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EPIDEMIOLOGY
Carlen L. De Villa

EPIDEMIOLOGY
- The study of the distribution and determinants of health-related states or
events in specified populations and the application of this study to the
prevention and control of health problems.
- FOCUS: Population
- SCOPE: Diseases
Health-related states and events – described in terms of distribution
(frequency or pattern), determinants (risk factors or causes), and their
prevention and control
- Follows SCIENTIFIC METHOD (from defining the problem, gathering data,
analyzing and interpretation, sound conclusion and set of recommendation.
- Focuses on the FREQUENCY and PATTERN of health events in a population.
- Frequency – refers to the number of health events, such as # of cases
of pneumonia; ratio or rate of cases in the population to compare health
conditions or disease across a population
- Pattern – refers to the occurrence of health conditions by time, place
and person

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DESCRIPTIVE EPIDEMIOLOGY ANALYTIC EPIDEMIOLOGY

 Characterizing health events by time,  Focuses on identifying casual factors or causation of
place and person. disease
 Determinants – demographic characteristic, genetics,
behavior, environmental exposures
COMMUNICABLE DISEASES NON-COMMUNICABLE DISEASES (NCD’s)
 Are spread from one person to  Are chronic diseases which are the result of a
another through a variety of ways; combination of genetic, physiological, environmental
such as physical contact, with an and behavioral factors
infected person, contaminated food  Main Types:
or water, bites from insects or  Cardiovascular diseases (heart attack, stroke)
animals capable of transmitting the  Cancer
disease and breathing in an airborne  Chronic Respiratory Diseases (asthma, COPD)
virus.  Diabetes
 JOHN SNOW (Father of Field Epidemiology), 1854 – conducted studies of cholera outbreak to
discover the cause of the disease and to prevent its recurrence,
 Mid 20th century – epidemiology as been applied to non-communicable diseases including
health-related outcomes behavior and even knowledge and attitudes
 EMERGING INFECTIOUS DISEASE – are infection diseases that have been recently appeared
within population or those whose incidence or geographic range is rapidly increasing or threatens
to increase in the near future

SPORADIC
Tetanus, rabies, plague

ENDEMIC
Malaria, Flu, HIV, Syphilis

HYPERENDEMIC
High Cases of Endemic

EPIDEMIC
Measles, polio, smallpox, dengue

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Uses of Epidemiology in Public Health and Nursing

ASSESSMENT OF HEALTH STATUS OF POPULATIONS
1. Natural history of diseases – describes the sub-clinical changes to sign and symptoms of the
clinical disease until its resolution to either recovery or death.
 Exposure – the moment when pathogen enters a susceptible host
 Latent period – period between exposure and infection – without clinical sign and
symptoms of infection in the host
 Incubation period – period between exposure and onset of clinical sign and symptoms
 Infectious period – defined as the time during the host can infect another susceptible host
 Non-infectious period – is the period when the host’s ability to transmit the disease to
other hosts ceases.

Models of Disease Causation

EPIDEMIOLOGIC TRIAD
 the traditional model for infectious
(communicable diseases, consisting of
susceptible host, external agent and an
environment that bring the host and agent
together.

ICEBERG PRINCIPLE
 shows the disease situation where the
problem is subclinical, unreported or hidden
from view. Only the “tip of the iceberg” is
known.

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Models of Disease Causation

WEB OF CAUSATION
 shows the relationship between different
multiple factors that contribute to the
cause of a disease.
 This model proposes that diseases are
caused by the interaction between genetic
factors (biological, chemical, physical,
psychological, economic or cultural).
Personal behavior also affect this
interaction and interventions can be done
through health promotion.

SCREENING AND SURVEILLANCE

These are often used to develop screening programs, prevention and treatment
policies.

SCREENING – active search or process of detection for disease or disorders

among apparently healthy people.
Primary aim: Identify risk factors and diseases in their earlies stage.

SURVEILLANCE – is the systematic ongoing and analytic process of

monitoring to scrutinize disease condition.
 Event-based – for rapid detection, notification, verification and assessment of

public health events such as clusters of disease, rumors of unexplained deaths

 Indicator-based – are routine reporting of cases of diseases such as notifiable

disease surveillance systems.

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Levels of prevention in the context of

Epidemilogy
Primordial Prevention Primary Prevention
01 - Seeks to prevent at a very 02 - Prevention through the control of
early stage, even before the risk exposureto risk factors, before
factor is present. disease develoment

Secondary Prevention Tertiary Prevention

03 - Application of available 04 - Managing the disease
after the diagnosis to slow
measures to detect early the
disease or health condition or stop disease
before the onset of s/sx progression and limit
disability or complications.

Evaluating Interventions
Epiemiologic Methods are also used in evaluating the effectiveness and efficiency of
interventions:

POPULATION-BASED APPROACH
Interventions which attempt to change socio-cultural or structural factors in
the community, cities, or even country level. Example: Smoking bans in public
places

HIGH-RISK APPROACH
Interventions targeting those persons who are likely to have increase incidence
of a disease based on the presence of risk-factors. Examples: high blood
pressure, screening for breast cancer.

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TYPE OF STUDIES IN EPIDEMIOLOGY

Observational/Non-Experimental Study
DESCRIPTIVE “who, what, where, when” of the disease or health related event
ANALYTICAL “how” of the disease or health related event
CROSS- Examines the relationship between health problems and other
SECTIONAL variable of interest as they exist in a defined population at one
STUDY particular time,
COHORT STUDY Longitudinal study; subject are selected based on their
exposure status and should be disease free in the beginning of
the study
CASE-CONTROL A retrospective study; subjects are based on their disease
STUDY (health) status positive for the disease or health condition
(called the “case group) are compare with subjects who are
negative or have no disease or health condition (called the
“control group”)

TYPE OF STUDIES IN EPIDEMIOLOGY

EXPERIMENTAL STUDY
- Uses as experimental design or model to confirm a casual relationship
suggested by observational studies. Study control factors to reveal unbiased
relationships between exposures and outcomes
RANDOMIZED Are experiments with patients as subjects to evaluate a
CONTROL TRIALS potential cure for a disease and prevent death or
(RCT) disability. Used for testing new interventions or drug.
FIELD TRIALS Experiment done in the “field” involving the subjects free
of the disease or health condition but a high risk of
contracting them.
COMMUNITY Are extension of the field trials involving the whole
TRIALS community as the unit of assignment.

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SOURCES OF DATA IN EPIDEMIOLOGY

PRIMARY DATA
 Refers to the original data collected for a specific purpose by a researcher.
o Cholera outbreak

SECONDARY DATA
 Data which are already collected by other individuals and/or institution for some specific
purpose. Example:
Population Census Birth and death certificate Disease registries
Patient's medical records Health Insurance claims Health surveys
 Philippine Statistic Authority (PSA) –serve as the central statistical authority on primary data
collection in the Philippines by conducting censuses on different sectors of the Philippines
economy such as population, housing, agriculture, fisheries and business.
- collects, complies, analyzes and publishes statistical, demographic, political affairs,
and general affairs of the people of the Philippines.

POPULATION CENSUS – a total process of collecting, compiling,

evaluating, analyzing and publishing or otherwise disseminating,
demographic, economic and social data pertaining, at a specified time, to
all persons in a country or in a well delimited part of a country.

Philippine Census of population and housing – is a regularly occurring and

official inventory of the population as well as housing units in the
Philippines.
The population is enumerated every 5 years beginning on 1970 (except in
2005, where it was moved on 2007) and the result are used to allocate
congressional seats and government program funding.

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CIVIL REGISTRATION and VITAL STATISTICS (CRVS)

– are those system which produce births, deaths, and causes of death
information which are of fundamental strategic importance for countries
development process and governance.
- Must be continuous, timely, accurate, consistent ad complete registration and
reporting all human beings life vital events.

National Statistic Office (NSO) – defined the Mission of Philippine Civil

Registration and Vital Statistic System “as committed to collect, compile,
process and generate quality data on vital records through an effective and
efficient civil registration system to meet the needs of individuals, the nation,
and global community.

CIVIL REGISTRATION and VITAL STATISTICS (CRVS)

- Is important in planning and implementing the Health Agenda
of a country;
1. Defining patterns, trends and impact inclusive of the causes
of mortality
2. Understanding and emerging health issues and challenges
3. Defining appropriate and relevant health-sector reforms,
poverty reduction and development efforts
4. Defining baseline level and monitor and track progress
towards both national an international development goals and
assess effectiveness of health programs.

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DISEASE OR PATIENT REGISTRIES

- Are collection of secondary data related to patients with a
specific diagnosis, condition or procedure.
- Are organized systems that use observational study
methods to collect uniform data (clinical and other) to
evaluate specified outcomes for a population defined by a
particular disease, condition, or exposure and that serve
predetermined scientific, clinical, or policy purposes. –
Agency for Healthcare Research and Quality (AHRQ)

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DISEASE SURVEILLANCE AND NOTIFICATION

- Effective strategy for the prevention as an effective strategy for the
prevention and control of diseases especially epidemic prone diseases.
- Can be local, national and international

DISEASE SURVEILLANCE – is the continuous scrutiny of occurrence of

diseases and health-related events to enable prompt intervention for the
control of diseases.

DISEASE NOTIFICATION – is an integral part of disease surveillance. It

involves the official and timely reporting of the occurrence of specific
diseases and conditions to designate public health authorities by clinicians
and other health personnel for action using designated reporting tools.

POPULATION-BASED SURVEYS
- Are useful for disease surveillance when they ask people about information
which they maybe the most valid and reliable source.

1. Behavioral Risk Factors Surveillance System (BRFSS)

 Nationally coordinated with CDC, a state based
system of cross –sectional health surveys of
adults on health risk behaviors, preventive health
practices and healthcare access, primarily related
to the areas of chronic disease and injuries.
 BRFSS questionnaire are being administered on a
continuous basis by telephone using random digit
dial sampling method.
 Survey respondents are between the ages of 18
and 99, and only one adult pr household is
interviewed.

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2. Youth Risk Behavior Surveillance System (YRBSS)

- Conducted by the CDC and by state, territorial, and local education and health
agencies and tribal government.
- Focused on monitoring priority health risk behavior, including physical inactivity,
dietary behaviors, the prevalence of obesity and asthma among students in grade 9-
12.
- Purpose: provide critical behavior information on adolescent nationwide.
- A self-administered written questionnaire conducted in school classrooms.

3. National Health Interview Survey (NHIS)

- Federally funded survey conducted by the National Center for Health Statistics
- Provides data that are used widely to progress toward achieving national health
objectives.
- Cross sectional household interview survey of men and women between the ages of
1 and 99.

Vital Statistics
 Is the study of the characteristics of human populations.
 It comprises a number of important events in human life including birth,
death, fetal death, marriage, divorce, annulment, judicial separation, adoption,
legitimation, and recognition.
 Are used in identifying health-related concerns and planning for interventions
at the community or country level.

Individual Records
 Birth record – legal document establishing name, parentage, birthdate, order
of birth, legitimacy, citizenship, nationality, geographic place of birth.
 Death record – provides documentary proof surrounding death of the person
such as time and place of death as well as medical cause of death.
 Marriage and divorce record - are usually needed for social and economic
programs, tax privileges for couples, alimony, change of nationality and right
to remarry. Is the study of the characteristics of human populations.

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Population Records
 Serve as key of demographic variable in the
analysis of population size, growth and geographic
distribution.

 Population census can show population size and

growth trends, as well as socio-economic concerns
such as health, housing, education, family
structure, occupation and income.

Definition of Vital Events

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Definition of Vital Events

1. POPULATION INDICATORS

CRUDE BIRTH RATE (CBR)

 measures how fast people are added to the population through births.
 Frequently used overall measure of the reproduction of the population

 A CBR Greater than or equal to 45/1,000 livebirths implies high fertility rate
 A CBR Lesser than or equal to 20/1,000 livebirths implies low fertility.

Definition of Vital Events

1. POPULATION INDICATORS

CRUDE BIRTH RATE (CBR)

 measures how fast people are added to the population through births.
 Frequently used overall measure of the reproduction of the population

 A CBR Greater than or equal to 45/1,000 livebirths implies high fertility rate
 A CBR Lesser than or equal to 20/1,000 livebirths implies low fertility.

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Definition of Vital Events

GENERAL FERTILITY RATE

 A GFR 200/1,000 womens implies high fertility rate

 A GFR 60/1,000 womens implies low fertility rate

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POPULATION PYRAMID

 Graphical representation of the

age-sex composition of the
Philippines.
 The shape of the pyramid provides
insight into the fertility and
mortality patterns of the population
as well as the health services.

Definition of Vital Events

2. MORTALITY INDICATORS
Mortality – measure of the frequency of occurrence of death in a defined population during
a specified interval.

CRUDE DEATH RATE (CBR)

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Definition of Vital Events

2. MORTALITY INDICATORS
Mortality – measure of the frequency of occurrence of death in a defined population during
a specified interval.

CRUDE DEATH RATE (CBR)

SPECIFIC DEATH RATE

Age-specific death rate Sex-specific death rate

Cause-specific death rate

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X 100,000

6.81 homicide deaths per 100,000

CAUSE-SPECIFIC DEATH RATE

The cause-specific death rate gives the

rate of death due to specific causes.
Factors affecting the cause-specific death
rates are the completeness of registration
of deaths, the composition of the
population, and more importantly, the
accuracy of ascertaining the cause of
death.

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PROPORTIONATE MORTALITY RATIO

MATERNAL MORTALITY INFANT MORTALITY

RATE (MMR) RATE (IMR)
Maternal mortality rate (MMR) refers proxy for the age-specific death rate
to deaths due to complications from for the “under one year of age grou”
pregnancy or childbirth, both direct intended to measure the risk of dying
and indirect. during the first year of life.

The maternal mortality ratio is a

measure of obstetric risk (direct
maternal deaths). MMR is affected by
maternal health practices, diagnostic
ascertainment, and completeness of
registration of births. Live births are
used as the denominator for MMR
since the number of pregnancies is not
usually available.

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NEONATAL PERINATAL
MORTALITY RATE MORTALITY RATE
(NMR) (PeMR)
The neonatal mortality rate and This measures deaths occurring
the post neonatal mortality rate during the perinatal period or the
add up to the IMR. Deaths period of time surrounding the
among infants less than 28 event of birth, including the time
days old are due mainly to that a fetus spends in utero after it
prenatal or genetic factors, has reached 22 weeks of gestation
while those in the later months and continues through the birth
are influenced by environmental process until the end of the first
and nutritional factors as well week of life after birth.
as infections.

EARLY NEONATAL POSTNEONATAL

MORTALITY RATE MORTALITY RATE
(EPNMR) (PeMR)
Deaths among infants that This measures deaths of children
survived the first seven days ages 29 days to one year.
but die before the one month of
age.

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The central goals of epidemiology are:

● Describing the disease patterns,

● Identifying the etiological factors in disease

development,
● Taking the most effective preventive measures.
In describing disease patterns and occurrence, two important
concepts must be understood: RISK AND RATE.

RISK -refers to the probability or chance of an adverse event(i.e., the likelihood that
healthy people exposed to a specific factor will acquire a specific disease).
RISK FACTORS- refers to specific exposure factors; such as high cholesterol, lack of
physical activity, cigarette smoke, hypertension, and excessive stress, which are
known risk factors for non-communicable diseases.
• Risk factors may also be intrinsic factors or fixed characteristics of people; such as
age, sex, and genetic makeup.
•Risk factors are nonmodifiable, they may still be influenced by some lifestyle or
environment changes, such as hormonal supplements and weight-bearing exercises.
EPIDEMIOLOGISTS describe disease patterns in aggregates and measure the effects
of risk factors on disease rates.
RATE is a population proportion in which the numerator is the number of events
occurring in a specified period and the denominator consists of those in the population
at the specified time period (e.g., per day, per week, or per year). This proportion is
multiplied by a constant (k) that is a multiple of 10, such as 1000, 10,000, or 100,000.
Thus, a rate can be the number of cases of a disease occurring for every 1000, 10,000,
or 100,000 people in the population.
•Rates allow meaningful comparison of the magnitude of health problems or diseases
across countries, groups, or time periods.

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Morbidity – defined as “any departure, subjective or

objective, from a state of physiological or psychological
well-being”.
- Comprises “disease, injury, and disability”

Morbidity Rate – refer to either incidence or prevalence.

Incidence – proportion of initial case of a disease to a
population
Prevalence – proportion of initial and existing cases of a
disease to a population

INCIDENCE RATE- Describe the occurrence of new cases of a disease

or condition over a given period relative to of the size of the
population at risk for that disease or condition during that same
period.

is considered the most sensitive indicator of the changing health of a

community because it entails the follow-up of a cohort of disease-free
people who are at risk of developing the disease of interest within a
specified period of time and thereby captures the fluctuations of disease
in a population.

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Prevalence Rate is the number of all cases of a specific

disease or condition in a population at a given point in
time relative to the population at the same point in time.

When prevalence rates describe the number of people with the disease at a
specific point in time, they are sometimes called point prevalence.

Period prevalence represents the number of existing cases

during a specified period or interval of time and includes old
cases and new cases that appear within the same period

Prevalence Proportion - measures the total number of

existing cases of a disease at a particular point in time
divided by the number of people at that point in time.
Thus, if the point in time is the time of examination, then
the denomination is the number of people examined.

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Thank you…

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