:
http://bmjopen.bmj.com/content/6/6/e010764?utm_source=trendmd&utm_medium=cpc&utm_campaign=bmjopen&trendmd
-shared=1&utm_content=Journalcontent&utm_term=TrendMDPhase4

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5. Complete Clinical Picture

To help complete the clinical picture by including all types of cases in
proportion; by relating clinical disease to the subclinical; by observing
secular changes in the character of disease, and its picture in other
countries.

Cause-effect relationships are determined

E,g, smoking frequently causes higher risk of lung cancer

Completing the Clinical Picture of Disease

Breadth
• Hospital studies
 poorly represent health event in general population
 biased if only health facility studies used
 do not include the pre-pathogenic and follow-up phases of the disease studied
 Need community studies

Depth
• Going to the bottom; deeper part of the iceberg to study earlier part of disease;
either stoppable or at least preventable by searching for

• Precursors of the disease

• Dispositions due to disease
• Asymptomatic disease
• Subclinical cases
• Latent cases
• Carrier state

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Pyramid of
Evidence
CRITICAL
APPRAISALS

EXPERIMENTAL
STUDIES

OBERSVATIONAL
STUDIES

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6. Syndrome Identification
In identifying syndromes from the distribution of clinical phenomena
among sections of the population.

A syndrome is a set of medical signs and symptoms that are correlated

with each other.

Establish criteria to define syndromes

E.g. Down syndrome, SIDS, etc

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Syndrome Identification

LUMPERS
&
SPLITTERS
Grouping and dividing the
symptom- complexes and naming
them as syndromes is the starting
point for the study of natural
history of any disease

7. Determine Causes/Risk Factors for Causal

Relationships
Search for causes of health and disease

Starting with the discovery of groups with high and low rates

Study the differences in relation to differences in ways of living

Test (where possible) these notions in the actual practice among

populations

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SEARCH FOR CAUSES

• Finding the causes through studying the difference between health/disease
rates between different groups
• Determination of source or causes leads to control, prevention, elimination
of disease/injury/disability/death rates

• Several causes single disease

• Single cause  several diseases

• Search for cause in interrelated diseases may yield clues for new causes /
risk factors

SCOPE of EPIDEMIOLOGY

Epidemiology is Applicable at all Stages of Life

No life science, where the epidemiological approach

and principles cannot be applied

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The very first

requirement in a
hospital is that it
should do the
sick no harm

Healthcare Aquired/Associated Infections

(nosocomial/iatrogenic)

Refer to infections associated with health care

delivery in any setting
• hospitals
• long-term care facilities
• community and ambulatory settings
• home and community care

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Healthcare Aquired/Associated Infections

• Definition
• A localised or systemic infection that results from an adverse reaction to the
presence of an infectious agent(s) or its toxin(s), for which there is no
evidence of infection on admission to a health care facility

• An infection is frequently considered an HAI if it appears ≥48 hours

after admission

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Epidemiology of HAIs
• Explains occurrence of HAIs among patients and the magnitude
of the problem

• Includes the distribution of HAIs by

• patient type
• causative pathogen
• unit of treatment
• period of time

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Major Types of HAIs

• Catheter-associated urinary tract infection

(CAUTI)
• Ventilator-associated pneumonia (VAP)
• Surgical site infection (SSI)
• Catheter related bloodstream infection (CR-BSI)

Epidemiologic Factors

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Host Factors
• Advanced age or
• Coma premature birth
• HIV infection • severe burns and
• Malignancies certain skin diseases
• Diabetes mellitus • Chronic obstructive
pulmonary disease
• Severe malnutrition
• Immunodeficiency (due
• Circulatory impairment to drug, or irradiation)
• Open wound or trauma
• Bronchopulmonary disease

Agent Factors
• An infectious agent can be bacteria, virus, fungus, or parasite
• The majority of HAIs are caused by bacteria or viruses
• Two major types of bacteria that cause HAIs
• Gram-positive cocci (e.g., Staphylococci and Streptococci)
• Gram-negative bacilli (e.g., Acinetobacter, Pseudomonas,
Klebsiella)

• 25 Common bacteria &viruses causing HAI

https://www.beckershospitalreview.com/quality/most-common-healthcare-associated-
infections-25-bacteria-viruses-causing-hais.html

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Diseases and Organisms in Healthcare

1. Acinetobacter 7. Methicillin-resistant
2. Clostridium difficile Staphylococcus aureus (MRSA
3. Enterobacteriaceae 8. Norovirus
(carbapenem-resistance) 9. Tuberculosis (TB)
4. Gram-negative bacteria 10. Vancomycin-intermediate
5. Hepatitis Staphylococcus aureus and
Vancomycin-resistant
6. Klebsiella Staphylococcus aureus
11. Vancomycin-resistant
Enterococci (VRE)

• Acinetobacter - group of bacteria commonly found in soil and water. Outbreaks typically occur in
ICU; rarely occur outside of healthcare settings.
• Clostridium difficile - bacterium that causes an inflammation of the colon; diarrhea and fever
most common symptoms of Cdiff infection. Overuse of antibiotics is the most important risk for
getting infection.
• Noroviruses - group of viruses that cause gastroenteritis (inflammation of the lining of the
stomach and intestines), causing acute onset of severe vomiting and diarrhea
• Gram-negative bacteria – cause infections including pneumonia, bloodstream infections, wound
or surgical site infections, and meningitis in healthcare settings. Resistant to multiple drugs and
increasingly resistant to most available antibiotics. Gram-negative infections include those caused
by Klebsiella, Acinetobacter, Pseudomonas aeruginosa, and E. coli., as well as many other less
common bacteria.
• Klebsiella - type of Gram-negative bacteria that can cause healthcare-associated infections;
Increasingly, Klebsiella bacteria have developed antimicrobial resistance. Klebsiella bacteria
normally found in the human intestines (where they do not cause disease). Also found in human
stool (feces). In healthcare settings, Klebsiella infections commonly occur among sick patients
who are receiving treatment for other conditions. Patients who have devices like ventilators
(breathing machines) or intravenous (vein) catheters, and patients who are taking long courses of
certain antibiotics are most at risk for Klebsiella infections.
• Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that is resistant to
certain antibiotics called beta-lactams. These antibiotics include methicillin and other more
common antibiotics such as oxacillin, penicillin, and amoxicillin. In the community, most MRSA
infections are skin infections. More severe or potentially life-threatening MRSA infections occur
most frequently among patients in Healthcare Settings. [Methicillin-resistant Staphylococcus
aureus is also called MRSA]

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Environment Factors
• Extrinsic factors that affect either the infectious agent or a
person’s risk of exposure to that agent

• Include both the animate (health care personnel, other

patients in the same unit, families, and visitors) and
inanimate environment (medical instruments and equipment
and environmental surfaces) of patients

Chain of Infection
Infectious agent

Host Reservoir

Portal of entry Portal of exit

Mode of transmission

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HAI Surveillance
• Systematic, active, on-going observation of the occurrence
and distribution of HAIs and of the events or conditions
that increase the risk of HAI occurrence

• Information that allows facility to direct efforts toward the

most serious HAI problems and risks, to obtain support of
personnel, and to provide feedback on the results of
preventive changes

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Surveillance Information

• Provide baseline information on HAI occurrence

• Identify epidemics
• Evaluate efficacy of HAI preventive measures
• Reinforce appropriate infection prevention and patient-care practices
• Defend against malpractice suits
• Provide data for comparisons, problem solving and/or research
• Plan and measure the impact of implementing recommendations

Summary
• Study of natural history of diseases. Ex HIV
• Search for causes and risk factors of disease.
• Historic study of rise and fall of diseases.
Example plague, influenza, lung cancer
• To identify syndromes.

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Summary cont’d
• HAIs can cause serious complications and
greatly impact patients, their families, and
health care personnel

• Health care personnel need to understand

the epidemiology of HAIs to prevent them
in their own settings

• Understanding the chain of infection and

epidemiology of HAIs can lead to effective
prevention and control intervention

Summary cont’d
• Epidemiology explains what happens to whom, and
where and when it happens
• E.g., the occurrence and distribution of HAIs
• Using evidence-based recommendations
• Support effective planning and implementation of
programs
• Reduce disease/mortality/infection/disability rates

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References
• The uses of ‘Uses of Epidemiology’
http://www.med.mcgill.ca/epidemiology/hanley/c609/material/DaveyS
mithUsesOfUsesOfEpi2001.pdf

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