PUBLIC HEALTH

Part 2 – Epidemiology | Fundamentals and

Role in Healthcare Management

Kheya Furtado | GIM

WHAT IS PUBLIC HEALTH ?
• The science and art of preventing disease, prolonging life, and
promoting health through the organized efforts of society

How is public health practice different from the practice of clinical

medicine?
Public health is not = government health services; its much more
Requires all components of a health system to contribute to the
outcomes

Kheya Furtado | GIM

 Epidemiology
What are we studying and WHY?

Kheya Furtado | GIM

Epidemiology is the foundation science of Public
Health (along with biostatistics)
Task: Design a national programme for the prevention of
cardiovascular disease

• Do we need a national programme for the prevention of

cardiovascular disease (CVD)?
• What causes cardiovascular disease?
• Who should we target?
• What strategies should we prioritize?
• If we develop this programme, how much CVD will it prevent?
Kheya Furtado | GIM
Epidemiological tools/ evidence will guide decision making
Task: Design a national programme for the prevention of cardiovascular disease

• Do we need a national programme for the prevention of cardiovascular disease

(CVD)?  burden of disease compared to others (measures of morbidity &
mortality)
• What causes cardiovascular disease? risk factors associated with disease
(epidemiological studies from association to causation)
• Who should we target? identification of high-risk groups, burden of disease by
age, gender, socio-economic group, geography
• What strategies should we prioritize? epidemiological studies of the
effectiveness of interventions for CVD
• If we develop this programme, how much CVD will it prevent? Combination of
measures; Attributable risk
PLUS: Data on finances, infrastructure, operations, etc.

Kheya Furtado | GIM

But the Public Health folks aren’t the only ones who need
these tools!
TASK:

A. A pharmaceutical company has a new potential TB drug developed. What data do they
need to generate before they can hope to sell?

B. A diagnostic manufacturer wants to introduce a new diagnostic test for detection of

dengue into the market. What validity measures of the test are necessary for its use in
the population?

C. An insurance company has to make a decision on inclusion/exclusion of

treatment/therapies in its list of covered services. What information does it need to
make these decisions?

Kheya Furtado | GIM

Epidemiology- tools that enable decision
making
• The study of the distribution and determinants of health-related states or
events in specified populations, and the application of this study to control
of health problems."

ALSO, Individual decisions

• Deciding to quit smoking?
• Deciding to take the stairs instead of the elevator?
• Eat a salad instead of a burger?

If you work in Health, you need to know Epidemiology!

Kheya Furtado | GIM
The Epidemiological process
WHAT Diagnosis/ Defining the health event
Count

WHO Person
Descriptive Epidem
WHERE Place
Divide

WHEN Time

Causes/Determinants/ Risk factors/ modes of

WHY Analytical Epidem Compare
transmission

Kheya Furtado | GIM

WHAT (is happening)= Case definition
• A case definition is a set of standard criteria for classifying whether a person
has a particular disease, syndrome, or other health condition.
• Standard (can be set by a national or international body)
• Allows comparison across geographies
• Important for surveillance
• ICD-10 codes for recording in electronic medical records

Kheya Furtado | GIM Source: National Centre for Disease Control, MoHFW
WHO (is affected)
Analyze the condition by age distribution

Assume this data represents: CVD fatalities by age group

What does this data tell you?

Is age a risk factor for CVD fatalities?

What are the limitations of this data?

Adapted figure: CDC, 2012. Principles of Epidemiology in Public Health Practice

Kheya Furtado | GIM
The correct way of identifying WHO is affected
CVD Death rates by age group

Denominators matter!
Cases/ deaths should be reported as a
proportion of persons in the respective age
group to understand risk

Source: CDC, US Dept of Health and Human Services 2012. Principles of Epidemiology in Public Health Practice
Kheya Furtado | GIM
Analyze the condition by sex distribution

Death rates in men and women

Is sex a risk factor for lung cancer deaths?

Source: Woodward 2019. Int. J. Environ. Res. Public Health 2019, 16(7), 1165

Kheya Furtado | GIM

Analyze the condition by socio-economic group
Infant mortality in the USA by ethnic groups
Is race a risk factor
for infant mortality
in the US?

Source: CDC, US Dept of Health and Human Services 2012. Principles of Epidemiology in Public Health Practice
Kheya Furtado | GIM
WHEN ( periodicity, seasonality, peaks, spikes)
Analyze the condition by periodicity/ time

Malaria in Kurseong block, Darjeeling District, West Bengal, India, 2000-2004

Source: IDSP, Govt of India

Kheya Furtado | GIM
 Analyze the condition by region
WHERE Epidemiological Transition
ratio of the States of India;
1990 and 2016

ETL: Ratio of burden of

Communicable diseases/ burden of
Non-Communicable diseases

Kheya Furtado | GIM

Source: ICMR-DHR, PHFI, IHME 2017. India: Health of the Nation’s States
Combining analysis variables
Analyze the condition by sex and region

Source: QuickStats: Age-Adjusted Death Rates from Heart Disease Among Adults Aged 45–64 Years, by Urbanization Level and
Sex — National Vital Statistics System, United States, 2019. MMWR Morb Mortal Wkly Rep 2021;70:1621.

Kheya Furtado | GIM

John Snow

Using the
Epidemiological
Approach (1854)- he
became known as
the Father of Field
Epidemiology
The Spot map

Kheya Furtado | GIM

Source: CDC, US Dept of Health and Human Services 2012. Principles of Epidemiology in Public Health Practice
Kheya Furtado | GIM
Observations that led to Policy & Practice
• Semmelweis -19th century
Maternal mortality due to childbed fever, General Hospital, Vienna

OBSERVATION

Source: Gordis L. Epidemiology 5th Edition Kheya Furtado | GIM

 ACTION

FOR DISCUSSION:

Evidence that promotes un-

popular policy and its
implications
https://www.nytimes.com/2020/06/27/worl
d/europe/coronavirus-spread-
asymptomatic.html?smid=nytcore-ios-
Source: Gordis L. Epidemiology 5th Edition
share

Kheya Furtado | GIM

Dynamics of Disease Causation &
Transmission

Kheya Furtado | GIM

Models of causation of disease
The Epidemiological triad
(mainly for infectious diseases..)
Biological-Bacteria, Viruses
Chemical- poison, smoke,
alcohol
Physical- trauma, radiation,
fire
Nutritional- lack, excess
Agent
Kheya Furtado | GIM
Age Sex Race Religion Customs Occupation
Genetic profile Marital status Family history
Behaviour Previous disease Immune status
Host
Temperature Humidity Altitude
Crowding Housing Sanitation
Neighbourhood Air pollution
Vector
Environment
Why use models to understand disease?
• To find ways to prevent, control, manage

Kheya Furtado | GIM

Component causes and causal pies
• More suitable to understand non communicable diseases with multiple etiology
 Example: Coronary artery disease

Both models represent two sets of sufficient causes

Source: Madhukar Pai, McGill University

https://www.teachepi.org/wp-content/uploads/OldTE/documents/courses/fundamentals/Pai_Lecture1_Overview%20of%20epi_Part2.pdf
Example: Pneumonia

Is there a Necessary cause here?

Kheya Furtado | GIM

Chain of infection: public health measures address the
different components of the chain

Kheya Furtado | GIM

Iceberg concept of disease
Clinical and sub-clinical disease
Discuss:

• Why did we need to

quarantine travelers
without symptoms in
the early days of
Covid-19?

Kheya Furtado | GIM

Source: Gordis L. Epidemiology 5th Edition