Introduction to

Epidemiology

Mamata Manandhar
M. Sc Nursing
2011
 Classically speaking

Epi = upon

Demos = people

Ology = science

Epidemiology = the science which deals

with what falls upon people..

Bridge between biomedical, social and

behavioral sciences
 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
 What is Epidemiology?
Epidemiology is the study of the determinants,
distribution, and
frequency of disease (who gets the disease and
why)

epidemiologists study sick people

epidemiologists study healthy people
to determine the crucial dierence between those who
get the disease and those who are spared

epidemiologists study exposed people

epidemiologists study non-exposed people
-to determine the crucial eect of the exposure
 Contd
Dictionary gives a detailed denition :
The study of the distribution and
determinants of health-related states or
events in specied populations, and the
application of this study to control of health
problems
 A Modern Definition

Study of the occurrence and distribution of

health-related diseases or events in
specied populations, including the study
of the determinants influencing such
states, and the application of this
knowledge to control the health problem
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)
 Aims of Epidemiology
To describe the distribution and magnitude
of health and disease problems in population

To identify the aetiological factors in disease

pathogenesis

To provide data essential to planning,

implementation and evaluation of services
for prevention, control and treatment of
disease and to set priorities.
 CONCEPT OF DISEASE

There have been several attempt to dene

disease.

Webster denes disease as a condition in

which body health is impaired, a departure
from a state of health, an alteration of human
body interrupting the of performance of vital
functions.

From an ecological point of view, disease is

dened as a maladjustment of human
organism to the environment
 Contd..
The simplest denition of disease is
Disease is just the opposite of
health
Any deviation from normal
functioning or state of complete
physical or mental well being
 Contd
WHO has dened health but not
disease

Disease literally means

Without ease (Uneasiness)

Disease is opposite of ease

 Contd
Distinction between the word disease,
illness and sickness

Disease: a physiological/psychological
dysfunction

Illness : subjective state of person who feels

aware of not being well.

Sickness: state of social disfunction, i.e., a role

that an individual assumes when ill (sick role)
 Concept of Causation

Germ theory of disease

Epidemiological triad

Multifactoral causation

Web of causation
 Contd..
1. Germ theory
Germ theory of disease became popular
during the 19th and early of 20th century.

It attributes microorganisms as the only cause

of disease. According to this theory, there is
only one single specic microorganism
(causative agent) to every disease.

This is also called as Single Cause Theory.

 Contd
2. Theory of Epidemiological triad:
The germ theory has many limitations. It
was experienced that everyone exposed to
disease agent did not contract disease.

This means there were other factors related

to man and environment which contributed
to occurrence of disease.
This lead to Theory of Epidemiological triad
 Contd..
This model is also called Ecological model
and is evolved through study of infectious
study.

Host
Three factors are:
Agent
Host
Environment

Agen Environmen
t t
 Contd..
3. Multifactoral causation

Pettenkofer of Munich (1819-1901) was an early

proponent of this concept. The Epidemiological
triad is not applicable to non infectious and
chronic diseases like mental illness, coronary
heart disease, etc.

These diseases are caused by multi factors. For

e.g., CHD is associated with certain lifestyle
activities such as : smoking, intake of high level of
cholesterol, lack of exercise, increase stress etc.
 Contd
Control of diet, regular exercise, use of
eective stress management techniques
have shown to risk of experiencing
Myocardial Infarction .

This lead to theory of multi factorial

causation.

The theory stress the multiplicity of

interactions between host and environment.
 Content

Review of previous class

Continue of Concept of Disease
Web of Causation
Natural History of Disease
Contd
 Contd..
4. Web of Causation

This concept of disease etiology is given by Mac

Mohan and Pugh.

According to this concept, disease (eect)

develops as a result of chains of causations in
which each link itself is a result of complex
interaction of preceding events.
 Contd..
This epidemiological model suggests that
there are cluster of causes and
combinations of eect related to each
other and need to be studied to identify
possible interventions to reduce
occurrence of particular diseases.

For e.g., cardio-vascular diseases may

include avoidance of smoking, diet control,
exercise, stress management etc.
 Contd..
This model is particularly applicable to
chronic diseases where the causative
agent is unknown and which are due to
interaction of multiple factors e.g.
cardiovascular diseases, cancer etc.
E.g. of Web of Causation
E.g. of Web of Causation
 Contd..
5. Devers Epidemiological Model
Another approach to conceptualize interaction of
various factors involve in the development of
particular condition.

This model is based on Blums model of health

paradigm.

The model is composed of 4 major categories of

factors such as human biology, life style,
environment and health care system.
e.g. of Devers Epidemiological
Model
e.g. of Devers Epidemiological
Model
Natural History of Disease

It is the way in which a disease evolves

over time from the earliest stage of its pre-
pathogenesis phase to its termination as
recovery, disability or death, in the absence
of treatment or prevention.

It is a key concept in epidemiology.

Pre-pathogenesis Phase

Period preliminary to the onset of disease

in man

The diseases agent has not yet entered

the man.

The factors which favor its interaction with

the human host are already existing in the
environment.
 Pathogenesis Phase

The pathogenesis phase begins with the

entry of the disease agent in the
susceptible human host.

The nal outcome of disease may be

recovery, disability or death.

This phase may be modied by

interventional measures such as
immunization and chemotherapy.
Natural History of Disease

Disease results from a complex

interaction between

man, agent and the environment

 The Epidemiologic Triangle
Three characteristics that are examined to
study the cause(s) for disease in analytic
epidemiology
Host
Host
agent
environment

Agen Environmen
t t
 Contd..
Host
personal traits
behaviors
Host
genetic predisposition
immunologic factors

Agen Environmen
t t
Agent
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.

Disease may have a single or a number of

independent agents or a complex of two or
more factors
 Contd..
Agents
biological
physical
Host
Chemical
influence the chance
for disease or its severity

Agen Environmen
t t
Agent contd..

Biological agents- living agent of disease

Bacteria, Viruses, protozoa, fungi, rickettsia

Nutrient agents- Protein, carbohydrate,

vitamins, minerals and water
Any excess or deciency of the nutrient
elements may result in nutritional disorders,
anemia, goiter, obesity

Physical agents Exposure to excessive heat,

cold, humidity, pressure, radiation, sound
 Agent contd..

Chemical agents- metal fumes, dust,

gases, insecticides

Mechanical agents exposure to chronic

friction and other mechanical forces may
result in crushing, tearing, sprains,
dislocations

Social agents poverty, smoking, abuse

of drugs, unhealthy life style, social
isolation
 Contd..
Environment
external conditions
physical/biological/social
Host
contribute to the disease
process
e.g. air, water, food,
housing etc

Agen Environmen
t t
 Contd..
Epidemics occur when ..
host, agent and environmental factors are not in
balance

due to new agent

due to change in existing agent(infectivity,

pathogenicity, virulence)

due to change in number of susceptible in the

population
due to environmental changes that aect
transmission of the agent of growth of the agent
Model based on Leavell-Clark and Mausner
and Karma
Iceberg of
Disease
Iceberg of Disease
 Iceberg of Disease

Floating tip of the iceberg represents what

the physician sees in the community-clinical
cases

The vast submerged portion of the iceberg

represents the hidden mass of disease-
latent, inapparent, presymptomatic and
undiagnosed cases and carriers in the
community

Water line represents the demarcation

between apparent and inapparent disease
 content
Review of previous class
Level of prevention
Modes of disease transmission
Prevention

The goals are

To promote and protect health

To minimize suerings and disabilities

To restore health when it is impaired

Levels of Prevention

Primordial Prevention

Primary Prevention

Secondary Protection

Tertiary Prevention
 Primordial Prevention

Prevention of the emergence or development of

risk factors in a population in which they have
not yet appeared
Obesity origin in childhood
Life styles- eating patterns, physical exercise

Main intervention in primordial

prevention is through individual and mass
education
Directed towards discouraging children from
adopting harmful life styles. E.g. smoking
leading to CPD should be discouraged,
Overeating
 Primary Prevention
Action taken prior to the onset of
disease

Removes the possibility the disease

will ever occur
Intervention in the pre-pathogenesis
phase of a disease or health problem

Health Promotion
Specic Protection
Health Promotion
Measures to promote optimal level of health

Provision of adequate nutrition

Health counseling to parents and community

Provision of adequate housing

Health education, counselling

Periodical health examinations

Environmental changes

Provision of safe water

Sanitary latrines

Insect and rodent control

 Specific Protection
Measures applicable to a disease or group of
diseases to intercept the cause before the
involvement

Specic immunization -Communicable diseases

Specic Nutrient - Nutritional deciency

Dental carries Fluoride

Goiter Iodine

Protection against hazards Cancer smoking

Chemoprophylaxis
Secondary Protection
Early diagnosis and prompt treatment
Patient comes in contact with health
worker or health facility

Action which halts the progress of a

disease at its early stage and prevent
complication

Arrest the disease process and restore

health

Screening (e.g. TB- Skin and sputum

test), case nding programs
 Tertiary Prevention
It signies intervention in the late
pathogenesis stage.

All measures to reduce or limit impairments

and disabilities, minimize suering from
disease and to promote the patients
adjustment in society

Disability limitation
limiting further progress of disability
Measures of prevention at this level is
provision of therapeutic substances to arrest
the disease and prevent further disability
 Rehabilitation
To train the individual to be useful member
Medical rehabilitation
Vocational rehabilitation
Social rehabilitation
Psychological rehabilitation

Through occupational therapy, speech

therapy, audiology, psychology,
education, social work, vocational
guidance, placement services etc.
 Disease Transmission
Fomites: inanimate objects that serve as a
role in disease transmission
Pencils, pens, doorknobs, infected blankets

Vector: any living non-human carrier of

disease that transports and serves the
process of disease transmission
Insects: fly, flea, mosquito; rodents; deer

Reservoirs: humans, animals, plants, soils

or inanimate organic matter (feces or food) in
which infectious organisms live and multiply
Humans often serve as reservoir and host
 Disease Transmission
Zoonois: when a animal transmits a
disease to a human
Carrier: one that spreads or harbors an
infectious organism
Some carriers may be infected and not be sick.
e.g. Typhoid Mary
Mary Mallon (1869 1938) was the rst
person in the United States to be identied as a
healthy carrier of typhoid fever. Over the course
of her career as a cook, she infected 47 people,
three of whom died from the disease.
 Contd
E.g. of carrier
 Disease Transmission
Active carrier: individual exposed to and
harbors a disease-causing organism. May
have recovered from the disease
Convalescent carrier: exposed to and
harbors disease-causing organism
(pathogen) and is in the recovery phase but
is still infectious. E.g. Diphtheria, Hepatitis
B virus.
Healthy carrier: exposed to an harbors
pathogen, has not shown any symptoms.
For example, in
poliovirus, meningococcus and hepatitis
 Disease Transmission
Incubatory carrier: exposed to and harbors a
disease and is in the beginning stages of the
disease, showing symptoms, and has the ability
to transmit the disease. E.g. Measles, mumps,
chickenpox and hepatitis.

Intermittent carrier: exposed to and harbors

disease and can intermittently spread the
disease

Passive carrier: exposed to and harbors

disease causing organism, but has no signs or
symptoms
 Mode of transmission

Refers to the mechanisms by which

an infectious agent is transferred
from one person to another or from a
reservoir to a new host. Transmission
may be direct or indirect.
1. Direct transmission
2. Indirect transmission
 Contd
1. Direct transmission: direct skin to skin contact,
mucosa to mucosa, or mucosa to skin of same or
another person. Consists of essentially immediate
transfer of infectious agents from an infected host
or reservoir to an appropriate portal of entry. This
could be:

. Direct Vertical such as: transplacental

transmission of syphilis, HIV, etc.

. Direct horizontal :Direct touching, biting, kissing,

sexual intercourse, droplet
 Contd
2. Indirect transmission: 5Fs (flies, ngers,
formites, food and fluid)

a. Vehicle-borne transmission: Indirect contact

through contaminated inanimate objects (fomites)
like:
Bedding, toys, handkerchiefs, soiled clothes,
cooking or eating utensils, surgical instruments.

Contaminated food and water (most frequent)

Biological products like blood, serum, plasma or IV-

fluids etc
 Contd
b. Vector-borne transmission: Occurs when the
infectious agent is conveyed by an arthropod
(insect) to a susceptible host.

1. Mechanical transmission: The arthropod

transports the
agent by soiling its feet or proboscis. (e.g. common
house fly.)

2. Biological transmission: This is when the agent

multiplies in the arthropod before it is transmitted,
such as the transmission of malaria by mosquito
 Contd
c. Air-borne transmission: Dissemination
of microbial agent by air to a suitable
portal of entry, usually the respiratory
tract.

Two types of particles are implicated in

this kind of spread: dusts and droplet
nuclei. E.g. respiratory infections, TB,
common cold, diphtheria, meningococcal
meningitis etc.
Review
 Modes of Transmission
Direct transmission Indirect transmission
Direct contact Vehicle borne (typhoid
fever, cholera, diarrhoea, food
Droplet infection
poisoning, hepatitis A, & B,
Contact with soil malaria etc)
(hookworm larvae, Vector- borne (plague,
tetanus)
malaria, laria )
Inoculation into skin or
mucosa (rabies, Air borne (droplet nuclei,
hepatitis B) dust) e.g. resp. infection,
nosocomial infection etc.
Transplantal (vertical)
e.g. TORCH agents- Fomite borne (eye & skin
toxoplasma gondii, inf., hepatitis A, typhoid )
rubella virus,
cytomegalovirus and Unclean hands and ngers
 Epidemiological Approach
Epidemiological Approach to health
problems & disease is based on two
major foundation:

1. Asking questions and making

observations

2. Making comparisons
 Contd
1. Asking questions and making observations

Epidemiological studies are done to know the

incidence and prevalence of diseases in various
subgroups of population by time, place and person.

Epidemiologist asks variety of questions and make

observations related to nature and extent
(magnitude) of problem, geographical distribution
(where ?) time trends (when ?) and personal
characteristics of people who get the disease
(who ?).
 Contd..
Through these querries and observations, the
investigators tries to nd out whether there is
increase or decrease in the incidence and
prevalence of disease over time.

Further questions are asked pertaining to :

causative factors, preventive and therapeutic
measures, resources required and difficulties that
may be encountered.

Answers to these questions would help in nding

clues to determinants of disease which are further
evaluated.
 Contd
Asking questions
Epidemiology has been dened as a means
of learning or asking questions .and
getting answers that lead to further
questions. For e.g.
Related to health events
What is the event? (problem)
What is its magnitude?
Where did it happen?
When did it happen?
Who are aected?
Why did it happen?
 Contd
Related to health action
What can be done to reduce this problem and its consequences?
How can it be prevented?

What action should be taken by the community? By the health

services? By other sectors? Where and for whom these activities
carried out ?

What resources are required ? How are the activities to be

organized?

What difficulties may arise, and how might they be overcome?

Answers to above questions may provide clues to disease

aetiology, and help epidemiologist to guide planning and
evaluation.
 Contd

2. Making comparisons

This is another approach which is very

important in epidemiological studies especially
analytical and experimental studies to test
aetiological hypothesis of various diseases and
evaluate the eectiveness of preventive and
therapeutic measures .

Comparison is done by taking two or more

groups- case & control group.
 Vital Statistics

Vital Statistics (VS) means data

which gives quantitative information
on vital events occurring in life, i.e.
migration, births, marriages, and
deaths in a given population.

They form essential tools in any

demographic study.

3/4/17 06:03:21 PM 72
 Vital Statistics cont

Vital statistics are perhaps the most

widely used national, state, and local
data for identifying and addressing
major public health issues.

Vital statistics include indicators such

as birth rate, death rate, natural
growth rate, life expectancy at birth,
mortality and fertility rates.
3/4/17 06:03:21 PM 73
 Contd
Uses of Vital & Health Statistics

Measurement of state of health

Comparison of health status

Planning

Evaluation

Research
 Contd
Sources of Vital & Health Statistics
Census

Registration

Notication
Records

Health surveys
 Census
Census means the enumeration of the total
population of the country at a given movement
of time.

The rst population count was undertaken in

Nepal in 1911.

Since then, the process has been continuing in

every ten-year The 2011 AD Population Census
was the eleventh in a series of these censuses.
Registration of Vital events

It is done on a continuous basis by

various agencies such as VDC office,
metropolitan /sub-metropolitan office
etc.

3/4/17 06:03:22 PM 77
 Notication of diseases
Notication of certain communicable
diseases is compulsory throughout the
country from peripheral level to centre.

The epidemiological statistics of

communicable diseases is collected from
the national government by the Regional
offices of WHO and are published
periodically.

The three diseases that are internationally

notiable
3/4/17 06:03:22 PM to the WHO are cholera, plague,
78
 Community surveys

Health, nutrition and morbidity

surveys are conducted in certain
communities from time to time.
Community survey may also be
carried out specically to nd out the
prevalence or incidence of certain
conditions such as TB, malaria,
cancer, PEM etc.

3/4/17 06:03:22 PM 79
 Thank you

3/4/17 06:03:22 PM 80