Epidemiology: Challenges and Answers in the Context of Globalization

1
Epidemiology Challenges and Answers in the
Context of Globalization
Moyses Szklo Professor of Epidemiology and
Medicine The Johns Hopkins Bloomberg School of
Public Health and School of Medicine
2
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evaluation of natural history phase specific risk factors Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

3
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Demographic transition Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
4
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
5
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
6
Host
Primary Prevention Strategies
Vector
Environment
Agent
THE EPIDEMIOLOGIC TRIAD AGENT, HOST AND
ENVIRONMENT
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Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
8
NATURAL HISTORY
Early Detection (if possible)
TIME
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Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
10
Causal Components and Sufficient Causes of
Stroke Hypothetical Causality Chain
Sufficient cause a set of minimal conditions
and events that inevitably produce disease
(Rothman K. Modern Epidemiology. Boston, Toronto
Little Brown and Company,1986)
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STROKE PREVENTION
Population-wide strategy ? per capita salt
intake 33 ? ? stroke incidence 22 (Law MR,
et al. Br Med J 1991302819-24)
In order to implement preventive measures, it is
not necessary to understand the causal mechanisms
in their entirety (MacMahon B, Pugh TF, Ipsen J.
Epidemiology Principles and Methods. Boston
Little, Brown and Co., 1960, p. 18)
Poor access to healthy foods
Low Social Class
Excessive salt content of processed foods
Distal Sufficient Cause
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STROKE PREVENTION
No. of individuals
Systolic Blood Pressure
High Salt Intake
Obesity
Low Levels of Physical Activity
Stress
Intermediate Sufficient Cause
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STROKE PREVENTION
High risk strategy identification, treatment and
control of all patients with hypertension ? ?
stroke incidence 15 (Law MR, et al. Br Med J
1991302819-24)
BP levels with high RR, low ARPOP
No. of individuals
Systolic Blood Pressure
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STROKE PREVENTION
Blood pressure levels with low RR and high ARPOP
High risk strategy identification, treatment and
control of all patients with hypertension ? ?
stroke incidence 15 (Law MR, et al. Br Med J
1991302819-24)
BP levels with high RR, low ARPOP
No. of individuals
Systolic Blood Pressure
15
STROKE PREVENTION
Risk of Stroke
Systolic Blood Pressure
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STROKE PREVENTION
Population-wide strategy ? per capita salt
intake 33 ? ? stroke incidence 22 (Law MR,
et al. Br Med J 1991302819-24)
Blood pressure levels with low RR and high ARPOP
BP levels with high RR, low ARPOP
No. of individuals
Systolic Blood Pressure
17
STROKE PREVENTION
Population-wide strategy ? per capita salt
intake 33 ? ? stroke incidence 22 (Law MR,
et al. Br Med J 1991302819-24)
Blood pressure levels with low RR and high ARPOP
BP levels ? high RR, low ARPOP
No. of individuals
Systolic Blood Pressure
18
STROKE PREVENTION
Population-wide strategy ? per capita salt
intake 33 ? ? stroke incidence 22 (Law MR,
et al. Br Med J 1991302819-24)
(Rose G, Int J Epidemiol 19851432-38)
No. of individuals
Kenia nomads
Civil servants
Systolic Blood Pressure
Poor access to healthy foods
Low Social Class
Excessive salt content of processed foods
Distal Sufficient Cause
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Life Time Associated Risks of Cancer
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How Much Breast and Ovarian Cancer Is Hereditary?
15-20
510
510
Ovarian Cancer
Breast Cancer
Sporadic Hereditary
GENETIC INHERITANCE - High Relative Risk - Low
Population Attributable Risk
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• SENSITIVITY OF A HIGH RISK SCREENING PROGRAM FOR
  INCIDENT BREAST CANCER CASES DURING ONE YEAR IN A
  TARGET POPULATION OF 100 000 WOMEN
• Average yearly incidence in S. Paulo, 1998-2000 ?
  278/100 000

1st Phase Sensitivity of Family History of
Breast Cancer 0.54 2nd Phase Sensitivity of
Mammography 0.93
Câncer no Brasil- Dados do Registro de Câncer de
Base Populacional. Disponível em
http//www.inca.gov.br/vigilancia/ CONPREV-INCA-MS
e IBGE-MP
Szklo M. J Gen Intern Med 1990
5(Suppl)S47-S49 Hartmann et al, New Eng J Med
2005353229-37 Mushlin et al, Am J Prev Med
199814143-53
22

• SENSITIVITY OF A HIGH RISK SCREENING PROGRAM FOR
  INCIDENT BREAST CANCER CASES DURING ONE YEAR IN A
  TARGET POPULATION OF 100 000 WOMEN
• Average yearly incidence in S. Paulo, 1998-2000 ?
  278/100 000

1st Phase Sensitivity of Family History of
Breast Cancer 0.54 2nd Phase Sensitivity of
Mammography 0.93
Total No. of False Negatives at the End of the
2nd Phase 128 10 138
Câncer no Brasil- Dados do Registro de Câncer de
Base Populacional. Disponível em
http//www.inca.gov.br/vigilancia/ CONPREV-INCA-MS
e IBGE-MP
Szklo M. J Gen Intern Med 1990
5(Suppl)S47-S49 Hartmann et al, New Eng J Med
2005353229-37 Mushlin et al, Am J Prev Med
199814143-53
23
Use of Genetic Epidemiology in Public Health

• Identification of genotypes that are effect
  modifiers equivalent to selective screening
  two steps (1) identification of susceptibility
  gene, and (2) prevention or cessation of risk
  factor in those with the gene.
• Possible negative consequence shifts the
  responsibility of prevention to the individual
  Genetic Epidemiology the epidemiology of the
  individual (Wynder, personal communication).
• Advantages study of disease mechanisms,
  pharmacogenetics, vector resistance, etc.

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ONE OF THE MAIN FOUNDATIONS OF THE
POPULATION-WIDE PREVENTION STRATEGY SOCIAL
EPIDEMIOLOGY
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STROKE PREVENTION
INDIVIDUAL LEVEL
INDIVIDUAL LEVEL
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INCIDENCE OF CORONARY EVENTS IN WHITES AND
BLACKS, ARIC STUDY (Diez Roux et al, New Engl J
Med 200134599-106)
Men Men Men Women Women Women
Neighborhood group socio-economic score Neighborhood group socio-economic score No. of events Rate per 1000 PYs (95 CI) No. of events Rate per 1000 PYs (95 CI)
Whites Whites
1 (low) 119 9.5 (7.7, 11.5) 68 3.9 (2.9, 5.1)
2 109 8.3 (6.8, 10.0) 45 2.6 (2.0, 3.6)
3 (high) 70 4.9 (3.8, 6.3) 24 1.5 (1.0, 2.3)
Blacks Blacks
1 (low) 38 9.8 (7.0, 13.7) 40 5.1 (3.7, 7.2)
2 27 7.5 (5.1, 11.0) 34 5.1 (3.6, 7.2)
3 (high) 26 6.4 (4.3, 9.4) 15 2.7 (1.6, 4.5)
Adjusted for center and age (5-year categories.
CI, confidence interval
Neighborhood groups correspond to 3 race-specific
groups of neighborhoods defined according to
summary socioeconomic scores. Group 1 (scores in
the lower third) most disadvantaged
neighborhood. Group 3 (highest third) most
advantaged neighborhoods
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(J Epidemiol Community Health 200256588-594)
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Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
30
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
31
Examples of Epidemiologic Research Findings that
Influenced Policy

• Seatbelts
• Active smoking
• Indoor smoking (environmental tobacco smoking)
• Salt content in baby foods
• Disclosure of saturated fat content of food items
• Radiation standards
• Screening for cervical cancer

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RULES OF EVIDENCE TO ASSESS THE EFFECTIVENESS OF
A PREVENTIVE OR CURATIVE INTERVENTION OR PROGRAM
ARE BASED ON EPIDEMIOLOGIC STUDY DESIGNS

• LEVELS
• META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS WITH
  HOMOGENEITY
• AT LEAST ONE RANDOMIZED CLINICAL TRIAL
• TEMPORAL TREND DEMONSTRATING A DRAMATIC EFFECT
  OF THE INTERVENTION (NATURAL EXPERIMENT)
  E.G., INSULIN IN DIABETES
• META-ANALYSIS OF OBSERVATIONAL STUDIES WITH
  HOMOGENEITY
• AT LEAST ONE OBSERVATIONAL STUDY (COHORT STUDIES
  ARE ASSIGNED A HIGHER LEVEL THAN CASE-CONTROL
  STUDIES)
• QUASI-EXPERIMENTAL STUDIES
• TEMPORAL TREND NOT SHOWING DRAMATIC EFFECT
  (WITHOUT CONTROLS)
• CASE SERIES
• EXPERT OPINION NOT BASED ON THE ABOVE STUDIES

Based on US Task Force on Preventive Services
Canadian Task Force on Periodic Health
Examination
Bigby M, Szklo M Evidence-Based Dermatology. In
Fitzpatrick, Dermatology in General Medicine
(ed. By Freedberg IM et al). Vol. II 2003
McGraw-Hill Medical Publishing Division, New
York, pp. 2301-2311, 2003
33
RULES OF EVIDENCE TO ASSESS THE EFFECTIVENESS OF
A PREVENTIVE OR CURATIVE INTERVENTION OR PROGRAM
ARE BASED ON EPIDEMIOLOGIC STUDY DESIGNS

• LEVELS
• META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS WITH
  HOMOGENEITY
• AT LEAST ONE RANDOMIZED CLINICAL TRIAL
• TEMPORAL TREND DEMONSTRATING A DRAMATIC EFFECT
  OF THE INTERVENTION (NATURAL EXPERIMENT)
  E.G., INSULIN IN DIABETES
• META-ANALYSIS OF OBSERVATIONAL STUDIES WITH
  HOMOGENEITY
• AT LEAST ONE OBSERVATIONAL STUDY (COHORT STUDIES
  ARE ASSIGNED A HIGHER LEVEL THAN CASE-CONTROL
  STUDIES)
• QUASI-EXPERIMENTAL STUDIES
• TEMPORAL TREND NOT SHOWING DRAMATIC EFFECT
  (WITHOUT CONTROLS)
• CASE SERIES
• EXPERT OPINION NOT BASED ON THE ABOVE STUDIES

Based on US Task Force on Preventive Services
Canadian Task Force on Periodic Health
Examination
Bigby M, Szklo M Evidence-Based Dermatology. In
Fitzpatrick, Dermatology in General Medicine
(ed. By Freedberg IM et al). Vol. II 2003
McGraw-Hill Medical Publishing Division, New
York, pp. 2301-2311, 2003
34
PUBLICATION BIAS SELECTION BIAS THAT OCCURS WHEN
PUBLICATION OF A PAPER REPORTING FINDINGS OF A
STUDY IS BASED ON FACTORS OTHER THAN THE QUALITY
OF THE STUDY
(Chan AW et al. Empirical evidence for selective
reporting of outcomes in randomized trials
comparison of protocols to published articles.
JAMA 20042912457-65)
35
SAMPLING A POPULATION OF STUDIES PUBLICATION
BIAS
Number of studies
Total population of studies
20
40
0
-20
-40
-60
60
Efficacy of an intervention ()
36
105 RANDOMIZED TRIALS
Identification of published RCTs approved for
funding by the Canadian Institutes of Health
Research from 1990-98
(Chan AW et al. CMAJ 2004171735-740)
37

• QUESTIONS
• IS PUBLICATION BIAS ENCOURAGED BY PEER REVIEWED
  JOURNALS?

• PUBLICATION BIAS MAY BE THE RESULT OF THE
  JOURNALS EDITORIAL POLICY

• ARE AUTHORS AFRAID OF REJECTION OF NEGATIVE
  REPORTS?

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Factors Associated with the Odds of Publication
Multivariate Analysis (No. of studies 285)
(Easterbrook et al, 1991)
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Direction of findings in published trials by
source of support
Source of Support No. of studies Results favored new therapy
Pharmaceutical 37 (100) 33 (89)
General 70 (100) 43 (61)
(Davidson, 1986)
44
Language Bias Egger M, et al. Lancet.
1997350326329.

• Randomized trials published by German
  investigators in either German or English
  journals from 1985 through 1994
• No differences in quality between German- and
  English-written papers
• Statistically significant results
• English-written papers 63
• German-written papers 35
• Conclusion using language as a criterion for
  inclusion in a systematic review or meta-analysis
  may result in publication bias

45
Language Bias Egger M, et al. Lancet.
1997350326329.

• Randomized trials published by German
  investigators in either German or English
  journals from 1985 through 1994
• No differences in quality between German- and
  English-written papers
• Statistically significant results
• English-written papers 63
• German-written papers 35
• Conclusion using language as a criterion for
  inclusion in a systematic review or meta-analysis
  may result in publication bias

46
Language Bias Egger M, et al. Lancet.
1997350326329.

• Randomized trials published by German
  investigators in either German or English
  journals from 1985 through 1994
• No differences in quality between German- and
  English-written papers
• Statistically significant results
• English-written papers 63
• German-written papers 35
• Conclusion using language as a criterion for
  inclusion in a systematic review or meta-analysis
  may result in publication bias

47
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
48
Sensitivity Analysis a Tool for Public Health
Policy

• Approach to examine the changes in the output
  (results) of a given model resulting from varying
  certain model parameters (or assumptions) over a
  reasonable range (Szklo Nieto. Epidemiology
  Beyond the Basics. 2nd Edition, Jones Bartlett,
  In press).

49
Probability of the Event (E) that Vaccines S
(standard) and N (new) Are Expected to Prevent.
Assume That, In Order To Determine Eligibility,
Individuals in Whom Side Effects Occur Can be
Identified in Advance
(I) Probability of event (E) (II) Joint probability of eligibility and event (E) (III) (I) (II)
Eligible to receive vaccine S Yes 0.90 0.10 0.90 0.10 0.09
Eligible to receive vaccine S No 0.10 0.40 0.10 0.40 0.04
Total 1.00 0.09 0.04 0.13 or 13

Eligible to receive vaccine N Sim 0.70 0.05 0.70 0.05 0.035
Eligible to receive vaccine N Nao 0.30 0.40 0.30 0.40 0.12
Total 1.00 0.035 0.12 0.155 or 15.5
Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2

Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S
Eligible to receive vaccine N Yes 0.90 0.05 0.90 0.05 0.045
Eligible to receive vaccine N No 0.10 0.40 0.10 0.40 0.04
Total 1.00 0.045 0.04 0.085 or 8.5
Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6
50
Probability of the Event (E) that Vaccines S
(standard) and N (new) Are Expected to Prevent.
Assume That, In Order To Determine Eligibility,
Individuals in Whom Side Effects Occur Can be
Identified in Advance
(I) Probability of event (E) (II) Joint probability of eligibility and event (E) (III) (I) (II)
Eligible to receive vaccine S Yes 0.90 0.10 0.90 0.10 0.09
Eligible to receive vaccine S No 0.10 0.40 0,10 0.40 0.04
Total 1.00 0.09 0.04 0.13 or 13

Eligible to receive vaccine N Sim 0.70 0.05 0.70 0.05 0.035
Eligible to receive vaccine N Nao 0.30 0.40 0.30 0.40 0.12
Total 1.00 0.035 0.12 0.155 or 15.5
Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.155) 0.13 100 -19.2

Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S Sensitivity Analysis -- Assumption Incidence of vaccine N side effects is same as for vaccine S
Eligible to receive vaccine N Yes 0.90 0.05 0.90 0.05 0.045
Eligible to receive vaccine N No 0.10 0.40 0.10 0.40 0.04
Total 1.00 0.045 0.04 0.085 or 8.5
Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6 Effectiveness of vaccine N vis-à-vis vaccine S (0.13 0.085) 0.13 100 34.6
51
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
52
(No Transcript)
53
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology

• Resurgence of Social Epidemiology

Relevant to Public Health
54
(No Transcript)
55
Timeless Epidemiologic Principles (Relatively) New Developments Related to Epidemiology Public Health/Epidemiologic Challenges
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention Population-wide strategies are more effective than high-risk strategies Evidence-based Public Health Sensitivity Analysis Mathematical Models GeoInformation Systems Life Course Epidemiology Migrant Health Increasing urbanization Population aging Public Health Vs. Academic Epidemiology
The epidemiologic triad agent, host, environment Natural history of disease primary prevention, when possible, is usually more effective than secondary (and tertiary) prevention