Acta Tropica 91 (2004) 219225

Spatial analysis for epidemiology

Abstract

Remote sensing, geographical information systems (GIS) and spatial analysis provide important tools that are as yet under-
exploited in the fight against disease. As the use of such tools becomes more accepted and prevalent in epidemiological studies,
so our understanding of the mechanisms of disease systems has the potential to increase. This paper introduces a range of
techniques used in remote sensing, GIS and spatial analysis that are relevant to epidemiology. Possible future directions for the
application of remote sensing, GIS and spatial analysis are also suggested.
2004 Elsevier B.V. All rights reserved.

Keywords: Remote sensing; Geographical information systems; Spatial statistics; Geostatistics; Scale; Ecology

1. Introduction storage, retrieval, analysis and display of spatial data.

This special issue assembles papers originally pre-
sented at, or inspired by, a 1-day meeting held at the
University of Salford, UK, in June 2003, on Epidemi-
ology: A Spatial Perspective. The meeting was con-
vened to discuss the roles of remote sensing, geograph-
ical information systems (GIS), geostatistics, ecology
and spatial modelling in epidemiology and public
health. The papers in this special issue have been se-
lected to provide the reader with an insight into the op-
portunities offered by remote sensing, GIS and spatial
analysis for enhancing epidemiological investigations.
Epidemiology is an established discipline in the
health sciences and researchers and practitioners are
used to dealing with spatial data. However, despite
acknowledging the importance of spatially explicit
processes in determining disease risk, the use of spa-
tial information beyond recording spatial location and
mapping disease risk is rare (Jacquez, 2000). Devel-
opments in the application of remote sensing, GIS and
spatial analysis (e.g., spatial statistics, geostatistics,
spatially distributed process models) in epidemiolog-
ical studies over the last 25 years, and particularly
in the past decade, have enhanced the acquisition,
Such techniques have great potential to increase un-
derstanding of the links between disease processes
and explanatory spatial variables.
Much research using GIS and spatial analysis tech-
niques relies on data acquired by satellite-based ob-
serving systems. Satellite sensors have the potential
to revolutionise research and operational studies in
epidemiology as they acquire unparalleled amounts
of data about the surface of the planet with synoptic
cover at a variety of spatial and temporal resolutions.
Comprehensive reviews on the use of remote sensing
and GIS for epidemiological applications have been
provided recently by Thomson and Connor (2000)
and Hay et al. (2000) and they indicate that with
reductions in cost and increases in ease of access, dis-
semination and use of such remote sensing data, the
benefits of remote sensing are now within the reach
of many epidemiologists. Spatial data on vegetation
type, land cover, land surface temperature and soil
moisture are all examples of variables that are poten-
tially useful in epidemiology and may be estimated
from remotely sensed data.
A GIS is a series of tools for the acquisition, stor-
age, retrieval, analysis and display of spatial data. A

0001-706X/$ see front matter 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.actatropica.2004.05.001
220 A.J. Graham et al. / Acta Tropica 91 (2004) 219225
GIS can be used readily to integrate data represented
in different formats (e.g., raster data model or image
data, vector data model or point, line and area data),
at different spatial resolutions, represented in differ-
ent coordinate systems, with different errors (via error
propagation modelling). Commonly, a GIS is used to
combine such diverse data sources to map a property
that is a function of them using operations such as
overlay.
Spatial statistical methods account for the spatial
variation inherent in spatial data and can be used for
statistical inference. For example, geostatistical tech-
niques can be used for optimal spatial prediction (in-
terpolation) between sparse sample points. This spatial
prediction can be made based entirely on a stochastic
model, or in combination with a deterministic trend
(model of a non-stationary mean). The papers in this
special issue deal specifically with the applications of
such remote sensing, GIS and spatial analysis tech-
niques to different diseases.
2. Remote sensing and the ecology of disease
Disease ecology is a relatively new sub-discipline of
epidemiology. A controversial addition to the panoply
of techniques available to the epidemiologist (Gewin,
2004), it can potentially add to our understanding
of disease transmission processes. Disease ecology
attempts to investigate the biological, physical and
anthropogenic links between the environment and
disease and consequently must account for spatial
variation in transmission, a function of environmental
spatial variation. Transmission of communicable dis-
eases requires close contact between susceptibles and
infectives and may be linked to landscape and en-
vironmental variables through a definable ecological
system (Graham et al., 2004). Remotely sensed images
can be used to predict landscape properties at spatial
resolutions ranging from less than one metre to tens
of kilometres. The two most common terrestrial vari-
ables derived from satellite sensor imagery are land-
scape structure and vegetation cover maps (Beck et al.,
2000) and these data may be correlated with disease
transmission processes using a range of modelling
approaches. A typical approach involves classifying
remotely sensed images into habitats for disease vec-
tors. This has been achieved for the malaria vector
(Anopheles spp. mosquitoes) (Wood et al., 1992), the
vector of trypanosomiasis (Glossina spp. tsetse flies)
(Rogers, 2000), for tick-borne encephalitis (Randolph,
2000) and tick habitats for Lyme disease (Dister et al.,
1997). Ecological and remote sensing methods have
been employed for a wider range of diseases: dengue
(Carbajo et al., 2001), onchocerciasis (Thomson et al.,
2000), human fasciolosis (Fuentes et al., 2001) and
schistosomiasis (Brooker, 2002).
3. Spatial scale
The epidemiological factors that control disease
transmission operate over a range of spatial and
temporal scales to produce spatially and temporally
complex patterns of disease incidence. Many current
deterministic epidemiological models fail to take this
complexity into account and also fail to account for
the stochastic nature of disease transmission (Morgan
et al., 2004). Remote sensing provides a source of
data that can be used to characterise climate and
land surface variables at different spatial resolutions.
These variables can then be combined with other spa-
tial data to provide the building blocks for spatially
explicit transmission risk models.
Climate is a significant factor that affects the spa-
tial distribution of many infectious diseases through
controls on host or vector physiology and behaviour.
For example, meningitis epidemics in Africa have
been related to climatic conditions (Molesworth et al.,
2002) and the El Nin Southern Oscillation has been
implicated for increased cholera risk in Bangladesh
and malaria in South East Asia (Kovats et al., 2003).
Seasonal variation in land surface temperature de-
rived from remotely sensed data has been related to
tick-borne encephalitis distribution and Lyme disease
in Europe (Randolph et al., 2000). Spatial prediction
of malaria vector distributions has been undertaken
for large areas of the African continent using re-
motely sensed data to map temperature, moisture and
vegetation cover (Hay et al., 2000), and these coarse
spatial resolution data are now used in early warning
systems for malaria epidemics (Hay et al., 2001).
Brooker and Michael (2000) reviewed the application
of remote sensing and GIS in the study of human
helminth infections and showed that environmental
factors, such as temperature, humidity and altitude,
 A.J. Graham et al. / Acta Tropica 91 (2004) 219225
which affect the distribution of helminths, may be de-
termined from remotely sensed data and used within a
GIS environment to provide increased understanding
of parasite transmission.
In general, climatic variables influence disease epi-
demiology in a similar way over large areas so that
satellite sensor data with a coarse spatial resolution of
1 km or more are adequate to capture the epidemiolog-
ically important patterns in such variables. Landscape
factors may vary at a finer spatial scale and give rise
to local variability in host distributions, transmission
patterns and disease risk. Linking to disease ecology
studies, habitat mapping of larval mosquito popula-
tions associated with fresh or brackish water has been
undertaken (Wood et al., 1992). Land cover informa-
tion is required for small areas, and therefore, requires
the use of medium spatial resolution remotely sensed
data, commonly data from the Landsat series of satel-
lites with a spatial resolution of 30 m. The relevant
land cover data may be imported into a GIS and sim-
ple spatial measures of distance between village and
mosquito habitat used to predict risk of malaria trans-
mission (Thomas and Lindsay, 1999).
Some parasitic diseases are transmitted in a wide
variety of hosts so that their spatial distribution is de-
pendent on the location of suitable host habitats and
on host species ranges. Furthermore, there may be no
requirement for direct contact between hosts. For ex-
ample, the fox tapeworm Echinococcus multilocularis
is transmitted between a canid definitive host (fox,
dog, coyote) and a range of small mammal intermedi-
ate hosts (Danson et al., 2003). The tapeworm has an
indirect lifecycle where the egg stage may be isolated
in the environment for long periods of time before in-
gestion by a small mammal (Graham et al., 2004). In
this case, microclimatic conditions determine, in part,
the spatial distribution of infective eggs and landscape
composition determines the presence or absence of in-
termediate small mammal hosts and their population
dynamics. Further, for sustainable transmission the
eggs must be deposited within the home range of one
or more foxes. This gives rise to highly complex spa-
tially variable transmission patterns which require fine
spatial resolution data for landscape mapping (Morgan
et al., 2004).
It is clear that disease epidemiology often has a spa-
tial dimension which may be related to coarse spatial
scale variation in climate or to fine spatial scale varia-
221
tion in landscape. Seasonal or longer-term climate or
landscape change will influence transmission risk pat-
terns in many different ways and satellite remote sens-
ing provides one source of data to map and monitor
these patterns.
4. Spatial statistics
Spatial statistics can be divided into (i) methods for
point pattern analysis, (ii) methods for lattice data and
(iii) geostatistics (Cressie, 1991). Of these, the geosta-
tistical approach is most relevant to epidemiological
analysis conducted at the landscape scale and based on
remote sensing and so it forms the focus of this sec-
tion. For more information on geostatistical methods,
the reader is referred to Goovaerts (1997) and Chiles
and Delfiner (1999). For examples of geostatistics in
epidemiology, see Webster et al. (1994), Diggle et al.
(2002) and Goovaerts (2004).
As suggested in the introduction, although location
is an implicit aspect of most epidemiological analyses,
explicit use of location is rare. In geostatistics, use is
made of the phenomenon of spatial dependence: the
tendency for proximate observations to be more sim-
ilar than more distant ones. Spatial dependence may
be represented by a range of functions. Here, we fo-
cus on the variogram. Given n data z(xi ) on property z
at locations xi , i = 1, 2, . . . , n, the sample variogram
(h) may be estimated for a set of discrete lag (dis-
tance and direction) vectors h using:
N(h)
1

(h) = {z(xi ) z(xi + h)}2 (1)
2N(h)
i=1
where N(h) is the number of paired comparisons at
the set of discrete lags h. The variogram represents
the spatial dependence (the tendency for proximate
points to be more related than more distant ones)
in the data. Alternative functions such as the spatial
covariance and autocorrelation function may also be
used. Once the sample variogram has been estimated,
it is necessary to fit a continuous mathematical model
to it to allow statistical inference (see McBratney and
Webster, 1986).
The modelled variogram can be used in a wide range
of geostatistical operations. The geostatistical method
for spatial prediction known as kriging is optimal
222 A.J. Graham et al. / Acta Tropica 91 (2004) 219225
(minimum prediction variance and unbiased) under
the constraint that the prediction z(x0 ) at location x0
is a linear weighted sum of j neighbouring data z(xj ):
m


z(x0 ) = j z(xj ) (2)
j=1
where the j are the j weights. Optimality is obtained
by selecting the weights based on the variogram: prox-
imate neighbours receive more weight than more dis-
tant data, and the exact weights are determined from
the fitted mathematical (variogram) model. Unbiased-
ness is achieved by setting the sum of the kriging
weights to one. The kriging variance (the minimised
prediction variance) is estimated as a by-product of
the kriging process; a useful model-based measure of
uncertainty for epidemiological analyses.
Kriging comes in many forms depending on (i)
whether the objective is to predict to points, blocks or
the entire region, (ii) whether the data are univariate
or multivariate and (iii) how the mean value is mod-
elled (Goovaerts, 1997; Pleydell et al., 2004). Kriging
has obvious utility in epidemiology where risk data
are generally obtained at a sparse set of locations only
(e.g., health facilities or survey points; see Gething
et al. (2004)).
While kriging is optimal on a point-by-point basis,
a major drawback is that as a consequence of smooth-
ing, the (known) spatial character of the original data
is not maintained in the predicted map. Conditional
simulation or stochastic imaging (Journel, 1996) is an
alternative to kriging that honours the original vari-
ogram (the variogram of the predictions matches that
of the original data). In a general sense, this is achieved
by drawing a value randomly from the posterior dis-
tribution of the prediction rather than taking its mean.
The stochastic element of the method allows the re-
alization (drawing) of an infinite number of alterna-
tive maps, each of which honours the variogram (is a
possible reality). Conditional simulation has potential
use in epidemiology, particularly where the investiga-
tor wishes to convey the uncertainty in the prediction
process to the practitioner or user of the map.
Many other useful geostatistical operations exist,
including regularization (convolution of the vari-
ogram) and optimal sampling design. Geostatistics
now provides a powerful toolkit for the epidemiol-
ogist analysing spatial data and such techniques are
easily implemented using freeware packages such as
Gstat (Pebesma and Wesseling, 1998).
5. Papers in this special issue
Pleydell et al. (2004) examine the tapeworm
Echinococcus multilocularis and its distribution across
Europe. The authors emphasise the need to map in-
fection risk in wildlife in order to monitor spatial and
temporal change in transmission risk to humans. This
is achieved through the use of geostatistical interpola-
tion of laboratory analysed faecal matter. The results
suggest the importance of ecologically relevant trend
parameters and the need to accurately define those
parameters in a kriging model. Graham et al. (2004)
continue the theme of analysing epidemiological data
in terms of landscape and disease transmission ecol-
ogy. As with Pleydell et al. (2004), the emphasis is on
the transmission of Echinococcus multilocularis, this
time for high risk populations in China rather than Eu-
rope. A map of vegetation cover was generated using
Landsat remotely sensed data and landscape metrics
were extracted and related to infection prevalence for
sample villages at different temporal and spatial in-
tervals. The results demonstrate that spatially linked
habitat form and function are important factors in
determining transmission of this disease under these
environmental and social conditions.
Noor et al. (2004) are interested specifically in the
use of GIS for data acquisition and analysis. They
report on the geographic inequalities of health ser-
vice provision in Kenya and the disparities caused by
economic, social, service and environmental factors.
As stated in their paper, our understanding of spatial
determinants of risk, access to services and health
equity in much of the developing world is poor.
The authors describe the construction of a Kenyan
national map of health service providers to bring to
light the problems in the region and state how GIS
can inform national, international, governmental and
non-governmental bodies. Closely linked to this paper
is another in the special issue. Gething et al. (2004)
recognise decision-makers need for knowledge of
spatio-temporal variation in disease rates and associ-
ated levels of access to health services. Their paper
uses a data-driven approach to assess approaches to
health facility catchment mapping in Kenya. The re-
 A.J. Graham et al. / Acta Tropica 91 (2004) 219225
sults refute the previously held hypothesis that facili-
ties have an equal power to draw potential patients. In
particular, fuzzy choice values are used to demon-
strate the influence of facility type on catchment size.
Two papers deal explicitly with cluster analysis. Lin
and Zhang (2004) focus on spatial clustering and in-
troduce a testing method devised to test for the exis-
tence of high or low value clustering. Such methods
could then be applied to epidemiological data to anal-
yse spatial anomalies in an average disease surface.
Baker (2004) adds a temporal dimension to the spa-
tial clustering method stating that a cluster of cases
that are close both in space and in time indicates an
infectious aetiology. The test used in Bakers paper
is modelled as a point with intensity increasing with
distance towards an infector.
6. Discussion
This introduction, and the papers included in this
special issue, reflect the growing importance of spa-
tial data acquisition and analysis in epidemiology. Fu-
ture epidemiological studies should seek to make ex-
plicit use of spatial information, and in particular, it is
suggested that surveys should include measurement of
spatial location as a matter of course to allow a com-
plete analysis of the spacetime phenomenon that is a
disease outbreak.
The variety of methods outlined in the papers in this
special issue demonstrate, using a sample of the tech-
niques available to epidemiologists and health work-
ers, the potential of remote sensing, GIS and spatial
analysis for epidemiological analysis. However, if this
potential is to be realized, user groups must be con-
ducive to their uptake. Jacquez (2000) listed some of
the reasons for the slow uptake of remote sensing and
GIS techniques in the health sciences. They included
epidemiologists not being trained to think spatially, a
dearth of studies that demonstrated adequately the po-
tential of GIS and the lack of bespoke GIS packages
for health applications.
The future spatial analysis of epidemiological data
will be driven by several key issues. Included in these
are increases in the speed and storage capacity of
computers, the development of process-based spatial
disease transmission models and the dissemination
of useful software packages to workers in the health
223
sector. For the research community, larger, more ac-
curately positioned datasets are the goal for more ef-
fective and accurate spatial analysis. Remote sensing,
particularly from the new generation of fine spatial
resolution satellite sensors, provides a potential so-
lution, at least locally. With increased computational
power and data storage such analysis need not be
constrained to local areas (Coetzee, 2004), but may
be extended to regional or even to global scales.
The complexity of most disease systems means
that accurate process-driven models of transmission
may be difficult to construct. Nevertheless, many
epidemiologists are currently aiming to develop spa-
tially distributed process models (Gewin, 2004). Such
models will link disease transmission function, space
and time. Importantly, the process understanding en-
capsulated by the models will allow predictions to
be made into the future based on (i) real-time sce-
narios (e.g., using data assimilation techniques) for
early warning and efficient disease control and (ii)
possible whatif scenarios of the future (e.g., under
uncertain climate change).
There is considerable debate about the likely change
in the epidemiology of infectious diseases under fu-
ture climate scenarios. Increases in temperature and
rainfall predicted for some parts of the world may
give rise to change in the spatial distribution and in-
cidence of disease, although the patterns are likely
to be disease-specific (Molyneaux, 2003). Change in
the spatial distribution of malaria in east Africa has
been attributed to climate change (Patz et al., 2002)
although it may be difficult to determine cause and ef-
fect since changes in resistance to anti-malarial drugs
and reductions in control activities may be more im-
portant (Hay et al., 2002). Spatial analysis will be a
key tool for building and testing predictive models of
the effect of changing climate on disease patterns.
Some key issues were explored in a panel discus-
sion as part of the 1-day meeting at the University of
Salford. The key issues raised by delegates were as
follows:
(i) The difficulties of calibrating and validating spa-
tial predictions (maps were discussed). Epidemi-
ology, possibly more than any other discipline,
creates numerous maps of risk, many of which are
untestable or difficult to test satisfactorily. Such
spatial predictions need to be subjected to rigor-
224 A.J. Graham et al. / Acta Tropica 91 (2004) 219225
ous validation to provide researchers and practi-
tioners with information on the uncertainties in
their data and maps. Decision-makers must be
presented with both prediction and associated un-
certainty.
(ii) Statistical uncertainty should be incorporated into
spatial models where possible. Modelling uncer-
tainty enables predictions to be evaluated in terms
of their precision (e.g., kriging variance) without
the need to refer to external (e.g., split sample) or
internal (e.g., jack-knifing) data-based validation
procedures.
(iii) Validation is also a pre-requisite to model choice.
It is important to understand which of several
competing models is most useful for a particular
application or problem and validation can help
in this regard. Further, the techniques and proce-
dures used to predict disease spatially should be
wholly transparent to enable both the techniques
used and predictions made in competing studies
to be compared sensibly.
(iv) Issues of scale and spatial resolution were also a
concern. Choosing an appropriate spatial resolu-
tion for a particular investigation is difficult. In
general terms, spatial resolution should be chosen
in relation to the frequency of spatial variation
in the property of interest, and critically, so as to
resolve the variation of interest. In practice, it is
likely that data with several different spatial reso-
lutions may need to be combined within a single
analysis and that the results of different analyses
may be presented at different spatial resolutions,
confounding direct comparison. The same argu-
ments apply to the temporal dimension.
To date, remote sensing, GIS and spatial analysis
tools have generally been used off-the-shelf by epi-
demiologists. In line with the recommendations made
by Jacquez (2000), it is time for epidemiologists to
seize the initiative and work with software program-
mers and spatial analysts to create bespoke spatial
techniques for use with epidemiological data.
Acknowledgements
The authors would like to thank C. Cain for her
assistance in organising Epidemiology: A Spatial
Perspective, the editors of Acta Tropica for agreeing
to publish this special issue, the participants of the
meeting and the contributors to this special issue.
All reviewers of papers in this special issue are also
acknowledged gratefully.
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A.J. Graham
TALA Research Group, Department of Zoology
University of Oxford, South Parks Road
Oxford OX1 3PS, UK
Corresponding author
E-mail address:
alastair.graham@zoology.oxford.ac.uk
P.M. Atkinson
School of Geography, University of Southampton
Highfield, Southampton SO17 1BJ, UK
F.M. Danson
Centre for Environmental Systems Research
Research Institute for the Built and Human
Environment, School of Environment and
Life Sciences, University of Salford
Manchester M5 4WT, UK