Professional Documents
Culture Documents
Epidemiology
Yigzaw Kebede
University of Gondar
In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education
2004
Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.
Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.
All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.
This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.
Acknowledgements
Recognizing the importance of and the need for the preparation of the
lecture note for the Training of Health Extension workers THE
CARTER CENTER (TCC) ETHIOPIA PUBLIC HEALTH TRAINING
INITIATIVE (EPHTI) facilitated the task for Gondar University to write
the lecture note in consultation with the Health Extension
Coordinating Office of the Federal Ministry of Health.
i
i
Table of Contents
Acknowledgement .................................................. ii
Introduction ............................................................ 1
UNIT ONE: Introduction to Epidemiology .......... 1
Objectives ................................................... 2
Definition .................................................... 2
Exercise ...................................................... 6
Objective ..................................................... 7
Definition ..................................................... 7
Exercise .................................................... 10
Objectives ................................................... 11
ii
ii
Levels of Disease Prevention ..................... 16
Exercise: .................................................. 18
Objectives ................................................. 20
Definition .................................................. 20
Exercise .................................................... 26
Objective ..................................................... 32
iii
iii
Measurements of morbidity ...................... 35
Exercise: ................................................... 44
Objectives: ................................................ 46
Exercise: ................................................... 52
Exercise ................................................... 66
Objectives ................................................. 68
iv
iv
Definition .................................................. 68
Exercise .................................................... 76
Reference ................................................... 77
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v
Introduction
This lecture note will familiarize the students about the definition of
words which are commonly used in Epidemiology, levels of
prevention; Infectious diseases Epidemiology; measuring morbidity
and mortality; sources and method of data collection; Epidemic
investigation and management; and Surveillance.
The examples and exercises given in this lecture note will enable the
health extension worker to better understand the concepts of
Epidemiology.
UNIT ONE
1
Introduction to Epidemiology
Learning Objectives:
Define Epidemiology
1.1. Definition
2
2. Frequency. This shows that epidemiology is mainly a quantitative
science. Epidemiology is concerned with the frequency (occurrence)
of diseases and other health related conditions. Frequency of
diseases is measured by morbidity and mortality rates.
3
Although epidemiological thinking has been traced to the time of
Hippocrates, who lived around 5th century B.C., the discipline did not
flourish until 1940s.
Exercise
1. What is epidemiology?
5
2. "Fifty percent of malaria cases in North Gondar Zone occurred
in Metema Woreda." This statement shows, please choose
the best
6
UNIT TWO
Disease Causation
Learning Objectives
Definition
The etiology of a disease is the sum total of all the factors (primary
causes and risk factors) which contribute to the occurrence of the
disease.
It is the interaction of the agent, the host, and the environment which
determines whether or not a disease develops, and this can be
illustrated using the epidemiologic triangle.
Agent
Host Environment
The environment includes all external factors, other than the agent,
that can influence health. These factors are further categorized
according to whether they belong in the social, physical, or
biological environments.
9
Exercise
Identify the primary causes and risk factors for the following diseases
Tuberculosis
HIV/AIDS
Amoebiasis
Measles
Common cold
10
UNIT THREE
Levels of Prevention
Learning Objectives
There are four stages in the natural history of a disease. These are:
1. Stage of susceptibility
11
1. Stage of susceptibility
In this stage, disease has not yet developed, but the groundwork has
been laid by the presence of factors that favor its occurrence.
Examples:
At this stage the person has developed signs and symptoms of the
disease. The clinical stage of different diseases differs in duration,
12
severity and outcome. The outcomes of this stage may be recovery,
disability or death.
Examples:
Some diseases run their course and then resolve completely either
spontaneously or by treatment. In others the disease may result in a
residual defect, leaving the person disabled for a short or longer
duration. Still, other diseases will end in death.
13
Examples:
14
Healthy person
Sub clinical
disease
Recovery Death
Disability
15
3.2 Levels of Disease Prevention
16
Examples can be provision of safe and adequate water,
proper excreta disposal, and vector control.
Examples:
17
3) Tertiary prevention:– is targeted towards people with
permanent damage or disability. Tertiary prevention is needed
in some diseases because primary and secondary preventions
have failed, and in others because primary and secondary
prevention are not effective. It has two objectives:
Exercise:
18
2. Write the primary, secondary, and tertiary prevention
strategies for the diseases or conditions listed in the
table below?
Measles
Pulmonary
tuberculosis
A person lost
his leg by car
accident
Poliomyelitis
19
UNIT FOUR
Learning Objectives
4.1 Definition
1. The Agent
2. Its reservoirs
3. Its portal of exits
4. Its mode of transmission
5. Its portals of entry
6. The human host
I. The Agents
II. Reservoirs
21
HIV/AIDS/Sexually Transmitted Infections (STIs), measles,
typhoid etc.
Portal of exit is the way the infectious agent leaves the reservoir.
Possible portals of exit include all body secretions and discharges:
Mucus, saliva, tears, breast milk, vaginal and cervical discharges,
excretions (feces and urine), blood, and tissues. For example feces is
the portal of exit for the eggs of hook worm.
22
Modes of transmission include the various mechanisms by which
agents are conveyed to other susceptible hosts. Transmission may
be direct or indirect.
1. Direct Transmission
2. Indirect transmission
23
toys, or surgical instruments; as well as through
contaminated food, water, IV fluids etc.
Examples:
Exercise:
i. Infectious agent
ii. Reservoir
v. Portal of entry
UNIT FIVE
Descriptive Epidemiology
Learning Objectives
26
At the end of this unit the student is expected to:
Define descriptive Epidemiology
Identify the most important Time, Place and personal
variables in Descriptive Epidemiology
Describe cross sectional study (survey)
5.1 Definition
5.2.1 Person
27
People can be categorized with respect to many variables. In
Epidemiologic study it is common to specify three characteristics of a
person – age, sex and ethnic group or race.
5.2.2 Place
The frequency of disease is different in different places. These
differences can occur because of the natural boundaries (e.g.
mountain range, rivers, deserts). An area defined by natural
boundaries may have a high or low frequency of certain diseases
because it is characterized by some particular environmental or
climatic conditions, such as temperature, humidity, rainfall, altitude,
mineral content of soil, or water supply. For example - Malaria is
common in low lands but relapsing fever is common in highlands.
5.2.3 Time
28
Study of disease occurrence by time is a basic aspect of
epidemiologic analysis. Occurrence is usually expressed on a
monthly or annual basis.
Some diseases occur periodically or cycles. Cycles may be annual
or have some other periodicity. The most common types of periodicity
are in relation to seasonal changes, or in relation to changes in the
number of susceptible persons in a population. Malaria is one of the
example of diseases with seasonal periodicity, where high peaks
occur in relation to the rainy season. Epidemic of malaria are common
in October and November, when stagnant water bodies are
convenient for the breeding of mosquitoes.
29
If somebody wants to conduct a survey, he/she can follow the
following procedures:
Write the objectives of the survey
Identify the methods of data collection. Data can be
collected by using questionnaire, interview, self-
administered questionnaire, observation, applying
laboratory tests etc.
Recruit and train data collectors
Calculate (determine) the number of people needed
for the survey
Collect the data
Analyse the data
Disseminate the findings
Exercises
30
1. Suppose you want to determine the prevalence of hypertension
among adult population in your kebele. How do you conduct cross
sectional studies for this purpose?
Learning Objectives
Ratio
32
A ratio quantifies the magnitude of one occurrence or condition to
another. It expresses the relationship between two numbers in the
form of x: y or x/y X k
Example:
Proportion
Rate
33
the measure that most clearly expresses probability or risk of disease
in a defined population over a specified period of time, hence, it is
considered to be a basic measure of disease occurrence. Accurate
count of all events of interest that occur in a defined population during
a specified period is essential for the calculation of rate.
Incidence rate
34
Total Population during the given period of time
5000
35
That means out of every 1000 people living in “Kebele X”, 10 of them
acquired relapsing fever in Ginbot 1995.
Attack rate = No. of new cases of a specific disease reported during an epidemic X k
That means out of 100 people who ate the food served by Ato
Alemitegnaw, 90 of them developed diarrhea on Tir 8, 1995.
36
significantly higher in one area, then the cause of that disease can be
systematically searched.
Prevalence rate
Total population
37
Calculate the point prevalence rate of trachoma for that school.
Point prevalence rate= 100 X 100 = 50 trachoma patients per 100 students
200 on Hidar10,1996
2
38
Below are given some formulas for the commonly used mortality rates
and ratios.
CDR = Total no. of deaths reported during a given time interval X 1000
39
Example: The average total population of “Kebele Y” in 1996 was
6000 (3500 female & 2500 male). In the same year 300 people died
(100 female & 200 male). Calculate the mortality rate (Crude death
rate) for females.
3500
40
Case fatality rate represents the probability of death among
diagnosed cases or the killing power of a disease.
1000
That means 10% of tuberculosis patients will die once they develop
the disease
Example: In 1996 there were a total of 5000 live births in “Zone B”.
Two hundred of them died before 28 days after birth. Calculate the
Neonatal Mortality Rate (NMR).
That means out of 1000 live births in 1996, 40 of them died before 28
days after birth.
41
Death during the neonatal period is largely due to prematurity,
malformations, accidents or injuries at birth, and lack of cleanliness
and sterility during or after delivery. In addition, it reflects the
inadequacy of antenatal care.
Infant mortality rate reflects the health of the community in which the
child is being brought up. Thus, it is high among people who have
little health care, chiefly because infections, such as pneumonia,
diarrhea and malaria, are common among their infants. Malnutrition is
also one of the killer of infants in developing countries. The infant
mortality rate in Ethiopia is one of the highest in the world (96.8 per
1000 live births). That means out of 1000 live births about 97 die
before they celebrate their first birth day.
42
NB: The numerator says 0-4 years. 0-4 years in this formula means
children from birth to less than five years of age i.e the upper
age limit is not 4.
10,000
That means in “Zone C”, out of 1000 under five children, 20 died in
1996.
Exercise:
43
The following information is about kebele X which was collected for
the year 1999:
45
UNIT SEVEN
Learning Objectives:
I. Sources of Data
46
1. Census:
In Ethiopia census was conducted twice, i.e., in 1984 and 1994 (G.C).
Data was collected on:
Mortality, fertility
Language, ethnicity
Housing
47
Limitation
2. Vital statistics:
48
3. Health Service Records
Advantages:
Easily obtainable
Limitations:
49
Lack of denominator – catchment area is not
known in the majority of cases.
The major problems related to this source (health service records) are
low compliance and delays in reporting.
4. Health Surveys
50
1. Surveys of specific diseases: These are studies conducted on
each specific disease. Examples are:
Diarrheal Diseases
HIV/AIDS
Trachoma
Tuberculosis / Leprosy
Limitations:
51
II. Methods of data collection
1. Observation
Exercise
52
UNIT EIGHT
Learning Objectives
Define epidemic
53
Definition of terms related to the level of occurrence of disease
The definition of epidemic indicates that the term can have a broad
meaning. It may include any kind of disease or injury including non –
infectious diseases. There is no general rule about the number of
cases that must exist for a disease to be considered an epidemic. If
the number of cases exceeds the expected level on the basis of the
past experience of the particular population, then it is an epidemic. It
54
is important to note that this level varies for different diseases and
different circumstances. An epidemic may cover a small area within a
city, or an entire nation or may have a worldwide distribution. It may
encompass any time period ranging from few hours (chemical
intoxication, bacterial food poisoning), a few weeks (influenza,
hepatitis) to several years (AIDS). A disease that remains epidemic
over many years eventually may be considered endemic.
55
have a wide peak because of the range of exposures and the range
of incubation periods.
56
- What is/are the predominant modes of transmission?
Uncovering outbreaks
clarify your and your team role in the field. Arrange where and
when to meet them.
58
Always consider whether initial reports are correct. Carry out clinical
and laboratory investigations on the reported cases. For example the
already collected blood film slides can be seen by laboratory experts
to check whether the initial report was correct. It is important to
investigate the index case (the first case that comes to the attention
of health authorities) and other early cases. The importance of the
index case and other early cases for diseases that are known to
occur in epidemic form, such as relapsing fever, is as an indication to
health authorities of the possible start of an outbreak. The sooner the
index case and other early cases are investigated, the greater the
opportunity to arrest the outbreak at earliest stage possible. The
health extension worker requests support from the Woreda Health
Office or the nearest Health Center for confirming the diagnosis.
59
Cases can better be identified by active case detection using all
available means including house to house visits. They can also be
identified by stimulated passive case detection, for example by
alerting the public about the epidemic and requesting them to report
to the nearest health institution when they have signs and symptoms
of that disease. The health extension worker can identify and count
cases based on the sign and symptoms of the disease.
If there is effective drug for the treatment of that disease, cases can
be treated while identifying them. Additionally other control measures
can be taken side by side to arrest the epidemic before many people
are affected.
60
Spot map is a map of locality where the outbreak has occurred, on
which the location of cases is plotted. The spot map is often helpful in
detecting the source of an outbreak. Mapping disease can be done at
kebele, woreda, regional, and national level. One limitation of spot
map is that it does not take into account underlying geographic
differences in population density. Thus the spot map needs to be
supplemented by calculation of place specific attack rates.
Person specific attack rates: The tool that is important for the
analysis of disease outbreaks by personal characteristics is person
specific attack rates like attack rates by age, sex, occupation, income,
religion etc.
61
Confirmation of the diagnosis can be done by using additional tests
which are more accurate. In addition to knowing the etiologic agent,
more emphasis should be given to identify the risk factors. Investigate
the environmental conditions such as food sanitation, suspected
breeding sites, animal reservoirs, according to the type of disease
outbreak being investigated.
62
Understanding the nature of the reservoir is necessary in the
selection of an appropriate control methods and their likelihood of
success. The following are examples of control measures against
diseases with various reservoirs:
Humans as reservoir
63
for the duration of the usual maximal incubation period of the
disease. Cholera, Plague, and yellow fever are the three
internationally quarantinable diseases by international
agreement.
i. Purification of water
64
In the case of diseases that involve an intermediate host for
transmission, for example schistosomiasis, clearing irrigation farms
from snails is an appropriate measure.
65
Recommendations for the prevention of
similar episodes in the future.
Exercise
c. Propagated epidemic
d. Mixed epidemic
66
b. Common source epidemic with continued
exposure
c. Propagated epidemic
d. Mixed epidemic
67
UNIT NINE
Epidemiological Surveillance
Learning Objectives
Define surveillance
9.1 Definition
68
To provide scientific baseline data and information for
priority setting, planning, implementing and evaluating
disease control program for both communicable and
non-communicable health problems.
Passive surveillance
it is relatively cheap
69
covers a wider area
Most of the time, you may not get the kind of information
you desire
Active surveillance
it is expensive
71
In unusual situations such as:
Timely notification
72
Availability of a strong laboratory service for accurate
diagnoses of cases
73
Are top causes of high morbidity and mortality in Ethiopia (for
example, malaria, pneumonia, diarrheal diseases,
tuberculosis, and HIV/AIDS)
A. Epidemic-Prone Diseases
74
Cholera
Diarrhea with blood (Shigella)
Yellow fever
Measles
Meningitis
Plague
Viral hemorrhagic fevers***
Typhoid fever
Relapsing fever
Epidemic typhus
Malaria
75
_____
*** Viral Hemorrhagic Fever (VHF) is not in the National priority
diseases list, but every health worker should be aware of its epidemic
proneness and high fatality
Exercise
76
Reference
77
10. Berhane Y. Principle of Epidemiology. Lecture Note.
Department of Community Health, faculty of Medicine, Addis
Ababa University, 1997.
78
18. Disease Prevention and Control Department, MOH. National
Technical Guideline for Integrated Disease Surveillance and
Response (IDSR); 2003.
79