BASIC EPIDEMIOLOGIC

CONCEPTS AND
PRINCIPLES
CHAPTER 1
Learning Objectives
At the end of the session the learners should be able to:
1. Discuss epidemiology, triad of disease, its causation
and principles
2. Describe the aetiology and natural history of disease
and can apply that with illustrated examples
3. Differentiate examples of diseases and its relationship
with the host, the agent and the environment
4. Describe the risk factors for disease in relation to biologic
factors and behaviour factors, environmental factors,
immunologic factors, nutritional factors, genetic factors and
social and spiritual factors
5. Discuss the ecologic issues in epidemiology like
vaccination and patterns of disease, effects of sanitation,
vector control and synergism of factors predisposing to
disease
6. Analyse measures of morbidity, measures of mortality,
measures of rates, ratios and proportions
7. Describe, analyse and interpret National Health
Statistics and their significance to the health picture of
our city, region and country.
8. Identify the epidemiologists and their contributions in
actual clinical or community setting
9. Discuss and explain the biologic spectrum of diseases
10. Describe and explain the biologic spectrum of
diseases
 What is epidemiology
- Study of factors that determine the occurrence and
distribution of disease in a population
- Epi meaning upon
- Demos meaning people
- Logos meaning discussion
- Deals with more than the study of epidemics
- Epidemiologists collect data on an entire population;
while health care practitioners collect data on a single
patient
Four Levels in the Scientific Study of
Disease
1. Sub-molecular or molecular level
Ex. Cell biology, genetics, biochemistry and immunology
2. Tissue or Organ level
Ex. Anatomic pathology
3. Level of Individual Patients
Ex. Clinical Medicine
4. Level of Populations
Ex. Epidemiology
Epidemiology
- Is the study and analysis of the distribution, patterns
and determinants of health and disease conditions in a
defined population
- It is a cornerstone of public health, and shapes policy
decisions and evidenced based practice by identifying
risk factors for disease and targets for preventive health
care
- Study of diseases in populations, investigating how,
when and why they occur
- Source: wikipedia
TYPES OF EPIDEMIOLOGY
1. Classical Epidemiology
- Population oriented
- Studies the community origins of health problems like health
problems related to
- a. Infectious agents
- b. Nutrition
- c. the environment
- d. human behaviour
- e. psychological, social, and spiritual state of a population
- * Classical epidemiologists are interested in discovering RISK
FACTORS that might be altered in a population to prevent or
delay disease, injury and death
2. Clinical Epidemiology
- Study patients in health care settings to improve the
prevention, early detection, diagnosis, and treatment
and care of various diseases and the prognosis for
patients already affected by a disease
- They must take special care to adjust for the presence
of other diseases (comorbidity) and for any clinical
treatments.
Etiology and natural history of disease
Stages of Disease
1. The Pre-Disease
- Before the pathologic process begins
- Early intervention may prevent exposure to the agent of
disease preventing the disease process from starting (
fatty acids, microbes )
- This is called PRIMARY PREVENTION
2. Latent Stage
- When the disease process has begun, but is still
asymptomatic screening and appropriate treatment may
prevent progression to symptomatic disease
- This is called SECONDARY PREVENTION
3.Symptomatic Stage
- When disease manifestations are evident intervention
may slow, arrest or reverse the progression of disease
- This is called TERTIARY PREVENTION
MECHANISMS AND CAUSES OF
DISEASE
Biologic Mechanisms of Disease and the Social and
Environmental Causes of Disease

Ex. Excessive fat intake, smoking and lack of exercise are

social factors that contribute to biologic mechanisms of
atherogenesis such as elevated LDL cholesterol and VLDL
cholesterol and reduced blood levels of HDL cholesterol
Ex. Osteomalacia a bone disease may have social and biologic
causes among Muslim women who have reached puberty.
Prevent irradiation of ergosterol in the skin. Irradiated
ergosterol is an important source of D vitamins which are
necessary for rapid growth.
Host, Agent and Environment
Causes of Disease are often considered in terms of a triad
of factors namely;
- The host
- The agent
- The environment
- Fourth factor the vector
 Host Factors
- Are responsible for the degree to which the individual is able to
adapt to the stressors produced by the agent.
- Host resistance is influenced by a
a. Persons genotype – ex. Dark skin reduces sun born
b. Nutritional status and Body mass index
c. Ex. Obesity increases susceptibility to many diseases
d. Immune system for resistance to cancer as well as microbial
disease
e. Social behaviour - physical exercise enhances resistance to
many diseases including depression
Agents of Disease or Illness
Categories:
a. Biologic agents
- allergens
- infectious organisms like bacteria and viruses
- biologic toxins like botulinum toxin
- foods like high fat diet
b. Chemical agents
- chemical toxins like lead and dusts
c. Physical Agents
- kinetic energy in cases involving bullet wounds,
blunt trauma and vehicular injuries
- radiation, heat, cold and noise
 ENVIRONMENT
- Influences the probability and circumstances of contact
between the host and the agent
- Ex. Poor restaurant sanitation
Poor roads and poor weather conditions
Crowded homes and Schools
Political structure and economic health
 Vectors of Disease
- Insects like mosquitoes
- Arthropods like ticks, mites, lice
- Animals
- Human beings
- Objects

- * To be an effective transmitter of disease, the vector

must have a specific relationship to the agent, the
environment and host
RISK FACTORS FOR DISEASE:
BEINGS MODEL
BEINGS: an acronym for remembering the categories of
Preventable Cause of Death

B – Biologic factors and Behavioural factors

E – Environmental factors
I – Immunological factors
N – Nutritional factors
G – Genetic factors
S – Services, Social and Spiritual factors
BIOLOGIC FACTORS
Ex. Of Biologic Factors
1. Gender
2. Age
3. Weight
4. Bone density
Ex. Of Human Behavioural Factors
1. Smoking
2. Increase of overweight and obesity
3. Inactivity and diet
4. Male homosexual activity
5. Intravenous drug used
ENVIRONMENTAL FACTORS
Ex.
1. Epidemiologic studies were done during the outbreak of
severe pneumonia among individuals attending a 1976
American Legion conference in Philadelphia.
Studies suggested that the epidemic was caused by an
infectious agent distributed through the air conditioning and
ventilation systems of the hotels hosting the
conference. Etiologic agent identified was named
Legionella pneumophilia and this bacteria thrives in air
conditioning cooling towers and in warm water systems.
2. Epidemiologic research concerning an illness that was
first reported in 1975 in Old Lyme, Connecticut,
suggested that the arthritis, rash and other symptoms of
the illness were caused by an infection transmitted by a
tick.
Not until 1982 was the causative agent Borrelia
burgdorferi was discovered and shown to be spread by
the ticks.
IMMUNOLOGIC FACTORS
- Herd Immunity results when a vaccine reduces an
immunized person’s ability to spread a disease, leading
to reduced disease transmission
- Herd immunity is the prevention of disease
transmission to susceptible individuals through
acquired immunity
NUTRITIONAL FACTORS
- In the 1950’s, it was shown that the Japanese-Americans
living in Hawaii had a much higher rate of myocardial
infarction than did the people of the same age and sex in
Japan
- Japanese–Americans in California had a similar higher rate
of this disease compared with similar individuals in Japan
- Investigators believed that dietary differences were the most
important factors producing the differences in disease and
their beliefs have been supported by subsequent research
GENETIC FACTORS
-Genetic inheritance of individuals interacts with diet and
environment in complex ways to promote or protect
against a variety of
illnesses including heart disease and cancer
- Genetic Epidemiology is a growing field of research
- Genetic screening is important for identifying problems
in new born
SERVICES, SOCIAL FACTORS AND
SPIRITUAL FACTORS
-2.9% TO 3.7% OF hospitalized patients experience “adverse
events” during their hospitalization
- Of these 19% are due to Medication Errors and 14% are due
to wound infections
- Unnecessary or inappropriate diagnostic or surgical
procedures
- One study reviewed the literature concerning the association
of religious faith with generally better health and found that
strong religious faith was associated with better health and
quality of life.
-Berkman and Syme showed that for all age groups, the
greater one’s participation in churches and other groups
and the stronger one’s social the network the lower the
mortality that was observe
- Psychiatrist Frankl documented the importance of a
person’s having a meaning and purpose in life, which can
alleviate stress and improve coping.
ECOLOGIC ISSUES IN
EPIDEMIOLOGY
1. Solution of Public Health Problems and Unintended
Creation of New Problems
a. Vaccination and Patterns of Immunity
- In herd immunity it not only protects the immunized
individual, but also prevents that person from
transmitting the disease to others
- If there is greater than 50% herd immunity the infection
would die out eventually
b. Effects of Sanitation
- The sanitary revolution which began in England about
the middle of the century was the most important factor
in reducing infant mortality rate
- The reduction of infant mortality contributed in a major
way to increasing the effective birth rate and the rate of
population growth
- This results in rapid population growth the so called
demographic gap.
c. Vector Control and Land Use Patterns
- A successful effort was made to control the tsetse fly,
which is the vector of the African Sleeping sickness in
cattle and sometimes in human.
- Control of the vector enabled herders to keep larger
numbers of cattle and this lead to overgrazing .
- The overgrazed areas were subjected to frequent
droughts.
d. River Dam Construction and Patterns of Disease
- As the epidemiologists predicted, the number of cases
of schistosomiasis increased in the area supplied by the
Aswan High Dam after it was erected in Egypt
-
2. Synergism of Factors Predisposing to Disease
- There maybe a synergism between diseases or between
factors predisposing to disease, so that it makes the
other worse or more easily acquired
- Ex.
- a. Sexually transmitted diseases especially those that
produce open sores predispose to the spread of HIV
b. The relationship between malnutrition and infection is
complex
c. The relationship of ecologic and genetic factors can
interact to produce new strains of influenza virus
Ex. The new avian influenza (H5N1) virus from
Southeast Asia differs greatly from human strains and it
has caused mortality in most people who were infected
by the birds
CONTRIBUTIONS OF
EPIDEMIOLOGISTS TO MEDICAL
SCIENCE
A. Investigating Epidemics and New Diseases
1. Knowledge of the modes of transmission led
epidemiologists to suggest ways to prevent each of these
diseases before the causative agents were determine or
extensive laboratory results were available.
2. Rapid growth in population, increased travel and contact
with new areas such as jungles, declining effectiveness of
antibiotics and insecticides and many other factors
encourage the development of new diseases or the
resurgence of older ones.
B. Studying the Biologic Spectrum of Disease
- Biologic spectrum of disease or the Iceberg
phenomenon is referred to as the variation in severity of
a disease process
- The Iceberg Phenomenon is appropriate because most
of an iceberg remains unseen, below the surface,
analogous to asymptomatic and mild cases of disease
C. Surveillance of Community Health Interventions
- Randomized trials of preventive measures in the field
(field trials) are an important phase of evaluating a new
vaccine before it is given to the community at large.
Ex. In 1954, a large scale field trials of the Salk IPV
vaccine ( Inactive Polio vaccine ) were done and these
confirmed the value and safety of the vaccine.
In 1955, the polio surveillance program of the CDC (
Center for Disease Control ) discovered an outbreak of
vaccine associated poliomyelitis which was linked to
vaccine from Cutter Laboratories
Ex. Epidemiologists were able to show that much of the
unexpected disease occurs in college students and others
who received measles vaccine before 12 months of age
without a later booster dose
-The timing of the vaccine mattered because if it was
given while maternal antibody against measles persisted
in the infants, the antigenicity of the vaccines was
reduced
- Such findings have led to the current recommendations
to give measles vaccine initially at 15 months of age, to
give a booster dose of measles vaccine before primary
school entry and to ensure that students have at least two
doses of measles vaccine before graduating from high
school
D. Setting Disease Control Priorities
- Should be based on
1. Existing size of the problem
2. Potential of a disease to spread to others
3. Its likelihood to cause death and disability
4. Its cost to individuals, families and the community
Ex. Against Smoking, Against the spread of HIV/AIDS,
Lifestyle Modifications, Against SARS where the first case
appeared in China in 2003 and was caused by an animal
corona virus trace to some unusual food animals, now against
the new form of avian influenza ( H5N1)
E. Improving Diagnosis, Treatment and Prognosis of Clinical
Disease
- The methods of clinical epidemiology frequently are used to
determine the most effective TREATMENT in a given
situation
Ex. Methylprednisolone reduced spinal cord damage and
improved residual motor function after acute spinal cord
injury
- Epidemiologic methods also help improve PROGNOSIS

- Epidemiologic methods permit RISK ESTIMATION

F. Improving Health Services Research
- The principles and methods of epidemiology are used
in planning and evaluating medical care.
- In health planning, epidemiologic measures are
employed to determine present and future community
health needs
- In health program evaluation and in the broader field of
cost-benefit analysis, epidemiologic methods are used
to determine the effects of medical care
G. Providing Expert Testimony in Courts of Law
- Epidemiologists are being called on to testify regarding
state of knowledge about product hazards and probable
risks and effects of various environmental exposures or
medications
Ex.
Damage from general environmental exposures (
possible association of magnetic fields and brain cancer)
- Occupational Illness Claims ( occupational lung
damage from workplace asbestos)
- Medical liability ( adverse effects of vaccines or
medications)
- Product liability ( association of lung cancer with
tobacco use, of toxic shock syndrome with tampon use,
and with cyclooxygenase1 inhibitors with
cardiovascular disease )
* Expert medical testimony often requires a high level of
epidemiologic expertise
Reference:
JEKEL’S EPIDEMIOLOGY, BIOSTATISTICS,
PREVENTIVE MEDICINE AND PUBLIC HEALTH
4TH EDITION, copyright 2014