INTRODUCTION

“I keep six honest serving men; they taught me all I know, their names are what, when, how,
where & who.”

Epidemiology is the basic science of preventive & social medicine. Its ramification cover not
only study of disease distribution, and causation, but also health and health related events
occurring in human population. Epidemiology is derived from the word epidemic, epi- among,
demos- people, logos-study, means it is the study among people.

According to John M. Last -1988.

Epidemiology has been defined as –“The study of the distribution and determinants of health
related states or events in specified population, and the application of this study to the control
of health problems”.

Other definitions of epidemiology are-

1.) The science of the mass phenomena of infectious diseases (Frost, 1927).
2.) The branch of medical science which treats of epidemics. (Parkin, 1873).
3.) The study of the distribution and determinants of disease frequency in man.
(Mac Mohan, 1960).

On the basis of above mentioned definition, there could be three components of epidemiology.

A.) Studies of disease frequency.

B.) Studies of the distribution, and

C.) Studies of the determinants.

Studies of disease frequency-

Inherent in the definition of epidemiology is measurement of frequency of disease, disability, or

death and summarizing this information in the form of rates and ratio e.g. - prevalence rate,
Incidence rate, death rate etc. Thus the basic measurements of disease frequency are rate and
ratio.

Distribution of disease-

It’s well known that disease is not uniformly distributed in human populations. The distribution
of disease occurs in patterns in a community. The important function of epidemiology is to
Study these distribution patterns in the various subgroup of the population by time, place and
person.

Determinants of disease:

A unique feature of epidemiology is to test etiological hypothesis and identify the underline
causes or risk factor of disease.

AIMS OF EPIDEMIOLOGY-

According to the International Epidemiological Association (IEA), Epidemiology has three main
aims-

1.) To describe the distribution and magnitude of health and disease problems in human
populations.
2.) To identify etiological risk factors in the pathogenesis of disease.
3.) To provide the data essential to planning, implementation and evaluation of services for
the prevention, control and treatment of disease and to the setting up of priorities
among those services.

The ultimate aim of epidemiology is to lead to effective action-

-To eliminate or reduce the health problem or its consequences, and

-To promote the health and well-being of society as a whole.

EPIDEMIOLOGICAL APPROACH

It is a search for association between risk factors and disease; then to derive appropriate
inference about causal relationship.

CAUSATION MODELS OF DISEASE

Chain of infection:

Reservoir of infectious agents’  mode of transmission  susceptible host.

Reservoir: Any person, animal, arthropod, plant, soil, or substance in which an infectious agent
normally lives and multiplies, on which it depends primarily for survival and where it produces
itself in such manner that it can be transmitted to a susceptible host.

Transmission: Any mechanism by which, a susceptible host is exposed to an infectious agent.

Host: Any susceptible person.

TYPES OF DISEASE TRANSMISSION-

 Direct Transmission:

This may be by direct contact as by biting, touching, kissing or sexual intercourse, or by direct
droplet spray. It occurs usually a distance of one meter or less.

 Indirect Transmission:
 Vehicle Borne.
 Vector Borne - Mechanical and Biological.
 Air Borne - Droplet nuclei and dust.

Vehicle Borne - Contaminated inanimate materials or objects (fomites) such as toys,

handkerchiefs, soiled cloths beddings, cooking or eating utensils, surgical instruments, or
dressings, water food or biological products including blood, serum, plasma, tissues or organs
by which an infectious agent is transported and introduced into susceptible host through a
suitable portal of entry.

Vector Borne -

Mechanical: Includes simple mechanical carriage by a crawling and flying insects through soiling
of its feet or proboscis.

Biological: propagation/ multiplication, cyclic development or a combination of this

(cyclopropagative) is required before the arthropod can transmit the infective form of the agent
to human. An incubation period is required following infection before the arthropod becomes
infective.

Airborne: The dissemination of microbial aerosols to a suitable portal of entry, usually a

respiratory tract. Microbial aerosols are suspensions of particles in the air consisting partially or
wholly of micro organisms. They may remain suspended in the air for long period of time, some
retaining and others losing infectivity or virulence. These are –

Droplet nuclei: usually the small residues that results from evaporation of fluid from
droplets emitted by an infected host.

Dust: The small particles of widely varying size that may arise from soil (e.g. Fungus, spores,
separated from dry soil) clothes, bedding or contaminated floors.

CLASSICAL DISEASE MODEL FOR INFECTIOUS DISEASES

 EPIDEMIOLOGICAL TRIAD -(TRIANGLE)

 Emphasis on relationship of disease to the host,the agent and environmental factors.

 Model works for both infectious or non infectious diseases.

For T.B.  In this model the agent is the T.B. bacterium, host factor includes non – immune,
weakened resistance, poor nutrition, and environmental factors includes crowded conditions,
poor ventilation and bad sanitation.

WEB OF CAUSATION: The web of interconnected factors which lead to disease.

This model

 Works with complex disease etiologies.

 Developed for use with diseases with many co-factors.
 Example is ‘lung cancer’.
 If we consider T.B. in this model- The factors of exposure to the agent, poor nutrition,
crowding, poverty, low immunity and concurrent disease may interact directly or indirectly
to disease.

WHEELS OF CAUSATION:

 Disease factors in singular or plural are required for disease occurrence.

 If ‘A’ is ‘necessary’ then disease will not occur without it, but ‘A’ may require other
factors to be sufficient e.g. T.B. several factors together may be sufficient for disease,
but no one factor may be necessary in itself.

A wheel of causation illustrates how disease may occur through the interplay of several causal
factors without any being necessary in itself.

T.B. as an example- one sufficient wheel might include; contact with a carrier, low immunity,
and crowding, another wheel might include contact with a carrier, having AIDS, poor hygiene.
Both wheels are sufficient to produce disease, but factors differ. But for T.B., both wheels must
have the T.B. organism, is necessary factor for T.B. to occur.

BASIC MEASUREMENTS IN EPIDEMIOLOGY:

Epidemiology focuses, among other things on measurements of mortality and morbidity in

human populations. These includes –

 Measurement of mortality.
 Measurement of morbidity.
  Measurement of disability.
 Measurement of natality.
 Measurement of the presence, absence or distribution of the characteristics or
attributes of the disease.
 Measurements of medical needs, health care facilities, utilization of health services, and
other health related events.
 Measurement of presence, absence, or distribution of the environmental and other
factors.
 Measurement of demographic variables.

TOOLS OF MEASUREMENTS:

The basic tools of measurements in epidemiology are-

 Rates.
 Ratio, and
 Proportion.

Rates: A rate measures the occurrence of some particular events in a population during a given
time period e.g.-

Death rate = No. of deaths in one year/mid-year population*1000

The rate is expressed per 1000 or some other round figure (10,000, 100,000) selected according
to convenience to avoid fractions. The various categories of rates are-

o Crude rate –These are the actual observed rates such as birth and death rates. Crude
rates are also known as standardized rates.
o Specific rates –These are the actual observed rates due to specific causes (e.g.
Tuberculosis) or occurring in specific groups (e.g. age, sex group) or during specific time
period e.g. annual, monthly or weekly rates.
o Standardized rates – These are obtained by direct or indirect method of standardization
or adjustment e.g. age, sex standardized rates.

Ratio: It expresses a relation in size between two random quantities .Broadly ratio is the result
of dividing one quantity by another. It is expressed in the form of –

X: Y or X / Y

E.g. the ratio of W.B.Cs. relative to R.B.Cs. is 1:600, or 1/600, meaning that for each white cell
there are 600 red cells.
Other example includes- sex ratio, doctor-population ratio, women-child ratio etc.

Proportion: A proportion is a ratio which indicates the relation in magnitude of a part of the
whole. The proportion is expressed as a percentage.

e.g.- The no. of children with scabies at a certain time *100

The total no. of children in the village at the same time.

MEASUREMENT OF MORTALITY: The commonly used measures are –

Crude death rate: It is defined as ‘‘the no. of deaths (from all cases) per 1000 estimated mid-
year population in one year in a given place.’’ The crude death rate is calculated from-

= No of deaths during the year * 1000

Mid-year population

It summarizes the effect of two factors – Population composition and Age-specific death rates.

Specific death rates: when analysis is planned to through light on etiology, it is essential to use
specific death rates. It may be-

 Cause or disease specific, e.g. tuberculosis, accidents, cancer etc.

 Related to specific group e.g. age and sex specific

E.g. Specific death rate for male=No. of deaths among males during a calendar year *1000

Midyear population of males

Case fatality rate: Case fatality rate represents the killing power of a disease. It’s simply the
ratio of deaths to cases. Formula is-

Total no. of deaths due to a particular disease *100

Total no. of cases due to the same disease.

Proportional mortality rate:

It expresses the no. of deaths due to a particular cause or in a specific age group per 100 or
1000 total deaths.

Proportional mortality rate for a specific disease-

 = No. of deaths from the specific disease in a year *100

Total deaths from all causes in that year

Under 5 proportional mortality rates-

= No. of deaths under 5yrs of age in the given year *100

Total no. of deaths during the same period

Survival rate: it is the proportion of the survivors in a group (e.g. patients) studied and followed
over a period (e.g. 5 yrs period).

Survival rate = total no. of patients alive 5 yrs after *100

Total no. of patients diagnosed or treated

MEASUREMENTS OF MORBIDITY: Morbidity has been defined as “any departure, subjective or

objective, from state of physical wellbeing”.

According to W.H.O. Expert Committee on health statistics, morbidity could be measured in

terms of 3 units-

 Persons who were ill.

 The illness that these persons experienced, and
 The duration of these illnesses (days, weeks etc.)

Three aspects of morbidity are commonly measured are- frequency, duration and severity.

Incidence rate: it is defined as the no. of new cases occurring in a defined population during
a specified period of time.

Incidence Rate = No. of new cases of specific disease during a given time period *1000

Population at risk during that time period.

If there had been 500 new cases of an illness in a population of 30,000, in a year, the
incidence rate will be 16.7 per 1000 per year.

Prevalence rate: The term ‘disease prevalence’ refers specifically to all current cases (old
and new) existing at a given point in time, or over a period of time in a given population.

= No. of existing cases of a specified disease during a given period of time *100

Estimated midyear population at risk

Prevalence helps to-

 Estimate the magnitude of disease problems in the community.

 Identify potential high-risk population.
 Useful for administrative and planning purpose.

TYPES OF EPIDEMIOLOGICAL STUDIES

Epidemiological studies can be classified as observational studies, and experimental studies

with further subdivisions.

OBSERVATIONAL STUDIES-

 Descriptive studies.
 Analytical studies 
o Ecological or co relational, with ---- population as unit of study.
o Cross- sectional or prevalence, with ----individual as unit of study.
o Case control or case reference, with ----individual as unit of study.
o Cohort or follow up, with----individual as unit of study.

EXPERIMENTAL OR INTERVENTIONAL STUDIES-

 Randomized or clinical trials, with----patient as unit of study.

 Field-trials or community intervention study, with----healthy people as unit of study.
 Community trial, with----communities as unit of study.

These studies or methods can’t be regarded as watertight compartments; they complement

one another.

An observational study allows nature to take its own course, the investigator measures but
doesn’t intervene.

Descriptive study is limited to a description of the occurrence of a disease in a population.

An analytical study goes further by analyzing relationship between health status and other
variables.

Experimental or intervention study involves an active attempt to change a disease determinant

or the progress of a disease, and is similar in design to experiments in other sciences.

DESCRIPTIVE EPIDEMIOLOGY-

This statement emphasizes the importance of making the best use of observations on
individuals or populations exposed to suspected factors of disease. These studies are concerned
 with observing the distribution of disease, or health related characteristics in human
populations, and identifying the characteristics with which the disease in question seems to be
associated. Such studies basically ask the questions-

When is the disease occurring? ---- Time distribution.

Where it is occurring? ---- Place distribution.

Who is getting the disease? ---- Person distribution.

The various procedures involved in descriptive studies may be outlined as-

 Defining the population to be studied.

 Defining the disease under study.
 Describing the disease by – time, place, and person.
 Measurement of disease.
 Comparing with known indices.
 Formulation of an etiological hypothesis.

Following characteristics are examined in descriptive study-

Time place person

Year, season, month, Climatic zone country, Age, sex, marital status, Birth order, family size,
week, day, hour of onset, region-urban, rural, local occupation, social height, weight, blood
duration. community, towns, status, education. pressure and
cities, institutions. cholesterol, and
personal habits.

ANALYTICAL EPIDEMIOLOGY-

Analytical studies are the second major type of epidemiological studies. In contrast to
descriptive studies that look at entire populations, in analytical studies, the subject of interest is
the individual within the population. The objective is not to formulate, but test hypothesis. It
comprises two distinct types of observational studies-

Case control study and cohort or prospective study.

CASE CONTROL STUDY:

Case control study, often called ‘retrospective study’. In recent years case control approach has
emerged as a permanent method of epidemiological investigation. A case control study involves
two populations- cases and controls; in this, the unit is individual rather than group. The focus is
on a disease or some other health problem that has already developed. These are basically
comparison studies, cases and controls must be comparable with respect to know confounding
factors, such as- age, sex, occupation, social status etc.

There are four basic steps in conducting a case control study-

o Selection of cases and controls.

o Matching.
o Measurement of exposure, and
o Analysis and interpretation.

Selection of cases and controls- The first step is to identify a suitable group of cases and a
group of controls. The cases may be drawn from hospitals general population. The control must
be free from the disease under study. The control must be selected from hospitals, relatives,
neighbors, and general population.

Matching- Matching is the process by which we select controls in such a way that they are
similar to cases with regards to certain pertinent variables (e.g. age).

Measurement of exposure: The information about exposure should be obtained in precisely

the same manner both for cases and controls. This may be obtained by interviews, by
questionnaire or by studying post records of cases such as hospital records, employment
records etc.

Analysis: The final step is analysis, to find out-

o The exposure rate among cases and controls to suspected factor.

o Estimation of risk associated with exposure.

ADVANTAGES-

o Relatively easy to carry out.

o Rapid and inexpensive.
o Requires comparatively few subjects.
o Suitable to investigate rare disease.
o No risk to subject.

DISADVANTAGES-

o Not suited to the evaluation of therapy.

o The selection of appropriate control group may be difficult.
o Don’t distinguish between causes and associated factors.
 o A problem of bias relies on memory or past record.

EXPERIMENTAL OR INTERVENTION STUDY- The experimental studies involve some action,

intervention, and manipulation, such as- changing one variable in the causative chain in the
experimental group, while making no change in the control group, and observing and
comparing the outcome of the experiment in both the groups. The experimental studies are of
two types-

o Randomized controlled trials.

o Non-randomized or non-experimental trials.

Randomized controlled trials: The basic steps in conducting a RTC includes the following-

o Drawing up a protocol.
o Selecting reference and experimental population.
o Randomization.
o Manipulation and intervention.
o Follow-up.
o Assessment of outcome.

DESIGN OF A RANDOMIZED CONTROLLED TRIALS-

Select suitable population (reference or target population)

Select suitable sample (experimental or study population)

Make necessary exclusions. (Those not eligible.)

(Those who don’t wish to give consent.)

Randomize

Experimental and control group

Manipulation and follow up

Assessment.

NON-RANDOMIZED TRIALS-

When the disease frequency is low and the natural history long (e.g. Ca cervix) randomized
controlled trials requires follow up of thousands of people for a decade or more. The cost and
logistics are often prohibitive. These trials are rare, in such situations we must depend upon
other study designs- these are referred to as Non Randomized/ non experimental trials.
Example: Natural Experiments –where experimental studies are not possible in human
populations, the epidemiologists seeks to identify ‘natural circumstances’ that mimic an
experiment; e.g.- In respect of cigarette smoking, people have separated themselves, naturally
in to two groups –smokers and non smokers. Epidemiologists have taken advantages of this
separation and tested hypothesis regarding lung cancer and cigarette smoking.

A major earth quake in ATHENS in 1981 provided a ‘natural experiment’ to epidemiologists,

who studied the effect of acute stress on cardiovascular mortality. They showed an excess of
deaths from cardiac and external causes on the days after major earth quake, but no excess
death from other causes.

USES OF EPIDEMIOLOGY:

While the study of disease distribution and causation remains central to epidemiology. The
techniques of epidemiology have a wider application covering many more important areas,
relating not only to disease but also health and health services. The main uses of epidemiology
are-

o To study historically the rise and fall of disease in the population.

o For community diagnosis of the presence, nature, and distribution of health and
disease among the population and the dimensions of these in incidence, prevalence,
and mortality, taking into account that society is changing and health problems are
also changing.
o To study the working of health services.
o To estimate from the common examples the individuals chances and risk of diseases.
o To identify Syndromes.
o To help complete the clinical picture by including all types of cases in population. /
completing the natural history of disease.
o In the search for causes and risk factors of health and disease.
REFERENCES:-

 K.Park, Text book of ‘Preventive and social medicine’ Nineteenth edition, page no.
48- 87.

 B.T. Basavanthapa, Text book of ‘community Health Nursing’ fourth edition, page
no.341 -343.

 Kasturi Sunder Rao, Text book of ‘community Health Nursing’ seventh edition, page
no.619.

 Night angle nursing times, “A window for health in action” July 2006, volume -2, Issue 4,
pg.no. 21-23.

 FAO Corporate Document Repository, Title- veterinary epidemiology and economics in

Africa, A manual for use.., pg. no. -619.

 Nursing journal of India, volume-2, January 2003,

 www.pubmed.com

 www.sciencedirect. Com

 www.Google.com
 A
CONTENT
ON
EPIDEMIOLOGICAL
APPROACHES

SUBMITTED TO: SUBMITTED BY:

MADAM SUNITA SHARMA MANJU RAJPUT
LECTURER M.Sc. 1ST YEAR
N.I.N.E., PGIMER, CANDIGARH. (2008-2010)