Public Health 101 Series

Introduction
to Epidemiology
Instructor name
Title
Organization

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 Course Topics

Introduction to Epidemiology
1. A Public Health Approach
2. What Is Epidemiology?
3. Key Concepts and Terms
4. Calculating Rates
5. Approach and Methodology
6. Data Sources and Study Design
7. Investigating an Outbreak

2
 Learning Objectives

After this course, you will be able to

define epidemiology
describe basic terminology and concepts of
epidemiology
identify types of data sources
identify basic methods of data collection and
interpretation
describe a public health problem in terms of time, place,
and person
identify the key components of a descriptive
epidemiology outbreak investigation

3
 Topic 1
A Public Health Approach

4
 A Public Health Approach

Risk Factor Intervention

Surveillance Implementation
Identification Evaluation

5
Public Health Core Sciences

6
 Topic 2
What Is Epidemiology?

7
 Epidemiology Defined

Study of the distribution and

determinants of health-related
states among specified
populations and the application
of that study to the control of
health problems

Adapted from: Last JM, ed. A dictionary of epidemiology. 2nd ed. Toronto, Canada: Oxford University Press; 1988. 8
 Epidemiology Purposes
in Public Health Practice

Discover the agent, host, and environmental factors

that affect health

Determine the relative importance of causes of

illness, disability, and death

Identify those segments of the population that have

the greatest risk from specific causes of ill health

Evaluate the effectiveness of health programs and

services in improving population health

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 Solving Health Problems
Step 1 -

Step 1 Step 1 -
Data Surveillance; determine
collection time, place, and person

Step 2 Step 2
Assessment Inference
Solving health
problems
Step 3 Step 3
Hypothesis
Determine how and why
testing

Step 4 Step 4
Action Intervention
Action 10
 Knowledge Check
All of the following illustrate the purpose of
epidemiology in public health, except
A. identifying populations who are at risk for certain
diseases.

B. assessing the effectiveness of interventions.

C. providing treatment for patients in clinical

settings.

D. determining the importance of causes of illness

11
 Knowledge Check

Epidemiologists use a model for studying infectious

disease and its spread that involves the microbe that
causes the disease, the organism that harbors the
disease, and the external factors that cause or allow
disease transmission. This is also known as
A. host, vector, and transmission.
B. transmission, host, and environment.
C. host, agent, and environment.
D. organism, transmission, and
environment.

12
 Topic 3
Epidemiology Key Terms

13
 Epidemiology Key Terms

epidemic or outbreak: disease occurrence among a population

that
is in excess of what is expected in a given time and place.
cluster: group of cases in a specific time and place that might
be more than expected.

endemic: disease or condition present among a population at

all times.

pandemic: a disease or condition that spreads across

regions.

rate: number of cases occurring during a specific period;

always dependent on the size of the population during that
period.
14
 Knowledge Check
Match each term with the correct example.

A. endemic B. pandemic C. epidemic

A. endemic 1. Malaria is present in Africa at all times

because of the presence of infected
mosquitoes. Malaria is _____ in Africa.
C. epidemic 2. The Ebola virus in parts of Africa is in
excess of what is expected for this
region. This virus is a/an ________.
B. pandemic 3. HIV/AIDS is one of the worst global
diseases in history. It is a/an
_________. 15
 Knowledge Check

Choose the correct answer.

A. distribution B. cluster C. determinant

In March 1981, an outbreak of measles occurred

among employees at Factory X in Fort Worth,
Texas.

This group of cases in this cluster

specific time and place
can be described as a ________________.

16
 Topic 4
Calculating Rates

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Comparing Population Characteristics

Rates help us compare

health problems among
different populations that
include two or more groups
who differ by a selected
characteristic

18
 Rate Formula
To calculate a rate, we first need to determine
the frequency of disease, which includes

the number of cases of the illness or condition

the size of the population at risk

the period during which we are calculating the rate

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 Scenario: Unexplained Pneumonia

American Legion Health care provider at a veterans hospital

Convention, in Philadelphia calls CDC to report cases
Philadelphia, of severe respiratory illness among
Pennsylvania attendees of the American Legion
Convention

August 2 August 2
July 2124 July 26Aug 1
(Morning) (Evening)

18 deaths 71 additional
reported among cases reported
conventioneers

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297:118997. 20
 Legionnaires Disease, by Age Group
Hotel A Residents
Time: July 2124, 1976
Frequency Unit size

Age (yrs) Sick Total Percentag

e
39 3 44 6.8
4049 9 160 5.6
5059 27 320 8.4
6069 12 108 11.1
70 11 54 20.4
Unknown 0 2 0

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297:118997.
21
Legionnaires Disease Rate

Hotel A Residents
Time: July 2124, 1976
Frequency Unit Rate

Age (yrs) Sick Total Percentag

e
39 3 44 6.8
4049 9 160 5.6
5059 27 320 8.4
6069 12 108 11.1
70 11 54 20.4
Unknown 0 2 0

22
 Knowledge Check
On Day 1 of a technology conference in San Diego, 15
presenters who were setting up for their sessions in Annex X
became ill with flu-like symptoms. During the course of the
conference, 20 participants who attended sessions in Annex X
also became ill with the same symptoms.

To begin calculating the rate of this outbreak, investigators

should first determine

A. the size of the conference population.

B. the number of cases of illness.

C. the number of days the conference was held.

D. the location of the conference.

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 Topic 5
Epidemiology Approach
and Methods

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 Epidemiology Study Types

Experimenta
l
Epidemiolog
y study
Descriptive
types
Observation
al
Analytic

25
Descriptive and Analytic Epidemiology

Descriptive Analytic
epidemiology epidemiology
When was the How was the
population affected? population affected?
Where was the Why was the
population affected? population affected?
Who was affected?

26
Fatalities Associated with Farm Tractors

In 1982, the number of

farm tractor-associated
deaths was described in
terms of time, place, and
person by using records
from an existing
surveillance system

27
 Fatalities Associated with Farm Tractors

Goodman RA, Smith JD, Sikes RK, et al. Fatalities associated with farm tractor injuries: an epidemiologic study. Public Health Rep 28
1985;100:32933.
 Fatalities Associated with Farm Tractors

Goodman RA, Smith JD, Sikes RK, et al. Fatalities associated with farm tractor injuries: an epidemiologic study. Public Health Rep
1985;100: 32933.
29
 Fatalities Associated with Farm Tractors

Goodman RA, Smith JD, Sikes RK, et al. Fatalities associated with farm tractor injuries: an epidemiologic study. Public Health Rep 30
1985;100:32933.
 Knowledge Check

Choose the correct answer from the following

choices:
A. Qualitative B. Experimental C. Observational

C. Observational An epidemiologist is doing a study

on the sleep patterns of college
students but does not provide any
intervention. What type of study is
this?

31
 Knowledge Check

Match each term to the correct example below.

A. Descriptive B. Analytic

B. Analytic 1. A study of heart disease comparing a

group who eats healthy foods and
exercises regularly with one who does
not in an effort to test association
A. Descriptive 2. A study to describe the eating habits
of adolescents aged 1318 years in
Community X

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 Topic 6
Epidemiology Data Sources
and Study Design

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 Data Sources and Collection Methods
Source Method Example

Individual persons Questionnaire Foodborne illness outbreak

Survey CDCs National Health and
Nutrition Examination Survey
Health data on U.S. residents
Environment Samples from the Collection of water from area
environment (river streams check for
water, soil) chemical pollutants
Sensors for Air-quality ratings
environmental changes
Health care Notifications to health Report cases of meningitis to
providers department if cases of health department
certain diseases are
observed
Nonhealthrelated Sales records Cigarette sales
sources (financial, Court records Intoxicated driver arrests
legal)
34
Conducting Studies

Studies are conducted in

an attempt to discover
associations between an
exposure or risk factor and
a health outcome

35
Study Design Cross-Sectional Study

Subjects are selected

because they are
members of a certain
population subset at a
certain time

36
Study Design Cohort Study

Subjects are categorized

on the basis of their
exposure to one or more
risk factors

37
Study Design Type Case-Control Study

Subjects identified as
having a disease or
condition are compared
with subjects without the
same disease or condition

38
 Knowledge Check

Which of the following are examples of a health-

related source of data collection?

A. Intoxicated driver arrests.

B. Electronic health records.

C. Measurementof toxins in a river.

D. Medical board action against a physician.

39
 Knowledge Check

Match each study with the correct definition.

A. Cross-Sectional B. Cohort C. Case-Control

C. Case-Control 1. Subjects with diabetes are compared

with subjects without diabetes.
A. Cross-Sectional 2. A study of women aged 5060
years in a community located close
to a nuclear power facility.
B. Cohort 3. Subjects who have received
nutritional counseling and who
have exercised twice a week are
compared with subjects who have
not. 40
 Topic 7
Investigating an Outbreak

41
 Outbreak Investigation
Ten steps are involved in outbreak investigations,
including
establishing the existence of an
outbreak
preparing for fieldwork
verifying the diagnosis
defining and identifying cases
using descriptive epidemiology
developing hypotheses
evaluating the hypotheses
refining the hypotheses
implementing control and prevention
measures
communicating findings
42
 Outbreak Investigation Steps 1 and
2
Step 1 Establishing the
existence of an outbreak
Use data from data
sources

Step 2 Preparing for field

work
Research the disease
Gather supplies and
equipment
Arrange travel

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297 118997. 43
 Outbreak Investigation Steps 3 and
4
Step 3 Verifying the
diagnosis
Speak with patients
Review laboratory
findings and clinical test
results
Step 4 Defining and
identifying cases
Establish a case
definition by using a
standard set of criteria
Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297 118997. 44
 Outbreak Investigation Step 5

Step 5 Using descriptive

epidemiology

Describe and orient the

data

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med 1977;297 118997.
45
 Legionnaires Disease Cases, by Day

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297:118997.
46
 Legionnaires Disease Attack Rates
Hotel A Hotel B Hotel C
Age Ill Total Percent Ill Total Percent Ill Total Percent
(yrs) ill ill ill
39 3 44 6.8 3 116 2.6 6 160 3.7

4049 9 160 5.6 11 232 4.7 20 392 5.1

5059 27 320 8.4 25 523 4.8 52 843 6.2

6069 12 108 11.1 19 207 9.1 31 315 9.8

70 11 54 20.4 5 76 6.5 16 130 12.3

Unknow 0 2 0 0 7 0 0 9 0
n
Total 62 688 9.0 63 1,161 5.4 125 1,849 6.8

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297: 118997.
47
 Outbreak Investigation Steps 6, 7, and
8
Step 6 Develop a focused
hypothesis

Step 7 Evaluate the

hypothesis for validity
Step 8 Refine the hypothesis
as needed

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297:118997.
48
Legionnaires Disease Study Results

Five months after the first

cases of Legionnaires disease
occurred, results of the case-
control study indicated that
spending time in the lobby of
Hotel A was a risk factor for
illness

49
Legionnaires Disease Study Results

In December 1976, a CDC

laboratorian successfully located
the source bacteria after
continuing to test the specimens
that were thought to be dead

50
 Outbreak Investigation Steps 9 and 10

Step 9 Implement control and

prevention measures
Control and prevent additional
cases

Step 10 Communicate findings

Determine who needs to know
Determine how information will
be communicated
Identify why the information
needs to be communicated

Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic of pneumonia. New Engl J Med
1977;297:118997.
51
 Knowledge Check

In 1976, during an American Legion Convention, 11

attendees had died of apparent heart attacks by August 1.
Dr. Campbell contacted the Pennsylvania Department of
Health after realizing he had treated 3 of those 11 attendees.
What is the first step the Pennsylvania Department of Health
should have followed?

A. Establish a surveillance system.

B. Alert the convention attendees.
C. Establish the existence of an outbreak.
D. Send an investigation team to the hotel.

52
 Knowledge Check

CDC then launched an investigation. However, no effective

communication existed between scientists in the field
interviewing patients and those in the laboratory who were
testing specimens.

As a first step in stopping this outbreak, what should the

team have done to identify persons who were part of the
outbreak?

A. Verify a diagnosis.
B. Establish a case definition to identify cases.
C. Communicate findings to the public.
D. Implement prevention measures.
53
 Knowledge Check

In speculating that the cooling system might be the

source of the outbreak, what step was the
epidemiologist implementing?

A. Developing a hypothesis.
B. Refining a hypothesis.
C. Evaluating a hypothesis.
D. Verifying a diagnosis.

54
 Knowledge Check
In January 1977, the Legionella bacterium was finally
identified and isolated and was found to be breeding in the
cooling tower of the hotels air-conditioning system; the
bacteria then spread through the building whenever the
system was engaged. What should the investigation team
do regarding their original hypothesis?

A. Evaluate it.

B. Refine it.

C. Confirm it.

D. Both A and B.

55
 Knowledge Check

The finding from this outbreak investigation lead to

development of new regulations worldwide for climate
control systems. What step does this illustrate?

A. Communicate the findings.

B. Implement control and prevention measures.
C. Perform descriptive epidemiology.
D. Refine the hypothesis.

56
 Course Summary
During this course, you learned to
define epidemiology
describe basic terminology and concepts of
epidemiology
identify types of data sources
identify basic methods of data collection and
interpretation
describe a public health problem in terms of time, place,
and person
identify the key components of a descriptive
epidemiology outbreak investigation

57
QUESTIONS?

58
Resources and Additional Reading
Bogdanich W. Panama releases report on 06 poisoning. The New York Times, February
14, 2008.http://www.nytimes.com/2008/02/14/world/americas/14panama.html.
Centers for Disease Control and Prevention (CDC). CDC helps solve Panama mystery
illness. Atlanta, GA: US Department of Health and Human Services, CDC News, October
7, 2006. http://www.cdc.gov/news/2006_10/panama.htm.
Dean H. Introduction to public health, epidemiology, and surveillance. Atlanta, GA: US
Department of Health and Human Services, CDC Science Ambassador Program, July 16,
2012.
Fraser DW, Tsai, T, Orenstein W, et al. Legionnaires disease: description of an epidemic
of pneumonia. New Engl J Med 1977;297:118997.
Goodman RA, Smith JD, Sikes RK, et al. Fatalities associated with farm tractor injuries:
an epidemiologic study. Public Health Rep 1985;100:32933.
Centers for Disease Control and Prevention (CDC). How to investigate an outbreak.
Epidemiology in the Classroom, November 17, 2004. Atlanta, GA: US Department of
Health and Human Services, CDC.
http://www.cdc.gov/excite/classroom/outbreak/steps.htm#step1.
Last JM, ed. A dictionary of epidemiology. 2 nd ed. Toronto, Canada: Oxford University
Press; 1988.
Rentz DE, Lewis L, Mujica OJ, et al. Outbreak of acute renal failure in Panama in 2006: a
case-control study. Bull World Health Organ 2008;86:74956.
Sakamoto R, Ohno A, Nakahara T, et al. Legionella pneumophilia in rainwater on roads.
Emerg Infect Dis 2009;15:12957.
Thacker SB, Birkhead GS. Surveillance [Chapter 3]. In: Gregg, MB, ed. Field
epidemiology. 3rd ed. New York, NY: Oxford University Press; 2008. 59
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not imply endorsement by the Division of Scientific Education and Professional
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U.S. Department of Health and Human Services.

The findings and conclusions in this course are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control
and Prevention.

60
For more information, please contact the Centers for Disease Control
and Prevention

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Visit: http://www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or
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The findings and conclusions in this course are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention.

Center for Surveillance, Epidemiology, and Laboratory Services

Division of Scientific Education and Professional
Development