Part-II: 16 Aug 2023 Dr Kalyani Addya

EPIDEMIOLOGY KEY TERMS

• Epidemic or Outbreak: disease occurrence among a population that

is in excess of what is expected in a given time and place.
• Cluster: group of cases in a specific time and place that might be
more than expected.
• Endemic: disease or condition present among a population at all
times.
• Pandemic: a disease or condition that spreads across regions.
 EPIDEMIOLOGY KEY TERMS

▪ Contamination
➢ The presence of an infectious agent on a body surface, on or in
clothes, beddings, toys, surgical instruments or dressings, or
other articles or substances including water and food

▪ Infestation
➢ It is the lodgment, development and reproduction of arthropods
on the surface of the body or in the clothing, e.g. lice, itch mite,
invasion of gut by parasites e.g. round worms.

▪ Contagious Disease
➢ A contagious disease is the one that is transmitted through
contact e,g. scabies, trachoma, sexually transmitted disease
and leprosy.
 INFECTION

• Definition of Infection.
➢ Infection is the entry and development or multiplication of an
infectious agent in the body of man or animals.
➢ An infection does not always cause illness.
➢ Gradients of infection:
✓ Colonization (S. Aureus in skin and normal nasopharynx)
✓ Subclinical or inapparent infection (Polio)
✓ Latent infection (Herpes Simplex)
✓ Manifest or clinical infection
 TYPES OF CASES

▪ Case
➢ Defined as “a person in the population or study group identified
as having the particular disease, health disorder, or condition
under investigation”
▪ Confirmed Case
➢ Meets the clinical description and criteria for laboratory
confirmation
➢ Classified as definitive for surveillance purposes and is
laboratory confirmed by one or more tests
➢ May fulfill the described clinical case definition or not.
➢ If testing is unavailable or limited, confirmed case counts will
not reflect the true burden of disease
 TYPES OF CASES

▪ Probable Case.
➢ Refers to an individual displaying clinical signs and symptoms
consistent with a specific disease or condition and meets
certain criteria outlined.
➢ Might not have undergone confirmatory laboratory testing or
may have inconclusive test results
▪ Possible Case.
➢ Refers to an individual exhibiting signs and symptoms that
could potentially indicate a particular disease or condition, but
who does not meet all the specific criteria required for a
definitive diagnosis according to a given case definition.
➢ Often categorized when there is uncertainty about the presence
of certain diagnostic factors, or when additional information or
testing is needed to confirm or rule out the disease.
 TYPES OF CASES

▪ Laboratory Case.
➢ Refers to an individual classified as having a particular disease
or condition based primarily on the results of laboratory
testing.
➢ Timing of the test in relation to symptom onset is important.
➢ Plays a crucial role in disease surveillance, outbreak
investigations, and research.
➢ Examples:- HIV, Tuberculosis, Influenza, COVID-19, etc
 TOOLS TO MEASURE DISEASE FREQUENCY

➢ Count
➢ Proportion
➢ Ratio
➢ Rate
➢ Incidence
➢ Prevalence
Note:- All functions of numerators (cases) and denominator
(population at risk or those at risk but disease free)
 COUNT

➢ Simplest and most frequently performed quantitative measure

➢ Refers to the number of cases of disease or other health related

phenomenon

➢ Occurrence of a single or a few cases regardless of the size of the

population at risk

➢ Enough to initiate a public health response

 PROPORTION

➢ A proportion is a fraction in which the numerator is a part of the

denominator

➢ Usually expressed as a percentage

Number of Students with Jaundice
Total Number of Students
 RATIO

➢ A Ratio is a fraction in which there may be no specified relation

between the numerator and denominator

➢ Examples

✓ Ratio between number of males who had jaundice and number of

females who had jaundice

✓ Doctor – Population Ratio

✓ Sex Ratio
 RATE

➢ Rate is number of cases occurring during a specific period;

➢ Dependent on the size of the population during that period

➢ Calculated to determine the frequency of disease which includes:-

✓ The number of cases of the illness

✓ The size of the population at risk

✓ The period during which the rate is calculated

Rate % = Number of Cases x 100

Population at Risk
 MORTALITY MEASURES

➢ Crude Death Rates

➢ Specific Death Rates

➢ Case Fatality Ratio

➢ Proportional Mortality Ratio

➢ Survival Rate
 CRUDE DEATH RATE

➢ Number of deaths in one year per 1000 estimated mid year

population in a given place

➢ Summarizes

✓ Age composition of the population

✓ Age specific death rates

✓ Lacks Comparability

✓ Able to portray mortality in a single figure

✓ Useful in demography
 SPECIFIC DEATH RATES

➢ Cause or Disease Specific

✓ Tuberculosis

✓ Cancer

✓ Accidents

➢ Group Specific

✓Age

✓Gender
 CASE FATALITY RATIO (CFR)

➢ Total number of Deaths due to a particular disease x 100

Total number of Cases of the disease
➢ Represents the killing power of the disease
➢ Typically used in acute infectious diseases
➢ Is closely related to virulence
➢ May change because of changes in the:-
✓ Agent
✓ Host
✓ Environment
 PROPORTIONAL MORTALITY RATIO

➢ For a Specific Disease

Number of deaths due to a specific disease x 100
Total number of deaths from all causes
✓ Infectious diseases / Vaccine preventable diseases
✓ Non Communicable diseases
➢ For a Specific Group
Number of deaths below five years of age x 100
Total number of deaths
✓ Population groups
✓ Different periods of time
 SURVIVAL RATE

➢ Is the proportion of survivors among a group of patients followed

up over a period of time
➢ Used as a yardstick for assessment of therapy
➢ Used specifically in malignancies

Total number of patients alive after 5 years x 100

Total number of patients of the disease
 MEASURES OF MORBIDITY

➢ Describes the magnitude and characteristics of the disease load

➢ Clinically more relevant than mortality data
➢ Essential for research on disease etiology
➢ Useful for prioritizing and monitoring health care activities
➢ Incidence
✓ Attack Rate
✓ Secondary Attack Rate
➢ Prevalence
✓ Point
✓ Period
 INCIDENCE

➢ Number of new cases of a disease

✓ In a given population
✓ Over a specified period of time
➢ Describes the rate of development of disease
➢ Components
✓ Numerator: Number of new cases
✓ Denominator: Population at risk
✓ Time: Period during which the cases accrue
✓ Multiplier
 SPECIAL INCIDENCE RATES

➢ Attack Rate
✓ An incidence rate
✓ Result of a specific exposure
✓ Population observed for a short period of time
✓ Expressed as a percentage

➢ Secondary Attack Rate

✓ Percentage of exposed persons who develop the disease within
the incubation period following exposure to a primary case

Number of exposed persons developing

disease within the incubation period x 100
Total number of exposed susceptible
contacts
 SPECIAL INCIDENCE RATES

➢ Secondary Attack Rate

✓ Applied to infectious diseases where the primary case is
infective for a short period of time
✓ Susceptibles need to be clearly identified
✓ Difficult to calculate in diseases with a large proportion of sub –
clinical cases
✓ Useful in evaluating effectiveness of control measures
✓ Isolation
✓ Vaccination
 PREVALENCE

➢ Prevalence of a disease or condition in a population is defined as:

✓ The total number of cases (existing cases) of the disease in the

population at a given time

or

✓ The total number of cases in the population, divided by the

number of individuals in the population

➢ It is a proportion usually expressed as a percentage

 PREVALENCE AND INCIDENCE

➢ Prevalence is a function of incidence and duration of an illness

➢ P= ID

➢ I=P/D

➢ D=P/I

➢ P- Prevalence, I – Incidence , D - Duration

 INCIDENCE VS PREVALENCE

➢ Incidence

✓ Research into aetiology of disease

✓ Initiating control measures

✓ Checking efficacy of preventive or therapeutic measures

➢ Prevalence

✓ Useful for administrative and planning purposes

✓ Estimate the magnitude of disease in the community

 REPRODUCTIVE RATE OF INFECTION

➢ Potential for an infectious disease to spread.

➢ Factors include
✓ Probability of transmission between an infected and a
susceptible individual
✓ Frequency of population contact
✓ Duration of infection
✓ Virulence of the organism
✓ Immunity of the population
DYNAMICS OF DISEASE TRANSMISSION: CHAIN OF INFECTION

I II III

Source or Reservoir Modes of Transmission Susceptible Host

 ELEMENTS OF AN EPIDEMIOLOGICAL TRIAD

➢ Host. Lodgment to an infectious agent under natural conditions

➢ Types of Hosts
✓ Obligate host,
✓ Definitive (primary) host
✓ Intermediate host
✓ Transport host
➢ Reservoir.
✓ Person, animal, arthropod, plant, soil, substance, or combination of these
✓ Infectious agent lives and multiplies
✓ Depends primarily for survival, and reproduces itself in such a manner that it
can be transmitted to a susceptible host
✓ Natural habitat of the infectious agent.
➢ Agent / Vector.
✓ Any living carrier that transports an infectious agent from an infected
individual or its wastes to a susceptible individual or its food or immediate
surroundings
✓ Both biological and mechanical transmissions are encountered
 TYPES OF RESERVOIRS

Reservoir

Human Animal Non-living

reservoir reservoir reservoir
 HUMAN RESERVOIR

Human Reservoir

Type:
•Incubatory
•Convalescent
•Primary case •healthy
Cases •Index case Carriers
•Secondary cases

Duration:
•Temporary
According to spectrum of disease: •Chronic Portal of exit:
•Clinical cases •Urinary
(mild/severe-typical/atypical) •Intestinal
•Sub-clinical cases •Respiratory
•Latent infection cases •others
 CARRIERS

➢ Either due to inadequate treatment or immune response, the

disease agent is not completely eliminated, leading to a carrier
state.
➢ It is an infected person or animal that harbors a specific infectious
agent in the absence of visible clinical disease and serves as a
potential source of infection to others.
➢ Three essential elements of a carrier state:
✓ Presence of disease agent.
✓ Absence of recognizable symptoms and signs of disease.
✓ Shedding of the virus / bacterial in the discharge / excretions.
 ANIMAL RESERVOIRS

➢ Zoonosis. Is an infection transmitted from animals to man, e.g.

rabies, plague, bovine tuberculosis, etc

➢ Reservoir in Non-living Things.

✓ Soil and inanimate matter can also act as reservoir of infection.

✓ E.g. Tetanus, Anthrax, etc

 MODES OF TRANSMISSION

Mode of Transmission

Direct Indirect
Transmission Transmission

Vehicle-borne
Direct Contact
•Vector-borne:
Droplet Infection •Mechanical
•Biological Propagative

Cyclo-prop.
Contact with Soil
Air-borne Cyclo-develop.

Inoculation into Skin or Mucosa

Fomite-born

Trans - Placental (vertical) Unclean hands

and fingers
 SUSCEPTIBLE HOST

➢ An infectious agent seeks a susceptible host.

➢ Four stages are required for successful parasitism:

✓ Portal of entry

✓ Site of election inside the body

✓ Portal of exit

✓ Survival in external environment

 VIRULENCE AND CASE FATALITY RATE

➢ Virulence.
✓ Degree of pathogenicity; the disease evoking power of a micro-
organism in a given host.
✓ Numerically expressed as the ratio of number of cases of overt
infection to total number infected, as determined by
immunoassay.
➢ Case Fatality Rate for Infectious Diseases.
✓ It is the proportion of infected individuals who die of the
infection.
✓ It is a function of severity of the infection and is heavily
influenced by un-diagnosed mild cases.
 SERIAL INTERVAL AND INFECTIOUS PERIOD

➢ Serial interval:

✓ The interval between onset of the primary and the secondary

cases.

✓ The interval between receipt of infection and maximal infectivity

of the host (also called generation time).

➢ Infectious (communicable) Period:

✓ Length of time a person can transmit disease.

 INCUBATION AND LATENT PERIODS

➢ Incubation Period:

✓ Time from exposure to development of disease (first sign or

symptom of the disease).

➢ Latent period:

✓ The period between exposure and onset of infectiousness (may

be shorter or longer than the incubation period).

✓ E.g. Herpes Zoster

 TRANSMISSION PROBABILITY RATIO (TPR)

➢ TPR is a measure of risk transmission from infected to susceptible

individuals during a contact.

➢ Types of Transmission Probabilities.

✓ p00: tp from unvaccinated infective to unvaccinated susceptible

✓ p01: tp from vaccinated infective to unvaccinated susceptible

✓ p10: tp from unvaccinated infective to vaccinated susceptible

✓ p11: tp from vaccinated infective to vaccinated susceptible

ARE EXPOSURE AND DISEASE LINKED?

E D

Exposure Disease
 EPIDEMIOLOGY STUDY TYPES
Randomized
control studies

Experimental Field Trials

Epidemiology Community
Study Trials
Types

Descriptive
Observational

Analytic

Case Control
Cohort Study
Study
 DESCRIPTIVE STUDIES: STEPS

➢ Step #1: Defining the Population.

➢ Step #2: Defining Disease under Study.

➢ Step #3: Describing the Disease - Time, Place, Person.

➢ Step #4: Measurement of Disease - Mortality/ Morbidity.

➢ Step #5: Compare - Between different Population, Subgroups.

➢ Step #6: Formulate Hypothesis.

 CROSS-SECTIONAL STUDIES: PREVALENCE

➢ Simplest form of observational study.

➢ Based on single examination of cross-section of population at one

point of time.

➢ Results can be projected to the entire population.

➢ Useful for chronic illnesses, e.g. hypertension.

➢ Save on time and resources,

➢ Provides minimum information about natural history of disease

and incidence of illness.

 CASE CONTROL STUDIES

➢ The study proceeds backwards from effect to cause

➢ Both exposure and outcome have occurred before start of the

study
 RISK FACTORS & RISK GROUPS

➢ Risk Factors

✓ An attribute or exposure significantly associated with

development of disease

✓ A determinant that can be modified by intervention, reducing

the possibility of occurrence of disease / outcome.

✓ Risk Groups

✓ Directly proportionate to needs.

✓ Used to prevent disease by removal or minimizing the risk.

 ODDS RATIO

➢ It is a measure of strength of association between the risk factor

and outcome.

➢ The derivation of the odds ratio is based on three assumptions:-

✓ The disease being investigated is relatively rare

✓ The cases must be representative of those with the disease

✓ The controls must be representative of those without the

disease
 ODDS RATIO

 A 2×2 table is constructed, displaying exposed

cases (A), exposed controls (B), unexposed
cases (C) and unexposed controls (D).

CASE CONTROLS
EXPOSED A B
UNEXPOSED C D

 To measure association is the odds ratio (OR),

which is the ratio of the odds of exposure in the
cases (A/C) to the odds of exposure in the
controls (B/D), i.e.
OR = (AD/BC).
 ODDS RATIO

Category Case with lung Control without

cancer lung cancer
Smokers (less than 33 (a) 55 (b)
5)
Non-Smokers 2 (c) 27 (d)
(less than 5 )
1. Exposure rates among cases
=a/(ac) = 33/35 =94.2%
2. Exposure rate among the controls
=b/(bd) = 55/82 =67%
Odds ratio = a x d / b x c
33X27/55X2 = 8.1
 People who smoke less than 5 cigarettes per day
showed a risk of having lung cancer 8.1 times higher
as compared to non-smokers.
 ODDS RATIO

 OR is > 1- "those with the disease are more likely

to have been exposed,"

 OR close to 1 then the exposure and disease are

not likely associated.

 OR <1-exposure is a protective factor in the

causation of the disease.
 REFERENCES

➢ A Short Introduction to Epidemiology (Neal Pearce):

http://csm.lshtm.ac.uk/files/2010/09/A-Short-Introduction-
to-Epidemiology-Second-Edition.pdf

➢ Principles of Epidemiology in Public Health Practice, Third

Edition (CDC Course)

➢ Online: http://www.cdc.gov/ophss/csels/dsepd/ss1978/

➢ PDF:
http://www.cdc.gov/ophss/csels/dsepd/SS1978/SS1978.pdf
DISCUSSION