Session 1.

Problem Solving In Epidemiology

 Definition

Dictionary of Epidemiology:
„The study of the occurrence and distribution of health-related states or
events in specified populations, including the study of the determinants
influencing such states, and the application of this knowledge to control
the health problems”
„…The primary ‘knowledge object’ of epidemiology as a scientific
discipline are causes of health-related events in population”

Briefly:
„ Epidemiology is the science that studies the pattern of
disease in populations to help understand their causes. This
knowledge is applied to prevent and control the problem”
 THE CONCEPT OF EPIDEMIOLOGY

1. Study the pattern of disease = Where, When, Who?

Describe the occurrence of a disease in a population

Comparison of disease occurrences

(over time, between places and between different types of people)

Demonstrate variation

Why?

2. Causal understanding

If we know the underlying causes than we can interfere

3. Prevention
 THE TOOLS OF EPIDEMIOLOGY

1. Study the pattern of disease = Where, when, who?

Tools to describe disease occurrences in population:

• Demography
• Epidemiological measures (ie.: incidence, prevalence, etc.)

Tools for comparison:

• Epidemiological triad: time, place, person
• Biostatistical methods (i.e.:
• Descriptive epidemiological studies (i.e.:

2. Causal understanding

3. Prevention
 THE TOOLS OF EPIDEMIOLOGY

1. Study the pattern of disease = Where, when, who?

Tools to describe disease occurrences in population:

• Demography
• Epidemiological measures (ie.: incidence, prevalence, etc.)

Tools for comparison:

• Epidemiological triad: time, place, person
• Biostatistical methods (i.e.:
• Descriptive epidemiological studies (i.e.:

2. Causal understanding

Test causal relationship: Analytical and experimental studies

Help to make the decision: Causal criteria

Help to understand causality: models

3. Prevention
Evidence Based Medicine: Evidence pyramid
Exercise No.1
Story of Semmelweis

Ignatz Semmelweis (1818-1865)

 The problem: Childbed fever

• Ignatz Semmelweis (1818-1865) observed that

the mortality from childbed fever (now known as
puerperal fever) was as follows:

First clinic Second clinic

Births Deaths Rate Births Deaths Rate

20042 1989 9.92 17791 691 3.88

 Causal understanding: Kolletschka’s death

• In 1847, his colleague and friend Professor Kolletschka

died following a fingerprick with a knife used to conduct an
autopsy.
• Kolletschka’s autopsy showed inflammation to be
widespread, with peritonitis (inflammation in the lining of the
gut), and meningitis (inflammation of the lining of the brain).

“Day and night I was haunted by the image of Kolletschka’s

disease and was forced to recognise, ever more decisively
that the disease from which Kolletschka died was identical
to that from which so many maternity patients died.”

• Semmelweis' inspired idea was that particles had been

transferred from the scalpel to the vascular system of his
friend and that the same particles were killing maternity
patients
 The sollution
• He introduced chlorina liquida, and then for
reasons of economy, chlorinated lime.

• The maternal mortality rate plummeted:

Rate in 1849: 1,26
 Lessons to learn

• Clues to the causes of disease are inherent within their

population patterns
• Deep knowledge lies in the explanation of the disease
pattern rather than in their description
• The questioning mind may solve the secret in the pattern
• Inspiration is needed and my come from unexpected
sources
• Effective action can be performed only if we know the
causal factors
• Action can not always wait until the complete
understanding of the mechanism
Excercise No.2
The Story of Pellagra
• Pellagra is a vitamin deficiency disease caused by
dietary lack of niacin.

• Symptoms:
- weakness;
- skin problems: high sensitivity to sunlight, dermatitis
(inflammation of skin);
- mental disorders: insomnia, confusion, aggression,
dementia, depression, etc.
- disturbances of the gastrointestinal tract: diarrhoea,
abdominal pain, etc.

• Main sources of niacin:

- milk, meat, liver, yeast
- full-milled wheet and oat products, potatoe
- Can not be absorbed from corn!
• Pellagra was first described in Spain in 1735 by Gaspar
Casal
• Because pellagra outbreaks occurred in regions where
maize (corn) was a dominant food crop, the belief for
centuries was that the maize either carried a toxic
substance or was a carrier of disease.
• In 1915, Joseph Goldberger, assigned to study
pellagra. He established that a balanced diet or a small
amount of brewer's yeast prevented pellagra.
• Scepticism nonetheless persisted in the medical
community until 1937, when it was showed that the
vitamin niacin cured pellagra in dogs. Later studies
established that niacin also cured pellagra in humans.
 (if there is time left)

Exercise 3.
The importance of heterogenity

• How would you study the link between tobacco and lung
cancer in a society where everybody smokes 20
cigarettes a day?
Problem:
In a society where everyone smokes, epidemiology would be
virtually powerless, because it is not possible to comparing and
contrasting the disease pattern in people with and without the
exposure.

Possible solution:
To persuade some of the population to stop smoking. (= do an
experiment)

Lesson learnt:
In epidemiology we utilize the inherent heterogeneity of the
population. We look for differences in characteristics that are
potential explanations for disease variations.