Epidemiology 1

EPIDEMIOLOGY
Objective [The goal intended to be attained and which is believed to be attainable]
To equip the learner with knowledge, skills, and attitudes which would enable him/her to apply
Epidemiological approaches in the promotion and control of health problems?
SUBJECT OUT-LINE
1. Definition of terms used in Epidemiology.
2. Description of the Epidemiological approaches.
3. Principles of Epidemiology.
4. Uses of Epidemiology in Public Health.
5. Disease determinants [A determining or causal element or factor].
6. Levels of disease prevention.
PREAMBLE
Epidemiology, literally meaning "the study of what is upon the people", is derived from Greek
epi, meaning "upon, among", demos, meaning "people, district", and logos, meaning "study,
word, discourse", suggesting that it applies only to human populations. However, the term is
widely used in studies of zoological populations (veterinary epidemiology), although the term
"epizoology" is available, and it has also been applied to studies of plant populations (botanical
or plant disease epidemiology).
The distinction between "epidemic" and "endemic" was first drawn by Hippocrates, to
distinguish between diseases that are "visited upon" a population (epidemic) from those that
"reside within" a population (endemic). The term "epidemiology" appears to have first been used
to describe the study of epidemics in 1802 by the Spanish physician Villalba in Epidemiología
Española. Epidemiologists also study the interaction of diseases in a population, a condition
known as a syndemic.
The term epidemiology is now widely applied to cover the description and causation of not only
epidemic disease, but of disease in general, and even many non-disease health-related conditions,
such as high blood pressure and obesity. Therefore, this epidemiology is based upon how the
pattern of the disease cause changes in the function of everyone.
History: The Greek physician Hippocrates is known as the father of medicine. Hippocrates
sought logic to sickness; he is the first person known to have examined the relationships between
the occurrence of disease and environmental influences. Hippocrates believed sickness of the
human body to be caused by an imbalance of the four Humors (air, fire, and water and earth
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Prepared by O.E. Akoth

“atoms”). The cure to the sickness was to remove or add the humor in question to balance the
body. This belief led to the application of bloodletting and dieting in medicine. He coined the
terms endemic (for diseases usually found in some places but not in others) and epidemic (for
diseases that are seen at some times but not others).
Epidemiology is defined as the study of distribution and determinants of health related states in
populations and use of this study to address health related problems.
One of the earliest theories on the origin of disease was that it was primarily the fault of human
luxury. This was expressed by philosophers such as Plato and Rousseau, and social critics like
Jonathan Swift.
In the middle of the 16th century, a doctor from Verona named Girolamo Fracastoro was the first
to propose a theory that these very small, unseeable, particles that cause disease were alive. They
were considered to be able to spread by air, multiply by themselves and to be destroyable by fire.
In this way he refuted Galen's miasma theory (poison gas in sick people). In 1543 he wrote a
book De contagione et contagiosis morbis, in which he was the first to promote personal and
environmental hygiene to prevent disease. The development of a sufficiently powerful
microscope by Anton van Leeuwenhoek in 1675 provided visual evidence of living particles
consistent with a germ theory of disease.4
Another pioneer, Thomas Sydenham (1624–1689), was the first to distinguish the fevers of
Londoners in the later 1600s. His theories on cures of fevers met with much resistance from
traditional physicians at the time. He was not able to find the initial cause of the smallpox fever
he researched and treated.
The practice: Epidemiologists employ a range of study designs from the observational to
experimental and generally categorized as descriptive, analytic (aiming to further examine
known associations or hypothesized relationships), and experimental (a term often equated with
clinical or community trials of treatments and other interventions). In observational studies,
nature is allowed to “take its course”, as epidemiologists observe from the sidelines.
Controversially, in experimental studies, the epidemiologist is the one in control of all of the
factors entering a certain case study. Epidemiological studies are aimed, where possible, at
revealing unbiased relationships between exposures such as alcohol or smoking, biological
agents, stress, or chemicals to mortality or morbidity. The identification of causal relationships
between these exposures and outcomes is an important aspect of epidemiology. Modern
epidemiologists use informatics as a tool.
Observational studies have two components: descriptive, or analytical. Descriptive observations

pertain to the “who, what, where and when of health-related state occurrence”. However,
analytical observations deal more with the ‘how’ of a health-related event.

Experimental epidemiology contains three case types: randomized control trial (often used for
new medicine or drug testing), field trial (conducted on those at a high risk of conducting a
disease), and community trial (research on social originating diseases).
Unfortunately, many epidemiology studies conducted cause false or misinterpreted information

to circulate the public. According to a class taught by professor Madhukar Pai MD, PhD at
McGill, “...optimism bias is pervasive, most studies biased or inconclusive or false, most
discovered true associations are inflated, fear and panic inducing rather than helpful; media-
induced panic, cannot detect small effects; big effects are not to be found anymore”.
The term 'epidemiologic triad' is used to describe the intersection of Host, Agent, and
Environment in analyzing an outbreak.
Legal interpretation: Epidemiological studies can only go to prove that an agent could have
caused, but not that it did cause, an effect in any particular case:
"Epidemiology is concerned with the incidence of disease in populations and does not address
the question of the cause of an individual's disease. This question, sometimes referred to as
specific causation, is beyond the domain of the science of epidemiology. Epidemiology has its
limits at the point where an inference is made that the relationship between an agent and a
disease is causal (general causation) and where the magnitude of excess risk attributed to the
agent has been determined; that is, epidemiology addresses whether an agent can cause a disease,
not whether an agent did cause a specific plaintiff's disease.”
Population-based health management: Epidemiological practice and the results of

epidemiological analysis make a significant contribution to emerging population-based health
management frameworks.
Population-based health management encompasses the ability to:
1. Assess the health states and health needs of a target population;

2. Implement and evaluate interventions that are designed to improve the health of that
population; and
3. Efficiently and effectively provide care for members of that population in a way that is
consistent with the community's cultural, policy and health resource values.
Modern population-based health management is complex, requiring a multiple set of skills

(medical, political, technological, mathematical etc.) of which epidemiological practice and
analysis is a core component that is unified with management science to provide efficient and
effective health care and health guidance to a population. This task requires the forward looking
ability of modern risk management approaches that transform health risk factors, incidence,
prevalence and mortality statistics (derived from epidemiological analysis) into management
metrics that not only guide how a health system responds to current population health issues, but
also how a health system can be managed to better respond to future potential population health
issues.
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Examples of organizations that use population-based health management that leverage the work
and results of epidemiological practice include Canadian Strategy for Cancer Control, Health
Canada Tobacco Control Programs, Rick Hansen Foundation, Canadian Tobacco Control
Research Initiative.
Each of these organizations use a population-based health management framework called Life at
Risk that combines epidemiological quantitative analysis with demographics, health agency
operational research and economics to perform:
1. Population Life Impacts Simulations: Measurement of the future potential

impact of disease upon the population with respect to new disease cases, prevalence,
premature death as well as potential years of life lost from disability and death;
2. Labor Force Life Impacts Simulations: Measurement of the future potential

impact of disease upon the labor force with respect to new disease cases, prevalence,
premature death and potential years of life lost from disability and death;
3. Economic Impacts of Disease Simulations: Measurement of the future potential

impact of disease upon private sector disposable income impacts (wages, corporate
profits, private health care costs) and public sector disposable income impacts (personal
income tax, corporate income tax, consumption taxes, publicly funded health care costs).
Population-based health management: Epidemiological practice and the results of

epidemiological analysis make a significant contribution to emerging population-based health
management frameworks.
Population-based health management encompasses the ability to:
1. Assess the health states and health needs of a target population;

2. Implement and evaluate interventions that are designed to improve the health of that
population; and
3. Efficiently and effectively provide care for members of that population in a way that is
consistent with the community's cultural, policy and health resource values.
Modern population-based health management is complex, requiring a multiple set of skills

(medical, political, technological, mathematical etc.) of which epidemiological practice and
analysis is a core component that is unified with management science to provide efficient and
effective health care and health guidance to a population. This task requires the forward looking
ability of modern risk management approaches that transform health risk factors, incidence,
prevalence and mortality statistics (derived from epidemiological analysis) into management
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metrics that not only guide how a health system responds to current population health issues, but
also how a health system can be managed to better respond to future potential population health
issues.
Examples of organizations that use population-based health management that leverage the work
and results of epidemiological practice include Canadian Strategy for Cancer Control, Health
UNIT 1
TERMS IN EPIDEMIOLOGY
1. Epidemiology is the study of the distribution, frequency and determinants of health related
states or events or diseases in specified populations against the background of its total
environment or the study (or the science of the study) of the patterns, causes, and effects of
health and disease conditions in defined populations.
It is the cornerstone of public health, and informs policy decisions and evidence-based medicine
by identifying risk factors for disease and targets for preventive medicine. Epidemiologists help
with study design, collection and statistical analysis of data, and interpretation and dissemination
of results (including peer review and occasional systematic review). Epidemiology has helped
develop methodology used in clinical research, public health studies and, to a lesser extent, basic
research in the biological sciences.
Major areas of epidemiological study include disease etiology, outbreak investigation, disease
surveillance and screening, bio-monitoring, and comparisons of treatment effects such as in
clinical trials. Epidemiologists rely on other scientific disciplines like biology to better
understand disease processes, statistics to make efficient use of the data and draw appropriate
conclusions, social sciences to better understand proximate and distal (Situated farthest from
point of attachment or origin, as of a limb or bone) causes, and engineering for exposure
assessment.
Key terms in this definition reflect some of the important principles of epidemiology:
i. Study: Epidemiology is a scientific discipline with sound methods of scientific

inquiry at its foundation. Epidemiology is data driven and relies on a systematic and
unbiased approach to the collection, analysis, and interpretation of data. Basic
epidemiologic methods tend to rely on careful observation of valid comparison
groups to assess whether what was observed, such as the number of cases of disease
in a particular area during a particular time period or the frequency of an exposure
among persons with disease, differs from what might be expected. However
epidemiology also draws on methods from other scientific fields, including

biostatistics and informatics, biologic, economic, and social and behavioral sciences.
In fact, epidemiology is often described as the basic science of public health, and for
good reason. First, epidemiology is a quantitative discipline that relies on a working
knowledge of probability, statistics and sound research methods. Second,
epidemiology is a method of causal reasoning based on developing and testing
hypotheses grounded in such scientific fields such as biology, behavioral sciences,
physics and ergonomics to explain health related behaviors, states, and events.
However, epidemiology is an integral component of public health, providing the
foundation for directing practical appropriate publication based on science and causal
reasoning.
ii. Distribution: Epidemiology is concerned with the frequency and pattern of health
events in a population:
iii. Frequency: refers not only to the number of health events such as the number of
cases of meningitis or diabetes in a population but also to the relationship of that
number to the size of the population. The resulting rate allows epidemiologists to
compare disease occurrence across different populations.
The occurrence of disease is examined in terms of relationship or pattern between man and his
total environment. These include place, time and person.
1. Place pattern: include:
a) Geographic variations
b) Climatic zone,
c) Country,
d) Region,
e) Province,
f) District,
g) Location,
h) City wards,
i) Urban and rural areas differences and

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j) Institutions and locations of work sites.
2. Time pattern: may be:
a) Annual,
b) Seasonal variations,
c) Weekly,
d) Daily,
e) Hourly,
f) Weekday versus weekends,
g) Secular trends,
h) Periodic changes,
i) Any other breakdown of time that may influence disease or injury occurrence.
3. Personal pattern: which includes:
a) demographic factors which may be related to risk of:
i. illness,
ii. injury, or
iii. disability such as:
a) age,
b) sex,
c) marital status, and
d) socio-economic status, as well as behaviors and environmental

exposures environmental exposures
iv. Education,
v. Occupation,
vi. Social status,
vii. Nutrition,
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viii. Trauma, and
ix. Fatigue.
N/B Characterizing events by time, place, and person, are activities of descriptive epidemiology.
1. Determinants: any factor, whether event, characteristics or other definable entity, that brings
about a change in a health condition or other defined characteristic.
Epidemiology is also used to search for determinants which are the causes and other factors that
influence the occurrence of disease and other health- events.
2. Population: The complete collection of individuals that have some particular

characteristic(s) in common.
3. Population Risk: A defined population and comprises the number of individuals in that
original population that is considered capable of acquiring the particular disease or disease
characteristic is studied.
4. Infection: The invasion of a living organism, the host, by another ling organism – the
agent.
5. Infectivity: a measure of the ability of a disease agent to establish itself in the host. The
term can be used qualitatively, when an agent is referred to as being low, medium or high
infectivity or quantitatively. Attempts to quantify infectivity normally involve use of a
statistic known as ID. This refers to the individual dose or numbers of the agent required to
infect 50% of a specified population of susceptible s under controlled environmental
condition. Having become infected, the host may or may not become diseased, and this is
again determined by a range of intrinsic determinants affecting the agent and the host. Two
terms – virulence and pathogenicity- are often used to describe the ability of the agent to
cause disease.
6. Virulence: a measure of the severity of a disease caused by a specified agent. Virulence is

a laboratory term and is used to measure the varying ability of disease agents to produce
disease under controlled conditions. It is often quantified by a statistic known as LD 50 which

refers to the individual dose or numbers of the agent which will kill 50% of specified
population of susceptible under controlled environmental conditions.
7. Disease: a derangement in the function of the whole body of the host or any of its parts. It
also can be defined as a derangement in the function of the whole body of the host or any of
its parts, or it can be defined as abnormal medical condition of an organism that impairs
bodily functions associated with specific symptoms and signs. It may be external factors such
as infectious disease, or it may be caused by internal dysfunction such as auto-immune
disease.
8. Physiology: The branch of the biological sciences dealing with the functioning of
organisms or Processes and functions of an organism.
9. Determinant: Any factor or variable that can affect the frequency with which a disease
occurs in a population. Determinants can be broadly classified as being either intrinsic or
extrinsic in nature.
a) Intrinsic Determinants of Disease: are physical or physiological

characteristics of the host or disease agent [or intermediate host or vector, if present]
which are generally determined genetically. Disease agents as determinants of
disease: agents associated with disease can be categorized into two brad groups:
i. “Living” agents, such as viruses, bacteria, rickettsia, protozoa,

helminthes, protozoa etc.
ii. “Non-living” agents, such as heat and cold, water, nutrients, toxic
substances etc.
In instances of infectious diseases, the presence of the etiological agent is the main determining
factor in the epidemiology of the disease. Obviously, disease cannot occur in the absence of the
agent, but, conversely, disease need not always result from the presence of the agent. This leads
to the important epidemiological distinction between infection and disease.

b) Extrinsic Determinants: are normally associated with some form of
environmental influence on the host or disease agent [or intermediate host or vector,
if present].
10. Frequency: refers not only to the number of health events such as the number of cases of
meningitis or diabetes in a population but also to the relationship of that number to the size of
the population. The resulting rate allows epidemiologists to compare disease occurrence
across different populations.
11. Health Related States or Events: is defined as states or events that affect the well-
being of a population. Epidemiology was originally focused exclusively on epidemics of
communicable diseases but was subsequently expanded to address endemic communicable
diseases and non-communicable infectious diseases. By the middle of 20 th century, additional
epidemiologic methods had been developed and applied in chronic diseases, injuries, birth
defects, mental-child health, occupational health, and environmental health. Then
epidemiologists began looking at behaviors related to health and well-being such as amount
of exercise, and use of seat-belt.
12. Specified Populations: Although epidemiologists and direct health-care providers are
both concerned with occurrence and control of disease, they differ greatly in how they view
patients. The clinician is concerned about the health of an individual; the epidemiologist is
concerned about the collective health of the community or population. In other words, the
clinician’s patient is an individual; the epidemiologist’s patient is the community. Therefore,
the clinician and the epidemiologist have different responsibilities when faced with a person
with illness. For example, when patients with diarrheal disease presents, both are interested
in establishing the correct diagnosis. However, while clinician usually focuses on treating
and caring for the individual, the epidemiologist focuses on identifying the exposure or
source that caused the illness; the number of persons who may have similarly exposed; the
potential for further spread in community; and interventions to prevent additional cases or
recurrences.
Application: Epidemiology is not “just the study” of health in a population; it also involves
applying the knowledge gained by the studies to community-based practice. Like the practice of
medicine, the practice of epidemiology is both science and art. To make the proper diagnosis and
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prescribe appropriate treatment for a patient, the clinician combines medical (scientific)
knowledge with experience, clinical judgment, and understanding of the patient. Similarly, the
epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well as
experience, epidemiologic judgment, and understanding of local conditions in “diagnosing” the
health of a community and proposing appropriate, practical, and acceptable public health
interventions to control and prevent disease in the community.
13. Health: is the level of functional or metabolic efficiency of a living organism. In humans, it
is the general condition of a person's mind and body, usually meaning to be free from illness,
injury or pain (as in "good health" or "healthy"). The World Health Organization (WHO)
defined health in its broader sense in 1946 as "a state of complete physical, mental, and
social well-being and not merely the absence of disease or infirmity." Although this
definition has been subject to controversy, in particular as lacking operational value and
because of the problem created by use of the word "complete," it remains the most enduring.
Other definitions have been proposed, among which a recent definition that correlates health
and personal satisfaction. Classification systems such as the WHO Family of International
Classifications, including the International Classification of Functioning, Disability and
Health (ICF) and the International Classification of Diseases (ICD), are commonly used to
define and measure the components of health.
Systematic activities to prevent or cure health problems and promote good health in humans are
undertaken by health care providers. Applications with regard to animal health are covered by
the veterinary sciences. The term "healthy" is also widely used in the context of many types of
non-living organizations and their impacts for the benefit of humans, such as in the sense of
healthy communities, healthy cities or healthy environments. In addition to health care
interventions and a person's surroundings, a number of other factors are known to influence the
health status of individuals, including their background, lifestyle, and economic and social
conditions; these are referred to as "determinants of health." Studies have shown that high levels
of stress can affect your health
Determinants of health: Generally, the context in which an individual lives is of great

importance for his health status and quality of life. It is increasingly recognized that health is
maintained and improved not only through the advancement and application of health science,
but also through the efforts and intelligent lifestyle choices of the individual and society.
According to the World Health Organization, the main determinants of health include:
1. The social and economic environment,

2. The physical environment, and
3. The person's individual characteristics and behaviors.
More specifically, key factors that have been found to influence whether people are healthy or
unhealthy include:
1. Income and social status 7. Personal health practices and

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2. Social support networks coping skills
3. Education and literacy 8. Healthy child development
4. Employment/working conditions 9. Biology and genetics
5. Social environments 10. Health care services
6. Physical environments 11. Gender
12. Culture
An increasing number of studies and reports from different organizations and contexts examine
the linkages between health and different factors, including:
1. lifestyles,
2. environments,
3. health care organization, and
4. health policy, and the series of World Health Reports of the World Health
Organization, which focuses on global health issues including access to health care
and improving public health outcomes, especially in developing countries.
The concept of the "health field," as distinct from medical care, emerged from the Lalonde report
from Canada. The report identified three interdependent fields as key determinants of an
individual's health. These are:
1. Lifestyle: The aggregation of personal decisions (i.e., over which the individual has
control) that can be said to contribute to, or cause, illness or death;
2. Environmental: All matters related to health external to the human body and over which
the individual has little or no control;
3. Biomedical: All aspects of health, physical and mental, developed within the human
body as influenced by genetic make-up.
The maintenance and promotion of health is achieved through different combination of physical,
mental, and social well-being, together sometimes referred to as the "health triangle." The
WHO's 1986 Ottawa Charter for Health Promotion further stated that health is not just a state,
but also "a resource for everyday life, not the objective of living. Health is a positive concept
emphasizing social and personal resources, as well as physical capacities."
Focusing more on lifestyle issues and their relationships with functional health, data from the
Alameda County Study suggested that people can improve their health via:
1. Exercise,
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2. Enough sleep,
3. Maintaining a healthy body weight,
4. Limiting alcohol use, and
5. Avoiding smoking.
The ability to adapt and to self manage have been suggested as core components of human
health.
The environment is often cited as an important factor influencing the health status of individuals.
This includes characteristics of the natural environment, the built environment, and the social
environment. Factors such as clean water and air, adequate housing, and safe communities and
roads all have been found to contribute to good health, especially to the health of infants and
children. Some studies have shown that a lack of neighborhood recreational spaces including
natural environment leads to lower levels of personal satisfaction and higher levels of obesity,
linked to lower overall health and well being. This suggests that the positive health benefits of
natural space in urban neighborhoods should be taken into account in public policy and land use.
Genetics, or inherited traits from parents, also play a role in determining the health status of
individuals and populations. This can encompass both the predisposition to certain diseases and
health conditions, as well as the habits and behaviors individuals develop through the lifestyle of
their families. For example, genetics may play a role in the manner in which people cope with
stress, mental, emotional or physical (One difficulty is the issue raised by the debate over the
relative strengths of genetics and other factors; interactions between genetics and environment
may be of particular importance.).
An increasing number of studies and reports from different organizations and contexts examine
the linkages between health and different factors, including lifestyles, environments, health care
organization, and health policy – such as the 1974 Lalonde report from Canada; the Alameda
County Study in California; and the series of World Health Reports of the World Health
Organization, which focuses on global health issues including access to health care and
improving public health outcomes, especially in developing countries.
Social determinants of health: are the economic and social conditions – and their distribution
among the population – that influence individual and group differences in health status. They are
risk factors found in one's living and working conditions (such as the distribution of income,
wealth, influence, and power), rather than individual factors (such as behavioural risk factors or
genetics) that influence the risk for a disease, or vulnerability to disease or injury. According to
some viewpoints, these distributions of social determinants are shaped by public policies that
reflect the influence of prevailing political ideologies of those governing a jurisdiction. The
World Health Organization says that “This unequal distribution of health-damaging experiences
is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social
policies, unfair economic arrangements [where the already well-off and healthy become even
richer and the poor who are already more likely to be ill become even poorer], and bad politics
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Commonly accepted social determinants of health: There is no single definition of the social
determinants of health, but there are commonalities, and many governmental and non-
governmental organizations recognize that there are social factors which impact the health of
individuals.
In 2003, the World Health Organization (WHO) Europe suggested that the social determinants of
health included:
1. Social gradients (life expectancy is shorter and disease is more common further down the
social ladder)
2. Stress (including stress in the workplace)
3. Early childhood development
4. Social exclusion
5. Unemployment
6. Social support networks
7. Addiction
8. Availability of healthy food
9. Availability of healthy transportation
The WHO later developed a Commission on Social Determinants of Health, which in 2008
published a report entitled "Closing the Gap in a Generation". This report identified two broad
areas of social determinants of health that needed to be addressed. The first area was daily living
conditions, which included healthy physical environments, fair employment and decent work,
social protection across the lifespan, and access to health care. The second major area was
distribution of power, money, and resources, including equity in health programs, public
financing of action on the social determinants, economic inequalities, resource depletion, healthy
working conditions, gender equity, political empowerment, and a balance of power and
prosperity of nations.
The 2011 World Conference on Social Determinants of Health brought together delegations from
125 member states and resulted in the Rio Political Declaration on Social Determinants of
Health. This declaration involved an affirmation that health inequities are unacceptable, and
noted that these inequities arise from the societal conditions in which people are;
1. Born,
2. Grow, live,
3. Work, and
4. Age, including
5. Early childhood development,
6. Education,
7. Economic status,
8. Employment and decent work,
9. Housing environment, and
10. Effective prevention and treatment of health problems.
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The United States Centers for Disease Control defines social determinants of health as "life-
enhancing resources:
1. Such as food supply,

2. Housing,
3. Economic and
4. Social relationships,
5. Transportation,
6. Education, and
7. Health care, whose distribution across populations effectively determines length and
quality of life".
These include access to care and resources such as:
1. Food,
2. Insurance coverage,
3. Income,
4. Housing, and
5. Transportation.
Social determinants of health influence health-promoting behaviours, and health equity among
the population is not possible without equitable distribution of social determinants among
groups.
"The degree to which social conditions affect health is illustrated by the association between
education and mortality rates". Reports in 2005 revealed the mortality rate was 206.3 per
100,000 for adults aged 25 to 64 years with little education beyond high school, but was twice as
great (477.6 per 100,000) for those with only a high school education and 3 times as great (650.4
per 100,000) for those less educated.
Based on the data collected, the social conditions such as education, income, and race were very
much dependent on one another, but these social conditions also apply independent health
influences.
Marmot and Bell found that in wealthy countries, income and mortality are correlated as a
marker of relative position within society, and this relative position is related to social conditions
that are important for health including:
1. Good early childhood development,

2. Access to good quality education,
3. Rewarding work with some degree of autonomy,
4. Decent housing, and
5. A clean and safe living environment.
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The social condition of autonomy, control, and empowerment turns are important influences on
health and disease, and individuals who lack social participation and control over their lives are
at a greater risk for heart disease and mental illness.
Mental health: The World Health Organization describes mental health as "a state of well-being
in which the individual realizes his or her own abilities, can cope with the normal stresses of life,
can work productively and fruitfully, and is able to make a contribution to his or her
community". Mental Health is not just the absence of mental illness.
Mental illness is described as 'the spectrum of cognitive, emotional, and behavioural conditions
that interfere with social and emotional wellbeing and the lives and productivity of people.
Having a mental illness can seriously impair; temporarily or permanently, the mental functioning
of a person. Other terms include: 'mental health problem', 'illness', 'disorder', 'dysfunction'.
Maintaining health: Achieving and maintaining health is an ongoing process, shaped by both
the evolution of health care knowledge and practices as well as personal strategies and organized
interventions for staying healthy known as Lifestyle Management.
Role of science in health: Health science is the branch of science focused on health. There are
two main approaches to health science: the study and research of the body and health-related
issues to understand how humans (and animals) function, and the application of that knowledge
to improve health and to prevent and cure diseases and other physical and mental impairments.
The science builds on many sub-fields, including biology, biochemistry, physics, epidemiology,
pharmacology, medical sociology. Applied health sciences endeavor to better understand and
improve human health through applications in areas such as health education, biomedical
engineering, biotechnology and public health.
Organized interventions to improve health based on the principles and procedures developed
through the health sciences are provided by practitioners trained in medicine, nursing, nutrition,
pharmacy, social work, psychology, occupational therapy, physical therapy and other health care
professions. Clinical practitioners focus mainly on the health of individuals, while public health
practitioners consider the overall health of communities and populations. Workplace wellness
programs are increasingly adopted by companies for their value in improving the health and
well-being of their employees, as are school health services to improve the health and well-being
of children.
Role of public health: Public health has been described as "the science and art of preventing
disease, prolonging life and promoting health through the organized efforts and informed choices
of society, organizations, public and private, communities and individuals." It is concerned with
threats to the overall health of a community based on population health analysis. The population
in question can be as small as a handful of people or as large as all the inhabitants of several
continents (for instance, in the case of a pandemic). Public health has many sub-fields, but
typically includes the interdisciplinary categories of:
1. Epidemiology,
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2. Biostatistics and
3. Health services.
4. Environmental health,
5. community health,
6. behavioral health, and
7. Occupational health are also important areas of public health.
The focus of public health interventions is to prevent and manage diseases, injuries and other
health conditions through surveillance of cases and the promotion of healthy behavior,
communities, and (in aspects relevant to human health) environments. Its aim is to prevent health
problems from happening or re-occurring by implementing educational programs, developing
policies, administering services, and conducting research. In many cases, treating a disease or
controlling a pathogen can be vital to preventing it in others, such as during an outbreak.
Vaccination programs and distribution of condoms to prevent the spread of communicable
diseases are examples of common preventive public health measures, as are educational
campaigns to promote vaccination and the use of condoms (including overcoming resistance to
such).
Public health also takes various actions to limit the health disparities between different areas of
the country and, in some cases, the continent or world. One issue is the access of individuals and
communities to health care in terms of financial, geographical or sociocultural constraints to
accessing and using services. Applications of the public health system include the areas of
maternal and child health,
1. Health services administration,

2. Emergency response, and
3. Prevention and control of infectious and chronic diseases.
The great positive impact of public health programs is widely acknowledged. Due in part to the
policies and actions developed through public health, the 20th century registered a decrease in
the mortality rates for infants and children and a continual increase in life expectancy in most
parts of the world.
Self-care strategies: Personal health depends partially on the active, passive, and assisted
cues people observe and adopt about their own health. These include personal actions for
preventing or minimizing the effects of a disease, usually a chronic condition, through
integrative care. They also include personal hygiene practices to prevent infection and illness,
such as bathing and washing hands with soap; brushing and flossing teeth; storing, preparing and
handling food safely; and many others. The information gleaned from personal observations of
daily living – such as about sleep patterns, exercise behavior, nutritional intake, and
environmental features – may be used to inform personal decisions and actions (e.g., "I feel tired
in the morning so I am going to try sleeping on a different pillow"), as well as clinical decisions
and treatment plans (e.g., a patient who notices his or her shoes are tighter than usual may be
having exacerbation of left-sided heart failure, and may require diuretic medication to reduce
fluid overload).
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Personal health also depends partially on the social structure of a person's life. The maintenance
of strong social relationships, volunteering, and other social activities have been linked to
positive mental health and even increased longevity. One American study among seniors over
age 70, found that frequent volunteering was associated with reduced risk of dying compared
with older persons who did not volunteer, regardless of physical health status. Another study
from Singapore reported that volunteering retirees had significantly better cognitive performance
scores, fewer depressive symptoms, and better mental well-being and life satisfaction than non-
volunteering retirees.
Prolonged psychological stress may negatively impact health, and has been cited as a factor in
cognitive impairment with aging, depressive illness, and expression of disease. Stress
management is the application of methods to either reduce stress or increase tolerance to stress.
Relaxation techniques are physical methods used to relieve stress. Psychological methods
include cognitive therapy, meditation, and positive thinking, which work by reducing response to
stress. Improving relevant skills, such as problem solving and time management skills, reduces
uncertainty and builds confidence, which also reduces the reaction to stress-causing situations
where those skills are applicable.
4. Environment may refer to:
1. Environment (biophysical), the physical and biological factors along with their chemical
interactions that affect an organism
2. Environment (systems), the surroundings of a physical system that may interact with the
system by exchanging mass, energy, or other properties
3. Environments (series), a series of LPs, cassettes and CDs depicting natural sounds
It may also refer to:
1. Built environment, constructed surroundings that provide the setting for human activity,
ranging from the large-scale civic surroundings to the personal places
2. Knowledge environment, social practices, technological and physical arrangements
intended to facilitate collaborative knowledge building, decision making, inference or
discovery
3. Natural environment, all living and non-living things
4. Social environment, the culture that an individual lives in, and the people and institutions
with whom they interact
5. Physical environment, in ecology
In computing:
1. Desktop environment, in computing, the graphical user interface to the computer

2. Environment variables, the dynamic set of variables defined in a process
3. Integrated development environment, a type of computer software that assists computer
programmers in developing software
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4. Runtime environment, a virtual machine state which provides software services for
processes or programs while a computer is running
5. Environmental health is that branch of public health that is concerned with all aspects
of the natural and built environment that may affect human health. Other phrases that
concern or refer to the discipline of environmental health include environmental
public health, and environmental protection. The field of environmental health is
closely related to environmental science and public health as environmental health is
concerned with environmental factors affecting human health.
"Environmental health addresses all the physical, chemical, and biological factors external to a
person, and all the related factors impacting behaviours. It encompasses the assessment and
control of those environmental factors that can potentially affect health. It is targeted towards
preventing disease and creating health-supportive environments. This definition excludes
behaviour not related to environment, as well as behaviour related to the social and cultural
environment, as well as genetics."
Environmental health is defined by the World Health Organization as:
1. Those aspects of the human health and disease that are determined by factors in
the environment. It also refers to the theory and practice of assessing and
controlling factors in the environment that can potentially affect health.
2. Environmental health as used by the WHO Regional Office for Europe, includes
both the direct pathological effects of chemicals, radiation and some biological
agents, and the effects (often indirect) on health and well being of the broad
physical, psychological, social and cultural environment, which includes housing,
urban development, land use and transport.
3. Environmental health services are defined by the World Health Organization as:
i. Those services which implement environmental health policies

through monitoring and control activities. They also carry out that role
by promoting the improvement of environmental parameters and by
encouraging the use of environmentally friendly and healthy
technologies and behaviors. They also have a leading role in
developing and suggesting new policy areas.
ii. Environmental medicine may be seen as the medical branch of the

broader field of environmental health. Terminology is not fully
established, and in many European countries they are used
interchangeably.
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Environmental health profession: Environmental health professionals may be known as
environmental health officers, environmental protection officers, public health inspectors,
environmental health specialists, environmental health practitioners, sanitarians, environmental
inspectors, or environmental specialists. In many European countries, physicians and
veterinarians are involved in environmental health. In the United Kingdom, practitioners must
have a graduate degree in environmental health and be certified and registered with the Chartered
Institute of Environmental Health. In Canada, practitioners in environmental health are required
to obtain an approved bachelor's degree in environmental health along with the national
professional certificate - the Certificate in Public Health Inspection (Canada). Many states in the
United States also require that individuals have a bachelor's degree and professional licenses in
order to practice environmental health. California state law defines the scope of practice of
environmental health as follow.
"Scope of practice in environmental health" means the practice of environmental health by

registered environmental health specialists in the public and private sector within the meaning of
this article and includes, but is not limited to, organization, management, education,
enforcement, consultation, and emergency response for the purpose of prevention of
environmental health hazards and the promotion and protection of the public health and the
environment in the following areas: food protection; housing; institutional environmental health;
land use; community noise control; recreational swimming areas and waters; electromagnetic
radiation control; solid, liquid, and hazardous materials management; underground storage tank
control; onsite septic systems; vector control; drinking water quality; water sanitation;
emergency preparedness; and milk and dairy sanitation pursuant to Section 33113 of the Food
and Agricultural Code.
The environmental health profession had its modern-day roots in the sanitary and public health
movement of the United Kingdom. This was epitomized by Sir Edwin Chadwick, who was
instrumental in the repeal of the poor laws and was the founding president of the Association of
Public Sanitary Inspectors in 1884, which today is the Chartered Institute of Environmental
Health.
Disciplines: Three basic disciplines generally contribute to the field of environmental health:
environmental epidemiology, toxicology, and exposure science. Each of these disciplines
contributes different information to describe problems in environmental health, but there is some
overlap among them.
1. Environmental epidemiology studies the relationship between environmental exposures

(including exposure to chemicals, radiation, microbiological agents, etc.) and human
health. Observational studies, which simply observe exposures that people have already
experienced, are common in environmental epidemiology because humans cannot
ethically be exposed to agents that are known or suspected to cause disease. While the
inability to use experimental study designs is a limitation of environmental epidemiology,
this discipline directly observes effects on human health rather than estimating effects
from animal studies.
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2. Toxicology studies how environmental exposures lead to specific health outcomes,
generally in animals, as a means to understand possible health outcomes in humans.
Toxicology has the advantage of being able to conduct randomized controlled trials and
other experimental studies because they can use animal subjects. However there are many
differences in animal and human biology, and there can be a lot of uncertainty when
interpreting the results of animal studies for their implications for human health.
3. Exposure science studies human exposure to environmental contaminants by both

identifying and quantifying exposures. Exposure science can be used to support
environmental epidemiology by better describing environmental exposures that may lead
to a particular health outcome, identify common exposures whose health outcomes may
be better understood through a toxicology study, or can be used in a risk assessment to
determine whether current levels of exposure might exceed recommended levels.
Exposure science has the advantage of being able to very accurately quantify exposures
to specific chemicals, but it does not generate any information about health outcomes like
environmental epidemiology or toxicology.
Information from these three disciplines can be combined to conduct a risk assessment for
specific chemicals or mixtures of chemicals to determine whether an exposure poses significant
risk to human health. This can in turn be used to develop and implement environmental health
policy that, for example, regulates chemical emissions, or imposes standards for proper
sanitation.
Concerns: Environmental health addresses all human-health-related aspects of both the natural
environment and the built environment. Environmental health concerns include:
1. Air quality, including both ambient outdoor air and indoor air quality, which also
comprises concerns about environmental tobacco smoke.
2. Body art safety, including tattooing, body piercing and permanent cosmetics.
3. Climate change and its effects on health.
4. Disaster preparedness and response.
5. Food safety, including in agriculture, transportation, food processing, wholesale and retail
distribution and sale.
6. Hazardous materials management, including hazardous waste management, contaminated
site remediation, the prevention of leaks from underground storage tanks and the
prevention of hazardous materials releases to the environment and responses to
emergency situations resulting from such releases.
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7. Housing, including substandard housing abatement and the inspection of jails and
prisons.
8. Childhood lead poisoning prevention.
9. Land use planning, including smart growth.
10. Liquid waste disposal, including city waste water treatment plants and on-site waste
water disposal systems, such as septic tank systems and chemical toilets.
11. Medical waste management and disposal.
12. Noise pollution control.
13. Occupational health and industrial hygiene.
14. Radiological health, including exposure to ionizing radiation from X-rays or radioactive
isotopes.
15. Recreational water illness prevention, including from swimming pools, spas and ocean
and freshwater bathing places.
16. Safe drinking water.
17. Solid waste management, including landfills, recycling facilities, composting and solid
waste transfer stations.
18. Toxic chemical exposure whether in consumer products, housing, workplaces, air, water
or soil.
19. Vector control, including the control of mosquitoes, rodents, flies, cockroaches and other
animals that may transmit pathogens.
According to recent estimates, about 5 to 10% of disability adjusted life years (DALYs) lost is
due to environmental causes in Europe. By far the most important factor is fine particulate matter
pollution in urban air. Similarly, environmental exposures have been estimated to contribute to
4.9 million (8.7%) deaths and 86 million (5.7%) DALYs globally.
Prevalence: In epidemiology, the prevalence or prevalence proportion is the proportion of a

population found to have a condition (typically a disease or a risk factor such as smoking or seat-
belt use). It is arrived at by comparing the number of people found to have the condition with the
total number of people studied, and is usually expressed as a fraction, as a percentage or as the
number of cases per 10,000 or 100,000 people. "Point prevalence" is the proportion of a
population that has the condition at a specific point in time. "Period prevalence" is the proportion
of a population that has the condition at some time during a given period ("12-month
prevalence", etc.), and includes people who already have the condition at the start of the study
period as well as those who acquire it during that period. "Lifetime prevalence" (LTP) is the
proportion of a population that at some point in their life (up to the time of assessment) have
experienced the condition.
Prevalence estimates are used by epidemiologists, health care providers, government agencies,
and insurers.
Prevalence is contrasted with incidence, which is a measure of new cases arising in a population
over a given period (month, year, etc.). For mnemonic purposes, the difference between
prevalence and incidence can be summarized thus: prevalence answers "How many people have
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this disease right now?" and incidence answers "How many people per year newly acquire this
disease?"
In science, prevalence describes a proportion (typically expressed as a percentage). For example,

the prevalence of obesity among American adults in 2001 was estimated by the U. S. Centers for
Disease Control (CDC) at approximately 20.9%.
Prevalence is a term which means being widespread and it is distinct from incidence. Prevalence
is a measurement of all individuals affected by the disease at a particular time, whereas incidence
is a measurement of the number of new individuals who contract a disease during a particular
period of time.
To illustrate, a long term disease that was spread widely in a community in 2002 will have a high
prevalence at a given point of 2003 (assuming it has a long duration) but it might have a low
incidence rate during 2003 (i.e. lots of existing cases, but not many new ones in that year).
Conversely, a disease that is easily transmitted but has a short duration might spread widely
during 2002 but is likely to have a low prevalence at any given point in 2003 (due to its short
duration) but a high incidence during 2002 (as many people develop the disease). As such,
prevalence is a useful parameter when talking about long lasting diseases, such as HIV, but
incidence is more useful when talking about diseases of short duration, such as chickenpox.
Uses: include the following:
1. Lifetime prevalence: Lifetime prevalence (LTP) is the number of individuals in a

statistical population that at some point in their life (up to the time of assessment)
have experienced a "case" (e.g., a disorder), compared to the total number of
individuals (i.e. it is expressed as a ratio or percentage). Often, a 12-month
prevalence (or some other type of "period prevalence") is used in conjunction
with lifetime prevalence. There is also point prevalence, the prevalence of
disorder at a more specific (a month or less) point in time. There is also a related
figure lifetime morbid risk - the theoretical prevalence at any point in life for
anyone, regardless of time of assessment.
2. Period prevalence: In epidemiology, Period prevalence is the proportion of the

population with a given disease or condition over a specific period of time. It could
describe how many people in a population had a cold over the cold season in 2006, for
example. It is expressed as a percentage of the population and can be described by the
following formula:
Period prevalence (ratio) = Number of cases that occurred in a given period ÷
Number of people in the population during this period.The relationship between
incidence (rate), point prevalence (ratio) and period prevalence (ratio) is easily
explicated via an analogy with photography. Point prevalence is akin to a flashlit
photograph: what is happening at this instant frozen in time. Period prevalence is
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analogous to a long exposure (seconds, rather than an instant) photograph: the
number of events recorded in the photo whilst the camera shutter was open. In a
movie each frame records an instant (point prevalence); by looking from frame to
frame one notices new events (incident events) and can relate the number of such
events to a period (number of frames).
3. Point prevalence: In epidemiology, point prevalence is a measure of the

proportion of people in a population who have a disease or condition at a
particular time, such as a particular date. It is like a snap shot of the disease in
time. It can be used for statistics on the occurrence of chronic diseases. This is in
contrast to period prevalence which is a measure of the proportion of people in a
population who have a disease or condition over a specific period of time, say a
season, or a year. Point prevalence can be described by the formula: Prevalence =
Number of existing cases on a specific date ÷ Number of people in the population
on this date
4. Limitations: It can be said that a very small error applied over a very large
number of individuals (that is, those who are not affected by the condition in the
general population during their lifetime; for example, over 95%) produces a
relevant, non-negligible number of subjects who are incorrectly classified as
having the condition or any other condition which is the object of a survey study:
these subjects are the so-called false positives; such reasoning applies to the 'false
positive' but not the 'false negative' problem where we have an error applied over
a relatively very small number of individuals to begin with (that is, those who are
affected by the condition in the general population; for example, less than 5%).
Hence, a very high percentage of subjects who seem to have a history of a
disorder at interview are false positives for such a medical condition and
apparently never suffered a fully clinical syndrome.
Incidence: Incidence is the number of new cases of a condition, symptom, death, or injury that
develop during a specific time period, such as a year. The number is often expressed as a
percentage of a population. For example, 25% of Americans were diagnosed with the flu in
2002.
Incidence shows the likelihood that a person in that population will be affected by the condition.
1. Incidence is a measure of the risk of developing some new condition within a

specified period of time. Although sometimes loosely expressed simply as the
number of new cases during some time period, it is better expressed as a
proportion or a rate with a denominator.
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2. Incidence proportion (also known as cumulative incidence) is the number of
new cases within a specified time period divided by the size of the population
initially at risk. For example, if a population initially contains 1,000 non-diseased
persons and 28 develop a condition over two years of observation, the incidence
proportion is 28 cases per 1,000 persons, i.e. 2.8%.
3. Incidence rate: The incidence rate is the number of new cases per population at
risk in a given time period. When the denominator is the sum of the person-time
of the at risk population, it is also known as the incidence density rate or person-
time incidence rate. In the same example as above, the incidence rate is 14 cases
per 1000 person-years, because the incidence proportion (28 per 1,000) is divided
by the number of years (two). Using person-time rather than just time handles
situations where the amount of observation time differs between people, or when
the population at risk varies with time. Use of this measure implicitly implies the
assumption that the incidence rate is constant over different periods of time, such
that for an incidence rate of 14 per 1000 persons-years, 14 cases would be
expected for 1000 persons observed for 1 year or 50 persons observed for 20
years.
4. Incidence vs. prevalence: Incidence should not be confused with prevalence,

which is the proportion of cases in the population at a given time rather than rate
of occurrence of new cases. Thus, incidence conveys information about the risk of
contracting the disease, whereas prevalence indicates how widespread the disease
is. Prevalence is the proportion of the total number of cases to the total population
and is more a measure of the burden of the disease on society with no regard to
time at risk or when subjects may have been exposed to a possible risk factor.
Prevalence can also be measured with respect to a specific subgroup of a
population (see: denominator data). Incidence is usually more useful than
prevalence in understanding the disease etiology: for example, if the incidence
rate population of a disease increases, then there is a risk factor that promotes the
incidence.
For example, consider a disease that takes a long time to cure and was widespread in 2002 but
dissipated in 2003. This disease will have both high incidence and high prevalence in 2002, but
in 2003 it will have a low incidence yet will continue to have a high prevalence (because it takes
a long time to cure, so the fraction of affected individuals remains high). In contrast, a disease
that has a short duration may have a low prevalence and a high incidence. When the incidence is
approximately constant for the duration of the disease, prevalence is approximately the product
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of disease incidence and average disease duration, so prevalence = incidence × duration. The
importance of this equation is in the relation between prevalence and incidence; for example,
when the incidence increases, then the prevalence must also increase. Note that this relation does
not hold for age-specific prevalence and incidence, where the relation becomes more
complicated.
Epidemic: In epidemiology, an epidemic (from επί (epi), meaning "upon or above" and δήμος
(demos), meaning "people") occurs when new cases of a certain disease, in a given human
population, and during a given period, substantially exceed what is expected based on recent
experience. Epidemiologists often consider the term outbreak to be synonymous to epidemic, but
the general public typically perceives outbreaks to be more local and less serious than epidemics.
Epidemics of infectious disease are generally caused by a change in the ecology of the host
population (e.g. increased stress or increase in the density of a vector species), a genetic change
in the parasite population or the introduction of a new parasite to a host population (by
movement of parasites or hosts). Generally, an epidemic occurs when host immunity to a parasite
population is suddenly reduced below that found in the endemic equilibrium and the
transmission threshold is exceeded.
An epidemic may be restricted to one location; however, if it spreads to other countries or

continents and affects a substantial number of people, it may be termed a pandemic. The
declaration of an epidemic usually requires a good understanding of a baseline rate of incidence;
epidemics for certain diseases, such as influenza, are defined as reaching some defined increase
in incidence above this baseline. A few cases of a very rare disease may be classified as an
epidemic, while many cases of a common disease.
Causes: There are several changes that may occur in an infectious agent that may trigger an
epidemic these included.
1. Increased virulence
2. Introduction into a novel setting
3. Changes in host susceptibility to the infectious agent
An epidemic disease is not required to be contagious, and the term has been applied to West Nile
fever and the obesity epidemic, among others.
The conditions which govern the outbreak of epidemics include infected food supplies such as
contaminated drinking water and the migration of populations of certain animals, such as rats or
mosquitoes, which can act as disease vectors. Certain epidemics occur at certain seasons: for
example, whooping-cough occurs in spring, whereas measles produces two epidemics, one in
winter and one in March. Influenza, the common cold, and other infections of the upper
respiratory tract, such as sore throat, occur predominantly in the winter. There is another
variation, both as regards the number of persons affected and the number who die in successive
epidemics: the severity of successive epidemics rises and falls over periods of five or ten years.
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Types:
1. Common source outbreak: In a common source outbreak, the affected

individuals had an exposure to a common agent. If the exposure is singular and all
of the affected individuals develop the disease over a single exposure and
incubation course, it can be termed a point source outbreak. If the exposure was
continuous or variable, it can be termed a continuous outbreak or intermittent
outbreak, respectively.
2. Propagated outbreak: In a propagated outbreak, the disease spreads person-to-
person. Affected individuals may become independent reservoirs leading to
further exposures.
Many epidemics will have characteristics of both common source and propagated outbreaks. For
example, secondary person-to-person spread may occur after a common source exposure or an
environmental vector may spread a zoonotic diseases agent.
Transmission:
1. Airborne transmission: Airborne transmission is the spread of infection by droplet

nuclei or dust in the air. Without the intervention of winds or drafts the distance over
which airborne infection takes place is short, say 10 to 20 feet.
2. Arthropod transmission: Arthropod transmission takes place by an insect, either

mechanically through a contaminated proboscis or feet, or biologically when there is
growth or replication of an organism in the arthropod.
3. Biological transmission: Involving a biological process, e.g. passing a stage of

development of the infecting agent in an intermediate host. Opposite to mechanical
transmission.
4. Colostral transmission: A form of vertical transmission via successive generations.
5. Contact transmission: The disease agent is transferred directly by biting, sucking,

chewing or indirectly by inhalation of droplets, drinking of contaminated water, traveling
in contaminated vehicles.
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6. Cyclopropagative transmission: The agent undergoes both development and
multiplication in the transmitting vehicle.
7. Developmental transmission: The agent undergoes some development in the

transmission vehicle.
8. Fecal-oral transmission: The infectious agent is shed by the infected host in feces and
acquired by the susceptible host through ingestion of contamined material.
9. Horizontal transmission: Lateral spread to others in the same group and at the same
time; spread to contemporaries.
10. Mechanical transmission: The transmitter is not infected in that tissues are not invaded
and the agent does not multiply.
11. Propagative transmission: The agent multiplies in the transmission vehicle.
12. Vertical transmission: From one generation to the next, perhaps transovarially or by
intrauterine infection of the fetus. Some retroviruses are transmitted in the germ line, i.e. their
genetic material is integrated into the DNA of either the ovum or sperm.
Pandemic: The word pandemic comes from the Greek pandemos meaning "pertaining to all
people". The Greek word pan means "all" and the Greek word demos means "people". According
to the Medilexicon´s medical dictionary a pandemic is "Denoting a disease affecting or attacking
the population of an extensive region, country, continent, global; extensively epidemic."
A pandemic is an outbreak of global proportions. It happens when a novel virus emerges among
humans - it causes serious illness and is easily human transmissible (spreads easily from person-
to-person).
A pandemic (from Greek πᾶν pan "all" + δῆμος demos "people") is an epidemic of infectious
disease that has spread through human populations across a large region; for instance multiple
continents, or even worldwide. A widespread endemic disease that is stable in terms of how
many people are getting sick from it is not a pandemic. Further, flu pandemics generally exclude
recurrences of seasonal flu. Throughout history there have been a number of pandemics, such as
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smallpox and tuberculosis. More recent pandemics include the HIV pandemic as well as the
1918 and 2009 H1N1 pandemics.
Definition and stages: A pandemic is an epidemic occurring on a scale which crosses

international boundaries, usually affecting a large number of people.
The World Health Organization (WHO) has a six-stage classification that describes the process
by which a novel influenza virus moves from the first few infections in humans through to a
pandemic. This starts with the virus mostly infecting animals, with a few cases where animals
infect people, then moves through the stage where the virus begins to spread directly between
people, and ends with a pandemic when infections from the new virus have spread worldwide.
A disease or condition is not a pandemic merely because it is widespread or kills many people; it
must also be infectious. For instance, cancer is responsible for many deaths but is not considered
a pandemic because the disease is not infectious or contagious.
In a virtual press conference in May 2009 on the influenza pandemic, Dr Keiji Fukuda, Assistant
Director-General ad Interim for Health Security and Environment, WHO said "An easy way to
think about pandemic ... is to say: a pandemic is a global outbreak. Then you might ask yourself:
“What is a global outbreak”? Global outbreak means that we see both spread of the agent ... and
then we see disease activities in addition to the spread of the virus."
In planning for a possible influenza pandemic, the WHO published a document on pandemic
preparedness guidance in 1999, revised in 2005 and in February 2009, defining phases and
appropriate actions for each phase in an aide memoir entitled WHO pandemic phase descriptions
and main actions by phase. The 2009 revision, including definitions of a pandemic and the
phases leading to its declaration, were finalized in February 2009. The pandemic H1N1 2009
virus, was neither on the horizon at that time nor mentioned in the document. All versions of this
document refer to influenza. The phases are defined by the spread of the disease; virulence and
mortality are not mentioned in the current WHO definition, although these factors have
previously been included.
Current pandemics: HIV and AIDS: HIV spread to the United States and much of the rest
of the world beginning around 1969. HIV, the virus that causes AIDS, is currently a pandemic,
with infection rates as high as 25% in southern and eastern Africa. In 2006 the HIV prevalence
rate among pregnant women in South Africa was 29.1%. Effective education about safer sexual
practices and blood borne infection precautions training have helped to slow down infection rates
in several African countries sponsoring national education programs. Infection rates are rising
again in Asia and the Americas. AIDS could kill 31 million people in India and 18 million in
China by 2025, according to projections by U.N. population researchers. AIDS death toll in
Africa may reach 90–100 million by 2025.
Pandemics and notable epidemics through history: There have been a number of
significant pandemics recorded in human history, generally zoonoses which came about with
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domestication of animals, such as influenza and tuberculosis. There have been a number of
particularly significant epidemics that deserve mention above the "mere" destruction of cities:
What is the difference between a pandemic and an epidemic? : A pandemic is different from an
epidemic or seasonal outbreak.
1. Put simply, a pandemic covers a much wider geographical area, often worldwide. A
pandemic also infects many more people than an epidemic. An epidemic is specific to
one city, region or country, while a pandemic goes much further than national borders.
2. An epidemic is when the number of people who become infected rises well beyond what
is expected within a country or a part of a country. When the infection takes place in
several countries at the same time it then starts turning into a pandemic.
3. A pandemic is usually caused by a new virus strain or subtype - a virus human either
have no immunity against, or very little immunity. If immunity is low or non-existent the
virus is much more likely to spread around the world if it becomes easily human
transmissible.
4. In the case of influenza, seasonal outbreaks (epidemics) are generally caused by subtypes
of a virus that is already circulating among people. Pandemics, on the other hand, are
generally caused by novel subtypes - these subtypes have not circulated among people
before. Pandemics can also be caused by viruses, in the case of influenza, that perhaps
have not circulated among people for a very long time.
5. Pandemics generally cause much higher numbers of deaths than epidemics. The social
disruption, economic loss, and general hardship caused by a pandemic are much higher
than what an epidemic can cause.
What are the Six Stages of a pandemic? The World Health Organization has a Six Stage
influenza program, plus two Periods:
1. Stage 1: No animal influenza virus circulating among animals have been reported to
cause infection in humans.
2. Stage 2: An animal influenza virus circulating in domesticated or wild animals is known

to have caused infection in humans and is therefore considered a specific potential
pandemic threat.
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3. Stage 3: An animal or human-animal influenza reassortant virus has caused sporadic
cases or small clusters of disease in people, but has not resulted in human-to-human
transmission sufficient to sustain community-level outbreaks.
4. Stage 4: Human-to-human transmission of an animal or human-animal influenza

reassortant virus able to sustain community-level outbreaks has been verified.
5. Stage 5: The same identified virus has caused sustained community level outbreaks in
two or more countries in one WHO region.
6. Phase 6: In addition to the criteria defined in Phase 5, the same virus has caused
sustained community level outbreaks in at least one other country in another WHO
region.
7. Lost Peak Period: Levels of pandemic influenza in most countries with adequate
surveillance have dropped below peak levels.
8. Post Pandemic Period: Levels of influenza activity have returned to the levels seen for
seasonal influenza in most countries with adequate surveillance.
According to the WHO, if an influenza pandemic were to emerge today, we could expect:
1. As people today are highly internationally mobile, the pandemic virus would spread
rapidly around the world.
2. Vaccines, antiviral agents, and antibiotics to treat secondary infections would rapidly be
in short supply
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3. Several months would be needed before any vaccine became available. This is because
pandemic viruses are new ones.
4. Medical facilities would be overwhelmed
5. There would be sudden and potentially considerable shortages of personnel to provide

vital community services as the illness became widespread.
Holoendemic:A disease is holoendemic when essentially every individual in a population is

infected. As the disease is ubiquitous, the young are more likely to express pathogenic responses,
whilst the older hosts will carry the disease asymptomatically, or with reduced damage, due to
adaptive immunity.[2][3] Examples of this holoendemic pattern are seen with malaria in areas of
sub-saharan Africa (where 75% of the deaths are in children under 5) and trachoma in areas of
Saudi-Arabia.
METHODS USED IN EPIDEMIOLOGY
These include:
i. Collection of health related data,
ii. As a diagnostic tool for numerator data,
iii. For estimating the population at risk for the denominator data,
iv. For recording data,
v. For tabulation and analysis of data to introduce the essential information.
vi. Use of information for decision making and evaluation.
UNIT 2
Epidemiological Approaches
As with all scientific endeavors, the practice of epidemiology relies on a systemic approach. In
very simple terms Epidemiologist:
1. Counts cases or health events, and describes them in terms of time, place, and person;
32

2. Divides the number of cases by appropriate denominator to calculate rates; and
3. Compares these rates over time or for different groups of people.
Before counting cases, however, the epidemiologist must decide what a case is. This is done by
developing a case definition. Then, using this case definition, the epidemiologist finds and
collects information about the case- patients. The epidemiologist then performs descriptive
epidemiology by characterizing the cases collectively according to time, place, and person. To
calculate the disease rate, the epidemiologist divides the number of cases by the size of the
population. Finally, to determine whether this rate is greater than what one would normally
expect, and if so identify factors contributing to this increase, the epidemiologist compares the rate
from this population to the rate in an appropriate comparison group, using analytic epidemiology
techniques.
Defining a Case: Before counting cases, the epidemiologist must decide what to count, that is,
what to call a case. For that, the epidemiologist uses a case definition. A case definition is a set
standard criterion for classifying whether a person has a particular disease, syndrome, or other
health condition. Some case definitions, particularly those used for national surveillance, have
been developed and adopted as national standards that ensure comparability. Use of an agreed up
on standard case definition ensures that every case is equivalent, regardless of when or where it
occurred, or who identified it. Furthermore, the number o cases or rate of disease identified in
one time or place can be compared with the number or rate from another time or place.
Comparison is the essence of Epidemiology. Populations are used for Epidemiological studies,
but more specific characteristics and outcomes at the individual level.
The following approaches may be used:
1. Routinely available data e.g. hospital out-patient, birth and deaths, registration of persons data
e.t.c.
2. Disease surveillance: close observation of circumstances that are likely to cause disease.
3. Health systems research or approach [approach to health delivery] which includes:
i. Equitable access to health service
ii. The quality and responsiveness of health services,
iii. The efficiency and effectiveness of interventions,
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iv. A combination of the three elements above together determine the out-come of service
delivery.
4. Community studies [community diagnosis].
5. KAPB [knowledge, attitude, practice and belief] surveys.
6. Qualitative Epidemiology, involving distinctions based on qualities or relating to or involving

comparison based on qualities.
7. Epidemiological studies like:
i. Case control studies: used to study associations between environmental or genetic

factors suspected from ecologic associations.
N/B, Ecology is a branch of biology concerned with relations between organisms and their environment.
ii. Cohort [group] studies: used for the study of a more intensive resource study.
iii. Meta-analysis: used to analyze data accumulated from several separate studies.
iv. Human experimentation: used to test effects on a controlled population.
Epidemiological approaches can be broadly classified as follows:
1. A diagnostic phase, in which the presence of the disease is confirmed.
2. A descriptive phase, which describes the population at risk and the distribution of disease, both
in time and space, within these populations. This may then allow a series of hypotheses [A
proposal intended to explain certain facts or observations or a tentative insight into the natural
world; a concept that is not yet verified but that if true would explain certain facts or phenomena
or a message expressing an opinion based on incomplete evidence] to be formed about the likely
determinants of the disease and the effects of these on the frequency with which the disease
occurs in populations at risk.
This phase captures disease distribution and frequency. It includes questions like:
a) What is the problem?

34

b) What is the frequency?
c) Who is involved?
d) Where does it occur?
e) When does it occur?
Answers to the above questions provide clues to the factors which determine the occurrence of
diseases/health problems.
3. An investigating phase, which normally involves the implementation of a series of field studies
designed to test these hypotheses.
4. An Experimental phase, in which experiments are performed under controlled conditions to test
these hypotheses in more detail, should the results of phase three prove promising. This phase is
normally applied in clinical and community trials to answer questions about the effectiveness of
new methods for controlling diseases or for improving underlying conditions.
5. Analytical phase, in which the results produced by the above investigations are analyzed. This is
often combined with attempts to model epidemiology of the disease using information generated.
Such a process often enables the epidemiologist to determine whether any vital bits of
information about the disease process are missing. It attempts to analyze causes or determinants
of diseases by testing hypothesis to answer questions such as:
a) How is the disease caused and
b) Why is it continuining?
6. An intervention phase: aim at seeing the effects of active intervention which results in either the
exposure or the prevention of exposure of a group of people to some determinant or risk factor.
In this approach, appropriate methods of control of the disease are examined either under experimental
conditions or in the field to answer questions about the effectiveness of new methods for controlling
diseases or for improving underlying conditions. Interventions in the disease process are effected by
manipulating existing determinants or introducing new ones.
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7. A decision-making phase, in which knowledge of the epidemiology of the disease is used to
explore the various options available for its control. This often involves the modeling of the
effects that these different options are likely to have on the incidence of the disease. These
models can be combined with other models that examine the costs of the various control
measures and compare them with the benefits, in terms of increased productivity, that these
measures are likely to produce. The optimum control strategy can then be selected as a result of
the expected decrease in disease incidence in the populations at risk.
8. A monitoring phase, which takes place during the implementation of the control measures are to
ensure that these measures are being properly applied, are having desired effect on reducing
disease incidence, and that developments that are likely to jeopardize the success of the control
program are quickly detected.
9. Evaluative phase: in this phase, attempts are made to measure the effectiveness of different
health services.
UNIT 3
Principles of Epidemiology
Epidemiology is the study of the distribution and determinants of health-related states or events
in specified populations, and the application of this study to the control of health problems.
Every public health worker should be familiar with the basic principles in this definition and how
they are useful.
1. Distribution - Epidemiology is concerned with the frequency and pattern of health events in a
population. Frequency includes not only the number of events in a population, but also the rate or
risk of disease in the population. Determining the rate of disease occurrences (number of events
divided by size of the population) is critical for making valid comparisons across different
populations.
2. Determinants - Epidemiology is also used to search for causes and other factors that influence
the occurrence of health-related events. The occurrence of a health-related event is usually related
to multiple determinants that should be considered. Examples of determinants include host
susceptibility to a disease, and opportunity for exposure to a microorganism, environmental toxin,
insect vector or other infected individual that may pose a risk for acquiring disease.
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3. Specified populations - Epidemiologists are concerned with the collective health of people in a
community or other area and the impact of health events on that population.
4. Application - Epidemiology provides data for directing public health action. An epidemiologist
uses the scientific methods of descriptive and analytic epidemiology in "diagnosing" the health of
a community, but also must call upon experience and creativity when planning how to control
and prevent disease in the community.
Disease surveillance usually begins with descriptive epidemiology -- defining the what, who,
when and where of health-related events.
1. What - Define the disease events and/or its determinants
2. Who - Descriptions of demographic characteristics are helpful in determining which groups are at
risk for some outcome. The demographic characteristics usually include age, sex and
race/ethnicity. Other categories include socioeconomic status, history of occupation, or smoking
habits, which provide useful information about exposures that, may present a risk. A history of
underlying diseases may be useful for determining susceptibility to certain conditions.
3. When - Following changes in disease rates over time, following long-term disease trends and
knowledge of the seasonality of certain diseases helps identify unusual occurrences that may
define epidemics. Temporal associations between particular exposures on illness give information
about incubation periods and exposures posing a risk to others.
4. Where - Insight into the geographical extent of health-related events gives an idea of where the
agent that causes a disease normally lives and multiplies, what may carry or transmit it and how it
spreads.
The Primary Applications of Epidemiology in Public Health

To set policy and plan programs, public health officials must assess the health of the population
they serve and must determine whether health services are available, accessible, effective and
efficient. Epidemiology provides data for directing public health action. The information is used
when planning how to control and prevent disease in the community. Through public health
surveillance, a health systematically collects, analyzes, interprets and disseminates health data on
an ongoing basis. By knowing the ongoing pattern of disease occurrence and disease potential, a
health agency can effectively and efficiently investigate, prevent and control disease in the
community.
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Uses of Epidemiology:
1. Count health-related events

2. Describe the distribution of health-related events in the population
3. Describe clinical patterns
4. Identify risk factors for developing diseases
5. Identify causes or determinants of disease
6. Identify control and/or preventive measures
7. Establish priorities for allocating resources
8. Select interventions for prevention and control
9. Evaluate programs
10. Conduct research
i. risk factors and causes

ii. drug trials / vaccine trials
iii. operational research
Purposes of Communicable Disease Investigation and General Principles of

Preventing Transmission
Introduction: These guidelines have been written to assist public health staff engaged in
investigating communicable diseases. Their intent is to provide basic, practical, up-to-date and
easy-to-understand information which has been coalesced and interpreted from a variety of
sources. These guidelines have been written as carefully as possible to balance the amount of
work necessary to follow up a reported case against the probability of controlling spread of the
disease.
Only certain diseases are included in these guidelines. This is based upon their frequency and
complexity. For further information about these and other diseases, consult Control of
Communicable Diseases in Man.
Remember, these are only guidelines. All situations differ and best judgment should prevail.
Some situations require a more stringent approach. Some require a less stringent approach.
Purposes of Communicable Disease Investigation: Nothing is less self-fulfilling than going

through the motions of a task without understanding its purpose. When investigating a report of
communicable disease, always keeps in mind the purposes are to:
1. Prevent Transmission from Cases to Contacts: A full discussion of this topic begins
below.
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2. Identify the Source of the Disease: The source may be in the environment, a food, or
another person. Its identification can lead to control.
3. Identify Other Cases: Each reported case should be regarded as a sentinel health event.
Efforts to identify other cases which are not diagnosed and/or reported may uncover
outbreaks and common sources. It is important to question the reported case about others
who have been exposed or who have similar symptoms.
4. Conduct Surveillance: Information collected when investigating a reported disease can

be examined on a state or regional basis to identify outbreaks or trends and to formulate
policy. This information is collected on standardized forms and often is sent to the
Centers for Disease Control and Prevention for surveillance on a national basis.
5. Ensure that the Patient has Adequate Medical Supervision: Our responsibilities
include making sure the patient is well cared for and understands the consequences of his
illness. Where medical care is inadequate, appropriate referrals should be made.
General Principles of Preventing Transmission: This section describes how cases and contacts
can be managed to prevent transmission.
Case Management:
1. Verify the Diagnosis: It is very important to promptly establish or verify the etiologic
agent responsible for the disease. For many diseases reported by physicians or others,
there are often little or no laboratory data initially available to verify the diagnosis. Since
control efforts depend on the exact diagnosis, it is important to: (a) determine if this
information exists; (b) arrange for laboratory tests if the information does not otherwise
exist; or (c) make the best guess about diagnosis if it cannot be obtained.
2. Determine if the Case is Infectious or Possibly Infectious: If the case is still infectious,
you must identify available measures for preventing transmission. There are two ways to
assess the case's infectivity:
i. Estimation--uses the date of onset of illness, dates of known treatment, and

known periods of infectiousness for an illness. For example, hepatitis A is no
longer infectious after 1 week of the onset of symptoms. Strep throat is no longer
infectious after 24 hours of treatment.
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ii. Verification--requires laboratory testing of specimens for the case (for example, a
stool specimen for a food handler with salmonellosis). Which method you use
depends upon the disease (the period of communicability for some diseases is
precise; for others it is not precise), the quality of information about the case (e.g.,
is date of onset known?), and the need to know definitely whether the case is
infectious.
In practice, because of delays in diagnosis and reporting, many cases will have
passed the infectious stage by the time they are reported. In this instance, the
opportunity to prevent transmission is lost, but preventive efforts can be directed
to the case's contacts, and other purposes of case investigation can be fulfilled.
You may need to contact the physician to fill in information about the case,
determine results of laboratory tests, or arrange for tests. Also ask about similar
cases for which a report may be pending.
3. Minimize the Duration of the Case's Infectivity: Drugs (antimicrobials) are the most
important means to shorten the duration of infectivity for many diseases. Usually,
decisions about drug treatment will be made by the time you investigate. However,
sometimes it may be necessary to work with the patient and physician to ensure the
patient is appropriately treated.
4. Put into Effect Practices for Preventing Transmission: These practices depend upon
the disease and other circumstances. If the disease warrants, the case may have to employ
these practices while ill and for a period after recovery during which (s)he is still
infectious:
i. Disinfect and dispose of contaminated material (e.g., blood, saliva, feces, urine,
eating utensils, bedding, clothes, toys, etc.)
ii. Disinfect the case, clothing, bedding, etc. (e.g., lice)
iii. Encourage behavioral practices of the case (e.g., handwashing, covering the nose
and mouth when coughing/sneezing, protecting lesions from contact with another
person. Also, there may be a need for changes if individual is a foodhandler.)
iv. Isolate the case -- the duration and degree depends upon the illness
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Contact Management:
1. Determine the risk of infection to contacts: What is the frequency, duration and dosage
of the exposure? Often, these characteristics can only be described vaguely. It is usually
reasonable to assume persons living in the same household had opportunity for exposure.
Is the contact susceptible? Has the person been vaccinated, or previously infected? Is
there evidence of a compromised immune system (surgery, steroids, etc.)? Does the
disease result in immunity or are people generally susceptible?
2. Determine if the contact is ill or infected: Look for clinical signs or symptoms. It is
important to know if the contact is in the early stages of an illness or asymptomatic
infected, you must rely on the laboratory. If you determine that a contact is ill or infected,
manage him/her as a case.
3. Prevent illness in susceptibles: It may be useful for you to think of contacts in two
ways: Those who have been exposed, and those who might yet be exposed, either to the
original source or to a contact who subsequently acquires an infection.
The choice of the preventive measure depends upon the disease. Rapid identification of
susceptibles is important. Remember, vaccines usually require a time period greater than
one incubation period to develop antibody. Therefore, they rarely prevent illness in the
first generation of contacts. They can, however prevent illness in later generations.
Immune globulins must be given within a few days of contact to prevent or modify an
infection, but they provide only short-term protection. Antimicrobials are particularly
important for contacts exposed to strep, tuberculosis and meningitis.
Limit the activities of exposed persons -- sometimes it may be prudent to recommend
cessation of contact between the contact and the source. Another example is quarantining
exposed persons to protect others not yet exposed.
Conduct personal surveillance of the exposed person -- it may be important to call an
exposed person by the end of the maximum incubation period to see if (s) he is ill (e.g.,
for hepatitis A), or simply ask the contact to call you if (s) he develops symptoms. The
intensity of the surveillance depends upon the importance attached to preventing
transmission from that person.
General Guidelines for Outbreak Investigations: The first action of a health agency when it
receives a report of a case or a cluster of cases of a disease is to investigate. The investigation
may be anything from a limited phone call to confirm reported information, or it may be as
extensive as a field investigation coordinating the efforts of many people to determine the extent
and cause of a large outbreak.
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Outbreaks may be detected when routine, timely analysis of surveillance data reveals an increase
in reported cases or an unusual clustering of cases. In South Carolina, for example, the weekly
tabulation of disease reports by county is a useful way to monitor trends, evaluate geographical
distribution throughout the state and identify possible clusters.
Why do we Investigate Outbreaks?
The health agency has a responsibility to institute control and prevention measures. Outbreak
investigations may be considered as opportunities to study disease events and are training
exercises for those conducting the investigation. If cases are continuing to occur, the goal may be
to prevent additional cases. If an outbreak appears to be almost over, the goal may be to prevent
outbreaks in the future. The objective here would be to identify factors which contributed to the
outbreak to implement measures that would prevent serious outbreaks in the future. Other
concerns like public relations, political concerns and legal obligations may also need to be
considered.
Steps in the Investigation:
1. Prepare for field work - talk to others with experience, review the literature.
2. Establish the existence of an outbreak - An outbreak or epidemic is the occurrence of

more cases of disease than expected in a given area or among a specific group of people
over a particular period of time. A cluster is an aggregation of cases in a given area over
a particular period without regard to whether the number of cases is more than expected.
Defining an epidemic requires that one determine what the expected number of cases
would be usually from existing surveillance data. Some reasons for a "false" epidemic
may be reports of sporadic cases of unrelated cases of the same disease, reports of similar
cases but unrelated diseases, or changes in surveillance or reporting procedures.
3. Verify the diagnosis - Collect clinical information, contact the diagnosing physician,
confirm results of laboratory tests done.
4. Define and identify cases - Establish a case definition for the disease using a standard
set of criteria for deciding whether an individual should be classified as having the health
condition of interest.
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5. Perform descriptive epidemiology - Collect information to characterize an outbreak by
time, place and person. Remember the what, who, when and where of descriptive
epidemiology.
6. Develop hypotheses - After collecting some of the initial information characterizing the
outbreak, one should be able to formulate a hypothesis that addresses the source of the
agent, the mode (and vehicle or vector) of transmission, and the exposures that caused the
disease.
7. Evaluate hypotheses - Compare your hypothesis with the established facts. Is it

plausible and consistent? If not, the hypothesis should be revised.
8. As necessary, reconsider/refine hypotheses and execute additional studies.
9. Implement control and prevention measures - This is the primary goal of most
outbreak investigations. Although mentioned far down on the list, prevention and control
measures should be implemented as soon as possible in an outbreak setting. This may be
accomplished by destroying contaminated foods, removing an infected food handler from
the job, or immunizing and providing prophylaxis to a population at risk.
10. Communicate findings - An oral briefing or a written report are always useful to
summarize an investigation. Formally presenting recommendations provides a blueprint
for action and may serve in the health agency as a reference if the health agency
encounters a similar situation in the future.
Data Collection Guidelines
1. Line listings. Traditionally we collect data on a standard case report form or

questionnaire. A separate sheet of information from each person interviewed often makes
synthesizing the data difficult. To create a line listing, critical items are selected from the
data collection form and are organized so that data from multiple cases can be entered in
columns on a single sheet to summarize the data. In a line listing, each column represents
an important variable, such as name or identification number, age, sex, case
classification, etc., while each row represents a different case.
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2. The epidemic curve. The "epi" curve serves as a map of an epidemic. It provides a
simple visual display of the outbreak's magnitude and time trend. Although simple it
provides a great deal of information about an epidemic. You will usually be able to tell
where you are in the time course of an epidemic, and what the future course might be. If
you have identified the disease and know its usual incubation period, you usually can
deduce a probable time period of exposure and can develop a questionnaire focusing on
that time period. Finally, you may be able to draw inferences about the epidemic pattern
-- whether it is common source or propagated, or both. Drawing an epidemic curve,
plotting time on the x axis and the number of cases on the y axis, will provide additional
clues in furthering the investigation. Mapping of individual cases should be done by their
date of onset. Changing the unit of time on the x axis may be necessary to best "see" the
outbreak. This will depend on the incubation period of the disease you are dealing with.
UNIT 4
Uses of Epidemiology in Public Health

1. It is used in the investigation of:
i. Diseases – communicable and non-communicable.
ii. Problems.
iii. Situations, and
iv. Events that have affected or are affecting or will be affecting the health of the
organism in our environment.
2. It is a basic tool for looking for signs and symptoms in the health of a community.
3. It can be used to:
i. elucidate causal mechanism,
ii. explanation of local health characteristics of disease occurrence, and
iii. Administrative guidance in the provision of health services.
It can be used on preventive interventions.
4. It can be used to determine the fertility of a population.
5. It can determine the number of accidents and their causes.
6. It can be used to study the health history of a population.

44

7. It can be used to diagnose the health of a community and measures of ill-health in terms
of:
i. Incidence,
ii. Prevalence, and
iii. Mortality from a defined disease.
8. It can be used to study the working and utilization of health services.
9. It can be used to estimate the group experience; what the individual’s risk on the average
of disease incidence and defects.
10. It can be used to complete a clinical picture of a chronic disease and describe its natural
history.
11. It can be used to identify syndromes by describing :
i. The distribution,
ii. Association, and
iii. Disassociation of phenomena on the population.
12. It can be used to search for cases of health and disease by studying the incidence in
different groups to estimate the relative importance of different causes in multiple
etiologies.
13. It can be used as a strategy for studying man and his total environment.
14. It can be used to develop knowledge about both the earliest and beginnings of
dysfunction and characteristics of individuals within the groups that predispose them to
futuristic problems.
dysfunction and characteristics of individuals within the groups that predispose them to
futuristic problems.
16. It is used to make a community diagnosis, so that you identify and describe health
problems in a community. This will be a cross-sectional study since observations are
made at a specific time e.g.
i. Prevalence anemia.
ii. Weight for height profile of children.

45

17. It is used to monitor continuously over a period of time the change of health in a
community. This will be a longitudinal as it involves the collection of information over a
period of time and will commonly be related to measures which have been taken e.g.
effect of program of vaccination, health, education, nutritional supplementation, safe
water supply and sanitation etc.
18. It is used to practice surveillance for specific diseases e.g. cholera in order to act quickly
and cut short any out-break.
19. It is used to investigate an - out-break of communicable disease, analyze the reasons for
it, plan a feasible remedy and carry out and monitor the effects of the remedy on the out-
break.
20. It is used to plan effective health services.
Note: Epidemiology is about information: the information needed for health planning and
supervision and evaluation of health promotion and disease control activities.
UNIT 5
Measures of Epidemiology
There are two measures used in Epidemiology namely:
1. Prevalence rate.
2. Incidence rate.
Prevalence Rate: In Epidemiology, the prevalence of a disease in a statistical population is

defined as the total cases of the disease in the population at any given time or the total
number of cases in the population divided by the number of individuals in the population. It
is used as an estimate of how a common condition is within a population over a certain
period of time. It is also defined as a measure of morbidity which is the number of cases of a
disease, infected persons, or condition present at a particular time in relation to the size of the
population from which it is drawn. For example, the number of cases of Measles with in a
population as of 1st July. It helps physicians or other health professionals understand the
probability of certain diagnoses and are routinely used by Epidemiologists, health care
providers, government agencies and insurers.
Prevalence rate is controlled by two elements:
i. The number of individuals who have been diseased in the past.
ii. The length of/ or duration of the illness.
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Factors which affect Prevalence in a Population
Prevalence rates are increased by:
i. Immigration of ill cases [in coming].
ii. Emigration of healthy persons [out going].
iii. Immigration of susceptible cases or those with the potential of becoming cases.
iv. Prolongation of life of cases in throat cure [increased duration of disase-chronicity]
v. Increased occurrences of new cases [increase in incidence]
Prevalence rates are increased by:
i. Immigration of healthy persons.
ii. Emigration of all cases.
iii. Improved cure rate of cases.
iv. Increased death rates from the diseases.
v. Decreased occurrences of diseases [incidence].
vi. Shorter duration of illnesses [acuteness]
vii. Death.
As new diseases develop in a population [as new cases rise] incidence goes up. As incidence
goes up prevalence goes up.
The duration of disease affects prevalence: When disease has a long duration, prevalence
remains higher and longer.
Intervention and treatment have effects on prevalence: as treatment reduces case, the
duration of diseases and number of cases goes down – prevalence reduces.
- Immigration prevents new cases and reduces prevalence.
- Prolongation of life of cases can increase duration and can add to the prevalence of chronic
diseases.
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Prolongation of non-diseased and healthy population can reduce prevalence of acute diseases and
and as healthy people increased, life expectancy increases.
Mathematically, prevalence rate [1] = Number of existing cases of a disease at a point in time
x1000
Total population
Prevalence [2] = Total number of cases of disease at a given time x1000
Total number of population at risk at a given time
To calculate the prevalence of a disease the following is involved:
a) Total cases.
b) Total population.
c) Specific point in time. i.e.
Total cases x1000 at specific time
Total population
If the TB register on June 30th [specific point in time] shows 200 cases [total cases] and the
population of the catchment area is 20,000 [total population] the prevalence of TB therefore
equals,
200x1, 000 on June 30th
20,000
=10 cases per 1,000.
There are four types of prevalence rates that are used by investigators:
1. Point Prevalence: This refers to the number of cases that occur during specified period of
time, for example a year or the number of cases of individuals with a disease, condition,
48

or illness at a single specific point in time divided by the number of existing cases at a
point in time.
Point prevalence therefore = Number of existing cases of the disease at a point in time x
1,000
Total study population
Point prevalence measures the presence of a disease or a condition on a single short time
point, theoretically stopping the clock for a minute, hour or day counting the existing cases of
the disease.
The numerator includes all persons having the disease at a given moment irrespective of the
length of time which has elapsed from the beginning of the illness to the time when
prevalence is measured.
The denominator is the total population [affected and unaffected] within which the disease is
present.
In contrast, incidence +rates measures events, while point prevalence rates measure what
prevails or exists.
2. Period Prevalence: This is a measure that expresses the total number of cases of a
disease known to have existed at some time during a specified period. It is the sum of
point prevalence [the number of cases existing at the beginning of the period] and
incidence [the number of case coming into existence during the period]i.e. period
prevalence starts at the point in time and stops at a point in time.
Period prevalence therefore= Number of existing cases of the disease within a period of time x
1,000
Average study population
Reflection of Period Prevalence:

i. All persons with disease that has been carried over from the previous time period
or become ill at the end of the time period are included.
ii. New cases [incidence] occurring within the time period are included.
iii. Recurrences during a succeeding time period [usually one year] are included.
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3. Life Time Prevalence: This refers to the total number of individuals that have had a
condition, problem, or disease throughout their life, or at least major part of it. Life
prevalence is considered as a form of period prevalence.
4. Annual Prevalence: The total number of people with a condition, problem, disease at
any given time throughout the year. Cases of disease that started before the date of
prevalence count but extended into study period are included in the annual prevalence
rates. Those cases that started prior to the end of the study period and extended
throughout the year and/or had not yet recovered before the study period ended are
counted.
Uses of Prevalence and Incidence Rates:

1. Planning health services - public health services, medical services community health
services.
2. Projecting medical care and need for hospital beds.
3. Research-epidemiological studies.
4. Predicting future.
5. Describing events of illness as they are.
6. Making comparisons.
Incidence Rates: Incidence is the relative frequency of occurrence of something.

Incidence rates are the measure of the risk of developing some new condition within a
specified time. Although sometimes loosely expressed as the number of new cases during
sometime period, it is better expressed as a proportion or rate with a denominator.
Incidence proportion is the number of new cases within a specified period divided by the
size of the population initially at risk. For example, if a population initially contains 1000
non diseased persons and 28 diseased or cases over two years of observation, the incidence
proportion is 28 cases per 1,000 persons i.e. 28%
Incidence rates are designed to provide measures of rate at which people without a disease,
illness, and injury develop the conditions during a specified period of time eg a number of
new cases of in a population over a period of time stated as the number of case which came
into existence within a certain period of time per specified unit of population.
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In actual application of incidence rates, it is challenging as times of onset of disease may be
unclear. In such cases,
1. Time of diagnosis
2. Date of reporting
3. Time of appearance of symptoms
4. Visit to hospital
5. Appearance at the emergency room or
6. At other times element of factor that identify the beginning of an outbreak may be used.
Incidence is not the onset of an outbreak, but the frequency of new cases or events in the time
period and in a specific population.
A calculation of incidence rate involves:
a) The number of cases.
b) Total population.
c) Period of time.
Incidence rate:
= Number of new cases of a disease occurring in the population during a specified Period of time
x 1000
Number of persons exposed to risk of developing the disease during that period of time
Or
Incidence rate:
= Number of a disease or new cases over a period of time x 1,000
Population at risk of developing the disease.
For example, if there were 100 cases of TB in the catchment area of 20,000 [total population] in
12 month [period of time].
Calculate the incidence.
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Incidence= New cases x 1,000
Total population
= 100 x 1,000
20, 000
Incidence therefore = 5 cases per 1,000 population per year.
This means that in 12 months period you can expect to see 5 cases of TB for every 1,000 in your
catchment area.
Incident rates may be used to measure short time acute communicable diseases such as cholera
or measles or may be used to measure chronic or long time conditions such as cancer or diabetes
mellitus.
Incidence Rates Denominator/Numerator issues: The denominator as used in the

incidence rates should accurately set forth the number at risk or under study in the group or
population.
N/B as the time passes, the number of persons at risk in the population changes. Some people are
exposed to the risk at the end of the period while other people are removed from risk shortly after
the defined period starts.
To accommodate the transient population problem, the epidemiologist picks the population
number/cases at midpoint in the time period to represent the average population at risk.
Since incidence rate is used to study the new cases of a disease, only those individuals at risk of
developing the disease i.e. population at risk should be individuals in the denominator. The
denominator should include:
1. Individuals with the disease.
2. Those who have already had the disease [if they no longer susceptible].
3. Those not susceptible due to immunization.
Numerator in Incidence: The numerator in incidence provides specific information about the
occurrences of a disease. If the number of cases or persons can vary, the numerator should
clearly reflect the differences. The numerator is the number of new cases or incidences starting
within time period.
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There are two approaches of incidence rates that are used:
1. Cumulative incidence rate: This is the number of person’s at risk and is used as
denominator. In case of this nature, cumulative incidence rates useful longitudinal studies
due time and secular variations. The cumulative incidence is used to study a group of
persons followed over a period of time.
2. Incidence density or Force morbidity: This is the number of cases of disease which
occur per unit of a population and at a point in unit time. It is used to predict the risk that
a well person has of getting ill over a certain period of time. The population and time
element are used in the denominator; whereas the numerator includes new cases of
disease or disorder.
Force morbidity is also referred to as incidence density.
Note: the prevalence rate equals the incidence rate multiplied by the average duration of the
disease.
For example, if the average duration of a disease is three years and its incidence rate is 10 per
1000; the prevalence rate would be 30 per 1000.
The duration of disease is usually measured from the time of diagnosis to death.
In summary, the incidence rate is an accurate estimate of the risk probability of getting a
disease within a certain time period and the denominator is only “at risk” population.
Principles of Incidence Rate Use:

1. An incidence rate can be used to estimate the probability of or risk of developing a
disease during a specific period.
2. As the incidence rate goes up, the risk possibility or the probability of getting the disease
goes up.
3. Time- if the incidence rate is consistently higher during a specified time of the year, such
as rainy season, the risk of developing diseases goes up at that time eg cholera or malaria
are highest during rainy seasons.
4. Place- if the incidence rates are consistently higher, among people, who live in a certain
place, the risk goes up for developing disease if one lives within the area.
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5. Person- if incidence rates are consistently higher among individuals with specific life
style factor the risk goes up among that group eg lung cancer increases among cigarette
smokers.
6. Higher incidence implies many new cases, thus risk increases.
7. When incidence of disease is known to be high, the existence of or potential for an

epidemic becomes known and predictable.
Reflections: It is important to note that incidence is a bit like a motion picture of the
development of a disease in a population. It provides a picture of the measure of the movement
of disease through a population, the rate at which people without disease develop the disease
during a specific period of time.
i. Incidence is a fundamental tool for studying the etiologic factors of both acute and
chronic illness.
ii. Incidence rates are important because they provide a direct measure of the rate at
which individuals in a given population become ill and thus provide basis for
statements about probability or risk of illness.
Prevalence varies in direct relation to both duration and incidence.
Successful intervention and treatment will prolong life and will have an effect on reducing
prevalence. The decrease in incidence and shortening of the duration of a disease decreases the
prevalence.
Application of Epidemiological Concepts on Health Services:

1. It is used in the investigation of diseases [communicable and non-communicable],
problems, situations and events that have affected or are affecting or will be affecting
health of the organism in our environment.
2. It is a basic tool for looking for signs and symptoms in a community health.
3. It can be used in the elucidation [An act of explaining that serves to clear up and cast
light on or an interpretation that removes obstacles to understanding] of causal
mechanisms, the explanation of local health characteristics of disease occurrence and
administrative guidance in the provision of health services.
4. It can be used in preventive interventions.
5. It can be used to determine fertility in a population.
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6. It can be used to determine the number of accidents and their causal mechanisms.
7. It can be used to study the health history of a population.
8. It can be used to diagnose the health of a community and measures of ill health [A state
in which you are unable to function normally and without pain] in terms of incidence,
prevalence, and mortality from a defined disease.
9. It can be used to study the working and utilization of health services.
10. It can be used to estimate the group experience; what are the individual’s risk on the
average of disease incidence and defects.
11. It can be used to complete a clinical picture of chronic disease and describe its natural
history [The scientific study of plants or animals (more observational than experimental)
usually published in popular magazines rather than in academic journals].
12. It can be used to identify syndromes [A pattern of symptoms indicative of some disease]
by describing the distribution, association and disassociation of phenomena [Any state or
process known through the senses rather than by intuition or reasoning or a remarkable
development] on the population.
13. It can be used to search for cases of health and disease by study the incidence in different
groups to estimate the relative importance of different causes in multiple etiologies [The
philosophical study of causation].
14. It can be used as strategy [An elaborate and systematic plan of action] for studying man
and his total environment.
dysfunction and the characteristics of individuals within the groups that predispose them
to futuristic problems.
Uses of Epidemiologic studies:

These are periodic or continuing assessment of the health status of the community.
i. Periodic or continuing evaluation of the effectiveness of health services.
ii. Surveillance of specific diseases.
iii. Investigation and containment of disease out-breaks.
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Uses of Epidemiologic Health Surveys:
i. To measure the total amount of illness in the population.
ii. To measure the amount of illness caused by a specific disease.
iii. To study the nutritional status of the population.
iv. To examine the utilization of existing health care facilities and demand for new ones.
v. To measure the distribution in the population of a particular characteristic e.g. sources

of water.
vi. To examine the role and relationship of one or more factors in etiology of disease.
Study Designs: There are two main types of study designs:

i. Descriptive studies [designed to collect facts].
ii. Analytical studies [designed to test hypothesis and examine cause-effect-relationship.
Descriptive Study Design: This study is limited to description of occurrence of disease in a

population and is often the first step in epidemiological investigation.
Descriptive studies make no attempt to analyze the link between exposures and effect. They are
designed to describe certain characteristics of a problem or variables as WHO, WHERE, and
WHEN [person. Place and time] by collecting information on specific diseases in specified
population groups.
Who - in terms of sex, age, occupation, income, culture, religion, and nutritional status.
Where – the place where people live or work may determine which disease and/or the health
problems they suffer from.
When – it is important to know when the health problem is severe or the incidence of new cases.
Descriptive studies may be:
1. Cross-sectional study, which investigates individual at single point in time thus giving
estimates of point prevalence.
56

2. Longitudinal study, which measures individuals over a period of time, thus giving
estimates of incidences. Longitudinal studies may either be prospective [looking
forward], measuring individuals as they become ill or recover, or retrospective [looking
back], studying events of illness that occurred in the study population in the past. The
information which is obtained may enable us to develop hypothesis about the pattern of
disease.
Analytical Study Design - This attempts to analyze causes or determinants of disease by testing
hypotheses [A proposal intended to explain certain facts or observations] to answer such
questions as how is disease caused, its significance, and important causative or predisposing
factors so as to take appropriate action for solution.
Analytical study design also tests hypotheses about the influence which determines that one
person is affected by disease and another one is not.
Analytical studies are designed to explain the distribution of diseases in specified population
groups by testing hypotheses.
These hypotheses may be arrived at from a:
1. Descriptive study,
2. Clinical observation or from
3. An examination of existing records.
Analytical studies attempt to show whether particular events e.g. consumption of certain foods or
states such as malnutrition or living in overcrowded conditions acts as “causes “whose “effects”
is the resulting disease.
Analytical studies are therefore based on the comparison of two or more groups of individuals.
Three kinds of comparison s can be made and there are correspondingly three types of analytical
studies namely:
1. Cross-sectional study,
2. Retrospective study,
3. Cohort [A group of people having approximately the same age] or prospective study.
The effects of the intervention on the study group are determined by comparing this group with a
similar group of controls who did not receive the intervention. The evaluation of a disease
control program is a type of intervention study.
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UNIT 6
Determinants of Disease
The determinants explored below are organized into four categories, based upon a model
developed by Murray & Lopez (see figure below)
Social/Environmental/ Behavioral/Individual Clinical/Physiological Health Outcomes

Political Determinants Determinants Determinants [clinical [premature mortality
[sources: The Solid [sources: Attribution conditions -- some of and DALYs, plus
Facts: Social Matrix and McGinnis these also appear as major public health
Determinants of Health & Foege (or, more DALYs, since programs, plus several
(pdf), some key articles, recently, Mokdad et al) Disability Adjusted that were identified by
plus several hours of plus deliberation by the Life Years includes the workgroup]
deliberation by the workgroup. morbidity] (listing not in rank
workgroup, which order)
identified key areas of
focus]
physical environment alcohol heart disease ischemic heart
(transport) disease*
firearms/violence high blood pressure hiv/aids
social inequality (low lung cancer
SES) illicit drugs diabetes (type 2) stroke*
depression*
social exclusion motor vehicle traffic high cholesterol suicide
(institutional racism) breast cancer
physical inactivity overweight/obesity poisonings (overdose)
social support (lack of traffic accidents
social connectedness) poor diet asthma drug overdose
hypertensive heart
tobacco hiv/aids disease
colorectal cancer
unsafe sex depression COPD
violence (homicide)
stress malnutrition Alzheimers/dementia
osteoarthritis
substance use alcohol use disorder
problems colorectal cancer
diabetes
cirrhosis of liver
sexually transmitted
disease
tuberculosis
low birth weight
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infant mortality
abscess
* leading health
outcomes
(cardiovascular disease
is main cause of
premature mortality;
depression is leading
cause of DALYs)
Simplified causal web linking exposures and outcomes. For a discussion of the issues involved in
quantification of risks within this framework
Sampling Methods: These are:

1. Random sampling method: A sample may be defined as random if every individual
in the population being sampled has an equal likelihood of being included in the
sample. Random selection is the basis of all good sampling techniques. Selection of a
sample entails identification of all the individuals from whom the selection will be
made. Then make a list of the study population from whom to select the sample. You
may also assign a number to each individual and ten select certain numbers by
reference to random sample. The starting point for selection should be randomly
chosen.
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2. Systematic Sampling: Here every nth is selected from the list or from some other
ordering. A systematic sample can be drawn from patients ordered according to the
time of their attendance, admission or discharge from a hospital. This enables a
sample to be drawn without initial listing of all people among whom the selection will
be made. This method has major advantage over a simple random sample. The
starting point for selection should be randomly chosen.
3. Multi-stage sampling method: In a survey covering a large area such as a district,

province or country, an initial sample may be taken from units of population such as
village or schools. The villages or schools are listed and a random sample of the
required number is selected. Then a list of the individuals within the chosen villages
is made and a sample taken from them. This is a two - stage sampling that is used for
such surveys as B.C.G. scar and tuberculin test surveys. This procedure of sub-diving
population into two smaller units may be extended to two or more stages as required.
Listing is restricted to the smaller units from whom the final selection is made. In this
case, a village or a school is a cluster sample as the individuals selected are clustered
in the same village/school. The method may cause error if the variable attribute or
disease is itself clustered in the population e.g. Onchocerciasis clustering in the
village near the streams where simulium flies breed.
4. Stratified Sampling: if a disease is unevenly distributed within a population in

respect to sex, age, etc a stratified sample is used.
5. Choice of Sampling Method: The choice of a particular sampling method is largely

determined by practical consideration. In field work it is almost impossible to select a
sample that is fully random. To check a bias that is always in every sample, the
investigator must have some basic knowledge of the study population. For example,
prevalence of trachoma cannot be determined solely by examining a sample of people
attending health center.
Control Groups: These are groups of subjects in analytical epidemiological surveys whereby
the study group with a disease is compared with those without the disease or condition.
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Examples:
i. In case-control study of the association between a causation and disease.
ii. In representative survey, the incidence of the disease among persons exposed to the
causative factor can be compared with those persons not exposed.
iii. The ideal control group is one which is exactly the same as the study group in all
respects except for the characteristics which are to be studied. Controls can be
selected from the general population or patients with one or more other diseases.
Attack Rate: Attack rates are cumulative incidence rates and are used in epidemics. These
rates refer to the number of persons ill from a specific disease in a limited time period in a
specific group i.e. they are computed based on limited time exposure and risk and the limited
group of people at risk.
Sometimes the term infection rate shows the incidence of all persons with signs and symptoms of
disease and also includes the unapparent cases of infections.
Attack rates are commonly used in food poisoning situations or chemical exposure in a group of
workers.
In cases of food poisoning, food sanitation preparation measures vary and likely food borne
illness due to bacteria occur among those who might have eaten a particular food. In carrying out
an investigation of an out-break of this nature, one need to look at:
1. Various food sources.
2. Who prepared what food?
3. Cases of ill people verses well people.
4. Who eats what when and how much?
From the results of the investigation, attack rates are calculated.
The epidemiological concept here is to determine whether there is an association between the
risk of exposure [eating the food], at specific event and the specific illness.
Attack rate therefore is number of persons developing the disease within the range of the
incubation period within a total population exposed to the risk factor.
Attack rate= Number of cases in the exposed population x100 = %
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Total population exposed
Crude attack rate = Number of people [Cases] ill with disease x1, 000
Number of people attending the event [exposed]
General attack rate = Number of people ill [cases] within the time period x 1,000
Number of people at risk within the time period
Food specific attack rate = Number of people who ate a specific food and became ill x1, 000
Total number of people who ate the food
Attack rates are determine from the broad perspective [crude attack rate] downward to narrow
focus [attack rate], and then finally a very specific assessment is conducted [food – specific
attack rate]
Primary and Secondary Attack: This refers to number of persons who had contact or
exposure to the primary infectious person or the primary source of infection within the
incubation period of the pathogen.
The assessment uses the total number of exposed cases of exposed cases i.e. the number of
infected persons per number susceptible exposed persons multiplied by 1,000.
Note: the denominator excludes individuals who have previously had the disease and are now
immune of susceptibly exposed persons multiplied by 1,000.
Secondary attack rate = Number of exposed persons developing the disease within incubation
period x1, 000
Total number of persons exposed to the primary case
Case Fatality: A number of people will die from those with the disease over a period of time.
Mortality: This measure tells what proportion of the entire population die yearly from the
disease.
Significance: measures the spread of infection within a family or household following

exposure to the first or primary case in the family.
The numerator is the number of case and the denominator consists of all persons who are
exposed to the risk.
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Significance =Number of cases
All persons who are exposed to the risk factor
Assessment of Accuracy of Validity: Two indices are used to evaluate the accuracy of a test –
those of the sensitivity and specificity. These indices are usually determined by administering the
test to one group of persons who have the disease and to another group who do not and then
comparing the results.
Those testing positive have the disease and are called “true positive”, those testing positive and
do not have the disease are called “false positive”.
Those testing negative and have the disease are called “false negative”, and those testing
negative and do not have the disease are called “true negatives”.
Sensitivity: is defined as the percent of those who have the disease and are so indicated by the
test.
Specificity: is defined as the percent of those who do not have the disease and are indicated by
the test.
Types of Epidemiological Studies
Types of studies:
Case series: Case-series may refer to the qualititative study of the experience of a single patient,
or small group of patients with a similar diagnosis, or to a statistical technique comparing periods
during which patients are exposed to some factor with the potential to produce illness with
periods when they are unexposed.
The former type of study is purely descriptive and cannot be used to make inferences about the
general population of patients with that disease. These types of studies, in which an astute
clinician identifies an unusual feature of a disease or a patient's history, may lead to formulation
of a new hypothesis. Using the data from the series, analytic studies could be done to investigate
possible causal factors. These can include case control studies or prospective studies. A case
control study would involve matching comparable controls without the disease to the cases in the
series. A prospective study would involve following the case series over time to evaluate the
disease's natural history.
The latter type, more formally described as self-controlled case-series studies, divide individual
patient follow-up time into exposed and unexposed periods and use fixed-effects Poisson
regression processes to compare the incidence rate of a given outcome between exposed and
unexposed periods. This technique has been extensively used in the study of adverse reactions to
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vaccination, and has been shown in some circumstances to provide statistical power comparable
to that available in cohort studies.
Case control studies: Case control studies select subjects based on their disease status. A group
of individuals that are disease positive (the "case" group) is compared with a group of disease
negative individuals (the "control" group). The control group should ideally come from the same
population that gave rise to the cases. The case control study looks back through time at potential
exposures that both groups (cases and controls) may have encountered. A 2×2 table is
constructed, displaying exposed cases (A), exposed controls (B), unexposed cases (C) and
unexposed controls (D). The statistic generated to measure association is the odds ratio (OR),
which is the ratio of the odds of exposure in the cases (A/C) to the odds of exposure in the
controls (B/D), i.e. OR = (AD/BC).
Case Controls
Exposed A B
Unexposed C D
If the OR is clearly greater than 1, then the conclusion is "those with the disease are more likely
to have been exposed," whereas if it is close to 1 then the exposure and disease are not likely
associated. If the OR is far less than one, then this suggests that the exposure is a protective
factor in the causation of the disease. Case control studies are usually faster and more cost
effective than cohort studies, but are sensitive to bias (such as recall bias and selection bias). The
main challenge is to identify the appropriate control group; the distribution of exposure among
the control group should be representative of the distribution in the population that gave rise to
the cases. This can be achieved by drawing a random sample from the original population at risk.
This has as a consequence that the control group can contain people with the disease under study
when the disease has a high attack rate in a population.
A major drawback for case control studies is that, in order to be considered to be statistically
significant, the minimum number of cases required at the 95% confidence interval is related to
the odds ratio by the equation:
total cases = (a+c) =

(1.96)^2×(1+N)×(1÷ln(OR))^2×((OR+2√OR+1)÷√OR)≈15.5×(1+N)×(1÷ln(OR))^2
Where N = the ratio of cases to controls. As the odds ratio approached 1, approaches 0; rendering
case control studies all but useless for low odds ratios. For instance, for an odds ratio of 1.5 and
cases = controls, the table shown above would look like this:
Case Control
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Exposed 103 85
Unexposed 84 103
For an odds ratio of 1.1:
Exposed 1732 1652

Unexposed 1652 1732
Cohort studies: Cohort studies select subjects based on their exposure status. The study
subjects should be at risk of the outcome under investigation at the beginning of the cohort study;
this usually means that they should be disease free when the cohort study starts. The cohort is
followed through time to assess their later outcome status. An example of a cohort study would
be the investigation of a cohort of smokers and non-smokers over time to estimate the incidence
of lung cancer. The same 2×2 table is constructed as with the case control study. However, the
point estimate generated is the relative risk (RR), which is the probability of disease for a person
in the exposed group, Pe = A / (A + B) over the probability of disease for a person in the unexpo
sed group, Pu = C / (C + D), i.e. RR = Pe / Pu.
Case Non-Case Total
Exposed A B A+B
Unexposed C D C+D
As with the OR, a RR greater than 1 shows association, where the conclusion can be read "those
with the exposure were more likely to develop disease."
Prospective studies have many benefits over case control studies. The RR is a more powerful
effect measure than the OR, as the OR is just an estimation of the RR, since true incidence
cannot be calculated in a case control study where subjects are selected based on disease status.
Temporality can be established in a prospective study, and confounders are more easily
controlled for. However, they are more costly, and there is a greater chance of losing subjects to
follow-up based on the long time period over which the cohort is followed.
Cohort studies also are limited by the same equation for number of cases as for cohort studies,
but, if the base incidence rate in the study population is very low, the number of cases required is
reduced by ½.
Validity
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Precision and bias: Different fields in epidemiology have different levels of validity. One way
to assess the validity of findings is the ratio of false-positives (claimed effects that are not
correct) to false-negatives (studies which fail to support a true effect). To take the field of genetic
epidemiology, candidate-gene studies produced over 100 false-positive findings for each false-
negative. By contrast genome-wide association appears close to the reverse, with only one false
positive for every 100 or more false-negatives. This ratio has improved over time in genetic
epidemiology as the field has adopted stringent criteria. By contrast other epidemiological fields
have not required such rigorous reporting and are much less reliable as a result.
Random error
Random error is the result of fluctuations around a true value because of sampling variability.
Random error is just that: random. It can occur during data collection, coding, transfer, or
analysis. Examples of random error include: poorly worded questions, a misunderstanding in
interpreting an individual answer from a particular respondent, or a typographical error during
coding. Random error affects measurement in a transient, inconsistent manner and it is
impossible to correct for random error.
There is random error in all sampling procedures. This is called sampling error.
Precision in epidemiological variables is a measure of random error. Precision is also inversely

related to random error, so that to reduce random error is to increase precision. Confidence
intervals are computed to demonstrate the precision of relative risk estimates. The narrower the
confidence interval, the more precise the relative risk estimate.
There are two basic ways to reduce random error in an epidemiological study. The first is to
increase the sample size of the study. In other words, add more subjects to your study. The
second is to reduce the variability in measurement in the study. This might be accomplished by
using a more precise measuring device or by increasing the number of measurements.
Note, that if sample size or number of measurements are increased, or a more precise measuring
tool is purchased, the costs of the study are usually increased. There is usually an uneasy balance
between the need for adequate precision and the practical issue of study cost.
Systematic error: A systematic error or bias occurs when there is a difference between the true value
(in the population) and the observed value (in the study) from any cause other than sampling variability.
An example of systematic error is if, unknown to you, the pulse oximeter you are using is set incorrectly
and adds two points to the true value each time a measurement is taken. The measuring device could be
precise but not accurate. Because the error happens in every instance, it is systematic. Conclusions you
draw based on that data will still be incorrect. But the error can be reproduced in the future (e.g., by using
the same mis-set instrument).
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A mistake in coding that affects all responses for that particular question is another example of a
systematic error.
The validity of a study is dependent on the degree of systematic error. Validity is usually
separated into two components:
1. Internal validity is dependent on the amount of error in measurements, including

exposure, disease, and the associations between these variables. Good internal validity
implies a lack of error in measurement and suggests that inferences may be drawn at least
as they pertain to the subjects under study.
2. External validity pertains to the process of generalizing the findings of the study to the
population from which the sample was drawn (or even beyond that population to a more universal
statement). This requires an understanding of which conditions are relevant (or irrelevant) to the
generalization. Internal validity is clearly a prerequisite for external validity.
Three types of bias:

Selection bias: Selection is one of three types of bias that can threaten the validity of a study.
Selection bias occurs when study subjects are selected or become part of the study as a result of a
third, unmeasured variable which is associated with both the exposure and outcome of interest.
For instance, it has repeatedly been noted that cigarette smokers and non smokers tend to differ
in their study participation rates. (Sackett D cites the example of Seltzer et al., in which 85% of
non smokers and 67% of smokers returned mailed questionnaires). It is important to note that
such a difference in response will not lead to bias if it is not also associated with a systematic
difference in outcome between the two response groups.
Information bias: Information bias is bias arising from systematic error in the assessment of a
variable. An example of this is recall bias. A typical example is again provided by Sackett in his
discussion of a study examining the effect of specific exposures on fetal health: "in questioning
mothers whose recent pregnancies had ended in fetal death or malformation (cases) and a
matched group of mothers whose pregnancies ended normally (controls) it was found that 28%
of the former, but only 20% of the latter, reported exposure to drugs which could not be
substantiated either in earlier prospective interviews or in other health records". In this example,
recall bias probably occurred as a result of women who had had miscarriages having an apparent
tendency to better recall and therefore report previous exposures.
Confounding: Confounding has traditionally been defined as bias arising from the co-
occurrence or mixing of effects of extraneous factors, referred to as confounders, with the main
effect(s) of interest. A more recent definition of confounding invokes the notion of
counterfactual effects. According to this view, when one observes an outcome of interest, say
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Y=1 (as opposed to Y=0), in a given population A which is entirely exposed (i.e. exposure X = 1
for every unit of the population) the risk of this event will be RA1. The counterfactual or
unobserved risk RA0 corresponds to the risk which would have been observed if these same
individuals had been unexposed (i.e. X = 0 for every unit of the population). The true effect of
exposure therefore is: RA1 − RA0 (if one is interested in risk differences) or RA1/RA0 (if one is
interested in relative risk). Since the counterfactual risk RA0 is unobservable we approximate it
using a second population B and we actually measure the following relations: RA1 − RB0 or
RA1/RB0. In this situation, confounding occurs when RA0 ≠ RB0. (NB: Example assumes binary
outcome and exposure variables.)
Some epidemiologists prefer to think of confounding separately from common categorizations of

bias since, unlike selection and information bias, confounding stems from real causal effects
Broadly speaking there are two main types of epidemiological study:
1. Observational study.
2. Experimental study.
Observational Studies:
a. In an observational setting the epidemiologist is not able to control conditions.
b. Observational studies allow nature to take its own course.
c. Observational study involves the following approaches or studies:
i. Descriptive studies,
ii. Analytical studies,
iii. Ecological or correlation studies used in studying populations.
iv. Cross-sectional studies or prevalence studies used in individuals,
v. Case control or case-reference studies used in individuals,
vi. Cohort or follow-up studies used in studying individuals ‘
vii. Evaluative studies used in studying the efficacy of health delivery services.
viii. Observational prospective studies,
ix. Observational retrospective studies,

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1. Descriptive Observational Studies: Descriptive observational studies are carried
out to determine:
a) The frequency of a disease,
b) The kind of people who suffer from it and
c) Where and when it occurs.
Information would be obtained about the patient’s age, sex, where and when the patient
developed the disease.
Since such information can only be obtained from hospital records, the patients are only
characterized in terms of data in the case – notes. i.e. :
a) Age,
b) Sex,
c) marital status,
d) occupation, and
e) Place of residence and/work.
f) Geographical distribution of a disease and any variations in its occurrence at different

time of the year can only be deduced from the addresses that patient recorded during
admission.
More specific information can be obtained through interviews and examination of the patients.
Descriptive studies seek to characterize people who are affected by a disease and relate
observation obtained from them to the general population.
Descriptive observational studies comprise:
1. Observation made at one point in time [cross-sectional observational study] or
2. Longitudinal in which observations are repeated in the same community over a

prolonged period of time.
Descriptive observational studies are also indicated to understand:
a) The relationship between the environment and organism,
69

b) The disease agent and the vectors and
c) Geographical location of the vectors,
d) Age, and sex relationship and the frequency to the site.
In descriptive observational studies, it is usual to define study population and make observation
on a sample taken from it. The study population in descriptive observational study is commonly
defined by:
a) Geographical location,
b) Age,
c) Sex,
d) Occupation and
e) Ethnic groups.
2. Analytical Studies: These are carried to test the hypothesis about the influence which
determines that one person is infected by a disease and other is not. They are designed to
show whether particular events or states act as causes whose effects are the resulting
disease i.e. the relationship between di et and pellagra.
For example:
a) Comparing people with disorder and normal people show that the determinant occurs
more frequently in some people with the disorder than those without it [among a
group of people with pellagra, there will be a greater proportion of individuals eating
maize diet than there will be among a comparable group not affected by the disease.
b) Comparing people exposed to the determinant and those not among the exposed show
that a greater proportion of people develop the disease among the exposed group than
among the non-exposed.
N/B: Population A=maize diet=more pellagra.
Population B=meat and vegetable=less pellagra.
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In practice, practice analytical [Not representative of a group, class, or type] observational
studies are not carried out on groups of patients who are atypical of all patients with the disorder
unless there is a special indication to do this.
The most important characteristics of a study cohort are:
1. It should include the individuals exposed to the determinant being investigated.
2. It should comprise a group of people who can be followed up for a period of time
between exposure to the determinant and development of the disorder. If a reasonable
proportion of persons in the cohort cannot be followed, the outcome will be biased
because those untraced are likely to be different from the others making available
proportion not to be representative of the initial cohort.
3. Ecological [Correlational] Observational Studies: In these studies, the units of analysis

are populations or groups of people rather than individuals e.g. sale of anti – asthma
drugs and occurrence of high number of asthma deaths. Ecological studies usually rely on
data collected for other purposes.
4. Cross-sectional [prevalence] Observational Studies: these are studies which compare

the characteristics of a person with the disease [cases] with persons without disease
[controls] to find out when the suspected determinant [a determining or causal element
disease.ent or factor] occurs more frequently among persons with the disease. They
attempt to examine and compare estimates of disease prevalence between various
populations and subsets of populations at a particular point in time. They measure the
prevalence of diseases and are often called prevalence studies. In cross-sectional studies,
the measurements of exposure and effect are made at the same time. The key question to
be asked is whether the exposure precedes or follows the effect. If the exposure data are
known to represents exposure before any effect occurred, the date analysis can be
approached in a similar way as in cohort studies. The format for conducting cross-
sectional study is similar to that of conducting retrospective study. The difference is,
while retrospective relies on past information to determine the cause of the disease, cross-
sectional relies on instantaneous information to determine the cause of the disease. For
example, in determining the relationship between cerebra-vascular disease [stroke] and
the level of serum cholesterol, a group of cases and appropriate controls are selected and
blood taken from them to determine their serum cholesterol levels. If the levels are
71

significantly higher among the cases than controls, statistical association is said to exist
between stroke and elevated serum cholesterol levels.
NB: In cross-sectional approach, there is no way of determining whether the elevated serum
cholesterol levels preceded stroke or followed.
Advantages of Cross-Sectional [prevalence] Observational Studies: These are:
i. It is relatively easy to conduct and economical.
ii. They are used for investigating exposure to fix characteristics of individuals such as
ethnicity, socio-economical status and blood group.
5. Case - Control [reference] Observational Studies: These are used to study causes of
diseases especially rare diseases:
a) They include people with a disease [or other out-come variable] of interest and a suitable
control group [or comparison or reference group] of people unaffected by the disease or
outcome variable.
b) The occurrence of the possible cause is compared with cases and control.
c) Case - control Observational studies are thus longitudinal. They have also been called
retrospective studies since the investigator looks backwards from the disease to the
possible cause.
d) Case - control Observational studies begin with the selection of cases which should
represent all cases from a specified population.
e) Then the selection of controls so as to sample the exposure prevalence in the population
that generated cases.
f) The controls should represent people who would have designated cases if they had
developed the disease.
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g) Case-control Observational studies use new [incident] cases.
h) In case-control Observational study design, the exposure status of cases is usually

determined after the development of the disease [retrospective data] and usually by direct
questioning of the affected persons or relative or friend.
Distinguishing Case-Control from Cohort Studies

1. To test the hypothesis that smoking is associated with lung cancer using a case-control
study you would begin with a group of patients with lung cancer [cases] and a group of
patients without lung cancer [controls]. You would then retrospectively determine the
number of smokers in both cases and control groups.
2. To test your hypothesis that smoking is associated with a cohort of persons who are either
smokers or non-smokers. You would then follow this cohort prospectively to determine
how many smokers and non-smokers eventually develop cancer.
Advantages of Case-Control [Retrospective] Studies:
1. Study design guaranteed the number of persons with the disease because we begin the
study by selecting a group of cases.
2. Study takes a short time compared with the cohorts which takes years.
3. Simple to carry out.
4. Relatively cheap.
Disadvantages of Case-Controls Studies: These are:
1. It is difficult to select the proper controls.
2. Determining exposure will often rely on the memory of the persons in the study and may
be biased by knowing whether the person is a case or control.
3. It is not easy to be certain that exposure to the determinant occurred before the disease
manifested itself.
4. Persons die as a result of disease caused by the determinant may not be known to the
study.
DESIGN OF CASE-CONTROL STUDY

73

Time
Direction of inquiry
Exposed
Cases
Not Exposed
Population
Exposed Controls
Not Exposed
Cohort Observational Studies: Compares over a period of time the characteristics of persons
exposed to the determinant [controls] to find out whether a greater proportion of those exposed
to the determinant develop the disease and those who are not exposed. These studies begin with
the identification of a group of people who are exposed to the suspected determinant. It is
defined as a group of people sharing a common experience. The study comprises observation of
two groups of people, one exposed to a suspected determinant for a period of time and the other
not. The two types of studies give answers to two different questions:
Forcep delivery (a)
Case- control Epilepsy
Normal delivery (c)
If the proportion (a) of epileptic children with forceps delivery
Foeceps delivery (b)
74

Case-control No epilepsy
No
rmal delivery (d)
Advantages of Cohort [Prospective] Studies: These are:
They provide direct estimate of the relative risk [the probability of the event occurring in the
exposed group verses a non-exposed group or the risk of developing a disease relative to
exposure] of out-come associated with a particular exposure or factor compared with case-
control studies in which only indirect estimate of relative risk- the odds ratio.
Relative risk [RR] = People [exposed]
People [non-exposed]
Example: probability of developing lung cancer among smokers was 20% and among non-
smokers 1%.
This situation is expressed in the 2x2 table below.
Disease status
Risk Present Absent
Smoker a b
Non- c d
Smoker
Where: a=20
b=80
c=1
d=99
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Disease status
Risk Present Absent
Smoker 20 80
Non- 1 99
Smoker
Relative risk associated with smoking would be:
RR= a/ (a+b) = 20/100
c/(c+d) = 1/100
= 20/(20+80) =20/100 = 20
1/ (1+99) = 1/100
Smokers would be 20 times as likely to develop lung cancer.
Another form of relative risk is the risk ratio because it is the risk in the exposed divided by the
risk in the non-exposed.
Disadvantages of Cohort Studies
1. If the disease in question is relatively rare, then this approach may require large
populations and long time and thus would also be expensive.
2. Participation in the study may influence the relationship between the determinant and
development of disease.
3. Problems may be created by people who drop out of the study.
4. We can be certain that the exposure or determinant was present before the disease out-
come, and we can also note changes in exposure with time. More than one outcome can
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be studied, whereas in case-control studies, the groups are defined by a single disease
out-break.
Prospective Observational Studies, which look forward over a period of time and normally
attempt to examine associations between determinants and the frequency of occurrence of a
disease by comparing attack rates or incidences of diseases in groups of individuals in which the
determinant is either present or absent, or its frequency of occurrence varies.
Prospective observational study involves:
1. Selection of individuals based upon exposure to an agent or causal factor.
2. A sample of the population is selected and information obtained to determine which

persons either has a particular characteristics such as certain living habit or physiological
trait that is suspected of being investigated or have been exposed to a possible etiological
agent.
3. The individuals are then followed up to a period of time to observe who develops and /or
dies from that disease.
4. Incidences or death rates are then calculated and the rates are compared for those with the
characteristics of interest and those without it. If the rates are different either relatively or
absolute an association is referred or is said to be existing between the characteristic and
the disease.
The characteristics observed in the study group are:
1. Age,
2. Sex,
3. color, and
4. Occupation.
The above characteristics are in addition to the specific characteristics of interest in order to be
able to account for an influence of factors that are known to be related to the disease.
Prospective observational study has been described by a variety of terms:
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1. Cohort,
2. Incidence,
3. Longitudinal,
4. Forward looking,
5. Follow-up,
Types of Prospective Observational Studies:
a. Concurrent [Occurring or operating at the same time]which involves:
i. The general population samples and
ii. Selection of the population.
b. Non-concurrent which involves:
i. Population censure taken in the past and
ii. Selecting groups of the population.
At times the investigator uses census results of the community which was conducted in the past.
Samples of the population covered by the census can be selected and be traced from the time of
the census.
Non-concurrent prospective observational studies usually involves specially exposed groups or

industrial populations because of unavailability of such past census information and
unavailability of employment, medical or other types of records.
Non-concurrent prospective observational study of industrial exposure to a possible etiological

agent of a disease can only be carried out by using the past company records of present
employees which include information on the date of their employment, age at hiring and whether
they are living or dead
A major source of carrying out a non-concurrent prospective observational study is maintenance

of tracing up selected persons.
This is least troublesome in concurrent prospective observational study because at the very
beginning of the study methods can be adopted for keeping contact with the population i.e.
i. Periodic home visit.
ii. Telephone calls.

78

iii. Mailed questionnaire.
These can be done on annual basis.
The names and addresses of several friends and relatives can be obtained at the beginning of the
study so that they may be contacted if the person moves out of the area.
Diagrammatic Presentation of Concurrent and Non-Concurrent Prospective

Observational Studies
NON-CONCURRENT CONCURRENT
In 1980, select exposed and non-exposed groups. In 1980, select exposed and non-exposed
Trace them for a number of years. Groups and follow them for a number of years.
Trace the groups by various Follow the groups by various means
means from 1950 to 1980 from 1980 to desired period.
1950 1980
Advantages of Prospective study: These are:
1. They provide direct estimate of risk of developing diseases in individuals with specific
characteristics relative to those without the characteristics.
2. If the criteria and procedure of the study are established in advance, they decrease the
possibility of subjective bias in obtaining necessary information.
3. In prospective study, one starts with individuals who have the characteristics under study.
4. Depending on the disease, and characteristics under study one can obtain information on
people whose status have changed with regard to the characteristics.
5. Information can be obtained on the relationship of the characteristics to the disease.
Disadvantage of Prospective Observational Study: These are:
1. The study is usually more difficult and expensive to execute requiring large study
populations and long periods of observations for definite results.
2. In prospective study involving periodic examination of people, it is possible that

participation in the study may influence the development of disease in individuals. For
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example, participants in a study of diet and heart disease may voluntary change their
dietary habits simply because of their participation in the study.
NB: Prospective study cannot be used in studying a rare disease.
Retrospective Observational Study [case history]: which look backward over a period of time
and normally attempt to compare the frequency of occurrence of a determinant in groups of
diseases and non-diseased individuals.
In retrospective study, comparison is made between groups of persons without the disease
[control groups] and persons with disease [cases]. In the retrospective studies, the proportion of
cases [those with necessary characteristics of interest or causal factor] is compared to the
corresponding proportion of persons in the control group.
If higher frequency of individuals with characteristics of interest is found among the cases that
controls then an association between cases and the characteristics can be referred. For example,
in a retrospective study one would see information on the level of serum cholesterol that was
present before the onset of stroke. If statistical association is established a casual association can
be inferred with greater confidence.
Disadvantage of Retrospective Studies: These are:
1. Retrospective studies, the statement of relative risk is direct. Estimating the developing of
disease is not possible.
2. In retrospective studies, only one disease is selected for a study as opposed to prospective
study where a whole spectrum of the exposed can be studied.
3. In retrospective study one has to depend on the individual’s memory for information on
the occurrence of an event or on availability of records.
4. Even the best designed retrospective study is limited to individuals who have survived for
a period of time after exposure to possible etiological agent or event.
5. During the period of the initial event and the occurrence of the disease at which time
retrospective study is conducted some individuals in the groups will have died. If the
characteristic or exposure under study is related to mortality, the deaths that occurred
during the interval will not be presented in the groups selected for retrospective study.
This may result into underestimating the degree of association between the characteristic
under study and the disease which would not occur in prospective study.
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DISTINCTION BETWEEN PROSPECTIVE AND RETROSPECTIVE STUDIES
PROSPECTIVE STUDY RETROSPECTIVE STUDY
Etiological characteristics or exposure Diseased groups [cases]

[exposed or cases]
Non-exposed or controls Non-diseased groups [controls]
EPIDEMIOLOGIC STUDY
CONTROLED UN CONTROLED
ASSIGNMENT ASSIGNMENT
NOT RANDOMZED
EXPERIMENTAL STUDIES
OBSERVATIONAL STUDIES
NOT RANDOMIZED
RANDOMIZED ASSIGNMENT SAMPLING WITH REGARD SAMPLING UNITS IN REGARD TO
TO DISEASE OR EFFECT EXPOSURE, CHARACTERISTICS OR CAUSE
PROSPECTIVE STUDY
CLINICAL
COMMUNITY TRIALS TRIALS CROSS-SECTIONAL OR
RETROSPECTIVE STUDY
HISTORY OF EXPOSURE OR
CHARACTERISTIC [PRIOR TO TIME
OF STUDY]
EXPOSURE OR
CHARACTERISTIC AT
RETROSPECTIVE STUDY
TIME OF STUDY
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CROSS-SECTIONAL STUDY
Experimental Studies: Under experimental studies there are:
i. Randomized controlled trials [clinical trials] used in studying patients,
ii. Field trials used in studying healthy people,
iii. Community trials [community intervention or diagnosis] used in studying

communities.
The strength of the experimental study method lies in the investigator’s direct control over the
assignment of individuals in the study groups.
In observational studies by contrast, the investigator accepts the conditions as they are.
Broadly considered are two types of epidemiologic experiments:
1. Clinical trials
2. Community trials or field experiments.
Clinical Trials: In clinical trials, the efficacy of a preventive or therapeutic agent or procedure
is tested in individual subjects. These are methods that are used to evaluate the efficacy of
treatment of a disease. They are also used to evaluate a prophylactic agent such as vaccine or
public health procedure such as screening methods. The clinical trial is an experiment in which
individuals are randomly allocated to two groups known as experimental and control groups.
The experimental group is given the drug being tested and the control group is given the drug in
use or a placebo [sugar pill or saline injection in absence of current drug].
Randomization: the major difference between a clinical trial and a prospective study is the
randomization nature of of clinical trial. The experiment and control groups must compare in all
factors except in what is being studied – the drug. For example, if in randomized control trial a
drug successfully lowers serum cholesterol levels and intern reduces the incidence of coronary
heart disease , not only has the utility of the drug being demonstrated but also a strong link has
been added to the chain of evidence showing a causal relationship between elevated serum
cholesterol levels and heart disease.
Factors used to compare Experimental and Control Groups: These are:
1. Age,
2. Sex,
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3. Race.
One cannot match individuals for factors whose influence are not known.
Those problems can be resolved by the random allocation of individuals to the experimental and
control groups which ensure the comparability of these groups with respect to these factors –
known and unknown, measurable and immeasurable except for the drug being studied.
In addition, randomization is the means by which the investigator avoids introducing conscious
or sub-conscious bias into the process of allocating a degree of comparability to all other things
being equal.
Types of Clinical Trials: These are:
1. Therapeutic trials: in these trials, therapeutic agent /procedure are given/used in an

attempt to relieve symptoms and or improve survivorship of those with the disease. if in
therapeutic trial, the therapeutic agent success successfully relieve the symptoms of
disease or increases the survivorship of those with disease, then the agent may be used to
treat the disease.
2. Intervention trials: in these trials the investigator intervenes before the disease develops
in individuals with a characteristic that increases their risk of developing the disease.
Intervention trials are used to reduce the risk factors by intervention.
3. Preventive [prophylactic] trials: in this trial all attempts are made to determine the
efficacy of preventive agent/procedure.
4. Seization: Experiment: this experiment is used to evaluate the termination of living

habits considered to be of etiological importance. To confirm the association between
cigarette smoking and lung cancer, one would select a group of smokers and randomly
allocate them to two groups. The first group continues with cigarette smoking and the
second group stops/seizes smoking. If lung cancer mortality in the second group is lower
than in the first group, causal implication is obvious.
The testing of preventive agent can be illustrated by a vaccine or a given disease or some form of
chemoprophylaxis such as Isoniazid for TB. If randomized clinical trial shows that the vaccine
83

[chemo prophylactic agent] lowers the incident of disease, then that vaccine or agent may be
used as a preventive measure against the disease.
TYPES AND EXAMPLES OF CLINICAL TRIALS
TYPE EXAMPLES
Therapeutic trials o Lesser treatment for diabetic

retinopathy.
o Simple mastectomy for breast

cancer.
Intervention trials o Anti-hypertensive drugs which

reduces the risk of developing
stroke.
o Physical exercise for decreasing the

risk of myocardial infarction.
Preventive trials o BCG vaccination for TB.
o Ionized drugs for preventing TB.
SELECTION OF STUDY GROUPS
At the beginning of a clinical trial, a decision regarding the characteristics of a population

[reference population] to be studied must be made e.g. age, sex, disease characteristics, etc
making the population eligible for inclusion in the experiment.
In brief, the investigator selects a reference target population that may be composed of people
suffering from a certain disease [a set of characteristics related to the disease / persons in a
specific age group, geographical area or occupations that would suggest their inclusion in the
study.
The type of reference population selected depends on the purpose of the study as well as the
difficulties in reaching the individuals. Once a target population has been selected, the
participants in the trial must be recruited. Several strategies are involved but can generally be
classified into:
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1. Accrual [accumulative] strategy: where the subjects needed for trial are recruited
during the course of the study.
2. Non-accrual strategy: where the subjects needed for trial are recruited before the study
begins.
HISTORICAL CONTROLS
Historical controls are selected from patients who have been treated in the past so that their out-
come may be compared with that of patients using new method. The term is also used to decide a
group of patients using drugs and compared to a much broader group prior to the experiment to
the standard form of treatment. In this method there is no allocation of treatment and control
groups. Such comparison is normally used if prior experience with a disease indicates that the
standard method of treatment had resulted into very high case fatality rates such as 95%. This
was the case with procaine penicillin. Before its introduction, the case fatality rate from some
infections was 100% and this was sharply reduced when the infections were treated with
procaine penicillin.
Problems Experienced in These Studies:
1. Volunteers: in many studies only volunteers can be used. This limits the reference that
can be derived from the results.
2. Refusal to continue [withdrawals]: in any follow-up study, there are those who at one
point withdraw from the study.
3. Lost to follow-up: there are those who die during the study.
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OUT-LINE OF RANDIZED CLINICAL TRIAL
REFERENCE POPULATION
EXPERIMENTAL POPULATION
PARTICIPANTS
NON-PARTICIPANTS
RANDOM ALLOCATION OF TREAMENT FOR

STUDY AND CONTROL GROUPS
FOLLOED-UP
TREATMENT FOR
CONTROL GROUP
STUDY GROUP
TREATED REFUSED
FOLLOWED-UP TREATMENT
OUT-COME OUT-COME OUT-COME OUT-COME OUT-COME OUT-COME

KNOWN KNOWN KNOWN KNOWN KNOWN KNOWN
86
OUT-COME OUT-COME
KNOWN KNOWN
ETHICAL CONSIDERATION
Clinical trials are similar to observation studies in many ways; however, because of random
allocation of subjects of the experimental and control groups, certain ethical questions arise
naturally. It is important therefore that before a trial can be carried out:
1. The consent of the subjects must be obtained.
2. It is also important that the subject must be informed that they may be assigned to either
the experimental or control groups.
Consent: Consent is the agreement of the volunteer to participate in the protocol. It involves
more than a signature or agreement to sign a form obtained BEFORE any study specific
procedures are done.
Informed Consent:
i. The volunteer is provided with all available information about the trial.
ii. The volunteer demonstrates understanding.
iii. The volunteer agrees to participate in the study.
If the subject, though provided with this information still decides to participate in the study then
they are said to have given their “informed consent.” Such concerns should be obtained in
accordance with the regulations of government agencies or of the institution where the trial is to
be conducted. The following are the ethical consideration in clinical trial.
1. Is the proposed treatment safe [unlikely to bring harm to] for the patient?
2. For the sake of controlled trials can the treatment ethically be withheld from any patient
in doctor’s case?
3. Which patient may be brought into controlled trial and allocated randomly to any of the
different treatments?
4. Is it ethical to use placebo [Anything of no direct medical benefit which nevertheless

makes people feel better or benefit psychologically] or dummy treatment?
5. Is it proper for the trial to be in any way blind?
Consent Process: This is a series of steps over time:

87

1. Provide information
2. Allow adequate time
3. Assess comprehension
4. Address other influences of their decision
5. Obtain their decision or consent
Informed Consent Document: This document contains the following:
1. Research
2. Purpose
3. Assignment
4. Trial procedures
5. Duration
6. Confidentiality
7. New findings
8. Contact information
9. Termination of participation
10. Risks
11. Benefits
12. Alternatives
13. Compensation
14. Experimental aspects
15. Anticipated expenses
16. Voluntary participation
17. Access to records
18. Number of volunteers.
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19. Volunteer responsibilities.
GENERAL PLAN OF A CLINICAL TRIAL
The plan of a clinical trial is formerly stated in protocol [A procedure for how an activity should
be performed] which contains the objectives and specific procedure to be used in the trial. It
must be written before the trial starts and should contain such information as the methods of
selecting the study groups and details for the performance of any laboratory tests. During the
trial, if any question arises because of a given contingency, the protocol is referred to as the
guide for what the investigator is to do.
GENERAL OUT-LINE OF A PROTOCOL FOR CLINICAL TRIAL
1. Rational background of the study.
2. Specific objectives of the study.
3. Concise [Expressing much in few words] statement of the study design [masking,
randomization schemes, types and duration of treatment and number of patients].
4. Criterion [A basis for comparison; a reference point against which other things can be
evaluated] for inclusion and exclusion of subjects.
5. Out-line of treatment procedures.
6. Definition of clinical, laboratory etc methods.
7. Methods of assuring the integrity [An undivided or unbroken completeness or totality

with nothing wanting] of data.
8. Major and minor points [death, myocardial infarction]
9. Provision of observing and recording side effects.
10. Procedure of handling problems/cases.
11. Procedure of obtaining informed consent from the subjects.
12. Procedure of analyzing data.
13. Appendices.
COMMUNITY TRIALS
These are experiments/trials or field trials that involve communities as wholes, whether in
animals or humans. They are used to determine the efficacy of a drug or a procedure.
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In community trials, a group as a whole is collectively studied, while in a clinical trial, it is the
individual within the group [the experimental or control group] that is studied.
Studies in which epidemics are experimentally produced in groups of animals are also called
community trials.
HUMAN TRIAL
Human trials have been conducted when particular circumstances require that community as a
whole serve as experimental unit with regard to testing specific etiological hypothesis or a
preventive procedure. The very nature of such trials does not usually allow for the use of
randomization. An example of this type of trial is the introduction of fluoride into community
water supply in order to determine whether it would decrease frequency of dental carriers.
UNIT 7
LEVELS OF DISEASE PREVENTION
Levels of preventions are subdivided into three categories:

1. Primary,
2. Secondary and
3. Tertiary level.
1. First is the Primary level of prevention. It is the most basic and the most
desirable form of prevention since it primarily focuses on the avoidance of the
occurrence of a problem. It provides specific protection against diseases. Primary
preventive actions spare the client from the costs, discomforts and threats to the
quality of life that an illness may cause. It aims to prevent the disease from
occurring. So primary prevention reduces both the incidence and prevalence of a
disease. Encouraging people to protect themselves from the sun's ultraviolet rays
is an example of primary prevention of skin cancer. Primary prevention methods
are used before the person gets the disease.
2. The Secondary level of prevention is where the actual problem has already
occurred. Its focus is on the early diagnosis and treatment of the disease to at least
prevent, delay, or stop further complications, thus limiting disability. Secondary
prevention is used:
i. After the disease has occurred, but
ii. Before the person notices that anything is wrong.
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A doctor checking for suspicious skin growths is an example of secondary prevention of skin
cancer. The goal of secondary prevention is to find and treat disease early. In many cases, the
disease can be cured.
Secondary preventive measures can be delivered in hospitals, homes and other secondary
facilities. It comprises diagnostic screening programs, public education to promote self
examinations to be able to recognize early signs and symptoms of certain diseases.
3. The Tertiary level of prevention begins early in the period of the client's recovery from
illness. It occurs when a disease or disability is present or is permanent and irreversible. It
focuses more on the rehabilitation to either restore or maximize an individual to an
optimal level of functioning as well helping the individual learn to cope and live
productively even with the presence of certain limitations. The tertiary level which
focuses more on the rehabilitation includes strict compliance of giving medications,
moving and positioning to prevent complications, passive/active exercises, and
continuing health supervision during rehabilitation. So Tertiary prevention targets the
person who already has symptoms of the disease.
The goals of tertiary prevention are:
1. Prevent damage and pain from the disease

2. Slow down the disease
3. Prevent the disease from causing other problems (These are called "complications.")
4. Give better care to people with the disease
5. Make people with the disease healthy again and able to do what they used to do.
The three levels of prevention each have corresponding health programs:

As for the primary level of intervention, Primary preventive measures would include:
1. Educating,
2. Counseling,
3. Lifestyle modifications,
4. Health education programs for communities,
5. Wellness and fitness programs,
6. Mandatory immunization for children,
7. Environmental sanitation activities,
8. The adoption other specific health practices and other programs geared towards
the safety and wellness of the community.
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Universal, selective, and indicated
.
Level Definition
Primary Methods to avoid occurrence of disease. Most population-based health promotion efforts
prevention are type.
Secondary Methods to diagnose and treat existent disease in early stages before it causes significant
prevention morbidity.
Tertiary Methods to reduce negative impact of existent disease by restoring function and reducing
prevention disease-related complications.
Tier Definition
Involves whole population (nation, local community, school, district) and aims to prevent or
Universal
delay the abuse of alcohol, tobacco, and other drugs. All individuals, without screening, are
prevention
provided with information and skills needed to prevent the problem.
Involves groups whose risk of developing problems of alcohol abuse or dependence is above
Selective
average. Subgroups may be distinguished by traits such as age, gender, family history, or
prevention
economic status. For example, drug campaigns in recreational settings.
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Involves a screening process, and aims to identify individuals who exhibit early signs of
Indicated substance abuse and other problem behaviours. Identifiers may include falling grades
prevention among students, known problem consumption or conduct disorders, alienation from
parents, school, and positive peer groups etc.
UNIT 8
DISEASE SURVEILANCE
Public health surveillance: Public health surveillance is the continuous, systematic

collection, analysis and interpretation of health-related data needed for the planning,
implementation, and evaluation of public health practice. Such surveillance can:
1. Serve as an early warning system for impending public health emergencies;

2. Document the impact of an intervention, or track progress towards specified goals; and
3. Monitor and clarify the epidemiology of health problems, to allow priorities to be set and
to inform public health policy and strategies.
The concept of workplace health surveillance is new to occupational safety and health and is
frequently confused with medical screening. Health screening refers to the early detection and
treatment of diseases associated with particular occupations, while workplace health surveillance
refers to the removal of the causative factors.
NIOSH defines occupational health surveillance as “the tracking of occupational injuries,

illnesses, hazards, and exposures.” The Joint ILO/WHO Committee on Occupational Health at
its 12th Session in 1995 defined an occupational health surveillance system as “a system which
includes a functional capacity for data collection, analysis and dissemination linked to
occupational health programmes”
Public health surveillance is the ongoing systematic collection, analysis, and interpretation of
data, closely integrated with the timely dissemination of these data to those responsible for
preventing and controlling disease and injury (Thacker and Berkelman 1988). Public health
surveillance is a tool to estimate the health status and behavior of the populations served by
ministries of health, ministries of finance, and donors. Because surveillance can directly measure
what is going on in the population, it is useful both for measuring the need for interventions and
for directly measuring the effects of interventions. The purpose of surveillance is to empower
decision makers to lead and manage more effectively by providing timely, useful evidence.
Increasingly, top managers in ministries of health and finance in developing countries and donor
agencies are recognizing that data from effective surveillance systems are useful for targeting
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resources and evaluating programs. The HIV and severe acute respiratory syndrome (SARS)
epidemics underscored the critical role of surveillance in protecting individual nations and the
global community. For example, in 2005, China rapidly began to expand its surveillance and
response capacity through its Field Epidemiology Training Program (FETP); Brazil and
Argentina chose to use World Bank loans to develop surveillance capacity; and the U.S. Agency
for International Development (USAID) redesigned its surveillance strategy to focus on the use
of data to improve public health interventions (USAID 2005). Additionally, the guidelines for
implementing the 2004 draft revised International Health Regulations require World Health
Organization (WHO) member states to have key persons and core capacities in surveillance.
Just as decision makers require competent, motivated economists to provide quality technical
analyses, they also need competent staff members to provide scientifically valid surveillance
information and communicate the results as information for action. Competent epidemiologists
and surveillance staff members are not a luxury in developing countries; they are a necessity for
rational planning, implementation, and intervention.
Definitions and Basic Concepts of Terms Used in Public Health Surveillance
1. Indicator: a measurable factor that allows decision makers to estimate objectively the size of a
health problem and monitor the processes, the products, or the effects of an intervention on the
population (for example, the number of new cases of diarrhea, the proportion of children fully
immunized in a district, or the percentage of high school students who report that they smoke at
least one cigarette a day).
2. Active surveillance: a system employing staff members to regularly contact heath care providers
or the population to seek information about health conditions. Active surveillance provides the
most accurate and timely information, but it is also expensive.
3. Passive surveillance: a system by which a health jurisdiction receives reports submitted from
hospitals, clinics, public health units, or other sources. Passive surveillance is a relatively
inexpensive strategy to cover large areas, and it provides critical information for monitoring a
community's health. However, because passive surveillance depends on people in different
institutions to provide data, data quality and timeliness are difficult to control.
4. Routine health information system: a passive system in which regular reports about diseases
and programs are completed by public health staff members, hospitals, and clinics.
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5. Health information and management system: a passive system by which routine reports about
financial, logistic, and other processes involved in the administration of the public health and
clinical systems can be used for surveillance.
6. Categorical surveillance: an active or passive system that focuses on one or more diseases or
behaviors of interest to an intervention program. These systems are useful for program managers.
However, they may be inefficient at the district or local level, at which staff may need to fill out
multiple forms on the same patient (that is, the HIV program, the tuberculosis program, the
sexually transmitted infections program, and the Routine Health Information System). At higher
levels, allocating the few competent surveillance experts to one program may leave other
programs under-served, and reconciling the results of different systems to establish the nation's
official estimates may be difficult.
7. Integrated surveillance: a combination of active and passive systems using a single

infrastructure that gathers information about multiple diseases or behaviors of interest to several
intervention programs (for example, a health facility–based system may gather information on
multiple infectious diseases and injuries). Managers of disease-specific programs may be
evaluated on the results of the integrated system and should be stakeholders. Even when an
integrated system is functioning well, program managers may continue to maintain categorical
systems to collect additional disease-specific data and control the quality of the information on
which they are evaluated. This practice may lead to duplication and inefficiency.
8. Syndromic surveillance: an active or passive system that uses case definitions that are based
entirely on clinical features without any clinical or laboratory diagnosis (for example, collecting
the number of cases of diarrhea rather than cases of cholera, or "rash illness" rather than measles).
Because syndromic surveillance is inexpensive and is faster than systems that require laboratory
confirmation, it is often the first kind of surveillance begun in a developing country. However,
because of the lack of specificity (for example, a "rash illness" could be anything from the
relatively minor rubella to devastating hemorrhagic fevers), reports require more investigation
from higher levels. Also an increase in one disease causing a syndrome may mask an epidemic of
another (for example, rotavirus diarrhea decreases at the same time cholera increases).
9. In the specialized area of surveillance for biologic terrorism, syndromic surveillance

refers to active surveillance of syndromes that may be caused by potential agents used by
biologic terrorists and sometimes refers to alternative measures such as increases in the
use of over-the-counter drugs or increases in calls to emergency departments.
10. Behavioral risk factor surveillance system (BRFSS): an active system of repeated surveys that
measure behaviors that are known to cause disease or injury (for example, tobacco or alcohol use,
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unprotected sex, or lack of physical exercise). Because the aim of many intervention program
strategies is to prevent disease by preventing unhealthy behavior, these surveys provide a direct
measure of their effect in the population, often long before the anticipated health effects are
expected. These surveys are useful for providing timely measures of program effectiveness for
both communicable and non-communicable disease interventions.
Objectives of Surveillance Systems: Public health surveillance provides the scientific and factual
database essential to informed decision making and appropriate public health action. The key objective of
surveillance is to provide information to guide interventions. The public health objectives and actions
needed to make successful interventions determine the design and implementation of surveillance
systems. For example, if the objective is to prevent the spread of epidemics of acute infectious diseases,
such as SARS, managers need to intervene quickly to stop the spread of disease. Therefore, they need a
surveillance system that provides rapid early warning information from clinics and laboratories. In
contrast, chronic diseases and health-related behaviors change slowly. Managers typically monitor the
effect of programs to change risky behaviors such as tobacco smoking or chronic diseases once a year or
even less often. A surveillance system to measure the population effects of a tuberculosis control program
might provide information only every one to five years—for example, through a series of demographic
and health surveys. The principle is that different public health objectives and the actions required to
reach them require different information systems The type of action that can be taken, when or how often
that action needs to be taken, what information is needed to take or monitor the action, and when or how
frequently the information is needed should determine the type of surveillance or health information
system.
Principles and Uses of Surveillance: Foege, Hogan, and Newton (1976) state that "the reason for
collecting, analyzing, and disseminating information on a disease is to control that disease. Collection and
analysis should not be allowed to consume resources if action does not follow." The fundamental
principle of public health surveillance is that the surveillance should be designed and implemented to
provide valid (true) information to decision makers in a timely manner at the lowest possible cost.
Because managers are unlikely to need to make interventions to address small differences between areas,
sacrificing precision makes sense to improve timeliness and save resources that can be used for public
health interventions. The utility of surveillance data can be viewed as immediate, annual, and archival, on
the basis of the public health actions that can be taken.
Establishing and Maintaining a Surveillance System: What is worth doing is worth doing
right. Managers who decide to use public health surveillance as a management tool must
recognize that they will need to commit political support and human and financial resources. As
with every health system, competent, motivated health workers need to be found or trained and
provided with career paths and supervision. After a manager decides to create a surveillance
system, there are six steps to establishing the system. Because the system must adapt constantly
to changes in the population and the physical and social environment, these steps are linked
continuously.
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Analysis and Dissemination of Surveillance Data: Surveillance information is analyzed by
time, place, and person. Knowledgeable technical personnel should review data regularly to
ensure their validity and to identify information of use to top managers. Simple tables and graphs
are most useful for summarizing and presenting data. Timely dissemination of data to those who
make policy and implement intervention programs is critical to the usefulness of surveillance
data.
The rapidly evolving field of public health informatics, which deals with collection,
classification, storage, retrieval, analysis, and presentation of large amounts of health data, offers
the potential for truly integrated public health surveillance based on data standardization, a
communications infrastructure, and policies on data access and sharing. Surveillance will benefit
by incorporating a systematic approach to standards for data content. For example, the U.S.
Centers for Disease Control and Prevention (CDC) has used standards-based systems to support
automatic electronic reporting of diagnostic laboratory results of notifiable diseases, thereby both
increasing the number of cases reported and receiving results more rapidly). Use of data
standards facilitates comparability of surveillance information over time (for example,
measurement of effect of program interventions), across different surveillance approaches (for
example, facility-based reporting compared with sample surveys), and across countries and
regions. To be credible, a standard should be developed through an open, participatory process,
by an internationally recognized accredited standards-development organization that is also
capable of long-term maintenance and evolution of the standard. Public health data needs extend
into multiple areas beyond clinical medicine (for example, environmental toxins, unintentional
injury, and food safety).
Surveillance as a Component of National Public Health Systems: WHO and the World Bank
cite public health surveillance as an essential function of a public health system. When linked to
policy and program units, surveillance information improves the efficiency and effectiveness of
health services by targeting interventions and documenting their effect on the population.
A critical challenge in the health sector in developing countries is to ensure quality and
effectiveness of surveillance and public health response in an environment of decentralization.
National-level program and surveillance system managers may lose control of the quality and
timeliness of locally collected data. This situation can be avoided by training local decision
makers in how to use information to meet their needs and negotiating with them over the core
information collected by each district local unit. National-level managers or donors can also
improve information quality by sponsoring national surveillance scientific and quality assurance
networks, linking funding to provision of adequate data, and performing periodic surveys to
confirm the results of local reporting. If the responsibility for implementing programs is
devolved to local managers, then national-level managers need only a few summary indicators,
rather than the detailed information they may be used to. District or local managers tend to prefer
integrated systems to minimize filling out redundant forms.
Donors need surveillance data to target and evaluate their investments. If they perceive weakness
in the national system, they may create parallel nongovernmental surveillance systems to gather
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data directly to meet their needs. These systems invariably pay workers more than government
jobs do, so the most competent people in the government system may leave to work for the
parallel system. Although this system meets donors' short-term needs, it invariably weakens
government systems. Parallel systems may weaken the very ministries that they are meant to
help and may not be sustainable after external funding ends. Therefore, parallel systems are
inherently inequitable and should be used only as a last resort.
Surveillance as a Tool to Improve Public Health: Managers need focused, timely,

scientifically sound information that provides evidence to make decisions on interventions for
improving the health of the population in their jurisdiction. Simply collecting data and presenting
them are not enough.
Using Surveillance Information for Evidence-based Decisions: A major gap in promoting

effective surveillance lies between the production of data and the ability to convert those data
into usable information and then initiate the appropriate public health action. Surveillance and
response can be described in terms of a data generation hemisphere and a data use hemisphere).
The data generation hemisphere is the traditional view of surveillance, whereas the data use
hemisphere is the public health response that begins with interpretation of the data from the
surveillance system.
Surveillance and Response Conceptual Framework: Substantial attention and the

accompanying resources in surveillance have been devoted to the prompt and complete
production of surveillance data. Although developing countries experience weaknesses in both
hemispheres, more attention is needed to creating and strengthening the local capacity within
developing countries to identify and manage effective responses to disease outbreaks and public
health conditions of national and international concern. In some disease-specific programs, this
capacity has to be imported through short-term expatriate assistance. Even when local capacity is
developed, it is often specific to the disease program, making transfer of skills to other areas
problematic. The failure to develop this indigenous capacity has limited the ability of developing
countries to build national surveillance systems that respond to both international public health
threats and local health concerns. This capability is essential to the sustained development of
countries.
Role of Field Epidemiologists in Providing Evidence: Developed countries have constructed their
public health and disease control strategies by using the principles of field epidemiology. Developing
countries need to build and sustain human capacity in field epidemiology. Strengthened field
epidemiologic capacity can serve a country in the following specific areas:
1. Providing a response to acute problems

2. Providing the scientific basis for program and policy decisions
3. Implementing disease surveillance systems
4. Supporting national health planning
5. Making resource allocation decisions
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6. Allocating the human capacity base for national health priorities.
Specific competencies that should be developed include, but are not limited to, the ability to
accomplish the following:
4. Design, implement, and evaluate surveillance for a health event

5. Identify and assess an actual public health problem
6. Design and conduct a scientific investigation
7. Analyze and interpret data from an investigation
8. Recommend logical and practical public health actions after the analysis and
interpretation of data
9. Be proficient in all aspects of diseases of public health importance (for example, HIV and
AIDS, sexually transmitted diseases, malaria, tuberculosis, and zoonoses).
These competencies need to be tailored to the various levels of the health care system.
Selected Surveillance Strategies: Surveillance systems need to be designed and implemented to

meet top management's needs for focused, reliable, timely evidence gathered efficiently and
presented effectively. Because these needs differ, depending on management's needs, a number
of different strategies have been developed. Here are some of the most useful.
Sentinel Surveillance: In a sentinel surveillance system, a prearranged sample of reporting

sources agrees to report all cases of defined conditions, which might indicate trends in the entire
target population. When properly implemented, these systems offer an effective method of using
limited resources and enable prompt and flexible monitoring and investigation of suspected
public health problems. Examples of sentinel surveillance are networks of private practitioners
reporting cases of influenza or a laboratory-based sentinel system reporting cases of certain
bacterial infections among children. Sentinel surveillance is excellent for detecting large public
health problems, but it may be insensitive to rare events, such as the early emergence of a new
disease, because these infections may emerge anywhere in the population.
Periodic Population-based Surveys: Population-based surveys can be used for surveillance if

they are repeated on a regular basis). Examples of population-based surveys in surveillance
include the BRFSS in the United States, HIV-prevalence surveys, household surveys, and the
demographic and health surveys that many developing countries conduct every five years.
Population-based surveys require careful attention to the methodology, particularly the use of
standard protocols, supervision of interviewers, comparable sampling strategy, and standard
questionnaires. These surveys require a clear definition of the target population to which the
results can be generalized, and they need careful attention to the sample size, based on efficiency
and the epidemiologic characteristics of the health condition under surveillance (for example,
rare conditions require substantial samples). Supervising interviewers and maintaining high
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response rates are critical to avoid bias. Because the surveys are repetitive, population changes
(caused, for example, by mortality or mobility) might bias results.
Environmental Public Health Surveillance: Surveillance for environmental public health

practice requires the collection, analysis, and dissemination of data on hazards, exposures, and
health outcomes.
The Process of Adverse Effects and the Corresponding Surveillance: Health outcomes of
relevance include death, disease, injury, and disability. However, relating those outcomes to
specific environmental hazards and exposures is critical to environmental public health
surveillance. Hazards include toxic chemical agents, physical agents, biomechanical stressors,
and biologic agents that are located in air, water, soil, food, and other environmental media.
Exposure surveillance is the monitoring of members of the population for the presence of an
environmental agent, its metabolites, or its clinically in apparent (for example, subclinical or
preclinical) effects.
Four challenges complicate environmental public health surveillance. First, the ability to link
specific environmental causes to adverse outcomes is limited by our poor understanding of
disease processes, long lead times, inadequate measures of exposure, and multiple potential
causes of disease. Second, data collected for other purposes rarely include sufficient information
to meet a case definition for a condition caused by an environmental agent. Third, public alarm is
often out of proportion to the hazard of concern, and sentiment will often influence public policy
disproportionately to scientific information. Fourth, biologic markers will become increasingly
critical elements of environmental exposure surveillance.
Obtaining data on exposure, which can include estimates derived from hazard data through
sophisticated modeling or direct measurements of individual exposure obtained from use of
personal monitors (for example, passive air samplers), is generally impractical in developing
countries. Childhood blood lead levels are the only bio-monitoring data that are collected
routinely in several countries, either in national surveys or from screening programs for children
at high risk.
Health outcome surveillance as applied to environmental public health is similar to traditional

surveillance efforts. In the United States, the focus is on surveillance for birth defects;
developmental disabilities (for example, cerebral palsy, autism, and mental retardation); asthma
and other chronic respiratory diseases (for example, bronchitis and emphysema); cancer; and
neurological diseases (for example, Parkinson's disease, multiple sclerosis, and Alzheimer's
disease). Other nations have different sets of priority conditions for surveillance. Disease
registries, vital statistics data, annual health surveys, and administrative data systems (for
example, hospital discharge data) are sources that have been used for monitoring health
conditions. The challenges mentioned previously have constrained our ability in all nations,
regardless of level of development, to establish and maintain effective and comprehensive
environmental public health surveillance systems. As we invest in understanding the enlarging
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threats in the global environment, we must overcome these challenges and establish improved
surveillance systems. The health of the global community depends on this investment.
Injury Surveillance: Injuries are a major public health problem and are among the 10 leading causes of
death worldwide, killing an estimated 5 million persons each year and causing high rates of disability.
People from all economic groups are at risk for injuries, but death rates caused by injury tend to be higher
in developing countries. Injury surveillance includes monitoring the incidence, causes, and circumstances
of fatal and nonfatal injuries. Injuries are classified by the intention of the act into two groups:
unintentional injuries and violence-related injuries. WHO and the Pan American Health Organization
have developed guidelines for establishing injury surveillance systems in developing countries.
If the range of fatal and nonfatal injuries, as well as the risk factors that can lead to injury, are to
be fully captured, surveillance systems need to be established in multiple settings. Fatal injuries
can be captured by using forensic or death certificate data. A far greater number of injuries are
nonfatal and can be tracked through hospital- or primary care–based systems. Systematic
information on nonfatal injuries, including prevalence, incidence, and related risk behaviors can
also be obtained through ongoing population-based surveys.
Critical points should be addressed when planning an injury surveillance system in a developing
country. First, data sources need to be clarified. In some developing countries, routine data on
injuries are not always captured in health information systems. It is therefore necessary to
consider other sources of data—for example, law enforcement agencies, coroners, or medical
examiners. Next, the events and variables in an injury surveillance system should be defined
according to the objectives of the system. Criteria such as the intentionality (violence-related
injuries versus unintentional injuries); the outcome (fatal injuries versus nonfatal injuries); and
the nature of violence-related injuries (physical, sexual, psychological, deprivation, or neglect)
should be considered when establishing the system. Finally, case definitions and coding
procedures should be defined before implementing the system
EPIDEMIOLOGICAL SURVEILLANCE
This is an ongoing or continuous systemic collection, analysis and interpretation of health data
essential to the planning, implementation and evaluations of public health practice as well as the
timely dissemination of these data to those who need to know.
Epidemiologic surveillance may be carried out to monitor changes in disease frequency and
changes in prevalence of risk factors. Much information on morbidity and mortality of diseases
come from programs of systemic disease surveillance.
Epidemiologic surveillance is most frequently conducted for infectious diseases but in recent
years it has become increasingly important in monitoring changes in other types of conditions
such as congenital malformation, cancer, asthma, and chemical poisoning, injuries and illnesses;
after disasters hurricanes or earthquakes.
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The aim of epidemiologic Surveillance:
1. To estimate the epidemiological importance of disease in order to identify health needs

and to rank priorities of health actions.
2. Measures the impacts of health actions.
3. Identify health problems that need immediate actions.
4. Select major fields of research.
Epidemiologic Surveillance is also used to monitor:
1. Completeness of vaccination and immunization coverage,
2. Population protection,
3. The prevalence of drug resistance,
4. Organisms such as drug resistant T.B. and Malaria.
Surveillance is carried out by observing trends in:
1. Time ----------------------------when the effect occurs
2. Place----------------------------where the effect occurs and
3. Persons---------------------------who is affected?
Changes can be observed or anticipated then appropriate action including investigative or control
measures taken.
Sources of surveillance data should relate directly to:
1. Disease or
2. Factors influencing health.
These sources include:
1. Registration of births,
2. Morbidity and mortality rates reports based on:
i. Death certificates
ii. Hospital records
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iii. General practice sentinels or
iv. Notification of diseases.
3. Laboratory diagnosis,
4. Out-breaks of epidemics,
5. Vaccine utilization – up-take and side effects,
6. Sickness absence reports or records,
7. Disease determinants such as biological changes in:
a. Agent,
b. Vectors,
c. Reservoirs.
8. Data concerning availability, use and untoward effect of vaccine and toxoids, immune
globins, insecticides and other substances in control.
9. Information regarding immunity levels in segment populations.
10. Investigation of individual cases and epidemics,
11. Distribution of animal reservoir and vector,
12. Production, distribution and care of vaccines, sera and drugs,
13. Demographic data,
14. Environmental data.
Effective of surveillance: This depends on the:
1. Data derived survey and programs,
2. Mechanism by which pertinent epidemiological data are brought together to be evaluated,

correlateted and interpreted by competent epidemiologists. Most programs, control and
eradication use surveillance to:
a) Make initial assessment,
b) Evaluate the progress of the program.
Purpose of Epidemiologic Surveillance:

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1. Planning for public health programs,
2. Identification of disease occurrence changes,
3. Identification of risk factors associated with disease and suggests hypothesis.
4. To look at case-control study e.g. AIDS pandemic.
5. Monitor safety and effectiveness of preventive and control measures.
Components of Epidemiologic Surveillance: These are:
1. Study population,
2. Target population,
3. Resources,
4. Planning.
Forms of Epidemiologic Surveillance These are:
1. Individual case investigation [applicable in infections e.g. paralytic polio, Ebola, Yellow
fever, Cancer e.t.c.]
2. Epidemic reporting,
3. Sentinel system [screening without informing the individuals being screened],
4. Health surveys [incidences and prevalence]
Activities Involved in Surveillance: These are:
1. Data collection,
2. Data analysis,
3. Data summary,
4. Data presentation,
5. Case identification,
6. Logistic management [helps in determining conducts of personnel]
Types of Epidemiologic Surveillance Data: These are:
1. Mortality data whose sources are:

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a. Health institutions,
b. Formal and informal leaders.
2. Morbidity data generated by notification of diseases under Public Health cap. 242 LOK.
3. Laboratory data given out during epidemics and during analysis of an item.
4. Drug use data,
5. Performance survey data,
6. Demographic data,
7. Environmental data.
Uses of Epidemiologic Surveillance Data: Surveillance data are basically used to portray the
natural history of a disease. They are:
1. Trends,
2. Communicability,
3. Period of communicability,
4. It is used to test hypothesis e.g. utilization of health services,
5. It is used to monitor changes in infectious agents,
6. It is used to identify and evaluate control measures,
7. It is used to monitor isolation activities eg quarantine,
8. It is used to detect changes in health practices
9. It is used in planning.
How to Plan Epidemiologic Surveillance Data Collection:
1. Define roles,
2. Define resources,
3. Define management in-put.
Dissemination of Epidemiologic Surveillance Results: The main method is the media:-
1. Electronic [internet, med-line, radio, TV etc],

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2. Print.
The information disseminated has acknowledgement of those who assisted.
Criteria for Establishing an Epidemiologic Surveillance System:
1. The frequency and severity of the disease,
2. Case-fatality rate,
3. Segment of population:
a. Age differences,
b. Sex differences,
c. Occupation.
4. To introduce intervention,
5. Associate risk factors with prevention.
Factors to consider when establishing Epidemiologic Surveillance Systems:
1. Statement of objective
2. Definition of the problem within the community,
3. Identification of implementers of surveillance eg:
a. Health providers,
b. The community,
c. Health agencies.
Epidemiologic Surveillance is divided into two types:
1. Active Epidemiologic surveillance,
2. Passive Epidemiologic surveillance.
Passive Epidemiologic Surveillance: this involves collection of data on reportable diseases and
examination of hospital records. Passive surveillance is relatively inexpensive and relatively easy
to develop since the data collected concern morbidity and mortality within institution – health
facility. The information collected helps in:
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1. Determining the trends and patterns of a disease,
2. Evaluating existing programs in disease control.
In passive epidemiologic surveillance those expected to report new cases are often our burden by
their primary responsibility of preventive health care and administering health services.
Record Review: This is a form of passive epidemiologic surveillance which involves use of
information obtained from routine record of activities.
Active Epidemiologic Surveillance: This involves surveys. The surveys used in active
surveillance are:
1. Cross-sectional,
2. Longitudinal,
3. Sentinel centers.
SURVEILLANCE
Active Passive
Routine Records Surveys Epidemic

investigation
Cross-sectional Longitudinal Sentinel Center
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In active epidemiologic surveillance, those involved are employed to carry out the responsibility
and this makes it more accurate than passive surveillances.
UNIT 9
OUT-BREAK OR EPIDEMIC INVESTIGATION
This is a form of active surveillance when there is an epidemic. This kind of surveillance or
survey involves:
a. Interviews i.e.:
i. Questionnaire,
ii. Interview schedule.
b. Physical examination,
c. Specimen collection and examination,
d. Combination of all the above.
System of Carrying out Disease Out-Break Investigation:
1. Confirm out-break [verification of diagnosis] by:
i. Signs
ii. Symptoms,
iii. Laboratory,
iv. Records.
2. Identify the affected and their characteristics [A prominent attribute or aspect of

something or a distinguishing quality].
3. Formulate hypothesis as to source of spread of epidemic based on what you are seeing,
4. Manage epidemic by :
i. Treating cases
ii. Preventing the spread of the epidemic using control measures’

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iii. Writing report.
CASE INVESTIGATION
1. Identify the information by:
a. Name and case number,
b. Age,
c. Sex’
d. Address of the family head and occupation,
e. Date of interview,
f. Name of interviewer.
2. Clinical information:
a. Signs,
b. Symptoms.
3. Past medical history:
a. Immunization status,
b. Any previous cases.
4. Laboratory information:
a. The agent isolated,
b. Body response to the agent.
5. Possible source of infection,
6. Contacts since infection.
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FORMAT OF AN EPIDEMIOLOGIC INVESTIGATION
START
Own observation
idea or a problem
Suggestion from for investigation
Others
Conduct search for past records
post studies records past studies
of similar situations Journal articles
Unpublished data
Possibility of problem
No
End
Yes
State problem
 Formulate hypothesis
 Determine objectives
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Determine methods
Study design
Sampling study aspects administration
and Logistics
Aspects Materials Observation
population
Study Materials
Measurements required Transport
Instruments Implement study Schedule
Collect data manpower
Communication
Process data shelter
Finance
Analyze data
Present data
End
THE STUDY POPULATION
This is the population of individual units [whether they are persons, families, medical records,
certificates, nursery schools etc] to be investigated.
Epidemiologically, a human population is a group of people including both sick and healthy
about whose health statement is to be made or any group of people defined in a specific way.
This is known as target population. A subset of this is the study population. Usually, the study
population will be larger than the one the investigation requires and actual examination will be
limited to a sample of this population.
111

All epidemiological findings must relate to the defined population. It relates the disease to the
population in which it occurs in terms of location and restriction to a particular age-group, sex, or
occupation.
For example, if the study is to determine the nutrition status of children in Kuria District, then
the population must comprise children in Kuria District. One needs to be more specific in terms
of age limits of the children and their migration status.
It is usually unnecessary and impractical to make observations on an entire population such as all
children in Kuria district.
A properly selected sample of appropriate size which is usually referred to as a representative

sample, will enable generalization to be made about the population.
For example, if a study is to
If it is human study population, then the following decisions are considered:
a) Description of the study population in terms of place, time, and any other relevant criteria
[A basis for comparison; a reference point against which other things can be evaluated]
i. If the study comprises cases of disease, the procedures to be used for case
identification should be tested
ii. If controls are to be chosen, their method of selection should be stated.
iii. Selecting the study population depends on objectives [The goal intended to be
attained (and which is believed to be attainable)] of the study otherwise this is
where there is likely to be variations which may not validate the subsequent
generalization from the findings e.g.
1. Volunteer populations: persons who volunteer to enter a study or submit

to a procedure may be different in many respects from those who do not
volunteer therefore the findings in a volunteer population do not
necessarily apply to the population at large.
112

2. Persons diagnosed as having a disease: Such persons are not necessarily
a representative of all those who have the disease for the following
reasons:
i. Differences between population groups in the availability and use of

medical services and the,
ii. Establishment of diagnosis may be influenced by the diagnostic

facilities available, the severity of symptoms, cases with wild or
no symptoms may remain undiagnosed.
3. Hospitals or clinics: persons receiving medical care are obviously not

representatives of general population or necessarily of all ill persons.
4. Population with good medical records: this is essential for studies like
surveys of work of general practitioners whereby doctors are selected for
comparison.
5. Persons living at home: a study population comprises persons living at

home. This may exclude those who are in hospitals and other institutions.
6. Autopsy populations: persons submitted to autopsy [An examination and

dissection or post-mortem of/on a dead body to determine cause of death
or the changes produced by disease] e.g. those suspected or diagnosed as
cancer cases.
7. Groups characterized by their behavior or occupation: These are:
i. Smokers
ii. Joggers
iii. Migrants
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iv. Truck drivers
8. Population in which the same individuals appear more than once: if

the same individuals appear more than once in a study population, the
findings in these individuals may have an undue effect on the results. This
may arise because a researcher may not obtain the required information
due to over researching based on the past findings.
SAMPLING
Conditions for sampling are:
a. Sample must be well chosen so as to be representative of the parent population.
b. Sample must be sufficiently large so that if a number of representative samples

are drawn from the same parent population and are investigated by chance there
will be difference between findings in each sample. This is a problem of sampling
variations which is minimized by selecting a large sample.
c. There must be adequate coverage of the sample to minimize sample bias.
The most commonly used sampling technique is:
1. Sample size: to generalize sample observation to the study population, one needs to work
out an appropriate sample size. Although samples cannot be exactly representative of the
study population, it should give a reasonable estimate of what happens in the study
population. The larger the sample the more precise the sample estimate will become. This
needs to be examined against the cost and the time that the sample will require.
2. Choice of sample size: A sample must be chosen in such a way that specified sampling
error [qualitative data] or standard error [quantitative data] are taken into account while
calculating the size that gives the degree of precision that is required. The dominant
considerations in the choice of the sample size are practical ones such as the availability
of resources, staff and time. In descriptive observational study this may be acceptable as
long as accompanying errors may not reveal the effect of the measure thus not meriting
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any form firm conclusions. It should be noted that there are many other sources of errors
such as:
a) Mistakes in the measurements,
b) Laboratory techniques, and
Non-response of individuals selected for inclusion in the sample.
SCREENING
It is the presumptive identification of unrecognized disease or defect by application of tests,

examination or procedures which can rapidly be applied.
It can be referred to as the search for unsuspected disease. Screening tests sort out apparently
well persons who probably have the disease from those who probably do not.
A screen test is not diagnostic. Those with suspicious positive findings must be referred to their
physicians for diagnosis and necessary treatment. Screening is initial examination only and
positive respondents require diagnostic examination. The initiative for screening comes from the
investigator or a person or an agency providing care rather than from the patient with a
complaint. Screening is usually concerned with chronic illness and aims at detecting diseases not
under medical care.
Types of Screening: There are different types of screening each with its own aim:
1. Mass screening: This is carried out when the tests are applied to a
large unselected population.
2. Multiple or Multiphasic screening: This type involves a variety of

screening tests used at the same time.
3. Prescriptive Screening: This type is used in early detection of

presumptive healthy individuals of a specific disease that can controlled
better if detect early in their natural history. For example, the use of
mammography in breast cancer.
Characteristics of Screening Tests: These include:
1. Accuracy – reliability,
2. Estimates of yields,
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3. Precision,
4. Reproducibility, Repeatability
5. sensitivity,
6. Specificity and Measures of validity
7. Validity.
Validity: Validity has been defined as the ability a test has to distinguish a patient who have a
disease and who doesn’t.
Validity has two components:
1. Sensitivity,
2. Specificity.
Sensitivity Test: It is defined as the ability of a test to identify correctly those who have the
disease.
Specificity Test: it is defined as the ability of a test to identify correctly those who do not have
the disease.
Sensitivity therefore measures false negative rates, while specificity measures false positive
rates.
A good screening test must therefore have high sensitivity in order not to miss the few cases of
disease that are present, and a high specificity to reduce the number of people with false positive
who require further tests.
TRUE DISEASE CLASSIFICATION OF APPARENTLY WELL POPULATION
SCREENING RESULTS SENSITIVITY DISEASE SPECIFICITY DISEASE
Positives Positive Tests [True positives] False positives [Those without

disease - positive tests]
Negatives False negatives [Those with True negatives [Negative

disease - Negative results] results]
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Totals Positive cases [Total known Total negatives.
cases]
Sensitivity = T.P.
T.P. + F.P.
Specificity = TN
TN+FP
CONCEPT OF SENSITIVITY AND SPECIFICITY OF SCREENING EXAMINATION
Example: Discuss a population of 1000 people out of whom 100 have a disease and 900 of them
do not have. Curry out a test to identify the people with the disease.
TRUE CHARACTERISTICS IN OF THE POPULATION
RESULTSOF DISEASED NOT DISEASED TOTALS

SCREENING [POSITIVES] [NEGATIVES]
Positives 80 100 180
Negatives 20 800 820
Totals 100 900 1000
Sensitivity =80x100 =80%
100
Specificity = 800x100 =89%
900
Acceptable Screening Test: The screening test must be acceptable to the population being
tested. it therefore calls for awareness creation of what is to be done. It is also important and
ethical that what is discovered must be adequately followed up because it is not good for the
people concerned when a screening is undertaken and then the whole matter is dropped. The
follow up program must be a prominent part of planning a screening survey.
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Yield of a Screening Test: this is the measure of previously unrecognized disease. Other forms
of yield are provided by patients with known disease who previously lapsed in treatment.
NB: sensitivity and specificity can also be used to evaluate screening test.
Benefits of Screening Test: These are:
1. They improve prognosis,
2. They minimize resources.
3. They help in prevention of Public Health diseases.
4. They define carriers.
5. They help avoid radical treatment [very expensive]
6. They are tools for assurance for those who are disease positive especially those with
unpreventable diseases.
7. They help in identification of the type of intervention programs.
SCREENING PROGRAMS
1. Mammography,
2. Breast cancer- self- examination,
3. Ante-natal-mothers screening program,
4. Pelvic assessment,
5. Height of ante-natal-mothers to determine pelvic size,
6. Pap smear for cancer of the cervix,
7. Head circumference of children for micro and hydrocephalus,
8. Screening of food-handlers for infectious diseases,
9. Mantoux test for TB,
10. X-ray for TB of the lungs.
UNIT 10
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CONCEPT OF DEMOGRAPHY
Demography can be defined as the scientific study of human populations.
There are two types of demography:
1. Formal demography or demographic analysis and
2. Population studies.
Formal Demography: This is the scientific study of human populations with respect to their
size, distribution, structure, and change.
Size: refers to the number of persons in the population.
Distribution: refers to the arrangement of the population in space at a given time – that is
geographically or among various residential areas, or occupations.
Structure: refers to the distribution of population according to sex and age groups.
Change: refers to growth or decline in the total population or one of its structural units.
Main Features of Formal Demography: These are:
1. It is fundamentally descriptive or analytic rather than explanatory in nature.
2. It is concerned with demographic phenomena in isolation, not with their interaction with
economic, social or other phenomena.
Common Rates and Ratios
1. The crude birth rate, the annual number of live births per 1,000 people.
2. The general fertility rate, the annual number of live births per 1,000 women of
childbearing age (often taken to be from 15 to 49 years old, but sometimes from 15 to
44).
3. Age-specific fertility rates, the annual number of live births per 1,000 women in
particular age groups (usually age 15-19, 20-24 etc.)
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4. The crude death rate, the annual number of deaths per 1,000 people.
5. The infant mortality rate, the annual number of deaths of children less than 1 year old
per 1,000 live births.
6. The expectation of life (or life expectancy), the number of years which an individual at
a given age could expect to live at present mortality levels.
7. The total fertility rate, the number of live births per woman completing her reproductive
life, if her childbearing at each age reflected current age-specific fertility rates.
8. The replacement level fertility, the average number of children a woman must have in
order to replace herself with a daughter in the next generation. For example the
replacement level fertility in the US is 2.11. This means that 100 women will bear 211
children, 103 of which will be females. About 3% of the alive female infants are expected
to decrease before they bear children, thus producing 100 women in the next generation.
9. The gross reproduction rate, the number of daughters who would be born to a woman
completing her reproductive life at current age-specific fertility rates.
10. The net reproduction ratio is the expected number of daughters, per newborn
prospective mother, who may or may not survive to and through the ages of childbearing.
11. A stable population, one that has had constant crude birth and death rates for such a long
period of time that the percentage of people in every age class remains constant, or
equivalently, the population pyramid has an unchanging structure.
12. A stationary population, one that is both stable and unchanging in size (the difference
between crude birth rate and crude death rate is zero.
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Basic equation: Suppose that a country (or other entity) contains Populationt persons at time
t. What is the size of the population at time t + 1 ?
Natural increase from time t to t + 1:
Net migration from time t to t + 1:
POPULATION STUDIES
Demography is scientific study of human population
It focuses on 3 phenomena:
i. Changes in population size
ii. Composition of population
iii. Population distribution in space
Important ‘demographic processes’ include: fertility, mortality, marriage, education & social
mobility
In a broader sense, additional characteristics such as ethnicity (race, mother tongue), social
characteristics (marital status, literacy, educational attainment, women’s status), and economic
characteristics (employment status, occupation, income) also need to be considered when
describing population characteristics:
1. Census
2. National Survey
3. Registration of vital events
4. Demographic Studies
The wider scope of demography is concerned only with population variables but also with
relationships between population changes and other variables e.g.
121

1. Social,
2. Economic,
3. Political,
4. Biological,
5. Genetic,
6. Geographical,
7. Intelligence and
8. Health.
Population studies extend to applications of its data findings in a number of fields including the
study of problems associated with demographic processes. The field of demographic studies is as
broad as the interest in determining the consequences of population trends.
In a broader sense, additional characteristics such as ethnicity (race, mother tongue), social
characteristics (marital status, literacy, educational attainment, women’s status), and economic
characteristics (employment status, occupation, income) also need to be considered when
describing population characteristics:
1. Census
2. National Survey
3. Registration of vital events
4. Demographic Studies
Population studies are concerned not only with population variables but also with relationships
between population changes & other variables – social, economic, political, biological, genetic,
geographical, environmental, health & the like
Definition of Key Words
1. Size refers to the number persons in the population
2. Distribution refers to the arrangement of the population in space at a given time
3. Structure is the distribution of population among its sex & age groupings
4. Change is the growth or decline of the total population or one of its structural units. The
components of change total population are births, deaths, & migrations
5. Age-Sex Composition of a population refers to the proportion of males & females in

different age-groups. It has a direct bearing on social, economic, health needs of
122

communities or countries. In an “old” population, for example, the society has to arrange
for the care of the elderly, & the country’s health system must be organized accordingly.
In a “young” population, on the other hand, the country has to provide more schools,
immunizations, & economic support for the young
6. Net-Migration refers to the total number of persons added or subtracted from a

population as a result of the combined effect of immigration & emigration
7. Urbanization refers to mass migration of rural population into urban centers resulting in
increasing the urban population & growth of cities
8. Population Growth Rate (%/ year) is the rate at which a given population is expected to
increase in a given period of time.
9. Population Doubling Time refers to the time that would take for a population to double.
Because the population increase is on the compound interest formula, a 1% per year
increase would cause the population to double in about 70 years. If the population is
increasing at 3% per year, than the doubling time will be 23.3 years
10. Population Pyramid is a pictorial presentation of the age-sex composition of a population
11. Replacement Level Fertility (or Zero population growth) is activated when a couple has
two births during their reproductive life, just enough to replace themselves. At a
community scale, the replacement level is considered when there are, on the average, 2.1
births per woman, to compensate for child deaths
12. Momentum of Population Growth is the characteristic of population growth when a sharp
decline in births does not bring in an immediate reduction in natural increase
There are four ways in which the number of people in an area can change during two time
periods t0 & t1
Pt1 = Pto + (B – D) + (IM – OM)
B = number of live births to mothers in the area
D = number of residents died
IM = number of persons moving into the area fro permanent residence
OM = number of persons moving out of the area to live elsewhere
Thus the population of an area may change due to natural reasons (B – D) known as natural
increase or due to migration (IM – OM) known as net-migration. Subsequently:
123

Population Growth = Natural Increase + Net Migration
While characteristic is an attribute of an individual (e.g. male, young, healthy, employed etc),
composition is a property of a group of people. It describes how the total given population is
constituted (e.g. 51% males, 20% below age 5, 85% healthy 7& 30% employed etc).
Dependency Ratio is an index summarizing an age distribution. Strictly, this is he ratio of

population who are economically not active to those who are economically active. However, due
to the difficulties in defining economic activity in many countries, especially when international
comparisons are made, a ratio of age group is used instead:
Population Composition (Cont’d)
Dependency Ratio
= Children + Elderly X 100
Working Age
= Pop below 15 + 65 & above X 100
Pop 15 – 64 years
Dependency Ratio of Pakistan = 95.1
Dependency Ratio of UK = 66.5
 Sex Ratio: The overall sex ratio is simply the ratio of males to females in
the population & is calculated by taking the number of males in a
population & dividing it by the number of females in the same population
Sex Ratio = Number of Males X 100
Number of Females
Demographic Cycle
World history suggests that every nation passes

through a demographic cycle. The stages are:
1. High Stationary Stage: characterized by high birth rate and high death rate
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2. Early Expanding: The death rate begins to decline while birth rate remains unchanged
3. Late Expanding: The death rate declined still further and birth rate tend to fall
4. Low Stationary Stage: Low birth and low death rates
5. Declining Stage: birth rate is lower than the death rate and population starts declining
 Old Balance: (High fertility & High Mortality)
A large supply of births was necessary to compensate for

the large number of deaths. MMR & IMR extremely high
 New Balance: (Low fertility & Low Mortality)
Represents an improved condition of human efficiency &

health, with fewer deaths considerably less efforts required to bring a generation to maturity.
Production of agricultural & industrial commodities is greater & life style is more comfortable
 Imbalance: (High Fertility & Low Mortality)
In between old & new balance is the period of rapid natural increase. This growth is helpful for
under-populated nations. Too fast growth of population leading economic, social & political
chaos ( being faced by numerous developing countries including Pakistan)
1. World PopulationTrend/ Population Dynamics: The rampant population growth is

viewed as the greatest obstacle to the economic & social development of the majority of
peoples in the underdeveloped world
Approximately 95% of population growth is in developing countries
Currently, 1/3 of the world population is < 15, & will soon enter the reproductive bracket, giving
more potential for population growth
The expected number of births per woman, at current fertility rate is:
Africa 6.1
Asia 3.2
Latin America 3.4
North America 2.0
Europe 1.6
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Economic implications: Due to population explosion there are:
1. Short term pressure affects during 2-3 decade

2. Long term over next century and beyond economic affects
Demographic Implications: In population with low birth and death rate, 20-30% of population
is under 15; 9-13% is 65 or more. The median age for this population is 32 and there is increased
demand for senior citizen
Environmental / Ecological Implications
Due to population explosion there are
Short term pressure affects during 2-3 decade
Long term over next century and beyond economic affects
Social / Political Implications
In population with low birth and death rate, 20-30% of population is under 15; 9-13% is 65 or
more. The median age for this population is 32 and there is increased demand for senior citizens
USES OF DEMOGRAPHIC INFORMATION
Demographic information can be used in:
1. Economic Planning: by providing basic data needed planning:
a) Population size,
b) Growth rate,
c) Available labor force.
2. Policy making: the data on growth rate for example can be used by the government to
encourage family planning.
3. Administrative purposes: whether or not to sub-divide an administrative area mainly

depends on the population to be served.
126

4. Political purposes: the number of constituencies in a given district depends on the
population of the district.
5. Distribution of Social welfare: in institutions, facilities and services e.g. health,

education, security, water supplies, transport, e.t.c. depend on the population of the area:
i. The number of health institutions to be established in a given area depends on the

population to be served.
ii. The number of primary schools to be established in an area depends on the

population of the primary school going age.
iii. The capacity of water supply installation to supply an urban center depends on the
population of the center’s catchment area besides other factors.
6. Health indicators: the health status of a community is easily portrayed by the various
rates calculated in demography e.g.
i. Mortality rates,
ii. Fertility rates,
iii. Morbidity rates,
iv. Birth rates and
v. Life expectancy.
7. Social Research: Any social research must make use of some demographic information.
8. Distribution of communal Burden: a country like Kenya which has relied on fund
raising [Harambee] for development of most of the social infrastructures like schools and
health institutions has to allocate quotas to divisions, locations, sub-locations or villages
primarily according to their populations.
127

9. Distribution of human resources: to determine human resources in terms of labor as a
factor or economic production, its potential and actual exploitation [labor force,
employed, underemployed and unemployed].
MEASUREMENT OF HUMAN POPULATION
Health services apply demographic studies in several ways e.g.
Fertility Measures: of a group of women reveals their performance in child bearing which in
turn implies how their health may directly or indirectly be affected by the revealed fertility rate.
Mortality Measure: of a population would reveal at what rate the people are dying. High
mortality rate would indicate poor health which in turn would call for investigation to the causes
in order to institute corrective measures.
Average Life expectancy: of individual in a society indicates the general health status of the
society.
SOURCES OF DEMOGRAPHIC DATA
The raw materials of informal demography are data collected in:
1. Population census,
2. Demographic sample survey,
3. Registration of vital events e.g.
i. Births,
ii. Deaths,
iii. Migrations and
iv. Marriages.
4. Compulsory national social security scheme records,
5. Records of establishments,
6. Statutory registration of persons,
7. Hospital records,
8. Various publications e.g. U.N. statistical year book.

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EPIDEMIOLOGY

Objective [The goal intended to be attained and which is believed to be attainable]

1. Definition of terms used in Epidemiology.

2. Description of the Epidemiological approaches.

4. Uses of Epidemiology in Public Health.

5. Disease determinants [A determining or causal element or factor].

6. Levels of disease prevention.

Prepared by O.E. Akoth

Observational studies have two components: descriptive, or analytical. Descriptive observations

Prepared by O.E. Akoth

Unfortunately, many epidemiology studies conducted cause false or misinterpreted information

Population-based health management: Epidemiological practice and the results of

Population-based health management encompasses the ability to:

1. Assess the health states and health needs of a target population;

Modern population-based health management is complex, requiring a multiple set of skills

Prepared by O.E. Akoth

1. Population Life Impacts Simulations: Measurement of the future potential

2. Labor Force Life Impacts Simulations: Measurement of the future potential

3. Economic Impacts of Disease Simulations: Measurement of the future potential

Population-based health management: Epidemiological practice and the results of

Population-based health management encompasses the ability to:

1. Assess the health states and health needs of a target population;

Modern population-based health management is complex, requiring a multiple set of skills

Prepared by O.E. Akoth

i. Study: Epidemiology is a scientific discipline with sound methods of scientific

Prepared by O.E. Akoth

1. Place pattern: include:

i) Urban and rural areas differences and

Prepared by O.E. Akoth

2. Time pattern: may be:

f) Weekday versus weekends,

3. Personal pattern: which includes:

a) demographic factors which may be related to risk of:

iii. disability such as:

c) marital status, and

d) socio-economic status, as well as behaviors and environmental

vi. Social status,

Prepared by O.E. Akoth

2. Population: The complete collection of individuals that have some particular

6. Virulence: a measure of the severity of a disease caused by a specified agent. Virulence is

Prepared by O.E. Akoth

a) Intrinsic Determinants of Disease: are physical or physiological

i. “Living” agents, such as viruses, bacteria, rickettsia, protozoa,

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Determinants of health: Generally, the context in which an individual lives is of great

1. The social and economic environment,

1. Income and social status 7. Personal health practices and

Prepared by O.E. Akoth

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1. Such as food supply,

These include access to care and resources such as:

1. Good early childhood development,

Prepared by O.E. Akoth

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1. Health services administration,

Prepared by O.E. Akoth