EPIDEMIOLOGY

 OVERVIEW:
 Studies the following:
 Occurrences & distribution of diseases (in terms of age, gender, race,
geography)
 Distribution & determinants of health states or events in specified population
(involves explanation of the patterns of disease distribution in terms of causal
factors)
 The outcome of the study is then applied to control health problems
 It is the backbone of the prevention of disease because epidemiology seeks to
know the conditions surrounding its occurrence & the factors favoring the
development of the disease
 Republic Act 3573, the Law on Reporting of Communicable Diseases, enacted in
1929, mandated the reporting of diseases listed in the law to the nearest health
station.

 USES OF EPIDEMIOLOGY:
 Study the history of the health population & the rise & fall of diseases & changes in
their character
 Diagnose the health of the community & the condition of people to measure the
distribution & dimension of illness in terms of incidence, prevalence, disability &
mortality, to set health problems in perspective & to define their relative importance
& to identify groups needing special attention
 Study the work of health services with a view of improving them
 Estimate the risk of disease, accident, defects & the chances of avoiding them
 Identify syndromes by describing the distribution & association of clinical
phenomena in the population
 Complete the clinical picture of chronic disease & describe their natural history
 Search for cause of health & disease by comparing the experience of groups that are
clearly defined by their composition, inheritance, experience, behavior &
environment

 EPIDEMIOLOGIC TRIANGLE:

 AGENT
 The intrinsic property of microorganism to survive & multiply in the
environment to produce a disease
 Causative agent is the infectious agent or toxic component that is transmitted
from the source of infection to the susceptible body
 Could also be the following:
 Nutritive Elements (↑ cholesterol; ↓ vitamins & proteins)
 Chemical Agents (poisons such as carbon monoxide, drugs or allergens
such as poison ivy)
 Physical Agents (heat, light, radiation)

 HOST
 Intrinsic factors that influence exposure, susceptibility or response to agents
 Host factors include genetic, age, sex, ethnic group, physiologic, immunologic,
pre-existing disease, human behavior

 ENVIRONMENT
 Extrinsic factors the influence the existence of the agent, exposure, or
susceptibility to agent
 Includes the following:
 Physical (geology, climate)
 Biologic (human population density, flora such as food, influence on
vertebrates & anthropod as source of agent)
 Socio-Economic (occupation such as exposure to chemicals; urbanization
such as crowding, tension & pressures; disruption such as wars, disasters
 VARIABLES OF EPIDEMIOLOGIC DATA:

 TIME – refers both to the period during which the cases of the diseases being
studied were exposed to the source of infection & the period during which the
illness occurred

 PERSONS – refers to the characteristic of individuals who were exposed & who
contacted the infection or the disease in question

 PLACE – refers to the features, factor or conditions which existed in or described

the environment in which the disease occurred; it is the geographic area described
in terms of street, address, city, municipality, province, region or country.

 DEMOGRAPHY - study of population size, composition and spatial distribution as

affected by births, deaths and migration.
 Sources : Census – complete enumeration of the population
 2 Ways of Assigning People:
1. De Jure - People were assigned to the place they usually live regardless of
where they are at the time of census.
2.De Facto - People were assigned to the place where they are physically
present at are at the time of census regardless, of their usual place
of residence.
 Components:
1. Population size
2. Population composition
* Age Distribution
* Sex Ratio
* Population Pyramid
* Median age - age below which 50% of the population fall and above
which 50% of the population fall. The lower the median
age, the younger the population (high fertility, high death rates).
* Age – Dependency Ratio - used as an index of age-induced economic drain on
human resources
* Other characteristics:
- occupational groups
- economic groups
- educational attainment
- ethnic group
3. Population Distribution
* Urban-Rural - shows the proportion of people living in urban compared to the
rural areas
* Crowding Index - indicates the ease by which a communicable disease can be
transmitted from 1 host to another susceptible host.
* Population Density - determines congestion of the place

 PATTERNS OF OCCURRENCE & DISTRIBUTION

 SPORADIC
 The intermittent occurrence of a few isolated & unrelated cases in a given
locality
 The cases are few & scattered so that there is no apparent relationship between
them
 Occurs on & off through a period of time

 ENDEMIC
 Continuous occurrence throughout a period of time, of the usual number of
cases in a given locality
 The disease is always occurring in the locality & the level of occurrence is more
or less constant throughout a period of time.
 The disease is more or less inherent in the locality & it is in a way identifiable
with the locality itself
  Examples: Schistosomiasis (Leyte, Samar); Filariasis (Sorsogon)
 EPIDEMIC
 Occurrence is of unusually large number of cases in a relatively short period of
time
 There is a disproportionate relationship between the number of cases & the
period of occurrence, the more acute is the disproportion, the more urgent &
serious is the problem
 The number of cases is not in itself necessarily big or large, but such number of
cases when compared with the usual number of cases may constitute epidemic
in a given locality
 For example, there has been no case of bird’s flu in any area of the country, so
that the occurrence of few cases in a given area in a given time would constitute
a bird’s flu epidemic

 PANDEMIC
 The simultaneous occurrence of epidemic of the same disease in several
countries.
 It is another pattern of occurrence from an international perspective

 OUTLINE FOR EPIDEMIOLOGIC INVESTIGATION

 ESTABLISH FACT OF PRESENCE OF EPIDEMIC

 Verify diagnosis (clinical & lab studies)
 Reporting (prompt & complete)
 Unusual prevalence of the disease

 ESTABLISH TIME & SPACE RELATIONSHIP OF THE DISEASE

 Are the cases limited to or concentrated in any particular geographical
subdivision of the affected community?
 Relation of cases by days of onset to onset of first known cases

 RELATIONS TO CHARACTERISTIC OF THE GROUP OF COMMUNITY

 Relation of cases to age, group, sex, color, occupation, school attendance, past
immunization
 Relation to sanitary facilities, especially water supply, sewerage disposal,
general sanitation of homes
 Relation to animal or insect vectors
 Relation to milk & food supply

 CORRELATION OF ALL DATA OBTAINED

 Summarize the data clearly with the aid of such tables & charts which are
necessary to give a clear picture of the situation
 Build up the case for the final conclusion carefully utilizing all the evidence
available
 Establish the source of the epidemic & the manner of the spread, if possible
 Make suggestion as to the control, if disease is still present in community & as
to prevention of future outbreaks

 PUBLIC HEALTH SURVEILLANCE

 An ongoing systematic collection, analysis, interpretation & dissemination of health
data
 Surveillance system is often considered information loops or cycles which involves
the health care providers, public health agencies & the public
 Role of the Nurse in Surveillance – Researcher
 Objectives of Surveillance – measure the magnitude of the problem & measure the
effect of the control program
 The data collection gathered in the surveillance can be used to improve strategies &
prevent disease from occurring

 NATIONAL EPIDEMIC SENTINEL SURVEILLANCE SYSTEM (NESSS)

  A hospital-based information system that monitors the occurrence of infectious
diseases with outbreak potential
 It also serves as a supplemental information system of the Department of Health

 OBJECTIVE OF NESSS:
 To provide early warning on occurrence of outbreaks
 To provide program managers, policy makers & public administrators rapid,
accurate & timely information so that inventive & control measures can be
instituted

 NESSS DATA:
 Trends of cases across time
 Demographic characteristic of cases
 Estimates of case fatality ratio
 Clustering of cases in a geographical area
 Information to formulate hypotheses for disease causation

 DISEASES UNDER SURVEILLANCE BY NESSS:

 Laboratory Diagnosed
 Cholera
 Hepatitis A & B
 Malaria
 Typhoid Fever
 Clinically Diagnosed
 Dengue Hemorrhagic Fever
 Diptheria
 Measles
 Meningococcal Disease
 Neonatal Tetanus
 Pertussis
 Rabies
 Leptospirosis
 Poliomyelitis
 Under Surveillance System:
 Poliomyelitis
 Measles
 Maternal & neonatal tetanus
 Paralytic shellfish poisoning
 Fireworks & related injury
 HIV/AIDS

 OUTBREAK INVESTIGATION

 IMPORTANCE:
 Control & prevention measures
 Severity & risk to others
 Research opportunities
 Public, political or legal concerns
 Program consideration
 Training

 SOURCES:
 Surveillance data
 Medical Practitioner
 Affected persons/group
 Concerned citizen
 Media
 STEPS: bq

1. PREPARE FOR FIELD WORK

 Supplies/equipment
 Administrative procedures like travel documents, allowance
 Consultation – know expected role; local contact person

2. ESTABLISH EXISTENCE OF AN OUTBREAK

 Compare the current number of cases with the number of cases from
comparable period during the previous years
 Use data from surveillance records, hospital records, registries, mortality
statistics, data from neighboring areas, community survey

3. VERIFY DIAGNOSIS
 Ensure proper diagnosis of reported cases
 Review clinical findings, laboratory results, summarize clinical findings
with frequency distribution, visit patients

4. DEFINE & IDENTIFY CASES

 Establish a case definition
 Standards set of criteria for the health condition (clinical criteria such as
the signs & symptoms; restrictions by time, place, person)
 Note: exposure or risk factor is not included in the case definition
 Identify & count cases
 Identifying information – name, address, contact number
 Demographic information – age, sex, race, occupation
 Clinical information – onset, hospitalization, death
 Risk factor information – food or water sources, toilet facility
 Reporter information

5. PERFORM DESCRIPTIVE EPIDEMIOLOGY

 Describe & orient the data in terms of time, place & person

6. DEVELOPING HYPOTHESES
 Consider source of agent, mode of transmission, vectors of transmission,
risk factors
 Hypotheses should be testable

7. EVALUATE HYPOTHESES
 Done by comparing with established facts & use of analytical epidemiology
(case control studies & retrospective control studies)

8. REFINE HYPOTHESES & EXECUTE ADDITIONAL STUDIES

9. IMPLEMENT CONTROL & PREVENTION MEASURES

 Done to prevent additional cases & prevent outbreaks in the future

10. COMMUNICATE FINDINGS

 Through:
 Writing & disseminating full report
 Meetings & discussions
 Local & mass media
 To the:
 Local government officials
 Local health workers
 Concerned authorities
 Regional health authorities
 Department of Health
 11. FOLLOW-UP RECOMMENDATIONS
 What activities have been undertaken?
 If health status has improved
 If health problem has been reduced

 FUNCTIONS OF THE EPIDEMIOLOGY NURSE

 General:
 Implement public health surveillance
 Monitor local health personnel conducting disease surveillance
 Conduct &/or assist other health personnel in outbreak investigation
 Assist in the conduct of rapid surveys & surveillance during disasters
 Assist in the conduct of surveys, program evaluations & other epidemiologic
studies
 Specific Roles during Epidemiological Investigation:
 Maintains surveillance of the occurrence of notifiable disease
 Coordinates with other members of the health team during the disease outbreak
 Participates in case findings & collection of laboratory specimens
 Isolates cases of communicable diseases
 Renders nursing care, teaches & supervises giving of care
 Performs & teach household members method, concurrent & terminal
disinfection
 Gives health teachings to prevent further spreads of disease to individual &
families
 Follow up cases & contacts
 Organizes, coordinates & conducts community health education
campaign/meetings
 Refers cases when necessary
 Coordinates with other concerned community agencies
 Accomplishes & keeps records & reports & submits to proper office/agency

VITAL STATISTICS

 OVERVIEW
 Statistics – refers to a systematic approach of obtaining, organizing, &
analyzing numerical facts so that the conclusion may be drawn from them
 Vital Statistics – refers to the systematic study of vital events such as births,
illnesses, marriages, divorce, separation & deaths
 Statistics of morbidity (disease) and mortality (death) indicate the state of
health of a community & the success rate or failure of health work
 Statistics on population & its characteristics are obtained from the National
Statistics Office (NSO)
 Births & Deaths are registered in the Office of the Local Civil Registrar of the
municipality or city

 USE OF VITAL STATISTICS

 Provide indices of the health & illness status of a community
 Serve as basis for planning, implementing, monitoring, & evaluating
community health nursing programs & services

 SOURCES OF DATA
 Population census
 Registration of vital data
 Health survey
 Studies & researches

 RATES & RATIOS

 RATE
  Shows the relationship between a vital event & those persons exposed to the
occurrence of said event, within a given area & during a specified unit of
time
 It is evident that the person experiencing the event (Numerator) must come
from the total population exposed to the risk of same event (Denominator)

 RATIO
 Is used to describe the relationship between two (2) numerical quantities or
measures of events without taking particular considerations to the time or
place
 These quantities need not necessarily represent the same entities although
the unit of measure must be the same for both numerator & denominator of
the ratio

 CRUDE OR GENERAL RATES

 Referred to the total living population
 It must be presumed that the total population was exposed to the risk of the
occurrence of the event

 SPECIFIC RATE
 The relationship is for a specific population class or group
 It limits the occurrence of the events to the portion of the population
definitely exposed to it

 FORMULA:

 CRUDE BIRTH RATE

 A measure of one characteristic of the natural growth or increase of a
population
 CBR = Total number of live births registered in a
given calendar year
-------------------------------------------------------- X 1000
Estimated population as of July 1 of same year
 CRUDE DEATH RATE
 A measure of one mortality from all causes which may result in a decrease
in population
 CDR = Total number of deaths registered in a
given calendar year
-------------------------------------------------------- X 1000
Estimated population as of July 1 of same year

 INFANT MORTALITY RATE

 Measures the risk of dying during the 1st year of life
 It is a good index of the general health condition of a community since it
reflects the changes in the environment & medical condition of a community
 IMR = Total No. of deaths under 1yr of age registered in a
given calendar year
------------------------------------------------------------------ X 1000
Total No. of registered live births of same calendar year

 MATERNAL MORTALITY RATE

 Measures the risk of dying from causes related to pregnancy, childbirth &
puerperium
 It is an index of the obstetrical care needed & received by women in the
community
 MMR = Total No. of deaths from maternal causes registered
in a given year
-------------------------------------------------------------- X 1000
Total No. of live births registered of same year
 FETAL DEATH RATE
 Measures pregnancy wastage
 Death of the product of conception occurs prior to the complete expulsion,
irrespective of the duration of the pregnancy
 FDR = Total No. of Fetal Deaths registered in a given
calendar year
---------------------------------------------------------------- X 1000
Total No. of live births registered on same year

 NEONATAL DEATH RATE

 Measures the risk of dying during the 1st month of life
 It serves as an index of the effects of prenatal care & obstetrical
management of the newborn
 NDR = Total No. of deaths under 28 days of age registered
in a given calendar year
---------------------------------------------------------------- X 1000
Total No. of Live Births registered of same year

 SPECIFIC DEATH RATE

 Describes more accurately the risk of exposure of certain classes or groups
to particular diseases
 To understand the forces of mortality, the rates should be made specific
provided the data are available for both the population & the event in their
specifications
 Specific rates render more comparable & thus reveal the problem of public
health
 SDR = Deaths in specific class/group registered in a given year
------------------------------------------------------------------- X 100,000
Estimated population as of July 1 in same specified
class/group of said year

 CAUSE SPECIFIC DEATH RATE

 CSDR = No. of Deaths from specific cause registered
in a given year
---------------------------------------------------------- X 100,000
Estimated population as of July 1st of same year

 AGE SPECIFIC DEATH RATE

 ASDR = No. of deaths in a particular age group
registered in a given calendar year
------------------------------------------------- X 100,000
Estimated population as of July 1 in same
age group of same year

 SEX SPECIFIC DEATH RATE

 SSDR = No. of deaths of a certain sex registered
in a given calendar year
------------------------------------------------ X 100,000
Estimated population as of July 1
in same sex for same year

 INCIDENCE RATE – number of new cases only

 Measures the frequency of occurrence of the phenomenon during a given
period of time
 IR = No. of new cases of a particular disease registered
during a specified period of time
------------------------------------------------------------ X 100,000
 Population at risk

 PREVALENCE RATE – number of both new and old cases

 Measures the proportion of the population which exhibits a particular
disease at a particular time
 This can only be determined following a survey of the population concerned
 Deals with total (old & new) number of cases
 PR = No. of old & new cases of a certain disease
registered at a given time
--------------------------------------------------- X 100
Total No. of persons examined at same
given time

 ATTACK RATE
 A more accurate measure of the risk of exposure
 AR = No. of persons acquiring a disease registered
in a given year
----------------------------------------------------------- X 100
No. of exposed to same disease in the same year

 CASE FATALITY RATIO

 Index of a killing power of a disease
 CFR = No. of registered deaths from a specific disease
for a given year
--------------------------------------------------------- X 100
No. of registered cases from same specific
disease in same year

▲ SEX RATIO is the number of males for every 100 females in the population.

▲ SWAROOP’S INDEX is the proportion of deaths aged 50 & above. The higher the
Swaroop’s index of a population, the greater the proportion of the deaths who were
able to reach the age of at least 50 years., ie more people grew old before they died.

▲ GENERAL OR TOTAL FERTILITY RATE: divide the number of registered live

births by the number of females of reproductive age (15-45yo) then multiply by
1000.

▲ SALIENTS POINTS IN VITAL STATISTICS:

 X 100 = “PAC” (Prevalence Rate, Attack Rate, Case Fatality Ratio)
 X 1000 = Crude Birth & Death Rates; All Mortality Rates; General Fertility Rate
 X 100,000 = All Specific Death Rates; Incidence Rate
 Denominator = Estimated Population as of July 1 of same year
 Crude Birth & Death Rates; All Specific Death Rates
 Denominator = Total Number of Live Births Registered at same year
 All Mortality Rates

 PRESENTATION OF DATA:

 LINE OR CURVED GRAPHS

 Shows peaks, valleys & seasonal trends
 Also used to show the trends of birth & death rates over a period of time

 BAR GRAPHS
 Each bar represents or expresses a quantity in terms of rates or percentages
of a particular observation like causes of illness & deaths

 PIE CHARTS
 Aka “Area Diagram”
  Shows the relative importance of parts to the whole

 FUNCTIONS OF THE NURSE VITAL STATISTICS

 Collects data
 Tabulates data
 Analyzes & interprets data
 Evaluates data
 Recommends redirection &/or strengthening of specific areas of health
programs as needed