Introduction to Epidemiology

Spring Semester, 2013 Randall E. Harris, MD, PhD Professor of Epidemiology OSU College of Public Health OSU College of Medicine Harris.44@osu.edu 292-4720 Office Hours: M W, 2:00 – 4:00 PM 306 Cunz Hall

Textbook
• Epidemiology Kept Simple: an introduction to traditional and modern epidemiology • Author: B. Burt Gerstman • Course content/syllabus • Assigned readings • WebCT (Carmen)
http://carmen.osu.edu

Lectures on Carmen
• Direct your URL to http://carmen.osu.edu Click on "view all courses" Click on the category of your course on the left. For example "Public Health" Click on on the title for your course on the right. For example "PUBH-EPI 510: Introduction to Epidemiology" Enter your Username and password. If you have problems getting into the course, you will be presented with an Online Form. The quickest way to receive assistance is to complete the form including any specific comments about your log in attempt. • For more information about your OSU Internet ID visit http//www.oit.ohio-state.edu/userpass.html

Rx for Survival: a global health challenge • • • • Six part documentary Critical Health Issues of 21st Century Global Impact Historical Events in Epidemiology & Public Health • Narrated by Brad Pitt .

Teaching Assistant
• • • • Yue Jin [jin.177@buckeyemail.osu.edu] Office Hours: Tues & Thursday 9:30-10:30 AM 300 B Cunz Hall

Goals and Objectives
• • • • Epidemiology defined Historical Events Accomplishments Causal Concepts in Disease • Infectious Disease • Screening for Disease • Testing Accuracy • Incidence & Prevalence • Age Adjustment • Rates, Ratios, Proportions, Risks • Epidemiologic study Design • Error & Bias • Biostatistical Measures

Goals and Objectives • • • • • Retrospective Case Control Studies Prospective Cohort Studies Clinical Trials Life Tables & Survival Analysis Investigation of Outbreaks .

.

.

.

Confirmed human cases of Avian Influenza A (H5N1) reported to WHO 600 500 400 300 200 100 0 Cases Deaths Source: World Health Organization. 2012 l ta To 11 20 10 20 09 20 08 20 07 20 06 20 05 20 04 20 03 20 .

.

H1N2 HA NA . H3N2.Influenza A Viruses Subtyped based on surface glycoproteins: • 16 hemagglutinins (HA) and 9 neuraminidases (NA) • current human subtypes: H1N1.

.

Swine Swine Avian Human Avian Swine Swine Swine .

USA H1N1 .INFLUENZA: 2006-2009.

470 deaths .2009 H1N1 Epidemic 61 million cases 12.

.

H1N1 Pandemic: 2009 Total Cases: 50 000+ confirmed cases 5 000+ confirmed cases 500+ confirmed cases 50+ confirmed cases 5+ confirmed cases 1+ confirmed cases .

chronic pulmonary. immunosuppression caused by medications or by HIV) • Residents of nursing homes and other chronic-care facilities.. . neuromuscular. or metabolic disorders • Adults and children who have immunosuppression (e. cardiovascular.Persons at Higher Risk for H1N1: CDC • • • • Children younger than 5 years old Persons aged 65 years or older Pregnant women Anyone with who asthma.g. hematological. hepatic. neurologic.

vomiting. and diarrhea .Symptoms of Flu: CDC fever (often high) headache extreme tiredness dry cough sore throat runny or stuffy nose muscle aches Stomach symptoms nausea.

Transmission of Influenza: CDC • • • • Person to Person Contamination Hand to Mouth Exposed persons can shed the virus 1-2 days before symptoms occur and 5-7 days after symptoms subside .

weakened flu viruses that do not cause the flu (sometimes called LAIV for "Live Attenuated Influenza Vaccine").Vaccination: CDC • Flu Shot: Inactivated vaccine containing “killed virus” approved for people 6 months & older • The nasal-spray flu vaccine – a vaccine made with live. . LAIV is approved for use in healthy* people 2-49 years of age who are not pregnant.

including: – Health care workers – Household contacts of persons at high risk for complications from the flu – Household contacts and out of home caregivers of children under 6 months of age .Seasonal Flu Vaccination: CDC • • • • Children aged 6 months up to their 19th birthday Pregnant women People 50 years of age and older People of any age with chronic medical conditions • People who live in nursing homes and other longterm care facilities • People who live with or care for those at high risk for complications from flu.

• Children less than 6 months of age (influenza vaccine is not approved for use in this age group). • People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen. .Vaccination Precautions • People who have a severe allergy to chicken eggs. • People who developed Guillian-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine previously. • People who have had a severe reaction to an influenza vaccination in the past.

. and medical care left up to 6 million people highly susceptible to infectious diseases such as diarrhea. typhoid.000 Approximately 10. and dysentery. cholera. hepatitis.000 Americans were lost 1 Million people were injured or disabled 5 Million people were displaced from their homes WHO estimates the lack of clean water. sanitation.Measure of Disaster: Earthquake & Tsunami in southern Asia • • • • • The cumulative death toll is approximately 217. food.

8. Thailand: 4. Bangladesh: 2 12. Seychelles: 1 11.560 5. Sri Lanka: 28. 7. Indonesia: 79.CONFIRMED DEATH TOLLS 1. Tanzania: 10 10. Kenya: 1 .940 2.508 3. Somalia: 120 Burma: 90 Maldives: 67 Malaysia: 65 9.763 4. India (inc Andaman and Nicobar Is): 10. 6.

temporary shelter. and medical needs stand at $165 million for only a few weeks. & sugar). food (rice.Measure of Disaster: Earthquake & Tsunami in southern Asia • Initial estimates for clean water. lentils. Initial damage estimates for housing stand at approximately $14 million • Public health and health care systems in the region are grossly insufficient to handle the crisis • Few tsunami victims have insurance • The world has pledged over $2 billion in aid (USA pledges total over $350 million) .

The Tsunami .

Tsunami crashing into Thailand's Phuket Island .

. food. and other stationary items. heat. the strong suction of debris being pulled into large populated areas can further cause injuries and undermine buildings and services. • Medical care is critical in areas where little medical care exists. • Loss of shelter leaves people vulnerable to insect exposure. shelter. As the water recedes. • The majority of deaths associated with tsunamis are related to drowning. Injuries such as broken limbs and head injuries are caused by the physical impact of people being washed into debris such as houses. and other environmental hazards. and medical care for injuries.Immediate health concerns • After the rescue of survivors. the primary public health concerns are clean drinking water. trees. but traumatic injuries are also a primary concern. • Flood waters can pose health risks such as contaminated water and food supplies.

Tsunami Victims .

Tsunami Victims • • .

However.Collateral Damage • Natural disasters do not necessarily cause an increase in infectious disease outbreaks. contaminated water and food supplies as well as the lack of shelter and medical care may have a secondary effect of worsening illnesses that already exist in the affected region. • Decaying bodies create very little risk of major disease outbreaks. . • The people most at risk are those who handle the bodies or prepare them for burial.

Rotavirus Parasites Amebiasis. Hepatitis E. Salmonella (Typhoid). Cholera. Cryptospirdiosis. Leptospirosis. Shigellosis Hepatitis A. Entamoeba Histolytica. Coli. Giardiasis .Diarrhea From Food or Water Bacteria & Viruses E.

nonwaterproof containers that has come in contact with untreated water. floodwater. . wash your hands with clean water and soap before and after you eat or prepare food and after you use the latrine or bathroom. • Do not eat any food that has not been sealed in waterproof containers (commercially canned or sealed plastic containers) and that may have come in contact with untreated water. If you do not have clean water. use waterless hand sanitizers until clean water is available for washing. or pond water.Foodborne Diseases • To prevent foodborne diseases. river water. Throw away any food not in nonsealed. such as seawater.

They cannot be disinfected. Use a marker to note the contents and expiration date on the cans. or if they have been home canned. crimped caps (soda pop bottles). or flip tops. twist caps.25%) in 5 gallons (approximately 19 liters) of treated drinking-quality water. Remove the can labels.25 liters) of household bleach (5.Foodborne Diseases • Undamaged commercially canned foods can be saved. snap lids. wash the outsides of the cans with soapy water. . • If opened food containers have screw caps. approximately 0. throw them away if they have come in contact with untreated water. and thoroughly disinfect the cans using a solution of 1 cup (8 ounces.

if not promptly treated. vivax. ovale. • Infection with any of the malaria species can make a person feel very ill. falciparum. Patients with malaria typically are very sick with high fevers. Although malaria can be a fatal disease.Mosquitoe Vectors: Malaria • Malaria Malaria is a serious and sometimes fatal disease caused by a parasite. shaking chills. and flu-like illness. P. infection with P. P. malariae. Four kinds of malaria parasites can infect humans: Plasmodium falciparum. may be fatal. and P. illness and death from malaria are largely preventable. .

• Plague is characterized by periodic disease outbreaks in rodent populations.Illness From Animals/Insects • Plague Plague. hungry infected fleas that have lost their normal hosts seek other sources of blood. . some of which have a high death rate. During these outbreaks. caused by a bacterium called Yersinia pestis. is transmitted from rodent to rodent by infected fleas. thus increasing the increased risk to humans and other animals frequenting the area • Rabies Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal.

. and severe muscle spasms • Complications: Death in about 11% of cases. especially people over age 60 Transmission Enters the body through a break in the skin • Vaccine: Tetanus toxoid (contained in DTaP. DT. stiffness in the neck and abdomen. and difficulty swallowing Later symptoms: fever. elevated blood pressure. and Td vaccines) can prevent this disease.Wound Infections & Diseases • Tetanus A disease of the nervous system caused by bacteria Symptoms Early symptoms: lockjaw.

water systems. housing. . including • surveying and monitoring for infectious and water. • restoring normal primary health services. and employment.Aftermath of Disaster • The effects of a disaster last a long time. and • assisting the community to recover mentally and socially when the crisis has subsided. The greater need for financial and material assistance is in the months after a disaster. • diverting medical supplies from nonaffected areas to meet the needs of the affected regions.or insect-transmitted diseases.

Mental Health Psychological trauma of death and destruction will produce longstanding mental health issues for the population. .

Plasmodium Falciparum .

Anopheles Mosquito .

Global Malaria .

.

Malaria Rates in Andaman District .

as a high-level Category 3 hurricane with sustained winds of 145 miles per hour and a 25-foot storm surge.Hurricane Katrina Hurricane Katrina made landfall near the MississippiLouisiana border on 29. Among the chief adverse effects of the hurricane on the lives of Mississippi residents. Katrina was the fourth most intense Atlantic Basin hurricane on record. . was the mortality suffered during the hurricane’s impact phase. and the considerable disruption of livelihoods. and resulted in the largest displacement of a US population in history. August 2005.

. which resulted in deaths of 6 immunocompromised hosts. Texas. parahaemolyticus wound infections. a cluster of infections with methicillinresistant Staphylococcus aureus (MRSA) was reported in approximately 30 pediatric and adult patients at an evacuee facility in Dallas.Hurricane Katrina • Widespread Outbreak of Norovirus Gastroenteritis among Evacuees of Hurricane Katrina Residing in a Large “Megashelter” in Houston. • 24 cases of Vibrio vulnificus and V. Texas • Among hurricane evacuees from the New Orleans area.

nontoxigenic V. few cases of diarrheal disease were being reported.Hurricane Katrina • Sporadic nontyphoidal Salmonella. and other infections were identified. cholerae O1. • About 1000 cases of viral gastroenteritis and sporadic cases of bacterial diarrhea also were reported in evacuation centers in four states • Three weeks after the initial displacement caused by Katrina. .

West Nile Virus: Louisiana & Mississippi .

034 Million) • Annual Deaths = 62 Million • Annual Crude Probability of Death = 0. 2012 • World Population = 7.034 Billion (7.88 % “We are all approaching death. but some are moving at a relatively faster pace than others” REH .Global Mortality.

884 2.2 2. WHO.272 1. 10.1 622 618 . The World Health Organization (WHO).243 1.124 923 911 873 850 % of total 12.2 1.2 2. 7.6 1.208 5.7 6. 1.0 1.5 1. 2003. 17.Top 20 Causes of Mortality Throughout the World. 18.6 1.509 3. 9. 5.566 1. 2004 Rank 1.2 2. 15. 4.4 1. 6.8 4. 3.192 1.9 4.1 1. 13.5 16.777 2. 14. 11. 12.1% 2.798 1.7 2.6% 9. Cirrhosis of the liver Nephritis/nephrosis Colon/rectum cancer Liver cancer 786 677 Source: The World Health Report.8 3. 2. 19. Cause Ischaemic heart disease Cerebrovascular disease Lower respiratory infections HIV/AIDS COPD Diarrheal diseases Tuberculosis Malaria Cancer of trachea/bronchus/lung Road traffic accidents Childhood Diseases Other unintentional injuries Hypertensive heart disease Self-inflicted Stomach cancer Total deaths (in thousands) 7.748 1. 8.

2010 .000 Per Year Source. WHO.Global Annual Mortality Rates Deaths Per 100.

Death Rate by GDP .

484.678.180.512.000 499.346.103.000 657.000 669.000 .000 3.000 674.000 Causes of death in developed countries Ischaemic heart disease Stroke Chronic obstructive pulmonary disease Number of deaths 3.000 571.000 748.000 1.217.793.000 1.021.000 2.000 635.000 1.000 1.000 Lower respiratory infections 1.829.000 1.000 Lung cancer Car accident Stomach cancer High blood pressure Tuberculosis Suicide 938.643.000 2.000 1.381.Global Causes of Death Causes of death in developing countries HIV-AIDS Lower respiratory infections Ischaemic heart disease Diarrhea Cerebrovascular disease Childhood diseases Malaria Tuberculosis Chronic obstructive pulmonary disease Measles Number of deaths 2.

e.Malnutrition & Starvation • Undernutrition is either directly or indirectly responsible for up to 30% of deaths worldwide. • WHO estimates that one of seven older adults is malnourished thereby impacting mortality rates of selected chronic conditions. heart disease.. • WHO estimates that six million of the ten million deaths occurring annually in children under age five years are attributable to undernutrition.g. diabetes II . cancer.

pregnancy. alcohol • Greatly increased need for calories.Causation of Undernutrition • Lack of access to food • Disorders or drugs that interfere with the intake.. breast feeding .. e. e. nicotine. diabetes. steroids. metabolism or absorption of nutrients.g. diuretics. thyroid disease.g.

due to lack of transportation or physical impairment) • Disorders that interfere with the intake. or absorption of nutrients .Causation of Undernutrition • Poverty • Famine • Inability to obtain food (for example. metabolism.

Causation of Undernutrition (Children)
• • • • Vomiting Diarrhea Infection Diabetes (Type I)

Causation of Undernutrition (Adults)
• • • • • • • • • • AIDS (HIV Disease) Cancer Diabetes (Type II) Kidney failure Malabsorption disorders Inflammatory bowel disorders Liver disorders Anorexia nervosa Depression Alcoholism

Marasmus

• It tends to develop in infants and very young children. It typically results in weight loss and dehydration. • Breastfeeding usually protects against marasmus.Malnutrition & Starvation • Undernutrition is a deficiency of calories or of one or more essential nutrients. . • Marasmus is a severe deficiency of calories and protein.

Malnutrition & Starvation • Starvation is the most extreme form of Marasmus (and undernutrition). • Starvation results from a partial or total lack of essential nutrients over time. .

Kwashiorkor .

• Kwashiorkor is less common than Marasmus. • The term means “first child-second child” because a first-born child often develops kwashiorkor when the second child is born and replaces the first-born child at the mother's breast. .Malnutrition & Starvation • Kwashiorkor is a severe deficiency of protein rather than of calories.

making them appear puffy and swollen. they are usually older than those who have Marasmus. • Kwashiorkor tends to be confined to certain areas of the world where staple foods used to wean babies are deficient in protein even though they provide enough calories as carbohydrates. If Kwashiorkor is severe. cassava. and green bananas.Malnutrition & Starvation • Because children tend to develop Kwashiorkor after they are weaned. . People with Kwashiorkor retain fluid. the abdomen may protrude. sweet potatoes. • Anyone can develop Kwashiorkor if their diet consists mainly of carbohydrates. Examples of such foods are yams. rice.

33 Million HIV Seropositive 1.8 Million Deaths Per Year .

5. 2004 Due to HIV/AIDS <10 10-25 25-50 50-100 100-500 500-1000 1000-2500 2500-5000 5000-7500 7500-10000 10000-50000 >50000 .Figure 47. Disability Adjusted Years. Disability Adjusted LifeLife Years HIV/AIDS.

Incidence of Kaposi’s Sarcoma in African Men .

.

responsible for 200 million active cases and 55 million deaths. • 10 million will develop active disease • 3 million die from TB annually • If there are no changes in current levels of infection. 1 billion people will be infected by 2020. .Tuberculosis (TB) • 30 million people are infected with TB worldwide.

7 million deaths per year • Multi-Drug resistant TB (MDR-TB) and HIV strains are evolving worldwide .HIV & Tuberculosis • HIV and Tuberculosis coexist • HIV/TB co-infections cause 1.

.

.

224 Percent (%) 29.1 2.3 . Nephrosis Septicemia Deaths 710. 2000 Cause of Death Heart Disease Cancer Stroke COPD Accidents Diabetes Pneumonia/Influenza Alzheimer’s Disease Nephritis.7 2.009 97.6 23.0 5.9 2.661 122.1 1. USA.900 69.091 167.301 65.251 31.1 4.558 37.0 7.760 553.313 49.5 1.Top Ten Causes of Death.

1991—1998 JAMA 1999. 282:16:1519–1522.Citations • BRFSS. MMWR 2006. diabetes. et al. The spread of the obesity epidemic in the United States. Prevalence of obesity. JAMA 2003: 289:1: 76–79 • CDC. and obesityrelated health risk factors. • Mokdad AH. Behavioral Risk Factor Surveillance System http: //www. The continuing epidemics of obesity and diabetes in the United States. 2001.cdc.985–988 . 55(36).gov/brfss/ • Mokdad AH. • Mokdad AH. JAMA. 2001. State-Specific Prevalence of Obesity Among Adults — United States. et al. 2005. 286:10:1519–22. et al.

or Body Mass Index (BMI) of 30 or higher. .S. specifically the adult’s weight in kilograms divided by the square of his or her height in meters. Adults between 1985 and 2007 Definitions: • Obesity: Having a very high amount of body fat in relation to lean body mass.Obesity Trends Among U. • Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height.

nccd.gov/brfss) as slightly different analytic methods are used. Each year. adults. Adults between 1985 and 2007 Source of the data: • The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS).cdc. .S.S. • Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.Obesity Trends Among U. state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.

Thirty states had a prevalence equal to or greater than 25%. three of these states (Alabama. 10 states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%. . among states participating in the Behavioral Risk Factor Surveillance System. no state had prevalence less than 10%. seven states had a prevalence of obesity between 20-24%. Mississippi and Tennessee) had a prevalence of obesity equal to or greater than 30%.• In 1990. and no state had prevalence equal to or greater than 25%. • By 1998. • In 2007. only one state (Colorado) had a prevalence of obesity less than 20%.

Adults BRFSS. overweight for 5’ 4” person) No Data <10% 10%–14% .Obesity Trends* Among U. 1985 (*BMI ≥30.S. or ~ 30 lbs.

or ~ 30 lbs. 1986 (*BMI ≥30. overweight for 5’ 4” person) No Data <10% 10%–14% .Obesity Trends* Among U. Adults BRFSS.S.

overweight for 5’ 4” person) No Data <10% 10%–14% . or ~ 30 lbs. 1987 (*BMI ≥30.Obesity Trends* Among U.S. Adults BRFSS.

Obesity Trends* Among U. or ~ 30 lbs. Adults BRFSS. overweight for 5’ 4” person) No Data <10% 10%–14% .S. 1988 (*BMI ≥30.

1989 (*BMI ≥30. Adults BRFSS.S. or ~ 30 lbs.Obesity Trends* Among U. overweight for 5’ 4” person) No Data <10% 10%–14% .

1990 (*BMI ≥30. or ~ 30 lbs.Obesity Trends* Among U. Adults BRFSS. overweight for 5’ 4” person) No Data <10% 10%–14% .S.

1991 (*BMI ≥30.S.Obesity Trends* Among U. or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% . Adults BRFSS.

1992 (*BMI ≥30. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% . or ~ 30 lbs.S.Obesity Trends* Among U. Adults BRFSS.

S. 1993 (*BMI ≥30.Obesity Trends* Among U. Adults BRFSS. or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% .

Adults BRFSS.S. or ~ 30 lbs.Obesity Trends* Among U. 1994 (*BMI ≥30. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% .

or ~ 30 lbs. 1995 (*BMI ≥30. Adults BRFSS.S. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% .Obesity Trends* Among U.

Obesity Trends* Among U. Adults BRFSS. 1996 (*BMI ≥30. or ~ 30 lbs.S. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% .

Obesity Trends* Among U. Adults BRFSS. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% . 1997 (*BMI ≥30.S. or ~ 30 lbs.

Adults BRFSS. 1998 (*BMI ≥30. or ~ 30 lbs.S. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% .Obesity Trends* Among U.

overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% . 1999 (*BMI ≥30. Adults BRFSS. or ~ 30 lbs.Obesity Trends* Among U.S.

Obesity Trends* Among U.S. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% . 2000 (*BMI ≥30. Adults BRFSS. or ~ 30 lbs.

Adults BRFSS. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% .S.Obesity Trends* Among U. 2001 (*BMI ≥30. or ~ 30 lbs.

Adults BRFSS.S.Obesity Trends* Among U. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% . 2002 (*BMI ≥30. or ~ 30 lbs.

Obesity Trends* Among U. or ~ 30 lbs. 2003 (*BMI ≥30. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% .S. Adults BRFSS.

or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% . 2004 (*BMI ≥30.S. Adults BRFSS.Obesity Trends* Among U.

S.Obesity Trends* Among U. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% . Adults BRFSS. or ~ 30 lbs. 2005 (*BMI ≥30.

overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% . or ~ 30 lbs.S. 2006 (*BMI ≥30. Adults BRFSS.Obesity Trends* Among U.

S. 2007 (*BMI ≥30. or ~ 30 lbs. Adults BRFSS.Obesity Trends* Among U. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% .

Adults BRFSS.S. 2008 (*BMI ≥30. or ~ 30 lbs. overweight for 5’ 4” person) .Obesity Trends* Among U.

Obesity Trends* Among U.S. Adults BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. Adults BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Figure 8. Dose Response in the Risk of Type 2 Diabetes by BMI
Men 100 90 80 70 60 Relative Risk 50 40 30 20 10 0 23 25 27 29 31 33 35 Body Mass Index Women

Age-adjusted cancer mortality in the USA, 1930-2008
200

Rate per 100,000

150 100 50 0

143

152

156

158

163

168

173

164

170

1930

1940

1950

1960

1970 Year

1980

1990

2000

2008

.

.

Odds Ratios for Lung Cancer by Amount Smoked 50 45 40 35 30 Odds Ratio 25 20 15 10 5 0 Never 1-10 11-20 21-30 31-40 Cigarettes per Day Women Men 41+ .

01) 1940 1950 1960 1970 1980 1990 2000 Year .Lung Cancer Mortality and Cigarettes Per Capita. USA 100 90 80 70 60 50 40 30 20 10 0 1930 r = 0.000 Cigarettes per capita (x 0.98 Mortality per 100.

77. whites. NCI .00.02 63 73 76 79 82 90 95 99 01 03 04 06 07 08 Five year survival rates.74.93.97.83.80.Lung Cancer Survival 50 40 Survival (%) 30 20 10 0 60.70.

Smoking Prevalence: A Global Problem 50 45 40 35 30 25 20 15 10 5 0 Europe NA SA Asia Africa World Women Men WHO: 1/3 of the world population smokes .

Population Attributable Risk: Lung Cancer & Smoking 100 90 80 70 60 50 40 30 20 10 0 Europe NA SA Asia Africa World PAR (%) Average PAR = 87% .

000 300.000 600.000 Number of 500.000 0 Lung Cancer Heart Diseases COPD Other Cancers Stroke WHO: Total Deaths: 3 Million .000 700.Annual Deaths Attributable to Cigarette Smoking 900.000 200.000 800.000 Deaths 400.000 100.

Prostate and Colon Cancer combined .Lung Cancer • Most common cause of cancer-related death among men and women • Mortality has increased by 600% in women since 1950 • 28% of all cancer deaths in USA • Smoking is the most important etiologic factor and is responsible for approximately 87% of cases • Cell Types: Small Cell and Non-Small Cell • More People die each year from Lung Cancer than Breast.

• In older adults and persons with immunocompromising conditions. and adults with weakened immune systems. newborns. flu-like illness followed by fetal loss or bacteremia and meningitis in their newborns. a serious infection usually caused by eating food contaminated with the bacterium Listeria monocytogenes • The disease primarily affects older adults. pregnant women. septicemia and meningitis are the most common clinical presentations.Listeriosis • Listeriosis. • Pregnant women may experience a mild. .

Listeriosis: Listeria monocytogenes .

• Listeria monocytogenes is commonly found in soil and water. Listeria can grow and multiply in some foods in the refrigerator. • The bacterium is killed by pasteurization and cooking. a gram-positive rod-shaped bacterium. however. • Most human infections follow consumption of contaminated food. in some ready-to-eat foods.Listeriosis • Listeria monocytogenes. Rare cases of nosocomial transmission have been reported. Animals can carry the bacterium without appearing ill and can contaminate foods of animal origin. such as meats and dairy products. such as hot dogs and deli meats. contamination may occur after factory cooking but before packaging. . Unlike most bacteria.

one woman pregnant at the time of illness had a miscarriage.Listeriosis • As of November 1. . In addition. • Twenty-nine deaths have been reported. a total of 139 persons infected with any of the four outbreakassociated strains of Listeria monocytogenes have been reported to CDC from 28 states. 2011.

2011 .Listeriosis Epidemic.

.

.

.

Methicillin Resistant Staphylococcus Aureus (MRSA) USA: 18.500 MRSA-related deaths in 2008 .

MRSA Hospital Infections .

USA .MRSA Deaths.

What is Science? • Methods Systematic observation of natural events and conditions in order to discover facts about them and to formulate laws and principles based on these facts. Any specific branch of this general body of knowledge. • Content The organized body of knowledge derived from such observations. .

Public Health vs Medicine • Medicine: Diagnosis and Treatment of the Individual • Public Health: Diagnosis and Treatment of the Population .

Primary Fields of Public Health • Biostatistics: data analysis • Epidemiology: disease etiology • Environmental Health: macro/micro agents • Behavioral Science: life style • Health Administration: cost benefit .

What is Health? • Health = Absence of Disease • Disease = Dis-ease .

from Greek “upon” • Demos .from Greek “the people” Literally: • “The study of that which is visited upon the people.” .Definition of Epidemiology • Epi .

mortality.Epidemiology Defined • Systematic study of the distribution of disease and risk factors in the human population to determine disease etiology • Examination of distributions of incidence. and related measures in time. and person . place. risk factors.

Place. and Person • Time: Has there been an increase or decrease in the disease over time? • Place: Do some geographic areas have different morbidity or mortality than other areas? • Person: Do the characteristics of persons with the disease distinguish them from those who are disease free? .Time.

Dose Response. Compliance . Bias. Biological Plausibility. Specificity.Epidemiologic Issues • Criteria of Judgment Consistency. Strength of Association. Temporality • True vs False Effect Study Design. Confounding.

000 200 150 100 50 0 CHD Stroke Influenza Cancer 1950 2000 National Center for Health Statistics.Change in CVD Mortality USA. 1950-2000 450 400 350 300 Rate per 250 100. USA Data age-adjusted to 1970 USA population .

.

Ecological Correlation of Breast Cancer Mortality and Dietary Fat Intake 30 Mortality Rate/100.000 25 20 15 10 5 0 0 50 100 USA Japan n = 39 countries r = 0.84 150 200 Total Dietary Fat Intake (g/day) .

000 10 5 0 55 65 75 85 Year 95 2000 2005 USA Japan .Breast Cancer Mortality USA vs Japan 30 25 20 Rate per 15 100.

000 6 4 2 0 55 65 75 85 Year 95 2000 2005 USA Japan .Prostate Cancer Mortality USA vs Japan 16 14 12 10 Rate per 8 100.

000 10 5 0 55 65 75 85 Year 95 2000 2005 USA Japan .Colon Cancer Mortality USA vs Japan 30 25 20 Rate per 15 100.

Percentage fat calories or mortality per 100. breast. and colon cancer: Japan vs.000 Dietary fat intake and combined mortality from prostate. USA JAPAN 35 30 25 20 15 10 5 0 55 65 75 85 95 20 05 USA 80 70 60 50 40 30 20 10 0 55 65 75 85 95 20 05 Combined cancer mortality % total fat .

STD Exposure . Residence • Lifestyle/Behaviors: Use of Tobacco. Marital Status • Biological/Genetic Characteristics: Blood levels of antibodies. • Socioeconomic Factors: SES. Place of birth. etc. Exercise. Alcohol and other drugs. Education. Gender. Race/Ethnicity. enzymes. glucose. Occupation. hormones.Personal Characteristics • Demographics: Age. Diet.

Behavioral Risk Factor Surveillance System. Ohio: 2000 90 80 70 60 50 40 30 20 10 0 Lack of Exercise Overweight Smoking Drinking .

. when. • identify the risk factors. and where to intervene. • quantify their importance. • to determine how.Purpose of Epidemiology The purpose of epidemiology is to: • elucidate etiology of disease.

& Mortality • Evaluate Health Services • Evaluate Individual Risk of Disease • Elaborate the Clinical Picture of Disease • Identify Syndromes • Identify Causative & Preventive Factors .General Uses of Epidemiology Table 1. Prevalence.2 • Study the Rise and Fall of Disease • Monitor Incidence.

Selected Terms Table 1.1 • • • • Endemic: normal rate of disease Epidemic: marked excess of disease Pandemic: epidemic affects many nations Morbidity: rate of adverse events due to disease (excluding death) • Mortality: Death Rate .

Standard Measures in Epidemiology • Mortality = deaths / population at risk for a specific period of time • Incidence = new cases / population at risk for a specific period of time • Prevalence = new + old cases / population at risk • Relationship of incidence and prevalence: Prevalence = Incidence x Duration .

Strategies for Disease Prevention • Primary Prevention : Eliminate exposure to the etiologic agent Active: Behavioral change Passive: No behavioral change • Secondary Prevention: Screening for early detection of precursor conditions • Tertiary Prevention: Limit disability from disease .

altering susceptibility or reducing exposure for susceptible individuals…. .Primary Prevention Prevention of disease by preventing exposure to the etiologic agent.

Primary Prevention General health promotion Nutrition Clothing Shelter Rest Recreation Education Health Care Work .

Primary Prevention Active Immunization Personal Hygiene Hand washing Passive Environmental Sanitation Protection against injury and occupation hazards Political control of stores of infectious agents .

accuracy. and acceptance of the screening test in the population.Secondary Prevention Early detection and effective treatment of antecedent conditions Benefit vs risk of screening depends upon cost. .

Ohio: 2000 Mammography 90 80 70 60 50 40 30 20 10 0 Pap Smear FOBT PSA Women Men .Behavioral Risk Factor Surveillance System.

Tertiary Prevention • • • • Limitation of disability Rehabilitation Altering diet/exercise after cardiac event Compliance with medication schedule Glucose control in diabetes. Blood pressure control in hypertension .

400 BC “First do no harm…” “Let thy food by thy medicine…” Father of Medicine Father of Epidemiology .Hippocrates.

death (e. more males born than females).. Graunt analyzed mortality data.John Graunt. divided deaths into types of causes: acute and chronic). infant mortality for different groups. He noted differences between males-females. He quantified patterns of birth (e. males die sooner than females).g. urban-rural areas. and developed a better understanding of diseases. . 1520-1674 Dr. and disease (e.g. as well as sources and causes of death. and seasonal variation of mortality rates.g.

John Graunt. 1620-1674 .Dr.

Yearly Mortality Bill. 1632 Top Ten Causes of Death 2500 2000 1500 Chrisomes Consumption Fever Small Pox Dropsie 1000 Collick 500 0 Flux Childbed Liver .

Women & Men Worldwide Rank: 18th . USA.Life Expectancy.

developed centralized registration system for disease classification .William Farr. 1807-1883.

Epidemiologic Transition Transition from infectious diseases as the predominant causes of morbidity and mortality to a predominance of noninfectious (chronic) diseases .

Malaria. Diarrhea . 2011 • World Population = 7. Renal Disease • 26 Million Deaths From Acute Diseases -HIV/AIDS.0 Billion People • Annual Deaths = 62 Million Deaths • 36 Million Deaths From Chronic Diseases -CVD. Diabetes. COPD. Cancer.Worldwide Deaths. TB. WHO.

WHO Acute Disease 14 12 10 Millions of 8 Deaths 6 4 2 0 Low Low Middle High Middle High Chronic Disease Injury World Bank Income Group .Figure 5. Worldwide Deaths by Major Cause and National Income. 2009.

7 Heart Disease 137.9 Nephritis 88.0 Diabetes Mellitus 11.0 2 3 4 5 6 7 8 9 10 Tuberculosis 194.0 Accidents 32.2 Diphtheria 40.3 Cancer 135.2 HIV Disease 9.3 Cancer 64.7 COPD 19. USA Rank 1900 1990 1 Pneum & Influ 202.7 Pneum & Infl 14.Cause Specific Mortality.5 Stroke 27.0 Senility 50.4 Enteritis 142.6 Accidents 72.2 Heart Disease 152.8 .4 Stroke 106.5 Homicide 10.7 Suicide 11.

Population Pyramid: 1950 .

Population Pyramid :2000 .

2000 • Number of deaths annually: 2.404.000 population • Life Expectancy: 76.9 years at birth .351 • Death Rate (age-adjusted): 873.Deaths/ Mortality: United States.1 deaths per 100.

5 1. 2000 Cause of Death Heart Disease Cancer Stroke COPD Accidents Diabetes Pneumonia/Influenza Alzheimer’s Disease Nephritis.251 31.1 1.0 7.301 65.091 167.1 4.6 23.313 49.7 2. USA.009 97.760 553.9 2.1 2.224 Percent (%) 29.661 122. Nephrosis Septicemia Deaths 710.900 69.0 5.3 .558 37.Top Ten Causes of Death.

Jenner and Smallpox 1796 Jenner and Smallpox .

“The World is my laboratory” Louis J. Pasteur .

.

Jonathan Snow: Cholera in London. 1850 .

Koch-Henle Postulates • Microorganism must be present in every case • Microoganism must be isolated and grown in pure culture • Innoculation of microorganism into susceptible host must reproduce disease • Microorganism must be observed and recovered .

Cholera.Robert Koch Early microscopic studies of TB. Smallpox Microbes . Anthrax.

1890 Development of Anti-toxins Vaccinology (Immunizations): Smallpox. Measles. Rubella.Public Health in the 20th Century Louis Pasteur. Paul Erlich. 1880 Germ Theory of Disease Robert Koch. Influenza . Tetanus. Mumps. Polio. Diphtheria.

1913 .Joseph Goldberger Pellagra.

and occupational medicine . toxicology.Alice Hamilton. MD: Founder of Occupational Medicine (1869-1970) • Received her medical degree from the University of Michigan in 1893 • Founder of [modern] occupational medicine • First woman professor at Harvard Medical School • First woman to receive the Lasker Award in public health • Classic publications on industrial hygiene.

Alice Hamilton. Founder of Occupational Medicine . 1869-1970.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.