L1-OVERVIEW OF

EPIDEMIOLOGY
BY
DR.CIROOBE
Classically speaking
 Epi = upon
 Demos = people
 Ology = science
 Epidemiology = the science which deals with what
falls upon people…..
 Bridge between biomedical, social and behavioral
sciences
 Scope of Epidemiology
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.
•(Porta M, Last J, Greenland S. A Dictionary of

Epidemiology, 2008)

Key terms in this definition reflect some of the important

•

principles of epidemiology
 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 interpretati on
of data.
 Basic epidemiologic methods tend to rely on careful observation
and use of valid comparison groups to assess whether what was
observed, such as the number of cases of disease in a particular
area during a particular time period or the frequency of an
exposure among persons with disease, differs from what might
be expected.
 However, epidemiology also draws on methods from other
scientific fields, including biostatistics and informatics, with
biologic, economic, social, and behavioral sciences
 Distribution

 Epidemiology is concerned with the frequency and pattern of health events in a

population:
 Frequency refers not only to the number of health events such as the number of
cases of meningitis or diabetes in a population, but also to the relationship of that
number to the size of the population. The resulting rate allows epidemiologists to
compare disease occurrence across different populations.
 Pattern refers to the occurrence of health- related events by time, place, and
person.
 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 exposure
 Characterizing health events by time, place, and person are activities of descriptive
epidemiology
 Determinants
 Epidemiology is also used to search for determinants, which are
the causes and other factors that influence the occurrence of
disease and other health -related events.
 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.
 To search for these determinants, epidemiologists use analytic
epidemiology or epidemiologic studies to provide the “Why”
and “How” of such events.
 They assess whether groups with different rates of disease differ
in their demographic characteristics, genetic or immunologic
make-up, behaviors, environmental exposures, or other so-called
potential risk factors.
 Ideally, the findings provide sufficient evidence to direct prompt
and effective public health control and prevention measures.
 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
 Specified populations
 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 is concerned about the health of an individual; the
epidemiologist is concerned about the collective health of the people in a
community or population.
 In other words, the clinician’s “patient” is the individual; the epidemiologist’s
“patient” is the community. Therefore, the clinician and the epidemiologist
have different responsibilities when faced with a person with illness.
 For example, when a patient with diarrheal disease presents, both are
interested in establishing the correct diagnosis.
 However, 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.
 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.
 Like the practice of medicine, the practice of epidemiology is both a
science and an art. 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 epidemiologist uses the scientific methods of

descriptive and analytic epidemiology as well as experience,
epidemiologic judgment, and understanding of local conditions in
“diagnosing” the health of a community and proposing appropriate,
practical, and acceptable public health interventions to control and
prevent disease in the community.
 Summary
 Epidemiology is the study (scientific, systematic,
data -driven) of the distribution (frequency, pattern)
and determinants (causes, risk factors) of health -
related states and events (not just diseases) in
specified populations (patient is community,
individuals viewed collectively), and the application
of (since epidemiology is a discipline within public
health) this study to the control of health problems
Who is an epidemiologist ?

A professional who strives to study and control the

factors that influence the occurrence of disease or
health-related conditions and events in specified
populations and societies, has an experience in
population thinking and epidemiologic methods,
and is knowledgeable about public health and
causal inference in health
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)
 Epidemiologists are required to have some
knowledge of:

• Public health: because of the emphasis on disease prevention

•Clinical medicine: because of the emphasis on disease classification and
diagnosis (numerators)
• Pathophysiology: because of the need to understand basic biological
mechanisms in disease (natural history)
• Biostatistics: because of the need to quantify disease frequency and its
relationships to antecedents (denominators, testing hypotheses)
• Social sciences: because of the need to understand the social context in which
disease occurs and presents (social determinants of health phenomena)
 Purposes of Epidemiology

1. To investigate nature / extent of health-

related phenomena in the community /
identify priorities
2. To study natural history and prognosis of
health-related problems
3. To identify causes and risk factors
4. To recommend / assist in application of /
evaluate best interventions (preventive
and therapeutic measures)
5. To provide foundation for public policy
 Classical versus Modern Applications

 Classical: descriptive, observational, field, analytical,

experimental, applied, healthcare, primary care,
hospital, CD, NCD, environmental, occupational,
psycho-social, etc
 Modern: risk-factor, molecular, genetic, life-course,
CVD, nutritional, cancer, disaster, etc
 Broad Types of Epidemiology

DESCRIPTIVE EPI ANALYTIC EPI

Examining the distribution of a Testing a specific hypothesis

disease in a population, and about the relationship of a
observing the basic features of its disease to a specific cause, by
distribution in terms of time, conducting an epidemiologic
place, and person. We try to study that relates the
formulate hypothesis, look into exposure of interest to the
associations ? outcome of interest (? Cause-
effect relationship)
Typical study design: Typical study designs: cohort,
community health survey case-control, experimental
(synonyms: cross-sectional design
study, descriptive study)
 Descriptive Epidemiology Is A Necessary

Antecedent of Analytic Epidemiology

To undertake an analytic epidemiologic

study you must first:
 Know where to look

 Know what to control for

 Be able to formulate / test hypotheses

compatible with a-priori lab / field

evidence
 Basic Triad of Descriptive
Epidemiology

THE THREE ESSENTIAL CHARACTERISTICS

OF DISEASE WE LOOK FOR IN DESCRIPTIVE
EPIDEMIOLOGY ARE:

 PERSON
 PLACE
 TIME
 Personal Characteristics (whom)

 Age
 Gender
 Socio-economic status (education,
occupation, income)
 Marital status
 Ethnicity/race/genetic profile
 Behavior / habits
 Place (where ?)
 Geographically restricted or widespread
(outbreak, epidemic, pandemic)? Off-shore
(tsunami…)
 Climate effects (temperature, humidity,
combined effects..)
 Urban / sub-urban-squatter / rural
 Relation to environmental exposure
 (water, food supply, etc)
 Multiple clusters or one?
Time (when ?)

 Changing or stable?

 Clustered (epidemic) or evenly

distributed (endemic)?

 Time-trends: Point source,

propagated, seasonal, secular,
combinations
 THE THREE PHENOMENA ASSESSED IN
ANALYTIC EPIDEMIOLOGY ARE:

Basic triad of analytical epidemiology

HOST

AGENT ENVIRONMENT
Agents
 Biological (micro-organisms)
 Physical (temperature, radiation,
trauma, others)
 Chemical (acids, alkalis, poisons,
tobacco, others)
 Environmental (nutrients in diet,
allergens, others)
 Psychological experiences
 Host Factors
 Genetic endowment
 Immunologic status
 Personal characteristics
 Personal behavior
 Definitive versus intermediate (in
vector-borne diseases)
 Environment
 Living conditions (housing, crowding,
water supply, refuse, sewage, etc)
 Atmosphere / climate
 Modes of communication: phenomena
in the environment that bring host
and agent together, such as: vector,
vehicle, reservoir, etc)
Epidemiology as a problem solving discipline:
Integrating principles

The first integrating principle is that epidemiology is

an information science.
The second integrating principle is that
epidemiology operates within an environment of
complex systems.
Third integrating principle is that epidemiology is
not just a scientific discipline but a professional
practice area.
 (I) Epidemiology is an
information science

Epidemiology is an information science:

Data generated by epidemiologists is to be used for
decision making.
Epidemiology is purposive: methods and knowledge are
to be used for the ultimate purpose of prevention of
disease, disability and death
Epidemiology is under public scrutiny.
Information affects decisions at the public policy level,
at the level of individuals, and by health professionals.
A social responsibility.
 INFORMATION  DECISION  ACTION
GENERATION PROCESS .

EPIDEMIOLOGIC  PROCESS OF  INTERVENTION

METHODS INFERENCES .
Epidemiology assists:

 Systems: information, surveillance

 Decisions: political, management
Information Systems:
Value and Quality
1. Timeliness
2. Quantity
3. Frequency
4. Use for Decision Making
5. Presence of Feedback Loop
Surveillance Systems:
Evaluation
1. Sensitivity
2. Predictive value positive
3. Simplicity
4. Flexibility
5. Acceptability
6. Representativeness
7. Timeliness
8. Reliability or precision
Political Decisions
l Budget and Resource Allocation
l Jurisdiction of agencies
l Personnel selection
l Legislation
 Management Decisions

l Efficacy – Patient Care

l Effectiveness – Public Health
l Compliance
l Quality Assurance
l Training
l Planning
l Programming
In a health-system, epidemiology
supports:

 Structure
 Process
 Outcome
 How does this work ?

Structure: Does a structure exist to implement the health

care intervention (program) and what are its
characteristics?
Process: Is the process to implement the health care
intervention (program) working?
Outcome: What effect has the intervention had on the
outcome(s) of interest?
What outcomes ?

Mortality: all cause / cause-specific

Morbidity
Disease-specific indicators / General indicators:
clinic use, hospitalization, medication use
Quality of life
General / Disease-specific
Costs
 (II) Epidemiology operates within complex
systems.
Our etiologic investigations continue to have a focus of simple
models even if we use multivariate analyses.
Etiologic factors operate in complex systems and we need to
consider the use of a systems analysis approach in
investigating etiology. Epidemiologists, need to work at
multiple levels to make the appropriate inferences.
“As a physician working in this health center I am not just
interested in the trends and distribution of the disease but I
want first to know individually who are my diabetic patients
and what is being done to them”
 CLASSIC EPIDEMIOLOGIC
RESEARCH INTO ETIOLOGY

Environmental Outcome
factor(s)
 CLASSIC EPIDEMIOLOGIC
RESEARCH INTO ETIOLOGY

Other factors including

health care

Environmental
Outcome
Factor(s)
 CLASSIC HEALTH SERVICES
RESEARCH INTO EFFECTIVENESS

Health
Outcome
Care
 CLASSIC HEALTH SERVICES
RESEARCH INTO EFFECTIVENESS

Environmental and
other factors

Health
Outcome
Care
(III) Epidemiology is a professional
practice area
John Racy defined a profession as “a socially
sanctioned activity whose primary object is the well-
being of others above the professional’s personal
gain”
Epidemiology:
-a solid disciplinary scientific base
-requires well grounded academic preparation
-objectives within the public-social domain
-uses well defined paradigms of problem
investigation, analysis, and inferences.
From the Present to the Future 1
Science is universal but we each bring to it our own
way of thinking and the wealth of experience and
heritage for some common goal.
When we are inspired and driven by the potential
impact of what we can achieve, then we can make a
great leap forward for the discipline.
From the Present to the Future 2
Henry Siegerist: one of the problems of medicine
through the ages has been that technology has
always outpaced sociology
Epidemiology is in need of sociology more than
additional technology. Sociology in epidemiology is
in the context of its uses and its practice within the
framework of health services.
From the Present to the Future 3

Human beings are not just a collection of cells or

molecules but also have spirituality that binds the
molecules and cells with an integrative purpose and
the resultant direction. Thus, in every culture and
with every individual there is this search for dignity
that elevates us out of our biological complexity
Public health action, problem solving and a sense of
mission is what brings many of our students to health
sciences and epidemiology