EPID 600: Introduction to Epidemiology

University of Michigan School of Public Health

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 Course details
Fall Term 2008
Lecture on Tuesdays 10:00am-11:30am
Lecture is in SPHII Auditorium

Discussion sections on Thursdays

All students should be in a section at either 10:00am-11:30am OR
11:30am-1:00pm.

Discussion sections are in SPH-II M1170 or M4332 or M4318

Discussion sections are mandatory

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 Primary instructor
Sandro Galea, MD, DrPH
Center for Social Epidemiology and Population Health
Department of Epidemiology
University of Michigan
1214 S. University
Ann Arbor, MI 48103
734.647.9741
sgalea@umich.edu

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Malta

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Toronto

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 Toronto

Philippines
Guatemala PNG

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Geraldton

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Geraldton

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Somalia

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Boston

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New York

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 My work

Social and economic determinants of health, a focus on the

macrosocial determinants of health; urban health
Epidemiology of mental health and drug use
Consequences of disasters and mass trauma
URL: www.disasterresearch.org

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 Graduate student instructors
Lauren Wallner, MPH
lwallner@umich.edu

Elsie Grace, MPH

elgrace@umich.edu

Jennifer Smith, MPH

smjenn@umich.edu

All instructors are VERY available by email and by appointment when you need us

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 Course objectives

  To discuss and define basic epidemiologic principles

  To
introduce concepts central to epidemiologic
measurement
  To
compare and contrast different epidemiologic study
designs and to consider the application of these study
designs to different research questions
  Todiscuss factors that guide the interpretation of
epidemiologic studies
  Todiscuss the role of epidemiology in public health and
the interrelation between epidemiology, clinical research,
and other disciplines in public health and medicine.
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 The point of the course

  To
introduce epidemiology students to the key concepts
and methods of epidemiology
  Toprepare students for further courses in epidemiology,
particularly EPID 655 and EPID 601
  Tointroduce students to and to familiarize students with
epidemiologic writing in peer-reviewed journals

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 Therefore, the implicit aims of this course

  Thecourse will involve a combination of lectures and

discussion groups
  Therewill be about 10 assignments in the course; all
assignments will involve epidemiologic computations and
also will require the reading of a recent peer-reviewed
epidemiologic paper.
  Itis an implicit goal of the course that by the time they
finish the course all students will have familiarity with how
to read and evaluate epidemiologic papers

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 Course organization

Section 1: Introduction to epidemiology, basic

concepts and measures
Section 2: Study design and analysis
Section 3: Special topics in epidemiology

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 Course grading

Class participation (10%)

Weekly assignments (25%)
Mid-term exam (15%), take-home, due October 28,
2008 at 10am
Epidemiologic paper critique (20%) due on
November 25, 2008 at 10am
Final exam (30%)

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 Class participation (10%)

Speak up in class and in discussion sections

You can miss no more than 2 discussion sections
Speak up!

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 Structure of discussion sections

30’: review of material covered in any given week

30’: review of answers from preceding week’s assignment
30’: discussion of epidemiologic paper for following week’s
assignment

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 Assignments (25%)

Assignments are key to success in this course

All assignments are graded out of 30; all questions have
equal weighting; some questions are harder than others
Assignments are intentionally designed to be
computationally intensive
Most of the assignments are stand-alone questions
A part of each assignment refers to a recently published
epidemiologic paper
Please read the whole paper before answering the
assignment questions

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 Epidemiologic paper critique (20%)

A structured analysis and critique of an epidemiologic paper

There will be four papers handed out and students will
choose one of the four to critique
The critique will be no longer than 2,500 words
“How to critique an epidemiologic paper” will be formally
discussed on October 28, 2008

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 Exams; mid-term + final (15+30%)

Open-book, open-resource, i.e., you can use

whatever resources you want, except for friends and
family; mid-term is take home, final is in-class
Exams will mirror format of assignments; if you have
done well on assignments you should have nothing
to worry about
Mid-term exam handed out on October 23, and is
due October 28, 2008; it is strongly recommended
that you spend 1 hour on the mid-term
Final exam is on December 16, 2008 from 4-6pm.

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 How did people typically do in this
60
class?
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Number of students

30

20

10

0
A A- B+ B B- C+
Letter grade
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 So how do I do well in this course?

  Attend all sessions, do all assignments

  Carefully read all the papers, both attached to class and
to the assignments
  Do extra questions. There are many examples online.
Best, you should be doing all questions in the textbook.
Sample answers are at:
http://www.us.oup.com/us/companion.websites/
0195135547/chapter.questions/?view=usa

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 So, should I be in this class?

Epidemiology track students welcome

All other students are welcome provided you are
interested in being in a computationally challenging
course that is intended as preparation for higher-
level epidemiology courses

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 Academic conduct

School of public health policy is that student conduct should

be consistent with that of a professional person
Academic misconduct includes plagiarism, cheating,
fabrication, falsification, and aiding/abetting such acts
Practically speaking—we expect that students will work
together on assignments but ask that all students hand in
their own individual answers
Please be creative; there is no reason to hand in identical
work to that of others

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 The trouble with epidemiologists and the
solutions for this course
Use of different terminology
Occasionally cantankerous adherence to one way
of doing and speaking about things
We will use a book by Rothman, the same author
for the book used in EPID 601
There may be some inconsistencies between EPID
600 lectures and the book—for the purposes of this
course, the material in the lectures should guide
answers to assignments and exams
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What is epidemiology?

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 What is epidemiology?

The study of the distribution of disease and the

determinants of disease
The study of the “causes” of disease
The “science of public health”

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 Operationally

“Counting” the causes of morbidity and mortality

Determining the variables that are associated with the
causes of morbidity and mortality
Identifying the factors that are “causes” and are potentially
modifiable
Guiding (and evaluating) interventions to improve health

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 Definition of epidemiology

Three Greek words

epi = among
demos = people
logos = doctrine

So, “the doctrine of what is among or happening to people”

Note, this is shared Greek root with “epidemic” (from Greek
epi upon + demos people) but not derived from “epidemic”

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 Basic assumptions of epidemiology

1.  Death and disability do not occur at random

2.  There are causal factors that can be identified through
the systematic investigation of human populations
3.  Identifying these causal factors can lead to preventive
intervention

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 Epidemiology and populations

Epidemiology is fundamentally concerned with

populations
Epidemiology concerns itself with measuring
distribution of disease in populations and the factors
associated with those distributions
This has implications later on as we consider the
nature of causation in epidemiology

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 History of epidemiology (1)

5th century, BCE, Hippocrates suggests that the

development of human disease might be related to the
external as well as the personal environment of an
individual

1662, John Gruant publishes “The nature and political

observations made upon the bills of mortality”, analyzing
the weekly births and deaths in London, and quantifying
(for the first time) the patterns of disease in a population

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 History of epidemiology (2)

1796, Edward Jenner took cowpox from a lesion on the

hand of a dairy maid and inoculated an 8-year old
“volunteer”, then exposed the child to smallpox 6 weeks
later

1839, William Farr, a physician with responsibility for

medical statistics in the Office of the Registrar General of
England and Wales, sets up a system for routine
collection of numbers and causes of death

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 William Farr (1807-1883)
“The fatality of every class of
disease...is augmented in the
concentrated city population...
let the rejected vegetables, the
offal of slaughtered animals, the
filth produced in every way
decay in the houses...and the
atmosphere will be an active
poison, which will destroy...5-7
percent of the inhabitants
annually.”

Farr W. Letter to the Registrar General. First Annual Report of the Registrar General of Births, Deaths, and Marriages in England. 1839; London, HMSO. 46
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 Life expectancy, England and Wales,
1800-1900
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Life expectancy (years)

Public Health Act

45 of 1848

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1800 1810 1820 1830 1840 1850 1860 1870 1880 1890 1900

Year

Bongaarts J, ed. Beyond Six Billion: Forecasting the World’s Population. 2000; National Academy Press, pg. 123. 49
 History of epidemiology (3)

1855, John Snow, a physician best known for his

developments in anesthesiology, formulates and tests a
hypothesis that drinking water supplied by the Southwark
and Vauxhall Company increased the risk of cholera
compared with water from the Lambeth company

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Cholera and John Snow
Four cholera epidemics with over 100,000
deaths in London in the mid-nineteenth
century
“Miasma” and “Germ” theories
John Snow published treatise in 1849
supporting germ theory and suggesting
contaminated water as a means of
transmission
An 1854 cholera outbreak was shown to be
associated with one of London’s two water
companies

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Determinants of cholera
200,000 cesspools

Manure sold to farms

London expanded rapidly

Maintenance revenue fell

Cesspools in disrepair

Calls for removal unheeded for many

years
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The Broad Street Pump
John Snow removed pump handle in 1854 to
stop the spread of cholera

Academic folklore: “The birth of public health”

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The efficacy of medical interventions?

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 History of epidemiology (4), the
twentieth century
During the first half of the twentieth century, the study of
epidemiology was largely concerned with infectious
diseases
In the second half of the twentieth century, epidemiology
was concerned with chronic diseases
HIV/AIDS confuses the whole focus in the late 1980s
Growing emphasis on the “proximal” and immediate causes
of health and disease until recent (past decade) rediscovery
of the “social” determinants of health

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 Ten greatest public health achievements, US,
1900-1999
Vaccination
Motor-vehicle safety
Safer workplace
Control of infectious disease
Decline in deaths from coronary heart disease and stroke
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco use as a health hazard

MMW. April 02, 1999 / 48(12);241-243 . http://www.cdc.gov/MMWR/preview/mmwrhtml/00056796.htm 56

 A digression...Michigan’s role

1944, Thomas Francis, Jr, Chair of Epidemiology, develops

Influenza vaccine for US army

1955, Salk polio vaccine trials (N~1,800,000) end declaring

vaccine safe and effective

1985, Ken Warner’s study on health implications of tobacco

consolidate federal taxation policy as smoking disincentive
etc

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A metaphor

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Rich

Poor

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Leading causes of death in the US, 2005

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Leading causes of death in the US, 2005

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Leading causes of death in the US, 2005

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 Leading causes of death in the US, 2005

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Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005. National vital statistics reports; vol 56 no 10. Hyattsville, MD: National Center for Health Statistics. 2008.
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Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005. National vital statistics reports; vol 56 no 10. Hyattsville, MD: National Center for Health Statistics. 2008.
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Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005. National vital statistics reports; vol 56 no 10. Hyattsville, MD: National Center for Health Statistics. 2008.
 Leading causes of death?

McGinnis and Foege 1993

Mokdad AH, Marks JS, Stroup DF, Gerberding DL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-45 68
 “Actual” causes of death?

McGinnis and Foege 1993

Mokdad AH, Marks JS, Stroup DF, Gerberding DL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-45 69
 Leading causes of death, worldwide, 2001

World Health Organization Annual Report, 2002 70

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http://www.who.int/mediacentre/factsheets/fs310.pdf
 The usual epidemiologic approach

1.  Identify a disease of interest

2.  Identify exposures of interest based on what is known about the
disease (prior epidemiologic research, biology, laboratory studies)
3.  Examine statistical associations between exposures and disease
4.  Hold constant factors that may be “mixed up” in this measure of
association
5.  Infer a causal association between exposure and disease on the
individual level
6.  Recommend intervention

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 Epidemiologic papers, papers, papers...

  This course aims to introduce all students to reading

modern epidemiologic papers
  You will have papers to read every week for course
assignments
  There are papers that are used in each lecture for
examples (the orange slides)
  There is a final paper critique assignment
  Remember—this course is meant for epidemiology
students, so learning how to read and analyze papers is
critical
  All papers are on C-tools already...read away!
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So, what does an epidemiologic paper
look like?

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 The empiric epidemiologic paper

Introduction

Methods

Results

Discussion

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 Introduction
What is the scope of the problem?
e.g., obesity is a national emergency etc

What do we know about the problem?

e.g., changes in eating patterns have influenced obesity

What do we not know about the problem?

e.g., does neighborhood social cohesion influence eating patterns?

What is the purpose of this paper?

e.g., to assess the relation between neighborhood social cohesion and
eating patterns
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 Methods

Sample
Location, time, population, data collection methods, IRB
approval

Variables
Discuss each variable used in analysis

Analysis
Step-by-step analysis

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 Results

Table 1 shows…

Figure 1 shows...

Table 2 shows…

Table 3 shows…

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 Discussion
Summary of study results
i.e., “This population-based study showed…”

How this study builds on previous knowledge

“This study is consistent with previous work…”
“This study differs from previous work…”
“Explanations for these findings…”

Limitations

Conclusions/implications
“Notwithstanding these limitations…”
“Implications of this work are…”
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