EPIDEMIOLOGY

DEFINITION
EPIDEMIOLOGY :
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 (1988)
Concept of disease:
Germ theory of disease:
The germ theory of disease is
generally referred to as a one-to-one relationship or single
cause idea between causal agent and disease.
Disease Agent Man Disease

Multifactorial causation:
Pettenkofer of munich (1819- 1901)
Epidemiological triad

Agent

Host Environment
Web of causation for myocardial infarction:
Changes in lifestyle stress
Abundance of food Smoking Emotional disturbances
obesity Lack of exercise Hypertension
Aging&other
factor
Hyperlipidemia catacholamine and thrombotic tendency
Changes in walls of artery

Coronary atherosclerosis Coronary occlusion

Myocardial ischemia

Myocardial infarction
 NATURAL HISTORY OF DISEASE
PERIOD OF PRE-PATHOGENESIS PERIOD OF PATHOGENESIS

Disease Before man is involved The course of the disease in the

process man
Agent Hos
Death
t
Environment( bring
Defect or chronic
agent and host together) Disability
stage
illness
Signs and symptom
recovery
Tissue and physiological
changes
Agent multiplication

In the human host interaction

Host re
Of host and
stimuli

Early
Levels of prevention
Primary prevention pathogenesis
Secondary early lesions
Tertiary
disease convalescence
prevention prevention
Aims of epidemiology
1.To describe the distribution and magnitude of
health and disease problems in human
populations.
2.To identify aetiological factors (risk factors) in the
pathogenesis of the diseases.
3.To provide the data essential to the planning
,implementation and evaluation of services for the
prevention,control and treatment of disease and to
the setting up of priorities among those services
 Uses of Epidemiology

1. To study historically the rise and fall of disease in

the population
2. Community diagnosis
3. Planning and evaluation
4. Evluation of individuals risk and chances
5. Syndrome identification
6. Completing the natural history of disease
7. Searching for causes and risk factors
MEASUREMENTS IN EPIDEMIOLOGY

1. Measurement of mortality
2. Measurement of morbidity
3. Measurement of disability
4. Measurement of natality
5. Measurement of the presence, absence (or)distribution of
the characteristics (or)attributes of the disease
6. Measurement of medical needs,health care
facilities,utilization of health services and other health
related events
7. Measurement of demographic variables
TOOLS OF MEASUREMENT
RATE :
The occurrence of some particular events in a
population during a given period of time
Death rate =Number of deaths in one year x 1000
Mid year population

RATIO :
Measure of disease freguency in a ratio .it
expresses a relation in size between two random
guantities
The number of children with scabies at a certain time

-------------------------------------------------------------
The number of children with malnutrition at a
certain time
PROPORTION

The number of children with scabies at a certain

Time
---------------------------------------------------------------
x100
The total number of children in the village at the same
time
 Methods of Epidemiology

1.Observational studies
a. Descriptive studies
b. Analytical studies
(i) Ecological or correational , with populations as unit of
study
(ii)cross sectional or prevalence, with individuals as unit
of study
(iii)case control or case reference with individuals as unit
of study
 (iv ) Cohort or follow up, with individuals as a unit of study
2. Experimental studies intervention studies
a.Randomized controlled trails or clinical trails, patients as unit
of study
b.Field trails or community intervention studies, with healthy
people as unit of study
c.Community trails , with communities as unit of study
 Descriptive Epidemiology

a. When is the disease occuring ? - Time distribution

b. Where is the disease occuring ? - Place distribution

c. Who is getting the disease ? - person distribution

 Procedures in Descriptive studies
1. Defining the population to be studied
2. Defining the disease under study
3. Describe the disease by
a) Time
b) Place
c) Person
4. Measurement of disease
5. Comparing with known indices
6. Formulation of an aetiological hypothesis
 Description of disease in terms of distribution:

Time distribution Person distribution

Weekly Place distribution
International Age,sex,occupation,
Monthly Marital status,habits,social
Year variation
National variation class,
Season Stress,migration.behavior
Rural-urban
duration
variation
Local distribution
Short term Periodic
fluctuation fluctuation Long term
Cyclic fluctuation
Common source Season
trend
epidemic al trend
Slow
Single Repeated epidemic
exposure Propagated
exposure
epidemic
 Types of Epidemics

Three major types of epidemics

A. Common sourse epidemics
a. Single exposure or point sourse epidemics
b. Continuous or multiple exposure epidemics.
B. Propagated epidemics
a. Person to person
b. Arthropod vector
c. Animal reservoir
C. Slow (modern) epidemics
 Analytical Epidemiology
CASE CONTROL STUDY
Factor Cases with
Individual
Present particular disease
(or) Controls
Individual without
Absent particular disease

PROSPECTIVE ( cohort) STUDY

Presence or
Individual exposed to absence of
particular factor particular
Individual unexposed to disease
particular factor

TIME
 CASE CONTROL STUDY
The case control method has three distinct features:

a. Both exposure and outcome have occurred before the start of the
study
b. The study proceeds backwards from effect to cause and
c. It uses a control or comparison groups to support or refute an
inference.

BASIC STEPS

1. Selection of cases and controls

2. Matching
3. Measurement of exposure
4. Analysis and interpretation
 Elements of a Cohort study

The elements of a cohort study are:

1. Selection of study subjects
2. Obtaining data on exposure
3. Selection of comparison groups
4. Follow up
5. Analysis
 Relative Risk

Incidence of disease (or death) among exposed

RR = ________________________________
Incidence of disease (or death) among non - exposed
 Attributable Risk

Incidence of disease rate among exposed

minus incidence of disease rate among non -exposed
= ------------------------------------------------------------------------
x 100
Incidence rate among exposed
 Experimental Epidemiology

Two types are:

1. Randomized controlled trails
2. Non- randomized trails
 Randomized controlled trails

The basic steps in conducting a RCT include the following:

1. Drawing up a protocol
2. Selecting reference and experimental population
3. Randomization
4. Manipulation or intervention
5. Follow up
6. Assessment of outcome.
DESIGN OF RANDOMIZED CONTROLLED TRIAL

Select suitable population

(Reference or target population)

Select suitable Sample

(Experimental or study population) Those not
eligible

Make necessary exclusions

Those who do
not wish to
RANDOMIZE give consent

Experimental
Control group
group

Manipulation & follow -up

Assessment
MEASUREMENT OF MORBIDITY :
INCIDENCE RATE
PREVALENCE RATE

INCIDENCE RATE:

Incidence rate refers to frequency of new cases of specific

disease during a given period in a defined population(population at risk )
during that period .

= No.of new cases of specific disease during a given time period x1000

Population at risk during that period

Prevalence rate:
Point prevalence
Period prevalence
Point prevalence :
It is the number of all current new and old
cases of a disease at one point of time in relation to a defined
population

Number of current new and old cases of a specified disease existing at a

given point of time x100

Estimated population at the same point of time

Period prevalence:
It is the frequency of all current new & old
cases during a defined period of time in relation to a defined
population .
= No.of current new& old cases of a specified disease during a given period of
time interval x 100

Estimated mid- interval population at risk

MEASUREMENT OF MORTALITY:
1.Crude Death Rate:
It measures the frequency of deaths
occuring from various causes in a given population during a
specified period .
CDR = No.of deaths during the year x 1000
Mid year population
2.Specific Death Rates:
It can be a. Disease specific b. Group specific
a. Disease specific :
=No.of deaths from cancer during a calender year x1000
Mid year population
Group specific: Age

=No.of deaths among females

Sex
during a calender year x1000
Mid year population of females
Specific death rate in a age group of 15-45 years.
=No.of deaths of persons aged 15-45 years during a calender year
x1000
Mid year population of persons aged 15- 45 years
Dynamics of disease transmission:

Source Susceptible
Or Mode of transmission
host
reservoir

Modes
Of
transmissi
on
Source: The person,animal,object or substance from which an
infectious agent passes or is disseminated to the host.
Reservoir : Any person,animal,arthropod,plant,soil or substance
in which an infectious agent lives and multiplies,on which it
depends primarily for survival ,and where it reproduces itself
in such manner that it can be transmitted to a susceptible host .

Source or reservoir
Human reservoir
Animal reservoir
Reservoir in non- living things
Human reservoir cases Clinical cases

carriers Sub clinical

cases
latent

cases - A person in the population or study group identified as

having the particular disease,health disorder or condition under
investigation

1.Clinical case:Mild or moderate,typical or atypical ,severe or fatal

2.Subclinical cases: Inapparent, covert,missed,abortive
3.Latent cases : Have infectious agent,dont show symptoms,the
infectious agent lies dormant.
Investigator:
Primary case- It is the first case of a communicable disease
introduced into the population being studied.
Secondary case Those cases which develop from the contact
with primary case .
Index case This term refers to first case which has come in
attention of investigator.
Carriers - An infected person or animal that
harbours a specific infectious agent in the
absence of discernible clinical disease and
serves as a potential source of infection for
others.
Carriers may be classified as below ,
1. Incubatory Those who shed the infectious
agent during the incubation period of disease
Ex : measles,mumps,polio
2.Convalescent carriers To shed the disease agent during the
period of convalescence.
Ex: Typhoid fever ,cholera,diptheria
3.Healthy carriers A person whose infection remains
subclinical may or may not be a carrier.
Duration :
Temporary carriers Those who shed the infectious agent for
short periods of time .
Chronic carriers - A chronic carrier is one who excretes the
infectious agent for indefinite periods .
Portal of Exit :
Urinary
Intestinal
Respiratory
Others
Mode of transmission:
1.Direct transmission:
Direct contact
Droplet infection
Contact with soil
Inoculation into skin or mucosa
Transplacental(vertical )
2.Indirect transmission :
Vehicle borne
Vector borne Mechanical

biological
Air borne
droplet

dust
 Fomite borne
Unclean hands and fingers
1.Direct transmission:
Direct contact:
skin to skin,mucosa to mucosa or mucosa to skin of the
same person or another.
Droplet infection:
Direct projection of spray of saliva or naso
pharyngeal secretions
Contact with soil:Ex: hook worm infestations,tetanus etc
Inoculation into skin or mucosa:
ex: rabies virus by dog bite,heptitis B by
contaminated needles
 Transplacental transmission:
Ex:TORCH(Toxoplasma gondi,rubella virus, cyto megalo virus,
herpes virus)
2.Indirect transmission:( 5 Fs flies,fingers,fomites,food,fluid)
a.Vehicle born Transmission of infectious agent
through water,food,raw
vegetables,fruits,milk,ice,blood,serum
b.Vector born (Arthropod, vertebrate, non-vertebrate)
Invertebrate type: (Arthropod)
Flies and mosquitoes,fleas,cockroaches,sucking
lice,bugs,ticks,mites,cyclops.)
vertebrate type:Mice,rodents,bats
By transmission chain:
A . Man and a non-vertebrate host:
Man-arthropod-man (malaria)
Man-snail-man (schistosomiasis)
B . Man, vertebrate host ,and a non vertebrate host:
Mammal arthropod man(plaque)
Bird arthropod man(encephalitis)
c. Man and 2 intermediate hosts :
Man cyclops fish Man (fish tape worm)
By methods in which vectors transmit agent:
Biting, regurgitation, scratching in of infective faeces,
contamination of host with body fluids of vectors
 Airborne :
Droplet,dust(1 -10 micron range)
Fomite borne :other than water or food (soiled
clothes,towels,linen,glasses etc)
Unclean hands and fingers
III.The vector born transmission on the basis of involvement of
vector and propagation of parasites,is of 2 types,

Mechanical transmission: The infectious agent doesnot develop

or multiply on or within the vector and is transmitted
mechanically by arthropods through soiling of its feet.

Biological transmission: The infectious agent multiply or replicate

or both occur in the vector before transmission.
 Biological transmission is classified into 3 types,

CHARACTERISTICS Propagative Cyclo propagative Cyclodevelopmental

MULTIPLICATION yes yes No

DEVELOPMENT No yes yes

EXAMPLE Plaque bacilli in rat Malaria prasites Microfilaria in

flea mosquito
Epidemiology : Terminologies
1.Infection :
The entry and development or multiplication of an
infectious agent in the body of man or animals .
2.Contamination :
The presence of an infectious agent on a body surface
,also on or in clothes, beddings ,toys , surgicl instruments or
inanimate articles or substances including water, milk ,food.

3.Infestation:
For persons or animals the lodgement ,
,development and reproduction of arthropods on the surface of the
body or in the clothing .
Ex :lice, itch mite
Host :
A person or animal, including birds and arthropods ,that
affords subsistence or lodgement to an infectious agent
under natural conditions .
Obligate host - the only host Ex : man in measles ,typhoid
Definite host or primary - Host in which the parasite attains
maturity or passes its sexual stage .
Intermediate or secondary - Larval or Asexual stage.
Transport host - Carrier

Infectious disease :
A clinically manifest disease of man or
animals resulting from an infection .
Contagious disease :
A disease that is transmitted through
contact.
Ex: Scabies,trachoma
Communicable Disease :
An illness due to a specific infectious
agent or its toxic products capable of being directly or
indirectly transmitted from man to man ,animal to animal or
from the environment( air,dust,soil).
Epidemic:
Epi = upon , demos = people,the unusual occurrence in
a community or region of disease ,specific health related
behaviour or health related events clearly in excess of
expected occurrence.
Endemic :
En = in ,demos = people ,It refers to the constant
presence of a disease or infectious agent within a given
geographic area or population group .
Sporadic :
The word sporadic means scattered about ,the cases
occur irregularly ,haphazardly from time to time ,and
generally infrequently . Ex :polio
Pandemic:
An epidemic usually affecting a large proportion of
the population
Ex : Section of a nation, the entire nation Ex :chleora.
Exotic:
Diseases which are imported into a country in which
they do not other wise occur.
Ex: rabies
Zoonoses :
An infection or infectious disease transmissible
under natural conditions from vertebrate animals to man .
Ex: rabies ,anthrax
Epizootic :
An outbreak(epidemic) of disease in an animal
population .
Ex: Anthrax, JE
Epizootic :
An outbreak (epidemic) of disease in an animal
population .:
Ex: influenza
Epornithic :
An outbreak (epidemic) of disease in a bird
population.
Enzootic :
An endemic occuring in animals
Ex: anthrax
Noso comial Infection:
Nosocomial (hospital acquired )infection is
an infection originating in a patient while in a hospital or
other health care facility.
Opportunistic Infection:
This is infection by an organism that takes the
opportunity provided by a defect in host defence to infect the
host and hence cause disease.
Ex:AIDS
Iatrogenic (physician Induced)disease:
Any untoward or adverse consequence of a
preventive ,diagnostic or therapeutic regimen or procedure
,that causes impairment ,handicap, disability or death resulting
from a physicians professional activity.