HC 101

LECTURE
INTRODUCTION TO EPIDEMIOLOGY

WHAT IS EPIDEMIOLOGY? ð refers to the occurrence of health-related events by time,

place, and person.
ð “the study of the distribution, frequency and determinants of ð Time patterns may be annual, seasonal, weekly, daily, hourly,
health problems and disease in human populations, and the weekday versus weekend, or any other breakdown of time
application of this study to the control of health problems” that may influence disease or injury occurrence.
ð The unit of interest is the population ð Place patterns include geographic variation, urban/rural
differences, and location of work sites or schools.
EPIDEMIOLOGY ... ð Personal characteristics include demographic factors which
may be related to risk of illness, injury, or disability such as
 Is a scientific discipline with sound methods of scientific
age, sex, marital status, and socioeconomic status, as well as
inquiry at its foundation
behaviors and environmental exposures.
 is data-driven and relies on a systematic and unbiased
approach to the collection, analysis, and interpretation of DETERMINANTS
data.
 described as the basic science of public health ð which are the causes and other factors that influence the
occurrence of disease and other health-related events.
DISTRIBUTION ð Epidemiologists assume that illness does not occur randomly
in a population, but happens only when the right
ð Epidemiology is concerned with the frequency and pattern
accumulation of risk factors or determinants exists in an
of health events in a population
individual.

EPIDEMIOLOGY

Allows the distribution of health and ill-health in a population to be

described in terms of:

– WHAT is the problem and its frequency?

– WHO is affected?

– WHERE and WHEN does it occur?

– WHY does it occur in this particular population?

USES OF EPIDEMIOLOGY
ð To study the cause (or etiology) of disease(s), or conditions,
FREQUENCY disorders, disabilities, etc.
 determine the primary agent responsible or
ð refers not only to the number of health events such as the ascertain causative factors
number of cases of meningitis or diabetes in a population,  determine the characteristics of the agent or
but also to the relationship of that number to the size of the causative factors
population.  define the mode of transmission
ð The resulting rate allows epidemiologists to compare disease  determine contributing factors
occurrence across different populations.  identify and determine geographic patterns
ð To determine, describe, and report on the natural course of
PATTERN disease, disability, injury, and death.
ð To aid in the planning and development of health services
and programs
 ð To provide administrative and planning data FIELD INVESTIGATION

LEADING CAUSES OF DEATH, PHILIPPINES, 2016

ð The investigation may be as limited as a phone call to the
health-care provider to confirm or clarify the circumstances
(NUMBER OF DEATHS)
of the reported case, or it may involve a field investigation
1. Coronary Heart Disease requiring the coordinated efforts of dozens of people to
2. Cerebrovascular Disease characterize the extent of an epidemic and to identify its
3. Influenza & Pneumonia cause
4. Diabetes Mellitus ð the objective of an investigation may simply be to learn more
5. Tuberculosis about the natural history, clinical spectrum, descriptive
6. Hypertension epidemiology, and risk factors of the disease before
7. Lung Disease determining what disease intervention methods might be
8. Nephritis, nephrotic syndrome appropriate.
9. Breast Cancer
10. Asthma ANALYTIC STUDIES

LEADING CAUSES OF DEATH WORLDWIDE, 2000

 Descriptive epidemiology.
The descriptive approach involves the study of
(BASED ON NUMBER OF GLOBAL DEATHS)
disease incidence and distribution by time, place,
1. Ischemic Heart Disease and person. It includes the calculation of rates and
2. Cerebrovascular Disease identification of parts of the population at higher
3. Lower Respiratory Infections risk than others.
4. HIV/AIDS  Analytic epidemiology.
5. COPD the use of a valid comparison group
6. Perinatal Conditions
7. Diarrhoeal Diseases EVALUATION
8. Tuberculosis
ð is the process of determining, as systematically and
9. Road Traffic Injuries
objectively as possible, the relevance, effectiveness,
10. Lung Cancers
efficiency, and impact of activities with respect to established
goals
PURPOSE OF EPIDEMIOLOGY
ð Effectiveness refers to the ability of a program to produce
ð “To obtain, interpret and use health information to promote the intended or expected results in the field; effectiveness
health and reduce disease through developing disease differs from efficacy, which is the ability to produce results
control and prevention measures for groups at risk. This under ideal conditions.
translates into developing measures to prevent or control ð Efficiency refers to the ability of the program to produce the
disease” intended results with a minimum expenditure of time and
resources.
CORE EPIDEMIOLOGIC FUNCTIONS

ð In the mid-1980s, five major tasks of epidemiology in public LINKAGES

health practice were identified: public health surveillance, ð During an investigation an epidemiologist usually participates
field investigation, analytic studies, evaluation, and as either a member or the leader of a multidisciplinary team.
linkages. Other team members may be laboratorians, sanitarians,
ð A sixth task, policy development, was recently added infection control personnel, nurses or other clinical staff,
and, increasingly, computer information specialists.
PUBLIC HEALTH SURVEILLANCE
ð is the ongoing, systematic collection, analysis, interpretation, POLICY DEVELOPMENT
and dissemination of health data to help guide public health ð Epidemiologists working in public health regularly provide
decision making and action input, testimony, and recommendations regarding disease
ð The purpose of public health surveillance, which is control strategies, reportable disease regulations, and
sometimes called “information for action,” healthcare policy.
ð is to portray the ongoing patterns of disease occurrence and
disease potential so that investigation, control, and TWO BROAD TYPES OF EPIDEMIOLOGY
prevention measures can be applied efficiently and
effectively Descriptive Epidemiology
  Examining the distribution of disease in a population, and
observing the basic features of its distribution
Example
Analytic Epidemiology
• You have been asked to investigate an event in which 2,220 people
 Testing a hypothesis about the cause of disease by studying were exposed and 1,520 of them died. Your role as an epidemiologist is
how exposures relate to the disease to ask questions about person, place and time.

DESCRIPTIVE EPIDEMIOLOGY IS THE ANTECEDENT TO ANALYTICAL How do we ask questions?

EPIDEMIOLOGY
 Surveys
• Analytic epidemiology studies require information to ….
 of survivors
 of next-of-kin
 know where to look
 of other related persons
 know what to control for
 develop viable hypotheses
with questions you learn that ...

THREE ESSENTIAL CHARACTERISTICS OF DISEASE THAT WE LOOK • Person: Men, women and children were all exposed and at risk. The
FOR IN DESCRIPTIVE STUDIES ARE... majority of people who died were wealthy and young men between
18-50 years (when compared to survivors).
Person
• Place: All those exposed were within 1 block of one another, the
 Age, gender, ethnicity
climate was cold.
 Genetic predisposition
 Concurrent disease
• Time: Mid April, people died within hours of the precipitating
 Diet, exercise, smoking
exposure.
 Risk taking behavior
 SES, education, occupation
DESCRIPTIVE EPIDEMIOLOGY: APPLICATIONS
Place
studying the frequency and distribution of disease
 Geographic place
 presence or agents or vector
 climate
 geology
 population density
to generate hypotheses to inform local public
 economic development
about causes (the health function (the
 nutritional practices
academic focus) service focus)
 medical practices

Time
ANALYTIC EPIDEMIOLOGY
 Calendar Time
ð key feature of analytic epidemiology is a comparison group
 Time since an event
ð concerned with the search for causes and effects, or the why
 Physiologic cycles
and the how.
 Age (time since birth)
ð quantify the association between exposures and outcomes
 Seasonality
and to test hypotheses about causal relationships
 Temporal trends
ð purpose of an analytic study in epidemiology is to identify
and quantify the relationship between an exposure and a
DESCRIPTIVE EPIDEMIOLOGY
health outcome
ð Often makes use of routinely collected data, e.g. death ð The hallmark of such a study is the presence of at least two
certification data, hospital episode statistics, infectious groups, one of which serves as a comparison group.
disease notifications ð Epidemiologic studies fall into two categories: experimental
ð May require special surveys and observational.
ð Can’t answer ‘why?’ but can raise hypotheses about causes
ð Can often provide sufficient information for public health EXPERIMENTAL STUDIES
action to be taken
ð In an experimental study, the investigator determines
through a controlled process the exposure for each individual
 (clinical trial) or community (community trial), and then  Incidence
tracks the individuals or communities over time to detect the  Prevalence
effects of the exposure.
INCIDENCE
OBSERVATIONAL STUDIES ð The incidence is the number of NEW CASES of disease that
ð simply observes the exposure and disease status of each develop in a population during a specified time period
study participant ð Usually expressed as the number of new cases per 100,000
ð The two most common types of observational studies are population per year.
cohort studies and case-control studies; a third type is cross- ð Incidence quantifies the number of new cases of disease that
sectional studies develop in a population of individuals at risk during a
specified time period
COHORT STUDY
number of new cases∈ period of time
ð In a cohort study the epidemiologist records whether each Incidence=
population at risk
study participant is exposed or not, and then tracks the
participants to see if they develop the disease of interest. ð The denominator “population at risk” should consist of the
ð Investigator observes rather than determines the entire population in which new cases can occur.
participants’ exposure status. ð Need specified Population and time period
 Follow-up or prospective cohort study
 Retrospective cohort study. Incidence Example

CASE-CONTROL STUDY In 24 practices in Scotland with a total male population of size 60,577
there were 165 new patients in one year with epilepsy.
ð In a case-control study, investigators start by enrolling a
group of people with disease. Incidence=
ð As a comparison group, the investigator then enrolls a group 165
of people without disease (controls). Investigators then =0.0027∨2.7 cases per 1000 per year
60,577
compare previous exposures between the two groups.
ð The key in a case-control study is to identify an appropriate
PREVALENCE
control group, comparable to the case group in most
respects, in order to provide a reasonable estimate of the ð Prevalence is a measure of the individuals in a population
baseline or expected exposure. who have the disease at a specific instant.
ð Can be expressed as a proportion, percentage or per 1,000
CROSS-SECTIONAL STUDY
population.
ð Can be point, period or lifetime prevalence
ð In this third type of observational study, a sample of persons
ð Often referred to as prevalence rate, but it is not strictly
from a population is enrolled and their exposures and health
speaking a rate.
outcomes are measured simultaneously.
ð The cross-sectional study tends to assess the presence
(prevalence) of the health outcome at that point of time
total no . cases at given time
Prevalence =
without regard to duration. total population at that time
ð From an analytic viewpoint the cross-sectional study is
Prevalence Example
weaker than either a cohort or a case-control study because
a cross-sectional study usually cannot disentangle risk factors In 24 practices in Scotland with a total male population of size 60,577
for occurrence of disease (incidence) from risk factors for there were 577 male patients with epilepsy. Thus the prevalence of
survival with the disease. epilepsy in this population is:
ð A cross-sectional study is a perfectly fine tool for descriptive
epidemiology purposes. Cross-sectional studies are used 577
routinely to document the prevalence in a community of Prevalence = =0.0095 or 9.5 cases per 1,000
60577
health behaviors (prevalence of smoking), health states
(prevalence of vaccination against measles), and health Why might the prevalence of a condition appear to have changed?
outcomes, particularly chronic conditions (hypertension,
diabetes).

MEASURES OF DISEASE FREQUENCY

The two main measures of disease frequency are:

HOW ARE INCIDENCE AND PREVALENCE RELATED?

ð For diseases with a low incidence rate but where those with
the disease are affected for a long time period e.g. diabetes WHEN TO USE INCIDENCE OR PREVALENCE
or asthma, the prevalence will be high relative to the PREVALENCE INCIDENCE
incidence.
descriptive studies Studying etiology
ð If the rate of development of a disease is high, but it has a
short duration, the prevalence will be low relative to the (cause of disease)
incidence. can calculate the effect of a can establish the sequence of
particular disease in a events
Prevalence = Incidence x Average Duration of Disease community
can predict the health care Not susceptible to bias by
requirements survival

IN SUMMARY: INCIDENCE AND PREVALENCE

Incidence:

ð the number of new cases of disease per n of population

occurring in a specified time period

Prevalence:

ð the number of persons with disease at one point in time as a

proportion of the total number of persons in that population.

THREE ESSENTIAL CHARACTERISTICS THAT ARE EXAMINED TO

STUDY THE CAUSE(S) FOR DISEASE IN ANALYTIC EPIDEMIOLOGY
ARE...

 Host
 Agent
 Environment

HOST

AGENT ENVIRONMENT

HOST FACTORS
ð Personal traits behaviors genetic predisposition immunologic
factors
ð Influence the chance for disease or its severity
 ð Genetic Predisposition  hypothesis testing
 Hormones
 Lack of part or structure Descriptive epidemiology
 Chromosomal Factors +
Focus on cause and effect
 Immunological factors
=
ð Biological Factors “Analytical epidemiology”
ð Socio Economic Factors
CONCLUSIONS

AGENTS ð Epidemiology is a core part of public health.

ð It allows the distribution of health and ill-health in a
ð Biological, Physical, Chemical
population to be described, and possible causal factors to be
ð necessary for disease to occur
identified.
ð Biological agents
ð It enables public health professionals to understand health
 virus Characteristics:
problems and take appropriate action
 bacteria
 infectivity
 protozoa
 pathogenicity MEASURES OF DISEASE OCCURRENCE
 fungus
 virulence
ð Physical agents ð These are measurements of the
 exposure to excessive heat, cold, humidity, frequency/magnitude/amount of disease in populations
pressure, radiation, electricity, sound, etc.
ð Chemical agents How do we measure diseases?
 endogenous
 exogenous •Four quantitative descriptors

 Numbers • Proportions
 Ratios • Rates

ENVIRONMENT RATIO
ð external conditions
ð A ratio is the relative magnitude of two quantities or a
ð physical, biologic or social
comparison of any two values.
ð contribute to the disease process
ð It is calculated by dividing one interval-or ratio-scale variable
ð environmental factors
by the other.
 physical environment
ð The numerator and denominator need not be related.
 biological environment
Therefore, one could compare apples with oranges or apples
 psycho social environment
with number of physician visits.

EPIDEMICS
PROPORTION
ð arise when host, agent, and environmental factors are not in
ð A proportion is the comparison of a part to the whole.
balance
ð It is a type of ratio in which the numerator is included in the
 Due to new agent
denominator.
 Due to change in existing agent (infectivity,
ð You might use a proportion to describe what fraction of clinic
pathogenicity, virulence)
patients tested positive for HIV, or what percentage of the
 Due to change in number of susceptibles in the
population is younger than 25 years of age. A proportion may
population
be expressed as a decimal, a fraction, or a percentage.
 Due to environmental changes that affect
transmission of the agent or growth of the agent
RATE

EPIDEMIOLOGIC ACTIVITIES Ð In epidemiology, a rate is a measure of the frequency with

which an event occursin a defined population over a
• Analytic epidemiology
specified period of time.
ð built around the analysis of the relationship between two Ð Because rates put disease frequency in the perspective of the
items size of the population, rates are particularly useful for
 Exposures comparing disease frequency in different locations, at
 Effects (disease) different times, or among different groups of persons with
ð looking for determinants or possible causes of disease potentially different sized populations; that is, a rate is a
ð useful for measure of risk.
NUMBERS  Sex-specific mortality rate
 Cause-specific mortality rate
ð Numbers: Use of actual number of events  Proportionate mortality ratio
–e.g100 cases of TB in community A  Case fatality rate
 Fetal death rate
WHEN WE CALL...  Perinatal mortality rate
 Neonatal mortality rate
ð When we call a measure a ratio, we mean a nonproportional
 Infant mortality rate
ratio
ð When we call a measure a proportion, we mean a  Child mortality rate
proportional ratio that doesn’t measure an event overtime  Under-five mortality rate
ð When we call a rate, we mean a proportional ratio that does  Maternal mortality ratio
measure an event in a population overtime
Crude mortality rate

TYPES OF RATES ð An estimate of the rate at which members of a population

die during a specified period.
•Crude rates: –Apply to the total population in a given area
ð The numerator is the number of people dying during the
•Specific rates: –Apply to specific subgroups in the population (age, period; the denominator is the size of the population, usually
sex etc) or specific diseases at the middle of the period (mid-year population).

•Standardized rates: –used to permit comparisons of rates in number of deaths during a specified period
population which differ in structure (e.gage structure) n
number of persons at risk of dying during the x 10 period
ð Counts all deaths
 All causes
 All ages and both sexes
ð Denominator includes entire population
MORBIDITY

ð defined as any departure, subjective or objective, from a SPECIFIC RATES

state of physiological or psychological well-being.
ð In contrast to crude rates, a specific rate refers to a particular
ð In practice, morbidity encompasses disease, injury, and
segment of the population.
disability.
ð It focuses attention on a more homogeneous group within
ð The term refers to the number of persons who are ill, it can
the total population and
also be used to describe the periods of illness that these
ð Rates may also be made specific for more than one
persons experienced, or the duration of these illnesses
characteristic of the population, such as age-, sex-, and race-
specific death rates.
MORBIDITY RATES ð Is expressed on the basis of any characteristic of the
ð Morbidity rates are rates that are used to quantify the population such as
magnitude/frequency of diseases  age, sex, marital status, race, etc.
ð Two common morbidity rates
– Incidence rates STANDARDIZED MORTALITY RATE (SMR)
(Cumulative incidence, incidence density)
ð Standardization is used when comparing mortality in two
– Prevalence
populations that have different demographic structures.
(Period prevalence, point prevalence)
ð Standardization can be either direct (leading to an Age-
Standardized Mortality Rate [ASMR]) or indirect (producing a
MORTALITY RATES
Standardized Mortality Ratio [SMR]).
ð These rates measures magnitude of deaths in a community ð It removes the effect of differences in age (or other
ð Some are crude like the crude death rate confounding variables that affect mortality rate) between the
ð Others are cause-specific mortality rate populations.
ð Some others are adjusted like standardized mortality ration –For example, Victoria, B.C. has more elderly
people than Whitehorse, Yukon, so a crude
Common Mortality rates comparison of overall mortality rates per thousand
would not be helpful because we would expect
 Crude death rate higher death rates in Victoria simply because of its
 Age-specific mortality rate older population.
AGE-SPECIFIC MORTALITY RATE ð The amount of a particular disease that is usually present in a
community is referred to as the baseline or endemiclevel of
ð Counts only deaths in specific age group the disease.
ð Usually calculated for children less than 5 years of age
ð Denominator includes only persons in that age group •Epidemics

INFANT MORTALITY RATE occur when an agent and susceptible hosts are present in
ð
adequate numbers, and the agent can be effectively
ð The infant mortality rate is the total number of deaths in a conveyed from a source to the susceptible hosts.
given year of children less than one year old, divided by the ð More specifically, an epidemic may result from:
total number of live births in the same year, multiplied by 1) A recent increase in amount or virulence of the
1,000. agent,
ð It is an approximation of the number of deaths per 1,000 2) The recent introduction of the agent into a setting
children born alive who die within one year of birth. where it has not been before,
3) An enhanced mode of transmission so that more
deaths among childrenless than 1 year of age
infant mortality rate= × 1000susceptible persons are exposed,
number of live births ∈the same year 4) A change in the susceptibility of the host response
to the agent, and/or
ð The IMR is often quoted as a useful indicator of the level of 5) Factors that increase host exposure or involve
health development in a community. introduction through new portals of entry
ð Counts deaths in children less than 12 months of age, divides
by number of live births in same time period SPORADIC

ð refers to a disease that occurs infrequently and irregularly

•Ex. (Single case of histoplasmosiswas diagnosed in a community.)

PERINATAL MORTALITY RATE (PMR)

ð In most industrially developed nations, this is defined as ENDEMIC

fetal deaths ( ¿ 28 weeks of gestation ) +deaths occuring with 1 week refers to the constant presence and/or usual prevalence of a
ð postnatally
×1000 agent in a population within a
disease or infectious
fetal deaths ( ¿ 28 weeks of gestation ) +live births geographic area

NEONATAL MORTALITY RATE (NMR) •Ex. (About 60 cases of gonorrhea are usually reported in this region
per week, slightly less than the national average.)
ð Deaths in infants under 28 days of age in a yearx 1000Live
births in same period.
HYPERENDEMIC

MATERNAL MORTALITY RATE ð refers to persistent, high levels of disease occurrence.

ð The number of maternal deaths related to •Ex. (Average annual incidence was 364 cases of pulmonary
childbearingdivided by the number of live births (or by the tuberculosis per 100,000 population in one area, compared with
number of live births + fetal deaths) in that year. national average of 134 cases per 100,000 population)
ð Counts deaths in women due to pregnancy or child birth,
divides by number of live births in same time period EPIDEMIC

UNDER-5 MORTALITY RATE ð refers to an increase, often sudden, in the number of cases of
a disease above what is normally expected in that population
ð Counts deaths in the first 5 years of life, divides by number of in that area
live births in the hypothetical cohort of newborns. ð Outbreak carries the same definition of epidemic, but is
often used for a more limited geographic area
EPIDEMIC DISEASE OCCURRENCE
•Ex. (22 cases of legionellosisoccurred within 3 weeks among
•Level of disease residents of a particular neighborhood (usually 0 or 1 per year)
PANDEMIC

ð refers to an epidemic that has spread over several countries

or continents, usually affecting a large number of people.

•Ex. (Over 20 million people worldwide died from influenza in 1918–

1919)