Epidemiology

By Nigusie SH.(Bsc., MPHE)

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 Session objectives
• At the end of this session students will be able
to
– Define and classify epidemiology
– Describe levels of disease occurrence
– Describe levels of disease prevention
– Explain infectious disease cycle
– Discuss different models of disease causation

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 Introduction
What is Epidemiology?
Greek: EPI - Upon
DEMOS - People
LOGOS - Study of, Body of
Knowledge
“The study of that which falls upon the common
people.”

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 Introduction …
Definition
 Epidemiology is the study of the frequency,
distribution, and determinants of health-related
states or events in specified populations, and the
application of this study to the control of health
problems.

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 Classification of Epidemiology

1. Descriptive epidemiology
– concerned with describing diseases and other health
related conditions by person, place and time

– answers the questions who, where and

when.

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2. Analytic epidemiology
₋ concerned with identification of causes and other
factors

₋ It answers the questions why and how.

₋ Involves explicit comparison of groups

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 SCOPE OF EPIDEMIOLOGY:

Genetic markers of disease risks recently

+▲
Health related behavior
▲
+ Past 25 yrs
Chronic diseases,
injuries,
birth defects
MCH Middle of
Occupational health 20th century
Env’tal health
Since 5th
▲+ century
Endemic communicable diseases &
Non communicable diseases

▲+
Epidemic of communicable diseases
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 Use/applications of Epidemiology

• Clarify the natural history of disease.

• Describe the health status of the population.
• Found disease causation
• Provide basic information about what causes or
sustains disease in populations.
• Guide healthcare policy and health planning.

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 Use/applications of Epidemiology…

• Assist in the management and care of health

and disease in individual
• Evaluations of preventive, diagnostic and
therapeutic programmes and technologies.
• Define standards and ranges for normal values
of biological and social measures.

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 Basic epidemiological assumptions

The two basic assumptions in epidemiology are:

1. Human disease does not occur at random:
 There are patterns of occurrence in which some
behavioral and environmental factors (exposures)
increase the risk of acquiring/developing a particular
disease among group of individuals

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 Basic epidemiological assumptions

2. Human disease has causal and preventive

factors
 that can be identified through systematic
investigation.
 Thus, identifying these factors creates opportunity for
prevention and control of disease

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 Level of disease occurrence

• Diseases occur in a community at different levels

• Some diseases are usually present in a community at a

certain predictable level, this is called the expected
level

• But at times disease may occur in excess of what is

expected

• There are various term used to describe the level

occurrence of disease at a particular place, person
and specified time
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 Level of disease occurrence… cont’d

• Generally the level of disease occurrence

classified as
Expected levels
Excess of what is expected

Terms used to describe the expected level of

disease occurrence includes
 Endemic
 Hyper-endemic
 Sporadic
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Expected level of disease occurrence

 Endemic: a persistent level of low to moderate

occurrence of disease at a particular place ,person
and time

 Hyper-endemic: A persistently high level of

occurrence of disease at a particular geographical
area ( place) ,at a particular group of individuals
(person ) and at specified period ( time)

 Sporadic: These are occasional cases occurring at

irregular intervals
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 Excess occurrence of disease
• Epidemic: occurrence of disease in excess of
what is expected in a limited period.
• Outbreak: same as epidemic, However, ‘outbreak’
is usually used when diseases happen in a more limited
geographic area.
• If an outbreak of a diseases spreads quickly to more
people than experts would expect and moves into a
large geographic area, it is often then called an
epidemic.
• Pandemic: an epidemic spread over several
countries or continents, affecting a large number
of people.
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 The Natural History of Diseases
(NHD)
 refers to the progression of a disease process in an
individual over time, in the absence of intervention
 The process begins with exposure to the causative agent
 Without medical intervention, the process ends with
recovery, disability, or death.

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 The stages of NHD

Four stages
1. Stage of susceptibility
2. Stage of subclinical disease
3. Stage of clinical disease
4. Stage of outcomes

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 Fig 1 Natural History of Disease Timeline

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 Healthy person

Sub clinical disease

Recovery Clinical disease

Death
Recovery Disability

Fig 2 – A schematic diagram of the natural history of

diseases
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 Level of disease prevention

 Disease prevention means to interrupt or slow

the progression of disease.

 Fluctuation in patterns of morbidity and

mortality of disease over time indicate that
causes of disease are preventable.

 Hence, epidemiology plays a central role in

disease prevention by identifying those
modifiable causes.
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 Level of disease prevention….

Levels of disease prevention;

A. Primary
B. Secondary
C. Tertiary

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 Levels of disease prevention

Levels Phase of the disease

Primary Specific causal factors
Secondary Early stage of the disease
Tertiary Late stage of the disease

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 B. Primary prevention
Is prevention of occurrence of disease.
• It Has three phases
I. Promotive –enhance health & body’s ability to
resist disease. It is non specific.
– E.g. Socioeconomic status, proper diet
II. Prevent exposure –limit contact with agents of
disease
– E.g. Safe water supply, Bed net
III. Prevent disease -limit development of disease
after exposure to agents
– E.g. immunization, prophylaxis
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 C. Secondary prevention

• Prevent progression of disease after development

• Limit complications of disease
• Stop or slow progression
• Use early detection & treatment of disease

E.g. Early detection and treatment of malaria from a

patient with acute fever.

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 D. Tertiary prevention
• Reduce impact of established disease outcome
(disability)
• It is rehabilitative care for abilities affected with the
disease
• It is restoration of person’s physical, psychological,
social &emotional abilities
E.g.
Reduce stigma towards fistula, HIV/AIDS
Wheel chair provision and hearing aid for patients
affected by leprosy

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 Infectious disease cycle

• Is the process by which agent leaves its

reservoir or host through a portal of exit, is
conveyed by some mode of transmission, and
enters through an appropriate portal of entry
to infect a susceptible host.
• Simply it is the chain of infection

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 Chain of Infection

• Chain of infection- is a model used to

understand the infection process which has
different components
• Understanding the characteristics of each link
provides insight for methods to prevent the
spread of infection.

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 Chain of Infection … Cont’d
• Infection-implies that the agent has achieved
entry and begun to develop or multiply, whether or
not the process leads to disease.

• Disease- is a condition in which clinically apparent

onset of the problem was observed

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 Components of Chain of Infection
1. Causative Agent
2. Reservoir host
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Susceptible host

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 Chain of disease Transmission

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1. Causative Agent

• Is a particle which range from small viral

particles to complex multi cellular organisms
(parasites)
• Host –agent interaction is characterized by
− Infectivity
− Pathogenicity
− Virulence
− Immunogenicity
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• Infectivity: The ability of the agent to invade and
multiply in the host (the ability to produce infection )
• Pathogenicity: the ability to produce clinically apparent
infection
• Virulence: the ability of an infectious agent to cause severe
disease
• Immunogenicity: the infection ability to produce
specific immunity

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 Case

• When individuals are infected by measles

virus for the first time they develop specific
antibody against the agent and they will
not be susceptible for the next time.
– Which characteristic of host-agent interaction
is best described by this statement? Why?

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 2. Reservoir

• Is the habitat in which an infectious agent normally

lives, grows, and multiplies.
• Can be human, animal and environmental
reservoir
• Human reservoirs may be symptomatic or carriers

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 Types of Carriers
a) Healthy or asymptomatic carriers
 Persons whose infection remains unapparent through
out its course.
E.g. In polio virus, meningococcal and hepatitis virus
infections
b) Incubatory or precocious carriers
 Persons who shed the pathogens during the
incubation period
E.g. Measles
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 Types of Carriers…
c) Convalescent carriers
• These are those who continue to harbor the
infective agent after recovering from the illness.
E.g. Diphtheria
d) Chronic carriers
• The carrier state persists for a long period of time

E.g. Typhoid fever

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36
3. Portal of exit is the way the infectious agent
leaves the reservoir host and these includes all body
secretions and discharges
4. Mode of transmission is the various
mechanisms by which agents are conveyed to a
susceptible host
• Can be
– Direct (direct contact, droplet spread)
– Indirect (airborne, vehicle borne, vector borne)
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 5. Portal of entry

• Is through which an infectious agent enters

a susceptible host
For Example:
 Nasal ------ ------ -Common cold
 Injury site ------ ---Tetanus
 Skin ------ ------ -- Hookworm infection
 Respiratory ------ --Tuberculosis

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 6. Susceptible host

• The chain of infection may be interrupted if the agent

does not find a susceptible host.
• Host susceptibility can be seen at
• Individual level – individual immunity and genetics
• Community level - herd immunity

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 Models of disease causation
• In epidemiology, there are several models of disease
causation that help understand disease process
• The most widely applied models are:
– The epidemiological triad (triangle)
– The web of causation
– The wheel and
– The sufficient cause and component causes models
(Rothman’s component causes model)

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 The epidemiological triad (triangle)

• Depicts a relationship among three key factors

• This model holds true for infectious disease which has
specific agent
• Is the best known, but most dated model of communicable
disease
• A change in any of the components will alter an existing
equilibrium

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 The epidemiological triad (triangle) ….

Fig. Two versions of The epidemiological triad model (epidemiologic triangle

and beam balance)

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 The web of causation model

• The process that actually generates disease or leads to

injury is more complex
• This complexity is better portrayed by the web of causation
• There is no single cause &causes of disease are interacting
• Was developed especially to enhance understanding of
chronic disease, such as cardiovascular disease but it also
be applied to the study of injury and communicable disease

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 Web of Causation

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 The Wheel of Causation model

• The wheel consists of a hub (host or human) which has

genetic makeup as its core
• Surrounding the host is the env’t, divided into biological,
social and physical
• The relative sizes of the d/t components of the wheel depend
upon the specific disease under consideration
• For hereditary disease, the genetic core would be relatively
large

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 The Wheel of Causation model…

• For conditions like measles, the state of immunity of the

host and biological sector would contribute more heavily
• In contrast to the web of causation, the wheel model does
encourage separate delineation of host and env't factors, a
distinction useful for epidemiologic analyses

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 The Wheel of Causation model

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Rothman’s Component Causes and Causal Pies Model

• Rothman's model has emphasized that the causes of disease

comprise a collection of factors
• These factors represent pieces of a pie, the whole pie
(combinations of factors) are the sufficient causes for a
disease
• a disease may have more than one sufficient cause

48

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 Rothman’s Component Causes…

• The factors represented by the pieces of the pie in this

model are called component causes
• Each single component cause is rarely a sufficient cause by
itself, but may be necessary cause
• Control of the disease could be achieved by removing one of
the components in each "pie" and if there were a factor
common to all "pies“ (necessary cause) the disease would
be eliminated by removing that alone

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 Necessary Vs Sufficient
• Necessary: the disease will not occur without the
presence of the factor
Example: Mycobacterium TB for TB
• Sufficient: the presence of the factor always result in
disease
Example: Rabies virus for rabies

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 Causal Relationships

Types of Causal Relationships

• There are four types of causal relationship in disease
causation.
a) Necessary and sufficient cause
b) Necessary but not sufficient cause
c) Sufficient but not necessary cause
d) Neither sufficient nor necessary cause

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 Causal Relationships
a) Necessary and sufficient cause – without the
factor, disease never develops; with the factor,
disease always develops (this situation rarely
occurs).

E.g. HIV, Rabies

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 Causal Relationships
b) Necessary but not sufficient cause – the factor in itself
is not enough to cause disease.
o Multiple factors including main factor are required,

o E.g. Tuberculosis

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 Causal Relationships
C) Sufficient but not necessary cause – the factor alone
can cause disease, but so can other factors in its
absence.

E.g. sun can cause burn without the presence of the other
factor such as fire
 radiation exposure vs cancer

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 Causal Relationships
d) Neither sufficient nor necessary cause–
o the factor cannot cause disease on its own, nor
o is it the only factor that can cause that disease.
o This is the probable model for chronic disease
relationships.

o Example: High fat diet and heart disease,

hypertension, diabetes and so on.

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 Rothman’s Component Causes and Causal Pies Model

Which factor is/are necessary cause/s?

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Thank you all!

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