INTRODUCTION TO

EPIDEMIOLOGY
EPIDEMIOLOGY
• The word epidemiology comes from the Greek words epi, meaning on
or upon, demos, meaning people, and logos, meaning the study of
• In other words, the word epidemiology has its roots in the study of
what befalls a population
• 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
Study
• Epidemiology is a scientific discipline with sound methods of scientific
inquiry at its foundation
• Epidemiology is data-driven and relies on a systematic and unbiased
approach to the collection, analysis, and interpretation of data
• Basic epidemiologic methods tend to rely on careful observation and
use of valid comparison groups to assess whether what was observed,
such as the number of cases of disease in a particular area during a
particular time period or the frequency of an exposure among
persons with disease, differs from what might be expected
Distribution
• Frequency refers not only to the number of health events such as the
number of cases of meningitis or diabetes in a population, but also to
the relationship of that number to the size of the population
• Pattern refers to the occurrence of health-related events by time,
place, and person
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
• To search for these determinants, epidemiologists use analytic
epidemiology or epidemiologic studies to provide the “Why” and
“How” of such events
Health-related states or events
• Epidemiology was originally focused exclusively on epidemics of
communicable diseases3 but was subsequently expanded to address
endemic communicable diseases and non-communicable infectious
diseases
• By the middle of the 20th Century, additional epidemiologic methods
had been developed and applied to chronic diseases, injuries, birth
defects, maternal-child health, occupational health, and
environmental health
• Then epidemiologists began to look at behaviors related to health and
well-being, such as amount of exercise and seat belt use
Specified populations
• Although epidemiologists and direct health-care providers are both
concerned with occurrence and control of disease, they differ greatly in
how they view “the patient.”
• The clinician is concerned about the health of an individual; the
epidemiologist is concerned about the collective health of the people in a
community or population
• However, while the clinician usually focuses on treating and caring for the
individual, the epidemiologist focuses on identifying the exposure or
source that caused the illness; the number of other persons who may
have been similarly exposed; the potential for further spread in the
community; and interventions to prevent additional cases or recurrences
Application
• Epidemiology is not just “the study of” health in a population; it also
involves applying the knowledge gained by the studies to community-
based practice
• To make the proper diagnosis and prescribe appropriate treatment for a
patient, the clinician combines medical knowledge with experience,
clinical judgment, and understanding of the patient
• Similarly, the epidemiologist uses the scientific methods of descriptive
and analytic epidemiology as well as experience, epidemiologic judgment,
and understanding of local conditions in “diagnosing” the health of a
community and proposing appropriate, practical, and acceptable public
health interventions to control and prevent disease in the community
Summary
• Epidemiology is the study of the distribution and determinants of
health-related states and events in specified populations , and the
application of this study to the control of health problems
Historical Evolution of
Epidemiology
• Although epidemiology as a discipline has blossomed since World War
II, epidemiologic thinking has been traced from Hippocrates through
John Graunt, William Farr, John Snow, and others
• Hippocrates attempted to explain disease occurrence from a rational
rather than a supernatural viewpoint
• In his essay entitled “On Airs, Waters, and Places,” Hippocrates
suggested that environmental and host factors such as behaviors
might influence the development of disease
1662
• Another early contributor to epidemiology was John Graunt, a London
haberdasher and councilman who published a landmark analysis of
mortality data in
• This publication was the first to quantify patterns of birth, death, and
disease occurrence, noting disparities between males and females,
high infant mortality, urban/rural differences, and seasonal
variations.5
1800
• William Farr built upon Graunt’s work by systematically collecting and
analyzing Britain’s mortality statistics
• Farr, considered the father of modern vital statistics and surveillance,
developed many of the basic practices used today in vital statistics
and disease classification
• He concentrated his efforts on collecting vital statistics, assembling
and evaluating those data, and reporting to responsible health
authorities and the general public.4
1854
• Mortality from Cholera in London Related to the Water Supply of
Individual Houses in Districts Served by Both the Southwark and
Vauxhall Company and the Lambeth Company, July 9– August 26,
1854
19th and 20th centuries
• In the mid- and late-1800s, epidemiological methods began to be
applied in the investigation of disease occurrence
• 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
USES
• Epidemiology and the information generated by epidemiologic
methods have been used in many ways
• Some common uses are described below
1. Assessing the community’s
health
• What are the actual and potential health problems in the community?
• Where are they occurring?
• Which populations are at increased risk?
• Which problems have declined over time?
• Which ones are increasing or have the potential to increase?
• How do these patterns relate to the level and distribution of public health
services available?
2. Making individual decisions
• Many individuals may not realize that they use epidemiologic
information to make daily decisions affecting their health
• In the 1970s, epidemiologists documented the role of exercise and
proper diet in reducing the risk of heart disease
• These and hundreds of other epidemiologic findings are directly
relevant to the choices people make every day, choices that affect
their health over a lifetime
3. Completing the clinical
picture
• When investigating a disease outbreak, epidemiologists rely on health-
care providers and laboratorians to establish the proper diagnosis of
individual patients
• But epidemiologists also contribute to physicians’ understanding of the
clinical picture and natural history of disease
• More recently, epidemiologists, clinicians, and researchers around the
world have collaborated to characterize SARS, a disease caused by a new
type of coronavirus that emerged in China in late 2002.14 Epidemiology
has also been instrumental in characterizing many non-acute diseases,
such as the numerous conditions associated with cigarette smoking —
from pulmonary and heart disease to lip, throat, and lung cancer
4. Searching for causes
• Much epidemiologic research is devoted to searching for causal factors
that influence one’s risk of disease
• One can argue that epidemiology can never prove a causal relationship
between an exposure and a disease, since much of epidemiology is
based on ecologic reasoning
• For example, epidemiologists were able to identify a variety of risk
factors during an outbreak of pneumonia among persons attending the
American Legion Convention in Philadelphia in 1976, even though the
Legionnaires’ bacillus was not identified in the laboratory from lung
tissue of a person who had died from Legionnaires’ disease until almost
6 months later
Core Epidemiologic Functions
• In the mid-1980s, five major tasks of epidemiology in public health
practice were identified: public health surveillance, field investigation,
analytic studies, evaluation, and linkages
• A sixth task, policy development, was recently added
• These tasks are described below
Public health surveillance
• Public health surveillance is the ongoing, systematic collection, analysis,
interpretation, and dissemination of health data to help guide public
health decision making and action
• The purpose of public health surveillance, which is sometimes called
“information for action,”18 is to portray the ongoing patterns of disease
occurrence and disease potential so that investigation, control, and
prevention measures can be applied efficiently and effectively
• While public health surveillance traditionally has focused on
communicable diseases, surveillance systems now exist that target
injuries, chronic diseases, genetic and birth defects, occupational and
potentially environmentally-related diseases, and health behaviors
 Field investigation
• One of the first actions that results from a surveillance case report or
report of a cluster is investigation by the public health department
• The investigation may be as limited as a phone call to the health- care
provider to confirm or clarify the circumstances of the reported case,
or it may involve a field investigation requiring the coordinated efforts
of dozens of people to characterize the extent of an epidemic and to
identify its cause
• Investigations often lead to the identification of additional unreported
or unrecognized ill persons who might otherwise continue to spread
infection to others
• Field investigations of the type described above are sometimes
referred to as “shoe leather epidemiology,” conjuring up images of
dedicated, if haggard, epidemiologists beating the pavement in search
of additional cases and clues regarding source and mode of
transmission
 Analytic studies
• Design includes determining the appropriate research strategy and study
design, writing justifications and protocols, calculating sample sizes,
deciding on criteria for subject selection , choosing an appropriate
comparison group, and designing questionnaires
• Conduct involves securing appropriate clearances and approvals, adhering to
appropriate ethical principles, abstracting records, tracking down and
interviewing subjects, collecting and handling specimens, and managing the data
• Analysis begins with describing the characteristics of the subjects
• Finally, interpretation involves putting the study findings into
perspective, identifying the key take-home messages, and making sound
recommendations
Evaluation
• Effectiveness refers to the ability of a program to produce the
intended or expected results in the field; effectiveness differs from
efficacy, which is the ability to produce results under ideal conditions

• Efficiency refers to the ability of the program to produce

 Linkages
• Epidemiologists working in public health settings rarely act in isolation
• Other team members may be laboratorians, sanitarians, infection
control personnel, nurses or other clinical staff, and, increasingly,
computer information specialists
• Mechanisms for sustaining such linkages include official memoranda
of understanding, sharing of published or on-line information for
public health audiences and outside partners, and informal
networking that takes place at professional meetings
 Policy development
• Epidemiologist who understand a problem and the population in
which it occurs are often in a uniquely qualified position to
recommend appropriate intervention
• As a result, epidemiologists working in public health regularly provide
input, testimony, and recommendations regarding disease control
strategies, reportable disease regulations, and health-care policy
The Epidemiologic Approach
• Counts cases or health events, and describes them in terms of time,
place, and person
• Divides the number of cases by an appropriate denominator to
calculate rates; and
• Compares these rates over time or for different groups of people
Components of a case definition
for outbreak investigations
• A case definition consists of clinical criteria and, sometimes,
limitations on time, place, and person
• Case definitions used during outbreak investigations are more likely to
specify limits on time, place, and/or person than those used for
surveillance
• Contrast the case definition used for surveillance of listeriosis with the
case definition used during an investigation of a listeriosis outbreak in
North Carolina in 2000.25,26 Both the national surveillance case
definition and the outbreak case definition require a clinically
compatible illness and laboratory confirmation of Listeria
monocytogenes from a normally sterile site, but the outbreak case
definition adds restrictions on time and place, reflecting the scope of
the outbreak
Criteria in case definitions
• A generalized rash lasting greater than or equal to 3 days
• A temperature greater than or equal to 101.0°F
• Cough, coryza, or conjunctivitis
• Positive serologic test for measles immunoglobulin M antibody, or
• Significant rise in measles antibody level by any standard serologic
assay, or
• Isolation of measles virus from a clinical specimen
Case classification
• International
• Out-of-State
Modifying case definitions
• The first case definition for SARS, based on clinical symptoms and
either contact with a case or travel to an area with SARS transmission,
was published in CDC’s Morbidity and Mortality Weekly Report on
March 21, 2003 .27
• On March 29, after a novel coronavirus was determined to be the
causative agent, an interim surveillance case definition was published
that included laboratory criteria for evidence of infection with the
SARS- associated coronavirus
• In anticipation of a new wave of cases in 2004, a revised and much
more complex case definition was published in December 2003.28
Variation in case definitions
• Case definitions may also vary according to the purpose for classifying
the occurrences of a disease
• A sensitive case definition is one that is broad or “loose,” in the hope
of capturing most or all of the true cases
• For example, the case definition for a suspected case of rubella is “any
generalized rash illness of acute onset.”25 This definition is quite
broad, and would include not only all cases of rubella, but also
measles, chickenpox, and rashes due to other causes such as drug
allergies
DESCRIPTIVE EPIDEMIOLOGY
• Descriptive study is the first phase of epidemiological investigation
• Observing the distribution of disease or health related events in
human population
• Identify the characteristics with which the disease is associated
• Basically 3 question are asked who, when, and where
• Who means the person affected, where means the place and when is
the time distribution
Steps of descriptive study
• Defining the population
• Defining the disease
• Describing the disease by (a) Time (b) Place (c) Person
• Measurement of disease
• Comparing with known indices
• Formulation of etiological hypothesis
Defining the population

• Age and sex composition of selected group

• Education
• Occupation
• Socio-economic status
• Marital status
Defining the disease
Mainly operational definition of the disease keeping in the mind the
objective of study
Describing the disease-
Time distribution

Short term fluctuation Periodic fluctuation Long term fluctuation

A. Common source epidemic A. Seasonal trend A. Secular trend
1. Single exposure or point source B. Cyclic trend
2. Continuous or multiple source
B. Propagated epidemic
1. Person to person 2. arthropod vector 3. animal reservoir

c. Slow or modern epidemic

Place distribution
Presence of disease varies in different geographical areas depended
upon the environmental condition and genetic variation of the host.
a. International variation- Ca Cx and Ca oral cavity in india, Ca breast in
western countries.
b. National variation- malaria, endemic goitre, fluorosis
c. Rural urban variation- urban- lung Ca, CVDs, mental illness, chr.
Bronchitis. Rural- skin disease, zoonosis, soil transmitted diseases
d. Local distribution- endemic goitre, yellow fever
Person distribution
AGE: Childhood- measles, upper respiratory tract illness, pneumonia etc.
Middle Age- Cancer, accident, occupational dis, peptic ulcer
Old age- atherosclerosis, cancer, cardiovascular dis, hypertension, chronic degenerative dis.
Bio modality- Hodgkin’s dis
SEX: Some disease are common in females and some in males.
In males- lung ca
In females- breast, ovarian, cervical ca
MARITAL STATUS: Cancer cx more common in early marriage, multiple sex partners.
OCCUPATION: sedentary occupation more of cardiovascular risk, diabetes, obesity.
Occupational hazards like skin ca and allergy in dye industry, bronchitis, and lung did
in dusty trades.
SOCIAL CLASS: Low socio-economic status: malnutrition, respiratory and skin
disease.
High socio-economic status: cardiovascular dis, coronary artery dis.
BEHAVIOUR: Human behavior is looked as a risk factor. Coronary heart dis, cancer,
obesity, accidents are modern day dis.
Smoking, sedentary lifestyle, overeating, drug abuse
STRESS: effect on susceptibility, exacerbation of symptoms, compliance of medical
regimen.
Measurement of disease
• Mandatory to know the disease load in the population. Measured in terms of
mortality, morbidity, and disability
• Mortality can be measured as crude rates or specific rates. E.g Age specific
and sex specific mortality rates
• Morbidity measured in terms of incidence rates (point prevalence and period
prevalence). Incidence rates obtained by longitudinal studies and prevalence
rate by cross sectional studies (simplest form of observational studies based
on single examination at one point of time in the whole population
• Longitudinal studies are done for a longer time and follow up examination
done useful for study of natural history of dis, find out risk factors and
incidence rate of dis.
Comparing with known indices:
• The epidemiological studies done to compare with known indices or comparing
with two communities or two groups of population.
Formulation of hypothesis:
1. The population characteristics
2. Specific causes
3. Expected outcome of the disease
4. Dose response relationship
5. Time response relationship
Types of descriptive study
1. Case report and case series: describe about the case, sign,
symptoms, laboratory test, finding etc.

2. Cross-sectional descriptive studies

3. Longitudinal descriptive studies: epidemiological descriptive studies

done according to person, place, and time.
Difference between Descriptive and
Analytical epidemiology
Descriptive epidemiology Analytical epidemiology
• Only one group studies • At least two groups are studied
• At the start of study there is no for comparison
explicit hypothesis regarding • At the start of the study there is
cause effect relationship definite hypothesis regarding an
• The study ends in development exposure possibly causing an
of hypothesis regarding cause outcome
and effect relationship but does • At the end of the study it
not confirm or reject such confirms or rejects the
hypothesis hypothesis with which it started
Analytic Epidemiology
• Second major type of epidemiological studies
• Subject of interest is the individual or small groups of individuals in
contrast to descriptive studies where researcher deals with large
population
• Tests the hypothesis
• Inference is to population
Case control studies

• A common first approach to test causal hypothesis

• Increasingly used to know the cause of diseases, especially rare
diseases
• Other names: case referent
retrospective or
trohoc studies
Features of case control studies

• Both exposure and outcome have occurred before the onset of the
study
• Study proceeds backwards, from effect to cause
• Use a control or comparison group to support or refute an inference
Steps
1. Selection of cases and controls

2. Matching

3. Measurement of exposure

4. Analysis and interpretation

1. Selection of cases and controls
• Selection of cases
- define the cases
diagnostic criteria
eligibility criteria
- sources of cases
hospitals
general population
• Selection of controls
- crucial step in case control studies
- controls must be
free from the disease under study.
Be similar to the cases except for the absence
the disease under the study.
• Sources of controls

- hospitals
- relatives
- neighborhood controls
- general population
2. Matching
• Definition:

“The process by which we select controls in such a way that they are
similar to cases with regard to certain pertinent selected variables,
which are known to influence the outcome of disease and which, if not
adequately matched for comparability could distort or confound the
result.”
Confounding factor
- One which is associated with exposure and disease; and is distributed
unequally in study and control groups
- Although associated with ‘exposure’ under investigation, it itself is a
risk factor for the disease.
Eg alcohol- esophageal cancer : confounding factor- smoking
-Do no match the suspected etiological factor
- Methods of matching
Group matching
Matching by pairs
3. Measurement of exposure
• Exposure can be measured by
- Interviews
- Questionnaires
- By studying past records
- Examinations
• Bias should be avoided while measuring the exposure by blinding the
investigator
4.Analysis
• Involves two steps

1. Exposure rates among cases and controls to suspected factor

2. Estimation of disease risk associated with exposure(odds ratio)

Cohort studies
• Usually undertaken to obtain additional evidence to refute or support
the existence of an association between suspected cause and disease
• Other names
- Incidence study
- Forward looking study
- Longitudinal study
- Prospective study
Features
• Cohorts are identified prior to the appearance of the disease under
investigation
• Study groups are observed over a period of time to determine the
incidence of disease
• The study proceeds from cause to effect
Concepts of Disease Occurrence
• A critical premise of epidemiology is that disease and other health
events do not occur randomly in a population, but are more likely to
occur in some members of the population than others because of risk
factors that may not be distributed randomly in the population
• As noted earlier, one important use of epidemiology is to identify the
factors that place some members at greater risk than others
• Cohort is defined as a group of people who share a common
characteristic or experience within a defined period

• E.g., age cohorts, occupational cohorts, exposure to a drug cohorts,

marriage cohort etc.
Types of cohort study

• Prospective cohort study

• Retrospective cohort study

• Combination of retrospective and prospective cohort studies

Steps in cohort study

• Selection of study cohorts

• Obtaining data on exposure

• Selection of comparison groups

• Follow up

• analysis
Selection of study subjects

• Cohorts can be selected from

• General population

- Special groups

select groups (e.g. Doctors, lawyers, teachers, etc.)

exposure groups
Obtaining data on exposure
• Information can be obtained from
- Cohort members
- Review of records
- Medical examination or special tests
- Environmental surveys
• Information about exposure should facilitate classification of cohort
members
- According to whether or not they were exposed
- According to the degree of exposure
Selection of comparison groups

• Internal comparison

• External comparison

• Comparison with general population

 Follow up

• Periodic medical examination of each member

• Reviewing physician and hospital records

• Routine surveillance of morbidity and mortality records

• Mailed questionnaires, telephone interviews, periodic home visits

 Analysis

• Data is analyzed in terms of

i) Incidence rates of outcome among exposed and non-exposed

ii) Estimation of risk

- Relative risk

- Attributable risk
Epidemiological triad
• Agent originally referred to an infectious microorganism or pathogen: a virus,
bacterium, parasite, or other microbe
• Host refers to the human who can get the disease
• Environment refers to extrinsic factors that affect the agent and the opportunity
for exposure
AGENT

HOST ENVIRONMENT
Natural History and Spectrum of
Disease
• Natural history of disease refers to the progression of a disease process
in an individual over time, in the absence of treatment
• For example, untreated infection with HIV causes a spectrum of clinical
problems beginning at the time of seroconversion and terminating with
AIDS and usually death
• It is now recognized that it may take 10 years or more for AIDS to
develop after seroconversion.43
• Many, if not most, diseases have a characteristic natural history,
although the time frame and specific manifestations of disease may vary
from individual to individual and are influenced by preventive and
therapeutic measures
Natural History and Spectrum of
Disease
• For cancer, the exposure may be a factor that initiates the process, such as
asbestos fibers or components in tobacco smoke , or one that promotes the
process, such as estrogen
• This stage of subclinical disease, extending from the time of exposure to onset
of disease symptoms, is usually called the incubation period for infectious
diseases, and the latency period for chronic diseases
• During this stage, disease is said to be asymptomatic or inapparent
• Although disease is not apparent during the incubation period, some
pathologic changes may be detectable with laboratory, radiographic, or other
screening methods
• The onset of symptoms marks the transition from subclinical to clinical disease
Chain of Infection

• Human reservoirs

• Animal reservoirs

• Environmental reservoirs
 Portal of exit
• Path by which pathogen leaves the host
• Corresponds to the site where the pathogen is localized. E.g. influenza
viruses and mycobacterium tuberculosis exit the respiratory tract,
schitosomes through urine, cholera vibrios in feces, sarcoptes scabiei
in scabies skin lesions, and enterovirus 70, a cause of hemorrhagic
conjunctivitis, in conjunctival secretions.
• Some blood borne agents can exit by crossing the placenta from
mother to fetus (rubella, syphilis, toxoplasmosis), while others
through cuts or needles in the skin (hepatitis B) or (blood-sucking
arthropods (malaria)
Modes of transmission
• Direct
- Direct contact
- Droplet spread
• Indirect
- Airborne
- Vehicle borne
- Vector borne (mechanical or biological)
Modes of transmission

• Direct contact occurs through skin-to-skin contact, kissing, and sexual

intercourse

• Droplet spread refers to spray with relatively large, short-range

aerosols produced by sneezing, coughing, or even talking
• Indirect transmission refers to the transfer of an infectious agent
from a reservoir to a host by suspended air particles, inanimate
objects , or animate intermediaries
• Airborne transmission occurs when infectious agents are carried by dust or
droplet nuclei suspended in air
• Vehicles that may indirectly transmit an infectious agent include food, water,
biologic products , and fomites
• Vectors such as mosquitoes, fleas, and ticks may carry an infectious agent
through purely mechanical means or may support growth or changes in the
agent
Portal of entry

• Controlling or eliminating agent at source of transmission

• Protecting portals of entry

• Increasing host’s defenses

Epidemic Disease
Occurrence
Level of disease
• Hyperendemic refers to persistent, high levels of disease occurrence
• Pandemic refers to an epidemic that has spread over several countries or
continents, usually affecting a large number of people
• Epidemics occur when an agent and susceptible hosts are present in
adequate numbers, and the agent can be effectively conveyed from a
source to the susceptible hosts
• A recent increase in amount or virulence of the agent
• The recent introduction of the agent into a setting where it has not been before
• An enhanced mode of transmission so that more susceptible persons are exposed
• A change in the susceptibility of the host response to the agent, and/or
• Factors that increase host exposure or involve introduction
Epidemic Patterns
• Common-source
• Point
• Continuous
• Intermittent
• Propagated
• Mixed
• Other