EPIDEMIOLOGY

AND
BIOSTATISTICS IN
CHN

NURSING 4006 (Unit 1-5)

WHAT IS EPIDEMIOLOGY

– often described as the cornerstone science of public health is concerned with the
occurrence, distribution and determinants of states of health and disease in human
groups and. Scientific knowledge, which predominates in medicine and
epidemiology, is associated with facts and theories.
– It is the study of frequency, distribution, and determinants of diseases and other
health-related conditions in a human population and the application of this study to
the prevention of disease and promotion of health.
– The word epidemiology is derived from Greek terms- “epi”-upon, among, “demos” –
people, district, “logos” –study, word, discourse.
– Epidemiology literally is the study of something that affects population.
– Epidemic : ( Epi = upon : demos = people ) An outbreak of disease in a
community in excess of “normal expectation ”
– Endemic: (en = in; demos = people). The constant presence of disease within a
geographic area or the usual prevalence of a given disease in a particular area.
malaria, tuberculosis, etc.
– Pandemic: (pan = all: demos = people) An epidemic which spreads from country
to country or over the whole world, as for example, the recent epidemic of
AIDS.
PURPOSE OF CONDUCTING

– studying the history of diseases in population in terms of profile, time & trends.
– determining the most common causes of death, diseases and disability.
– community diagnosis in terms of morbidity, and mortality rates and ratio.
– determining the effective control method of disease when known.
– provision of data for proper planning and evaluation of health services
– identifying deficiencies in ongoing programs
– identifying the priority areas for medical research
EPIDEMIOLOGICAL PROCESS

1. Asking questions
Epidemiology has been defined as a means of learning or asking questions.. and
getting answers that lead to further questions RELATED TO HEALTH EVENTS:
•What is the event? (the problem)
•Where did it happen?
•When did it happen?
•Who are affected?
•Why did it happen?
2. Making comparisons
Asking questions RELATED TO HEALTH ACTIONS:
•What can be done to reduce this problem and its consequences ?
•How can it be prevented In the future ?
•What action should be taken by the community ? By the health services? By other
sectors ?
•What resources are required ? How are the activities to be organized ?
2. Making comparisons •This approach is to make comparisons and draw
inferences. •Comparison may be made between different population at a given
time eg. Rural with urban population •Between sub group of population eg. Male
with female population •Between various periods of observation eg. Different
seasons
Tools of measurement 1. Rates 2. Ratios 3. Proportions 1. Rates A rate measures
the occurrence of some particular event (development of disease or the
occurrence of death) in a population during a given time period.
Death rate = (Number of deaths in one year/ Mid-year population) X 1000
(1) Crude rates: These are the actual observed rates such as the birth and death
rates. Crude rates are also known as unstandardized rates.
(2) Specific rates: These are the actual observed rates due to specific causes (e.g.,
tuberculosis); or occurring in specific groups (e.g., age-sex groups) or during
specific time periods (e.g.. annual, monthly or weekly rates).
(3) Standardized rates: These are obtained by direct or indirect method of
standardization or adjustment, e.g., age and sex standardized rates.
2.RATIO
Another measure of disease frequency is a ratio. It expresses a relation in size
between two random quantities. examples include:
•The number of children with malnutrition at a certain time
• sex-ratio, doctor population ratio, child woman ratio, etc.
3.PROPORTION
A proportion is a ratio which indicates the relation in magnitude of a part of the
whole. The numerator is always included in the denominator. A proportion is
usually expressed as a percentage. The number of children with scabies at a certain
time Example x 100 The total number of children in the village at the same time
DYNAMICS OF INFECTIOUS
DISEASE TRANSMISSION
– Communicable diseases are transmitted from the reservoir/source of infection
to susceptible host through .
SOURCE OR RESERVOIR

These are natural habitat of infectious agents in which an infectious agent normally
lives and multiplies.
Examples are:
Human reservoirs
Animal reservoirs (zoonotic diseases)
Reservoir in non-living things
MODES OF TRANSMISSION

– Communicable diseases transmitted from the reservoir or source of infection to

a susceptible host in many ways.
SUCEPTIBLE HOST

– The person who is at risk for developing an infectious disease.

Factors making person susceptible are:
Age (young and elderly are more at risk)
Underlying chronic diseases such as diabetes
Immuno-suppression conditions like HIV chemotherapy, and malnutrition.
EPIDEMIOLOGICAL
TRIAD

The interaction of an agent and host in an

appropriate environment results in disease.
EPIDEMIOLOGICAL TRIAD
AGENT

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

bacterium, parasite, or other microbe. Generally,
– the agent must be present for disease to occur; however, presence of that
agent alone is not always sufficient to cause disease. A variety of factors
influence whether exposure to an organism will result in disease, including the
organism’s pathogenicity (ability to cause disease) and dose.
HOST

– refers to the human who can get the disease. A variety of factors intrinsic to the
host, sometimes called risk factors, can influence an individual’s exposure,
susceptibility, or response to a causative agent. Opportunities for exposure are
often influenced by behaviors such as sexual practices, hygiene, and other
personal choices as well as by age and sex. Susceptibility and response to an
agent are influenced by factors such as genetic composition, nutritional and
immunologic status, anatomic structure, presence of disease or medications,
and psychological makeup.
ENVIRONMENT

– refers to extrinsic factors that affect the agent and the opportunity for
exposure. Environmental factors include physical factors such as geology and
climate, biologic factors such as insects that transmit the agent, and
socioeconomic factors such as crowding, sanitation, and the availability of
health services.
 LEVELS OF
PREVENTION
PRIMARY

– Health promotion
– Specific protection
- Targeted at healthy people
Objectives:
Promotion of health
Prevention of exposure and
Prevention of disease
SECONDARY

– Early diagnosis (screening tests, case finding programs )

– Adequate treatment
– Targeted at sick individuals
Objective:
To stop or slow the progression of disease and to prevent or limit permanent
damage through early detection & treatment.
TERTIARY

– Targeted at people with chronic diseases & disabilities that can’t be cured
– Objective:
To prevent further disability or death and to limit impacts of disability through rehabilitation
– Disability limitation
– Rehabilitation
 Functional rehabilitation
 Vocational rehabilitation
 Social rehabilitation
 Psychological rehabilitation
EPIDEMIOLOGICAL
VARIABLE
TIME

– The occurrence of disease changes over time. Some of these changes occur regularly, while
others are unpredictable. Two diseases that occur during the same season each year include
influenza (winter) and West Nile virus infection (August– September). 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.
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.
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 data sets 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).
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.
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.
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.
CHAIN OF INFECTION
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, and
enters through an appropriate portal of entry to infect a susceptible host. This
sequence is sometimes called the 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.
For example, 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.8
– 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.
– Carriers commonly transmit disease because they do not realize they are infected, and consequently
take no special precautions to prevent transmission. Symptomatic persons who are aware of their
illness, on the other hand, may be less likely to transmit infection because they are either too sick to be
out and about, take precautions to reduce transmission, or receive treatment that limits the disease.
– 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. Many fungal 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 Legionella pneumophila
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:
1. Direct
− Direct contact
− Droplet spread
2. Indirect
− Airborne
− Vehicleborne
− Vectorborne (mechanical or biologic)
DIRECT CONTACT

– In 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. Thus,
infectious mononucleosis (“kissing disease”) and gonorrhea are spread from person to
person by direct contact. Hookworm is spread by direct contact with contaminated soil.
– 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.
Pertussis and meningococcal infection are examples of diseases transmitted from an
infectious patient to a susceptible host by droplet spread.
INDIRECT CONTACT

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).
Airborne transmission occurs when infectious agents are carried by dust or droplet nuclei
suspended in air. Airborne dust includes material that has settled on surfaces and become
resuspended by air currents as well as infectious particles blown from the soil by the
wind. Droplet nuclei are dried residue of less than 5 microns in size. In contrast to droplets
that fall to the ground within a few feet, droplet nuclei may remain suspended in the air
for long periods of time and may be blown over great distances. Measles, for example,
has occurred in children who came into a physician’s office after a child with measles had
left, because the measles virus remained suspended in the air.46
Vehicles that may indirectly transmit an infectious agent include food, water, biologic products
(blood), and fomites (inanimate objects such as handkerchiefs, bedding, or surgical scalpels). A
vehicle may passively carry a pathogen — as food or water may carry hepatitis A virus.
Alternatively, the vehicle may provide an environment in which the agent grows, multiplies, or
produces toxin — as improperly canned foods provide an environment that supports production
of botulinum toxin by Clostridium botulinum.
Vectors such as mosquitoes, fleas, and ticks may carry an infectious agent through purely
mechanical means or may support growth or changes in the agent. Examples of mechanical
transmission are flies carrying Shigella on their appendages and fleas carrying Yersinia pestis, the
causative agent of plague, in their gut. In contrast, in biologic transmission, the causative agent of
malaria or guinea worm disease undergoes maturation in an intermediate host before it can be
transmitted to humans.
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. For example, persons with sickle cell trait seem to be at least partially protected from a
particular type of malaria. Specific immunity refers to protective antibodies that are directed against a
specific agent. Such antibodies may develop in response to infection, vaccine, or toxoid (toxin that has
been deactivated but retains its capacity to stimulate production of toxin antibodies) or may be acquired
by transplacental transfer from mother to fetus or by injection of antitoxin or immune globulin.
Nonspecific factors that defend against infection include the skin, mucous membranes, gastric acidity,
cilia in the respiratory tract, the cough reflex, and nonspecific immune response. Factors that may
increase susceptibility to infection by disrupting host defenses include malnutrition, alcoholism, and
disease or therapy that impairs the nonspecific immune response.
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. Interruption of direct
transmission may be accomplished by isolation of someone with infection, or
counseling persons to avoid the specific type of contact associated with
transmission. Vehicle borne transmission may be interrupted by elimination or
decontamination of the vehicle. To prevent fecal-oral transmission, efforts often
focus on rearranging the environment to reduce the risk of contamination in the
future and on changing behaviors, such as promoting handwashing. For airborne
diseases, strategies may be directed at modifying ventilation or air pressure, and
filtering or treating the air. To interrupt vector borne transmission, measures may be
directed toward controlling the vector population, such as spraying to reduce the
mosquito population.