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MPH 604:

EPIDEMIOLOGY
CHAPTER 2
APPLICATIONS OF EPIDEMIOLOGY
Learning Objectives
Discuss uses and applications of epidemiology

Define epidemiologic transition and the influence of population dynamics on


community health

Discuss the clinical applications of epidemiology

Cite causal mechanisms from the epidemiologic perspective


Seven Uses for Epidemiology
Health Status and Health Services
1. Study history of the health of populations
2. Diagnose the health of the community
3. Examine the working of health services

Disease Etiology
1. Estimate the individual risks and chances
2. Identify syndromes
3. Complete the clinical picture
4. Search for causes
Demographic Transition
Shift from high birth and death rates found in agrarian societies to lower birth and
death rates found in developed countries.
Epidemiologic Transition
Shift in the pattern of morbidity and mortality from infectious and communicable
diseases to chronic, degenerative diseases.
Epidemiology and the Health
of the Community
Provides
a key to the types of
problems requiring attention

Determines the need for specific


health services
Demographic and Social Variables

Age and sex distribution


Socioeconomic status
Family structure
Racial, ethnic, and religious
composition
Variables Related to Community
Infrastructure
Availability of social and health
services
Quality of housing stock
Social stability (residential mobility)
Community policing
Employment opportunities
Health-Related Outcome Variables

Homicide and suicide rates


Infant mortality rate
Chronic and infectious diseases
Drug and alcohol abuse rates
Teen pregnancy rates
Sexually transmitted diseases
Birth rate
Environmental variables
Air pollution from stationary and mobile sources
Access to parks/recreational facilities
Availability of clean water
Availability of markers that supply healthful groceries
Number of liquor stores and fast-food outlets
Nutritional quality of foods and beverages vended to school-children
Figure 2.0.TA: Leading Causes of Death and Rates for Those Causes in 1900 and 2009,
United States
Causality
Epidemiology and Disease Etiology

Applications include:
Search for causes
Individual risks
Specific clinical concerns
Causality in Epidemiologic
Research
Epidemiologic research is the
subject of criticism.
Many conflicting studies
Henle-Koch postulates are not
relevant to many contemporary
diseases.
Multivariate causality
Risk Factors Defined

Due to the uncertainty of causal factors the term risk factor is used.
Definition: exposure that is associated with a disease
Example of a risk factor: smoking.
Risk Factors Defined (contd)
Three Criteria for Risk Factors
The frequency of the disease varies by
category or value of the factor, e.g., light
smokers vs. heavy smokers.
The risk factor precedes onset of the
disease.
The observation must not be due to
error.
Modern Concepts of Causality: 1964 Surgeon
Generals Report

Five criteria for causality


Strength of association
Time sequence
Consistency upon repetition
Specificity
Coherence of explanation
Modern Concepts of Causality: Sir
Austin Bradford Hill

Hillexpanded the list of criteria to


include:
Biologic gradient
Plausibility
Experiment
Analogy
Prevention of Disease

Research is applied to identify where in a


diseases natural history effective
intervention might be implemented.
The natural history of disease refers to the
course of disease from its beginning to its
final clinical end points.
Natural History of Disease
Prepathogenesis--before agent
reacts with host
Pathogenesis--after agent reacts
with host
Later stages include development of
active signs and symptoms.
Clinical end points are: recovery,
disability, or death.
Rules of Evidence

Criminal Law Disease Causality


1. Criminal present at scene of crime 1. Agent present in lesion of the disease
2. Premeditation 2. Causal events precede onset of
disease
3. Accessories involved in crime
3. Cofactors and/or multiple causalities
4. Severity or death related to state involved
of victim
4. Susceptibility and host response
5. Motivation: the crime must make determine severity
sense in terms of gain to the
criminal 5. Role of the agent in the disease must
make biologic and common sense
6. No other suspect could have
committed 6. No other agent could have caused
the disease under the circumstances
7. The proof of the guilt must be given
established beyond a reasonable
doubt 7. Proof of causation must e established
beyond reasonable doubt or role of
chance
Disease/Outcome Prevention
Primary Prevention as a General Concept

Occurs during prepathogenesis


phase
Includes health promotion and
specific protection against diseases
Primordial Prevention
Concerned with minimizing health
hazards in general
Examples include improvement of:
Economic conditions
Social conditions
Behavioral conditions
Cultural patterns of living
Primary Prevention as a Specific Concept

Involvesspecific protection against


disease-causing hazards
Examples:
Utilization of specific dietary supplements
Immunizations
Educational campaigns against unintentional
injuries
Primary Prevention: Active and Passive

Active
Necessitates behavior change on the part of the
subject
Examples: Vaccinations and wearing protective
devices

Passive
Does not require any behavior change
Examples: Fluoridation of public water and vitamin
fortifications of milk and bread products
Secondary Prevention

Occurs during pathogenesis phase

Designed to reduce the progress of disease

Examples are screening programs for cancer


and diabetes.
Tertiary Prevention

Takes place during late pathogenesis

Designed to limit disability from disease

Also directed at restoring optimal functioning


(rehabilitation)

Examples include: physical therapy for stroke


patients, halfway houses for alcohol abuse
recovery, and fitness programs for heart attack
patients.