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Lesson 3: Epidemiology April 11, 2006

Lesson 3. Epidemiology

Human Disease:
Identification &
Control Strategies

April 11, 2006


Chuck Treser
University of Washington
Dept. of Environmental and
Occupational Health Sciences
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Definition of Health

 “Health is the state of complete


physical, mental and social well
being and not merely the absence of
disease or infirmity.”
World Health Organization
1970

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Determinants of Health

Intrinsic
Environmental
Genetic
Exposures
Susceptibility

Age / Time
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Lesson 3: Epidemiology April 11, 2006

“Genetics loads the gun . . .


but the environment pulls the
trigger.”
Dr. Judith Senn
Professor of Nutrition & Internal Medicine
Univ. Of California, Davis

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Disease Causation

Agent Host

Environment

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Disease Causation

Agent Host

Environment

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Disease & Injury

 Acute Effects
 Infectious Diseases
 Injuries
 Chronic Effects
 Chronic Disease
 Disability

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Epidemiological Model

Agent Host

Environment

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Origins

John Snow
(1813-1858)
John Snow's original 1854 map on the location of 578 deaths from Cholera, from An Introduction to Visualisation
Software for Astronomy, Starlink Guide 8.1, A C Davenhall, 9th February 1996 CCLRC / Rutherford Appleton
Laboratory Particle Physics & Astronomy Research Council

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Lesson 3: Epidemiology April 11, 2006

Epidemiology

 Looks for patterns of disease


occurrence
 Geographically
 Demographically

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Definition

Epidemiology is the study of


the distribution and
determinants of
health effects (disease & injuries)
in human populations

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Distribution Factors

 Person
 Place
 Time

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Lesson 3: Epidemiology April 11, 2006

Distribution Factors

Person
Age
Race
Sex
Occupation
Education
Hobbies
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Population Differences

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Distribution Factors

 Person Time
 Age
 Race
Episodic
 Sex Cyclical
Secular

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Lesson 3: Epidemiology April 11, 2006

Temporal Distribution

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Distribution Factors

 Person  Place
 Age  Geographic
 Race  Longitude &
Latitude
 Sex
 Geologic
 Time  Climatic
 Episodic  Geo-political
 Cyclical  Urban / Rural
 Industry
 Secular
 Pollution

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Spatial Distribution

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Lesson 3: Epidemiology April 11, 2006

Determinants

 Determinants
 Agent
 Host
 Environment

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Determinants

 Agent Factors  Environment


 Biological Factors
 Chemical  Natural
 Physical Environment
 Host Factors  Built Environment
 Socio-cultural
 Genetic
Environment
Predisposition
 Temporal
 Exposure
Environment

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Disease Agents Human Host

Balance Beam
Parasitic, Nutrient, Chemical,
Physical & Mechanical Affects equilibrium through:
1. Interaction with agents
Affect equilibrium through: 2. Individual habits & group customs
1. Their basic nature and character 3. Age, sex & race characteristics
2. Resistance and lability 4. Defense Mechanisms
3. Reservoir and Sources 5. Constitution and heredity
4. Conditions of dissemination 6. Psychologic characterisitics

These determine the


balance of health and Changes upset
preventive attack balance

At Equilibrium

Physical
Biological
Economic &
Variable Social-Political Variable
fulcrum fulcrum
position Environment position

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Simplified diagram of factors influencing equilibrium. Adapted from Leavell HR and Clark EG. Preventive
Medicine for the Doctor in his Community.

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Lesson 3: Epidemiology April 11, 2006

The Disease Process

 Natural History of Disease


 Problems with Detection & Reporting

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THE NATURAL HISTORY OF ANY DISEASE IN MAN

Before man is
involved DEATH

The course of disease in man Chronic


Interrelationship of the various
Defect
AGENT / HOST / ENVIRONMENT
Factors
Disability
(Known and Unknown)
Illness
Which
which bring together the
Signs &
Clinical Horizon Symptoms
AGENT and HOST
Tissue &
Or Physiologic
Changes
Produce a disease producing STIMULUS or AGENT
becomes established
RECOVERY
and increases by multi-
In the plication or increment
STMULUS Human
Host
Interaction of
HOST & STIMULUS HOST
REACTION

Discernable
Early Advanced
Early Convalescence
Pathogenesis Disease
Lesions

Prepathogenesis
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Lesson 3 Period of Pathogenesis 23

Adapted from: Leavell, Hugh R. and E. Gurney Clark, Preventive Medicine for the Doctor in His Community
.

Schematic Diagram of the Stages of Infection in a Host

Disease in host

Agent being shed

Total period of infection (agent present)

Incubation
period

Latent
period
Period of
communicability

Infection Infection
Latent
patent

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24
Epidemiology:
m: Fox, Hall, Elveback. , The Macmillan Company, 1970:57. become latent or
intermittently patent

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Lesson 3: Epidemiology April 11, 2006

THE NATURAL HISTORY OF ANY DISEASE IN MAN

Interrelations of Agent, Host and


Reaction of the HOST to the STIMULUS
Environment Factors

Production of STIMULUS Early Discernable Advanced Conva-


Pathogenesis Early Lesions Disease lescence

Prepathogenesis Period Period of Pathogenesis

HEALTH PROMOTION
SPECIFIC PROTECTION
Health Education
EARLY DIAGNOSIS &
Good standard of nutrition Use of specific PROMPT TREATMENT DISABILITY
adjusted to the develop- immunizations
LIMITATIONS REHABILITATION
mental phase of life Case-finding measures,
Attention to personal individual and mass
Attention to personality hygiene Provision of hospital and
development Screening surveys community facilities for
Use of environmental Adequate treatment to retraining and education
sanitation Selective examinations arrest the disease for maximum use of re-
Provision of adequate
process and to prevent maining capacities
housing, recreation
Protection against Objectives complications and
and agreeable working
occupational hazards • To cure and prevent sequelae Education of the public
conditions
disease processes and industry to utilize
Protection from accidents • To prevent the spread Provision of facilities to the rehabilitated
Marriage Counseling
of communicable disease limit disability and to
and sex education
Use of specific nutrients • To prevent complications prevent death As full employment as
Genetics and sequelae possible
Protection from carcinogens • To shorten the period
Periodic selective of disbility Selective placement work
examinations Avoidance of allergens therapy in hospitals

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Primary Prevention Secondary Prevention Tertiary Prevention
LEVELS OF APPLICATION OF PREVENTIVE MEASURES

Contingencies of Morbidity Reporting


Symptoms? Complaints? Consultation Diagnosis Diagnosis Report Made?
• Stoical Sought? Suspected? Established? • Ignorance
• Ashamed • Lack of funds • MD's acumen • Too early • Indifference
• Indifference • Nature of • Too late • Forgot
• "Don't believe Complaint • Follow up • Rarity of
No in doctors" • Communication disease
• Rarity of
disease
POPULATION
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes

Yes
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Concepts & Methods

 Disease Prevalence – the proportion


of a population with the disease, at a
chosen point in time. (snap shot)
 Rp = CT / P (x 100,000)
(at that time)
 E.g., 10% of the population of King
County has respiratory asthma at
present.

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Lesson 3: Epidemiology April 11, 2006

Prevalence Rate

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Prevalence Rate

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Concepts & Methods Continued

 Incidence Rate – the proportion of a


population with newly-diagnosed
disease per given unit of time.
(New cases over time)
 Ri = Cn / P (x 100,000)
(at the midpoint of the unit of time)
 E.g., the total mortality rate (all
deaths) is 0.89% per year among the
population of Seattle

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Lesson 3: Epidemiology April 11, 2006

Incidence Rates

 That is, in a given year there were 4450


deaths reported among residents of
Seattle, a population of 500,000.
 Incidence rate = 4450 / (500,000 x 1
year) = 0.0089/year
= 890 per 100,000 persons per year
= 2.4 per 100,000 persons per day

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Incidence Rate

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Analytic Techniques
 Stratification – dividing the sample
according to some characteristic,
e.g. age:
 Age-specific deaths from heart disease among non-smoking
British male doctors
Age Deaths/104 persons per year
35-44 1.064
45-54 11.23
55-64 49.04
65-74 96.71
75-84 212.04
Total 25.75

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Analytic Techniques Continued

 Association of disease with an


environmental factor – comparing
disease prevalence or incident rates
between groups with and without
exposure to the environmental factor

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Analytic Techniques Continued

 Age-specific deaths from heart


disease among smoking British male
doctors.
 Relative Risk
Age Deaths/10 4 persons per year (RR)
35-44 6.106 5.74
45-54 24.05 2.14
55-64 72.00 1.47
65-74 146.88 1.52
75-84 191.84 0.91
Total 44.29 1.72

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Analytic Techniques Continued

 What if smoking British male doctors


drink more ethanol, compared to
non-smoking British male doctors?
Since from other studies we know
that ethanol is associated with heart
disease, can we argue that smoking is
the cause of heart disease mortality
in this group?
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Lesson 3: Epidemiology April 11, 2006

Analytic Techniques Continued

 Confounding factor: a factor that is


associated both with exposure and
outcome, and thus interferes in
determining the relationship
between exposure and outcome.
Ethanol in this case is a confounder

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Limitations

 Most environmental diseases have


multiple contributing causes – e.g. lung
cancer, heart disease – so multiple
exposures must be measured.
 Smoking, age, diet, and genetic make-
up are powerful interfering factors

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Limitations Continued

 Measurement of exposure can be


highly inaccurate, especially when
past exposures are needed. The
usual result is called misclassifica-
tion, and any underlying association
between exposure and illness is
likely to be missed or underesti-
mated
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Lesson 3: Epidemiology April 11, 2006

Limitations Continued

 Latency of many (most?) environmental


diseases is years to decades.
 Thus exposures from the distant past are
most relevant, and least likely to be known
quantitatively.
 Longitudinal epidemiology, in which
exposed persons are followed over
years, is most precise.
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Limitations Continued

 Examples of longitudinal studies:


 Framingham, Mass. heart disease;
 Fluoridation of water and dental caries;
 Salk vaccine and polio incidence;
 Smoking and several diseases.

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Limitations Continued

 An observed association between


environmental agent and disease should
not be termed a cause-effect relation-
ship until a biological mechanism has
also been demonstrated.
 Otherwise, the observed epidemiologic
outcome could easily be a coincidence.

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Lesson 3: Epidemiology April 11, 2006

Disease Causation

Agent Host

Environment

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Disease Causation

Agent Host

Environment

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Disease Control

Agent Host

Environment

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Prevention & Control

Modify the environment


 Engineering Controls
Modify Behavior
 Legal/Regulatory Controls
 Administrative Controls
 Education
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Engineering Controls Tactics

 Substitution
 Treatment
 Isolation
 Shielding
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Control Tactics Continued

New
compound or
process

Agent Host

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Substitution 48

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Lesson 3: Epidemiology April 11, 2006

Control Tactics Continued

Agent Host

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Treatment 49

Control Tactics Continued

Agent Host

Isolation
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Control Tactics Continued

Agent Host

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Shielding 51

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Lesson 3: Epidemiology April 11, 2006

Regulatory Controls

 Statutes
 Rules and Regulations
 Enforcement Programs
 Private Sector Control

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Administrative Controls

 Planning
 Supervision
 Biological Monitoring
 Work Scheduling

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Education

 Education
 Training
 Safety campaigns

 Administrative priority

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Lesson 3: Epidemiology April 11, 2006

Control Strategies Continued

 In order of effectiveness
 Engineering Control Tactics
 Legal / Regulatory Controls
 Administrative Controls
 Education
 How do we operationalize these?

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Summary

 Epidemiology is the study of the


distribution and determinants of
health effects in human populations
 Distribution  Determinants
 Person  Agent
 Place  Host
 Time  Environment

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Next Lesson

Ecology
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