Community Health Nursing- Agustine Jay P.

Tacdol, RN, MSPH

1st SEM- FINALS
CHN
Individual and Family as Clients Where: F is any number of the base 10 (usually 100) that is
used as a multiplier to avoid having decimals
Vital Statistics
 Interpretation: percentage of the population
 Collection of statistics on vital events in a lifetime afflicted with the disease
of a person as well as relevant characteristics of
the events themselves and of the persons Incidence Measures
concerned
 Best measures to use for evaluating the
Health indicators effectiveness of health interventions
 Derived by following up a group of disease-free
 Quantifiable characteristics of a population used people who are at risk of developing the disease
to describe its health status of interest within a specified period of time
Uses (cohort study)
 Two types:
 Hypothesis testing and formulation 1. Cumulative incidence / incidence proportion
 Identifying public health problems and needs 2. Incidence density / incidence rate
 Planning, implementation, and evaluation of
intervention and strategies Incidence Proportion or Cumulative Incidence (CI)
 Prioritizing resource allocation  Measures the average risk (probability) of
 Monitoring and evaluating health programs developing the disease within a specified period
 Determining factors that may contribute to of time
causation and control of disease  Requires no losses to follow-up
Health Indicators  Duration of follow-up is the same so that the
denominator is the initial size of the cohort being
 Quantitative measures, usually expressed as followed-up.
rates, ratios, or proportions that describe &
summarize various aspects of the health status of Number of new cases that developed during the period
the population. CI  F
Number of persons followed-up
 Used to describe the health status of the
population (i.e., for situational analysis or Incidence Density (ID) Rate
community diagnosis).
 There are various types (e.g., morbidity indicators,  Applicable when some cohort members are lost
mortality indicators, fertility indicators, etc.) to follow-up
depending on the aspect of health that is of  Measures the average instantaneous rate of
interest. disease occurrence
 Denominator: total person-time at risk for the
Morbidity Indicators entire cohort
 Time at risk for each cohort member: duration of
 Can partly answer two epidemiologic questions: time during which the person under observation
“What are the health problems in our area?” remains disease-free
“How many cases occur in the area?”  Examples:
 Two types: - A person who develops the disease after 2
 Prevalence years contributes 2 person-years to the
 Incidence denominator
Prevalence Proportion (P) - One who is lost to follow-up after 6 months
contributes half a year
 Estimated from cross-sectional studies (surveys)
 Provides an indication of the magnitude of a
health problem
Number of new cases that develop during the period
 Used for projecting the scope of health services ID  F
needed by the community Sum of person-time at risk
Number of existing cases of a disease at a particular point in time
P F
Number of people examined at that point in time

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

 Very often, it is not possible to determine disease- Specific Mortality Rates

free period of every cohort member
 hence, the denominator is approximated by Number of deaths in a specified group in a calendar year
Specific mortality rate = F
multiplying the average size of the study Midyear population of the same specified group
population by the length of the study period
assuming the population size is stable & the Age-Specific Mortality Rates per 1,000 population,
incidence rate is low Philippines, 2000

Number of cases during the period

ID  F
Average population  duration of follow-up 80

Rate per 1,000 population

70
Specific Morbidity Rates
60
 Show disease rates in specific population groups 50
 by age, sex, occupation, education,
exposure to risk factors, place of 40
residence, or combinations of these 30
factors 20
 Can also be computed specifically by seasons of
the year
10
 Answer epidemiologic questions: 0

1-4
5-9
<1

70 & over
10-14

60-64
“Who is affected?

15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59

65-69
“Where do they occur?”
“When do they occur or increase?”
 Descriptive epidemiology: orienting a disease as
to time, place, and person characteristics Age-group
Ex. TB morbidity rate for the age group 20 – 24
years
Cause-of-Death Rate
Number of TB cases among those aged 20--24 years
100, 000  Gives the rate of dying due to specific causes
Midyear population aged 20--24 years
 Identifies the leading causes of mortality
Mortality Indicators  Affected by:
- completeness of registration of deaths
 Provide important information on the health - composition of the population
status of the community because death is the - accuracy of ascertaining the cause of death
most serious outcome of a morbid episode
 Pattern of causes of death indicate the most life- Number of deaths from a certain cause in a calendar year
Cause-of-death rate = F
threatening diseases Midyear population
 Crude death rate (CDR) sometimes called force
of mortality is defined as the rate with which Infant Mortality Ratio (IMR)
mortality occurs in a given population:
 Factors that affect CDR: age and sex  used as an approximation of the risk of dying
composition of the population, adverse within the first year of life
environmental, occupational & the peace and  a good index of the level of health in a
order conditions community because infants are very sensitive to
adverse environmental conditions
Number of deaths in a calendar year  Thus, a high IMR implies low levels of health
CDR  1,000 standards, poor environmental sanitation, poor
midyear population maternal & child health care, malnutrition, or
deficient health service delivery.

Deaths under 1 year of age in a calendar year

IMR= 100
Number of live births in the same year

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS
Number of deaths due to pregnancy, delivery, puerperium in a calendar year
Neonatal Mortality Rate MMR= 100
Nnumber of live births in the same year
3.2 By 2030, end preventable deaths of newborns and Case Fatality Rate (CFR)
children under 5 years of age, with all countries aiming to
reduce neonatal mortality to at least as low as 12 per  Proportion of cases that end up fatally
1000 live births and under-5 mortality to at least as low as  Gives the risk of dying among persons afflicted
25 per 1000 live births. with a particular disease
 Higher for hospital cases compared to cases
from the community since the hospitalized cases
are usually the more severe cases of the disease

Number of deaths from a specified cause

CFR = 100
Number of cases of the same disease
Population Indicators

Neonatal Mortality Rate (NMR) and Post neonatal  Includes population growth indicators (e.g.,
Mortality Rate (PNMR) crude birth rate, general fertility rate, total fertility
rate, and annual growth rate) and other
 NMR and PNMR add up to the IMR population dynamics indicators (e.g., migration)
 Neonatal deaths are mainly caused by prenatal that can affect the age-sex structure of the
or genetic factors population and vice versa
 Post-neonatal deaths are influenced by  Crude birth rate (CBR) measures how fast people
environmental and nutritional factors as well as are added to the population through births
infections  Affected by the fertility, marriage pattern and
practices of the place, sex and age composition
of a population, and birth registration practice

Number of registered live births in a year

CBR= 1,000
Midyear population

General Fertility Rate (GFR)

Maternal Mortality Rate  more akin to a specific rate than the CBR since
3.1 By 2030, reduce the global maternal mortality ratio to births are related to the population sub-group
less than 70 per 100 000 live births. deemed to be capable of giving birth, i.e.,
women in the reproductive age groups
 reproductive age group: 15–49 years in some
countries; 15–44 years in others including the
Philippines

Number of registered live births in a year

GFR= 1,000
Midyear population of women 15--44 years of age

Population Pyramid

Maternal Mortality Ratio (MMR)  Graphical representation of the age–sex

composition of the population
 Maternal death: “Death of a female from any  Should be examined during the assessment of
cause related to or aggravated by pregnancy the health status of the community
or its management (excluding accidental or  Shape of the pyramid provides insights into the
incidental causes) during pregnancy and fertility and mortality patterns of the community
childbirth or within 42 days of termination of and the most probable health problems that
pregnancy, irrespective of the duration & the site would likely need health services
of the pregnancy”.  Triangular shape:
 A measure of obstetric risk; affected by maternal  characteristic of less-developed
health practices, diagnostic ascertainment, and countries where a large proportion of the
completeness of registration of births.

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

population belongs to the younger age

groups
 depicts high fertility and a high mortality
among the elderly
 indicates higher resource allocation for
health problems of younger age groups
 Almost rectangular shape:
 Characteristic of developed countries
where a substantial proportion of the
population are elderly
 May be due to lower mortality from
infectious diseases and improved access
to health care
 Priority of such countries should be the
prevention and control of chronic
degenerative diseases and the provision
of care for older persons

Population pyramid of the Philippines (a) and Japan (b),

2010.

Sources of Data for Calculation of Health Indicators

 Census
 Vital registration system
 Disease notification
 Disease registries
 Surveillance system
 Hospital data
 Health insurance
 School health program
 Downloadable data sets
 Surveys (morbidity, demographic and health)

Disease Notification

 An integral part of disease surveillance

 Republic Act 3573: Law on reporting of
communicable diseases mandates health
workers to report notifiable diseases (e.g.,
dengue, rabies, leptospirosis, and HIV/AIDS to
local and national health authorities
 Many people who need services do not have
access to health facilities.

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

 Minimal vigilance in reporting cases of the  Active surveillance:

notifiable diseases among health care providers,
particularly private practitioners o Public health staff members actively and
 Leads to gross underreporting  distorted picture regularly contact heath care providers or
of health problems in the community the population to obtain information
about the disease of interest.
Disease Registry
o Much more expensive but yields more
 A compilation of information about a particular accurate and timely data.
disease.
 Aim: to include all cases of the disease in the o Allows both an early detection of an
registry without duplication impending epidemic and a more valid
 Attainment of this aim is dependent on: evaluation of the impact of public health
- cooperation of agencies and health facilities interventions.
that feed the registry o A very active surveillance system should
- having a unique patient identifier that will be used to detect every case to monitor
allow record linkage eradication and elimination programs.
 In the Philippines:
 A cancer registry covers Metro Manila  The Philippine Integrated Disease Surveillance
and Rizal Province and Response (PIDSR) integrates health statistics
 An HIV/AIDS registry intended to include generated through the major disease
all newly detected cases of HIV infection surveillance systems in the country , viz.,
and AIDS in the Philippines
o Notifiable Disease Reporting System
Disease Surveillance System (NDRS)

 Public health surveillance: The ongoing, o Field Health Service Information System
systematic collection, analysis and interpretation (FHSIS)
of health-related data needed for the planning,
implementation, and evaluation of public health o National Epidemiology Sentinel
practice. Surveillance System (NESSS)
 Surveillance systems were initially developed for o Expanded Program on Immunization
monitoring high burden diseases, detecting Surveillance System (EPI Surveillance)
disease outbreaks, and monitoring progress
towards attainment of targets for the control, o HIV-AIDS Registry
elimination, or eradication of a specific disease.
 New public health paradigms for surveillance  In the Philippines, one may request for data from
advocate inclusion of the detection of toxins, the National Statistics Office for a fee; it takes a
hazardous chemicals, genetically modified long time to avail of the data
products, and risky behaviors.  In developed countries, several data resources
 The Philippine Integrated Behavioral and can be downloaded from the Internet
Serologic Surveillance (IHBSS) monitors not only
seropositivity among most at-risk groups for HIV  USAID-funded Demographic and Health Survey
infection but also their behaviors that put them at that includes many low- and middle-income
risk for the infection. countries can be downloaded from the Internet

 Passive surveillance Considerations in the Analysis and Interpretation of Health

Indicators
o Public health staff receives reports from
hospitals, clinics, public health units, or 1. Is the denominator of the rate the most
other sources. appropriate one? Preferably, it should be the
population in which gave rise to the events in the
o The count of cases is expected to be numerator.
grossly underestimated and utility of
data may be greatly diminished since it 2. Is the numerator an accurate count of the
may become available only when it is no number of events? Inaccuracies can arise due to
longer needed. under-registration, underreporting, or duplication.

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

3. There should be correspondence in time and  John Graunt

geographical location of the events in the • Recorded descriptive characteristics of birth
numerator and the population in the and death data
denominator. • First to employ quantitative methods
in describing population vital statistics
4. Time specifications are usually on an annual • Allowed discovery of trends in births & trends:
basis. However, special indicators may have disparities between males & females, high infant
other period specifications and these should be mortality, urban/rural differences and seasonal
stated. variations
5. The factor used in the computation of the  John Snow (mid-1800’s)
different rates may be any number of the base • “Father of epidemiology”
10. • Investigated a cholera epidemic
which illustrates the classical sequence
Pioneering Work Grounded on Epidemiology from descriptive epidemiology to
hypothesis generation to application
 Hippocrates: Explicated that disease could be  John Snow’s study (1854)
associated with climate and the physical - Epidemic of cholera in Golden Square of
environment London
 William Farr: Used census and vital registration -Investigation:
data to describe the mortality patterns in  -Determine where the persons with
population subgroups such as occupational cholera lived and worked
groups, prisoners, and various age groups  Marked each residence on an area
 Snow’s investigation of the cholera epidemic in (spot map)
London in 1854  Notice that more cases clustered around
 Framingham Heart Study: Identified the risk Pump A
factors for coronary heart disease - With no knowledge of the existence of
 Doll and Hill Study: Provided compelling microorganisms, his study supported that water
evidence of the role of smoking in the incidence could serve as a vehicle for transmitting cholera.
of lung cancer
 Salk Vaccine Field Trial: Showed the protective
effect of the vaccine against paralytic
poliomyelitis

Historical Evolution of Epidemiology

 Ancient Greeks
• Attributed diseases causality to supernatural
forces
• Early causal explanation for
epidemics included wrath of the gods,
breakdown of religious beliefs & morality, and
bad air  William Farr
 “miasma” • Developed a more sophisticated system for
 • Miasmic theory: codifying medical conditions than was
• Bad air is the cause of the disease previously in use
• Provided the foundation for the International
Classification of Diseases
 Hippocrates (400BC) • Explored the possible linkage
 In On Airs, Waters, and Places between mortality and population density
• Disease might be associated with • Attributed mortality to factors such
 physical environment as “impurities of water, pernicious dirts, floating
• Movement away from dusts, zygomatic contagions, and crowdings”
supernatural explanations of disease causation
to a rational account

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

 Robert Koch  During the 1960s and early 1970s health workers
• Die Aetiologie der Tuberkolose (1882) applied epidemiologic methods to eradicate
• Made possible the classification of disease naturally occurring smallpox worldwide. This was
by specific causal organisms an achievement in applied epidemiology of
• Koch’s postulates: unprecedented proportions.
• The microorganism must be observed in every
case  In the 1980s, epidemiology was extended to the
• It must be isolated and grown in pure culture studies of injuries and violence. In the 1990s, the
• The pure culture must, when inoculated into related fields of molecular and genetic
a susceptible animal, produce the disease epidemiology (expansion of epidemiology to
• The organism must be observed in, and look at specific pathways, molecules and genes
recovered from, the experimentally diseased that influence risk of developing disease) took
animal root.
 Framingham study (1948)  Meanwhile, infectious diseases continued to
• One of the pioneering research investigations challenge epidemiologists as new infectious
of risk factors for coronary heart disease agents emerged (Ebola virus, Human
• Over the years, it became a multigenerational Immunodeficiency virus (HIV)/ Acquired
study that analyzes family patterns Immunodeficiency Syndrome (AIDS)), were
of cardiovascular and other diseases identified(Legionella, Severe Acute Respiratory
Syndrome (SARS)), or changed (drug-resistant
Mycobacterium tuberculosis, Avian influenza).
Beginning in the 1990s and accelerating after the
terrorist attacks of September 11, 2001,
epidemiologists have had to consider not only
natural transmission of infectious organisms but
also deliberate spread through biologic warfare
and bioterrorism.

 Today, public health workers throughout the

world accept and use epidemiology regularly to
characterize the health of their communities and
to solve day-to-day problems, large and small.

Uses

 Epidemiology and the information generated by

epidemiologic methods have been used in many
ways.
 Assessing the community’s health
 Doll and Peto study (1951)  Making Individual decisions
• Research on the association between smoking  Completing the clinical picture
& lung cancer on male British physicians  Searching for causes
• British doctors’ cohort established the
association between smoking & lung cancer Definition of Epidemiology

 Etymology: from the Greek words: epi “upon”,

demos “people,” and logos “study”
 Last’s definition: Study of the distribution and
determinants of health-related states or events in
specified populations, and the application of this
study to the prevention and control of health
problems
 Makes use of concepts and methods from
biology, sociology, demography, geography,
environmental science, policy analysis and
statistics

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

 The word epidemiology comes from the Greek

words epi, meaning on or upon, demos, meaning
people, and logos, meaning the studyof. 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
Introduction to Epidemiology  Study
 MacMahon defines Epidemiology as the “Study - Employs a systematic approach that includes,
of the distribution and determinants of disease among others, surveillance, observation,
frequency in human populations” (McMahon, hypothesis generation, and hypothesis testing
1996).  Distribution
- Refers to the analysis of health-related states or
 Distribution of disease refers to the frequency of
disease in terms of person, place, and time events in terms of person, place and time
characteristics. This provides information on the characteristics.
characteristics of people who suffer the disease - Frequency refers not only to the number of
most, when the disease occurs, and where the health events such as the number of cases of
disease is found highest. These three variables meningitis or diabetes in a population, but also to
are the general categories of Epidemiologic the relationship of that number to the size of the
variables. Knowledge on the person, place and population
time distribution provides clue to the cause and - Pattern refers to the occurrence of health-related
events by time, place, and person.
the mode of transmission of a disease. This
 Determinants
function of Epidemiology is known as
Descriptively Epidemiology. - Refers to factors that influence health- biological,
 Determinants of disease refer to the factors that chemical, physical, social, cultural, economic,
genetic and behavioral
influence occurrence of disease (causal factors).
By employing appropriate Epidemiologic - To search these determinants, epidemiologist use
methods, causal associations are established analytic epidemiology or epidemiologic studies
and disease determinants identified. In to provide the “why” and “how” of such events.
 Health-related states and events
Epidemiology, causal association refers to an
association between categories of events (factor - Can refer to specific health outcomes (i.e
and outcome), in which an alteration in the disease, discomfort, disability, destitution,
amount and/or quality of one category (factor) dissatisfaction, death) including positive states of
is followed by a change in the other (outcome). health (e.g. life expectancy); behaviors; and
They can involve the presence of a factor or the provision of health services
 Specified populations
lack of a preventive factor which can increase
the likelihood of disease (risk factor) or the - Examines the occurrence of health-related states
presence of a factor that protects one from among populations vs individuals.
 Application
developing the disease (protective factor).These
factors include personal behavior/lifestyle, an - Epidemiology is not just “the study of’ health in a
environmental exposure, inborn or inherited population; it also involves applying the
characteristic that are associated with a health- knowledge gained by the studies to community-
related condition. based practice.
 Summary
- Epidemiology is the study (scientific, systematic,
data-driven) of the distribution (frequency,
pattern) and determinants (causes, riskfactors) of
health-related states and events (not just

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

diseases) inspecified populations (patient is Basic Concepts of Cause

community, individuals viewed collectively), and
the application of (since epidemiology is a  Informally, a cause is something that bring about
discipline within public health) this study to the an effect.
control of health problems.  In epidemiology, a cause is an event, condition,
characteristics or combination of these factors
Practical Applications of Epidemiology which has a role in producing the health
outcome.
 Assessment of the health status of the community  Identifying what causes disease is a major aspect
or community diagnosis of epidemiology. Strategies for the prevention
 Elucidation of the natural history of disease and control of disease are formulated to address
 Determination of disease causation these disease causes
 Prevention and control of disease
 Monitoring and evaluation of health interventions  Figure 1.
 Provision of evidence for policy formulation Germ theory
of disease
Elucidation of the Natural History of Disease causation
 Natural history of a disease: course of the
diseases over time from pre-pathogenesis stage
to termination. This theory states that being exposed to a specific type of
 A prospective cohort study could plot the natural microorganism always leads to development of the
history of disease better because of the benefit corresponding disease. However, we know now that this
of observing the cohort from the time that the is not true in all cases. Two people may be exposed to
members are disease-free to the time they the same microorganism, but only one of them may
develop the disease through its termination. develop the disease. There are other factors that need to
 The applicable level of prevention that is be considered. Hence, other disease causation models
administered to the patient is dependent on the were developed.
stage of the disease when the patient was
diagnosed. Models of Disease Causation

Determination of Disease Causation Triad model

 Interventions that target the causes of a public  Suggests that the agent and the susceptible
health problem have greater chances of having human host are interacting freely in a common
positive outcomes. (physical, biologic, socioeconomic) environment.
 Answering the epidemiologic questions “What  Disease does not occur for as long as the
factors contribute to disease causation? Why balance is maintained or is tilted in favor of the
does disease occur?” based on valid evidence host (because of good nutritional status and high
will contribute to the success of health levels of immunity).
interventions.  Disease eventually occurs when the balance is
 A review of literature and an understanding of tilted in favor of the agent (through increased
the natural history of the disease will contribute to dosage, virulence, pathogenicity of the agent).
the development of an epidemiologic disease  Environmental elements (i.e. climate) can also tilt
model representing the factors that influence the balance in favor of the agent.
disease causation.
 An epidemiologic approach assumes a causal
path and posits that changing or breaking a link
in that causal path can either prevent the
occurrence of the disease or alter its course, so
that the more serious sequelae can be avoided.
 Examination of the complex interrelationships of
multiple factors in disease causation through
case-control, cohort, quasi-experimental, and
experimental studies is a function of analytic
epidemiology.

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

Basic Concepts of Cause have you ever thought of why some people do
not develop a certain disease, even if almost all
 The epidemiologic triad describes that disease of the people surrounding him are getting sick?
occurs as a result of the interaction between the Not unless an individual is susceptible that he can
agent, host, and environment. be infected and/or develops the disease. A
 Figure 2. host’s susceptibility to infection and disease is
Epidemiologic influenced by a lot of host factors such as his or
triad model of her genetics, age, sex, culture and traditions,
disease causation personal beliefs and behavior, occupation,
immune status, and nutritional status.
 The environment pertains to the external
surrounding and conditions where the individual
 Among the several models of disease causation, lives and develops. For humans, this includes his
the epidemiologic triangle or epidemiologic triad physical surroundings, condition of interaction
was the most popular, particularly for infectious with fellow humans and other living organisms,
diseases. This model explains that diseases are and socio-political and economic situations.
influenced by the interaction among these three
factors: agent, host, and environment. A host  -Informally, a cause is something that bring about
can acquire the disease caused by a certain an effect.
agent if the host is susceptible and is in an  In epidemiology, a cause is an event, condition,
environment that supports the transmission of the characteristics or combination of these factors
agent. Likewise, the disease may occur if the which has a role in producing the health
agent is virulent enough to cause the disease. An outcome.
imbalance among the three factors can tweak  Identifying what causes disease is a major aspect
the path towards the development of the of epidemiology. Strategies for the prevention
disease. and control of disease are formulated to address
 The presence or absence of an agent can these disease causes
initiate or ensue the disease process. In the past,
the concept of epidemiologic triangle has been Figure 1. Germ theory of
confined only to cover infectious diseases with disease causation
microbes as the agents. Over time, the concept
of agent scaled up to cover non-living agents
such as physical and mechanical agents,
chemical agents, and nutrients. In accidents, the  This theory states that being exposed to a
resulting morbidity is due to trauma. During specific type of microorganism always leads to
summer, you let yourself be kissed by the sun as development of the corresponding disease.
you sunbathe on the beach, but you acquired However, we know now that this is not true in all
sunburn instead of a copper-toned skin. This cases. Two people may be exposed to the same
second-degree burn resulted from extreme microorganism, but only one of them may
temperature. Suppose you are hypersensitive to develop the disease. There are other factors that
nuts and you unknowingly drink into a glass of need to be considered. Hence, other disease
water of a friend who happens to be eating nuts. causation models were developed.
Suddenly, you had difficulty breathing and Models of Disease Causation (continued)
turned red because of anaphylactic reaction.
Have you heard of scurvy? In the 15th century, this Wheel model
was actually common among sailors who
experienced bleeding episodes and roughening  Gives emphasis on the role of the genetic
of skin while aboard on their ships. This disease is makeup of the host that is presented as the inner
due to lack of vitamin C. That explains why citrus core of the wheel’s hub.
fruits are among the valuables for explorers who  The outer core of the hub includes host
would be undergoing expeditions in those times. characteristics (sex, age, socioeconomic status,
Can you think of other diseases that are caused behaviors).
by these non-microbial agents?  The rim or the outer edge represents the biologic,
 A host is the organism that gets the disease upon physical, and chemical environment.
having an established contact with an agent. But  In contrast to the triad, the infectious agent for
communicable diseases is considered a part of
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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

the biologic  All of these information should be utilized by

environment along with health workers who are tasked to plan preventive
vectors, animal reservoir programs so that the probability of attaining the
of infection, flora and program objectives is increased.
fauna.  Epidemiologic methods can be utilized for
investigating a disease outbreak, so that
appropriate control measures may be
implemented.

Web model: Disease Prevention and Control

 became more applicable for non- As defined by Charles-Edward A. Winslow in 1920, disease
communicable diseases to capture the complex prevention is one of the key goals of public health,
interrelationships of numerous factors that alongside prolonging life and promoting physical health
influence disease occurrence either by and efficiency through organized community efforts. We
increasing the risk or protecting against the often encounter the term prevention alongside the term
disease. of control. How do these two concepts differ? Prevention
 Under this model, disease can be prevented by refers to efforts aimed at thwarting the occurrence of
breaking the weakest strand of the causal web disease. If the disease is already in place, we initiate an
as identified previously through various types of intervention instead. Control is an encompassing term for
epidemiologic studies the containment of any disease. It includes both
Example: Causal diagram, Leptospirosis in Metro prevention and intervention measures. Dowdie (1998)
Manila (next slide) proposed a definition for control, which is the “reduction
 Web-like model depicting the intricate in the incidence, prevalence, morbidity or mortality of an
interrelationships of the various socio- infectious disease to a locally acceptable level;
demographic characteristics and behaviors of elimination as reduction to zero of the incidence of
the host as well as the numerous environmental disease or infection in a defined geographical area; and
factors eradication as permanent reduction to zero of the
worldwide incidence of infection”.
Causal diagram, Leptospirosis in Metro Manila
The concept of disease prevention in public health is akin
to the concept of disease prevention in preventive
medicine, where it pertains to instituting efforts that will
block the occurrence of a certain disease to an
individual or halt its progression towards disability and
death. In public health, we just have to escalate the
efforts towards the population level. The similarity of the
concepts lies in the goal, task and the structure. The
primary task is to develop interventions that will address a
specific population problem. Structurally, there are three
levels of application of preventive measures in controlling
disease. These are primary, secondary, and tertiary level.

 Primary level of prevention is aimed at

preventing the occurrence of the disease.
 In secondary level of prevention, the focus is not
to prevent the occurrence of the disease but to
delay the onset of the disease and to minimize
Prevention and Control of Diseases the severity of disease or damage due to the
disease.
 Epidemiology can be used to identify the  In tertiary level of prevention- blocking the
important public health problems of the progression of the disease towards disability or
community, determine the magnitude and death and improving quality of life.
distribution of the health problem, elucidate the
natural history of the disease, determine why the
problem disease occurs, and identify the factors
that contribute to disease causation.

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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

Classification of Disease in Public Health  An impending outbreak is usually detected

through the surveillance system
 Diseases have been classified in several ways. In  An outbreak investigation should be conducted
medicine, diseases are classified based on the to:
organ system. Another method is by the 1. Identify and eliminate the source of infection
causative agent, which can either be biological, and prevent the occurrence of more cases
chemical or physical. This has been useful in the 2. Assess the preventive strategies that are
practice of medicine because this facilitates currently implemented
triaging patients. 3. Devise strategies for preventing similar
 In public health, disease classification is also outbreaks in the future
important because it directs the selection of an
appropriate disease prevention and control Basic steps in an outbreak investigation:
measure. One way to classify diseases is based
on communicability. Communicable diseases 1. Operationally define what constitutes a case.
are diseases caused by biological agents or by 2. Based on the operational definition, identify the
their action to the host. Sometimes, it is the host cases.
immune response to the biological agent that 3. Based on the number of cases identified, verify
triggers the disease process. We often refer to this the existence of an outbreak.
type of disease as infectious diseases. 4. Establish the descriptive epidemiologic features
Noncommunicable diseases are those that of the cases.
cannot be transmitted from person to person. 5. Record the clinical manifestations of cases.
More often than not, they have multifactorial 6. Based on the clinical manifestations, incubation
causes such as genetics, lifestyle, nutrition, period, available laboratory findings, and other
occupation, and social history so on and so forth. information gathered, formulate hypothesis
regarding the probable etiologic agent, the
Another way to classify diseases is based on the duration sources of infection, the mode of transmission,
of clinical manifestations. Acute diseases are those and the best approach for controlling the
diseases whose peak severity of clinical signs or symptoms outbreak.
occurs and subsides within 3 months. More often than 7. Test the hypotheses by collecting relevant
not, the outcome of these diseases leans towards specimens from the patients and from the
complete recovery. Examples of communicable diseases environment.
with acute nature are seasonal flu, common colds, 8. Based on the results of the investigation,
dengue and measles. On the other hand, acute implement prevention and control measures to
noncommunicable diseases include appendicitis, prevent recurrence of a similar outbreak.
paracetamol overdose, and injury due to fall. If the 9. Disseminate the findings of the investigation
duration of the clinical manifestations persists for more through media and other forms to inform the
than three months or remains for a lifetime, then the public.
disease is classified as a chronic disease or condition.
Examples of chronic communicable diseases are HIV Monitoring and Evaluation of Health Interventions
infection, rheumatic heart disease, and tertiary syphilis,  A health intervention plan should include the
Chronic noncommunicable diseases include diabetes plan for its monitoring and evaluation.
mellitus, cancer, and hypertension. Psychiatric conditions  Monitoring is done while the intervention is still
such as major depressive disorders and schizophrenia are being implemented to provide feedback on its
chronic conditions that are noncommunicable. current status.
Outbreak Investigation  Evaluation is done at the end of the project to
assess whether or not its objectives were
 Disease outbreak: the occurrence of cases of achieved.
disease in excess of what would normally be
expected in a defined community, geographical
area or season  Monitoring
 Occurrence of a single case of a communicable  An ongoing activity during program
disease is considered an outbreak if the disease: implementation to assess the current status of its
1. is a previously unknown disease implementation in terms of compliance to the
2. has never occurred in the area design of the program, timelines, and attainment
3. has been absent from the population for a of midterm goals
long time
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Candice Lian M. BEnig 2BSN2
 Community Health Nursing- Agustine Jay P. Tacdol, RN, MSPH
1st SEM- FINALS

 As a result of monitoring, the project be relatively simple in some instances, for

management team is able to: example, avoiding certain food items.
 Assess the progress of program implementation,  The NBS Act of 2004 institutionalized the “National
 Identify problems, NBS System” which ensures that:
 Take corrective action, 1. Every baby born in the Philippines is offered
 Have a tool for quality assurance and NBS;
management, 2. A sustainable NBS System is established and
 Measure achievement of midterm program integrated into the public health delivery
objectives, system;
 Lay the groundwork for program evaluation. 3. All health practitioners are aware of the
 Evaluation benefits of NBS and of their responsibilities in
 A process that systematically and objectively offering it to their patients; and
assesses compliance to the design of the 4. All parents are aware of NBS and their
program, the performance, relevance and responsibility in protecting their child from
success of a project, that is, the extent to which a any of the disorders.
project accomplishes its intended results
(outcomes) and achieves measurable impacts.
 Employs research techniques and applies the
methods of epidemiology and health statistics.
 Its primary purpose is to provide feedback on the
results (outcomes) and impact of the project in
order to inform policymakers and planners about
the efficacy of the intervention.
 It answers such questions as:
 Did the program work as intended?
 What results (outcomes) did the program
accomplish?
 What measurable impacts did the
program achieve?
 Is the program cost effective?

Guiding principles for evaluation:

1. Impartiality
2. Independence
3. Partnership
4. communication and coordination
5. Credibility
6. transparency

Provision of Evidence for Health Policy Formulation

 Epidemiologic evidence is necessary for the

formulation of health policy.
 Example: the legislation of Republic Act 9288
(Newborn Screening (NBS) Act of 2004.
 Passed due to the compelling evidence from a
study done by a group of obstetricians and
pediatricians from 24 hospitals in Metro Manila.
 The Philippine Newborn Screening Project
(PNBSP) showed that the incidence of six
metabolic conditions is high enough to be
considered of public health importance.
 Although the sequelae of these conditions can
compromise the functionality of cases as they
mature, the secondary level of prevention could

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Candice Lian M. BEnig 2BSN2