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Epidemiology الوبائيات 2023
Epidemiology الوبائيات 2023
of
General Epidemiology
for
Faculty of Nursing- Third Year Students
By
Staff Members of
Public Health & Community Medicine
Faculty of Medicine- Assiut University
Prof. Ekram Mohamed Abdel-Khalek
Table of Contents
Page
Chapter (1): Principals of General Epidemiology 1
Evaluation
Chapter (2): Infectious Cycle
Evaluation
Chapter (3): Prevention and Control of Communicable Diseases
Evaluation
Chapter (4): Epidemiology of Non- Communicable
Diseases
Evaluation
Chapter (5): Screening
Evaluation
Chapter (6): Measurements of Health and Disease
Evaluation
Chapter (7): Public Health Surveillance
Evaluation
Chapter (8): Epidemic Disease Occurrence
Evaluation
General Revision
References
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Prof. Ekram Mohamed Abdel-Khalek
Objectives:
At the end of the chapter the student should be able to:
1- Define epidemiology
2- List and describe uses of epidemiology
3- Define the types of epidemiology
4- Identify the key features of descriptive and analytic epidemiology
5- Identify the types of epidemiological studies
So, epidemiology is the science which deals with what falls upon people.
Definition of epidemiology
Epidemiology is “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”.
Uses of epidemiology:
1- Causation of disease
Epidemiology is used to study the different causes of a disease or any
health related event. Identification of disease etiology is important for its
prevention and control.
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Prof. Ekram Mohamed Abdel-Khalek
Death Recovery
4- Evaluating interventions
Epidemiology is used for measuring the outcome of health care
programs. This is can be achieved by compare the health status of a certain
population before and after application of the health program.
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Types of epidemiology:
1- Descriptive epidemiology:
Examining the distribution of a disease in a population and observing
the basic features of its distribution in terms of time, place, and person.
2- Analytic epidemiology:
Testing a specific hypothesis about the relationship of a disease to a
specific cause, by conducting an epidemiologic study that relates the
exposure of interest to the outcome of interest (cause-effect relationship).
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Prof. Ekram Mohamed Abdel-Khalek
Place (where?)
Disease occurrence varies among different geographical areas. Factors
responsible for this variation include:
Time (when?)
Four types of variation in disease occurrence related to the time:
1- Secular variation
It is a long term variation where changes in the disease occurrence
take long period of time.
3- Seasonal variation
Many infectious diseases increase at a certain time of the year. e.g.
Influenza increases in winter while diarrhea increases in summer
4- Rapid fluctuation
Sudden increase or decrease in occurrence of a certain disease may
occur.
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Prof. Ekram Mohamed Abdel-Khalek
Agent
It is a factor cause a disease or health event such as:
Biological (micro-organisms)
Physical (temperature, radiation, trauma, others)
Chemical (acids, alkalis, poisons, tobacco, others)
Environmental (nutrients in diet, allergens, others)
Psychological experiences
Host
A person or other species including animal, bird and arthropod that
harbor the causative agent and transmit it to others under natural condition.
Host factors include:
Genetic factors
Immunologic status
Personal characteristics
Personal behavior
Environment
All that is external to the individual human host which can be:
Living conditions (housing, water supply, refuse, sewage, etc)
Atmosphere / climate
Modes of communication: phenomena in the environment that bring
host and agent together, such as: vector, vehicle, reservoir, etc)
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Prof. Ekram Mohamed Abdel-Khalek
researchers determine the exposure status for each individual (clinical trial)
the researchers simply observe the exposure and outcome status of each
study participant.
1- Interventional studies
Used to:
current therapies.
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Prof. Ekram Mohamed Abdel-Khalek
the intervention.
intervention so that a subject will not know to which study group they are
assigned.
Advantages
Disadvantages
Expensive
Ethically problematic
Observational studies:
cohort with no control over risk factors or variables. They are often
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1- Cross-sectional studies
followed over time. Typically used to measure prevalence (i.e., how many
Advantages:
Easy to perform
Disadvantages:
measured simultaneously.
2- Case-control studies
who had an exposure. Two groups are compared based on disease outcome:
Advantages:
Disadvantages:
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selection bias.
3- Cohort studies
exposure and observes this group over time (prospectively) to see who
Advantages:
Minimizes bias
Disadvantages:
attrition).
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Evaluation
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Objectives:
At the end of this chapter the student should be able to:
1- Know the 6 links of the infectious cycle
2- Identify types of reservoir
3- Identify the importance and types of carriers
4- Know the immunity
Causative
organism
Susceptible Reservoir
host
Inlet of
infection Exit of
infection
Mode of transmission
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Prof. Ekram Mohamed Abdel-Khalek
1- Causative organism:
The causative organism may be:
Bacteria (typhoid, tuberculosis)
Virus (Measles, influenza)
Parasite (ascaris, bilharzias)
Fungus (tinea)
Rickettsia (typhus)
protozoa (malaria, amebic dysentery)
2- Reservoir:
The source or reservoir of infection may be man, animal, insect
(vector), plant, water, air, soil, objects soiled by pathogenic organisms.
A- Human reservoir:
The human reservoir may be case or carrier.
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Types of carriers:
Carriers are classified according to different methods:
1- Chronological classification
Incubatory carriers (measles, hepatitis A, etc.)
Contact carriers (Cholera, meningitis, etc.)
Convalescent carriers (typhoid fever, etc.)
2- Duration of carriage
Temporary carriers (mumps, hepatitis A, etc)
Chronic carriers (hepatitis B, HIV, typhoid, etc.)
3- Place of carriage
According to the habitat of the microorganisms:
Upper respiratory tract (diphtheria)
Fecal carriers (typhoid, hepatitis A)
Urinary carriers (typhoid, brucellosis)
Skin carriers (staphylococcal infection)
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B- Animal reservoir:
Some animals (including birds) are the reservoir of infection of certain
diseases which may transmit from animal to man „zoonotic diseases‟ such
as salmonillosis, brucellosis
3- Exit of infection:
Pathogenic organisms find exit from the body of reservoir through:
Respiratory tract (influenza virus)
Alimentary tract (hepatitis A)
Urinary tract (typhoid)
Genital tract (AIDS)
Skin (syphilis)
Blood (malaria, AIDS)
In-utero transmission (rubella, syphilis)
4 - Modes of transmission
Pathogenic organisms finding exit form the body of reservoir can
reach the new host by different means of transmission.
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Prof. Ekram Mohamed Abdel-Khalek
5- Inlet of infection:
The portal of entry into the susceptible host is similar to the portal of
exit.
Respiratory tract (influenza virus)
Urinary tract (typhoid)
Genital tract (STD‟s)
Alimentary tract (Hepatitis A)
Skin (syphilis)
In-utero transmission (rubella, syphilis)
6- Susceptible host:
There must be a susceptible host for the disease transmission to occur.
Microbiologic agents surround and abound in humans. In general people
stay healthy because of their own host defense mechanisms that belong to:
2- Immunity
Immunity to a disease is achieved through the presence of antibodies
to that disease in a person‟s system. Antibodies are proteins produced by
the body to neutralize or destroy toxins or disease-carrying organisms.
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Passive immunity occurs when antibodies are given to the host. Although
of short duration, passive immunity provides immediate protection.
However, passive immunity lasts only for a few weeks or months. Passive
immunity is natural or acquired.
Natural immunity: A newborn baby acquires passive immunity from
its mother through the placenta. Passive antibodies protect newborn babies
during the first several months of life.
Acquired immunity: People can also get passive immunity through
antibody-containing blood products such as immune globulin, which may
be given when immediate protection from a specific disease is needed.
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Prof. Ekram Mohamed Abdel-Khalek
Evaluation
Mention whether each of the following statements is true (T) or false (F):
1 Pathogenicity refers to the proportion of infected persons who T F
develop clinical disease.
2 Diseases that can be transmitted under natural conditions from T F
vertebrate animals to humans are called zoonoses.
3 While an agent of disease may be necessary for a disease, T F
exposure to an agent does not always cause clinical symptoms.
4 Passive immunity occurs when the host develops long lasting T F
antibodies to fight infection.
5 Typhoid is an example of food-borne disease. T F
Objectives:
At the end of this chapter the student should be able to:
1- Define and identify the levels of prevention.
2- Know the different methods of each level of prevention.
3- List the measures of prevention and control of communicable
diseases.
Levels of prevention
1- Primary prevention is the prevention of disease or injury. Primary
prevention activities can be directed at individuals or at the environment.
It includes:
Health education
Environmental modification
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Air borne route difficult to control ultra violet rays and isolation of
patients in well ventilated rooms have been used.
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Evaluation
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Objectives:
At the end of this chapter the student should be able to:
1- Identify what are non-communicable diseases.
2- Identify people at risk of non-communicable diseases.
3- List both modifiable and non-modifiable risk factors of non-
communicable diseases.
4- Know the preventive measures of non-communicable diseases.
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Prof. Ekram Mohamed Abdel-Khalek
People of all age groups, regions and countries are affected by NCDs.
These conditions are often associated with older age groups. Children,
adults and the elderly are all vulnerable to the risk factors contributing to
NCDs, whether from unhealthy diets, physical inactivity, exposure to
tobacco smoke or the harmful use of alcohol.
Risk factors
1- Modifiable behavioral risk factors:
Modifiable behaviors, such as tobacco use, physical inactivity, unhealthy
diet and the harmful use of alcohol, all increase the risk of NCDs.
2- Non-modifiable risk factors:
Risk factors that cannot be reduced or controlled by intervention, for
example: age, sex, race and family history (genetics).
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Prof. Ekram Mohamed Abdel-Khalek
2- Primary prevention
It aims to prevent disease or injury before it ever occurs. This is done by
preventing exposures to hazards that cause disease or injury, altering
unhealthy or unsafe behaviors that can lead to disease or injury, and
increasing resistance to disease or injury. Primary
prevention can be adopted by two modes of intervention:
Health promotion
The measures of health promotion may include:
Genetic counseling (premarital and marriage counseling)
Efficient antenatal care and postnatal care
Promotion of breastfeeding and proper weaning
Adequate nutrition
Health education (on nutrition education, life-style, etc.).
Recreation facilities (sports, games, cultural activities, etc.)
Specific protection
The measures of specific protection may include:
Use of specific nutrients (Vitamin A against nutritional blindness,
iron against nutritional anemia, iodized salt against iodine
deficiency disorders).
Helmet against head-injury
3- Secondary prevention
The intervention is by „early diagnosis and treatment‟. This can be done
by screening procedures for the early diagnosis of the disease as:
Periodical recording of weight of a child with for malnutrition
Blood and urine exam for diabetes mellitus
Recording of blood pressure for hypertension
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4- Tertiary prevention
It aims to reduce the impact of an ongoing illness or injury that has
lasting effects (e.g. chronic diseases, permanent impairments) in order
to improve as much as possible their ability to function, their quality of
life and their life expectancy. Tertiary prevention can be adopted by two
modes of intervention, disability limitation and rehabilitation.
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Evaluation
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Objectives:
At the end of this chapter the student should be able to:
1- Identify definition, aims and objectives of screening.
2- Identify types and uses of screening.
3- Recognize the criteria required to launch a screening program.
4- Identify measures for evaluation of screening test.
Definition of screening:
The search for unrecognized disease or defect by means of rapidly applied
tests, examinations or other procedures to sort out apparently well persons
who probably have a disease from those who probably do not.
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Evaluation
Circle the correct answer (MCQ):
Screening is used in:
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. None of the above
Objectives:
At the end of the chapter the student should be able to:
1- Define incidence and prevalence rates
2- List different mortality rates used
3- List different fertility rates used
4- Calculate different measures of health and disease
5- Interpret different measures of health and disease
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Ratio
The value obtained by dividing one quantity by another. The relation
between two numbers in the form of x: y or x/y
Proportion
It is a specific type of ratio in which the numerator is included in the
denominator.
Rate
It is the special form of proportion that includes specification of time.
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Attack rate:
An attack rate is a variant of an incidence rate, applied to a narrowly
defined population observed for a limited time, such as during an epidemic.
For example, in the case of a food borne disease outbreak, the attack
rate can be calculated for each type of food eaten, and then these rates
compared to identify the source of the infection.
Attack rate =
Number of new cases among the population during the period
× 100
Population at risk at the beginning of the period
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Mortality Rates
A mortality rate is a measure of the frequency of occurrence of death
in a defined population during a specified interval.
CDR =
Total number of deaths in a certain year and locality
× 1000
Estimated mid-year population of the same year & locality
CSMR=
Number of deaths from certain disease a certain year and locality
× 1000
Estimated mid-year population of the same year &locality
Case Fatality
Case fatality is a measure of disease severity and is defined as the
proportion of cases with a specified disease or condition who die within a
specified time. It is usually expressed as a percentage.
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ASDR=
Number of deaths of a certain age in a certain year & locality
× 100
Mid-year population of the same age group of the same year & locality
Proportionate Mortality:
Occasionally the mortality in a population is described by using
proportionate mortality, which is actually a ratio: the number of deaths
from a given cause per 100 or 1000 total deaths in the same period.
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Fertility Rates:
Crude Birth Rate (CBR) =
Number of live births in a certain place & time
× 1000
Mid year population of the same place & time
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Evaluation
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Objectives:
At the end of this chapter the student should be able to:
1- Define public health surveillance
2- List objectives of health surveillance
3- Identify types of surveillance
4- Identify uses of health surveillance
Definition
Health surveillance is the ongoing systematic collection, analysis and
interpretation of health data essential for planning, implementing and
evaluating public health activities.
Objectives of surveillance:
1- Know what diseases are occurring so effective control can be initiated.
2- Detecting outbreaks
3- To evaluate the effectiveness of control programs
4- Increase the knowledge of the disease process
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Types of surveillance:
1- Active surveillance occurs when the health department calls, or visits
health care providers to see if they have seen any cases of a particular
disease.
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Uses of surveillance:
Surveillance is an essential feature of epidemiologic practice and may
be used to:
1- Recognize isolated or clustered cases.
2- Assess the public health impact of events and assess trends.
3- Measure the causal factors of disease.
4- Monitor effectiveness and evaluate the impact of prevention and control
measures, intervention strategies and health policy changes.
5- Plan and provide care.
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Evaluation
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Objectives:
At the end of the course the student should be able to:
1- Identify the patterns of disease occurrence in a population
2- Define an epidemic
3- Explain the difference between different types of epidemics
4- Investigation of an outbreak
Definitions
Baseline level of the disease: The amount of a particular disease that is
usually present in a community.
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Epidemic patterns:
A common source outbreak is one in which people are exposed
intermittently or continuously to a common harmful source. The period of
exposure may be brief or long. For example, a group of persons is exposed
to a common noxious influence, such as an infectious agent or a toxin.
Investigation of an outbreak
The purpose of investigating a communicable disease epidemic is to
identify its cause and the best means to control it. This requires detailed
and systematic epidemiological work in simultaneous steps:
7- Control of epidemics
8- Reporting and disseminating findings on the epidemic
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6- Environmental assessment
An analysis of the data may indicate an environmental source for the
outbreak. This can be confirmed by obtaining samples of suspected food or
water for examination.
7- Control of epidemic
The main elements in the control of an epidemic are:
Attach source of infection and mode of transmission
Treat and isolate all cases
Increase resistance of local population
Continue surveillance
• Pattern of spread
• Magnitude
• Outliers
• Time trend
• Exposure and/or disease incubation period
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Fig. (4): Example of an epidemic curve from Fig. (5): Example of an epidemic curve from
a common intermittent exposure source a common continuous exposure source
Fig. (6): Example of a point source epidemic Fig. (7): Example of a propagated epidemic
curve curve
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Evaluation
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General Revision
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c. Accidents prevention
d. All of the above
9- The term that best describes „12 new cases of Tuberculosis / 100,000
populations in 2018 is:
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Prof. Ekram Mohamed Abdel-Khalek
a) Proportion
b) Incidence rate
c) Point prevalence
d) Period prevalence
10- The value obtained by dividing one quantity by different another one in
the form of x: y or x/y is…………………
a) Proportion
b) Rate
c) Ratio
d) Percent
11- Covering mouth when coughing, sneezing and use of disposable tissues is a
preventive measures directed to the:
a. Agent
b. Reservoir
c. Exit of infection
d. Mode of transmission
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References:
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