Introduction to Epidemiology

Introduction and History

From time immemorial man has been interested in trying to
control disease, Medical knowledge in fact has been derived, to a very
great degree, from the intuitive and observational and cumulative
experiences. Hippocrates attempted to explain disease occurrence from
a rational rather than a supernatural viewpoint. In his essay entitled “On
Airs, Waters, and Places,” Hippocrates suggested that environmental
and host factors such as behaviors might influence the development of
disease. Cholera which is often called the "father of public health"
appeared time and again in the western world during the 19th century.
An English epidemiologist, John Snow, studied the epidemiology of
cholera in London from 1848 to 1854 and established the role of
polluted drinking water in the spread of cholera.
Although of ancient lineage, it made only slow progress up to the start of
20th century where epidemiology has evolved rapidly during the past
few decades. Its ramifications cover not only study of disease
distribution and causation (and thereby prevention), but also health and
health-related events occurring · in human population. Modern
epidemiology has entered the most exciting phase of its evolution. By
identifying risk factors of chronic disease, evaluating treatment
modalities and health services, it has provided new opportunities for
prevention, treatment, planning and improving the effectiveness and
efficiency of health services.
The period since World War II has seen an explosion in the development
of research methods and the theoretical underpinnings of epidemiology.
Epidemiology has been applied to the entire range of health-related
outcomes, behaviors, and even knowledge and attitudes. The studies by
Doll and Hill linking lung cancer to smoking and the study of
cardiovascular disease among residents of Framingham, Massachusetts
are two examples of how pioneering researchers have applied
epidemiologic methods to chronic disease since World War II. During the
1960s and early 1970s health workers applied epidemiologic methods to
eradicate naturally occurring smallpox worldwide. This was an
achievement in applied epidemiology of unprecedented proportions. In
the 1980s, epidemiology was extended to the studies of injuries and
violence. In the 1990s, the related fields of molecular and genetic
epidemiology (expansion of epidemiology to look at specific pathways,
molecules and genes that influence risk of developing disease) took root.
Meanwhile, infectious diseases continued to challenge epidemiologists
as new infectious agents emerged (Ebola virus, Human
Immunodeficiency virus (HIV)/ Acquired Immunodeficiency Syndrome
(AIDS)), were identified (Legionella, Severe Acute Respiratory Syndrome
(SARS)), or changed (drug-resistant Mycobacterium tuberculosis, Avian
influenza). Beginning in the 1990s and accelerating after the terrorist
attacks of September 11, 2001, epidemiologists have had to consider not
only natural transmission of infectious organisms but also deliberate
spread through biologic warfare and bioterrorism. Today, public health
workers throughout the world accept and use epidemiology regularly to
characterize the health of their communities and to solve day-to-day
problems, large and small.

Definition of Epidemiology
The word epidemiology comes from the Greek words epi, meaning on or
upon, demos, meaning people, and logos, meaning the study of. In other
words, the word epidemiology has its roots in the study of what befalls a
population.
Epidemiology is a scientific study of factors and conditions related to
disease as they occur in people.
Epidemiology is the basic science of preventive and social medicine.
epidemiology was laid in the 19th There appears to be almost as many
definitions of epidemiology as there are authors who have written on
the subject, ranging from Hippocrates to those of the present day. A
short list is given below
1. That branch of medical science which treats epidemics (Parkin, 1873).
2. The science of the mass phenomena of infectious diseases (Frost,
1927).
3. The study of disease, any disease, as a mass phenomenon
(Greenwood, 1934)
4. The study of the distribution and determinants of disease frequency in
man (MacMahon, 1960).
Many definitions have been proposed, but the following definition
captures the underlying principles and public health spirit of
epidemiology
Epidemiology 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 control of health problems.

Epidemiology, like public health itself, is often more concerned with the
well-being of society as a whole, than with the well-being of individuals.
Although there is no single definition to which all epidemiologists
subscribe, three components are common to most of them. First, studies
of disease frequency; second, studies of the distribution; and third,
studies of the determinants. Each of these components confers an
important message.
Key terms in this definition reflect some of the important principles of
epidemiology
Study Epidemiology is a scientific discipline with sound methods of
scientific inquiry at its foundation. Epidemiology is data-driven and relies
on a systematic and unbiased approach to the collection, analysis, and
interpretation of data. Basic epidemiologic methods tend to rely on
careful observation and use of valid comparison groups, epidemiology
also draws on methods from other scientific fields, including biostatistics
and informatics, with biologic, economic, social, and behavioral sciences.
In fact, epidemiology is often described as the basic science of public
health. Epidemiology is not just a research activity but an integral
component of public health, providing the foundation for directing
practical and appropriate public health action based on this science and
causal reasoning.
Distribution Epidemiology is concerned with the frequency and pattern
of health events in a population, Inherent in the definition of
epidemiology is measurement of frequency of disease, disability or
death. Frequency refers not only to the number of health events such as
the number of cases of meningitis or diabetes in a population, but also
to the relationship of that number to the size of the population, and
summarizing this information in the form of rates and ratios. The
resulting rate allows epidemiologists to compare disease occurrence
across different populations.
Pattern refers to the occurrence of health-related events by time, place,
and person. Time patterns may be annual, seasonal, weekly, daily,
hourly, weekday versus weekend, or any other breakdown of time that
may influence disease or injury occurrence. Place patterns include
geographic variation, urban/rural differences, and location of work sites
or schools. Personal characteristics include demographic factors which
may be related to risk of illness, injury, or disability such as age, sex,
marital status, and socioeconomic status, as well as behaviors and
environmental exposures. An important outcome of this study is
formulation of an etiological hypothesis. This aspect of epidemiology is
known as "descriptive epidemiology".
Determinants Epidemiology is also used to search for determinants,
which are the causes and other factors that influence the occurrence of
disease and other health-related events. Epidemiologists assume that
illness does not occur randomly in a population, but happens only when
the right accumulation of risk factors or determinants exists in an
individual. To search for these determinants, a unique feature of
epidemiology is to test etiological hypotheses and identify the
underlying causes (or risk factors) of disease. This requires the use of
epidemiological principles and methods. This is the real substance of
epidemiology. This aspect of epidemiology is known as "analytical
epidemiology". Analytical strategies help in developing scientifically
sound health programmers, interventions and policies. In recent years,
analytical studies have contributed vastly to our understanding of the
determinants of chronic diseases, e.g., lung cancer and cardiovascular
diseases.
Epidemiologists use analytic epidemiology or epidemiologic studies to
provide the “Why” and “How” of such events. They assess whether
groups with different rates of disease differ in their demographic
characteristics, genetic or immunologic make-up, behaviors,
environmental exposures, or other so-called potential risk factors.
Ideally, the findings provide sufficient evidence to direct prompt and
effective public health control and prevention measures.
Health-related states or events Epidemiology was originally focused
exclusively on epidemics of communicable diseases but was
subsequently expanded to address endemic communicable diseases and
non-communicable infectious diseases. By the middle of the 20th
Century, additional epidemiologic methods had been developed and
applied to chronic diseases, injuries, birth defects, maternal-child health,
occupational health, and environmental health. Then epidemiologists
began to look at behaviors related to health and well-being, such as
amount of exercise and seat belt use. Now, with the recent explosion in
molecular methods, epidemiologists can make important strides in
examining genetic markers of disease risk. Indeed, the term
healthrelated states or events may be seen as anything that affects the
well-being of a population. Nonetheless, many epidemiologists still use
the term “disease” as shorthand for the wide range of health-related
states and events that are studied.
Specified populations Although epidemiologists and direct health-care
providers (clinicians) are both concerned with occurrence and control of
disease, they differ greatly in how they view “the patient.” The clinician
is concerned about the health of an individual; the epidemiologist is
concerned about the collective health of the people in a community or
population. In other words, the clinician’s “patient” is the individual; the
epidemiologist’s “patient” is the community. Therefore, the clinician and
the epidemiologist have different responsibilities when faced with a
person with illness. For example, when a patient with diarrheal disease
presents, both are interested in establishing the correct diagnosis.
However, while the clinician usually focuses on treating and caring for
the individual, the epidemiologist focuses on identifying the exposure or
source that caused the illness; the number of other persons who may
have been similarly exposed; the potential for further spread in the
community; and interventions to prevent additional cases or
recurrences.
Application Epidemiology is not just “the study of” health in a
population; it also involves applying the knowledge gained by the studies
to community-based practice.
Like the practice of medicine, the practice of epidemiology is both a
science and an art. To make the proper diagnosis and prescribe
appropriate treatment for a patient, the clinician combines medical
(scientific) knowledge with experience, clinical judgment, and
understanding of the patient. Similarly, the epidemiologist uses the
scientific methods of descriptive and analytic epidemiology as well as
experience, epidemiologic judgment, and understanding of local
conditions in “diagnosing” the health of a community and proposing
appropriate, practical, and acceptable public health interventions to
control and prevent disease in the community.
Summary Epidemiology is the study (scientific, systematic, data-driven)
of the distribution (frequency, pattern) and determinants (causes, risk
factors) of health-related states and events (not just diseases) in
specified populations (patient is community, individuals viewed
collectively), and the application of (since epidemiology is a discipline
within public health) this study to the control of health problems.

Epidemiological approach
The epidemiological approach to problems of health and disease is
based on two major foundations:
a. Asking questions
Epidemiology has been defined as "a means of learning or asking
questions .... and getting answers that lead to further questions

RELATED TO HEALTH EVENTS: What is the event? (the problem)

What is its magnitude? Where did it happen? When did it
happen? Who are affected? Why did it happen?
 RELATED TO HEALTH ACTION: What can be done to reduce this
problem and its consequences? How can it be prevented in the
future? What action should be taken by the community? By the
health services? By other sectors? Where and for whom these
activities be carried out? What resources are required? How are
the activities to be organized? What difficulties may arise, and
how might they be overcome?
Answer to the above questions may provide clues to disease
etiology, and help the epidemiologist to guide planning and
evaluation.

b. Making comparisons.
The basic approach in epidemiology is to make comparisons and
draw inferences. This may be comparison of two (or more groups}
- one group having the disease (or exposed to risk factor) and the
other group(s) not having the disease (or not exposed to risk
factor}, or comparison between individuals. By making
comparisons, the epidemiologist tries to find out the crucial
differences in the host and environmental factors between those
affected and not affected. Clues to aetiology come from such
comparisons.

Core Epidemiologic Functions

In the mid-1980s, five major tasks of epidemiology in public health
practice were identified:
1. Public health surveillance
2. Field investigation
3. Analytic studies
4. Evaluation
5. Linkages.
6. A sixth task, policy development, was recently added.
Public health surveillance Public health surveillance is the ongoing,
systematic collection, analysis, interpretation, and dissemination of
health data to help guide public health decision making and action.
Surveillance is equivalent to monitoring the pulse of the community. The
purpose of public health surveillance, which is sometimes called
“information for action,” is to portray the ongoing patterns of disease
occurrence and disease potential so that investigation, control, and
prevention measures can be applied efficiently and effectively. This is
accomplished through the systematic collection and evaluation of
morbidity and mortality reports and other relevant health information,
and the dissemination of these data and their interpretation to those
involved in disease control and public health decision making.
Morbidity and mortality reports are common sources of surveillance
data for local and state health departments. These reports generally are
submitted by health-care providers, infection control practitioners, or
laboratories that are required to notify the health department of any
patient with a reportable disease such as pertussis, meningococcal
meningitis, or AIDS. Other sources of health-related data that are used
for surveillance include reports from investigations of individual cases
and disease clusters, health program data such as immunization
coverage in a community, disease registries, and health surveys. Most
often, surveillance relies on simple systems to collect a limited amount
of information about each case.
Field investigation As noted above, surveillance provides information for
action. One of the first actions that results from a surveillance case
report or report of a cluster is investigation by the public health
department. The investigation may be as limited as a phone call to the
healthcare provider to confirm or clarify the circumstances of the
reported case, or it may involve a field investigation requiring the
coordinated efforts of dozens of people to characterize the extent of an
epidemic and to identify its cause. The objectives of such investigations
also vary. Investigations often lead to the identification of additional
unreported or unrecognized ill persons who might otherwise continue to
spread infection to others. For example, one of the hallmarks of
investigations of persons with sexually transmitted disease is the
identification of sexual partners or contacts of patients. When
interviewed, many of these contacts are found to be infected without
knowing it, and are given treatment they did not realize they needed.
Identification and treatment of these contacts prevents further spread.
Occasionally, the objective of an investigation may simply be to learn
more about the natural history, clinical spectrum, descriptive
epidemiology, and risk factors of the disease before determining what
disease intervention methods might be appropriate.
Analytic studies Surveillance and field investigations are usually
sufficient to identify causes, modes of transmission, and appropriate
control and prevention measures. But sometimes analytic studies
employing more rigorous methods are needed. Often the methods are
used in combination — with surveillance and field investigations
providing clues or hypotheses about causes and modes of transmission,
and analytic studies evaluating the credibility of those hypotheses.
Clusters or outbreaks of disease frequently are investigated initially with
descriptive epidemiology. The descriptive approach involves the study of
disease incidence and distribution by time, place, and person. It includes
the calculation of rates and identification of parts of the population at
higher risk than others. Occasionally, when the association between
exposure and disease is quite strong, the investigation may stop when
descriptive epidemiology is complete and control measures may be
implemented immediately. John Snow’s 1854 investigation of cholera is
an example. More frequently, descriptive studies, like case
investigations, generate hypotheses that can be tested with analytic
studies. While some field investigations are conducted in response to
acute health problems such as outbreaks, many others are planned
studies. The hallmark of an analytic epidemiologic study is the use of a
valid comparison group. Epidemiologists must be skilled in all aspects of
such studies, including design, conduct, analysis, interpretation, and
communication of findings.
• Design includes determining the appropriate research strategy and
study design,
• Conduct
• Analysis
• Finally, interpretation involves putting the study findings into
perspective, identifying the key take-home messages, and making sound
recommendations.
Evaluation Epidemiologists, have come to play an important role in
evaluation of public health services and other activities. Evaluation is the
process of determining, as systematically and objectively as possible, the
relevance, effectiveness, efficiency, and impact of activities with respect
to established goals. The evaluation itself may focus on plans (formative
evaluation), operations (process evaluation), impact (summative
evaluation), or outcomes — or any combination of these. Evaluation of
an immunization program, for example, might assess the efficiency of
the operations, the proportion of the target population immunized, and
the apparent impact of the program on the incidence of vaccine-
preventable diseases. its usefulness.
Linkages Epidemiologists working in public health settings rarely act in
isolation. In fact, field epidemiology is often said to be a “team sport.”
During an investigation an epidemiologist usually participates as either a
member or the leader of a multidisciplinary team. Other team members
may be laboratorians, sanitarians, infection control personnel, nurses or
other clinical staff, and, increasingly, computer information specialists.
Policy development The definition of epidemiology ends with the
following phrase: “...and the application of this study to the control of
health problems.” , epidemiologists who understand a problem and the
population in which it occurs are often in a uniquely qualified position to
recommend appropriate interventions. As a result, epidemiologists
working in public health regularly provide input, testimony, and
recommendations regarding disease control strategies, reportable
disease regulations, and health-care policy.