Mekelle University

College of Health Sciences

Department of Public Health

Introduction to Epidemiology

Gebretsadik Berhe (PhD, Associate Professor)

2014

Gebretsadik Berhe
 Unit 1 Learning Objectives

1. Distinguish between the concepts of disease and health.

2. Define and understand the uses of epidemiology.

3. Be familiar with the definition and history of epidemiology.

4. Understand basic assumption and principles of epidemiology.

6. Distinguish between epidemiology and clinical medicine.

Gebretsadik Berhe
 Epidemiology Textbooks
• Rothman KJ. Epidemiology, an introduction.
Oxford University Press. 2002
• Szklo M, Nieto FJ. Epidemiology, beyond the
basics. Jones and Barlett. 2007
• Henekkens.C: Epidemiology in Medicine
• Ahrens.W, Pigeot.I: Handbook of Epidemiology

Gebretsadik Berhe
 Chapter 1- Introduction to Epidemiology

• Definition of disease, illness, sickness

• Definition of epidemiology

• History of epidemiology

• Basic assumptions,

• Principles and Concepts in epidemiology

Gebretsadik Berhe
 DEFINITIONS OF DISEASE

Thus, M.W. Susser has suggested that they be

used as follows:

- Disease is a physiological/psychological
dysfunction.

- Illness is a subjective state of the person who

feels aware of not being well.

- Sickness is a state of social dysfunction, i.e., a

role that the individual assumes when ill. (1995)
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 Definition of Epidemiology

• The classical definition of Greek origin:

Greek: EPI – Upon

DEMOS – People

LOGOS - Study of, Body of Knowledge

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 Simple Old Definitions

Oxford English Dictionary

The branch of medical science which treats epidemics.

Kuller LH: American J of Epidemiology 1991;134:1051

Epidemiology is the study of "epidemics" and their
prevention.

Anderson G. In: Rothman KJ: Modern Epidemiology

The study of the occurrence of illness.

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 Comprehensive Modern Definition

What is Epidemiology?

• The study of the distribution and determinants of

disease frequency in human populations. (1970)

• 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. (1988)

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 Comprehensive Modern Definition …
• This definition of epidemiology includes several terms which
reflect some of the important principles of the discipline.

• Distribution - Epidemiology is concerned with the frequency and

pattern of health events in a population.

• Frequency is the number of occurrences of a health event in a

population within a given time period and is measured by rates
and risks of health events in a population.

• Pattern refers to the occurrence of health-related events by time,

place, and personal characteristics.

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 Frequency

 Involves quantification of existence or occurrence of disease

Number and proportion of people with the outcome of

interest (Disease)
Number and proportion of exposed group

 Such data are prerequisite for any systemic investigation

of patterns of disease occurrence in human
population.

 Epidemiology is quantitative science

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 Person

• Who is affected: age, sex, occupation, SES, etc.

• If aim is to explain differences, comparison or for

in observed rates, it is important to standardize
for age, sex, etc., which can confound association.

• However, if aim is to assess burden or plan

services, important not to standardize: do
not remove the observed differences.

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 Place
• Place characteristics include geographic variation, urban-
rural differences, and location of worksites or schools.
• Maps –(Spot and area)
• Spot-maps: Plot location of each case of a disease,
usually by residence or workplace
• Traditionally used to investigate outbreaks of disease.

• Density of spots can be related to density of population

or workplaces.
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Example of spot map John Snow’s Cholera Map

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 Choropleth (Area) Maps

• Shaded maps for plotting rates

• The Choropleth map is based on predefined
areal units, such as states, countries, census, etc
• Can summarize huge amounts of data and very
appealing to decision-makers.
• Large, thinly populated areas can dominate map,
creating false impressions.

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 Clusters

• Groupings of cases of a disease that occur

closer together in space or time (or both) than
expected by chance alone.
• May signal existence of an unsuspected
hazardous exposure.

• Hard to evaluate their probability, since they

have already occurred (post hoc hypotheses)
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 Time
• Time characteristics include annual occurrence,
seasonal occurrence, and daily or even hourly
occurrence during an epidemic.

• Best-known examples are epidemic curves, which

can help to distinguish point-source from or
propagated outbreaks.

• Statisticians sometimes fit various functions to

observed curves.
Gebretsadik Berhe
 Comprehensive Modern Definition …
• Determinants of a disease (Risk factors)
• Identifies factors associated with the disease occurrence.

• Derived from the first two, since knowledge of frequency

and distribution is important to test hypothesis.

– Answers why and how?

– How  mode of transmission
– Why casual link (Genetic Vs environmental)
(Social Vs Cultural)

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 Comprehensive Modern Definition …

• Health-related states or events :

– endemic communicable diseases and non-communicable
infectious diseases.
– More recently, epidemiologic methods have been applied to
chronic diseases, injuries, birth defects, maternal-child health,
occupational health, and environmental health.
– Now, even behaviors related to health and well-being (amount
of exercise, seat-belt use, etc.) are recognized as valid subjects
for applying epidemiologic methods.
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 Comprehensive Modern Definition …

• Specified populations - epidemiologists are concerned

with the collective health of the people in a community
or other area.

• Application - Epidemiology is more than “the study of.”

As a discipline within public health, epidemiology
provides data for directing public health action.

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 History of Epidemiology
• Epidemiology originates from Hippocrates’ observation
more than 2000 years ago that environmental factors
influence the occurrence of disease.

• However, it was not until the nineteenth century that

the distribution of disease in specific human population
groups was measured to any large extent.

• This work marked not only the formal beginnings of

epidemiology but also some of its most spectacular
achievements.
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 History of …

• John Snow (1813-1858):

• The father of epidemiology – proposed the

Waterborne Theory to postulate why people were
getting sick from a specific well in central London.

• John Snow controlled cholera epidemic 44 years

before vibrio was identified.

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Southwark and Vauxhall (S & V) and the Lambeth private companies were supplying
drinking water in London during the nineteenth century.

Original map by Dr. John Snow showing the clusters of cholera cases in
the London epidemic of 1854 Gebretsadik Berhe
 History of Epidemiology …

 John Graunt - In 1662: began to count (births, deaths,

men, women), designed the first life table (pct of
residents surviving at a certain age.)

 William Farr, 1839 : Established vital statistics system as

a source for health information and introduced use of
comparison groups in epidemiology.

 Lindy – In 1747 conducted a study of treatment of

scurvy – one of the first experimental study.
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 History of Epidemiology …

Case-control studies:

Doll & Hill. Smoking and carcinoma of the lung: Preliminary report.
[Br. Med. J. 2:739, 1950]

Doll and Hill in 1950 investigated the relationship between cigarette

smoking and lung cancer.
Cohort Studies:

The Framingham Heart Study. 10,000 residents gave baseline

information. Follow-up is now 50 years. [Annals New York
Academy of Sciences 107:539;1963]
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 Historical Roots of Epidemiology

• Ancient Times: Hippocrates (460 to 375 BC)

• Middle Ages: 1348 - Plague (“Black Death”)

• 18th century: Florence Nightingale (1820–1910)

• 19th century: Modern epidemiology

– Causal thinking

– Sanitary statistics
– Infectious-disease epidemiology

– Chronic-disease epidemiology
• Current: Eco-epidemiologyGebretsadik Berhe
Development of modern epidemiology

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 Purpose of Epidemiology

• First, to identify the etiology or the cause of a disease and the

risk factors (factors that increase a person's risk for a disease).

• Second, to determine the extent of disease found in the

community. What is the burden of disease in the community?

• Third, to study the natural history and prognosis of disease.

• Fourth, to evaluate both existing and new preventive and

therapeutic measures and modes of health care delivery.

• Fifth, to provide the foundation for developing public policy and

making regulatory decisions relating to environmental problems.

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 Fundamental assumptions of epidemiology

1. Non-random distribution of diseases; i.e. disease

occurrence in a population is not random or by chance

2. Human disease has causal and protective factors that can

be identified through systematic investigation of different
population or subgroups of individuals within population in
different places or at different times.

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 Scope of Epidemiology

• A focus of an epidemiological study is the population defined in

geographical or other terms; for example, a specific group of
hospital patients or factory workers could be the unit of study.
• A common population used in epidemiology is one selected from
a specific area or country at a specific time.
• This forms the base for defining subgroups with respect to sex,
age group or ethnicity.
• The structures of populations vary between geographical areas
and time periods.
• Epidemiological analyses must take such variation into account.

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 The main epidemiological theories and principles

• Disease in populations is more than the sum of the disease in individuals.

• Populations differ in their disease experience.

• Disease experiences within populations differ in subgroups of the
population.
• Disease variations can be described and their causes explored by
assessing whether exposure variables are associated with disease
patterns.
• Knowledge about health and disease in human populations can be
applied to individuals and vice versa.
• Health policies and plans, and clinical care can be enriched by
understanding of disease patterns in populations.
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 Types of Epidemiology

1. Descriptive epidemiology
1.1. Distribution
 Frequency
 Pattern

2. Analytic epidemiology
2.1. Determinants of disease and…

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 Descriptive Epidemiology

• Describes the amount and distribution of health

problems in relation to person, place, time.

• Not intended to find causes.

• Indices of person:
• Age, race, marital status, occupation

• Sex (female Vs Male)

• Life style such as the consumption of various foods

and/or medication use, socioeconomic status
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 Descriptive Epidemiology
• Characteristics of place

• Geographical distribution of disease (low Vs high land,

U/R)
• Variation among countries and within a country

• Time characteristics

• Day Vs night

• Seasonal variation

• Long term variation (today Vs 5 or 10 years before or

after)
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 Descriptive Epidemiology

• Descriptive data provides valuable information to

enable health care providers and administrators.
– Fairly easy and quick to use and understand

– to allocate resources efficiently

– to plan effective prevention or education

programs

– Provided the first important clues about possible

determinants of a disease (formulation of
hypothesis).
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 Descriptive Epidemiology

• Basic to public health

– Surveillance, identifying outbreaks

– Measuring health

• Basic to health policy

– Measuring health
– Assessing needs

– Identification of priorities

– Health planning and evaluation

• Can be hypothesis-generating
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 Analytic epidemiology

• Involves explicit comparison of groups of individuals to

identify determinants of health and disease.
• Exposed Vs Non-exposed

• Diseased Vs health individuals

• Determinants of a disease
– How:- Mechanism for spread- mode of transmission
– Why:- Casual link – Genetic Vs Environment
• Social Vs cultural condition

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 Epidemiological sub-disciplines
• Various epidemiological sub-disciplines are now recognized.

• These generally reflect different areas of interest, rather than

fundamentally different techniques.

– Clinical epidemiology
– Social Epidemiology

– Computational epidemiology
– Genetic epidemiology
– Field epidemiology

– Molecular epidemiology
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Individual vs. population perspectives’ approach to health
problems

• Epidemiology emphasizes the population perspective and

populations are dynamic, diverse, heterogenous - demographic
characteristics have major impact on health.

• Individual perspective - diagnosis (presenting complaint, history,

physical exam, lab tests), treatment derived from biomedical
understanding of etiology.

• Population perspective - “community diagnosis” (surveillance,

descriptive data, surveys and analytic studies), intervention via
health care system, policy, ..

Gebretsadik Berhe
Gebretsadik Berhe
 Assignment

• Is epidemiology a science, an art or both?

• Why is epidemiology the basic science of public

health?

Gebretsadik Berhe