9/1/2018

SPH 596– Epidemiology

Methods I
Week 1
September 7, 2018

Instructors/TAs
• Shelby Yamamoto
– shelby.yamamoto@ualberta.ca
– ECHA 3-263
– Office hours: Tuesdays, 11:00-12:00

• TAs
– Carla Ickert (carla.ickert@ualberta.ca)
– Adrianna Paiero (paiero@ualberta.ca )
– Vishal Sharma (vishal@ualberta.ca )

1
 9/1/2018

Objectives
• To differentiate modes of disease transmission
using the epidemiological approach to
communicable diseases as a model
• To understand the spectrum of disease
• To understand the concept of epidemiologic
transition
• To understand the concept of herd immunity and
evaluate its importance in public health
• To understand, calculate, interpret and apply
attack rates

What is epidemiology?
“The study of the occurrence and distribution and
determinants of health-related events, states and
processes in specified populations, including the study of
the determinants influencing such processes, and the
application of this knowledge to control relevant health
problems”

Miquel Porta, A Dictionary of Epidemiology

2
 9/1/2018

Epidemiology

Individuals Populations
• Age • Where people live
• Sex • Access to care
• Smoking • Smoking legislation
• Treatment • Health insurance
• Disease • Schools

Why is it important?

3
 9/1/2018

Applied vs Academic Epidemiology

In Snow's Footsteps: Commentary on Shoe-Leather and Applied Epidemiology, Am J Epidemol, 172 (6): 737-739

What?

4
 9/1/2018

Cholera
• Bacterium Vibrio cholerae colonize the
small intestine
• Acute diarrhoeal disease
• Lack of clean water access and proper
sanitation facilities

Howard, L. http://remf.dartmouth.edu/Cholera_SEM/

When?

• UK epidemics
– 1830s
– 1848-1849
– 1853-1855

John Snow (1813–1858)

5
 9/1/2018

How? Prevailing theory of how it was

spread…
• Registrar General William Farr (1854)
• Miasma theory
– Poisonous air
– Suspended particles of decaying matter
– Foul smell

http://www.ph.ucla.edu/epi/snow/snows_testimony.html

Who was affected?

Yes Not so much…

• Cabinet maker • Inmates in a prison near
• Schoolchildren Soho?
• Woman, her niece and • Brewery workers?
aunt who lived outside of
Soho

6
 9/1/2018

Where?
• London
– Soho
• Crowded
conditions
• Shared water
(central pump)
• No indoor Hungerford Stairs 1830 by John Harley. Copyright Museum of London

plumbing…

John Snow map of cholera

deaths in Soho (1853)

Snow, S., (2008), John Snow: the making of a hero? Lancet, Vol 372(9632): 22-3.

7
 9/1/2018

https://faculty.humanities.u
ci.edu/bjbecker/Plaguesand
People/week8a.html

Private Water Companies in London using different raw water

sources provided ideal conditions for studying these theories

Ralph R. Frerichs www.ph.ucla.edu/EPI/snow/watermap1856/watermap_1856.html

8
 9/1/2018

Grand experiment

https://faculty.humanities.uci.edu/bjbecker/PlaguesandPeople/week8a.html

9
 9/1/2018

Epidemiology in the 20th Century

• Smoking in the 1950s

– 80% of middle aged
men smoked regularly
– Smoking was
prescribed by doctors
to treat anxiety, for
weight control, etc.

http://tobacco.stanford.edu/tobacco_main/images.php?token2=fm_st001.php&token1=fm_img0071.php&theme_file=fm_mt001.php&the
me_name=Doctors%20Smoking&subtheme_name=More%20Doctors%20Smoke%20Camels

Just disease?
• Communicable diseases
– E.g. flu, STDs, Zika virus
• Non-communicable diseases
– E.g. chronic obstructive pulmonary disease
• Injuries,; birth defects, occupational health,
environmental health
• Health related quality of life, exercise, nutrition,
health behaviors related to well-being and health

No longer just “disease” oriented

10
 9/1/2018

Objectives of epidemiology
• Identify etiology (cause) of disease and risk factors

• Burden of disease in a community

• Natural history and prognosis of disease

• Evaluate existing and new preventive and therapeutic

measures, modes of health care delivery

• To inform public health policy

Low carbohydrate, high fat diet

impairs exercise economy and
negates the performance
benefit from intensified training
in elite race walkers
Burke et al. 2016
• Adaptation to an LCHF diet impairs performance
in elite endurance athletes despite a significant
improvement in peak aerobic capacity

11
 9/1/2018

Does compassion go viral?

Social media, caring, and the
Fort McMurray wildfire
• Boulianne et al. 2018
• Those who followed news about the
wildfire on social media express higher
overall levels of care and concern for
those affected, which led to helping those
impacted by the wildfire

Alcohol use and burden for 195

countries and territories, 1990–
2016: a systematic analysis for
the Global Burden of Disease
Study 2016
• GBD 2016 Alcohol Collaborators
• Level of consumption that minimises
health loss is zero

12
 9/1/2018

Epidemiological triad of disease

Host

Vector

Agent Environment

Factors Associated with Disease

Risk

13
 9/1/2018

An example?

Host

Vector

Agent Environment

Modes of Disease Transmission

Direct Indirect
• Common Vehicle
• Person-to-person contact – e.g. air, water
– e.g. STDs – Single exposure
– Multiple exposures
– Continuous exposures
• Vector
– e.g. airplane, mosquito

14
 9/1/2018

Iceberg concept of infectious

disease

Terms

• Endemic
– Habitual presence of disease in geographic
area or “usual” occurrence of disease
• Epidemic
– Occurrence of excess illness in area
• Pandemic
– Epidemic crossing borders.

15
 9/1/2018

Examples?

Time Place Example

Epidemic: limited limited

Pandemic: limited unlimited

Endemic: unlimited limited

Disease Outbreak
Outbreak
• epidemic limited to a localized, rapid
increase in the incidence of a disease
(Porto, 2014, Dictionary of Epidemiology)

• Usually refer to infectious diseases

• Common locations:
– Hospitals, schools, nursing homes, daycare,
cruise ships

16
 9/1/2018

Outbreak types
• Common-vehicle
– Common source of a pathogen, often at the
same time or within a brief period of time
– E.g. Vibrio parahaemolyticus from raw
shellfish from B.C. between May to Aug 2015
• Exposures
– Single or point
– Multiple
– Continuous

Who is affected?

Susceptibility Immunity
• At risk • Not at risk
• Previously had disease
• Immunized
• Genetics

17
 9/1/2018

Herd immunity

Herd immunity

• Resistance of a group of people to which a

large proportion of the members of the
group are immune
• Transmission is limited
• Protects even those who are susceptible

18
 9/1/2018

But….

• Assumes single host species transmission

• Relatively direct
• No reservoirs
• Solid immunity

Incubation period

• Time between infection and onset of

clinical illness
• No clinical symptoms during this period
• Can still spread infection

19
 9/1/2018

Common source

http://www.med.uottawa.ca/sim/data/public_health_epidemic_curves_e.htm

Continuing source

http://www.med.uottawa.ca/sim/data/public_health_epidemic_curves_e.htm

20
 9/1/2018

Intermittent or periodic

http://www.med.uottawa.ca/sim/data/public_health_epidemic_curves_e.htm

What disease is this?

21
 9/1/2018

Attack Rate

Number of people at risk who develop the illness

Number of people at risk

Example
Those who ate specified foods
Food Number ill Total Attack rate (%)
Turkey 97 133 73
Potatoes and gravy 92 127 72
Salad 1 4 25
Cake 22 36 61
Those who did not eat specified foods
Food Number ill Total Attack rate (%)
Turkey 2 25 8
Potatoes and gravy 7 31 22
Salad 98 154 64
Cake 77 122 63

22
 9/1/2018

Cross-tabulation

Ate turkey Did not eat turkey

Food ill Total Attack rate (%) ill Total Attack rate (%)
Ate potatoes and 92 127 72 0 0 n/a
gravy
Did not eat 5 6 83 2 25 8
potatoes and gravy

Epidemiologic transition

• Causes of morbidity and mortality are

different across countries and time
• As countries develop (economically,
socially, demographically), this pattern of
morbidity and mortality change
• General transition from communicable to
non-communicable diseases
• Known as the epidemiologic transition

23
 9/1/2018

Epidemiologic transition

Anjana et al. (2011), The need for obtaining accurate nationwide estimates of diabetes prevalence in India - Rationale for a national study on
diabetes, Indian J Med Res. 2011 April; 133(4): 369–380.

Rockett, (1999), Population and Health: An Introduction to Epidemiology, Bulletin, Vol. 54, No. 4

24
 9/1/2018

GBD Group, (2015), Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of
death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015, Lancet, Vol. 388 (10053): 1459–1544.

Investigating disease
occurrence
• Who?

• When?

• Where?

25
 9/1/2018

Who?

• Age • Health Status

• Sex • Immunization status
• Race/Ethnicity • Lifestyle practices
• Socioeconomic status • Environmental
• Occupation exposures
• Education • Others…
• Religion
• Marital status

26
 9/1/2018

Where?

Blencowe et al. (2012), National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990
for selected countries: a systematic analysis and implications, Lancet, Vol 379(9832): 2162-2172

When?
Lung Cancer: European Age-Standardised Incidence Rates and Smoking Prevalence,
Great Britain, 1948-2013

27
 9/1/2018

Steps in an outbreak
investigation
1. Prepare for field work 8. Evaluate hypotheses
2. Establish the existence of an epidemiologically
outbreak 9. As necessary, reconsider,
3. Verify the diagnosis refine, and re-evaluate
4. Construct a working case hypotheses
definition 10. Compare and reconcile with
5. Find cases systematically laboratory and/or environmental
and record information studies
6. Perform descriptive 11. Implement control and
epidemiology prevention measures
7. Develop hypotheses 12. Initiate or maintain surveillance
13. Communicate findings

How does epidemiology work in

practice?
• Observation
• Hypotheses and research questions
• Investigate
– Descriptive
– Analytic
– Causality?
• Communication

28