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[FAMILY AND COMMUNITY MEDICINE II]

Module #1

INTRODUCTION TO EPIDEMIOLOGY #1
Michael Q. Van Haute, MD, DPAAB, MSPH July 4,2018

Outline  Such groups can be defined (geographical, occupational,


I. What is Epidemiology? other characteristics)
A. Characteristic features
B. Risk factor Distribution of health-related states
C. Epidemiology
D. Historical antecedents  (disease,death, discomfort, disability, dissatisfaction,
II. Disease occurrence in the population destitution)
A.Concept of disease occurrence
B. Causation vs Association
o Occurrence by person, place, and time
C. Epidemiologic Methods Determinants
D. Describing disease occurences
E. Descriptive Epidemiology  Factors capable of bringing about change in health state

LEGEND EPIDEMIOLOGY
 Book  Can be applied to a wide range of problems, from
Recordings transmission of an infectious disease agent to the design of a
new strategy for health care delivery.
WHAT IS EPIDEMIOLOGY
 This methodology is continually changing as it is adapted to a
 Study of (logos, λόγος) what is upon (epi, ἐπί) the people
greater range of health problems and more techniques are
(demos, δῆμος)
borrowed and adapted from other disciplines (such as
 The study of the and of disease and health-related states and
mathematics and statistics).
events in and application of knowledge in prevention, control,
and mitigation of these problems.
HISTORICAL ANTECEDENTS OF EPIDEMIOLOGY
CHARACTERISTIC FEATURES
Hippocrates (400BCE)
– Attributed disease causality to environmental factors

(“environment is a factor in disease causation”)
John Graunt (1662)
– Employed quantitative methods in describing population
vital statistics; presented mortality data in tabular form (counts
of events)
John Snow (1854)
– Father of Epidemiology; investigated cholera outbreak 

– Marked the formal beginnings of the field of Epidemiology
(experiment) 

• Hypothesis: contaminated water, not air, spreads cholera.
– Cholera rates high in areas supplied by 2 companies
(Southwark & Vauxhall, and Lambeth) Source: polluted part of
Thames River
Figure 1 Characteristic features

Overall Goal
1. Identification of risk factors
-Know the cause* of disease
-Eliminate all compounding conditions

2.Prevent disease
Figure 2 Source: Snow J. Snow on Cholera. London: Humphrey Milford:
WHAT IS A RISK FACTOR Oxford U Press, 1936
 Last (2001)
-“An aspect of personal or behavioral lifestyle, – In 1852, Lambeth relocated its source to less-polluted
environmental exposure, inborn or hereditary, which, on the areas which results to decreased cholera incidence.
basis of epidemiological evidence, is known to be associated
with a health-related condition considered important to
prevent.”

Specific Population
 Concerns itself with groups or population instead of
individuals

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FAMILY AND COMMUNITY MEDICINE II INTRODUCTION to EPIDEMIOLOGY MODULE #1, LECTURE #1

– A number of factors contribute to causation (Theory of


Multiple Causation)
– Some factors are essential for the development of the
disease, and some increased the risk of its development
(Sufficient-Component Cause Model)
In Sufficient-Component Cause Model you actually have two
causes: a necessary cause and a sufficient cause.

Apparently, very notorious itong pump along Broad Street and


the farther away you go from that pump, the lesser the deaths

Ignaz Semmelweis (1847)


– Discovered that the incidence of puerperal fever could be
drastically cut by use of hand-washing standards in obstetrical Figure 3 Lifted from the lecturer's powerpoint
clinics
 Puerperal fever (“childbed fever”) was common in the
mid-19th century hospitals, and was often fatal
 Vienna General Hospital’s First Obstetrical Clinic:
doctor-wards had 3 times the mortality of midwife-
wards 

Framingham study (1949)
– Risk factors for CHD
– 1948: longitudinal study of a defined population in
Framingham, MA
– 5,209 Framingham residents between 30 to 60 years of age
– Relationship between given characteristics and the risk of
death from myocardial infarction
– Produced a landmark report:
Figure 4 Lifted from the lecturer's powerpoint
 Predictive power of BP, blood cholesterol levels,
and cigarette smoking for CHD
DISEASE OCCURRENCE in the POPULATION
According to the Framingham Study, that there is significant Concepts of Disease Occurrence
relationship between high blood pressure, blood cholesterol, Critical premise
smoking with CHD – Disease and other health events do not occur randomly in a
Doll and Peto (1951) population, but are more likely to occur in some members of
– Longitudinal study: lung cancer and smoking the population than others because of risk factors that may
– 34,440 male British doctors surveyed about their smoking not be distributed randomly in the population.
habits: followed for 20 years
– this long-term follow-up study indicated a strong Critical premise is the disease and other health events do not
association between lung cancer and smoking (dose-response occur randomly. There has to be a reason why a disease occurs.
relationship)
Cause
What do you understand about dose-response relationship? – an event, condition, characteristics, or combination of these
The higher you have of something, the higher the chances of factors, which play an important role in the occurrence of a
getting the associated outcome. disease
Characteristics of a Cause
– some non-smokers developed lung cancer while some
 Cause must precede the effect
heavy smokers did not develop the disease
 Can be either a host or environment factor (e,g.,
characteristics, conditions, actions of individuals, events,
What do you notice also was some non-smokers developed lung
natural, social, or economic phenomenon)
cancer while some heavy smokers did not develop the disease.
So what does that tell you now? There might be other factors  May be positive (presence of a causative exposure) or
associated with lung cancer. negative (lack of a preventive exposure)

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FAMILY AND COMMUNITY MEDICINE II INTRODUCTION to EPIDEMIOLOGY MODULE #1, LECTURE #1

A cause might be positive or negative. Positive in a sense that if that a cause has occurred first before a disease. So if A occurs
the cause is around or the cause is present it causes disease or then B should occur.
a lack of the cause prevents the disease..
Types of Association
Why is knowledge on cause important?  Causal association
– Formulation of intervention measures – An association in which an alteration in the frequency and
– Formulation of preventive and control measures quality of one category is followed by a change in the other

Now why do we need to know all these? It’s important because An association in which an alteration in the frequency and quality
to be able to formulate what kind of interventions we can give in of one category it could be exposure is followed by a change in
a larger scale. We also want to know these because we want to the other which is the outcome or the disease.
formulate a preventive and control measures.
 Non-causal
Concept of Causation – Disease causing the exposure (rather than the exposure
causing the disease)
 Often times, causal relationship between an exposure and a – The disease and the exposure are both associated with a
disease can never be proven third (confounding) factor, X, is inadvertenly measured.
 Risk factor (determinant)
– A variable associated with an increased risk of disease or
infection Non-causal association which is often times called as artifactual
– Person characteristics (behavior/lifestyle, family or spurious. What do we call this particular variable? We call
background, inborn/inherited condition) them your ‘confounders’ which could distort the relationship that
o Environmental characteristics (exposure to a you are after.
substance/product) 

– Can be:
o Non-modifiable (age, family history), or
o Modifiable (BMI, blood pressure)
 Many diseases have specific causes (e.g., RNA virus
Morbillivirus causes measles), BUT cause remain uncertain
for many chronic diseases (cancers, AD, CHD)
– Scientist/investigators look for factors that appear to be Figure 5 Types of Association
linked to the development of a disease
– if risk factors are present, there is an increased chance, Association is NOT equal to causation
but not a certainty, that the disease will develop

Knowledge of Risk Factors


 Even in the absence of known pathogenic causes or cellular
mechanisms, knowledge of risk factors can lead to effective
treatment and prevention
 Epidemiologic research provided information that has formed
the basis for public health decisions long before the
mechanism of a particular disease was understood.

Causation vs Association
 Association
– identifiable relationship between exposure and disease
(co-existence)
– AB

In Association, if A increases B will also increase alongside.
Epidemiologic Methods
 Causation
 Epidemiology does not determine the cause of a disease in a
– Presence of mechanism that leads from exposure to
given individual. Instead, it determines the association
disease (cause-effect)
between a given exposure and frequency of disease in
– AB populations.
 Epidemiologic studies are undertaken to demonstrate a link
How about Causation? When we say Causation we actually are (statistical association) between factor and disease
talking about a particular mechanism and it follows a timeline – Statistical association allow epidemiologists to make
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FAMILY AND COMMUNITY MEDICINE II INTRODUCTION to EPIDEMIOLOGY MODULE #1, LECTURE #1

inferences about causal association.  Sources of data


 Different techniques for gathering and analyzing epidemiologic – Routinely-collected type (e.g., census data, vital statistics,
data clinical records employment health examination)
– Vary depending on the type of disease being monitored  Uses:
 Objectives of many epidemiologic studies: – Trend analysis
– Identify factors that are causally related to the occurrence o Describe patterns of disease occurrence
of a disease – Health care planning
– Once identified, assess how much such factors o Efficient allocation of resources
contribute to the occurrence of disease o Education and prevention progress for identified target
 Factor = “determinant” population
 Given this association, one may expect that the higher the – Hypothesis generation
level of the factor, the more frequent the disease in the o Formulation of research questions
population. o First step in risk factor determination
 Conversely, one may also expect that manipulation (more
specifically, elimination of the factor) would lower the Descriptive Research Designs
incidence of the disease (i.e. the occurrence of new cases) =  Types (according to hierarchy of evidence for cause-effect
Prevention (one of the major goals of the epidemiology) relationships)
o Case Report
Descriptive Epidemiology o Case Series
o Ecologic studies
 Amount (magnitude) and distribution of disease within a o Cross-sectional studies – could either be descriptive or
population by person, place, and time (measures of analytical studies
frequency)
Analytic Epidemiology
We are interested in the magnitude. How grabe o laganap is a  Interested in determinants of disease
disease.  Critical distinction from descriptive: analytic epidemiology
Generation of hypothesis involves studies designed to test a hypothesis (not just
count/record data)
Analytic Epidemiology  Is there an association between
 Determinants of the disease (etiology, causation)  Independent and dependent variables?
 Determines if an association exists (between exposure  Predictor and outcome?
and disease)  Exposure and disease?
Descriptive Studies  Key feature: a comparison group
 Inquiry into:  Key strategy: use of comparison group
 The nature of an unknown phenomenon (new disease)
or the occurrence of an event 2 x 2 Contingency Table

Like for instance in new disease starts showing up. Of course,


you know nothing about the disease yet and you conduct a
prevalence studies so you would understand the disease even
more.
 The amount and distribution of disease within a population
or across population groups
 The pattern of occurrence of disease or condition by person,
place, time
 First step in risk factor determination
 Data lead to formulation of research hypotheses
 Study of
– The amount or occurrence of disease and its distribution
within a population
– For the purpose of identifying a non-random variation in Figure 6 2x2 contingency table
disease occurrence
Two Categories of analytic studies
You need to find if there is a pattern. If there is actually a cluster 1. Observational
of a particular population wherein you notice more of a disease  Observation of exposure and disease status of each study
that there might be something going on in that particular cluster. participant (no manipulation)
 Types:
o Cross-sectional
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o Case-control Person
o Cohort study  Inherent characteristics (you can’t do anything about it)
2. Experimental  Acquired characteristics (modifiable)
Investigators manipulate the level of exposure (intervention)  Characteristics are important because:
for each individual or community; its effects on exposure  They affect risk of exposure to a source of infection
are then tracked over time  They affect host’s resistance or susceptibility to infection
 Random assignment of exposure
 Clinical trials : Community trials Person : Age
 Single most useful variable to describe occurrence and
Describing Disease Occurrences distribution of disease
Methods to describe disease occurrences  Its usefulness in understanding risk factors of disease
1. Statistical measures Is a consequence of the association between a person’s
 Measures of disease frequency (prevalence) age and
 Measures of central tendency/dispersion/location (interval,  Potential exposure to a source (e.g., occupation, lifestyles)
ratio)What are the two central tendency measure? It could  Level of immunity and resistance
either be the Mean or Median.
 Physiologic activity at the tissue level
What is the very important measure of dispersion? Standard  Is associated with mortality (death rate) and morbidity
deviation. (incidence rate)
 Frequency of disease
For location, we have quartiles, percentiles.  Severity of disease
2. Graphs
Age-mortality relationship
 Line graphs, bar, pie, histogram
3. Spot maps
 Location of cases marked

Descriptive Epidemiology
 Provides a way of organizing and analyzing data in order to
understand variations in disease frequency geographically
and over time, and how disease (or health) varies among
people based on a host of personal characteristics (person,
place, and time)
 Epidemiologic variables: 5Ws
 What: health issue of concern (case definition)
 Who: person, characteristics of persons at risk for the
disease
 When: time (e.g., time of the day, season…)
 Where: place, geographic location Figure 7 Death rate per 100,000 people by Age Groups
 Why/How: causes, risk factors, modes of transmission

Reasons for compiling and analyzing data by using 5Ws


1. To learn the extent and pattern of the public health problem
being investigated (e.g., which months, which neighborhoods,
which groups of people)
2. To create a detailed description of the health of a population
that can be easily communicated with tables, graphs, and
maps
3. To identify areas or groups within the population that have
high rates of or are at greater risk for disease (provides clues
to the disease causestestable hypotheses)

Uses of descriptive data


 Basis for formulation of hypotheses (clue to disease etiology)
 Public health planning and administration
 Allocation of resources (especially in areas where they are
limited)
 Planning for effective prevention or education programs Figure 8 Leading causes of death in the United States

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FAMILY AND COMMUNITY MEDICINE II INTRODUCTION to EPIDEMIOLOGY MODULE #1, LECTURE #1

Age-morbidity relationship
 Canadian Study of Health and Aging: Risk factors for
Alzheimer’s Disease in Canada
– Age found to be the strongest risk factor
– The older, the higher the risk factor for AD
o 1 in 100 between ages 65-74
o 1 in 14 between ages 75-84
o 1 in 4 over ages 85 and older

Person : Age
 In describing data by age
– Age groups should be kept relatively small so differences
can be detected
o Usually by 5-year age intervals
o Large groupings can hide important differences in
Figure 9 Schematized age curves for several acute infectious diseases distribution of cases
 One can be able to compute age-specific
incidence/prevalence/death rates

Importance of using appropriate age groups

Figure 10 Reported STDs in the United States

Figure 11 Registrations of newly diagnosed cases of cervical cancer


by age groups, females, England, 2011

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Person : Sex (Gender) Person : Race


 Associated with mortality (death rate)  Diseases common in certain races than others
 Higher for males than females  Sickle cell anemia (African descent)
 Associated with morbidity (incidence rate)  Cystic fibrosis (Caucasian descent)
 Rate from all causes higher for females than males (health
 Brugada syndrome/channelopathy (SE Asian males)
care-seeking behavior)
 Some diseases more common in one gender over the other  Due to:
 Could be due to the following (each providing different  Environmental patterns (economic, health care access)
opportunities for exposure to source of infection/disease):  Customs, habits, recreational patterns, patterns of diet
 Differing environment/patterns of behavior (recreation,  Inherited characteristics
travel)
 Sex-linked inheritance
 Differences in hormonal balance

Sex-mortality relationship

Figure 12 Median male and female age-specific suicide rates for


Canada, 2001-2005
Figure 13 Race and State of the US homicide gun deaths
Sex-morbidity relationship
 Men
o Prostate cancer
o X-linked recessive inheritance (e.g., color, blindness,
hemophilia)
o Abdominal aortic aneurysm (6x more common in men)
o Autism (4x more prevalent in males)
o Psychologists more likely to diagnose men with antisocial
personality disorder and substance-abuse disorders
 Women
o Toxic shock syndrome
o Breast cancer (99% in women)
o Ovarian cancer
Figure 14 Drug related death rates by age group, per 100,000, by
o Endometriosis
race
o Osteoporosis
Person : Occupation
o Autoimmune disease more prevalent (75%) in women
o Alzheimer’s disease (2x higher in women)  Identification of specific risks associated with exposure to
o Eating disorders (anorexia, bulimia) noxious agents peculiar to certain occupations (e.g., in
o Borderline or histrionic personality disorder factories, manufacturing)
 Indication of general conditions under which an occupational
group works – physical, mental, stress (e.g., call-center
Sex differences in morbidity and mortality
agents)
 Morbidity: F; Mortality: M
 Examples:
 Women seek medical care at an earlier age of disease
 Pulmonary fibrosis (exposure to free silica)
 The same disease will tend to have a less lethal course in
 Mesothelioma/lung malignancies (asbestos)
women than men
 Depression (FM)
Person : Others
Attempted suicide (F>M)
 Marital status
Complete suicide (M>F)
Differences in the ways of life of single and married
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(widowed/divorced) persons that are casually related to – Timing of control measures – to show impact of intervention
certain diseases on disease occurrence
 Religion  Trends:
 Practices (e.g., food intake, alcohol use, birth control, – Secular (Long-term)
personal hygiene) – Cyclic fluctuation
 Family size o Seasonal
o Day-of-week and time-of-day
 Affects nutrition, income, crowding – Epidemic

Place Secular Trend


 Could refer to:  Change in death/disease frequency that occur gradually over
1. Geographic distribution/category long periods of time (several decades)
– Rural vs. Urban
 Could be due to:
– Coastal vs. Uplands
– Change in age distribution
– Socio-economic differences
– Change in reporting, diagnosis
2. Features/conditions which existed to describe the
 Uses:
environment in which the disease occurred (e.g., distance
– To assess the prevailing direction of disease occurrence
from the area)
(increasing, decreasing, flat)
– Radiation
– To evaluate programs or make policy decisions
– Landfill
– To infer what caused an increase/decrease in disease
– River
occurrence
 Unit may be as large as a continent or country or as small as
– To use past trends as a predictor of future incidence of
a street address, hospital wing, or operating room
disease
 The following gives some basis for distribution of cases by
place:
– Place of residence
– Place of work
– Place of diagnosis
– Place visited/route of travel
– Birthplace

Figure 16 Secular trends of measles incidence in Poland, 1966-2009

Figure 15 Geographic distribution of Ebola virus disease outbreaks in


humans and animals

Time
 Period during which the individual cases of the diseases
were exposed and the period during which illness occurred.
 Some diseases can occur regularly, while others are
unpredictable
 Displaying the patterns of disease occurrence by time is Figure 17 Trends in Incidence Rates for Selected Cancers by Sex,
critical for monitoring disease occurrence in the community United States, 1975 to 2008
and for assessing whether the public health interventions
made a difference
 Represented as 2-dimensional graphs (time along x-axis)
– Period of exposure – may lead to insights into what may
have caused illness

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FAMILY AND COMMUNITY MEDICINE II INTRODUCTION to EPIDEMIOLOGY MODULE #1, LECTURE #1

Figure 18 Trends in Death Rates Among Males for Selected Cancers,


United States, 1930 to 2008

Figure 20 A. Rubella, 1963-1969 B. Influenza, 1994-2000 C. Rotavirus,


1994-2000

Day of week & Time of day


Figure 19 Trends in Death Rates Among Females for Selected  Shorter time periods
Cancers, United States, 1930 to 2008  Particularly appropriate for conditions related to occupational
or environmental exposures that tend to occur at regularly
Seasonal Trend
scheduled intervals.
 Disease occurrence can be graphed by week or month over  Patterns that emerge may suggest hypotheses and possible
the course of a year or more to show its seasonal pattern, if explanations that could be evaluated with further study.
any.
 Months or quarter-years often used
 Indicate variation in exposure to sources of infection
 May suggest hypotheses about how the infection is
transmitted, what behavioral factors increase risk, and other
possible contributors to the disease or condition

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FAMILY AND COMMUNITY MEDICINE II INTRODUCTION to EPIDEMIOLOGY MODULE #1, LECTURE #1

Figure 21 Farm Tractor Death by Day of Week


Epidemic
 Marked increase in frequency of disease over a period of time
– Can be as broad as weeks (prolonged epidemic) or narrow
as minutes (e.g., food poisoning), depending on the
incubation period and routes of transmission
 Epidemic curve
– Conventionally displayed as a histogram
– Sometimes, each case is displayed as a square
– Shape and other feature can suggest hypotheses about the
time and source of exposure, the mode of transmission, and
the causative agent

Figure 22 Number of confirmed cases of Ebola virus disease (Ebola)


and establishment of first Ebola treatment unit, by week of symptom
onset and key milestones

Combination of Person, Place


 Person – Place
– Studies on migrant populations
o Why trying to separate factors associated with place from
those that are characteristics of person

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