Chapter 4

Descriptive Epidemiology:
Patterns of DiseasePerson, Place,
Time

Learning Objectives
Define the term descriptive epidemiology
Discuss types of descriptive epidemiologic studies
and their uses
Describe the process of epidemiologic inference in
the context of descriptive epidemiology
Give two examples each of person, place, and time
variables and describe how they relate to the
distribution of health outcomes

Introduction
Unequal distributions of health and disease in
populations
To determine why health conditions vary
throughout populations, one must answer the
following questions:
Who was affected?
Where did the (health) event occur?
When did the (health) event occur?

Definition: Descriptive
Epidemiology
The field of descriptive epidemiology classifies the
occurrence of disease according to the following
variables:
person (who is affected)
place (where the condition occurs)
time (when and over what time period the condition has
occurred)

Descriptive Epidemiologic Study

A descriptive epidemiologic study is one
that is ...concerned with characterizing the
amount and distribution of health and
disease within a population.

Descriptive Epidemiology
Provides valuable information for the
following activities:
Prevention of disease
Design of interventions
Conduct of additional research

Example of a Descriptive
Epidemiologic Study
U.S. infants born in 2004 who were exclusively
breastfed:
About 30% of infants were breastfed during first three
months of life.
About 11% were breastfed through the age of six
months.
From descriptive information, hypotheses for
interventions to increase breastfeeding can be derived.

Uses of Descriptive Epidemiologic

Studies
Permit evaluation of trends in health and disease
Provide a basis for planning, provision, and
evaluation of health services
Identify problems to be studied by analytic
methods and suggest areas that may be fruitful for
investigation

Types of Descriptive Epidemiologic

Studies
Case reports
Case series
Cross-sectional studies

Case Reports
Accounts of a single occurrence of a noteworthy
health-related incident or of a small collection of
such events
Example: Adverse reactions due to cosmetic surgery
in the United States

Case Series
In comparison with a case report, a case series is a
larger collection of cases of disease, often grouped
consecutively and listing common features, e.g.
characteristics of affected patients.
Example: reported cases of primary
meningoencephalitis (121 cases reported between
1937 and 2007)

Cross-Sectional Studies
A type of investigation that examines the
relationship between diseases (or other healthrelated characteristics) and other variables of
interest as they exist in a defined population at one
particular time.
A type of prevalence study
Example: the Behavioral Risk Factor Surveillance
System (BRFSS)

Epidemiologic Inferences from

Descriptive Data
Descriptive epidemiology and descriptive studies
provide a basis for generating hypotheses.
Descriptive epidemiologic studies connect
intimately with the process of epidemiologic
inference.
Epidemiologic inference is initiated with
descriptive observations.

Person Variables: Examples

Age
Sex
Race/Ethnicity
Socioeconomic Status

Marital Status
Nativity (place of
origin)
Migration
Religion

Age
Perhaps the most important factor to consider
when describing occurrence of disease or illness
Age-specific disease rates usually show greater
variation than rates defined by almost any other
personal attribute.

Examples of Age Associations

The incidence of and mortality from chronic
diseases increase with age.
Some infections, e.g., mumps and chickenpox occur
more commonly during childhood.
The leading cause of death among young adults is
unintentional injuries.
Maternal age is associated with rates of diabetes and
related complications.

Sex
Epidemiologic studies have shown sex differences
in a wide scope of health phenomena including
morbidity and mortality.
Examples:
All cause age-specific mortality rates higher among
males
Differences in cancer rates, e.g., cancers of the genital
system

Age-adjusted invasive cancer incidence rates per

100,000 for the 10 primary sites with the highest
rates within race- and ethnic-specific categories.

Source: Adapted and reprinted from U.S. Cancer Statistics Working Group. United States Cancer Statistics: 2003
Incidence and Mortality. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention and National Cancer Institute; 2006:220 and 222.

Race/Ethnicity
Five major categories in Census 2000:

White
Black or African American
American Indian and Alaska Native
Asian
Native Hawaiian and other Pacific Islander

Census 2000 allowed respondents to check a

multiracial category.

Racial/ethnic distribution of the population

of the United States, 2006 estimates. Data
for individuals who declare only one race.

Source: Author. Data from U.S. Census Bureau. Fact Sheet: 2006 American Community Survey
Data Profile Highlights. Available at: http://factfinder.census.gov/servlet/ACSSAFFFacts.
Accessed August 15, 2008.

Race/Ethnicity:
Other Considerations
Somewhat ambiguous classification
Tends to overlap with nativity and religion
Some scientists propose that it is a social
construct rather than a biological construct.
Used to track various health outcomes

Nativity
Place of origin of the individual or his or her
relatives
Subdivisions include:
Foreign-born
Native-born

Race/Ethnicity (cont.)
Examples of racial/ethnic differences in health
characteristics include the following:
Lower frequency of asthma reported among Hispanics.
Non-Hispanic whites and non-Hispanic blacks less
frequently report that they have no usual source of
medical care than Hispanics.
Incidence of gonorrhea is higher among non-Hispanic
blacks than other groups.

Socioeconomic Status (SES)

Defined as a Descriptive term for a persons
position in society,
Often formulated as a composite measure of the
following dimensions:
A persons income level
Education level
Type of occupation

A single dimension of SES (e.g., poverty level) may

be used.

Socioeconomic Status (SES) (cont.)

The social class gradient
Strong, inverse association of SES with levels of
morbidity and mortality
Those in lowest SES positions are confronted with
excesses of morbidity and mortality from numerous
causes.

Example: access to dental care (see Figure 4-10)

No dental visit in
the past year
among persons
with natural teeth,
by age and
percent of poverty
level: United
States, 2005.

Definition: Health Disparities

Differences in the occurrence of diseases and
adverse health conditions in the population

Example: cancer health disparities adverse

differences in cancer incidence (new cases), cancer
prevalence (all existing cases), cancer death
(mortality), cancer survivorship, and burden of
cancer or related health conditions that exist among
specific population groups in the United States.
African Americans (in comparison with other groups)
have the highest age-adjusted overall cancer
incidence and death rates.

Place Variables

International
National (within-country)
Urban-rural differences
Localized patterns of disease

International
World Health Organization (WHO) studies:
Both infectious and chronic diseases show great
variation from one country to another.

Climate, cultural factors, national dietary habits,

and access to health care affect disease
occurrence.
Variations in life expectancy (U.S. ranked
number 47 in 2008).
Wild poliovirus is endemic in parts of Asia and
Africa (2005 data).

National (Within-Country)
Regional differences may affect the prevalence and
incidence of disease.
Factors include:
Climate
Latitude
Environmental pollution

Example: Regional variations in stroke (see Figure

4-12)

Urban-Rural Differences
Urban and rural sections of the United States show
variations in morbidity and mortality related to
environmental and lifestyle issues.
Urban example: elevated occurrence of lead poisoning
among children who live in older buildings.
Rural example: pesticide exposure and farming injuries
among agricultural workers.

Localized Patterns of Disease

Associated with specific environmental conditions
that may exist in a particular geographic area.
Examples:
Cancer and radon gas
Naturally occurring arsenic in water supply
Presence of disease vectors: Dengue fever along the
Texas-Mexico border

Time Variables

Secular trends
Cyclic (seasonal) trends
Point epidemics
Clustering

Secular Trends
Refer to gradual changes in the frequency of
disease over long time periods. Examples:
Yearly suicide rates of U.S. females
firearm-associated suicides decreased, but
those by hanging increased.
Age-adjusted prevalence of hypertension
(no secular trend shown).

Cyclic (Seasonal) Trends

Cyclic trends are increases and decreases
in the frequency of a disease or other
phenomenon over a period of several
years or within a year.
Example 1: severe weather events in
the Atlantic basin.
Example 2: mortality from pneumonia
and influenza (peaks during February).

Point Epidemics
A point epidemic may indicate the response of a
group of people circumscribed in place to a common
source of infection, contamination, or other etiologic
factor to which they were exposed almost
simultaneously.
Example: outbreak of Vibrio infections following
Hurricane Katrina in 2005

Clustering
A closely grouped series of events or cases of a
disease or other health-related phenomena with welldefined distribution patterns in relation to time or
place or both.

Clustering (cont.)
Often used to describe aggregation of uncommon
conditions such as leukemia.
Clustering may reflect:
Common exposure to an etiologic agent
Chance occurrences

Spatial clusteringrefers to aggregation of

events in a geographic region.
Temporal clusteringdenotes the occurrence of
events related to time.

Conclusion
Descriptive epidemiology classifies the
occurrence of disease according to the variables
of person, place, and time.
Descriptive epidemiologic studies aid in
generating hypotheses that can be explored by
analytic epidemiologic studies.
Descriptive studies include case reports, case
studies, and cross-sectional studies.