INTRODUCTION TO EPIDEMIOLOGY

Epidemiology Terms:
● Case fatality is the percent of people that have died compared to everyone with the disease
● Positive percent is the percent of population that tested positive

Common Diseases:
● COVID-19
● AIDS
● Zika (no treatment)
● Ebola

Epidemic vs. Endemic:

● Epidemic is an occurrence, in a community or region, of cases of an illness, specific health-related
behavior, or other health-related events clearly in excess of normal expectations
● Endemic is the constant presence of a disease within a given geographic area or population

Pandemic:
● Pandemic is an epidemic occurring worldwide or over a very wide areas crossing international boundaries
and usually affecting a large number of people

What is Epidemiology?
● Epidemiology is the distribution and determinants of health and diseases, morbidity, injuries, disability, and
mortality in populations
○ Distribution- implies that occurrence of disease varies in populations (some subgroups more
frequently affected than others)
○ Determinants- are any factor that brings about change in health condition
■ Biologic agents
■ Chemical agents
■ Less specific (behavioral)
○ Outcomes- possible results that may stem from exposure to a determinants/risk factor
■ Morbidity- illnesses due to a specific disease or condition
■ Mortality- death
● Epidemiology searches for associations between determinants and health outcomes
● Has a population based focus

Population focus:
● Focus is on the occurrence of health and disease in a population
○ Population- all the inhabitants of a given country or area considered together

Prevention:
● Epidemiologists research to find ways to intervene on disease development
● In terms of the three types of prevention, where would be the ideal place to intervene
● Primary- prevention of initial development of disease
● Secondary- early detection of existing asymptomatic disease to keep from becoming symptomatic
● Tertiary- reducing the social/physical impact of symptomatic disease

Important People and their studies:

● Ignaz Semmelweis= puerperal fever
● James Lind= scurvy on ships
○ Caused by lack of Vitamin C, spongy gums, loose teeth, bleeding into skin and mucous
membranes
○ Conducted 1st ever clinical trial
○ 12 sailors into 6 groups of 2
 ○ Took British Navy 40 years to adopt his recommendation
● John Snow= cholera
○ The father of epidemiology
○ Determined that cholera was an infectious disease spread by contaminated drinking water
● Robert Koch= Koch’s postulates
○ Verified that human disease was caused by a specific living organism
● Doll and Hill= smoking and lung cancer
○ WWII marked a transition away from the predominance of infectious diseases to chronic disease
○ Studies showed very strong associated between smoking cigarettes and lung cancer

Snow: Cholera and water origin:

● Soho District in London had major cholera outbreak in 1849
● Lambeth and S&V (water companies) supplied water from the Thames River
● In 1852,the Lambeth company relocated its sources of water to a less polluted portion o the river
● Snow noted that during the 1854 cholera outbreak, those residents served by the Lambeth had fewer cases
of cholera than residents served by S&V

Robert Koch 1843-1910:

● The organism must be observed in every case of the disease
● It must be isolated and grown in pure culture
● The pure culture must, when inoculated into a susceptible animal, reproduce the disease
● The organism must be observed in, and recovered from, the experimental animal

A.B. Hill Nine Criteria for Causality:

● Initial studies between determinants and outcomes
○ Is it causation or correlation?
● Characterizes the body of evidence

Historical transitions worldwide:

● Demographic transition- shift from high birth and death rates found in agrarian societies to lower birth and
death rates in developed countries
● Parallels epidemiologic transition which is a shift in morbidity/mortality from causes related primarily to
infectious diseases to causes associated with chronic diseases

DESCRIPTIVE EPIDEMIOLOGY: Person, Place, and Time

Intro:
● Unequal distributions of health and disease in populations
● To determine why health conditions vary throughout populations, ask:
○ Who was affected?
○ Where did the event occur?
○ When did the event occur?
Descriptive epidemiology:
● Descriptive studies- classifies the occurrence of disease according to
○ Person
○ Place
○ Time
● Descriptive epidemiologic studies definition- characterize the amount/ distribution of health in a disease in a
population

Uses of Descriptive Studies:

● Provides information and clues about disease
● Describes extent of problem
● Identifies who is at greatest risk
 ● Provides a basis for planning, providing, and evaluation of health services
● Generates info for future analytic studies

3 Approaches to Descriptive Epidemiology:

● Case reports- simplest category
○ One person’s disease
● Case series- summarize characteristics of patients from major clinical settings
○ Group of 10-15 people
● Cross-sectional studies- surveys of the population to estimate the proportion of a disease or exposure
present

Do diseases differ by age?

● Incidence and mortality from chronic diseases increase with age
● Some infections more common during childhood
● The leading cause of death in young adults is car crash
● Increasing maternal age is associated with increased rates of diabetes and related complications
● Multi-modal associations

Average Life Expectancy at Birth:

● Countries with highest life expectancy
○ Japan
○ Swaziland
● Counties with lowest life expectancy (in Africa)
○ Central Africa Republic
○ Chad
● U.S. expectancy is 78.99 years
○ Between Lebanon and Cuba

Race:
● Can be used to describe a population
● Can also be used to test a hypothesis that race is associated with an outcomes
○ Racial disparities and adverse health outcomes
● Race is not a dichotomous variable but a continuous variable
● Race can be used as a descriptive variable who is at higher risk
● Rate as a determinant- much more difficult because biologically
○ Poorly defined, not well understood
○ Race is a “visual classification”

Do disease rates differ by marital status?

● Marriage may operate as a protective or selective factor
○ protective/causative: may provide an environment conducive to health
○ Selective: people who marry may be healthier to begin with

Do disease rates differ by SES?

● Defined as a “descriptive term for a person’s position in society
● Often a composite measure:
○ Income level
○ Education level
○ Type of occupation

Do disease rates differ by religious affiliation?

● Certain religions prescribe lifestyles that may influence rates of morbidity and mortality
○ Example- Seventh Day Adventists
■ Follow vegetarian diet and abstain from alcohol and tobacco use
 ■ Have low rates of CHD, reduced cancer risk and lower BP

Place-specific exposures:
● Built environment related to study of BMI
○ Access to physical activity opportunities
■ Sidewalks
■ Neighborhood walkability
■ Proximity to play space
○ Access to food outlets
■ Availability of fast food restaurants
■ Number of food stores

Place considerations:
● Place can be considered from a distribution perspective or determinant
● Distribution perspective
○ Comparison of outcomes across geographic areas
■ Compare disease rates across regions
■ Countries
■ Hospital referral region
■ County, state, urban vs. rural differences
■ Neighborhood
● Determinants perspective
○ Measures an exposure geographically
■ Built environment and walkability
Time considerations:
● Secular trends
○ Gradual change in frequency of disease over period of time
● Cyclic (seasonal trends)
○ Increases and decreases in frequency of outcome over time
● Point epidemics

Point epidemics:
● May indicate response to a common source of exposure
○ Tuberculosis outbreak at elementary school at USC
○ Cancer among persons exposed to radiation at the Chermabyl Nuclear Power Plant explosion
○ Salmonella outbreak- reception at family reunion

SOURCES OF DATA
Quality and utility of data:
● Nature-
○ Data source?
○ Affects type of analysis and inferences
● Availability
○ Publicly accessible?
○ Important identifiers excluded?
○ Costs
● Completeness
○ Representativeness (generalization of findings)
○ Thoroughness (extent to which all cases have been identified)
● Strength vs. Limitations
○ Cases duplicated?
○ Missing data?
○ Timeliness of the data
Data/record Linkage:
● Joining data from two or more sources
● Linked by a common variable
● Must be concerned about whether linkage will inadvertently lead to the ability to identify specific persons

Sources of Data:
● Epidemiologic data comes in 2 forms
○ Raw- you sort and analyze it yourself
○ Processed- reported in text, tables, or figures

Population based Surveys:

● BRFSS- Behavioral Risk Factor Surveillance System
○ Collects state data from 400,000 U.S. residents each year regarding their health-related risk
behaviors, chronic health conditions, and use of preventive and screening services
● YRBSS- Youth risk Factor Surveillance System
○ Monitors health-risk behaviors that contribute to the leading causes of death and disability in youth
and adults
● NHANES- National Health and Nutrition Examination Survey
○ Designed to assess the health and nutritional status of adults and children in the U.S.; interviews
and exams 5,000 individuals annually

Case registries:
● A centralized database for collection of information about a disease
● Data can be used to:
○ Estimate incidence, prevalence, and survival
○ Track patient course of treatment/time to death
○ Select cases for case-control studies
● i.e.) cancer, Alzheimers, Autism
● SEER- Surveillance, Epidemiology, and End Results Program
○ Operated by the National Cancer Institute (NCI)
○ Authoritative source on cancer incidence and survival since 1973
○ Geographic reach: 8 states, 3 tribes, 9 cities/regions

National Center for Health Statistics- Surveys:

● NHANES
● NHIS- National Health Interview Survey
○ Program of the NCHS since 1957
○ Monitor the health of the U.S. population through the collection and analysis of data
○ Covers non-institutionalized population (excludes active duty military, prisoners, persons in long-
term care facilities)
○ 75-100k individuals surveyed in 35-40k households
● NVSS- National Vital Statistics Survey
○ Collects data on deaths, births, fetal deaths, marriages, and divorces
■ Death certificate and birth certificate

Medical Records Data:

● Inpatient and outpatient data
● Limitations of datta
○ Not representative of any specific population
○ Different info collected on each patient
○ Confidentiality of patient data
○ Settings may differ according to social class of patients
● Advantages
○ Verify self-reported medical history or behaviors
 ○ Determine patient’s exposure to medical treatments
○ Have a temporal record of the patient’s medical history

Insurance Data:
● Social security
○ Datta on disability benefits and Medicare
● Health insurance
○ Data on those who receive care through a prepaid medical program
● Life insurance
○ Data on causes of mortality
○ Data from physical examinations
● Medicare
○ Collected based on claims
○ Difficult to get this data; often not publicly available

Other Surveys:
● U.S. Census Bureau
● Decennial census (1980, 1990, 2000, 2010..)
● American Community Survey
● Economic census

Other sources of data:

● School health records
● Military health records
● Employee absenteeism data
● Social media and internet search activity data
● Reportable disease records

Types of Literature:
● Second types of data source
● Popular
○ Broad audience
● Scholarly (peer-reviewed)
○ Scientific audience
● Professional

Types of Literature:
● Popular
○ Broad audience
● Scholarly
○ Scientific audience
● Professional
○ Trade audience
Peer-reviewed literature:
● Peer review is a process of “subjecting research methods and findings to the scrutiny of others who are
experts in the same field”
● Peer review is an indication, but not a guarantee of quality

Grey literature:
● Produced on all levels of government, academics, business, and industry, in print, and electronic formats,
but which is not controlled by commercial publishers
○ Can be scholarly or professional
○ May be internally reviewed, but is rarely peer reviewed
In-class activity STDs:
● 1 in 5 people have and STD
● STD cases increase annually
● Almost half of the new STDs are found in ages 15-24
● STD prevention tries to focus more on women and youth
● CDC estimates that STD costs U.S. $16 billions in medical costs in 2018
● There are 8 common STDs seen in the U.S. population
● Men who have intercourse with other men are more likely to get an STD

SURVEILLANCE
Purpose and Characteristics:
● Evolved from infectious disease monitoring to include more chronic diseases, injuries, and environmental
exposures
● Occurs at many geographic/administrative levels
● May or may not occur in a well defined population
● Data collection may be active, passive, or both

History and Definition:

● Initially used to describe monitoring of persons who, because of an exposure, were at risk of developing
disease
○ If they exhibited evidence of disease, they could later be quarantined to prevent its spread
● Late 1800s- early 1900s
● Plague, cholera, yellow fever
● World Health Organization defines surveillance as “continuous, systematic collection, analysis, and
interpretation of health-related data”

Purpose and Characteristics:

● Data collection may be active, passive, or both
● Denominator information is critical
○ Denominator is number of patients in hospitals
○ Denominator is from census in large populations
● Must have quality control measures
○ Completeness and validity of data

Surveillance is an activity and NOT the data or data system used to collect or manage the data

Analyzing surveillance data:

● Descriptive statistics are usually appropriate
○ Counts vs. rates
○ Analyze by person, place, and time

What organizations do surveillance?

● CDC
● DHEC
● NCI
● WHO
● FDA
● Examples of surveillance programs
○ SEER program
■ Collects and publishes cancer data from population-based cancer registries in the U.S.
■ Periodically report on the cancer burden as it relates to cancer incidence and mortality and
patient survival overall
○ NNDSS- National Notifiable Diseases Surveillance System
 ■ Performs surveillance on diseases designated as nationally notifiable during Hepatitis A,B,
and C, tetanus, syphilis, rabies, cancer
■ Publishes findings from 57 state, territorial and local reporting jurisdictions weekly

Type of Surveillance:
● Passive- relies on health-care providers to report cases of notifiable diseases to the health department on a
case-by-case basis
○ i.e.) Notifiable diseases, SEER cancer registry, FDA adverse events
● Active- involves regular outreach to physicians and laboratories by the health department to get info on
specific conditions, often for brief periods of time
○ i.e.) DHEC contacting doctor’s, clinics, hospitals, and labs to find all new cases of Hepatitis C
● Syndromic- focuses not so much on cases of disease but rather clusters of symptoms and clinical findings
which might be suggestive of disease using existing data sources

Uses of Surveillance:
● Describe trends
● Planning prevention strategies
● Evaluation of intervention
● Projection of future trends
● Research
● Education and policy

MEASURES OF MORTALITY: Crude, Adjusted, and Specific Rules

Overview of Epidemiologic Measures:
● Count or ratio
● Count = actual count of people with disease
● Ratio = value obtained by dividing one quality of measure into another
● Most general form does not have any relationship between numerator and denominator
○ Rate is a type of ratio
○ X and Y are independent groups
○ i.e.) ratio of males to females in class
■ number of males in EPID 410 (X)
number of females in EPID 410 (Y)

Frequency Measure Rate:

● Rate = differs from a ratio in that the denominator includes the element of time
● Numerator is frequency of disease over a specified period of time
● Denominator is size of population at risk during a specified time period
● i.e.) number of males in class who got an “A” in Spring 2021, divided by males enrolled in class during
Spring 2021
○ Males in EPID who got an “A” in Spring ‘21 (X)
All males in EPID enrolled in Spring ‘21 ((Y)
** must know “population at risk” (Y)

Crude rates:
● Have NOT been modified to consider factors such as demographic composition of the population
● Crude death rate used to project population changes
● i.e.) number of deaths in a given year x 1000
Population at midpoint of the year
● Advantage: actual summary rate
● Disadvantage: often difficult to interpret since populations vary in composition

Crude mortality rate calculation:

● From these values, construct the crude mortality rate
 ○ Number of deaths in 2019 in U.S.= 2,854,838
○ U.S. population on 7/1/19= 328,239,523
■ Crude mortality rate = 2,854,838 = 0.00864*1,000= 8.64 deaths per 1,000
328,239,523

Crude birth rate:

● Used to project population changes
● Affected by the number and age distribution of women
● Number of live births within given period x 1000
Population at midpoint of that period

Crude birth rate calculation:

● Number of live births in 2019 = 3,747,540
● U.S. population as of 7/1/19 = 328,239,523
○ Crude birth rate = 0.0114 * 1,000= 11.4 births per 1,000 population

Infant Mortality Rate (IMR):

● Used for comparisons between groups - high rate indicates unmet health needs and poor environmental
conditions
● IMR = number of infant deaths during the year
number of live deaths during the year

Limitations of Crude Rates:

● Observed differences in crude rates may be the result of systematic factors within the population rather than
true variation in rates
○ This is why we need adjusted or specific rates

Adjusted rates:
● Summary measure
○ Statistical procedures used
○ Remove the effect of differences in population composition
● Necessary so we can…
○ Compare rates across states, countries, and regions
● What do we adjust for?
○ Age
○ race/ethnicity
○ Gender
○ SES
● Advantages: summary statement and differences in composition of population removed, allowing unbiased
comparison
● Disadvantages: fictional rate and magnitude depends on standard population chosen

Specific Rates:
● Refer to a particular subgroup of the population defined in terms of race, age, sex, or single cause of death
or illness
● i.e.) age-specific, sex-specific
● Age-specific example
○ No. of deaths among those aged 15-24 yrs. During given time period x 1000
No. of persons ages 15-24 yrs. During given time period
● Advantages: homogeneous subgroups and derailed aes can be useful for epidemiological purposes
● Disadvantages: cumbersome to compare many subgroups across 2 or more populations

Case Fatality (NOT a rate):

● Tell us how legal a disease is
 ● Reported as a percent
● i.e.) No. of deaths due to disease during given time x 100
No. of cases of disease during given time

Proportionate Mortality (NOT a rate):

● Proportion of all deaths attribute to specific cause
● Why is this different from a mortality rate?
○ Denominator is people who died, NOT total population
● i.e.) deaths due to by disease in given time period x 100
All deaths due to all causes in same time period
Practice:
1. Compare the rate of dying in Uzbekistan to the rate of dying in Japan
a. Adjusted death rates
2. Calculate the proportion off all deaths in the United Kingdom due to influenza
a. Proportionate mortality
3. Determine the risk of dying for babies aged 0-365 days in Bangladesh
a. Infant mortality rate
4. For 2020, determine whether persons in India who contracted COVID were more likely to die of their disease
compared to persons in India who contracted the influenza
a. Case fatality
5. Calculate the death rate for 45-64 year old in the U.S. who died as a result of suicide
a. Specific rate

MEASURES
Descriptive Epidemiology
● How we describe disease, health, disability and mortality in populations?
● Numbers
○ How much disease do we have?
○ If this is a new disease, how quickly are people developing disease?
○ If this is a disease that’s been around awhile, are people developing it again? How quickly?
○ If it’s been around awhile, how much disease is present in the community?
■ Where? Who is getting it?
■ Do we have the resources to take care of people who are sick?
■ Is this a disease that’s lethal? If so, can we develop a treatment, vaccine, or screening
test?

Prevalence:
● Number of existing cases of a disease over total population
○ Point prevalence= at a given point in time
○ Period prevalence= within a period of time (week, month, etc.)
■ Number of cases at beginning of time interval (point) + new cases that occur during time
period
● Asthma prevalence example:
○ Point: number of USC students with asthma based on self-report at time X
all USC students, based on X time
○ Period: No. of USC students with pre-existing or new asthma diagnosis in 2014
all USC students based on total 2014 enrollment

Uses of Prevalence Data:

● Indicate extent of health problem
○ What health care services are needed in a community
○ Allocation of facilities and personnel
● Estimate frequency of exposure in a population
 ● Not as good for studies looking at etiology
● Why is prevalence data not desirable when studying etiology of disease?
○ C (prevalence can include those recently diagnosed and those diagnosed a long time ago &
prevalence can include just individuals who survived the disease)

What increases or decreases prevalence?

● Increased by…
○ Ability to prolong life of patients without an actual cure
○ Improved diagnostic tests or reporting
○ Longer duration of disease
● Decreased by …
○ Discovery of a cure for the disease or good prevention strategy
○ Shorter duration of disease
○ High-case fatality

Incidence:
● Contains three elements
○ Numerator = number of new cases
○ Denominator = the population at risk
○ Time = the period during which the cases occur
● Population at risk
○ Capable of developing the disease
○ Individual in denominator must have the potential to be in numerator
● i.e.) incidence of prostate cancer in past year
○ New cases= 5
○ Population 2500 men and women

Incidence Rate:
● Number of new cases * multiplier
total population at risk
● Can you calculate incidence? yes

Applications of Incidence Data:

● Help in etiologic research of a disease
● Used to estimate the risk of developing a disease in those with/without risk factor
● Attack “rate” used in outbreak investigation, often reported as a percent

Describing disease using numbers:

● Incidence = new cases of disease X
Population at risk of developing disease
● Prevalence = existing cases of disease X
Total population

INFECTIOUS DISEASE EPIDEMIOLOGY

Infectious or communicable disease defined:
● “An illness due to specific infectious agent or its toxic products through transmission of an agent to the
susceptible host indirectly or directly through the environment
● Host: age, sex, genetic profile, previous diseases, immune status, etc.
● Agent: biologic (bacteria or virus), chemical (poison or alcohol), physical (trauma or radiation), nutritional
(lack or excess)
● Environment: temperature, humidity, crowding, housing, water, milk food, noise, etc.

Agent, Host, Environment:

● Agent- factor, such as a microorganism, whose presence is necessary for disease to occur
 ○ Virulence- severe clinical disease or highly fatal
○ Infectivity- ability to enter hose and multiply
○ Toxin production- agent produces toxin that causes illness
● Host- a person or other living animal that provides home for an infectious agent
○ Incubation period- time interval between invasion of agent and appearance of the first symptom of
the disease
○ Subclinical infection- an infection that does NOT show obvious symptoms
○ Carrier status- harbors agent, without apparent clinical disease, serves as potential source of
infection
■ i.e.) Typhoid Mary- was a cook that had to be quarantined for spreading typhoid disease
to those she cooked for
○ Index case- first case of epidemic that comes to attention of authorities
○ Patient zero- person to whom the outbreak can be traced back (official person who contracted
disease initially)
■ i.e.) Gaytan Dugas patient zero for AIDS
○ Immunity- host’s ability to fight infection
● Environment- anything external to the host
○ Physical - water, soil
○ Climatologic- warm, moist climate
○ Biologic- reservoirs available
○ Social behavioral- overcrowding
○ **each can increase or decrease likelihood of agent survival, contact between host and agent

Immunity:
● Active immunity- usually of long duration (measured in years)
○ Active natural- developed as result of natural infection with microbial agent
■ i.e.) getting chicken pox and becoming immune
○ Active artificial- acquired from an injection of a vaccine that contains an agent
■ i.e.) vaccine for chickenpox to be immune
● Passive immunity- usually short duration (measured in days or months)
○ Passive natural- newborn’s natural immunity received through mother
■ i.e.) mother’s breast milk
○ Passive artificial- immunity conferred by injections of antibodies contained in immune serums
■ i.e.) immune globulin

Modes of Transmission:
● Agent to host can be…
○ Direct transmission- refers to the spread of infection through person-to-person contact
○ Indirect transmission- contact with some intermediary…
■ Vehicle-borne: non-living object that is contaminated by agent
● Food borne or water borne
■ Vector-borne: agent has to go into vector (mosquitoes, flies, ticks) first then into the host
■ Airborne: involve the spread of droplet nuclei that are present in the air

Types of infectious diseases:

● Foodborne
● Waterborne (i.e.) cholera
● Sexually transmitted (i.e.) HIV/AIDS, gonorrhea, herpes, syphilis, chlamydia
● Vaccine-preventable (i.e.) measles, mumps, pertussis, polio, rubella
● Vector-borne (i.e) zika virus in pregnant women
● Zoonotic- from vertebrae animal to human (i.e) rabies, anthrax, avian influenza, hantavirus pulmonary
syndrome
● Emerging infectious diseases- newly appeared or known for some time but is rapidly increasing in incidence
or geographic range (i.e.) ebola and COVID-19
 ● Bioterrorism-related diseases- the deliberate release of viruses, bacter, or other germs to cause illness or
death in people or animals (i.e.) anthrax

Zika Virus:
● Agent: Zika virus
○ Characteristics: mild infection in host
○ Serious complications for unborn children of pregnant women
● Transmission: vector borne disease
○ Mosquito

Anthrax:
● Agent: Bacillus anthracis
○ Characteristics: toxin production
○ Case fatality rate approx. 50%
● Transmission: vehicle borne infection
○ Can be put in food, water, spray
○ Small amount can infect many

Principles of Sensors using B cells:

● Living B cells genetically altered so surface antibodies recognize bioagent antigens
● Aequorin gene is added to B cells
● When anthrax antigen attaches itself to B cell, an amplification process results in the B cell emitting light
● Light is detachable by the CCD array

How do B cells detect Bioterrorism agents?

● Sample comes through bioprocessor which purifies for use by B-cells
● Each of the colored squares represents a different bioterrorist agent and each emits a different color light
● Finally, the light is transformed into an electric current which notifies authorities

Are we prepared for the next pandemic?

● Current administration is conducting a whole-of-government review and update of U.S. National
Biopreparedness Policies
○ Final document: Administration’s Strategy on Biodefense and Pandemic Readiness. Five pillars:
■ Transforming our medical defense
■ Ensuring situational awareness
■ Strengthening public health systems
■ Building core capabilities
■ Managing the mission

What disease is next on the list for global eradication?

● Agent: Poliovirus
● Direct transmission
● No cure but vaccine preventable
● Continues in Afghanistan, Nigeria, and Pakistan
● Been around for 40+ years
● 375 cases worldwide in 2018
● Goal is worldwide eradication

OUTBREAK INVESTIGATIONS
Agent:
● Introduction of new agent (i.e. COVID-19)
● Change in old agent (i.e. influenza)
● New means of entry into host
● Increased dosage
 ● Increased virulence of an agent
● Longer exposure to old agent
● Multiple agents

Host factors:
● Highly susceptible subgroups
● Travel to endemic area
● Increased susceptibility
● Cultural or behavioral factors

Environment:
● New growth media
● New methods of dispersion
● Specialized facilities
● Invasive procedures
● New sexual practices
● Intravenous drug abuse
● Exposure to new environments

Practice change in agent, host, or environment:

● Legionnaires disease- disease spreaded throughout air conditioning in hotel
○ Change in environment
● Ebola
○ Change in agent
● Harrington dental clinic- patients had Hepatitis C and HIV due to using different sets of instruments for
patients he thought had HIV on patients that did not (different cleaning method on tools)
○ Change in environment
● Toxic shock syndrome- tampon used for several days had allowed bacteria to grow
○ Change in host
● HIV
○ Change in agent
● Covid-19
○ Change in agent

AIDS Pandemic:
● Initial focus on surveillance of cases
○ Identification of persons at highest risk
○ Possible mechanism of transmission
○ Environmental settings in which infection occurred
● Identification of HIV as the agent occurred years into the epidemic

Incubation periods:
● Shorter incubation periods- hours or days
○ i.e.) acute food poisoning, salmonella, Legionnaires disease
● Longer incubation periods- weeks or months

Point Source Epidemic:

● A group exposed to a common source of infection at a single place in time
● i.e.) church picnic or neighborhood and commercial distribution of food

Temporal Aspects of an Epidemic:

● Vary in duration from hours to years depending on:
○ Nature of the agent
○ The agent’s incubation period
 ○ The length of time required for effective contact
○ Number in the susceptible population

Epidemic cessation factors:

● Source of contamination eliminated or modified or agent is rendered nonpathogenic
● Mode of transmission is interrupted or eliminated
● Number of exposed or susceptible persons reduced
● Modification or elimination of vector required for primary agent

Steps in Foodborne Outbreak Investigation:

● Detecting a possible outbreak
● Defining and finding cases
● Generating hypothesis
● Testing hypothesis
○ Analytic studies
○ Lab testing
● Finding association between food and illness
● Finding the contamination and source of the food
● Controlling an outbreak
○ Recall products
○ Remove source of contamination
○ Revise production process
● Decide an outbreak is over

Case definition:
● Features of the illness
● The pathogen or toxin
● Certain symptoms typical for that pathogen or toxin
● Time range for when the illness occurred
● Geographic range, such as residency in a state or region
● Other criteria, such as DNA fingerprint

Attack rate:
● Used to describe the occurrence of food-bornes illness and other acute epidemics
● Attack rate = ill x 100 during time period
ill + well

ETHICS
Definition of Ethics:
● Ethics are “norms for conduct that distinguish between acceptable and unacceptable behavior”
● Public health sets the ethics for the population

What are some ethical issues in public health?

● Required childhood vaccinations to attend school
● Fluoridation of water
● Quarantine in case of highly infectious disease
● Rationing of scarce resources
● Question- does the need of the individual supersede the need of the population?

Why is it important to follow Ethical Principles in Research?

● Promotes aims of research
 ● Promotes values that are essential to collaborative work
● Holds researchers accountable to public
● Builds public support for research
● Promotes social responsibility

Nazi Medical War Crimes (1939-1945):

● Experiments conducted by Nazi physicians during WWII
● “Medical experiments” performed on concentration camps
○ Inject salt water into people’s veins and performed live autopsies
● Lead to Nuremberg Code 1946
○ Voluntary and informed consent is essential
○ 1st international code of research ethics

Declaration of Helsinki:
● World Medical Association developed set of ethical principles for the medical community for human
experimentation
● Not a legal document but guides national/international policy

What precipitated the next set of rules about ethical conduct in research?
● The Tuskegee Syphilis Studies
● Wanted to record the history of syphilis in black people
● Purpose of study “to record the natural history of syphilis in hopes of justifying treatment programs for
blacks”
● Study participants-
○ Men that participated in study were offered great incentives
■ If they left the study they lost their benefits
● Consent? Treatment?
○ Participants were not told they had syphilis, never told they received treatment
○ Participants never gave informed consent to participate
○ Researchers told men they were being treated for “bad blood” a local term used to describe several
ailments
○ Appropriate treatment as never given to participants even though it was discovered in 1947 that
penicillin was known to be effective

What is syphilis?
● Sexually transmitted disease
● Bacterial agent Treponema pallidum
● Can have sudden onset and long term phases

Class Action Lawsuit:

● Filed in 1973
● $10 million dollar settlement and medical and health benefits

What happened post Tuskegee?

● National Research Act enacted by the 93rd Congress on July 12, 1974
● Created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral
Research who wrote the Belmont Report
● Oversees and regulates the use of human experimentation in medicine

Belmont Report:
● Respect for persons
● Individuals with diminished autonomy are entitled to protection (i.e. prisoners, children, elders, disabled)
● Beneficence
○ “Do no harm”
 ○ Maximize possible benefits and minimize possible harms
● Justice
○ Individuals should be treated equally
○ Selection of subjects should not be based on convenience and manipulability

Changes since Belmont:

● HIPAA
○ Enacted in 1996
○ Title I- requires health insurance coverage for individuals when they change their jobs
○ Title II- standards for collection and privacy of health care
○ Transactions and provider identifiers
○ Privacy rule
○ Monetary penalties for violation of HIPAA
● Common Rule
○ Published in 1991 ub Code of Federal Regulations
○ Establishes criteria for:
■ IRB membership, review, and operations
■ Requirements for informed consent
■ Use of federal research funds
■ Suspension or termination IRB approval of research
○ Lays out specific rules that apply to federal agencies and those funded by federal agencies
● IRB

Ethics/Institutional Review Committees:

● Reviews and approves protocols for use of human subjects in research
● IRB consists of scientists, non-scientists, and community members
● Categories of research reviewed: exempt, expedited, and full review
● Required for institutions receiving federal research support

Examples of Unethical Conduct in Research:

● Guatemala STD Experiments
○ To test the effect of penicillin on syphilis
○ Used prisoners, psychiatric patients, soldiers, sex workers, orphans, and school kids
○ Problems: deliberately exposed persons to STD without consent, deception in conducting the
research study, use of highly vulnerable populations
● Willowbrook Study
○ To examine the development of hepatitis and test the effect of gamma globulin against hepatitis
○ Used mentally disabled children with hepatitis
○ Problems:unknown benefits to the children who were vulnerable, possible coercion of parents
● Arizona State- Havasupai Tribe
○ Study the behavioral and genetic contributions to DM
○ Used Havasupai Indian Tribe
○ Problems: blood samples used for other studies, blood samples sent elsewhere without consent of
tribe