Lecture 2

Introduction to
Epidemiology
 The word epidemiology is derived from
Greek and means “Studies upon people”

Epi – Upon, Demos – People, Logia – Study

Clinical medicine epidemiology involves the

study of group of people rather than
individuals.
The concepts of epidemiology were first
suggested by Hippocrates in the 5th century
B.C. that the development of human disease
might be related to external and personnel
environment of an individual.
 Epidemiologist vs.
clinician
A clinician identifies the ailment in his patients
using certain scientifically developed tools to
ascertain history of illness, clinical examination
and investigations.

Epidemiologist addresses the understanding

of the distribution and determinants of a
disease in a community (not an individual)
using standard parameters.
 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 difference between those who

get the disease and those who are spared

Epidemiologists study exposed people
Epidemiologists study non-exposed people
To determine the crucial effect of the exposure
 What is Epidemiology? A detailed definition

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.
 Uses of Epidemiology

 to determine, describe, and report on the natural course of

disease, disability, injury, and death
 to aid in the planning and development of health services
and programs
 to provide administrative and planning data
 to study the cause (or etiology) of disease(s), or
conditions, disorders, disabilities, etc.
 to determine the primary agent responsible or ascertain
causative factors
 to determine the characteristics of the agent or causative
factors
 to determine the mode of transmission
 to determine contributing factors
 to identify and determine geographic patterns
 Purpose of Epidemiology

 to provide a basis for developing disease, control

and prevention measures for groups at risk

 this translates into developing measures to prevent

or control disease
Lecture 4
 Two Broad Types of Epidemiology:

1. Descriptive epidemiology: examining the distribution of

disease in a population, and observing the basic
features of its distribution

2. Analytic epidemiology: investigating a hypothesis about

the cause of disease by studying how exposures relate
to disease
Descriptive epidemiology is antecedent to analytical epidemiology:
analytical epidemiology studies require information to ...

 know where to look

 know what to control for
 develop viable hypotheses
three essentials characteristics of disease that we look for in descriptive
studies are ...

 Person
 Place
 Time
 Person

i. age, gender, ethnic group

ii. genetic predisposition
iii. concurrent disease
iv. diet, physical activity, smoking
v. risk taking behavior
vi. education, occupation
 Geographic Place

i. presence of agents or vectors

ii. Climate
iii. Geology
iv. population density
v. economic development
vi. nutritional practices
vii. medical practices
 Time

i. calendar time
ii. time since an event
iii. physiologic cycles
iv. age (time since birth)
v. seasonality
vi. temporal trends
 The Epidemiologic Triangle: three characteristics
that are examined to study the cause(s) for disease
in analytic epidemiology

Host Host

Agent
Environment
Agent Environment

Host Agents Environment

personal traits biological external conditions
behaviors physical physical/biological/social
genetic predisposition chemical contribute to the disease
immunologic factors process
influence the chance for
disease or its severity
 Epidemics occur when ..

host, agent and environmental

factors are not in balance

 due to new agent

Host
due to change in existing agent
(infectivity, pathogenicity,
virulence)
due to change in number of
susceptibles in the population
due to environmental changes Agent
Environment
that affect transmission of the
agent of growth of the agent
 Epidemiologic Activities

 often concentrate on PPT

 demographic distribution
 geographic distribution
 seasonal patterns and temporal trends
 frequency of disease patterns
 are built around the analysis of the
relationship between
) exposures
) disease occurrence

 are built around the analysis of

differences between
) cases
) healthy controls
Lecture 3
 What constitute
epidemiology
Epidemiology includes:-

1. The methods for measuring the health of

groups and determining the attributes
and exposures that influence health.
2. The study of the occurrence of disease in
its natural habitat rather than in the
controlled environment of the laboratory.
3. The methods for the quantitative study of
the distribution, variation, and determinants
of health related outcomes in specific
groups (sub populations) of individuals, and
the application of this study to the
diagnosis, treatment, and prevention of
disease status or events.
 Evolution of epidemiology

The evolution of medical sciences in its

earlier phase was based on curative
medicine. The primary objective was to cure
a patient of his illness. Doctors in historical
times looked at their patients as ill people
who needed some treatment.
 Thus medical science was individual
oriented. But gradually it became evident
that better human health could be achieved
by prevention of diseases rather than by
cure.
 A Historical Sketch

A Long sketch of time ran for more than 2

millennia from Hippocrates (470-400 B.C.) to
the first third of 19th century.

Hippocrates developed the medical

approach by providing concise, accurate and
complete description of actual clinical cases.
 An Italian clinician called Bernardino
Ramazzini in 1700 moved from observation of
clinical cases to the consideration of ‘work
circumstances’ in similar cases. He is now
regarded as the founder of occupational
medicine. (Explained in his book. “De Morbis
Artificum Diatriba”).
 The major step forward in epidemiology
occurred in 1662. John Graunt analyzed
the weekly reports of births and deaths in
London.

For the first time in the history, a quantified

pattern of disease, deaths and births was
Found. John Graunt is regarded as the
founder of demography now.
 After two centuries William Farr (1839) a
physician was given the responsibility for
medical statistics in England and Wales. He
set up a system for routine compilation of vital
statistics and application of data for evaluation
of deaths.
 Hippocrates, Ramzinni, Graunt and Farr
contributed to the understanding of disease
frequency and distribution.

Another British physician John Snow

formulated and tested a hypothesis concerning
the origins of an epidemic of cholera in London
on the basis of available descriptive data.
Snow postulated that cholera was transmitted by
contaminated water. (then unknown mechanism)

He observed that death rates from Cholera were

particularly high in certain areas of London.
 Concepts of epidemiology
 Definitions

“Epidemiology is defined as the study of the

distribution and determinants of health related
status or events in specified populations and
the application of this study to control the health
problems” (Last 1988)
 Applications of epidemiology
The epidemiology is useful in:

1. Search of cause/causes of disease/diseases.

2. Helps to describe the health status of

population or groups.

3. Helps to discover and bridge gaps in

natural history of diseases.
4. Helps in controlling the diseases. To break
the weakest link in chain of transmission of
communicable diseases and reducing non
communicable diseases.
5. Helps in planning of health programs on
evidence basis and setting up of health
priorities.
6. Helps to evaluate health programs and
interventions.
7. Helps to determine the chances or
probability of occurrence of disease/
deaths and disability
8. Helps in better management of health
services and hospital services.
9. Helps to set-up cut-off levels between
normal and abnormal population and
establish trigger levels for action or
intervention.
 Sources of
epidemiological
Measurements
1. Cross sectional surveys
2. Medical records
3. Death certificate
4. Census
5. Organizational data
 Domains of epidemiology
 Descriptive epidemiology
Descriptive epidemiology is the most basic
form of epidemiology. It is concerned with the
description of the patterns of occurrence of health-
related status or events in groups.

The determination of frequency and distribution of

disease, incidence, prevalence, and mortality rates
are included in descriptive epidemiology.
 Analytical epidemiology

Analytical epidemiology is based on the

observations made in the descriptive
epidemiology. The design, execution and
analysis of subjects between groups helps
evaluate potential association between risk
factors and health outcomes to answer the
question “why?”.
Analytical epidemiology consists of
two types of research processes

1. Observational process
2. Experimental studies
 Basic triads of descriptive and
analytical epidemiology

There are two different triads (3 essential

components) considered in studying different
sections
Descriptive Analytical
epidemiology epidemiology
 Time (when) Host

Place (where) Agent

 Person (who)  Environment

 Triad of descriptive
epidemiology
 Time

 Changing or stable
 Seasonal variations
 Secular trends (long-term study of
incidence)
 Point source or propagated
 Cyclical variations (spikes of
incidences at regular intervals)
 Triad of descriptive
epidemiology
 Place

 Geographically restricted or wide

spread
 Relation to water and food supply
 Multiple cluster involvement or one
 Rural/Urban distribution
 Triad of descriptive
epidemiology

 Person

 Age
 Socio economic status
 Gender
 Ethnicity / Race
 Behavior
 Triad of analytical
epidemiology
 Agent
 Nutrients
 Poisons
 Allergens
 Radiation
 Physical trauma
 Microbes
 Psychological factors
 Triad of analytical
epidemiology
 Host factors

 Genetic factors
 Immunologic state
 Age
 Personal behavior
 Triad of analytical
epidemiology
 Environment

 Overcrowding
 Atmospheric changes
 Modes of transmission
Vector
Vehicle
Reservoir
 Clinical epidemiology

When periodic observations are made over

a long period of time in patients with a wide
spectrum of clinical manifestations of the
disease, a complete profile of the natural
history of the disease may be obtained.

This forms the basis of clinical epidemiology.

 Epidemiology of diseases

Sri Lanka is said to be facing a double

disease burden due to communicable and non
communicable diseases (NCD) today.

What is triple burden???

The diseases burden in the country is given in
terms of (apart from basic measures)
1.Years of potential life lost
2.Life expectancy free from disability
3. Disability adjusted life years lost – DALYs
4.Quality adjusted life years lost - QUALYs
loss per 1000 population.

Country has to fight to control communicable

and non communicable diseases.
 Epidemiology of communicable
diseases (CCD)
 Definition :- Communicable disease

A communicable or infectious disease is an

illness caused by transmission of a specific
infectious agent or its toxic products from an
infected person or animal to a susceptible
host, either directly or indirectly through an
intermediate animal host, vector or inanimate
environment
Disease Transmission

Man to man

Animal to man
 What is an Epidemic?

It is the occurrence of cases of illness,

specific health related behavior or other
health related events clearly in excess of
normal expectancy in a community or region.
 An Endemic disease

A disease that usually present in a

population or given area at a relatively high
prevalence and incidence rates in compared
to other areas.

E.g. Malaria is an endemic disease in

Polonnaruwa
Major emerging and re-emerging
infectious diseases

1. HIV/AIDS
2. Hepatitis B and Hepatitis C
3. Tuberculosis
4. Dengue
5. Malaria
6. Japanese encephalitis
7. Plague
8. Cholera
 Major reasons for emergence of
infectious diseases
 High population growth, uncontrolled and
unplanned urbanization,
 Poor environmental sanitation,
 Migration of population,
 Natural disasters,
 Growing international trade, tourism and rapid travel,
 Alterations in microorganisms,
 Resistance to antimicrobials,
 Insecticide resistance,
 Weak public health system.
 Illiteracy and ignorance.
 Chain of infection or chain
of transmission

Infectious agent Transmission process Host

ENVIRONMENTS
Infectious agent

 Pathogenicity
 Virulence
 Infectivity
 Transmission process

This is the second important link in the

chain of infection.

Transmission is defined as “Spread of

infectious agent through the environment or to
another person, from the reservoir and
source”.
 Methods of transmission

 Direct and
 Indirect
 Direct methods of
transmission
 Touching
 Kissing
 Sexual intercourse
 Child birth
 Breast-feeding
 Air borne, short distance via droplets
(by coughing, Laughing, sneezing, spitting).
 Transfusion of blood
 Transplacental from mother to fetus
 Indirect transmission

 Vehicle borne transmission (by

contaminated food and water)
 Vector borne transmission
 Parenteral by unsafe injection
 Fomite transmission
 Unclean hands
 Control of communicable
diseases (CCD)-discuss
under 5 headings
1. Control of infectious agents in the
environments
2. Control of infectious agent in host
3. Control of outbreaks of CCD
4. Other measures
5. Specific measures for control of HIV
epidemic
 (1) Control of infectious
agents in the environments
 Controlling sources of infection
1. Supply of safe drinking water by treatment and
chlorination of water, pasteurization of milk.
2. Safe disposal of human excreta and animal excreta by
sewerage system and sanitary latrines, compost
pits/manure pits.
3. Control vectors of diseases – by source reduction and
anti-larval and anti-adult measures.
4. Animals – vaccinate dogs against rabies and eliminate
street dogs.
5. Rodent control measures-trapping and killing
6. Hospital waste management
7. Disinfections
 (2) Control of infectious
agent in host
1. Reservoir control
2. Practice of chemoprophylaxis
3. Surveillance
4. Notification
5. Quarantine
1. Complete quarantine
2. Modified quarantine
6. Isolation
7. Education and behavior
 (3) Control of outbreaks of
CCD-different steps will be
discussed later

Communicable diseases like Malaria,

JE, DHF , Hepatitis E & A, Hepatitis B and
Diarrhoeal diseases quite often occur in
epidemic proportion. Many local and focal
outbreaks are being reported quite frequently;
Hence, control of outbreaks of these diseases
is an essential requirement.
 (4) Other measures

1. Legislation

Epidemic disease control act. And

notification helps control of CCD.

2. Observe international health

regulations
Notifiable diseases

Group A

• Cholera
• Plague
• Yellow fever
Group B

• Rubella
• Diphtheria
• Enteric fever
• Food poisoning
• Leptospirosis
• Measles
• Tuberculosis
• Whooping cough
• Acute anterior poliomyelitis
• Simple continued fever of over seven
days
• Dengue
• Dysentery • Encephalitis
• Human rabies
• Malaria
• Tetanus
• Typhus fever
• Viral Hepatitis
 Epidemiology of non-
communicable diseases (NCD)
Non communicable diseases cover wide
range of heterogeneous conditions affecting
different organs and systems of different
socioeconomic groups.
Over the last two decades morbidity and
mortality due to cardiovascular diseases,
mental disorders, cancer and trauma have
been rising due to following causes.
 Causes

1. Rise in life expectancy and increasing

number of senior citizens.

2. Changing life styles: Faulty diet, use of

alcohol, sedentary life-physical inactivity
and rising stress-leading to obesity and
stress related problems.
3. Exposure to environmental risk factors-air
pollution.

4. Use of tobacco

5. Increasing population and rise in

automobiles and trauma incidence.
 Implications

In view of the chronic morbidity and high

cost involve in the management of non-
communicable diseases attention need to be
focused on prevention, early detection and
appropriate management. Further, these
diseases cause lot of disability and
dependency and disease burden.
 Multi - factorial origin

Causes of NCD are multi-factorial. Range

of life styles: risk taking behavior, changing
dietary pattern, physical inactivity, use of
alcohol and tobacco and stress in life have
been incriminated.
 Future

For non-communicable diseases throughout

the all levels of care so as to reduce morbidity
and mortality.
1. Well-structured information education and
communication for primary and secondary
prevention of NCD.

2. Reorientation and skill up gradation of

health care providers
3. Establishment of Referral linkages between
primary secondary and tertiary institution.

4. Production and provision of drugs for NCD.

5. Development of institution for rehabilitation

of disabled persons due to NCD, teaching
persons to live with their disability.
6. Development of hospices for terminally ill
people who cannot have home based care.

7. Creation of epidemiological database on

NCD especially, CVD’s, strokes and
diabetes.