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EPIDEMIOLOGY

DEFINITION
EPIDEMIOLOGY :
The study of the distribution and determinants of
health related states (or) Events in specified populations , and the
application of this study to the control of health problems

-John M.Last (1988)

Concept of disease:
Germ theory of disease:
The germ theory of disease is
generally referred to as a one-to-one relationship or single
cause idea between causal agent and disease.
Disease Agent
Man
Disease

Multifactorial causation:
Pettenkofer of munich (1819- 1901)

Epidemiological triad

Agent

Host

Environment

Web of causation for myocardial infarction:


Changes in lifestyle
Abundance of food
obesity
factor
Hyperlipidemia

stress
Smoking

Emotional disturbances

Lack of exercise

Hypertension
Aging&other

catacholamine and thrombotic tendency


Changes in walls of artery

Coronary atherosclerosis

Coronary occlusion
Myocardial ischemia
Myocardial infarction

NATURAL HISTORY OF DISEASE


PERIOD OF PRE-PATHOGENESIS
Disease
process

PERIOD OF PATHOGENESIS

Before man is involved

The course of the disease in the


man

Hos
t
Environment( bring
agent and host together)

Agent

Death
Defect or chronic
Disability
stage
illness
Signs and symptom
recovery
Tissue and physiological
changes
Agent
multiplication
In the human host
Host re

interaction
Of host and

stimuli
Levels of prevention

Primary prevention

Early
pathogenesis
early
lesions
Secondary
Tertiary
disease convalescence
prevention
prevention

Aims of epidemiology
1.To describe the distribution and magnitude of
health and disease problems in human
populations.
2.To identify aetiological factors (risk factors) in the
pathogenesis of the diseases.
3.To provide the data essential to the planning
,implementation and evaluation of services for the
prevention,control and treatment of disease and to
the setting up of priorities among those services

Uses of Epidemiology
1. To study historically the rise and fall of disease in
the population
2. Community diagnosis
3. Planning and evaluation
4. Evluation of individuals risk and chances
5. Syndrome identification
6. Completing the natural history of disease
7. Searching for causes and risk factors

MEASUREMENTS IN EPIDEMIOLOGY
1.
2.
3.
4.
5.

Measurement of mortality
Measurement of morbidity
Measurement of disability
Measurement of natality
Measurement of the presence, absence (or)distribution of
the characteristics (or)attributes of the disease
6. Measurement of medical needs,health care
facilities,utilization of health services and other health
related events
7. Measurement of demographic variables

TOOLS OF MEASUREMENT
RATE :
The occurrence of some particular events in a
population during a given period of time
Death rate =Number of deaths in one year x 1000
Mid year population
RATIO :
Measure of disease freguency in a ratio .it
expresses a relation in size between two random
guantities

The number of children with scabies at a certain time


------------------------------------------------------------The number of children with malnutrition at a
certain time

PROPORTION
The number of children with scabies at a certain
Time
--------------------------------------------------------------x100
The total number of children in the village at the same
time

Methods of Epidemiology
1.Observational studies
a. Descriptive studies
b. Analytical studies
(i) Ecological or correational , with populations as unit of
study
(ii)cross sectional or prevalence, with individuals as unit
of study
(iii)case control or case reference with individuals as unit
of study

(iv ) Cohort or follow up, with individuals as a unit of study


2. Experimental studies intervention studies
a.Randomized controlled trails or clinical trails, patients as unit
of study
b.Field trails or community intervention studies, with healthy
people as unit of study
c.Community trails , with communities as unit of study

Descriptive Epidemiology
a. When is the disease occuring ?

- Time distribution

b. Where is the disease occuring ?

- Place distribution

c. Who is getting the disease ?

- person distribution

Procedures in Descriptive studies


1. Defining the population to be studied
2. Defining the disease under study
3. Describe the disease by
a) Time
b) Place
c) Person
4. Measurement of disease
5. Comparing with known indices
6. Formulation of an aetiological hypothesis

Description of disease in terms of distribution:


Time distribution
Weekly
Monthly
Year
Season
duration

Short term
fluctuation

Place distribution
International
variation
National variation
Rural-urban
variation
Local distribution
Periodic
fluctuation

Common source
epidemic
Single
exposure

Person distribution
Age,sex,occupation,
Marital status,habits,social
class,
Stress,migration.behavior

Repeated
exposure

Season
al trend

Cyclic
trend

Propagated
epidemic

Long term
fluctuation

Slow
epidemic

Types of Epidemics
Three major types of epidemics
A. Common sourse epidemics
a. Single exposure or point sourse epidemics
b. Continuous or multiple exposure epidemics.

B. Propagated epidemics
a.
b.
c.

Person to person
Arthropod vector
Animal reservoir

C. Slow (modern) epidemics

Analytical Epidemiology
CASE CONTROL STUDY
Factor
Present
(or)
Absent

Cases with
Individual
particular disease
Controls

Individual without
particular disease

PROSPECTIVE ( cohort) STUDY


Presence or
absence of
particular
disease

Individual exposed to
particular factor
Individual unexposed to
particular factor
TIME

CASE CONTROL STUDY


The case control method has three distinct features:
a. Both exposure and outcome have occurred before the start of the
study
b. The study proceeds backwards from effect to cause and
c. It uses a control or comparison groups to support or refute an
inference.
BASIC STEPS
1.
2.
3.
4.

Selection of cases and controls


Matching
Measurement of exposure
Analysis and interpretation

Elements of a Cohort study


The elements of a cohort study are:
1.
2.
3.
4.
5.

Selection of study subjects


Obtaining data on exposure
Selection of comparison groups
Follow up
Analysis

Relative Risk
Incidence of disease (or death) among exposed
RR = ________________________________
Incidence of disease (or death) among non - exposed

Attributable Risk

Incidence of disease rate among exposed


minus incidence of disease rate among non -exposed
= -----------------------------------------------------------------------x 100
Incidence rate among exposed

Experimental Epidemiology
Two types are:
1. Randomized controlled trails
2. Non- randomized trails

Randomized controlled trails


The basic steps in conducting a RCT include the following:
1.
2.
3.
4.
5.
6.

Drawing up a protocol
Selecting reference and experimental population
Randomization
Manipulation or intervention
Follow up
Assessment of outcome.

DESIGN OF RANDOMIZED CONTROLLED TRIAL


Select suitable population
(Reference or target population)
Select suitable Sample
(Experimental or study population)

Those not
eligible

Make necessary exclusions


Those who do
not wish to
give consent

RANDOMIZE
Experimental
group

Control group
Manipulation & follow -up
Assessment

MEASUREMENT OF MORBIDITY :

INCIDENCE RATE
PREVALENCE RATE

INCIDENCE RATE:

Incidence rate refers to frequency of new cases of specific


disease during a given period in a defined population(population at risk )
during that period .
= No.of new cases of specific disease during a given time period
Population at risk during that period

x1000

Prevalence rate:
Point prevalence
Period prevalence
Point prevalence :
It is the number of all current new and old
cases of a disease at one point of time in relation to a defined
population
Number of current new and old cases of a specified disease existing at a
given point of time
x100

Estimated population at the same point of time

Period prevalence:
It is the frequency of all current new & old
cases during a defined period of time in relation to a defined
population .
= No.of current new& old cases of a specified disease during a given period of
time interval
x 100
Estimated mid- interval population at risk

MEASUREMENT OF MORTALITY:

1.Crude Death Rate:


It measures the frequency of deaths
occuring from various causes in a given population during a
specified period .
CDR = No.of deaths during the year
x 1000
Mid year population
2.Specific Death Rates:
It can be a. Disease specific b. Group specific
a. Disease specific :
=No.of deaths from cancer during a calender year x1000
Mid year population

Age
Group specific:
Sex
=No.of deaths among females
during a calender year x1000

Mid year population of females


Specific death rate in a age group of 15-45 years.
=No.of deaths of persons aged 15-45 years during a calender year
x1000
Mid year population of persons aged 15- 45 years

Dynamics of disease transmission:

Source
Or
reservoir

Modes
Of
Mo
transmissi
on

Susceptible
host

Source: The person,animal,object or substance from which an


infectious agent passes or is disseminated to the host.
Reservoir : Any person,animal,arthropod,plant,soil or substance
in which an infectious agent lives and multiplies,on which it
depends primarily for survival ,and where it reproduces itself
in such manner that it can be transmitted to a susceptible host .
Source or reservoir
Human reservoir
Animal reservoir
Reservoir in non- living things

Human reservoir

cases

Clinical cases

carriers

Sub clinical
cases
latent

cases - A person in the population or study group identified as


having the particular disease,health disorder or condition under
investigation
1.Clinical case:Mild or moderate,typical or atypical ,severe or fatal
2.Subclinical cases: Inapparent, covert,missed,abortive
3.Latent cases : Have infectious agent,dont show symptoms,the
infectious agent lies dormant.

Investigator:
Primary case- It is the first case of a communicable disease
introduced into the population being studied.
Secondary case Those cases which develop from the contact
with primary case .
Index case This term refers to first case which has come in
attention of investigator.

Carriers - An infected person or animal that


harbours a specific infectious agent in the
absence of discernible clinical disease and
serves as a potential source of infection for
others.
Carriers may be classified as below ,
1. Incubatory Those who shed the infectious
agent during the incubation period of disease
Ex : measles,mumps,polio

2.Convalescent carriers To shed the disease agent during the


period of convalescence.
Ex: Typhoid fever ,cholera,diptheria
3.Healthy carriers A person whose infection remains
subclinical may or may not be a carrier.
Duration :
Temporary carriers Those who shed the infectious agent for
short periods of time .
Chronic carriers - A chronic carrier is one who excretes the
infectious agent for indefinite periods .
Portal of Exit :
Urinary
Intestinal
Respiratory
Others

Mode of transmission:
1.Direct transmission:
Direct contact
Droplet infection
Contact with soil
Inoculation into skin or mucosa
Transplacental(vertical )
2.Indirect transmission :
Vehicle borne
Mechanical
Vector borne
Air borne

biological
droplet
dust

Fomite borne
Unclean hands and fingers
1.Direct transmission:
Direct contact:
skin to skin,mucosa to mucosa or mucosa to skin of the
same person or another.
Droplet infection:
Direct projection of spray of saliva or naso
pharyngeal secretions
Contact with soil:Ex: hook worm infestations,tetanus etc
Inoculation into skin or mucosa:
ex: rabies virus by dog bite,heptitis B by
contaminated needles

Transplacental transmission:
Ex:TORCH(Toxoplasma gondi,rubella virus, cyto megalo virus,
herpes virus)
2.Indirect transmission:( 5 Fs flies,fingers,fomites,food,fluid)
a.Vehicle born
Transmission of infectious agent
through water,food,raw
vegetables,fruits,milk,ice,blood,serum
b.Vector born
(Arthropod, vertebrate, non-vertebrate)
Invertebrate type: (Arthropod)
Flies and mosquitoes,fleas,cockroaches,sucking
lice,bugs,ticks,mites,cyclops.)
vertebrate type:Mice,rodents,bats

By transmission chain:
A . Man and a non-vertebrate host:
Man-arthropod-man (malaria)
Man-snail-man (schistosomiasis)
B . Man, vertebrate host ,and a non vertebrate host:
Mammal arthropod man(plaque)
Bird arthropod man(encephalitis)
c. Man and 2 intermediate hosts :
Man cyclops fish Man (fish tape worm)
By methods in which vectors transmit agent:
Biting, regurgitation, scratching in of infective faeces,
contamination of host with body fluids of vectors

Airborne :
Droplet,dust(1 -10 micron range)
Fomite borne :other than water or food (soiled
clothes,towels,linen,glasses etc)
Unclean hands and fingers
III.The vector born transmission on the basis of involvement of
vector and propagation of parasites,is of 2 types,
Mechanical transmission: The infectious agent doesnot develop
or multiply on or within the vector and is transmitted
mechanically by arthropods through soiling of its feet.
Biological transmission: The infectious agent multiply or replicate
or both occur in the vector before transmission.

Biological transmission is classified into 3 types,


Propagative

Cyclo propagative

Cyclodevelopmental

MULTIPLICATION

yes

yes

No

DEVELOPMENT

No

yes

yes

EXAMPLE

Plaque bacilli in rat


flea

Malaria prasites

Microfilaria in
mosquito

CHARACTERISTICS

Epidemiology : Terminologies
1.Infection :
The entry and development or multiplication of an
infectious agent in the body of man or animals .
2.Contamination :
The presence of an infectious agent on a body surface
,also on or in clothes, beddings ,toys , surgicl instruments or
inanimate articles or substances including water, milk ,food.
3.Infestation:
For persons or animals the lodgement ,
,development and reproduction of arthropods on the surface of the
body or in the clothing .
Ex :lice, itch mite

Host :
A person or animal, including birds and arthropods ,that
affords subsistence or lodgement to an infectious agent
under natural conditions .
Obligate host - the only host Ex : man in measles ,typhoid
Definite host or primary - Host in which the parasite attains
maturity or passes its sexual stage .
Intermediate or secondary - Larval or Asexual stage.
Transport host - Carrier
Infectious disease :
A clinically manifest disease of man or
animals resulting from an infection .

Contagious disease :
A disease that is transmitted through
contact.
Ex: Scabies,trachoma
Communicable Disease :
An illness due to a specific infectious
agent or its toxic products capable of being directly or
indirectly transmitted from man to man ,animal to animal or
from the environment( air,dust,soil).
Epidemic:
Epi = upon , demos = people,the unusual occurrence in
a community or region of disease ,specific health related
behaviour or health related events clearly in excess of
expected occurrence.

Endemic :
En = in ,demos = people ,It refers to the constant
presence of a disease or infectious agent within a given
geographic area or population group .
Sporadic :
The word sporadic means scattered about ,the cases
occur irregularly ,haphazardly from time to time ,and
generally infrequently . Ex :polio
Pandemic:
An epidemic usually affecting a large proportion of
the population
Ex : Section of a nation, the entire nation Ex :chleora.

Exotic:
Diseases which are imported into a country in which
they do not other wise occur.
Ex: rabies
Zoonoses :
An infection or infectious disease transmissible
under natural conditions from vertebrate animals to man .
Ex: rabies ,anthrax
Epizootic :
An outbreak(epidemic) of disease in an animal
population .
Ex: Anthrax, JE

Epizootic :
An outbreak (epidemic) of disease in an animal
population .:
Ex: influenza
Epornithic :
An outbreak (epidemic) of disease in a bird
population.
Enzootic :
An endemic occuring in animals
Ex: anthrax
Noso comial Infection:
Nosocomial (hospital acquired )infection is
an infection originating in a patient while in a hospital or
other health care facility.

Opportunistic Infection:
This is infection by an organism that takes the
opportunity provided by a defect in host defence to infect the
host and hence cause disease.
Ex:AIDS
Iatrogenic (physician Induced)disease:
Any untoward or adverse consequence of a
preventive ,diagnostic or therapeutic regimen or procedure
,that causes impairment ,handicap, disability or death resulting
from a physicians professional activity.