Introduction to Epidemiology

12/22/2022 1
Learning objectives

At the end of this chapter students will be able:

– Define epidemiology
– Recognize historical development of Epidemiology
– Describe the use/applications of Epidemiology
– Describe the scope of epidemiology
– Identify basic assumptions of epidemiology
– Explain theories of disease causation
– Describe levels of disease occurrence
– Identify with branches of epidemiology

12/22/2022 2
 Introduction

Definition of health:
• Lay definition of health:
– To the general public, being healthy may mean simply
“ not being ill”
– There are some positive ways where the general
public thinks about health
– Reflections in phrases like ‘building on strength’ and
‘having resistance to infection’

12/22/2022 3
 Holistic concept of health

• WHO defined health as: ‘’ complete state of physical,

mental, and social well-being and not the absence of
disease or infirmity’’

(Over half a century ago in 1948)

12/22/2022 4
 Con…
• Disease: is a physiological/psychological dysfunction
• Illness: a subjective state of the person who feels aware of
not being well
• Sickness: is a state of social dysfunction that is a role that
the individual assumes when ill
• Risk factors: are factors positively associated with the risk of
developing disease but are not sufficient.
– Some risk factors are associated with many diseases while
some diseases are associated with many factors.
12/22/2022 5
 Cont…
• Public health- Is the science and art of preventing
diseases, prolonging life and promoting health by
community efforts and governments action.
• Public health is:
– Preventing disease, prolonging life
– Improving quality of life
– Eliminating health inequalities
– Organizing community to promote active participation
• Many disciplines: Epidemiology, Biostatistics, RH, Nutrition etc
– Epidemiology is considered as the basic science of public
health
12/22/2022 6
 Epidemiology
Definition
• The word epidemiology comes from the Greek words
– Epi= “on or upon,”
– Demos, = “people,”
– Logos, = “the study of.”
– “The study up on people”
• Many definitions have been proposed over time by
different scholars.
12/22/2022 7
 Con…

• The term epidemiology was originally applied to the

study of acute infectious diseases and was defined as

follows:

– “The science of epidemics.”

12/22/2022 8
 Con…
• Current definition
– The study of the frequency, distribution and
determinants of health and health related events
in specific populations, and the application of it to
prevention and control of health problems.

12/22/2022 9
 Key words in the definition are:

• Study: Epidemiology is a scientific discipline,

sometimes called “the basic science of public
health.”

– It has, at its foundation, sound methods of

scientific inquiry.

12/22/2022 10
 Con…
• Frequency
– It is a quantitative science
– It measures frequency of occurrence
• Measure frequency of death using mortality rates,
• Quantify occurrence of disease using morbidity rates,
• Example
– Number of exposed people
– Number of people with the outcome of interest
– Proportion of exposed people
– Proportion of people with the outcome of interest

12/22/2022 11
 Con…
Distribution:

• It is the occurrence of diseases and other health

problems in terms of person, place and time.

• This attempts to answer

– Who? Where? And When?

12/22/2022 12
 Con…
Determinants:
• Factors that are related with the occurrence of a disease in
individuals.
• The causative factors for the occurrence of a disease
• It attempts to answer questions like:
– How?...............Mechanism
– Why?...............Causal link

• More on possible cause or means for disease

occurrence
12/22/2022 13
 Con…
Disease and Health-related problems

• It includes – both diseases and physiological and/or

psychological dysfunction of the body

• It also includes other health related problems like:

– Vital events, births, deaths, marriage, divorces etc

– Health related behavior – sexual behavior, smoking,

alcoholism, drug abuses

– Social factors, such as poverty

12/22/2022 14
 Con…
• Human population:
– Epidemiology studies the health of the groups, communities
and whole or specific population.
• Characterize a basic difference in approach between
community medicine and clinical medicine
• In epidemiology, we study effects of diseases on
populations, while in clinical medicine we study effects of
diseases on individuals.
– Clinical medicine – focuses largely on the health of sick
individuals
12/22/2022 15
 Cont…

Application:
– Epidemiology is an applied science

• It is applied science, i.e. direct practical applications.

– The central concern of epidemiology is promotion and

maintenance of health through the prevention of diseases.

– The aims are all about frequency, distribution of diseases is

to identify effective prevention and control strategies

12/22/2022 16
 Con…
• The definition emphasizes that epidemiology is concerned
the collective health of individuals in communities and in
getting appropriate solution to alleviate the health
problems.
• Used to describe the health problem (what is occurring),
and its frequency (how many); who is affected, where,
when;
• Why diseases are occurring; and how we can influence the
occurrence (what type of intervention).
12/22/2022 17
 Cont…
• The study of the distribution and dynamics of disease
in the human population.

• The study of the distribution and determinants of

health related phenomena in the human population.

12/22/2022 18
 Con…
• Epidemiology is considered as the basic science of
public health

• It provides useful tools and methods to describe

variations in disease occurrence and

• Identify factors that influence the occurrence of disease

among population groups

12/22/2022 19
 History of Epidemiology

• Although epidemiologic thinking has been traced to the

time of Hippocrates, the discipline did not flourish until
the 1940s.
– Some key dates and contributions to the development of
epidemiologic thinking and methods include;

Hippocrates
– he suggested that the development of human disease might
be related to the external as well as personal and
environmental of an individual.
12/22/2022 20
John Graunt (1620-1674)
– Is an English man, attributed to most important advance in
epidemiology

– Published natural and political observations on the bills of

mortality.

– He was the first to quantify patterns of birth, death and

diseases occurrence, noting male births out numbered female
births, urban deaths out numbered rural deaths, high infant
mortality rate, and seasonal variations.

12/22/2022 21
Lind (1747)
– Used an experimental approach to study causes of scurvy by
showing it could be treated effectively with fresh fruit.

William Farr (1839)

– He took responsibility for medical statistics in the office of the
registrar General for England and Wales.

– He established application of vital statistical data for the

evaluation of health problems.

12/22/2022 22
John Snow (1854)
– He was an English physician.

– He demonstrated that the risk of mortality due to cholera

was related to the drinking water provided by a particular
supplier in London.

– Snow in 1854, he linked an epidemic of cholera to a

specific pump, the "Broad Street Pump".

– According to literatures, Snow removed the handle of

that pump and aborted the cholera epidemic.
12/22/2022 23
 Con…

Austin Bradford Hill (1937):

– He mainly worked on the Principles of Medical
Statistics and suggested the criteria for establishing
causation

12/22/2022 24
 Use Epidemiology (Purposes Of Epidemiology)

1. Establishing causation of diseases

– Is an antecedent event, condition or characteristic that was
necessary for the occurrence of the disease at the moment
– It occurred, given other conditions are fixed.

2. Studies (Elucidation) of the natural history of diseases

– Is essential to make prognosis or the likely outcome of a
patients illness.
– Gives basis for rational decision about therapy.
12/22/2022 25
 Cont…
3. Description of health status of populations

– Measure disease frequency- quantify disease

– Assess distribution of disease

• Who is getting disease?

• Where is disease occurring?

• When is disease occurring?

– Formulation of hypotheses concerning causal and

preventive factors
12/22/2022 26
 Cont…
4. Identify determinants of diseases
– Purpose of epidemiologic study is the identification of
determinants of disease, whose manipulation could lead to
prevention and control of diseases.
– Hypothesis is developed after description of occurrence by
person, place and time.
– Hypotheses are tested using epidemiologic studies
• Determinants of health
» Genetic factors
» Lifestyle
» Poverty and effluence
» Health care facilities
12/22/2022
» Environment-physical, biological and psychological
27
 Cont…
• Among the determinant, the most amenable for
modification is the physical environment.
• Providing conducive physical environment implies:
• Safe water
• Sanitary conveniences
• Clean environment
• Good food etc.
• This involves a lot of spending and therefore it is often said
that public health is “purchasable”.
12/22/2022 28
 Purposes Cont…

5. Evaluation of intervention programs

– Efficiency, effectiveness, feasibility and impact interventional
programs
6. Classification of diseases
– e.g. based on route of transmission
• Gonorrhea- as STD
• Shigellosis- fecal- oral route of transmission.

7. Guide health and healthcare policy and planning

8. Assist in the management and care of health and

disease in individuals
12/22/2022 29
 Scope of epidemiology

• Originally, epidemiology was concerned with epidemics

of communicable diseases,

• Lately; epidemiology was extended to endemic

communicable diseases and non-communicable
infectious diseases.

• More recently, applied to many conditions

12/22/2022 30
 Con…
▪ More recently, epidemiologic methods have been applied to
– Infectious and non infectious diseases
– Injuries and accidents
– Nutritional deficiencies
– Mental disorders
– Maternal and child health
– Congenital anomalies
– Cancer
– Occupational health
– Environmental health
– Health behaviors
– Violence, etc.
• Hence, epidemiology can be applied to all disease conditions
and other health related events.
12/22/2022 31
 Con…
• Now, even health behaviors, such as care seeking, safety

practices, violence and hygienic practices are valid

subjects for epidemiologic investigation.

• It is used in laboratory sciences, clinical medicine and

public health

12/22/2022 32
• Its scope in public health ranges from routine surveillance
to research strategies for the testing of hypotheses about
causes, measurement of health and disease risks and
evaluations of preventive, diagnostic and therapeutic
programs and technologies.

• Epidemiology is also a collection of applied disciplines, i.e.,

every disease entity has its own epidemiology (infectious,
cardio-vascular, cancer, etc.).
12/22/2022 33
 Fundamental Assumptions In Epidemiology

1. Human disease does not occur at random

2. Human disease has causal factors

3. These causal factors can be identified through systematic

investigation of populations.

4. Human disease can be prevented (have preventive

factors)

12/22/2022 34
 Theories/ principles of diseases causation

Disease causation
• The cause of a disease is an event, condition or
characteristics that precede the diseases event and
without which the disease event either would not have
occurred at all or would not have occurred some latter
time
• Not all associations between exposure and diseases are
causal
12/22/2022 35
 Types of causes
Necessary cause:
– A necessary cause is a causal factor whose presence is
required for the occurrence of the effect

– If disease does not develop without the factor being

present, then we term the causative factor “necessary”

– Must be present for disease to occur, disease never

develops in the absence of that factor

– E.g.) Tubercle bacilli is a necessary factor for tuberculosis

12/22/2022 36
 Con…
Sufficient causes:
– Sufficient cause is a “minimum set of conditions, factors
or events needed to produce a given outcome.
– A set of conditions without any one of which the disease
would not have occurred
– Not usually a single factor, often several
• Rabies virus is necessary as well as sufficient for developing
clinical rabies
12/22/2022 37
 Con…
Principles of causation
• There are two principles of disease causation
– The single germ theory
– The ecological approach
Germ theory
– Luis Pasteur isolated microorganisms.
– This discovery led to Koch’s postulate in 1877.
– Koch’s postulate states that
• The organism must be present in every case
• The organism must be isolated and grown in culture
• The organism must, when inoculated in to a susceptible
animal, cause the specific disease.
• The organism must then be recovered from the animal.
12/22/2022 38
 Con…
Ecological approach
– Ecology is the study of the relationship of organism to each
other as well as to all other aspects of the environment
– The requirement that more than one factor be present for
disease to develop is referred to as multiple causation or
multi-factorial etiology
– Etiology of a disease includes all factors that contribute to
the occurrence of a disease.
• These factors are related to agent, host, and environment
12/22/2022 39
Con…
– In the ecological view, an agent is considered to be
necessary but not sufficient cause of a disease
because the conditions of the host and
environment must also be optimal for a disease to
develop.
• Example- Mycobacterium tubercle bacillus is a necessary
but not sufficient cause for tuberculosis

12/22/2022 40
 General Models of Causation
• In epidemiology, there are several models of disease
causation that help to understand disease process.
• The most widely applied models are:
– The epidemiological triad (triangle)
– the wheel
– the web
– The sufficient cause and component causes models
(Rothman’s component causes model)

12/22/2022 41
 The epidemiological triad (triangle)

• It is the traditional model of infectious disease

causation.

• It has three components: an external agent, a

susceptible host, and an environment that brings the
host and agent together

12/22/2022 42
 The Epidemiologic Triad

12/22/2022 43
 Agent factors

❖ Infectious agents: agent might be microorganism—virus,

bacterium, parasite, or other microbes. e.g. polio, measles,
malaria, tuberculosis

✓Generally, these agents must be present for disease

to occur.
▪ Nutritive: excesses or deficiencies (Cholesterol, vitamins,
proteins)

▪ Chemical agents: (carbon monoxide, drugs, medications)

▪ Physical agents e.g.) Ionizing radiation

12/22/2022 44
 Host factors
• Host factors are intrinsic factors that influence an
individual’s exposure, susceptibility, or response
to a causative agent
• Host factors that affect a person’s risk of
exposure to an agent:
– e.g. Age, race, sex, socioeconomic status, and
behaviors (smoking, lifestyle, sexual practices and
eating habits)
• Host factors which affect susceptibility &response
to an agent:
– Age, genetic composition, nutritional and
immunologic status, anatomic structure, presence of
disease or medications
12/22/2022 45
 Environmental factors
• Environmental factors are extrinsic factors which affect
the agent and the opportunity for exposure

• Environmental factors include:

– Physical factors such as geology, climate,..

– Biologic factors such as insects that transmit an agent; and

– Socioeconomic factors such as crowding, sanitation, and the

availability of health services

12/22/2022 46
 Malaria
Agent

Vector

Host
12/22/2022
Environment
47
 Web of Causation
• There is no single cause
• Causes of disease are interacting
• Illustrates the interconnectedness of possible causes
– Developed to de-emphasis agent
– Chain of causation
– Complexity of origin is web
– Multiple factors promote or inhibit

• Emphasizes multiple interactions between host and

environment
12/22/2022 48
Web of Causation

12/22/2022 49
The Wheel of Causation

• The Wheel of Causation de-emphasizes the agent as

the sole cause of disease

• It emphasizes the interplay of physical, biological and

social environments

• It also brings genetics into the mix

12/22/2022 50
 The Wheel of Causation

Social Environment
Biological Environment
Host
(human)

Genetic Core

Physical Environment

12/22/2022 51
 Rothman’s component causes model
• The factors or conditions that form a sufficient cause
are called component causes
• Example
– The tubercle bacillus is required to cause tuberculosis
but, alone, does not always cause it,
– So tubercle bacillus is a necessary, not a sufficient,
cause

12/22/2022 52
 Rothman’s Component Causes Model…

• Rothman's model has emphasised that the causes of disease

comprise a collection of factors.
– These factors represent pieces of a pie, the whole pie
(combinations of factors) are the sufficient causes for a
disease.
– It shows that a disease may have more that one sufficient
cause, with each sufficient cause being composed of several
factors.
– The factors represented by the pieces of the pie in this
model are called component causes.
12/22/2022 53
 Con…

• Each single component cause is rarely a sufficient cause

by itself, But may be necessary cause.

– Example: rabies

• Control of the disease could be achieved by removing

one of the components in each "pie" and if there were a
factor common to all "pies“ (necessary cause) the disease
would be eliminated by removing that alone.

12/22/2022 54
 The sufficient cause and component causes model
(Rothman’s component causes model)

12/22/2022 55
 Levels of disease occurrence
• Diseases occur in the community at different levels at a
particular point in time.

• Some diseases are usually present in a community at a

certain predictable level; this is called the expected
level.

• But at times, diseases may occur in excess of what is

expected.
12/22/2022 56
 Con…

• Expected level
– Endemic: a persistent level of low to moderate
occurrence of diseases
– Hyper endemic: a persistently high level of
occurrence of disease
– Sporadic: occasional cases occurring at irregular
intervals
12/22/2022 57
 Con….
• Excess of what is expected
– Epidemic: occurrence of diseases in excess of what is
expected in a limited period

– Outbreak: same as epidemic often used by public health

officials because it is less provocative to the public

– Pandemic: an epidemic spread over several countries or

continents, affecting a large number of people

12/22/2022 58
In generally, Epidemiology can be categorized into two:

❖Descriptive Epidemiology

❖Analytical epidemiology

• Descriptive Epidemiology - Defines the amount and

distribution of health problems in relation to person, place and
time.

• It answers the questions who, where and when

– Time, place and person are the basic triad of descriptive

epidemiology

– Examples: case series, case reports, cross sectional study

12/22/2022 59
 Con…
• Analytic Epidemiology: involves explicit comparison of groups
individuals to identify determinants of health and diseases

• It answers the questions why and how

• Analytic epidemiology uses comparison groups to provide

baseline data so that associations between exposures and
outcomes can be quantified and hypotheses about the cause of
the problem can be tested

– Examples: case-control and cohort studies

12/22/2022 60
 Fields Of Epidemiology

• As epidemiology continues to develop and to expand

into new areas, the field has diversified into many
forms:
– Microbial epidemiology
– Clinical epidemiology
– Molecular epidemiology
– Genetic epidemiology
– Nutritional epidemiology
12/22/2022 61
 Con…
– Social epidemiology

– Reproductive epidemiology

– Global epidemiology

– Infectious diseases epidemiology

– Occupational epidemiology

– Environmental epidemiology

12/22/2022 62
Thank you
12/22/2022 63