COURSE:PUH 112 INTRODUCTION TO PUBLIC HEALTH

Topic: Epidemiology

The historical context

Origins
Epidemiology originates from Hippocrates’ observation more than 2000 years ago that
environmental factors influence the occurrence of disease. However, it was not until the
nineteenth century that the distribution of disease in specific human population groups was
measured to any large extent. This work marked not only the formal beginnings of
epidemiology but also some of its most spectacular achievements.
Early epidemiological observation;
The finding by John Snow located the home of each person who died from cholera in London
pduring 1848–49 and 1853–54, and noted an apparent association between the source of
drinking water and the deaths. He compared cholera deaths in districts with different water
supplies and showed that both the number of deaths and the rate of deaths were higher
among people supplied water by the Southwark company. On the basis of his meticulous
research, Snow constructed a theory about the communication of infectious diseases and
suggested that cholera was spread by contaminated water. He was able to encourage
improvements in the water supply long before the discovery of the organism responsible for
cholera; his research had a direct and far-reaching impact on public policy. Snow’s work
reminds us that public health measures, such as the improvement of water supplies and
sanitation, have made enormous contributions to the health of populations, and that in many
cases since 1850, epidemiological studies have identified the appropriate measures to take. It
is noteworthy, however, that outbreaks of cholera are still frequent among poor populations,
especially in developing countries. In 2006, Angola reported 40 000 cholera cases and 1600
deaths; Sudan reported 13 852 cases resulting in 516 deaths in the first few months of the
year, that the risk of cholera in London was related to the drinking of water supplied by a
particular company provides a well-known example. Snow’s epidemiological studies were
one aspect of a wide-ranging series of investigations that examined related to physical,
chemical, biological, sociological and political processes.
Comparing rates of disease in subgroups of the human population became common
practice in the late nineteenth and early twentieth centuries. This approach was to be useful
way of linking environmental conditions or agents to specific diseases.
In the second half of the twentieth century, these methods were applied to chronic non-
communicable diseases such as heart disease and cancer, especially in middle and high-
income countries.
Recent developments in epidemiology
Epidemiology in its modern form is a relatively new discipline and uses quantitative
methods to study diseases in human populations, to inform prevention and control
efforts. For example, Richard Doll and Andrew Hill studied the relationship between
tobacco use and lung cancer, beginning in the 1950s. Their work was preceded by
experimental studies on the carcinogenicity of tobacco tars and by clinical observations
linking tobacco use and other possible factors to lung cancer. By using long term cohort
studies, they were able to establish the association between smoking and lung cancer.
Smoking is a particularly clear-cut case, but for most diseases, several factors contribute to
causation. Some factors are essential for the development of a disease and some increase the
risk of developing disease. New epidemiological methods were needed to analyse these
relationships.
In low- and middle-income countries where HIV/AIDS, tuberculosis and malaria are
common causes of death, communicable disease epidemiology is of vital importance. This
branch of epidemiology has now become important in all countries with the emergence of
new communicable diseases such as sudden acute respiratory syndrome (SARS), bovine
spongiform encephalopathy (BSE), and pandemic influenza. Epidemiology has evolved
considerably over the past 50 years and the major challenge now is to explore and act upon
the social determinants of health and disease, most of which lie outside the health sector.

Definition, scope, and uses of epidemiology

Definition
Epidemiology as defined by Last, (2001) is “the study of the distribution and determinants of
health-related states or events in specified populations, and the application of this study to the
prevention and control of health problems”.

The word “epidemiology” is derived from the Greek words: epi “upon”, demos “people” and
logos “study”. This broad definition of epidemiology can be further elaborated as follows:

Term Explanation
-Study includes: surveillance, observation, hypothesis testing, analytic research and
experiments.
-Distribution: refers to analysis of: times(when), persons(who), and places(where).
-Determinants: include factors that influence health: biological(e.g pathogenic
microorganisms; Mycobacterium tuberculosis ), chemical(poison,), physical(temperature),
social(lifestyle), cultura(FGM), economic(poverty), genetic(SCD) and behavioural.
-Health-related states and events refer to: diseases, causes of death, behaviours such as use
of tobacco, positive health states, reactions to preventive regimens and provision and
use of health services.
-Specified populations include those with identifiable characteristics, such as occupational
groups.
-Application to prevention and control the aims of public health—to promote, protect, and
prolong life (restore health).
Epidemiologists are concerned not only with death, illness and disability, but also with more
positive health states and, most importantly, with the means to improve health. The term
“disease” encompasses all unfavourable health changes, including injuries and mental health.
Scope
A focus of an epidemiological study is the population defined in geographical or other terms;
for example, a specific group of hospital patients or factory workers could be the unit of
study. A common population used in epidemiology is one selected from a specific area or
country at a specific time. This forms the base for defining subgroups with respect to sex, age
group or ethnicity. The structures of populations vary between geographical areas and time
periods. Epidemiological analyses must take such variation into account.

Epidemiology and public health

Public health, broadly speaking, refers to collective actions to improve population
health. Epidemiology, one of the tools for improving public health, is used in several
ways. Early studies in epidemiology were concerned with the causes (etiology) of
communicable diseases, and such work continues to be essential since it can lead to the
identification of preventive methods. In this sense, epidemiology is a basic medical science
with the goal of improving the health of populations, and especially the health of the
disadvantaged
Uses of Epidemiology:
-Causation of disease
Although some diseases are caused solely by genetic factors, most result from an interaction
between genetic and environmental factors. Diabetes, for example, has both genetic and
environmental components. We define environment broadly to include any biological,
chemical, physical, psychological, economic or cultural factors affect this interplay, and
epidemiology is used to study their influence and the effects of preventive interventions

-Natural history of disease

Epidemiology is also concerned with the course and outcome (natural history) of diseases in
individuals and groups.
Good health-Subclinical-changes-Clinical-Changes-Recovery-Death
-Health status of populations
Epidemiology is often used to describe the health status of population groups. Knowledge of
the disease burden in populations is essential for health authorities, who seek to use limited
resources to the best possible effect by identifying priority health programmes for prevention
and care. In some specialist areas, such as environmental and occupational epidemiology, the
emphasis is on studies of populations with particular types of environmental exposure.

-Evaluating interventions
To the effectiveness and efficiency of health services.This means determining things such as
the appropriate length of stay in hospital for specific conditions, the value of treating high
blood pressure, the efficiency of sanitation measures to control diarrhoeal diseases and the
impact of reducing lead additives in petrol.
-Identification of at-risk group
-Classification of Disease
What is epidemiology? 5
Applying epidemiological principles and methods to problems encountered in the practice of
medicine has led to the development of clinical epidemiology. Similarly, epidemiology has
expanded into other fields such as pharmacoepidemiology, molecular epidemiology, and
genetic epidemiology.

-Molecular and genetic epidemiology

Molecular epidemiology measures exposure to specific substances and early biological
response, by:
• evaluating host characteristics mediating response to external agents, and
• using biochemical markers of a specific effect to refine disease categories.
Genetic epidemiology deals with the etiology, distribution, and control of disease in groups
of relatives, and with inherited causes of disease in populations.
Genetic epidemiological research in family or population studies aims to establish:
• A genetic component to the disorder,
• The relative size of that genetic effect in relation to other sources of variation in disease
risk, and
• The responsible gene(s).
Public health genetics include:
• Population screening programs,
• Organizing and evaluating services for patients with genetic disorders, and
• The impact of genetics on medical practice.

Dr. Alexander Peter