Introduction to Epidemiology

Spring Semester, 2013 Randall E. Harris, MD, PhD Professor of Epidemiology OSU College of Public Health OSU College of Medicine Harris.44@osu.edu 292-4720 Office Hours: M W, 2:00 4:00 PM 306 Cunz Hall

Textbook
Epidemiology Kept Simple: an introduction to traditional and modern epidemiology Author: B. Burt Gerstman Course content/syllabus Assigned readings WebCT (Carmen)
http://carmen.osu.edu

Lectures on Carmen
Direct your URL to http://carmen.osu.edu Click on "view all courses" Click on the category of your course on the left. For example "Public Health" Click on on the title for your course on the right. For example "PUBH-EPI 510: Introduction to Epidemiology" Enter your Username and password. If you have problems getting into the course, you will be presented with an Online Form. The quickest way to receive assistance is to complete the form including any specific comments about your log in attempt. For more information about your OSU Internet ID visit http//www.oit.ohio-state.edu/userpass.html

Rx for Survival: a global health challenge

Six part documentary Critical Health Issues of 21st Century Global Impact Historical Events in Epidemiology & Public Health Narrated by Brad Pitt

Teaching Assistant
Yue Jin [jin.177@buckeyemail.osu.edu] Office Hours: Tues & Thursday 9:30-10:30 AM 300 B Cunz Hall

Goals and Objectives

Epidemiology defined Historical Events Accomplishments Causal Concepts in Disease Infectious Disease Screening for Disease Testing Accuracy Incidence & Prevalence Age Adjustment Rates, Ratios, Proportions, Risks Epidemiologic study Design Error & Bias Biostatistical Measures

Goals and Objectives

Retrospective Case Control Studies Prospective Cohort Studies Clinical Trials Life Tables & Survival Analysis Investigation of Outbreaks

Confirmed human cases of Avian Influenza A (H5N1) reported to WHO

600 500 400 300 200 100 0 Cases Deaths

Source: World Health Organization, 2012

l ta To 11 20 10 20 09 20 08 20 07 20 06 20 05 20 04 20 03 20

Influenza A Viruses
Subtyped based on surface glycoproteins: 16 hemagglutinins (HA) and 9 neuraminidases (NA) current human subtypes: H1N1, H3N2, H1N2

HA

NA

Swine Swine Avian Human Avian Swine Swine Swine

INFLUENZA: 2006-2009, USA

H1N1

2009 H1N1 Epidemic 61 million cases 12,470 deaths

H1N1 Pandemic: 2009

Total Cases:

50 000+ confirmed cases 5 000+ confirmed cases 500+ confirmed cases 50+ confirmed cases 5+ confirmed cases 1+ confirmed cases

Persons at Higher Risk for H1N1: CDC

Children younger than 5 years old Persons aged 65 years or older Pregnant women Anyone with who asthma, chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders Adults and children who have immunosuppression (e.g., immunosuppression caused by medications or by HIV) Residents of nursing homes and other chronic-care facilities.

Symptoms of Flu: CDC

fever (often high) headache extreme tiredness dry cough sore throat runny or stuffy nose muscle aches Stomach symptoms nausea, vomiting, and diarrhea

Transmission of Influenza: CDC

Person to Person Contamination Hand to Mouth Exposed persons can shed the virus 1-2 days before symptoms occur and 5-7 days after symptoms subside

Vaccination: CDC
Flu Shot: Inactivated vaccine containing killed virus approved for people 6 months & older The nasal-spray flu vaccine a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for "Live Attenuated Influenza Vaccine"). LAIV is approved for use in healthy* people 2-49 years of age who are not pregnant.

Seasonal Flu Vaccination: CDC

Children aged 6 months up to their 19th birthday Pregnant women People 50 years of age and older People of any age with chronic medical conditions People who live in nursing homes and other longterm care facilities People who live with or care for those at high risk for complications from flu, including: Health care workers Household contacts of persons at high risk for complications from the flu Household contacts and out of home caregivers of children under 6 months of age

Vaccination Precautions
People who have a severe allergy to chicken eggs. People who have had a severe reaction to an influenza vaccination in the past. People who developed Guillian-Barr syndrome (GBS) within 6 weeks of getting an influenza vaccine previously. Children less than 6 months of age (influenza vaccine is not approved for use in this age group). People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen.

Measure of Disaster: Earthquake & Tsunami in southern Asia

The cumulative death toll is approximately 217,000 Approximately 10,000 Americans were lost 1 Million people were injured or disabled 5 Million people were displaced from their homes WHO estimates the lack of clean water, food, sanitation, and medical care left up to 6 million people highly susceptible to infectious diseases such as diarrhea, cholera, typhoid, hepatitis, and dysentery.

CONFIRMED DEATH TOLLS

1. Indonesia: 79,940 2. Sri Lanka: 28,508 3. India (inc Andaman and Nicobar Is): 10,763 4. Thailand: 4,560

5. 6. 7. 8.

Somalia: 120 Burma: 90 Maldives: 67 Malaysia: 65

9. Tanzania: 10 10. Seychelles: 1 11. Bangladesh: 2 12. Kenya: 1

Measure of Disaster: Earthquake & Tsunami in southern Asia

Initial estimates for clean water, food (rice, lentils, & sugar), temporary shelter, and medical needs stand at $165 million for only a few weeks. Initial damage estimates for housing stand at approximately $14 million Public health and health care systems in the region are grossly insufficient to handle the crisis Few tsunami victims have insurance The world has pledged over $2 billion in aid (USA pledges total over $350 million)

The Tsunami

Tsunami crashing into Thailand's Phuket Island

Immediate health concerns

After the rescue of survivors, the primary public health concerns are clean drinking water, food, shelter, and medical care for injuries. Flood waters can pose health risks such as contaminated water and food supplies. Loss of shelter leaves people vulnerable to insect exposure, heat, and other environmental hazards. The majority of deaths associated with tsunamis are related to drowning, but traumatic injuries are also a primary concern. Injuries such as broken limbs and head injuries are caused by the physical impact of people being washed into debris such as houses, trees, and other stationary items. As the water recedes, the strong suction of debris being pulled into large populated areas can further cause injuries and undermine buildings and services. Medical care is critical in areas where little medical care exists.

Tsunami Victims

Tsunami Victims

Collateral Damage
Natural disasters do not necessarily cause an increase in infectious disease outbreaks. However, contaminated water and food supplies as well as the lack of shelter and medical care may have a secondary effect of worsening illnesses that already exist in the affected region. Decaying bodies create very little risk of major disease outbreaks. The people most at risk are those who handle the bodies or prepare them for burial.

Diarrhea From Food or Water

Bacteria & Viruses E. Coli, Cholera, Salmonella (Typhoid), Leptospirosis, Shigellosis Hepatitis A, Hepatitis E, Rotavirus Parasites Amebiasis, Entamoeba Histolytica, Cryptospirdiosis, Giardiasis

Foodborne Diseases
To prevent foodborne diseases, wash your hands with clean water and soap before and after you eat or prepare food and after you use the latrine or bathroom. If you do not have clean water, use waterless hand sanitizers until clean water is available for washing. Do not eat any food that has not been sealed in waterproof containers (commercially canned or sealed plastic containers) and that may have come in contact with untreated water, such as seawater, floodwater, river water, or pond water. Throw away any food not in nonsealed, nonwaterproof containers that has come in contact with untreated water.

Foodborne Diseases
Undamaged commercially canned foods can be saved. Remove the can labels, wash the outsides of the cans with soapy water, and thoroughly disinfect the cans using a solution of 1 cup (8 ounces; approximately 0.25 liters) of household bleach (5.25%) in 5 gallons (approximately 19 liters) of treated drinking-quality water. Use a marker to note the contents and expiration date on the cans. If opened food containers have screw caps, snap lids, crimped caps (soda pop bottles), twist caps, or flip tops, or if they have been home canned, throw them away if they have come in contact with untreated water. They cannot be disinfected.

Mosquitoe Vectors: Malaria

Malaria Malaria is a serious and sometimes fatal disease caused by a parasite. Patients with malaria typically are very sick with high fevers, shaking chills, and flu-like illness. Four kinds of malaria parasites can infect humans: Plasmodium falciparum, P. vivax, P. ovale, and P. malariae. Infection with any of the malaria species can make a person feel very ill; infection with P. falciparum, if not promptly treated, may be fatal. Although malaria can be a fatal disease, illness and death from malaria are largely preventable.

Illness From Animals/Insects

Plague Plague, caused by a bacterium called Yersinia pestis, is transmitted from rodent to rodent by infected fleas. Plague is characterized by periodic disease outbreaks in rodent populations, some of which have a high death rate. During these outbreaks, hungry infected fleas that have lost their normal hosts seek other sources of blood, thus increasing the increased risk to humans and other animals frequenting the area Rabies Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal.

Wound Infections & Diseases

Tetanus
A disease of the nervous system caused by bacteria Symptoms Early symptoms: lockjaw, stiffness in the neck and abdomen, and difficulty swallowing Later symptoms: fever, elevated blood pressure, and severe muscle spasms Complications: Death in about 11% of cases, especially people over age 60 Transmission Enters the body through a break in the skin Vaccine: Tetanus toxoid (contained in DTaP, DT, and Td vaccines) can prevent this disease.

Aftermath of Disaster
The effects of a disaster last a long time. The greater need for financial and material assistance is in the months after a disaster, including surveying and monitoring for infectious and water- or insect-transmitted diseases; diverting medical supplies from nonaffected areas to meet the needs of the affected regions; restoring normal primary health services, water systems, housing, and employment; and assisting the community to recover mentally and socially when the crisis has subsided.

Mental Health
Psychological trauma of death and destruction will produce longstanding mental health issues for the population.

Plasmodium Falciparum

Anopheles Mosquito

Global Malaria

Malaria Rates in Andaman District

Hurricane Katrina
Hurricane Katrina made landfall near the MississippiLouisiana border on 29, August 2005, as a high-level Category 3 hurricane with sustained winds of 145 miles per hour and a 25-foot storm surge. Katrina was the fourth most intense Atlantic Basin hurricane on record, and resulted in the largest displacement of a US population in history. Among the chief adverse effects of the hurricane on the lives of Mississippi residents, was the mortality suffered during the hurricanes impact phase, and the considerable disruption of livelihoods.

Hurricane Katrina
Widespread Outbreak of Norovirus Gastroenteritis among Evacuees of Hurricane Katrina Residing in a Large Megashelter in Houston, Texas Among hurricane evacuees from the New Orleans area, a cluster of infections with methicillinresistant Staphylococcus aureus (MRSA) was reported in approximately 30 pediatric and adult patients at an evacuee facility in Dallas, Texas. 24 cases of Vibrio vulnificus and V. parahaemolyticus wound infections, which resulted in deaths of 6 immunocompromised hosts.

Hurricane Katrina
Sporadic nontyphoidal Salmonella, nontoxigenic V. cholerae O1, and other infections were identified. About 1000 cases of viral gastroenteritis and sporadic cases of bacterial diarrhea also were reported in evacuation centers in four states Three weeks after the initial displacement caused by Katrina, few cases of diarrheal disease were being reported.

West Nile Virus: Louisiana & Mississippi

Global Mortality, 2012

World Population = 7.034 Billion (7,034 Million) Annual Deaths = 62 Million Annual Crude Probability of Death = 0.88 %
We are all approaching death, but some are moving at a relatively faster pace than others REH

Top 20 Causes of Mortality Throughout the World, WHO, 2004

Rank 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Cause Ischaemic heart disease Cerebrovascular disease Lower respiratory infections HIV/AIDS COPD Diarrheal diseases Tuberculosis Malaria Cancer of trachea/bronchus/lung Road traffic accidents Childhood Diseases Other unintentional injuries Hypertensive heart disease Self-inflicted Stomach cancer Total deaths (in thousands) 7,208 5,509 3,884 2,777 2,748 1,798 1,566 1,272 1,243 1,192 1,124 923 911 873 850 % of total 12.6% 9.7 6.8 4.9 4.8 3.2 2.7 2.2 2.2 2.1% 2.0 1.6 1.6 1.5 1.5

16.
17. 18. 19.

Cirrhosis of the liver

Nephritis/nephrosis Colon/rectum cancer Liver cancer

786
677
Source: The World Health Report, 2003, The World Health Organization (WHO).

1.4
1.2 1.1 1.1

622 618

Global Annual Mortality Rates Deaths Per 100,000 Per Year

Source, WHO, 2010

Death Rate by GDP

Global Causes of Death

Causes of death in developing countries HIV-AIDS Lower respiratory infections Ischaemic heart disease Diarrhea Cerebrovascular disease Childhood diseases Malaria Tuberculosis Chronic obstructive pulmonary disease Measles Number of deaths 2,678,000 2,643,000 2,484,000 1,793,000 1,381,000 1,217,000 1,103,000 1,021,000 748,000 674,000 Causes of death in developed countries Ischaemic heart disease Stroke Chronic obstructive pulmonary disease Number of deaths 3,512,000 3,346,000 1,829,000

Lower respiratory infections 1,180,000 Lung cancer Car accident Stomach cancer High blood pressure Tuberculosis Suicide 938,000 669,000 657,000 635,000 571,000 499,000

Malnutrition & Starvation

Undernutrition is either directly or indirectly responsible for up to 30% of deaths worldwide. WHO estimates that six million of the ten million deaths occurring annually in children under age five years are attributable to undernutrition. WHO estimates that one of seven older adults is malnourished thereby impacting mortality rates of selected chronic conditions, e.g., cancer, heart disease, diabetes II

Causation of Undernutrition
Lack of access to food Disorders or drugs that interfere with the intake, metabolism or absorption of nutrients, e.g., diabetes, thyroid disease, diuretics, steroids, nicotine, alcohol Greatly increased need for calories, e.g., pregnancy, breast feeding

Causation of Undernutrition
Poverty Famine Inability to obtain food (for example, due to lack of transportation or physical impairment) Disorders that interfere with the intake, metabolism, or absorption of nutrients

Causation of Undernutrition (Children)

Vomiting Diarrhea Infection Diabetes (Type I)

Causation of Undernutrition (Adults)

AIDS (HIV Disease) Cancer Diabetes (Type II) Kidney failure Malabsorption disorders Inflammatory bowel disorders Liver disorders Anorexia nervosa Depression Alcoholism

Marasmus

Malnutrition & Starvation

Undernutrition is a deficiency of calories or of one or more essential nutrients. Marasmus is a severe deficiency of calories and protein. It tends to develop in infants and very young children. It typically results in weight loss and dehydration. Breastfeeding usually protects against marasmus.

Malnutrition & Starvation

Starvation is the most extreme form of Marasmus (and undernutrition). Starvation results from a partial or total lack of essential nutrients over time.

Kwashiorkor

Malnutrition & Starvation

Kwashiorkor is a severe deficiency of protein rather than of calories. Kwashiorkor is less common than Marasmus. The term means first child-second child because a first-born child often develops kwashiorkor when the second child is born and replaces the first-born child at the mother's breast.

Malnutrition & Starvation

Because children tend to develop Kwashiorkor after they are weaned, they are usually older than those who have Marasmus. Kwashiorkor tends to be confined to certain areas of the world where staple foods used to wean babies are deficient in protein even though they provide enough calories as carbohydrates. Examples of such foods are yams, cassava, rice, sweet potatoes, and green bananas. Anyone can develop Kwashiorkor if their diet consists mainly of carbohydrates. People with Kwashiorkor retain fluid, making them appear puffy and swollen. If Kwashiorkor is severe, the abdomen may protrude.

33 Million HIV Seropositive 1.8 Million Deaths Per Year

Figure 47.5. Disability Adjusted Years, Disability Adjusted LifeLife Years HIV/AIDS, 2004 Due to HIV/AIDS

<10 10-25 25-50 50-100 100-500 500-1000 1000-2500 2500-5000 5000-7500 7500-10000 10000-50000 >50000

Incidence of Kaposis Sarcoma in African Men

Tuberculosis (TB)
30 million people are infected with TB worldwide. 10 million will develop active disease 3 million die from TB annually If there are no changes in current levels of infection, 1 billion people will be infected by 2020, responsible for 200 million active cases and 55 million deaths.

HIV & Tuberculosis

HIV and Tuberculosis coexist HIV/TB co-infections cause 1.7 million deaths per year Multi-Drug resistant TB (MDR-TB) and HIV strains are evolving worldwide

Top Ten Causes of Death, USA, 2000

Cause of Death
Heart Disease Cancer Stroke COPD Accidents Diabetes Pneumonia/Influenza Alzheimers Disease Nephritis, Nephrosis Septicemia

Deaths
710,760 553,091 167,661 122,009 97,900 69,301 65,313 49,558 37,251 31,224

Percent (%)
29.6 23.0 7.0 5.1 4.1 2.9 2.7 2.1 1.5 1.3

Citations
BRFSS, Behavioral Risk Factor Surveillance System http: //www.cdc.gov/brfss/

Mokdad AH, et al. The spread of the obesity epidemic in the United States, 19911998 JAMA 1999; 282:16:15191522.
Mokdad AH, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001; 286:10:151922.

Mokdad AH, et al. Prevalence of obesity, diabetes, and obesityrelated health risk factors, 2001. JAMA 2003: 289:1: 7679
CDC. State-Specific Prevalence of Obesity Among Adults United States, 2005; MMWR 2006; 55(36);985988

Obesity Trends Among U.S. Adults between 1985 and 2007

Definitions: Obesity: Having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher.
Body Mass Index (BMI): A measure of an adults weight in relation to his or her height, specifically the adults weight in kilograms divided by the square of his or her height in meters.

Obesity Trends Among U.S. Adults between 1985 and 2007

Source of the data: The data shown in these maps were collected through CDCs Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults.
Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used.

 In 1990, among states participating in the Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%. By 1998, no state had prevalence less than 10%, seven states had a prevalence of obesity between 20-24%, and no state had prevalence equal to or greater than 25%. In 2007, only one state (Colorado) had a prevalence of obesity less than 20%. Thirty states had a prevalence equal to or greater than 25%; three of these states (Alabama, Mississippi and Tennessee) had a prevalence of obesity equal to or greater than 30%.

Obesity Trends* Among U.S. Adults BRFSS, 1985

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

Obesity Trends* Among U.S. Adults BRFSS, 1986

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

Obesity Trends* Among U.S. Adults BRFSS, 1987

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

Obesity Trends* Among U.S. Adults BRFSS, 1988

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

Obesity Trends* Among U.S. Adults BRFSS, 1989

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

Obesity Trends* Among U.S. Adults BRFSS, 1990

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

Obesity Trends* Among U.S. Adults BRFSS, 1991

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

Obesity Trends* Among U.S. Adults BRFSS, 1992

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

Obesity Trends* Among U.S. Adults BRFSS, 1993

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

Obesity Trends* Among U.S. Adults BRFSS, 1994

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

Obesity Trends* Among U.S. Adults BRFSS, 1995

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

Obesity Trends* Among U.S. Adults BRFSS, 1996

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

Obesity Trends* Among U.S. Adults BRFSS, 1997

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%

Obesity Trends* Among U.S. Adults BRFSS, 1998

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%

Obesity Trends* Among U.S. Adults BRFSS, 1999

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%

Obesity Trends* Among U.S. Adults BRFSS, 2000

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%

Obesity Trends* Among U.S. Adults BRFSS, 2001

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%

Obesity Trends* Among U.S. Adults BRFSS, 2002

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%

Obesity Trends* Among U.S. Adults BRFSS, 2003

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%

Obesity Trends* Among U.S. Adults BRFSS, 2004

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%

Obesity Trends* Among U.S. Adults BRFSS, 2005

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%29%

30%

Obesity Trends* Among U.S. Adults BRFSS, 2006

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%29%

30%

Obesity Trends* Among U.S. Adults BRFSS, 2007

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

No Data

<10%

10%14%

15%19%

20%24%

25%29%

30%

Obesity Trends* Among U.S. Adults BRFSS, 2008

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

Obesity Trends* Among U.S. Adults BRFSS, 2009

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

Obesity Trends* Among U.S. Adults BRFSS, 2010

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

Figure 8. Dose Response in the Risk of Type 2 Diabetes by BMI

Men 100 90 80 70 60 Relative Risk 50 40 30 20 10 0 23 25 27 29 31 33 35 Body Mass Index Women

Age-adjusted cancer mortality in the USA, 1930-2008

200

Rate per 100,000

150 100 50 0

143

152

156

158

163

168

173

164

170

1930

1940

1950

1960

1970 Year

1980

1990

2000

2008

Odds Ratios for Lung Cancer by Amount Smoked

50 45 40 35 30 Odds Ratio 25 20 15 10 5 0 Never
1-10 11-20 21-30 31-40 Cigarettes per Day

Women Men

41+

Lung Cancer Mortality and Cigarettes Per Capita, USA

100 90 80 70 60 50 40 30 20 10 0 1930

r = 0.98

Mortality per 100,000 Cigarettes per capita (x 0.01)

1940

1950

1960

1970

1980

1990

2000

Year

Lung Cancer Survival

50 40

Survival (%)

30 20 10 0 60- 70- 74- 77- 80- 83- 93- 97- 00- 02 63 73 76 79 82 90 95 99 01 03 04 06 07 08

Five year survival rates, whites, NCI

Smoking Prevalence: A Global Problem

50 45 40 35 30 25 20 15 10 5 0 Europe NA SA Asia Africa World

Women Men

WHO: 1/3 of the world population smokes

Population Attributable Risk: Lung Cancer & Smoking

100 90 80 70 60 50 40 30 20 10 0 Europe NA SA Asia Africa World

PAR (%)

Average PAR = 87%

Annual Deaths Attributable to Cigarette Smoking

900,000 800,000 700,000 600,000 Number of 500,000 Deaths 400,000 300,000 200,000 100,000 0 Lung Cancer Heart Diseases COPD Other Cancers Stroke

WHO: Total Deaths: 3 Million

Lung Cancer
Most common cause of cancer-related death among men and women Mortality has increased by 600% in women since 1950 28% of all cancer deaths in USA Smoking is the most important etiologic factor and is responsible for approximately 87% of cases Cell Types: Small Cell and Non-Small Cell More People die each year from Lung Cancer than Breast, Prostate and Colon Cancer combined

Listeriosis
Listeriosis, a serious infection usually caused by eating food contaminated with the bacterium Listeria monocytogenes The disease primarily affects older adults, pregnant women, newborns, and adults with weakened immune systems. In older adults and persons with immunocompromising conditions, septicemia and meningitis are the most common clinical presentations. Pregnant women may experience a mild, flu-like illness followed by fetal loss or bacteremia and meningitis in their newborns.

Listeriosis: Listeria monocytogenes

Listeriosis
Listeria monocytogenes, a gram-positive rod-shaped bacterium. Listeria monocytogenes is commonly found in soil and water. Animals can carry the bacterium without appearing ill and can contaminate foods of animal origin, such as meats and dairy products. Most human infections follow consumption of contaminated food. Rare cases of nosocomial transmission have been reported. The bacterium is killed by pasteurization and cooking; however, in some ready-to-eat foods, such as hot dogs and deli meats, contamination may occur after factory cooking but before packaging. Unlike most bacteria, Listeria can grow and multiply in some foods in the refrigerator.

Listeriosis
As of November 1, 2011, a total of 139 persons infected with any of the four outbreakassociated strains of Listeria monocytogenes have been reported to CDC from 28 states. Twenty-nine deaths have been reported. In addition, one woman pregnant at the time of illness had a miscarriage.

Listeriosis Epidemic, 2011

Methicillin Resistant Staphylococcus Aureus (MRSA)

USA: 18,500 MRSA-related deaths in 2008

MRSA Hospital Infections

MRSA Deaths, USA

What is Science?
Methods Systematic observation of natural events and conditions in order to discover facts about them and to formulate laws and principles based on these facts. Content The organized body of knowledge derived from such observations. Any specific branch of this general body of knowledge.

Public Health vs Medicine

Medicine: Diagnosis and Treatment of the Individual
Public Health: Diagnosis and Treatment of the Population

Primary Fields of Public Health

Biostatistics: data analysis Epidemiology: disease etiology Environmental Health: macro/micro agents Behavioral Science: life style Health Administration: cost benefit

What is Health?
Health = Absence of Disease Disease = Dis-ease

Definition of Epidemiology
Epi - from Greek upon Demos - from Greek the people
Literally: The study of that which is visited upon the people.

Epidemiology Defined
Systematic study of the distribution of disease and risk factors in the human population to determine disease etiology
Examination of distributions of incidence, mortality, risk factors, and related measures in time, place, and person

Time, Place, and Person

Time: Has there been an increase or decrease in the disease over time? Place: Do some geographic areas have different morbidity or mortality than other areas? Person: Do the characteristics of persons with the disease distinguish them from those who are disease free?

Epidemiologic Issues
Criteria of Judgment
Consistency, Strength of Association, Dose Response, Specificity, Biological Plausibility, Temporality

True vs False Effect

Study Design, Confounding, Bias, Compliance

Change in CVD Mortality USA, 1950-2000

450 400 350 300 Rate per 250 100,000 200 150 100 50 0 CHD Stroke Influenza Cancer

1950 2000

National Center for Health Statistics, USA Data age-adjusted to 1970 USA population

Ecological Correlation of Breast Cancer Mortality and Dietary Fat Intake

30
Mortality Rate/100,000

25 20 15 10 5 0 0 50 100

USA Japan n = 39 countries r = 0.84

150 200 Total Dietary Fat Intake (g/day)

Breast Cancer Mortality USA vs Japan

30 25 20
Rate per 15 100,000

10 5 0
55 65 75 85 Year 95 2000 2005

USA Japan

Prostate Cancer Mortality USA vs Japan

16 14 12 10
Rate per 8 100,000 6

4 2 0
55 65 75 85 Year 95 2000 2005

USA Japan

Colon Cancer Mortality USA vs Japan

30 25 20
Rate per 15 100,000

10 5 0
55 65 75 85 Year 95 2000 2005

USA Japan

Percentage fat calories or mortality per 100,000

Dietary fat intake and combined mortality from prostate, breast, and colon cancer: Japan vs. USA
JAPAN
35 30 25 20 15 10 5 0
55 65 75 85 95 20 05

USA
80 70 60 50 40 30 20 10 0
55 65 75 85 95 20 05
Combined cancer mortality % total fat

Personal Characteristics
Demographics: Age, Gender, Race/Ethnicity, Marital Status Biological/Genetic Characteristics: Blood levels of antibodies, enzymes, hormones, glucose, etc. Socioeconomic Factors: SES, Education, Occupation, Place of birth, Residence Lifestyle/Behaviors: Use of Tobacco, Alcohol and other drugs, Diet, Exercise, STD Exposure

Behavioral Risk Factor Surveillance System, Ohio: 2000

90 80 70 60 50 40 30 20 10 0

Lack of Exercise

Overweight
Smoking Drinking

Purpose of Epidemiology
The purpose of epidemiology is to: elucidate etiology of disease, identify the risk factors, quantify their importance, to determine how, when, and where to intervene.

General Uses of Epidemiology Table 1.2

Study the Rise and Fall of Disease Monitor Incidence, Prevalence, & Mortality Evaluate Health Services Evaluate Individual Risk of Disease Elaborate the Clinical Picture of Disease Identify Syndromes Identify Causative & Preventive Factors

Selected Terms Table 1.1

Endemic: normal rate of disease Epidemic: marked excess of disease Pandemic: epidemic affects many nations Morbidity: rate of adverse events due to disease (excluding death) Mortality: Death Rate

Standard Measures in Epidemiology

Mortality = deaths / population at risk for a specific period of time Incidence = new cases / population at risk for a specific period of time Prevalence = new + old cases / population at risk Relationship of incidence and prevalence: Prevalence = Incidence x Duration

Strategies for Disease Prevention

Primary Prevention : Eliminate exposure to the etiologic agent Active: Behavioral change Passive: No behavioral change Secondary Prevention: Screening for early detection of precursor conditions Tertiary Prevention: Limit disability from disease

Primary Prevention
Prevention of disease by preventing exposure to the etiologic agent, altering susceptibility or reducing exposure for susceptible individuals.

Primary Prevention
General health promotion
Nutrition Clothing Shelter Rest Recreation Education Health Care Work

Primary Prevention
Active
Immunization Personal Hygiene Hand washing
Passive Environmental Sanitation Protection against injury and occupation hazards Political control of stores of infectious agents

Secondary Prevention
Early detection and effective treatment of antecedent conditions
Benefit vs risk of screening depends upon cost, accuracy, and acceptance of the screening test in the population.

Behavioral Risk Factor Surveillance System, Ohio: 2000

Mammography
90 80 70 60 50 40 30 20 10 0

Pap Smear

FOBT PSA

Women Men

Tertiary Prevention
Limitation of disability Rehabilitation Altering diet/exercise after cardiac event Compliance with medication schedule Glucose control in diabetes, Blood pressure control in hypertension

Hippocrates, 400 BC

First do no harm Let thy food by thy medicine Father of Medicine Father of Epidemiology

John Graunt, 1520-1674

Dr. Graunt analyzed mortality data, and developed a better understanding of diseases, as well as sources and causes of death. He quantified patterns of birth (e.g., more males born than females), death (e.g. males die sooner than females), and disease (e.g. divided deaths into types of causes: acute and chronic). He noted differences between males-females, urban-rural areas, infant mortality for different groups, and seasonal variation of mortality rates.

Dr. John Graunt, 1620-1674

Yearly Mortality Bill, 1632 Top Ten Causes of Death

2500 2000 1500

Chrisomes Consumption Fever Small Pox Dropsie

1000

Collick
500 0

Flux

Childbed Liver

Life Expectancy, USA, Women & Men

Worldwide Rank: 18th

William Farr, 1807-1883, developed centralized registration system for disease classification

Epidemiologic Transition
Transition from infectious diseases as the predominant causes of morbidity and mortality to a predominance of noninfectious (chronic) diseases

Worldwide Deaths, WHO, 2011

World Population = 7.0 Billion People Annual Deaths = 62 Million Deaths 36 Million Deaths From Chronic Diseases -CVD, Cancer, COPD, Diabetes, Renal Disease
26 Million Deaths From Acute Diseases -HIV/AIDS, TB, Malaria, Diarrhea

Figure 5. Worldwide Deaths by Major Cause and National Income, 2009, WHO
Acute Disease
14 12 10 Millions of 8 Deaths 6 4 2 0 Low Low Middle High Middle High

Chronic Disease

Injury

World Bank Income Group

Cause Specific Mortality, USA

Rank 1900 1990 1 Pneum & Influ 202.2 Heart Disease 152.0 2 3 4 5 6 7 8 9 10 Tuberculosis 194.4 Enteritis 142.7 Heart Disease 137.4 Stroke 106.9 Nephritis 88.6 Accidents 72.3 Cancer 64.0 Senility 50.2 Diphtheria 40.3 Cancer 135.0 Accidents 32.5 Stroke 27.7 COPD 19.7 Pneum & Infl 14.0 Diabetes Mellitus 11.7 Suicide 11.5 Homicide 10.2 HIV Disease 9.8

Population Pyramid: 1950

Population Pyramid :2000

Deaths/ Mortality: United States, 2000

Number of deaths annually: 2,404,351 Death Rate (age-adjusted): 873.1 deaths per 100,000 population Life Expectancy: 76.9 years at birth

Top Ten Causes of Death, USA, 2000

Cause of Death
Heart Disease Cancer Stroke COPD Accidents Diabetes Pneumonia/Influenza Alzheimers Disease Nephritis, Nephrosis Septicemia

Deaths
710,760 553,091 167,661 122,009 97,900 69,301 65,313 49,558 37,251 31,224

Percent (%)
29.6 23.0 7.0 5.1 4.1 2.9 2.7 2.1 1.5 1.3

Jenner and Smallpox 1796 Jenner and Smallpox

The World is my laboratory

Louis J. Pasteur

Jonathan Snow: Cholera in London, 1850

Koch-Henle Postulates
Microorganism must be present in every case Microoganism must be isolated and grown in pure culture Innoculation of microorganism into susceptible host must reproduce disease Microorganism must be observed and recovered

Robert Koch

Early microscopic studies of TB, Cholera, Anthrax, Smallpox Microbes

Public Health in the 20th Century

Louis Pasteur, 1880 Germ Theory of Disease Robert Koch, Paul Erlich, 1890 Development of Anti-toxins Vaccinology (Immunizations): Smallpox, Polio, Diphtheria, Measles, Mumps, Rubella, Tetanus, Influenza

Joseph Goldberger Pellagra, 1913

Alice Hamilton, MD: Founder of Occupational Medicine (1869-1970)

Received her medical degree from the University of Michigan in 1893 Founder of [modern] occupational medicine First woman professor at Harvard Medical School First woman to receive the Lasker Award in public health Classic publications on industrial hygiene, toxicology, and occupational medicine

Alice Hamilton, 1869-1970, Founder of Occupational Medicine