Epidemiology & Health

This course intends to familiarize the students about -

•the importance of epidemiology and related concepts,
•Communicable & non-communicable diseases,
•importance of hospital infection control,
•Relevance and implementation of National Health
programmes in hospitals,
•National Health Policy,
•role of medical social workers in healthcare system.
 Epidemiology
• Epidemiology is the study of the factors that cause or encourage diseases. Some
diseases are more common in certain geographic areas, among people with certain
genetic or socioeconomic characteristics, or at different times of the year.

• Epidemiology is considered a cornerstone methodology of public health research, and

is highly regarded in evidence-based medicine for identifying risk factors for disease.
• In the study of communicable and non-communicable diseases, the work of
epidemiologists ranges from outbreak investigation to study design, data collection
and analysis including the development of statistical models to test hypotheses and
the documentation of results for submission to peer-reviewed journals.
• Epidemiologists also study the interaction of diseases in a population, a condition
known as a syndemic. Epidemiologists rely on a number of other scientific disciplines
such as biology (to better understand disease processes), biostatistics (the current raw
information available), Geographic Information Science (to store data and map
disease patterns) and social science disciplines (to better understand proximate and
distal risk factors).
• Epidemiology can help identify causes as well as guide prevention efforts.
 Can you define?
• What is illness?
• An illness refers to the human response to disease. Feelings like pain, fatigue, weakness, discomfort, distress, confusion,
dysfunction, etc. – the reasons people seek healthcare – and usually the way people measure their success with treatment.

• What is disease?
• A disease is an alteration of the mental and/or physical structure of the human body or mind. Diseases can have numerous
causes: biological (like viruses), chemical (like drugs or heavy metals), genetics, physical agents (like temperature
extremes), and alterations in immunity or metabolism (like allergies or hormonal disturbances.) With disease comes specific
signs and symptoms that manifest themselves, allowing physicians/medical experts to diagnose their patients.

• What is sickness?
• Sickness is related to a different phenomenon, namely the social role a person with illness or sickness takes or is given in
society, in different arenas of life.

• What is disability?
• Disability is an impairment of body function or structure that restricts normal functioning.

• What is disorder?
• In medicine, a disorder is a functional abnormality or disturbance. Medical disorders can be categorized into
mental disorders, physical disorders, genetic disorders, emotional and behavioral disorders, and functional disorders

• A medical condition is a broad term that includes all diseases and disorders. While the term medical condition generally
includes mental illnesses, in some contexts the term is used specifically to denote any illness, injury, or disease except for
mental illnesses
• Morbidity (from Latin morbidus, meaning "sick, unhealthy") is a diseased state, disability, or poor health due to any cause.
[12]
The term may be used to refer to the existence of any form of disease, or to the degree that the health condition affects the
patient
• In general, "illness" is more general then "disease", which in turn is more general than "sickness".
 DISEASE, ILLNESS, SICKNESS
• Disease
• Professionally defined physiological or psychological
dysfunction

• Illness
• Subjective state of the
individuals who feels
aware of not being well

• Sickness
• State of social dysfunction
based on
professional-social arrangement
 Health -definition
• Webster: The condition of being sound in body, mind or spirit,
especially freedom from physical disease or pain.
• Oxford English dictionary: soundness of body or mind; that
condition in which its functions are duly and efficiently discharged
• A condition or quality of the human organism expressing the
adequate functioning of the organism in given conditions, genetic
and environmental.

• WHO definition: Health is a state of complete physical, mental and

social well-being and not merely the absence of disease or
infirmity.
Recently, this has been amplified to include the ability to lead a
socially and economically productive life.
 Health
There are three components of Health-

• Physical – how healthy your body is.

• Social - ability to have healthy relationships.
• Emotional – how you cope with circumstances
(good and bad) in your life.

• Each component can have an effect on another.

Being healthy means you have good physical,
social AND emotional health.
 The Health Triangle Review
• There are 3 major areas
of the health triangle:
physical, mental and
social.
• Good decision making
and healthy choices
reduce the risk of
disease and increase
health overall.
 Contemporary Definitions of Health – New
definition:

• New definition of health recognizes the

inextricable links between and individual and
her/his environment. It is known as “socio-
ecological” definition.
• Health defined as: The ability to identify and
realize aspirations, to satisfy needs, and to
change or cope with environment. Health is
therefore a resource for everyday life, not the
objective of living. Health is a positive concept
emphasizing social and personal resources.
 New philosophy of health

Health-
• Is a fundamental human right
• Is the Essence of productive life
• Is intersectoral
• Is an integral part of development
• Central to the concept of quality of life
• Involves individual, state and international responsibility
• Health and its maintenance is a major social investment
• Worldwide social goal.
 Concepts of health
1. Biomedical concept- absence of disease/free
from disease (germ theory of disease)
Body as a machine, disease, doctor
Drawback-no consideration of environmental,
social, psychological, cultural determinants.

Cannot explain -Malnutrition, chronic disease,

accidents, drug abuse, mental illness, etc.
2. Ecological concept:
Health- relative absence of pain & discomfort
& a continuous adaptation and adjustment to
the environment to ensure optimal function.
Human ecological and cultural adaptation for
better health
Availability of food, population explosion, etc.
Imperfect man-imperfect environment.
3. Psychological health:
Health is not only biomedical but influenced
by social, economical, psychological, cultural,
ecological and political factors.
Health is both biological and social
phenomenon.
4. Holistic concept:
Synthesis of all the above concepts
Strength of social, economic, political, psychological,
environmental influence
Unified multidimensional process
Wellbeing of whole person in the context of his environment
All sectors of society-agriculture, animal husbandry, housing,
communication and other sectors
Emphasis on promotion and protection of health rather than
cure of disease.
Concepts of Health
 How would you describe your physical health? What effects your
physical health?

What is spiritual health? Does What is there in your

everyone have it? What effects society that effects your
it? health?

How would you describe your mental What is there in your

health? What effects your psychological environment that effects your
health? health?
 Dimensions
Health is multidimensional
• WHO-the physical, the mental and the social
• Many more-spiritual, emotional, vocational and political dimensions
• Physical dimension-
– perfect functioning of the body
• Mental dimension-
– ability to respond to the many varied experiences of life with flexibility and a sense of
purpose.
– State of balance between the individual and the surrounding world (harmony)
• Social dimension-
– Harmony and integration within the individual between each individual and other
members of society and with the world in which they live.
• Spiritual dimension
– Integrity, principles, and ethics, the purpose in life, commitment to some higher being and
belief in concepts that are not subject to state of the art explanation.
• Emotional dimension-
– Mental health relates to knowing or cognition and emotional relates to feeling
• Vocational dimension-
– Part of human existence, physical work, goal achievement and self realization
• Others (non medical)
– Philosophical, cultural, socio-economic, environmental, nutritional , curative, preventive
 Positive Concept Negative Concept of
of Health Health
Well Being
You are healthy
Not JUST the when you have
absence of disease
the absence of
Feeling good in many disease
ways
Perfect functioning
of the body and mind Therefore, if you
don’t have a
disease, you are
healthy
 What is well -being
Well-being:
Objective component-standard of living or
level of living.
Subjective component-quality of life.
 1. Standard of living
• Usual scale of our expenditure, the goods we
consume and the services we enjoy.
• Includes levels of education, employment
status, food, dress, house, amusements,
comforts of modern living.
• Income & occupation, standards of housing,
sanitation, and nutrition, the level of provision
of health, educational, recreational and other
services may all be used individually as
measures of socio-economic status and
collectively as an index of the standard of living.
 2. Level of living
Nine components-
1. Health
2. Food consumption
3. Education
4. Occupation & working condition
5. Housing
6. Social security
7. Clothing
8. Recreation
9. Leisure and human rights

Health as the most important component as its impairment impairs

level of living.
 3. Quality of life
• The condition of life resulting from the
combination of the effects of the complete
range of factors such as those determining
health, happiness education, social and
intellectual attainments, freedom of action,
justice and freedom of expression.
• Evaluated by assessing a person’s subjective
feelings of happiness or unhappiness about
the various life concerns.
 Quality of life
1. Physical quality of life index (PQLI)-
Three indicators-
Infant mortality, life expectancy at age one, literacy.
Scale of 0 to 100- 0 worst performance and 100 best performance
Ultimate objective -100 PQLI

2. Human development index (HDI)-

-composite index- three dimensions-
a)longevity (life expectancy at birth), 25 & 100
b)knowledge (adult literacy rate and means of years of schooling) 0%
& 100%
c)income (real GDP per capita in purchasing power parity in US
dollars) $100 & $40,000
Index= (actual value) – (minimum value)
(maximum value) – (minimum value)
3. Human Poverty Index (HPI):
HDI measures average achievements in basic dimensions of
human development
HPI measures deprivation in those dimensions

4. Gender-Related Development Index (GDI):

a)Gender-related development index (GDI)
-reflects achievements in the basic human development
adjusted for gender inequalities
b)Gender Empowerment Measure (GEM)-
-Measures gender inequalities in economic and political
opportunities.
 Spectrum of Health
• Health and disease - continuum with no single cut-off point.

Positive health
Better health
Freedom from sickness

Unrecognized sickness
Mild sickness
Severe sickness
Death

• Fluctuates within a range of optimum well-being to various levels of dysfunction, state of

total dysfunction namely, death.
• Transition is gradual
• Spectral concept-not static, but dynamic and process of continuous change, with subtle
variation
• Ever to be renewed
• Degrees of levels of health as degrees of levels of illness
 Determinants of Health
• Health is multi-factorial
• Within and outside factors interacting-
1. Biological
2. Behavioural and socio-cultural
3. Environment
4. Socio-economic
5. Health services
6. Aging of the population
7. Gender
8. Other factors
1. Biological-
Genetic makeup
Diseases of genetic origin-chromosomal anomalies, errors of
metabolism, mental retardation, some types of diabetes
Medical genetics-prevention and treatment
Genetic screening and gene therapy.

2. Behavioural & socio-cultural-

behavioural patterns and lifelong personal habits
Social values, attitudes and activities
Learnt through interactions with parents, friends, peers,
siblings and school and mass media
Association between health and lifestyle of individuals
Disparity in developed and developing countries.
3. Environment-
Hippocrates related health to environment
a)Internal (domain of internal medicine)
each and every component part, every tissue, organ and organ
system an their harmonious functioning within the system.
b) external environment (all to which man is exposed)
All that which is external to the individual human host.

-physical, biological, psychosocial components

-Microenvironment, Occupational environment, socio-economic

environment and moral environment.
4. Socio-economic conditions-
Health status determined by level of socio-economic
development-per capita GNP, education, nutrition,
employment, housing, political system of country
Economic status- per capita GNP
Education- especially female education(Kerala 87.86%
literacy rate, IMR-15)
Occupation- work promotes health, income, status
Political system- implementation of health technologies,
resource allocation, manpower, availability of health
services, health care, % of GNP spent on
healthcare(3% WHO target is 5%),
5. Health services-
Health & family welfare services-
Treatment of disease, prevention of illness,
promotion of health
Immunization, safe water, sanitation, care for
pregnant women & children,
Reach social periphery, equitably distributed,
accessible at low cost, socially acceptable (primary
healthcare)
6. Aging of the population:
2020 - >1 billion people aged 60 and over
2/3rd in developing countries
Chronic diseases, disabilities- special attention

7. Gender:
Women’s issues-1993 Global Commission on Women Health established
Women’s health-nutrition, reproductive health, violence, aging, lifestyle
conditions, occupational environment
Development plans

8. Other factors:
Post industrial age - informational age
Development of technology-access to information, medication,
Health related systems-agriculture, education, adoption of policies, standard
of living, employment opportunities, wages, prepaid medical programmes,
family support systems.
DETERMINANTS OF HEALTH – HEALTH FIELD ELEMENTS
FROM LALONDE DOCUMENT
 Indicators of Health
• Measure the health status of a community
• Compare the health status of a country with
other
• Assessment of healthcare needs
• Allocation of resources
• Monitoring and evaluation of healthcare
services, activities and programmes (target and
achievement)
• WHO guidelines-variables which help to
measure changes.
 Characteristics of health indicator

Ideal indicators should be-

• Valid
• Reliable
• Sensitive
• Specific
• Feasible
• Relevant
Matter of subjective judgement

Health is multidimensional and interlinking of factors

 Health Indicators
1. Mortality indicators
2. Morbidity indicators
3. Disability rates
4. Nutritional status indicators
5. Healthcare delivery indicators
6. Utilization rates
7. Indicators of social and mental health
8. Environmental indicators
9. Socio-economic indicators
10.Health policy indicators
11.Indicators of quality of life and
12.Other indicators
 Mortality Indicators
1. Crude death rate
2. Expectation of life
3. Infant mortality rate
4. Child mortality rate
5. Under-5 proportionate mortality rate
6. Maternal (Puerperal ) mortality rate
7. Disease-specific mortality rate
8. Proportional mortality rate
 Morbidity indicators
1. Incidence and prevalence
2. Notification rates
3. Attendance rates at out-patient departments,
health centres, etc,
4. Admission, readmission and discharge rates
5. Duration of stay in hospitals
6. Spells of sickness or absence from work or
school
 Disability rates
1. Event-type indicators
No. of days of restricted activity
Bed disability days
Work-loss days within a specified period

2. Person-type indicators
Limitation of mobility
Limitation of activity

Sullivan’s index: Expectation of life free of disease

Computed by subtracting from the life expectancy the probable duration of bed
disability and inability to perform major activities, according to cross-sectional data
from the population surveys

HALE (Health adjusted life expectancy)-changed from disability adjusted life expectancy
(DALE) to Health adjusted life expectancy (HALE)

DALY (disability adjusted life year)-One DALY is one lost year of healthy life
 Nutritional status indicators
• Positive health indicator
• Anthropometric measurement of pre-school
children, (wt, ht, mid-arm circumference)
• Heights of children at school entry
• Prevalence of low birth weight (<2.5 kg)

Health care delivery indicators

• Doctor-population ratio
• Doctor-nurse ratio
• Population-bed ratio
• Population per health/subcentre
• Population per traditional birth attendant
 Utilization rates
Social responsibility for the organization in delivery of healthcare
services. Few include-
– Proportion of infants who are fully immunized against the 6 EPI diseases
– Proportion of pregnant women receiving antenatal care or their deliveries
supervised by trained birth attendant
– % of population using the various methods of family planning
– Bed occupancy rate
– Average length of stay
– Bed turn-over ratio

Indicators of social & mental health

As positive indicators for social and mental health are scarce we use
negative indicators such as suicide, homicide, other acts of violence,
crime, RTA, juvenile delinquency, drug abuse, smoking, etc.
 Environmental indicators
• Quality of physical & biological environment in which diseases occur and
in which people live
• Pollution of water, air, radiation, solid wastes, noise, exposure to toxic
substances in food or drink
• Proportion of population having access to safe water, sanitary facilities,
etc.
Socio-economic indicators
• Rate of population increase
• Per capita GNP
• Level of unemployment
• Dependency ratio
• Literacy rates (females)
• Family size
• Housing
• Per capita calorie availability
 Health policy indicators
Allocation of adequate resources
Proportion of GNP spent on health services
Proportion of GNP spent on health-related
activities
Proportion of total health resources devoted to
primary health rate
Indicators of quality of life

PQLI-infant mortality, life expectancy at age one,

literacy
 Other indicators series
• Social indicators
• Basic needs indicators
• Health for All indicators-by 2000 AD
• Health For All (HFA) is a programming goal of the
World Health Organization (WHO), which envisions securing the health
and well being of people around the world that has been popularized
since the 1970s.
• Attainment by all the people of the world by 2000 AD of a level of health
that will permit them to lead a socially and economically productive life.
• Concept of equity in health i.e., all people should have an opportunity to
enjoy good health.
• It is the basis for the World Health Organization's primary health care
strategy to promote health, human dignity, and enhanced quality of life.
– Health policy indicators
– Social and economic indicators related to health
– Indicators for provision of healthcare
– Health status indicators
 MDGs
Millennium development goals (MDGs)
– Adopted by UN in the year 2000 to improve global health The eight Millennium
Development Goals (MDGs) – which range from halving extreme poverty rates to halting the
spread of HIV/AIDS and providing universal primary education, all by the target date of 2015
– form a blueprint agreed to by all the world’s countries and all the world’s leading
development institutions (goals 1, 4, 5, 6, 7, 8)

1. To eradicate extreme poverty and hunger

2. To achieve universal primary education
3. To promote gender equality and empowering women
4. To reduce child mortality rates
5. To improve maternal health
6. To combat HIV/AIDS, malaria, and other diseases
7. To ensure environmental sustainability
8. To develop a global partnership for development

Each goal has specific targets and dates for achieving those targets. There are eight
goals with 21 targets, and a series of measurable health indicators and
economic indicators for each target.
 Health care
Healthcare- concern for fellow human beings
Definition: multitude of services rendered –
– to individuals, families or communities
– by the agent of health services or professionals
– for the purpose of promoting, maintaining, monitoring or restoring
health.
• Medical care - personal services that are provided directly by
physicians or rendered as a result of the physicians instructions.

• Characteristics of healthcare-
1. Appropriateness
2. Comprehensiveness
3. Adequacy
4. Availability
5. Accessibility
6. Affordability
7. feasibility
 Health system
Constitutes management sector, involves organizational
matters-planning, determining priorities, mobilizing and
allocating resources, translating policies into services,
evaluation and health education.
Aim: health development (continuous and progressive
improvement of health status of population)
Goal: Achieve Health For All by the year 2000.

Components of health system include-

– Concepts (health & disease)
– Ideas (equity, coverage, effectiveness, efficiency, impact)
– Objects (hospitals, health centres, health programmes)
– Persons (providers, consumers)
 Levels of health care

Primary health care:

– Essential health care is provided(1st level of contact b/w
individual & health system)
– PHCs, sub-centres
Secondary Health care:
– More complex problem dealt with.
– Essential curative services
– District hospitals, community health centres
– First referral level in health system
Tertiary health care:
– Super specialist care
– Regional central level institutions
– Planning and managerial skills and teaching for specialized staff
 Declaration of Alma Ata (1978)
First international conference in Alma Ata, USSR
It expressed the need for urgent action by all governments,
all health and development workers, and the world
community to protect and promote the health of all
people. It was the first international declaration
underlining the importance of primary health care
Concept of primary health care was defined-
essential healthcare based on practical, scientifically
sound and socially acceptable methods and technology
made universally accessible to individuals and families in
the community through their full participation and at a
cost that the community and the country can afford to
maintain at every stage of their development in the spirit
of self determination.
 Primary health care
• PHC is based of principles of social equity, nation-wide coverage, self
reliance, intersectoral coordination, and people’s involvement in planning
and implementation of health programmes in pursuit of common health
goals.
• Health by the people and placing people’s health in people’s hands

• Declaration of alma Ata-

– Education about prevailing health problems & methods of preventing and
controlling them.
– Promotion of food supply and proper nutrition
– Adequate supply of safe water and basic sanitation
– Maternal and child health care, including family planning
– Immunization against infections diseases
– Prevention and control of endemic diseases
– Appropriate treatment of common diseases and injuries
– Provision of essential drugs
 Concept of disease
Disease- dis ease, without ease, uneasiness
Definition: a condition in which body health is
impaired, a departure from a state of health,
an alteration of the human body, interrupting
the performance of vital functions
A condition of the body or some part organ of
the body in which its functions are disrupted
or deranged.
 Concept of causation

Germ theory of disease-

• One-to-one relationship between causal agent
and disease.
• Disease agent man disease
Drawback -Other conditions like malnutrition,
cardiovascular diseases did not have explanation.
But modern medicine has moved towards
multifactorial causation for disease.
 Epidemiological Triad
The Epidemiologic Triangle: three characteristics that are examined to study the cause(s) for
disease in analytic epidemiology
• Host
– personal traits
– Behaviors
– genetic predisposition Host
– immunologic factors
• Agent
– biological
– physical
Time
– Chemical
– influence the chance for
– disease or its severity
• Environment Agent Environment
– external conditions
– physical/biological/social
– contribute to the disease process
• Time
- accounts for incubation periods,
- life expectancy of the host or pathogen,
- duration of the course of illness or condition
 Multifactorial causation
• Pettenkofer of Munich (1819-1901) early
proponent .
• Modern diseases of civilization-lung cancer,
chronic bronchitis, coronary artery disease,
mental illness, etc.-multifactorial
• Food habits, lifestyle, stress, etc.
• TB, leprosy-bacilli, poverty, overcrowding,
malnutrition, etc.
 Web of causation
• Macmohan and Pugh
• Ideal for chronic disease where the disease agent
is often not known but is the outcome of
interaction of multiple factors
• Considers all the predisposing factors of any type
and their complex interrelationship with each
other
• Study the clusters of causes and combinations of
effects and how they relate to each other.
• Possible interventions to break the web.
 Natural history of disease
• Disease-complex interaction between man, agent and the environment
• Signifies the way in which a disease evolves over time from the earliest
stage of is prepathogenesis phase to its termination as recovery,
disability or death in the absence of treatment or prevention.
• Physician studies disease in a hospital environment whereas
Epidemiologists study disease in community setting hence fill in the
gaps in our knowledge about the natural history of disease.

• Study of natural history of disease is necessary to understand the

prepathogenetic chain of events for a particular disease and for the
application of preventive measures.

Two phases:
– a) prepathogenesis phase (process in the environment)
– b) Pathogenesis phase (process in man)
 Prepathogenesis phase
• Period preliminary to the onset of disease in man
• Factors favouring its interaction with human host
existing in the environment
• Man in the midst of disease or exposed to the
risk of disease.
• Causative factors are agent, host, environment
• Interaction b/w them necessary for disease
process initiation in man.
 Pathogenesis phase
• Begins with the entry of the disease agent in
the susceptible human host.
• Disease agent multiplies and induces tissue
and physiological changes
• Period of incubation and
• Early and late pathogenesis
• Recovery, disability or death
Pathogenesis phase
 Agent factors
Substance living or nonliving, a force, tangible or intangible the
excessive presence or relative lack of which may initiate or
perpetuate a disease process.
Single agent, no. of independent alternative agents or a complex of
two or more factors whose combined presence is essential for the
development of the disease.

Broadly classified as-

1. Biological agents-living agents-bacteria, viruses, rickettsiae, fungi,
protozoa, metazoa.
Host related biological properties like –
Infectivity- invade & multiply in a host
Pathogenecity-induce clinically apparent illness
Virulence- proportion of clinical cases resulting in severe clinical
manifestations.
 Agents…
2. Nutrient agents- proteins, fats, carbohydrates, vitamins, minerals
and water.
Excess or deficiency of intake lead to nutritional disorders
Eg: PEM, Anaemia, Obesity, goitre, vitamin deficiencies

3. Physical agents- excessive heat, cold, humidity, pressure,

radiation, electricity, sound

4. Chemical agents-
a)Endogenous-chemicals produced within the body (urea, serum
bilirubin, CaCO3)
b)Exogenous-agents arising outside the body (allergens,
pesticides, metals, fumes, gases, dust) through inhalation ,
ingestion, inoculation
 Agents…
5.Mechanical agents- chronic friction, other mechanical
forces-crushing, tearing, sprains, dislocations and even
death.
6.Absence or insufficiency or excess of a factor necessary
to health-
Chemical –hormones
– Nutrient – fats, proteins, carbohydrates, etc.
– Lack of structure-thymus
– Lack of part of structure-cardiac defects
– Chromosomal – mongolism, turner’s syndrome
– immunological- agammaglobulinemia.
7. Social agents- poverty, smoking, drug abuse, unhealthy
lifestyle, social isolation, etc.
 Host
In epidemiology human host is referred to as “soil”
and the disease agent as “seed”.
1. Demographic- age, sex, ethnicity
2. Biological- genetic, blood groups, enzymes,
cellular constituents of blood, immunological
factors, physiological function of different organs,
organ systems
3. Social and economic- status, education,
occupation, stress, marital status, housing
4. Lifestyle- personality traits, living habits,
nutrition, physical exercise.
 Environmental factors
I Extrinsic- macroenvironment
1. Physical- nonliving things, soil, air, water,
housing, heat, light, etc.
2. Biological- universe of living things-microbial
agents, insects, rodents, animals, plants.
disease producing agent/ reservoirs of
infection/ intermediate host/ vectors of disease
Adjustment & readjustment for survival
Harmonious relationship-disturbance-illhealth.
 Environmental factors
3. Psychosocial environment- varied social, economic and cultural contexts of diff.
countries and their social standards and value systems
Factors affecting personal health, health care and community well being that stem
from psychosocial make-up of individuals and the structure and functions of
social groups.
Cultural values, customs, beliefs, habits, attitudes, morals, education, lifestyles, etc.
People-member of social group, family, of a caste, community, nation.
Harmony or disharmony
Favourable environment- good health, opportunities, add to quality of life
Psychosocial factors- poverty, urbanization, exposure to stressful situations,
Leading to changes in endocrine, autonomic, motor systems which when prolonged
lead to genetic and personality factors may lead to structural changes

Psychosomatic disorders include-duodenal ulcers, bronchial asthma, HT, CAD,

mental disorders, socially deviant behaviour

Lung cancer-chemical –psychosocial cause-behaviour-smoking

 Risk factors
• Where the disease agent is not firmly established the
aetiology is discussed in terms of risk factors
• An attribute or exposure that is significantly associated with
the development of a disease
• A determinant that can be modified by intervention thereby
reducing the possibility of occurrence disease or other
specified outcomes.
• May be truly causative, merely contributive to the undesired
outcome, predictive in a statistical sense
• Some factors can be modified (amenable to intervention) ,
others cannot be (immutable).
 Risk groups
• Risk groups /target groups
• Identification of them in the population by
certain identified criteria and direct
appropriate action to them first- risk approach
• Something for all but more for those in need-
in proportion to the need.
• Managerial device to increase efficiency of
healthcare services within the limits of
existing resources.
 Iceberg of disease
Disease in a community can be compared to an
iceberg-
• floating tip of the iceberg represents what the
physician sees in the community-clinical cases
• Vast submerged portion of the iceberg represents
the hidden mass of disease-latent, inapparent,
presymptomatic and undiagnosed cases and
carriers in the community.
• Waterline represents the demarcation b/w
apparent and inapparent disease.
 Challenges in healthcare
• Diseases like HT, diabetes, anaemia, malnutrition,
mental illness- unknown morbidity > known morbidity
• Hidden portion of iceberg represents the important,
undiagnosed reservoir of infection or disease in the
community
• Detection and control is a challenge
• Chronic diseases of unknown aetiology, challenge is
absence of methods to detect the subclinical state-
bottom of the iceberg.
 Control
Concept of control:
The term disease control describes ongoing operations
aimed at reducing:
– The incidence of disease
– The duration of disease and consequently the risk of
transmission
– The effects of infection, including both the physical and
psychosocial complications
– The financial burden to the community.
 Concepts of control
Control activities- primary or secondary prevention
or both.
Tertiary prevention is less relevant to control efforts.

Disease agent is permitted to persist in the

community at a level where it ceases to be a public
health problem according to the tolerance of the
local population.
Equilibrium exists b/w disease agent, host and
environment components of the disease process.
Eg. Malaria control vs. malaria eradication.
• Control activities focus on primary prevention
or secondary prevention, but most programs
combine both.
control

elimination

eradication
• Disease elimination -regional elimination –interruption of
transmission of disease, eg. Measles, polio, diphtheria from large
geographic regions or areas-important precursors of eradication

• Disease eradication- tear out by roots- termination of all

transmission of infection by extermination of the infectious agent-all
or none phenomenon-cessation of infection and disease from the
whole world. (small pox)

• Once morbidity of a disease reaches a very low level a residual

infection usually persists in the population –equilibrium b/w host,
agent, environment
• -hidden foci of infection-unrecognised methods of transmission-
resistance of vector or organism, all of which may flare up when the
agent-host-environment equilibrium is disturbed-failure of
eradication programmes-malaria, yaws, plague, kala-azar, yellow
fever.
 Monitoring and surveillance
Monitoring- performance and analysis of routine
measurements aimed at detecting changes in the
environment or health status of the population
• On-going measurement of performance of health
service or a health professional or extent of patient
compliance with or adhere from health professionals
• Continuous oversight of activities to ensure that they
are proceeding according to plan
• Keeps track of achievements, staff, money spent,
resources available-if anything is wrong to take
corrective measures.
Surveillance- watch over with great attention, authority and with suspicion
• Continuous scrutiny of disease and other conditions of ill-health
• Objectives-
 to provide information about new and changing trends in health status of a
population
 to provide feed-back which may be expected to modify the policy and the system
itself and lead to redefinition of objectives
 Provide timely warning of public health disasters so that interventions can be
mobilized
Sentinel surveillance-method for identifying the missing cases and thereby
supplementing the notified cases.
Advantages-reporting biases are minimized, feed-back of information to the
providers is simplified. Sentinel surveillance agencies, development of
sentinel sites, notification system for providing more detailed information.

Evaluation of control: process by which results are compared with the

intended objectives or assessment of how well a programme is
performing. Used during the planning and implementation stages .
Control of infectious diseases (the 4 “C”s)
Control

Cases Contacts Carriers Community

Diagnosis

notification
standard Epidemiological
isolation strict
observation detection
Investigation &
protective
disinfection containment
treatment
follow up
release
 Concepts of prevention
Goals of medicine-
• To promote health
• To preserve health
• To restore health when it is impaired
• To minimize suffering and distress

These goals are embodied in the word

"prevention" .
 Prevention: Definition and Concept

• Actions aimed at eradicating, eliminating or

minimizing the impact of disease and disability, or if
none of these are feasible, retarding the progress of
the disease and disability.

• The concept of prevention is best defined in the

context of levels, traditionally called primary,
secondary and tertiary prevention. A fourth level,
called primordial prevention, was later added.
 Determinants of Prevention
• Successful prevention depends upon:
– a knowledge of causation,
– dynamics of transmission,
– identification of risk factors and risk groups,
– availability of prophylactic or early detection and
treatment measures,
– an organization for applying these measures to
appropriate persons or groups, and
– continuous evaluation of and development of procedures
applied
 Levels of prevention
1. Primordial
2. Primary
3. Secondary
4. Tertiary

1. Primordial- prevention of emergence or development of risk factors in countries or

population groups in which they have not yet appeared through individual and
mass education.
Eg. Lifestyle changes in children to prevent obesity.

2. Primary- action taken prior to the onset of disease which removes the possibility of
occurrence of disease. Intervention in the prepathogeneis phase. Concerns an
individuals attitude towards life and health and his initiatives towards this for
himself, family and community, cancer by elimination or modification of risk factors
of disease through-
-population (mass) strategy (socioeconomic, behavioral, lifestyle changes)
-high-risk strategy
• Holistic approach –health education and concept of individual and community
responsibility for health
 Primary prevention

Achieved by

Health promotion Specific protection

Immunization and seroprophylaxis

Health education
chemoprophylaxis
Environmental modifications Use of specific nutrients or supplementations
Protection against occupational hazards
Nutritional interventions Safety of drugs and foods
Life style and behavioral changes Control of environmental hazards,
e.g. air pollution
3. Secondary- action which halts the progress of a disease
at its incipient stage and prevents complications.
• Interventions- early diagnosis (screening tests, case
finding programmes) and adequate treatment
• Arrest the disease process, restore health by seeking out
unrecognized diseases and treating it before irreversible
pathological changes have taken place, and reverse
communicability to infectious diseases, thereby
protecting others in the community
• Largely domain of clinical medicine
• Health programmes by government
• More expensive and less effective than primary
4. Tertiary- intervention in the late pathogenesis
phase.
• All measure available to reduce or limit
impairments and disabilities, minimise
suffering caused by existing departures from
good health and to promote the patient’s
adjustment to irremediable conditions.
• Rehabilitation-psychosocial, vocational and
medical
 Leavell’s Levels of Prevention
Stage of disease Level of prevention Type of response

Pre-disease Primary Prevention Health promotion and

Specific protection

Latent Disease Secondary prevention Pre-symptomatic

Diagnosis and treatment

Symptomatic Disease Tertiary prevention •Disability limitation for

early symptomatic disease
•Rehabilitation for late
Symptomatic disease
 Modes of Intervention
Intervention- any attempt to intervene or interrupt the
usual sequence in the development of disease in
man by provision of treatment, education, help or
social support.
Modes of intervention-
1. Health promotion
2. Specific protection
3. Early diagnosis and treatment
4. Disability limitation
5. Rehabilitation
1. Health promotion- process of enabling people to increase control over
and to improve health. Not directed against any particular disease but
strengthen the host by:
– Health education
– Environmental modifications
– Nutritional interventions
– Lifestyle and behavioural change
2. Specific protection- to avoid disease altogether by:
– Immunization
– Use of specific nutrients
– Chemoprophylaxis
– Protection against occupational hazards
– Protection against accidents
– Protection from carcinogens
– Avoidance of allergens
– Control of specific hazards in the general environment
– Control of consumer product quality, safety of foods, drugs, cosmetics
3. Early diagnosis and treatment- detection of disturbance of
homeostatic and compensatory mechanism while biochemical,
morphological and functional changes are still reversible.
– prognosis and preventing occurrence of further cases or long-
term disability
– reduce mortality and morbidity in certain diseases like essential
hypertension, cancer cervix, breast cancer
– TB, STD, leprosy (only effective mode of intervention)
– Mass treatment in yaws, pinta, bejel, malaria

4. Disability limitation- prevent or halt the transition of the disease

from impairment to handicap.
Disease impairment disability handicap
Impairment- any loss or abnormality or psychological, physiological
or anatomical structure or function. Loss of foot, vision defects,
Visible/invisible, temporary/permanent, progressive/regressive
Disability- inability to carry out certain activities, any restriction or lack
of ability to perform an activity in the manner or within the range
considered normal for a human being.
Handicap- a disadvantage for a given individual, resulting from an
impairment or a disability that limits or prevents the fulfillment of a
role that is normal for that individual.
Disability prevention –
• Reducing occurrence of impairment (primary prevention)
• Disability limitation by appropriate treatment (secondary
prevention)
• Preventing the transition of disability into handicap (tertiary
prevention)

5. Rehabilitation- combined and coordinated use of medical, social,

educational and vocational measures for training and retraining the
individual to the highest possible level of functional ability.
 Rehabilitation

Medical Vocational Social Psychological

rehabilitation rehabilitation rehabilitation rehabilitation
 International Classification of Diseases (ICD)

• The International Classification of Diseases (ICD) is the standard

diagnostic tool for epidemiology, health management and clinical
purposes. This includes the analysis of the general health situation
of population groups. It is used to monitor the incidence and
prevalence of diseases and other health problems.
• The ICD is the foundation for the identification of health trends and
statistics globally. It is the international standard for defining and
reporting diseases and health conditions. It allows the world to
compare and share health information using a common language.
• Revised about every 10 years and the 10 th revision came into effect
on January 1, 1993.
• ICD-10 was endorsed by the Forty-third World Health Assembly in
May 1990 and came into use in WHO Member States as from 1994.
The 11th revision of the classification has already started and will
continue until 2017.
 Disease classification
John gaunt –arranged diseases in an alphabetical order
• Part of the body affected
• Aetiologic agent
• Kind of morbid changes produced by the disease or injury.

ICD-10 is arranged in 21 major chapters.

Coding system: The first character of ICD-10 code is a letter and each letter is
associated with a particular chapter, except for the letter D, which is used in
chapters II and III and letter H which is used in chapter VII and VIII, chapter I, II, XIX
and XX use more than one letter in the first position of their codes.

Not all available codes are used allowing provision for further revision and
expansion.

ICD-10 consists of three volumes. It contribute to a uniform classification that can

be used throughout the world to make accurate comparisons of morbidity and
mortality data for decision-making in prevention, in management of health care
and in facilitating research on particular health problems.
 International Statistical Classification of Diseases and Related Health Problems 10th
Revision
Chapter Blocks Title

I A00–B99 Certain infectious and parasitic diseases

II C00–D48 Neoplasms

Diseases of the blood and blood-forming organs and

III D50–D89
certain disorders involving the immune mechanism

IV E00–E90 Endocrine, nutritional and metabolic diseases

V F00–F99 Mental and behavioural disorders

VI G00–G99 Diseases of the nervous system

VII H00–H59 Diseases of the eye and adnexa

VIII H60–H95 Diseases of the ear and mastoid process

IX I00–I99 Diseases of the circulatory system

X J00–J99 Diseases of the respiratory system

 XI K00–K93 Diseases of the digestive system

XII L00–L99 Diseases of the skin and subcutaneous tissue

Diseases of the musculoskeletal system and

XIII M00–M99
connective tissue

XIV N00–N99 Diseases of the genitourinary system

XV O00–O99 Pregnancy, childbirth and the puerperium

Certain conditions originating in the

XVI P00–P96
perinatal period

Congenital malformations, deformations and

XVII Q00–Q99
chromosomal abnormalities

Symptoms, signs and abnormal clinical and

XVIII R00–R99
laboratory findings, not elsewhere classified

Injury, poisoning and certain other

XIX S00–T98
consequences of external causes

XX V01–Y98 External causes of morbidity and mortality

Factors influencing health status and contact

XXI Z00–Z99
with health services

XXII U00–U99 Codes for special purposes

 Uses of ICD
• It is used to classify diseases and other health problems recorded on
many types of health and vital records including death certificates and
health records.
• Enabling the storage and retrieval of diagnostic information for clinical,
epidemiological and quality purposes.
• Provide the basis for the compilation of national mortality and morbidity
statistics by WHO Member States.
• sharing and comparing health information between hospitals, regions,
settings and countries
• data comparisons in the same location across different time periods.
• It is used for reimbursement and resource allocation decision-making by
countries.
• Users include physicians, nurses, health workers, researchers, health
information managers, policy-makers, insurers and national health
programme managers, among others.
 ICD-10
• On April 1, 2014, the Protecting Access to Medicare
Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted,
which said that the Secretary may not adopt ICD-10
prior to October 1, 2015. Accordingly, the U.S.
Department of Health and Human Services expects to
release an interim final rule in the near future that will
include a new compliance date that would require the
use of ICD-10 beginning October 1, 2015. The rule will
also require HIPAA (Health Insurance Portability and
Accountability Act) covered entities to continue to use
ICD-9-CM through September 30, 2015