Historic Developments in Epidemiology

© Jones & Bartlett© Kevin Eaves/Shutterstock Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CHAPTER 2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HistoricNOT FOR Developments SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

OBJECTIVES © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAfter OR completing DISTRIBUTION this chapter, you will be able to: NOT FOR SALE OR DISTRIBUTION ■■ Describe important historic events in the field of epidemiology. ■■ List and describe the contributions made by several key individuals to epidemiology. ■■ Recognize the development and use of certain study designs in the advancement of epidemiology. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION he history of epidemiology has involved of the natural course of disease to a knowledge of the many key players who sought to understand probable causes, modes of transmission, and health and explain illness, injury, and death from an outcomes; and from no means for preventing and Tobservational scientific perspective. These individuals controlling disease to effective approaches for solving © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC also sought to provide information for the preven- public health problems. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tion and control of health-related states and events. Initially, epidemiologic knowledge advanced They advanced the study of disease from a super- slowly, with large segments in time where little or natural viewpoint to a perspective based on a scien- no advancement in the field occurred. The time tific foundation; from no approach for assessment to from Hippocrates (460–377 BCE), who attempted © Jones & Bartlettsystematic Learning, methods for LLC summarizing and describing© Jones to &explain Bartlett disease Learning, occurrence LLC from a rational view- NOT FOR SALEpublic OR health DISTRIBUTION problems; from no clear understandingNOT FORpoint, SALE to John OR Graunt DISTRIBUTION (1620–1674 CE), who described © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

18 Chapter 2 Historic Developments in Epidemiology

© Jonesdisease & Bartlett occurrence Learning, and death LLC with the use of system- © Jonesshould be& Bartlettexamined Learning,and advised LLCthat the source of atic methods and who developed and calculated life water should be considered.1–4 He asked questions NOT FOR SALE OR DISTRIBUTION NOT FORtables SALE and ORlife expectancy,DISTRIBUTION and Thomas Sydenham such as, “Is the water from a marshy soft-ground (1624–1689), who approached the study of disease source, or is the water from the rocky heights? Is the from an observational angle rather than a theoretical water brackish and harsh?” Hippocrates also made one, was 2,000 years. Approximately 200 years later, some noteworthy observations on the behavior of the William Farr (1807–1883)© Jones advanced & Bartlett John Graunt’s Learning, populace. LLC He believed the effective© Jones physician & Bartlett should Learning, LLC work to better describe NOTepidemiologic FOR SALE problems; OR JohnDISTRIBUTION be observant of people’s behavior,NOT FOR such SALEas eating, OR DISTRIBUTION Snow laid the groundwork for descriptive and analytic drinking, and other activities. Did they eat lunch, eat epidemiology; Robert Koch and Louis Pasteur pro- too much, or drink too little? Were they industrious? vided scientific evidence for germ theory; Ignaz Sem- Hippocrates suggested that traveling physicians melweis© discoveredJones & thatBartlett handwashing Learning, standards LLC in become familiar© Jones with local& Bartlett diseases Learning, and with theLLC obstetrical clinics could reduce the incidence of puer- nature of those prevailing diseases. He believed that as NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION peral fever; and Florence Nightingale showed that time passed, the physician should be able to tell what certain environmental conditions (e.g., fresh air, light, epidemic diseases might attack and in what season, cleanliness) could improve recovery among patients and that this could be determined by the settings of in hospitals. In the early 1900s, Edgar Sydenstricker the stars. Sources of water, smells, and how water sets © Jonesclassified & Bartlett morbidity Learning, statistics LLC to improve the value of © Jonesor flows & were Bartlett always Learning,considered in LLC his study of disease NOT FORthis SALE information OR DISTRIBUTION and conducted community health NOTstates. FOR1–4 SALE OR DISTRIBUTION surveys to provide valuable public health information; Hippocrates identified hot and cold diseases and, Janet Lane-Claypon developed study designs for iden- consequently, hot and cold treatments. Hot diseases tifying risk factors for breast cancer; Alice Hamilton were treated with cold treatments, and cold diseases pioneered the field of ©toxicology; Jones & and Bartlett Wade Learning,Hamp- required LLC hot treatments. The© Jones process & of Bartlett deciding Learning, LLC ton Frost showed that epidemiology is an analytical whether a disease was hot or cold was complex. An NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION science closely integrated with biology and medicine. example is diarrhea, which was considered a hot dis- Since then, the science of epidemiology has rapidly ease and was believed to be cured with a cold treat- progressed. Although it is impossible to identify all ment, such as eating fruit.1–4 the contributors to the field of epidemiology here, sev- Hippocrates also ascribed to and incorporated eral of ©these Jones individuals & Bartlett and their Learning, contributions LLC are into his theory© Joneswhat is &now Bartlett considered Learning, the atomic LLC consideredNOT in FOR this chapter. SALE OR DISTRIBUTION theory—thatNOT is, the FOR belief SALE that everything OR DISTRIBUTION is made of tiny particles. He theorized that there were four types of atoms: earth atoms (solid and cold), air atoms (dry), ▸▸ Hippocrates, the First fire atoms (hot), and water atoms (wet). Additionally, Epidemiologist Hippocrates believed that the body was composed of © Jones & Bartlett Learning, LLC © Jonesfour humors: & Bartlett phlegm Learning, (earth and LLCwater atoms), yel- NOT FORHippocrates SALE OR was DISTRIBUTION a physician who is commonly NOTlow FOR bile (fireSALE and OR air DISTRIBUTIONatoms), blood (fire and water regarded as the father of medicine. He may also be atoms), and black bile (earth and air atoms). Sickness thought of as the first epidemiologist. In his three was thought to be caused by an imbalance of these books, Epidemic I, Epidemic III, and On Airs, Waters, humors, and fever was thought to be caused by too and Places, he attempted© Jonesto describe & Bartlett disease from Learning, a much LLC blood. The treatment for© fever Jones was &to Bartlettreduce the Learning, LLC rational perspective ratherNOT than FOR from SALE a supernatural OR DISTRIBUTION amount of blood in the body throughNOT FOR bloodletting SALE ORor DISTRIBUTION basis. He observed that different diseases occurred the application of bloodsuckers (leeches). Imbalances in different locations. He noted that malaria and yel- were ascribed to a change in the body’s “constitution.” low fever most commonly occurred in swampy areas. Climate, moisture, stars, meteorites, winds, vapors, It was not known, however, that the mosquito was and diet were thought to cause imbalances and con- responsible© Jones for such & Bartlettdiseases until Learning, Walter Reed, LLC MD, tribute to disease.© Jones Diet was & Bartlettboth a cause Learning, of and a cure LLC a U.S. NOTArmy FORphysician SALE working OR DISTRIBUTIONin the tropics, made for disease. CuresNOT for FOR illness SALE and protection OR DISTRIBUTION from dis- the connection in 1900. Hippocrates also introduced ease came from maintaining a balance and avoiding terms like epidemic and endemic.1–4 imbalance in the constitution. Hippocrates gave advice to people wishing to pur- The essentials of epidemiology noted by Hippo- © Jonessue & theBartlett science Learning, of medicine LLCand provided insights on © Jonescrates included & Bartlett observations Learning, on how LLC diseases affected NOT FORthe SALEeffects ORof the DISTRIBUTION seasons of the year and hot and cold NOTpopulations FOR SALE and ORhow DISTRIBUTION disease spread. He further winds on health. He believed the properties of water addressed issues of diseases in relation to time and © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

The Epidemiology of Scurvy 19

© Jones & Bartlettseasons, place,Learning, environmental LLC conditions, and disease© Jones Sydenham & Bartlett published Learning, his observations LLC in a book in control, especially as it related to water and season. 1676 titled Observationes Medicae.4 NOT FOR SALE OR DISTRIBUTION NOT FOR SALEThe ORbroader DISTRIBUTION contribution to epidemiology made by One of Sydenham’s major works was the classifica- Hippocrates was that of epidemiologic observation. tion of fevers plaguing London in the 1660s and 1670s. His teachings about how to observe any and all con- Sydenham came up with three levels or classes of tributing or causal factors of a disease are still sound fevers: continued fevers, intermittent fevers, and small- epidemiologic concepts.© Jones1–4 & Bartlett Learning, LLCpox. Some of Sydenham’s© Jones theories & wereBartlett embraced, Learning, LLC NOT FOR SALE OR DISTRIBUTIONwhereas others were criticized,NOT FOR mostly SALE because OR DISTRIBUTION his ideas and observations went against the usual Hippo- ▸▸ Disease Observations cratic approaches. He treated smallpox with bed rest of Sydenham and normal bed covers. The treatment of the time, © Jones & Bartlett Learning, LLC based on© theJones Hippocratic & Bartlett theory, Learning, was to use LLCheat and Thomas Sydenham (1624–1689), although a graduate extensive bed coverings. He was met with good results NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of Oxford Medical School, did not at first practice med- but erred in identifying the cause of the disease.4 icine but served in the military and as a college admin- Sydenham was persecuted by his colleagues, who istrator. While at All Souls College, Oxford, Sydenham at one time threatened to take away his medical license became acquainted with Robert Boyle, a colleague for irregular practice that did not follow the theories © Jones & Bartlettwho sparked Learning, his interest LLC in diseases and epidemics.© Jones of &the Bartlett time; however, Learning, he gained LLC a good reputation NOT FOR SALESydenham OR DISTRIBUTION went on to get his medical license, andNOT he FORwith SALE the public, OR andDISTRIBUTION some young open-minded physi- spoke out for strong empirical approaches to medi- cians agreed with his empirical principles. Sydenham cine and close observations of disease (FIGURE 2-1). described and distinguished different diseases, includ- Sydenham wrote the details of what he observed about ing some psychological maladies. He also advanced diseases without letting© Jones various & Bartletttraditional Learning, theories of LLCuseful treatments and ©remedies, Jones including& Bartlett exercise, Learning, LLC disease and medical treatment influence his work and fresh air, and a healthy diet, which other physicians NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION observations. From this close observation process, he rejected at the time.4 was able to identify and recognize different diseases.

▸▸ The Epidemiology of Scurvy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION In the NOT1700s, FORit was SALE observed OR that DISTRIBUTION armies lost more men to disease than to the sword. James Lind (1716–1794), a Scottish naval surgeon, focused on illnesses in these populations. He observed the effect of time, place, weather, and diet on the spread of disease. © Jones & Bartlett Learning, LLC © JonesHis & 1754Bartlett book, Learning, A Treatise onLLC Scurvy, identified the NOT FOR SALE OR DISTRIBUTION NOT FORsymptoms SALE of OR scurvy DISTRIBUTION and noted that the disease became common in sailors after as little as a month at sea.3,4 Lind noticed that while on long ocean voyages, sailors would become sick from scurvy, a disease © Jones & Bartlett Learning, LLCmarked by spongy and© Jonesbleeding & gums,Bartlett bleeding Learning, LLC NOT FOR SALE OR DISTRIBUTIONunder the skin, and extremeNOT FORweakness. SALE He ORsaw DISTRIBUTIONthat scurvy began to occur after 4–6 weeks at sea. Lind noted that even though the water was good and the provisions were not tainted, the sailors still fell sick. Lind noted that the most common months for scurvy © Jones & Bartlett Learning, LLC were April,© Jones May, and & BartlettJune. He also Learning, observed thatLLC cold, NOT FOR SALE OR DISTRIBUTION rainy, foggy,NOT FORand thick SALE weather OR DISTRIBUTION was often present. Influenced by the Hippocratic theory of medicine, Lind kept looking to the air as the source of disease. Dampness of the air, damp living arrangements, and © Jones & Bartlett Learning, LLC © Joneslife & at Bartlett sea were Learning,the main focus LLC of his observations as NOT FOR SALEFIGURE OR 2-1 ThomasDISTRIBUTION Sydenham NOT FORhe searchedSALE OR for DISTRIBUTIONan explanation for the cause of dis- 5 Sydenham, detail of an oil painting by Mary Beale, 1688; in the National Portrait Gallery, London. ease and, most of all, the cause of scurvy. Although © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

20 Chapter 2 Historic Developments in Epidemiology

© Joneshe & was Bartlett not correct Learning, about the LLC link with weather and © Jones & Bartlett Learning, LLC climate at sea, Lind looked at all sides of the issue and ▸▸ Epidemiology of Cowpox NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION considered what was happening to the sick. He then and Smallpox compared their experiences with the experiences of those who were healthy. In England, Benjamin Jesty, a farmer/dairyman in When Lind began to look at the mariners’ diet, the mid-1700s, noticed that his milkmaids never got he observed that the sea© diet Jones was extremely & Bartlett gross Learning, and smallpox LLC , a disease characterized© Jones by &chills, Bartlett fever, Learning, LLC hard on digestion. ConcernedNOT FOR with theSALE extent OR of sickDISTRIBUTION- headache, and backache, with NOTeruption FOR of pimples SALE that OR DISTRIBUTION ness in large numbers of sailors, Lind set up some blister and form pockmarks; however, the milkmaids experiments with mariners. In 1747, while serving did develop cowpox from the cows. Jesty believed on the HMS Salisbury, he conducted an experimental there was a link between acquiring cowpox and not study on© scurvyJones wherein & Bartlett he assigned Learning, different LLC supple- getting smallpox.© Jones At the time,& Bartlett smallpox Learning, was common LLC mental dietary interventions to 12 ill patients who had in Europe, with 400,000 people dying annually from NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION all the classic symptoms of scurvy. They all seemed the disease and a third of the cases going blind.6 In to have a similar level of the illness. He described 1774, Jesty exposed his wife and children to cowpox to their symptoms as putrid gums, spots, and lassitude, protect them from smallpox. It worked. The exposed with weakness in their knees. He put the sailors in family members developed immunity to smallpox. © Jonessix & groups Bartlett of two Learning, and, in addition LLC to a common diet © JonesUnfortunately, & Bartlett little Learning,was publicized LLC about Jesty’s NOT FORof foods SALE like OR water-gruel DISTRIBUTION sweetened with sugar, fresh NOTexperiment FOR SALE and observations. OR DISTRIBUTION4 mutton broth, puddings, boiled biscuit with sugar, Jesty’s experiment and similar reported expe- barley and raisins, rice and currants, and sago and riences in Turkey, the Orient, America, and Hun- wine, each of the groups received an additional dietary gary were known to Edward Jenner (1749–1823), an intervention. Two men ©received Jones a quart& Bartlett of cider Learning, a day English LLC rural physician. He personally© Jones observed & Bartlett that Learning, LLC on an empty stomach. Two men took two spoonfuls dairymen’s servants and milkmaids got cowpox and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of vinegar three times a day on an empty stomach. did not get smallpox. For many centuries, the Chinese Two men were given a half-pint of sea water every day. had made observations about weaker and stronger Two men were given lemons and oranges to eat on an strains of smallpox. They learned that it was wise to empty stomach. Two men received an elixir recom- catch a weaker strain of the disease. If one had a weak mended© by Jones a hospital & Bartlett surgeon, and Learning, two men wereLLC fed a strain of the disease,© Jones one &would Bartlett not get Learning, the full disease LLC combinationNOT ofFOR garlic, SALE mustard OR seed, DISTRIBUTION and horseradish. later on. ThisNOT was termed FOR variolationSALE OR. 3,4DISTRIBUTION Lind said that the men given the lemons and oranges In the late 1700s, servants were often the ones ate them with “greediness.” The most sudden and vis- who milked the cows. Servants were also required ible good effects were seen in those who ate lemons to tend to the sores on the heels of horses affected and oranges. In 6 days, the two men eating citrus were with cowpox. The pus and infectious fluids from © Jonesfit & for Bartlett duty. All Learning, the others had LLC putrid gums, spots, las- © Jonesthese sores & Bartlett were referred Learning, to as “theLLC grease” of the NOT FORsitude, SALE and ORweakness DISTRIBUTION of the knees. Free of symptoms, NOTdisease. FOR Left SALE unwashed OR DISTRIBUTION because of a lack of concern the two citrus-eating sailors were asked to nurse the about sanitation and cleanliness, the servants’ grease- others who were still sick. Thus, Lind observed that covered hands would then spread the disease to the oranges and lemons were the most effective remedies cows during milking. The cowpox in turn was trans- for scurvy at sea.5 As a consequence© Jones & of Bartlett Lind’s epidemi Learning,- mitted LLC to the dairymaids. Jenner© Jones observed & thatBartlett when Learning, LLC ologic work, since 1895,NOT the British FOR navySALE has ORrequired DISTRIBUTION a person had cowpox, this sameNOT person FOR would SALE not getOR DISTRIBUTION that limes or lime juice be included in seamen’s diet, smallpox if exposed to it. In May 1796, Jenner identi- resulting in the nickname “limeys” to refer to British fied a young dairymaid, Sarah Nelms, who had fresh seamen. cowpox lesions on her hand. With the matter from Lind’s epidemiologic contributions were many. Nelms’s lesions, Jenner inoculated an 8-year-old boy, He was© concerned Jones & with Bartlett the occurrence Learning, of diseaseLLC in James Phipps.© James Jones developed & Bartlett a mild Learning, fever and a lossLLC large groupsNOT of FOR people. SALE Lind notOR only DISTRIBUTION participated in the of appetite, butNOT was FOR soon feelingSALE muchOR DISTRIBUTION better. In July identification of the effect of diet on disease, but also 1796, Jenner inoculated the boy with a fresh small- made clinical observations, used experimental design, pox lesion. No disease developed. Cowpox was thus asked classic epidemiologic questions, observed pop- found to shield against smallpox. Jenner invented a © Jonesulation & Bartlett changes Learning, and their effect LLC on disease, and con- © Jonesvaccination & Bartlett for smallpox Learning, with this LLC knowledge. The NOT FORsidered SALE sources OR ofDISTRIBUTION disease, including place, time, and NOTvaccine FOR was SALE used OR to protectDISTRIBUTION populations from this season. disease.3,4,6–8 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

Epidemiology of Childbed Fever in a Lying-In Hospital 21

© Jones & Bartlett Learning, LLC © JonesAs & unvaccinated Bartlett Learning, people proliferate, LLC so does the risk of future smallpox epidemics. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

▸▸ Epidemiology of Childbed © Jones & Bartlett Learning, LLC Fever in a Lying-In© Jones Hospital & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Historically, epidemiology was centered on the study of the great epidemics: cholera, bubonic plague, smallpox, and typhus. As the diseases were identified and © Jones & Bartlett Learning, LLC differentiated,© Jones the & focus Bartlett of epidemiology Learning, LLCchanged. Such a change in focus came through the work of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION another physician, epidemiologist Ignaz Semmelweis, in the early to mid-1800s.9 In the 1840s, one of the greatest fears a pregnant mother had was dying of childbed fever, a uterine © Jones & Bartlett Learning, LLC © Jonesinfection, & Bartlett usually Learning, of the placental LLC site, after childbirth. NOT FOR SALE OR DISTRIBUTION NOT FORBabies SALE were ORborn DISTRIBUTION to mothers with the usual risks that warranted obstetric assistance, and this often resulted in an uneventful birth; however, after the birth of the child, the mother would get an infection and die of © Jones & Bartlett Learning, LLCchildbed fever, a streptococcal© Jones disease. & Bartlett Many times,Learning, LLC the child would become infected and die as well. After NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a few years of observing the course of the disease and the symptoms associated with childbed fever, Sem- melweis began a series of investigations.9 The Viennese Maternity Hospital (called a © Jones & Bartlett Learning, LLC lying-in© hospital), Jones &of Bartlettwhich Semmelweis Learning, was LLC clinical NOT FOR SALE OR DISTRIBUTION director,NOT was FORdivided SALE into two OR clinics. DISTRIBUTION The first clinic FIGURE 2-2 Picture of a Boy with Smallpox Taken by Dr. Stan consistently had greater numbers of maternal deaths Foster, EIS Officer, Class of 1962 than the second clinic. In 1846, the maternal mortal- Courtesy of Centers for Disease Control and Prevention, Atlanta, Georgia. ity rate of this clinic was 5 times greater than that of the second clinic, and over a 6-year period, it was 3 © Jones & BartlettThe Learning, Worldwide LLC Global Smallpox Eradication© Jones times & Bartlett greater. Semmelweis Learning, observed LLC that the mothers NOT FOR SALECampaign OR DISTRIBUTION of the late 1960s and early 1970s encourNOT- FORbecame SALE ill eitherOR DISTRIBUTION immediately during birth or within aged vaccination against smallpox and was effective 24–36 hours after delivery. The mothers died quickly at eliminating this disease. As part of the effort to of rapid-developing childbed fever. Often the children eradicate smallpox, a photograph was widely distrib- would soon die as well. This was not the case in the uted in 1975 of a© small Jones child & who Bartlett had been Learning, stricken LLCsecond clinic.9 © Jones & Bartlett Learning, LLC with the disease NOT(FIGURE FOR 2-2). SALEOn October OR DISTRIBUTION 26, 1977, Semmelweis observedNOT it was FOR not SALE the actual OR labor DISTRIBUTION World Health Organization workers supposedly that was the problem, but the examination of the tracked down the world’s last case of naturally patients that seemed to be connected to the onset of occurring smallpox. The patient was 23-year-old Ali the disease. Through clinical observation, retrospec- Maow Maalin, a hospital cook in Merka, Somalia. tive study, collection and analysis of data on mater- Two© Jones cases of& smallpoxBartlett occurredLearning, in 1978LLC as a result nal deaths© Jones and infant & Bartlett deaths, and Learning, clinically controlled LLC ofNOT a laboratory FOR SALE accident. OR BecauseDISTRIBUTION it is believed that experimentation,NOT FOR he SALE was able OR to DISTRIBUTION ascertain that the smallpox has been eradicated from the earth, vac- communication of childbed fever was through germs cinations have been halted; however, some public passed from patient to patient by the physician in health and healthcare professionals are skeptical and the process of doing pelvic examinations. Semmel- © Jones & Bartlettfear that Learning, such acts may LLC set the stage for an unex© Jones- weis & Bartlettdiscovered Learning, that, unlike LLCin the second clinic, the NOT FOR SALEpected OR future DISTRIBUTION epidemic of smallpox because NOTthe FORmedical SALE students OR DISTRIBUTION who worked in the first clinic would pathogen still exists in military and government labs. come directly from the death house after performing © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

22 Chapter 2 Historic Developments in Epidemiology

© Jonesautopsies & Bartlett of infected Learning, and decaying LLC dead bodies and © Jones & Bartlett Learning, LLC then would conduct pelvic exams on the mothers NOT FOR SALE OR DISTRIBUTION NOT FORready SALE to give OR birth. DISTRIBUTION Handwashing or any form of infection control was not a common practice. Student doctors conducted the routine daily pelvic exams with putrefied cadaver material on their hands, and the practice was never questioned.© Jones There & Bartlett was no Learning,reason LLC © Jones & Bartlett Learning, LLC to be concerned about cleanNOT hands FOR because SALE the OR theory DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of medicine accepted at the time relied on the Hip- pocratic theory of medicine and the idea that disease developed spontaneously. Semmelweis observed that a whole© row Jones of patients & Bartlett became illLearning, while patients LLC in the © Jones & Bartlett Learning, LLC adjacent row stayed healthy.9 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Semmelweis discovered that any infected or putrefied tissue, whether from a living patient or a cadaver, could cause disease to spread. To destroy the cadaverous or putrefied matter on the hands, it was © Jonesnecessary & Bartlett that everyLearning, person—physician LLC or midwife— © Jones & Bartlett Learning, LLC NOT FORperforming SALE ORan examination DISTRIBUTION wash his or her hands in NOT FOR SALE OR DISTRIBUTION chlorinated lime on entering the labor ward of the first clinic. At first, Semmelweis said it was only neces- sary to wash during entry to the labor ward; however, a cancerous womb was© discovered Jones & to Bartlett also cause Learning, the LLC © Jones & Bartlett Learning, LLC spread of the disease, so Semmelweis required wash- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ing with chlorinated lime between each examination. FIGURE 2-3 John Snow When strict adherence to handwashing was followed National Library of Medicine. by all medical personnel who examined patients in the maternity hospital, mortality rates fell at unbelievable contributors to the field. Many of the approaches, con- rates. In© 1842, Jones the percentage& Bartlett of Learning,deaths was 12.1% LLC (730 cepts, and methods© Jones used &by BartlettSnow in his Learning, epidemiologic LLC of 6,024),NOT compared FOR SALE with 1.3% OR (91 DISTRIBUTION of 7,095) in 1848.9 work are stillNOT useful FOR and SALEvaluable OR in DISTRIBUTIONepidemiologic At this time in the history of public health, the work today.10–12 causes of disease were unknown, yet suspected. It Throughout his medical career, Snow studied was known that handwashing with chlorinated lime cholera. Cholera is an acute infectious disease char- between each examination reduced the illness and acterized by watery diarrhea, loss of fluid and electro- © Jonesdeaths & Bartlett from childbed Learning, fever, but LLC even with the evidence © Joneslytes, dehydration, & Bartlett and Learning, collapse. From LLC his studies, he NOT FORof this SALE success, OR Semmelweis’s DISTRIBUTION discovery was discounted NOTestablished FOR SALE sound ORand usefulDISTRIBUTION epidemiologic methods. by most of his colleagues.9 Today, it is known that He observed and recorded important factors related handwashing is still one of the best sanitation practices. to the course of disease. In the later part of his career, What Ignaz Semmelweis discovered is still one of the Snow conducted two major investigative studies of easiest disease- and infection-control© Jones & methodsBartlett known. Learning,cholera. LLC The first involved a ©descriptive Jones &epidemiologic Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONinvestigation of a cholera outbreakNOT FORin the SALE Soho dis OR- DISTRIBUTION trict of London in the Broad Street area. The second involved an analytic epidemiologic investigation of a ▸▸ John Snow’s Epidemiologic cholera epidemic in which he compared death rates Investigations of Cholera from the disease to where the sufferers got their water, © Jones & Bartlett Learning, LLC either the Lambeth© Jones Water & Company Bartlett or Learning, the Southwark LLC In the 1850s,NOT FORJohn Snow SALE (1813–1858) OR DISTRIBUTION was a respected and VauxhallNOT Water FOR Company. SALE10–12 OR DISTRIBUTION physician and the anesthesiologist for Queen Victoria In the mid-1840s, in the Soho and Golden Square of England (FIGURE 2-3). He is noted for his medical districts of London, a major outbreak of cholera work with the royal family, including the adminis- occurred. Within 250 yards of the intersection of © Jonestration & Bartlett of chloroform Learning, to the LLC queen at the birth of her © JonesCambridge & Bartlett Street and Learning, Broad Street, LLC about 500 fatal NOT FORchildren; SALE however, OR DISTRIBUTION Snow is most famous for his pio- NOTattacks FOR of SALEcholera OR occurred DISTRIBUTION in 10 days. Many more neering work in epidemiology. Among epidemiolo- deaths were averted because of the flight of most of gists, Snow is considered one of the most important the population. Snow was able to identify incubation © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

John Snow’s Epidemiologic Investigations of Cholera 23

© Jones & Bartletttimes, the Learning, length of time LLC from infection until death,© Jones pick & Bartlettand choose Learning, which water LLC company they wanted modes of transmission of the disease, and the impor- for their household water. Thus, by mere coincidence, NOT FOR SALE OR DISTRIBUTION NOT FOR SALEtance ORof the DISTRIBUTION flight of the population from the danger- Snow encountered a populace using water randomly ous areas. He also plotted statistics based on dates and selected throughout the south district. Snow could not mortality rates. He studied sources of contamination have arranged better sampling techniques than those of the water, causation and infection, and the flow of that had occurred by chance.10–12 the water in the© underground Jones & Bartlett aquifer byLearning, assessing LLC The registrar general© Jones in London & Bartlett published Learning, a LLC water from wells NOTand pumps. FOR HeSALE found OR that DISTRIBUTION nearly all “Weekly Return of BirthsNOT and FORDeaths.” SALE On November OR DISTRIBUTION deaths had taken place within a short distance of the 26, 1853, the Registrar General observed from a table Broad Street pump. of mortality that mortality rates were fairly consistent Snow observed that in the Soho district, there across the districts supplied with the water from the were© Jones two separate & Bartlett populations Learning, not so heavilyLLC affected Hungerford© Jones Market & area.Bartlett The Learning, old supply systemLLC of by the cholera epidemic, such that death rates were Lambeth and the regular supply of the Southwark and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION not equal to those of the surrounding populations. Vauxhall Company were separate systems but drew A brewery with its own wells and a workhouse, also water from the same area in the river. The registrar with its own water source, were the protected popula- general also published a mortality list from cholera. tions. Snow used a spot map (sometimes called a dot Snow developed comparison tables on death by source © Jones & Bartlettmap) to identifyLearning, the locations LLC of all deaths. He plotted© Jones of &water Bartlett by subdistricts. Learning, Snow LLC was able to conclude NOT FOR SALEdata onOR the DISTRIBUTION progress of the course of the epidemic NOTand FORthat SALE the water OR drawn DISTRIBUTION upriver solely by Lambeth Water the occurrence of new cases, as well as when the epi- Company caused no deaths. The water drawn down- demic started, peaked, and subsided. Snow examined stream, in areas that were below the sewage inlets and the water, movement of people, sources of exposure, mostly by Southwark and Vauxhall Water Company, 10–12 transmission of the© Jonesdisease between & Bartlett and amongLearning, close LLCwas associated with very© high Jones death & rates. Bartlett Learning, LLC and distant people, and possible causation. Toward the Gaining cooperation and permission from the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION end of the epidemic, as a control measure, as protec- registrar general, Snow was supplied with addresses tion from any reoccurrence, and as a political state- of persons who had died from cholera. He went into ment to the community, Snow removed the handle the subdistrict of Kennington One and Kennington from the Broad Street pump.10–12 Two and found that 38 of 44 deaths in this subdistrict © JonesIn his early & Bartlett days as a Learning, practicing physician LLC before received© theirJones water & Bartlettfrom Southwark Learning, and LLCVauxhall theNOT Broad FOR Street SALE outbreak, OR DISTRIBUTION Snow recorded detailed Company.NOT Each FOR house SALE had ORrandomly DISTRIBUTION selected differ- scenarios of several cases of cholera, many of which ent water companies, and many households did not he witnessed firsthand. Some of the details he chose to know from which one they received water. By sam- record were epidemiologic in nature, such as various pling water from within the houses of those he con- modes of transmission of cholera, incubation times, tacted, Snow developed a test that used chloride of © Jones & Bartlettcause–effect Learning, association, LLC clinical observations© and Jones silver & Bartlett to identify Learning, the water source LLC for each household. NOT FOR SALEclinical OR manifestations DISTRIBUTION of the disease, scientific obserNOT- FORSnow SALE was eventually OR DISTRIBUTION able to tell the source of water by vations on water and the different sources (including appearance and smell.10–12 observations made with a microscope), temperature, Vital statistics data and death rates compared climate, diet, differences between those who got the according to water supplier presented conclusive evi- disease and those© who Jones did not, & Bartlettand immigration Learning, and LLCdence as to the source of© contamination.Jones & Bartlett A report Learning, to LLC 10–12 emigration differences.NOT FOR SALE OR DISTRIBUTIONParliament showed that NOTin the FOR30,046 SALE households OR DISTRIBUTIONthat In 1853, a larger cholera outbreak occurred in were supplied water by the Southwark and Vauxhall London. London had not had a cholera outbreak for Company, 286 people died of cholera. Of the 26,107 about 5 years. During this period, the Lambeth Water houses supplied by Lambeth, only 14 died of cholera. Company moved its intake source of water upriver The death rate was 71 per 10,000 in Southwark and on© Jonesthe Thames, & Bartlett from Learning,opposite Hungerford LLC Market Vauxhall© Joneshouseholds, & Bartlett and 5 per Learning, 10,000 for LLCLambeth toNOT a source FOR above SALE the OR city, DISTRIBUTION Thames Ditton. By mov- households.NOT TheFOR mortalitySALE OR at the DISTRIBUTION height of the epi- ing the source of water upriver to a place above the demic in households supplied with water by South- sewage outlets, Lambeth was able to draw water free wark and Vauxhall was 8–9 times greater than that in from London’s sewage, contamination, and pollution. those supplied by Lambeth. Snow was finally able to © Jones & BartlettThe Southwark Learning, and LLCVauxhall Water Company, how© Jones- prove & Bartlett his hypothesis Learning, that contaminated LLC water pass- NOT FOR SALEever, didOR not DISTRIBUTION relocate its source of water. ThroughoutNOT FORing SALEdown the OR sewers DISTRIBUTION into the river, then being drawn the south district of the city, both water companies from the river and distributed through miles of pipes had pipes down every street. The citizens were free to into people’s homes, produced cholera throughout © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

24 Chapter 2 Historic Developments in Epidemiology

A Simple Filtration Procedure Produces a 48% Reduction in Cholera Cholera continues to plague© Jones developing & Bartlett countries Learning,and surfaces sporadically LLC throughout the world.© JonesAn estimated & Bartlett Learning, LLC 1.3–4.0 million cases of choleraNOT FOR and as SALE many as OR143,000 DISTRIBUTION deaths from cholera occur each year. ProvisionNOT ofFOR safe waterSALE and OR DISTRIBUTION sanitation is the primary way to reduce the impact of cholera and other waterborne diseases. Oral cholera vaccines may also be taken in conjunction with conventional control measures. Researchers developed a simple filtration procedure involving both nylon filtration and sari cloth (folded four to eight times) filtration for rural villagers in Bangladesh to remove Vibrio cholerae attached to plankton in environmental water.© The Jones research & hypothesis Bartlett was Learning, that removing LLC the copepods (with which Vibrio© Jones cholerae & is Bartlett associated) Learning, from water LLC used forNOT household FOR SALEpurposes, OR including DISTRIBUTION drinking, would significantly reduce theNOT prevalence FOR SALEof cholera. OR The DISTRIBUTION study was conducted over a 3-year period. Both the nylon filtration group and the sari filtration group experienced significantly lower cholera rates than the control group. Both filters were comparable in removing copepods and particulate matter from the water. The study estimated that the sari cloth filtration reduced the occurrence of cholera by about 48%. Given the low cost of sari cloth © Jones filtration,& Bartlett this Learning,prevention method LLC has considerable potential© in Jones lowering & the Bartlett occurrence Learning, of cholera in LLC developing NOT FORcountries. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Modified from World Health Organization. Cholera. https://www.who.int/en/news-room/fact-sheets/detail/cholera. Accessed February 22, 2019; Colwell RR, Huq A, Islam MS, et al. Reduction of cholera in Bangladeshi villages by simple filtration. Proc Natl Acad Sci. 2003;100(3):1051–1055.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the community. SnowNOT showed FOR that SALE cholera OR was DISTRIBUTION a Medicine for his work in microbiology.NOT FOR Pasteur SALE had OR DISTRIBUTION waterborne disease that traveled in both surface and distinguished himself as a scientist and a respected groundwater supplies.10–12 contributor to the field of medicine and public health Snow laid the groundwork for descriptive and (although it was not recognized as a separate field at analytic© epidemiologicJones & Bartlett approaches Learning, found usefulLLC in the time). Pasteur© Jones had already & Bartlett identified Learning, the cause LLC of epidemiologyNOT FOR today. SALE He identified OR DISTRIBUTION various modes of rabies and manyNOT other FOR devastating SALE OR diseases. DISTRIBUTION Because transmission and incubation times and, in his second of his many past successes in microbiology, Pasteur study, employed a comparison group to establish more had confidence in his ability to take on the challenge definitively a cause–effect association. It was not until of conquering anthrax.3,4 Koch’s work in 1883 in Egypt, when he isolated and cul- Pasteur was convinced that it was the bacte- © Jonestivated & Bartlett Vibrio cholerae Learning,, that theLLC accuracy and correct- © Jonesria identified & Bartlett as anthrax Learning, that causedLLC the disease, NOT FORness SALE of Snow’s OR work DISTRIBUTION was proved and accepted.3,4,10–12 NOTbecause FOR anthrax SALE bacteria OR DISTRIBUTION were always present on nec- Because of John Snow’s contributions, many have ropsy (autopsy) of sheep that died from anthrax. It referred to him as the Father of Epidemiology. was unclear, however, why the course of the disease occurred the way it did. The cause–effect association seemed to have some loopholes in it. How did the ▸▸ Epidemiologic© Jones Work & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONsheep get anthrax? How were theNOT sheep FOR disposed? SALE Why OR DISTRIBUTION of Pasteur and Koch did the anthrax occur in some areas and not in others? How was the disease transmitted? How did the disease In the 1870s, on journeys into the countryside in survive? All were questions that Louis Pasteur sought Europe, it was not uncommon to see dead sheep lying to answer. in the ©fields. Jones These & Bartlett sheep had Learning, died from LLC anthrax, a Pasteur observed© Jones that & Bartlettthe dead sheepLearning, were bur LLC- bacterialNOT disease FOR that SALE most OR commonly DISTRIBUTION afflicts ani- ied. The key NOTand insightful FOR SALE discovery OR wasDISTRIBUTION that anthrax mals (e.g., cattle, sheep, horses) but can also occur spores or bacteria were brought back to the surface in humans. Anthrax is a serious bacterial infection, by earthworms. Koch had previously shown that the usually fatal, caused by Bacillus anthracis. Anthrax anthrax bacteria existed in silkworms and that anthrax © Joneswas & aBartlett major epidemic Learning, that LLCplagued the farmers and © Joneswas an intestinal & Bartlett disease. Learning, Pasteur made LLC the earthworm 3,4 NOT FORdestroyed SALE them OR economically.DISTRIBUTION NOTconnection. FOR SALE OR DISTRIBUTION By this time, Louis Pasteur (1822–1895), a French Pasteur and his assistants had worked on a vac- chemist, had been accepted into France’s Academy of cine for anthrax for months, and in 1881, an effective © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

The Invention of the Microscope 25

© Jones & Bartlettvaccine wasLearning, discovered. LLC After a presentation at© the Jones epidemiology & Bartlett wasLearning, a paper onLLC waterborne epidemics Academy of Sciences in Paris, Pasteur was challenged and how they can largely be prevented by proper water NOT FOR SALE OR DISTRIBUTION NOT FOR SALEto prove OR thatDISTRIBUTION his vaccine was effective. He put his filtration.3,4,13 career and reputation at stake to prove that his vac- Koch, who began as a country family physician, cine would work, that disease was caused by micro- pioneered the identification of microorganisms and organisms, and that a cause–effect association exists many different bacteria that caused different dis- between a particular© Jones microbe & and Bartlett a certain Learning, disease. LLCeases, as well as pure culturing© Jones techniques & Bartlett for growLearning,- LLC Pasteur agreedNOT to FORthe challenge SALE ORwith DISTRIBUTION a public ing microorganisms inNOT laboratory FOR conditions.SALE OR Some DISTRIBUTION demonstration to prove that his vaccination process of the major public health contributions that Koch could prevent sheep from getting anthrax. He went to made were identification of the tuberculosis and chol- a farm in rural France where 60 sheep were provided era microorganisms, and establishment of the impor- for© theJones experiment. & Bartlett He was Learning, to vaccinate LLC 25 of the sheep tance of© water Jones purification & Bartlett in Learning,disease prevention. LLC He with his new vaccine. After the proper waiting time, was the recipient of many honors throughout his life- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pasteur was to inoculate 50 of the sheep with a vir- time, including the Nobel Prize in 1905 for his work in ulent injection of anthrax. Ten sheep were to receive microbiology.3,4,13,14 no treatment and were used to compare with the Both Pasteur and Koch were successful in putting survivors of the experiment (a control group). Pas- to rest a major misguided notion of medicine at the © Jones & Bartlettteur was Learning,successful. The LLC inoculated sheep lived.© TheJones time: & Bartlett that disease Learning, was a result LLC of “spontaneous gen- NOT FOR SALEunvaccinated OR DISTRIBUTION sheep died, and the control group NOThad FOReration”—that SALE OR is, DISTRIBUTION organisms would simply appear out no changes. Pasteur successfully demonstrated that of other organisms, and a fly would spontaneously his method was sound, that vaccinations were effective appear out of garbage, and so forth.10 approaches in disease control, and that bacteria were indeed causes of disease.© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Historically, many scientists have contributed ▸▸ The Invention NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to the methods used in epidemiology. Robert Koch of the Microscope (1843–1910) lived in Wollstein, a small town near Breslau, in rural Germany (Prussia). Koch was a pri- The important findings of Koch, Pasteur, Snow, and vate practice physician and district medical officer. many others in this era of sanitation and microbe dis- Because© Jones of &his Bartlett compelling Learning, desire to LLC study disease covery ©would Jones have & been Bartlett impossible Learning, without theLLC use of experimentally,NOT FOR SALE he set ORup a DISTRIBUTIONlaboratory in his home and the microscope.NOT FOR Koch’s SALE camera OR wouldDISTRIBUTION not have been purchased equipment, including photography equip- invented if the microscope had not been developed ment, out of his meager earnings. Koch became a key and its lenses adapted to picture taking. medical research scientist in Germany in the period The microscope first found scientific use in marked by the explosion of knowledge in medicine the 1600s through the work of Cornelius Drebbel © Jones & Bartlettand public Learning, health, and LLC he used photography to take© Jones (1572–1633), & Bartlett the Learning, Janssen brothers LLC of the Netherlands NOT FOR SALEthe first OR picturesDISTRIBUTION of microbes to show the world NOTthat FOR(1590s), SALE and OR Antoni DISTRIBUTION van Leeuwenhoek (1632–1723). microorganisms do in fact exist and that they are what The microscope was used for medical and scientific cause disease.3,4,13 purposes by Athanasius Kircher of Fulda (1602–1680). In the 1870s, Koch showed that anthrax was trans- In 1658 in Rome, he wrote Scrutinium Pestis. He con- missible and reproducible© Jones in& experimentalBartlett Learning, animals LLCducted experiments on the© Jones nature of& putrefaction Bartlett Learning, and LLC (mice). He identifiedNOT theFOR spore SALE stage OR of theDISTRIBUTION growth showed how microscopicNOT living FOR organisms SALE and OR mag DISTRIBUTION- cycle of microorganisms. The epidemiologic signif- gots develop in decaying matter. He also discovered icance that Koch demonstrated was that the anthrax that the blood of plague patients was filled with count- bacillus was the only organism that caused anthrax in less “worms” not visible to the human eye. a susceptible animal. Most of the credit goes to Leeuwenhoek for the © JonesIn 1882, & KochBartlett discovered Learning, the tubercle LLC bacillus advancement,© Jones development, & Bartlett and Learning, perfection ofLLC the use withNOT the FOR use SALEof special OR culturing DISTRIBUTION and staining meth- of the microscope.NOT FOR He SALE was the OR first DISTRIBUTION to effectively apply ods. Koch and his assistant also perfected the con- the microscope in the study of disease and medicine cept of steam sterilization. In Egypt and India, he and even though he was not a physician. Because of a driv- his assistants discovered the cholera bacterium and ing interest in the microscope, Leeuwenhoek was able © Jones & Bartlettproved that Learning, it was transmitted LLC by drinking water, food,© Jones to &devote Bartlett much Learning,time to microscopy, LLC owning more than NOT FOR SALEand clothing. OR DISTRIBUTION Incidental to the cholera investigations,NOT FOR247 SALEmicroscopes OR DISTRIBUTION and more than 400 lenses (many of Koch also found the microorganisms that cause infec- which he ground himself). He was the first to describe tious conjunctivitis. One of his major contributions to the structure of the crystalline lens. © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

26 Chapter 2 Historic Developments in Epidemiology

TABLE 2-1 © Jones &Leeuwenhoek Bartlett Learning, made contributions LLC to epidemiol- © JonesIt is summarized & Bartlett in Learning,. This LLC was the first major ogy. He did a morphologic study of red corpuscles in contribution to record-keeping on a population and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the blood. He saw the connection of arterial circula- was the beginning of the vital statistics aspect of epi- tion to venous circulation in the human body through demiology. When Graunt took over the work, he sys- the microscopic study of capillary networks. With his tematically recorded ages, gender, who died, what microscope, Leeuwenhoek contributed indirectly to killed them, and where and when the deaths occurred. epidemiology through ©microbiology Jones & Bartlett by discovering Learning, Graunt LLC also recorded how many© Jones persons & diedBartlett each Learning, LLC “animalcules” (microscopicNOT organisms,FOR SALE later OR called DISTRIBUTION year and the cause of death.4,13NOT FOR SALE OR DISTRIBUTION microbes, bacteria, and microorganisms). Through the analysis of the bills of mortality In addition to epidemiology and microbiology, already developed for London, Graunt summarized chemistry and histology were developed because mortality data and developed a better understanding of of the ©advent Jones of the& Bartlett microscope, Learning, which influenced LLC diseases, as well© Jonesas sources & andBartlett causes Learning, of death. Using LLC advances in the study and control of diseases.4,15 the data and information he collected, Graunt wrote NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Natural and Political Observations Made Upon the Bills of Mortality. From the bills of mortality, Graunt identi- ▸▸ John Graunt and Vital fied variations in death according to gender, residence, Statistics season, and age. Graunt was the first to develop and © Jones & Bartlett Learning, LLC © Jonescalculate & life Bartlett tables andLearning, life expectancy. LLC He divided NOT FORAnother SALE major OR contributorDISTRIBUTION to epidemiology, but in NOTdeaths FOR into SALE two typesOR DISTRIBUTIONof causes: acute (struck sud- a different manner, was John Graunt (1620–1674). denly) and chronic (occurred over a long period).4,13 In 1603 in London, a systematic recording of deaths When Graunt died, little was done to continue commenced and was called the “bills of mortality.” his good work until 200 years later, when William © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 2-1 Selections from Natural and Political Observations Made Upon the Bills of Mortality by John Graunt

The Diseases and Casualties This Year Being 1632

Abortive© Jones and Stillborn & Bartlett Learning, LLC 445 Chrisomes,© and Jones Infants & Bartlett Learning,2,268 LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Afrighted 1 Cold and Cough 55

Aged 628 Colick, Stone, and Strangury 56

Bit with a mad dog 1 Cut of the Stone 5 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Bloody flux, Scowring, and Flux 348 Dead in the street and starved 6 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Brused, Issues, Sores, and Ulcers 28 Dropsie and Swelling 267

Burnt and Scalded 5 Drowned 34 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Burst,NOT and Rupture FOR SALE OR DISTRIBUTION 9 Executed andNOT Prest FOR to Death SALE OR DISTRIBUTION18 Cancer, and Wolf 10 Falling Sickness 7

Canker 1 Fever 1,108 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORChildbed SALE OR DISTRIBUTION 171NOT FOR Fistula SALE OR DISTRIBUTION 13 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

John Graunt and Vital Statistics 27

Gangrene 5 Pleurisie, and Spleen 36

Gowt © Jones & Bartlett Learning, LLC4 Purples, and Spotted Fever© Jones & Bartlett38 Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Grief 11 Quinsie 7

Jaundies 43 Rising of the Lights 98 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Jawfain 8 Sciatica 1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Impostume 74 Scurvey, and Itch 9

Killed by Several Accident 46 Suddenly 62 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEKing’s OR Evil DISTRIBUTION NOT38 FOR SurfetSALE OR DISTRIBUTION 86

Lethargie 2 Swine Pox 6

Lunatique 5 Teeth 470 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Made away themselvesNOT FOR SALE OR DISTRIBUTION15 Thrush, Sore Mouth NOT FOR SALE OR40 DISTRIBUTION

Measles 80 Tissick 13

Murthered 7 Tympany 34 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTOver-laid/starved FOR SALE at nurse OR DISTRIBUTION 7 VomitingNOT FOR SALE OR DISTRIBUTION1

Palsie 25 Worms 27

Piles 8 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEChristened OR DISTRIBUTION NOT FOR BuriedSALE OR DISTRIBUTION

Males 4,994 Males 4,932

Females © Jones & Bartlett Learning,4,590 LLC Females © Jones & Bartlett4,603 Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In All 9,584 In All 9,535

Increased in the Burials in the 122 Parishes, and at the Pesthouse this year—993 Decreased of the Plagues in the 122 Parishes, and at the Pesthouses this year—266 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTData from FOR Hull CH, ed. SALE In The Economic OR Writings DISTRIBUTION of Sir William Petty. New York, NY: Cambridge University Press; 1899.NOT FOR SALE OR DISTRIBUTION

Farr (1807–1883) was appointed registrar general vital statistics system, much of which is still in use in England. Farr built on Graunt’s ideas. The con- today. Another of Farr’s important contributions was © Jones & Bartlettcept of “political Learning, arithmetic” LLC was replaced by a new© Jones the & promotion Bartlett Learning,of the idea thatLLC some diseases, espe- multifactorial NOT FOR SALEterm, OR “statistics.” DISTRIBUTION Farr extended the use of vital NOTsta- FORcially SALE chronic OR diseases, DISTRIBUTION can have a tistics, and he organized and developed a modern etiology.16 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

28 Chapter 2 Historic Developments in Epidemiology

© Jones▸ ▸& Bartlett Learning, LLC © Jonesidentified & Bartlettthe danger Learning, posed by LLCmercury, which was Occupational Health and used by mirror makers, goldsmiths, and others. He NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Industrial Hygiene observed that very few of these workers reached old age. If they did not die young, their health was so Bernardino Ramazzini (1633–1714) was born in undermined that they prayed for death. He observed Carpi near Modena, Italy. He received his medical that many had palsy of the neck and hands, loss of training at the University© ofJones Parma & and Bartlett did postgrad Learning,- teeth, LLC vertigo, asthma, and paralysis.© Jones Ramazzini & Bartlett also Learning, LLC uate studies in Rome. RamazziniNOT FOR eventually SALE ORreturned DISTRIBUTION studied those who used or processedNOT FOR organic SALE mate OR- DISTRIBUTION to the town of Modena, where he became a professor rials, such as mill workers, bakers, starch makers, of medicine at the local university. He was interested tobacco workers, and those who processed wool, flax, in the practical problems of medicine and not in the hemp, cotton, and silk—all of whom suffered from study of ancient theories of medicine, a fact not well © Jones & Bartlett Learning, LLC inhaling the fine© Jones dust particles & Bartlett in the Learning,processing of LLCthe received by his colleagues. Through Ramazzini’s con- materials.3,4,13,15 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tinuous curiosity and his unwillingness to confine Ramazzini further examined the harmful effects himself to the study of ancient medical theories, he of the physical and mechanical aspects of work, such became recognized for his innovative approaches to as varicose veins from standing, sciatica caused by medical and public health problems. For example, in turning the potter’s wheel, and ophthalmia found in © Jones1692, & Bartlett at the age Learning, of 60, Ramazzini LLC was climbing down © Jonesglassworkers & Bartlett and blacksmiths. Learning, Kidney LLC damage was NOT FORinto SALE 80-foot OR wells DISTRIBUTION to take temperature and barometric NOTseen FOR to be SALEsuffered OR by DISTRIBUTIONcouriers and those who rode for readings so as to discover the origin and rapid flow long periods, and hernias appeared among bearers of of Modena’s spring water. He tried to associate baro- heavy loads.3,4,13,15 metric readings with the cause of disease by taking Ramazzini’s major epidemiologic contributions daily readings during a typhus epidemic (typhus, © Jones & Bartlett Learning,were LLC not only his investigation© Jonesinto and & description Bartlett Learning, LLC an infectious disease caused by one of the bacteria in of work-related maladies, but also his great concern NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the family rickettsiae, is characterized by high fever, a for prevention. Ramazzini suggested that the cesspool 3,4,13,15 transient rash, and severe illness). workers fasten transparent bladders over their eyes Ramazzini came upon a worker in a cesspool. to protect them and take long rest periods or, if their In his conversation with the worker, Ramazzini was eyes were weak, to get into a different line of work. In told that© continuedJones & workBartlett in this Learning, environment LLC would discussing the© various Jones trades, & Bartlett he suggested Learning, changing LLC cause theNOT worker FOR to goSALE blind. OR Ramazzini DISTRIBUTION examined the posture, exercising,NOT FORproviding SALE adequate OR DISTRIBUTION ventilation in worker’s eyes after he came out of the cesspool and workplaces, and avoiding extreme temperatures in the found them bloodshot and dim. After inquiring about workplace. other effects of working in cesspools and privies, he Ramazzini was an observant epidemiologist. He 3,4,13,15 was informed that only the eyes were affected. described the outbreak of lathyrism in Modena in © Jones & EncounteringBartlett Learning, the cesspool LLC worker turned © Jones1690. He & also Bartlett described Learning, the malaria LLC epidemics of the NOT FORRamazzini’s SALE OR mind DISTRIBUTION to a general interest in the relation- NOTregion FOR and SALE the Paduan OR DISTRIBUTIONcattle plague in 1712.3,4,13,15 ship of work to health. He began work on a book that would become influential in the area of occupational medicine and provide related epidemiologic implica- ▸▸ Florence Nightingale tions. He completed The© JonesDiseases &of BartlettWorkers in Learning,1690, LLC © Jones & Bartlett Learning, LLC but it was not published until 1703. It was not accept- Florence Nightingale (1820–1910) was the daughter of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION able to pity the poor or simple laborers during this upper-class British parents (FIGURE 2-4). She pursued a period, so Ramazzini delayed publication because he career in nursing, receiving her initial training in Kai- thought it would not be accepted.3,4,13,15 serworth at a hospital run by an order of Protestant Ramazzini observed that disease among workers deaconesses. Two years later, she gained further expe- had two© causes.Jones The & Bartlett first, he Learning,believed, was LLC the harm- rience as the superintendent© Jones & Bartlett at the Hospital Learning, for Invalid LLC ful characterNOT FORof the SALE materials OR that DISTRIBUTION workers handled, GentlewomenNOT in London, FOR SALEEngland. OR17–21 DISTRIBUTION because the materials often emitted noxious vapors After reading a correspondence series from the and very fine particles that could be inhaled. The London Times in 1854 on the plight of wounded sol- second was ascribed to certain violent and irregular diers fighting in the Crimea, Nightingale asked the © Jonesmotions & Bartlett and unnatural Learning, postures LLC imposed on the body © JonesBritish secretary& Bartlett of warLearning, to let her LLC work in military while working.3,4,13,15 hospitals at Scutari, Turkey. In addition to granting NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ramazzini described the dangers of poisoning her permission, he designated her head of an official from lead that potters used in their glaze. He also delegation of nurses. Nightingale worked for the next © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

Typhoid Mary 29

© Jones & Bartlett Learning, LLC © Jones &Her Bartlett outspoken Learning, Notes onLLC Matters Affecting the Health, Efficiency and Hospital Administration of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION British Army (1858) and Notes on Hospitals (1859) helped to create changes in hygiene and overall treatment of patients. She also founded the groundbreak- ing Nightingale Training School for nurses and in © Jones & Bartlett Learning, LLClater years published dozens© Jones of books & Bartlett and pamphlets Learning, LLC NOT FOR SALE OR DISTRIBUTIONon public health. NightingaleNOT FORwas awarded SALE theOR Royal DISTRIBUTION Red Cross by Queen Victoria in 1883, and in 1907, she became the first woman to receive the Order of Merit.17 © Jones & Bartlett Learning, LLC With© Jonesthe encouragement & Bartlett of Learning, her father, LLCNightin- gale received an education, studying Italian, Latin, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Greek, and history, and received excellent training in mathematics. During her time at Scutari, she collected data and systematized record-keeping practices. She used the data as a tool for improving city and military © Jones & Bartlett Learning, LLC © Joneshospitals. & Bartlett She collected Learning, and generatedLLC data and statis- NOT FOR SALE OR DISTRIBUTION NOT FORtics SALEby developing OR DISTRIBUTION a Model Hospital Statistical Form for hospitals. Nightingale’s monitoring of disease mortality rates showed that with improved sanitary methods in hospitals, death rates decreased. Nightin- © Jones & Bartlett Learning, LLCgale developed applied ©statistical Jones methods& Bartlett to display Learning, LLC her data, showing that statistics provided an organized NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION way of learning and improving medical and surgical practices. In 1858, she became a Fellow of the Royal Statistical Society and in 1874 became an honorary FIGURE 2-4 Florence Nightingale member of the American Statistical Association.17–21 © GeorgiosArt/iStock/Getty Images. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2 years to improve the sanitary conditions of army ▸▸ Typhoid Mary hospitals and to reorganize their administration. The Times immortalized her as the “Lady with the Lamp” In the early 1900s, 350,000 cases of typhoid occurred because she ministered to the soldiers throughout each year in the United States. Typhoid fever is an © Jones & Bartlettthe night. Learning,17–21 LLC © Jonesinfectious & Bartlett disease Learning, characterized LLC by a continued fever, NOT FOR SALEWhen OR DISTRIBUTIONshe returned to England, Nightingale carNOT- FORphysical SALE and OR mental DISTRIBUTION depression, rose-colored spots ried out an exhaustive study of the health of the British on the chest and abdomen, diarrhea, and sometimes Army. She created a plan for reform, which was com- intestinal hemorrhage or perforation of the bowel. piled into a 500-page report entitled Notes on Matters An Irish cook, Mary Mallon, referred to as “Typhoid Affecting the Health,© Jones Efficiency, & Bartlett and Hospital Learning, Adminis- LLCMary,” was believed to be© Jonesresponsible & Bartlett for 51 cases Learning, of LLC tration of the British Army (1858). In 1859, she pub- typhoid fever in a 15-year period.14 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION lished Notes on Hospitals, which was followed in 1860 George Soper, a sanitary engineer studying sev- by Notes on Nursing: What It Is and What It Is Not. eral outbreaks of typhoid fever in New York City in the That same year, she established a nursing school at St. 1900s, found that the food and water supply was no Thomas’s Hospital in London.17–21 longer suspect as the primary means of transmission © JonesNightingale & Bartlett wanted to Learning, make nursing LLC a respectable of typhoid.© Jones Soper continued& Bartlett to searchLearning, for other LLC means professionNOT FOR and SALE believed OR that DISTRIBUTION nurses should be trained of communicationNOT FOR ofSALE the disease. OR DISTRIBUTION He began to look to in science. She also advocated strict discipline and an people instead of fomites, food, and water. attention to cleanliness, and she felt that nurses should He discovered that Mary Mallon had served as a possess an innate empathy for their patients. Although cook in many homes that were stricken with typhoid. © Jones & BartlettNightingale Learning, became anLLC invalid after her stay in© the Jones The & Bartlettdisease always Learning, seemed to LLC follow, but never precede, Crimea, she remained an influential leader in public her employment. Bacteriologic examination of Mary NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION health policies related to hospital administration until Mallon’s feces showed that she was a chronic carrier her death on August 13, 1910.17–21 of typhoid. Mary seemed to sense that she was giving © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

30 Chapter 2 Historic Developments in Epidemiology

© Jonespeople & Bartlett sickness, Learning, because when LLC typhoid appeared, she © JonesIn the 1880s, & Bartlett it was observedLearning, that LLC when young mice would leave with no forwarding address. Mary Mallon were fed purified diets, they died quickly. When fed NOT FOR SALE OR DISTRIBUTION NOT FORillustrated SALE the OR importance DISTRIBUTION of concern over the chronic milk, they flourished. In 1887, a naval surgeon, T. K. typhoid carrier causing and spreading typhoid fever. Takaki, eradicated beriberi from the Japanese navy by Like 20% of all typhoid carriers, Mary suffered no adding vegetables, meat, and fish to their diet, which obvious illness from the disease. Epidemiologic inves- until then had been mostly rice. In 1889, at the Lon- tigations have shown ©that Jones carriers & Bartlettmight be Learning,over- don LLC Zoo, it was demonstrated© that Jones rickets & in Bartlett lion cubs Learning, LLC looked if epidemiologicNOT searches FOR are SALE limited OR to DISTRIBUTION the could be cured by feeding themNOT crushed FOR bone,SALE milk, OR DISTRIBUTION water, food, and those with a history of the disease.14,22 and cod liver oil.13,23,24 From 1907 to 1910, Mary was confined by health The first major epidemiologic implications of defi- officials. The New York Supreme Court upheld the ciency illnesses came in 1886, when the Dutch com- community’s© Jones right & to Bartlett keep her Learning,in custody and LLC isola- missioned the© firm Jones of C. & A.Bartlett Pekelharing Learning, and Winkler, LLC tion. Typhoid Mary was released in 1910, through which sent Christiaan Eijkman (1858–1930), an army NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION legal action she took, but she disappeared almost doctor, to the East Indies to investigate the cause of immediately. Two years later, typhoid fever occurred beriberi. Eijkman observed that chickens fed on pol- in a hospital in New Jersey and a hospital in New York. ished rice developed symptoms of beriberi and recov- More than 200 people were affected. It was discovered ered promptly when the food was changed to whole © Jonesthat & TyphoidBartlett Mary Learning, had worked LLC at both hospitals as a © Jonesrice, but & he Bartlett mistakenly Learning, attributed LLC the cause of the NOT FORcook SALE but under OR aDISTRIBUTION different name. This incident taught NOTdisease FOR to SALE a neurotoxin. OR DISTRIBUTION Gerrit Grijns (1865–1944), public health officials and epidemiologists the impor- a physiologist, correctly identified that beriberi was tance of keeping track of carriers. It also showed that a result of a deficiency of an essential nutrient in the typhoid carriers should never be allowed to handle outer layers of grain that is removed by polishing. food or drink intended© forJones public & consumption. Bartlett Learning, In LLCIn 1906, Frederick Gowland© Hopkins Jones (1861–1947),& Bartlett Learning, LLC later years, Typhoid Mary voluntarily accepted isola- a British biochemist, did similar studies with a concern NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tion. She died at 70 years of age from pneumonia.14,22 for the pathogenesis of rickets and scurvy. Hopkins The investigating, tracking, and controlling of cer- suggested that other nutritional factors exist beyond tain types of diseases that can affect large populations the known ones of protein, carbohydrates, fat, and were epidemiologic insights gained from the Typhoid minerals, and these must be present for good health. Mary experience.© Jones &The Bartlett importance Learning, of protecting LLC pub- In 1911, ©Casimir Jones Funk& Bartlett (1884–1967), Learning, a Polish LLC lic foodNOT supplies FOR and SALE the importance OR DISTRIBUTION of the investiga- chemist, isolatedNOT a chemical FOR SALE substance OR that DISTRIBUTION he believed tive aspects of disease control were again reinforced belonged to a class of chemical compounds called and further justified as public health measures. Today, amines. Funk added the Latin term for life, vita, and antibiotic therapy is the only effective treatment for invented the term “vitamine.” He authored the book typhoid fever. Vitamines. In 1916, Elmer McCollum (1879–1967) © Jones & Bartlett Learning, LLC © Jonesshowed that& Bartlett two factors Learning, were required LLC for the normal NOT FOR SALE OR DISTRIBUTION NOTgrowth FOR of SALErats, a fat-soluble OR DISTRIBUTION “A” factor found in butter ▸▸ Vitamins and Nutritional and fats and a water-soluble “B” factor found in non- Diseases fatty foods such as whole-grain rice. These discover- ies set the stage for labeling vitamins by letters of the Vitamins are organic© componentsJones & Bartlett in food Learning, that alphabet. LLC McCollum in the United© Jones States &and Bartlett E. Mel- Learning, LLC are needed in very smallNOT amounts FOR SALEfor metabolism, OR DISTRIBUTION lanby in Great Britain showedNOT that theFOR “A” SALEfactor was OR DISTRIBUTION growth, and maintaining good health. The discovery effective in curing rickets. It was also demonstrated of vitamins and the role they play in life and health that the “A” factor contained two separate factors. A have an interesting history. In the mid- to late 1800s, heat-stable factor was identified and found to be the bacteria were being identified as the major causes of one responsible for curing rickets. A heat-labile factor disease;© however,Jones &the Bartlett discovery Learning, of microorganisms LLC that was capable© Jones of healing & Bartlett xerophthalmia Learning, (dryness LLC and theirNOT connection FOR SALE to disease OR clouded DISTRIBUTION the discovery of the conjunctivaNOT FORleading SALE to a diseased OR DISTRIBUTION state of the of the causes of other life-threatening diseases. Beri- mucous membrane of the eye resulting from vitamin beri, rickets, and pellagra were still devastating popu- A deficiency) was also discovered. The heat-stable fac- lations around the world. It was believed in 1870 that tor was named vitamin D, and the heat-labile factor © Jonesas & many Bartlett as one-third Learning, of poor LLC children in the inner- © Joneswas termed & Bartlett vitamin A. Learning,13,23 LLC NOT FORcity SALE areas of OR major DISTRIBUTION cities in the world suffered from NOT FORThe SALEdiscovery OR of DISTRIBUTION vitamin D connected obser- serious rickets. Biochemistry was being advanced, vations about rickets and cod liver oil. Cod liver oil and new lines of investigation were opening up. cured rickets because it contains vitamin D. It was © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

Beginning of Epidemiology in the United States 31

© Jones & Bartlettobserved Learning,that children LLC exposed to sunshine were© Jones & Bartlett Learning, LLC less likely to get rickets. In Germany in 1919, Kurt NOT FOR SALE OR DISTRIBUTION NOT FOR SALEHuldschinsky OR DISTRIBUTION (1883–1940) also showed that expos- ing children to artificial sunshine cured rickets. It was found that vitamin D was produced in the body when sunshine acted on its fats. It was later discovered that the antiberiberi substance© Jones vitamin & Bartlett B was alsoLearning, effective LLC © Jones & Bartlett Learning, LLC against pellagra.13,23–25NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In this era, the role of social and economic factors was observed to contribute much to the causation of disease, especially poverty conditions, which clearly 11 contributed© Jones &to nutritionalBartlett Learning, deficiencies. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION FIGURE 2-NOT5 The FORMosquito SALE and Yellow OR DISTRIBUTION Fever. It has been said ▸▸ Beginning of Epidemiology that of all the people who ever died, half of them died from the bite of the mosquito. For thousands of years, it was not known that the mosquito was responsible for diseases such as yellow fever and malaria. These two in the United States diseases are still not fully contained in many parts of the world. In 1900, © Jones & Bartlett Learning, LLC © JonesWalter & BartlettReed, MD, a U.S. Learning, Army physician LLCworking in the tropics, made In 1850, Lemuel Shattuck (1793–1859) published the the epidemiological connection between the mosquito (Aedes aegypti NOT FOR SALEfirst ORreport DISTRIBUTION on sanitation and public health problemsNOT FORspecies) SALE and yellow OR fever. DISTRIBUTION in the Commonwealth of Massachusetts. Shattuck Courtesy of Centers for Disease Control and Prevention, Atlanta, Georgia. was a teacher, sociologist, and statistician, and he served in the state legislature. He was the chair of a The infectious nature of yellow fever was established in 1900 (FIGURE 2-5). In 1902, the United States legislative committee© Jones to study & Bartlettsanitation Learning, and public LLC © Jones & Bartlett Learning, LLC health. The report set forth many public health pro- Public Health Service was founded, and in 1906, the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION grams and needs for the next century. Of the many Pure Food and Drug Act passed. Standard methods of needs and programs suggested, several were epide- water analysis were also adopted in 1906. The pasteur- miologic in nature. To ensure that epidemiology, its ization of milk was shown to be effective in controlling investigations, and the all-important control and pre- the spread of disease in 1913, and in the same year, vention© Jones aspects & Bartlett of its work Learning, are achieved, LLC an organized the first© schoolJones of &public Bartlett health, Learning, the Harvard LLCSchool of andNOT structured FOR SALE effort OR is needed. DISTRIBUTION The organized effort Public Health,NOT FOR was established. SALE OR26,27 DISTRIBUTION has to come through an organization sponsored by Alice Hamilton (1869–1970) received a doctor of the government. medicine degree from the Medical School at the Uni- Shattuck’s report set forth the importance of versity of Michigan. She then completed internships establishing state and local boards of health. It rec- at the Minneapolis Hospital for Women and Children © Jones & Bartlettommended Learning, that an organizedLLC effort to collect© and Jones and & theBartlett New England Learning, Hospital LLC for Women and Chil- NOT FOR SALEanalyze OR vital DISTRIBUTION statistics be established. Shattuck alsoNOT FORdren. SALE She became OR DISTRIBUTION a leading expert in occupational recommended the exchange of health information, health and a pioneer in the field of toxicology. In 1919, sanitary inspections, research on tuberculosis, and she became the first woman appointed to the faculty at the teaching of sanitation and prevention in med- Harvard Medical School, joining a new department in ical schools. The© healthJones of & schoolchildren Bartlett Learning, was also LLCIndustrial Medicine.28 © Jones & Bartlett Learning, LLC of major concern.NOT As a FORresult ofSALE the report, OR DISTRIBUTION boards of Wade Hampton FrostNOT (1880–1938) FOR SALE received OR DISTRIBUTION a health were established, with state departments of medical degree from the University of Virginia. He health and local public health departments soon to later became the first professor of epidemiology at the follow—organizations through which epidemiologic Johns Hopkins School of Hygiene and Public Health. activities took place.26,27 Frost created an epidemiology curriculum for the © JonesQuarantine & Bartlett conventions Learning, were held LLC in the 1850s. new academic© Jones discipline. & Bartlett He also Learning, worked closely LLC with TheNOT first FOR in SALEthe United OR StatesDISTRIBUTION was in Philadelphia in Lowell NOTReed ofFOR the Department SALE OR of DISTRIBUTION Biostatistics, which 1857. The prevention of typhus, cholera, and yellow established the close working relationship between fever was discussed. Port quarantine and the hygiene the two disciplines for addressing public health prob- of immigrants were also of concern. Public health lems. He showed that epidemiology is an analytical © Jones & Bartletteducational Learning, activities beganLLC at this time. In 1879, ©the Jones science & Bartlett closely Learning,integrated with LLC biology and medical NOT FOR SALEfirst ORmajor DISTRIBUTION book on public health, which included NOTepi- FORscience. SALE His OR work DISTRIBUTION focused on the epidemiology of demiologic topics, was published by A. H. Buck. The poliomyelitis, influenza, diphtheria, and tuberculo- book was titled Hygiene and Public Health.26,27 sis. In 1918, Frost, along with Edgar Sydenstricker, © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

32 Chapter 2 Historic Developments in Epidemiology

© Jonesinvestigated & Bartlett the Learning, impact of the LLC influenza pandemic on © Jones &of Bartlett records ofLearning, illnesses in LLCworkers in large 18 different localities in the United States, providing industries in the United States was of NOT FOR SALE OR DISTRIBUTION NOT FORimportant SALE insights OR DISTRIBUTION for public health experts. Because concern because it added to the difficulty of his contributions to our understanding of the nat- of defining and explaining work-related ural history of selected diseases and advances in the illness. Criteria for determining disability methods and scientific discipline of epidemiology, from illness or injury at work and when Wade Hampton Frost is© often Jones considered & Bartlett the father Learning, of LLC sick benefits should© beJones allowed & wereBartlett not Learning, LLC modern epidemiology.29NOT FOR SALE OR DISTRIBUTION well developed. MalingeringNOT FOR was SALE also con- OR DISTRIBUTION sidered, as was its effect on the illness rates of workers. It was suggested that if illness ▸▸ Historical Development of records showing absence from school were Morbidity© Jones & in Bartlett Epidemiology Learning, LLC kept© with Jones a degree & Bartlett of specificity, Learning, they could LLC be of value to the understanding of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION An epidemiology professional of the early 1900s who effect of disease on these populations. helped advance the study of disease statistics (mor- 4. Illness surveys. These have been used by bidity) was Edgar Sydenstricker (1881–1936). Devel- major insurance companies to determine opment of a morbidity statistics system in the United the prevalence of illness in a specific popu- © JonesStates & Bartlett was quite Learning, slow. One problem LLC was that morbidity © Jones &lation. Bartlett House-to-house Learning, canvassLLC approaches NOT FORstatistics SALE cannot OR DISTRIBUTIONbe assessed and analyzed in the same NOT FOR SALEhave been OR used. DISTRIBUTION Incidence of diseases manner as death (mortality) statistics. Sydenstricker within a given period is not revealed by struggled with the mere definition of sickness and such methods, whereas chronic-type dis- recognized that to all persons, disease is an undeni- eases are found to be of higher incidence able and frequent experience.© Jones Birth & and Bartlett death come Learning, to LLC (which should be expected© Jones and & predicted). Bartlett Learning, LLC a person only once, but illness comes often. This was 5. Records of the incidence of illness in a NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION especially true in Sydenstricker’s era, when sanitation, population continuously or frequently public health, microbiology, and disease control and observed. To benefit epidemiologic studies, prevention measures were still being developed.30 two study methods were employed: (1) In the early 1900s, morbidity statistics of any given determination of the annual illness rate in kind were© Jones not regularly & Bartlett collected Learning, on a large scale. LLC Inter- a representative© Jones & population Bartlett Learning,and LLC est in diseaseNOT FORstatistics SALE came ORonly DISTRIBUTIONafter the demand for (2)NOT development FOR SALE of an epidemiologic OR DISTRIBUTION them arose from special populations and when the sta- method whereby human populations could tistics would prove useful socially and economically. be observed to determine the existence of In addition, Sydenstricker noted that there were barri- an incidence of various diseases as they ers to collecting homogeneous morbidity data in large were manifested under normal conditions © Jonesamounts: & Bartlett differences Learning, in data LLC collection methods and © Jones &within Bartlett the community.Learning,30 LLC NOT FORdefinitions, SALE OR time DISTRIBUTION elements, and the existence of pecu- NOT FOR SALE OR DISTRIBUTION 30 A morbidity study by Sydenstricker and his col- liar factors that affect the accuracy of all records. leagues under the direction of the United States Sydenstricker suggested that morbidity statistics Public Health Service in Hagerstown, Maryland, be classified into five general groups in order to be of was conducted in 1921–1924. The study involved value: © Jones & Bartlett Learning,16,517 LLC person-years of observation© Jones or an & equivalentBartlett Learning, LLC 1. Reports of communicableNOT FOR SALEdisease. ORNotifi- DISTRIBUTIONpopulation of 1,079 individualsNOT who FOR were SALE observed OR DISTRIBUTION cation of those diseases for which reason- for 28 months beginning in 1921. Illnesses discovered ably effective administrative controls have in field investigations, when family members reported been devised. being sick or when researchers observed a sick person, 2.© JonesHospital & and Bartlett clinical Learning,records. These LLC records were recorded© during Jones each & Bartlettfamily visit. Learning, A fairly accu LLC- NOTwere FOR viewed SALE as being OR ofDISTRIBUTION little value in iden- rate record ofNOT actual FOR illness SALE was obtained OR DISTRIBUTION by a commu- tifying incidence or prevalence of illness in nity interview method. Two findings were that only populations (at this time, most people were 5% of illnesses were of a short duration of 1 day or less, treated at home unless they were poor and and 40% were not only disabling but caused bed con- in need of assistance). Such records were finement as well. An accurate data-gathering process © Jones & Bartlettdeemed Learning, only of value LLC for clinical studies. © Joneswas developed & Bartlett from theLearning, experience. LLC30 NOT FOR SALE3. Ins ORurance DISTRIBUTION and industrial establishment NOT FORIn the SALE study, 17,847 OR DISTRIBUTION cases of illness were recorded and school illness records. The absence in a 28-month period. An annual rate of 1,081 per © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

The Framingham Heart Study 33

© Jones & Bartlett1,000 person-years Learning, was LLC observed, being about one© ill Jones- breastmilk & Bartlett gained Learning, more weight LLC than those fed cow’s ness per person-year. The illness rate was 100 times milk. She used statistical methods to show that the NOT FOR SALE OR DISTRIBUTION NOT FOR SALEthe annual OR DISTRIBUTION death rate in the same population.30 difference in weight between the two groups was The most interesting results of this first morbid- unlikely to be due to chance. She also assessed whether ity study were the variations of incidence of illness confounding factors could explain the difference. She according to age. The incidence of frequent attacks of was a strong advocate for breastfeeding, midwife train- illness, four or more© Jones a year, was & Bartlett highest (45%) Learning, in chil- LLCing, and prenatal services© toJones reduce & premature Bartlett births,Learning, LLC dren aged 2–9 yearsNOT and FOR lowest SALE in those OR aged DISTRIBUTION 20–24 stillbirths, and maternalNOT mortality. FOR32,33 SALE OR DISTRIBUTION years (11%). By 35 years old, the rate rose again to 21%. In 1923, Lane-Claypon conducted a case-control When severity of illness was looked at, it was found study that involved 500 women with a history of that the greatest resistance to disease was in children breast cancer (cases) and 500 women without a his- between© Jones 5 and & 14Bartlett years of Learning, age. The lowest LLC resistance to tory of ©breast Jones cancer & (controls).Bartlett Learning, She then investigated LLC disease was in early childhood, birth through 4 years, whether the cases differed from the controls with NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and toward the end of life.30,31 respect to occupation and infant mortality (proxies of social status), nationality, marital status, and age. She also investigated reproductive health histories. Until ▸▸ Breast Cancer Epidemiology this study, no large-scale review of this type had been © Jones & Bartlett Learning, LLC © Jonesconducted. & Bartlett32,33 Learning, LLC NOT FOR SALEJanet ORLane-Claypon DISTRIBUTION (1877–1967) was an English phyNOT- FOR SALEIn 1926, OR Lane-Claypon DISTRIBUTION conducted another cohort sician who received a doctorate in physiology and an study, which followed a large group of surgically MD at the London School of Medicine for Women treated women with pathologically confirmed breast FIGURE 2-6 ( ). In her early career, she applied her skills cancer for up to 10 years. The study showed that disease in the research lab, investigating the biochemistry of © Jones & Bartlett Learning, LLCstage at the time of diagnosis© Jones was &directly Bartlett related Learning, to LLC milk and reproductive physiology, but later focused survival. Lane-Claypon recognized the importance of NOT FOR SALE OR DISTRIBUTION32,33 NOT FOR SALE OR DISTRIBUTION her thinking on the epidemiology of breast cancer. accurate staging and the potential bias that inaccurate In 1912, Lane-Claypon published the results staging could have on the results. Further, she showed from a novel cohort study showing that babies fed that breast cancer risk was greater for women who did not have children, who married at a later-than-average © Jones & Bartlett Learning, LLC age, or ©who Jones did not & Bartlettbreastfeed. Learning, She also recognized LLC NOT FOR SALE OR DISTRIBUTION that genesNOT could FOR influence SALE cancerOR DISTRIBUTION risk.32,33

▸▸ The Framingham Heart Study © Jones & Bartlett Learning, LLC © JonesIn & 1948, Bartlett the Framingham, Learning, Massachusetts,LLC cardiovas- NOT FOR SALE OR DISTRIBUTION NOT FORcular SALE disease OR study DISTRIBUTION was launched. The aim of the study was to determine which of the many risk factors contribute most to cardiovascular disease. At the beginning, the study involved 6,000 people between 30 and 62 years of age. These people were recruited to par- © Jones & Bartlett Learning, LLCticipate in a cohort study© thatJones spanned & Bartlett 30 years, Learning, with LLC NOT FOR SALE OR DISTRIBUTION5,100 residents completingNOT the FOR study. SALE In the OR30 years, DISTRIBUTION medical exams and other related testing activities were conducted with the participants. The study was initially sponsored by the National Institutes of Health, © Jones & Bartlett Learning, LLC the Massachusetts© Jones &Department Bartlett Learning,of Public Health, LLC and 34–36 NOT FOR SALE OR DISTRIBUTION the FraminghamNOT FOR Department SALE OR of Health.DISTRIBUTION The site for the study was determined by several factors. It was implied that Framingham was a cross-section of America and was a typical small American city. Framingham had a fairly stable pop- © Jones & Bartlett Learning, LLC © Jonesulation. & Bartlett One majorLearning, hospital LLC was used by most of NOT FOR SALEFIGURE OR 2-6 JanetDISTRIBUTION Lane-Claypon NOT FORthe SALEpeople ORin the DISTRIBUTION community. An annual updated © National Library of Medicine/Photo Researchers, Inc. city population list was kept, and a broad range of © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

34 Chapter 2 Historic Developments in Epidemiology

© Jonesoccupations, & Bartlett jobs, Learning, and industries LLC were represented. © Joneswere 10 × Bartlett more likelyLearning, to die ofLLC lung cancer than The study approach used in the Framingham study nonsmokers. NOT FOR SALE OR DISTRIBUTION NOT FORwas SALEa prospective OR DISTRIBUTION cohort study.34–36 The case-control and cohort study designs used by The diseases of most concern in the study were these researchers remain commonly used in epidemi- coronary heart disease, rheumatic heart disease, con- ologic research today. gestive heart failure, angina pectoris, stroke, gout, gallbladder disease, and© eye Jones conditions. & Bartlett Several Learning, clin- LLC © Jones & Bartlett Learning, LLC ical categories of heart NOTdisease FOR were SALE distinguished OR DISTRIBUTION in ▸▸ Modern EpidemiologyNOT FOR SALE OR DISTRIBUTION this study: myocardial infarction, angina pectoris, coronary insufficiency, and death from coronary heart The expanding role of epidemiology has been accom- disease, as shown by a specific clinical diagnosis.34–36 panied by an increasing number of methods for con- ducting epidemiologic research. In the 1960s and Many© Jones study design & Bartlett methods Learning, and approaches LLC were © Jones & Bartlett Learning, LLC advanced in the investigation, such as cohort tracking, 1970s, epidemiologists tended to be physicians with NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION population selection, sampling, issues related to age of a primary interest in disease etiology. Some of these the population, mustering population support, com- physicians were effective in collaborating with statis- munity organization, a specific chronic disease focus, ticians. Olli S. Miettinen (1936–) is a statistician who and analysis of the study findings. The study advanced developed and published several landmark papers on © Jonesunderstanding & Bartlett Learning,of the epidemiology LLC of hypertensive or © Jonescausal, design, & Bartlett and statistical Learning, approaches LLC in epidemi- NOT FORarteriosclerotic SALE OR cardiovascularDISTRIBUTION disease. It also identi- NOTology. FOR47–50 SALESeveral ORother DISTRIBUTION statisticians contributed to fied much of what we know today about the effects of modern epidemiologic thinking: Sir Austin Bradford diet, exercise, and common medications such as aspi- Hill (1897–1991), who pioneered the randomized rin on heart disease. clinical trial and presented criteria for determining causal associations;51,52 Jerome Cornfield (1912–1979), © Jones & Bartlett Learning,who LLC contributed to the development© Jones of clinical & Bartlett trials, Learning, LLC ▸▸ Cigarette SmokingNOT FOR and SALE Cancer OR DISTRIBUTIONBayesian inference, and the relationshipNOT FOR between SALE sta OR- DISTRIBUTION tistical theory and practice;53 Joseph L. Fleiss (1937– After World War II, vital statistics indicated a sharp 2003), who contributed to mental health statistics increase in deaths attributed to lung cancer. The first and developed a statistical measure of interrater reli- epidemiologic© Jones reports & Bartlett indicating Learning, a link between LLC ciga- ability called© kappa; Jones54,55 &Sander Bartlett Greenland Learning, (1951–), LLC rette smokingNOT FOR and lungSALE cancer OR appearedDISTRIBUTION in the early who contributedNOT primarily FOR SALE to meta-analysis, OR DISTRIBUTION Bayes- 1950s.37–41 By the time of the 1964 report by the Sur- ian inference, and causal inference; Norman Breslow geon General of the United States, there had been 29 (1941–), who developed and promoted greater use case-control studies and 7 prospective cohort studies of the case-control matched sample research design; published, all showing a significantly increased risk of Nathan Mantel (1919–2002), who, with William © Joneslung & Bartlettcancer among Learning, tobacco smokers.LLC 42 © JonesHaenszel, & developed Bartlett theLearning, Mantel-Haenszel LLC test and the NOT FOR SALEThe first OR case-controlDISTRIBUTION studies that assessed the NOTMantel-Haenszel FOR SALE oddsOR ratio;DISTRIBUTION56 and William G. Cochran association between smoking and lung cancer were (1909–1980), who developed and advanced research conducted in the late 1940s by Wynder and Graham in experimental designs and sampling techniques.57–60 in the United States (1950) and Doll and Hill in Great Britain (1950).43,44 These studies first identified © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC cases with lung cancer and controls and then inves- ▸▸ Conclusion tigated whether peopleNOT with FOR lung SALEcancer ORdiffered DISTRIBUTION NOT FOR SALE OR DISTRIBUTION from others without the disease with respect to their This chapter describes the contributions of many smoking history. Both studies showed that lung key players to the field of epidemiology who sought cancer patients were more likely to have a history to explain illness, injury, and death from an obser- of smoking.© Jones & Bartlett Learning, LLC vational, scientific© Jones perspective. & Bartlett Individuals Learning, were LLCpre- TheNOT first FOR cohort SALE study OR assessing DISTRIBUTION the association sented who helpedNOT FORshape SALEthe discipline OR DISTRIBUTION as we know between smoking and lung cancer was conducted in it today. These people were physicians, statisticians, 1951 by Doll and Hill.45,46 Physicians in Great Britain engineers, sociologists, chemists, and more. Pioneers were sent a questionnaire to determine their smoking in the area of epidemiology introduced germ theory, habits. They were then followed over a 25-year period the microscope, vaccinations, study designs, evalua- © Joneswith & Bartlettdeath certificate Learning, information LLC collected to deter- © Jonestion methods, & Bartlett sources Learning, and modes ofLLC disease transmis- NOT FORmine SALE whether OR deaths DISTRIBUTION were attributed to lung cancer NOTsion, FOR and theSALE importance OR DISTRIBUTION of monitoring and evaluating or some other cause. The study found that smokers health-related states or events. © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

Exercises 35

Key Terms Define the following© Jones terms. & BartlettCholera Learning, LLC Typhoid© Jones fever & Bartlett Learning, LLC Anthrax NOT FOR SALE ORMultifactorial DISTRIBUTION etiology TyphusNOT FOR SALE OR DISTRIBUTION Atomic theory Scurvy Variolation Childbed fever Smallpox Vitamins

Study© Jones Questions & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT1. Match FOR the SALE individuals OR DISTRIBUTION in the left-hand column 4. WhaNOTt type FOR of epidemiologicSALE OR DISTRIBUTION study was used by of TABLE 2-2 with their contributions. James Lind? 2. List some of the contributions of the micro- 5. What types of epidemiologic studies were used scope to epidemiology. by Doll and Hill? © Jones & Bartlett3. Wha Learning,t two individuals LLC contributed to the birth© Jones6. & BartlettWhat types Learning, of epidemiologic LLC studies were used of vital statistics? by Janet Lane-Claypon? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

TABLE 2-2 History of Epidemiology: Names and Contributions © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Hippocrates NOT FOR A.SALE Identified OR variousDISTRIBUTION modes of transmission and incubationNOT times FOR for cholera SALE OR DISTRIBUTION

Thomas Sydenham B. Provided classifications of morbidity statistics to improve the value of morbidity information

©James Jones Lind & Bartlett Learning,C. Observed LLC in the 17th century that certain© Jones jobs carried & Bartlett a high risk Learning,for disease LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Benjamin Jesty D. Introduced the words “epidemic” and “endemic”

Edward Jenner E. Advanced useful treatments and remedies including exercise, fresh air, and a healthy diet, which other physicians rejected at the time © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEIgnaz OR Semmelweis DISTRIBUTIONF. Through an experimentalNOT study, FOR showed SALE that OR lemons DISTRIBUTION and oranges were protective against scurvy

John Snow G. Invented a vaccination for smallpox

Louis Pasteur © Jones &H. Bartlett The father Learning,of modern epidemiology LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Robert Koch I. Used data as a tool for improving city and military hospitals

John Graunt J. Conducted the first cohort study investigating the association between smoking and © Jones & Bartlett Learning,lung cancer LLC © Jones & Bartlett Learning, LLC NOTWilliam FOR Farr SALE OR DISTRIBUTIONK. Promoted the idea that some diseases,NOT especially FOR chronic SALE diseases, OR DISTRIBUTION can have a multifactorial etiology

Bernardino Ramazzini L. Observed that milkmaids did not get smallpox, but did get cowpox © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEEdgar OR Sydenstricker DISTRIBUTION M. Developed a vaccineNOT for anthrax FOR SALE OR DISTRIBUTION (continues) © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

36 Chapter 2 Historic Developments in Epidemiology

© Jones &TABLE Bartlett 2-2 History Learning, of Epidemiology: LLC Names and Contributions© Jones & Bartlett Learning, LLC (continued ) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Doll and Hill N. Pioneered the use of cohort and case-control studies to identify risk factors for breast cancer

Florence Nightingale © JonesO. A pioneer& Bartlett in the fieldLearning, of toxicology LLC © Jones & Bartlett Learning, LLC Janet Lane-Claypon NOT FORP. Credited SALE with ORproducing DISTRIBUTION the first life table NOT FOR SALE OR DISTRIBUTION

Alice Hamilton Q. Used photography to take the first pictures of microbes to show the world that microorganisms existed and that they caused many diseases © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC WadeNOT Hampton FOR Frost SALE OR R. A DISTRIBUTION statistician who was a pioneer in developingNOT the theor FORy of SALE epidemiologic OR DISTRIBUTION study design and causal inference

Olli S. Miettinen S. Discovered that the incidence of puerperal fever could be drastically cut by using handwashing standards in obstetrical clinics © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

References 1. Hippocrates. Airs, waters,© Jones places. In:& BartlettBuck C, Llopis Learning, A, 14. LLC Nester EW, McCarthy BJ, ©Roberts Jones CE, &Pearsall Bartlett NN. Learning, LLC Najera E, Terris M, eds. The Challenge of Epidemiology: Microbiology: Molecules, Microbes and Man. New York, NY: Issues and Selected ReadingsNOT. Washington, FOR SALE DC: World OR Health DISTRIBUTION Holt, Rinehart and Winston; 1973.NOT FOR SALE OR DISTRIBUTION Organization; 1988:18–19. 15. Seelig MG. Medicine: An Historical Outline. Baltimore, MD: 2. Dorland WA, ed. Dorland’s Illustrated Medical Dictionary. Williams and Wilkins; 1925. 25th ed. Philadelphia, PA: Saunders; 1974. 16. Fox JP, Hall CE, Elveback LR. Epidemiology: Man and 3. Cumston CG. An Introduction to the History of Medicine. Disease. New York, NY: Macmillan Company; 1970. New© York, Jones NY: Alfred & Bartlett A. Knopf; 1926.Learning, LLC 17. Cohen IB.© FlorenceJones &Nightingale. Bartlett Scientific Learning, American LLC. 4. GarrNOTison FORFH. History SALE of ORMedicine DISTRIBUTION. Philadelphia, PA: 1984;250:128–137.NOT FOR SALE OR DISTRIBUTION Saunders; 1926. 18. Cohen IB. The Triumph of Numbers: How Counting Shaped 5. Lilienfeld AM, Lilienfeld DE. Foundations of Epidemiology. Modern Life. New York, NY: W. W. Norton & Company; 2nd ed. New York, NY: Oxford University Press; 1980:30–31. 2006. 6. Barquet N, Domingo P. Smallpox: the triumph over the 19. Kopf EW. Florence Nightingale as a statistician. J Am Stat most terrible of the ministers of death. Ann Intern Med. Assoc. 1916;15:388–404. © Jones & 1997;127(8,Bartlett pt.Learning, 1):635–642. LLC © Jones20. Nut tal& P.Bartlett The passionate Learning, statistician. LLC Nurs Times. 1983; NOT FOR7. SALEWillis NJ. OR Edward DISTRIBUTION Jenner and the eradication of smallpox. NOT FOR28:25–27. SALE OR DISTRIBUTION Scott Med J. 1997;42:118–121. 21. Grier MR. Florence Nightingale and statistics. Res Nurs 8. Jenner E. An inquiry into the causes and effects of the variolae Health. 1978;1:91–109. vaccine. In: Buck C, Llopis A, Najera E, Terris M, eds. The 22. Health News. Medical Milestone: Mary Mallon, Typhoid Challenge of Epidemiology: Issues and Selected Readings. Mary, November 1968. New York, NY: New York Department Washington, DC: World© Health Jones Organization; & Bartlett 1988:31–32. Learning, LLCof Health; 1968. © Jones & Bartlett Learning, LLC 9. Semmelweis I. The etiology, concept, and prophylaxis of 23. Krause MV, Hunscher MA. Food, Nutrition and Diet Therapy. childbed fever. In: BuckNOT C, Llopis FOR A, Najera SALE E, Terris OR M, DISTRIBUTION eds. 5th ed. Philadelphia, PA: Saunders;NOT 1972. FOR SALE OR DISTRIBUTION The Challenge of Epidemiology: Issues and Selected Readings. 24. Guthrie HA. Introductory Nutrition. St. Louis, MO: Mosby; Washington, DC: World Health Organization; 1988:46–59. 1975. 10. Benenson AS, ed. Control of Communicable Diseases in 25. Clayton T, ed. Taber’s Medical Dictionary. 14th ed. Man. 15th ed. Washington, DC: American Public Health Philadelphia, PA: Davis; 1981:762. Association;© Jones 1990:367–373. & Bartlett Learning, LLC 26. Green L, Anderson© Jones C. Community & Bartlett Health. Learning, 5th ed. St. Louis, LLC 11. SnoNOTw J. On FOR the Mode SALE of Communication OR DISTRIBUTION of Cholera. 2nd ed. MO: TimesNOT Mirror/Mosby; FOR SALE 1986. OR DISTRIBUTION London, UK: John Churchill; 1955. 27. Picket G, Hanlon J. Public Health: Administration and 12. Vinten-Johansen P, Panera N, Rip M, Zuck D, Brody H. Practice. 9th ed. St. Louis, MO: Times Mirror/Mosby; 1990. Cholera, Chloroform, and the Science of Medicine: A Life of 28. Centers for Disease Control and Prevention, National John Snow. New York, NY: Oxford University Press; 2003. Institute for Occupational Safety and Health (NIOSH). © Jones13. & RosenBartlett G. A HistoryLearning, of Public LLC Health. Baltimore, MD: Johns © JonesHistory & Bartlettof Alice Hamilton, Learning, M.D. http://www.cdc.gov/niosh LLC Hopkins University Press; 1958. /awards/hamilton/HamHist.html. Accessed January 3, 2012. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

Exercises 37

29. Daniel TM. Wade Hampton Frost, Pioneer Epidemiologist 45. Doll R, Hill AB. Mortality in relation to smoking: ten years’ © Jones & Bartlett1880–1938: Learning, Up to the MountainLLC . Rochester, NY: University© ofJones & observationsBartlett Learning,of British doctors. LLC BMJ. 1964;1:1399–1410. NOT FOR SALERochester OR DISTRIBUTION Press; 2004. NOT FOR46. SALEDoll R, Peto OR R. MortalityDISTRIBUTION in relation to smoking: twenty years’ 30. Sydenstricker E. A study of illness in a general population. observations on male British doctors. BMJ. 1976;2:1525. Public Health Rep. 1926;61:12. 47. Miettinen OS. Individual matching with multiple controls 31. Sydenstricker E. Sex difference in the incidence of certain in the case of all-or-none responses. Biometrics. 1969;22: diseases at different ages. Public Health Rep. 1928;63:1269–1270. 339–355. 32. Winkelstein W ©Jr. VignettesJones of& the Bartlett history of Learning,epidemiology: LLC48. Miettinen OS. Principles© of Jones Epidemiologic & Bartlett Research. UnpubLearning, LLC three firsts by JanetNOT Elizabeth FOR Lane-Claypon. SALE OR Am DISTRIBUTION J Epidemiol. lished manuscript. Cambridge,NOT FOR MA: SALEHarvard ORUniversity; DISTRIBUTION 2004;160(2):97–101. 1975. 33. Morabia A. Janet Lane-Claypon: interphase epitome. 49. Miettinen OS. Estimability and estimation in case-referent Epidemiology. 2010;21(4):573–576. studies. Am J Epidemiol. 1976;103(2):226–235. 34. Miller DF. Dimensions of Community Health. 3rd ed. 50. Miettinen OS, Wang JD. An alternative to the proportionate Dubuque, IA: William C. Brown; 1992. mortality ratio. Am J Epidemiol. 1981;114:144–148. 35.© JonesHennekens & BartlettCH, Buring Learning, JE. Epidemiology LLC in Medicine. 51. Farewell© Jones V, Johnson & Bartlett T. Woods andLearning, Russell, Hill, LLC and the NOTBoston, FOR MA: SALE Little, Brown OR andDISTRIBUTION Company; 1987. emergenceNOT ofFOR medical SALE statistics. OR Stat DISTRIBUTIONMed. 2010;29:1459–1476. 36. Dawber TR, Kannel WB, Lyell LP. An approach to doi:10.1002/sim.3893 longitudinal studies in a community: the Framingham study. 52. Armitage P. Obituary: Sir Austin Bradford Hill, 1897–1991. Ann NY Acad Sci. 1963;107:539–556. J Royal Stat Soc. 1991;154(3):482–484. 37. Doll R, Hill AB. Smoking and carcinoma of the lung: 53. Greenhouse SW, Greenhouse JB, Cornfield J.Encyclopedia of © Jones & Bartlettpreliminary Learning, report. BMJ LLC. 1950;2:739–748. © Jones & BiostatisticsBartlett. NewLearning, York, NY: John LLC Wiley & Sons; 2005. NOT FOR SALE38. Nor ORr R. DISTRIBUTION Cancer by the carton. Read Dig. December 1952:7–8.NOT FOR54. SALEScott W. ORReliability DISTRIBUTION of content analysis: the case of nominal 39. Cigarettes. What CU’s test showed: the industry and its scale coding. Public Opin Q. 1955;19(3):321–325. advertising, and how harmful are they? Consum Rep. 55. Fleiss JL. Measuring nominal scale agreement among many 1953:58–74. raters. Psychol Bull. 1971;76(5):378–382. 40. Miller LM, Monahan J. The facts behind the cigarette 56. Mantel N, Haenszel W. Statistical aspects of the analysis of controversy. Read Dig. 1954:1–6. data from the retrospective analysis of disease. J Natl Cancer 41. Tobacco smoking© andJones lung cancer. & Bartlett Consum Rep Learning,. 1954:54, 92. LLC Inst. 1959;22(4):719–748.© Jones & Bartlett Learning, LLC 42. United States DepartmentNOT FOR of Health SALE and OR Human DISTRIBUTION Services. 57. Cochran WG, Cox GM.NOT Experimental FOR Designs.SALE 2nd OR ed. DISTRIBUTIONNew Smoking and Health: Report of the Advisory Committee to York, NY: John Wiley & Sons; 1992. the Surgeon General of the Public Health Service. Publication 58. Cochran WG. Sampling Techniques. 3rd ed. New York, NY: PHS 1103. Washington, DC: U.S. Government Printing John Wiley & Sons; 1977. Office; 1964. 59. Snedecor GW, Cochran WG. Statistical Methods, Applied to 43.© JonesWynder EL,& GrahamBartlett EA. TobaccoLearning, smoking LLC as a possible etio Experiments© Jones in Agriculture& Bartlett and Biology.Learning, 5th ed. LLCAmes, IA: logic factor in bronchiogenic carcinoma: a study of six hundred Iowa State College Press; 1956. NOTand FOR eighty-four SALE proved OR cases. DISTRIBUTION JAMA. 1950;143:329–336. 60. MosesNOT LE, FOR Mosteller SALE F, eds. OR Planning DISTRIBUTION and Analysis of 44. Doll R, Hill AB. Smoking and carcinoma of the lung: Observational Studies. New York, NY: John Wiley & Sons; preliminary report. BMJ. 1950;2:739–748. 1983.

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