Practical Applications of Epidemiology

© Vit-Mar/Shutterstock© Jones & Bartlett 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 NOT FORPractical SALE OR DISTRIBUTION ApplicationsNOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning,of Epidemiology LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

LEARNING OBJECTIVES © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC By the end of this chapter the reader will be able to: NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ contrast the seven uses of epidemiology ■■ explain how population dynamics influence community health ■■ differentiate between uses of epidemiology for health services and disease etiology ■■ relate epidemiologic methods to specific clinical applications © Jones & Bartlett■■ compare Learning, epidemiologic LLC models of causality © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

CHAPTER OUTLINE

© Jones & Bartlett Learning,Introduction LLC © JonesApplications & Bartlett Relevant Learning, to Disease Etiology LLC NOT FOR SALE OR DISTRIBUTIONWhat Are the Key Uses of Epidemiology? NOT FORConclusion SALE OR DISTRIBUTION Applications for the Assessment of the Health Study Questions and Exercises Status of Populations and Delivery of Health References Services

Demographic transition Health disparities Secondary prevention Dynamic population Population dynamics Tertiary prevention © Jones & EpidemiologicBartlett Learning, transition LLCPrimary prevention © Jones & Bartlett Learning, LLC NOT FOR SALEFixed population OR DISTRIBUTIONPrimordial prevention NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning,© Jones LLC & Bartlett Learning LLC, an Ascend Learning© Jones Company. & NOT Bartlett FOR SALE Learning, OR DISTRIBUTION. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284191127_CH02_Friis.indd 49 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 50 Chapter 2 Practical Applications of Epidemiology

▸▸ Introduction© Jones & Bartlett Learning,▸ ▸LLCWhat Are the Key© Uses Jones & Bartlett Learning, LLC In two majorNOT sections, FOR this SALE chapter OR provides DISTRIBUTION of Epidemiology?NOT FOR SALE OR DISTRIBUTION a broad overview of the uses of epidemiology in support of public health practice. You will JN Morris encapsulated the uses of epidemi- see how epidemiology provides a method- ology in his brilliant and classic 1975 work ological toolkit for implementation in public titled Uses of Epidemiology.1 This book has © Joneshealth &practice Bartlett and health Learning, sciences LLCmore gen- withstood the test© Jones of time and& Bartlett remains releLearning,- LLC NOTerally. FOR The SALE first ORsection DISTRIBUTION covers applications vant today: MorrisNOT argued FOR that SALE the uses OR could DISTRIBUTION of epidemiology in health status and health be summarized under seven categories, which services. For example, you will discover how remain current in contemporary epidemiol- epidemiology helps public health practi- ogy. (See FIGURE 2-2 and EXHIBIT 2-1 for the tioners and administrators plan for alloca- seven uses of epidemiology.) © Jones & Bartletttion Learning, of resources. LLC Also, you will gain insight © JonesEpidemiologic & Bartlett research Learning, leads to LLCobtain- NOT FOR SALE ORinto DISTRIBUTIONhow epidemiology helps to evaluate NOTing knowledgeFOR SALE that may OR be DISTRIBUTION helpful in efforts to services that have been implemented. The prevent disease and elicits the attention of the second part concerns the uses of epidemiol- popular media. Results of epidemiologic stud- ogy in exploring disease causality, which in ies are often quite newsworthy and sometimes controversial. More and more frequently, medi- many instances© Jones (e.g., some & Bartlett forms of cancer)Learning, LLC © Jones & Bartlett Learning, LLC remains unknown. (See FIGURE 2-1.) You will cal journals such as the New England Journal of find out howNOT epidemiologists FOR SALE in a OR variety DISTRIBUTION of Medicine (NEJM) are publishing reportsNOT ofFOR epi- SALE OR DISTRIBUTION settings (research universities, federal agen- demiologic studies.2 These studies proliferate for cies, private organizations, and elsewhere) a number of key reasons. First, they concentrate continue their quest for clues as to the nature on associations between diseases and possible lifestyle factors, such as a habit, type of behavior, © Jonesof disease. & Bartlett You will Learning,acquire insights LLC into the © Jones & Bartlett Learning, LLC strengths and limitations of applying epide- or some element of the diet, that presumably can NOTmiologic FOR SALE methods OR to theDISTRIBUTION search for causes of be changed. Consequently,NOT FOR “The SALE reports OR are . DISTRIBUTION. . disease. Finally, you will learn about some of often of great interest to the popular media and the applications of epidemiology in clinical the public, as well as to physicians interested in decision-making. preventive medicine.”2(p823) A second reason is that the major diseases predominant in American © Jones & Bartlett Learning, LLC © societyJones are & “chronic, Bartlett degenerative Learning, diseases LLC that NOT FOR SALE OR DISTRIBUTION NOTprobably FOR have SALE several OR contributing DISTRIBUTION causes, some of which have to do with lifestyle, operating over long periods.”2(p823) An NEJM editorial noted,

It is usually very difficult to investi- © Jones & Bartlett Learning, LLCgate such risk factors through© exper Jones- & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONimental (or interventional) NOTstudies. FOR SALE OR DISTRIBUTION In some cases it is impractical and in some it is unethical. For example, researchers cannot expose half of a group of children to lead for 10 years © Jones & Bartlett Learning, LLC to compare© theirJones IQs &20 Bartlettyears later Learning, LLC NOTFIGURE FOR 2-1 SALE Researching OR theDISTRIBUTION Causes of Diseases Is a with those NOTof the unexposedFOR SALE children. OR DISTRIBUTION Major Activity of Epidemiology We must therefore rely on epidemio- © Gorodenkoff/Shutterstock logic (or observational) studies.2(p823)

9781284191127_CH02_Friis.indd 50 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION What Are the Key Uses of Epidemiology? 51

© Jones & Bartlett Learning, LLCStudy Diagnose Examine the© JonesEstimate & BartlettIdentify CoLearning,mplete Search LLC for history of the health working of individual syndromes the clinical causes NOT FOR SALE OR DISTRIBUTIONthe health of the health NOTrisks FORand SALE OR pictuDISTRIBUTIONre of community services chances populations

FIGURE 2-2 The Seven Uses of Epidemiology © DataJones from Morris JN. Uses& of EpidemiologyBartlett. 3rd ed. Edinburgh, Learning, UK: Churchill Livingstone;1975:262–263. LLC © 1975, with permission of Elsevier. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION EXHIBIT 2-1 Seven Uses of Epidemiology

The epidemiological method is the only way of asking some questions in medicine, one way of asking © Jones & others,Bartlett and no Learning, way at all to ask LLC many. Several uses of epidemiology© Joneshave been & described: Bartlett Learning, LLC NOT FOR SALE1. To studyOR theDISTRIBUTION history of the health of populations, and of the NOTrise and FOR fall of diseases SALE and OR changes DISTRIBUTION in their character. Useful projections into the future may be possible. 2. To diagnose the health of the community and the condition of the people, to measure the true dimensions and distribution of ill-health in terms of incidence, prevalence, disability, and mortality; to set health problems in perspective and define their relative importance; to identify groups needing special attention. Ways of life change, and with them the community’s health; © Jones & Bartlett Learning,new LLC measurements for monitoring them© Jones must therefore & Bartlett constantly Learning,be sought. LLC NOT FOR SALE OR DISTRIBUTION3. To study the working of health services NOTwith a view FOR to their SALE improvement. OR DISTRIBUTION Operational research translates knowledge of (changing) community health and expectations in terms of needs for services and measure [sic] how these are met. The success of services delivered in reaching stated norms, and the effects on community health—and its needs—have to be appraised, in relation to resources. Such knowledge may be applied in action research pioneering better ©services, Jones and & in Bartlett drawing up Learning,plans for the future. LLC Timely information on health and© Joneshealth services & Bartlett Learning, LLC is itself a key service requiring much study and experiment. Today, information is required at NOTmany FORlevels, from SALE the local OR district DISTRIBUTION to the international. NOT FOR SALE OR DISTRIBUTION 4. To estimate from the group experience what are the individual risks on average of disease, accident and defect, and the chances of avoiding them. 5. To identify syndromes by describing the distribution and association of clinical phenomena in the population. © Jones & Bartlett6. To complet Learning,e the clinical pictureLLC of chronic diseases and describe© Jones their natural & Bartlett history: by includingLearning, LLC NOT FOR SALEin dueOR proportion DISTRIBUTION all kinds of patients, wherever they present,NOT together FOR with SALE the undemanding OR DISTRIBUTION and the symptomless cases who do not present and whose needs may be as great; by following

(continues)

9781284191127_CH02_Friis.indd 51 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 52 Chapter 2 Practical Applications of Epidemiology

EXHIBIT ©2-1 Jones Seven Uses& Bartlett of Epidemiology Learning, LLC (continued)© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the course of remission and relapse, adjustment and disability in defined populations. Follow-up of cohorts is necessary to detect early subclinical and perhaps reversible disease and to discover precursor abnormalities during the pathogenesis, which may offer opportunities for prevention. 7. To search for causes of health and disease by computing the experience of groups defined by © Jones &their Bartlett composition, Learning, inheritance andLLC experience, their behaviour and© environments. Jones & ToBartlett confirm Learning, LLC particular causes of the chronic diseases and the patterns of multiple causes, describing their NOT FORmode SALE of operation OR DISTRIBUTION singly and together, and to assess their importanceNOT in FORterms of SALE the relative OR DISTRIBUTION risks of those exposed. Postulated causes will often be tested in naturally occurring experiments of opportunity and sometimes by planned experiments.

Reprinted from Morris JN. Uses of Epidemiology. 3rd ed. Edinburgh, UK: Churchill Livingstone, 262–263, © 1975, with permission of Elsevier. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION as the major causes of morbidity and mortal- ▸▸ Applications for ity in contemporary industrialized societies. the Assessment of Mortality data shed light on the overall health © Jones & Bartlett Learning,status LLC of populations, suggest long-term© Jones trends & Bartlett Learning, LLC the HealthNOT FOR Status SALE OR DISTRIBUTIONin health, and help to identify subgroupsNOT FORof the SALE OR DISTRIBUTION population that are at greater risk of mortality of Populations and than other subgroups. FIGURE 2-3 identifies the top 10 causes of Delivery of Health death for two contrasting years: 1900 and 2015, © JonesServices & Bartlett Learning, LLC a period of more© Jonesthan one ¢ury. Bartlett The dataLearning, LLC NOT FOR SALE OR DISTRIBUTION show that influenzaNOT and FOR pneumonia SALE droppedOR DISTRIBUTION As Morris noted, principal uses of epidemi- from the top position in 1900 to 8 in 2015. The ology under this category include the history leading cause of death in 2015 was diseases of of the health of populations, diagnosis of the the heart, followed by cancer in second place. health of the community, and the working of The overall crude death rate from all causes © Jones & Bartletthealth Learning, services.1 LLC © declinedJones greatly& Bartlett during Learning,this period of LLC about NOT FOR SALE OR DISTRIBUTION NOTone FORcentury—from SALE 1,719.1OR DISTRIBUTION in 1900, to 844.0 per 100,000 population in 2015. FIGURE 2-4 Historical Use of Epidemiology: presents additional data on mortality trends in Study of Past and Future Trends the United States. Since the early 1960s, the leading causes in Health© and Jones Illness & Bartlett Learning,of LLCdeath over decades changed© Jonesmarkedly & Bartlett Learning, LLC An example NOTof the historicalFOR SALE use of epidemiolOR DISTRIBUTION- (Figure 2-4). For example, death ratesNOT for FORheart SALE OR DISTRIBUTION ogy is the study of changes in disease frequency disease, cancer, and stroke have shown long- over time. (These changes are known as secu- term declining trends. Alzheimer’s disease, lar trends.) Illnesses and causes of mortality kidney disease, and hypertension manifested that afflict humanity, with certain exceptions, increases. FIGURE 2-5 demonstrates the increase © Joneshave shown & Bartlett dramatic Learning, changes in industrialized LLC (starting around© 1920) Jones and subsequent& Bartlett decline Learning, LLC NOTnations FOR SALEfrom the OR beginning DISTRIBUTION of modern medi- (about 1960) inNOT mortality FOR from SALE heart ORdisease. DISTRIBUTION cine to the present day. In general, chronic con- FIGURE 2-6 shows the rankings of the five lead- ditions have replaced acute infectious diseases ing causes of mortality in 1900, 1950, and

9781284191127_CH02_Friis.indd 52 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Applications for the Assessment of the Health Status of Populations and Delivery of Health Services 53

Mortality in 1900 Mortality in 2015 10 9 © Jones & Bartlett Learning,9 LLC © Jones & Bartlett Learning, LLC Diphtheria, 40.3 Kidney dis., 10 Senility, 50.2 8 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION15.7 Suicide, 8 7 Flu-pneu., 13.7 Cancer, 64.0 Diabetes 17.8 mellitus, 24.7 1 6 7 Influenza and Alzheimer’s Accidents, 72.3 © Jones & Bartlett Learning, LLC pneumonia,© Jones 202.2 & Bartlett Learning,disease, 34.4 LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION5 1 6 Cerebrovascular Diseases of the Nephritis (kidney 2 diseases, 43.7 heart, 197. 2 disease), 81.0 Tuberculosis (all forms), 194.4 4 Accidents, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 45.6 5 NOT FOR SALE OR DISTRIBUTIONCerebrovascular NOT FOR SALE OR DISTRIBUTION 2 diseases, 106.9 Cancer (malignant 3 neoplasms), 185.4 Chronic lower 3 respiratory 4 Diarrhea and diseases, 48.2 Diseases of the enteritis, 139.9 © Jones & Bartlett Learning,heart, LLC137. 4 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Mortality in 1900 Mortality in 2015 10 9 9 Diphtheria, 40.3 Kidney dis., 10 Senility, 50.2 8 © Jones & Bartlett Learning, LLC 15.7 Suicide,© Jones & Bartlett Learning, LLC 8 7 Flu-pneu., 13.7 Cancer, 64.0 NOT FOR SALE OR DISTRIBUTIONDiabetes 17.8 NOT FOR SALE OR DISTRIBUTION mellitus, 24.7 1 6 7 Influenza and Alzheimer’s Accidents, 72.3 pneumonia, 202.2 disease, 34.4 5 1 6 © Jones & Bartlett Learning, LLCCerebrovascular © Jones & BartlettDiseases of Learning, the LLC Nephritis (kidney NOT FOR SALE OR DISTRIBUTION2 diseases, 43.7 NOT FOR SALEheart, OR 197. 2 DISTRIBUTION disease), 81.0 Tuberculosis (all forms), 194.4 4 Accidents, 45.6 5 Cerebrovascular © Jones & Bartlett Learning, LLC 2 © Jones & Bartlett Learning, LLC diseases, 106.9 Cancer (malignant 3 NOT FOR SALE OR DISTRIBUTIONneoplasms), 185.4 NOT FOR SALE OR DISTRIBUTION Chronic lower 3 respiratory 4 Diarrhea and diseases, 48.2 Diseases of the enteritis, 139.9 heart, 137. 4 FIGURE 2-3 The 10 Leading Causes of Mortality, 1900 and 2015, Rank, Cause, and Crude Death Rate per © Jones &100,000 Bartlett (not age Learning, adjusted) LLC © Jones & Bartlett Learning, LLC NOT FOR†Data SALE for 1900 exclude OR infant mortality. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Data from U.S. Bureau of the Census, Statistical Abstract of the United States: 1957, p. 69; United States Public Health Service, Vital Statistics Rates in the United States 1900–1940, Washington, DC: United States Government Printing Office, 1947; and Murphy SL, Xu J, Kochanek KD, et al. Deaths: final data for 2015. Natl Vital Stat Rep. 2017;66(6):6.

9781284191127_CH02_Friis.indd 53 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 54 Chapter 2 Practical Applications of Epidemiology

1,000.0 © JonesICD–7 & Bartlett ICD–8 Learning, LLCICD–9 ICD–10© Jones & Bartlett Learning, LLC 1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2

100.0 5

4 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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13 © Jones & Bartlett Learning, LLC © Jones14 & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION1.0 NOT FOR SALE OR DISTRIBUTION Rate per 100,000 U.S. Standard Population

0.1© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT1960 FOR 1965 SALE 1970 OR 1975 DISTRIBUTION 1980 1985 1990 1995 2000 2005 2010NOT 2015 FOR SALE OR DISTRIBUTION 1958

1 Diseases of heart 9 Nephritis, nephrotic syndrome and nephrosis © Jones & Bartlett Learning,2 Malignant neoplasms LLC 13 Hypertension© Jones & Bartlett Learning, LLC NOT FOR SALE OR5 DISTRIBUTION Cerebrovascular diseases 14 Parkinson’sNOT FOR disease SALE OR DISTRIBUTION 4 Accidents (unintentional injuries) 6 Alzheimer’s disease

FIGURE 2-4 Age-Adjusted Death Rates for Selected Leading Causes of Death: United States, 1958–2015 Notes: ICD: International Classification of Diseases. Numbers indicate ranking of conditions as leading causes of death in 2015. © Jones & BartlettMurphy Learning, SL, Xu J, Kochanek KD, et al.LLC Deaths: final data for 2015. Natl Vital Stat Rep. 2017;66(6):1–75.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2000. In 1950 and 2000, heart disease and can- categories of disease used in earlier cer were the two leading causes of death. eras may be omitted altogether. The In determining the reasons for these diagnostic criteria may be more precise trends, one must© Jones take into & account Bartlett factors Learning, that LLCat a later time; for instance, considerable© Jones & Bartlett Learning, LLC may affect the reliability of observed changes. NOT FOR SALE OR DISTRIBUTIONinformation has been obtainedNOT over FOR SALE OR DISTRIBUTION (Refer to FIGURE 2-7.) According to MacMahon three-quarters of a century about chronic and Pugh, these consist of “variation in diag- diseases. In some cases, when changes in nosis, reporting, case-fatality, or some other diagnostic procedures are due to known circumstance other than a true change of inci- alterations in diagnostic coding systems, 3 (p159) © Jonesdence.” & Bartlett Specific Learning,examples follow: LLC the changes© will Jones be abrupt & Bartlettand readily Learning, LLC NOT■ FOR■ Lack SALE of comparability OR DISTRIBUTION over time due to identifiable.NOT FOR SALE OR DISTRIBUTION altered diagnostic criteria. The diagnostic ■■ Aging of the general population. As the criteria used in a later time period reflect population ages because of the reduced new knowledge about disease; some impact of infectious diseases, improved © Jones & Bartlett Learning,© Jones LLC & Bartlett Learning LLC, an Ascend Learning© Jones Company. & NOT Bartlett FOR SALE Learning, OR DISTRIBUTION. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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700.0 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 600.0NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

500.0

400.0

100.0

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© Jones & Bartlett Learning,Rate per 100,000 U.S. Standard Population LLC1900 1910 1920 1930 1940© Jones 1950 1960& Bartlett 1970 1980 Learning, 1990 2000 LLC 2010 2020 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Legend for causes of death Accidents Influenza and pneumonia Cancer Stroke Heart disease © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 2-5 Age-A FORdjusted SALE Death OR Rates DISTRIBUTIONfor Selected Major Causes of Death: United States,NOT 1900–2015 FOR SALE OR DISTRIBUTION Tejada Vera B, Bastian B, Arias E, et al. Mortality trends in the United States, 1900–2015. National Center for Health Statistics. 2017. Designed by Y Chong, L Lu, and JM Keralis: CDC/National Center for Health Statistics.

Year Leading causes © Jones & Bartlett Learning,Heart LLCdisease © Jones & Bartlett Learning, LLC Cancer NOT FOR SALE2000 OR DISTRIBUTIONStroke NOT FOR SALE OR DISTRIBUTION Chronic respiratory diseases Accidents Heart disease Cancer 1950 Vascular lesions © Jones & Bartlett Learning, LLC Accidents © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONCertain diseases of infancy NOT FOR SALE OR DISTRIBUTION Influenza/pneumonia Tuberculosis 1900 Diarrhea/enteritis/ulcerative colitis Heart disease Stroke © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION0k 100k 200k 300k 400k 500kNOT 600k FOR 700k SALE OR DISTRIBUTION Number of Deaths

FIGURE 2-6 Five Leading Causes of Death: United States, 1900, 1950, and 2000 Tejada Vera B, Bastian B, Arias E, et al. Mortality trends in the United States, 1900–2015. National Center for Health Statistics. 2017. Designed by Y Chong, L Lu, and JM Keralis: CDC/National Center for Health Statistics. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEmedical OR care, DISTRIBUTION and a decline in the death of theNOT underlying FOR causeSALE of deathOR DISTRIBUTIONwhen rate, there may be greater uncertainty older individuals are affected by chronic about the precise cause of death. Also, disease because multiple organ systems there may be inaccurate assignment may fail simultaneously. © Jones & Bartlett Learning,© Jones LLC & Bartlett Learning LLC, an Ascend Learning© Jones Company. & NOT Bartlett FOR SALE Learning, OR DISTRIBUTION. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284191127_CH02_Friis.indd 55 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 56 Chapter 2 Practical Applications of Epidemiology

Changes in disease © Jones & Bartlett Learning,Aging LLC of the fatality © Jones & Bartlett Learning, LLC population NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Changes in diagnostic criteria © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORFIGURE DISTRIBUTION 2-7 Factors That Affect the Reliability of ObservedNOT Changes FOR in DiseaseSALE Trends OR Over DISTRIBUTION Time

• Smallpox (eradicated) • Sexually • Polio transmitted infections • Measles (2019 © Jones & Bartlett Learning, LLC • Tobacco use © Jones & Bartlett Learning, LLC resurgence) NOT FOR SALE OR DISTRIBUTION • Infant mortality NOT FOR SALE OR DISTRIBUTION Disappearing Residual

Persisting New epidemic • Cancer (some forms) • Lung cancer © Jones & Bartlett Learning,• Mental LLC disorders © Jones & Bartlett• Alzheimer Learning,’s LLC NOT FOR SALE OR DISTRIBUTION• Cerebrovascular NOT FOR SALE diseaseOR DISTRIBUTION diseases • Obesity

FIGURE 2-8 Four Trends in Disorders © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Changes in the fatal course of the and new epidemic disorders.4 Changes in condition.NOT Over FOR the long SALE run, such OR DISTRIBUTIONthe occurrence and patterns ofNOT morbidity FOR SALE OR DISTRIBUTION changes would cause decreases in the and mortality result from a range of factors, number of people with the disease who including improvements in medical care (e.g., actually die of it. development of new immunizations and med- © JonesDespite & Bartlett the factors Learning, that reduce LLC the reli- icines), alterations© Jones in environmental & Bartlett condi Learning,- LLC NOTability FOR of SALE observed OR changes DISTRIBUTION in morbidity and tions (e.g., increasedNOT FORlevels ofSALE pollution OR and DISTRIBUTION mortality, FIGURE 2-8 identifies four trends in the presence of toxic chemicals in our food), disorders: disappearing, residual, persisting, and appearance of new or more virulent forms

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of microbial disease agents. The definitions of syndrome (AIDS) appeared in the the four© Jonestrends are & as Bartlett follows: Learning, LLC 1980s as new epidemic© disorders. Jones From& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONa historical perspective,NOT new epidemicFOR SALE OR DISTRIBUTION ■■ Disappearing disorders are those disorders have appeared over time and disorders that were formerly common several factors have contributed to their sources of morbidity and mortality in emergence. These include increased developed countries but at present have life expectancy of the population, new nearly disappeared in their epidemic © Jones & Bartlett Learning, LLC environmental© Jones exposures, & Bartlett and changesLearning, LLC form. Under this category are smallpox NOT FOR SALE OR DISTRIBUTION in lifestyle,NOT FORdiet, and SALE other practicesOR DISTRIBUTION (currently eradicated), poliomyelitis, and associated with contemporary life. other diseases such as measles that have International travel increases the risk of been brought under control by means transferring endemic infectious disease of immunizations, improved sanitary agents to nonendemic locations. © Jones & Bartlett Learning,conditions, LLC and the use of antibiotics ©and Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONother medications. NOT FOR SALE OR DISTRIBUTION ■■ Residual disorders are diseases for which the key contributing factors are largely Predictions About the Future known, but specific methods of control The study of population dynamics in relation have not been effectively implemented. to sources of morbidity and mortality reveals Sexually© Jones transmitted & Bartlett diseases, Learning, perinatal LLCmuch about possible future© trends Jones in a popula& Bartlett- Learning, LLC tion’s health. A population pyramid represents andNOT infant FOR mortality SALE among OR DISTRIBUTION the NOT FOR SALE OR DISTRIBUTION economically disadvantaged, and the age and sex composition of the population 5 health problems associated with use of of an area or country at a point in time. By tobacco and alcohol are examples. examining the distribution of a population by ■■ Persisting disorders are diseases that age and sex, one may ascertain the impacts of © Jones & Bartlettremain common Learning, because LLC an effective mortality© from Jones acute & and Bartlett chronic Learning,conditions LLC as well as the quality of medical care available NOT FOR SALEmethod OR of preventionDISTRIBUTION or cure evades NOT FOR SALE OR DISTRIBUTION discovery. Some forms of cancer and to a population. mental disorders are representative of FIGURE 2-9 shows the age and sex distri- this category. bution of the population of developed and ■■ New epidemic disorders are diseases that developing countries for three time periods: are increasing markedly in frequency 1950, 1990, and 2030. The left and right sides © Jones & Bartlett Learning, LLC © Jonesof &each Bartlett chart compare Learning, males LLCand females, NOT FOR SALE OR DISTRIBUTIONin comparison with previous time NOT FOR SALE OR DISTRIBUTION periods. They include both infectious respectively. The x-axis (bottom of each and noninfectious conditions. The reader chart) gives the number of the population in may surmise that noninfectious examples millions. The y-axis (left side of each chart) of these are lung cancer and Alzheimer’s presents ages grouped into 5-year intervals. disease.© Jones Increases & Bartlett in the levels Learning, of LLCThe following trends in the© age Jones and sex & distri Bartlett- Learning, LLC butions are evident: obesity andNOT FOR type SALE 2 diabetes OR in DISTRIBUTIONmany NOT FOR SALE OR DISTRIBUTION parts of the world, notably in developed ■■ Developing countries. In 1950 and countries and also in developing areas, 1990, less developed countries had a are also examples. New infectious triangular population distribution. disease epidemics (toward the end of the This distribution reflects high death © Jones & Bartlettdecade 2010–2019) Learning, include LLC Ebola virus rates© from Jones infections, & Bartlett high birth Learning, rates, LLC NOT FOR SALEdisease OR and DISTRIBUTION Zika virus disease; human andNOT other conditionsFOR SALE that takeOR a DISTRIBUTIONheavy immunodeficiency virus (HIV) infection toll during the childhood years. These and acquired immunodeficiency deaths result from a constellation of

9781284191127_CH02_Friis.indd 57 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 58 Chapter 2 Practical Applications of Epidemiology

≥80 © Jones & Bartlett Learning, LLC 1950 © Jones & Bartlett Learning, LLC 75–79 Developing countries 70–74 NOT 65–69FOR SALEDeveloped OR countries DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 60–64 55–59 50–54 45–49 Male Female 40–44 35–39 © Jones & BartlettAge Group 30–34 Learning, LLC © Jones & Bartlett Learning, LLC 25–29 NOT FOR SALE OR20–24 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 15–19 10–14 5–9 0–4 400 300 200 100 0 100 200 300 400 © Jones & Bartlett Learning, LLC Population© Jones (millions) & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION≥80 NOT FOR SALE OR DISTRIBUTION 1990 75–79 70–74 65–69 60–64 55–59 50–54 45–49 © Jones & BartlettMale Learning, LLC Female © Jones & Bartlett Learning, LLC 40–44 NOT 35–39FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Age Group 30–34 25–29 20–24 15–19 10–14 5–9 © Jones & Bartlett 0–4Learning, LLC © Jones & Bartlett Learning, LLC 400 300 200 100 0 100 200 300 400 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Population (millions)

80 ≥ Projections for 75–79 2030 70–74 65–69 60–64 © Jones & Bartlett Learning, LLC55–59 © Jones & Bartlett Learning, LLC 50–54 NOT FOR SALE OR DISTRIBUTION45–49 NOT FOR SALE OR DISTRIBUTION 40–44 Male Female 35–39 Age Group 30–34 25–29 20–24 15–19 © Jones10–14 & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 5–9 NOT FOR0–4 SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 400 300 200 100 0 100 200 300 400

Population (millions)

FIGURE 2-9 Population Age Distribution for Developing and Developed Countries, by Age Group And Sex: © JonesWorldwide & Bartlett, 1950, 1990, Learning, and 2030 LLC © Jones & Bartlett Learning, LLC NOTData FOR from Centers SALEfor Disease Control andOR Prevention. DISTRIBUTION Trends in Aging—United States and Worldwide. MMWR Morb Mortal Wkly Rep. 2003;52(6):103.NOT The United NationsFOR and the SALEU.S. Bureau of the CensusOR are theDISTRIBUTION authors of the original material.

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factors associated with poverty and Population Dynamics deprivation:© Jones poor& Bartlett nutrition; Learning, lack of LLC © Jones & Bartlett Learning, LLC potableNOT FORwater; andSALE unavailability OR DISTRIBUTION of and Epidemiology NOT FOR SALE OR DISTRIBUTION basic immunizations; antibiotics, and The term population dynamics denotes sewage treatment. Consequently, high changes in the demographic structure of childhood death rates mean that fewer populations associated with factors such as children survive into old age. The net births and deaths, and immigration and emi- © Jones & Bartletteffect is smaller Learning, numbers LLC of persons in gration. ©This Jones section & presents Bartlett definitions Learning, of LLC NOT FOR SALEthe older OR groups DISTRIBUTION and narrowing of the two typesNOT of populations—fixed FOR SALE OR populations DISTRIBUTION top of the population pyramid. By 2030, and dynamic populations—and illustrates improvements in health in developing how populations grow and wane. Noteworthy countries are likely to result in greater related concepts are the demographic transi- survival of younger persons, causing tion and the epidemiologic transition. © Jones & Bartlett Learning,a projected LLC change in the shape of the© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONpopulation distribution. NOT FORTerminology: SALE OR DISTRIBUTIONFixed Populations ■■ Developed countries (industrialized societies). These countries manifest and Dynamic Populations a rectangular population distribution. A population may be either fixed or dynamic. This rectangular shape was consistent A fixed population is one distinguished by a for© 1950Jones and 1990& Bartlett and, with Learning, some LLCspecific happening and ©consequently Jones & addsBartlett Learning, LLC exceptions,NOT FOR is projected SALE alsoOR for DISTRIBUTION 2030. no new members; therefore,NOT the FOR population SALE OR DISTRIBUTION Characteristically, infections take a decreases in size as a result of deaths only. smaller toll than in developing countries, Examples of a fixed population are survi- causing a greater proportion of children vors of the 9/11 terrorist attack in New York, to survive into old age; approximately residents of New Orleans during Hurricane © Jones & Bartlettequal numbers Learning, of individuals LLC are present Katrina, ©and Jones persons & who Bartlett have had Learning, a medi- LLC NOT FOR SALEin each OR age DISTRIBUTIONgroup except among the very cal procedureNOT such FOR as hipSALE replacement OR DISTRIBUTION during oldest age groups, with larger numbers of a given year. A dynamic population is one older women who survive as compared that adds new members through immigration with men. Because of reduced mortality and births or loses members through emigra- due to infectious diseases and improved tion and deaths. An example of a dynamic © Jones & Bartlett Learning,medical LLC care in comparison with less© Jonespopulation & Bartlett is the Learning,population of LLCa county, city, NOT FOR SALE OR DISTRIBUTIONdeveloped regions, residents of developedNOT FORor state SALE in the OR United DISTRIBUTION States. countries enjoy greater life expectancy. With continuing advances in medical Influences on Population Size care, the population of developed Three major factors affect the sizes of popula- countries will grow increasingly tions: births, deaths, and migration.5 The latter older.© Jones The U.S. & Bureau Bartlett of the Learning, Census LLC © Jones & Bartlett Learning, LLC term includes immigration and emigratio n— estimatesNOT FOR that about SALE one-fifth OR DISTRIBUTIONof the U.S. NOT FOR SALE OR DISTRIBUTION permanent movement into and out of a coun- population in 2030 will be 65 years of age try, respectively. FIGURE 2-10 demonstrates and older. There will be a need for health how the three variables affect the net size of a services that affect aging and all of its population. associated dimensions. One illustration is © Jones & Bartlettincreasing Learning, the availability LLC of programs for ■■ Population© Jones in equilibrium & Bartlett or Learning,a steady LLC NOT FOR SALEthe major OR chronicDISTRIBUTION diseases, with respect stateNOT—the threeFOR factors SALE do ORnot contribute DISTRIBUTION to both preventive care in the early years to net increases or decreases in the and direct care in the older years. number of persons, meaning that the

9781284191127_CH02_Friis.indd 59 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 60 Chapter 2 Practical Applications of Epidemiology

Emigration Deaths © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Population size NOT FOR SALE OR DISTRIBUTION

Immigration Births

Stable population © Jones & Bartlett Learning,(equilibrium) LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Emigration Deaths Population size

Immigration Births © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION Increasing population NOT FOR SALE OR DISTRIBUTION

Emigration Deaths © Jones & Bartlett Learning, LLC Population size © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Immigration Births

Decreasing population © JonesFIGURE 2-10& Bartlett How Births, Learning, Deaths, and Migration LLC Affect the Net Size of a Population© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION number of members exiting for various societies to much lower birth and death rates reasons equals the number entering. found in developed countries.5 Improvement ■■ Population increasing in size—the in general hygienic and social conditions, © Jones & Bartlett Learning,net effect caused LLC when the number of © industrialization,Jones & Bartlett and urbanization Learning, contribute LLC persons immigrating plus the number to a decline in mortality and the birth rate. The NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of births exceeds the number of term epidemiologic transition describes a persons emigrating plus the number shift in the pattern of morbidity and mortal- of deaths. ity from causes related primarily to infectious ■■ Population decreasing in size—the and communicable diseases to causes associ- net effect© causedJones when & Bartlett the number Learning, ated LLC with chronic, degenerative diseases.© Jones The & Bartlett Learning, LLC of persons emigrating plus the NOT FOR SALE OR DISTRIBUTIONepidemiologic transition accompaniesNOT FOR the SALE OR DISTRIBUTION number of deaths exceeds the number demographic transition. The demographic of persons immigrating plus the transition, however, is not without its own set number of births. of consequences: Both industrialization and The population pyramid reflects birth urbanization have led to environmental con- © Jonesand death & Bartlett rates and Learning, portends a LLCcommuni- tamination, concentration© Jones of& social Bartlett and health Learning, LLC NOTty’s FOR health SALE patterns. OR The DISTRIBUTION term demographic problems in theNOT urban FORcore areas SALE of the OR United DISTRIBUTION transition refers to the historical shift from States, and out-migration of inner city resi- high birth and death rates found in agrarian dents to the suburbs.

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Health© Jones of the & Community Bartlett Learning, LLC © Jones & Bartlett Learning, LLC As shownNOT in FORFIGURE SALE2-11, members OR DISTRIBUTION of a healthy NOT FOR SALE OR DISTRIBUTION community are prepared to cope with the vicissitudes of society. One of the important applications in epidemiology is to provide methodologies used to describe the overall © Jones &health Bartlett of a particular Learning, community. LLC The result- © Jones & Bartlett Learning, LLC NOT FORing SALE description OR mayDISTRIBUTION then provide a key to the NOT FOR SALE OR DISTRIBUTION types of problems that require attention and also accentuate the need for specific health services. A complete epidemiologic description would include indices of health as well FIGURE 2-11 A Healthy Community Is a Prepared © Jones & Bartlett Learning,as indicators LLC of the psychosocial milieu of© the Jones Community & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONcommunity. EXHIBIT 2-2 lists representativeNOT FOR© william87/iStock/Getty SALE Images OR Plus/Getty DISTRIBUTION Images

EXHIBIT 2-2 Descriptive Variables for the Health of the Community

Demographic© Jones and & social Bartlett variables: Learning, LLC © Jones & Bartlett Learning, LLC 1. NOTAge and FOR sex distributionSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. Socioeconomic status 3. Family structure, including marital status and number of single-parent families 4. Racial, ethnic, and religious composition Variables related to community infrastructure: © Jones & Bartlett1. Availability Learning, of social and LLC health services, including hospitals© and Jones emergency & Bartlett rooms Learning, LLC NOT FOR SALE2. Quality OR of DISTRIBUTION housing stock, including presence of lead-basedNOT paint andFOR asbestos SALE OR DISTRIBUTION 3. Social stability (residential mobility) 4. Community policing 5. Employment opportunities Health-related outcome variables: © Jones & Bartlett Learning,1. Homicide LLC and suicide rates © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION2. Infant mortality rate NOT FOR SALE OR DISTRIBUTION 3. Mortality from selected conditions (cause specific) 4. Scope of chronic and infectious diseases 5. Alcoholism and substance abuse rates 6. Teenage pregnancy rates 7. Occurrence of sexually transmitted diseases 8. ©Birth Jones rate & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC EnvirNOTonmental FOR variables: SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Air pollution from stationary and mobile sources 2. Access to parks/recreational facilities 3. Availability of clean water 4. Availability of markets that supply healthful groceries © Jones & Bartlett5. Number Learning, of liquor stores LLC and fast-food outlets © Jones & Bartlett Learning, LLC NOT FOR SALE6. Nutritional OR DISTRIBUTION quality of foods and beverages vended to schoolchildrenNOT FOR SALE OR DISTRIBUTION 7. Soil levels of radon

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variables for possible inclusion in a description persons may be less aware of dietary and exer- of the health© of Jones the community. & Bartlett Learning,cise LLC practices that promote good ©health. Jones They & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONare more likely to obtain employmentNOT inFOR the SALE OR DISTRIBUTION Demographic and Social service sector, which usually does not carry a full range of health benefits in comparison with Variables professional and other occupations. Age and sex distribution: Refer to Exhibit 2-2 Racial, ethnic, and religious composi- © Jonesand the & first Bartlett set of variables Learning, shown—demograp LLC hic tion: The racial© andJones ethnic & compositionBartlett Learning, of LLC NOTand FOR social SALE variables. OR Consider DISTRIBUTION the example of the the communityNOT influences FOR its SALE health ORprofile. DISTRIBUTION relationship between the age and sex composition Some health outcomes are more common in of the population and typical health problems. In one racial or ethnic group than in another— a community that consists primarily of senior citi- for example, sickle cell anemia among African zens (as in a retirement community), health prob- Americans or diabetes mellitus among Latinos. © Jones & Bartlettlems Learning, related to aging LLC would tend to predominate. © Tay-SachsJones & disease Bartlett tends Learning,to be more common LLC NOT FOR SALE ORChronic DISTRIBUTION diseases (e.g., cancer, heart disease, and NOTamong FOR persons SALE of EasternOR DISTRIBUTION European Jewish stroke) increase in prevalence among the elderly. extraction than among other groups. Because of the longer life expectancy of women, A community may demonstrate charac- an older population would tend to have a majority teristic health patterns associated with mem- of elderly women, who might have unique health bers of a religious denomination if that group needs such as© screeningJones &and Bartlett interventions Learning, for has LLC settled in the community. Adherents© Jones of & Bartlett Learning, LLC osteoporosis,NOT risk of FORfalling, andSALE other OR conditions DISTRIBUTION some religious denominations adoptNOT lifestyles FOR SALE OR DISTRIBUTION associated with aging. and dietary practices that may affect the com- In contrast, a younger community would munity health profile. For example, members also have a distinctive morbidity and mortal- of some religious groups may abstain from ity profile. In a community with many young alcohol consumption and smoking or avoid © Joneschildren & andBartlett teenagers, Learning, health officials LLC might certain foods that© Jonesare high in& saturatedBartlett fats Learning, or LLC NOTbe FOR particularly SALE ORconcerned DISTRIBUTION with providing that increase cancerNOT risks. FOR Consequently, SALE OR such DISTRIBUTION immunizations against vaccine-preventable communities would be expected to have lower infectious diseases. Another topic would be frequencies of adverse health outcomes related the prevention of sexually transmitted dis- to alcohol consumption, tobacco use, and diet. eases (e.g., HIV/AIDS) and health education Thus, the health of the community may be © Jones & Bartlettprograms Learning, for avoidance LLC of substance use and © determinedJones & toBartlett some extent Learning, by racial, LLCethnic, NOT FOR SALE ORsmoking. DISTRIBUTION Finally, attention would need to be NOTand religiousFOR SALE factors. OR DISTRIBUTION directed to the control of unintentional injuries and deaths, which are the leading cause of Variables Related to Community mortality among younger persons, particularly young males. Infrastructure Socioeconomic© Jones status: & Bartlett Socioeconomic Learning, Availability LLC of health and social services:© Jones The & Bartlett Learning, LLC status (SES),NOT which FOR comprises SALE income OR DISTRIBUTIONlevel, socioeconomic characteristics of NOTthe commu FOR- SALE OR DISTRIBUTION educational attainment, and type of occupa- nity relate in part to the availability of health tion, is a major determinant of a community’s and social services and ability to pay for health- health. Often, persons who have inadequate care services. Wealthy communities, because income and employment opportunities lack of greater tax resources, have the capacity to © Joneshealth &insurance Bartlett and Learning, access to health LLC care. By provide a greater© Jonesrange of &social Bartlett and health- Learning, LLC NOTdefinition, FOR SALE an aspect OR of DISTRIBUTION low SES is low educa- related services,NOT which FOR may be SALE more up OR to date DISTRIBUTION tion levels. Individuals who have low education and conveniently located as compared with levels in comparison with more highly educa ted less affluent areas. Low-income residents may

9781284191127_CH02_Friis.indd 62 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Applications for the Assessment of the Health Status of Populations and Delivery of Health Services 63

use, as their primary source of medical care, U.S. Census Bureau operates the American public© health Jones services, & Bartlett which mayLearning, be over- LLCHousing Survey, which ©provides Jones statistical & Bartlett Learning, LLC crowdedNOT and FOR inaccessible SALE by OR public DISTRIBUTION transpor- information on the qualityNOT of housing FOR inSALE the OR DISTRIBUTION tation. Often, when state and federal funding United States.6 FIGURE 2-12 presents data for are curtailed, wealthy communities have the 2007 and 2009. In both years, slightly more means to backfill lost revenue with local fund- than 5% of housing units were classified as ing resources, whereas poorer locales do not inadequate and 23% as unhealthy, meaning © Jones &have Bartlett this option. Learning, LLC that housing© Jones had rodent & Bartlett infestations, Learning, absence LLC NOT FOR SALEQuality OR of housingDISTRIBUTION stock: Safe and clean of smokeNOT alarms, FOR leaks, SALE and peeling OR paint. DISTRIBUTION housing is essential to the health of the com- Social stability: Some of the newer community. The presence of toxic lead, danger- munities, such as those in the Sunbelt of the ous asbestos, and vermin in older housing southern United States and geographic regions detract from the quality of housing stock and with growing economies, have highly mobile © Jones & Bartlett Learning,contribute LLCto adverse health outcomes. ©The Jones residents. & Bartlett Frequent Learning, residential mobilityLLC might NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

19.2 21.9 Unhealthy housing 27.1 © Jones & Bartlett Learning, LLC 27.1 © Jones & Bartlett Learning, LLC NOT FOR SALE OR4.2 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 5.6 Inadequate housing 4.3 6.5

7.1 9.3 © Jones & BartlettNo smokeLearning, alarm LLC © Jones & Bartlett Learning, LLC 6.0 NOT FOR SALE OR DISTRIBUTION4.9 NOT FOR SALE OR DISTRIBUTION

1.8 2.4 Peeling paint 3.3 2.8 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 6.6 NOT FOR SALE OR DISTRIBUTION 8.3 NOT FOR SALE OR DISTRIBUTION Leaks 14.7 11.3

31.9 37.3 Rodents © Jones & Bartlett Learning, LLC 33.9 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT43.1 FOR SALE OR DISTRIBUTION

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 Percentage

© Jones & Bartlett Learning, LLC West South Midwest© Jones Northeast & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-12 The Quality of Housing in the United States Data from Raymond J, Wheeler W, Brown MJ. Inadequate and unhealthy housing, 2007 and 2009. MMWR Morb Mortal Wkly Rep. 2011;60:22, 23, 25, 26.

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contribute to a sense of social instability, alien- sexually transmitted diseases among ation, and lack© Jones of social & connectedness, Bartlett Learning, and, LLCteenagers within specific communities© Jones & Bartlett Learning, LLC in turn, resultNOT in social FOR pathology SALE and OR adverse DISTRIBUTION suggest the need for appropriateNOT FOR SALE OR DISTRIBUTION mental and physical health outcomes. Less education and counseling services affluent urban communities of some parts targeted to this age group. of the United States have high unemploy- ■■ Homicide rates: High firearm death ment levels that encourage out-migration of rates and homicide rates reflect adverse © Jonesyounger & residents Bartlett who Learning, are seeking betterLLC eco- conditions ©within Jones the community. & Bartlett Learning, LLC NOTnomic FOR prospects, SALE ORleaving DISTRIBUTION behind a majority of Mass shootings,NOT gang FOR warfare, SALE and OR DISTRIBUTION older and indigent individuals. interpersonal violence contribute to Community policing programs reinforce homicide rates. In 2003, Washington, social stability by reducing violent crime. D.C. led all the other areas in the United Communities that form partnerships with States in mortality from assaults and © Jones & Bartlettthe Learning, police force (e.g.,LLC through neighborhood © Jonesfirearms, & Bartlett with age-adjusted Learning, death ratesLLC of NOT FOR SALE ORwatch DISTRIBUTION programs) often are more successful NOT FOR31.5 and SALE 26.9, respectively, OR DISTRIBUTION per 100,000 at policing the community and maintaining population.7 Later data (FIGURE 2-13) lower crime rates than in communities where portray U.S. age-adjusted firearm death such partnerships do not exist. rates from 2008 to 2014. The salmon- Health-related outcome variables: Mea- colored areas on the chart denote sures of health© outcomesJones & shown Bartlett in Exhibit Learning, 2-2 LLCconcentrations of high rates in© Alaska, Jones & Bartlett Learning, LLC are a barometerNOT of FOR community SALE health OR statusDISTRIBUTION Montana, Wyoming, and the NOTSouth FOR SALE OR DISTRIBUTION and suggest needed social and health-related Central United States. services. ■■ Infant mortality rate: Inadequate Environmental Variables © Jonesprenatal & Bartlett care, insufficient Learning, maternal LLC diets, Environmental ©variables Jones and & factors Bartlett affect Learning, the LLC NOT FORand SALEa deficit ORof relevant DISTRIBUTION social and health health of the communityNOT FOR in SALEnumerous OR ways. DISTRIBUTION services correlate with elevated infant Members of some economically disadvantaged mortality rates. communities have high levels of exposure to ■■ Suicide rates: Depression, social air pollution that emanate from diesel trucks isolation, and alienation within the and other vehicles on freeways that traverse © Jones & Bartlett Learning,community mayLLC contribute to increased © theJones region. & BartlettOther sources Learning, of air pollution LLC NOT FOR SALE OR suicideDISTRIBUTION rates and elevated rates of NOTinclude FOR nearby SALE industrial OR DISTRIBUTION and power plants, alcoholism and substance abuse. and port facilities where ships are offloaded. ■■ Chronic and infectious diseases: Lack of available land may limit access to Often, chronic diseases and conditions playgrounds and public parks. Nutritious and (e.g., obesity and type 2 diabetes) healthful foods, particularly in meals supplied result from© Jones poor dietary & Bartlett choices and Learning, to LLCschoolchildren, may not be an© optionJones for & Bartlett Learning, LLC the existenceNOT of FOR “food deserts”SALE inOR the DISTRIBUTION community residents. In some communities,NOT FOR SALE OR DISTRIBUTION community. A resurgence of preventable the dominant food sources are snacks from infectious diseases, such as measles and liquor stores, the fare sold by fast-food out- tuberculosis, may stem from the failure of lets, and sugar-laden beverages sold in vend- immunization and community infectious ing machines. Some low-SES communities are © Jonesdisease & Bartlett surveillance Learning, programs. LLC overcrowded and© Jonesmore likely & Bartlettto have associ Learning,- LLC NOT■ FOR■ Teenage SALE pregnancy OR DISTRIBUTION rates/sexually ated unsanitaryNOT condit FORions (e.g.,SALE presence OR DISTRIBUTIONof transmitted diseases: Increases in the rats and disease vectors), which afford trans- occurrence of pregnancies, births, and mission of infectious diseases.

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3.10–8.82 8.83–11.25 11.26–14.21 © Jones & Bartlett Learning, LLC © Jones14.22–18.66 & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-13 Age-Adjusted Firearm Death Rates per 100,000 Population, United States, 2008–2014 The Statistics, Programming & Economics Branch, National Center for Injury Prevention and Control, CDC. NCHS National Vital Statistics System or Numbers of Deaths: US Census Bureau or Population Estimates. https://wisqars.cdc.gov:8443/cdcMapFramework/mapModuleInterface.jsp. Accessed September 8, 2018.

© Jones &Health Bartlett Disparities Learning, LLC HIV infection/AIDS,© Jones & and Bartlett immunizations. Learning, In LLC NOT FOR SALE OR DISTRIBUTION a 2011 report,NOT theFOR CDC SALE noted ORthat DISTRIBUTION“increas- Using epidemiology to describe the health of ingly, the research, policy, and public health the community relates to Goal 2 of Healthy practice literature report substantial dispari- People 2010, “Eliminate Health Disparities.” ties in life expectancy, morbidity, risk factors, Goal 2 strives “to eliminate health disparities and quality of life, as well does persistence of © Jones & Bartlett Learning,among segments LLC of the population, including© Jones these & disparitiesBartlett amongLearning, segments LLC of the pop- differences that occur by gender, race or eth- 11(p3) NOT FOR SALE OR DISTRIBUTION NOT FORulation.” SALE AsOR the DISTRIBUTION U.S. population ages and nicity, education or income, disability, geo- becomes more ethnically and socioeconom- 8(p11) graphic location, or sexual orientation.” ically diverse, health disparities are likely to A later document, Healthy People 2020, con- increase in the future. Previously, the authors tinues to express this goal. One of the four singled out infant mortality as an indicator of overarching© Jones goals &of BartlettHealthy People Learning, 2020 is to LLCthe health of the community.© WhileJones the & infant Bartlett Learning, LLC “[a]chieveNOT health FOR equity, SALE eliminate OR DISTRIBUTION disparities, mortality rate in the UnitedNOT States FORhas trended SALE OR DISTRIBUTION and improve the health of all groups.”9 downward, it had a low ranking (5.9 per 1,000 Health disparities are “differences in live births based on 2016 data) in compari- health outcomes that are closely linked with son with other developed nations. Within the social, economic, and environmental disad- United States, African American infants have © Jones &v ant Bartlett a g e .” 10(p1) SixLearning, areas are the LLC focus of the U.S. approximately© Jones 2.43 × Bartlett the mortality Learning, rate LLC NOT FORDepartment SALE OR of DISTRIBUTIONHealth and Human Services: of whiteNOT infants FOR (11.73 SALE per 1,000 OR vs. DISTRIBUTION 4.82 per infant mortality, cancer screening and man- 1,000 in 2015).12 With respect to the health agement, cardiovascular disease, diabetes, of the community, epidemiologic techniq ues

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help to identify geographic areas with ele- and health outcomes such as inequality in the vated rates ©of Jonesinfant mortality& Bartlett (and Learning, other number LLC of healthy days. FIGURE 2-14© Jonesshows the & Bartlett Learning, LLC adverse healthNOT conditions). FOR SALE Epidemiolog OR DISTRIBUTIONy state-specific index of inequality NOTin the FORnum- SALE OR DISTRIBUTION assists in identifying risk factors for these ber of healthy days and the average number of elevated rates. healthy days in the United States for 2007. The lowest levels of health inequality and highest Income Inequality Income inequality refers mean number of healthy days occurred in © Jonesto the unequal& Bartlett distribution Learning, of incomes LLC across Utah, Connecticut,© Jones and North & Bartlett Dakota, Learning,the LLC NOTthe FOR population. SALE PersonsOR DISTRIBUTION at the lower end of three states thatNOT had theFOR lowest SALE Gini ORscores. DISTRIBUTION the income distribution are more likely to be At the bottom of the list were Tennessee, affected by heath disparities than those who Kentucky, and West Virginia, which had the have higher incomes. A common measure of three highest Gini scores and, consequently, income inequality is known as the Gini index, the highest health inequality and lowest aver- © Jones & Bartlettwhich Learning, is a number LLC that ranges from 0 to 1. The © ageJones number & ofBartlett healthy days. Learning, LLC NOT FOR SALE ORcloser DISTRIBUTION the index is to 1, the greater the level of NOT FOR SALE OR DISTRIBUTION inequality. For example, a value of 0 indicates Poverty As noted previously, poverty is an total equality and a value of 1 total inequality. additional determinant of adverse health out- Income inequality is highest among advanced comes in the community. In the United States, developed economies; in 2007, the Gini index the poverty rate was almost 12 percent; about for the United© JonesStates was & Bartlett0.46.11 To portrayLearning, 38 LLCmillion persons were in poverty© Jones in 2018. & Bartlett Learning, LLC the effects ofNOT income FOR inequality, SALE statisticiansOR DISTRIBUTION Poverty is based on an index thatNOT takes FOR into SALE OR DISTRIBUTION report associations between the Gini index account the size of a family unit, including

Poverty in the United States © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORHighlights—Comparing SALE OR DISTRIBUTION 2018 and 2017 NOT FOR SALE OR DISTRIBUTION ■■ The official poverty rate in 2018 was 11.8 percent, down 0.5 percentage points from 12.3 percent in 2017. This is the fourth consecutive annual decline in poverty. Since 2014, the poverty rate has fallen 3.0 percentage points, from 14.8 percent to 11.8 percent. ■■ In 2018, for the first time in 11 years, the official poverty rate was significantly lower than 2007, the © Jones & Bartlett Learning,year before the LLC most recent recession. © Jones & Bartlett Learning, LLC NOT FOR SALE OR■■ DISTRIBUTIONIn 2018, there were 38.1 million people in poverty,NOT approximately FOR SALE 1.4 million OR fewer DISTRIBUTION people than 2017. ■■ Between 2017 and 2018, poverty rates for children under age 18 decreased 1.2 percentage points from 17.4 percent to 16.2 percent. Poverty rates decreased 0.4 percentage points for adults aged 18 to 64, from 11.1 percent to 10.7 percent. The poverty rate for those aged 65 and older (9.7 percent) was not statistically different from 2017. ■■ From 2017© Jonesto 2018, the & poverty Bartlett rate decreased Learning, for non-Hispanic LLC Whites; females; native-born© Jones & Bartlett Learning, LLC people; people living in the Northeast, Midwest, and West; people living inside metropolitan statisticalNOT areas andFOR principal SALE cities; OR people DISTRIBUTION without a disability; those with some college NOTeducation; FOR SALE OR DISTRIBUTION people in families; and people in female householder families. ■■ Between 2017 and 2018, people aged 25 and older without a high school diploma were the only examined group to experience an increase in their poverty rate. Among this group, the poverty rate increased 1.4 percentage points to 25.9 percent, but the number in poverty was not statistically © Jones different& Bartlett from 2017. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Semega J, Kollar M, Creamer J, Mohanty A. Income and Poverty in the United States: 2018. U.S. Census Bureau, Current Population Reports, P60-266, U.S. Government Printing Office, Washington, DC; 2019:12.

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0.25 25 © Jones & Bartlett Learning,ys LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 0.2 Gini index 20 © Jones & Bartlett Learning, LLC © Jones0.15 & Bartlett Learning, LLC Number of Healthy Da Number of Healthy NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

0.1

NOT FOR SALE OR DISTRIBUTION I owa NOT FOR SALE OR DISTRIBUTION Utah Ohio wa rolina rolina Idaho Te rmont lllinois Maine Hawaii Alaska Florida Indiana Virginia Kansas Oregon Arizona Nevada Georgia Ve Missouri Montana Alabama Michigan Colorado Kentuc New New Wy oming Maryland Arkansas Dela California Nebraska Louisiana Wisconsin Oklahoma Minnesota Tennessee Mississippi New jersey New Washington Connecticut New Mexico New West Virginia West Pennsylvania North Da Rhode Island South Da North Ca South Ca Massachuset New Hampshire New State © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURENOT 2-14 State-Specific FOR SALE Gini IndexOR ofDISTRIBUTION Inequality in Number of Healthy Days and AverageNOT Number FOR of SALE OR DISTRIBUTION Healthy Days: United States, 2007 Reproduced from Centers for Disease and Control and Prevention. CDC health disparities and inequalities report—United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60(suppl):7.

© Jones &related Bartlett children Learning, younger than LLC 18 years of age. estimated© minimum Jones &income Bartlett required Learning, to meet LLC NOT FORFor SALE example, OR in DISTRIBUTION 2016, the poverty threshold the basicNOT needs FOR of a family. SALE Poverty OR DISTRIBUTION refers to for a family of four with two adults and two an income that is below the income level for children was $24,339. The threshold is the the poverty threshold, which the U.S. Census

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Numbers in millions 50 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 45 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Number in poverty 40 35 38.1 Million 30 © Jones25 & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR20 SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Percent 25

20 Poverty rate 15 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 10 11.8 Percent NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 5

0 1959 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2018

© Jones & Bartlett Learning,Recession LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-15 Number in Poverty and Poverty Rate: 1959 to 2018 Semega J, Kollar M, Creamer J, Mohanty A. Income and Poverty in the United States: 2018. U.S. Census Bureau, Current Population Reports, P60-266, U.S. Government Printing Office, Washington, DC; 2019:12.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Bureau updates each year. Refer to FIGURE 2-15, among Transgender Youths. Refer to NOTwhich FOR presents SALE data OR on DISTRIBUTION poverty and the pov- FIGURE 2-16NOT for an FORinfographic SALE about OR DISTRIBUTION erty rate from 1959 to 2018, for more details. transgender teens.

Case Studies: Programs that Address Policy Evaluation Health Disparities Diverse approaches © Jones & Bartlett Learning, LLC © RegardingJones & the Bartlett health of Learning, the community, LLC epi- for addressing health disparities include demiology not only is a descriptive tool, but NOT FOR SALE ORchanges DISTRIBUTION in the provision of health care, NOT FOR SALE OR DISTRIBUTION also plays a role in policy evaluation. As Ibra- media releases to increase public awareness him has pointed out, “Health planning and of chronic diseases, and prevalence studies policy formulation in the ideal sense should of sub-populations that experience health apply to total communities and employ a disparities. The following three case studies © Jones & Bartlett Learning,centralized LLC process, which facilitates© Jones an over -& Bartlett Learning, LLC provide examples of programs for reducing view of the whole rather than selected health health disparities:NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION problems.”13(p4) Samet and Lee wrote, “The ■■ Eliminating Disparities in Care findings of epidemiologic research figure ■■ African American Women and Mass prominently in nearly all aspects of develop- Media (AAMM) Campaign to Increase ing policies to safeguard the public’s health. © JonesAwareness & Bartlett of Mammograms Learning, LLC Epidemiologic ©evidence Jones receives& Bartlett consider Learning,- LLC NOT■ FOR■ Violence SALE Victimization, OR DISTRIBUTION Substance Use, ation at the nationalNOT FORand even SALE global OR levels, DISTRIBUTION Suicide Risk, and Sexual Risk Behaviors while also directly and indirectly influencing

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FIGURE 2-16 Transgender Teens Need Safe and Supportive Schools Data Source: The Youth Risk Behavior Survey (YRBS), 2017 Image© source: Jones Centers for Disease & Control Bartlett and Prevention. https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm. Learning, LLC Accessed October 18, 2019. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

individual decisions concerning lifestyle, to mind, including fluoridation of water, work, and family.”14(pS1) Legislators and gov- helmet protection for motorcycle riders, ernment officials are responsible for enacting mandatory seat belt use in motor vehicles, © Jones &laws, Bartlett enforcing Learning, them, and LLCcreating policies, and requiring© Jones automobile & Bartlett manufacturers Learning, to LLC NOT FORmany SALE of whichOR DISTRIBUTION have substantial impacts on install airNOT bags FORin vehicles. SALE Another OR DISTRIBUTION chapter public health. Numerous examples that have explores the roles of epidemiology in policy- occurred in distant and recent history come making in greater detail.

Adventist HealthCare’s Center on Health Disparities The Center . . . was created in 2007 to reduce and eliminate disparities in health status and healthcare access, treatment, quality, and outcomes . . . . Through training and education, research, and health services,© Jones the Center & is Bartlett working to ensureLearning, that all physicians LLC and staff provide culturally© competent Jones and& Bartlett Learning, LLC compassionateNOT FOR care SALE to patients OR . . . . InnoDISTRIBUTIONvative, practical strategies . . . include: NOT FOR SALE OR DISTRIBUTION ■■ Community outreach ■■ Continuing education and training for . . . providers . . . ■■ Enhancing linguistic skills of staff and community partners . . . ■■ Conducting evidence-based research and analysis . . . © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAdapted and ORreprinted DISTRIBUTION from Adventist Health Care, Center on Health Disparities. Eliminating disparitiesNOT in FOR care. https://www.aha.org/system/files SALE OR DISTRIBUTION /content/00-10/08dispcase-center.pdf. Accessed October 17, 2019.

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CASE STUDY© Jones 2: & BartlettAfrican Learning,American LLC Women and Mass Media© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (AAMM) Campaign to Increase Awareness of Mammograms

© JonesAfrican & AmericanBartlett women Learning, who get breast LLC cancer are more likely to die from© Jones the disease & than Bartlett white Learning, LLC NOT FORwomen SALE and are lessOR likely DISTRIBUTION to survive for 5 years after diagnosis. Studies suggestNOT thatFOR this SALEdisparity isOR DISTRIBUTION due to African American women being diagnosed with breast cancer at a later stage and receiving treatment later after diagnosis. The CDC developed the African American Women and Mass Media (AAMM) pilot campaign, which used radio and print media to make more women aware of the importance of getting © Jones & Bartlettmammograms Learning, to LLC find breast cancer early. The campaign© Jones also sought & Bartlett to increase theLearning, use of the CDC’s LLC National Breast and Cervical Cancer Early Detection Program (NBCCEDP) screening services among NOT FOR SALE ORAfrican DISTRIBUTION American women aged 40 to 64. The campaignNOT was FOR piloted SALEin Savannah OR and DISTRIBUTION Macon, Georgia. The AAMM pilot campaign goals included: ■■ Increasing knowledge about breast cancer and mammography. ■■ Increasing awareness of the importance of mammograms for early detection of breast cancer. ■■ Increasing awareness of the NBCCEDP’s low- or no-cost mammogram services. ■■ Increasing© Jonesthe number & of Bartlett women who Learning, get a mammogram LLC through the Breast Test and More© Jones & Bartlett Learning, LLC programNOT (NBCCEDP FOR in Georgia)SALE at OR their DISTRIBUTIONlocal health department. NOT FOR SALE OR DISTRIBUTION The campaign featured public service announcements (PSAs) that consisted of testimonials by breast cancer survivors in Savannah and Macon. The AAMM campaign distributed promotional print materials in Savannah, Georgia. The materials featured positive images of African American women aged 40 to 64 years and explained the © Jonesimportance & Bartlett of getting Learning, a mammogram. LLC They were displayed in and around© JonesSavannah &in retailBartlett stores, Learning, LLC NOT FORpharmacies, SALE grocery OR stores, DISTRIBUTION and the health department. In addition, theyNOT were givenFOR out SALE at local OR DISTRIBUTION community events widely attended by African American women. This campaign was developed, implemented, and evaluated jointly by the CDC, the Georgia Department of Human Services, (https://dhs.georgia.gov/), and the National Cancer Institute’s Cancer Information Service (https://www.cancer.gov/contact/contact-center). These organizations share an interest in reducing the number of deaths from breast cancer among African American © Jones & Bartlettwomen. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Adapted and reprinted from Centers for Disease Control and Prevention. African American Women and Mass Media (AAMM) Campaign. https://www .cdc.gov/cancer/healthdisparities/what_cdc_is_doing/aamm.htm. Accessed October 17, 2019.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CASE STUDYNOT FOR 3: SALE Violence OR DISTRIBUTIONVictimization, Substance Use,NOT FOR SALE OR DISTRIBUTION Suicide Risk, and Sexual Risk Behaviors among Transgender Youths

© JonesTransgender & Bartlett youths (thoseLearning, whose gender LLC identity* does not align with ©their Jones sex†) experience & Bartlett Learning, LLC NOT FORdisparities SALE in violence OR victimization,DISTRIBUTION substance use, suicide risk, and sexualNOT risk comparedFOR SALE with their OR DISTRIBUTION cisgender peers (those whose gender identity does align with their sex).

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©The Jones Youth Risk & BehaviorBartlett Survey Learning, (YRBS) is conducted LLC biennially among local, state,© Jones and & Bartlett Learning, LLC nationally representative samples of U.S. high school students in grades 9–12. In 2017, 10 states (Colorado,NOT Delaware,FOR SALE Hawaii, OR Maine, DISTRIBUTION Maryland, Massachusetts, Michigan, Rhode Island,NOT Vermont, FOR SALE OR DISTRIBUTION and Wisconsin) and nine large urban school districts (Boston, Broward County, Cleveland, Detroit, District of Columbia, Los Angeles, New York City, San Diego, and San Francisco) piloted a measure of transgender identity. Using pooled data from these 19 sites, the prevalence of transgender identity was assessed, and relationships between transgender identity and violence, victimization, © Jones & substanceBartlett use, Learning, suicide risk, and LLC sexual risk behaviors were evaluated© Jones using logistic& Bartlett regression. Learning, LLC NOT FOR SALECompared OR with DISTRIBUTION cisgender males and cisgender females, transgenderNOT studentsFOR SALE were more OR likely DISTRIBUTION to report violence victimization, substance use, and suicide risk, and, although more likely to report some sexual risk behaviors, were also more likely to be tested for human immunodeficiency virus (HIV) infection. These findings indicate a need for intervention efforts to improve health outcomes among transgender youths. © Jones & Bartlett Learning,Overall, LLC 1.8% of students enrolled in the© participating Jones & 10 Bartlett state and nine Learning, urban school LLCdistricts identified as transgender. NOT FOR SALE OR DISTRIBUTIONTransgender youths in high school appearNOT to faceFOR serious SALE risk for OR violence DISTRIBUTION victimization, substance use, and suicide, as well as some sexual risk behaviors, indicating a need for programmatic efforts to better support the overall health of transgender youths. Taking steps to create safe learning environments and to provide access to culturally competent physical and mental health care might be important to improving the health of transgender youths. Continued research into the health of transgender© Jones youths & andBartlett development Learning, of effective LLC intervention strategies are warranted.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION * Gender identity refers to an individual’s sense of their self as male, female, transgender, or something else. Gender identity is distinct from, but related to, gender, or the cultural roles, behaviors, activities, and attributes expected of women and men based on their sex. † Sex refers to an individual’s biologic status as male, female, or something else. Sex is assigned to individuals at birth, and is associated with physical attributes, such as anatomy and chromosomes. © Jones & AdaptedBartlett and reprinted Learning, from Johns MM, Lowry LLC R, Andrzejewski J, et al. Transgender identity and© experiences Jones of violence & Bartlett victimization, substance Learning, use, LLC suicide risk, and sexual risk behaviors among high school students—19 states and large urban school districts, 2017. MMWR Morb Mortal Wkly Rep. NOT FOR SALE2019;68(3):67–70. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Working of Health Services: health services.”16(p140) Major contributions of epidemiology to operations research are the © Jones & Bartlett Learning,Operations LLC Research and © Jonesdevelopment & Bartlett of Learning,research designs, LLC analytic NOT FOR SALE OR DISTRIBUTIONProgram Evaluation NOT FORtechniques, SALE andOR measurementDISTRIBUTION procedures. Operations research strives to answer the The term operations research (operational following kinds of questions, among others: research) is defined as “the systematic study, by observations and experiment, of the working ■■ What health services are not being of a system© Jones (e.g., health& Bartlett services), Learning, with a view LLC supplied by an agency ©in theJones community? & Bartlett Learning, LLC to improvement.”NOT FOR15 SALEEpidemiology OR DISTRIBUTION applied to ■■ Is a particular health serviceNOT FOR SALE OR DISTRIBUTION operations research refers to the study of the unnecessarily duplicated in the placement of health services in a community community? and the optimum use of such services. “The ■■ What segments of the community usual epidemiologic approaches—descrip- are the primary users of a service, © Jones &tive, Bartlett analytic, Learning,and experimental—are LLC all used and which© Jones segments & Bartlett are being Learning, LLC NOT FORin SALE health ORservices DISTRIBUTION research and, in addition, underserved?NOT FOR SALE OR DISTRIBUTION methods of evaluation have been expanded ■■ What is the most efficient organizational through their application to problems in and staff power configuration?

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■■ What characteristics of the community, seemed to have no effect on the providers,© Jonesand patients & Bartlettaffect service Learning, LLCrisk of breast cancer. In October,© Jones it & Bartlett Learning, LLC deliveryNOT and outcome? FOR SALE OR DISTRIBUTIONwas abortions and breast cancer.NOT . . FOR. SALE OR DISTRIBUTION ■■ What procedures could be used to assess, [Later] it was electromagnetic fields match, and refer patients to service (EMF) from power lines. . . facilities? These are not isolated examples of the © JonesThe chapter & Bartlett on “Epidemiology Learning, and LLC Health conflicting nature© Jones of epidemiologic & Bartlett stud Learning,- LLC Policy” provides additional information and NOT FOR SALE OR DISTRIBUTION ies; they are justNOT a few FOR to hitSALE the newspaOR DISTRIBUTION- case studies regarding the use of epidemiology pers. Over the years, such studies have come to study the working of health services. up with a mind-numbing array of potential disease-causing agents, from hair dyes (lym- phomas, myelomas, and leukemia), to coffee © Jones & Bartlett▸▸ Learning,Applications LLC Relevant © (pancreaticJones & cancer Bartlett and heartLearning, disease), LLCto oral NOT FOR SALE OR DISTRIBUTION NOTcontraceptives FOR SALE and other OR hormoneDISTRIBUTION treatments to Disease Etiology (virtually every disorder known to women). The second group of applications encom- The pendulum swings back and forth, sub- passes uses of epidemiology that are jecting the public to an “epidemic of anxiety,” connected with disease etiology (e.g., deter- as Lewis Thomas wrote many years ago.17(p164) mining the ©causes Jones of infectious & Bartlett and chronicLearning, Indeed, LLC the New England Journal© Jonesof Medi -& Bartlett Learning, LLC diseases suchNOT as tuberculosis FOR SALE and ORcancer, DISTRIBUTION as cine published an editorial by editorsNOT Marcia FOR SALE OR DISTRIBUTION well as preventing them). Under this general Angell and Jerome Kassirer asking the pithy area, Morris1 noted the search for causes, question, “What Should the Public Believe?” individual risks, and specific clinical con- “Health-conscious Americans,” they wrote, cerns. (See Figure 2-2.) “increasingly find themselves beset by con- © Jones & Bartlett Learning, LLC tradictory advice.© NoJones sooner & do Bartlett they learn Learning, the LLC NOTCausality FOR SALE in EpidemiologicOR DISTRIBUTION results of one researchNOT FORstudy thanSALE they OR hear DISTRIBUTIONof one with the opposite message.”17(p164) Research Part of the reason for the skepticism As an observational science, epidemiology is about epidemiologic research is the inabil- frequently subject to criticism. The prestigious ity of the discipline to “prove” anything. The © Jones & Bartlettjournal Learning, Science ran LLC a special news report enti- © contributionsJones & Bartlett of Koch Learning, are considered LLC by NOT FOR SALE ORtled, DISTRIBUTION“Epidemiology Faces Its Limits.”17 The NOTsome FOR as a basisSALE for thisOR skepticism. DISTRIBUTION His pos- subtitle read: “The Search for Subtle Links tulates, first developed by Henle, adapted in Between Diet, Life Style, or Environmental 1877, and further elaborated in 1882, also Factors and Disease Is an Unending Source are referred to as the Henle–Koch postulates. of Fear—but Often Yields Little Certainty.” A They were instrumental in efforts to prove portion of the© report Jones follows: & Bartlett Learning,(or LLC disprove) the causative involvement© Jones of & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONa microorganism in the pathogenesisNOT ofFOR an SALE OR DISTRIBUTION In January . . . a Swedish study found infectious disease. The postulates specified [that] residential radon exposure was that the agent must be present in every case associated with lung cancer. A Cana- of the disease, must be isolated and grown dian study did not. Three months in pure culture, must reproduce the disease © Joneslater, & Bartlett it was pesticide Learning, residues. LLC The when reintroduced© Jones into a healthy & Bartlett susceptible Learning, LLC NOT FORJournal SALE of the OR National DISTRIBUTION Cancer Insti- animal, and mustNOT be FOR recovered SALE and OR grown DISTRIBUTION tute [reported] in April . . . that . . . again in a pure culture. In addition, the agent DDT metabolites in the bloodstream should occur in no other disease: the one

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agent–one disease criterion. This classical be reasonable to suspect the Henle–Koch© Jones concept & Bartlett of causality, Learning, sometimes LLC smoking–lung ©cancer Jones association & Bartlett Learning, LLC referredNOT to FORas pure SALE determinism, OR DISTRIBUTION becomes even if such anNOT experiment FOR was SALE OR DISTRIBUTION problematic when one attempts to apply it never conducted? As pointed to the chronic diseases prevalent in modern out in the introduction to eras. Let us examine separately three of the this chapter, there are simply four criteria that form part of Koch’s concept some exposures that cannot © Jones &of causality:Bartlett Learning, LLC © beJones evaluated & Bartlettin the context Learning, of LLC NOT FOR SALE OR DISTRIBUTION NOTcontrolled FOR experimentalSALE OR studies.DISTRIBUTION 1. Agent present in every case of Epidemiology must be relied on the disease. How well would this to provide such information. criterion apply to cardiovascular disease (CVD)? Decades of In addition to the three issues just dis- © Jones & Bartlett Learning, LLCresearch have established that© Jonescussed & Bartlett that are directLearning, tests of LLCKoch’s postu- NOT FOR SALE OR DISTRIBUTIONindividuals who develop CVDNOT FORlates, SALE others must OR be DISTRIBUTION considered. It is relatively tend to be overweight, physically straightforward to categorize individuals with inactive, cigarette smokers and respect to the presence or absence of an expo- have high blood pressure and sure when the exposure is an infectious agent; high total cholesterol. If we were one is either exposed or not exposed. However, © Jonesto apply & Koch’s Bartlett postulates Learning, strictly, LLCeven this simplification ignores© Jones the complicat- & Bartlett Learning, LLC NOTthen FOR every SALE case of OR CVD DISTRIBUTION would ing issue of biologically effectiveNOT FORdose. WhatSALE OR DISTRIBUTION have all these characteristics— about something such as blood pressure? Indi- clearly not true. viduals with “elevated” blood pressure are more 2. One agent–one disease. How likely to develop a stroke than individuals with would this criterion hold up “low” blood pressure. Where does one draw © Jones & Bartlettagainst Learning, cigarette smoking?LLC We the line between© Jones elevated & Bartlett and normal Learning, (or low)? LLC NOT FOR SALE ORjust pointedDISTRIBUTION out that smokers At what NOTlevel should FOR an SALE individual OR be DISTRIBUTION consid- are more likely to develop CVD ered obese? A more subtle concept to consider than nonsmokers. Is CVD the is that, for diseases of unknown etiology, we only disease associated with are dealing with imperfect knowledge. For smoking? No. In fact, smoking example, although we may know that smokers © Jones & Bartlett Learning, LLCis associated with lung cancer, © Jonesare &20 Bartletttimes more Learning, likely to develop LLC lung cancer NOT FOR SALE OR DISTRIBUTIONpancreatic cancer, oral cancer, NOT FORthan SALEnonsmokers, OR whyDISTRIBUTION is it that not all smok- nasopharyngeal cancer, cervical ers develop the disease? There must be other cancer, emphysema, chronic factors (e.g., diet, alcohol intake, and host sus- obstructive pulmonary disease, ceptibility) that are part of the total picture of and stroke, to name just a few. causality. When not all the contributing factors © JonesTherefore, & Bartlett the one agent–one Learning, LLCare known, it is problematic© Jonesindeed to & know Bartlett Learning, LLC NOTdisease FOR criterion SALE isOR not DISTRIBUTIONparticularly truly and accurately the completeNOT FOR cause SALE of a OR DISTRIBUTION helpful, especially for diseases of given disease. The issue of causality and epi- noninfectious origin. demiology has been the focus of debate for 3. Exposure of healthy subjects decades. Some of the early writings are still to suspected agents. The fascinating and relevant today. For example, © Jones & Bartlettethical Learning, conduct ofLLC research on refer to Causal© Jones Thinking & Bartlett in the Health Learning, Sciences LLC NOT FOR SALE ORhumans DISTRIBUTION forbids exposure of by the lateNOT Mervyn FOR Susser. SALE18 The OR work DISTRIBUTION Eras in subjects to risks that exceed Epidemiology by Susser and coauthor Zena potential benefits. Would it Stein presents information on the histo rical

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evolution of epidemiologic ideas.19 Their book disease as a risk factor. There are three requi- illustrates how© Jones epidemiology & Bartlett relies onLearning, and site LLC criteria for risk factors: © Jones & Bartlett Learning, LLC contributes NOTto carefully FOR formulated SALE OR concepts DISTRIBUTION 1. The frequency of the diseaseNOT variesFOR SALE OR DISTRIBUTION of cause, whether derived experimentally or by category or value of the factor. observationally in the laboratory or general Consider cigarette smoking and environment, both physical and social. lung cancer. Light smokers are To summarize, the doctrine of multiple © Jones & Bartlett Learning, LLC more© likely Jones to develop & Bartlett lung cancer Learning, LLC causality (instead of single causal agents) is than nonsmokers, and heavy NOTnow FOR accepted SALE widely; OR DISTRIBUTIONcurrent research indi- smokersNOT are FOR more likelySALE still OR to DISTRIBUTION cates that a framework of multiple causes for develop the disease. chronic diseases such as heart disease, cancer, 2. The risk factor must precede the and diabetes mellitus is appropriate. The late onset of disease. This criterion, John Cassel, a noted epidemiologist, was an © Jones & Bartlett Learning, LLC © Jones &known Bartlett as temporality, Learning, applies LLC to the articulate proponent of multifactorial causality smoking–lung cancer example. We NOT FOR SALE ORfor contemporary DISTRIBUTION diseases. In the fourth Wade NOT FOR nowSALE know OR that DISTRIBUTIONsmoking causes lung Hampton Frost Lecture, Cassel noted that early cancer. Nevertheless, hypothetically theories stated “disease occurred as a result of speaking, if individuals with lung new exposure to a pathogenic agent.” The sin- cancer began to smoke after the gle agent causal model was extended to “the © Jones & Bartlett Learning, LLC onset of disease, smoking© wouldJones & Bartlett Learning, LLC well-known triad of host, agent and environ- not be a likely cause of their 20(pp107–108) The ment in epidemiologicNOT FOR thinking.” SALE OR DISTRIBUTIONcondition. The issue of NOTthe temporal FOR SALE OR DISTRIBUTION formulation was satisfactory to explain diseases relationship between exposure and of importance during the late 19th and early disease is particularly relevant to 20th centuries, when agents of overwhelming chronic diseases such as cancer. pathogenicity and virulence produced con- Epidemiologists may not be able to © Jonesditions & such Bartlett as typhoid Learning, and smallpox. LLC Cassel © Jones & Bartlett Learning, LLC determine when exposure occurred suggested that the triad of agent, host, and NOT FOR SALE OR DISTRIBUTION in relationshipNOT FOR to onset SALE of the OR DISTRIBUTION environment is no longer satisfactory because disease. “In a modern society the majority of citizens 3. The observed association must are protected from these overwhelming agents not be due to any source of error. and most of the agents associated with current © Jones & Bartlett Learning, LLC © Jones &In Bartlett illustration, Learning, researchers couldLLC diseases are ubiquitous in our environment . . . introduce methodological errors NOT FOR SALE OR[There DISTRIBUTION may be] categories or classes of envi- NOT FOR atSALE any of severalOR DISTRIBUTION points during an ronmental factors that are capable of changing epidemiologic investigation. These 20(p108) One human resistance in important ways.” errors might occur in the selection group of factors, Cassel argued, was the social of study groups, measurement of environment (“presence of other members of exposure and disease, and data the same species”),© Jones which & might Bartlett be capable Learning, of LLC © Jones & Bartlett Learning, LLC analysis. profoundly influencingNOT FOR host SALE susceptibility OR DISTRIBUTION to NOT FOR SALE OR DISTRIBUTION environmental disease agents, whether they are microbiologic or physiochemical.20(p108) Modern Concepts of Causality The 1964 Surgeon General’s © JonesRisk &Factors Bartlett Defined Learning, LLC Report © Jones & Bartlett Learning, LLC NOTBecause FOR SALEof the uncertainty OR DISTRIBUTION of “causal” factors Causal inferencesNOT derived FOR SALEfrom epidemi OR DISTRIBUTION- in epidemiologic research, it is customary to ologic research (especially in the realm of refer to an exposure that is associated with a noninfectious diseases) gained increasing

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popularity as a topic of formal discussion of the causal significance of an association22 as a ©result Jones of findings & Bartlett (in the Learning, early 1950s) LLCand, based on these criteria,© Jones concluded & Bartlettthat Learning, LLC regardingNOT the FOR association SALE betweenOR DISTRIBUTION smoking smoking was a cause of lungNOT cancer FOR among SALE OR DISTRIBUTION and lung cancer.21 The publication of Smoking men. (EXHIBIT 2-3 provides a description of and Health, Report of the Advisory Commit- the report.) Susser,23 Hill,24 and Rothman25 tee to the Surgeon General of the Public Health addressed these criteria subsequently in their Service listed five criteria for the judgment writings. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION EXHIBIT 2-3 Case Study: Does Smoking Cause Lung Cancer?

The first Surgeon General’s report on smoking and health was published in 1964. This report generated © Jones & Bartlett Learning,global reaction LLC by stating that cigarette smoking© Jones is a cause & of Bartlett lung cancer Learning, in men and is linked LLC to other disabling or fatal diseases. Five criteria were identified as necessary for the establishment of a NOT FOR SALE OR DISTRIBUTIONcausal relationship between smoking and lungNOT cancer. FOR The report’sSALE authors OR concludedDISTRIBUTION that, to judge the causal significance of the association between cigarette smoking and lung cancer, several of these criteria would have to be taken into account in combination, and no single criterion would, in itself, be “pathognomonic” (pathognomonic means characteristic or diagnostic). The criteria of judgment were strength of association, time sequence, consistency of relationship upon repetition, specificity of association,© Jones and coherence & Bartlett of explanation. Learning, LLC © Jones & Bartlett Learning, LLC 1. NOTStrength FOR of association: SALE ORThe r eportDISTRIBUTION stated that the relative risk ratio was the mostNOT direct FOR measure SALE OR DISTRIBUTION of the strength of association between smoking and lung cancer; several retrospective and prospective studies completed up to the time of the report demonstrated high relative risks for lung cancer among smokers and nonsmokers. Thus, it was concluded that the criterion of strength of association was supported. © Jones & Bartlett2. Time sequence: Learning, The report LLC argued that early exposure to tobacco© Jones smoke & and Bartlett late manifestation Learning, LLC NOT FOR SALEseemed OR toDISTRIBUTION meet the criterion of time sequence, at least superficially.NOT FOR SALE OR DISTRIBUTION 3. Consistency upon repetition: With regard to the causal relationship between smoking and health, the report asserted that this criterion was strongly confirmed for the relationship between smoking and lung cancer. Numerous retrospective and prospective studies demonstrated highly significant associations between smoking and lung cancer; it was unlikely that these findings would be obtained unless the associations were causal or else © Jones & Bartlett Learning,due LLC to unknown factors. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION4. Specificity: The hypothesis that smokingNOT causes FOR lung cancerSALE has OR been DISTRIBUTION attacked because of the lack of specificity of the relationship; smoking has been linked to a wide range of conditions, including cardiovascular disease, low birth weight, and bladder cancer. The report claimed, however, that rarely in the biologic realm does an agent always predict the occurrence of a disease; in addition, accumulating evidence about chronic diseases suggests that a given ©disease may Jones & have Bartlett multiple causes.Learning, LLC © Jones & Bartlett Learning, LLC 5. Coherence of explanation: The report contended that the association between cigarette NOTsmoking FOR and SALElung cancer OR was DISTRIBUTION supported for this criterion. Evidence noted includedNOT the FOR rise in SALE OR DISTRIBUTION lung cancer mortality with increases in per capita consumption of cigarettes and increases in lung cancer mortality as a function of age cohort patterns of smoking among men and women; the sex differential in mortality was consistent with sex differences in tobacco use. General smoking rates were higher among men than among women; the report noted that young © Jones & Bartlettwomen Learning, were increasing LLC their rates of smoking, however. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Data from U.S. Department of Health, Education and Welfare, Public Health Service. Smoking and Health, Report of the Advisory Committee to the Surgeon General of the Public Health Service. Public Health Service publication 1103. Washington, DC: Government Printing Office; 1964.

9781284191127_CH02_Friis.indd 75 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 76 Chapter 2 Practical Applications of Epidemiology

Sir Austin Bradford Hill Further elaborating on his statement, Hill © Jones & Bartlett Learning,asserted LLC that in some instances, much© Jones research & Bartlett Learning, LLC In 1965, Sir Austin Bradford Hill, Professor NOT FOR SALE OR DISTRIBUTIONwould be required to determine theNOT existence FOR SALE OR DISTRIBUTION Emeritus of Medical Statistics at the Univer- of a causal association. In other cases, a smaller sity of London, published one of the seminal body of information would be adequate. Thus, articles that elaborated on the five criteria making causal inferences depends on the cir- for causality in epidemiologic research.24 The cumstances of an association. Hill’s landmark article, which was his President’s Address to © Jones & Bartlett Learning, LLC article identified© nine Jones issues & that Bartlett are relevant Learning, LLC the Section of Occupational Medicine of the NOT FOR SALE OR DISTRIBUTION to causality andNOT epidemiologic FOR SALE research. OR (Refer DISTRIBUTION Royal Society of Medicine, lists nine aspects to Table 2-1.) of an empirical association to consider when one is trying to decide whether the associa- 1. Strength of association. One tion is consistent with cause and effect. (Refer example cited by Hill was the © Jones & Bartlettto TABLELearning, 2-1.) These LLC were not intended to be © Jones &observation Bartlett ofLearning, Percival Pott LLC that chimney sweeps had an enormous NOT FOR SALE ORinterpreted DISTRIBUTION as criteria of causality, but none- NOT FOR SALE OR DISTRIBUTION theless they have been presented as such in increase in scrotal cancer in several textbooks. The following is a quotation comparison with other workers; from his article: the mortality was more than 200 times that of workers not exposed I have ©no Jones wish, nor & Bartlettthe skill, Learning,to LLC to tar and mineral oils.© A Jonesstrong & Bartlett Learning, LLC embark upon a philosophical discus- association is less likely to be the sion of NOTthe meaning FOR SALEof “causation.” OR DISTRIBUTION result of errors. NOT FOR SALE OR DISTRIBUTION The “cause” of illness may be imme- 2. Consistency upon repetition. diate and direct, it may be remote and This term refers to whether the indirect, underlying the observed association between agent and © Jonesassociation. & Bartlett But Learning, with the aims LLC of putative© Jones health effects & Bartlett has been Learning, LLC occupational, and almost synony- observed by different persons in NOT FORmously SALE preventive, OR DISTRIBUTION medicine in mind, differentNOT places, FOR circumstances, SALE OR and DISTRIBUTION the decisive question is whether the times. The Surgeon General’s report frequency of the undesirable event B of 1964 cited a total of 36 different will be influenced by a change in the studies that found an association 24(p295) © Jones & Bartlett Learning,environmental LLC feature A. © Jones &between Bartlett smoking Learning, and lung LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 2-1 Aspects of an Association That Suggest Causality

1. Strength 2. Consistency © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 3. SpecificityNOT FOR SALE OR DISTRIBUTION4. Time sequence NOT FOR SALE OR DISTRIBUTION

5. Biologic 6. Plausibility

7. Coherence 8. Experiment © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR9. Analogy SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Data from Hill AB. The environment and disease: association or causation? Proc R Soc Med. 1965;58:295–300.

9781284191127_CH02_Friis.indd 76 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Applications Relevant to Disease Etiology 77

cancer.22 Hill felt that consistency poisonings are relatively easy to © Joneswas especially & Bartlett important Learning, when the LLC pinpoint as to cause.© Jones Diseases & thatBartlett Learning, LLC NOTexposure FOR SALE was rare. OR DISTRIBUTION have longer latencyNOT periods FOR (many SALE OR DISTRIBUTION 3. Specificity. With respect to forms of cancer, for example) are occupational exposures, Hill noted more difficult to relate to a causal that if “the association is limited to agent; it is said that the onset of specific workers and to particular chronic diseases is insidious and © Jones & Bartlettsites Learning, and types of LLCdisease and there © thatJones one is & ignorant Bartlett of the Learning, precise LLC NOT FOR SALE ORis no DISTRIBUTION association between the work NOTinduction FOR periods SALE for OR chronic DISTRIBUTION and other modes of dying, then diseases. Many different causal clearly that is a strong argument factors could intervene during the in favor of causation.”24(p297) He latency period. This is why a great later went on to acknowledge deal of detective work was needed © Jones & Bartlett Learning, LLCthat the criterion of specificity© Jones & Bartlettto link Learning, early exposure LLC to asbestos NOT FOR SALE OR DISTRIBUTIONshould be used as evidence in NOT FOR SALEin ORshipyards DISTRIBUTION to subsequent favor of causality; however, if development of mesothelioma, a evidence of a specific association form of cancer of the lining of the cannot be obtained, this fact is not abdominal cavity. necessarily a refutation of a causal 5. Biologic gradient. Evidence of a © Jonesassociation. & Bartlett Learning, LLC dose–response curve© Jones is another & Bartlett Learning, LLC NOT4. Time FOR se quence.SALE In OR Hill’s DISTRIBUTION words, important criterion.NOT Hill FOR noted, SALE OR DISTRIBUTION “Which is the cart and which is “The fact that the death rate from the horse?” For example, if one lung cancer increases linearly is trying to identify the role of with the number of cigarettes diet in the pathogenesis of colon smoked daily adds a great deal to © Jones & Bartlettcancer, Learning, one has to LLC be careful © theJones simpler & evidence Bartlett that Learning, cigarette LLC NOT FOR SALE ORto sort DISTRIBUTION out dietary preferences NOTsmokers FOR have SALE a higher OR death DISTRIBUTION that lead to colon cancer versus rate than non-smokers.”24(p298) dietary changes that result from MacMahon and Pugh stated, early stages of the disease. There “The existence of a dose-response is some evidence that low intakes relationship—that is, an increase © Jones & Bartlett Learning, LLCof calcium are associated with © Jones & Bartlettin disease Learning, risk with increase LLC in the NOT FOR SALE OR DISTRIBUTIONincreased risk of colon cancer.NOT FOR SALEamount OR DISTRIBUTIONof exposure—supports the If early stages of disease create view that an association is a causal problems with digestion of milk on e .” 3(p235) FIGURE 2-17 illustrates products (which are good sources a dose–response relationship of calcium), individuals may between number of cigarettes © Joneslower their& Bartlett intake of milkLearning, (and LLC smoked per day© and Jones lung cancer & Bartlett Learning, LLC NOTcalcium) FOR SALE as a consequence OR DISTRIBUTION of the mortality amongNOT male FORBritish SALE OR DISTRIBUTION disease. The shorter the duration physicians. between exposure to an agent 6. Plausibility. If an association is and development of the disease biologically plausible, it is credible (i.e., the latency period), the on the basis of existing biomedical © Jones & Bartlettmore Learning, certain one LLC is regarding the © knowledge.Jones &15 Bartlett The weakness Learning, of LLC NOT FOR SALE ORhypothesized DISTRIBUTION cause of the disease. NOTthis FORline of evidenceSALE ORis that DISTRIBUTION it is For this reason, many of the acute necessarily dependent on the infectious diseases or chemical biologic knowledge of the day.

9781284191127_CH02_Friis.indd 77 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 78 Chapter 2 Practical Applications of Epidemiology

Cancer of lung © Jones300 & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 251 NOT FOR SALE OR DISTRIBUTION 250 † te 200 h Ra

at 150 127 © Jones & Bartlett De Learning, LLC © Jones & Bartlett Learning, LLC 100 NOT FOR SALE OR DISTRIBUTION 78 NOT FOR SALE OR DISTRIBUTION Annual 50 10 0 Non-smokers 1–14 15–24 25+ © Jones & Bartlett Learning, LLC Number of Cigare© Jonesttes Smoked & pe Bartlettr Day Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-17 Lung Cancer Death Rates Among British Physicians by Number of Cigarettes Smoked Per Day † Per 100,000 men, standardized for age. Data from Doll R, Peto R. Mortality in relation to smoking: 20 years’ observation on male British doctors. BMJ. 1976;2(6051):1529, Table IV. ©1976, BMJ Publishing Group.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 7. CoherNOTence FOR of explanation. SALE OR The DISTRIBUTION was associated subsequentlyNOT FOR SALE OR DISTRIBUTION association must not seriously with severe birth defects. Rubella conflict with what is already (German measles), if contracted known about the natural history during pregnancy, has been linked and biology of the disease. Data to birth defects, stillbirths, and © Jones & Bartlettfrom laboratory Learning, experiments LLC on miscarriages.© Jones Given & Bartlett that such Learning, LLC NOT FOR SALEanimals OR may DISTRIBUTION be most helpful. For associationsNOT FOR have alreadySALE been OR DISTRIBUTION example, the ability of tobacco demonstrated, “we would surely extracts to cause skin cancer in be ready to accept slighter but mice is coherent with the theory similar evidence with another that consumption of tobacco drug or another viral disease in © Jones & Bartlett Learning,products LLC in humans causes lung © Jones &pre Bartlett g n an c y.” 24(p299) Learning, LLC NOT FOR SALE OR DISTRIBUTIONcancer. NOT FORAlthough SALE it is notOR critical DISTRIBUTION that all these 8. Experiment. In some instances, lines of evidence be substantiated to uphold a “natural experiments” may shed causal association, the more that are supported, important light on a topic. The the more the case of causality is strengthened. observation that communities More important, careful consideration of these with© Jones naturally & fluoridated Bartlett water Learning, concepts LLC is helpful in trying to decide© Jones at what & Bartlett Learning, LLC hadNOT fewer FOR dental SALE caries amongOR DISTRIBUTION point one needs to take action. OneNOT of FORHill’s SALE OR DISTRIBUTION their citizens than communities concluding remarks was particularly apropos: without fluoridated water is one example. All scientific work is incomplete, 9. Analogy. The examples Hill cited whether it be observational or exper- © Jones & Bartlettare thalidomide Learning, and rubella. LLC imental. All© scientificJones &work Bartlett is liable Learning, LLC NOT FOR SALEThalidomide, OR DISTRIBUTION administered in to be upsetNOT or modified FOR SALE by advanc OR- DISTRIBUTION the early 1960s as an antinausea ing knowledge. That does not con- drug for use during pregnancy, fer upon us a freedom to ignore the

9781284191127_CH02_Friis.indd 78 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Applications Relevant to Disease Etiology 79

knowledge we already have, or to questions leading to judgments, whereas in postpone© Jones the &action Bartlett that it appearsLearning, to LLCany field practitioners must© Jonesgive answers & Bartlett to Learning, LLC demandNOT FOR at a given SALE time. 24(p300)OR DISTRIBUTIONunstructured questions leadingNOT FORfrom SALEjudg- OR DISTRIBUTION ment to decision and implementation.”23(p1) Evans,26 in a compelling discussion of causality, drew an analogy between ascertain- ment of causality and establishment of guilt in Study of Risks to Individuals © Jones &a criminal Bartlett trial. Learning, Evans’ detailed LLC arguments are In many ©instances, Jones epidemiologic & Bartlett research Learning, on LLC NOT FORfound SALE in EXHIBIT OR DISTRIBUTION 2-4. disease etiologyNOT FORinvolves SALE collection OR of DISTRIBUTION data on Frequently, the processes of causal infer- a number of individual members of different ence and statistical inference overlap, yet study groups or study populations. Epidemi- represent different principles. According to ologists use two main types of observational Susser, “Formal statistical tests are framed studies for research on disease etiology: case- © Jones & Bartlett Learning,to give mathematical LLC answers to structured© Jones contr &ol Bartlett and cohort Learning, studies. When LLC subst antiated, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

EXHIBIT 2-4 Rules of Evidence: Criminality and Causality

Mayhem or murder and criminal law © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1. Criminal present at scene of crime. 2. NOTPremeditation. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3. Accessories involved in the crime. 4. Severity or death related to state of victim. 5. Motivation: The crime must make sense in terms of gain to the criminal. 6. No other suspect could have committed the crime. © Jones & Bartlett7. The proof Learning, of the guilt must LLC be established beyond a reasonable© Jones doubt. & Bartlett Learning, LLC NOT FOR SALEMorbidity, OR mortality, DISTRIBUTION and causality NOT FOR SALE OR DISTRIBUTION 1. Agent present in lesion of the disease. 2. Causal events precede onset of disease. 3. Cofactors and/or multiple causalities involved. 4. Susceptibility and host response determine severity. © Jones & Bartlett Learning,5. The LLC role of the agent in the disease must© Jonesmake biolog &ic Bartlett and common Learning, sense. LLC NOT FOR SALE OR DISTRIBUTION6. No other agent could have caused theNOT disease FOR under theSALE circumstances OR DISTRIBUTION given. 7. The proof of causation must be established beyond reasonable doubt or role of chance. In criminal law, the presence of the criminal at the scene of the crime would be equivalent to the presence of the agent in a lesion of the disease. Premeditation would be similar to the requirement that the causal exposure precede the onset of the disease. The presence of accessories at the scene of the© crimeJones might & be Bartlett compared toLearning, the presence LLCof cofactors and/or multiple causes© forJones human & Bartlett Learning, LLC diseases. The severity of the crime or the consequence of death might be loosely equivalent to susceptibilityNOT FOR and the SALE host responses, OR DISTRIBUTION which determine the severity of the illness. TheNOT motivation FOR SALE OR DISTRIBUTION involved in a crime should make sense in terms of reward to the criminal, just as the role of the causal agent should make biologic sense. The absence of other suspects and their elimination in a criminal trial would be similar to that of the exclusion of other putative causes in human illness. Finally, the need for the proof of guilt to be established beyond a reasonable doubt would be true for both © Jones & criminalBartlett justice Learning, and for disease LLC causation. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Data from Evans AS. Causation and disease: a chronological journey. Am J Epidemiol. 1978;108(4):254–255. Used with permission of the Johns Hopkins University School of Hygiene and Public Health. © 1978.

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these two designs imply increased risks to consistent is the finding with previous research? individuals who© Jones are exposed & Bartlett to a hypothesized Learning, Is thereLLC biologic plausibility? All these© Jones issues are & Bartlett Learning, LLC factor. (The NOTconverse FOR is also SALE true: Lower OR DISTRIBUTIONlevels important, but a major issue for theNOT clinician FOR is SALE OR DISTRIBUTION of exposure to the factor decrease risk levels.) the relevance to each particular patient. Epide- Bear in mind that case-control studies involve miologic studies employ groups of individuals; participants who have and do not have a dis- the studies provide evidence that groups with ease or other health outcome. Cohort studies particular exposures or lifestyle characteristics © Jonesbegin with& Bartlett participants Learning, who have andLLC do not are more or less© likely Jones to develop & Bartlett disease thanLearning, LLC NOThave FOR an SALEexposure OR that DISTRIBUTION is hypothesized to be groups of individualsNOT FORwithout SALE the exposures. OR DISTRIBUTION associated with a health outcome. Extrapolation to the individual from findings In a case-control design, researchers based on observations of groups should be compare a group of individuals who have a made with caution. The observation that ciga- disease of interest (the cases) with a group of rette smokers are 20 times more likely to develop © Jones & Bartlettindividuals Learning, who doLLC not have the disease (the © lungJones cancer & thanBartlett nonsmokers Learning, does not LLC neces- NOT FOR SALE ORcontrols). DISTRIBUTION The comparisons between the two NOTsarily FOR entitle SALE someone OR to tell DISTRIBUTION a smoker, “You are groups can involve a variety of hypothesized 20 times more likely to get lung cancer than a exposures (e.g., diet, exercise habits, or use of nonsmoker.” The problem is that a number of sunscreens). Differences in exposures that are other factors may be important contr ibutors observed between the two groups may suggest to the cause of lung cancer. A more accurate why one group© Jones has the disease& Bartlett and the Learning, other statement LLC would be, “Collectively,© groupsJones of & Bartlett Learning, LLC does not haveNOT a disease FOR or otherSALE outcome. OR DISTRIBUTION individuals who smoke are 20 timesNOT more FORlikely SALE OR DISTRIBUTION The second observational research to develop lung cancer than nonsmokers.” The method is the cohort study, discussed in more difference is subtle, yet important. Another issue detail elsewhere in the text. For the purposes of for the clinician is the size of the risk; an example the present discussion, let’s consider a simpli- is the slight risk of mortality from CVD associ- © Jonesfied example & Bartlett of a two-group Learning, exposure-based LLC ated with a high© serum Jones cholesterol & Bartlett level. If Learning, the LLC NOTcohort FOR study. SALE Let’s OR speculate DISTRIBUTION that investigators risk is small, a personNOT mayFOR reasonably SALE notOR wish DISTRIBUTION perform a cohort study to determine whether to change his or her lifestyle.27 The 1990 editorial a particular exposure is related to a health out- in the New England Journal of Medicine is par- come. In this example, investigators assem- ticularly illustrative.2 Suppose that the 10-year ble two study groups free from an outcome risk of death is 1.7% in middle-age d men with © Jones & Bartlettof Learning,interest. Then LLC they identify an exposure © cholesterolJones & levels Bartlett below 200Learning, mg/dL but LLC4.9% if NOT FOR SALE ORhypothesized DISTRIBUTION to increase (or decrease) the NOTthe cholesterolFOR SALE level isOR above DISTRIBUTION 240 mg/dL.35 This chance of getting the outcome (e.g., a disease). difference in risk of approximately 3.0% may not They follow the groups over time for the devel- be sufficient to induce an otherwise healthy man opment of disease, comparing the frequency to try to lower his cholesterol level. Conversely, with which disease develops in the groups even if the risk factor is strong, it may still be exposed and© not Jones exposed & to Bartlettthe factor. Learning,unimportant LLC to individual patients ©if theJones disease & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONis rare. NOT FOR SALE OR DISTRIBUTION Thus, the extrapolation of epidemio- Using Epidemiology for Clinical logic research to individuals is complicated. Another aspect of risk concerns public health Decision Making implications. A risk factor that may be rel- © JonesThe criteria & Bartlett of causality, Learning, covered in theLLC previous atively unimportant© Jones for individuals & Bartlett may Learning, be LLC NOTsection, FOR influenceSALE OR he extent DISTRIBUTION to which the results important indeedNOT when FOR the effect SALE is multiplied OR DISTRIBUTION of an epidemiologic study influence clinical over the population as a whole, especially if the decision making. How large is the effect? How disease is common.

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Another example of this application of population-based data, mortality from these epidemiology© Jones is &predicting Bartlett the Learning, individual’s LLC“minor” diseases might not ©be Jonesobvious. In& 2015, Bartlett Learning, LLC prognosisNOT and FOR likelihood SALE of survivalOR DISTRIBUTION if afflicted influenza was responsible NOTfor 2.1 FOR percent SALE of OR DISTRIBUTION by a serious medical condition. Clinicians total deaths in the United States.12 can use such information to aid the patient in Epidemiologic data may be used to pre- decision-making about whether to undergo dict cancer prognosis and mortality. Both vary invasive surgical procedures or debilitating by site of the tumor, type, and a number of © Jones &treatments Bartlett for Learning, cancer. Information LLC about social variables,© Jones such &as Bartlettsocioeconomic Learning, status, LLC NOT FORprognosis SALE ORhelps DISTRIBUTION demonstrate the efficacy of race, andNOT sex. FIGURE FOR 2-18 SALE presents OR the DISTRIBUTION 5-year medical interventions (e.g., coronary bypass relative survival rate for selected forms of surgery) by showing whether the practice cancer by race from 2002 to 2008. Differences yields an increase in long-term survival for the in survival are evident by both cancer type and population. Some additional illustrations of race. Among African Americans in compari- © Jones & Bartlett Learning,the use of LLCepidemiology to study risks to© the Jones son & with Bartlett whites, Learning,the 5-year survival LLC rates for NOT FOR SALE OR DISTRIBUTIONindividual are making predictions of mortalityNOT FORall cancer SALE sites OR were DISTRIBUTION 59.9% and 68.9%, respec- from cancer and other serious chronic illnesses tively. Survival rates for cancer of the pan- and developing assessments of morbidity and creas and lung (6.0% and 16.9%, respectively) mortality from infectious diseases. were lower than the rates for prostate cancer Epidemiologic research indicates that there (99.9%) and breast cancer (90.2%).29 is an important© Jones contribution & Bartlett to mortalityLearning, from LLC Another illustration of© the Jones study of& risksBartlett Learning, LLC commonNOT infectious FOR SALE diseases, OR such DISTRIBUTION as influ- to the individual involves prognosisNOT FOR of survival SALE OR DISTRIBUTION enza and colds. Sometimes mortality results from coronary bypass surgery. The Veterans from complications that can occur in high-risk Administration Cooperative Study30 traced groups such as neonates, elderly persons, and the survival of 596 patients treated by medi- immunocompromised individuals. Without cation or by surgery for chronic stable angina © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

99.9 99.9 100.0 97.7 All Whites Blacks 90.0 90.2 91.7

80.0 78.0 © Jones & Bartlett Learning, LLC 68.9 70.2 © Jones & Bartlett Learning, LLC 70.0 67.7 68.8 NOT FOR SALE OR DISTRIBUTION 59.9 61.1 NOT FOR SALE OR DISTRIBUTION 60.0 50.0 rcentage 40.0 Pe © Jones30.0 & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT20.0 FOR SALE OR DISTRIBUTION16.9 17.3 13.5 NOT FOR SALE OR DISTRIBUTION 10.0 6.0 6.2 4.8 0.0 All cancer Cervix Lung Pancreas Breast Prostate sites © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORFIGURE SALE 2-18 ORFive- YearDISTRIBUTION Relative and Period Survival (%) from InvasiveNOT Cancer FOR by Race SALE and Sex ORin the DISTRIBUTION United States, 2002–2008 Data from Howlander N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2009 (Vintage 2009 Populations). Bethesda, MD: National Cancer Institute; 2012.

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in a large-scale prospective, randomized study. be a highly virulent and new condition. The Findings indicated© Jones no differences & Bartlett in survival Learning, at outbreak LLC of a mysterious illness ©that Jones ravaged & Bartlett Learning, LLC 21 and 36 monthsNOT between FOR surgerySALE patients OR DISTRIBUTION and participants at the American Legion’sNOT FOR July SALE OR DISTRIBUTION medically treated patients. Thus, the factors 1976 convention in Philadelphia riveted pub- of mortality from surgery itself and expense lic attention. Concerned officials appealed to of the operation need to be weighed against local and federal epidemiologists to investigate increases in life expectancy and improvement the outbreak. Disease detectives ascertained © Jonesin the &quality Bartlett of life Learning,due to improved LLC arterial that Legionnaires’© Jonesdisease was & associatedBartlett withLearning, LLC NOTcirculation. FOR SALE This isOR an epidemiologicDISTRIBUTION question a previously unidentifiedNOT FOR bacterium, SALE OR Legio DISTRIBUTION- that may be raised about risks associated with nella pneumophila. Although the Philadelphia other types of surgical procedures as well. outbreak suggested initially that Legionnaires’ disease was highly fatal, subsequent research found a much lower case fatality rate; about © Jones & BartlettEnlargement Learning, LLC of the Clinical © 15%Jones of the & people Bartlett who developedLearning, the LLCdisease NOT FOR SALE ORPicture DISTRIBUTION of Disease NOTdied FORfrom SALEit. The ORpreviously DISTRIBUTION unrecognized disease had probably occurred sporadically in When a new disease first gains the attention other areas of the country before 1976. of health authorities, usually they observe the most dramatic cases initially. One may con- clude incorrectly© Jones that the & Bartlettnew disease Learning, is an Prevention LLC of Disease © Jones & Bartlett Learning, LLC extremely acuteNOT or FOR fatal condition; SALE OR later DISTRIBUTION epi- NOT FOR SALE OR DISTRIBUTION demiologic studies may reveal that the most One of the potential applications of research common form of the new disease is a mild, on disease etiology is to identify where, in the subclinical illness that occurs widely in the disease’s natural history, effective intervention population. To develop a full clinical picture might be implemented. The natural history © Jonesof the &disease, Bartlett thorough Learning, studies are LLC necessary of disease refers© to Jones the course & ofBartlett disease from Learning, LLC NOTto FOR find outSALE about OR the subacuteDISTRIBUTION cases; an ade- its beginning toNOT its final FOR clinical SALE end ORpoints. DISTRIBUTION quate study may require a survey of a com- FIGURE 2-19 illustrates the prepathogenesis and plete population. pathogenesis periods of the natural history of One example of this use of epidemiology any disease in humans. is the investigation of the 1976 Legionnaires’ During prepathogenesis, the precursors © Jones & Bartlettdisease Learning, outbreak, LLC which at first seemed to © ofJones disease & (e.g., Bartlett the bacterium Learning, that LLCcauses NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Transfer of agent Disease agents present to host Initiation of in environment without pathogenesis © Jonesaffecting & aBartlett human host Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Prepathogenesis Process of development (before pathogenesis of a disease within a © Jones & Bartlett Learning,begins) LLC host (pathogenesis)© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-19 The Natural History of Any Disease in Humans. Prepathogenesis and Pathogenesis Periods of Natural History

9781284191127_CH02_Friis.indd 82 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Applications Relevant to Disease Etiology 83

Pathologic Onset of Usual time Exposure © Jones & Bartlett Learning,changes LLCsymptoms of diagnosis© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Stage of Stage of Stage of Stage of recovery, © Jones & Bartlettsusceptibility Learning, LLCsubclinical disease clinical disease© Jonesdisabili & Bartlettty, or death Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-20 Disease Progression from Prepathogenesis to Pathogenesis in the Natural History of Disease Centers for Disease Control and Prevention. Principles of Epidemiology. 2nd ed. Atlanta, GA: U.S. Department of Health and Human Services; 1992.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONLegionnaires’ disease) have not yet interactedNOT FORemergence SALE and OR estab DISTRIBUTIONlishment of processes with the host (the person who gets the dis- and factors (enviro nmental, economic, ease). The period of pathogenesis occurs after social, behavioral, cultural) known to the precursors have interacted with the host, increase the risk of disease.”15 Primordial an event that is marked by initial appear- prevention is concerned with minimizing ance ©of Jonesdisease (the& Bartlett presymptomatic Learning, stage) LLChealth hazards in general,© whereas Jones primary & Bartlett Learning, LLC and isNOT characterized FOR SALE by tissue OR DISTRIBUTIONand physi- prevention seeks to lowerNOT the occurrence FOR SALE of OR DISTRIBUTION ologic changes. Later stages of the natural disease. Primordial prevention is achieved history include development of active signs in part through health promotion, which and symptoms and, eventually, recovery, dis- includes health education programs in gen- ability, or death (all examples of clinical end eral, marriage counseling, sex education, and © Jones &points). Bartlett FIGURE Learning, 2-20 shows LLCdisease progres- provision© of Jones adequate & housing. Bartlett Learning, LLC NOT FORsion SALE from ORprepathogenesis DISTRIBUTION to pathogenesis in ExamplesNOT FORof primary SALE prevention OR DISTRIBUTION that the natural history of disease timeline. involve specific protection against disease- According to the model that Leavell and causing hazards are wearing protective Clark31 advanced, three strategies for dis- devices to prevent occupational injuries, use ease prevention—primary, secondary, and of specific dietary supplements to prevent © Jones & Bartlett Learning,tertiary—coincide LLC with the periods of ©pre Jones- nutritional & Bartlett deficiency Learning, diseases, LLC immuniza- NOT FOR SALE OR DISTRIBUTIONpathogenesis and pathogenesis. The threeNOT FORtions SALE against OR specific DISTRIBUTION infectious diseases, forms of prevention are described in more and education about the hazards of starting detail in the following sections. smoking. Interventions to reduce the number of alcohol-related traffic accidents similarly may focus on education, media campaigns, Primary© Jones Prevention & Bartlett Learning, LLCand warning labels on alcohol-containing© Jones & Bartlett Learning, LLC PrimaryNOT prevention FOR SALE occurs OR during DISTRIBUTION the period beverages. NOT FOR SALE OR DISTRIBUTION of prepathogenesis, As shown in FIGURE 2-21, Primary prevention may be either active primary prevention includes health promo- or passive. Active prevention necessitates tion and specific protection against diseases. behavior change on the part of the subject. The former is analogous to a type of preven- Wearing protective devices and obtaining © Jones &tion Bartlett known asLearning, primordial LLCprevention. The vaccinations© Jones require & involvement Bartlett ofLearning, the indi- LLC NOT FORterm SALE primordial OR DISTRIBUTION prevention denotes “con- vidual toNOT receive FOR the SALEbenefit. ORPassive DISTRIBUTION inter- ditions, actions and measures that minimize ventions, on the other hand, do not require hazards to health and that hence inhibit the any behavior change. Fluoridation of public

9781284191127_CH02_Friis.indd 83 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 84 Chapter 2 Practical Applications of Epidemiology

Primary prevention: Prevention before the occurrence © Jones & Bartlettof disease Learning, during prepathogenesis LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Specific prevention Primordial prevention (e.g., personal protective © Jones & Bartlett Learning,(e.g., creation LLC of devices for work©ers; Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONhealthy living and vaccinationsNOT for FOR SALE OR DISTRIBUTION social conditions) vaccine-preventable diseases)

FIGURE 2-21 Primary Prevention of Disease © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION water supplies and vitamin fortification One example of secondary prevention is early of milk and bread products achieve their diagnosis and prompt treatment linked to desired effects without any voluntary effort cancer screening programs, which are efforts of the recipients.© Jones & Bartlett Learning,to LLCdetect cancer in its early stages© (when Jones it is & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONtreated more successfully) amongNOT apparently FOR SALE OR DISTRIBUTION healthy individuals. One should note that Secondary Prevention in the instance of a positive screening result Secondary prevention, which takes place confirmed by a diagnostic workup, cancer during the pathogenesis phase of the nat- is already present; however, detection of the © Jonesural history & Bartlett of disease, Learning, encompasses LLC early tumor before the© Jonesonset of clinical& Bartlett symptoms Learning, LLC NOTdiagnosis FOR SALE and prompt OR DISTRIBUTION treatment, as well as reduces the likelihoodNOT FOR of SALEprogression OR DISTRIBUTIONto disability limitation. FIGURE 2-22 describes death. Most cancer screening programs are secondary and tertiary prevention of disease. forms of secondary prevention. However,

Secondary prevention Tertiary prevention © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Rehabilitation programs Screening programs for those affected by the for early detection of late sequelae of disease, disease, e.g., cancer e.g., occupational screening, infectious © Jones & Bartlett Learning, LLC therapy among wo© rkJonesers & Bartlett Learning, LLC disease screening NOT FOR SALE OR DISTRIBUTION recovering from NOTinjuries FOR SALE OR DISTRIBUTION

FIGURE 2-22 Secondary and Tertiary Prevention of Disease

9781284191127_CH02_Friis.indd 84 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Study Questions and Exercises 85

screening for colorectal cancer can be con- patients. This category of prevention seeks sidered© Jonesalso as primary & Bartlett prevention: Learning, Because LLCto achieve maximum use ©of theJones capacities & Bartlett of Learning, LLC most NOTcolorectal FOR cancersSALE ariseOR DISTRIBUTIONthrough a persons who have disabilitiesNOT and FOR help SALEthem OR DISTRIBUTION precancerous lesion (adenomatous polyp), regain full employment. screening that detects and removes polyps can prevent cancer, rather than merely detect cancer early. © Jones & BartlettLater in Learning,the natural history LLC of disease ▸▸ Conclusion© Jones & Bartlett Learning, LLC NOT FOR(when SALE discernible OR DISTRIBUTION lesions or advanced disease NOT FOR SALE OR DISTRIBUTION This chapter identified seven uses of epide- have appeared), a type of secondary preven- miology. The historical use of epidemiology tion called disability limitation is designed to traced changes in rates of disease from early in limit and shorten the period of disability and this century to the present. Patterns of morbid- prevent death from a disease. Another goal ity and mortality have changed dramatically © Jones & Bartlett Learning,of disability LLC limitation is to prevent the ©side Jones & Bartlett Learning, LLC during this time period. Predictions of future NOT FOR SALE OR DISTRIBUTIONeffects and complications that may be associNOT- FOR SALE OR DISTRIBUTION trends in health status incorporate population ated with a disease. dynamics or shifts in the demographic composition of populations. Operations research Tertiary Prevention and program evaluation are examples of using Tertiary© Jones prevention & Bartlett takes place Learning, during late LLCepidemiologic methods to© improveJones health& Bartlett- Learning, LLC pathogenesisNOT FOR (advanced SALE disease OR DISTRIBUTION and con- care services. Public healthNOT practitioners FOR SALE and OR DISTRIBUTION valescence stages). (Refer to Figure 2-22.) researchers employ epidemiologic methods Thus, disease already has occurred and has for describing the health of the community, been treated clinically, but rehabilitation is identifying causes of disease, and studying needed to restore the patient to an optimal risks to individuals. One of the most import- © Jones &functional Bartlett level. Learning, Examples LLCinclude physical ant epidemiologic© Jones applications & Bartlett is Learning,the study LLC NOT FORtherapy SALE for OR stroke DISTRIBUTION victims, halfway houses of the causalityNOT FORof disease; SALE a detailed OR DISTRIBUTION account for persons recovering from alcohol abuse, of causality was provided. The chapter con- sheltered homes for the developmentally dis- cluded with a review of primary, secondary, abled, and fitness programs for heart attack and tertiary prevention of diseases.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Study Questions and Exercises 1. Define in your own words the 2. Name three approaches for prevention ©fol Joneslowing terms: & Bartlett Learning, LLC (primary, secondary,© and Jones tertiary) & of Bartlett Learning, LLC NOTa. secula FORr trends SALE OR DISTRIBUTION each of the followingNOT health FOR problems/ SALE OR DISTRIBUTION b. operations research conditions: c. risk factor a. motor vehicle accidents d. the natural history of disease b. obesity e. demographic transition © Jones & Bartlettf. epidemiologic Learning, transition LLC c.© hepati Jonestis A & Bartlett Learning, LLC NOT FOR SALEg. ORdisor ders:DISTRIBUTION disappearing, residual, d.NOT hepat FORitis B and SALE C OR DISTRIBUTION persisting, epidemic e. foodborne illness on cruise ships h. population pyramid f. mortality due to gang violence

9781284191127_CH02_Friis.indd 85 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 86 Chapter 2 Practical Applications of Epidemiology

3. Apply the seven uses of epidemiology causality of disease. Suggest other (as fo©rmulated Jones by & Morris Bartlett1) to a Learning, LLCexamples of how epidemiology© Jones might & Bartlett Learning, LLC publicNOT health FOR issue SALE(e.g., reduction OR DISTRIBUTION be applied to study the causalityNOT of FOR SALE OR DISTRIBUTION of health disparities). For example, disease. use of number 2, “Diagnose the 9. The following questions refer to health of the community,” might TABLE 2-A1. involve identification of groups in a. Calculate the percentage decline in © Jones &the Bartlett community Learning, that are at high LLC risk the death© Jones rate for &all Bartlettcauses. What Learning, LLC NOT FORfor SALE sexually OR transmitted DISTRIBUTION diseases. generalizationsNOT FOR can SALE be made OR about DISTRIBUTION Similarly, the remaining six uses changes in disease rates that have could be applied to other aspects of occurred between 1900 and the health disparities. Are the uses of present? epidemiology defined in the chapter b. Contrast the changes in death rates © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC distinct or overlapping? Can you due to cancer, heart disease, and NOT FOR SALE OR DISTRIBUTIONthink of other uses of epidemiology NOT FORcerebrovascular SALE OR DISTRIBUTION diseases. What not identified in the chapter? Do all additional information would be the uses belong exclusively to the useful to specify better the changes domain of epidemiology? in these conditions? 4. Descri©be Jones a role for & epidemiology Bartlett Learning, in LLCc. Note the decline in mortality© Jones for & Bartlett Learning, LLC the field of policy evaluation. Consider the four communicable diseases how theNOT field FOR of epidemiology SALE OR might DISTRIBUTION (1, 2, 3, and 10) since 1900.NOT With FOR SALE OR DISTRIBUTION inform policy evaluation of laws that the exception of pneumonia and regulate tobacco consumption in influenza, these are no longer public places. among the 10 leading causes of © Jones5. &How Bartlett are the rules Learning, of evidence LLC for death.© CanJones you speculate & Bartlett regarding Learning, LLC NOT FORcriminality SALE OR similar DISTRIBUTION to or different how NOTmuch ofFOR each SALEis due to OR DISTRIBUTION from the rules of evidence for disease environmental improvements and causality? (Refer to Exhibit 2-4 to help how much to specific preventive with your answer.) and curative practices? 6. Clinicians and epidemiologists differ d. Among the 10 leading causes of © Jones & Bartlett Learning,in their assessment LLC of the importance © Jones &death Bartlett in 2015 Learning,were chronic lowerLLC NOT FOR SALE OR DISTRIBUTIONof risks. State how the clinical and NOT FORrespiratory SALE OR diseases DISTRIBUTION (48.2 per epidemiologic approaches differ. 100,000—rank 3), Alzheimer’s Give an example by using a disease disease (34.4 per 100,000—rank 6), or condition that is important for diabetes (24.7 per 100,000— society. rank 7), and suicide (13.7 per 7. Descri©be Jones how it is &possible Bartlett for an Learning, LLC 100,000—rank 10). (Note:© JonesData & Bartlett Learning, LLC infectiousNOT disease FOR to SALE be considered OR DISTRIBUTION are not shown in Table NOT2A-1.) InFOR SALE OR DISTRIBUTION an extremely acute or fatal condition 1900, these were not among the 10 when it first comes to the attention of leading causes of death. How do public health authorities, but then later you account for these changes? it is found to be mild or benign in its 10. The following questions refer to © Jones &most Bartlett common Learning, form. Give an LLC example Figure 2-3.© Jones & Bartlett Learning, LLC NOT FORof SALE such a disease.OR DISTRIBUTION a. List aNOTnd describe FOR the SALE trends ORin DISTRIBUTION 8. This chapter stated how epidemiology death rates by the five leading may be applied to the study of the causes of death.

9781284191127_CH02_Friis.indd 86 20/02/20 8:56 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Study Questions and Exercises 87

TABLE© Jones 2-A1 Leading& Bartlett Causes Learning, of Death and RatesLLC for Those Causes in 1900 and© Jones 2015, & Bartlett Learning, LLC NOT FORUnited Sta SALEtes OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Rate per 100,000 Population

1 Influenza and pneumonia, except pneumonia of newborn 202.2 17.8 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 2 Tuberculosis, all forms NOT FOR SALE OR DISTRIBUTION194.4 NAb

3 Diarrhea and enteritis 139.9 NA

4 Disease of heart 137.4 197.2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 5 NOT CerebrovascularFOR SALE diseases OR DISTRIBUTION 106.9 NOT FOR 43.7 SALE OR DISTRIBUTION

6 Chronic nephritis 81.0 15.5

d © Jones & Bartlett7 Accidents Learning, and adverse LLC effects © Jones &72.3 Bartlett Learning, 45.6 LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 8 Malignant neoplasms 64.0 185.4

9 Senility 50.2 NA

© Jones & Bartlett Learning,10 LLC Diphtheria © Jones & Bartlett Learning,40.3 LLCNA NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a Some categories may not be strictly comparable because of change in classification. b NA: These are no longer listed among the top 10 causes of death. c Crude death rate d Accidents (unintentional injuries) Data from U.S. Bureau of the Census. Statistical Abstract of the United States: 1957. Washington, DC: U.S. Bureau of the Census; 1957: 69; U.S. Public Health© Service. Jones Vital Statistics & RatesBartlett in the United States,Learning, 1900–1940. Washington, LLC DC: U. S. Government Printing Office; 1947;© Heron Jones M. Deaths: &leading Bartlett Learning, LLC causesNOT for 2015. NatlFOR Vital Stat SALE Rep. 2017;66(5). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

b. Describe the trend for c. Does the curve for accidental deaths hypertension and Parkinson’s correspond to our expectations from © Jones & Bartlettdisease. Learning, Can you suggestLLC an ©various Jones publicity & Bartlett reports? Learning, LLC NOT FOR SALE ORexplanation DISTRIBUTION for the trends in d.NOT What FOR is the trendSALE for ORAlzheimer’s DISTRIBUTION hypertension and Parkinson’s disease? Can you offer an disease deaths? explanation?

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11. Organize a discussion panel in your 13. In your own opinion, what methods of classroom© Jones or online & forumBartlett regarding Learning, LLCcommunication are likely to© be Jones most & Bartlett Learning, LLC the impactsNOT ofFOR poverty SALE on adverse OR DISTRIBUTIONsuccessful for reaching sub-populationsNOT FOR SALE OR DISTRIBUTION health outcomes. Develop a set of 10 at risk of health disparities? recommendations for improving the 14. In your own opinion, how can health status of persons in poverty the school environment be either status. detrimental or conducive to reduction © Jones12. &Cond Bartlettuct an online Learning, search of theLLC of health© disparities Jones among& Bartlett diverse Learning, LLC NOT FORliterature SALE on OR programs DISTRIBUTION to reduce health groups ofNOT students? FOR Be SALEsure to give OR DISTRIBUTION disparities. Write a case study about a examples. program for reducing health disparities.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORReferences DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Morris JN. Uses of Epidemiology. 3rd ed. Edinburgh, 13. Ibrahim MA. Epidemiology and Health Policy. UK: Churchill Livingstone; 1975. Gaithersburg, MD: Aspen Publishers; 1985. 2. Angell M. The interpretation of epidemiologic studies. 14. Samet JM, Lee NL. Bridging the gap: Perspectives on Editorial. N Engl J Med. 1990;323:823–825. translating epidemiologic evidence into policy. Am 3. MacMahon© B, JonesPugh TF. Epidemiology & Bartlett Principles Learning, and LLCJ Epidemiol. 2001;154(12)(suppl):S1–S3.© Jones & Bartlett Learning, LLC Methods. Boston, MA: Little, Brown; 1970. 15. Porta M. A Dictionary of Epidemiology. 6th ed. New 4. Susser MW,NOT Watson FOR W, Hopper SALE K. ORSociology DISTRIBUTION in York, NY: Oxford University Press; 2014.NOT FOR SALE OR DISTRIBUTION Medicine. 3rd ed. New York, NY: Oxford University 16. Hulka BS. Epidemiological applications to health Press; 1985. services research. J Community Health. 1978;4: 5. Mausner JS, Kramer S. Epidemiology: An Introductory 140–149. Text, 2nd ed. Philadelphia: Saunders; 1985. 17. Epidemiology faces its limits. Science. 1995;269: 6. Raymond J, Wheeler W, Brown MJ. Inadequate and 164–169. © Jonesunhealthy & Bartlett housing, 2007 Learning, and 2009. MMWR. LLC 2011;60 18. Susser M. Causal© thinkingJones in the& healthBartlett sciences . Learning,New LLC NOT FOR(supplement):21–27. SALE OR DISTRIBUTION York, NY: OxfordNOT University FOR Press; SALE 1973. OR DISTRIBUTION 7. Hoyert DL, Heron MP, Murphy SL, Kung H. Deaths: 19. Susser M, Stein Z. Eras in Epidemiology. New York, Final data for 2003, National Vital Statistics Reports. NY: Oxford University Press; 2009. Vol. 46, No 13, p. 5. Hyattsville, MD: National Center 20. Cassel J. The contribution of the social environment for Health Statistics, 2006. to host resistance. Am J Epidemiol. 1976;104:107–123. 8. U.S. Department of Health and Human Services. 21. Winkelstein W Jr. Invited commentary on “Judgment © Jones & Bartlett Learning,Healthy People 2010: LLC Understanding and Improving © Jonesand causal & Bartlett inference: criteriaLearning, in epidemiologic LLC Health. 2nd ed. Washington, DC: U.S. Government studies.” Am J Epidemiol. 1995;141:699–700. NOT FOR SALE ORPrinting DISTRIBUTION Office; November 2000. NOT22. U.S. FOR Depa rtmentSALE of Health,OR DISTRIBUTION Education and Welfare, 9. U.S. Department of Health and Human Services. Public Health Service. Smoking and Health, Report Healthy People 2020. Office of Disease Prevention and of the Advisory Committee to the Surgeon General Health Promotion. ODPHP Publication No. B0132. of the Public Health Service. Public Health Service http://www.healthypeople.gov. Published November Publication 1103. Washington, DC: Government 2010. Accessed© Jones August 17, &2019. Bartlett Learning, LLCPrinting Office; 1964. © Jones & Bartlett Learning, LLC 10. U.S. Department of Health and Human Services. 23. Susser M. Judgment and causal inference: Criteria in HHS ActionNOT Plan to FORReduce RacialSALE and EthnicOR DISTRIBUTIONHealth epidemiologic studies. Am J Epidemiol.NOT 1977;105:1–15. FOR SALE OR DISTRIBUTION Disparities: A Nation Free of Disparities in Health and 24. Hill AB. The environment and disease: Association or Health Care. Washington, D.C.: U.S. Department of causation? Proc R Soc Med. 1965;58:295–300. Health and Human Services; April 2011. 25. Rothman KJ. Modern Epidemiology. Boston, MA: 11. Truman BI, Smith CK, Roy K, et al. Rationale Little, Brown; 1986. © Jonesfor ®ular Bartlett reporting Learning, on health disparities LLC and 26. Evans AS. Causation© Jones and disease: & Bartlett A chronological Learning, LLC inequalities–United States. MMWR Morb Mortal journey. Am J Epidemiol. 1978;108:254–255. NOT FORWkly RepSALE. 2011;60(suppl):3–10. OR DISTRIBUTION 27. Brett AS. TreatingNOT hypercholesterolemia: FOR SALE how OR should DISTRIBUTION 12. Heron M. Deaths: Leading causes for 2015. Natl Vital practicing physicians interpret the published data for Stat Rep. 2017;66(5). patients? N Engl J Med. 1989;321:676–680.

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28. Pekkanen J, Linn S, Heiss G, et al. Ten-year mortality 30. Murphy M, Hultgren HN, Detre K, et al. Treatment of fro©m cardiovascularJones & diseaseBartlett in relation Learning, to cholesterol LLC chronic stable angina: a preliminary© Jones report of & survival Bartlett Learning, LLC level among men with and without preexisting data of the randomized Veterans Administration cardiovascularNOT FOR disease. SALE N Engl OR J MedDISTRIBUTION. 1990;322: Cooperative Study. N Engl J MedNOT. 1977;297:621–627. FOR SALE OR DISTRIBUTION 1700–1707. 31. Leavell HR, Clark EG. Preventive Medicine for 29. Howlader N, Noone AM, Krapcho M, et al., eds. SEER the Doctor in His Community: An Epidemiologic Cancer Statistics Review, 1975–2009 (Vintage 2009 Approach. 3rd ed. New York, NY: McGraw-Hill Book Populations). Bethesda, MD: National Cancer Institute. Company; 1965. © Jones & Bartletthttps://seer.cancer.gov/archive/csr/1975_2009 Learning, LLC © Jones & Bartlett Learning, LLC _pops09/. Accessed October 18, 2019. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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