1.

DEFINITION, HISTORY AND USES OF EPIDEMIOLOGY

1.1 Definition of epidemiology
Epidemiology is the study of the frequency, distribution and determinants of diseases and other
health related conditions in human populations, and the application of this study to the promotion
of health, and to the prevention and control of health problems.

1.2 Major components of the definition

1.2.1 Population
The main focus of epidemiology is on the effect of disease on the population rather than
individuals. For example malaria affects many people in Nigeria but lung cancer is relatively
rare. If an individual develops lung cancer, it is more likely that he/she will die. Even though
lung cancer is more killer, epidemiology gives more emphasis to malaria since it affects many
people.

1.2.2 Frequency
This shows that epidemiology is mainly a quantitative science. Epidemiology is concerned with
the frequency (occurrence) of diseases and other health related conditions. Frequency of diseases
is measured by morbidity and mortality rates.

1.2.3 Health related conditions

Epidemiology is concerned not only with disease but also with other health related conditions
because everything around us and what we do also affects our health. Health related conditions
are conditions which directly or indirectly affect or influence health. These may be injuries,
births, health related behaviors like smoking, unemployment, poverty etc.

1.2.4 Distribution
Distribution refers to the geographical distribution of diseases, the distribution in time, and
distribution by type of persons affected.

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1.2.5 Determinants
Determinants are factors which determine whether or not a person will get a disease.

1.2.6. Application of the studies to the promotion of health and to the prevention and
control of health problems
This means the whole aim in studying the frequency, distribution, and determinants of disease is
to identify effective disease prevention and control strategies.

1.3 History of epidemiology

Although epidemiological thinking has been traced to the time of Hippocrates, who lived around
5th century B.C., the discipline did not flourish until 1940s. Hippocrates displayed an
extraordinary awareness of the impact of environment and behavior on personal well–being.
Hippocrates, therefore, identified forces that epidemiologists today recognize as major
determinants of human health. There were many other scientists who contributed to the
development of epidemiology. One of them was John Snow. In 1849, John Snow, an English
physician, formulated and tested a hypothesis concerning the origin of an epidemic of cholera in
London. On the basis of the available data Snow postulated that cholera was transmitted by
contaminated water through a then unknown mechanism. He observed that death rates from
cholera were particularly high in areas of London that were supplied with water by the Lambeth
Company or the Southwark and Vauxhall Company, both of which drew their water from the
Thames River at a point heavily polluted with sewage. Between 1849 and 1854, the Lambeth
Company changed its source to an area of the Thames where the water was "quite free from the
sewage of London". The rates of cholera declined in those areas of the city supplied by the
Lambeth Company, while there was no change in those areas receiving water from the
Southwark and Vauxhall Company. Finally, Snow concluded that the source of cholera outbreak
was contaminated water.

1.4 Uses of epidemiology

1. To make a community diagnosis: Epidemiology helps to identify and describe health
problems in a community (for example, the prevalence of anaemia, or the nutrition status
of children).

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2. To monitor continuously over a period of time the change of health in a community: (for
example, the effect of a vaccination program, health education, nutritional
supplementation).
3. To practice surveillance for a specific disease in order to be able to act quickly and so
cut short any outbreak (example cholera).
4. To investigate an outbreak of a communicable disease, analyze the reasons for it, plan a
feasible remedy, and monitor the effects of the remedy on the outbreak.
5. To plan effective health services: Effective services, interventions and remedies all
depend on accurate community data.

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 2 EPIDEMIOLOGICAL TERMS AND CONCEPTS
Some epidemiological terms are enumerated below:

2.1 Attack rate or case ratio:

This ratio expresses incidence rates in population groups during specified time periods or under
special circumstances such as in an epidemic. It is often expressed as a percent (cases per 100).

2.2 Secondary attack rate

This is the proportion of persons who develop infection within an appropriate incubation period
after exposure to a primary case divided by the number exposed. The groups so exposed are
frequently family members or persons located in an institution.

3.3 Carrier
A carrier is a person, animal, or arthropod who harbors a specific infectious agent in the absence
of clinical illness with or without a detectable immune response. The carrier state may reflect
carriage of the organism in the incubation period before clinical symptoms appear, during an
apparent or inapparent infection (healthy or asymptomatic carrier), or following recovery from
illness; it may be of short or long duration (chronic carrier), and it may be intermittent or
continuous. Carriers may spread the infectious agent to others.

3.4 Case-fatality rate

Number of deaths of a specific disease divided by the number of cases multiplied by 100.

3.5 Cell-mediated immunity

This term has been used previously to designate immune mechanisms largely dependent on
lymphocyte activity and in contrast to “humoral immunity.”As T lymphocytes are now
recognized as playing an important role in both, the term T-cell immunity is being more widely
used.

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3.6 Chemoprophylaxis
Administration of a chemical or antibiotic to prevent infection or to prevent the development of
disease in a person already infected.

3.7 Colonization
Multiplication of an organism on a body surface (e.g., skin, epithelium, mucus membrane)
without evoking a tissue or immune response.

3.8 Communicable period

Time during which a person (or animal) is infectious for another person, animal, or arthropod.

3.9 Endemic
This term denotes the constant or usual presence of an infection or disease in a community.

3.10 Epidemic
An epidemic or outbreak is said to exist when an unusual number of cases of a disease occur in a
given time period and geographic area as compared with the previous experience with that
disease in that area. For diseases already present in the community, it is necessary to know the
number of existing cases (prevalence) as well as new cases (incidence) to determine whether an
increase has occurred.

3.11 Host
A person, animal (including birds), or arthropod in which infectious agents subsist or infect
under natural conditions.

3.12 Immunity
The specific resistance to an infectious agent resulting from humoral and local antibodies and
from cell mediated responses constitutes immunity. Immunity may be acquired through natural
infection, by active immunization, by transfer of immune factors via the placenta, or by passive
immunization with antibodies from another person or animal. The immune state is relative and

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not absolute, is governed largely through genetic control, and may be altered by disease- or drug-
induced immunosuppression.

3.13 Immunodeficiency
A state representing impairment of the immune system of the host that affects its ability to
respond to a foreign antigen. This may result from an inherited defect, or an acquired one such as
a result of the disease itself, or of immunosuppressive drugs or an infectious agent that depresses
the immune system. The human immunodeficiency viruses (HIV-1 and HIV-2) are the major
examples of the latter.

3.14 Incidence rate

The number of new events (specific infection or disease) occurring in a given time period in a
given population as the numerator and the number of susceptible persons in that population
exposed to the agent as the denominator. This is usually stated as cases (or infections) per 100,
1,000, or 100,000. This rate may be adjusted for an age- or sex-specific numerator and
denominator or any other characteristic of interest. Laboratory procedures may be required for
numerator data on new infections, as measured by isolation of the agent or by antibody rises, or
by both. They may also be required to identify those actually at risk in the denominator, i.e.,
those lacking antibody; other means of refining the denominator would be by eliminating adults
in calculating rates of childhood diseases or eliminating those with a valid history of having had
the disease.

3.15 Incubation period

The incubation period is the interval between exposure and the appearance of the first detectable
sign or symptom of the illness. Ill-defined exposure to a source of infection or exposure to
persons without apparent illness may obscure the starting point of the incubation period, and
vague, premonitory, or prodromal signs of illness may obscure its termination point. The best
estimate is often derived from single exposures of short duration to a clinical case or established
source of infection (e.g., air, food, water, arthropod vector) and the development of the first
characteristic or classic features of the disease. Experimental infections in volunteers give well-
defined incubation periods, but these may not always be the same as under natural conditions.

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3.16 Index case
This is the index or primary case of an illness in a family, group, institution, or community that
may serve as a source of infection to others.

3.17 Infection
Infection represents the deposition, colonization, and multiplication of a microorganism in a host
and is usually accompanied by an immune response. Infection may occur with or without clinical
illness.

3.18 Isolation
This is a term applied to the separation of infected persons in such places and/or under such
conditions as to prevent contact or airborne transmission of the infectious agent to others during
the period of communicability.

3.19 Morbidity rate

An incidence rate in which the numerator includes all persons clinically ill in a defined time and
population, and the denominator is the population involved or a subunit thereof, usually
expressed as the number of cases per 100,000 persons at risk.

3.20 Mortality rate

The same as morbidity rate except the numerator consists of deaths. This may be the total
number of deaths in a population group (crude mortality rate, usually expressed as deaths per
1,000) or deaths from a specific disease (disease-specific mortality, usually expressed as deaths
per 100,000).

3.21 Nosocomial infections

This term refers to infections that develop after entry into a hospital or other health care
institutions and that are not present or incubating at the time of admission or the residual of an
infection acquired during a previous admission.

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3.22 Pathogenicity
The ability of an infectious agent to produce disease in a susceptible host. Some nonpathogenic
agents can become pathogenic in an immunocompromised host such as persons infected with
HIV.

3.23 Prevalence rate

The ratio of the number of persons in a defined population who are affected with the disease at
any one time as the numerator and the exposed population at that point as the denominator. Most
infectious diseases are acute and short lived, so that prevalence rates are not commonly used.
The use of prevalence rates is more relevant to more protracted illnesses such as sub-acute
bacterial endocarditis, tuberculosis, and leprosy, or to reflect carrier states that may persist for
months or years.

3.24 Quarantine
The restriction of persons or animals exposed to an infected source during the incubation period
for that disease to observe if the disease develops in order that other persons will not be exposed
to the infectious agent during that period.

3.25 Reservoir
A person, animal, soil, or other environment in which an infectious agent normally exists and
multiplies and which can be a source of infection to other hosts.

3.26 Surveillance
As concerns public health, surveillance is the systematic collection of data pertaining to the
occurrences of specific diseases or health-related conditions, the analysis and interpretation of
these data, and the dissemination of consolidated and processed information to contributors to
the program and other interested persons for purposes of control and/or prevention

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3.27 Susceptibility
A state in which a person or animal is capable of being infected with a microorganism. The lack
of specific protective antibody usually indicates susceptibility to that agent, although reactivation
or reinfection to some agents may occur in the presence of antibody.

3.28 Transmission
The mechanism by which an infectious agent is spread to another host.

3.29 Virulence
A measure of the degree of pathogenicity of an infectious agent as reflected by the severity of the
disease produced and its ability to invade the tissues of the host.

3.30 Zoonosis
An infection or infectious disease transmissible under natural conditions from animals to man. It
may be endemic (enzootic) or epidemic (epizootic).

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 3. DISEASE CAUSATION
The “cause of disease” can be defined as an event, condition, characteristic or a combination of
these factors which plays an important role in producing the disease. The causes of disease can
be classified in to two categories:

1. Primary causes: These are the factors which are necessary for a disease to occur, in
whose absence the disease will not occur. The term “etiologic agent” can also be used to
represent the primary causes of diseases. For example Mycobacterium tuberculosis is the
primary cause (etiologic agent) of pulmonary tuberculosis.
2. Risk factors (contributing, predisposing, or aggravating factors): These are not the
necessary causes of disease but they are important for a disease to occur. A factor
associated with an increased occurrence of a disease is a risk factor for the exposed
group. Risk factors could be related to the agent, the host and the environment.
The “etiology of a disease” is the sum total of all the factors (primary causes and risk factors)
which contribute to the occurrence of the disease. It is the interaction of the agent, the host, and
the environment which determines whether or not a disease develops, and this can be illustrated
using the epidemiologic triangle (Figure 3.1).

Figure 3.1: The Epidemiologic Triangle

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The epidemiologic triangle depicts the relationship among three key factors in the occurrence of
disease or injury: agent, environment and host. An agent is a factor whose presence or absence is
necessary for a particular disease or injury to occur. The environment includes all external
factors, other than the agent, that can influence health. From the perspective of epidemiologic
triangle, the host, agent and environment can coexist harmoniously. Disease and injury occur
only when there is altered equilibrium between them.

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 4. LEVELS OF PREVENTION
The natural history of diseases and it different stages will initially be elucidated as a prelude to
understanding the levels of disease prevention.

4.1 Natural history of disease

The “natural history of disease” refers to the progression of disease process in an individual over
time, in the absence of intervention. There are four stages in the natural history of a disease.
These are the stage of susceptibility, pre-symptomatic (sub-clinical) disease, clinical disease, and
disability or death.

4.1.1 Stage of susceptibility

In this stage, disease has not yet developed, but the groundwork has been laid by the presence of
factors that favor its occurrence. An example is the susceptibility to muscles by unvaccinated
children.

4.1.2 Stage of pre-symptomatic (sub-clinical) disease

In this stage there are no manifestations of the disease but pathologic changes (damages) have
started to occur in the host. The disease can only be detected through special tests since the signs
and symptoms of the disease are not present. An example is the detection of antibodies against
HIV in an apparently healthy person. Another example is the detection of ova of intestinal
parasite in the stool of apparently healthy children. The pre-symptomatic stage may lead to the
clinical stage, or may sometimes end in recovery without development of any signs or
symptoms.

4.1.3 The clinical stage

At this stage the person has developed signs and symptoms of the disease. The clinical stage of
different diseases differs in duration, severity and outcome. The outcomes of this stage may be
recovery, disability or death. Typical examples of the clinical stage are as follows:
1. Common cold has a short and mild clinical stage and almost everyone recovers quickly.
2. Polio has a severe clinical stage and many patients develop paralysis becoming disabled
for the rest of their lives.

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 3. Rabies has a relatively short but severe clinical stage and almost always results in death.
4. Diabetes Mellitus has a relatively longer clinical stage and eventually results in death if
the patient is not properly treated.

4.1.4 Stage of disability or death

Some diseases run their course and then resolve completely either spontaneously or by treatment.
In others the disease may result in a residual defect, leaving the person disabled for a short or
longer duration. Still, other diseases will end in death. Disability is limitation of a person's
activities including his role as a parent, wage earner, etc. For example, trachoma may cause
blindness while Meningitis may result in blindness or deafness and most probably death.

A schematic diagram of the natural history of diseases and their expected outcomes is
shown in Figure 4.1.

Figure 4.1: Schematic diagram of the natural history of diseases and their expected outcomes

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4.2 Levels of Disease Prevention
The major purpose in investigating the epidemiology of diseases is to learn how to prevent and
control them. Disease prevention means to interrupt or slow the progression of disease.
Epidemiology plays a central role in disease prevention by identifying those modifiable causes.
The three levels of prevention are briefly described below.

4.2.1 Primary prevention

The main objectives of primary prevention are promoting health, preventing exposure and
preventing disease. Primary prevention keeps the disease process from becoming established by
eliminating causes of disease or increasing resistance to disease. Primary prevention has three
components. These are health promotion, prevention of exposure, and prevention of disease.

4.2.1.1 Health promotion

This consists of general non-specific interventions that enhance health and the body's ability to
resist disease. Improvement of socioeconomic status, provision of adequate food, housing,
clothing, and education are examples of health promotion.

4.2.1.2 Prevention of exposure

This is the avoidance of factors which may cause disease if an individual is exposed to them.
Examples can be provision of safe and adequate water, proper excreta disposal, and vector
control.

4.2.1.3 Prevention of disease

This is the prevention of disease development after the individual has become exposed to the
disease causing factors. Immunization is an example of prevention of disease. Immunization acts
after exposure has taken place. Immunization does not prevent an infectious organism from
invading the immunized host, but does prevent it from establishing an infection. If measles
vaccine is administered, it does not prevent the virus from entering into the body but it prevents
the development of the disease.

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4.2.2 Secondary prevention
The objective of secondary prevention is to stop or slow the progression of disease so as to
prevent or limit permanent damage. Secondary prevention can be achieved through detecting
people who already have the disease as early as possible and treat them. It is carried out before
the person is permanently damaged. Examples are the prevention of blindness from Trachoma,
as well as the early detection and treatment of breast cancer to prevent its progression to the
invasive stage, which is the severe form of the disease.

4.2.3 Tertiary prevention

This is targeted towards people with permanent damage or disability. Tertiary prevention is
needed in some diseases because primary and secondary preventions have failed or not effective.
This form of prevention has two objectives: (i). Treatment to prevent further disability or death
and (ii) To limit the physical, psychological, social and financial impact of disability, thereby
improving the quality of life. This can be done through rehabilitation, which is the retraining of
the remaining functions for maximal effectiveness. For example, when a person becomes blind
due to vitamin A deficiency, tertiary prevention (rehabilitation) can help the blind or partly blind
person learn to do gainful work and be economically self supporting.

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 5. EPIDEMIOLOGIC TRANSITION
The epidemiologic transition describes changing patterns of population distributions in relation
to changing patterns of mortality, fertility, life expectancy and leading causes of death. The
perspective has its origins in demography, but finds a compatible conceptual home in public
health and epidemiology in particular. There are two major components of the transition: (1)
changes in population growth trajectories and composition, especially in the age distribution
from younger to older, and (2) changes in patterns of mortality, including increasing life
expectancy and reordering of the relative importance of different causes of death. The
“epidemiological transition theory” was first formulated in a paper published by Abdel Omran in
1971. Omran’s formulation of the theory consisted of five propositions.

5.1 Omran’s propositions

5.1.1 The first proposition
Omran’s first proposition is quoted as follows: “The theory of epidemiologic transition begins
with the major premise that mortality is a fundamental factor in population dynamics. At first
glance this seems self-evident and of little heuristic value; however, this proposition is grounded
in the insight that declining mortality is typically followed by declining fertility, and it is the
combination of lower birth rates as well as lower death rates and higher life expectancy that
produce the altered population age distribution. If birth rates remained stable, the process of
change in the shape of the population distribution would follow a different pattern.

5.1.2 The second proposition

Omran’s second proposition is quoted as follows: “During the transition, a long-term shift occurs
in mortality and disease patterns whereby pandemics of infection are gradually displaced by
degenerative and man-made diseases as the chief form of morbidity and primary cause of death”.
Because this proposition is really at the heart of the theory and includes changes in patterns of
mortality and morbidity, as well as in the age distribution, it is more complex and requires more
extended elaboration, as described by the three typical phases of transition posited by Omran.

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5.1.2.1 The first transition
The first transition phase, called the “Age of Pestilence and Famine”, is characterized by high
and fluctuating mortality rates, variable life expectancy with low average life span, and periods
of population growth that are not sustained. The earliest transition dates to pre-history (Neolithic
period, approximately 10,000 years ago) across geographically widely separated cultures. The
transitions were a result of the transformation from hunter-gatherer societies to agrarian
societies, with more settled life required in order to tend cultivated crops and domesticated
animals. The change in patterns of livelihood and living conditions also meant changes in
population size and density and daily life in closer proximity to animals. The reduction in human
and animal migration created a new kind of ecological imbalance. There was an increase in
infectious diseases as a result of exposure to human and animal waste and contaminated water
and the reciprocal transmission of organisms between human and animal hosts. The disease
patterns that emerged were determined by increasing microbial exposures, dietary deficiencies
because the food supply, though perhaps more reliable in good years, was less diverse, illnesses
due to inadequate food storage, increased transmission rates and endemic disease as a result of
increased population density, eventual development of global trade with a concomitant increase
in potential for disease spread over wide geographic regions, and increased mortality which, in
keeping with the epidemiologic transition model, would lead to increased birth rate.

5.1.2.1 The second transition

The second transition phase is characterized as the “Age of Receding Pandemics”, and is marked
by declining mortality rates that become steeper as epidemics occur less frequently, an increase
in average life expectancy from about 30 years to about 50 years of age, and more sustained
population growth that eventually becomes exponential. This transition occurs in the early
modern period and is characterized by a shift in patterns of disease and mortality from primarily
infectious diseases to what have come to be called “chronic” diseases. The theory proposes that
this shift is accompanied by a shift in the population age distribution as early infectious disease
deaths decline and deaths from chronic and degenerative disease increase, the latter a result not
only of the receding competing risk from infectious diseases, but also of the new environmental
hazards that came with industrial development and increasing urban living. Explanations for
these changes are multi-faceted and complex and include changes in the relationships in the

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classic matrix of agent, host, and environment; socioeconomic, political, and cultural changes;
improved living conditions and standard of living, including the contributions of the sanitary
movement to water and sanitary services, improved nutrition, better personal hygiene, and less
overcrowding; medical and public health advances and interventions; better understanding of
infectious diseases with acceptance of the germ theory and adoption of antiseptics and
pasteurization; lower fertility and longer birth intervals with better infant and child survival; and
increasing lifespan resulting in an older population.

5.1.2.3 The third transition

The third transition phase is termed the “Age of Degenerative and Man-Made [sic] Diseases”. In
this phase it is theorized that infectious disease pandemics are replaced as major causes of death
by degenerative diseases, and infectious agents as the major contributor to morbidity and
mortality are overtaken by anthropogenic causes. With declines in mortality rates, average life
expectancy increases to > 50 years, fertility becomes more important to population growth, and
the anthropogenic and biologic determinants of disease also change. This transition is typically
associated with the late 19th and 20th centuries in developed countries. Life expectancy
increases from less than 50 years of age at the beginning of the 20th century to over 75 years at
the beginning of the 21st century, particularly in the developed countries. However, there was a
sharp, but transient drop in life expectancy as a result of the influenza pandemic of 1918. This
illustrates the impact that a pandemic can have on life expectancy and population distribution.

5.1.3 The third proposition

Proposition three states as follows: “During the epidemiologic transition the most profound
changes in health and disease patterns occur among children and young women.” This
phenomenon is largely a result of declining infant and maternal mortality and a consequent drop
in fertility..

5.1.4 The fourth proposition

The fourth proposition holds that “The shifts in health and disease patterns that characterize the
epidemiologic transition are closely associated with the demographic and socioeconomic
transitions that constitute the modernization complex. This proposition in some ways bridges the

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other propositions in that, consistent with the third, it is characterized by lower fertility and
longer birth intervals, and in keeping with the second and fifth it is posited that improved
socioeconomic status leads to better nutrition and sanitation, which in turn improve health and
reduce morbidity and mortality.

5.1.5 The fifth proposition

The final proposition outlines three basic models of the epidemiologic transition that are a
function of “peculiar variations in the pattern, the pace, the determinants and the consequences of
population change”. These three models are “the classical or western model, the accelerated
model and the contemporary or delayed model.” They roughly correspond respectively to (1) the
experience of developed countries that evidence slow declines in death rates followed by lower
fertility that accompanies modernization; (2) the experience of countries, such as Japan, where
the course of the transition was much more rapid and the amount of time required to reach the
milestone mortality rate of 10 deaths per 1000 population is much shorter; and (3) the experience
of developing countries where there have been more recent declines in mortality, but not in
fertility rates because infant and maternal mortality rates still remain high.

5.2 Epidemiological transition in Nigeria

Nigeria is increasingly facing the problem of a double-disease burden. According to the World
Health Organization (WHO) in 2016, maternal and neonatal diseases in Nigeria still accounted
for about 63% of deaths, and communicable (including maternal and neonatal) diseases were the
top four causes of deaths in 2019. At the same time, deaths from non-communicable diseases
such as cardiovascular disease have also increased in the last 10 years.

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 5. INFECTIVE AGENTS IN COMMUNICABLE DISEASES
Communicable disease (infectious disease) is an illness due to a specific infectious agent or its
toxic products that arises through transmission of that agent or its products from an infected
person, animal, or reservoir to a susceptible host, either directly or indirectly through an
intermediate plant or animal host, vector, or the inanimate environment.

5.1 Components of the infectious process

The infectious process of a specific disease can be described by the following components,
which constitute the chain of disease transmission.
i. The Agent
ii. Its reservoirs
iii. Its portal of exits
iv. Its mode of transmission
v. Its portals of entry
vi. The human host

5.1.1 The agents

The agents in the infectious process range from viral particles to complex multi-cellular
organisms.

5.1.2 Reservoirs
A reservoir is an organism or habitat, in which an infectious agent normally lives, transforms,
develops and/or multiplies. Reservoirs for infectious agents may be humans, animals, plants or
other inanimate objects. Some diseases with human reservoirs include HIV/AIDS/Sexually
Transmitted Infections (STIs), measles, typhoid, etc. All infected humans, whether showing
signs and symptoms of the disease or not, are potential sources of infection to others. A person
who does not have apparent clinical disease, but is a potential source of infection to other people
is called a Carrier. An example of carrier is a person infected with HIV. A person infected with
HIV might not have the signs and symptoms but he/she is capable of transmitting the infection to
others. Some diseases are transmitted to human beings from animals. These diseases are called
zoonoses. Examples of zoonoses include Rabies, anthrax, etc.

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5.1.3 Portal of Exit
Portal of exit is the way the infectious agent leaves the reservoir. Possible portals of exit include
all body secretions and discharges, for example, mucus, saliva, tears, breast milk, vaginal and
cervical discharges, excretions (feces and urine), blood and tissues. For example feces is the
portal of exit for the eggs of hook worm.

5.1.4 Mode of Transmission

Modes of transmission include the various mechanisms by which agents are conveyed to other
susceptible hosts. Transmission may be direct or indirect.

5.1.4.1 Direct Transmission

i. Direct contact: This occurs when there is contact of skin, mucosa or conjunctiva with
infectious agents directly from person or vertebrate animal, via touching, kissing, biting,
passage through the birth canal, or during sexual intercourse. Examples include
HIV/AIDS/STIs, rabies, etc.

ii. Direct Projection: This refers to transmission by projection of saliva droplets during
coughing, sneezing, singing, spitting or talking. An example is common cold.

iii. Transplacental: This means transmission from mother to foetus through the placenta.
Examples include syphilis, HIV/AIDS.

5.1.4.2 Indirect transmission

The following are the different types of indirect transmission.
i. Vehicle-borne: Transmission occurs through indirect contact with inanimate objects such
as fomites, for example, bed sheets, towels, toys or surgical instruments; as well as
through contaminated food, water, IV fluids, etc.

ii. Vector-borne: The infectious agent is conveyed by an arthropod to a host. Vectors may
be biological or mechanical. A vector is called biological vector if the agent multiplies in
the vector before transmission. The anopheles mosquito is a biological vector for malaria.

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 A vector is called mechanical vector if the agent is directly infective to other hosts,
without having to go through a period of multiplication or development in the vector. The
vector simply carries the agent by its body parts (leg, proboscis etc) to convey it to
susceptible hosts. Flies are mechanical vectors for the transmission of trachoma.

iii. Airborne: This transmission may occur by dust or droplet nuclei (dried residue of
aerosols). An example is Tuberculosis. When pulmonary tuberculosis patients cough,
they emit many aerosols which consist of the agents of tuberculosis. When these aerosols
dry, droplet nuclei are formed. These droplet nuclei will remain suspended in the air for
some time. When other healthy susceptible individual breaths, he/she inhale the droplet
nuclei and may become infected with tuberculosis.

5.1.5 Portal of entry

This is the site where an infectious agent enters a susceptible host. Examples include the
followings:
i. Nasal mucosa is portal of entry for common cold.
ii. Conjunctiva is the portal of entry for trachoma.
iii. Injury site is portal of entry for tetanus.

5.1.6 Susceptible human host

The susceptible human host is the final link in the infectious process. Host susceptibility or
resistance can be seen at the individual and at the community level. Host resistance at the
community (population) level is called herd immunity. Herd immunity can be defined as the
resistance of a population to the introduction and spread of an infectious agent, based on the
immunity of a high proportion of individual members of the population, thereby lessening the
likelihood of a person with a disease coming into contact with susceptible human host. For
example, if 90 % of the children are vaccinated for measles, the remaining 10 % of the children
who are not vaccinated might not become infected with measles because most of the children (90
%) are vaccinated. That means transmission from infected person to other susceptible children
will not be easier.

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 6. RISK FACTORS IN COMMUNICABLE DISEASES
The main risk factors that have been identified to likely cause communicable diseases are
highlighted below:

6.1 WASH
Water, sanitation and hygiene are central elements to limit the risk of communicable diseases.
WASH risk factors include issues such as lack of safe drinking water, lack of hygiene, hygiene
behaviour, lack of soap, and general water scarcity, as well as lack of adequate sanitation and
latrines. These factors considerably increase the risk for diarrhoeal diseases and compound risks
for other types of communicable diseases especially if they are coupled with other risk factor
categories such as overcrowding and mass population displacement.

6.2 Overcrowding
Overcrowding is usually a function of either mass population displacement or entrapment. While
overcrowding can also be an issue in ad hoc shelters after the widespread destruction of homes
and infrastructure, it is more prevalent if populations are forced to become refugees or internally
displaced persons and are forced into camps. Overcrowding affects both hygiene-related
diseases, such as diarrhoeal diseases, but also increases the transmission rate of diseases such as
measles and other infections that spread from person to person.

6.3 Mass population displacement

Mass population displacement is a trigger for most risk factor categories. Mass population
displacement is usually associated with large numbers of people moving into camp settings,
often associated with overcrowding, inadequate shelter and poor WASH conditions.
Additionally, populations are displaced into regions and areas with insufficient resources and
services and with potentially increased contact of naive populations with new disease vectors.
Early camp structures (such as layout of tents and citing of toileting areas) can lead to further
complications. Early layout often develops as an ad hoc response to mass population
displacement but may prove completely unsuitable as the camp expands.

23
6.4 Nutrition
While nutrition factors such as malnutrition, food shortages and exposure to contaminated food
are mainly risk factors at the individual level, they also pose increased risk to populations as a
whole if a sufficient percentage of the population is exposed. Nutrition factors are related to
increased susceptibility to communicable diseases with resulting greater shedding and
transmission to others. At the population level, nutritional factors can exacerbate other risk
factors and risk factor clusters, for example by increasing the risk of violence and social unrest.
Root causes for nutrition risk factors lie mainly in other risk factor clusters such as insecurity and
armed conflict or mass displacement and inadequate humanitarian response.

6.5 Living conditions

Poor living conditions are a combination of inadequate shelter, overcrowding and other
individual factors in the immediate surroundings of an individual or group of individuals. A key
risk for people uprooted from their normal lives and subject to inadequate resources and shelter
is indoor air pollution. This is due to indoor fires, both for cooking purposes and for heating.

6.6 Insecurity
Insecurity is a multifaceted bundle of risk factors that is one of the main root causes for increased
mortality. Insecurity is composed of factors such as armed conflict, social disruption and
political instability. Insecurity triggers other factors such as a lack of an adequate humanitarian
response as it poses risks to aid workers and inhibits access to beneficiaries. Additionally, it also
inhibits access for the population to health services and has a high potential to disrupt all other
services.

6.7 Humanitarian response

Poor response during periods of emergencies can itself become a risk for the spread of
communicable diseases. Problems can lie with the response itself, due to a lack of international
commitment or a lack of professionalism of the responding agencies and organizations. Problems
can also arise domestically due to restrictions by governments or warring parties, unsafe
conditions in which aid workers cannot properly work without unacceptable levels of risk for
themselves or lack of access for various reasons.

24
6.8 Environment
Environmental factors can increase the likelihood of communicable diseases outbreaks.
Environmental risk factors include weather and climate factors, such as cold and dust storms, but
also vector habitats, increased contact with animals and endemic diseases.

6.9 Economy
Economic factors such as poverty and lack of resource are also implicated as factors that can
increase the likelihood of communicable disease outbreaks.

6.10 Health and public health services

Breakdown of health and public health services is probably one of the main risk factors for
communicable diseases. Lack of access to health and medical care is a key risk factor for severe
progressions of most communicable diseases for the individual. It also facilitates the further
spread of communicable diseases such as tuberculosis, and makes detection of cases and
outbreaks harder.

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 7. NON-COMMUNICABLE DISEASES
Non-communicable diseases (NCDs), also known as chronic diseases, are medical conditions
that are associated with long durations and slow progress. Most NCDs are non-infectious and are
the result of several factors, including genetic, physiological, behavioral, and environmental
factors. According to the World Health Organization (WHO), NCDs are the leading cause of
death worldwide, responsible for 71% of the total number of deaths each year. The top four
killers among NCDs with the highest number of deaths are cardiovascular diseases (17.9 million
deaths annually), cancers (9.0 million), respiratory diseases (3.9 million) and diabetes (1.6
million). A list of non-communicable diseases is shown in Figure 7.1.
Several factors can increase the amount of opportunities to develop NCDs and can be
classified in different ways. In one approach, risk factors are classified as modifiable or non-
modifiable factors. The modifiable risk factors involve high blood pressure, smoking, diabetes
mellitus, physical inactivity, obesity and high blood cholesterol; while the non-modifiable risk
factors involve age, gender, genetic factors, race, and ethnicity. The non-modifiable factors can
also be classified into three classes: (i) biological factors, such as being overweight,
dyslipidemia, hyper-insulinaemia and hypertension; (ii) behavioral factors, such as diet, lack
physical activity, tobacco smoking and alcohol consumption; and (iii) societal factors, which
involve complex combinations of interacting socioeconomic, cultural and environmental
parameters. A model to classify the risk factors of NCDs is presented in Figure 7.2.

26
Figure 7.1: List of non-communicable diseases

Figure 7.2: A model used in classifying the risk factors of NCDs

27
 8. EPIDEMIOLOGICAL METHODS
Epidemiology is used to describe the distribution of diseases in a population and to analyze the
causes of these diseases. The three major types of epidemiologic study designs or techniques are
descriptive, analytic and experimental. Although all three can be used in investigating the
occurrence of disease, the method used most is descriptive epidemiology. Once the basic
epidemiology of a disease has been described, specific analytic methods can be used to study the
disease further, and a specific experimental approach can be developed to test a hypothesis.

8.1 Descriptive epidemiology

8.1.1 Definition
Descriptive epidemiology is one of the basic types of epidemiology, which is concerned with
describing the frequency and distribution of diseases and other health related conditions by time,
place and person.

8.1.2 Core variables in descriptive epidemiology

The major variables in descriptive epidemiology can be classified under the headings: person,
place and time. To describe the occurrence of a disease fully, the following questions must be
answered. Who is affected? Where and when do the cases occur?

8.1.2.1 Person
People can be categorized with respect to many variables. In epidemiologic study, it is common
to specify three characteristics of a person – age, sex and ethnic group or race. Age: Age is the
most important determinant among the personal variables. Example: Measles affects children.
Sex: There are some diseases which are common among females. For example, breast cancer is a
disease of females. Ethnic group and Race: Many diseases differ markedly in frequency,
severity, or both in different racial or ethnic groups.
Other personal variables that should be considered during epidemiologic studies include
social class, religion, occupation, marital status, environmental exposure, etc.

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8.1.2.2 Place
The frequency of disease is different in different places. These differences can occur because of
the natural boundaries (e.g., mountain range, rivers and deserts). An area defined by natural
boundaries may have a high or low frequency of certain diseases because it is characterized by
some particular environmental or climatic conditions, such as temperature, humidity, rainfall,
altitude, mineral content of soil, or water supply. For example, malaria is common in tropical
areas.

8.1.2.3 Time
Study of disease occurrence by time is a basic aspect of epidemiologic analysis. Occurrence is
usually expressed on a monthly or annual basis. Some diseases occur periodically or cycles.
Cycles may be annual or have some other periodicity. The most common types of periodicity are
in relation to seasonal changes, or in relation to changes in the number of susceptible persons in a
population. Malaria is one of the examples of diseases with seasonal periodicity, where high
peaks occur in relation to the rainy season. The malaria epidemic is common in October and
November when stagnant water bodies are convenient for the breeding of mosquitoes.

8.1.3 Categories of descriptive epidemiology

Descriptive epidemiology consists of study designs that are categorized as Case report, Case
series, Incidence, Cross-sectional and Ecologic studies.

8.1.3.1 Case report

A case report is a detailed description of disease occurrence in a single person. It can also be
defined as a detailed report of the symptoms, signs, diagnosis, treatment and follow-up of an
individual patient. Case reports may contain a demographic profile of the patient, but usually
describe an unusual or new occurrence which may suggest a new hypothesis about the causes or
mechanisms of disease.
The advantages of case report are stated as follows:
i. Identification of new trends or diseases.
ii. Detect new drug side effects and potential uses.

29
 iii. Identify rare manifestations of a disease
The disadvantages of case report are as follows:
i. Cases may not be generalized.
ii. Not based on systematic studies.
iii. Causes or associations may have other explanations.

8.1.3.2 Case series

Case series represents one of the most basic types of study designs in which researchers describe
the experience of a small group of people. It presents a detailed account of the clinical
experience of individual study subjects and can evaluate large numbers of individuals and
summarize the data using descriptive statistical measures. The Dictionary of Epidemiology
defined a case series as a collection of patients with common characteristics used to describe
some clinical, patho-physiological or operational aspects of a disease, treatment or diagnostic
procedures.

8.1.3.3 Incidence
Incidence, in epidemiology, refers to the occurrence of new cases of disease, injury or other
medical conditions over a specified time period, typically calculated as a rate or proportion.
Examples of incident cases or events include a person developing diabetes, becoming infected
with HIV or starting to smoke. It is also important to no note that incidence contrasts with
prevalence, which includes both new and existing cases. For example, a person who is newly
diagnosed with diabetes is an incident case, whereas a person who has had diabetes for 10 years
is a prevalent case. For chronic diseases, such as diabetes, a person can have an incident case just
once in a lifetime. For diseases that can be resolved (e.g., the common cold, malaria, etc.), a
person can have multiple incidences over his or her lifetime.
The advantages of incidence case are as follows:
i. Provides information about the etiology (or cause) of a disease and its outcome.
ii. Allow researchers to determine the risk factors for a disease or other medical condition.
The disadvantage of prevalent cases is as follows:
i. Combines the study of new and surviving cases, making it unclear as to whether risk
factors are the causes of new cases or causes of survival.

30
8.1.3.4 Cross-sectional study design (survey)
Cross-sectional study is a type of observational study design which is mainly concerned with the
distribution of diseases with respect to time, place and person. By conducting survey, the
magnitude of diseases or other health-related condition will be known. In cross sectional studies,
information about the status of an individual with respect to the presence or absence of exposure
and disease is assessed at a point in time. The point in time may be as short as few minutes or as
long as two or three months. The time frame of "point in time" is based on the speed of data
collection.
Cross-sectional studies are often carried using the following procedures:
1. Write the objectives of the survey.
2. Identify the methods of data collection. Data can be collected by using questionnaire,
interview, observation, applying laboratory tests, etc.
3. Recruit and train data collectors.
4. Calculate (determine) the number of people needed for the survey (sample size)
5. Collect the data.
6. Analyze the data.
7. Disseminate the findings.
The advantages of cross-sectional studies are stated below:
1. One-stop, one-time collection of data.
2. Less expensive and easier to conduct.
3. Provide much information useful for planning health services and medical programs.
4. Show relative distribution of conditions, disease, injury and disability in groups and
populations. For example by conducting survey in different towns, it is possible to know
which towns are highly affected by HIV/AIDS.

8.1.3.5 Ecologic studies

Ecologic studies are studies in which the unit of observation affects a group, not separate
individuals, for one or more study variables. For example, exposure and risk factors are known
only at the group level, such as the average air pollution concentration in different cities. The
occurrence of the health outcome may also be only known at the group level, such as overall
mortality rates from chronic lung disease in the same cities with measured levels of air pollution.

31
The goal of ecological studies is the influence of the environment on the health of a group of
individuals, which is a very complex issue. When dealing with group level information, it is
important to be aware of what is called the ecologic fallacy. This fallacy results from concluding
that because an association exists between exposure and a health outcome at the group level, it
therefore exists at the individual level.

8.1.4 Measurements in descriptive epidemiology

One of the important objectives of measurements used in descriptive studies is to identify risk
factors. Prevalence and incidence are the two key measures used in descriptive epidemiology.
These measures constitute fundamental information to inform public health and policy decisions.
Health status of a community is assessed by the collection, compilation, analysis and
interpretation of data on illness (morbidity), death (mortality), disability and utilization of health
services. Even though descriptive studies may appear to have a simple design, some
methodologic aspects need to be considered.

8.1.4.1 Ratio, proportion and rates

Ratio: A ratio quantifies the magnitude of one occurrence or condition to another. It expresses
the relationship between two numbers in the form of x:y or x/y × k. An example is the ratio of
males to females (M:F) in Nigeria or the ratio of male tuberculosis patients to female
tuberculosis patients.

Proportion: A proportion quantifies occurrences in relation to the populations in which these

occurrences take place. It is a specific type of ratio in which the numerator is included in the
denominator and the result is expressed as a percentage. For example, the proportion of all births
that were female is calculated as follows:

Female births
Proportion = ×100
Female + Male births

Rates: Rate is the most important epidemiological tool used for measuring diseases. Rate is a
special form of proportion that includes time. It is the measure that most clearly expresses

32
probability or risk of disease in a defined population over a specified period of time. Hence, it is
considered to be a basic measure of disease occurrence. Accurate count of all events of interest
that occur in a defined population during a specified period is essential for the calculation of rate.

8.1.4.2 Measurement of morbidity

Morbidity rates are rates used to quantify the occurrence of disease. Measures of morbidity
include incidence, period prevalence and point prevalence rates.

Incidence: The incidence of a disease is defined as the number of new cases of a disease that
occur during a specified period of time in a population at risk for developing the disease. New
cases refer to the number of persons in a defined population who develop a disease for the first
time during a defined period in time. Incidence can be categorized into risk and rate. It is
important to make a distinction between risk (cumulative incidence) and rate (incidence rate).
The cumulative incidence or risk is often interpreted as the number of individuals who develops
a specified disease in a population within a period in time. The incidence rate considers the time
period in which each individual was in fact at risk of developing the specified disease and could
be monitored. This period is designated as person-time (the time which a study participant
contributed to the study).

Cumulative incidence per period =

Number of new cases of a disease ∈thetime period
×K
Total number of persons selected for the study
K is a constant factor representing the defined population

Number of new cases of a disease ∈thetime period

Incidence rate = ×K
Total person−time at risk
K is a constant factor representing the defined population

Calculation of person-time and incidence rate: Person-time is an estimate of the actual time-at-
risk in years, months or days that all participants contributed to a study. In certain studies people

33
are followed for different lengths of time, as some will remain free of a health outcome or
disease longer than others. A subject is eligible to contribute person-time to the study only so
long as that person does not yet have the health outcome under study and, therefore, is still at risk
of developing the health outcome of interest. By knowing the number of new cases of the health
outcome and the person-time-at-risk contributed to the study, an investigator can calculate the
rate of the health outcome or disease, or how quickly people are acquiring the health outcome or
disease. The denominator for incidence rate (person-time) is a more exact expression of the
population at risk during the period of time when the change from non-disease to disease is being
measured. The denominator for the incidence rate changes as persons originally at risk develop
the health outcome during the observation period and are removed from the denominator.
As an example, suppose an investigator conducting a study of the rate of tuberculosis
followed 5 subjects from baseline (all subjects are at risk at the beginning of study) for up to 10
weeks and obtained results graphically displayed as follows:

The graph shows how many days each subject remained in the study as a non-case (no
tuberculosis disease in subjects) from baseline. From this graph the investigator can calculate
person-time. Person-time is the sum of total time contributed by all subjects. The unit for person-
time in this study is person-days (p-d). Time contributed by each subject is as follows:

Subject A: 53 days, Subject B: 70 days, Subject C: 24 days, Subject D: 70 days, Subject E: 19

days
Therefore, total person-days in the study is calculated as follows: 53+70+24+70+19 = 236
person-days. 236 person-days (p-d) now becomes the denominator in the incidence rate measure.

34
The total number of subjects becoming cases (subjects A, C, and E) is the numerator in the
incidence rate measure.

Therefore, the incidence rate of tuberculosis = 3 cases/(236 person-days) = 0.0127 cases per
person-days. By multiplying the numerator and denominator by K = 1000, the incidence rate =
13 cases per 1000 person-days.

In another example, suppose an investigator studied the rate of breast cancer in women
with a family history of breast cancer; and subjects were examined once a year for up to five
years. In order to calculate person-time when the investigator was only examining the patients at
specified intervals (once a year), the investigator must determine when a newly diagnosed case
acquired the disease within the last year. In order to adequately determine the amount of person-
time, the investigator may decide that the onset of breast cancer occurred at the midpoint of the
time interval between being disease-free and becoming a case. This is because the investigator
would not know precisely when the subjects developed breast cancer. Assuming the graph below
displayed the amount of time until onset of breast cancer for each subject.

Time contributed by each subject would be: Subject A = 2.5 years, Subject B = 5 years, Subject
C = 1.5 years, Subject D = 5 years, Subject E = 0.5 years

Total person-years in the study would be: (2.5+5+1.5+5+0.5) =14.5 person-years

35
14.5 person-years is the denominator in the rate of breast cancer. The incidence rate = 3
cases/(14.5 person-years) = 0.207 cases person-years. By multiplying both the numerator and
denominator by K = 1000, the incidence rate would become 207 cases per 1000 person-years.

Example of cumulative incidence: If in 2023, there were 50 new cases of malaria in Okada, Edo
State, Nigeria; with an average study population of 5000. Given that K is 1000, calculate the
cumulative incidence.
50
Cumulative incidence = ×1000 = 10 new cases per 1000 persons per year in Okada
5000
This result can be interpreted as follows: Out of every 1000 persons living in Okada, 10 of them
acquired malaria in Year 2023.

Attack rate: Another commonly used measure of morbidity is attack rate. Attack rate is a type of
incidence which is mainly used during epidemics.

Number of new cases of a specific disease reported duringan epidemic

Attack rate = ×K
Total population at risk duringthe same time
K is a constant factor representing the defined population

As an example, if 100 persons visited a restaurant and they all eat jellof rice spiced with salad,
then by the next day 90 out the 100 people who ate that food developed diarrhea. Given that K =
100, calculate the attack rate of diarrhea.

90
Attack rate = ×100 = 90 cases of diarrhea per 100 persons
100

Prevalence rate:
Prevalence rate measures the number of people in a population who have a disease at a given
time. It includes both new and old cases. The major type of prevalence is point prevalence rate.
Point prevalence rate measures the proportion of a population with a certain condition at a given
point in time. Point prevalence rate can be determined by conducting cross-sectional study.

36
 All persons wit h a specific condition at one poin ∈time
Point prevalence rate = ×K
Total study population
K is a constant factor representing the defined population

Example: A researcher conducted a survey in one of the private-owned universities in Edo State,
Nigeria in 12th July 2023 to know the prevalence of asymptomatic bacteriuria in that school. The
total number of students selected for the study was 200, and they were all examined for
asymptomatic bacteriuria. After the bacteriological analysis, 100 students were found to be
positive for asymptomatic bacteriuria. Given that K = 100, calculate the point prevalence rate of
asymptomatic bacteriuria for that school.

100
Point prevalence rate = ×100 = 50
200
This result means that for every 100 students in the university, 50 students had asymptomatic
bacteriuria as at 12th July 2023.

8.1.4.3 Measurement of mortality

The mortality rate is calculated from the number of deaths, rather than the number of new
diseases. Mortality rates and ratios measure the occurrence of deaths in a population using
different ways. Rates whose denominators are the total population is commonly calculated using
either the mid-interval population or the average population. This is done because population
size fluctuates over time due to births, deaths and migration. The mid-interval population can be
estimated by adding together the number of people in the population at the start of the period of
observation and the number at the end, and dividing by 2. It is mathematically represented as
follows:

Mid-interval population =
Population count at the start of the period of observation+ ¿ Population count at the end of the timeinterval conside
2

The formulae for the commonly used mortality rates and ratios are outlined below.

37
Crude mortality rate: The crude mortality rate measures the proportion of the population dying
every year, or the number of deaths in the community per a population of 1000 persons. It
reflects the risk of death in that community or country. However, since population vary in
composition (e.g., age and sex), differences in crude rates may be difficult to interprete.

Number of deaths∈a specific age group during a given timeinterval

Crude mortality rate = ×1000
Estimated mid interval population during the giventime interval

Age-specific mortality rate: This rate provides a broader view of mortality for sub-groups
stratified by age. The numerator and denominator are limited to a specific age group. The rate is
comparable across populations. Some examples of age-specific mortality rate are Infant
Mortality Rate and Neonatal Mortality Rate.

Total number of deaths reported during a giventime

Age-specific mortality rate = × 1000
Estimated mid interval population

Infant mortality rate: Infant mortality rate reflects the health of the community in which the
child is being brought up. Thus, it is high among people who have little health care, chiefly
because infections, such as pneumonia, diarrhea and malaria, are common among their infants.
Malnutrition is also one of the killers of infants in developing countries.

Number of deaths under 1 year of age during a giventime

Infant mortality rate = × 1000
Number of live births reported duringthe same time interval

Neonatal mortality rate: Death during the neonatal period is largely due to prematurity,
malformations, accidents or injuries at birth, and lack of cleanliness and sterility during or after
delivery. In addition, it reflects the inadequacy of antenatal care. Neonatal mortality rate is
calculated as follows:

38
 Neonatal mortality rate =
Number of deaths under 28 days of age reported during a given time
×1000
Number of live births reported during the same time

Example: Assuming in 2023 there were a total of 5000 live births at the Igbinedion University
Teaching Hospital, Okada, Edo State, Nigeria. Two hundred (200) of them died before 28 days
after birth. Calculate the neonatal mortality rate.

200
Neonatal mortality rate = ×1000 = 40 per 1000 live births
5000
The result showed that out of 1000 live births in 2023, 40 of them died before 28 days after birth.

Case fatality rate: Case fatality rate represents the probability of death among diagnosed cases.

Case fatality rate =

Number of deaths ¿ a specific disease duringa given time ¿ × 10
Number of cases of that disease during the same time

Example: In 2023 there were 1000 HIV/AIDS patients in Benin City, Edo State, Nigeria. Out of
the 1000 patients, 100 died in the same year. Calculate the case fatality rate of HIV/AIDS.

100
Case fatality rate = ×100 = 10%
1000
This result indicates that 10% of HIV/AIDS patients will die once they develop the disease.

Maternal mortality rate: Maternal Mortality Rate reflects the standards of all aspects of maternal
care (antenatal, delivery and postnatal).

Maternal mortality rate =

Number of pregnancy−associated deaths of mothers ∈a given time
×100000
Number of live births∈the same time

39
Proportionate mortality ratio: The proportionate mortality ratio proffers answers to the
proportion of deaths that are due to a certain cause. For example, if the proportionate mortality
ratio breast cancer is 30 %, it means that out of a total of 100 deaths from all causes of death, 30
persons died due to breast cancer ailment.

Proportionate mortality ratio =

Number of deaths ¿ a specific cause during a given time ¿ all causes∈the same time ¿ ×100
Total number of deaths ¿

8.2 Analytic epidemiology

Analytical studies are observational studies that are aimed at objective examination and
assessment or analysis of causal relationships between exposure to potential disease determinants
(risk factors) and subsequent disease, as well as testing of the hypotheses that emerged from the
descriptive phase of the epidemiological investigation. A hypothesis is an educated guess about
an association that is testable in a scientific investigation. The information to develop a
hypothesis is often provided by descriptive data.
Analytical study designs require working with two qualitatively different sets:
1) Study group - a selected group of people with the observed characteristic (disease,
exposure to a risk factor, biological agent...)
2) Control group - a selected group of people that is identical to the monitored group in
basic epidemiological characteristics. It is used for comparison with the observed group,
which enables statistical testing of the obtained data and an objective assessment of the
observed causal connections (relationships).
Analytical studies are carried out using three main methods: Cohort, Case control and Cross-
sectional.

8.2.1 Cohort studies

These are studies that proceed from the cause (exposure to the suspected factor) to the effect
(disease), seeking an answer to the question of whether exposure to the suspected factor (cause)
will cause the disease (effect). They prospectively study two populations: one that has had
contact with the suspected causal factor under study and a similar group that has had no contact
with the factor. For example, in an investigation of the relationship between smoking and cancer

40
of the lungs, the studied group consists of smokers (exposed group), control non-smokers
(unexposed group). So, data is primarily selected from the exposed and non-exposed population.
The advantages of cohort studies are stated as follows:
i. They are accurate
ii. They are reliable.
iii. They are objective.
iv. They assess the multiple consequences of a single exposure.

The disadvantages of cohort studies are stated as follows:

i. They are financial and time-consuming.
ii. They are not suitable for the study of rare diseases.

8.2.2 Case control studies

The case-control method starts with the effect (disease) and retrospectively investigates the cause
that led to the effect. The case-control studies proceed from the effect to the cause, looking for an
answer to the question of whether the observed disease was caused by a suspected factor. The
case group consists of individuals with the disease; a comparison group has members similar to
those of the case group except for absence of the disease. These two groups are then compared to
determine differences that would explain the occurrence of the disease. An example of a case-
control study is selecting individuals with meningococcal meningitis and a comparison group
matched for age, sex, socioeconomic status, and residence, but without the disease, to see what
factors may have influenced the occurrence in the group that developed disease.
The advantages of case-control studies are stated as follows:
i. They are relatively fast
ii. They are inexpensive
iii. They are rapidly repeatable
iv. They are suitable for studying rare diseases
v. They are suitable for studying chronic diseases and diseases with long latency
vi. They have the possibility of monitoring multiple risk factors for one disease.

The disadvantages of case-control studies are stated as follows:

41
 i. They rely on human memory
ii. They have high risk of selection bias.

8.2.3 Cross-sectional studies

These are essentially prevalence studies that are carried out at a point in time (one-time study)
and may not have a control group. Cross-sectional studies contrast longitudinal studies that are
regarded as long-term studies which maintain long-term contact with the study participants to
obtain data important to a study.

8.2.4 Measurements in analytic epidemiology

Epidemiology is concerned with the degree to which a particular exposure might cause or
prevent a particular disease. However, it is difficult to claim causal-effects relationship from a
single epidemiologic study; implying that exposures and diseases are (or are not)
statistically associated. Therefore, exposure can be said to be disproportionately distributed
between individuals with and without the disease. The degree to which exposures and health
outcomes are associated is conveyed through a measure of association. Which measure of
association to choose depends on whether incidence or prevalence data are used for
epidemiologic analysis, which in turn depends on the type of study design (cohort, case-control,
randomized controlled trials and cross-sectional) used.

8.2.4.1 2 × 2 notation routinely used in analytic epidemiology designs

The necessary first step in analytic study designs is the 2 × 2 notation. Therefore, before getting
into analytical study designs and measures of association, it is important to understand the
notation used in epidemiology to convey exposure and disease data: the 2 × 2 table. A 2 × 2
(or two-by-two table) is a compact summary of data for 2 variables from a study, namely, the
exposure and the health outcome. For example if a 10-person study was carried out on smoking
(exposure) and lung cancer (health outcome), and the following data presented in the table below
was collected, where Y indicated yes and N indicated no:

Participant Smoker Lung cancer

1 Y Y

42
 2 Y N
3 Y Y
4 Y Y
5 N N
6 N Y
7 N N
8 N N
9 N Y
10 N N

From the table, the participants consisted of 4 smokers and 6 nonsmokers. 5 participants had
lung cancer and 5 participants were without lung cancer. In this example, smoking is the
exposure and lung cancer is the health outcome, implying that the 4 smokers are “exposed” (E+)
and the 6 nonsmokers are “unexposed” (E−); while the 5 participants with lung cancer are
“diseased” (D+) and the 5 participants without lung cancer are “non-diseased” (D−). This
information can be organized into a 2 × 2 table as follows:

D+ D- Total
E+ 3 1 4
E- 2 4 6
Total 5 5 10

The 2 × 2 table summarizes the information from the longer table above so that the 3 participants
that were both exposed and diseased (persons 1, 3, and 4) can be quickly seen; one participant
was exposed but not diseased (person 2); two participants were unexposed but diseased (persons
6 and 9); and the remaining 4 participants were neither exposed nor diseased (persons 5, 7, 8, and
10). Though, it does not really matter whether exposure or disease is placed on the left or across
the top of a 2 × 2 table, the convention in epidemiology is to have exposure on the left and
disease across the top.
When discussing 2 x 2 tables, epidemiologists use the following shorthand to refer to
specific cells, as shown below:

D+ D- Total

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 E+ A B A+B
E- C D C+D
Total A+C B+D A+B+C+D

8.2.4.2 Cohort study

This is a prospective study design which uses incidence data. A cohort study is one that is
characterized by looking for new cases of disease. It is also a type of study in which some
longitudinal follow-up occurs to allow for these new cases to develop. It is again a study which
must start with those who are at risk (i.e., without the disease or health outcome) as the baseline.
The prospective cohort study begins with the target population which contains both diseased and
non-diseased individuals, as shown using Figure 8.1. However, in most epidemiology research,
studies are rarely conducted on entire populations because they are too big to be logistically

Figure 8.1: A target population

feasible to study everyone in the population. Therefore, a sample is drawn and the individuals in
the sample are used to perform the study. For a cohort study, since incidence will be calculated,
the study starts with individuals who are at risk of the outcome. Therefore, non-diseased sample
are drawn from the target population, as shown in Figure 8.2.

44
 Figure 8.2: Non-diseased sample (D- sample) drawn from the target population

The next step in a cohort study is to assess the exposure status of the individuals in the sample
and determine whether they are exposed or not. By definition, at the beginning of a cohort
study, everyone is still at risk of developing the disease. However, as the study progresses some
individuals in the study may no longer be at risk upon development of the disease, and are thus
regarded as cases. It is important to note that in an attempt to determine the number of cases in a
cohort study, the participants in the study are followed for some length of time to detect incident
cases as they arise. Figure 8.3 shows a generalized approach used in cohort study.

E+: Exposed participants; E-: Non-exposed participants

Figure 4.8: Generalized approach used in cohort study

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However, the length of follow-up varies depending on the disease process in question. For a
research question regarding childhood exposure and late-onset cancer, the length of follow-up
would be decades. For an infectious disease outbreak, the length of follow-up might be a matter
of days or even hours, depending on the incubation period of the particular disease.
Recall that the original goal of the cohort study is to see whether exposure is associated
with disease. The most common way of doing this is to calculate the combined ratio, consisting
of the risk ratio and rate ratio.

8.2.4.2.1 Risk ratios

When risks are computed in a cohort study, the risk ratio is the measure that compares the
Riskexposed to the Riskunexposed. The risk ratio is defined as the risk in the exposed cohort (the index
group) divided by the risk in the unexposed cohort (the reference group). A risk ratio may vary
from zero to infinity. For example, suppose researchers conduct a cohort study and gather the

following data on the effects of tobacco smoke exposure on respiratory illness among tobacco
smokers, and obtained the data as presented in the Table below.

In this study, the risk in the exposed group is 60/200, or 0.30 cases per person (30 cases per 100
people), and the risk in the unexposed group is 25/200, or 0.125 cases per person (13 cases per
100 people). Therefore, the risk ratio is 0.30/0.125, or 2.4. A risk ratio of 2.4 implies that the
exposed group has 2.4 times the risk of developing respiratory illness as the unexposed group.

46
General interpretation of risk ratio (RR): If the RR is greater than 1, it means that more disease
is observed in the exposed group than in the unexposed group. Likewise, if the RR is less than 1,
it means that less disease is observed in the exposed group than in the unexposed group. If
causality is assumed, an exposure with an RR < 1 is preventing disease, and an exposure with an
RR > 1 is causing disease. The null value for a risk ratio is 1.0, which would mean that there was
no observed association between exposure and disease. Because the null value is 1.0, one must
be careful if using the words higher or lower when interpreting RRs. For instance, an RR of 2.0
means that the disease is twice as common, or twice as high, in the exposed compared to the
unexposed—not that it is 2 times more common, or 2 times higher, which would be an RR of 3.0
(since the null value is 1, not 0). The correct interpretation of an RR is:
“The risk of [disease] was [RR] times as high in [exposed] compared to [unexposed]
over [x] days/months/years.”

8.2.4.2.2 Rate ratio

When rates are computed in a cohort study, the rate ratio is the measure that compares the
Rateexposed to the Rateunexposed. The rate ratio is defined as the rate of health outcome occurrence in
the exposed cohort (the index group) divided by the rate of health outcome occurrence in the
unexposed or less-exposed cohort (the reference group). If in the previous example, the person-
time-at risk is that each study participants contributed to the study had been recorded in the table
as shown below:

In this study, the rate in the exposed cohort is 60/175 person-years, or 0.34 cases/person-year.
The rate in the unexposed cohort is 25/188 person-years, or 0.13 cases/person-year. The rate
ratio in this study is 0.34/0.13, or 2.6, which is higher than the rate ratio calculated above. This
rate ratio reveals that respiratory illness among smokers exposed to tobacco fumes is developing

47
at 2.6 times the rate that respiratory illness is developing among non-smokers not exposed to
tobacco fumes.
An exposure may be preventive (e.g., vitamin intake) or harmful (e.g., toxic chemical
exposure). Confounding is one type of systematic error that can occur in epidemiologic studies.
Confounding can cause an over- or under-estimate of the observed association between exposure
and a health outcome. Assuming there are no other factors that may confound the association, a
risk ratio less than 1 indicates that the risk in the smoker (index) group is less than the risk in the
unexposed or less-exposed (reference) group, and therefore, the exposure is preventive. A risk
ratio or rate ratio that equals 1 (the null value) indicates that there is no difference in risk or rates
between exposed and unexposed groups. A rate or risk ratio greater than one indicates that the
risk in the exposed is greater than the risk in the unexposed. Therefore, the exposure is harmful.
The following table may be applied to both risk and rate ratios:

The farther away the risk ratio or rate ratio is from the null value of one, the greater the effect of
exposure is on the study group. This is shown in the following diagram.

8.2.4.2.3 Risk and Rate differences

Difference measures are absolute measures of disease burden and helpful for public health
program planning. Ratio measures are relative measures; they are commonly used to research the
etiology of disease. Risk and rate differences answer the question “how much disease is

48
attributed to the exposure?” Risk difference is defined as the risk in the exposed minus the risk in
the unexposed (Equation 1). The risk difference is the excess risk of disease among the exposed
population. Rate difference uses a similar equation (Equation 2.) In the past, risk difference was
called “attributable risk”; sometimes attributable risk is still used. “Attributable fraction among
the exposed” is the risk difference reported as a percent of the exposed population (Equation 3).
“Attributable proportion” or “attributable risk percent” are alternative terms for Equation 3.
Lastly, the attributable fraction among the total population (Equation 4) answers the question
“what proportion of disease in the total population is associated with the exposure?” See Figure
4.9, terms, and equations defined below.

Figure 4.9: Rate difference

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8.2.4.3 Case control study
This is a retrospective study that uses prevalence data. Following participants while waiting for
incident cases of disease is expensive and time-consuming. Often, epidemiologists need a faster
(and cheaper) answer to their question about a particular exposure/disease combination. One
might instead take advantage of prevalent cases of disease, which by definition have already
occurred and therefore require no wait. In this study since incident cases are not used, risk and
rate ratios cannot be calculated. Instead, case control study is analyzed using odds ratio.

8.2.4.3.1 Calculating the Odds Ratio

An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR
represents the odds that an outcome will occur given a particular exposure, compared to the odds
of the outcome occurring in the absence of that exposure. The odds ratio can also be used to
determine whether a particular exposure is a risk factor for a particular outcome; and to compare
the magnitude of various risk factors for that outcome.
Odds ratios (OR) can be calculated using a two-by-two frequency table as shown below.

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An example of a case-control study using a 2×2 table to summarize the data from a lead
poisoning study can be analyzed using the exposure odd ratio as follows:

17 13 17 ×87
Odds ratio = ÷ = =1.37
83 87 13 ×83

The interpretation of an OR is the same as that of an RR, with the word odds substituted for risk:

The odds of lead poisoning were 1.37 times as high in persons that work in mine compared to
persons that do not work in mines.

Note that time is no longer mentioned, as these data came from a cross-sectional study, which
does not involve time. As with interpretation of RRs, ORs greater than 1 mean that exposure is
associated with higher odds of outcome, and ORs less than 1 means that exposure is associated
with lower odds of outcome. OR = 1 (Null value) means that exposure does not affect odds of
outcome.

8.2.4.4 Cross-sectional study

Cross-sectional studies are often referred to as snapshot or prevalence studies in which one takes
a “snapshot” at a particular point in time, determining who is exposed and who is diseased
simultaneously. In cross sectional study, the sample does not compose entirely of those at risk
because of the use of prevalent cases. Thus by definition, some proportion of the sample will be
diseased at baseline. As mentioned, risk and rate ratios can be not be calculated in cross-sectional
studies, so instead odds ratio (OR) is calculated. The prevalence ratio and prevalence odds ratio
are the two major variables that are used for epidemiological analysis in cross-sectional studies.
The OR in a cross-sectional study is often referred to as prevalence odds ratio—presumably, just

51
as a reminder that cross-sectional studies are conducted on prevalent cases. The calculation of
such a measure is exactly the same as the OR as presented above.

Prevalence of disease∈ exposed group

Prevalence ratio (PR) = or
Prevalence of disease ∈unexposed group

PR = [ ]
a
a+b
÷[
c
c+ d
]

a ×d
Prevalence odds ratio (POR) =
c ×b

The following 2 × 2 table of a breast cyst study is used as an example to calculate PR and POR:

Prevalence of breast cyst among ever user of oral contraceptives = 124/3247 = 0.038

Prevalence of breast cyst among never user of oral contraceptives = 77/2644 = 0.029

Prevalence ratio = 0.038/0.029 = 1.3

124 ×2557
Prevalence odds ratio = =1.3
3123 ×77

8.3 Experimental epidemiology

The third epidemiologic method is the experimental approach. It is a study design in which a
hypothesis is developed and an experimental model is constructed in which one or more selected
factors are manipulated. The effect of the manipulation will either confirm or disprove the

52
hypothesis. An example is the evaluation of the effect of a new drug on a disease. A group of
people with the disease is identified, and some members are randomly selected to receive the
drug. If the only difference between the two is use of the drug, the clinical differences between
the groups should reflect the effectiveness of the drug. Measurements in experimental
epidemiology mainly use the randomized control trials (RCT) technique.
The procedure for a randomized controlled trial (RCT) is exactly the same as the
procedure for a prospective cohort, with one exception: instead of allowing participants to self-
select into “exposed” and “unexposed” groups, the investigator in an RCT randomly assigns
some participants (usually half) to “exposed” and the other half to “unexposed.” In other words,
exposure status is determined entirely by chance. This is the type of study required by the Food
and Drug Administration for approval of new drugs in which half of the participants in the study
will be randomly assigned to the new drug and half to the old drug (or to a placebo, if the drug is
intended to treat something previously untreatable). RCT still involves generating incidence data
that will be epidemiologically analyzed by calculating either the risk ratio or the rate ratio.

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 9. EPIDEMIC INVESTIGATION AND MANAGEMENT
9.1 Levels of Disease Occurrence
Diseases occur in a community at different levels at a particular point in time. Some diseases are
usually present at a predictable level. This is called the expected level. But sometimes they occur
in excess of what is expected. The examples of expected level are endemic and hyper-endemic.
When the disease occur as epidemic, outbreak or pandemic it is considered as excess of what is
expected.

9.2 Definition of terms related to the level of occurrence of disease

1. Endemic: Presence of a disease at more or less stable level.
2. Hyper endemic: Persistently high level of disease occurrence.
3. Sporadic: Occasional or irregular occurrence of a disease.
4. Epidemic: The occurrence of disease or other health related condition in excess of the
usual frequency in a given area or among a specific group of people over a particular
period of time.
5. Outbreak: Epidemics of shorter duration covering a more limited area.
6. Pandemic: An epidemic involving several countries or continents affecting a large
number of people. For example the worldwide occurrence of HIV/AIDS is a pandemic.

54
The definition of epidemic indicates that the term can have a broad meaning. It may include any
kind of disease or injury including non–infectious diseases. There is no general rule about the
number of cases that must exist for a disease to be considered an epidemic. If the number of
cases exceeds the expected level on the basis of the past experience of the particular population,
then it is an epidemic. It is important to note that this level varies for different diseases and
different circumstances. An epidemic may cover a small area within a city, or an entire nation or
may have a worldwide distribution. It may encompass any time period ranging from few hours
(chemical intoxication, bacterial food poisoning), a few weeks (influenza, hepatitis) to several
years (AIDS). A disease that remains epidemic over many years eventually may be considered
endemic.

9.3 Types of epidemics

Epidemics (outbreaks) can be classified according to the method of spread or propagation, nature
and length of exposure to the infectious agent, and duration.
1. Common Source Epidemics: Disease occurs as a result of exposure of a group of
susceptible persons to a common source of a pathogen, often at the same time or within a
brief time period. When the exposure is simultaneous, the resulting cases develop within
one incubation period of the disease, and this is called a point source epidemic. The
epidemic curve in a point source epidemic will commonly show a sharp rise and fall.
Food borne epidemic following an event where the food was served to many people is a
good example of point source epidemic. If the exposure to a common source continues
over time it will result in a continuous common source epidemic. A waterborne outbreak
that spreads through a contaminated community water supply is an example of a common
source epidemic with continuous exposure. The epidemic curve may have a wide peak
because of the range of exposures and the range of incubation periods.

2. Propagated/ Progressive Epidemics: The infectious agent is transferred from one host to
another. It can occur through direct person to person transmission or it can involve more
complex cycles in which the agent must pass through a vector as in malaria. Propagated

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 spread usually results in an epidemic curve with a relatively gentle upslope and
somewhat steeper tail. An outbreak of malaria is a good example of propagated epidemic.

3. Mixed Epidemics: The epidemic begins with a single, common source of an infectious
agent with subsequent propagated spread. Many foodborne pathogens result in mixed
epidemics.

9.4 Investigation of an Epidemic

The purpose is to determine the specific cause or causes of the outbreak at the earliest time and
to take appropriate measure directed at controlling the epidemic and preventing future
occurrence. The following questions should be answered when investigating an epidemic. What
is the etiological agent responsible for the epidemic?; What is/are the predominant modes of
transmission?; What specific source/s of disease can be identified? E.g. human carriers, breeding
sites for vectors, etc; What specific practices or environmental deficiencies have contributed to
the outbreak? E.g. improper food handling, human-made breeding sites for mosquitoes; What is
the chain of events that led to the outbreak? E.g. accumulation of susceptible hosts in an area.

9.5 Uncovering outbreaks

Outbreaks are detected in one of the following ways: Through timely analysis of routine
surveillance data; Report from clinician; Report from the community, either from the affected
group or concerned citizen.

9.6 Steps in Epidemic Investigation

There is no fixed step in the investigation of epidemics but the following step can be considered
as one option.
1. Prepare for fieldwork: Before leaving for the field you should be well prepared to
undertake the investigation. Preparations can include the following:
 Investigator must have the appropriate scientific knowledge, supplies, and
equipment to carry out the investigation. It might be difficult for the health
extension worker to fully investigate the epidemic, hence, he/she should inform
and involve other high level health professionals from the outset.

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  Collect sample questionnaire.
 Arrange transportation and organize personnel matters.
 Clarify the team role in the field. Arrange where and when to meet.
2. Verify (confirm) the existence of an epidemic: This initial determination is often made on
the basis of available data. Compare the number of cases with the past levels to identify
whether the present occurrence is in excess of its usual frequency. Instead of comparing
absolute numbers it is advisable to compare rates like incidence rate
3. Verify (confirm the diagnosis): Always consider whether initial reports are correct. Carry
out clinical and laboratory investigations on the reported cases. For example the already
collected blood film slides can be seen by laboratory experts to check whether the initial
report was correct. It is important to investigate the index case (the first case that comes
to the attention of health authorities) and other early cases. The importance of the index
case and other early cases for diseases that are known to occur in epidemic form, such as
relapsing fever, is as an indication to health authorities of the possible start of an
outbreak. The sooner the index case and other early cases are investigated, the greater the
opportunity to arrest the outbreak at earliest stage possible
4. Identify and count case: Prepare “case definition” before starting identification of cases.
Case definition is defined as a standard set of criteria to differentiate between cases and
non cases. Cases can be one of the following: Confirmed/definite: A case with laboratory
verification. Probable: A case with typical clinical features but without laboratory
confirmation. Possible: A case with fewer of typical clinical features. Cases can better be
identified by active case detection using all available means including house to house
visits. They can also be identified by stimulated passive case detection, for example by
alerting the public about the epidemic and requesting them to report to the nearest health
institution when they have signs and symptoms of that disease. The health extension
worker can identify and count cases based on the sign and symptoms of the disease. If
there is effective drug for the treatment of that disease, cases can be treated while
identifying them. Additionally other control measures can be taken side by side to arrest
the epidemic before many people are affected.
5. Describe the epidemic with respect to person, place and time: Each case must be defined
according to standard epidemiologic parameters: the date of onset of the illness, the place

57
 where the person lives or became ill, and the sociodemographic characteristics (age, sex,
education level, occupation). The tools to be used when characterizing the epidemic are
epidemic curve, spot map and attack rates. Epidemic curve is an important tool for the
investigation of disease outbreaks. In epidemic curve the distribution of cases is plotted
over time, usually in the form of histogram, with the date of onset of cases on the
horizontal axis, and the number of cases corresponding to each date of onset on the
vertical axis. Spot map is a map of locality where the outbreak has occurred, on which
the location of cases is plotted. The spot map is often helpful in detecting the source of an
outbreak. One limitation of spot map is that it does not take into account underlying
geographic differences in population density. Thus the spot map needs to be
supplemented by calculation of place specific attack rates. Person specific attack rates:
The tool that is important for the analysis of disease outbreaks by personal characteristics
is person specific attack rates like attack rates by age, sex, occupation, income, religion
etc.
6. Identify the causes of the epidemic: All factors that can contribute to the occurrence of
the epidemic should be assessed. The epidemic investigating team should try to answer
questions like: Why did this epidemic occur?; Are there many susceptible individuals? Is
the temperature favorable for the transmission of the diseases?; Are there breeding sites
for the breeding of vectors? Etc. Confirmation of the diagnosis can be done by using
additional tests which are more accurate. In addition to knowing the etiologic agent, more
emphasis should be given to identify the risk factors. Investigate the environmental
conditions such as food sanitation, suspected breeding sites, animal reservoirs, according
to the type of disease outbreak being investigated.
7. Management of epidemic and follow up: Although it is discussed late, intervention must
start as soon as possible depending on the specific circumstances. One might aim control
measures at the specific agent, source, or reservoir. For example, an outbreak might be
controlled by destroying contaminated foods, disinfecting contaminated water, or
destroying mosquito breeding sites or an infectious food handler could be suspended
from the job. Management of epidemics requires an urgent and intelligent use of
appropriate measures against the spread of the disease. Action to be taken is dependent
on the type of the disease as well as the source of the outbreak. However, the actions can

58
 be generally categorized as presented below to facilitate easy understanding of the
strategies.
I. Measures Directed Against the Reservoir.
2. Understanding the nature of the reservoir is necessary in the selection of an
appropriate control methods and their likelihood of success. The following are examples of
control measures against diseases with various reservoirs:
Domestic animals as reservoir:
􀂃 Immunization. Example – giving anti-rabies vaccine for dogs
􀂃 Destruction of infected animals e.g anthrax. Wild animals as reservoir: post-exposure
prophylaxis for human beings- Example: rabies
Humans as reservoir:
a. Isolation of infected persons. This is separation of infected persons from non-infected for the
period of communicability. This is not suitable in the control of diseases in which a large
proportion are inapparent infection (without signs and symptoms) or in which maximal
infectivity precedes overt illness.
b. Treatment to make them noninfectious- e.g., tuberculosis.
c. Quarantine- is the limitation of freedom of movement of apparently healthy persons or animals
who have been exposed to a case of infectious disease. Usually imposed
for the duration of the usual maximal incubation period of the disease. Cholera, Plague, and
yellow fever are the three internationally quarantinable diseases by international
agreement. Now quarantine is replaced in some countries by active surveillance of the
individuals; maintaining close supervision over possible contacts of ill persons to detect infection
or illness promptly; their freedom of movement is not restricted.

B. Measures that interrupt the transmission of organisms

Action to prevent transmission of disease by ingestion:
i. Purification of water
ii. Pasteurization of milk
iii. Inspection procedures to ensure safe food
supply.
iv. Improve housing conditions.

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Actions to reduce transmission of respiratory infections include ventilation of rooms.
In the case of diseases that involve an intermediate host for transmission, for example
schistosomiasis, clearing irrigation farms from snails is an appropriate measure.

C. Measures that reduce host susceptibility

􀂃 immunization (vaccination). Example vaccination for meningitis
􀂃 Chemoprophylaxis: for example, use of chloroquine to persons traveling to malaria endemic
areas. After the epidemic is controlled, strict follow up mechanisms should
be designed so as to prevent similar epidemics in the future.

8. Report of the investigation

At the end prepare a comprehensive report and submit to the appropriate/concerned bodies like
the World Health Office. The report should follow the usual scientific format: introduction,
methods, results, discussion, and recommendations.
The report should discuss in detail:
􀂃 Factors leading to the epidemic.
􀂃 Measures used for the control of the epidemic.

􀂃 Recommendations for the prevention ofmsimilar episodes in the future.

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