Houston Community College System Epidemiology Career Path Questions

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I’m stuck on a Public Health question and need an explanation.

For the Chapter 2 Homework, you will make a connection between what you have learned so far about epidemiology and historical figures in the field with your own career path. You will reflect on this connection and respond to the following questions:

  1. In 2-3 sentences, please describe your desired career path. Be specific and detailed. State what job or field of work you seek and what specific duties you would perform.
  2. In 2-3 sentences, please make a connection between an epidemiological concept we learned about in Chapter 1 or 2 and the work that you would do (for example, I am an infection preventionist for a hospital, so I might choose to discuss the chain of infection, what it is, and how understanding this can help me to prevent the spread of infectious diseases in hospitals). 
  3. In 2-3 sentences, make a connection between a historical development in epidemiology that we learned about in Chapter 2 and the work that you hope to do in the future (for example, in my case, I could discuss Semmelweis' work in infection prevention in a maternity ward). 

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© Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Kevin Eaves/Shutterstock NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION CHAPTER 2 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Historic Developments in Epidemiology © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION OBJECTIVES © Jones & Bartlett Learning, LLC AfterOR completing this chapter, you will be able to: NOT FOR SALE DISTRIBUTION ■■ ■■ ■■ T © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Describe important historic events in the field of epidemiology. List and describe the contributions made by several key individuals to epidemiology. Recognize the development and use of certain study designs in the advancement of epidemiology. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION he history of epidemiology has involved of the natural course of disease to a knowledge of the many key players who sought to understand probable causes, modes of transmission, and health and explain illness, injury, and death from an outcomes; and from no means for preventing and observational scientific perspective. These individuals controlling disease to effective approaches for solving © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC also sought to provide information for the prevenpublic health problems. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORknowledge DISTRIBUTION tion and control of health-related states and events. Initially, epidemiologic advanced They advanced the study of disease from a superslowly, with large segments in time where little or natural viewpoint to a perspective based on a scienno advancement in the field occurred. The time tific foundation; from no approach for assessment to from Hippocrates (460–377 BCE), who attempted systematic methods for summarizing and describing to &explain disease occurrence from a rational view© Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC publicOR health problems; from no clear understanding point, to John Graunt (1620–1674 CE), who described NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 18 Chapter 2 Historic Developments in Epidemiology disease occurrence and death with the use of system- should be examined and advised that the source of & Bartlett Learning, LLC © Jones & methods Bartlettand Learning, LLC and calculated life © Jones atic who developed water should be considered.1–4 He asked questions SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION suchFOR as, “Is the water from a marshy soft-ground tables and OR life expectancy, and Thomas Sydenham NOT source, or is the water from the rocky heights? Is the (1624–1689), who approached the study of disease water brackish and harsh?” Hippocrates also made from an observational angle rather than a theoretical some noteworthy observations on the behavior of the one, was 2,000 years. Approximately 200 years later, physician should Learning, LLC William Farr (1807–1883) advanced John Graunt’s © Jones & Bartlett Learning,populace. LLC He believed the effective © Jones & Bartlett be observant of people’s behavior, such SALE as eating, work to better describe NOT epidemiologic problems; NOT FOR OR DISTRIBUTION FOR SALE OR John DISTRIBUTION drinking, and other activities. Did they eat lunch, eat Snow laid the groundwork for descriptive and analytic too much, or drink too little? Were they industrious? epidemiology; Robert Koch and Louis Pasteur proHippocrates suggested that traveling physicians vided scientific evidence for germ theory; Ignaz Sembecome familiar with local diseases and with the melweis discovered that handwashing standards in © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nature of those prevailing diseases. He believed that as obstetrical clinics could reduce the incidence of puerNOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION time passed, the physician should OR be able to tell what peral fever; and Florence Nightingale showed that epidemic diseases might attack and in what season, certain environmental conditions (e.g., fresh air, light, and that this could be determined by the settings of cleanliness) could improve recovery among patients the stars. Sources of water, smells, and how water sets in hospitals. In the early 1900s, Edgar Sydenstricker or flows & were always considered in LLC his study of disease morbidity statisticsLLC to improve the value of © Jones © Jonesclassified & Bartlett Learning, Bartlett Learning, 1–4 states. thisSALE information and conducted community health NOT NOT FOR OR DISTRIBUTION FOR SALE OR DISTRIBUTION Hippocrates identified hot and cold diseases and, surveys to provide valuable public health information; consequently, hot and cold treatments. Hot diseases Janet Lane-Claypon developed study designs for idenwere treated with cold treatments, and cold diseases tifying risk factors for breast cancer; Alice Hamilton required hot treatments. The process of deciding pioneered the field of toxicology; and Wade Hamp© Jones & Bartlett Learning,whether LLC a disease was hot or©cold Jones & Bartlett Learning, LLC was complex. An ton Frost showed that epidemiology is an analytical NOT FOR OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION example is diarrhea, which was consideredSALE a hot disscience closely integrated with biology and medicine. ease and was believed to be cured with a cold treatSince then, the science of epidemiology has rapidly ment, such as eating fruit.1–4 progressed. Although it is impossible to identify all Hippocrates also ascribed to and incorporated the contributors to the field of epidemiology here, sevinto his theory what is & now considered the atomic eral of ©these individuals and their contributions are Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC theory—thatNOT is, theFOR beliefSALE that everything is made of considered this chapter. NOTinFOR SALE OR DISTRIBUTION OR DISTRIBUTION tiny particles. He theorized that there were four types of atoms: earth atoms (solid and cold), air atoms (dry), ▸▸ fire atoms (hot), and water atoms (wet). Additionally, Hippocrates believed that the body was composed of © Jones & Bartlett Learning, LLC © Jones & Bartlett four humors: phlegmLearning, (earth and LLC water atoms), yelNOT FOR SALE OR SALE DISTRIBUTION lowFOR bile (fire andOR air atoms), blood (fire and water Hippocrates wasDISTRIBUTION a physician who is commonly NOT atoms), and black bile (earth and air atoms). Sickness regarded as the father of medicine. He may also be was thought to be caused by an imbalance of these thought of as the first epidemiologist. In his three humors, and fever was thought to be caused by too books, Epidemic I, Epidemic III, and On Airs, Waters, was to the Learning, LLC and Places, he attempted to describe disease from a © Jones & Bartlett Learning,much LLCblood. The treatment for©fever Jones &reduce Bartlett amount of blood in the body through bloodletting or rational perspective rather than from a supernatural NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the application of bloodsuckers (leeches). Imbalances basis. He observed that different diseases occurred were ascribed to a change in the body’s “constitution.” in different locations. He noted that malaria and yelClimate, moisture, stars, meteorites, winds, vapors, low fever most commonly occurred in swampy areas. and diet were thought to cause imbalances and conIt was not known, however, that the mosquito was © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tribute to disease. Diet was both a cause of and a cure responsible for such diseases until Walter Reed, MD, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION for disease. Cures for illness and protection from disa U.S. Army physician working in the tropics, made ease came from maintaining a balance and avoiding the connection in 1900. Hippocrates also introduced imbalance in the constitution. terms like epidemic and endemic.1–4 The essentials of epidemiology noted by HippoHippocrates gave advice to people wishing to purcrates observations on how diseases affected sue the science of medicine and provided insights on © Jones & Bartlett Learning, LLC © Jonesincluded & Bartlett Learning, LLC populations and how disease spread. He further the effects of the seasons of the year and hot and cold NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION addressed issues of diseases in relation to time and winds on health. He believed the properties of water Hippocrates, the First Epidemiologist © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. The Epidemiology of Scurvy seasons, place, environmental conditions, and disease 19 Sydenham published his observations in a book in © Jones & Bartlett Learning, LLC 4 © Jones & Bartlett Learning, control, especially as LLC it related to water and season. 1676 titled Observationes Medicae. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION One of Sydenham’s major works was the classificaThe broader contribution to epidemiology made by tion of fevers plaguing London in the 1660s and 1670s. Hippocrates was that of epidemiologic observation. Sydenham came up with three levels or classes of His teachings about how to observe any and all confevers: continued fevers, intermittent fevers, and smalltributing or causal factors of a disease are still sound 1–4 theories embraced, epidemiologic concepts. © Jones & Bartlett Learning, LLCpox. Some of Sydenham’s © Jones & were Bartlett Learning, LLC whereas others were criticized, mostly because his NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ideas and observations went against the usual Hippo▸▸ cratic approaches. He treated smallpox with bed rest and normal bed covers. The treatment of the time, based on the Hippocratic theory, was to use heat and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC extensive bed coverings. He was met with good results Thomas Sydenham (1624–1689), although a graduate NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION but erred in identifying the cause of the disease.4 of Oxford Medical School, did not at first practice medSydenham was persecuted by his colleagues, who icine but served in the military and as a college adminat one time threatened to take away his medical li­cense istrator. While at All Souls College, Oxford, Sydenham for irregular practice that did not follow the theories became acquainted with Robert Boyle, a colleague of &the time; however, he gained who sparked his interest © Jones & Bartlett Learning, LLCin diseases and epidemics. © Jones Bartlett Learning, LLC a good reputation withSALE the public, some young open-minded physiSydenham went on to get his medical license, andNOT he FOR NOT FOR SALE OR DISTRIBUTION OR and DISTRIBUTION cians agreed with his empirical principles. Sydenham spoke out for strong empirical approaches to medidescribed and distinguished different diseases, includcine and close observations of disease (FIGURE 2-1). ing some psychological maladies. He also advanced ­Sydenham wrote the details of what he observed about useful treatments and remedies, including exercise, diseases without letting various traditional theories of © Jones & Bartlett Learning, LLCfresh air, and a healthy©diet, Jones & Bartlett Learning, LLC which other physicians disease and medical treatment influence his work and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 4 rejected at the time. observations. From this close observation process, he was able to identify and recognize different diseases. Disease Observations of Sydenham © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ▸▸ The Epidemiology of Scurvy © Jones & Bartlett Learning, LLC In the NOT 1700s,FOR it wasSALE observed armies lost more ORthat DISTRIBUTION men to disease than to the sword. James Lind (1716–1794), a Scottish naval surgeon, focused on illnesses in these populations. He observed the effect of time, place, weather, and diet on the spread of disease. © Jones & Bartlett Learning, LLC © Jones & 1754 Bartlett LLC His book,Learning, A Treatise on Scurvy, identified the NOT FOR SALE OR DISTRIBUTION NOT FOR SALEofOR DISTRIBUTION symptoms scurvy and noted that the disease became common in sailors after as little as a month at sea.3,4 Lind noticed that while on long ocean voyages, sailors would become sick from scurvy, a disease bleeding& gums, bleeding © Jones & Bartlett Learning, LLCmarked by spongy and © Jones Bartlett Learning, LLC under the skin, and extreme weakness. He saw that NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION scurvy began to occur after 4–6 weeks at sea. Lind noted that even though the water was good and the provisions were not tainted, the sailors still fell sick. Lind noted that the most common months for scurvy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCcold, were April, May, and June. He also observed that NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION rainy, foggy, and thick weather was often present. Influenced by the Hippocratic theory of medicine, Lind kept looking to the air as the source of disease. Dampness of the air, damp living arrangements, and life&atBartlett sea were Learning, the main focus of his observations as © Jones & Bartlett Learning, LLC © Jones LLC he searched for an explanation for the cause of disFIGUREOR 2-1 Thomas Sydenham NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Sydenham, detail of an oil painting by Mary Beale, 1688; in the National Portrait Gallery, London. ease and, most of all, the cause of scurvy.5 Although © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 20 Chapter 2 Historic Developments in Epidemiology he was not correct about the link with weather and Epidemiology of Cowpox and Smallpox © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, ▸▸ climate at sea, Lind looked atLLC all sides of the issue and NOT FOR SALE what OR DISTRIBUTION considered was happening to the sick. He then NOT FOR SALE OR DISTRIBUTION compared their experiences with the experiences of those who were healthy. In England, Benjamin Jesty, a farmer/dairyman in When Lind began to look at the mariners’ diet, the mid-1700s, noticed that his milkmaids never got he observed that the sea©diet was extremely gross and Jones & Bartlett Learning, LLC © Jones Bartlett smallpox, a disease characterized by & chills, fever, Learning, LLC hard on digestion. Concerned with the extent of sickheadache, and backache, with NOT eruption of pimples FOR SALEthat OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ness in large numbers of sailors, Lind set up some blister and form pockmarks; however, the milkmaids experiments with mariners. In 1747, while serving did develop cowpox from the cows. Jesty believed on the HMS Salisbury, he conducted an experimental there was a link between acquiring cowpox and not study on scurvy wherein he assigned different supplegetting smallpox. At the time, smallpox was common © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mental dietary interventions to 12 ill patients who had in Europe, with 400,000 people dying annually from NOT FOR SALE OR DISTRIBUTION NOT FORofSALE ORgoing DISTRIBUTION all the classic symptoms of scurvy. They all seemed the disease and a third the cases blind.6 In to have a similar level of the illness. He described 1774, Jesty exposed his wife and children to cowpox to their symptoms as putrid gums, spots, and lassitude, protect them from smallpox. It worked. The exposed with weakness in their knees. He put the sailors in family members developed immunity to smallpox. of two and, in addition Unfortunately, little Learning, was publicized © Jonessix&groups Bartlett Learning, LLC to a common diet © Jones & Bartlett LLC about Jesty’s 4 of foods likeOR water-gruel sweetened with sugar, fresh NOT experiment and observations. NOT FOR SALE DISTRIBUTION FOR SALE OR DISTRIBUTION mutton broth, puddings, boiled biscuit with sugar, Jesty’s experiment and similar reported expebarley and raisins, rice and currants, and sago and riences in Turkey, the Orient, America, and Hunwine, each of the groups received an additional dietary gary were known to Edward Jenner (1749–1823), an intervention. Two men received a quart of cider a day English rural physician. He personally observed that © Jones & Bartlett Learning,dairymen’s LLC © Jones & Bartlett Learning, LLC on an empty stomach. Two men took two spoonfuls servants and milkmaids got cowpox and NOT FORthe SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of vinegar three times a day on an empty stomach. did not get smallpox. For many centuries, Chinese Two men were given a half-pint of sea water every day. had made observations about weaker and stronger Two men were given lemons and oranges to eat on an strains of smallpox. They learned that it was wise to empty stomach. Two men received an elixir recomcatch a weaker strain of the disease. If one had a weak mended by a hospital surgeon, and two men were fed a strain of the disease, one & would not getLearning, the full disease © Jones & Bartlett Learning, LLC © Jones Bartlett LLC 3,4 combination garlic, mustard and horseradish. later on. This NOT was termed NOT of FOR SALE ORseed, DISTRIBUTION FOR variolation. SALE OR DISTRIBUTION Lind said that the men given the lemons and oranges In the late 1700s, servants were often the ones ate them with “greediness.” The most sudden and viswho milked the cows. Servants were also required ible good effects were seen in those who ate lemons to tend to the sores on the heels of horses affected and oranges. In 6 days, the two men eating citrus were with cowpox. The pus and infectious fluids from © Jonesfit&forBartlett LLC & Bartlett Learning, LLCgrease” of the duty. All Learning, the others had putrid gums, spots, las- © Jones these sores were referred to as “the NOT FOR SALE DISTRIBUTION FORLeft SALE OR DISTRIBUTION situde, and OR weakness of the knees. Free of symptoms, NOT disease. unwashed because of a lack of concern the two citrus-eating sailors were asked to nurse the about sanitation and cleanliness, the servants’ grease-­ others who were still sick. Thus, Lind observed that covered hands would then spread the disease to the oranges and lemons were the most effective remedies cows during milking. The cowpox in turn was transof Lind’s epidemifor scurvy at sea.5 As a consequence observed when Learning, LLC © Jones & Bartlett Learning,mitted LLCto the dairymaids. Jenner © Jones & that Bartlett ologic work, since 1895, the British navy has required a person had cowpox, this same person would not NOT FOR SALE get OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION that limes or lime juice be included in seamen’s diet, smallpox if exposed to it. In May 1796, Jenner identiresulting in the nickname “limeys” to refer to British fied a young dairymaid, Sarah Nelms, who had fresh seamen. cowpox lesions on her hand. With the matter from Lind’s epidemiologic contributions were many. Nelms’s lesions, Jenner inoculated an 8-year-old boy, © Jones & Bartlett Learning, LLC Jones & Bartlett LLC He was concerned with the occurrence of disease in James Phipps.©James developed a mildLearning, fever and a loss NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION large groups of people. Lind not only participated in the of appetite, but was soon feeling much better. In July identification of the effect of diet on disease, but also 1796, Jenner inoculated the boy with a fresh smallmade clinical observations, used experimental design, pox lesion. No disease developed. Cowpox was thus asked classic epidemiologic questions, observed popfound to shield against smallpox. Jenner invented a ulation changes and their effect on disease, and convaccination for smallpox with this knowledge. The © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC sidered sources of disease, including place, time, and vaccine was used to protect populations from this NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION season. disease.3,4,6–8 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. Epidemiology of Childbed Fever in a Lying-In Hospital © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 21 As unvaccinated people proliferate, so does the risk © Jones & Bartlett Learning, LLC of future smallpox epidemics. NOT FOR SALE OR DISTRIBUTION Epidemiology of Childbed © Jones & Bartlett Learning, LLC Fever in a Lying-In © JonesHospital & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▸▸ Historically, epidemiology was centered on the study of the great epidemics: cholera, bubonic plague, smallpox, and typhus. As the diseases were identified and differentiated, the focus of epidemiology changed. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Such a change in focus came through the work of NOT FOR SALE OR DISTRIBUTION FORepidemiologist SALE OR DISTRIBUTION anotherNOT physician, Ignaz Semmelweis, in the early to mid-1800s.9 In the 1840s, one of the greatest fears a pregnant mother had was dying of childbed fever, a uterine infection, usually of the placental © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCsite, after childbirth. Babies wereOR bornDISTRIBUTION to mothers with the usual risks that NOT FOR SALE OR DISTRIBUTION NOT FOR SALE warranted obstetric assistance, and this often resulted in an uneventful birth; however, after the birth of the child, the mother would get an infection and die of childbed fever, a streptococcal disease. Many times, © Jones & Bartlett Learning, LLCthe child would become©infected Jonesand & die Bartlett Learning, LLC as well. After NOT FOR SALE OR NOT FOR SALE OR DISTRIBUTION a few years of observing the course of the disease DISTRIBUTION and the symptoms associated with childbed fever, Semmelweis began a series of investigations.9 The Viennese Maternity Hospital (called a lying-in of Bartlett which Semmelweis wasLLC clinical © Jones & Bartlett Learning, LLC ©hospital), Jones & Learning, director, was FOR dividedSALE into two The first clinic NOT FOR SALE OR DISTRIBUTION NOT ORclinics. DISTRIBUTION FIGURE 2-2 Picture of a Boy with Smallpox Taken by Dr. Stan consistently had greater numbers of maternal deaths Foster, EIS Officer, Class of 1962 than the second clinic. In 1846, the maternal mortalCourtesy of Centers for Disease Control and Prevention, Atlanta, Georgia. ity rate of this clinic was 5 times greater than that of the second clinic, and over a 6-year period, it was 3 © Jones & Bartlett © Jones & Bartlett Learning,observed LLC that the mothers The Learning, Worldwide LLC Global Smallpox Eradication times greater. Semmelweis NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Campaign of the late 1960s and early 1970s encourbecame ill either immediately during birth or within aged vaccination against smallpox and was effective 24–36 hours after delivery. The mothers died quickly at eliminating this disease. As part of the effort to of rapid-developing childbed fever. Often the children eradicate smallpox, a photograph was widely distribwould soon die as well. This was not the case in the 9 uted in 1975 of a©small child who had been stricken Jones & Bartlett Learning, LLCsecond clinic. © Jones & Bartlett Learning, LLC with the disease NOT (FIGURE 2-2). On October 26, 1977, Semmelweis observed it was notSALE the actual NOT FOR ORlabor DISTRIBUTION FOR SALE OR DISTRIBUTION World Health Organization workers supposedly that was the problem, but the examination of the tracked down the world’s last case of naturally patients that seemed to be connected to the onset of occurring smallpox. The patient was 23-year-old Ali the disease. Through clinical observation, retrospecMaow Maalin, a hospital cook in Merka, Somalia. tive study, collection and analysis of data on mater© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Two cases of smallpox occurred in 1978 as a result nal deaths and infant deaths, and clinically controlled NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of a laboratory accident. Because it is believed that experimentation, he was able to ascertain that the smallpox has been eradicated from the earth, vaccommunication of childbed fever was through germs cinations have been halted; however, some public passed from patient to patient by the physician in health and healthcare professionals are skeptical and the process of doing pelvic examinations. Semmelfear that such acts may set the stage for an unexweis discoveredLearning, that, unlikeLLC in the second clinic, the © Jones & Bartlett Learning, LLC © Jones & Bartlett pected future epidemic of smallpox because the medical students who worked in the first clinic would NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION pathogen still exists in military and government labs. come directly from the death house after performing © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 22 Chapter 2 Historic Developments in Epidemiology autopsies of infected and decaying dead bodies and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, then would conduct pelvicLLC exams on the mothers NOT FOR SALE ORbirth. DISTRIBUTION ready to give Handwashing or any form of NOT FOR SALE OR DISTRIBUTION infection control was not a common practice. Student doctors conducted the routine daily pelvic exams with putrefied cadaver material on their hands, and the practice was never questioned. There was no reason © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to be concerned about clean theory NOT FOR SALE OR DISTRIBUTION NOThands FORbecause SALEthe OR DISTRIBUTION of medicine accepted at the time relied on the Hippocratic theory of medicine and the idea that disease developed spontaneously. Semmelweis observed that a whole row of patients became ill while patients in the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC adjacent row stayed healthy.9 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Semmelweis discovered that any infected or putrefied tissue, whether from a living patient or a cadaver, could cause disease to spread. To destroy the cadaverous or putrefied matter on the hands, it was that every person—physician or midwife— © Jones & Bartlett Learning, LLC © Jonesnecessary & Bartlett Learning, LLC performing an examination wash his or her hands in NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION chlorinated lime on entering the labor ward of the first clinic. At first, Semmelweis said it was only necessary to wash during entry to the labor ward; however, a cancerous womb was discovered to also cause the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC spread of the disease, so Semmelweis required washNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-3 John Snow ing with chlorinated lime between each examination. National Library of Medicine. When strict adherence to handwashing was followed by all medical personnel who examined patients in the maternity hospital, mortality rates fell at unbelievable contributors to the field. Many of the approaches, conrates. In©1842, the percentage of deaths was 12.1% (730 cepts, and methods used & by Bartlett Snow in his epidemiologic Jones & Bartlett Learning, LLC © Jones Learning, LLC 9 of 6,024), compared with 1.3% of 7,095) in 1848. work are stillNOT useful and SALE valuableOR in DISTRIBUTION epidemiologic NOT FOR SALE OR(91 DISTRIBUTION FOR At this time in the history of public health, the work today.10–12 causes of disease were unknown, yet suspected. It Throughout his medical career, Snow studied was known that handwashing with chlorinated lime cholera. Cholera is an acute infectious disease charbetween each examination reduced the illness and acterized by watery diarrhea, loss of fluid and electro© Jonesdeaths & Bartlett Learning, LLC & Bartlettand Learning, LLChis studies, he from childbed fever, but even with the evidence © Jones lytes, dehydration, collapse. From NOT FOR SALE ORSemmelweis’s DISTRIBUTION FOR SALE DISTRIBUTION of this success, discovery was discounted NOT established sound OR and useful epidemiologic methods. by most of his colleagues.9 Today, it is known that He observed and recorded important factors related handwashing is still one of the best sanitation practices. to the course of disease. In the later part of his career, What Ignaz Semmelweis discovered is still one of the Snow conducted two major investigative studies of easiest disease- and infection-control methods known. © Jones & Bartlett Learning,cholera. LLC The first involved a descriptive © Jonesepidemiologic & Bartlett Learning, LLC investigation of a cholera outbreak in the Soho disNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION trict of London in the Broad Street area. The second involved an analytic epidemiologic investigation of a ▸▸ cholera epidemic in which he compared death rates from the disease to where the sufferers got their water, © Jones & Bartlett Learning, LLC © Jones BartlettorLearning, LLC either the Lambeth Water&Company the Southwark 10–12OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION NOT FOR SALE In the 1850s, John Snow (1813–1858) was a respected and Vauxhall Water Company. physician and the anesthesiologist for Queen Victoria In the mid-1840s, in the Soho and Golden Square of England (FIGURE 2-3). He is noted for his medical districts of London, a major outbreak of cholera work with the royal family, including the adminisoccurred. Within 250 yards of the intersection of tration of chloroform to the queen at the birth of her Cambridge Street and Broad Street, about 500 fatal © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC children; however, Snow is most famous for his pioattacks of cholera occurred in 10 days. Many more NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION neering work in epidemiology. Among epidemiolodeaths were averted because of the flight of most of gists, Snow is considered one of the most important the population. Snow was able to identify incubation John Snow’s Epidemiologic Investigations of Cholera © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. John Snow’s Epidemiologic Investigations of Cholera times, the length of time from infection until death, 23 pick and choose which water company they wanted © Jones & Bartlett Learning, LLC © Jones & Bartlett modes ofLearning, transmissionLLC of the disease, and the imporfor their household water. Thus, by mere coincidence, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE tance OR of theDISTRIBUTION flight of the population from the dangerSnow encountered a populace using water randomly ous areas. He also plotted statistics based on dates and selected throughout the south district. Snow could not mortality rates. He studied sources of contamination have arranged better sampling techniques than those of the water, causation and infection, and the flow of that had occurred by chance.10–12 in London published a the water in the©underground aquifer by assessing LLC The registrar general Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC “Weekly Return of Births and FOR Deaths. ” On November water from wells NOT and pumps. foundOR thatDISTRIBUTION nearly all NOT SALE OR DISTRIBUTION FOR He SALE 26, 1853, the Registrar General observed from a table deaths had taken place within a short distance of the of mortality that mortality rates were fairly consistent Broad Street pump. across the districts supplied with the water from the Snow observed that in the Soho district, there Hungerford Market area. The old supply system of were two separate populations not so heavily affected © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Lambeth and the regular supply of the Southwark and by the cholera epidemic, such that death rates were NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Vauxhall Company were separate systems but drew not equal to those of the surrounding populations. water from the same area in the river. The registrar A brewery with its own wells and a workhouse, also general also published a mortality list from cholera. with its own water source, were the protected populaSnow developed comparison tables on death by source tions. Snow used a spot map (sometimes called a dot of &water by subdistricts. Snow was able to conclude map) to identify the locations © Jones & Bartlett Learning, LLC of all deaths. He plotted © Jones Bartlett Learning, LLC thatSALE the water drawn upriver solely by Lambeth Water data on theDISTRIBUTION progress of the course of the epidemic NOT and FOR NOT FOR SALE OR OR DISTRIBUTION Company caused no deaths. The water drawn downthe occurrence of new cases, as well as when the epistream, in areas that were below the sewage inlets and demic started, peaked, and subsided. Snow examined mostly by Southwark and Vauxhall Water Company, the water, movement of people, sources of exposure, was associated with very high death rates.10–12 transmission of the disease between and among close © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC Gaining cooperation and permission fromLearning, the and distant people, and possible causation. Toward the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION registrar general, Snow was supplied with addresses end of the epidemic, as a control measure, as protecof persons who had died from cholera. He went into tion from any reoccurrence, and as a political statethe subdistrict of Kennington One and Kennington ment to the community, Snow removed the handle Two and found that 38 of 44 deaths in this subdistrict from the Broad Street pump.10–12 In his early days as a practicing physician before received water from Southwark and LLC Vauxhall © Jones & Bartlett Learning, LLC © their Jones & Bartlett Learning, the Broad Street outbreak, Snow recorded detailed Company. Each house had OR randomly selected differNOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION scenarios of several cases of cholera, many of which ent water companies, and many households did not he witnessed firsthand. Some of the details he chose to know from which one they received water. By samrecord were epidemiologic in nature, such as various pling water from within the houses of those he conmodes of transmission of cholera, incubation times, tacted, Snow developed a test that used chloride of © Jones & Bartlett Learning, LLCclinical observations © & Bartlett LLC for each household. cause–effect association, andJones silver to identifyLearning, the water source NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION clinical manifestations of the disease, scientific obserSnow was eventually able to tell the source of water by vations on water and the different sources (including appearance and smell.10–12 Vital statistics data and death rates compared observations made with a microscope), temperature, according to water supplier presented conclusive eviclimate, diet, differences between those who got the A report to disease and those©who did not, and immigration and Jones & Bartlett Learning, LLCdence as to the source of © contamination. Jones & Bartlett Learning, LLC Parliament showed that in the 30,046 households that emigration differences.10–12 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In 1853, a larger cholera outbreak occurred in were supplied water by the Southwark and Vauxhall London. London had not had a cholera outbreak for Company, 286 people died of cholera. Of the 26,107 about 5 years. During this period, the Lambeth Water houses supplied by Lambeth, only 14 died of cholera. Company moved its intake source of water upriver The death rate was 71 per 10,000 in Southwark and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, on the Thames, from opposite Hungerford Market Vauxhall households, and 5 per 10,000 for LLC Lambeth NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to a source above the city, Thames Ditton. By movhouseholds. The mortality at the height of the epiing the source of water upriver to a place above the demic in households supplied with water by Southsewage outlets, Lambeth was able to draw water free wark and Vauxhall was 8–9 times greater than that in from London’s sewage, contamination, and pollution. those supplied by Lambeth. Snow was finally able to The Southwark and Vauxhall Water Company, howprove his hypothesis that contaminated water pass© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ever, did not relocate its source of water. Throughout ing down the sewers into the river, then being drawn NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the south district of the city, both water companies from the river and distributed through miles of pipes had pipes down every street. The citizens were free to into people’s homes, produced cholera throughout © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 24 Chapter 2 Historic Developments in Epidemiology © Jones & Bartlett Learning, LLC NEWS FILE NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Preventing Cholera A Simple Filtration Procedure Produces a 48% Reduction in Cholera Cholera continues to plague developing countries Learning, and surfaces sporadically throughout the world. An estimated © Jones & Bartlett LLC © Jones & Bartlett Learning, LLC 1.3–4.0 million cases of cholera and as many as 143,000 deaths from cholera occur each year. Provision safe water andOR DISTRIBUTION NOT of FOR SALE NOT FOR SALE OR DISTRIBUTION sanitation is the primary way to reduce the impact of cholera and other waterborne diseases. Oral cholera vaccines may also be taken in conjunction with conventional control measures. Researchers developed a simple filtration procedure involving both nylon filtration and sari cloth (folded four to eight times) filtration for rural villagers in Bangladesh to remove Vibrio cholerae attached to plankton in environmental water.© The research&hypothesis that removing the copepods (with which Vibrio cholerae&isBartlett associated)Learning, from water LLC Jones Bartlettwas Learning, LLC © Jones used for household purposes, including drinking, would significantly reduce the prevalence of cholera. The study was NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION conducted over a 3-year period. Both the nylon filtration group and the sari filtration group experienced significantly lower cholera rates than the control group. Both filters were comparable in removing copepods and particulate matter from the water. The study estimated that the sari cloth filtration reduced the occurrence of cholera by about 48%. Given the low cost of sari cloth this prevention method lowering & theBartlett occurrenceLearning, of cholera in LLC developing © Jones filtration, & Bartlett Learning, LLChas considerable potential©in Jones countries. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Modified from World Health Organization. Cholera. https://www.who.int/en/news-room/fact-sheets/detail/cholera. Accessed February 22, 2019; Colwell RR, Huq A, Islam MS, et al. Reduction of cholera in Bangladeshi villages by simple filtration. Proc Natl Acad Sci. 2003;100(3):1051–1055. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORPasteur SALEhad OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Medicine for his work in microbiology. the community. Snow showed that cholera was a distinguished himself as a scientist and a respected waterborne disease that traveled in both surface and 10–12 contributor to the field of medicine and public health groundwater supplies. Snow laid the groundwork for descriptive and (although it was not recognized as a separate field at analytic© epidemiologic approaches found useful in the time). Pasteur had already identified the causeLLC of Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, epidemiology today. He identified various modes of rabies and many other devastating diseases. Because NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION transmission and incubation times and, in his second of his many past successes in microbiology, Pasteur study, employed a comparison group to establish more had confidence in his ability to take on the challenge definitively a cause–effect association. It was not until of conquering anthrax.3,4 Pasteur was convinced that it was the bacteKoch’s work in 1883 in Egypt, when he isolated and cul© Jonestivated & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the disease, ria identified as anthrax that caused Vibrio cholerae, that the accuracy and correct3,4,10–12 NOT FOR ORwork DISTRIBUTION NOT FORanthrax SALEbacteria OR DISTRIBUTION because were always present on necnessSALE of Snow’s was proved and accepted. Because of John Snow’s contributions, many have ropsy (autopsy) of sheep that died from anthrax. It referred to him as the Father of Epidemiology. was unclear, however, why the course of the disease occurred the way it did. The cause–effect association in it. How did the Learning, LLC © Jones & Bartlett Learning,seemed LLC to have some loopholes © Jones & Bartlett ▸▸ sheep get anthrax? How were the sheep disposed? Why NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION did the anthrax occur in some areas and not in others? How was the disease transmitted? How did the disease In the 1870s, on journeys into the countryside in survive? All were questions that Louis Pasteur sought Europe, it was not uncommon to see dead sheep lying to answer. Jones & sheep Bartlett LLC a © Jonesthat & Bartlett Learning, LLC in the © fields. These hadLearning, died from anthrax, Pasteur observed the dead sheep were burNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION bacterial disease that most commonly afflicts aniied. The key and insightful discovery was that anthrax mals (e.g., cattle, sheep, horses) but can also occur spores or bacteria were brought back to the surface in humans. Anthrax is a serious bacterial infection, by earthworms. Koch had previously shown that the usually fatal, caused by Bacillus anthracis. Anthrax anthrax bacteria existed in silkworms and that anthrax major epidemic that LLC plagued the farmers and © Jones was an intestinal disease. Pasteur made © Joneswas & aBartlett Learning, & Bartlett Learning, LLCthe earthworm destroyed them economically.3,4 connection. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION By this time, Louis Pasteur (1822–1895), a French Pasteur and his assistants had worked on a vacchemist, had been accepted into France’s Academy of cine for anthrax for months, and in 1881, an effective Epidemiologic Work of Pasteur and Koch © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. The Invention of the Microscope vaccine was discovered. After a presentation at the 25 epidemiology was a paper on waterborne epidemics © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC AcademyLearning, of Sciences in Paris, Pasteur was challenged and how they can largely be prevented by proper water NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3,4,13 to prove that his vaccine was effective. He put his filtration. Koch, who began as a country family physician, career and reputation at stake to prove that his vacpioneered the identification of microorganisms and cine would work, that disease was caused by micromany different bacteria that caused different disorganisms, and that a cause–effect association exists techniques for growbetween a particular microbe&and a certain disease. LLCeases, as well as pure culturing © Jones Bartlett Learning, © Jones & Bartlett Learning, LLC ing microorganisms inNOT laboratory Pasteur agreed to FOR the challenge withDISTRIBUTION a public FOR conditions. SALE ORSome DISTRIBUTION NOT SALE OR of the major public health contributions that Koch demonstration to prove that his vaccination process made were identification of the tuberculosis and cholcould prevent sheep from getting anthrax. He went to era microorganisms, and establishment of the impora farm in rural France where 60 sheep were provided tance of water purification in disease prevention. He for the experiment. He was to vaccinate 25 of the sheep © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC was the recipient of many honors throughout his lifewith his new vaccine. After the proper waiting time, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORinDISTRIBUTION time, including the Nobel Prize 1905 for his work in Pasteur was to inoculate 50 of the sheep with a virmicrobiology.3,4,13,14 ulent injection of anthrax. Ten sheep were to receive Both Pasteur and Koch were successful in putting no treatment and were used to compare with the to rest a major misguided notion of medicine at the survivors of the experiment (a control group). Pastime: that disease was a result of “spontaneous genteur was Learning, successful. The inoculated sheep lived. © TheJones © Jones & Bartlett LLC & Bartlett Learning, LLC eration”—that organisms would simply appear out unvaccinated sheep died, and the control group NOT had FOR NOT FOR SALE OR DISTRIBUTION SALE ORis,DISTRIBUTION of other organisms, and a fly would spontaneously no changes. Pasteur successfully demonstrated that appear out of garbage, and so forth.10 his method was sound, that vaccinations were effective approaches in disease control, and that bacteria were indeed causes of disease. © Jones & Bartlett Learning, LLC▸▸ © Jones & Bartlett Learning, LLC Historically, many scientists have contributed NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to the methods used in epidemiology. Robert Koch (1843–1910) lived in Wollstein, a small town near The important findings of Koch, Pasteur, Snow, and Breslau, in rural Germany (Prussia). Koch was a primany others in this era of sanitation and microbe disvate practice physician and district medical officer. covery © would have& been impossible without the use of Because of his compelling desire to study disease © Jones & Bartlett Learning, LLC Jones Bartlett Learning, LLC the microscope. Koch’s camera not have been experimentally, he set OR up a DISTRIBUTION laboratory in his home and NOT FOR SALE NOT FOR SALE ORwould DISTRIBUTION invented if the microscope had not been developed purchased equipment, including photography equipand its lenses adapted to picture taking. ment, out of his meager earnings. Koch became a key The microscope first found scientific use in medical research scientist in Germany in the period the 1600s through the work of Cornelius Drebbel marked by the explosion of knowledge in medicine © Jones & Bartlett Learning, © Jones & Bartlettthe Learning, LLC of the Netherlands (1572–1633), Janssen brothers and public health, andLLC he used photography to take NOT FOR SALE ORpictures DISTRIBUTION NOT FOR SALE DISTRIBUTION (1590s), andOR Antoni van Leeuwenhoek (1632–1723). the first of microbes to show the world that The microscope was used for medical and scientific microorganisms do in fact exist and that they are what purposes by Athanasius Kircher of Fulda (1602–1680). cause disease.3,4,13 In the 1870s, Koch showed that anthrax was transIn 1658 in Rome, he wrote Scrutinium Pestis. He conmissible and reproducible in experimental animals nature of and © Jones & Bartlett Learning, LLCducted experiments on the © Jones &putrefaction Bartlett Learning, LLC (mice). He identified the spore stage of the growth showed how microscopic living organisms and magNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cycle of microorganisms. The epidemiologic signifgots develop in decaying matter. He also discovered icance that Koch demonstrated was that the anthrax that the blood of plague patients was filled with countbacillus was the only organism that caused anthrax in less “worms” not visible to the human eye. a susceptible animal. Most of the credit goes to Leeuwenhoek for the © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC In 1882, Koch discovered the tubercle bacillus advancement, development, andLearning, perfection of the use NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION with the use of special culturing and staining methof the microscope. He was the first to effectively apply ods. Koch and his assistant also perfected the conthe microscope in the study of disease and medicine cept of steam sterilization. In Egypt and India, he and even though he was not a physician. Because of a drivhis assistants discovered the cholera bacterium and ing interest in the microscope, Leeuwenhoek was able proved that it was transmitted by drinking water, food, to & devote muchLearning, time to microscopy, © Jones & Bartlett Learning, LLC © Jones Bartlett LLC owning more than and clothing. Incidental to the cholera investigations, 247 microscopes and more than 400 lenses (many of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Koch also found the microorganisms that cause infecwhich he ground himself). He was the first to describe tious conjunctivitis. One of his major contributions to the structure of the crystalline lens. The Invention of the Microscope © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 26 Chapter 2 Historic Developments in Epidemiology Leeuwenhoek made contributions to epidemiol- It is summarized in TABLE 2-1. This was the first major & Bartlett Learning, LLC © Jones & He Bartlett Learning, study LLC of red corpuscles in © Jones ogy. did a morphologic contribution to record-keeping on a population and SALE OR DISTRIBUTION NOT FOR ORsaw DISTRIBUTION the SALE blood. He the connection of arterial circula- NOT wasFOR the beginning of the vital statistics aspect of epi- tion to venous circulation in the human body through demiology. When Graunt took over the work, he systhe microscopic study of capillary networks. With his tematically recorded ages, gender, who died, what microscope, Leeuwenhoek contributed indirectly to killed them, and where and when the deaths occurred. epidemiology through ©microbiology by discovering Jones & Bartlett Learning,Graunt LLC also recorded how many © Jones & died Bartlett persons each Learning, LLC “animalcules” (microscopic later year and the cause of death.4,13NOT FOR SALE OR DISTRIBUTION NOT organisms, FOR SALE ORcalled DISTRIBUTION microbes, bacteria, and microorganisms). Through the analysis of the bills of mortality In addition to epidemiology and microbiology, already developed for London, Graunt summarized chemistry and histology were developed because mortality data and developed a better understanding of of the advent of the microscope, which influenced diseases, as well as sources and causes of death. Using © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC advances in the study and control of diseases.4,15 the data and information he collected, Graunt wrote NOT FOR SALE OR DISTRIBUTION NOT FOR SALE Made OR DISTRIBUTION Natural and Political Observations Upon the Bills of Mortality. From the bills of mortality, Graunt identi▸▸ fied variations in death according to gender, residence, season, and age. Graunt was the first to develop and calculate&life tables and life expectancy. © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC He divided Another major to epidemiology, but in NOT deaths into two types of causes: acute (struck sudNOT FOR SALE OR contributor DISTRIBUTION FOR SALE OR DISTRIBUTION a different manner, was John Graunt (1620–1674). denly) and chronic (occurred over a long period).4,13 In 1603 in London, a systematic recording of deaths When Graunt died, little was done to continue commenced and was called the “bills of mortality.” his good work until 200 years later, when William John Graunt and Vital Statistics © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION TABLE 2-1 Selections from Natural and Political Observations Made Upon the Bills of Mortality by John Graunt The Diseases and Casualties This Year Being 1632 © Jones & Bartlett Abortive and Stillborn Learning, LLC 445 NOT FOR SALE OR DISTRIBUTION Afrighted 1 Aged 628 © Jones & Bartlett Learning, LLC Ague NOT FOR SALE OR DISTRIBUTION Apoplex, and Meagrom Bit with a mad dog Jones Chrisomes,©and Infants & Bartlett Learning, 2,268 LLC NOT FOR SALE OR DISTRIBUTION Cold and Cough 55 Colick, Stone, and Strangury 56 43© Jones & Bartlett Learning, LLC Consumption 1,797 NOT FOR SALE OR DISTRIBUTION 17 1 Convulsion Cut of the Stone 241 5 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 348 Dead in the street and starved 6 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Bloody flux, Scowring, and Flux Brused, Issues, Sores, and Ulcers Burnt and Scalded © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Burst, and Rupture Cancer, and Wolf Canker © Jones & Bartlett Learning, LLC NOT FORChildbed SALE OR DISTRIBUTION 28 Dropsie and Swelling 5 Drowned 9 Executed and Prest to Death 10 1 267 34 © Jones & Bartlett Learning, LLC 18 NOT FOR SALE OR DISTRIBUTION Falling Sickness Fever © Jones & Bartlett Learning, LLC OR DISTRIBUTION 171NOT FOR Fistula SALE 7 1,108 13 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 27 John Graunt and Vital Statistics © Jones & Bartlett Flox andLearning, Small Pox LLC NOT FOR SALE OR DISTRIBUTION © Jones &Plague Bartlett Learning, LLC 531 NOT FOR SALE OR DISTRIBUTION French Pox 12 Gangrene 5 Gowt 8 Planet 13 Pleurisie, and Spleen 36 © Jones & Bartlett Learning, LLC © Jones & Bartlett38Learning, LLC 4 Purples, and Spotted Fever NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Grief 11 Quinsie Jaundies 43 Rising of the Lights © Jones & Bartlett Learning, LLC Jawfain NOT FOR SALE OR DISTRIBUTION 8 98 © Jones & Bartlett Learning, LLC 1 NOT FOR SALE OR DISTRIBUTION Sciatica Impostume 74 Scurvey, and Itch Killed by Several Accident 46 Suddenly © Jones & Bartlett Learning, LLC King’s EvilDISTRIBUTION NOT FOR SALE OR 7 9 62 © Jones & Bartlett Learning, LLC 38 FOR Surfet NOT SALE OR DISTRIBUTION 86 Lethargie 2 Swine Pox 6 Lunatique 5 Teeth 470 80 Tissick 13 Tympany 34 Worms 27 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Made away themselves 15 Thrush, Sore Mouth NOT FOR SALE OR 40 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Measles Murthered © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Over-laid/starved at nurse Palsie Piles Females In All 7 25 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Christened Males 7 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Vomiting 1 8 © Jones & Bartlett Learning, LLC NOT FOR Buried SALE OR DISTRIBUTION 4,994 Males 4,590 © Jones & Bartlett Learning, LLC Females NOT FOR SALE OR DISTRIBUTION 9,584 In All 4,932 4,603 © Jones & Bartlett Learning, LLC NOT FOR SALE 9,535 OR DISTRIBUTION Increased in the Burials in the 122 Parishes, and at the Pesthouse this year—993 Decreased of the Plagues in the 122 Parishes, and at the Pesthouses this year—266 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Data from Hull CH, ed. In The Economic Writings of Sir William Petty. New York, NY: Cambridge University Press; 1899. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Farr (1807–1883) was appointed registrar general vital statistics system, much of which is still in use in England. Farr built on Graunt’s ideas. The contoday. Another of Farr’s important contributions was cept of “political arithmetic” was replaced by a new the promotion of the idea that some diseases, espe© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC term, “statistics.” Farr extended the use of vital stacially chronic diseases, can have a multifactorial NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tistics, and he organized and developed a modern etiology.16 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 28 Chapter 2 Historic Developments in Epidemiology Occupational Health and Industrial Hygiene ▸▸& Bartlett Learning, LLC © Jones NOT FOR SALE OR DISTRIBUTION identified the danger posed by mercury, which was © Jones & Bartlett Learning, LLC used by mirror makers, goldsmiths, and others. He NOT FOR that SALE observed veryOR fewDISTRIBUTION of these workers reached old age. If they did not die young, their health was so Bernardino Ramazzini (1633–1714) was born in undermined that they prayed for death. He observed Carpi near Modena, Italy. He received his medical that many had palsy of the neck and hands, loss of training at the University Parma&and did postgradRamazzini also Learning, LLC © of Jones Bartlett Learning,teeth, LLCvertigo, asthma, and paralysis. © Jones & Bartlett uate studies in Rome. Ramazzini eventually returned studied those who used or processed organic mateNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to the town of Modena, where he became a professor rials, such as mill workers, bakers, starch makers, of medicine at the local university. He was interested tobacco workers, and those who processed wool, flax, in the practical problems of medicine and not in the hemp, cotton, and silk—all of whom suffered from study of ancient theories of medicine, a fact not well inhaling the fine dust particles in the processing of the ©by Jones & Bartlett Learning, LLCcon© Jones & Bartlett Learning, LLC received his colleagues. Through Ramazzini’s materials.3,4,13,15 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE the ORharmful DISTRIBUTION tinuous curiosity and his unwillingness to confine Ramazzini further examined effects himself to the study of ancient medical theories, he of the physical and mechanical aspects of work, such became recognized for his innovative approaches to as varicose veins from standing, sciatica caused by medical and public health problems. For example, in turning the potter’s wheel, and ophthalmia found in 1692, at the age of 60, Ramazzini was climbing down glassworkers and blacksmiths. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,Kidney LLC damage was intoSALE 80-footOR wellsDISTRIBUTION to take temperature and barometric NOT seenFOR to beSALE sufferedOR by couriers and those who rode for NOT FOR DISTRIBUTION readings so as to discover the origin and rapid flow long periods, and hernias appeared among bearers of of Modena’s spring water. He tried to associate baroheavy loads.3,4,13,15 metric readings with the cause of disease by taking Ramazzini’s major epidemiologic contributions daily readings during a typhus epidemic (typhus, were not only his investigation into and description © Jones Learning, Jones & Bartlett an infectious disease caused by one&ofBartlett the bacteria in ofLLC work-related maladies, but©also his great concern Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the family rickettsiae, is characterized by high fever, a for prevention. Ramazzini suggested that the cesspool 3,4,13,15 transient rash, and severe illness). workers fasten transparent bladders over their eyes Ramazzini came upon a worker in a cesspool. to protect them and take long rest periods or, if their In his conversation with the worker, Ramazzini was eyes were weak, to get into a different line of work. In told that continued work in this environment would discussing the©various he suggested changing © Jones & Bartlett Learning, LLC Jonestrades, & Bartlett Learning, LLC cause the worker to go blind. Ramazzini examined the posture, exercising, providing adequate ventilation in NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION worker’s eyes after he came out of the cesspool and workplaces, and avoiding extreme temperatures in the found them bloodshot and dim. After inquiring about workplace. other effects of working in cesspools and privies, he Ramazzini was an observant epidemiologist. He was informed that only the eyes were affected.3,4,13,15 described the outbreak of lathyrism in Modena in the cesspool © Jones & Encountering Bartlett Learning, LLC worker turned © Jones Bartlett Learning, LLC 1690. He&also described the malaria epidemics of the Ramazzini’s mind to a general interest in the relationNOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION region andSALE the Paduan cattle plague in 1712.3,4,13,15 ship of work to health. He began work on a book that would become influential in the area of occupational medicine and provide related epidemiologic implica▸▸ tions. He completed The Diseases of Workers in 1690, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Florence Nightingale (1820–1910) was the daughter of but it was not published until 1703. It was not acceptNOT2-4). FOR NOT FOR SALE OR DISTRIBUTION upper-class British parents (FIGURE SheSALE pursuedOR a DISTRIBUTION able to pity the poor or simple laborers during this career in nursing, receiving her initial training in Kaiperiod, so Ramazzini delayed publication because he serworth at a hospital run by an order of Protestant thought it would not be accepted.3,4,13,15 Ramazzini observed that disease among workers deaconesses. Two years later, she gained further expehad two first, he believed, was the harmrience as the superintendent at the Hospital for Invalid © causes. JonesThe & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 17–21 ful character of theSALE materials workers handled, GentlewomenNOT in London, England.OR NOT FOR ORthat DISTRIBUTION FOR SALE DISTRIBUTION After reading a correspondence series from the because the materials often emitted noxious vapors London Times in 1854 on the plight of wounded soland very fine particles that could be inhaled. The diers fighting in the Crimea, Nightingale asked the second was ascribed to certain violent and irregular British secretary of war to let her work in military motions and unnatural postures imposed on the body © Joneswhile & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC hospitals at Scutari, Turkey. In addition to granting working.3,4,13,15 NOT FOR SALE OR DISTRIBUTION NOT FOR SALEheOR DISTRIBUTION Ramazzini described the dangers of poisoning her permission, designated her head of an official from lead that potters used in their glaze. He also delegation of nurses. Nightingale worked for the next Florence Nightingale © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. Typhoid Mary © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 29 Her outspoken Notes on Matters Affecting the © Jones & Bartlett Learning, LLC Health, Efficiency and Hospital Administration of the NOT FOR SALE OR DISTRIBUTION British Army (1858) and Notes on Hospitals (1859) helped to create changes in hygiene and overall treatment of patients. She also founded the groundbreaking Nightingale Training School for nurses and in of books and pamphlets © Jones & Bartlett Learning, LLClater years published dozens © Jones & Bartlett Learning, LLC on public health. Nightingale was awarded NOT FOR SALE the ORRoyal DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Red Cross by Queen Victoria in 1883, and in 1907, she became the first woman to receive the Order of Merit.17 With the encouragement of her father, Nightin© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC gale received an education, studying Italian, Latin, NOT FOR SALE OR DISTRIBUTION FOR and SALE OR DISTRIBUTION Greek, NOT and history, received excellent training in mathematics. During her time at Scutari, she collected data and systematized record-keeping practices. She used the data as a tool for improving city and military hospitals. She collected and generated data and statis© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tics SALE by developing a Model Hospital Statistical Form NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION for hospitals. Nightingale’s monitoring of disease mortality rates showed that with improved sanitary methods in hospitals, death rates decreased. Nightingale developed applied statistical methods to display © Jones & Bartlett Learning, LLCher data, showing that statistics © Jones & Bartlett Learning, LLC provided an organized NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION way of learning and improving medical andOR surgical practices. In 1858, she became a Fellow of the Royal Statistical Society and in 1874 became an honorary FIGURE 2-4 Florence Nightingale member of the American Statistical Association.17–21 © GeorgiosArt/iStock/Getty Images. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Typhoid Mary 2 years to improve the sanitary conditions of army ▸▸ hospitals and to reorganize their administration. The In the early 1900s, 350,000 cases of typhoid occurred Times immortalized her as the “Lady with the Lamp” each year in the United States. Typhoid fever is an because she ministered to the soldiers throughout 17–21 infectious disease characterized the night.Learning, © Jones & Bartlett LLC © Jones & Bartlett Learning, LLCby a continued fever, When she returned to England, Nightingale carphysical and mental depression, rose-colored spots NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ried out an exhaustive study of the health of the British on the chest and abdomen, diarrhea, and sometimes Army. She created a plan for reform, which was comintestinal hemorrhage or perforation of the bowel. piled into a 500-page report entitled Notes on Matters An Irish cook, Mary Mallon, referred to as “Typhoid Affecting the Health, Efficiency, and Hospital AdminisMary,” was believed to be responsible for 51 cases of © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tration of the British Army (1858). In 1859, she pubtyphoid fever in a 15-year period.14 NOT FOR SALE OR sevDISTRIBUTION NOT FOR SALE OR DISTRIBUTION George Soper, a sanitary engineer studying lished Notes on Hospitals, which was followed in 1860 eral outbreaks of typhoid fever in New York City in the by Notes on Nursing: What It Is and What It Is Not. 1900s, found that the food and water supply was no That same year, she established a nursing school at St. 17–21 longer suspect as the primary means of transmission Thomas’s Hospital in London. Nightingale wanted toLearning, make nursing a respectable of typhoid. Soper continued to search for other means © Jones & Bartlett LLC © Jones & Bartlett Learning, LLC profession andSALE believed that nurses should be trained of communication the disease. He began to look to NOT FOR OR DISTRIBUTION NOT FORofSALE OR DISTRIBUTION in science. She also advocated strict discipline and an people instead of fomites, food, and water. attention to cleanliness, and she felt that nurses should He discovered that Mary Mallon had served as a possess an innate empathy for their patients. Although cook in many homes that were stricken with typhoid. Nightingale became an invalid after her stay in the The disease always seemed to follow, but never precede, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Crimea, she remained an influential leader in public her employment. Bacteriologic examination of Mary NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORshowed DISTRIBUTION health policies related to hospital administration until Mallon’s feces that she was a chronic carrier her death on August 13, 1910.17–21 of typhoid. Mary seemed to sense that she was giving © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 30 Chapter 2 Historic Developments in Epidemiology people sickness, because when typhoid appeared, she In the 1880s, it was observed that when young mice © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC would leave with no forwarding address. Mary Mallon were fed purified diets, they died quickly. When fed FOR OR In DISTRIBUTION NOT FOR SALEthe OR DISTRIBUTION illustrated importance of concern over the chronic NOT milk, theySALE flourished. 1887, a naval surgeon, T. K. typhoid carrier causing and spreading typhoid fever. Takaki, eradicated beriberi from the Japanese navy by Like 20% of all typhoid carriers, Mary suffered no adding vegetables, meat, and fish to their diet, which obvious illness from the disease. Epidemiologic invesuntil then had been mostly rice. In 1889, at the Lontigations have shown © that carriers might be Learning, overdon Zoo, it was demonstrated© that rickets&inBartlett lion cubs Learning, LLC Jones & Bartlett LLC Jones looked if epidemiologic searches limited the could be cured by feeding them crushed milk, NOT FOR bone, SALE OR DISTRIBUTION NOT FORare SALE ORtoDISTRIBUTION water, food, and those with a history of the disease.14,22 and cod liver oil.13,23,24 From 1907 to 1910, Mary was confined by health The first major epidemiologic implications of defiofficials. The New York Supreme Court upheld the ciency illnesses came in 1886, when the Dutch comcommunity’s right to keep her in custody and isolamissioned the firm of C. A. Pekelharing and Winkler, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tion. Typhoid Mary was released in 1910, through which sent Christiaan Eijkman (1858–1930), an army NOT FOR SALE OR DISTRIBUTION OR DISTRIBUTION legal action she took, but she disappeared almost doctor, to theNOT East FOR Indies SALE to investigate the cause of immediately. Two years later, typhoid fever occurred beriberi. Eijkman observed that chickens fed on polin a hospital in New Jersey and a hospital in New York. ished rice developed symptoms of beriberi and recovMore than 200 people were affected. It was discovered ered promptly when the food was changed to whole had worked rice, but&heBartlett mistakenly attributedLLC the cause of the © Jonesthat & Typhoid BartlettMary Learning, LLCat both hospitals as a © Jones Learning, cook but under different name. This incident taught NOT disease a neurotoxin. Gerrit Grijns (1865–1944), NOT FOR SALE OR aDISTRIBUTION FORtoSALE OR DISTRIBUTION public health officials and epidemiologists the impora physiologist, correctly identified that beriberi was tance of keeping track of carriers. It also showed that a result of a deficiency of an essential nutrient in the typhoid carriers should never be allowed to handle outer layers of grain that is removed by polishing. food or drink intended for public consumption. In In 1906, Frederick Gowland Hopkins (1861–1947), © Jones & Bartlett Learning,a British LLC biochemist, did similar © studies Joneswith & Bartlett Learning, LLC later years, Typhoid Mary voluntarily accepted isolaa concern NOT FOR SALE OR NOT FOR SALE OR DISTRIBUTION 14,22 tion. She died at 70 years of age from pneumonia. for the pathogenesis of rickets and scurvy. Hopkins DISTRIBUTION The investigating, tracking, and controlling of cersuggested that other nutritional factors exist beyond tain types of diseases that can affect large populations the known ones of protein, carbohydrates, fat, and were epidemiologic insights gained from the Typhoid minerals, and these must be present for good health. Mary experience. The importance of protecting pubIn 1911, ©Casimir (1884–1967), a Polish © Jones & Bartlett Learning, LLC JonesFunk & Bartlett Learning, LLC lic foodNOT supplies andSALE the importance of the investigachemist, isolated a chemical substance he believed FOR OR DISTRIBUTION NOT FOR SALE ORthat DISTRIBUTION tive aspects of disease control were again reinforced belonged to a class of chemical compounds called and further justified as public health measures. Today, amines. Funk added the Latin term for life, vita, and antibiotic therapy is the only effective treatment for invented the term “vitamine.” He authored the book typhoid fever. Vitamines. In 1916, Elmer McCollum (1879–1967) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCfor the normal showed that two factors were required NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION growth of SALE rats, a fat-soluble “A” factor found in butter ▸▸ and fats and a water-soluble “B” factor found in nonfatty foods such as whole-grain rice. These discoveries set the stage for labeling vitamins by letters of the Vitamins are organic© components in food that States & and E. Mel- Learning, LLC Jones & Bartlett Learning,alphabet. LLC McCollum in the United © Jones Bartlett are needed in very small amounts for metabolism, lanby in Great Britain showed that the “A” factor was NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION growth, and maintaining good health. The discovery effective in curing rickets. It was also demonstrated of vitamins and the role they play in life and health that the “A” factor contained two separate factors. A have an interesting history. In the mid- to late 1800s, heat-stable factor was identified and found to be the bacteria were being identified as the major causes of one responsible for curing rickets. A heat-labile factor © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC disease; however, the discovery of microorganisms that was capable of healing xerophthalmia (dryness NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and their connection to disease clouded the discovery of the conjunctiva leading to a diseased state of the of the causes of other life-threatening diseases. Berimucous membrane of the eye resulting from vitamin beri, rickets, and pellagra were still devastating popuA deficiency) was also discovered. The heat-stable faclations around the world. It was believed in 1870 that tor was named vitamin D, and the heat-labile factor 13,23 as many as one-third of poor children in the innerwas termed vitamin A. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The discovery of vitamin D connected obsercity areas of major cities in the world suffered from NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION vations about rickets and cod liver oil. Cod liver oil serious rickets. Biochemistry was being advanced, cured rickets because it contains vitamin D. It was and new lines of investigation were opening up. Vitamins and Nutritional Diseases © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. Beginning of Epidemiology in the United States 31 observed that children exposed to sunshine were © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC less likelyLearning, to get rickets. In Germany in 1919, Kurt NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Huldschinsky (1883–1940) also showed that exposing children to artificial sunshine cured rickets. It was found that vitamin D was produced in the body when sunshine acted on its fats. It was later discovered that the antiberiberi substance vitamin B was also effective LLC © Jones & Bartlett Learning, against pellagra.13,23–25 NOT FOR SALE OR DISTRIBUTION In this era, the role of social and economic factors was observed to contribute much to the causation of disease, especially poverty conditions, which clearly contributed to nutritional deficiencies.11 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ▸▸ Beginning of Epidemiology in the United States © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT SALE OR DISTRIBUTION FIGURE 2-5 TheFOR Mosquito and Yellow Fever. It has been said that of all the people who ever died, half of them died from the bite of the mosquito. For thousands of years, it was not known that the mosquito was responsible for diseases such as yellow fever and malaria. These two diseases are still not fully contained in many parts of the world. In 1900, Walter Reed, MD, a U.S. Army physician working in the tropics, made In 1850, Lemuel Shattuck (1793–1859) published the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the epidemiological connection between the mosquito (Aedes aegypti first report on sanitation and public health problems NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION species) and yellow fever. in the Commonwealth of Massachusetts. Shattuck Courtesy of Centers for Disease Control and Prevention, Atlanta, Georgia. was a teacher, sociologist, and statistician, and he The infectious nature of yellow fever was estabserved in the state legislature. He was the chair of a lished in 1900 (FIGURE 2-5). In 1902, the United States legislative committee to study sanitation and public © Jones & Bartlett Learning, LLCPublic Health Service was © Jones Bartlett Learning, LLC founded,&and in 1906, the health. The report set forth many public health proNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pure Food and Drug Act passed. Standard methods of grams and needs for the next century. Of the many water analysis were also adopted in 1906. The pasteurneeds and programs suggested, several were epideization of milk was shown to be effective in controlling miologic in nature. To ensure that epidemiology, its the spread of disease in 1913, and in the same year, investigations, and the all-important control and prethe first©school of public health, Learning, the Harvard School vention aspects of its work are achieved, an organized © Jones & Bartlett Learning, LLC Jones & Bartlett LLC of 26,27 Public Health, was established. and structured effort OR is needed. The organized effort NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Alice Hamilton (1869–1970) received a doctor of has to come through an organization sponsored by medicine degree from the Medical School at the Unithe government. versity of Michigan. She then completed internships Shattuck’s report set forth the importance of at the Minneapolis Hospital for Women and Children establishing state and local boards of health. It rec© Jones & Bartlett Learning, LLC © Jones & the Bartlett Learning, LLC and New England Hospital for Women and Chilommended that an organized effort to collect and NOT FOR SALE ORvital DISTRIBUTION NOT FOR SALE OR DISTRIBUTION dren. She became a leading expert in occupational analyze statistics be established. Shattuck also health and a pioneer in the field of toxicology. In 1919, recommended the exchange of health information, she became the first woman appointed to the faculty at sanitary inspections, research on tuberculosis, and Harvard Medical School, joining a new department in the teaching of sanitation and prevention in med28 ical schools. The©health of schoolchildren was also Jones & Bartlett Learning, LLCIndustrial Medicine. © Jones & Bartlett Learning, LLC Wade Hampton Frost (1880–1938) received a of major concern. As a result of the report, boards of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION medical degree from the University of Virginia. He health were established, with state departments of later became the first professor of epidemiology at the health and local public health departments soon to Johns Hopkins School of Hygiene and Public Health. follow—organizations through which epidemiologic Frost created an epidemiology curriculum for the activities took place.26,27 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCwith new academic discipline. He also worked closely Quarantine conventions were held in the 1850s. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Lowell Reed of the Department of Biostatistics, which The first in the United States was in Philadelphia in established the close working relationship between 1857. The prevention of typhus, cholera, and yellow the two disciplines for addressing public health probfever was discussed. Port quarantine and the hygiene lems. He showed that epidemiology is an analytical of immigrants were also of concern. Public health science closely Learning, integrated with educational activities began theJones © Jones & Bartlett Learning, LLC at this time. In 1879, © & Bartlett LLCbiology and medical science. His work focused on the epidemiology of first major book on public health, which included epiNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION poliomyelitis, influenza, diphtheria, and tuberculodemiologic topics, was published by A. H. Buck. The 26,27 sis. In 1918, Frost, along with Edgar Sydenstricker, book was titled Hygiene and Public Health. © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 32 Chapter 2 Historic Developments in Epidemiology investigated the impact of the influenza pandemic on of records of illnesses in workers in large © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, 18&different localities in the LLC United States, providing industries in the United States was of DISTRIBUTION NOT FOR SALEinsights OR DISTRIBUTION important for public health experts. Because NOT FOR SALE concernOR because it added to the difficulty of his contributions to our understanding of the natof defining and explaining work-related ural history of selected diseases and advances in the illness. Criteria for determining disability methods and scientific discipline of epidemiology, from illness or injury at work and when Wade Hampton Frost is©often considered the father of allowed& were not Jones & Bartlett Learning, LLC sick benefits should©beJones Bartlett Learning, LLC modern epidemiology.29NOT FOR SALE OR DISTRIBUTION well developed. Malingering wasSALE also conNOT FOR OR DISTRIBUTION sidered, as was its effect on the illness rates of workers. It was suggested that if illness ▸▸ records showing absence from school were kept with a degree of specificity, they could © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC be of value to the understanding of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION An epidemiology professional of the early 1900s who effect of disease on theseOR populations. helped advance the study of disease statistics (mor4. Illness surveys. These have been used by bidity) was Edgar Sydenstricker (1881–1936). Develmajor insurance companies to determine opment of a morbidity statistics system in the United the prevalence of illness in a specific popuwas quiteLearning, slow. One problem House-to-house © JonesStates & Bartlett LLC was that morbidity © Jones &lation. Bartlett Learning, canvass LLC approaches statistics cannot be assessed and analyzed in the same NOT FOR SALE have been Incidence of diseases NOT FOR SALE OR DISTRIBUTION ORused. DISTRIBUTION manner as death (mortality) statistics. Sydenstricker within a given period is not revealed by struggled with the mere definition of sickness and such methods, whereas chronic-type disrecognized that to all persons, disease is an undenieases are found to be of higher incidence able and frequent experience. Birth and death come to (which should be expected and predicted). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a person only once, but illness comes often. This was 5. Records of the incidence of illness in a NOTorFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION especially true in Sydenstricker’s era, when sanitation, population continuously frequently public health, microbiology, and disease control and observed. To benefit epidemiologic studies, prevention measures were still being developed.30 two study methods were employed: (1) In the early 1900s, morbidity statistics of any given determination of the annual illness rate in kind were not regularly collected on a large scale. Intera representative and © Jones & Bartlett Learning, LLC © Jones &population Bartlett Learning, LLC est in disease statistics came OR onlyDISTRIBUTION after the demand for (2)NOT development of an epidemiologic NOT FOR SALE FOR SALE OR DISTRIBUTION them arose from special populations and when the stamethod whereby human populations could tistics would prove useful socially and economically. be observed to determine the existence of In addition, Sydenstricker noted that there were barrian incidence of various diseases as they ers to collecting homogeneous morbidity data in large were manifested under normal conditions © Jonesamounts: & Bartlett Learning, Bartlett Learning,30LLC differences in dataLLC collection methods and © Jones &within the community. NOT FOR SALE OR SALE OR DISTRIBUTION definitions, timeDISTRIBUTION elements, and the existence of pecu- NOT FOR A morbidity study by Sydenstricker and his colliar factors that affect the accuracy of all records.30 leagues under the direction of the United States Sydenstricker suggested that morbidity statistics Public Health Service in Hagerstown, Maryland, be classified into five general groups in order to be of was conducted in 1921–1924. The study involved value: © Jones & Bartlett Learning,16,517 LLC person-years of observation © Jones Bartlett Learning, LLC or an&equivalent Historical Development of Morbidity in Epidemiology Reports of communicable disease. OR Notifipopulation of 1,079 individuals who wereSALE observed NOT FOR OR DISTRIBUTION NOT FOR SALE DISTRIBUTION cation of those diseases for which reasonfor 28 months beginning in 1921. Illnesses discovered ably effective administrative controls have in field investigations, when family members reported been devised. being sick or when researchers observed a sick person, 2. Hospital and clinical records. These records were recorded family visit. A fairly accu© Jones & Bartlett Learning, LLC ©during Joneseach & Bartlett Learning, LLC were viewed as being of little value in idenrate record of actual illness was obtained by a commuNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tifying incidence or prevalence of illness in nity interview method. Two findings were that only populations (at this time, most people were 5% of illnesses were of a short duration of 1 day or less, treated at home unless they were poor and and 40% were not only disabling but caused bed conin need of assistance). Such records were finement as well. An accurate data-gathering process 30 © Jones & Bartlett Learning, LLCfor clinical studies. © Jones & Bartlett Learning, LLC deemed only of value was developed from the experience. In theSALE study, 17,847 cases of illness were recorded 3. Insurance and industrial establishment NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION in a 28-month period. An annual rate of 1,081 per and school illness records. The absence 1. © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. The Framingham Heart Study 1,000 person-years was observed, being about one ill- 33 breastmilk gained more weight than those fed cow’s © Jones & Bartlett Learning, LLC © Jones & Bartlett ness per Learning, person-year. LLC The illness rate was 100 times milk. She used statistical methods to show that the NOT FOR SALE in OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 30 the annual death rate in the same population. difference weight between the two groups was The most interesting results of this first morbidunlikely to be due to chance. She also assessed whether ity study were the variations of incidence of illness confounding factors could explain the difference. She according to age. The incidence of frequent attacks of was a strong advocate for breastfeeding, midwife trainillness, four or more a year, was highest (45%) in chil- LLCing, and prenatal services reduce&premature © Jones & Bartlett Learning, © to Jones Bartlettbirths, Learning, LLC 32,33 dren aged 2–9 years and lowest in those 20–24 stillbirths, and maternalNOT mortality. FOR SALE OR DISTRIBUTION NOT FOR SALE ORaged DISTRIBUTION In 1923, Lane-Claypon conducted a case-­control years (11%). By 35 years old, the rate rose again to 21%. study that involved 500 women with a history of When severity of illness was looked at, it was found breast cancer (cases) and 500 women without a histhat the greatest resistance to disease was in children tory of breast cancer (controls). She then investigated between 5 and 14 years of age. The lowest resistance to © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC whether the cases differed from the controls with disease was in early childhood, birth through 4 years, NOT FOR SALE OR DISTRIBUTION FOR SALE OR mortality DISTRIBUTION respectNOT to occupation and infant (proxies of and toward the end of life.30,31 social status), nationality, marital status, and age. She also investigated reproductive health histories. Until this study, no large-scale review of this type had been ▸▸ 32,33 conducted. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Janet Lane-Claypon (1877–1967) was an English phyIn 1926,OR Lane-Claypon conducted another cohort NOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION sician who received a doctorate in physiology and an study, which followed a large group of surgically MD at the London School of Medicine for Women treated women with pathologically confirmed breast (FIGURE 2-6). In her early career, she applied her skills cancer for up to 10 years. The study showed that disease in the research lab, investigating the biochemistry of stage at the time of diagnosis was directly related to © Jones & Bartlett Learning, Jones & Bartlett Learning, LLC milk and reproductive physiology, but later focused LLCsurvival. Lane-Claypon © recognized the importance of her thinking on the epidemiology of breast cancer.32,33 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION accurate staging and the potential bias that inaccurate In 1912, Lane-Claypon published the results staging could have on the results. Further, she showed from a novel cohort study showing that babies fed that breast cancer risk was greater for women who did not have children, who married at a later-than-average age, or©who did not breastfeed.Learning, She also recognized © Jones & Bartlett Learning, LLC Jones & Bartlett LLC that genes could influence risk.32,33 NOT FOR SALE OR DISTRIBUTION NOT FOR SALEcancer OR DISTRIBUTION Breast Cancer Epidemiology ▸▸ © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION The Framingham Heart Study In 1948, the Framingham, Massachusetts, cardiovas© Jones & Bartlett Learning, LLC cular disease study was launched. The aim of the study NOT FOR SALE OR DISTRIBUTION was to determine which of the many risk factors contribute most to cardiovascular disease. At the beginning, the study involved 6,000 people between 30 and 62 years of age. These people were recruited to par© Jones & Bartlett Learning, LLCticipate in a cohort study © that Jones & Bartlett LLC spanned 30 years,Learning, with 5,100 residents completing theFOR study.SALE In the OR 30 years, NOT DISTRIBUTION NOT FOR SALE OR DISTRIBUTION medical exams and other related testing activities were conducted with the participants. The study was initially sponsored by the National Institutes of Health, the Massachusetts of Public Health, © Jones & Bartlett Learning, LLC © Jones &Department Bartlett Learning, LLC and the Framingham Department of Health.34–36 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The site for the study was determined by several factors. It was implied that Framingham was a cross-section of America and was a typical small American city. Framingham had a fairly stable pop© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ulation. One major hospital was used by most of the people in the community. An annual updated NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-6 Janet Lane-Claypon © National Library of Medicine/Photo Researchers, Inc. city population list was kept, and a broad range of © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 34 Chapter 2 Historic Developments in Epidemiology occupations, jobs, and industries were represented. were 10 times more likely to die of lung cancer than © Jones & Bartlett Learning, LLC © Jones & study Bartlett Learning, The approach used inLLC the Framingham study nonsmokers. NOT FOR SALE ORand DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 34–36 was a prospective cohort study. The case-control cohort study designs used by The diseases of most concern in the study were these researchers remain commonly used in epidemicoronary heart disease, rheumatic heart disease, conologic research today. gestive heart failure, angina pectoris, stroke, gout, gallbladder disease, and©eye conditions. SeveralLearning, clinJones & Bartlett LLC © Jones & Bartlett Learning, LLC ical categories of heart NOT diseaseFOR wereSALE distinguished in NOT FOR SALE OR DISTRIBUTION OR DISTRIBUTION ▸▸ this study: myocardial infarction, angina pectoris, The expanding role of epidemiology has been accomcoronary insufficiency, and death from coronary heart 34–36 panied by an increasing number of methods for condisease, as shown by a specific clinical diagnosis. ducting epidemiologic research. In the 1960s and Many study design methods and approaches were © Jones & Bartlett Learning, LLC © Jonestended & Bartlett LLC 1970s, epidemiologists to be Learning, physicians with advanced in the investigation, such as cohort tracking, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a primary interest in disease etiology. Some of these population selection, sampling, issues related to age of physicians were effective in collaborating with statisthe population, mustering population support, comticians. Olli S. Miettinen (1936–) is a statistician who munity organization, a specific chronic disease focus, developed and published several landmark papers on and analysis of the study findings. The study advanced causal, design, and statistical approaches of the epidemiology © Jonesunderstanding & Bartlett Learning, LLC of hypertensive or © Jones & Bartlett Learning, LLC in epidemi47–50 Several other statisticians contributed to ology. arteriosclerotic disease. It also identi- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR cardiovascular DISTRIBUTION modern epidemiologic thinking: Sir Austin Bradford fied much of what we know today about the effects of Hill (1897–1991), who pioneered the randomized diet, exercise, and common medications such as aspiclinical trial and presented criteria for determining rin on heart disease. causal associations;51,52 Jerome Cornfield (1912–1979), © Jones & Bartlett Learning,who LLC © Jones & Bartlett contributed to the development of clinical trials, Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Bayesian inference, and the relationship between sta▸▸ 53 tistical theory and practice; Joseph L. Fleiss (1937– After World War II, vital statistics indicated a sharp 2003), who contributed to mental health statistics increase in deaths attributed to lung cancer. The first and developed a statistical measure of interrater reli54,55 epidemiologic reports indicating a link between cigaGreenland (1951–), ability called©kappa; © Jones & Bartlett Learning, LLC Jones &Sander Bartlett Learning, LLC rette smoking and lung cancer appeared in the early who contributed primarily to meta-analysis, BayesNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1950s.37–41 By the time of the 1964 report by the Surian inference, and causal inference; Norman Breslow geon General of the United States, there had been 29 (1941–), who developed and promoted greater use case-control studies and 7 prospective cohort studies of the case-control matched sample research design; published, all showing a significantly increased risk of Nathan Mantel (1919–2002), who, with William cancer among tobacco smokers. © Joneslung & Bartlett Learning, LLC 42 © Jones &developed Bartlett the Learning, LLC test and the Haenszel, Mantel-Haenszel 56 The first case-control studies that assessed the and William Mantel-Haenszel odds ratio; NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTIONG. Cochran association between smoking and lung cancer were (1909–1980), who developed and advanced research conducted in the late 1940s by Wynder and Graham in experimental designs and sampling techniques.57–60 in the United States (1950) and Doll and Hill in Great Britain (1950).43,44 These studies first identified Jones & and Bartlett Learning, LLC © Jones & Bartlett Learning, LLC cases with lung cancer © and controls then inves▸ ▸ NOT FOR SALE OR DISTRIBUTION NOT DISTRIBUTION tigated whether people withFOR lungSALE cancer OR differed from others without the disease with respect to their This chapter describes the contributions of many smoking history. Both studies showed that lung key players to the field of epidemiology who sought cancer patients were more likely to have a history to explain illness, injury, and death from an obserof smoking. vational, scientific perspective. Individuals were pre© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TheNOT first FOR cohortSALE study OR assessing the association sented who helped shapeSALE the discipline as we know DISTRIBUTION NOT FOR OR DISTRIBUTION between smoking and lung cancer was conducted in it today. These people were physicians, statisticians, 1951 by Doll and Hill.45,46 Physicians in Great Britain engineers, sociologists, chemists, and more. Pioneers were sent a questionnaire to determine their smoking in the area of epidemiology introduced germ theory, habits. They were then followed over a 25-year period the microscope, vaccinations, study designs, evalua© Joneswith & Bartlett Learning, LLC collected to deter- © Jones & Bartlett LLC death certificate information tion methods, sourcesLearning, and modes of disease transmisNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION mine whether deaths were attributed to lung cancer ...
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