COLLEGE OF NURSING

EPIDEMIOLOGY
 Learning Outcomes

1 2 3
Describe The Compare, contrast Describe key features
Concept Of the different stages of and applications of
Epidemiology natural history of descriptive
disease epidemiology
 Definition of Epidemiology
Greek words

“epi” “Logos”

“demos”
 Definition of Epidemiology

1) health 2) probable factors

study of
circumstances that influence
occurrence,
(disease, death, development of
distribution :
deformities) health conditions.
 Definition of Epidemiology
STUDY OF…

distribution, application of this

determinants of study to
health-related prevention &
states / events in control of health
specified problems
populations (Last, 1988)
Definition of Epidemiology

Process of Epidemiological
Study

Uses variety of concepts:

• Biology sociology
• Demography geography
environmental science statistics
• Policy analysis
 Key terms that
reflect important
Principles of
Epidemiology
 Other Descriptions of Epidemiology

1. Epidemiology is a scientific
discipline with sound methods of
STUDY scientific inquiry at its foundation
• Epidemiology is data-driven
• Comprises of:
• surveillance,
• observation,
• hypothesis testing,
• analytic research then
• experiments
 Other Descriptions of Epidemiology

Epidemiology is concerned
2.
DISTRIBUTION
with
the frequency and pattern of
health events in a population:
• Analysis by:
• places
• time and
• classes of people affected
 FREQUENCY

• Frequency refers to the number of

health events & the relationship of
that number to the size of the
population.
• compare disease occurrence across
different populations.
 PATTERN

• refers to occurrence of health-related

events by time, place, and person.
Time patterns may be annual,
seasonal, weekly, daily, hourly,
weekday versus weekend, or any other
breakdown of time that may influence
disease or injury occurrence
Other Descriptions of Epidemiology
3.
DETERMINANTS

Contain all
• biological
• chemical
• physical
• social
• cultural
• economic
• generic behavioral factors that
influence health
Other Descriptions of Epidemiology

DETERMINANTS
REFERS to any factor, whether
event, characteristic, or other
definable entity, that brings about a
change in a health condition or
other defined characteristic.
 Other Descriptions of Epidemiology

Nurse epidemiologists use

analytic epidemiology or
epidemiologic studies to
provide the “Why” and
“How” of such events.
 Other Descriptions of Epidemiology
4. HEALTH-
RELATED health-related refers to states or events may be seen
STATES OR as anything that affects the well-being of a
EVENTS population.

• Focus & investigates cause of death,

behaviors such as use of tobacco,
positive health states, reactions to
preventive regimens & provision / use of
health services
 Other Descriptions of Epidemiology

5. SPECIFIED Epidemiologist is concerned about the

POPULATIONS collective health of people in a community or
population.
• The epidemiologist’s “patient” is the community.

• Comprise those with identifiable characteristics such as

occupational groups
Other Descriptions of Epidemiology

potential for
number of further spread
identify
other persons in community;
exposure or
who may have & interventions
source that
been similarly to prevent
caused illness;
exposed; additional cases
or recurrences.
 Other Descriptions of Epidemiology
6.
APPLICATION
The aim of public-health is to
TO promote, protect & restore
PREVENTION
AND CONTROL good health
• scientific methods of descriptive &
analytic epidemiology in “diagnosing”
health of a community & propose
public health interventions to control
& prevent disease in the community.
Beginnings of
Epidemiology
 Beginnings of Epidemiology
● Hippocrates

○ Disease is associated with climate & physical

environment

● John Snow
○ Investigation of Cholera epidemic in 1854

● William Farr
○ Use of census & vital registration of data
○ described pattern of mortality pattern in subgroups such
as occupational group, prisoners & other age-group
 Beginnings of Epidemiology
● Framingham Heart Study
○ identified the risk factors for coronary heart disease

● Richard Doll and Bradford Hill

○ Doll and Hill's Study
○ Provided compelling evidence of the role of
smoking in the incidence of lung cancer

● Jonas Salk
○ Developed and introduced in 1955 the Salk Vaccine. Field
trial showed protective effect of the vaccine against
paralytic poliomyelitis.
 PRACTICAL APPLICATIONS OF
EPIDEMIOLOGY

01 Assessment of health 04 Prevention & control

status of community or of disease
community diagnosis.

02 Elucidation of 05 Monitoring &

natural history of evaluation of health
disease. intervention

03 Determination of 06 Provision of evidence

disease causation for policy formulation
Practical applications for PHN:
Nurse epidemiologist measures
frequency & distribution of health
conditions using VITAL
STATISTICAL indices

EPIDEMIOLOGY is used to
analyze different factors that
contribute to disease
development
 Aids in ranking Identify RISK
health problems FACTORS
Practical
applications
for PHN: MONITOR & Design targeted
EVALUATE health
interventions INTERVENTION
Natural Life
History of
Disease
Natural Life History of Disease
its course over time, starting from
pre-pathogenesis stage to
termination
 Stages of Natural
History of Disease

Pre-pathogenesis Pathogenesis
Stage
Stage

Natural Life History of Disease

 Stages of Natural
History of Disease

1. Pre-pathogenesis Stage
• Disease not started yet
• Interrelations of agent, host & environment
• There are factors that favor disease occurrence (ex.
Malnourish)
- stimulus
• Susceptibility stage
 Stages of Natural Stage
2. Pathogenesis
History of Disease
• Reaction of HOST & STIMULUS
• Disease has already developed.
• 3 sub – stages:
• Pre-symptomatic
• Discernible lesions
• Advance disease
Natural Life History of Disease
Pathogenesis Stage : 3 sub – stages
Pre-symptomatic
or Early-pathogenesis. Pathologic
changes began, but NO symptom

Discernible lesions
Early s/s developing. Changes
discernible with sophisticated lab test.

Advance disease
Anatomical & functional changes
produced identifiable s/s
Natural Life History of Disease

Clinical data of patients with

several stages of the disease
are put together to determine
its natural history
Natural Life History of Disease

Prospective Cohort Study

plot better because of
advantage in observing cohort
FROM the time members are
disease- free to the time they
develop the disease through its
termination
Natural Life History of Disease
Prospective Cohort Study
Natural Life History of Disease
PREVENTION

Refers to identification of potential

problems to minimize or eradicate
possible disability or deformity
Natural Life History of Disease
LEVELS OF
PREVENTION
•By Moore &
Williamson
 LEVEL OF PREVENTION
administered to patient is
dependent
on the stage of the disease when
patient was diagnosed

Natural Life History of Disease

 3 LEVELS OF
PREVENTION
OF HEALTH
PROBLEMS

By Moore &
Williamson
 Natural Life History of Disease & Application
of Levels of Disease Prevention

Early Discernible Advanced

Prepathogenesis
Pathogenesis lesions Disease

Tertiary Tertiary
Prevention Prevention

Primary Secondary
Prevention Prevention
-Arrest disease
process to -Limit disability,
prevent prevent death
complication
 Primary
prevention Directed
to
LEVELS OF
PREVENTION
healthy
people
 Primary prevention
PRIMORDIAL SPECIFIC
PREVENTION PROTECTION
focusing on prevention Removal of the risk
of emergence of risk factors of reduction of
factors their levels
LEVELS OF PREVENTION
 Primary prevention
HEALTH
PROMOTION
Activities include provision of
proper nutrition, safe water supply
& waste disposal system, vector
control, promotion of healthy
lifestyle & good personal habits
SPECIFIC
MEASURES
Includes provision of
immunization & prophylaxis to
vulnerable or at-risk groups

LEVELS OF PREVENTION
 Secondary Aims to
prevention
identify & treat
existing health
LEVELS OF
problems at
PREVENTION earliest
possible time.
 Tertiary Limits disability
prevention progression.
Reduce magnitude
of residual effects
of both infections
LEVELS OF and non-
PREVENTION communicable
disease.
 Concept of causality and association

● HENLE-KOCH Postulate
states cause of a disease is
event, condition,
characteristic or
combination of these factors
that play an vital role in
generating disease
 Concept of causality and association

● NECESSARY CAUSE
fact that the factor
must be present for the
disease to occur.
 Concept of causality and association

● SUFFICIENT CAUSE
if a factor is present, disease
CAN occur, but the factor’s
presence DOES NOT ALWAYS
result in the disease
occurrence.
Concept of causality and association

● RISK
probability of an
unfavorable event,
disease, disability,
defect or even death.
 Concept of causality and association

●ASSOCIATION
concurrence of two variables
more often than would be
expected by chance, then two
variables under investigation
are said to be associated.
MODELS OF
DISEASE
CAUSATION
 MODELS OF DISEASE
CAUSATION

ecological
wheel web
triad
 The Wheel Model of
Disease Causation

Parts
Inner Outer Outer
core Core Edge
MODELS OF DISEASE CAUSATION
Wheel :Inner Core

MODELS OF DISEASE CAUSATION

 Inner core of
Wheel

This gives emphasis

on the role of genetic
makeup of the host

MODELS OF DISEASE CAUSATION

Outer Core of the
Hub

Host Characteristics
– ex. sex, age,
socioeconomic
status & behaviors

MODELS OF DISEASE CAUSATION

 The Rim or the
Outer Edge

Represents the
biologic, physical
& chemical
environments
MODELS OF DISEASE CAUSATION
The WEB MODEL
OF DISEASE
CAUSATION
 shows complex
interrelatedness
of risk factors
The WEB MODEL OF
DISEASE CAUSATION

Applicable For
Non -
Communicable
Disease
 The WEB MODEL OF
DISEASE CAUSATION

One Headed Arrow

signifying the ancestors,

Antecedent Factors at the

tail of the arrow &

Intermediate factors at the

head of the arrow
 The
Ecological
Triad
The Ecological Triad
Depicts the “Multiple Theory of Disease Causation”

*external agent,
*susceptible host
*environment that
brings them
together
The Ecological Triad
Depicts the “Multiple Theory of Disease Causation”

*the most useful

among models of
disease causation
The Ecological Triad
Also known as
epidemiologic triangle or
triangle model

occurrence of disease is
balance of host, agent &
environment factors
HOST
a susceptible human host

actual or potential recipient / victim of

disease.

hosts characteristics…either predispose

to them to or protect them
HOST Characteristics :

biological (e.g., age, sex, and degree of

immunity)
behavioral (e.g., habits, culture &
lifestyle)
social (e.g., attitudes, norms & values)
 Host - resistance

Non
Specific
specific
 AGENT is the
factor / forces that
precipitate disease
occurrence.
 AGENT
- vir ulent
- incr ease in
number
Agents are

Biological: parasites, protozoans,

bacteria, virus
Nutritive factors: ex.food, iron &
iodine deficiency
Chemical agents: gases & natural
or synthetic compounds
ex. Lead, mercury, insecticides
Agents are

Physical agents: ex. Humidity,

Ionizing Radiation, atmospheric
pressure
Mechanical – Trauma, stab
ENVIRONMENT
includes all external
factors / surrounding,
other than host & agent
that influence health
ENVIRONMENT
supports transmission
of the agent from a
source to that host.
Element of Environment
Environment are either:
p h y s i c a l - such as geology and climate,
b i o l o g i c - such as insects that transmit the
agent
socio-economic - such as crowding,
sanitation, and the availability of health services.
EPIDEMIOLOGICAL
APPROACHES
EPIDEMIOLOGICAL APPROACHES
a systematic approach
Counts cases or health events, and
describes them in terms of time, place,
and person;
Divides the number of cases by an
appropriate denominator to calculate
rates; and
Compares these rates over time or for
different groups of people
EPIDEMIOLOGICAL APPROACHES
answer the questions

• Who is sick?
• What are their symptoms?
• When did they get sick?
• Where were they exposed
to the illness?
EPIDEMIOLOGICAL
APPROACH
 Descriptive Analytical
Phases Of Epidemiology Epidemiology

Epidemiological
Approach
Intervention or
Experimental Evaluation
Epidemiology
Epidemiology
Descriptive Epidemiology
• Describes frequency &
distribution of disease in given
population
• Observes & records existing
pattern of occurrence of disease.
• Describes disease as to: person,
place & time characteristics.
 Analytical
Epidemiology
Attempts to analyze the
causes or determinants
of disease through
hypothesis testing
 Intervention or
Experimental
Epidemiology
Answers questions about the
effectiveness of new
methods for controlling
diseases or for improving
underlying conditions
 Evaluation
Epidemiology
Attempts to measure
the effectiveness of
different health
services and programs
 STEPS OF
EPIDEMIOLOGICAL
INVESTIGATION
 Basic steps are:
1. Operationally define what constitute a “case”

Case Definition
It is a set of standard criteria for classifying
whether a person has a particular disease,
syndrome, or other health condition
 Basic steps are:

Case finding / screening activities:

Screening is the presumptive identifications of

unrecognized diseases or defects
Case finding is done to look for previously
unidentified cases of diseases
Sensitivity is the proportion of persons with a
disease who test positive on a screening
test.
Specificity is the proportion of persons
without a disease who have negative results
on a screening test.
 Basic steps are:

2. Based on the operational definition,

identify the cases

Case classification
Suspected: A case that meets the clinical case definition.
Probable: A suspected case as defined above or ongoing epidemic
and epidemiological link to a confirmed case.
Confirmed: A suspected or probable case with laboratory confirmation.
 Basic steps are:
1. Operationally define what constitute a “case”

case “ classified as suspected or

“
probable while waiting for the
laboratory results to become available.
If laboratory provides report, case
can is reclassified as either confirmed
or “not a case”
 Basic steps are:
3. Based on the number of cases identified, verity
the existence of an outbreak

Outbreak carries the same definition of epidemic,

but is often used for a more limited geographic
area.
3. Based on the number of cases identified, verity
the existence of an outbreak

Cluster
aggregation of cases grouped in place & time
that are suspected to be greater than the
number expected, even though the expected
number may not be known.
 Basic steps are:
3. Based on the number of cases identified, verity
the existence of an outbreak
 Basic steps are:
3. Based on the number of cases identified, verity
the existence of an outbreak
 Basic steps are:
4. Establish the descriptive epidemiologic features
of the cases

Correlate : char. Of grp of persons, place, time

Time
The occurrence of disease changes over
time. Some of these changes occur
regularly, while others are unpredictable.
 Basic steps are:
Time Variations
➢FLUCTUATION in incidence
CYCLICAL • short period of time
VARIATION • Due to seasonal
• Ex. Measles

SECULAR ❑Changes in the TREND of disease

occurrence
VARIATION • over a long period of time.
 Basic steps are:
Time Variations

➢a) COMMON SOURCE

EPIDEMIC =
➢Simultaneous exposure of a
SHORT TIME large number of people to a
FLUCTUATIONS common infectious agent.
b) PROPAGATED EPIDEMIC =
➢Person-to-person transmission
 Basic steps are:
Place
Describing occurrence of
Characterization by
disease by place
place
provides insight into:
• geographic scope of • refers not only to place
the problem of residence but to any
• geographic variation. geographic site
pertinent to disease
occurrence.
 Basic steps are:
Place
a map provides a
more striking visual
display of place data.
 Basic steps are:
Place
Disease
Mapping
Host
➢Number of source of
infection
CHANCE
➢Location of source
of infection / host
Host

EXPOSURE • Depends on
RATE /
CONTACT frequency of
RATE contact
Host

• Depends on
HERD
IMMUNITY the number of
immunes
PATTERN OF
DISEASE
OCCURRENCE
PATTERN OF DISEASE OCCURRENCE

EPIDEMIC
Situation when there is a
marked upward fluctuation
in disease incidence
PATTERN OF DISEASE OCCURRENCE

ENDEMIC
Habitual presence of
disease in a given
geographic location
 PATTERN OF DISEASE OCCURRENCE

SPORADIC
When disease occur every now
and then affecting only small
number of people relative to total
population
PATTERN OF DISEASE OCCURRENCE

PANDEMIC

worldwide
occurrence
 Nurse characterize
pattern of disease
occurrence in terms of
date or time onset is a visual display
indicated in EPIDEMIC of the onset of
illness among
OR ATTACK CURVE

cases associated
with an outbreak.
 “epi curve”
X and Y Axes
two axes that intersect at right
angles.
horizontal x-axis date or time
of illness onset among cases.
vertical y-axis number of cases.

Each axis is divided into equally

spaced intervals
Intervals for 2 axes may differ.
“epi curve”
Basic steps are:

5. Record the clinical manifestation of cases

STEPS OF EPIDEMIOLOGICAL INVESTIGATION
The basic steps :
6. Based on clinical manifestations, incubation
period, available laboratory findings & other
information gathered, formulate a hypothesis
regarding probable etiologic agent, sources of
infection, mode of transmission & the best
approach for controlling an outbreak
7. Test hypotheses by collecting relevant specimens
from patients and from environment
Formulate hypothesis about probable
etiologic agent, sources of infection,
mode of transmission outbreak
formulate hypothesis about best approach for
controlling an outbreak
STEPS OF EPIDEMIOLOGICAL INVESTIGATION
The basic steps :
8. Based on the results of
investigation, implement prevention
and control measures to prevent
recurrence of a similar outbreak.
9. Disseminate findings of investigation
through media and other forms to inform
public
MONITORING &
EVALUATION OF
HEALTH
INTERVENTIONS
 Monitoring
Ongoing activity during program implementation to
assess current status of its implementation.
Monitor in terms of :

01 Compliance to design of
program

02 Timeliness

Despite being red, Mars

03 is actually a cold place
Monitoring result enables team to:

01 Assess progress of
program implementation

02 Identify problems

03 Take corrective action

Monitoring result enables team to:

04 Have a tool for quality assurance &

management

05 Measure achievement of midterm

program objectives

06 Lay the groundwork for program evaluation

EVALUATION
 EVALUATION
Describe as systematically & objectively
assesses compliance to:

design of the performance relevance success

program of project
 EVALUATION

Outcome Evaluation.
Evaluates the extent to which a project
accomplishes its intended results.
It measures program effects in the target
population by assessing the progress in the
outcomes or outcome objectives that the
program is to achieve
 EVALUATION

Impact Evaluation.
assesses in interval the program
effectiveness in achieving its ultimate goals
The essence of impact evaluation is for
comparison.
 EVALUATION
Impact Evaluation.
Comparisons are based on observations of
different groups at the same time or of the
same group at different points over time.

Done to measure & compare these

differences & conclude whether or not
observed differences may be attributes to
the project.
Thanks!
Prepared by: Aida V. Garcia, MAN, RN
For CHN2
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References:

Famorca, Z. et al., (2013). Nursing Care of the Community, a

comprehensive text on community and public health nursing in the
Philippines. Sauders

Journal of Advance Research, July 2020, www. ScienceDirect.

Maglaya, A ( 2009.) Nursing Practice In the Community. Argonauta Corporation

Principles of Epidemiology, www.cdc.gov

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