EPIDEMIOLOGY
By Ms. Maria Francisca F. Palicpic, R.N.
Greek Words:
epi = “upon”
demos = “people”
logos = “study
According to Last, EPIDEMIOLOGY is the study of
the distribution & determinants of health-related states
or events in specified populations, & the application of
this study is the prevention & control of health
problems.
This field of study makes use of concepts & methods
from numerous other fields such as biology, sociology,
demography, geography, environmental science &
policy analysis & most notably from statistics.
Practical Applications of Epidemiology
 Assessment of the health status of the community
or community diagnosis.
 Elucidation of the natural history of disease.
 Determination of disease causation.
 Prevention & control of disease.
 Monitoring & evaluation of health interventions.
 Provision of evidence for policy formulation.
ASSESSMENT OF THE HEALTH STATUS OF
THE COMMUNITY (COMMUNITY
DIAGNOSIS)
Health Indicators
- Are quantitative measures (rates, ratios or
proportions) that describe & summarize
various aspects of the health status of the
population.
- Aside from assessing the health status of the
population, these are also used for:
a. Determining factors that may contribute to
causation & control of diseases.
b. Identifying public health problems & needs.
c. Indicating priorities for resource allocation.
d. Monitoring implementation of health
programs.
e. Evaluating outcomes of health programs.
Types of Health Indicators & their examples:
Morbidity Indicators
 Are generally based on the disease-specific
incidence or prevalence for the common & severe
diseases.
 These indicators answer 2 epidemiologic
questions:
a. What are the health problems in the area?
b. How many cases occur in the area?
 Prevalence proportion (P)
Prevalence provides an indication of the magnitude of
a health problem & is used for projecting the scope of
health services needed by the community.
Factors affecting Prevalence
Morbidity Indicators
 Incidence
- Measures the number of new cases, episodes or
events occurring over a specified period of
time (a year), within a specified population at
risk.
- Best indicator whether a condition is
decreasing, increasing or remaining static.
Hence, the best measure to use for evaluating
the effectiveness of health interventions.
 Cohort
- Is a group of people who share a common
defining characteristic
 At-risk group
- Members of the group are free of the disease but
have the potential for developing a particular
disease within the specified period of time.
 Types of Incidence Measures:
a. Cumulative Incidence (or incidence
proportion)
b. Incidence density rate
 Cumulative Incidence (CI)
- Can be derived if there are no losses to follow-
up & the duration of follow-up is the same so
that the denominator is the initial size of the
cohort being followed-up.
- Risk period: measures the average risk or
probability of developing the disease within a
specified period of time.
- Attack rate: is used instead of CI when the risk
period of the occurrence of disease is very
short.
 Incidence density rate
- Is used in the event of losses to follow-up
(censoring): follow-up period is relatively long,
cohort members are lost to follow-up due to
death, out-migration or refusal to continue.
- This morbidity indicator measures the average
instantaneous rate of disease occurrence.
- If the rate of disease occurrence is low, as with
many chronic diseases, it is also a good estimate
of the CI or risk of developing the disease.
Since it may not be possible to measure disease-free
period precisely,
 Specific morbidity rates
- Shows disease rates in specific population
groups such as by age, sex, occupation,
education, exposure to risk factors, place of
residence, or combination of these factors
- Answers the questions: (descriptive
epidemiology – orienting a disease as to time,
place & person characteristics through various
study designs including ecologic studies)
a. Who is affected?
b. Where do they occur?
c. When do they occur or increase?
Mortality Indicators
 Mortality statistics provide important information
of the health status of the people in the
community. The pattern of causes of death
indicates the most life-threatening diseases that are
prevalent in the community, although it fails to
detect the nonfatal conditions but are nonetheless
widespread.
 Crude death rate (CDR)
- Rate with which mortality occurs in a given
population.
- Factors that affect the level of CDR:
a. Age & sex composition of the population
b. Adverse environmental & occupational
conditions
c. Peace & order conditions of the place

 Specific mortality rate
- Rate of dying in a specific population groups.
 Cause-of-death rate
- Rate of dying due to specific causes.
- This is also a crude rate but made specific by
relating the deaths from a specific cause &
group to the midyear population of that
specified group.
- Factors affecting:
a. Completeness of registration of deaths
b. Composition of the population
c. Accuracy of ascertaining the cause of death
- Identifies the greatest threat to the survival of
the people, hence prevent death.
 Infant mortality rate (IMR)
- Defined as the number of deaths of infants
under 1 year of age in a calendar year per 1,000
live births in the same period.
- It is used as an approximation of the risk of
dying within the 1st year of life but not a true
measure of risk because not all infants who die
in a calendar year were also born in that year.
- The IMR is a good index of the level of health
in a community because infants are very
sensitive to adverse environmental conditions.
- High IMR = low levels of health standards
secondary to poor maternal health & child
health care, malnutrition, poor environmental
sanitation, or deficient health service delivery.
 Neonatal Mortality Rate & Postneonatal Mortality
Rate
- Neonatal death (infants less than 28 days old)
due mainly to prenatal or genetic factors.
- Postneonatal death (later months) are
influenced by environmental & nutritional
factors (infections).
 Maternal Death
- Defined as death of a female from any cause
related to or aggravated by pregnancy or its
management (excluding accidental or
incidental causes) during pregnancy &
childbirth or within 42 days of termination of
pregnancy, irrespective of the duration & the
site of pregnancy.
 Maternal Mortality Ratio (MMR)
- Measure of obstetric risk & is affected by
maternal health practices, diagnostic
ascertainment & completeness of registration
of births.
 Case Fatality Rate (CFR)
- Proportion of cases that end up fatally.
- Quantifies the risk of dying among persons
afflicted with a particular disease.
- The magnitude of CFR depends on the nature
of the disease itself, the diagnostic
ascertainment & the level of reporting in the
population.
Population Indicators
- Include not only the population growth
indicators (CBR, general fertility rate, total
fertility rate, & annual growth rate) but also
other population dynamics (migration) that can
affect the age-sex structure of the population
& vv.
 Crude Birth Rate (CBR)
- Measures how fast people are added to the
population through births.
- Useful measure of population growth.
- It is affected by: fertility, marriage pattern &
practices of the place, sex, & age composition
of a population & birth registration practice.
- A crude rate since it is related to the population
including men, children & the elderly who are
not capable of giving birth.

 General Fertility Rate (GFR)
- More specific than CBR since birth is related
to the segment of the population deemed to be
capable of giving birth (women in reproductive
age: 15-44 years old).
 Population Pyramid
- Graphical representation of the age-sex
composition of the population.
- The shape of the pyramid provides insights
into the fertility & mortality patterns of the
community as well as the most probable health
problems that would likely need health
services.
- Study Figure 8.2 of page 165 (green book of
Famorca)
Sources of Health Data
 Primary Sources:
a. Government Agencies – Department of
Health
b. Others – Research Institutions, private sector
(insurance companies, etc.)
 Secondary Sources:
a. Census
b. Vital registration system
c. Disease notification
d. Disease registries
e. Surveillance system
f. Hospital data
g. Health insurance
h. School health program
i. Downloadable data sets
j. Surveys (morbidity, demographic & health)
 Disease Notification
- Many people who need services do not have
access to health facilities that is why Disease
Notification plays an integral part of disease
surveillance.
- In the Philippines, all individuals, health
facilities (private & government), in all levels of
governance (barangay, municipal, city,
provincial, regional & national) are mandated
by Act 3573 (Law on Reporting of
Communicable Diseases) to report notifiable
diseases.
 Disease Registry
- A compilation of information about a
particular disease and aims to include all cases
of the disease without duplication and this aim
is dependent on the cooperation of agencies &
health facilities that feed the registry & on a
unique patient identifier that will allow record
linkage.
- Example: Cancer Registry in Metro Manila &
HIV/AIDS Registry in Rizal Province
 Public Health Surveillance System
- WHO – the ongoing, systematic collection,
analysis & interpretation of health-related data
needed for the planning, implementation &
evaluation of public health practice.
- Application of epidemiologic principles &
methods is essential to achieve the primary goal
of serving as an early warning system for
impending epidemics of diseases & other
public health emergencies.
- Before VS Now:
a. Before – developed for monitoring high
burden diseases, detecting disease outbreaks &
monitoring progress to control, eliminate &
eradicate specific disease.
b. Now – advocates inclusion of detection of
toxins, hazardous chemicals, genetically
modified products & risky behaviors.
Types:
a. Passive – a system by which public health staff
receives reports from hospitals, clinics, public
health units or other sources.
b. Active – a system by which public health staff
members actively & regularly contact health
care providers or the population to obtain
information about the disease of interest.
- Active is ore expensive but it yields more
accurate and timely data. This allows early
detection of the disease & more valid
evaluation of the impact of public health
interventions. Therefore, a very active
surveillance system should be used so that
every case that occurs can be detected.
 - Disease Surveillance Systems in the Philippines
(PIDSR – Philippine Integrated Disease
Surveillance & Response)
➢ Notifiable Disease Reporting System
(NDRS)
➢ Field Health Service Information
System (FHSIS)
➢ National Epidemiology Sentinel
Surveillance System (NESSS)
➢ Expanded Program on Immunization
Surveillance System (EPI Surveillance)
➢ HIV-AIDS Registry
➢ Study Box 8.3 page 168 (green book of
Famorca)
 Downloadable data sets
- This is common in first world countries like the
USA where several data resources can be
downloaded from the Internet. Unfortunately,
not for the Philippines.
Considerations in the analysis & interpretation of
Health Indicators
1. Is the denominator of the rate the most
appropriate one?
2. Is the numerator an accurate count of the
number of events?
3. There should be correspondence in time &
geographical location of the events in the
numerator & the population in the
denominator.
4. Time specifications are usually on an annual
basis. However, special indicators may have
other period specifications & these should be
stated.
5. The factor used in the computation of the
different rates may be any number of the base
10.
ELUCIDATION OF THE
NATURAL HISTORY OF DISEASE
 The natural history of the disease is its course over
time, starting from the prepathogenesis stage to its
termination.
 A prospective cohort study could plot better the
history of the disease because of the benefit of
observing the cohort from the time that the
members are disease-free to the time they develop
the disease through its termination.
 The applicable level of prevention that is
administered to the patient is dependent on the
stage of the disease when the patient was
diagnosed.
(Read further the discovery of AIDS in page 169, green
book of Famorca)
 Stages in the Natural History of Disease & the
Level of Prevention
1. Stage of Susceptibility (Prepathogenesis)
- The person is not yet sick but may be exposed
to the risk factors of the disease.
- Primary level of prevention – health education
& immunization to avoid the development of
the disease.
2. Stage of Subclinical Disease
- The person is still apparently healthy since
clinical manifestations of the disease are not yet
shown, although pathologic changes have
already occurred.
- Secondary level of prevention – diagnostic
procedures to prompt treatment to avoid
progression of the disease.
- Stages in the Natural History of Disease & the
Level of Prevention
3. Stage of Clinical Disease
- The patient now manifests recognizable signs
& symptoms.
- Tertiary level of prevention – limit disability &
restore the functional capability of the patient.
4. Resolution Stage
- - The patient either recovers completely from
the disease, becomes a chronic case, with or
without disability or dies.
DETERMINATION OF
DISEASE CAUSATION
 Questions:
a. What factors contribute to disease causation?
b. Why does disease occur?
- Answering these epidemiologic questions
based on valid evidence will contribute to the
success of health interventions.
 A revie of the theoretical & research literature & an
understanding of the natural history of the disease
will contribute to the development of an
epidemiologic disease model representing the
factors that influence disease causation.
 An epidemiologic approach assumes a causal path
& posits that changing or breaking a link in that
 causal path can either prevent the occurrence of
the disease or alter its course, so that the more
serious sequelae can be avoided.
Models of Disease Causation
 Epidemiologic Triad or Triangle Method
- The agent and the susceptible host are
interacting freely in a common (physical,
biologic, socioeconomic) environment.
- For as long as the balance is maintained or is
tilted in favor of the host (good nutritional
status, high levels of immunity) disease does
not occur. However, when the balance is tilted
in favor of the agent (increased dosage &
pathogenicity of the agent), disease eventually
occurs.
Asdasd
 Wheel Model
- Gives emphasis on the role of genetic makeup
of the host that is presented as the inner core
of the wheel’s hub.
- The outer core of the hub includes host
characteristics (sex, age, socioeconomic status
& behaviors).
- The rim or the outer edge represents the
biologic, physical & chemical environment.
 Spider’s Web or Web-like
- When there is an interconnection of multitude
of factors.
- Under this model, disease can be prevented by
breaking the weakest strand of the causal web
through various types of epidemiologic studies.
- Study Figure 8.5 page 173 (green book of
Famorca)
PREVENTION AND CONTROL
OF DISEASES
- Epidemiologic information should be utilized
by health workers who are tasked to plan
preventive programs so that the probability of
attaining the program objectives is increased.
 Outbreak Investigation
- WHO – occurrence of cases of disease in
excess of what would normally be expected in
a defined community, geographical area or
season.
- Occurrence of outbreak:
a. Previously unknown disease
b. Disease never occurred in the area
c. Disease has been absent from the population
for a long time
- Impending outbreak is detected through:
(report unusual disease or large number of
cases)
a. Surveillance system
b. Perceptive clinicians
c. Infection control nurse
d. Laboratory workers
- Outbreak investigation should be conducted in
order to identify then eliminate the source of
infection and thus prevent the occurrence of
more cases.
- Basic steps in an Outbreak Investigation:
1. Operationally define what constitutes a case.
2. Based on the operational definition, identify
the case.
3. Based on the number of cases identified, verify
the existence of an outbreak.
4. Establish the descriptive epidemiologic
features of the case.
5. Record the clinical manifestations of cases.
6. Based on the clinical manifestations,
incubation period, available laboratory
findings, & other information gathered,
 formulate a hypothesis regarding the probable  Example: Republic Act 9288 – Newborn Screening
etiologic agent, the sources of infection, the Act of 2004 (NBS)
mode of transmission & the best approach for
controlling the outbreak.
7. Test the hypothesis by collecting relevant
specimens from the patients & from the
environment.
8. Based on the results of the investigation,
implement prevention & control measures to
prevent recurrence of a similar outbreak.
9. Disseminate the findings of the investigation
through media & other forms to inform the
public.

MONITORING & EVALUATION OF

HEALTH INTERVENTIONS
 Monitoring
- An ongoing activity during program
implementation to assess the current status if
its implementation in terms of compliance to
the design of the program, timelines &
attainment of midterm goals.
- Results of monitoring:
a. Assess the progress of program
implementation
b. Identify problems
c. Take corrective action
d. Have a tool for quality assurance &
management
e. Measure achievement of midterm program
objectives
f. Lay the groundwork for program evaluation.
 Evaluation
- Is a process that systematically & objectively
assesses compliance to the design of the
program, the performance, relevance &
success of a project.
- This process employs research techniques &
applies the methods of epidemiology & health
statistics.
- Primary purpose:
a. Provide feedback on the results or outcomes
b. Impact of the project to inform policymakers
& planners about the efficacy of the
intervention.
 Epidemiologic evidence is necessary for the
formulation of health policy .