INTRODUCTION

Epidemiology is the basic science of preventive and social

medicine. Epidemiology has evolved rapidly during the past three decades. It not only
studies disease distribution and causation but also health and health related events
occurring in human population. By identifying risk factors of chronic disease, evaluating
treatment modalities and health services it has provided new opportunities for treatment,
prevention planning and improving the effectiveness and efficiencies of health services.
The current interest of medical sciences in epidemiology has given rise to newer
offshoots such as infectious disease epidemiology, chronic disease epidemiology, clinical
epidemiology, cancer epidemiology and so on.

MEANING OF EPIDEMIOLOGY

The term epidemiology is derived from three Greek words

Epi – upon, among Demos – people and Logos – science, study. Thus it is the science of
events that occur in a community. Epidemiological methods such as measures of health,
serve as a tool for assessing community needs and evaluating the needs of community
health programs

DEFINITION

1. The study of distribution and determinants of health related states or events in

specified populations and application of this study to the control of health
problems.
- John.M.Last (1988)

2. Epidemiology is concerned with the pattern of disease occurrence in human

population and factors that influence these patterns.
- Lilienfield (1980)

3. Epidemiology is the study of patterns of health, illnesses and associated factors at

the population level. It is the cornerstone method of public health research and
helps in informing evidence based medicine for identifying risk factors of disease.
- www.wikipedia.org

4. Epidemiology is the study of the distribution and determinants of health related

states or events and application of this study to control of disease and other health
problems.
- WHO

5. The study of distribution and determinants of disease frequency in man.

 - McMohan and Pugh (1960)

AIMS OF EPIDEMIOLOGY

According to International Epidemiological Association,

epidemiology has three main aims:

 To describe the distribution and size of disease problem in human population

 To identify the etiological factors in the pathogenesis of a disease
 To provide the data essential to the planning, implementation and evaluation of
the services for the prevention, control and treatment of disease and setting up of
priorities among these services

The ultimate aim of epidemiology is to lead effective action to

eliminate or reduce the health problems or its complication and to prevent its occurrence
in future. The aims of epidemiology include knowledge of distribution of disease in order
to elucidate causal mechanisms, explain local disease occurrences, describe natural
history of disease and provide guidance in providing the services.

USES OF EPIDEMIOLOGY

 To study the effects of disease rate in a population over a time and predict future
health needs
 To diagnose the health of the community
 To evaluate the health services
To estimate the individual risk from the group
 To identify the syndrome
 To complete the clinical picture of chronic diseases and describe their natural
history
 To search the natural course of disease and illness

The uses of epidemiology encompass two main components:

a. The systematic collection of health data (including the utilization of data collected
for other purposes)
 Identification of health problems and assessment of priorities in allocation
of resources
 Detection of new problems or changes in frequency of existing problems
 Identification of risk factors enabling efficient distribution of resources
assigned to a particular problem
 Evaluation of effectiveness of control programme
 Formulation of hypothesis regarding the reasons for nonrandom
distribution of diseases
b. The search for cause of ill health
 Identification of alterable causes
  Identification of susceptible groups for special surveillance
 Identification of disease entities
 Identification of early manifestations of disease or disease syndrome

ADVANTAGES OF EPIDEMIOLOGY

o Epidemiology provides a framework within which basic and behavioral science

can be used for community nursing practice
o The nursing process extended through application of epidemiology to describe
community needs and evaluate nursing services
o Public health principle of family is the unit of society ,prevention and control of
disease and health promotion are activated and quantifies through epidemiological
process
o Epidemiology provides inter disciplinary language to promote interprofessional
communication and trust
o An epidemiological perspective provides a method of extending the relationship
of family problems to community welfare
o The epidemiological model promotes understanding of relationship between the
environment and agents that expose susceptible population at risk of
impediments to health
o Epidemiology provides time honoured method of quantifying outcomes such as
lack of compliance and activities of daily living to promote and to improve the
quality of nursing care in the community

EPIDEMIOLOGICAL PROCESS

Basic concepts in epidemiology aids in identifying

variables that public health professionals consider when they describe the distribution
patterns and determinants of health, disease and condition frequencies in population.
They help to analyze caused relationships in diseases or condition outbreaks. To establish
these causal relationships, health professionals use a scientific process known as
epidemiological process.

The epidemiological process is a systematic course of action taken to identify:

 Who are affected (persons)

 Where the affected persons reside (place)
 When the affected persons were affected ( time)
 Causal factors of health and disease occurrence
 Prevalence and incidence of health and disease
 Prevention and control measures in relation to the natural history of
disease
Epidemiology : the systematic
scientific study of the
distribution patterns and
determinants of health and
disease frequencies in
population
The epidemiological process has eight basic steps, they are interrelated and dependent on
each other.

STEP I : FINDOUT THE NATURE EXTEND AND SCOPE OF THE PROBLEM

The primary responsibilities during this initial step include :

 Verify the diagnosis by data collection from multiple sources

 Determine the extend and possible significance of the verified problem

Data collection begins when a case is roprted or when there is a noticeable change
in the incidence rate of particular disease or condition.once the case is known to
the health personnels data are collected from various sources to determine ifa
problem really exists.
Clinical observations,laboratory studies and lay reporting assist the
epidemiological team in confirming the homogenicity of the current
event.Timely,accurate and thorough data collection is a critical factor in this
step.The health professionals needs to be detective by interviewing the affected
individuals and then find out the individual’s environment to track down the host
agent environment factors that influence disease occurrence.
Analysing data in terms of person,place and time helps to estimate the magnitude
of the problem.Data tell the health professional the proportion of the people
affected, seriousness of affect on thehost and community,geographical distribution
of disease and also in identifying the potential source of infection.And the health
professional makes an educated guess as to the nature of causative agent on the
basis of data collected and this is called the formulation of tentative diagnosis or
hypothesis
For example : if 4 hospital emergency rooms have reported that several
individuals were treated for food poisoning in the last 24 hoursthe health personnel would
want to immediately take the following actions:

 Interview the affected persons to determine the nature of the symptoms

and to identify the loci of origin according to person,place and time.
 Review laboratory studies to confirm a common causative organism
 Interview friends,relatives and lay men to discern their description of the
events that led up to the reported illness and to determine whether other
individuals have symptoms.

STEP II : FORMULATE TENTATIVE HYPOTHESIS

When dealing with infectious disease,rapid preliminary analysis of the data is

essential.Disease can spread quickly affecting a large number of population in a
short period of time.Usually this analysis results in the formulation of several
hypothesis.laboratory test are invaluable in valuable in validating
 hypotheses.Explanation of the most probable source of infection is made in terms
of:
 Agent causing the problem
 Source of infection
 Environmental conditions that allowed it to occur

For example different strains of M.tuberculosis can be compared on the basis of

their genetic content or genotype called DNA fingertyping.These patterns can be
compared with others to determine the potential relatedness of bacterial
stains.This information can be used to:

 Determine whether bacterial strains from different clients are potentially

related
 Determine if a clinical isolate matches those obtained fromsamples
implicated in an outbreak
 Determine if a particular isolate is being found in other states or region

STEP III : COLLECT AND ANALYSE FURTHER DATA TO TEST

HYPOTHESES

A basic starting point in this step is to identify the group affected by the disease or
problem under investigation.Individual epidemiological histories should be obtained to
classify persons according to their exposure to the suspected or causative agents and to
identify the clinical data and bacteriological findings needed to substantiate the
diagnosis.Significant variations in the incidence in the contrasted population groups
should be noted.These variations can be identified through the study of attck rates
An attack rate is an incidence rate that identifies the number of people at risk who
become ill

No: of persons affected × 100

No: of persons eating food item

No: of persons affected × 100

No: of persons not eating food item

For example : In studying a food borne disease outbreak the attack rates for persons who
had certain foods were compared to those persons who did not have certain foods.This is
done in an attempt toidentify which food was infected by the causative agent
However identifying the causative agent is not only the step in preventing further spread
of the disease.Knowing the agent assists in treating the ill individuals who seek medical
help but does not tell how the disease is being transmitted.The chain of transmission must
be broken to stop the spread of the disease.Since one factor alone does not cause any
disease,it is not sufficient toidentify just the causative agent.After the possible agents and
attack groups have been identified,the common sources to which the affected individuals
were exposed and the environment should be investigated.
For example : with food borne disease the origin,method of preparation,sanitary
conditions of the restuarent, area were food was supplied, water supply etc are to be
assessed.

STEP IV :PLAN FOR CONTROL

When planning for control,it is essential to identify the preventive measures based on the
knowledge of natural history of disease.Host-agent-environment factors should be
analysed to determine the following:
 Population at risk
 Primary ,secondary and tertiary methods of prevention that are available
 Feasibility of implementing the control plan considering factors such as
available community resources,time and cost,supplies and personnel
 Significance of the problem related to thecommunity needs
Control measures are directed towards breaking the chain of transmission.This includes
destroying the reseviour,interrupting the transmission of the agent or decreasing the
ability of the agent
Community health nurses are instrumental in helping the public to see the need for
effective control of the disease through effective control of disease through active
immunization.The community health nurse must identify the population at risk and
immunize them against communicable disease
Casefinding is the process which focuses on early diagnosis and treatment of nwly
detectedcases of a disease.Careful record keeping assists the epidemiologist to quickly
spot changing trends in diseases or conditions

STEP V: IMPLEMENT CONTROL PLAN

An active effort should be made to elicit and coordinate the cooperation of the lay public
as well as private and official agencies,when control measures are put into action.A
control programme that takes into consideration the beliefs attitudes and customs of the
community is more likely to be accepted by the public than one that ignores community
norm.
There may be many barriers to the successful implementation of the
control plan. Barriers to control involve factors such as unknown etiology, no known
treatment unavailable community resources lack of reporting etc. an individual without
disease symptoms but who harbors the disease organism is called the carriers. Individuals
for whom the diagnosis is not suspected or confirmed are also barriers to control of the
disease.
STEP VI : EVALUATE CONTROL PLAN
Evaluation ensures that an epidemiological process can be improve the next time it is
repeated. The first step in evaluation is to determine how well the objectives were
achieved. The next question to be answered is how the current situation compares to the
situations before the investigation. Finally the practicality of the control measures should
be determined. Feasibility and cause in terms of money time staff facilities and
community support should be analysed
STEP VII : MAKE APPROPRITE REPORT
 Prompt accurate and concised epidermiological reporting provide a
basis for future investigations and controlled measures. Reporting should include what
was involved in the epidermiological process diagnosis, factors leading to epidermic,
control measures and recommendations for preventing similar situations
Accurate reporting is essential for the identification of the major
community health problems and preventive health actions is necessary. But for many
reasons underreporting of epidermiological investigations occur . completion of
necessary forms may be tedious and time consuming and therefore neglected. There may
be no one person assigned the responsibility for completion of the reports so
responsibility is overlooked. Usually more effective reporting occurs when one person is
designated to report activities

STEP VIII : CONDUCT RESEARCH

If health services to the population are to be improved,epidemiological research is
essential.Health professionals must be prepared to collect and analyse data
systematically so that gaps in knowledge relative to disease causation.prevention and
control are eliminated.it is unfortunate that research in the practice setting is often
lacking,and also it is quite exciting and challenging to know that it can really improve the
health status of the community.

EPIDEMIOLOGICAL TRIAD

Agent – etiological factor

Host – particular group or individual of immediate concern
Environment – all that is external to the agent and human host
Any particular disease is the result of the interaction between agent,host and the
environment.

AGENT
An agent is a factor whose presence or absence causes a disease.It is a specific factor
without which a disease cannot occur.
The disease agents are classified as follows:
 Physical agents : it includes various mechanical forces,friction as well as
atmospheric abnormalities such as extremes of heat,cold,humidity,pressure etc
 Biological agents : includes all living organisms such as bacteria,virus,fungi
 Chemical agents
a) Endogenous : some chemicals are produced in the body such as urea,
ketones, uric acid
b) Exogenous : arising out of the human host like allergans,metals,gases
 Genetic agents : transmitted from parent to child
 Nutrition agents: include specific dieary components that are
neede to survive like proteins,fats and excess or deficiencies
may cause malnutrition
 Absence or insufficiencies or excess of factors
Chemical hormones – insulin
Nutrients
 Chromosomes
HOST
Host refers to humans or animalks that come in contact with the agent.host factors
influence the interaction with the agent and the environment as follows :
a) Age : certain diseases are most common in some age groups than others like
childhood – measeles and oldage – atherosclerosis
b) Sex
c) Race : some disease are specifically present in certain races
d) Habits : lifestyle habits and dietary patterns of individual such as use of tobacco,
alcohol
e) Nutrition : poor nutrition increases susceptibility to infections
f) Customs : certain traditional systems like superstitions lead to diseases
g) Immunity : the reaction of human host to different infections will depend on his
previous immunologic experiences
h) Social status : certain diseases like TB are more prevalent in low socio economic
status
i) Economic status
j) Educational status

ENVIRONMENT
The environment refers to the aggregate of all the external conditions that
influence the life and development of the organism
 Physical environment :it includes the non living things and physical
factors such as water, air, soil,heat,climate
 Biologic environment : it involves all the living things created in the world
including the bacteria,virus etc
 Social envirionment : man is a social animal and should follw the accepted
patterns of society such aschabits, beliefs, customs
 Economic environment : man and economic factors may at at times be a
factor of disease

MULTIPLE CAUSATION OF DISEASE

This concept considers that effect never depends on on single isolated
cause but rather develop as a result of chain of causes. The multiple
causation approach is based on the idea that effects of disease are not
results of several improvements and significant factors acting together.

EPIDEMIOLOGICAL STUDIES
Epidemiological approaches to relationship fall into two broad categories:
 Observational bstudies – the amount and distribution of disease
within a population by person, plce and time are noted
 Experimental studies – the investigator intervenes and actually
changes one variable and observes what happens to other,the
investigator controls the condition
TYPES OF EPIDEMIOLOGICAL STUDIES
Epidemiological
studies

observational experimental

Prophylactic or Therapeutic or
descriptive analytical
clinical trials community trials

Retrospective Prospective
(case control) (cohort study)

OBSERVATIONAL STUDIES
Observational studies fall under two classifications:
Descriptive epidemiology
Analytical epidemiology

Descriptive epidemiology : it is the study of the amount and distribution of disease and
health status within the population by person, place and time.it usually involves
determination of incidences,prevalences and mortality rates for disease in large
population groups according to characterstics such as age, sex, race etc
It is the study of factors responsible for distribution of health and disease inhuman
population such as age, sex, social status, income, occupation etc

For example
Emergency medicine in Paarl, South Africa: a cross-sectional descriptive study
A study conducted by Hanewinckel R, Jongman HP, Wallis LA, Mulligan TM.

Abstract

BACKGROUND: Emergency Medicine (EM) in South Africa is in its earliest stages of

development. There is a paucity of data about emergency department (ED) patient
demographics, epidemiology, consultation and admission criteria and other
characteristics.

AIMS: This information is absolutely necessary to properly guide the development of EM

and appropriate emergency care systems. In order to provide this information, we
performed a study in a rural hospital in Paarl, 60 km outside Cape Town.
CONCLUSION: This descriptive epidemiological study provides necessary data that will
be used for further needs assessments and for future EM development in Paarl, and can
be used as a template in other EDs and hospitals to provide similar data necessary for
initial EM development strategy.

Analytical epidemiology
Analytical epidemiology is concerned with searching for the underlying causes.its main
purposes are to uncover the source and mode of spread of disease.here the
epidemiologists seeks to determine the multiple factors that brought the disease
situation .the clue about origin, nature and size of the problem is discovered.
Data derived from descriptive studies often provide clues or findings about a problem
that leads an investigator to make guesses or formulate hypotheses for further study.
These ypothesses are tested by analytical methods.The study focuses on the determinant
of or reasons for relatively high or low frequencies of disease in specific groups.The
methos analytical study commonly employed for testing epidemiological hypothesis are :
Retrospective method (backward survey)
Prospective survey (forward survey)

Retrospective method (backward survey)

It is a backward survey. It is economic and time saving study.This type of sudy starts
from diagnosed cases who are easily available in the hospitals.Retrospective methods are
often called Case control study because it compares the cases and control with regard to
presence of some elements in their past experiences.This method compares a group of
people who have diagnosed with a problem (cases) with a group who free of that
particular problem(control).This method is retrospective because the researcher looks
backward at the history of the cause.For example : the cause of lung cancer is smoking
,here the investigator looks backward at the history of smoking in both the groups.In this
the researcher looks backward to see if a disease or a condition is precede by a particular
event
ADVANTAGES
Inexpensive
Easily repeated
Can study as many characterstics as possible
DISADVANTAGES
Investigator has to depend for information either on individuals memory or some
available records

Example :A retrospective epidemiological study of bacterial meningitis

in an urban area in Belgium
Abstract
In order to obtain epidemiological data on the incidence of bacterial meningitis (BM) before the
systematic introduction of vaccination against Haemophilus influenzae type b, a retrospective
study of 124 children with proven BM was performed in an urban area in Belgium. N.
meningitidis was the most prevalent cause, followed by H. influenzae and S. pneumoniae. Over a
period of 6 years the incidence of BM increased ten fold, mainly due to an increase in N.
meningitidis. The median age of the children with BM was 17 months and 35% of those with H.
influenzae were younger than 1 year. Significant risk factors for BM as a whole were: age under 1
year, male gender, non-Caucasian descent and winter time. These findings may have implications
for future vaccination policy in Belgium.
Conclusion Future vaccination schemes in Belgium should take into account that N.
meningitis was the prevalent cause of bacterial meningitis and that certain factors increase the
risk for developing bacterial meningitis.

PROSPECTIVE
It is a forward study in which the host, agent, and environmental factors are studied.the
study is planned in a population group in which frequency and distribution of a disease is
to be studied.A prospective method is also called cohort study.The cohort is a specific
group of people at a certain time.The study begins with aa disease or a condition and
watches it over a period of time to see what develops.The prospective method helps to
make estimation about the risk of developing particular condition in presence of certain
charcterstics,two kinds of risk are measured:
Relative risk is the ratio between the incidence or mortality among exposed to the
incidence or mortality among non exposed
Relative risk = incidence among exposed
An attributed risk is the rate of the disease in the exposed individuals that can be
attributed to suspected cause

Example :
EXPERIMENTAL STUDIES
In experimental studies the researcher intervenes and changes one variable and observes
what happens to the others.In this method the conditions are under the careful control of
the investigator.Experimental studies are taken to confirm an etiological hypothesis or to
assess the effectiveness of a therapeutic agent before applying them to community.These
studies may be conducted in laboratory or fieldsThe basic principles involved in the
experimental epidemiology includes:
Random allocation of subjects to appropriate sub groups :in this two groups are
formed one the experimental or study group which receives a intervention and a
control group which receives no treatment
Medical, ethical and moral issues : these are observed while conducting
experiments particularly on human beings
Ability to generalize : if the experiment is conducted on a represetntative sample
of the toytal population it is possible to make generalization
Double blindedness : in a double blinded study neither the investigator nor the
subjects know who receives the study treatment and who receives the control
treatment.The outcome is measured in such a way that the type of treatment is not
known.Thus no bias is introduced
TYPES:
Prophylactic or clinical types : this type is designed to prevent a disease in which
the efficiency of the therapeutic or preventive agent is tested in individual
subjects
Example: administration of BCG vaccine as prophylaxis for TB
Community trials this type is designed to treat a established disease process in
which a group of individuals as a whole is used to ddtermine the efficiency of a
drug or procedure
Example:the evaluation of flurides in preventing dental caries

STATISTICAL DATA
Staistical data of malarial epidemiology on world
Increased risk of malarial andemic in areas of central and south America, Africa
and tropical regions of asia
Major cause of infant death in tropical regions of world
Malaria is the most common cause of fever in trvellers returning fron foreign
countries
Incidence
Worldwide estimate of 300 – 500 million cases of malaria occurring annually
1.5 – 3 million children die
- WHO
Malaria in india
Malaria kills nearly 2 lakh people in india every year including 80000 children
below 15 years