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Concepts Theory Epidemiology

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Epidemiology Concepts and Theory:

Definition, Purpose, Goal and Functions


Definition: Epidemiology is the study of the distribution & determinants of
health & illness, morbidity, injuries, disabilities, morbidity & mortality in
populations.
Epidemiology is the discipline that provides a systematic
framework for examining states of health, causation of
diseases/injuries & control of health problems in the human
population.
Epidemiology is concerned with:

the traditional study of diseases caused by infectious agents

Health related problems related to suicide, climate, toxic agents


environmental pollution and catastrophic radiation

Asking pertinent questions related to: occurrence of diseases and state


of health among populations; frequency of illnesses in geographic areas;
conditions under which diseases occur; effectiveness of Rx & programs
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Epidemiology: Definition, Purpose


Goal and Functions
Epidemiology focuses on:
1.
2.
3.

Factors that determine the health status of the


population
Controlling health problems
Questions related to what, who, when, where, how &
why in relation to distribution & description of
diseases in a population Eg: Out break of measles in
NYC, Global problems with AIDS, SARS etc

Epidemiology: Definition, Purpose


Goal and Functions
Purposes of Epidemiology
To search for causal relationships in health and illness
To understand why conditions develop
To offer effective prevention for & protection against
disease and social maladies
Goals of Epidemiology
1. Determine the extent of disease in a population
2. Identifies patterns & trends in occurrence of disease
3. Identify causes of disease
4. Evaluates the effectiveness of actions for prevention &
treatment of diseases
5. Keeps record of epidemiological data for quality
improvement
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Historical Roots of Epidemiology


Ancient

Times: Hippocrates (460 to 375 BC):

Belief that diseases affected individuals as well


as the masses. Linked diseases with lifestyles &
environmental factors

Middle

Ages:1348 - Plague (Black Death):

Link between disease (The Plague) and microbes discovered and


accepted by scientists. Confidence that disease can be controlled if
source is eliminated. War against rats control of the plague

18th century: Florence Nightingale (18201910):


1st nurse researcher to show evidence that fresh air, good
nutrition, clean techniques will reduce rate of infection & death of
patients. Kept epidemiologic data re health conditions of injured
soldiers in the Crimean War
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Historical Roots of Epidemiology

19th century: Modern epidemiology based on causal thinking


Table 7-1)

(see

Sanitary statistics (1800-1850): held that disease was caused


by poisonous and malodorous particles from decomposed organic
matter

Infectious-disease epidemiology (1850-1950): Disease

viewed in a simple cause & effect relationship. Advent of vaccines,


antibiotics intended to eliminate causal agents

Chronic-disease epidemiology (1950-2000): Focused on

understanding & controlling chronic diseases. Linked life style with


chronic diseases.
Non-infectious chronic diseases # 1 cause of deaths in the USA
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Historical Roots of Epidemiology (cont)


Current: Eco-epidemiology (Currently emerging):

Global health patterns are in transformation.

Despite knowledge of microbes & risk factors, outbreaks of


disease still occur
Knowledge of how to control AIDS- but thousands of new
cases reported annually (The mystery is controlling human behavior)
With modern technology researchers are able to tract
geographical distribution of diseases in relation to health
risk.
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Epidemiologic Principles and


Theoretical Concepts
Disease states are best understood by a study of the:

Epidemiologic triad
Causality
Risk

Host, agent & environmental factors

Copied from Allender, Rector & Warner (2005) 6th8 Ed

Epidemiologic Principles
and Theoretical Concepts
Host: susceptible human or animal who harbors and nourishes a
disease causing agent
Factors influencing susceptibility and response of host:
Physical e.g.: age, sex, ethnicity and genetic risk factors

Genetic: Cystic fibrosis, Huntington's disease


Age: Childhood illnesses, Alzheimer's disease
Sex: Rheumatoid arthritis (Female more affected)
Ethnic group: sickle cell disease
Physiological state: Fatigue, pregnancy, puberty, stress, nutritional state

(Nies, Mary A.. Community/Public Health Nursing: Promoting the Health of Populations, 4th Edition. W.B. Saunders Company, 102006. 4.4).

Psychological e.g.: attitude towards life, stress


Lifestyle: diet, exercise, sleep pattern and habits

Theoretical concept of inherent resistance:


Ability of some people to resist pathogens.
They are less vulnerable to diseases even after exposure to it.
Related to physical, psychological and lifestyle factors
Cite example
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Epidemiologic Principles and


Theoretical Concepts

Agents:

Factors that contribute to health problems


The primary cause of a health problem or condition
Factors may be present e.g.: virus, drugs & guns or absent
(e.g.: traffic light at busy intersection)

5 Types of agents:
-biological: fungus, insects, viruses, bacteria,
worms,

-chemical gas, dust, fumes


-nutrient dietary excess or

deficiency

- physical mechanical, material, atmospheric, geographic


-psychological stress related events eg job, school
Classification of Agents
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Infectious e.g.: AIDS, measles

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Environment:

External factors that influence vulnerability or


resistance to health problems or conditions

Environmental factors may be physical or psycho-social

Physical environment: climate, geography,


presence of plants, insects, microbes, food and
water supply

Psycho-social environment: access to health


care, cultural beliefs, poverty, stressors in family, at
work or school, public policies, attitudes

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Host, agent and environment interact to cause


disease or health problems.
Intervention to prevent the spread of a disease may
focus on any of these 3 points.
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Copied from Community Health Nursing Caring for Populations (Clark 2003, p.219)

Buzz Groups: 4 in each group


~ Cite a health problem or condition applying the concept of the
epidemiologic triad to identify host, agent and environment
~ Choose a point of intervention & discuss how the spread of the health
problem or condition could be intercepted
~ In seeking to interrupt the spread of the West Nile virus, which aspect of
the epidemiologic triangle is being targeted (host, agent, environment)
in the following example:
Avoiding mosquito bitesuse insect repellant, wear protective clothing
Staying in doors at dawn and early evening
Eliminating stagnant water where mosquitoes can lay eggs
Reporting the presence of several dead birds in the area
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Implementing an organized mosquito control program

Epidemiological Theories & Concepts

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Copied from Community Health Nursing Caring for Populations (Clark 2003, p.211)

Epidemiological Theories & Concepts:


1. Causality
The relationship between a cause and its effect

In epidemiology causal relationships between host,

agent & environment are studied


One event is the result of another event.

Very linear in approach and unsuitable for

understanding the multiple causes of non-infectious


diseases.
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Epidemiological Theories & Concepts (Cont)

Chain of Causation (Fig 7.2): Links the transmission


of an infectious disease in the following way:
Reservoir: where the causal agent lives

Portal of Exit: In order for disease to be transmitted, the causative


agent must leave the body of the reservoir

Mode of Transmission: the vehicle that transports the agent from one
person to the next

Causative Agent: taken to a new portal of entry by insect, food, water,


human

Portal of Entry: may be via skin, mucus membranes, vaginal, GI,


respiratory, etc.

Host: become infected as causative agent is deposited into the


system
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Epidemiological Theories & Concepts (Cont)

Chain of Causation: Illustration

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Concept of Multiple Causation


Linear application of Chain of Causation insufficient for
understanding non-infectious diseases such as CV diseases,
cancer etc.

2. Concept of Multiple Causation or Web of


Causation offered better understanding about the
relationship between populations, health, disease
& their multiple factors

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Epidemiological Theories & Concepts (Cont)

Web of Causation or Denver Epidemiological Model:

Examines multiple causative agents responsible for health


and illness

Considers the impact of biology, life style and environment

on health status of host


Identifies all possible influences on health and illness.

Forces the user to apply critical thinking skills


Useful for explaining problems that cannot be explained in

single causal terms


Suggests various points where intervention may be

appropriate

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Basic Epidemiological Concepts (Cont)


Immunity: Ability of host to resist a particular infectious disease. 4 types of
immunity
Passive Immunity: Short term, acquired naturally (maternal antibodies)
or artificially (via inoculation with antibodies)
Active Immunity: Long term naturally (from disease) or artificially
acquired (via vaccine)

Cross Immunity: Immunity to one disease provides immunity to other


related diseases. May be passive or active. Eg natural immunity to
small pox cow pox
Herd Immunity: Describes level of immunity present in a given population
Risk: Probability that disease or health condition will develop in a particular
group.

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Risk

Probability that a disease or unfavorable health condition will


develop

Directly influenced by biology, environment, lifestyle, and


system of health care.

Risk factors: negative influences

Populations at risk: collection of people among whom a


health problem has the possibility of developing because
certain influencing factors are present or absent or because
there are modifiable risk factors
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Epidemiological Theories & Concepts (Cont)

Natural History of the Disease or Condition


Refers to a description of events that occurred:

Before the development of a disease

During the course of the disease

During the conclusion of the disease

Involve interaction among host, agent and


environment

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Epidemiological Theories & Concepts (Cont)


Natural History to Diseases or Health Conditions
2 Phases Natural History to Diseases:

-Pre-Pathogenesis
-Pathogenesis
Natural progression of a disease occurs in 4 stages
Phase 1: Pre Pathogenesis consists of the first 2 stages:
1st Stage: Susceptibility.
Absence of disease, no exposure to condition but strong possibility for exposure. After
exposure, disease will not progress if immune system is intact. E.g.: Toddlers in a day
care are susceptible to measles.

2nd Stage: Subclinical Disease:

-Exposure to health problem or causative agent but no symptoms of disease.

-Followed by an incubation period where organism multiplies to produce a host


reaction & clinical symptoms
-For noninfectious disease there is an induction or latency period ie time between
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exposure & onset of symptoms

Epidemiological Theories & Concepts (Cont)


Natural History to Diseases or Health Conditions

Phase II Pathogenesis of Natural History:


Stage 3: Clinical Disease:
There is evidence of disease
Clinical signs and symptoms are present
Positive lab test for disease or condition
Disease or condition can be diagnosed at this stage

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Epidemiological Theories & Concepts (Cont)


Natural History to Diseases or Health Conditions

Pathogeneses Phase II Natural History cont


Stage 4: Resolution, Recovery, Disability or Death
Recognizable signs and symptoms of disease
persist
Disease may be mild or severe
Conclusion of disease may result in
Return in health
Residual or chronic form of disease
Death

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In Class Group Work


In groups of 4 5, identify a host, an agent and
an environmental factor. Describe the
progression of a disease or conditions in
outline form.

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Definitions of Health

World Health Organization (WHO): A state of complete


physical, mental & social well being and not merely the absence
of diseases.

Other Definitions: A person physical, mental and spiritual


state; may be positive or negative. A dynamic state of being

Holistic state of well being, including mind, body and spirit

Betty Neuman: Views health on a continuum- with wellness at


one extreme & illness at the other. Health is equated with
optimal stability, best possible wellness state. Client may
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experience varying levels of health.

Concept of Health Promotion

Health Promotion: All efforts that seek to move people


closer to optimal wellness; eg health education, behavior
modification. Has to do with disease prevention. May
involve client as a person, family or community.

Goal: To raise public awareness of living healthy. To


initiate healthful programs eg Health People 2020
Health Maintenance: Focuses on sustaining good health
& providing services after returning client to a state of
well-being eg medical equipment, exercise programs
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Levels of Prevention: Strategic Points of Control


Concern is not only with treating diseases but also

involves wellness at various levels

Disease or health problems may be prevented, halted

or reversed at various points during its natural history

Identifying strategic points of control and designing

programs to promote wellness are primary concerns


of epidemiologists

Disease control may be implemented at the

primary, secondary or tertiary levels of prevention

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Levels of Prevention: Primary Prevention


Primary Prevention:
Aims at altering susceptibility or reducing exposure of
persons who are at risk for injuries or developing a
particular disease
Geared towards a generally healthy population
Involves visionary planning and implementation of

programs before disease, injury or problem strikes

Seeks to prevent the occurrences of health problems


Include health promotion and disease prevention

measures. E.g.: health teaching, nutritional counseling,


immunizations, safety devices to prevent falls, MVA etc
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Levels of Prevention: Secondary Prevention


Secondary Prevention:

Aims at early detection and prompt treatment

Seeks to cure or reduce progression of disease

Geared to prevent disability and complications

Includes screening programs for early detection of


diseases eg lead screening in toddlers,

Screening susceptible people who are asymptomatic

Early case finding prompt treatment & nursing care

Preventing the development of health condition


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Levels of Prevention: Tertiary Prevention


Tertiary Prevention: Aims at:
Reduce the extent or severity of a health problem thus
limiting disability in early stages of the disease
Rehabilitation for injured persons
Education to prevent further deterioration
Continued treatment and nursing care
Referrals to support groups and resource agencies to offer
support and help minimize loss of function
Minimizing effects of unhealthy conditions

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Understanding Key Terms


Rates of Occurrence
Express the proportions of people with a health

condition among a population at risk


Examining rates of occurrence allow comparison

between groups of different sizes with respect to a


particular problem e.g.: a community of 1000
reporting 50 cases of syphilis a year has the same
magnitude of a problem as a city with 100,000 people
reporting 5,000 cases/year

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Key Terms
Prevalence: Refers to all the people with a particular
health condition, living in a given population at a
specific point in time.
Prevalence Study: Describes patterns of occurrence
Risk

Probability that a disease will develop

Directly influenced by factors such as lifestyle,


environment, healthcare system, biology

Negative influences are called risk factors


37

Key Terms
Incidence: refers to all new cases of a disease
appearing during a given time
Incident rate describes the proportion of

persons contracting the disease in relation to


the population at risk during a given period of
time.

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Key Terms
Population at risk:
Group(s) of people who have the greatest
potential to develop a particular health problem
because of the presence or absence certain
contributing factors.
~ Clark 2003 p. 212

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Key Terms
Epidemic: High incidence of a disease occurring in a
community that significantly exceeds the normal or
expected frequency
Pandemic: Significant increase in the incidence of a disease
occurring world wide e.g.: AIDS
Mortality rate: sum of death in a given population
Morbidity: Incident of disease and disability in a given
population
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Sources of Data for Epidemiologic Study


3 Major Sources of Information
- Existing data
- Informal investigation
- Scientific studies
1. Existing Data
Information available nationally, regionally, by state, county or

urbanized area

Include vital statistics, census data, morbidity data on infectious

disease

Local health departments provide data upon request and give advice

on specific problems

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Buzz Group pages 231-235


Describe the following sources of data and explain their
relevance to the study of epidemiology.
Cite examples or brief case scenarios to validate your understanding.
Group A

~ vital statistics & disease registries

~ census data & reportable disease


Group C ~ environmental monitoring & National Center for
Health Statistics
Group B

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Sources of Data for Epidemiologic Study

2. Informal Observational Studies

May be triggered by any client seen by the nurse

Nurse has s suspicion about a client

Informal inquiries are made by the nurse

Major problems are revealed

Questions are raised and hypothesis suggested that may


form the basis for larger studies

Data to support the need for such studies may be obtained


from various sources of existing data
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Sources of Data for Epidemiologic Study

Scientific Studies:
Carefully designed studies
Findings from studies used to develop or add

to body of professional knowledge

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Research Process for an Epidemiologic Study

1. Identify the problem.


2. Review the literature.
3. Design the study.
4. Collect the data.
5. Analyze the findings.
6. Develop conclusions and applications.
7. Disseminate the findings.
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Nursing Process for Communicable


Disease Control
Assessment:

case identification, case finding;


comprehensive; no assumptions; communitys need
for surveillance or new/improved control programs

Nursing

Dx: Analyze the data, formulate goals


Planning: assisting with immunizations, symptom
relief, controlling disease if present, limiting exposure,
collaboration
Implementation:

service delivery; supervision of


staff; agency functions; primary prevention education
for future infections; record keeping and reporting

Evaluation:

Measuring the effectiveness of the


program or treatment
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Infectious Diseases of Bioterrorism


Anthrax

Acute bacterial disease that affects mainly


the skin (cutaneous) or respiratory tract
(inhalation)
Case fatality: 520% for cutaneous, 100% for
inhalation

Smallpox

Variola virus transmitted person to person


Risks associated with smallpox vaccination
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Awareness of Bioterrorism
Community health nurses must raise their awareness & preparedness of
bioterrorism
These personnel should be knowledgeable about the consequences of
biological terrorism because:
They work in the community and are in a position of responsibility to
educate the public and allay fear
Correct information must be provided to families, groups &
aggregates
They will need to help people in the decision-making process re need
for immunization against possible terror attacks

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