This background lesson provides several working definitions of epidemiology—the basic science of public health. First to set the stage, consider the three incidents that follow, stepping into the shoes of the public health officer who received the initial report and asking yourself the question, “What do I do now?” Some of these examples made national news and may be familiar to you.
In March 1985, a nurse epidemiologist in a county health department noted, while reviewing surveillance data, three cases in a single month of hepatitis B of unusual origin. Hepatitis B, or serum hepatitis, is transmitted through sexual contact and by exposure to infected bodily fluids, but these three patients did not seem to have the usual risk factors. All three people did, however, indicate having received injections at the same health care facility.
The nurse’s immediate questions were:
Is this a coincidence? Did these three cases occur by chance or is there a link? In this instance, the nurse decided to pursue an investigation.
At 8:30 in the morning on August 2, 1976, Dr. Robert B. Craven of Centers for Disease Control’s (CDC) Viral Diseases Division received a call from a nurse at a Veterans’ Hospital in Philadelphia, Pennsylvania. The nurse reported two cases of severe respiratory illness, one of which had been fatal. Both people had attended the annual American Legion Convention held July 21-24. By the evening of August 2, 71 more of the people attending the convention had the same illness, with symptoms of acute onset of fever, chills, headache, malaise, dry cough, and myalgia. Further conversations with local and state public health officials revealed that between July 26 and August 2, 18 conventioneers had died. Deaths were due primarily to pneumonia.
An intense investigation began immediately. The incident became known as the first outbreak of Legionnaires’ disease and led to the discovery of the gram-negative pathogen, Legionnella pneumophila.
On October 30, 1989, a New Mexico physician notified the state’s health department of three patients with marked peripheral eosinophilia and severe myalgia. All three patients had been taking oral preparations of L-tryptophan, a nonprescription drug sold as a dietary supplement in health food stores. Despite extensive clinical evaluation and testing, the illness could not be identified.
An investigation followed and resulted in the characterization of eosinophilia-myalgia syndrome, EMS. The investigation implicated a vehicle for exposure—L-tryptophan dietary supplements—before a suspected agent was identified, and the product was taken off the market. Eventually, the problem was traced to a contaminant that had been introduced by changes in the production process at a single manufacturing facility.
These three examples illustrate some of the key reasons for needing applied, or field, epidemiology:
- They were unexpected.
- They demanded a response.
- The investigators had to go out into the field to solve the problem.
A definition of epidemiology is “the study of the distribution and determinants of health-related states in specified populations, and the application of this study to control health problems.” A look at the key words will help illuminate the meaning:
- Epidemiology is the basic science of public health. It’s a highly quantitative discipline based on principles of statistics and research methodologies.
- Distribution Epidemiologists study the distribution of frequencies and patterns of health events within groups in a population. To do this, they use descriptive epidemiology, which characterizes health events in terms of time, place, and person
- Determinant Epidemiologists also attempt to search for causes or factors that are associated with increased risk or probability of disease. This type of epidemiology, where we move from questions of “who,” “what,” “where,” and “when” and start trying to answer “how” and “why,” is referred to as analytical epidemiology
A comparison between the practice of public health and the more familiar practice of health care helps in describing epidemiology. First, where health care practitioners collect data on an individual patient by taking a medical history and conducting a physical exam, epidemiologists collect data about an entire population through surveillance systems or descriptive epidemiological studies. The health care practitioner uses his or her data to make a differential diagnosis. The epidemiologist’s data is used to generate hypotheses about the relationships between exposure and disease. Both disciplines then test the hypotheses, the health care practitioner by conducting additional diagnostic studies or tests, the epidemiologist by conducting analytical studies such as cohort or case-control studies. The final step is to take action. The health care practitioner prescribes medical treatment, and the epidemiologist, some form of community intervention to end the health problem and prevent its recurrence.
|Health Care Professional||Epidemiologist|
|Collects data on an individual patient by taking a medical history and conducting a physical exam||Collects data about an entire population through surveillance systems or descriptive epidemiological studies|
|Uses his or her data to make a differential diagnosis||Data is used to generate hypotheses about the relationships between exposure and disease|
|Tests the hypothesis by conducting additional diagnostic studies or tests||Tests the hypothesis by conducting analytical studies such as cohort or case-control studies|
|Prescribes medical treatment||Develops community intervention to end the health problem and prevent its recurrence|
One way to sum up the task of epidemiologists is to say that they “count things.” Basically, epidemiologists count cases of disease or injury, define the affected population, and then compute rates of disease or injury in that population. Then they compare these rates with those found in other populations and make inferences regarding the patterns of disease to determine whether a problem exists.
For example, in the hepatitis B example earlier, you might ask: Is the rate of disease among people with no know risk factors greater than we would expect? Is the pattern or distribution of the cases suspicious? Once a problem has been identified, the data are used to determine the cause of the health problem; the modes of transmission; any factors that are related to susceptibility, exposure, or risk; and any potential environmental determinants.