1、1,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 ，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 medicin
2、e,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,HistoryDefinition MethodsPrincipleApplication FeaturesProspect,历史定义方法原理应用特点展望,5,Brief History of Epidemiology
3、 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 -1700sForming 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 BC)A Firs
4、t Epidemiologist,Epidemic Epidemic 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)第一个流行病学家,主要的流行病学著作：Epidemic Epidemic On
5、Airs, Waters and Places,中国：“疫”“时疫”“疫疠”,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,9,1347-1351年 鼠疫导致2400万人死亡,10,Italy- Venice - the earliest quarantine 15th Century : The people in order to avoid the infectious disease spreading, the request exter
6、nal ships must Away (outside) from the port 40 days .That is (quadraginta (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,14世纪 外来船只必须在港外停留检疫40天quadraginta (拉丁语，意思为40) quarantine1423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 (
7、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 ideaHis contribution is the first time to introduceStatistics to Epidemiology,Natural and Political Ob
8、servations Made Upon the Bills of Mortality,13,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,Natural and Political Observations Made Upon the Bills of Mortality,14,Graunts Observations,Excess of males over females among births but higher mortality
9、in malesHigh infant mortality rateSeasonal variation in morbidityAcute versus chronic diseasesUrban versus rural mortalityRural migration to the cityFirst 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 17161795 - A surgeon of English navy - By m
10、eans of Epidemiologic experiment Discovered Orange prevent scurvy,2. Form stage,Start the experimental Epidemiology,16,James Lind (1716-1794),VitC缺乏 坏血病 (1747)开创了流行病学临床试验的先河,二、学科形成期,17,-Edward Jenner (1796) He used cowpox immunization in preventing smallpox.,18,Edward Jenner (1749-1823),(1796)接种牛痘预防
11、天花,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 eliminated in the whole world.Smallpox eradication should be attributed to his research .,20,Sir Percivall Pott: 1775,English surgeon in LondonWe all best known for “
12、Potts fracture”He is one of earliest accounts of cause and 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: 1775,英国外科医生以“Potts 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 (18
13、07-1883),Statistician (English )First person who routine collect population and death data in England Put important words: Standard mortality, Person year、 Dose-response relationship、 P=ID,23,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公共卫生运动的领导者之
14、一,24,-London Epidemiological Society (1850) established,It is a first one in the world,It is showed that the discipline already formed,25,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 (1848-1854),27,The great French Bacteriologist Louis Pasteur (1822-1895),He establish
15、ed the Germ theoryManufacture 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
16、,第一节 流行病学发展史,29,3, Development stage （发展阶段） (20th Century 40s, 50s -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
17、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 emerge 有更
18、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-communicable diseasesTime: Mid 20th Century First RCTs: streptomycin and respiratory tuberculosis in 1948Early case-control studies: smoking and lung cancer in 1950Early c
19、ohort studies: Framingham Study in 1948 British Doctors Study in 1951,Sir Austin B. Hill: The Father of Modern Epidemiology,Sir 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 195
20、1,Sir Austin B. Hill: The Father of Modern Epidemiology,Sir 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 EPIDEMIOLOGY,From Study of distributions to study of causes of diseaseIn humans and observation
21、al: 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 MEDICINE1992年： 循证医学诞生,“A new paradigm f
22、or medical practice is emerging in 1992”出现医学实践进模式-A New Approach to Teaching the Practice 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
23、,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 ce
24、nters 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
25、 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,DiseasePopulationDistribution prevention & controlSocial medicine,疾病人群分布预防空中社会医学,43,The relationship between epidemiology and clinical me
26、dicine,PopulationsStudies/assessmentsPreventionEvaluationPlanning,IndividualsDiagnosisTreatmentCuringCaring,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,4
27、6,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 useReactions to preventive regimensProvision and use of health services,49,Epi
28、demiology,Population Medicine群体医学 The Language of Quantification定量语言,50,Factors influencing the spread of disease,Socioeconomic conditionsSanitationNutritionLifestyleAgeGender,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 processRelationship of human and environment Ca
29、usationCausal 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 Problems2. 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
30、病学应用,4. Study the 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1-1 中国1954-1998年死亡率变化趋势,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
31、,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,First stage 1.22.28,Second stage3.84.23,Third stage4.245.31,Fourth6.16.24,图1-2 Time distribution of SARS,59,图1-3,60,图1-4,61,Proportion of pers
32、on 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,Proportion of person contacted with Symptom period SARS to total isolated 37% (383/1028),63,监测目的 描 述 现 状 应 急 反 应 决 策 依 据
33、干 预 评 价,三、疾病相关监测 Disease related surveillance,Purpose of surveillanceDescribe the situationEmergency responseBasis for decision makingEvaluation for intervention,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
34、 (blood, serum, plasma, saliva ) Behavior surveillance (smoking, alcohol drinking, drug.)Environmental surveillance natural， social，EnvironmentVector 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 infec
35、tion 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-)
36、,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 century-） integrate：National public healt
37、h surveillance system,68,Risk factor and disease smoking and lung cancer,图61,图62,图63,图64,69,五、疾病自然史研究,图1-7,70,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）
38、A B C D,71,0,1,2,3,4,5,6,7,8,9,10,11,12,13,Week,Response,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 pre
39、vent and treatment,73,Features 特点,Population medicineCompareProbability 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+MirocosmicCommunicable +non-communicablePopulation health Emergency events and EIDEthicEvidence-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?,76,The End,谢谢大家Thank you！,
