Foundations of Epidemiology

Chapter 1

What is Health?

The absence of illness 6 dimensions of health

What are the 6 Dimensions of Health?

Physical Ability of the human body to function properly; includes physical fitness and activities of
daily living.

Social

Ability to have satisfying relationships; interaction with social institutions and societal
mores.

Mental

Ability to think clearly, reason objectively, and act properly.

Emotional
Spiritual

Ability to cope, adjust and adapt; self-efficacy and self-esteem.

Feeling as if part of a greater spectrum of existence; personal beliefs and choices.

Environmental Comprised of external factors (i.e., ones surroundings such as habitat or occupation) and internal factors (i.e., ones internal structure such as genetics).

What is Public Health?

Public health is the science and art of promoting health and extending life on the population level. Public health is concerned with threats to health in the population (a group of people sharing one or more characteristics). The mission of public health is to ensure conditions that promote the six dimensions of health in the population as a whole.

What is the Meaning of Population?

Population refers to a collection of individuals that share one or more observable personal or observational characteristics from which data may be collected and evaluated. Social Economic Family (marriage and divorce) Work and labor force Geographic factors

How does Public Health Relate to Epidemiology?

There are many subfields of public health, including epidemiology, biostatistics, and health services. Because of its central role in public health, epidemiology is commonly referred to as the foundation of public health.

What is Epidemiology?
Epidemiology is the study of the distribution and determinants of health-related states or events in human populations, and the application of this study to prevent and control health problems.

What is Epidemiology?
The word epidemiology is based on the Greek words:
epiprefix meaning on, upon, or befall demosroot meaning the people logossuffix meaning the study

In other words, epidemiology is the study of what befalls the population.

Key Terms in the Definition

Study - Epidemiology involves sound methods of scientific investigation. Methods rely on careful observation and the use of valid comparison groups to determine whether the observed health events differ from what might be expected.

Key Terms in the Definition

Distribution Study of frequency and pattern of health events in the population Frequency number, and number in relation to the population Pattern the health-related state or event by person, place, and time characteristics

Key Terms in the Definition

Determinants Search for causes and other factors of health-related states or events.

Key Terms in the Definition

Health-related states or events Disease states cholera, influenza, pneumonia, mental illness Conditions associated with health

Events

physical activity, nutrition, environmental poisoning, seat belt use, and provision and use of health services injury, drug abuse, and suicide

Key Terms in the Definition

Application of this study to prevent and control health problems.

Why is Epidemiology Considered by Many to be the Foundation of Public Health?

Because of its central role in carrying out the three core public health functions:
1. The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities. 2. The formulation of public policies designed to solve identified local and national health problems and priorities. 3. To assure that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care.

The Epidemiologic Focus

Clinical focus vs. epidemiologic focus

Epidemiology and the Scientific Method

Epidemiology uses the scientific method to describe and analyze health-related states or events.

What is the Scientific Method?

The scientific method involves using appropriate study designs and statistical techniques for investigating an observable occurrence and acquiring new knowledge. The health problem Hypotheses Statistical testing Interpretation Dissemination

Study Designs in Epidemiology

Descriptive epidemiology Involves study designs used to answer: Who? What? When? Where? Analytic epidemiology Involves study designs used to answer: Why? How? Later chapters will focus on describing these study designs.

The Importance of Descriptive Epidemiology

A means to characterizing the distribution of health-related states or events by Person who? Place where? Time when? Clinical criteria what?

The Importance of Analytic Epidemiology

A means to identifying and quantifying associations, testing hypotheses, and supporting statements about causality Explains why and how health-related states or events occur

Selected Activities Performed in Epidemiology

Identifying risk factors for disease, injury, and death Describing the natural history of disease Identifying individuals and populations at greatest risk for disease Identifying where the public health problem is greatest Monitoring diseases and other health-related events over time Evaluating the efficacy and effectiveness of prevention and treatment programs

Selected Activities Performed in Epidemiology

Providing information useful in health planning and decision making for establishing health programs with appropriate priorities Assisting in carrying out public health programs Being a resource person Communicating public health information

Epidemiology in Public Health Practice and Individual Decision Making

Epidemiological findings contribute to Preventing and controlling disease, injury, disability, and death How? By providing information leading to informed public health policy and planning, as well as individual health decision making

Selected Types of Epidemiologic Information

Public health assessment Causes of disease Completing the clinical picture Program evaluation Efficacy Effectiveness

Questions that Need Epidemiology

Diagnosis
Is there such a problem as myalgic encephalitis? Is prostate specific antigen a good test for prostate cancer?

Causes
Why did this patient suffer a stroke? Is obesity the cause of metabolic syndrome?

Questions that Need Epidemiology

Treatment
Is this the best treatment for Parkinson's disease? Is my surgery as good as that of everyone else?

Prognosis
What are the chances of a recurrent heart attack? How long will this knee joint prosthesis last?

Questions that Need Epidemiology

Health promotion and protection Do current school meals harm children's future health? Will the Irish smoking ban in public places work better than the English policy? Health and disease surveillance Why are there 10 fold international differences in suicide rates? When will the next influenza pandemic occur?

Questions that Need Epidemiology

Health inequalities Why should life expectancy be nearly five years lower in unskilled manual workers? Do health services reduce or increase health inequalities?

Epidemic, Endemic, and Pandemic

Epidemic Health-related state or event in a defined population above the expected over a given period of time Endemic Persistent, usual, expected healthrelated state or event in a defined population over a given period of time Pandemic Epidemic affecting a large number of people, many countries, continents, or regions

Common Source, Propagated, and Mixed Epidemics

Common source Point Intermittent Continuous Propagated Spread from person to person Mixed epidemics A mixture of common source and mixed

Common Source
Tend to result in more cases occurring more rapidly and sooner than host-to-host epidemics. Identifying and removing exposure to the common source typically causes the epidemic to rapidly decrease.

Common Source
Examples anthrax, traced to milk or meat from infected animals botulism, traced to soil-contaminated food cholera traced to fecal contamination of food and water

Propagated
Arise from infections being transmitted from one infected person to another Transmission can be through direct or indirect routes Host-to-host epidemics rise and fall more slowly than common source epidemics

Propagated
Examples tuberculosis whooping cough influenza measles

Mixed Epidemics
Occurs when a common source epidemic is followed by person-to-person contact and the disease is spread as a propagated outbreak Example Shigellosis occurred among a group of 3000 women attending a music festival. Over the next few weeks, subsequent generations of shigella cases spread by person-to-person transmission from festival attendees.

Disease Transmission
Disease transmission usually occurs by direct, person-to-person contact (e.g., STDs) fomite-borne (e.g., Hepatitis A spread by a contaminated eating utensil) vehicle-borne (e.g., HIV/AIDS spread through needle sharing drug users) vector-borne (e.g., Malaria spread through mosquitoes)

Accurate Assessment Requires a Standard Case Definition

A standard set of criteria, or case definition, assures that cases are consistently diagnosed, regardless of where or when they were identified and who diagnosed the case

Concepts and Principles of Case as Used in Epidemiology

A case is a person who has been diagnosed as having a disease, disorder, injury, or condition

Primary Case, Index Case

The first disease case in the population is the primary case. The first disease case brought to the attention of the epidemiologist is the index case. The index case is not always the primary case.

Secondary Case
Those persons who become infected and ill after a disease has been introduced into a population and who become infected from contact with the primary case

Different Levels of Diagnosis

Suspect An individual who has all of the signs and symptoms of a disease or condition, yet not diagnosed Confirmed All criteria met

Different Levels of Diagnosis

As more information (such as laboratory results) becomes available to the physician, he or she generally upgrades the diagnosis. When all criteria are met and they meet the case definition, the case is classified as a confirmed case.

Epidemiology Triangle for Infectious Disease

Triangle is Based on the Communicable Disease Model

Shows the interaction and interdependence of agent, host, environment, and time as used in the investigation of diseases and epidemics.
Agent is the cause of the disease Host is an organism, usually a human or an animal, that harbors a disease Environment includes those surroundings and conditions external to the human or animal that cause or allow disease transmission Time accounts for incubation periods, life expectancy of the host or the pathogen, and duration of the course of the illness or condition.

Stopping an Epidemic
An epidemic can be stopped when one of the elements of the triangle is interfered with, altered, changed, or removed from existence, so that the disease no longer continues along its mode of transmission and routes of infection

Some Disease Transmission Concepts

Fomites Objects such as clothing, towels, and utensils that may harbor a disease agent and are capable of transmitting it; usually used in the plural Example transmission of cutaneous anthrax from drums to an individual

Vector
An invertebrate animal (e.g., tick, mite, mosquito, bloodsucking fly) capable of transmitting an infectious agent among vertebrates Can spread an infectious agent from an infected animal or human to other susceptible animals or humans through its waste products, bite, body fluids, or indirectly through food contamination

Plague
Yersinia pestis (the bacteria that causes plague) is found in animals throughout certain parts of the world, most commonly in rats, but occasionally in other wild animals, such as prairie dogs. Plague transmission from these infected animals generally occurs in one of three ways:

Plague
Bites from infected rodent fleas (85%) Direct contact with infected tissue or bodily fluids
For example, people can become directly infected with plague by handling infected rodents, rabbits, or wild carnivores that prey on these animals when plague bacteria enter through the person's skin.

Inhaling infected droplets.

Reservoir
The habitat (living or nonliving) on which an infectious agent lives, grows, multiplies, and is dependent on for its survival in nature Humans often serve as both reservoir and host

Zoonosis
When an animal transmits a disease to a human Examples rabies, Rocky Mountain spotted fever, shigellosis

Carrier
A carrier contains, spreads, or harbors an infectious organism Example Typhoid Mary

Modes of Disease Transmission

Direct transmission direct physical contact such as touching with contaminated hands, skin-to-skin contact, kissing, or sexual intercourse
Indirect transmission occurs when pathogens or agents are transferred or carried by some intermediate item, organism, means, or process to a susceptible host, resulting in disease

Advanced Epidemiology Triangle for Chronic Diseases and Behavioral Disorders

Three Levels of Prevention Used in Public Health and Epidemiology

Primary prevention (occurs prior to exposure) Immunization Sanitation Education Media campaigns Warning labels

Active Primary Prevention

Requires behavior change on part of subject Wearing protective devises Health promotion Lifestyle changes Community health education Ensuring healthy conditions at home, school and workplace

Passive Primary Prevention

Does not require behavior change Vitamin fortified foods Fluoridation of public water supplies

Secondary Prevention
Occurs to reduce the progress of disease The disease already exists in the person Cancer screening cancer already present. The goal is to detect the cancer before clinical symptoms arise in order to improve prognosis and prevent conditions from progressing and from spreading

Tertiary Prevention
To reduce the limitation of disability from disease The disease has already occurred Physical therapy for stroke victims Halfway houses for recovering alcoholics Shelter homes for the developmentally disabled Fitness programs for heart attack patients