公衛政策的基礎:流行病學

主講者：謝芳宜

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Introduction of Epidemiology

• Epidemiology is defined as
〝The study of the distribution and
determinants of health-related states or
events in specified populations and the
application of this study to control of
health problems.〞

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The objectives of epidemiology

• Identify the etiology or the cause of a

disease
• Determine the extent of disease found in the
community
• Study the natural history and prognosis of
disease
• Evaluate new preventive and therapeutic
measures and new modes of health care
delivery
• Provide the foundation for developing public
policy and regulatory decisions relating to
environmental problems
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Changing patterns of community health problems

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Life expectancy at birth and at 65 years of age,
by race, and sex, USA, 1900, 1950, and 2014
The decreases in infant mortality
and in mortality from childhood
diseases

Remaining
years of
expected life

001003

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Epidemiology and prevention

• Primary prevention
- Prevent the development of a disease
• To immunize a person against certain diseases
so that the disease never develop.
• Stop smoking can eliminate about 70% to 80%
of lung cancer.
• Secondary prevention
- Identify people with disease at an early stage
of disease’s natural history through screening
and early intervention.
• Routine testing of the stool for occult blood
can detect treatable colon cancer .
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Epidemiology and prevention (continue)

• Tertiary prevention
- Reduce the impact of a disease
• Prompt and appropriate treatment
• Rehabilitation for stroke

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Epidemiology and prevention (continue)

• Population-based approach to prevention

- Inexpensive and non-invasive
• Prudent dietary advice for preventing
coronary disease
• High-risk approach to prevention
- Expensive and invasive
• Screening for cholesterol in children might be
restricted to overweight children

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Epidemiology and clinical practice

diagnosis
Clinical practice

- diagnosis
- prognostication
- selection of therapy population-
based data

prognostication selection
of therapy

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Frequency of agents by age of children with
pharyngitis(咽炎), 1964-1965

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The Epidemiologic approach

• How do we proceed to identify the cause of a

disease?
Gonorrhea: reported cases per 100,000 population, USA, 2015

Are these differences real?

Why have they occurred?

Environmental differences?
Differences in the people who live in those
areas?

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The Epidemiologic approach
Relationship between rate of dental caries in children’s permanent
teeth and fluoride content of public water supply

Natural level of fluoride

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The Epidemiologic approach
Artificially
added fluoride
DMF teeth per 100 children to drinking
with permanent teeth water supply

Fluoride can prevent caries.

DMF indices after 10 years of fluoridation, 1954-1955

DMF, decayed, missing, and filled teeth
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The Epidemiologic approach
Effect of discontinuing fluoridation in Antigo, Wisconsin,
November 1960.
Mean DMF per child
examined

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Epidemiology is an invaluable tool
 for providing the rational basis on effective
prevention programs
 For conducting clinical investigations that
contribute to the control of disease and to the
amelioration of the human suffering associated
with it.

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Endemic, epidemic, and pandemic

• Endemic
- The habitual presence of a disease within a given
geographic area.
• Epidemic
– The occurrence in a community or region of a group
of illness of similar nature, clearly in excess of
normal expectancy, and derived from a common
source.
• Pandemic
– Worldwide epidemic

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London Smog Disaster, 1952
‧ Air pollution causes respiratory illnesses and death
‧ When fog and soot from coal burning created a
dense smog in Winter, 1952, in London, the smog
was around for five days from December 5–10,
1952
‧ There was a substantial increase in mortality
− Estimated premature death of 12,000
‧ The death rate in London in the previous week was
around 2,062
− In the week of the smog, 4,703 died

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Approximate weekly mortality and SO2 concentrations for
Greater London, 1952-1953

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Exploring the occurrence of the disease

• Define what will be studied

• Who was attacked by the disease?
• When did the disease occur?
• Where did the cases arise?
• Why the disease has such a distribution?
• How the problem is occurring?

6W: What, Who, When, Where, Why, How

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Who - sex, age, race
Gonorrhea, reported cases per 100,000 by sex, USA, 1986-2005,
and the Health People Year 2010 target.

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Pertussis, reported cases per 100,000 population by
year, USA, 1974-2004

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Pertussis, reported numbers of cases by age group,
USA, 2004

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When
Aseptic meningitis(無菌性腦膜炎), reported cases per
100,000 population by month, USA, 1986-1993

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Where
Lyme disease, reported cases by county, USA, 2005

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West Nile virus activity by state, USA, 1999-2002

鳥蚊子鳥

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Number of human West Nile meningoen-cephalitis cases, by
location and week and month of illness onset, USA, June-Nov 2002

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 Epidemiologic Study Designs

Experimental Observational
(RCTs)

Analytical Descriptive

Case-Control Cohort
+ cross-sectional & ecologic

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Epidemiologic Study Designs

Descriptive studies
Examine patterns of disease

Analytical studies
Studies of suspected causes of diseases

Experimental studies
Compare treatment modalities

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Observational Studies

 Descriptive:
 Most basic demographic studies
 Analytical
 Comparative studies testing an hypothesis
 cross-sectional

(a snapshot; no idea on cause-and-effect relationship)

 Cohort

(prospective; cause-and-effect relationship can be

inferred)
 Case-control

(retrospective; cause-and-effect relationship can be

inferred)

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Analytical Studies

Cohort (prospective)
 Begins with an exposure (smokers and non-smokers)

Case-control (retrospective)
 Begins with outcome (cancer cases and healthy
controls)

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Cohort Studies

Disease
People Exposed No disease
Population without
disease Not Disease
exposed
No disease

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Cohort Studies_example

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Case-Control Studies

Exposed
Not
Cases
exposed
Population
Exposed Controls
Not
exposed

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Case-Control Studies

34 Schulz & Grimes, 2002

Example

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Epidemiologic Study Designs

36 Grimes & Schulz, 2002 (www)

Hierarchy of Epidemiologic Study Design

37 Tower & Spector, 2007 (www)

Measuring the occurrence of the disease

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 Measures of morbidity

Incidence
 A specified period of time in a population at
risk for developing the disease

Incidence per 1000

No. of new cases of a disease occurring in the populaiton during a specified period of time
 1000
No. of persons who are at risk of developing the disease during that period of time

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Incidence proportion

Incidence proportion
 A measure of risk
 Number of sick people who drank beverage
divided by the total number of people who
drank beverage at a meeting
Cumulative incidence
 Number of new asthma cases in ten years
divided by total number of people at risk
during that period

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 Incidence rate (Incidence density)

People at risk are observed for

different periods of time

Incidence rate per 1000

No. of NEW cases of a disease occurring in the populaiton during a specified period of time
 1000
Total person - time (The sum of the time periods of observatio n of each person who
has been observed for all or part of the entire time period)

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Person-years of observation

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Calculation person-time as person-time observed

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Identifying newly detected cases of a disease:
Step 1: screening for prevalent cases at baseline

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Identifying newly detected cases of a disease:
Step 2: Follow-up and rescreening at 1 year to identify cases
that developed during the year

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 Prevalence

Prevalence
 What proportion of the population is affected
by the disease at a specific time
 The numerator includes both new and existing
cases of disease
 Time is not a part of the denominator (does
not use person-time)

Prevalence per 1000

No. of cases of a disease present in the populaiton at a specified time
 1000
No. of persons in the populaiton at that specified time
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Example of incidence and prevalence: I
5 cases of a disease in a community in 2008

What is the numerators for incidence in 2008?

What is the numerators for prevalence in 2008?

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Mortality rates

Annual mortality rate for all causes

(per 1000 population)
Total no. of deaths from all causes in 1 year
1000
No. of persons in the population at midyear

 Anyone in the group represented by the

denominator must have the potential to enter
the group represented by the numerator

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Mortality rates

Annual mortality rate from all causes

for children younger than 10 years of
age
(per 1000 population)
-Age-specific mortality rate
No. of deaths from all causes in 1 year
in children younger th an 10 years of age
1000
No. of children in the population
younger th an 10 years of age at midyear
 The same restriction must apply to both the
numerator and the denominator
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Mortality rates

Annual mortality rate from lung

cancer
(per 1000 population)
-Disease-specific mortality rate
-Cause-specific mortality rate
No. of deaths from lung cancer in 1 year
1000
No. of persons in the population at midyear

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Death certificate for the state of Maryland

Funeral
director

physician

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 Immediate cause of death

Underlying cause of death

Registry for cause of death: ICD (the International Classification
of Disease)

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Mortality rates

Annual mortality rate from Leukemia

in children younger than 10 years of
age
(per 1000 population)
No. of deaths from leukemia in 1 year
in children younger th an 10 years of age
1000
No. of children in the population
younger th an 10 years of age at midyear

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Case-fatality rates

Case-fatality rates (percent)

 What percentage of people diagnosed as
having a certain disease die with a certain time
after diagnosis?
 A measure of disease severity
No. of individual s dying during a specified
period of time after disease onset or diagnosis
100
No. of individual s with the specified disease

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 Comparison of mortality rate and case-fatality rate

Assume a population of 100,000 people of

whom 20 are sick with disease X, and in 1
year, 18 of the 20 die from disease X
 Mortality rate of disease X
18
*1000  0.00018  0.18 per 1000 population
100000
 Case-fatality rate of disease X
18
 0.9  90 %
20

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 Proportionate mortality

Proportionate mortality
 Not a rate, but a proportion
 Proportionate mortality from CVDs in the U.S.
in 1999 (percent)
No. of deaths from CVDs in the U.S. in 1999
100
Total deaths in the U.S. in 1999

 What proportion of deaths was caused by

CVDs?

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Comparison of mortality rate and proportionate mortality

Deaths from heart disease in Two communities

Community A Community B
Mortality rate
from all causes 30/1000 15/1000

proportionate
mortality from 10% 20%
heart disease
Mortality rate
from heart disease 3/1000 3/1000

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 Comparison of mortality rate and proportionate
mortality

Mortality rate and proportionate mortality in two periods

Early period Later period

Cause of Mortality proportionate Mortality proportionate

death rate mortality rate mortality

Heart
40/1000 50% 80/1000 66.7%
disease
Cancer
20/1000 25% 20/1000 16.7%

All other
20/1000 25% 20/1000 16.7%
causes
All deaths
80/1000 100% 120/1000 100%
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Hypothetical example of proportionate mortality:
Changes in proportionate mortality from heart disease,
cancer, and other causes from the early period to the
late period

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 Comparison of mortality rate and proportionate
mortality

Deaths from heart disease in Two communities

Community A Community B
Mortality rate
from all causes 20/1000 10/1000

proportionate
mortality from 30% 30%
heart disease
Mortality rate
from heart disease 6/1000 3/1000

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A mortality rate is a good reflection of
the incidence rate :
 case-fatality is high
 duration of disease is short

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Ectopic pregnancy rates (per 1000 reported
pregnancies), by year, USA, 1970-1987

• Improved diagnosis
• Increased frequency of pelvic
inflammatory disease resulting
from sexually transmitted
diseases.

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Ectopic pregnancy death rates (per 1000 reported
pregnancies), by year, USA, 1970-1987

• Earlier detection
• Increasingly prompt medical
and surgical intervention

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Thyroid cancer incidence and mortality, USA, 1973-2002

True increase?
Only an increase in apparent
incidence due to the improve of
the diagnostic method?

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Histologic types of thyroid cancer and their prognoses

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Trends in incidence of thyroid cancer by
histologic type, USA, 1973-2002

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Trends in incidence of papillary tumors of
the thyroid, by size, USA, 1988-2002

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Drop in death rates for diabetes among 55- to 64-year-
old men and women, USA, 1930-1960, due to changes in
ICD coding.

ICD 7th to ICD 8th

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Thank You !

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