Epidemiology

Hamzeh AlZabadi, PhD

What is Epidemiology?
Origins:
 Over 2000 years ago, epidemiology
used to be recognize as environmental
factors that can influence the
occurrence of disease “Hippocrates and others”
 In the nineteenth century start to be
defined as the distribution of disease in
specific human population groups
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What is Epidemiology
Origins:
 This was the time when John Snow observed that the risk
of cholera, in London, was related to the drinking of
water supplied by a particular company (Southwark
company)
 Snow’s discovery led to encourage improvements in the
water supply long before discovering the organism
responsible for Cholera
 His research has a direct impact on public policy with an
emphasize on communicable diseases where
associations between environmental conditions or
agents and specific diseases were investigated

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What is Epidemiology
Modern Epidemiology:
 Starts with the work that was done by
Doll and Hill in 1950s
 Both studied the relationship between
cigarette smoking and lung cancer
 This research expand epidemiological
interest to chronic diseases

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Figure 1: Distribution of cholera cases in the Golden Square
area of London, August-September 1854
According to Snow, the Broad Street pump was the source of
the epidemic

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Definition of Epidemiology
Epidemiology: “Is the study of the
distribution and determinants of
health-related states or events in
specified populations, and the
application of this study to control of
health problems” (Last, 1988)

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Introduction
 From the definition: epidemiology can be divided
in two:
1. Descriptive epidemiology: what, who,when and
where? It describes the frequency and pattern of
health events in a population (rate, time, place
and personal characteristics, describe
transmission, distribution and Natural history of
disease)

2. Analytical epdemiology: why and how?

Determinants, causes, and factors that influence
the occurance of the health-related events
(Establish determinates and causes of disease

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Scope of epidemiology
 The target of a study in epidemiology is a human
population
 A population can be defined in geographical or
other terms, e.g.:
1. Specific group of hospital patients
2. Factory workers
 The most common population used in
epidemiology is that in a given area or country
at a given time
 Demographic factors such as age, sex, ethnicity
should be taken into consideration while doing
epidemiological analysis

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Scope of epidemiology
Using of epidemiology in public health:
 Can lead to the identification of
preventive methods
 Epidemiology lends strong support to
both preventive and clinical medicine
 Epidemiology is often used to describe
the health status of population groups
and thus helps policy makers in
identifying priority health programes for
prevention and care

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Scope of epidemiology
 Epidemiologist can be involved in
effectiveness and efficiency of health
services through:
1. The value of treating high blood pressure
2. The efficiency of sanitation measures to
control diarrheal diseases
3. The impact on public health of reducing
lead additives in petrol, and so on

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Achievements in epidemiology
 Smallpox: The elimination of smallpox
from the world contributed greatly to
the health and well being of millions of
people, mainly in the poorest countries
 The last naturally occurring case of
smallpox was reported in 1977

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Achievements in
epidemiology_Smallpox
 Several factors contributed to the
success of the program:
1. Universal political commitment
2. Definite goal
3. Precise timetable
4. Well trained staff
5. Flexible strategy
6. In addition to the availability of an
effective heat-stable vaccine

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Achievements in epidemiology

Methyl-mercury poisoning: in 1950,

mercury compounds were released
with the water discharged from a
factory in Minamata, Japan, into a
small lake. This led to the
accumulation of methyl-mercury in
fish, causing sever poisoning in people
who eat them (WHO, 1976)

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Achievements in epidemiology_
Methyl mercury poisoning
A reported epidemic of disease
caused by environmental pollution
 The first cases thought to be infectious
meningitis
 Through observation they found that
121 infected patients were living near
the Minamata lake

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Achievements in epidemiology_
Methyl mercury poisoning
 A survey was done to investigate the causes.
The results showed that:
 Victims were exclusively members of families
whose main occupation was fishing
 People visiting these families and family
members who ate small amounts of fish did
not suffer from the disease
 It was concluded that something in the fish
poisoned the patients and the disease was
not communicable or genetically determined

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Achievements in epidemiology
Rheumatic fever and rheumatic heart
disease:
 Is associated with poverty, particularly poor
housing and overcrowding, where
streptococcal upper respiratory tract
infections favor to spread
 In many developed countries the
decline in rheumatic fever started at the
beginning of the 20th centaury, long
before the introduction of effective drugs
such as sulfonamides and penicillin

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Achievements in epidemiology
Rheumatic fever and rheumatic heart disease:
 Today the disease has almost disappeared from
developed countries except in few areas among
socially and economically disadvantage groups
 Today, RHD is the most common forms of heart
disease in developing countries
 Epidemiological studies have highlighted the role
of social and economic factors that contribute to
outbreaks of rheumatic fever and to the spread
of streptococcal throat infection

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Achievements in epidemiology

Iodine deficiency: It associated by the

loss of physical and mental wellbeing
that is caused by inadequate
production of the iodine_containing
thyroid hormone
 Only in 1915 effective prevention and
control was applied through the use of
iodized salt to cure from Goiter

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Achievements in epidemiology
Iodine deficiency:
 In 1924, a large trials with iodine were carried out in
Ohio/USA, on 5000 girls aged between 11-18 years. The
prophylactic ad therapeutic effects were impressive and
iodized salt was introduced on a community scale
 This prevention is effective because salt is used by all
sections of society roughly the same level throughout the
year
 Success depends on the effective production and
distribution of the salt and requires legislative
enforcement, quality control and public awareness
 However, there was unnecessary delay in adopting this
strategy in the developing countries where iodine
deficiency is still endemic

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Epidemic Disease Occurrence
 Level of disease:

 The baseline level of a disease in a community is

often considered as the expected level of the disease

 Example: over the past 4 years the number of

reported cases of poliomyelitis has ranged from 5 to
9. Therefore, assuming there is no change in
population, we would expect to see approximately 7
reported cases next year

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Epidemic Disease Occurrence

Level of disease:

• Endemic: when the disease is maintained in the

population without the needs for external
outputs

(A persistent level of occurrence with a

low to moderate disease level is
referred to as an endemic level)

• An irregular pattern of occurrence, with

occasional cases occurring at irregular
intervals is called sporadic
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Epidemic Disease Occurrence

Level of disease:

• Epidemic (Outbreak): occurs when new cases

of a disease, in a given human population, and
during a giving period of time, substantially
exceed what is expected based on recent
experience in an area

• Pandemic: if an epidemic spreads to other

countries or continents and affects substantial
number of people
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Uses of epidemiology in public health
practice

1. Health surveillance

2. Disease investigation

3. Analytic studies

4. Program evaluation
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Descriptive Epidemiology

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Descriptive epidemiology

 In descriptive epidemiology, we
organize and summarize data
according to time, place, and
person. They are sometimes
called the epidemiological
variables

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Descriptive epidemiology; Time
Health problem rate exchange over time
Depending on our interests: we might
describe the pattern in years, months,
weeks….etc! and we can here identify
the epidemic period.
We can use for example « secular-long
term-trends » by graphing annual cases
or rate of a disease over a period of years
(Fig. 2)
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Figure 2: Malaria by year, United States,
1930-1990

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Descriptive epidemiology; Time
 We can use also « seasonality » by graphing
the occurrence of a disease by week or
month over the course of a year or more
(Fig. 3)

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Descriptive epidemiology; Place
To gain insight into the geographical
extent of the problem
We may use place of residence,
birthplace, place of employment, school
district, hospital unit..etc!!
Sometimes we may find it useful to
analyze data according to place
categories such as urban or rural,
refugee camps..etc!!
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Descriptive epidemiology; Place
By analyzing data by place, we
can get an idea of where the
agent that causes a disease
normally lives and multiplies
What may carry or transmit it,
and how it spreads

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Descriptive epidemiology; Person
 We may use inherent characteristics of people
(for example, age, race, sex)
 Their acquired characteristics (immune or
marital status)
 Their activities (occupation, foods, use of
medications/tobacco/drugs)
 Or the conditions under which they live
(socioeconomic status, access to medical care)
 These categories determine who is at greatest
risk of experiencing some health condition

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Analytical Epidemiology

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Analytical epidemiology
 Analytical epidemiology is concerned with
the search for causes and effects, or the
why and the how.
 Identifying factors that are associated with
disease helps us identify populations at
increased risk of disease
 Identifying risk factors also provides keys
to direct research activities into the causes
of a disease, hence prevention

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Analytical epidemiology; Bradford Hill
 Bradford Hill (1965) criteria of causation;
Suggested that the following aspects of an
association be considered in attempting to
distinguish causal from non-causal
associations: NEXT SLIDE

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Analytical epidemiology; Bradford Hill
 Bradford Hill (1965) criteria of causation;
1. Temporal relationship
2. Strength of the association
3. Biological plausibility
4. Dose–response relationship
5. Replication of the findings
6. Effect of removing the exposure (reversibility)
7. Study design
8. Consistency with other knowledge

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Analytical epidemiology; Bradford Hill
1. Temporal Effect:
Exposure must precede disease
Essential
Essential criterion for causality
Knowledge of:
– Latency period
– Incubation period

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Analytical epidemiology; Bradford Hill
2. Strength of association;
Strong associations are more likely to be
causal than weak ones

Smoking > 20 cigarettes/day lead to higher

risk of lung cancer

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Analytical epidemiology; Bradford Hill
3. Biologic plausibility; is consistent with current
biological and medical common knowledge.
Smoking

Ingesting of chemicals and known carcinogens

Lung cancer
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Analytical epidemiology; Bradford Hill
4. Dose-response relationship;
Risk increases with more intense/more
frequent exposure
The more cigarettes are smoked, the greater
the risk of lung cancer.

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Analytical epidemiology; Bradford Hill
5. Consistency with other knowledge;
Association is supported by the results of
different disciplines
 e.g:
– Animal studies
– Other data sets

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Analytical epidemiology; Bradford Hill
6. Study design….
Chance?
Mistakes?
Mistakes?
Alternative hypothesis?

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Analytical epidemiology; Bradford Hill
7. Replication of the findings; similar findings
found in:
Different areas
Different populations
By using different study designs

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Analytical epidemiology; Bradford Hill
8. Effect of removing the exposure;
A decrease in the
outcome of interest E.g How improving road would influence

is seen when the The occurrence of road traffic crashes?

exposure is
removed

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Analytical epidemiology; Bradford Hill
Specificity of the association is also important
 Strengthens evidence if the cause has ONLY
one effect.

Asbestos exposure

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Causation
A cause of a disease is an event, condition,
characteristic, or combination of these factors
which plays an important role in producing
the disease
A cause could be sufficient or necessary

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Sufficient and component cause
A sufficient cause is a set of minimal conditions or events that inevitably produce
disease
Potato chips
Y
W Obesity
No exercise High
A
cholesterol
C
T
Genes
X B
Smoking
Stress

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Risk Factors
The term risk factors refers to those
factors that have a direct link to the
cause of the disease but are not
sufficient to cause the disease
They increase the chance of
contacting a health condition but
themselves not enough. e.g. poverty,
education, smoking... etc.
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Analytical Epidemiology
 Analytical epidemiologic studies fall into
two categories: experimental (intervention)
and observational

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