EPIDEMIOLOGICAL APPROACH

AND EPIDEMIOLOGICAL
METHODS

PRESENTED BY
HOINEITING REBECCA HAOKIP
MSC NURSING 1ST YEAR
CONTENT
 History of epidemiology
 Definition of epidemiology.
 Aims of epidemiology
 the epidemiological triad
 Epidemiological Approach
 Epidemiological methods
 Applications and uses of epidemiology
 References.
 Research articles.
“I keep six honest serving men; they taught
me all I know.
Their names are what,why,when,how,where
and who.’’
HISTORY OF EPIDEMIOLOGY
 Epidemiology began with Adam and eve, both trying to
investigate the qualities of the forbidden fruit.
Epidemiology is derived from the word epidemic epi-
among; demos-people; logos-study.
 The history of epidemiology has its origin in the idea, goes
back to (400BC) Hippocrates through John Graunt (1662),
William Farr, John Snow and others that environmental
factors can influences the occurrences of diseases instead
of supernatural viewpoint of diseases.
 John Graunt analysis and published the mortality data in
1662.He was the first quantify pattern of death, birth and
diseases occurrences. No one built upon Graunt’s work until
1800’s. when William Farr began to systematically collect and
analyse the Britain’s mortality statistics. Farr considered as the
father of vital statistics and diseases classifications.
There are some important achievements in epidemiology they are;
 John Snow and cholera epidemic in London in 1848-1854.
 Framingham heart study started in 1950 in Massachusetts, USA and
still continuing to identify the factors leading to the development of
the coronary heart diseases
 Smoking and lung cancer by Doll and Hill in 1964.
 Polio Salk vaccine field trial in 1954 to study the protective efficacy
of vaccine in a million school children.
 Methyl Mercury poisoning 1950s in Minamata
DEFINITION OF EPIDEMIOLOGY

Epidemiology has been defined by John M. Last in 1988 as:

 “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”.
COMPONENTS OF DEFINITION OF EPIDEMIOLOGY

1.Disease frequency: measurement of frequency of disease,

disability or death, and summarizing this information in the form
of rates and ratios (eg. prevalence rate, incidence rate, death rate,
etc. Thus basic measures of frequency is a rate or ratio.

It is also concern with measurement of health related events and

states in the community which include disease, disability,
physiological conditions and different states of health.
2.Population: It includes both human and animal populations.
Epidemiology is now extensively used for the study of
diseases in animals

3.Distribution: It refers to distribution of the event in relation

to time, place and person. The description of such distribution
is known as descriptive epidemiology.
CONT.DEFINITION

4.Determinants: these refer to the etiological or risk factor

related to a particular disease. When these factors are studied and
analyzed along with information from other disciplines (such as
genetics, biochemistry, microbiology, immunology etc. The field
is known as analytical epidemiology
AIMS OF EPIDEMIOLOGY:

According to the International Epidemiological Association

(IEA) Epidemiology has three main aims.

 To describe the distribution and magnitude of health and

disease problems in human populations.

 To identify etiological factors(risk factors) in the

pathogenesis of diseases.
CONT.AIMS OF EPIDEMIOLOGY

 To provide the data essential to the planning, implementation

and evaluation of services for the prevention, control and
treatment of diseases and to the setting up of priorities among
those services.
THE EPIDEMIOLOGICAL TRIAD
AGENT

 The first link in the chain of disease transmission is a disease agent.

 The disease agent is defined as a substance, living or non living or

a force, tangible or intangible, the excessive presence or relative
lack of which may initiate or perpetuate a disease process.

 A disease may have a single agent, but more factors are responsible
for disease transmission.
EPIDEMIOLOGICAL APPROACH
 The epidemiological investigation to health problems involves
the two basic approaches.

a. Asking question

b. Making comparisons

A. ASKING QUESTIONS

The key information can be approached through a series of

questions
CONT.
Related to health events
 What are the actual and potential health problems its manifestations and
characteristics?
 Who are affected, with reference to age, sex, social class………?
 Where are they occur in terms of place?
 Which populations are increased at risk?
 When does it happen in terms of day, month, season etc?…
 Why does it happen in terms of contributing or causative factors?
 Which problems have declined?
 Which problems are increasing or have the risk to increase?
CONT.

Related to health action

 What can be done to reduce the problem and its consequences?
 How can it be prevented in the future?
 What action should be taken by the community to prevent and manage the problem?
 Action taken by the health services?
 Action taken by other sectors?
 Where and for whom these activities carried out?
 What resources are required in future?
 How are the activities to be organized?
 What difficulties may arise, and how it has to overcome?
CONT.

 B. MAKING COMPARISONS: This approach is to make

comparisons and draw inferences.
 Comparison may be made
 between different population at a given time eg. Rural with
urban population
 between sub group of population eg. Male with female
population
 between various periods of observation eg. Different seasons
EPIDEMIOLOGICAL METHODS
EPIDEMIOLOGICAL METHODS
It can be classified as follows:
1.OBSERVATIONAL STUDIES:
a) Descriptive studies
b) Analytical studies
 ecological or correlational (with population as a unit of study)
 cross sectional or prevalence (with individuals as unit of study)
 case control or case reference (with individuals as a unit of study)
 cohort or follow up (with individuals as a unit of study)
2.EXPERIMENTAL STUDIES INTERVENTION STUDIES:
a) Randomized controlled trials or clinical trials (with patients
as a unit of study)

b) Field trials (with healthy people as a unit of study)

c) community trials or community intervention studies (with

communities as unit of study)
DIFFERENCES BETWEEN DESCRIPTIVE AND ANALYTIC
Descriptive
 Used when little is known about the disease
 Rely on pre-existing data
 Who, where, when
 Illustrates potential associations
Analytic
 Used when insight about various aspects of disease is available
 Rely on development of new data
 Why?
 Evaluates the causality of associations
1.OBSERVATIONAL STUDIES: In this study nature is allowed to take its
own course, investigator only measure do not intervene or manipulate any
variable.
a) Descriptive epidemiology:
 they are usually the first phase of an epidemiological investigation.
 These studies are concerned with observing the distribution of disease or
health related characteristics in human populations and identifying the
characteristics with which the disease in question seems to be associated.
 Such studies ask questions like
 When is the disease occurring? -time distribution
 Where it is occurring? -place distribution
 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.describing the disease by

-time, place, person

4.measurement of disease

5.comparing with known indices

6.formulation of an aetiological hypothesis

B) ANALYTICAL EPIDEMIOLOGY:

In analytical studies the subject of interest is the individual within the

population. The object is not to formulate but to test hypothesis.
Nevertheless the although individuals are evaluated in analytical studies,
the inference is not to individuals, but to the population from which they
are selected.

 Analytical studies comprise two distinct types of observational studies:

 a) case control study

 b) cohort study
CONT.
A) CASE CONTROL STUDY: it is often called retrospective studies
are a common first approach to test causal hypothesis.it has three
distinct features,

i)both exposure and outcome have occurred before the start of the study.

ii)the study proceeds backwards from effect to cause.

iii)it uses a control or comparison group to support or refute an

inference
 Basic steps of case control study:

1.selection of case and control

2.matching

3.measurement of exposure

4.analysis and interpretation

ADVANTAGES:

a) relatively easy to carry out

b) rapid and inexpensive

c)require comparatively few subjects

d)suitable to investigate rare disease about which little is

known

e) risk factors can be identified.

CONT.

f) allows the study of several different aetiological factors

g)no attrition problems, because case control studies do not

require follow up of individuals in the future.

h) ethical problems is minimal

DISADVANTAGES:

a) problems of bias relies on memory or past records, the

accuracy of which may be uncertain; validation of information
obtained is difficult.

b) selection of an appropriate control group may be difficult

c)we cannot measure the incidence, and can only estimate the
relative risk.

d)do not distinguish between causes and associated factors

 B)COHORT STUDY: It is another type of analytical
(observational) study which is usually undertaken to obtain
additional evidence to refute or support the existence of an
association between suspected cause and disease.

 Also known as prospective study, longitudinal study, incidence

study, and forward looking study.
CONT.
 The features are as follows:

i)the cohort are identified prior to the appearance of the disease

under investigation.

ii)the study groups, so defined are observed over a period of time

to determine the frequency of disease among them

iii)the study proceeds forward from cause to effect.

CONT.

 Types of cohort study: i)prospective cohort study

ii) retrospective cohort study.

iii) combination of retrospective and

prospective study.
 Elements of a cohort study:

1.selection of study subjects

2.obtaining data on exposure

3.selection of comparison groups

4.follow up and

5.Analysis
ADVANTAGES:
a) incidence can be calculated
b) cohort studies provide a direct estimate of relative risk.
c)we can study the association between smoking and lung cancer
DISADVANTAGES:
a)involve a large no.of people
b)it takes a long time to complete (20-30)years or more.
c)administrative problems such as loss of experienced staff,loss of
funding etc.
EXPERIMENTAL EPIDEMIOLOGY

 In 1920,It means the study of epidemics among colonies of

experimental animals such as rats, and mice.

 In modern experimental epidemiology, it is often equated with

RANDOMIZED CONTROLLED TRIALS.

 They may be conducted in animals or human beings.

RCT:

 The basic steps of RCT are:

1.drawing up a protocol

2.selecting reference and experimental populations.

3.randomization

4.follow up

5.assessment of outcome.
APPLICATION AND USES OF EPIDEMIOLOGY
1.to study historically the rise and fall of disease in the population

2.community diagnosis

3.planning and evaluation

4.evaluation of individual risk and chances.

5.syndrome identification

6.completing the natural history of disease.

7.searching the cause and risk factors

REFERENCES:

1.K. Park “. Park textbook of preventive and social medicine. banarsidas Bhanot
publishers.21st edition.2011
2.Mahajan and Gupta.textbook of preventive and social medicine, revised by
Rabindranath Roy &indranil saha. jaypee publications.4th edition.2013
3.Esther M. John, Gary G. Schwartz, Darlene
M. Dreon and Jocelyn Koo.Vitamin D and Breast Cancer Risk: The NHANES
I Epidemiologic Follow-up Study, 1971–1975 to 1992 published in May 2
 RESEARCH ARTICLES
1.Esther M. John, Gary G. Schwartz, Darlene M. Dreon and Jocelyn KooVitamin D and
Breast Cancer Risk: The NHANES I Epidemiologic Follow-up Study, 1971–1975 to
1992A study was conducted from the data of the first National Health and Nutrition
Examination Survey Epidemiologic Follow-up Study to test the hypothesis that vitamin D
from sunlight exposure, diet, and supplements reduces the risk of breast cancer. We
identified 190 women with incident breast cancer from a cohort of 5009 white women who
completed the dermatological examination and 24-h dietary recall conducted from 1971–
1974 and who were followed up to 1992. Using Cox proportional hazards regression, we
estimated relative risks (RRs) for breast cancer and 95% confidence intervals, adjusting for
age, education, age at menarche, age at menopause, body mass index, alcohol
consumption, and physical activity.
CONT.

 Several measures of sunlight exposure and dietary vitamin D intake were associated
with reduced risk of breast cancer, with RRs ranging from 0.67–0.85. The associations
with vitamin D exposures, however, varied by region of residence. The risk reductions
were highest for women who lived in United States regions of high solar radiation,
with RRs ranging from 0.35–0.75. No reductions in risk were found for women who
lived in regions of low solar radiation. Although limited by the relatively small size of
the case population, the protective effects of vitamin D observed in this prospective
study are consistent for several independent measures of vitamin D. These data
support the hypothesis that sunlight and dietary vitamin D reduce the risk of breast
cancer
CONT.

2.helen egger M.D.M.R.C.Psych.The Epidemiology of Child and Adolescent

Psychiatric Disorders. To review recent progress in child and adolescent psychiatric
epidemiology in the area of prevalence and burden. Methods for assessing the
prevalence and community burden of child and adolescent psychiatric disorders have
improved dramatically in the past decade. There are now available a broad range of
interviews that generate DSM and ICD diagnoses with good reliability and validity.
Clinicians and researchers can choose among interview styles (respondent based,
interviewer based, best estimate) and methods of data collection (paper and pencil,
computer assisted, interviewer or self-completion) that best meet their needs. Work is
also in progress to develop brief screens to identify children in need of more detailed
assessment, for use by teachers, paediatricians, and other professionals..
CONT.

 The median prevalence estimate of functionally impairing child and adolescent

psychiatric disorders is 12%, although the range of estimates is wide. Disorders that
often appear first in childhood or adolescence are among those ranked highest in the
World Health Organization's estimates of the global burden of disease. There is
mounting evidence that many, if not most, lifetime psychiatric disorders will first
appear in childhood or adolescence. Methods are now available to monitor youths and
to make early intervention feasible.