Family and community medicine

Epidemiological Models
(Descriptive Epidemiology)

Assist. Prof. Dr. Nawar Sahib Khalil

Lecture Objectives: At the end of the lecture, the students are expected to

• Identify the method of studying of disease in community.

• Recognize the main models in epidemiology.
• Identifying the basic elements of Epidemiological model (Descriptive
epidemiology).
• Understand the importance of epidemiological models in description
of health related events.

Study the disease or any health event in community

Descriptive epidemiology: Examine the distribution of the disease or

health event in a population, and observing the basic features of its
distribution in term of Person, Place and Time that called the basic triad of
descriptive epidemiology.

Descriptive epidemiology:

Person

Time Place

Descriptive epidemiology is the starting point to formulate the

hypothesis for better understanding any disease or a health event. It asks
around: What is the problem and its frequency, who is involved, where, and
when?

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First: Person

In descriptive epidemiology, we organize or analyze data by person

characteristics. There are several person categories available. We may use
inherent characteristics of people (age, race, sex), their acquired
characteristics (immune or marital status), their activities (occupation,
leisure activities, use of medications/ tobacco/ drugs), or the conditions
under which they live (socioeconomic status, access to medical care). These
categories determine to a large degree who is at greatest risk of experiencing
some undesirable health conditions, such as becoming infected with a
particular disease organism.

Person categories

Age
Sex
Ethnicity,
Socio-economic
Occupation
Habits
Others

Age:
Age is probably the single most important person attributes, due to that
almost every health-related event or state varies with age. A number of
factors that also vary with age are behind this association (Explanation of
disease variation by age): susceptibility or degree of immunity, opportunity
for exposure for risk factors, latency or incubation period of the disease, and
physiologic response to causative agent (which affects among other things,
the disease development).

The person’s age affect for example;

1. Type of disease:
• In neonate: Congenital anomalies, and birth trauma.
• In elderly: Degenerative diseases, Cardiovascular disease (CVD).

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 2. Severity of disease:
• Whooping cough is severe under one year.
• Pneumonia is fatal in early two months of life.
• Fracture is severe in persons with old age.

3. Clinical form of disease:

• Thyroxin deficiency cause Cretinism in young, whereas it cause
Myxedema in adults
• TB is Miliary in children, and it is Pulmonary in adults.

50
Reported cases per 100,000 population

45

40

35

30

25

20

15

10

0
<1 1_4 5_9 10_14 15_19 20+
Age group (years)

Figure: Distribution of X disease according to age

Sex:

Some diseases are sex-linked due to anatomic differences like cancer of

cervix, cancer of prostate or genetic differences between the sexes e.g.
Haemophilia.

Other diseases are related to occupations and environmental exposure

which differ in both sexes, like accidents and lung diseases.
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 In general, males have higher rates of illness and death than females do
for a wide range of diseases. For some diseases, this sex-related difference
is because of inherent differences added to hormonal and anatomical
differences between the sexes. These inherent differences affect their
susceptibility or physiologic responses

For example, pre-menopausal women have a lower risk of heart disease

than men of the same age. This difference is attributed to higher estrogen
levels in women. On the other hand the sex-related differences in the
occurrence of many diseases reflect differences in opportunity or levels of
exposure.

Figure below shows that hand/ wrist disorders occur almost twice as
often in females than in males.

16
14
12
% Prevalence

10
8
6
4
2
0
Male Female
Sex

Figure: Prevalence of hand/ wrist cumulative trauma disorder by sex

What are some sex-related differences that would cause a higher level of this
disorder in females?

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Ethnic and racial groups

While examining epidemiologic data, we are interested in “any group

of people who have lived together long enough to acquire common
characteristics, either biologically or socially”. Several terms are
commonly used to identify such groups; race, nationality, religion, or local
reproductive or social groups, such as tribes and other geographically or
socially isolated groups.

Differences that we observe in racial ethnic or other groups may reflect

differences in their susceptibility or in their exposure, or they may reflect
differences in other factors that bear more directly on the risk of disease,
such as socioeconomic status and access to health care.

Some races are susceptible to specific diseases e.g. sickle cell anemia in
Negros due to genetic predisposition. Some races got immunity due to long
exposure.

In the following figure, the rates of suicide for five groups of people are
revealed.

30
Suside deaths per 100,000

25

20
population

15

10

0
American Asian/ Pacific Black Haspanic White
Indian/ Islander
Alaskan
Native
Race/ Ethnicity

Figure: Suicide death rates for persons 15-24 years of age according to
race/ ethnicity, United State, 1988

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Familiar tendency:

Clustering of some diseases within certain families may be due to

Genetic factors, or common exposure to the same dietetic, social,
psychological and environmental influences.

Religion:

Religion usually determines the behavior of its followers;

• Prohibition of alcohol and liver disease.

• Male circumcision and cancer cervix.

Socio-economic status:

Socioeconomic status is difficult to quantify. It is made up of many

variables such as occupation, family income, educational achievement,
living conditions, and social standing. The variables that are easiest to
measure may not reflect the overall concept. Nevertheless, we commonly
use occupation, family income, and educational achievement, while
recognizing that these do not measure socioeconomic status precisely.

The frequency of many adverse health conditions increases with

decreasing socioeconomic status;

For example, tuberculosis is more common among persons in lower

socioeconomic strata. Infant mortality and time lost from work due to
disability both associated with lower income. This pattern may reflect more
harmful exposures, lower resistance, and less access to health care, or they
may in part reflect an interdependent relationship which is impossible to
untangle, “Does low socioeconomic status contribute to disability? or Does
disability contribute to lower socioeconomic status ? ”

Contrarily, some adverse health conditions are more frequent among

persons of higher socioeconomic status. These conditions include breast
cancer, Kawasaki syndrome, and tennis elbow.

As a summary, socio-economic status is measured by;

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 • Education - health behavior
• Occupation - income
• Family income----environmental condition, housing conditions,
access to health facilities.

Occupation

Determine the occupational exposure to certain risk factors in work

place. In addition, occupation is also one of the determinants of
socioeconomic class which affects the disease occurrence (nutritional
diseases, filth diseases).

Second: Place

The description of health event by place is to gain insight into the

geographical extent of the problem. We may use place of residence,
birthplace, place of employment, school district, hospital unit, etc.,
depending on which may be related to the occurrence of the health event.

Similarly, we may use large or small geographic units: country, state,

county, census tract, street address, map coordinates, or some other standard
geographical designations. Sometimes, we may find it useful to analyze data
according to place categories such as urban or rural, south vs. north,
domestic or foreign and institutional or non-institutional.

By analyzing data by place, we can also get an idea of where the agent
that causes a disease normally lives and multiplies, what may carry transmit
it, and how it spreads (use spot map to locate the possible source or risk
factors). When we find that the occurrence of a disease is associated with a
place, we can infer that factors that increase the risk of the disease are
present either in the persons living there (host factors) or in the
environment, or both.

As an example, diseases that are passed from one person to another

spread more rapidly in urban areas than in rural ones, mainly because the

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greater crowding in urban areas provides more opportunities for susceptible
people to come into contact with someone who is infected. On the other
hand, diseases that are passed from animals to humans often occur in greater
numbers in rural and suburban areas because people in those areas are more
likely to come into contact with disease carrying animals.

Some criteria of place element:

• Increased rate observed in all ethnic groups in the area.

• Increased rate NOT observed in persons of similar groups
inhabiting other areas.
• Healthy persons entering area get ill at same frequency.
• People who leave do NOT show similar levels.

Third: Time

Disease rates change over time. Some of these changes occur regularly
and can be predicted.

For example, the seasonal increase of influenza cases with the onset of
cold weather is a pattern that is familiar to everyone. By knowing when flu
outbreaks will occur, health departments can time their flu shot campaigns
effectively.

Other disease rates make unpredictable changes, by examining events

that precede a disease rate increase or decrease, we may identify causes and
appropriate actions could done to control or prevent further occurrence of
the disease.

Some consider time is a center of triangle attributed to that; most

infectious diseases have an incubation period “the time elapsed between
when the host is infected and when disease symptoms occur”, or 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.

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 Annual occurrence, seasonal occurrence, and daily or even hourly
occurrence of disease may occur.

Therefore, knowing time trend of a disease will help health

professionals to establish the control measures.

Time trend include:

Secular (long-term) trends:

Is a graphing the annual cases or rate of a disease over a period of years

(decades or centuries) shows long-term or secular trends in the occurrence of
the disease. We commonly use these trends to suggest or predict the future
incidence of a disease. We also use them in some instances to evaluate
programs or policy decisions, or to suggest what caused an increase or
decrease in the occurrence of a disease, particularly if the graph indicates
when related events took place.

Secular (Long-term trends) is influenced by population features e.g.

change of degree of susceptibility e.g. by immunization, socioeconomic
status, environmental sanitation and nutritional status of a population.

Periodic (cyclic variation)

Where disease occurrence for a period, then increase again in cyclic

pattern e.g. measles in pre vaccination era occur every 2-3 years.

Seasonality

By graphing the occurrence of a disease by week or month over the

course of a year or more, we can show its seasonal pattern. Some diseases
are known to have characteristic seasonal distributions, as aforementioned
example, the number of reported cases of influenza typically increases in
winter. On the other hand, food poisoning and diarrhea increase in summer.

Seasonal patterns may suggest hypotheses about; How the infection is

transmitted? What behavioral factors increase risk? and other possible
contributors to the disease or condition.
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 The figure below shows fatalities associated with farm tractor injuries
by day of the week, and by time of the day (Georgia 1971-81). What factors
might contribute to its seasonal pattern?

40
35
30
25
Deaths

20
15
10
5
0
Mon Tues Wed Thu Fri Sat Sun
Day of the week

Figure: Fatalities associated with farm tractor injuries by day of the

week

30

25

20
Deaths

15

10

0
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10am

11pm
7am

9am

11am
12pm

10pm

12am
8am

Hour of accident

Figure: Fatalities associated with farm tractor injuries by hour of day of

the week

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Rapid fluctuation (short time)

Usually occur in the form of point source epidemics, that appear

abruptly and ends abruptly either natural or due to intervention e.g. food
poisoning.

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