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APPLIED EPIDEMIOLOGY
Prabesh Ghimire
APPLIED EPIDEMIOLOGY MPH 19th
Batch
Table of Contents
UNIT 1: COMMUNICABLE AND NON-COMMUNICABLE DISEASES ................................................................................ 4
Concept and Approaches of Communicable and Non-Communicable Diseases ...................................................... 4
Epidemic ............................................................................................................................................................... 6
Epidemiologic Transmission of Infectious and Non Infectious Diseases ................................................................... 6
Emerging, Remerging Diseases and Existing Diseases .............................................................................................. 9
Epidemiological Overview of Major Communicable Disease as Public Health Problem in Nepal...........................11
Cholera ................................................................................................................................................................ 11
Srub Typhus ........................................................................................................................................................ 12
Ebola Virus .......................................................................................................................................................... 13
Zika Virus............................................................................................................................................................. 15
Dengue ................................................................................................................................................................ 16
Malaria ................................................................................................................................................................ 17
Kala-azar (Visceral Leishmaniasis)....................................................................................................................... 19
Lymphatic Filariasis ............................................................................................................................................. 20
Influenza ............................................................................................................................................................. 21
Tuberculosis ........................................................................................................................................................ 23
Leprosy ................................................................................................................................................................ 25
HIV & AIDS .......................................................................................................................................................... 26
Measles (Rubeola) .............................................................................................................................................. 28
Rubella(German Measles)................................................................................................................................... 29
Typhoid Fever ..................................................................................................................................................... 29
Epidemiological Overview of Major Non-Communicable Disease as Public Health Problem in Nepal...................30
Atherosclerosis ................................................................................................................................................... 30
Road Traffic Accidents ........................................................................................................................................ 31
Diabetes .............................................................................................................................................................. 32
Prevention, Control and Management of Communicable and Non-communicable Diseases ................................ 33
SOCIAL EPIDEMIOLOGY ............................................................................................................................................... 34
Concept, Scope and Process.................................................................................................................................... 34
Social Determinants of Health ................................................................................................................................ 36
Evidence Based Public Health Practice.................................................................................................................... 38
Distinction between Evidence Based Public Health (EBPH) and Evidence Based Medicine (EBM).........................39
Critical Appraisal of Research Article ...................................................................................................................... 39
The process begins with exposure to or accumulation of factors capable of causing diseases. Without
medical intervention, the process ends with recovery, disability or death.
typical or atypical or the host may become a carrier with or without having clinical disease as in the
case of poliomyelitis.
- In chronic diseases, the early pathogenesis phase is less dramatic. In this case it is referred to as
pre-symptomatic phase. During this stage there is no manifestation of disease.
- The pathological changes are essentially below the level of clinical horizon.
- In many chronic diseases, the disease agent-host-environment interaction is not well understood.
The chain of infection is a model used to explain the components necessary for disease transmission. By
using a chain analogy, we can better understand that all components must be in place for a disease
transmission to take place. The chain of infection includes the following components
i. Causative agent:
- The causative agent/pathogen can include bacteria, viruses,
worms, chemicals or any other plant or animal substances or
factor that can causes disease, disability, illness, syndrome,
or death.
- The greater the organism's pathogenecity, virulence and
invasiveness, the greater the possibility that the organism will
cause an infection.
Epidemic
The unusual occurrence in a community or region of disease, specific health behaviour or other health
related events clearly in excess of expected occurrence is called epidemic.
Epidemiologic Transition
The epidemiologic transition describes changing patterns of population distributions in relation to
changing patterns of mortality, fertility, life expectancy, and leading causes of death. There are two main
components of the transition:
i. Changes in population growth trajectories and composition, especially in the age distribution from
younger to older.
ii. Changes in patterns of mortality, including increasing life expectancy and reordering of the relative
importance of different causes of death.
In 1983, Omran recognized the need to update his theory to incorporate a more extended
description of the transition, as emerging analyses of transition patterns based on historical data
did not fit the original model. He added two stages to his original theory:
d. Stage Four: The age of declining cerebrovascular mortality, ageing, lifestyle modifications and
resurgent diseases
- In this stage, life expectancy continues to increase (up to 80-85 years).
- The mortality attributed to cardiovascular diseases declines and stabilizes as a result of improved
medical care and lifestyle modifications.
e. Stage Five: The age of aspired quality of life, with paradoxical longevity and persistent inequities
iii. Proposition Three: During the epidemiologic transition the most profound changes in health and
disease patterns obtain among children and young women.
iv. Proposition Four: The shifts in health and disease patterns that characterize epidemiologic transition
are closely associated with the demographic and socio-economic transitions that constitute the
modernization complex.
v. Proposition Five: Peculiar variations in the pattern, the pace, the determinants and the consequences
of population change differentiate three basic model of the epidemiologic transition: the classic or
western model, the accelerated model and the contemporary or delayed model.
a. Classic Western Model: It describes the gradual progressive transition from high mortality and
high fertility to low mortality and low fertility, that accompanied the process of modernization in
most western European societies.
b. The Accelerated Model: It describes the accelerated mortality that occurred most notably in
Japan. A major distinction of the accelerated model is that the period taken for mortality to reach
10 per 1,000 level was much shorter than that of classic model.
c. Contemporary or delayed model: It describes the relatively recent and yet to be completed
transition of most developing countries where there have been more recent declines in mortality
but not in fertility rates because infant and maternal mortality rates still remain high.
Infectious diseases have for centuries ranked as major challenges to human progress and survival. They
remain among the leading causes of death and disability worldwide. Against a constant background of
established infections, epidemics of new and old infectious diseases periodically emerge, greatly
magnifying the global burden of infections.
Re-emerging, or resurging, diseases are those that have been around for decades or centuries, but have
come back in a different form or a different location. Re-emerging infectious diseases are diseases that
once were major health problems globally or in a particular country, and then declined dramatically, but
are again becoming health problems for a significant proportion of the population (malaria and
tuberculosis are examples).
Cholera
1. Burden of disease
i. Global
- Researchers have estimated that each year there are 1.3 to 4.0 million cases of cholera, and 21 000
to 143 000 deaths worldwide due to cholera
iii. Nepal
- As of Oct 2016, 152 cholera cases were confirmed by the National Public Health Laboratory since 30
June.
- The majority of cases were from Lalitpur and Kathmandu.
2. Epidemiological Features:
i. Causative Agent: Vibrio cholerae bacteria, sero-groups 01 and 0139
- In severe cases rapid dehydration, leading to circulatory shock and possible death. In such cases
immediate fluid and electrolyte replacement is required.
- Severe untreated cases have a 50% mortality, but <1% fatality with the correct treatment.
3. Diagnosis
- Stool microscopy and culture
- Rapid diagnostic kit can detect cholera in stool
- PCR for serotyping and biotyping
Srub Typhus
1. Burden of disease
i. Nepal
- As of Nov 2016, a total of 707 cases of scrub typhus including 14 deaths were reported from 47
districts since July 2016.
- Majority of the cases were from Chitwan and Kailali districts.
2. Epidemiological Features
i. Agent: Oriential (formerly Rickettsia tsutusgamushi), a gram negative bacterium
ii. Host factor
- Agricultural workers,
- People living in houses with shrubs/ bush nearby, and
- Travelers in areas with potential exposure to mice and mites, for e.g. camping, rafting, or trekking.
iii. Environment
- This is found in areas with a suitable climate, plenty of moisture and scrub vegetation.
- Areas like forest clearings, riverbanks, and grassy regions provide optimal conditions for the infected
mites to thrive.
- It occurs more frequently during the rainy season
v. Incubation period: About 5 to 20 days (mean, 10-12 days) after the initial bite
Ebola Virus
1. Burden of disease
i. Global
- The last outbreak in West Africa, (first cases notified in March 2014), is the largest and most complex
Ebola outbreak since the Ebola virus was first discovered in 1976.
- The most severely affected countries, Guinea, Liberia and Sierra Leone
- A total of more than 28000 confirmed, probable and suspected cases were reported in Guinea,
Liberia and Sierra Leone, with over 11000 deaths.
2. Epidemiological Features
i. Causal agent: Ebolavirus (Filoviridae family).
ii. Host factors
- Healthcare providers caring for Ebola patients
- Family and friends in close contact with Ebola patients
iii. Environment
- First Ebola outbreaks occurred in remote villages in Central Africa, near tropical rainforests
- The most recent outbreak in West Africa has involved major urban as well as rural areas
3. Diagnosis
- Difficult to distinguish EVD from other infectious diseases such as malaria, typhoid fever and
meningitis.
- Confirmation of Ebola virus infection are made using the following investigations:
antibody-capture enzyme-linked immunosorbent assay (ELISA)
reverse transcriptase polymerase chain reaction (RT-PCR) assay
electron microscopy
virus isolation by cell culture.
4. Treatment
- No effective treatment is available.
- Severe cases require intensive supportive care.
Zika Virus
1. Burden of disease
i. Global
- 73 countries and territories have reported evidence of mosquito-borne Zika virus transmission since
2007 (67 with reports from 2015 onwards), of which:
56 with a reported outbreak from 2015 onwards.
Seven with having possible endemic transmission or evidence of local mosquito borne Zika
infections in 2016.
- Since February 2016, 12 countries have reported evidence of person-to-person transmission of Zika
virus
2. Epidemiological Features
i. Agent: single-stranded RNA virus of the Flaviviridae family
iii. Environment
- Monsoons and hot climate increases the breeding of mosquito hence the incidence rate increases
with it.
- Areas that favour breeding of Aedes mosquito such as artificial water containers.
iv. Reservoir: Nonhuman and human primates are likely the main reservoirs of the virus
v. Incubation period: The incubation period (the time from exposure to symptoms) of Zika virus disease
is not clear, but is likely to be 3-12 days
vii.
Common clinical features
- The symptoms are similar to other arbovirus infections such as dengue
- Includes fever, skin rashes, conjunctivitis, muscle and joint pain, malaise, and headache.
- Symptoms are usually mild and last for 2-7 days.
- Complications: There is scientific consensus that Zika virus is a cause of microcephaly and Guillain-
Barr syndrome.
3. Diagnosis:
- Infection with Zika virus may be suspected based on symptoms and recent history of travel (e.g.
residence in or travel to an area with active Zika virus transmission).
- A diagnosis of Zika virus infection can only be confirmed through laboratory tests on blood or other
body fluids, such as urine, saliva or semen.
Dengue
1. Burden of disease
i. Global
- Recent estimate indicates 390 million dengue infections per year of which 96 million (67136 million)
manifest clinically (with any severity of disease).
- Another study, of the prevalence of dengue, estimates that 3.9 billion people, in 128 countries, are at
risk of infection with dengue viruses
ii. Nepal
- Till Nov 2016, a total of 1315 dengue cases including one death were reported from 30 different
districts since January 2016 out of which majority of the cases were from Chitwan and Jhapa districts.
- Fifty-eight cases of Dengue were reported through EWARS in 2015.
2. Epidemiological Features
i. Causative agent:
- Dengue fever and dengue haemorrhagic (DHF) fever are caused by a flavivirus with 4 distinct
serogroups (DEN- 1, DEN-2, DEN-3 and DEN-4).
vii. Mode of transmission: Through the bite of an infected female Aedes mosquito.
3. Diagnosis
- Laboratory finding suggestive of dengue are Leucopenia, Atypical lymphocytsis, Thrombocytopenia,
Hemoconcentration, raised ESR, LDH, urea and liver enzymes (ALT>AST).
- Honeycomb sign in USG is specific findings.
- Antigen detection test NS1 remains positive from day of fever to first week.
- Antibodies (IgG/IgM) are positive at the end of first week to first few months.
- Molecular technique PCR can be done during the period of positivity of NS1 antigen test
4. Treatment
- Supportive and symptomatic treatment
Malaria
1. Burden of disease
i. Global
- In 2000, there were 106 countries and territories with ongoing malaria transmission
- The number of malaria cases fell from an estimated 262 million globally in 2000, to 214 million in
2015, a decline of 18%.
- The number of malaria deaths globally fell from an estimated 839000 in 2000, to 438000 in 2015, a
decline of 48%.
iii. Nepal
- Confirmed cases dropped from 2092 in FY 2069/70 to 1352 in 2071/72.
- No Malaria deaths have been recorded after 2012 till date.
- Ninety cases of malaria were reported through EWARS in 2015
- In Nepal 54 VDC are at high risk of Malaria.
2. Epidemiological Features
i. Causative agents: Plasmodium vivax, falciprum, malariae, Ovale
v. Incubation period:
Agent Incubation period
1 P. falciparum 6-12 days
2 P. vivax 8-12 days
3 P. ovale 8-12 days
4 P. malariae 12-16 days
b. Severe malaria
- Cerebral malaria, with impairment of consciousness, seizures, coma, or other neurologic
abnormalities
- Severe anemia
- Hemoglobinuria (hemoglobin in the urine)
3. Diagnosis
- Rapid diagnostic test kits
- Microscopic tests
1. Burden of disease
i. Global
- Annually an estimated 900,0001.3 million new cases occur globally
- An estimated 200,000 to 400,000 new cases of visceral leishmaniasis occur worldwide each year.
iii. Nepal
- 12 districts in Nepal are endemic to Kala-azar
- The trend of Kalaazar cases has been decreasing significantly for the last several years.
- The total cases in FY 2071/72 were 220.
2. Epidemiological Features
i. Causative agent: Leishmania donovani
ii. Host factors:
- Males are affected twice as often as females
- Usually strikes the poorest of the poor
- Human behavior such as sleeping outside or on the ground increases risk of transmission
iv. Reservoir:
- There are variety of animal reservoirs e.g. dogs, jackals, rhodents and other mammals.
3. Diagnosis
- Rapid diagnosis using Rk39 dipstick test
- Serological tests
4. Treatment
- Amphotericin B
- Miltefosine
Lymphatic Filariasis
1. Burden of disease
i. Global
- 947 million people in 54 countries worldwide remain threatened by lymphatic filariasis and require
preventive chemotherapy to stop the spread of this parasitic infection.
- Data from World Health Organization (WHO) show that more than 556 million people worldwide were
treated for lymphatic filariasis in 2015
ii. Nepal
- Sixty one districts are endemic to Lymphatic filariasis in Nepal.
- LF mapping in revealed 13% average prevalence of LF infection in the country, ranging from <1% to
39%.
2. Epidemiological features
i. Causative agent
- Nematodes (roundworms) of the family Filariodidea.
- There are 3 types of these thread-like filarial worms:
Wuchereria bancrofti, which is responsible for 90% of the cases
Brugia malayi, which causes most of the remainder of the cases
Brugia timori, which also causes the disease.
iv. Reservoir: Humans are the only known reservoir for Wuchereria bancrofti
3. Diagnosis
- Blood smears- nocturnal bloods
4. Treatment
- Diethyl carbamazine (DEC)
- Albendazole
Influenza
1. Burden of disease
i. Global
- In April 2009, WHO declared the emergence of human cases of H1N1 swine influenza virus.
- In June 2009, WHO raised the pandemic alert (phase 5 to 6)
- Till May 2010 more than 214 countries reported lab confirmed pandemic influenza H1N1 2009,
including over 18097 deaths
- Between 2003-2016, total confirmed human cases of H5N1 influenza was 850 and total death of 450.
iii. Nepal
- FirsT case of H1N1 influenza was detected in Jun 2009.
- Four outbreak events of influenza with 1445 cases and 31 deaths were reported in FY 2071/72
2. Epidemiological Features
i. Causative agent
- Single stranded RNA virus of Orthomyxoviridae family
- Three distinct types: Influenza A, B and C
- Influenza A is divided into different subtypes of which clinically important subtypes are
H1N1 (Swine Flu)
H5N1,(Avian Influenza)
H7N9 (novel avian influenza)
iv. Reservoir:
- Pigs are most important reservoir of H1N1 virus.
- Aquatic birds are reservoirs for avian influenza (H5N1)
3. Diagnosis
- Clinical diagnosis (based on acute onset of fever and cough)
- Reverse-transcriptase polymerase chain reaction (RT-PCR)
Tuberculosis
1. Burden
i. Global
- Tuberculosis (TB) is one of the top 10 causes of death worldwide
- In 2015, 10.4 million people fell ill with TB and 1.8 million died from the disease. Over 95% of TB
deaths occur in low- and middle-income countries
- In 2015, an estimated 1 million children became ill with TB and 170 000 children died of TB
(excluding children with HIV).
- Globally in 2015, an estimated 480,000 people developed multidrug-resistant TB (MDR-TB).
iii. Nepal
According to Global TB Report 2016
- TB incidence (including HIV)- 44 per 1000
- Incidence of MDR/RR-TB 1.5 per 1000
- TB mortality- 6.1 per thousand
2. Epidemiological features
i. Causative agent:
- Microbacterium tuberculosis (gram positive bacteria)
- Microbacterium bovis (primarily from cattles)
iv. Reservoir: Primarily humans. In some areas diseased cattle, swine and other mammals are infected.
3. Diagnosis
- Sputum smear microscopy
- GeneXpert MTB/RIF
- Culture of mycobacterium
4. Treatment
- Active, drug-susceptible TB disease is treated with a standard 6 month course of 4 antimicrobial
drugs under DOTS therapy
DOTS Program
- DOTS is one of the effective strategy of National Tuberculosis Program for tuberculosis control.
- National TB Program has rapidly expanded DOTS strategy in 1996 with 4 pilot centers.
- The treatment of TB by DOTS is being implemented in all 75 districts of the country since April 2001.
- The expansion of this cost effective and highly successful treatment strategy has reduced TB
mortality and morbidity in Nepal.
- A total of 4224 DOTS treatment centers are providing TB treatment services in Nepal.
- Recently DOTS-plus programme is developed by WHO to manage drug resistant TB (DR-TB) using
second line anti TB drugs.
- The Nepal DOTS-Plus programme for treatment of drug resistant TB is the first pilot project in South
East Asia.
Leprosy
1. Burden of Disease
i. Global
- The prevalence rate of the disease has dropped by 99%: from 21.1 per 10 000 in 1983 to persons
to 0.24 per 10 000 in 2014.
- With the exception of few small countries (with populations of less than 1 million), leprosy has
been eliminated from all countries.
ii. Nepal
- During the year 2071/72, a total number of 3053 new leprosy cases were detected and were put
under multi drug therapy (Multi Drug Therapy).
- 2461 cases were under treatment and receiving MDT at the end of the fiscal year.
2. Epidemiolgical Features
i. Causative Agent: Microbacterium leprae
v. Incubation period:
- 9 months to 20 years.
- The average is thought to be 4 years from tuberculoid leprosy and 8 years for lepromatous leprosy.
1. Burden of Disease
i. Global
- There were approximately 36.7 million people living with HIV at the end of 2015.
- In 2015, 1.1 million people died from HIV-related causes globally.
- By end-2015, 17.0 million people living with HIV were receiving antiretroviral therapy (ART) globally.
iii. Nepal
- Prevalence of HIV among FSWs is 2%, MSM &TG - 2.4%, MLM-0.3-0.6%
- Total people living with HIV in Nepal in 2015: 22,267
- PLHIV receiving HIV care in 2015: 20,307
1. Epidemiological Features
i. Causative agent: Human Immune Deficiency Virus (HIV)
iv. Incubation period: The time from HIV infection to diagnosis of AIDS has an observed range of less
than 1 year to 15 years or longer.
v. Mode of transmission:
Contribution to total number of
Mode of transmission Risk of transmission
cases
Sexual transmission 0.01-1% >80%
Mother to child transmission 20-40% 1%
Blood transfusion 90% 3-5%
Infected syringes and needles <0.5 5-10%
b. Clinical stage II
- Weight loss <10% body weight
- Minor mucocutaneous manifestations (seborrhoeic dermatic, prurigo, fungal nail infections, oral
ulcerations)
d. Clinical stage IV
- HIV wasting syndrome
- Pneumocystic carinii pneumonia
- Cytomegalo virus disease
- Lymphoma
- Kaposis sarcoma
- HIV encephalopathy
2. Diagnosis
- Serological tests such as RDTs or enzyme immune assays (EIAs)
3. Treatment
- HIV cannot be treated but can be supporessed by Anti retro viral therapy (ART)
Measles (Rubeola)
1. Burden of disease
i. Global
- Measles is one of the leading causes of death among young children.
- In 2014, there were 114 900 measles deaths globally.
- Measles vaccination resulted in a 79% drop in measles deaths between 2000 and 2014 worldwide.
ii. Nepal
- In 2009, Nepal has had already achieved the goal of measles control.
- In 2014, there were only 9 cases of measles.
2. Epidemiological Features
i. Causal agent: Measles virus (paramyxovirus family)
v. Incubation period: 10 days from exposure to onset of fever, and 14 days after appearance of rash
3. Diagnosis
- Commonly diagnosed with signs and symptoms
- Serological tests
Rubella(German Measles)
1. Epidemiological Features
i. Agent: RNA virus of Toga virus family
Typhoid Fever
1. Epidemiological Features
i. Causative agent: Salmonella typhii
2. Diagnosis
- Culture isolation of organisms
Atherosclerosis
- Atherosclerosis, a disease of the large arteries, is the primary cause of heart disease and stroke.
- Atherosclerosis is a leading cause of vascular disease worldwide.
- Its major clinical manifestations include ischemic heart disease, ischemic stroke, and peripheral
arterial disease.
- Diabetes
- Overweight or obesity
- Lack of physical activity
- Unhealthy diet
- Older age
- Family history of early heart disease
Burden of RTAs
- Road traffic injuries are currently estimated to be the ninth leading cause of death across all age
groups globally.
- About 1.25 million people die each year as a result of road traffic crashes.
- 90% of the world's fatalities on the roads occur in low- and middle-income countries
- Road Traffic Accident (RTA) is one among the top five causes of morbidity and mortality in South-
East Asian countries.
- According to the latest WHO data published in may 2014 Road Traffic Accidents Deaths in Nepal
reached 5,036 or 3.18% of total deaths.
- Well maintained roads with frequent relaying of road surfaces and markings of road safety signs.
- Footpaths for pedestrians and pedestrian crossings at intersections.
- Provision of separate lanes for slow-moving and fast-moving vehicles.
- Widening of roads and junctions
Diabetes
Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or
when the body cannot effectively use the insulin it produces.
Types of diabetes
i. Type 1 diabetes
- Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-onset) is characterized
by deficient insulin production and requires daily administration of insulin.
- The cause of type 1 diabetes is not known and it is not preventable with current knowledge.
- Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight
loss, vision changes and fatigue. These symptoms may occur suddenly.
- Type 2 diabetes comprises the majority of people with diabetes around the world , and is largely the
result of excess body weight and physical inactivity.
- Symptoms may be similar to those of Type 1 diabetes, but are often less marked. As a result, the
disease may be diagnosed several years after onset, once complications have already arisen.
Risk Factors
- Physical inactivity/ sedentary behaviour
- Hypertension
- Smoking and alcohol consumption
Consequences
- Adults with diabetes have a 2-3-fold increased risk of heart attacks and strokes.
- Combined with reduced blood flow, neuropathy (nerve damage) in the feet increases the chance of
foot ulcers, infection and eventual need for limb amputation.
- Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term
accumulated damage to the small blood vessels in the retina. 2.6% of global blindness can be
attributed to diabetes.
- Diabetes is among the leading causes of kidney failure
SOCIAL EPIDEMIOLOGY
Social Epidemiology is defined as the branch of epidemiology that considers how social interaction and
collective human activities affect health. In other words, social epidemiology is about how a societys
innumberable social arrangements, past and present, yield different exposures and thus differences in
health outcomes among the persons who comprise the population.
Berkman and Kwachi defined social epidemiology as the branch of epidemiology that studies the social
distribution and social determinants of states of health.
- Social epidemiology focuses particularly on the effects of socio-structural factors on states of health
- The major premise of social epidemiology is that each society forms its own distribution of health and
disease. In other words, social epidemiology assumes that the distribution of health and disease in a
society reflects the distribution of advantages and disadvantages in that society. Based on this
premise, social epidemiology examines which socio-structural factors affect the distribution of health
and disease, as well as how these factors influence individual and population health.
- Examples of socio-structural factors include
Social class
Gender
Ethnicity
Discrimination
Social network
Social policy
Income distribution
- In a seminal article, Saxon Graham (1963) discussed the social epidemiology of selected chronic
illnesses. While never giving an explicit definition of social epidemiology, he suggested that a union of
sociology with the medical sciences would produce a new and more successful epidemiology.
- In 1969, Leo G Reeder presented a major address to the American Sociological Association called
Social Epidemiology: an Appraisal. He defined social epidemiology as the study of the roles of
social factors in the aetiology of dieases.
- At the end of 19th century, Germ Theory established germs as the major cause of disease. Major
epidemiologic studies were concentrated on identifying new germs that cause diseases and social
factors affecting health were overshadowed.
- Later in early 20th century, the idea that disease is caused by exposure to multiple individual risk
factors (called web of causation) entered the mainstream of epidemiological theories.
- By the 1980s, several epidemiologists developed social epidemiology, underscoring the importance
of socio-structural factors on health.
i. Psychosocial Theory
- A psychosocial theory views health outcomes as functions of host-agent-environment interactions
(i.e., impact of social environment to host resistance to disease).
- Although socio-structural constructs such as dominance hierarchies, material deprivation,
victimization, and social isolation are identified as fundamental social determinants, the chronic stress
produced by these determinants and effect of chronic stress on the individual biological defenses is
viewed as the intervening mechanism of host-pathogen susceptibility.
- Richard Wilkinson states that the lower levels of social cohesion, trust, and social support that are
prevalent in hierarchical societies promote both material deprivation and a pathogenic quality of social
relationships that have direct effects on an individuals defenses against a wide array of diseases.
- Biological responses to stress-inducing situations are ameliorated by the strength of the social
support provided by other people as being important by the individual.
Summary:
In contemporary social epidemiology, the three main theoretical frameworks for explaining disease
distribution are i) Psychosocial, 2) Social production of disease/ political economy of health, and 3)
eco-social theory.
A psychosocial framework directs attention to endogenous biological responses to human
interactions; a social production of disease/ political economy of health framework explicitly
addresses economic and political determinants of health and disease but leave biology opaque; eco-
social theory seeks to integrate social and biological reasoning and a dynamic, historical and
ecological perspective to develop new insights into determinants of population distribution of disease
and social inequalities in health.
The social determinants of health (SDH) are the conditions in which people are born, grow, work, live,
and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and
systems include economic policies and systems, development agendas, social norms, social policies and
political systems. (WHO)
- Social exclusion results from racism, discrimination, stigmatization, hostility and unemployment.
- Social exclusion increases the risks of divorce and separation, disability, illness, addiction and
deprivation to basic health services.
iv. Food
- A good diet and adequate food supply are central for promoting health and well-being.
- A shortage of food and lack of variety causes malnutrition and deficiency diseases.
- In many countries, the poor tend to substitute cheaper processed foods for fresh food. High fat intake
often occur in all social groups.
- People on low incomes, such as young families, elderly people and the unemployed, are least able to
eat well.
v. Addiction
- Drug use is both a response to social breakdown and an important determinant in worsening the
resulting inequalities in health.
- Alcohol dependence, illicit drug use and cigarettes smoking are all closely associated with markers of
social and economic disadvantage.
- Addiction are associated to health risks, accidents, violence, poisonoing, injury and suicide.
vi. Stress
- Social and psychological circumstances can cause long-term stress.
- Continuing anxiety, insecurity, low self-esteem,social isolation and lack of control over work and
home life have powerful effects on health.
- Long term stress makes people vulnerable to a wide range of conditions including, diabetes, high
blood pressure, heart attack, stroke, depression and aggression.
vii. Culture
- All cultures have systems of health beliefs to explain what causes illness, how it can be cured or
treated, and who should be involved in the process.
- Cultural issues play a major role in determining a person's health or the health of a community as a
whole.
Evidence based public health can be defined as the conscientious, explicit and judicious use of current
best evidence in making decisions about the care of communities and populations in the domain of health
protection, disease prevention, health maintenance and improvement (health promotion).
- Jenicek, 1997
- For public health professionals, evidence is some form of data, including epidemiologic (quantitative)
data, results of program or policy evaluations, and qualitative data- for uses in making judgments or
decisions.
- Public health evidence is usually the result of a complex cycle of observation, theory or experiment.
Distinction between Evidence Based Public Health (EBPH) and Evidence Based Medicine
(EBM)
Basis of Evidence Based Public Health (EPPH) Evidence Based Medicine (EBM)
difference
Type of - Public health interventions usually rely - Medical studies of pharmaceuticals and
evidence on cross-sectional studies, quasi- procedure often rely on randomized
experimental designs, and time series controlled trials of individuals, the
analyses. scientifically rigorous of epidemiological
- These studies sometimes lack studies
comparison group and require more
caution when interpreting the results.
Evidence - Generating evidences from large - The treatment of a medical condition (e.g.
collection community based trials can be more antibiotic for symptom of pneumonia) is
expensive to conduct than likely to produce effects in days or weeks,
randomized experiments in a clinic. or even a surgical trial for cancer with
- Population based studies generally endpoints of mortality within a few years.
require a large period between - So, the evidences are generated relatively
intervention and outcome (smoking faster and conveniently than in public
exposure to development of lung health
cancer).
Heterogenity - Public health relies in a variety of - Medicine is more structured and
in decision disciplines. formalized and therefore decision making
making - Fewer than 50% public health workers process is relatively homogenous
have any formal training in a public
health discipline. This high level of
heterogeneity means that multiple
perspectives are involved in decision-
making process
The overall goal of a research critique is to formulate a general evaluation of the merits of a study and to
evaluate its applicability to public health practice. A research critique goes beyond a review or summary
of a study and carefully appraises a studys strengths and limitations. The critique should reflect an
objective assessment of a studys validity and significance. A research study can be evaluated by its
component parts, and a thorough research critique examines all aspects of a research study. Some
common questions used to guide a research critique include: