Basics of Epidemiology

Q. Define the Science of Epidemiology/what is Epid and explain its scope.

Definition of Epidemiology:
Epidemiology is the basic science of preventive and social medicine which covers not only the
study of disease distribution and causation(thereby prevention) but also health and health
related events occurring in human population.
It is the study of the nature, cause, control and determinants of the frequency and distribution of
disease, disability and death in human populations. (Timreck, 1994).
It is the study of the distribution and determinants of disease frequency in human populations.
(McMahon and Trichopoulos, 1996).
The study of distribution and determinants of health-related states or events in specified
populations, and the application of this study to the control of health problems(Last, 1988).
Scope of modern Epidemiology includes:

Identification ofrisk factors of chronic diseases;

Provision of new opportunities for prevention, treatment, planning and improving effectiveness and
efficiency of health services.
Promotion ofhealth and well-beingof the society as a whole and not health of any individuals.

Three components of Epidemiology are:

Disease frequency:refers to study of measurement of frequency of disease& related health events

frequency of occurrence of adisease, disability and death in the form of rates and ratios, viz: prevalence
rate, incidence rate, death rate etc, which are the basic measures of disease frequency.
o These rates/ measures are essential for comparing the disease frequency in different population or subgroup of the same population leading to suspected causes/ factors of the disease occurrence in a given
population.
o This helps in development of strategiesfor prevention and control of health problems.
health related events, like, health needs, health care utilisation etc. are included besides the disease

measurement in a given population over a period of time.

Variables like, BP,height etc.

Distribution of disease: refers to study of distribution patterns in terms of person, place and time;
increase or decrease of disease over a span of time in a community;
variations in patterns of disease suggesting control or prevention of disease.
Determinants of disease: refers to study of Underlying causes/risk factors causing disease.
This aspect helps to develop analytical strategies, such as analytical epid.

Aims of Epidemiology:
The broadaims ofEpidemiology are to:
Describe the distribution and magnitudeof health & disease problems in human population.
Identify causes/risk factors in pathogenesis of disease:
Provide data essential for :
o Planning,Implementation and Evaluation of services for prevention, control &treatment of disease

o Setting up of priorities among those services.

Eliminate/reduce health problems and their consequences.
Promote health and well-being of society as a whole.

 Epidemiological Approach/ Principles of Epidemiology:

The epidemiological approach is based on:
Asking questionsrelated to health events:
o What is the problem
o What is the magnitude
o Where did it happen
o Who are affected
o Why did it happen

Asking questions related to health action:

o What can be done to reduce the problem

o How can it be prevented in future
o What are the resources required etc.

Making comparisons:

o Comparisons can be made of two or different groups having a particular disease with those not
having the same disease.
Basic Measurements in Epidemiology focus on:
measurement of mortality and morbidity in human population
measurement of disability and natality
measurement of presence, absence and distribution of disease
measurement of health facilities available
measurement of utilisation of health services etc.
The basic requirements of measurements are :
- validity
:
- reliability :
- accuracy
:
- sensitivity :
- specificity :
The purpose of quality control in measurement is to reduce errors as much as possible.
However, measurement of psycho-social aspects have not been covered.

Tools of Measurement:

Three basic tools of measurement in Epidemiology are Rates, Ratios and Proportions.
Rate measures the occurrence of death/development of disease in a population during a given
time period. Rate comprises of numerator, denominator, time specification and multiplier. Rate is
always expressed as per 1000 or per 10,000 or per 1 lakh.

Example: death rate = no. of deaths per year

-------------------------- * 1000
mid-year population

Categories of rate are:

- crude rate : are the actual observed rates such as birth and death rates (unstandard)
- specific rate : these are actual observed rates due to specific causes. eg. TB occurring in
specific groups or sex annually or monthly, etc.
- standardised rate: obtained by direct or indirect method of standardisation. eg age and sex
standardised rates.

Ratio is the measurement of disease frequency which expresses relation in size between two
random quantities. It is the result of dividing one quantity by another and is expressed as x:y or
x/y.
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eg.(i) ratio of white blood cells in relation to red blood cells is expressed as 1:600 or 1/600. This
means that for each white blood cell there are 600 red blood cells.
(ii) Other examples include- sex-ratio, bed-patient ratio, doctor-population ratio etc.
Proportion is a ratio which indicates the relation in magnitude of a part of the whole. It is
expressed as percentage.

Example:
no. of children with scabies at a particular time
---------------------------------------------------------total no. of children in the village at the sametime.

* 100

Classification of Epidemiological Studies/ Epidemiologic Methods:

Epidemiological studies can be classified as Observational Studies and Experimental studies.

Observational studies:investigator does not intervene; but only observes the extent of exposure of a person to a
disease or the causative factors related to occurrence of the disease.

(a) Descriptive studies: relate to description of the occurrence of disease in a population.

(b) Analytical studies: relate to analysing relationship of health status and other variables.
(i)
(ii)
(iii)
(iv)

Ecological:co-relational- with population as unit of study

Cross-sectional: prevalence -with individuals as unit of study
Case-control :case reference- with individuals as unit of study
Cohort:follow upwith individuals as unit of study

Experimental/interventional studies:involve effort to change progress of disease/determinant of a disease.

(a) Randomised controlled studies: clinical trials- with patientsas unit of study
(b) Field Trialswith healthy peopleas unit of study
(c) Community Trials: Community intervention studies-with communities as unit of study

USES OF EPIDEMIOLOGY:
i.
ii.

iii.
iv.

Elucidates disease etiology:Identifiescausation of diseases related to genetic causes or environmental factors.

Provides description of health status of population: Helps to explain local disease patterns and formulate
preventive measures suitable to a particular community, especially with a particular disease outbreak .
Helps to describe natural history of disease by identifying factors related to(i) course of the disease, (ii)duration
of the disease and(iii) probability of outcome by age, sex, etc.
Helps to provide guidance in administration and evaluation of health services: the knowledge of frequency and
natural history of diseases in the population helps in the estimation of number of hospital beds etc. required for patients with
specific diseases.

v.
vi.
vii.

viii.

ix.
x.

Provides guidance to policy makers for planning intervention programmes: through knowledge of how many
cases of a particular disease are prevalent in a given population during a given period of time.
Helps in conductingepidemiological studies for Prevention of disease and Promotion of health.
Descriptive studies in epidemiology provides:
Data regarding magnitude and types of diseases in a community (morbidity/ mortality rates).
Clues to causation of diseases.
Backgrounddata for planning, organising, preventive and curative services.
Contribution to research in disease occurrence and its prevention.
Analytical Epidemiological studies provide information on:
Frequency of exposure to a disease

Estimation of disease risk associated with exposure to disease.

Experimental Studies in Epidemiology are useful for:

Investigation of disease aetiology(causes) and preventive& therapeutic measures/appropriate interventions.

Evaluation of Interventions for:(i)health promotion(ii) preventive measures (iii) public health services provided.
----------------------------

Types of Epidemiological Studies: (DETAILS)

I.DescriptiveEpidemiological Studies:
Study of frequency of health events by asking questions like:
Who is getting the disease? (person distribution )
Where is it occurring
(place distribution) and
When is the disease occurring (time distribution).
Steps/ Procedures in Descriptive studies:

Defining the population to be studied and not individuals-criteria forpopulation base:

Total no. of people to be studied;
Composition: age, sex, occupation, cultural characters.
Whole population in a geographic area/ representative sample;
Selected population group needs to be chosen: age group, occupational group,Sex group,
hospital patients,school children etc.
Population needs to beLarge(for generalisations to be made).
Stable population(without being in or out migration population);
Community participation should be visible;
Health facility should be located nearby.

Defining the disease/ condition being investigated under study:

Precise and accurate estimate(measurement) of disease in a given population is required on
who has the disease and who does not to have the disease.

Describing the Disease:The occurrence and distribution of disease by time, place and person:

(i)Time distribution: whereby, Pattern of disease may be described by:

- time of occurrence- week, month, hour of onset of disease, day of week etc.
- whether seasonal occurrence;
- whether there is periodic increase or decrease;
- consistency of time trend, which are generally of 3 kinds:
o Short term fluctuations/trends: are occurrences of diseases which may appear in the form of
epidemics, which are generally of 3 types:
Common source epidemics- which may be single or continuous exposure:
- Common source with singleepidemic:
- these are known as point source epidemics and exposure to disease agent is brief;
- the epidemic curve rises and falls rapidly;
- clustering of cases occur resulting in development of all within one incubation
period.
- these epidemics may due to exposure to infectious agent, contamination of
environment,(air, water, soil) by industrial pollutants etc.
- Common source with Continuous/ repeated exposure:
-Repeated / prolonged exposure of disease takes place with same / multiplesources.
e.g. a well of contaminated water may infect people for a prolonged period with
repeated exposures to the contaminated water resulting in disease outbreaks.
Propagated epidemics- which may be transmitted fromperson to person, anthropod
vector or animal reservoir.
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This epidemic is of infectious origin resulting from person-person transmissioneg:spread of hepatitis and polio.
the epidemic curve rises gradually and falls over a much longer period of time.
Spread of infection depends upon period of exposure to the infected persons.

o Periodic trends/ fluctuations: may be of seasonal trend or cyclic trend.

- Seasonal trend-disease occurrence due to variation in environmental conditions;
e.g:(i) measles occur in early spring; upper respiratory infections occur in winters while,
bacterial infections are prominent in summer months
(ii)Seasonal variation/trend of Dengue can be seen in Table given below:
Table-Seasonal Variation- Dengue
Months
January
Februar
y
March
April
May
June
July
Nov
Dec

2005
151
80

2006
281
193

2007
83
64

50
68
130
172
742
1500
800

181
175
185
279
478
1900
910

46
50
175
186
487
802
201

From the above Table, it is clear that each year, rise of dengue is from May- Nov. However,
there is decrease in the occurrence of the disease in winter month of Dec.

Cyclic trend- Some diseases occurin cyclic periods; eg: influenza is seen to occur after
every 7-10 years; accidents in US is witnessed more during weekends etc.

o Long term trends/secular trends: when changes in occurrence of disease happens over a
long period of time.eg: lifestyle diseases like diabetes, lung cancer, heart diseases have
shown upward trend in developed countries while there is decline in Tuberculosis, typhoid
etc. in these countries.
(ii)Place distribution:

i.
ii.
iii.
-

-This is distribution of disease in different population not only between different countries but
also within countries (geographic variation in disease occurrence).
- These variations in mortality and morbidity are classified as international variations, national
variations, rural-urban variation and local distributions:
Eg. cancer of stomach is common in Japan but unusual in US. Cancer of oral cavity and
uterine cervix are common in India, etc.These variations lead to study of cause-effect
relationships between environmental factors and disease for prevention of disease.
e.gDistribution of malaria, leprosy, nutritional deficiency diseases vary within different parts
of India. Such information helps to demarcate the affected areas for providing appropriate
health care services.
e.gThe variations in death rates (infant and maternal mortality rates) are higher in rural than
urban areas in India, which may be due to differences in social class, lack of medical care,
sanitation, education, etc.
All diseases showdefinite patterns of geographic distribution which may provide evidence of
source of disease and mode of spread.
By relating these variations to agent, host and environmental factors, the cause of the disease
and its frequency can be found out.
Diseases are also classified by geographic occurrence as:
Endemic: habitual presence of a disease in a given geographical area.
Epidemic: occurrence of group of diseases in a community in excess of normal expectancy or an
outbreak.
o Pandemic: world-wide epidemic is known as pandemic.
o
o

(iii)

Person distribution:
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The disease is characterised by defining the persons who develop the disease by age, sex,
occupation, marital status, social class (host factors in epidemiological studies), etc.
- Some of the host factors are :
i.
age: certain diseases are more frequent in certain age groups than in others. Eg.
measles in childhood and arthritis in old age however, communicable disease is
common to all age groups.
ii.
Sex: certain chronic disease such as diabetes etc. are common in women than men
while lung cancer and heart diseases are less frequent in women.
iii.
Marital status: some studies indicate that mortality rates were lower in married males
and females than the unmarried ones of the same age and sex. (K.Park)
iv.
Occupation: while workers in coal mines suffer from silicosis, those in sedentary jobs
suffer from heart diseases.
v.
Social class: certain diseases like hypertension, diabetes, etc. are common in upper
classes than in lower class.

Measurement of Disease:
The information on disease load in a population is available in terms of mortality, morbidity,
disability, etc. the magnitude of health and disease problems in human population is obtained
bycross-sectional studies and longitudinal studies in descriptive epidemiology.

Cross-sectional studies: (i)arethe simplest form of observational study based on a

single examination of a cross-section of population at one point of time.
(ii)These studies are also known as prevalent study.
(iii)Cross-sectional are more useful for chronic diseases like hypertension.
(iv)Cross-sectional study provides information about disease prevalence but very less
information about natural history of disease etc.

Longitudinal studies: observations are repeated in the same population over a

prolonged period of time through follow-up. Longitudinal studies are useful to study:
(i)natural history of disease,(ii) identification of risk factors of disease and(iii) finding
out incidence rate.

Comparing with known indices:

The causes of diseases can be understood by making comparisons between different
populations or sub-groups of the same populations.

Formulation of hypothesis :
By studying the distribution of disease and by utilizing techniques of descriptive
epidemiology, it is possible to formulate hypothesis relating to causation of disease.

Uses of Descriptive Epidemiology:

Descriptive studies provide:

- Data regarding magnitude and types of diseases in a community (morbidity and
mortality rates).
- Clues to causation of diseases.
- Background data for planning, organising, preventive and curative services.
- Contribution to research in disease occurrence.
II. Analytical Epidemiology:
- Study ofdeterminants: search for causes/risk factors;
- Response to a study hypothesisby using various epid methods.
- In contrast to descriptive study which looks at entire population, the analytical study looks
at the individual within the population.
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- the objective of analytical study is to test hypothesis unlike formulation of hypothesis in

descriptive studies.
- Analytical studies comprise of 2 types of observational studies:
i.
Case control study (comparison studies between cases and control groups)
ii.
Cohort study (study of group of people who share common characteristic or
experience within a defined time period).

i.

o Experimental/Intervention (Applied Epidemiology):

- All health outcomes through application of epid. Methods.
- These studies are similar to cohort studies carried out under direct control of the
investigator.
- The aim of experimental studies are to provide :
scientific proof of causes or risk factors in control diseases.
ii.
Method of measuring effectiveness and efficiency of health services for
prevention, control and treatment of diseases.