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Introduction, Concept, Scope,
Definition, Trends, History and
development of Modern
Epidemiology, Contribution of
epidemiology, Implication.

Submitted by: Submitted to:

R.Hemaladha Prof.Dr.J.RUKUMANI
M.Sc. Nursing II Yr Principal CON

Table of Content Content Page
1 Introduction 3

2 Definition 4

3 Concept of Epidemiology 5-11

-Models related to concept of
4 Scope,Aims and uses of 12
5 History and Trends in Modern 13-18
-Eras in Evolution of modern
-Milestones in History of
6 Implications of Epidemiology 18-19

7 Contributions of Epidemiology 19-23

8 Conclusion 24

9 References 25-26

Introduction, Concept, Scope, Definition,
Trends, History and development of Modern
Epidemiology, Contribution of epidemiology,

Epidemiology is concerned with the distribution and determinants of health and

diseases, morbidity, injuries, disability, and mortality in populations. It is a specialized
form of scientific research that can provide health care workers, including community
health nurses, with a body of knowledge in which to base their practice and methods
for studying new and existing problems. The term is derived from the Greek words,
Epi: Upon, Demos: People, epi (upon) + demos (people) + logos (study) (i.e.)
epidemiology is the study of what is upon the people.

The ultimate goal of epidemiology are to determine the extent of disease in a

population, identify patterns and trends in disease occurrence, identify the causes of
disease, and evaluate the effectiveness of prevention and treatment options. With
knowledge regarding the scale and nature of human health problems, solutions to
prevent disease can be sought thereby contributing to the improved health of the entire
population. Epidemiology offers community health nurses a specific methodology for
assessing the health of aggregates. Furthermore it provides a frame of reference for
investigating and improving clinical practice in any setting. For example if a
community health nursing goal is to lower the incidence of sexually transmitted
diseases, in a given community such a preventing plan requires information about
population groups . How many STD cases have been reported in this community in the

past year? What is the expected number of STD cases? Which members of the
community are at highest risk of contracting STDs?


1. Epidemiology is defined as the study of the distribution and determinants of

health related states or events in specified population and application of this study to
the control of health problems. - [Last, 2001]

The words in the definition has the meaning such as

Study : It includes observation, surveillance, hypothesis testing, analytical

research methods and experiments.

Distribution : The disease is not distributed uniformly in human population but

it occurs in patterns in community. (Place, person, time)

Determinants : Determinants are the factors which influence the health and can
affect the frequency with which a disease occurs in a population. (Intrinsic and

Health related states/events: includes diseases, cause of death, behavior such as

tobacco, reaction to preventive regiments.

2. Epidemiology is the study of disease in populations and of factors that

determine its occurrence. - [Thurshfield, 1995]

3. Epidemiology is the study of the patterns, causes and control of disease in

groups of people. - U.S National Institute of Health.

4. Epidemiology is the study of disease in populations - [Schwable et al, 1977]

5. Epidemiology is the study of distribution and determinants of disease

frequency in man McMohan & Pugh, 1960


Epidemiology is a scientific study of factors and conditions related to disease as

they occur in people.

One of the earliest concepts expressed by philosophers Plato and Roussean was
that the disease was primarily the fault of human luxury. The Greek physician
Hippocrates examined the relationship between the occurrence of disease and
environmental influences and coined the terms endemic and epidemic. According to

Endemic : for diseases usually found in some places but not in others.

Epidemic : for disease that are seen at sometimes but not others.

As the infectious diseases were the major health problems the epidemiological
concept 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 and health related events.

In the early 20th century, mathematical methods were introduced into

epidemiology by Ronald Ross, Anderson Gray Mckendrick and 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. and it is a study at the undergraduate,
graduate and postgraduate degrees including a master of public health in some of

As a public health / health protection practitioners, epidemiologists work in a

number of different settings such as in the field, (i.e.) in the community, non-profit
organizations, universities, hospitals and larger government entities [centers for disease
control and prevention (CDC), the health protection agency]. In the community they

are often at the forefront of investigating and combating disease outbreaks while
providing public health services.

The studies are aimed at revealing unbiased relationship and identifying causal
relationships. Identifying causal relationship between these exposures and outcomes
are important aspects of epidemiology. The term epidemiologic trial is used to
describe the intersection of host, agent and environment in analyzing on outbreak,
Modern epidemiologist use informatics as a tool.

As a public health discipline, epidemiological evidences are used to guide and

teach the public, both personal measures (diet change) and corporate measures
(removal of junk food advertising) in order to help people to make informed decisions
about their health. In this way, epidemiological practice and the results of
epidemiological analysis make a significant contribution to emerging population based
health management framework.

3.1. Models related to concept of Epidemiology


It is a model that scientist have developed for studying health problems. It helps
to understand infectious disease and how they spread. Triangle has three corners called
as vertices.

Agent it refers to microbes includes Bacteria, viruses, fungi & Protozoa (What of the

Host It refers to the organism harboring the disease (Who of the triangle)

Environment Those external factors that cause or allow the disease transmission (the
where of the triangle)

Mission of an epidemiology is to break at least one of the sides of the triangle,
disrupting the connection between environment, host and agent and stopping the
continuation of disease.


The advanced model recognizes that disease states and conditions affecting a
population are complex and that causative factors are many. It gives recognition to the
fact that many factors and elements contribute to disease in population. The concept of
agent is replaced with causative factors- multiple causes for disease, disability, injury
and death.


Pathogen Environment

In the center of the triangle is TIME. Most infectious disease has an incubation period
that is the invasiveness of organism into body till the clinical symptoms appears. Or the
time may describe the duration of the illness or the amount of time a person can be sick

before death or recovery occurs. Time also describes the period from an infection to the
threshold of an epidemic for a population.


Any particular disease or health problem is the result of an interaction between a

number of specific or associated risks which can be classified as agent, host and
environmental factors. These instructions can be best understood by visualizing the
concepts of Positive health and disease.

Positive health is the supremacy of the most over the causative and associated
factors. This is possible when the host becomes stronger and or the agent is removed or
the environment becomes unfavorable to the agent.

Disease or disorder occurs when the agent is more powerful than the Host and or
the Host becomes weaker and or environment becomes favorable for growth,
multiplication and survival of the agent


It indicates that a disease may be caused by more than one causal mechanism
(sufficient cause) which is defined as a set of minimal conditions and events that
inevitably produce disease.

According to Rothman & Greenland, a given disease can be caused by more than
one causal mechanism, and every causal mechanism involves the joint action of a
multitude of component causes.

A single letter indicates a single component cause (A), in other cases the
component causes for each causal mechanism could be different for each mechanism.

Example: Etiology of lung cancer Lung cancer caused by smoking; Lung cancer
caused by exposure to ionizing radiation; Lung cancer caused by inhalation of
carcinogenic solvents in the work place.

A common factor- is genetic predisposition. Several other components- include

smoking, exposure to ionizing radiation & inhalation of carcinogenic solvents, etc.

A set of component causes occurring together may complete the pie creating a
sufficient cause and thus initiating the disease process. Commonly appearing
component will have larger impact on disease.

It helps to clarify how the necessary and non necessary component causes
contributes to disease occurrence on a population level.

Factor A and B are necessary component.

Factor C, D, E, F, G, H are non necessary component.


The epidemiological triad model is applicable to infectious diseases only and has
been in use for many years. It helps to understand different factors related to
communicable diseases. However, it is not applicable to non infectious and chronic
diseases like mental illness, coronary heart disease, rheumatoid arthritis etc. It is

because these diseases are not linked with specific causation agent and these cannot be
prevented and controlled by immunization, isolation and quarantine techniques and by
improvement of sanitation like infectious diseases.

These diseases are caused by multiple factors. For example, coronary heart
disease is associated with certain life style activities such as: smoking, ingestion of food
containing high level of cholesterol, lack of exercise, increased mental and emotional
stress and environmental pollution etc. Control of diet, regular exercise and use of
effective stress management techniques have shown to reduce the risk of experiencing
myocardial infarction. This leads to the theory of multi factorial causation. This theory
thus stresses the multiplicity of interactions between host and environment. This model
is equally applicable to infectious diseases except that specific agents causing infectious
and non infectious diseases (nutrition deficiency diseases) are considered as integral
part of the environment.

The multi factorial causation model helps epidemiologist to understand

the various associated causative factors, prioritize these and plan preventive and
control measures for a particular disease.

It is also found that several causative factors produce many observed effects e.g. air
pollution; smoking and specific form of radiation (causes) may produce lung cancer,
emphysema and bronchitis (effects).


This epidemiological concept of disease etiology is given by Mac Mohan

and Pugh. According to this concept, disease (effect) never depends upon single
isolated cause. Rather it develops as a result of chains of causations in which each link
itself is the result of complex interaction of preceding events and circumstances. This
chain of causation which may be a fraction of the whole complex is known as web of

This epidemiological model suggests that there are cluster of causes and
combinations of effects which are related to each other and need to be studied to
identify possible interventions to reduce the occurrence of a particular disease. For
example, cardio-vascular diseases may include avoidance of smoking, diet control,
exercise, stress management etc.

But fortunately it is not necessary to understand the whole causal mechanism to effect
prevention and control of a particular disease. It requires identification of the most
important link(s) in the chains of causation of a disease.

This model is particularly applicable to chronic diseases where the causative
agent is unknown and which are due to interaction of multiple factors
e.g. cardiovascular diseases, cancer etc


Its application is used to study infectious disease.

The principles of epidemiology have been applied to the study of noninfectious
disease situation as pellagra, other vitamin and mineral deficiencies, goiter and
Application of epidemiology studies also used in occupational diseases to find
and prevent the hazards of lead, mercury and carbon monoxide poisoning.
Epidemiological methodology has also been applied to investigating accidents
and environmental pollution problems.
Diseases of unknown etiology such as multiple sclerosis. Leukemia and various
forms of cancer are all being approached by epidemiological methods.


1.To describe the distribution and magnitude of health and disease problems in
humans populations.
2.To identify a etiological factors in the pathogenesis of disease.
3.To provide the data essentials to the planning implementation and evaluation of
services for the prevention ,control and treatment of disease.


This epidemiological model provides another approach to conceptualize

interaction of various factors involved in the development of a particular condition.
This model is based on Blums model of health paradigm. The model is composed of

four major categories of factors such as human biology, life style, environment and
health care system.


The ancient roots of epidemiology have been traced to Hippocrates, a Greek

Physician. Who is sometimes referred to as the first epidemiologist

In the fourth century BC, Hippocrates and members of his school believed that
disease not only affects individuals but also affects the masses. This was one of the
earliest associations of the occurrence of disease with lifestyle and environmental
factors, specifically geographical location. His approach to disease anticipated the major
categories of descriptive epidemiology: the distribution of health states by personal
characters, place, and time. However, modern epidemiology did not emerge until the
19th century, and it was only in 20th century that field developed as a discipline with a
distinctive identity


Modern epidemiology can be described as having four distinct eras, each based
on causal thinking, sanitary statistics, infectious-disease epidemiology, and chronic
disease epidemiology. In light of new research, the eco-epidemiology era is currently

Early 18th century:

Early causal thinking was dominated by the miasma theory, which had its
origins in the work of the Hippocratic School and was formally developed in the early
1700s. This theory held that a substance called miasma was composed of malodorous
and poisonous particles generated by the decomposition of organic matter and was the
cause of disease. Despite its base on faulty reasoning, this type of prevention had
positive consequences because it made people aware that decaying organic matter can
be a source of infectious diseases, this theory dominated until the first half of the 19th
century. Nightingale herself never accepted the link between micro organisms and
disease and based her practice on this same approach. Her work in the Crimea, with its
emphasis on sanitation, had positive results nonetheless.

Similarly, the pioneering work of John Snow, (often called father of

epidemiology) in identifying the source of cholera in England in the mid 1800s was
based on a faulty assumption that the climate was involved. Even so, he was able to
trace the source of the infectious agent to the water supply and brought public attention
to the link between sanitary conditions and disease, we owe much to these individuals;
that they didnt understand the exact mechanisms in disease causation does not
diminish their pioneering work in applied epidemiology.

Mid 18th century:

The era of infectious disease epidemiology was dominated by the contagion

theory of disease, which developed by the mid 18th century. Prompted by the

development of increasingly sophisticated microscopes, this theory attempted to
identify the microorganisms that cause diseases as a first step in prevention. It inspired
various theories of immunity, and even prompted some initial attempts at vaccination
against smallpox.

Late 19th century to mid 20th century:

Based on the work of Louis Pasteur, Jakob Henle, and Robert Koch, the
contagion theory was refined and became best known as the germ theory of disease,
which was predominant from the late 19th century through the first half of the 20th

In the era of infectious-disease epidemiology, scientists viewed disease in terms

of a simple cause-and-effect relationship. Finding a single cause and attacking it
seemed to be the solution for presenting many diseases. E.g. In the case of bubonic
plague, mycobacterium tuberculosis, this approach appeared to be quite effective.
However, scientific research eventually revealed that disease causation was much more
complex than first suspected.

Late 20th century to early 21st century:

After World War II, the causative agents of major infectious diseases were
identified, methods of prevention were recognized, and antibiotics and chemotherapy
were added to fight communicable diseases. The focus then became understanding and
controlling the new chronic disease epidemics. With the increase in chronic disease,
epidemiologists realized the necessity of looking beyond single agents toward a multi-
factorial etiology, now called ecological model.

E.g. Researchers completed case-control and cohort studies that linked the
causative factors of cholesterol levels and smoking with coronary heart disease and
associated smoking with lung cancer. Today the major causes of mortality are non-
infectious diseases.

21st century

We are entering a new era of eco-epidemiology, distinguished by transforming

global health patterns and technological advances. Global health patterns, the route,
form, and virulence in which diseases appear in countries around the world, with
consideration of environmental, ecological, human, technologic, and political factors are
in transformation. E.g. HIV SARS. In most cases, causative organisms and critical risk
factors are known, yet diseases occur, spread and suddenly appear in countries or
regions previously free of them. We are at a loss about how to create a climate of
permanent change, even when entire populations are at stake.

Eras in Evolution of Modern Epidemiology

Eras in the evolution of modern epidemiology

Era Paradigm Analytic Approach Prevention Approach
Sanitary spastics Miasma Theory: Clustering of Drainage, sewage,
(1800 1850) Poisoning from morbidity and sanitation
foul emanations mortality
Infectious Germ theory : Laboratory isolation Interrupt transmission
disease Single agent and culture from (Vaccines, isolation and
Epidemiology related to disease sites and antibiotics)
(1850 1950) specific disease reduce lesions.
Chronic disease Exposure related Risk ratio of exposure Control risk factors by
epidemiology to outcome to outcome at modifying life style
(1950 2000) individual level in (diet) agent (gums) or
populations environment (pollution)
Eco- Relations within Analysis of Apply both information
epidemiology and between determinants and and biomedical
(emerging) localized outcomes at different technology to find
structures levels of organization leverage at effecting

organized in a using new levels
hierarchy of information systems
levels. and biomedical

Milestones in history of epidemiology

Significant milestones in the history of epidemiology

Year person / Significant event
1662 John Graunt Used bills of mortality (forerunner of modern vital record)
to study patterns of deaths in various populations in
Published early form of life table analysis.
1747 James Lind Studies scurvy using observation and comparison of
responses to various dietary treatments. (early precursor of
clinical trial)
1760 Daniel Bernoulli Used life table technique to demonstrate life table
technique to demonstrate that smallpox inoculation
conferred lifelong immunity.
1775 Percival Pott First cancer epidemiologist noted that a high
proportion of clients presenting with cancer of
scrotum were chimney sweeps. Inferred exposure to
soot was the cause.
1798 Edward Jenner Demonstrated effectiveness of smallpox vaccination
1798 Marine hospital Forerunner of U.S public health service (1912).

1836 Pierre Charles Comparative observational studies to demonstrate
Alexandre Louis ineffectiveness of bloodletting. Emphasized the
importance of statistical methods.

1840 William Farr Pioneered mortality surveillance and anticipated many of

the basic concepts in epidemiology. His data provided
much of the basis for snows work on cholera
1850 Lemuel Shattuck Reported on sanitation and public health in
1850s John snow Epidemiologic research on transmission of
cholera. Used mapping and natural experiment, comparing
rates in groups exposed to different water Supplies.
1870 Robert Koch Discovered causal agents for anthrax, tuberculosis and
1880s cholera, development of causal criteria.
1887 Joseph Kinyoun Founded laboratory of hygiene, fore runner of the national
institutes of health (1930).
1921 Wade Harpton Founded first U.S academic program in epidemiology at
Frost Johns Hopkins university. Office of malarial control in war
areas established; became communicable centre (CDC) in
1946; Then centers for disease control (1973); now centers
for disease control and prevention.
1948 Framingham cohort study of cardiovascular disease begins.
1950s A. Bradford Hill Pioneering studies on smoking and lung cancer.
and Richard Poll
1952 Jonas salk Production of polio vaccine
1964 U.S. Surgeon First surgeon generals report on smoking and health
1976 Frank speizer Nurses health study begins.

1977 WHO Organizations smallpox eradication campaign succeeds;
last known case of smallpox in the world occurs.
1983 HIV-I retro virus is identified as the causal agent of AIDS.
1991 National Womens health initiative established.
Institutes of
2002 WHO World report on violence and health, the first
comprehensive summary of the global impact of violence as
a public health problem.


To study the history of disease in relation to its rise and fall in a community.
To diagnose the health problems of the community by studying their occurrence,
fluctuation, distribution by age, sex, occupation, locality and estimating risk, or
morbidity and mortality.
To find out chances of risk involved for individual in acquiring the disease.
To fill the gap in the knowledge of the natural history of diseases in their clinical
picture by analyzing the disease in a group and persons.
To identify clinical syndromes by observing its behavior in a group of persons.
Through operational research it helps in evaluating the effectiveness of present
health services in the community.
To search for chest to causes of disease and ill health by studying community
habits, customs, social patterns, biological aspects. This will also include a study of
new disease problems.
To collect variety of data from different sources and to frame logical chains to
explain multiple factors and events in diseases.
To establish epidemiological diagnosis of a disease with better understanding of
its different aspects after observing its behavior in a group of persons.

To measure indirectly the effectiveness of control and preventive measures.

1. To study the occurrence of Disease in a population.
Here epidemiologists study the history of the disease of the population and the
rise and fall of diseases and changes in their character and predict the future
health needs.
2. Diagnose the health of the community.
Community diagnosis generally refers to the identification and
quantification of health problems in a community in terms of mortality,
morbidity rates and ratios and identifications of their correlates for the purpose
of defining those individuals or groups at risk or those in need of health care
Quantification of health problems helps to
Lay down the priorities in disease control and prevention.
Evaluate health services at a later date.
Provide new knowledge about disease distribution, causation and
3. Planning and evaluation of health services

Planning is essential for allocation of the limited resources.

Epidemiologic information about the distribution of health problems over
time and place provides the fundamental basis for planning and
developing the needed health services and for assessing the impact of
these services of the peoples problems. Planning include,

Planning facilities of medical care number of hospital beds required

for patient with specific disease, health manpower planning.
Planning facilities for preventive services screening programmes,
immunization campaigns, provision of services.
Planning for research.

Evaluation Epidemiological measures that are taken to control or prevent a
disease must be followed by an evaluation to find out whether the measures
undertaken are effective in reducing the frequency of the disease. It includes the
cost and effectiveness of the measures.

4. Estimate individual risks and chances: Here the work of the epidemiologist is to
estimate the risk of diseases, accident and defect, and chances of avoiding them. So, it
helps to identify the people at risk over a period of time, and predicts the future health
needs and provides the base for preventive measure and their evaluation and helps in
logical planning of facilities for health care.

5. Syndrome Identification

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. Complete the clinical picture of chronic disease and describe their natural history

The epidemiologist study the complete clinical picture of the disease patterns in
the community in relation to agent, host and environment is in a better portion to fill up
the gaps in the natural history of disease than the clinician

7. To search for causes of health and disease/ to forecast future diseases trends
Epidemiology helps in understanding the causation of disease and disability and
providing data which helps to explain the etiology of disease and local disease patterns
which in turn helps to test the hypothesis clinically or experimentally.


With steady progress in the control of major communicable diseases and

consequent changes in the disease spectrum of populations in many areas of the world,

new problems have emerged and gained magnitude over the years. In these
circumstances epidemiology is destined to play an increasingly important role in
defining the magnitude of the problems, forecasting their long term consequences and
deriving appropriate strategies for their prevention and control. The following are some
of the contributions of epidemiology

Disease antecedents
Disease correlates
Disease behavior
Disease causation
Strategy formulation
Programme evaluation

Epidemiology has always stressed the importance of exploring the natural

history of diseases in their entirety, with special stress on the identification of disease
antecedents rather than disease consequents. Examples are

Anopheles Identified as the vector of malaria by Ronald Ross in 1897.

Tsetse fly Identified as the vector of sleeping sickness by Bruce and Nabarro
in 1903.

Sand fly Implicated in the transmission of oriented sore by sergeant brothers

in 1904.

These inventions helped in identifying the natural history of diseases.


Epidemiology has revolutionized the concept of antilogy and autogenesis.

Germ theory of diseases

Web of disease causation

Multi factorial causation, these things helped in identification of causes and risk
factors for both the communicable and non communicable diseases. This disease
correlates has been instrumental in reducing maternal and child mortality on a
universal scale.

Disease behavior is studied by a process of epidemiological surveillance whereby

diseases are kept under constant observation firstly to identify their normal distribution
patterns and normal temporal fluctuations and secondly to detect any deviations in
their expect behavior pattern. Epidemiological surveillance is applied to diseases of
international significance.

WHO introduced influenza surveillance in 1947 with a view monitor the

behavior of influenza in human and non-human hosts
AIDS surveillance revealed its distribution pattern, the direction in which it has
been moving.
By studying the behavior of diseases, epidemiologists provide information on their
distribution trends and epidemic potential.


Kochs postulates provide a scientific basis for establishing the causation of

communicable diseases. Many epidemiological studies established the cause effect
association of many diseases. Example

Smoking and lung cancer

Smoking and coronary heart disease.
Rebel infection and congenital anomalies

Control or eradication of diseases is much more complex than their prevention or
treatment. The success of a control programme is mainly determined by its operational
strategy. A sound control strategy is one that is epidemiologically relevant and
operationally feasible. Examples

Pulse Polio Immunization

AIDS control strategy
Epidemiology plays an important role in strategy formulation for disease control
programmes and improves programme efficiency and effectiveness.


Evaluation of public health programmes is not a managerial and an

epidemiological process. For purposes of evaluation, programme objectives must be
quantified and expressed in concrete statistical indices, as the indices serve as yard
sticks for measurements, Programme effectiveness is judged by the extent to which the
programme has succeeded in achieving the set objectives within the specified time
frame. (E.g.) Eradicate polio by the year 2010.


By identifying risk factors and etiological factors of infectious diseases and

chronic diseases, evaluating treatment modalities and health services, it has proved new
opportunities for prevention, treatment, planning and improving the effectiveness and
efficiency of health services. The current interest of medical sciences in epidemiology
has given rise to newer off-shoots such as infectious disease epidemiology, chronic
disease epidemiology, clinical epidemiology, serological epidemiology, cancer
epidemiology, malaria epidemiology, Neuro- epidemiology, genetic epidemiology,
occupational epidemiology, psychosocial epidemiology and so on. This trend is bound
to increase in view of the increasing importance given to the pursuit of epidemiological


1. Allender, Ann Judith & Spradley, Walton Barbara. (2007), Community Health Nursing

Promoting and Protecting Publics Health, (7th ed.), Philadelphia: Lippincott Williams

and Wilkins, 172 197..

2. Basavanthappa, BT. (2008), Community Health Nursing, (2nd edition), Jaypee, 619 -660

3. Gupta, J.P & Sood, A.K. (2005), Contemporary Public Health Policy, Planning and

Management, Daryaganj : Apothecaries foundation, 2.81 2.88.

4. Gupta, M.C. & Mahajan, B.K. (2007), Textbook of Preventive and Social Medicine, (3rd

ed.), Daryaganj : Jaypee brothers, 11 24.

5. Gulani K.K, (2008). Community health Nursing principle and practices, (2nd
ed.). Kumar: Pitampura, 225 237.
6. Mathur, J.S. (2007), Preventive and Social Medicine A Comprehensive Textbook,

Daryaganj : CBS publishers, 123 171.

7. McEwen& Melanie. (2008), Community based Nursing an Introduction, (3rd edition),

Saunders elsevier, 83 94.

8. O.P. Ghai & Gupta Piyush. (2007), Textbook of Preventive and Social Medicine, (2nd

edition), New Delhi: CBS publishers, 536 564.

9. Park, K. (2011), Parks Textbook of Preventive and Social Medicine, (21st ed.), Jabalpur

: Banarsidas Bhanot, 50 76

10. Stanhope, Marcia & Lancaster, Jeanette. (2008), Public Health Nursing Population

Centered Health Care in Community, (7th ed.), Missouri : Mosby, 243 - 274.

11. Stone, Clemen. (2002), Comprehensive Community Health Nursing Family,

aggregate and Community Practice, (6th ed.), Missouri: Mosby, 16 18.

Net References:

12. Epidemiology, http://<>, 12 October 2012.

13. Epidemiological Principles and concepts, <>, 12
October 2012.