Epidemiology 6th Semester BSN Notes, Educational Platform

Epidemiology Course Syllabus
Unit 1: Introduction of Epidemiology Unit 6: Epidemiological transitions in disease patterns

• Use of epidemiology • Health and demographic transition
• Scope of Epidemiology • Population changes (population pyramid)
Unit 2: Concept of Health & Disease • Factors affecting population change (dependency
• Health ratio, sex ratio)
• Health indicator • Changes in life expectancy
• Disease • Changes in major causes of death
• Concept of causation Unit 7: Epidemiological Methods
• Illness • Description – Person, place and Time
• Well being
• Analytical: Basic Concepts of Cross Sectional
• Determinants of disease in individuals and Prospective & Retrospective
community
• Intervention / Experimental study
Unit 3: Epidemiological Models
Unit 8: Surveillance and notification
• Natural History of Disease
• Web of causation • Define the term surveillance.
• Triad • Discuss the principles of surveillance and
Unit 4: Concept of Prevention
notification
• Primary • Describe different methods.
• Secondary • Identify nurses’ role in surveillance
• Tertiary • Health indicators
Unit 5: Basic Measurement Unit 9: Screening
• Mortality, Morbidity, Rate, Ratio, • Definition
• Incidence, Prevalence • Types
• Maternal and Infant rates Unit 10: Data management and presentation
Introduction to the
Fundamentals of Epidemiology
Muhammad Aurangzeb
BSN & Master in Public Health (KMU)
Assistant Teacher INS/KMU
Objectives :
• At the end of this presentation the student will be

able to:
• Define epidemiology
• Discuss type of epidemiology
• Enlist uses of epidemiology
• Describe scope of epidemiology.

2
What is Epidemiology?
• Epidemiology, literally meaning "the study of what

is upon the people", is derived from Greek epi,
meaning "upon, among", demos, meaning "people,
district", and logos, meaning "study, ",
• It applies only to human populations

• It is the study of how disease is distributed in
population and of the factors that influence or
determine this distribution.
(Gordis, 1996)
• Study of disease and other health related
phenomena in groups of persons
(kramer, 1990)
5
Definitions of Epidemiology
Oxford English Dictionary
The branch of medical science which treats of

epidemics
Kuller LH: Am J Epid 1991
Epidemiology is the study of "epidemics" and their

prevention
Definitions of Epidemiology
The study of distribution and determinants of
health, disease, or injury in human populations and
the application of this study to the control of health
problem
Epidemiology
• Epidemiology is the study of the determinants,

distribution, and frequency of disease
• Who gets disease and why
• Epidemiologists study sick and well people to determine
the crucial difference between those who get disease
and those who are spared
• Some describe it as the study of epidemics
• What is an epidemic?
• An epidemic occurs when there are significantly

more cases of the same disease than past
experience would have predicted.
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Is Epidemiology a Science?
•What are the characteristics of a

science?
•What disciplines are sciences?
•What disciplines are not sciences?
•How do they differ from sciences?
•Is public health a science?
•Is epidemiology a science?
Is Epidemiology a Science?
•Science is a creative endeavor

•It relies on questioning,
imagination, exploration
•It seeks out empirical evidence
•It tests ideas
•Study questions
•Hypotheses
What Is The Unique Skill Of
Epidemiologists?
Measuring disease
frequency in
populations
Epidemiology
•Epidemiology weighs and balances

•Epidemiology contrasts and compares
•Epidemiologists use RATES
• events/population at risk
Epidemiology
•Numerator
•the number of people to whom something
happened (i.e. they got sick, died, etc.)
•Denominator
•the population at risk -- all the people at risk
for the event
Uses of Epidemiology
•To study the cause (or etiology) of disease(s), or

conditions, disorders, disabilities, etc.
•determine the primary agent responsible or
ascertain causative factors
•determine the characteristics of the agent or
causative factors
•define the mode of transmission
•determine contributing factors
•identify and determine geographic patterns
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
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.
•In other words:
• To minimize or eradicate the disease
• To prevent the re-occurrence
Two Broad Types of Epidemiology
DESCRIPTIVE EPIDEMIOLOGY ANALYTIC EPIDEMIOLOGY
Examining the distribution Testing a specific hypothesis
of a disease in a population, about the relationship of a
and observing the basic disease to a putative cause,
features of its distribution in by conducting an
terms of time, place, and epidemiologic study that
person. relates the exposure of
interest to the disease of
Typical study design: interest.
community health survey Typical
(approximate synonyms - study designs: cohort, case-
cross-sectional study, control
descriptive study)
Descriptive Epidemiology is the
Antecedent to Analytical Epidemiology
•Analytic epidemiology studies
require information to ….
•know where to look

•know what to control for
•develop viable hypotheses
Three essential characteristics of disease that
we look for in descriptive studies are...
•Person
•Place
•Time
Person
•Age, gender, ethnicity

•Genetic predisposition
•Concurrent disease
•Diet, exercise, smoking
•Risk taking behavior
•SES, education, occupation
Place
•Geographic place
•Presence or agents or vectors
•Climate
•Population density
•Economic development
•Nutritional practices
•Medical practices
Time
•Time since an event

•Physiologic cycles
•Age (time since birth)
•Seasonality
•Temporal trends
Example
•You have been asked to investigate an

event in which 2,220 people were exposed
and 1,520 of them died.
•Your role as an epidemiologist is to ask
questions about person, place and time.
How do we ask questions?
Surveys
-of survivors
-of next-of-kin
-of other related persons
with questions you learn that ...
•Person: Men, women and children were all
exposed and at risk. The majority of people
who died were wealthy and young men
between 18-50 years (when compared to
survivors).
•Place: All those exposed were within 1 block of
one another, the climate was cold.
•Time: Mid April, people died within hours of
the precipitating exposure.
Epidemiologic Activities
•Descriptive epidemiology – person, place

& time
• Demographic distribution
• Geographic distribution
• Seasonal patterns etc.
• Frequency of disease patterns
•Useful for:
• Allocating resources
• Planning programs
• Hypotheses development
Epidemiologic Activities
•Analytic epidemiology
•built around the analysis of the
relationship between two items
• Exposures
• Effects (disease)
•looking for determinants or possible
causes of disease
•useful for
• hypothesis testing
The Basic Triad Of
Analytic Epidemiology
The three phenomena assessed in analytic
epidemiology are:
HOST
AGENT ENVIRONMENT
Agents is an organism or substance, the presence or lack
of which may initiate disease process
Agents may be living or non living

• Poisons
• Allergens
• Radiation
• Physical trauma
• Microbes
• Psychological experiences
Host Factors
the host is the human himself and his characteristics
• Genetic
• Immunologic state
• Age
• Personal behavior
Environment
(environment act as a reservoir for the agent of disease
• Crowding
• Atmosphere
• Modes of communication – phenomena in the
environment that bring host and agent together,
such as:
• Vector
• Vehicle
• Reservoir
Classification of Environment
• Physical environment: it is the space around man

containing gases (air), liquids (water) and solids.
• Biological environment: all living thing that

surrounds man, both animals and plants.
• Social environment: it includes the customs, habits,

culture, education and living standards.
35
REFERENCE
• Principles of Epidemiology in Public Health

Practice, Third Edition An Introduction to
Applied Epidemiology and Biostatistics
• http://www.cdc.gov/ophss/csels/dsepd/ss1978/
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Unit-II Concept of Health & Disease
Muhammad Aurangzeb
BSN & MPH (Khyber Medical University)
Assistant Teacher INS/KMU
Educational Platform
Objectives :
• At the end of this presentation the student will be

able to:
• Discuss the terms of Health, Disease, Well being.
• Describe the concept of causation.
• Understand the Health indicator.
2
CONCEPT OF HEALTH
• Health is evolved over the centuries. Changing
concept of health till now are:
– Biomedical concept
– Ecological concept
– Psychosocial concept
– Holistic concept
3
BIOMEDICAL CONCEPT
• Traditionally, health has been viewed as an
“absence of disease”, and if one was free from
disease, then the person was considered healthy.
• This concept has the basis in the “germ theory of
disease”.
• The medical profession viewed the human body
as a machine, disease as a consequence of the
breakdown of the machine and one of the
doctor’s task as repair of the machine.
4
ECOLOGICAL CONCEPT
• Form ecological point of view; health is
viewed as a dynamic equilibrium between
human being and environment, and disease a
maladjustment of the human organism to
environment.
• According to Dubos “Health implies the
relative absence of pain and discomfort and a
continuous adaptation and adjustment to the
environment to ensure optimal function.”
5
PSYCHOSOCIAL CONCEPT
• According to psychosocial concept “health is
not only biomedical phenomenon, but is
influenced by social, psychological, cultural,
economic and political factors of the people
concerned.”
6
HOLISTIC CONCEPT
• This concept is the synthesis of all the above
concepts.
• It recognizes the strength of social, economic,
political and environmental influences on
health.
• It described health as a multi dimensional
process involving the wellbeing of whole
person in context of his environment .
7
WHAT IS Health?
• “A state of complete
physical, mental, and
social well-being and
not merely the
absence of disease or
infirmity”
WHO. (1948).
8
RISK FACTORS & DETERMINANTS
• Risk Factor is any attribute, characteristic or

exposure of an individual that increases the
likelihood of developing a disease or injury.
• Some examples of the more important risk factors

are underweight, unsafe sex, high blood pressure,
tobacco and alcohol consumption, and unsafe
water, sanitation and hygiene.
• Determinant of Health: Many factors combine

together to affect the health of individuals and
communities.
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determinants of health
• The determinants of
health include:
1. Socio- economic
2. Physical
3. Person’s individual
characteristics &
behaviours.
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DETERMINANTS OF HEALTH
Genetic
s&
Biologic Behavi
Human oral
Right al
Environ
Equity mental
and
social
justice Communiti
es
Socio-
Famili Health Econo
Gender Societi mic
es
es
Informati
on &
Individua Health
communi ls Service
cation System
Science Socio-
and Aging Cultural
Technol of the
ogy populat
ion 11
Well-being
• "Well-being is a subjective perception of

vitality (energy) and feeling well.....can be
described objectively, experienced, and
measured......and can be plotted ( design) on
a continuum". It is a component of health.
CONCEPT OF WELLBEING
• Wellbeing of an individual or group of
individuals have several components and has
been expressed in various ways, such as
‘standard of living’ or ‘level of living’ and
‘quality of live’.
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WELLBEING
• Wellbeing of an individual or group of
individuals have objective (standard of living
or level of living) and subjective (quality of
life) components.
• Thus, a distinction is drawn between the
concept of ‘level of living’ consisting of
objective criteria and of ‘quality of life’
comprising the individual’s own subjective
evaluation of these.
14
TWO ASPECTS OF HEALTH

• Subjective: It is formed by sensations and feelings
of a person suffering from disease.
• Objective: Its basis is formed by objective
parameters obtained by measurement of
structures and functions of a person during
disease.
• The quality of life can be evaluated by assessing
the persons subjective feeling of happiness or
unhappiness about the various life concerns.
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Wellness & Well-Being
• Wellness further describes health status. It

allows health to be placed on a continuum
from one’s optimal level (“wellness”) to a
maladaptive state (“illness”)
Wellness
• Wellness is a dynamic process that is ever
changing. The well person usually has some
degree of illness and the ill person usually has
some degree of wellness.
Cont…
• The classic description of wellness was
developed by Dunn in the early 1960s.
According to Dunn (1961), high-level wellness
means functioning to one’s maximum health
potential while remaining in balance with the
environment.
Health-Illness Continuum
• Measure person’s perceived level of wellness
• Health and illness/disease opposite ends of a health
continuum
• Move back and forth (forward) within this continuum day by
day
• Wide ranges of health or illness
Copyright 2008 by Pearson Education, Inc.

Dimensions of Wellness
Copyright 2008 by Pearson Education, Inc.

1. Physical
• The ability to carry out daily tasks, achieve
fitness (e.g. pulmonary, cardiovascular,
gastrointestinal), maintain adequate nutrition
and proper body fat, avoid abusing drugs and
alcohol or using tobacco products, and
generally to practice positive lifestyle habits.
2. Social.
• The ability to interact successfully with people
and within the environment
3. Emotional.
• The ability to manage stress and to express
emotions appropriately, Emotional wellness
involves the ability to recognize, accept, and
express feelings.
4. Intellectual.
• The ability to learn and use information
effectively for personal, family, and career
development
5. Spiritual.
• The belief in some force (nature, science,
religion, or a higher power) that serves to
unite human beings and provide meaning and
purpose of life
6. Occupational.
• The ability to achieve a balance between work
and leisure time, A person's beliefs about
education, employment, and home influence
personal satisfaction and relationships with
others.
7. Environmental.
• The ability to promote health measures that
improve the standard of living and quality of
life in the community
CONCEPT OF DISEASE
• Webster defines disease as “a condition in
which body health is impaired, a departure
from a state of health, an alteration of the
human body interrupting the performance of
vital functions”.
• The oxford English Dictionary defines disease
as “ a condition of the body or some part or
organ of the body in which its functions are
disturbed or deranged”.
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CONCEPT OF DISEASE
• Ecological point of view disease is defined as
“a maladjustment of the human organism to
the environment.”
• The simplest definition is that disease is just
the opposite of health: i.e. any deviation from
normal functioning or state of complete
physical or mental well-being.
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Distinction between Disease,

Illness and Sickness
• The term disease literally means “without
ease” (uneasiness), when something is wrong
with bodily function.
• Illness refers to the presence of a specific
disease, and also to the individual’s
perceptions and behavior in response to the
disease, as well as the impact of that disease
on the psychosocial environment.
• Sickness refers to a state of social dysfunction.
30
Distinction between Disease,

Illness and Sickness
• Disease is a physiological/psychological
dysfunction.
• Illness is a subjective state of the person who
feels aware of not being well.
• Sickness is a state of social dysfunction i.e. a
role that the individual assumes when ill
(sickness role).
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MODELS/THEORIES OF DISEASE CAUSATION
• Human disease results from an interaction of the

– Host
– Agent
– Environment
• Disease causation is usually described in terms of
four models:
1. Germ theory
2. Epidemiologic Triad
3. Wheel of Causation
4. Web of Causation
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Epidemiological Triad
• The best known, but most dated model of disease
(communicable) is the “Epidemiologic Triad”.
• According to this model disease results from an

interaction among;
i. Agent
ii. Host
iii. Environment
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1. Agent — cause of the disease

2. Host — Living things, usually humans or
animals, which are exposed to and harbor
a disease.
3. Environment —external factors that
cause or allow disease transmission.
35
• The mere presence of

agent, host and
environmental factors is
not sufficient to start the
disease in man.
• It is the interaction of
theses factors; that is
required to initiate the
disease process in man.
36
EPIDEMIOLOGICAL TRIAD: EXAMPLES
37
EPIDEMIOLOGICAL TRIAD
38
DISEASE AGENTS
• Biologic (Infectious
agents, insect and animal
allergens)
• Chemical (Air pollutants,

toxic wastes, pesticides)
• Physical (Noise,
radiation, heat, cold,
electricity)
39
AGENTS
• Mechanical Agents
(Exposure to chronic
friction & other
mechanical forces may
result in crushing,
tearing, sprains,
dislocation& even death)
• Social (poverty, access

to health care, social
isolation, deprivation)
40
Web of causation
• McMahon and Pugh forwarded the theory of

“epidemiological web of causation”,
wherein the various factors (e.g.
hypercholesterolemia, smoking,
hypertension) are like an interacting web of a
spider.
• Each factor has its own relative importance

in causing the final departure from the state
of health, as well as interacts with others,
modifying the effect of each other.
41
WEB OF CAUSATION
42
The Wheel of Causation
• Wheel theory:
• As medical knowledge advanced, an additional

aspect of interest that came into play is the
comparative role of “genetic” and the
“environmental” (i.e. extrinsic factors outside the
host) factors in causation of disease.
• The “triad” as well as the “web” theory does not

adequately cover up this differential.
• To explain such relative contribution of genetic and

environmental factors, the “wheel” theory has been
postulated (Mausner & Kramer, 1985) .
43
• The theory de-emphasizes

the agent as the sole cause
of disease.
• The theory visualizes

human disease in the form
of a wheel, which has a
central hub representing
the “genetic components”
and the peripheral portion
representing the
“environmental
component”.
44
• Like any wheel, the outer

part (environmental
component) has spokes (3
in this model) and the
environmental component
is thus divided into 3 sub
components;
1. Physical
2. Biological
3. Social
45
NATURAL HISTORY OF DISEASE
• The term “Natural History Of Disease” is a

key concept in epidemiology.
• Natural History of Disease refers to “the

uninterrupted progression of the disease
process in an individual over time, in the
absence of intervention”.
• Knowledge of the natural history of disease is

important for disease prevention and control.
46
• After contact with an infectious agent there is a

theoretical point at which the disease process
may begin.
• Without medical intervention, the process ends

with:
o Recovery
o Disability or
o Death
47
48
Spectrum of Disease
• In some people, however, the disease process
may never progress to clinically apparent
illness.
• In others, the disease process may result in

illness that ranges from mild to severe or fatal.
• This range is called the Spectrum of Disease.

49
Spectrum of Disease
• Because the spectrum of disease can include
asymptomatic and mild cases, the cases of illness
diagnosed by clinicians in the community often
represent only the tip of the iceberg.
• Many additional cases may be too early to diagnose
or may never progress to the clinical stage.
• Persons with inapparent or undiagnosed infections
may be able to transmit infection to others.
• Such persons who are infectious but have subclinical
disease are called carriers.
50
ICEBERG OF DISEASE PHENOMENON
• The Iceberg Phenomenon is the

representation of disease burden of a
community.
• Iceberg has two portions:
1. Tip of the ice berg

2. Submerged(hidden) part
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ICEBERG OF DISEASE
52
ICEBERG OF DISEASE PHENOMENON
• The floating tip represents the clinically apparent

cases; what the physician sees in his
practice/clinic/hospital etc.
• The clinically apparent cases represent only a small
fraction of the total cases of disease in the
community.
• The remaining large hidden part of the iceberg
represents the mass of unrecognized disease in the
community (e.g., subclinical cases, carriers,
undiagnosed cases);
• hidden from view of the general public or physician.
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INDICATORS OF HEALTH
• A variable which helps to measure changes , directly
or indirectly (WHO,1981).
• The health indicators are defined as those variables
which measures the health status of an individual and
community.
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• Mortality Indicators: Crude Death rate, Life
Expectancy, Infant mortality rate, Child mortality
rate, Under five mortality rate, Maternal mortality
ratio, Disease specific mortality, proportional
mortality rate etc.
• Morbidity Indicators: Incidence and prevalence rate,
OPD attendance rate, Admission, readmission and
discharge rate, duration of stay in hospital and spells
of sickness or absence from work or school.
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• Nutritional Status Indicators: Anthropometric
measurement of preschool children, Prevalence of
low birth weight etc.
• Health Care Delivery Indicators: Doctor-population
ratio, Bed-nurse ratio, Population-bed ratio,
Population per health facility etc.
• Utilization Rates: immunization coverage, ANC
coverage, % of Hospital Delivery, Contraceptives
prevalence rate, Bed occupancy rate, average length
of stay in hospital etc.
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• Indicators of social and mental health: Rates of
suicides, violence, crimes, RTAs, drug abuse, smoking
and alcohol consumption etc.
• Environmental indicators: proportion of population
having access to safe drinking water and improved
sanitation facility, level of air pollution, water pollution,
noise pollution etc.
• Socio Economic Indicators: rate of population increase,
Per capita GNP, Dependency ratio, Level of
unemployment, literacy rate, family size etc.
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UNIT-III
OBJECTIVES
 At the end of this session the students will be able to:

 Define Natural history of Disease.
 Define the term, Host, Agent and environment.
 Identify the concept of epidemiology and diseases with

the help of epidemiological Trait.
 Identify epidemiological approach in community
EPIDEMIOLOGIC TRIAD
A traditional model of infectious disease
causation, known as the Epidemiologic Triad.
 The triad consists of an external agent,
a host and an environment in which host and
agent are brought together, causing the disease
to occur in the host.
 A vector, an organism which transmits infection
by conveying the pathogen from one host to
another without causing disease itself, may be
part of the infectious process. 3
EXAMPLE
A classic example of a vector is
the Anopheles mosquito. As the mosquito
ingests blood from an infected host, it picks up
the parasite plasmodium.
 After being stored in the salivary glands and
then injected into the next human upon which
the mosquito feeds, the plasmodium can cause
malaria in the infected human.
 Thus, the Anopheles mosquito serves as a vector
for malaria. 4
CONT….
 In epidemiologic triad model, transmission
occurs when the agent leaves
its reservoir or host through a portal of exit, is
conveyed by a mode of transmission to enter
through an appropriate portal of entry to infect
a susceptible host.
 Transmission may be direct or indirect.
5
EPIDEMIOLOGICAL TRIAD
6
AGENT FACTORS
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 AGENTS
 Chemical (Air pollutants,

toxic wastes, pesticides)
 Physical (Noise,
radiation, heat, cold,
electricity)
8
AGENTS
 Mechanical Agents
(Exposure to chronic
friction & other mechanical
forces may result in
crushing, tearing, sprains,
dislocation& even death)
 Social (poverty, access to

health care, social isolation,
deprivation)
9
Contd…………
 Biological agents:
These are living agents of disease, viruses, fungi,
bacteria, protozoa.
Biological properties such as:

 Infectivity:
This is the ability of an infectious agent to invade
and multiply in a host:
Cont…
 Pathogenicity : This is the ability to induce clinically

apparent illness..
 Virulence: the proportion of clinical cases resulting in

severe clinical manifestations
HOST FACTORS
Host — Living things, usually humans or animals, which
are exposed to and harbor a disease.
The human host is referred to as “soil” and the disease

agent as “seed” . In some situations, host factors play a
major role in determining the outcome of an individuals
exposure to infection.eg. Tuberculosis.
CONT…
The host factors may be classified as;
 Demographic
 Biological
 Social and economic characteristics such as

socioeconomic status, education, occupation, stress ,
marital status , housing, etc.
 Lifestyle factors such as personality traits , living

habits, nutrition, physical exercise, use of alcohol,
drugs and smoking, behavioral patterns.
3 ENVIRONMENTAL FACTORS
For human beings the environment is not limited, as it
normally is for plants and animals, to a set of climatic
factors.
For Example, for man, social and economic

conditions are more important than the mean annual
temperature.
CONT….
 Physical
 Biological
 Psychosocial.
 Physical environment:
The term “physical environment” is applied to non-living
things and physical factors (e.g.. Air, water, soil, housing,
climate, geography, heat, light, noise, debris & radiation)
CONT….
 Biological environment:- The biological

environment is the universe of living things which
surrounds man, including man himself. The living
things are the viruses and other microbial agents,
insects, rodents animals and plants
 Psychosocial environment:- “Those factors

affecting personal health, health care and
community well-being that stem from the
psychosocial make-up of individuals and the
structure and functions of social groups.”
 The term “Natural History Of Disease” is a key concept in

epidemiology.
 Natural History of Disease refers to “the uninterrupted

progression of the disease process in an individual over
time, in the absence of intervention”.
 Knowledge of the natural history of disease is important for

disease prevention and control.
17
 After contact with an infectious agent (or following some

other physiopathologic event) there is a theoretical point
at which the disease process may begin.
 Without medical intervention, the process ends with:
o Recovery
o Disability or
o Death
18
19
20
 The disease process begins with the appropriate exposure

to or accumulation of factors sufficient for the disease
process to begin in a susceptible host.
 For an infectious disease, the exposure is a

microorganism.
 For cancer, the exposure may be a factor that initiates the

process, such as asbestos fibers or components in
tobacco smoke (for lung cancer).
21
 Subclinical Disease:
 After the disease process has been triggered, pathological

changes then occur without the individual being aware of
them.
 This stage of subclinical disease, extending from the time

of exposure to onset of disease symptoms, is usually
called the incubation period for infectious diseases.
 During this stage, disease is said to be asymptomatic (no

symptoms) or inapparent. 22
 Although disease is not apparent during the incubation

period, some pathologic changes may be detectable with
laboratory, radiographic, or other screening methods.
 Most screening programs attempt to identify the disease

process during this phase of its natural history, since
intervention at this early stage is likely to be more
effective than treatment given after the disease has
progressed and become symptomatic.
23
 Clinical Disease:
 The onset of symptoms marks the transition from

subclinical to clinical disease.
 Most diagnoses are made during the stage of clinical

disease.
 Ultimately, the disease process ends either in recovery,

disability or death.
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THE NATURAL HISTORY OF DISEASE IN A PATIENT
Preclinical Phase Clinical Phase
(A) (P) (S) (M) (D) (T)
 A ; Biologic onset of disease

 P ; Pathologic evidence of disease if Sought
 S ; Signs and symptoms of disease
 M ; Medical care sought
 D ; Diagnosis
 T ; Treatment
Gordis L. Epidemiology. WB Saunders Company. 1996
DISEASE PROCESS OUTCOMES
DISEASE
IMPAIRMENT
DISABILITY
HANDICAP
26
DISEASE PROCESS OUTCOMES
27
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THE NATURAL HISTORY OF A DISEASE
STIMULUS to
HOST REACTION RECOVERY
the HOST
interrelation of
Agent, Host and Latent Period (Pre- Symptoms, with or without Defects,
Environmental symptomatic) Signs(Clinical) Disability
factors
PREPATHOGE
PERIOD OF PATHOGENESIS
NESIS
Health
Promotion
Specific Disability Limitation
Early Diagnosis and Prompt Treatment,
Protection Rehabilitation
PRIMARY SECONDARY TERTIARY

TREATMENT
PREVENTION
( PREVENTION PREVENTION
Leavell's Level of Application of Preventive Medicine)
 Latent period
the time interval from infection to development of
infectiousness
 Infectious period
the time during which time the host can infect another
susceptible host
 Non-infectious period
the period when the host’s ability to transmit disease to

other hosts ceases
 Incubation period
the time interval between infection to development of

clinical disease
THE EPIDEMIOLOGIC APPROACH
 The practice of epidemiology relies on a systematic
approach. In very simple terms, the epidemiologist:
 Counts cases or health events, and describes them in
terms of time, place, and person;
 Divides the number of cases by an appropriate
denominator to calculate rates; and
 Compares these rates over time or for different groups
of people.
31
CONT…
 Before counting cases, however, the epidemiologist
must decide what a case is. This is done by developing a
case definition. Then, using this case definition, the
epidemiologist finds and collects information about the
case-patients. The epidemiologist then performs
descriptive epidemiology by characterizing the cases
collectively according to time, place, and person.
32
CONT..
 To calculate the disease rate, the epidemiologist divides
the number of cases by the size of the population.
Finally, to determine whether this rate is greater than
what one would normally expect, and if so to identify
factors contributing to this increase, the epidemiologist
compares the rate from this population to the rate in an
appropriate comparison group, using analytic
epidemiology techniques.
33
DEFINING A CASE
 Before counting cases, the epidemiologist must decide
what to count, that is, what to call a case. For that, the
epidemiologist uses a case definition. A case definition is
a set of standard criteria for classifying whether a
person has a particular disease, syndrome, or other
health condition. Some case definitions, particularly
those used for national surveillance, have been
developed and adopted as national standards that
ensure comparability.
34
COMPONENTS OF A CASE DEFINITION FOR OUTBREAK
INVESTIGATIONS
 A case definition consists of clinical criteria and,

sometimes, limitations on time, place, and person. The
clinical criteria usually include confirmatory laboratory
tests, if available, or combinations of symptoms
(subjective complaints), signs (objective physical
findings), and other findings
35
CRITERIA IN CASE DEFINITIONS
 A case definition may have several sets of criteria,
depending on how certain the diagnosis is. For example,
during an investigation of a possible case or outbreak of
measles, a person with a fever and rash might be
classified as having a suspected, probable, or confirmed
case of measles, depending on what evidence of
measles is present
 Suspected: Any febrile illness accompanied by rash
 Probable: A case that meets the clinical case definition,

has noncontributory or no serologic testing,
 Confirmed: A case that is laboratory confirmed or that
36
meets the clinical case definition.
REFERENCE
 Principles of Epidemiology in Public Health

 http://www.cdc.gov/ophss/csels/dsepd/ss1978/
 Video link:
http://www.healthynashville.org/index.php?mod
ule=InitiativeCenters&func=display&icid=14
37
THANK YOU
38
UNIT-IV
Level of Prevention
Bakhtyar Ali Shah
PhD (Scholar)
OBJECTIVES
At the completion of this unit students will be
able to:
 Define prevention
 Discuss the level of prevention
 Describe Primordial and Primary level of

prevention
 Discuss Secondary and Tertiary level of
prevention
2
PREVENTION; DEFINITION AND CONCEPT
 The goals of medical sciences are to:
3
1. Promote health,
2. Preserve health,
3. Restore health when it is impaired, and
4. Minimize suffering and distress
 These goals are embodied in the word "prevention”.

WHAT IS PREVENTION?
 “The action of stopping something from happening or

arising”.
DISEASE PREVENTION
 Disease prevention refers to deliberate actions to halt or

delay disease progression from one stage to the next.
 The prevention of disease obviously has a potentially

greater impact on public health than medical treatment.
5
LEVELS OF PREVENTION
 There are three levels of

disease prevention called
primary, secondary and
tertiary prevention.
 A fourth level, called

primordial prevention,
was later added.
6
PRIMORDIAL PREVENTION
 It is the prevention of the emergence or development of

risk factors in population groups in which they have not
yet appeared.
 Primordial prevention consists of measures that inhibit

the emergence of risk factors in the form of
environmental, economic, social, and behavioral
conditions and cultural patterns of living etc.
PRIMORDIAL PREVENTION
 The main intervention in

primordial prevention is
through “individual and
mass education”.
 Primordial prevention
targets whole population.
8
PRIMARY PREVENTION
 Primary prevention aims to prevent the disease from

occurring.
 Primary prevention seeks to reduce the frequency of new

cases of disease occurring in a population and, thus is
most applicable to persons who are in the stage of
susceptibility.
9
PRIMARY PREVENTION
 It signifies intervention in the pre-pathogenesis phase of

a disease or health problem.
 Primary prevention may be accomplished by measures of;
i. Health promotion
ii. Specific protection
PRIMARY PREVENTION
 Health promotion:
 These strategies include health education and health

promotion programs designed to foster healthier
lifestyles and environmental health programs designed to
improve environmental quality.
11
PRIMARY PREVENTION
 Specific protection:
 Specific examples of primary prevention measures

include;
i. Immunization against communicable diseases;
ii. Public health education about good nutrition, exercise,
iii. Chlorination and filtration of public water supplies
12
Primary Prevention of Cardiovascular Diseases
13
SECONDARY PREVENTION
 Secondary prevention attempts to reduce the number of

existing cases in a population.
 It is therefore, most appropriately aimed those in the

stage of pre-symptomatic disease or the early stage of
clinical disease.
 Its purpose is to cure disease, slow its progression, or

reduce its impact on individuals or communities.
14
SECONDARY PREVENTION
 Secondary prevention focuses on early detection and swift

treatment of disease.
15
 The specific interventions are:
i. Early diagnosis (e.g. Screening tests, and case finding

programs….) And
ii. Adequate treatment.
SCREENING FOR DISEASE
 A common approach to secondary prevention is

screening for disease.
 It is search for unrecognized disease or defect by means

of rapidly applied tests, examinations or procedures in
apparently healthy population.
 Screening is performed to detect disease early so prompt

treatment can be initiated.
16
SCREENING FOR DISEASE
 Examples of screening include;
 Mammography for breast cancer detection;

 Eye tests for glaucoma;
 Occult blood tests for colorectal cancer;
 The Pap smear for cervical cancer
 The Prostate-Specific Antigen(PSA) test for prostate

cancer.
17
TYPES OF SCREENING
 Mass Screening:
 Involves the whole population.

 Example: Measure the B.P of all adults in a population.
TYPES OF SCREENING
 Targeted Screening:
 Selected groups who are anticipated to have an

increased prevalence of the condition for which
screening has been instituted.
 Example: Measuring the blood cholesterol in relatives

of people with familial hyperlipidemia
CRITERIA FOR SCREENING PROGRAMS
 There are WHO guidelines for deciding when screening is

appropriate, drawn up by Wilson and Jungner in 1968;
1. Condition should be an important health problem

2. The natural history should be well understood.
3. There should be a detectable early stage.
4. There should be a suitable test for the early stage.
5. The test should be acceptable to the population to be
screened.
6. The cost should be balanced against benefits.
DISEASE TREATMENT
 Examples of other secondary prevention methods include

treatment of hypertension to prevent complications and
removal of skin cancer lesions as they occur.
21
TERTIARY PREVENTION
 Tertiary prevention tries to limit disability and improve

functioning following disease or its complications, often
through rehabilitation.
 Therefore, it is most applicable during the late clinical

stage or the stage of diminished capacity.
 Aim of Tertiary prevention is to promote the patients’

adjustment to irremediable conditions.”
22
TERTIARY PREVENTION
 Intervention that should be

accomplished in the stage of
tertiary prevention are;
i. Disability limitation
ii. Rehabilitation (the combined
and coordinated use of
medical, social, educational,
and vocational measures for
training and retraining the
individual to the highest
possible level of functional
23
ability)
TERTIARY PREVENTION
 Examples include;
i. treatment of diabetics to prevent complication of the

disease and
ii. the ongoing management of chronic heart disease
patients with medication, diet, exercise, and periodic
examination.
24
• the combined and coordinated use of medical, social,
educational, and vocational measures for training and
retraining the individual to the highest possible level of
functional ability
REHABILITATION
Medical Vocational Social Psychological

rehabilitation rehabilitation rehabilitation rehabilitation
25
LEVELS OF PREVENTION
 The natural history of disease and the levels of
26
prevention are closely linked.
 When, Where and to whom apply levels of prevention?

27
28
REFERENCES
 Principles of Epidemiology in Public Health Practice,
Third Edition An Introduction to Applied Epidemiology
and Biostatistics
 http://www.cdc.gov/
29
THANK YOU
30
Unit-V
Basic Measurement In Epidemiology
Objectives
At the end of this session the student will be able to:-
• Understand the concept Mortality, Morbidity
• Discuss the Rate, Ratio, Incidence, and Prevalence
• Identify the Maternal and Infant rates in the specific

community
Mortality
• Mortality: is the term used for the number of people
who died within a population
• Mortality rate: , a measure of the number of deaths

in a given population
Morbidity
• Morbidity refers to the state of being diseased or
unhealthy within a population.
OR
• The extent of illness, injury or disability in a defined

population.
• Morbidity rate: a measure of diseases in a given

population, E.g. prevalence rate, incidence rate etc.
Measures of disease
frequency
Summary Measures
• Public health questions are about populations
• Information about population characteristics is often

summarized in an index
• Changes in population characteristics can be

assessed by comparing summary measures
Rates, Ratios, Proportions
• Three general classes of mathematical parameters.
• Often used to relate the number of cases of a disease
[numerator] or health outcome to the size of the
source population [denominator] in which they
occurred.
• Numerator (“case”) has to be defined
• Denominator (“population size”) has to be defined

Ratio
• Obtained by dividing one quantity by another. These
quantities may be related or may be totally independent.
• Usually expressed as: X/Y
• Example: Number of stillbirths per thousand live births.

Number of still births/number of live births x 1000
• “Ratio” is a general term that includes Rates and Proportions.
• Dictionary: “The value obtained by dividing one quantity by

another.” *Porta 2008+
Examples of Ratios: Example 1
• Ratio= Observed cases of AIDS in country A in June/ expected
number of AIDS cases in County A during June
• Example: 40 cases / 20 cases = 2

• No units
Examples of Ratios: Example 2
• R = number of hospitals / (population size)
• R may be multiplied by k = 10,000
• Units = hospitals per 10,000 people
• Suppose R = 4 hospitals/20,000 people = 0.0002

hospitals per person
• R*k = 0.0002 * 10,000 = 2 hospitals per 10,000
people
• Units = hospitals per 10,000 people
Proportion
• A ratio in which the numerator (x) is included in the
denominator (y)
• Example: The number of fetal deaths out of the total number
of births.
Number of fetal deaths/live births + still birth X 100
• Answer often read as a percent.
• Dictionary: “A type of ratio in which the numerator in included
in the denominator.” *Porta 2008+
Properties of Proportions
• n = the number of individuals in a population
• X = the number of individuals in the same population possess

characteristic C
• p= proportion in the population with characteristic C is equal

to x/n
Properties of Proportions
• p takes on values between 0 and 1 (p is a fraction)
• p has no units
• p may be multiplied by a constant k

− Where k is a number such as 100, 1,000, or 100,00
Example of Proportion
• Proportionate mortality
• In 1995, 53% of all deaths in Africa were children under age

5
• p = 0.53 = 53% = 53 per 100 = 530 per 1,000

Rate
• A measure of how quickly something of interest happens.
• Example: The number of new cases of Parkinson’s disease
which develops per 1,000 person-years of follow-up.
• Time, place and population must be specified for each type of

rate.
• In a rate, numerator may or may not be a subset of the
denominator
• Rate may or may not be a proportion
Properties of Rates
• The calendar time period is the same in both the numerator
and denominator of a rate.
• A rate expresses the relative frequency of an event per unit

time (“risk”)
Examples of Rates in Vital Statistics
• Infant mortality rate (IMR)= number of infant deaths per
1,000 live births during a calendar year
• The IMR is a ratio.
• The IMR is not a proportion because the numerator is not
necessarily part of the denominator (some infants may have
been born during the previous calendar year)
Examples of Rates: Incidence and
Prevalence
Incidence(I): Measures new cases of a disease that develop over
a period of time.
• Very helpful for etiological/causal inference
• Difficult to estimate
• Implies follow-up over time (i.e. cohort design)
Prevalence(P): Measures existing cases of a disease at a
particular point in time or over a period of time.
• Very helpful for quantifying disease burden (e.g. public
health)
• Relatively easy to estimate
• Implies a cross-sectional design
Prevalence
vs. Incidence
• Prevalence can be
viewed as
describing a pool of
disease in a
population.
• Incidence describes
the input flow of
new cases into the
pool.
• Deaths and cures
reflects the output
flow from the pool.
Cumulative Incidence
CI = I/N
• I = # of new cases during follow-up N = # of disease-free
subjects at start of follow-up
• Measures the frequency of addition of new cases of disease
and is always calculated for a given period of time (e.g. annual
incidence)
• Must always state the time period (since time is not
automatically captured in CI)
Person-Time and Rates
Individuals may be exposed to the risk of an event for varying

amounts of time during a total time period of a certain length
due to:
• Entering the time period later
• Leaving the time period earlier
• Experiencing the event of interest
Person-time − Is a calculation combining persons and time
• Is the sum of the individual units of time that people have
been exposed to the risk of an event
• Is used in the denominator of person-time rates
• Is often used in epidemiology and vital statistics
Person Years Of Observation In 10 Year
Heart
Disease Research Project
NO. OF SUBJECTS LENGTH OF
OBSERVATION(YRS)
30 10
10 9
7 8
2 7
1 1
Total : 50
No. of heart attacks observed during 10 yr
period: 5
Incidence Density = ?
Person Years Of Observation In 10 Year
Heart
Disease Research Project
NO. OF SUBJECTS LENGTH OF PERSON YEARS
OBSERVATION(YRS) 300
90
30 10
10 9 56
7 8 14
2 7 1
1 1 Total : 461
Total : 50
No. of heart attacks observed during 10 year period: 5
Incidence Density = ?
Example 1
• In 2003, 44,232 new cases of acquired
immunodeficiency syndrome (AIDS) were reported in
the United States. The population of the U.S. in 2003 at
risk was approximately 290,809,777.Calculate the
incidence rate of AIDS in 2003.
Numerator = 44,232 new cases of AIDS

Denominator = 290,809,777 at risk
10n = 100,000
Incidence rate = (44,232 / 290,809,777) x 100,000
= 15.21 of AIDS per 100,000 population
Dr Waqar Ali, IPH&SS, KMU

Example 2
The diabetes follow-up study included 218 diabetic women and 3,823 non
diabetic women. By the end of the study, 72 of the diabetic women and 511
of the non diabetic women had died. The diabetic women were observed for
a total of 1,862 person years; the non diabetic women were observed for a
total of 36,653 person-years. Calculate the incidence density(rates) of death
for the diabetic and non-diabetic women.
• For diabetic women,
Numerator = 72 And Denominator = 1,862
Person-time Rate = 72 / 1,862
= 0.0386
= 38.6 Per 1,000 Person
For non diabetic women,
• Numerator = 511 And Denominator = 36,653
• Person-time Rate = 511 / 36,653 = 0.0139
• = 13.9 Per 1,000 Person
Dr Waqar Ali, IPH&SS, KMU

Risk
Risk
The likelihood that an individual will contract a

disease.
Odds Ratio
The formula for Odds Ratio is :
Disease/Outcome
ad + -
OR =
Exposure/Cause + a b
bc
- c d
Attributable Proportion
The formula for attributable proportion is :
Risk for exposed group – Risk for unexposed group

AR = X 100%
Risk for exposed group
QUESTION?
References
• Principles of Epidemiology in Public Health Practice,
Third Edition An Introduction to Applied
Epidemiology and Biostatistics
• http://www.cdc.gov/
• Jhonhopkin university epidemiology lectures

Epidemiological transition
Bakhtyar ali Shah
Khyber Medical University
Objectives
At the completion of this unit learners will be able to:
 Define Population changes and population pyramid
 Explain Factors affecting population change (dependency ratio,
sex ratio)
 Discuss Changes in life expectancy and changes in age / sex
distribution
 Discuss Changes in major causes of death Changes in age / sex
distribution
Demography
Demo- from Ancient Greek word dēmos, means "the
people"
and -graphy from graphō, implies writing, description
or measurement.
Demography is the statistical study of populations,

and changes occurring with in populations over time
over time or space.
Population
 Definition:
 “Group of individuals of same species living
in the same geographic area at the same time”
 A population is often defined by demographers according
to the specific needs of the research and researcher.
 Three processes are relevant to demography:
 Fertility,
 Mortality, and
 Migration
Population: basic concepts
 There are only two ways to enter a population by

birth and by in-migration.
 There are two ways to leave a population, by
death and by out-migration.
Population structures
 The rates of natural increase, births, deaths, infant

mortality and life expectancy all affect the population
structure of a country.
 The population structure of a country can be shown by a

population or age-sex pyramid.
Population pyramids show
 The total population divided into five-year age

groups
 The percentage of people in each of those age

groups
 The percentage of males and females in each age

group
Population pyramids are useful
because they show:
 Trends in the birth rate, death rate, infant mortality rate and life
expectancy - these trends can help a country to plan its future
services, e.g. more homes for the elderly if there is an ageing
population or fewer schools if there is a decreasing birth rate.
 The proportion of the population who are economically active and

the proportion who are dependent upon them (dependency ratio).
P. Pyramids- Early Expanding
1) EARLY EXPANDING
- Wide base= high birth
rate
- Narrow top= short life
expectancy
*few countries today fall in

this category
P. Pyramids- Expanding
2) EXPANDING
- Wide base= high birth
rates
- Middle expands=
improved medical care,
modern hygiene,
improved diet
P. Pyramids- Stable
3) STABLE
- Birth rate falls= changing
attitude towards family
(Education programs,
changing societal
attitudes, economic
factors)
- Death rate lowered=
improved medical care
P. Pyramids- Contracting
4) Contracting
- Very low birth rate= women
in work force, child-rearing
is expensive, contraception,
state encourages small
families
- Death rate continues to
decrease
- Life expectancy increases
Demographic transition model
 Demographic transition model describes a

sequence of changes in the relationships
between birth and death rates.
 It suggests that the population growth rates for
all countries can be divided into 4 stages.
 All countries pass through four or five stages to
a state of maturity.
http://www.uwec.edu/Academic/
Geography/Ivogeler/w111/demmo
del.htm
Demographic Transition Model
 Stage 1- high birth, high death=small growth

 High infant mortality
 Low life expectancy
 Common a few hundred years ago, and in developing
countries today
 Stage 2- High birth, low death= population explosion
 Medical & scientific advances

 Vaccines, drinking water, sewage systems
 1800s
 Stage 3- low death, declining birth

 Social programs, industrialization, urbanization= smaller
families
 voluntary decisions to reduce family size aided by
improved contraception. Related to improved standard of
living. Natural increase rate falls.
 Stage 4- low birth, low death=slow population growth
 Changing role of women
 Family planning programs
 Some African countries, birth rates still highLower birth
rates
 Sub-Saharan Africa- HIV= high death
 Stage 5- birth rate lower than death rate

 Future, however some European nations and Japan
starting to enter this stage
Life expectancy
 Life expectancy is the average number of years an
individual of a given age is expected to live if
current age-specific mortality rates continue to
apply.
 Life expectancy at birth; Average number of years
a newborn is expected to live if current mortality
structure persists throughout its life.
 Because of the gender difference, life expectancy is
calculated also separately for men and women.
 Life expectancy is an indicator of current health and
mortality conditions.
Population Change
 Definition: The difference between the size of

the population at the end and the beginning of a
period. It is equal to the algebraic sum of natural
increase and net migration
Population growth rate
Net Migration Rate = Immigration rate-Emigration rate
Natural increase = crude birth rate- crude death rate
Population growth rate = natural increase + net migration

rate
Dependency ratio
 The dependency ratio is a measure showing the

number of dependents (aged 0-14 and over the age of
65) to the total population (aged 15-64). Also referred
to as the "total dependency ratio".
Dependency Ratios
Definition
Comparison between the productive (working)and non-
productive (non working) population.
Often expressed in non-productive per 100 productive.
OLD DEPENDANTS
ECONOMICALLY
ACTIVE
YOUNG
MALES FEMALES DEPENDANTS
To the left To the right
The dependency ratio can be expressed
as:
 children (0-14) and elderly (65 and over)x 100

those of working age
e.g. UK 1971 (figures in millions):
 13 387 + 7307 x100 = 65.45

31616
So for every 100 people of working age there were

65.45 people dependent upon them
Sex ratio
 Sex ratio is the ratio of males to females in a population.

The Sex-Ratio (SR) is defined as the number of
males/number of females:
SR = m/f.
The numerator of the Sex-Ratio (males) is not part of the
denominator (females),
thus the SR is not a proportion, which would be
Pmales = m/(m+f).
Epidemiological transition
 “As mortality has changed, the cause-structure has shifted

from a preponderance of deaths due to infectious and
parasitic causes to a preponderance of deaths due to
degenerative causes or injuries.
 This change, which is associated with the change in age
pattern of mortality, is called the epidemiologic
transition.”
Cont…
 During the epidemiologic transition, a long-term shift

occurs in mortality and disease patterns whereby
pandemics of infection are replaced by degenerative
and man-made diseases...
Age of Pestilence and Famine
 Characterized by high mortality rates, wide swings in

the mortality rate, little population growth and very
low life expectancy
Age of Receding Pandemics
 Epidemics become less frequent, infectious diseases

in general become less frequent, a slow rise in
degenerative diseases begin to appear
Age of Degenerative and man-made
diseases
 Non-communicable disease
 Cancer
 Diabetes
 Chronic respiratory disorders (COPD)
 Cardiovascular disorders
 Injuries and trauma
Life Improved medical
expectancy care and social Healt
determinants h
influences health
Increased economic growth
improves use of ecological
resources and provides basic Healt
social services h Age of chronic
diseases
Poor use of ecological

resources and lack of
social and economic Age of receding
capital pandemics
Health
h
Age of pestilence and

Demoghraphy & Epidemiological Transition
famine
44
Time 6/15/2023
First Epidemiological Transition
 The First Epidemiological
Transition occurred 100 centuries ago
when man moved towards the
agricultural society.
 By adopting the nomadic lifestyle,
people stayed in one place and
increased their contact with human
(and animal) waste, and contaminated
their water supplies.
Demoghraphy & Epidemiological Transition 45 6/15/2023

First Epidemiological Transition…
 And even the cultivation of
soil, and the clearing of land,
exposed people to insect bites,
bacteria, and parasites.
 As cities grew, and exploration

of the surrounding world
increased, man spread deadly
diseases in ever-greater
numbers.

First Epidemiological Transition…..
 This epidemiological transition
was described as
“the age pestilence and famine" .
 Epidemic, famines and wars

caused huge numbers of deaths.
 Infectious diseases were

dominant, causing high mortality
rates, especially among children.

The domestication of animals
brought other disease vectors in
close contact with humans.
Anthrax, tuberculosis gained access
to human hosts.
While increasing food security and
nutrition, this transition also
introduced several significant
disease factors.

Small pox, Cholera, plague, influenza all became major threats for
humanity.

First Epidemiological Transition….
 Small pox : 12,000 Years of Terror
 It first appeared in agricultural
settlements in north-eastern Africa
around 10,000 B.C.
 Egyptian merchants spread it from
Africa to India.
 In Europe, near the end of the
eighteenth century, the disease
accounted for nearly 400,000
deaths each year.

 Plague – The Black Death.
 The first recorded case of the
plague was in China in 224 B.C.
 But the most significant outbreak
was in Europe in the mid-fourteenth
century.
 Over a five-year period from 1347
to 1352, 25 million people died.
 One-third to one-half of the
European population was wiped out
!!!!!!

First Epidemiological Transition
 Cholera
 The major cholera pandemics
are generally listed as:
 First: 1817-1823,
 Second: 1829-1851,
 Third: 1852-1859,
 Fourth: 1863-1879,
 Fifth: 1881-1896,
 Sixth: 1899-1923,
 Seventh: 1961- 1970,

First Epidemiological Transition….
 High levels of mortality and fertility.
 Crude Death Rate (CDR) is high and ranges from 30

to over 50 deaths per 1,000 population.
 Infant mortality rate 200-300 deaths per 1,000 live

births.
 Life expectancy between 20-40 years.

First Epidemiological Transition…..
 In this stage, women of
childbearing age also faced
considerable risks due to
the complications
associated with pregnancy
and childbirth.
 Some developing countries
are still in this stage.

Second Epidemiological Transition
 The Second Epidemiological
Transition began roughly 200 years
ago, with the Industrial
revolution.
 While many of the existing
diseases brought forth during the
first transition certainly did not go
away, new-chronic, non-infectious,
degenerative diseases – were added
to the mix.

 This phase was described as

“age of receding pandemics” by Omran.
 It involved a reduction in the prevalence of infectious
diseases, and a fall in mortality rates.
 CDR reaches a level of less than 30 deaths per 1,000
population.
 IMR was 150 per 1,000 live births.
 As a consequence, life expectancy at birth climbed
rapidly from about 35 to 50 years.
 Increased economic growth led to a
sharp fall in deaths from infectious
diseases, and from malnutrition.
 This Improvement occurred before
effective medical treatment and was
due to impact of following
interventions:
 clean water
 sanitary sewage
 mosquito suppression
(malaria/fever)
 increased food safety –
refrigeration and pasteurization
 increased pre & post-natal care



 Finally, the introduction of modern healthcare

and health technologies, e.g.
 immunization programmes
 introduction of antibiotics
enabled the control and elimination of group of

infectious diseases such as Diphtheria, polio and
smallpox.
 Technology also brought with it
smokestack industries, chemical
toxins, working indoors, stress,
greater access to less `healthful’ food;
beside advances in medicine and
sanitation.
 And with this second transition we’ve
seen rises in allergies, asthma,
autoimmune disorders, and sexually
transmitted diseases as well.
Third Epidemiological Transition
 Began in the late 20th century.
 This phase was described as
 „The age of chronic diseases‟ by
Omran.
 In the third stage the elimination
of infectious diseases makes way
for chronic diseases among the
elderly.
 The major causes of death are so-
called chronic degenerative and
man-made diseases such as
cardiovascular diseases, cancer,
and diabetes. 62
Demoghraphy & Epidemiological Transition 6/15/2023
Infectious Diseases
NIDDM CHD
Trauma
CA
Mortality Rates
Epidemiologic Transition
Third Epidemiological Transition
 Due to low levels of mortality and fertility, there is little

population growth.
 CDR stabilises at a level of less than 20 deaths per 1,000
population.
 By the end of the third stage, infant mortality reaches a level of
less than 25 deaths per 1,000 live births.
 When the health transition is at an advanced stage, life
expectancy may exceed 80 years.
 However, the prevalence of one or more diseases means that
such a long life also includes, on average, a relatively long
period of morbidity.

 Although death is a universal reality, the conditions or
diseases that cause death have changed over time.
Today, the leading cause of death is cancer, while 60
years ago—before significant public health
interventions—infectious diseases and accident
 The first half of the 20th century saw several
significant public health improvements, including
immunization against smallpox and diphtheria, milk
pasteurization to prevent bovine tuberculosis, and
chlorination to disinfect drinking water.
 In addition, routine childhood immunization became
common during this period.
 Life-altering scientific discoveries—such as insulin and
penicillin—also led to treatments that were more effective for
diabetes and infections. The downward trend in death rates
reflects the effects of these public-health interventions, most of
which were aimed at reducing deaths from infectious and
parasitic diseases.
 In addition, while maternal mortality (deaths associated with
pregnancy and delivery) peaked during the mid-1930s,
improvements in pre-natal and post-natal care have had a
beneficial effect on the life expectancy of women.
References
 Principles of Epidemiology in Public Health

 http://www.cdc.gov/
 Jhonhopkin university epidemiology lectures

THANK YOU
71
Unit VII: Epidemiological Methods
Bakhtyar Ali Shah

BSN, CHPE, MSN, MPH, MHR, PhD
(Scholar)
Objectives
At the completion of this unit learners will be
able to:
• Define study design,
• Discuss classification of study design.
• Describe the Descriptive study designs.
• Discuss the Analytical study designs
Study design
A study design is a specific plan or protocol for
conducting the study, which allows the
investigator to translate the conceptual
hypothesis into an operational one.
3
Study design
A set of defined steps required to carry out research
on a problem under study. The design will define:
• How study subject are selected?
• Method of sample size estimation
• Procedure of data collection
• Procedure of data analysis
• Types of statistical test required
4
Cont….
• The proof for evidence-based medicine is all
collected via research, which uses a variety of
study designs.
• Different study designs provide information of
different quality.
• Therefore, you need to understand the
strengths and limitations of each type of study
design, as applied to a particular research
purpose.
Classification of Epidemiological
Research/Study Designs
Descriptive Analytical
Research Research
66
Descriptive Research
Individual based
Population based
Case reporting
Case series
Ecological /
Correlational Cross-sectional surveys

7
Analytical Research
Observational Experimental /
Interventional
Cohort study Randomized Control

Trials
Case–control study
Cross-sectional study Quassi 8

Objectives at various levels
Study Types Objectives

1. Knowing the frequency of disease
DESCRIPTIVE STUDIES 2. Knowing the distribution
3. Developing the hypothesis
OBSERVATIONAL 1. Testing the hypothesis

ANALYTICAL 2. Establishing association
EXPERIMENTAL OR
INTERVENTIONAL 1. Strength of association
STUDIES 2. Establishing the cause
9
The researcher
The researcher
intervenes to
Study Types studies, but does
not alter, what
change reality, then
observe what
occurs
happens
STUDY TYPES
Descriptive Analytical/Experimental
( hypothesis formulation) (hypothesis testing )
Individual based Population based Observational Interventional
Case studies Ecological Case-control RCT’s (III)
Quasi-
Case series cohort
Experimental
Cross-
sectional
Descriptive Studies
• Describe only; do NOT examine associations
between Exposure (E) and health Outcome (O).
• Generally the purpose is to describe the variability in

a health outcome and/or formulate hypotheses.
• A descriptive study involves describing the

characteristics of a particular situation event or case.
• Descriptive studies can be carried out on a small or

larger scale.
11
Types of Descriptive Studies
Individual Based
Case Study
A study of one diseased individual, providing a detailed
description of an uncommon disease; provides timely
or rare information.
OR
A single patient’s clinical history is described in detail,
and then discussed in relation to the literature. Almost
always a rare unusual, or atypical case.
Individual based
Case Series :
A study of multiple occurrences of unusual cases that
have similar characteristics.
Investigators can calculate the frequency of symptoms
or characteristics of people with the disease.
Results may generate causal hypotheses. Neither a case
study nor a case series includes a comparison group.
Descriptive Study Designs
Case Report One case of unusual

finding
Case Series Multiple cases of

finding
Individuals Based
Cross sectional Surveys
– Subjects or institutions are surveyed in order to
describe the prevalence of health outcomes and
/or characteristics of a population
15
Descriptive Studies
Population Based
• Ecological
– An ecological study focuses on groups of people
(rather than individuals) as the units of analysis.
– The variables include measurements taken at the
group level e.g. infant mortality rates of different
countries.
16
Types of Observational Analytical
Studies
17
Analytical (Non-
Intervention) Studies
Cross-
sectional Cohort
studies studies
Case-
control
studies
Cross-sectional study
 A cross sectional study measures the
prevalence of health outcomes or
determinants of health, or both, in a
population at a point in time or over a short
period.
CROSS-SECTIONL STUDY
Information is collected from each subject at one point of time
Used to provide a snapshot of a population at a point in time
The main out-come measure is prevalence
Limited to the measurement of risk factor and out-comes at one

simultaneous point in time
Examples: screening surveys

knowledge attitude and practice (K.A.P.) surveys
Begin with: Target Population
I
Determine presence or
Sample absence of exposure &
presence or absence of
disease
Gather Data on Exposure and Disease
Exposed; Exposed; Not Not Exposed;

Have Do not Exposed; Do not have
Disease have Have Disease
Disease Disease
4 groups are possible

Disease No disease II
Exposed a b
Not
Exposed c d
Disease No disease Disease No disease
Exposed a b Exposed a b
Not
Exposed
c d Not c d
Exposed
III
Exposed
a b Exposed a b
Not Not c d
Exposed
c d Exposed
Prevalence of exposure Prevalence of disease

compared in diseased and compared in exposed and
non diseased non exposed
a b a c
vs. OR vs.
a+c b+d a+b c+d
Advantages of cross-sectional
• Outcomes and exposures measured at the same
time
• Uncovers associations for further study
• Useful for hypothesis generation
• Quick & cheap (no follow up)
• Best way to determine prevalence
• Questionnaire/interview based
• Useful for assessing practice, attitudes,
knowledge, beliefs , utilisation of services etc
Advantages of Cross-Sectional study
• Can be conducted to assess the health care needs of

the population
• Helpful in measuring access and utilization of health
services
• Provides information between disease and various
variables
• Provides information regarding distribution of a
disease
• Determines burden of the diseases in a population.
So helpful for planning purposes
Limitations of Cross-Sectional study
• No temporal or time sequence

so gives no information whether which comes first e.i. Cause or Disease
• Gives no idea about natural history of the disease or etiology
• Gives no measure of new cases occurrence

• Not useful for rare exposures or rare outcomes
COHORT STUDY
• Cohort studies are also called “Follow-up or Incidence

Studies”.
• Because the data on exposure and disease refer to different

points in time, cohort studies are also longitudinal.
• Cohort studies have also been called “Prospective Studies”.

Cohort studies
• The observation of a cohort over time to

measure outcome(s)
• Synonymous terms (Last’s)
◦Follow-up
◦Longitudinal
◦Prospective
Cohort studies
Birth cohort: all individuals in a defined
geographical area born in the same period (usually
a year)
Inception cohort: all individuals assembled at a
given point based on some factor e.g. Workplace
Cohort studies
Exposure cohort: a group of individuals that
potentially share a common exposure e.g.
Radiation
Disease cohort: a group of individuals with a

specific disease.
STEPS IN COHORT STUDY
• Cohort studies are conducted in three fundamental steps:
1. Identify cohorts of exposed and unexposed individuals who

are free of the disease/outcome of interest at the beginning of
the study.
2. Observe each cohort over time for the development of the
outcome(s) of interest.
3. Compare the risks of outcomes between the cohorts.
COHORT STUDY DESIGN
Cohort studies
Recruitment
Prospective
Exposure Outcome
Retrospective
Exposure Outcome
Exposure Outcome
Ambidirectional
Exposure Outcome
Time
COHORT STUDY DESIGN
• Cohort study measure:
i. Incidence rate
ii. Relative Risk
iii. Attributable Risk
DESIGN OF A COHORT STUDY
Then Follow to see whether
Disease Disease Total Incidence

Develop Does not Rate of
Develop Disease
First Exposed a b a+b a/a+ b

Select
Not
Exposed c d c+d c/c + d
INCIDENCE RATE
• Incidence in exposed group = a/ a + b
• Incidence in unexposed group = c/ c + d
• Incidence in total (exposed + unexposed)
• = a+c
a+b+c+d
RELATIVE RISK
• Cohort study determine whether there is an association

between exposure to a factor and development of a disease.
• Relative Risk = Incidence in exposed

Incidence in unexposed
= a/ a + b
c/ c + d
ATTRIBUTABLE RISK
• This is determined by the “Attributable Risk”, which is

defined as “the amount or proportion of diseases incidence
(or disease risk) that can be attributed to a specific
exposure”.
• Attributable Risk is calculated as follow:
• Risk Difference = (Incidence in exposed group ) – (Incidence

in non-exposed group [Background risk]
Advantages of cohort studies
• Useful for rare exposures

• Useful for more than one outcome
• Incidence of the outcome (and incidence rates)
• Temporal relationship between exposure and outcome is
clear as exposure status defined at start of study
• If prospective, minimises bias in measurement of
exposure
• Sometimes the only ethical or legal way to do study
• Stratification, nested case-controls, and multivariate
analyses (adjustment) can be applied
Disadvantages of cohort studies
• Not good for study of rare outcomes

• If retrospective they rely on the adequacy of
records
• Exposed may be followed more closely than
unexposed
• If prospective they can be very expensive and slow
• As they are follow up studies, the validity of results
is highly sensitive to losses to follow up (migration,
withdrawal, lack of participation, death)
CASE-CONTROL STUDY DESIGN
Case-control studies
•An analytical epidemiologic study design in which
individuals who have the disease under study, also
called cases, are compared to individuals free of
disease (controls) regarding past exposures.
•Exposure differences between cases and controls
are helpful to find potential risk or protective
factors. The purpose is to determine if there are
one or more factors associated with the disease
under study.
CASE-CONTROL STUDY
• To examine the possible relation of an exposure to a

certain disease, we identify;
1. A group of individuals with the disease (called cases)

and for purpose of comparison,
2. A group of people without the disease or outcome

variable (called controls ).
3. The study compares the occurrence of the possible

cause in cases and in controls.
DESIGN OF A CASE-CONTROL STUDY
Advantages of case-control Studies
• Can be carried out quickly and quite cheaply

• Useful for rare diseases and outcomes
• Can study multiple exposures for a single
outcome
• Case control studies can be ideal for the study
of rare diseases or those with a long latency
• Compares odds of exposure between cases
and controls
Disadvantages of case-control studies
• Selection of control population, overmatching

• Information bias as exposures – similar status
determined after outcome has occurred e.g. Recall
• Selection bias especially regarding controls
• Cannot establish sequence of events (temporal
relationship)
• Not good for rare exposures
• Cannot usually be used to estimate incidence
rates, relative risks or attributable risks
EXPERIMENTAL STUDY DESIGN
Randomised controlled trial (RCT)
”An epidemiological experiment in which subjects

in a population are randomly allocated into groups,
usually called study and control groups to receive
and not receive an experimental preventive or
therapetuic procedure, maneuver, or
interventition”
Randomized Control Trials (R.C.T)
Randomized:
Allocation of participants to various groups in
random fashion
Control:
A control group is used to compare the effects of a
particular treatment
Trials:
An experiment conduction.
60
RCT
Reference population
Taraget population
Sample
Random Allocation
Changed group
Intervention group during study Control group
Loss to
Loss to Outcome measure follow up
follow up
RANDOMIZED CONTROLLED TRIAL
• The true experimental study design (RCT) has three

characteristics:
1. RANDOMIZATION - the researcher takes care to randomly

assign subjects to the control and experimental groups.
• (Each subject is given an equal chance of being assigned to

either group.)
2. CONTROL - the researcher introduces one or more control

group(s) to compare with the experimental group.
3. MANIPULATION - the researcher does something to one

group of subjects in the study.
• Note: The strength of experimental studies is that by

randomization of confounding variables.
• In Randomized Controlled Trial (RCT), we begin with a

defined population.
• Subjects in the study population are randomly allocated to

intervention and control groups, and the results are
assessed by comparing outcomes.
• The basic design of RCT is given below;

Allocation of study subjects -
randomization
•Random = governed by chance
•Randomization = allocation of individuals to

groups by chance
•Each sampling unit has the same chance of

selection
BLINDING IN RCT
• Blinding represents an important, distinct aspect of

randomized controlled trials.
• The term blinding (masking) refers to keeping trial

participants, investigators (usually healthcare providers), or
assessors (those collecting outcome data) unaware of an
assigned intervention, so that they are not influenced by that
knowledge.
• Blinding prevents bias at several stages of a trial.

TYPES OF BLINDING
• Single Blind
– The subjects are not knowing the group to which they are
belonging .
• Double blind trials

– Neither the subject nor care giver is aware about the groups
• Triple blind trials

– The subject, the care giver (nurse or doctor) and the person
doing the analysis are not aware about the groups in.
75
75
Advantages of RCT
• Exposure in under control.

• Due to randomization both intervention and control groups
have similar characteristics.
• By blinding the study, the observer and selection bias can be
eliminated.
• If properly designed & conducted, it can reduce the
confounding.
• Can confirm or refute etiological hypothesis.
• Can evaluate the efficacy / effectiveness / efficiency of
health services.
• Best method for studying causal relationship.
76
Disadvantages of RCT
• Ethical problems
Due to adverse effects
Due to benefits of intervention in the treated group
Provision of Placebo
• Relatively expensive
77
QUASI EXPERIMENTAL STUDY
• In a Quasi Experimental Study, at least one characteristic of a

true experiment is missing, either randomization or the use of a
separate control group.
• A quasi experimental study, however, always includes

manipulation of an independent variable that serves as the
intervention.
• One of the most common quasi experimental designs uses two

(or more) groups, one of which serves as a control group in
which no intervention takes place.
• Both groups are observed before as well as after the

intervention, to test if the intervention has made any
difference.
• The subjects in the two groups (study and control groups) have
not been randomly assigned.
• Another type of design that is often chosen because it is quite

easy to set up uses only one group in which an intervention is
carried out.
• The situation is analyzed before and after the intervention to

test if there is any difference in the observed problem. This is
called a "Before- After" study .
STUDY TYPES & STRENGTH OF EVIDENCE
• Analytic Study involves the systematic evaluation of

suspected relationships, for example, between an exposure
and a health outcome.
• Analytic studies typically provide stronger evidence

concerning particular relationships.
• An experimental design is the only type of study design

that can actually prove causation.
References
• Principles of Epidemiology in Public Health Practice,
Third Edition An Introduction to Applied
Epidemiology and Biostatistics
• http://www.cdc.gov/
• Jhonhopkin university epidemiology lectures

THANK YOU
for supporting me
Best of luck in your exam
Bakhtyar Ali Shah PhD (scholar)
A. Professor INS-KMU
Objectives
By the end of the session the participants will be to:
 Define surveillance and purpose of surveillance.

 Describe the types of surveillance.
 Discuss the conceptual framework and components of a
surveillance system.
 Identify nurses role in surveillance
Surveillance
 Surveillance is the ongoing, systematic collection, analysis,
and interpretation of outcome specific data for use in
planning, implementing and evaluating public health
policies and practices.
 "sur" means "from above"

and "veiller" means
"to watch”
Key function of disease
surveillance
 Early warning of the potential threat to
public health
 Monitoring (Disease specific or multi-

disease program)
 Providing information to plan public

health interventions
 Stimulating research
Example of surveillance
 Early warning signs the CDC made the public for
taking prevention there is an outbreak of:
 SARS
 Bird flue (Avian Influenza)
 Potential threat from biological or
chemical agents
 Ebola
Types of surveillance
Active:
 verify, investigate and validate the diseases in the
community and to detect more cases in the community
 more accurate, timely, short periods, more resource
intensive
Passive:
 doesn't verify and investigate: send the data without
verification.
 passive surveillance may give you the information you need
for future planning
Types of surveillance
Sentinel Surveillance
• Encompasses a wide range of activities focused on

monitoring key health indicators in general or in
special populations.
• May be passive or active
• Key health events
• Clinics or other sites at which health events are
monitored
Health Care System Public Health Authority
Reporting
Data Information
Analysis &
Evaluation Interpretation
Feedback
Action Decision
Surveillance (JPFCM, Jan. 2010) Ghaiath

14
Elements of the surveillance System
All surveillance system involve six key elements
1. Detection and notification of a health event.

2. Investigation and confirmation
(Epidemiological, Clinical, Laboratory)
3. Collection of data
4. Analysis and interpretation of data
5. Feedback and dissemination of results
6. Response….A link to public health programs,
specifically actions for prevention and control.
Source: Adapted from WHO 1999a
Outbreak Detection and Response
Without Preparedness
First Late Delayed

90 Case Detection Response
80
70
60
50
Opportunity
40 for control
CASES
30
20
10
0
10
13
16
19
22
25
28
31
34
37
40
1
DAY
Outbreak Detection and Response
With Preparedness and rapid response
Early Rapid
90 Detection Response
80
70
Potential
60 First
50 Case
Cases Prevented
40
CASES
30
20
10
0
10
13
16
19
22
25
28
31
34
37
40
1
DAY
Sources of data collection
• Mortality reports
• Morbidity reports
• Epidemic reports
• Reports of laboratory utilization (including laboratory test
results)
• Reports of individual case investigations
• Reports of epidemic investigations
• Special surveys (e.g., hospital admissions, disease registers, and
• serologic surveys)
• Information on animal reservoirs and vectors
• Demographic data
• Environmental data
Flow of information data
Vital Statistics Surveillance (VSS)
 Records of births and deaths: a basic but critical
cornerstone of public health surveillance
 Mortality data over past century show decrease in rate of
deaths due to infectious diseases; rate of death from non-
infectious causes remain steady
 Infant mortality rate (number of deaths among infants per
1,000 live births) long used as indicator of overall
population health
 Birth data used to monitor incidence of preterm birth, risk
factor for variety of adverse health outcomes
Vital Statistics
 In Pakistan vital statistics are available from National
institute of Population studies (NIPS) Islamabad,
Pakistan. www.nips.org.pk
 In Pakistan Demographic and Health survey is conducted

each year and published by NIPS.
Disease Reporting/surveillance
 A structured approach to strengthen national
communicable disease surveillance systems could include:
 Assessment
 Prioritization
 SWOT Analysis of existing system
 Developing a strategic action plan
 Implementation
 Monitoring
 Evaluation
Monitoring
 Monitoring in the context of surveillance and response
systems refers to the routine and continuous tracking of
the implementation of planned surveillance activities
(monitoring the implementation of the plan of action) and
of the overall performance of surveillance and response
systems.
Monitoring
Evaluation
 Evaluation is the periodic assessment of the relevance,
effectiveness and impact of activities in the light of the
objectives of the surveillance and response systems.
Evaluation
Indicators
 Indicators are variables that can be measured repeatedly
(directly or indirectly) over time and provide measures of
change in a system.
 Indicators:
 provide useful information on the status of the system
and flag areas that need improvement
 usually expressed as simple counts, proportions, rates or
ratios
Types of indicators
 Indicators can be classified in various ways. In the logical
framework approach (LFA), there are five types of
indicators:
 Input
 Process
 Output
 Outcome
 Impact
Indicators Types
 Input indicators are the resources needed to implement
the system
 Trained personnel, finance, standards and guidelines,

communication facilities, forms for surveillance,
computers, stockpiles for emergency response, and any
other logistics as deemed necessary.
Types of Indicators
 Process indicators are used to monitor and track
implementation of the planned activities which are critical
for attaining the surveillance core functions
 such as training, supervision, development of guidelines

and tools, etc.
Indicators Types
 Output indicators are measures of the
immediate results of the activities.
 Such as reports of surveillance data, feedback
 Outcome indicators are measures of the quality
of the surveillance system and the extent to which
the surveillance objectives are achieved.
 Such as use of surveillance data for policy and
program decisions, and appropriateness of
outbreak response.
Indicators Types
 Impact indicators are measures of the extent to which the
overall objectives of the system are being achieved.
Ways to improve Surveillance
System
 Improve Awareness of Practitioners
 Simplify Reporting
 Frequent Feedback
 Widen the Net
 Active Surveillance
Filling the DEWS Form
Weekly Morbidity (disease) and Mortality (death)
Surveillance Reporting Form MORTALITY INFORMATION
(Please send to EDO-H/WHO office every Saturday before 12.00)
(Please note the number deaths by cause in each age group and by sex in the table)
Province:________________________ District: __________________ Sub district/Tehsil:__________________ 0-<5 yrs = >5 - < 15 yrs 15-44 yrs 45 + yrs
Town/Village/Camp:______________ Population:________________ Population <5yrs ___________________

Cause of deaths M F M F M F M F
Date:____/____/____ Epidemiological Week _____ from Saturday: ____/____/2009 to Friday ____/____/2009 1 Pregnancy related deaths
2 Neonatal deaths(<28 days)
Supporting Agency/NGOs__________ Health Facility________Phone # ________________________________
3
Name of contact Officer_________________________________ Phone # ________________________________ 4
5
No of Consultations
6
Events Under Surveillance 0-<5yrs = >5 - < 15yrs 15-44yrs 45 + yrs
7
M F M F M F M F
8
01 Acute Diarrhoea
02 AWD/ Suspected Cholera
Instructions:
03 Bloody Diarrhoea
04 Acute Flaccid Paralysis (AFP)  Please include only new cases that were examined / admitted during the surveillance week. Each case
should be counted only once.
05 Suspected Malaria
 Write “0” (zero) if you had no case or death of one of the Health Events listed in the form.
Acute Upper Respiratory
06
Infection  Be careful to report only the cases and deaths that occurred during the week
Acute Lower Respiratory  Deaths should be included in the mortality section. Please fill-in the following table for each reported
07 death.
Infection
08 Suspected Measles Sex
09 Suspected Meningitis No Name Age Cause Residence/Address
M F
10 Acute Jaundice Syndrome
11 Neonatal Tetanus 1
12 Suspected Hemorrhagic Fever 2
0
13 Unexplained Fever >38.5 C
14 Scabies
3
15 Bronchial Asthma 4
16 Hypertension
5
17 Diabetes
18 Injuries 6
Severe Malnutrition
19
(wfh* < -3Z) Red Zone 7
Moderate Malnutrition
20
(wfh* -2 to -3Z) Orange zone 8
21 No. of Antenatal Consultations
22 No. of normal deliveries 9
** No. of Pregnant women
23 10
referred
24 Others
11
25
26 12
27
Total Consultations
Page 2 of 2
* Weight for height
** No of pregnant women referred due to high-risk pregnancies, complications during pregnancy and delivery
Page 1 of 2
Filling the DEWS / Surveillance Form
 Compile the data from the Daily OPD Register by age

and sex for each Health event under surveillance
 Transfer the data on the Surveillance form
 Write the Morbidity (# of cases) and Mortality (# of
deaths) data clearly in the relevant section
 Write Zero if there is no case or death for a health event
in any age or sex group
 Submit the form to the relevant/focal authority
(DHO/EDO Health or Surveillance Coordinator) on
daily basis
General Information
Weekly Morbidity (disease) and Mortality (death)

Surveillance Reporting Form
(Please send to EDO-H/WHO office every Saturday before 12.00)
Province:________________________ District: __________________ Sub district/Tehsil:__________________
Town/Village/Camp:______________ Population:________________ Population <5yrs ___________________
Date:____/____/____ Epidemiological Week _____ from Saturday: ____/____/2009 to Friday ____/____/2009
Supporting Agency/NGOs__________ Health Facility________Phone # ________________________________
Name of contact Officer_________________________________ Phone # ________________________________

Events Under Surveillance No of Consultations
Events Under Surveillance 0-<5yrs = >5 - < 15yrs 15-44yrs 45 + yrs
M F M F M F M F
01 Acute Diarrhoea
02 AWD/ Suspected Cholera
03 Bloody Diarrhoea
04 Acute Flaccid Paralysis (AFP)
05 Suspected Malaria
06 Acute Upper Respiratory Infection
07 Acute Lower Respiratory Infection

08 Suspected Measles
09 Suspected Meningitis
10 Acute Jaundice Syndrome
11 Neonatal Tetanus
12 Suspected Hemorrhagic Fever
13 Unexplained Fever >38.50 C
14 Scabies
15 Bronchial Asthma
16 Hypertension
17 Diabetes
18 Injuries
Severe Malnutrition
19
(wfh* < -3Z) Red Zone
Moderate Malnutrition
20
(wfh* -2 to -3Z) Orange zone
21 No. of Antenatal Consultations
22 No. of normal deliveries
23 ** No. of Pregnant women referred
24 Others
25
26
27
Total Consultations
MORTALITY INFORMATION
Brief details of reported deaths
Nurses role in surveillance
 Assessment of communicable disease risks to identify
major public health threats.
 Prioritization of public health threats to ensure that
surveillance is limited to the important public health
events.
 Assessment of existing systems to review strengths,
weaknesses, and opportunities for strengthening the
systems.
 Development of a strategic plan of action based on the
findings of the assessment.
42
Crude death rate
 Crude Death Rate (CDR) =___number of deaths during time period____ X 100,000
total population at mid-point of time period
 EXAMPLE:
 CDR for Peshawar 2012 = __number of deaths in Peshawar in 2012_ X 100,000
total population Peshawar 2012
 Numerator = number of deaths in Peshawar in 2012 = 301
 Denominator = total population Peshawar 2012 = 30,726
 Constant = 100,000
 Time period = 2012
 CDR for Peshawar 2012 = __301__ X 100,000 = 979.6/ 100,000 population
30,726
Crude birth rate
 Crude Birth Rate (CBR) = number of live births during time period_ X
1,000
total population at mid-point of time period
 EXAMPLE:
 CBR for KPK 2012 = number of KPK live births in 2012 X 1,000
population of KPK in 2012
 Numerator = number of KPK live births in 2012 = 27,206

 Denominator = population of KPK in 2012= 1,819,046
 CBR for KPK 2012 = __27,206__ X 1,000 = 14.9/ 1,000 population

1,819,046
Infant Mortality Rate
 Infant Mortality Rate (IMR) = __number of infant deaths during time period__ X
1,000
number of live births during time period
 EXAMPLE:
 IMR for Peshawar 2001 =__number infant deaths Peshawar 2012_ X 1,000
number of live births Peshawar 2012
 Numerator = number infant deaths Peshawar 2012= 50

 Denominator = number of live births Peshawar 2012 = 8,357
 IMR for Peshawar 2012 = __50 __ X 1,000 = 5.9/ 1,000 live births
8,357
Perinatal mortality Rate
 Perinatal mortality rate= number of perinatal deaths during time period x
1000 total number of
births (still births + live births)
 Example:
 MMR in Peshawar = Number of perinatal death in Peshawar in 2012 X 1000
Number of total births (still+live) in Peshawar
 Numerator = number perinatal death in Peshawar in 2012 = 10

 Denominator=number of total births (still+live) in Peshawar in 2012= 100,000
 Constant = 1000
 Time period= 2012
 PMR in Peshawar = 10 X1000 = 10 per 10,000 live birth.

100,000
Neonatal Mortality Rate
 Neonatal Mortality Rate = number of deaths to children <28 days of age during time period X
1,000
number of live births during time period
 EXAMPLE:
 NMR in Peshawar = __number deaths to age <28 days in Peshawar 2012__ X 1,000
number live births in Peshawar 2012
 Numerator = number of deaths to age <28 days in Peshawar 2012= 41

 Denominator = number live births in Peshawar 2012= 8,357
 Neonatal mortality rate for Peshawar 2012 = __41__ X 1,000 = 4.9/ 1,000 live births
8,357
Maternal Mortality Rate
Maternal Mortality Rate= number of maternal death X 10,000
number of live births
 Example:
 MMR in Peshawar= Number of maternal death in Peshawar X 10,000
Number of total live births in Peshawar
 Numerator = number of maternal death in Peshawar= 10

 Denominator=number of live birth= 100,000
 MMR in Peshawar= 10 X10,000 = 1 per 10,000 live birth.

100,000
Incidence Rate
 Incidence Rate = number of new cases of a disease during time period X constant
population at risk during time period
 EXAMPLE:
 Diabetes Incidence =___number of new cases of Diabetes in Peshawar in 2012___ X 1,000
(population of Peshawar 2012-number already diagnosed with diabetes before 2012)
 Numerator = number of new cases of Diabetes in Peshawar in 2012= 20

 Denominator=(population of Peshawar 2012 - number with diabetes already)=(30,726-
367)=30,359
 Incidence Rate of diabetes in Peshawar 2012 = 20__ X 1,000 = 0.65/ 1,000 population
30,359
Prevalence Rate
 Prevalence Rate = _number of existing cases of a disease during time period_ X 100
total population during time period
 (Note: Prevalence is often expressed as a percentage)
 EXAMPLE:
 Diabetes Prevalence Rate = _number of diabetics in Peshawar 2013_ X 100
Peshawar 2013 total population of Peshawar 2013
 Numerator = number of diabetics in Peshawar 2013= 387

 Denominator = total population of Peshawar 2013= 30,726
 Constant = 100
 Diabetes prevalence Rate Peshawar 2013 = __387__ X 100= 1.3%

30,726
General Fertility Rate
 Fertility Rate = __number of live births during time period__ X 1,000
total population of females age 15-44 at mid-point of time period
 EXAMPLE:
 Fertility Rate for Peshawar 2013 = __number of live births in Peshawar in 2012__ X
1,000
population of Peshawar females 15-44 in 2012
 Numerator = number of live births in Peshawar in 2012 = 169

 Denominator = population of Peshawar 15-44 in 2012= 3,105
 Fertility Rate for Peshawar 2012 = __169__ X 1,000 = 54.4 /1,000 females ages 15-44
3,105
The dependency ratio can be expressed as:
 children (0-14) and elderly (65 and over)x 100
those of working age
e.g. UK 1971 (figures in millions):
 13 387 + 7307 x100 = 65.45
31616
So for every 100 people of working age there were 65.45

people dependent upon them
Sex ratio
 Sex ratio is the ratio of males to females in a
population.
The Sex-Ratio (SR) is defined as the number of
males/number of females:
SR = m/f.
The numerator of the Sex-Ratio (males) is not part of
the denominator (females),
thus the SR is not a proportion, which would be
Pmales = m/(m+f).
References
 Baig M, Shaikh B. Disease Surveillance System: A Mandatory Conduit
for Effective Control of Infectious Diseases in Pakistan. Asia-Pacific
Journal of Public Health. 2012;24(4):586-594.
Screening
Bakhtyar Ali Shah
MPH, MHR, MSN, PhD (Scholar)
Objectives
At the end of this session the student will be
able to:
1. Define screening.
2. Discussed the deferent kind of screening.
3. Enlist the types and characteristics of screening.
Introduction
• Screening is the identification of unrecognized
disease by application of rapid tests to separate well
persons who probably have the disease from those
who probably do not have the disease.
• A screening test is not intended to be diagnostic.
• Persons with positive results should be referred for

diagnosis and treatment.
3
Different kinds of testing
in medicine
• A diagnostic test is used to determine the presence
or absence of a disease when a subject shows signs
or symptoms of the disease
„
• A screening test identifies asymptomatic individuals
who may have the disease
„
• The diagnostic test is performed after a positive
screening test to establish a definitive diagnosis
Cont…
CASE-FINDING:
Usually in an investigation of exposed people, to sort the exposed and ill from
the exposed and well.
(E.g., test people who were in contact with a case of tuberculosis)

Some Common
Screening Tests
• Pap smear for cervical cancer
• Fasting blood cholesterol for heart disease
• Fasting blood sugar for diabetes
• Blood pressure for hypertension
• Mammography for breast cancer
• PSA test for prostate cancer
• Fecal occult blood for colon cancer
• Ocular pressure for glaucoma
„
•
Types
Mass screening
of screening
o Involve the whole population.
o Example: Measure the B.P of all adults in a population.
• Targeted screening
o Selected groups who are anticipated to have an increased prevalence of the condition for
which screening has been instituted.
o Example: Measuring the blood cholesterol in relatives of people with familial
hyperlipidemia .
7
Logic of screening
Apparently well population
Screening test
Positive results:
Negative results Diagnostic test

(False negative) (True negative) (True positive) (False positive)
How good is the test?
Disease present?
Yes No
Positive
True positive False positive
Test result
Negative False negative True negative
Sensitivity = True positive

True positive + False negatives
Specificity = True negative

True negative + False positives
Quality of Screening Tests
• Depends on:
o Validity – Ability of the test to distinguish between who has a disease and who does not
• A perfect test would be perfectly valid
o Reliability – Repeatability of a test

• A perfectly reproducible method of disease ascertainment would produce the same
results every time it was used in the same individual.
10
ValidityItof Screening
has Two components;
Test
o Sensitivity – the ability of the test to identify correctly those
who HAVE the disease; the search for diseased persons
o Specificity – the ability of the test to identify correctly those

who DO NOT HAVE the disease; the search for well persons
o Sensitivity and specificity quantify a test’s accuracy in the

presence of known disease status.
11
Breast Cancer
Physical Exam + -
and Mammo-
graphy + 132 983
- 45 63650
Sensitivity: a / (a + c)
Sensitivity =
Specificity: d / (b + d)
Specificity =
27
Breast Cancer
Physical Exam + -
and Mammo-
graphy
+ 132 983
- 45 63650
Sensitivity = 132 / (132 + 45) = 74.6%
Specificity = 63650 / (983 + 63650) = 98.5%
28
Sensitivity = 132 / (132 + 45) = 74.6%
Specificity = 63650 / (983 + 63650) = 98.5%
Sensitivity: Screening by physical exam and mammography will

identify 75% of all true breast cancer cases.
Specificity: Screening by physical exam and mammography will

correctly classify 98.5% of all non-breast cancer
patients as being disease free.
29
Predictive Value of a test
• Reflects diagnostic power of a test.
• The probability that a patient with a positive test has in fact the
disease in question
o Positive PV
• The probability that a patient with a negative test has in fact not
got the disease in question
o Negative PV
30
Criteria for Screening Programs
• There are WHO guidelines for deciding when
screening is appropriate ,drawn up by Wilson and
Jungner in 1968;
o Condition should be an important health problem
o The natural history should be well understood.
o There should be a detectable early stage.
o There should be a suitable test for the early stage.
o The test should be acceptable to the population to be
screened.
o The cost should be balanced against benefits.
40
THANK YOU
41
Data Management & Presentation
By: Ibne Amin

Institute of Nursung sciences
Khyber Medical University,Peshawar
Objectives
• Define the term data
• Discuss the types of data and various methods
of data collection.
• Discuss the different means and interpretation
of data presentation through:
• Graphs,
• Tables,
• Charts.
Data
DATA are informations which may lead to an answer or a
solution to a particular question or a problem
OR
Collection of information in numerical form.
(Data are numerical facts)
OR
The values of observations recorded for variables
OR
Informations,coming from observations, counts,
measurements,or response (Singular = datum)
VARIABLE a variable is defined as anything that has a quantity or quality that varies.
Types of Data
1.Quantitative data
Numerical data that you can add, subtract, multiply, and divide
Numerical values, often with units of measurement
Examples:
• Age (possible units: years)
• Blood pressure (mm of Hg)
• BMI (kg/m2)
• Pulse (beats/minute)
• Annual income (possible units: thousands of PKR)
• Number of children (count therefore no other units)
• Optimism on a 0 to 100 scale
• Exercise in hours per week
• Coffee drinking in ounces per day
Types of Data
2.Qualitative Data
Also called categorical data
• When the data are arranged in categories on the basis of
their quality or attribute and there is gap between two values,
it is called qualitative data, e.g name, religion, marital status,
socioeconomic status, awareness.
• Qualitative data cannot be expressed in numerical forms.
Source of Data Collection
• Routinely kept records

• External sources
• Natural observation :
• Survey
• Case study :
• Experiment :
Routinely kept records
It is difficult to imagine any type of organization
that does not keep records of day-to-day
transactions of its activities. Hospital medical
records, for example, contain immense amounts
of information on patients, while hospital
accounting records contain a wealth of data on
the facility’s business activities. When the need
for data arises, we should look for them first
among routinely kept records.
External sources
The data needed to answer a question may already exist in
the form of published reports, commercially available
data banks, or the research literature. In other words, we
may find that someone else has already asked the same
question, and the answer obtained may be applicable to
our present situation.
• Natural observation :
– Go out into the field and observe phenomena (People,
animal), and if possible without interfering with the
phenomena itself
• Survey
– It is also kind of observational study. You are just
collecting information without having any control
• Case study :
– One unusual individual is intensively studied
• Experiment :
– Where one variable is deliberately manipulated. It is a
kind of research plan that have another group called
controls.
Data Presentation
• Summarize data in an informative and accurat
e way
• Help reader grasp the key feature of the data
• The goal is have a graphic that is simple, easy
to understand, and most effective in presenting
the data to the general public.
Presentation of Data
• Statistical data are generally presented by:
Tables
- Frequency table
- Cross-tabulation
Graphs
- For Qualitative data
- For Quantitative data
14
Presentation of qualitative Data by Table
- A Psychologist asked a list of questions to measure the level of Anxiety and

Depression in the patient. In one of the question she asked:
“Have you had lack of interest in your daily activities during past two
weeks?”
Code: 0=Never; 1=few times; 2=often; 3=Always
The responses of 20 randomly selected patients for the above question
were:
Few times; Always; Never; Often;

Often; Often; Always; Few times;
Often; Always; Often; Never;
Always; Often; Always; Often;
Often; Few times; Often; Always;
15
Presentation of Qualitative Data by Table
________________________________________________________________
Response Frequency Relative
Frequency_
Tally Number of
Marks Patients Proportion
Never II 2 2/20=0.10
Few Times III 3 3/20=0.15
Often IIIIIIII 9 9/20=0.45
Always IIIII 6 6/20=0.30
_________________________________________________________________
Total 20 1.00
Note: Relative frequency can also be presented in times of percentage by

multiplying 100.
16
Presentation of Quantitative Data by
Table
Problem Description:
The class of 2004 at the Isra University conducted a
baseline sample survey at Rehri Goth for the
Emergency obstetric care project. As the baseline
information, the students also asked about the
number of living children per women (15-49 years).
The following data has been collected based on a
random sample of n=30 woman.
2,2,5,3,0,1,3,2,3,4,1,3,4,5,7,
3,2,4,1,0,5,8,6,5,4, 2,4,4,7,6
17
Presentation of Quantitative Data by
Table
Number of Cumulative
Living children Tally Frequency Frequency
0 II 2 2
1 III 3 5
2 IIII 5 10
3 IIII 5 15
4 IIIII 6 21
5 IIII 4 25
6 II 2 27
7 II 2 29
8 I 1 30
_______________________________________________
Total 30
18
What happened when you have a lot of
different observation?
Problem description:
A sample survey was conducted in a squatter (thicker, unlawful
residents, shorter) settlement of Karachi, the households
were asked about the average monthly amount (in Rs.) spent
on health by them? The following data was collected based
on random sample of n=25 households.
90,75,140,80,60,55,105,70,298,180,105,
130,145,150,270,235,125,245,100,205,50,
85,160,275,194.
19
Steps to summarize the into
Frequency Distribution Table
The following steps should be taken:
Step 1: compute the interval spanned by the
data. We can obtain this interval by arranging
the data into an array, a listing all observations
from smallest to Largest.
50,55,60,70,80,85,90,100,105,105,125,130,140
145,150,160,180,194,205,235,245,270,275,298
20
• Step 2: Divide the range into an arbitrary number but
usually equal and non-overlapping segments (each data
value belonging to one and only one segments) called class
intervals. The number of intervals depends on the number of
observations but in general should range from 5 to 15.
Suppose we want to group the data into five non-overlapping
classes
Approximate Class Width =
Largest data value – Smallest data value
Number of Classes
298 -50 = 248 = 49.6
5 5
Rounding up, we choose to create five classes of width of 50
each
21
Expenditure on Tally Frequency Relative
Health (Rs.) Cumulative
Frequency
50-99 IIIIIII 08 8/25= 0.32
100-149 IIIIII 07 0.60
150-199 IIII 04 0.76
200-249 III 03 0.88
250-299 III 03 1.00
Total 25
Note: Relative Frequency can also be presented in terms of percentage

by multiplying 100
Class Lower Upper Midpoint Frequency Relative Cumulative Cum. Rel.
Limit Limit Frequency Frequency Frequency
0 62 66 64 0 0 0 0
1 66 70 68 1 0.01 1 0.01
2 70 74 72 0 0 1 0.01
3 74 78 76 0 0 1 0.01
4 78 82 80 2 0.02 3 0.03
5 82 86 84 8 0.08 11 0.11
6 86 90 88 5 0.05 16 0.16
7 90 94 92 14 0.14 30 0.3
8 94 98 96 18 0.18 48 0.48
9 98 102 100 11 0.11 59 0.59
10 102 106 104 18 0.18 77 0.77
11 106 110 108 6 0.06 83 0.83
12 110 114 112 8 0.08 91 0.91
13 114 118 116 5 0.05 96 0.96
14 118 122 120 3 0.03 99 0.99
15 122 126 124 1 0.01 100 1
16 126 130 128 0 0 100 1
17 130 134 132 0 0 100 1
18 134 138 136 0 0 100 1
19 138 142 140 0 0 100 1
20 142 146 144 0 0 100 1
21 146 150 0 0 100 23 1
Presentation of Data by Cross Tabulation
Cross tabulation (or crosstabs for short):

It is a statistical process that summarizes categorical data to
create a contingency table.. They provide a basic picture of the
interrelation between two variables and can help find
interactions between them.
24
Sample # Gender Handedness
1 Female Right-handed
2 Male Left-handed
4 Male Right-handed
5 Male Left-handed
6 Male Right-handed
8 Female Left-handed
9 Male Right-handed
:
25
26
Cross-Tabulation
Contingency table
Left handed Right handed total
Males 2 3 5
Females 1 4 5
total 3 7 10
27
Graphs
• Graphs are Geometrical designs:
- Convey information at a glance

- Mathematically less sophisticated (no formula
used, no calculations)
28
Graphical Presentation of Quantitative
Data
• Histogram
• Frequency Polygon
• Stem and Leaf
29
Conti
Histogram
• Used for Quantitative, Continuous, Variables.
• It is used to present variables which have no
gaps e.g age, weight, height, blood pressure,
blood sugar etc.
• It consist of a series of blocks. The class
intervals are given along horizontal axis and
the frequency along the vertical axis.
• Histogram
– Similar to bar chart
 bars closely
situated
– # of bars?
• Too few  data
clumps
• Too many  overly
detailed
31
HISTOGRAM
14
12
10
FREQUENCY INDIVIDUALS
Std. Dev = 10.06

2
Mean = 57.7
0 N = 50.00
35.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0
AGE
32
Conti…
Frequency polygon
Frequency polygon is an area diagram of frequency
distribution over a histogram. It is a linear
representation of a frequency table and histogram,
obtained by joining the mid points of the hitogram
blocks. Frequency is plotted at the central point of a
group
percentage
34
STEM & LEAF GRAPH
35
STEM & LEAF GRAPH
Graphical Presentation of Qualitative Data
• Simple Bar chart

• Multiple Bar chart
• Component Bar Chart
• Sliding Bar Chart (e.g. Population Pyramid)
• Pie Chart
37
80
BAR CHART
70
Frequency
60
50
Male Female
Sex
38
MULTIPLE BAR CHART (VERTICAL)
60
50
ASCITES
40
30
Ascites
20
Yes
10 No
Male Female
GENDER
39
SLIDING BAR CHART
40
PIE CHART
Figure 2.3 Pie chart showing the number of students of each category
41
References
Biostatistics by Prem P. Panta
Fundamentals of Research Methodology and
Statistics by Yogesh k. Singh
Research Design by J. W. Creswell
Internet

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Epidemiology Course Syllabus

Unit 1: Introduction of Epidemiology Unit 6: Epidemiological transitions in disease patterns

• At the end of this presentation the student will be

• Discuss type of epidemiology

• Enlist uses of epidemiology

• Describe scope of epidemiology.

• Epidemiology, literally meaning "the study of what

• It applies only to human populations

Oxford English Dictionary

The branch of medical science which treats of

Kuller LH: Am J Epid 1991

Epidemiology is the study of "epidemics" and their

• Epidemiology is the study of the determinants,

• Some describe it as the study of epidemics

• An epidemic occurs when there are significantly

•What are the characteristics of a

•Science is a creative endeavor

•Epidemiology weighs and balances

•To study the cause (or etiology) of disease(s), or

•To determine, describe, and report on

•To provide a basis for developing disease

•know where to look

•Age, gender, ethnicity

•Time since an event

•You have been asked to investigate an

•Descriptive epidemiology – person, place

Agents may be living or non living

• Physical environment: it is the space around man

• Biological environment: all living thing that

• Social environment: it includes the customs, habits,

• Principles of Epidemiology in Public Health

• At the end of this presentation the student will be

RISK FACTORS & DETERMINANTS

• Risk Factor is any attribute, characteristic or

• Some examples of the more important risk factors

• Determinant of Health: Many factors combine

• "Well-being is a subjective perception of

TWO ASPECTS OF HEALTH

Wellness & Well-Being

• Wellness further describes health status. It

Copyright 2008 by Pearson Education, Inc.

Copyright 2008 by Pearson Education, Inc.

Distinction between Disease,

Distinction between Disease,

MODELS/THEORIES OF DISEASE CAUSATION

• Human disease results from an interaction of the

• According to this model disease results from an

1. Agent — cause of the disease

• The mere presence of

• Chemical (Air pollutants,

• Social (poverty, access

• McMahon and Pugh forwarded the theory of

• Each factor has its own relative importance

The Wheel of Causation

• As medical knowledge advanced, an additional

• The “triad” as well as the “web” theory does not

• To explain such relative contribution of genetic and

• The theory de-emphasizes

• The theory visualizes

• Like any wheel, the outer