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Epidemiology Kept

Simple
Chapter 1
Epidemiology Past & Present
re: The text
• EKS = Epidemiology Kept Simple
• 20 chapters
• Multiple sections (§) per chapter
• Chapter outlines on first page of each
chapter
§1.1 Epidemiology, Health,
and Public Health
• What is epidemiology?
• What is public health?
• What is health?
Epidemiology Defined
• Greek roots
• epi = upon
• demos = the people
• ology = study of
• Literally - “study of epidemics”
• Modern definitions include references to
• distributions of health determinant (statistical concept)
• determinants of disease (pathophysiologic concept)
• application in control of health problems (biological
and social concepts)
Comparison of epi &
medicine
• Main unit of concern
• Epi  population
• Medicine  individual
• But …
• Epi becoming increasingly individualized
• Medicine becoming group-based
Public Health
• Definitions of public health include reference to:
• organized effort (“activity”)
• reduction of morbidity / mortality
• improvements in health
• Public health comprises many disciplines
• Epi is just one such discipline
• Compare epi and public health
• Epi  a “study of”
• Pub health  an activity
Health
• No single definition
• Medical definition  absence of disease
• WHO definition (1948)  reference to
“physical, mental, and social well-being”
• Should definitions of health reference quality
of life?
• Pros
• Cons
Additional Terms
• Morbidity = related to disease or disability
• Mortality = related to death
• Occurrence of disease = prevalence or
incidence of disease & health-related
conditions
• Endemic = normal occurrence of a condition
• Epidemic = greater than normal occurrence of
a condition
• Pandemic = epidemic on multiple continents
§1.2 Uses of Epi (Morris, 1957)
(pp. 3 – 4 in text)

1. Historical study
2. Community diagnosis
3. Working of health services
4. Individual chances
5. Complete clinical picture
6. Identify new syndromes
7. Determine cause (ultimate importance)
§1.3 Epidemiologic Transition
(pp. 4 – 10)
• The epidemiologic transition of the 20th
century
• Acute and contagious  chronic and non-
contagions
• Decrease mortality rates
• Morbidity shifted to older age groups and
“degenerative diseases”
§1.3 Epidemiologic Transition
of the 20th century
Leading Causes of Death, 1900 and 1990
1900 1990
1 Pneumonia / influenza Heart disease

2 TB Neoplasms

3 Diarrhea Cerbrovascular

4 Heart disease* COPD

5 Cerebrovascular* Pneumonia/ influenza

* Large % had infectious component


Factors behind
Epidemiologic Transition
• Medical technology (antibiotics, anesthesia)
• Birth control
• Nutrition
• Sanitation and vector control
• Education
• Improved standard of living
• Many other factors that can’t be over-
simplified
Demographic Transition
U. S. Mortality 1950 – 1990
(Fig 1.2, p. 8)
Mortality of Selected Cancers, U.S., 1940 - 1995

(Fig. 1.3, p. 9)
Life Expectancy at Birth (Fig. 1.4, p. 10)
§1.4 Selected Historical Figures
and Events
• Understanding medical history is an
important part of epidemiology
• This section divided into three eras
• 400BC – 1850
• 1850 - 1900
• Twentieth century epi
The role of Western Civilization
and “The Scientific Revolution”
• Age of Enlightenment and Western
Civilization
• Science liberates itself from philosophy,
morality, and religion
• Recommended reading:
Demographic Approach
(pp. 12–14)

John Graunt (1620 – 1674)


Graunt’s 17th Century Life Table
Living to age % surviving
6 64
16 40
26 25
36 16
46 10
56 6
60 3
76 1
80 0
Lessons Learned from Graunt
(Rothman, 1996)
• was brief
• made reasoning clear
• subjected theories to multiple and varied tests
• invited criticism
• willing to change ideas when confronted with
contradictory evidence
• avoided mechanically simplistic
interpretations
Germ Theory
(p. 14)

• The idea that disease could be caused by a self-replicating


(i.e., biological) agent began in the 16 th century but was
not accepted until the later part of the 19th century
• For most of the 19th century, germ theory played second
fiddle to miasma theory (“miasma” = atmospheric
pollution)
• Early contagionists
• Fracastoro (16th century Italian)
• Henle & Koch (German physiologists)
• Pasteur (of course)
• Snow (epi hero)
• Daniel Salmon (Salmonellosis; vector borne transmission)
John Snow (1813–1858)
• Victorian surgeon & anesthesiologist
• Conducted near perfect epidemiologic investigations
Snow’s Waterborne Theory
• Water borne transmission
• Free-living agent
• Fecal-oral transmission (person-to-person)
• Water-borne transmission
• Agent multiplies within the host
• Clinical and pathophysiologic features
• diarrhea  fluid loss  smudging of blood 
“asphyxiation”  death
• Epidemiologic features
• epidemics followed routes of commerce
• association with fecal contamination of water
Snow’s Methods
(Winkelstein, 1995)
• Ecological studies
• cholera rates by region
• Cohort
• cholera rates in exposed and non-exposed
household
• Case-control
• water source in cases and controls
Snow’s Ecological Data (Figure 1.13, p. 24)
Snow’s Cohort Study (Table 1.7, p. 25)
• Cholera mortality per 10,000 household and
water source
• Rate Southwark & Vauxhall = 1263 / 40,046 × 10,000 = 315
• Rate Lambeth = 98 / 26107 × 10,000 = 37.5
• Southwark & Vauxhall drew water from fecal
contaminated water region
• Supporting evidence for water-borne
transmission theory
Snow’s Case-Control Study
• Epidemic area of Golden Square area (1854 epidemic)
• Interviewed cases and non-cases to determine water source
• Cases
• 61 used water from Broad St. pump
• 6 did not use Broad St. pump
• 6 could not determine if used Broad St. pump
• Controls were less likely to use Broad St. pump water
• e.g., Among Brewer workers (non-cases), “the men were
allowed a certain quantity of malt liquor, and Mr. Huggins
[the proprietor] believes they do not drink water at all”
• Map showing proximity to pump and no. of cases (next
slide)
Snow’s Map (Fig 1.14)
20th Century Epidemiology
(p. 26)

• The epidemiologic transition from acute


contagious to chronic non-contagious
causes of morbidity effected the way
epidemiologists studied disease
• Illustrative examples
• British Doctors Study (Doll & Hill)
• Framingham Heart Study (cardiovascular
disease risk factors)

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