Chapter 1

1. Chapter 1 • The History and Scope of Epidemiology

2. Tap Water Increases Miscarriages • Swan et al. (1998) released results on total trihalomethanes (TTHMs) in drinking water. • Human exposure to TTHMs may be related to adverse pregnancy outcomes.

3. Bioterrorism-Associated Anthrax Cases • Index case reported in Florida. • Additional cases, including fatal cases, reported in New York, New Jersey, Connecticut. • Contaminated mail linked to some of the cases.

4. Epidemiology Defined • Epidemiology derives from "epidemic," a term which provides an immediate clue to its subject matter. Epidemiology originates from the Greek words, epi (upon) + demos (people) + logy (study of).

5. Definition of Epidemiology • Epidemiology is concerned with the distribution and determinants of health and diseases, morbidity, injuries, disability, and mortality in populations.

6. Key Aspects of This Definition • Determinants • Distribution • Population • Health phenomena • Morbidity and mortality

7. Determinants • Factors or events that are capable of bringing about a change in health.

8. Examples of Determinants • Biologic agents--bacteria • Chemical agents--carcinogens • Less specific factors--stress, drinking, sedentary lifestyle, or high-fat diet

9. The Search for Determinants • Outbreak of Fear--Ebola virus in Kikwit, Zaire • Fear on Seventh Ave.--Legionnaires’ disease in New York City • Red Spots on Airline Flight Attendants--dye from life vests

10. Distribution • Frequency of disease occurrence may vary from one population group to another.

11. Disease Distribution Examples • Hypertension more common among young black men than among young white men. • Coronary heart disease occurrence differs between Hispanics and non-Hispanics.

12. Population • Epidemiology examines disease occurrence among population groups, not individuals. • Epidemiology is often referred to as population medicine. • The epidemiologic description indicates variation by age groups, time, geographic location, and other variables.

13. Health Phenomena • Epidemiology investigates many different kinds of health outcomes: • Infectious diseases • Chronic diseases • Disability, injury, limitation of activity • Mortality • Active life expectancy • Mental illness, suicide, drug addiction

14. Morbidity and Mortality • Morbidity--designates illness. • Mortality--refers to deaths that occur in a population or other group. • Note that most measures of morbidity and mortality are defined for specific types of morbidity or causes of death.

15. Aims and Levels • To describe the health status of populations. • To explain the etiology of disease. • To predict the occurrence of disease. • To control the occurrence of disease.

16. Foundations of Epidemiology • Interdisciplinary • Methods and procedures--quantification • Use of special vocabulary • Epidemic frequency of disease

17. Epidemiology Is Interdisciplinary • Epidemiology is an interdisciplinary field that draws from biostatistics and the social and behavioral sciences,as well as from the medically related fields of toxicology, pathology, virology, genetics, microbiology, and clinical medicine.

18. Quantification • Quantification is a central activity of epidemiology. • Epidemiologic measures often require counting the number of cases of disease. • Disease distributions are examined according to demographic variables such as age, sex, and race.

19. Epidemic • “The occurrence in a community or region of casesof an illness(or an outbreak)clearly in excess of expectancy…” • Relative to usual frequencyof the disease.

20. Infectious Disease Epidemics • A single case of a long absent communicable disease. • First invasion of a communicable disease. • Two cases of such a disease associated in time and place are sufficient evidence of transmission to be considered an epidemic.

21. Concept of Epidemic and Non-infectious Diseases • Some examples that use the concept of an epidemic are: • Love Canal • Brown lung disease • Asbestosis among shipyard workers • Diseases associated with lifestyle

22. Pandemic • “ . . . an epidemic on a worldwide scale; during a pandemic, large numbers of persons may be affected and a disease may cross international borders.” An example is a flu pandemic.

23. Ascertainment of Epidemics • Surveillance • Epidemic threshold

24. Surveillance • The systematic collection of data pertaining to the occurrence of specific diseases. • Analysis and interpretation of these data. • Dissemination of disease-related information.

25. Epidemic Threshold • The minimum number of cases (or deaths) that would support the conclusion than an epidemic was underway.

26. Historical Antecedents • Environment and disease • Use of mortality counts • Use of natural experiments • Identification of specific agents of disease

27. The Environment • Hippocrates wrote On Airs, Waters, and Places in 400 BC. • He suggested that disease might be associated with the physical environment. • This represented a movement away from supernatural explanations of disease causation.

28. Use of Mortality Counts • John Graunt, in 1662, published Natural and Political Observations Made upon the Bills of Mortality.

29. John Graunt’s Contributions • Recorded seasonal variations in births and deaths. • Showed excess male over female differences in mortality. • Known as the “Columbus” of biostatistics.

30. Use of Natural Experiments • John Snow was an English physician and anesthesiologist. • He investigated a cholera outbreak that occurred during the mid-19th century in Broad Street, Golden Square, London.

31. Snow’s Contributions • Linked the cholera epidemic to contaminated water supplies. • Used a spot map of cases and tabulation of fatal attacks and deaths.

32. Snow’s Natural Experiment • Two different water companies supplied water from the Thames River to houses in the same area. • The Lambeth Company moved its source of water to a less polluted portion of the river. • Snow noted that during the next cholera outbreak those served by the Lambeth Company had fewer cases of cholera.

33. Natural Experiment • Definition: The epidemiologist does not manipulate a risk factor but rather observes the changes in an outcome as the result of a naturally occurring situation.

34. Contemporary Natural Experiments • Currently, natural experiments may be the result of legislation, policy changes or environmental interventions.

35. Examples of Contemporary Natural Experiments • Seat Belt Law--Did seat belt use reduce fatalities from motor vehicle accidents? • Tobacco Tax--Did the increase in cigarette price decrease the sale of cigarettes? • Helmet Law--Did requiring the use of helmets by motorcyclists reduce the number of head injuries sustained?

36. William Farr • Appointed compiler of abstracts in England, 1839. • Provided foundation for classification of diseases (ICD system). • Examined linkage between mortality rates and population density.

37. Koch's Postulates • Microorganism must be observed in every case of the disease. • Microorganism must be isolated and grown in pure culture. • Pure culture must, when inoculated into a susceptible animal, reproduce the disease. • Microorganism must be observed in, and recovered from, diseased animal.

38. Other Historical Developments • Alexander Langmuir established CDC’s Epidemiologic Intelligence Service. • Wade Hampton Frost was the first professor of epidemiology in the U.S. • Joseph Goldberger discovered the cure for pellagra.

39. Recent Applications of Epidemiology • Framingham Heart Study (since 1949) investigates coronary heart disease risk factors. • Smoking and lung cancer; e.g., Doll and Peto’s study of British doctors’ smoking. • AIDS, chemical spills, breast cancer screening, secondhand smoke.

40. Additional Applications of Epidemiology • Infectious diseases • Environmental health • Chronic diseases • Lifestyle and health promotion • Psychiatric and social epidemiology • Molecular and genetic epidemiology