Epidemiology: An Overview

Ahmed Mandil, MBChB, DrPH

Prof of Epidemiology
High Institute of Public Health,
University of Alexandria, Egypt
 Headlines
 Epidemiology Presentations
 What is epidemiology ? What
sciences does it draw from ? How
is it demarcated ?
 What are its uses ?
 What are its basic concepts ?
 What are its modern applications ?
 What are good references ?
Epidemiology
Presentations
 Overview (AM)
 Causal inference (AM)
 Study designs (AM)
 Sources of epidemiological data (KR)
 Measurements in epidemiology (KR)
 Sources of measurement error (KR)
What is Epidemiology?
 Demarcation of
Epidemiology
 Demarcation of scientific disciplines evolves
historically as their intellectual, institutional
and professional environments evolved
 Epidemiology benefits from a rich plurality of
scientific cultures and practices; consequently
it enjoys diverse demarcation discourses, with
diverse applications in public health policy,
clinical practice, basic research….
 IEA book: Development of modern
epidemiology
Classically speaking
 Epi = upon
 Demos = people
 Ology = science
 Epidemiology = the science which
deals with what falls upon people…..
 Bridge between biomedical, social
and behavioral sciences
 Simple Old Definitions
Oxford English Dictionary
THE BRANCH OF MEDICAL SCIENCE WHICH TREATS
EPIDEMICS
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
 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)
 Who is an epidemiologist ?
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)
 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)
 Purposes of Epidemiology

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
 Classical versus Modern
Applications
 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
 Broad Types of Epidemiology
DESCRIPTIVE EPI ANALYTIC EPI

Examining the distribution of a Testing a specific hypothesis

disease in a population, and about the relationship of a
observing the basic features of its disease to a specific cause, by
distribution in terms of time, conducting an epidemiologic
place, and person. We try to study that relates the
formulate hypothesis, look into exposure of interest to the
associations ? outcome of interest (? Cause-
effect relationship)
Typical study design: Typical study designs: cohort,
community health survey case-control, experimental
(synonyms: cross-sectional study, design
descriptive study)
 Descriptive Epidemiology Is A Necessary

Antecedent of Analytic Epidemiology

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
 Basic Triad of Descriptive
Epidemiology

THE THREE ESSENTIAL CHARACTERISTICS OF

DISEASE WE LOOK FOR IN DESCRIPTIVE
EPIDEMIOLOGY ARE:

 PERSON
 PLACE
 TIME
 Personal Characteristics (whom)

 Age
 Gender
 Socio-economic status (education,
occupation, income)
 Marital status
 Ethnicity/race/genetic profile
 Behavior / habits
 Place (where ?)
 Geographically restricted or
widespread (outbreak, epidemic,
pandemic)? Off-shore (tsunami…)
 Climate effects (temperature,

humidity, combined effects..)

 Urban / sub-urban-squatter / rural

 Relation to environmental exposure

(water, food supply, etc)

 Multiple clusters or one?
 Time (when ?)
 Changing or stable?

 Clustered (epidemic) or evenly

distributed (endemic)?

 Time-trends: Point source,

propagated, seasonal, secular,
combinations
What designs do
epidemiologists use ?
 Qualitative designs
 Quantitative designs
 Observational
 Experimental
 Building evidence
 What measures do
epidemiologists use ?
 Frequency measures
 Effect measures
 Impact fractions
Among Unique Skills of
Epidemiologists:

MEASURING DISEASE
FREQUENCY IN
POPULATIONS
Measuring Disease Frequency
Has Several Components
 Classifying and  Defining the period
categorizing disease of time of risk of
 Deciding what disease
constitutes a case of  Obtaining
disease in a study permission to study
 Finding a source for people
ascertaining the cases  Making
 Defining the population measurements of
at risk of disease disease frequency
 Relating cases to
population and
time at risk
 Basic triad of analytical
epidemiology

THE THREE PHENOMENA ASSESSED IN

ANALYTIC EPIDEMIOLOGY ARE:
HOST

AGENT ENVIRONMENT
Agents
 Biological (micro-organisms)
 Physical (temperature, radiation,
trauma, others)
 Chemical (acids, alkalis, poisons,
tobacco, others)
 Environmental (nutrients in diet,
allergens, others)
 Psychological experiences
 Host Factors
 Genetic endowment
 Immunologic status
 Personal characteristics
 Personal behavior
 Definitive versus intermediate
(in vector-borne diseases)
 Environment
 Living conditions (housing, crowding,
water supply, refuse, sewage, etc)
 Atmosphere / climate
 Modes of communication:
phenomena in the environment that
bring host and agent together, such
as: vector, vehicle, reservoir, etc)
Does epidemiology assist in
problem-solving in health-
related policy-making ?
 Epidemiology 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
 Epidemiology as a problem solving
discipline: Integrating principles

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.
 (I) Epidemiology is an
information science

Epidemiology is an information science:

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.
 INFORMATION  DECISION  ACTION
GENERATION PROCESS .

EPIDEMIOLOGIC  PROCESS OF  INTERVENTION

METHODS INFERENCES .
 Epidemiology assists:

 Systems: information,
surveillance
 Decisions: political,

management
Information Systems:
Value and Quality
1. Timeliness
2. Quantity
3. Frequency
4. Use for Decision Making
5. Presence of Feedback Loop
Surveillance Systems:
Evaluation
1. Sensitivity
2. Predictive value positive
3. Simplicity
4. Flexibility
5. Acceptability
6. Representativeness
7. Timeliness
8. Reliability or precision
Political Decisions
l Budget and Resource
Allocation
l Jurisdiction of agencies
l Personnel selection
l Legislation
Management Decisions
l Efficacy – Patient Care
l Effectiveness – Public Health
l Compliance
l Quality Assurance
l Training
l Planning
l Programming
In a health-system,
epidemiology supports:
 Structure
 Process
 Outcome
 How does this work ?

Structure: Does a structure exist to

implement the health care intervention
(program) and what are its characteristics?
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?
 What outcomes ?
Mortality: all cause / cause-specific
Morbidity
Disease-specific indicators /
General indicators: clinic use,
hospitalization, medication use
Quality of life
General / Disease-specific
Costs
 (II) Epidemiology operates
within complex systems.

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”
 CLASSIC EPIDEMIOLOGIC
RESEARCH INTO ETIOLOGY

Environmental Outcome
factor(s)
 CLASSIC EPIDEMIOLOGIC
RESEARCH INTO ETIOLOGY

Other factors including

health care

Environmental
Outcome
Factor(s)
 CLASSIC HEALTH SERVICES
RESEARCH INTO EFFECTIVENESS

Health
Outcome
Care
 CLASSIC HEALTH SERVICES
RESEARCH INTO EFFECTIVENESS

Environmental and
other factors

Health
Outcome
Care
(III) Epidemiology is a
professional practice area
John Racy defined a profession as “a
socially sanctioned activity whose primary
object is the well-being of others above
the professional’s 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.
From the Present to the
Future 1
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.
From the Present to the
Future 2
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.
 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
 Pierre Teilhard de Chardin
mentioned that:

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.
 References
 Porta M. A dictionary of epidemiology. 5th edition.
Oxford: Oxford University Press, 2008
 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
 Websites
 World Health Organization: [Link]
 Centers for Disease Control and Prevention:
[Link]
 Epidemiology Supercourse:
[Link]/~super1/
 International Epidemiological Association:
[Link]
 Oxford University Press: [Link]
 Email address: [Link]@[Link]
Thank you for your kind attention