UNIT 4 INTRODUCTION TO

Structure
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Objectives Introduction . Epidemiological Concepts 4.2.1 Epidemiological Trends and Definition 4.2.2 Aims of Epidemiology Epideiniological Aspects of Disease and Health 4.3.1 Epidemiological Models of Causation of Disease 4.3.2 Epidemiological Model of Determinants of Health 4.3.3 Natural History of Disease 4.3.4 Spectrum of Diseasc 4.3.5 Ice-berg of Disease 4.3.6 Levels of Prevention of Disease Epidemiological Methods 4.4.1 DescriptiveEpidemiology 4.4.2 Analytical Epidemiology 4.4.3 ExperimentalEpidemiology Epidemics 4.5.1 Concepts of Epidemics 4.5.2 Investigation of an Epidemics Preventive Epidemiology 4.6.1 Health Surveys 4.6.2 Screening of Disease I 4.6.3 rSurveillance 4.6.4 Monitoring and Evaluation Epidenliology and N~~rsing Let Us Sum Up Key Words

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4.3

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4.6

4.7

4.8
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4.10 Answers to Check Your Progress

4.0 OBJECTIVES
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After going through this unit, you should be able to: define the science of epidemiojogy; describe the epidemiological trends and explain the modern concept of
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state the aims and scope of epidemiology; discuss epide~niological theories of disease causation; discuss epidemiological models of health determinants;

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definq natural history af disease and discuss its process;

Principles and Practice of Community Health Nursing

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explain levels of prevention of disease; describe epidemiological methods; define different types of epidemic and describe investigation of epidemics; describe interventions of preventive epidemiology; and identify the role of a nurse in epidemiological process.

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4.1

TRODUCTION

Community health is the field concerned with the study of health and diseases in human population and its goal is to provide comprehensive need based health care services to the entire community to achieve the goal of Heal For All. The health worker, therefore, need to have some basic knowledge and skills which will help her1 him to identify health need, health problem, the related etiology and plan, implement and evaluate health care services. The science of epidemiology helps health workers to develop such knowledge and skills.Tn this unit we shall discuss about, concepts of epidemiology, epidemiological concepts of disease causation, epidemiological methods, Epidemics monitoring and evaluation of role of nurse in epidemiology.

4.2 EPIDEMIOLOGICAL CONCEPTS

The science of epidemiology deals with the study of health related states and events occurring in a population. The origin of this science has been traced to the time of Hippocratres who tried to explain the causative factors of discases. But it flourished rapidly during the last three decades of the present century and contributed extensively in the field of medicine and community health. As a science and academic field, epidenliology not only helps in understanding the health concepts, natural history of disease and disease causation, it also helps in planning, implementing and evaluating effective and efficient health care services.

4.2.1 Epidemiological Trends and Definition

The term "epidemiology" is derived from the term "Epidemic". The literal meaning of the term is "study among people" (Epi = among, demos = people, logos = study). The foundation of the epidemiology was laid in the 19th century when infections and communicable diseases like cholera, typhoid, plague etc., were most prevalent in the world in the form of epidemics and pandemics. During the late 19th century and the early 20th century, the study of frequency, distribution and determinants of infections and communicable diseases and their peventionand control were the primary focci of epideiniologists. There has been considerable reduction in the morbidity and mortality from these diseases as a result of epidemiological studies and improved methods of diagnosis, prevention and control. However, the threat of communicable disease is still present, specially in developing countries, because of substandard environmex~tal conditions, poor socio-econo~nic status and inadequate resources. It may also be defined as the study of frequency, distribution and determinants of health related states and events and disease in human populations. Frequency Distribution
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rates, ratio, normal ranges time, place and person

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From the above definition and concepts it can be said that it includes three important elements: 4 -

Introduction to Epidemiology

- All diseases and health-related diseases - both communicable and

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non-communicable Populations Ecological approach.

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While communicable diseases continue to be serious public health problems, many new problems have come up in the 20th century. These problems include cardio-vascular diseases, cancer, diabetes, accidents etc. These problems are taking the form of epidemic. The focus of epidemiologists is now, not only on communicable diseasQ but also on these new emergent and chronic diseases. In fact, the epidemiologists study all those conditions that affe'ct the health of a population at any given time. Thus, several definitions have been given by various authors based on their experience background and changing trends which are listed below: 1) The epidemiology is that branch of medical science which deals with epidemics (Parkin, 1873)

2) Epidemiology is the science of m a s phenomena of infectious diseases (Frost, 1927)

3) Epidemiology is the study of disease, any disease, as a mass phenomenon (Greenwood, 1934)
4) ,~ ~ i d e m i ois l the o ~ study ~ of the distribution and determinants of disease

frequency in man (MacMohan?1960)

5) Epidemiology is the stbdy of frequency, distribution and determinants of health related states, events and morbidity patterns in population, and the application of this study to control health problems (Last, 1983)
From these various definitions it is learnt that modern epidemiology deals with: Measurement of occurrence of health related statesland events iie., health needs, health demands, blood cholesterol level, etc., and measurement of frequency of disease, disability or death. The measurements are done in the form of rates, ratios and propo&on e.g., incidence rate, male - female ratio, percentage of children with malnutrition etc. Rates, ratios and proportions can help in making comparison of different population different time with re'spect to occurrence of disease, health related stateslevents.
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Distribution of disease pattern in a community .by time, place and person. The epidemiologist examines whether there is increase or decrease of disease or health related Bvents over time, whether there is high or lower concentration of .disease or health related events in different places; whether the occurrence is more in man than in woman and in what particular age and with particular life style etc,,aetiological hypothesis e.g, "Smoking of 15-20cigarettes per day over a p&bd of 10-15 yearsais associated with lung cancer in men and women occurrence of diarrhea is more frequent in non-breast fed infants than in breast fed infants of low sgcio-economic population", This aspect of epidemiology refers to descriptive epidexnialogy.'
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Testing of etiological hypothesis derived from descriptive study of diseases and health related events. This'iaspect of epidemiological s&es help in establishing cause and effect relationship dnd it refers to analytical and experimental epidemiology, , = .

Principles and Practice of Community Health Nursing

Planning of health card services based on the studies, implementation and evaluation of health care services. a
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The uses of epidemiology are:

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To study the health history of popylation and their disease trends. To arrive at community. diagnosis. To plan and evaluate health services.
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estimate individuals risk and chance.

To define and redefine syndromes.

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To complete the natural history of disease. To search for causes of health and disease by employing epidemiological methods.

4.2.2 Aims of ~pidemiology

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Based on the concept of epidemio1ogy;three main aims have been identified by InternationalEpidemiologicalAssociation: 1) to describe.the occurrence and distribution of disease problems in human population. 2) to identify aetiological factors in the pathogenesis of diseases.
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3) to provide information on health related states and events for planning, implementation and evaluation of comprehensive health care services to ded with health problems and promote health and well being of the society as a whole.

4.3 EPZDEMIOLOGICALASPECTS OF DISEASE AN'D

With the progress of civilization from the primitive period to modern time the concept of disease and health have changed from supra-natural to multifactorial causes and holistic health approach. But these old concepts still preyail among people in the world who are under-developed. Therefore, it is important to clarify the concept of health and disease.

Introduction to Epidernioloe

4.3.1 Epidemiological Models of Causation of Disease

Before the discovery of micro-organisms in 19th century diseases Cvere associated wi& supranatural and spiritual forces. The ge&i theory became popular during the 19th and early part of 20th century. According to this. theory there is one single specific causative agent to every disease as shown in the model given below. ] ~ x a m ~ l are: es . . .,
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Disease agent.. .... ....;'.... ......

.... ....Man.. .. .......,...........Disease

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Tuberculosis due to tuberculosis bacilli, cholera due to cholera vibrio, diphtheria due to mycobacterium diphtheria etc. But this'theory has mariy limitations. .For example every one exposid to disease agent did not get the disease say like tuberculosis, only those who were undernourished; susceptible and lived in slum got the disease. This means in addition to specific causative' agent there are many other factors related to host and environment which contribute to causation of disease as shown in the Fig. 4.1.

Epidemiological Biad
Agent Host

Environment

Epidemiological concept of interaction of Host, Agent and .Environment

Fig. 4.1: Epidemiological Methods of Causation of Disease

Principles and Practice of Community Health Nursing

This model 'is known as_Epidemio_~ogical Triad. According to this model disease is caused hy the interactionofagent, host and environment which is shown in the model Fig. 4.1. This means the disease will occur only when the host is'weak, the agent is strong and enters the host through the right channel and in sufficient amount and when environment conditions facilitate the interaction of host and agent. For example for pulmonary tuberculosis, the organisms must enter through respiratory tract and in sufficient amount, the host should not have specific resistance and should have weak general body resistance, poor, dark and dingy environment is conductive to the prevalence af tuberculosis on patiqnts. This model in ~ t h ewords r implies that disease will not occur without the optimal interaction of these three factors and remain in balanced state. This refer to state of health equilibrium and is represented in the following model of Alten Dever (see Fig. 4.2.) '

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Fig. 4.2: Ecological Model of Health Equilibrium

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This model is applicable to'infectious diseases and not to new types of chronic and degeAerative diseases which are a result of modern civiiization, for example cancer, cardiac diseases, diqbetes, nephroitic syndrome, mental disorders, etc. These diseases could not be prevent@ and controlled by the traditional methods of isolation, curative, immunization . and environmental sanitation, etc.
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Changes in

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. Stress

Overeating

lack of physical . exercise

Smoking
Emotional Disturbances .

Hyperlipidaernia

tncreased;hrombotic

Tenrny
Coronary atherasclerosis

Changes in walls of arteries

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Coronary Occlwsion
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Myocardial lsekaemia'
Myocardial Infarction
~ g4.3: . The Web of Causation.for Myocardial Infarction
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It has been epidemiologically recognized that these diseases are caused due to complex interaction of multiple factors related to life style, human behaviour and the environmental conditions as shown in model Fig. 4.3. Agent is regarded as an integral part of total environment. This refers to web of causation as suggested by MacMohan and Pugh. This model suggests clusters of cases and combinations of effects related to each other. It also suggeits variety of intervention e.g., avoidance of smoking, diet control, exercise, regular health check ups, etc., for prevention and controlsf cardio-vascular diseases, cardio-pulmonary diseases, etc.

Introduction to Epidemiology

4.3.2 Epideqiological Model of Determinants of Health

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Of late the epidemiologist proposed a model for analysis of health of people rather than analysis ofksease among the people. According to this model, health is influenced by a v d e t y of factors which are classified as life style, environment, human biology and health and health allied resources as shown in the model Fig. 4.4. These four categories of factors are related to an affect one another and interact with each other. Epidemiologists try to analyze these factors to study the health status, morbidity and mortality pattern in any community. This model refers to health force field model as suggested by Blum.

Health allied resources

Environment

Hg. 4.4: Model of D~terminantsof Health

4.3.3 Natural History of Disease

In the absence of any intervention (i.e., prevention or treatment) almost all disease follow a natural course of events which refers to "natural history of disease". It starts with the interaction of agent, host and environment i.e., epidemiological triaa as discussed earlier. The disease process in man depends on the characteristics of these three factors. The natural histo* of disease has'two phases: (i) Prepathogenisis phase and (ii) Pathogenesis phase.

Prepathogenisis Phase

p his phase is before the onset of disease in man and it is in the environment. The disease agent has yet not entered the host (&an). But the factors that favour its (agents) interaction with the human host exist in the environment (Fig. 4.5) e.g., poor physical environment, climate condition and prevalence of insects, pests and rodents, etc., unhygienic habits and health behavior, traditional practices and biological factors i.e., age, s&, marital status, genetic traits, physiological status, etc., we h e always exfiosed to k e risk to disease but disease process in man starts only when there is interaction m o n g agent, host and environmental factors as shown in the model ~~idemiblogical Triad (Fig. 4.1 and Fig. 4.5).

Principles and Practice of Community Health Nursing

Prepathogenisis Period Before man,is diseasec Agent

Period of Pathogeniss

The course of disease in human

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Death
+ Fastegium t

Environment

clinical Horizon
Early

Discernible Advanced Defer- Conval - Defection early ' disease vescence escence Disease

Pathogenisis Incubation period

Fig. 4.5: Prepathogenisis and Pathogenisis Periods of Natural History

Pathogenesis Phase This phase begins with the entry of the disease agent in the human host. As the agent e.g., 'measles virus' enter the body through appropriate channel e.g., in case of measles virus, the respiratory tract, the agent in this case i.e., the visus grow and multiply and bring in physiological changes in the body. These changes are sub-clinical i.e., clinical signs and symptoms of the disease are absent. The host remains apparently healthy and arnbulant.'After a lapse of some period, which difIer in various diseases, the health equilibrium within the body is dislurbed, the signs and symptoms of disease begins to appear. This period is called as incubation period. The signs and symptoms are vague during the first few days (1 to 4 days ) of illness e.g., in measles, running nose, watering of ejres, etc. This period is called as prodromal period and it is early prepathogenesis phase. But as the disease advances, the signs and symptoms usually become clear cut and clinical diagnosis can be made with ease e.g., skin ashes all over the body in measles. This stage of pathogenesis (disease process) refer to Fastegium. Its duration varies from disease to disease and in case of same disease in different people depending upon the virulence of causative agent and the susceptibility' of human host. The end results of disease. pwcess may be complete recovely which refers to defervescence and convalescence or it may end into some kind of disability1 defect, chronic state or death. From this discussion of pathogenesis phase of a disease we learn that each disease has a series of stages as shown in the Fig. 4.5.

4.3.4 Spectrum of Disease

whenever any disease occurs in the community everyone does not get sick. It is only some people who get sick who show' clinical signs and symptoms of the disease. The severity of the sicbess also varies ranging from mild to severe. These variations are due to susceptibility of the host, virulence of the agent and the various environmental factors which influence the host agent interaction. Many people get the infection but remain sub-clinical i.e.,do not show recognizable signs and sylnptoms but remain as carriers of infection. They are a source of risk to others and create public health problems. @ The graphic representation of these variations in disease occurrence refer t;o spectryrh o f disease which is like a spectrum of sunlight having different shades of colors froin one end to the other. At one end of the spectrum are sub-clinical cases whereas i t the other end ase very serious and fatal cases (see Fig. 4.6).

4.3.5 Ice-berg of Disease

From the spectrum of disease we 1ea1-n that when a disease occurs in a co~nmunity the physician will be able to recognize only clinical cases which is like the floating tip of the ice-berg which is visible on the surface of water. He is not able to recognize a large number of sub-clinical or presymptomatic and missed, cases which remain hidden like the vast submerged portion of the ice-berg as shown in the Figure. The hidden cases we much more8thanknown cases and they are a source of infection beca~~se they ase casriers of infection. The detection and control of hidden cases is a challenge for health personnel in the field of community health.

Introduction to Epidemiology

4.3.6 Levels of Prevention of Disease

We are all familiar with a vely popular phrase "Prevention is better than cure". It is because of the i'act that prevenlion helps to promote and preserve health and minimizes the sulfcrings and distress. It is also economical because preventive . measures can be followed and practiced by all at the village and ho~lle level. It does not require sophisticated infrastmcture, equipmenls and material. Above all it is a positive appmach L o healthful living. Epidemiologically, the concept of prevention is broad based. According to natural histo~y of disease, three levels of prevention have been identified. They are: (i) Pri~nary Prevention, (ii) Secondary Prevention, (iii) Tertiary Prevention.

I) Primary Level of Prevention: It refers to prevenlive measures taken before the qccurrence of a disease i.e., during the prepathogenesis phase of disease. Preventive measures during this period of a disease process prevent the occusrence of disease and promote health. These measures we classified as:
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Health Promotion: Health promotive factors include wholesome nutritious life-style and adequate resources. All food, safc environmnent to live, healthf~~l these aspects ase directly related to socio-economic and cultural status of the fanlily which rnusl be ;mnproved. Much of the morbidity and nlortality due to conz~nunicable diseases such as typhoid, cholera, dysentery, tuberculosis. Plague, leprosy etc., have been reduced due to these preventive measures. Health protnotive measures are equally applicable to thc prcvention of chronic and non-communicable diseases such as casdiovasculas, diabetes, accidents, etc. Specific Protection: I1 refers to actions to protect from a particular disease or group of disease, like B.C.G. imnzunization for tuberculosis, D.P.T. for diphtheria, pertusis and tetanus, increase or decrease of specific nutrient in diet'and or supplelnenting it e.g., iron rich diet and supplementing with iron tablets in case of prevention of anaemia.
Primary prevention is given major emphasis in health care and it is identified with health education because it is considered as the responsibility of the individual, family and coinxnunity.

2) Secondary Level of Prevention: Seconday level of prevention refers to * measures taken during pathogenesis period to control. the progress of disease in man to stop or control the spread of disease in the community. Secondary preventive measures pre~ent'disabilit~ or defects, and restore health. It includes early identification of cases and their contacts and giving them timely treatment 'and follow-up e.g., early diagnosis and treattnent of all cases of tuberculosis and their contacts. These actions help in early recovery prevent cavilation and consolidation of the affected p a t of the lungs and also prevent further sprgad of the tuberculosis in community. Similarly, early diagnosis and treatment of high blood pressure will help in the lxevention of possible cardiovascular emergencies. Thus secondary level of prevention reduces prevalence rate of the disease i.e.,' prevents the occurrence of new cases and controls old cases.

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Principles and Practice of Community Health

Nursing
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3) Tertiary Level of Prevention: The purpose of tertiary level prevention is to limit the disability and help the individual adjust to permanent impairment and disabilities so as to lead a useful life. The measures included are physical, vocational and psychosocial rehabilitation e.g., deep breathing exercise, . meditation, etc., for efficient lung expansion; guidance and training to learn new vocation and guidance and counseling for restoration of family and social relations, etc., in case of patients with pulmonary tuberculosis.

Introduction to Epidemioloj!y

Principles and Practice o f Commui~ity Health Nursil~g Iti

4.4

EPHDENIPOLOGICAL

The epidemiologist and comtnunity health workers are interested in the study of the health status of the population at large, idenlify morbidity and mortality patterns, determine the factors affecting health and disease and utilize this infonllation in planning to provide need based health care services. Such epidemiological study requires systematic collection of health data, its analysis, description of health needs and health problems, identification of factors associated with the probleins and stating the hypothesis which are: (i) Descriptive method, (ii) Analytical method, (iii) Experimental method. Descriptive and analytical methods or studies are also known as observational studies because the investigator does not intervene, he or she makes an observation of the frequency and distribution of the disease by person, place and time.

4.4.1 Descriptive Epidemiology

Descriptive epidemiology is concerned with the study of frequency and distribution of disease and health related events in population in terms of person, place and time. Its . purpose is to provide and overview of the extent of health problems and to give a clue to possible etiological factors involved. This method gives information about who all are affected by a particular disease or health related problems, where the cases occur and when they occur. The data is collected about: 1) Perso~ial characteristics such as age, sex, marital status, occupation, education, income, social class, dietary pattern habits.

2) Place distiibution of cases i.e., areas of high concentration, low concentration and spotting of cases in the map.
3) Time distribution/trends such as year, season, month, weak, day and hour of onset I of the disease. Such information gives clues to possible associated factors such as age with specific disease e.g., measles, diphtheria, pertusis, in early childhood, cancer, dietary pattern with obesity; seasonal variation, periodic fluctuation, etc. The data collected are analyzed and presented in terms of percentage, rates and ratios. This refers to statistical i~iformation of a problem and are given in the table for you to learn to coinpute. Thus, descriptive epidemiology provides information for: 1) making community diagnosis i.e., describing the nature of diseases or problems and measuring their extent in terms of incidence/prevalencerate, raC%., mortality rates, etc., by age, sex, occupation, social class, etc.

2) providing ch~es to etiology of disease for further rigorous investigation and confrontation of the causes.
3) planning, organizing mid implementation of health care services to deal with these problems.

4.4.2 Analytical Epidemiology

You have learnt that descriptive studies yield etiological clues for various diseasqs which helps in making a guess or formulation of hypothesis for further vigorous study or testing e.g. "cigarette smoking (10 to 20) in a day causes lung cancer in 10 to 15 percent of smokers after 20 years of exposure". These type of hypothesis are further studied and tested by analytical studies to determine the association of cause with the effect. 0 Thus, analytical epidemiology goes beyond the descriptive epidemiology. It consists of two type of observational studies: (i) Case Control Study, and (ii) Cohart Study.

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Case Control Study: In this method a group of people who have been diagnosed as having a particular problem (cases) are compared with a group of people who are similar in charactei.istics to that of cases but they are free from the problem under study (controls). Here the approach used is retrospective i.e., the disease has already occurred and the epidemiologist goes back in time. He reviews the records, interviews the cases and their family members. The data thus collected about the suspected factorlfactors is analyzed statistically to determine the extent of its association with the disease. This method, therefore, is called as retrospective method. This approach has helped in identification of causative factors of many diseaseslproblems, etc. e.g. Rubella in mothers during early pregnancy in the cause of congential deformities in children, smoking associated with lung cancer, iodine deficiency associated with hyperthyroidism. These conclusions are based on repeated case control studies. Case control studies are easy to organize and are less expensive.

Intraduction to Epidemiology

2) Cohart Study: A cohart is a specilic group of people, at a certain time, sharing common charactegstics or experience e.g., people born on the same day or the sane year (birth cohart), couple married in the same year (marriage cohart), a class of nursing students (experience cohart), people with same occupations (occupational cohart) etc.

oha art study is prospective in nature because the group under study is free from the disease but exposed to risk factor. In this method of study the epidemiologist selects a cohart i.e., a group of prople say in the same age group and who are exposed to a certain risk factor say cigarette smoking (study group) and who are not exposed to the risk factors (contribi group). Both the groups are followed up for several years and observations are made with reference to frequency and distribution of the suspected disease (in this example lung cancer) over a period of time. The data is statistically analysed and comparisons are done between the incidence among smokers and non-smokers to determine the association of risk factors to the disease.
The prospective study is expensive and time consuming but it has its advantages over retrospective method. This method can help in studying the natural history of disease, estimating incidence rates, risk factor under study to other diseases or problems e.g., cigarette smoking and high blood pressure, cardio-vascular problems etc,

4.4.3 Experimental Epidemiology

Experimental studies are similar in approach to cohart studies expect that conditions are under the caref~~l control of the investigator. Experimental studies are done to confirm the cause and effect association of the efficacy of preventive or therapeutic agent or procedure. In these studies the investigator administers and does investigatiodgives treatment to the experimental group which is either exposure to caGsative agent or preventive/therapeutic agent, but not to the control group which is similar to the experimental in all its aspects. He then observes and analyze the outco~nes using statistical methods and confirm the cause of diseases, and establishes the efficacy or preventive measures and drugs under study. Usually these experiments are done in the laboratoly animals. But clinical and community trials are done to determine efficacy of preventive or therapeutic laboratory animals. These trials do involve medical, ethical and moral issues.

Principles and Practice of Community Health Nursing

In 1994 we read a great deal in the newspaper about plague epidemic in our country. What is an epidemic?

4.5.1 Concepts of Epidemics

Epidemic is defined as the occurrence of a disease for more than normal expectancy in a cqnmunity or region during a specific time period e.g., outbreak of influenza in .

Delhi in a large number in November-December, food poisoning cases, cholera in s u F etc. There are mainly two types of epidemics, namely: (i) Common source epidemic, (ii) Propagated epidemic. I) Common Source Epidemic: Most of the time the epidemic occurs due to exposure to an infectious agent from common source, contaminated air, water, food, soil. Examples of epidemic include influenza, hepatitis, cholera, Bhopal Gas tragedy. The common source epidemic can be due to:
0

Introduction to Epidemiology

Single exposure or point source infection: In single exposure or point source infection, the exposure to the agent is brief and simultaneous. The resultant cases develop the problem within one incubation prior to the disease. The classical example is for a brief period, i.e. first time and all those who have to develop the problem, develop within one incubation period because the exposure to infection is only one time. The epidemic is explosive, the epidemic rises and falls rapidly as shown in the Fig. 4.7. there is a clustering of cases (i.e., cases occur in one particular location usually) within a short period one incubation period. Multiple exposure or continuous exposure: Multiple exposure or continuous exposure is common source epidemic. In this the exposure to infection is continuous repeated or intermittent but may not be at the same time or place e.g., epidemic of cholera or infective hepatitis or any other such problem due to unsafe water supply, milk supply or contaminated well water, epidemic of STDs through infected prostitutes. These epidemics are irregular, extended over a period of time and continued beyond the range of one incubation period.

2) Propagated 'Epidemic: this epidemic results from person to person contact and mostly due to infectious agent. The epidemic flares up gradually depending upon the herd immunity, opportunity for contact. It tails off gradually bver a long period of time. Transmission continues as long as susceptible people are there in the community and are exposed to infected people,

4 . 5 . 2 Investigation of an Epidemic
Investigation of epidemic is essential to determine the particular condition or factors which are responsible for the outbreak. Often health team at the grass root level is made responsible to investigate and plan and implement the intervention to control the epidemic. Investigation of epidemic is a systematic process and goes thraugh orderly steps which are discussed as under:

1) Verfication of Diagnosis of Disease: The first step is to diagnose the disease

and is done on the basis of clinical examination of cases. Laboratory examination is done wherever necessary and applicable.

2) Confirmation of the Existence of an Epidemic: This is done on the bases of the frequency of the disease. If the frequency is more than normal e'xpectancy in the community then it is considered as an epidemic. Often such comparison is not required because there is sudden increase in number of cases within a short period which happens with common source epidemic of cholera, hepatitis, food poisoning, etc.
3) Defining the Population at Risk: It includes:
Obtaining or preparing a map of the area, The map should show the landmarks, roads, sections and locations of all dwelling units,

Demographic study which includes total population composition. This information is necessary for calculating epide~niological measurement e.g., morbidity and mortality rates and proportions, etc.

Principles and Practice of Community Health Nursing

4) Identification of all Cases and their Characteristics: This can be done by organizing house to house search till the area is free of epidemic and medical examination of population at risk. An epidemiological sheet is prepared for every case. It includes basic information on age, sex, occupation, time of the onset of the disease, signs and symptoms, information contacts, movements, history of immunization, information on common source of infection according to the disease under investigation e.g., piuties attended; food eaten sources of w ~ t e retc. ,

5 ) Study of Ecological Factors: It includes investigation of all those ecological factors, agent factors and host,factors. This information will help in identification of the planning of preventive and control measures.
6) Data Analysis: The data analysis is the same as in descriptive epidemiology. Description of the cases in terms of person, place and time distribution. A complete list of cases by chronological order is prepared to show the beginning of the epidemic. An attempt is made to identify the first case and follow its movements to trace the source and spread of infection. Spot maps are prepared to find out the geographical distribution of cases. Concentration of cases (clustering) will indicate the common source of infection.

7) Formulation of Hypothesis: Analysis of data will reveal the possible causes of epidemic and the inode of the spread of infection. Ultimately the investigator is able to formulate the hypothesis.
8) Recommendation for Prevention and Control: Based on the information revealed about the epidemic, the epidemiologist / health worker prepared a programme of prevention and control of the epidemic not only the present but also for its prevention in future.

4.6 PREVENTIVE EPIDEMIOLOGY

Preventive epidemiology is concerned with those measures at the community level which help in identification of population at risk and environmental factors leading to ill health and detection of persons with early, mild and symptomatic diseases. These measures include: Health surveys, Screening, Surveillance and Monitoring.

Introduction to Epidemiology

4.6.1 Health Surveys

Health surveys are investigations to identify health problems in health and disease in a community, i.e. occurrence and distribution and the factors affecting health and disease i.e. determinants. Health surveys help in making community diagnosis. The health surveys provide comprehensive data about health and sickness status of the whole community. General health survey is not a regular practice in our country. It has only been done once or twice in our country. Once I 1946 by the Health Survey *and Development Committee headed by Sir Joseph Bhore and again in 1962 by Health Survey and Development committee headed by Dr. Mudaliar. Special and specific health surveys deal with the investigation of selected health problems e.g,, filarial malaria or tuberculosis etc. Whether general or specific health surveys can be cross-sectional or longitudinal. Cross-sectional surveys provide data about the prevalence and distribution of illness and the state of health of a community at one point in time., Longitudinal; surveys provide v'aluable information about the natural history of diseases, incidence and prev&nce of diseases and the underlying causes, etc., but are difficult to organize and are time consuming etc.

4.6.2 Screening of Diseases

Screening of disease is defined. as "The search for unrecognized diseases by means of rapidly applied tests, examination or procedures in an apparently healthy population". Screening helps to detect persons with early mild and symptomatic diseases. The basic purpose of screening for disease protection is to separate from a large group of apparently healthy population, those who have high possibility of having the disease under study, so that they may undergo further investigation and if diseased, brought to treatment. The screening test are usually very simple, rapid and inexpensive because they are meant for large population. These are not diagnostic tests eg mass chest screening by miniature X-rays. This will help in detecting lesions which may or may not be tubercular and hence require further investigation. Similarly pap smear for cancer of the cervix. The important point is that we must concentrate on the early detection of those diseases for which early treatment is available and it is effective eg tuberculosis, diabetes, cancer of cervix and the breasts. There are three types of screening, namely: i)

Mass screening i.e., screening of the whole population or the subgroups whet]ner or not exposed to the risk of having the disease under study. It is not advisable under the present limited resources. Selective or high risk screening i.e, screening of only those who are at high risk to have a particular problem or disease, e.g. women 35 + and lower social group have more chances of cancer of cervix and if they are screened for that, then there are more chances of detecting the cases. Similarly people having a family history of diabetes, breast cancer should be screened for such problems.

ji)

iii) Multiple screening - In this a number of tests for different condition are krouped together to screen for a number of condition at one and the same time eg test for lung cancer, cardiovascular diseases, diabetes, anaemia, kidney diseases, cancer of the breast and uterus, visual and audio defects are grouped together.

~rinciples and Practice of Community Health Nursing

4.6.3 Surveillance
The literal meaning or surveillance is supervision or close watch specially on suspected person Epidemiologically surveillance means continuous scrutiny of the factors that determine the occurrence,and distribution of diseases and other conditions of ill health It is more than simple reporting of cases. It includes identification of missed and suspected cases and contacts, their confirmation by laboratory investigations, finding out source of infection, routes of transmission. This information will help in planning and implementing prevention and control of diseases in the community. The main steps involved are : collection of relevant information about the disease under surveillance; analysis and interpretation of this information, dissemination of this information to the concerned authority for decisions and actions leading to prevention and control of diseases, The epidemiological surveillance can be:
i) ii)

Individual Surveillance - it includes surveillance of an infected person as long as he is the source of infection to others e.g., typhoid cases and carriers. Local Population Surveillance - e.g., implementation of active and passive surveillance for the prevention and control of malaria.

iii) National Surveillance - e.g., surveillance of small pox after its eradication.
iv) International Surveillance - surveillance of some of the important diseases like influenza, polio, malaria done by WHO and it provides information to the countries in the world to take timely action.

4.6.4 Monitoring and Evaluation

The literal meaning of monitoring is maintaining regular surveillance, Epidemiologically it is a specific and essential part of surveillance, Monitoring is ongoing, day-to-day follow-up of surveillance activities which are to.be implemented as planned. This implies maintaining records of surveillance activities performed and reporting deviation to authority to take corrective measures.

Introduction to Epidemiology

5) Defixie surveillance and monitoring?

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6) What are the differet~t: types of' surveilllmcel?

The science of epidemiology is basic to profession 01nursing wherever it is practiced.

i)

A nurse working in the community deals with the people in various settings and h d p them to solve their health problems. A nurse makes use of epidemiological

Principles and Practice of Community Health Nursing

process in solving t h e problem i.e. she identifies and investigates the problems, formulates alternative interventions and implements the prevention and control of problem and evaluates the effectiveness of the intervention. She may deal with the problem independently especially when there are minor ailments or simple health conditions and she is the only health worker in the health agency. She may pmicipate as one of the team members especially when it is large scale investigation. E.g. occurrence of any epidemic or community level general health survey or specific health survey, surveillance activities and screening-etc. She participates in data collection data analysis, planning, iniplementing and evaluation.
ii)

Nurses in the community have an active role in prevention and control of communicable disease which include: Participation in early diagnosis and treatment i.e. identification of all cases.
e
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Notification of certain specific diseases like measles, diphtheria, tetanus, hepatitis, rabies, STD to the health authority. Trace the contacts, keep them under surveillance. Identify the source of infection, method of spread of infection. Health education of,people in general.

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iii) The nurses should take notice of any uliusual occurrence of any disease in large numbers and report the same to the authority, They also participate in its investigations.

iv) Nurses in the community have an important role in prevention and control of chronic and non-infectious problems such as cardio-vascular conditions, accidents, cancer, mental health problems, etc., through health education and helping people in their life style. Kiowledge of the basic concepts involved in the epidemiological process is essential for any nurse, not only those who are working in the community setting, Nurses play a key role in prevention and control of diseases as well as in restoring and maintaining optimum health wherever they practice.

4.8

LET US SUM UP

After going through this unit, you have learnt that epidemiology is the basic science of community health. Epidemiological methods such as descriptive, analytical and experimental are useful for greater understanding of population health, community diagnosis, and necessary background information which helps in planning and implementing effective health services to prevent and control various health and health related problems including infectious, non infectiobs and chronic diseases. Epidemiologically there are three major categories of factors i.e. agent, host and , environment which interact to cause various diseases. But chronic and degenerative diseases are caused due to complex interaction of multiple factors related to life style, human behavious and environmental condition known as " web of causation". In the absence of any intervention almost all diseases follow a natural cause of event which refers to the natural history of disease, having two phases, One phase is in the environment before the onset of disease and refers to 'pre pathogenesis', the secaid is in human host which start with the interaction of agent and host undqr a favorable environment and refers to 'pathogenesis'. h e severity of illness .# ranges from mild to severe. The sub clinical, mild undiagnosed cases remain hidden and become a source of infection to others, '

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According to natural history of disease there are &ee levels of prevention which include:
Introduction to Epidemiology

Primary level prevention to prevent the occurrence of disease which includes health promotion and specific protection. Secondary level prevention includes measures taken during the pathogenesis phase to stop or control the spread of disease by early detection and treatment. Tertiary level prevention to limit viability and help individual to adjust the permanent impairment by physical, vocational and psychological rehabilitation.

The occurrence of disease more than nor~nal expectancy in a community during a specific time is known as an epidemic which can be due to common source of infection' or due to spread of infection from one person to another. It is very important to do systematic investigations not only to deal with the existing problem of the epidemic but also to deal with the problem in the future. Preventive measures which can be planned and implemented at the community level to prevent and control diseases are: i) conduct of health service, to determine health needs and problems, ii) screening for disease or detect persons with early mild and symptomatic diseases, iii) suweillance, monitoring and evaluation. Epidemiology is a basic requirement for preparation of community health nurse and all othe'r members of health team to function effectiverly in the community. Community health nurses play an important role in epidemiological studies of human population and their problems by way of collection of information, analysis and interpretation of these information.

4.9 KEYWORDS
Agent
: Causative factor invading a susceptible host

through a favorable environment to produce disease, which may be biological, chemical or physical in nature.

Clustering Communicable Ecology

: Grouping offcolony oflcrowding of.

: Able to be transmitted from one host to another.

: A branch of biological science concerned with the

study of interrelationship of organism and their environment.

Endemic

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Habitual or usual presence of a disease or infectious agent within a defined geographical area. enhance or inhibit the interaction between host and agent; they may be physical, biological, social, cultural and economical.

Environment

: The aggregated of all external conditions that may

Epidemic

: The occurrence in a community or region of an illness or.a group of illness of similar nature clearly

in excess of normal expectation.

Etiology

: Cause of a disease condition.

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Principlqs and Practice of Community Health Nursing

Host

A vertebrate or invertebrate species (human, animals, etc) capable of being infected or affected by an agent.

Hypothesis Immunity Incidence

Statement showing relationship of one factor with the other. Insusceptibility to disease or condition, may be natural or acquired.
A measurement of the number of new cases of a disease or other event occurring in.a population during a given period.
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Infection

: The entry and development or multiplication of an

infectious agents in the body of host; not synonymous to disease. Morbidity Mortality
: Illness or some other conditions, not including
.

death.
: Death.
: An epidemic over a wide geographical area, or

Pandemic
Prevalence

even worldwide.
: Measurement of all cases (old or new) of disease

or other conditions present in a population at a given time. Scrutiny

.

: Close or detailed exsunination, critical gaze.

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Susceptible Host

: Sensitive host i.e., the host who does not 'have imm.unity.

4.10 ANSWERS TO CHECCK YOU PROGRESS

Check Your Progress 1
1) Epidemiology is the study of frequency, dishbution and determinants of health related states/events ai~d morbidity patterns in population and the applications of this study to control health problems.
2) 'To determine the morbidity pattern, health related States and events and their determinants for the.purpose of planning and implementing comprehensive health care services.

3) Modern epidemiology not only deals with study of frequency, distribution ahd determinants, disabilities Ad mortality among people but also those hkalth related conditions and events and situation which have direct or indirect effect on-health of the people. It also deals with planning,implemeriting, evaluating and monitoring bf health services.

Check Your progress 2

1) Germ theory : epidemiologicid dlad, web of causation, determinants of health. 2) Epidemiological triad theory explains that the disease is caused due to interaction of three categories of factors which include host, agent and environment. This theory differed from germ theory which explains t$t there is one shingle specific causative agent to every disease i.e., one cause - one effect whereas according

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to epidemiological triad in addition to one single specific cause there are othe~ factors which are responsible for causing disease i.e., three categories of causative factors to cause a disease.
3) Web of causation means that there are multiple causes which have multiple effects i.e. more than one disease and there is complex interaction among the causative factors.

Introduction to Epidemiology

4) a) Human biology, b) Life style, c) Environment, d) Health and health allied resources.

5) See the definitions given in the text.

6) Prepathogenesis is the first phase of disease and it is before the occurrence of disease in man. Agent has yet not entered in the human host i.e., there has not been optimal interaction of agent, host and environtnent. These factors are in state of equilibrium.
Pathogenesis : This phase begins with the entry of agent in human being. The disease will occur only when there is optimal interaction of agent, host and environment. In that case disease process goes through series of stages as shown in Fig 4.5 in the text. Draw your own figure. 7) Spectrum of disease refers to graphic represenlation of the variation of disease occurrence in people. See Fig. 4.6. Draw your own figure.
8) Occurrence of disease is compared with the ice berg because only in a few which is like floating up clinical diagnosed cases are known to the epiden~iologist of the ice berg which is visible on the surface, whereas majority of the subclinical presympton~atic,~nissed cases are unknown like the hidden portion of the ice berg under the water.

9) Three levels of prevention of disease are bascd on the stages of natural history of disease. During the prepathogenesis period the disease has yet not occurred. Measures taken at this stage will help monitoring the health ecluilibrium of agent, host and environment and thus prevent optimal interaction of these factors and hence prevent the occurrence of the disease. During the pathogenesis period the state of equilibrium is lost, disease have occurred in man, n~easures taken during this period will prevent the occurrence of disease to others, enhance the quick and conlplete recovery and prevent disability and premature death. These measures refer to secondary level prevention and tertiary level of prevention.
10) Primary Level Prevention - Health promotion i.e. health education, good nutrition, adequate housing, recreation, good working conditions, personalily development, sex education, marriage counseling, genetics, periodical selective screening, specific protection i.e. imnlunization, personal hygiene, environtnental sanitation, use of specific nutrition, avoidance of allergens, protection from occupational accidents etc.
Secondary level prevention - Early diagnosis and prompt treatment which includes case finding, screening selective examinations, disability limitations adequate treatment, provision of facilities. Tertiary Level Prevention - Facilities for retraining and education for ~naximum use of remaining capacities, occupational theory.

Check Your Progress 3

1) There are two major approaches to the epidemiological study of any disease or health problem i.e. (a) investigation - means asking questions, making observations through records etc., to know the details of the problem in question,

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Principles and Practice of Community Health Nursing

(b) making comparison of two different groups one with the problem and other without the problem and to find why it is so? i.e, the factor causing the problem. Comparison can also be made of two groups - one exposed to the risk factor and the other not exposed to the risk factor and to observe the effect over a period of time.

2 ) Descriptive epidemiology is a method of study of occurrences and distribution of

disease and health related events in a population by person, time and place. This method helps to know he community health status and make diagnosis i.e. determine health deficits, health threats and foreseeable crisis situation and possible associated factors as discussed in community identification unit. studies are done on the basis of etiological clues obtained by 3) ~nalytical descriptive studies i.e. these studies go beyond descriptive studies and help in determining the causative factors. Thus this method have contributed in of the disease. understanding the causative factors and natural h s t o ~ y

4) Case control method is retrospective i.e. the disease have already occurred and the investigator investigates the etiological factor i.e. the direction is from effect but to cause. Whereas in case of cohart study, the disease have yet not occur~ed people are exposed to the iisk factor under study. The investigator makes observation over a long period of time of the expected outcomes. Cohslrt study is prospective in nature. In this, the direction is from cause to effect.

5 ) Experimental studies are impostant because these studies help to (a) confirm the
cause and effect association of the disease, and (b) evaluate or assess the efficacy of preventive or therapeutic agent or procedure. Experimental studies are comparative studies like analytical studies but are different from analytical studies in their design. In experimental studies, the condition under careful control of investigator. The investigator administers an interventionltreatme~ltto the o the experimental group but not in the control group which is similar L experimental group in all its characteristics.

Check Your Progress 4

1) See the definition given in the text.
2) In common source epidemic it if is due to single exposure, there is clustering and sudden explosion of the cases and rapid fall in case. If it is due to continuuus or extended over a repeated exposure, epidemic are not explosive, but il.regulas ~md period of time i.e. beyond the range of one incubation period. In propagated epidemics, the epidemic is due to porlion to person contact. It flares gradually depending upon herd immunity, opportunity for contact. It gradually fall off.

3) Investigation of epide&c help to:

confirm the existence of epidemic, know the population at risk, find out all cases, understand underlying factors causing epidemic, and foilnulation and implementation of alternative actions that will help prevent and control of the existing epidemic and epidemic in future.

I I

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Check Your Progress 5

1) Health Surveys are investigations to identify problems of health and disease in a i comnunity and the factors affecting them. The health surveys can be general and 1 specific and these can be cross-~ect~iional and longitudinal. I

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See definition given in the text. The purpose to identify persons from normal population, who have high possibility of having a disease under study. a) Mass screening - screening of whole population.
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Introduction to Epidemiology

b) Selective or high risk screening - screening only those people who are at high risk of problem under study. c) Multiple screening. See the definition in the text. local population surveillance,national surveillance and Individual surveilla~lce, international surveillance. 7) a) Identificatibn of conlrnunity health stalus and making diagnosis i.e., determination of health deficits, health threats, foreseeable crisis situation and possible association of factors. b) Planning and evaluation and monitoring of health care services. c) Study of natural history of diseases.
d) Conforming the cause and effect relationship.

e) Evaluating and assessing the efficacy of the prevention and therapeutic agents. Identification of epidemics, people at risk and accordingly plan and ilnpleinent services.