CONCEPT, SCOPE, DEFINITION, TRENDS, HISTORY AND DEVELOPMENT OF MODERN EPIDEMIOLOGY, CONTRIBUTION AND IMPLICATIONS OF EPIDEMIOLOGY

INTRODUCTION Epidemiology is the basic science of preventive & social medicine. Modern epidemiology has entered the most exciting phase of its evolution. By identifying the risk factors of chronic diseases, evaluating treatment modalities & health services, it has provided new opportunities for prevention, treatment, planning & improving the effectiveness & efficiency of health services. DEFINITION 1. Acc. to John M. Last (1988), The study of the distribution and determinants of health- related states & events in population & the application of this study to the control of health problems. 2. Acc. to WHO(1981),It is the study of distribution & determination of the disease & health related events in the human population with the view to ensure that health services are planned rationally, disease surveillance is effected and that preventive & control measures are undertaken. 3. Epidemiology is that branch if medical science that deals with epidemics. (PARKINS) 4. Epidemiology is the science of mass phenomena of infectious diseases. (FROST) 5. Epidemiology is concerned with the study of the processes which determine or influence the physical, mental and social health of people. (CASSEL) The wide variety of meanings attached to epidemiology is expression of wide ranging subject matter. The diseases included in the subject matter have increased from those which occur in epidemics to include infectious diseases, accidents, & mental health. Modern epidemiology has also taken within its scope the study of health related states, events & facts of life occurring in human population. This includes study of health services used by the population & to measure their impact. Epidemiology, like public health itself, is often more concerned with the well-being of society as a whole, than with well-being of individuals. Although there is no single definition to which all epidemiologists subscribe, three components are common to most of them. First, studies of disease frequency: 2nd, studies of distribution: 3rd, studies of determinants. Each of these components confers an important message. 1. Disease frequency: Inherent in the definition of epidemiology is measurement of frequency o disease, disability or death, & summarizing this information in the form of rates & ratios (prevalence rate, incidence rate, death rate, etc). Thus, the basic measure of disease frequency in different populations or sub groups of the same population in relation to suspected casual factors. Such comparisons may yield important clues to disease etiology. This is a vital step in the development of strategies for prevention or control of health problems.
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Equally epidemiology concerned with the measurement of health related events & states in the community (e.g., heath needs, demands, activities, tasks, health care utilizations) & variables such as blood pressure, serum cholesterol, height, weight ,etc. in this respect, epidemiology has features of quantitative science. Much of subject matter of measurement of disease & health related events falls in the domain of biostatistics, which is a basic tool of epidemiology. 2. Distribution of disease: It is well- known that disease, or for that matter health, is not uniformly distributed in human populations. An important function of epidemiology is to study these distribution patterns in the various sub-groups of the population by time, place, & person. Epidemiology addresses itself to study of these variations or patterns, which may suggest or lead to measures to control or prevent disease. An important outcome of this study is formulation of etiological hypothesis. This aspects epidemiology is known as descriptive epidemiology. 3. Determinant of disease A unique feature of epidemiology is to test etiological hypothesis & identify the underlying causes (or risk factors) of disease. This requires the use of epidemiological principles & methods. This is real substance of epidemiology. This aspect of epidemiology is known as analytic epidemiology. Analytic strategies help in developing scientifically sound health programs, interventions & policies. In recent years, analytic studies have contributed vastly to our understanding of determinants of chronic disease, e.g. Lung cancer & cardiovascular diseases. TERMINOLOGY RELATED TO EPIDEMIOLOGY EPIDEMIOLOGICAL TRIAD: includes an agent, susceptible host and an environment that brings the host and agent together so that disease occurs in the host. HOST: A person or other living organisms. HOST FACTOR: An intrinsic factor such as age, sex, race, behaviors, etc, which influences an individuals susceptibility for exposure to a causative agent. AGENT: A factor whose presence or relative absence is essential for the occurrence of a disease such as micro-organisms, chemical substance, etc. ENVIRONMENTAL FACTOR: An extrinsic factor such as climate, insects, sanitation and health services which affects the agent and the host. DISEASE: can be defined as a derangement in the function of whole body or any parts of the body of host. CONTAGIOUS DISEASE: is the disease which can be transmitted through contact, e.g., scabies. COMMUNICABLE DISEASE: is the disease which can be transmitted directly or indirectly due to infectious agents from man to man, animal to animal, environment to man or animal. INFECTIVITY: is a measure of the ability of a disease agent to establish itself in host. VIRULENCE: is a laboratory term used to measure the varying ability of disease agents to produce disease under controlled conditions. PATHOGENICITY: is used to describe the ability of a particular disease agent of known virulence to produce disease in a range of hosts.
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 CARRIER: is an individual that is infected by a disease agent and is capable of disseminating that disease agent without the sign of clinical disease. INCUBATION PERIOD: is the period of time that elapses from infection by the agent to the appearance of clinical symptoms of the host. LATENCY PERIOD: a period of subclinical or inapparent pathologic changes following exposure, ending with the onset of symptoms of chronic diseases. PREPATENT PERIOD: is the period between the infection of the host by the agent and the detection of the agent in the tissues or secretions of the host. INFECTION: is defined as the invasion of a living organism in the host. OPPORTUNISTIC INFECTIONS: Whenever there is a defect in the host defense, then an organism takes an opportunity to infer the host and produce illness. RESERVOIR: is the habitat where an infectious agent lives, grows and multiplies. It includes humans, animals and environmental reservoirs to occur. ENDEMIC: The constant presence of a disease or infectious agent within a given geographic area or population group. EPIDEMIC: is a disease that occurs in a population in excess of its normally expected frequency to occur. PANDEMIC: is a large epidemic affecting several countries or even one or more continents. SPORADIC: disease means a disease which is scattered about i.e. the cases occur irregularly, haphazardly from time to time and generally infrequently. EXOTIC; The imported disease which otherwise do not occur. CONCEPTS OF EPIDEMIOLOGY One of the earliest concepts expressed by philosophers Plato & Rousseau was that disease was primarily the fault of human luxury. The Greek physician Hippocrates (the Father of Epidemiology) examined the relationship between the occurrence of disease & environmental influences & coined the terms in endemic & epidemic. According to him: Endemic: for disease usually found in some places but not in others. Epidemic: for disease that are seen at some times but not others. When the bubonic plague occurred in 14th century, Ibn Khatima hypothesized that infectious diseases are caused by small minute bodies which enter the human body & cause disease. In 1854, Dr John Snow identified the cause of the outbreak of cholera in Londons Soho district which has been perceived as a major event in the history of public health & is regarded as the founding event of science of epidemiology. In 1849, Danish physician P.A. Schleisner related his work on the prevention of epidemic of tetanus neonatrum on the Vestmanna Islands in Iceland. Joseph Lister discovered antiseptics in 1865 in light of the work of Louis Pasteur. As infectious diseases were the major health problems, epidemiological concepts was restricted to infectious diseases. With the emergence of other disease conditions, the concept is now applied not only to infectious conditions but to all disease conditions & health related events. In early 20th century, mathematical methods were introduced in epidemiology by Ronald Ross,Andreson Gray McKendrick& others. With the changing concept of epidemiology, a separate area of epidemiology has been formulated such as infectious disease epidemiology, cardiovascular epidemiology, cancer epidemiology, neuro epidemiology etc, & it is studied at undergraduate, graduate & post graduate degrees including Master of Public Health
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in some universities. And Doctorates include the Doctor of Public Health, Doctor of Science, Doctor of Medicine, Doctor of Philosophy, Doctor of Pharmacy. There are many epidemiologists who are physician. As public health / health protection practitioners, epidemiologists work in number of different settings such as in the field, i.e. in the community, non profit organizations, universities, hospitals & larger government entities (centers of disease control & prevention (CDC), the Health Protection Agency). In the community they are often at the forefront of investigating & combating disease outbreaks while providing public health services. A range of study designs such as observational, experimental being categorized as descriptive, analytical & experimental are employed by epidemiologists. The study is aimed at revealing unbiased relationships & identifying causal relationship between these exposures & outcomes are aspects of epidemiology. The term Epidemiological Triad is used to describe the intersection of Host, Agent, and Environment in analyzing an outbreak. Modern epidemiologists use informatics as tools. As public health discipline, epidemiological evidences are used to guide & teach the public both personal measures (diet change) & corporate measures (removal of junk food advertising) in order to help people to make informed decisions about their health. In this way, epidemiological practice & result of epidemiological analysis make a significant contribution to emerging population-based health management frameworks. HISTORY OF EPIDEMIOLOGY The roots of epidemiology can be traced to Hippocrates (460-477 BC) who for sometimes referred to as the 1st epidemiologist. Hippocrates believed that disease not only affected individuals but was a mass phenomenon. He was one of the 1st people to associate the occurrence of disease with lifestyle and environmental factors. However, it was not until the late 19th century that modern epidemiology actually came into existence. In past centuries cholera, bubonic plague and small pox swept through the community killing thousands of people, changing the community structure and altering the lifestyle of masses of people. Florence Nightingales Influence The roots of epidemiology in nursing can be traced back to Florence Nightingale (1820-1910). Nightingale obtained advice on issues related to hospital statistics and disease classification from William Fast who was chief statistician of Englands General Register Office for health and vital statistics. Her detailed record keeping and careful description of the health conditions among the military in the crime represents one of the first systematic description studies of the distribution and patterns of disease in a population charges according to her suggestions. Early theories Early causal thinking was dominated by Syderhams Miasma Theory. This theory held disease caused by noxious vapors associated with decaying against, matter. Prevention based on this theory attempted to eliminate the services of the Miasma vapors. A contagion theory had developed by the mid 18th century.
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Causal relationships The purpose of epidemiologic study has been to discover causal relationships in order to offer effective protection over the years. The scientific study of health and disease has expanded epidemiology. Disease causation has grown more complex around triparticle model of agent, host and environment; epidemiologists have used the idea of causation. A couple of years back a more advanced concept of multiple causation emerged to explain the existence of health and illness and to provide guiding principles for epidemiological practice, sometimes it was discussed as a web of causation. This model attempts to identify all the possible influence on the health illness process. Contemporary epidemiologists continued to explore new and more comprehensive ways of viewing health and illness.

YEAR 1662

RESPONSIBLE PERSON/ ORGANIZATION John Grant

SIGNIFICANT EVENT Used Bills of Mortality (forerunner of modern vital records) to study patterns of death in various populations in England. Published early form of life table analysis. Studied scurvy using observation and comparison of responses to various dietary treatments. Used life table technique to demonstrate that smallpox inoculation conferred lifelong immunity. First cancer epidemiologist. Demonstrated effectiveness of small pox vaccination. Comparative observational studies to demonstrate effectiveness of blood-letting. Emphasized the importance of statistical methods. Influenced by many of the pioneers in epidemiology in England and US. Developed forerunner of modern vital records system in Registrar General Office. Study of mortality in Liverpool led to significant public health reform. Pioneered mortality surveillance and anticipated many of basic concepts in epidemiology. His data provided much of the
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1747

James Lind

1760

Daniel Bernoulli

1775 1798 1836

Percival Pott Edward Jenner Pierre Charles Alexander Louis

1840s

William Farr

1842 1850 1870-1880s 1887 1921 1950s 1952 1964 1976 1977

Edwin Chadwick Lenuel Shattuck Robert Koch Joseph Kinijoun Wade Hampton Frost A. Bradford Hill and Richard Doll Jonas Salk US Surgeon General Frank Speizer WHO

1980s

US department of Health and human services.

1991 1992

National Institutes of Health. US department of health and Human Services.

basis for Snows work on cholera. Report on the Sanitary Conditions of the laboring population of the Great Britain. Report on sanitation and public health in Massachusetts. Discovered causal agents for antrax, TB and cholera; development of causal criteria. Founded laboratory of hygiene, forerunner of National Institute of Health. Founded 1st US academic program in epidemiology at John Hopkins University. Pioneering studies on smoking and lung cancer. Production of polio vaccine. First Surgeon Generals report on smoking and health. Nurses Health study begins. Organizations smallpox eradication campaign succeeds last known case of small pox in the world appears. Report of the Secretarys Task Force on Black and minority health. A landmark report documenting the health status disparities of minority populations in US. Womens health initiative established. Race and health initiative.

DEVELOPMENT OF EPIDEMIOLOGY

ERA Sanitary statistics (first half of nineteenth century) Infectious disease (late nineteenth century through first half of twentieth century)

PARADIGM

Chronic disease epidemiology (latter

ANALYTIC APPROACH Miasma: poisoning by Demonstrate foul emanations soil, clustering of air and water. morbidity and mortality. Germ theory: single Laboratory isolation agents relate one to and culture from specific diseases. disease sites, experimental transmission and reproduction of lesions. Black box: exposure Risk ratio of exposure related to outcome, to outcome at

PREVENTIVE APPROACH Introduce drainage, sewage, sanitation.

Interrupt transmission (vaccines, isolation of the affected through quarantine and fever hospitals, and ultimately antibiotics. Control risk factors by modifying
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half of the twentieth century)

without necessity for intervening factors or pathogenesis.

individual level in populations.

Eco epidemiology

Chinese boxes: relations within and between localized structures organized in a hierarchy of levels.

Analysis of determinants and at different levels of organization: within and across contexts (using new information system) and in depth using new biomedical techniques.

lifestyle(e.g. diet, exercise), agent (e.g. food), or environment (e.g. pollution, passive smoking.) Apply both information and biomedical technology to find leverage at efficacious levels from contextual to molecular.

CONTRIBUTION OF EPIDEMIOLOGY 1. To study the effects of disease state in a population over a time and predict future health needs : Here epidemiologists study the history of the health of the populations and the rise and fall of diseases and changes in their character and predict the future health needs. 2. To diagnose the health of the community: Here the epidemiologists study the conditions of the people; to measure the distribution and dimension of illness in terms of incidence, prevalence, disability and mortality; to set health problems in perspective and to define their relative importance; and to identify groups needing special attention. New methods of monitoring must be constantly sought. In short it helps in diagnosing the health status of the community. 3. To evaluate health services: Here epidemiologists study the working of health with a view to their improvement by evaluating the health care services in the community. Operational research shows how community expectations can result in the actual provision of service. 4. To estimate the individual risk from group experiences: Here the work of an epidemiologist is to the risks of diseases, accident and defect, and chances of avoiding them. So it studies the effects of disease state in populations over a period of time and predicts the future health care needs and provides the base for preventive measure and their evaluation and also helps in logical planning of facilities for health care. 5. To identify the syndrome: Here, the epidemiologist helps to identify syndromes by describing the distribution and association of clinical phenomena in the population or helps in evolving and describing the natural history of disease. 6. To complete the clinical picture of chronic diseases and describe their natural history: It provides complete clinical picture of disease, so the preventions can be accomplished before disease becomes irreversible.
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7. To search for causes of health and disease: This can be done by comparing experience of groups that are clearly defined by their composition, inheritance, experience, behavior and environments. So, epidemiology helps in understanding the causation of disease and disability and providing data which helps to explain the etiology of the disease and local disease patterns which in turn helps to test the hypothesis clinically or experimentally. 8. The systematic collection of health data (including the utilization of data collected purposes): a) Identification of health problems and assessment of priorities in allocation of resources including surveillance. b) Detection of new problems or changes in frequency of existing problems. c) Identification of risk factors enabling efficient distribution of resources assigned to particular problems. d) Evaluation of effectiveness of control program. e) Formulation of hypothesis regarding the reasons for non random disease distribution ( disease etiology). 9. The search for causes of ill health: a) b) c) d) Identification of alterable causes. Identification of susceptible groups for special surveillance. Identification of disease entities. Identification of early manifestations of disease or disease syndrome.

10. Epidemiology provides a framework within which basic science can be used for community nursing practice. 11. The nursing process extended through applications of epidemiological methods to describe community needs and evaluate nursing services. 12. Epidemiology provides and interdisciplinary languages to promote inter- professional communication and trust. 13. An epidemiological perspective provides a method of extending the relationship of family problems to community welfare. 14. The epidemiological model promotes understanding the relationship between the environment and agents that expose susceptible populations at risk of impediments to health. 15. Epidemiology provides time-honored method of quantifying nursing outcomes such as recidivism. IMPLICATIONS OF EPIDEMIOLOGY o An understanding of the epidemiological concepts and principles are vital for nurses in the community as well as in the hospital setting.
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o Most community health nurses are employed by authorities that interact directly with individual patients and families. o Knowledge of the methods is useful to the community health nurse, both as a tool in conducting the investigation to evaluate and explain phenomena observed in the course of work and as a basis for interpreting and evaluating the epidemiological literature. o Epidemiological methods such as measures of health, serve as tools for assessing community needs and evaluating the impact of community health programs of disease prevention and health promotion. o The body of knowledgederived fromepidemiological studies, including natural history and patterns of disease occurrence, and factors associated with high risk for developing disease, serves as an information base for community health nursing practice. o Knowledge of epidemiological methods provides a framework for planning and evaluating community intervention programmers aimed at primary, secondary and tertiary prevention. o Programmers of primary prevention focus on distancing disease agents from susceptible hosts, decreasing agents viability, increasing host resistance and altering the established agent-host environment relationship. o Screening and risk factor reduction programmes are the examples of secondary prevention. o Vocational retraining and rehabilitative exercises for the disabled are tertiary prevention strategies. o For an individual nurse, the body of knowledge derived from the epidemiological research serves as a basis for assessing individual and family health needs and for planning nursing interventions. It also provides tools for evaluating the success of the interventions. o Community health nurse often cast in the role of interpreting study findings to families, schools, industries and others. o It is important to monitor the relative frequency of an event in time and space to determine health and disease patterns in a community. o A variety of methods are used to collect data about these patterns and to identify aggregates at risk in a population. These methods include such interventions as analyzing all available statistics, carrying out surveys, and interviewing key community informants. SCOPE OF EPIDEMIOLOGY With the changing pattern of population morbidity & mortality, the scope of epidemiology has been enlarging. It is generally accepted that epidemiological studies can appropriately be applied to all disease conditions & health related events & it is concerned not only with epidemics, but also with inter epidemic periods & with sporadic & endemic occurrence of disease(Mausner,1985). For more than half century epidemiology is considered as an aggregate of knowledge with the methodological core. It has been expanded in a multiplicity of directions, penetrating in capillary way the whole field of medicine & public health (Sarauci, 2004) With an increasing use of epidemiological methods in investigating health problems, a separate area of epidemiology according to disease group & according to the group actors having relationship with disease is formulated. Chronic disease epidemiology is involved with diseases of long duration (e.g., cancers), many of which are non-infectious.
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According to the disease group: Infectious disease epidemiology Cardiovascular epidemiology Cancer epidemiology Neuro epidemiology & others According to group of factor epidemiology is social epidemiology Nutritive epidemiology Reproductive epidemiology Environmental epidemiology Later in 20th century the developmental led to clinical epidemiology. Clinical epidemiology is the use of epidemiological principles, methods & findings in the care of individuals, with particular reference to diagnosis & prognosis (Last, 1988). New biochemical techniques now enable microbiologists to study small genetic & antigenic differences between viruses & other micro-organisms at higher level of discrimination than has been possible using conventional serological techniques. The methods peptide mapping, nucleic acid fingerprinting & hybridization (Keller & Manak,1989; Kricka,1992),restriction enzyme analysis, monoclonal antibodies (Oxford,1985;Goldspink & Gerlach,1990;Goldspink,1993)& the polymerase chain reaction (Belak& Ballagi-Pordany,1993) . In recent years the use biomarkers of exposure & effects has led to boom to molecular epidemiology. Molecular epidemiology is part of the wider use biological markers (Hulka et al, 1990). Even an understanding of human genome led to rapid progress of genetic epidemiology. Genetic epidemiology is study o the cause, distribution & control of disease in related individuals, & of inherited defects in populations (Morton, 1982; Roberts, 1985). The geneticist & epidemiologist are both concerned with interactions between genetic & non-genetic factor-only the frequently indistinct time of interaction may be used to classify an investigation as genetic or epidemiological. Computational epidemiology involves the application of computer science to epidemiological studies (Habtemariam et al, 1988). It includes the representation of disease by mathematical models & the use of expert systems. There are several other epidemiological sub disciplines such as micro-epidemiology, comparative epidemiology macro-epidemiology. Micro-epidemiology is the study of disease in small group of individuals with respect to factors that influence its occurrence in larger segments of the population (Torres Anjel &Tshikuka, 1988). Macro-epidemiology is the study of national patterns of disease, & social, economic & political factors that influence them (Hueston& Walker, 1993) TRENDS IN EPIDEMIOLOGY Trend is a tendency of development of the incidence of some disease or tendency of development of some other epidemiologic important factor. Changes of the trend over time may occur in the characteristic of a
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host (exposure, susceptibility), a disease agent, or the environment and these may affect the disease incidence and prevalence. Disease trends that vary over time may reflect actual changes in pathogenicity of the disease agent or the hosts response to a given exposure. Disease rates usually fluctuate over time. The change may be real or may occur because of non-biologic factors, such as changes in diagnostic criteria for disease classification, change in population characteristics, or change in case finding or reporting procedures. Secular trend refers to changes that occur gradually over long periods of time: in epidemiology the term usually implies change in disease frequency encompassing many years. Cyclic fluctuations are usually the consequence of the cyclic variations and the seasonal variations of the trend. In communicable disease epidemiology the cyclic variations of the trend reflect the balance between the agent circulating in the population and the herd immunity of this population (measles, mumps, pertussis, rubella, etc.) Seasonal influences Seasonal variation in the flora and fauna of the environment and seasonal changes in weather have a profound effect on many human diseases. (Acute respiratory infections cold months, acute diarrhea summer). Seasonal fluctuation in occupational and recreational activities may also account for variation in exposure to sources of infection. (Tick-born encephalitis, leptospirosis) Seasonal circumstances manmade may also play a part in seasonal disease patterns. (Rises in serum cholesterol levels of accountants corresponding to critical dates in the tax calendar) REFRENCES Park K. Text Book of Preventive and Social Medicine. 18thed: 2005. BanarsidasBhanot. Jabalpur. Pp 49-50. KumariNeelam. Community Heath Nursing. 1sted: 2010. PeeVee. Jalandhar. Pp 303-307. Gulani. K.K. Community Health Nursing Principles and Practices. Kumar publishers. 1st Edition. 2007. Pp-181-184. I. Clement. Basic Concept of Community Health Nursing. Jaypee brother Publishers. 2nd Edition. 2010. Pp-102-103. http://www.cs.columbia.edu/digigov/LEXING/CDCEPI/gloss.html

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PRESENTATION ON
CONCEPT, SCOPE, DEFINITION, TRENDS, HISTORY AND DEVELOPMENT OF MODERN EPIDEMIOLOGY, CONTRIBUTION AND IMPLICATIONS OF EPIDEMIOLOGY

SUBMITTED TO:Mrs. Hardeep Kaur

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Vice Principal and Professor Shri Guru Ram Dass College of Nursing, Hoshiarpur.

SUBMITTED BY: Amrinder Kaur MSc. (N) 2nd Year. Roll No-1.

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