Kennedy Muthoka

PhD Public Health

JKUAT: ITROMID/KEMRI
Classically speaking
Origin is Greek
 EPI - Upon
 DEMOS - People (Democracy)
 LOGOS - Science
• Epidemiology = the science which deals with what falls
upon people…..
• Bridge between biomedical, social and behavioral
sciences
• However, no mention of Disease
Early Mentions of Epidemiology
 1802 – Spanish used term ‘EPIDEMILOGIA’ in the
title ‘Spanish History of Epidemics’

 1850 – ‘London Epidemiology Society’ was formed.

John Snow among founding members

 1873 – Defined in Oxford English Dictionary by

Perkins
Epidemic
Term is much Older than Epidemiology

Over 2400 yrs ago, Hippocrates used the word. From his
works in medicine he is assumed to be an epidemiologist

 1603 – Appears in Oxford English Dictionary

 1775 – Appears in Johnson’s Dictionary

WHAT IS EPIDEMIC???
 Simple Old Definitions
• 1873 Perkins Oxford Eng. Dictionary –
Branch of Medical Science that treats Epidemics
• Kuller LH: American J of Epidemiology
1991;134:1051
• Epidemiology is the study of "epidemics" and their
prevention
• Anderson G. In: Rothman KJ: Modern
Epidemiology
• The study of the occurrence of illness
Definitions of Epidemiology cont..

 Concerned with patterns of disease occurrence in

human pops and factors that influence these patterns
(Lillienfeld)

 Distribution of diseases in human populations and

factors that determine such distribution (WHO)

The Science of Epidemics

A Modern Definition

 Study of Distribution and Determinants of Health

Related States or Events in Specified populations and
Application of the studies to control health problems
(Dic. of Epid – Last).
 Epidemiology is the study of how disease is
distributed in populations and the factors that
influence or determine this distribution
Who is an epidemiologist ?
A professional who strives to study and control the
factors that influence the occurrence of disease or
health-related conditions and events in specified
populations and societies, has an experience in
population thinking and epidemiologic methods, and is
knowledgeable about public health and causal inference
in health
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)
Scope of Epidemiology
• Initially for diseases especially Epidemics to
establish cause, progression & distribution
• Modern NOT only considers why some become
ill, but why some don’t become ill (Sports
medicine)
• Study both illness & health
• Morbid anatomy (Normal v/s abnormal)
TYPES OF EPIDEMIOLOGY

• Descriptive Epidemiology
• Analytic Epidemiology
• Clinical Epidemiology
DESCRIPTIVE EPIDEMIOLOGY

• Characterizes distribution of disease in

population by person, place, and time variables
• The first step in the generation of hypotheses
concerning etiology or causes of diseases
• These hypotheses can later be verified by more
refined studies
ANALYTIC EPIDEMIOLOGY

• Investigates determinants of disease

• More specifically, it investigates relationships
between exposures (e.g., environmental,
lifestyle) and occurrence of disease
• The focus is on disease etiology
CLINICAL EPIDEMIOLOGY

• Deals with natural history of disease

• Example, factors affecting the prognosis of
disease in persons already having the disease
• Helps determine prognosis of disease
Applications of Epidemiology
• Quantifies or assesses disease burden to plan for
health intervention eg. training
• To evaluate new preventive and therapeutic
measures- impact of interventions, quality of life
• Provide foundation for developing public policy
(Cigarettes & lung cancer) & regulatory decisions
relating to social or environmental problems
–Mobile phones, Microwave, GM foods,
Thalidomide
Applications of Epidemiology cont…

• Public Health Surveillance including natural history

& prognosis.
• Analytic Studies (Measures of association in
determining risk or Cause of disease) - relevant risk
factors
• Program evaluation – whether program works.
Why does a disease develop in some
people and not in others?
Epidemiologist

• Interested in health related conditions in terms of;

- Person (Cough)
- Place (Malaria)
- Time (Flu)
Person Characteristics
• Age – measles in children, Ca. in adults
• Sex – premenopausal women have a lower risk of heart
disease than men of the same age. Difference attributable
to higher estrogen levels in women
• Color/Race– Filter mechanisms in skin
• Ethnic –
– Kuru virus – New Papua Guinea (mad cow disease)
– Bomet & Cancer of throat
• Biological – Antibody levels
Person Characteristics cont…:
• Enzymes – Lactase
• Cellular blood constituents – sickle cell
• Socio-economic (education, occupation, income) –
CHDs (Angina)
• Personal Habits – Smoking, Drinking, Exercise
• Genetic – Cystic fibrosis, Von recklinghausens
• Marital status – HIV/AIDS
Place (where ?)
• Geographically restricted or widespread (outbreak,
epidemic, pandemic)? Off-shore (tsunami…)
• Climate effects (temperature, humidity, combined
effects..)
• Urban / sub-urban-squatter / rural
• Relation to environmental exposure - (water, food
supply, etc)
Time (when ?)

• Changing or stable?
• Clustered (epidemic) or evenly distributed
(endemic)?
• Time-trends: Point source, seasonal,
combinations
Key issues in History of Epidem.
 That Disease is connected with environment
- First expressed by Hippocrates 2400 yrs
- Made careful clinical observations without counts
- In 17th century, Thomas Sydenham, a London
physician wrote about history of disease agreeing
with Hippocrates. Became british father of
Epidemiology.
Key issues in History of Epidem. Cont..
• Counting and Measurements
– John Gaunt in 1662 counted deaths in infants and
showed variation by season
–Looked at how plague affected people numerically
–Started applying statistics and analysis
–Became father of Statistics
Key issues in History of Epidem. Cont..

• William Farr (1893) is the father of modern

epidemiology
• Collected data & established health problems in mines,
cholera etc
• Noted that 8 prisoners executed while 51 died from
imprisonment
Early Natural Experiments
John Snow
– First to demonstrate spread of cholera by
contamination of water
– 1854 in Soho area of London, he noted that cholera
was in small area with over 500 deaths in 10 days
– Pinpointed deaths on a map and noted they mostly
were in Broad street area with hand pumps
Original map by John Snow showing the clusters of
cholera cases in the London epidemic of 1854
Early Experiments cont…
•Evidence existed that contact with diseased persons
transmitted disease
•Investigated other deaths outside Soho
–Old woman in Hampstead died. Had taken broad
street water
•Her niece from Islington visited and drank same water
died
• Snow removed pump handle and deaths reduced
dramatically
Early Natural Experiments cont..
• Also investigated brewery and workers in workhouse
in Broad street - found few deaths
–He noted that these had own water supply
• Further he investigated water supplies by particular
companies and noted that
– Cholera rates were high with Lambeth, Southwark
and Vauxhall companies
Early Natural Experiments cont..
• Noted that they all drew water from contaminated
river Thames
• He relocated Lambeth to less polluted area and cholera
decreased (1849 –1854)
• There was no change in Vauxhall and Southwark
• Further he divided the populations into 2;
–Affluent and Less Affluent
Early Natural Experiments cont..
• He looked at differences in mortality but these did not
differ where they all drew water from same source

• HENCE HE HYPOTHESIZED WHAT!!!

Early Natural Experiments cont..
• Snow’s procedures show 4 main steps in scientific
investigations;
–Observations (plotting for deaths)
–Hypothesis formulation
– Testing the Hypothesis (tracing the relationship
back to areas of low morbidity)
– Implementing the outcome (Removing the
Broadway water supply
John Snow (1813 to 1858)

FATHER OF EPIDEMIOLOGY
Experimental Studies on man
• These are Intervention Studies (for etiology of Disease)
– Lind’s Trial of citrus fruits in treating scurvy (1747). (6
days – vinegar, sea water, oranges and lemons)
– Fletcher on Beriberi – Kuala Lumpur, Lunatic asylum
(1909)
– Edward Jenner with Cow pox vaccine for small pox
(1796) administered to 8 yr old. After 6 wks, gave small
pox, no infection
Hypothesis

 Observation
- That whisky drinking number of
clergymen

- Thus whisky drinking number of

clergymen
 THE NATURAL HISTORY OF DISEASE
• Refer to the progress of d’se process in an individual over
time, in the absence of intervention
• It is the natural evolution of pathological process, from its
beginning to its resolution, without the help of man
• The process begins with exposure to or accumulation of
factors able to cause d’se
What are the four major possible
outcomes in an individual after
exposure to a causal agent?
Outcomes
• The exposure may have no discernible effect
• The effect may be an illness that is rapidly contained
by the body's defence mechanism (recovery)
• The illness may progress until it leads to continuing
long term problems - Irreversible damage (disability)
• The illness may progress until it leads to death
• The outcome will depend on the interactions of host,
agent and environmental factors.
 Death
1b 2c

2b

2a

exposed 1a

Full health Time

Infancy childhood adolescence adulthood old age

1a: primary infection with complete remission (death from other causes); 1b: Fatal
tuberculous meningitis;
2a: recurrence with successful treatment (death from other causes); 2b: TB with residual
disability (and TB contributary or actual cause of death); 2c: recurrence with fatal outcome
 Natural history of disease
TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious Non-infectious

Exposure Onset
Definitions
• Latent period - the time interval from infection to
development of infectiousness
• Infectious period - the time during which time the host
can infect another susceptible host
• Non-infectious period - the period when the host’s
ability to transmit disease to other hosts ceases
• Incubation period - the time interval between infection
to development of clinical disease
Types of Prevention
• Primary
• Secondary
• Tertiary
Primary Prevention
• Preventing the initial development of a disease eg
Immunization
• Preventing the occurrence of disease or injury by
modifying risk factors
Primary Prevention
• General health promotion
– Proper nutrition, mental hygiene, adequate housing, appropriate
balance between work and play, rest and exercise, useful and
productive place in society, are among the best recognized factors
contributing to maintenance of optimum health - Commission on
Chronic illness, USA, 1957
• Specific protection
• Health Promotion
– Health promotion is any combination of educational, organizational,
economic, and environmental supports for behavior and conditions of
living conducive to health - LW Green, 1992
Secondary Prevention

• Early detection of existing disease to reduce severity

and complications eg HIV testing
• Early detection and intervention, preferably before
the condition is clinically apparent, and has the aim
of reversing, halting, or at least retarding the
progress of a condition
• It sometimes happens that a patient first becomes
aware of a disease when it is already too late for it to
be successfully treated
Tertiary Prevention

• Reducing the impact of the disease eg Rehab for

stroke
• Minimizing the effects of disease and disability by
surveillance and maintenance aimed at preventing
complications and premature deterioration
• Medical rehabilitation
 THE NATURAL HISTORY OF A DISEASE
STIMULUS to the
HOST REACTION RECOVERY
HOST
Interrelation of
Agent, Host and Latent Period Symptoms, With or without Defects,
Environmental (Pre-symptomatic) Signs(Clinical) Disability
factors

PREPATHOGENES
PERIOD OF PATHOGENESIS
IS

Health Promotion Disability Limitation

Specific Protection Early Diagnosis and Prompt Treatment
Rehabilitation

PRIMARY SECONDARY
TREATMENT TERTIARY PREVENTION
PREVENTION PREVENTION
The Dynamics of Disease Transmission
 The Dynamics of Disease Transmission
• Human disease does not arise in a vacuum
• Results from an interaction of
– the host (a person),
– the agent (e.g., a bacterium), and
– the environment (e.g., a contaminated water supply)
• Even those that have genetic origin, virtually all results
from an interaction of genetic and environmental factors
The Epidemiologic Triad
 Types of Agents
Biological Chemical Physical Nutritional
Helminths Foods Heat/fire Lack
Protozoan Poisons Radiation Excess
Fungi Drugs Noise
Bacteria Allergens Vibration
Rickettsia Alcohol Trauma
Viral Smoke/
Tobacco
 Types of host characteristics
• Physiological • Age
• Anatomical • Sex
• Genetic • Race
• Behavioral • Marital status
• Occupational • Immune status
• Cultural/Family
background/Religion
• Previous diseases
 Types of Environmental Factors
– Housing
• Environ factors that
affect presence and – Neighborhood
levels of agents; – Water
– Temperature – Food
– Humidity – Radiation
– Altitude – Air pollution
– Crowding – Noise
 Homeostatic Balance
A
H
A H

E
E
The proportion of susceptibles
Agent becomes more A H in population decreases
pathogenic

H
E
At equilibrium A
A
Steady rate
E H
Environmental changes that E
favor the agent
Environmental changes that
favor the host
MODES OF TRANSMISSION
Modes of Transmission

• Direct
• Indirect
Modes of Transmission
• Direct transmission
– Person-to-person contact
• Indirect
– Common vehicle
• Single exposure
• Multiple exposures
• Continuous exposure
– Vector
 Contact
• Direct
– Direct physical contact (body surface to body surface)
between infected individual and susceptible host eg
chlamydia
• Indirect
– Infectious agent deposited onto an object or surface
(fomite) and survives long enough to transfer to another
person who subsequently touches the object eg RSV
• Droplet
– Via coughing or sneezing eg respiratory viruses
 Non-contact
• Airborne
– Transmission via aerosols (airborne particles <5µm)
– Ex. TB, measles
• Vehicle
– A single contaminated source spreads the infection (or
poison)
– Ex. Food-borne outbreak from infected batch of food
• Vector-borne
– Transmission by insect or animal vectors
– Ex. Mosquitoes –malaria vector
VEHICLE – An inanimate object which serves to
communicate disease. For example, a glass of water
containing microbes, or a dirty rag, etc
VECTOR – A live organism that serves to communicate
disease. For example, mosquitoes and other arthropods

RESERVOIR – A location that serves as a continuing

source of disease – for example, a water tower (common
in legionella infections), the soil for tetanus, etc
From: thepaulnetwork.com