Basic Public Health and Epidemiology

Objectives: 1. 2. 3. 4. 5. Learn basic concepts of public health / epidemiology Begin to think quantitatively Understand how causes of disease are identified Learn examples of how prevention works Consider the application of prevention science to Africa

Key Concepts in Public Health

1. 2. 3.

Natural populations are the target. Surveillance systems provide information. Public health infrastructure links institutions that gather, disseminate and act on surveillance information.

4. 5.

Communities are mobilized. Health and disease are the result of social processes.

Rudolf Virchow said . . . . . (1845)

Mass disease means society is out of joint.

Ottawa Charter WHO

The fundamental conditions and resources for health are:

Peace Shelter Education Food Income A stable eco-system Sustainable resources Social justice Equity

Public health is the science of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention.
Public health involves the application of many different disciplines including: biology sociology mathematics anthropology public policy medicine education psychology computer science business engineering and much, much more . . . . Public health is concerned with protecting the health of entire populations. These populations can be as small as a local neighborhood, or as big as an entire country. Public health professionals try to prevent problems from happening or re-occurring through implementing educational programs, developing policies, administering services, and conducting research, in contrast to clinical professional, such as doctors and nurses, who focus primarily on treating individuals after they become sick or injured.

What is Epidemiology?
Classic definition: Study of the distribution and determinants of disease in populations.

Also: Study of outcomes and effectiveness of medical interventions. In its technical application epidemiology relies heavily on statistics.

Science and medicine have different ends. The intellectual foundation for medicine lies not in basic science but in epidemiology. The epidemiological setting provides the proper ground on which debates about the applicability of research evidence to practice should take place.

Lancet, 1995

Key Concepts in Epidemiology

Epidemiology has Two Branches: 1. Observational StudiesIncluding - cross-sectional, case series, case-control, prospective (cohort) studies 2. Interventional StudiesRandomized controlled trials; individuals or communities Some Basic Vocabulary : Measures of occurrence: Prevalence Incidence

Measures of risk:

Relative risk

Odds Ratio

Attributable Risk

Age adjustment

Learning to think quantitatively . . . . .

Mathematics is the language of science.

John Snows Investigation of Cholera Deaths, London, 1854

Water Supply Southwark & Vauxhall Co. Lambeth Co. Number of Houses Deaths per 10,000 Houses

Deaths

40,046 26,107

1,263 98

315 37

Rest of London

256,423

1,422

59

John Snows Cholera Map, London, 1854

Vital Statistics Measures

Numerator (Events) Birth rate Live Births Denominator (Pop. at risk) Midyear pop.

Crude death rate

Deaths

Midyear pop.

Infant mortality rate

Deaths before age 1

Live Births in the year

Age-specific mortality

Deaths for a specific age group

Pop. in age group

Age-adjusted mortality

Crude rate adjusted to a standard pop.

Le ading C a uses of D e at h in U S, 2 000

Center s for Disease C ontr ol & P r evention
He a rt Dis e a s e Ca n c e r Stro k e Re s p i ra to ry Dis In j u ry Dia b e te s Pn e u m o n i a /F lu Alz h e im e r' s Di s Kid n e y Dis e a s e 0 5 10 15 20 25 30 35

P er centage (of all deaths)

Actual Causes of Death in the US, 1990 & 2000

1990 2000

Tobac c o Die t/In a c tiv ity Alc o h o l M ic ro b ia l Ag e n t T o x ic Ag e n ts M o tor Ve h ic le s F ire a rm s Se x ua l Be h a v io r Illic it Dru g s 0 5 10 15 20

T ob a c c o Die t/In a c tiv ity Alc o h o l M ic ro b ia l Ag e n t T ox ic Ag e n ts M otor Ve hic le s F ire a rm s Se x ua l Be h a v ior Illic it Dru gs 0 5 10 15 20

P er centage (of all deaths)

P er centage (of all deaths)

www.cdc.gov, 2004

Percent of Energy from Different Food Components

HunterHunterGatherers 1515-20 Peasant Agriculturalists 1010-15 5 3535-40 Modern Affluent Societies

Fat

5050-70

6060-75

20

Sugar

2525-30

Starch

1515-20 1010-15 Salt (g/d) Fiber (g/d) 1 40 5-15 6060-120 12 10 20

Protein

Age-Adjusted Prevalence of Overweight or Obesity in US Adults

80
NHANES I I ( 1976- 80)

70

NHANES I I I ( 1988- 94) NHANES ( 1999- 2000)

Percent of Population

60 50 40 30 20 10 0 Ov e rwe i g h t o r Ov e rwe i g h t

Ob e s e

Ob e s e

from National Center for Health Statistics website www.cdc.gov/nchs

Blood Lead Measurements 1975-1981

110 100
Predicted blood lead

18

Lead used in gasoline 90 (thousands of tons)

16

80 70

Gasoline lead

Mean blood lead levels 14 g/dl Observed blood lead

60 50

12

10 40 30 8

1975

1976

1977

1978 Year

1979

1980

1981

Source: Pirkle et al JAMA 272:284-91, 1994

Cancer Death Rates, Men, US, 1930-2003

100
Rate Per 100,000 Lung & bronchus

80

60
Stomach

40

Prostate Colon & rectum

20

Pancreas

Leukemia

Liver

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Trends in Serum Cholesterol, Selected Countries

Men,

Serum Cholesterol and Risk of CHD, MRFIT

CHD and Saturated Fat Intake in 40 Countries

Causal Process in Atherosclerosis

Hypertension Obesity / Diabetes Diet High in Animal Fat Elevated Cholesterol Physical Inactivity Atherosclerosis

Smoking

The Development Process of CVD

Pathway Social and Environmental Conditions Adverse Behavioral Patterns Major Risk Factors First Event/ Sudden Death Disability/ Risk of Recurrence Late Death

Target Population Whole Population Whole Population Persons with Risk Factors Cases with First Fatal or NonNon-Fatal Events Survivors Late Deaths

Interventions Policy and Environmental Change Behavior Change Risk Factor Detection and Control Emergency Care/Acute Case Management Rehabilitation /Long/Long-Term Care End-OfEnd-OfLife Care

Death Rates from CHD and Stroke, US, 1950-2002

600 500
Rate Per 100,000

400 300 200 100 0

1950 1955

CHD 70%

Stroke

70%

1960

1965

1970

1975

1980

1985

1990

1995

2000

Trends in Stroke, 1967-97, Men

Goal of adjustment
Age Adjustment
- Age influences rate of most disease - Comparison of rates must account for age differences in populations

To reduce distortions and incomparability of rates when making comparison over time and among populations So we are not comparing apples to oranges
25

Crude Mortality Rates in Florida & Alaska 1988

Florida Number of Deaths 131,044 Alaska 2,064

Total Pop.

12,335,000

524,000

Rate (/100,000)

1,062

394

Age-Adjusted Mortality for Florida & Alaska, 1988

Age Group <5 5-19 20-44 45-64 >65 Age - Specific Death Rate Florida Alaska 284 57 198 815 4425 274 65 188 629 4350 U. S. Pop. Structure (%) 7.4 21.5 39.9 18.7 12.5 100% Age - adjusted rate = [ Crude rate 817.8 808.5 394] Standardized Rate Florida Alaska 21.0 12.3 79.0 152.4 553.1 20.3 14.0 75.0 117.6 543.8

= 1,062

Cross-Sectional Community Survey

- Population based - Requires sampling frame to be representative - Provides prevalence estimates - Can be a baseline for a Prospective Study

Prevalence and Incidence

Prevalence = Number of Cases in Population Population

Incidence =

Number of New Cases Total Number at Risk

Prospective or Cohort Study

Time Past Present Determine Exposure Future Determine Outcome

Cohort Study
Exposed or subjects

With Outcome

Cohort selected for study

Without Outcome

With Outcome Unexposed or controls Without Outcome

Onset of study

Time Direction of inquiry

Relationship between BMI and Risk of Type 2 Diabetes Mellitus

100
Men

A ge-A djusted R elative R isk

80

Women

60

40

20

<2 2

<2 3

2 -2 .9 3 3

2 -2 .9 4 4

2 -2 .9 5 6

2 -2 .9 7 8

2 -3 .9 9 0

3 -3 .9 1 2

BMI
Chan JM Diabetes Care 1994;17:961-69.

3 -3 .9 3 4

3+ 5

Prospective Study Hepatitis B Antibody Status and Liver Cancer

Hep B Ab Status Pos. Neg. Number of People at Baseline, 1975 3, 454 19, 253 Number of Cases 1975 - 1986 152 9 Incidence Rate, per 100,000 495 5

Relative Risk = 495/5 = 99

Prospective or Cohort Study

Study Design
Exposure: Yes No Number with Disease A C Number without Disease B D

A A+B

Statistic of Interest: Relative Risk =

C C+D

Prospective or Cohort Study

Smoking and Mortality Vital Status at 20 Years Exposure: Smokers Non-Smokers Dead 333 132 Alive 1336 486 Total 1498 819

Prospective or Cohort Study

Smoking and Mortality Vital Status at 20 Years A A+B C Incidence in Unexposed = C+D Relative Risk = 22.2 16.1 = 333 1498 132 819 = 1.4 = 16.1 per 100

Incidence in Exposed =

= 22.2 per 100

Randomized Controlled Trial

Study Design

Demonstration by Pasteur of Anthrax Vaccination, 1881

60 Sheep

10 Controls

25 Vaccinated

25 Unvaccinated

May 5, 1st Vaccination

May 17, 2nd Vaccination

10 Survivors

May 31, Injection of Anthrax Culture

24 Survivors 1 pregnant ewe dying

23 Dead 2 Moribund

Randomized Controlled Trial

With Outcome Experimental subjects Subjects meeting entry criteria Controls Without Outcome Without Outcome

With Outcome

Onset of study

XXXX
Intervention

Time

Randomized Controlled Trial

Study Design
Disease Outcome Exposure - ie, treatmentStatus Yes No
A

Yes A C

No B C

Statistic of Interest: Relative Risk =

A+B C C+D

Streptomycin in the Treatment of Tuberculosis

Appearance of chest x-ray at six months xX-ray Appearance Considerable Improvement Moderate Improvement No Change Moderate Deterioration Considerable Deterioration Death Streptomycin 28 10 2 5 6 4 55
Brit Med J, 1948

Control 4 13 3 12 6 14 52

Randomized Controlled Trial

Lipid Research Clinics CHD Primary Prevention Trial Disease Outcome
Treatment: Yes No CHD 155 187 Non-CHD 1751 1713 Total 1906 1900

Randomized Controlled Trial Lipid Research Clinics CHD Primary Prevention Trial Disease Outcome
Incidence in exposed - ie, treated = 155 1906 = 8.1 per 100

Incidence in unexposed - ie, untreated = 187 1900 Relative Risk = 8.1 9.8 = 0.83

= 9.8 per 100

Systolic BP Change in the DASH Trial

Prevalence of Obesity in Populations of African Origin

50 45 40 35 30 25 20 15 10 5 0
) s s s a i) s a o a ria a s ng oon nia cra fric uci ck ado aic lle ack e m e r la o g za A c A tL B a rb a m ch Bl ( Ni Ku f C me an h S t y J ( o Ca T na UK B US a ou Se c a n li S h G ha ub G ep R

Percent

Women
Cappuccio et al, in press

Men

Prevention of Type 2 Diabetes, Finnish Lifestyle Prevention Study

NEJM, 2001

The Potential of Population-wide Prevention of Diabetes . . . Per capita Daily Energy Intake in Cuba, 1980-2005
3500 3250

FAO data

Kcal / day / person

3000 2750 2500 2250 2000 1750

Food Surveys Apparent Intake

Franco, Cooper et al Am J Epidemiology, 2007

Prevalence of Obesity in Cienfuegos and Havana, Cuba, 1990-2000

Prevalence of Obesity %

15 14 13 12 11 10 9 8 7 6 5

Havana

Cienfuegos

Trends in Mortality from Diabetes, CHD, Cancer and All-Causes, Cuba, 1980 - 2005
Diabetes
125

25

Cancer

20
120

15
115

10

110

105

Mortality Rate

Mortality Rate

100

CHD
160 150 140 130 120 110 100 90 80 70
80 19 82 19 84 19 86 19 88 19 90 19 92 19 1 4 99 1 6 99 98 19 00 20 02 20 04 20

All Causes All-Causes

6.3 6.1 5.9 5.7 5.5 5.3 5.1 4.9 4.7 4.5
80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 19 00 20 02 20 04 20 06 20

Year

Year

Per 100,000

Measures to improve public health, relating as they do to such obvious and mundane matters as housing, smoking, and food, may lack the glamour of high-technology medicine, but what they lack in excitement they gain in their potential impact on health, precisely because they deal with the major causes of common disease and disabilities.

Geoffrey Rose, The Strategy of Preventive Medicine. Oxford University Press, 1992