UNIT: 1

INTRODUCTION TO EPIDEMIOLOGY: DEFINITIONS

Objectives of the lecture

By the end of this lecture the student successfully should:

1. Define Epidemiology

2. Discuss and outline the terms: Study, Distribution,

Determinants, Health-related States or Events, Specified
Populations, Application.

Introduction:
The term epidemiology is derived from three Greek words " Epi"-upon ,
among, "Demos" people and " logos" science, study, Thus it is the science
or study of events that occur among the people in a Community. It is a
study of health of population in relation to their environment and ways of
living. John Snow, a British physician is frequently considered the
“father” of epidemiology.
Definition of Epidemiology

There is a general definition is that given by Schwabe et al (1977), “the

study of disease in populations.”

Useful Definition:

Stated by Olsen et al (2000): “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”.

Principles of Epidemiology:

The broad definition of epidemiology contains below listed basic principles:

 Study refers to scientific, systematic, data-driven work and includes:

1. Surveillance 4. Analytic research

2. Observation 5. Experiment

3. Hypothesis testing
 Distribution refers to frequency and pattern for analysis of health
events in a population.
 Determinants include causes and risk factors that influence health such
as:

1. Biological

2. Chemical

3. Physical

4. Social

5. Cultural

6. Economic

7. Genetic

8. Behavioral

 Frequency refers to the way how to measure health events such as:

1. Incidence

2. Prevalence

3. rates

 Pattern refers to the occurrence of health-related events by:

1. Times 3. Places

2. Persons 4. Classes of people affected

 Health-related states or events which are not just diseases and

refer to:

1. Diseases 4. Positive health states

2. Causes of death 5. Reactions to preventive

regimes
3. Behaviors such as use of
tobacco 6. Provision and use of health
services
  Specified populations are patients in community and individuals viewed
collectively which include: those with identifiable characteristics, such as
Occupational groups.
 Application include the practice of recommendations since epidemiology
is a discipline within public health to:

1. Prevention and control the aims of public health

2. Promote, protect, and restore health.

Concept of epidemiology:

Epidemiology is basically concerned with the reasons why those individuals

became diseased in the first time and place. Basic concepts in epidemiology
have been discussed to lay a foundation for epidemiological investigation of
community health problems. These concepts aids in identifying variables that
public health professional consider when they describe the distribution patterns
and determinants of health, disease and condition frequencies in populations.
They help to analyze the relationships in disease or condition outbreaks. To
establish these casual relationships, health professionals use a scientific process
known as the epidemiological process.

The epidemiological process is a systematic course of action taken to identify

person who is affected, place where the affected persons reside, when the person
were affected (time), casual factors of health and disease, and prevention and
control measures in relation to the natural life history of a disease or condition.

Terminology Used In Epidemiology:

1. Agent: A biological, physical or chemical entity capable of causing disease.

2. Antibody: A protein substance produced in response to either naturally or

artificially introduced antigenic stimulation which tends to neutralize the
antigens.

3. Antigen: A substance that stimulates the production of antibodies when it

gains entrance to the blood or body tissues.

4. Antiserum: Serum containing specific antibody.

5. Attack Rate: A measure of the frequency of new cases of a disease in a

defined population during a given period, usually expressed as a percentage.

6. Carrier: A person ( or animal) who harbors' a specific disease causing agent

in the absence of clinical manifestations and who serves as a potential source
of infection to others.
 7. Communicable: Capable of being transmitted directly or indirectly from an
infected person or animal to a susceptible host.

8. Communicable disease: An illness due to a specific infectious agent or its

toxic products which transmitted from an from an infected person or animal
or a reservoir to a susceptible host, either directly or indirectly through an
intermediate host, vector or the inanimate environment.

9. Communicable period: The times during which an infectious agent may be

transferred directly or indirectly from an infected person to an animal including
anthropoid.

10. Contamination: The presence of an infections agent on a body surface,

article, clothes, bedding, toys, surgical instruments or dressing or other
inanimate article or substance including water, milk, and food.

11. Contagious disease: A clinically manifest disease of man or animals relating

from an infection.

12. Disinfection: Destruction of pathogenic microorganisms by physical or

chemical means.

13. Droplet Nuclei: Small airborne residues that result from evaporation of
droplets, emitted by an infected host.

14. Endemic: The constant presence of a disease or infectious agent within

a given geographical area.

15. Environment: The entire surroundings external to the human host.

16. Epidemic: Prevalence of disease in a community at once, but not presiding

continuously.

17. Epidemiology: The study of the distribution and determinants of disease in

human population.

18. Epidemiologist:

 An epidemiologist is a public health scientist, who is responsible for carrying

out all useful and effective activities needed for successful epidemiology
practice.

 A person who applies epidemiologic principles and methods for

prevention and control of disease.
19. Epizootic: An epidemic out break of disease in an animal population often
with the implication that it may also affect human populations

20. Epronithic: An epidemic out break of disease in a bird population.

21. Exotic: Disease which are imported into a country in which they do not
otherwise occur,
Eg, Epidemic occurrence of polyarthritis in visitors to Fizi, due to Ross River
virus which is an alpha virus presumed to have been introduced by infected
mosquitoes harbored in aircraft.

22. Fatality Rate: Usually expressed as a percentage of the number of persons

diagnosed as having a specified disease and the number who die as a result of
that illness.

23. Fomites: Inanimate articles other than food or water contaminated by the
infectious discharges from a patient and capable of harboring and transferring
the infectious agent to a healthy person.
Eg: Hand kerchief, pencils, toys, utensils, drinking glasses.

24..Herd immunity: Resistance of a group to invasion and spread of an infectious

agent, based on the immunity of a high proportion of individual numbers of
the group.

25. Host: Vertebrate or invertebrate species capable of being infected by an agent.

26. Immunity: The state of being immune ie, possessing specific

antibodies as a result of previous infection or immunization.

27. Incidence: Frequency of occurrence of new cases of a disease in a population

over a stated period of time expressed as a rate.

28. Incidence Rate: A quotient (rate) with the number of new cases of a specified
disease diagnosed or reported during a defined period of time as the numerator
and the number of persons in the population in which they occurred as the
denominator. This is usually expressed as cases per 1000 or 1, 00,000
populations.

29. Incubation Period: The time interval between contact with an infectious
agent and appearance of first sign or symptom of disease in person.

30. Index Case: The first case among a number of similar cases which are
epidemiologically related.
31. Infection: The entity and development or multiplication of an infectious agent
in the body of a person or animal.

32. Infectious Agent: An organism ( viral, rickettsia, bacterial, fungal, protozoal

or helminthes) that is capable of producing infection or infectious diseases.

33. Infestation: The lodgment development and reproduction of arthropods on the

surface of the body or in clothing, infested articles or premises are those that
harbor or give shelter to animal forms especially arthropods and rodents.

34. Isolation: Limitation of movement of a person having a communicable

disease or of a carrier who harbors' an infective agent.

35. Mortality Rate: A measure of the frequency of deaths in a defined population

during a specified time and expressed as the number of deaths per 1,000 or 1,
00,000 populations.

36. Morbidity: According to WHO terms of morbidity could be measured in

3units a) Person who were ill, b) the illnesses (periods or spells of illness) that
these persons experienced c) the duration of ( days, weeks etc) of these
illnesses all these aspects of morbidity is measured by morbidity rates and
morbidity ratio.
37. Nosocomical infection: Nosocomial infection is an infection originating in a
patient while in a hospital or other health care facility. It is otherwise known as
hospital acquired infection.

38. Non Communicable: Disease which is not transferred from person to person
eg, cancer, cardiovascular diseases, diabetes etc.

39. Pathogenicity: Ability to cause disease.

40. Pandemic: Capability of an agent to cause disease in a susceptible host.

41. Prevalence: The number of cases of a disease, existing at a particular time

within a given population.

42. Prevalence Rate: A quotient (rate) obtained by using as the numerator the
number of sick persons or portraying a certain condition in a stated population
at a particular time, regardless of when that illness or condition began and as
the denominator the number of person in the population in which they
occurred, expressed as a number of cases per 1,000 or 1, 00,000 population.

43. Prodromal: Indicating impending attack, premonitory symptoms of a

disease.
44. Prophylaxis: Measures taken for prevention of the development and spread
of a disease.

45. Quarantine: Restriction of movement of those who have been in contact with
a communicable disease for the period of time during which they may be
potentially infectious to others.

46. Reservoir: Animate or inanimate matter in which an infectious agent

normally lives and multiplies.

47. Source of infection: Person, animal, objects or substance from which an

infectious agent passes to a host.

48. Surveillance of disease: The continuous scrutiny of all aspects of

occurrence and spread of disease.

49. Sporadic case: A person whose medical history and symptoms suggest that
he may have or be developing a particular disease.

50. Transmission: Direct or indirect transfer of an infectious agent from a

reservoir to a susceptible host.

48.Vector: An arthropod or other invertebrate that transmits an infectious agent

from a source of infection to susceptible host.

51. Vehicle: An object or substance will be a source of infection.

52. Virulence: The degree of pathogenicity of infectious agent.

53.Zoonoses: An infection or an infectious disease transmissible under natural

conditions between animal and men.

References

• Basic of Epidemiology Pages 3-4

• 31-31 ‫أساسيات علم الوبائيات صفحة‬

The end
 UNIT 2

BASICS OF EPIDEMIOLOGY - EVOLUTION

Objectives of the lecture

By the end of this lecture the student successfully should:

1. Discuss the historical aspects of Epidemiology

2. Discuss the developmental stages of epidemiology

Historical development of epidemiology

Hippocrates (460-370 BC) Ancient age

1. He was, the first to use the terms "Epidemic" and "endemic" in his
books: "Air, water and places" and "Epidemics"
2. He spoke about disease distribution according to time, place
affected persons
3. He spoke about relation between disease and environment
4. His books included Important epidemiological remarks.

Islamic Age

1. Arab Islamic civilization Physicians such as Razi, Ibn Sina

(Avicina) and Ali ibn Abbas, they talk about epidemics in detail.
2. They rich the field of epidemiology with valuable studies like
smallpox and measles.

Age of Quantitative methods in epidemiological analysis

1. John Graunt (1620-1674) his studies included:

a. List of deaths in London.
b. Conduct the first analytical studies in the vital statistics
2. Thomas Sydenham (1624-1689)
a. Recognized as a founder of clinical medicine and
epidemiology
b. Emphasized detailed observations of patients & accurate
record keeping
3. Alexander Louis (1787-1872) practiced applications of statistics in
biology and medicine
 4. James Lind (1700’s) Designed first experiments to use a
concurrently treated control group
5. Ignas Semmelweis (1840’s) Pioneered hand washing to help
prevent the spread of septic infections in mothers following birth

Age of Traditional Epidemiological Surveys

It is the most important and richest stage, in which the

epidemiological methods were used in the study of health problems, and
epidemics of infectious diseases.

The most prominent men of this stage are:

1. Edward Jenner (1749-1823) Pioneered clinical trials who made his

first epidemiological test of vaccination against smallpox
2. John Snow (1813-1858), who studied the cholera epidemic in
London in 1854 and used the survey in descriptive, analytical,
and experimental epidemiological methods
3. Peter L. Panum (1820-1885) who studied a measles epidemic in
the Faroe Islands and presented an important report on the
response of virgin population to infection.

Age of Focusing on Infectious Diseases

It is another important stage in the evolution of epidemiology, this stage

has accompanied the first important discoveries of germ by Louis Pasteur
(1822-1895) and Robert Koch (1843-1910)

Achievements of this stage are:

1. Many pathogens have been discovered.

2. Attention focused on microorganisms and their role in causing the
disease
3. Assumptions of Robert Koch (A specific microorganism is always
associated with a given disease) considered as the guide proof of the
establishment of disease causes.
4. laying the foundations for the control and eliminate of infectious
diseases through epidemiological thought.
Age of Non-Communicable Diseases

Joseph G. Berger (1874-1927) is a pioneer in this stage. He proved

by his excellent food experiments that Pellagra (corn disease or illness)
caused by dietary deficiency and not a contagious (infectious) disease.

The age of study of the etiology of the disease

This advanced stage Based the development in epidemiological

studies such as randomized controlled studies.

It includes:

1. Clinical trials efficiency of medicines and vaccines.

2. Its role in the fight against health problems.

Age of the use of epidemiology to assess health care

1. This age began in the second half of the twentieth century.

2. They use experimental epidemiology to study the effectiveness
and efficiency of a large number of health care activities.
3. The leader in this was Cochrane (1988-1909) whom his book
“Effectiveness and efficiency “is a Traditional reference in
Epidemiology and become an essential tool in health services
planning and evaluation planning and evaluation of health services

Florence Nightingale Period

 Florence Nightingale period between (1820–1910) she pursued a

career in nursing and she is the pioneer of modern nursing.
Nightingale worked to improve the sanitary conditions of army
hospitals and to reorganize their administration.
 The Times immortalized her as the “Lady with the Lamp” because
she ministered to the soldiers throughout the night.
 When she returned to England, Nightingale carried out an
exhaustive study of the health of the British Army.
 She created a plan for reform, which was compiled into a 500-page
report entitled Notes on Matters Affecting the Health, Efficiency,
and Hospital Administration of the British Army(1858).
  In 1859, she published Notes on Hospitals, which was followed in
1860 by Notes on Nursing: What It Is and What It Is Not. That
same year she established a nursing school at St. Thomas’s
Hospital in London.
 Nightingale wanted to make nursing a respectable profession and
believed that nurses should be trained in science. She also
advocated strict discipline and an attention to cleanliness, and felt
that nurses should possess an innate empathy for their patients.
 Nightingale’s monitoring of disease mortality rates showed that
with improved sanitary methods in hospitals death rates decreased.
 Nightingale developed applied statistical methods to display her
data, showing that statistics provided an organized way of learning
and improving medical and surgical practices.
 In 1858, she became a Fellow of the Royal Statistical Society, and
in 1874 became an honorary member of the American Statistical
Association.

References

Basic of Epidemiology Page 14-15

31-31 ‫أساسيات علم الوبائيات صفحة‬

The end
 UNIT 3

BASICS OF EPIDEMIOLOGY- USES

Objectives of the lecture:

By the end of this lecture the student successfully should:

1. Discuss and enumerate the uses of Epidemiology

2. Discuss and enumerate Core Epidemiologic Functions

3. Discuss the Natural History and Spectrum of Disease:

Uses of Epidemiology

1-Assessing the community’s health

Public health officials responsible for policy development, implementation, and

evaluation use epidemiologic information as an accurate 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).

2-Making individual decisions

Individuals used epidemiologic information to take a daily decision affecting

their health. Such as: decide to quit smoking, climb the stairs rather than wait
for an elevator, eat a salad rather than a cheeseburger with fries for lunch.

3-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.
4-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.

Core Epidemiologic Functions:

1-Public health surveillance

Public health surveillance is the ongoing, systematic collection, analysis,

interpretation, and distribution of health data to help guide public health
decision making and action.

Surveillance is equivalent to monitoring the pulse of the community.

2-Field investigation

One of the first actions that results from a surveillance case report or report of a
cluster is investigation by the public health department. The investigation may
be as limited as a phone call to the health-care provider to confirm or clarify
the circumstances of the reported case, or it may involve a field investigation
requiring experts and systemic work.

3- Analytic studies

Surveillance and field investigations are usually sufficient to identify causes,

modes of transmission, and appropriate control and prevention measures. But
sometimes analytic studies employing more rigorous methods are needed.

4-Evaluation

Evaluation is the process of determining, as systematically and objectively as

possible, the relevance, effectiveness, efficiency, and impact of activities with
respect to established goals.

1. Relevancy refers to the degree to which something is related or useful

to what is happening

2. Effectiveness refers to the ability to be successful and produce the

intended results
 3. Efficiency refers to the ability of the program to produce the intended
results with a minimum time and resources.

4. Impact refers to have an influence on something

5- Linkage

field epidemiology is often said to be a “team sport.” During an investigation

an epidemiologist usually participates as either a member or the leader of a
multifunction team. Other team members may be laboratorians, sanitarians,
infection control personnel, nurses or other clinical staff, and, increasingly,
computer information specialists.

6-Policy development

Really, epidemiologists who understand a problem and the population in which

it occurs are often in a uniquely qualified position to recommend appropriate
interventions.

As a result, epidemiologists working in public health regularly provide input

and recommendations regarding disease control strategies,

Natural History and Spectrum of Disease:

Natural history of disease refers to the progression of a disease process in an

individual over time, in the absence of treatment.
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.
Incubation period:

The period from exposure to infection to the onset of symptoms or signs of

infectious disease.

The length of incubation period depends on:

 The portal of entry.

 The rate of growth of the organism in the host.

 The dosage of the infectious agent.

 The host resistance.

Period of Communicability

The time during which an infectious agent may be transmitted directly or

indirectly from an infected person to a susceptible person or animal.

Its length varies from one disease to another

Spectrum of disease:

The spectrum of disease is the range of is the disease process which may result
in illness that ranges from mild to severe or fatal.

Infectivity: refers to the proportion of exposed persons who become infected.

Capacity of agent to enter and multiply in a susceptible host ( Polio and
measles)

Virulence: refers to the degree of pathogenicity of an infectious agent. i.e. the

ability of the agent to invade and damage tissues of the host causing severe
manifestations or death.

Benefits of epidemiology for nursing:

 A model for quantitative nursing research

 A strategy for evaluating the clinical nursing research literature
 A framework for thinking for clinical decisions
 A mechanism for the effective and efficient planning and delivery
of nursing services to those who most need them
 An opportunity to enrich current nursing concepts, or to create new
and mutually enhancing shared theory
Implications in nursing practice:

 Epidemiological research is of immense value in determining the

health of populations

 Much epidemiological research informs the planning and

implementation of health-related policy. Much of this policy has a
fundamental impact on the way that the nursing profession delivers
its care

 Many nurses are unaware of the impact that epidemiology has on

their working practice. Nursing research in this area is limited and
inconsistent

 Epidemiology is traditionally seen as a discipline associated with

medicine and public health. Many other health-related disciplines
are now seen to be using and adapting it for their own purposes and
reaping its benefits. Nursing has yet to adopt epidemiology’s
knowledge base in its own educational and practice arenas

References

• Basic of Epidemiology Pages 4-6

• 8-6 ‫أساسيات علم الوبائيات صفحة‬

The end
 UNIT:4

MEASURING HEALTH AND DISEASE

The objectives:

By the end of this lecture the student should:

1. Discuss the importance of health and disease Measurement

2. Define health according to WHO.
3. Define and discuss measuring disease frequency.

Importance of measuring health and disease

1. The measurement of health and disease, is a key element in

Epidemiology.
2. There are multiple types of measurements to describe the health
of the population.
3. The great challenge facing the Epidemiologists is the lack of
health and disease measures in many countries of the world.

WHO definition of Health

Health is a state of complete physical, mental and social well-

being and not merely (Just) the absence of disease or infirmity.

• Today, three types of definition of health seem to be possible and

are used.

1. The first is that health is the absence of any disease or impairment.

2. The second is that health is a state that allows the individual to
adequately cope with all demands of daily life.
3. The third definition states that health is a state of balance, an
equilibrium that an individual has established within himself and
between himself and his social and physical environment.

Diagnostic Criteria

o Based on: Symptoms, Signs , History, Test results

 Eg: Hepatisis -------------- anti bodies
o Also: Simple criteria Such as :
 Bacterial pneumonia--------respiratory rate
 In : HIV AIDS
 o Major sign:
 Weight loss, chronic diarrhea Prolong fever
o Minor sign:
 Persistent chough, herpes zoster, lymphnode swelling
o Recently:
 CD4+ lymphocyte less than 200/µL
Measuring Disease Frequency

Population at risk:

– They are the people who are susceptible to a given disease

The incidence and incidence rate:

1. Incidence is the number of newly diagnosed cases of a disease.

2. An incidence rate = the number of new cases of a disease
divided by the number of persons at risk for the disease.
• If, in one year, 5 women are diagnosed with breast cancer,
• -the total female study population is 200
• -then we would say the incidence rate of breast cancer in
this population is: 5/200=0.025.

Prevalence and prevalence rate:

1. The prevalence of disease is the frequency of existing case

in a defined population at a given point in time.
2. The number of prevalent cases is the total number of cases of
disease existing in a population.
 3. A prevalence rate is the total number of cases of a disease
existing in a population divided by the total population.
4. P= total number of cases\total population x 10n

Morbidity and Morbidity rate:

1. Morbidity is another term for illness.

2. A person can have several co-morbidities simultaneously.
3. So, morbidities can range from Alzheimer's disease to cancer
to traumatic brain injury.
4. Morbidities are NOT deaths.
5. Morbidity rate looks at the incidence of a disease across a
population and/or geographic location during a single year.
6. Morbidity rates vary depending on the disease in question. Some
diseases are highly contagious (spreadable), while others are not.
7. Similarly, some diseases are more likely to affect one
demographic than another.
8. Morbidity rates help doctors, nurses, and scientists to calculate
risks and make recommendations for personal and public health
matters accordingly.

Mortality and mortality rate:

1. Mortality is another term for death.

2. Mortality rate is the rate of death in a population.
3. A mortality rate = the number of deaths divided by the total population.
4. If there are 25 lung cancer deaths in one year in a population of 30,000,
then the mortality rate for that population is 83 per 100,000.
5. Mortality rate = 25\30,000=8.3 or 8.3x 100 = 83 per 100,000
6. The mortality and morbidity are often used together to calculate the
prevalence of a disease e.g., measles and how likely that disease is to be
deadly, particularly for certain demographics.

References

• Basic of Epidemiology Pages 15-29

• 73-52 ‫أساسيات علم الوبائيات صفحة‬
 UNIT:5

EPIDEMIOLOGICAL DATA

Objectives of the lecture

By the end of this lecture the student successfully should:

1. Discuss the concept of Epidemiological data

2. Discuss the uses of Epidemiological data
3. Enumerate the sources of epidemiological data
4. Organize and summarize data

Concept of epidemiological data

Epidemiological data are a key prerequisite for identifying deficits and
problems in health care systems, and offering guidance in service
planning and resource allocation.

Uses Epidemiological Data for Risk Assessment

1. Epidemiologists use primary and secondary data sources to
calculate rates and conduct studies.
2. Epidemiological data play an important role in healthcare policy
making
 Epidemiological data helps to plan and strategies to prevent and
manage epidemic diseases or illness.
3. Epidemiological data remain an important evidence for a risk
assessment.
a) DIET AND CANCER
 Epidemiological data have shed light on some of the
mechanisms of cancers of the colon and rectum,
 Diets high in fruits and vegetables have been associated with
lower rates of colorectal cancer.
 Diets high in red meat have been associated with higher rates
of colorectal cancer.
b) Cigarette Smoke Interferes with Oocyte and Embryo Transport
 Epidemiological data have revealed a correlation between
smoking and ectopic pregnancy in women.
 c) Co-morbidity
 Epidemiological data suggests co-morbid psychiatric
disorders are common and in fact more the rule rather than the
exception
d) Tobacco Smoking
 Epidemiological data provide strong evidence for a causal
association between cigarette smoking and other lifestyle
factors and decreased fertility.
Sources of epidemiological data
1. Primary data is the original data collected for a specific purpose by
or for an investigator.
 For example, an epidemiologist may collect primary data by
interviewing people who became ill after eating at a restaurant in
order to identify which specific foods were consumed.
 Collecting primary data is expensive and time-consuming,
2. Secondary data is data collected for another purpose by other
individuals or organizations.
 Examples of sources of secondary data that are commonly used in
epidemiological studies include:
1. birth and death certificates,
2. population census records,
3. patient medical records,
4. disease registries,
5. insurance claim forms and billing records,
6. public health department case reports,
7. and surveys of individuals and households.

Sources Of Information For Epidemiologic Study

Epidemiologic investigators may draw data from any of three

major sources: existing data, informal investigations, and scientific
studies

I. Existing Data:
A variety of information is available nationally, by state, and by
section, such as county, region, or urbanized area.
This information includes vital statistics, census data, and
morbidity statistics:
 • Vital Statistics: Vital statistics refers to the information gathered
from ongoing registration of births, deaths, adoptions, divorces,
and marriages. Certification of births, deaths, and fetal deaths are
the most useful vital statistics in epidemiologic studies.
• Census Data: Data from population censuses taken every 10 years
in many countries are the main source of population statistics.
• Population statistics : It can be analyzed by age, sex, race, ethnic
background, type of occupation, income, marital status, educational
level, or other standards, such as housing quality.
• Reportable Diseases: Each state has developed laws or regulations
that require health organizations and practitioners to report to their
local health authority cases of certain communicable and infectious
diseases that can be spread through the community. This reporting
enables the health department to take the most appropriate and
efficient action.
• Disease Registries: Some areas or states have disease registries
with major public health impact. Cancer registries provide useful
incidence, prevalence, and survival data and assist the community
health nurse in monitoring cancer patterns within a community.
• Environmental Monitoring: State governments, through health
departments, now monitor health hazards found in the
environment. Pesticides, industrial wastes, radioactive or nuclear
materials, chemical additives in foods, and medicinal drugs have
joined the list of pollutants.

Concerned community members and leaders view these as

risk factors that affect health at both community and individual levels.

II. Informal Observational Studies:

A second information source in epidemiologic study is

informal observation and description. Almost any client group
encountered by the community health nurse can trigger such a
study.
If several cases of diabetes come to the attention of a
nurse serving on a Navajo reservation, a widespread problem might
come to light through informal inquiries about the incidence and
age at onset of the disease among this Native American population.
III. Scientific Studies:

The third source of information used in epidemiologic

inquiry involves carefully designed scientific studies.
→ Systematic studies such as these, as well as informal studies
and existing epidemiologic data, can provide the community
health nurse with valuable information that can be used to
positively affect aggregate health.

Organizing and summarizing epidemiological data

 In descriptive epidemiology, there are three variables Time, Place
and Person Through which data can be organize and summarize.
 Organizing and analyzing data by time, place, and person is
desirable for several reasons.
1. The investigator becomes familiar with the data and so with the
public health problem being investigated.
2. It provides a detailed description of the health of a population
that is easily communicated.
3. Such analysis identifies the populations at greatest risk of
acquiring a particular disease.
4. This information provides important evidences to the causes of the
disease and these clues can be turned into testable hypotheses.
Time & Demonstration
1. Disease rates change over time, some of these changes occur
regularly and be predicted.
For example:
 The seasonal increase of influenza cases with the onset of
cold weather is a pattern that is familiar to everyone.
 2. Time data can be demonstrated as a graph (histogram, chart or pie).
3. Such a graph provides a simple visual illustration of the relative
size of a problem.

Place & Demonstration

1. Health event can be described by place to gain insight into the
geographical extent of the problem.
For example:
 Place of residence, birth place, place of employment, school
district, hospital unit, etc., can be used depending on which may
be related to the occurrence of the health event.
 Similarly, large or small geographic units such as country, state,
street address, or map coordinates can be used.
 Sometimes, it may find useful to analyze data according to
place categories such as urban or rural, domestic or foreign, and
institutional or non-institutional.
2. It believed that provides more useful information to show the data
in Table.
3. Analyzing data by place, it could be also getting an idea of where
the agent that causes a disease normally lives and multiplies, what
may carry or transmit it, and how it spreads.
 Person & Demonstration

1. In descriptive epidemiology, organizing or analyzing data by

“person”, there are several categories available such as
 Inherent characteristics of people (for example, age, race, sex)
 Their acquired characteristics (immune or marital status)
 Their activities (occupation, free activities, use of medications
/tobacco)
 Or the conditions under which they live (socioeconomically,
access to medical care).
2. These categories determine who is at greatest risk.
3. Person data can be shown in either tables or graphs.

References

• Basic of Epidemiology Pages 63-66

• 37-37 ‫أساسيات علم الوبائيات صفحة‬

 UNIT:6
EPIDEMIOLOGICAL STUDIES
By the end of this lecture the student successfully should:
1. Define the types of epidemiological studies
2. Discuss the concepts of descriptive epidemiology
3. Discuss some examples of epidemiological studies

Types of Epidemiological studies

Epidemiologic studies fall into two categories:
A. Observational studies
In an observational study, the epidemiologist simply observes the
exposure and disease status of each study participant and is often the first
step in an epidemiological investigation.

Observational studies further classified in to:

1. Descriptive Epidemiology: It aims to describe the distributions of

diseases and determinants. It provides a way of organizing and analyzing these
data to describe the variations in disease frequency among populations by
geographical areas and over time (i.e., person, place, and time).
The 5W’s of descriptive epidemiology:
What = health problem of concern
Who = person
Where = place
When = time
Why/how = causes, risk factors, modes of transmission

A. Time
 The occurrence of disease changes over time. Some of these
changes occur regularly, while others are unpredictable.
 Influenza (winter) and West Nile virus infection (August–
September). Hepatitis B and salmonellosis can occur at any time.
 Seasonality. Disease occurrence can be graphed by week or month
over the course of a year or more to show its seasonal pattern, if
any.
B. Place
Describing the occurrence of disease by place provides insight into
the geographic extent of the problem and its geographic variation.
 C. Person
Because personal characteristics may affect illness, organization and
analysis of data by “person” may use inherent characteristics of people
(for example, age, sex), biologic characteristics (immune status), acquired
characteristics (marital status), activities (occupation, leisure activities,
use of medications/tobacco drugs), or the conditions under which they live
(socioeconomic status, access to medical care).
i. Age.
Age is probably the single most important “person”
attribute, because almost every health-related event varies
with age. A number of factors that also vary with age include:
susceptibility, chance for exposure or incubation period of the
disease, and physiologic response.
ii. Sex.
Males have higher rates of illness and death than do
females for many diseases. For some diseases, this sex-related
difference is because of genetic, hormonal, anatomic, or other
inherent differences between the sexes. These inherent
differences affect susceptibility or physiologic responses.
iii. Ethnic and racial groups.
Sometimes epidemiologists are interested in analyzing
person data by biologic, cultural or social grouping such as
nationality, religion, or social groups such as tribes and other
geographically or socially isolated groups. Differences in
racial, ethnic, or other group variables may reflect differences
in susceptibility or exposure, or differences in other factors
that influence the risk of disease.
iv. Socioeconomic status.
Socioeconomic status is difficult to quantify. It is made up of
many variables such as job, family income, educational
achievement, and living conditions.

2. Analytic Epidemiology:
As noted earlier, descriptive epidemiology can identify patterns
among cases and in populations by time, place and person. From
these observations, epidemiologists develop hypotheses about the
causes of these patterns and about the factors that increase risk of
disease.
In other words, epidemiologists can use descriptive epidemiology
to generate hypotheses, but only rarely to test those hypotheses. For
that, epidemiologists must turn to analytic epidemiology.
Thus, analytic epidemiology is concerned with the search for
causes and effects, or the why and the how. Epidemiologists use
analytic epidemiology to quantify the association between
exposures and outcomes and to test hypotheses about causal
relationships.
The purpose of an analytic study in epidemiology is to identify and
quantify the relationship between an exposure and a health
outcome.
Types of analytical studies
i. Cohort study .
Cohort studies, also called follow-up or incidence studies. In a
cohort study the epidemiologist records whether each study
participant is exposed or not, and then tracks the participants to see
if they develop the disease of interest .

ii. Case-control study

In a case-control study, investigators start by enrolling a group of
people with disease. As a comparison group, the investigator then
enrolls a group of people without disease (controls). Investigators
then compare previous exposures between the two groups. The
control group provides an estimate of the baseline or expected
amount of exposure in that population.
Case-control studies provide a relatively simple way to investigate
causes of diseases, especially rare diseases.
 iii. Cross-sectional study
In this third type of observational study, a sample of persons from
a population is enrolled and their exposures and health outcomes
are measured at the same time.
The cross-sectional study tends to assess the prevalence of the
health outcome at that point of time without regard to duration.

B. Experimental studies
In an experimental study, the investigator determines through a controlled
process the exposure for each individual (clinical trial) or community
(community trial), and then tracks the individuals or communities over
time to detect the effects of the exposure.

Clinical trials
 Clinical trials are research studies performed in people that are
aimed at evaluating a medical, surgical, or behavioral intervention.
 They are the primary way that researchers find out if a new
treatment, like a new drug or diet or medical device is safe and
effective in people.

Community trials
 In this form of experiment, the treatment groups are communities
rather than individuals.
 This is particularly appropriate for diseases that are influenced by
social conditions, and for which prevention efforts target group
Behavior.

Reference :

Pages 39- 52 basic epidemiology

 UNIT: 7
EPIDEMIOLOGY AND PREVENTION

INTRODUCTION:
Epidemiology can play a central role in prevention by identifying causes of disease. In
particular it provides quantitative measures of relative risk and absolute risk that help directly
preventive action, and it plays a major role in evaluating whether preventive programs actually
work in practice. Prevention may take place at any point along the spectrum of the disease, from
the prevention of the disease or injury to the prevention of impairment, disability or dependency.

DEFINITION:
Prevention is defined as “actions aimed at eradicating, eliminating or minimizing the impact of
disease and disability.

AIMS OF EPIDEMIOLOGY OF PRVENTION

1. Promote and preserve health and longevity in individuals and community by

adoption of healthy life style and health education.

2. Prevent and limit diseases, injuries, and other ill health effects.

3. Enhance quality of health care system and assure that all populations have
access to appropriate and cost effective care.

4. Use epidemiology to assess and monitor the health of communities and

populations at high risk to identify health problems.

DETERMINANTS OF PREVENTION
Successful prevention depends upon:
a knowledge of causation,
dynamics of transmission,
identification of risk factors and risk groups,
availability of prophylactic or early detection and treatment measures,
an organization for applying these measures to appropriate persons or
groups, and
continuous evaluation of and development of procedures applied
CATEGORIES OR LEVELS OF DISEASE PREVENTION

1- Primordial prevention: (Acting on risk factor) consists of actions and

measures that inhibit the emergence of risk factors in the form of
environmental, economic, social, and behavioral conditions and cultural
patterns of living etc.
2- Primary prevention: (Acting before disease occurrence) Activities designed to
prevent onset of disease. We act before the development of the sign and
symptoms of the disease. Ex: Immunization, ban on smoking, speed limit, seat
belts.
3- Secondary prevention: (Acting after disease occurrence) Early identification
of health problems to reduce the risk of progression or transmission. Ex: Early
diagnosis of HT, DM, cervical CA, breast CA, STD.
4- Tertiary prevention: (Acting after complications occurrence) Focused on
rehabilitation to reduce the impairment. Ex: Learning to walk after stroke,
adjusting diet and life style after MI, learning to live with DM

(1) Primordial Prevention: Primordial prevention consists of actions and

measures that inhibit the emergence of risk factors in the form of environmental,
economic, social, and behavioral conditions and cultural patterns of living etc.

Intervention In Primordial Prevention

 It is the prevention of the emergence or development of risk factors in countries
or population groups in which they have not yet appeared
 For example, many adult health problems (e.g., obesity, hypertension) have
their early origins in childhood, because this is the time when lifestyles are
formed (for example, smoking, eating patterns, physical exercise). In
primordial prevention, efforts are directed towards discouraging children from
adopting harmful lifestyles
 The main intervention in primordial prevention is through individual and mass
education
(2) Primary Prevention : Primary prevention can be defined as the action taken
prior to the onset of disease, which removes the possibility that the disease will
ever occur.
Concept/ Strategy Of Primary Prevention
 It includes the concept of "positive health", a concept that encourages
achievement and maintenance of "an acceptable level of health that will
enable every individual to lead a socially and economically productive life".
 Primary prevention may be accomplished by measures designed to promote
general health and well-being, and quality of life of people or by specific
protective measures
  It signifies intervention in the pre-pathogenesis phase of a disease or health
problem.
 Primary prevention may be accomplished by measures of “Health
promotion” and “specific protection”
 The purpose of primary prevention is to limit the incidence of disease by
controlling specific causes and risk factors

PRIMARY PREVENTION
Health Promotion Specific Protection
-Immunization
-Health Education -Chemoprophylaxis
-Use Of Specific Nutrients Or Supplementations
-Environmental Modification
-Protection Against Occupational Hazars
-Nutritional Interventions -Safety Of Drugs And Foods
-Life Style And Behavioral -Control Of Environmental Hazards
Example :Air Pollution

Primary prevention efforts can be directed at:

 The whole population with the aim of reducing average risk (the population
or “mass” strategy); or
 People at high risk as a result of particular exposures (the high-risk-
individual strategy).
 Combining the population strategy and a high-risk strategy is useful in many
situations
(3) Secondary Prevention: It is defined as “ action which halts the progress of a disease at
its incipient stage and prevents complications.”

Specific Interventions Of Secondary Prevention:

The specific interventions are: early diagnosis (e.g. screening tests, and case
finding programs….) and adequate treatment.

The earlier the disease is diagnosed, and treated the better it is for prognosis
of the case and in the prevention of the occurrence of other secondary cases
Interventions:
 Early diagnosis: better prognosis, better prevention of further occurrence of a disease /
long term disability.
Screening
Contact Tracing
Individual exam (History, GPE, lab investigation)
 Prompt treatment
Individual T/M
Mass T/M by (total mass T/M, juvenile mass T/M and selective mass T/M)

Approaches To Secondary Prevention

There are two approaches to secondary prevention of communicable disease
i. Screening

ii. Contact investigation, partner notification, and case-finding.

i. Screening

 The term screening is used in community health and disease prevention to

describe programs that deliver a testing mechanism to detect disease in
groups of asymptomatic, apparently healthy individuals.
 Screening is a secondary prevention method because it discovers those who
may have already become infected in order to initiate prompt early treatment.
 It is important to remember that the screening itself is not diagnostic but
rather seeks to identify those persons with positive or suspicious findings
who require further medical evaluation or treatment.

Criteria for Screening Tests:

 Validity and Reliability. The screening test must be valid and reliable.
Validity refers to the test's ability to accurately identify those with the
disease. Reliability refers to the test's ability to give consistent results when
administered on different occasions by different technicians.
  Predictive Value and Yield. The predictive value of a screening test is
important for determining whether the screening intervention is justified.
Yield refers to the number of positive results found per number tested.

ii. Contact Investigation, Partner Notification, and Case-Finding

o Another secondary prevention approach is known as contact investigation, partner
notification, and case-finding. In this approach, the community health nurse seeks to
discover and notify those who have had contact with a person diagnosed with a
communicable disease such as with TB and to notify partners in the case of STDs.
o The objective of contact investigation and partner notification is specifically to reach
contacts of the index case (diagnosed person) before the contacts, in turn, become
infectious (CDC, 2002c).
o Community health nurse seek to discover and notify those who have had contact with
a person diagnosed with a communicable disease.
o Individuals with disease can identify the person with whom they are close

(4)Tertiary Prevention: It is defined as “all the measures available to reduce or

limit impairments and disabilities, and to promote the patients’ adjustment to
irremediable conditions.”

Intervention Of Teritary Prevention

Intervention that should be accomplished in the stage of tertiary prevention are
disability limitation, and rehabilitation
i. Disability Limitation
 When a patient report late in the pathogenesis phase, the mode of
intervention is disability limitation.
 Disability is thus not just a health problem. It is a complex phenomenon,
reflecting the interaction between features of a person’s body and features of
the society in which he or she lives.
 Evidence suggests that people with disabilities face barriers in accessing the
health and rehabilitation services they need in many settings.
 The stages of Disability limitation are disease, impairment, disability,
handicap

Disease:
The term disease broadly refers to any condition that impairs normal
function, and is therefore associated with dysfunction of normal
homeostasis.

Impairment:
Impairment is “any loss or abnormality of psychological, physiological or
anatomical structure or function.”
Disability:
Disability is “any restriction or lack of ability to perform an activity in the
manner or within the range considered normal for the human being.”

Handicap:
Handicap is termed as “a disadvantage for a given individual, resulting from
an impairment or disability, that limits or prevents the fulfillment of a role
in the community that is normal (depending on age, sex, and social and
cultural factors) for that individual.”

ii. Rehabilitation

Rehabilitation is “ the combined and coordinated use of medical, social,

educational, and vocational measures for training and retraining the
individual to the highest possible level of functional ability.”

Types Of Rehabilitation
 Medical rehabilitation
 Vocational rehabilitation
 Social rehabilitation
 Psychological rehabilitation

Community-based rehabilitation (CBR)

 Community-based rehabilitation (CBR) focuses on enhancing the quality of
life for people with disabilities and their families, meeting basic needs and
ensuring inclusion and participation.
 CBR was initiated in the mid-1980s but has evolved to become a multi-
sectoral strategy that empowers persons with disabilities to access and
benefit from education, employment, health and social services.
 CBR is implemented through the combined efforts of people with
disabilities, their families, organizations and communities, relevant
government and non-government health, education, vocational, social and
other services.
Approaches To Tertiary Prevention
There are three approaches to s tertiary prevention of communicable disease
 Isolation and quarantine of infected person
 Control of Transmission of disease by health care workers
 Safe handling and control of infectious waste
 i. Isolation and quarantine of infected person
Isolation and quarantine are used to protect the public by preventing exposure to
infected persons or to persons who may be infected. Isolation is used to separate ill persons who
have a communicable disease from those who are healthy. Quarantine is used to separate and
restrict the movement of well persons who may have been exposed to a communicable disease to
see if they become ill. Quarantine can also help limit the spread of communicable disease.
Isolation
• Isolation refers to separation of the infected person from the others for a
period to limit transmission of the infectious agent to susceptible persons.
 Need Of Isolation: Isolating sick people helps prevent the spread or
transmission of disease.
 Location Of Isolation: The location of isolation depends on how sick the
person is. Isolation might take place at home, but if the illness is more serious
— or if the patient is already hospitalized — isolation might take place in the
hospital.
 Period Of Isolation: The duration of isolation will depend on the severity of the
illness and how quickly the individual recovers.
 Information To People Regarding The Need For Isolation:A physician or
public health official will write orders for an individual to be isolated, either at
home or in a hospital, once he or she is diagnosed with or suspected to have the
disease.

Quarantine
• Quarantine refers to restrictions placed on healthy contact of an infectious
case for the duration of the incubation period to prevent transmission if
infection should develop.
 Need Of Quarantine: Some infections can be spread even before a person
knows he or she is sick or has any symptoms, so the person need quarantine.
 Location Of Quarantine: A person is usually quarantined in his or her own
home.
 Duration Of Quarantine: The individual and often the entire family will stay
at home until the risk of developing the disease or its symptoms is over and
health officials determine it is safe to end the quarantine. The length of time
varies, depending on the disease and its incubation period.
 Public Knowledge Regarding The Need For Quarantine: If widespread
quarantine is needed, people will be informed through public health news
announcements made on TV, on radio, in newspapers or using other media.
 Care Of Quarantine Person And Becomes Ill: A quarantined person who
develops symptoms associated with the disease in question should immediately
contact his or her personal physician and local public health department. Once
ill, the individual will be considered to be in “isolation” instead of quarantine.
 ii. Control of Transmission of disease by health care workers

Health care workers are at risk of exposure to a variety of infectious

diseases which may cause them illness and which may be transmitted from them to
other staff and patients.

General measures /Prevention of infection by health care workers:

 Assess infection risks to personnel and prioritize preventive measures.

 Implement an ongoing education programme about safety and infection prevention
related to the specific risks of work in the facility.
 Determine susceptibility to vaccine preventable diseases and implement an appropriate
immunization programme.
 Conduct exposure investigations, including review of post-exposure management.
 Implement surveillance of occupational blood exposures and develop prevention
strategies for high-risk practices or departments.
 Keep accurate, easily retrievable health records for all health care workers.
 Screen new employees for a history of communicable diseases. Immunize for vaccine
preventable diseases.
 Record needle stick and other injuries in an "accident' log; data on the epidemiology of
blood exposures should be analyzed periodically to audit practice and identify
preventable risks.
 Provide evaluation and guide work restrictions for staff with infectious diseases or
exposures.
 Ensure that all staff cover lesions on exposed skin with a waterproof dressing.

Other Preventive Measures:

Preventing the spread of infection often requires us to 'break the chain of infection',
i.e., to interrupt the normal routes of transmission.

Contact Prevention :

 Wash hands when they are likely to have been soiled and before beginning care for a new
patient.
 Waterless hand antiseptics are acceptable unless the hands are visibly soiled.
 For contact with all mucous membranes and non-intact skin, wear gloves that are clean at
the time of use.
 Use sterile gloves for normally sterile body sites.
 Wear appropriate barriers for the task, e.g., eyewear for spatter and appropriate gloves for
contact with all moist body substances.
 Disinfect all items between patients. Handle all clinical specimens as if known to be
infectious.
 Handle soiled linen and trash to avoid skin contact.
Airborne Prevention:

 Restricting susceptible staff from exposure is the best and often the only prevention
strategy for diseases transmitted in whole or in part by air.
 Common surgical masks provide minimal protection.
 High efficiency, respirator type masks may offer some protection when in close contact
with a coughing patient with tuberculosis.

Blood borne Prevention:

 Immunization is recommended for all healthcare workers who have exposure to blood
and body fluids.
 Observe safe practices to reduce needle stick injuries and other blood exposures.

For example,

Only re-cap disposable needles using a one-handed technique.

Place used sharps in puncture-proof containers before reprocessing or disposal.
Use no touch techniques (forceps or gloves) to handle blood or blood contaminated material.
Wear gloves for handling sharp items
Establish a procedure for reporting blood exposures to take management actions.
Surveillance for occupational blood exposures can provide data to direct prevention efforts.

iii. Safe handling and control of infectious waste

The environmental regulations actually mandate the treatment of infectious
medical waste on a daily basis if it is stored at room temperature. A number of treatment
methods are available. The final choice of suitable treatment method is made carefully, on the
basis of various factors, many of which depend on local conditions including the amount and
composition of waste generated, available space, regulatory approval, public acceptance, cost,
etc.
 UNIT :8
INVESTIGATION AND CONTROL OF EPIDEMICS
INTRODUCTION:
The goals of epidemiologic investigation are to identify the causal mechanisms of health
and illness states and to develop measures for preventing illness and promoting health.
Outbreaks are usually limited to a small area and usually within one district
or few blocks .An epidemic covers larger geographic areas. Epidemics
usually linked to control measures on a district/state wide basis
DEFINITION:
An epidemic is commonly defined as the occurrence in a community or area of cases of a
disease that are clearly in excess of what is expected.

PURPOSE OF CONDUCTING AN EPIDEMIOLOGIC INVESTIGATION

 The purpose of the epidemiologic investigation is to identify a problem,
collect data, formulate and test hypotheses. It involves the collection and
analysis of more facts or data to determine the cause of illness and to
implement control measures to prevent additional illness.

 Epidemiologic investigations are usually conducted in outbreak situations.

The main reasons for conducting an epidemiologic investigation are:
 to determine the cause of an outbreak, and
 to implement control measures to prevent additional illness

APPROACES OF EPIDEMIOLOGIC INVESTIGATIVE PROCESS:

Epidemiologists employ an investigative process that involves sequence of three approaches that
build on one another: descriptive, analytic, and experimental studies.

I. Descriptive Epidemiology :
Descriptive epidemiology includes investigations that seek to observe and describe patterns of
health-related conditions that occur naturally in a population.
For example, how many children in a school district have been immunized for measles, how
many home births occur each year in the country.
 Counts :The simplest measure of description is a count.
 Rates: Rates are statistical measures expressing the proportion of people with a given health
problem among a population at risk. The total number of people in the group serves as the
nominator for various types of rates.
• Several rates have wide use in epidemiology. Those most important for the community health
nurse to understand are the prevalence rate, and the incidence rate.
 Prevalence: It refers to all of the people with a particular health condition existing in a given
population at a given point in time.
 The prevalence rate : It describes a situation at a specific point in time.
• If a nurse discovers 50 cases of measles in an elementary school, that is a simple count. If that
number is divided by the number of students in the school, the result is the prevalence of
measles, for instance, if the school has 500 students, the prevalence of measles on that day
would be 10% (50 measles /500 population)
• Prevalence rate = number of persons with a characteristic
Total number in population
 Incidence : It refers to all new cases of a disease or health condition appearing during a given
time. Incidence rate describes a proportion in which the numerator is all new cases appearing
during a given period of time and the denominator is the population at risk during the same period.
To describe The morbidity rate, which is the relative incidence of disease in a population, the ratio
of the number of sick individuals to the total population is determined. The mortality rate refers or
sum of deaths in a given population at a given time
II. Analytic Epidemiology:
Analytic epidemiological studies aim to investigate and identify factors associated with the presence
of disease within populations, through the investigation of factors which may vary between
individual members of these populations.
Analytic studies include cohort, case-control and cross sectional studies, and may investigate
possible associations between risk factors and disease by either comparing the risk factor exposure
status in animals with disease to those without, or by comparing the occurrence of disease amongst
'exposed' animals to 'unexposed' animals.
• Cohort Studies: Cohort studies, rather study the development of a condition over time. A
cohort study begins by selecting a group of people who display certain defined characteristics
before the onset of the condition being investigated
• Case-Control Studies: Case-control studies compare people who have a health or illness
condition (number of cases with the condition) with those who lack this condition (controls).
These studies begin with the cases and look back over time for presence or absence of the
suspected causal factor in both cases and controls.
• Cross – sectional Studies: In a cross-sectional study, data is usually collected through a
survey. A population of interest is queried on a variety of possible exposures and on a variety
of diseases. For each exposure and each disease, there are four possible outcomes as listed in
this slide. These fours groups can be compared to suggest possible relations between
exposure and disease

III. Experimental Epidemiology:

It is used to study epidemics, the etiology of human disease, the value of preventive and therapeutic
measures, and the evaluation of health services.
• Experimental studies are carried out under carefully controlled conditions. The investigator
exposes an experimental group to some factors thought to cause disease, improve health,
prevent disease, or influence health in some way (as in the Women's Health Study).
Simultaneously, the investigator observes a control group that is similar in characteristics to
the experimental group but without the exposure factor.

STEPS IN AN EPIDEMIOLOGIC INVESTIGATION

The following steps need to be taken in all epidemiologic investigations.
1. Confirm the existence of an epidemic or an outbreak.
2. Confirm the diagnosis.
3. Determine the number of cases.
4. Orient the data in terms of time, person and place.
5. Develop a hypothesis.
6. Compare the hypothesis with the established facts.
7. Execute control and preventive measures.
8. Write a written report.
 1. Confirm the existence of an epidemic or an outbreak:
• Identify validity of source of information to avoid false alarm/a data entry
error
• Check with the concerned medical officer:
? Abnormal increase in the number of cases
? Clustering of cases
? Epidemiological link between cases
? Occurrence of some triggering event
? Occurrence of deaths
• Review if the source and mode of transmission are known
• If not, constitute team with:
? Medical officer
? Epidemiologist
? Laboratory specialist
2. Confirm the diagnosis:
This is done by obtaining appropriate specimens for laboratory study and
obtaining clinical histories.
Determine the number of cases. Remember, this information is
confidential and should be shared with only those individuals involved in the
investigation.

3. Determine the number of cases (ill people):

This helps to get an idea of the magnitude of the problem. Determination
of case numbers is based on creating a case definition. A case definition is a set of
criteria for deciding whether an individual should be classified as a case. The
common elements of a case definition include information on symptoms,
laboratory results, time, place and person.
a) Symptoms: People with the same illness do not always have the same
symptoms, but they will experience similar ones.
b) Laboratory results: during an outbreak of illness, efforts should be made to
send all specimens and/or isolates to the State Laboratory Institute (SLI) for
further identification, confirmation and to assure coordination of the
investigation.
c) Time: Multiple ways to consider this
Calendar time
Age
Time since an event
Can also examine different patterns
Long-term variation (e.g., trends)
Short-term variation (e.g., outbreaks, epidemics)
 d) Place: Characteristics of environment can show relationship between
physical features and disease.
For example, one can look at:
 Altitude, sunlight, temperature, pollution
 Proximity to Water/other natural resources
 Hazards or toxins
 Habitat of pathogen

e) Person: The outbreak may or may not take place within a particular group
of people. Therefore, characteristics such as age, sex, occupation, ethnic
group, social affiliations or function attendance greatly assist in qualifying
the case definition.

The Questionnaire/Survey
A common method of finding cases, organizing and analyzing data is
to conduct a questionnaire or survey among the population you believe to be
at risk, (e.g., attendees of a wedding). A questionnaire that targets specific
questions about foods eaten and symptoms experienced is a valuable
epidemiologic tool.
4. Orient The Data In Terms Of Time, Place, And Person:
The purpose of data orientation or epidemiological characterizations is to
arrange all incoming data so it means something. The investigator is searching for
common associations based on TIME, PLACE, and PERSON to strengthen or
amend current hypotheses. A common method of data orientation is plotting, on a
graph, the cases by time of symptom onset to get an epidemic curve.
An epidemic curve is a graph that depicts the association of the time of illness
onset of all cases that are associated with the outbreak. It helps to determine
whether the outbreak originated from a common source or person to person. Time
is plotted on the horizontal axis and the number of cases plotted on the vertical
axis.
The shape of the epidemic curve may suggest what kind of outbreak is
occurring. A common-source or point-source outbreak looks different than a
propagated-source or person-to-person outbreak and a continual source outbreak.
5. Develop a hypothesis:
It explains the specific exposure(s) that may have caused the disease (and
test this by appropriate statistical methods). Using the information gathered from
the previous steps, consider the possible source(s) from which the disease may
have been contracted.

Hypotheses are developed in a variety of ways. First, consider

what the known epidemiology for the disease: What is the agent's usual reservoir?
How is it usually transmitted? What are the known risk factors? Consider all the
'usual suspects'.
 6. Compare the hypothesis with the established facts and draw
conclusions:
The term "comparisons" in multiple comparisons typically refers to
comparisons of two groups, such as a treatment group and a control group.

A comparison with established facts is useful when the evidence is so

strong that the hypothesis does not need to be tested.

Hypothesis Testing: Deciding whether your data shows a “real” effect,

or could have happened by chance
• Hypothesis testing is used to decide between two possibilities:
– The Research Hypothesis
– The Null Hypothesis
• H1: The Research Hypothesis
– The effect observed in the data (the sample) reflects a “real” effect (in
the population)
• H0: The Null Hypothesis
– There is no “real” effect (in the population)
– The effect observed in the data (the sample) is just due to chance
(sampling error)

Five Steps of Hypothesis Testing

1. Write the null hypothesis (H0).

2. Write the alternative hypothesis (H1).

3. Set alpha level (amount of error allowed) and

determine degrees of freedom.

4. Pick & calculate the significance test that fits your

design.

5. Decision Step: Accept or Reject the null.

Common test statistics

One-sample tests are appropriate when a sample is being compared to the

population from a hypothesis. The population characteristics are known from
theory or are calculated from the population.

Two-sample tests are appropriate for comparing two samples, typically

experimental and control samples from a scientifically controlled experiment.
 Paired tests are appropriate for comparing two samples where it is impossible to
control important variables. Rather than comparing two sets, members are paired
between samples so the difference between the members becomes the sample.
Typically the mean of the differences is then compared to zero.

Z-tests are appropriate for comparing means under stringent conditions regarding
normality and a known standard deviation. T-tests are appropriate for comparing
means under relaxed conditions (less is assumed). Tests of proportions are
analogous to tests of means (the 50% proportion).

Chi-squared tests use the same calculations and the same probability distribution
for different applications:

 Chi-squared tests for variance are used to determine whether a normal

population has a specified variance. The null hypothesis is that it does.
 Chi-squared tests of independence are used for deciding whether two variables
are associated or are independent.
 Chi-squared goodness of fit tests are used to determine the adequacy of curves
fit to data.

F-tests (analysis of variance, ANOVA) are commonly used when deciding

whether groupings of data by category are meaningful.

In the table below, the symbols used are defined at the bottom of the table. Many
other tests can be found in other articles.

Name Formula Assumptions or notes

(Normal population or n > 30) and
σ known.

(z is the distance from the mean in

relation to the standard deviation of
One-sample z-test the mean). For non-normal
distributions it is possible to
calculate a minimum proportion of
a population that falls within k
standard deviations for any k (see:
Chebyshev's inequality).
Normal population and
Two-sample z-test independent observations and σ1
and σ2 are known

(Normal population or n > 30) and

One-sample t-test
unknown
 (Normal population of differences
Paired t-test or n > 30) and unknown or small
sample size n < 30

Two-sample pooled (Normal populations or n1 + n2 >

t-test, equal 40) and independent observations
variances and σ1 = σ2 unknown
[18]

Two-sample (Normal populations or n1 + n2 >

unpooled t-test, 40) and independent observations
unequal variances and σ1 ≠ σ2 both unknown

[18]

n .p0 > 10 and n (1 − p0) > 10 and it

One-proportion z-
is a SRS (Simple Random Sample),
test
see notes.

n1 p1 > 5 and n1(1 − p1) > 5 and n2

Two-proportion z-
p2 > 5 and n2(1 − p2) > 5 and
test, pooled for
independent observations, see
notes.

n1 p1 > 5 and n1(1 − p1) > 5 and n2

Two-proportion z-
p2 > 5 and n2(1 − p2) > 5 and
test, unpooled for
independent observations, see
notes.

Chi-squared test for Normal population

variance
df = k - 1 - # parameters estimated,
and one of these must hold.

• All expected counts are at least

Chi-squared test for 5.[19]
goodness of fit
• All expected counts are > 1 and
no more than 20% of expected
counts are less than 5[20]
 Normal populations
Two-sample F test
Arrange so and reject H0
for equality of
variances for
[21]

In general, the subscript 0 indicates a value taken from the null hypothesis, H0, which should
be used as much as possible in constructing its test statistic. ...

Definitions of other symbols:

 , the probability of Type I  = sample  = x/n = sample
error (rejecting a null variance proportion, unless
hypothesis when it is in fact  = sample 1 specified otherwise
true) standard deviation  = hypothesized
 = sample size  = sample 2 population proportion
 = sample 1 size standard deviation  = proportion 1
 = sample 2 size  = t statistic  = proportion 2
 = sample mean  = degrees of  = hypothesized
 = hypothesized freedom difference in proportion
population mean  = sample mean  = minimum
 = population 1 mean of differences of n1 and n2
 = population 2 mean  = hypothesized 
 = population standard population mean 
 = F statistic
deviation difference
 = population variance  = standard
 = sample standard deviation of
deviation differences
 = Chi-squared
 = sum (of k numbers) statistic

The process of drawing conclusions has three steps and is best approached by
laying out all your information in front of you:

First, gather all your information in one place. Do the following:

1. Lay out each hypothesis from the study.

2. Arrange the data from each dependent variable under its corresponding
hypothesis.
3. Attach the statistical analysis decisions with each hypothesis.
4. Attach information regarding the test validity and reliability of each
dependent variable to each hypothesis.
5. Have available to the side, information regarding the internal and external
validity of your study.
Second, decide if the data are of acceptable quality. If the data were not gathered
under conditions of good reliability and validity (test, internal, and external) you
should not continue further.

Always look at all three aspects of validity.

1. First, consider the validity of the measuring instruments and the operational
definitions of the variables.
2. Second, review all possible aspects of the study design that could have
affected the degree of control exercised by the researchers to maintain
internal validity.
3. Finally, consider the population the researchers are generalizing to, and the
extent to which external validity was insured by the careful selection of the
sample.

The reliability and validity need not be perfect for a study to provide useful
information.

Third, if the reliability and validity are acceptable, you can go on to decide about
each hypothesis. Based on the statistical test results decide if each hypothesis is
supported or denied (true or false).

8.Write a report:
After analysis of epidemiologic and environmental data, conclusions
should be summarized in a report. This is one of the most important steps in the
outbreak investigation. Not only does the report detail your agency’s efforts, but
identifies a potential source(s) of the outbreak and suggests control measures to
prevent future illness.
 Preliminary report by the nodal medical officer (First information report)
 Daily situation update
 Interim report by the rapid response team
 Final report
CONTROL OF EPIDEMICS

When the causative organism, its source and the route of transmission are known it will probably
be easy to explain why the epidemic occurred. Control measures depend on the individual
disease concerned. The main strategies for the control of communicable diseases can be
summarized under three headings,

Main strategies for the control of an epidemic due to a communicable disease

Attack source Interrupt transmission Protect susceptible people

Treatment of cases and carriers Environmental hygiene Immunization
Isolation of cases Personal hygiene Chemoprophylaxis
Surveillance of suspects Vector control Personal protection
Control of animal reservoirs Disinfection and sterilization Better nutrition
Notification of cases Restrict population movements
SPECIFIC OUTBREAK CONTROL MEASURES
• Waterborne outbreaks
 Access to safe drinking water
 Sanitary disposal of human waste
 Frequent hand washing with soap
 Adopting safe practices in food handling
• Vector borne outbreaks
 Vector control
 Personal protective measures
• Vaccine preventable outbreaks
 Supplies vaccines, syringes and injection equipment
 Human resources to administer vaccine
 Ring immunization when applicable
 UNIT:9

EPIDEMIOLOGICAL SURVEILLANCE AND RESPONSE

Learning Objectives

By the end of this lecture, the student will be able to:

1. Define surveillance
2. Identify the purpose of surveillance
3. Describe the types of surveillance
4. Identify conditions in which active surveillance is appropriate
5. Discuss the activities of surveillance
6. Determine features of a good surveillance system
7. Recognize epidemiological surveillance in KSA

Definition of surveillance

Surveillance is defined as the continuous (ongoing) search for the factors

that determine the occurrence and distribution of diseases and other
health related events through a systematic collection of data.

Purpose of surveillance

1. To be able to identify diseases, injuries, hazards and other health related

events as early as possible, i.e. prediction and early detection of outbreaks
2. To provide scientific baseline data and information for setting, planning,
implementing and evaluating disease control program for both
communicable and non-communicable health problems.
3. To define the extent and distribution of diseases by time, person and place
dimension.
4. Assessing magnitude of problem

5. Monitoring implementation of health programs

6. Understanding local epidemiology of the problem
7. Assessing changes in trend of disease or its distribution
8. Identifying specific groups at risk
9. To enable predictions about pattern of occurrence of diseases
10. In assessing the impact of the programme intervention for control of
diseases
Types of surveillance

The three common types of surveillance are passive , active & sentinel
surveillance.
1. Passive surveillance

Passive surveillance may be defined as a mechanism for routine

surveillance based on passive case detection and on the routine
recording and reporting system. The information comes to the health
institutions for help. It involves collection of data as part of routine
provision of health services.

Advantages of passive surveillance

1. Covers a wide range of problems

2. Does not require special arrangement
3. It is relatively cheap
4. Covers a wider area
Disadvantages of passive surveillance

1. The information generated is to a large extent unreliable, incomplete

and inaccurate
2. Most of the time, data from passive surveillance is not available on time
3. Most of the time, it is difficult to get the required kind of information
4. It lacks representativeness of the whole population since passive
surveillance is mainly based on health institution reports

2.Active surveillance

Active surveillance is defined as a method of data collection usually on a

specific disease, for relatively limited period of time. It involves
collection of data from communities such as in house-to-house surveys or
mobilizing communities to some central point where data can be
collected. This can be arranged by assigning health personnel to collect
information on presence or absence of new cases of a particular disease at
regular intervals. Example: investigation of out-breaks
The advantages of active surveillance

The collected data is complete and accurate information collected is timely.

Disadvantages of active surveillance

1. It requires good organization

2. It is expensive
3. It requires skilled human power
4. It is for short period of time (not a continuous process)
5. It is directed towards specific disease conditions
Conditions in which active surveillance is appropriate

Active surveillance has limited scope. Unlike passive surveillance, it

cannot be used for routine purposes. There are certain conditions
where active surveillance is appropriate. These conditions are:
1. For periodic evaluation of an ongoing program
2. For programs with limited time of operation such as eradication program
3. In unusual situations such as:
 New disease discovery
 New mode of transmission
 When a disease is found to affect a new subgroup of the population.
 When a previously eradicated disease reappears.

Activities in Surveillance

The different activities carried out under surveillance are:

1. Data collection and recording
2. Data gathering, analysis and interpretation
3. Reporting and notification
4. Dissemination of information
Features of a good surveillance system

 Using a combination of both active and passive surveillance techniques

 Timely notification
 Timely and comprehensive action taken in response to notification
 Availability of a strong laboratory service for accurate diagnoses of cases

3.Sentinel surveillance: It is a reporting system based on selected

institutions or people who provide regular, complete reports on one or
more diseases occurring ideally in a defined attachment. It also provides
additional data on cases.

Epidemiological surveillance at KSA

1. The Centers for Disease Control and Prevention (CDC) has

worked with the Kingdom of Saudi Arabia for over 20 years.
2. It has formed partnerships with the Ministry of Health, WHO, local
partners, and other U.S. Government agencies to reduce the impact of
emerging diseases, build capacity in areas such as laboratory systems
and epidemiology, strengthen immunization services, respond to
public health emergencies, and conduct surveillance, surveys, and
studies.
3. For the sake of Global Health Security CDC works with the
Kingdom of Saudi Arabia and other countries to strengthen its public
health systems and build capacity for disease surveillance and
outbreak response.
4. Field Epidemiology Training Program, CDC supports workforce
capacity building in KSA through the Field Epidemiology Training
Program (FETP).
5. The KSA FETP program started in 1989 as the first program in the
Middle East. The tow year training program leads to a Diploma in
Field Epidemiology from King Saud University, which is recognized
as equivalent to a Master’s Degree by Saudi Council for Health
Specialties.
6. The Saudi FETP currently accepts residents from Oman and has
accepted residents from other countries in the region.
7. The recent Middle East Respiratory Syndrome (MERS) outbreak in
Saudi Arabia has provided multiple opportunities for current FETP
fellows to become involved in field investigations.
8. A new Resident Advisor, Dr. Mark Beatty, has been hired and
expected to be in country early 2016. Dr. Beatty has an extensive
background in domestic and international field investigations and has
worked in challenging socio-economic and political environments in
Southeast Asia, India, Africa, and Central and South America focused
on arboviral and enteric diseases including cholera.

References

• Basic of Epidemiology

End
 UNIT:10
COMMUNICABLE DISEASE.
The objectives:

By the end of this lecture the student should have comprehensive

knowledge about the followings:

1. Concepts of Disease Occurrence

2. Causation

3. Agent

4. Natural History and Spectrum of Disease

5. Incubation period

6. Spectrum of disease

7. Chain of infection

Concepts of Disease Occurrence

A critical principle of epidemiology is that disease and other health events do
not occur randomly in a population, but are more likely to occur in some
members of the population than others because of risk factors that may not be
distributed randomly in the population.

Causation
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 describe this model are shown in this figure.

Agent:

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.

Host:

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 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:

Environment refers to extrinsic factors that affect the agent and the
opportunity for exposure. Environmental factors include physical, biologic and
socioeconomic factors.
 Chain of Infection
The traditional epidemiologic triad model holds that infectious diseases result
from the interaction of agent, host, and environment. More specifically,
transmission occurs when the agent leaves its reservoir or host through a
portal of exit, is conveyed by some mode of transmission, and enters through
an appropriate portal of entry to infect a susceptible host. This sequence is
sometimes called the chain of infection.
Chain of Infection

Reservoir

The reservoir of an infectious agent is the habitat in which the agent normally
lives, grows, and multiplies. Reservoirs include humans, animals, and the
environment. The reservoir may or may not be the source from which an agent is
transferred to a host.

A. Human reservoirs.

Many common infectious diseases have human reservoirs. Diseases that are
transmitted from person to person without intermediaries include the sexually
transmitted diseases, measles, mumps, streptococcal infection, and many
respiratory pathogens.

B. Animal reservoirs.
 Humans are also subject to diseases that have animal reservoirs. Many of these
diseases are transmitted from animal to animal, with humans as incidental
hosts.

The term zoonosis: refers to an infectious disease that is transmissible under

natural conditions from vertebrate animals to humans.

C. Environmental reservoirs.

Plants, soil, and water in the environment are also reservoirs for some
infectious agents. Many fungal agents, live and multiply in the soil.

Carriers:

Are such persons who are infectious but have subclinical disease.

Types of Carriers:

1- Asymptomatic (In-apparent) carrier:

The carrier state that may occur in an individual with an infection that is in-
apparent throughout its course

Examples: Polio virus, meningococcus, hepatitis A virus

2-Incubatory, Convalescent, Post-Convalescent carriers:

The carrier state may occur during the incubation period, convalescence, and
post convalescence of an individual with a clinically recognizable disease.

Examples of Incubatory carrier: Measles, chickenpox

Portal of exit:

Portal of exit is the path by which a pathogen leaves its host. The portal of exit
usually corresponds to the site where the pathogen is localized.

For example:

 Influenza viruses and Mycobacterium tuberculosis exit the respiratory tract.

 schistosomes through urine.

 cholera vibrio in feces.

 Sarcoptes scabiae in scabies skin lesions.

Modes of transmission

An infectious agent may be transmitted from its natural reservoir to a

susceptible host in different ways. There are different classifications for modes
of transmission. Here is one classification:

Direct transmission:

an infectious agent is transferred from a reservoir to a susceptible host by

direct contact or droplet spread.

 Direct contact occurs through skin-to-skin contact, kissing, and sexual

intercourse. Direct contact also refers to contact with soil or vegetation
harboring infectious organisms.

 Droplet spread refers to spray with relatively large, short-range aerosols

produced by sneezing, coughing, or even talking. Droplet spread is classified
as direct because transmission is by direct spray over a few feet, before the
droplets fall to the ground.

Indirect transmission:

refers to the transfer of an infectious agent from a reservoir to a host by

suspended air particles, inanimate objects (vehicles), or animate intermediaries
(vectors)

1. Airborne transmission:

It occurs when infectious agents are carried by dust or droplet nuclei

suspended in air.

2. Vehicles borne transmission:

That may indirectly transmit an infectious agent include food, water, biologic
products (blood), and fomites (handkerchiefs, bedding, or surgical scalpels).

3. Vectors borne transmission:

such as mosquitoes, fleas, and ticks may carry an infectious agent through:

A- mechanical transmission as flies carrying Shigellaon on their appendages.

B- biological transmission as fleas carrying Yersinia pestis, (the causative

agent of plague), in their gut.
Portal of entry

The portal of entry refers to the gateway or manner in which a pathogen enters
a susceptible host. The portal of entry must provide access to tissues in which
the pathogen can multiply or a toxin can act. For example,…..

Host

The final link in the chain of infection is a susceptible host. Susceptibility of

a host depends on genetic or healthy factors, specific immunity, and nonspecific
factors that affect an individual’s ability to resist infection or to limit pathogenicity.

References

Basic of Epidemiology
 EPIDEMIOLOGY OF COMMUNICABLE DISEASES
MALARIA, TUBERCULOSIS, & NOSOCOMIAL INFECTION
Learning Objectives:
By the end of this lecture the student should have comprehensive
knowledge about the followings:
1. How to determine the burden of disease priorities
2. Malaria prevalence, symptoms, prevention
3. Tuberculosis prevalence, symptoms, prevention
4. Nosocomial infection prevalence, symptoms, prevention
The burden of disease
The World Health Organization uses three guiding principles for determining
priorities:
1. Diseases with a broad impact on mortality, morbidity and disability
such as HIV and AIDS, tuberculosis and malaria diseases.
2. Diseases that can cause epidemics such as influenza and cholera.
3. Diseases that can be controlled effectively interventions are cost-
effective diseases such as diarrhea and tuberculosis.
Malaria
1. Malaria is threatening disease caused by parasites of the species
Plasmodium transmitted between humans.
2. The disease transmits by bites of Anopheles mosquito that carries
malaria, which is called "malaria vectors".
Prevalence of the disease
1. The prevalence of the disease depends on the climatic conditions such
as rainfall patterns, temperature and humidity.
2. In 2016, an estimated 216 million cases of malaria occurred worldwide,
compared with 237 million cases in 2010 and 211 million cases in
2015.
3. In 2016, there were an estimated 445,000 deaths from malaria globally,
compared to 446,000 estimated deaths in 2015.
4. The WHO African Region accounted for 91% of all malaria deaths in
2016, followed by the WHO South- East Asia Region (6%).
5. Malaria is a disease which is preventable and curable.
Symptoms
1. Malaria is acute febrile diseases.
 2. Symptoms may be fever, headache, vomiting and shivering.
3. The falciparum malaria, if not treated within 24 hours can develop to
severe disease leading to death in many cases.
4. Severe anemia
5. Respiratory distress,
6. Cerebral malaria.
7. In patients with vivax and ovale malaria the disease relapses after
weeks or months after the first exposure to infection may occur.
Population at risk
1. Almost half the world's population faces the risk of malaria.
2. The groups at risk in particular are:
1. Young children who have no immunity that.
2. Pregnant women who do not have the sufficient immunity.
3. Pregnant hiv-infected women who do not possess a sufficient
degree of immunity in areas where malaria is occur in stable rate.
4. People with hiv infection and aids.
5. International travelers coming from malaria-endemic areas.
6. Immigrants from malaria-endemic areas.
Diagnosis and treatment
1. Diagnosis and treatment in the early stages reduce the complications of
disease and prevents death.
2. The World Health Organization recommends that careful before giving
treatment to confirm all cases of suspected malaria diagnosis confirms
the presence of the parasite py proper diagnosis.
3. An estimated 409 million treatment courses of artemisinin-based
combination therapy (ACT) were procured by countries in 2016.
Resistance to anti-malarial drugs
1. The phenomenon of resistance to antimalarial medicines is repeated
problems.
2. Plasmodium falciparum became resistance to previous generations of
drugs, such as Cholorquine and Sulfadoxine-Pyrimethamine.
3. WHO recommends monitoring of antimalarial drugs routinely
resistance.
Prevention
1. Vector control is the main method for reducing malaria transmission at
the community level.
2. Protection from mosquito bites represents the first line of defense for
the prevention of disease.
 3. Two main interventions to guarantee the effectiveness of vector control
in a variety of conditions, namely:
1. Insecticide-treated bed nets (itns)
2. Residual spraying insecticides indoors
Vaccines against malaria
Currently there is no licensed vaccine against malaria infection.

Tuberculosis, or TB
1. Tuberculosis (TB) is one among diseases cause death worldwide.
2. Is a common disease caused by Mycobacterium tuberculosis
3. it is usually attacks the lungs but can also affect other parts of the body.
4. The disease is transmitted through the air when the transmission spray
saliva of individuals infected with active TB by coughing or sneezing,
5. The disease causing the deaths of more than 50% of sufferers.
Symptoms
1. Classic symptoms of active TB infection is chronic cough with sputum
with blood
2. Fever
3. Night sweats
4. Weight loss
5. Injury to other organs
Diagnosis
1. Diagnosis depends on active TB infection on X Ray
2. Microscopic examination
3. Microbiological cultue of sputum and other body fluids
Treatment
 TB is a treatable and curable disease.
 Active, drug-susceptible TB disease is treated with a standard 6 month
course of 4 antimicrobial drugs that are provided with information,
supervision and support to the patient by a health worker or trained
volunteer.
The epidemiology of the disease
1. In 2017, 10 million people fell ill with TB, and 1.6 million died from
the disease .
 2. In 2017, an estimated 1 million children became ill with TB and 230
000 children died of TB.
3. TB is a leading killer of HIV-positive people.
1. Multidrug-resistant TB (MDR-TB) remains a public health crisis and a
health security threat.
2. Globally, TB incidence is falling at about 2% per year.
3. Ending the TB epidemic by 2030 is among the health targets of the
Sustainable Development Goals.

Nosocomial infection
1. Nosocomial infection is an infection acquired by patients after entering
the hospital, which means that the person did not have the infection
when he entered the hospital
2. It is appears after 72 hours or more of entering.
3. These infections can lead to serious disease and high mortality rate
4. The diagnosis and treatment and care of patients infections is very high
cost.
The most important reasons of Nosocomial infections
Several factors contribute to the increased risk of NI, such as:
1. The best medical practice cannot be avoided,
2. The age of patients
3. The seriousness of the disease nature as well as immunologically
compromised as patients with diabetes and cancer.
But there are factors that can help ease the impact of good governance include:
1. The length of the patient's stay in hospital.
2. Use of antibiotics with broad-spectrum inappropriately.
3. The use of permanent venous and urinary catheters.
4. Do not clean their hands health care workers and their tools and lack of
attention to hygiene in hospitals.
Pathogens that cause infections:
The most important bacteria causing Nosocomial infections:
1. Methicillin-resistant Staphylococcus aureus,
2. Staphylococcus aureus resistant to vancomycin,
3. Pseudomonas species
4. Enterobacteriaceae resistant species
5. Some types of Escherichia coli.
These bacteria require certain types of powerful antibiotics intensive
treatment after a culture and sensitivity test.
Most infections acquired in the hospital
The most common infections acquired in the hospital:
• Pseudomonas aeruginosa pneumonia,
• Infections of the throat and tonsils staphylococcal antibiotic resistance,
• Herpes skin golden staphylococcal resistance to antibiotics,
• Infections of the urinary tract serious types of Escherichia coli.

End of the lecture

 PREVENTION AND CONTROL OF COMMUNICABLE DISEASE

Objectives of the lecture

By the end of this lecture the student successfully should:

1- How to prevent and control the disease?

2- Know the levels of prevention

Preventing and Controlling Infection

Medical Asepsis: -

A: Strategies of prevent and control infection must be based on

knowledge of agent host environment to prevent the spread of
infectious agent.

1. The hand washing even when using gloves.

2. Disinfection, sterilization, and environmental sanitation.

3. Treatment infections by using drugs.

4. Early detection of infection in patient reporting data.

5. Protective barriers include gloves, gowns, masks, overhead, over

shoes, and protective eye.

6. Isolation procedures to prevent transmission of pathogens among

hospitalized patient health care person visitors.

7. Isolation procedures depending on diagnosis several category

specific isolations (private room, mask, gown, gloves) body fluid or
drainage secretion precautions.

8. Instructions for each category were printed on color coded cards and
placed on the doors and bed of the patients.

9. Program for immunization.

10. Disused of drugs and antibiotics to improve immune response.

B: Breaking the chain of infection:

1. Eliminate infections agent through: -

a. Proper cleaning and disinfectant by antiseptic solution for articles before

used.
b. Hand washing to remove microbes.
c. The nurse must be alert to the physiological changes in the
infectious patient such as:
i. Elevated white blood cells.
ii. Pus or exudates discharge from wound.
iii. Production of thick, tenacious sputum or cloudy urine.
iv. Elevate body temperature.
v. proper cleaning, disinfection, and sterilization of contaminated
objects.

2. Eliminate the reservoir through: -

1. Bathing to remove dirty.

2. Change dressing that becomes wet or soiled.
3. Contaminated articles should be placed in plastic bag for proper
disposal.
4. Contaminated needles should be recapped or broken out placed in
puncture proof container and labeled.
5. Wound drainage bottles or bags should be kept to prevent accumulation
of serous fluid under the skin.
6. Healthy person in the hospital.
7. Environmental cleaning and sanitation.
8. Sterilization and disinfection of the equipment.
9. Eliminate sources of body fluid, drainage, or solutions that might harbor
microorganisms.
10. Carefully discard articles that become contaminated.

3. Control port of exit through:-

1. Covering the mouth and nose when sneezing coughing.

2. Carful handling of exudates urine or feces.
3. Wear disposal gloves when there is a chance of contamination fluids.
4. Dispose soiled articles appropriately.
5. Hand washing.
6. Proper waste disposal.
7. Prober handling of the blood, secretion, excretion, and mucus.
8. Follow aseptic practices.
9. A nurse who has mild cold, can wear mask especially when changing
dressing or performing a sterile procedure.
4. Control mode of transmission through:-

1. Frequent hand washing.

2. Use personal items for each patient.
3. Avoid shaking of bed clothes.
4. Avoid contact of soiled items with uniform.
5. Discard any item tough floor.
6. Proper waste disposal.
7. Prober handling of the blood, secretion, excretion, and mucus.
8. A nurse who has mild cold, can wear mask especially when changing
dressing or performing a sterile procedure.

5. Control port of entry through:-

1. Changing patient’s position frequent oral hygiene.

2. Keep bed linen clean " free from wrinkles or wet".
3. Follow aseptic technique.
4. Be adherent to aseptic technique for cleaning wound.
5. Proper catheters care.
6. Proper wound care.
7. Proper closed drainage system care.
8. Healthy body systems.
9. hand washing.
10. Proper waste disposal, e.g. needle disposal.

6. Protection of susceptibility host to infection:-

1. Recognition of the high-risk patients.

2. Treatment of any underlying diseases.
3. Increase the host resistance through; vaccination for patients and health
care workers.

Levels of Prevention

1. Primary Prevention:

When measures occur before disease development there are two activities
include:

a. Health Promotion - actions that are general in nature and designed to

foster health lifestyle and a safe environment e.g. regular exercise.

b. Specific protection - actions aimed at reducing the risk of specific

disease s; immunization.
 2. Secondary Prevention:
Occurs after pathogenesis.
Those measures designed to detect disease at its earliest stage, namely
screening, and physical examinations that are aimed at early diagnosis and
interventions that provide for early treatment and cure of disease.

3. Tertiary Prevention:
Includes the limitations of disability and rehabilitation of these with
irreversible disease such as diabetes and spinal injury.

References:
WHO Basics of epidemiology, 2nd edition, Pages 99-113
UNIT:11
NON-COMMUNICABLE DISEASES

Learning Objectives

After completion of this lecture, each student should be able to:

1) Define the concept of non-communicable disease.
2) List common features of non-communicable disease.
3) Enumerate risk factors for non-communicable disease.
4) Discuss and enumerate some non-communicable disease.
Non-communicable diseases
1. Disease- a harmful change in the state of health of your body or
mind.
2. Non-communicable diseases- are diseases that are NOT transmitted
by pathogens
3. Diseases can be caused by infections, lack of nutrients, birth, or
lifestyle behaviors
4. Examples of Non-Communicable Diseases:
a. Chronic disease- diseases that are present either continuously
or off and on over a long time
b. Degenerative disease- disease that causes breakdown in body
cells, tissues, and organs as they progress
Non-communicable diseases and risk factors
1. Many non-communicable diseases cannot be prevented
2. Some are inherited from parents
3. Some are present at birth, but are not inherited
4. Risk factors- characteristic or behavior that raises a person’s
chances of getting a non-communicable disease
Risk factors with no control over:
1. Age 2. Gender 3. Race
Risk factors with control over:
1. Amount of food 2. Type of food 3. Diet 4. Smoking (risky
behavior)- something that increases chance of getting a non-
communicable disease
 Preventing non-communicable diseases
1. Most diseases caused by injury are preventable
2. Diet and exercise can help prevention of some non-
communicable diseases
3. Not smoking or drinking can prevent some non-communicable
diseases
Gene and hereditary diseases
1. A disease caused by defective genes inherited by a child from
one or both parents
2. Sickle Cell- caused by change to one gene
3. Down syndrome- born with part or all of an extra 21
chromosome
Metabolic and nutritional disease
1. Metabolic and nutritional diseases
2. Metabolism is a Process by which the body converts the energy in
food into energy the body can use.
3. Takes places after digestion
Metabolic Diseases:
1. Phenylketonuria (PKU) is an inborn error of metabolism that
results in decreased metabolism of the amino acid
phenylalanine. Happens before birth
2. Diabetes- happens after birth
Causes:
1. Hereditary
2. Nutrition and diet
3. Some other causes
4. Nutrition is extremely important- low Vitamin D may cause
rickets (deformed bones), low Vitamin A (blindness) too much
Vitamin A (hair loss or liver disease)
Diabetes
1. A disease that prevents the body from converting food into
energy
2. The body has to breakdown food into glucose
3. To transport glucose cells, the body needs insulin- a hormone
produced by the pancreas
Types of Diabetes
1. Type 1 Diabetes- condition in which the immune system
attacks insulin-producing cells in the pancreas
2. Type 2 Diabetes- condition in which the body cannot
effectively use the insulin it produces
i. It is more likely to occur in people 40 and over who
are obese in physically inactive
ii. It is becoming more common in children and teens

Diagnosing Diabetes
1. Frequent urination with excessive thirst
2. Unexplained weight loss
3. Extreme hunger
4. Sudden vision changes
5. Numbness in hands or feet
6. Feeling tired much of the time
7. Very dry skin
8. Sores that are slow to heal
9. Lab. Diagnosis:
 Impaired fasting glucose: Plasma glucose > 125mg.100ml-1 (>7mmol.L-
1) following an 8 h fast.
 A random blood glucose test, blood glucose level of 200 mg/dl or higher
indicates diabetes.
 Glucose tolerance test (GTT): Oral drink a solution in which 75 g of
anhydrous glucose is dissolved in water. 2 hours later plasma glucose
>200mg.100ml-1 (>11.1mmol.L-1).

Preventing and treating diabetes

1. There is no known prevention for Type 1 diabetes
2. Treatment for Type 1 involves daily insulin injections
3. Healthy weight and physical activity reduce the chance of
developing Type 2 diabetes
4. Type 2 involves oral medication or dietary changes
Preventing nutritional diseases
1. Important to have a normal life- nutritious diet
2. Proper balance of carbohydrates, fats, protein, vitamins, and minerals
3. Eating the right amount of food is just as important as eating the right
food (need to try and get 2,000-2,500 calories a day)
4. Obesity is linked to heart disease, high blood pressure, some types of
cancer, type 2 diabetes, and a variety of other diseases
5. Don’t eat snacks while watching TV
6. Exercise (20-30 minutes in vigorous exercise a day)

Allergy
1. Our body will react to a foreign substance by trying to weaken
or eliminate the substance
2. Allergens cause allergic reactions
3. Between 40-50 million people are affected with allergies
4. Most common forms food, plants, pollen, medications, mold,
animals with hair or feather, insect stings, synthetic materials,
poison.
5. The body responds to allergens by releasing histamines-
chemicals in the body that cause symptoms
Common symptoms:
o Watery eyes
o Sneezing
o Skin rash
o Hives- small raised bumps on the skin that are very itchy
1. Diagnosing is fairly easy- hives after eating peanuts, sneezing
beside a cat.
2. There is no cure for allergies, just ways to cope with them.
3. Most basic way is to avoid the allergen
4. There are treatments-specific to each one
Cancer
1. A disease in which cells grow uncontrollably and invade and
destroy healthy tissues
2. Malignant- are cancerous and can be life threatening
 They can spread through the body, invade other organs and
tissues (metastasis) , and tend to get worse.
3. Benign- are not cancerous and not usually life threatening
 They do not spread to other organs or tissues.
4. Cancer can affect any tissue or organ in the body
5. Common cancers in women:
 Breast, Ovarian, Lung
6. Common cancers in men:
 Prostate, Colon, Lung
7. Common cancer in children
 Leukemia
8. Skin cancer is one of the most common types
 Basal cell carcinoma (BCC) is the most common type
 Melanoma is the most serious type
Diagnosis of cancer
1. When a warning sign is described to a doctor, they will call for a biopsy.
2. A biopsy is a sample of tissue removed to see whether cancer cells are
present.
3. If they are detected then the doctor will order tests to determine size and
location.
Types of Treatment
1. Surgery-removing cancer cells from the body
2. Chemotherapy- chemicals used to destroy cancer cells
3. Radiation-High-radioactive substances help destroy or
shrink cancer cells
4. Immunotherapy- it stimulates the body’s immune system to
fight infection
5. Hormone therapy –cancer is treated with hormones or
medicines that interfere with production of hormones
Prevention of cancer
1. Eat nutritious foods
2. Be physically active
3. Limit sun exposure
4. Avoid tobacco and alcohol

Heart diseases
1. Heart disease is any condition that weakens the heart or blood
vessels or interferes with the functions they perform and depends
on age, lifestyle behaviors, and hereditary.
2. Accumulation of fats in coronary arteries can lead to heart attacks
3. Accumulation of fats in blood vessels can lead to stroke
4. Blood pressure is the force of blood on the inside walls of arteries
5. High blood pressure is when your blood pressure is consistently
higher than normal for your age
6. Heart attack- is a condition where blood flow to a part of the heart
is greatly reduced or blocked
Prevention of heart disease
1. Manage stress
2. Manage weight
3. Manage physical activity
4. Manage poor eating habits
5. Manage tobacco and alcohol use

Arthritis
1. Two most common types: rheumatoid arthritis and osteoarthritis
2. A chronic disease caused by pain, inflammation, swelling, and
stiffness of joints
3. Joints affected: hands, feet, elbows, shoulders, neck, knees, hips,
and ankles
4. It is usually symmetrical in the body: both hands will hurt
5. The cause is unknown
 Treatment
a. No known treatment
b. Medicines to relieve pain, reduce swelling, and keep joints
functioning as normal as possible
c. Exercise, rest, joint protection, and physical therapy are
recommended

Diseases caused by environment

1. Chemical waste (poisons)
a. Chemicals are necessary and useful, but some are poison
can cause illness or death if swallowed or inhaled
b. Some poisons are toxins- produced by a living organism
Example-snake
2. Certain construction materials and traffic (accidents)
a. Accidents are unexpected events that cause damage,
injury, or death
b. Most are minor, but some can cause traumatic injuries
3. Secondhand smoke

Prevention
1. Do not drink alcoholic beverages
2. Do not play with guns
3. Always wear appropriate safety equipment when playing a sport
4. Learn Cardiopulmonary resuscitation CPR
5. Wear a seatbelt every time you are in the car

References
• Basic of Epidemiology
 UNIT:12
PRACTICE IN EPIDEMIOLOGY (CLINICAL EPIDEMIOLOGY)

Objectives of the lecture:

By the end of this lecture the student should be able to:
1. Define normality and abnormality
2. Explain the accuracy of diagnostic tests
3. Recognize natural history and prognosis of disease
4. Take note of effectiveness of treatment
5. Describe the prevention in clinical practice.
Introduction:
1. Clinical epidemiology is the application of epidemiological principles and methods
to the practice of clinical medicine.
2. It usually involves a study conducted in a clinical setting, most often by clinicians,
with patients as the subjects of study.
The fundamental alarms of clinical epidemiology are:
1. Definitions of normality and abnormality
2. Accuracy of diagnostic tests
3. Natural history and prognosis of disease
4. Effectiveness of treatment
5. Prevention in clinical practice.
Definitions of normality and abnormality
1. The first priority in any clinical consultation is to determine whether the patient’s
symptoms, signs or diagnostic test results are normal or abnormal.
2. This is necessary before any further investigations or treatment.
3. There are three ways to differentiate such distribution:
 Normal as common
 Abnormal as associated with disease
 Abnormal as treatable.
Diagnostic tests
1. The first objective in a clinical situation is to diagnose any treatable disease.
2. The purpose of diagnostic testing is to help confirm possible diagnoses suggested
by the patient’s signs and symptoms.
3. While diagnostic tests usually involve laboratory investigations, the principles that
help to determine the value of these tests should also be used to assess the
diagnostic value of signs and symptoms.
Value of a test
 A disease may be either present or absent and a test result either positive or
negative.
Natural history and prognosis
1. The term natural history refers to the stages of a disease, which include:
 Pathological onset;
 The pre symptomatic stage,
 Clinical signs to decreases or progress to death.
2. Detection and treatment at any stage can alter the natural history of a disease.
3. The effects of treatment can only be determined if the natural history of the disease
in the absence of treatment is known.
Prognosis
1. Prognosis is the prediction of the course of a disease and is expressed as the
probability that a particular event will occur in the future.
2. Epidemiological information from many patients is necessary to provide
sound predictions on prognosis and outcome.
3. Prognosis in terms of mortality is measured as case-fatality rate or
probability of survival.
4. Survival analysis is a simple method of measuring prognosis.
Effectiveness of treatment
1. Some treatments are so clearly advantageous that they require no formal assessment
of indication; this is true of antibiotics for pneumonia and surgery for trauma.
2. Use of evidence-based guidelines have been defined as systematically developed
statements or recommendations to assist practitioners and patients in making
decisions about appropriate health care for specific clinical circumstances.
Prevention in clinical practice
1. Sound epidemiological knowledge encourages the practice of prevention in clinical
practice.
2. Antenatal care is a good example of the integration of prevention into routine
clinical practice.
Reducing risks
 Doctors, dentists and other health workers are able to convince at least some
of their patients to stop smoking.
Reducing risks in patients with established disease
 For cardiovascular disease and diabetes, evidence-based methods to
reducing the risk of adverse outcomes in those with the disease are very
similar to the methods used to reduce disease onset.
 The major difference is that the risk for future clinical events is much
greater once disease is established.
 Both behavioral and pharmacological interventions, amongst others, have
been shown to affect the prognosis of these diseases.

Reference :

Pages 146, 155 - basic epidemiology