INTRODUCTION TO

EPIDEMIOLOGY

Our Lady of Fatima University

College of Medical Laboratory
Science
Biostatistics and Epidemiology
Epidemiology- Defined

 Study of the distribution and

determinants of health-related states
among specified populations and
the application of that study to the
control of health problems

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 Epidemiology Purposes
in Public Health Practice

• Discover the agent, host, and environmental

factors that affect health

• Determine the relative importance of causes of

illness, disability, and death

• Identify those segments of the population that

have the greatest risk from specific causes of
ill health

• Evaluate the effectiveness of health programs

and services in improving population health

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 Solving Health Problems
Step 1 -

Step 1 Data collection Step 1 - Surveillance; determine t

Step 2
Step 2 Assessment
Inference
Solving health
problems
Step 3 Hypothesis testing Step 3
Determine how and why

Step 4 Intervention
Step 4
Action

Action 4
DISEASE CAUSATION

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Theories of Disease Causation

 Disease was due to evil spirits

 Recovery was attributed to good spirits
 Disease as a form of punishment
 Control measures include offering
sacrifices and “casting-out demons”
Theories of Disease Causation
Filth Theory “Bad air”
 Associates disease
 was the cause of fever .
with the physical
 Building huge fires can
environment
purify the air
 Disease change with
 Programs to remove
seasons, climate,
filth likewise put up to
temperature,
serve to advance
overcrowding and filth
community sanitation.
 Diseases were due to
poisonous substances
and gases from the
earth
Theories of Disease Causation

Germ or Bacteriological Theory

 Koch confirmed Pasteur’s previous claims
 Disease is due to microscopic forms of life
 Opened the concepts of isolation and
quarantine
 Measures to destroy and remove the
bacteriological cause such as disinfection ,
fumigation and general cleanliness
 Bacteriology – explained the origins and
spread of communicable disease
Henle-Koch's postulates (1877,1882)

Koch stated that four postulates should be met before

a causal relationship can be accepted between a
particular bacterial parasite (or disease agent) and
the disease in question. These are:
1. The agent must be shown to be present in every
case of the disease by isolation in pure culture.
2. The agent must not be found in cases of other
disease.
3. Once isolated, the agent must be capable of
reproducing the disease in experimental animals.
4. The agent must be recovered from the experimental
disease produced.
Theories of Disease Causation

Concept of Multiple causation

 Disease results from the interaction of
multiple ecologic factors within a
dynamic system made up of an agent
of disease, host and the environment
Models of Disease Causation

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The Web

 States that effects never depend on single

isolated causes but rather develop as the
result of chains of causation  result of
complex genealogy and antecedents

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Web of Causation for the
Major Cardiovascular
Diseases
Web of Causation for
Myocardial
Infarction
Epidemiologic Lever
 The host and agent are at the opposite ends of a
hypothetical lever while the environment serves as the
fulcrum
 Based on biologic laws:
 Disease results from an imbalance between
disease agent and man
 The nature and extent of the imbalance depends on
the nature and characteristics of the host and the
agent
 The characteristic of the two are influenced
considerably by the conditions of their environment

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The Epidemiologic Lever

Agent Host

Environment
 Host

Agent

Environment

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The Epidemiologic Triangle

Agent

Host Environment
ENVIRONMENTAL
FACTORS OF DISEASE

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1. THE ENVIRONMENT

external to the host and in which the agent

may exist, survive, or originate
physical, climatologic, biologic, social and
economic

Physical:
water, humidity, geologic formations, etc
Social:
characteristics of a group of people

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Environment

enhance or diminish survival of agent

serve to bring agent and host

into contact

reservoir that fosters the survival

of infectious disease agent

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Reservoir
- living organism or inanimate matter in which an
infectious agent normally lives and multiplies on
which the agent depends primarily for survival
and reproduces itself in such manner that it can
be transmitted to a susceptible host

- Reservoir of infection

- Physical environment
- Animals or insects
- Human beings (main reservoirs)
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Human Reservoirs

Cases
(+) infection and (+) disease

Carriers
(+) infection but (-) disease

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Animal reservoirs

Zoonotic diseases

infectious diseases of animals that can

cause disease when transmitted to
humans.

- rabies
- plague

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The Agent Factor of Disease

 Agent is any element, substance, or

force whether living or non-living, the
presence or absence of which can
initiate or perpetuate a disease
process.

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Types of Agents

 1. Non-living
 2. Living

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1. Non-living Agents

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Non-living Agents

 1. Physical and Mechanical

- extremes of temperature, light, electricity,
physical trauma

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Non-living Agents

 2. Chemicals
2.a Exogenous – poisons
2.b Endogenous – accumulation of
toxic products of metabolism

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Non-living Agents

 3. Nutrients
3.a Deficiency Agents – anemia
from iron deficiency
3.b Excess Agents- obesity from
over- eating

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2. Living Agents
biological organism capable of
causing disease
TYPES
 Bacteria: TB, shigellosis
 Viruses and rickettsia: AIDS, hepatitis
 Fungi: candidiasis, athlete’s foot
 Protozoans: amoebiasis, giardiasis
 Helminthes: schistosomiasis, ascariasis

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Characteristics of Agents of
Diseases
 1. Inherent Characteristics
 2. Characteristics directly related to man
 3. Characteristics related to
the environment

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Inherent Characteristics

 1. Physical Features
- include morphology, motility, presence
or absence of capsule, spore or cyst
forms

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Inherent Characteristics

 2. Biologic Requirements
- refers to the things needed by agent
to survive
- Ex. some are aerobic,
anaerobic, capnophilic

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Characteristics directly related to
man

 Infectivity
 Pathogenicity
 Virulence
 Immunogenicity

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1.Infectivity - the ability of an agent to
invade and multiply in a host.
e.g. infection of high infectivity: measles

infection of low infectivity: leprosy

 Infectivity is dependent on a number of
factors including viability, portal of
entry, susceptibility of the host,
susceptible tissues and body defenses
of the host.
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2.Pathogenicity – ability to produce
clinically apparent illness.
- dependent on factors such as dosage,
presence or absence of capsule, degree
of toxigenicity, condition of the host
3.Virulence – severity of the reaction
produced and measured in terms of
fatality

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4.Immunogenecity – infections ability to
produce specific immunity.
ex. measles produces lifelong immunity

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Characteristics in relation to the
environment

 1. Reservoir
 2. Sources of infection
 3. Modes of transmission

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Modes of Transmission

 refer to the mechanisms by which

an infectious agent is transported
from reservoir to susceptible human
host

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Modes of Transmission

 There are three modes of pathogen

transmission:
 Contact transmission
 Vehicle transmission

 Vector transmission

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CONTACT TRANSMISSION

 A host is exposed to infectious agents by

making contact with the agent or items
contaminated with the pathogen so it can
reach a portal of entry into the host

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Direct Contact Transmission

 There is no intermediary between infected

and uninfected individuals.
 It encompasses such things as touching, kissing,
and sexual interactions.
 Diseases transmitted through direct contact include:
 Hepatitis A
 Staphylococcal infections
 Sexually transmitted diseases.

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Droplet Transmission

 Droplet transmission is seen in the transfer of

respiratory diseases such as influenza and
whooping cough.
 It can occur through sneezing, coughing, and
even laughing.

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Indirect Contact Transmission
 Takes place through intermediates:
 Tissues, Handkerchiefs
 Towels
 Bedding
 Contaminated needles (the latter easily transferring HIV
and hepatitis B).
 Nonliving intermediates that act as the agents of
transmission by indirect contact are referred to
as fomites.

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VEHICLE TRANSMISSION

 Vehicle transmission involves pathogens riding along on

supposedly clean components.
 Examples of vehicles include:
 Air
 Food
 Water
 Blood
 Bodily fluids
 Drugs
 Intravenous fluids

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VEHICLE TRANSMISSION

 Air is a difficult vehicle to control.

 Dust uses air as a vehicle and can contain
huge numbers of pathogens.
 Microbial spores and fungal spores can also
use air to travel from host to host.

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VECTOR TRANSMISSION

 Pathogens are transmitted by

carriers, usually arthropods:
 Fleas
 Ticks
 Flies
 Lice
 Mosquitoes

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VECTOR TRANSMISSION

There are two types of vector

transmission:
 Mechanical vector–
pathogens are on vector’s
body parts and are
passively brushed off and
onto the host
 Biological vector –
pathogens are within the
vector and transmission
to the host is through a
bite
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3. THE HOST
 goes through chain of events
leading from inapparent infection to
a clinical case of the disease

GRADIENT OF INFECTION
- Range of infection, from inapparent to
severe disease

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the host

 Severity of illness depends on resistance of

the host (immunity level)

 end result of infection

-- complete recovery
-- permanent disability/disfigurement
-- death
-- chronicity

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Characteristics of the host

Non-specific Defense Mechanisms

 Skin
 mucosal surface
 Tears
 Saliva
 acid pH of gastric juice
 phagocytes & macrophages
 Age, nutrition status, genetic factors

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Other concepts related to
causation

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Necessary versus Sufficient
Cause
 Necessary Cause – Factor must be
present for the disease to occur  it
must invariably precede an effect
 Sufficient Cause – Cause that
inevitably initiates or produce an
effect
 includes “component causes”
Any given cause may be necessary,
sufficient, both, neither
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Types of Causal
Relationships
 Necessary and sufficient – without the factor, disease never develops
 With the factor, disease always develops (this situation rarely occurs)

 Necessary but not sufficient – the factor in and of itself is not enough
to cause disease
 Multiple factors are required, usually in a specific temporal
sequence (such as carcinogenesis)

 Sufficient but not necessary – the factor alone can cause disease,
but so can other factors in its absence
 Benzene or radiation can cause leukemia without the presence of
the other

 Neither sufficient nor necessary – the factor cannot cause disease on

its own, nor is it the only factor that can cause that disease
 This is the probable model for chronic disease relationships
HERD IMMUNITY

immunity of a group or a community

“resistance” of a group to invasion and
spread of an infectious agent based on the
immunity of a high proportion of individual
members of the group
important factor underlying the dynamics of
propagated epidemics

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NATURAL HISTORY OF
THE DISEASE

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NATURAL HISTORY OF DISEASE
TWO PHASES
 PREPATHOGENESIS
 Phase before man is involved

 Through interaction of agent, host and

environmental factors, agent finally reaches man
 PATHOGENESIS
 Includes the success invasion and establishment
of the agent in the host
 From incubation period to production of
detectable evidence of the disease process
(Clinical Horizon), until it is interrupted by
treatment
Natural History of Disease
 “Progression of a disease process in an
individual over time, in the absence of
treatment” --(CDC)
STAGE OF SUSCEPTIBILITY
 Pre-exposure period in the natural history of disease,
in which the individual in the population is vulnerable or
at risk to acquire the infection and/or amenable to get
exposed to and be harmed by a health determinant.

 During this stage, the individual in the population does

not have the disease nor the infection; only the risk
factors are present.

 The susceptibility stage ends with the effective

exposure.
Pre-Pathogenesis

Susceptibility
EXPOSURE

Adaptation
Who is at Risk?

 Risk factors
 Poor health and nutrition
 Lack of immunity

 Behaviors that increase opportunity for

exposure
Adaptation

 Failure leads to pathogenesis

 Immediate response of the body

 Immune system
STAGE OF PRESYMPTOMATIC
DISEASE (Sublinical stage)
 The etiological factors (e.g. infectious agent, risk
behaviours, environmental toxins) are present in the
body and are causing pathological changes, but there
are not yet any discernible signs or symptoms.

 In this stage there is no manifest of disease but

pathogenic changes have started to occur

 The time required for the agent to establish itself,

multiply and produce toxins
Sub-clinical stages of disease
Incubation period Latency period
 Asymptomatic  Asymptomatic
 Time between exposure  Time between exposure
to onset of symptoms to causal factor and
 Infectious diseases disease detection

 **common in NCD
CDC.G
OV
STAGE OF CLINICAL DISEASE

 Refers to the period of time at the onset of signs or symptoms of

the disease.
 Sufficient end-organ changes have occurred so that there are
recognizable signs or symptoms of disease
 The outcomes of this stage may be recovery, disability or death.
 It is important to subdivide this stage for better management of
cases and for purposes of epidemiologic study
 Morphologic subdivision or on functional or therapeutic
considerations
STAGE OF DISABILITY

 The final stage in the natural history of disease

concerns the outcome: recovery, disability or death.

 Some diseases run their course and then resolve

completely either spontaneously or by treatment

 Any temporary or long term reduction of a person’s

activities
Pre-
Pathogenesis
Susceptibilit
y EXPOSUR
E

Adaptation
Pathogenesis

Subclinical

Clinical

Outcome
Levels of Prevention

Primordial • Before risk factors

Primary • Pre-pathogenesis
Secondary • Subclinical or very early clinical
Tertiary • Middle to late clinical
pinter
est
Primordial Prevention

 Prevent development of risk factors

 Target: National Policies and Programs

Mass
Education

Individual Education
Primary Prevention

 Prevent disease:
 Reduction of risk factors
 Immunization

 Removal of harmful agents

 Target:
Secondary Prevention

 Early detection
 Prompt treatment
 Cure disease at the earliest stage

 Target:
Tertiary Prevention

 Complete treatment
 Limit disability
 Rehabilitation

 Target:
Classification of diseases

 Method of grouping of diseases

based on their specific features

 Ensures universal criteria for

diagnosing diseases

 Usually dependent on current level

of knowledge about the disease
Classification of Diseases

Classification Data Used Examples

Clinical Signs and symptoms Cancer CVD

Etiologic Presumed cause Tuberculosis AIDS

Sources of Epidemiologic
Data
Sources of Epidemiologic Data

WHO-HMN
2008
 Considerations in Choosing the
Source of Data
 Research Objective

 Data Quality

 Sensitivity Issues

 Logistics
General Types of Data

 Primary Data: collected by the

researcher firsthand

 Secondary Data: derived from

another source that may have other
objectives for collecting the data
Data Sources according to Type of Data

Primary Secondary
 A. Queries  A. Computerized
 Interviews bibliographic databases
 Questionnaires
 FGD
 B. Surveillance data
 Census
 B. Observations  Registries
 Direct  Hospital records
 With tools  Insurance records
Secondary: Census

 Advantage  Disadvantage
 Info on population  Small number of
numbers and health questions that
distributions by age, can be included
sex and others
 Allows small-area
estimation and
disaggregation like
socio-economic
status
Secondary: Civil Registry

 Primary purpose: establishment of

legal documents as required by law

 Major and most effective source of

vital statistics

 **Cause of death together with ICD

Civil registry

 Advantage  Disadvantage

 Enables the routine  In low and lower-

production of vital middle-income
statistics essential countries, civil
for improving health registry is weak or
outcomes, as well as non-existent
the provision of
small-area data
Civil Registry: Birth Statistics

 Most visible evidence of a government’s

existence of a person as a member of the society
 Uses of birth certificate data:
 Calculation of birth rates

 Maternal conditions, length of gestation,

birth weight, congenital abnormalities..

 Problems: completeness of entries, unreliable

data from the mother, neonatal defects undetected
at birth
Civil Registry: Death Statistics
 Mortality data have the advantage of being almost
totally complete because deaths are unlikely to go
unrecorded

 **Cause of Death
 Immediate cause of death: final disease, injury,
complication
 Antecedent cause of death: intervening event
between immediate and underlying cause of death
 Underlying cause of death: disease that initiated
chain of morbid events
Civil Registry: Death Statistics

 Uses of death certificate:

 Calculation of mortality rates
 Information on CoD

 Problems:
 Correctness of entries
 Stigma associated with certain illnesses
 Lack of standardization of diagnostic criteria
 Change of coding for CoD over time
Notifiable Disease Statistics
 Reportable diseases
 Selected for being epidemic-prone

 Targeted for eradication or elimination

 Subject to international health regulation

 USES
 Monitor progress towards disease reduction targets

 Measure achievements of disease prevention

activities
 Identify hidden outbreaks or problems so that early
action may be taken
Notifiable Diseases
 Category 1  Category 2
 acute flaccid paralysis,  Acute blood diarrhea,
anthrax, adverse event acute encephalitis, acute
following immunization, hemorrhagic fever,
human avian influenza, acute viral hepatitis,
measles, meningococcal bacterial meningitis,
disease, neonatal cholera, dengue,
tetanus, paralytic diptheria, influenza-like,
shellfish poisoning, leptospirosis, Malaria,
rabies, SARS, Non-neonatal tetanus,
outbreaks, clusters of pertussis, typhoid and
diseases, unusual paratyphoid fever
diseases or threats
Population (Sample) Survey

 Advantage  Disadvantage

 Prime data sources  Less efficient in rare

on risk factors events
 Sampling error
 Possible to generate  Estimates for local
important data on the areas may not be
links between health possible
and socio-economic
determinants
Institution-based Surveillance Data

Within the Health Sector Beyond the Health Sector

 Case reporting  Food and agricultural
 Morbidity and mortality records
data  Occupational reports
 Availability and quality of  Police records
services
 Services delivered and
commodities provided
 Resources
Data Quality and Utility

 Nature of the data

 Vital statistics, registries, surveys
 Availability of the data
 Accessibility to the researcher
 Completeness of population coverage
 Representativeness
 Vale and
limitations
 usefulness
Data Privacy and Confidentiality

 Privacy vs. Confidentiality ?

 Republic Act 10173: Data Privacy Act

of 2012

 Executive Order No. 2 s. 2016:

Freedom of Information
Sensitive personal information (RA 10173)

 Individual’s race, ethnic origin, marital status,

age, political affiliations, etc.

 Individual’s health, education, genetic or

sexual life of a person, etc.

 Issued by government agencies like SSS

number, licenses, tax returns, etc.
Data Sharing

 Voluntary release of information by one

investigator or institution to another for
purposes of scientific research

 Advantage: enhancement of knowledge

 Issues:
 Loss of control over intellectual property
 Loss of privacy and confidentiality of the research
subject
Data Linkage

 Joining data from two or more sources

 Requires interoperability of data sources

 Talk with each other
 Use of common identifying features to
connect data records on a single individual
THANKYOU!

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