Department of Epidemiology Public Health College of Harbin Medical University 1 Introduction of Epidemiology 流行病学绪论 Introduction of Epidemiology 哈尔滨医科大学流行病学教研室

Department of Epidemiology

Public Health College of Harbin Medical University

1

流行病学绪论Introduction of EpidemiologyIntroduction of Epidemiology

哈尔滨医科大学流行病学教研室

Department of epidemiology ， Harbin Medical University



2

医学 Medicine

Basic medicine Clinical medicine Preventive medicine

Epidemiology has always been a

necessary part of medicine practice.

流行病学一直医学实践必不可少的部分

基础医学临床医学预防医学



3

医学之母 The mother of medicine

Because, the epidemiology is from macro point of view to observe the any question. e.g. from macro point of view to study the disease and health.

因为流行病学是从宏观观察问题，亦即从宏观研究疾病和健康



4

CONTENTS 目录History

Definition

Methods

Principle

Application

Features

Prospect

历史定义方法原理应用特点展望



5

Brief History of Epidemiology 流行病学简史

学科形成前期 -18 世纪

学科形成期 18 世

纪末 -20 世纪初学科发展期（现代

流行病学时期） 20 世纪 40 、 50年代 -

Before the form of Epidemiology

--1700s Forming of Epidemiology End of 1700s— beginning of 20 century Development of Epidemiology （ Modern Epidemiology ） 40s-50s of 20 century



6

Earlier stage: ----- 18th century

-Hippocrates (460-377 -Hippocrates (460-377 BC)BC)

A First Epidemiologist 《 Epidemic Ⅰ 》《 Epidemic Ⅲ 》《 On Airs, Waters and Places 》

- 中国：“疫”、“时疫”、“疫疠”

From there is the human history of civilization to the 18th century. During this time ,This discipline( branch) not yet forms, but had its embryonic form.



7

Hippocrates (460-377 BC)Hippocrates (460-377 BC)

第一个流行病学家主要的流行病学著作：

《 Epidemic Ⅰ》《 Epidemic Ⅲ》《 On Airs, Waters and Places 》

中国：“疫”“时疫”“疫疠”

一、学科形成前期一、学科形成前期 -18 世纪

自从有人类文明到 18 世纪 . 这期间 ,该学科（分支）尚未形成，但已形成雏形 .



8

The Black Death in Europe ca.1300s 欧洲黑死病



9

1347-13511347-1351 年年鼠疫导致鼠疫导致 24002400 万人死亡万人死亡



10

Italy-- Venice ---- the earliest quarantine 15th Century : The people in order to avoid the infectio

us disease spreading, the request external ships mus

t Away (outside) from the port 40 days .That is (quadr

aginta (latin =40)) →.

1423: set up first

infectious diseases

hospital

中国：隋朝开设“疠人坊” (leprosy hospital) 隔离麻风病人



11

意大利威尼斯－最早的检疫意大利威尼斯－最早的检疫

14 世纪外来船只必须在港外停留检疫 40 天 qu

adraginta ( 拉丁语，意思为 40) → quarantine

1423 年成立了首家传染病隔离医院

中国：隋朝开设“疠人坊”以隔

离麻风病人



12

-John Graunt (1620-1674)-John Graunt (1620-1674)

Use death data to study distribution

of disease

Make first life table calculate

expectation of life

Summarizes death process with

probability of survival and death

Producce control group idea

His contribution is the first time to introduceHis contribution is the first time to introduce

Statistics to Epidemiology Statistics to Epidemiology

《 Natural and Political Observations Made Upon the Bills of Mortality 》



13

John Graunt (1620-1674)John Graunt (1620-1674)

利用死亡数据进行死亡分布及规律性研究

创制了第一张寿命表，计算期望寿命

用生存概率和死亡概率来概括死亡经历

提出设立比较组的思想

将统计学引入流行病学领域将统计学引入流行病学领域《 Natural and Political Observations Made Upon the Bills of Mortality 》



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Graunt’s Observations Excess of males over females

among births but higher mortality in males

High infant mortality rate Seasonal variation in

morbidity Acute versus chronic diseases Urban versus rural mortality Rural migration to the city First attempts at a life table

出生时男性多于女性，但男性死亡高

婴儿死亡率高发病呈季节变动比较急性与慢性疾病城市与农村死亡比较农村象城市流动首次尝试寿命表



15

Lind .James 1716—1795Lind .James 1716—1795

- A surgeon of English navy - By means of Epidemiologic experiment Discovered Orange prevent scurvy

2. Form stage

Start the experimental Start the experimental EpidemiologyEpidemiology



16

James Lind (1716-1794)James Lind (1716-1794)

VitC 缺乏 – 坏血病 (1747)(1747)

开创了流行病学临床试验的先河开创了流行病学临床试验的先河

二、学科形成期



17

-Edward Jenner-Edward Jenner (1796) (1796)

He used cowpox immunization in preventing smHe used cowpox immunization in preventing smallpoxallpox. .



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Edward JennerEdward Jenner (1749-1823) (1749-1823)

(1796)(1796)

接种牛痘

预防天花

开创了主动免疫的先河开创了主动免疫的先河

施民安 . 琴纳发现牛痘预防天花的经过 . 见 : 钱宇平 , 主编 . 流行病学研究实例 ( 第 1 卷 ). 北京 : 人民卫生出版社， 1984. p38-42.



19

In 1979 WHO declared that smallpox has been In 1979 WHO declared that smallpox has been eliminated in the whole world.eliminated in the whole world.

Smallpox eradication should be attributed to his Smallpox eradication should be attributed to his research .research .



20

Sir Percivall Pott: 1775Sir Percivall Pott: 1775 English surgeon in London We all best known for “Pott’s fracture” He is one of earliest accounts of cause a

nd effect linkage for an occupational carcinogen.

He found that the scrotal cancer was particularly in the workers of

Chimney (stovepipe) cleaning



21

Sir Percivall Pott: 1775Sir Percivall Pott: 1775

英国外科医生以“ Pott’s 骨折著称他最早将职业致癌物与病因联系起来他发现阴囊癌为烟筒清洁工所特有



22

William Farr (1807-William Farr (1807-1883)1883)

Statistician (English )

First person who routine collect population and death data in England

Put important words: Standard mortality,

Person year 、 Dose-response relationship 、 P=I×D



23

William Farr (1807-1883)William Farr (1807-1883)

在英国首创人口和死亡的常规资料收集

提出许多流行病学的重要概念：标化死亡率、人年、剂量反应关系、患病率

患病率＝发病率 × 病程

现代流行病学的奠基人之一现代流行病学的奠基人之一

公共卫生运动的领导者之一公共卫生运动的领导者之一



24

--London Epidemiological Society London Epidemiological Society (1850) (1850) establishedestablished

It is a first one in the world

It is showed that the discipline already formed



25

London Epidemiological Society (1850)London Epidemiological Society (1850)

全世界第一个流行病学学会

标志着流行病学学科的形成



26

-John Snow (1848--John Snow (1848-1854)1854)



27

The great French The great French Bacteriologist Bacteriologist

Louis Pasteur (1822-1895)Louis Pasteur (1822-1895)He established the Germ theory

Manufacture animal vaccine:

-anthrax,

-fowl cholera,

-swine erysipelas

-Rabies---virus---vaccine

Pasteurization– 600C –30’

the new useful disinfection method



28

伟大的法国微生物学家伟大的法国微生物学家Louis Pasteur (1822-1895)Louis Pasteur (1822-1895)

微生物理论 (germ theory)

开发了鸡霍乱、炭疽、猪丹毒疫苗

减毒的微生物可以用作免疫

提出狂犬病是由一种显微镜看不到的物质传播的（即病毒），并开发疫苗治疗和预防狂犬病

巴斯德杀菌法



29

3, Development stage （发展阶段） (20th Century 40’s, 50’s ------now)

Features （特点） : (1) Spectrum of disease : The study area extended from communicable diseases--- to Non-communicable /chronic disease --- to health

疾病谱研究领域从传染病—非传染病 ---健康



30

Ten leading causes of death 1900 and 1990



31

Children of Polio脊髓灰质炎患儿



32

Features （特点） :（ 2 ） Research method from Survey and analysis to qualitative and quantitative combined, and macroscopic and microscopic combined

研究方法从调查分析到定性和定量结合，宏观与微观结合 (3) Social behavior factors is very important 社会行为因素非常重要 (4) There are more other related Branch of epidemiology e

merge 有更多的流行病学相关分支出现



33

REVIVAL OF EPIDEMIOLOGY: BEGINNING OF MODERN EPIDEMIOLOGY

Main characteristic: From communicable diseases to non-co

mmunicable diseases

Time: Mid 20th Century

First RCTs: streptomycin and respiratory

tuberculosis in 1948Early case-control studies: smoking and

lung cancer in 1950Early cohort studies: Framingham Study

in 1948 British Doctors Study in 1951

Sir Austin B. Hill: Sir Austin B. Hill: The Father of The Father of ModernModern EpidemiologyEpidemiology

Sir Richard Doll: The Godfather of EpidemiologySir Richard Doll: The Godfather of Epidemiology



34

流行病学复兴：现代流行病学的开始

主要特点 : 从传染病倒非传染病时间 : 20th 世纪中叶

第一个 RCTs: 链霉素与肺结核 1948早期病例对照研究：吸烟和肺癌的关系 1950早期队列研究 : Framingham 研究 1948

英国医生研究 1951 Sir Austin B. Hill: Sir Austin B. Hill: The Father of The Father of ModernModern EpidemiologyEpidemiology

Sir Richard Doll: The Godfather of EpidemiologySir Richard Doll: The Godfather of Epidemiology



35

Kenneth Rothman: The Philosopher in Epidemiology

现代流行病学中的哲学家 Kenneth Rothman



36

ROTHMAN AND MODERN ROTHMAN AND MODERN EPIDEMIOLOGYEPIDEMIOLOGY

From Study of distributions to study of causes of diseaseIn humans and observational: case-control & cohort studiesIn order o avoid the Confounding bias he suggested :

By means of the …… * Restriction and matching

*Standardization *Stratified analysis *Adjustment by regression can be control the confounding bias



37

1992: BIRTH OF EVIDENCE-BASED MEDICINE

1992 年：循证医学诞生

“A new paradigm for medical practice is emerging in 1992”

出现医学实践进模式-A New Approach to Teaching the Practi

ce of Medicine

医学教育新方法



38

DAVID SACKETT

Activist in clinical epidemiology 临床流行病学活动家

The pioneer in EBM 循证医学先驱

The first book on EBM 第一本循证医学书

McMaster University Health Science Centre

Chairman of Oxford Centre for EBM



39

WORLD COCHRANE COLLABORATION

国际 COCHRANE合作 In 1992, the very first

Cochrane centre was established in Oxford.

Mission: Collecting, summarizing and disseminating evidence from organized research.

1992 年第一个 COCHRANE中心在牛津建立

使命：收集、总结和传播研究证据



40

Today there is a total of 15 national or regional Cochrane centers and over 40 review groups world wide.

Chinese national Cochrane/EBM Centre is in Sichuan University

目前，全球有 15个国家和地区 COCHRANE 中心和 40多个评价组

中国国家循证医学中心在四川大学

WORLD COCHRANE COLLABORATION国际 COCHRANE合作



41

Definition of Epidemiology流行病学定义

Epidemiology: the study of the distribution and determinants and the occurrence of health-related states or

events in specified and the application of this study to control health problems.

(Last)



42

the meaning of this definition

Disease Population Distribution –

prevention & control Social medicine

疾病人群分布—预防空中社会医学



43

The relationship between epidemiology and clinical medicine

Populations Studies/assessments Prevention Evaluation Planning

Individuals Diagnosis Treatment Curing Caring



44

Study methods 研究方法 -Observation

-Experimental

-Theoretical



45

STUDY Surveillance Observation Hypothesis testing Analytic research Experiments Theoretical

epidemiology

监测观察假设检验分析研究实验理论流行病学



46

Distribution

Place Time Persons



47

Determinantsby means of:

Physical Biological Social Cultural Behavioral Factors



48

Health- related states and events 健康相关状态和事件

Diseases Causes of death Behavior: Tobacco, Alcohol, Drug use Reactions to preventive regimens Provision and use of health services



49

Epidemiology Population Medicine

群体医学 The Language of Quantification

定量语言



50

Factors influencing the spread of disease

Socioeconomic conditions

Sanitation Nutrition Lifestyle Age Gender

社会经济状况卫生营养生活方式年龄性别



51

Principle of epidemiology

流行病学原理 Distribution Epidemic process Relationship of human

and environment Causation Causal inference Prevention Theoretical epidemiology

流行分布人语自然关系病因病因推断预防理论流行病学



52

Application of epidemiology

流行病学应用1. Determine great public

health Problems

2. Response and deal with emergency event

3. Surveillance of disease related

重大公共卫生问题的确定突发事件的应急与处理疾病相关监测



53

Application of epidemiology

流行病学应用4. Study the cause and risk

factor of disease

5. To study the natural history and prognosis of disease.

6. Evaluate the prevent effect

疾病病因和危险因素研究疾病的自然史研究疾病防治的效果评价



54

一、重大公共卫生问题的确定Determine great public health Problems

图图 1-11-1 中国中国 1954-19981954-1998 年死亡率变化趋势年死亡率变化趋势

0

100

200

300

400

500

600

700

800

900

1954 1957 1963 1975 1980 1985 1990 1995 1998

CD

R （1

/10

0,0

00 ）

OthersOthers Injuries & Injuries & poisoningpoisoning

Non-communicable Non-communicable diseasesdiseases

CommunicablCommunicable,e,

maternal and maternal and child diseaseschild diseases



55(2006 中国卫生统计提要 )

表 1-1 2005 年中国部分市县前十位疾病死亡专率及死亡原因构成



56

顺位城市　农村疾病患病率构成　疾病患病率构成

1 高血压高血压 54.722.

8高血压高血压 16.4

13.6

2 糖尿病糖尿病 16.3 6.8 胃肠炎 10.5 8.7

3 脑血管病脑血管病 13 5.4 类风湿性关节炎 8.7 7.2

4 缺血性心脏病缺血性心脏病 12.4 5.2 慢性阻塞性肺病慢性阻塞性肺病 7.3 6

5 胃肠炎 9.8 4.1 胆结石胆囊炎 4.7 3.9

6 胆结石胆囊炎 8.5 3.5 脑血管病脑血管病 4.4 3.7

7 类风湿性关节炎 8.4 3.5 锥间盘疾病 4 3.3

8 慢性阻塞性肺病慢性阻塞性肺病 8.2 3.4 消化性溃疡 3.8 3.2

9 锥间盘疾病 8.1 3.4 缺血性心脏病缺血性心脏病 2 1.6

10 消化性溃疡 3.4 1.4 　糖尿病糖尿病 1.9 1.6

表 1-2 2003年中国居民慢性病患病率 (‰)及疾病构成(%)

( 第三次国家卫生服务调查结果 )



57

二、突发事件的应急与处理Response and deal with emergency event

SARS

人感染猪链球菌病

Meningitis Caused by Streptococcus Suis



58

0

20

40

60

80

100

120

140

160

180

First stage 1.2—2.28

Second stage3.8—4.23

Third stage4.24—5.31

Fourth6.1—6.24

图 1-2 Time distribution of SARS



59

图 1-3



60

6 10 SARS截止月日北京市病例发病时间分布情况

0

20

40

60

80

100

120

140

3-53-63-73-83-93-103-113-123-133-143-153-163-173-183-193-203-213-223-233-243-253-263-273-283-293-303-314-14-24-34-44-54-64-74-84-94-104-114-124-134-144-154-164-174-184-194-204-214-224-234-244-254-264-274-284-294-305-15-25-35-45-55-65-75-85-95-105-115-125-135-145-155-165-175-185-195-205-215-225-235-245-255-265-275-285-295-305-316-16-26-36-46-56-66-76-86-96-10

发病时间

病例数

确诊疑似

发热门诊

强化疫情报告

密切接触者隔离

病人管理

疫点消毒与隔离

输入期扩散期高峰期高峰期缓降期平稳期

重点人群管理

集中医院收治

爆发点处理

新发病例分析与排查

6 10 SARS截止月日北京市病例发病时间分布情况

0

20

40

60

80

100

120

140

3-53-63-73-83-93-103-113-123-133-143-153-163-173-183-193-203-213-223-233-243-253-263-273-283-293-303-314-14-24-34-44-54-64-74-84-94-104-114-124-134-144-154-164-174-184-194-204-214-224-234-244-254-264-274-284-294-305-15-25-35-45-55-65-75-85-95-105-115-125-135-145-155-165-175-185-195-205-215-225-235-245-255-265-275-285-295-305-316-16-26-36-46-56-66-76-86-96-10

发病时间

病例数

确诊疑似

发热门诊

强化疫情报告

密切接触者隔离

病人管理

疫点消毒与隔离

输入期扩散期高峰期高峰期缓降期平稳期

重点人群管理

集中医院收治

爆发点处理

新发病例分析与排查

图 1-4



61

Cause of isolationNO. of isolated

NO. of incidence

Attack rate(%)

Contacted SARS patient 630 24 3.8

Contacted SARS patient but excluded 140 0 0

Contacted person contacted SARS patient 130 0 0

Diagnosed as SARS ， but excluded and disparage of hospital

45 0 0

Patient with Fever or contact with Patient with Fever

31 0 0

No contact with SARS or close contact person

26 0 0

Isolated SARS patient after discharge 8 0 0

No answer 18 0 0

Total 1028 24 2.3

Proportion of person contacted SARS to all isolated 61%（ 630/1028)

Table 1-5 Incidence of isolated medical observers of 1028



62

Table 1-6 Incidence situation of 630 person close contacted with SARS

Contacted period No. of isolated

No. ofpatients

Attack rate %)

Symptom period 383 24

6.3

Incubation period 167 0 0.0

unclear 50 0 0.0

Not Answer 30 0 0.0

Total 630 24 3.8

Proportion of person contacted with Symptom period SARS to total is

olated 37% (383/1028)



63

监测目的

描述现状

应急反应

决策依据

干预评价

三、疾病相关监测 Disease related surveillance

Purpose of surveillance

Describe the situation

Emergency response

Basis for decision mak

ing

Evaluation for interven

tion



64

疾病监测（发病、死亡）

生物学监测（全血、血浆、血清、唾液及液……）

行为监测（吸烟、饮酒、锻炼、性行为、毒……）

环境监测（自然环境、社会环境）

虫媒监测（鼠、蚊……）

Disease surveillance (incidence, death)

Biology surveillance (blood, serum, plasma, saliva …)

Behavior surveillance (smoking, alcohol drinking, drug..)

Environmental surveillance natural ，

social ， Environment

Vector surveillance （ mouse mosquito……）

监测类型 Type of surveillance



65

第一阶段（ 20 世纪 50 年代－）全国法定传染病疫情报告系统 (1950 年 )

First stage (50s of 20 century-- )

The notifiable infection disease system

in China (1950)

我国的监测系统Surveillance system in China



66

第二阶段（ 20 世纪 70 年代后期－）传染病监测（单病监测系统）出生、死亡监测综合疾病监测系统（ 1980 年） Second stage (70s of 20 century--)

infectious disease surveillance (single disease

surveillance system)

birth, death surveillance

comprehensive surveillance system (1980-)



67

第三阶段（ 20 世纪 80 年代后期－）传染病监测、出生、死亡监测慢性非传染性疾病监测行为监测 The third stage （ 80s 20 century--） infectious disease surveillance； birth, death surveillance

Chronic non-communicated disease 、 behavior surveillance

第四阶段（ 21 世纪初－）整合：国家公共卫生监测体系 The fourth stage （ beginning of 20 centur

y--） integrate ： National public health surveillance system



68

Risk factor and disease– smoking and lung cancer

图图 66 －－11

图图 66 －－22

图图 66 －－33

图图 66 －－44



69

五、疾病自然史研究

图图 1-1-77



70

The Natural History of Disease

A- Stage of susceptibility （易感期）B-Stage of pre-symptomatic disease （症状前期）C-Stage of clinical disease （临床病人）D-Stage of disability or recovery or death （残疾、恢复或死亡）

A B C D



71

0 1 2 3 4 5 6 7 8 9 10 11 12 13Week

Re

sp

on

se

Clinical illness

ALT

IgM IgG

HAV in stool

Infection

Viremia

EVENTS IN HEPATITIS A VIRUS INFECTION



72

RANDOMIZED CONTROLLED TRIAL, RCT随机对照试验

EVIDENCE BASED MEDICINE循证医学

流行病学循证医学“生产”证据的科学方法

决策过程中利用证据所必需的知识技能

六、疾病防治效果的评价 Evaluate the effect of prevent and treatment



73

Features 特点Population medicine

Compare

Probability theory and statistics

Social medicine

Prevention

Development

群体的特征对比的特征概率论和数理统计学的

特征社会心理的特征预防为主的特征发展的特征



74

Prospect 展望Macroscopic+Mirocosmic

Communicable +non-communicable

Population health

Emergency events and EID

Ethic

Evidence-based medicine

宏观与微观并举传染病和非传染病并重重视人群健康和生活质量研究发展应急和现场流行病学重视流行病学研究中的伦理学

问题强化流行病学在循证实践中的

作用



75

Question

1. What is Epidemiology?

2. What is the meaning of this definition?

3. What is the study method of epidemiology?

4. what is the use of epidemiology?



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Department of Epidemiology Public Health College of Harbin Medical University 1 Introduction of Epidemiology 流行病学绪论 Introduction of Epidemiology 哈尔滨医科大学流行病学教研室