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ADIGRAT UNIVERSITY

COLLEGE OF MEDICINE AND


HEALTH SCIENCES
DEPARTMENT OF PUBLIC HEALTH

Epidemiology
( 3 credit hr)

May, 2018

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Objectives of the course
– Describe the principles of Epidemiology

– Describe concepts of disease causation

– Calculate the measures of disease and death

– Explain types of study design

– Investigate and control outbreaks or epidemics

– Describe the purpose and types of surveillance

– Explain factors that affect validity of studies

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UNIT ONE:
INTRODUCTION TO EPIDEMIOLOGY
EPIDEMIOLOGY

Greek: EPI - Upon

DEMIOS - People

LOGY - Study of, Body of


Knowledge

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DEFINITIONS OF EPIDEMIOLOGY

• Is a science which studies the frequency, distribution and determinants of


health and health related events in populations, and the application of this
knowledge for the promotion of health, prevention and control of diseases.

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Key words in the definition are:
1. Frequency- how much? It occur in the population.

2. Distribution- who? where? And when? Is the occurrence of health and health related
events.

3. Determinants- factor which may be event, characteristic or any definable entity that brings
about change in health and health related conditions. It refers to “why diseases occur in
certain places? In a certain period? Or in a certain population groups?”

4. Health and health related events- epidemiology is concerned not only with disease but
events like birth, death, migration e.t.c.

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The central concern of epidemiology is promotion and maintenance of health through the
prevention of diseases. However, we have defined epidemiology in terms of disease.
This is because it is easier to define and measure disease, disability and death than to
produce operational definition of health.

5. Human population- though epidemiology is concerned with population, even though


there is strong interrelation with clinical medicine.

6. Application- epidemiology is an applied science. The ultimate purpose of all


epidemiological studies is the prevention and control of health problems.

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TWO BROAD TYPES OF EPIDEMIOLOGY
DESCRIPTIVE EPIDEMIOLOGY ANALYTIC EPIDEMIOLOGY

Examining the frequency and distribution of a Testing a specific hypothesis about the

disease in a population, and observing the relationship of a disease to a putative cause, by

basic features of its distribution in terms of conducting an epidemiologic study that relates

time, place, and person. the exposure of interest to the disease of

Typical study design: interest.

community health survey (approximate Typical study designs: cohort, case-control

synonyms cross-sectional study, descriptive


study)

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TWO FUNDAMENTAL ASSUMPTIONS

1. Non-random distribution of diseases; i.e. disease occurrence in a population is not random


or by chance.

– Epidemiology uses systematic approach to study the differences in disease distribution


in subgroup/group

– Why certain individuals/group acquire disease and others not?

2. Human disease has causal and protective factors that can be identified through systematic
investigation of different population or subgroups of individuals within population in different
places or at different times.

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SCOPE OF EPIDEMIOLOGY:

Genetic markers of disease risks


recently
▲+
Health related behavior
▲+ Past 25 yrs
Chronic diseases,
injuries, birth defects
MCH, Occupational Middle of
health, Env’tal health 20th century

Since 5th
▲+ century
Endemic communicable diseases &
Non communicable diseases
▲+
Epidemic of communicable diseases
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HISTORY OF EPIDEMIOLOGY
 Hippocrates in the 5th century (500 B.C.) expressed that environmental factors can
influence the occurrence of disease.

 John Graunt-In 1662, the first time he quantified deaths and births

 William Farr, 1839: Established vital statistics system as a source for health
information.

 John Snow (1813-1858) -In 1854, controlled cholera epidemic.

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DEVELOPMENTS IN MODERN EPIDEMIOLOGY

Observational Studies:

 Case-control studies

Doll & Hill: in 1950 investigated the relationship between cigarette smoking
and lung cancer. Preliminary report.

 Cohort Studies :The Framingham Heart Study. 10,000 residents gave


baseline information.

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PURPOSES/USE OF EPIDEMIOLOGY:
1. population/community health diagnosis: To assess health of a community, relevant sources
of data must be identified and analyzed by time, person and place.

2. Individual decision:

- 1950’s - cancer- higher among smokers

- 1970’s- exercise + proper diet – reduced HDs

- Mid 1980’s – risk of HIV related to behavior

• These and hundreds of epidemiologic findings have helped individuals to make decisions.

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3. Completing the clinical picture (elucidation of the natural history of diseases):
Epidemiologic findings contribute to physicians understanding of the clinical
picture & natural history of disease.

4. Search for causes of diseases: It has been said that epidemiology can never
prove causative, but provides enough information for action.

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5. Classification of diseases: e.g. based on route of transmission

- Gonorrhea- as STD

- Shigellosis- under diarrhea diseases based on its clinical manifestation of diarrhea and as
fecal-oral route of transmission.

6. Monitoring of health programs: Efficiency, effectiveness, feasibility and impact any program
designed to prevent and control a disease must be accompanied by methods for assessing
whether the measures are effective in reducing the frequency of the disease.

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CONCEPT OF DISEASE CAUSATION:
Definition:

The cause of a disease is an event, condition or a characteristic that precedes the


disease event and with out of which the disease event either would not
occurred at all or would not have occurred until some later time.

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WHAT DOES CAUSE DISEASE?
There are different theories :

A. Supernatural

B. Hippocratic

C. Single germ

D. Classic epidemiologic

E. Ecological

F. Multifactorial causation

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SUPERNATURAL THEORY:

• In the early past, disease was thought mainly due to either the curse of God or
due to the evil force of the demons.

• At least 10% of the people in developed countries and 30% in developing


countries still believe in supernatural origin;

• Even today superstitions are becoming major obstacles in disease control;

• Most of the literates view that disease is the result of microbes;

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HIPPOCRATIC THEORY:
• Hippocrates is credited with being the first physician to reject superstitions
and beliefs that credited supernatural or divine forces with causing illness.

• He separated the discipline of medicine from religion, believing and arguing


that disease was not a punishment inflicted by the gods but rather the
product of environmental factors, diet and living habits.

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THE SINGLE GERM THEORY
HENLE-KOCH POSTULATES:
Sometimes called “pure determinism”
• Each disease will be caused by a germ

• Without that germ that disease will not be caused

• By introducing that germ, that disease can be caused in animals experimentally,

• And that germ can again be isolated from that sick animal experimented with.

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CLASSIC EPIDEMIOLOGIC THEORY

 Agents
 Living organisms
 Exogenous chemicals
 Genetic traits
 Psychological factors and stress
 Nutritive elements
 Endogenous chemicals
 Physical forces

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 Host factors:

– Immunity and immunologic response

– Host behavior

 Environmental factors:

– Physical environment (heat, cold, moisture)

– Biologic environment (flora, fauna)

– Social environment (economic, political, culture)

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THE ECOLOGICAL THEORY
• Since disease arises within an ecological system, a basic principle of epidemiology
is that an ecological approach is necessary to explain the occurrence of disease.

• Interactions among humans, other living creatures, plants, animals, micro


organisms, ecosystems, and climate, geography, and topography are so complex that
despite much study we are often uncertain what is really happening.

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MULTIFACTORIAL CAUSATION THEORY
• Petten koffer contradicted the unifactorial theory of disease causation and
emphasized that disease is multifactorial in causation.

• Several causes or factors acting jointly, cumulatively, by complementing or


in an unexplained manner will lead to the disease.

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CAUSAL RELATIONSHIPS:

A causal pathway may be direct or indirect:

• Direct causation, A causes B without intermediate effects

• Indirect causation, A causes B, but with intermediate effects

• In human biology, intermediate steps are almost always present in any


causal process.

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Types of Causal Relationships
 Necessary and sufficient – without the factor, disease never
develops
 With the factor, disease always develops (this situation rarely
occurs)

 Necessary but not sufficient – the factor in and of itself is not enough
to cause disease
 Multiple factors are required, usually in a specific temporal
sequence (such as carcinogenesis)

 Sufficient but not necessary – the factor alone can cause disease,
but so can other factors in its absence
 Benzene or radiation can cause leukemia without the presence of
the other

 Neither sufficient nor necessary – the factor cannot cause disease


on its own, nor is it the only factor that can cause that disease
 This is the probable model for chronic disease relationships
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DISEASE MODELS:

• A schematic description of a system, or phenomenon that accounts


for its known or inferred properties and may be used for further
study of its characteristics.

• There are different disease causation models, the following are the
most widely used ones:

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1. THE EPIDEMIOLOGIC TRIANGLE AND TRIAD (BALANCE
BEAM):
Consists of three components-host, environment, and agent. A change in any of the
components will alter an existing equilibrium to increase or decrease the frequency of the
disease.
This model holds true for infectious disease which has specific agent as necessary cause.
Figure 5.4

Host
The underlying cause of the
disease is a result of the
interaction of several factors,
which can be analysed using
the components of the
Agent Environment
epidemiological triangle.
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EPIDEMIOLOGICAL TRIAD CONT…
• Epidemiological triangle=triad=balance beam

DRAWBACKS:
1. Agents may be many e.g.= lung cancer=>smoking, asbestos
2. One cause---one disease
3. Many causes---one disease=> DD, ARI
4. Many causes—many diseases
E.g.- Bronchitis
- CHD
- Lung cancer

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EPIDEMIOLOGICAL TRIAD CONT…
A. AGENT
• Biological factors- micro organisms

• Nutritional factors

• Physical factors/excess heat

• Chemical factors/gases, insecticides

• Endogenous factors/ excess or deficiency of hormones

B. HOST FACTORS

• Immune status

• Lifestyle- diet, smoking

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Behavioral factors 30
EPIDEMIOLOGICAL TRIAD CONT…
C. ENVIRONMENT

• Physical environment-air, water

• Biological environment-rodents

• Psychosocial environment-family, social climate, poverty, urbanization,


migration, cultural & traditional habits and customs.

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2. THE WEB OF CAUSATION MODEL:

The process that actually generates disease or leads to injury is much more
complex.

This complexity is better portrayed in a second model called the web of


causation.

The web of causation was especially developed to enhance understanding


of chronic diseases.

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Web of Causation for the Major Cardiovascular Diseases

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3. THE WHEEL MODEL:

 The wheel consists of a hub (the host or human), which has genetic make-
up as its core.

 The relative sizes of the different components of the wheel depend upon
the specific disease under consideration.

 For hereditary disease, the genetic core would be relatively large.

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Biological env’t

Social env’t
Genetic
core

Physical env’t

Fig. wheel model


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4. THE CAUSAL PIE MODEL:
The Rothman’s causal Pie model illustrates the factors that act to cause disease as
pieces of a pie, the whole pie making up the sufficient for a disease.

Each pieces cause is seen as necessary and sufficient cause in itself to produce the
effect.

Necessary cause: A causal factor whose presence is required for the occurrence of the
disease.

Sufficient cause: A causal factor or collection of factors whose presence is always


followed by the occurrence of the disease
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Rothman’s pie model…. Ctd

I II III

E J
H I
A
D A G F
B A
C B F C

Fig: Rothman’s causal pieces conceptual scheme for the causes of hypothetical disease.

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THANK YOU!

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