Prof RN Basu

CONTENT
Topic Slide No
1. Introduction 3
 Definition 3
 Health related states or events 6
 Specified population 7
 Application 8
2. Core Epidemiologic Functions 9
 Public health surveillance
(Epidemiology Concepts & Descriptive
 Field investigation
 Analytic Studies
10
11
14
 Evaluation
 Linkage Epidemiology)
 Policy development
19
21
23
3. Epidemiologic approach 26
 Using counts and rates 28
4. Descriptive epidemiology 31
 Time 33
 Epidemic period
 Epidemic curve
Prof (Dr) RN Basu 37
39
 Epidemic pattern 40
 Place 46
 Spot map 47
 Person 48
 Age 49
 Sex 49
 Ethnic and racial groups
50
 Socioeconomic status
50
• Definition
• 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
• Key terms in the definition
• These are:
• Study
• Distribution
• Determinants

3
 • Health related states or events
• Specified population
• Application
• Study
• Epidemiology is a scientific discipline
• It is based on sound methods, data, their analysis, interpretation, and drawing
conclusion
• Distribution
• Epidemiology deals with the frequency and pattern of health events in a
population

4
 • Frequency is not only counting the numbers but also relationship of that
number to the size of the population
• Pattern indicates occurrences of health related events by time, place and
person
• Health events characterised by time, place and person are
activities done in descriptive epidemiology
• Determinants
• The study of epidemiology also tries to elucidated the causes of the health
events
• For this purpose analytic epidemiology is used

5
• Health related states or events
• The earlier concept of epidemiology was pertaining to only infectious and
communicable diseases
• Present concept has enlarged its scope
• Epidemiological methods can be applied to many other health events
such as study of cause and effect of obesity, cardiovascular diseases,
cancer and so on
• The epidemiological methods can even be applied to non-health related
events, such as road traffic accidents

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• Specified population
• Views of epidemiologists and clinicians differ on occurrence and control of
disease
• Clinicians view disease in a single patient and is concerned with the patient’s
treatment and cure
• But the epidemiologists take a collective view of diseases in community and
focus on identifying the exposure or source that caused illness.
• And also the number of other persons who were similarly exposed causing the
illness
• The potential of spread of the disease is also a concern for the epidemiologist

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• Application
• Epidemiology is not only a scientific study of diseases but also is
concerned with applying the knowledge gained by the study in controlling
the disease or condition
• Like a clinician, an epidemiologist also applies his/her knowledge, skill,
experience and epidemiologic judgement in diagnosing the health of the
community
• Also the knowledge gained by the study is then used in recommending a
public health intervention
• Thus the very purpose of epidemiology is ultimately control of a disease

8
• There are six functions of epidemiology
• These are:
• Public health surveillance
• Field investigation
• Analytic studies
• Evaluation
• Linkage, and
• Policy development

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• Public health surveillance
• For the purposes of control of a disease, monitoring needs to be
done
• This is done by data collection about the disease occurrence, its spread,
population affected, the source of exposure and so on
• Morbidity and mortality data and other relevant health information is
analysed
• The data is interpreted and disseminated to those who need them
for control of disease and decision making for public health
purposes

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• Field investigation
• Information is required for decision making and action
• This information is provided by epidemiologic surveillance
• The scope of investigation may vary widely depending on the situation
• It may be as limited as a simple interaction with a clinician, or
• It may be much more elaborate where a large number of investigator descend on
the field and laboriously observe and collect data
• This type of elaborate and painstaking investigation may reveal many
unreported or unrecognised patients who may be spreading disease
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• This elaborate investigation may identify a source or vehicle of
infection which was even not recognised by the person suffering
• When a source or a vehicle is identified by field investigation, that can be
eliminated or controlled
• Identification of source, can reveal the other persons that were exposed
to the same source or was affected by the same vehicle
• Sometimes the source can be traced to a commercial product
• Under such circumstances a public announcement can be made for
avoiding that product and the product can be withdrawn

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• Sometimes, the purpose of an investigation may be different from
that of controlling a disease
• It can simply be to learn more about the natural history of the disease,
clinical spectrum, place and person distribution of the disease, the factors
that predisposes a person to the risks of getting the disease
• These information then can be applied for making a strategy for disease
control
CDC
• This type of field investigation is sometimes called
“shoe leather epidemiology “
• It signifies that the investigator has walked so much
that a hole has developed in the sole
13
• Analytic studies
• In an outbreak or clusters of disease, epidemiologists look for answers
to causes, modes of transmission and control and prevention measures
• Most often surveillance and field investigation provide the answers the
epidemiologists are looking for
• Sometimes analytic methods are needed and often used in combination
with surveillance and field investigation
• They provide, for the analytic studies, clues for hypothesis about
causes and transmission mode
• Analytic studies can then evaluate their acceptance or rejection

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• Clusters or outbreaks of diseases are initially investigated with
descriptive epidemiologic methods
• The descriptive method studies incidences of disease and distribution by
time, place and person
• It also calculates rates and identifies those who are at higher risk
• After the descriptive study, if strong association between disease and
exposure is found, further progress of analytic study may be suspended
• Control measures to be adopted to stop or slow down the progression
becomes clear
• These control measures can then be implemented

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• The analytical study involves
• Design
• This includes:
• the appropriate research design,
• writing a protocol and justification of study,
• appropriate sample size,
• criteria for subject selection,
• choosing an appropriate comparison group and
• designing data collection tool (questionnaire)

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• Conduct
• It includes
• approval for the study,
• ethical clearance from the institutional ethical committee
• abstracting records
• tracking down the interviewing subjects
• collecting and handling specimens, and
• data management

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• Analysis
• It includes:
• Describing characteristics of subjects
• Creation of comparative tables (two-by-two tables)
• Computation of measures of association, such as
• Risk ratios or odds ratios
• Tests of significance
• E.g. chi-square test
• Confidence interval and so on
• Some studies would need advanced analytic techniques such as stratified
analysis, regression and modelling

18
 • Interpretation
• This involves:
• Putting the study findings into perspective
• Identifying the conclusion drawn, and
• Making recommendation
• Evaluation
• It is the process of determining systematically and objectively the
relevance, effectiveness, efficiency, and impact as per the pre-
determined goal of the exercise

19
• Effectiveness
• It is the ability of a programme to produce the intended or expected
results in the field
• Effectiveness differs from efficacy
• It is the ability to produce results under ideal conditions
• Efficiency
• It is the ability of the programme to produce intended results with a
minimum expenditure of time and resources

20
 • The evaluation process has three variations, these are classified as
per the focus of the evaluation
• Formative evaluation – focuses on plans
• Process evaluation – focuses on operations
• Summative evaluation – focuses on impact
• Linkage
• Epidemiologist work in a team and not in isolation
• The teams may be laboratarians, sanitarians, infection control
personnel, nurses, or other clinical staff and IT personnel
21
• An outbreak may cross a geographical boundary
• Then the epidemiologists might have to work with many other
organisations and people and government agencies
• This calls for coordination and collaboration among these
divergent groups and building relationships with them
• The mechanism for sustaining such linkage includes:
• MOU
• Sharing of information
• Informal networking at professional meetings

22
• Policy development
• Purpose of epidemiology is to apply the insight gained through
epidemiologic study for prevention of diseases and control of outbreaks
• This policy shall be applicable both for communicable and non
communicable diseases
• The control measures, and interventions can be undertaken, as per the
policy, by the public health personnel
• The policy includes recommendations regarding control measures and
other appropriate interventions

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• Epidemiologic approach
• The epidemiologist pursue a systematic approach for
epidemiologic studies like any other branches of science
• Basically, the epidemiologists for their study proceeds to
• Count cases or health events
• These occurrences are linked to place person and time
• Calculates rates
• This is done by dividing the number of cases by an appropriate denominator

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 • Compare
• These rates are compared over time periods or for different groups of people
• In the count of the number of cases, only those cases have to be
included that conforms to the defined criteria of the case
• Therefore, what constitutes a case under study must be defined
appropriately
• Defining a case
• A case definition is a set of standard criteria for classifying whether a
person has the disease, syndrome or other health conditions under study

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• For national surveys the case definitions are included in the
national standards
• The agreed upon standard definition of cases would ensure that
every case is equivalent irrespective of who, where and when the
number was compiled
• Moreover, for comparison of occurrence over different time
periods, the standard case definition shall eliminate chances of
error
• If there is a national organisation that monitors occurrences of
notifiable diseases, they may provide standard case definitions

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• A case definition consists of clinical criteria
• The clinical criteria usually needs confirmation by laboratory tests
• It can also be combination of symptoms, signs and other findings
• Case definition during an outbreak investigations may include limits on time,
place, and/or person
• E.g., A case definition for L. monocytogenes may be like, clinically compatible illness with
L. monocytogenes isolated from a normally sterile site in a resident of North Carolina
with onset between October 24, 2000 and January 4, 2001
• This may not be included when case definitions are used for surveillance
• A case definition, depending on how certain the diagnosis is, may have
several sets of criteria
• The cases may be classified as confirmed, probable or suspected
27
• Using counts and rates
• Public health is responsible to identifying and counting occurrences of
disease, their extent and pattern
• This occurrences have to be related to place, person, and time
• These count is done from the various reports submitted by health
facilities
• This count will help the public health to identify outbreaks and clusters
of disease in the community
• Counts are also useful for assessing health need and for health planning

28
• Raw data of counts do not provide useful information unless processed
• Counts must be related to the population from where the counts were
obtained
• Rates are measures that inform how many cases per defined size of
population arose during a certain period of time
• Size of population may be thousand, 100 thousand or similar
• Unit of time may be month or year or similar periods
• Example:
• Such as the number of cases per 100000 population per year in a defined
geographical area

29
• Rates are useful for purposes of comparison of disease occurrence in
different time periods
• When different subgroups of populations are used to count rates, it
may help identifying those who are at higher risks
• Example:
• Elderly population above 65 years of age are at higher risk for COVID-19 infection
• Further analysis of the high risk groups may reveal risk factors, e.g., elderly
population with comorbidities are more susceptible to COVID-19 infection
• Some risk factors can be modified while others cannot be, e.g., smoking or
hypertension or obesity as cardiovascular diseases risk factors are modifiable
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• Descriptive Epidemiology
• Description of an epidemiologic event is not complete, unless
certain facts are included
• The essential facts are:
• Case definition,
• Person, place, time, and
• Causes/risk factors/mode of transmission
• Descriptive epidemiology covers time, place, and person
31
• Compilation and analysing data by time, place and person is
important due to various reasons
• Firstly
• An experienced epidemiologist by carefully looking at the data can
identify its limitations and discrepancies, such as
• Incomplete or missing data
• Inconsistency in data such as those data which are outlying
• Secondly
• Epidemiologist can have a feel of the extent and pattern of the public
health problem being investigated in the community
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 • Thirdly
• Epidemiologist creates a detailed profile of population health with visual
presentation of tables, graphs and maps
• Fourthly
• By this method the epidemiologist can identify where in the community
higher rates of disease is occurring
• This can provide some indication about the causes of the disease
• Time
• Occurrence of disease varies over time

33
• Some diseases predictably occur during a particular season, such
as influenza which occurs in winter
• Occurrence of some other disease cannot be predicted, such as
Hepatitis A may occur in any season
• When the disease occurrence is predictable, its preventive
measures can be planned and implemented
• When presented in a graph, the disease-time relationship can be
represented in a two-dimensional graph with time on x-axis and
no of cases on y-axis

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• A graph sometimes may show the timing of events
• These events may be related to the trend of the disease being graphically
displayed.
• The graph may be used to show the period of exposure or the date of
implementation of control measures
• Studying the period of exposure may indicate the probable cause of the
disease, and
• A graph that shows the timing when the control measure was instituted may
indicate the effectiveness of the control measures
• Disease-Time graph may show trends of the disease

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• Secular (long-term) trend
• Disease’s annual rate when plotted on the graph over a long period of time shall
show long-term or secular trend of the disease
• This trend can be used to evaluate program effectiveness or deciding the need
for any change in the program strategy
• Seasonality
• In the plotted graph when the time periods are shorter such as days or weeks,
the graph will show the seasonal trend of the disease
• The seasonal pattern may help hypothesising on how the disease is transmitted,
the behavioural pattern that increases the risk or other possible conditions that
contributed towards disease occurrence

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• Day of week and time of day
• When such data are plotted, the graph may show occupational or environmental
exposure to risk factors
• These can be then a subject of further study for evaluation
• Epidemic period
• For showing time course of a disease use of a curve known as epidemic curve is
quite helpful
• In the epidemic curve,
• the number of cases is shown on the vertical (y-axis) and
• the time is shown on the horizontal axis (x-axis) either as date of onset or date of
diagnosis

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• The scale of time to be shown on the x-axis will depend on the incubation period
• Depending on the incubation period of the disease and route of exposure, the scale
can be broad (weeks, for prolonged epidemic) or short (days/hour/minutes)
• Example:
• Food poisoning with chemical may show symptoms within minutes

• Conventionally, the data is displayed as histogram

• Sometimes each case is displayed as a square
• The shape and other features of an epidemic curve can suggest hypothesis about
time and source of exposure, the mode of transmission, and the causative agent

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Epidemic Curve
Source: CDC 39
• Epidemic pattern
• Epidemics can be classified according to their manner of spread
through a population:
• Common-source
• Point
• Continuous
• intermittent
• Propagated
• Mixed
• Other
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• A common-source outbreak
• In this type of outbreak, a group of persons are all exposed to an
infectious agent, or a toxin from the same source
• The group may be exposed over a relatively brief period
• Everyone who becomes sick does so within one incubation period
• In this case, this outbreak is further classified as point-source outbreak
• Point source
• The epidemic curve, in this case would have a steep upslope and a more
gradual down slope

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Point Source of Outbreak

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• Continuous common-source outbreak
• Case-patients get exposed over a period of days, weeks, or longer
• The range of exposures happens over a longer period of time
• The incubation periods of the cases will be spread over a time period
• Both these tend to flatten the top of the epidemic curve
• Intermittent Common-source outbreak
• Pattern of the curve points to the intermittent nature of the exposure
• Propagated outbreak
• Results from transmission from one person to another.
• Usually, transmission is by direct person-to-person contact, as with HIV

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Continuous Common Source Outbreak
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Measles Cases by Date of 0nset, October 15, 1970 – January 16, 1971

Intermittent Common Source Outbreak

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• Place
• When the disease occurrence is described by place, it throws light
on
• The geographic extent of the problem and its geographic variation
• The locations may include, place of diagnosis, site of employment,
hospital unit or hospital floor, school or a restaurant or recent travel
destination
• In the place description, the unit may be large such as a continent or a
country, or may be small like a house, hospital wing, or operating room
• Space may be only a category such as urban or rural, domestic or foreign

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• Place data may be shown in a table or a map
• A map would be more visually appealing
• Spot map
• Another type of map that is used is called a spot map
• This is used when the clusters or outbreaks are limited in number
• A dot or X is placed on the location that is most relevant to the disease
• Usually, this is where the victim lived or worked
• If known, sites that are relevant such as probable locations of exposure
(water pumps) are noted on the map

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 • When data is plotted by place, very important information may be obtained such
as communities at higher risk of disease
• It can generate hypothesis for further study
• Person
• Susceptibility and manifestation of a disease in a person may vary
• The variable factors are:
• Inherent characteristics (age, sex, race),
• Biologic characteristics (immunity status),
• Acquired characteristics (marital status),
• Activities (occupation, leisure activities)
• Use of Medication, tobacco, drug, alcohol

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• Age
• It is the most important personal attribute
• Most health-related varies with age
• Factors that vary with age are: susceptibility, opportunity for exposure latency or
incubation period of the disease and physiologic response
• Sex
• For many diseases males have higher rates of illness and mortality than females
• This is due to genetic, hormonal, anatomic, or other inherent differences
between the sexes
• These differences influence susceptibility and physiologic responses

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• Ethnic and racial groups
• Sometimes person data may need to be analysed by biologic, cultural, or
social groups such as race, nationality, religion, or social groups
• Many personal factors may affect susceptibility or exposure
• These factors are differences in ethnic, racial or some other group variables
• There are some other factors that influence the risk of disease
• These are: socioeconomic status and access to health care
• Socioeconomic status
• This is made up of many variables and difficult to quantify

50
• The frequency of many adverse health conditions increases with adverse
socioeconomic status
• Like lower socioeconomic status increases risk to some diseases or health related
conditions, the higher status also may predispose to certain other health conditions
• Example
• Gout was known as the “diseases of kings”
• Breast cancer, Kawasaki syndrome, chronic fatigue syndrome and tennis elbow are
related to higher socioeconomic status
• The reason for these differences could be due to differences in exposure
• This may account for at least some if not most of the differences in the frequency of
these conditions

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End of Part 1