Introduction to Epidemiology

Presented by L. Mupara
 What is Epidemiology?

Confusion
 Learning objectives
At the end of this lecture students be able to:
• Define some of the basic epidemiologic
vocabulary
• Discuss the aims and goals of epidemiology
• Discuss the uses of epidemiology
• Discuss the different sources of epidemiological
data
 Outline
• Definition of terms
• Historical perspective of epidemiology
• Objectives of epidemiology
• Importance and uses of epidemiology
• Sources of data used in epidemiology
Definitions
EPI DEMOS LOGOS
Upon People Study

The study of anything that

happens to people
 What is Epidemiology?
Basic science of
public health Environment
Person Time
the dynamic 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
Injury
Dictionary of Epidemiology Death
Transmission Exposure
 Epidemiology is

the study of the patterns of

disease occurrence
 Epidemiology

identifies the risk factors

 Epidemiology

defines the relationship of disease to the

population at risk
 Branches of epidemiology
Time

Descriptive study Distribution Place

Person
Epidemiology

Analytic study Risk factors Etiology

Descriptive epidemiology

• What (How much): occurred

• Who: animals or humans
• When: time
• Where: place
 Descriptive epidemiology

• Detection of individual case

• Detection of outbreaks
• Measuring the impact of disease
• Understand the nature of a disease
• Understand the way that disease spreads
and is distributed
 Descriptive epidemiology

• Generate hypotheses and ideas for further

research
• Evaluation of prevention and control
measures
• Support planning activities for animal health
program
Basic Measures and Tools of
Descriptive Epidemiology

• Data collection
• classification / organization
• summarizing
• presentation
Analytical epidemiology

• How: adjust policy and response

• Why: prevent and control
 Features of Epidemiology
• It is interdisciplinary
– Draws from biostatistics and other social
and behavioral sciences as well as from
medically-related fields of toxicology,
pathology, virology, genetics,
microbiology, parasitology and clinical
medicine.
 Features of Epidemiology
• Use of population research techniques
and requires quantification of relevant
factors
– E.g. the presence or absence (or the amount)
of exposure and the magnitude of the
outcome
– E.g, those people who develop diabetes how
much fats (in milliters) have they taken in 10
years?
 Comparison
• Clinician • Epidemiologist
Patient’s Community’s
diagnostician diagnostician

Investigations  Investigations

Diagnosis  Predict trend

Therapy  Control
Cure  Prevention
 Exposure and Outcome
In Epidemiology there are two main factors
that are considered:
exposure and outcome

• Exposure refers to factors that might

influence one’s risk of developing a
condition or disease
• Outcome refers to case definitions or
results of the exposure
 Example
• Hypothesis: People who ate at the church picnic
were more likely to become ill
– Exposure is eating at the church picnic
– Outcome is illness – this would need to be defined, for
example, ill persons are those who have diarrhea and
fever or nausea

• Hypothesis: People who ate the egg salad at the

end of year party were more likely to have
laboratory-confirmed Salmonella
– Exposure is eating egg salad at the end of year party
– Outcome is laboratory confirmation of Salmonella
 Case Definition
• A set of standard diagnostic criteria that
must be fulfilled in order to identify a
person as a case of a particular disease

• Ensures that all persons who are counted

as cases actually have the same disease

• Typically includes clinical criteria (lab

results, symptoms, signs) and sometimes
restrictions on person, place, and time
 Endemic

• The constant low-level presence of a

disease or infection
• E.g the prevalence of Syphilis amongst
pregnant women in Botswana is around
16%
Endemic pattern

Sporadic pattern
 Epidemic

• Occurrence of disease clearly in excess of

the number of cases normally found or
expected; if confined to a limited
population, it is an ‘outbreak’
• An increase in incidence above the expected in
a defined geographic area within a defined time
period
• E.g if the prevalence of Syphilis was to increase
from 16% then it becomes an out break
Epidemic pattern
 Epidemic Threshold
• The minimum number of cases (or deaths)
that would support the conclusion than an
epidemic was underway.
 Pandemic
• (Greek word) is an epidemic of infectious
disease that is spreading through human
populations across a large region; for
instance a continent, or even worldwide

• Meaning very widespread, often global,

disease
• For example HIV/AIDS, smallpox,
Tuberculosis
History of Epidemiology
 History of Epidemiology
• Vital Statistics
– John Graunt (1620-1674)
– William Farr (1807-1883)
• Occupational medicine
& Industrial Hygiene
– Bernardino Ramazzini (1633-1714)
• Role of carriers in transmission
– Typhoid Mary & George Soper
Hippocrates (460-377 B.C.)
On Airs, Waters, and Places
 hypothesized that
disease might be
associated with physical
environment
 Including seasonal
variation in illiness
 Hippocrates (460-377 B.C.)
• • Hippocrates began the conversation to
dispel demons as the cause of disease
and injury.
• During the age of enlightenment and the
industrial revolution several individuals
began to define the discipline:
 John Graunt (1620-1674)
• began to count (births, deaths, men,
women), designed the first life table
(probability of residents surviving at a
certain age.)
 Thomas Sydenham
(1624-1689)
Recognized as a founder of
clinical medicine and
epidemiology
Emphasized detailed
observations of patients &
accurate recordkeeping
 James Lind (1700’s)

 Designed first experiments to

use a concurrently treated
control group
Edward Jenner (1749-1823)
 Pioneered clinical trials for vaccination to
control spread of smallpox
 Jenner's work influenced many others,
including Louis Pasteur who developed
vaccines against rabies and other
infectious diseases
 William Farr (1807-1883)
• William Farr was a leading
British epidemiologist but qualified doctor
• Was a pioneer in the field of medical
statistics
• He was able to develop his interest in the
generation and use of medical statistics
• He set up a system that routinely recorded
the cause of death.
 William Farr (1807-1883)
• Such detailed raw data allowed a far more
detailed analysis of death within the
general population
• For example, the mortality rates of
different professions or of those living in
different locations could be compared
• He took particular interest in
environmental conditions
Ignas Semmelweis (1840’s)

 Pioneered handwashing to
help prevent the spread of
septic infections in mothers
following birth
 John Snow (1813-1858)
 Father of epidemiology
 Careful mapping of cholera
cases in East London during
cholera epidemic of 1854
 Traced source to a single well
on Broad Street that had been
contaminated by sewage
 John Snow (1813-1858)
• John Snow – proposed the Waterborne
Theory to postulate why people were
getting sick from a specific well in central
London.
• Snow’s methods represent the modern
foundation of epidemiological study (study
designs)
 John Snow (1813-1858)
• Compared cholera rates by neighborhood
– ecological studies
• Compared disease rates in exposed and
unexposed persons (people who drew
water from the Broad Street pump & those
who didnt) – cohort studies
• • Compared water source in infected and
uninfected persons – case/control studies
Historical considerations Nightigale
• Nightingale's most famous contribution
came during the Crimean War in 1854
• in Scutari (modern-day Üsküdar in
Istanbul)
• She found wounded soldiers being badly
cared for by overworked medical staff
• Medicines were in short supply
• Hygiene was being neglected
• Mass infections were common, many of
Historical considerations Nightigale
• No equipment to process food for the
patients
• Death rates did not drop; on the contrary,
they began to rise
• Soldiers died from illnesses such as
typhus, typhoid, cholera and dysentery
than from battle wounds
• Conditions at the temporary barracks
hospital were so fatal
Historical considerations Nightigale
• Overcrowding and the hospital's defective
sewers and lack of ventilation
• Six months after Nightingale effected
flushing out the sewers and improvements
to ventilation
• Death rates were sharply reduced
• She reduced the death rate from 42% to
2% either by making improvements in
hygiene herself or by calling for the
Sanitary Commission
Historical considerations Nightigale
• She continued believing the death rates
were due to
Poor nutrition and supplies
Overworking of the soldiers
• She came to believe that most of the
soldiers at the hospital were killed by poor
living conditions not war related injuries
Historical considerations Nightigale
• She then advocated sanitary living
conditions as of great importance
• Consequently, she turned attention to the
sanitary design of hospitals
• She also used graphical presentations of
statistics to show sources of patient
mortality
• For example Pie chart and developed a
polar area diagram
Goal and
Objectives
 Ultimate Goal of Epidemiology
• Prevention of Disease
• Maintenance of Health
 Objectives of Epidemiology
• Determine the primary agent of or
ascertain causative factors
• Understand the causation of diseases,
disorders, or conditions
• Determine the characteristics of the agent
or causative factors
• Define the mode of transmission
• Define and determine contributing factors
• Identify and explain geographic disease
patterns
 Objectives of Epidemiology
• Determine, describe, and report the
natural course of disease, disability, injury,
and death
• Determine control methods
• Determine preventative measures
• Aid in the planning and development of
health services
• Provide administrative and planning data
 Objectives of Epidemiology
• To evaluate both existing and newly
developed preventive and therapeutic
measure and modes of health care
delivery
• To provide the foundation for developing
public policy relating to environmental
problems
Importance and uses of
Epidemiology
 Uses of Epidemiology
• To study history of diseases
• Population or Community diagnosis
• Looks at risks of individuals as they affect
groups or populations
• Assessment, Evaluation and research
• Completing the clinical picture
• Identification of syndromes
• Determine the cause and sources of
disease
• Individual decisions
 Uses of Epidemiology

• Describe the distribution of disease

• Identify factors that increase/decrease risk
• Predict trends
• Consider mechanisms of transmissions
• Identify health needs
 Uses of Epidemiology
Genetic Factors

Genetic Factors Ill health

• Causation
Environmental factors
(including lifestyle)

Death

• Natural History Good health Subclinical changes Clinical Disease

Recovery

Proportion with ill Good health

• Description of
health, change over
health status of time, change with
populations Ill
age, etc. health

Time

Treatment, Medical care

• Evaluation of
intervention Good health Ill health

Health promotion
Preventive measures
Public health services
 To study history of diseases
• Epidemiology studies the trends of a
disease for the prediction of trends
• The results of the epidemiological studies
are useful in planning for health services
and public health
 Estimation of number of hospital beds required for patients with
specific disease (e.g. mental illness) or for given segments of the
population (e.g. prematurely born infants, disabled elderly) will
require knowledge of the frequency and natural history of particular
diseases or of all diseases in the affected segments of the
population
 Population or community health
diagnosis
• What are the diseases, conditions,
injuries, disorders, disabilities, defects
causing illness, health problems, or death
in a community or region
• public health officials must assess the
health of the population or community they
serve
• lead to improved health for the population
they serve.
 Population or community health
diagnosis cont’
• Then determine whether health services
are available, accessible, effective, and
efficient
• must find answers to many questions
• Then make informed decisions that will
lead to improved health for the population
they serve.
Looks at risks of individuals as they
affect groups or populations
• What are the risks factors, problems,
behaviours that affect groups
• Groups are studied by doing risk factor
assessments and health appraisal
approaches e.g. health risk, appraisal,
health screening. Medical exams, disease
assessments
 Assessment, Evaluation and
research
• How well do public health and health
services meet the problems and needs of
the population or group
• Effectiveness; efficiency; quality; access;
availability of services to treat, control, or
prevent diseases; disability; or death
 Assessment, Evaluation and
research
• Provide guidelines in the administration
and evaluation of health services
– The planning of efficient research (diagnostic,
therapeutic, preventive) will require
knowledge of how many cases of a particular
disease are likely to be found in a given
population during a given period
– Knowledge of the relative frequency of
disease in population subgroups is useful if it
enables intervention programs to target these
populations (e.g. screening programs)
 Completing the clinical picture
• Identification and diagnostic processes to
establish that a condition exists or that a
person has specific disease
• Cause-effect relationships are determined,
e.g., alcohol intake can cause liver
cirrhosis
• But epidemiologists also contribute to
physicians’ understanding of the clinical
picture and natural history of disease
Completing the clinical picture cont’
• For example, in late 1989 three patients in
New Mexico were diagnosed as having
myalgias (severe muscle pains in chest or
abdomen) and unexplained eosinophilia
(an increase in the number of one type of
white blood cell)
• Their physician could not identify the
cause of their symptoms, or put a name to
the disorder
Completing the clinical picture cont’
• Epidemiologists began looking for other
cases with similar symptoms, and within
weeks had found enough additional cases
of eosinophilia-myalgia syndrome to
describe the illness, its complications, and
its rate of mortality
 Individual decisions
• People may not realize that they use
epidemiologic information in their daily
decisions
• quitting smoking, taking stairs instead of
the elevator, ordering a salad instead of a
cheeseburger with French fries, or choose
one method of contraception instead of
another
may be influenced, consciously or
unconsciously, by epidemiologists’
• assessment of risk
 Individual decisions cont’
• epidemiologists documented the increased
risk of lung cancer among smokers; in the
1960’s and 1970’s
• noted a variety of benefits and risks
associated with different methods of birth
control
• These and hundreds of other
epidemiologic findings are directly relevant
to the choices that people make every
day, choices that affect their health over a
lifetime
 Identification of syndromes
• Helps to establish and set criteria to define
syndromes, some examples are: down,
fetal alcohol, sudden death in infants, etc
Determine the cause and sources
of disease
• Much of epidemiologic research is devoted
to a search for causes, factors which
influence one’s risk of disease
• Sometimes this is an academic pursuit,
but more often the goal is to identify a
cause so that appropriate public health
action might be taken
• Epidemiological findings allow for control,
prevention and elimination of the causes
of diseases, conditions, injury, disability, or
death
 Determine the cause and sources
of disease cont’
• Nevertheless, epidemiology often provides
enough information to support effective
action
• Examples include John Snow’s removal of
the pump handle and the withdrawal of a
specific brand of tampon that was linked
by epidemiologists to toxic shock
syndrome
• often, epidemiology and laboratory
science converge to provide the evidence
needed to establish causation
 Determine the cause and sources
of disease cont’
• For example, a team of epidemiologists
were able to identify a variety of risk
factors during an outbreak of a pneumonia
among persons attending the American
Legion Convention in Philadelphia in 1976
• However, the outbreak was not “solved”
until the Legionnaires’ bacillus was
identified in the laboratory almost 6
months later
Sources of data
 Data
• Health information is an integral part of
national health system
• There is a need to provide reliable ,
relevant, up-to-date adequate, timely and
reasonably complete information for health
managers at all levels
 Data
• Data consist of discrete observations of
attributes or events that carry little
meaning alone.
• Data need to be transformed into
information by reducing them ,
summarizing and adjusting them so that
comparison over time and place are
possible
Sources of data used in Epidemiology
• Health insurance statistics
• Data from medical clinics
• Special epidemiologic surveys, including
morbidity surveys
• Vital statistics
• Census
• Absenteeism data from schools or work
settings
• Disease registers
• Hospital and clinic statistics
• Surveillance system
 Census
• It is an important source of health
information
• It is taken in most countries of the World at
regular intervals- every 10 years, BW 2011
• It is a process of collecting, compiling and
publishing demographic , economic and
social data pertaining at a specified time to
all persons in a country.
• It provide demographic information such
as total count of population
 Census
• It provides framework of reference and
baseline for planning , action and
research ,
• It provides basic data needed to compute
vital statistical rates and other health,
demographic and socioeconomic
indicators.
• The main drawback of census as data
source is that the full results are usually
not available quickly
 Vital Statistics
• Vital events registration system as defined by UN
include legal registration , statistical recording and
reporting of the occurrence of and the collection ,
compilation, presentation, analysis and distribution
of statistics pertaining to vital events
• Vital events include births, deaths, marriage,
divorce, adoption, seperation, etc
• Keeps continuous check on demographic changes
• If registration of vital events is complete and
accurate , it can serve as a reliable source of
health data.
 Vital Statistics
• In large majority of countries properly
functioning vital events registers do not
exist
• Challenges- lack of awareness on part of
the public , accessibility, registrar are not
skilled and inadequate in number .
 Disease Notification
• Notification of infectious diseases was the
first health information sub system to be
established.
• The primary purpose is to effect
prevention and /or control of diseases
• It is a valuable source of information
• List of notifiable diseases vary from
country to country
 Disease Notification
• At international level , the following
diseases are notifiable under the
International Health regulation.
• They are cholera, plague and yellow fever,
Dysentery, Meningococcal Meningitis,
H1N1
• Most of these conditions, etc are placed
under international surveillance including
in Botswana
 Disease Notification
• Notification provides valuable information
about fluctuation of disease frequency
• It provides early warning about new
occurrences or outbreaks of disease.
• The concept has been extended to non
communicable diseases – cancer , stroke
etc recently
 Disease Notification
• Reliable reporting of priority diseases and
conditions to the next level and appropiate
health authorities
• Emergency notification : any case or death to
any of the following diseases –AIDs, Anthrax
,meningitis (Meningococcal) ,Cholera, Plague,
Human rabies, Typhoid and paratyphoid,
Dysentery and Yellow fever
• Immediate reporting by fax, telephone and fill
MH2072 form
 Disease Notification
• Regular monthly notification
Diseases of immediate threat to public
health and diseases addressed by control
programmes
Cases and deaths may be reported, daily,
weekly, monthly or quarterly
 Disease Notification
• Limitations are it covers only a small part
of the total sickness in the community.
• System suffers from a good deal of under
reporting
• Many cases especially atypical and
subclinical cases escape notification due
to non recognition.
• Accuracy of diagnosis which is important
in notification depends upon availability of
facilities for laboratory examinations
 Hospital records
• When registration of vital events is
defective and notification of infectious
disease extremely inadequate , hospital
data constitute a basic and primary
source of information about disease
prevalent .
• Hospital statistics is an integral and basic
part of the national statistical programme.
• Lot of useful information about health care
activities can be derived from hospital
records
 Hospital records
• Hospital data provide information on
geographic sources of patients, age and
sex distribution of disease and duration of
hospital stay , distribution of diagnosis,
association between different diseases,
period between disease and hospital
admission , distribution of patient
according to different social and biological
characteristics and cost of care.
 Hospital records
• This information may be of great value in
planning of health care services
• Establishment of medical record
department in all hospitals and
computerisation of medical records will
enable medical care to be more effectively
rendered , better planned and better
evaluated.
 Hospital records
• The drawbacks are – it constitute the tip of
iceberg – provide information on only those
patients who seek medical care but not a
representative sample of the population
• Admission policy vary from hospital – hospital
statistics is highly selective
• Population served by the hospital (population
at risk )cannot be defined. It provides only
numerator not denominator
• Hospital statistics are considered as poor
guide to the estimation of disease frequency.
 Disease registers
• A register ensures permanent record to
be established , that cases followed up
and that basic statistical tabulations be
prepared both on frequency and on
survival
• Morbidity registers are a valuable source
of information as to duration of illness,
case fatality and survival.
• Registers allow follow up of patients and
provide continuous account of frequency
of disease
 Disease registers
• In the absence of population base , useful
information may be obtained from
registers on natural course of disease.
• It can provide data on morbidity from the
particular diseases, treatment given and
disease –specific mortality
 Uses of disesase registers
• Patient care
– regular review and recall
– structured care programmes
– monitoring high risk groups
– managing demand / regulating access
– communication
– risk stratification
 Uses of disease registers cont’
• Technology assessment
• Research
– descriptive studies
– improving the performance of clinical trials
– studies of process
– hypothesis testing when trials are not
available
 Uses of disease registers cont’
• Public Health
– surveillance
– planning the provision of health care
– monitoring the burden of ill health
– monitoring the impact of prevention
 Disease surveillance
• A systematic collection, collation and
analysis of data with prompt dissemination
to those who need to know for relevant
action to be taken (WHO,2001)
• The application of this process to diseases
is known as disease surveillance
 Disease surveillance
• Particular diseases are endemic, targeted
for control, elimination and eradication.
• Surveillance systems are set up to report
on occurrence of new cases and efforts to
control the diseases .
• These programme have yielded
considerable morbidity and mortality data
for specific diseases
 Active Disease surveillance
• In-depth search for cases of a few
selected diseases likely to cause
epidemics e.g sentinel surveillance for EPI
diseases
 Passive Disease Surveillance

• Surveillance data is typically obtained

through health provider initiated reports
such as notification forms filled by nurses
of health department, solicited reports.
• It is good for conditions that have clear
symptomatology e.g. measles.
• It is less costly than active surveillance.
 Population surveys
• Routine statistics collected from sources
discussed earlier do not provide all
information about health and disease in
the community.
• This calls for population surveys to
complement routinely collected statistics.
• Health surveys is used for surveys relating
to any aspect of health. e.g BFHS
 Population surveys
• The following types of surveys are covered
under health survey
• Surveys for evalauting health status of a
population – community diagnosis
• Information about distribution of these
problems over time and space provides
the basis for planning and developing
needed services
 Population surveys
• Surveys for investigation of factors
affecting health and disease- environment,
occupation e.g DHS
• These surveys are helpful for studying the
natural history of disease , obtaining new
information about disease etiology and risk
factors. e.g BIAS
• Surveys relating to administration of health
services e,g use of health services ,
evaluation of population health needs and
unmet needs e.g BFHS
 Summary
Type of data Information Source
Mortality statistics Distribution of death rates- Death certificate
age ,sex, location
Derived statistics- life
expectancy, life table
Hospital discharge statistics Length of stay, outcome, Hospital charts
Service, procedures
Notifiable disease statistics Incidence of communicable, Notifications , pathology
Communicable occupational diseases , reports
Occupational cancer
Cancer
others
Health care utilization Frequency of patient Health insurance claim
statistics contact with health care data, school health reports
system , use of prescribed
drugs
Morbidity statistics Frequency of symptoms Responses to questions in
community surveys
Natality statistics Age, parity of mother, birth Birth certificate
weight, type of birth
 Overview of problems with
epidemiologic data sources
• This problems apply to most if not all
routine data collection systems
 Overview of problems with
epidemiologic data sources cont’
• Missing data
• Incomplete data
• Duplicate data
• Differential reporting owing to resources
differences
• Data recording problems, e.g. errors on
tick sheets, in registers or in patient notes
• Data capture errors, incorrect capture of
data records into computer databases
 Overview of problems with
epidemiologic data sources cont’
• Small numbers which may not be
statistically significant but may be of public
health significance, e.g. disease outbreaks
• Inaccurate denominator data for rates
• A lack of depth in the data (few data items
collected per case)
Questions and Comments?
Thank you