EPIDEMIOLOGY

EPIDEMIOLOGICAL
APPROACHES AND
PROCESSES
INTRODUCTION
The word "epidemiology" has its roots in Greek and can be broken down as follows

1 Epi: In Greek, "epi" means "among" or "upon."

2. Demos: "Demos" in Greek refers to "people" or "population

3. Legos: "Logos stands for "study", "science," or "knowledge"

When these components are combined, "epidemiology" literally means the study of what happening to
people. Epidemiology is the study of the determinants, occurrence and distribution of health and
disease in a defined population
 An endemic disease is one that is always
present throughout a region or group of people
and remains fairly consistent. An example of this
is coccidioidomycosis, or valley fever, which is
endemic to the Southwestern United States and
northern Mexico.
 An epidemic occurs when a disease
unexpectedly increases among a large population
or region. An example is ebola, which spread
rapidly throughout West Africa in 2014–2016.
 A pandemic spreads across multiple countries or
continents, affecting large numbers of people. An
example of this is COVID-19, which results from a
coronavirus called SARS-CoV-2 that first appeared
in one region before spreading around the world.
 Definition Of Epidemiology-

 Epidemiology is the study of how diseases and

other health conditions spread and affect people
in a community.
 Epidemiology is the study and analysis of the
distribution (who, when, and where), patterns
and determinants of health and disease
conditions in a defined population, and
application of this knowledge to prevent
diseases.
CONCEPTS OF
EPIDEMIOLOGY
 1. Incidence and prevalence: Incidence
refers to the rate of new cases of a disease
population over a specified time period.
Prevalence, on the other hand, measures
the total of cases (both new and existing) at
a specific point in time.

 2. Risk factors: Risk factors are factors

that increase the likelihood of developing
Epidemiologists identify and study risk
factors to understand why some individuals
on more susceptible to specific health
conditions.
 3. Causality: Epidemiology plays a crucial role in
establishing causal relationships exposures (eg
smoking) and health outcomes (eg lung cancer).
Causal inference is an aspect of epidemiological
research.

 4. Surveillance: Disease surveillance involves

ongoing data collection, analysis and monitoring
health events. Surveillance systems are critical for
early detection of outbreaks and disease trends.

 5. Outbreak investigation: Epidemiologists

investigate disease outbreaks to determine the
outbreak, modes of transmission, and control
measures. This is essential for responses.
 6. Population health: Epidemiology contributes
to improving the health of populations by public
health policies, interventions, and healthcare
planning. It helps address health and improve
overall health outcomes.

 7. Interdisciplinary approaches: Epidemiology

collaborates with various disciplines, biology,
statistics, sociology, medicine, and
environmental science, to understand the
nature of health and disease.
 DISTRIBUTION AND FREQUENCY OF DISEASE

 Disease distribution refers to the patterns,

trends, and variations in the occurrence of a
particular disease or health-related event within
a population.

 Disease frequency quantifies the existence or

occurrence of a specific disease or health-related
event within a population. It provides numerical
information about the number of cases or
events. Measures of disease frequency: Two
primary measures of disease frequency are
incidence and prevalence.
SPATIAL AND TEMPORAL PATTERNS

 1. Spatial patterns: Disease distribution can

vary geographically, with some regions or
communities experiencing higher rates of
specific diseases due to factors like
environmental exposures or population
characteristics.

 2. Temporal patterns: Diseases can also

exhibit temporal patterns, with fluctuations in
year occurrence over time. For example,
some diseases may be more prevalent during
certain seasons or years.
AIMS OF EPIDEMIOLOGY
 1. To establish a community diagnosis.
 2. To identify causes.
 3. To identify and describe various
syndrome in the community
 4. To investigate epidemic problems.
 5. To complete natural history of
disease.
 6. To estimate individual risk and
chances towards disease occurrence.
USES OF EPIDEMIOLOGY
 To study the natural history of disease,
disability, injury, and death.
 To make a community diagnosis.
 To assess risk factors of diseases in the
population.
 To assess, evaluate, and conduct
research on health programs.
 To complete a clinical picture and
identify syndromes.
 To search for causes of health and
disease.
 EPIDEMIOLOGICAL MODELS
OF CAUSATION OF DISEASE
 KOCH'S POSTULATES

 This classical model of causation was developed

by the German physician Robert Koch in the late
19th century and is primarily used for infectious
diseases. Koch's Postulates consist of four criteria
that establish a causal relationship between a
microorganism (eg. bacteria) and a specific
disease. While Koch's Postulates are a valuable
tool for proving causation in certain cases, they
may not be applicable to all diseases, especially
those with multifactorial causes.
CONCEPTS OF DISEASE
TRANSMISSION
 It refers to how infectious agents, such
as bacteria, viruses, parasites, or other
pathogens, are passed from one host
(individual or organism) to another,
leading to the spread of disease.
MODES OF DISEASE TRANSMISSION –DIRECT,
INDIRECT AND CHAIN OF INFECTION
DIRECT TRANSMISSION
DIRECT CONTACT
INDIRECT CONTACT-
VECTOR BORNE
CHAIN OF INFECTION
The chain of infection is an epidemiological
model that describes how an infectious
disease spreads. It's made up of six links that
can be broken to stop the spread of infection.
The six links of the chain of infection:
 Infectious agent: The microorganism that
causes the disease, such as a virus or
bacteria
 Reservoir: The place where the
microorganism lives and multiplies, such as
in a person, animal, or in the environment
 Portal of exit: How the microorganism
leaves the reservoir, such as through
coughing, sneezing, or open wounds .
 Mode of transmission: How the
microorganism is passed on, such as
through direct contact, inhalation, or
ingestion .
 Portal of entry: How the
microorganism enters a new host, such
as through broken skin, the respiratory
tract, or mucous membranes .
 Susceptible host: The person who is
vulnerable to infection .
CHAIN OF INFECTION
TIME TRENDS OR FLUCTUATIONS
IN DISEASE OCCURRENCE
 Short-term fluctuations
(Outbreaks/Epidemics):
These are sudden increases in disease cases,
often within a limited period, potentially
indicating a new transmission source or a
change in susceptible population.
 Cyclic Trends (Periodic Fluctuations):

These are regular fluctuations in disease

occurrence, often occurring on an annual or
seasonal basis. Examples include influenza,
which peaks during winter months in many
regions.
 Long-Term Trends (Secular Trends):

These are long-term variations in disease

incidence or prevalence, such as the increasing
prevalence of chronic diseases or shifts in
disease patterns over decades.
EPIDEMIOLOGICAL
APPROACHES
 The epidemiological approach is a scientific
method that studies how diseases spread and
affect populations. It's used to identify risk
factors, prevent disease, and develop public
health interventions.

How does the epidemiological approach work?

 Collect data: Count cases and health events,
and record them by time, place, and person
 Analyze data: Calculate rates and compare
them over time or between groups
 Identify patterns: Look for risk factors and
associations between diseases and other factors
 Apply findings: Use the findings to control
health problems
APPROACHES
 Asking Questions

 Making comparisons.
?
OBSERVATIONAL STUDIES
 In Observational studies, frequency and
distribution of disease or death are
reported by time
(year/month/week/day/hour/season),
 place (country/urban-rural/in homes)
 and demographic characteristics
(age/sex/income/education/occupation/
marital status, religion/caste).
DESCRIPTIVE STUDIES
 A descriptive epidemiological study is a
study that describes the distribution of
health-related events in a population. It
can help identify risk factors, understand
the spread of disease, and develop
hypotheses.
 Collects and analyzes data about people,
places, and time
 Identifies patterns in disease occurrence
 Estimates caseloads
 Determines resource needs
 Identifies high-risk groups
 Generates hypotheses
Questions asked-

 What is the health issue?

 How many people are affected?
 Where is it occurring geographically?
 When did the event happen?
 Who are the most affected groups (age,
gender, socioeconomic status)?
STEPS IN DESCRIPTIVE EPIDEMIOLOGY
Define the population and disease: Identify the specific
population and disease being studied.

 Collect and summarize data: Gather data on the disease's

occurrence by time, place, and person.

 Describe disease characteristics: Note the patterns of

disease occurrence.

 Measure disease occurrence: Calculate the incidence and

prevalence of the disease.

 Compare to other populations: Compare the disease's

occurrence in the study population to other populations.

 Formulate hypotheses: Develop hypotheses to explain the

observed patterns and suggest preventive measures.
 Inform public health decisions: Use the findings to inform
policies and programs for disease prevention and control.
CASE REPORTS
Case reports are detailed descriptions of
Individual cases of disease, typically highlighting
unusual or rare clinical presentations. A case
report provides a comprehensive account of a
single patient's medical history, symptoms,
clinical examinations, laboratory results, and
treatment.

Ex-An Atypical Sellar Mass: Sellar Tuberculoma in

a Young Patient - Case Report
8-Year-Old Child with Cerebral Palsy Treated with
Pelvic Osteotomies Using 3.5 mm Blade Plate
Having Subsequent Bilateral Implant Aseptic
Loosening: A Case Report
CASE SERIES
Case series involve the collection and
presentation of a small group of cases
with similar characteristics or disease.

Example
A case series of children and young
people admitted to a tertiary care hospital
in Germany with COVID-19.
A case series on food borne disease in a
particular community.
SURVEY METHOD
 In Epidemiology, survey is a fact finding
investigation dealing with the nature
and problem of a community where
information related to the problem is
systematically collected without using
any experimental method. It provides
reliable and accurate epidemiological
data
ANALYTICAL
EPIDEMIOLOGY
 Analytic epidemiologic studies measure
the association between a particular
exposure and a disease, using
information collected from individuals,
rather than from the aggregate
population.
QUESTIONS ASKED
 Analytical:

 What factors are associated with the

health issue?
 What are the potential risk factors?
 How do exposure levels relate to the
disease occurrence?
 Can we establish a causal relationship
between exposure and disease
TYPES
 Case-Control Studies: Compare individuals
with a disease (cases) to those without
(controls) to identify past exposures that might
be associated with the disease.
 Community health nurses identify cases with
the health outcome of interest and select
controls without the outcome, matching them
by relevant characteristics. Exposures are then
compared between cases and controls.

For example, a group of researchers examined

whether using sleeping pills puts people at risk of
Alzheimer's disease. They selected 1976
individuals that received a dementia diagnosis
(“cases”) with 7184 other individuals (“controls”)
 Cross-Sectional Studies: Examine
exposures and outcomes at a single point in
time, providing a snapshot of the population.
 Community health nurses collect data on
exposures and outcomes from a sample of
the population simultaneously.
 For example, researchers wanted to
determine the prevalence of inappropriate
antibiotic use to study the growing concern
about antibiotic resistance. Participants
completed a self-administered questionnaire
assessing their knowledge and attitude
toward antibiotic use. Then, researchers
performed statistical analyses on their
responses to determine the relationship
between the variables.
 Cohort Studies: Follow groups of individuals
with and without a specific exposure over time
to see who develops a disease or outcome.
 Community health nurses identify a cohort,
collect baseline exposure data, and follow
participants for a specified period, regularly
assessing outcomes. Comparisons are made
between exposed and unexposed groups within
the cohort.
 One of the longest cohort studies today is The
Harvard Study of Adult Development. This
cohort study has been tracking various health
outcomes of 268 Harvard graduates and 456
poor individuals in Boston from 1939 to 2014.
Physical screenings, blood samples, brain scans
and surveys were collected on this cohort for
over 70 years. This study has produced a wealth
of knowledge on outcomes throughout life.
STEPS
1. Formulate a Research Question and
Hypothesis.
2. Choose an Appropriate Study Design.
3. Data collection
4. Data Interpretation
5. Interpretation and Conclusion
6. Communicate findings
EXPERIMENTAL STUDY
DESIGN-
 The experimental type of study designs
is employed to find the etiology of
disease, to evaluate effect of
interventions/services and to investigate
the cost and benefit analysis of the
interventions. Hypotheses are tested
using experimental studies.
QUESTIONS ASKED
EXPERIMENTAL

 What interventions can be implemented

to prevent or control the health issue?
 How can we target high-risk
populations?
 What policies or programs can be
developed to promote health?
The key steps include defining
 the research question,
 identifying variables,
 formulating a hypothesis,
 designing the experiment,
 assigning subjects to groups,
 implementing the intervention,
 and assessing outcomes.
TYPES OF EXPERIMENTAL STUDY DESIGNS
Randomized Controlled Trials (RCTs):
 Participants are randomly assigned to different groups,
with one group receiving the intervention and the other
serving as a control.

 the control group is a group of participants who do not

receive the experimental intervention being tested, but
instead receive either no treatment, a standard treatment,
or a placebo, allowing researchers to isolate the effect of
the intervention.

 Comparison: The outcomes of the two groups are then

compared to determine if the intervention has a significant
effect.

 Prospective Study: RCTs are prospective studies, meaning

they follow participants forward in time to observe the
effects of the intervention.
 A study comparing the effectiveness of
two different surgical techniques.
 A study comparing the effectiveness of
a new educational program to a
traditional program.
 A study comparing the effectiveness of
a new therapy for anxiety to a standard
therapy.
COMMUNITY TRIALS
 Involve interventions at the community
level, such as implementing a new
health program in a specific area.
 These trials are useful for studying the
impact of interventions on population
health
 Examples:
 Newburgh-Kingston water fluoridation trial:
This trial investigated the effectiveness of
adding fluoride to the community water
supply to prevent dental decay.
 Community Intervention Trial for Smoking
Cessation (COMMIT): This trial evaluated
the effectiveness of a community-level
intervention to reduce smoking
prevalence.
 Indonesian Vitamin A Study: This study
investigated the effectiveness of vitamin A
supplementation in reducing childhood
mortality.
FIELD TRIALS

 These trials are conducted in the "real

world" setting, rather than in a controlled
clinical environment.
 Field trials are useful for studying the
effectiveness of interventions in a
population that is at risk of a specific
disease.
 in epidemiology, field trials are studies
conducted outside of clinical settings,
evaluating preventive interventions on
healthy individuals at risk of disease,
aiming to determine if an intervention
reduces disease risks.
 These trials often involve interventions
like vaccines, nutritional supplements,
health education campaigns, or
interventions aimed at controlling
disease vectors.
 A field trial might test the effectiveness
of a new vaccine against a specific
disease by administering it to a group of
healthy individuals in a community and
then monitoring them for the disease.
QUASI-EXPERIMENTAL OR NON-
RANDOMIZED DESIGNS:

 These studies use a non-randomized approach

to assign participants to groups.
 Quasi-experimental designs are often used
when randomization is not feasible or ethical.
 Non-random assignment: Participants are
assigned to groups based on non-random
criteria.
 Focus on causality: Like true experiments, quasi-
experiments aim to determine if an intervention
or treatment causes a specific outcome.
 Real-world interventions: They often study
interventions in real-world settings, which can
enhance the external validity of the findings.
Examples:
 Evaluating the impact of a new policy on
crime rates.
 Assessing the effectiveness of a school-
based mental health program.
 Studying the effects of a new drug on
patients with a specific condition.
TYPES
 1.Uncontrolled trials: Uncontrolled trials
assess the effects of an intervention or
treatment on a single group without a control
group for comparison. Participants receive the
intervention, and outcomes are measured
before and after the intervention.

 2. Natural studies: Natural studies, also known

as natural experiments, leverage naturally
occurring events or exposures to investigate
their effects on health outcomes. Researchers
do not manipulate exposures but observe the
effects of naturally occurring events.
 3. Interventional studies without control: These studies
assess the effects of an intervention on a single group
without a separate control group. Participants receive the
intervention, and outcomes are measured before and after
the intervention. Can provide preliminary evidence of the
intervention's effects.

 4. Pre and post interventional studies: Pre and post

interventional studies evaluate the effects of an
intervention by comparing outcomes before and after the
implementation of the intervention. Outcomes are
measured in the same group of participants both before
and after the intervention. Allows for the assessment of
changes within the same group over time.

 5. Crossover interventional studies: Crossover

interventional studies investigate the effects of different
interventions within the same group of participants, often
with a washout period in between. Participants are
exposed to one intervention, followed by a washout
period, and then exposed to a different intervention.
LEVELS OF PREVENTION
OF DISEASE
 Principles of control measures:

 a.Targeted approach: Control measures should be

targeted to the specific disease, condition, or risk
factor.
 b. Evidence-based: Control measures should be based
on scientific evidence and best practices. Research and
data analysis play a crucial role in informing these
measures.
 c. Multifaceted approach: In many cases, a
combination of interventions is necessary to effectively
control diseases.
 d. Community engagement: Community involvement
and education are vital for the success of control
measures.
 e. Monitoring and evaluation: Continuous monitoring of
disease trends and the impact of control measures is
essential for making necessary adjustments and
improvements.
INVESTIGATION
 Investigating a communicable disease
epidemic involves
 confirming its existence,
 verifying diagnoses,
 defining cases,
 finding and describing cases,
 generating and testing hypotheses,
 and implementing control measures to
stop the outbreak and
 prevent future illness.
Following questions should be answered by
community health nurse when investigating an
epidemic.
 1. What is the etiological agent responsible for
the epidemic?
 2. What is/are the predominant modes of
transmission?
 3. What specific source/s of disease can be
identified?
 4. What specific practices or environmental
deficiencies have contributed to the outbreak?
 5. What is the chain of events that led to the
outbreak?
 UNCOVERING OUTBREAKS
 Outbreaks are detected in one of the
following ways:
 1. Through timely analysis of routine
surveillance data
 2. Report from clinician.
 3. Report from the community, either
from the affected group or concerned
citizen.
 STEPS IN EPIDEMIC INVESTIGATION -

 1 Prepare for fieldwork

 2. Verify the existence of an epidemic
 3. Confirm the diagnosis
 4. Identify and count cases
 5. Describe the epidemic with respect to
person, place, and time
 6. Generate hypotheses.
 7. Collect and analyze data
 8. Test hypotheses
 9. Implement control measures
 10. Report of the investigation
 11.Communicate to the public
 12.Monitor and evaluate
TOOLS
 1. Surveillance: Surveillance involves the
ongoing collection, analysis, interpretation, and
dissemination of data on health-related events
within a community.
 2. Case definition: A case definition outlines the
criteria for diagnosing and confirming cases of
a specific disease or condition.
 3.Descriptive epidemiology: Descriptive
epidemiology characterizes the distribution of
diseases with respect to person, place, and
time.
 4.Cross-sectional studies: Cross-sectional
studies assess the prevalence of a specific
condition or exposure at a single point in time.
 5. Case-control studies: Case-control studies compare
individuals with a specific disease cases those without the
disease (controls) to identify potential risk factors.
 6. Cohort studies: Cohort studies follow a group of
individuals over time to examine the association between
exposures and outcomes.
 7. Statistical analysis: Statistical analysis helps quantify
associations, measure risk, and tent hypotheses.
 8. Geographic Information Systems (GIS): GIS is used to
map the geographic distribution of diseases and visualize
spatial patterns.
 9. Outbreak investigation: Outbreak investigations aim to
identify the source and causes of a sudden increase in
disease cases.
 10. Risk assessment: Risk assessment evaluates the
likelihood and consequences of exposure to specific
hazards.
 11. Health Impact Assessment (HIA): HIA assesses the
potential health effects of policies, programs, or projects in
various sectors. It informs policymakers about the health
consequences of their decisions and help design
interventions that promote health.