Chapter 1

The History and Scope of Epidemiology

Learning Objectives
Define the term epidemiology Define the components of epidemiology (determinants, distribution, morbidity, and mortality) Name and describe characteristics of the epidemiologic approach Discuss the importance of Hippocrates hypothesis and how it differed from the common beliefs of the time Discuss Graunts contributions to biostatistics and how they affected modern epidemiology Explain what is meant by the term natural experiments, and give at least one example

2006 Outbreak of Escherichia coli

Outbreak during late summer and fall of 2006 Affected 199 persons and caused 3 deaths Caused 102 (51%) of ill persons to be hospitalized A total of 31 patients (16%) were afflicted with hemolytic-uremic syndrome (HUS) Spread across 26 states Fresh spinach linked to the outbreak

Epidemiology Defined
Epidemiology derives from "epidemic," a term which provides an immediate clue to its subject matter. Epidemiology originates from the Greek words, epi (upon) + demos (people) + logy (study of).

Definition of Epidemiology
Epidemiology 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.

Key Aspects of This Definition

Determinants Distribution Population Health phenomena Morbidity and mortality

Determinants
Factors or events that are capable of bringing about a change in health.

Examples of Determinants
Biologic agents--bacteria Chemical agents--carcinogens Less specific factors--stress, drinking, sedentary lifestyle, or high-fat diet

The Search for Determinants

Anthrax outbreak Outbreak of Fear--Ebola virus in Kikwit, Zaire Fear on Seventh Ave.--Legionnaires disease in New York City Red Spots on Airline Flight Attendants-dye from life vests Bioterrorism-Associated Anthrax Cases

Bioterrorism-Associated Anthrax Cases

Index case reported in Florida. Additional cases, including fatal cases, reported in New York, New Jersey, Connecticut. Contaminated mail linked to some of the cases.

Distribution
Frequency of disease occurrence may vary from one population group to another.

Disease Distribution Examples

Hypertension more common among young black men than among young white men. Coronary heart disease occurrence differs between Hispanics and non-Hispanics.

Population
Epidemiology examines disease occurrence among population groups, not individuals. Epidemiology is often referred to as population medicine. The epidemiologic description indicates variation by age groups, time, geographic location, and other variables.

Health Phenomena
Epidemiology investigates many different kinds of health outcomes:
Infectious diseases Chronic diseases Disability, injury, limitation of activity Mortality Active life expectancy Mental illness, suicide, drug addiction

Morbidity and Mortality

Morbidity--designates illness. Mortality--refers to deaths that occur in a population or other group. Note that most measures of morbidity and mortality are defined for specific types of morbidity or causes of death.

Aims and Levels

To describe the health status of populations. To explain the etiology of disease. To predict the occurrence of disease. To control the occurrence of disease.

Foundations of Epidemiology
Interdisciplinary Methods and proceduresquantification Use of special vocabulary Epidemic frequency of disease

Epidemiology Is Interdisciplinary
Epidemiology is an interdisciplinary field that draws from biostatistics and the social and behavioral sciences, as well as from the medically related fields of toxicology, pathology, virology, genetics, microbiology, and clinical medicine.

Quantification
Quantification is a central activity of epidemiology. Epidemiologic measures often require counting the number of cases of disease. Disease distributions are examined according to demographic variables such as age, sex, and race.

Epidemic
The occurrence in a community or region of cases of an illness (or an outbreak) clearly in excess of expectancy Relative to usual frequency of the disease.

Infectious Disease Epidemics

A single case of a long absent communicable disease. First invasion of a communicable disease. Two cases of such a disease associated in time and place are sufficient evidence of transmission to be considered an epidemic.

Concept of Epidemic and NonInfectious Diseases

Some examples that use the concept of an epidemic are:
Love Canal Brown lung disease Asbestosis among shipyard workers Diseases associated with lifestyle

Pandemic
. . . an epidemic on a worldwide scale; during a pandemic, large numbers of persons may be affected and a disease may cross international borders. An example is a flu pandemic.

Ascertainment of Epidemics
Surveillance Epidemic threshold

Surveillance
The systematic collection of data pertaining to the occurrence of specific diseases. Analysis and interpretation of these data. Dissemination of disease-related information.

Epidemic Threshold
The minimum number of cases (or deaths) that would support the conclusion than an epidemic was underway.

Historical Antecedents
Environment and disease The Black Death Use of mortality counts Smallpox vaccination Use of natural experiments Identification of specific agents of disease The 1918 influenza pandemic

The Environment
Hippocrates wrote On Airs, Waters, and Places in 400 BC. He suggested that disease might be associated with the physical environment. This represented a movement away from supernatural explanations of disease causation.

The Black Death

Occurred between 1346-1352 Claimed one-quarter to one-third of population of Europe

Use of Mortality Counts

John Graunt, in 1662, published Natural and Political Observations Made upon the Bills of Mortality.

John Graunts Contributions

Recorded seasonal variations in births and deaths. Showed excess male over female differences in mortality. Known as the Columbus of biostatistics.

Edward Jenner
Developed a method for smallpox vaccination

Use of Natural Experiments

John Snow was an English physician and anesthesiologist. He investigated a cholera outbreak that occurred during the mid-19th century in Broad Street, Golden Square, London.

Snows Contributions
Linked the cholera epidemic to contaminated water supplies. Used a spot map of cases and tabulation of fatal attacks and deaths.

Snows Natural Experiment

Two different water companies supplied water from the Thames River to houses in the same area. The Lambeth Company moved its source of water to a less polluted portion of the river. Snow noted that during the next cholera outbreak those served by the Lambeth Company had fewer cases of cholera.

Natural Experiment
Definition: The epidemiologist does not manipulate a risk factor but rather observes the changes in an outcome as the result of a naturally occurring situation.

Contemporary Natural Experiments

Currently, natural experiments may be the result of legislation, policy changes or environmental interventions.

Examples of Contemporary Natural Experiments

Seat Belt Law--Did seat belt use reduce fatalities from motor vehicle accidents? Tobacco Tax--Did the increase in cigarette price decrease the sale of cigarettes? Helmet Law--Did requiring the use of helmets by motorcyclists reduce the number of head injuries sustained?

William Farr
Appointed compiler of abstracts in England, 1839. Provided foundation for classification of diseases (ICD system). Examined linkage between mortality rates and population density.

Koch's Postulates
Microorganism must be observed in every case of the disease. Microorganism must be isolated and grown in pure culture. Pure culture must, when inoculated into a susceptible animal, reproduce the disease. Microorganism must be observed in, and recovered from, diseased animal.

The 1918 Influenza Pandemic

Occurred between 1918 and 1919 Killed 50- to 100 million persons worldwide 2.5% case-fatality rate versus 0.1% for other influenza pandemics Deaths most frequent among 20- to 40year-olds

Other Historical Developments

Alexander Langmuir established CDCs Epidemic Intelligence Service. Wade Hampton Frost was the first professor of epidemiology in the U.S. Joseph Goldberger discovered the cure for pellagra.

Recent Applications of Epidemiology

Framingham Heart Study (since 1948) investigates coronary heart disease risk factors. Smoking and lung cancer; e.g., Doll and Petos study of British doctors smoking. AIDS, chemical spills, breast cancer screening, secondhand smoke.

Additional Applications of Epidemiology

Infectious diseases
Avian influenza

Environmental health Chronic diseases Lifestyle and health promotion Psychiatric and social epidemiology Molecular and genetic epidemiology

Chapter 1 Quiz
Define the following terms:
Epidemic Health Phenomena Morbidity and Mortality List and describe the 4 Principle Aims of Epidemiology

List the contributions to Epidemiology of:

Hippocrates, Edward Jenner, and Robert Koch