APPLICATION OF EPIDEMIOLOGY IN HEALTH CARE DELIVERY

The ultimate goals of health care services are: to promote and protect health, to alleviate and
minimize sufferings and disabilities and to regain health so as to lead socially useful and
economically productive life. Preventive approach is the best approach to achieve these goals
because preventive measures can be implemented with the joint efforts of health personnel and
the people at large at the family and the community level. Epidemiologically the concept of
preventive approach is broad based. There are three major levels of prevention i.e. primary,
secondary, tertiary prevention. Each of these levels of prevention serves distinct purposes and
involves specific interventions which are applied to entire population considering its physical,
mental, social and spiritual domains.
1. Primordial Prevention: this includes prevention of the emergence or development of risk
factors in countries or population groups in which they have not yet appeared. For e.g. many
adult health problems (e.g. obesity, hypertension) have their origins in the childhood, because
this is the time when lifestyles are formed (for e.g. smoking, eating patterns, physical exercise).
In primordial prevention, efforts are directed towards discouraging children from adopting
harmful lifestyles. The main interventi9n is through individual and mass education.
2. Primary Prevention: primary prevention can be defined as action taken prior to the onset
of disease, which removes the possibility that the disease will ever occur. Primary prevention is
the first level prevention and is associated with the prepathogenesis phase or stage of
susceptibility of the disease process when the epidemiological factors like: Agent-HostEnvironment have not yet interacted to cause a disease. Primary prevention strategies during prepathogenesis phase of a disease are aimed to prevent the interaction of these epidemiological
factors. If preventive measures are successful then the disease will not occur. There are two types
of primary prevention:
a. General health promotion: health promotive factors include health education, wholesome
nutritious diet, clean and safe environment to live, healthful life style, healthful behaviors and
adequate resources. All these aspects are directly related to socioeconomic and cultural aspects of
the family and community which must be improved. Health promotive measures encompass
activities related to health education, environmental modification, nutritional interventions, life
style and behavior changes, effective utilization of resources. These must be planned and
executed effectively and efficiently.
b. Specific protection: specific protection includes those measures which are directed to
intercept causative agents of a particular disease or group of diseases before these agents effect
people. These measures include immunization, use of specific nutrients, protection against
accidents and environmental and occupational hazards , use of prophylactic and suppressive
drugs, avoidance of allergens, protection from carcinogens, stimulation of proper personal

hygiene, control of quality safety of foods, cosmetics and drugs and genetic therapy and
counseling.
The basis of primary prevention measures is to alter the host, agent and environment in such a
way that the disease process does not initiate and does not occur. Much of the morbidity,
mortality due to infectious diseases,
Non-infectious and chronic diseases have been averted and reduced due to primary preventive
measures.
3. Secondary Prevention:
secondary prevention can be defined as action which halts the process of a disease at its
incipient stage and prevents complications. Secondary prevention is second level prevention and
is associated with pathogenesis i.e. presymptomatic stage and symptomatic i.e. clinical stage of
the pathogenesis phase of the disease process.
The objectives of secondary preventive measures are: Diagnose the disease at early stage.
Control the process of disease in man.
Prevent complication.
Restore health.
Prevent the spread of infections to others in the community.
Secondary prevention is more important and emphasized in some chronic and non-infectious
diseases such as diabetes; caner, blood pressure etc. because there is limited knowledge of causes
and primary preventive strategies. Secondary preventive measures include two types of
strategies:
a. Early diagnosis and treatment: early diagnosis and treatment are the measures which control
the disease process, prevent the spread of infection to others in case of communicable diseases,
prevent complications and long term disabilities and restore health. Early diagnosis and
treatment has been found the more effective mode of intervention in communicable diseases like
tuberculosis, leprosy and STD. It helps in reducing the morbidity and mortality due to these
infectious and non-infectious diseases. In case of acute communicable diseases, early diagnosis
and treatment helps to shorten the period of communicability, thus limits the spread of infection
and reduces mortality.
b. Disability limitations: disability interventions are applicable during the late pathogenesis
period or clinical stage of the disease process. The objective of these interventions is to prevent

or delay the consequences of clinically advanced disease i.e. prevent impairment leading to
disability and handicap. The sequence of events leading to disability and handicap is as follows:
Impairment: any loss or abnormality of psychological, physiological, or anatomical structure or
function, e.g. loss of foot, defective vision or mental retardation. Impairment can be visible or
invisible; temporary or permanent; progressive or regressive. Further one impairment can lead to
second impairment like leprosy damage of nerves lead to plantar ulcers. Disability: because of
impairment the affected person may be unable to carry out certain activities considered normal
for his age, sex, etc. this inability to carry out certain activities is termed as disability. A
disability can be defined as any restriction or lack of ability to perform an activity in the
manner or within the range considered normal for a human being Handicap: it is a disadvantage
for a given individual resulting from impairment or a disability that limits or prevents the
fulfillment of a role that is normal (depending on age, sex and social and cultural factors) for that
individual. Example: - Accident is disease.
Loss of foot impairment
Cannot walk is disability.
Unemployed is handicap (socialized).
Some of the nursing measures which may limit the impairment and are advisable in immobile
patients are back-care, passive exercise; for diabetic patient include health teaching, exercise,
skin care, psychological boosting.
4. Tertiary Prevention: tertiary prevention can be defined as all measures available to reduce
or limit impairments and disabilities, minimize sufferings caused by the existing departures from
good health and to promote the patients adjustment to irremediable conditions Tertiary
prevention is the third level of prevention. It occurs late in the pathogenesis stage of disease
process when irreversible changes either in anatomy or physiology or both have occurred. At this
point the disease process has advanced its clinical stage and entered the disability stage. It is
either because the primary and secondary preventive measures have not been effective or not
known. Tertiary prevention helps to prevent disability through rehabilitative strategies.
Rehabilitative stratigies are used to attain the highest possible level of functional ability. It
involves coordinated efforts of medical personnel, sociologists, clinical psychologists, nurses etc.
for training and retraining of and helping the person to function, lead a useful life as far as
possible and restore a feeling of wellbeing.
Rehabilitation is with regard to restoration of: Bodily functions (medical rehabilitation).
Personal dignity and confidence (psychological rehabilitation).
Family and social relationship (social rehabilitation).

 The capacity to earn livelihood (vocational rehabilitation).

To conclude the three levels of preventions are relative to various stages of natural history of
disease. Mutually exclusive relationship exists among all the three levels of prevention.
HEALTH SURVEILLANCE
The surveillance means supervision or close watch especially on suspected person.
Epidemiologically surveillance means close vigilance on occurrence and distribution of diseases
and health related problems, population dynamics, community behavior and environmental
processes resulting in increased risk of ill health in the community. It involves identification of
missed and suspected cases and contacts, their confirmation by laboratory investigations;
identifying source of infection and channel of transmission. This informations will help in
planning and implementation of prevention and control programmers for various diseases in the
community. Thus monitoring of the disease prevalence, its related risk factors and intervention of
control programmers for the same are the important activities of surveillance.
The epidemiological surveillance can be done at the following levels:
I. Individual /family Surveillance: It includes surveillance of an infected person in a family as
long as the individual is source of infection to others e.g. typhoid case and carriers.
II. Community /Local population Surveillance: It include surveillance of the whole
community for early detection and prevention and control of a disease e.g. Malaria.
III. National Surveillance: It includes surveillance at the National level e.g. surveillance of
small pox after its eradication.
IV. International Surveillance: It includes surveillance of some of the diseases which are listed
by WHO e.g. Malaria, Influenza, Filarial, Polio etc. and are to be reported to WHO which then
provides information to the countries in the world to take timely actions.
SURVELLIANCE PROCESS: Surveillance is a systematic process. The main steps involved
are:1. Collection of relevant information about the diseases under surveillance: effectiveness of
surveillance system depends upon identification of cases, collection of relevant information
about disease, their recording and reporting. There are number of methods for collection of
relevant information about the diseases under surveillance. It may be easier to find some diseases
and may be difficult to identify some others. Because of this difficulty no single method can be
adopted for surveillance of all diseases. The various methods of surveillance are as under:
a) Routine reporting of cases and deaths recorded at health centers, dispensaries and hospitals:
All these institutions are required to maintain record of cases reported in their outpatient
departments and clinics. Daily recording of cases in OPD of Health Centers includes month,

name, age, sex, address, diagnosis, date of onset and remarks. From this record daily, weekly,
monthly and yearly reports of diseases occurred and reported at the centre are prepared. This
kind of routine reporting can help in making assessment of frequency and distribution of diseases
by age, sex, area and time. Such reports are sent to the district and state health authorities. The
practice of recording of cases under the routine reporting system is called as passive surveillance.
b) Active surveillance: It means actively looking for those particular types of cases who have not
been recorded under the routine system. Active surveillance is done by health workers and
community people e.g. surveillance of Malaria or Tuberculosis cases.
c) Epidemiological investigations: Epidemiological investigations are usually done when there is
occurrence of more than usual number of cases in a particular place during particular time
period: when there is sudden outbreak of any disease and when a communicable disease which
has never occurred before but it has occurred now. This will help in picking up cases and the
associated causative factors. Thus epidemiological investigations provide important
supplementary information which is not obtained by other surveillance methods.
d) Sentinel centers: sentinel centers are those hospitals, health centers, laboratories, special
disease hospital etc. which are identified for collecting information for selected diseases. The
information are collected, compiled and forwarded to higher authority for immediate action and
for making future plans and policies. Sentinel survey can provide reliable information about
selected diseases indicating the trend of disease prevalence in a particular area. Such information
can call for immediate actions to control the disease and also timely remedial actions in future to
prevent the occurrence of disease.
e) Special sample survey: Special sample survey of disease is an active and efficient method of
surveillance. There are different methods of sample surveys but the survey by cluster sampling
technique is recommended by the WHO. The target population, the sample size vary from
disease to disease e.g. the target population for poliomyelitis is 5-9 years, for diarrhea 0-4 years,
preceding the date of survey.
2. Compilation and analysis of data: Once the surveillance data is collected for a reporting
period by whatever method, it needs to be compiled and analyzed to assess the frequency and
distribution by person, place and time. The reporting period can be a week, a month and a year.
This information can be presented in tables, spot maps, charts and graphs. This kind of
presentation helps in determining the pattern of occurrence of disease and whether there is
decrease or increase in the number of cases.
3. Reporting of data and providing feedback: Once the data is analyzed a report a report is to
be prepared in the format prescribed by the authority. The report is sent regularly for each
reporting period. The report should be complete. If there is nil information, it should be reported.
If some information is missed or received late, it should be included in the next reporting period.
If further investigations are done during the period and if any section is taken or going to be

taken, it needs to be reported. Feedback should be given to all the members of health team as to
how the data are used which are collected by them and reported through regular meetings and as
and when desired by anyone.
HEALTH INFORMATION
Health information system is an integral part of the national health system. The health
information system can be defined as: a mechanism for the collection, processing, analysis and
transmission of information required for organizing and operating health services and also for
research and training
Objectives Of Health Information System:
To provide reliable, relevant, up-to-date, adequate, timely and reasonably complete
information for health managers at all levels(i.e. centre, intermediate and local)
To share technical and scientific information by all health personnel participating in the health
services of the country.
To provide at periodic intervals the data that will show the general performance of the health
services.
To assist planners in studying their current functioning and trends in demand and workload.
Difference Between Data And Information: Data consist of discrete observations of events that
carry little meaning when considered alone. Data as collected from operating health care systems
are inadequate for planning. Data need to be transformed into information by reducing,
summarizing, adjusting them for variations, such as age, sex composition of population so that
comparisons over time and place are possible. Requirements To Be Satisfied By Health
Information System: A W.H.O. Expert Committee identified the following requirements to be
satisfied by the health information systems:
1. The system should be population based.
2. The system should avoid the unnecessary agglomeration of data.
3. The system should be problem-oriented.
4. The system should employ functional and operational terms(e.g. episodes of illness, treatment
regimens, laboratory tests)
5. The system should express information briefly and imaginatively(e.g. tables, charts,
percentages)
6. The system should make provision for the feed-back of data.

COMPONENTS OF A HEALTH INFORMATION SYSTEM:

A comprehensive health information system requires information and indicators on the following
subjects:
1. Demography and vital events.
2. Environmental health statistics.
3. Health status: mortality, morbidity, disability and quality of life.
4. Health resources: facilities, beds, manpower.
5. Utilization and non-utilization of health services: attendance, admissions waiting lists.
6. Indices of outcome of medical care.
7. Financial statistics (cost, expenditure) related to the particular objective.
USES OF HEALTH INFORMATION:
The important uses to which health information may be applied are:1) To measure the health status of the people and to quantify their health problems and medical
and health care needs.
2) For local, national and international comparisons of health status.
3) For planning administration and effective management of health services and programmers.
4) For assessing the attitudes and degree of satisfaction of the beneficiaries with the health
system.
5) For research into particular problems of health and disease.
SOURCES OF HEALTH INFORMATION:
1. Census: the census is an important source of health information. It is take in most of the
countries of the world at regular intervals, usually of 10 years. A census is defined by the United
Nations as the total process of collecting, compiling and publishing demographic, economic
and social data pertaining at a specified time or times to all persons in the country or delimited
territory. Census is a massive undertaking to contact every member of the population in a given
time and collect a variety of information. The first regular census in India was taken in 1881, and
others took place at 10 year intervals. The supreme officer who directs guides and operates the
census is the Census Commissioner for India.

2. Registration of Vital Events: registration of vital events (e.g. births and deaths) keeps a
continuous check on demographic changes. If registration of vital events is complete and
accurate, it can serve as a reliable source of health information. Much importance is therefore
given to registration in certain countries. The United Nations defines a vital events registration
system as including legal registration, statistical recording and reporting of the occurrence of,
and the collection, compilation,presentation, analysis and distribution of statistics pertaining to
vital events, i.e., live births, deaths, fetal deaths, marriages, divorces, adoptions, leg imitations,
recognitions, annulments and legal separations. India has a long tradition of registration of births
and deaths. In 1873, the Govt. of India had passed the Births, Deaths and Marriages Registration
Act, but the act provided only for voluntary registration. However, the Registration system in
India tended to be very unreliable, the data being grossly deficient in regard to accuracy,
timeliness, completeness and coverage. This is because of illiteracy, ignorance, lack of concern
and motivation. There are also other reasons such as lack of uniformity in the collection,
compilation and transmission of data which is different for rural and urban areas, and multiple
registration agencies (e.g. health agency, panchayat agency, police agency and revenue agency).
The Central Births and Deaths Registration Act, 1969:- The Govt. of India promulgated the
Central Births and Deaths Registration Act in 1969 in an effort to improve the civil registration
system. The Act came to force on 1 April 1970. The Act provides for compulsory registration of
births and deaths throughout the country and compilation of vital statistics in the states so as to
ensure uniformity and comparability of data. The Act also fixes the responsibility for reporting
births and deaths. While the public (e.g. parents, relatives) are to report events occurring in
households, the heads of the hospitals, nursing homes, hotels, jails or dharamshalas are to report
events occurring in such institutions to the concerning Registrar. The time event for registering
the event of births is 14 days and that for the deaths is 7 days. In case of default a fine up to a
fine up to Rs.50 can be imposed. Lay Reporting: Lay reporting is defined as the collection of
information, its use, and its transmission to other levels of the health system by non-professional
health workers like village health guides to record births and deaths in the community.
3. Sample Registration System (SRS): SRS was initiated in mid-1960s to provide reliable
estimates of births and death rates at the national and state levels. The SRS is a dual record
system, consisting of continuous enumeration of births and deaths by an enumerator and an
independent survey every 6 months by an investigator-supervisor. This system is more reliable
for information on birth and death rates, age specific fertility and mortality rates, infant and adult
mortality etc.
4. Notification of Diseases: the primary purpose of notification is to effect prevention and
control of the disease. Notification is also a valuable source of morbidity data i.e. the incidence
and distribution of certain specified diseases which are modifiable. Lists of modifiable diseases
vary from country to country and also within the same country between the states and between
urban and rural areas. At the international level the diseases like cholera, plague, yellow fever,
relapsing fever, polio, influenza, malaria, and rabies are modifiable to W.H.O. The limitations of

notification are: (a) it covers only a small part of the total sickness in the community (b) it suffers
from under-reporting (c) many cases esp. atypical and sub clinical cases escape notification due
to non recognition e.g. rubella, non-paralytic polio etc. In spite of the above limitations,
notification provides valuable information about fluctuations in disease frequency and provides
early warning about new occurrences or outbreaks of disease.
5. Hospital Records: in India where registration of vital events is defective and notification of
infectious diseases is extremely inadequate, hospital data constitute a basic and primary source of
information about diseases prevalent in the community. The main drawbacks of hospital data
are: They provide information on only those patients who seek medical care. Mild cases may not
attend hospital; sub clinical cases are always missed.
The admission policy may differ from hospital to hospital; therefore hospital statistics may be
highly selective.
Population served by a hospital cannot be defined. There are no precise boundaries to the
catchment area of the hospital.
In spite of above limitations, a lot of useful information about health care activities can be
derived from hospital records. A study of hospital data provides information on the following
aspects:
Geographic sources of patients
Age and sex distribution of different diseases and duration of hospital stay
Distribution of diagnosis
Association between different diseases
The period between disease and hospital admission
The distribution of patients acc. to different social and biological characteristics
The cost of hospital care
Such information is of great value in planning of health care services.
6. Disease Registers: a register requires that a permanent record be established, that the cases be
followed up, and the basic statistical tabulations be prepared both on frequency and on survival.
Morbidity registers exist only for certain diseases such as stroke, myocardial infarction, cancer,
blindness, and congenital defects. Tuberculosis and leprosy are also registered in many countries
where they are common. These registers are of valuable information as to the duration of illness,
case fatality and survival. These registers provide follow-up of patients and provide a continuous

account at the frequency of disease in the community. The useful information can be obtained
from registers on the natural course of disease, esp. chronic diseases. If the reporting system is
effective the register can provide useful data on morbidity from the particular diseases, treatment
given and disease-specific mortality.
7. Record Linkage: the term record linkage is used to describe the process of bringing together
records relating to one individual (or to one family), the records originating in different times or
places. The term medical record linkage implies the assembly and maintenance for each
individual in a population, of a file of the more important records relating to his health. The
events commonly recorded are birth, marriage, death, hospital admission and discharge. Other
useful data might also be included such as sickness absence from work, prophylactic procedures,
use of social services etc. the main problem with the record linkage is the volume of data that can
accumulate. Therefore in practice record linkage has been applied only on a limited scale e.g.
twin studies, measurement of morbidity, chronic disease epidemiology and family and genetic
studies.
8. Epidemiological Survelliance: in many countries where particular diseases are endemic
special control eradication programmers have been instituted for example National Disease
Control Programmers against malaria, tuberculosis, leprosy etc. the surveillance programmers
are set up to report on the occurrence of new cases and on efforts to control the diseases e.g.
immunization is performed. These programmers have yielded considerable morbidity and
mortality data for the specific diseases.
9. Other Health Service Records: these are hospital OPDs, primary health centers and sub
centers, polyclinics, private practitioners, mother and child health centers, school health records,
diabetic and hypertensive clinics etc. For e.g. records in MCH centers provide information about
birth weight, height, arm circumference, immunization, disease specific mortality and morbidity.
The drawback is that it relates only to a certain segment of the general population and the data
generated by these records is mostly kept for administrative purposes rather than for monitoring.
10. Enviornmental Health Data: health statistics provide data on various aspects of air, water
and noise pollution; harmful food additives; industrial toxicants; inadequate waste disposal and
other aspects of combination of population explosion with increased production and
consumption of material goods. Environmental data is helpful in the identification and
quantification of factors causative of disease.
11. Health and Manpower Statistics: this information relates to the number of physicians (by
age, sex, specialty and place of work), dentists, nurses, medical technicians etc. there records are
maintained by The State Medical/Dental/Nursing Councils and the Directorates of Medical
Education. The census also provides information about occupation. The Institute Of Applied
Manpower Research attempts estimates of manpower, taking into account different sources of

data, mortality and out turn of qualified persons from different institutions. The Planning
Commission also gives estimates of active doctors for different states.
12. Population Surveys: the term health surveys is used for surveys relating to any aspect of
health- morbidity, mortality, nutritional status etc. when the mean variable to be studied is
disease suffered by the people, the survey is referred as morbidity survey. The following
types of surveys are included under health surveys:
Surveys for evaluating the health status of a population that is community diagnosis of
problems of health and disease.
Surveys for investigations of factors affecting health and disease e.g. environment, occupation,
income, circumstances associated with the onset of illness etc.
Surveys relating to administration of health services e.g. use of health services, expenditure on
health. Evaluation of population health needs and unmet needs, evaluation of medical care.
Population surveys can be conducted in almost any setting. These may be cross-sectional or
longitudinal; descriptive and analytical or both.
Classification of Health Surveys:
a) Health examination surveys: provide more valid information. This survey is carried out by
teams consisting of doctors, technicians and interviewers. The main disadvantage of this type is
it is expensive and cannot be carried out on the extensive scale. It also considers the provision of
treatment to people found suffering from certain diseases.
b) The health interview: it measures subjective phenomena such as morbidity, disability,
impairment, economic loss due to illness, expenditure on disease, beliefs and attitudes.
c) Health records survey: involves collection of data from health service records. It is the
cheapest method of collecting data. The disadvantages of this method are that the estimates
available from records are not population based; reliability is open to question and lack of
uniform procedures in recording the data.
d) Questionnaire: it is simpler and cheaper and they may be sent. A certain level of skill and
education is expected from respondents. There is usually high rate of non response. It is more
time consuming also.
Other Routine Statistics Related To Health:
Demographic: in addition to routine census data, statistics on other demographic phenomena
as population density, movement and education level.

 Economic: consumption of consumer goods like tobacco, dietary fats, sales of drugs,
employment and non-employment data.
Social security schemes: medical insurance schemes make it possible to study the occurrence
of illnesses in the insured population.
. Non-Quantifiable Information: health planners require this information e.g. information on
health policies, health legislation, public attitudes, programmed costs, procedures and
technology. There should be proper storage, processing and dissemination of information.
EPDEMIOLOGY
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.
Public health surveillance is the ongoing, systematic collection, analysis, interpretation, and
dissemination of data about a health-related event for use in public health action to reduce
morbidity and mortality and to improve health.
GOALS OF SURVEILLANCE SYSTEM
Detect outbreaks
Detect public health threats
Detect infectious cases (case finding)
Monitor trends in a target population
Monitor exposed individuals for symptoms
Monitor treated individuals for complications
Direct public health interventions
Evaluate public health interventions
Generate hypotheses for further evaluation
Types of disease surveillance
Passive surveillance
Enhanced passive surveillance
Active surveillance
Sources of surveillance data
Mortality data
Death registry, medical examiner
Morbidity data
Legally reportable diseases, including cancer
Birth registry
Hospital discharge diagnoses
(utilization data)
Special surveys (NHANES, NHIS, CHIS)

ROLE OF A NURSE IN EPIDEMIOLOGY