INTRODUCTION TO EPIDEMIOLOGY AND DETERMINANTS

DESCRIPTIVE EPIDEMIOLOGY  Any factor, whether event, characteristic, or other

OVERVIEW OF EPIDEMIOLOGY
 “Epi” – upon, befall
 “Demo” – people, population, man
 “Logo” - a study of
 The study of anything that happens to people
(“that which befalls man”)
 The study of the distribution and determinants of
health-related problems or events in a specified
population and the application of this study
to control health problems
STUDY
 A quantitative discipline that relies on probability,
statistics, and sound research methods
 A method of causal reasoning based on developing and
testing hypotheses
 It is an applied science that is generally observational and
uses systematic and orderly methods
DISTRIBUTION
 Frequency - refers not only to the number of health
events, but also to the relationship of that number to the
size of the population
 Pattern - refers to the occurrence of health-related events
by time, place, and person (Descriptive Epidemiology)
HEALTH-RELATED STATES/EVENTS
 May be seen as anything that affects the well-being of a
population
 Originally focused on epidemics of communicable
diseases but subsequently expanded to include
non-communicable diseases, chronic diseases, injuries,
maternal-child health, occupational health, and
environmental health
definable entity, that brings about a change in a health
condition or other defined characteristic (Analytical
Epidemiology)
 Epidemiologists assume that illness does not occur
randomly in a population, but happens only when the
right accumulation of risk factors or determinants exists in
an individual
 Clinical Epidemiology – application of epidemiological
principles and methods to practice of clinical medicine
 Preventive Medicine – branch of medicine that
concentrates on keeping people well with the goal of
disease prevention and health promotion
BIOMEDICAL
 Fix it approach
 Relies heavily on hospital and medical profession
 “Individual approach”
PREVENTIVE
 Changing the behavior of individuals
 Focus on groups
 “You don’t want the disease to set in”
SOCIAL
 Social Environmental and Economic
 Focus on communities and population
 “Social, environmental, and economic risk factors for
the disease”

SPECIFIED POPULATIONS
 Focuses on the collective health of the people in a
community or population
USES OF EPIDEMIOLOGY
 Identifying the exposure or source that caused the illness
 The number of other persons who may have been
 Identification of the cause of disease
similarly exposed
 Determination of the natural history of disease and
 The potential further spread in the community
progression
 Interventions to prevent additional cases or recurrences
 Identification of risk factors
 Formulation of health programs, adequate measures of
APPLICATION
diagnosis, treatment and prevention
 Applying the knowledge gained by the studies to
 Evaluation of effectiveness
community-based practice
 Uses descriptive and analytic epidemiology as well as
experience, epidemiologic judgment, and understanding
of local conditions in “diagnosing” the health of a
community
 PIONEERS OF EPIDEMIOLOGY BRADFORD HILL

JOHN SNOW  Hill’s criteria for causation

 Father of Epidemiology  Attributed lung cancer with smoking
 Investigated the cholera epidemic in London
 Was the first to use the Spot Map Hill’s criteria of causation

Useful in establishing epidemiologic evidence of causal

Used statistics to illustrate the connection between the
quality of the water source and cholera cases
• Hallmark event of the science of Epidemiology
• Plotted all of the cases and identified a confluence
Saw that all of the cases are centered around the broad street
water pump
HIPPOCRATES
 True Father of Epidemiology
JOHN GRAUNT
 Wrote the Bills of Mortality
 Developed census and statistics
 Responsible for the death certificates
 Founded the science of demography
relationship between a presumed case and an observed effect
BROAD DETERMINANTS OF EPIDEMIOLOGY
Descriptive Epidemiology
 Study of the amount/frequency and distribution of
disease, etc. in populations
 Example: case studies, incidence and prevalence rates
Analytic Epidemiology
 Study of the determinants of etiology of disease and
related conditions
 Cause and effect relationship
Exa Example: case control, cohort studies

Bills of Mortality DESCRIPTIVE EPIDEMIOLOGY

• Tried to study the causes of death in their community
Aims:
and used that to analyze mortality rates in London at
the time of the bubonic plague  Permit evaluation of trends in health and disease
• Attempted to characterize London in terms of
different profiles or parameters that would be  Provide a basis for planning, provision, and evaluation of
descriptive of the entire population (e.g. the top 10 health services
causes of morbidity and/or mortality)
 Identify problems to be studied by analytic methods and
WILLIAM FARR suggest areas that may be fruitful for investigation
 Father of Modern Vital Statistics and Surveillance VARIABLES
 Responsible for the International Classification of
Diseases

International Classification of Diseases

• Used in the diagnosis of diseases and filling out of death

certificates

JAMES LIND
 Who develops the disease? (Person variables)
 Studied about scurvy (Vitamin C deficiency)
 When does the disease occur? (Time variables)
 Scorbutic sailors
 Where does the disease occur? (Place variables)
 Used different treatment plans (oranges, lemons, etc.)
TIME TRENDS
 “Of this they drank half a pint every day, and sometimes
more or less, as it operated, by way of gentle physic. Two Secular
others had each two oranges and one lemon given them
 Looking at the trends of the disease for long periods of
every day. These they ate with greediness, at different
time (such as for 10, 15, 20 years)
times, upon an empty stomach.” - James Lind
 Disease is increasing or decreasing or absence of trend

 Example: Double Burden of Disease in the Philippines

 “Although communicable diseases are going down, non- • Dry season - Chickenpox , heat stroke, sore eyes, measles,
communicable diseases are going up” heat rashes (bungang araw), dog bites, scabies (in jail)

Cyclic SEASONAL VARIATION OF CHIUCKEN POX

 Looking at what is happening to the disease within a

short period of time (such as 3, 4, or 5 years)
 “Increase or decrease in a specified amount of time”

Cases of chickenpox (pink line) increase during summer

compared to mumps (light pink line)

SEASONAL INFLUENZA

Graph indicates that suicide has a relation with solar activity

index (blue line), geomagnetic activity index (green line) and
daily mean temperature (black line)

As solar activity index, geomagnetic index and daily mean

temperature increases, incidence of suicide increases

CYCLIC PATTERN OF DENGUE

 Cases of influenza increase during rainy season

 Flu vaccines are given during May or June (time
when company releases the vaccines)
 Flu vaccines expire after 8 months

ATTENTION PHENOMENON
 Increase in the number of cases of disease but not
enough to say that there is an epidemic or outbreak
Every 7 or 10 years, there’s a sudden increase of dengue in
Indonesia BEHAVIOR OF DISEASES IN THE COMMUNITY

In the Philippines before, every 3 years, there’s an increased Attention Phenomenon

mortality rate of dengue with type IV strain
Nowadays, there’s no more cyclic pattern of dengue in the
Philippines
Endemic
• Because dengue is endemic in the Philippines
• Every year, we have cases of dengue especially
during rainy season
 Sudden increase in the number of cases of disease but
not enough to say that there is an epidemic or
outbreak
 High number of cases of disease in the community all
throughout the year (does not fluctuate) but not
enough to say that there is an epidemic or outbreak

Seasonal If rate of disease is higher but not enough to say that there
is an epidemic or outbreak – hyperendemic
• Looking at the trend of the disease within a year

• “Depends on the season” – dry or wet seasons

• Examples:

• Rainy season - Leptospirosis, Dengue, Bronchial Asthma,

Influenza, Pneumonia
EPIDEMIC/PROPAGATED EPIDEMIC
 Sudden increase in the number of cases of disease in the
community
 When can you say that there is an epidemic?
 If the sudden increase is 2 standard deviations away from
the average number of cases of disease in the community
PANDEMIC
 Increase in the number of cases not only on one country
OUTBREAK
 Disease has only one source
 In graphs, there is a sudden increase and sudden decrease
in the number of diseases
Phases 1-3 – mostly animals
Phase 4 – human to human transmission
Phase 5 – one WHO region
Phase 6 – two or more WHO region
PLACE VARIABLES
 Characterization by place refers not only to place of
residence, but also to any geographic location relevant to
disease occurrence
 Subdivided into three sub-categories: International,
National and Local
INTERNATIONAL
 Characterized by having a geographic variation, location
variation and different race and culture
 Countries are strict that individuals entering should show
certificates that they are cleared and vaccinated from all
possible disease that may affect their country
 Example: Global prevalence and burden of the disease
tuberculosis
 Example: Italian Paradox
 Despite the Italians’ diet of meat and pasta, there is low
incidence of CVD due to their fondness of drinking wine
National
o Involves sociodemographic characteristics of the different
cities, provinces and local community in a country
 Changes within a country
 Different provinces within a country
o Involves only all the individuals residing in the area
o Example: Malaria in Palawan, Philippines
o Example: Infant and Maternal Mortality Rate
 ARMM – highest IMR and MMR due to poverty
 NCR and CAR - low IMR and MMR
Local
 Characterized by local communities, towns, or cities that
have access to health
 If there is a presence of disease that is endemic to a
particular community, should there be a presence of
tourists in the environment, the incidence rate would
increase
Characterized by the variation of occurrence in relation to the
personal characteristics that may reflect the differences in:
 the level of exposure to causal factors
 susceptibility to the effects of causal factors
 or both exposure and susceptibility
Age
 Age groups are susceptible to different dangers
 Children:
o Most vulnerable group
o Infectious diseases
o High Infant mortality rate means high infectious
diseases
 Age groups are susceptible to different dangers
 Teens:
 Cause of mortality is violence, substance abuse, and
other drug-related events
 Age groups are susceptible to different dangers
 Young Adults:
o Most susceptible to accidents
 Older Adults:
o Most susceptible to chronic diseases
Gender/Sex
 Certain diseases only affect one gender and some
mostly affects only one gender as well
 Female lifespan (72) is longer than male lifespan (69)
o Filipino average lifespan is 70
Men
o Have higher incidence of CVD at a certain age
o Have higher all cause specific mortality rate
o Higher incidence of completed suicide (death)
Women
o Before menopause, women have a lower rate of CVD
o After menopause, women have a higher rate of CVD
 Women lose hormonal protection after
menopause
o Women with MI receive less guideline-based diagnostic
and less-invasive treatments than men
o Women with heart failure receive fewer:
o Guideline-based diagnosis and treatments
o Fewer implantations and heart transplantations
o Women have a better outcome than men
 Women with atrial fibrillation receive less anticoagulation
treatment with warfarin
 Have greater risk for stroke than men
 Obtain dialysis later than men
 Undergo fewer kidney transplants than men
(from both living and deceased donors)
 Significant delay in referral of female patients with
rheumatoid arthritis to an early arthritis clinic compared
with male patients
 Osteoporosis and depression are considered female
disease
 Both are under-diagnosed in men
 Females have higher incidence of suicide
Civil Status
o Married women have higher risk for cervical cancer
o Single men and women with myocardial infarction
compared with married individuals have:
 increased mortality
 increased odds of CVD, CHD, CHD death and
stroke death
o Never married men were associated with higher risk of
hypertension and all-cause mortality
o Never married women had a lower risk of hypertension