EPIDEMIOLOGY

Definition:
. . .Science is concerned with the circumstances under which diseases
occur, where diseases tend to flourish and where they do not.

. . . .Study of distribution and determinants of disease prevalence.

. . .is the field of science, which is concerned with the various factors, and
conditions that determine the occurrence and distribution of health, disease,
defects, disability, and death among groups of individuals.

. . . is the study of the distribution and dynamics of disease occurrence in

human populations with the aim given identifying factors of causation as a
basis for determining preventive and control measures.

Terms used in epidemiology:

Endemic – the constant presence of a disease or infectious agent within a

given geographic area. There is an equal number of susceptible and immunes
in the said population.

Epidemic – the occurrence in a community or region of cases of a disease

condition clearly over normal expectancy and derived from a common or
propagated source. There are more immunes than susceptibles.

Pandemic – denoting a disease affecting or attacking all or a large portion of

the population; extensive epidemic with wide geographic distribution.

Sporadic – A term describing the occurrence of a few cases of disease now

and then in a geographic area. There are more immunes than susceptibles.

Infection – the entry and development of an infectious agent in a man’s or

animal’s body.

Infectious agent – an organism, chiefly a microorganism but including

helminths that is capable of producing infection or infectious disease.

Infectious disease – an apparent or manifest condition of man or animals

resulting from an infection.

Incubation period – the interval between exposure to an infectious agent and

the appearance of the first signs and symptoms of the disease.

The source of infection is the person, animal, object, or substance from which
an infectious agent immediately passes to a host.

Primary case – the first case that occurs to a family or community as a unit.

Secondary case – a case resulting from a primary case.

Reservoir – any human being, animal, arthropod, plant, soil, or inanimate

object in which an infectious agent normally lives and multiplies and on which
it depends primarily for survival and reproduces itself in such a manner that it
can be transmitted to a susceptible host.

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Susceptible- a person or animal presumably not possessing sufficient
resistance against a particular agent to prevent contracting a disease if or
when exposed to the agent.

Carrier – A person (or animal) who harbors a specific disease-causing agent, in

the absence of clinical manifestations and who served as a source of infection
for others.

Contact – A person (or animal) who has been in association with the infected
person or animal or a contaminated environment.

Incidence – frequency or occurrence of new cases of a disease in a population

over a stated period expressed as a rate.

Isolation is the limitation of movement of a person with a communicable

disease or a carrier who harbors an infectious agent.

Quarantine – restriction of movement of those who have been in contact with a

communicable disease for some time during which they may be potentially
infectious to others.

METHODS OF EPIDEMIOLOGIC STUDY

I. Descriptive method. The epidemiologist seeks an accurate description

of a specific disease phenomenon that has already occurred. He
gathers pertinent data regarding time (year, season, day) and the place
of occurrence (geographic, political, subdivision, rural/urban areas). He
investigates the characteristics of persons affected ( age, sex, ethnic
group, occupation, family history).

2. Formulation of hypotheses – acceptable hypotheses must be consistent with

known facts regarding disease occurrence.

3. Testing of hypotheses – analytic studies which may be either observational

or experiment, are designed to test the hypotheses.

The Epidemiologic Triad

HOST
(particular individual or group
of immediate concern)

AGENT ENVIRONMENT
(etiologic agent) (all that is external to the
agent & the host)

These three elements are closely bound together and each affects the other.
The interaction of the host, agent, and environment determines the modes
of transmission, natural history, occurrence, and control of disease, illness, or
other conditions. The health of an individual or community depends upon the
state of equilibrium maintained within this triad of elements.

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Transmission of infectious agents could be:

Direct transmission
Indirect transmission may be:

Vehicle-borne
Vector-borne
Airborne

Phases of Epidemiological Approach

Exploratory Phase: Descriptive Studies

As in any type of study, the first phase in an epidemiological

investigation of a disease condition is the collection,
organization, and analysis of data, which is considered the
exploratory phase. Since data collection alone is oftentimes an
expensive and arduous process, this phase depends largely on
already available information ( e.g. vital statistics). This
presupposes that the diagnosis has been verified and the major
task is to describe accurately the distribution of the disease in a
population ( a strategy in epidemiology called descriptive studies)
as a basis for analysis.

Verification of the Diagnosis

A pre-requisite in describing the occurrence of a disease/condition

is its recognition or identification with reasonable certainty.
Is the disease that it is reported to be? To answer these questions
may only require a recognition of the clinical manifestations
of a disease (as in measles and chicken pox) or many necessary
laboratory and diagnostic tests ( as in gastroenteritis and
tuberculosis). In the presence of various clinical manifestations, it
will be necessary to state one’s definition of a case and in so doing,
two factors should be considered: sensitivity and specificity

Sensitivity is the ability of a definition of a test (if such is

used) to pick up all cases or avoid false positives.

Specificity is the ability to exclude other cases or avoid false

negatives. Taking a test for diabetes as an example, urine sugar
determination is a sensitive test because it can pick up all
diabetics. Determination of fasting blood sugar, on the other hand,
is both a sensitive and specific test because one can pick up most
if not all diabetics and can exclude non-diabetics. Taking the
definition of a case in a gastrointestinal outbreak as another
example, one would have to decide which among various
manifestations (e.g. diarrhea, vomiting, nausea, abdominal
cramps) should be included in the definition for it to be both
sensitive and specific.

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 Description of the Disease/Condition

After verifying the diagnosis, the next step is to describe the

disease pattern in terms of place, person, and time ( not
necessarily in this order). The frequency of disease as shown by
morbidity and mortality statistics varies by place, person, and
time and the study of factors that influence these variations
offers important clues to disease causation.

Characteristics of place. The frequency of disease can be related

to the place of occurrence in terms of areas set off either by natural
barriers (e.g. rivers, mountains, etc.) or political subdivisions.
Places separated by natural barriers offer more useful clues to
differences in disease frequency because of certain
environmental and climactic conditions, differences in
economic and social activities, and availability of
transportation and medical facilities.

Characteristics of Person. In describing the disease pattern in terms of

person, morbidity rates are computed according to some characteristics
like age, sex, occupation, residence, etc. These characteristics are
analyzed to determine the susceptible population group.

Persons differ biologically as well as in their manner of living. These

differences in individuals and in groups, whether natural or acquired
affect the occurrence and distribution of diseases. Where communicable
diseases constitute the major public health problems in a
community/country, it will be useful to understand how such
differences in groups affect the behavior of a disease, which can be
illustrated by a community’s reaction is the total of the reaction of
individuals who compose a population group.

Several factors determine the reaction of a

community/population group to disease agent invasion. These are:

Herd immunity. This is the state of resistance of a population group

to a certain disease at a given time. In other words, it is the level of
immunity of the group, which is contributed by the state of immunity of
each member. Some have high levels of immunity, while still, others
have no immunity at all. The number of individuals, on the other hand,
determines the susceptibility status of a community, with little or no
immunity.

The susceptibility level changes as individuals become infected. These

individuals develop immunity and recover. If the resulting immunity is
durable, susceptibility decreases with age.

The immunity level of a population may be reflected by mortality and

morbidity figures. High morbidity and mortality rates are reflected by
low herd immunity. A survey of the community using serological tests
will give a more accurate measure of the population’s herd immunity. For
example, high antibody titers are indicative of high immunity. In
addition, determining the age distribution of immunity by serological
tests will give an idea of the time that the disease was last present.

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The proportion of immune to susceptible also determines whether
there will be an epidemic or whether a disease will be endemic or
sporadic in nature in a population. When the number of susceptible far
outweighs the number of immunes, an epidemic may be expected to
occur. In an inverse situation, sporadic cases are expected to occur.
However, a balance between the number of immunes and susceptible
will probably result in an endemic situation.

Exposure or contact rate. This represents the opportunities for

progressive transfer or transmission of an infectious agent to a new host.
The probability of transfer depends on:

Size of the reservoir, which determines the frequency of contact

The facility of transmission is, in turn, affected by population density
(in case of contact-borne disease), and standard of hygiene ( in case of
vehicle-borne diseases). For example, tuberculosis (which is transmitted
by contact) has a higher probability of spread in a densely populated
area; there is a higher incidence of gastroenteritis in areas with poor
sanitation than in those with good sanitation; and diseases transmitted
by vectors such as malaria is abound in areas with high mosquito
density.

Chance. This is the probability of contact between the source of infection

and the susceptible individual, which will depend upon:

The number of sources of infection (the more sources of infection

giving
the greater chance of infection
The location of the source of infection (the nearer it is to the
susceptible population, the greater the chances of exposure).
The number of immunes (the lower the number of immunes, the
greater the chances of exposure.

Characteristics of Time. The study of disease occurrence with time is a

basic component of epidemiological analysis. The occurrence of disease is
expressed on a daily, weekly, monthly, or yearly basis and is usually
reckoned in terms of time onset rather than any other criteria such as
time of reporting or admission to a medical/health facility. The interval
from the time of onset to diagnosis is short for acute diseases time
interval may produce a distorted pattern of disease occurrence. Marked
changes in disease frequency in a very short time are often easier to
explain than changes that evolve slowly. These changes in disease
frequency with time may be categorized under three headings depending
upon the time scale involved:

Short Time fluctuations (Epidemic). Changes in disease frequency in a

very short time, which are characteristics of epidemics can be illustrated
utilizing an epidemic curve. An epidemic curve is a graphical
presentation of the distribution of cases by date/time of onset. The
epidemic curve may be used to determine the type of epidemic by mode
of transmission.
Two principal types of epidemics are generally known:
1. Common Source epidemic. This type of epidemic is due to the
exposure of a group of persons to a common vehicle, commonly water or

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food. The onset is usually rapid, although variations may occur
depending upon the length of exposure of the victims to the common
source. Its typical form is called the point source outbreak wherein the
exposure is brief and simultaneous. All the cases develop within one
incubation period so that the epidemic curve shows a rapid rise and fall
and is usually skewed (slanted) to the right.
A variation of the common source epidemic occurs when there is
somewhat prolonged exposure to the source so that the infectious agent
is taken over long periods about the incubation period.

Propagated epidemic. This type of epidemic results from direct or

indirect transmission of an infectious agent from an infected to a
susceptible person. The onset is usually gradual, the cases occurring
over several cases in such successive periods (reflected by the ascending
limbs in a wavy epidemic curve) until several susceptibles are exhausted,
in which case the number of cases declines until the outbreak ends.

It should be underscored that the epidemic curves described represent

typical patterns. However, the variability of incubation periods may
obscure these patterns. For example, a propagated outbreak of a disease
that is highly infectious and has a short incubation period may result in
a rapidly rising and rapidly falling curve similar to the point of the
outbreak. In like manner, a typical point outbreak may be obscured by
continued contamination of the source or by a long, variable incubation
period.

Cyclic variations. This refers to recurrent fluctuations of disease

frequency, which may exhibit cycles lasting for certain periods. The
occurrence of certain diseases at certain months of the year is
referred to as seasonal occurrence. Seasonal variation is usually based
on the characteristics of the infectious agent itself, the life pattern of the
vector or animal hosts, or changes in the likelihood of person-to-person
spread. Examples of seasonal occurrences in the Philippines are:
Cholera (which reaches a peak during the rainy months of August and
September when floods and other factors facilitate transmission).
Pneumonia (which is common during the cold months from November to
January)

Secular Variation. This refers to changes in disease frequency over a

period of many years (e.g. decades, centuries). Major changes in
population patterns and the way of life bring about corresponding
changes in disease patterns. One general example of this trend is the
decreasing incidence of most communicable diseases and a rise in
chronic degenerative diseases in many countries, particularly in
developed ones.

Analysis of Disease Pattern

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Careful analysis of a disease/condition according to place and time is
needed to determine the general patterns of disease occurrence and
identify groups, which are at high risk of the disease concerned. In the
process of analysis, one tries to find out if there is a statistical
relationship between a disease and the biological or social attributes
revealed from descriptive studies. Understanding the meaning of a
statistical relationship is therefore important.

A statistical association may be causal or non-causal in nature: a

non-causal one being artifactual or secondary. Possible explanations
for these types of associations are given.

Artifactual or spurious associations may be due to certain procedural

aspects involved in a study (e.g. selecting the study subjects, obtaining or
collecting information, and recording information/observations). For
example, if the subjects in the study are patients in the Philippine
General Hospital and one finds a direct relationship between the socio-
economic status and the disease concerned. This relationship is spurious
since most patients in this hospital belong to the lower-income group in
the first place.

Secondary. When a factor and a disease are associated only because

both are related to some common underlying condition, such association
is secondary in nature. A change in the factor responsible for the
secondary association will not produce a corresponding change also
affects the underlying condition. For example, a high incidence of peptic
ulcer among lung cancer patients can be attributed to smoking, which is
a contributing factor to both diseases.

Causal. A causal relationship exists whenever there is evidence to show

that certain factors increase the probability of occurrence of a disease
and that the diminution of one or more of these factors decreases the
frequency/occurrence of the disease.

Hypotheses Formulation Phase

The second strategy in an epidemiological investigation consists of

hypothesis formulation. Hypotheses are formed from descriptive
studies to explain the patterns of disease distribution in a
population.

Methods of Formulating Hypotheses

Hypotheses regarding disease causation must be consistent with all

known facts regarding the occurrence of the disease. Formulation of
hypotheses may be classified into the following methods:

Method of Difference. This method assumes that if the frequency of a

disease is markedly different under two different circumstances and
some factor can be identified in one circumstance that is absent in the
other, this factor or its absence may be the cause of the disease. For
example, cancer of the cervix, while common among females, is extremely
rare in nuns. This implies that some aspect of the reproductive process
predisposes to this condition.
Method of Agreement. This method assumes that if a factor is common
to several different circumstances that are associated with the presence

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of a disease, this factor may be the cause of the disease. For example,
cancer of the cervix is associated with sexual intercourse at an early age,
multiple partners, and low socio-economic factors. A common factor may
be a generally transmitted virus.

Method of Concomitant Variation. This method assumes that the

frequency of the factor in question varies with the frequency of the
disease associated with it. This is a quantitative way of looking at the
same assumptions mentioned in the first two methods. Examples of this
method are the relationship of frequencies of various dietary constituents
to coronary heart disease and fluoride concentrations in water and
dental caries.

Method of Analogy. This method makes use of deductive reasoning

(generalities to specifics) where epidemiological principles already
existing are applied to specific situations. This method differs from the
first three methods in this respect---the first three methods make use of
inductive reasoning (from specifics to generalities). For example, the
observation that age and sex patterns for tuberculosis in adults are
similar to lung cancer and the knowledge that lung cancer is related to
smoking may lead to the hypothesis that smoking is a factor in
tuberculosis.

Considerations in Formulating Hypotheses

From the experiences of many epidemiologists/investigators have been

derived the following considerations or guidelines in hypotheses
formulation:

1. Correlating epidemiological findings with that of other disciplines

form new hypotheses. Epidemiological findings are most useful when
viewed in the light of clinical and laboratory data.

2. The stronger statistical association is present, the more likely is

the causal relationship. The strength here refers to the situation of a
disease being absent in one circumstance and present in another. An
example would be the association between lung cancer and smoking
which is stronger than that between smoking and cardiovascular
disease.

3. Observations of changes in disease over time have been

productive of new hypotheses especially those occurring over very
short periods. For example, babies born to women who took thalidomide
tablets during their pregnancy involve a short period (9 months) for
congenital malformation to be apparent.

4. An isolated or unusual case deserves special attention, as it may

be productive of new hypotheses. This can be illustrated in the
following example: There was an outbreak of measles on an island. The
source of the infection was a seaman who has no disease. An
epidemiological investigation revealed a high attack rate among children
while those who had measles in an outbreak about 30 years ago were
spared. These findings support the conclusion that measles may give life-
long immunity.

5. Observations that appear to conflict with an existing situation is

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maybe productive of new hypotheses. For example, high levels of
estrogen are associated with breast cancer. However, women usually
deliver babies at high levels of estrogen but may not develop breast
cancer. This implies that only certain kinds of estrogen are implicated in
breast cancer development.

Hypotheses Testing Phase. Analytic Studies

The third phase in an epidemiological investigation consists of

testing the hypotheses formulated by analytic studies, which may
be experimental or non-experimental in nature.

Experimental Studies
Experimental studies are made to test a cause-effect relationship by
deliberately applying or withholding a supposed causative factor and
observing for the subsequent presence or absence of the expected effect.
These studies generally utilize animals but may also utilize human
beings in certain situations. The limitations of both animal and human
experimentation are given.

Animal Experimentation. The use of animals in experimental studies is

widely practiced due to the absence of ethical considerations. However,
the assumption that results in animals can be generalized to humans is
not always true as many reactions are specific to certain species of
animals. This is the main limiting factor in such studies.

Human Experimentation. The use of human beings in experimental

studies is usually limited to those which involve the addition of things
presumed to be beneficial or the removal of things presumed to be
harmful. In addition, such studies require the cooperation of the subjects
to be successful. Field trials to evaluate the efficacy of certain
immunizing agents or vaccines are an example of experimental studies
utilizing human subjects.

Non-experimental Studies

Non-experimental studies make use of natural circumstances that

simulate an experiment to test a cause-effect relationship. They differ
from experimental studies in that there is no deliberate application or
withholding of supposed causative factors but identifies the supposed
cause and determines the expected effect or vice-versa thru analysis of
actual occurrence. Hence, they are also called analytic studies.
Non-experimental or analytic studies may be classified into types: the
cohort (or prospective) study and the case-history (or retrospective)
study.

1. Cohort Study (or Prospective). This is a type of study in which the

investigator selects a group of persons to be studied in terms of
characteristics to manifest before the appearance of the disease under
investigation and observes them over some time to determine the
frequency of the disease among them. It is also called a prospective study
because it is forward-looking.

Advantage:
Permits direct comparison of incidence rates and computation of the

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relative risk. Also termed as Incidence Study
It has shown associations with other diseases, besides the one under
investigation, as a by-product

Disadvantage:
The main disadvantage of this study is that it is usually a long,
expensive, and large-scale undertaking since a large sample is required.
Knowledge of the exposure is a source of bias in determining the
presence or absence of disease among the study groups. Because of the
long follow-up period, the subjects may be lost to the study or the
investigator himself.

Indications:
This is the method of choice in rare exposures (which makes the study
group easily identifiable), where resources are adequate, and in
situations when the effects are observable or obtainable within a short
period.

2. Case history (or Retrospective Study). This is a type of study in

which groups of individuals are selected in terms of whether they do or
do not have the disease under investigation and the groups are then
compared in terms of exposure to a factor associated with the disease. It
is also called a retrospective study because it is backward-looking.

Advantages:
It is relatively inexpensive and easier to undertake since it requires a
a smaller number of subjects.
It provides relatively quick results.

Disadvantage:
This study does not permit direct computation of incidence rates

Cross-Sectional Study. In addition to the common types of study,

another study that can be undertaken is the Cross-sectional study.
This study examines the relationship between diseases and other
variables of interest as they exist in a defined population at one
particular time, hence, it is also called a prevalence study. The presence
or absence of disease and other variables are determined in each member
of the study population or a representative sample defined in terms of
the absence or presence of the variables and disease respectively.

Applying Epidemiology to Community Health

The epidemiologist views the whole community as his patient. In making

diagnosis, principles of clinical medicines and laboratory diagnosis as
well as observations and techniques should be utilized in determining
the best source of action for prevention and control to promote
community health.

Several steps should be involved in the epidemiological approach to

establishing a control program for a health problem:

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Determining the natural history of the disease condition or health
problem which involves the epidemiological triad:

Host
Demographic characteristics---age, sex, ethnic group, etc.
General Health Status---anatomic structure, physiological state,
nutrition, genetic determinants, stress reaction.

Body defenses---skin and mucous membranes, lymphatic system

State of immunity and immunological response---natural immunity,
artificial immunity (passive, active).

Human behavior, diet. Food handling, personal hygiene, forms of

personal contact, household hygiene, occupation, and recreation.

Agent
Biological – bacteria, viruses, fungi, helminths, protozoa, and
determination of their life cycle, morphology, chemical composition,
multiplication, virulence, viability, and vulnerability.
Physical – temperature, noise, radiation
Chemical – gases, dust, vapors, and liquids
Absence of Substance – nutrient deficiencies

Environment

Physical – weather, climate, season, soil, terrain, geology, geography

Biological – animal reservoirs, arthropods, vectors, food supply
Social – family and community structure, population density and
mobility, political and economic realities, occupations, roles and status,
schools, housing, transportation, and provision of health services.

Determining the extent of the problem:

What proportion of the people is affected?

How serious are the effects on the host?
How serious are the effects on the community?
What is the geographic distribution?
What are the time relationships?

Planning the strategy of control:

Knowledge of the natural history of the condition

Identification of the vulnerable groups in which the problem is centered.
Identification of points at which the agent is most vulnerable to attack,
and control measures available for use.
Identification of strategic points at which changes in the environment
may affect the health problems favorably for man and selection of
appropriate control measures.
Priorities are determined based on the relative importance of the problem
to the community as a whole in comparison with other problems the
community must face.
The application of appropriate control measures must be determined
based on available community resources and other factors in the total

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situation.

Establishing a control program – a working plan is formulated with

clearly defined objectives. After determining the strategy of control, the
health department, or other agency responsible for coordinating the
program, seeks community approval and cooperation from the public,
the government, and other agencies.
The control program will include services directed at the applicable levels
of prevention that is, promotion of health-specific protection, early
diagnosis and treatment, disability limitation, and rehabilitation.

Evaluating the results:

To see how well the objectives of the program were met.
To compare the new situation with the original situation.
To present to the whole community the results of responsible action by
an agency that is held accountable for the health of the people.

Promoting research
To learn more about the natural history of the health problem.
To find improved control measures.
To seek better ways of applying these measures.

Uses of Epidemiology:

1. Provide data (combined with information from other disciplines) to

elucidate the etiology of the disease.

2. Determine whether epidemiologic data are consistent with

etiological hypotheses developed either clinically at the bedside or
experimentally in the laboratory.

3. Provide a basis for preventive and public health services.

4. Realization of the value of knowledge of disease frequency and

distribution during epidemic and non-epidemic times even when
the predominant concern is the explanation of epidemics.

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