Epidemiology by Samuel

Introduction to
epidemiology
By Samuel D.(MPHE)
kasadr21@gmail.com
Objectives
At the end of this unit the student is expected to know the
• Definition of epidemiology
• History of Epidemiology
• Use of Epidemiology
• applications of Epidemiology
• Scope of epidemiology
• Basic assumptions of epidemiology
• Branches of epidemiology
How we view the world?
• Pessimist: The glass is half

empty.
• Optimist: The glass is half full.
• Epidemiologist: As compared
to what?
Definitions
Health:
A state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity (WHO,1948).
Disease:
A physiological or psychological dysfunction.
Illness:
A subjective state of not being well.
Sickness:
A state of social dysfunction.
Definitions…
Public health: The science & art of:-
►Preventing disease,
►prolonging life,
►promoting health &efficiency
through organized community effort (Winslow, 1920)

Introduction to epidemiology
Epidemiology:
 Considered as the basic science of public health.
 Provides useful tools and methods to describe

variations in disease occurrence.
 Identify factors that influence the occurrence of

disease.
Introduction to epidemiology…
The word Epidemiology comes from the Greek roots/words:
“Epi” = on, upon or between
“Demos” = people or population
“Logos” = study of, Body of Knowledge, Doctrine
So epidemiology is the study of what happens in a population.
*Some books state the word epidemiology come from the word
epidemic
Definition of epidemiology…
Epidemiology is the study of:
►frequency,
►distribution and
►determinants of diseases and
other health related conditions in specified human populations,

and the application of this study to the promotion of health, and
control of health problems.
– Last, Dictionary of Epidemiology

Components of the definition
Study: Systematic collection, analysis and interpretation of data.
 Epidemiology involves collection, analysis and interpretation
of health related data.
“Epidemiology is a science”
Components…
Frequency: the number of times an event occurs
 Epidemiology studies the number of times a disease occurs.
It answers the question How many?
 Frequency of diseases is measured by morbidity and
mortality rates.
“Epidemiology is a quantitative science”

Components…
Distribution:
 Refers to how disease is distributed throughout the

population related to Time, place, person
 It answers the question who, where and when?
“Epidemiology describes health events”

Components…
 Two Broad Types of Epidemiology
1. Descriptive epidemiology
 Defines the amount and distribution of health problems in relation
to person, place and time.
 It answers the questions who, where and when.

2. Analytic epidemiology
 exploring the cause of disease by studying how exposures relate to
disease
 involves explicit/clear comparison of groups of individuals to

identify determinants of health and diseases.
 It answers the questions why and how.

Basic Epidemiologic Approach
Descriptive epidemiology Analytical Epidemiology
Observe
Compare rates
Count cases (events)
Describe Test hypothesis
►Time, Implement action
►place,
►person ►(control, prevention)
 Calculate rates
Develop hypothesis
Components…
 Descriptive epidemiology:
►is antecedent to analytical epidemiology
 Three essentials characteristics of disease that we look for in
descriptive studies are ... Person, Place, Time
Person
►inherent Cx(age, sex, ethnic group, genetic predisposition…),
►acquired Cx (immune or marital status, education, …)
►their activities(occupation, physical activity, leisure activities,
use of medications/tobacco/drugs…)
►conditions under which they live (SES, access to medical care
and diet…).
Components…
Place
►presence of agents or vectors, climate, geology,
geographic variation
►population density, economic development
►nutritional practices, medical practices

Time
►calendar time, time since an event daily/hourly
(time of epidemic), physiologic cycles,
►age (time since birth), seasonality, temporal trends

Components…
 Descriptive epidemiology provides the What, Who, When, and
Where of health-related events.
Components…
Determinants:
 Factors the presence/absence of which affect the
occurrence and level of an event.
 Epidemiology studies what determines health events.
 It answers the question how and why?
 Epidemiology is also used to search for causes and

other factors that influence the occurrence of health-
related events.
“Epidemiology analyzes health events”

Components…
Diseases & other health related events
 Epidemiology is not only the study of diseases.
 It also includes health related problems like:
►Vital events:, births, deaths, marriage, divorces etc.
►Health related behaviour:, sexual behaviour, smoking,

alcoholism, drug abuses, amount of exercise, seat-belt use, etc.
►Social factors, such as poverty.
“Epidemiology is a broader science”

Components…
Human population
 Epidemiology diagnoses and treats communities/populations.
 Clinical medicine diagnoses and treats patients.

 epidemiologists are concerned with the collective health of
the people in a community.
 So the epidemiologist’s “patient” is the community.
“Epidemiology is a basic science of public health”

Medicine vs. Epidemiology
Medicine Epidemiology
Focus  Individuals  Populations
Main goal  Diagnosis and  Prevention and Control
Treatment
Questions  What is wrong with  What are leading causes of

this patient? illness, death or disability
 What treatment is in this population?
appropriate?  What intervention can be
done to reduce them?
Medicine vs. Epidemiology…
FOR EXAMPLE, although the clinician and the epidemiologist both are
interested in establishing the correct diagnosis, they have different
responsibilities.
 The clinician: focuses on
-treating and
-caring for the individual.
 The epidemiologist: focuses on
-the exposure (action or source that caused the illness),
-the number of other persons who may have been similarly exposed,
-the potential for further spread in the community, and
-interventions to prevent additional cases or recurrences.

Scientific Method Applied to Patient and Community
step Clinician Epidemiologist
Data base History, Surveillance, descriptive epi

physical exam
Assessment Differential dx Inference
Hypothesis Diagnostic studies Analytical epi

testing
Action Treatment Community intervention
Components…
Application
 Epidemiological studies have direct and practical applications
for prevention of diseases & promotion of health.
 Epidemiology is both the science and the practice.
 Knowledge for action
• action -- to control, (ideally to prevent), health problems
“Epidemiology is an applied science”

History of Epidemiology
Although epidemiological thinking has been traced to the time of
Hippocrates, the discipline did not flourish as an independent
discipline until the 20th century.
1. Hippocrates(Greek Physician) 460-377 B.C
 The father of modern medicine also father of epidemiology.
 Examined the relationship between the occurrence of disease &

environment influence.
 Explain disease from a rational rather than supernatural viewpoint.
 Coined the terms epidemic and endemic
History of Epidemiology…
2. Galen(Greek physician) 130-210
 Describe that life style and personality can influence health and disease.
 He wrote “Miasma” theory which proposed that bad (foul smelling)

air caused disease.
3. John Graunt (1620-1674)
 By published Natural and Political Observations on the Bills of

Mortality.
 He quantify patterns of birth, death and disease occurrence.

 High infant mortality, urban-rural differences, and seasonal

variations.
 Disaggregated data by sex, age, geographic location and season.
4. James Lind (Scottish surgeon)1716-94
 used an "experimental" approach to prove the cause of scurvy
 showing it could be treated effectively with fresh fruit.

5. William Farr(1839):
 Established application of vital statistics for the evaluation of
health problems.
 Extended the epidemiologic analysis of morbidity and

mortality.
 Looking at effects of marital status, occupation, and altitude.
6. John Snow (1854):

 Demonstrated that the risk of mortality due to cholera was
related to the drinking water provided by a particular
supplier in London.
 He used a "natural experiment" to test his hypothesis.
7. Austin Bradford Hill (1937):
 Mainly worked on the Principles of Medical Statistics.
 Suggested the criteria for establishing causation.
8. Alexandre Louis (1872):

 sometimes called the “Father of Epidemiology”.
 systematized the application of numerical thinking.
 He demonstrated that bloodletting was not effective therapy.
 His influence was widespread, primarily through his students.
 Epidemiological thought emerged in 460 BC.
 Epidemiology flourished as a discipline in 1940s.

From 1950's-1970's.
 Major epidemiology successes in the area of:
♯ fluoride, tobacco, blood pressure and stroke, CHD risk factors,
toxic shock syndrome…
Important factors that lead to progressive development
of epidemiology
 The need for quantitative reasoning in public health
 Possibility of conducting comparative studies
 Increasing availability of vital statistics system
 Hygienic and public health movement
 Improvements in diagnosis and classification
 Advances in the field of statistics
 Advances in computer applications and statistical software
 Biotechnology revolution
 Advances in genomics…
Scope of Epidemiology
Originally, Epidemiology was concerned with investigation &
management of epidemics of communicable diseases.
Lately, Epidemiology was extended to endemic communicable

diseases and non-communicable infectious diseases.
Recently, Epidemiology can be applied to all diseases and other

health related events.
Uses of Epidemiology
 Determine the magnitude and trends of disease
 Identify the etiology or cause of disease
 Determine the mode of disease transmission
 Identify risk factors or susceptibility
 Determine the role of the environment
 Evaluate the impact of the control measures
 I to provide administrative and planning data

Application of epidemiology
 Elucidation of the natural history of disease.
 Description of the health status of the population.
 Establishing component causes of a disease.
 Evaluating efficaciousness and effectiveness of

interventions.
Application of epidemiology…
 Epidemiology supplies information for decision:
– At Individual level:
 behavioral changes… contraception, sexual
– At Public health level :
 Interventions, priority setting, resource allocation,

evaluating effectiveness of intervention
(evaluation).
Features of Epidemiology
 Studies are conducted on human population
 Examines patterns of events in groups of people
 Can establish cause and effect relationship without the

knowledge of biologic mechanism
Smoking and lung cancer
 Covers a wide range of conditions

♦From infectious to non-infectious
♦From simple survey to complex drug trials
Epidemiologist Core Functions
 Public health surveillance
 Investigation of an outbreak
 Data analysis (both descriptive/ analytic)
 Evaluation of programs
 Communication
 Management and teamwork

Nature of Epidemiology
 It is a toolkit of methods for:
 Answering public health questions.
 Identifying relationships between exposures and

outcomes.
 Assessing the efficacy of interventions (solutions

to alleviate public health problems).
Fundamental Epidemiological Assumptions
 Diseases (or other health events) do not

occur at random or by chance.
 Diseases (or other health events) have

causal and preventive factors that can
be identified.
key focuses for Epidemiological Studies
 Quantitative (rather than qualitative)
 Observational (rather than experimental)

Evolution of Epidemiology
1. Trends in Epidemiology
Emerging- HIV/AIDS Improved SES
Re-emerging – TB, Malaria Improved control activities
Infectious
Diseases
Non-infectious
diseases
Epidemiological transition
2. Evolution in Epidemiology
Multi-level causality (21st Century): focus on

risk-factors and causal pathways at the societal
level and with pathogenesis at the molecular level.
Chronic disease era (Modern Epidemiology):
focus on risk-factor at individual level.
Germ theory: infectious disease era
Miasma theory: focus on environment; the theory

that all disease was due to bad air – contaminations
(miasma)
Epidemiology Fields
Surveillance: “shoe-leather” epidemiology (outbreak investigations),
and epidemic control.
Descriptive epidemiology: examination of patterns of occurrence of

disease and injury.
Microbial/Infectious epidemiology: biology and ecology of

pathogenic microorganisms, their lifecycles, and their interactions with
their human and non-human hosts.
“Risk factor” epidemiology: searching for exposure disease

associations that may provide insights into etiology and avenues for
prevention.
Epidemiology fields…
Clinical epidemiology: and the evaluation of healthcare – assess
accuracy, efficacy, effectiveness, and unintended consequences of
methods of prevention, early detection, diagnosis, treatment, and
management of health conditions
Social epidemiology: interpersonal and community-level factors
influencing health at the population level
Molecular epidemiology: investigate disease at the molecular level to
precisely characterize pathological processes and exposures, to
elucidate mechanisms of pathogenesis, and to identify precursor
conditions
Genetic epidemiology: the confluence of molecular biology, population
studies, and statistical models with an emphasis on heritable
influences on disease susceptibility and expression
Epidemiology Fields…
Big Epidemiology: multisite collaborative trials, such as them Hypertension
Detection and Follow-up Program (HDFP), Coronary Primary Prevention
Trial (CPPT), Multiple Risk Factor Intervention Trial (MRFIT), Women’s
Health Initiative (WHI)
Entrepreneurial epidemiology: building institutions and careers by winning

research funding and facilities
Testimonial epidemiology: giving depositions and testifying in court or in

legislative hearings on the state of epidemiologic evidence on a matter of
dispute
• Global epidemiology: assessing the effects of human activity on the

ecosystem that supports life on Earth.
Principles of Disease Causation and Models
Disease Causation
Cause of a disease:
 Is an event, condition, or characteristic that preceded the disease
event and without which the disease event either would not have
occurred at all, or would not have occurred until some later time.
 The cause of any effect must consist of a constellation of

components that act in concert.
Theories of disease causality
 theory is an idea to explain something, or a set of guiding principles.
Ninetieth century theories
 Contagion theory: disease prevention activities were based on the

hypothesis that illness is contagious(la quarantine).
 Supernatural theory: argue that supernatural forces cause disease.
 Personal behavior theory: disease results from wrong personal

behavior.
 Miasma theory: argues that disease is caused by the odor of decaying

of organic materials.
Theories of disease causality…
Twentieth century theories
 Germ theory (Single): microorganisms cause diseases and it is
possible to control diseases using antibiotics and vaccines.
 In the mid 1800s Louis Pasteur developed the concept of causality
with the germ theory of disease
 states that specific transmissible pathogens are responsible for
disease
Henle-Koch's Postulates (1884 and 1890)
To establish a causal relationship between a parasite and a disease, all
four must be fulfilled:
1. The organism must be found in all diseased animals
2. The organism must be isolated from a diseased animal cultured
3. The cultured organism should cause disease
4. The organism must be re-isolated
Theories of disease causality…
 Lifestyle theory: unhealthy lifestyles are causes for diseases.
 Environmental(ecological) theory: explains that significant
number of chronic disease are caused by toxins in the environment.
 Multi-causal (web of disease causation)theory: express that
there are multiple factors for a cause of a single disease entity.

Etiology of a disease
 The sum of all factors contribution to the occurrence of a
disease.
Agent factors + Host factors + Environmental factors

= Etiology of a disease
e M o de l s
Di se a s
Disease Models…
How do diseases develop?
Epidemiology helps researchers visualize disease and

injury etiology through models.
Disease Models cont…
 Common known models of disease
 Epidemiologic triangle
 Web of causation
 Wheel model
 Sufficient – component cause model

Epidemiologic triangle
 Traditional model of infectious disease causation
Epidemiologic triangle…
 the host, agent, and environment can coexist harmoniously.
 Disease and injury occur only when there is interaction or

altered equilibrium between them.
 an agent, in combination with environmental factors, can

act on susceptible host to cause disease
 disruption of any link among these three factors can also

prevent disease.
Epidemiologic triangle…
Host factors Agent factors Environmental factors
♦Age ♦Virulence of organisms ♦Home overcrowding

♦Sex ♦Serotype of organisms ♦Air pollution
♦Previous disability ♦Antibiotic resistance ♦Workplace hygiene
♦Behaviour ♦Cigarette-tar content ♦Weather
♦Genetic inheritance ♦Type of glass in motor ♦Water composition
♦Height ♦car windscreen ♦Food contamination
♦Weight ♦Animal contact
Implications for Public Health
Knowledge of the chain of infection provides a basis for

determining appropriate control measures.
In general, control measures are usually directed against the

segment in the infection chain that is most susceptible to
intervention, unless practical issues dictate otherwise.
For some diseases, the most appropriate intervention is controlling

or eliminating the agent at its source. For a disease with a human
host, the patient can be treated to eliminate the source.
Implications for Public Health
In the community, soil can be decontaminated or covered to prevent
the agent’s escape.
Some interventions are directed at the mode of transmission.
Interruption of direct transmission can be accomplished by isolating

someone with infection.
Vehicle-borne transmission can be interrupted by eliminating or

decontaminating the vehicle. For airborne diseases, strategies are
sometimes directed at modifying ventilation or air pressure and
filtering or treating the air.
The web of causation
 the process that generates disease or leads to injury is
much more complex.
 This complexity is better portrayed or mentioned in web of

causation model.
 The web of causation was developed especially to enhance

understanding of chronic diseases, such as cardiovascular
disease.
Web of causation...
 it can also be applied to the study of injury and
communicable diseases.
 web of causation de-emphasizes the role of the agent

and highlights other factors that encourage the onset
of disease.
The Wheel
The wheel consists of a hub (the host or human), which has
genetic makeup as its core.
Surrounding the host is the environment, schematically divided
into biological, social, and physical.
The relative sizes of the different components of the wheel depend
upon the specific disease problem under consideration.
For hereditary diseases, the genetic core would be relatively large.
In contrast to the web of causation, the wheel model does
encourage separate delineation of host and environmental factors.
The wheel…
Sufficient-Component Cause Model
 In 1976, Rothman outlined the sufficient-component cause
model
 He defined a sufficient cause as “complete causal mechanism

that inevitably produce disease”
 A sufficient cause is not a single factor but rather a minimal

set of factors that unavoidably produce disease
 Each participating factor in a sufficient cause is termed a

component cause
Sufficient-Component Cause Model...
 A single component cause or a sub-set of component causes
does not result in disease- the entire constellation is needed
 Different sufficient causes may or may not have causal

components in common
 A causal component that is a member of every sufficient

cause is termed as a necessary cause.
 E.g. exposure to HIV (by whatever route) is a necessary

cause of AIDS
 Most component causes are neither necessary nor
sufficient causes of a disease.
 The causal pies first presented by Rothman is

presented to illustrate the concepts of sufficient,
component, and necessary causes
 The figure shows a disease with 3 sufficient causes
 Each sufficient cause has 5 component causes labeled A through
J
 Component cause A is regarded a necessary cause. Why?
Sufficient-Component Cause...
 An individual factor that contributes to cause disease is shown as a
piece of a pie. After all the pieces of a pie fall into place, the pie is
complete and disease occurs.
 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.
INFECTIOUS/COMMUNICABLE DISEASE
EPIDEMIOLOGY
Infectious disease/Communicable disease
 Is an illness due to a specific infectious agent or its toxic products

that arises through transmission of that agent or its products from
►an infected person,

►animal or
►reservoir
To a susceptible host,
either directly or indirectly through
►an intermediate plant,
►animal host,
►vector or inanimate environment.
Definition of communicable/ Infectious
disease epidemiology
The study of circumstances under which both infection
and disease occur in a population and the factors which
influence their frequency, spread and distribution of
infectious diseases.
What is Infectious Disease Epidemiology?
Infectious Disease Epidemiology

Epidemiology
Deals with one Population

Two or more populations
Risk case A case is a risk factor
Identifies causes The cause often known

What is infectious disease epidemiology?...
Two or more populations
• Humans
• Infectious agents
– Helminthes, bacteria, fungi, protozoa, virus, prions
• Vector
–Mosquito(protozoa-malaria),snails (helminthes-schistosomiasis)
– Blackfly (microfilaria-onchocerciasis)
• Animals
– Dogs and sheep/goats – Echinococcus
– Mice and ticks – Borrelia
What is infectious disease
epidemiology?...
A case is a risk factor …
Infection in one person can be transmitted to others
What is infectious disease
epidemiology?...
• The cause often known
– An infectious agent is a necessary cause
What is infectious disease epidemiology then used for?
• Identification of causes of new, emerging infections, e.g. HIV, SARS, Swine

flu
• Surveillance of infectious disease
• Identification of source of outbreaks
• Studies of routes of transmission and natural history of infections
• Identification of new interventions

Transmission
Cases
• Index – the first case identified
• Primary – the case that brings the infection
into a population
• Secondary – infected by a primary case
• Tertiary – infected by a secondary case
Natural History of Disease
 natural history of disease refers to the progression of a disease
process in an individual over time, in the absence of intervention.
 The process begins with exposure to the causative agent capable of

causing disease.
 For an infectious disease, the exposure is a microorganism.
 For lung cancer, the exposure may be a factor that initiates the
process, such as asbestos fibers or components in tobacco smoke
 Without medical intervention, the process ends with
recovery or disability or death.

Natural History of Disease…
Four stages in the natural history of a disease
1. Stage of susceptibility
 this is a stage in which disease has not developed but the ground
work has been laid by the presence of factors that favor its
occurrence.
 Susceptible person is lacking sufficient resistance to particular

pathogenic agent to prevent disease if or when exposed.
 Presence of factors
 No disease
 Incubation period: is time interval between entry and development
of signs and symptoms of disease.(exposure-----syptomatic)
Incubation period in infectious diseases, is equivalent to combination

of induction and latent periods in non infectious diseases.
 Induction period- is the period of time from causal action until

disease initiation.(causal----initiation)
 Latent period- is the period from asymptomatic disease to

development of symptoms.(asymptomatic-----symptomatic)
2. Stage of sub-clinical disease
 There is no manifest disease. In other words no signs and

symptoms are detected. The person does not know that he has
any disease. The sub clinical stage of disease may lead to the
clinical stage or the individual may recover.
 Presence of pathogenic changes (biological onset)
 No disease manifestations.
3. Stage of clinical disease
 In this stage the person has symptoms and signs of disease.
 There are various grades of illness with different outcomes

depending on the agent host interaction.
 Some diseases are short and mild that every one recovers
quickly while others are very serious leading to
complications and death.
 Presence of sign and symptoms (clinical onset)

4. Stage of recovery, disability, or death
 some diseases run their course and then resolve completely
either spontaneously or under the influence of therapy.
 However there are a number of conditions which give rise to

residual defects of short or long term duration leaving the
person disabled to a greater or lesser extent.
The Spectrum of Illness from Communicable Disease
Inapparent Mild Severe

infection Disease Disease
Death
No signs or Clinical illness with signs and

symptoms symptoms
 clinical illness can be mild or severe or even fatal. This range of

clinical manifestations is called the spectrum of disease.
Natural History of Diseases…
Distribution of clinical severity for three classes of infections.
Infectious Disease Process/cycle
Components of the infectious disease process (Chain
of Infection)
There are six components of the infectious disease process constituting chain of
disease transmission
1.The agent
2.Its reservoir
3.Its portal of exit
4. Its mode of transmission
5. Its portal of entry
6. Susceptible host
The agents
Infectious agent:
 An organism that is capable of producing infection or
infectious disease.
 On the basis of their size, etiological agents are generally
classified into:
 Metazoa (multicellular organisms). (e.g. Helminths).
 Protozoa (Unicellular organisms) (e.g. Ameobae)
 Bacteria (e.g. Treponema pallidum, Mycobacterium
tuberculosis)
 Fungus (e.g. Candida albicans)
 Virus (e.g. Chickenpox, polio, etc.)
The agents…
 Possible outcomes of exposure to an infectious
agent
 Infection: invasion & multiplication in the host

 Infectivity: the proportion of exposed who
becomes infected
Infection rate= Infected/exposed
 Disease: A clinically apparent infection

The agents…
 Pathogenicity: the proportion of infected who develop
clinical disease
Clinical-to-Subclinical ratio
 Pathogenetic Mechanisms:
 The pathogenetic effects produced by infectious agents may
result from a variety of mechanisms like:
1. Direct tissue invasion – e.g amoebiasis
2. Production of toxins – e.g tetanus

The agents…
3.Immunologic enhancement or allergic reaction leading to damage
to the host .
E.g post-streptococcal glomerulonephritis
4. Enhancement of host susceptibility to drugs of otherwise

minimal toxicity.
Infection by viral agents like varicella and Influenza B viruses may

result in severe disease (encephalitis) when the patient is treated
with medication containing salicylates
5. Immune suppression.
The agents…
 Virulence: the proportion clinical cases resulting in severe
clinical disease
Case fatality & hospitalization rate
 Immunogenecity: the infection’s ability to produce specific
immunity
Disease outcome
Exposure Infection Disease
Infectiousness Pathogenesis
(Clinical to sub- Virulence
(Infection rate) (Case-fatality rate,
clinical ratio)
Hospitalization rate)
Reservoirs
A reservoir is an organism or habitat, in which an infectious
agent normally:
►lives,
►transforms,
►develops and/or multiplies.
Reservoirs for infectious agents may be humans, animals,

plants or other inanimate objects(environment).
Many infectious disease have more than one reservoir.

Reservoirs…
 Reservoirs include humans, animals, and the environment.
 The reservoir may or may not be the source from which an agent
is transferred to a host.
 For example, the reservoir of Clostridium botulinum is soil, but

the source of most botulism infections is improperly canned food
containing C. botulinum spores.
Reservoirs…
Human reservoirs
 Many of the common infectious diseases have human reservoirs.
 Diseases which are transmitted from person to person without

intermediaries include the sexually transmitted diseases, measles, and
many others.
Two types of human reservoir exist:
► persons with symptomatic illness
►carriers
 A carrier is a person without apparent disease who is nonetheless

capable of transmitting the agent to others.
Reservoir Vs Carrier
Reservoir
 An organism or habitat in which an infectious agent normally
lives, transforms, develops and/or multiplies
Carrier
 A person who doesn’t have apparent clinical disease, but is a

potential source of infection to other people
Reservoirs…
Classification of carriers:
 Incubatory carriers: Transmitting the disease during incubation
period. Example: Measles, mumps
 Convalescent carriers: Transmitting the disease during
convalescence period i.e. from the time of recovery to when
shedding stops. Example: Typhoid fever
 Asymptomatic carriers: Transmitting the disease without ever
showing manifestations of the disease.
Example: Polio, Amoebiasis
 Chronic carriers: Transmitting the disease for a long period /

indefinite transmission. Example: Viral Hepatitis, Typhoid fever.
Importance of carriers
 Number- carriers may outnumber cases
 Difficulty in recognition- carriers don’t know that they are
infected
 Mobility- carriers are mobile, cases are restricted
 Chronicity- carriers re-introduce infection and contribute to
endemicity
Effect of carriers on disease transmission
 Ice-berg effect in temperate zone
 Hippopotamus effect in tropical zone
These are the fact that carriers constitute a hidden reservoir of infection and that they may outnumber actual cases
Reservoirs…
Animal reservoirs
 Infectious diseases that are transmissible under normal conditions
from animals to humans are called zoonoses.
 E.gs: -bovine tuberculosis (from cows)
-rabies (from dogs, bats, foxes, and other wild animals)
-anthrax (from sheep)
-brucellosis (from cows, pigs, and goats).
Environmental reservoirs
 Plants, soil, and water in the environment are also reservoirs for
some infectious agents.
 e.gs fungal agents, histoplasmosis, live and multiply in the soil.
Portal of exit
 Is the way the infectious agent leaves the reservoir. OR
 is the path by which an agent leaves the source host
 Possible portals of exit include all body secretions and

discharges: Mucus, saliva, tears, breast milk, vaginal
and cervical discharges, excretions (feces and urine),
blood, and tissues (including the placenta).
Portal of exit…
 The portal of exit usually corresponds to the site at which the
agent is localized. Thus,
 tubercle bacilli and influenza viruses exit the respiratory tract.
 schistosomes through urine, cholera vibrios in feces,
 Sarcoptes scabiei in scabies skin lesions,
 blood borne agents can exit by crossing the placenta (rubella,

syphilis, toxoplasmosis),
 cuts or needles (hepatitis B) or blood-sucking arthropods

(malaria) exit by way of the skin (percutaneously).
Mode of Transmission
 Mode of transmission is the various mechanisms by which
agents are conveyed to a susceptible host.
 Can be direct or indirect
Direct transmission
Is immediate transfer of the agent from a reservoir to a

susceptible host by direct contact or droplet spread.
May be:- ►Direct contact
►Direct projection
►Transplacental
Mode of Transmission…
1.Direct contact
 The contact of skin, mucosa, or conjunctiva with infectious agents
directly from person or vertebrate animal, via touching, kissing,
biting, passage through the birth canal, or during sexual
intercourse.
2. Direct projection or Droplet spread
 direct spray over a few feet, before the droplets fall to the ground.
 saliva droplets by coughing, sneezing, singing, spitting or talking.

Example: common cold
3.Transplacental
 Transmission from mother to fetus. Example: syphilis
 Indirect transmission
 an agent is carried from a reservoir to a susceptible host by
suspended air particles or by animate (vector) or inanimate
(vehicle) intermediaries.
Can be: ►Vehicle-borne
►Vector-borne
►Airborne
►Non vector intermediate host

1. Vehicle-borne
 is any non-living substance or object by which an infectious agent

can be transported and introduced in to a host through a suitable
portal of entry.
 Transmission occurs through indirect contact with inanimate

objects (fomites): bedding, toys, or surgical instruments; as well as
through contaminated food, water, IV fluids etc.
Mode of Transmission cont…
2. Vector-borne
 A vector is an organism (usually an arthropod) which transports an
infectious agent to a susceptible host or to a suitable vehicle.
Can be: ►Biological vector
► Mechanical vector
2.1.Biological vector
 A period of multiplication and/or development of the agent in the

vector is required before transmission to the host can occur (extrinsic
incubation period).
 Transmission occurs while the vector is feeding on its host.

Two ways of transmission by biological vector:
►salivarian
►stercorarian
Salivarian
Infective saliva is directly injected in to the host.
E.g: Malaria by the anophelus mosquito
Stercorarian
Infective fecal or regurgitated material is deposited near the bite wound .
The host then auto inoculates the infective material by scratching the
itching bite.
Alternatively, infective material from a crushed louse can be rubbed into
the bite wound or into a skin abrasion.
E.g: fleaborne or louseborne typhus.
2.2.Mechanical vector
 agent is directly infective to the host, without having to

go through a period of multiplication or development.
 agent is transported (carried) on the leg or mouth parts of

the vector, or passes through its gastrointestinal tract and
is excreted or regurgitated onto the host or vehicle.
 Introduction of the agent into the host is either:
►by bite (e.g. rift valley fever by blood sucking flies) or
►by vector-host contact (e.g.- Trachoma by flies) or
►through contamination of a vehicle
(e.g. contamination of food by flies or cockroaches).

3. Airborne
 Airborne transmission is by particles that are suspended in air.
 are two types of these particles:

dust and
droplet nuclei.
Dust: includes infectious particles blown from the soil by the wind as well
as material that has settled on surfaces and become resuspended by air
currents.
Droplet nuclei: are the residue of dried droplets. The nuclei are less than 5
µ (microns) in size and may remain suspended in the air for long periods.
 may be blown over great distances, and are easily inhaled into
the lungs and exhaled.
 which may occur by dust or droplet nuclei (dried residue of

aerosols)
Example: Tuberculosis
4. Non vector intermediate host
 hosts not playing an active role in transporting the agent to

humans.
Example: Aquatic snails in the transmission of schistosomiasis.

Importance of mode of transmission
 A disease often has several modes of transmission
 It is important to distinguish between the predominant mode of
transmission and those of secondary importance
 Identifying primary and secondary modes of transmission is
important to identify most effective prevention and control
measures
Portal of entry
 Is the site where an infectious agent enters a susceptible host.
These are:
1. The Mucosa:
Nasal - common cold
Conjunctival - Trachoma
Respiratory - Tuberculosis
Vaginal - Sexually transmitted diseases
Urethral - Chlamydial infection
Anal - Sexually transmitted diseases
2. Injury site: -Tetanus
3. Skin: -Hook worm infection (Ancylostomiasis)
Host
The susceptible human host is the final link in the infectious process.
Host susceptibility can be seen at the individual level and at the

community level.
At the individual level: The state of the host at any given time is the
interaction of genetic endowment with the environment over the entire
life span.
Examples: Genetic factors: sex, blood type, ethnicity etc.
Environmental factors: immunity acquired as a result of past infection
At the community level: Host resistance at the community (population)

level is called herd immunity.
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Time course of an infectious disease
 Pre-patent Period: The time interval between biological onset
and the time of first shedding of the agent.
 Incubation Period: Interval between infection ( biological onset)
and the first clinical manifestations of disease (clinical onset).
 Communicable Period: The time interval during which the agent
is shed by the host.

Time course of an infectious disease …
 Latent Period: The interval between recovery and the
occurrence of relapse or recrudescence in clinical disease.
-Examples of diseases in which a latent period can occur include
malaria and epidemic typhus.
The term “latent period” is some times used instead to refer to
the incubation period.

Time lines for Infection and Disease
Time of
Infection
Dynamics of Noninfectious
Infectiousness Latent period Infectious
period -removed
-dead
Susceptible -recovered
Dynamics of
Disease
Incubation Symptomatic Non-diseased
period period -removed
-dead
-recovered
Susceptible
Time Course of a Disease in Relation to Its Clinical
Expression and Communicability
o f Di se a se
S pr e a d
Spread of Disease
Is the distribution of disease to susceptible host.
Index Cases – the first case identified
Primary Cases – the case that brings the infection into a population
Secondary Cases– infected by a primary case
Tertiary Cases– infected by a secondary case

Disease Transmission from Infectious host to
susceptible host
Infectious Susceptible
Host Host
Contact
Transmission depends on:

-infectious host
-susceptible host
-contact
-infectious agent
Spread of Disease…
 The three important aspects of person-to-person spread of
disease are
►Generation time
►Secondary attack rates and
►Herd immunity
Generation time
 It is the time between the receipt of infection by a host and
maximal communicability of that host.

 With person-to-person spread, the interval between cases is
determined by the generation time.

 In general the generation time is roughly equivalent to the
incubation period.
 However, the two terms are not identical.
 The time of maximal communicability may precede or follow the
end of the incubation period.

Generation time…
 Incubation period can only be applied to infections that
result in manifest disease
 Since infectious agents can be spread by persons with
inapparent infection as well as clinically manifest cases,
 The concept of generation time is essential in studies of
the dynamics of transmission of infection

Basic reproductive number (Ro)
 Another important parameter in infectious disease is the
basic reproductive number (Ro).
 Ro is the expected number of new infectious hosts that

one infectious host will produce during his/her period
of infectiousness in a large population that is
completely susceptible.
Basic reproductive number…
 Ro does not include the new cases produced by the secondary
cases, or further down the chain.
 It also does not include secondary cases who do not become

infectious.
 Example - If Ro=9 for measles, that means one person with

measles introduced to that population would be expected to
produce 9 new secondary infectious cases before recovering, if
the population were completely susceptible.
 If the person produced 2 additional cases who did not become
infectious, Ro would still be 9.
 In general, for an epidemic to occur in a susceptible population, Ro

must be > 1.
 If Ro < 1, an average case will not produce itself, so an epidemic

will not spread.
 Since Ro is an average, it is possible that a particular infectious
person will produce more than one infective case, even when R o <
1, so there may be a small cluster of cases.
 For micro-parasitic infections, Ro is a composite of 3 important
aspects of infectious diseases:
 the rate of contacts (c),
 the duration of infectiousness (d), and
 the transmission probability per potential infective contact (p).
 The average number of contacts made by an infective during

the infectious period is the product of the contact rate and the
duration of infectiousness – (cd).
Reproductive Number...
probability of transmission per contact
duration of infectiousness
R0 = p • c • d
contacts per unit time
Infection will …. disappear, if Ro < 1

become endemic, if Ro = 1
become epidemic, if R o> 1
What determines R0 ?
 p, transmission probability per exposure – depends on the
infection
HIV, p(hand shake)=0, p(blood transfusion)=1, p(sex)=0.001
 interventions often aim at reducing p,
use gloves, screen blood, condoms
 c, number of contacts per time unit – relevant contact depends
on infection
same room, within sneezing distance, skin contact,
 interventions often aim at reducing c
Isolation, sexual abstinence
 d, duration of infectious period
may be reduced by medical interventions (E.gTB)
 The contact rates in rural areas will be lower than contact
rates in urban areas, so we expect the Ro of measles to be
lower in rural than in urban areas.
 Without further information about the magnitude of the

parameters that make up Ro, we can not conclude much
about the time frame of an epidemic, the transmissibility
of the infectious agent, or the contact rate.
 Ro is about 9 for measles in some populations and also about
9 for HIV infection in some populations of intravenous drug
abusers.
 We know from other sources that measles has a high

transmission probability and short duration of infectiousness
and moves much faster than HIV, which has a low average
transmission probability and longer duration of infectiousness.
 If we knew only that Ro=9 for both, then we would

know that they both could result in major epidemics, but
we would not be able to draw conclusions about the
relative time frames of the two.
 If a woman infects on average 2 men and a man infects on
average 3 women, then one infectious case amplifies on
average to 6 infectious cases in the same host population.
 By definition, Ro assumes that all contacts are with

susceptibles.
In real populations, however, there are often people who

are already immune to a parasite.
 Under these circumstances, the expected number of new
cases produced by an infectious person is less than Ro and
is called the effective reproductive number (R).
 R is the product of Ro times the proportion “x” of the

contacts that are with susceptible:
R = Ro x
• Example: Assume that Ro = 9 for measles in a
population and that one-half of the population is
immune. Then, the R for measles will be 9X0.5= 4.5.
• A case of measles would produce on average only 4.5
new secondary cases in this population

Levels of Disease Occurrence
EXPECTED LEVEL
 Sporadic level: occasional cases occurring at irregular intervals
 Endemic level: persistent occurrence with a low to moderate
level
 Hyperendemic level: persistently high level of occurrence
EXCESS OCCURRENCE
 Epidemic or outbreak: occurrence clearly in excess of the
expected level for a given time period
 Pandemic: epidemic spread over several countries or continents,
affecting a large number of people
Endemic - Epidemic - Pandemic
R>1
Cases
R=1
R<1
Time
 Endemic
 Transmission occur, but the number of cases remains constant

 Epidemic
 The number of cases increases
 Pandemic
 When epidemics occur at several continents – global epidemic
Disease Clustering
• Clustering is commonly due to an aggregation of relatively rare
events or diseases in time and/or place.
• Clustering should not be used in the context of common diseases.
• Clustering could be a mini-epidemic of a rare event in which

occurrence of the disease is clearly in excess of expected.
• Clusters provide useful clues to public health action

Implications of Ro
• If R0 < 1 then infection cannot invade a population
– implications: infection control mechanisms unnecessary

(therefore not cost-effective)
• If R0 > 1 then (on average) the pathogen will invade that

population
– implications: control measure necessary to prevent
(delay) an epidemic
Herd immunity
• is the resistance of a community (group) to invasion and
spread of an infectious agent, based on the immunity of a
high proportion of individuals in the community.
• The high proportion of immunes prevents transmission
by highly decreasing the probability of contact between
reservoirs and susceptible hosts.

Herd immunity...
 If R0 is the mean number of secondary cases in a susceptible
population, then R is the mean number of secondary cases in a
population where a proportion, p, are immune
R = R0 – (p • R0)
What proportion needs to be immune to prevent epidemics?

If R0 is 2, then R < 1 if the proportion of immune, p, is > 0.50
If R0 is 4, then R < 1 if the proportion of immune, p, is > 0.75

If the mean number of secondary cases should be < 1, then
R0 – (p • R0) < 1 p > (R0 – 1)/ R0 = 1 – 1/ R0
 If R0 =15, how large will p need to be to avoid an epidemic?

p > 1-1/15 = 0.94
The higher R , the higher proportion of immune required for herd immunity
Herd immunity…
Conditions under which herd immunity best functions
1) Single reservoir (the human host): If there is other source of
infection it can transmit the infection to susceptible hosts.
2) Direct transmission (direct contact or direct projection): Herd

immunity is less effective for diseases with efficient airborne
transmission.
3) Total immunity: Partially immune hosts may continue to shed
the agent, and hence increase the likelihood of bringing the
infection to susceptible hosts.
Herd immunity…
4) No shedding of agents by immune hosts (no carrier state).
5) Uniform distribution of immunes: Unfortunately, susceptibles
usually happen to live in clusters or pockets because of
socioeconomic, religious, or geographic factors.
6) No overcrowding: Overcrowding also increases the likelihood of

contact between reservoirs and susceptible hosts.
• However, these conditions for the operation of herd immunity are
seldom fulfilled.
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Estimating the Transmission Probability
Transmission probability is the probability of successful transfer
of the agent so that the susceptible host becomes infected.
Two common ways of estimating transmission

probability are:
• Secondary attack rate
• Binomial Model
Secondary attack rate
 Is a measure of the frequency of new cases of a disease among the
contacts of known cases.
Secondary cases: are those with time of onset between the end of
minimum incubation period (E1) relative to the beginning of the index
case (t=0) and the end of maximum incubation period (E2) relative to
the time of the maximum infectious period of the primary case, (t=I).
Secondary attack rates…
 The data required for estimating secondary attack rate are:
 The time of onset of disease for each case in the household
 Knowledge of who is susceptible
 Estimates minimum and maximum incubation periods
 The latent period
 Maximum time that a person remains infectious

Exercise one
In a particular community, 115 persons in a population of
4,399 became ill with a disease of unknown etiology.
The 115 cases occurred in 77 households. The total number

of persons living in these 77 households was 424.
 Calculate the secondary attack rate in the affected households,
assuming that only one case per household.
Exercise two
Seven cases of hepatitis A occurred among 70 children attending a
child care center. Each infected child came from a different family.
The total number of persons in the 7 affected families was 32.
One incubation period later, 5 family members of the 7 infected

children also developed hepatitis A.
Secondary attack rate among family contacts of those cases =?

Binomial Model of Transmission Probability
Number of susceptible who become infected
Total number of contacts with infectives
•The numerator is the same as for secondary attack rate

(SAR).
•Denominator include the total number of potentially
infectious contacts that susceptible individuals make
Levels of disease prevention
Three major levels of disease prevention
1. Primary prevention
Targeted at healthy people
Objectives are: -Promotion of health

-Prevention of exposure and
-Prevention of disease
Levels of disease prevention…
2. Secondary prevention
Targeted at sick individuals
 Objective:
 is to stop or slow the progression of disease
 to prevent or limit permanent damage through early

detection & treatment
Levels of disease prevention…
3. Tertiary prevention:
 Targeted at people with chronic diseases & disabilities
that can’t be cured
Objective:
 is to prevent further disability or death and to limit
impacts of disability through rehabilitation
Levels of prevention & Natural History of Disease
Method for prevention and control of
infectious diseases
1. Increasing host resistance
2. Breaking the chain of transmission of infection
3. Inactivating the infectious agents

Method for prevention and control of infectious diseases…
1. Increasing host resistance
– Use of vaccines
– Improvement in general health- proper nutrition, exercise
2. Breaking the chain of transmission of infection
 Rapid case detection and treatment
 Isolation of infectious cases and quarantine of their contacts
 Chemo-prophylaxis before or after exposure to an infectious
diseases
 Control of animals and other biological vectors
 Environmental control of air, dust, which may harbor infectious
agents
 Use of aseptic techniques in management of patients, their
excretion and secretions
 Control of general sanitation- food, water, sewage
 Personal measures for avoiding exposure as limiting spread of
infectious diseases
2. Inactivating the infectious agents

 Use of physical agents: Heat, Cold , Radiation
 Use of chemical methods: Chlorination of water supplier

and sewage effluents
Measures of Disease Occurrence
By Samuel D.(MPH)
kasadr21@gmail.com
Learning objectives
Measures of …..
….frequency – Count
– Ratio
– Proportion
–Rate
…..Crude and adjusted rates
…..Standardisation -Direct
Indirect
…disease frequency– Prevalence
– Incidence
• Cumulative incidence (CI),(Incidence proportion)
• Incidence density (ID),
Measures of frequency
 Count
 Ratios
 Proportions
 Rates
Count…
♦ Common descriptive measure
♦ First step in calculating rates
♦ Essential for service delivery, planning
♦ It is simple counting of cases of a disease

Simple count
Ratio
♦ A ratio is the relative size of two quantities
♦ It quantifies the magnitude of occurrence of something in
relation to another.
♦ One character divided by another
♦ Example: sex ratio

Ratio…
 No specific relationship is necessary between the
numerator and denominator (numerator NOT
necessarily included in the denominator)
 Either the numerator or denominator is set to 1.
 n:y or n/n: y/n or 1 to y/n

Ratio…example
♦ # beds per doctor
– 120 beds/10 doctors or 120/10 : 10/10 or 12 beds for a doctor
♦ # students per facilitator
♦ # inhabitants per latrine
♦ Sex ratio: – Male / Female

Proportion
 It is comparison of a part to the whole population
 Numerator MUST BE INCLUDED in the denominator
 Its result ranges between 0 and 1 or (0–100%)
 Percentage = Proportion x 100

…example
Population
3500 women
6500 men
Proportion of men
= 6500 / (3500 + 6500) = 0.65 or 65 %
Male to female ratio
= 6500 / 6500 = 1.00 to 3500/6500 = 0.54
Example
1 male for 0.54 females
Rate
 measures the occurrence of an event in a
population over time.
 It is similar to proportion, but it also adds time

dimension
Rate…
Rate may be expressed in any power of 10 (100, 101,

102, 103, 10n)
• 100, 1,000, 10,000, 100,000
Types of rates
♦ Crude rates
– total population (e.g. crude birth rate)
♦ Specific rates
– population subgroups (e.g. age-group specific death rate)
♦ Standardized rates
– Rates after adjusting for a specific grouping (age, sex,

etc.)
Crude rates
 Summary rates
 Based on numbers of events
– e.g. births, deaths, diseases
 CBR & CDR widely used
 Crude death rate is influenced by:-
–Individual probability of dying
–Population age distribution

Crude rates …
Advantages
• Actual summary rates
• Calculable from minimum information
• Widely used despite limitations
Disadvantages
• Difficult to interpret due to variation in composition (e.g. age)
• Obscure significant differences in risk between subgroups

Specific rates
 Apply to specific subgroups in the population, such as a specific
age group, sex and occupation
 Denominator should be the population in that specific group
except for cause-specific rates
Uses
 Detailed understanding of disease occurrence in different
population subsets.
 It could show detailed rates of specific group (Age, sex,
ethnicity)
Disadvantages
– Difficult to compute/ interprate
Standardized (adjusted) rates
 Crude rates
• Comparison is suitable only when populations are
similar in all respects
 Adjustment or standardization
• Produces summary rates adjusted (controlled) for
(age, sex, etc) difference
• Standardization makes the population comparison

Standardized (adjusted) rates…
Advantages:
 Are summary rates
 Permit unbiased comparison
 Easy to interpret
Disadvantages:
 Fictitious rates
 Absolute magnitude depends on standard population
Two types of standardization method
 Direct
 Indirect
Direct Adjustment/Standardization of Rates
Would the overall prevalence be different if the
population distribution was the same?
 It requires
 a standard population to which the estimated specific rates are
applied
 Specific rates of event for the study population

Standard Population
1. European standard population 2. WHO world population
3. One of the study populations 4. Sum of the study populations

Examples
Standard Population formation

 Comparing the death rate among the 9 regional states
in Ethiopia,
 The national population census of Ethiopia may be

used as a standard population or
 It is also possible to use population of a single state as

a standard population
Direct Standardization
Population living in geographic area AAA is used as reference population

Direct Method
Comparisons are performed using the geographic area AAA

population as standard (reference) population.
Indirect Standardization of rate
Would the overall prevalence be different if the
populations had the same age-specific rates?
Indirect method requires
♦ Age structure of the sample study population
♦ Total cases (death) in the sample population
♦ Age-specific event (death) rates for a standard population
Summary figure is a Standardized Mortality Ratio (SMR)

Indirect standardization
Indirect Method
Comparisons are performed using the low exposure group prevalence

(rate) as standard.
Choosing Standardization Method
 If the exposed group is small use the indirect
method which compares observed and expected
number of cases.
 When comparing more than two groups use the

direct method.
Difference
 The difference between the two lies simply in the
source of the weights/populations and the rates
 In the direct method weights/population come from

the standard population.
 In the indirect method rates come from the standard

population.
SMR
SMR = 100
– Rates are similar to the standard population
♦ SMR < 100

– Fewer deaths occurred than expected (rates are lower
than the standard)
♦ SMR > 100

– More deaths occurred than expected (rates are higher
than the standard)
Measures of disease occurrence
Two types of measures :
1. Prevalence
Which measures a population’s disease status (two forms)
1. Point Prevalence 2. Period prevalence
2. Incidence
Assesses frequency of disease onset (two forms)
1. Cumulative incidence/ incidence proportion
2. Incidence density or incidence rate

Prevalence
 It is proportion of a population affected by a disease at a given
time.
 It is expressed as a percentage, per thousand, per hundred

thousand
HIV/AIDS in X city in 2005:
Population 210,000
Cases 3,200
Prevalence 1.5%
Point Prevalence
• It is proportion of a population that is affected by disease at a given
point in time
 The point can be either a particular calendar date such as
December 1, 2010 or a point in someone's life such as college

graduation.
point prevalence =
• The amount of disease in a population usually changes constantly
• Thus, may not be useful for assessment of diseases with short

generation period
Period prevalence
If we want to know how much disease is present over a longer period
of time, period prevalence would be preferred.
Period prevalence =
Period prevalence refers to the proportion of the population that is

diseased during a specified duration of time, such as during the year
2010.
The period prevalence includes the number of cases that were present
at the start of the period (for example, January 1, 2010) as well as the
number that developed during the period (for example, January 2
through December 31, 2010).
It may be helpful to think of period prevalence as derived from a
series of snapshots.
Incidence
The number of new events of a disease in a defined
population at risk within a specified period of time.
There are three key ideas in this definition.

 incidence measures new disease events.
(diseases occur more than once, measures the first occurrence of the disease).
 new cases of disease are measured in risk population
 incidence takes into account the specific amount of

time (transition time from a healthier to a diseased state)
Incidence…
Two forms
1. Cumulative incidence/CI/
2. Incidence density/ID/
Cumulative Incidence(CI)
It assumes that the entire population is at risk/candidate
and is followed up for specified time of period.
CI=
Incidence density (rate)
Instantaneous concept of rate (= speed)
ID= number of new cases of disease
Person –time of observation in candidate population
Denominator:
- the sum of each individual’s time at risk (or time free of a disease) is
counted
♦ Incidence rate must take into account
- Number of individuals who become ill in a population
- Time periods experienced by member of the population during follow

up.
Person- time
♦ It is sum of length of time period passed free of illness (at risk) by
each individual member of study
♦ It accounts for the amount of exposure time of members
♦ It is a good measure in a dynamic cohort
♦ Dynamic cohort is a cohort of people leaving and entering a study
at different time of period.

Example
what are strengths and weaknesses of CI &ID?

Comparing Incidence and Prevalence
Incidence Prevalence
• New cases or events over • All cases at point/period of

period of time time
• Useful to study factors • Useful for measuring size

causing disease, of problem
• Useful in “risk” estimation • Useful for planning

Relationship between Incidence, Prevalence and Disease Duration
Factors influencing Prevalence
Increased By Decreased By
• By longer duration of the disease • Shorter duration of the disease

• Prolongation of life of patients without
cure • High case fatality
• Increase in new cases (increase in • Decrease in new cases (decrease in
incidence) incidence)
• In-migration of cases • In-migration of health people
• Out-migration of healthy people • Out-migration of cases
• Out-migration of susceptible people

• In-migration of susceptible people
• Improved diagnostic facilities (better • Improved cure rate of cases)
reporting)
Mortality Frequency Measures
Mortality rate
 is a measure of the frequency of occurrence of death
in a defined population during a specified interval.
 Morbidity and mortality measures are often the
same mathematically;
 it’s just a matter of what you choose to measure,
illness or death.
 The formula for the mortality of a defined
population, over a specified period of time, is:
Measures of Mortality
 Mortality in a population can be monitored
through a variety of measures:
Crude death rates
Category specific death rate
Standardized death rate
Crude mortality rate (crude death rate)
 The number of deaths in a population over a given
period of time, usually a calendar year
 usually expressed per 1000 population.
Eg. the US in 2003, a total of 2,419,921 deaths occurred.

The estimated population was 290,809,777. The crude
mortality rate in 2003 was, therefore, (2,419,921/
290,809,777) x 100,000, or 832.1 deaths per 100,000
population.
Category Specific Rates:
Used to construct rates for specific segments of the
population; so we can compare among strata or between
groups (used especially for age, race, ethnicity, gender)
We can also construct cause-specific rates to compare rates

among causes
Category Specific rates
• Examples:
• Age-specific rates
• Gender-specific rates
• Race-specific rates
• Cause-specific rates
Age-specific Death Rate(ASDR)
The number of deaths of persons of a given age divided by
the mid-year population in that same age category.
Infant mortality rate(IMR)
 The infant mortality rate is one of the most commonly used measures
for comparing health services among nations.
IMR= # deaths under 1 year of age during a given time interval X 1000
#l live births reported during the same time interval
 This is a good index of -health and nutrition
-socio-economic development
-maternity and child health
-services, available and utilized.

Neonatal Mortality Rate(NMR)
 The neonatal period is defined as the period from birth up to but
not including 28 days.
NMR=# deaths under 28 days of age during a given time interval1,000
# live births during the same time interval
 that of the infant mortality rate, is the number of live births
reported during the same time period.
 Estimates events immediately after birth, primarily congenital
malformations, prematurity and low birth weight
Post-neonatal Mortality Rate(PNMR)
The postneonatal period is defined as the period from 28 days of age
up to but not including 1 year of age.
PNMR # deaths from 28 days to, but not including,

1 year of age, during a given time interval x 1000
Maternal Mortality Rate(MMR)
 The maternal mortality rate is really a ratio used to measure
mortality associated with pregnancy.
# deaths assigned to pregnancy-related causes

MMR= during a given time interval X100000
 Reflect health care access and socioeconomic factors

Death-to-Case Ratio(DCR)
# deaths assigned to a specific disease

DCR = during a given time interval X100
# new cases of that disease reported
during the same time interval
Cause-specific Death Rate (CSDR)
specific death rates are computed for the total population.
 Numerator is often too small, hence the rates may be

 calculated per 1, 00,000 instead of per 1,000 to avoid
small decimal figures.
Proportional Mortality Rate (PMR)
 This is the ratio of the number of deaths due to a specific cause
or in specific age or in specific sex or area to the total number
of deaths.
 This ratio is multiplied by 100.
 By this, relative importance of factors contributing to the total
deaths can be assessed.
Case Fatality Rate (CFR)
 It is the ratio of deaths due to a particular disease to the
number of persons who suffered from the same disease.
 What proportion of total cases die from disease X ?

 CFR tells the virulence of the organism.
Cause Specific Death Rate
Identifies the proportion of people who died due to disease X
# Of deaths from a specified

cause in a year
CSDR= ---------------------------------------- x 100,000
Average population in the same period
Proportionate Mortality Ratio(PMR)
PMR = No. of deaths from a sp. Cause

during a given time x 100
Total no. of deaths from all other causes
in the same time
What proportion of deaths as compared to other causes of death

is due to disease X ?
Case Fatality
No. of deaths from a sp. disease

Rate (CFR) = during a given time x 100
No. of cases of that disease
during the same time
 What proportion of total cases die from disease X ?

 CFR tells the virulence of the organism.
Age- Specific Mortality Rate(ASMR)
No. of deaths in a specific age group
ASMR = during a given time X1000
Estimated mid interval population
of same age group

Sex- specific mortality rate = No. of deaths in a specific sex during a given timeX 1000
Estimated mid interval population of same sex
Sex- Specific Mortality Rate(SSMR)
SSMR = No. of deaths in a specific
sex during a given time X 1000
Estimated mid interval population of same sex
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Introduction to

• Basic assumptions of epidemiology

• Pessimist: The glass is half

• Optimist: The glass is half full.

Public health: The science & art of:-

►promoting health &efficiency

through organized community effort (Winslow, 1920)

 Considered as the basic science of public health.

 Provides useful tools and methods to describe

 Identify factors that influence the occurrence of

“Epi” = on, upon or between

“Demos” = people or population

“Logos” = study of, Body of Knowledge, Doctrine

So epidemiology is the study of what happens in a population.

►determinants of diseases and

other health related conditions in specified human populations,

– Last, Dictionary of Epidemiology

Study: Systematic collection, analysis and interpretation of data.

 Epidemiology involves collection, analysis and interpretation

of health related data.

 Epidemiology studies the number of times a disease occurs.

It answers the question How many?

 Frequency of diseases is measured by morbidity and

“Epidemiology is a quantitative science”

 Refers to how disease is distributed throughout the

 It answers the question who, where and when?

“Epidemiology describes health events”

 It answers the questions who, where and when.

 involves explicit/clear comparison of groups of individuals to

 It answers the questions why and how.

►population density, economic development

►nutritional practices, medical practices

►age (time since birth), seasonality, temporal trends

 Epidemiology studies what determines health events.

 It answers the question how and why?

 Epidemiology is also used to search for causes and

“Epidemiology analyzes health events”

 It also includes health related problems like:

►Vital events:, births, deaths, marriage, divorces etc.

►Health related behaviour:, sexual behaviour, smoking,

►Social factors, such as poverty.

“Epidemiology is a broader science”

 Clinical medicine diagnoses and treats patients.

 So the epidemiologist’s “patient” is the community.

“Epidemiology is a basic science of public health”

Questions  What is wrong with  What are leading causes of

 The epidemiologist: focuses on

-the exposure (action or source that caused the illness),

-the potential for further spread in the community, and

-interventions to prevent additional cases or recurrences.

step Clinician Epidemiologist

Data base History, Surveillance, descriptive epi

Hypothesis Diagnostic studies Analytical epi

 Epidemiology is both the science and the practice.

 Knowledge for action

• action -- to control, (ideally to prevent), health problems

“Epidemiology is an applied science”

 The father of modern medicine also father of epidemiology.