Introduction to Epidemiology

Dr. Alok Acharya

Assistant Professor
MD. (Community Medicine)
Nobel Medical College
 Epidemiology
• Epidemiology is the study of the distribution
and determinants of disease and health-
related states or events in specified
populations and the application of this study
to the control of health problems.
 Distribution of disease
• This part of epidemiology is called as
‘Descriptive epidemiology’

• Frequency (number/rate)
• Pattern (time, place and person)
 Determinants
• What is the cause of these health related
event? (test aetiological hypotheses and
identify the underlying causes or risk factors
with the use of epidemiological principles and
methods)___ “Analytical epidemiology”
• One basic concept of Epidemiology is disease
does not occur randomly. It occurs when
certain factors come together.
Epidemiological triad

Host Agent

Disease

Environment
 Specified populations
• Epidemiology sees disease as distributed
within a group, NOT as a property of an
individual.
• Epidemiologist normally does not deal with
individual patients but an entire population.
• Epidemiologist also deals with applying the
knowledge gained through the study of
disease.
 Epidemiological approach
• The epidemiological approach to problems of
health and disease is based on two major
foundations
– Asking questions
– Making comparisons
 Questions related to the Disease
• What is the problem?
• What is its magnitude?
• Where did it happen?
• When did it happen?
• Who are affected?
• Why did it happen?
 Questions related to Health Action

• What can be done to reduce the problem?

• How can it be prevented in future?
• What action should be taken by community?
• What resources are required?
• What difficulties may arise?
 Comparison
• Basic approach to epidemiology is to make
comparisons and draw inferences.
• Comparisons between two (or more) groups
• One group having the disease and other not
having disease
 BASIC MEASUREMENTS IN
EPIDEMIOLOGY

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 Measurements in Epidemiology
a. Measurement of mortality
b. Measurement of morbidity
c. Measurement of disability
d. Measurement of natality
e. Measurement of the presence, absence or distribution of the
characteristic or attributes of the disease
f. Measurement of medical needs, health care facilities, utilization of
health services and other health-related events
g. Measurement of the presence, absence or distribution of the
environmental and other factors suspected of causing the
disease, and
h. Measurement of demographic variables
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 Tools of measurement

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 Basic measurements in Epidemiology

• Tools of measurements
– Rates
– Ratios
– Proportions

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 Rate
• Rate measures the occurrence of some health
related event in a population during a given
time period.
• It can measure risk of developing a disease.
– E.g. Incidence rate of Lung cancer among
smokers is 8 per 1000. There is 8 per 1000
chance of developing Lung cancer among
smokers

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 Rate
• Rate has 4 elements
– Numerator,
– Denominator,
– Time specification
– Multiplier(1000 or 100,000… or 10n to
make round figure).

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 Rate
Numerator Time period
(Actual case)

Number of deaths in One Year

Death rate = X 1000

Mid- year population

Multiplier
Denominator
(Potential case)

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 Ratio
• Ratio expresses the relation in size between
two random quantities.
• The numerator is not a component of the
denominator
• The numerator and denominator represent
two different entities/ things

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 Ratio

Numerator

Number of Females in a population

Sex ratio =
Number of Males in a population

Denominator

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 Proportion
• Is a measure which indicates the relation of
part to the whole/full.
• The numerator is always part of denominator
• Usually expressed as a percentage

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 Proportion
• Proportion of children having scabies in a
village in year 2008 =
Numerator

Number of children with scabies (in 2008)

X 100

Total number of children in the village (in

2008)
Denominator

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 Mortality rates and ratios
• 1. Crude death rate
• The simplest measure of mortality is the
'crude death rate'.
• It is defined as "the number of deaths (from all
causes) per 1000 estimated mid-year
population in one year, in a given place"

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 We can limit the rate to deaths from a
certain disease, that is, a disease specific
or a cause-specific rate

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We can also place restrictions on more than one
characteristic simultaneously, for example, age and
cause of death

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• 2. Specific death rates
– Cause or disease specific
– Group specific - age specific, sex specific

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 Differences between Case fatality and
mortality

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 Case fatality
• In a mortality rate, the denominator represents
the entire population at risk of dying from the
disease, including both those who have the
disease and those who do not have the disease
(but who are at risk of developing the disease).
• In case fatality, the denominator is limited to
those who already have the disease.
• Case fatality is a measure of the severity of the
disease.
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 Case fatality
• Case fatality rate represents the killing power
of a disease - the ratio of deaths to cases.
• The time interval is not specified.
• Case fatality rate is typically used in acute
infectious diseases (e.g., food poisoning,
cholera, measles).
• Its usefulness for chronic diseases is limited.

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Proportional mortality rate (Ratio)
• Proportional mortality rate expresses the
"number of deaths due to a particular cause
(or in a specific age group) per 100 (or 1000)
total deaths".

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• E.g of proportional mortality rate.

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 Measurement of morbidity
• Incidence
• Prevalence

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 Incidence
• Incidence is defined as “the number of NEW
cases occurring in a defined population during
a specified period of time”.

Number of new cases of specific disease during a

Incidence= given period of time
X 1000

Population at risk during that period

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 Incidence
• There are 500 new cases of Hepatitis in a city with a
population of 30,000 in 2008
• Incidence of hepatitis =

500
= 16.7 per 1000 per
X 1000 year
30,000

• The Incidence rate MUST contain the time period

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 Incidence
• Incidence includes new cases recurring in the
same person
• If a person suffers from Common cold two
times in a year it has to be counted as two
new cases
• Special incidence rates are
– Attack rate
– Secondary attack rate

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• Risk
– The likelihood that an individual will
contract a disease

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 Problem with numerator
• Who has the disease?
• Who to include in numerator?
• Interview errors

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 Problem with denominator
• Everyone in denominator must have potential
to enter numerator group

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 Prevalence
• Prevalence is defined as all cases (old and
new) present at a given point of time or a
period of time in a given population.
• Prevalence is of two types:
– Point prevalence
– Period prevalence

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 Point Prevalence
• Point prevalence refers to the total number of
cases (old and new) present at given point of
time, usually a day.
• Prevalence of Cutaneous leishmaniasis in
Eastern Nepal on 5th May, 2009
• Normally when we say prevalence it is Point
Prevalence

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 Prevalence

Number of all current cases (old and new) of

specific disease during a given point of time
X 100
Estimated Population at at the same point in
time

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 Period Prevalence
• Is the total number of cases (old and new)
existing during a defined period of time in a
defined population.
• Prevalence of Pulmonary Tuberculosis in
Nepal in year 2008

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 Investigation of Epidemic

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 CHALLENGES
(during an epidemic)

- To initiate control measures as quickly as

possible

- To study the situation in detail at the same time

- Steps designed to address both the concerns

simultaneously
 The steps in investigation of an epidemic

I. Confirmation of the diagnosis

II. Confirmation of the existence of an

epidemic
- Previous records
 The steps in investigation of an epidemic

III) Defining whole population which is exposed

• -Census data
• -Local health centre data,
• - Voter’s list
• -Actual counting of the population
• -The latest map of the area is obtained with the
important landmarks and divisions
 The steps in investigation of an epidemic

IV) A quick search for cases and study their

characteristics
- Using a check list

V) Analysis of the initial data

-Everyday new cases are counted and described
in terms of time, place and person.
 The steps in investigation of an epidemic

VI. Study of ecological factors i.e. the environment.

VII. Formulation of several possible hypotheses and

application of control measures based on these.
• Based on distribution of the disease and associated
factors
• Immediate control measures are to be employed
 The steps in investigation of an epidemic

VIII. Further and more detailed investigation of

the disease distribution and associates RF’s in
the population.
-Once the compulsion of rapid investigation is
over and the control measures initiated
- More detailed study into the epidemiology of
the outbreak
 The steps in investigation of an epidemic

IX. Testing of various hypotheses to conclude the

final possible explanation for the outbreak
- Each hypothesis is examined by assessing the
evidence for and against.
-The hypothesis which explains all the known
facts is finally adopted as the cause of the
epidemic
 X. Writing the report
- Background information of the affected population
- Methodology adopted for the investigation
- Characteristics of the cases
- Findings and their interpretation e.g. Attack rate,
Secondary Attack rate, Median Incubation Period
etc.
- Control measures undertaken
-Lessons learnt and recommendations for
prevention in future and for early control should
an outbreak occur in future