Government College of Nursing Raipur (c.

g)
SUBJECT- COMMUNITY HEALTH NURSING

SEMINAR ON-

EPIDEMIOLOGY

Submitted to-
Mrs. Shabiba daharia Submitted by-
( Msc. Demonstrator ) ms Babita
dhruw
Dept. Of CHN , M.Sc. Nursing II
year
Govt. College of Nursing jagdalpur(c.g.) Govt. College of
Nursing,
Jagdalpur( c.g.)
INTRODUCTION:-
The science of Epidemiology which deals with the study of health related states and events occurring in
defined community, equip community health nurses/ health workers with a body of knowledge and skills
in making health assessment and planning and implementing need based care to community as a whole. It
provides a frame of reference for investigative approach to deal with any problem in the family, group
and community. It is therefore desirable to understand epidemiological concepts, principles and methods.

EPIDEMIOLOGICAL TRENDS AND CONCEPTS;-

Historical background and trends of epidemiology

 The origin of epidemiology has been traced back to Hippocrates (460-447BC) who tried to explain the
association of lifestyle and environmental factors with the occurrence of disease.
 However, the foundation of modern epidemiology was laid down in the 19th century, when infectious
communicable disease like cholera, Typhoid, Plague etc. were most prevalent in the world in the form
of epidemics and pandemics.
 Other communicable disease which were the major concerns of epidemiologists and Public Health
Personnel included Smallpox, Tuberculosis, Poliomyelitis, Measles, Hepatitis, Sexually Transmitted
Disease- Syphilis, Gonorrhea, Herpes.
 During the late, 19th century and the early 20th century the primary focus of epidemiologists was to
study the prevalence, prevention, and control of various infectious and communicable diseases.
 The focus of epidemiologists is not only on communicable diseases but also on new emergent
problems.
 The literal meaning of the term epidemiology which is derived from Greek words epi (upon)
demos(the people) and Logos (knowledge) thus knowledge and study of anything that comes upon or
affect people.
 The application of epidemiology in nursing can be traced back to Florence Nightingale(1820-1910).

DEFINITION
 The epidemiology is that branch of medical science which deals with epidemics.

-Parkin,1873

 Epidemiology is the science of mass phenomena of infectious diseases.

-Frost,1927

 Epidemiology is the study of the distribution and determinants of health-related states or events
(including disease), and the application of this study to the control of diseases and other health
problems. Various methods can be used to carry out epidemiological investigations: surveillance
and descriptive studies can be used to study distribution; analytical studies are used to study
determinants.
WHO 2017
 The goal of epidemiology, very broadly speaking, is to understand the patterns of disease and
health dynamics in populations as well as the causes of these patterns, and to use this
understanding to mitigate and prevent disease, and to promote health. The goal of digital
epidemiology is exactly the same. . .Digital epidemiology is epidemiology that uses data that was
 generated outside the public health system, i.e. with data that was not generated with the primary
purpose of doing epidemiology. Epidemiology, in general, is “the science of occurrence of
diseases i
Slathe M 2018

MODERN CONCEPTS OF EPIDEMIOLOGY

The modern epidemiology deals with:

 Measurements of occurrence of health related states or events which include

diseases, disabilities, death, physiological conditions, health needs, health demands,
health behaviour and health care utilization etc.
 The measurements are done in the form of rates, ratios and proportions e.g.
incidence and prevalence rates for various diseases, male-female ratio; percentage
of bedridden elderly population; various mortality rates etc.
 These rates and ratios can help in doing comparison of different communities from
time to time with respect to prevalence of health related states or events.
 Study of distribution of disease pattern, disabilities or death and other health related
states or events in a community by place, person or time.
 The epidemiologists investigate and determine whether there is increase or decrease
in the occurrence of these events over time in a given community or different
community and in what concentration (high or low) and whether the occurrence is
more in men than in women or vice-versa, and in particular age, lifestyle,
socioeconomic status etc. such information helps in identification of
possible/tentative cause and effect relationship i.e. etiological hypothesis
e.g. the smoking of 25-30 cigarette per day over a period of 20-25 years causes lung
cancer in 10 to 15 % of men and women.
“ The incidence of diarrhoea is more in bottle fed infants than in breast fed infants
of low socioeconomic families”.
This aspect of epidemiology is known as Descriptive Epidemiology.

PURPOSES AND OBJECTIVES OF EPIDEMIOLOGY

The basic purpose of epidemiology are:

 To prevent, control and eradicate health and health related problems.

 To reduce/minimise the impact of these problems
 To promote health and quality of life of people at large.

These purpose are achieved by the following aims, objectives of epidemiology:

  Study of frequency and distribution of health and health related problems in
community at large.
 Identification of determinants i.e. aetiological factors causing health and health
related problems.
 Need based planning and administration of comprehensive health programmes with
the available resources to deal with health and health related problems.
 Evaluative and effectiveness of the programmes to provide feedback.

USES OF EPIDEMIOLOGY

Epidemiology helps to:

 Study the occurrence and distribution of diseases in a community.

 Identify the determinants of diseases.
 Diagnose the health status of the community by identifying health problems on the
basis of morbidity and mortality pattern and by identifying groups/individuals who
are at risk and require special attention/care.
 Estimate the risk i.e. statistical probability of disease, accident and
defect/disabilities and the chances of avoiding them.
 Plan effective need based health care services on the basis of epidemiological
information regarding frequencies and distribution of diseases and disabilities, their
associated factors and causes.
 Determine the effectiveness of health care services planned and implemented on the
basis of predetermined criteria regarding its relevance, effectiveness, efficiency and
impact on community health. This can help to plan better services in future.
 Determine the usefulness and effectiveness of new/innovative techniques, measures
and programmes etc. before these are used widely e.g. evaluation of polio vaccine,
new anti-rabies vaccine, pulse polio vaccination programme etc.
 Complete the clinical picture of chronic diseases and slow growing diseases or those
which remain asymptomatic for a long time and describe their natural history. E.g.
degenerative diseases of the central nervous system.
 Identify syndromes by describing the distribution and association of clinical
phenomena in the population.
 Forecast the likely occurrence of certain diseases on the basis of epidemiological
principles e.g. changing trends in the occurrence of malaria due to changes in
climatic factors such as rainfall or the forecasts which are made in the occurrence of
HIV infection.

EPIDEMIOLOGICAL ASPECTS OF DISEASES

It is very important to understand the concept of disease causation and disease progress
because it can help in identifying public health measures to prevent and control diseases.
The aims of epidemiological studies are to acquire knowledge about the nature of
diseases/health problems, their etiological factors and then utilize that knowledge in
planning community health services to prevent and control diseases/health problems.

THEORIES AND MODELS OF DISEASE CAUSATION

Several theories explaining the causes of diseases were put forward from time to time.

1. The Germ Theory

 The Germ Theory became popular during the 19th and early part of 20th century.
 According to this theory, there is one single specific micro-organism (causative agent)
to every disease.
 This refers to ‘one to one relationship’ between the causative agent and the disease as
shown in epidemiological model. This is also called as Single Cause Theory.

Causative agent Man Disease

Cause Effect

 For example: Diphtheria due to corney bacterium diphtheria,

Cholera due to Vibrio cholerae ,
Tuberculosis due to tuberculosis bacilli.
 This theory is limited to infectious diseases only.
 The single cause theory was further supported by the identification of other specific
agents as causative agents for certain health problem. E.g. lack of Vitamin C was
found to cause Scurvy.

2. Theory of Epidemiological Triad

 The Germ Theory has many limitations. It was experienced that everyone exposed
to disease agent did not contract the disease.
For e.g. Tuberculosis, all those who were exposed to the tuberculosis organisms, did
not suffer from tuberculosis. Only those who were undernourished, lived in dark
and dingy places and who did not have immunity against tuberculosis got the
disease.
 This means it was not only the causative agent that was responsible for causing
disease by there were other factors related to man (host) and environment which
contributed to the occurrence of a disease. This leads to the theory of
epidemiological triad as shown in epidemiological model.
 AGENT

HOST ENVIRONMENT
 This model is also called as ecological model and is evolved through the infectious disease.
 According to this model there are three elements or major factors which are responsible for
particular disease causation. These are agent, host and environment.
 The agent is considered to be the primary factor(e.g. amoeba, bacteria, fungi, virus) without which
a particular disease can not occur.
 The host refers to human beings who come in contact with the agent.
The host related factors which play an important role are genetic make-up, age, sex, race,
immunity, health behaviour etc.
 The environment includes all that is external to the host and agent but that may influence
interaction between them.
 These three factors, if remain in equilibrium or in balance then disease will not occur and referred
as state of health equilibrium.

Agent Host

Environment
Fig. Ecological Model of Health Equilibrium

 The disease will occur when equilibrium is disturbed due to change or disruption in any of these
factors. For example: poor environmental sanitation, open defecation, contamination of water
foods etc.
 Other examples of disruption that could increase the possibility of disease occurrence include:
i. Conditions in the host such as severe malnutrition, disturbed immune system, poor specific
resistance etc. which increases his/her susceptibility to disease.
ii. The increased number and mutation of virus which may increase their virulence and and ability to
infect the human host.
 Infact, there has to be optimal interaction of all the three factors to cause the disease in a man.
 It implies that disease will occur only when the agent is strong and enters the host through the right
channel and in sufficient amount, the host is susceptible and when environmental conditions
facilitate the interaction of host and agent.
 T
N
E
G
A
Fig. Epidemiological concept of interaction of Host, Agent and Environment
 For example: the causation of pulmonary tuberculosis mentioned earlier, the live tuberculosis
bacilli must enter through respiratory tract and in sufficient amount, the host must be susceptible
i.e. has no specific resistance and weak general body resistance and the environment must
facilitate interaction of host and organisms i.e. environment is crowded, dark and dingy.

3. Multifactorial Causation Theory

 The epidemiological triad model is applicable to infectious diseases only. It is not applicable to
no-infectious and chronic diseases like mental illness, coronary heart disease, rheumatoid arthritis
etc.
 It is because these diseases are not linked with specific causation agent and these cannot be
prevented and controlled by immunization, isolation and quarantine techniques and by
improvement of sanitation like infectious diseases.
 These diseases are caused by multiple factors.
 For example: coronary heart disease is associated with certain lifestyle activities such as: smoking,
ingestion of food containing high level of cholesterol, lack of exercise, increased mental and
emotional stress environmental pollution etc. control of diet, regular exercise and use of effective
stress management techniques have shown to reduce the risk of experiencing myocardial
infarction. This leads to the theory of multi-factorial causation.
 The multi-factorial causation model helps epidemiologist to understand the various associated
causative factors, prioritise these and plan preventive and control measures for a particular
disease.

Cause

Cause

Cause

Fig. Multi cause/ Single Effect Model

Effect (disease)
  It is also found that several causative factors produce many observed effects e.g. air pollution,
smoking and specific form of radiation (cause) may produce lung cancer, emphysema and
bronchial (effects). The model can be depicted as:

Cause Effect

Cause Effect

Cause Effect
Fig. Multi Cause/ Multi Effect Model

4. Web of Causation
 This epidemiological concepts of disease aetiology is given by Mac Mohan and Pugh.
 According to this concept, disease (effect) never depends upon single isolated cause. Rather it
develops as a result of chains of causations in which each link itself is the result of complex
interaction of preceding events/ circumstances.
 These chain of causation which may be a fraction of the whole complex is known as web of
causation.
 This epidemiological model suggest that there are cluster of causes and combinations of effects
which are related to each other and need to be studied to identify possible interventions to reduce
the occurrence of a particular disease.
 For example: cardio-vascular diseases may include avoidance of smoking, diet control, exercise,
stress management etc.

Changes in life style Stress Genetic Inheritance

Ting Smoking Ageing and

Other factors

Obesity Hypertension

Hyperlipidaemia Increased Thrombotic Changes in

Tendency walls of
Arteries

Coronary Atherosclerosis cardiovascular diseases

 Fig. Web of Causation-Cardiovascular Diseases

This model is particularly applicable to chronic diseases where the causative agent is unknown and which
are due to interaction of multiple factors e.g. cardiovascular diseases, cancer etc.

5. Dever’s Epidemiologic Model

 The model is composed of four major categories of factors such as human biology, life style,
environment and health care system.
 Human biological factors are host related factors of epidemiological triad and include genetic
inheritance, complex physiologic systems, factors related to maturation and ageing.
 Life style factors include daily living activities, customs, traditions, health habits and behaviour
etc.
 Environmental factors include physical, biological, social and spiritual components and are similar
to environment aspects of epidemiological triad.
 Health care system factors include availability, accessibility, adequacy and use of health care
services at all levels.
 All these factors influence health status either positively or negatively.

NATURAL HISTORY OF DISEASE

 In the absence of any intervention i.e. prevention or treatment, all disease follow a natural
course of events which refers to “Natural History of Disease”.
 The concept was defined and associated with preventive and control strategies in 1953 by
Leavell and Clark with the help of Schema of natural history of disease.
 Leavell and Clark have defined the Natural History of Disease model as under:
“A narrative and schematic representation which portrays a chronological sequencing of
departure from health. The sequence begins with the factors that promote health, but the
model also addresses the very first force that inaugurates pathological departure. An innate
function of this model is to describe various approaches to prevent and control pathological
processes and this function is collectively known as the level of prevention. ”
 It depicts its confrontation/interaction of three essential elements i.e. agent, host and environment
to influence the onset of any disease, the continuum of pathogenesis.
PRE-PATHOGENESIS PERIOD PATHOGENESIS PERIOD
(IN ENVIRONMENT) (IN MAN)

Confrontation A H
& Interaction

E 3
CLINICAL STAGE DISABILITY STAGE
Provokes Stimulus
Clinical
Recognizable

Early Advance Con Chron

Diseas d vale ic
e Disease scen State
Early Pathogenesis ce Disabi
 Interaction of lity &
Host-Agent/ Defec
Stimulus t
 Tissues
Reaction
 Physiological
changes
INCUBATION PERIOD

2
PRESYMPTOMATIC
STAGE

PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY

PREVENTION

This model is based on the following assumptions.

Health is a relative state: it is assumed that every one possesses some degree or level of health &
it depends upon factors related to people(host)- inherent or acquired characteristics, factors related
to agents or factors related to environment in which people (host )live.
Disease is a process: it is assumed that disease is not static. It is a process and begins before the
individual is affected. It means that the conditions which stimulate illness are present in the
environment and in the people (hosts) themselves. This process thus depends upon the nature and
 characteristics of agent, host and disease producing stimuli from within the environment and
individual.
Disease is effected due to multiple causation: the occurrence of any disease depends upon the
epidemiologic triangle composed of agent, host and environment. The host refers to the individual
or population affected. The agent is an element, a substance or a force, whose contact with the
susceptible host under appropriate environmental conditions is essential to serve as a stimulus to
effect the disease process. Agents in case of infectious disease are microbes but also include
physical, chemical, mechanical and nutrient agents for both infectious and non-infectious diseases.
Environment is the aggregate of all the external conditions and influences affecting the life and
development of host and agent and their interaction.

The natural history of any disease as viewed by Leavell and Clark which has two stages/phases. These
are:

I. Pre-pathogenesis stage/phase
II. Pathogenesis stage/phase
I. Pre-pathogenesis stage/phase:
 This stage is before the onset of disease and is also called as Pre-disease stage.
 The causative agent has not yet entered the susceptible host (human being). But the factors that
favour the interaction of agent and host exist in the environment e.g. poor environmental
sanitation, climatic condition, presence of insects, pests and rodents etc; unhygienic habits and
health behaviour, harmful cultural and traditional practices; and biological factors i.e. age, sex,
marital status, genetic and physiological status of people.
 This means people living in any particular environment are always predisposed to the risk of
disease i.e. they are in pre-pathogenesis stage of many infectious and non-infectious diseases.
 The disease will not occur in man unless these three factors i.e. agent, host and environment
confront and interact to produce disease provoking stimuli.
 This stage is also described as stage of susceptibility by Mausner and Kramer because risk factors
of various intensity related to agent, host and environment are present to contract the disease any
time.
II. Pathogenesis Stage:
 This phase begins with entry of causative agent in the susceptible human host.
 As the agent enters the body through appropriate channel (e.g. in case of Chickenpox, the agent
Varicella Zoster virus, must enter through the respiratory tract ), it induces tissue and physiological
changes in the body.
 These changes are subclinical i.e. clinical sign and symptoms of disease are absent. The host remains
apparently healthy and ambulant.
 After a lapse of some period which is variable from disease to disease and ranges in a specific
disease, the health equilibrium within the body is lost and the sign and symptoms of the disease
begin to appear.
 This period which lapse between the entry of causative agent and just before the appearance of
clinical sign is called as Incubation Period.
 In case of chickenpox this period is usually 14-16 days.
 The sign and symptoms are sometimes vague during first few days of illness e.g. in case of
chickenpox running nose and watering of eyes which are common to many other diseases. This
period is usually called as Pro-dromal Stage.This is Early Pathogenesis Phase and is below the
clinical horizon.
 This Early Pathogenesis Phase which is preclinical/ subclinical phase/ period is also called as Pre-
symptomatic Phase/ stage especially for chronic and non-infectious diseases.
 The length of Pre-symptomatic Phase/ stage varies greatly ranging from instantaneous time to many
years. For example, in case of accidental injuries it is instantaneous to few hours, and in case of
disease like cardiovascular and diabetes it can be many years.
 But as the pathological changes advance in the body system the sign and symptoms become clear
and clinical diagnosis can be done. E.g. appearance of skin rashes on different parts of the body in
case of chickenpox and the diseases reaches its peak.
 But in many diseases especially chronic and non-infectious diseases, by the time recognizable sign
and symptoms arise and clinical diagnosis is possible, the disease process or pathological changes
are well in advance.
 This period of recognizable pathogenesis is also called as clinical phase/stage.
 The end result of disease process may result in complete recovery. It takes time to recover and the
period is called as convalescence period or it may end into chronic state, varying level of disability
defect or death. This period is also called as disability phase/stage .
 The reaction to infection and period of pathogenecity vary from disease to disease and from person
to person for the same disease depending upon the virulence of causative agent and the susceptibility
of the host and environmental factors.
 The infection may be clinical or subclinical; typical or atypical or the host may become carrier with
or without having clinical disease e.g. in case of typhoid fever and diphtheria. The period of
pathogenesis can also be labelled as gradient of infection.
 The variation in the manifestation of the diseases in the pathogenesis phase ranges from sub-clinical
to clinical cases.
 The clinical cases ranges in severity from mild to severe and fatal cases.
 These variation in the manifestation of a disease can be represented graphically and is called as
Spectrum of disease.

Subclinical mild moderate severe fatal

DETERMINANTS OF DISEASE- CAUSATIVE/ RISK FACTORS

I. Definition and Concept of Risk factors

i. Definition :
The risk factor is defined as “a factor/ or an attribute that is significantly
associates with the development of a disease and when modified reduce the
possibility of occurrence of disease or other specified outcomes.”
ii. Concepts:
 The risk factor may be truly causative
There is strong statistical relationship between the risk factor and disease.
e.g. smoking and lung cancer.
But one can neither conclude that all individuals with the risk factor (i.e. all smokers) will
develop disease (i.e. will have lung cancer) nor the absence of risk factor (who never smoked)
will ensure the subsequent absence of disease (i.e. will not have lung cancer).
 The risk factors may be just contributory factors
e.g. high blood pressure, diabetes, obesity for heart diseases.
  The risk factors may or may not be modifiable.
e.g. host risk factors, such as age, sex, race, genetic factors which are associated with some
diseases, cannot be altered.
 The factors which can be altered or modified include health related behaviour, hypertension,
obesity, dietary intake etc.
 Manipulation of these risk factors is also limited to what is reasonable and feasible.
e.g. alcoholism can be prevented and controlled by removing the alcoholic beverages through
legislation etc.
 There can be overlapping of some risk factors i.e. the same factor can be considered as host, agent
or environment related factor.
e.g. tobacco smoking- it can be considered as an agent related factor because of its significant
statistical association with the occurrence of various diseases;
it can be considered as host related risk factor because it is concerned with individual’s smoking
behaviour;
it can be considered as environment related risk factor because some environments are more
conducive or permissive to smoking and also exhaled smoke is found in the environment which is
risk factor for others in that environment.
 On the basis of risk factors the population can be categorised as one which is at high, low or no
risk for a given disease.
e.g. in case of HIV infection people who are at high risk may include those who engage in
multiple sex activities, sex worker, intravenous drug abusers etc; people who are at low risk may
include nurses and doctors who take care of patients with HIV infection; and people are at no risk
or lowest risk may include all those who are sexually not active and do not use intravenous drugs.
 It is very important to identify the risk factors, so that effective measures can be planned and
implemented to prevent or delay the occurrence of disease.
 Epidemiological studies have helped in identification of risk factors associated with various
diseases to alert people to take preventive and control measures for those diseases.

RISK FACTORS FOR SELECTED DISEASES

Selected Diseases Risk Factors

Cancer Smoking, alcohol, solar and ionizing agent, occupational hazards,
dietary factors, environmental pollution, infectious agents,
medications etc.
Cirrhosis of liver Alcohol, poisons, medications, infection etc.
Diabetes Diet, obesity etc.
Heart Disease Smoking, high blood pressure, diabetes, obesity etc. lack of
exercise, emotional stress, elevated serum cholesterol etc.
High speed, drink and driving, roadway design, non compliance of
Road Accident traffic rules etc.
Smoking, high blood pressure and serum cholesterol etc.
Stroke
II. Agent, Host and Environmental Risk Factors
a) Agent Factors:
 A disease agent is the primary link in the development of disease.
 The disease agent is defined as “an element, a substance-living or nonliving, or a force-tangible or
intangible, the presence or absence of which may following the effective contact with susceptible human
host under proper environmental conditions serve as a stimulus to initiate or perpetuate a disease
process”.
 The disease agents are usually classified as under:
 i. Biological agents:
Biological agents are living agents and include arthropods and helminths, protozoa, fungi,
bacteria, rickettsial and viruses.
ii. Physical agents:
Physical agents include abnormalities in atmospheric pressure, temperature and humadity;
unusual intensity of sound; abnormalities of radiation and electricity. These agents are usually
associated with certain occupational exposure.
iii. Chemical agents:
Chemical agents may include useful substances like iodide and fluoride and harmful substances
like noxious gases, volatile gases and fumes, airborne solid particles. Some chemicals may also
be produced in the body as a result of malfunctioning of body systems for example urea,
bilirubin, ketones, calcium carbonate, uric acid etc.
iv. Mechanical agents:
Mechanical agents include chronic friction and mechanical forces that result in crushing, tearing
or penetrating wounds, sprains, dislocation and other accidental injuries and even death.
v. Nutrient agents:
Nutrient agents include fats, carbohydrates, proteins, vitamins, minerals and water. Intake of
these elements either in excess or in deficiency results in nutritional disorders. For example
anaemia, night blindness, PEM, goitre.
b) Host risk factors:
 Host is one of the epidemiological determinants of disease.
 There are varied attributes related to host which predispose the interaction of host and agent to
cause a disease.
 These host related attributes or risk factors include:
i. Demographic characteristics:
These include age, sex, race, ethnic origin, marital status etc.
ii. Biological factors:
These include genetic factors, blood chemistry, blood groups, physiological functioning of
body system, immune system etc.
iii. Psychosocial and economic characteristics:
These include personality traits, education occupation social class and status, mental status
and emotional makeup, health knowledge and attitude etc.
iv. Life style:
These include daily living and cultural practices including customs and traditions health
habits and health seeking behaviours such as physical exercise, nutrition practices, sexual
practices, use of alcohol, drugs and smoking etc.
v. Past history of exposure:
Exposure can range from infectious diseases to smoke in the environment exposure to
various occupational hazards.
c) Environmental Risk Factors:
 Environment is the aggregate of all the external conditions and influences affecting the life and
development of an organism.
 The environment has three components. These are physical, biological and psychosocial.
i. Biological environment:
The biological environment includes living things comprising of animal kingdom, plants
and microorganisms. Some of these are infectious agent, reservoir of infection,
intermediate host and vectors that transmit diseases.
ii. Physical environment:
 Physical environment includes all those things which are non living, chemical agents and physical
factors. These are air, water, soil, environmental sanitation, housing radiation, gravity, atmospheric
pressure, noise, electricity, electronic and electrical machines, radio broadcasting and television
transmitter and radar etc.
 Increasing population, urbanization, industrialization, migration, electronic and electrical devices and
media technology etc. have been the causes of environment pollution and resultant emergent health
problems.
 Lack of environmental sanitation is the cause for various infectious diseases among people.

iii. Psychosocial environment:

 It includes over all socio-economic and political organization that affects health care and its
delivery system; health legislation; socio-cultural customs, traditions, values, belief s and attitude;
education, religion and morals; lifestyle and family and community life.
 The psycho-social factors which can affect health are: poverty, migration, increasing population,
urbanization, stressful situations such as loss of loved ones, loss of job, accidental disabilities,
menopause, birth of retarded or handicapped child etc; defective life style, harmful health attitude,
behaviour and practices etc.

LEVELS OF PREVENTION OF DISEASE

Preventive approach is the best approach to achieve the goals of health care services because preventive
measures can be implemented with the joint efforts of health personnel and people at large at the family
and community level.

There are three major levels of prevention associated with natural history of disease. These are Primary,
Secondary & Tertiary Prevention.

1) Primary prevention:
 Primary prevention is first level prevention and is associated with the pre-pathogenesis phase or
stage of susceptibility of the disease process when the epidemiological factors like: Agent-Host-
Environment have not yet interacted to cause a disease.
 Primary preventive strategies during pre-pathogenesis phase of a disease are aimed to prevent the
interaction of these three epidemiological factors. If preventive measures are successful then the
disease will not occur.
 There are two types of primary prevention:
i. General health promotion:-
Health promotive factors include health education, wholesome nutritious diet, clean and
safe environment to live, healthful lifestyle, healthful behaviours and adequate resources.
All these aspects are directly related to socioeconomic and cultural aspects of the family
and community which must be improved.
ii. Specific protection:-
 Specific protection comprises those measures which are which are directed to intercept
causative agents of a particular disease or group of diseases before these agents affect
people.
 Specific protective measures include immunization, use of specific nutrients, protection
against accidents and environmental and occupational hazards, use of prophylactic and
suppressive drugs, avoidance of allergin, protection from carcinogens, stimulation of
proper personal hygiene, control of quality and safety of foods, cosmetics and drugs and
genetic therapy and counselling.
 All primary preventive measures may not fall directly within the domain of nursing practice but
awareness of these preventive modalities can help community health nurse to educate and counsel
individual, family and community people intelligently.
For eg. Community health nurse should know about chemoprophylaxis, carcinogens, allergins,
occupational hazards etc. so that accordingly she can give informations and refer them to the
concerned medical person and agency etc.

2) Secondary prevention
 Secondary prevention is second level prevention and is associated with pathogenesis i.e. pre-
symptomatic stage and symptomatic i.e. clinical stage of the pathogenesis phase of the disease
process.
 The objectives of secondary preventive measures are to: diagnose the disease at early stage,
control the progress of disease in man, prevent complication, restore health and prevent the
spread of infections to others in the community, in case of communicable diseases.
 Secondary preventive measures include two types of interventions. These are early diagnosis and
treatment and disability limitations.
i. Early diagnosis and treatment:-
 Early diagnosis and treatment are the measures which control the disease process, prevent the
spread of infection to others in case of communicable diseases, prevent complications and
long term disabilities and restore health.
 Early diagnosis and treatment has been found the most effective mode of intervention in
communicable diseases in communicable diseases like tuberculosis, leprosy and STD and also
in chronic diseases where causes and primary prevention are not clearly known. It has thus
helped in reducing morbidity and mortality due to these chronic infectious and no-infectious
diseases.
 In case of communicable diseases, early diagnosis and treatment helps to shorten the period of
communicability, thus limits the spread of infection and reduces mortality.
ii. Disability Limitations:-
 Disability interventions are applicable during the late pathogenesis period or clinical stage of
the disease process.
 The objective of these interventions is to prevent or delay the consequences of clinically
advanced disease i.e. prevent impairment leding to disability and handicap.
 For eg. Some of the nursing measures which may limits impairment and which are
advisable for immobile patients include back care, passive exercise, medication etc.; for
diabetic patient or patients who have undergone mastectomy and are mobile include
individualized health teaching, exercise, skin care, psychological boosting etc.
 Nurses and other health workers can help in making early diagnosis and treatment by case finding
and appropriate referral and by providing nursing care.
 Care of the minor ailments and limited care during emergencies are rendered by nurses and their
auxiliaries at the village level.
3) Tertiary prevention:
 It occurs late in the pathogenesis stage of disease process when irreversible changes either in
anatomy and physiology or both have occurred.
 At this point the disease process has advanced its clinical stage and entered the disability stage.
 Rehabilitative strategies are used to attain the highest possible level of functional ability.
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It involves co-ordinated efforts of medical personnel, sociologists, clinical psychologist, nurses
etc. for training and retraining of and helping the person to function, lead useful life as for as
possible and restore a feeling of well being.
Rehabilitation is with regard to restoration of:
 Bodily functions (medical rehabilitation)
 Personal dignity and confidence (psychological rehabilitation)
 Family and social relationship (social rehabilitation)
 The capacity to earn livelihood (vocational rehabilitation)
It is also considered as the responsibility of all doctors and nurses to help patient to recognise their
disability, restore their personal dignity, confidence and social relationship; and also refer them to
appropriate department and agency for further medical and vocational rehabilitation e.g. for
physiotherapy, speech therapy, vocational guidance etc.

UNIVERSAL INFECTION CONTROL MEASURES IN COMMUNITY

The purpose of universal infection control precautions in the community is to prevent transmission of
cross infection from one person to another, from one place to another either directly or indirectly.

Some of the important measures which should be practiced by the health team are;


Hand washing before and after doing any procedure or while coming in contact with body fluids,
soiled articles etc.
Use of gloves and other protective devices(gowns, masks and goggles) while conducting delivery
or any such procedures.
Use of disposable gloves as for as possible if not, these should be changed and disinfected or
sterilized after use for each patient/client.
Follow up of strict aseptic procedure while giving injections.
  Restrict the use of injections and skin piercing procedures as for as possible.
 Prevent injuries with sharps- by taking time to do the procedures, do not recap, bend or break used
needles before disposal, place them in puncture resistant container.
 All contaminated articles after use must be thoroughly cleaned by rinsing and washing with soap
and water which are then sterilized or disinfected.
 Sterilization by autoclaving or pressure cooker at 15 ibs pressure for 20 min.
 Disinfection by use of household bleach(1:10), 3% phenol, 4% formaldehyde, 70% ethyl
alcohol.
 Infected solid waste including needles should be incinerated or may be disposed of hygienically
in controlled land fill or pit latrine.
 Liquid wastes such as infected blood should be poured down a drain connected to adequately
treated sewer system or disposed of in a pit latrine.

APPROACH

 Prevention of cross infection is not only the responsibility of community health nurse and health
workers but also the individual, family and the community as a whole.
 Individuals and families must adopt values, lifestyle and behaviours which is compatible to health
and curtail the transmission of infection to others.
 Community must ensure safe environment to minimize transmission of infection.
 Information, Education and Communication is one of the strategic approach to infection control in
the community and is to be done at individual, family and community level using different
approaches, methods and media.

EPIDEMIOLOGY OF EPIDEMICS

DEFINITION:

Epidemic is defined as the occurrence of disease or health related event in more than normal expectancy
in a community or region during a specific time period. E.g. outbreak of influenza in Delhi in large
number in November-December, food poisoning cases.

Epidemics is a relative condition to frequency of the disease in the same area and during the same period
in specific group.

TYPES OF EPIDEMICS:

There are mainly two types of epidemics namely:

1. Common source epidemic

2. Propagated epidemic
1. Common source epidemic
 Most of the time the epidemic occurs due to an infectious agent from common source, but
epidemic can also occur due to pollution of air, water, food, soil by pollutants from industries. E.g.
Bhopal gas tragedy.
 The common source of epidemics can be due to:
i. Single exposure or point source infection
ii. Multiple exposure or continuous exposure to infection
i. Single exposure or point source infection:
 In single exposure, the exposure to the agent is brief and simultaneous.
  Those who are exposed to the source of infection develop the problem within one
incubation period of the disease.
 The classical example of such type of epidemic is food poisoning- all peoples are
exposed to the source of infection i.e. infected food at the same time from the same
place.
 The epidemic is explosive, the epidemic rises and falls rapidly.

ii. Multiple exposure or continuous exposure:

 In this, the exposure to infection from the same source is continuous, repeated or
intermittent but may not be at the same time or place e.g. epidemic of cholera or
infective hepatitis or any other such problem due to unsafe water supply, milk supply
or contaminated well water, epidemic of S.T.Ds through infected prostitutes.
 Usually there is no explosive rise in the number of cases. Fig. Shows common source
multiple exposure epidemic.
2. Propagated Epidemic:-
 This epidemic occurs in communities where large number of susceptible people lowering
herd immunity, live.
 Propagated epidemic results from person to person contact and mostly due to infectious
agent.
 Transmission continues as long as susceptible people are there in the community and are
exposed to infected people.

INVESTIGATION OF EPIDEMIC

Investigation of epidemic is a systematic process and goes through orderly steps which are discussed here
to help community health nurses to learn the process of investigation of epidemic.

1. Verification of diagnosis of disease: this is the first step and is done on the basis of clinical
examination of sample of cases.
2. Confirmation of the existence of an epidemic: this is done on the basis of the frequency of
disease.
3. Defining the problem at risk: it includes:
i. Obtaining or preparing a map of the area.
ii. Demographic study which may include the study of the total population or sub-groups or
population at risk and their composition. This information is necessary for calculating
various epidemiological measurements. E.g. morbidity and mortality rates and proportion
etc.
4. Identification of all cases and their characteristics:
 This can be done by organising house to house search till the area is free of epidemic and
medical examination of population at risk.
 An epidemiological sheet is prepared for every case. It includes basic information on age,
sex, occupation, time of the onset of diseases, sign and symptoms, history of
immunizations, common source of infection according to the disease under investigation
e.g. parties attended, food eaten, source of water etc.
5. Study of ecological factors: these include environmental factors, agent factors and host factors.
These informations will help in identification of source of infection, reservoir of infection and
modes of transmission and thereby planning of preventive and control measures.
 6. Data analysis: description of the cases in terms of person, place and time of distribution. A
complete list of cases by chronological order is prepared to show the beginning of epidemic.
Attempt is made to identify the first case and follow its movements to trace the source and spread
of infection.
7. Formulation of hypothesis: analysis of data will reveal the possible source, causes, agents, hosts
and environmental risk factors of infection. This will help the investigator formulate the
hypothesis which may suggest further investigation and help in identification of interventions.
8. Recommendation for prevention and control: based on the information revealed about the
epidemic, the epidemiologist/health worker prepares a programme of prevention and control of the
epidemic not only for the present but also for its prevention in future.
9. Preparation for a formal report: a formal report should be prepared and communicated to health
authority for information, evaluation and feedback for future actions.

PREVENTIVE EPIDEMIOLOGY

Preventive epidemiology is concerned with those measures at the community level which help in
identification of population at risk and environmental factors leading to ill health and detection of persons
with early, mild and asymptomatic diseases. These measures include:

1. Health surveys
2. Screening
3. Surveillance
4. Monitoring
1. Health surveys
 Health surveys are investigations to identify the frequency, distribution and the determinants of
health related events or states in the community.
 Health surveys help in knowing the community and making community diagnosis.
 The health surveys can be general health surveys and special or specific health surveys.
 General health surveys provide comprehensive data about health and sickness status of the whole
community.
It is not a regular practice in our country. Once in 1946by health survey and Development
Committee headed by sir Joseph Bhore and again in 1962 by health survey and Development
Committee headed by Dr. Mudiliar.
 Special or specific health surveys deal with investigation of any aspect of health- morbidity
status e.g. filarial, malaria or tuberculosis etc. mortality and nutritional status.
 Cross sectional surveys provide data about the prevalence and distribution of illness and the state
of health of a community at one point in time.
 Longitudinal surveys provide valuable information about the natural history of diseases,
incidence and prevalence of diseases and underlying causes etc. by doing surveys on the same
population over a longer period but are difficult to organize and are time consuming etc.
 The data for health survey can be collected by using various methods. These are:
I) Questioning
II) Health examination and laboratory investigation
III) Record review
IV) Observation
I) Questioning: questioning is an invaluable method to seek subjective informations through
interview and self administered questionnaire.
II) Health examination and laboratory investigation: this method helps in getting more valid
information than by questioning method about clinical cases. But this method is expensive and
requires more time.
III) Record review: records are valuable source of health informations and record review in a
systematic way which can help obtain health data. The informations may be incomplete
because there are no set procedures and standards for record keeping.
IV) Observation: it requires lot of planning and systematic methods for data collection. This
method is expensive and time consuming.
2. Screening:-
 It is defined as the method of search for unrecognised diseases by means of rapidly applied tests,
examinations and procedures in apparently healthy population.
 The basic purpose of screening for disease protection is to identify from a large group of
apparently well population those who have a high probability of having the disease under study,
so that they may undergo further investigations and if diseased brought to treatment.
 There are three types of screening namely:
I) Mass screening: in this screening of the whole population or the subgroups whether or
not exposed to the risk of having the disease under study.
II) Selective or high risk screening: in this screening of only those who are at high risk to
have a particular problem or disease e.g. women 35+ and lower social group have more
chances of cancer cervix and if they are screened for that, then more chances of detecting
the cases. Similarly people having family history of diabetes, breast cancer should be
screened for such problems.
III) Multiphase screening: in this screening number of tests for different diseases are grouped
together to screen for number of conditions at the same time e.g. test for lung diseases,
cardiovascular diseases, diabetes, anaemia, kidney diseases, cancer of the breast and
uterus, visual and audio defects are grouped together.
 Criteria for screening:
Some of the criteria which are considered for screening are as under:-
The disease has high prevalence.
The disease has early asymptomatic or latent stage and its natural history is clearly
understood so that one knows at what stage it is irreversible.
Simple, inexpensive and reliable tests are there to detect the disease prior to its onset.
Facilities for further confirmation tests and treatment etc are available.
It is for sure that detection and treatment will prevent and control, morbidity, disability
and mortality.
The screening tests are reliable and valid i.e. sensitive and specific.
The test is acceptable to the people for whom it is done.
3. Surveillance:
 The dictionary meaning of surveillance is supervision or close watch especially on suspected
person.
 Epidemiologically surveillance means close vigilance on occurrence and distribution of
diseases and health related problems, population dynamics, community behaviour and
environmental processes resulting in increased risk of ill health in the community.
 The Epidemiological surveillance can be done at individual and family level, national and
international level.
 I) Individual/Family Surveillance: it includes surveillance of an infected person in a family
as long as the individual is source of infection to others e.g. typhoid case and carriers.
II) Community/Local Population Surveillance: it includes active and passive surveillance
of the whole community for early detection and prevention and control of a disease e.g.
malaria.
III) National surveillance: it includes surveillance at the national level e.g. surveillance of
smallpox after its eradication.
IV) International surveillance: it includes surveillance of some of the diseases which are
listed by WHO e.g. malaria, influenza, filarial, polio etc and are reported to WHO
which then provides information to the countries in the world to take timely actions.

Surveillance process:

Surveillance is a systematic process. The main step involved are:

I) Collection of relevant information about the disease under surveillance
II) Analysis and interpretation of these informations
III) Reporting of these informations to the concerned authority for decisions and actions
leading to prevention and control of diseases.
I) Collection of relevant information about the disease under surveillance
Effectiveness of surveillance system depends upon identification of cases, collection of
relevant informations about the disease, their recording and reporting. The various methods for
surveillance are as under:-
a) Routine reporting of cases and deaths recorded at health centres, dispensaries and hospitals:
A sample recording from which is usually practised is given below:

Daily recording of cases in OPD of health centres

S.no. Months no. Name Age Sex Address Diagnosis Date of Remarks
onset
1
2
3
.
.
.
.
30
From this record daily, weekly, monthly and yearly reports of disease occurred and reported at the centre
are prepared.

b) Active surveillance:
It means actively looking for those particular type of cases who have not been recorded under the
routine system. It is done by health workers and community people e.g. surveillance of malaria or
tuberculosis cases.
c) Epidemiological investigation:
These are usually done when there is occurrence of more than usual number of cases in a
particular place during particular time period. When there is sudden outbreak of any disease and
when a communicable disease which has never occurred before but it has occurred now. This will
help in picking up cases and the associated causative factors.
d) Sentinel centres:
 Sentinel centres are those hospitals, health centres, laboratories, special disease hospitals etc.
which are identified for collecting informations for selected diseases. The informations are
collected, compiled and forwarded to higher authority for use: for immediate action and for
making future plans and policies etc.
e) Special sample survey:
Special sample survey of disease is an active and efficient method of surveillance. There are
different methods of sample surveys but the survey by cluster sampling technique is recommended
by the WHO. The target population, the sample size vary from disease to disease e.g. the target
population for poliomyelitis is 5-9 years, for diarrhoea 0-4 years, preceding the date of survey.
II) Analysis and interpretation of these informations
 The data needs to be compiled and analysed to assess the frequency and distribution by
person, place and time.
 These informations can be presented in tables, spot maps. Charts and graphs. This kind of
presentation helps in determining the pattern of occurrence of disease and whether there is
decrease or increase in the number of cases.
III) Reporting of data and providing feedback:
 Once the data is analysed a report is to be prepared in the format prescribed by the authority.
 The report is sent regularly for each reporting period.
 The report should be complete.
 If there is nil information. Missed or received late, it should be included in the next reporting
period.
 Feedback should be given to all the members of health team as to how the data are used which are
collected by them and reported through regular meetings and when desired by any one.
4. Monitoring:
Monitoring is day to day measuring and analysis i.e. making assessment of: health status
of people, and their environment to determine any changes; performance of health
services and health professional to determine effectiveness and efficiency; health
behaviour of client to determine compliance of behaviour.

EPIDEMIOLOGY AND NURSING

 Epidemiology is one of the basic sciences applicable to nursing .

 Nurses working in the community deal with the people in various settings and help them to solve
their health problems.
 She makes use of nursing process which is comparable to epidemiological process in solving the
problems etc.
 She identifies and investigates the problem, formulates and tests hypothesis regarding causal
factors, formulates alternative interventions and implements to prevent and control the problems
and evaluates the effectiveness of intervention.
 Nurses in the community have an active role in prevention and control of communicable diseases
which include:
 Participation in early diagnosis and treatment i.e. identification of all cases.
 Notification of certain specific diseases like measles, diphtheria, tetanus, hepatitis, rabies,
S.T.D. to the health authority.
 Trace the contacts, keep them under surveillance.
 Identify source of infection, methods of spread of infection.
 Health education of people in general.
 Nurses in the community as a member of the health team participates in surveillance at all levels
which will depend upon existing situations, her preparation, the level at which she works.
 The nurses working in the community are required to take notice of any unusual occurrence of
any disease or in large number and report to the authority.
 Nurses in the community have an important role in prevention and control of chronic and non-
infectious problems such as cardiovascular conditions, accidents, cancer, mental health problems
etc through health education and helping people change their life style.
SUMMARY
Epidemiology is the basic science of community health. Epidemiology deals with the
measurements of occurrence and distribution and determinants of health related states and events
in specified community and the application of findings in the prevention and control of diseases.
Epidemiologically there are three major categories of factors i.e. agent, host and environment
which interact to cause various diseases.
According to natural history of diseases there are three levels of prevention i.e. primary,
secondary and tertiary level prevention.
Epidemiology is basic to preparation of community health nurse and all other members of the
health team. Community health nurses play an important role in epidemiological studies of
human population and their problems.
 BIBLIOGRAPHY
1. Park k. Textbook of Preventive And Social Medicine, 19th edition, Banarsidas Bhanot Publishers,
2007; page no. 31, 34, 87, 621
2. Swarnkar keshav, Textbook of Community Health Nursing, Third edition, N. R. Brothers
Publishers, 2011; page no. 11, 64, 65, 824
3. Gulani K.K ” Community Health Nursing(Principal & Practice)” First Edition
2004,KumarPublication,New Delhi Page no. 181-221
4. Sunderlal et al ”Text book of Community Medicine Preventive and social medicine ” Second
Edition CBS Publishers & Distributors New Delhi Page no.
5. en.wikipedia.org/wiki/Epidemiology
6. medical-dictionary.thefreedictionary.com/epidemiology 
7. www.merriam-webster.com/dictionary/.0epidemiology
8. simple.wikipedia.org/wiki/Epidemiology 
9. journals.lww.com/epidem
10. www.jhsph.edu/departments/epidemiology