哈醫(yī)大流行病學(xué)緒論

1、1,流行病學(xué)緒論Introduction of Epidemiology,哈爾濱醫(yī)科大學(xué)流行病學(xué)教研室 Department of epidemiology ，Harbin Medical University,2,醫(yī)學(xué) Medicine,Basic medicine Clinical medicine Preventive medicine Epidemiology has alwa

2、ys been a necessary part of medicine practice. 流行病學(xué)一直醫(yī)學(xué)實踐必不可少的部分,基礎(chǔ)醫(yī)學(xué)臨床醫(yī)學(xué)預(yù)防醫(yī)學(xué),,,,,,,,,,,,,3,醫(yī)學(xué)之母 The mother of medicine,Because, the epidemiology is from macro point of view to observe the any question. e.g. fr

3、om macro point of view to study the disease and health. 因為流行病學(xué)是從宏觀觀察問題， 亦即從宏觀研究疾病和健康,4,CONTENTS 目錄,HistoryDefinition MethodsPrincipleApplication FeaturesProspect,歷史定義方法原理應(yīng)用特點展望,5,

4、Brief History of Epidemiology 流行病學(xué)簡史,學(xué)科形成前期 -18世紀(jì)學(xué)科形成期 18世紀(jì)末-20世紀(jì)初學(xué)科發(fā)展期（現(xiàn)代流行病學(xué)時期） 20世紀(jì)40、50年代-,Before the form of Epidemiology --1700sForming of Epidemiology End of 1700s— be

5、ginning of 20 century Development of Epidemiology （Modern Epidemiology） 40s-50s of 20 century,6,Earlier stage: ----- 18th century,-Hippocrates (460-377 BC)A First Epidemiologist,《Epidemic Ⅰ》《Epidemic Ⅲ》《On

6、 Airs, Waters and Places》-中國：“疫”、“時疫”、“疫癘”,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-

7、377 BC)第一個流行病學(xué)家,主要的流行病學(xué)著作：《Epidemic Ⅰ》《Epidemic Ⅲ》《On Airs, Waters and Places》,中國：“疫”“時疫”“疫癘”,一、學(xué)科形成前期-18世紀(jì),自從有人類文明到18世紀(jì). 這期間,該學(xué)科（ 分支） 尚未形成，但已形成雛形.,8,The Black Death in Europe ca.1300s 歐洲黑死病,9,13

8、47-1351年 鼠疫導(dǎo)致2400萬人死亡,10,,Italy-- Venice ---- the earliest quarantine 15th Century : The people in order to avoid the infectious disease spreading, the request external ships must Away (outside) from the port 40 days .

9、That is (quadraginta (latin =40)) →. 1423: set up first infectious diseases hospital,中國：隋朝開設(shè)“癘人坊” (leprosy hospital) 隔離麻風(fēng)病人,11,意大利威尼斯－最早的檢疫,14世紀(jì) 外來船只必須在港外停留檢疫40天quadraginta (拉丁語，意思為40) → qua

10、rantine1423年成立了首家傳染病隔離醫(yī)院,中國：隋朝開設(shè)“癘人坊”以隔離麻風(fēng)病人,12,,-John Graunt (1620-1674),Use death data to study distribution of disease Make first life table calculate expectation of life Summarizes death process with

11、 probability of survival and death Producce control group ideaHis contribution is the first time to introduceStatistics to Epidemiology,《Natural and Political Observations Made Upon the Bills of Mortality》,13,

12、John Graunt (1620-1674),利用死亡數(shù)據(jù)進行死亡分布及規(guī)律性研究創(chuàng)制了第一張壽命表，計算期望壽命用生存概率和死亡概率來概括死亡經(jīng)歷提出設(shè)立比較組的思想將統(tǒng)計學(xué)引入流行病學(xué)領(lǐng)域,《Natural and Political Observations Made Upon the Bills of Mortality》,14,Graunt’s Observations,Excess of males o

13、ver females among births but higher mortality in malesHigh infant mortality rateSeasonal variation in morbidityAcute versus chronic diseasesUrban versus rural mortalityRural migration to the cityFirst attempts at a

14、 life table,出生時男性多于女性，但男性死亡高嬰兒死亡率高發(fā)病呈季節(jié)變動比較急性與慢性疾病城市與農(nóng)村死亡比較農(nóng)村象城市流動首次嘗試壽命表,15,,Lind .James 1716—1795 - A surgeon of English navy - By means of Epidemiologic experiment Discovered Orange preven

15、t scurvy,2. Form stage,Start the experimental Epidemiology,16,James Lind (1716-1794),VitC缺乏 – 壞血病 (1747)開創(chuàng)了流行病學(xué)臨床試驗的先河,二、學(xué)科形成期,17,-Edward Jenner (1796) He used cowpox immunization in preventing smallpox.,,,18,Edward Je

16、nner (1749-1823),(1796)接種牛痘預(yù)防天花,開創(chuàng)了主動免疫的先河,施民安. 琴納發(fā)現(xiàn)牛痘預(yù)防天花的經(jīng)過. 見:錢宇平, 主編. 流行病學(xué)研究實例 (第1卷). 北京: 人民衛(wèi)生出版社，1984. p38-42.,19,In 1979 WHO declared that smallpox has been eliminated in the whole world.Smallpox eradication sh

17、ould be attributed to his research .,20,Sir Percivall Pott: 1775,English surgeon in LondonWe all best known for “Pott’s fracture”He is one of earliest accounts of cause and effect linkage for an occupational carcinogen

18、.He found that the scrotal cancer was particularly in the workers of Chimney (stovepipe) cleaning,21,Sir Percivall Pott: 1775,英國外科醫(yī)生以“Pott’s 骨折著稱 他最早將職業(yè)致癌物與病因聯(lián)系起來他發(fā)現(xiàn)陰囊癌為煙筒清潔工所特有,22,,William Farr (1807-1883),Stati

19、stician (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 (1807-18

20、83),在英國首創(chuàng)人口和死亡的常規(guī)資料收集提出許多流行病學(xué)的重要概念：標(biāo)化死亡率、人年、劑量反應(yīng)關(guān)系、患病率 患病率＝發(fā)病率×病程,現(xiàn)代流行病學(xué)的奠基人之一公共衛(wèi)生運動的領(lǐng)導(dǎo)者之一,24,-London Epidemiological Society (1850) established,It is a first one in the world,It is showed that the discipline a

21、lready formed,25,London Epidemiological Society (1850),全世界第一個流行病學(xué)學(xué)會標(biāo)志著流行病學(xué)學(xué)科的形成,26,-John Snow (1848-1854),27,The great French Bacteriologist Louis Pasteur (1822-1895),He established the Germ theoryManufacture animal v

22、accine: -anthrax, -fowl cholera, -swine erysipelas -Rabies---virus---vaccine Pasteurization– 600C –30’ the new useful disinfection method,28,偉大的法國微生物學(xué)家Louis Pasteur (1822-1895),微生物理論 (germ theo

23、ry)開發(fā)了雞霍亂、炭疽、豬丹毒疫苗減毒的微生物可以用作免疫提出狂犬病是由一種顯微鏡看不到的物質(zhì)傳播的（即病毒），并開發(fā)疫苗治療和預(yù)防狂犬病巴斯德殺菌法,第一節(jié) 流行病學(xué)發(fā)展史,29,3, Development stage （發(fā)展階段） (20th Century 40’s, 50’s ------now)Features （特點）: (1) Spectrum of disease : The

24、study area extended from communicable diseases--- to Non-communicable /chronic disease --- to health 疾病譜 研究領(lǐng)域從 傳染病—非傳染病---健康,30,Ten leading causes of death 1900 and 1990,31,,Children of

25、Polio脊髓灰質(zhì)炎患兒,32,Features （特點）:（2）Research method from Survey and analysis to qualitative and quantitative combined, and macroscopic and microscopic combined 研究方法從調(diào)查分析到定性和定量結(jié)合，宏觀與微觀結(jié)合

26、 (3) Social behavior factors is very important 社會行為因素非常重要 (4) There are more other related Branch of epidemiology emerge 有更多的流行病學(xué)相關(guān)分支出現(xiàn),33,REVIVAL OF EPIDEMIOLOGY: BEGINNING OF MODERN EPIDEMIOLOGY,Main ch

27、aracteristic: From communicable diseases to non-communicable diseasesTime: Mid 20th Century First RCTs: streptomycin and respiratory tuberculosis in 1948Early case-control studies:

28、 smoking and lung cancer in 1950Early cohort studies: Framingham Study in 1948 British Doctors Study in 1951,Sir Austin B. Hill: The Father of Modern Epidemiology,Sir Richard Doll: Th

29、e Godfather of Epidemiology,34,流行病學(xué)復(fù)興：現(xiàn)代流行病學(xué)的開始,主要特點: 從傳染病倒非傳染病時間: 20th世紀(jì)中葉 第一個 RCTs: 鏈霉素與肺結(jié)核 1948早期病例對照研究：吸煙和肺癌的關(guān)系 1950早期隊列研究: Framingham 研究1948 英國醫(yī)生研究 1951,Sir

30、 Austin B. Hill: The Father of Modern Epidemiology,Sir Richard Doll: The Godfather of Epidemiology,35,Kenneth Rothman: The Philosopher in Epidemiology現(xiàn)代流行病學(xué)中的哲學(xué)家 Kenneth Rothman,36,ROTHMAN AND MODERN EPIDEMIOLOGY,From

31、 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 an

32、d matching *Standardization *Stratified analysis *Adjustment by regression can be control the confounding bias,37,1992: BIRTH OF EVIDENCE-BASED MEDICINE1992年： 循證醫(yī)學(xué)誕生,“A new paradigm

33、 for medical practice is emerging in 1992”出現(xiàn)醫(yī)學(xué)實踐進模式-A New Approach to Teaching the Practice of Medicine醫(yī)學(xué)教育新方法,,38,DAVID SACKETT,Activist in clinical epidemiology 臨床流行病學(xué)活動家The pioneer in EBM 循證醫(yī)學(xué)先驅(qū)

34、The first book on EBM 第一本循證醫(yī)學(xué)書 McMaster University Health Science Centre Chairman of Oxford Centre for EBM,39,WORLD COCHRANE COLLABORATION國際COCHRANE合作,In 1992, the very first Cochrane

35、 centre was established in Oxford. Mission: Collecting, summarizing and disseminating evidence from organized research.,1992年第一個COCHRANE中心在牛津建立使命：收集、總結(jié)和傳播研究證據(jù),,,40,Today there is a total of 15 national or regional Co

36、chrane centers and over 40 review groups world wide. Chinese national Cochrane/EBM Centre is in Sichuan University,目前，全球有15個國家和地區(qū)COCHRANE 中心和40多個評價組中國國家循證醫(yī)學(xué)中心在四川大學(xué),WORLD COCHRANE COLLABORATION國際COCHRANE合作,41,Definit

37、ion of Epidemiology流行病學(xué)定義,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.

38、 (Last),42,the meaning of this definition,DiseasePopulationDistribution – prevention & controlSocial medicine,疾病人群分布—預(yù)防空中社會醫(yī)學(xué),43,The relationship between ep

39、idemiology and clinical medicine,PopulationsStudies/assessmentsPreventionEvaluationPlanning,IndividualsDiagnosisTreatmentCuringCaring,,,44,Study methods 研究方法 -Observation -Experimental -Theoretical,45,ST

40、UDY,Surveillance Observation Hypothesis testing Analytic research Experiments Theoretical epidemiology,監(jiān)測觀察假設(shè)檢驗分析研究實驗理論流行病學(xué),46,Distribution,Place Time Persons,47,Determinantsby means of:,Physical Biologic

41、al Social Cultural Behavioral Factors,48,Health- related states and events 健康相關(guān)狀態(tài)和事件,Diseases Causes of death Behavior: Tobacco, Alcohol, Drug useReactions to preventive regimensProvision and use of health servic

42、es,49,Epidemiology,Population Medicine群體醫(yī)學(xué) The Language of Quantification定量語言,50,Factors influencing the spread of disease,Socioeconomic conditionsSanitationNutritionLifestyleAgeGender,社會經(jīng)濟狀況衛(wèi)生營養(yǎng)生活方式年齡性別,51

43、,Principle of epidemiology 流行病學(xué)原理,Distribution Epidemic processRelationship of human and environment CausationCausal inference Prevention Theoretical epidemiology,流行分布人語自然關(guān)系病因病因推斷預(yù)防理論流行病學(xué),52,Application of e

44、pidemiology流行病學(xué)應(yīng)用,1. Determine great public health Problems2. Response and deal with emergency event 3. Surveillance of disease related,重大公共衛(wèi)生問題的確定突發(fā)事件的應(yīng)急與處理疾病相關(guān)監(jiān)測,53,Application of epidemiology流行病學(xué)應(yīng)用,4. Study the

45、cause and risk factor of disease5. To study the natural history and prognosis of disease.6. Evaluate the prevent effect,疾病病因和危險因素研究疾病的自然史研究疾病防治的效果評價,54,一、重大公共衛(wèi)生問題的確定Determine great public health Problems,圖1-1 中國1954

46、-1998年死亡率變化趨勢,55,,(2006中國衛(wèi)生統(tǒng)計提要),表1-1 2005年中國部分市縣前十位疾病死亡專率及死亡原因構(gòu)成,56,,表1-2 2003年中國居民慢性病患病率(‰)及疾病構(gòu)成(%),(第三次國家衛(wèi)生服務(wù)調(diào)查結(jié)果),57,二、突發(fā)事件的應(yīng)急與處理Response and deal with emergency event,SARS 人感染豬鏈球菌病Meningitis Caused by Streptoco

47、ccus Suis,58,,First stage 1.2—2.28,Second stage3.8—4.23,Third stage4.24—5.31,Fourth6.1—6.24,圖1-2 Time distribution of SARS,59,圖1-3,60,圖1-4,61,Proportion of person contacted SARS to all isolated 61%（630/1028)

48、,Table 1-5 Incidence of isolated medical observers of 1028,62,Table 1-6 Incidence situation of 630 person close contacted with SARS,Proportion of person contacted with Symptom period SARS to total isolated 37% (383/102

49、8),63,監(jiān)測目的 描 述 現(xiàn) 狀 應(yīng) 急 反 應(yīng) 決 策 依 據(jù) 干 預(yù) 評 價,三、疾病相關(guān)監(jiān)測 Disease related surveillance,Purpose of surveillanceDescribe the situationEmergency responseBasis for decision makingEvaluation for intervention,64,疾病監(jiān)測（發(fā)病

50、、死亡）生物學(xué)監(jiān)測（全血、血漿、血清、唾液及液……）行為監(jiān)測（吸煙、飲酒、鍛煉、性行為、毒……）環(huán)境監(jiān)測（自然環(huán)境、社會環(huán)境）蟲媒監(jiān)測（鼠、蚊……）,Disease surveillance (incidence, death)Biology surveillance (blood, serum, plasma, saliva …) Behavior surveillance (smoking, alcohol drinki

51、ng, drug..)Environmental surveillance natural， social，EnvironmentVector surveillance （mouse mosquito……）,監(jiān)測類型 Type of surveillance,65,第一階段（20世紀(jì)50年代－） 全國法定傳染病疫情報告系統(tǒng) (1950年) First stage (50s of 20 ce

52、ntury-- ) The notifiable infection disease system in China (1950),我國的監(jiān)測系統(tǒng)Surveillance system in China,66,第二階段（20世紀(jì)70年代后期－） 傳染病監(jiān)測（單病監(jiān)測系統(tǒng)） 出生、死亡監(jiān)測 綜合疾病監(jiān)測系統(tǒng)（1980年）

53、 Second stage (70s of 20 century--) infectious disease surveillance (single disease surveillance system) birth, death surveillance comprehensive surveil

54、lance system (1980-),67,第三階段（20世紀(jì)80年代后期－） 傳染病監(jiān)測、出生、死亡監(jiān)測 慢性非傳染性疾病監(jiān)測 行為監(jiān)測 The third stage （80s 20 century--） infectious disease surveillance； birth, death surveillance Chronic non-comm

55、unicated disease、behavior surveillance 第四階段（21世紀(jì)初－） 整合：國家公共衛(wèi)生監(jiān)測體系 The fourth stage （beginning of 20 century--） integrate：National public health surveillance system,68,Risk factor and disease– smoking

56、and lung cancer,圖6－1,圖6－2,圖6－3,圖6－4,69,五、疾病自然史研究,圖1-7,70,The Natural History of Disease,A- Stage of susceptibility（易感期）B-Stage of pre-symptomatic disease （癥狀前期）C-Stage of clinical disease （臨床病人）D-Stage of disability o

57、r recovery or death（殘疾、恢復(fù)或死亡） A B C D,,71,0,1,2,3,4,5,6,7,8,9,10,11,12,13,,,,,,,,,,,,,,,,,,,,,,,Week,Response,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Clinic

58、al illness,,ALT,IgM,IgG,HAV in stool,Infection,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Viremia,EVENTS IN HEPATITIS A VIRUS INFECTION,72,RANDOMIZED CONTROLLED TRIAL, RCT隨機對照試驗,EVIDENCE BASED MEDICINE循證醫(yī)學(xué),流行病學(xué)?循證醫(yī)學(xué)“生產(chǎn)”證據(jù)的科學(xué)方法決策

59、過程中利用證據(jù)所必需的知識技能,,六、疾病防治效果的評價 Evaluate the effect of prevent and treatment,73,Features 特點,Population medicineCompareProbability theory and statistics Social medicine Prevention Development,群體的特征 對比的特征 概率論和數(shù)理統(tǒng)計學(xué)的

60、 特征 社會心理的特征 預(yù)防為主的特征 發(fā)展的特征,74,Prospect 展望,Macroscopic+MirocosmicCommunicable +non-communicablePopulation health Emergency events and EIDEthicEvidence-based medicine,宏觀與微觀并舉 傳染病和非傳染病并重 重視人群健康和生活質(zhì)量研究 發(fā)展應(yīng)急和現(xiàn)場流行病

61、學(xué) 重視流行病學(xué)研究中的倫理學(xué) 問題 強化流行病學(xué)在循證實踐中的 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?,76,The End,謝謝大家