Chapter 2

Practical Applications of Epidemiology

Learning Objectives
Discuss uses and applications of epidemiology Define the influence of population dynamics on community health State how epidemiology may be used for operations research Discuss the clinical applications of epidemiology Cite causal mechanisms from the epidemiologic perspective

Seven Uses of Epidemiology

To study the history of the health of populations. To diagnose the health of the community. To study the working of health servicesoperations research. To estimate the individual risks of disease and other conditions, and the chances of avoiding them.

Uses, continued...
To identify syndromes. To complete the clinical picture of chronic diseases. To search for causes of health and disease.

Historical Use of Epidemiology

Refers to the study of past and future trends in health and illness. For example: Secular trends--changes in disease frequency over time.

Examples of Trends
Chronic diseases have replaced acute infectious diseases as the major causes of morbidity and mortality. Leading causes of U.S. deaths now are heart disease, cancer, and stroke. (Figure 2-1)

Factors Affecting Reliability of Observed Changes

Lack of comparability over time due to altered diagnostic criteria. Aging of the general population. Changes in the fatal course of the condition.

Four Trends in Disorders

Disappearing Residual Persisting New epidemic

Disappearing Disorders
This category refers to conditions that were once common but are no longer present in epidemic form; an example is smallpox. Immunizations, improvement in sanitary conditions, and the use of antibiotics and other medications led to eradication of these diseases.

Residual Disorders
Conditions for which the key contributing factors are largely known. Methods of control not implemented effectively. Examples: STDs, alcohol abuse, tobacco use.

Persisting Disorders
Diseases for which there is no effective method of prevention or no known cure. Examples: certain types of cancer and mental disorders.

New Epidemic Disorders

Diseases that are increasing in frequency. Examples: HIV, Type 2 diabetes

Predictions About the Future

About 20% of the U.S. population in 2030 will be age 65 and older. The need for health- and aging-related services will grow.

Population Dynamics
Three factors that affect the size of populations are births, deaths, and migration. When these factors do not contribute to net increases or decreases, the population is in equilibrium.

Population Terms
Fixed population--adds no new members and, as a result, decreases in size due to deaths only. Dynamic population--adds new members through migration and births or loses members through emigration and deaths.

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.

Steady Population
A population is in steady state when the number of members exiting equals the number entering.

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 Selected mortality rates Drug and alcohol abuse rates Teen pregnancy rates Birth rate

Healthy People 2010, Goal 2

. . . To eliminate health disparities among segments of the population, including differences that occur by gender, race, or ethnicity, . . .

Epidemiology and Policy Evaluation

Using epidemiologic methodologies to evaluate public health policies Examples: tobacco control policies, drug treatment systems, food sold to schoolchildren

Working of Health Services

Operations research (OR) Program evaluation

Operations Research (OR)

The study of the placement and optimum utilization of health services in a community.

Examples of OR
Coordination of programs for the developmentally disabled Studies of health care utilization Minority access to health insurance

Program Evaluation
Uses epidemiologic tools to determine how well a health program meets certain stated goals.

Epidemiology and Program Evaluation

Methods for selecting target populations Data analysis techniques Research designs Measurement procedures

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 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

Hill expanded the list of criteria to include:
Biologic gradient Plausibility Experiment Analogy

Study of Risks to Individuals

Etiologic study designs used
Case-control Cohort

Case-Control Design
A type of design that compares persons who have a disease (cases) with those who are free from the disease (controls). This design explores whether differences between cases and controls result from exposures to risk factors.

Cohort Design
A group of people free from a disease is assembled according to a variety of exposures. The group (cohort) is followed over a period of time for development of disease.

How Results Impact Clinical Decisions

The following considerations determine a studys influence:
Criteria of causality Relevance to each patient
Size of the risk

Public health implications

Individual vs. population

Enlargement of the Clinical Picture of Disease

Cases of a new disease often the most dramatic cases Need to survey a complete population Example of a new diseaseLegionnaires disease

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.

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

Involves specific protection against diseasecausing hazards. Examples:
Immunizations Smoking cessation Educational campaigns against accidents

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
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.

Chapter 2 Quiz
Define the following terms: Fixed population Steady population Demographic Transition Epidemiologic Transition Define the term health disparity. Discuss possible causal associations among health disparities and the health of the community. Define risk factor and give three criteria for risk factors. Explain how the extrapolation of findings from epidemiologic research may have different implications for individuals and the population. What should a clinician consider when giving recommendations to a patient?