Assignment No: ACE512/01/22

Assignment on First Internal Assessment Questions

Advanced Concept of Epidemiology

In partial fulfillment of the requirements for the Master Degree of Public Health (MPH) Internal
Assessment

Submitted To
Dr. Damaru Prasad Paneru
School of Health and Allied Sciences
Pokhara University

Submitted By:
Sagar Parajuli
Master’s Degree of Public Health (MPH)- Semester I
School of Health and Allied Sciences
July, 2022
Q1. Discuss scope of epidemiology in advancing public health in its multiple dimensions.
Also highlight the chronology of evolution of epidemiology with suitable illustrations
Epidemiology is defined as the study of the distribution and determinants of health-related states
or events in specified population and the application of this study to control the health-related
problems. – John M Last, 2006 And, Public health is the science and practice of protecting and
promoting and preventing disease and prolonging life of the people in the community.
Epidemiology is an integral component and one of the major tools of public health.

Epidemiology is the basic science of public health, because it is the science that describes the
relationship of health or disease with other health-related factors in human populations.
Epidemiology is a methodological discipline that provides evidences for prevention and control of
health problem. The scope of epidemiology in public health can be categorized in to the following
sub categories:

1. Evolution/developmental scope
2. Scientific discipline: Disciplinary Scope
3. Utility Scope: Field of Application

Evolution/Developmental Scope-Initially epidemiology was limited with the investigation and

management of only communicable diseases but later on study of non-communicable diseases was
also included under area of epidemiology and now it is applied to study any disease, health-related
events, health system and other non-health events having health consequences.

Scientific discipline: Disciplinary Scope- Epidemiology relies on scientific process/methodology

and provides evidences for preventing and controlling health, analyzing data and scientific
information, epidemiology can track diseases and its future outcomes. Epidemiological methods
are used for disease surveillance and for building resilient health system for health emergencies,
outbreaks, epidemics and pandemics.

Utility Scope: Field of application- Epidemiology has been applied to different study area like
nutrition known as nutritional epidemiology, study of cancer known as cancer epidemiology,
infectious disease epidemiology, genetics epidemiology, geriatric epidemiology, cardiovascular
epidemiology and many more.
Chronological Development of Epidemiology

Hippocrates Hippocrates also known as ‘Father of medicine’ and the first

(460-377 BC) epidemiologist
Identified influence of environmental factors on occurrence of disease on
human body causing imbalance on four humors
Made distinction between epidemic and endemic as epidemic- diseases
visited upon population, endemic- diseases reside within population
Joaquin de Villalba Use of term ‘epidemiology’ as study of epidemics in Epidemiology
1802 Espanola
John Graunt 1662 Studied disease occurrence and death with the use of systematic methods
and developed and calculated life tables and life expectancy
Studied mortality statistics and published mortality data in 1662
James Lind 1747 Discovered the cause of scurvy performing scientific experiment
Edward Jenner Developed immunization against smallpox through use of cowpox virus,
1796 which resulted into smallpox eradication in 1980
William Farr 1800 Highlighted systematic collection, analysis and evaluation of data on vital
statistics and disease classification
Considered as ‘Father of modern vital statistics’
John Snow 1854 Epidemiological investigation of Cholera outbreak at London (1848-1854)
Use of spot map for locating source of causative agent
Austin Bradford Introduced concept of randomization in epidemiological study for
Hill- Mid 1900s minimizing biases and for control of confounders
Fletcher 1905 Studied Beriberi and found as nutritional deficiency
1930-40s Epidemiologists studied occurrence of infectious as well as non-infectious
disease, which broaden scope of epidemiology.
1980s-2000 Eradication of Smallpox and epidemiology extended to the study of
injuries and violence, molecular and genetic epidemiology (studying
specific genes, pathways, and molecules that influence risk of developing
disease)
 Following 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.
21st Century Epidemiology now focused on study of not only disease and health
problem but also on problem having health consequences in an
interdisciplinary approach
Emergence of epidemiology in inter-disciplinary approach
Application of epidemiological methods for COVID19 prevention and
control proven the need of epidemiology as scientific discipline for
building global resilient health system

Q2. Epidemiologists’ assertion with evidences “Epidemiology enormously contributes at a

large in promoting and protecting health, preventing and controlling diseases and health
problems and managing treatment services. Justify claims with an example of each of the
interventions relating public health issues of ever concern.

Epidemiology being basic science of public health and methodological discipline enormously
contributes at a large in promoting and protecting health, preventing and controlling diseases and
health problems and managing treatment services.

Epidemiology contribution in promoting and protecting health: Health promotion is a process of

enabling people to increase control over their health. Epidemiology provides evidences and
information on different risk factors and causative agent, and promotes healthy lifestyle of people.
It encourages healthy behavior and health seeking behavior among individuals, supports for risk
factor control and environmental modification. The contribution of epidemiology in promoting
and protecting health are mentioned below:

• Health Education- risk communication, promoting healthy behavior

• Risk Factor identification and control- provides evidences on risk factors and helps to
identify population at risk and intervene accordingly
• Environmental intervention- study of influences of environmental factors on human health
• Specific Protection: Immunization, use of helmet and seat belt for RTAs
Epidemiology contribution in preventing and controlling disease and management of health
problems: Epidemiology helps to identify population at higher risk for developing diseases and
directs preventive and control measures depending on the nature of health problem/disease. Based
on nature of health problem, three level of prevention can be applied:

1. Primordial Prevention- Identifying underlying social, economic and environmental factors

leading to causation
2. Primary Prevention- Protection of health by individual or community efforts like enhancing
nutritional status, immunization
3. Secondary Prevention- Early diagnosis and treatment
4. Tertiary prevention- Disability limitation and rehabilitation

Epidemiology helps in control and management of health problems providing facts and
information about health problem like management of COVID19 cases through establishment of
community isolation and quarantine centers.

Q3. What are the gradients of infection? Spell out the criteria to declare the “Disease
eradication” with specific reference to any disease amenable for eradication.

Gradient of infection can be defined as range of possible host reactions to an invading pathogenic
organism, from inapparent subclinical through mild clinical to severe to fulminating and
overwhelming generalized fatal bacteremia. The gradient of infection simply refers of level of
infection in an individual, from latent to clinical manifestations. There are mainly three levels of
infection (gradients of infection). They are listed below:

Clinical Infection Infection with observable or detectable signs and symptoms in an

individual
Subclinical Also known as inapparent, silent infection. No signs and symptoms of
Infection an infection are observed. This is also called asymptomatic stage, in
which there is presence of causative agent within body, undergoes
multiplication but shows no any clinical manifestations.
Latent Infection Infection in dormant or inactive stage known as latent infection
Latent infection is generally static with presence of causative agent
within the body with no multiplication and manifestation of symptoms.
 Latent infection can be observed in Herpes simplex, Varicella Zoster

Disease Eradication can be defined as extinction of disease pathogen, elimination of occurrence of

given disease even in absence of all preventive measures, control of an infection to the point at
which transmission ceased and reduction of worldwide incidence of a disease to zero as a result of
deliberate efforts, obviating further necessity for further control measures. Simply, disease
eradication means an extreme extermination of an organism or tearing out disease by roots.

Some of the criteria for declaring disease eradication are listed below:

• Availability of effective intervention against disease to interrupt transmission of disease.

Smallpox vaccination for smallpox eradication, the vaccination being cost-effective
intervention was adopted initially with target of achieving 80% vaccine coverage in each
country followed by case finding and ring vaccination.
• Availability of diagnostic tool with sufficient sensitivity and specificity to detect the level of
infection that can lead to transmission and sufficiently simple to be applied at globally by
laboratories within a range of capabilities and resources.
• Biological Characteristics of agent favoring eradication of disease, being human integral part
of life-cycle of an agent, having no other vertebrae reservoir and incapable to amplify in the
environment. Some of the biological characteristics of an agent outlined in 1997 Dahlem
workshop favoring disease eradication are listed below: these characteristics mainly focuses
on epidemiological susceptibility (no non-human reservoir and naturally induced immunity).
1. The microbial agents infecting human only.
2. There cannot be non-human reservoir for the microbial agent.
3. The infection must induce life-long immunity.
• Economic Consideration- Cost effectiveness of an intervention, analyzing cost vs. benefits of
an intervention along with direct and indirect effects. The intervention and eradication
programs must be cost-effective.
• Social and Political Criteria
1. Social and political commitment for disease eradication at national, regional and global
level and popular support
 2. Perceived burden of disease: The disease under consideration must be of recognized
public health importance, with broad international appeal and perceived as worthy goal
by all level of communities and societies globally,
3. Development of technically feasible intervention and eradication strategy and adoption
based on evidence generated on piloting and field-testing,
4. Consensus on priority and justification of disease must be developed by technical
experts, decision makers and scientific communities.
5. The expected cost of eradication must be minimal and the eradication goal must be
global supporting developing countries by developed countries.
6. Synergy of eradication efforts with other interventions- utilizing existing framework
and resources
7. Realized need of eradication than control, considering socio-economic impact as well
as impact on health of people

The smallpox eradication program received social and political support as smallpox was
recognized as disease of public health importance and many countries-initiated smallpox
eradication activities at national level focusing on vaccination, active case finding, which resulted
into smallpox eradication in 1980.

Q4. What kinds of interventions do you apply for Control and prevention of epidemics? How
does rules and regulations measures effectively contribute for the prevention and control of
disease. Illustrate with examples.
Epidemics can be defined as public health emergencies with more than expected/usual number of
cases of disease within single incubation period, following by waves. Epidemics can be
humanitarian crisis resulting into a greater number of cases, deaths and limited surge capacity of
health facility and hospital can make health system overstressed to response and to intervene for
prevention and control of epidemics. For epidemic management, a rationale public health
emergency response is essential with series of intervention focused at prevention and control of
epidemic. The severity of problem, study of etiological agent, level of scientific certainty of
problem, socio-political context, legal considerations & grounds, intervention administrative
feasibility determines an intervention to be applied. Intervention for preventing and controlling an
infectious disease epidemic and non-infectious disease will be different, and requires systematic
process of rolling out intervention activities. Some natures of interventions for prevention and
control of epidemic are tabulated below:

Interventions for prevention and control of epidemics

A. Intervention focused at control of agent, reservoir and vector
Activities: Identification of possible source of infection through Patient History and contact
tracing
Interventions:
1. Source & Vector control: Search and destroy strategy for destroying breeding places and
larvae of Aedes Mosquito for Dengue Control and Anopheles for Malaria Control
2. Case Investigation and Contact tracing
B. Intervention focused at breaking dynamic of disease transmission
Activities: Identification of possible modes of transmission, associated factors and enabling
environments, identification of high at-risk population and special needs communities.
Possible Interventions
1. Isolation of cases (cases hereby refers to confirmed cases with proven diagnostic test)
2. Quarantine of suspected/probable cases
3. Contact tracing and follow-up
4. Health Promotion: Hygiene, Environmental Sanitation, Risk factor modification
5. Disinfection, Infection Prevention and Control Practices
6. Risk communication & community engagement (RCCE) through media and methods
C. Intervention focused at cases management & building resilient health system
Activities: Epidemic projection and estimation based on current trend/reproduction number,
Calculating surge capacity of health system in terms of HRH and other resources
Possible Interventions
1. Cases management based on severity of cases
2. Special focus to marginalized and vulnerable populations
3. Mobilization of human resources as per need
4. Engagement of private sectors for epidemic control
5. Establishing call centers
6. Building surveillance system for monitoring cases and trend of epidemics
 C. Intervention focused at levels of prevention (Primary, Secondary and Tertiary)
Activities: Epidemic projection and estimation based on current trend/reproduction number,
Calculating surge capacity of health system in terms of HRH and other resources
Possible Interventions
1. Primary Prevention: Health awareness based on SBCC strategies
2. Secondary Prevention: Specific protection- vaccination if available, early diagnosis and
treatment
➢ Screening- Community, Ground crossing and Point of Entries (PoE)
➢ Application of rapid diagnostic tests
➢ Confirmatory test for suspected ones
➢ Identification of high-risk area and applying PHSM measures accordingly
3. Tertiary Prevention: Rehabilitation, psycho-social support and recovery activities

The abovementioned natures of intervention can be applied for epidemic prevention and control
depending upon nature of epidemic.

Rules and regulations effectively contribute to the prevention and control of disease in following
ways:

• Controlling human behaviors that poses potential risk/potential for disease transmission
Fine for people not wearing mask at early stage of COVID19 promoted use of masks
among public, nation-wide lockdown and pocket area lockdown restricting people mobility
and breaking chain of infection, Vehicle pass for travel minimized unnecessary movement
of people during COVID19.
• Promotion of precautionary behaviors at individual level and regulation of activities
Mandatory PCR test for people coming to Nepal for controlling epidemic and compulsory
COVID19 vaccination certificate at public and private institutions promoted vaccination
among people.
 • Community participation and engagement
Rules and regulations indirectly promote community participation and engagement,
making every individual in community obliged to follow them and ensure utilization of
community resources as per need as well.
Utilization of schools and public spaces for quarantine during COVID19

Q5. What the key criteria for selecting health problems for surveillance? Critically discuss
the surveillance cycle with reference to any disease under surveillance in Nepal.
Public Health Surveillance is the ongoing and systematic collection, analysis, and interpretation of
health data, essential to planning, implementation and evaluation of public health practice closely
integrated with timely dissemination of these data to those responsible for prevention and control.
Public health surveillance provides and interprets data to facilitate prevention and control of
disease/health problem and is used for planning, implementing, and evaluating public health
interventions and programs.

Surveillance is an ongoing and systematic process of data collection, analysis and interpretation
so it consumes considerable amount of time, cost and resources. So, mostly the public health
problem of recognized importance is taken into consideration for surveillance but these selection
and prioritization of health problems for surveillance differs among countries. In most of countries,
selection is based on criteria developed for prioritizing diseases, review of available morbidity and
mortality data, knowledge of diseases and their geographic and temporal patterns, and impressions
of public and political concerns, sometimes augmented with surveys of the general public or non-
health-associated government officials.

Some of the key criteria for selecting and prioritizing health problems for surveillance are as
follows:

❖ Public health importance of the problem- The health problem taken into consideration must be
of recognized public health importance in terms of

• Incidence, prevalence,
• Severity, sequela, disabilities,
• Mortality caused by the problem,
 • Socioeconomic impact,
• Communicability,
• Potential for an outbreak,
• Public perception and concern, and
• International requirements
❖ Ability to prevent, controls, or treat the health problem:
• Preventability
• Control measures and treatment
❖ Capacity of health system to implement control measures for the health problem:
• Speed of response
• Economics
• Availability of resources
• Requirements of surveillance of event

Surveillance cycle: Surveillance is ongoing, systematic and cyclic phenomenon from data
collection to analysis and interpretation, followed by dissemination of information and
actions/interventions.

• Data collection
• Data analysis and interpretation
• Dissemination of information
• Action/intervention must be followed by repeating the cycle

COVID19 Surveillance through IMU system

IMU also known as Information Management Unit under Integrated Health Management
Information System (IHMIS) functions as COVID19 Surveillance system, connecting labs,
hospitals and municipalities through a single system.

Municipalities get notification on IMU when person is tested positive on doing RT-PCR or
Antigen Test at community and system enforces municipalities to initiate contact tracing and
follow-up for finding possible cases at community level.
The system is also used at Ground Crossing and Point of Entries (GC/POE) at border area and at
airports. The hospital module of IMU keeps records of admitted COVID19 cases, monitor their
health condition based on information provided by hospital and along with gives information about
availability of beds- General bed, HDU, ICU at hospital. Active case finding approach is carried
out through contact tracing of positive cases during follow-up calls. In this way, surveillance is
carried for COVID19 in Nepal.