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Questions for Epidemiology

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1. Is it safe to eat the tomatoes? 2. Will I get lung cancer if I smoke? 3. How can youth violence be prevented? 4. What's causing the obesity epidemic? 5. Who's at risk for substance abuse?

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Formal Definition: Epidemic

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"The occurence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess of normal expectancy"

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Pandemic

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-"An epidemic occurring worldwide, or over a very wide area, crossing international boundaries, and usually affecting a large number of people" -Example: the 1918 influenza (Spanish Flu) -Current: HIV/AIDS -Post: H1N1 (2010) -cases discovered in more than 214 countries worldwide

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Definition of Epidemiology

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-"is concerned with the distribution and determinants of health and diseases, morbidity, injuries, disability, and mortality in populations. Epidemiologic studies are applied to the control of health problems in populations" -causality is important -other societal concerns (bullying, low education rate)

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Key Characteristics of Epidemiology

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-Population Focus -Distribution (where diseases are distributed) -Determinants -Exposures (how much of an exposure) -Outcomes -Expressed in terms of morbidity and mortality -Quantification -Control of Health Problems

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Evolving Concept of Epidemiology as a Liberal Art

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-is interdisciplinary -uses the scientific method -is an observational science

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Descriptive Epidemiology

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-person, place, time to describe outcomes -epidemiologic studies that are concerned with characterizing the amount and distribution of health and disease within a population

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Analytic Epidemiology

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-exposures and health conditions -a type of epidemiology that examines causal (etiologic) hypotheses regarding the association between exposures and health conditions. -proposes and evaluates causal models for etiologic associations and studies them empirically

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Natural Experiments

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- a type of research design in which the experimenter does not control the manipulation of a study factor(s). The manipulation of the study factor occurs as a result of natural phenomena or policies that impact health.

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Hippocrates (460 BC- 370 BC)

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-Greek authority departed from superstitious reasons for disease outbreaks -wrote On Airs, Waters, and Places in 400 BC -suggested disease might be associated with environmental factors

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Black Death (occurred between 1346 and 1352)

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-Of great significance for epidemiology -thought to be caused by a bacterial infection of Yersinia pestis transmitted via flea bites -Claimed up to one-third of population of Europe (20 to 30 million out of 100 million people) -Characterized by: -swollen lymph nodes -fever -apperance of black splotches on the skin

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Paracelsus (1493-1541)

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-one of the founders of the field of toxicology -contributions include: -the dose- response relationship (how much of a toxin for response) -the notion of target organ specificity of chemicals

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John Graunts (1620-1674)

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- published natural and political observations mentioned in a following index, and made upon the bills of mortality (1662) -first to employ quantitative methods (numbers) -known as the Columbus of statistics table

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Ramazzini (1633-1714)

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-founder of the field of occupational medicine -he authored De Morbis Artificum Diatriba (Diseases of Workers), published in 1700

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Sir Percival Pott (1714-1788)

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-first person to describe an environmental cause of cancer -observed that chimeny sweeps had a high incidence of scrotal cancer

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Edward Jenner (1749-1823)

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-developed a method for smallpox vaccination in 1796

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John Snow (1813-1858)

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-described the link between cholera and contaminated water -important epidemiologic discoveries -power of observation and written expression -mapping -data tables -participation in a natural experiment -recommendation of public health measures

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Miasmatic Theory of Disease

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-"...disease was transmitted by a miasm, or cloud, that clung low on the surgace of the earth" -no relationship between microorganisms and disease yet

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William Farr (1807- 1883) "Compiler of Abstracts"

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-developed a more sophisticated system for codifying medical conditions -examined possible linkage between mortality rates and populations density (defined as number of persons per square mile)

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Robert Koch (1843-1910), a German physician

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-Published Die Aetiologie der Tuberkulose in 1882 -postulates demonstrated the association between a microorganism and a disease - 4 postulated 1. the organism must be observed in every case of the disease 2. it must be isolated and grown in pure culture 3. the pure culture must, when inoculated into a susceptible animal, reproduce the disease 4. the organism must be observed in, and recovered from, the experimental animal

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Pandemic Influenza (1918-1919)

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-also known as the Spanish Flu -killed 50 to 100 million persons globablly -field hospitals to treat people on the spot -not as big as black death

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Discovery of penicillin

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-Alexander Fleming (1881-1995) discovered the anti-microbial properties of the mold Penicillium notatum in 1928 -Antibiotic became available toward the end of World War II still use today

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The Contemporary Era (1940 to present)

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-Framingham study (ongoing since 1948) investigates risk factors for coronary heart disease -Epidemic Intelligence Services (EIS) 40's bioterriorism -Publication of U.S. Surgeon General's report, Smoking and Health (1964) identified deleterious effect of smoking upon health -Smallpox eradication (the only disease) -Discovery of the following associations: -human papillomavirus and cervical cancer -bacterium (helicobacter pylori) and peptic ulcers -genetic factors and cancer development

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Historical Use

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-documents the patterns, types, and causes of morbidity and mortality over time -example: decline in infectious disease mortality

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Community Health Use

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-"to diagnose the health of the community and the condition of the people, to measure the true dimensions and distribution of ill-health in terms of incidence, prevalence, disability and mortality..."

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Health Services Use

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-to study the working of health services with a view to their improvement -sample application: operational (operations) research

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Disease Management

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-refers to a method of reducing healthcare costs by providing integrated care for chronic conditions -examples include integrated care for: -heart disease -hypertension -diabetes -also known as self care management

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Risk Assessment Use

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-"to estimate from the group experience what are the individual risks on average of disease, accident and defect, and the chances of avoiding them

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Risk

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-the probability that an event will occur..

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Risk factor

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-an exposure that is associated with a disease, morbidity, mortality, or other adverse health outcome

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Risk assessment

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-a methodology used to provide quantitative measurements of risk to health

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Disease Causality Use

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-in order to assess potential causal associations, criteria must be considered

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Ethics in Research

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-refers to "...norms for conduct that distinguish between... acceptable and unacceptable behavior."

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Adherence to ethical norms in research

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-promotes the aims of research, such as knowledge, truth, and avoidance or error -promotes values that are essential to collaborative work, such as trust, accountability, mutual respect, and fairness -helps to ensure that researchers can be held accountable to the public -helps build public support for research -promotes a variety of other important moral and social values, such as social responsibility, human rights, animal welfare, compliance with the law, and health and safety

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U.S. Public Health Services Syphilis Study at Tuskegee

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-syphilis investigation from 1932 to 1972 -purpose was to "...record the natural history of syphilis in hopes of justifying treatment programs for blacks..." -total of 600 African American men participated -399 syphilis cases and 201 syphilis-free controls -never gave informed consent -despite discovery of penicillin, men were never offered treatment -class-action suit filed in 1973

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Ethics Guidelines for Epidemiologists

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-developed by the American College of Epidemiology (ACE) -the following are a few of these guidelines: -minimizing risks and protecting the welfare of research subjects -obtaining the informed consent of participants -submitting proposed studies for ethical review -maintaining public trust -[meeting] obligations to communities

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Counting and Tabulating Cases

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-data cleaning: the review of data for accuracy and completeness -a clean data set contains a group of data that are ready for coding and analysis

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Graphical Presentations

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-used to summarize key aspects of the data set -types of graphs: -bar chart -line graph -pie chart

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Bar Chart

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-frequency of discrete variables

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Line Graph

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-examine trends

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Pie Chart

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-proportion of diseases

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Mathematical formulas

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-Ratio (R) -Rate (r)* -Proportion (p) -Percent (P)

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Ratio

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-defined as "The value obtained by dividing one quantity by another" -types include -rates -proportions -percentages -expressed as X/Y

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Example of a Ratio Calculation

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-with respect to AIDS mortality, the sex ratio of deaths (males to female deaths)= X/Y where: X= 450,451 male Y= 89,895 female the sex ratio = 450,451/89,895= 5 to 1

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Proportion

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-a type of ratio in which the numerator is part of the denominator (ratio it is not) -may be expressed as a percentage

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Example of a Proportion

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-calculate this type of deaths from AIDS that occured among males A= number of deaths from AIDS among males= 450,451 B= number of deaths from AIDS among females= 89,895 TOTAL (A+B) 450,451+89,895 -A/(A+B)= 450,451/540,346=0.8336

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Percentage

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-a proportion that has been multipled by 100 -the formula is A/(A+B)*100

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Example of a Percentage

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-calculate this type of deaths from AIDS that occurred among males A= number of deaths from AIDS among males= 450,451 B= number of deaths from AIDS among females= 89,895 TOTAL (A+B) 450,451+89,895 -A/(A+B)*100= 450,451/540,346*100= 83.36%

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Magnitude of a Health Condition

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-proportions and percentages indicate how important a health outcome is relative to the size of a group -consider two separate sorority houses. One house has 100 residents, the other house has 30 residents. If 10 of the women in each house have the flu, what is the magnitude of the health issue in each house? -100 residents-->10/100= 10% -30 residents-->10/30-33.33%

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Rate

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-also a type of ratio, differs from proportion because the denominator involves a measure of time -used to measure risks associated with exposures and provide information about the speed of development of a disease -used to make comparisons among populations

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General Information Regarding Epidemiologic Measure

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-epidemiologic measures provide the following types of information: -the frequency of a disease or condition -associations between exposures and health outcomes -strength of the relationship between an exposure and a health outcome

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Types of Epidemiologic Measures

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-quantitative terms are useful in epidemiology to characterize the occurrence of disease, morbidity, and mortality in populations -quantitative terms include: -counts -incidences -prevelance

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Count

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-refers to the number of cases of a disease or other health phenomenon being studied -reports of single causes may have public health significance -case reports of patients with particularly unusual presentations or combinations of symptoms often spur epidemiologic investigations -example: one case of Ebola virus, smallpox

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Incidence

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-refers to the occurrence of new disease or mortality within a defined period of observation (e.g. a week,month,year, or other time period) in a specified population (population at risk) -describe the risks associated with certain exposures

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Incidence Rate Formula

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number of new cases/ total population at risk over a time period x multipler (e.g., 100,000)

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Prevalence

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-the number of existing cases of a disease or health condition, or deaths in a population at some designated time -variations: -period -point -lifetime

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Period Prevalence

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-all cases of a disease within a period of time -example: -percentage of people in U.S. who has asthma during the past 12 months of any particular year

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Point Prevalence

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-all cases of a disease, health condition, or deaths that exist at a particular point in time relative to a specific population from which the cases are derived -smaller period of time for a much smaller group of people

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Point Prevalence Formula

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number of persons ill/ total number in the group at a point in time

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Lifetime Prevalence

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-cases diagnosed at any time during the person's lifetime -example: lifetime asthma diagnosis

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four measures of morbidity (illness) and mortality (death)

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-crude rates -case fatality rates -proportional mortality ratio -cause-specific rates

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Crude Rate

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-has not been modified -includes a time period during which an event occurred -has limitations -entire population in population of interest frequency of disease over a period of time --------------------------------------------------------- unit size of population

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Crude Death Rate Calculation

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-number of deaths in the U.S. in 2005= 2,448,017 -population of the U.S. as of July 1,2005= 296,410,404 (2,448,017/296,410,404)*1,000=8.25

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Crude Death Rate

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number of deaths in a given year ------------------------------------------------ X100,000 reference population (during midpoint)

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Case Fatality Rate (CFR)

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-the number of deaths due to a disease that occur among persons who are afflicted with that disease number of deaths due to disease "X" ---------------------------------------------------- X100 number of cases of disease "X"

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Proportional Mortality Ration (PMR)

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-the number of deaths within a population due to a specific disease or cause divided by the total number of deaths in the population mortality due to a specific cause during a timer per ------------------------------------------------------------------ mortality due to all causes during the same time period X100

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Specific Rates

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-three examples are: -cause-specific rates -age-specific rates -sex-specific rates

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Cause-specific rates

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-a measure that refers to mortality (or frequency of a given disease) divided by the population size at the midpoint of a time period times a multiplier

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Age-specific rate (R)

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-the number of cases per age group of population during a specified time period number of deaths among those aged --------------------------------------------------- X100,000 number of persons who are aged (during time per.

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Sex-specific rate

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-the frequency of a disease in a gender group divided by the total number of persons within that gender group during a time period times a multipler

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Adjusted Rate

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-a rate of morbidity or mortality in a population in which statistical procedures have been applied to permit fair comparisons across populations by removing the effect of differences in the composition of various populations -age is a factor used in rate adjustment

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Factors that Affect the Quality of Epidemiologic Data

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-quality is determined by the sources used to obtain the data and how completely the data cover the reference population -the quality of data affects the permissible applications of the data and the types of statistical analyses that may be performed -ask the following questions: -what is the nature of the data, including sources and content? -how available are the data? -how complete is the population coverage? -what are the appropriate and inappropriate uses of the data? what are you going to do with it?

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Representativeness

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-also known as external validity -refers to the generalizability of the findings to the population from which the data have been taken

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U.S. Bureau of the Census

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-provides data that can be used to define the denominator in rates with respect to official estimates of total population size and subdivisions of the population by geographical area -conducted every ten years

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Vital Registration System and Vital Events

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-vital events are deaths, births, marriages, divorces, and fetal deaths -the vital registration system in the United States collects information routinely on those events

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Deaths

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- mortality data are almost complete because deaths are unlikely to go unrecorded in the United States -National Center for Health Statistics (NCHS) compiles and publishes national mortality rates -note that the specified cause may not be entirely accurate -primary cause sometimes unclear -diagnostic criteria may lack consistent standards -some conditions may be unreported because of stigma (AIDS, suicide, overdose)

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Information included on death certificate data in U.S.

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-demographic characteristics (e.g., age) -date and place of death (e.g., hospital) -cause of death (e.g., immediate cause and contributing factors)

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Birth statistics

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-include live births and fetal deaths -presumed to be nearly complete -used to calculate birth rates -helpful in understanding birth defects, length of gestation, birth weight, and demographic background of mother -affected by mother's failure to recall events during pregnancy -may miss conditions that were not detected at birth

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Data from Public Health Surveillance Programs

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-three examples are surveillance systems for the following: -communicable and infectious diseases -noninfectious diseases -risk factors for chronic diseases

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Public Health Surveillance

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-referes to the systematic and continuous gathering of information about the occurence of diseases and other health phenomena

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Syndromic Surveillance

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-describes "... using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response ." -Boston

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Reportable and notifiable disease statistics

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-by legal statute, physicians and other health-care providers must report cases of certain diseases to health authorities -usually infectious and communicable diseases that might endager a population

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Examples of Reportable and Notifiable Disease Statistics

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-sexually transmitted diseases -rubella -tetanus -measles -plague -foodborne disease

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Deficiencies of Reportable and Notifiable Disease Statistics

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-population coverage may be incomplete -no information is available about persons who develop the disease and do not seek medicial attention -infected individual may be asymptomatic -physicians and other providers may fail to fill out proper forms

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Chronic Disease Surveillance: the example of Asthma

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-asthma, a highly prevalent disease -asthma surveillance programs -1.asthma prevalence/severity -2. scheduled office visits -3 unscheduled office visits -4 ED/ urgent care -5 hospitalization -6 Morality -7 quality of life -8 cost -9 pharmacy -10 triggers

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Behavioral Risk Factor Surveillance System (BRFSS)

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-used by the United States to monitor at the state level behavioral risk factors that are associated with chronic diseases -examples of data collected relate to: -health risks behaviors -preventive health practices -health care access

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Case Registries

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-a registry is a centralized database for collection of information about a disease -register refers to the document used to collect the information -examples include: -the National Program of Cancer Registries -The Surveillance, Epidemiology, and End Results Program

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Data from the National Center for Health Statistics (NCHS)

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-scope of information is extensive -includes national surveys -immunization history, disabilities, health behaviors -examples of surveys and data collection systems include: -the National Health Interview Survey -National Health and Nutrition Examination Survey (NHANES) -The Vital Statistics System

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Life expectancy

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number of years that a person is expected to live, at any particular year (e.g., at birth)

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Maternal Mortality

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-encompasses maternal deaths that result from causes associated with pregnancy -a measure is the maternal mortality rate -lack of personal care, malnutrition, atopic pregnancy, low income, low education

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Maternal Mortality Rate

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number of deaths assigned to causes related to childbirth ------------------------------------------------------X100,000 number of live births

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Infant Mortality Rate

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-related to inadequate health care and poor environmental conditions -substantial racial and ethnic variations -crude rate since race and ethnicity were not involved

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Infant Mortality rate

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number of infant deaths among infants aged 0-365 days during the year ---------------------------------------------------------X1,000 number of live births during the year

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Fetal Mortality

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-death of the fetus when it is in the uterus and before it has been delivered -two measures are -fetal death rate -late fetal death rate (after 28 weeks)

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Fetal Death Rate

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number of fetal deaths after 20 weeks or more gestation ---------------------------------------------------------X1,000 number of live births+ number of fetal deaths after 20 weeks or more gestation

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Late Fetal Death Rate

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number of fetal deaths after 28 weeks or more gestation ---------------------------------------------------------X1,000 number of live births+ number of fetal deaths after 28 weeks or more gestation

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Crude Birth Rate

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affects the size of the population number of live births within a given period ---------------------------------------------------------X1,000 population size at the middle of that period

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General Fertility Rate

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# of live births within a year -------------------------------------------------X 1,000 # of women aged 15-44 yrs during the midpoint of the year

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Perinatal Mortality Rate

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number of late fetal deaths after 28 weeks or more gestation plus infant deaths within 7 days of birth ---------------------------------------------------------X1,000 number of live births + number of late fetal deaths

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World Health Organization (WHO)

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-provides global infectious disease surveillance -yields data on health indicators (WHOSIS database) -collects mortality data

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European Union

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public health data include social and health inequalities and determinants of health

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Determinant

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a factor or event that is capable of bringing about a change in the health status of a population

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