Epidemiology

Luz Barbara P. Dones, MPH,RN

Associate Professor
UP Manila College of Nursing
 Epidemiology: Etymology
• Literally means “the study of what is upon
the people”

epi • upon, among

demos • people, district

logos • study, word, discourse

 Epidemiology: Definition

Epidemiology is the study of the

distribution and determinants of
disease frequency in man
-MacMahon and Pugh, 1970
 Epidemiology: Definition
Epidemiology

Distribution of Search for

disease determinants

Explains patterns of disease

Describes health status in terms
of demographic profile factors related to place, person
“WHO?”
Characterized by measures of
disease frequency
IR, PR
“HOW MANY?”
distribution in terms of causal
and time
“WHO,WHAT, WHERE, WHEN ,
HOW”
Characterized by measures of
disease association
RRR, AR, OR
 • Girolamo
• Hippocrates – Fracastro
Father of (1543) – first to
promote
Epidemiology; personal and
One of the
earliest environmental
theories on hygiene
the origin of • Anton van
first person to disease was Leeuwenhoek
examine that it was 1675)-Germ
relationships primarily the Theory
between fault of
occurrence of human luxury
disease and Very small,
environmental unseeable particles
influences; • Plato that cause disease
coined the • Rosseau were alive and can
terms epidemic, be spread by air,
• Jonathan multiply by
endemic Swift themselves and
destroyable by fire
 Investigated
into the • Peter Anton
• John causes of Schleisner,1849,
Graunt, the19th prevention of neonatal
1662 century tetanus in Iceland
cholera • Ignaz Semmelweis, 1847
brought down infant
epidemics mortality in a Vienna
Used analysis and regarded hospital by instituting
of the as the disinfection procedure
mortality rolls founding • Joseph Lister, 1865,
in London event of the British surgeon discovered
before the antiseptics
Great Plague; science of
provided epidemiology
statistical Ronald Ross and Anderson
evidence for • Dr John Gray McKendrick introduced
many theories Snow, mathematical methods into
on disease 1854 epidemiology in the early 20th
century
 Epidemiology: Purposes

1. Elucidate causal mechanisms of disease.

a. Develop hypotheses that explain patterns
of disease distribution in terms of specific
human characteristics or experiences
b. Test such hypotheses through specially
designed studies
c. Test validity of concepts on which disease
control programs are based
d. Aid in classification of ill persons into groups that
appear to have etiologic factors in common
 Epidemiology: Purposes

2. Explaining local disease patterns.

3. Describing the natural history of disease.

4. Provide guidance in administering health

services.

5. Evaluate efficiency of interventions.

 Basic Epidemiologic Concepts

• Multiple Causation or Ecologic Concept of

Disease
– Agent, Host and Environment
– Models of Multiple Causation Theory (The Triangle,
The Web and The Wheel)
• Concept of Causal Association
– Necessary versus Sufficient Cause
– Types of Associations
• Natural History of Disease or Illness
• Levels of Disease Prevention
 Basic Epidemiologic Concepts:
Multiple Causation or Ecologic Concept of
Disease
Premises:

• Disease results from an imbalance between the

disease agent and man as the host
• The nature and extent of the imbalance depends
upon nature and characteristics of agent and
host
• The characteristics of agent and host and their
interaction are directly related to and largely
dependent on the nature of the environment.
 Multiple Causation Theory Person or other living
animal that affords
subsistence or lodging to
an infectious agent;
HOST characterized by
susceptibility and risk of
exposure to an agent
Inanimate objects
or living organisms Sum total of all
causing disease; external conditions
characterized in terms and influences that
of intensity, impact, affects life and
virulence, development of
excess/deficiency human individual or
organism

AGENT The Epidemiologic Triangle ENVIRONMENT

Model
Models of Multiple Causation Theory
The Wheel Model Genetic Make-up

Demographic
characteristics;
personal habits
and lifestyles

Physical, social,
economic,
cultural, political
environments
Models of Multiple Causation Theory
Poor
health
habits
Low
Poor housing
educational conditions
status

TB
Poor Bacilli Congestion
and
nutritional environmental
status pollution

Low socio-
Poor
economic environment
status
The Web Model
 Basic Epidemiologic Concepts:
Concept of Causal Association

Premises:

• Disease does not occur at random

• Disease has identifiable causal and

preventive factors
 Concept of Causal Association
Historical Development of Theories of Disease
Causation
Era Period Characteristic
Religious era 2000 – 600 Disease caused by divine
BC intervention, possibly as
punishment for sins or test of faith
Environmental 400 BC Disease caused by harmful
era miasma or mists or other
substances in the environment
Bacteriologic 1870 - 1900 Disease caused by specific
era bacteriologic or nutritive agents
Era of multiple 1900 to Disease caused by interaction of
causation present multiple factors
Concept of Causal Association

Cause of a Disease
A cause must precede
An event, condition, a disease.
characteristic or a
combination of these
factors that plays an
important role in
producing a disease Cause Disease
Concept of Causal Association

The cause of a disease must be necessary and

sufficient for the occurrence of disease (Henle-
Koch Postulate)
Sufficient cause indicates
Necessary cause refers that if a factor is present,
to the fact that the factor the disease CAN occur;
MUST be present for the but the factor’s presence
disease to occur. does not ALWAYS result
in the disease’s
occurrence
Concept of Causal Association

Association – concurrence of two variables

more often than would be expected by
chance; does not necessary imply a
causal relationship
 Concept of Causal Association
Bradford-Hill Criteria for assessing evidence
of causation (1965)
• A small association does not mean
that there is NOT a causal effect,
Strength though the larger the association, the
more likely that it is casual.
• Consistent findings observed by
different persons in different places
Consistency with different samples strengthens
likelihood of an effect

• A single putative cause produces a

Specificity specific effect
 Concept of Causal Association
Bradford-Hill Criteria for assessing evidence
of causation (1965)
• The effect has to occur after the cause
(and if there is an expected delay
Temporality
between the cause and expected effect,
then the effect must occur after that delay.

• Greater exposure should generally lead to

Biologic greater incidence of the effect; mere
gradient (dose-
response presence of factor triggers effect; in some
relationship) cases, greater exposure leads to lower
incidence

Plausibility • Association agrees with currently

accepted pathological processes
 Concept of Causal Association
Bradford-Hill Criteria for assessing evidence
of causation (1965)
• Coherence between epidemiological
Coherence and laboratory findings increases the
likelihood of effect

• Condition can be altered (prevented

Experiment or ameliorated) by an appropriate
experimental regimen

• Consider other possible explanations

Analogy that will produce the same effect
 Concept of Causal Association:
Types of Association
1. Spurious or artifactual – association when
none really exists
Example:
Perinatal Mortality in Hospital and Home Deliveries
Type of Delivery N Perinatal Mortality
(per 1000
live births)
Home delivery 5714 5.4/1000 live births
Hospital delivery 11156 27.5/1000 live births
Concept of Causal Association:
Types of Association
2. Indirect – presence of a known or unknown
factor common to both a characteristic and a
disease may wholly or partly explain a statistical
association.

A B C
Paternal Age Maternal Age Infant’s Birth
Weight
Concept of Causal Association:
Types of Association
3. Direct or causal Example:

a. one to one Tonsillitis

causal – suggests
that when one factor
Hemolytic Scarlet
is present, disease Streptococci Fever
results; conversely,
Erysipelas
when the disease is
present, the factor
must also be present
Concept of Causal Association:
Types of Association
b. multifactorial causation – several factors
acting independently or synergistically can
produce a disease
Example:

Smoking
Reaction at
Air Pollution Cellular Cancer
Level
Exposure to
asbestos
Concept of Causal Association:
Types of Association

Malnutrition
+
Crowded Reaction
housing at Cholera
+ Cellular
Exposure to Level
contaminated
water
Concept of Causal Association

RISK refers to the probability of an

unfavorable event

Risk to an individual developing a disease due to

a particular exposure is derived by comparing
the occurrence of a disease in a population
exposed to the causal agent to the occurrence
of disease in a non-exposed population.
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease
Relative Risk Ratio (RRR)
• Direct measure or index of the strength of association
between a suspected cause and effect
• Is the ratio of the incidence of the disease among the
exposed population and incidence of the disease among
the non-exposed population
• Interpreted as: RR = 1 no association
RR > 1 positive association; exposure is
a risk factor
RR < 1 exposure is a protective factor
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease
Relationship between History of Child Abuse
and Mental Illness

Child Abuse History Incidence Rate of

(Exposure Factor) Mental Illness (per
100,000 population)
Positive 227/100,000
Negative 7/100,000

227
RRR = ----- = 32 The risk of mental illness among abused children is
7 32 times higher compared to children who do not
have child abuse history.
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease
Attributable Risk (AR)
• Provides information about absolute effect of
the exposure or the excess risk of the disease to
a causal agent
• Gives a better idea than the RRR of the impact
of successful preventive or public health
program might have in reducing the problem
• Is the difference in the incidence rates of
disease between exposed and non-exposed
population
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease
Prenatal Clinic Visits and Maternal Complications

Attendance to Regular Pre- Incidence Rate of Maternal

Natal Clinic Visits Complications (per 10,000
live births)
Positive 53/10,000 live births
Negative 798/10,000 live births

AR = 53/10,000 – 798/10,000 = 745 excess cases of maternal

complications can be attributed to
non-attendance of regular prenatal
clinic visits
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease
Odds Ratio (OR)
• Closely related to relative risk ratio
• Compares cases and controls with respect to
the frequency of an exposure whose potential
etiologic role is being evaluated
• Derivation is based on three assumptions:
• Disease being investigated must be relatively RARE
• CASES must be representative of those with the disease
• CONTROLS must be representative of those without the
disease
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease

Disease Status
Exposure Factor With Disease Without Disease
Exposed a b
Not exposed c d

OR = ad / bc
Concept of Causal Association:
Measures of Association between Exposure to
and Risk of Disease
Tonsillectomy and Development of Hodgkin’s Disease
Prior Cases Controls Total
Tonsillectomy
YES 67 (a) 43 (b) 110
NO 34 (c) 64 (d) 98
UNKNOWN 8 2 10
Total 109 109 218
Ignoring the unknowns, the Odds Ratio from the formula
ad/bc= (67) (64)/(43) (34) = 2.9

Interpretation: The relative risk of developing Hodgkin’s

Disease was about three times greater for those with prior
tonsillectomy than for persons with intact tonsils.
 Natural History of Disease and Levels of
Disease Prevention
Interaction of the
Agent, Host and Disease
the Environment stimulus
PREPATHOGENESIS
Primary Prevention
Promotes health and wellness and
prevents disease in the population
1. Health Promotion – efforts to
improve the quality of life and
enhance the level of physical
and mental health
2. Specific Protection – specific
procedures of disease
prevention
Reaction of the Host
Early signs Discernible Advanced
and lesions illness Convalescence
Symptoms
P A T H O G E N E S I S
Secondary Prevention Tertiary Prevention
Halts the progress of a disease at Prevents potential consequences of
its incipient stage and prevents disease
complications
1. Early Diagnosis 1. Disability Limitation
- case finding measures
(individual and mass) 2. Rehabilitation
- screening surveys
- periodic examination
- selective examination of people
at high risk
2. Treatment and Disease Control
The Phases of the Epidemiologic Approach
Descriptive Epidemiology
Concerned with disease distribution and frequency;
who, where and when

Analytical Epidemiology
Attempts to analyze the causes or determinants of disease
through hypothesis-testing; how is the disease caused and
why is it continuing

Intervention or Experimental Epidemiology

Answers questions about the effectiveness of new methods for
controlling diseases or for improving underlying conditions

Evaluation Epidemiology
Attempts to measure the effectiveness of different
health services and intervention programs
Strategies of Epidemiology
Descriptive
Studies
Ecologic studies; Case reports;
Case series; Cross sectional
studies
Generate
Modify hypothesis
hypothesis

Experimental
Analytic Studies
Studies
Cohort studies;
Laboratory experiments;
Case-control studies
Clinical trials; Community
trials

Test of Hypothesis
Descriptive Epidemiology
Disease or condition need to be
recognized with reasonable certainty
1. Observation and through SCREENING.
recording of existing
patterns of disease Screening – is the presumptive
identification of unrecognized
occurrence for the disease or defect by the application
condition under study of tests, examinations or other
procedures that can be applied
2. Description of the rapidly and inexpensively to
disease or condition as populations.
to person, place or time
• Mass screening – applied
unselectively to entire population or
3. Analysis of the general selectively to high risk groups
• Casefinding – search for previously
pattern of occurrence of unidentified cases of diseases
the disease or condition • Multiphasic screening – using
variety of screening tests on the
same occasion
Descriptive Epidemiology
Screening tests and procedures are applied to
detect people with risk factors or sub-clinical
disease; thus, consider the following factors:

Sensitivity – is the proportion of persons with

disease who test positive on a screening test;
the probability of the test correctly identifying a
case.

Specificity – is the proportion of persons without

disease who have negative results on a
screening test; the probability of correctly
identifying non-cases.
Descriptive Epidemiology

Distribution of Disease Status and

Screening Test Results in a Population
Screening Test True Diagnosis Total
Result Diseased Not Diseased
Positive True Positive False Positive TP + FP

Negative False Negative True Negative FN + TN

Sensitivity = Specificity =
TP TN
---------------------- --------------------
TP + FN TN + FP
 Descriptive Epidemiology
In a study done in Hospital X in 1998, information was collected on the
heights of 622 women who did or did not require Caesarean Section
(CS) for Cephalopelvic Disproportion (CPD). The results are shown
below:

Screening Test Will develop CPD, Will not develop

thus will require CPD, thus will not
CS require CS
Height of 146 cm 19 182
or less
Height over 146 2 419
cm
Descriptive Epidemiology
1. Observation and Characteristic of Person
recording of existing • described in terms of
patterns of disease susceptibility or resistance
occurrence for the against an agent of disease;
condition under study • depends on demographic,
genetic/hereditary and socio-
economic variables
2. Description of the
disease or condition as Factors that determine reaction of a
to person, place or time community or population to
disease invasion:
• Herd immunity
3. Analysis of the general • Exposure or contact rate
pattern of occurrence of • Chance
the disease or condition
Descriptive Epidemiology
Herd immunity – state of resistance of a population group to
a particular disease at a given time and is
determined by the immunity and
susceptibility levels of individuals

Types of community reaction against disease invasion:

• Epidemic – marked upward fluctuation in disease incidence

• Endemic – implies habitual presence of a disease or agent
of disease within a given area
• Sporadic – implies occurrence of a few cases every now
and then in a given geographic area
• Pandemic – global or worldwide epidemic
Descriptive Epidemiology
Exposure or Contact Rate – represents opportunities for
progressive transfer or
transmission of an infectious
agent to a new host

Probability of transfer depends on:

• size of the reservoir
• frequency of contact
• population density
• standard of hygiene
• vector density
Descriptive Epidemiology

Chance – is the probability of contact between the source

of infection and the susceptible individual and
depends on:

- the number of sources of infection

- the location of the source of infection
- the number of immunes
 Descriptive Epidemiology
Characteristics of Time
• described in terms of an
epidemic curve or attack
curve
Epidemic or Attack Curve is
a graphical presentation of
the distribution of cases by
date or time of onset
• Short-time fluctuation
• Cyclic variation
• Secular variation
Short-time fluctuations – changes
in disease frequency in very
short time; of two types:
1. Common source or point-
source epidemic –
characterized by simultaneous
exposure of a large number of
susceptible to a common
infectious agent
2. Propagated epidemic –
caused by person to person
transmission of disease agent
Descriptive Epidemiology
Cyclic Variation – refers to Characteristics of Place –
recurrent fluctuations of demonstration of
disease frequency which association of disease
may exhibit cycles lasting with place implies:
for certain periods • That the inhabitants of the
place possess characteristics
of etiologic importance
Secular Variation – refers different from people of other
to changes in disease place
frequency over a period • That the etiologic factors are
of many years present in the biologic,
chemical, physical or social
environments of the people
inhabiting that place
Analytical Epidemiology

• Done for the purpose of systematically

determining whether or not the risk of
disease is different for individuals exposed
or not exposed to a factor of interest

• Of two types:
• Observational – cohort , case-control
• Experimental – Randomized control trials
Cohort Study: Follow-up or incidence study

Disease
Exposed

No Disease

POPULATION
Disease

Not exposed

No Disease

Measure of Disease Frequency: Incidence Rate

Measures of Disease Association: RRR, OR, AR
 Case-Control Study

Exposed

Case

Not exposed
POPULATION
Exposed

Control
Not exposed

Measure of Disease Frequency: Cannot be computed

Measure of Disease Association: OR
 Cross-Sectional Study

Exposed, Diseased

Exposed, No Disease

POPULATION
No exposure, Diseased

No exposure, No Disease

Measure of Disease Frequency : Prevalence Rate

Measures of Disease Association: RRR, AR, OR