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BASIC EPIDEMIOLOGY

GENERAL OBJECTIVE:
To know the basic concepts and strategies of Epidemiology
SPECIFIC OBJECTIVES: At the end of the lecture, the student must know the:
1. 2.

Definition of Epidemiology Concepts of Epidemiology

SPECIFIC OBJECTIVES:
3. Principles of Epidemiology 4. Aims and purposes of Epidemiology 5. Relationship of the other branches of Science to Epidemiology 6. Ecologic Concepts of diseases 7. Types of Disease Agents 8. Attributes of the Human host 9. Attributes of the Environment 10. Relationship among Agent, Host and Environment

SPECIFIC OBJECTIVES:
11. General and specific defense mechanisms of the body 12. Mode of Disease Transmission 13. Nature of communicable diseases 14. Classification of disease in human 15. The stages of the natural history of disease 16. Levels of disease prevention 17. Steps in scientific inquiry

SPECIFIC OBJECTIVES:
18. Strategies of Epidemiology 19. Methods of hypothesis formulation 20. Description of the different study designs 21. Concept of Descriptive Epidemiology in relation to Person, Place and time 22. Sources of Epidemiological data 23. Description of disease frequency as to counts, ratios, proportions and rates

DEFINITION OF EPIDEMIOLOGY
- The study of the distribution and determinants of disease frequency in man

- From the Greek word epi meaning ON or UPON and demos which means POPULATION

MODERN DEFINITION OF EPIDEMIOLOGY

- A branch of medical science concerned with the relationships of the various factors and conditions which influence the frequencies and distribute health, infectious disease process, defect, disability or death as it occurs in aggregations or groups of individuals in a population

CONCEPT OF EPIDEMIOLOGY
1. -

Concept of the shrinking world The world is becoming smaller not because of physical size but due to:

a). Marked improvement in transportation b). Better communication and transportation makes easier exchange of information about diseases

CONCEPT OF EPIDEMIOLOGY
2. Changes in nature of disease problem a). Socio-economic conditions b). Improvement and progress of medical science 3. Much have been done to fight communicable diseases a). Better facilities for early Dx & Tx b). Better control measures- vaccines

CONCEPT OF EPIDEMIOLOGY
4. Epidemics are now a rarity - study more the endemic behavior of disease rather than epidemic occurrences 5. Realization of the different applications of methods in Public Health both for infectious and non-infectious diseases

PRINCIPLES OF EPIDEMILOGY
1. Exact observation (strict, accurate, precise)
2. Correct interpretation ( free from error) 3. Rational instruction (by expert knowledge

and technical skills)

AIMS & PURPOSES OF EPIDEMIOLOGY


1. To analyze carefully the roles and interactions of agents, host and environmental factors in the natural history of disease to discover gaps in the knowledge and contribute to preventive medicine

AIMS & PURPOSES OF EPIDEMIOLOGY


2. To describe and analyze disease occurrence and distribution according to such variables as age, sex, occupation, temporal frequency, periodic fluctuation, long term trends and geographic distribution to make community diagnosis making an estimate of morbidity and mortality risks

AIMS & PURPOSES OF EPIDEMIOLOGY


3. To aid in filling gaps in knowledge about the causes of disease processes by observing the range, amplitude and group behavior of clinical syndromes in populations

AIMS & PURPOSES OF EPIDEMIOLOGY


4. To study immediate and special problems in the field of health. This would include the study of new diseases, endemic disease problems, epidemics and administrative problems 5. To measure the effectiveness of preventive and control programs in health

RELATIONSHIP OF OTHER BRANCHES OF SCIENCE TO EPIDEMIOLOGY


Clinical Medicine to obtain details of clinical diagnosis for epidemiological descriptions of the distribution of diseases or disorders 2. From Bacteriology, Entomology, Parasitology, Zoology for information about nature and characteristics, reservoirs, sources and modes of transmission of living agents of disease
1.

RELATIONSHIP OF OTHER BRANCHES OF SCIENCE TO EPIDEMIOLOGY

3. From Demography on the composition and characteristics of the population 4. From Chemistry, Physics, Nutrition and Industrial Medicine for information about health hazards 5. From Anthropology and Sociology for information about habits, customs, cultural and social characteristics of the population

RELATIONSHIP OF OTHER BRANCHES OF SCIENCE TO EPIDEMIOLOGY

6. Genetics and Psychology for characteristics of persons which may influence occurrence of diseases 7. Meteorology for data on weather and climate in relation to occurrence of diseases 8. Biostatistics analytic and descriptive 9. Vital statistics containing data on natality, morbidity and mortality

ECOLOGIC CONCEPT OF DISEASE


The ecologic concept of disease is based on the 3 premises of the biologic laws: 1. The disease results from an imbalance between disease agents and man 2. That the nature and extent of imbalance depend on the nature and characteristics of the host and the agent

ECOLOGIC CONCEPT OF DISEASE


3. That the characteristics of agent and host and their interaction are directly related to and depend largely on the nature of physical, social, economic and biologic environment

DISEASE AGENT
- May be defined as an element, a substance or a force, either animate or inanimate, the presence or absence of which, may following effective contact with susceptible human host under proper environmental conditions, serve as stimulus to initiate or perpetuate a disease process

TYPES OF DISEASE AGENTS


1. Biologic
2. Nutrients 3. Chemical 4. Physical 5. Mechanical 6. Psychological

ETIOLOGIC FACTORS OF AGENTS OF DISEASE


1. 2. 3. 4. 5. 6.

Biologic living plants and animals, parasites Nutritive agents cholesterol, vitamins, proteins, fats Chemical poisons, allergens, metals, drugs Physical climate, season, weather, radiation Mechanical machines, cars, engines Psychological/ social mental stress

CHARACTERISTICS OF THE LIVING AND NONLIVING AGENTS

Inherent nature and characteristics in morphologic agents 2. Viability and resistance 3. Infectivity and pathogenicity to man 4. Reservoirs and sources of infection 5. Vehicles and condition of dissemination
1.

CHARACTERISTICS OF LIVING AND NON-LIVING AGENTS


LIVING AGENTS Morphology Mortality Physiology Reproduction Metabolism Nutrition Toxic products

NON-LIVING AGENTS Dust Crystals Solutions Insoluble substances Corrosive & noncorrosive substances

THE INCUBATION OF NON-INFECTIOUS AGENTS DEPENDS ON:

1. Strength of stimulus 2. Repeated increments of the agent 3. Period of exposure 4. Tissue involved

DISEASE AGENTS MAY:


Fail to lodge in the body, being expelled or dislodged by the non-specific outer defenses of the host 2. In-apparent infection lodge, multiply and yet produce no discernible action on the host 3. Sub-clinical cases- reactions may be so mild to escape detection
1.

Whatever the original reaction is, the end result may be:

1. Elimination of the agent leading to

complete recovery 2. Clinical recovery without elimination of the agent (carrier state) 3. Death, defect or disability of the host

ATTRIBUTES OF THE HUMAN HOST


1. IMMUNE RESPONSE
2. HABITS & CUSTOMS 3. AGE, SEX & RACE 4. MARITAL FACTORS 5. OCCUPATIONAL FACTORS 6. OTHERS: Constitution, heredity,

psychological factors

GENERAL & SPECIFIC DEFENSE MECHANISMS


Resistance: the sum total of the defense mechanism of the host
Non-specific resistance a). Skin & mucous membranes b). Phagocytosis c). Reticuloendothelial system d). Hormones e). Different reflexes or physiologic mechanisms
1.

Different reflexes or physiologic mechanisms:


Winking reflex
Tears Sneezing

Diarrhea
Urination Genito-urinary

Coughing
vomiting

discharge Sweating

Specific Resistance or immunity of the human host


Possession of antibodies for a specific disease Passive immunity either attained by maternal transfer or by inoculation of specific antibodies; brief duration of immunity 2. Active immunity natural immunity and artificial immunity; vaccines 3. Latent immunity developed due to the giving of small doses for a long period of time
1.

The human host may be :

1. Susceptible a person not possessing

resistance against a particular pathogenic agent 2. Immune a person who possesses antibodies that are specific and protective

CHARACTERISTICS OF AGENTS IN RELATION TO HOST:

INFECTIVITY the ability of an agent to invade and adapt itself to the human host 2. PATHOGENICITY the measure of the ability of an agent when lodged in the body to set up either a local or general tissue reaction 3. VIRULENCE the measure of the severity of the reaction produced 4. ANTIGENIC PROPERTIES the activity to stimulate the host to produce agglutinins, opsonins, presipitins, antitoxins, complement fixing, neutralizing and sensitizing antibodies
1.

ATTRIBUTES OF THE ENVIRONMENT:


- Influence existence of the agent - Influence exposure or susceptibility to agent a). Physical environment geology, climate b). Biologic environment human population density, crowding index - flora and fauna sources of food, vertebrate hosts, arthropod vectors c). Socio-economic occupation, urbanization, pollution, disruption (wars, floods, earthquakes)

RELATIONSHIP AMONG AGENT, HOST & ENVIRONMENT

A E

MODE OF DISEASE TRANSMISSION


Infectious diseases can spread through human population by: 1. Common vehicle epidemics - the etiologic agent is transmitted by water, food, air or inoculation a). Vehicle water, food, soil b). Vector snails, mosquitoes 2. Epidemics propagated by serial transfer from host to host a). Airborne droplets, anal, oral, genital route b). Infected blood or sera

NATURE OF COMMUNICABLE DISEASES


COMMUNICABLE DISEASES - an illness due to specific infectious agents or its toxic products CONTAGIOUS DISEASES implies transmission of the disease through direct contact

Periodicity of Communicable Disease Occurrence:


EPIDEMIC Endemic a disease constantly occurring in a geographical area 3. Pandemic epidemic occurring within more than one country or territory 4. Sporadic occasional or infrequent occurrence of a disease 5. Epizootic or enzootic diseases occurring in animals 6. Zoonotic disease of animals transmissible to man
1. 2.

Biologically, disease agents are classified according to decreasing sizes into the following seven categories:

Arthropods scabies, lice, ticks 2. Helminths schistosoma, ascaris 3. Protozoa plasmodium 4. Fungi yeast and molds 5. Bacteria spirochetes, streptococci, TB bacilli 6. Ricketssiae typhus 7. Viruses flu, measles, Hepa B, HIV
1.

Host factors in the occurrence and distribution of communicable diseases

1. Reservoir of agents man, animals, plants, soils, inanimate organic matter 2. Portals of entry and exit interrupt the

natural history before man is infected - by detecting agents, abolishing reservoir, interfering with transmission, barriers against infection

CLASSIFICATION OF DISEASES
Communicable or

Infectious Bacteria Virus Ricketsiae Arthropods Helminths Protozoa Fungi

Non-communicable or non-infectious

Occupational Environmental Life-style diseases Familial or hereditary

THE NATURAL HISTORY OF DISEASE


Stage of susceptibility a). Portal of entry 2. Stage of pre -symptomatic disease a). Incubation period 3. Stage of Clinical Disease a). Clinical horizon 4. Stage of disease outcome a). Complete recovery b). Disability or defect c). Carrier state d). death
1.

STAGE OF SUSCEPTIBILITY
- The disease has not developed but the groundwork has been laid by the presence of risk factors which favors its occurrence
- Portal of entry is a pre-requisite for successful infection

STAGE OF PRESYMPTOMATIC DISEASE


- There is no manifest disease but usually through the interaction of factors, pathogenic changes have started to occur - INCUBATION PERIOD the interval between the time of entry of agent into the host and the onset of signs and symptoms

STAGE OF CLINICAL DISEASE


- Sufficient end-organ changes have occurred so that signs and symptoms of the disease can be recognized
- Classification and Staging of Disease

STAGE OF DISEASE OUTCOME


- Some diseases run their course and then resolve completely either spontaneously or under the influence of therapy - Some diseases will give rise to residual defect of short or long duration with disability

NATURAL HISTORY OF DISEASE


DISEASE
INCUBATION PERIOD CLINICAL CASE RECOVERY COMPLETE DEATH CARRIER

DISABILITY OR DEFECT

LEVELS OF DISEASE PREVENTION


1. -

PRIMARY LEVEL Pre-pathogenesis Isolation, quarantine Health education, food sanitation, proper waste disposal, eradication of animal reservoir, specific protection Active and passive immunization

LEVELS OF DISEASE PREVENTION


2. SECONDARY LEVEL - PATHOGENESIS period - Early diagnosis and prompt treatment of the disease to prevent its spread - Example: killing of rabid dogs, cows with MCD, pigs with FMD - Screening tests for diseases , periodic examinations, case-finding, adequate treatment and follow-up

LEVELS OF DISEASE PREVENTION


3. TERTIARY LEVEL - Stage of Disease outcome - Disability limitation - Rehabilitation - Intensive, periodic follow-up and treatment

Health Screening
For CVS diseases: Chest x-ray & ECG
Blood sugar for diabetes Paps smear for cervical cancer Digital rectal examination Newborn Screening Hearing Screening Mantoux Test

STEPS OF SCIENTIFIC INQUIRY


1. Examining existing facts and hypotheses and identifying gaps in knowledge
2. Formulating a new and a more specific

hypothesis 3. Obtaining additional information to test the acceptability of the new hypothesis 4. Evaluating the new evidence and deriving appropriate conclusions

The Epidemiologic Approach or Strategy


1. identify the problem
2. review of related literature 3. identify critical knowledge gaps about the

problem 4. special data collection activities 5. hypothesis formulation 6. hypothesis testing

Features of a good hypothesis: Formulating the Hypothesis


The cause being investigated is usually a

The population to whom the hypothesis will apply (the target population)

particular environmental exposure. It could be a physical, chemical, biologic or psychological factor The outcome is usually the disease or condition of interest

Features of a good hypothesis: Formulating the hypothesis The dose response relationship is the
amount of exposure necessary for the disease or condition to develop The time-response relationship is the time period between the exposure and the development of the outcome. This concept is synonymous to the incubation period for infectious diseases and to the latency period of non-infectious diseases

Some considerations in formulating hypothesis


a). New hypotheses are commonly formed by relating observations from several different fields b). The stronger the statistical association between the exposure and the disease, the more likely it is to suggest a causal hypothesis

Some consideration in formulating hypothesis


c). Observed changes in the frequency of disease can lead to very productive hypothesis d). An isolated or an unusual case should receive particular attention in forming hypothesis e). Observations that appear in conflict or those which present a paradox should be considered

Study Designs
Descriptive studies case studies, case series and cross-sectional studies Observational studies cohort studies, casecontrol studies Experimental studies clinical trials, RCTs, community trials

Sources of Data
Two Types of Data according to Source: 1). Primary Data obtained by the investigator Example: interviews physical examination laboratory examinations - More accurate and up-to-date but more expensive and difficult to obtain

Sources of Data
2). Secondary Data data actually gathered by other individuals or agencies Example: published reports clinical/hospital records census - More readily available but incomplete - Confidentiality of information

Surveillance
In most health departments, routinely collected statistics provide the key data for monitoring morbidity and mortality trends Surveillance System includes a functional capacity for data collection, analysis and dissemination linked to public health

programs

Epidemiologic Surveillance
Has been defined by the Centers for Disease Control (CDC) as the ongoing systematic collection, analysis and interpretation of

health data essential to the planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know

Specific Data that are Useful in Epidemiologic Studies


1. Data on vital events birth, death, marriages, divorces, adoptions, total births/deaths, deaths by specific causes,

mortality rate, case fatality rate, etc. 2. Disease statistics prevalence and incidence of specific diseases

Specific Data that are Useful in Epidemiologic Studies


3. Data on physiologic or pathologic conditions prenatal Hgb levels, blood sugar levels among diabetics, BP readings 4. Statistics on Health Resources and Services number of hospital beds, vaccine vials consumed, number of health center staff

Specific Data that are Useful in Epidemiologic Studies


5. Statistics pertaining to the environment number of households with sanitary water source, number of snail breeding places, amount of pollution in the air, level of noise in the factory, workers protective gears 6. Demographic data total number of population, age groups, gender, rural-urban residence, occupation, income 7. Socio-cultural data knowledge, attitude, practices of people regarding health

Sources of Data
1. Registers of births and deaths
2. Certificates of death 3. Disease registers 4. Disease notifications 5. Census 6. Clinic/hospital records 7. Surveys

10 Key Sources of Data for Surveillance Systems Designated by the WHO: Mortality registration Morbidity reporting Epidemic reporting Laboratory investigation Individual case investigations Epidemic field investigations Surveys Animal-reservoir and vector distribution studies 9. Biologic and drug utilizations 10. Knowledge of the population and the environment
1. 2. 3. 4. 5. 6. 7. 8.

Other Sources of Surveillance Data


1. Hospital and medical care statistics
2. Panels of cooperating physicians 3. Public health laboratory reports 4. Absenteeism from work or school 5. Telephone and household surveys 6. Newspaper and news broadcasting reports

Data can readily be available from


National Center for Health Statistics Centers for Disease Control & Prevention Birth Defects Monitoring Program Metropolitan Atlanta Congenital Defects Cancer Surveillance, Epidemiology and End Results (SEER) Program 6. Morbidity and Mortality Weekly Report from the CDC 7. Medical Specialty Societies 8. World Health Organization
1. 2. 3. 4. 5.

Locally, data may be available from:


1. Department of Health
2. National Institutes of Health 3. Medical Specialty Societies 4. National Congenital Defects Registry 5. Newborn Screening Program 6. Specialty Hospitals 7. National Census and Statistics Office

Descriptive Epidemiology: Person, Place and Time


Descriptive Epidemiology the study of the amount and distribution of disease within a population by person, place and time. WHO (person) is affected? WHERE (place) do the cases occur? WHEN (time) do the cases occur?

PERSON
Characteristics of PERSON 1. age 7. family variables 2. sex 8. other personal

3. ethnic group variables: 4. social class Blood type 5. occupation Environmental exposures 6. marital status Personality traits

AGE
- The most important determinant among the personal variables
- Death rate is fairly high in infancy

- Lowest point is between 5-14 years old


- Doubling in rate from 40 and every decade of

life

AGE
- Chronic conditions tend to increase with age whereas the relation of age to acute infectious diseases is less consistent - Age is related to the frequency and severity of infectious diseases - High rate of injury in particular age group

SEX
- Death rates are higher for males than

females, but morbidity rates are higher for females - In utero and neonatal death rates are also higher for males - The higher death rates for males throughout life maybe due to sex-linked inheritance, differences in hormonal balance, environment or habit patterns

SEX
- The higher mortality rate for men are not paralleled by higher rates of illness
- Women have more episodes of illness and

more physician contacts than men have


- Rate of attempted suicide is higher in women but completed suicides are more common in men - Toxic shock syndrome

SEX
Possible explanations for the relatively high morbidity and low mortality in women: 1). That women seek medical care more freely and perhaps at an earlier age of disease
2). That the same disease will tend to have less lethal course in women than in men

ETHNIC GROUP & RACE


Blacks have higher rates of deaths caused by CHVD, CVA, TB, SY Whites have higher rates of death from suicide, leukemia and atherosclerotic disease Many differences in rates of diseases and death reflect at least in part, differences in various environmental exposures, in lifestyle and in the extent and quality of medical care

SOCIAL CLASS
Difference in wealth, power, prestige: difference in access to medical care and facilities Poverty affects utilization of medical services
More common cases of mental illness in

lower strata

OCCUPATION

This influence may occur thru a variety of exposures unfavorable physical conditions (heat, cold, changes in atmosphere), chemicals, noise, stress in work Silica (pulmonary fibrosis), asbestos (lung cancer), aniline dyes (bladder cancer) Injury, trauma, social and psychological climate of the job or workplace

MARITAL STATUS
Marital status is associated with level of mortality for both sexes Psychological and physical support from the

spouse For women, marital status may also be related to health through differences in sexual exposure, pregnancy, childbearing and lactation

FAMILY VARIABLES
Family size: larger families especially if they are poor, children may be in a disadvantage: higher rates of fetal, neonatal and infant deaths, higher childhood mortality, and a tendency to poorer intellectual performance
Birth order: first borns tend to be more healthy and better educated

Personal Variables
Maternal age: etiologic importance in congenital malformations Parental deprivation psychiatric, psychosomatic disorders, TB incidence, attempted suicides and accident repeaters Blood type A- gastric CA, Type O doudenal ulcer Environmental exposure Personality traits medical advice, compliance

PLACE
Frequency of disease can be related to place of

occurrence in terms of areas set off either by natural barriers or by political boundaries Frequency of disease may be related to temperature, humidity, rainfall, altitude, mineral content of soil or water supply Lack of iodine, mottled dental enamel Rural-urban differences Migrants in national and international borders

TIME
Disease occurrence is usually expressed on a

monthly or annual basis Secular trends refers to changes over a long period of time, years, decades Cyclic change refers to recurrent alterations in the frequency of disease If there are enough cases of a particular disease annually for stable rates, cases for several years around a census may be combined

Measures of Disease Frequency


Count the basic measure of disease frequency
Ratio a measure that shows the relationship

between quantities Proportion the numerator in the proportion is part of the denominator Rate the most common measure

Measures of Morbidity
Prevalence the proportion of individuals with the disease during a a given point in time

- the probability that a person randomly chosen from the population will have a disease at the time he was examined.
Prevalence = no. of existing cases of a disease ----------------------------------------Total population examined

Measures of Morbidity
Incidence refers to the proportion of the population

who developed the disease in a given interval time


- the numerator is the count of new cases of disease in the population - a measurement of the risk of developing the disease in the population at risk of the disease Cumulative incidence no. of new cases of disease ---------------------------------population at risk

Relationship of Incidence and Prevalence


The higher the number of new (incident) cases, then there would be a greater number of existing (prevalent) cases

Study of Epidemics
Two Types of Epidemics:

1. Common Vehicle Epidemic 2. Propagated or Progressive Type

Common Vehicle Type of Epidemic


Single exposure, single source or point epidemic It indicates simultaneous exposure of the

population to a common source Example: food or chemical poisoning - Multiple exposure - Water-supply epidemic (Dysentery)

Propagated or Progressive Type of Epidemic


Also called contact epidemic, propagated by:

a). Person to person spread b). Arthropod c). Vector reservoir

Characteristics of Epidemic
1). Type of onset or manner of onset a). Sudden, abrupt or explosive time factor is the period of incubation b). Insidious or gradual most cases start after the incubation period 2). Types of infection a). Mass infection more of primary cases b). Progressive infection more of secondary cases

Types of Epidemic Curves


1). Classical Epidemic Curve short ascending and descending limbs - picture of common source - rapid transmission due to big dose of organism - longer descending limb is due to the development of secondary cases - more deaths on the ascending limb because of heavier dose of the organism and less resistance

Classical Epidemic Curve

Inverted Epidemic Curve


- Long ascending and short descending limb
- Indicates that the transmission is more

complex and the disease has a longer incubation period - Person to person spread, insect-borne diseases (malaria, DHF)

Inverted Epidemic Curve

Bell-shaped Epidemic Curve


- Rapid ascending and rapid descending limb
- The spread is rapid and the transmission is

simple so there is rapid elimination of susceptible - Measles and poliomyelitis

Bell-shaped Curve

Investigation of Epidemics
DEFINITION OF THE PROBLEM - define clearly the nature and extent of the problem a). Verify the diagnosis through clinical signs and symptoms of the disease aided by laboratory examinations b). Verify whether epidemic exists. Compare the incidence of the disease with its usual incidence in the community
1.

Investigation of Epidemics
2. APPRAISAL OF EXISTING INFORMATION
a). Orient as to time, the chronologic order of the disease (epidemic curve) b). Orient as to place, determine geographic distribution of cases c). Orient as to the persons characteristics (age, sex, occupation, socioeconomic conditions, etc.)

Investigation of Epidemics
3. FORMULATE TENTATIVE HYPOTHESIS
What could be the cause/ causes? Classify according to mode of transmission: 3.1. Common Vehicle single exposure multiple or continuous exposure 3.2. Propagated person to person arthropod vector reservoir

Investigation of Epidemics
4. TESTING THE HYPOTHESIS a). Epidemiological investigation of all cases or representative sample b). Search for additional information c). Analyze detailed data attack rates, common source or vehicle d). test various hypotheses e). Formulate conclusions as to source, mode of transmission and all features of the epidemic which require explanations

Investigation of Epidemics
5. CONCLUSIONS & PRACTICAL APPLICATIONS
- evaluate the results in terms of local situations - conclusions are based on pertinent evidence to control present outbreak and prevent future similar epidemics

- reports should be simple, clear and honest


- collection of data must be made in a scientific manner which requires exact observation, correct interpretation and rational explanation