WHAT IS EPIDEMIOLOGY?

What is epidemiology?
• Epidemiology is a fundamental science of public health.
• Epidemiology has made major contributions to improve population health.
• Epidemiology is essential to the process of identifying and mapping emerging
diseases.
• There is often a delay between acquiring epidemiological evidence and applying
this evidence to health policy.
The historical context
• 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.
• Epidemiology in its modern form is a relatively new discipline and uses
quantitative methods to study diseases in human populations to inform
prevention and control efforts.
Definition

• Epidemiology as defined by Last is “the study of the distribution and determinants

of health-related states or events in specified populations, and the application of
this study to the prevention and control of health problems”.
• Epidemiologists are concerned not only with death, illness and disability, but
also with more positive health states and, most importantly, with the means to
improve health. The term “disease” encompasses all unfavourable health changes,
including injuries and mental health.
Scope

• 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.
Epidemiology and public health
• Public health, broadly speaking, refers to collective actions to improve
population health.
• Epidemiology, one of the tools for improving public health, is used in several ways.
Early studies in epidemiology were concerned with the causes (etiology) of
communicable diseases, and such work continues to be essential since it can lead
to the identification of preventive methods.
• In this sense, epidemiology is a basic medical science with the goal of
improving the health of populations, and especially the health of the
disadvantaged.
Causation of disease
• Although some diseases are caused solely by genetic factors, most result
from an interaction between genetic and environmental factors. Diabetes, for
example, has both genetic and environmental components.
• We define environment broadly to include any biological, chemical, physical,
psychological, economic or cultural factors that can affect health.
• Personal behaviours affect this interplay, and epidemiology is used to study
their influence and the effects of preventive interventions through health
promotion.
Natural history of disease
• Epidemiology is also concerned with the course and out- come (natural history) of
diseases in individuals and groups.
 Health status of populations
• Epidemiology is often used to describe the health status of population groups.
Knowledge of the disease burden in populations is essential for health authorities, who
seek to use limited resources to the best possible effect by identifying priority health
programmes for prevention and care.
• In some specialist areas, such as environmental and occupational epidemiology, the
emphasis is on studies of populations with particular types of environmental exposure.
Evaluating interventions

• Archie Cochrane convinced epidemiologists to evaluate the effectiveness

and efficiency of health services.
• This means determining things such as the appropriate length of stay in hospital
for specific conditions, the value of treating high blood pressure, the efficiency of
sanitation measures to control diarrheal diseases and the impact of reducing
lead additives in petrol.
• Applying epidemiological principles and methods to problems encountered in
the practice of medicine has led to the development of clinical
epidemiology.
• Similarly, epidemiology has expanded into other fields such as
pharmacoepidemiology, molecular epidemiology, and genetic epidemiology.
 Achievements in epidemiology
1. Epidemiological features of smallpox

Epidemiological methods were used to establish the following features of

smallpox:
• there are no non-human hosts,
• there are no subclinical carriers,
• recovered patients are immune and cannot transmit the infection,
• naturally-occurring smallpox does not spread as rapidly as other infectious
diseases such as measles or pertussis,
• transmission is generally via long-lasting human-to-human contact, and
• most patients are bedridden when they become infectious, which limits
transmission.
 Achievements in epidemiology
2. Iodine deficiency

Epidemiologists have helped to solve the iodine deficiency problem; there are effective
measures of mass prevention, and ways to monitor iodization programmes.
Nevertheless, there have been unnecessary delays in using this knowledge to reduce
suffering among the millions of people in those developing countries where iodine
deficiency is still endemic; approximately one-third of the world's school-age children
have less than optimal iodine intake.
Significant progress has been made in the last decade with almost 70% of households
having access to iodized salt compared with 20–30% in 1990.
Achievements in epidemiology
• 3. HIV, epidemiology and prevention

• Epidemiological and sociological studies have played a vital role in identifying the
epidemic, determining the pattern of its spread, identifying risk factors and social
determinants, and evaluating interventions for prevention, treatment and control.
• The screening of donated blood, the promotion of safe sexual practices, the treatment
of other sexually transmitted infections, the avoidance of needle-sharing and the
prevention of mother-to-child transmission with antiretrovirals are the main ways of
controlling the spread of HIV/AIDS.
• With the development of new antiretroviral drugs given in combination, the lives of
people with HIV living in high-income countries have been prolonged and improved. The
cost of these drugs, however, severely limits their use, and they are currently
unavailable to most infected people.
 Disease definition

• Most diseases lack a clear diagnostic test that totally discriminates between
disease and normality, though infectious disease and trauma are two obvious
exceptions.
Most often the diagnosis is based on clinical opinion, with the
latter based on experience, prejudice or arbitrary rules.
In the absence of a
standardised definition of disease, results from etiological, prognostic or
therapeutic studies cannot be directly compared.
• The development of disease criteria is a separate topic in itself which requires a
careful epidemiological study of the occurrence of specific features in cases
determined by anotional gold standard, such as the expert clinician’s
diagnosis.
• These features are then compared with those from an appropriate group of
non-cases and the level of agreement evaluated.
Disease causation
• Similarly, the use of epidemiology to unravel causative mechanisms is one of
its major roles.
• It is, however, too simplistic for most chronic diseases, to consider their
influence on disease risk as present or absent.
• It is the strength of any disease association with possible risk factor variables
that is of more interest.
Disease outcome
• Investigations concerning the frequency and prediction of specific disease
outcomes in patient populations may be considered as the clinical
epidemiological parallels of studies of disease occurrence and causation in
normal populations.
• Thus the population epidemiologist may wish to ascertain the incidence of, and
risk factors for, angina in a stated population; whereas the clinical
epidemiologist may wish to ascertain the incidence of, and risk factors for,
subsequent myocardial infarction and sudden death in patients with angina.
Disease management and disease
prevention
• The use of the clinical trial to evaluate the effectiveness of a particular
therapeutic intervention is well established in medicine.
• Epidemiologically, the clinical trial can be considered as an experimental study
where the investigator has intervened to alter the ‘exposure’, e.g.
management, in order to measure the effect on disease occurrence or
outcome.
• The term ‘intervention study’ describes this broad activity.
• A further aim of this type of study is to determine whether a link between a
suspected risk factor and disease is causative rather than simply an
association.
Study design
• The first demand is to clearly frame and there after focus on the specific
questions posed.
• In the following two chapters, the various options for studies of disease
occurrence and causation are outlined.
• A decision has to be made about the choice of study design that can best
answer the question posed, taking into account the often conflicting demands
of scientific validity and practicality.
Population selection
• The subjects to be studied have to be defined both in terms of the group(s) from which
they are to be selected and, in selecting individuals, the inclusion and exclusion rules.
• Specific problems arise in comparative studies when it is necessary to recruit two or
more groups based on their disease or on their risk factor status. Problems in population
selection are one of the major reasons for a study’s conclusions being invalid. A specific
difficulty is that of sample size.
• Cost, time, or other practical considerations may limit the availability of subjects for
study. A scientific approach to sample size estimation is given for the different study
design.
• Non-response or loss to follow-up can reduce the number of subjects available for
analysis and an adequately large study at the onset may prove too small by the end.
Information quality
• This major issue relates to the quality of the data obtained. There is a
particular problem when the approach requires a subject to recall past
symptoms or exposures.
• The most appropriate method for obtaining information must be selected. This
might, for example, be a choice between interview and self administered
questionnaire.
• Other sources of information such as data collected prior to the study, often
for another purpose such as the medical record, may be available.
Data handling and analysis
• The time spent on this activity is frequently longer than that spent on the data
collection itself.
• In particular, there is a need to ensure that the data analysed are complete and
error-free. The next problem is to choose the appropriate method of analysis.
Logistical issues
• Two important areas to be addressed are those of ethics and cost.
• Studying free-living individuals imposes ethical constraints on the
investigators, and the need for cost containment is self-evident.
• Indeed, these issues have to be considered early as they are likely to influence
the final study design.