Epidemiological

study
Cont

 A proper study design means that the approach and methods will
yield results that are as valid and as precise as possible.
 It also means that the study design is appropriate for the current
scientific thinking on the topic.
 Each of the study designs can provide useful information when
applied in the appropriate situation and with the proper methods.
 However, the study design alone does not ensure that the results
are valid and precise and generalizable.
 The devil is in the details! It is critical that epidemiologists develop a
keen ability to recognize the strengths and limitations of any study.
Descriptive or Analytic Studies

Descriptive studies
 Generate hypotheses
 Answer what, who, where, and when

Analytic studies
 Test hypotheses
 Answer why and how
Cont..

 The evidence for evidence-based medicine is all collected via

research, which uses a variety of study designs

 Different study designs provide information of different quality.

 you need to understand the strengths and limitations of each type

of study design, as applied to a particular research purpose
Cont..

 The purposes we will consider include

1 describing the prevalence of health problems;

2 identifying causes of health problems (etiological research),

3 evaluating therapy, including treatment and prevention.

Descriptive epidemiology

 Descriptive epidemiology describes the distribution of disease (recall that

epidemiology is the study of the distribution and determinants of disease in
populations).
 Descriptive epidemiology searches for patterns by examining characteristics of
person (race, age, or sex), place(geographic location) , & time(a specific year
or a span of time).
 These characteristics are carefully considered when a disease outbreak occurs,
because they provide important clues regarding the source of the outbreak.
 Hypotheses about the determinants of disease arise from considering the
characteristics of person, place, and time and looking for differences, similarities,
and correlations
Cont..

The 5W's of descriptive epidemiology:

 What = health issue of concern
 Who = person
 Where = place
 When = time
 Why/how = causes, risk factors, modes of transmission
Cont..

Person
 age, gender, ethnic group , genetic predisposition , concurrent
disease diet, physical activity, smoking , risk taking behaviour ,
education, occupation

geographic Place
 presence of agents or vectors , climate , geology , population
density economic development , nutritional practices , medical
practices
Cont..

Time
 calendar time , time since an event , physiologic cycles , age (time
since birth) , seasonality , temporal trends
Cont..

 In order to make inferences about causes or determinants of health

conditions (the second part of the definition of epidemiology) one
must conduct studies to study the relationship between exposures
(risk or protective factors) and outcomes.

 There are two major types of studies:

1. experimental studies and
2. observational studies
Cont..

 In observational studies, the researcher observes and systematically

collects information, but does not try to change the people (or
animals, or reagents) being observed.
 In an experiment, by contrast, the researcher intervenes to change
something (e.g., gives some patients a drug) and then observes
what happens. In an observational study there is no intervention.

 A descriptive study is one in which information is collected without

changing the environment (i.e., nothing is manipulated)
Cont..

 . In public health and epidemiology, most studies are observational

in nature.
 Although an outcome may be a disease, we will primarily refer to
outcomes as any result of interest that may be linked to a specific
exposure (which may be a risk factor, protective factor, or
intervention
 Descriptive research can be explained as a statement of affairs as
they are at present with the researcher having no control over
variable.
 Moreover, “descriptive research may be characterised as simply the
attempt to determine, describe or identify what is, while analytical
research attempts to establish why it is that way or how it came to
be
Cont..

This type of research describes what exists and may help to uncover
new facts and meaning.
The purpose of descriptive research is to
 Observe
 Describe
 document
This involves the collection of data that will provide an account or
description of individuals, groups or situations. Instruments we use to
obtain data in descriptive studies include
 Questionnaires
 interviews (closed questions)
 observation (checklists, etc.)
Cont..

 Another purposes of descriptive studies can be explained as

describing, explaining and validating research findings.
Cont..

 Advantages of Descriptive Research

1. Effective to analyse non-quantified topics and issues
2. The possibility to observe the phenomenon in a completely natural
and unchanged natural environment
3. The opportunity to integrate the qualitative and quantitative
methods of data collection
Cont..

 Disadvantages of Descriptive Research

1. Descriptive studies cannot test or verify the research
problem statistically
2. Research results may reflect certain level of bias due
to the absence of statistical tests
3. The majority of descriptive studies are not
‘repeatable’ due to their observational nature
Case Report

 case reports are considered the lowest level of evidence, but they are also the
first line of evidence, because they are where new issues and ideas emerge.
 A good case report will be clear about the importance of the observation being
reported.

 In medicine, a case report is a detailed report of the symptoms, signs, diagnosis,

treatment, and follow-up of an individual patient.

 Case reports may contain a demographic profile of the patient, but usually
describe an unusual or novel occurrence. Some case reports also contain a
literature review of other reported cases.

 If multiple case reports show something similar, the next step might be a case-
control study to determine if there is a relationship between the relevant
variables.
 Cont..

Most case reports are on one of six topics:

 An unexpected association between diseases or symptoms.
 An unexpected event in the course of observing or treating a patient.
 Findings that shed new light on the possible pathogenesis of a disease or an adverse
effect.
 Unique or rare features of a disease.
 Unique therapeutic approaches.
 A positional or quantitative variation of the anatomical structures.
Case series

 A descriptive, observational study of a series of cases, typically

describing the manifestations, clinical course, and prognosis of a
condition, is called a case series.
 A case series provides weak empirical evidence because of the
lack of comparability unless the findings are dramatically different
from expectations.
 Case series are best used as a source of hypotheses for investigation
by stronger study designs, leading some to suggest that the case
series should be regarded as clinicians talking to researchers
Case series

 Experience of a group of patients with a similar diagnosis

• Assesses prevalent disease
 Cases may be identified from a single or multiple sources
 Generally report on new/unique condition
 A realistic design for rare disorders
Cont..

Case series
• Variation on the theme of the solitary case report
• Retrospective look at series of cases that have features in common
• Common diagnosis, treatment, measures – In the literature already
• Each case may be separately described, or the cases may be
lumped together with data summaries
Cont..

Case series Advantages

 Useful for hypothesis generation
 Informative for very rare disease with few established risk factors
 Characterizes averages for disorder Disadvantages
 Cannot study cause and effect relationships
 Cannot assess disease frequency
Cont..

 The case series is one of the most common study types in the clinical literature.
 It is a description of a single case, typically describing the manifestation, clinical
course, and prognosis of that case. Due to the wide range of natural biologic
variability in these aspects, a single case report provides little empirical evidence
to the clinician.

 They only describe how others diagnosed and treated the condition, and what
the clinical outcome was.

 Case series and case reports, since they do not use control groups, have no
statistical validity.
Cont..

 A case series (also known as a clinical series) is a type of medical

research study that tracks subjects with a known exposure, such as
patients who have received a similar treatment, or examines their
medical records for exposure and outcome.
 Case series may be consecutive or non-consecutive, depending on
whether all cases presenting to the reporting authors over a period
were included, or only a selection.
Ecological (correlational) Study

 An ecological study is an observational study defined by the level at

which data are analysed, namely at the population or group level,
rather than individual level.
 Ecological studies are often used to measure prevalence and
incidence of disease, particularly when disease is rare.
 They are inexpensive and easy to carry out, using routinely collected
data, but they are prone to bias and confounding.
 Group-level study may also be the only way to study the effects of
group-level constructs, such as laws (e. g., the impact of a seatbelt
law)
Cont..

 Ecological studies are fairly quick and easy to perform and they are
useful for hypothesis generation. However, they do not allow causal
conclusions to be drawn since the data are not associated with
individual persons and are not good for hypothesis testing.

 Disease rates and exposures are measured in each of a series of

populations and their relation is examined. Often the information
about disease and exposure is abstracted from published statistics
and therefore does not require expensive or time consuming data
collection
 A study in which at least one variable, either an exposure or the
outcome, is measured at the group (not individual) level.
 Examples of group-level measures include the incidence rate of
cancer among a specific population, the mean level of blood
pressure of patients seen at a clinic
 The occurrence of disease is compared between groups that have
different levels of an exposure, which affords this study design to
have at least one comparison group.
An ecological study design is used
when
The purpose of the study is to monitor population health so that public health

strategies may be developed and directed;

 The purpose of the study is to make large-scale comparisons, eg, comparisons

between countries;

 The purpose of the study is to study the relationship between population-level

exposure to risk factors and disease, or in order to look at the contextual effect of
risk factors on the population;
Cont..

 measurements at individual level are not available, eg.

confidentiality might require that individuals are anonymised by
aggregation of data to small area level; or

 the disease under investigation is rare, requiring aggregation of

data for any analysis to be carried out.
Causal inferences from ecological
studies can be made at three
different levels.
 Biological. Causation is only through a biological pathway.
Among unvaccinated persons, low-income people have increased risk
of Hepatitis B because having a low-income increases a person's stress
which increases a person's risk for Hepatitis B.
 Ecological. Causation is only through a group characteristic.
Among unvaccinated persons, people living in a low-income
community have increased risk for Hepatitis B infection because low-
income communities have high levels of exposure to Hepatitis B.
 Contextual. Causation is through both biologic and group
characteristics. Among unvaccinated persons, both high-income and
low-income people who live in a low-income community have
increased risk for Hepatitis B infection because of increased stress and
increased exposure.
Types of measurement in
ecological studies
 In ecological studies health outcomes are aggregates of individual
health data, eg: prevalence, incidence, rate of disease. Ecological
risk or exposure data takes the form of one or more of the following:

 Aggregate measures; the data are summaries of individual level

data eg, mean dmft, percentage of children with no caries, area-
level deprivation indices
 Environmental measures; equivalent individual level data are
conceivable eg, mean annual exposure to fluoridation
 Global measures; there are no equivalent individual level data
eg, number of dental practices, population density.
Cross sectional studies

 In a cross-sectional study, data are collected on the whole study

population at a single point in time to examine the relationship
between disease (or other health related state) and other variables
of interest.
 Cross-sectional studies therefore provide a snapshot of the
frequency of a disease or other health related characteristics in a
population at a given point in time.
 This methodology can be used to assess the burden of disease or
health needs of a population, for example, and is therefore
particularly useful in informing the planning and allocation of health
resources.
When to conduct cross sectional
study
 To estimate prevalence of a health condition or prevalence of a
behavior, risk factor, or potential for disease

 To learn about characteristics such as KAP, knowledge, attitude and

practices of individuals in a population

 To monitor trends over time with serial cross-sectional studies

Types of cross-sectional study

Descriptive

 A cross-sectional study may be purely descriptive and used to

assess the frequency and distribution of a particular disease in a
defined population.
 For example a random sample of schools across Addis Ababa may
be used to assess the burden or prevalence of asthma among 12-14
year olds.
Cont..

Analytical

 Analytical cross-sectional studies may also be used to investigate

the association between a assumed risk factor and a health
outcome.

 However this type of study is limited in its ability to draw valid

conclusions about any association or possible causality because the
presence of risk factors and outcomes are measured simultaneously.
Cont..

 It may therefore be difficult to work out whether the disease or the

exposure came first, so causation should always be confirmed by
more rigorous studies.

 The collection of information about risk factors is also retrospective,

running the risk of recall bias.
Issues in the design of cross-
sectional surveys
1 Choosing a representative sample
 A cross-sectional study should be representative of whole the
population, if generalisations from the findings are to have any
validity.
 For example a study of the prevalence of diabetes among women
aged 40-60 years in Town A should comprise a random sample of all
women aged 40-60 years in that town.
 If the study is to be representative, attempts should be made to
include hard to reach groups, such as people in institutions or the
homeless
Cont..

2 Sample size
 The sample size should be sufficiently large enough to estimate the
prevalence of the conditions of interest with adequate precision.

 Sample size calculations can be carried out using sample size tables
or statistical packages such as Epi Info.

 The larger the study, the less likely the results are due to chance
alone, but this will also have implications for cost.
Cont..

3 Data collection
 As data on exposures and outcomes are collected simultaneously,
specific inclusion and exclusion criteria should be established at the
design stage, to ensure that those with the outcome are correctly
identified.

 The data collection methods will depend on the exposure, outcome

and study setting, but include questionnaires and interviews, as well
as medical examinations. Routine data sources may also be used.
Cont..

Potential bias in cross-sectional studies

 Non-response is a particular problem affecting cross-sectional
studies and can result in bias of the measures of outcome.

 This is a particular problem when the characteristics of non-

responders differ from responders
Cont…

Analysis of cross-sectional studies

 In a cross-sectional study all factors (exposure, outcome, and

confounders) are measured simultaneously.

 The main outcome measure obtained from a cross-sectional study is

prevalence:
Strengths and weaknesses of cross-sectional
studies

Strengths
 Relatively quick and easy to conduct (no long periods of follow-
up).

 Data on all variables is only collected once.

 Able to measure prevalence for all factors under investigation.

Cont..

 Multiple outcomes and exposures can be studied.

 The prevalence of disease or other health related characteristics

are important in public health for assessing the burden of disease in
a specified population and in planning and allocating health
resources.

 Good for descriptive analyses and for generating hypotheses.

Cont..

Weaknesses

 Difficult to determine whether the outcome followed exposure in

time or exposure resulted from the outcome.
 Not suitable for studying rare diseases or diseases with a short
duration.
 As cross-sectional studies measure prevalent rather than incident
cases, the data will always reflect determinants of survival as well as
aetiology.
Cont..

 Unable to measure incidence.

 Associations identified may be difficult to interpret.

 Susceptible to bias due to low response and misclassification due

to recall bias.
Analytic Studies

 Analytic studies (hypothesis testing studies) are designed specifically

to test causal hypotheses that have usually been generated from
descriptive studies.

 Analytic studies test hypotheses about exposure-outcome

relationships

 Measure the association between exposure and outcome

 Include a comparison group

Cont..

 A hypothesis is an educated guess about an association that is

testable in a scientific investigation.

 Descriptive data (Who? What? Where? When?) provide information

to develop hypotheses.

 Hypotheses tend to be broad initially and are then refined to have a

narrower focus.
Cont..

 analytic epidemiology is concerned with the search for causes and

effects, or the why and the how.

 Epidemiologists use analytic epidemiology to quantify the association

between exposures and outcomes and to test hypotheses about
causal relationships.

 It has been said that epidemiology by itself can never prove that a
particular exposure caused a particular outcome. Often, however,
epidemiology provides sufficient evidence to take appropriate control
and prevention measures.

Cont..

 In an observational study, the epidemiologist simply observes the

exposure and disease status of each study participant.

 John Snow’s studies of cholera in London were observational

studies.

 The two most common types of observational studies are cohort

studies and case-control studies; a third type is cross-sectional
studies
Cont..

 the purpose of an analytic study in epidemiology is to identify and

quantify the relationship between an exposure and a health
outcome.

 The hallmark of such a study is the presence of at least two groups,

one of which serves as a comparison group.

 In an experimental study, the investigator determines the exposure

for the study subjects; in an observational study, the subjects are
exposed under more natural conditions.
Cont..

 In an observational cohort study, subjects are enrolled or grouped

on the basis of their exposure, then are followed to document
occurrence of disease.

 Differences in disease rates between the exposed and unexposed

groups lead investigators to conclude that exposure is associated
with disease.
 In an observational case-control study, subjects are enrolled
according to whether they have the disease or not, then are
questioned or tested to determine their prior exposure
Cont..

 . Differences in exposure prevalence between the case and control

groups allow investigators to conclude that the exposure is
associated with the disease.

 Cross-sectional studies measure exposure and disease status at the

same time, and are better suited to descriptive epidemiology than
causation.
Cont..

The three major types of analytic studies are:

 cohort studies (prospective and retrospective),
 case control studies, and
 cross sectional studies
Cohort Studies

 A cohort (from the Latin cohors, plural cohorts; large military unit) is a
group of people from a given population who share a common
characteristic or experience within a defined time period

 Cohort studies are considered the strongest of all observational

designs. In a cohort study, the investigator usually starts with two

 one exposed to a possible risk factor and another who are not
exposed.
Cont..

 Cohort studies start with a group of exposed and a group of

unexposed individuals.
 These groups are then followed up over time and assessed to see
who develops the disease.
 The incidence rate of disease in the exposed group is then
compared to that in the unexposed group, therefore measuring
relative risk (RR).
 Since we only select subjects by exposure, we can study several
health outcomes at the same time. By properly selecting groups of
exposed people we can study relatively rare exposures.
Cont..

 Detailed information on confounding factors can be collected

allowing control for them either in the analysis or design.

 The disadvantage of cohort studies is that they can take long time
and generally are expensive.

 For rare diseases, the number of subjects that need to be studied is

often so large (since there is a huge majority likely not show the
disease), as to make cohort study impractical or unfeasible.
Types of Cohort Studies

Prospective cohort studies

 Group participants according to past or current exposure and
follow
up into the future to determine if outcome occurs

Retrospective cohort studies

 At the time that the study is conducted, potential exposure and
outcomes have already occurred in the past
 ----------------------------------------------------------------------------------------------------
----------------------------------------------------------------------
Case-Control

 Case-control studies are very useful for rare disease (or other rare
health events) where cohort studies would be either difficult or
impossible (too large) in order to collect enough events.

 Case-control studies compare exposures in disease cases vs. healthy

controls from the same population.

 Researchers start with outcome (event/disease) and measure prior

exposure in cases and in controls (comparison group).
Cont..

 These studies can be used to evaluate many different exposures

and are relatively quick to be conducted.

 The main weakness is that they can look at only one outcome. The
reliability of the study depends on the choice of controls.

 Data are collected retrospectively, therefore they are relatively

unreliable. The results are the odds ratio.
Cont..

Purpose:
 To study rare diseases
 To study multiple exposures that may be related to a single outcome
Study Subjects
Participants selected based on outcome status:
 Case-subjects have outcome of interest
 Control-subjects do not have outcome of interest
When to Conduct a
Case-Control Study
 The outcome of interest is rare
 Multiple exposures may be associated with a single outcome
 Funding or time is limited
 Advantages

 Good for studying rare conditions or diseases

 Less time needed to conduct the study because the condition or
disease has already occurred
 Lets you simultaneously look at multiple risk factors
 Useful as initial studies to establish an association
 Can answer questions that could not be answered through other
study designs
 Disadvantages

 Retrospective studies have more problems with data quality

because they rely on memory and people with a condition will be
more motivated to recall risk factors (also called recall bias).
 Not good for evaluating diagnostic tests because it’s already
clear that the cases have the condition and the controls do not
 It can be difficult to find a suitable control group
 Design pitfalls to look out for

 Care should be taken to avoid confounding, which arises when an

exposure and an outcome are both strongly associated with a third
variable. Controls should be subjects who might have been cases in
the study but are selected independent of the exposure. Cases and
controls should also not be "over-matched."

 Is the control group appropriate for the population? Does the

study use matching or pairing appropriately to avoid the effects of a
confounding variable? Does it use appropriate inclusion and
exclusion criteria?
Case-Control Study:
Analysis Format
Expouser Case Control
Yes a b
No c d
 Exposure odds ratio (OR) ≈RR when disease is rare
 Odds of being exposed among the cases = a/c
 Odds of being exposed among the controls = b/d
 Exposure odds ratio = (a/c)/(b/d) = (a*d)/(b*c)
 (Cross product ratio)
Prevalence Ratio and Prevalence
Odds Ratio
 Chronic disease date of onset is unknown
 Measure prevalence rather than incidence
 RR---------PR (prevalence ratio)
 OR-----------POR (prevalence odds ratio)
Prevalence Ratio

 In an experimental study, the investigator determines through a

controlled process the exposure for each individual (clinical trial) or
community (community trial), and then tracks the individuals or
communities over time to detect the effects of the exposure
Experimental Studies

 Experimental Studies - Some epidemiologic studies are interventional, intended

to test methods to reduce the incidence or severity of the disease.

 Community-based epidemiologic studies - Instead of randomizing individuals,

communities may be randomly selected to receive a treatment. For instance in
the 1950s, certain communities were randomly selected to have fluoride added
to the drinking water; in other communities, no flouride was added. The
incidence of dental caries between the flouridated communities and the non-
flouridated communities were then compared.
 Clinical (experimental) study - In this type of study, the researcher controls the
exposure that individuals receive. A prime example is a clinical trial, in which
patients may be randomized to a receive a specific treatment. Measurements
are made on the individual, but these studies do not typically measure the
effect on study particiapnts that might come from a group-level exposure.
Measurements of Morbidity and
Mortality
 Health status of a community is assessed by the collection,
compilation, analysis and interpretation of data on illness
(morbidity), death (mortality), disability and utilization of health
services.

 One of the central concerns of epidemiology is to find and

enumerate appropriate denominators in order to describe and
compare groups in a meaningful and useful way
Ratios, proportions, and rates

 Ratio : the result of dividing one quality by another.

 Ratio express a quantity relative to another.
 There are two class of ratio that are proportion and rate.
 The numerator and denominator are two separate distinct
quantities and may be measured in the same or different units
 Example : ratio=A/B
sex ratio =(No. of male)/(No. of female)
fetal death ratio =(No. of fetal death )/(No. of alive birth)
CONT..

 Proportion : the numerator is part of or contained in the

denominator
 The numerator is a fractional component of a denominator
 A proportion can range only between 0 and 1 inclusive.
 Proportion=a/(a+b)
 Proportion of male =(number of males)/(number of males)+(number
of female)
CONT..

 Rate :is a measure of disease frequency that describes how rapidly

health events such as new diagnose and death.
 Rate is the ratio of change in one quantity to a change in another
quantity with a denominator quantity often being time.
 Rate is a special type of proportion with time is added as dimention.

 Rate = Number of events in a specific period x

10
n
Population at risk of these events in a specified Period
In summary: Differences between ratio,
proportion and rates

 When we call a measure a ratio, we usually mean a non-

proportional ratio.

 When we call a measure a proportion, we usually mean a

proportional ratio that doesn’t measure an event over time, and
when we use the term rate

 we frequently refer to a proportional ratio that does measure an

event in a population over time
CONT..

 Type of rate : crude rate

:specific rate
:adjusted rate
Measuring morbidity

 In epidemiologic studies we use a measure of disease frequency to

determine how often the disease or other out come occurs

 There are two measure of disease frequency ,measure of incidence

and measure of prevalence
CONT..

 Incidence : is defined as the number of new case divided by the

population risk over time.

 Components incidence are new cases , population at risk and interval

time

 Incidence measure population at risk

 Incidence = number of new case 10

n
number of population at risk over time
CONT..

 Prevalence : measures existing cases of a health condition at a

particular point in the time or over the time
 It is most basic of epidemiologic measures.
 Identifies the existing cases and the primary design of cross sectional
studies.
 Point Prevalence rate: measures the proportion of a population with
a certain condition at a given point in time
CONT..

 Prevalence = No. of cases of disease present in the population at a

specified time X10n
No. of persons in the population at that specified
time
Measures of mortality

Uses of mortality statistics

 mortality statistics provide an important indicator of the health and
well-being of a population.
 Mortality statistics are required to estimate summary measures of
population health,

 for example the life expectancy at birth , as well as to understand

differentials in population health among different sub-groups in the
population.

 mortality statistics provide information about the nature and efficacy of

health care delivery systems.
Cont..

 Thus, for example, if high levels of child mortality are observed, this
may spur interventions to improve child health through changing
models of care and service provision, availability of immunisation
programmes etc.

 To be truly useful, however, it is important that information is not

only collected on the numbers of deaths by age and sex, but also to
be able to attribute death to its underlying cause
Cont..

 Where information on cause of death is also collected, data on

mortality can assist in helping policymakers understand a country’s
trajectory through the epidemiological transition.

 For this reason, it is recommended practice that the process of

certifying death records not only the basic demographic
characteristics of the dead, but also for a cause of death and
occupation to be recorded.
Cont..

 Information on cause of death is also important for epidemiological

studies: the links between exposure to asbestos and higher mortality
were first identified by observing that people who worked in
environments with high levels of asbestos particles present suffered
not only elevated mortality, but also tended to have higher death
rates
from lung-related diseases.
The crude death rate (CDR)

 Crude death rate – the total number of deaths per year per 1,000
people

 Note that the crude death rate can be misleading. The crude death
rate depends on the age (and gender) specific mortality rates and the
age (and gender) distribution of the population

 The crude death rate (CDR) is the simplest and one of the more
common indicators of mortality in a population. It is the ratio of the
numbers of deaths (D) observed in a population in a year to the
population at risk of dying in that year (N), usually multiplied by 1 000:
CONT..

 CDR =Total no. of deaths reported during a given time interval*1000

Estimated mid interval population
Age-specific mortality rates

 Among other limitations, the crude death rate makes no allowance for
the mortality pattern in a population by age.

 In most populations, mortality rates are very high in infancy, fall to a low-
point in late childhood (around the age of 10), and increase with
increasing age thereafter.

 It therefore makes sense to calculate mortality rates by single years of

age (although often there will be a significant element of random
variation in these) or for fairly narrow age groups.
Cont..

 The high level of mortality in infancy means that conventional

demographic practice is to mortality in the first year of life distinctly
from mortality at other ages in early childhood, resulting in a usual
classification of age-specific mortality measures covering ages 0-1; 1-4;
and 5-year age groups thereafter up to some final open interval,
perhaps beginning at age 80, or some higher age above which rather
few deaths occur.
Cont..

 Therefore differences between populations in the Crude Death Rate

may reflect differences in their age structures rather than accurately
reflect differences in individuals’ propensity to die given their ages.

 An age-specific death rate is defined similarly to that of a crude

death rate:
Cont..

AMR = No. of deaths in a specific age group during a given time

*1000
Estimated mid interval population of specific age group
Cont..

 . Infant Mortality Rate (IMR): measures the risk of dying during

infancy (i.e. the first age of life), and is defined as:

 IMR= Deaths of children under one year of age × 1000

Total live births

 Infant Mortality rate: the probability of dying between birth and age
one year per 1000 live births
Cont..

 Neonatal Mortality Rate (NMR): measures the risk of dying within 28

days of birth. It is defined as:
 NMR= Deaths of children under 28 days of age × 1000
Total live Births

 Post - Neonatal Mortality Rate (PNMR): Measures the risk of dying

during infancy after the first 4 weeks of life, and is defined as:
 PNMR= Death of children aged 28 days to under one year × 1000
Total live Births
Cont..

 . Maternal Mortality Rate (MMR): is defined as the number of deaths

of mothers (Dm) due to maternal causes, i.e. complications of
pregnancy, child birth, and puerperium, per 100,000 live births
during a year, i.e.

 MMR= Deaths of Mothers due to maternal causes in a year × 1000

Total live births in the same year
Cont..

Sex- specific mortality rate =No. of deaths in a specific sex

during a given time X
1000
Estimated mid interval population of same sex
Cont..

 Example: The average total population of “Kebele Y” in 1996 was

6000 (3500 female & 2500 male). In the same year 300 people died
(100 female & 200 male). Calculate the mortality rate (Crude death
rate) for females.

CDR for females = 100 X 1000 = 29 per 1000 female population

3500

That means out of 1000 female population living in “Kebele Y”, 29

females died in 1996.
Cont..

 Case Fatality Rate (CFR) = No. of deaths from a specific disease

during a given time x 100
No. of cases of that disease during the same time
Cont..

 Example: In 1996 there were 1000 tuberculosis patients in one region.

Out of the 1000 patients 100 died in the same year. Calculate the
case fatality rate of tuberculosis.

CFR = 100 x 100 = 10 %

1000

That means 10% of tuberculosis patients will die once they develop
the disease
Introduction to standardisation

 The previous page demonstrated that the Crude Death Rate is a

weighted average of age-specific mortality rates in the population,
weighted by the proportion of the population in each age group.

 This means that Crude Death Rates cannot be compared validly

across populations unless they have the same (or very similar) age
distributions.
CONT..

 To facilitate comparisons of this kind, the effects of differing age

structures need to be removed before valid comparisons can be
drawn. The process of doing this is called standardisation. The rest of
this section describes two approaches to standardising data.
CONT..

 Confounding arises from the situation where an association

between an exposure and an outcome is entirely or partially due to
another exposure (called the confounder).

 Mortality varies greatly with age and age structure differs between
populations and changes over time.

 Therefore, age is almost certain to confound comparisons of the

death rates for different populations or points of time
CONT..

 One way to control for confounding is to stratify the analysis by the

confounding variable, as we did by deriving age-specific death rates
for the two countries.

 A special application of stratification known as standardisation Tooltip

link is often used to control for the confounding effects of age so that
rates of disease or mortality can be compared in populations with
different age structures.

 Standardisation allows a single index of comparative mortality to be

derived, in a way that permits comparison of mortality measures that
are free of the effects of the underlying age distributions of the
populations under observation.
MEASURES OF ASSOCIATION
Cont..

Measures of Association Measures of Impact

Relative Risk Attributable Risk

Odds Ratio Attributable Risk Percent

Population Attributable Risk

Population Attributable Risk Percent

Cont..

 In epidemiologic research the calculation of appropriate measures

of disease frequency is the basis for the comparison of populations
and, hence the identification of disease determinants.

 The two frequencies (frequency among exposed and frequency

among non-exposed) being compared can be combined into a
single summary parameter that estimates the association between
an exposure and the risk of developing a disease.
Cont..

 This can be accomplished by calculating either the ratio of the

measures of disease frequency for the two populations,

 which indicates how much more likely one group is to develop a

disease than another, or the difference between the two, which
indicates on an absolute scale how much greater the frequency of
disease is in one group compared to with the other.

 These measures of association, the relative risk and the attributable

risk, are the two most frequently used in epidemiology.
Cont..
CONT..

 Statistical tests like Chi-square show mainly the presence or absence

of association.

 The strength of association is assessed by calculating Relative Risk

(RR), Odds Ratio (OR) or other measures of association.
Cont..

 Risk is a proportion that is defined as =

The chances of something happening
The chances of all things happening

 Odds is a ratio which is defined as=

The chances of something happening
The chances that it is not happening
Relative Risk (RR) or Risk Ratio

 Relative Risk (RR) shows the magnitude of association between

exposure & disease.

 It indicates the likelihood of developing the disease in exposed

group relative to non exposed.

 Relative risk can also be used to compare risks of death, injury, and
other possible outcomes of the exposure.
 RR = Incidence among exposed (Ie)
Incidence among non exposed (Io)

 RR = a/a+b
c/c+d
 Cont..
Bacteruria

Yes No Total

O
C Yes 27 455 482

U
S No 77 1831 1908
E

Total 104 2286 2390

Cont..

 Calculate the Relative Risk (RR) using the above data

 RR = Incidence in exposed (Ie) = 27/482 = 1.4

Incidence in nonexposed (Io) 77/1908

 Interpretation: women who used oral contraceptive had 1.4 times

higher risk of developing bacteruria when compared to non-users
Odds Ratio (OR)

 In case control studies, RR can be estimated by calculating the ratio

of the odds of exposure among the cases to that among the
controls i.e.

RR= OR = a/c = ad
b/d bc
Cont..

 An odds ratio (OR) is a measure of association between an

exposure and an outcome.

 The OR represents the odds that an outcome will occur given a

particular exposure, compared to the odds of the outcome
occurring in the absence of that exposure.

 Odds ratios are most commonly used in case-control studies,

however they can also be used in cross-sectional and cohort study
designs as well (with some modifications and/or assumptions).
Cont..

 Odds ratios are used to compare the relative odds of the

occurrence of the outcome of interest (e.g. disease or disorder),
given exposure to the variable of interest (e.g. health characteristic,
aspect of medical history).

 The odds ratio can also be used to determine whether a particular

exposure is a risk factor for a particular outcome, and to compare
the magnitude of various risk factors for that outcome.
Cont..

 OR=1 Exposure does not affect odds of outcome

 OR>1 Exposure associated with higher odds of outcome
 OR<1 Exposure associated with lower odds of outcome
Cont..

 Of 156 women with Myocardial Infarction (MI), 23 were current OC users at

the time of their hospital admission. Of the 3120 control women without MI,
304 were current OC users. Calculate the measure of association and interpret
it.

 This table shows data from case control study of oral contraceptive (OC) use
& myocardial infarction in pre-menopausal female nurses.

Myocardial Infarction
Yes No Total
Current Yes 23 304 327
OC Use No 133 2816 2949
Total 156 3120 3276
CONT..

 Calculate OR
 OR = ad = (23) (2816) = 1.6
bc (304) (133)

 Interpretation: Women who were current OC users had 1.6 times

higher risk of developing myocardial infarction when compared to
non-users of OC
CONT..

 When is the Odds Ratio a good estimate of the Relative Risk?

 The relative risk (RR ) can be estimated by the odds ratio (OR) if the
following conditions are fulfilled:
• The controls are representative of the general population
• The selected cases are representative of all cases
• The disease is rare
IMPACT MEASURES
Cont..

 Measures of impact includes:

• Attributable Risk (AR)
• Attributable Risk Percent (ARP)
• Population Attributable Risk (PAR)
• Population Attributable Risk Percent (PARP)
Attributable Risk (AR) / Risk
Difference (RD)
 Attributable Risk (AR) provides information about the absolute effect
of the exposure or the excess risk of disease in those exposed.

 It quantifies the risk of disease in the exposed group that is

attributable to the exposure by removing the risk of disease that
occurs due to other causes.
Cont..

 The Attributable risk expresses the most that we can hope to

accomplish in reducing the risk of the disease if we completely
eliminate the exposure.

 Thus, attributable risk tells us the potential for prevention

 Cont..

 AR = Incidence among exposed (Ie) - Incidence among non-exposed (Io)

 Alternative Naming of Attributable Risk

 Risk difference,
 Rate difference,
 Cumulative incidence difference or Incidence density difference
Cont..

 Among 2390 women aged 16 to 49 years who were free from

bacteriuria, 482 were OC users at the initial survey in 1973, while 1908
were not. At a second survey in 1976, 27 of the OC users had
developed bacteriuria, as had 77 of the non users. Calculate the
measure of association and interpret it.
co

 calculate AR
 AR = 27 _ 77
482 1908
=0.0156=1566 per 100,000 OC users

 Interpretation: The excess occurrence of bacteruria among OC

users attributable to their OC use is 1566 per 100,000 OC users
Attributable Risk Percent (ARP)

 Attributable Risk Percent estimates the proportion of the disease

among the exposed that is attributable to the exposure, or the
proportion of the disease in the exposed group that could be
prevented by eliminating the exposure and is calculated as follows:

 AR % = Incidence in exposed – Incidence in non-exposed X100

Incidence in exposed
 Refer to example 1 and calculate AR%
AR % = 1566/105 X 100 =27.96 %
 27/482

 Interpretation: If OC use causes bacteruria, about 28 % of bacteruria

among women who use OC can be attributed to their OC use and
can be eliminated if they did not use oral contraceptives.
End to this class
Epidemiologic aspect of
communicable disease
Communicable Diseases

 Communicable diseases are diseases that are as a result of the

causative organism spreading from one person to another or from
animals to people

 It is an illnesses due to specific infectious agents or its toxic

products.
which arise through transmission of that agent, or its toxic products
from an infected person, animal or inanimate reservoir to a susceptible
host, either directly or indirectly, through an intermediate plant or
animal host, vector or inanimate environment.
Chain of Disease Transmission
 It refers to a logical sequence of factors or links of a chain that are essential to
the development of the infectious agent and propagation of disease
 The six factors involved in the chain of disease transmission are
 Infectious agent (etiology or causative agent)
 Reservoir
 Portal of exit
 Mode of transmission
 Portal of entry
 Susceptible host
 Cont…

a, Infectious agent: An organism that is capable of producing infection or infectious

disease.
 On the basis of their size, etiological agents are generally classified into
 Metazoa (multicellular organisms). (e.g. Helminths). ƒ
 Protozoa (Unicellular organisms) (e.g. Ameobae) ƒ
 Bacteria (e.g. Treponema pallidum, Mycobacterium tuberculosis, etc.) ƒ
 Fungus (e.g. Candida albicans) ƒ
 Virus (e.g. Chickenpox, polio, etc.)
Cont..

b Reservoir of infection: Any person, animal, arthropod, plant, soil or

substance (or combination of these) in which an infectious agent
normally lives and multiplies.
 It depends primarily for survival and where it reproduces itself in
such a manner that it can be transmitted to a susceptible host
Types of reservoirs

1. Man: There are a number of important pathogens that are

specifically adapted to man, e.g measles, smallpox, typhoid,
meningococcal meningitis, gonorrhea and syphilis. The cycle of
transmission is from human to human.
2. Animals: Some infective agents that affect man have their
reservoir in animals. The term “zoonosis” is applied to disease
transmission from animals to man under natural conditions
Cont…

E.g Bovine tuberculosis - cow to man ƒ

Brucellosis - Cows, pigs and goats to man ƒ
Anthrax - Cattle, sheep, goats, horses to man ƒ
Rabies - Dogs, foxes and other wild animals to man Man is not
an essential part (usual reservoir) of the life cycle of the agent.
 Animal …….. Animal…………Animal
↓
Human
Cont…

3. Non-living things as reservoir Many of the agents are basically

saprophytes living in soil and fully adapted to live freely in nature.
E.g. Clostridium botulinum etiologic agent of Botulism
Clostridium tetani etiologic agent of Tetanus
Clostridium welchi etiologic agent of gas gangrene
Cont..

c. Portal of exit (mode of escape from the reservoir): This is the site
through which the agent escapes from the reservoir.
e.g : GIT: typhoid fever, bacillary dysentery, amoebic dysentery,
cholera, ascariasis, etc.
Respiratory: tuberculosis, common cold, etc.
Skin and mucus membranes: Syphilis
Cont…

d. Mode of transmission (mechanism of transmission of infection) Refers to the

mechanisms by which an infectious agent is transferred from one person to
another or from a reservoir to a new host. Transmission may be direct or indirect.

Direct transmission: Consists of essentially immediate transfer of infectious agents from

an infected host or reservoir to an appropriate portal of entry. This could be
Cont..

a. Direct Vertical Such as: transplacental transmission of syphilis, HIV,

etc.
b. Direct horizontal Direct touching, biting, kissing, sexual intercourse,
droplet spread onto the conjunctiva or onto mucus membrane of eye,
nose or mouth during sneezing coughing, spitting or talking; Usually
limited to a distance of about one meter or less.

Cont…
Indirect transmission
a. Vehicle-borne transmission: Indirect contact through contaminated inanimate
objects (fomites) like: handkerchiefs, soiled clothes, cooking or eating utensils, surgical
instruments , Contaminated food and water Biological products like blood, serum,
plasma or IV-fluids or any

 substance serving as intermediate means by which an infectious agent is transported

and introduced into a susceptible host through a suitable portal of entry.

 The agent may or may not multiply or develop in the vehicle before it is introduced
into man.
cont.

b. Vector-borne transmission : Occurs when the infectious agent is conveyed by an

arthropod (insect) to a susceptible host.

1. Mechanical transmission: The arthropod transports the agent by soiling its feet or
proboscis, in which case multiplication of the agent in the vector does not occur.
(e.g. common house fly.)
Cont…

2. Biological transmission: This is when the agent multiplies in the

arthropod before it is transmitted, such as the transmission of malaria
by mosquito.

C. Air-borne transmission: Dissemination of microbial agent by air to a

suitable portal of entry, usually the respiratory tract. Two types of
particles are implicated in this kind of spread: dusts and droplet nuclei
Cont…

 Dust: small infectious particles of widely varying size that may arise
from soil, clothes, bedding or contaminated floors and be
suspended by air currents.

 Droplet nuclei : Small residues resulting from evaporation of fluid

(droplets emitted by an infected host). They usually remain
suspended in the air for long periods of time.
Cont…

e. Portal of entry: The site in which the infectious agent enters to the
susceptible host
e.g Mucus membrane
Skin
Respiratory tract
GIT
Blood
Cont….

f . Susceptible host (host factors): A person or animal lacking sufficient

resistance to a particular pathogenic agent to prevent disease if or
when exposed.

 Occurrence of infection and its outcome are in part determined by

host factors. The term “immunity” is used to describe the ability of
the host to resist infection.
Cont…

 Resistance to infection is determined by non-specific and specific

factors

Non-specific factors
 Skin and mucus membrane
 Mucus, tears, gastric secretion
 Reflex responses such as coughing and sneezing
Cont…

Specific factors Genetic-hemoglobin resistant to Plasmodium

falciparum Naturally acquired or artificially induced immunity.
Acquired immunity may be active or passive.

Active immunity- acquired following actual infection or immunization.

Passive immunity- pre-formed antibodies given to the host.

Carrier and Its Type

 A carrier is an infected person or animal who does not have

apparent clinical disease but is a pot
ential source of infection to others.

 a. Healthy or asymptomatic carriers: These are persons whose

infection remains unapparent.
For example, in poliovirus, meningococcus and hepatitis virus
I Infections, there is a high carrier rate.
Cont..

 b. Incubatory or precocious carriers: These are individuals or persons

who excrete the pathogen during the incubation period (i.e. before
the onset of symptoms or before the characteristic features of the
disease are manifested). E.g. Measles, mumps, chickenpox and
hepatitis
Cont…

 c. Convalescent Carriers: These are those who continue to harbor

the infective agent after recovering from the illness. E.g. Diphtheria,
Hepatitis B virus.

 d. Chronic Carriers: The carrier state persists for a long period of

time. E.g. Typhoid fever, Hepatitis B virus infection.
Time Course of Infectious Diseases

 Incubation period: It is the interval of time between infection of the

host and the first appearance of symptoms and signs of the disease

 Prodromal period: It is the interval between the onset of symptoms

of an infectious disease and the appearance of characteristic
manifestations
For example, in a measles patient, fever and coryza occur in the
first three days and Koplick spots in the buccal mucosa and
characteristics skin lesions appear on the fourth day.
Cont…

 Period of communicability: The period during which that particular

communicable disease (infectious agent) is transmitted from the
infected person to the susceptible host.
Natural history of disease

 The natural history of disease refer to the process of disease or

condition progression from the time it affect an individual to the
time the individual recovers or dies if appropriate measures are not
instituted.
 The process has two distinct periods
1. Pre-pathogenesis period: this is the period before the disease
infects an individual. The agent and host are interacting in the
environment. At this level the host defence system is well capable
of handling the agent (causative organisms) hence there is no
disease
Cont..

2. Pathogenesis period is the period that starts when the body defence
mechanism has been overcome by the agent (disease causing
organisms). This result to the host cells dying this takes various stages
 Cont..

 Sub clinical horizon; the host cells have started dying but to major effects are felt yet and
the host has no signs or symptoms of the disease. At this level only laboratory tests would
reveal the extent of damage.

 Clinical horizon; at this time the damage on the cells is so much that some of the hosts body
functions are starting to fail. This manifests in signs and symptoms of a disease that the host is
feeling uncomfortable or sick. If the host does not receive appropriate medical intervention
then thy get in to the next stage.
Cont..

 Early disease stage; at this time the disease effects are real as a
result of massive cell damages that are affecting tissues functions.
The host need appropriate intervention to correct the damage. If
they fail to receive correct interventions then the disease gets in to
the next level.
 Advanced disease; at this level the damage to the host systems is
massive and may be irreversible leading to disability, or permanent
damage. The host has three outcomes at this stage i.e. recover,
permanent disability, convalescence or in worst cases death.
Figure2 illustrates the natural history of disease/conditions process.
Cont..
Levels of Prevention

 The different points in the progression of a disease at which one can

intervene can be classified according to three levels of prevention
Primary,
Secondary
Tertiary.

a. Primary prevention: The objectives here are to promote health,

prevent exposure, and prevent disease.
Cont..

Health promotion: This consists of general non-specific interventions

that enhance health and the body’s ability to resist disease.

such as measures aimed at the improvement of socio-economic status

through the provision of adequately paid jobs, education and
vocational training, affordable and adequate housing, clothing, and
food, old-age pension benefits; emotional and social support, relief of
stress
Cont..

 In short it is any intervention that promotes a healthier and happier

life

 Prevention of exposure:- This includes actions such as the provision

of safe and adequate water, proper excreta disposal, vector
control, safe environment at home (e.g., proper storage of
insecticides and medicines, out of children’s reach), at school and
at work (e.g., proper ventilation, monitoring of harmful substances in
factories), and on the streets (e.g., driver licensing laws).
Cont..

 Prevention of disease:-This occurs during the latency period

between exposure and the biological onset of disease. An example
for this is immunization.

 Immunization against an infectious organism does not prevent it

from invading the immunized host, but prevents it from establishing
an infection.
Cont..

 . Active immunization means exposing the host to a specific antigen

against which it will manufacture its own protective antibodies after
an interval of about three weeks (during which the immunized
person remains susceptible to the disease).

 Passive immunization means providing the host with the antibodies

necessary to fight against disease
Cont..

 . Both forms of immunization act after exposure. However, for active

immunization to be protective, the timing of its administration must
be at least three weeks prior to exposure.

 Passive immunization, on the other hand, is commonly given after

exposure has occurred (as in the case of exposure to rabies or
tetanus), or shortly before an exposure is expected, as in the
administration of immune globulin to prevent viral hepatitis A).
Cont..

 Breastfeeding is an example of an intervention that acts at all three

levels of primary prevention:

 Health promotion: by providing optimal nutrition for a young child,

either as the sole diet up to six months of age, or as a supplement in
later months.

 Prevention of exposure: by reducing exposure of the child to

contaminated milk.

 Prevention of disease after exposure: by the provision of anti-infective

factors, including antibodies, white blood cells, and others.
Cont.

 This is the most common especially for communicable disease. This

level is targeted at the pre-pathogenesis period or the period
before the disease infects the individual.
 The interventions include General measures such as health
education, safety measures and healthy behaviour.
 Specific measures such as vaccination, prophylaxis medication etc.
Cont..

 b. Secondary prevention: After the biological onset of disease, but

before permanent damage sets in, we speak of secondary
prevention.

 The objective here is to stop or slow the progression of disease so as

to prevent or limit permanent damage, through the early detection
and treatment of disease.

 e.g. breast cancer prevention of the invasive stage of the disease,

trachoma ,prevention of blindness.
Cont..

 This mainly happen during the early stages of disease process. The
purpose is to prevent further damage to host cells and tissues and
thus avoid disease complications. Measures would include early
diagnosis, screening and prompt treatment.
Cont..

 c. Tertiary prevention: After permanent damage has set in, the

objective of tertiary prevention is to limit the impact of that
damage. The impact can be physical, psychological, social (social
stigma or avoidance by others), and financial.

 Rehabilitation refers to the retraining of remaining functions for

maximum effectiveness, and should be seen in a very broad sense,
not simply limited to the physical aspect. Thus the provision of
special disability pensions would be a form of tertiary prevention.
Cont..

 This takes place during the advanced stages of the disease

progression to minimise the complications or reverse the effects.
Main interventions are rehabilitative in nature and include physical
therapy, occupational therapy, psychotherapy,
corrective/rehabilitative surgery etc.
cont..

Communicable Disease Control

 This refers to the reduction of the incidence and prevalence of

communicable disease to a level where it cannot be a major public
health problem.
Methods of Communicable Disease
Control
 There are three main methods of controlling communicable
diseases:

1. Elimination of the Reservoir

a. Man as reservoir: When man is the reservoir, eradication of an
infected host is not a viable option. Instead, the following options are
considered:
Cont…

 Detection and adequate treatment of cases: arrests the

communicability of the disease e.g. Treatment of active
pulmonary tuberculosis.
 Isolation: separation of infected persons for a period of
communicability of the disease. Isolation is indicated for infectious
disease with the following features: - High morbidity and mortality -
High infectivity
 Quarantine: limitation of the movement of apparently well person or
animal who has been exposed to the infectious disease for a
duration of the maximum incubation period of the disease.
Cont..

 b. Animals as reservoir: Action will be determined by the usefulness

of the animals, how intimately they are associated to man and the
feasibility of protecting susceptible animals.
For example:
 Plague: The rat is regarded as a pest and the objective would be to
destroy the rat and exclude it from human habitation.
 Rabies: Pet dogs can be protected by vaccination but stray dogs
are destroyed.
 Infected animals used for food are examined and destroyed.
Cont..

 c. Reservoir in non-living things: Possible to limit man’s exposure to

the affected area (e.g. Soil, water, forest, etc.).
Cont..

2. Interruption of transmission This involves the control of the modes of

transmission from the reservoir to the potential new host through:
 Improvement of environmental sanitation and personal hygiene
 Control of vectors
 Disinfections and sterilization
Cont..

3. Protection of susceptible host: This can be achieved through:

 Immunization: Active or Passive
 Chemo-prophylaxis- (e.g. Malaria, meningococcal meningitis, etc.)
 Better nutrition
 Personal protection. (e.g. wearing of shoes, use of mosquito bed
net, insect repellents, etc.)
Immunization v. Vaccination

 Vaccines contain that can cause a particular disease, like tetanus,

or parts of a germ.
 When we are given a vaccine shot, our body immediately produces
antibodies against the germ.
 It is most believe that the body’s defence mechanism kicks in and
immunity will occur in the event that the said antigen gains entry
again into the body but, this is not the case with all vaccines.
Cont..

 Immunization means to make someone immune to something.

 Vaccination “a suspension of attenuated or killed

microorganisms…administered for prevention…or treatment of
infectious disease.”

 Vaccination does not guarantee immunity. Natural immunity

happens only after one recovers from the actual disease.
Cont..

 During the disease, the microorganism usually has to pass through

many of the body’s natural immune defence systems—in the nose,
throat, lungs, digestive tract and lymph tissue—before it reaches the
bloodstream

 According to the Center for Disease and Prevention Control, CDC,

not all that receive a vaccination will have immunity

 “This is explained by two factors. No vaccine is 100% effective. Most

routine childhood vaccines are effective for 85% to 95% of
recipients.”
Cont..

 , “Although vaccines have very high effectiveness rates, they are

not completely effective for 100% of the people who receive them.

 For example, a full series of measles vaccine will protect 99 of 100

children from measles and polio vaccine will protect 99 of 100
children from polio.
 This means when there is a disease outbreak, the very small number
of people for whom the vaccine did not work may still be able to
catch the disease.
Cont…

Prophylaxis
Definition
 A prophylaxis is a measure taken to maintain health and prevent
the spread of disease.
 Antibiotic prophylaxis is the focus refers to the use of antibiotics to
prevent infections.
Purpose
 Antibiotics are well known for their ability to treat infections. But
some antibiotics also are prescribed to prevent infections. This
usually is done only in certain situations or for people with particular
medical problems
Disease transmission

 Disease transmission process has three components i.e

source, transmission route and susceptible host.

 Source is the origin of the disease causing organism. This could be

infected person, animal, place or object.
Transmission route the main routes of
transmission are
 Direct contact for example sexual contact
 Vectors like mosquitoes
 Faecal oral (ingesting contaminated food and water)
 Airborne
 Trans placental (mother to foetus)
 Blood contact (transfusion, surgery, injection)
 Contact with animals or their products that are infected.
Cont..

• Susceptible host is an individual who has low resistance to

particular disease. This may be due to various factors such as;
• Lack of previous contact with the disease hence no immune cells
• Immuno suppressive illnesses such as AIDS
• Malnutrition
• Drugs that a person may be consuming.
Epidemiologic investigation and
management
PATTERNS OF DISEASE
OCCURRENCE AND EPIDEMICS
MANAGEMENT
 The amount of a particular disease that is usually present in a community is the
baseline level of the disease.

 This level is not necessarily the preferred level, which should in fact be zero;
rather it is the observed level.

 Theoretically, if no intervention occurred and if the level is low enough not to

deplete the pool of susceptible persons, the disease occurrence should
continue at the baseline level indefinitely.

 Thus, the baseline level is often considered the expected level of the disease.
Definition of common terms

 Different diseases, in different communities, show different patterns

of expected occurrence.

a) Occurrence of disease at expected level includes:

 An endemic disease is a disease that occurs in a population with
predictable regularity and with only minor deviations from its
expected frequency of occurrence.
Cont..

 Hyperendemic is an endemic disease that affects a high proportion

of the population at risk.

 Mesoendemic is an endemic disease that affects a moderate

proportion of the population at risk.

 Hypoendemic is an endemic disease that affects a small proportion

of the population at risk.
Cont..

b) Irregular and occasional occurrence of disease:

 Sporadic refers to occasional or irregular occurrence of disease.

 A sporadic disease is a disease that is normally absent from a

population but which can occur in that population, although rarely
and without predictable regularity.
Cont..

 c) Occurrence of disease at excess of the expected level includes:

 Epidemic refers to the occurrence of disease or health related
condition in excess of the usual frequency in a given area or among
a specified group of people over a particular period of time.

 Outbreak is an epidemic of shorter duration covering a limited area.

It is usually used interchangeably with Epidemic.
Cont..

 Pandemic is an epidemic involving several countries or continents

affecting a large number of people
Cont..

Epidemics occur when an agent and susceptible hosts are present in

adequate numbers, and the agent can effectively be conveyed from
a source to the susceptible hosts. More specifically, an epidemic may
result from the following:
•a recent increase in amount or virulence of the agent,
•the recent introduction of the agent into a setting where it has not
been before,
 •an enhanced mode of transmission so that more susceptible are
exposed,
 •some change in the susceptibility of the host response to the
agent,
 •factors that increase host exposure or involve introduction through
new portals of entry.
Types of epidemic

Three types are well recognized:

• Common source
• Propagated/progressive and
• Mixed.
1. Common source epidemics

 Common source epidemic is a type of epidemic caused by

exposure of a group of people to a common risk factor, such as an
infectious agent or a toxin or a chemical, etc.
 This can take two forms:
I) Point source epidemic
 If the exposure is brief and simultaneous, all exposed will develop
the disease within one incubation period – referred to as point
source epidemic/outbreak. Example: food borne outbreak of Acute
Gastroenteritis in attendants of a wedding feast
II) Continuous/ Intermittent common source
 If the source of an outbreak remains for a longer time, days, weeks
or longer either continuously or intermittently, it is called Continuous
or intermittent common source epidemic. A waterborne outbreak
that is spread through a contaminated community water supply
can be an example.
2. Propagated or progressive
epidemics
Outbreak of this type occurs from transmission of an infectious agent
from one susceptible an infected host to another. It can be through:
• Direct person-to-person transmission or
• Indirect transmission: through a vector, vehicle, etc.
Examples: epidemics of measles, yellow fever, malaria, etc.
3. Mixed Epidemic

 Mixed epidemic is an epidemic which shows the features of both

types of epidemics (common and propagated). It usually begins
with a common source of infectious agent with subsequent
propagated spread, e.g. most food borne outbreaks.
INVESTIGATION OF OUTBREAKS

 Outbreak investigation is a method for identifying and evaluating

people who have been exposed to an unusual occurrence of
disease or other health problems.

 It is an important component of epidemiology and public health,

which through a systematic way helps in identifying the source of
ongoing outbreaks and in preventing additional cases.
How are outbreaks recognized?

a. Review of routinely collected surveillance data can detect

outbreaks of known diseases, through regular analysis and
interpretation, if there is a strong and quality surveillance system in
place,

b. observant clinicians, infection control nurses, or clinical laboratory

workers first notice an unusual disease or an unusual number of cases
of a disease and alert public health officials,
Cont..

c. Frequently, it is the patient (or someone close to the patient) who

first suspects a problem, as is often the case in food borne outbreaks
after a shared meal,

d. Sometimes public health officials learn about outbreaks of disease

from the local newspaper or television news.
Why are Outbreaks Investigated?

a. The most compelling reason to investigate a recognized outbreak

of disease is that exposure to the source(s) of infection may be
continuing; the investigation provides helpful information to take
immediate action i.e. by identifying and eliminating the source of
infection, we can prevent additional cases.

b. Because the results of the investigation may lead to

recommendations or strategies for preventing similar future outbreaks,
thereby improving long term disease prevention activities.
Cont..

c. Other reasons include:

i. to describe new diseases and learn more about known diseases;
ii. to evaluate existing prevention strategies, e.g., vaccines;
iii. to address public concern about the outbreak.
When should outbreaks be
investigated?
 For some communicable diseases, a single suspected case might
suffice to start the process of investigation.

 For instance diseases with a potential for massive epidemics or

diseases caused by etiologic agents of high virulence need more
attention and alertness than others.

 Such diseases need immediate investigation followed by immediate

response. For example, viral hemorrhagic fevers,
Cont...

 For some other diseases, the investigation is initiated when a certain

threshold is passed, or when an unusual increase in the number of
deaths due to a certain cause is noticed during analysis of surveillance
data or when a cluster of deaths due to unknown cause is seen.
Steps of an Outbreak Investigation

 In the investigation of an ongoing outbreak, working quickly is

essential.

 Getting the right answer is essential, too.

 Under such circumstances, epidemiologists find it useful to have a

systematic approach to follow.

 This approach ensures that the investigation proceeds forward

without missing important steps along the way. In practice,
however, several steps may be done
Cont..

 at the same time, or the circumstances of the outbreak may dictate

that a different order be followed.

 For example, control measures should be implemented as soon as

the source and mode of transmission are known, which may be
early or late in any particular outbreak investigation.
What are the activities
accomplished in outbreak
investigation?
 There is no rigid step to follow during investigation of an outbreak.

 Several activities could be accomplished simultaneously.

 The steps to follow are set by the individual investigator depending

on the suspected cause of the outbreak.
Cont..

1. Prepare to conduct an investigation

2. Verify that there is an epidemic
3. Define and identify cases
a) Construct a case definition
b) Identify and count cases
4. Performing Descriptive Epidemiology
5. Develop hypothesis
Cont..

6. Evaluate hypothesis
7. As necessary, reconsider/refine hypotheses and execute additional
studies
a) Additional epidemiologic studies
b) Other types of studies – laboratory, environmental
8. Implement control and prevention measures
9. Report and disseminate findings
Step1: Prepare to conduct an
investigation
 Anyone about to embark on an outbreak investigation should be
well prepared before leaving for the field.

 Good preparation will facilitate a smooth field experience.

 The following are essential for investigation of an outbreak.

Cont..

a. Search and gather scientific information necessary for the outbreak

investigation:
No single investigator is fully knowledgeable about all diseases, and
health problems which need investigation and appropriate ways of
investigating and managing their outbreaks

Therefore , should always update him/her self with the necessary

scientific knowledge both about the nature of the disease to be
investigated and also about the scientifically proven or sound methods
of investigating and managing the outbreaks
Cont..

 This includes collecting sample questionnaires, discussing with

experienced people, reading applicable literatures, etc.
Cont..

b. Make important communications:

 As is often the case, there are people and units of governmental
organizations responsible for investigating and/or managing
epidemics.

 Identify these people and communicate with them to plan the

investigation and management together.
Cont..

 For example, using the already available data and with discussion
with responsible persons, decide where to undertake the
investigation taking the most affected geographical location as a
starting place for the outbreak investigation
Cont..

c. Establish an outbreak investigation and management team

For a smooth execution of outbreak investigation and management,
it is helpful to establish a team with clearly defined roles

Team members should be well aware of their specific roles in the

process of investigating the outbreak.

In addition the team should plan and decide how communication

among the team members will go during the outbreak investigation.
Cont..

 d. Develop data collection tool for the outbreak investigation

The investigation team should develop data collection tool relevant for
the health problem under investigation.

For example the following variables and information might be

important regardless of the disease under investigation
 • Identifying information: inclusion of names, address

 • Socio-demographic information: includes age, sex, marital

status, occupation, educational status, religion, income etc provides
the “person” characteristics of the population at risk.

 • Clinical and lab information: includes symptoms, signs, date of

onset, results of laboratory tests
Cont..

 • Risk factor information: include inquiries made to elicit

specifically exposure to the suspected cause(s), e.g. contact with
people with similar illness, travel history, immunization status etc.
Cont..

 e. Make administrative arrangements

Beginning from the start of the epidemic investigation, investigators
should plan for adequate transportation, personnel, equipment and
logistic supplies.

For example, most outbreak investigations entail laboratory materials

(e.g. serologic kits); every effort should be made to obtain essential
materials well in advance of the beginning of the actual investigation
activities.