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Lesson 1: Introduction to Epidemiology

Section 1: Definition of Epidemiology

Students of journalism are taught that a good news story, whether it be about a bank robbery, dramatic rescue, or presidential candidate's speech, must include the 5 W's: what, who, where, when and why (sometimes cited as why/how). The 5 W's are the essential components of a news story because if any of the five are missing, the story is incomplete.

The same is true in characterizing epidemiologic events, whether it be an outbreak of norovirus among cruise ship passengers or the use of mammograms to detect early breast cancer. The difference is that epidemiologists tend to use synonyms for the 5 W's: diagnosis or health event (what), person (who), place (where), time (when), and causes, risk factors, and modes of transmission (why/how).

The word epidemiology comes from the Greek words epi, meaning on or upon, demos, meaning people, and logos, meaning the study of. In other words, the word epidemiology has its roots in the study of what befalls a population. Many definitions have been proposed, but the following definition captures the underlying principles and public health spirit of epidemiology:

Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems (1).

Key terms in this definition reflect some of the important principles of epidemiology.

Study

Epidemiology is a scientific discipline with sound methods of scientific inquiry at its foundation. Epidemiology is data-driven and relies on a systematic and unbiased approach to the collection, analysis, and interpretation of data. Basic epidemiologic methods tend to rely on careful observation and use of valid comparison groups to assess whether what was observed, such as the number of cases of disease in a particular area during a particular time period or the frequency of an exposure among persons with disease, differs from what might be expected. However, epidemiology also draws on methods from other scientific fields, including biostatistics and informatics, with biologic, economic, social, and behavioral sciences.

In fact, epidemiology is often described as the basic science of public health, and for good reason. First, epidemiology is a quantitative discipline that relies on a working knowledge of probability, statistics, and sound research methods. Second, epidemiology is a method of causal reasoning based on developing and testing hypotheses grounded in such scientific fields as biology, behavioral sciences, physics, and ergonomics to explain health-related behaviors, states, and events. However, epidemiology is not just a research activity but an integral component of public health, providing the foundation for directing practical and appropriate public health action based on this science and causal reasoning.(2)

Distribution

Epidemiology is concerned with the frequency and pattern of health events in a population:

Frequency refers not only to the number of health events such as the number of cases of meningitis or diabetes in a population, but also to the relationship of that number to the size of the population. The resulting rate allows epidemiologists to compare disease occurrence across different populations.

Pattern refers to the occurrence of health-related events by time, place, and person. Time patterns may be annual, seasonal, weekly, daily, hourly, weekday versus weekend, or any other breakdown of time that may influence disease or injury occurrence. Place patterns include geographic variation, urban/rural differences, and location of work sites or schools. Personal characteristics include demographic factors which may be related to risk of illness, injury, or disability such as age, sex, marital status, and socioeconomic status, as well as behaviors and environmental exposures.

Characterizing health events by time, place, and person are activities of descriptive epidemiology, discussed in more detail later in this lesson.

Determinants

Determinant: any factor, whether event, characteristic, or other definable entity, that brings about a change in a health condition or other defined characteristic.

Epidemiology is also used to search for determinants, which are the causes and other factors that influence the occurrence of disease and other health-related events. Epidemiologists assume that illness does not occur randomly in a population, but happens only when the right accumulation of risk factors or determinants exists in an individual. To search for these determinants, epidemiologists use analytic epidemiology or epidemiologic studies to provide the “Why” and “How” of such events. They assess whether groups with different rates of disease differ in their demographic characteristics, genetic or immunologic make-up, behaviors, environmental exposures, or other so-called potential risk factors. Ideally, the findings provide sufficient evidence to direct prompt and effective public health control and prevention measures.

Health-related states or events

Epidemiology was originally focused exclusively on epidemics of communicable diseases (3) but was subsequently expanded to address endemic communicable diseases and non-communicable infectious diseases. By the middle of the 20th Century, additional epidemiologic methods had been developed and applied to chronic diseases, injuries, birth defects, maternal-child health, occupational health, and environmental health. Then epidemiologists began to look at behaviors related to health and well-being, such as amount of exercise and seat belt use. Now, with the recent explosion in molecular methods, epidemiologists can make important strides in examining genetic markers of disease risk. Indeed, the term health-related states or events may be seen as anything that affects the well-being of a population. Nonetheless, many epidemiologists still use the term “disease” as shorthand for the wide range of health-related states and events that are studied.

Specified populations

Although epidemiologists and direct health-care providers (clinicians) are both concerned with occurrence and control of disease, they differ greatly in how they view “the patient.” The clinician is concerned about the health of an individual; the epidemiologist is concerned about the collective health of the people in a community or population. In other words, the clinician's “patient” is the individual; the epidemiologist's “patient” is the community. Therefore, the clinician and the epidemiologist have different responsibilities when faced with a person with illness. For example, when a patient with diarrheal disease presents, both are interested in establishing the correct diagnosis. However, while the clinician usually focuses on treating and caring for the individual, the epidemiologist focuses on identifying the exposure or source that caused the illness; the number of other persons who may have been similarly exposed; the potential for further spread in the community; and interventions to prevent additional cases or recurrences.

Application

Epidemiology is not just “the study of” health in a population; it also involves applying the knowledge gained by the studies to community-based practice. Like the practice of medicine, the practice of epidemiology is both a science and an art. To make the proper diagnosis and prescribe appropriate treatment for a patient, the clinician combines medical (scientific) knowledge with experience, clinical judgment, and understanding of the patient. Similarly, the epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well as experience, epidemiologic judgment, and understanding of local conditions in “diagnosing” the health of a community and proposing appropriate, practical, and acceptable public health interventions to control and prevent disease in the community.

Summary

Epidemiology is the study (scientific, systematic, data-driven) of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (patient is community, individuals viewed collectively), and the application of (since epidemiology is a discipline within public health) this study to the control of health problems.

Pencil graphic Exercise 1.1

Below are three key terms taken from the definition of epidemiology, followed by a list of activities that an epidemiologist might perform. Match the term to the activity that best describes it. You should match only one term per activity.

  1. Distribution
  2. Determinants
  3. Application

  1. ____ 1. Compare food histories between persons with Staphylococcus food poisoning and those without
  2. ____ 2. Compare frequency of brain cancer among anatomists with frequency in general population
  3. ____ 3. Mark on a map the residences of all children born with birth defects within 2 miles of a hazardous waste site
  4. ____ 4. Graph the number of cases of congenital syphilis by year for the country
  5. ____ 5. Recommend that close contacts of a child recently reported with meningococcal meningitis receive Rifampin
  6. ____ 6. Tabulate the frequency of clinical signs, symptoms, and laboratory findings among children with chickenpox in Cincinnati, Ohio

Check your answer.

References (This Section)

  1. Last JM, editor. Dictionary of epidemiology. 4th ed. New York: Oxford University Press; 2001. p. 61.
  2. Cates W. Epidemiology: Applying principles to clinical practice. Contemp Ob/Gyn 1982;20:147–61.
  3. Greenwood M.Epidemics and crowd-diseases: an introduction to the study of epidemiology, Oxford University Press; 1935.

Lesson 1
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