EPIDEMIOLOGY

=The study of the frequency, distribution and determinants of disease & other health
related conditions in human population & the application of this study to the promotion of
health & the prevention & control of health problems

TERMINOLOGIES

Population-the entire group of individuals in whom the epidemiology is interested Public

health-the study & practice of managing threats to the health of the community Frequency-

the number of times an event occurs

Distribution-geographical spread of diseases in time & by the type of persons affected

Determinants- factors which show whether or not a person will get the disease Health

related conditions-conditions which directly or indirectly affect or influence

health

Study-surveillance, research, observation or expression Disease-physiological dysfunction

of the body

Health-state of complete physical, mental and social wellbeing of the body and not merely
the absence of the disease

Illness-physically or mentally unwell/state of being unhealthy

USES OF EPIDEMIOLOGY

Community Diagnosis

Monitoring over a period of time the change of health in a community Classification of

diseases

Observation of the natural history of a disease Evaluation of methods of disease control To

plan effective health services

Investigation of an outbreak of a communicable disease

TYPES OF EPIDEMIOLOGY STUDY

Descriptive studies-collect facts on who, where, and when.

-are designed only to describe the existing distribution of variables without regard to causal
or other hypothesis

Cross-sectional studies investigate individuals at a single point in time, thus giving an

estimate of point prevalence
-longitudinal study-measures individual over a period of incidence
Analytical studies-tests hypothesis and examine cause and effect relationship

-designed to examine association or hypothesized causal relationship

-sources of hypothesis include; description study, clinical observation, existing records

-case control studies-compare the characteristics of persons with disease(case)with the

persons without the disease(control)to find out whether the suspected
determinants(cause)occurs more frequently among persons with the disease

-Cohort study/follow up/longitudinal/perspective -compares over a period of time the

characteristics of the study population with controls to find out whether a greater
proportion of those exposed to the determinant develop the disease

CLASSIFICATION OF DISEASES

1. Communicable diseases
2. Natural/deficiency
3. Addictive
4. Toxic Occupational
5. Traumatic Degenerative
6. Mental Social
7. Congenital Hereditary
8. Allergy
9. Neoplastic/carcinogenic
10. Metabolic
11.
12.
13.
14.

DISEASE CAUSATION

-An event, condition, characteristic or combination of these factors which play an

important role in producing disease

TYPES OF CAUSES
1. Primary causes-factors which are necessary for a disease to
occur
2. Risk factors, contributing predisposing, aggravating factors-factors which
associated
arewith an increased occurrence of a disease

AETIOLOGY OF A DISEASE

-Is the sum total of all factors (primary causes and risk factors) which contribute to the
occurrence of a disease ie the epidemiologic triangle

1.Agent-a factor whose presence or absence, excess or deficit is necessary for the disease
to occur

2.Environment-all external factors other than the agent that influence health e.g. social,
physical and biological
-Social factors-education, unemployment, culture regarding diet,
-physical factors-climate, terrain and pollution

3. Biological factors-vectors, humans, plants serving as reservoirs of infection

DETERMINANTS OF DISEASE
1.Agent determinants
-Infectivity & invasiveness
-Pathogenicity & virulence
-Antigenicity
-Reservoirs
-resistance of the host
-Susceptibility of the host
2.Host factors
-Age
_Gender
-Genetic composition
-Immunity
-Socio-economic status
-Behavior Occupation
-Education status
3.Environment factors
-Hydrosphere
-Lithosphere
-Atmosphere

NATURAL HISTORY OF DISEASE

-The progression of disease process in an individual over time in the absence of
intervention

STAGES IN THE NATURAL HISTORY OF A DISEASE

I.Susceptibility-disease has not yet developed, but the ground work has been laid by the
presence of factors that favour its occurrence
II.. Pre-symptomatic-no manifestations of the disease but pathologic changes have started to
occur in the body. Eg on of antibodies against HIV in an apparently healthy person
III.Clinical-the person has developed signs and symptoms of the disease
IV.Disability or death-some diseases run their course and then resolve completely either
spontaneously or by treatment. In others disease may result in residual defect, disability or
death eg trachoma may cause blindness

LEVELS OF DISEASE PREVENTION

-Disease prevention-interruption or slowing down the progression of disease

I. Primary prevention
-promoting health, preventing exposure and preventing disease. The process of disease is
kept from becoming established by eliminating causes of disease or or increasing resistance
to disease.
-Health promotion- consists of general nonspecific interventions enhance health and the
body’s ability to resist disease
-Prevention of exposure-avoidance of factors which may cause disease if an individual is
exposed to them
-Prevention of diseases-prevention of disease development after the individual has become
exposed to the disease causing factors
II.Secondary prevention
-aims to stop or slow the progression of disease so as to prevent or limit permanent damage.
It is achieved through early detection and treatment
III.Tertiary prevention
-is implemented due to failure of both primary and secondary preventions and is aimed
towards people with permanent damage or disability to prevent further disability or death
and limit the physical,psychological,social and financial impactof disability thereby
improving the quality of life

COMMUNICABLE/INFECTIOUS DISEASES
-An illness due to specific infectious agent that arises through transmission of that agent
from an infected person, animal or reservoir to a susceptible host, either directly or
indirectly through an intermediate plant/animal host, vector or the inanimate environment
COMPONENTS OF THE INFECTIOUS PROCESS/CHAIN OF DISEASE
INFECTION
I.Agent- viral particles and complex multicellular organisms
II.Reservoir-an habitat in which an infectious agent lives, transforms, develops or
multiplies. Eg human, animals, plants or inanimates
III.Portal of exit-the way an infectious agent leaves the reservoir, it includes all body
discharges and secretions eg saliva, mucous etc
IV.Mode of transmission-mechanisms by which agents are conveyed to other susceptible
hosts either directly or indirectly
-Direct transmission-direct contact eg touching, kissing, biting, sexual intercourse and
transplacental
-Indirect transmission-vehicle borne i.e. transmission through indirect contact with
inanimate objects eg bedsheets, towels
-vector borne-anthropod to a host
Types of vectors
-Biological vectors-the agent multiplies in the vector before transmission
-Mechanical vector-the agent is directly ineffective to other hosts, without having to go
through a period of multiplication in the host
V.Portal of entry-the site where infectious agent enters susceptible host
VI.Human host/susceptible host-the final link in the infectious process
-Host resistance at the community level is called hard immunity

HERD IMMUNITY

Herd immunity occurs when a large portion of a community (the herd) becomes immune to
a disease.
The spread of disease from person to person becomes unlikely when herd immunity is
achieved. As a result, the whole community becomes protected — not just those who are
immune.
The resistance of the population to the introduction and spread of an infectious agent, based
on the immunity of a high proportion of individual members of the population, thereby
lessening the likelihood of a person with a disease coming into contact with susceptible.

DESCRIPTIVE EPIDEMIOLOGY

-Describes the frequency and distribution of diseases and other health related conditions by
time, place and time
ANALYTICAL EPIDEMIOLOGY

-Deals with causes and determinants of a disease

VARIABLES IN DESCRIPTIVE EPIDEMIOLOGY

I.Person (WHO)-age (measles affect children), sex (breast cancer affect females), ethnic
group& race (diseases differ in racial or ethnic groups). Other personal variables include
social class, religion, occupation, marital status, environmental exposure

II.Place(WHERE)-the frequency of diseases differs in different places depending on the

natural boundaries
it includes

a) humidity,
b) rainfall,
c) attitude etc

III. Time(WHEN)-occurrence is normally expressed on a monthly or annual

basis
-Some diseases occur periodically or cycles

-Cycles may be annual or have some other periodicity eg malaria

CROSS-SECTIONAL STUDY DESIGN OR SURVEY

Is concerned with the distribution of diseases with respect to time, place and
person.

-It reveals the magnitude of diseases or other health related conditions

STEPS/PROCEDURES IN CONDUCTING SURVEYS

1) Identify the problem
2) Write the objectives of the survey Identify the
3) methods of data collection Recruit and train data
4) collectors
5) Determine the number of people needed in the
6) survey Collect the data
7) Analyse the data Disseminate the findings
8)

ADVANTAGES OF SURVEYS

I. One step /time collection of data Less expensive

II Easy to conduct
. Provide useful information for planning medical services
II Show relative distribution of conditions, diseases, injury, & disability in
I. the population
I
V
.
MEASURES OF MORBIDITY AND MORTALITY
V
Measurement
. of health-collection, compilation, analysis, and interpretation of data on
a) illness(morbidity)
b) death (mortality),
c) disability and
d) utilization of health services

RATIOS, RATES AND PROPORTIONS

Ratio-an expression of the relationship between two numbers in the form of x:y

Proportion-type of ratio in which the numerator is included in the denominator and the result
is expressed as a percentage eg x/y times 100

Rate-a form of proportion that includes time eg

Rate=no of events in a specific period (over) population at risk of these events in a specified
period (times) K () constant

MEASURES OF MORBIDITY

-Quantifies the occurrence of the disease

COMPONENTS

1. Incidence Rate-
the number of new cases of a disease that occur during a specified period of time in a
population at risk for developing the disease

IR=no of new cases of a disease over a period of time (divided by) total population during
the given period (times)
K (constant)

If the incidence rate of a certain disease is high in one area, then the risk of acquiring that
disease by other healthy individuals will be high

=Attack Rate- a type of incidence rate mainly used during epidemics.

AR=no of new cases of a disease reported during an epidemic at a given time (divided by)
total population at risk during that period (times)K

USES OF INCIDENT RATE

-Fundamental tool for aetiological studies

2. Prevalence rate-
measures the number of people in a population who have a disease at a given time

=Point Prevalence Rate-

measures the proportion of a population with a certain condition at a given point in time
PPR=all persons with a specific condition at one point in time (divided by) total
population (times) K

NB-if total population is thousands, let K be 1000, if hundreds, let K be 100 etc

USES OF PREVALENCE RATE

a) Planning health facilities Planning of human
b) resource
c) Monitoring chronic disease control
programs
MEASUREMENTS OF MORTALITY

-Used to measure the occurrence of deaths in a population using different ways

-In getting the denominator/mid/average population, add population at the beginning of

the count to the population count at the end and then divide the result by two eg x+y/2

ANALYTICAL FORMULARS USED IN MORTALITY RATES & RATIOS

1. Crude Death Rate-measure the proportion of population dying every year or the
number of deaths in the community per 1000 population

CDR=total no of deaths reported (divided by) estimated mid interval population (times) K
(1000)

2.Age Specific Mortality Rate-eg infant mortality rate

ASMR=no of deaths in a specific age group (divided by) estimated mid interval
population of the same age (times) K (1000)

3.Sex Specific Mortality Rate-

SSMR=no of death in a specific sex (divided by) estimated mid population of same sex
(times) K (1000)

4.Proportionate Mortality Rate-

PMR=no of deaths from specific cause (divided by) total no of deaths from all
causes(times)K (100) hundred

5.Case Fertility Rate-

CFR=no of deaths from a specific disease (divided by) no of cases of that disease(times)K
(100),
NB-In PMR & CFR the K must be 100(one hundred)

6.Infant Mortality Rate-

IMR=no of deaths under one year (divided by) no of live births reported(times)K-1000

7.Neonatal Mortality Rate-

NMR=no of deaths under 28days reported (divided by) no of live births reported(times)K-
1000

8. Under5 Mortality Rate-

U5MR=no of deaths of 0-4years of age (divided by) midyear population of the same
age(times)K-1000

9. Maternal Mortality Rate-

MMR=no of pregnancy associated deaths of mothers (divided by) no of live births in the
same period(times)K-100,000
SOURCES OF DATA AND DATA COLLECTION METHODS
1. Census-
i.a periodic count or enumeration of population.
ii.It captures-; age, sex, size of the population, mortality, fertility, language,
ethnicity, housing

LIMITATIONS OF CENSUS
I. Conducting census is expensive
II. Carried in intervals of many
years
2. Vital statistics-
All births and deaths occurring nationwide are registered, reported and compiled
centrally

=Characteristics of vital statistics

a) Comprehensive
b) Compulsory by law
c) Continuous
d) Compiled centrally so that it can serve as a source of information

3. Health services records-

health institutions report activities to the ministry of health through the regional health
bureaus
=Advantages
a) Easily obtainable
b) Available at low cost
c) Continuous system of reporting
d) Causes of death and illness available

=Limitations
a) Lack of completeness
b) Lack of representativeness
c) Lack of denominator (catchment area)
d) Lack of uniformity in quality
e) Lack of compliance with reporting
f) Variation of diagnosis
4. Health surveys-
Studies conducted on a representative sample population to obtain more comprehensive
data for monitoring and health status of a population
=Types of surveys
I.Surveys of specific diseases- conducted on each specific disease
II.Surveys on general health status-
studies the general health status of the population
=Advantages of surveys
a)Denominator is not known
b)Data are more uniform in quality
c)More representative
=Limitations
I.Expensive
II.Accuracy depends on the interviewee

=Methods of data collection

a. Observation
 b. Interviews
c. Questionnaires
d. Documentary sources eg clinical records

MEASURES OF RISK

The probability of an event in the active group divided by the probability of the event in
the control group

=RR- relative risk is a measure of how much a particular risk factor (say cigarette
smoking) influence the risk of a specified outcome (say death by age 70)

=Example; RR of 2 associated with a risk factor means that person with that risk factor
have a 2 folds increased risk of having a specified outcome compared to persons
without that risk factor.

=Types of risk studies

1. Cohort study-groups with different exposures are followed over time and
health outcomes
selected are noted

2. Case control study-groups of sick people are compared to well persons to see to
if risk factors
see can be identified that might account for the ill-health

RISK-a likelihood of having an event following exposure to some factors

=TYPES OF RISK
1.Relative Risk-
the probability that a member of an exposed group will develop a disease relative to the
probability that a member of non-exposed group will develop the same disease.

Types of RR

a) Risk ratio (absolute risk)

b) Rate ratio
c) Odds ratio

=Odds Ratio-
measure of association which compares the disease of those exposed to the odds of
disease of the non-exposed group

OR=odds of disease among exposed (divided by) odds of disease among non-exposed.

CASE CONTROL TOTAL

EXPOSED A B A+B
NO EXPOSED C D C+D
TOTAL A+ C B+D A+B +C+D

Example; A group of 20 people went to a hotel. The next day 7 were ill. They suspected it
might be the fish they ate. Construct a 2by2 contingency table and calculate the odds
ratio, 5 ate fish and a total of 8 ate fish.

CASE CONTROL TOTAL

 Exposed 5 3 8
Non exposed 2 10 12
TOTAL 7 13 20

=Advantages of odds ratio

I. Appropriate to analyze between groups from case controls and prevalence

II. data Most appropriate for measuring association for
new diseases

III. It doesn’t require denominator unlike measuring

risk
IV. Appropriate method in estimating the strength of an association between
and outcome
exposure

=Disadvantages

-Measure association that doesn’t infer causation

Epidemics

-The occurrence of a disease in excess of the usual frequency in a given area over a
particular period of time

Types of epidemics

a. Food borne outbreaks

b)Communicable diseases with short incubation period
c)Communicable diseases with long incubation period
d)Toxic substances
e)Common source epidemics-occurs as a result of exposure of a group of susceptible
persons to a common source of a pathogen often at the same time or within a brief time
period
f)Propagated/progressive epidemics- The infectious agent is transferred from one host to
another
g)Mixed epidemics- begins with a single common source of an infectious agent with
subsequent propagated spread

Causes of epidemics

a) Endemic-presence of a disease at more or less stable level

b) Sporadic- an irregular occurrence of a disease
c) Pandemic- an endemic involving several countries affecting a large number of
people

An epidemic can be caused by various factors, including:

a)Virulent pathogens: Certain pathogens can cause severe and contagious diseases that can
spread rapidly.
b)Lack of immunity: If a population has not been previously exposed to a pathogen,
they may be more susceptible to infection and therefore more likely to experience an
epidemic.
c) Modes of transmission: Pathogens can be spread through various means, including
direct contact, respiratory droplets, contaminated food or water, and insect vectors.
d) Environmental factors: Climate, access to clean water and sanitation, and living
conditions can all contribute to the spread of pathogens.
e) Human behavior: Human activities, such as travel, can facilitate the spread of
pathogens, as can cultural practices and access to healthcare.
f) Globalization and urbanization: The movement of people and goods across borders,
as well as the concentration of large populations in urban areas, can contribute to the
spread of epidemics.

Investigation of epidemics

-To determine the specific cause of the outbreak at the earliest time and to take
appropriate measures directed at controlling the epidemics and preventing future
occurrence

Steps in the investigation of epidemics

i. Identify the problem

ii. Prepare for the field work
iii. Confirm the existence of the epidemic
iv. Confirm the diagnosis
v. Identify and count case
vi. Describe the epidemic with respect to person, place and time
vii. Identify the causes of the epidemics
viii.Management of epidemics
ix. Make follow up
x. Report of the investigation

Management of epidemics/measures directed against the reservoir

I. Domestic animal reservoir-immunization, destruction of infected animals

II. Human reservoir-isolation, treatment, quarantine

=Prevention of disease transmission by ingestion-purification of water, pasteurization

of milk, improve housing condition, inspection procedure to ensure safe food

=Prevention of respiratory infections- ventilation of rooms

=Prevention of host susceptibility- immunization, chemoprophylaxis

TERMINOLOGIES

Case-
an individual with a disease under investigation in a case control study
Case control study-
groups of individuals with disease and without the disease are identified and exposures
to risk factors in these groups are compared
Incidence-
the number of individuals who contract diseases in a particular time period usually
expressed as a proportion of those who are susceptible at the start or midpoint of
the period Incident case-
patients who have just been diagnosed
Odds ratio-
the ratio of two odds often taken as an estimate of relative risk in a case control study
Odds-
the ratio of the probabilities of having a disease divided by the probability of not having
the disease
Point prevalence-
the number of individuals with a disease at a particular point in time
Prevalence-
the number of individuals with a disease at a given point in time
Prevalence case-
patients who were diagnosed at some previous time
Proportion-
the ratio of the number of events of interest to the total number of events
Relative risk-
the ratio of two risks, usually the risk of a disease in a group of individuals exposed to
some factors divided by the risk in non-exposed individuals
Probable-
a case with typical clinical feature but without laboratory confirmations
Possible-
a case with fewer of typical clinical features
Case definition-
standard set of criteria to differentiate between cases and non-cases.
Confirmed or definite case-
a case with laboratory confirmations or verifications
Hyper-endemic-
persistently high level of disease occurrence
Epidemic-
the occurrence of a disease in excess of the usual frequency in a given area over a
particular period of time
Outbreak-
epidemics of shorter duration covering a more limited area.

EPIDEMIOLOGICAL SURVEILLANCE

Surveillance-
the continuous scrutiny of the factors that determine the occurrence and distribution of
disease and through a systematic collection of data.

PURPOSE OF THE SURVEILLANCE

I.To be able to identify diseases, injuries, hazards, and other health related factors as early
as possible

II.To define the magnitude and distribution of diseases by time, person and place
dimension

III. To provide scientific baseline data and information for priority setting, planning,
implementing and evaluating disease control program for both communicable
and non-communicable health problems

TYPES OF SURVEILLANCE

1. Passive surveillance-
a mechanism for routine surveillance based on passive case detection and on
the routine recording and reporting system
Advantages of passive surveillance
1. Covers a wide range of problems
2. Doesn’t require special
arrangement
3. It is relatively cheap
Disadvantages
a) Information collected is unreliable, incomplete and inaccurate
b) Most of the time, data from the passive surveillance is not available on time
c) You may not get the desired
d) It lacks representativeness of the whole population since passive
is mainlysurveillance
based on health institution reports
2. Active surveillance-
a method of data collection usually on a specific disease, for relatively limited
period of time
Advantages of active surveillance
a) The collected data is accurate and complete
b) Information collected is timely
3. Disadvantages
a) Requires good organization It is expensive
b) It requires skilled human power It is for short
c) period of time
d) It is directed towards specific disease
e) condition
Applications of active
1) For periodic evaluation of an ongoing program
surveillance
2) For programs with limited time of operation such as eradication
3) program In unusual situation such as;
a) -new disease discovery
b) -new mode of transmission
c) When disease is found to effect to a new subgroup of the population
d) -when a previously eradicated disease reappears
Activities in surveillance
a) Data collection and recording
b) Data compilation, analysis and
c) interpretation Reporting and notification
d) Dissemination of information

Features of a good surveillance

1.Timely notification
2.Using a combination of both passive and active surveillance techniques
3.Timely and comprehensive action taken in response to notification
4.Availability of a strong laboratory service for accurate diagnosis of cases
Inclusions in integrated disease surveillance system
1.Priority diseases
a) -Cholera
b) -measles
c) meningitis
d) -malaria
e) -typhoid fever
f) Yellow fever

2.Diseases targeted for eradication and elimination

a) -acute flaccid paralysis
b) -dracunculiasis
c) -leprosy
d) -neonatal tetanus

3.Other diseases of public health importance

-pneumonia, diarrhoea, new AIDS cases, STI, TB