EPIDEMIOLOGY insufficient to cause disease.
For example, while exploring
(Community/Public Health Nursing by Mary Nies & Melanie
McEwen)
Epidemiology is the study of the distribution and
determinants of health and disease in human populations
(World Health Organization, 2017) and is the principal
science of public health. It entails a body of knowledge
derived from epidemiological research and specialized
epidemiological methods and approaches to scientific
research. Community health nurses use epidemiological
concepts to improve the health of population groups by
identifying risk factors and optimal approaches that reduce
disease risk and promote health. Epidemiological methods
are important for accurate community assessment and
diagnosis and in planning and evaluating effective
community interventions. This chapter discusses the uses
of epidemiology and its specialized methodologies.
USE OF EPIDEMIOLOGY IN DISEASE CONTROL AND
PREVENTION
Although epidemiological principles and ideas originated in
ancient times, formal epidemiological techniques
developed in the nineteenth century. Early applications
focused on identifying factors associated with infectious
diseases and the spread of disease in the community. Public
health practitioners hoped to improve preventive strategies
by identifying critical factors in disease development.
Specifically, investigators attempted to identify
characteristics of people who had a disease such as cholera
or plague and compared them with characteristics of those
who remained healthy. These differences might include a
broad range of personal factors, such as age, gender,
socioeconomic status, and health status. Investigators also
questioned whether there were differences in the location
or living environment of ill people compared with healthy
individuals and whether these factors influenced disease
development. Finally, researchers examined whether
common time factors existed (i.e., when people acquired
disease). Use of this person-place-time model organized
epidemiologists' investigations of the disease pattern in the
community (Box 5.1). This study of the amount and
distribution of disease constitutes descriptive
epidemiology. Identified patterns frequently indicate
possible causes of disease that public health professionals
can examine with more advanced epidemiological
methods.
In addition to investigating the person, place, and time
factors related to disease, epidemiologists examine
complex relationships among the many determinants of
disease. This investigation of the causes of disease, or
etiology, is called analytic epidemiology.
Even before the identification of bacterial agents, public
health practitioners recognized that single factors were
the cholera epidemics in London in 1855, Dr. John Snow
collected data about social and physical environmental
conditions that might favor disease development. He
specifically examined the contamination of local water
systems. Snow also gathered information about people
who became ill—their living patterns, water sources,
socioeconomic characteristics, and health status. A
comprehensive database helped him develop a theory
about the possible cause of the epidemic. Snow suspected
that a single biological agent was responsible for the
cholera infection, although the organism, Vibrio cholerae,
had yet to be discovered. He compared the death rates
among individuals using one water well with those among
people using a different water source. His findings
suggested an association between cholera and water
quality (Box 5.2).
BOX 5.1 Person—Place—Time Model
Person: "Who" factors, such as demographic characteristics, health,
and disease status
Place: "Where" factors, such as geographic location, climate and
environmental conditions, and political and social environment
Time: "When" factors, such as time of day, week, or month and
secular trends over months and years
The epidemiologist examines the interrelationships
between host and environmental characteristics and uses
an organized method of inquiry to derive an explanation of
disease. This model of investigation is called the
epidemiological triangle because the epidemiologist must
analyze the following three elements: agent, host, and
environment (Fig. 5.1). The development of disease
depends on the extent of the host's exposure to an agent,
the strength or virulence of the agent, and the host's
genetic or immunological susceptibility. Disease also
depends on the environmental conditions existing at the
time of exposure, which include the biological, social,
political, and physical environments (Table 5.1). The model
implies that the rate of disease will change when the
balance among these three factors is altered. By examining
each of the three elements, a community health nurse can
methodically assess a health problem, determine
protective factors, and evaluate the factors that make the
host vulnerable to disease.
Conditions linked to clearly identifiable agents, such as
bacteria, chemicals, toxins, and other exposure factors, are
readily explained by the epidemiological triangle. However,
other models that stress the multiplicity of host and
environmental interactions have developed and
understanding of disease has progressed. The "wheel
model" is an example of such a model (Fig. 5.2). The wheel
consists of a hub that represents the host and its human
characteristics, such as genetic makeup, personality, and
immunity. The surrounding wheel represents the
environment and comprises biological, social, and physical
dimensions. The relative size of each component in the
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wheel depends on the health problem. A relatively large
genetic core represents health conditions associated with
heredity. Origins of other health conditions may be more
dependent on environmental factors (Mausner and
Kramer, 1985). This model subscribes to multiple-causation
rather than single-causation disease theory; therefore, it is
more useful for analyzing complex chronic conditions and
identifying factors that are amenable to intervention.
After the discovery of the causative agents of many
infectious diseases, public health interventions eventually
resulted in a decline in widespread epidemic mortality,
particularly in developed countries. The focus of public
health then shifted to chronic diseases such as cancer,
coronary heart disease, and diabetes during the past few
decades. The development of these chronic diseases tends
to be associated with multiple interrelated factors rather
than single causative agents.
In studying chronic diseases, epidemiologists use methods
that are similar to those used in infectious disease
investigation, thereby developing theories about chronic
disease control. Risk factor identification is of particular
importance to chronic disease reduction. Risk factors are
variables that increase the rate of disease in people who
have them (e.g., a genetic predisposition) or in people
exposed to them (e.g., an infectious agent or a diet high in
saturated fat). Therefore their identification is critical to
identifying specific prevention and intervention approaches
that effectively and efficiently reduce chronic disease
morbidity and mortality. For example, the identification of
cardiovascular disease risk factors has suggested a number
of lifestyle modifications that could reduce the morbidity
risk before disease onset. Primary prevention strategies,
such as dietary saturated fat reduction, smoking cessation,
and hypertension control, were developed in response to
previous epidemiological studies that identified these risk
factors (Box 5.3). The web of causation model illustrates the
complexity of relationships among causal variables for
heart disease (Fig. 5.3).
Host
Agent Environment
FIG. 5.1 Epidemiological triangle.
BOX 5.2 Example of the Epidemiological Approach
An early example of the epidemiological approach is John
Snow's investigation of a cholera epidemic in the 1850s.
He analyzed the distribution of person, place, and time
factor by comparing the death rates among people living
in different geographic sectors of London. His geographic
map of cases, shown here, is an early example of the use
of geographic information to formulate a hypothesis
about the causes of an epidemic. Snow noted that people
using a particular water pump had significantly higher
mortality rates from cholera than people using other
water sources in the city. Although the cholera organism
was yet unidentified, the clustering of disease cases
around one neighborhood pump suggested new
prevention strategies to public health officials (i.e., that
cholera might be reduced in a community by controlling
contaminated drinking water early sources). As an
immediate response, in September 1854, Snow
persuaded local leaders to remove the handle of the
pump, which to this day can be seen on Broadwick Street
in London (Snow, 1855.)
John Snow’s map of London neighborhood showing
location of cholera case cluster surrounding the Broad
Street water pump (Published by C. F. Cheffins, Lith,
Southhampton Buildings, London, England, 1854. In Snow
J, editor: On the mode of communication of cholera, ed 2,
London, 1855, John Churchill. Retrieved from:
http://www.ph.ucla.edu/epi/snow/snowmapl_
1854_lge.html.)
Replica of the famous Broad Street pump.
Broadwick Street, London. (Photo courtesy of
http://commons.wikimedia.org/wiki/File:John_
Snow_memorial_and_pub.jpg, Creative Commons
Attribution-Share Alike 2.0 Generic [CC BY-SA 2.01.).
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A newer paradigm, ecosocial epidemiology, challenges the E. Physiological state Fatigue, pregnancy, puberty,
more individually focused risk factor approach to stress, nutritional state
understanding disease origins. This ecosocial approach F. Prior Hypersensitivity, protection
emphasizes the role of evolving macro-level immunological Prior infection,
socioenvironmental factors, including complex political and experience: immunization
economic forces, along with microbiological processes, in Active Maternal antibodies,
understanding health and illness (Smith and Lincoln, 2011). Passive gamma globulin prophylaxis
Investigating the context of health will necessitate
alternative research approaches, such as qualitative and Diabetes, liver dysfunction,
ecological studies and studies of social institutions and hypertension
process and G. Intercurrent or
preexisting Personal hygiene, food
TABLE 5.1 A Classification of Agent, Host, and disease handling, diet, interpersonal
Environmental Factors that Determine the Occurrence of contact, occupation,
Diseases in Human Populations H. Human behavior recreation, use of health
Factors Examples resources, tobacco use
Agents of Disease—-
EtiologicaI Factors
A. Nutritive elements:
Excesses Cholesterol Environmental Factors (i.e.,
Deficiencies Vitamins, proteins extrinsic factors)— Geology, climate
lnfluence Existence of the
B. Chemical agents: Carbon monoxide, carbon Agent, Exposure, or Density
Poisons tetrachloride, drugs Susceptibility to Agent Sources of food, influence
Allergens Ragweed, poison ivy, A. Physical on vertebrates and
medications environment arthropods, as a source of
B. Biological agents
C. Physical agents: Sun exposure, medical environment Food sources, vertebrate
Ionizing radiation imaging Human hosts, arthropod vectors
Mechanical Repetitive motion injury populati
ons Exposure to chemical agents
Flora Urban crowding, tension
D. Infectious agents: Hookworm, schistosomiasis, and pressures, cooperative
onchocerciasis Fauna efforts in health and
Metazoa Amebae, malaria education
Protozoa Rheumatic fever, lobar C. Socioeconomic Wars, flood
Bacteria pneumonia, typhoid, environment
tuberculosis, syphilis Occupation
Histoplasmosis, athlete's Urbanization and economic
foot development
Fungi Rocky Mountain spotted
Rickettsia fever, typhus, Lyme disease Disruption
Viruses Measles, mumps, Modified from Lilienfeld DE, Stoley PD: Foundations of
chickenpox, smallpox, epidemiology, New York, NY, 1994, Oxford University Press.
poliomyelitis, rabies, yellow
fever, human
immunodeficiency virus In turn, the examination of social and contextual origins will
Host Factors (i.e., intrinsic enlighten the interventions of public health practitioners.
factors)—Susceptibility or
Response Influence For example, Buffardi et al. (2008) analyzed the
Exposure to Agent ecosocial and psychosocial correlates of diagnosis of
Cystic fibrosis, Huntington sexually transmitted infections (STIs) among young adults.
disease Specifically, they examined STI diagnosis within "contextual
Alzheimer disease conditions" such as low income, "housing insecurity,"
A. Genetic Rheumatoid arthritis childhood physical or sexual abuse, intimate partner abuse,
B. Age Tay-Sachs disease, sickle cell gang participation, personal history of having been
C. Sex disease arrested, and drug/alcohol use. It was determined that STIs
D. Ethnic group were statistically associated with housing insecurity,
exposure to crime, and having been arrested. The

3
researchers concluded that ecosocial or contextual
conditions strongly enhance STI risk by increasing sexual
risk behaviors and likelihood of exposure to infection.
In another study, Phillips (2011) applied an ecosocial
perspective when examining the effects of
social/contextual factors
FIG. 5.2 Wheel model of human—environment interaction.
(Redrawn from Mausner JS, Kramer S: Mausner and Bahn
epidemiology: an introductory text, ed 2, Philadelphia,
1985, Saunders)
BOX 5.3 Coronary Heart Disease (CHD) Risk
Factors Supported by Epidemiological Data from
the Framingham Study
• Age
• Gender (male)
• Current cigarette smoking
• Hypertension
• High level of low-density lipoprotein (LDL)
cholesterol
• Low level of high-density lipoprotein
(HDL) cholesterol
• (Diabetes)l
• Family history of premature coronary
heart disease?
Diabetes is not included in the Framingham Global Risk
Score but is now considered to be a coronary heart disease
risk equivalent, meaning that persons with diabetes will be
treated as intensively as those with coronary heart disease.
Included in NCEP list of major risk factors but not in the
Framingham Global Risk Score.
Data from the Executive summary of the third report of the
National Cholesterol Education Program (NCEP) expert
panel on detection, evaluation, and treatment of high blood
cholesterol in adults (adult treatment panel Ill), JAMA
285:2486-2497, 2001. The 2013 recommendations from
the American College of Cardiology/American Heart
Association indicate these risk factors predict 1 0-year
cardiovascular disease incidence (rather than CHD as in
NCEP ATP Ill), Circulation 2013. http://dx.doi.org/l O. 1
161/01.cir.0000437741 .48606.98, 2013
FIG. 5.3 The web of causation for myocardial infarction: A
current view. (From Friedman GD: Primer of epidemiology,
ed 5, New York, 2004, McGraw-Hill.)
on adherence to antiretroviral therapy (ART) among black
men who tested positive for human immunodeficiency
virus (HIV). He examined both individual factors (e.g.,
psychological state of mind, psychological distress, illicit
drug use) and interpersonal/social contextual factors (e.g.,
partner status, housing status, patient-provider
relationship, social capital [groups/ networks]). He
concluded that adherence to the medication regimen was
strongly associated with homelessness and how well the
individual tolerated the ART. Other factors included the
individual's state of mind and illicit drug use. Practice
implications included the observation that providers
should assess social and behavioral factors and intervene
accordingly. This would include identification of
psychological distress or presence of substance abuse. He
also suggested assessment of housing status and
facilitation of effective patient—provider relationships to
mitigate tolerability issues with ART.
CALCULATION OF RATES
The community health nurse must analyze data about the
health of the community to determine disease patterns.
The nurse may collect data by conducting surveys or
compiling data from existing records (e.g., data from clinic
facilities or vital statistics records). Assessment data often
are in the form of counts or simple frequencies of events
(e.g., the number of people with a specific health
condition). Community health practitioners interpret these
raw counts by transforming them into rates.
Rates are arithmetic expressions that help practitioners
consider a count of an event relative to the size of the
population from which it is extracted (e.g., the population
at risk). Rates are population proportions or fractions in
4
which the numerator is the number of events occurring in
a specified period. The denominator consists of those in the
population at the specified time period (e.g., per day, per
week, or per year), frequently drawing on demographic
data from the U.S. census. This proportion is multiplied by
a constant (k) that is a multiple of 10, such as 1000, 10,000,
or 100,000. The constant usually converts the resultant
number to a whole number, which is larger and easier to
interpret. Thus, a rate can be the number of cases of a
disease occurring for every 1000, 10,000, or 100,000 people
in the population, as follows:
RATE = _Numerator__
Denominator
= __Number of health events in a specified period___
Population in same area in same specified period
When raw counts or numbers are converted to rates, the
community health nurse can make meaningful comparisons
with rates from other cities, counties, districts, or states;
from the nation; and from previous periods. These analyses
help the nurse determine the magnitude of a public health
problem in a given area and allow more meaningful and
reliable tracking of trends in the community over time (Box
5.4).
BOX 5.4 Using Rates in Everyday Community Health
Nursing Practice
The following school situation exemplifies the value of
rates:
A community health nurse screened 500 students for
tuberculosis (TB) in Southside School and identified 15
students with newly positive tuberculin test results.
The proportion of Southside School students affected
was 15/500, or 0.03 (3%), or a rate of 30/1000
students at risk for TB. Concurrently, the nurse
conducted screening in Northside School and again
identified 15 students with positive tuberculin test
results. However, this school was much larger than
Southside School and had 900 potentially at-risk
students. To place the number of affected students in
perspective relative to the size of the Northside
School, the nurse calculated a proportion of 15/900, or
0.017 (1.7%), or a rate of 17/1000 students at risk in
Northside School.
On the basis of this comparison, the nurse
concluded that although both schools had the same
number of tuberculin conversions, Southside School
had the greater rate of tuberculin test conversions. To
determine whether rates are excessively high, the
nurse should compare rates with the city, county, and
state rates and then explore reasons for the
difference in these rates.
Sometimes a ration is used to express a relationship
between two variables. A ration is obtained by dividing one
quantity by another, and the numerator is not necessarily
part of the denominator. For example, a ratio could
contrast the number of male births to that of female births.
Proportions can describe characteristics of a population. A
proportion is often a percentage, and it represents the
numerator as part of the denominator.
Morbidity: Incidence and Prevalence Rates
The two principal types of morbidity rates, or rates of
illness, in public health are incidence rates and prevalence
rates. Incidence rates describe the occurrence of new cases
of a disease (e.g., tuberculosis, influenza) or condition (e.g.,
teen pregnancy) in a community over a given period
relative to the size of the population at risk for that disease
or condition during that same period. The denominator
consists of only those at risk for the disease or condition;
therefore known cases or those not susceptible (e.g., those
immunized against a disease) are subtracted from the total
population (Table 5.2):
Incidence rate =
Number of new cases or events occurring in a population in a specified
period__ Xk
Population at risk during same specified period (denominator)
TABLE 5.2 Examples of Rate Calculations
The incidence rate may be the most sensitive indicator of
the changing health of a community because it captures the
fluctuations of disease in a population. Although incidence
rates are valuable for monitoring trends in chronic disease,
they are particularly useful for detecting short-term
changes in acute disease—such as those that occur with
influenza or measles—in which the duration of the disease
is typically short.
If a population is exposed to an infectious disease at a given
time and place, the nurse may calculate the attack rate, a
specialized form of the incidence rate. Attack rates
document the number of new cases of a disease in those
exposed to the disease. A common example of the
application of the attack rate is food poisoning; the
denominator is the number of people exposed to a suspect
food, and the numerator is the number of people who were
exposed and became ill. The nurse can calculate and
5
compare the attack rates of illness among those exposed to
specific foods to identify the critical food sources or
exposure variables.
A prevalence rate is the number of all cases of a specific
disease or condition (e.g., deafness) in a population at a
given point in time relative to the population at the same
point in time:
Prevalence rate =
Number of existing cases in population at a specified point in
time (N)
Xk
Population at same specified point in time (D)
When prevalence rates describe the number of people
with the disease at a specific point in time, they are
sometimes called point prevalences. For this reason,
cross-sectional studies frequently use them. Period
prevalences represent the number of existing cases during
a specified period or interval of time and include old cases
and new cases that appear within the same period.
Prevalence rates are influenced by the number of people
who experience a particular condition (i.e., incidence) and
the duration of the condition. A nurse can derive the
prevalence rate (P) by multiplying incidence (I) by
duration (D): (P = I x D). An increase in the incidence rate
or the duration of a disease increases the prevalence rate
of a disease. With the advent of life-prolonging therapies
(e.g., insulin for treatment of type 1 diabetes and
antiretroviral drugs for treatment of HIV), the prevalence
of a disease may increase without a change in the
incidence rate. Those who survive a chronic disease
without cure remain in the "prevalence pot" (Fig. 5.4). For
conditions such as cataracts, surgical removal of the
cataracts permits many people to recover and thereby
move out of the prevalence pot. Although the incidence
has not necessarily changed, the reduced duration of the
disease (because of surgery) lowers the prevalence rate
of cataracts in the population.
FIG. 5.4 Prevalence pot: The relationship between incidence
and prevalence. (Redrawn from Morton RF, Hebel JR,
McCarter RJ: A study guide to epidemiology and
biostatistics, ed 3, Gaithersburg, MD, 1990, Aspen
Publishers.)
Morbidity rates are not available for many conditions
because surveillance of many chronic diseases is not widely
conducted. Furthermore, morbidity rates may be subject to
underreporting when they are available. Routinely
collected birth and death rates, or mortality rates, are more
widely available. Table 5.2 provides examples of calculating
selected rates.
Other Rates
Numerous other rates are useful in characterizing the
health of a population. For example, crude rates
summarize the occurrence of births (i.e., crude birth rate),
mortality (i.e., crude death rates), or diseases (i.e., crude
disease rates) in the general population. The numerator is
the number of events, and the denominator is the average
population size or the population size at midyear (i.e.,
usually July 1) multiplied by a constant.
The denominators of crude rates represent the total
population and not the population at risk for a given event;
therefore, these rates are subject to certain biases in
interpretation. Crude death rates are sensitive to the
number of people at the highest risk for dying. A relatively
older population will probably produce a higher crude
death rate than a population with a more evenly
distributed age range. Conversely, a young population will
have a somewhat lower crude death rate. Similar biases
can occur for crude birth rates (e.g., higher birth rates in
young populations).
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This distortion occurs because the denominator reflects the Death Rate Rate Per 100,000
entire population and not exclusively the population at risk Crude death rate 823.7
for giving birth. Age is one of the most common Age-adjusted death rate 724.6
confounding factors that can mask the true distribution of Age-specific death rates (years):
variables. However, many variables, such as race and <1 (infant) 588.0
socioeconomic status, can also bias the interpretation of 1-4 24.0
biostatistical data. Therefore, the nurse may use several 5—14 12.7
approaches to remove the confounding effect of these 15-24 65.5
variables on rates. 25-34 108.4
35—44 175.2
Age-specific rates characterize a particular age group in the 45—54 404.8
population and usually consider deaths and births. 55-64 870.3
Determining the rate for specific subgroups of a population 65—74 1786.3
and using a denominator that reflects only that subgroup 75—84 4564.2
remove age bias: ≥85 13,407.9
Modified from National Center for Health Statistics:
Deaths. Preliminary data for 2014, National Vita/ Statistics
Age specific rate = Reports 65(4):1—122, 2016. Retrieved from:
http•]/www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.p
Number of cases in a specific age category df.
In a population at a specified time X k
Population in the same age category at The same
specified time Therefore, the PMR requires consideration in the context
of the mortality experience of the population.

To characterize a total population using age-specific rates,

one must compute the rate for each category separately.
The reason is that a single summary rate, such as a mean,
cannot adequately characterize a total population. Specific
rates for other variables can be determined in a similar
fashion (e.g., race-specific or gender-specific rates) (Table
5.3).
Age adjustment or standardization of rates is another
method of reducing bias when there is a difference
between the age distributions of two populations. The
nurse uses either the direct method or the indirect
standardization method. The direct method selects a
standard population, which is often the population
distribution of the United States. This method essentially
converts age-specific rates for age categories of the two
populations to those of the standard population, and it
calculates a summary age-adjusted rate for each of the two
populations of interest. This conversion enables the nurse
to compare the two rates as if both had the standard
population's age structure (i.e., without the prior problem
of age distortion).
The proportionate mortality ratio (PMR) method also
describes mortality. It represents the percentage of deaths
resulting from a specific cause relative to deaths from all
causes. It is often helpful in identifying areas in which public
health programs might make significant contributions to
reducing deaths. In some situations, a high PMR may reflect
a low overall mortality or reduced number of deaths
resulting from other causes.
TABLE 5.3 Comparison of U.S. Mortality Rates—
2014 (Preliminary)
Number of deaths from a specific cause
PMR = _____In a specific time period X k
Total number of deaths in same
Time period
Table 5.4 summarizes the advantages and disadvantages of
crude, specific, and adjusted rates. Numerous other rates
assess particular segments of the population. One that is
followed closely by public health professionals is the infant
mortality rate, calculated by dividing the number of deaths
in infants less than 1 year old by the number of live births
for that period. This rate is considered a particularly
sensitive indicator of the health of a community or nation
and reflective of the care provided to women and children.
Disparities in infant mortality rates can be seen within
subgroups of the U.S. population, and the rate ranks 32
among 35 developed countries (Organisation for Economic
Cooperation and Development [OECD], 2017). Although
the United States achieved its Healthy People 2020 goal of
6.0 per 1000, the 2014 rate, 5.8 per 1000, masks disparities
within the population. Black infants experienced an infant
mortality rate 2.24 times higher than white infants (11.0 vs.
4.9 per 1000 in 2014) (Centers for Disease Control and
Prevention [CDC], 2016). Socioeconomic status and racial
disparities, which are frequently associated with
inadequate prenatal care, prematurity, adolescent
pregnancy, and smoking, are key risk factors. Recent
concern focuses on the steep rise in pregnancy-related
maternal mortality from 10 per 100,000 in 1990 to 17.3 per
100,000 in 2013 (CDC, 2017). Again, racial differences were
significant, with the presence of chronic conditions such as

7
hypertension, diabetes, and heart disease likely playing a
role. Table 5.5 provides a summary of the major public
health rates. A standard epidemiology textbook contains
more information.
USE OF EPIDEMIOLOGY IN HEALTH SERVICES
Epidemiological approaches, such as the ones presented
here, can be used to describe the distribution of disease and
its determinants in populations. However, epidemiological
principles are also useful in studying population health care
delivery and in describing and evaluating the use of
community health services. For example, analyzing the ratio
of health care providers to population size helps determine
the system's ability to provide care. The clients' reasons for
seeking care, the clients' payment methods, and the clients'
satisfaction with care are also informative. Regardless of
whether community health nurses or other health services
professionals collect these data, the information is essential
for those who strive to improve clients' access to quality
health care.
Health services epidemiology focuses on the population's
health care patterns. In particular, public health
practitioners are concerned with the accessibility and
affordability of services and the barriers that may
contribute to excess morbidity in at-risk groups.
Traditionally, children are a vulnerable group, and they are
a particular focus of health services research. Studies
examining poverty rates and care access have underscored
the need to expand insurance coverage to those who do not
have private medical insurance and do not qualify for
Medicaid programs or the State Children's Health Insurance
Program.
Ultimately, nurses must apply epidemiological findings in
practice. It is essential that they incorporate study results
into prevention programs for communities and at-risk
populations. Furthermore, the philosophy of public health
and epidemiology dictates that nurses extend their
application into major health policy decisions, because the
aim of health policy planning is to achieve positive health
goals and outcomes for improved population health.
A goal of policy development is to bring about desirable
social changes. Epidemiological factors, history, politics,
economics, culture, and technology influence policy
development. The complex interaction of these factors may
explain the challenges with the application of
epidemiological knowledge. Lung disease in the United
States exemplifies the incomplete progress in
implementing effective health policy. In the early 1950s,
studies identified and conclusively linked cigarette smoking
to lung cancer and heart disease (Doll and Hill, 1952).
Beginning in the 1950s, public policies to address this health
threat have included cigarette taxes, cigarette package
warning labels, smoking restrictions in public areas, the
institution of smoke-free workplaces, and restrictions on
selling tobacco to minors. Despite the successes of the past
60 years, approximately 20% of Americans continue to
smoke, with rates particularly high and effective among
young public adults, health suggesting policy. Community a
continued health need for focused nurses should exercise
"social responsibility" in applying epidemiological findings
but doing so will require the active involvement of the
consumer. Community health nurses collaborating with
community members can combine epidemiological
knowledge and aggregate-level strategies to effect change
on the broadest scale.
8
CASE STUDY. Application of the Nursing Process
Using an Epidemiological and Public Health Approach to Managing a Foodborne Outbreak
Nurses working in schools, daycare centers, camps, and other facilities where food is served must be cognizant of safe food-
handling principles. Furthermore, they must be aware of the potential for transmitting disease if proper procedures are not
followed. Outbreaks of foodborne illness must be assessed and managed, and often is the community health nurse who
initiates and participates in this process. The following is a scenario in which the nurse utilized the nursing process to analyze
and intervene in such an epidemic.

ASSESSMENT
On Wednesday, October 4, the school nurse at Greenly Elementary School saw eight students who complained of abdomina l
cramping, diarrhea, and fever. Parents of the sick students were called, and the students were sent home. On Thursday, the
nurse was alerted to a large number of absent students and teachers. Specifically, 62 students and 10 teachers were absent.
Most reported diarrhea symptoms. Because the absentee rate of 10% exceeded the average daily rate of 4% for the 620-
student school and because the nurse determined that the large number of diarrhea cases suggested an epidemic, the local
public health department was notified.

Public health officials arrived at the school and began to assess students still at school and those who were recovering at home.
Stool culture specimen were collected and sent to the state laboratory. Results indicated that the organism causing illness was
in most cases Shigella sonnie, the most commonly found form of the bacteria. Persons with severe symptoms were referred
to their physicians for possible antibiotic therapy. Food histories of meals eaten both at school and outside school were taken.

Friday saw a continuing increase in absenteeism among students and staff reporting gastrointestinal illness. Public health
specialists defined the criteria for identifying cases on the basis primarily of positive laboratory results, symptoms of diarrhea
or vomiting, fever with nausea or abdominal pain, or all of these. Cafeteria staff were interviewed, and it was determined that
one staff member had had diarrhea over the previous weekend but had returned to work on Monday. Public health staff
continued to take dietary histories of affected and unaffected persons and constructed rates of illness for all food served in
the cafeteria beginning on Friday of the previous week.

From the data, the students who ate lunch at school on Tuesday and ate fajitas and salad had higher rates of illness than those
who did not. Therefore, it was concluded that the outbreak of Shigella could be attributed to a food source.

DIAGNOSIS
Determining the likely cause of the outbreak was important in specifying a diagnosis and directing the planning of an
intervention. The following diagnosis was formulated.
Increased risk for Infectious diarrhea among elementary school children related to inadequate hygiene and food-handling
practices as evidenced by a 19% increase in reported cases within a 4-day period.

PLANNING
The school nurse, in conjunction with public health specialists. determined that several groups should be targeted in order to
eliminate the further spread of disease, they identified a need to assist families in understanding the nature of the disease,
how to care for their children who were ill, and how to prevent the spread at home. Within the school, there was a need to
review food-handling practices and the training that cafeteria workers received. Staff, including teachers, also required
information about Shigella and how it should be prevented in the everyday lives of students. Needs of special ages and
developmental levels of children were also important. A formal plan of what needed to be done, by whom. and when was
drawn up. Research into the nature and prevention of Shigella was gathered from the CDC and the local health department,
among other sources. The health department staff developed a plan to release information to the public about the prevention
of gastrointestinal illnesses, as many of these diseases are easily spread and so many students were already ill.

Long-Term Goal
An absence of cases of infectious diarrhea

Short- Term Goals

Treatment and recovery of all identified cases of diarrhea
Implementation of an effective program of hygienic practices among students and staff
Implementation of a food-handling program for all cafeteria workers e Adequate informing of the larger community in order
to prevent spread of the epidemic

INTERVENTION

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The school nurse took a central leadership role, directing action within the school aimed at staff, students, and student
families, teaching of appropriate hand washing was stressed. Hand-washing facilities were inspected for soap, paper towels,
and running water. Food preparation guidelines were reviewed with staff, and policies regarding remaining at home when ill
were reiterated. The health department staff provided technical assistance and made recommendations. They Informed
community physicians about surveillance and reporting requirements and provided information regarding case Identification
and treatment regimens. Daycare centers and preschools were advised to watch for diarrhea outbreaks and to adhere to strict
handwashing and practices, as these facilities tend to be high-risk areas for the transmission of organisms such as Shigella. The
media were contacted to elicit their help disseminating correct and useful Information to the community.

EVALUATION
Immediate evaluation involved monitoring the decline In Shigella cases both within the school and in the larger community.
The school nurse noted that the rate of absenteeism returned to normal on the following Monday. She determined that all
classes had received hygiene Instruction Within the following 2 weeks and that all teachers had received a flyer with specific
information about Shigella, Its care, and its prevention. She observed that bathrooms had filled soap dispensers, that friendly
signs reminding students to wash hands were posted near sinks, and that students were given the opportunity to wash hands
before lunch and snacks. The public health department likewise continued surveillance activities after encouraging physicians
to collect and submit stool culture specimens for suspected cases and to report cases to the health department Rates of
diarrhea declined rapidly in the week after the school outbreak The Infection did not spread to other schools or community
groups. This outcome can be attributed to successful epidemic management, yet surveillance remains crucial if the public's
health is to be protected.

LEVELS OF PREVENTION
Primary
• Teach students and staff about hand washing and hygienic practices.
• Maintain a system that promotes safe food-handling practices
• Exclude those with symptoms from school or food handling
Secondary
• Collect stool culture specimens from all symptomatic
• Treat those with advanced diarrhea symptoms with antibiotics
• Exclude those with positive culture results from food and exclude those with symptoms from school.
• Advise families and individuals in the care of those with diarrhea
Tertiary
• Treat and counsel those determined to be carriers of Shigella.

Information on Shigella infections is available at httpsflwnwvv cdc gov/shigella/ index.html

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