Lecture 1

Lecture 1
Notes based on
Gordis Epidemiology. David D. Celentano,
and Moyses Szklo.
Sixth edition. Philadelphia, PA: Elsevier, 2019.
What is Epidemiology?
• The study of the distribution and determinants of health-related

states or events in specified populations and the application of this
study to control of health problems.
Objectives of Epidemiology
• To identify the cause, of a disease and its relevant risk factors (i.e.,
factors that increase a person’s risk for a disease). We want to know
how the disease is transmitted from one person to another or from a
nonhuman reservoir to a human population or why it arises due to
risk behaviours the person engages in.
• The second objective of epidemiology is to determine the extent of

disease found in the community. What is the burden of disease in
the community?
Objectives of Epidemiology (continued…)
• A third objective is to study the natural history and prognosis of disease.
• Fourth, we use epidemiology to evaluate both existing and newly

developed preventive and therapeutic measures and modes of health care
delivery. For example, does screening men for prostate cancer using the
prostate-specific antigen (PSA) test improve survival in people found to
have prostate cancer?
• Finally, to provide the foundation for developing public policy relating to
environmental problems, genetic issues, and other social and behavioral
considerations regarding disease prevention and health promotion.
The Dynamics of Disease Transmission
• Human disease results from an interaction of the host (a person), the

agent (e.g., a bacterium or virus), and the environment (e.g., polluted
air).
• Virtually all disease results from an interaction of genetic, behavioral,
and environmental factors, with the proportions differing for different
diseases.
Disease Transmission
Modes of Transmission
• Diseases can be transmitted directly or indirectly.

• For example, a disease can be transmitted from person to person
(direct transmission) by means of direct contact (as in the case of
sexually transmitted infections).
• Indirect transmission can occur through a common vehicle such as a
contaminated air or water supply or by a vector such as the mosquito.
Different stages of disease
• CLINICAL DISEASE: Clinical disease is characterized by signs and symptoms.

• NONCLINICAL (INAPPARENT) DISEASE: Nonclinical disease may include the
following:
• Preclinical disease: Disease that is not yet clinically apparent but is destined to
progress to clinical disease.
• Subclinical disease: Disease that is not clinically apparent and is not destined to
become clinically apparent.
• Persistent (chronic) disease: A person fails to “shake off” the infection, and it persists
for years, at times for life.
• Latent disease: An infection with no active mul-tiplication of the agent.
Carrier Status
• A carrier is an individual who harbors the organism but is not infected

as measured by serologic studies (no evidence of an antibody
response) or shows no evidence of clinical illness.
• This person can still infect others, although the infectivity is generally
lower than with other infections.
• Carrier status may be of limited duration or may be chronic, lasting
for months or years.
Endemic, Epidemic, and Pandemic
• Endemic is defined as the habitual

presence of a disease within a given
geographic area. It may also refer to the
usual occurrence of a given disease within
such an area (sometimes referred to as the
“background rate of disease”).
• Epidemic is defined as the occurrence in a
community or region of a group of
illnesses of similar nature, clearly in excess
of normal expectancy and derived from a
common or a propagated source.
• Pandemic refers to a worldwide epidemic.
Immunity and Susceptibility
• The amount of disease in a population depends on a balance

between the number of people in that population who are
susceptible and therefore at risk for the disease and the number of
people who are not susceptible or immune and therefore not at risk.
• They may be immune because they have had the disease previously
(and have antibodies) or because they have been immunized. They
also may not be susceptible on a genetic basis.
• If the entire population is immune, no epidemic can develop.
• But the balance is usually struck somewhere in between immunity
and susceptibility, and when it moves toward susceptibility, the
likelihood of a disease outbreak increases.
Herd Immunity
• Herd immunity is defined as the resistance of a group of people to an

attack by a disease to which a large proportion of the members of the
group are immune.
• If a large percentage of the population is immune, the entire population is
likely to be protected, not just those who are immune.
• Why does herd immunity occur?
• It happens because disease spreads from one person to another in any
community. Once a certain proportion of people in the community are
immune, the likelihood is small that an infected person will encounter a
susceptible person to whom he can transmit the infection; more of his
encounters will be with people who are immune.
Why is the concept of herd immunity so
important?
• When we carry out immunization programs, it may not be necessary to achieve
100% immunization rates to immunize the population successfully. We can
achieve highly effective protection by immunizing a large part of the population;
the remaining part will be protected because of herd immunity.
• For herd immunity to exist, certain conditions must be met. The disease agent
must be restricted to a single host species within which transmission occurs, and
that transmission must be relatively direct from one member of the host species
to another. Infections must induce solid immunity.
• Herd immunity operates if the probability of an infected person encountering
every other individual in the population (“random mixing”) is the same.
• What percentage of a population must be immune for herd immunity to operate?
This percentage varies from disease to disease. Measles 94%
Incubation Period
• The incubation period is defined as the interval from receipt of infection to

the time of onset of clinical illness (the onset of recognizable symptoms).
• If you become infected today, the disease with which you are infected may
not develop for a number of days or weeks. During this time, the
incubation period, you feel completely well and show no signs of the
disease.
• It may reflect the time needed for the organism to replicate sufficiently
until it reaches the critical mass needed for clinical disease to result.
• The dose of the infectious agent received at the time of infection may also
influence the length of the incubation period.
Epidemic Curve
Each bar represents the number of cases of disease developing at a certain point in time after the exposure.
If we draw a line connecting the tops of the bars, it is called the epidemic curve, which is defined as the
distribution of the times of onset of the disease.
Critical variables in investigating an outbreak or
epidemic
1. When did the exposure take place?
2. When did the disease begin?
3. What was the incubation period for the disease?

Attack Rate
Secondary attack rate
• A person who acquires the disease from that exposure (e.g., from a
contaminated food) is called a primary case.
• A person who acquires the disease from exposure to a primary case is
called a secondary case.
• The secondary attack rate is therefore defined as the attack rate in
susceptible people who were not exposed to the suspected agent
who have been exposed to a primary case.
• It is a good measure of person-to-person spread of disease after the
disease has been introduced into a population, and it can be thought
of as a ripple moving out from the primary case. We often calculate
the secondary attack rate in family members of the index case.
Exploring Occurrence of Disease
• Who was attacked by the disease?

• The characteristics of the human host are clearly related to disease risk. Factors such
as sex, age, and race as well as behavioral risk factors (e.g., smoking) may have major
effects.
• When did the disease occur? Certain diseases occur with a certain
periodicity. The question of when is also addressed by examining trends in
disease incidence over time.
• Where did the cases arise? Disease is not randomly distributed in time or
place.
Who
When
Where
Cross Tabulation

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Lecture 1

• The study of the distribution and determinants of health-related

• The second objective of epidemiology is to determine the extent of

• Fourth, we use epidemiology to evaluate both existing and newly

• Human disease results from an interaction of the host (a person), the

• Diseases can be transmitted directly or indirectly.

• CLINICAL DISEASE: Clinical disease is characterized by signs and symptoms.

• A carrier is an individual who harbors the organism but is not infected

• Endemic is defined as the habitual

• The amount of disease in a population depends on a balance

• Herd immunity is defined as the resistance of a group of people to an

• The incubation period is defined as the interval from receipt of infection to

2. When did the disease begin?

3. What was the incubation period for the disease?

• Who was attacked by the disease?

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