Introduction:

Epidemiology

NUHAD RAISA SEOTY

ASSISTANT PROFESSOR

DEPARTMENT OF PUBLIC HEALTH

Health
 The WHO defined Health as: “A complete state of
physical, mental and social well-being and not
merely absence of illness.”

–World Health Organization, July 1946

 Public Health
 Public health is the science and art of
preventing disease, prolonging life and
promoting physical health and efficiency
through organized community efforts for the
sanitation of the environment, the control of
community infections, the education of the
individual in principles of personal hygiene, the
organization of medical and nursing service for
the early diagnosis and preventive treatment of
disease, and the development of social
machinery which will ensure to every
individual in the community a standard of
living adequate for the maintenance of health.

-Winslow, 1920
Public Health
Public Health is defined as the art and science of
preventing disease, prolonging life and promoting
health through the organized efforts of society.
  (Acheson, 1988; WHO).

Sir Donald Acheson

Public Health
Public health involves the application of many different disciplines:
 Biology

 Anthropology

 Public policy

 Mathematics

 Engineering

 Education

 Psychology

 Computer science

 Sociology

 Medicine

 Business

 and others
Epidemiology: Terminology
 The word epidemiology comes from the Greek
words
Epi- means on or upon
Demos- means people and
Logos- means the study of.

 In other words, the word epidemiology has its roots

in the study of what happens a population.
Epidemiology: Definition

Many definitions have been proposed, but the following definition captures the underlying principles
and public health spirit of epidemiology:

 Epidemiology is the study of the

distribution and determinants of
health-related states or events in
specified populations, and the
application of this study to the control
of health problems John M. Last
--------- Last JM, editor. Dictionary of
epidemiology. 4th ed. New York: Oxford
University Press; 2001. p. 61.
Key words: Study
 Epidemiology is often described as the basic
science of public health. Reasons are:
 First, epidemiology is a quantitative discipline that
relies on a working knowledge of probability, statistics,
and sound research methods.
 Second, epidemiology is a method of causal reasoning
based on developing and testing hypotheses grounded
in such scientific fields as biology, behavioral sciences,
physics explain health-related behaviors, states, and
events.
Key words: Specified population
 the epidemiologist is concerned about the collective
health of the people in a community or
population.
 In other words, the epidemiologist's “patient” is the
community. Therefore, the clinician and the
epidemiologist have different responsibilities when
faced with a person with illness.
Key words: Health related states or events
 The term health-related states or events may be seen
as anything that affects the well-being of a
population.

 Many epidemiologists still use the term “disease” as

shorthand for the wide range of health-related states
and events that are studied.
Key words: Health related states or events

 Health related state: The condition of health, disease,

disability, discomfort, dissatisfaction. health needs, health
demands, health activities, health care facilities, health care
utilization, lifestyle etc.

 Health related events:

 The vital events like birth, death, marriage, divorce,
migration
 Accidents like road traffic accidents, wars, fall from height,
drowning, poisoning, burn, nuclear explosion, injuries etc
Key words: Distribution
 Epidemiology is concerned with
 frequency and
 pattern
of health events in a population
Key words: Distribution (Frequency & Pattern)

 Frequency refers
 the number of health events such as the number
of diabetes cases in a population
 the relationship of that number to the size of the
population. The resulting rate allows
epidemiologists to compare disease occurrence
across different populations.
 Pattern refers to the occurrence of health-related
events by time, place, and person.
Key words: Determinants
 Epidemiology is also used to search for
determinants, which are
 The causes and other factors that influence the
occurrence of disease and other health-related events.
 Epidemiologists assume that illness does not occur
randomly in a population, but happens only when the
right accumulation of risk factors or determinants
exists in an individual.
Key words: Application
 Analysis, conclusion, distribution, and timely use
of epidemiologic information to protect the health
of the population.
 Approaches in Medicine vs. Epidemiology:
Approach Clinical Medicine Epidemiology

Focus Individuals Populations

Main Goal Diagnosis and treatment Prevention and control

Questions What is wrong with this What are the leading causes of
patient? death or disability in this
population? Risk factors?

Treatment What treatment is What can be done to reduce or

appropriate ? prevent disease or risk factors?

Physician, laboratorian, Epidemiologists, statisticians,

Who is involved? nurse, and others and others from diverse
disciplines
History of Epidemiology
HIPPOCRATES, the first epidemiologist

 The Greek physician Hippocrates the father of

medicine and first epidemiologist (460 BC- 370 BC)
 three books entitled
 Epidemic I, Epidemic III and On Airs, Waters and
Places
 He coined the terms
 endemic (for diseases usually found in some places
but not in others)
 epidemic (for disease that are seen at some times
but not others).
HIPPOCRATES, the first epidemiologist

 He observed that different diseases occurred in different

locations.
 relationships between the occurrence of disease and
environmental influences.
 He observed on how diseases affected populations and how
disease spread.
 He also addressed issues of diseases in relation to
 time and seasons
 place
 environmental conditions and
 The broader contribution to epidemiology made by
Hippocrates was epidemiologic observation.
HIPPOCRATES, the first epidemiologist

Hippocrates also made some noteworthy

observations on the behavior of the populace.

He believed the effective physician should be

observant of people’s behavior, such as eating,
drinking, and other activities.
Disease observations of Sydenham
 Thomas Sydenham (1624–1689)
 Although a graduate of Oxford Medical School, did
not at first practice medicine but served in the
military and as a college administrator.
 He spoke out for strong empirical approaches to
medicine and close observations of disease.
 From this close observation process, he was able to
identify and recognize different diseases.
 Sydenham published his observations in a book in
1676 titled ‘Observationes Medicae
Disease observations of Sydenham
 One of the major works of Sydenham was the
classification of fevers London in the 1660s and
1670s
 He classified three levels or classes of fevers:
 Continued fevers
 Intermittent fevers and
 Smallpox
 Some of Sydenham’s theories were embraced,
whereas others were criticized mostly because his
ideas and observations went against the usual
Disease observations of Sydenham
 He treated smallpox with bed rest and normal bed covers.
 The treatment of the time, based on the Hippocratic theory,
was to use heat and extensive bed coverings.
 He was met with good results but make a mistake in
identifying the cause of the disease.
 Sydenham was mistreated by his colleagues however, he
gained a good reputation with the public, and some young
open-minded physicians agreed with his empirical principles.
 Sydenham described and distinguished different Diseases.
 He also advanced useful treatments and remedies, including
exercise, fresh air, and a healthy diet, which other physicians
rejected at the time
The Epidemiology of Scurvy
 In the 1700s, it was observed that armies lost more men to
disease than to the sword. James Lind (1716–1794), a
Scottish naval surgeon, focused on illnesses in these
populations.
 He observed the effect of time, place, weather, and diet on the
spread of disease. His 1754 book, A Treatise on Scurvy,
identified the symptoms of scurvy and the fact that the disease
became common in sailors after as little as a month at sea
 Lind noticed that while on long ocean journey, sailors would
become sick from scurvy, a disease marked by spongy and
bleeding gums, bleeding under the skin, and extreme
weakness.
The Epidemiology of Scurvy
 Lind pointed out that the months most common to scurvy
were April, May, and June. He also observed that cold, rainy,
foggy, and thick weather were often present.
 he observed that the sea diet was extremely gross and hard on
digestion.
 He conducted an experimental study on scurvy wherein he
assigned different supplemental dietary interventions to 12 ill
patients who had all of the classic symptoms of scurvy.
 He put the sailors in six groups of two and, in addition to a
common diet of foods
 In 6 days, the two men eating citrus were fit for duty.
 Thus, Lind observed that oranges and lemons were the most
effective remedies for scurvy at sea.
The Epidemiology of Scurvy

The epidemiologic contributions of Lind:

 He was concerned with the occurrence of disease in
large groups of people.
 Lind not only participated in the identification of the
effect of diet on disease, but he made clinical
observations, used experimental design, asked classic
epidemiologic questions, observed population
changes and their effect on disease,
 And considered sources of disease, including place,
time, and season.
The Epidemiology of Scurvy
 As a consequence of Lind’s epidemiologic work,
since 1895, the British navy has required that limes
or lime juice be included in the diet of seamen,
resulting in the nickname of British seamen of
“limeys.”
The epidemiology of Cowpox and Smallpox

 In England, Benjamin Jesty, a farmer/dairyman in the

mid 1700s, noticed his milkmaids never got
smallpox, however, the milkmaids did develop
cowpox from the cows.
 Jesty believed there was a link between acquiring
cowpox and not getting smallpox.
 In 1774, Jesty exposed his wife and children to
cowpox to protect them from smallpox. The exposed
family members developed immunity to smallpox.
The epidemiology of Cowpox and Smallpox

 Edward Jenner (1749–1823), an English rural physician,

personally observed that dairymen’s servants and
milkmaids got cowpox and did not get smallpox.
 For many centuries, the Chinese had made observations
about weaker and stronger strains of smallpox. They
learned that it was wise to catch a weaker strain of the
disease. If one had a weak strain of the disease, one
would not get the full disease later on.
 Jenner invented a vaccination for smallpox with this
knowledge. The vaccine was used to protect populations
from this disease.
The epidemiology of Cowpox and Smallpox

 The Worldwide Global Smallpox Eradication Campaign of the late

1960s and early 1970s encouraged vaccination against smallpox and
was effective at eliminating this disease
 1975 of a small child who had been suffering with the disease small

pox.
 On October 26, 1977, World Health Organization workers evidently

tracked down the world’s last case of naturally occurring smallpox.

 Two cases of smallpox occurred in 1978 as a result of a laboratory

accident
 Some public-health and healthcare professionals are fear that such

acts may set the stage for an unexpected future epidemic of smallpox
because the pathogen still exists in military and government labs.
 As unvaccinated persons proliferate, so does the risk of future

smallpox epidemics
Epidemiology of Childbed Fever in a lying-in
Hospital

 In the 1840s, one of the greatest fears a pregnant mother had

was dying of childbed fever
 Semmelweis was a clinical director worked in a Maternity
Hospital
 Semmelweis observed that the mothers became ill either
immediately during birth or within 24–36 hours after
delivery. The mothers died quickly of rapidly developing
childbed fever. Often the children would soon die as well.
 Semmelweis observed that, the medical students would come
directly from he death house after performing autopsies of
infected and decaying dead bodies and then would conduct
pelvic exams on the mothers ready to give birth.
Epidemiology of Childbed Fever in a lying-in
Hospital

 Through clinical observation, retrospective study,

collection and analysis of data on maternal deaths and
infant deaths, and clinically controlled experimentation,
he was able to determine that the communication of
childbed fever was through germs passed from patient to
patient by the physician in the process of doing pelvic
examinations.
 In order to destroy the cadaverous or putrefied matter on
the hands, it was necessary that every person, physician
or midwife, performing an examination, would wash
their hands in chlorinated lime upon entering the labor
ward.
 Dr. John Snow
Father of Modern Epidemiology
John Snow’s epidemiologic investigations of
Cholera

Throughout his medical career, Snow studied cholera.

From his studies, he established sound and useful epidemiologic
methods. He observed and recorded important factors related to
the course of disease.
In the later part of his career, Snow conducted two major
investigative studies of cholera.
A descriptive epidemiologic investigation of a cholera outbreak
in the Soho district of London in the Broad Street area.
The second involved an analytic epidemiologic investigation of
a cholera epidemic in which he compared death rates from the
disease to where the sufferers got their water, either the
Lambeth Water Company or the Southwark and Vauxhall Water
Company.
John Snow’s epidemiologic investigations of
Cholera
 In the mid-1840s, in the Soho and Golden Square districts of
London, a major outbreak of cholera occurred. Within 250
yards of the intersection of Cambridge Street and Broad
Street, about 500 fatal attacks of cholera occurred in 10 days.
Many more deaths were avert because of the flight of most of
the population.
 Snow was able to identify incubation times, the length of time
from infection until death, modes of transmission of the
disease, and the importance of the flight of the population
from the dangerous areas.
John Snow’s epidemiologic investigations of
Cholera
 He also plotted statistics based on dates and mortality rates. He
studied sources of contamination of the water, causation and
infection, and the flow of the water in the underground aquifer by
assessing water from wells and pumps. He found that nearly all
deaths had taken place within a short distance of the Broad Street
pump

 Snow observed that in the Soho district there were two separate
populations not so heavily affected by the cholera epidemic, such
that death rates were not equal to those of the surrounding
populations. A brewery with its own wells and a workhouse, also
with its own water source, were the protected populations.
John Snow’s epidemiologic investigations of
Cholera

 Snow used a spot map (sometimes called a dot map) to identify

the locations of all deaths. He plotted data on the progress of
the course of the epidemic and the occurrence of new cases as
well as when the epidemic started, peaked, and subsided. Snow
examined the water, movement of people, sources of exposure,
transmission of the disease between and among close and
distant people, and possible causation.
 Toward the end of the epidemic, as a control measure,
protection from any reoccurrence, and as a political statement
to the community, Snow removed the handle from the Broad
Street pump.
John Snow’s epidemiologic investigations
of Cholera
 Map of
Cholera
outbreaks in
London
John Snow’s epidemiologic investigations of
Cholera

 In 1853, a larger cholera outbreak occurred in London. London

had not had a cholera out- break for about 5 years. During
this period, the Lambeth Water Company moved their intake
source of water upriver on the Thames, from opposite
Hungerford Market to a source above the city, Thames Ditton.
By moving the source of water upriver to a place above the
sewage out- lets, Lambeth was able to draw water free from
London’s sewage, contamination, and pollution.
 John Snow’s epidemiologic investigations of
Cholera

 The Southwark and Vauxhall Water Company, however, did

not relocate its source of water. Throughout the south district
of the city, both water companies had pipes down every street.
The citizens were free to pick and choose which water
company they wanted for their household water. Thus, by mere
coincidence, Snow encountered a populace using water
randomly selected throughout the south district. Snow could
not have arranged better sampling techniques than those
which had occurred by chance
Deaths from cholera in districts of London supplied by
two water companies, 3 8 July to 26 August 1854

Cholera
death rate
Water Supply Population
Cholera (per 1000
Company 1851 deaths (n) population)
Southwark 167 654 844 5.0

Lambeth 19 133 18 0.9

John Snow’s epidemiologic investigations of
Cholera
 Snow was finally able to prove his hypothesis that
contaminated water passing down the sewers into
the river, then being drawn from the river and
distributed through miles of pipes into people’s
homes, produced cholera throughout the
community. Snow showed that cholera was a
waterborne disease that traveled in both surface and
groundwater supplies
Epidemiologic Work of Pasteur
 Pasteur and his assistants had worked on a vaccine
for anthrax for months, and in 1881, an anthrax
vaccine was discovered. After a presentation at the
Academy of Sciences in Paris, Pasteur was
challenged to prove that his vaccine was effective.
He put his career and reputation at stake to prove
that his vaccine would work, that disease was
caused by microorganisms, and that a cause–effect
association exists between a particular microbe and
a certain disease
The Invention of the Microscope

 Most of the credit goes to Leeuwenhoek for the

advancement, development, and perfection of the use of the
microscope.
 Leeuwenhoek made contributions to epidemiology. He did a
morphologic study of red corpuscles in the blood. He saw
the connection of arterial circulation to venous circulation in
the human body through the microscopic study of capillary
networks.
 In addition to epidemiology and microbiology, chemistry and
histology were also developed because of the advent of the
microscope, which influenced advances in the study and
control of diseases
Modern Epidemiology cont...

 In the mid and late1800s, epidemiological methods began to be

applied in the investigation of disease occurrence. At that time, most
investigators focused on acute infectious diseases.
 In the 1930s and 1940s, epidemiologists extended their methods to
noninfectious diseases.
 The period since World War II has seen an explosion in the
development of research methods and the theoretical underpinnings of
epidemiology. Epidemiology has been applied to the entire range of
health-related outcomes, behaviors, and even knowledge and attitudes.
 The studies by Richard Doll and Andrew Hill linking lung cancer to
smoking and the study of cardiovascular disease among residents of
Framingham, Massachusetts are two examples of how pioneering
researchers have applied epidemiologic methods to chronic disease
since World War II.
Modern Epidemiology cont...

 During the 1960s and early 1970s health workers applied

epidemiologic methods to eradicate naturally occurring smallpox
worldwide. This was an achievement in applied epidemiology of
unprecedented proportions.
 In the 1980s, epidemiology was extended to the studies of injuries
and violence.
 In the 1990s, the related fields of molecular and genetic
epidemiology (expansion of epidemiology to look at specific
pathways, molecules and genes that influence risk of developing
disease) took root.
 Meanwhile, infectious diseases continued to challenge
epidemiologists as new infectious agents emerged eg. Ebola virus,
HIV/ AIDS, Severe Acute Respiratory Syndrome (SARS)), drug-
resistant Mycobacterium tuberculosis, Avian influenza.
Modern Epidemiology cont...

 Beginning in the 1990s and accelerating after the terrorist

attacks of September 11, 2001, epidemiologists have had to
consider not only natural transmission of infectious organisms
but also deliberate spread through biologic warfare and
bioterrorism.
 Today, public health workers throughout the world accept and
use epidemiology regularly to characterize the health of their
communities and to solve day-to-day problems, large and
small.
Purpose of Epidemiology
 To measure frequency of disease
 Quantify disease

 To assess distribution of disease

 Who is getting disease?
 Where is disease occurring?
 When is disease occurring?

 To form hypotheses about causes and preventive factors

 To identify determinants of disease Hypotheses are tested
using epidemiologic studies
Use of Epidemiology
 To study the cause (or etiology) of disease(s), or
conditions, disorders, disabilities, etc.
 determine the primary agent responsible or ascertain
causative factors
 determine the characteristics of the agent or causative
factors
 define the mode of transmission

 determine contributing factors

 identify and determine geographic patterns

Home Work
 Florence Nightingale
 Typhoid Mary