EPIDEMIOLOGY

INTRODUCTION:-

Epidemiology is the basis of preventive and social medicine . It is health related decipline and directly
applicable to community health and community health nursing. It not only helps to understand the health and
disease concept, their determinants but also help in planning , implementing and evaluating health services.

The origin of epidemiology had been traced back from the time
of Hippocarts, but the foundation of modern epidemiology was ldid down in the 19th century when infectious
and communicable disease like cholera, plage, typhoid etc was most prevalent in the world in the form of
epidemics and pandemic epidemiology focus on communicable as well as non communicable disease.

DEFINITION :-

 Epidemiology is derived from the Greek word Epi[upon], demo[the people],logos[study] thus it
means the knowledge and study of any thing that comes upon or affect people.
 Epidemiology is the study of various factor and conditions that determine the occurrence and
distribution of health, disease, defect, disability and death among groups of individuals.
{Clark 1965}
 Epidemiology is the study of the distribution and determinants of disease prevalence in man.
{Mac Mohan}
 Epidemiology is concerned with the study of the process which determine or influence the physical
mental and social health of people{Cassel1965}

NATURAL HISTORY OF DISEASE

 In the absence of any intervention i.e. prevention or treatment, all disease follow a natural course of
events which refers to “Natural History of Disease”.
 The concept was defined and associated with preventive and control strategies in 1953 by Leavell and
Clark with the help of Schema of natural history of disease.
 Leavell and Clark have defined the Natural History of Disease model as under:
“A narrative and schematic representation which portrays a chronological sequencing of
departure from health. The sequence begins with the factors that promote health, but the model
also addresses the very first force that inaugurates pathological departure. An innate function
of this model is to describe various approaches to prevent and control pathological processes
and this function is collectively known as the level of prevention. ”
 It depicts its confrontation/interaction of three essential elements i.e. agent, host and environment to
influence the onset of any disease, the continuum of pathogenesis.
PRE-PATHOGENESIS PERIOD PATHOGENESIS PERIOD
(IN ENVIRONMENT) (IN MAN)

Confrontation A H
& Interaction

E 3
CLINICAL STAGE DISABILITY STAGE
Provokes Stimulus
Clinical
Recognizable

Early Advance Con Chron

Diseas d vale ic
e Disease scen State
ce Disabi
Early Pathogenesis lity &
 Interaction of Defec
Host-Agent/ t
Stimulus
 Tissues
Reaction
 Physiological
changes
INCUBATION PERIOD

2
PRESYMPTOMATIC
STAGE

PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY

PREVENTION
THIS MODEL IS BASED ON THE FOLLOWING ASSUMPTIONS.
Health is a relative state: it is assumed that every one possesses some degree or level of health & it
depends upon factors related to people(host)- inherent or acquired characteristics, factors related to
agents or factors related to environment in which people (host )live.
It Disease is a process: it is assumed that disease is not static. It is a process and begins before the
individual is affected. means that the conditions which stimulate illness are present in the
environment and in the people (hosts) themselves. This process thus depends upon the nature and
characteristics of agent, host and disease producing stimuli from within the environment and
individual.
Disease is effected due to multiple causation: the occurrence of any disease depends upon the
epidemiologic triangle composed of agent, host and environment. The host refers to the individual or
population affected. The agent is an element, a substance or a force, whose contact with the
susceptible host under appropriate environmental conditions is essential to serve as a stimulus to
effect the disease process. Agents in case of infectious disease are microbes but also include physical,
chemical, mechanical and nutrient agents for both infectious and non-infectious diseases.
Environment is the aggregate of all the external conditions and influences affecting the life and
development of host and agent and their interaction.

The natural history of any disease as viewed by Leavell and Clark which has two stages/phases. These are:

I. Pre-pathogenesis stage/phase
II. Pathogenesis stage/phase
1. Pre-pathogenesis stage/phase:
 This stage is before the onset of disease and is also called as Pre-disease stage.
 The causative agent has not yet entered the susceptible host (human being). But the factors that favour
the interaction of agent and host exist in the environment e.g. poor environmental sanitation, climatic
condition, presence of insects, pests and rodents etc; unhygienic habits and health behaviour, harmful
cultural and traditional practices; and biological factors i.e. age, sex, marital status, genetic and
physiological status of people.
 This means people living in any particular environment are always predisposed to the risk of disease
i.e. they are in pre-pathogenesis stage of many infectious and non-infectious diseases.
 The disease will not occur in man unless these three factors i.e. agent, host and environment confront
and interact to produce disease provoking stimuli.
 This stage is also described as stage of susceptibility by Mausner and Kramer because risk factors of
various intensity related to agent, host and environment are present to contract the disease any time.
2. Pathogenesis Stage:
 This phase begins with entry of causative agent in the susceptible human host.
 As the agent enters the body through appropriate channel (e.g. in case of Chickenpox, the agent
Varicella Zoster virus, must enter through the respiratory tract ), it induces tissue and physiological
changes in the body.
 These changes are subclinical i.e. clinical sign and symptoms of disease are absent. The host remains
apparently healthy and ambulant.
 After a lapse of some period which is variable from disease to disease and ranges in a specific disease,
the health equilibrium within the body is lost and the sign and symptoms of the disease begin to appear.
 This period which lapse between the entry of causative agent and just before the appearance of clinical
sign is called as Incubation Period.
 In case of chickenpox this period is usually 14-16 days.
 The sign and symptoms are sometimes vague during first few days of illness e.g. in case of chickenpox
running nose and watering of eyes which are common to many other diseases. This period is usually
called as Pro-dromal Stage.This is Early Pathogenesis Phase and is below the clinical horizon.
 This Early Pathogenesis Phase which is preclinical/ subclinical phase/ period is also called as Pre-
symptomatic Phase/ stage especially for chronic and non-infectious diseases.
 The length of Pre-symptomatic Phase/ stage varies greatly ranging from instantaneous time to many
years. For example, in case of accidental injuries it is instantaneous to few hours, and in case of disease
like cardiovascular and diabetes it can be many years.
 But as the pathological changes advance in the body system the sign and symptoms become clear and
clinical diagnosis can be done. E.g. appearance of skin rashes on different parts of the body in case of
chickenpox and the diseases reaches its peak.
 But in many diseases especially chronic and non-infectious diseases, by the time recognizable sign and
symptoms arise and clinical diagnosis is possible, the disease process or pathological changes are well
in advance.
 This period of recognizable pathogenesis is also called as clinical phase/stage.
 The end result of disease process may result in complete recovery. It takes time to recover and the
period is called as convalescence period or it may end into chronic state, varying level of disability
defect or death. This period is also called as disability phase/stage .
 The reaction to infection and period of pathogenecity vary from disease to disease and from person to
person for the same disease depending upon the virulence of causative agent and the susceptibility of
the host and environmental factors.
 The infection may be clinical or subclinical; typical or atypical or the host may become carrier with or
without having clinical disease e.g. in case of typhoid fever and diphtheria. The period of pathogenesis
can also be labelled as gradient of infection.
 The variation in the manifestation of the diseases in the pathogenesis phase ranges from sub-clinical to
clinical cases.
 The clinical cases ranges in severity from mild to severe and fatal cases.
 These variation in the manifestation of a disease can be represented graphically and is called as
Spectrum of disease.

Subclinical mild moderate severe fatal

DETERMINANTS OF DISEASE- CAUSATIVE/ RISK FACTORS

I. Definition and Concept of Risk factors

i. Definition :
The risk factor is defined as “a factor/ or an attribute that is significantly associates with the development of
a disease and when modified reduce the possibility of occurrence of disease or other specified outcomes.”

ii. Concepts:
 The risk factor may be truly causative
There is strong statistical relationship between the risk factor and disease.
e.g. smoking and lung cancer.
But one can neither conclude that all individuals with the risk factor (i.e. all smokers) will
develop disease (i.e. will have lung cancer) nor the absence of risk factor (who never smoked)
will ensure the subsequent absence of disease (i.e. will not have lung cancer).
 The risk factors may be just contributory factors
e.g. high blood pressure, diabetes, obesity for heart diseases.
 The risk factors may or may not be modifiable.
e.g. host risk factors, such as age, sex, race, genetic factors which are associated with some
diseases, cannot be altered.
 The factors which can be altered or modified include health related behaviour, hypertension, obesity,
dietary intake etc.
 Manipulation of these risk factors is also limited to what is reasonable and feasible.
e.g. alcoholism can be prevented and controlled by removing the alcoholic beverages through
legislation etc.
 There can be overlapping of some risk factors i.e. the same factor can be considered as host, agent or
environment related factor.
e.g. tobacco smoking- it can be considered as an agent related factor because of its significant
statistical association with the occurrence of various diseases;
it can be considered as host related risk factor because it is concerned with individual’s smoking
behaviour;
it can be considered as environment related risk factor because some environments are more
conducive or permissive to smoking and also exhaled smoke is found in the environment which is
risk factor for others in that environment.
 On the basis of risk factors the population can be categorised as one which is at high, low or no risk
for a given disease.
e.g. in case of HIV infection people who are at high risk may include those who engage in multiple
sex activities, sex worker, intravenous drug abusers etc; people who are at low risk may include
nurses and doctors who take care of patients with HIV infection; and people are at no risk or lowest
risk may include all those who are sexually not active and do not use intravenous drugs.
 It is very important to identify the risk factors, so that effective measures can be planned and
implemented to prevent or delay the occurrence of disease.
 Epidemiological studies have helped in identification of risk factors associated with various diseases
to alert people to take preventive and control measures for those diseases.

RISK FACTORS FOR SELECTED DISEASES

Selected Diseases Risk Factors

 Cancer Smoking, alcohol, solar and ionizing agent, occupational hazards,
dietary factors, environmental pollution, infectious agents,
medications etc.
Cirrhosis of liver Alcohol, poisons, medications, infection etc.
Diabetes Diet, obesity etc.
Heart Disease Smoking, high blood pressure, diabetes, obesity etc. lack of
exercise, emotional stress, elevated serum cholesterol etc.
High speed, drink and driving, roadway design, non compliance of
Road Accident traffic rules etc.
Smoking, high blood pressure and serum cholesterol etc.
Stroke

II. Agent, Host and Environmental Risk Factors

a) Agent Factors:
 A disease agent is the primary link in the development of disease.
 The disease agent is defined as “an element, a substance-living or nonliving, or a force-tangible or
intangible, the presence or absence of which may following the effective contact with susceptible human
host under proper environmental conditions serve as a stimulus to initiate or perpetuate a disease
process”.
 The disease agents are usually classified as under:
i. Biological agents:
Biological agents are living agents and include arthropods and helminths, protozoa, fungi, bacteria,
rickettsial and viruses.
ii. Physical agents:
Physical agents include abnormalities in atmospheric pressure, temperature and humadity; unusual
intensity of sound; abnormalities of radiation and electricity. These agents are usually associated
with certain occupational exposure.
iii. Chemical agents:
Chemical agents may include useful substances like iodide and fluoride and harmful substances like
noxious gases, volatile gases and fumes, airborne solid particles. Some chemicals may also be
produced in the body as a result of malfunctioning of body systems for example urea, bilirubin,
ketones, calcium carbonate, uric acid etc.
iv. Mechanical agents:
Mechanical agents include chronic friction and mechanical forces that result in crushing, tearing or
penetrating wounds, sprains, dislocation and other accidental injuries and even death.
v. Nutrient agents:
Nutrient agents include fats, carbohydrates, proteins, vitamins, minerals and water. Intake of these
elements either in excess or in deficiency results in nutritional disorders. For example anaemia,
night blindness, PEM, goitre.
b) Host risk factors:
 Host is one of the epidemiological determinants of disease.
 There are varied attributes related to host which predispose the interaction of host and agent to cause
a disease.
 These host related attributes or risk factors include:
i. Demographic characteristics:
These include age, sex, race, ethnic origin, marital status etc.
 ii. Biological factors:
These include genetic factors, blood chemistry, blood groups, physiological functioning of
body system, immune system etc.
iii. Psychosocial and economic characteristics:
These include personality traits, education occupation social class and status, mental status
and emotional makeup, health knowledge and attitude etc.
iv. Life style:
These include daily living and cultural practices including customs and traditions health
habits and health seeking behaviours such as physical exercise, nutrition practices, sexual
practices, use of alcohol, drugs and smoking etc.
v. Past history of exposure:
Exposure can range from infectious diseases to smoke in the environment exposure to various
occupational hazards.
c) Environmental Risk Factors:
 Environment is the aggregate of all the external conditions and influences affecting the life and
development of an organism.
 The environment has three components. These are physical, biological and psychosocial.
i. Biological environment:
The biological environment includes living things comprising of animal kingdom, plants and
microorganisms. Some of these are infectious agent, reservoir of infection, intermediate host
and vectors that transmit diseases.
ii. Physical environment:
 Physical environment includes all those things which are non living, chemical agents and physical
factors. These are air, water, soil, environmental sanitation, housing radiation, gravity, atmospheric
pressure, noise, electricity, electronic and electrical machines, radio broadcasting and television
transmitter and radar etc.
 Increasing population, urbanization, industrialization, migration, electronic and electrical devices and
media technology etc. have been the causes of environment pollution and resultant emergent health
problems.
 Lack of environmental sanitation is the cause for various infectious diseases among people.

iii. Psychosocial environment:

 It includes over all socio-economic and political organization that affects health care and its delivery
system; health legislation; socio-cultural customs, traditions, values, belief s and attitude; education,
religion and morals; lifestyle and family and community life.
 The psycho-social factors which can affect health are: poverty, migration, increasing population,
urbanization, stressful situations such as loss of loved ones, loss of job, accidental disabilities,
menopause, birth of retarded or handicapped child etc; defective life style, harmful health attitude,
behaviour and practices etc.

LEVELS OF PREVENTION OF DISEASE

Preventive approach is the best approach to achieve the goals of health care services because preventive
measures can be implemented with the joint efforts of health personnel and people at large at the family and
community level.
There are three major levels of prevention associated with natural history of disease. These are Primary,
Secondary & Tertiary Prevention.

1) Primary prevention:
 Primary prevention is first level prevention and is associated with the pre-pathogenesis phase or stage
of susceptibility of the disease process when the epidemiological factors like: Agent-Host-
Environment have not yet interacted to cause a disease.
 Primary preventive strategies during pre-pathogenesis phase of a disease are aimed to prevent the
interaction of these three epidemiological factors. If preventive measures are successful then the
disease will not occur.
 There are two types of primary prevention:
i. General health promotion:-
Health promotive factors include health education, wholesome nutritious diet, clean and safe
environment to live, healthful lifestyle, healthful behaviours and adequate resources. All these
aspects are directly related to socioeconomic and cultural aspects of the family and
community which must be improved.
ii. Specific protection:-
 Specific protection comprises those measures which are which are directed to intercept
causative agents of a particular disease or group of diseases before these agents affect people.
 Specific protective measures include immunization, use of specific nutrients, protection
against accidents and environmental and occupational hazards, use of prophylactic and
suppressive drugs, avoidance of allergin, protection from carcinogens, stimulation of proper
personal hygiene, control of quality and safety of foods, cosmetics and drugs and genetic
therapy and counselling.
 All primary preventive measures may not fall directly within the domain of nursing practice but
awareness of these preventive modalities can help community health nurse to educate and counsel
individual, family and community people intelligently.
For eg. Community health nurse should know about chemoprophylaxis, carcinogens, allergins,
occupational hazards etc. so that accordingly she can give informations and refer them to the
concerned medical person and agency etc.

2) Secondary prevention
 Secondary prevention is second level prevention and is associated with pathogenesis i.e. pre-
symptomatic stage and symptomatic i.e. clinical stage of the pathogenesis phase of the disease
process.
 The objectives of secondary preventive measures are to: diagnose the disease at early stage, control
the progress of disease in man, prevent complication, restore health and prevent the spread of
infections to others in the community, in case of communicable diseases.
 Secondary preventive measures include two types of interventions. These are early diagnosis and
treatment and disability limitations.
i. Early diagnosis and treatment:-
  Early diagnosis and treatment are the measures which control the disease process, prevent the spread
of infection to others in case of communicable diseases, prevent complications and long term
disabilities and restore health.
 Early diagnosis and treatment has been found the most effective mode of intervention in
communicable diseases in communicable diseases like tuberculosis, leprosy and STD and also in
chronic diseases where causes and primary prevention are not clearly known. It has thus helped in
reducing morbidity and mortality due to these chronic infectious and no-infectious diseases.
 In case of communicable diseases, early diagnosis and treatment helps to shorten the period of
communicability, thus limits the spread of infection and reduces mortality.
ii. Disability Limitations:-
 Disability interventions are applicable during the late pathogenesis period or clinical stage of the
disease process.
 The objective of these interventions is to prevent or delay the consequences of clinically advanced
disease i.e. prevent impairment leding to disability and handicap.
 For eg. Some of the nursing measures which may limits impairment and which are advisable for
immobile patients include back care, passive exercise, medication etc.; for diabetic patient or
patients who have undergone mastectomy and are mobile include individualized health teaching,
exercise, skin care, psychological boosting etc.
 Nurses and other health workers can help in making early diagnosis and treatment by case finding
and appropriate referral and by providing nursing care.
 Care of the minor ailments and limited care during emergencies are rendered by nurses and their
auxiliaries at the village level.
3) Tertiary prevention:
 It occurs late in the pathogenesis stage of disease process when irreversible changes either in
anatomy and physiology or both have occurred.
 At this point the disease process has advanced its clinical stage and entered the disability stage.
 Rehabilitative strategies are used to attain the highest possible level of functional ability.
 It involves co-ordinated efforts of medical personnel, sociologists, clinical psychologist, nurses etc.
for training and retraining of and helping the person to function, lead useful life as for as possible and
restore a feeling of well being.
 Rehabilitation is with regard to restoration of:
 Bodily functions (medical rehabilitation)
 Personal dignity and confidence (psychological rehabilitation)
 Family and social relationship (social rehabilitation)
 The capacity to earn livelihood (vocational rehabilitation)
 It is also considered as the responsibility of all doctors and nurses to help patient to recognise their
disability, restore their personal dignity, confidence and social relationship; and also refer them to
appropriate department and agency for further medical and vocational rehabilitation e.g. for
physiotherapy, speech therapy, vocational guidance etc.
EPIDEMIOLOGICAL APPROACH

The Epidemiological Approach to problems of health and disease is based on two major foundations.

a) asking questions
b) making comparison
a. Asking questions:
Epidemiology has been defined as “a means of learning or asking questions…..and getting answers
that lead to further questions”. For example, the following questions could be asked.

RELATED TO HEALTH EVENTS:

a. What is the event?

b. What is its magnitude?
c. Where did it happen?
d. When did it happen?
e. Who are affected?
f. Why did it happen?
RELATED TO HEALTH ACTION:

a. What can be done to reduce this problem and its consequences?

b. How can it be prevented in the future?
c. What action should be taken by the community by the health services? By other sectors? Where and
for whom these activities be carried out?
d. What resources are required? How are the activities to be organized?
e. What difficulties may arise, and how might they be overcome?
Answer to the above questions may provide clues to disease actiology, and help the epidemiologist to
guide planning and evaluation.

b. Making comparisons

The basic approach in epidemiology is to make comparisons an draw inferences. This may be
comparison of two (or more groups). One group having the disease (or exposed to risk factor and the other
group (s) not having the disease (or not exposed to risk factor), or comparison between individuals. By
making comparisons, the epidemiologist tries to find out the crucial differences in the host and
environmental factors between those affected and not affected. In short the epidemiologist weighs, balances
and contrasts, clues to actiology come from such comparisons.

 One of the first considerations before making comparisons is to ensure what is known as
“comparability” between the study and control groups. In other words, both the groups should be
similar so that “like can be compared with like”.
 For facts to be comparable they must be accurate and they must be gathered in a uniform way.
Ex. The study and control groups should be similar with regard to their age and sex composition,
and similar other pertinent variables.

 The best method of ensuring comparability, in such cases, is by randomization or random allocation.
 Where random allocation is not possible (as in case control and cohort studies) what is known as
“matching” is done for selected characteristics that might can found the interpretation of results.
 Another alternative is standardization which usually has a limited application to a few characteristics
such as age, sex and purity. These biostatistical concepts are elaborated in the following pages. It
may be mentioned that international comparisons may be difficult because of difference in
terminology. It requires standardization of definitions, classifications, criteria and nomenclature.
BIBLIOGRAPHY:

books

1. Park k. Textbook of Preventive And Social Medicine, 19th edition, Banarsidas Bhanot Publishers
2. Gulani K.K ” Community Health Nursing(Principal & Practice)” First Edition
2004,KumarPublication,New Delhi Page no-265-293
3. Patney sunitha, Textbook of community health nursing, 1st edition, CBS publisher and distributor,
2008, published by satish kumar ,
4. S. Kamlam, Essential in community health practice, 3rd edition, JYPEE brother medical publisher ,
2012, publiehed by jitender vij,
5. Swarnkar, community health nursing, 3rd edition, published by NR brother , 2016,
6. Sundar lal, Adarsh pankaj, et al,Textbook of community medicine and prevention, 2nd edition, 1st
volume ,
7. I clement, manual community health nursing, 1st edition, jaypee, 2012,
8. Mary Ellen, community health nursing education and prevention , 2nd edition, 1997
9. S. Kamlam, Essential in community health practice, 3rd edition, JYPEE brother medical publisher ,
2012, publiehed by jitender vij,
10. A mary nies, et al, community health nursing promoting the health poplution ,3rd edition, elsevire
publisher.

Websites
1. www.wikipedia
2. http://www.who.int/topics/epidemiology/en/
 Government College of Nursing Raipur (c.g)
SUBJECT- COMMUNITY HEALTH NURSING
TOPIC PRESENTATION ON-

EPIDEMIOLOGY APPROCHES

SUBMITTED TO-
Mrs. Shabiba daharia SUBMITTED BY-
( MSC. Demonstrator ) Ms. Babita dhruw
Govt. College of Nursing, M.Sc. final year
jagdalpur(C.G.) Govt. College of Nursing,
jagdalpur(C.G.)