UNIVERSITY OF SAINT ANTHONY

( Dr. Santiago G. Ortega Memorial)

Iriga City
HEALTH CARE EDUCATION DEPARTMENT

Epidemiology

Submitted By: Xy-nique De leon

BSN-3B

Submitted To: Kenny Niño H. Tagum,

Ph.D Clinical Instructor
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HEALTH CARE EDUCATION DEPARTMENT
1. Define epidemiology

Epidemiology is defined as “ the study of the distribution and determinants of

health-related states or events in specified populations, and the application of this
study to the prevention and control of health problems” (Last, 2001). As a study,
epidemiology follows the scientific method; from defining the problem, gathering data
or information, analyzing and interpreting them to come up with a sound conclusion
and set of recommendations.
The study of epidemiology focuses on the frequency and pattern of health
events in the population. Frequency refers to the number of health events. It can also
refer to the ratio or rate of cases in the population to compare health conditions or
disease occurrence across different populations.
Epidemiologic methods are used to study both communicable and
noncommunicable disease and other health-related states or events Communicable
diseases are spread from one person to another through a variety of ways; such as
physical contact with an infected person, contaminated food and water, bites from
insects or animals capable of transmitting the disease, and breathing in an airborne
virus. Non Communicable diseases are chronic diseases which are the result of a
combination of genetic, physiological, environmental, and behavioral factors.
Originally, epidemiology was just focused on studying epidemics of communicable
diseases. But it has expanded to applications related to chronic diseases,
maternal-child health, occupational and environmental health, and other
health-related events

2. Enumerate uses of epidemiology in public health nursing.

Primary Prevention , The central goals of epidemiology are describing the disease
patterns, identifying the etiological factors in disease development, and taking the most
effective preventive measures. These preventive measures are specific to the stage of
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disease progression or the natural history of disease, from prepathogenesis through
resolution of the disease process. When interventions occur before disease
development, they are called primary prevention. Primary prevention relies on
epidemiological information to indicate those behaviors that are protective, or those
that will not contribute to an increase in disease, and those that are associated with
increased risk. Two types of activities constitute primary prevention. Those actions that
are general in nature and designed to foster healthful lifestyles and a safe environment
are called health promotion. Actions aimed at reducing the risk of specific diseases are
called specific protection. Public health practitioners use epidemiological research to
understand practices that are likely to reduce or increase disease rates. For example,
numerous research studies have confirmed that regular exercise is an important health
promotion activity that has positive effects on general physical and mental health.
Immunizations exemplify specific protection measures that reduce the incidence of
particular diseases.
Secondary and Tertiary Prevention
Secondary prevention occurs after pathogenesis. Those measures designed to
detect disease at its earliest stage, namely screening and physical examinations that are
aimed at early diagnosis, are secondary prevention. Interventions that provide for early
treatment and cure of disease are also in this category. Again, epidemiological data and
clinical trials determining effective treatments are crucial in disease identification.
Mammography, guaiac testing of feces, and the treatment of infections and dental
caries are all examples of secondary prevention. Tertiary prevention focuses on
limitation of disability and the rehabilitation of those with irreversible diseases such as
diabetes and spinal cord injury. Epidemiological studies examine risk factors affecting
function and suggest optimal strategies in the care of patients with chronic advanced
disease.
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Establishing Causality
As discussed earlier, a principal goal of epidemiology is to identify etiological
factors of diseases to encourage the most effective prevention activities and develop
treatment modalities. During the last few decades, researchers recognized that many
diseases have not one but multiple causes. Epidemiologists who examine disease rates
and conduct population-focused research often find multiple factors associated with
health problems. For example, cardiovascular disease rates may vary by location,
ethnicity, and smoking status. Even infectious diseases often require not only an
organism but also certain behaviors or conditions to cause exposure. Determining the
extent that these correlates represent associative or causal relationships is important for
public health practitioners who seek to prevent, diagnose, and treat disease. Definitively
establishing causality—particularly in chronic disease —is a challenge
. The following six criteria establish the existence of a cause-and-effect
relationship:
1. Strength of association: Rates of morbidity or mortality must be higher in the
exposed group than in the non exposed group. Relative risk ratios, or odds ratios, and
correlation coefficients indicate whether the relationship between the exposure variable
and the outcome is causal. For example, epidemiological studies demonstrated an
higher relative risk for heart disease among smokers than among nonsmokers.
2. Dose-response relationship: An increased exposure to the risk factor causes a
concomitant increase in disease rate. Indeed, the risk of heart disease mortality is
higher for heavy smokers than for light smokers.
3. Temporally correct relationship: Exposure to the causal factor must occur
before the effect, or disease. For heart disease, smoking history must precede disease
development.
4. Biological plausibility: The data must make biological sense and represent a
coherent explanation for the relationship. Nicotine and other tobacco-derived chemicals
are toxic to the vascular endothelium. In addition to raising low-density lipoprotein
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(LDL) and decreasing high-density lipoprotein (HDL) cholesterol levels, cigarette
smoking causes arterial vasoconstriction and platelet reactivity, which contribute to
platelet thrombus formation.
5. Consistency with other studies: Varying types of studies in other populations
must observe similar associations. Numerous studies using different designs have
repeatedly supported the relationship between smoking and heart disease.
6. Specificity: The exposure variable must be necessary and sufficient to cause
disease; there is only one causal factor. Although specificity may be strong causal
evidence in the case of infectious disease, this criterion is less important today. Diseases
do not have single causes; they have multifactorial origins. The exposure variable of
smoking

Screening
As explained previously, a central aim of epidemiology is to describe the course of
disease according to person, place, and time. Observations of the disease process may
suggest factors that aggravate or ameliorate its progress. This information also assists
in determining effective treatment and rehabilitation options (i.e., secondary or tertiary
prevention approaches). The purpose of screening is to identify risk factors and
diseases in their earliest stages. Screening is usually a secondary prevention activity
because indications of disease appear after a pathological change has occurred. In all
forms of secondary and tertiary prevention, the identification of illness prompts the
nurse to consider which forms of upstream prevention could have interrupted disease
development.
GUIDELINES FOR SCREENING PROGRAMS
• Screen for conditions in which early detection and treatment can improve disease
outcome and quality of life.
• Screen populations that have risk factors or are more susceptible to the disease.
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• Select a screening method that is simple, safe, inexpensive to administer, and
acceptable to clients, and has acceptable sensitivity and specificity.
• Plan for the timely referral and follow-up of clients with positive results.
• Identify referral sources that are appropriate, cost-effective, and convenient for
clients.
• Refer to evidenced-based screening recommendations published by the U.S.
Preventive Services Task Force
(http://www.uspreventiveservicestaskforce.org/index.html) and other organizations

3. Describe the types of studies in epidemiology

OBSERVATIONAL/NON EXPERIMENTAL STUDY
Descriptive epidemiology focuses on describing disease distribution by
characteristics relating to time, place, and people. This could be done through review of
records, routine data collection, or ecological surveys.It examines factors like age, sex,
education, socioeconomic status, or availability of heath services. Evaluations of specific
individuals may also include gathering information on behaviors.The primary
considerations for descriptive epidemiology are frequency and pattern.
Analytical epidemiology aims to understand the quality and the amount of
influence that determinants have on the occurrence of disease and health-related event.
This is usually done by group comparisons. Such a comparison starts from one or more
hypotheses about how the determinant may influence occurrence of a disease or event.
There are several types of analytical epidemiology: Cross-sectional, Cohort, and
Case-control.
Cross-sectional study examines the relationship between health problems and
other variables of interest as they exist in a defined population at one particular
time.The measurements of exposure and outcome are done at the same time. This
creates temporal ambiguity; hence, causal relationship cannot be established. This
study design is used to get baseline data, determine the magnitude of the health
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problem, or evaluate medical care or health service delivery.
Cohort study is a longitudinal study. Subjects are selected based on their
exposure status. They should be disease free in the beginning of the study. The cohort
is
followed through time to determine their later outcome status.
Case-control study is a retrospective study. Subjects are selected based on their
disease (health) status. Subjects positive for the disease or health condition (“case”
group) are compared with subjects who are negative or have no disease or health
condition (“control” group), ideally coming from the same population that gave rise to
the cases. It then look at the exposures that both groups may have encountered in the
Past.

EXPERIMENTAL EPIDEMIOLOGY
Randomized Control trials are experiments with patients as subjects to evaluate a
potential cure for a disease or health condition and prevent death or disability. These
are often used for testing new interventions or drugs. Subjects are enrolled into the
study based on a specific criteria. They are then randomly assigned to the interventions
– experimental group and control group – which later on are compared in terms of their
outcomes. These results are used to assess the effectiveness of the intervention,
particularly the extent to which the intervention or drug does patients more good than
harm. RCTs are the most stringent way of determining the cause-effect relationship
between the intervention and outcome. Field trials are experiment done in the
“field” involving subjects free of the disease or health conditions but at a high
risk of contracting them. In this study, the intervention is tested whether it
reduces the risk of developing the disease or condition. It usually cost more since they
require more subjects and would often necessitate visiting subjects in their home,
school, or workplace. Community trials are extension of the field trials involving the
whole community
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as the unit of assignment. For example, water treatment is done at the community
level through water supplies. The intervention can be evaluated by involving entire
communities who were assigned the water treatment.

4. Identify sources of data in epidemiology.

Epidemiologists collect and analyze data in doing the different types epidemiologic
studies. Their sources of data and either primary or secondary.

● Primary Data – refers to the original data collected for specific purpose by a
researcher.
● Secondary Data- In other cases and most often, epidemiologists use data already
collected by other individuals and/or institution for some specific purpose
(referred to as secondary data).
POPULATION CENSUS
A population census is the total process of collecting, compiling, evaluating,
analyzing and publishing or otherwise disseminating demographic, economic and social
data pertaining at a specified time, to all person in a country or in a well delimited part
of a country.
CIVIL REGISTRATION AND VITAL STATISTICS
Civil registration and vital statistics system (CVRS) are those systems which
produce births, deaths and causes of death information, which are fundamental
strategic importance for countries development process and governance.
The National Statistics Office (2014) defined the mission of the Philippine Civil
Registration and Vital Statistics System as “committed to collect, compile, process and
generate quality of data on vital records through an effective and efficient civil
registration system to meet the individuals, the nation, and global community.
CRVS data is important in planning and implementing the Health Agenda of a
country particularly in:
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1. defining patterns, trends and impact inclusive of the causes of mortality
2. understanding emerging health issues and challenges
3. defining appropriate and relevant health sectors reforms, poverty reduction
and development efforts
4. defining baseline levels and monitor and track progress towards both national
and international development goals and assess effectiveness of health programs.

DISEASE OR PATIENTS REGISTRIES

Disease or patient registries are collection of secondary data related to patients
with a specific diagnosis, condition, or procedure. They are organized system that use
observational study methods to collect uniform data to evaluate specified outcomes for
a population defined by a particular disease, condition, or exposure and that serve
predetermined scientific, clinical or policy purposes.

Disease surveillance and notification

have been recognized as an effective strategy for the prevention and control of disease
most especially epidemic prone disease.
Disease Surveillance- is the continuous scrutiny of occurrence of disease and
health related events to enable prompt intervention for the control of disease.

POPULATION BASED SURVEY

Population based survey are useful for disease surveillance when they ask people
about information for which they may be the most valid and reliable sources ; e.g., their
own private behaviors, attitudes, or mental health status or which they can report with
reasonable reliability, even if they are not the only or most valid source of information.
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5. Explain use of vital statistics in the assessment of community health

status.
Vital Statistics is the study of the characteristics of human population. It
comprises a number of important events in human life including birth, death, fetal
death marriage, divorce, annulment, judicial separation, adoption, legitimation, and
recognition. Some vital statistics are used in identifying health related concerns and
planning for intervention at the community or country level.

Individual Records
In many countries, the collection of vital statistics is through or included in the
civil registration system. Vital statistics is important as a legal document for the person
named as well as a document to describe the demographics and health of population.
The moat important individual records include birth, death, marriage/divorce. Birth
record is a legal document establishing name, parentage, birthdate, order of birth,
legitimacy, citizenship, nationality, geographic place of birth.

Population Record
Vital records of population serve as key demographic variables in the analysis of
population size, growth and geographic distribution. Population census can show
population size growth trends, as well as socio-economic concerns such as health,
housing, education, family structure, occupation and income.

Definition of Vital events

The WHO promulgates a number of vital statistics definitions as part of the
International Classification of Disease (ICD). Some of these definitions are listed on
Table 7.1
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Population Indicators
Population indicators include population growth indicators (crude birth rate.
General fertility rate, total fertility rate and annual growth rate) and other population
dynamics that can affect the age-sex structure of the population.

Crude birth rate

The crude birth rate (CBR) measures how fast people are added to the
population through births. It is the most frequently used overall measure of the
reproduction of a population.

General Fertility Rate

The GFR id the number of live births per 1,000 women aged 15-49 in a given year.

Population Pyramid
The population pyramid (Fig. 7.5) is a graphical representation of the age-sex
composition of the population.

Mortality Indicators
Mortality Indicators provide important information of the health status of the
people in the community. A mortality rate is a measure of the frequency of occurrence
of death in a defined population during a specified interval. Table 7.2 shows the health
status indicators (mortality) derived from the vital statistics.

Crude death rate

The crude death rate (CDR) is defined as the rate which mortality occurs in a given
population. CDR are sensitive to the number of people at the highest risk of dying.
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Age and sex-specific death rate

Many factors affect the level of CDR, including: age and sex composition of the
population adverse environmental and occupational conditions, and peace and order
situations. Age is one of the most common confounding factors that can ask the true
distribution of variables. Specific mortality rates show rates of dying in specific
population groups.

Cause-specific death rate

The cause-specific death gives the rate of dying due to specific causes. Factors affecting
the cause-specific rates are the completeness of registration of deaths, the composition
of the population, and more importantly, accuracy of ascertaining the cause of death.
The top leading causes of deaths indicate the greatest threat survival therefore pointing
to priority programs that are need to prevent them.

Infant Mortality Rate

Is used as a proxy for the age-specific death rate for the “under one year of age
group” intended to measure the risk o dying during the first year of life. Since many
causes of deaths at this age group are considered to be preventable through adequate
prenatal care, good nutrition for women and infants, and improved control of the
Environment.

Neonatal Mortality Rate

Deaths among infants less than 28 days old are due mainly to prenatal or genetic
factors, while those in the later months are influenced by environmental and nutritional
factors as well as infections.
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Maternal Mortality Rate

Refers to deaths due to complications from the pregnancy or childbirth, both
direct and indirect. MMR is affected by maternal health practices, diagnostics
ascertainment, and completeness of registration of births.

Perinatal Mortality Rate

Measures the death occurring during the perinatal period or the period of time
surrounding the event of birth, including the time that a fetus spends in utero after it
has reached 22 weeks of gestation and continues through the birth process until the
end of the first week of life after birth.

6. Analyze patterns of occurrence and distribution of disease

Pattern refers to the occurrence of health-related events by time, place, and
person. Time patterns may be annual, seasonal, weekly, daily, hourly, weekday
versus weekend, or any other breakdown of time that may influence disease or
injury occurrence.

Morbidity Rate
The term morbidity rate refers to the rate at which a disease occurs in a
population. These illnesses can range from acute to chronic, long-lasting
conditions. The rate of morbidity can be used to determine the health of a
population and its health care needs.

Incidence Rate
The term incidence rate refers to the rate at which a new event occurs over a
specified period of time. Put simply, the incidence rate is the number of new
Cases within a time period (the numerator) as a proportion of the number of people at
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risk for the disease (the denominator).

Prevalence Rate
Prevalence, sometimes referred to as prevalence rate, is the proportion of
Persons in a population who have a particular disease or attribute at a specified point in
time or over a specified period of time.

7. Discuss the steps in conducting epidemiologic investigations.

Step 1: Prepare for field work
The numbering scheme for this step is problematic, because preparing for field
work often is not the first step. Only occasionally do public health officials decide to
conduct a field investigation before confirming an increase in cases and verifying the
diagnosis.
More commonly, officials discover an increase in the number of cases of a
particular disease and then decide that a field investigation is warranted. Sometimes
investigators collect enough information to perform descriptive epidemiology without
leaving their desks, and decide that a field investigation is necessary only if they cannot
reach a convincing conclusion without one. Regardless of when the decision to conduct
a field investigation is made, you should be well prepared before leaving for the field.
The preparations can be grouped into two broad categories:
(a) scientific and investigative issues, and
(b) management and operational issues. Good preparation in both categories is needed
to facilitate a smooth field experience.

Step 2: Establish the existence of an outbreak

An outbreak or an epidemic is the occurrence of more cases of disease than
expected in a given area or among a specific group of people over a particular period of
time. Usually, the cases are presumed to have a common cause or to be related to one
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another in some way. Many epidemiologists use the terms outbreak and epidemic
interchangeably, but the public is more likely to think that epidemic implies a crisis
situation. Some epidemiologists apply the term epidemic to situations involving larger
numbers of people over a wide geographic area. Indeed, the Dictionary of Epidemiology
defines outbreak as an epidemic limited to localized increase in the incidence of disease,
e.g., village, town, or closed institution.
Step 3: Verify the diagnosis
The next step, verifying the diagnosis, is closely linked to verifying the existence
of an outbreak. In fact, often these two steps are addressed at the same time. Verifying
the diagnosis is important: (a) to ensure that the disease has been properly identified,
since control measures are often disease-specific; and (b) to rule out laboratory error as
the basis for the increase in reported cases.
Step 4: Construct a working case definition
. A case definition is a standard set of
criteria for deciding whether an individual should be classified as having the health
condition of interest. A case definition is a standard set of criteria for deciding whether
an individual should be classified as having the health condition of interest. A case
definition includes clinical criteria and — particularly in the setting of an outbreak
investigation — restrictions by time, place, and person. The clinical criteria should be
based on simple and objective measures such as “fever ≥ 40°C (101°F),” “three or
more loose bowel movements per day,” or “myalgias (muscle pain) severe enough to
limit the patient’s usual activities. ” The case definition may be restricted by time (for
example, to persons with onset of illness within the past 2 months), by place (for
example, to residents of the nine-county area or to employees of a particular plant) and
by person (for example, to persons with no previous history of a positive tuberculin skin
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Step 5: Find cases systematically and record information

As noted earlier, many outbreaks are brought to the attention of health authorities by
concerned healthcare providers or citizens. However, the cases that prompt the concern
are often only a small and unrepresentative fraction of the total number of cases. Public
health workers must therefore look for additional cases to determine the true
geographic extent of the problem and the populations affected by it. Usually, the first
effort to identify cases is directed at healthcare practitioners and facilities— physicians’
clinics, hospitals, and laboratories — where a diagnosis is likely to be made.
Investigators may conduct what is sometimes called stimulated or enhanced passive
surveillance by sending a letter describing the situation and asking for reports of similar
cases. Alternatively, they may conduct active surveillance by telephoning or visiting
the facilities to collect information on any additional cases.

Step 6: Perform descriptive epidemiology Conceptually

, the next step after identifying and gathering basic information on the persons with the
disease is to systematically describe some of the key characteristics of those persons.
This process,in which the outbreak is characterized by time, place, and person, is called
descriptive epidemiology. It may be repeated several times during the course of an
investigation as additional cases are identified or as new information becomes available.
This step is critical for several reasons. Summarizing data by key demographic variables
provides a comprehensive characterization of the outbreak — trends over time,
geographic distribution (place), and the populations (persons) affected by the disease.
From this characterization you can identify or infer the population at risk for the
disease. The characterization often provides clues about etiology, source, and modes of
transmission that can be turned into testable hypotheses (see Step 7). Descriptive
epidemiology describes the where and whom of the disease, allowing you to begin
intervention and prevention measures. Early (and continuing) analysis of descriptive
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data helps you to become familiar
with those data, enabling you to identify and correct errors and missing values.

Step 7: Develop hypotheses

Although the next conceptual step in an
investigation is formulating hypotheses, in reality, investigators usually begin to
generate hypotheses at the time of the initial telephone call.

Step 8: Evaluate hypotheses epidemiologically

After a hypothesis that might explain an outbreak has been developed, the next step is
to evaluate the plausibility of that hypothesis. Typically, hypotheses in a field
investigation are evaluated using a combination of environmental evidence, laboratory
science, and epidemiology. From an epidemiologic point of view, hypotheses are
evaluated in one of two ways: either by comparing the hypotheses with the established
facts or by using analytic epidemiology to quantify relationships and assess the role of
chance.
Step 9: Reconsider, refine, and re-evaluate hypotheses
Unfortunately, analytic studies sometimes are unrevealing. This is particularly true if
the hypotheses were not well founded at the outset. It is an axiom of field epidemiology
that if you cannot generate good hypotheses (for example, by talking to some
case-patients or local staff and examining the descriptive epidemiology and outliers),
then proceeding to analytic epidemiology, such as a case-control study, is likely to be a
waste of time. When analytic epidemiology is unrevealing, rethink your hypotheses.
Consider convening a meeting of the case-patients to look for common links or visiting
their homes to look at the products on their shelves. Consider new vehicles or modes of
transmission.
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Step 10: Compare and reconcile with laboratory and environmental studies
While epidemiology can implicate vehicles and guide appropriate public health action,
laboratory evidence can confirm the findings. The laboratory was essential in both the
outbreak of salmonellosis linked to marijuana and in the Legionellosis outbreak traced
to the grocery store mist machine. You may recall that the investigation of pneumonia
among attendees of an American Legion conference in Philadelphia in 1976 that gave
Legionnaires’ disease its name was not considered complete until a new organism was
isolated in the laboratory some six months later.

Step 11: Implement control and prevention

measures In most outbreak
investigations, the primary goal is control of the outbreak and prevention of additional
cases. Indeed, although implementing control and prevention measures is listed as Step
11 in the conceptual sequence, in practice control and prevention activities should be
implemented as early as possible.

Step 12: Initiate or maintain surveillance

Once control and prevention measures have been implemented, they must continue to
be monitored. If surveillance has not been ongoing, now is the time to initiate active
surveillance. If active surveillance was initiated as part of case finding efforts, it should
be continued. The reasons for conducting active surveillance at this time are twofold.
First, you must continue to monitor the situation and determine whether the prevention
and control measures are working. Is the number of new cases slowing down or, better
yet, stopping? Or are new cases continuing to occur? If so, where are the new cases?
Are they occurring throughout the area, indicating that the interventions are generally
ineffective, or are they occurring only in pockets, indicating that the interventions may
be effective but that some areas were missed?
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Step 13: Communicate findings
As noted in Step 1, development of a
communications plan and communicating with those who need to know during the
investigation is critical. The final task is to summarize the investigation, its findings, and
its outcome in a report, and to communicate this report in an effective manner. An oral
briefing for local authorities. If the field investigator is responsible for the epidemiology
but not disease control, then the oral briefing should be attended by the local health
authorities and persons responsible for implementing control and prevention measures.
Often these persons are not epidemiologists, so findings must be presented in clear and
convincing fashion with appropriate and justifiable recommendations for action. This
presentation is an opportunity for the investigators to describe what they did, what they
found, and what they think should be done about it. They should present their findings
in a scientifically objective fashion, and they should be able to defend their conclusions
and recommendations. A written report. Investigators should also prepare a written
report that follows the usual scientific format of introduction, background, methods,
results, discussion, and recommendations. By formally presenting recommendations,
the report provides a blueprint for action. It also serves as a record of performance
and a document for potential legal issues. It serves as a reference if the health
department encounters a similar situation in the future.
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