Teaching Epidemiology A guide for teachers in
epidemiology, public health and clinical medicine, 4th Edition
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Preface
Teaching epidemiology requires teaching skills and knowledge. The overriding
requirement is knowledge of the subject matter. The general advice is simple: if
you are not an expert on a topic, you should enrich your background know-
ledge before you start teaching. In this book we help you to locate the most
important sources of information you need to study before you start.
In addition, we provide expert teachers’ advice on how best to structure
teaching—what has worked in their hands. You should not, however, expect
that these guidelines will automatically work for you. You have to find your own
personal style and use examples of relevance for your audience. It is, neverthe-
less, always useful to make sure your teaching follows a predefined logical
sequence. The book will help you to set up this structure.
Most experienced epidemiologists are able to write and present scientific
findings by complying with the established rules for scientific writing. Teaching
is different because you also have to establish personal contact. Without per-
sonal contact, teaching may well be replaced by reading or web-based courses.
Personal contact requires that the teacher wants to teach and that the students
are willing to learn, or at least to give it a try. Evaluation of your success as a
teacher includes assessment of your knowledge and experience as well as how
the teaching was received. Any serious evaluation takes both aspects into
consideration.
Epidemiology is an old discipline but its concepts and principles are evolving
rapidly and, for that reason, a book like this needs frequent updating. Teachers
have different ideas as to what the level of sophistication in methods should be
and where to focus the attention of the students. We have not sought consensus
when inviting the authors to contribute. Science is not driven by consensus but
rather by diversity.
We advise you to read and make your own judgements and develop your pre-
ferred trajectory. But first, see what older and more experienced colleagues have
to offer. Then—but only then—you can throw it away.
This book is a fourth edition of Teaching Epidemiology, first published in
1992. The content has changed substantially since the second version (2007).
The first edition was published by Oxford University Press and the Commission
of the European Communities. Later versions are published by Oxford Univer-
sity Press in collaboration with the International Epidemiological Association
vi PREFACE
and the European Educational Programme in Epidemiology. The second edi-
tion of the book was awarded ‘Highly Commended in the Basis of Medicine
Category’ at the 2002 BMA Medical Book Awards in London.
We would like to thank all authors who agreed to share their experience and
knowledge with their less experienced colleagues. Without their contributions
there would not have been any book. We also thank Pernille Kümpel and Rikke
Sinding for their important administrative support and technical skills.
Jørn Olsen
Naomi Greene
Rodolfo Saracci
Dimitrios Trichopoulos
Acknowledgements
Dimitrios Trichopoulos died 1 December 2014 at 75 years of age. We thank him
for his valuable contribution to this book over the years and for his generosity
as a teacher, scientist, and friend.
Contents
Contributors xi
Part 1 Context
1 Introducing the history of epidemiology 3
Rodolfo Saracci
2 Important concepts in epidemiology 30
Olli S. Miettinen
3 Study design 37
Jørn Olsen and Olga Basso
4 Statistics in epidemiology 56
Per Kragh Andersen
5 Teaching a first course in epidemiologic principles and methods 67
Kenneth J. Rothman and Sherri O. Stuver
Part 2 Exposure-oriented epidemiology
6 Questionnaires in epidemiology 85
Jakob Bue Bjørner
7 Environment 98
Anders Ahlbom
8 Occupational epidemiology 105
Neil Pearce
9 Life course epidemiology 120
Yoav Ben-Shlomo and Diana Kuh
10 Pharmacoepidemiology 138
Susan Jick
11 Nutritional epidemiology 157
Walter C. Willett
12 Genetic epidemiology 177
Harry Campbell and Susan Service
13 Teaching molecular epidemiology 206
Betsy Foxman
14 Social inequalities in health 221
Nancy Krieger
x CONTENTS
15 Climate change and human health: issues for teacher
and classroom 251
Ulisses Confalonieri and Shilu Tong
Part 3 Outcome-oriented epidemiology
16 Infectious disease epidemiology 291
Marc Lipsitch
17 Cancer epidemiology 315
Pagona Lagiou and Dimitrios Trichopoulos
18 Teaching a course in psychiatric epidemiology 338
Rebecca Fuhrer and Kelly K. Anderson
19 Neurologic diseases 356
C. A. Molgaard, A. L. Golbeck, and John F. Rothrock
20 Reproductive epidemiology 374
Jørn Olsen and Ellen Aagaard Nøhr
21 Teaching chronic respiratory disease epidemiology 390
Josep M. Antó
22 Epidemiology of injuries 409
Eleni Petridou, Patricia Gerakopoulou, and Constantine
N. Antonopoulos
23 Dental epidemiology 429
Georgios Tsakos and Vibeke Baelum
24 Clinical epidemiology 444
John A. Baron, Henrik Toft Sørensen, and Harold C. Sox Jr
25 Study of clustering and outbreaks 463
Paul Elliott and Anna Hansell
26 Medical databases 475
Henrik Toft Sørensen and John A. Baron
27 Teaching epidemiology inside and outside the classroom 490
J. H. Abramson
Part 4 Pedagogies
28 Guide for teaching assistants in a methods course at a department
of epidemiology 521
Naomi Greeneand Tarun Bhatnagar
Index 537
Contributors
J. H. Abramson Olga Basso
Professor Emeritus of Social Associate Professor, Department of
Medicine, School of Public Health Epidemiology, Biostatistics, and
and Community Medicine, The Occupational Health, McGill
Hebrew University of Jerusalem, Israel University Faculty of Medicine,
Anders Ahlbom Montreal, Quebec, Canada
Professor of Epidemiology, Chair and Yoav Ben-Shlomo
Director, Institute of Environmental Professor, School of Social and
Medicine, Karolinska Institutet, Community Medicine, Bristol, UK
Stockholm, Sweden
Tarun Bhatnagar
Per Kragh Andersen Scientist C, National Institute of
Professor, Institute of Public Health, Epidemiology (Indian Council of
Dept. Of Biostatistics, University of Medical Research), Tamil Nadu
Copenhagen, Denmark Housing Board, Ayapakkam,
Kelly K. Anderson Chennai, India
Assistant Professor, Department of Jakob Bue Bjørner
Epidemiology and Biostatistics, Professor, National Research Centre
University of Western Ontario, Canada for the Working Environment,
Josep M. Antó Copenhagen, Denmark
Director and Researcher, Centre for Harry Campbell
Research in Environmental Professor, Centre for Population
Epidemiology (CREAL), Barcelona, Health Sciences and Institute of
Spain Genetics and Molecular Medicine,
Constantine N. Antonopoulos College of Medicine and Vet
Department of Hygiene, Epidemiology Medicine, University of Edinburgh,
and Medical Statistics, Medical School, UK
National and Kapodistrian University
Ulisses Confalonieri
of Athens, Greece
Professor, Laboratory on Education
Vibeke Baelum for Health and the Environment
Professor, Department of Dentistry, (LAESA), Rene Rachou Research
Health, Aarhus University, Denmark Center, The Oswaldo Cruz
John A. Baron Foundation (FIOCRUZ), Brazilian
Professor of Medicine, University of Ministry of Health, Belo Horizonte,
North Carolina at Chapel Hill, USA Brazil
xii CONTRIBUTORS
Paul Elliott Susan Jick
Professor Small Area Health Statistics Professor of Epidemiology, Director,
Unit, MRC-PHE Centre for Boston Collaborative Drug
Environment and Health, School of Surveillance Program, Boston
Public Health, Imperial College University School of Public Health,
London, UK MA, USA
Betsy Foxman Nancy Krieger
Professor, Department of Professor of Social Epidemiology,
Epidemiology, University of Department of Social and Behavioral
Michigan School of Public Health, Sciences, Harvard School of Public
Ann Arbor, MI, USA Health, Boston, MA, USA
Rebecca Fuhrer Diana Kuh
Professor, Department of Professor, MRC Unit for Lifelong
Epidemiology, Biostatistics, and Health and Ageing, London, UK
Occupational Health, McGill Pagona Lagiou
University Faculty of Medicine, Professor of Hygiene and
Montreal, Quebec, Canada Epidemiology, University of Athens
Patricia Gerakopoulou Medical School and Adjunct
Research Associate, National and Professor of Epidemiology, Harvard
Kapodistrian University of Athens School of Public Health, Boston, MA,
Medical School, Department of USA
Hygiene, Epidemiology and Medical Marc Lipsitch
Statistics, Athens, Greece Professor of Epidemiology,
A. L. Golbeck Department of Epidemiology and
Professor, The School of Public and Department of Immunology and
Community Health Sciences, The Infectious Diseases, Harvard School
University of Montana, Missoula, of Public Health, Boston, MA, USA
MT, USA Olli S. Miettinen
Naomi Greene Department of Epidemiology,
University of California, Los Angeles, Biostatistics, and Occupational
Fielding School of Public Health, Health, McGill University Faculty of
USA Medicine, Montreal, Quebec,
Anna Hansell Canada
Assistant Director, Small Area Health C. A. Molgaard
Statistics Unit, MRC-PHE, Centre for Professor and Chair, The School of
Environment and Health School of Public and Community Health
Public Health, Imperial College Sciences, The University of Montana,
London, UK Missoula, MT, USA
CONTRIBUTORS xiii
Ellen Aagaard Nøhr Shilu Tong
Professor, Department of Obstetrics School of Public Health, Institute
and Gynaecology, Odense University of Health and Biomedical,
Hospital and University of Southern Innovation Queensland University
Denmark, Odense, Denmark of Technology Kelvin Grove,
Jørn Olsen Qld. 4059, Australia
Professor, Section for Epidemiology, Harold C. Sox Jr
Department of Public Health, Aarhus Professor Emeritus, The Geisel
University, Denmark and Adjunct School of Medicine at Dartmouth,
Professor of Epidemiology, U niversity Hanover, NH, USA
of California, Los Angeles, USA
Sherri O. Stuver
Neil Pearce Assistant Director, Department of
Professor, London School of Hygiene Epidemiology, Boston University
and Tropical Medicine, UK School of Public Health, MA,
Eleni Petridou USA
Professor of Preventive Medicine and Henrik Toft Sørensen
Epidemiology, National and Professor, Department of Clinical
Kapodistrian University of Athens, Epidemiology, Aarhus University
Medical School, Department of Hospital, Denmark
Hygiene, Epidemiology and Medical
Dimitrios Trichopoulos
Statistics, Greece
Vincent L. Gregory
Kenneth J. Rothman Professor of Cancer Prevention and
Distinguished Fellow, RTI Health Professor of Epidemiology, Harvard
Solutions, Research Triangle Institute, School of Public Health, Boston,
Research Triangle Park, NC, USA MA, USA
John F. Rothrock Georgios Tsakos
Director, Renown Neurology Clinic, Department of Epidemiology and
Professor and Chief, Division of Public Health, University College
Neurosciences University of Nevada London, UK
and Reno School of Medicine, USA
Walter C. Willett
Rodolfo Saracci Professor, Departments of
Adjunct Professor, Section for Nutrition and Epidemiology,
Epidemiology, Department of Public Harvard School of Public Health,
Health, Aarhus University, Denmark and Channing Division of Network
Susan Service Medicine, Department of Medicine,
UCLA Semel Institute for Brigham and Women’s Hospital and
Neuroscience and Behavior, U niversity Harvard Medical School, Boston,
of California, Los Angeles, USA MA, USA
Part 1
Context
Chapter 1
Introducing the history
of epidemiology
Rodolfo Saracci
Nature cannot know its own history; humans can.
Introduction to the history of epidemiology
Why teach the history of epidemiology?
‘Know yourself ’: this Socratic maxim expresses the rationale for learning the
history of epidemiology. Self-knowledge, as derived from a view of the develop-
ment in time of epidemiology, promotes a positively critical attitude towards
the discipline and its practice by fostering an appreciation of
◆ the common features of all branches of epidemiology as a population health
science beyond today’s subdivision in specialized areas;
◆ the relationship of epidemiology to other scientific disciplines, and its meth-
odological specificities, strengths, and weaknesses in respect to them;
◆ the process of the emergence of key concepts, be they methodological, such
as ‘risk’, or substantive, such as the modes of diffusion of pathogens in the
community: this cumulative but irregular accrual of knowledge is character-
ized by controversies, blind alleys, sheer errors and, not rarely, also by mate-
rial hurdles, as well as personal and institutional conflicts; it usually appears
long when time is measured in years but much less so when a ‘generation’ of
scientists is—more appropriately—taken as the time unit;
◆ the influence of the demographic, health, social, cultural, and economic con-
text on the development of epidemiology and epidemiological methods;
◆ the role of epidemiology in society through its impact in the health field, an
impact largely mediated through the essential functions of epidemiology
within public health; and
4 Rodolfo Saracci
◆ the roots and dynamics of present trends in epidemiology, and the options
for reinforcing, inflecting, or contrasting them; in particular, the pressure
for resources and research to be concentrated on the ‘theme of the day’,
ignoring or paying lip service to the past and glossing over future implica-
tions. The increasingly technical and specialized character of most epidemi-
ology textbooks does little to keep this trend in check.
Each of these six perspectives on epidemiology should be regarded as essen-
tially descriptive and only tentatively as explanatory. Presentations on the long-
term evolution of epidemiology, especially ‘bird’s eye views’, as the one in
‘Annex: an historical sketch’, are affected to a variable but usually substantial
extent by ‘teleological bias’ (Saracci 2011). The bias arises from the unavoidable
tendency to reconstruct sequences of and links between past ideas, concepts,
and events in such a way that they can logically and consistently account for
today’s situation, for instance, today’s concept of ‘risk factor’. This in fact gener-
ates not a causal but a finalistic (pseudo) explanation because, as the historian
Trevor-Roper noted (Pearl et al. 1981), history is not only what occurred but
what occurred in the context of what could have occurred, namely, in light of all
possible alternative paths of evolution. I am not aware of any systematic work
that employs this counterfactual approach in the study of the long-term devel-
opment of epidemiology; indeed, scholarly historical work avoids overall nar-
ratives (counterfactual or not) and mostly develops meticulous ‘worm’s eye
views’ on limited, specific issues, based on the study of primary documentary
sources.
Whom to teach?
The teaching as here outlined is primarily addressed to students pursuing mas-
ter’s or doctoral degrees and who intend to become full-time epidemiologists,
as well as to those who will make a large use of epidemiology in their profes-
sional work (e.g. public health practitioners, clinicians, and occupational
physicians).
This teaching can only be regarded as preliminary for students who may wish
to proceed in one of two directions: historical epidemiology as a description
and analysis of health and diseases in given areas and past periods of time; and
history of epidemiology as the reconstruction of the development of theories,
concepts, methods, and practices, including the study of the role of individuals
and institutions.
For undergraduate students, for example in medicine, to whom a twenty- to
forty-hour course in epidemiology or epidemiological methods is imparted at a
number of medical schools, a short historical overview (one or two lectures)
