1/8/2025

Epidemiology in Public Health

Part I: History & Scope

of Epidemiology

Overview
 Overview of Group Projects
 Introductions
 Review of Course Syllabus/Policies
 What is Epidemiology?
 Key Historical Figures/Events
 Descriptive Epidemiology
 Disease Trends
 Ecological Fallacy
 Prevalence Ratios

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Introductions
 Name
 Something you would like to learn
as part of this class
 A question for Dr. Don

Course Syllabus/Policies

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Epidemiology Defined

Epidemiology is “[t]he study of the occurrence and

distribution 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 the control of
relevant health problems.”

Epidemiology and Public Health

Practice
Public health practice: “…the strategic, organized and
interdisciplinary application of knowledge, skills and
competencies necessary to perform essential public
health services and other activities to improve the
population’s health.”

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Controversies Regarding
Epidemiologic Research
 Vaccination against smallpox
 Dangers associated with Ebola virus
 Dietary practices
 Beverage consumption
 Prospects for global influenza pandemics

Public Health Topics and Concerns

 Headline topics in MMWR

 Foodborne illnesses
 Infectious diseases
 Injuries
 Pregnancy-related topics
 Sexually transmitted diseases
 Plus many others

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Brief History of
Epidemiology

Hippocrates (460
BC-370 BC)

 First
to describe disease from
rational perspective
 Introducedthe terms ‘endemic’
and ‘epidemic’
 Categorizeddiseases/
treatments as ‘hot’ or ‘cold’

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Bernandino Ramazzini
(1633-1714)
 Received medical training at the
University of Parma
 Interested
in practical application
of medicine
 Became interested in the effects
of work hazards on health
 Father
of occupational
epidemiology

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John Graunt (1620-

1724)
 One of the first to collect
population based data/vital
statistics
 Responsible for preparing
London’s ‘bills of mortality’
 Identified
variations in death
based on gender, residence,
season and age

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Benjamin Jesty (1736-

1816) & Edward Jenner
1749-1823)
 Jesty noted that milkmaids
never got smallpox
 Exposed family to cowpox to
protect from smallpox; it
worked.
 Jenner, a rural physician,
confirmed finding and
developed smallpox
vaccination

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NOT Jon Snow!

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John Snow (1813-

1858)
 Physician and anesthesiologist to
Queen Victoria
 Pioneered approaches, concepts
and methods still used today
 Identified source of cholera
outbreak by plotting cholera
cases on a map of London

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Ignaz Semmelweis
(1818-1865)
 Clinical Director of the Viennese
Maternity Hospital
 Observed that one clinic had much
higher childbed fever rates than the
other
 Determined through observation, data
collection/analysis that fever was
spread by physicians during pelvic
exams
 Mandated washing with chlorinated
lime between each examination
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Florence Nightingale (1820-1910) &

William Farr (1807-1833)
 Farr continued Graunt’s work
documenting mortality in London
 Nightingale returned to London
from Scutari, Turkey with
strategies for reducing hospital
mortality
 Worked together to improve
reporting of and help reduce
mortality in London hospitals

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Louis Pasteur (1822-1895) & Robert

Koch (1843-1910)
 Pasteur was a French microbiologist
 Proponent of bacteria theory and
vaccination
 Identified causes of several diseases
including rabies and anthrax
 Koch was a rural physician in Germany
 Extended Pasteur’s work by
photographing microbes for the first time
 Developed the methods of culturing and
staining
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Discussion

Of the historical figures who

contributed to the field of
epidemiology who do you think
made the most significant
contribution? Why?

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The Framingham Heart Study (1948-2003)

 In 1948, recruited 5,209 men and/women
aged 30-62 from Framingham, MA to study
cardiovascular disease
 Subjects returned every two years for a
detailed medical history, physical
examination, and laboratory tests
 One of the longest cohort studies in the
world
 Since 1948 new subjects added:
 1971: Second generation (children/spouses)
 1994: Omni I (racially/ethnically diverse cohort)
 2002: Third generation (grandchildren)
 2003: Omni II (second group of racially/ethnically
diverse participants)

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Cigarette Smoking & Cancer

 Late 1940s: First case control studies assessed for link between
smoking and cancer
 Wynder & Graham (US)
 Doll & Hill (UK)
 First cohort study of British physicians conducted by Doll & Hill in
1951 (25 year follow-up)
 Found that smokers 10 times more likely to die from lung cancer than
non-smokers
 By 1964, 29 case control studies and seven cohort studies all showed
significantly increased risk of lung cancer among tobacco smokers
 Case control and cohort study designs still in use today

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Today, Epidemiology Encompasses

 Cancer epidemiology
 Environmental/occupational epidemiology
 Neuroepidemiology
 Psychiatric or Psychoneuroepidemiology
 Cardiovascular epidemiology
 Genetic epidemiology
 Communicable disease epidemiology
 Veterinary epidemiology
 Social epidemiology
 Behavioral epidemiology
 Pharmacoepidemiology

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Part II: Descriptive

Epidemiology

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Objectives of Descriptive Epidemiology

 Evaluate trends in health/disease

 Allow comparisons among countries and
subgroups within countries
 Provide a basis for planning, provision and
evaluation of services
 Identify problems to be studied by analytic
methods
 Hypothesis generating

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Descriptive Studies
 Relatively inexpensive and less time-consuming than analytic
studies, they describe
 Seasonality
 Trends which are affected by changes
 In diagnostic techniques
 In the accuracy of the denominator data
 In the age distribution of the population
 In survival from improved treatment or disease mutation
 In actual disease incidence

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Descriptive Studies
 Relatively inexpensive and less time-consuming
than analytic studies, they describe
 Who gets sick and/or who does not (Person)
 Where rates are highest and lowest (Place)
 Temporal patterns of disease (Time)

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Person
Since disease does not occur at random:

What kinds of people tend to develop a

particular disease, and who tends to be
spared? What’s unusual about those people?

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Place
Since disease does not occur at random:

Where is the disease especially common or rare, and

what is different about those places?

 Investigation by place includes:

 Across countries (international)
 Within country variation
 Urban/rural differences
 Localized areas

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Time
Since disease does not occur at random:

How does disease frequency change over time, and what

other factors are temporally associated with those changes?

The occurrence of health-related events can vary by time:

 Trends
 Cyclic fluctuations
 Point epidemics

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Possible Reasons for Changes in Trends

 Artifactual:
Errors in numerator due to
Changes in the recognition of disease
Changes in the rules and procedures for
classification of causes of death
Changes in the classification code of causes of
death
Changes in accuracy of reporting age at death
Errors in the denominator due to error in the
enumeration of the population

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Possible Reasons for Changes in Trends

 Real
Changes in age distribution of the
population
Changes in survivorship
Changes in incidence of disease resulting
from
Genetic factors
Environmental factors

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Ecologic Studies
Ecologic studies (aka correlational studies) use
measures that represent characteristics of
entire populations (area aggregates) to describe
outcomes in relation to some factor of interest
such as age, time, utilization of services, or
exposures

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Ecologic Studies
 Advantages
 Inexpensive, quick, and simple (generally make
use of secondary data)
 You can generate hypotheses for case-control
studies and environmental studies
 You can target high-risk populations, time-periods,
or geographic regions for future studies

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Ecologic Studies
 Limitations
 Cannot link exposure-disease relationship at the
individual level
 Uses average exposure levels rather than actual
levels of exposure (i.e., dose-response
relationships cannot be identified)
 Inability to control for confounding factors

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Ecologic Studies
The “Ecological Fallacy”:

 Erroneous conclusions about individuals based on

grouped data

 Patterns observed on the aggregate level are not

observed on the individual level

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Breast Cancer Mortality and Dietary Fat Intake

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Incidence and Prevalence

 Incidence = New Cases
 Prevalence = New + Existing Cases
 Mathematical Relationship Between Incidence and
Prevalence:
P=IxD
 where P is prevalence (new + existing cases), I is
incidence (new cases only), and D is the duration of
disease

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Summary
 Epidemiology is an evolving field with key
contributions to its practice made by individuals
throughout history
 Descriptive epidemiology contains useful tools for
investigation, hypothesis generation and calculating
the prevalence of a disease in a population
 Prevalence is affected by many factors, including
migration in/out of the population of interest
 Descriptive epidemiology provides us with measures
of association but not causality

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Summary
 Our next Zoom session will be on Saturday, February
8th. Please be on time; Dr. Margo Erme will be
speaking to us about infectious disease and
surveillance.
 Please watch for emails from me. I will be organizing
the class into groups and each group will need to
prepare a group charter, communication plan and
timeline.
 Please feel free to reach out to me via email as
questions arise. I am also happy to schedule Zoom
meetings with you and/or your groups to answer
questions.

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