Slid CH01

Introduction to
Epidemiology
Eighth Edition
Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com.
Chapter 1
Foundations of
Epidemiology
Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com.
Objectives
 Define epidemiology.
 Define descriptive epidemiology.
Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com
 Define analytic epidemiology.
 Identify selected activities performed in epidemiology.
 Explain the role of epidemiology in public health practice and individual decision making.
 Define epidemic, endemic, and pandemic.
 Describe common-source, propagated, and mixed epidemics.
 Describe why a standard case definition and adequate levels of reporting are important in epidemiologic
investigations.
 Describe disease transmission concepts.
 Describe the epidemiology triangle for infectious disease.
 Describe selected models for chronic diseases and behavioral disorders.
 Define the three levels of prevention used in public health and epidemiology.
 Understand the basic vocabulary used in epidemiology.
 To understand epidemiology, let’s first describe the meaning of health.
Let’s Get Started
What is Health?
 Six dimensions of health

 The absence of illness
What Are the Six Dimensions of Health?
Physical Ability of the human body to function properly; includes physical fitness and activities of daily living.
Social Ability to have satisfying relationships; interaction with social institutions and societal mores.
Mental Ability to think clearly, reason objectively, and act properly.
Emotional Ability to cope, adjust and adapt; self-efficacy and self-esteem.
Spiritual Feeling as if part of a greater spectrum of existence; personal beliefs and choices.
Environmental Comprises external factors (i.e., one’s surroundings such as habitat or occupation) and internal factors (i.e.,
one’s internal structure such as genetics).

What is Public Health?
 Public health is the science and art of promoting health and extending life on
the population level.
 Public health is concerned with threats to health in the population (a group of
people sharing one or more characteristics).
 The mission of public health is to ensure conditions that promote the six
dimensions of health in the population as a whole.
What is the Meaning of Population?
 Population refers to a collection of individuals that share one or more

observable personal or observational characteristics from which data may be
collected and evaluated.
 Social
 Economic
 Family (marriage and divorce)
 Work and labor force
 Geographic factors
How does Public Health Relate to Epidemiology?
 There are many subfields of public health, including epidemiology, biostatistics,

and health services.
 Because of its central role in public health, epidemiology is commonly referred
to as the foundation of public health.
What is Epidemiology?
 Epidemiology is the study of the distribution and determinants of health-related

states or events in human populations, and the application of this study to
prevent and control health problems.
Key Terms in the Definition
 Health-related states or events

 Disease states
 cholera, influenza, pneumonia, mental illness
 Conditions associated with health
 physical activity, nutrition, environmental poisoning, seat belt use, and provision and use
of health services
 Events
 injury, drug abuse, and suicide
Why is Epidemiology the Foundation of Public Health?
 Because of its central role in carrying out the three core public health functions:
1. The assessment and monitoring of the health of communities and populations at
risk to identify health problems and priorities
2. The formulation of public policies designed to solve identified local and national
health problems and priorities
3. To assure that all populations have access to appropriate and cost-effective care,
including health promotion and disease prevention services, and evaluation of the
effectiveness of that care
Epidemiology and the Scientific Method
 Epidemiology uses the scientific method to describe and analyze health-related

states or events.
What is the Scientific Method?
 The scientific method involves using appropriate study designs and statistical
techniques for investigating an observable occurrence and acquiring new
knowledge.
 The health problem
 Hypotheses
 Statistical testing
 Interpretation
 Dissemination
Study Designs in Epidemiology
 Descriptive epidemiology
 Involves study designs used to answer: Who? What? When? Where?
 Analytic epidemiology
 Involves study designs used to answer: Why? How?
 Later chapters will focus on describing these study designs

The Importance of Descriptive Epidemiology
 A means to characterizing the distribution of health-related states or events by:

 Person – who?
 Place – where?
 Time – when?
 Clinical criteria – what?
The Importance of Analytic Epidemiology
 A means to identifying and quantifying associations, testing hypotheses, and

supporting statements about causality
 Explains why and how health-related states or events occur
Selected Activities Performed in Epidemiology
 Identifying risk factors for disease, injury, and death
 Describing the natural history of disease
 Identifying individuals and populations at greatest risk for disease
 Identifying where the public health problem is greatest
 Monitoring diseases and other health-related events over time
 Evaluating the efficacy and effectiveness of prevention and treatment programs
 Providing information useful in health planning and decision making for
establishing health programs with appropriate priorities
 Assisting in carrying out public health programs
 Being a resource person
 Communicating public health information
Selected Types of Epidemiologic Information
 Public health assessment
 Causes of disease
 Completing the clinical picture
 Program evaluation
 Efficacy
 Effectiveness
Questions that Need Epidemiology (1 of 2)
 Diagnosis
 Is there such a problem as myalgic encephalitis?
 Is prostate-specific antigen a good test for prostate cancer?
 Causes
 Why did this patient suffer a stroke?
 Is obesity the cause of metabolic syndrome?
 Treatment
 Is this the best treatment for Parkinson's disease?
 Is my surgery as good as that of everyone else?
 Prognosis
 What are the chances of a recurrent heart attack?
 How long will this knee joint prosthesis last?
Questions that Need Epidemiology (2 of 2)
 Health promotion and protection

 Do current school meals harm children's future health?
 Will the Irish smoking ban in public places work better than the English policy?
 Health and disease surveillance

 Why are there 10-fold international differences in suicide rates?
 When will the next influenza pandemic occur?
 Health inequalities
 Why should life expectancy be nearly 5 years lower in unskilled manual workers?
 Do health services reduce or increase health inequalities?
Epidemic, Endemic, and Pandemic
 Epidemic – Health-related state or event in a defined population above the

expected over a given period of time
 Endemic – Persistent, usual, expected health-related state or event in a
defined population over a given period of time
 Pandemic – Epidemic affecting a large number of people in many countries,
continents, or regions
Prevalence of Self-Reported Obesity Among U.S.
2017
Adults by State and Territory, BRFSS
2011
Disease Transmission
 Disease transmission usually occurs by one of the following:

 direct, person-to-person contact (e.g., STDs)
 fomite-borne; objects (e.g., hepatitis A spread by a contaminated eating utensil)
 vehicle-borne; inanimate intermediate (e.g., HIV/AIDS spread through needle-
sharing drug users)
 vector-borne; invertebrate animal (e.g., malaria spread through mosquitoes)
Common Source, Propagated, and Mixed Epidemics
 Common source
 Point
 Intermittent/Continuous
 Propagated
 Spread from person to person
 Mixed
 A mixture of common source and mixed
Common Source (1 of 2)
 Tend to result in more cases occurring more rapidly and sooner than host-to-
host epidemics
 Identifying and removing exposure to the common source typically causes the
epidemic to rapidly decrease.
Common Source (2 of 2)
 Examples
 Anthrax, traced to milk or meat from infected animals
 Botulism, traced to soil-contaminated food
 Cholera, traced to fecal contamination of food and water
Propagated (1 of 2)
 Arise from infections being transmitted from one infected person to another
 Transmission can be through direct or indirect routes.
 Host-to-host epidemics rise and fall more slowly than common source epidemics.
Propagated (2 of 2)
Whooping cough
Tuberculosis
Influenza
Measles
 Examples




Mixed
 Occurs when a common source epidemic is followed by person-to-person

contact and the disease is spread as a propagated outbreak
 Example – Shigellosis occurred among a group of 3,000 women attending a
music festival. Over the next few weeks, subsequent generations of shigella
cases spread by person-to-person transmission from festival attendees.
Accurate Assessment Requires a Standard Case
Definition
 A standard set of criteria, or a case definition, assures that cases are
consistently diagnosed, regardless of where or when they were identified and
who diagnosed the case.
Concepts and Principles of Case as Used in
Epidemiology
 A case is a person who has been diagnosed as having a disease, disorder,
injury, or condition.
Primary Case, Index Case
 The first disease case in the population is the primary case.
 The first disease case brought to the attention of the epidemiologist is the index
case.
 The index case is not always the primary case.
Secondary Case
 Those persons who become infected and ill after a disease has been
introduced into a population and who become infected from contact with the
primary case
Different Levels of Diagnosis
 Suspect
 An individual who has all of the signs and symptoms of a disease or condition, yet
not diagnosed
 Confirmed
 All criteria met
Epidemiology Triangle for Infectious Disease
FIGURE 1-1 The Triangle of Epidemiology

Triangle is Based on the Communicable Disease
Model
 Shows the interaction and interdependence of agent, host, environment, and
time as used in the investigation of diseases and epidemics.
 Agent is the cause of the disease.
 Host is an organism, usually a human or an animal, that harbors a disease.
 Environment includes those surroundings and conditions external to the human or
animal that cause or allow disease transmission.
 Time accounts for incubation periods, life expectancy of the host or the pathogen,
and duration of the course of the illness or condition.
Stopping an Epidemic
 An epidemic can be stopped when one of the elements of the triangle is

interfered with, altered, changed, or removed from existence, so that the
disease no longer continues along its mode of transmission and routes of
infection.
Some Disease Transmission Concepts
 Fomites
 Objects such as clothing, towels, and utensils that may harbor a disease agent and
are capable of transmitting it; usually used in the plural
 Example – transmission of cutaneous anthrax from drums to an individual
Vector
 An invertebrate animal (e.g., tick, mite, mosquito, bloodsucking fly) capable of

transmitting an infectious agent among vertebrates
 Can spread an infectious agent from an infected animal or human to other
susceptible animals or humans through its waste products, bite, or body fluids,
or indirectly through food contamination
Plague
 Yersinia pestis (the bacteria that causes plague) is found in animals

throughout certain parts of the world, most commonly in rats, but
occasionally in other wild animals, such as prairie dogs. Plague
transmission from these infected animals generally occurs in one of three
ways:
 Bites from infected rodent fleas (85%)
 Direct contact with infected tissue or bodily fluids
 For example, people can become directly infected with plague by handling infected
rodents, rabbits, or wild carnivores that prey on these animals when plague bacteria
enter through the person's skin.
 Inhaling infected droplets
Reservoir
 The habitat (living or nonliving) on which an infectious agent lives, grows,

multiplies, and is dependent on for its survival in nature
 Humans often serve as both reservoir and host
Zoonosis
 When an animal transmits a disease to a human
 Examples – rabies, Rocky Mountain spotted fever, shigellosis
Carrier
 A carrier contains, spreads, or harbors an infectious organism .
 Example – Typhoid Mary
Modes of Disease Transmission
 Direct transmission – direct physical contact such as touching with

contaminated hands, skin-to-skin contact, kissing, or sexual intercourse
 Indirect transmission – occurs when pathogens or agents are transferred or
carried by some intermediate item, organism, means, or process to a
susceptible host, resulting in disease
Advanced Epidemiology Triangle for Chronic
Diseases and Behavioral Disorders
FIGURE 1-3 Advanced Model of the Triangle of Epidemiology
Three Levels of Prevention Used in Public
Health and Epidemiology
 Primary prevention (occurs prior to exposure)
 Immunization
 Sanitation
 Education
 Media campaigns
 Warning labels
Active Primary Prevention
 Requires behavior change on part of subject

 Wearing protective devises
 Health promotion
 Lifestyle changes
 Community health education
 Ensuring healthy conditions at home, school and workplace
Passive Primary Prevention
 Does not require behavior change

 Vitamin-fortified foods
 Fluoridation of public water supplies
Secondary Prevention
 Occurs to reduce the progress of disease
 The disease already exists in the person.
 Cancer screening – cancer already present. The goal is to detect the cancer before
clinical symptoms arise in order to improve prognosis and prevent conditions from
progressing and from spreading
Tertiary Prevention
 To reduce the limitation of disability from disease
 The disease has already occurred.
 Physical therapy for stroke victims
 Halfway houses for recovering alcoholics
 Shelter homes for the developmentally disabled
 Fitness programs for heart attack patients

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Introduction to

 Six dimensions of health

Mental Ability to think clearly, reason objectively, and act properly.

Emotional Ability to cope, adjust and adapt; self-efficacy and self-esteem.

one’s internal structure such as genetics).

 Population refers to a collection of individuals that share one or more

 There are many subfields of public health, including epidemiology, biostatistics,

 Epidemiology is the study of the distribution and determinants of health-related

 Health-related states or events

 Epidemiology uses the scientific method to describe and analyze health-related

 Later chapters will focus on describing these study designs

 A means to characterizing the distribution of health-related states or events by:

 A means to identifying and quantifying associations, testing hypotheses, and

 Identifying risk factors for disease, injury, and death

 Public health assessment

 Health promotion and protection

 Health and disease surveillance

 Epidemic – Health-related state or event in a defined population above the

 Disease transmission usually occurs by one of the following:

 Occurs when a common source epidemic is followed by person-to-person

 The first disease case in the population is the primary case.

FIGURE 1-1 The Triangle of Epidemiology

 An epidemic can be stopped when one of the elements of the triangle is

 An invertebrate animal (e.g., tick, mite, mosquito, bloodsucking fly) capable of

 Yersinia pestis (the bacteria that causes plague) is found in animals

 The habitat (living or nonliving) on which an infectious agent lives, grows,

 When an animal transmits a disease to a human

 A carrier contains, spreads, or harbors an infectious organism .

 Direct transmission – direct physical contact such as touching with

 Requires behavior change on part of subject

 Does not require behavior change

 Occurs to reduce the progress of disease

 To reduce the limitation of disability from disease

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