EPIDEMIOLO

THE BASIC SCIENCE OF PUBLIC

GY
HEALTH
EPIDEMIOLOGY

Comes from the Greek words epi,

means upon, demos, means people
and logos, means the study of.
 Epidemiology is the study of the
health of human populations. It aims to
prevent the spread of disease and the
promotion of health. Many definitions
have been proposed, but the following
definition captures the underlying
principles and public health spirit of
epidemiology:
 Epidemiology is the study of the
distribution and determination of
health-related states or events in
specified populations, and the
application of this study to control
of public health problems.
 STUDY
Epidemiology
- a scientific discipline with sound methods of
scientific inquiry at its foundation.
- a data-driven and relies on a systematic and
unbiased approach to the collection, analysis
and interpretation of data.

Basic epidemiologic methods tend to rely on careful

observation and use if valid comparison groups to assess
whether what was observed, such as the number of
cases of disease in a particular area during a particular
time might be expected. However, epidemiology also
draws on methods from other scientific field , including
biostatistics and informatics, with biologic, economic,
social and behavioral sciences.
Epidemiology is the study of the health of human populations, its
functions are as follows:

1. To discover the agent, host, and environmental factors that affect

health to provide the scientific basis for the prevention of disease
and injury and the promotion of health;

2. To determine the relative importance of causes of

illness, disability, and death to establish priorities for research
and action.

3. To identify those sections of the population that have the greatest

risk from specific causes of ill health so that the indicated
action may be directed appropriately; and

4. To evaluate the effectiveness of health programs and services

in improving the health of the population.
What public health problems or events are investigated?

Environmental Lead and heavy metals

exposures Air pollutants and other asthma triggers
Infectious Foodborne-illness
diseases Influenza and pneumonia
Injuries Increased homicides in a community
National urge in domestic violence
Non-infectious Localized or widespread rise in a particular type of
diseases cancer
Increase in major birth defect
Natural diseases Hurricanes Katrina and Rita (2005)
Haiti earthquake (2010)
Terrorism World Trade Center (2001)
Anthrax release (2001)
 DISTRIBUTION
Epidemiology is concerned with the frequency and
pattern of health events in a population:
Frequency
refers not only the number of health events
such as the number to the size of the population.
The resulting rate allows epidemiologists to
compare disease occurrence across different
populations. epidemiology.
Pattern
refers to the occurrence of health-related
events by time, place, and person.
* Time patterns
may be annual, seasonal, weekly, daily, hourly,
weekdays versus weekend, or any other breakdown of
time that may influence disease or injury occurrence.
* Place patterns
include geographic variation, urban/rural
differences and location of work sites or schools.
Personal characteristics include demographic factors
which may be related to risk of illness, injury or
disability such as age, sex, marital status and
socioeconomic status, as well as behaviors and
environmental exposures.

Characterizing health events by time, place and person

activities of descriptive epidemiology.
 DETERMINAN
TS
These are the causes and other factors that influence the occurrence of disease
and other health-related events. Epidemiologists use analytic epidemiology or
epidemiologic studies to provide the “Why” and “How” of such events.
 DETERMINAN
TS
They assess whether groups with different rates of disease differ in their demographic
characteristics, genetic or immunologic make-up, behaviors, environmental exposures, or
other so-called potential risk factors. Ideally, the findings provide sufficient evidence to direct
prompt and effective pubic health control and prevention measures.
 HEALTH-RELATED STATES OR EVENTS
Epidemiology originally focused on epidemics of
communicable diseases but was subsequently
expanded to address endemic communicable diseases
and non-communicable diseases. By the middle of the
20th century, additional epidemiologic methods had
been developed and applied to chronic diseases,
injuries. Birth defects, maternal-child health,
occupational health, and environmental health. Then
epidemiologists began to look at behaviors related to
health and well-being , such as amount of exercise and
seat belt use. Now, with the recent explosion in
molecular methods.
 SPECIFIED POPULATIONS
Epidemiologists and direct health-care providers (clinicians) are
both concerned with the occurrence and control of disease. Both are
interested in establishing the correct diagnosis but they differ in how
they view their patient. They have different responsibilities when
facing a person with illness

Clinicians
- Concerned about the health of an individual.
- The clinician’s patient is the individual.
- Focuses on treating and caring for the individual.
Epidemiologist
- Concerned about the collective health of the people in the
community or population
- The epidemiologist’s patient is the community
- Focuses on identifying the exposure or source that caused the
illness.
- The number of other persons who may have been similarly
exposed.
- The potential for further spread in the community.
- Interventions to prevent additional cases or recurrences
 APPLICATION
Epidemiology involves applying the knowledge gained
by the studies to community-based practice. The practice
of epidemiology is both a science and an art.
Clinician
- Combines medical (scientific)
knowledge with experience,
clinical judgement and
understanding of the patient.
Epidemiologist
- uses scientific methods of descriptive and analytic
epidemiology as well as experience, epidemiologic
judgment, and understanding of local conditions in
“diagnosing” the health community and proposing
appropriate, practical and acceptable
public health interventions to control
and prevent disease in the
community.
USES
Epidemiology and the information
generated by epidemiologic methods have
been used in many ways. Some common uses
are described below:
ASSESSING THE COMMUNITY’S HEALTH
- To assess the health of a population or
community, relevant sources must be
identified and analyzed by person, place,
and time (descriptive epidemiology)
∙ What are the actual and potential health problems in
the community?
∙ Where are they occurring?
∙ Which populations are at increased risk?
∙ Which problems have declined over time?
∙ Which ones are increasing or have the potential to
increased?
∙ How do these patterns relate to the level and
distribution of public health services available?

- More detailed data may need to be collected and

analyzed to determine whether health services are
available, accessible, effective, and efficient.
MAKING INDIVIDUAL DECISIONS
Many individuals many not realized that
they use epidemiologic information to
make daily decisions affecting their health.
When a person decide to do something,
they may be influenced consciously or
unconsciously by epidemiologist’s
assessment of risk. People’s choices affect
their health over a lifetime.
COMPLETING THE CLINICAL PICTURE
- When investigating a disease outbreak,
epidemiologists rely on health-care
providers and laboratorians to establish
the proper diagnosis of individual patients.
Epidemiologists also contribute to
physician’s understanding of clinical
picture and natural history of disease.
SEARCHING FOR CAUSES
- Epidemiologic research is devoted to
searching for causal factors that
influence one’s risk of disease. Its
goal is to identify a cause so that
appropriate public health action
might be taken. Epidemiology
provides enough information to
support effective action.
CORE EPIDEMIOLOGIC FUNCTIONS
Five major tasks of epidemiology in public
health practice (mid-1980s)
∙ Public health surveillance
∙ Field investigation
∙ Analytic studies
∙ Evaluation
∙ Linkages
∙ Policy development (recently added)
Public health surveillance
•An ongoing, systematic collection, analysis interpretation and dissemination of
health data to help guide public health decision making and action.
Surveillance is equivalent to monitoring the pulse of the community. Public
health surveillance is sometimes called information
for action. Its purpose is to portray the ongoing patterns of
diseases occurrence and disease potential.

Surveillance information flows from public

and public and health care providers such as clinicians, laboratories, and
hospitals and health departments. Feedback flows from health departments
back to public and health care providers.
Field investigation
- Investigations often lead to the identification of additional unreported or
unrecognized ill person who might otherwise continue to spread infection
to others. Identification and treatment of these contacts prevent further
spread.

Analytic studies
Rigorous methods are need in analytic studies. Often methods used
in combination with surveillance and field investigations providing clues or
hypotheses about causes and modes of transmission, and analytic studies
evaluating the credibility of those hypotheses.
Evaluation
- Process of determining, as systematically and objectively as
possible, the relevance, effectiveness, efficiency and impact
of activities with respect to established goals.

∙ Effectiveness – refers to the ability of a program to produce

the intended or expected results in the field.
∙ Efficacy – ability to produce results under ideal conditions
∙ Efficiency – ability to produce the intended results with a minimum expenditure of time
and resources.
Linkages
- Epidemiologists working in public health rarely act in isolation. In fact, field
epidemiology is often said to be a team sport. During investigation, an epidemiologists
usually participate as either the member or leader of multidisciplinary team. Other
members may be laboratorians,sanitarians ,infection control personnel, nurses or
other clinical staff and increasingly, computer information specialist.

Policy development
- Epidemiologists who understand a problem and the population
which it occurs are often in a uniquely qualifies position to
recommend appropriate interventions.
 Descriptive and Analytic Epidemiology

Descriptive Epidemiology
- Identify patterns among cases and in population
- Covers time, place and person

The 5 W’s of descriptive epidemiology

∙ What = health issue of concern
∙ Who = person
∙ Where = place
∙ When = time
∙ Why/how = cause, risk factors, modes of transmission
 Analytical Epidemiology
- From the observations in descriptive
epidemiology, epidemiologist
develop hypotheses about the cause
of these patterns and about the
factors that increase risk of disease

- Used to test hypotheses.

 Epidemiologic studies
Experimental studies
- The investigator determines through a
controlled process the exposure of each
individual (clinical trial) or community
(community trial) and then tracks the
individuals or communities over times to
detect the effects of the exposure.
Observational studies
- Epidemiologist simply observes the
exposure and disease status of each study
participant.
 2 most common types:
∙ Cohort studies
∙ Case- control studies
∙ Cross-sectional studies (3rd type)

Cohort study
- Similar concept to the experimental
study.
- Epidemiologist records whether each
study participant us exposed or not,
then tracks the participants to see if
they develop the disease of interest.
Difference from experimental study:
- The investigator observes rather than
determines the participants exposure status.
- After a period of time: the investigator compares
the disease rate in the exposed group with the
disease rate in the unexposed group.
- The unexposed group serves as the comparison
group, providing an estimate of the baseline or
expected amount of disease occurrence in the
community.
- If the disease rate us substantively different in
the exposed group compared to the unexposed
group, the exposure is said to be associated with
illness
Framingham study
- A well-known cohort study that has
followed over 5000 residents of
Framingham, Massachusetts, since the
early 1950s to establish the rates and risk
factors for heart disease.

- This study is sometimes called follow-up or

prospective cohort study, because
participants are enrolled as the study
begins and are then followed prospectively
over time to identify occurrence if the
outcomes of interest.
Retrospective
- An alternative for cohort study.

- In this study, both the exposure

and the outcomes have already
occurred.

- The investigator calculates and

compares rates of disease in the
exposed and unexposed group
Case-control study
- Investigators start by enrolling a group of people with
disease (cases). As a comparison group, the investigator
then enrolls a group of people without disease (control).
- Investigators then compare previous exposures between
the two groups.
- If the amount of exposure among the case group is
substantially higher than the amount you would expect
based on the control group, then illness is said to be
associated with that exposure
- The key in a case-control study is to identify an
appropriate control group, comparable to the case
group in most respects, in order to provide a reasonable
estimate of baseline or expected exposure.
Cross-sectional study
- Tends to assess the
presence(prevalence) of the health
outcome at that point of time without
regard to duration.
 From analytic view of point the cross-
sectional study is weaker than either a cohort
or a case-control study because a cross-
sectional study usually cannot disentangle
risk factors for occurrence of
disease(incidence) from risk factors for
survival with the disease. On the other hand,
cross-sectional study is a perfect fine tool for
descriptive epidemiology purpose. It is used
routinely to document the prevalence in a
community of health behaviors (prevalence of
smoking), health states (prevalence of
vaccination against measles) and health
outcomes, particularly chronic conditions
(hypertension, diabetes).
 ea s e O cc u r re n c e
Concepts of Dis u r r a n d o m l y i n a
e v e n t s d o n o t o cc
s e a n d o th e r h ealth m e m b e r s o f
- Disea e l y o cc u r i n so m e
, b u t a r e m ore l ik a t m a y
p o pu l at i o n o f r i sk f a c t or s t h
n o th e r s b e c a u s e
p u la t i o n t h a
the po ly in t h e p o p u l at i on.
t r ib u t e d ra n d o m
not be dis
Causation
- A number of models of disease causation have been proposed. Among
the simplest of these is the epidemiologic triad or triangle, the
traditional model for infectious disease. The triad consist of an
external agent, a susceptible host, and an environment that brings the
host and agent together.
- Agent, host and environmental factors interrelate in a variety of
complex ways to produce disease.
Agent
– refers to an infectious microorganism or pathogen: a virus, bacterium, parasite
or other microbe.
– A variety of factors influence whether exposure to an organism will result in
disease including the organism’s pathogenicity( ability to cause disease) and
dose.
 
While the epidemiologic triad serves as a useful model for many disease, it
has proven inadequate for cardiovascular disease, cancer and other diseases
that appear to have multiple contributing causes without a single necessary
one.
Host
- Refers to the human who can get the disease. A variety factors
intrinsic to the host, sometimes called risk factors, can influence
an individual exposure, response to a causative agent.
- Opportunities for exposure are often influenced by behaviors such
as sexual practices, hygiene and other personal choices as well as
by age and sex.
- Susceptibility and response to agent are influenced by factors such
as genetic composition, nutritional and immunologic status,
anatomic structure, presence of disease or medications and
psychological makeup.
Environment
- Refers to extrinsic factors that affect the agent and the
opportunity for exposure.
- It includes physical factors such as geology and climate, biological
factors such as insects that transmit the agent and
socioeconomic factors such as crowding, sanitation and the
availability of health services.
 Component Causes and Casual Pies

Rothman in 1976 also known as Casual Pies has been proposed for multifactorial
nature of diseases. The individual factors are called component causes. A complete pie is
considered a casual pathway , is called a sufficient cause. Necessary cause is a component
that appears in every or pathway. Without it, disease does not occur.

Component Causes - intrinsic host factors as well as the agent and the environmental
factors of the agent-host-environment triad

• Single Component Cause - rarely sufficient cause by itself

- ex: exposure to a highly infectious agent such as Measles Virus doesn't invariably result in
measles virus
▪ Pneumocystis carinii
- an organism harmlessly colonizes respiratory tract of healthy persons, but can cause
potentially lethal pneumonia whose immune systems have been weakened by human
immunodeficiency virus.
- Presence of Pneumocysts carinii organisms is a necessary but not sufficient cause of
pneumocystis pneumonia.
 
• For example, lung cancer may result from a sufficient cause including smoking as a
component cause. Smoking is not a sufficient cause by itself, but not all smokers develop lung
cancer. Neither smoking is a necessary cause, because a small fraction of lung cancer victims
have never smoked
• Suppose Component B is dmoking and C is asbestod. Sufficient Cause 1 includes both
smoking (B) and asbestos (C). Sufficient Cause includes asbestos without smoking
EPIDEMIC DISEASE OCCURENCE
Level of Disease
• Sporadic refers to a disease that occurs infrequently and irregularly

• Endemic - particular disease usually present in community

- not necessarily desired level rather it is the observed level constant presence
or usual prevalence of a disease in a population within geographic area

• Hyperendemic - persistent, high levels of disease occurrence

 Error in Epidemiologic Study
Random error-is the result of fluctuations around a true because of
sampling variability.it can occur during data collection, coding,
transfer, or analysis.
Example: poor worded questions, a misunderstanding in interpreting an
individual answers
Two Basic Ways to Reduce Random Error in an Epidemiologic Study:
= to increase the sample size of the study
= to reduce the variability in measurement in the study.
Systematic error - occurs when there is a difference between the
true value(in the population) and the observed value
(in the study)from any cause other than sampling
variability.

Example:the pulse oximeter you are using is set incorrectly and

adds two points to the true value each time a measurement is
taken.
 The validity of a study is dependent on the degree of
systematic error and it’s separated into two components:

internal validity is dependent on the amount of error in measurements

,including exposure,disease,and the associations between these
variables.

external validity pertains to the process of generalizing the findings of

the study to the population from which the sample was drawn (or
even beyond that population to a more universal statement).
Bias and Confounding
- Bias and confounding are needed to be considered to minimize their
effect.
- Bias may be defined as any systematic error in an epidemiological
study that results in an incorrect estimate of the association between
exposure and risk of disease.
Selection bias
- Occurs when study subjects are selected or become part of the study
as a result of a third, unmeasured variable which is associated with
both the exposure and outcome of interests. It is important to note
that such a difference in response will not lead to bias if it is not also
associated with a systematic difference in outcome between the two
response group.
Information bias
- Bias arising from systematic error on the
assessment of a variable. An example of this
is a recall bias.
Recall bias is a systematic error that occurs
when participants do not remember
previous events or experiences accurately or
omit details: the accuracy and volume of
memories may be influenced by subsequent
events and experiences.
Confounding
- Traditionally defines as bias arising
from the co-occurrence or mixing of
effects of extraneous factors, referred
to as confounders, with the main
effects of interest.