Claire Maurice G.

Juanero
BSN III-C

EPIDEMIOLOGY
The word epidemiology comes from the Greek words epi, meaning on or upon, demos,
meaning people, and logos, meaning the study of. In other words, the word
epidemiology has its roots in the study of what befalls a population. Many definitions
have been proposed, but the following definition captures the underlying principles and
public health spirit 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.
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 and use 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,
with biologic, economic, social, and behavioral sciences.

Uses of Epidemiology
 Count health-related events
 Describe the distribution of health-related events in the population
 Describe clinical patterns
 Identify risk factors for developing diseases
 Identify causes or determinants of disease
 Identify control and/or preventive measures
 Establish priorities for allocating resources
 Select interventions for prevention and control
 Evaluate programs
 Conduct research
 o risk factors and causes

o drug trials / vaccine trials

o operational research

Assessing the community’s health

Public health officials responsible for policy development, implementation, and
evaluation use epidemiologic information as a factual framework for decision making.
To assess the health of a population or community, relevant sources of data must be
identified and analyzed by person, place, and time (descriptive epidemiology).
 What are the actual and potential health problems in the community?
 Where are they occurring?
 Which populations are at increased risk?
 Which problems have declined over time?
 Which ones are increasing or have the potential to increase?
 How do these patterns relate to the level and distribution of public health services
available?
More detailed data may need to be collected and analyzed to determine whether health
services are available, accessible, effective, and efficient. For example, public health
officials used epidemiologic data and methods to identify baselines, to set health goals
for the nation in 2000 and 2010, and to monitor progress toward these goals.
Making individual decisions
Many individuals may not realize that they use epidemiologic information to make daily
decisions affecting their health. When persons decide to quit smoking, climb the stairs
rather than wait for an elevator, eat a salad rather than a cheeseburger with fries for
lunch, or use a condom, they may be influenced, consciously or unconsciously, by
epidemiologists’ assessment of risk. Since World War II, epidemiologists have provided
information related to all those decisions. In the 1950s, epidemiologists reported the
increased risk of lung cancer among smokers. In the 1970s, epidemiologists
documented the role of exercise and proper diet in reducing the risk of heart disease. In
the mid-1980s, epidemiologists identified the increased risk of HIV infection associated
with certain sexual and drug-related behaviors. These and hundreds of other
epidemiologic findings are directly relevant to the choices people make every day,
choices that affect their health over a lifetime.
Completing the clinical picture
When investigating a disease outbreak, epidemiologists rely on health-care providers
and laboratorians to establish the proper diagnosis of individual patients. But
epidemiologists also contribute to physicians’ understanding of the clinical picture and
natural history of disease. For example, in late 1989, a physician saw three patients with
unexplained eosinophilia (an increase in the number of a specific type of white blood
cell called an eosinophil) and myalgias (severe muscle pains). Although the physician
could not make a definitive diagnosis, he notified public health authorities. Within
weeks, epidemiologists had identified enough other cases to characterize the spectrum
and course of the illness that came to be known as eosinophilia-myalgia syndrome.
More recently, epidemiologists, clinicians, and researchers around the world have
collaborated to characterize SARS, a disease caused by a new type of coronavirus that
emerged in China in late 2002. Epidemiology has also been instrumental in
characterizing many non-acute diseases, such as the numerous conditions associated
with cigarette smoking — from pulmonary and heart disease to lip, throat, and lung
cancer.
Searching for causes
Much epidemiologic research is devoted to searching for causal factors that influence
one’s risk of disease. Ideally, the goal is to identify a cause so that appropriate public
health action might be taken. One can argue that epidemiology can never prove a
causal relationship between an exposure and a disease, since much of epidemiology is
based on ecologic reasoning. Nevertheless, epidemiology often provides enough
information to support effective action. Examples date from the removal of the handle
from the Broad St. pump following John Snow’s investigation of cholera in the Golden
Square area of London in 1854, to the withdrawal of a vaccine against rotavirus in 1999
after epidemiologists found that it increased the risk of intussusception, a potentially life-
threatening condition. Just as often, epidemiology and laboratory science converge to
provide the evidence needed to establish causation. For example, epidemiologists were
able to identify a variety of risk factors during an outbreak of pneumonia among persons
attending the American Legion Convention in Philadelphia in 1976, even though the
Legionnaires’ bacillus was not identified in the laboratory from lung tissue of a person
who had died from Legionnaires’ disease until almost 6 months later.

Epidemiologic Concepts & Principles

 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.
  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.
 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.
 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.

The natural history of a disease in a population, sometimes termed the disease’s

ecology, refers to the course of the disease from its beginning to its final clinical
endpoints. The natural history begins before infection (prepathogenesis period) when
the agent simply exists in the environment, includes the factors that affect its incidence
and distribution, and concludes with either its disappearance or persistence
(endemnicity) in that environment. Although knowledge of the complete natural history
is not absolutely necessary for treatment and control of disease in a population, it does
facilitate the most effective interventions.
An important epidemiologic concept is that neither health nor disease occurs randomly
throughout populations. Innumerable factors influence the temporal waxing and waning
of disease. A disease is considered endemic when it is constantly present within a
given geographic area. For instance, animal rabies is endemic in the USA.
An epidemic occurs when a disease occurs in larger numbers than expected in a given
population and geographic area. Raccoon rabies was epidemic throughout the eastern
USA for much of the 1980s and 1990s. A subset of an epidemic is an  outbreak, when
the higher disease occurrence occurs in a smaller geographic area and shorter period
of time. Finally, a pandemic occurs when an epidemic becomes global in scope (eg,
influenza, HIV/AIDS).
The population at risk is an extremely important concept in epidemiology and includes
members of the overall population who are capable of developing the disease or
condition being studied. This concept seems simple at first, but misinterpretations can
lead to erroneous study results and conclusions. As a simple example, a study of
testicular cancer among residents in a population should not include women in the
population at risk (frequently expressed as the “denominator” in an epidemiologic ratio).
A ratio is the value obtained from dividing one quantity by another (X/Y). The numerator
and denominator may be independent of each other. In fact, in epidemiology, the term
ratio is applied when the numerator is not a subset of the denominator. For example, in
a class of veterinary students in which 88 are female and 14 are male, the sex ratio of
female students to male students is 88/14, or 6.3 to 1.
A proportion is a type of ratio in which the numerator is part of the denominator (A/[A +
B]). Therefore, they are not independent. For example, suppose that, among domestic
dogs testing positive for internal parasites in Glendale, Arizona, 889 were male and 643
were female. The proportion of female dogs among those found to have parasite
infections would be 643/(889 + 643), or 0.42.
A rate is another type of ratio in which the denominator involves the passage of time.
This is important in epidemiology, because rates can be used to measure the speed of
a disease event or to make epidemiologic comparisons between populations over time.
Rates are typically expressed as a measure of the frequency with which an event
occurs in a defined population in a defined time (eg, the number of
foodborne Salmonella infections per 100,000 people annually in the USA).
Incidence is a measure of the new occurrence of a disease event (eg, illness or death)
within a defined time period in a specified population. Two essential components are the
number of new cases and the period of time in which those new cases appear. In an
example regarding the class of veterinary students, if 13 of them developed influenza
over the course of 3 mo (one quarter), the incidence would be 13 cases per quarter.
An incidence rate takes the population at risk into account. In the previous example,
the incidence rate would be 13 cases per quarter/102 students, or 0.127 cases per
quarter per student. Incidence rates are usually expressed by a multiplier that makes
the number easier to conceptualize and compare. In this example, the multiplier would
be 100, and the incidence rate would be 12.7 cases per quarter per 100 students (or
12.7%). An attack rate is an incidence rate; however, the period of susceptibility is very
short (usually confined to a single outbreak).
A similar concept to incidence is prevalence. Prevalence (synonymous with “point
prevalence”) is the total number of cases that exist at a particular point in time in a
particular population at risk. Again using the influenza example from above, if 7 students
had influenza at the same time during the academic quarter, the prevalence would be
7/102 or 0.069 cases per class (or 6.9%).
Measures of disease burden typically describe illness and death outcomes
as morbidity and mortality, respectively. Morbidity is the measure of illness in a
population, and numbers and rates are calculated in a similar fashion as with incidence
and prevalence. Mortality is the corresponding measure of death in a population and
can be applied to death from general (nonspecific) causes or from a specific disease. In
the latter case, cause-specific mortality is expressed as the case fatality rate (CFR),
which is the number of deaths due to a particular disease occurring among individuals
afflicted with that disease in a given time period. In another example, consider a large
veterinary practice in the southwest USA that frequently sees dogs with
coccidioidomycosis. The practice diagnosed 542 clinical cases in a particular year, 83 of
which died from the disease in the course of that year. The month in which the most
cases were diagnosed was September, in which 97 cases were diagnosed. Further, at a
single point in time (perhaps based on the results of a serosurvey of dogs in the practice
area), 237 dogs of 6,821 dogs with active records in the practice had the disease. In this
scenario, the prevalence of coccidioidomycosis at the time of the serosurvey would be
237/6,821 or 0.035 (3.5%); the incidence in September would be 97 cases, and the
incidence rate would be 97/6,821 or 0.014 (1.4%). Finally, the annual mortality rate due
to coccidioidomycosis would be 83/6,821 or 0.013 (1.3%), and the case fatality rate
would be 83/542 or 0.153 (or 15.3%).
Public health surveillance is defined as the ongoing systematic collection, analysis,
interpretation, and dissemination of outcome-specific data essential to the planning,
implementation, and evaluation of public health practice. In epidemiology, health
surveillance is accomplished in either passive or active systems. Passive
surveillance occurs when individual health care providers or diagnostic laboratories
send periodic reports to the public health agency. Because this reporting is voluntary
(sometimes referred to as being "pushed" to health agencies), passive surveillance
tends to underreport disease, especially in diseases with low morbidity and mortality.
Passive surveillance is useful for longterm trend analysis (if reporting criteria remain
consistent) and is much less expensive than active surveillance. An example of passive
surveillance is the system of officially notifiable diseases routinely reported to CDC by
select health departments across the USA. Active surveillance, in contrast, occurs
when an epidemiologist or public health agency seeks specific data from individual
health care providers or laboratories. In this case, the data are “pulled” by the requestor,
usually during emerging diseases or significant changes in disease incidence. Active
surveillance is usually much more expensive and labor intensive; it typically is limited to
short-term analyses of high-impact events. An example is the 1-yr surveillance
conducted by CDC of the rapid increase in incidence of coccidioidomycosis among
people in Arizona in 2007–2008.

Multiple Causation Theory

A number of models of disease causation have been proposed. Among the simplest of
these is the epidemiologic triad or triangle, the traditional model for infectious disease.
The triad consists of an external agent, a susceptible host, and an environment that
brings the host and agent together. In this model, disease results from the interaction
between the agent and the susceptible host in an environment that supports
transmission of the agent from a source to that host. Two ways of depicting this model
are shown in Figure 1.16.
Agent, host, and environmental factors interrelate in a variety of complex ways to
produce disease. Different diseases require different balances and interactions of these
three components. Development of appropriate, practical, and effective public health
measures to control or prevent disease usually requires assessment of all three
components and their interactions.
Figure 1.16 Epidemiologic Triad

Agent originally referred to an infectious microorganism or pathogen: a virus,

bacterium, parasite, or other microbe. Generally, the agent must be present for disease
to occur; however, presence of that agent alone is not always sufficient to cause
disease. A variety of factors influence whether exposure to an organism will result in
disease, including the organism’s pathogenicity (ability to cause disease) and dose.
Over time, the concept of agent has been broadened to include chemical and physical
causes of disease or injury. These include chemical contaminants (such as the L-
tryptophan contaminant responsible for eosinophilia-myalgia syndrome), as well as
physical forces (such as repetitive mechanical forces associated with carpal tunnel
syndrome). While the epidemiologic triad serves as a useful model for many diseases, it
has proven inadequate for cardiovascular disease, cancer, and other diseases that
appear to have multiple contributing causes without a single necessary one.
Host refers to the human who can get the disease. A variety of factors intrinsic to the
host, sometimes called risk factors, can influence an individual’s exposure,
susceptibility, or response to a causative agent. Opportunities for exposure are often
influenced by behaviors such as sexual practices, hygiene, and other personal choices
as well as by age and sex. Susceptibility and response to an agent are influenced by
factors such as genetic composition, nutritional and immunologic status, anatomic
structure, presence of disease or medications, and psychological makeup.
Environment refers to extrinsic factors that affect the agent and the opportunity for
exposure. Environmental factors include physical factors such as geology and climate,
biologic factors such as insects that transmit the agent, and socioeconomic factors such
as crowding, sanitation, and the availability of health services.
Natural History of Disease
Natural history of disease refers to the progression of a disease process in an individual
over time, in the absence of treatment. For example, untreated infection with HIV
causes a spectrum of clinical problems beginning at the time of seroconversion (primary
HIV) and terminating with AIDS and usually death. It is now recognized that it may take
10 years or more for AIDS to develop after seroconversion. Many, if not most, diseases
have a characteristic natural history, although the time frame and specific
manifestations of disease may vary from individual to individual and are influenced by
preventive and therapeutic measures.
Figure 1.18 Natural History of Disease Timeline

The process begins with the appropriate exposure to or accumulation of factors

sufficient for the disease process to begin in a susceptible host. For an infectious
disease, the exposure is a microorganism. For cancer, the exposure may be a factor
that initiates the process, such as asbestos fibers or components in tobacco smoke (for
lung cancer), or one that promotes the process, such as estrogen (for endometrial
cancer).
After the disease process has been triggered, pathological changes then occur without
the individual being aware of them. This stage of subclinical disease, extending from the
time of exposure to onset of disease symptoms, is usually called the incubation
period for infectious diseases, and the latency period for chronic diseases. During this
stage, disease is said to be asymptomatic (no symptoms) or inapparent. This period
may be as brief as seconds for hypersensitivity and toxic reactions to as long as
decades for certain chronic diseases. Even for a single disease, the characteristic
incubation period has a range. For example, the typical incubation period for hepatitis A
is as long as 7 weeks. The latency period for leukemia to become evident among
survivors of the atomic bomb blast in Hiroshima ranged from 2 to 12 years, peaking at
6–7 years.

Levels of Disease Prevention

There are three levels of prevention:
1. improving the overall health of the population (primary prevention)
2. improving (secondary prevention)
3. improving treatment and recovery (tertiary prevention).
Each of the three approaches has an important role to play in disease prevention.
However, upstream approaches, e.g. primary prevention, generally tend to be cheaper
and more efficient, and they entail lower morbidity and mortality rates. Health promotion
(EPHO 4) is inextricably intertwined with disease prevention.
A recent self-assessment of public health services in 41 of the 53 countries in the WHO
European Region found that:
 Primary prevention: routine immunization programmes are established in some
form in all countries, and in most cases are well developed and effective.
However, arrangements for delivery of vaccine programmes are under-
developed in some countries, especially for minority populations. Some
Commonwealth of Independent States have seen an increase in vaccine
preventable diseases following the breakdown of services available in the Soviet
era.
 Secondary prevention: routine screening for major forms of cancer now exists
in many countries, but not in all of them. Screening programmes are not always
evidence-based and systemic health checks for noncommunicable diseases are
not routine in most countries.
 Tertiary prevention: lack of availability and affordability of treatment for early
stage cancers is a limiting factor in some countries. Staff need training in
evidence-based treatment and management approaches for noncommunicable
diseases, and modern equipment.
As a result, a recommendation was made to ensure a balance in the three disease
prevention approaches: primary (vaccination and health promotion), secondary
(screening and early detection of disease) and tertiary (integrated patient-centred
disease management).

EO 958
WHEREAS, in the latest revision of the maximum retail prices of cigarettes under
Executive Order No. 924, the allowed margins for price adjustment have become
inadequate to meet current levels of production costs;
WHEREAS, unless the existing statutory maximum retail prices of cigarettes are
adjusted, certain cigarette manufacturers may be constrained to cut down production
which may result in the dislocation of a considerable number of factory workers and a
substantial drop in revenue collection;
WHEREAS, to obviate these contingencies, it is imperative that the maximum retail
prices of cigarettes be revised to provide sufficient leeway for price adjustments in order
to meet present levels of production costs.

RA 1054
- AN ACT TO REVISE AND CONSOLIDATE THE PROVISIONS OF ACT
NUMBERED THREE THOUSAND NINE HUNDRED SIXTY-ONE, AS
AMENDED, RELATIVE TO FREE EMERGENCY MEDICAL TREATMENT, AND
REPUBLIC ACT NUMBERED TWO HUNDRED THIRTY-NINE, RELATIVE TO
FREE EMERGENCY DENTAL TREATMENT, FOR EMPLOYEES AND
LABORERS OF COMMERCIAL, INDUSTRIAL AND AGRICULTURAL
ESTABLISHMENTS.

RA 9211
- AN ACT REGULATING THE PACKAGING, USE, SALE, DISTRIBUTION AND
ADVERTISEMENTS OF TOBACCO PRODUCTS AND FOR OTHER
PURPOSES.

Republic Act No. 9211, also known as the Tobacco Regulation Act of 2003, is an
omnibus law regulating smoking in public places, tobacco advertising, promotion and
sponsorship, and sales restrictions, among other requirements. 

RA 6425
Republic Act No. 6425, otherwise known as the Dangerous Drugs Act of 1972, as
amended, and providing funds for its implementation. Under this Act, the Dangerous
Drugs Board (DDB) remains as the policy-making and strategy-formulating body in
planning and formulation of policies and program on drug prevention and control.

RA 9165
- AN ACT INSTITUTING THE COMPREHENSIVE DANGEROUS DRUGS ACT
OF 2002, REPEALING REPUBLIC ACT NO. 6425, OTHERWISE KNOWN AS
 THE DANGEROUS DRUGS ACT OF 1972, AS AMENDED, PROVIDING
FUNDS THEREFOR, AND FOR OTHER PURPOSES

The Comprehensive Dangerous Drugs Act of 2002, or (Republic Act of the

Philippines) R.A. No. 9165, is a consolidation of Senate Bill No. 1858 and House Bill
No. 4433. This Act repealed Republic Act No. 6425, otherwise known as the Dangerous
Drugs Act of 1972, as amended, and providing funds for its implementation. Under this
Act, the Dangerous Drugs Board (DDB) remains as the policy-making and strategy-
formulating body in planning and formulation of policies and program on drug prevention
and control.

RA 8423
- AN ACT CREATING THE PHILIPPINE INSTITUTE OF TRADITIONAL AND
ALTERNATIVE HEALTH CARE (PITAHC) TO ACCELERATE THE
DEVELOPMENT OF TRADITIONAL AND ALTERNATIVE HEALTH CARE IN
THE PHILIPPINES, PROVIDING FOR A TRADITIONAL AND ALTERNATIVE
HEALTH CARE DEVELOPMENT FUND AND FOR OTHER PURPOSES

AO 179
PREVENTION OF BLINDNESS PROGRAM

Government Mandates and Policies :

 Administrative Order No. 179 s.2004: Guidelines for the Implementation of the
National Prevention of Blindness Program

Vision:        

 All Filipinos enjoy the right to sight by year 2020

Mission:     

The DOH, Local Health Unit (LGU) partners and stakeholders commit  to:

1. Strengthen partnership among and with stakeholder to eliminate avoidable

blindness in the Philippines;
2. Empower communities to take proactive roles in the promotion of eye health and
prevention of blindness;
3. Provide access to quality eye care services for all; and
 4. Work towards poverty alleviation through preservation and restoration of sight to
indigent Filipinos.

Goal:

Reduce the prevalence of avoidable blindness in the Philippines through the provision
of quality eye care.

RA 7277

- AN ACT PROVIDING FOR THE REHABILITATION, SELF-DEVELOPMENT

AND SELF-RELIANCE OF DISABLED PERSONS AND THEIR INTEGRATION
INTO THE MAINSTREAM OF SOCIETY AND FOR OTHER PURPOSES.

PROCLAMATION 40

DECLARING THE FIRST WEEK OF AUGUST OF EVERY YEAR AS SIGHT-

CONSERVATION WEEK

WHEREAS, a preliminary survey made by the Philippine Eye Bank shows that
approximately 40,000 blind Filipinos could have saved their sight if the necessary
precautions had been taken; and

WHEREAS, this fact points up the necessity of carrying on an educational campaign

throughout the country to prevent blindness among the people.

Laws on the control of Communicable Diseases in the Philippines

SENATE BILL NO. 1647

- AN ACT PROVIDING POLICIES AND PRESCRIBING PROCEDURES ON

SURVEILLANCE AND RESPONSE TO NOTIFIABLE DISEASES, EPIDEMICS,
AND HEALTH RELATED EVENTS, AMENDING FOR THE PURPOSE
REPUBLIC ACT NO. 3573 ENTITLED, "AN ACT PROVIDING FOR THE
PREVENTION AND SUPPRESSION OF DANGEROUS COMMUNICABLE
DISEASES AND FOR OTHER PURPOSES", AND APPROPRIATING FUNDS

REPUBLIC ACT No. 11332

- An Act Providing Policies and Prescribing Procedures on Surveillance and
Response to Notifiable Diseases, Epidemics, and Health Events of Public Health
Concern, and Appropriating Funds Therefor, Repealing for the Purpose Act No.
3573, Otherwise Known as the "Law on Reporting of Communicable Diseases"