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Epidemiology

CMD-80325: Public Health


Jurisprudence
Lynette Phillips, PhD, MSPH

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What is Epidemiology?

2
Jim Borgman, The Cincinnati Enquirer, 1997.

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BATTLING BAD SCIENCE:


DR. BEN GOLDACRE

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Questions:

Did any of this surprise you?


What was the main message?
What does he mean by sunlight?
Epidemiology: The sunlight in health
knowledge

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Epidemiology Overview

Epidemiology
Descriptive
Epidemiology
Descriptive
Studies

Analytic
Epidemiology

Surveillance

Experimental
Studies

Clinical Trials

Observational
Studies

Cohort
Studies

Case-Control
Studies

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Descriptive Epidemiology

Studies the frequency and pattern of health


problems in specified populations by
person, place, and time
Describes populations and health problems
Involves conducting surveillance
Answers the questions Who?, What?,
Where?, and When?

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Analytic Epidemiology

Uses comparison groups to quantify the


associations between determinants and
health problems
Tests hypotheses about causal
relationships
Involves studies concerned with identifying
health-related causes and effects
Answers the questions How? and Why?
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Epidemiology & Public Health

3 Core Functions 10 Essential Services

8
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A trip to 1850s London

Cholera outbreaks:
1832
1848-49
1853
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Dr. John Snow

Everyone thought cholera was spread by


bad air
Snows hypothesis: poison found in feces
and vomit of cholera patients, transmitted
by contaminated drinking water
How to test this theory?

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Observations

Who was getting the disease?


What characteristics were tracking with
disease?
Where were the cases located?
When did they occur?
Why might they have been occuring?

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The process

Found the index case: a merchant seaman


who arrived from Hamburg by ship on Sept. 22,
1848, rented a room in London, developed
symptoms and died
2nd man to rent the same room also contracted
cholera and died 8 days later (Snow suspected
room hadnt been cleaned thoroughly between
renters)
Began seeing sick patients, all who complained
of digestive problems first
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The process (cont.)

Few cases of cholera between 1849 and


1853
During this time, Snow kept working on his
theory
Published On the Mode of
Communication of Cholera pamphlet in
August 1849
Gave talks; was well known as a pioneer
in anesthesiology
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New epidemic: Summer 1853

New huge increase in cholera cases in


area of London where Snow was
practicing (Soho district)
Found out two private companies were
supplying water to the district:
Southward and Vauxhall drew water from an
area along the Thames known to be polluted
by sewage
Lambeth recently had moved its intake to a
location above the sewer outlets
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Comparing death rates by water company

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Collecting data

Took water samples from area pumps;


insufficient evidence of contamination
Gathered statistical evidence to compile
the (now famous) map: where victims
lived, where they got their water
61/73 (83.5%) victims had drunk the water
from the Broad Street pump
14/73 (19.2%) would have been expected as
part of a general outbreak in London
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Is this statistically significantly


different?

Two-sample z-test:
1 2
=
1 (1 1 ) 2 (1 2 )
+
1
2
0.835 0.192
=
(0.835)(0.165) (0.192)(0.808)
+
73
73
0.643
=
= 10.2, < 0.0001
0.063

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What about cases that couldnt be explained


by the broad street pump hypothesis?
A woman and her niece lived elsewhere
but died from cholera during the outbreak
Few workers from Poland Street
Workhouse and none from brewery in
neighborhood contracted cholera

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Conclusion?

Remove the handle of the


Broad Street Pump

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Changing Emphasis

Figure 1-5: US Crude Death Rates for Infectious Diseases

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Changing Emphasis

National Center for Health Statistics, National Vital


Statistics Report. Vol 54, no 19, June 2006

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A trip to 1940s Massachusetts

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Framingham Heart Study

National Heart Institute (now the National


Heart, Lung and Blood Institute, or NHLBI)
wanted to know more about general
causes of heart disease and stroke
Recruitment of 5209 men and women
between 30 and 62 from Framingham, MA
Extensive physical exams and lifestyle
interviews; follow-up every two years
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Framingham Heart Study

1971: Offspring study recruited (5124 of


the original participants adult children and
their spouses)
1994: Omni cohort (includes more
diversity, from current Framingham
population)
2002: Grandchildren of original cohort

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Research Milestones
1960
1961
1967
1970
1970
1976
1978
1988
1994
1996
1998
1998

Cigarette smoking found to increase the risk of heart disease


Cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of heart disease
Physical activity found to reduce the risk of heart disease and obesity to increase the risk of heart disease
High blood pressure found to increase the risk of stroke
Atrial fibrillation increases stroke risk 5-fold
Menopause found to increase the risk of heart disease
Psychosocial factors found to affect heart disease
High levels of HDL cholesterol found to reduce risk of death
Enlarged left ventricle (one of two lower chambers of the heart) shown to increase the risk of stroke
Progression from hypertension to heart failure described
Framingham Heart Study researchers identify that atrial fibrillation is associated with an increased risk of all-cause mortality.
Development of simple coronary disease prediction algorithm involving risk factor categories to allow physicians to predict multivariate coronary heart
disease risk in patients without overt CHD

1999
2002
2004
2005
2008

Lifetime risk at age 40 years of developing coronary heart disease is one in two for men and one in three for women
Obesity is a risk factor for heart failure.
Serum aldosterone levels predict future risk of hypertension in non-hypertensive individuals.
Lifetime risk of becoming overweight exceeds 70 percent, that for obesity approximates 1 in 2.
Based on analysis of a social network of 12,067 people participating in the Framingham Heart Study (FHS), researchers discover that social networks
exert key influences on decision to quit smoking.

2008 Discovery by Framingham Heart Study and publication of four risk factors that raise probability of developing precursor of heart failure; new 30-year risk
estimates developed for serious cardiac events.
2009 A new genetic variant associated with increased susceptibility for atrial fibrillation, a prominent risk factor for stroke and heart failure, is reported in two
studies based on data from the Framingham Heart Study.
2009
2009
2010
2010
2010
2010
2010

Framingham Heart Study researchers find parental dementia may lead to poor memory in middle-aged adults.
Framingham Heart Study researchers find high leptin levels may protect against Alzheimer's disease and dementia
Sleep apnea tied to increased risk of stroke
Framingham Heart Study researchers identify additional genes that may play a role in Alzheimer's disease
Framingham Heart Study finds genes link puberty timing and body fat in women
Having first-degree relative with atrial fibrillation associated with increased risk for this disorder
First definitive evidence that occurrence of stroke by age 65 years in a parent increased risk of stroke in offspring by 3-fold

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WHAT CAN BE DONE WITH


THESE DATA?

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Using Epidemiologic Data from


Framingham Heart Study
Who: Risk of heart disease differs between men and
women; specifically, women experience heart disease
later in life than men but with equal overall lifetime risk
What: These results helped clinicians and researchers to
take CHD seriously in women as well as in men.

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Using Epidemiologic Data from


Framingham Heart Study
Where: Risk of heart disease is highest in the
southeastern areas of the United States

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Using Epidemiologic Data from


Framingham Heart Study
When: Heart disease mortality has decreased, but
prevalence has increased (due mostly to lifestyle changes)

Source:
http://nccd.cdc.gov/DHDSP_DTM/DetailedData.aspx?State=United+States&Category=7&Indicat
or=42&stratification=Total

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Source: http://www.who.int/cardiovascular_diseases/en/cvd_atlas_14_deathHD.pdf?ua=1

For your class projects:

Describe the problem:


Who does it affect
What are the risk factors
Where are the highest rates (incidence,
prevalence, and mortality)
When is the disease most problematic (Early
age? Under certain conditions or in specific
socioeconomic categories? Etc.)
Why is this a particular problem that needs to
be addressed? Is there an economic or public
health burden associated with it?

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For your class projects:

Sources of epidemiologic data:


The World Health Organization (www.who.int)
The Centers for Disease Control and Prevention
(www.cdc.gov)
The National Institutes of Health (www.nih.gov)
NHLBI for heart, lung, and blood diseases
NCI for cancer

National or international non-profit organizations:

American Heart Association (www.heart.org)


American Lung Association (www.lung.org)
American Diabetes Association (www.diabetes.org)
American Cancer Society (www.cancer.org)
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