Charles-Edward Amory Winslow, public health leader of early 20th c.

● Called epidemiology “the diagnostic discipline of public health”

○ Investigate causes, identify trends, evaluate effectiveness of interventions
○ Count number of cases and distribution of person, place, time

Endemic​ - usual rate of a disease

Epidemic ​- increase in the frequency of a disease above the usual rate

John Snow, father of modern epidemiology

London, 1853-4
● Cholera epidemic - hypothesized that cholera spread by polluted drinking water
● Broad Street outbreak
● Used ​vital statistics ​- government-collected data on births and deaths

Notifiable diseases ​- “surveillance system” - must be reported as soon as they are diagnosed; recognize
epidemic is occurring and prevent spread.
● ~60 NDs in the US: tuberculosis, hepatitis, measles, and syphilis
● Sometimes birth defects, cancer, noninfectious.
● Report to local health department → state health department → CDC
● Reporting of chronic diseases less widespread

Hepatitis A - notifiable in all 50 states. (p45 for full list)

● Has an incubation period of about 30 days
● Response: isolation of hepatitis-infected food workers

Endemic level ​- background level in a population

“Shoeleather epidemiology” - who, where (hardest), when

● Often food poisoning outbreaks caused by contamination with ​Salmonella​ or​ Shigella

Measles - highly contagious and preventable by vaccination

● Measles immunization required, 1970s
● Outbreaks on college campuses, 1989-91
● Concluded 2nd vaccination necessary for older children
● Response: vaccines

Legionnaires’ Disease, 1976

Philadelphia
● Fever, muscle aches, pneumonia
● Causative agent airborne; did not spread person to person
● Legionella b​ acteria had been pumped into the A/C and inhaled
● Responsible for outbreaks of pneumonia
● Legionellosis now a notifiable disease
● Response: stringent regulations on A/C systems
Eosinophilia-Myalgia Syndrome (EMS)
New Mexico
Consider infectious agents first, then exposure to a toxic substance.
● Fatigue, muscle pain, rashes, shortness of breath
● High counts of white blood cells (eosinophils)
● Victims took health food supplement - L-tryptophan
○ Recalled by FDA
○ Individual variations in susceptibility may exist - many people took the supplements with
no harm.
● Response: recall of contaminated food/drugs

Toxic Oil Syndrome, 1981

Spain
● Many chemicals at low concentrations may induce autoimmune responses and cause the immune
system to attack itself

Studying chronic diseases, such as cancer and heart disease, are much more difficult than investigations of
acute outbreaks of infectious diseases or toxic contamination.
● Many factors can cause it - “risk factors”
● Difficulty - they develop over long periods, hard to figure out what is relevant

Heart disease - leading cause of death in the US for men and women since the 1920s.
● Incline after WWII (⅕ men before age of 60 affected)
○ Framingham, Massachusetts Heart Study
○ Major risk factors: high blood pressure, high blood cholesterol, smoking
■ Weight gain, lack of exercise
○ Death rates falling by 1970s; decline in risk factors
● HDL (high density lipoprotein) cholesterol is good and LDL (low density) cholesterol is bad
● Drinking alcohol in moderation = good
● Smoker’s risk drops to that of nonsmokers soon after quitting
● Framingham Offspring Study, 1971
○ Studying diseases across families and generations - genetics

Lung cancer
● Mortality increasing since 1930s
● Linked to smoking
● British epidemiologists Richard Doll and A. Bradford Hill
○ Findings: death rate 20x higher in smokers
○ Death rate among ex-smokers declined over time
○ Difference not due to air pollution - same in urban and rural areas
○ Deaths from heart attacks more common among heavy smokers
● US epidemiologists E. Cuyler Hammond and Daniel Horn
○ Smokers 10x more likely to die of lung cancer
 ○ 5x more likely to die of other cancers
○ 2.4x more likely to die of heart disease
● Prospective cohort: most reliable to investigate chronic diseases - follow large numbers of people
over extended periods of time.
● Studies resulted in decline in smoking in US