Epidemiology

Reference: Nies, M. & McEwen, M. (2007). Community / public health nursing: Promoting the health of populations, 4th Ed. Saunders-Elsevier: St. Louis, MO

J. Carley MSN, MA, CNEFall, 2010

Fall, 2010 Community Health

The Broad Street Pump

Lillian Wald1912

CommunicableDisease

John Snow PubBroad Street, London

An Outline of Sorts…….

Introduction to Epidemiology Historical Perspective of Nursing Epidemiology Worldwide Implications Local Implications Group 2-hour Mini-Project: Each group research & prepare 10-15 minute presentation related to

epidemiology (broad subject!) See Next Slide Each group prepare two test (assessment questions related to

epidemiology) Evaluations required

About “Statistics….”& Health, Politics

“Demagogue” / “Demagoguery”

a leader who makes use of popular prejudices and false claims and promises in order to gain power

Keep in mind when this is being done, and how so…

Tendency to accept or reject ….depending upon your political point of view…Used to sway the “undecided.”

“Infant Mortality Rate” “Women are under

represented in medical studies”

Satel, Sally (2000) Politically correct, M.D. : How political correctness is corrupting medicine. Basic Books: New York

From wiki—ways to demigog…

Terminology: Epidemiology Levels of Prevention Primary Prevention Secondary Prevention Tertiary Prevention Epidemic Endemic Pandemic Distribution Determinants Incidence rate Risk Prevalence Prevalence proportion Attack rate Case Fatality Rate Mortality rate Morbidity

Attributable Risk Proportionate Mortality

Rate Adjusted mortality &

morbidity rates Yield Attack Rate Case-Specific Mortality

Rate

1918

1918World War I is rapidly drawing to its bloody conclusion.Millions have died in the carnage, including an entire generation of French,English, and Germans. Peace is at hand, the guns have been silenced, yet many more will die.Many more will die.

Song sung by children in U.S., 1918

I had a little bird,

Its name was Enza.

I opened the window,

And in-flu-enza.

PANDEMIC

June, 1917Trenton, N.J.

***Number of Mortalities to date attributed to Influenza Outbreak:(Each Figure equals one million deaths)

WWICombat Deaths

ENDEMIC…………………………………………….…….EPIDEMIC

Russell, KansasFall, 1917

Trenton, N.J.Fall, 1917

FranceFall, 1917

Nationwide,Spring 1918

Europe,1918

Africa,1918

AsiaSummer 1918

“Phase Shift”

Year 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18 19 20

Mortalities

2018161412108642

?

CONTEXT:AIDS DeathsWorld Wide =~19, 000, 000

“Spanish Flu”DeathsWorld Wide =20, 000, 000 –40, 000, 000

Millions

Typically, The very young and the very old.Spanish flu mortalities selected out the healthiest portion of the population, Those between 20 & 40 years old.

WHO DIES FROM INFLUENZA ?

Additionally, as with most infectious Disease Outbreaks: HEALTH CARE WORKERS,i.e., NURSES, DIED @ DISPROPORTIONATE RATES.

http://www.pandemicflu.gov/storybook/

Pandemic Influenza: The Phie Family

All eight family members were admitted to the emergency hospital in Loveland Colorado, and between October 30 and November 9, 1918: Jessie, age 40 (died Oct. 30); Florence, age 19 (died Nov. 1); Charlie, age 45 (died Nov. 2); Bobbie, age 8 (died Nov. 4); Harry, age 10 (died Nov. 5); Willie, age 4 (died Nov. 5). Tommy, age 16 (died Nov. 7); Davie, age 6 (died Nov. 9).

All eight died from the flu. They were all buried in Eaton, Coloradowhere they had lived previously.

The Phie Family

http://www.fluwikie.com/index.php?n=Main.Multimedia

http://www.cdc.gov/nchs/fastats/lcod.htm

10 Leading Causes of Death, U.S. (2004)*

Heart disease (654,092) Cancer (550,270) Stroke (150,147) Chronic lower respiratory diseases (123,884) Accidents (108,694) Diabetes (72,815) Alzheimer's disease ( 65,829) Influenza/Pneumonia (61,472) Nephritis, nephrotic syndrome, and nephrosis (42,762) Septicemia (33,464)

*Retrieved from: Center for Disease Control & Prevention’s National Center for Health Statistics FastStats at: http://www.cdc.gov/nchs/fastats/lcod.htm

http://www.cdc.gov/mmwr/PDF/wk/mm5553.pdf

Collaborative Learning / Research in Epidemiology & Communicable Disease   For the assigned ‘reportable’ communicable disease describe the disease, e.g., pathophysiology. Describe

and ‘plug-in’ the components of the disease as related to the epidemiological triangle (agent, host, environment, vector).

Is the disease vaccine preventable? Using MMWR provided, discuss the total monthly and yearly total reported cases for 2006. Discuss how the disease is diagnosed. Discuss treatment for the disease. Discuss morbidity & mortality for disease for year 2006. Discuss incidence of the disease by: Geographical region Age group Sex / gender Race Discuss reported cases of the assigned disease process for Clark County, NV this year (to date). Discuss primary, secondary, and tertiary prevention as it relates to assigned disease process. 5 Minute report by each group starting with group 11—10—9—8—7—6—5—4—3—2--1

Epidemiology Introduction Definitions Epidemiology – “The study of the

distribution and determinants of health-related states or events in specific populations, and the application of this study to control of health problems”. (Last, 2001, pp. 62)

http://www.waldenu.edu/c/Schools/Schools_6955.htm

Epidemiology Introduction Definitions Distributions – the patterns of health events in

specific populations http://www.cdc.gov/mmwr/ Determinants – factors or variables that affect

patterns and health events

Example: analysis of how and why a population has different health trends, financial factors, diet, sanitation, recent catastrophes, etc….

Epidemiology Introduction Definitions Incidence rate – the rate of health problems

that are developing in new cases Risk – the probability that the health event

will occur within a specific time, i.e. the risk of breast cancer over a lifetime in the United States

Epidemiology Introduction Definitions Prevalence – the actual measurement of

existing disease at a particular time in a specific group

Prevalence Proportion – the proportion of the group which has the existing disease at a particular time

Epidemiology Introduction Definitions Attack rate – The proportion of people who

are exposed to the disease and get the illness. Mortality Rate – a rate that indicates the

proportion of a population who has died from any cause in a certain period of time, i.e. one year.

Epidemiology Introduction Definitions Morbidity = RATE of which an illness or

health event occurs in a specific population, usually expressed as a proportion; determined by dividing the affected population by the total number of population in that group.

Epidemiology Introduction Definitions Epidemic – an

incidence of disease that is more than usual in a specific population – see example of West Nile Virus on CDC site

Epidemiology Introduction Definitions

Pandemic – a worldwide

incidence of disease that is more than usual

in world populations

Epidemiology Introduction Definitions Pandemic – WHO Organization has six stages of

alert for pandemics and a global preparedness plan. The stages range from Level I, which is the lowest

risk of human cases to - Level VI – Efficient and sustained “human – to –

human transmission.

Epidemiology History of Epidemiology Moses – wrote the laws for Exodus 4th Century B.C.E. = Hippocrates, defined

symptoms of disease, prevalence, and cure rates

( descriptive epidemiology – the who, where, and when) 1400’s – Turkish women inoculated children with a

needle and pieces of dried smallpox scabs to vaccinate them against future plagues.

Epidemiology History of Epidemiology 1853 -William Snow – the father of Epidemiology,

mapped the incidence and locality of cholera in relationship to the location of the water source, first use of a comparison group, above the city, or downstream from the city.

1870’s – Robert Koch – discovered the causative bacteria anthrax, T.B., and cholera

1952s -– Dr. Jonas Salk’s Production of Polio Vaccine

SnowSalk

Pasteur Koch

The Broad Street Pump

Miasma Theory

Intervention Which Stopped the Cholera Outbreak:

Epidemiology

History of Epidemiology World War I – the Public Health Nurse Corp

was formed by the Red Cross in answer to the 1919 worldwide influenza pandemic.

World War II – as nurses were called overseas in the Navy and Army Nurse Corps, Public Health nursing became the back up for the rural Americans with a local public health department for any population >50,000.

Epidemiology History of Epidemiology 1960’ CDC was formed as a government

institution separately from the military biological warfare labs.

1983 – cause of AID’s was discovered

Epidemiology Epidemiological

Concepts in Nursing Epidemiologic Triangle

Changes in any one

triangle component will

either increase or decrease

your risk of disease

Epidemiology Epidemiological Concepts in Nursing Agents – infectious diseases; bacterium, fungi,

viruses or parasites. May also be toxic chemicals or physical agents which create illness or injury.

Host –a host is the person or subject that is susceptible to an agent

Vector – a carrier or source that transmits the agent to or from the host.

Example: the vector for the West Nile virus is the mosquito, the agent is the virus, and the host can be human, horse, or bird. The environment requires standing water

Epidemiology Epidemiology Levels of Prevention Think outside of the Box – International! Example: AID’s in Africa: Primary Prevention: counseling young females and

school children on STD prevention and use of condoms.

Secondary Prevention: Screening pregnant females for HIV.

Tertiary Prevention – Providing AZT and instructions to pregnant mothers with HIV so that they do not transmit the disease

The New Mothers Project

Levels of Prevention Primary Prevention We use primary prevention methods before the

person gets the disease. Primary prevention aims to prevent the disease from

occurring. So primary prevention reduces both the incidence

and prevalence of a disease. Encouraging people to protect themselves from the

sun's ultraviolet rays is an example of primary prevention of skin cancer.

Prevalence: the actual measurement of existing disease at a particular time in a specific group

Incidence:the rate of health problems that are developing in new cases

Epidemiology Epidemiology Levels of Prevention Give an example of Primary Prevention for

this Influenza? Give an example of Secondary Prevention for

this Influenza? What are some of the Tertiary Prevention

interventions that could be used to prevent influenza?

Primary, Secondary, Tertiary

PEWSS (Pediatric Early Warning Sentinel Surveillance )Southern Nevada Health District (2009). Statistics, surveillance, and reports: PEWSS Reports. Retrieved from http://www.southernnevadahealthdistrict.org/stats-reports/influenza.php

The Pediatric Early Warning Sentinel Surveillance (PEWSS) program was initiated in June 2010. This innovative respiratory surveillance program monitors the level of respiratory virus activity within the community year round.

The PEWSS program provides laboratory surveillance data of four influenza viruses (Influenza AH1, Influenza 2009 A (H1N1), Influenza AH3, and Influenza B), and six non-influenza viruses (Adenovirus, Human metapneumovirus, Human parainfluenza virus 1, Human parainfluenza 2, Human parainfluenza virus 3, and Respiratory Syncytial Virus).

EpidemiologyCurrent Epidemics in the United States HIV STD’s / STI’s Smoking Heart Disease Hepatitis B & C Lyme’s Disease West Nile Virus Obesity

EpidemiologyCurrent Epidemics of the World: AIDS – number one – 38,000,000 people were

infected as of 2005 Avian Flu West Nile virus Tobacco use SARS Starvation TB

Epidemiology Current Epidemics in Clark County – from the

CCHD http://www.southernnevadahealthdistrict.org/epidemiology/disease_statistics.htm

Chlamydia/Gonorrhea HIV/AID’s Syphilis Smoking & Lung Disease West Nile Encephalitis Rotavirus

EpidemiologyEnvironmental Health from Healthy People 2010

Clark County Priorities Cultural programs Access to health care Bioterrorism response improvement Reduce second hand smoke exposure Increase food safety education Drowning in toddlers Reduce Suicide rate Decrease in low birth weight rate Use of seatbelts and child car restraints

Challenges for Public Health Nursing: Promote the health of communities Need for a bimodal focus on prevention,

health promotion, and home care Education to meet the needs of the aggregate Concern for cost-benefit ratios Population approach for nursing care

Disease Detective

http://library.thinkquest.org/06aug/01865/index.html

Outbreak at Water’s Edge http://www.mclph.umn.edu/watersedge/play.html

Some Good Sites…………….

WHOSIS(World Health Organization Statistical Information System)

The Office of Minority Health Brazos-Nurse.Org Community Health Page The Public Health Nursing Pages

Research Topic ------ Cite Sources Gp 1: Legionella Gp 2: Botulism (food borne & infant) Gp 3: Coccidiomycosis Gp 4: Gonorrhea Gp 5: Syphilis Gp 6: Chlamydia Gp 7: Typhus Gp 8: Shigellosis Gp 9: Tuberculosis Gp 10: Pertusis Gp 11: Psittacosis

“Cold Cases: Itinerant Nursing in South West Alaska”http://www.medscape.com/viewarticle/488041

American Anthrax Outbreak of 2001Medical Mystery American Anthrax Outbreak of 2001 http://www.ph.ucla.edu/epi/bioter/detect/antdetect_intro.html

SUPERCOURSE: Anthrax

http://www.pitt.edu/~super1/lecture/lec1221/index.htm

Cool Sites: http://wonder.cdc.gov/WelcomeT.html http://www.cdc.gov/nchs/fastats/default.htm http://www.cdc.gov/epiinfo/ http://www.southernnevadahealthdistrict.org/epidemiology/epidemiology.htm

http://www.bt.cdc.gov/surveillance/syndromedef/index.asp

DOWNLOADS (Free) EpiInfo http://www.cdc.gov/epiinfo/

Studying Populations http://www.dundee.ac.uk/~cdvflore/SPUpdates.htm

APPENDIX121 Cities Mortality Reporting System

In the late 1800's and early 1900's pneumonia and influenza deaths were reported to state and federal health officials only in times of an epidemic.

Health officials would then conduct personal interviews to collect information about the age, sex, severity of illness, and other demographic information regarding cases in the household.

The results of these interviews were the only source of mortality information available to researchers for measurement of the impact of an epidemic or prediction of future trends (Collins, et al. 1951).

In response to the influenza pandemic of 1918-1919, the U.S. Bureau of the Census reported one of the first quantitative measurements of the epidemic impact on mortality.

In the March 4, 1919, issue of the "Weekly Health Index," the death rates for 31 large cities for the period of September 18, 1918-March 1, 1919 were compared to the death rates for the same period in 1917-1918, and the difference between them was calculated as the "excess mortality" during the epidemic.

Selwyn Collins further refined this concept of a quantitative measure or index of the impact of influenza epidemics in the 1930's.

He used his refined method to characterize influenza epidemics for data collected monthly from 35 cities (1910-1919) and weekly from 90 cities (1920-1942), 56 cities (1943-1950), and 62 cities (1951-1956).

In 1957, fear of the Asian flu prompted the CDC (formerly Communicable Disease Center) to develop a method of early detection of an epidemic using a modification of Collins' procedures. At this time, the system consisted of 108 cities from which Collins had previously been collecting weekly (unpublished) data (Serfling, et al. 1962).

In 1962, after responsibility for publication of the Morbidity and Mortality Weekly Report (MMWR) was transferred to CDC from the National Office of Vital Statistics, CDC continued to collect weekly mortality data reported voluntarily by a number of selected cities in the United States.

Today, the 121 Cities Mortality Reporting System continues to serve as the most timely source of mortality data in the United States. Despite changes in the methods for reporting and the cities participating, the system has consistently captured one-third of the nation's deaths.

Furthermore, evaluations have shown that the 121 Cities Mortality Reporting System detects trends and patterns in pneumonia and influenza deaths similar to those shown by mortality statistics for the entire nation (Baron, et al. 1988). An updated evaluation of the representativeness of the 121 cities and the mortality patterns observed is currently underway.

The Influenza Branch, National Center for Infectious Diseases, also relies on this system for timely estimates of the impact of epidemic influenza on mortality each influenza season.

“121 cities” surveillance systemEASTERN Boston, MA

Bridgeport, CTCambridge, MAFall River, MAHartford, CTLowell, MALynn, MANew Bedford, MANew Haven, CTProvidence, RISomerville, MASpringfield, MAWaterbury, CTWorcester, MA

PACIFIC Berkeley, CA

Fresno, CAGlendale, CAHonolulu, HILong Beach, CALos Angeles, CAPasadena, CAPortland, ORSacramento, CASan Diego, CASan Francisco, CASan Jose, CASanta Cruz, CASeattle, WASpokane, WATacoma, WA

MOUNTAIN Albuquerque, NM

Boise, IDColorado Springs, CODenver, COLas Vegas, NVOgden, UTPhoenix, AZPueblo, COSalt Lake City, UTTucson, AZ

MID ATLANTICAlbany, NY

Allentown, PABuffalo, NYCamden, NJElizabeth, NJ

Erie, PAJersey City, NJ

New York City, NYNewark, NJPaterson, NJ

Philadelphia, PAPittsburgh, PAReading, PA

Rochester, NYSchenectady, NY

Scranton, PASyracuse, NYTrenton, NJUtica, NY

Yonkers, NY

E.N. CENTRALAkron, OHCanton, OHChicago, ILCincinnati, OHCleveland, OHColumbus, OHDayton, OH Detroit, MIEvansville, INFort Wayne, INGary, INGrand Rapids, MIIndianapolis, INLansing, MIMilwaukee, WIPeoria, ILRockford, ILSouth Bend, INToledo, OHYoungstown, OH

W.N. CENTRALDes Moines, IADuluth, MNKansas City, KSKansas City, MOLincoln, NEMinneapolis, MNOmaha, NESt. Louis, MOSt. Paul, MNWichita, KS

S. ATLANTICAtlanta, GABaltimore, MDCharlotte, NCJacksonville, FLMiami, FLNorfolk, VARichmond, VASavannah, GASt. Petersburg, FLTampa, FLWashington, DCWilmington, DE

E.S. CENTRALBirmingham, ALChattanooga, TNKnoxville, TNLexington, KYMemphis, TN Mobile, ALMontgomery, ALNashville, TN

W.S. CENTRALAustin, TXBaton Rouge, LACorpus Christi, TXDallas, TXEl Paso, TXFt. Worth, TXHouston, TXLittle Rock, ARNew Orleans, LASan Antonio, TXShreveport, LATulsa, OK

Evidence-Based Public Health

http://phpartners.org/tutorial/04-ebph/index.html

finis