Contents Preface xi About the Author xiv The Scope and Significance of Epidemiology Leaning Ovjetives 1 Introduction 1 Importance of Epidemiology to Public Health 2 Some Applications of Epidemiology 3 Definition of Boidemiology 6 Summary 1 Now Terns 11 Study Questions and Hercses It References 12 The Evolutionary Roots of Epidemiology Learning Objectives 15 Introduction 15 Early Pioneers of Epidemiology 20 ‘The Modern Era 29 Summary 31 New Terms 32 Study Questions and Bzecises 32 References 33 Selected Disease Concepts in Epidemiology Learning Objectives 35 Introduction 35, ‘Common Models of Disease and Health 37 Natural History of Disease 40 Levels of Prevention 43 Immunity to Disease 46 Summary 52 New Terms 52 Saudy Questions and Brercies $3 References 53Contents An Overview of Epidemiologic Study Designs Learning Objectives 55 Introduction 55 Categories of Epidemiotogic Stadies 56 Descriptive Studies 58 Analytic Studies 59 Experimental Studies 71 Scentifying Epidemiologic Study Desigas 7 Summary 79 New Terms 80 Study Questions and Exercises 80 References 82 Basic Measures of Occurrence in Epidemiology Learning Objectives 85 Introduction 85 Measures of Incidence 86 Measures of Prevalence 102 General Health and Population Indices 110 Other Measures of Occurrence 112 Confidence Intervals for Incidence and Prevalence 120 Summary 125 Now Terms 127 Study Questions and Exercises 128 References 129 Comparing Measures of Occurrence in Epidemiology 151 Learning Objectives 131 Tattoduetion 132 (Ceade and Specific Rates 132 Adjusted Rates 134 ‘Age Adjustment 135 Measures of Association 150 ‘Testing for Statistical Significance 171 Summary 173 Nev Terms 175 Study Questions and Exercises 175 References 177Contents 7 Association and Causation in Epidemiology Leamsing Objectives 179 Innoduction 179 ‘Types of Association 180 ‘Types of Causes 183 Guidelines for Assessing Causation 187 Summary 190 Now Terms 191 Siudy Questions and Sxercioes 192 References 192 Assessing the Accuracy of Epidemiologic Studies Learning O¥jectives: 195 Inwoduction 196 Accuracy ofa Study 196 Bias 199 Confounding 210 Random Ewor 217 Summary 226 New Terms 228 ‘Saucy Questions and Exercises 228 References 250 Ecological and Cross-Sectional Studies Learning Oljecsves 233 Introduction 233 “Analytic Keological Smdies 234 Descriptive Ecological Studies 246 Analytic Cross-Sectional Studies 246 Descriptive Cross-Sectional Studies 257 Summary 258 New Terms 260 ‘Study Questions and Faercises 260 References 261 Case-Control Studies Learning Objectives 263 Introduction 264 Conceptual Overview 265 Key Desiga Features 267 ‘Analysis and Interpretation ‘of Case-Control Studies 277 Controlling Confounding 282Contents Effect Measure Modification 291 Advantages and Disadvantages of Case-Control Studies 305 ‘Variations in the Case-Control Design 307 Summary 308 New Terms 310 Seudy Questions and Exercises 311 References 312 Cohort Studies Leaming Objectives 315 Introduction 316 ‘Types of Cohort Studies 317 Key Design Issues 320 Overat! Analysis of Cohor: Studies 334 Evaluating Confounding and Effect Measure Modification 342 Induction and Latency Periods 360 Advantages and Disadvantages of Cobort Stadies 361 Summary 364 New Terms 366 ‘Study Questions and Exercises 367 References 368 Experimental and Quasi-Experimental Studies Learning Objecives 371 Introduction 372 Randomized Contolled Trials 373 Analysis of Randomized Controlled Trials 398 ‘Major Advantages anc Disadvantages of Randomized Controlled Trials 417 Group Randomized Trials 420 ‘Quasi-Experimental Studies 431 Summary 434 New Terms 438 Study Questions and Exercises 439 References 442 ‘Screening for Disease and Other Conditions Leaming Objectives 447 Introduction 448 ‘Types of Screening 449Contents Screening Programs; To Screen or Not to Screen? 481 Evaluating Screening Programs 438, Summary 497 New Terms 500 Study Questions and Brcercises 50 References 504 Disease Outbreaks, Disease Clusters, and Pubfic Health Surveillance Learning Objectives 507 Introduction 508 Disease Outbreak Investigation 508 Epidemic Curyes and Types of Outareaks 514 ‘Testing Hypotheses Using Analytic Studies 520 Disease Clusters $26 Public Health Surveillance 535 Summary $45 New Terms 547 Study Questions and Brercises 548 References 550 Appendix A Practical Resources in Epidemiology Appendix 8 Surveys aud Data Systems National Center for Health Statistics Appendix ¢ Ten Common Health and Population Indices Used in Epidemiology Glossary Index 615| | CHAPTER ONE. The Scope and Significance of Epidemiology ‘This chapter provides a succinct overview of the importance, Practical uses, and dimensions of enidemsiology as it relates to ‘public health and medicine. Learning Objectives ‘Explain the importance of epidemiology. Descrite at least five common appliestions of epidemiology. Define and give examples of sik factors, risk markers, and the disease iceberg concept. Explain the meaning and give an exansple ofa disease outbreak, Discuss the meaning and scope of epidemiology. Define temporal pattern of disease and compare and contrast short-term fluctu- ations, cyelie patterns, and secular trends. Distinguish among descriptive, analytic, and experimental epidemiology. Distinguish between efficacy and effectiveness, INTRODUCTION Rpidemiology is a dynamic field concemed with the occurrence of disease or other healthstelated events in human populations. Its scope covers the descrip- tion of disease patterns, the search for causes of disease, and practical applica- tions releted to disease surveillance, prevention, and contvol. Epidemiology is one of the fundamental disciplines relevant to public health and provides a basis for understanding public health problems, including their distribution, etural hhiswory, antecedents, and management. Epidemiology is also important to the practice of medicine since increased knowledge of disease and its causes aids playsicians and other health professionals with patien: diagnosis, weatment, and 12 Chapter One prognosis, Before defining epidemiology in greater deta, we will st take a Tioser look at its importance and apglications to public health and medicine. IMPORTANCE OF EPIDEMIOLOGY TO PUBLIC HEALTH Epidemiology provides a basis for describing and explain ‘population. A typical epidemiologic question might be, “How many new Gases of acquired immune deficiency syndrome (AIDS) were seported in a {given population in a given year?” if 300 new cases were reported, tis tells us something about the occurrence of AIDS in this population. We need a refer- tence point, however, to make sense of this mumber. We right, for example, Giant to compare the muriber of reported cases in the population to numbers Ja previous years to get an idea of whether AIDS is increasing o° decreasing inthis population. It would be better, however, to compare ris ox rate mes ase OPATDS since the population may have changed fiom one year 0 the ae ‘These measures allow 15 %0 make comparisons that acrount for dies rere pine saes ofthe groure being compared, The importance of wing rk Sraate measures f0 rake comparisons is discussed in chapter 5 ‘Describing public ealth problems from an epidemiologic Perspsce ‘pelps as to understand thts potential significance and impact, Thzouth som petsoot of epidemiologic measures such as incidence, prevalence, and oe Piiey we can identify potentially highisk groups and perhaps bisih M explain the reasons behind the differences. For example the estimated sate of seers of AIDS among adults and adolescents in the United Staess i6 new sues times highe: in males than females a secking en expianacon cmette aiference, one might want to examine differences in behaviors between the sexes as well as biological differences. ‘Epidemiology is also important to public Realth becaose © provides @ sass or dewloping, prioritizing, ond evaluating puic helsh prrerss Public yealth programs should be developed based 00 need, end the epidemiologic ‘pprosch is help in needs assessment. As a prelude 99 Cor Onie new pro- ‘prams in public health, one might ask such questions “What health prob- Bra re present in the community?” “Which problems Hove the greatest public eakthirapact?” and “Aze adequate resourors ‘available to implement Beeded programms?” These questions, and related ones cot be answered epi- pee local, Public health sarvelance (coaptet 14) ¢ ‘tool of epidemiol- gy, and epidemiologic surveys (appendix B) S0 ‘be used to assess the: Peatseney and scope of speciic public heat probierss “Measures of morbid- iy, mortality, years of potential life Tost, as Wel = ‘other epidemiologic mea 1. of occumrence (chaptes 5), can be used to characte’ the potential {papact or significance of public health problems io.» ‘population. Epidemiot- gy ena alco be wae to evaluate the sacceos of PURE health programs. Signif- gay em guction in the rate of risk-taking behaviors) disease incidence, oF ican may be woeful mucasores of progras’slong-crm Sooo. Other “polcations of epidemiology are discussed inthe following S°00‘The Scope and Significance of Epidemiotogy SOME APPLICATIONS OF EPIDEMIOLOGY Identifying Risk Factors for Disease _A major objective of epidemiology is identifying risk fairs for disease. This is ‘step toward understanding disease causation, A risk factor may be defined, as a behavior, ecvironmental expostre, or inherent human characteristic that {increases the probability of the occurrence of a given disease? Therefore it plays a causative role (chapter 7) n disease occurrence, For example, hyperten- sion isa well mown risk factor for stroke, and excess sun exposure isan estab- lished risk factor for skin cancer. Control of a risk factor should result in reduction in the risk of the disease. Tavs, controlling hypertension should reduce one's tisk of stroke. A related concept is risk marker (or ssi indicator), ‘which refers to a factor that i statistically associated with an increased risk of a fiven disease but which is not considered a causal factor for that disease. Ele~ ‘vated Creastive protein, for example, is a factor statistically associated with coronary heart disease, but itis not considered a cause of the disease. Risk ‘markers are therefore noneausl factors that are presumably associated with ‘ther causes of the disease. Eliminating a risk maker will not necessarily result in a lowered risk of the disease because of its noncausal sole. Chapter 7 dis- ccustes the diflerences beswveen causal and noncansal factors in greater detail. ‘Perhaps the most well known risk factor today is cigarette smoking, Which the US. Surgeon General bas determined to be a cause of ung cancer heart disease, certain chronic fung diseases, and other conditions. Furth more, epidemiologists have demonstated convincingly that a reduction ia cigarette smoking in a population results in a reduction in the frequency of these diseases. Interestingly, the term ris factor was popularized after its repeated use in research papers based on the Framingham Heart Study, one of the most well-known and enduring studies in epidemiologic history? ‘The Framingham Heart Study, which began in 1948, is a longitudinal study (see chapter 4), which was originally designed to identify risk factors associated with cardiovascular disease (CVD). The study began with @ repre Sentative sample of approximately 5,200 adult men and women between 30 and 62 years of age residing in Tramingham, Massachusetts, a town of about 28,000. The subjects were tracked throughout the years by monitoring hospi tal admissions and other sources and examining subjects biennially for the presence of CVD, The Framingham Heart Scudy has contributed significantly to our understanding of the sk factors that predispose individuals to CVD, including hypertension, diabetes, cigarette smoking, end blood cholesterol levels Some significant milestones in the history of the Framingham Heart Study appear in exhibit It, Evaluating the Efficacy of Various Treatments ‘Ate aromatase inbibitors efficacious in preventing recumences of breast can- cer in postmenopausel womea? Should individuals at risk of heart diseasetake an aspirin a day to prevent a first heart atiack® Is chemotherapy with Tanotere (docetaxel) efficacious in treating advanced lung cancer? Each of these questions can be answered epidemiologically by # randomized con trolled trial Gee chapter 4), which has become the gold standard for determin ing the efficacy" of vatious preventive and therapeutic procedures. The well Known Hypestension Detection and Follow-Up Program, for exataple, evalu ‘ated two approaches to treatment using a randomized controled trial izvolv {ng 10,940 subjects with hypestension, Subjects were randomly assigned to ‘ther stepped care or refecred care. Those assigned to stepped care received ‘progressive increases in their prescribed blood pressure medications oz addi- Eonal antibypertensive medicines so as to achieve desited blood pressure lev- cls. Those in the referred care group were advised to see their usual healt Gold standard refers to something that “widely reoogized asthe Best arabe "#7 He acy vefen to the benefits of treatment, procedure, or program among those Who use it com Serta shore who do not The tern i mos often usd in reference (© randomized conmeled ins razed tris efetivenay, hic refers othe benefits among thoee fo whom & Seat saat ccedure or peogram iotleed whether orzo hey use it” These ess are used agai rhe 1d whercemperectal sade ave cocused Eiacy wn ffctveness ae aborted pon exhibit‘The Scope and Significance of Epidemiology 5 care providers for treatment. The study found thatthe five-year mortality was 17 percent lower for those receiving stepped care compared to those receiving: referred care. The implication was for more aggressive treatment of hyper- tension, a philosophy which has since become standard practice in treating ‘patents with mild to severe hypertension. Investigating Disease Outbreaks ‘When routine vaccination for adenovirus types 4 and 7 was suspended at Fort Jackson, South Carolina, due toa vaccine shortage, an outbreak of ade- novirus type 4associated acute respiratory disease arose, The victims ofthe ‘outbreak were soldier at he fort completing heir basic training In all, 1,018 men and women trainees were hospitalized from May through December ‘with fever and other acute respiratory symptoms consistent with the disease ‘The majority of these patients tested postive for adenovirus type 4. Forto- nately, in this cas, reinsttution ofthe vaccine was effective in preventing far- ther spread of the disease, and the outbreak quickly subsided ® Ditease ours, ike that at Fort Jackson, are circumstances where there is a clear increase in the murber of cases of a disease compared to what is normally expected for the particular time and place. Disease outbreaks and idemics (chapter 14) ace investigated to identify their causes $0 a8 to miai ‘ize thei immediate impact and, most importantly, to prevent similar situn- tions from occurring in the furore. These investigations are a challenging dimension of epidemiology, and one that is important ro the maintenance of ‘public health ® The investigation of disease outbreaks is discussed in detail in chapter 14, Other Uses of Epidemiology In addition to the applications already discussed, there are several other areas, chore epidemiology is useful. As implied in the section on the iemiology, the epidemiologic approach can be very helpfe! in the heaith plaoning process, particularly in needs assessment, objective setting, and pro- gram evaluation, Epidemiology is also useful in health policy formulation since it cen answer vital questions about the benefits or harm resulting from specific interventions. Epidemiclogy also increases our understanding of the natural history or life cycle of specific disorders (see chapter 3}. Moreover, it can help us est ‘ate an individual’s risk of a particular disease based on epidemiologic find. ‘ngs from populations with characteristics similar to the individual. ‘This is ‘the basis for heaith risk appraisals for diseases like cancer and heart discase, which are based on individual risk factors, such as age, sex, personal behav- iors, and medical history. Epidemiology also aids us in completing the clni- ‘al picture of a disease by filling in the gaps for health care providers Physicians, for example, ordinarily have a distorted view of the severity and frequency of disease in the communities they serve due to the fact that not everyone who is ill seeks treatment, This illustrates the disease iceberg con-6 Chapter One cept.!? For example, when a primary care physician sees influenza patients in her office curing the “fu season,” she often overestimates the severity of the disease since she tends to see only the sicker patients (those requiring medical treatment). Furthermore, if she were to rely on the number of patients seek- ing medical assistance to quantify the extent of influenza in the community, she would inevitably underestimate its true frequency since many patients rely on selftreatment at home. The disease iceberg concept is so named because of the fact that four-fifths of an iceberg is submerged and out of view. Heath care providers typically see only the tip of the iceberg when it comes igeases in a community. Some common applications of epidemiology are summarized in table 1-1 Table 1-1 Common Applications of Epidemiology + Describing and Explaining Disease Occurrence in 2 Communi * Assisting in Developing Prirkizing, and Evaluating Public Heath Programs + Identifying Risk Factors and Ceusas of Diseases Evaluating the Efeacy or Efectiveness of Varlous Treatment Options + Investigating Disease Outbreaks or Epidemics + Assisting in Health Planning and Health Policy Formation + Understanding the Natural History of Diseases + Estimating Individual Risks of Diseases + Completing the Clinical Picture of Diseases DEFINITION OF EPIDEMIOLOGY By now, you should have a faily good idea of what epidemiology is and why itis important to the practice of public health and medicine It would be help- ful, however, to have a good, concise definition of this important discipline. For those who are interested in the origin of terms, epiderniology is detived from the Greek words “epi” (on or upon), “demos” (people), and “logos” (orord or statemen:). Literally, it translates as “a statement of what is upon the people." more practical definition is presented below. This definition can be thought of as the 3-D definition of epidemiology, where each of the “D" words in the definition has special significance, Epidemiology isthe study ofthe distribution, determinants, and deterrents “ofmorbidity and mortatity in harman populations.” ‘tis tporat wo note the in aditon o mexbidty ad mortaliy, which comprise the eajor focus of epitemicigy, he sicptine also deals wick a variety of other healthslsed luce sac ‘a8 cholesterol evi, dug abose, violence, weline, and bealh cate practices,‘The Scope and Significance of Epidemiology 7 ‘The term distribution, the first “D” word in the definition, refers to how morbidity (ness, disease, injury, et.)* and mortality (death) are distributed in a given population or community. Specifically, we are interested in describ- ing the frequency and pattems of morbidity or mortality in terms of person, lace, or time variables, Person variables relate to who is affected; place variables relate to where they are affecied; and time variables zelate to when they are alfected. Table 1-2 lists some of the more common person variables that may be used to describe che distribution of mazhidity or mortality. As an cxaonple, ‘we might describe the distribution of ang eancer in the United States by age ‘group, Sex, race, smoking status, and occupation. This description would yield 8 fairly good picture of who is afflicted with lung cancer in the United States and would suggest what groups appear to be at greatest isk for this disease. Table 1-2 Commonly Used Person Variables + Age + Religion + Sex + Marta status + Racelethricity + Heatth status *Socioeconomicstatus > Immunization status + Occupation + Lifestyle or behavioral practices (e.g, substance use) +Education + Environmental exposures (ea, asbestos exposure} Place variables include specific geographic areas (eg., census tracts, ncighborkoods, cites, counties, stares, regions, countries) snd general ioca’ tions (usban or rural areas, schools or other institutions, indoors or outdoors, at home or at work, along the lake or inlend, etc, Time variables may include the time of onset of a given disease (hour of the day, day of the week, ‘month of the year, ete.) ot the time of diagnosis, especially for those health related conditions where itis vietually impossibie to know the actual time of onset (c.g, dementia, arthritis, prostate cancer). Infectious diseases are ust- ally classified by when the first symptoms of disease appear. Chronic diseases tend to be classified by the date of diagnosis. Classifying morbidity or mortal- ity by time can also reveal temporal patterns of disease, which refer 10 changes in disease frequency over time. Common teraporal patterns of mor- bidity and mortality are illustrated in figure 1-1. They include’ + Short-term fluctuations + Cyclic patterns » Secular trends ‘Morbidity is defines as any departure from physiological or pegchologcal wellbeing and may inciuée hom objective 2nd sobecive stat? ‘The seria common wed to desorbe dscasey, injusss, end oder nonfaal conditions. wuld be thought oF ia bce tena8 Chapter One Figure 1-7 Temporal Patterns of Disease Short-Term Fluctuation Days yelte Pattern ‘ears‘The Scope and Sigaificance of Epidemiology 9 Generaly, short-term fluctuations represent relatively brief, unexpected ‘increases in the frequency of a particular disease in a particular population Short-term fluctuations are commonly manifested in disease outbreaks or epidemics (chapter 14). The sudden outbreak of c-yptosporidiosis ia Mil. waukee, Wisconsin, in the spring of 1993 represents a short-term uctuation, Jn this case over 400,000 people were aflticted with a parasitic infection cas. ing diarhea and abdominal pain over the course of several weeks, The Source ofthe infection was traced to the protozoan Cryptosporidium parvum, ‘which was spread through the public water supply. Once improvements were made in the water treatment system, the incidence of eryptosporidiosis dropped dramazically. Cyclic patterns represent periodic, often predictable, incrcases in the fe. quency ofa particular cause of mozbidity or mortality in « particular popula tion. For example, each year over the Labor Day weekend we expect that the ‘number of trafic deaths in the United States will increase by an anticipated amount, Also, influenza in the midwest tends to show a seasonal variation in frequency each year with the number of cases peaking in the late fall and carly winter months. Secular trends represent longterm changes in morbidity or mortality Patterns in a population. The U.S. mortality rate for septicemia, for exemple, showed a steady increase between 1951 and 1988, During the same time Period, the mortality rate for cerebrovascular disease declined significantly and only recently has begun to level off Caution must be exercised in asso. ‘lating secular changes with external influences, Sometimes changes in diag, nostic criteria, completeness of reporting, demographics, and other factors ‘may explain part or all of a secular trend, Desecibing the distribution of morbidity and mortality by person, place, ‘or me variables isa major focus of what is sometimes called descriptive epi. Gemiology. This dimension of epidemiology is concerned with variations in morbidity and mortality in populations. This information is not only useful im health care planning but can provide clues to the poteatial causes of ds. ce2se. The characteristics of descriptive epidemiologic studies are discussed in chapter 4 ‘While the term disribution in the definition of epidemiology refers to the ‘who, where, and when of morbidity and mortality, the second “ID” term, deter. ‘inant refers to why morbidity and mortality occur. The goal ofthis aspect of epidemiology, generally known as analytic epidemiology, isto identify causes of morbidity and mortality, Unoovering the causes of merbidity and mortality » Ss usualy accomplished by testing predetermined hypotheses using one of sew. ral observational epidemiologic research desigas. Initial steps are usually directed at identtying end confirming suspected risk factors, Judgments about causation are then based on the weight of accurmulated evidence (see chapters 4 and 7), Discovering the causes of morbidity and mortality is one of the most challenging dissensions of epidemioiogy. When experimental or quasi-experi- ‘mental approaches are wsed to uncover determinants of morbidity and mortal.10 Chapter One ity, this aspect of epidemiology is more precisely referred to as experimental epidemiology. The main difference is that analytic epidemiotogy employs ‘observational studies of determinants, while experimental epidemiology uses experimental or quasi-experimental methods. Typically, experimental studies in epidemiology are designed to determine the efficacy or effectiveness of planned interventions (,e., how well an intervention reduces a particular out- come). Table 1-3 summarizes the important differences emong these three dimensions of epiemiology. Chapters 4 and 9-12 discuss various descriptive, analytic, and experimental studies in epidemiology. ‘The third “D”" word in the 3-D defmnition of epidemiology refers to deter rents, From a practical point of view, the ultimate goal of epidemiology is to prevent or reduce morbidity and premature mortality in human populations. JIn.a sense, describing the distribution and identifying the determinants of morbidity and mortality are a prelude to secking deterreats, Morbidity and premature mortality in a popalation can sometimes be prevented or reduced ‘without fully understanding their distribution or determinants, as history has shown (see chapter 2). Knoviledge of these aspects, however, usually leads 0 ‘more effective strategies for prevention and control. Finally, epidemiology is concerned with human populations. As a branch ‘of public health, epidemiology is @ human science, and epidemiologists seck to understand and explain health-related events in defined groups of people ‘or communities (eg., the population of a state or region, African Americans, ‘women between 45 and S4 years of age). Clinical epidemiology, an offshoot ‘of classical epidemiology, is patient oriented it seeks to use epidemiology to tid decision making about clinical cases of disease, such as their diagnosis, ‘treatment, and prognosis.” Clinical epidemiology can be defined as “the application of epidemiologic principles and methods to problems encour tered in clinical medicine" Unlike classical epidemiology, which is a ‘branch of public health, itis most appropriate to view clinical epidemiology as a branch of medicine. Aspects of clinical epidemiology are discussed in subsequent chapters along with more customary aspects of epidemiology related to public health. Chapter 2 delineates otter common specializations Tobie 143 Descriptive, Analytic, and Experimental Epidemiology Descriptive Epidemiology: frequency and distribution of morbidity or mortality in # population by person, place, ortime variables. Urefulin planning health programs and services identyieg potential heatth-alated issues or tends, and suggesting hypotheses fr further study Analytic Epidemiology: A facet of epidemiology concerned with uncovering the ‘auses of morbidity and mortality using observational methods. Useful in dentiying ak factors for disease and explaining disease pattems in a population Experimental Epidemiology: A facet of epidemiology concerned with deveemining ‘the eficacy or effectiveness of various interventions using experimental or quas-exper imental metrods. Useful in evaluating treatments, procedures, programs or services.sb scoanianeehee CR sateen ‘The Scope and Significance of Epidemiology U1 :n epidemiology. To sum wp, epidemiology is a field of study concerned with the patterns, causes, and control of morbidity end mortality in human popu: tations. I is an integral part of public health with applications in medicine and other disciplines as well. SUMMARY + Epidemiology is the study of the distribution, determinants, and deterrents of morbidity and mortality in human populations. It seeks to describe, explain, and prevent or reduce public health problems that plague our soci- ery, It also provides a basis for developing, prioritizing, and evaluating pub- lic health programs. Some of the specific applications of epiciemiology include identifying risk factors and causes of diseases, evaluating the ellicacy or effectiveness of various treatment options, investigating disease outbreaks, explaining the natural history of diseases, estimating an individual’s risk of a specific health problem, and completing the clinical picture of disease for health care providers. Depending on its purpose, epidemiology may be classified as descriptive, analytic, of experimental epidemiology. Descriptive epidemiology describes morbidity and mortality by person, place, or time variables. Anatytic and experimental epidemiology seek to identify the causes of moxbidity and mortality, Epidemiology is a branch of public health thet also has apolications in medicine and other disciplines as well. Clinical epidemiology, in particulaz, isa branch of clinical medicine oem nnn New Terms analytic epidemiology old standard ical epidemiology morbidity cyclic pattem mortality descriptive epidemiology risk fector disease iceberg concept risk indicator effectiveness risk marker efficacy socular trend epidemiology short-term fluctuation experimental epidemiology ‘temporal patterns of disease Study Questions and Exercises 1, Haman immunodeficiency vieus (HIV) infection is a significant public health issue in the United States and abroad. Untreated, an estimated 90%12 Chapter One ‘or more of those infecred with HIV will develop acquired immune deli ciency syndrome or AIDS, Research has identified a mumber of risk fac. IV infection. Identify and discuss four distinct risk factors and rank them in relative order of impostance in the spread of HIV infection in the United States . Planting public health programs at the community level typically involves six major steps: (a) assessment of needs, (b) determination of priorities, (6) development of goals and objectives, (€) desiga of activities to achieve objectives, (c) implementation of the program, and ({) evaluation of pro- ‘cesses and outcomes. Describe how epidemiology can contribute to each Of these steps. In which steps is epidemiology likely to make the greatest contributions and in which the least? . Because of the disease iceberg concept physicians often have a distorted ‘View of the true nature of = disease in the communities they serve. Since those who seek treatment fiom physicians often differ from those who do not, a physician's view of the severity or distribution of a disease in the ‘community may not be characteristic of the disease as a whole. Identify three diseases of conditions that are likely to exhibit the disease iceberg concept and indicate why. Also, name three diseases or conditions that age unlikely to demonstrate the disease iceberg concept and again indicate why, Epidemiology has been referred to as the cornerstone or foundation of public health, Other than its role in health planning, how is epideraiology fundamental to the practice of public health? ieee ernie ements References 1. Centers for Diseae Consol and Prevention, Notional Centr for IV, STD, and TB Preven fon, Divisions of HIV/ATDS Prevention (2008), Cae of UV lftion ae ADS in he Usted ‘Siac, 2003, Avaable: hp: / wc gov /hi/sats/2005SurvelanceRe por. Table. (sess te Sate 4, 2005), 2.Last 4M, ed (2001). 4 Dison of Fromiogy ihed, New Yanks Oxford University Pree. 5. Natoeal fastiutes of Health, National Hear, Lung, ané Blood Teste (2002), Framing ‘bam Heirt Stady: SO Years’ of Research Succes. Avedable: tp//woruahlhaih gov? sbout/fmingher/index html (Acces dat: Tape 78,2005). 4 Bank 5. (1998). Unlocking the Hans Sores, U.S, Nowe Weld Rot (On-Line). Avail: hep/rw2.senews.cam ascew/issu/960907/ 7am hima (Arete date January 5, 199) S.Heenoesens C. H., and Busing 1B (1887), Seonslgy sx Meme Boron: Lit, row sad Company. {.Diy, 5.1995) Disonary Sy Cine Tak, Chichester John Wiley & Sore, La Pletcher, RH, Flecher 5. W, and Wagner, % H. (198), Civil Epidemic: The sen. ‘i, Zed. Balsmove: Wiles and Wilkins Beinn, CL. (198). Cina Tak: Dei, Conds, and dais New York: Ono Unie sig Pes, 9. MoNell, KM, Hendrix, RM, Lindner, JL, Benton, FR, Monteith, $C, Tuchecheret, ‘M.A. Gray,G,C, and Gayss, 3. C. (1999). Large, Pessina Epidemic of Adeaovirus Type ‘Assorated Aewte Respiratory Disease in US. Army Tramoes. Snare Dyce Dios (6: 198-801.: a Seach ‘The Scope and Significance of Epidemiology 13 10, Reinga, A. (1998), OutrentIavestgnsons—A Perspective, Bering Ics Diana ayaa 2s Thre, NE A (1989), ptoniiogy and Beh Fee Rockville, MD: Aspen 42, Duncan, D. F. (1989), Zptienag: Bane fr Date Promecion and Hees Promotion. Neve ‘Yorke Macmnla, 15. Matielis, VC. (986). Epidemiclogy: Cocmertone for Heald Eduction. Heth Biteaten 16-17. 4 Hoyer, D. 1, Kochanek, K. D, and Marpay, S.L, (1996). Deathe: Final Data for 1997 ‘atonal Pid Sais Reports 7 (9), yateae, MD National Center fox Heal Sati