Government College of Nursing Raipur (c.

g)
SUBJECT- COMMUNITY HEALTH NURSING

SEMINAR ON-

EPIDEMIOLOGY

Submitted to-
Mrs. Shabiba daharia Submitted by-
( Msc. Demonstrator ) ms Babita dhruw
Dept. Of CHN , M.Sc. Nursing II year
Govt. College of Nursing jagdalpur(c.g.) Govt. College of Nursing,
Jagdalpur( c.g.)
INTRODUCTION:-

The science of Epidemiology which deals with the study of health related states and events
occurring in defined community, equip community health nurses/ health workers with a
body of knowledge and skills in making health assessment and planning and implementing
need based care to community as a whole. It provides a frame of reference for
investigative approach to deal with any problem in the family, group and community. It is
therefore desirable to understand epidemiological concepts, principles and methods.

EPIDEMIOLOGICAL TRENDS AND CONCEPTS;-

Historical background and trends of epidemiology

 The origin of epidemiology has been traced back to Hippocrates (460-447BC) who
tried to explain the association of lifestyle and environmental factors with the
occurrence of disease.
 However, the foundation of modern epidemiology was laid down in the 19 th
century, when infectious communicable disease like cholera, Typhoid, Plague etc.
were most prevalent in the world in the form of epidemics and pandemics.
 Other communicable disease which were the major concerns of epidemiologists and
Public Health Personnel included Smallpox, Tuberculosis, Poliomyelitis, Measles,
Hepatitis, Sexually Transmitted Disease- Syphilis, Gonorrhea, Herpes.
 During the late, 19th century and the early 20th century the primary focus of
epidemiologists was to study the prevalence, prevention, and control of various
infectious and communicable diseases.
 The focus of epidemiologists is not only on communicable diseases but also on new
emergent problems.
 The literal meaning of the term epidemiology which is derived from Greek words
epi (upon) demos(the people) and Logos (knowledge) thus knowledge and study of
anything that comes upon or affect people.
 The application of epidemiology in nursing can be traced back to Florence
Nightingale(1820-1910).

DEFINITION

 The epidemiology is that branch of medical science which deals with epidemics.

-Parkin,1873

 Epidemiology is the science of mass phenomena of infectious diseases.

-Frost,1927
  Epidemiology is the study of the distribution and determinants of health-related states or events
(including disease), and the application of this study to the control of diseases and other health
problems. Various methods can be used to carry out epidemiological investigations: surveillance
and descriptive studies can be used to study distribution; analytical studies are used to study
determinants.
WHO 2017
 The goal of epidemiology, very broadly speaking, is to understand the patterns of disease
and health dynamics in populations as well as the causes of these patterns, and to use this
understanding to mitigate and prevent disease, and to promote health. The goal of digital
epidemiology is exactly the same. . .Digital epidemiology is epidemiology that uses data
that was generated outside the public health system, i.e. with data that was not generated
with the primary purpose of doing epidemiology. Epidemiology, in general, is “the science
of occurrence of diseases i
Slathe M 2018

MODERN CONCEPTS OF EPIDEMIOLOGY

The modern epidemiology deals with:

 Measurements of occurrence of health related states or events which include

diseases, disabilities, death, physiological conditions, health needs, health demands,
health behaviour and health care utilization etc.
 The measurements are done in the form of rates, ratios and proportions e.g.
incidence and prevalence rates for various diseases, male-female ratio; percentage
of bedridden elderly population; various mortality rates etc.
 These rates and ratios can help in doing comparison of different communities from
time to time with respect to prevalence of health related states or events.
 Study of distribution of disease pattern, disabilities or death and other health related
states or events in a community by place, person or time.
 The epidemiologists investigate and determine whether there is increase or decrease
in the occurrence of these events over time in a given community or different
community and in what concentration (high or low) and whether the occurrence is
more in men than in women or vice-versa, and in particular age, lifestyle,
socioeconomic status etc. such information helps in identification of
possible/tentative cause and effect relationship i.e. etiological hypothesis
e.g. the smoking of 25-30 cigarette per day over a period of 20-25 years causes lung
cancer in 10 to 15 % of men and women.
“ The incidence of diarrhoea is more in bottle fed infants than in breast fed infants
of low socioeconomic families”.
This aspect of epidemiology is known as Descriptive Epidemiology.
PURPOSES AND OBJECTIVES OF EPIDEMIOLOGY

The basic purpose of epidemiology are:

 To prevent, control and eradicate health and health related problems.

 To reduce/minimise the impact of these problems
 To promote health and quality of life of people at large.

These purpose are achieved by the following aims, objectives of epidemiology:

 Study of frequency and distribution of health and health related problems in

community at large.
 Identification of determinants i.e. aetiological factors causing health and health
related problems.
 Need based planning and administration of comprehensive health programmes with
the available resources to deal with health and health related problems.
 Evaluative and effectiveness of the programmes to provide feedback.

USES OF EPIDEMIOLOGY

Epidemiology helps to:

 Study the occurrence and distribution of diseases in a community.

 Identify the determinants of diseases.
 Diagnose the health status of the community by identifying health problems on the
basis of morbidity and mortality pattern and by identifying groups/individuals who
are at risk and require special attention/care.
 Estimate the risk i.e. statistical probability of disease, accident and
defect/disabilities and the chances of avoiding them.
 Plan effective need based health care services on the basis of epidemiological
information regarding frequencies and distribution of diseases and disabilities, their
associated factors and causes.
 Determine the effectiveness of health care services planned and implemented on the
basis of predetermined criteria regarding its relevance, effectiveness, efficiency and
impact on community health. This can help to plan better services in future.
 Determine the usefulness and effectiveness of new/innovative techniques, measures
and programmes etc. before these are used widely e.g. evaluation of polio vaccine,
new anti-rabies vaccine, pulse polio vaccination programme etc.
 Complete the clinical picture of chronic diseases and slow growing diseases or those
which remain asymptomatic for a long time and describe their natural history. E.g.
degenerative diseases of the central nervous system.
 Identify syndromes by describing the distribution and association of clinical
phenomena in the population.
  Forecast the likely occurrence of certain diseases on the basis of epidemiological
principles e.g. changing trends in the occurrence of malaria due to changes in
climatic factors such as rainfall or the forecasts which are made in the occurrence of
HIV infection.

EPIDEMIOLOGICAL ASPECTS OF DISEASES

It is very important to understand the concept of disease causation and disease progress
because it can help in identifying public health measures to prevent and control diseases.
The aims of epidemiological studies are to acquire knowledge about the nature of
diseases/health problems, their etiological factors and then utilize that knowledge in
planning community health services to prevent and control diseases/health problems.

THEORIES AND MODELS OF DISEASE CAUSATION

Several theories explaining the causes of diseases were put forward from time to time.

1. The Germ Theory

 The Germ Theory became popular during the 19th and early part of 20th century.
 According to this theory, there is one single specific micro-organism (causative agent)
to every disease.
 This refers to ‘one to one relationship’ between the causative agent and the disease as
shown in epidemiological model. This is also called as Single Cause Theory.

Causative agent Man Disease

Cause Effect

 For example: Diphtheria due to corney bacterium diphtheria,

Cholera due to Vibrio cholerae ,
Tuberculosis due to tuberculosis bacilli.
 This theory is limited to infectious diseases only.
 The single cause theory was further supported by the identification of other specific
agents as causative agents for certain health problem. E.g. lack of Vitamin C was
found to cause Scurvy.

2. Theory of Epidemiological Triad

 The Germ Theory has many limitations. It was experienced that everyone exposed
to disease agent did not contract the disease.
For e.g. Tuberculosis, all those who were exposed to the tuberculosis organisms, did
not suffer from tuberculosis. Only those who were undernourished, lived in dark
 and dingy places and who did not have immunity against tuberculosis got the
disease.
 This means it was not only the causative agent that was responsible for causing
disease by there were other factors related to man (host) and environment which
contributed to the occurrence of a disease. This leads to the theory of
epidemiological triad as shown in epidemiological model.

AGENT

HOST ENVIRONMENT

 This model is also called as ecological model and is evolved through the infectious
disease.
 According to this model there are three elements or major factors which are
responsible for particular disease causation. These are agent, host and environment.
 The agent is considered to be the primary factor(e.g. amoeba, bacteria, fungi, virus)
without which a particular disease can not occur.
 The host refers to human beings who come in contact with the agent.
The host related factors which play an important role are genetic make-up, age, sex,
race, immunity, health behaviour etc.
 The environment includes all that is external to the host and agent but that may
influence interaction between them.
 These three factors, if remain in equilibrium or in balance then disease will not
occur and referred as state of health equilibrium.

Agent Host

Environment
Fig. Ecological Model of Health Equilibrium
  The disease will occur when equilibrium is disturbed due to change or disruption in
any of these factors. For example: poor environmental sanitation, open defecation,
contamination of water foods etc.
 Other examples of disruption that could increase the possibility of disease
occurrence include:
i. Conditions in the host such as severe malnutrition, disturbed immune system,
poor specific resistance etc. which increases his/her susceptibility to disease.
ii. The increased number and mutation of virus which may increase their
virulence and and ability to infect the human host.
 Infact, there has to be optimal interaction of all the three factors to cause the disease
in a man.
 It implies that disease will occur only when the agent is strong and enters the host
through the right channel and in sufficient amount, the host is susceptible and when
environmental conditions facilitate the interaction of host and agent.

AGENT

ENVIRONMENT HOST

Fig. Epidemiological concept of interaction of Host, Agent and Environment

 For example: the causation of pulmonary tuberculosis mentioned earlier, the live
tuberculosis bacilli must enter through respiratory tract and in sufficient amount, the
host must be susceptible i.e. has no specific resistance and weak general body
resistance and the environment must facilitate interaction of host and organisms i.e.
environment is crowded, dark and dingy.

3. Multifactorial Causation Theory

 The epidemiological triad model is applicable to infectious diseases only. It is not
applicable to no-infectious and chronic diseases like mental illness, coronary heart
disease, rheumatoid arthritis etc.
  It is because these diseases are not linked with specific causation agent and these
cannot be prevented and controlled by immunization, isolation and quarantine
techniques and by improvement of sanitation like infectious diseases.
 These diseases are caused by multiple factors.
 For example: coronary heart disease is associated with certain lifestyle activities
such as: smoking, ingestion of food containing high level of cholesterol, lack of
exercise, increased mental and emotional stress environmental pollution etc. control
of diet, regular exercise and use of effective stress management techniques have
shown to reduce the risk of experiencing myocardial infarction. This leads to the
theory of multi-factorial causation.
 The multi-factorial causation model helps epidemiologist to understand the various
associated causative factors, prioritise these and plan preventive and control
measures for a particular disease.

Cause

Cause Effect (disease)

Cause

Fig. Multi cause/ Single Effect Model

 It is also found that several causative factors produce many observed effects e.g. air
pollution, smoking and specific form of radiation (cause) may produce lung cancer,
emphysema and bronchial (effects). The model can be depicted as:

Cause Effect

Cause Effect

Cause Effect
Fig. Multi Cause/ Multi Effect Model

4. Web of Causation
 This epidemiological concepts of disease aetiology is given by Mac Mohan and
Pugh.
 According to this concept, disease (effect) never depends upon single isolated cause.
Rather it develops as a result of chains of causations in which each link itself is the
result of complex interaction of preceding events/ circumstances.
 These chain of causation which may be a fraction of the whole complex is known as
web of causation.
  This epidemiological model suggest that there are cluster of causes and
combinations of effects which are related to each other and need to be studied to
identify possible interventions to reduce the occurrence of a particular disease.
 For example: cardio-vascular diseases may include avoidance of smoking, diet
control, exercise, stress management etc.

Changes in life style Stress Genetic Inheritance

Ting Smoking Ageing and

Other factors

Obesity Hypertension

Hyperlipidaemia Increased Thrombotic Changes in

Tendency walls of
Arteries

Coronary Atherosclerosis cardiovascular diseases

Fig. Web of Causation-Cardiovascular Diseases

This model is particularly applicable to chronic diseases where the causative agent is
unknown and which are due to interaction of multiple factors e.g. cardiovascular diseases,
cancer etc.

5. Dever’s Epidemiologic Model

 The model is composed of four major categories of factors such as human biology,
life style, environment and health care system.
 Human biological factors are host related factors of epidemiological triad and
include genetic inheritance, complex physiologic systems, factors related to
maturation and ageing.
  Life style factors include daily living activities, customs, traditions, health habits
and behaviour etc.
 Environmental factors include physical, biological, social and spiritual components
and are similar to environment aspects of epidemiological triad.
 Health care system factors include availability, accessibility, adequacy and use of
health care services at all levels.
 All these factors influence health status either positively or negatively.

NATURAL HISTORY OF DISEASE

 In the absence of any intervention i.e. prevention or treatment, all disease follow a
natural course of events which refers to “Natural History of Disease”.
 The concept was defined and associated with preventive and control strategies in
1953 by Leavell and Clark with the help of Schema of natural history of disease.
 Leavell and Clark have defined the Natural History of Disease model as under:
“A narrative and schematic representation which portrays a chronological
sequencing of departure from health. The sequence begins with the factors that
promote health, but the model also addresses the very first force that
inaugurates pathological departure. An innate function of this model is to
describe various approaches to prevent and control pathological processes and
this function is collectively known as the level of prevention. ”
 It depicts its confrontation/interaction of three essential elements i.e. agent, host
and environment to influence the onset of any disease, the continuum of
pathogenesis.
PRE-PATHOGENESIS PERIOD PATHOGENESIS PERIOD
(IN ENVIRONMENT) (IN MAN)

Confrontation A H
& Interaction

E 3
CLINICAL STAGE DISABILITY STAGE
Provokes Stimulus
Clinical
Recognizable

Early Advance Con Chron

Diseas d vale ic
e Disease scen State
ce Disabi
Early Pathogenesis lity &
 Interaction of Defec
Host-Agent/ t
Stimulus
 Tissues
Reaction
 Physiological
changes
INCUBATION PERIOD

2
PRESYMPTOMATIC
STAGE

PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY

PREVENTION

This model is based on the following assumptions.

Health is a relative state: it is assumed that every one possesses some degree or
level of health & it depends upon factors related to people(host)- inherent or
 acquired characteristics, factors related to agents or factors related to environment in
which people (host )live.
Disease is a process: it is assumed that disease is not static. It is a process and
begins before the individual is affected. It means that the conditions which stimulate
illness are present in the environment and in the people (hosts) themselves. This
process thus depends upon the nature and characteristics of agent, host and disease
producing stimuli from within the environment and individual.
Disease is effected due to multiple causation: the occurrence of any disease
depends upon the epidemiologic triangle composed of agent, host and environment.
The host refers to the individual or population affected. The agent is an element, a
substance or a force, whose contact with the susceptible host under appropriate
environmental conditions is essential to serve as a stimulus to effect the disease
process. Agents in case of infectious disease are microbes but also include physical,
chemical, mechanical and nutrient agents for both infectious and non-infectious
diseases. Environment is the aggregate of all the external conditions and influences
affecting the life and development of host and agent and their interaction.

The natural history of any disease as viewed by Leavell and Clark which has two
stages/phases. These are:

I. Pre-pathogenesis stage/phase
II. Pathogenesis stage/phase
I. Pre-pathogenesis stage/phase:
 This stage is before the onset of disease and is also called as Pre-disease
stage.
 The causative agent has not yet entered the susceptible host (human
being). But the factors that favour the interaction of agent and host exist
in the environment e.g. poor environmental sanitation, climatic condition,
presence of insects, pests and rodents etc; unhygienic habits and health
behaviour, harmful cultural and traditional practices; and biological
factors i.e. age, sex, marital status, genetic and physiological status of
people.
 This means people living in any particular environment are always
predisposed to the risk of disease i.e. they are in pre-pathogenesis stage
of many infectious and non-infectious diseases.
 The disease will not occur in man unless these three factors i.e. agent,
host and environment confront and interact to produce disease provoking
stimuli.
 This stage is also described as stage of susceptibility by Mausner and
Kramer because risk factors of various intensity related to agent, host and
environment are present to contract the disease any time.
II. Pathogenesis Stage:
 This phase begins with entry of causative agent in the susceptible human host.
 As the agent enters the body through appropriate channel (e.g. in case of Chickenpox,
the agent Varicella Zoster virus, must enter through the respiratory tract ), it induces
tissue and physiological changes in the body.
 These changes are subclinical i.e. clinical sign and symptoms of disease are absent.
The host remains apparently healthy and ambulant.
 After a lapse of some period which is variable from disease to disease and ranges in a
specific disease, the health equilibrium within the body is lost and the sign and
symptoms of the disease begin to appear.
 This period which lapse between the entry of causative agent and just before the
appearance of clinical sign is called as Incubation Period.
 In case of chickenpox this period is usually 14-16 days.
 The sign and symptoms are sometimes vague during first few days of illness e.g. in
case of chickenpox running nose and watering of eyes which are common to many
other diseases. This period is usually called as Pro-dromal Stage.This is Early
Pathogenesis Phase and is below the clinical horizon.
 This Early Pathogenesis Phase which is preclinical/ subclinical phase/ period is also
called as Pre-symptomatic Phase/ stage especially for chronic and non-infectious
diseases.
 The length of Pre-symptomatic Phase/ stage varies greatly ranging from instantaneous
time to many years. For example, in case of accidental injuries it is instantaneous to
few hours, and in case of disease like cardiovascular and diabetes it can be many
years.
 But as the pathological changes advance in the body system the sign and symptoms
become clear and clinical diagnosis can be done. E.g. appearance of skin rashes on
different parts of the body in case of chickenpox and the diseases reaches its peak.
 But in many diseases especially chronic and non-infectious diseases, by the time
recognizable sign and symptoms arise and clinical diagnosis is possible, the disease
process or pathological changes are well in advance.
 This period of recognizable pathogenesis is also called as clinical phase/stage.
 The end result of disease process may result in complete recovery. It takes time to
recover and the period is called as convalescence period or it may end into chronic
state, varying level of disability defect or death. This period is also called as disability
phase/stage .
 The reaction to infection and period of pathogenecity vary from disease to disease and
from person to person for the same disease depending upon the virulence of causative
agent and the susceptibility of the host and environmental factors.
 The infection may be clinical or subclinical; typical or atypical or the host may
become carrier with or without having clinical disease e.g. in case of typhoid fever
and diphtheria. The period of pathogenesis can also be labelled as gradient of
infection.
 The variation in the manifestation of the diseases in the pathogenesis phase ranges
from sub-clinical to clinical cases.
 The clinical cases ranges in severity from mild to severe and fatal cases.
 These variation in the manifestation of a disease can be represented graphically and is
called as Spectrum of disease.

Subclinical mild moderate severe

fatal

DETERMINANTS OF DISEASE- CAUSATIVE/ RISK FACTORS

I. Definition and Concept of Risk factors

i. Definition :
The risk factor is defined as “a factor/ or an attribute that is
significantly associates with the development of a disease and when
modified reduce the possibility of occurrence of disease or other
specified outcomes.”
ii. Concepts:
 The risk factor may be truly causative
There is strong statistical relationship between the risk factor and disease.
e.g. smoking and lung cancer.
But one can neither conclude that all individuals with the risk factor (i.e. all
smokers) will develop disease (i.e. will have lung cancer) nor the absence of risk
factor (who never smoked) will ensure the subsequent absence of disease (i.e.
will not have lung cancer).
 The risk factors may be just contributory factors
e.g. high blood pressure, diabetes, obesity for heart diseases.
 The risk factors may or may not be modifiable.
e.g. host risk factors, such as age, sex, race, genetic factors which are associated
with some diseases, cannot be altered.
 The factors which can be altered or modified include health related behaviour,
hypertension, obesity, dietary intake etc.
 Manipulation of these risk factors is also limited to what is reasonable and
feasible.
e.g. alcoholism can be prevented and controlled by removing the alcoholic
beverages through legislation etc.
 There can be overlapping of some risk factors i.e. the same factor can be considered
as host, agent or environment related factor.
 e.g. tobacco smoking- it can be considered as an agent related factor because of its
significant statistical association with the occurrence of various diseases;
it can be considered as host related risk factor because it is concerned with
individual’s smoking behaviour;
it can be considered as environment related risk factor because some environments
are more conducive or permissive to smoking and also exhaled smoke is found in
the environment which is risk factor for others in that environment.
 On the basis of risk factors the population can be categorised as one which is at
high, low or no risk for a given disease.
e.g. in case of HIV infection people who are at high risk may include those who
engage in multiple sex activities, sex worker, intravenous drug abusers etc; people
who are at low risk may include nurses and doctors who take care of patients with
HIV infection; and people are at no risk or lowest risk may include all those who are
sexually not active and do not use intravenous drugs.
 It is very important to identify the risk factors, so that effective measures can be
planned and implemented to prevent or delay the occurrence of disease.
 Epidemiological studies have helped in identification of risk factors associated with
various diseases to alert people to take preventive and control measures for those
diseases.

RISK FACTORS FOR SELECTED DISEASES

Selected Diseases Risk Factors

Cancer Smoking, alcohol, solar and ionizing agent, occupational
hazards, dietary factors, environmental pollution,
infectious agents, medications etc.
Cirrhosis of liver Alcohol, poisons, medications, infection etc.
Diabetes Diet, obesity etc.
Heart Disease Smoking, high blood pressure, diabetes, obesity etc. lack
of exercise, emotional stress, elevated serum cholesterol
etc.
Road Accident High speed, drink and driving, roadway design, non
compliance of traffic rules etc.
Stroke Smoking, high blood pressure and serum cholesterol etc.
II. Agent, Host and Environmental Risk Factors
a) Agent Factors:
 A disease agent is the primary link in the development of disease.
 The disease agent is defined as “an element, a substance-living or nonliving, or a force-
tangible or intangible, the presence or absence of which may following the effective
contact with susceptible human host under proper environmental conditions serve as a
stimulus to initiate or perpetuate a disease process”.
 The disease agents are usually classified as under:
i. Biological agents:
 Biological agents are living agents and include arthropods and helminths,
protozoa, fungi, bacteria, rickettsial and viruses.
ii. Physical agents:
Physical agents include abnormalities in atmospheric pressure, temperature and
humadity; unusual intensity of sound; abnormalities of radiation and electricity.
These agents are usually associated with certain occupational exposure.
iii. Chemical agents:
Chemical agents may include useful substances like iodide and fluoride and
harmful substances like noxious gases, volatile gases and fumes, airborne solid
particles. Some chemicals may also be produced in the body as a result of
malfunctioning of body systems for example urea, bilirubin, ketones, calcium
carbonate, uric acid etc.
iv. Mechanical agents:
Mechanical agents include chronic friction and mechanical forces that result in
crushing, tearing or penetrating wounds, sprains, dislocation and other accidental
injuries and even death.
v. Nutrient agents:
Nutrient agents include fats, carbohydrates, proteins, vitamins, minerals and water.
Intake of these elements either in excess or in deficiency results in nutritional
disorders. For example anaemia, night blindness, PEM, goitre.
b) Host risk factors:
 Host is one of the epidemiological determinants of disease.
 There are varied attributes related to host which predispose the interaction of host
and agent to cause a disease.
 These host related attributes or risk factors include:
i. Demographic characteristics:
These include age, sex, race, ethnic origin, marital status etc.
ii. Biological factors:
These include genetic factors, blood chemistry, blood groups, physiological
functioning of body system, immune system etc.
iii. Psychosocial and economic characteristics:
These include personality traits, education occupation social class and status,
mental status and emotional makeup, health knowledge and attitude etc.
iv. Life style:
These include daily living and cultural practices including customs and
traditions health habits and health seeking behaviours such as physical
exercise, nutrition practices, sexual practices, use of alcohol, drugs and
smoking etc.
v. Past history of exposure:
Exposure can range from infectious diseases to smoke in the environment
exposure to various occupational hazards.
c) Environmental Risk Factors:
 Environment is the aggregate of all the external conditions and influences affecting
the life and development of an organism.
 The environment has three components. These are physical, biological and
psychosocial.
i. Biological environment:
The biological environment includes living things comprising of animal
kingdom, plants and microorganisms. Some of these are infectious agent,
reservoir of infection, intermediate host and vectors that transmit diseases.
ii. Physical environment:
 Physical environment includes all those things which are non living, chemical agents
and physical factors. These are air, water, soil, environmental sanitation, housing
radiation, gravity, atmospheric pressure, noise, electricity, electronic and electrical
machines, radio broadcasting and television transmitter and radar etc.
 Increasing population, urbanization, industrialization, migration, electronic and
electrical devices and media technology etc. have been the causes of environment
pollution and resultant emergent health problems.
 Lack of environmental sanitation is the cause for various infectious diseases among
people.

iii. Psychosocial environment:

 It includes over all socio-economic and political organization that affects health care
and its delivery system; health legislation; socio-cultural customs, traditions, values,
belief s and attitude; education, religion and morals; lifestyle and family and
community life.
 The psycho-social factors which can affect health are: poverty, migration, increasing
population, urbanization, stressful situations such as loss of loved ones, loss of job,
accidental disabilities, menopause, birth of retarded or handicapped child etc;
defective life style, harmful health attitude, behaviour and practices etc.

LEVELS OF PREVENTION OF DISEASE

Preventive approach is the best approach to achieve the goals of health care services
because preventive measures can be implemented with the joint efforts of health personnel
and people at large at the family and community level.

There are three major levels of prevention associated with natural history of disease. These
are Primary, Secondary & Tertiary Prevention.

1) Primary prevention:
 Primary prevention is first level prevention and is associated with the pre-
pathogenesis phase or stage of susceptibility of the disease process when the
 epidemiological factors like: Agent-Host-Environment have not yet interacted to
cause a disease.
 Primary preventive strategies during pre-pathogenesis phase of a disease are aimed
to prevent the interaction of these three epidemiological factors. If preventive
measures are successful then the disease will not occur.
 There are two types of primary prevention:
i. General health promotion:-
Health promotive factors include health education, wholesome nutritious diet,
clean and safe environment to live, healthful lifestyle, healthful behaviours
and adequate resources. All these aspects are directly related to
socioeconomic and cultural aspects of the family and community which must
be improved.
ii. Specific protection:-
 Specific protection comprises those measures which are which are directed to
intercept causative agents of a particular disease or group of diseases before
these agents affect people.
 Specific protective measures include immunization, use of specific nutrients,
protection against accidents and environmental and occupational hazards, use
of prophylactic and suppressive drugs, avoidance of allergin, protection from
carcinogens, stimulation of proper personal hygiene, control of quality and
safety of foods, cosmetics and drugs and genetic therapy and counselling.
 All primary preventive measures may not fall directly within the domain of nursing
practice but awareness of these preventive modalities can help community health
nurse to educate and counsel individual, family and community people intelligently.
For eg. Community health nurse should know about chemoprophylaxis,
carcinogens, allergins, occupational hazards etc. so that accordingly she can give
informations and refer them to the concerned medical person and agency etc.

2) Secondary prevention
 Secondary prevention is second level prevention and is associated with
pathogenesis i.e. pre-symptomatic stage and symptomatic i.e. clinical stage of the
pathogenesis phase of the disease process.
 The objectives of secondary preventive measures are to: diagnose the disease at
early stage, control the progress of disease in man, prevent complication, restore
health and prevent the spread of infections to others in the community, in case of
communicable diseases.
 Secondary preventive measures include two types of interventions. These are early
diagnosis and treatment and disability limitations.
i. Early diagnosis and treatment:-
  Early diagnosis and treatment are the measures which control the disease
process, prevent the spread of infection to others in case of communicable
diseases, prevent complications and long term disabilities and restore health.
 Early diagnosis and treatment has been found the most effective mode of
intervention in communicable diseases in communicable diseases like
tuberculosis, leprosy and STD and also in chronic diseases where causes and
primary prevention are not clearly known. It has thus helped in reducing
morbidity and mortality due to these chronic infectious and no-infectious
diseases.
 In case of communicable diseases, early diagnosis and treatment helps to shorten
the period of communicability, thus limits the spread of infection and reduces
mortality.
ii. Disability Limitations:-
 Disability interventions are applicable during the late pathogenesis period or
clinical stage of the disease process.
 The objective of these interventions is to prevent or delay the consequences of
clinically advanced disease i.e. prevent impairment leding to disability and
handicap.
 For eg. Some of the nursing measures which may limits impairment and
which are advisable for immobile patients include back care, passive exercise,
medication etc.; for diabetic patient or patients who have undergone
mastectomy and are mobile include individualized health teaching, exercise,
skin care, psychological boosting etc.
 Nurses and other health workers can help in making early diagnosis and treatment
by case finding and appropriate referral and by providing nursing care.
 Care of the minor ailments and limited care during emergencies are rendered by
nurses and their auxiliaries at the village level.
3) Tertiary prevention:
 It occurs late in the pathogenesis stage of disease process when irreversible changes
either in anatomy and physiology or both have occurred.
 At this point the disease process has advanced its clinical stage and entered the
disability stage.
 Rehabilitative strategies are used to attain the highest possible level of functional
ability.
 It involves co-ordinated efforts of medical personnel, sociologists, clinical
psychologist, nurses etc. for training and retraining of and helping the person to
function, lead useful life as for as possible and restore a feeling of well being.
 Rehabilitation is with regard to restoration of:
 Bodily functions (medical rehabilitation)
 Personal dignity and confidence (psychological rehabilitation)
 Family and social relationship (social rehabilitation)
  The capacity to earn livelihood (vocational rehabilitation)
 It is also considered as the responsibility of all doctors and nurses to help patient to
recognise their disability, restore their personal dignity, confidence and social
relationship; and also refer them to appropriate department and agency for further
medical and vocational rehabilitation e.g. for physiotherapy, speech therapy,
vocational guidance etc.

UNIVERSAL INFECTION CONTROL MEASURES IN COMMUNITY

The purpose of universal infection control precautions in the community is to prevent

transmission of cross infection from one person to another, from one place to another
either directly or indirectly.

Susceptible
host

Place of
Agent
Entry

Method of
Transmission
Reservoir

Place
of Exit

Some of the important measures which should be practiced by the health team are;

 Hand washing before and after doing any procedure or while coming in contact with
body fluids, soiled articles etc.
 Use of gloves and other protective devices(gowns, masks and goggles) while
conducting delivery or any such procedures.
 Use of disposable gloves as for as possible if not, these should be changed and
disinfected or sterilized after use for each patient/client.
 Follow up of strict aseptic procedure while giving injections.
 Restrict the use of injections and skin piercing procedures as for as possible.
  Prevent injuries with sharps- by taking time to do the procedures, do not recap, bend
or break used needles before disposal, place them in puncture resistant container.
 All contaminated articles after use must be thoroughly cleaned by rinsing and
washing with soap and water which are then sterilized or disinfected.
 Sterilization by autoclaving or pressure cooker at 15 ibs pressure for 20 min.
 Disinfection by use of household bleach(1:10), 3% phenol, 4%
formaldehyde, 70% ethyl alcohol.
 Infected solid waste including needles should be incinerated or may be disposed of
hygienically in controlled land fill or pit latrine.
 Liquid wastes such as infected blood should be poured down a drain connected to
adequately treated sewer system or disposed of in a pit latrine.

APPROACH

 Prevention of cross infection is not only the responsibility of community health

nurse and health workers but also the individual, family and the community as a
whole.
 Individuals and families must adopt values, lifestyle and behaviours which is
compatible to health and curtail the transmission of infection to others.
 Community must ensure safe environment to minimize transmission of infection.
 Information, Education and Communication is one of the strategic approach to
infection control in the community and is to be done at individual, family and
community level using different approaches, methods and media.

EPIDEMIOLOGY OF EPIDEMICS

DEFINITION:

Epidemic is defined as the occurrence of disease or health related event in more than
normal expectancy in a community or region during a specific time period. E.g. outbreak
of influenza in Delhi in large number in November-December, food poisoning cases.

Epidemics is a relative condition to frequency of the disease in the same area and during
the same period in specific group.

TYPES OF EPIDEMICS:

There are mainly two types of epidemics namely:

1. Common source epidemic

2. Propagated epidemic
1. Common source epidemic
 Most of the time the epidemic occurs due to an infectious agent from common
source, but epidemic can also occur due to pollution of air, water, food, soil by
pollutants from industries. E.g. Bhopal gas tragedy.
  The common source of epidemics can be due to:
i. Single exposure or point source infection
ii. Multiple exposure or continuous exposure to infection
i. Single exposure or point source infection:
 In single exposure, the exposure to the agent is brief and simultaneous.
 Those who are exposed to the source of infection develop the problem
within one incubation period of the disease.
 The classical example of such type of epidemic is food poisoning- all
peoples are exposed to the source of infection i.e. infected food at the
same time from the same place.
 The epidemic is explosive, the epidemic rises and falls rapidly.

ii. Multiple exposure or continuous exposure:

 In this, the exposure to infection from the same source 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
S.T.Ds through infected prostitutes.
 Usually there is no explosive rise in the number of cases. Fig. Shows
common source multiple exposure epidemic.
2. Propagated Epidemic:-
 This epidemic occurs in communities where large number of susceptible
people lowering herd immunity, live.
 Propagated epidemic results from person to person contact and mostly due to
infectious agent.
 Transmission continues as long as susceptible people are there in the
community and are exposed to infected people.

INVESTIGATION OF EPIDEMIC

Investigation of epidemic is a systematic process and goes through orderly steps which are
discussed here to help community health nurses to learn the process of investigation of
epidemic.

1. Verification of diagnosis of disease: this is the first step and is done on the basis of
clinical examination of sample of cases.
2. Confirmation of the existence of an epidemic: this is done on the basis of the
frequency of disease.
3. Defining the problem at risk: it includes:
i. Obtaining or preparing a map of the area.
 ii. Demographic study which may include the study of the total population or
sub-groups or population at risk and their composition. This information is
necessary for calculating various epidemiological measurements. E.g.
morbidity and mortality rates and proportion etc.
4. Identification of all cases and their characteristics:
 This can be done by organising 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 diseases, sign and
symptoms, history of immunizations, common source of infection according
to the disease under investigation e.g. parties attended, food eaten, source of
water etc.
5. Study of ecological factors: these include environmental factors, agent factors and
host factors. These informations will help in identification of source of infection,
reservoir of infection and modes of transmission and thereby planning of
preventive and control measures.
6. Data analysis: description of the cases in terms of person, place and time of
distribution. A complete list of cases by chronological order is prepared to show the
beginning of epidemic. Attempt is made to identify the first case and follow its
movements to trace the source and spread of infection.
7. Formulation of hypothesis: analysis of data will reveal the possible source, causes,
agents, hosts and environmental risk factors of infection. This will help the
investigator formulate the hypothesis which may suggest further investigation and
help in identification of interventions.
8. Recommendation for prevention and control: based on the information revealed
about the epidemic, the epidemiologist/health worker prepares a programme of
prevention and control of the epidemic not only for the present but also for its
prevention in future.
9. Preparation for a formal report: a formal report should be prepared and
communicated to health authority for information, evaluation and feedback for
future actions.

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 asymptomatic diseases. These measures
include:
1. Health surveys
2. Screening
3. Surveillance
4. Monitoring
1. Health surveys
 Health surveys are investigations to identify the frequency, distribution and the
determinants of health related events or states in the community.
 Health surveys help in knowing the community and making community diagnosis.
 The health surveys can be general health surveys and special or specific health
surveys.
 General health surveys provide comprehensive data about health and sickness
status of the whole community.
It is not a regular practice in our country. Once in 1946by health survey and
Development Committee headed by sir Joseph Bhore and again in 1962 by health
survey and Development Committee headed by Dr. Mudiliar.
 Special or specific health surveys deal with investigation of any aspect of health-
morbidity status e.g. filarial, malaria or tuberculosis etc. mortality and nutritional
status.
 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 valuable information about the natural history of
diseases, incidence and prevalence of diseases and underlying causes etc. by doing
surveys on the same population over a longer period but are difficult to organize
and are time consuming etc.
 The data for health survey can be collected by using various methods. These are:
I) Questioning
II) Health examination and laboratory investigation
III) Record review
IV) Observation
I) Questioning: questioning is an invaluable method to seek subjective
informations through interview and self administered questionnaire.
II) Health examination and laboratory investigation: this method helps in getting
more valid information than by questioning method about clinical cases. But this
method is expensive and requires more time.
III) Record review: records are valuable source of health informations and record
review in a systematic way which can help obtain health data. The informations
may be incomplete because there are no set procedures and standards for record
keeping.
IV) Observation: it requires lot of planning and systematic methods for data
collection. This method is expensive and time consuming.
 2. Screening:-
 It is defined as the method of search for unrecognised diseases by means of rapidly
applied tests, examinations and procedures in apparently healthy population.
 The basic purpose of screening for disease protection is to identify from a large
group of apparently well population those who have a high probability of having
the disease under study, so that they may undergo further investigations and if
diseased brought to treatment.
 There are three types of screening namely:
I) Mass screening: in this screening of the whole population or the subgroups
whether or not exposed to the risk of having the disease under study.
II) Selective or high risk screening: in this 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 cervix and if they are screened for
that, then more chances of detecting the cases. Similarly people having family
history of diabetes, breast cancer should be screened for such problems.
III) Multiphase screening: in this screening number of tests for different
diseases are grouped together to screen for number of conditions at the same
time e.g. test for lung diseases, cardiovascular diseases, diabetes, anaemia,
kidney diseases, cancer of the breast and uterus, visual and audio defects are
grouped together.
 Criteria for screening:
Some of the criteria which are considered for screening are as under:-
 The disease has high prevalence.
 The disease has early asymptomatic or latent stage and its natural history is
clearly understood so that one knows at what stage it is irreversible.
 Simple, inexpensive and reliable tests are there to detect the disease prior to
its onset.
 Facilities for further confirmation tests and treatment etc are available.
 It is for sure that detection and treatment will prevent and control,
morbidity, disability and mortality.
 The screening tests are reliable and valid i.e. sensitive and specific.
 The test is acceptable to the people for whom it is done.
3. Surveillance:
 The dictionary meaning of surveillance is supervision or close watch especially
on suspected person.
 Epidemiologically surveillance means close vigilance on occurrence and
distribution of diseases and health related problems, population dynamics,
community behaviour and environmental processes resulting in increased risk of
ill health in the community.
 The Epidemiological surveillance can be done at individual and family level,
national and international level.
 I) Individual/Family Surveillance: it includes surveillance of an infected
person in a family as long as the individual is source of infection to others
e.g. typhoid case and carriers.
II) Community/Local Population Surveillance: it includes active and passive
surveillance of the whole community for early detection and prevention
and control of a disease e.g. malaria.
III) National surveillance: it includes surveillance at the national level e.g.
surveillance of smallpox after its eradication.
IV) International surveillance: it includes surveillance of some of the diseases
which are listed by WHO e.g. malaria, influenza, filarial, polio etc and are
reported to WHO which then provides information to the countries in the
world to take timely actions.

Surveillance process:

Surveillance is a systematic process. The main step involved are:

I) Collection of relevant information about the disease under surveillance
II) Analysis and interpretation of these informations
III) Reporting of these informations to the concerned authority for decisions and
actions leading to prevention and control of diseases.
I) Collection of relevant information about the disease under surveillance
Effectiveness of surveillance system depends upon identification of cases,
collection of relevant informations about the disease, their recording and
reporting. The various methods for surveillance are as under:-
a) Routine reporting of cases and deaths recorded at health centres, dispensaries
and hospitals:
A sample recording from which is usually practised is given below:

Daily recording of cases in OPD of health centres

S.no. Months no. Name Age Sex Address Diagnosis Date of Remarks
onset
1
2
3
.
.
.
.
30
From this record daily, weekly, monthly and yearly reports of disease occurred and
reported at the centre are prepared.

b) Active surveillance:
 It means actively looking for those particular type of cases who have not been
recorded under the routine system. It is done by health workers and community
people e.g. surveillance of malaria or tuberculosis cases.
c) Epidemiological investigation:
These are usually done when there is occurrence of more than usual number of cases
in a particular place during particular time period. When there is sudden outbreak of
any disease and when a communicable disease which has never occurred before but
it has occurred now. This will help in picking up cases and the associated causative
factors.
d) Sentinel centres:
Sentinel centres are those hospitals, health centres, laboratories, special disease
hospitals etc. which are identified for collecting informations for selected diseases.
The informations are collected, compiled and forwarded to higher authority for use:
for immediate action and for making future plans and policies etc.
e) Special sample survey:
Special sample survey of disease is an active and efficient method of surveillance.
There are different methods of sample surveys but the survey by cluster sampling
technique is recommended by the WHO. The target population, the sample size vary
from disease to disease e.g. the target population for poliomyelitis is 5-9 years, for
diarrhoea 0-4 years, preceding the date of survey.
II) Analysis and interpretation of these informations
 The data needs to be compiled and analysed to assess the frequency and
distribution by person, place and time.
 These informations can be presented in tables, spot maps. Charts and graphs.
This kind of presentation helps in determining the pattern of occurrence of
disease and whether there is decrease or increase in the number of cases.
III) Reporting of data and providing feedback:
 Once the data is analysed a report is to be prepared in the format prescribed by the
authority.
 The report is sent regularly for each reporting period.
 The report should be complete.
 If there is nil information. Missed or received late, it should be included in the next
reporting period.
 Feedback should be given to all the members of health team as to how the data are
used which are collected by them and reported through regular meetings and when
desired by any one.
4. Monitoring:
Monitoring is day to day measuring and analysis i.e. making assessment of:
health status of people, and their environment to determine any changes;
performance of health services and health professional to determine
 effectiveness and efficiency; health behaviour of client to determine
compliance of behaviour.

EPIDEMIOLOGY AND NURSING

 Epidemiology is one of the basic sciences applicable to nursing .

 Nurses working in the community deal with the people in various settings and help
them to solve their health problems.
 She makes use of nursing process which is comparable to epidemiological process
in solving the problems etc.
 She identifies and investigates the problem, formulates and tests hypothesis
regarding causal factors, formulates alternative interventions and implements to
prevent and control the problems and evaluates the effectiveness of intervention.
 Nurses in the community have an active role in prevention and control of
communicable diseases which include:
 Participation in early diagnosis and treatment i.e. identification of all cases.
 Notification of certain specific diseases like measles, diphtheria, tetanus,
hepatitis, rabies, S.T.D. to the health authority.
 Trace the contacts, keep them under surveillance.
 Identify source of infection, methods of spread of infection.
 Health education of people in general.
 Nurses in the community as a member of the health team participates in
surveillance at all levels which will depend upon existing situations, her
preparation, the level at which she works.
 The nurses working in the community are required to take notice of any unusual
occurrence of any disease or in large number and report to the authority.
 Nurses in the community have an important role in prevention and control of
chronic and non-infectious problems such as cardiovascular conditions, accidents,
cancer, mental health problems etc through health education and helping people
change their life style.
SUMMARY
Epidemiology is the basic science of community health. Epidemiology deals with
the measurements of occurrence and distribution and determinants of health related
states and events in specified community and the application of findings in the
prevention and control of diseases.
Epidemiologically there are three major categories of factors i.e. agent, host and
environment which interact to cause various diseases.
According to natural history of diseases there are three levels of prevention i.e.
primary, secondary and tertiary level prevention.
Epidemiology is basic to preparation of community health nurse and all other
members of the health team. Community health nurses play an important role in
epidemiological studies of human population and their problems.
 BIBLIOGRAPHY
1. Park k. Textbook of Preventive And Social Medicine, 19th edition, Banarsidas Bhanot Publishers,
2007; page no. 31, 34, 87, 621
2. Swarnkar keshav, Textbook of Community Health Nursing, Third edition, N. R. Brothers
Publishers, 2011; page no. 11, 64, 65, 824
3. Gulani K.K ” Community Health Nursing(Principal & Practice)” First Edition
2004,KumarPublication,New Delhi Page no. 181-221
4. Sunderlal et al ”Text book of Community Medicine Preventive and social medicine ” Second
Edition CBS Publishers & Distributors New Delhi Page no.
5. en.wikipedia.org/wiki/Epidemiology
6. medical-dictionary.thefreedictionary.com/epidemiology
7. www.merriam-webster.com/dictionary/.0epidemiology
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