Epidemiology الوبائيات 2023

Handout
of
General Epidemiology
for
Faculty of Nursing- Third Year Students
By
Staff Members of
Public Health & Community Medicine
Faculty of Medicine- Assiut University
Prof. Ekram Mohamed Abdel-Khalek
Table of Contents
Page
Chapter (1): Principals of General Epidemiology 1
Evaluation
Chapter (2): Infectious Cycle
Evaluation
Chapter (3): Prevention and Control of Communicable Diseases
Evaluation
Chapter (4): Epidemiology of Non- Communicable
Diseases
Evaluation
Chapter (5): Screening
Evaluation
Chapter (6): Measurements of Health and Disease
Evaluation
Chapter (7): Public Health Surveillance
Evaluation
Chapter (8): Epidemic Disease Occurrence
Evaluation
General Revision
References
1
Chapter (1): Principals of General Epidemiology
Objectives:
At the end of the chapter the student should be able to:
1- Define epidemiology
2- List and describe uses of epidemiology
3- Define the types of epidemiology
4- Identify the key features of descriptive and analytic epidemiology
5- Identify the types of epidemiological studies
Epidemiology is considered the basic science of public health. The word

epidemiology comes from the Greek words:
 Epi = upon
 Demos = people
 Ology = science
So, epidemiology is the science which deals with what falls upon people.
Definition of epidemiology
Epidemiology is “the study of the distribution and determinants of
health related states or events in specified populations, and the application
of this study to the prevention and control of health problems”.
Uses of epidemiology:
1- Causation of disease
Epidemiology is used to study the different causes of a disease or any
health related event. Identification of disease etiology is important for its
prevention and control.
2
2- Natural history of disease

Epidemiology is also concerned with the course and outcome
(natural history) of diseases in individuals and groups.
Figure (1): Natural history of disease
Good Subclinical Clinical

health change disease
Death Recovery
The natural history of the disease: It is the progress of a disease

process in an individual over time, in the absence of intervention.
The process begins with exposure agents capable of causing disease.

Without medical intervention, the process ends with recovery, disability, or
death.
3- Health status of populations

Epidemiology is used to describe the health status of a certain
population. Knowledge of the disease burden in populations is essential for
health authorities, who seek to use limited resources to the best possible
effect by identifying priority health programs for prevention and control.
4- Evaluating interventions
Epidemiology is used for measuring the outcome of health care
programs. This is can be achieved by compare the health status of a certain
population before and after application of the health program.
3
Types of epidemiology:
1- Descriptive epidemiology:
Examining the distribution of a disease in a population and observing
the basic features of its distribution in terms of time, place, and person.
Typical study design:

Community health survey (cross-sectional study, descriptive study)
2- Analytic epidemiology:
Testing a specific hypothesis about the relationship of a disease to a
specific cause, by conducting an epidemiologic study that relates the
exposure of interest to the outcome of interest (cause-effect relationship).
Typical study designs: cohort, case-control, experimental design
1- Basic triad of descriptive epidemiology

The three essential characteristics of disease we look for in descriptive
epidemiology are:
 Person
 Place
 Time
Person (whom)
Personal characteristics used in description of a certain disease
include:
 Age
 Sex
 Socio-economic status (education, occupation, income)
 Marital status
 Ethnicity/race
 Familial tendency
 Behavior / habits
4
Place (where?)
Disease occurrence varies among different geographical areas. Factors
responsible for this variation include:
 Geology of the place

 Climate effects (temperature, humidity, combined effects)
 Urban / sub-urban-squatter / rural
 Relation to environmental exposure (water, food supply, etc)
 Characteristics and distribution patterns of the population
Time (when?)
Four types of variation in disease occurrence related to the time:
1- Secular variation
It is a long term variation where changes in the disease occurrence
take long period of time.
2- Recurrent and periodic time-trends

Certain diseases show regular increase or decrease in their occurrence.
Periodic occurrence may due to cyclical changes in the virulence of the
organism or changes in people immunity.
3- Seasonal variation
Many infectious diseases increase at a certain time of the year. e.g.
Influenza increases in winter while diarrhea increases in summer
4- Rapid fluctuation
Sudden increase or decrease in occurrence of a certain disease may
occur.
5
2- Basic triad of analytical epidemiology (Epidemiological triangle)

The three phenomena assessed in analytic epidemiology are:
 Agent
 Host
 Environment
Agent
It is a factor cause a disease or health event such as:
 Biological (micro-organisms)
 Physical (temperature, radiation, trauma, others)
 Chemical (acids, alkalis, poisons, tobacco, others)
 Environmental (nutrients in diet, allergens, others)
 Psychological experiences
Host
A person or other species including animal, bird and arthropod that
harbor the causative agent and transmit it to others under natural condition.
Host factors include:
 Genetic factors
 Immunologic status
 Personal characteristics
 Personal behavior
Environment
All that is external to the individual human host which can be:
 Living conditions (housing, water supply, refuse, sewage, etc)
 Atmosphere / climate
 Modes of communication: phenomena in the environment that bring
host and agent together, such as: vector, vehicle, reservoir, etc)
6
The epidemiologic studies:

Epidemiologic studies fall into two categories: interventional
(experimental) and observational studies. In an interventional study, the
researchers determine the exposure status for each individual (clinical trial)
or community (community trial); then follow the individuals or
communities to detect the effects of the exposure. In an observational study
the researchers simply observe the exposure and outcome status of each
study participant.
1- Interventional studies
Interventional studies are prospective experimental trials in which
investigators compare the effects of an intervention on subjects with a
control group. The most compelling type of interventional study is the
randomized controlled trial (RCT).
Randomized controlled trial
Also called randomized clinical trials. It is a gold standard for evidence.
It provides the strongest evidence for establishing causation. It can be
performed in both clinical and community settings.
Used to:
 Compare the efficacy of new therapy regimens and drugs against
current therapies.
 Evaluate new screening and prevention strategies.
Study groups: also called study arms
7
a) Intervention/experimental group: Participants are exposed or receive
the intervention.
b) Control group: Participants receive the current standard of care, a
placebo, or nothing at all.
Placebo: A medically ineffective intervention that mimics a real
intervention so that a subject will not know to which study group they are
assigned.
Advantages
 Confounding variables are well-controlled.
 Temporal relationship is well-established.
 Provides strong evidence for causation.
Disadvantages
 Expensive
 Study groups do not necessarily represent the real world.
 Ethically problematic
Observational studies:
Observational studies are used to observe and measure outcomes in a
cohort with no control over risk factors or variables. They are often
retrospective. Types of observational studies include cross-sectional
studies, case-control studies, and cohort studies.
8
1- Cross-sectional studies
Also called prevalence studies. Used to collect data about an entire
population at a single point in time (snapshot). Participants are not
followed over time. Typically used to measure prevalence (i.e., how many
people have the disease in a population).
Advantages:
 Inexpensive and fast
 Easy to perform
Disadvantages:
 Unable to determine causality because exposures and outcomes are
measured simultaneously.
 They allow information (recall) bias that affect results.
2- Case-control studies
Start from an outcome and work backward (retrospectively) in time to see
who had an exposure. Two groups are compared based on disease outcome:
a) Cases: those who have or have had the outcome or disease.
b) Controls: those who lack the outcome or disease.
Advantages:
 Inexpensive and less time consuming.
 They are efficient for rare diseases.
 Good for examining multiple exposures.
Disadvantages:
9
 Cannot measure the incidence.
 Subject to recall bias if exposure is measured by interviews.
 Identifying a sample of controls can be difficult and subject to
selection bias.
3- Cohort studies
An observational study that chooses a cohort that shares a common
exposure and observes this group over time (prospectively) to see who
develops the outcome of interest. It is a longitudinal study in which the
temporal relationship between exposure and outcome is established.
Advantages:
 Direct calculation of incidence.
 Clear temporal relationship between exposure and disease.
 Particularly efficient for the study of rare exposures.
 Can give information on multiple outcomes of a particular exposure.
 Minimizes bias
Disadvantages:
 They very expensive and time consuming.
 Often requires a large sample size.
 Not efficient for the study of rare diseases.
 Losses to follow-up may diminish their validity (problem of
attrition).
11
Evaluation
Circle the correct answer (MCQ):

Epidemiology is which of the followings?
a. The study of physical, chemical, biological, social and psychosocial
factors in the environment that affect human health
b. The study of distribution and determinants of heal events in specified
populations
c. The ongoing, systematic collection, analysis and interpretation of
health related data
d. The study of actions taken by an individual or group of individuals to
change or maintain their health status or prevent illness or injury
Descriptive epidemiology involves the followings elements except:

a. Severity
b. Person
c. Place
d. Time
Epidemiology can be used for:

a. Disease control
b. Evaluation of health programs
c. Accidents prevention
d. All of the above
The followings are advantages of case control studies except:

a. Not expensive
b. Take short time
c. Incidence rate can be calculated
d. There is no problem of attrition
11
Chapter (2): Infectious Cycle
Objectives:
At the end of this chapter the student should be able to:
1- Know the 6 links of the infectious cycle
2- Identify types of reservoir
3- Identify the importance and types of carriers
4- Know the immunity
Infection is maintained in the community by the cycle of infection. Six

links are needed:
Figure (2): Epidemiologic infectious cycle
Causative
organism
Susceptible Reservoir
host
Inlet of
infection Exit of
infection
Mode of transmission
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1- Causative organism:
The causative organism may be:
 Bacteria (typhoid, tuberculosis)
 Virus (Measles, influenza)
 Parasite (ascaris, bilharzias)
 Fungus (tinea)
 Rickettsia (typhus)
 protozoa (malaria, amebic dysentery)
Infectivity refers to the proportion of exposed persons who become

infected.
Pathogenicity refers to the proportion of infected persons who develop

clinical disease.
Virulence refers to the proportion of persons with clinical disease who

become severely ill or die.
Incubation period is a period of subclinical or unapparent pathologic

changes follows exposure, ending with the onset of symptoms.
2- Reservoir:
The source or reservoir of infection may be man, animal, insect
(vector), plant, water, air, soil, objects soiled by pathogenic organisms.
A- Human reservoir:
The human reservoir may be case or carrier.
Case: a patient showing manifestations of the disease.
Carrier: an infected individual who shows no signs and symptoms of

disease, but harbors in his/ her body a pathogenic organism, and thus can
spread infection.
13
Types of carriers:
Carriers are classified according to different methods:
1- Chronological classification
 Incubatory carriers (measles, hepatitis A, etc.)
 Contact carriers (Cholera, meningitis, etc.)
 Convalescent carriers (typhoid fever, etc.)
2- Duration of carriage
 Temporary carriers (mumps, hepatitis A, etc)
 Chronic carriers (hepatitis B, HIV, typhoid, etc.)
3- Place of carriage
According to the habitat of the microorganisms:
 Upper respiratory tract (diphtheria)
 Fecal carriers (typhoid, hepatitis A)
 Urinary carriers (typhoid, brucellosis)
 Skin carriers (staphylococcal infection)
Why carriers are important sources of infection?

 Infection is unapparent.
 They are free to move in the community.
 Their number is much greater than cases.
 Infectivity may persist for months or years.
Dangerous groups of carriers are:

 Food handlers.
 Nurses in care of children.
 Wet-nurses (now becoming of very limited number).
 Hospital personnel.
 School personnel.
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B- Animal reservoir:
Some animals (including birds) are the reservoir of infection of certain
diseases which may transmit from animal to man „zoonotic diseases‟ such
as salmonillosis, brucellosis
3- Exit of infection:
Pathogenic organisms find exit from the body of reservoir through:
 Respiratory tract (influenza virus)
 Alimentary tract (hepatitis A)
 Urinary tract (typhoid)
 Genital tract (AIDS)
 Skin (syphilis)
 Blood (malaria, AIDS)
 In-utero transmission (rubella, syphilis)
4 - Modes of transmission
Pathogenic organisms finding exit form the body of reservoir can
reach the new host by different means of transmission.
The basic modes of transmission are:

 Droplet infection (respiratory infection e.g., influenza).
 Food- borne infection (ingestion infection e.g., typhoid).
 Arthropod-borne infection (Malaria).
 Contact infection (AIDS, scabies)
The occasional means of transmission are:

 Injection infection (hepatitis B& C).
 In-utero infection (transplacental e.g., rubella, hepatitis B).
15
5- Inlet of infection:
The portal of entry into the susceptible host is similar to the portal of
exit.
 Respiratory tract (influenza virus)
 Urinary tract (typhoid)
 Genital tract (STD‟s)
 Alimentary tract (Hepatitis A)
 Skin (syphilis)
 In-utero transmission (rubella, syphilis)
6- Susceptible host:
There must be a susceptible host for the disease transmission to occur.
Microbiologic agents surround and abound in humans. In general people
stay healthy because of their own host defense mechanisms that belong to:
1- General factors of resistance

 Intact skin prevents most organisms from entering the body
 The cough reflex eliminates the organisms from the lungs.
 Gastric juice digests food as well as swallowed organisms.
 Diarrhea eliminates harmful agents from the alimentary tract.
 Normal bacterial flora prevents pathogenic organisms from growing.
 Phagocytosis, if the organisms succeed to reach the blood, some
white blood cells have phagocytic activity.
2- Immunity
Immunity to a disease is achieved through the presence of antibodies
to that disease in a person‟s system. Antibodies are proteins produced by
the body to neutralize or destroy toxins or disease-carrying organisms.
16
Active immunity occurs when the host develops antibodies to fight

infection. Antibody production can be acquired from natural disease or
vaccines. It normally takes several weeks of exposure or immunization
before protective antibodies are produced. if an immune person comes into
contact with that disease in the future, their immune system will recognize
it and immediately produce the antibodies needed to fight it. Active
immunity is long-lasting, and sometimes life-long.
Natural immunity is acquired from exposure to the disease organism

through infection with the actual disease.
Vaccine-induced immunity is acquired through the introduction of a

killed or weakened form of the disease organism through vaccination.
Passive immunity occurs when antibodies are given to the host. Although
of short duration, passive immunity provides immediate protection.
However, passive immunity lasts only for a few weeks or months. Passive
immunity is natural or acquired.
Natural immunity: A newborn baby acquires passive immunity from
its mother through the placenta. Passive antibodies protect newborn babies
during the first several months of life.
Acquired immunity: People can also get passive immunity through
antibody-containing blood products such as immune globulin, which may
be given when immediate protection from a specific disease is needed.
Herd immunity is a form of indirect protection that applies only to

contagious diseases. It occurs when a sufficient percentage of a population
in the community (or “herd”) has become immune to an infection, whether
through previous infections or vaccination, thereby reducing the likelihood
of infection for individuals who lack immunity.
17
Evaluation
Mention whether each of the following statements is true (T) or false (F):
1 Pathogenicity refers to the proportion of infected persons who T F
develop clinical disease.
2 Diseases that can be transmitted under natural conditions from T F
vertebrate animals to humans are called zoonoses.
3 While an agent of disease may be necessary for a disease, T F
exposure to an agent does not always cause clinical symptoms.
4 Passive immunity occurs when the host develops long lasting T F
antibodies to fight infection.
5 Typhoid is an example of food-borne disease. T F
Complete the followings:

The six links of infectious cycle are:
1) ………………………………………………………………………….
2) ………………………………………………………………………….
3) ………………………………………………………………………….
4) ………………………………………………………………………….
5) ………………………………………………………………………….
6) ………………………………………………………………………….
--------------------------- is an infected person or animal that harbors specific

infectious agents without showing signs or symptoms of the disease.
The causative agent of an infection could be:

1) ………………………………………………………………………….
2) ………………………………………………………………………….
3) ………………………………………………………………………….
Dangerous groups of carriers include:

1) ………………………………………………………………………….
2) ………………………………………………………………………….
3) ………………………………………………………………………….
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Chapter (3): Prevention and Control of Communicable

Diseases
Objectives:
1- Define and identify the levels of prevention.
2- Know the different methods of each level of prevention.
3- List the measures of prevention and control of communicable
diseases.
Disease prevention deals with techniques that prevent the occurrence

of disease [physical, mental, and emotional] or lead to early diagnosis
where therapy may cure, prevent, modify the progression of disease.
Health promotion deals with techniques that foster physical, and

emotional well-being, and increase length and quality of life. It deals with
the fact that many diseases are not caused by unknown or unpredictable
factors, but by personal modifiable life-style habits.
Levels of prevention
1- Primary prevention is the prevention of disease or injury. Primary
prevention activities can be directed at individuals or at the environment.
It includes:
 Health education
 Environmental modification
Health education efforts are directed at encouraging people to develop

good health habits (nutrition and exercise) and to avoid harmful substances
(alcohol, tobacco, drug abuse) and harmful circumstances (driving while
19
intoxicated). Specific protective measures (e.g. immunization, condom use)

can also prevent diseases from occurrence
Environmental modification can decrease injuries from falls, or

automobile accidents. Environmental sanitation is used to provide an
adequate sewage system, safe drinking water, clean air, and an environment
free of toxic substances.
2- Secondary prevention is the early detection and proper treatment of a

disease. It includes:
 Screening programs
 Medical care
Screening programs are used to detect diseases in the early preclinical

stages, when effective therapy may either cure the disease or limit its
progression, e.g. Pap smear to detect cervical cancer, glaucoma testing
Medical care is important to apply in early stage of the disease. With

such measures it is may be possible to cure the disease or decrease its
complications.
3- Tertiary prevention is the limitation of disability and rehabilitation

from disease. It emphasizes a person‟s remaining abilities and attempts
to restore the person to as normal a life as possible.
Measures of prevention and control of communicable diseases:

I. General methods of control and prevention directed towards the agent,
reservoir, exit of infection, mode of transmission, inlet of infection and
susceptible host.
II. Specific methods directed toward the host.
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General methods of control and prevention:
Measures directed to the agent

1. Eliminating the agent
2. Preventing the organism from multiplying to the level at which it
causes the disease
3. Eliminating the reservoir so that the agent has no natural place to
multiply
1. Eliminating the agent

a. Chemotherapeutic or chemoprophylactic agents kill biologic agents
internally so that they cannot infect others.
b. Disinfectants kill organisms outside the body.
c. Chlorination of water supply.
d. Heat and radiation used to pasteurize milk.
2. Preventing the organism from multiplying to the level at which it

causes the disease
a. Proper temperatures for storing and serving food.
b. Chlorination of air-cooling towers
3. Eliminating the reservoir

Certain agents (measles, small-pox) die out when there are no
susceptible hosts in which to live.
21
Measures directed to the reservoir
1. Human (cases & 2. Animals (wild 3. Environment (natural

carriers) animals & pets) & man-made)
a. Isolation or quarantine a. Avoidance of a. Bird droppings

b. Chemotherapeutic agents wild animals b. Mosquitoes (vector
c. Active immunization b. Regular checks control)
for pets
Measures directed to the exit of infection

Portal of exit cannot be blocked because the organism comes out with
normal functions.
Measures directed to the mode of transmission

Direct transmission:
 Hand washing is the most important procedure in preventing spread of
most infections
 Protective apparel is used mainly in health care settings to protect
health personnel from microorganisms transmitted mainly through
blood and body fluids. e. g. gloves, gowns, masks, protective eye wear
 Condoms
 Covering mouth when coughing, sneezing and use of disposable
tissues.
Indirect transmission
 Avoiding bites from arthropod vectors (door and window screens,
protective clothing, insect repellents).
 Avoiding diseases spread by common vehicle (disposable patient-care
equipment- blood screening) and proper canning, preparation, serving,
and storage of food.
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 Air borne route difficult to control ultra violet rays and isolation of
patients in well ventilated rooms have been used.
Measures directed to the inlet of infection

Percutaneous entry can be prevented by using sterile needles, by
avoiding insect bites, and by covering open cuts or sores.
Measures directed to the susceptible host

1. Good health habits such as rest, balanced diet, exercise, avoid
smoking, avoidance of alcohol intake.
2. Prevention of skin breakdown, avoidance of skin dryness.
3. Natural immunity
4. Artificially acquired immunity as vaccines
5. Chemoprophylaxis can protect temporarily a susceptible host during
periods of intense exposure.
23
Evaluation

The purpose of primary prevention is:
a. to detect early cases
b. to limit the incidence
c. to limit the prevalence
d. to treat patients
Vaccination is a tool of:

a. primary prevention
b. secondary prevention
c. tertiary prevention
d. None of the above
Cessation of cigarette smoking is:

a. primary preventive measure of cancer
b. secondary preventive measure of cancer
c. tertiary preventive measure of cancer
d. not a preventive measure of cancer

General measures of control and prevention of communicable disease
directed to the agent include:
1) ………………………………………………………………………….
2) ………………………………………………………………………….
3) ………………………………………………………………………….
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Chapter (4): Epidemiology of Non-Communicable Diseases
Objectives:
1- Identify what are non-communicable diseases.
2- Identify people at risk of non-communicable diseases.
3- List both modifiable and non-modifiable risk factors of non-
communicable diseases.
4- Know the preventive measures of non-communicable diseases.
Non-Communicable diseases (NCDs), also known as chronic diseases, tend

to be of long duration and are the result of a combination of genetic,
physiological, environmental and behavioral factors. In such chronic, non-
communicable diseases, the etiological (causative) agent is not known (or
not established) and the etiology is discussed in terms of „risk factors‟.
The main types of non-communicable diseases are cardiovascular diseases

(such as heart attacks and stroke), cancers, chronic respiratory diseases
(such as chronic obstructive pulmonary disease and asthma) and diabetes.
Chronic conditions are characterized by the followings:

– Do not result from an (acute) infectious process.
– Are not communicable “not infectious).
– Cause premature morbidity, dysfunction, and reduced quality of life.
– Usually develop and progress over long periods.
– Often initially insidious.
People at risk of NCDs
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People of all age groups, regions and countries are affected by NCDs.
These conditions are often associated with older age groups. Children,
adults and the elderly are all vulnerable to the risk factors contributing to
NCDs, whether from unhealthy diets, physical inactivity, exposure to
tobacco smoke or the harmful use of alcohol.
Risk factors
1- Modifiable behavioral risk factors:
Modifiable behaviors, such as tobacco use, physical inactivity, unhealthy
diet and the harmful use of alcohol, all increase the risk of NCDs.
2- Non-modifiable risk factors:
Risk factors that cannot be reduced or controlled by intervention, for
example: age, sex, race and family history (genetics).
Metabolic risk factors:

Metabolic risk factors contribute to four key metabolic changes that
increase the risk of NCDs:
 raised blood pressure;
 overweight/obesity;
 hyperglycemia (high blood glucose levels); and
 hyperlipidemia (high levels of fat in the blood).
Prevention and control of NCDs

1- Primordial prevention
It is a primary level of prevention of the disease but it is with reference
to non-communicable diseases. This consists of elimination or modification
of „risk factors‟ of the disease. An important way to control NCDs is to
focus on reducing the risk factors associated with these diseases.
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2- Primary prevention
It aims to prevent disease or injury before it ever occurs. This is done by
preventing exposures to hazards that cause disease or injury, altering
unhealthy or unsafe behaviors that can lead to disease or injury, and
increasing resistance to disease or injury. Primary
prevention can be adopted by two modes of intervention:
Health promotion
The measures of health promotion may include:
 Genetic counseling (premarital and marriage counseling)
 Efficient antenatal care and postnatal care
 Promotion of breastfeeding and proper weaning
 Adequate nutrition
 Health education (on nutrition education, life-style, etc.).
 Recreation facilities (sports, games, cultural activities, etc.)
Specific protection
The measures of specific protection may include:
 Use of specific nutrients (Vitamin A against nutritional blindness,
iron against nutritional anemia, iodized salt against iodine
deficiency disorders).
 Helmet against head-injury
3- Secondary prevention
The intervention is by „early diagnosis and treatment‟. This can be done
by screening procedures for the early diagnosis of the disease as:
 Periodical recording of weight of a child with for malnutrition
 Blood and urine exam for diabetes mellitus
 Recording of blood pressure for hypertension
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4- Tertiary prevention
It aims to reduce the impact of an ongoing illness or injury that has
lasting effects (e.g. chronic diseases, permanent impairments) in order
to improve as much as possible their ability to function, their quality of
life and their life expectancy. Tertiary prevention can be adopted by two
modes of intervention, disability limitation and rehabilitation.
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Evaluation

When a disease affects only the person who suffers from it and is not
transmitted to the others it is called a/ an:
a. Infectious disease
b. Communicable disease
c. Chronic disease
d. Emerging disease
Which of the following diseases is an example of non-communicable

diseases?
a. Cancer
b. Diabetes
c. Hypertension
d. All of the above

Three examples of modifiable risk factors:
a)……………………………………………………………………………
b)……………………………………………………………………………
c)……………………………………………………………………………
Three examples of non-modifiable risk factors:

a)……………………………………………………………………………
b)……………………………………………………………………………
c)……………………………………………………………………………
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Chapter (5): Screening
Objectives:
1- Identify definition, aims and objectives of screening.
2- Identify types and uses of screening.
3- Recognize the criteria required to launch a screening program.
4- Identify measures for evaluation of screening test.
Definition of screening:
The search for unrecognized disease or defect by means of rapidly applied
tests, examinations or other procedures to sort out apparently well persons
who probably have a disease from those who probably do not.
Aims and objectives of screening program:

The basic purpose of screening is to sort out from a large group of
apparently healthy persons those likely to have the disease or at increased
risk of the disease under study. The screening aims to:
1- reduce mortality by early detection and early treatment of a
condition;
2- reduce the incidence of a condition by identifying and treating its
precursors;
3- reduce the severity of a condition by identifying people with the
condition and offering effective treatment; and
4- increase choice by identifying conditions or risk factors at an early
stage in a life-course when more options are available.
The value of screening program is ultimately determined by its effect on

morbidity, mortality and disability.
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Types of screening programs:

1- Mass screening:
Mass screening simply means the screening of a whole population. There is
little justification for the use of mass screening as it is not a useful
preventive measure unless it is backed up by suitable treatment that will
reduce the duration of illness or alter its final outcome.
2- High risk or selective screening:
Screening will be most productive if applied selectively to high risk groups,
e.g., by screening other members of the family and close relatives for
certain diseases that tend to be aggregated in the family, the physician can
detect additional cases.
3- Multi-phasic screening:
The application of two or more screening tests in combination to a large
number of people at one time. The procedures may include a health
questionnaire, clinical examination and a range of investigations.
Criteria for instituting a screening program:
1- Disease
- Serious
- High prevalence of pre-clinical stage
- Natural history is understood
- Long period between first signs and overt disease
2- Screening test
- Sensitive and specific (valid)
- Reliable (repeatable)
- Simple and low cost
- Safe and acceptable
3- Diagnosis and treatment
- Facilities are adequate
31
- Effective, acceptable and safe treatment available
Evaluation of screening test:

Three parameters are used for evaluation of screening test, repeatability,
sensitivity and specificity of screening test.
1- Repeatability (or reliability) of a screening test:
A repeatable test is the test that gives the same results if it is repeated many
times on the same individual under the same conditions, so repeatability is
the percent agreement between multiple results of the test.
2- Sensitivity:
The probability of the screening test to be positive when the disease is truly
present i.e. the percent of those who have the disease and so indicated by
the test. Or it is the ability to identify correctly those who have the disease.
3- Specificity:
The probability of the screening test to be negative when the disease is
truly absent i.e. the percent of those who do not have the disease and are so
indicated by the test.
32
Evaluation
Screening is used in:
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
A screening test must be:

a. Simple, cheap and quick
b. Simple, expensive and accurate
c. Simple, cheap and slow
d. Highly accurate and can be slow
Repeatability mean that:

a. The test will give the same result if repeated under the same condition
b. The test will be interpreted well
c. The test is acceptable
d. The test will give the same results under different conditions
Sensitivity is the ability of the test to:

a. Detect all positive cases.
b. Detect false positive cases.
c. Detect false negative cases.
Complete the following:

The measures to enhance repeatability of a screening test are:
a) ……………………………………………………………………………
b) ……………………………………………………………………………
c) ……………………………………………………………………………
d) ……………………………………………………………………………
33
Chapter (6): Measurements of Health and Disease
Objectives:
At the end of the chapter the student should be able to:
1- Define incidence and prevalence rates
2- List different mortality rates used
3- List different fertility rates used
4- Calculate different measures of health and disease
5- Interpret different measures of health and disease
Definition of health and disease

Health is defined by the World Health Organization (WHO) as a state
of complete physical, mental, and social well-being and not merely the
absence of disease or infirmity.”
Definitions of health states used by epidemiologists tend to be simple,

for example, “disease present” or “disease absent”
A case definition is a set of standard criteria for deciding whether a

person has a particular disease or other health-related condition.
Population at risk (PAR)

People who are potentially susceptible to the diseases being studied.
For instance, men should not be included when calculating the frequency of
cervical cancer.
34
Figure (3): Population at risk of cancer cervix
35
Ratio
The value obtained by dividing one quantity by another. The relation
between two numbers in the form of x: y or x/y
Proportion
It is a specific type of ratio in which the numerator is included in the
denominator.
Rate
It is the special form of proportion that includes specification of time.
Morbidity Frequency Measures

Incidence rate (I) is calculated as follows:
Number of new cases occurring during a period of time
× 10n
PAR during the same time period
Prevalence rate (P) of a disease is calculated as follows:

All new and preexisting cases during a time period
× 10n
Population during the same time period
Point and period prevalence

The numerator in point prevalence is the number of persons with a
particular disease on a particular date.
The numerator in period prevalence is the number of persons who had

a particular disease at any time during a particular interval.
36
Table (1): Differences between incidence and prevalence
37
Attack rate:
An attack rate is a variant of an incidence rate, applied to a narrowly
defined population observed for a limited time, such as during an epidemic.
The attack rate can be calculated as the number of people affected

divided by the number exposed.
For example, in the case of a food borne disease outbreak, the attack
rate can be calculated for each type of food eaten, and then these rates
compared to identify the source of the infection.
A rate is calculated by dividing the number of cases by the

corresponding number of people in the population at risk and is expressed
as cases per 10n
Attack rate =
Number of new cases among the population during the period
× 100
Population at risk at the beginning of the period
Secondary Attack Rate:

A secondary attack rate is a measure of the frequency of new cases of
a disease among the contacts of known cases.
To calculate the total number of household contacts, we usually

subtract the number of primary cases from the total number of people
residing in those households.
Secondary attack rate =

Number of cases among contacts of primary cases within the
incubation period × 10n
Total number of contacts
38
Mortality Rates
A mortality rate is a measure of the frequency of occurrence of death
in a defined population during a specified interval.
Crude Death Rate (CDR)

It is the mortality rate from all causes of death for all ages
CDR =
Total number of deaths in a certain year and locality
× 1000
Estimated mid-year population of the same year & locality
Cause Specific Death Rate (CSMR)

It is the number of deaths of a certain disease in a certain locality and year
CSMR=
Number of deaths from certain disease a certain year and locality
× 1000
Estimated mid-year population of the same year &locality
Case Fatality
Case fatality is a measure of disease severity and is defined as the
proportion of cases with a specified disease or condition who die within a
specified time. It is usually expressed as a percentage.
Case fatality (%) =

Number of deaths from diagnosed cases in a given period
× 100
Number of diagnosed cases of the disease in the same period
39
Age-Specific Death Rates (ASDR)

Total number of deaths occurring in a specific age group of the
population in a defined area during a specified period.
ASDR=
Number of deaths of a certain age in a certain year & locality
× 100
Mid-year population of the same age group of the same year & locality
Infant Mortality Rate (IMR)

It is the number of death in children during the first year of life. It is
commonly used as an indicator of the level of health in a community.
IMR =
Number of deaths in a year of children less than one year of age
× 1000
Total number of live births in the same year
Proportionate Mortality:
Occasionally the mortality in a population is described by using
proportionate mortality, which is actually a ratio: the number of deaths
from a given cause per 100 or 1000 total deaths in the same period.
Maternal Mortality Ratio

The maternal mortality ratio refers to the risk of mothers dying from
causes associated with delivering babies, complications of pregnancy or
childbirth.
Number of maternal deaths in a given geographic area in a given year

×100,000
Number of live births that occurred
41
Fertility Rates:
Crude Birth Rate (CBR) =
Number of live births in a certain place & time
× 1000
Mid year population of the same place & time
General Fertility Rate=

Number of live births in a certain place & time
× 1000
Number of women in a reproductive age (15-49)
Age Specific Fertility Rate (ASFR)

It is the umber of live births borne to mothers of a certain 5-year age group.
ASFR=
Number of live births of women age 15-19 years
× 1000
Estimated number of women age 15-19 years
Total Fertility Rate

It is the average number of live births a woman would have during her
reproductive years, given all the age specific rates for the 7 age groups
(15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49)
Natural Increase Rate=

Number of live births - Number of deaths during a given time
× 1000
Estimated total population at mid-interval
41
Evaluation

Which of the followings is the calculation for prevalence?
a. The number of new cases divided by the number of people in the
population, over a specific period of time
b. The number of existing cases divided by the number of people in the
population
c. The number of exposed cases divided by the number of new cases
over a specific period of time
d. The number of existing cases divided by the number of new cases in a
specific population
Which of the following is the calculation for incidence?

a. The number of new cases divided by the number of people in the
population, over a specific period of time
b. The number of existing cases divided by the number of people in the
population
c. The number of exposed cases divided by the number of new cases
over a specific period of time
d. The number of existing cases divided by the number of new cases in a
specific population
In Egypt the number of women who died due to pregnancy, labor, or

perperium was 50/100,000 live births in the year 2012. This is:
a. Infant mortality rate
b. Maternal mortality ratio
c. Maternal morbidity rate
42
Chapter (7): Public Health Surveillance
Objectives:
1- Define public health surveillance
2- List objectives of health surveillance
3- Identify types of surveillance
4- Identify uses of health surveillance
Definition
Health surveillance is the ongoing systematic collection, analysis and
interpretation of health data essential for planning, implementing and
evaluating public health activities.
Objectives of surveillance:
1- Know what diseases are occurring so effective control can be initiated.
2- Detecting outbreaks
3- To evaluate the effectiveness of control programs
4- Increase the knowledge of the disease process
Public health surveillance, which has been called “information for

action”, is how a health department takes action of its community.
43
Public health action

Surveillance Priority setting
Collection Planning, implementing
Analysis evaluating diseases
Interpretation Investigation
Dissemination Control
Prevention
Types of surveillance:
1- Active surveillance occurs when the health department calls, or visits
health care providers to see if they have seen any cases of a particular
disease.
2- Passive surveillance occurs when the health department waits for

health care providers to report cases.
3- Sentinel surveillance Health authorities define homogeneous

subgroups of the population to be sampled. Then identify certain heath
units to give a heath care to the population subgroups and report the
specific disease.
Sources of disease surveillance data:

1. Individual case reports
2. Laboratory reports
3. Emergency reports
4. Hospital discharge summaries
5. Case investigations revealing additional cases
6. Death certificates
7. Surveys
44
Uses of surveillance:
Surveillance is an essential feature of epidemiologic practice and may
be used to:
1- Recognize isolated or clustered cases.
2- Assess the public health impact of events and assess trends.
3- Measure the causal factors of disease.
4- Monitor effectiveness and evaluate the impact of prevention and control
measures, intervention strategies and health policy changes.
5- Plan and provide care.
45
Evaluation

Which of the followings is passive surveillance?
a. Health care providers regularly report cases of disease to the local
health department based on a standard case definition of certain disease.
b. Local health departments initiate the collection of specific cases of
disease from health care providers.
c. The ongoing, systematic collection, analysis, interpretation, and
application of indicators for disease that allow for detection before
public health authorities identify them.
Which of the followings is active surveillance?

a. Health care providers regularly report cases of disease to the local
health department based on a standard case definition of certain disease.
b. Local health departments initiate the collection of specific cases of
disease from health care providers.
c. The ongoing, systematic collection, analysis, interpretation, and
application of indicators for disease that allow for detection before
public health authorities identify them.
Sentinel surveillance is used to:

a. Establish natural history of disease.
b. Define incidence or prevalence of selected diseases in a population.
c. Define homogeneous population subgroups and regions to be sampled.
Complete the following:
The objectives of surveillance system include:
a) …………………………………………………………………………
b) …………………………………………………………………………
c) …………………………………………………………………………
46
Chapter (8): Epidemic Disease Occurrence
Objectives:
At the end of the course the student should be able to:
1- Identify the patterns of disease occurrence in a population
2- Define an epidemic
3- Explain the difference between different types of epidemics
4- Investigation of an outbreak
Definitions
Baseline level of the disease: The amount of a particular disease that is
usually present in a community.
An endemic level: a persistent level of occurrence with a low to moderate

disease level.
Hyper-endemic level: persistently high level of disease occurrence.
Sporadic: an irregular pattern of occurrence, with occasional cases

occurring at irregular intervals is called.
Epidemic: occurrence of a disease within an area is clearly in excess of the

expected level for a given time period.
Pandemic: an epidemic spreads over several countries or continents,

affecting a large number of people.
Why does an epidemic occur?

1- A recent increase in amount or virulence of the agent.
2- The recent introduction of the agent into a setting where it has not
been before.
47
3- An enhanced mode of transmission.

4- Some change in the susceptibility of the host.
5- Factors that increase host exposure or involve introduction through
new portals of entry.
Epidemic patterns:
A common source outbreak is one in which people are exposed
intermittently or continuously to a common harmful source. The period of
exposure may be brief or long. For example, a group of persons is exposed
to a common noxious influence, such as an infectious agent or a toxin.
A point source outbreak is a common source outbreak in which the

exposure period is relatively brief. So that everyone who becomes ill
develops disease at the end of one incubation period.
A propagated outbreak is one that is spread from person to person.

Because of this, propagated epidemics may last longer than common source
epidemics and may lead to multiple waves of infection if secondary and
tertiary cases occur.
Investigation of an outbreak
The purpose of investigating a communicable disease epidemic is to
identify its cause and the best means to control it. This requires detailed
and systematic epidemiological work in simultaneous steps:
1- Establishing the diagnosis of reported cases

2- Confirming the epidemic
3- Describing the epidemic
4- Formulate and test hypothesis
5- Identify population at risk
6- Environmental assessment
48
7- Control of epidemics
8- Reporting and disseminating findings on the epidemic
1- Establishing the diagnosis of reported cases

The first step to the review the reported cases to diagnose the problem.
This can be done:
 Clinical history
 Laboratory tests
2- Confirming the epidemic

Confirm an unusual occurrence of the disease in a defined population
by compare the incidence of disease in the population now with previous
years.
3- Describing the epidemic

The important questions must be answered to describe an epidemic:
1- What is the disease of an epidemic?
2- What is the source of infection?
3- What is the mode of transmission?
4- Why does the epidemic occur?
4- Formulate and test hypothesis

Descriptive epidemiological analysis by who? Where? and when?
May give sufficient information to identify the source of the causative
agent and its mode of transmission.
5- Identify population at risk

When the source and mode of transmission have been confirmed,
persons at a high risk of exposure must be identified. Then appropriate
preventive and control measures implemented.
49
6- Environmental assessment
An analysis of the data may indicate an environmental source for the
outbreak. This can be confirmed by obtaining samples of suspected food or
water for examination.
7- Control of epidemic
The main elements in the control of an epidemic are:
 Attach source of infection and mode of transmission
 Treat and isolate all cases
 Increase resistance of local population
 Continue surveillance
8- Reporting and disseminating findings on the epidemic

A brief report on the epidemic should be written and should include
recommendations for preventive measures to avoid any epidemics in the
futures. Copies of the report should be send to the regional health officer
and ministry of health.
Epidemic Curve (epi curve)

An epi curve is a graphic depiction of the number of outbreak cases by
date of illness onset. It is useful because it can provide information on:
• Pattern of spread
• Magnitude
• Outliers
• Time trend
• Exposure and/or disease incubation period
51
Fig. (4): Example of an epidemic curve from Fig. (5): Example of an epidemic curve from
a common intermittent exposure source a common continuous exposure source
Fig. (6): Example of a point source epidemic Fig. (7): Example of a propagated epidemic
curve curve
51
Evaluation

The first step in investigation of infectious disease epidemic is:
a- Establishing the diagnosis of reported cases
b- Make a proper health education to the public
c- Demonstrate the existence of the epidemic
d- Environmental assessment
In the investigation of an epidemic a disease, the most appropriate

measure to describe the frequency the disease is the:
a- Incidence rate
b- Attack rate
c- Prevalence
d- Case fatality rate

Health departments investigate suspected outbreaks for:
1) ………………………………………………………………………….
2) ………………………………………………………………………….
3) ………………………………………………………………………….
Write shortly the steps of investigation of an outbreak:

1) ………………………………………………………………………….
2) ………………………………………………………………………….
3) ………………………………………………………………………….
4) ………………………………………………………………………….
5) ………………………………………………………………………….
6) ………………………………………………………………………….
7) ………………………………………………………………………….
8) ………………………………………………………………………….
52
General Revision
I- Mention whether the following statements is true (T) or false (F):

1 Epidemiology deals with any related health condition of T
people.
2 Passive immunity occurs when antibodies are given to the host. T
3 A case is a set of standard criteria for deciding whether a F
person has a particular disease.
4 Identification of causes of the disease is important for its T
prevention and control.
5 An „agent‟ is a person who responsible for transmission of F
infection.
6 A rate is a type of proportion that has time as a component. T
7 Pathogenicity refers to the proportion of persons with clinical F
disease who become severely ill or die.
8 Descriptive epidemiology tests a specific hypothesis about the F
relationship of a disease to a specific cause.
9 The portal of entry into the susceptible host is different from F
the portal of exit.
10 Population at risk is people who are potentially susceptible to T
the diseases.
11 Mortality refers to disability and death. F
12 In active surveillance health care providers regularly report F
cases of disease to the local health department.
13 While an agent of disease may be necessary for a disease, T
exposure to an agent does not always cause clinical symptoms.
14 Infection means invasion of the body by a pathogenic T
organism.
15 A contact carrier may get infected from the polluted F
environment.
1- Descriptive epidemiology involves the followings elements except:

a. Severity
b. Person
c. Place
d. Time
2- Epidemiology can be used for:

a. Disease control
b. Evaluation of health programs
53
c. Accidents prevention
d. All of the above
3- The most important personal factor affecting disease occurrence is……

a. Age
b. Climate
c. Place of residence
d. Periodic time trend
4- The epidemiologic triad of disease causation refers to:

a. Agent, inlet, exit
b. Time, place, person
c. Source, place, host
d. Agent, host, environment
5- Dangerous groups of carriers include:

a. Family members
b. Students
c. Food handlers
d. All of the above
6- Education and motivation for healthy lifestyle is..................................

d. Specific protection
7- Screening for breast cancer using mammography is…………………..

d. Specific protection
8- Primary preventive measure can be applied at which stage of the natural

history of disease?
a) Stage of good health
b) Subclinical change
c) Clinical disease
d) All of the above
9- The term that best describes „12 new cases of Tuberculosis / 100,000
populations in 2018 is:
54
a) Proportion
b) Incidence rate
c) Point prevalence
d) Period prevalence
10- The value obtained by dividing one quantity by different another one in
the form of x: y or x/y is…………………
a) Proportion
b) Rate
c) Ratio
d) Percent
11- Covering mouth when coughing, sneezing and use of disposable tissues is a
preventive measures directed to the:
a. Agent
b. Reservoir
c. Exit of infection
d. Mode of transmission
12- In the investigation of an epidemic of COVID 19, the most appropriate

measure to describe the severity of the disease is……………………….
a. Attack rate
b. Case fatality rate
c. Cause specific death rate
d. Age specific death rate
13- The active collection of data from a limited number of sites or

population stands for:
a. Screening
b. Survey
c. Sentinel surveillance
d. Census
14- A propagated epidemic is usually the result of what type of exposure.

a. Point source
b. Continuous common source
c. Intermittent common source
d. Person-to-person
55
References:
1. Park's Text Book of Preventive and social Medicine 23rd edition
2. Principles of Epidemiology in Public Health Practice Third Edition
3. Community Medicine with Recent Advances, Third Edition: 2014
4. World Health Organization websites: www.who.org
56

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Chapter (1): Principals of General Epidemiology

Epidemiology is considered the basic science of public health. The word

2- Natural history of disease

Figure (1): Natural history of disease

Good Subclinical Clinical

The natural history of the disease: It is the progress of a disease

The process begins with exposure agents capable of causing disease.

3- Health status of populations

Typical study design:

Typical study designs: cohort, case-control, experimental design

1- Basic triad of descriptive epidemiology

 Geology of the place

2- Recurrent and periodic time-trends

2- Basic triad of analytical epidemiology (Epidemiological triangle)

The epidemiologic studies:

(experimental) and observational studies. In an interventional study, the

or community (community trial); then follow the individuals or

communities to detect the effects of the exposure. In an observational study

Interventional studies are prospective experimental trials in which

investigators compare the effects of an intervention on subjects with a

control group. The most compelling type of interventional study is the

randomized controlled trial (RCT).

Randomized controlled trial

Also called randomized clinical trials. It is a gold standard for evidence.

It provides the strongest evidence for establishing causation. It can be

performed in both clinical and community settings.

 Compare the efficacy of new therapy regimens and drugs against

 Evaluate new screening and prevention strategies.

Study groups: also called study arms

a) Intervention/experimental group: Participants are exposed or receive

b) Control group: Participants receive the current standard of care, a

placebo, or nothing at all.

Placebo: A medically ineffective intervention that mimics a real

 Confounding variables are well-controlled.

 Temporal relationship is well-established.

 Provides strong evidence for causation.

 Study groups do not necessarily represent the real world.

Observational studies are used to observe and measure outcomes in a

retrospective. Types of observational studies include cross-sectional

studies, case-control studies, and cohort studies.

Also called prevalence studies. Used to collect data about an entire

population at a single point in time (snapshot). Participants are not

people have the disease in a population).

 Inexpensive and fast

 Unable to determine causality because exposures and outcomes are

 They allow information (recall) bias that affect results.

Start from an outcome and work backward (retrospectively) in time to see

a) Cases: those who have or have had the outcome or disease.

b) Controls: those who lack the outcome or disease.

 Inexpensive and less time consuming.

 They are efficient for rare diseases.

 Good for examining multiple exposures.

 Cannot measure the incidence.

 Subject to recall bias if exposure is measured by interviews.

 Identifying a sample of controls can be difficult and subject to

An observational study that chooses a cohort that shares a common

develops the outcome of interest. It is a longitudinal study in which the

temporal relationship between exposure and outcome is established.

 Direct calculation of incidence.

 Clear temporal relationship between exposure and disease.

 Particularly efficient for the study of rare exposures.

 Can give information on multiple outcomes of a particular exposure.

 They very expensive and time consuming.