EP713: Introduction to Epidemiology Section C1 6:00-8:00 pm Wednesday Fall 2012

Instructor: Kimberly Shea, PhD, MPH Talbot 425 East Phone: 617-638-7725 Email: kimshea@bu.edu

Why Are We Here?

MMWR Morb Mortal Wkly Rep. 1999 Apr 2;48(12):241-3.

Why Are We Here?

US Life Expectancy, 1850 - 2007
90 80
77.9

70

Years

60

50
40 30

38.3

20

(1) Haines M. Vital Statistics. In Historical Statistics of the United States: Millennial Edition, Cambridge University Press, 2002. (2) Health, United States, 2010. National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, Maryland. 2011.

Why Are We Here?

Difference from Overall Average Life Expectancy, U.S., 2007, by sex and race
10

Difference in Life Expectancy

8 6 4 2 0 -2 -4 -6 -8 -10 -7.9 2.9

Black Female White Female

-1.1

White Male
-2.0

Black Male

Health, United States, 2010. National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, Maryland. 2011.

Why Are We Here?

Life Expectancy 2005-2010 (est.), by country

United Nations (2007). World Population Prospects: The 2006 Revision, Highlights, Working Paper No. ESA/P/WP.202.

Why Are We Here?

Components of Public Health Epidemiology is the fundamental science of public health. All public health researchers and practitioners should have a functional understanding of epidemiology.
Adopted from Institute of Medicine Future of Public Health Report, 1988. 6

EP713: What to Expect

Course objectives Course resources Course format Assessment and grading

Course Objectives
To introduce basic principles & methods, and
demonstrate their applicability to public health and research

To provide skills necessary to critically evaluate and

interpret epidemiologic information and literature

To prepare students to incorporate epidemiology into

their public health careers, and for advanced courses

Very Important!
Multiple sessions of EP713 are not interchangeable

Course Resources
Required Textbook: Ann Aschengrau and George R.
Seage III. Essentials of Epidemiology in Public Health, 2nd Edition.

Course Website: http://blackboard.bu.edu

o Login using BU login ID & Kerberos password o Announcements, syllabus, lecture notes, assignments

You MUST have a calculator

o Natural log function o No sharing during exams

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Course Resources: Teaching Assistants

Student Last Name A Fal Fam L M Ra Rb - Z TA Jeff Ashburner Kelly Getz Kathryn Kinzel Julia Rohr TA Email jashburn@bu.edu kdgetz@bu.edu kkinzel@bu.edu jkrohr@bu.edu Workshop Location L-109A/B L-109C L-203 L-211

TA Q&A Sessions: Wednesday 5:00 5:50 pm 670 Albany Street * Except Sept 19: Room 107/108
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Course Format
Specific learning objectives for each class session Lectures
o Notes available the day before class

Required readings
o Practice questions and answers in text

Online quizzes based on reading material

o 10 short open-book online quizzes must be completed before

class o See course website and syllabus for instructions

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Course Format (Cont)

Problem sets
o 8 problem sets, never the week of or after an exam o Posted on Thursdays, due to your TA at beginning of class o Pesticide dataset

Workshops
o 3 in-class workshops designed to help you master the material

Exams
o 3 quizzes/exams

6:00 7:00 pm November 7 6:00 7:00 pm December 19 6:00 8:00 pm o Can only be rescheduled by contacting me before the exam

October 3

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Assessment/Grading
% of Grade
10% 25% 15% 20% 30%

What 10 Pre-class online quizzes 8 Problem sets Quiz 1 Quiz 2 Final Exam

When As indicated in syllabus As indicated in syllabus October 3 November 7 December 19

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When and How to Study

The learning objectives are key Read before class Come to class Complete all the problem sets; ask for clarification

Prepare for quizzes and exams

o Re-do pre-class quizzes and problem sets o Focus on understanding instead of memorizing

Keep up

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Introduction and Descriptive Epidemiology

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Learning Objectives
1. Define epidemiology 2. Define and generate a testable hypothesis 3. Describe the history of epidemiology and its current role in medicine
and public health

4. Describe the difference between descriptive and scientific/analytic

epidemiologic studies, and identify whether a particular study is descriptive or scientific/analytic

5. Explain the role of descriptive studies for identifying problems and

establishing hypotheses, including their use during disease outbreaks

6. Identify surveys and datasets available for public health research

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The Black Death

Bruegels Triumph of Death c. 1556

1330s-1350s pandemic
Total breakdown of society 25-33% of the European population died
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The Black Death: Suspected Causes

Misunderstanding about the causes of the plague
o Gods punishment

o o o o

Miasmas: unseen vapors from swamps & cesspits Poisoning by the Jews Contact with lepers Walking in the hot sun

Resulted in a variety of bizarre

and ineffective treatments

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The Black Death: The real causes

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The Black Death: What was missing?

Colossal failure of public health measures

L I N K
Exposure
Risk factors Determinants Independent variable

Outcome
Diseases Injuries Dependent variable

Why they failed

Not due to lack of technology No attempt to systematically test hypotheses in groups of people No framework to appropriately evaluate information
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What is Epidemiology?
Epidemiology is Based on Two Fundamental Assumptions
1) Human disease does not occur at random; there are factors or determinants which can increase or decrease the likelihood of disease

2) The factors or determinants (some are causal and some are preventive) can be identified by systematic investigation of populations or subgroups within populations

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What is Epidemiology?
The study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems

23

What is Epidemiology?
The study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems

A group of people with a common characteristic such as residence, age, gender, group membership, etc.

24

What is Epidemiology?
The study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems

Counting the number of cases of a disease over a specific time period

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What is Epidemiology?
The study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems

How is disease distributed throughout Counting the number of cases of a population? disease over the a specific time period Person: age, sex, SES, students Place: urban, US, near a school Time: June, annual, seasonal
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What is Epidemiology?
The study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems

The factors or things that cause some people to get disease when others do not. * We also call these exposures.

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What is Epidemiology?
The study of the distribution and determinants of disease frequency in human populations and the application of this study to control health problems

There is no point to collecting and analyzing data if it cannot be used for some purpose.

28

John Snow is often called the Father of Epidemiology

Based on observation & reason, proposed a new hypothesis for how cholera was transmitted.
Tested his hypothesis by systematically collecting data & comparing groups of people. Established an association between drinking water from Broad St. pump and development of cholera.

Argued for an intervention that prevented more cases.

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Sequence of Epidemiologic Investigations

Suspect that exposure influences disease occurrence Form specific hypotheses about exposure-disease association

Evaluate preventions and treatment

Conduct epidemiologic studies to measure relationship between exposure and disease Judge whether association may be causal, considering
Accumulated evidence Chance, bias, confounding + and of study design
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What is a Hypothesis?
A testable statement that tries to explain a set of observations that can be tentatively accepted or rejected through scientific research

3 criteria for epidemiologic hypotheses:

1. Compare two groups of people: E+ and E2. Predict the direction of an expected association between two or more measurable variables 3. Testable
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Examples of Hypotheses (1)

Fundamental Hypothesis: Cigarette smoking causes lung cancer
Operationalize this into

People who smoke cigarettes have a higher incidence of lung cancer over a 10-year period than people who do not smoke cigarettes

NOT: This study is on cigarette smoking and lung cancer

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Examples of Hypotheses (2)

Fundamental Hypothesis: Caregiving is stressful, and leads to physical health decline
Operationalize this into

Caregivers to relatives with dementia will have a higher incidence of high blood pressure than non-caregivers, mediated through higher levels of stress-related symptoms NOT: Caregivers to relatives with dementia will have high blood pressure
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Selected Sub-disciplines of Epidemiology

Disease Cancer Cardiovascular Infectious Injury Psychiatric Exposure Environmental Genetic Nutritional Occupational Pharmacologic Reproductive Social Population Clinical Geriatric Immunodeficient Pediatric Veterans

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Epidemiologic Milestones
Exposure
Contaminated water Niacin (B3) deficiency Water fluoridation Streptomycin Cigarettes Diethylstilbestrol (DES) Tampons

Outcome
Cholera Pellagra Cavities TB Lung cancer Vaginal Adenocarcinoma Toxic shock syndrome

Year
1854 1915 1940s 1940s 1950s 1971 1980s

Aspirin
Folate Sleeping on back

Reyes syndrome
Spina bifida SIDS

1980s
1980s 1990s

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So Whats Left?
HRT
Zoonoses

Cell phones Premature birth

Genes
Asthma

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2 Types of Epidemiology
Descriptive Description of disease patterns
1. Monitor the publics health 2. Evaluate intervention programs 3. Generate hypotheses Identify and count disease in populations
Case Report Case-Series Cross-Sectional Study Ecologic Study

1. Evaluate hypotheses

Analytic/ Scientific The search for causes of disease

2. Evaluate intervention programs

Compare groups to systematically determine: is there an association?

Clinical Trial Case-Control Study Cohort Study
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Sequence of Epidemiologic Investigations

Suspect that exposure influences disease occurrence

Descriptive

Form specific hypotheses about exposure-disease association

Evaluate preventions and treatment

Conduct epidemiologic studies to measure relationship between exposure and disease Judge whether Analytic association may be causal, considering
Accumulated evidence Chance, bias, confounding + and of study design
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A Closer Look at Descriptive Epidemiology

Public Health Surveillance

Defined by PERSON, PLACE, TIME

Main uses:
1. Identify problems, trends, and high-risk groups 2. Public health planning: where to spend resources 3. Generate hypotheses for analytical epidemiology

Limitation: CANNOT identify the causes of disease

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A Closer Look at Descriptive Studies

PERSON

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Mortality Rates* by Race and Ethnicity, Massachusetts 2008

1,000

Mortality Rate (per 100,000)

805.8 800 600 458.2 400 200 0

Total White nonHispanic Black nonHispanic Asian nonHispanic Hispanic

703.5

710.7

372.5

*Rates are per 100,000 population, and age-adjusted to the 2000 US standard population

Massachusetts Deaths 2008. Bureau of Health Information, Statistics, Research, and Evaluation; MA Dept of Public Health, Aug 2010.

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Mortality Rates* by Education in Adults 24-65 Years, Massachusetts 2008

600

Mortality Rate (per 100,000)

534.8

400

200

190.8

High School or Less

More than High School

*Rates are per 100,000 population, and age-adjusted to the 2000 US standard population

Massachusetts Deaths 2008. Bureau of Health Information, Statistics, Research, and Evaluation; MA Dept of Public Health, Aug 2010.

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Mortality Rates* by Education and Race/Ethnicity in Adults 24-65 Years, Massachusetts 2008
800

715.7

Mortality Rate (per 100,000)

High School or Less More than High School

600

508.9 460.3
400

347.2 199.4

200

183.2

0 White Non-Hispanics Black Non-Hispanics Hispanics

*Rates are per 100,000 population, and age-adjusted to the 2000 US standard population

Massachusetts Deaths 2008. Bureau of Health Information, Statistics, Research, and Evaluation; MA Dept of Public Health, Aug 2010.

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A Closer Look at Descriptive Studies

PLACE

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Incidence Rates* of Melanoma by State, 2007

8.6 to 16.7 16.8 to 19.2 19.3 to 22.1 22.2 to 28.1 Did not meet data quality criteria

*Rates are per 100,000 population, and age-adjusted to the 2000 US standard population

U.S. Cancer Statistics Working Group. United States Cancer Statistics: 19992007 Incidence and Mortality Web-based Report.

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Annual AIDS-related Deaths by Region, 2000-2009

UNAIDS Report on the global AIDS epidemic 2010: http://www.unaids.org/globalreport/Global_report.htm

46

Mortality Rates Due to Stomach Cancer by Region, 1950s-1960s

Mortality Rate* 58

Region Japanese in Japan

Japanese immigrants to California Sons of Japanese immigrants California residents (non-Japanese)

*Rates are per 100,000 population

30 12 8

Buell P, Dunn JE. Cancer mortality among Japanese Issei and Nisei of California. Cancer 1965;18:656-64.

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A Closer Look at Descriptive Studies

TIME

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Obesity Trends* Among U.S. Adults

BRFSS, 2000-2010
2000 2001 2002 2003

2004

2005

2006

2007

2008

2009

2010

No Data

<10%

10%14%

15%19%

20%24%

25%29%

30%
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Suicide by Time of Year and Day of Week Residents* of Sacramento County, CA; 1925 1983

* Adults <65 years Maldonado G et al., Suicide Life Threat Behav 1991 Summer;21(2):174-87. 50

Time of Sudden Cardiac Death In Relation to Hours After Waking 25

No. of Cardiac Deaths
20

15

10

0 Sleep 0-3 hrs 3-6 hrs 6-9 hrs 9-12 hrs 12-15 hrs >15 hrs

Waking
Willich SN et al., Am J Cardiol 1992;70:65-8

Hours After Waking

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A Note About Time Trends

Can you think of factors that can change the amount of disease we observe over time?
True changes:

Artifactual changes:

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Descriptive Epidemiology Leads to Hypotheses

Hypotheses Arise from Observations of
Differences: If the frequency of disease differs in two circumstances, the difference may be due to a factor that differs in the two circumstances.

Similarities: If a high frequency of disease is found in several different circumstances, and you can identify a common factor in the circumstance, the common factor may be responsible.

Correlations: If the frequency of disease varies in relation to some factor, presence or absence of that factor may be play a role.

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Mystery Epidemic
These data represent a true event

Adult Males SES N % Dead N

Adult Females % Dead N

Children % Dead N

Total % Dead

High
Middle Low Unknown Total

173
160 454 875 1662

66.5
91.1 87.9 78.4 81.0

144
93 179 23 439

3.5
16.1 45.3 8.7 23.5

5
24 76 0 105

0.0
0.0 71.1 --51.4

322
277 709 898 2206

37.3
58.5 75.3 76.6 68.2

The Sinking of the Titanic

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Reading Data and Interpreting Results

Having data is not enough How you look at the data is critically important

Accurate and meaningful presentation

Numbers vs. proportions and rates And laterhow reliable (valid) are your data? Do you have good enough data to base decisions on?

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Reading Data and Interpreting Results

Health Numeracy The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions

Levels of numeracy: Basic, Computational, Analytical, Statistical

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Reading Data and Interpreting Results

Terri Schiavo Case 1990: 26 year old Florida woman suffers cardiac arrest resulting in severe brain damage

1998:

After 8 years in persistent vegetative state, Terris husband petitioned courts to remove feeding tube Polarizing debate in the US
Feeding tube ultimately removed in March
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1998-2005:
2005:

Reading Data and Interpreting Results

Terri Schiavo Case
Based on what you have heard or read about the case, do you agree with the courts decision to have the feeding tube removed?

CNN.com

GALLOP.com
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Reading Data and Interpreting Results

A Common Headline:
Successful completion of this treatment will cut your risk in half
90 80 70 60
Risk

80 No treatment Treatment

50 40 30 20 10 0

40

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Reading Data and Interpreting Results

Said Another Way:

33% of mice responded well to the treatment and survived 33% of mice responded poorly and remained in a moribund condition The third mouse got away

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Sources of Epidemiologic Data

WHO Governments NGOs HMOs Hospitals Independent researchers WHAT US Census (*New 2010) Health surveys Death certificates Birth certificates Cancer registries Hospital discharge registries Infectious disease reporting

and more (see Chapter 4 in text)

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Sources of Epidemiologic Data

A note of caution

STRENGTHS

Already exist
o Low cost in terms of time and money

Established methodology May be available for no or little cost

WEAKNESSES

May have inaccurate information May not include the data you want Likely reporting delays May be very expensive May involve complicated methodology
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A Note About Terminology

Epidemiology is a young science, and is still emerging

Synonyms are common

Your job is to understand concepts, not to memorize
definitions

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Summary
Epidemiology is the basic science of public health. Descriptive and analytic epidemiology are used to describe
the health status of a population, identify causes of diseases, and evaluate public health interventions.

Reading epidemiologic data and interpreting results requires

critical evaluation and understanding health numeracy. This will be the discussed throughout the semester.

There are many sources of epidemiologic data of varying

degree of accuracy.

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Next Week
Assignments

1. Complete Problem Set 1 (about todays reading, lecture)

2. Read Chapter 2 (in preparation for next weeks lecture) 3. Complete Pre-Class Quiz 1 before class starts

Next Lecture Measures of Disease Frequency (6 8 pm)

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(Some) Public Health Resources

American Public Health Association: http://www.apha.org/ http://thenationshealth.aphapublications.org/ Harvard World Health News: http://www.worldhealthnews.harvard.edu/ MMWR: http://www.cdc.gov/mmwr/ New England Journal of Medicine: http://www.nejm.org/ Society for Epidemiologic Research: http://www.epiresearch.org/
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