Epidemiological triad
Olushola Ibiyemi (BDS, MPH, FMCDS, PhD)
Introduction
• Epidemiology: the scientific study of the distribution (frequency and pattern) and determinants of
disease or health related states and events in a specified population
• Germ theory of disease has many limitations eg not everyone exposed to an agent develops the
disease.
• There are other factors relating to the host and environment which are equally important to
determine whether or not a disease will occur in the exposed host.
• One important use of epidemiology is to identify the factors that place some members in population
at greater risk than others.
• For an epidemiologist, understanding how diseases spread is essential.
• Epidemiologist must know what makes populations susceptible to diseases, how diseases move
through populations and what allows them to survive and thrive.
• In this way, epidemiologists effectively STUDY and fight the spread of diseases.
• Epidemic or outbreak: more cases of a particular disease than expected in a given area or among a
specific group of people over a particular period of time.
• Endemic: when a population has a high level of the disease all the time.
• One of the models of disease causation.
• Also called epidemiologic triangle
• Traditional model for infectious disease
• A model for explaining the organism causing the disease and the conditions that allow it to
reproduce and spread.
• A model that scientists have developed for studying health problems
• Help us to understand infectious diseases and how they spread and how to combat it.
• Has 3 vertices:
1. Agent or microbe – cause of the disease (the what of the triangle)
2. Host eg humans, animals or carrier (the who of the triangle)
3. Environment or external factors that cause or allow disease transmission eg temperature, period
of the year, dirty water, blood (the where of the triangle)
Time – duration, center of the triangle
Agent
• Agent characteristics: toxicity, virulence, infectivity, susceptibility to antibiotics,
ability to survive outside the body
• Causative factors
• Risk factors
• Environmental exposures
• Interventions: eradicate, genetic modification
Interventions
Interventions
• Protect
• Remove breeding grounds
• Educate
Time • Improve sanitation
• Alter exposures
• Time characteristics
• Incubation/latency
• Length of disease
process
• Trends and cycles
Host Environment
• Person characteristics: age, prior exposure, • Place characteristics: climate, physical structures
susceptibility, co-infection, immune response population density, social structure
Interventions • Biological, physical and psychosocial environmen
• Group and population demographics
• Educate • Interventions: housing, sanitation, water provision
• Interventions: treat, isolate, immunize, nutrition
• Change activity patterns
• Quarantine
• Represent interactions between an agent , host or persons and environment or place within a
specific time dimension.
• Disease results from the interaction between the agent and the susceptible host in an environment
that supports transmission of the agent from a source to that host.
• Agent, host and environmental factors interrelate in a variety of complex ways to produce disease.
• Different diseases require different balances and interactions of these three components.
• Can be applied to non infectious diseases where the agent could be unhealthy behaviours, unsafe
practices or unintended exposures to hazardous substances.
• Agent is a necessary factor ie must be present especially for morbidity to occur
• For disease to occur it needs sufficient factors which are the host factors (age, sex, ethnic group or
occupation) and environment factors.
• To prevent the spread of disease, at least one side of the epidemiologic triangle must be broken.
• John Snow, a pioneer anesthesiologist and father of modern epidemiology, first described the Epid
Triad to trace the source of cholera outbreaks in London in the 1850s.
• Development of appropriate, practical and effective public
health measures to control or prevent disease usually requires
assessment of all three components and their interactions.
• Helps to identify areas of potential intervention to reduce
disease prevalence.
Agent
• Infectious organism or pathogen: virus, bacterium, parasite or other
microbe.
• Generally, the agent must be present for disease to occur
• Presence of agent alone not always sufficient to cause disease.
• A variety of factors influence whether exposure to an agent will cause
disease: Pathogenicity and dose
• Concept of agent broadened to include chemical and physical causes of
disease or injury.
• Useful model for many diseases
• Inadequate for CVDx and other diseases that appear to have multiple
contributing causes without a single necessary one.
Host
• Human, Animals
• Intrinsic factors to host (risk factors) can influence an individuals
exposure, susceptibility or response to a causative agent.
• Opportunities for exposure are often influenced by behaviours
such as sexual practices, hygiene and other personal choices as
well as by age and sex.
• Susceptibility and response to an agent are influenced by factors
such as genetic composition, nutritional and immunologic status,
anatomic structure, presence of disease or medications and
physiological makeup.
Environment
• Extrinsic factors that affect the agent and the opportunity for
exposure. Environmental factors include physical factors such
as geology and climate, biologic factors such as insects that
transmit the agent and socioeconomic factors such as
crowding, sanitation and the availability of health services.
• Mission of an epidemiologists – break at least one of the sides
of the triangle, thereby disrupting the connection between the
environment, the host and the agent and stopping the
continuation of disease.
Covid 19
• In the context of Covid 19, the agent is the severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2), including the
pathogenicity and virulence of various strains.
• The environment refers to extrinsic factors that affect the agent
and opportunities for exposure like respiratory droplets and
contaminated surfaces.
• The host is any uninfected person and their individual
susceptibility characteristics eg age, sex and comorbidities.
• Minimizing the interactions between these components would
reduce the spread of Covid 19.
Agent
(SARS_CoV-2)
• Strain, toxicity, virulence, infectivity, susceptibility to
antiviral agents,
ability to survive outside the body
• Pathogenicity
• Virulence
Agent-Host Agent-Environment
Interrupting factors X
X Interrupting factors
Covid -19
Host Environment
Uninfected patient/HCW X
Contaminated droplets/surfaces
• Age, prior exposure, susceptibility, • Virus survival
immune response • airflow
• Gender
• Comorbidities Environment-Host interrupting factors
• Viral susceptibility
Interrupting factors Community Hospital Aerosol generating medical
procedure such as
intubation and use of drills
Agent-Host interrupting • Vaccine
factors (decreasing the • Antiviral treatment
host’s susceptibility or
diminishing virus virulence)
Environment-Host • Sheltering in place • Cancelling elective surgeries • PPE with N95/PAPR
interrupting factors • Social distancing • Restricting hospital visitors • Barrier enclosure
(decreasing the opportunity • Hand washing or • PPE with N95/Powered Air devices eg face shields,
for active virus to infect disinfection Purifying Respirator (PAPR) gowns & gloves
new hosts) • Hand washing • Video laryngoscopy
• Hand washing
Agent-Environment • Self-quarantine of • Airborne infection isolation • Currently none
interrupting factors infected individuals rooms (AIIR) • Local evacuation face
(eliminating or decreasing • Travel restrictions • Negative pressure ORs tent system
the viral burden in droplets • Mask wearing • Dedicated Covid ward
and surfaces) • Cleaning surfaces • Dedicated Covid Team
• Mask wearing
• Cleaning surfaces
• Ultraviolet germicidal
irradiation (UVGI)
Epidemiological measurements
• Measurement of the presence, absence or distribution of
environmental factors and other factors suspected of causing
the disease.
• Basic requirements of measurements: validity, reliable, accuracy,
sensitivity and specificity.
• Tools of measurement or tools of epidemiology: Rates; Ratios;
Proportions
Epidemiological methods
• Methods used to study disease occurrence in a pop and this is carried out by
designing research strategies that will explore disease aetiology and patterns.
• Classification of Epidemiology methods
1) Observational studies
a) Descriptive studies – first phase of epidemiology investigation that
observe the distribution of disease in Time (when is disease occurring), Place
(where is disease occurring) and Person (who is getting disease). It formulates
hypothesis
i. case report (rare cases are reported)
ii. Case series (when 2 or more rare cases are reported)
iii. Cross-sectional studies (both exposure and disease occur together)
iv. Longitudinal studies (forward moving study in which both exposure
and disease occur together)
b) Analytical studies – 2nd major type of epidemiology studies that looks at
individual within the population but inference is to general population. It
test hypothesis.
i. Case-control studies(backward moving study – retrospective study ie
moves from disease to exposure)
ii. Cohort studies (forward moving study – prospective study ie moves
from exposure to disease)
2)Experimental studies – also called intervention studies. Similar to cohort
except that the study is under the control of the investigator thus involve
some action, intervention or manipulation. 3 major elements: control;
randomization and manipulation/intervention.
i. Randomized controlled studies/clinical trials )True experiments) or Non-
randomised controlled studies (False experiments) – individuals unit of
study
ii. Field trials or community trials – community unit of study
Revision
• What are the parts of the Epidemiologic triangle and how does it
help to understand any infectious disease.
• Describe how epidemiologists think about the causes and
spread of an infectious disease.
• Why is the epid triangle important to understanding the spread
of infectious diseases and how to stop hem.
Questions??????????
Thank you and best of luck
