Introduction to Epidemiology

Unit 1

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 EPIDEMIOLOGY
Definition

The study of the distribution and

determinants of health-related states
or events in specified human
populations and the application of
this study to control of health
problems.

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 EPIDEMIOLOGY
Consists of Three Greek Words

• Epi = among
• Demos = people
• Logos = doctrine

Means: The doctrine of what is

among or happening to people.

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 EPIDEMIOLOGY
Two Fundamental Assumptions

• Human disease does not

occur at random.
• Human disease has causal
and preventive factors that
can be identified through
systematic investigation of
human populations.
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 Objectives of Epidemiology

• To identify the etiology or the cause

of a disease and the true risk factors
- that is, factors that increase a
person’s risk for a disease.
• To determine the extent of disease
found in the community.
• To study the natural history and
prognosis of disease.
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 Objectives of Epidemiology
• To evaluate new modes of health care
delivery and new preventive and
therapeutic measures - that is, factors
that increase a person’s protection
from developing a disease (protective
factors).
• To provide the foundation for
developing public policy and
regulatory decisions relating to
environmental and genetic problems.
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The 10 Leading Causes of Death, as a Percent
of All Deaths, United States, 1900 vs. 2000

1900 2000

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 Ten Leading Causes of Death in World, Developed (European
countries, former Soviet countries, Canada, USA, Japan, Australia, and New
Zealand) and Developing Countries - 2000

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(Source: Beaglehole R et al. Lancet 362:903-908, 2003)
WHO

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Life Expectancy at Birth, United States
(Source: U.S. Census Bureau)
Years
90
1900 2000 79.5
80 74.1
70
60
46.3 48.3
50
40
30
20
10
0
Males Females
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Ten Great Public Heath Achievements –
U.S., 1900-99
• Vaccination
• Motor-vehicle safety
• Safer workplace
• Control of infectious
diseases
• Decline in deaths
from coronary heart
disease and stroke
Source: CDC. MMWR 48:241-243, 1999
• Safer and healthier
foods
• Healthier mothers and
babies
• Family planning
• Fluoridation of drinking
water
• Recognition of tobacco
use as a health hazard
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 Ten Great Public Heath Achievements –
U.S., 2001-2010

• Vaccine-preventable • Cardiovascular disease

diseases prevention
• Infectious disease • Occupational safety
prevention and • Cancer prevention
control • Childhood lead
• Tobacco control poisoning prevention
• Maternal and infant • Public health
health preparedness and
response
• Motor vehicle safety

Source: CDC. MMWR 60:619-623, 2011

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13
 Top Ten Causes of Death in Children < 5
Years Old, Worldwide, 2000

Source: Strebel P et al. Journal of Infectious Disease (Suppl 1) 187:S2, 2003 14

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 Contribution of Top Ten Risk Factors to Global Burden of
Disease in Developed and Developing Countries - 2000

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Source: Beaglehole R et al. Lancet 362:903-908, 2003
 Levels of Disease Prevention

• Primary • Risk factor reduction

• Protective factor enhancement
• Decreases incidence and
mortality

• Screening (early detection and

• Secondary medical treatment)
• Decreases mortality and
sometimes incidence
• Tertiary • Alleviation of disability
• Decreases mortality

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 EPIDEMIOLOGY
Two Approaches to Prevention

• Population-based (public health)

approach
• High-risk (often require clinical
action) approach

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 EPIDEMIOLOGY
Usual Pattern of Reasoning

• Develop a hypothesis
• Test the hypothesis on an exposed human
population and include an appropriate
comparison group
• Systematically collect and analyze the data
to determine whether a statistical association
exists

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 EPIDEMIOLOGY
Usual Pattern of Reasoning
• Assess the validity of any observed
statistical association by excluding possible
alternative explanations such as
– Chance (random error)
– Bias (systematic error)
– Effects of additional variables that might
be responsible for the observed
association (confounding)

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 EPIDEMIOLOGY
Usual Pattern of Reasoning

• Judge whether the observed association

represents a cause-effect relationship
between exposure and disease

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 History of Epidemiology

• Fifth century B.C. - Hippocrates, the father

of medicine, suggests the development of
human disease might be related to the
external, as well as, the personal
environmental of an individual.

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 History of Epidemiology
• 1662 - John Graunt - a petty merchandiser in
London, publishes The Nature and Political
Observations Made Upon the Bills of
Mortality in which he:
– Analyzes the weekly reports of births and
deaths in London
– For the first time, quantifies patterns of
disease in a population

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History of Epidemiology
• 1796 - Edward Jenner, convinced through reported
observations that cowpox vaccination protects against
smallpox, took cowpox material from a lesion on the hand of
a dairy maid and inoculated an 8 year old “volunteer”, then
exposed this child to smallpox 6 weeks later; the child did
not contract smallpox.

1802 caricature of Jenner vaccinating patients who

Cowpox lesions
feared it would make them sprout cowlike appendages.
 History of Epidemiology

• 1839 - William Farr, a physician given

responsibility for medical statistics in
the Office of the Registrar General for
England and Wales, sets up a system
for routine compilation of the numbers
and causes of deaths.

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 History of Epidemiology

• 1855 - John Snow, a British

physician:
– Reports on his formulation and
testing of a hypothesis that
drinking water supplied by the
Southwark and Vauxhall
Company increased the risk of
cholera compared with water from
the Lambeth company
– Becomes perhaps the first
investigator to draw together all
three components (frequency,
distribution, determinants) of the Dr. John Snow
definition of epidemiology Born15 March 1813
Died16 June 1858

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William Farr’s Hypothesis on Cholera (cholera is transmitted by a cloud (miasma)
that clings low to the ground surface)

Deaths of Cholera by Elevation of Residence above Sea

Level, London, 1848-49
Elevation above Number of Deaths
Sea Level in Feet per 10,000 inhabitants
< 20 120

20 – 40 65

40 – 60 34

60 – 80 27

80 – 100 22

100 – 120 17

340 – 360 8

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Source: Textbook, p. 14
Death Rates from Cholera, 1853-1854, London
by water company supplying actual house

Number Cholera Deaths per

Water Company of Houses Deaths 10,000 Houses

Southwark and Vauxhall 40,046 1,263 315

Lambeth 26,107 98 37

Rest of London 256,423 1,422 59

Source: Snow J. On the Mode of Communication of Cholera (2nd ed). London: Churchill, 1855. Reproduced in
Snow on Cholera. New York: Hafner, 1965.
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 In addition, Snow found that the
water coming from the Broad Street
pump was cloudy; people had
reported that it smelt bad in the
days preceding the outbreak. The
well was nine meters deep, but a
sewer only seven meters below
ground was just above it. On 7
September 1854, a week after the
outbreak began, Snow got the
authorities to remove the pump
handle. The number of infections
and deaths fell rapidly.

http://www.makingthemodernworld.org.uk/learning_module
s/geography/05.TU.01/?section=2
Illustration of the contents of a pail of water
sourced from a cistern, around the time of the
1854 cholera epidemic in the UK. 29
 Examples of Scientists who have
Questioned Existing Pathogenesis
• 1850s - John Snow (a British physician) and cholera in
London, England
– Pathogenesis questioned – Cholera is not caused by London
fog (Miasm)
– Showed drinking water contamination was important to
pathogenesis
– Reward: called Father of Epidemiology – first investigator to
draw together all three components (frequency, distribution,
determinants) of the definition of epidemiology

• 1980s – Barry Marshall and Robin Warren (Australian

physicians) and gastritis and peptic ulcer disease
– Pathogenesis questioned – stress and lifestyle are major
causes of peptic ulcer disease
– Made the remarkable and unexpected discovery that gastritis
and peptic ulcer disease are the result of an infection caused by
the bacterium Helicobacter pylori
– Reward: 2005 Nobel Prize in Physiology or Medicine
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 History of Epidemiology

• 1855 through first half of 20th century - the study

of epidemiology is largely confined to infectious
disease
• Second half of 20th century - chronic disease
epidemiology gains importance

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