1 Epidemiology Intro

Contents of this module
Definition of epidemiology
Goals of epidemiology
Application of epidemiology
Disease distribution
Disease etiology
Disease therapy and progression
Types of epidemiologic investigations

Observational studies
Experimental studies
HSS4303: Introduction to epidemiology
Class activity
Form groups of four and discuss the following:
SARS
SARS in Toronto
SARS worldwide
SARS current state (new knowledge on outbreaks,
diagnosis, prognosis)
To initiate the discussion check out the following

slides
SARS in Ontario: Acute conditions
SARS in Ontario
SARS in Toronto
Breast cancer in Canada: Chronic

conditions
In 2006, an estimated 22,200 women were diagnosed
with breast cancer and 5,300 died of it.
An estimated 160 men were diagnosed with breast
cancer and 45 died of it.
On average, 429 Canadian women will be diagnosed
with breast cancer every week.
On average, 102 Canadian women will die of breast
cancer every week.
One in 9 women is expected to develop breast cancer
during her lifetime. One in 27 will die of it.
Since 1993, incidence rates for breast cancer have
stabilized and death rates have declined steadily
Cancer incidence and mortality in

Canada
What is epidemiology?
Epi
Epidemiology is the core (hub) of a field of study that deals

with distribution, understanding and the cause of disease
Which
Why
How
Who
Epi
Epi
What
When
Where
Epidemiology asks and answers the questions:

Who, where, when, what, why, which and how
Disease rates
mortality
Which
Study
design
Why
How
Detrmnts
of health
Epi
Epi
Who
Population
What
Disease
incidence
When During
Lifespan/
season
Where
Disease
surveillance
Epidemiology answers are in the middle ring; these answers

are the course objectives and the basics of epidemiology
Epidemiology in layers
The core defines the basics the hub
The inner circle - articulates the questions
The middle circle provides the answers and are the

course objectives
The outer circle describes the actions which
epidemiologists take in solving the puzzles
Life
expectancy
Survival rates
Occupational &
Environmental
SMR & PMR
Case-Control
Cross sectional
Disease rates
mortality
Psychosocial
Determinants
of health
Which
Cohort &
Longitudinal
Demographic
profile
Study
design
How
Epi
Epi
Epi
Who
When
Population
What
Ethnicity
Disease
incidence
Prevalence
rates
Genetics
Why
Where
Disease
surveillance
During
lifespan or
season
Socioeconomic
status
Attack rates
Incidence
density
Survival
Ethnicity
A disease does not randomly distribute in a
population but the distribution is characteristic of
the individual, the population and environment.
These characteristics are:
The individual/population (genetic, demographic, lifestyle
factors)
The environment (home leisure, work factors)
Epidemiology helps to understand the disease and

the distribution of disease in a population and the
factors that influence or determine the
distribution
Epidemiology is defined as the study:
of the distribution and the determinants of health-related
states or events in specific populations and
The purpose is to understand and to monitor health problems
Epidemiology is used
To measure disease distribution and determine intervention

To identify the cause of disease
To diagnose and predict disease outcome
To measure the risk of disease development and death
To inform and evaluate policy
Objectives of epidemiology
To determine the etiology or the cause of a disease and
the risk factors i.e. the factors that increase a persons
risk for disease
To determine the extent of the disease found in the
community
To study the natural history and prognosis of the disease
To evaluate both the existing and new perspectives and
therapeutic measures and modes of health care delivery
To provide the foundation for developing public policy
and making regulatory decisions relating to
environmental problems
Epidemiology and community

Epidemiology tells us about the community
Health dynamics in the community

Lifestyle and behaviour
Health status
Quality of life
Health issues
Epidemiology tells us about disease in the community
Sentinel case
Epidemic
Endemic
Pandemic
Figure 1-2 Ten leading causes of death in the United States, 1900 and 2000.
(Redrawn from Grove RD, Hetzel AM: Vital Statistics Rates of the United
States, 1940-1960. Washington, DC, US Government Printing Office, 1968;
and National Center for Health Statistics, National Vital Statistics Report, Vol
49, No. 12, October 9, 2001.)
Figure 1-3 Life expectancy at birth and at 65 years of age, by race and sex, United States, 1900,
1950, and 2000. (Redrawn from National Center for Health Statistics: Health, United States, 1987
DHHS publication no. 88-1232. Washington, DC, Public Health Service, March 1988. National
Center for Health Statistics: National Vital Stat Rep 49, no. 12, October 9, 2001.)
Trends in cancer incidence in males

and females in Canada
Epidemiology and individual

Epidemiology tells us about the individual
Who gets sick (age, gender, health status, etc.)

Lifestyle and dietary habits
Time and place of occurrence
Sexual preference
Epidemiology tells us about disease in the individual
Sentinel case
Infectious
Acute or chronic
Prognosis and treatment options
Individual profile
A 29-year old previously healthy man was referred to the
UCLA Medical Center with a history of fever, fatigue,
lymph node enlargement and weight loss of almost 25 lb
ober the preceding 8 months.
He had a temperature of 39.50C, appeared physically
wasted and had swollen lymph nodes.
Laboratory evaluation revealed a depressed level of
peripheral blood lymphocytes.
The patient suffered from simultaneous infections
involving Candida albicans in his upper digestive tract,
cytomegalovirus in his urinary tract and Pneumocystis
carinii in his lungs.
Although antibiotic therapy was administered the patient
remained severely ill.
Sentinel cases in AIDS epidemic

Table 11. Characteristics of Sentinel Cases of AIDS in Los Angeles, 1981.
Characteristics of Sentinel
Cases
Personal Attributes
Age
Early 30s
Gender
Male
Prior health
Good
Sexual preference
Homosexual
Place of occurrence
Los Angeles
Time of occurrence
October 19, 1980 to June 19,

1981
Class activity
Clinical diagnosis for an individual
A 51-year old individual who has been well two weeks ago, has gone
to his GP for chest pains which he noticed while walking home from
work. He also experienced chest tightness which stopped after 2-3
minutes of rest.
He has experienced similar discomfort in the past sometimes during
exercise and sometimes during rest. He smokes one pack of
cigarettes a day and he has been diagnosed with high blood
pressure.
He is otherwise well and takes no medications and is worried about
his health
A complete physical examination at the GP and resting
electrocardiogram are normal, except for a blood pressure of 150/96
Could he have angina pectoris, esophageal spasm, stress, anxiety or
something more severe including cardiovascular diseases?
Goals of epidemiology
Disease prevention
disease dynamics, outbreaks, epidemics, pandemics
Clinical practice
diagnosis, treatment options, prognosis
Disease etiology
what causes the disease, disease progression, risk of disease
development
1. Epidemiology and prevention of

disease
Prevention of disease is one of the major goals of
epidemiology
Epidemiology helps to identify population at
high risk of developing disease
Epidemiology helps to identify specific factors or
characteristics that put populations at higher
risks
Non-modifiable risks (age, sex, race)
Modifiable risks (obesity, diet, lifestyle, occupation)
Prevention of disease
Prevention of disease
Primary prevention are actions taken to prevent the development of
disease in a person who is well and does not have the disease
Immunization, change of lifestyle, change of environment or occupation
Secondary prevention denotes actions to identify people who have

already developed a disease and are at an early stage in the diseases
natural history to prevent people from developing full blown disease or
becoming victims to disease (mortality or complications of disease)
Early detection of breast cancer through self examination and
mammography,
PSA testing for early detection of prostate cancer
Tertiary prevention involves efficient therapy so that disease

morbidity and mortality can be significantly reduced
Early breast surgery
Types of prevention approaches

Population-based approach wherein a preventive
measure is widely applied to the entire
population
Dietary advice for preventing coronary diseases
Advice against smoking
High-risk approach wherein a high-risk group is

targeted
Women at high risk of cardiovascular disease are advised
to alter lifestyle
2. Epidemiology and clinical practice

Diagnosis of disease is assisted by epidemiology
Flu, cardiovascular disease in hypertensive patients
Prognosis of disease through epidemiology

Survival rates in cancer patients, course of disease
Selection of appropriate therapy

Randomized clinical trials, treatment modalities
Figure 1-5 Frequency of agents by age of children with pharyngitis, 1964-1965. (From
Denny FW: The replete pediatrician and the etiology of lower respiratory tract infections.
Pediatr Res 3:464-470, 1969.)
3. Epidemiology and disease etiology

Epidemiology helps to examine the relationship
(association) between the development of
disease and associated factors
An environmental agent
Personal characteristics
Existence of relationship
Determine if the relationship is causal
Individual
Individual
Smoking
Farming
Lung cancer
Prostate cancer
Pesticides, fertilizers, lubricants

Epidemiology and disease etiology

Relationship between disease and exposure
Observational data
Environmental observations
Disease observations
Epidemiology and chronic and acute diseases
Observational studies
Person, place and time
Acute or chronic condition
Sentinel cases the first few affected patients
Epidemic sudden and great increase in the occurrence of a disease
within a population
Pandemic a rapidly emerging outbreak of disease that affects a
wide range of geographically distributed populations
SARS, STD, AIDS
Experimental studies
Contribution by clinicians, molecular biologists,
pathologists, toxicologists, pharmacologists, etc.
Animal studies
In-vitro studies
Human studies
Figure 1-6 Gonorrhea: reported cases per 100,000 population, United States and
territories, 1999. (Gonorrhea-Rates by State: United States and outlying areas, 1999.
http://www.cdc.gov/nchstp/od/program_brief_2001/Gonorrhea Rates by state United
States and outlying areas, 1999.htm, updated 6-30-01.)
Gonorrhea Rates by state: United States and outlying areas, 2006

Gonorrhea Rates by race/ethnicity: United States, 19972006

Figure 1-7 Relationship between rate of dental caries in permanent teeth and fluoride content
in public water supply. (Adapted from Dean HT, Arnold FA Jr, Elvove E: Domestic water and
dental caries: V. Additional studies of the relation of fluoride in domestic waters to dental
caries experience in 4,425 white children aged 12 to 14 years of 13 cities in 4 states. Public
Health Rep 57:1155-1179, 1942.)
Figure 1-8 DMF indices after 10 years of fluoridation, 1954-1955. DMF-Decayed, missing, and
filled teeth. (Adapted from Ast DB, Schlesinger ER: The conclusion of a 10-year study of water
fluoridation. Am J Public Health 46:265-271, 1956. Copyright 1956 by the American Public Health
Association. Adapted with permission.)
Figure 1-9 Effect of discontinuing fluoridation in Antigo, Wisconsin, November 1960. DMFdecayed, missing, and filled teeth; FL+, during fluoridation; FL-, after fluoridation was
discontinued. (Adapted from Lemke CW, Doherty JM, Arra MC: Controlled fluoridation: The
dental effects of discontinuation in Antigo, Wisconsin. J Am Dental Assoc 80:782-786, 1970.
Reprinted by permission of ADA Publishing Co., Inc.)
Observational data to preventive action

Epidemiological success: historical context
Figure 1-10 Photograph of Edward Jenner.

(From the Wellcome Historical Medical
Museum and Library, Mansell Collection,
London.)
Figure 1-11 Painting of the first vaccination. (Roses

DF: From Hunter and the great pox to Jenner and
smallpox. Surg Gynecol Obstet 175:365-372, 1992.
By permission of Surgery, Gynecology & Obstetrics,
now known as the Journal of the American College
of Surgeons.)
Pioneering work in epidemiology

Story of smallpox
400,000 people died each year in the late 18th century

1/3 of the survivors became blind
Survivors also developed immunity to smallpox
Efforts to prevent smallpox
Variolation
Edward Jenner took interest in cowpox to find solutions in

the prevention of smallpox
WHO and eradication of smallpox
In 1967 WHO began the eradication program

15 million people developed smallpox annually
2 million people died
In 1980 smallpox was eradicated
Shoe leather epidemiology
Figure 1-12 Photograph of John Snow. (From

the Wellcome Historical Medical Museum and
Library, London.)
Figure 1-13 A drop of Thames water, as depicted by

Punch in 1850. (From Extracts from Appendix (A) to
the Report of the General Board of Health on the
Epidemic Cholera of 1848 and 1849, published by
HMSO, London, 1850. Int J Epidemiol 31:900-907,
2002.)
Pioneering work in epidemiology

The story of cholera
Cholera was a major health problem in the 19th century
In 1854 in one week 600 people died not far from Broad
Street pump in London
Miasmatic theory by William Farr
John Snow believed that cholera was caused by
contaminated water
Lambeth company and Southwark and Vauxhall company
supplied most of the drinking water in London at that time
Vibrio cholerae was unknown then and disease biology was
also not known
Deaths from cholera and miasmatic

theory
Elevation above sea
level
Deaths in 10,000
inhabitants
<20
120
20-40
65
40-60
34
60-80
27
80-100
22
100-120
17
340-360
Deaths from cholera and water theory

Water supply
# of
houses
Deaths
from
cholera
Deaths
per
10,000
houses
Southwark and Vauxhall

Co
40,046
1,263
315
Lambeth Co
26,107
98
38
Other districts in London
256,423
1,422
56
Observational epidemiology
Many a times we do not know the cause of disease but we
can associate it with certain exposures
Streptococcal infection follows rheumatic fever and rheumatic heart
disease
Rheumatic fever is more frequent in army recruits than in school
children
Lung cancer and smoking

Epidemiology based on observational data leads us to
understand the association between the morbidity and
mortality from a disease and certain exposures, habits,
lifestyle choices
Figure 1-14 Breast versus lung cancer mortality: white females versus
black females, United States, 1973-1995, age-adjusted to 1970
standard. (From Ries LAG, Kosary CL, Hankey BF, Miller BA, Edwards
BK [eds]: SEER Cancer Statistics Review, 1973-1995. Bethesda, MD,
National Cancer Institute, 1998.)
Trends in cancer incidence in males

and females in Canada
Prevention and therapy

Prevention is integral to public health and also to
clinical practice
In clinical practice therapy is used to prevent
complications, disability and death
Prevention in public health and clinical practice
Primary prevention (immunization)
Secondary prevention (minimize disease complications)
Tertiary prevention (minimize disability)
Epidemiology is the basis for effective

prevention programs
Sources of water and cholera morality in

London 9th July 26th August 1854
Water supply
# of
houses
Deaths
from
cholera
Deaths
per
10,000
houses
Southwark and Vauxhall

Co
40,046
1,263
315
Lambeth Co
26,107
98
38
Other districts in London
256,423
1,422
56
What can you conclude about the cause of cholera from the above data? Discuss your answer.
Snows work on cholera

120
100
80
60
40
20
0
A19
A21 A23
A25 A27 A29 A31
S2
S4
S6
S8
S10
S12
S14
S16
S18
S20
S22
S24
S26
S28
S30
# of cases
Snow was convinced that pump A was the source of the cholera outbreak and he persuaded the local authorities
to remove the handle on pump A on Sept 8th. The dates of onset of symptoms of the 616 fatal cases of cholera
recorded between 19 August and 30 Sept are shown in the above graph.
What does the graph indicate?
Why do you think the epidemic stopped?
Applications of epidemiology
Disease surveillance
Disease etiology
Diagnostic testing
Clinical decisions
Therapy
Disease prevention
Branches of epidemiology
Descriptive epidemiology
Deals with activities related to characterizing the
distribution of disease within population(s)
Analytic epidemiology
Deals with activities related to identifying possible
causes for the occurrence of disease in individuals or
communities
Both branches are fundamental to the

prevention and control of disease and to the
advancement of medical knowledge (etiology,
course of disease, therapy, prognosis)
Answers questions: who, where and when
HSS4303: Introduction to
epidemiology
Branches of epidemiology
Subject based classification
Cancer epidemiology
Occupational epidemiology
Chronic disease epidemiology
Clinical epidemiology
Molecular epidemiology
Environmental epidemiology
Infectious disease epidemiology
HSS4303: Introduction to
epidemiology
Disease surveillance
Monitoring patterns of occurrence of a disease within a
population is referred to as surveillance.
There are many potential benefits from the collection of
surveillance data:
(1) can help to identify the new outbreak of an illness, such as AIDS,
(2) can provide clues, by considering the population groups that are
most affected by the illness, to possible causes of the condition,
(3) can be used to suggest strategies to control or prevent the spread of
disease,
(4) can be used to measure the impact of disease prevention and control
efforts, and finally,
(5) can provide information on the burden of illness, data that are
necessary for determining health and medical service needs
Estimated rates (per 100,00 population) for adults and adolescents living with HIV
infection (not AIDS) or with AIDS, 2005United States and dependent areas (Revised
June 2007)
Health Sciences and their

complementary relationships
HEALTH RESEARCH
Health Services
Epidemiology
Clinical Sciences
Biological Sciences
Primary focus
Health care systems
Populations
Individual patients
In-vivo; In-vitro; Genetics; Therapy
Etiological studies:
Schematic diagram of a casecontrol study of the association between the

number of male sexual partners of homosexual men and the risk of AIDS. Shaded areas represent subjects
with a large number of sexual partners, and unshaded areas represent subjects with a small number of
sexual partners.
Etiological studies:
Schematic diagram of a cohort study of the association between receptive

anal intercourse and risk of being HIV positive. Shaded areas indicate subjects who practice
receptive anal intercourse, and unshaded areas represent subjects who do not.
Diagnostic tests: false positive and false negative tests are used
to assess sensitivity and specificity
Disease prognosis and changes in therapeutic regimens
Schematic diagram of a study to evaluate prognostic factors for

persons with HIV infection
The shaded areas represent patients with the favorable
prognostic factors of interest and the unshaded areas represent patients without
the prognostic factors of interest
Schematic diagram of a randomized controlled clinical trial of reverse

transcriptase inhibitors (RTI) with or without a protease inhibitor (PI)
for the treatment of HIV infection.
The shaded areas indicates patients
randomized to receive combined treatment with RTI and a PI
Epidemiology: what and why

Epidemiology is the study of the distribution and determinants of diseases
within human populations. Research in this field is based primarily upon
observing people directly in their natural environments.
Epidemiology can be used for descriptive purposes, such as surveillance of the
occurrence (incidence) of a particular illness.
Epidemiology can be used for analytic purposes, such as studying risk factors
for disease development.
Epidemiologic methods can be used to assess the performance of diagnostic
tests.
Epidemiology can be used to study the progression or natural history of a
disease.
Epidemiologic methods can be used to study prognostic factors, which are
determinants of the progression of a disease.
Epidemiology can be used to evaluate treatments for a disease.
Study questions
What is the best descriptor of the likelihood over 10 years that an initially
unaffected person will develop hypertension?
What is the best descriptor off a characteristic such as hypertension that
affects the likelihood of developing a new myocardial infarction?
What is the best descriptor of the rapidity with which new cases of
myocardial infarction occur among a population of previously unaffected
persons?
What is the best descriptor of the percentage of persons unaffected by an
acute myocardial infarction who are classified correctly by a diagnostic test,
such as a cardiac troponin T assay?
What is the best descriptor of a characteristic, such as the severity of
coronary artery blockage, that affects the duration of survival following an
acute myocardial infarction?
What is the best descriptor of a sudden unexpected rise in the frequency of
occurrence of acute myocardial infarction in a community?
What is the descriptor of the percentage of patients with an acute
myocardial infarction who die within 10 years of their initial diagnosis?
What is the best descriptor of the percentage of persons with an acute
myocardial infarction who are classified correctly by a diagnostic test, such
as a cardiac troponin T assay?

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1 Epidemiology Intro

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Contents of this module

Types of epidemiologic investigations

To initiate the discussion check out the following

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

SARS in Ontario: Acute conditions

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

Breast cancer in Canada: Chronic

Cancer incidence and mortality in

HSS4303: Introduction to epidemiology

Epidemiology is the core (hub) of a field of study that deals

Epidemiology asks and answers the questions:

Epidemiology answers are in the middle ring; these answers

The middle circle provides the answers and are the

SMR & PMR

Epidemiology helps to understand the disease and

To measure disease distribution and determine intervention

Epidemiology and community

Health dynamics in the community

Epidemiology tells us about disease in the community

HSS4303: Introduction to epidemiology

Trends in cancer incidence in males

HSS4303: Introduction to epidemiology

Epidemiology and individual

Who gets sick (age, gender, health status, etc.)

Epidemiology tells us about disease in the individual

HSS4303: Introduction to epidemiology

Sentinel cases in AIDS epidemic

October 19, 1980 to June 19,

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

1. Epidemiology and prevention of

Secondary prevention denotes actions to identify people who have

Tertiary prevention involves efficient therapy so that disease

Types of prevention approaches

High-risk approach wherein a high-risk group is

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

2. Epidemiology and clinical practice

Prognosis of disease through epidemiology

Selection of appropriate therapy

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

3. Epidemiology and disease etiology

Pesticides, fertilizers, lubricants

Epidemiology and disease etiology

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

Epidemiology and chronic and acute diseases

HSS4303: Introduction to epidemiology

Gonorrhea Rates by state: United States and outlying areas, 2006

Gonorrhea Rates by race/ethnicity: United States, 19972006

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

HSS4303: Introduction to epidemiology

Observational data to preventive action

Figure 1-10 Photograph of Edward Jenner.

Figure 1-11 Painting of the first vaccination. (Roses

HSS4303: Introduction to epidemiology

Pioneering work in epidemiology