NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 3: Epidemio logy
OVERVIEW
The purpose of this module is to provide an introduction to epidemiology and its
importance in investigating disease patterns, in determining risk factors for disease and
in providing a sound basis for decision-making in clinical care and public health.
O BJECTIVES
At the conclusion of this module, the learner will be able to:
 Define epidemiology
 Discuss the aims of epidemiology
 Recognize key figures and events in the history of epidemiology
 Interpret measures of morbidity and mortality in descriptive studies
 Distinguish types of analytical studies: cross-sectional, case-control, cohort
 Contrast experimental studies: clinical trials, community trials
 Assess the quality of scientific evidence
 Explain how priorities are set in public health
 Provide an overview of priority setting using epidemiological data
R EQUIRED R EADINGS
 CDC Excite. Introduction to Epidemiology. Available
at http://hickmancharterscioly.pbworks.com/f/EXCITE+_+Epidemiology+in+t
he+
Classroom+_+Intro+Epi.pdf
R ECOMMENDED R EADINGS
 Coggon, D., Rose, G., & Barker, D. (2003). Epidemiology for the Uninitiated (5th
ed.). London: BMJ Publishing. Available at: Epidemiology for the
Uninitiated Available at http://www.pdftitles.com/book/13761/epidemiology-
for-the-uninitiated
This is a widely cited and used basic introduction to epidemiology.
 Clinical Epidemiology and Evidence Based Medicine Glossary.
Useful as a reference and to clarify specific terms

NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 3: Epidemio logy
HISTORY OF EPIDEMIOLOGY
Epidemiology is defined as the study of the distribution and determinants of disease in
populations
Source: MacMahon, B. & Trichopoulos, D. (1996). Epidemiology: principles and methods. (2nd
ed.).London: Little, Brown, & Co.
Epidemiology is used to:
1. Determine the distribution and frequency of various diseases and health
problems in the population
2. Identify the cause(s) of various diseases and identify risk factors, which
increase the risk of developing those diseases
3. Understand the natural history and prognosis of various diseases
4. Evaluate the effect(s) on health status of preventive measures, medical
therapies and health care delivery systems
5. Provide a scientific basis for sound decision-making in public health and clinical
care
Source: Gordis, L. (2008). Epidemiology, (4th ed.). Philadelphia: W.B. Saunders.
Epidemiological investigations have and continue to help us study a variety of problems
that include questions like:
 What causes coronary heart disease?
 Can diabetes be prevented? If so, how?
 What can individuals do to increase their lifespan?
 Does taking aspirin affect the risk of developing colon cancer?
 Is hypertension more common in Baltimore than the rest of Maryland?
 How many people in Maryland suffer from depression?
 What made Uncle Harry sick after the picnic last Sunday?
The American Public Health Association believes that it is critical to gain an appreciation
for the key figures and events in the development of the field of epidemiology. The
following is a brief synopsis of its history.
H IPPOCRATES – F IRST E PIDEMIOLOGIST
Hippocrates is often referred to as the first epidemiologist. In 400 BC he wrote in On Air,
Water and Places, a careful description of what we now refer to as the key
epidemiological variables – Person, Place and Time.
Hippocrates stated,
Whoever wishes to investigate medicine properly, should proceed thus: in the first place
to consider the seasons of the year, and what effects each of them produces for they
are not at all alike, but differ much from themselves in regard to their changes. Then the
winds, the hot and the cold, especially such as are common to all countries, and then
such as are peculiar to each locality. We must also consider the qualities of the waters,
for as they differ from one another in taste and weight, so also do they differ much in
their qualities. In the same manner, when one comes into a city to which he is a
stranger, he ought to consider its situation, how it lies as to the winds and the rising of
the sun; for its influence is not the same whether it lies to the north or the south, to the
rising or to the setting sun. These things one ought to consider most attentively, and
concerning the waters which the inhabitants use, whether they be marshy and soft, or
hard, and running from elevated and rocky situations, and then if saltish and unfit for
cooking; and the ground, whether it be naked and deficient in water, or wooded and well
watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and
the mode in which the inhabitants live, and what are their pursuits, whether they are
fond of drinking and eating to excess, and given to indolence, or are fond of exercise
and labor, and not given to excess in eating and drinking

K EY F IGURES AND E VENTS

The rise and fall of many civilizations can be understood in terms of their ability to
protect the health of the population. Moving forward 2000 years…
In the mid-1600s, in an era when disease was often attributed to poor moral or spiritual
character, and well before the germ theory was developed,
 Thomas Sydenham distinguished and described numerous infectious disease
symptoms.
 William Petty and John Graunt began to carefully analyze mortality data.
 William Farr developed statistical approaches to data analysis and occupational
mortality. He also developed a revolutionary system for the categorization of
disease. This became the foundation for the WHO ICD codes that we still use
today. The ICD codes are remarkably only in their 10th edition since their origin in
the mid-1600s.
J OHN S NOW 1813-1858
 In the mid-1800s, John Snow, an anesthetist, often
referred to as the father of epidemiology, conducted his landmark studies of cholera in
London.
He reported, The most terrible outbreak of cholera which ever occurred in this kingdom,
is probably that which took place in Broad Street, Golden Square, and the adjoining
streets, a few weeks ago. Within two hundred and fifty yards of the spot where
Cambridge Street joins Broad Street, there were upwards of five hundred fatal attacks
of cholera in ten days. The mortality in this limited area probably equals any that was
ever caused in this country, even by the plague; and it was much more sudden, as the
greater number of cases terminated in a few hours.
Polluted Drinking Water from Thames:
Could it be related to Cholera Epidemics?
His investigation began to center on the possible connection between water from the
Broad Street pump and the cholera epidemic. Snow wondered it was about the
water:
The sewer passes within a few yards of the well. The water at the time of the cholera
contained impurities of an organic nature, in the form of minute whitish flocculi visible on
close inspection to the naked eye. Dr. Hassall, who was good enough to examine these
particles … found a great number of very minute oval animalcules in the water and
deemed the animalcules to be of no importance at the time….
Despite this conclusion and prompted by John Snow’s inquiry, the local officials decided
to disable the Broad Street pump by removing the handle, which turned out to be a key
factor in ending the epidemic.

To learn more about this remarkable scientist, please review the ULCA School of Public
Health website devoted to John Snow.
E DWIN C HADWICK & L EMUEL S HATTUCK
Edwin Chadwick and Lemuel Shattuck are identified as the founders of the modern era
of public health.
Chadwick’s colorful report on the “Sanitary Conditions of the Labouring Classes in
Great Britain” in 1842 paid special attention to the working conditions and mortality of
child laborers as young as five. It was widely distributed and ultimately shifter public
consciousness from thinking that poverty and disease were individual concerns, to
recognizing that they were critical problems that affected the well-being of the nation
and required national legislation.
Shattuck’s “Report of the Sanitary Commission of Massachusetts” written in 1850
was much drier. Although it was well received by the medical community and published
in the New England Journal of Medicine, it wasn’t until 20 years later that it received
broad public acceptance. To this day, many of its 19 recommendations serve as the
foundation of public health practice across the world. They include:
1. Establish state and local boards of health
2. Collect and analyze vital statistics
3. Exchange health information
4. Initiate sanitation programs for towns and buildings
5. Maintain a system of sanitary inspections
6. Study the health of schoolchildren
7. Conduct research on tuberculosis
8. Study and supervise health conditions of immigrants
9. Supervise mental disease
10. Control alcoholism
11. Control food adulteration
12. Control exposure to nostrums
13. Control smoke nuisances
14. Construct model tenements
15. Construct standard public bathing and washhouses
16. Preach health from the pulpit
 17. Teach the science of sanitation in medical schools
18. Introduce prevention in all phases of medical practice
19. Sponsor routine health examinations
F LORENCE N IGHTINGALE

Although not given proper due as an epidemiologist in the

nursing literature, Florence Nightingale was a huge intellect in the field.
Her careful month-by-month analysis of the causes of mortality during the Crimean War,
and her startling diagrams referred to as coxcombs, led to the realization that soldiers
were not dying primarily of war wounds, as expected, but from infection which resulted
from the close living quarters, the unsanitary conditions and the poor food supply.
Florence Nightingale was a leading member and the first woman invited to join the
prestigious London Epidemiological Society begun in 1850.
P ASTEUR , K OCH , L ISTER & G OLDBERG
Soon afterwards, the remarkable discovers of Pasteur, Koch and Lister led to the Germ
Theory of Disease. Specific microbiological pathogens were recognized and ways of
increasing host resistance and decreasing disease transmission were identified.
In 1919, Joseph Goldberg demonstrated that Pellagra was due to a nutritional
deficiency, not an infectious agent.
F RAMINGHAM H EART S TUDY

In 1948, the Framingham Heart Study was initiated by the

NIH to ascertain whether heart disease was an inevitable outcome of aging or if
certain risk factors increased the risk for heart disease and stroke. This cohort
study and its next generation studies remain ongoing, over 60 years later. The
Framingham Study has resulted in over 1000 papers and landmark evidence regarding
the risk for heart disease, stroke and many other chronic diseases.
W YNDER , H ILL , & D OLL - S MOKING AND L UNG C ANCER
By 1950, Ernst Wynder, Bradford Hill and Richard Doll identified the strong link between
cigarette smoking and lung cancer. Not until 14 years later did the U.S. Surgeon
General issue the first report on Smoking and Health.

S ALK P OLIO V ACCINE

Jonas Salk discovered and developed the first polio vaccine. When asked who owned
the patent on his vaccine, he responded, “The people I would say. There is no patent.
Could you patent the sun? Watch this short video on the impact of the vaccine
worldwide.
On the 10th anniversary of President Franklin Roosevelt’s death, Dr. Thomas Francis
announced the results of the Salk Polio Vaccine Field Trials identifying the safety of the
vaccine. For more information on polio, its devastation, treatment strategies, such as
the iron lung noted in the photo, the vaccine and the 50th anniversary announcement,
go to this website.
E RADICATION OF S MALLPOX

In 1980, WHO declared that smallpox was eradicated.

With the issuing of the Surgeon Generals’ first report in 1979 on health promotion and
disease prevention, Healthy People, “ a new period in the modern era of public health
began. A companion document entitled, “Objectives for the Nation” was prepared to
establish goals and objectives for achieving a second public health revolution – the
control of chronic disease. Now in its 4th iteration, Healthy People 2020 forms the

national promotion agenda for the nation.

NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 3: Epidemio logy
DESCRIPTIVE EPIDEMIOLOGY
There are three types of epidemiological studies:
 Descriptive epidemiology
 Analytical epidemiology
 Experimental epidemiology
Descriptive epidemiology focuses on morbidity and mortality data.
M EASURES OF M ORTALITY AND M ORBIDITY
In order to critically review the scientific and clinical literature, it is essential to
understand the definitions and be able to distinguish among the various measures of
morbidity and mortality:
 numbers of deaths
 crude mortality rates
 age-specific mortality rates
 age-adjusted mortality rates
 years of life lost
 incidence rates
 prevalence
 attack rates
 case fatality rates
Measures of morbidity and mortality are generally expressed as a multiple of 10.
M EASURES OF M ORTALITY
The crude mortality rate expresses the actual observed mortality rate in a population
under study.

Crude mortality rates do not take into account the cause of mortality or the age, ethnicity
or sex of the population. Crude mortality rates should always be the starting point for
further development of adjusted rates.
Cause-specific mortality rate identifies the number of deaths from a particular
condition during a calendar year in the population under study.

If we study cause specific mortality from TB, this graph shows the dramatic decline in
rates over the past century.

This graph shows the similar decline in cause-specific mortality from diphtheria
Age-specific mortality rates focus on a particular age range, e.g., 20-29 years.
Age-adjusted mortality rates are calculated by applying age specific rates to the age-
distribution of the population at a particular point in time, usually either 1940, 1970 or
2000. These rates allow comparison of rates among communities, states or countries
with populations of different age distributions, for example Japan and India. They also
allow comparisons of morality rates over time within communities, states or countries as
age distribution changes over time.
Knowing that the average longevity of the population at the beginning of the century
was 47 and the current expected life span is near 75, by age-adjusting, it is possible to
see the impact of health problems over time. This chart shows that there has been a
tremendous decline in infectious diseases during the 20th century. The single exception
was the effect of the influenza pandemic in the early part of the century.
Years of life lost are a measure of the impact to society of deaths from various causes.
Rather than looking at the pure number of deaths, the age at which death occurs is the
focus. The number of premature deaths, usually considered as death before age 75, are
aggregated and then the toll on society from specific disease categories is calculated.
This measure reflects the years lost to society, in terms of work productivity, family life
and contributions to society as a whole.
Years of life lost were initially calculated based on the average of retirement—65, but
now they are more typically calculated based on 75 or 85. The older we get, the more
inclined we are to consider years of life lost as the sum total before 75, 85 or greater.
MEASURES OF MORBIDITY
Incidence measures the number of new cases of a disease over the population at risk
during a time frame, usually a year.

Such a rate is calculated for a specific period of time (usually one year) for a particular
geographic area. The rate is usually presented as the number of cases per 1000, or
100,000, or 1,000,000 population.
For example, there were 500 new cases of cancer per 100,000 population in Maryland
in 2010.
Prevalence measures of all cases that exist within the population at risk. The onset of
the disease is not a factor. It represents the number of people with a particular disease
or condition in a geographic area.
Prevalence represents the number of people with a particular disease or condition in a
specific area per 100 or 1000, or 100,000, or 1,000,000 population.Prevalence is
generally measured either at a point in time (“point prevalence”) or over a period of time
(“period prevalence”).
For example, there were approximately 2400 people per 100,000 population with
coronary heart disease in the United States in 2010. Note that because prevalence
does not measure new cases developing over time, it does not represent a rate, but
rather a proportion.
Relationship between Incidence and Prevalence
There is a relationship between incidence and prevalence.
prevalence = incidence X duration
If you know two of the three parameters, you can calculate the third.
A change in disease prevalence may be due either to an increase in incidence or to an
increase in the average length of time between disease onset and resolution (or death).
For infectious diseases, incidence rates are generally more useful than prevalence. In
contrast, for chronic diseases and conditions, prevalence may be more useful (e.g., for
hypertension).
Attack Rates are often calculated for outbreaks of infectious diseases having a very
rapid onset. They are similar to incidence rates, except it does not include the
dimension of time.

Attack rates are often calculated for outbreaks of foodborne illness, usually at picnics or
special events: the number of people who ate the food and became sick divided by the
number who ate the food.

Case Fatality Rates usually are calculated for outbreaks of infectious diseases. They
reflect the number of people who died from the disease over the number who
contracted the disease. Such rates were calculated for Legionnaires Disease and for
the deaths due to Anthrax following 9/11.

E XERCISE :
1. 1200 students out of 1500 in the School of Nursing currently are
habitually physically inactive.
a. What is that measure called?
b. Calculate the measure.
2. Six out of those 1500 students develop meningitis in the next year.
a. What is that measure called?
b. Calculate the measure.
3. Two of those six students die.
 a. What rate would you calculate?
b. Calculate the measure.
4. You wish to compare rates of death for UMB’s nursing and social work
students.
a. What rates should you first calculate?
5. You wish to compare death rates for male and female faculty members at
UMB.
a. What rates should you calculate?
6. You wish to compare rates of death from cancer for two countries.
a. What rates should you calculate?
Click here for answers to the exercise.
1. 200 students out of 1500 in the School of Nursing currently are habitually physically inactive. a. What
is that measure called? prevalence b. Calculate the measure. 1200/1500 = 800/1000

2. Six out of those 1500 students develop meningitis in the next year. a. What is that measure called?
incidence rate b. Calculate the measure. 6/1500 = 4/1000

3. Two of those six students die. a. What rate would you calculate? case fatality rate b. Calculate the
measure. 2/6 = 33%

4. You wish to compare rates of death for UMB’s nursing and social work students. a. What rates should
you first calculate? crude mortality rates

5. You wish to compare death rates for male and female faculty members at UMB. a. What rates should
you calculate? age-specific mortality rates 6. You wish to compare rates of death from cancer for two
countries. a. What rates should you calculate? age-adjusted mortality rates

ANALYTICAL EPIDEMIOLOGY
There are three types of epidemiological studies:
 Descriptive epidemiology
 Analytical epidemiology
 Experimental epidemiology
Analytical Epidemiology focuses on understanding the determinants and origins of
disease. Three major types of studies are used – cross-sectional, case control and
cohort.
C ROSS - SECTIONAL S TUDIES
Examples of cross-sectional studies or surveys include NHANES and BRFSS.
As noted earlier, NHANES provides a detailed portrait of the U.S. population as a
whole. These data show the prevalence of HBP in men and women in 2015-2016.
Figure 1. Prevalence of hypertension among adults aged 18 and over, by sex and
age; United States, 2015-2016

SOURCE: NCHS, National Health and Nutrition Examination Survey, 2015–

2016. https://www.cdc.gov/nchs/products/databriefs/db289.htm

Based on the continuing nature of the survey, NHANES data also

provides a snapshot of controlled versus uncontrolled high blood pressure during
different periods of time.
Figure 5. Age-adjusted trends in hypertension and controlled hypertension
among adults aged 18 and over: United States, 1999-2016
 SOURCE: NCHS, National Health and Nutrition Examination Survey, 1999–
2016. https://www.cdc.gov/nchs/products/databriefs/db289.htm
NHANES also gives a profile of serum cholesterol levels in the population.

Behavioral Risk Factor Surveillance System data provide an

annual portrait of a number of health behaviors, such as seat belt use…
…and the increasing prevalence of obesity since 1990.
 SOURCE: CDC, Behavioral Risk Factor Surveillance
System https://www.americashealthrankings.org/api/v1/render/charts/trend/report/2016-annual-
report/measure/173/state/ALL/size/1200x600.jpg

C ASE - CONTROL S TUDIES

Case-control studies are studies of populations that are as similar as possible, except
one has the disease and the other does not. Among the most widely noted case-control
studies were those done in the area of lung cancer.

Ernest Wynder’s landmark case-control studies, as far back as 1950, described tobacco
smoking as a possible factor in lung cancer.
1. Wynder, E.L. & Graham, E.A. (1950). Tobacco smoking as a possible etiologic
factor in bronchiogenic carcinoma: A study of 684 proved cases. Journal of
American Medical Association, 143(4), 329-36.
2. Wynder, E.L. (1954). Tobacco as a cause of lung cancer with special reference
to the infrequency of lung cancer among non-smokers. Pennsylvania Medical
Journal, 57, 1073-1083.
C OHORT S TUDIES
Cohort studies follow populations for years to determine the effect of various factors.
These are much more costly than cross-sectional or case-control studies and require
maintaining populations that are willing to continue to participate and be examined.
The Framingham Study has followed generations for more than 60 years. As a result of
these long term assessments landmark evidence has been obtained beginning in the
early 1960s that includes:

1960 Cigarette smoking found to increases risk of heart disease

1961 Cholesterol, blood pressure and EKG abnormalities found to increase risk of heart disease

1967 Physical activity found to reduce the risk of heart disease and obesity to increase the risk of heart
disease

1970 High blood pressure found to increase the risk of a stroke

1976 Menopause found to increase the risk of heart disease

1978 Psychosocial factors found to affect heart disease

1988 High levels of HDL cholesterol found to reduce risk of death

1994 Enlarged left ventricle shown to increase the risk of stroke

1996 Progression from hypertension to heart failure described

2001 High-normal blood pressure is associated with and increased risk of cardiovascular disease,
emphasizing the need to determine whether lowering high-normal blood pressure can reduce the
risk of cardiovascular disease

2002 Lifetime risk of developing high blood pressure in middle-aged adults is 9 in 10

2009 Parental dementia may lead to poor memory in middle-aged adults

2010 Sleep apnea tied to increased risk of stroke

2010 Occurrence of stroke by age 65 in parent increased risk of stroke in offspring by 3-fold

For more information on the Framingham Heart Study follow this link:
https://www.framinghamheartstudy.org/fhs-about/history/
 Another outstanding cohort study is the National Institute of
Aging’s Study of Women Across the Nation (SWAN).
The SWAN study is a multi-site longitudinal study that looks at the effects of aging on
women in different ethnic groups. It includes cohorts of Japanese, Chinese, Hispanic,
African-American and white women.
This critical study is looking at bone loss, hormonal levels, surgery, pain, menopausal
symptoms and many other factors in aging women.
The cohorts and analysis are well mapped out over the period of time of the study.
EXPERIMENTAL EPIDEMIOLOGY
There are three types of epidemiological studies:
 Descriptive epidemiology
 Analytical epidemiology
 Experimental epidemiology
Experimental epidemiology - describes clinical and community trials.
C LINICAL T RIALS
Examples:
 VA Cooperative Studies on Antihypertensive Agents
 Hypertension Detection and Follow-up Program
 Multiple Risk Factor Intervention Trial (MRFIT)
 Drug Trials
 Hormone Replacement Therapy (HRT) trials
Randomized Controlled Clinical Trials (RCTs) are the gold standard in epidemiology.
Evidence gained from these studies is the forefront for new therapies and risk factor
assessments. One example of a (RCT) is the Hormonal Replacement Therapy After
Breast Cancer (HABITS) investigation.
Before the trial was to have reached its end, the profound increase in repeat breast
cancer in the group that was receiving HRT as compared to the group that was not led
the investigators to stop the trial, citing HRT after breast cancer as an unacceptable risk
for women.
C OMMUNITY T RIALS
Community trials focus on whether evidence from clinical trials can be successfully
applied in community settings.
The North Karalia trial on the community control of cardiovascular diseases is an
outstanding example of such a trial.
North Karalia was the province in Finland that had the highest cardiovascular disease
mortality in the world, despite having a socialized medical system. In the early 1970’s,
citizens petitioned the government requesting that an urgent intervention be initiated to
address the problem.
The government agreed, and began an aggressive strategy aimed at reducing high
cholesterol, high blood pressure and smoking. After 20 years of intervention that
included dietary strategies aimed at reducing the fat in the diet, high blood pressure
control and smoking cessation, the prevalence of risk factors in the population dropped
dramatically, over 30% for high cholesterol, 15% for hypertension, and 20% for smoking
in men. However, smoking rates in women increased.
Most importantly, mortality changes dropped dramatically as a result of the reduction in
risk factors

After several years of implementation, the program expanded throughout all of Finland.
Now Finland’s longevity is higher than the U.S. and among the best in the world.
Q UESTION :
Given the information from descriptive, analytical and experimental epidemiological
studies, how do we interpret causal relationships?

CAUSAL RELATIONSHIPS
One of the leading standards is the Branford-Hill criteria to establish a relationship for
causality. Through the review of the literature of different types of studies, assessments
are made regarding:
1. Strength of the association
2. Dose-response relationship – the higher the dose, the more likely the problem
3. Consistency of the association – the relationship holds up regardless of the
type of study
4. Specificity of the association
5. Temporal relationship – the factor is present before the onset of the problem
6. Biological plausibility
7. Coherence of the evidence with other studies
8. Experimental evidence reducing exposure lowers risk*
* Not part of original Bradford-Hill criteria
Two key measures which determine the importance of causal associations:
 1. Relative risk requires assessing the magnitude of risk in exposed vs.
unexposed.
For example: What is the risk of lung cancer in individuals who smoke as
compared to those who do not?
2. Population attributable risk assesses the percent of the diseases due to
exposure to a risk factor.
For example: Approximately 80% of lung cancer is attributable to cigarette
smoking.
Q UALITY OF E VIDENCE
As we know, much of clinical practice is based on tradition, not evidence. All aspects
have not been studied and we know that scientific knowledge is doubling at least every
five years. Evidence-based practice requires that clinicians and other health care
providers know the scientific literature and the quality of evidence.
When assessing for quality of evidence, ask:
 What types of studies have been published?
 What are their strengths and weaknesses?
 Is there strong evidence for causality?
 Is there good evidence of effective interventions?
In order to assess the quality of evidence we look at the types of studies that have been
done:
 Case series, case reports that may or may not represent the disease pattern in
the population
 Case-control studies
 Cohort studies
 Clinical trials – RCTs are highest quality evidence for demonstrating causality
 Community trials – Best evidence that RCT results can benefit general
community.

Quality of evidence is ranked by the U.S. Preventive

Health Services Task Force (USPSTF) according to types of studies that have been
conducted:
I. Evidence from at least one properly randomized controlled trial.
II. Evidence from well-designed controlled trials without randomization.
III. Evidence from well-designed cohort or case-control analytic studies, preferably
from more than one center or research group.
IV. Evidence from multiple time series with or without the intervention. Dramatic
results in uncontrolled experiments (such as the results of the introduction of
penicillin treatment in the 1940s) could also be regarded as this type of evidence.
V. Opinions of respected authorities, based on clinical experience; descriptive
studies and case reports; or reports of expert committees.
Strength of recommendations is classified by the USPTSF on an A-D and I gradient
based on the extent of the scientific evidence:
A. The USPSTF recommends the service. There is high certainty that the net benefit
is substantial.
B. The USPSTF recommends the service. There is high certainty that the net benefit
is moderate or there is moderate certainty that the net benefit is moderate to
substantial.
C. The USPSTF recommends selectively offering or providing this service to
individual patients based on professional judgment and patient preferences. There
is at least moderate certainty that the net benefit is small.
D. The USPSTF recommends against the service. There is moderate or high
certainty that the service has no net benefit or that the harms outweigh the
benefits.
I. The USPSTF concludes that the current evidence is insufficient to assess the
balance of benefits and harms of the service. Evidence is lacking, of poor quality,
or conflicting, and the balance of benefits and harms cannot be determined.
Note: The lack of evidence of effectiveness, or the “I” recommendation, does not
mean an intervention is ineffective. It may mean that:
 current studies are inadequate to determine effectiveness,
 high quality studies have produced conflicting results,
 evidence of significant benefits is offset by evidence of important harm from
intervention, or studies of effectiveness have not been conducted.
E XERCISE :
Read the article, State Infant Mortality Rate Reaches Record Low, that uses
epidemiological evidence. Look at the data and the study design carefully. Does the
data support the reporter’s conclusions?
Click here for an answer to question.

ESTABLISHING PRIORITIES
Despite the power of epidemiological evidence, public health agencies and
organizations do not always use epidemiology, which is considered the core science of
public health, as the basis for decision-making and priority setting.
Priorities are also based on non-scientific grounds that include:
1. Incremental shifts from previous priorities
2. Personal preferences of new agency decision-maker(s)
3. Executive decisions from outside the agency
4. Legislative demands
5. Epidemiologic evidence
Each of these approaches has advantages and disadvantages
1. Incremental shifts from previous priorities
o Advantage: few object to these
o Disadvantage: rarely scientifically grounded
2. Personal preferences of new agency decision-maker(s)
o Advantage: presents opportunities for change
o Disadvantage: often not scientifically grounded
3. Executive decisions from outside the agency
o Advantage: presents opportunities for change
o Disadvantage: usually politically grounded
4. Legislative demands
o Advantage: thinking outside the “box”
o Disadvantage: may not be scientifically grounded
5. Epidemiologic evidence
o Advantage: decisions have a sound scientific foundation
o Disadvantage: may be politically unpopular
E XERCISE
Click on the links below to compare the initial news release by the CDC in the wake of
Hurricane Katrina with a report issued by The Lancet on the same day.
Question: How do the reports compare?
Update on CDC's Response to Hurricane Katrina

The CDC’s public health response to Hurricane Katrina continues to be intense. Early
disease and injury assessments have shown no unexpected health concerns. Vigilant
disease, environmental and injury surveillance continues.
Public health professionals remain concerned about mosquito control and health risks
posed by other pests such as rodents in some areas affected by Hurricane Katrina.
Katrina Reveals Fatal Weaknesses in U.S. Public Health
One of the most shocking aspects of the crisis caused by Hurricane Katrina has been
the poor emergency response. But the failure is no real surprise, says Samuel
Loewenberg in a World Report. This week's lead Editorial states: "for the response to
have been so sparse and so late that thousands of people had to endure 6 parched and
hungry days in the drowning city, the public-health authorities must have got things very
badly wrong…

Answer: Note how the CDC’s initial reporting of the response to Hurricane Katrina did
not raise the level of concern that was articulated by British health professionals in The
Lancet. Start thinking about how:
 health departments establish priorities,
 public health is often referred to as what you don’t see, and competing avenues
for funding influence public capacity to address crises.
USING EPIDEMIOLOGY TO ESTABLISH PRIORITIES
M AGNITUDE OF THE P ROBLEM
When priorities are based on epidemiology, a key element is the magnitude of the
problem as measured by:
1. Mortality/morbidity rates
2. Years of life lost
3. Direct and indirect costs
If the focus is the leading causes of death, heavier emphasis is placed on heart
disease, cancer, chronic lower respiratory diseases, and accidents and less on
infectious disease.

When we study our public health successes in terms of infectious and chronic diseases,
from this chart, we can see how there truly has been a revolution in the conquering of
infectious disease. We can also see that minimal success has been achieved in the
chronic disease arena.

When we consider measuring the magnitude of the problem in terms of years of life
lost, the greatest emphasis would shift to cancer, heart disease and accidents.

When we revisit the contributions of various factors to premature mortality, a modifiable

cause of lifestyle interventions become a leading priority.
P OPULATION - BASED S TRATEGIES
The most successful large scale interventions that have resulted in significant increases
in longevity and quality of life, like the Finland initiative, have moved beyond high risk
strategies to population-based strategies:
 high risk strategies - focus on identifying the relatively small number of
individuals who are at high risk in order to reduce their risk factor(s) and
subsequent development of disease
 population-based strategies - focus on changing behavior in large numbers of
people, most of whom have low or no risk at present, in order to prevent the
development of risk factors and disease
As we look at heart disease mortality in relation to cholesterol levels we see that
significant mortality occurs in the mid-range. Only focusing on those who are highest
risk would miss a considerable part of the population that is at risk as well.
This graph shows the distribution of cholesterol levels in the population and again
demonstrates that if prevention strategies are approached from a whole population
perspective, the impact on morality will be much more significant, than if only those at
highest risk are targeted.
E PIDEMIOLOGICALLY -B ASED C RITERIA
When health departments or agencies establish priorities based on the epidemiological
evidence they utilize the following criteria:
 Magnitude of the problem
 Mortality/morbidity rates
 Number of people effected
 Extent to which modifiable causes of the problem had been identified
 Extent to which interventions could reduce these causes and thereby reduce the
magnitude of the problem
 Cost of the program relative to accomplishments
 Whether the program set rigorous goals and objectives and accomplished them
S UMMARY
Putting in All Together
1. The different types of epidemiologic studies each have strengths and
weaknesses, but randomized clinical trials represent the gold standard.
2. Epidemiology provides the scientific tools for acquiring high-quality data and for
assessing the quality of others’ data.
3. Epidemiologic principles should serve as the foundation for priority setting, both
in public health and clinical practice.
4. Data should be the driving forces for scientific policy and decision-making,
although often they are not.
5. Critically reading and keeping up with the literature is crucial to maintaining
both clinical and policy-making skills.