Introduction To Epidemiology

Epidemiology
The curtain raiser

Dr. Sandeep K Panigrahi
Assistant Professor, Community Medicine Department,
IMS and SUM Hospital, SOA University, bhubaneswar
is this
Epidemiology?
10/28/16
Introduction to Epidemiology
Epi = upon
Demos = people
Classically
speaking
Ology = science
Epidemiology = the science which deals with what
falls upon people..
Bridge between biomedical, social and behavioral
sciences
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Oxford English Dictionary

THE BRANCH OF MEDICAL SCIENCE WHICH
TREATS EPIDEMICS
Simple Old
Definitions
Kuller LH: American J of Epidemiology

1991;134:1051
EPIDEMIOLOGY IS THE STUDY OF "EPIDEMICS"
AND THEIR PREVENTION
Anderson G. In: Rothman KJ: Modern
Epidemiology
THE STUDY OF THE OCCURRENCE OF ILLNESS
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Epidemiol
ogy
Epidemiology is the study of

the determinants,
distribution, and frequency of
disease
Who gets disease and why
Epidemiologists study sick
and well people to determine
the crucial difference between
those who get disease and
those who are spared
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A Modern
Definition
Study of the occurrence and

distribution of health-related diseases
or events in specified populations,
including the study of the
determinants influencing such states,
and the application of this knowledge
to control the health problem
(Porta M, Last J, Greenland S. A Dictionary of
Epidemiology, 2008)
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A Modern
Definition
Study of the occurrence and

distribution of health-related diseases
or events in specified populations,
including the study of the
determinants influencing such states,
and the application of this knowledge
to control the health problem
(Porta M, Last J, Greenland S. A Dictionary of
Epidemiology, 2008)
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Epidemiol
ogy
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Is it a science?
Or is it a method?
Is
Epidemiol
ogy a
Science?
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What are the

characteristics of a
science?
What disciplines are
sciences?
What disciplines are not
sciences?
How do they differ from
sciences?
Is public health a science?

Is epidemiology a RSscience?
Bhopal
Science is a creative
endeavor
Is
Epidemiol
ogy a
Science?
It relies on
questioning,
imagination,
exploration
It seeks out empirical
evidence
It tests ideas
Study questions
Hypotheses
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RS Bhopal
10
The
Essence
of
Science
Ask an impertinent
question, and you are
on the way to a
pertinent answer.
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Bronowski
11
Who is an
epidemiologi
st ?
A professional who strives to study and

control the factors that influence the
occurrence of disease or health-related
conditions and events in specified
populations and societies, has an
experience in population thinking and
epidemiologic methods, and is
knowledgeable about public health and
causal inference in health
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology,
2008)
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12
Epidemiologists are required to have some

knowledge of:
Public health: because of the emphasis on disease prevention
Clinical medicine: because of the emphasis on disease
classification and diagnosis (numerators)
Pathophysiology: because of the need to understand basic
biological mechanisms in disease (natural history)
Biostatistics: because of the need to quantify disease
frequency and its relationships to antecedents (denominators,
testing hypotheses)
Social sciences: because of the need to understand the social
context in which disease occurs and presents (social determinants
of health phenomena)
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13
Purposes of
Epidemiology
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1. To investigate nature / extent of

health-related phenomena in the
community / identify priorities
2. To study natural history and
prognosis of health-related problems
3. To identify causes and risk factors
4. To recommend / assist in application
of / evaluate best interventions
(preventive and therapeutic
measures)
5. To provide foundation for public
policy
14
Classical
versus
Modern
Applicatio
ns
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Classical: descriptive, observational,

field, analytical, experimental, applied,
healthcare, primary care, hospital, CD,
NCD, environmental, occupational,
psycho-social, etc
Modern: risk-factor, molecular,
genetic, life-course, CVD, nutritional,
cancer, disaster, etc
15
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16
Descriptive Epidemiology
Two Broad
Types of
Epidemiol
ogy
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Examining the distribution of

disease in a population, and
observing the basic features of
its distribution
Analytic Epidemiology
Testing a hypothesis about the
cause of disease by studying
how exposures relate to the
disease
17
DESCRIPTIVE EPIDEMIOLOGYANALYTIC EPIDEMIOLOGY
Broad Types of
Epidemiology
Examining the
distribution of a disease
in a population, and
observing the basic
features of its
distribution in terms of
time, place, and person.
We try to formulate
hypothesis, look into
associations ?
Typical study design:
community health
survey (synonyms:
cross-sectional study,
descriptive study)
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Testing a specific
hypothesis about the
relationship of a disease
to a specific cause, by
conducting an
epidemiologic study
that relates the
exposure of interest to
the outcome of interest
(? Cause-effect
relationship)
Typical study designs:
cohort, case-control,
experimental design
18
Descriptive
Epidemiology Is A
Necessary
Antecedent of
Analytic
Epidemiology
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To undertake an analytic epidemiologic study you must

first:
Know where to look
Know what to control for
Be able to formulate / test hypotheses compatible
with a-priori lab / field evidence
19
Basic Triad of Descriptive

Epidemiology
THE THREE ESSENTIAL CHARACTERISTICS OF
DISEASE WE LOOK FOR IN DESCRIPTIVE
EPIDEMIOLOGY ARE:
PERSON
PLACE
TIME
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20
Age
Personal
Characteristics
(whom)
Gender
Socio-economic status (education, occupation,
income)
Marital status
Ethnicity/race/genetic profile
Behavior / habits
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21
Geographically restricted or
widespread (outbreak, epidemic,
pandemic)? Off-shore (tsunami)
Place
(where ?)
Climate effects (temperature,

humidity, combined effects..)
Urban / sub-urban-squatter / rural
Relation to environmental exposure
(water, food supply, etc)
Multiple clusters or one?
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22
Changing or stable?
Time
(when ?)
Clustered (epidemic) or evenly

distributed (endemic)?
Time-trends: Point source,
propagated, seasonal, secular,
combinations
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23
Example
You have been asked to

investigate an event in
which 2,220 people were
exposed and 1,520 of
them died.
Your role as an
epidemiologist is to ask
questions about person,
place and time.
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24
How do we ask questions?

Surveys
-of survivors
-of next-of-kin
-of other related persons
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25
with
questions
you learn
that ...
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Person: Men, women and

children were all exposed and at
risk. The majority of people who
died were wealthy and young
men between 18-50 years (when
compared to survivors).
Place: All those exposed were
within 1 block of one another, the
climate was cold.
Time: Mid April, people died
within hours of the precipitating
exposure.
26
What
designs do
epidemiologi
sts use ?
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Qualitative designs
Quantitative designs
Observational
Experimental
Building evidence
27
What
measures do
Frequency measures
Effect measures
epidemiologi
sts use ?
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Impact fractions
28
Among Unique Skills of

Epidemiologists:
MEASURING
DISEASE
FREQUENCY IN
POPULATIONS
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29
Classifying and
categorizing disease
Measuring
Disease
Frequency
Has Several
Components
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Deciding what
constitutes a case
of disease in a
study
Finding a source for
ascertaining the
cases
Defining the
population at risk of
disease
Defining the period

of time of risk of
disease
Obtaining
permission to study
people
Making
measurements of
disease frequency
Relating cases to
population and time
at risk
30
Basic triad of analytical epidemiology
THE THREE PHENOMENA ASSESSED IN

ANALYTIC EPIDEMIOLOGY ARE:
HOST
AGENT
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ENVIRONMENT
31
Epidemic
s arise
when
host,
agent,
and
environm
ental
factors
are not in
balance
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Due to new agent

Due to change in existing
agent (infectivity,
pathogenicity, virulence)
Due to change in number of
susceptibles in the population
Due to environmental changes
that affect transmission of the
agent or growth of the agent
32
Biological (micro-organisms)
Agents
Physical (temperature, radiation, trauma, others)

Chemical (acids, alkalis, poisons, tobacco, others)
Environmental (nutrients in diet, allergens, others)
Psychological experiences
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33
Genetic endowment
Immunologic status
Host
Factors
Personal characteristics
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Personal behavior
Definitive versus intermediate (in vector-borne
diseases)
34
Living conditions (housing, crowding,

water supply, refuse, sewage, etc)
Atmosphere / climate
Environment
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Modes of communication: phenomena

in the environment that bring host
and agent together, such as: vector,
vehicle, reservoir, etc)
35
Epidemiolog
y goes
Popperian
As a scientific discipline, epidemiology

is liberating because it does not accept
dogma. It has helped liberate the
practice of public health and medicine
from dogmatic thinking over the past
century
Popperian thinking in epidemiology:
-Refutation of the existing way of
thinking
-A hypothesis can never be proven.
However, there are hypotheses that
have never been rejected so far
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36
Epidemiology
as a problem
solving
discipline:
Integrating
principles
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The first integrating principle is that

epidemiology is an information
science.
The second integrating principle is
that epidemiology operates within
an environment of complex
systems.
Third integrating principle is that
epidemiology is not just a
scientific discipline but a
professional practice area.
37
Epidemiology is an information science:
(I)
Epidemiology
is an
information
science
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Data generated by epidemiologists is to be

used for decision making.
Epidemiology is purposive: methods and
knowledge are to be used for the ultimate
purpose of prevention of disease, disability
and death
Epidemiology is under public scrutiny.
Information affects decisions at the public
policy level, at the level of individuals, and
by health professionals. A social
responsibility.
38
INFORMATION
GENERATION
DECISION ACTION
PROCESS
EPIDEMIOLOGIC PROCESS OF INTERVENTION

METHODS
INFERENCES
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39
Epidemiolog
y assists:
Systems: information,
surveillance
Decisions: political,
management
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40
Informati
on
Systems:
Value and
Quality
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1.
Timeliness
2.
Quantity
3.
Frequency
4.
Use for Decision Making
5.
Presence of Feedback Loop
41
1. Sensitivity
2. Predictive value positive
Surveilla
nce
Systems:
Evaluation
3. Simplicity
4. Flexibility
5. Acceptability
6. Representativeness
7. Timeliness
8. Reliability or precision
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42
Political
Decisions
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Budget and Resource

Allocation
Jurisdiction of agencies
Personnel selection
Legislation
43
Efficacy Patient Care

Effectiveness Public Health
Compliance
Manageme
nt Decisions
Quality Assurance
Training
Planning
Programming
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44
In a healthsystem,
epidemiolog
y supports:
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Structure
Process
Outcome
45
Structure: Does a structure exist to

implement the health care
intervention (program) and what are
its characteristics?
How does
this work ?
Process: Is the process to implement

the health care intervention (program)
working?
Outcome: What effect has the
intervention had on the outcome(s) of
interest?
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46
Mortality: all cause / cause-specific
What
outcomes
?
Morbidity: Disease-specific
indicators / General indicators: clinic
use, hospitalization, medication use
Quality of life: General / Diseasespecific
Costs
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47
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48
(II)
Epidemiol
ogy
operates
within
complex
systems.
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Our etiologic investigations continue to have

a focus of simple models even if we use
multivariate analyses.
Etiologic factors operate in complex systems
and we need to consider the use of a
systems analysis approach in investigating
etiology. Epidemiologists, need to work at
multiple levels to make the appropriate
inferences.
As a physician working in this health
center I am not just interested in the
trends and distribution of the disease
but I want first to know individually
who are my diabetic patients and what
is being done to them
49
CLASSIC EPIDEMIOLOGIC
RESEARCH INTO ETIOLOGY
Environmental
factor(s)
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Outcome
50
CLASSIC EPIDEMIOLOGIC
RESEARCH INTO ETIOLOGY
Other factors including
health care
Environmental
Factor(s)
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Outcome
51
CLASSIC HEALTH SERVICES

RESEARCH INTO EFFECTIVENESS
Health
Care
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Outcome
52
CLASSIC HEALTH SERVICES

RESEARCH INTO EFFECTIVENESS
Environmental and
other factors
Health
Care
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Outcome
53
(III)
Epidemiol
ogy is a
professio
nal
practice
area
John Racy defined a profession as a

socially sanctioned activity whose
primary object is the well-being of
others above the professionals
personal gain
Epidemiology:
-a solid disciplinary scientific base
-requires well grounded academic
preparation
-objectives within the public-social
domain
-uses well defined paradigms of
problem investigation, analysis, and
inferences.
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54
From the
Present to
the Future 1
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Science is universal but we each bring to it our own

way of thinking and the wealth of experience and
heritage for some common goal.
When we are inspired and driven by the potential
impact of what we can achieve, then we can make a
great leap forward for the discipline.
55
From the
Present to
the Future 2
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Henry Siegerist: one of the problems of medicine

through the ages has been that technology has
always outpaced sociology
Epidemiology is in need of sociology more than
additional technology. Sociology in epidemiology is in
the context of its uses and its practice within the
framework of health services.
56
From the
Present to
the Future 3
Human beings are not just a collection

of cells or molecules but also have
spirituality that binds the molecules
and cells with an integrative purpose
and the resultant direction. Thus, in
every culture and with every
individual there is this search for
dignity that elevates us out of our
biological complexity
Public health action, problem solving
and a sense of mission is what brings
many of our students to health
sciences and epidemiology
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57
Pierre
Teilhard de
Chardin
mentioned
that:
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In the final analysis, the questions of why bad

things happen to good people transmutes
itself into some very different questions, no
longer asking why something happened, but
asking how we will respond, what we intend
to do now that it happened
It is our duty as men and women to proceed
as though the limits of our abilities do not
exist
We are not human beings having a spiritual
experience. We are spiritual beings having a
human experience
We are one, after all, you and I. Together we
suffer, together exist, and forever will
recreate each other.
58
Porta M. A dictionary of epidemiology. 5th

edition. Oxford: Oxford University Press,
2008
References
Holland W, Olsen J, Du V Florey C. The

development of modern epidemiology:
Personal reports from those who were there.
Oxford, New York: Oxford University Press,
2007
Paneth N. Introduction to epidemiology.
Michigan State University, USA.
Armenian H. Epidemiology: A problem
solving journey. Am J Epidemiology, Nov 12,
2008
10/28/16
59
World Health Organization: www.who.int

Centers for Disease Control and Prevention:
www.cdc.gov
Websites
Epidemiology Supercourse:
www.pitt.edu/~super1/
International Epidemiological Association:
www.IEAweb.org
Oxford University Press: www.oup.org
Email address: ahmed.mandil@yahoo.com
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60
Thank you .
10/28/16
61

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Epidemiology

The curtain raiser

Oxford English Dictionary

Kuller LH: American J of Epidemiology

Epidemiology is the study of

Study of the occurrence and

Study of the occurrence and

What are the

Is public health a science?

A professional who strives to study and

Epidemiologists are required to have some

1. To investigate nature / extent of

Classical: descriptive, observational,

Examining the distribution of

DESCRIPTIVE EPIDEMIOLOGYANALYTIC EPIDEMIOLOGY

To undertake an analytic epidemiologic study you must

Basic Triad of Descriptive

Climate effects (temperature,

Clustered (epidemic) or evenly

You have been asked to

How do we ask questions?

Person: Men, women and

Among Unique Skills of

Defining the period

Basic triad of analytical epidemiology

THE THREE PHENOMENA ASSESSED IN

Due to new agent

Physical (temperature, radiation, trauma, others)

Living conditions (housing, crowding,

Modes of communication: phenomena

As a scientific discipline, epidemiology

The first integrating principle is that

Epidemiology is an information science:

Data generated by epidemiologists is to be

EPIDEMIOLOGIC PROCESS OF INTERVENTION

Use for Decision Making

Presence of Feedback Loop

Budget and Resource

Efficacy Patient Care

Structure: Does a structure exist to

Process: Is the process to implement

Mortality: all cause / cause-specific

Our etiologic investigations continue to have

CLASSIC HEALTH SERVICES

CLASSIC HEALTH SERVICES

John Racy defined a profession as a

Science is universal but we each bring to it our own

Henry Siegerist: one of the problems of medicine

Human beings are not just a collection

In the final analysis, the questions of why bad

Porta M. A dictionary of epidemiology. 5th

Holland W, Olsen J, Du V Florey C. The

World Health Organization: www.who.int

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