Epidemiology

Ephrem M (MPHE, PhD fellow)

Assistant Professor of Epidemiology

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 Credit hrs: 3Cr

 Mode of evaluation (assessment)

• Continuous assessment -----------40%

• Final written examination --------60%

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 Course outline
• Introduction to Epidemiology

• Infectious Disease Epidemiology

• Basic measurements in epidemiology

• Epidemiological study designs

• Measures of association and establishing causation

• Validity of Epidemiological studies

• Outbreak investigation and management

• Screening and Diagnostic Tests

• critical review of epidemiology

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 Course References
1. Hennekens CH & Buring JE. Epidemiology in Medicine. Little,
Brown and Company. Boston/Toronto. 1987.
2. Madeleine Fletcher. Principles and practice of epidemiology

3. Mausner and Kramer. Epidemiology: An Introductory Text. W. B.

Saunders Company: West Washington Square, Philadelphia. 1985

4. Rothman KJ and Greenland S. Modern Epidemiology. Lippincott

Williams & Wilkins, Philadelphia. 1998.

5. Berhane Y. Lecture Notes: Epidemiology I, Principles of

Epidemiology. Department of Community Health, Faculty of
Medicine, AAU.
Ephrem M, BSc, MPH
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 1. Introduction to Epidemiology

Current definition
The study of the
frequency, distribution and determinants
of Disease and other health related events
in specific populations, and
the application of it to prevention and
control of health problems.
Ephrem M, BSc, MPH 5
Terms taken from the definition
1. Frequency:
It is a quantitative science
(it measures frequency of occurrence)
Example

– Number of exposed people

– Number of people with the outcome of interest
– Proportion of exposed people
– Proportion of people with the outcome of interest
Ephrem M, BSc, MPH
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 Cont...
2. Distribution
It is the occurrence of diseases and other
health problems in terms of person, place
and time.

This attempts to answer

Who? Where? And When?

Ephrem M, BSc, MPH

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 Descriptive Epidemiology

Cases

Person Time
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1200
1000
800
600
Place 20

15

10
400
200 5

0 0
0-4 '5-14 '15- '45- '64+ 1 2 3 4 5 6 7 8 9 10
44 64
Age Group

Who? Where? When?

Ephrem M, BSc, MPH
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 Cont…
3. Determinants –
Factors that are related with the occurrence of a disease in
individuals.

the causative factors for the occurrence of a disease.

– It attempts to answer questions like:

How?  Mechanism
Why?  Causal link

– More on possible cause or means for disease occurrence

Ephrem M, BSc, MPH

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 Cont…
4. Disease and Health-related problems
• It includes – both diseases and physiological
and/or psychological dysfunction of the body
• Time course (acute and chronic)
• Cause (infectious and none infectious)

cause acute chronic

infectious

Non infectious
Ephrem M, BSc, MPH
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 Cont…

• It also includes other health related problems like:

– Vital events, which include births, deaths, marriage,
divorces etc

– Health related behaviour – sexual behaviour,

smoking, alcoholism, drug abuses

– Social factors, such as poverty.

Ephrem M, BSc, MPH

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 Cont…
6. Human population –

Epidemiology studies the health of the groups, communities and

specific population.

Clinical medicine – focuses largely on the health of sick

individuals.

6. Application …. to the prevention and control of …..-

It is applied science, ie direct practical applications.
The aim of all about frequency, distribution of diseases is to
identify effective prevention and control strategies.
Ephrem M, BSc, MPH
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 Broad Categories of Epidemiology

1. Descriptive Epidemiology - Defines the amount and

distribution of health problems in relation to person, place
and time.

1. Analytic Epidemiology – involves explicit comparison of

groups of individuals to identify determinants of health
and diseases.

Ephrem M, BSc, MPH

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 Basic Assumptions in Epidemiology
• There are two basic assumptions in epidemiology.

• Non random distribution of diseases i.e. the distribution of

disease in human population is not random or by chance.

• Human diseases have causal and preventive factors that

can be identified through systematic investigations of
different populations.

Ephrem M, BSc, MPH

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 Scope of Epidemiology

• Originally, epidemiology was concerned with epidemics of

communicable diseases and epidemic investigations.

• Later it was extended to endemic communicable diseases

and non-communicable diseases.

At present epidemiologic methods are being applied to:

• Infectious and non infectious diseases, Injuries and accidents,
Nutritional deficiencies, Mental disorders
• Maternal and child health, Congenital anomalies
• Health behaviors, Occupational health, Environmental health
and etc Ephrem M, BSc, MPH
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 Purpose/Use of Epidemiology

The ultimate purpose of Epidemiology is prevention and control of

disease, in an effort to improve the health status of populations.
This is realized through:

• Description of the health status of the population

• Identification of population at risk

• Establishing the determinants/causation of disease

• Evaluation of intervention

• Conduct surveillance of disease, injury and risk factors

Ephrem M, BSc, MPH
• • Investigate outbreaks 16
2. Infectious Disease
Epidemiology

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 2. Infectious Disease
Epidemiology

Infectious disease (Communicable 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
inanimate environment

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Natural History of Diseases
It refers to the progression of a disease process in an
individual over time, in the absence of intervention.

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 Cont…
• Begins by exposure to a causative agent capable of
causing disease.

• Without intervention, the process ends with

recovery, disability or death.

• The course can be halted at any time in the

progression by intervention, host factors and other
influences.

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Time Course of a Disease in Relation to Its
Clinical Expression and Communicability

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Generation period
 Cont…
The natural history of infectiousness includes:

Prepatent period: the time interval from infection to

becoming infectious (shedding of the agent).

Infectious period: the time during which an infected host

could infect another host or vector.

Incubation period: the time interval from infection to

symptomatic disease.
Latent Period: The interval between recovery and the
occurrence of relapse or recrudescence in clinical disease.
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 Carriers
• Incubatory carriers: Transmitting the disease during incubation period,
i.e. from infection until the clinical onset.
Example:
• Chronic carriers: Transmitting the disease for a long period / indefinite
transmission.
Example:

• Asymptomatic carriers: Transmitting the disease without ever showing

manifestations of the disease.
Example:

• Convalescent carriers: Transmitting the disease during convalescence

period i.e. from the time of recovery to when shedding stops.
Example:
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Components of Infectious Disease Process

• Infectious diseases result from the interaction between the

infectious agent, host/reservoir and environment.

Host

Agent Environment

Fig 2. Components of infectious diseases

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• Agent: Agent is an infectious micro-organism- virus, bacteria,
parasite, or other microbe.

• Host: Host factors influence individual's exposure,

susceptibility or response to a causative agent. For example-
age, sex, race, socioeconomic status, and behaviours (smoking,
drug abuse, lifestyle, sexual practices and contraception, eating
habits) affect

• Environmental factors are extrinsic factors which affect the

agent and the opportunity for exposure.
• Physical like climate, and biologic factors socioeconomic
factors such as crowding, sanitation, and the availability of
health services.
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I. Sufficient and Necessary causes model
• It is also called multiple causality of diseases

• Necessary cause: A causal factor whose presence is

required for the occurrence of the disease.
• A factor (contributing) that is necessary (or with
out which) the disease doesn’t exist or occur is a
necessary cause
• Sufficient cause. A causal factor or collection of
factors whose presence is always followed by the
occurrence of the disease.

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 Cont…
An example of three sufficient causes of a disease
I II III
U U U
A B A E B E

• Assume that these three causes are operating in the diagram

• Without ‘U’, there is no disease. ‘U’ is considered as necessary

cause, but all diseases are not due to ‘U’ alone.

• ‘E’ causes disease through two mechanisms, II and III, all

diseases arising from II and III are due to ‘E’.

• No component cause acts alone, the factors interact with their

complementary factors to produce disease
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Infection and Disease Outcome
Exposure to an infectious agent does not necessarily lead to infection,
An infection does not necessarily lead to disease
Infection may remain asymptomatic or sub-clinical, or may lead to overt
clinical disease
Exposure Infection Disease Disease
outcome

Infectiousness Pathogenicity Virulence

Outcomes at each stage of infection

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 1. Infectiousness
(1) is the characteristics of the disease agent that embodies capabilities
to enter, survive, and multiply (produce infection) in the host.
(2) The proportion of exposures, in defined circumstance, that results
in infection

1. From exposure to infection

 Infectiousness: the proportion of an exposed susceptible host who become
infected (measured by infection rate), as:

No. infected X 100

No. susceptible and exposed
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 2. Pathogenicity
 is the ability to produce clinically apparent illness
 many host and environmental factors as well as the dose, route
of entrance of the infection, and source of the infection may
alter the pathogenecity of a particular infectious disease agent.

 the proportion of infected people who develop clinical disease,

and measured by the clinical-to sub-clinical ratio, as:

No. of clinical cases X 100

No. of sub-clinical cases
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 3. Virulence
3. From disease to disease outcome
 the proportion of persons with clinical disease who
become severely ill or die, and it is measured by
Case-fatality-rate or hospitalization rate
 depend on dose, route of infection, and host
factors such as age or race.
No of death of a specific disease X 100
Case-fatality-rate =
Total No of cases of that specific disease

No of hospitalized persons of a specific disease X 100

Hospitalization rate =
Total No of cases of that specific disease

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 Case 1
• One hundred people attended a wedding feast and eighty of
them ate apiece of the wedding cake. Ten of the participant
were later hospitalized with sever gastroenteritis but
fortunately none of them are died. When the incident was
later investigated it was found that the wedding cake was
harbored the infectious agent\IGM\ indicative of recent
infection were found in 60 out of 80 participant who had
eaten cake including the 10 hospitalized ones. Another 20 of
the 60 had reported having experienced with diarrhea but
not serious enough to report to health services.
• .

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 question
• how many peoples are infected by infective agent

• How many peoples develop disease?

• Infectiousness of the disease

• Pathogenecity of the disease

• Virulence of the disease 33

 Basic reproductive number (Ro)
 Another important parameter in infectious disease is the basic
reproductive number (Ro).

 number of newly infected people from a single case

 the expected number of new infectious hosts that one infectious

host will produce during his/her period of infectiousness in a
large population that is completely susceptible.

 Ro does not include the new cases produced by the secondary

cases, or further down the chain.
 Ro
Ro > 1
Cases

Ro = 1

Ro < 1
Time

Infection will ….. disappear, if R < 1

become endemic, if R = 1
become epidemic, if R > 1 35
• In general, for an epidemic to occur in a
susceptible population, Ro must be > 1.

• If Ro < 1, an average case will not produce

itself, so an epidemic will not spread.

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 Transmission Rate (Ro) SARS-CoV-2
 Indicate how rapidly the disease spreads

 A more recent study a Ro as high as 4.1, WHO's recent

estimate between 3.6 and 4.0

 On average every case of the SARS-CoV-2would create 3

to 4 new cases

 The Ro for MERS is 0.7 and for SARS was 2.0.

• Zhidong Cao et al, 2020, prelimenary data, 2020, WHO

2020
 Effective reproductive number (R)

• If x is the proportion of a randomly mixing, homogeneous

population that is susceptible, R is the product of Ro times
the proportion x of the contacts that are with susceptible

• R = Rox

• Example: Assume that Ro = 9 for measles in a population

and that three fourth of the population is immune. Then, the
R for measles

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 How dangerous is the Agent?

 Transmission Rate (Ro) - number of newly

infected people from a single case

Case Fatality Rate(CFR) - percent of cases

that result in death
The COVID-19 CFR : 3.4%, the CFR for
SARS was 10%, and for MERS 34%

 Asymptomatic Transmission of the disease

 Herd immunity
Herd immunity
• is the resistance of a community (group) to invasion
and spread of an infectious agent, based on the
immunity of a high proportion of individuals in the
community.
• The high proportion of immunes prevents
transmission by highly decreasing the probability of
contact between reservoirs and susceptible hosts.
 Herd immunity cont…
Conditions under which herd immunity best functions
1) Single reservoir (the human host): If there is other
source of infection it can transmit the infection to
susceptible hosts.
2) Direct transmission (direct contact or direct projection):
Herd immunity is less effective for diseases with
efficient airborne transmission.
3) Total immunity: Partially immune hosts may continue
to shed the agent, and hence increase the likelihood of
bringing the infection to susceptible hosts.
 Herd immunity cont…
4) No shedding of agents by immune hosts (no carrier
state).
5) Uniform distribution of immunes: Unfortunately,
susceptibles usually happen to live in clusters or
pockets because of socioeconomic, religious, or
geographic factors.
6) No overcrowding: Overcrowding also increases the
likelihood of contact between reservoirs and
susceptible hosts.
• However, these conditions for the operation of herd
immunity are seldom fulfilled.
Thank you

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