HSCI 451 (4 units) Principles of Epidemiology Lecture 1

Health promotion/education What is public health? How do you define public health? Healthcare is the ambulance while public health is the fence. Epidemiology is one of the first steps in the spectrum of public health. Epidemiology Health promotion/education Policy

Class Objectives After today’s class, students will be able to: Define epidemiology Discuss the types of epidemiologic studies Uses of epidemiology Core functions of epidemiology List top 3 epidemiologic issues in the U.S. List top 3 global epidemiologic issues List one national (U.S.) and one international agency for epidemiologic information

Defining Epidemiology Greek word epi meaning on or upon, demos meaning people, and logos meaning the study of. CDC uses the following definition: 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 the control of health problems 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 the control of health problems (Last, 2001). Last JM, editor. Dictionary of epidemiology. 4th ed. New York: Oxford University Press; 2001. p. 61.

Study Basic science of public health Uses scientific method Uses un-biased data Decisions and programs are data driven Develop and test hypotheses grounded in other sciences Study Epidemiology is a scientific discipline with sound methods of scientific inquiry at its foundation. Epidemiology is data-driven and relies on a systematic and unbiased approach to the collection, analysis, and interpretation of data. Basic epidemiologic methods tend to rely on careful observation and use of valid comparison groups to assess whether what was observed, such as the number of cases of disease in a particular area during a particular time period or the frequency of an exposure among persons with disease, differs from what might be expected. However, epidemiology also draws on methods from other scientific fields, including biostatistics and informatics, with biologic, economic, social, and behavioral sciences. In fact, epidemiology is often described as the basic science of public health, and for good reason. First, epidemiology is a quantitative discipline that relies on a working knowledge of probability, statistics, and sound research methods. Second, epidemiology is a method of causal reasoning based on developing and testing hypotheses grounded in such scientific fields as biology, behavioral sciences, physics, and ergonomics to explain health-related behaviors, states, and events. However, epidemiology is not just a research activity but an integral component of public health, providing the foundation for directing practical and appropriate public health action based on this science and causal reasoning.(2)

Distribution Epidemiologists are concerned with frequency and pattern of health events. Frequency: number of health events and the relationship of that number to the size of the population. Results in rates. Pattern: occurrence of health-related events by time, place, and person. This is often called _____________ epidemiology Distribution Epidemiology is concerned with the frequency and pattern of health events in a population: Frequency refers not only to the number of health events such as the number of cases of meningitis or diabetes in a population, but also to the relationship of that number to the size of the population. The resulting rate allows epidemiologists to compare disease occurrence across different populations. Pattern refers to the occurrence of health-related events by time, place, and person. Time patterns may be annual, seasonal, weekly, daily, hourly, weekday versus weekend, or any other breakdown of time that may influence disease or injury occurrence. Place patterns include geographic variation, urban/rural differences, and location of work sites or schools. Personal characteristics include demographic factors which may be related to risk of illness, injury, or disability such as age, sex, marital status, and socioeconomic status, as well as behaviors and environmental exposures. Characterizing health events by time, place, and person are activities of descriptive epidemiology, discussed in more detail later in this lesson.

Determinants Any factor that brings about a change in a health condition or other characteristics. Social determinants Physical environment Genetics Lifestyle behaviors Determinants Epidemiology is also used to search for determinants, which are the causes and other factors that influence the occurrence of disease and other health-related events. Epidemiologists assume that illness does not occur randomly in a population, but happens only when the right accumulation of risk factors or determinants exists in an individual. To search for these determinants, epidemiologists use analytic epidemiology or epidemiologic studies to provide the “Why” and “How” of such events. They assess whether groups with different rates of disease differ in their demographic characteristics, genetic or immunologic make-up, behaviors, environmental exposures, or other so-called potential risk factors. Ideally, the findings provide sufficient evidence to direct prompt and effective public health control and prevention measures. Determinant: any factor, whether event, characteristic, or other definable entity, that brings about a change in a health condition or other defined characteristic.

Health-Related States or Events Anything that affects the well-being of the population. Can often be called disease even if the outcome is a behavior (such as smoking). Historically-communicable diseases Today-focus on chronic diseases Health-related states or events Epidemiology was originally focused exclusively on epidemics of communicable diseases (3) but was subsequently expanded to address endemic communicable diseases and non-communicable infectious diseases. By the middle of the 20th Century, additional epidemiologic methods had been developed and applied to chronic diseases, injuries, birth defects, maternal-child health, occupational health, and environmental health. Then epidemiologists began to look at behaviors related to health and well-being, such as amount of exercise and seat belt use. Now, with the recent explosion in molecular methods, epidemiologists can make important strides in examining genetic markers of disease risk. Indeed, the term health-related states or events may be seen as anything that affects the well-being of a population. Nonetheless, many epidemiologists still use the term “disease” as shorthand for the wide range of health-related states and events that are studied.

Specific Subpopulations Who is the patient? Healthcare professional (doctor, nurse): ________ Public health: _____________ Among populations who is the primary? Maternal-child health Geriatric care Minority health Global Specified populations Although epidemiologists and direct health-care providers (clinicians) are both concerned with occurrence and control of disease, they differ greatly in how they view “the patient.” The clinician is concerned about the health of an individual; the epidemiologist is concerned about the collective health of the people in a community or population. In other words, the clinician’s “patient” is the individual; the epidemiologist’s “patient” is the community. Therefore, the clinician and the epidemiologist have different responsibilities when faced with a person with illness. For example, when a patient with diarrheal disease presents, both are interested in establishing the correct diagnosis. However, while the clinician usually focuses on treating and caring for the individual, the epidemiologist focuses on identifying the exposure or source that caused the illness; the number of other persons who may have been similarly exposed; the potential for further spread in the community; and interventions to prevent additional cases or recurrences. The population can also be very diverse (example the whole community) or specific (women, elderly, etc.)

Application The knowledge gained by studies is applied to community-based practice. Results from a study: Pollution in San Bernardino and high asthma among children. Application: Asthma prevention and management classes to help population. Application Epidemiology is not just “the study of” health in a population; it also involves applying the knowledge gained by the studies to community-based practice. Like the practice of medicine, the practice of epidemiology is both a science and an art. To make the proper diagnosis and prescribe appropriate treatment for a patient, the clinician combines medical (scientific) knowledge with experience, clinical judgment, and understanding of the patient. Similarly, the epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well as experience, epidemiologic judgment, and understanding of local conditions in “diagnosing” the health of a community and proposing appropriate, practical, and acceptable public health interventions to control and prevent disease in the community.

Quiz Time Match the following: Distribution Determinants Application Compare food histories between persons with Staphylococcus food poisoning and those without Graph the number of cases of congenital syphilis by year for the country Recommend that close contacts of a child recently reported with meningococcal meningitis receive Rifampin Match which of the examples listed (1, 2 or 3) is an example of distribution, determinants, or application component of epidemiology.

Defining Epidemiology The 5 W’s of epidemiology What, Who, Where, When and Why (how) What: Diagnosis or health event Who: Person Where: Place When: Time Why/How: Causes, risk factors, mode of transmission The 5W’s are critical for any story and if anything is missing, the story is incomplete.

APPLICATION TIME Identify the 5Ws in each of the examples Pick your favorite person from the group and tell your story to the rest of the class

Class Objectives After today’s class, students will be able to: Define epidemiology Discuss the types of epidemiologic studies Uses of epidemiology Core functions of epidemiology List top 3 epidemiologic issues in the U.S. List top 3 global epidemiologic issues List one national (U.S.) and one international agency for epidemiologic information

Types of Epidemiology Social epi.: Study of the social distribution of social determinants of health What are social determinants of health? Examples? Molecular epi.: Study of how genetic and environmental risk factors (at the molecular level) contributes to health outcomes 1977: the application of sophisticated techniques to the epidemiologic study of biological matter. 1994: using molecular biomarkers in epidemiology Social determinants of health: economic and social conditions that influence health of populations and/or individuals. The CDC uses: The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world Source: Commission on Social Determinants of Health (CSDH), Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. 2008, World Health Organization: Geneva.

Types of Epidemiology Environmental epi.: Study of how environmental factors contribute to health outcomes Others: Infectious disease Occupational/Injury Maternal-child health Pediatric epidemiology Reproductive epidemiology Chronic disease epidemiology Many more

Quiz Time The percent of population who have heart disease. Is yoga class helpful for those with depression. The genes responsible for diabetes among Asian Indians are the same as those for Hispanics. Drug A works better than Drug B in curing HIV/AIDS. Mice exposed to smoke and risk of heart attack. Noise pollution and blood pressure.

Class Objectives After today’s class, students will be able to: Define epidemiology Discuss the types of epidemiologic studies Uses of epidemiology Core functions of epidemiology List top 3 epidemiologic issues in the U.S. List top 3 global epidemiologic issues List one national (U.S.) and one international agency for epidemiologic information

Uses of Epidemiology Assessing community's health Making decisions Example: diabetes Making decisions Completing the clinical picture Searching for causes

Core Functions Public health surveillance Field investigation Analytic studies Evaluation Linkages Policy development Public health surveillance: Public health surveillance is an ongoing, systematic data collection, analysis, interpretation, and dissemination of data to create public health actions. Reviewing reports of test results for Chlamydia from clinics Field investigation Interviewing persons infected with Chlamydia to identify their sex partners Analytical studies Comparing persons with symptomatic versus asymptomatic Chlamydia infection to identify predictors Evaluation: efficacy Conducting an analysis of patient flow at the public health clinic to determine waiting times for clinic patients Linkages Meeting with directors of family planning clinics and college health clinics to discuss Chlamydia testing and reporting Policy development Developing guidelines/criteria about which patients coming to the clinic should be screened (tested) for Chlamydia infection

Class Objectives After today’s class, students will be able to: Define epidemiology Discuss the types of epidemiologic studies Uses of epidemiology Core functions of epidemiology List top 3 epidemiologic issues in the U.S. List top 3 global epidemiologic issues List one national (U.S.) and one international agency for epidemiologic information

Epidemiologic Issues U.S. The top four leading causes of death in the U.S. are preventable Heart disease and stroke are the __________and __________ leading causes of deaths, respectively. Others include COPD, diabetes, growing trends in __________________. Developing nations Infectious diseases and rising chronic diseases Neglected tropical diseases

What’s going on right here? Data Source: California Department of Public Health, 2010.

Data Source: U.S. Census Bureau, 2013.

Data source: Population Division, DESA, United Nations (2011). Global population aged 80+ years (projections for 2025, 2050): 1950-2050 Data source: Population Division, DESA, United Nations (2011).

Class Objectives After today’s class, students will be able to: Define epidemiology Discuss the types of epidemiologic studies Uses of epidemiology Core functions of epidemiology List top 3 epidemiologic issues in the U.S. List top 3 global epidemiologic issues List one national (U.S.) and one international agency for epidemiologic information

Quiz Time Name one national and one international organization to obtain epidemiologic information from? National: _________________ International: _____________________

Next class… Historical aspects of epidemiology Disease transmission Read chapters 1 and 2 ©Monideepa B. Becerra, 2013