Introduction to

Epidemiology

Tewodros Mekonin (BSc, MPHE)

June 2024
Session objectives
 At the end of this chapter, participants will be able to:
 Define epidemiology and understand concepts in the definition
 Differentiate between descriptive and analytic epidemiology
 Understand the history of epidemiology
 Understand the scope and purpose of epidemiology
 Explain the assumptions of epidemiology
 Understand natural history of disease

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Contents
 Definition of Epidemiology
 History of Epidemiology
 Scope and Purposes of Epidemiology
 Fundamental Assumptions in Epidemiology
 Natural History of Diseases

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1. Definition of Epidemiology

 The term “epidemiology”:

Origin: Greek roots.

Greek English equivalent

 Epi upon
 Demos Population
 Logia Science/Study
 Epidemiology is science/study upon population

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Definition…
“The basic science of public health”
 Epidemiology is the study of the:

 frequency

 distribution and

 determinants
of diseases and other health related states (conditions) or
events in specified populations, and the application of this
study to the promotion of health, and to the prevention and
control of health problems.
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Concepts in the Definition of
Epidemiology
 “Populations”
 This element characterizes the basic difference in approach
between Epidemiology and Clinical Medicine, both of which are
concerned with health and disease.
 Clinical Medicine - focuses on the effect of disease on individuals

 Epidemiology - focuses on the effect of disease on populations

 These two approaches are not mutually exclusive rather

complement each other (e.g. Clinical Epidemiology)
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Concepts…
 “Disease and other health related conditions”
 This indicates the vast area covered by Epidemiology since
everything around us and everything we do affects our health.

Examples of health related conditions (other than disease):

 Injuries

 Vital events (births, deaths, marriages, divorces)

 Health related behavior (e.g. sexual behavior, smoking,

alcoholism, drug abuse)
 Social factors (e.g. poverty)
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Concepts…
 “Frequency”
 This indicates that Epidemiology is quantitative science
 We measure frequency of disease using:
 Morbidity rates (quantify the occurrence of illness)
 Mortality rates (quantify the occurrence of death)
 etc.

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Concepts…
 “Distribution”
 This refers to the occurrence of diseases by person,
place and time.
 Who? (type of persons most or least affected)
 Where? (geographic areas most or least affected)
 When? (seasonal fluctuations)

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Concepts…
 “Determinants”:
 These are factors which determine whether or not a
person will get a disease (i.e. causative factors)
 It asks the questions, “Why and how diseases occur
in certain places, at certain periods of time and in
certain population groups?”

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Concepts…
Determinants….
 The causes of disease can be classified as:
 Primary causes: factors which are necessary for a disease to
occur, in whose absence, the disease will not occur.

Examples: infectious agents, carcinogens, etc

Note:
 The term ‘etiological agent’ is reserved for infectious agents
 For many diseases, a primary cause has not been identified
(e.g. coronary heart disease, many types of cancers, etc)
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Concepts…
Determinants….
 Contributing, predisposing, or aggravating factors:
 also referred to as risk factors

 further classified as:

 Factors relating to the agent (when primary cause has been
identified)
 Factors relating to the human host
 Factors relating to the environment (physical, biological,
socioeconomic, cultural and political)
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Concepts…
Determinants….
 Etiology of a disease is the sum total of all the factors which
contribute to the occurrence of the disease including:
 primary cause or etiological agent and

 all associated risk factors

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Concepts…
 “Application … to the prevention and control of human problems”

 Epidemiology is applied science with direct practical appns

 An important aim in the study of frequency, distribution and

determinants of the disease, is to identify effective disease
prevention and control strategies.

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 Descriptive epidemiology
Descriptive epidemiology is a way of organizing data related to
health and health related events by person (Who), place (Where)
and time (When) in a population.

 provides information about:

1) the magnitude of the problem,
2) the populations at greatest risk of acquiring a particular disease

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Descriptive epid…(cont.)
Time: Information organized by time

 Easily shows the trend of the disease over time and

establishes the usual occurrence of the disease in the
population which is essential in identifying excess
occurrence (epidemics).
 It can also be used to predict seasonal and secular (long-
term) trends.

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Time
Secular trends refer to gradual changes in disease occurrence
over long periods of calendar time.
---Example: Death from communicable diseases has been
declining where as deaths from chronic diseases has been
raising in some developing countries

Cyclic fluctuations/ periodic refer to shorter-term increases

and decreases in disease occurrence over a period of years,
or within a year.

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 Descriptive epid…(cont.)
Place: This provides information on geographic distribution of the
disease.
 provides clue in identifying factors influencing the

occurrence of the disease either in the host or environment.

Person: Describing disease occurrence by personal characteristics

 Important to identify some modifiable factors in order to prevent
or control the disease.

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 Descriptive epid…(cont.)

 Person data include:

 the inherent characteristics of people (age, ethnic group, gender),
 their acquired characteristics (educational, marital,
immune, or nutritional status),
 their activities (occupation, leisure activities,
use of alcohol, tobacco, or medications), or
 the conditions in which they live
(socioeconomic status, access to health care).

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 Descriptive epid…(cont.)
Important features of descriptive studies

⎯ Concerned with the distribution of diseases with respect to

time, place and person.

⎯ Useful allocate resource and to plan effective prevention

programs.

⎯ generate epidemiological hypothesis:

⎯ less expensive and less time-consuming

⎯ most common type of epidemiological design

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Descriptive epid…(cont.)
Types of descriptive studies:

• Correlational/ecological

• Case report or case series

• Cross-sectional

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Analytical epidemiology
 Concerned with why and how a health problem
occurs.
 Focuses on testing hypothesis
 Uses appropriate comparison group

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2. History of Epidemiology
 The history and practice of Epidemiology extends over many
centuries (as old as medicine itself).
 However, the discipline did not blossom until the end of the
Second World War.
 Hippocrates, considered the father of medicine, laid down the
earliest cornerstones of Epidemiology.
 He first suggested (in 5th C B.C) that the development of human
disease might be related to external as well as personal (host)
environment of the individual.
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History…
 Hippocrates is the First
Epidemiologist.
 His three books, Epidemic I,
Epidemic III, and On Airs,
Waters, and Places,
attempted to describe disease
from a rational perspective
rather than from a
supernatural basis.
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History…
 In 1603 – construction of the first life table (analysis of
mortality data) by John Graunt
 He was the first to quantify patterns of birth, death, and
disease occurrence, noting male-female disparities, high
infant mortality, urban-rural differences, and seasonal
variations.
 In 1747 – experimental study on the etiology of scurvy from
epidemiological observation by James Lind
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History…
 In 1760 – epidemiological analysis
and evaluation of the smallpox
vaccine by Daniel Beronoulli
 Variolation
 Edward Jenner invented a
vaccination for smallpox.

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History…
 In 1830s – several observational studies made by Pierre
Charles-Alexander Louis

 In 1839 – William Farr set up a system for routine

compilation of the numbers and causes of death and established
a tradition of careful application of vital statistical data to the
evaluation of health problems of the general public health.

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History…

 Farr, considered the father of modern vital statistics and

surveillance, developed many of the basic practices used
today in vital statistics and disease classification.

 He extended the epidemiologic analysis of morbidity and

mortality data, looking at the effects of marital status,
occupation, and altitude.

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History…
 During 1848-1854 – classical studies of cholera epidemic in
London by John Snow (the father of field epidemiology).
 Twenty years before the development of the microscope,
Snow conducted studies of cholera outbreaks both to:
 Discover the cause of disease

 Prevent its recurrence

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History…
 His work classically illustrates the sequence from descriptive
epidemiology to hypothesis generation, hypothesis testing
(analytic epidemiology) and application.
 Snow conducted his classic study in the Golden Square of London
 He began his investigation by determining where in this area
persons with cholera lived and worked
 He then used this information to map the distribution of cases on
what epidemiologists call a spot map
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History…

Figure 1. Distribution of cholera cases in Adapted from: Snow, J., On the Mode
31 of
the Golden Square Area of London, Communication of Cholera. (Sec. Edition).
Aug-Sep 1848 1855. Churchill, London.
History…
 Snow believed that water was a source of infection for cholera
 He marked the location of water pumps on his spot map
 Then he looked for a relationship between the distribution of
cholera case households and the location of pumps
 He noticed that more case households clustered around Pump
A, the Broad Street pump, than around Pump B or C
 He concluded that the Broad Street pump was the most likely
source of infection
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History…
 Interviewing residents who lived near the other pumps, he
found that:
 They avoided Pump B because it was grossly contaminated,
 Pump C was located too inconveniently for most residents of
the Golden Square area
 Finally, it appeared to Snow that the Broad Street pump was
probably the primary source of water for most persons with
cholera in the Golden Square area
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History…
 To confirm that the Broad Street pump was the source of the
epidemic:
 Snow gathered information on where persons with
cholera had obtained their water.
 Consumption of water from the Broad Street pump was
the one common factor among the cholera patients
 According to legend, Snow removed the handle of that
pump and aborted the outbreak
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History…
 Snow’s second major contribution involved another investigation
of the same outbreak of cholera that occurred in London in 1854
 In a London epidemic in 1849, Snow had noted that districts with
the highest mortalities had water supplied by two companies:
 Lambeth Company
 Southwark and Vauxhall Company
 At that time, both companies obtained water from the Thames
River, at intake points that were below London.
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History…
 In 1852, Lambeth Company moved their water works to above
London, thus obtaining water that was free of London sewage.
 When cholera returned to London in 1853, Snow realized the
Lambeth Company’s relocation of its intake point would allow
him to compare districts that were supplied with:
 water from above London
 water from below London

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History…
Table 1. Mortality from cholera in the districts of London supplied by the

Southwark and Vauxhall, and the Lambeth Companies, July 9-August 26, 1854

Districts with Water Population Deaths from Cholera Death

Supplied by (1851 Census) Cholera Rate per 1,000 Popn
Southwark and 167,654 844 5.0
Vauxhall Co. only
Lambeth Co. only 19,133 18 0.9
Both companies 300,149 652 2.2
Conclusion:
 Risk of death from cholera was more than 5 times higher in districts served
only by the Southwark and Vauxhall Company than in those served only by the
Lambeth Company.
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History…
 These data were consistent with the hypothesis that water obtained
from the Thames below London was a source of cholera.
 Thus, efforts to control the epidemic were directed at changing the location
of the water intake of the Southwark and Vauxhall Company to avoid
sources of contamination.
 Snow demonstrated through epidemiologic studies that water could serve
as a vehicle for transmitting cholera and that epidemiologic information
could be used to direct prompt and appropriate public health action.

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History…
 During 1857-1873 – William Budd’s studies of typhoid fever were
published
 In 1844 – sophisticated epidemiological studies of Semmelweiss on
maternal mortality in the maternity wards of a university hospital in
Vienna.
 In 1846 – investigation of epidemic of measles in Faroe Islands by the
Danish physician P.L. Panum.
 In 1914 – comparative experimental study on etiology of pellagra by
Goldberger
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3. Developments in Modern Epidemiology
 The first major developments of modern Epidemiology:

 Doll and Hill’s Case-control study (1950s) to investigate the

relationship between cigarette smoking and lung cancer.

 Framingham Heart study (1950s) to explore the

relationships of a wide variety of risk factors with coronary
heart disease.

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Developments…
 Clinical trial (1950s) to show the efficacy and safety of polio
vaccine.
 PHARMACOEPIDEMIOLOGY – evaluation of new
preventive and therapeutic agents and procedures

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4. Scope of Epidemiology
 Concerned with infectious Ds and mainly epidemics in the past
 Now, the scope of Epidemiology has expanded to include
infectious and non-infectious diseases such as:

 Nutritional deficiency states  Cancer

 Mental disorders  Congenital anomalies
 Hypertension  Degenerative diseases
 Accidents  etc.

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Scope…
 Epidemiologic principles and methods are also being applied to
evaluation of the effects of new approaches for prevention and
treatment of diseases.
 In general, there are various fields of Epidemiology:
 Infectious diseases epidemiology
 Non infectious diseases epidemiology
 Occupational epidemiology
 Environmental epidemiology
 Reproductive epidemiology
 Clinical epidemiology
 Molecular, genetic, nutritional, social, etc.
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Purpose of Epidemiology

1) Diagnostic Purpose
 Epidemiological studies provide data for community diagnosis,
which encompasses the identification and detailed analysis of:
 Health needs and demands
 Priorities and
 Resources of a defined community
 basis for the planning and implementation of health
interventions
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Purpose…
2) Identification of determinants of diseases
 This is one of the most important purposes of epidemiological
studies
3) Evaluation of Methods of Disease Control
 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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Purpose…
4) Observation of the natural history of diseases
 Knowledge of the natural history of disease is essential to make
prognosis or likely outcome of a patient's illness
5) Classification of diseases
 The epidemiological characteristics of disease are an integral
part of its basic description by means of which it is defined and
recognized.

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5. Fundamental Assumptions in Epidemiology

1. Non-random distribution of diseases in human population

2. Human disease has causal and preventive factors that can be

identified through systematic investigation

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6. Dynamics of disease

Infection
Dynamics of Latent Infectious Non-infectious
infectiousness period period
Dead, cured,
removed, immune
Susceptible
Time
Infection

Dynamics of Incubation Symptomatic Non-diseased

disease period period
Dead, cured,
immune, carrier
Susceptible
Time
05/28/25 48
Natural history of disease

 Is the course of a disease process in an individual over time

without/unaffected by treatment or intervention.
 Each disease has its own natural history.
 Helps in understanding the intervention measures; i.e.
prevention and/or control of the disease.
 There are different stages in the natural history of diseases.

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Natural history…
 Stage of susceptibility (period of exposure)
 Disease has not yet developed, but there are factors that

favor occurrence.
 Stage of sub-clinical disease (pre-symptomatic stage)
 Disease process has already begun, but disease is not

manifested.
 Stage of clinical disease
 Sn & Sx are manifested

 Stage of disability or death

 Disease has occurred and left over damage to the body

that limits the activity of the victim (disability) or has

ended with death of the victim. 50
Natural history…

E.g. Traveling to
malaria
endemic areas Non diseased
Immune
Carrier
recovered

(Biologic onset)

Figure 2. Natural history of a disease 51

(Note: Recovery can take place at any stage in the course of the disease)
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