Patterns of Disease Incidence

▪ Endemic level: a disease that is always present in a certain population or region (Malaria).
➢ is constantly present in a group or geographic area.
➢ Under certain circumstances, an epidemic can lead to a disease becoming endemic
➢ often at a low level
▪ Sporadic level: refers to a disease that occurs infrequently and irregularly
➢ Examples of sporadic diseases include tetanus, rabies, and plague.
▪ Epidemic diseases: Diseases for which a larger than expected number of cases occurs in a
short time within a geographic region
➢ Influenza is a good example of a commonly epidemic disease

▪ An epidemic that occurs on a worldwide scale is called a pandemic disease. For example,
HIV/AIDS is a pandemic disease and novel influenza virus strains often become pandemic

▪ Outbreak carries the same definition of epidemic, but is often used for a more limited
geographic area.

▪ Cluster refers to an aggregation of cases grouped in place and time that are suspected to be
greater than the number expected, even though the expected number may not be known
 Component causes and causal pies
Rothman KJ. Causes. Am J Epidemiol 1976;104:587–92.
• Causal pies are pie charts with each
component cause as a slice. Slice A is in
each pie. Slice B is only in pies 1 and 2.
Slice C is only in pies 1 and 3.
• The individual factors are called
component causes
• The complete pie, which might be
considered a causal pathway, is called a
sufficient cause.
• A disease may have more than one
sufficient cause, with each sufficient cause
being composed of several component
causes that may or may not overlap.
• A component that appears in every pie
or pathway is called a necessary cause,
because without it, disease does not occur
Rothman’s Causal Pies
Suppose Component Cause B is smoking and Component
Cause C is asbestos. Sufficient Cause I includes both
smoking (B) and asbestos (C). Sufficient Cause II includes
smoking without asbestos, and Sufficient Cause III includes
asbestos without smoking. But because lung cancer can
develop in persons who have never been exposed to either
smoking or asbestos, a proper model for lung cancer would
have to show at least one more Sufficient Cause Pie that
does not include either component B or component C.
Disease prevention can be accomplished by blocking any
single component of a sufficient cause, at least through
that pathway. For example, elimination of smoking
(component B) would prevent lung cancer from sufficient
causes I and II, although some lung cancer would still occur
through sufficient cause III.
18
 Introduction to Health Surveillance

• Health surveillance is “the ongoing, systematic collection,

analysis, and interpretation of health-related data essential to
planning, implementation, and evaluation of public health
practice.” — Field Epidemiology.

19
20
 Public Health Headlines
Whooping Cough Kills Five in California;
State Declares an Epidemic

New CDC Report Shows Adult Obesity

Growing or Holding Steady in All States

Increase Seen in Deaths from

Pneumonia and Flu

Number of Rare E. Coli Cases

In U.S. Rose Last Year

Percentage of New Yorkers Lighting Up

is Down to 14%
21
 Number of Rare E. Coli Cases
In U.S. Rose Last Year

Neuman W. Number of Rare E. Coli Cases In U.S. Rose Last Year. The New York Times. June 7, 2011. http://www.nytimes.com.
Accessed July 8, 2014. 22
Public Health Surveillance
Types and Attributes

23
24
25
 Surveillance System Attributes
Attribute Question It Answers
How useful is the system in
Usefulness accomplishing its objectives?
How reliable are the available data?
How complete and accurate are data
Data quality
fields in the reports received by the
system?
Timeliness How quickly are reports received?
How quickly can the system adapt to
Flexibility changes?

Simplicity How easy is the system’s operation?

26
 Surveillance System Attributes
Attribute Question It Answers
Does the surveillance system work
Stability well?
Does it break down often?
How well does it capture the
Sensitivity intended cases?
Predictive value How many of the reported cases
positive meet the case definition?
How good is the system at
Representativeness representing the population under
surveillance?
Acceptability How easy is the system’s operation?
27
Public Health Surveillance
Process

28
 Surveillance Process

Data
Collection Before collecting data, decide
on the overarching goal
Data Analysis of the system
Data
Interpretation

Data
Dissemination

Link to Action

29
 Data Sources for Public Health Surveillance

• Reported diseases or syndromes

• Electronic health records (e.g., hospital discharge
data)
• Vital records (e.g., birth and death certificates)
• Registries (e.g., cancer, immunization)
• Surveys (e.g., National Health and Nutrition
Examination Survey [NHANES])

30
31
 Patients Hospitalized with West Nile
Virus Infection, by Week, New York, 1999

Week of illness onset

Nash D, Mostashari F, Fine A, et al. Outbreak of West Nile virus infection in the New York City area in 1999.
N Engl J Med. 2001;344:1807–14. 32
 Surveillance Data Analysis by Place
Laboratory-Confirmed WNV Human Cases — August–September 1999

North Queens
Serosurvey Area

Map Courtesy of the New York City Department of Health and Mental Hygiene
33
 Data Analysis by Person
Do you notice any patterns in the rates?
Demographics for Persons Hospitalized for WNV and Population Rates of Infection
Rate of Infection per
Characteristic No. of Patients (%) Population at Risk Million Population
Age (years)
0–19 2 (3) 2,324,081 0.9
20–29 1 (2) 1,553,981 0.6
30–39 3 (5) 1,549,111 1.9
40–49 1 (2) 1,177,190 0.8
50–59 9 (15) 867,331 10.4
60–69 12 (22) 814,838 16.0
70–79 18 (31) 534,785 33.7
≥80 12 (20) 281,054 42.7
Age category (years)
≥50 52 (88) 2,498,008 20.8
<50 7 (12) 6,604,363 1.1
Sex
Male 31 (53) 4,289,988 7.2
Female 28 (47) 4,812,383 5.8
Race
White 41 (69) 5,983,901 6.9
Nonwhite 9 (15) 3,118,470 2.9
Unknown 9 (15) -- --
Borough or county of residence
New York City
Brooklyn (Kings) 3 (5) 2,300,664 1.3
Bronx 9 (15) 1,203,789 7.5
Manhattan 1 (2) 1,487,536 0.7
Queens 32 (54) 1,951,599 16.4
Staten Island (Richmond) 0 379,999 0.0
New York State
Nassau 6 (10) 1,287,348 4.7
Westchester 8 (14) 847,866 9.1

Nash D, Mostashari F, Fine A, et al. Outbreak of West Nile virus infection in the New York City area in 1999. N Engl J Med. 34
2001;344:1807–14.
 Surveillance Data Interpretation

Data
Collection
Data interpretation
Data Analysis is closely coupled
with data analysis
Data
Interpretation
Data
Dissemination

Link to Action

35
 What Can Account for an
Apparent
Number Increase inCases
of Rare E. Coli Cases?
In U.S. Rose Last Year

Neuman, W. Rare E. Coli Cases Rose In the U.S. Last Year. New York Times June 7, 2011. http://www.nytimes.com. Accessed
July 9, 2014. 36
 Data Dissemination

Data • Health agency newsletters,

Collection bulletins, or alerts

Data Analysis
• Surveillance summaries and
Data reports
Interpretation
• Medical and epidemiologic
Data
Dissemination journal articles

Link to Action • Press releases and social

media
37
 Data Dissemination Target Audiences

• Public health practitioners

• Clinicians and other health care providers
• Policy and other decision makers
• Community organizations
• The general public

38
 Surveillance Link to Action

Data
Collection
Public health surveillance
Data Analysis should always have a
Data
link to action
Interpretation

Data
Dissemination

Link to Action

39
 Link to Action
Monitor trends and patterns in disease, risk factors, and agents

Pertussis (Whooping Cough) Cases, by Year — United States, 1922–2000

Source: Centers for Disease Control and Prevention (CDC). National Notifiable Diseases Surveillance System and Supplemental
Pertussis Surveillance System and 1922-1949, passive reports to the US Public Health Service. Atlanta, GA: US Department of
Health and Human Services, CDC. Available at: http://www.cdc.gov/pertussis/images/incidence-graph.jpg. 40
 Link to Action
Provide data for programs, policies, and priorities
% Reporting diabetes

1994–95 1996–97 1998–99 2000–01 2002 2003 2004

Year
Kim M, Berger D, Matte T. Diabetes in New York City: public health burden and disparities. New York: New York City Department of
Health and Mental Hygiene; 2006. http://www.nyc.gov/html/doh/downloads/pdf/epi/diabetes_chart_book.pdf. 41
 Link to Action
Evaluate prevention and control efforts

Water Boil-water
system order
No. of cases

flushed

Date of onset

Swerdlow DL, Woodruff BA, Brady RC, et al. A waterborne outbreak in Missouri of Escherichia coli O157:H7 associated with bloody
diarrhea and death. Ann Intern Med 1992;117:812–9. 42
 Link to Action
Evaluate prevention and control efforts (continued)

Boil-water Chlorine
Water order added
system
flushed
No. of cases

Date of onset

Swerdlow DL, Woodruff BA, Brady RC, et al. A waterborne outbreak in Missouri of Escherichia coli O157:H7 associated with bloody
diarrhea and death. Ann Intern Med 1992;117:812–9. 43
Principles of Communicable
Diseases Epidemiology
 Incidence and prevalence of infectious
diseases
• Incidence of an infectious disease: number of new cases in a
given time period expressed as percent infected per year
(cumulative incidence) or number per person time of
observation (incidence density).

• Prevalence of an infectious disease: number of cases at a

given time expressed as a percent at a given time. Prevalence
is a product of incidence x duration of disease, and is of little
interest if an infectious disease is of short duration (i.e.
measles), but may be of interest if an infectious disease is of
long duration (i.e. chronic hepatitis B).
 Epidemic
• “The unusual occurrence in a community of
disease, specific health related behavior, or
other health related events clearly in excess of
expected occurrence”
• (epi= upon; demos= people)
• Epidemics can occur upon endemic states too.
 Epidemic Patterns
• classified according to their manner of spread
through a population
1. common-source outbreak: if a group of
persons are all exposed to an infectious agent or
a toxin from the same source.
a. point-source outbreak: If the group is exposed
over a relatively brief period so everyone who
becomes ill does so within one incubation
period; leukemia cases in Hiroshima following
the atomic bomb blast
Hepatitis A Cases by Date of
Onset
b. continuous common-source outbreak case-
patients may have been exposed over a period
of days, weeks, or longer

Diarrhea Illness in
City Residents by
Date of Onset and
Character of Stool,
December 1989–
January 1990
 2. propagated outbreak: results from
transmission from one person to another.
Usually, transmission is by direct contact
(syphilis) or indirect transmission by vehicles
(hepatitis B or HIV by sharing needles) or
vectorborne (yellow fever by mosquitoes).
- cases occur over more than one incubation
period
Measles Cases by Date of Onset
3. mixed epidemics: have features of both
common-source epidemics and propagated
epidemics
shigellosis

transmission
• some epidemics are neither common-source
in its usual sense nor propagated from person
to person.
• Transmission from animal to human (zoonotic
transmission)
 Endemic
• It refers to the constant presence of a disease
or infectious agent within a given geographic
area or population group. It is the usual or
expected frequency of disease within a
population.
• (En = in; demos = people)
 Hyperendemic and holoendemic
• The term “hyperendemic” expresses that the disease
is constantly present at high incidence and/or
prevalence rate and affects all age groups equally.

• The term “holoendemic” expresses a high level of

infection beginning early in life and affecting most of
the child population, leading to a state of equilibrium
such that the adult population shows evidence of the
disease much less commonly than do the children
(e.g. malaria)
Pandemic and Exotic
• An epidemic usually affecting a large proportion of
the population, occuring over a wide geographic area
such as a section of a nation, the entire nation, a
continent or the world, e.g. Influenza pandemics.

• Exotic diseases are those which are imported into a

country in which they do not otherwise occur, as for
example, rabies in the UK.
 Sporadic
• The word sporadic means “scattered about”. The cases occur
irregularly, haphazardly from time to time, and generally
infrequently. The cases are few and separated widely in time and
place that they show no or little connection with each other, nor a
recognizable common source of infection e.g. polio,
meningococcal meningitis, tetanus….

• However, a sporadic disease could be the starting point of an

epidemic when the conditions are favorable for its spread.
 Attack rates and primary/secondary cases
• Attack rate: proportion of non-immune exposed
individuals who become clinically ill.

• Primary (index)/secondary cases: The person who

comes into and infects a population is the primary
case. Those who subsequently contract the infection
are secondary cases. Further spread is described as
"waves" or "generations".
 Reproductive rate of infection:
• Reproductive rate of infection: potential for an
infectious disease to spread. Influential factors
include the probability of transmission between an
infected and a susceptible individual; frequency of
population contact; duration of infection; virulence
of the organism and population immune proportion .
 Basic reproduction number (R0)
The basic reproduction number (R0) is used to measure the transmission potential
of a disease. It is the average number of secondary infections produced by a typical
case of an infection in a population where everyone is susceptible.1 For example, if
the R0 for measles in a population is 15, then we would expect each new case of
measles to produce 15 new secondary cases (assuming everyone around the case
was susceptible). R0 excludes new cases produced by the secondary cases.

The basic reproductive number is affected by several factors:

-The rate of contacts in the host population

-The probability of infection being transmitted during contact
-The duration of infectiousness.

In general, for an epidemic to occur in a susceptible population R0 must be >1, so

the number of cases is increasing.

In many circumstances not all contacts will be susceptible to infection. This is

measured by the effective reproductive rate (R)
 Effective reproductive number (R)
A population will rarely be totally susceptible to an infection in the real world.
Some contacts will be immune, for example due to prior infection which has
conferred life-long immunity, or as a result of previous immunisation. Therefore,
not all contacts will become infected and the average number of secondary cases
per infectious case will be lower than the basic reproduction number. The effective
reproductive number (R) is the average number of secondary cases per infectious
case in a population made up of both susceptible and non-susceptible hosts. If
R>1, the number of cases will increase, such as at the start of an epidemic. Where
R=1, the disease is endemic, and where R<1 there will be a decline in the number
of cases.

The effective reproduction number can be estimated by the product of the basic
reproductive number and the fraction of the host population that is susceptible (x).
So:
R = R0x

For example, if R0 for influenza is 12 in a population where half of the population is

immune, the effective reproductive number for influenza is 12 x 0.5 = 6. Under
these circumstances, a single case of influenza would produce an average of 6 new
secondary cases.

To successfully eliminate a disease from a population, R needs to be less than 1.

 Virulence and Case Fatality Rate
• Virulence: is the degree of pathogenicity; the disease evoking
power of a micro-organism in a given host. Numerically expressed
as the ratio of the number of cases of overt infection to the total
number infected, as determined by immunoassay. When death is
the only criterion of severity, this is the case fatality rate.

• Case fatality rate for infectious diseases: is the proportion of

infected individuals who die of the infection. This is a function of
the severity of the infection and is heavily influenced by how many
mild cases are not diagnosed.
 Serial interval and Infectious period
• Serial interval: (the gap in time between the onset of
the primary and the secondary cases) the interval
between receipt of infection and maximal infectivity
of the host (also called generation time).

• Infectious (communicable) period: length of time a

person can transmit disease (sheds the infectious
agent).
 Incubation and Latent periods
• Incubation period: time from exposure to development
of disease. In other words, the time interval between
invasion by an infectious agent and the appearance of
the first sign or symptom of the disease in question.

• Latent period: the period between exposure and the

onset of infectiousness (this may be shorter or longer
than the incubation period).
Transmission Probability Ratio (TPR)

TPR is a measure of risk transmission from

infected to susceptible individuals during a contact.

TPR of differing types of contacts, infectious

agents, infection routes and strains can be
calculated.

There are 4 types of transmission probabilities.

 TPR (cont.)
Transmission probabilities:
• p00: tp from unvaccinated infective to unvaccinated
susceptible
• p01: tp from vaccinated infective to unvaccinated
susceptible
• p10: tp from unvaccinated infective to vaccinated
susceptible
• p11: tp from vaccinated infective to vaccinated
susceptible
 TPR (cont.)
• To estimate the effect of a vaccine in reducing
susceptibility, compare the ratio of p10 to p00.
• To estimate the effect of a vaccine in reducing
infectiousness, compare the ratio of p01 to p00.
• To estimate the combined effect of a vaccine,
compare the ratio of p11 to p00.
 Key facts
• Non-communicable diseases (NCDs) kill 41 million people each year,
equivalent to 71% of all deaths globally.
• Each year, more than 15 million people die from a NCD between the ages
of 30 and 69 years; 85% of these "premature" deaths occur in low- and
middle-income countries.
• 77% of all NCD deaths are in low- and middle-income countries.
• Cardiovascular diseases account for most NCD deaths, or 17.9 million
people annually, followed by cancers (9.3 million), respiratory diseases
(4.1 million), and diabetes (1.5 million).
• These four groups of diseases account for over 80% of all premature NCD
deaths.
• Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy
diets all increase the risk of dying from a NCD.
• Detection, screening and treatment of NCDs, as well as palliative care, are
key components of the response to NCDs.
 Definition of NCDs

▪ Non-communicable diseases (NCDs), also known as chronic

diseases, tend to be of long duration and are the result of a
combination of genetic, physiological, environmental and
behavioural factors.

▪ The main types of NCD are cardiovascular diseases (such as

heart attacks and stroke), cancers, chronic respiratory
diseases (such as chronic obstructive pulmonary disease and
asthma) and diabetes.
 Non-Modifiable risk factors
• These risk factors are inherent to an individual and cannot be changed, such as
age, sex and family history.
1. Age-With increasing age, our body undergoes changes. As we grow older,
there is an increase in the risk of developing hypertension (high blood pressure),
high blood sugar levels, high levels of body and blood fats. These conditions can
lead to Non-Communicable Diseases like- heart and blood vessel diseases (stroke),
diabetes, cancer, respiratory problems, etc.
2. Sex- Both women and men are at risk of developing Non-Communicable
Diseases. Men are at a higher risk of developing Non-Communicable Diseases.
However, women who have reached menopause are more likely to suffer from
heart attacks than pre-menopausal women. Some risk factors for developing Non-
Communicable
• Diseases such as high blood pressure or high blood glucose can affect women
even during pregnancy.
3. Family history- If a person has a family history of NCDs (if a close family
member parents, siblings also have the disease) she/he has a high chance of getting
the disease.
 Modifiable risk factors
• These are risk factors that can be changed by specifi c action. The
harmful effect can be reduced with changes in lifestyle and
treatment.

• These risk factors include-

1. Unhealthy diets (high fat, sugar and salt content; and low fruit and
vegetable and fibre intake)

2. Physical inactivity

3. Tobacco use

4. Harmful use of Alcohol

 Intermediate risk factors
(metabolic or physiological)
• The non-modifiable and modifiable risk factors (lifestyle related)
result in ‘intermediate risk factors’ or ‘biological’ risk factors.
These are:

1. Hypertension (high blood pressure), Impaired blood glucose

levels, high levels of harmful blood fats – Hyperlipidemia

2. Overweight/Obesity (excess amount of body fat)

• Over the past few years, we are noticing an increase in deaths and illnesses due
to Non-Communicable Diseases. Some of the reasons are:
1. People shifting from rural areas to urban areas and making changes in
lifestyles related to diet, exercise and other behaviours.
2. Increase life expectancy of people and thus more people living at an
increasing age.
3. Decrease in physical activity due to availability of motor vehicles for
transport.
4. Lack of adequate, safe spaces for regular exercise.
5. Availability and use of tobacco and alcohol for all age groups.
6. Increased use of foods high in fats, salt, sugar and sugar sweetened
beverages.
7. Low consumption of fruits and vegetables because of high costs/lower
availability.
8. Increased consumption of refined and packaged foods.
9. Growing environmental pollution (air, food, water).
Public Health & Epidemiology

Section two: Epidemiology and

Epidemiological studies

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