Family and community medicine

Introduction to Community Medicine

(General Epidemiology)

Assist. Prof. Dr. Nawar Sahib Khalil

 Lecture Objectives: At the end of the lecture, the students are expected to

• Understand the main concepts in Community Medicine.

• Describe the main dimensions of epidemiology definition.
• Understand the importance of preventive medicine.
• Recognize the natural history of disease.
• Understand the iceberg phenomena of disease.

Introduction

Millions of people die of preventable diseases each year. The leading

causes are cardiovascular disease, respiratory disease, injuries, diabetes,
added to infectious diseases. World Health Organization (WHO) estimates
that around 57 million people died worldwide in 2015, two third of them
died from non-communicable diseases, like stroke, cardiovascular diseases,
respiratory diseases and cancer.

In 2015, 7.8 million children died under the age of 5. Child death
(mortality) is caused by a variety of factors include infections, poverty and
environmental factors.

Every day, about 830 women die from preventable causes related to
pregnancy and childbirth. Other emerging risk factors and conditions that
affect the health of community: obesity, STDs, smoking, accidents, violence
and addiction.

The study of health and disease could be carried out by observing their
effect on individual, by laboratory investigation of experimental animals, or
by measuring the distribution of health problems in population (such
method is epidemiology).

The epidemiology is a word derived from Greek word Epidemic that

mean (Epi: on or upon, demos: peoples, logy: science or study of). Such
word determines the first concern of epidemiologist that was to investigate,
control and prevent epidemic.

Epidemiology based on two fundamental assumptions:

1. Human disease does not occur randomly and,

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 2. Human disease has an etiological and preventable factor that could be
identified through systemic investigations of human population.

From this we can directly define the epidemiology (as the study of
frequency, distribution and determinants of health phenomena in
human population).

Frequency: it is mean the quantity of occurrence of disease or any other

health phenomena by incidence and prevalence.

Distribution: it is by answering the following questions; Who: mean

Person, Where: mean Place, When: mean Time, these also followed by the
question Why and How.

Determinants: it is mean factors influence the risk, increasing or

decreasing the disease frequency or disease distribution.

Host (genetic) factors: that determines susceptibility of person to get

the disease (e.g. age, sex, nutrition, immune status).

Environmental factors: that determines host exposure to specific

agents (e.g. Family size, family composition, crowding, climate).

Historical background of Epidemiology:

Epidemiology originally defined as the scientific study of epidemic. As

the scope of epidemiology has enlarged over the years, the definition of
epidemiology has also changed from this previous narrow definition and
broadened to recognize the application of epidemiology in prevention and
control of health problems.

Epidemiology is old as medicine itself, and in the same way it has

passed the era of evil spirit in the causation of disease.

Hippocrates (400 BC) who considered the father of epidemiology, he

has statement regarding the field of epidemiological studies:
(Whoever wishes to investigate disease properly, should proceed thus
in first place to consider; the season of the year, winds, location, mode of
living, type of work).

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 During Islamic era: there is an emphasis on the personal hygiene to
control the spread of infection.

John Snow “the father of modern epidemiology”; he is a British

physician formulated and tested a hypothesis concerning the origin of an
epidemic of Cholera in London between1853-1854. He observed that the
death rate from cholera were particularly high in the area of London that
were supplied with water by different water companies that take their water
from Themes river at area nearer to the sewage point of the city (water
pollution is the cause prior to discovering the etiological cause of cholera).

Epidemiology was defined as “the branch of medical science dealing

with epidemics” (suggested by Parkin in 1873).

Frost in 1927 defined epidemiology as “the science of mass phenomena

of infectious disease…. Which represent the leading cause of death at that
time.”

Greenwood 1934 defined epidemiology as “the study of disease, any

disease as a mass phenomenon”.

Mac Mahon in 1970 defined it as “the study of the distribution and

determinant of disease frequency”.

Sartwell 1975 defined epidemiology as the study of the dynamics of

health phenomena in human population”.

Out of the above definitions, the most useful, comprehensive and

modern definition of epidemiology is:

“The study of the distribution and determinants of health related

states and events in populations and the application of this study to control
health problems”. More simply,

“Epidemiology is the study of distribution and determinants of health

related events in population”.

Events are health related events include disease, disability,

physiological conditions and different states of health.

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 Population includes both human and animal populations.
Epidemiology is now extensively used for study of diseases in animals.

Uses of Epidemiology

1. Historical study: is a community health improving; getting better or

worse, by counting rate over time.

2. Population or community health diagnosis or assessment: the actual

and potential health problem in the community, their nature, impact
and diagnosis.

To set a policy and plan program, public health officials must assess the
health of the population or community they serve and determine whether
health service are available, accessible, effective and efficient. For doing
this, public health officials must find answers for many questions:

What are the actual / potential health problems?

Where are they?
When the problems are tends to occur?
Who is at risk?
Which problems are increasing or decreasing over time?
How do this pattern relate to the level and distribution of service
available?

Thus; the methods of descriptive and analytic epidemiology

provide a way to answer these and other questions.

3. Working of health services: efficiency and effectiveness of health

services that help in health services administration for future needs.

4. Individual decision (risk and chance): when people decide to stop

smoking, taking the stairs instead of elevator, order a salad instead of
a cheeseburger with French fires, or choose one method of
contraception (family planning) instead of another, they may be
influenced either consciously or unconsciously by epidemiology.

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 The unique contribution of epidemiology is that epidemiological
studies are conducted on human population and provide information
considered useful for population to engage a healthy lifestyle.

Examples of the epidemiological findings are:

✓ In 1950s, epidemiologist documented the increased risk of lung

cancer among smokers;
✓ In 1960s and 1970s, epidemiologist noted a variety of benefits
and risks associated with different methods of birth control.
✓ In the mid of 1980s, epidemiologist identified the increased risk
of human immunodeficiency virus (HIV) infection associated
with certain sexual and drug-related behaviors, and more
positively, epidemiologist continue to document the role of
exercise and proper diet in reducing the risk of heart disease.

These and other hundreds epidemiological findings are directly relevant

to the choices that people make every day, choices that affect their health
over a lifetime.

5. Completing the clinical picture:

When studying a disease outbreak, epidemiologists depend on clinical

physicians and laboratory scientists for the diagnosis of individual patients.

But epidemiologists also contribute to physicians’ understanding of the

clinical picture and of the natural history of diseases. For example,
epidemiologists have documented the course of HIV infection from the
initial exposure to the development of a wide variety of clinical syndrome
(AIDS). Similarly, they have documented the numerous conditions that are
associated with cigarettes smoking from pulmonary and heart disease to lung
and cervical cancer.

6. Searching for cause; by identifying casual factors or at least risk

factors.

It has been said that epidemiology can never prove a causal relation
between an exposure and a disease, nevertheless, epidemiology often
provide enough information to support effective action, e.g. John Snow’s
removal of the pump handle.
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 Furthermore, epidemiology has often provided information long before
the basic mechanism of particular disease was understood, e.g. AIDS,
epidemiology was the first science that discovered that AIDS is contagious,
that it is mainly STD and mainly among homosexual and IV drug’s’ addicts,
this mean a blood-borne infection long before the discovery of its viral
origin.

7. Identification of syndromes: during epidemiological investigations,

sometimes it is possible to group together several different
manifestations of condition or to separate seemingly identical diseases
into more than one category e.g. hepatitis A, B).

8. Clinical decision analysis about the best methods of managing

patients with particular disease.

Approach of Epidemiology

The epidemiological process begins by making a suspicion concerning

the possible influence of particular factors on the occurrence of a disease.
This suspicion may arise from clinical practice, laboratory research or even
from theoretical speculations and lead to the formulation of specific
hypothesis. This hypothesis is going to be tested through epidemiological
studies.

The epidemiological sequence is:

1. Observation.
2. Counting cases or events.
3. Relating cases or events to the population at risk.
4. Making comparisons.
5. Developing the hypothesis.
6. Testing the hypothesis.
7. Making scientific inference.
8. Conducting experimental studies.
9. Intervention and evaluation.

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The comparison between clinical and epidemiological approach

Item Clinical Epidemiological

Etiology Cause of developing disease Cause of spread of disease in
in individual community
Unit of study Case or cases Defined population or population
at risk
Consideration Concerned with disease in Concerned with disease pattern
the individual patient in the entire population
Diagnosis Identifying disease in Identify the magnitude of disease
individual in community
Therapy Recovery Control and eradication

Application of epidemiology

1. Studying of the disease and natural history of disease.

✓ Infectious diseases
✓ Non communicable diseases
✓ Accident
✓ MCH and family planning.
✓ Iatrogenic diseases.
✓ Mental diseases.
2. Screening for disease.
3. Identifying population at risk.
4. Identifying disease etiology.
5. Investigation of epidemic.
6. Surveillance of disease.
7. Providing data for health planning.
8. Clinical research studies.
9. Studying public health problems.
10.Health program evaluation.
11.Evaluating new treatment methods.
12.Collection and analysis of birth and deaths.
13.Collection and analysis of morbidity data.

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Lecture 1 Part 2: Concepts in community medicine

Public Health: The science and art of preventing disease, prolonging

life and promoting health through organized efforts and informed choices of
society, organizations, public and private, communities and individuals"
(Winslow 1851).

Public health practice requires multidisciplinary teams of public health

workers and professionals including physicians specializing
preventive/community medicine/infectious disease, psychologists, medical
assistants, nurses, midwives, medical microbiologists, environmental health
inspectors, pharmacists, dentists, dietitians and nutritionists, veterinarians,
public health engineers, public health lawyers, sociologists, community
development workers, communications experts, bioethicists, computer
informaticians, and others.

Community Health: A subject of study within the medical and clinical

sciences which focuses on population groups and communities as opposed to
individual patients. It is a discipline which concerns itself with the study &
improvement of the health characteristics of families & communities.

Community medicine (Preventive or Social Medicine): can be

defined as “the combination of sciences, skills and beliefs that are directed
to the maintenance and improvement of the health of people”.

It has been defined as “The field concerned with the study of health and
disease in the population of a defined community or group. Its goal is to
identify the health problems and needs of defined populations (community
diagnosis) and to plan, implement and evaluate the extent to which health
measures effectively meet these needs”

Is the science that concerns with the promotion of health, prevention,

control, and management of diseases, disabilities, and other health problems
in the community.

The emphasis in community medicine is on the early diagnosis of

disease, the recognition of environmental and occupational hazards for good
health, and the prevention of disease in the community through collaborative
community action and research.

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Modern medicine: include;

Curative medicine: defined as the treatment of the disease by the use

of drug which produces a reaction that itself neutralize the disease.

Its primary objective is the removal of the disease from the patient
(rather than the mass). It employs diagnostic techniques and treatment.

Preventive medicine: It is a branch of medicine distinct from public

health applied to healthy people concerned primarily with preventing
physical, mental and emotional diseases and injury by the action affecting a
large numbers of populations.

Its primary objective is prevention of disease and promotion of health

(through e.g. vaccine, antisera, quarantine, nutrition, or recently through
screening for the diagnosis of the disease in its pre-symptomatic stage.

Health and disease

Concept of health:

Health is one of the most difficult terms to define. Health can mean
different things to different people. To some it may mean freedom from any
sickness or disease while to some it may mean harmonious functioning of all
body systems.

The WHO (1948) has attempted to construct a positive definition of

Health and has described Health as “a state of complete physical, mental
and social wellbeing and not merely an absence of disease or infirmity”.
Later on (1978), it has been added as to lead a “socially and economically
productive life”.

Health is a state of dynamic equilibrium between man and his

environment.

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Concept of disease:

Disease: is maladjustment or disequilibrium between man and his

environment.

Disease is the converse of health. Disease refers to any change from a

normal state of health or an abnormal state in which part or all of the body is
not properly adjusted or is not capable of carrying on its normal functions.

Literary, "DIS-EASE", is the opposite of ease, when something wrong

in the body function, or any deviation from normal. The words "disease",
"illness", "sickness", are loosely interchangeable, but are better regarded as
not wholly synonymous.

Disease: A cluster of signs, symptoms and laboratory findings linked

by a common patho-physiologic sequence.

Illness: The subjective state of the individual who feels aware of not
well-being (The ill individual may or may not be suffering from disease).

Note that: Disease is an objectively measurable pathological condition of

the body. Tooth decay, measles, or a broken bone, are examples. In contrast,
illness is a feeling of not being normal and healthy. Illness may, in fact, be
due to a disease. However, it may also be due to a feeling of psychological
or spiritual imbalance.

Sickness: the social role assumed by an individual suffering from an

illness.

Syndrome: When the signs and symptoms have not yet clearly been
placed in a common patho-physiologic sequence.

Natural history of disease:

Natural history of disease signifies the way in which a disease evolves

in the absence of intervention. It comprises two phases:
1. Pre-pathogenesis phase.
2. Pathogenesis phase.

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Pre-pathogenesis phase:

This refer to the period preliminary to the onset of disease, during this
phase, man is not yet involved, but he is very much in the midst of disease or
at the risk of the disease. During this phase the three epidemiological factors
that are involved in disease occurrence (Agent, Host and Environment) are
in isolation, but when interact occur, man move from the pre-pathogenesis to
the pathogenesis phases. These factors are commonly referred as the
“Epidemiological triad” or “Ecological triad”, these factors determine the
onset as well as the distribution of disease in the community.

Agent Host

Environment

Pathogenesis phase:

It begins with entry of disease agent in the human host. There is a time
between the entry of the disease agent and the onset of clinical signs and
symptoms of disease that’s known as the incubation period, which varies
from one disease to another. During this phase there is tissue and
physiological changes which could be subclinical (difficult to be recognized
by the usual methods of diagnosis).

After the incubation period and when the health equilibrium is

disturbed, the signs and symptoms of disease begins to appear, in the first
few days of illness, these signs and symptoms are not clear-cut (called early
pathogenesis phase), but as disease advances, they usually become clear-cut
to make a clinical diagnosis.

The end result of disease process may be complete recovery, chronicity,

disability or death.

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The iceberg phenomena of disease

Disease in a community may be compared with an iceberg; the floating

tip of the iceberg represents what physician see in the community (clinical
cases). The “water line” represents the demarcation between apparent and
inapparent disease.

The submerged portion of the iceberg represents the hidden mass of the
disease (e.g., inapparent, pre-symptomatic or subclinical cases, carriers,
undiagnosed cases in the community).

The remaining mostly large hidden portion far exceeds the exposed part
of the iceberg that constitutes the important, undiagnosed or unrecognized
mass of disease in the community and its detection and control is a challenge
to modern techniques in preventive medicine.

The concept of the "iceberg phenomenon of disease" gives an idea of the

progress of a disease from its sub-clinical stages to overt or apparent disease
state.

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Importance of natural history

Natural history is as important as causal understanding for the

prevention and control of disease.
The earlier you can become aware of the attack, the more likely you
will be able to intervene and save lives.

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The concept of prevention:

Prevention: Is the anticipatory action taken to reduce the possibility of an

event or condition occurring or developing, or to minimize the damage that
may result from the event or condition if it does occur.

Prevention may take place at any point along the spectrum of the
disease, from the prevention of the disease or injury to the prevention of
impairment, disability or dependency.

Disease or injury Impairment Disability Dependence

Primary prevention Secondary prevention Tertiary prevention

Level of disease prevention:

Primordial prevention: (Acting on risk factor)

It is consists of actions and measures that inhibit the emergence of risk

factors in the form of environmental, economic, social, and behavioral
conditions and cultural patterns of living etc.

It is a new aspect that receiving a special attention in the prevention of

chronic diseases, it is a primary prevention in its purest sense, that is
prevention of development of risk factors in countries or population groups
in which they have not yet appeared, for example, many adult health
problems (obesity, hypertension) have their early origin in childhood,
because this is the time when lifestyle are formed (smoking, eating pattern,
physical activity). In primordial prevention, efforts are directed towards
discouraging children from adopting harmful lifestyle. The main
intervention in primordial prevention is through individual and mass
education.

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Primary prevention: (Acting before disease occurrence)
It refers to the action taken prior to the disease development in man, or
to the action taken prior to the onset of disease to remove the possibility that
a disease will ever occur.

It done by two measures: health promotion and specific protection.

The goal of primary health is not merely the prevention of early mortality
and prolongation of life but even the prevention of morbidity following the
statement “AN OUNCE OF PREVENTION IS WORTH A POUND OF
CURE” (Henry De Bracton, 1240).

Health promotion:

It is the strengthening of the host by improving the general health and

quality of life of individuals and communities through;
1. Improving food distribution and nutrition.
2. Basic sanitation e.g. safe water supply, sewage disposal, refusal
disposal, control of insects and rodents.
3. Personal hygiene.
4. Health education of public; improving the general level of population.
5. Increasing the physical fitness of the population.
6. Marriage counseling.
7. Limitation the availability of alcohol, tobacco and other hazardous
material to health.
8. Family planning and good child rearing.
9. Improving the standards of living of people.
10.Health legislation.

Specific protection:
It is mean that we are going to give a protection of certain human being
against specific disease, it include:
1. Immunization.
2. Use of specific nutrients.
3. Chemoprophylaxis.
4. Protection against occupational hazards.
5. Protection against accidents.
6. Protection from carcinogens.
7. Avoidance of allergens.
8. Control of hazards in the environment.
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Secondary prevention: (Acting after disease occurrence)

It denotes the identification of people who have already developed the

disease at an early stage in the disease’s natural history (early diagnosis and
treatment).

It is an action which halts the progress of disease at its incipient stage

and prevents complications.

It is the domain field of clinical medicine action, it seeks to relive pain,

arrest or cure disease, prevent disability and death and prevent spread of
disease in the community.

Early diagnosis and treatment:

The earlier a disease is diagnosed and treated, the better it is from the
point of view of spread of disease in the community, and any long-term
disability.
Early diagnosis and treatment through;
1. Case finding measures.
2. Screening.
3. Periodic examination.
4. Selective examination of people at high risk.

Tertiary prevention: (Acting after complications occurrence)

It is the prevention of disease potential consequences or complication

by disability limitation and rehabilitation.

Disability limitation:

It is to halt the disease process by instituting appropriate treatment and

thereby limiting the disability (any restriction or lack “resulting from an
impairment” of ability to perform activity in the normal range for
human being). It is through:

1. Reducing the occurrence of impairment (immunization against polio)

2. Disability limitation by appropriate treatment.
3. Preventing the transition of disability into handicap.

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Rehabilitation:

Defined by WHO as “the combined and coordinated use of medical,

social, educational and vocational measures for training and retraining
the individual to the highest possible level of functional ability, and at
enabling the disabled and handicapped to achieve social attention”.

It involves medical, vocational, social, and psychological rehabilitation.

Rehabilitation makes productive people out of non-productive people.

Quaternary prevention:

It is the prevention from iatrogenic (medical) harm. This action taken to

identify patients:
1. At risk of (over) medication.
2. To protect him from new medical invasion.
3. To suggest to him interventions, which are ethically acceptable.

Then, prevention is any intervention that seeks to reduce or eliminate

diagnosable conditions and may be applied at individual level, as in
immunization, or the community level, as in the chlorination of water
supply.

Control of diseases:

Disease control describes ongoing operations aimed at reducing:

1. Incidence of disease
2. Duration of disease
3. Complications (physical & psychological)
4. Financial burden

Disease Elimination:
It is the interruption of transmission of disease in the community, e.g.:
elimination of measles, polio and diphtheria

Disease Eradication:

It is the process of “Termination of all transmission of infection by

extermination of the infectious agent through surveillance and containment”.
To-date, only one disease has been eradicated, that is smallpox.
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