I.

The Epidemiological Approach to Disease and Intervention

A. Introduction
i. What is Epidemiology? (Celantano & Szklo, 2009)
a. the field of inquiry concerned with the distribution of illnesses within populations
and the many variables that contribute to or shape this distribution
b. proposes that the distribution of illnesses is not a result of random occurrences
c. person has distinct qualities that may either make them more susceptible to or
provide protection against illnesses (environmental, behavioral, or societal).
d. “the study of the distribution and determinants of health-related states or events in
specified populations and the application of this study to control of health
problems” - Porta (2008)
ii. Historical Development (LibreTexts Biology, 2022)
a. Hippocrates: The one who first investigated the correlations between the
prevalence of illnesses and environmental factors.
b. Joaquín de Villalba: The word "epidemiology" is believed to have originated in
1802, when it was first used to denote the scientific study of epidemics.
c. Dr. John Snow - Renowned for his extensive inquiries into the etiology of the
cholera outbreaks that occurred throughout the 19th century, this individual has
also earned the distinction of being recognized as the progenitor of contemporary
epidemiology.
ii. Objectives of Epidemiology (Celantano & Szklo, 2009)
a. ascertain the etiology, or underlying cause, of a disease together with its pertinent
risk factors
b. determine the prevalence of illness within a certain population
c. investigate the natural history and prognosis of a particular illness
d. to assess the efficacy of both established and emerging preventative and therapeutic
interventions, as well as various models of healthcare provision
e. epidemiology serves as a fundamental basis for the formulation of public policy
pertaining to environmental concerns, genetic factors, and many social and
behavioral aspects relevant to the prevention of diseases and the promotion of
health.
iii. Epidemiology and Prevention (Celantano & Szklo, 2009)
a. Primary prevention refers to the proactive measures used to impede the
progression of a disease in an individual who is in good health and currently does
not exhibit symptoms of the specific illness in question.
b. Secondary prevention entails the identification of individuals who have started a
disease progression, although have not yet shown any clinical manifestations or
symptoms of the ailment
c. Tertiary prevention refers to the act of mitigating difficulties in individuals who
have previously shown manifestations and indications of an ailment and have
received a formal diagnosis
d. Population-based approach population-wide preventative intervention is
extensively implemented
e. High-risk approach is a preventative approach that specifically focuses on those at
high risk
iv. Epidemiologic Approach (Celantano & Szklo, 2009)
 a. the first stage involves establishing the existence of a potential relationship
between the exposure to a certain factor or feature of an individual and the
occurrence of the relevant illness
b. the subsequent stage involves attempting to deduce suitable conclusions about a
potential causal connection based on the observed patterns of connections that
have been previously established.
vi. Challenges and Ethical consideration (Cooke et al., 2022).
a. Insufficient informed consent
b. The distribution of resources in an inequitable manner.
c. Competing interests

B. The Dynamics of Disease Transmission

i. Modes of Transmission (Celantano & Szklo, 2009)
a. Direct
(1) Person-to-person contact
b. Indirect
(1) Common vehicle
(a) Single exposure
(b) Multiple exposure
(c) Continuous exposure
(2) Vector
ii. Clinical and Subclinical Disease (Boldogh & Porter, 1996; Celantano & Szklo, 2009;
Schermer, 2023)
a. Clinical Disease
(1) Clinical disease is distinguished by observable markers and experienced
symptoms.
b. Nonclinical (inapparent) disease)
(1) Preclinical disease: A condition that is now asymptomatic but is expected
to progress into a clinically evident illness.
(2) Subclinical disease: An asymptomatic disease refers to a medical
condition that does not exhibit any clinical manifestations and is not expected
to develop clinical symptoms in the future. The diagnosis of this particular
illness is often established by the examination of serologic (antibody) reaction
or the cultivation of the causative organism.
(3) Persistent (chronic) disease: An individual is unable to effectively
eliminate the infection, resulting in its prolonged presence for many years, and
in some cases, for the duration of their lifetime.
(4) Latent disease: An infection characterized by the absence of active
replication of the pathogen, such as when viral genetic material becomes
integrated into the nucleus of a cell in the form of a provirus.
iii. Carrier status (Brachman, 1996)
a. Carrier:An individual who serves as a host for the organism but does not exhibit
signs of infection, as determined by serologic testing indicating the absence of an
antibody response or the absence of clinical symptoms.
b. Mary Mallon: one of the best-known examples of a long-term carrier
iv. Endemic, Epidemic, and Pandemic (Columbia University Irving Medical School,
2023)
 a. Endemic is characterized by the consistent occurrence of a certain illness within a
specific geographical region.
b. Epidemic is described as the manifestation of a cluster of diseases within a certain
population or geographical area, beyond the anticipated frequency and originating
from a shared source or mode of transmission.
c. Pandemic is the term "refers to a global pandemic."
iv. Disease Outbreaks (Celantano & Szklo, 2009; LaMorte, 2016)
a. Common vehicle exposure: a situation where multiple individuals are exposed to a
shared source of infection or risk, typically through a common vehicle such as
contaminated food or water, leading to a potential outbreak or spread of disease.
b. Single exposure: an individual's exposure to a specific source or agent
v. Characteristics of Outbreak (Celantano & Szklo, 2009)
a. abrupt and substantial surge in the prevalence of a certain illness or condition
within a given community
b. scope of the instances is restricted to those who have a shared exposure.
vii. Immunity and Susceptibility (Kurowski et al., 2022)
a. Immunity: is a person who is not exposed to infection by a disease
b. Susceptibility: is a person who is vulnerable to being polluted by a certain disease
c. Interplay: The prevalence of disease within a community is contingent upon the
equilibrium between the susceptible individuals, who are vulnerable to the disease
and hence at risk, and the non-susceptible or immune individuals, who are not at
danger.
viii. Herd Immunity (Celantano & Szklo, 2009; Desai & Majumder, 2020)
a. Herd immunity: refers to the collective resistance shown by a population against
the invasion of a disease, when a significant part of individuals within the
population possess immunity to the pathogen.
b. Why does herd immunity occur?
(1) Once a certain threshold of immunized individuals within a given
population is reached, the probability diminishes significantly for an
infected individual to come into contact with a susceptible individual,
hence reducing the possibility of transmission of the virus.
(2) The existence of a substantial number of individuals with immunity among
the community reduces the probability of an individual with the condition
encountering someone who is at risk.
c. Why is it important?
(1) provide a very effective means of safeguarding a significant proportion of
the population.
d. What are the condition needed to achieve herd immunity?
(1) the disease-causing agent should be confined to a solitary host species,
wherein transmission takes place, and this transmission should be relatively
direct from one individual of the host species to another.
(2) it is necessary for infections to elicit robust immune responses leading to
the establishment of durable immunity.
ix. Incubation Period (Cheng et al., 2021; Rashmit, 2020)
a. Incubation period: is operationally defined as the duration between the
acquisition of an infection and the manifestation of clinical disease, marked by
the emergence of identifiable symptoms.
 (1) consider the temporal requirements for the organism to undergo replication
to a significant extent, ultimately leading to the attainment of a critical mass
necessary for the manifestation of clinical illness.
b. Quarantine: refers to a designated time of seclusion or confinement enforced
upon those who may have encountered a communicable illness, with the aim of
impeding its transmission.

C. The Occurrence of Disease: I. Disease Surveillance and Measures of Morbidity

i. Surveillance Definitions (Wolitski et al., 2004)
a. Epidemiologic surveillance: defined as a comprehensive and continuous process
that involves the systematic gathering, analysis, and interpretation of
health-related information. This data is crucial for informing the development,
execution, and assessment of public health initiatives. Additionally, it is
necessary to promptly share this information with relevant stakeholders.
b. may be conducted to observe changes in illness prevalence or to track
fluctuations in the magnitude of hazards associated with certain diseases.
c. Surveillance plays a crucial role in informing policymakers about the most
effective ways for designing and executing disease prevention and control
programs.
ii. Passive and Active Surveillance (Celantano & Szklo, 2009)
a. Passive surveillance refers to a form of surveillance where existing data on
diseases that are required to be reported are utilized, or where the government or
local health authority mandates or requests the reporting of diseases. In this
context, the responsibility for reporting is typically placed on healthcare
providers or district health officers.
b. Active surveillance refers to a structured framework whereby project personnel
are purposefully enlisted to execute a program of surveillance. The individuals
are enlisted to conduct regular field visits to healthcare establishments, including
clinics, primary healthcare centers, and hospitals, with the purpose of detecting
and documenting new instances of a certain ailment.
iii. Stages of Disease in an Individual and in a Population (Celantano & Szklo, 2009)
a. The measurement of disease occurrence may be accomplished via the use of rates
or proportions.
(1) rates provide information on the speed at which the illness is manifesting
within a certain population.
(2) Proportions provide insight into the percentage of the population that is
impacted.
iv. Measure of Morbidity (Celantano & Szklo, 2009; Forthofer et al., 2007)
a. Incidence Rate: The incidence rate of a disease is a quantitative measure that
represents the number of newly diagnosed cases during a certain timeframe,
specifically among a population that is susceptible to acquiring the illness.
 (1)A crucial aspect in the determination of the incidence rate is to the
identification of newly occurring instances of a particular illness.
(2) The incidence rate is a metric used to quantify the level of risk.
(3) The denominator of an incidence rate signifies the population size of
individuals who are susceptible to the onset of the disease.
(4) Incidence measures may be calculated using two distinct denominators:
individuals at risk who are under observation for a certain duration, or, in
cases when complete observation of all individuals for the whole time
period is not feasible, person-time.
b. Attack rate
(1) attack rate: refers to the ratio of individuals who developed illness after
being exposed to a potentially contaminated food, divided by the total
number of individuals who were exposed to this food.
(2) the time period is not clearly indicated, but it is often observed that the
majority of cases in food-borne illness outbreaks manifest within a certain
timeframe after exposure, typically ranging from a few hours to a few days.
(3) more accurately described as a percentage rather than a rate.
c. Prevalence
(1) Prevalence: refers to the ratio of the number of individuals afflicted by a
certain condition within a given population at a specific point in time,
divided by the total number of individuals in that population at that same
moment.

(2) may be seen as a momentary representation or cross-section of the

population, whereby we ascertain the presence or absence of a certain
illness among individuals at a specific point in time.
(a) Point prevalence: refers to the frequency of a disease at a certain
moment in time,
(b) Period prevalence: What is the cumulative number of individuals
who have been afflicted with the disease at any given moment
throughout a certain temporal interval?
v. Problems with incidence and prevalence measurements (Celantano & Szklo, 2009; Spronk
et al., 2019)
a. Problems With Numerators
(1) The first issue is in establishing a clear definition of the individuals
affected by the condition.
(2) Determining the individuals to be included in the numerator
b. Problems With Denominators
(1) It is possible for there to be a deliberate and purposeful
underrepresentation of certain demographic groupings within the
population.
 (2) for a rate to possess logical coherence, it is essential that each individual
included within the group denoted by the denominator have the inherent
capacity to gain entry into the group denoted by the numerator.
c. Problem with Hospital Data
(1) hospital admissions are selective
(2) hospital records are primarily intended for patient care rather than research
purposes.
(3) One issue arises when attempting to establish denominators due to the lack
of clearly defined catchment areas in most hospitals. Catchment areas refer
to certain regions where all individuals requiring hospitalization inside
those areas are admitted to a designated hospital, but those from outside the
catchment area are not admitted to that particular hospital.

D. The Occurrence of Disease: II. Mortality and Other Measures of Disease Impact
i. Measure of Mortality (Celantano & Szklo, 2009)
a. Mortality rates may be computed for varying time intervals, such as one year,
five years, or beyond. The chosen time interval is subjectively determined,
however it necessitates a precise specification.

b. Case-fatality
(1) Mortality rates may be calculated for many time periods, including one
year, five years, or longer durations. The selected time period is set
subjectively, although it requires a precise definition.

c. Proportionate Mortality
(1) What is the percentage of mortality attributed to [illness] among the total
number of deaths in [place]?

ii. Importance of Mortality (Choi et al., 2019)

a. Mortality serves as a reliable indicator of illness severity, as seen from both
clinical and public health perspectives. Additionally, mortality may be used as a
measure of disease susceptibility.
b. Obtaining mortality data is comparatively more convenient than acquiring
incidence data for a specific illness, therefore making the use of mortality data as
a surrogate indicator for incidence more practical.
 c. The ease of obtaining death data in comparison to gathering incidence data for a
particular disease makes the use of mortality data as a surrogate indicator for
incidence more feasible.
iii. Problems with Mortality Data (Celantano & Szklo, 2009)
a. Fatalities are classified based on the fundamental factor responsible for their
occurrence.
b. Modifications in the conceptualization of disease may have a substantial
influence on the quantity of disease cases that are documented or later
categorized as fulfilling the diagnostic criteria.
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