BIOSTATISTICS AND EPIDEMIOLOGY Chronic → Addresses the etiology,

3rd term / Midterms / Lecture 1 – Intro to Epidemiology disease prevention, distribution, natural
history, and treatment
Epidemiology outcomes of chronic health
disorders.
Etymology Greek roots:
▪ Epi – upon ▪ Etiology – origin/cause of
▪ demos – people/population disease
▪ logos – study ▪ Chronic – lasts for months/
years.
Epidemiology → the study of diseases in a ▪ Acute – rapid progression
population level.
→ study of factors that determine
the occurrence of and Scientific study of disease
distribution of disease in a Can be approached at the following four levels:
population.
(1) Submolecular/ molecular level
Epidemiologist → Public health professionals who ­ biology, genetics, biochem, immunology
investigate (1) patterns, (2) (2) Tissue/ organ level
causes of disease, and (3) injury ­ anatomic pathology
in humans. (3) Level of individual patients
­ clinical medicine – study of signs and
symptoms
Types of epidemiology (4) Level of population
­ epidemiology
Classical → population oriented
→ studies the community origins Etiology and natural history of disease
of health problems
→ interested in discovering risk
Natural history of disease
factors (considers those that
→ natural course of the disease without medical
does not belong to the case)
intervention.
Clinical → Studies patients in health care → helps to know how and when to intervene
settings.
→ Improve prevention, early Stage Level of Type of response
detection, diagnosis, treatment, prevention
prognosis, and care of illness in
Pre-disease Primary o Health promotion
individuals.
o Specific protection
Syndromic → looks for patterns of signs and
Latent disease Secondary o Pre-symptomatic
symptoms that indicate an o Diagnosis and
origin in bioterrorism. (have disease treatment
but no sympt)
▪ Syndrome – constellation of
signs and symptoms Symptomatic Tertiary o Disability
disease (mitigation) limitation for early
Infectious → study of complex relationships symptomatic
disease among hosts and infectious disease
agents o Rehabilitation for
→ dependent on laboratory late symptomatic
support (microbiology-serology) disease
 Mechanisms and causes of disease → Influences the probability and circumstances of
contact between the host and the agent.
a) Biological mechanisms
b) Social, behavioral, and environmental (4) Vectors
­ ex. osteomalacia on muslims not getting
sunlight. → The “how”
­ obesity on americanss (not all) because of → The one who transmits the disease.
food portions (big) → to be an effective transmitter of disease, a vector
must have a specific relationship to the agent, the
*Factors Involved in Natural History of Disease environment, and the host.

May include:
o Insects, arachnids, mammals
o Human groups (asymptomatic)
o Inanimate objects
o Part of the environment

Risk Factors and Preventable causes

1964 – WHO estimates majority of cancer cases are

potentially preventable and were caused by
(1) Host factors
“extrinsic/environmental factors”
→ The “who” (person/ organism with the disease) ˃ These factors include things like viral
→ Responsible for the degree to which the individual infections, nutrition, and personal choices.
can adapt to the stressors produced by the agent.
▪ Intrinsic factors – genetics, nutritional status,
Host resistance: reproductive activities, personal behavior
o Genotype o Immune system ▪ Extrinsic factors – man-made or naturally
o Nutritional status o Social behavior occurring carcinogens, viral infections, etc.
o Body mass index
☆ Certain behaviors and factors can increase the risk of
(2) Agents of disease/ illness developing life-threatening diseases like cancer.
→ The “what” (whatever causes the disease)
Beings model
Categories Categories of preventable cause of disease
Biological agents Allergens, infectious organisms,
biological toxins, foods B Biological and Behavioral factors
→ Influenced by gender, age, weight, bone
Chemical agents Chemical toxins, dusts
density, etc.
Physical agents Kinetic energy, radiation, heat,
cold, noise
Risk factors:
Social and Anxiety, depression o Cigarette smoking
psychological o Overweight / obesity
stressors o Unprotected sexual intercourse
o Excessive alcohol intake
(3) Environment o Abuse of legal and illegal drugs
o Driving under the influence
→ The “where” (external factors that cause or allow o Homicide / suicide attempts
the disease transmission)
E Environmental Factors
→ Epidemiologists describe the patterns of the Iatrogenic disease
disease, develop and test hypotheses about ­ Occurs when a disease is induced
causal factors, and introduce methods to inadvertently by treatment or during a
prevent further cases of disease. diagnostic procedure. (hospital-acquired)

I Immunologic Factors Social and spiritual factors

­ Personal beliefs, religious faith
Smallpox ­ Family support, social network
­ First infectious disease known to have
been eradicated from the globe
Ecological issues in epidemiology
Herd immunity
­ When a vaccine diminishes an
• Classical epidemiologists consider their field to be
immunized person’s ability to spread the
disease, leading to reduced disease an "ecologic perspective" as it considers the social
transmission context and views people as members of a
community.
Immunodificiency • The world is understood as a complex ecosystem
­ Genetic abnormalities o Infections where every action affecting the ecosystem.
­ certain medications ˃ Every intervention aimed at solving public
health problems has unintended
▪ Edward Jenner – invented vaccines. consequences that can create new
N Nutritional factors problems.
→ Dietary variations play an important role in
producing differences in disease rates among ☆ a change in one part of a system can lead to an
populations. inevitable change in other parts of the system.

▪ Dennis Burkitt – found out that many *examples of unintended consequences:

Western diseases, which were rare in Initial Health Solution Unintended
Africa, were the result diet and lifestyle. problem consequences
(hypertension and diabetes)
Childhood Vaccination Decrease in the level of
G Genetic factors infections immunity during
adulthood, caused by
Genetic epidemiology a lack of repeated
­ Addresses the distribution of normal and exposure to infection
abnormal genes in each population. High infant Improved Increase in the
mortality sanitation population growth
Heritability rate rate; appearance of
epidemic paralytic
­ Contribution of genes relative to all
poliomyelitis
determinants of disease
Sleeping Control of tsetse Increase in the area of
sickness in fly (disease land subject to
Genetic screening cattle vector) overgrazing and
­ Important in identifying problems in drought, caused by
newborns and in determining an increase in the
susceptibility genes. cattle population
Malnutrition Erection of large Increase in rates of
S Services, social factors, and spiritual factors and river dams some infectious
need for (e.g., Aswan High diseases, caused by
Medical care services larger areas Dam, water system
of tillable Senegal River changes that favor
­ May be beneficial to health but can also
land dams) the vectors of
be dangerous.
disease
 A. Vaccination and patterns of immunity Smallpox → Caused by variola virus
→ eradicated through effective
Vaccine → provides herd immunity by not immunization, including the use
only protecting individuals but of the smallpox vaccine that was
also prevent the spread of effective against both variola
diseases to others. minor (mild) and variola major
→ Vaccination – from vaca “cow” (severe) forms of the disease.
→ Variolation caused a more sever
Herd immunity → occurs when enough people skin eruption, than vaccination
are immune to a disease, but one less severe than full-
which causes the prevalence blown smallpox.
of the disease organism in the
population to decline. ▪ Variolation – Intentionally
infecting a person with
smallpox in a controlled
manner to induce immunity.

Poliomyelitis → Caused by poliovirus.

→ Transmitted by person-to-person
through fecal-oral route or by
vehicle (food)
→ Officially eradicated in 36 Western
Pacific countries

Two types of vaccines:

a. Inactivated or killed polio
☆ In the presence of 50% herd immunity, the number of vaccine (IPV) / Salk
cases remains constant. b. Live, attenuated oral polio
vaccine (OPV) / Sabin
*Examples to illustrate vaccination programs and
population immunity includes: Syphilis → Caused by the spirochete bacteria
o Diphtheria (Treponema pallidum subspecies
o Smallpox pallidum)
o Poliomyelitis
Three stages:
o Human papillomavirus (HPV)
1. Primary
o Syphilis ­ produces a highly
infectious skin lesion
Diphtheria → Caused by Corynebacterium known as a chancre.
diphtheriae 2. Secondary
→ In 1990, major epidemic appeared ­ body rash or other lesions
in Russia despite vaccination appear.
among individuals. 3. Tertiary stage
→ By 1992, 72% of cases = older ­ affects internal organs.
than 14 years old

Vaccine-produced immunity B. Effects of sanitation

decreases over time.
19th century:
Recommendation: additional single
▪ Diarrhea – primary killer of children
vaccination for adults to provide
▪ Tuberculosis – leading cause of adult mortality
natural booster effect
Sanitary revolution: Antigenic shift → Occurs when two or more
→ Reduced infant mortality, increased effective birth strains of a virus combine to
rate. form a new subtype of a
˃ But a cause of today’s worldwide virus.
population problem → Can cause pandemics.

Demographic gap: Antigenic drift → Accumulation of mutations

within virus genes over time.
→ Difference between birth rate and death rate that
→ Can cause major regional
develops when a country undergoes demographic
outbreaks.
transition.
Global pandemic → Widespread outbreak
C. Vector control and land use patterns involving multiple continents.

• Successful tsetse fly control led to overgrazing,

droughts, and famine in sub-Saharan Africa.
Contributions of Epidemiologists
D. River dam construction and patterns of disease
Investigating epidemics and new diseases
• Large river dams in developing countries led to
• Epidemiologists provide initial hypotheses about
increased incidence of schistosomiasis, malaria, Rift
disease causation for other scientists to test in the
Valley fever, and dengue fever after construction.
laboratory.
• Construction of the Aswan High Dam in Egypt and
o types of agents
the Senegal River Project in West Africa are
o modes of transmission for new or emergent
examples where warnings of epidemiologists were
diseases
ignored.
o ways to prevent them.
Synergism of factors predisposing to disease
• After this basic epidemiological research, lab work
Synergism – Interaction or combination of factors that to identify causal agents, clarify pathogenesis, and
produce a greater effect than the sum of their separate develop vaccines/treatments for these diseases
effects. often continues for years.

Biologic spectrum of disease (Iceberg Phenomenon)

→ There is a variation in the severity of a disease

process; disease is a spectrum.
→ It represents the biologic spectrum of disease, with
most cases remaining unseen below the surface.
→ Paramount to the field of epidemiology because
studying only symptomatic individuals can be
misleading.

• Malnutrition and infection have a synergistic

relationship. (Malnutrition makes infections worse,
and infections make malnutrition worse.)
­ A malnourished child has more difficulty
making antibodies and repairing tissue
damage which makes the child less resistant
to infectious diseases.
 Surveillance of community health interventions Improving health services research

Field trials → Randomized trials of preventive Health services research

measures → examines how people get access to health care
→ Important phase of evaluating a and health care services, the costs of such
new vaccine services, and outcomes.
Ongoing → Ensure a vaccine’s continued
surveillance safety and effectiveness. • Principles and methods of epidemiology are used in
programs Ex. polio, smallpox, measles planning and evaluating medical care.

Syndromic → identify changes in disease Examples:

surveilance occurrence and suspicious ­ Health planning
symptom patterns. ­ Demographic projection techniques
→ Epidemiologists contributing to
­ Analyses of disease pattern frequency
national security
­ Health program evaluation
­ Cost-benefit analysis
Setting disease control priorities
Providing expert testimony in courts of law
Disease control priorities
→ should be based not only on the currently • Epidemiologists can be called to testify in court:
existing size of the population (and its problem), o Product hazards
but also: o Probable risks and effects of various
o potential spread of disease environmental exposures and medications
o likelihood of death and disability
o its cost to individuals, families, and
• Lawsuits may rely on epidemiologic data:
the community.
o General environmental exposures
Examples:
o Occupational illness claims
­ HIV/AIDS prioritization
o Medical liability
­ Type 2 diabetes
o Product liability
­ Severe Acute Respiratory Syndrome (SARS)
­ Zoonotic infections like avian influenza (H5N1)
☆ Expert medical testimony often requires a high level
of epidemiologic expertise.
Improving diagnosis, treatment, and prognosis of clinical
disease

Diagnosis → Process of identifying the nature

and cause of a disease through
evaluation of the clinical history,
review of symptoms,
examination, or testing

Effective → Determined by methods of

treatment clinical epidemiology

Prognosis → improved understanding through

epidemiology
Risk → Epidemiology forecasts the
estimation probability and impact of risks

LD