Principles of Epidemiology

D. NYING TATAMENTAN

UNIT 1
Table of Contents
Objectives........................................................................................................................................................................4
UNIT 1: INTRODUCTION TO EPIDEMIOLOGY........................................................................................................5
INTRODUCTION.................................................................................................................................................5
Definition of Epidemiology and key principles.............................................................................................................5
A. Historical Evolution of Epidemiology..................................................................................................................8
B. Uses........................................................................................................................................................................9
C. Core Epidemiologic Functions...........................................................................................................................10
D. The Epidemiologic Approach.............................................................................................................................12
E. Descriptive Epidemiology..................................................................................................................................13
F. Analytic Epidemiology........................................................................................................................................18
G. Concepts of Disease Occurrence........................................................................................................................20
ii. Natural History and Spectrum of Disease..........................................................................................................22
iii. Chain of Infection................................................................................................................................................23
iv. Epidemic Disease Occurrence............................................................................................................................26
Objectives
Students who successfully complete this course should be able to correctly:
 Describe key features and applications of descriptive and analytic epidemiology.
 Calculate and interpret ratios, proportions, incidence rates, mortality rates,
prevalence, and years of potential life lost.
 Calculate and interpret mean, median, mode, ranges, variance, standard
deviation, and confidence interval.
 Prepare and apply tables, graphs, and charts such as arithmetic-scale line,
scatter diagram, pie chart, and box plot.
 Describe the processes, uses, and evaluation of public health surveillance.
 Describe the steps of an outbreak investigation.

You will find examples and summaries/explanations highlighted in blue and assignments in red both in this
unit and the other units of this course.
 UNIT 1: INTRODUCTION TO EPIDEMIOLOGY
INTRODUCTION
Public health workers use epidemiologic principles as the foundation for disease surveillance and
investigation activities.

Epidemiology studies the patterns, causes, and effects of health and disease conditions in defined
populations. It is the cornerstone of public health, and informs policy decisions and evidence-based medicine
by identifying risk factors for disease and targets for preventive medicine. Epidemiologists help with study
design, collection and statistical analysis of data, and interpretation and dissemination of results.
Epidemiology has helped develop methodology used in clinical research, public health studies and, to a lesser
extent, basic research in the biological sciences.

Definition of Epidemiology and key principles

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

Epidemiology is the study of the distribution and determinants of health-related states or events in
specified populations, and the application of this study to the control of health problems.1

Key terms in this definition reflect some of the important principles of epidemiology.

1. Study
Epidemiology is a scientific discipline with sound methods of scientific inquiry at its foundation.
Epidemiology is data-driven and relies on a systematic and unbiased approach to the collection, analysis, and
interpretation of data. Basic epidemiologic methods tend to rely on careful observation and use of valid
comparison groups to assess whether what was observed, such as the number of cases of disease in a
particular area during a particular time period or the frequency of an exposure among persons with disease,
differs from what might be expected. It equally draws on methods from other scientific fields, including
biostatistics and informatics, with biologic, economic, social, and behavioral sciences.

Epidemiology is often described as the basic science of public health, and for good reason. First, epidemiology
is a quantitative discipline that relies on a working knowledge of probability, statistics, and sound research
methods. Second, epidemiology is a method of causal reasoning based on developing and testing
hypotheses grounded in such scientific fields as biology, behavioral sciences, physics, and ergonomics to
explain health-related behaviors, states, and events. However, epidemiology is not just a research activity but
an integral component of public health, providing the foundation for directing practical and appropriate
public health action based on this science and causal reasoning.
 2. Distribution
Epidemiology is concerned with the frequency and pattern of health events in a population. Determining the
rate of disease occurrences (number of events divided by size of the population) is critical for making valid
comparisons across different populations

Frequency refers not only to the number of health events such as the number of cases or events in a
population, but also to the relationship of that number to the size (the rate or risk of disease) in the
population. The resulting rate allows epidemiologists to compare disease occurrence across different
populations.

Pattern refers to the occurrence of health-related events with respect to time, place, and person. This is
descriptive epidemiology
– Time patterns may be annual, seasonal, weekly, daily, hourly, weekday versus weekend, or any
other breakdown of time that may influence disease or injury occurrence.
– Place patterns include geographic variation, urban/rural differences, and location of work sites or
schools.
– Personal characteristics include demographic factors which may be related to risk of illness,
injury, or disability such as age, sex, marital status, and socioeconomic status, as well as behaviors
and environmental exposures.

3. Determinants
Epidemiology is also used to search for causes and other factors that influence the occurrence of health-
related events. The occurrence of a health-related event is usually related to multiple determinants that
should be considered. Examples of determinants include host susceptibility to a disease, and opportunity for
exposure to a microorganism, environmental toxin, insect vector or other infected individual that may pose a
risk for acquiring disease. Epidemiologists assume that illness does not occur randomly in a population, but
happens only when the right accumulation of risk factors or determinants exists in an individual. The search
for these determinants uses analytic epidemiology
Determinant: any factor, whether event, characteristic, or other definable entity, that brings about a change in a health condition or other defined
characteristic.

Disease surveillance usually begins with defining the what, who, when and where of health-related events.

 what - Define the disease events and/or its determinants

 who - Descriptions of demographic characteristics are helpful in determining which groups are at risk for
some outcome. The demographic characteristics usually include age, sex and race/ethnicity. Other categories include
socioeconomic status, history of occupation, or smoking habits, which provide useful information about exposures
that may present a risk. A history of underlying diseases may be useful for determining susceptibility to certain
conditions.
 when - Following changes in disease rates over time, following long-term disease trends and knowledge of
the seasonality of certain diseases helps identify unusual occurrences that may define epidemics. Temporal
associations between particular exposures on illness give information about incubation periods and exposures
posing a risk to others.
 where - Insight into the geographical extent of health-related events gives an idea of where the agent that
causes a disease normally lives and multiplies, what may carry or transmit it and how it spreads.
 4. Health-related states or events
Epidemiology was originally focused exclusively on epidemics of communicable diseases but was
subsequently expanded to address endemic communicable diseases and non-communicable infectious
diseases. By the middle of the 20th Century, additional epidemiologic methods had been developed and
applied to chronic diseases, injuries, birth defects, maternal-child health, occupational health, and
environmental health. Then epidemiologists began to look at behaviors related to health and well-being, such
as amount of exercise and seat belt use. Now, with the recent explosion in molecular methods, epidemiologists
can make important strides in examining genetic markers of disease risk. Indeed, the term health- related
states or events may be seen as anything that affects the well-being of a population. Nonetheless, many
epidemiologists still use the term ―disease‖ as shorthand for the wide range of health-related states and
events that are studied.

5. Specified populations
Epidemiologists are concerned with the collective health of people in a community or other area and the
impact of health events on that population.
Although epidemiologists and direct health-care providers (clinicians) are both concerned with occurrence
and control of disease, they differ greatly in how they view ―the patient. The clinician and the
epidemiologist have different responsibilities when faced with a person with illness. While the clinician
usually focuses on treating and caring for the individual, the epidemiologist focuses on identifying the
exposure or source that caused the illness; the number of other persons who may have been similarly
exposed; the potential for further spread in the community; and interventions to prevent additional cases or
recurrences.

6. Application
Epidemiology is not just ―the study of health in a population; it also involves applying the knowledge
gained by the studies to community-based practice. Epidemiology provides data for directing public health
action. An epidemiologist uses the scientific methods of descriptive and analytic epidemiology in "diagnosing"
the health of a community, but also must call upon experience and creativity when planning how to control
and prevent disease in the community.
To make the proper diagnosis and prescribe appropriate treatment for a patient, the clinician combines
medical (scientific) knowledge with experience, clinical judgment, and understanding of the patient.
Similarly, the epidemiologists uses the scientific methods of descriptive and analytic epidemiology as well as
experience, epidemiologic judgment, and understanding of local conditions to diagnose the health of a
community and propose appropriate, practical, acceptable public health measures for control/prevention.
A. Historical Evolution of Epidemiology
Although epidemiology as a discipline has blossomed since World War II, epidemiologic thinking has been
traced from Hippocrates through John Graunt, William Farr, John Snow, and others. The contributions of some
of these early and more recent thinkers are described below.5

Circa 400 B.C.

Hippocrates attempted to explain disease occurrence from a rational rather than a supernatural viewpoint. In
his essay entitled ―On Airs, Waters, and Places,‖ Hippocrates suggested that environmental and host
factors such as behaviors might influence the development of disease.

1662
Another early contributor to epidemiology was John Graunt, a London haberdasher and councilman who
published a landmark analysis of mortality data in 1662. This publication was the first to quantify patterns of
birth, death, and disease occurrence, noting disparities between males and females, high infant mortality,
urban/rural differences, and seasonal variations.5

1800
William Farr built upon Graunt’s work by systematically collecting and analyzing Britain’s mortality statistics.
Farr, considered the father of modern vital statistics and surveillance, developed many of the basic practices
used today in vital statistics and disease classification. He concentrated his efforts on collecting vital statistics,
assembling and evaluating those data, and reporting to responsible health authorities and the general public.4

1854
In the mid-1800s, an anesthesiologist named John Snow was conducting a series of investigations in London
that warrant his being considered the ―father of field epidemiology.‖ Twenty years before the development
of the microscope, Snow conducted studies of cholera outbreaks both to discover the cause of disease and to
prevent its recurrence. His work illustrates the classic sequence from descriptive epidemiology to hypothesis
generation to hypothesis testing (analytic epidemiology) to application.

Assignment: Snow’s works set the pace sequence from descriptive epidemiology to hypothesis
generation to hypothesis testing (analytic epidemiology) to application. Based on the definitions of descriptive
and analytic epidemiology, bring out the aspects of his experiments that illustrate these tzo principles. (return
via: [email protected])

19 th and 20th centuries

In the mid- and late-1800s, epidemiological methods began to be applied in the investigation of disease
occurrence. At that time, most investigators focused on acute infectious diseases. In the 1930s and 1940s,
epidemiologists extended their methods to noninfectious diseases. The period since World War II has seen an
explosion in the development of research methods and the theoretical underpinnings of epidemiology.
Epidemiology has been applied to the entire range of health-related outcomes, behaviors, and even
knowledge and attitudes. The studies by Doll and Hill linking lung cancer to smoking6and the study of
cardiovascular disease among residents of Framingham, Massachusetts7 are two examples of how pioneering
researchers have applied epidemiologic methods to chronic disease since World War II. During the 1960s and
early 1970s health workers applied epidemiologic methods to eradicate naturally occurring smallpox
worldwide.8 This was an achievement in applied epidemiology of unprecedented proportions.

In the 1980s, epidemiology was extended to the studies of injuries and violence. In the 1990s, the related
fields of molecular and genetic epidemiology (expansion of epidemiology to look at specific pathways,
molecules and genes that influence risk of developing disease) took root. Meanwhile, infectious diseases
continued to challenge epidemiologists as new infectious agents emerged (Ebola virus, Human
Immunodeficiency virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS)), were identified (Legionella,
Severe Acute Respiratory Syndrome (SARS)), or changed (drug-resistant Mycobacterium tuberculosis, Avian
influenza). Beginning in the 1990s and accelerating after the terrorist attacks of September 11, 2001,
epidemiologists have had to consider not only natural transmission of infectious organisms but also
deliberate spread through biologic warfare and bioterrorism.
Today, public health workers throughout the world accept and use epidemiology regularly to characterize the
health of their communities and to solve day-to-day problems, large and small.

B. Uses
Epidemiology and the information generated by epidemiologic methods have been used in many ways.
Some common uses are described below.

i. Assessing the community’s health

Public health officials responsible for policy development, implementation, and evaluation use
epidemiologic information as a factual framework for decision making. To assess the health of a population or
community, relevant sources of data must be identified and analyzed by person, place, and time (descriptive
epidemiology).
 What are the actual and potential health problems in the community?
 Where are they occurring?
 Which populations are at increased risk?
 Which problems have declined over time?
 Which ones are increasing or have the potential to increase?
 How do these patterns relate to the level and distribution of public health services available?

ii. Making individual decisions

Many individuals may not realize that they use epidemiologic information to make daily decisions affecting
their health. When persons decide to quit smoking, climb the stairs rather than wait for an elevator, eat a salad
rather than a cheeseburger with fries for lunch, or use a condom, they may be influenced, consciously or
unconsciously, by epidemiologists’ assessment of risk. These and hundreds of other epidemiologic findings
are directly relevant to the choices people make every day, choices that affect their health over a lifetime.

iii. 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. Epidemiology has also been instrumental
in characterizing many non-acute diseases, such as the numerous conditions associated with cigarette
smoking — from pulmonary and heart disease to lip, throat, and lung cancer.

iv. 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. For example,
epidemiologists were able to identify a variety of risk factors during an outbreak of pneumonia among
persons attending the American Legion Convention in Philadelphia in 1976, even though the Legionnaires’
bacillus was not identified in the laboratory from lung tissue of a person who had died from Legionnaires’
disease until almost 6 months later.16
C. Core Epidemiologic Functions
In the mid-1980s, five major tasks of epidemiology in public health practice were identified: public health
surveillance, field investigation, analytic studies, evaluation, and linkages. A sixth task, policy
development, was recently added. These tasks are described below.

i. Public health surveillance/information for action

Public health surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of
health data to help guide public health decision making and action. Surveillance is equivalent to monitoring
the pulse of the community. The purpose of public health surveillance, which is sometimes called ―information
for action, is to portray the ongoing patterns of disease occurrence and disease potential so that
investigation, control, and prevention measures can be applied efficiently and effectively.

Figure 1.3. Surveillance Cycle

Because epidemiologists are likely to be called upon to design and use these and other new surveillance
systems, an epidemiologist’s core competencies must include design of data collection instruments, data
management, descriptive methods and graphing, interpretation of data, and scientific writing and
presentation.

ii. Field investigation

As noted above, surveillance provides information for action. 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 the coordinated efforts of dozens of people to characterize the extent of
an epidemic and to identify its cause.

The objectives of such investigations also vary. Investigations often lead to the identification of additional
unreported or unrecognized ill persons who might otherwise continue to spread infection to others. For
example, one of the hallmarks of investigations of persons with sexually transmitted disease is the
identification of sexual partners or contacts of patients. When interviewed, many of these contacts are found
to be infected without knowing it, and are given treatment they did not realize they needed. Identification and
treatment of these contacts prevents further spread.
 iii. 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. Often the methods are used in combination with surveillance and field investigations
providing clues or hypotheses about causes and modes of transmission, and analytic studies evaluating the
credibility of those hypotheses.

Clusters or outbreaks of disease frequently are investigated initially with descriptive epidemiology. The
descriptive approach involves the study of disease incidence and distribution by time, place, and person. It
includes the calculation of rates and identification of parts of the population at higher risk than others.
Occasionally, when the association between exposure and disease is quite strong, the investigation may stop
when descriptive epidemiology is complete and control measures may be implemented immediately. John
Snow’s 1854 investigation of cholera is an example.
The hallmark of an analytic epidemiologic study is the use of a valid comparison group. Epidemiologists must
be skilled in all aspects of such studies, including design, conduct, analysis, interpretation, and
communication of findings.

iv. Evaluation
Epidemiologists, who are accustomed to using systematic and quantitative approaches, have come to play an
important role in evaluation of public health services and other activities. 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.
 Effectiveness refers to the ability of a program to produce the intended or expected results in the
field; effectiveness differs from efficacy, which is the ability to produce results under ideal conditions.
 Efficiency refers to the ability of the program to produce the intended results with a minimum
expenditure of time and resources.

The evaluation itself may focus on plans (formative evaluation), operations (process evaluation), impact
(summative evaluation), or outcomes — or any combination of these.
Evaluation of an immunization program, for example, might assess the efficiency of the operations, the
proportion of the target population immunized, and the apparent impact of the program on the incidence of
vaccine- preventable diseases. Similarly, evaluation of a surveillance system might address operations and
attributes of the system, its ability to detect cases or outbreaks, and its usefulness

v. Linkages
Epidemiologists working in public health settings rarely act in isolation. In fact, 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 multidisciplinary team. Other team members may be laboratorians, sanitarians, infection
control personnel, nurses or other clinical staff, and, increasingly, computer information specialists. To
promote current and future collaboration, the epidemiologists need to maintain relationships with staff of
other agencies and institutions.

vi. Policy development

The definition of epidemiology ends with the following phrase: ―...and the application of this study to the
control of health problems. While some academically minded epidemiologists have stated that
epidemiologists should stick to research and not get involved in policy development or even make
recommendations, public health epidemiologists do not have this luxury. Indeed, 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, testimony, and recommendations regarding disease control strategies, reportable disease regulations,
and health-care policy.
D. The Epidemiologic Approach
As with all scientific endeavors, the practice of epidemiology relies on a systematic approach. In very simple
terms, the epidemiologist:
 Counts cases or health events, and describes them in terms of time, place, and person;
 Divides the number of cases by an appropriate denominate or to calculate rates; and
 Compares these rates over time or for different groups of people.

Before counting cases, however, the epidemiologist must decide what a case is. This is done by developing a
case definition. Then, using this case definition, the epidemiologist finds and collects information about the
case-patients. The epidemiologist then performs descriptive epidemiology by characterizing the cases
collectively according to time, place, and person.
To calculate the disease rate, the epidemiologist divides the number of cases by the size of the population.
Finally, to determine whether this rate is greater than what one would normally expect, and if so to
identify factors contributing to this increase, the epidemiologist compares the rate from this population to the
rate in an appropriate comparison group, using analytic epidemiology techniques. These epidemiologic
actions are described in more detail below.
Subsequent tasks, such as reporting the results and recommending how they can be used for public health
action, are just as important.

i. Defining a case
Before counting cases, the epidemiologist must decide what to count, that is, what to call a case. For that, the
epidemiologist uses a case definition. A case definition is a set of standard criteria for classifying whether a
person has a particular disease, syndrome, or other health condition.
Use of an agreed- upon standard case definition ensures that every case is equivalent, regardless of when or
where it occurred, or who identified it.

ii. Components of a case definition for outbreak investigations

A case definition consists of clinical criteria and, sometimes, limitations on time, place, and person. The clinical
criteria usually include confirmatory laboratory tests, if available, or combinations of symptoms (subjective
complaints), signs (objective physical findings), and other findings. Case definitions used during outbreak
investigations are more likely to specify limits on time, place, and/or person than those used for surveillance.
Contrast the case definition used for surveillance of listeriosis (see box below) with the case definition used
during an investigation of a listeriosisoutbreak in North Carolina in 2000.25,26

Both the national surveillance case definition and the outbreak case definition require a clinically compatible
illness and laboratory confirmation of Listeria monocytogenes from a normally sterile site, but the outbreak
case definition adds restrictions on time and place, reflecting the scope of the outbreak.

iii. Modifying case definitions

Case definitions can also change over time as more information is obtained.

Variation in case definitions

Case definitions may also vary according to the purpose for classifying the occurrences of a disease. A
sensitive case definition is one that is broad or ―loose, in the hope of capturing most or all of the true
cases. For example, the case definition for a suspected case of rubella (German measles) is ―any generalized
rash illness of acute onset. This definition is quite broad, and would include not only all cases of rubella, but
also measles, chickenpox, and rashes due to other causes such as drug allergies. So while the advantage of a
sensitive case definition is that it includes most or all of the true cases, the disadvantage is that it sometimes
includes other illnesses as well.
On the other hand, an investigator studying the causes of a disease outbreak usually wants to be certain that
any person included in a study really had the disease. That investigator will prefer a specific or
―strict case definition. For instance, in an outbreak of Salmonella Agona infection, the investigators would be
more likely to identify the source of the infection if they included only persons who were confirmed to have been
infected with that organism, rather than including anyone with acute diarrhea, because some persons may have
had diarrhea from a different cause. In this setting, the only disadvantages of a strict case definition are the
requirement that everyone with symptoms be tested and an underestimation of the total number of cases if
some people with salmonellosis are not tested.

iv. Using counts and rates

As noted, one of the basic tasks in public health is identifying and counting cases. These counts, usually
derived from case reports submitted by health-care workers and laboratories to the health department, allow
public health officials to determine the extent and patterns of disease occurrence by time, place, and person.
They may also indicate clusters or outbreaks of disease in the community.

Counts are also valuable for health planning. For example, a health official might use counts (i.e.,
numbers) to plan how many infection control isolation units or doses of vaccine may be needed.

Rates are also useful for comparing disease occurrence during different periods of time. In addition, rates of
disease among different subgroups can be compared to identify those at increased risk of disease. These so-
called high risk groups can be further assessed and targeted for special intervention. High risk groups can also
be studied to identify risk factors that cause them to have increased risk of disease. While some risk factors
such as age and family history of breast cancer may not be modifiable, others, such as smoking and unsafe
sexual practices, are. Individuals can use knowledge of the modifiable risk factors to guide decisions about
behaviors that influence their health.

E. Descriptive Epidemiology
As noted earlier, every novice newspaper reporter is taught that a story is incomplete if it does not describe
the what, who, where, when, and why/how of a situation, whether it be a space shuttle launch or a house
fire. Epidemiologists strive for similar comprehensiveness in characterizing an epidemiologic event, whether
it be a pandemic of influenza or a local increase in all-terrain vehicle crashes. However, epidemiologists tend
to use synonyms for the five W’s listed above: case definition, person, place, time, and causes/risk
factors/modes of transmission.
Descriptive epidemiology covers time, place, and person.

Compiling and analyzing data by time, place, and person is desirable for several reasons.
 First, by looking at the data carefully, the epidemiologist becomes very familiar with the data.
He or she can see what the data can or cannot reveal based on the variables available, its limitations
 Second, the epidemiologist learns the extent and pattern of the public health problem being
investigated — which months, which neighborhoods, and which groups of people have the most
and least cases.
 Third, the epidemiologist creates a detailed description of the health of a population that can be
easily communicated with tables, graphs, and maps.
 Fourth, the epidemiologist can identify areas or groups within the population that have high rates
of disease. This information in turn provides important clues to the causes of the disease, and these
clues can be turned into testable hypothesis.
Time
The occurrence of disease changes over time. Some of these changes occur regularly, while others are
unpredictable. Some diseases like malaria occur during the same season each year. In contrast, diseases
such as hepatitis B and salmonellosis can occur at any time. For diseases that occur seasonally, health
officials can anticipate their occurrence and implement control and prevention measures, such as an
influenza vaccination campaign or mosquito spraying. For diseases that occur sporadically,
investigators can conduct studies to identify the causes and modes of spread, and then develop
appropriately targeted actions to control or prevent further occurrence of the disease.

In either situation, displaying the patterns of disease occurrence by time is critical for monitoring
disease occurrence in the community and for assessing whether the public health interventions made a
difference.

Time data are usually displayed with a two-dimensional graph. The vertical or y-axis usually shows the
number or rate of cases; the horizontal or x-axis shows the time periods such as years, months, or days.
The number or rate of cases is plotted over time. Graphs of disease occurrence over time are usually
plotted as line graphs (Figure 1.4) or histograms (Figure 1.5).

Figure 1.4 Reported Cases of Salmonellosis per 100,000 Population, by Year — United States, 1972– 2002

Source: Centers for Disease Control and Prevention. Summary of notifiable diseases–United States, 2002. Published April 30, 2004, for MMWR
2002;51(No. 53): p. 59.

Figure 1.5 Number of Intussusception Reports After the Rhesus Rotavirus Vaccine-tetravalent (RRV- TV) by Vaccination Date—
United States, September 1998–December 1999

Source: Zhou W, Pool V, Iskander JK, English-Bullard R, Ball R, Wise RP, et al. In: Surveillance Summaries, January 24, 2003. MMWR 2003;52(No. SS-1):1–26.
V PLACE
Describing the occurrence of disease by place provides insight into the geographic extent of the
problem and its geographic variation. Characterization by place refers not only to place of residence
but to any geographic location relevant to disease occurrence. Such locations include place of
diagnosis or report, birthplace, site of employment, school district, hospital unit, or recent travel
destinations. The unit may be as large as a continent or country or as small as a street address,
hospital wing, or operating room.
Sometimes place refers not to a specific location at all but to a place category such as urban or rural,
domestic or foreign, and institutional or non-institutional.
Although place data can be shown in a table, a map provides a more striking visual display of place
data. On a map, different numbers or rates of disease can be depicted using different shadings, colors,
or line patterns, as in Figure 1.11.
.
Figure 1.11 Mortality Rates for Asbestosis, by State — United States, 1968–1981 and 1982–2000

Source: Centers for Disease Control and Prevention. Changing patterns of pneumoconiosis mortality–United States, 1968-2000. MMWR 2004;53:627–32.

Another type of map for place data is a spot map, such as Figure
1.12. Spot maps generally are used for clusters or outbreaks with a limited number of cases. A dot or X is
placed on the location that is most relevant to the disease of interest, usually where each victim lived or
worked, just as John Snow did in his spot map of the Golden Square area of London (Figure 1.1). If known,
sites thatare relevant, such as probable locations of exposure (water pumps in Figure 1.1), are usually noted
on the map.

Figure1.12SpotMapofGiardiaCases
 Analyzing data by place can identify communities at increased risk of disease. Even if the data cannot reveal
why these people have an increased risk, it can help generate hypotheses to test with additional studies. For
example, is a community at increased risk because of characteristics of the people in the community such as
genetic susceptibility, lack of immunity, risky behaviors, or exposure to local toxins or contaminated food? Can
the increased risk, particularly of a communicable disease, be attributed to characteristics of the causative
agent such as a particularly virulent strain, hospitable breeding sites, or availability of the vector that
transmits the organism to humans? Or can the increased risk be attributed to the environment that brings the
agent and the host together, such as crowding in urban areas that increases the risk of disease transmission
from person to person, or more homes being built in wooded areas close to deer that carry ticks infected with
the organism that causes Lyme disease?

Person
Because personal characteristics may affect illness, organization and analysis of data by
―person may use inherent characteristics of people (for example, age, sex, race), 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). Age and sex are included in almost all datasets and are the two most commonly analyzed ―person
characteristics. However, depending on the disease and the data available, analyses of other person variables
are usually necessary. Usually epidemiologists begin the analysis of person data by looking at each variable
separately. Sometimes, two variables such as age and sex can be examined simultaneously. Person data are
usually displayed in tables or graphs.

- 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, opportunity for
exposure, latency or incubation period of the disease, and physiologic response (which affects, among
other things, disease development).

When analyzing data by age, epidemiologists try to use age groups that are narrow enough to detect any age-
related patterns that may be present in the data. For some diseases, particularly chronic diseases, 10-year age
groups may be adequate.
Figure 1.13a Pertussis by 5-Year Age Groups Figure 1.13b Pertussis by <1, 4-Year, Then 5-Year Age Groups

- 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. For
example, premenopausal women have a lower risk of heart disease than men of the same age. This
difference has been attributed to higher estrogen levels in women. On the other hand, the sex-related
 differences in the occurrence of many diseases reflect differences in opportunity or levels of exposure.

Ethnic and racial groups. Sometimes epidemiologists are interested in analyzing person data by biologic,
cultural or social groupings such as race, 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, such as socioeconomic status and access to
health care. In Figure 1.15, infant mortality rates for 2002 are shown by race and Hispanic origin of the
mother.
Figure 1.15 Infant Mortality Rates for 2002, by Race and Ethnicity of Mother

Source: Centers for Disease Control and Prevention. QuickStats: Infant mortality rates, by selected racial/ethnic populations—United States, 2002, MMWR
2005;54(05):126.

Socioeconomic status. Socioeconomic status is difficult to quantify. It is made up of many variables such as
occupation, family income, educational achievement or census track, living conditions, and social standing.
The variables that are easiest to measure may not accurately reflect the overall concept.
Nevertheless, epidemiologists commonly use occupation, family income, and educational achievement, while
recognizing that these variables do not measure socioeconomic status precisely.

The frequency of many adverse health conditions increases with decreasing socioeconomic status. For
example, tuberculosis is more common among persons in lower socioeconomic strata.
Infant mortality and time lost from work due to disability are both associated with lower income. These
patterns may reflect more harmful exposures, lower resistance, and less access to health care. Or they may in
part reflect an interdependent relationship that is impossible to untangle: Does low socioeconomic status
contribute to disability, or does disability contribute to lower socioeconomic status, or both? What accounts
for the disproportionate prevalence of diabetes and asthma in lower socioeconomic areas?

A few adverse health conditions occur more frequently among persons of higher socioeconomic status. Gout
was known as the ―disease of kings because of its association with consumption of rich foods. Other
conditions associated with higher socioeconomic status include breast cancer, Kawasaki syndrome, chronic
fatigue syndrome, and tennis elbow. Differences in exposure account for at least some if not most of the
differences in the frequency of these conditions.
F. 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.

The key feature of analytic epidemiology is a comparison group.

Consider a large outbreak of hepatitis A that occurred in Pennsylvania in 2003. Investigators found almost all
of the case- patients had eaten at a particular restaurant during the 2–6 weeks (i.e., the typical incubation
period for hepatitis A) before onset of illness. While the investigators were able to narrow down their
hypotheses to the restaurant and were able to exclude the food preparers and servers as the source, they did
not know which particular food may have been contaminated. The investigators asked the case-patients which
restaurant foods they had eaten, but that only indicated which foods were popular. The investigators,
therefore, also enrolled and interviewed a comparison or control group — a group of persons who had eaten
at the restaurant duringthe same period but who did not get sick. Of 133 items on the restaurant’s menu, the
most striking difference between the case and control groups was in the proportion that ate salsa (94% of
case-patients ate, compared with 39% of controls). Further investigation of the ingredients in the salsa
implicated green onionsas the source of infection. Shortly thereafter, the Food and Drug Administration issued
an advisory to the public about green onions and risk of hepatitis A. This action was in direct response to the
convincing results of the analytic epidemiology, which compared the exposure history of case-patients with
that of an appropriate comparison group.

When investigators find that persons with a particular characteristic are more likely than those without the
characteristic to contract a disease, the characteristic is said to be associated with the disease. The
characteristic may be a:
 Demographic factor such as age, race, or sex;
 Constitutional factor such as blood group or immune status;
 Behavior or act such as smoking or having eaten salsa; or
 Circumstance such as living near a toxic waste site.

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. It has been said that epidemiology by itself can never prove that a
particular exposure caused a particular outcome, however, epidemiology provides sufficient evidence to take
appropriate control and prevention measures.

Epidemiologic studies fall into two categories: experimental and observational.

i. 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. For example, in a clinical trial of a new vaccine, the investigator
may randomly assign some of the participants to receive the new vaccine, while others receive a placebo shot.
The investigator then tracks all participants, observes who gets the disease that the new vaccine is intended to
prevent, and compares the two groups (new vaccine vs. placebo) to see whether the vaccine group has a lower
rate of disease. Similarly, in a trial to prevent onset of diabetes among high-risk individuals, investigators
randomly assigned enrollees to one of three groups — placebo, an anti-diabetes drug, or lifestyle intervention.
At the end of the follow-up period, investigators found the lowest incidence of diabetes in the life style
intervention group, the next lowest in the anti-diabetic drug group, and the highest in the placebo group.39
ii. Observational studies
In an observational study, the epidemiologist simply observes the exposure and disease status of each study
participant. John Snow’s studies of cholera in London were observational studies. The two most common
types of observational studies are cohort studies and case-control studies; a third type is cross- sectional
studies.

ii.1. Cohort study. A cohort study is similar in concept to the experimental study. 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. Note that this differs from an experimental study because, in a
cohort study, the investigator observes rather than determines the participants’ exposure status. After a
period of time, the investigator compares the disease rate in the exposed group with the disease rate in the
unexposed group. The unexposed group serves as the comparison group, providing an estimate of the baseline
or expected amount of disease occurrence in the community. If the disease rate is substantively different in
the exposed group compared to the unexposed group, the exposure is said to be associated with illness.

These studies are sometimes called follow-up or prospective cohort studies, because participants are
enrolled as the study begins and are then followed prospectively over time to identify occurrence of the
outcomes of interest.

An alternative type of cohort study is a retrospective cohort study. In this type of study both the exposure
and the outcomes have already occurred. Just as in a prospective cohort study, the investigator calculates and
compares rates of disease in the exposed and unexposed groups. Retrospective cohort studies are commonly
used in investigations of disease in groups of easily identified people such as workers at a particular factory or
attendees at a wedding.

ii.2. Case-control study. In a case-control study, investigators start by enrolling a group of people with disease
(at CDC such persons are called case-patients rather than cases, because case refers to occurrence of disease,
not a person). 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. If the amount of
exposure among the case group is substantially higher than the amount you would expect based on the
control group, then illness is said to be associated with that exposure.

ii.3. 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 simultaneously. The cross-sectional study
tends to assess the presence (prevalence) of the health outcome at that point of time without regard to
duration.

From an analytic viewpoint the cross-sectional study is weaker than either a cohort or a case-control study
because a cross- sectional study usually cannot disentangle risk factors for occurrence of disease (incidence)
from risk factors for survival with the disease.
On the other hand, a cross-sectional study is a perfectly fine tool for descriptive epidemiology purposes.
Cross- sectional studies are used routinely to document the prevalence in a community of health behaviors
(prevalence of smoking), health states (prevalence of vaccination against measles), and health outcomes,
particularly chronic conditions (hypertension, diabetes).

In summary, the purpose of an analytic study in epidemiology is to identify and quantify the relationship
between an exposure and a health outcome. The hallmark of such a study is the presence of at least two
groups, one of which serves as a comparison group.
In an experimental study, the investigator determines the exposure for the study subjects; in an observational
study, the subjects are exposed under more natural conditions. In an observational cohort study, subjects are
enrolled or grouped on the basis of their exposure, then are followed to document occurrence of disease.
Differences in disease rates between the exposed and unexposed groups lead investigators to conclude that
exposure is associated with disease. In an observational case-control study, subjects are enrolled according to
whether they have the disease or not, then are questioned or tested to determine their prior exposure.
Differences in exposure prevalence between the case and control groups allow investigators to conclude that
the exposure is associated with the disease. Cross-sectional studies measure exposure and disease status at
the same time, and are better suited to descriptive epidemiology than causation.
G. Concepts of Disease Occurrence
A critical premise 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. As noted earlier, one important use of
epidemiology is to identify the factors that place some members at greater risk than others.

i. 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 depicting this model are shown in
Figure1.16.

Figure 1.16 Epidemiologic Triad

Component causes and causal pies
Because the agent-host-environment model did not work well for many non-infectious diseases, several other
models that attempt to account for the multifactorial nature of causation have been proposed. One such model
was proposed by Rothman in 1976, and has come to be known as the Causal Pies.
This model is illustrated in Figure 1.17. An individual factor that contributes to cause disease is shown as a
piece of a pie. After all the pieces of a pie fall into place, the pie is complete and disease occurs. The individual
factors are called component causes.
The complete pie, which might be considered a causal pathway, is called a sufficient cause. A disease may
have more than one sufficient cause, with each sufficient cause being composed of several component causes
that may or may not overlap. A component that appears in every pie or pathway is called a necessary cause,
because without it, disease does not occur.
Note in Figure 1.17 that component cause A is a necessary cause because it appears in every pie.
Figure 1.17 Rothman’s Causal Pies

Source: Rothman KJ. Causes. Am J Epidemiol 1976;104:587–592.

The component causes may include intrinsic host factors as well as the agent and the environmental factors of
the agent-host- environment triad. A single component cause is rarely a sufficient cause by itself. For example,
even exposure to a highly infectious agent such as measles virus does not invariably result in measles disease.
Host susceptibility and other host factors also may play a role.

At the other extreme, an agent that is usually harmless in healthy persons may cause devastating disease
under different conditions. Pneumocystis carinii is an organism that harmlessly colonizes the respiratory tract
of some healthy persons, but can cause potentiallylethal pneumonia in persons whose immune systems have
been weakened by human immunodeficiency virus (HIV). Presence of Pneumocystis carinii organisms is
therefore a necessary but not sufficient cause of pneumocystis pneumonia. In Figure 1.17, it would be
represented by component cause A.

As the model indicates, a particular disease may result from a variety of different sufficient causes or
pathways. For example, lung cancer may result from a sufficient cause that includes smoking as a component
cause. Smoking is not a sufficient cause by itself, however, because not all smokers develop lung cancer.
Neither is smoking a necessary cause, because a small fraction of lung cancer victims have never smoked.
Suppose Component Cause B is smoking and Component Cause C is asbestos.
Sufficient Cause I includes both smoking (B) and asbestos (C). Sufficient Cause II includes smoking without
asbestos, and Sufficient Cause III includes asbestos without smoking. But because lung cancer can develop in
persons who have never beenexposed to either smoking or asbestos, a proper model for lung cancer would
have to show at least one more Sufficient Cause Pie that does not include either component B or
component C.
ii. 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. For example, untreated infection with HIV causes a spectrum of clinical problems
beginning at the time of seroconversion (primary HIV) and terminating with AIDS and usually death. It is now
recognized that it may take 10 years or more for AIDS to develop after seroconversion. Many, if not most,
diseases have a characteristic natural history, although the time frame and specific manifestations of disease
may vary from individual to individual and are influenced by preventive and therapeutic measures.

Figure 1.18 Natural History of Disease Timeline

Source: Centers for Disease Control and Prevention. Principles of epidemiology, 2nd ed. Atlanta: U.S. Department of Health and Human Services;1992.

The process begins with the appropriate exposure to or accumulation of factors sufficient for the disease
process to begin in a susceptible host. For an infectious disease, the exposure is a microorganism. For cancer,
the exposure may be a factor that initiates the process, such as asbestos fibers or components in tobacco
smoke (for lung cancer), or one that promotes the process, such as estrogen (for endometrial cancer).

After the disease process has been triggered, pathological changes then occur without the individual being
aware of them. This stage of subclinical disease, extending from the time of exposure to onset of disease
symptoms, is usually called the incubation period for infectious diseases, and the latency period for chronic
diseases. During this stage, disease is said to be asymptomatic (no symptoms) or inapparent. This period may
be as brief as seconds for hypersensitivity and toxic reactions to as long as decades for certain chronic
diseases. Even for a single disease, the characteristic incubation period has a range. For example, the typical
incubation period for hepatitis A is as long as 7 weeks. The latency period for leukemia to become evident
among survivors of the atomic bomb blast in Hiroshima ranged from 2 to 12 years, peaking at 6–7 years. 44
Incubation periods of selected exposures and diseases varying from minutes to decades are displayed in Table
1.7.

Table 1.7 Incubation Periods of Selected Exposures and Diseases

Exposure Clinical Effect Incubation/Latency Period

Saxitoxin and similar toxins from Paralytic shellfish poisoning (tingling, few minutes–30 minutes
shellfish numbness around lips and fingertips,
giddiness, incoherent speech,
respiratory paralysis, sometimes death)
 Organophosphorus ingestion Nausea, vomiting, cramps, headache, few minutes–few hours
nervousness, blurred vision, chest pain,
confusion, twitching, convulsions

Salmonella Diarrhea, often with fever and cramps usually 6–48 hours
SARS-associated corona virus Severe Acute Respiratory Syndrome (SARS) 3–10 days, usually 4–6 days

Varicella-zoster virus Chickenpox 10–21 days, usually 14–16 days

Treponema pallidum Syphilis 10–90 days, usually 3 weeks
Hepatitis A virus Hepatitis 14–50 days, average 4 weeks
Hepatitis B virus Hepatitis 50–180 days, usually 2–3 months
Human immunodeficiency AIDS <1 to 15+ years
virus
Atomic bomb radiation (Japan) Leukemia 2–12 years
Radiation (Japan, Chernobyl) Thyroid cancer 3–20+ years
Radium (watch dial painters) Bone cancer 8–40 years

The onset of symptoms marks the transition from subclinical to clinical disease. Most diagnoses are made
during the stage of clinical disease. In some people, however, the disease process may never progress to
clinically apparent illness. In others, the disease process may result in illness that ranges from mild to severe
or fatal. This range is called the spectrum of disease. Ultimately, the disease process ends either in recovery,
disability or death.
For an infectious agent, infectivity refers to the proportion of exposed persons who become infected.
Pathogenicity refers to the proportion of infected individuals who develop clinically apparent disease.
Virulence refers to the proportion of clinically apparent cases that are severe or fatal.

Because the spectrum of disease can include asymptomatic and mild cases, the cases of illness diagnosed by
clinicians in the community often represent only the tip of the iceberg. Many additional cases may be too early
to diagnose or may never progress to the clinical stage. Unfortunately, persons with inapparent or
undiagnosed infections may nonetheless be able to transmit infection to others. Such persons who are
infectious but have subclinical disease are called carriers. Frequently, carriers are persons with incubating
disease or inapparent infection.
iii. Chain of Infection
As described above, 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,
Figure 1.19 Chain of Infection
and enters through an appropriate portal of entry to infect a
susceptible host. This sequence is sometimes called the chain
of infection.
 Mallon, or Typhoid Mary, who was an
asymptomatic chronic carrier of
Salmonella Typhi. As a cook in New
York City and New Jersey in the early
1900s, she unintentionally infected
dozens of people until she was placed in
isolation on an island in the East River,
where she died 23 years later

- 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
maynot be the source from which an agent is transferred to a
host. Fore xample, the reservoir of Clostridium botulinum is
soil, but the source of most botulism infections is improperly
canned food containing C. botulinum spores.

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. Because humans were the
only reservoir for the smallpox virus, naturally occurring
smallpox was eradicated after the last human case was
identified and isolated.

Human reservoirs may or may not show the effects of illness.

As noted earlier, a carrier is a person with inapparent infection
who is capable of transmitting the pathogen to others.
Asymptomatic or passive or healthy carriers are those who
never experience symptoms despite being infected.
Incubatory carriers are those who can transmit the agent
during the incubation period before clinical illness begins.
Convalescent carriers are those who have recovered from
their illness but remain capable of transmitting to others.
Chronic carriers are those who continue to harbor a
pathogen such as hepatitis B virus or Salmonella Typhi, the
causative agent of typhoid fever, for months or even years
after their initial infection. One notorious carrier is Mary
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. Long
recognized zoonotic diseases include brucellosis (cows and pigs), anthrax (sheep), plague (rodents),
trichinellosis/trichinosis (swine),tularemia (rabbits), and rabies (bats, raccoons, dogs, and other mammals).
Zoonoses newly emergent in North America include West Nile encephalitis (birds), and monkeypox (prairie
dogs).
Many newly recognized infectious diseases in humans, including HIV/AIDS, Ebola infection and SARS, are
thought to have emerged from animal hosts, although those hosts have not yet been identified.

Environmental reservoirs. Plants, soil, and water in the environment are also reservoirs for some infectious
agents. Manyfungal agents, such as those that cause histoplasmosis, live and multiply in the soil. Outbreaks of
Legionnaires disease are often traced to water supplies in cooling towers and evaporative condensers,
reservoirs for the causative organism Legionellapneumophila.

- 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 vibrios in feces, Sarcoptes scabiei in scabies skin lesions,
and enterovirus 70, a cause of hemorrhagic conjunctivitis, in conjunctival secretions. Some bloodborne agents
can exit by crossing the placenta from mother to fetus (rubella, syphilis, toxoplasmosis), while others exit
through cuts or needles in the skin (hepatitis B) or blood-sucking arthropods (malaria).

- 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
 Direct contact
 Droplet spread
 Indirect
 Airborne
 Vehicle borne
 Vector borne (mechanical or biologic)

Portal of entry
The portal of entry refers to the 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.
Often, infectious agents use the same portal to enter a new host that they used to exit the source host. For
example, influenza virus exits the respiratory tract of the source host and enters the respiratory tract of the
new host. In contrast, many pathogens that cause gastroenteritis follow a so- called ―fecal-oral route because
they exit the source host in feces, are carried on inadequately washed hands to a vehicle such as food, water,
or utensil, and enter a new host through the mouth. Other portals of entry include the skin (hookworm),
mucous membranes (syphilis), and blood (hepatitis B, human immunodeficiency virus).
Host
The final link in the chain of infection is a susceptible host. Susceptibility of a host depends
on genetic or constitutional factors, specific immunity, and nonspecific factors that affect an
individual’s ability to resist infection or to limit pathogenicity. An individual’s genetic
makeup may either increase or decrease susceptibility.

Implications for public health

Knowledge of the portals of exit and entry and modes of transmission provides a basis for
determining appropriate control measures. In general, control measures are usually directed
against the segment in the infection chain that is most susceptible to intervention, unless
practical issues dictate otherwise.

For some diseases, the most appropriate intervention may be directed at controlling or
eliminating the agent at its source. A patient sick with a communicable disease may be
treated with antibiotics to eliminate the infection. An asymptomatic but infected person may
be treated both to clear the infection and to reduce the risk of transmission to others. In the
community, soil may be decontaminated or covered to prevent escape of the agent.

Some interventions are directed at the mode of transmission.

Some strategies that protect portals of entry are simple and effective. For example, bed nets
are used to protect sleeping persons from being bitten by mosquitoes that may transmit
malaria.
Some interventions aim to increase a host’s defenses. Vaccinations promote development of
specific antibodies that protect against infection.

Finally, some interventions attempt to prevent a pathogen from encountering a susceptible

host. The concept of herd immunity suggests that if a high enough proportion of individuals
in a population are resistant to an agent, then those few who are susceptible will be
protected by the resistant majority, since the pathogen will be unlikely to ―find those few
susceptible individuals.
iv. Epidemic Disease Occurrence
Level of disease
The amount of a particular disease that is usually present in a community is referred to as
the baseline or endemic level of the disease. This level is not necessarily the desired level,
which may in fact be zero, but rather is the observed level. In the absence of intervention and
assuming that the level is not high enough to deplete the pool of susceptible persons, the
disease may continue to occur at this level indefinitely. Thus, the baseline level is often
regarded as the expected level of the disease.

Sporadic refers to a disease that occurs infrequently and irregularly.

Endemic refers to the constant presence and/or usual prevalence of a disease or infectious
agent in a population within a geographic area.
Hyperendemic refers to persistent, high levels of disease occurrence.

Occasionally, the amount of disease in a community rises above the expected level. Epidemic
refers to an increase, often sudden, in the number of cases of a disease above what is
normally expected in that population in that area.
Outbreak carries the same definition of epidemic, but is often used for a more limited
geographic area. Cluster refers to an aggregation of cases grouped in place and time that are
suspected to be greater than the number expected, even though the expected number may
not be known.
Pandemic refers to an epidemic that has spread over several countries or continents,
usually affecting a large number of people.

Epidemics occur when an agent and susceptible hosts are present in adequate numbers, and
the agent can be effectively conveyed from a source to the susceptible hosts. More
specifically, an epidemic may result from:
 A recent increase in amount or virulence of the agent,
 The recent introduction of the agent into a setting where it has not been before,
 An enhanced mode of transmission so that more susceptible persons are exposed,
 A change in the susceptibility of the host response to the agent, and/or
 Factors that increase host exposure or involve introduction through new portals of
entry.

The previous description of epidemics presumes only infectious agents, but non-infectious
diseases such as diabetes and obesity exist in epidemic proportion in our communities.

Epidemic Patterns
Epidemics can be classified according to their manner of spread through a population:
 Common-source
 Point
 Continuous
 Intermittent
 Propagated
 Mixed
 Other

ASSIGNMENT: EXPLAIN EACH OF THE ABOVE EPIDE;IC PATTERNS GIVING

ELABORATE EXAMPLES IN EACH CASE (return via: [email protected])