BASIC EPIDEMIOLOGY

GENERAL OBJECTIVE:
To know the basic concepts and strategies of Epidemiology
SPECIFIC OBJECTIVES: At the end of the lecture, the student must know the:
1. 2.

Definition of Epidemiology Concepts of Epidemiology

SPECIFIC OBJECTIVES:
3. Principles of Epidemiology 4. Aims and purposes of Epidemiology 5. Relationship of the other branches of Science to Epidemiology 6. Ecologic Concepts of diseases 7. Types of Disease Agents 8. Attributes of the Human host 9. Attributes of the Environment 10. Relationship among Agent, Host and Environment

Mode of Disease Transmission 13. Classification of disease in human 15. The stages of the natural history of disease 16.SPECIFIC OBJECTIVES: 11. Levels of disease prevention 17. Steps in scientific inquiry . Nature of communicable diseases 14. General and specific defense mechanisms of the body 12.

SPECIFIC OBJECTIVES: 18. Concept of Descriptive Epidemiology in relation to Person. Strategies of Epidemiology 19. proportions and rates . Sources of Epidemiological data 23. Place and time 22. ratios. Description of disease frequency as to counts. Methods of hypothesis formulation 20. Description of the different study designs 21.

From the Greek word epi meaning ON or UPON and demos which means POPULATION .The study of the distribution and determinants of disease frequency in man .DEFINITION OF EPIDEMIOLOGY .

infectious disease process.A branch of medical science concerned with the relationships of the various factors and conditions which influence the frequencies and distribute health. defect. disability or death as it occurs in aggregations or groups of individuals in a population .MODERN DEFINITION OF EPIDEMIOLOGY .

- Concept of the “shrinking world“ The world is becoming smaller not because of physical size but due to: a). Marked improvement in transportation b). Better communication and transportation makes easier exchange of information about diseases .CONCEPT OF EPIDEMIOLOGY 1.

CONCEPT OF EPIDEMIOLOGY 2. Better control measures. Much have been done to fight communicable diseases a). Socio-economic conditions b).vaccines . Improvement and progress of medical science 3. Better facilities for early Dx & Tx b). Changes in nature of disease problem a).

Epidemics are now a rarity .CONCEPT OF EPIDEMIOLOGY 4. Realization of the different applications of methods in Public Health both for infectious and non-infectious diseases .study more the endemic behavior of disease rather than epidemic occurrences 5.

precise) 2.PRINCIPLES OF EPIDEMILOGY 1. Correct interpretation ( free from error) 3. Rational instruction (by expert knowledge and technical skills) . Exact observation (strict. accurate.

To analyze carefully the roles and interactions of agents.AIMS & PURPOSES OF EPIDEMIOLOGY 1. host and environmental factors in the natural history of disease to discover gaps in the knowledge and contribute to preventive medicine .

To describe and analyze disease occurrence and distribution according to such variables as age. periodic fluctuation. sex. long term trends and geographic distribution to make community diagnosis making an estimate of morbidity and mortality risks .AIMS & PURPOSES OF EPIDEMIOLOGY 2. occupation. temporal frequency.

AIMS & PURPOSES OF EPIDEMIOLOGY 3. amplitude and group behavior of clinical syndromes in populations . To aid in filling gaps in knowledge about the causes of disease processes by observing the range.

This would include the study of new diseases. To study immediate and special problems in the field of health. endemic disease problems.AIMS & PURPOSES OF EPIDEMIOLOGY 4. epidemics and administrative problems 5. To measure the effectiveness of preventive and control programs in health .

sources and modes of transmission of living agents of disease 1. Parasitology. . reservoirs. From Bacteriology. Zoology for information about nature and characteristics.RELATIONSHIP OF OTHER BRANCHES OF SCIENCE TO EPIDEMIOLOGY Clinical Medicine to obtain details of clinical diagnosis for epidemiological descriptions of the distribution of diseases or disorders 2. Entomology.

From Demography on the composition and characteristics of the population 4. From Chemistry.RELATIONSHIP OF OTHER BRANCHES OF SCIENCE TO EPIDEMIOLOGY 3. From Anthropology and Sociology for information about habits. customs. Physics. Nutrition and Industrial Medicine for information about health hazards 5. cultural and social characteristics of the population .

Meteorology for data on weather and climate in relation to occurrence of diseases 8. Genetics and Psychology for characteristics of persons which may influence occurrence of diseases 7. morbidity and mortality . Biostatistics – analytic and descriptive 9. Vital statistics containing data on natality.RELATIONSHIP OF OTHER BRANCHES OF SCIENCE TO EPIDEMIOLOGY 6.

That the nature and extent of imbalance depend on the nature and characteristics of the host and the agent . The disease results from an imbalance between disease agents and man 2.ECOLOGIC CONCEPT OF DISEASE The ecologic concept of disease is based on the 3 premises of the biologic laws: 1.

social. economic and biologic environment . That the characteristics of agent and host and their interaction are directly related to and depend largely on the nature of physical.ECOLOGIC CONCEPT OF DISEASE 3.

serve as stimulus to initiate or perpetuate a disease process .DISEASE AGENT . a substance or a force. the presence or absence of which. either animate or inanimate. may following effective contact with susceptible human host under proper environmental conditions.May be defined as an element.

Psychological . Nutrients 3. Physical 5. Biologic 2. Chemical 4.TYPES OF DISEASE AGENTS 1. Mechanical 6.

6. metals. 3. allergens. drugs Physical – climate. 4. fats Chemical – poisons. season. engines Psychological/ social – mental stress . cars. Biologic – living plants and animals. 5. vitamins. parasites Nutritive agents – cholesterol. radiation Mechanical – machines. weather. 2. proteins.ETIOLOGIC FACTORS OF AGENTS OF DISEASE 1.

.CHARACTERISTICS OF THE LIVING AND NONLIVING AGENTS Inherent nature and characteristics in morphologic agents 2. Infectivity and pathogenicity to man 4. Reservoirs and sources of infection 5. Vehicles and condition of dissemination 1. Viability and resistance 3.

CHARACTERISTICS OF LIVING AND NON-LIVING AGENTS LIVING AGENTS Morphology Mortality Physiology Reproduction Metabolism Nutrition Toxic products NON-LIVING AGENTS Dust Crystals Solutions Insoluble substances Corrosive & noncorrosive substances .

Strength of stimulus 2. Repeated increments of the agent 3. Tissue involved .THE INCUBATION OF NON-INFECTIOUS AGENTS DEPENDS ON: 1. Period of exposure 4.

multiply and yet produce no discernible action on the host 3. being expelled or dislodged by the non-specific outer defenses of the host 2. .reactions may be so mild to escape detection 1. In-apparent infection – lodge.DISEASE AGENTS MAY: Fail to lodge in the body. Sub-clinical cases.

defect or disability of the host . the end result may be: 1. Elimination of the agent leading to complete recovery 2. Death. Clinical recovery without elimination of the agent (carrier state) 3.Whatever the original reaction is.

psychological factors . OTHERS: Constitution. AGE. SEX & RACE 4. OCCUPATIONAL FACTORS 6. MARITAL FACTORS 5. heredity.ATTRIBUTES OF THE HUMAN HOST 1. HABITS & CUSTOMS 3. IMMUNE RESPONSE 2.

. Phagocytosis c). Hormones e).GENERAL & SPECIFIC DEFENSE MECHANISMS Resistance: the sum total of the defense mechanism of the host Non-specific resistance a). Skin & mucous membranes b). Different reflexes or physiologic mechanisms 1. Reticuloendothelial system d).

Different reflexes or physiologic mechanisms:  Winking reflex  Tears  Sneezing  Diarrhea  Urination  Genito-urinary  Coughing  vomiting discharge  Sweating .

brief duration of immunity 2.Specific Resistance or immunity of the human host Possession of antibodies for a specific disease Passive immunity – either attained by maternal transfer or by inoculation of specific antibodies. . Latent immunity – developed due to the giving of small doses for a long period of time 1. vaccines 3. Active immunity – natural immunity and artificial immunity.

Susceptible – a person not possessing resistance against a particular pathogenic agent 2. Immune – a person who possesses antibodies that are specific and protective .The human host may be : 1.

VIRULENCE – the measure of the severity of the reaction produced 4. opsonins. . antitoxins. presipitins.CHARACTERISTICS OF AGENTS IN RELATION TO HOST: INFECTIVITY –the ability of an agent to invade and adapt itself to the human host 2. complement fixing. neutralizing and sensitizing antibodies 1. PATHOGENICITY – the measure of the ability of an agent when lodged in the body to set up either a local or general tissue reaction 3. ANTIGENIC PROPERTIES – the activity to stimulate the host to produce agglutinins.

climate b). earthquakes) . Socio-economic – occupation.Influence exposure or susceptibility to agent a). pollution. vertebrate hosts. disruption (wars. Physical environment –geology. urbanization. crowding index . floods. Biologic environment – human population density. arthropod vectors c).Influence existence of the agent .flora and fauna – sources of food.ATTRIBUTES OF THE ENVIRONMENT: .

RELATIONSHIP AMONG AGENT. HOST & ENVIRONMENT A E H .

Vector – snails. oral. soil b). Common vehicle epidemics . anal. air or inoculation a).the etiologic agent is transmitted by water.MODE OF DISEASE TRANSMISSION Infectious diseases can spread through human population by: 1. Vehicle – water. Infected blood or sera . food. Epidemics propagated by serial transfer from host to host a). mosquitoes 2. genital route b). food. Airborne droplets.

NATURE OF COMMUNICABLE DISEASES COMMUNICABLE DISEASES .an illness due to specific infectious agents or its toxic products CONTAGIOUS DISEASES – implies transmission of the disease through direct contact .

Sporadic – occasional or infrequent occurrence of a disease 5. .Periodicity of Communicable Disease Occurrence: EPIDEMIC Endemic – a disease constantly occurring in a geographical area 3. Epizootic or enzootic – diseases occurring in animals 6. 2. Pandemic – epidemic occurring within more than one country or territory 4. Zoonotic – disease of animals transmissible to man 1.

lice. TB bacilli 6. HIV 1.Biologically. Fungi – yeast and molds 5. ascaris 3. Bacteria – spirochetes. Viruses – flu. . streptococci. disease agents are classified according to decreasing sizes into the following seven categories: Arthropods – scabies. Protozoa – plasmodium 4. Ricketssiae – typhus 7. ticks 2. Hepa B. measles. Helminths – schistosoma.

Portals of entry and exit – interrupt the natural history before man is infected . soils. plants. inanimate organic matter 2. interfering with transmission.Host factors in the occurrence and distribution of communicable diseases 1. abolishing reservoir.by detecting agents. animals. Reservoir of agents – man. barriers against infection .

CLASSIFICATION OF DISEASES  Communicable or Infectious Bacteria Virus Ricketsiae Arthropods Helminths Protozoa Fungi  Non-communicable or non-infectious Occupational Environmental Life-style diseases Familial or hereditary .

THE NATURAL HISTORY OF DISEASE
Stage of susceptibility a). Portal of entry 2. Stage of pre -symptomatic disease a). Incubation period 3. Stage of Clinical Disease a). Clinical horizon 4. Stage of disease outcome a). Complete recovery b). Disability or defect c). Carrier state d). death
1.

STAGE OF SUSCEPTIBILITY
- The disease has not developed but the groundwork has been laid by the presence of risk factors which favors its occurrence
- Portal of entry is a pre-requisite for successful infection

STAGE OF PRESYMPTOMATIC DISEASE
- There is no manifest disease but usually through the interaction of factors, pathogenic changes have started to occur - INCUBATION PERIOD – the interval between the time of entry of agent into the host and the onset of signs and symptoms

Sufficient end-organ changes have occurred so that signs and symptoms of the disease can be recognized .STAGE OF CLINICAL DISEASE .Classification and Staging of Disease .

STAGE OF DISEASE OUTCOME .Some diseases will give rise to residual defect of short or long duration with disability .Some diseases run their course and then resolve completely either spontaneously or under the influence of therapy .

NATURAL HISTORY OF DISEASE DISEASE INCUBATION PERIOD CLINICAL CASE RECOVERY COMPLETE DEATH CARRIER DISABILITY OR DEFECT .

specific protection Active and passive immunization . - - PRIMARY LEVEL Pre-pathogenesis Isolation. quarantine Health education. proper waste disposal. food sanitation. eradication of animal reservoir.LEVELS OF DISEASE PREVENTION 1.

periodic examinations. case-finding.PATHOGENESIS period .Screening tests for diseases . cows with MCD.Early diagnosis and prompt treatment of the disease to prevent its spread . pigs with FMD . adequate treatment and follow-up . SECONDARY LEVEL .LEVELS OF DISEASE PREVENTION 2.Example: killing of rabid dogs.

LEVELS OF DISEASE PREVENTION 3. TERTIARY LEVEL .Intensive.Stage of Disease outcome .Disability limitation . periodic follow-up and treatment .Rehabilitation .

Health Screening  For CVS diseases: Chest x-ray & ECG  Blood sugar for diabetes  Pap’s smear for cervical cancer  Digital rectal examination  Newborn Screening  Hearing Screening  Mantoux Test .

Formulating a new and a more specific hypothesis  3.STEPS OF SCIENTIFIC INQUIRY  1. Examining existing facts and hypotheses and identifying gaps in knowledge  2. Obtaining additional information to test the acceptability of the new hypothesis  4. Evaluating the new evidence and deriving appropriate conclusions .

hypothesis formulation  6. identify critical knowledge gaps about the problem  4.The Epidemiologic Approach or Strategy  1. special data collection activities  5. review of related literature  3. identify the problem  2. hypothesis testing .

biologic or psychological factor  The outcome is usually the disease or condition of interest .Features of a good hypothesis: Formulating the Hypothesis  The cause being investigated is usually a  The population to whom the hypothesis will apply (the target population) particular environmental exposure. chemical. It could be a physical.

Features of a good hypothesis: Formulating the hypothesis  The dose response relationship is the amount of exposure necessary for the disease or condition to develop  The time-response relationship is the time period between the exposure and the development of the outcome. This concept is synonymous to the incubation period for infectious diseases and to the latency period of non-infectious diseases .

Some considerations in formulating hypothesis a). New hypotheses are commonly formed by relating observations from several different fields b). The stronger the statistical association between the exposure and the disease. the more likely it is to suggest a causal hypothesis .

Some consideration in formulating hypothesis c). An isolated or an unusual case should receive particular attention in forming hypothesis e). Observed changes in the frequency of disease can lead to very productive hypothesis d). Observations that appear in conflict or those which present a paradox should be considered .

case series and cross-sectional studies  Observational studies – cohort studies. casecontrol studies  Experimental studies – clinical trials. RCT’s. community trials .Study Designs  Descriptive studies – case studies.

Sources of Data Two Types of Data according to Source: 1).More accurate and up-to-date but more expensive and difficult to obtain . Primary Data – obtained by the investigator Example: interviews physical examination laboratory examinations .

Secondary Data – data actually gathered by other individuals or agencies Example: published reports clinical/hospital records census .Sources of Data 2).More readily available but incomplete .Confidentiality of information .

routinely collected statistics provide the key data for monitoring morbidity and mortality trends  Surveillance System – includes a functional capacity for data collection.Surveillance  In most health departments. analysis and dissemination linked to public health programs .

closely integrated with the timely dissemination of these data to those who need to know .Epidemiologic Surveillance  Has been defined by the Centers for Disease Control (CDC) as the ongoing systematic collection. implementation and evaluation of public health practice. analysis and interpretation of health data essential to the planning.

divorces. deaths by specific causes. Disease statistics – prevalence and incidence of specific diseases . mortality rate. 2. death.Specific Data that are Useful in Epidemiologic Studies 1. adoptions. case fatality rate. Data on vital events – birth. total births/deaths. marriages. etc.

Statistics on Health Resources and Services – number of hospital beds. blood sugar levels among diabetics. BP readings 4. number of health center staff . vaccine vials consumed. Data on physiologic or pathologic conditions – prenatal Hgb levels.Specific Data that are Useful in Epidemiologic Studies 3.

practices of people regarding health . Demographic data – total number of population. amount of pollution in the air. income 7. number of snail breeding places. attitude. Socio-cultural data – knowledge. rural-urban residence. workers’ protective gears 6. gender. level of noise in the factory. Statistics pertaining to the environment – number of households with sanitary water source. age groups.Specific Data that are Useful in Epidemiologic Studies 5. occupation.

Surveys .Sources of Data 1. Registers of births and deaths 2. Disease registers 4. Certificates of death 3. Disease notifications 5. Clinic/hospital records 7. Census 6.

. 6.10 Key Sources of Data for Surveillance Systems Designated by the WHO: Mortality registration Morbidity reporting Epidemic reporting Laboratory investigation Individual case investigations Epidemic field investigations Surveys Animal-reservoir and vector distribution studies 9. Knowledge of the population and the environment 1. 3. 4. 8. 2. 5. 7. Biologic and drug utilizations 10.

Newspaper and news broadcasting reports . Panels of cooperating physicians 3. Public health laboratory reports 4. Absenteeism from work or school 5. Hospital and medical care statistics 2. Telephone and household surveys 6.Other Sources of Surveillance Data 1.

2. 5. Medical Specialty Societies 8. World Health Organization 1. Epidemiology and End Results (SEER) Program 6. Morbidity and Mortality Weekly Report from the CDC 7. 3. 4. .Data can readily be available from National Center for Health Statistics Centers for Disease Control & Prevention Birth Defects Monitoring Program Metropolitan Atlanta Congenital Defects Cancer Surveillance.

Specialty Hospitals 7. Medical Specialty Societies 4. Newborn Screening Program 6. Department of Health 2. data may be available from: 1. National Congenital Defects Registry 5. National Census and Statistics Office .Locally. National Institutes of Health 3.

WHO (person) is affected? WHERE (place) do the cases occur? WHEN (time) do the cases occur? .Descriptive Epidemiology: Person. place and time. Place and Time Descriptive Epidemiology – the study of the amount and distribution of disease within a population by person.

sex 8. social class Blood type 5. ethnic group variables: 4. occupation Environmental exposures 6. family variables 2. other personal 3. age 7. marital status Personality traits .PERSON  Characteristics of PERSON 1.

Doubling in rate from 40 and every decade of life .The most important determinant among the personal variables .AGE .Death rate is fairly high in infancy .Lowest point is between 5-14 years old .

High rate of injury in particular age group .Age is related to the frequency and severity of infectious diseases .Chronic conditions tend to increase with age whereas the relation of age to acute infectious diseases is less consistent .AGE .

SEX . but morbidity rates are higher for females . environment or habit patterns .Death rates are higher for males than females.The higher death rates for males throughout life maybe due to sex-linked inheritance. differences in hormonal balance.In utero and neonatal death rates are also higher for males .

Women have more episodes of illness and more physician contacts than men have .Rate of attempted suicide is higher in women but completed suicides are more common in men .SEX .Toxic shock syndrome .The higher mortality rate for men are not paralleled by higher rates of illness .

That women seek medical care more freely and perhaps at an earlier age of disease 2).SEX Possible explanations for the relatively high morbidity and low mortality in women: 1). That the same disease will tend to have less lethal course in women than in men .

TB.ETHNIC GROUP & RACE Blacks have higher rates of deaths caused by CHVD. CVA. leukemia and atherosclerotic disease Many differences in rates of diseases and death reflect at least in part. in lifestyle and in the extent and quality of medical care . SY Whites have higher rates of death from suicide. differences in various environmental exposures.

SOCIAL CLASS  Difference in wealth. prestige: difference in access to medical care and facilities  Poverty affects utilization of medical services  More common cases of mental illness in lower strata . power.

cold. chemicals. changes in atmosphere). social and psychological climate of the job or workplace . asbestos (lung cancer). aniline dyes (bladder cancer)  Injury. trauma. stress in work  Silica (pulmonary fibrosis).OCCUPATION  This influence may occur thru a variety of exposures – unfavorable physical conditions (heat. noise.

childbearing and lactation . marital status may also be related to health through differences in sexual exposure. pregnancy.MARITAL STATUS  Marital status is associated with level of mortality for both sexes  Psychological and physical support from the spouse  For women.

higher childhood mortality.FAMILY VARIABLES  Family size: larger families – especially if they are poor. neonatal and infant deaths. and a tendency to poorer intellectual performance  Birth order: first borns tend to be more healthy and better educated . children may be in a disadvantage: higher rates of fetal.

compliance .gastric CA. Type O –doudenal ulcer Environmental exposure Personality traits – medical advice.Personal Variables Maternal age: etiologic importance in congenital malformations Parental deprivation – psychiatric. attempted suicides and accident repeaters Blood type A. TB incidence. psychosomatic disorders.

mottled dental enamel Rural-urban differences Migrants in national and international borders . altitude.PLACE  Frequency of disease can be related to place of     occurrence in terms of areas set off either by natural barriers or by political boundaries Frequency of disease may be related to temperature. mineral content of soil or water supply Lack of iodine. humidity. rainfall.

cases for several years around a census may be combined . years. decades  Cyclic change – refers to recurrent alterations in the frequency of disease  If there are enough cases of a particular disease annually for stable rates.TIME  Disease occurrence is usually expressed on a monthly or annual basis  Secular trends – refers to changes over a long period of time.

Measures of Disease Frequency  Count – the basic measure of disease frequency  Ratio – a measure that shows the relationship between quantities  Proportion – the numerator in the proportion is part of the denominator  Rate – the most common measure .

Measures of Morbidity  Prevalence – the proportion of individuals with the disease during a a given point in time .the probability that a person randomly chosen from the population will have a disease at the time he was examined. Prevalence = no. of existing cases of a disease ----------------------------------------Total population examined .

of new cases of disease ---------------------------------population at risk .Measures of Morbidity  Incidence – refers to the proportion of the population who developed the disease in a given interval time .a measurement of the risk of developing the disease in the population at risk of the disease Cumulative incidence – no.the numerator is the count of new cases of disease in the population .

then there would be a greater number of existing (prevalent) cases .Relationship of Incidence and Prevalence  The higher the number of new (incident) cases.

Common Vehicle Epidemic 2.Study of Epidemics  Two Types of Epidemics: 1. Propagated or Progressive Type .

Multiple exposure .Common Vehicle Type of Epidemic  Single exposure. single source or point epidemic  It indicates simultaneous exposure of the population to a common source Example: food or chemical poisoning .Water-supply epidemic (Dysentery) .

Vector reservoir . Person to person spread b). propagated by: a).Propagated or Progressive Type of Epidemic  Also called contact epidemic. Arthropod c).

Characteristics of Epidemic
1). Type of onset or manner of onset a). Sudden, abrupt or explosive – time factor is the period of incubation b). Insidious or gradual – most cases start after the incubation period 2). Types of infection a). Mass infection – more of primary cases b). Progressive infection – more of secondary cases

Types of Epidemic Curves
1). Classical Epidemic Curve –short ascending and descending limbs - picture of common source - rapid transmission due to big dose of organism - longer descending limb is due to the development of secondary cases - more deaths on the ascending limb because of heavier dose of the organism and less resistance

Classical Epidemic Curve

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DHF) .Indicates that the transmission is more complex and the disease has a longer incubation period . insect-borne diseases (malaria.Person to person spread.Long ascending and short descending limb .Inverted Epidemic Curve .

Inverted Epidemic Curve .

The spread is rapid and the transmission is simple so there is rapid elimination of susceptible .Rapid ascending and rapid descending limb .Measles and poliomyelitis .Bell-shaped Epidemic Curve .

Bell-shaped Curve .

Compare the incidence of the disease with its usual incidence in the community 1.define clearly the nature and extent of the problem a). Verify the diagnosis through clinical signs and symptoms of the disease aided by laboratory examinations b). Verify whether epidemic exists.Investigation of Epidemics DEFINITION OF THE PROBLEM . .

Investigation of Epidemics 2. Orient as to place. socioeconomic conditions. Orient as to the person’s characteristics (age. etc. the chronologic order of the disease (epidemic curve) b). occupation.) . sex. determine geographic distribution of cases c). Orient as to time. APPRAISAL OF EXISTING INFORMATION a).

Investigation of Epidemics 3.1. Common Vehicle – single exposure multiple or continuous exposure 3. FORMULATE TENTATIVE HYPOTHESIS What could be the cause/ causes? Classify according to mode of transmission: 3. Propagated – person to person arthropod vector reservoir .2.

mode of transmission and all features of the epidemic which require explanations . TESTING THE HYPOTHESIS a). test various hypotheses e). Search for additional information c). common source or vehicle d). Formulate conclusions as to source. Epidemiological investigation of all cases or representative sample b).Investigation of Epidemics 4. Analyze detailed data – attack rates.

CONCLUSIONS & PRACTICAL APPLICATIONS .conclusions are based on pertinent evidence to control present outbreak and prevent future similar epidemics .evaluate the results in terms of local situations .reports should be simple. correct interpretation and rational explanation .Investigation of Epidemics 5.collection of data must be made in a scientific manner which requires exact observation. clear and honest .

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