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Principles of Epidemiology �for Public Health (EPID600)

Introduction to the course

Faculty: Victor J. Schoenbach, PhD home page� Lorraine K. Alexander, PhD

Department of Epidemiology�Gillings School of Global Public Health�University of North Carolina at Chapel Hill

www.unc.edu/epid600/

(Note: these slides have verbatim speaker notes.)

1/11/2011

Introduction

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Safety warnings�(actual instructions on products)

Marks and Spencer bread pudding: “Product will be hot after heating”

Rowenta iron: “Do not iron clothes on body”

Nytol (a sleep aid): “Warning: may cause drowsiness”

Kitchen knife: “Warning: keep out of children”

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Introduction

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Safety warning:�Don’t believe everything you read

Introduction

3

Are the Durham Public Schools that bad?

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From Consumer Reports, Selling It

Introduction

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EPID600, Principles of Epidemiology

Introduction

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EPID600 Instructors

Faculty

Victor Schoenbach (“Vic”)� EPID600(160) classroom since fall 2001� Internet since summer 2002

Lorraine Alexander� EPID600(160) since 1994 (Carl M. Shy)

Introduction

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1/11/2011

And now some introductions. My name is Victor Schoenbach (please call me “Vic”). I've been a member of the faculty in the Department of Epidemiology since 1980 and have taught an introductory epidemiology course here every year since then. For the first 20 years I taught EPID168 (now EPID710), the introductory course for epidemiology majors, and since fall 2001 I’ve taught EPID600 (formerly known as EPID160) every semester.

The second EPID600 faculty member is Lorraine Alexander, who is also the Department of Epidemiology’s Associate Chair for Distance Learning and co-leads the Certificate Program in Field Epidemiology. Lorraine has been with this course since 1994. In fact, she and Carl Shy, with the help of a number of our ablest doctoral students and specialists in distance learning and information technology, developed the Internet version of the course in the 1990s.

The rest of the instructor team are our very bright, knowledgeable, organized, helpful, dedicated, and congenial teaching assistants. They are the key to the success of this course.

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John C. Cassel, M.D.

8/15/2007

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John Cassel was an inspiring man. He pioneered community-oriented primary care in South Africa in the 1940s and 50s. His work in providing health care to Africans, however, was not appreciated by the apartheid government, so he left South Africa and came to Chapel Hill, as the first permanent chairperson of the Department of Epidemiology. A believer in multidisciplinary perspectives, Dr. Cassel broadened the Department by bringing in social scientists and practicing physicians. He launched the first community-based cardiovascular disease cohort study in a biracial community (the Evans County Study) and was one of the founders of the field of social epidemiology.

I recently came across John Cassel’s EPID160 lectures from fall 1972. I scanned them and posted rough versions of the files at www.unc.edu/~vschoenb/EPIDhistory/JohnCassel-MarionLectures/

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John C. Cassel, M.D.

5/12/2010

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9

“Epidemiology is fundamentally engaged in the broader quest for social justice and equality.”

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August, 1973

7/24/2010

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10

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“I’m studying epidemiology”:�3 responses

- You're studying what?”

“Does that have something to do with skin?”
“Uh-huh. And what else are you studying?”

8/15/2007

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The epidemiologic perspective

Epidemiology is a way of thinking about health – human ecology
Much more than a collection of methods – a way of using them
Epidemiologists consider context, heterogeneity, dynamics, inference

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What is epidemiology?

“The study of the distribution and determinants of health related states and events in populations, and the application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

8/15/2007

Introduction

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There are a number of definitions of epidemiology. One of my favorites is the one in John Last’s Dictionary of Epidemiology: “The study of the distribution and determinants of health related states and events in populations, and the application of this study to control health problems” (3rd edition). Let’s examine the definition phrase by phrase. The definition refers to the distribution of health-related states. Epidemiology studies where diseases are found in the population – who gets them (e.g., young people, older people, women, men), where they occur (e.g., in urban areas, rural areas, industrialized countries, developing countries), and the patterns of disease occurrence by season and over time. “Distribution and determinants” – we say “determinants” because epidemiology is interested in the factors that influence the occurrence of disease – risk factors, environmental factors, and preventive factors. The object is to prevent disease, and in order to do that we need to identify the factors that affect its occurrence.

I’ve been saying “disease” as a short-hand for “health-related states and events”. Epidemiology can be used to study any phenomena that exist (“states”) or occur (“events”). Besides disease, epidemiology can study positive conditions (e.g., immunity) and positive behaviors (e.g., physical activity) as well as adverse ones. Epidemiologists are usually most interested in studying events, since once a condition has existed for some time, its antecedents are often harder to discern. However, health-related states are also important to study, since with some conditions, e.g., anxiety, depression, and immunity, their duration may be as important as their occurrence.

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What is epidemiology? (con’t)

“The study of the distribution and determinants of health related states and events in populations, and the application of this study to control health problems”

John M. Last, Dictionary of Epidemiology

8/15/2007

Introduction

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Epidemiology studies populations. This aspect is one of the defining characteristics of epidemiology. In fact, the word for “people” is part of the derivation of the word “epidemiology” (from the Greek: epi - upon, demos = people, logy = study). However, there are also veterinary epidemiologists, who study populations of other animals.

Take a look now at the last part of the definition, the application of this study to control health problems. This component of the definition is actually a point of some debate among epidemiologists, and not all definitions include it. In fact, three of my colleagues, including our past Department chair, published an article several years ago in the American Journal of Public Health in which they argued that the application of the results of epidemiologic studies to disease control should not be part of epidemiology. Policymakers and health education specialists are better prepared to do that, their argument went, and though epidemiologists can become involved in disease control and advocacy as individuals when they do so they are not acting as epidemiologists. Others (e.g., UNC EPID alumnus Douglas Weed, in an article in the Annals of Epidemiology) counter that drawing implications and advocating for policy changes should indeed be part of epidemiology, since epidemiologists are the ones most equipped to interpret the data they generate. Since some decisions involving resources, and approvals are based on what is or is not epidemiology (e.g., acceptable topics for an epidemiology dissertation or appointment to an epidemiology position), the question is somewhat consequential.

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What is epidemiology, really?

Study of the health and disease of the “body politic” – the population.
Basic science of public health

What causes disease?
How does disease spread?
What prevents disease?
What works in controlling disease?

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What is epidemiology, really? Epidemiology is the study of the health and disease of the “body politic” – the population. Clinicians prevent, detect, monitor, and treat diseases in individual patients; epidemiologists prevent, detect, monitor, and “treat” epidemic and endemic diseases, in populations.

Epidemiology is a basic science of public health. Epidemiologic studies provide the basis for public health practice and policymaking, by attempting to find out what causes disease, how does disease spread, what prevents disease, and what works in controlling disease?

Of course, other disciplines are concerned with these questions, too. Many fields evaluate programs, for example. One difference is that epidemiologists emphasize evaluation in relation to health outcomes, rather than to processes, such as utilization of services. However, epidemiologists are by no means the only professionals concerned with health outcomes, nor with the causes and dissemination of disease. But when other people study health and disease in populations, then they are practicing epidemiology. I am beating the drum not so much for epidemiologists as I am for epidemiology.

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What for?

1. Provide the scientific basis to prevent disease & injury and promote health.

2. Determine relative importance to establish priorities for research & action.

3. Identify sections of the population at greatest risk to target interventions.

4. Evaluate effectiveness of programs in improving the health of the population.

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What for? – more

5. Study natural history of disease from precursor states through clinical course

6. Conduct surveillance of disease and injury occurrence in populations

7. Investigate disease outbreaks

– Milton Terris, The Society for Epidemiologic Research (SER) and the future of epidemiology. Am J Epidemiol 1992; 136(8):909-915, p 912

8/15/2007

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Natural history of disease

Disease is a process
Natural history is the entire process of development of a disease
Tells us what we can expect to happen
Fundamental concept for studying and controlling disease

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Let me elaborate briefly on the concept of natural history of disease, a fundamental concept in epidemiology and public health. Disease is generally best understood as a process that unfolds over time. “Natural history” refers to the entire process of the development of a disease, and its course after it manifests. In principle, “natural” refers to that process in the absence of intervention.

Why is that important? In order to know if an intervention could make a difference, it is necessary to know what would happen without intervention. For example, screening programs for early detection of chronic diseases must be based on an accurate understanding of the natural history of the condition. As we shall see in an upcoming lecture, early detection and screening requires that the disease have a stage during which it can be detected but would not ordinarily come to medical attention. Moreover, treatment during this presymptomatic stage must be more effective than treatment after the disease becomes symptomatic. Why? If the treatment is no more efficacious before symptoms appear, then why bother to screen? If the same health outcomes could be obtained without the costs and logistical challenges of screening by just waiting for symptoms to bring the patient to the clinic, then why bother to screen?

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www.lauriegarrett.com

During her doctoral studies in bacteriology and immunology, Laurie Garrett began working as a journalist to earn some extra money. She was so good at it and enjoyed it so much that she left microbiology for journalism, where she has been extremely successful. After a best-selling book The Coming Plague presented the problem of emerging and re-emerging infectious diseases and how the world was ill-prepared to cope with them, Garrett turned her attention to the collapse of the public health institutional infrastructure around the world. In the Betrayal of Trust, Laurie Garrett chronicles two major disease outbreaks that were exacerbated by the lack of an effective public health system. She then chronicles the deterioration of the public health infrastructure in Russia and the United States. The following account of the 1994 outbreak of plague in India vividly illustrates how disease outbreaks can unfold and the importance of public health for modern society.

The bubonic plague is caused by a bacterium called Yersinia pestis. Since only recently have the genetic sequences of bacteria become known, they are characterized most often by how they appear through a microscope. Yersinia pestis is shaped like a rod and is “gram-negative”, i.e., it belongs to a group of bacteria that have cell walls that prevent them from absorbing a commonly used dye (a “Gram stain”).

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Plague!

September 30, 1993 earthquake levels over one million homes in Maharashtra State, in India, with powerful aftershocks.

Peasants harvest and store their crops, then decamp.

August 1994, farmers return to stored grains, rats, fleas & Yersinia pestis.

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Yersinia pestis was responsible for the Black Death in Europe in the Middle Ages and has killed many millions of people throughout the world. The bacteria are transmitted primarily through the bite of a flea that infests black rats. Fortunately, the plague is readily treated with antibiotics, but when treatment does not begin in time, the bacteria produces a pneumonia (pneumonic plague) that progresses very rapidly – and that can spread from person-to-person.

On September 30, 1993, a powerful earthquake leveled a million homes in Maharashtra State, in India. The peasants quickly harvested their crops, stored them, and then fled. A year later, in summer 1994, the peasants returned to retrieve their stored grain, which had since been colonized by rats, who in turn were infested with fleas, which in turn were infected with Yersinia pestis.

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Plague!

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September 14, 1994 – four cases of bubonic plague in Mamala, Beed District, Maharashtra State.

Health care infrastructure still disrupted from earthquake.

September 18, Festival of Ganesh in Surat, hundreds of miles to northwest, rapidly growing and crowded city.

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Plague!

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September 21, cases of pneumonic plague in Surat.

Public hospital doctors alert private doctors, but 80% flee Surat, closing all private clinics and hospitals

September 22 – media barrage in India and outside – “Surat Fever”. 500,000 Surati’s depart in one week.

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Plague!

8/15/2007

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Suratis take trains all over India, disappearing into densely-packed cities.

Five Indian states go on emergency health alert status.

Actions by Indian federal government are slow in coming and ineffectual; Minister of Health is not even a physician. WHO also ineffectual.

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Plague!

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Remaining medical personnel in Surat work round the clock, suffer exhaustion.

Sales of tetracycline soar and become depleted.

Plague expertise in short supply throughout the world (CDC has a half-time scientist).

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Plague!

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Indian and multinational drug companies promote anitibiotics, cleansers, pesticides, rat poison.

20% of tourism packages canceled; Gulf State Nations, Pakistan, and Sri Lanka ban all flights, citizens, goods, and postal communications (!) with India.

Bombay stock market crashes.

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Plague!

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Russia, China, Egypt, Malaysia, Bangladesh close all connections to India; others inspect all Indian travellers (10 suspected cases in NYC had malaria, typhoid, viruses, liver dis.). KLM sprays pesticides in plane cabins.

Delhi closes all public schools.

October 2 – Indian federal officials announce over 4,000 cases.

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Plague!

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India’s National Institute of Communicable Diseases and All India Institute of Medical Sciences engage in stand-off over specimens and decline outside laboratory assistance despite limited equipment and no air-conditioning. Most of original specimens deteriorate through lack of proper handling.

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Plague!

8/15/2007

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Lack of definitive laboratory diagnosis undercuts governmental public health authority. Alternative theories abound – hantavirus, melioidosis, Burkholderia pseudomallei, leptospirosis, tularemia, Pseudomonas pseudomallei, conspiracy theories (rebels, U.S.).

Ministry of Defense takes over all remaining blood and sputum samples.

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Plague!

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Thousands of worried well fill hospitals.

Widespread inappropriate use of antibiotics, DDT.

$1.3 billion lost trade and tourism.

Lessons learned: Public health matters.

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About EPID600

Cooperative learning model designed by Carl M. Shy in 1990s - structured learning tasks where students

apply concepts and methods
exercise critical judgment
confront complexities of real life

Small group with TA consultant

Resources

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Learning resources

Lectures – live, recorded, Powerpoint slides with verbatim speaker notes, and audio tutorials (web searchable)
Textbook (see www.unc.edu/epid600/ for information)
Case studies, approximately weekly

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1/11/2011

We also offer numerous learning resources. First is a set of stimulating, thought-provoking lectures, such as this one. These are presented live at the UNC Gillings School of Global Public Health and are available as Powerpoint slides with verbatim speaker notes. The lectures have been recorded as audio tutorials that can be streamed or downloaded from the web. Because of the lag involved in re-recording, though, I encourage you to use them in conjunction with the separately posted Powerpoint slides, which will always be the most up-to-date. (Note that each lecture slide has a date in the lower left-hand corner; the date gets changed when I update the slide or speaker notes.)

We also use a published textbook (see the EPID600 webpage at www.unc.edu/epid600/ ). My lectures are designed to complement the textbook and in some cases to comment on it. Epidemiology is a relatively new field, and even its fundamentals are still evolving. This evolution can make for considerable confusion, since different authors and investigators use terms in different ways and make statements that reflect the era in which the writer learned epidemiology. Fortunately the newer conceptual framework provides greater clarity than the earlier ones. The lectures will try to provide the benefit of these recent developments.

The course is organized into weekly modules. Most modules contain, besides the lecture, a case study consisting of a reading or two and a dozen or so questions taken largely from past examinations.

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Learning resources – con’t

Course websites (just Google “EPID600”):

http://blackboard.unc.edu – announcements, all materials organized by course module, and links to everything
http://www.unc.edu/epid600/ – most of the content and submission forms that are displayed in Blackboard – for when you can’t or don’t want to log in to Blackboard

Instructors – your TA, Vic, Lorraine
Each other

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We provide

Two course websites, where you can find the class schedule, lecture slides, case studies, and information about the conduct of the course and its policies, including grading, plus links to other Internet resources (be sure to check out Epigrad Today). One course website is in Blackboard (http://blackboard.unc.edu), and the other is open to the public. The Blackboard site has everything you will need for the course, including announcements, a folder for each weekly module to hold all of the materials and links for that module including the lecture slides, case studies, and supplementary materials, and links to submission forms. The public website, at www.unc.edu/epid600/, has most of the content and submission forms that are available in the Blackboard site. The public website is available when you cannot cannot login to Blackboard.

A teaching assistant and the course faculty, who will answer your questions, make suggestions, and provide feedback about your answers on case study and examination questions.

Your fellow students, many of whom have public health and other relevant training and/or experience. You will work in a small group on case studies and other tasks to gain experience working on epidemiologic questions of the sort that arise in the lives of public health professionals.

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Finding information

Search the net – open or targeted, e.g.� predictive value site:epidemiolog.net/epid160/lectures
www.epidemiolog.net: Understanding the fundamentals of epidemiology – an evolving text (includes problems and answers), old EPID168 exercises, examinations, spreadsheets, more …

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If you would like to read more of what I would say than is presented in the lectures, take a look at my Evolving Text, which I was developing during my years of teaching EPID168, the introductory course for Epidemiology majors at UNC. You can find it and other resources at www.epidemiolog.net

With all these resources, how can one find anything? Try search the lectures through a search website. Use the advanced search option and specify the domain to be searched as:

predictive value site:epidemiolog.net/epid160/lectures

You can then open the document(s) located and search with Edit | Find

Search the Evolving Text in the same way; use the domain epidemiolog.net/evolving or epidemiolog.net/es/endesarrollo

Search the case study answers by downloading the instructor answers to a folder on your disk drive, as they are posted; then use your operating system’s search tool or another program. (Please remember that instructor answers are not to be given to others.)

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Course schedule

9-12 hours/week (including class attendance)
Most weeks – 1-2 textbook chapter(s), a case study article with questions, small group discussion
Three examinations interspersed
Suggestion to spread out the workload:�- Before Exam 1 read ahead in textbook�- After Exam 1 begin your final paper (Exam 3)

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A word about the course schedule. All versions of EPID600 are designed to provide a 3-credit graduate level introductory epidemiology course that satisfies the accreditation requirements for masters and doctoral degrees in public health. The rule of thumb for UNC-CH graduate courses is 3 or 4 hours of in-class or outside work for each credit hour, so the estimated workload for EPID600 is about 9-12 hours/ week.

Besides the lecture, most weeks will involve reading a chapter or two in the textbook, reading a published article and answering questions for the Case Study, and participating in discussions with your small group. In addition, there are three examinations, the last of which is an article critique often called “the final paper”.

To balance your workload across the semester, we suggest that you read ahead in the textbook, at least to familiarize yourself with it, during the weeks before the posting of the first examination. After the first examination is over, read over the article you will be critiquing for the final paper (Exam 3) and begin drafting your answers (instructions will be posted on the web site). Then work on the second examination when it is posted, and after it is finished, go back and complete your paper. With this schedule you can spread the workload over the entire semester and can have the benefit of time and reflection in writing your article critique.

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Course schedule

1/11/2011

Introduction

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A word about the course schedule. All versions of EPID600 are designed to provide a 3-credit graduate level introductory epidemiology course that satisfies the accreditation requirements for masters and doctoral degrees in public health. The rule of thumb for UNC-CH graduate courses is 3 or 4 hours of in-class or outside work for each credit hour, so the estimated workload for EPID600 is about 9-12 hours/ week.

Besides the lecture, most weeks will involve reading a chapter or two in the textbook, reading a published article and answering questions for the Case Study, and participating in discussions with your small group. In addition, there are three examinations, the last of which is an article critique often called “the final paper”.

To balance your workload across the semester, we suggest that you read ahead in the textbook, at least to familiarize yourself with it, during the weeks before the posting of the first examination. After the first examination is over, read over the article you will be critiquing for the final paper (Exam 3) and begin drafting your answers (instructions will be posted on the web site). Then work on the second examination when it is posted, and after it is finished, go back and complete your paper. With this schedule you can spread the workload over the entire semester and can have the benefit of time and reflection in writing your article critique.

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Challenges in an introductory course

Diversity of backgrounds – biology, physiology, math/statistics, public health, epidemiology
Diversity of interest –� from: “I epidemiology”� to: “Let me out of here!”
Basic epidemiologic concepts are still evolving

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And now, to elicit your sympathy and understanding, I want to call your attention to some of the challenges of teaching an introductory course in epidemiology. First, since this graduate level course does not follow an undergraduate epidemiology course, students vary greatly in their previous exposure to epidemiology and to the many related fields. That means that nearly everything I might say is going to be too familiar to some of you and too unfamiliar to others.

Second, since EPID600 is a required course, there is a diversity of interest, from those who are excited at the opportunity to learn epidemiology to those who are taking the course “under duress”.

Third, as I mentioned earlier, epidemiologic concepts are still evolving. So there remains more inconsistency and confusion than will be the case in another decade or two.

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Course objectives

1. Explain the population perspective, access population data, describe public health problems

2. Apply and interpret measures of disease occurrence and correlates in populations

3. Use basic methods for investigating disease outbreaks

4. Explain relative strengths and limitations of different epidemiologic study designs

5. Identify and control major sources of error in community health studies

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The objectives of this course, designed to meet the Council on Education in Public Health requirements, are to:

1. Explain the population perspective, access population data, and describe public health problems

– The population perspective is at the heart of epidemiology and public health, and being able to describe populations and health problems is the first step in thinking about them effectively.

2. Apply and interpret measures of disease occurrence and correlates in populations

– Since epidemiology studies populations, we need to have measures that quantify the occurrence and presence of disease, and the presence of exposures that influence them, in groups of people

3. Use basic methods for investigating disease outbreaks

4. Explain the relative strengths and limitations of different epidemiologic study designs

5. Identify and control major sources of error in community health studies

– Every science has to contend with error. But since epidemiology is an observational science, our abilities to avoid and control error through experimental design – standard temperature and pressure, for example – are very limited. People are not easy to study.

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Course objectives – continued

6. Evaluate epidemiologic evidence by applying criteria for causal inference

7. Use epidemiologic methods in evaluating public health interventions

8. Comprehend basic ethical and legal principles related to epidemiologic data

9. Appreciate complexities in applying scientific evidence in making policy

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6. Evaluate the evidence from different epidemiologic studies

– Rarely does a single epidemiologic study establish anything. There are too many possible sources of error and other influences to consider. So weighing the evidence from different studies is an essential part of interpreting findings and reaching conclusions.

7. Use epidemiologic methods in evaluating public health interventions

8. Comprehend basic ethical and legal principles related to collecting, maintaining, and using epidemiologic data

9. Appreciate the complexities in applying scientific evidence in making policy

– Epidemiology helps to provide the scientific basis for public health practice and policy, but the connection is often not straightforward. Appreciating the complexities is an important part of using epidemiologic data appropriately.

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Evaluation and grading

Several examinations:

Two with multiple choice / calculation / short answer
One with essay questions (the “final paper”)

Class participation / group work

See Blackboard | Syllabus | Grading & Evaluation

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UNC-CH Honor Code

Integrity of academic work is vital to scholarly activity
Integrity of academic work is an individual and collective responsibility
Your participation in EPID600 implies full observance of the Honor Code

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Speaking of grading, I need to mention that all submitted work for this course comes under the Honor Code of the University of North Carolina at Chapel Hill. Integrity of academic work is vital to scholarly activity, and this University takes the Honor Code very seriously . You as students depend on your instructors to be truthful in the material we present and to be honest with you in our interactions. All of us depend on researchers and writers to be honest in their descriptions of what they have done and what they have found. The occasional lapses of integrity serve to remind us that without it what use would the information in scientific journals be? (e.g., see http://www.nytimes.com/2010/02/03/health/research/03lancet.html )

Integrity of academic work is the responsibility of each of us as individuals and of all of us collectively. When students engage in improper collaboration or use others’ work improperly, there is a corrosive effect on the entire enterprise. Students who do play by the rules may feel they are at a disadvantage and wonder why they should observe the rules if others do not.

I accept my responsibility as a faculty member to report instances where I have reason to suspect that an Honor Code violation has occurred, and I use a computer-based screening procedure to detect such situations. I have had to report a significant number of EPID600 students, and it has pained me greatly to do so. These students had various motives for engaging in the behaviors that got them in trouble, and some students were taken advantage of by other students. So please help me to protect EPID600 students’ honor.

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What is prohibited?

Academic cheating includes unauthorized copying, collaboration on examinations, and plagiarism.

Plagiarism is the intentional representation of another person's words, thoughts, or ideas as one's own.

If you are uncertain in a specific instance, ask an instructor.

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What does the Honor Code require? In general the Code requires that all of us avoid cheating and plagiarism. Academic cheating includes unauthorized collaboration or communication on an assignment. EPID600 provides specific guidelines for permissible and impermissible collaboration on assignments. In brief, you may not have access to instructor answers before they have been posted in Blackboard and you may not communicate about an examination except with the course instructors, including teaching assistants. Plagiarism is the intentional representation of another person's words, thoughts, or ideas as one's own. These issues are most likely not new to you, but if you are uncertain in any specific instance, ask an instructor. Since cheating and plagiarism involve misrepresentation, raising the question with an instructor demonstrates that you are not attempting to mislead or misrepresent.

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What students say about EPID600

“EPID600 was an excellent overview of the methods.”

“Epi was great, and Bios was also good”

“EPID600 was very interesting and probably one of the most valuable as epidemiology is a foundation of public health and through that course you learned history and practical knowledge.”

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What students say about EPID600

“. . . Extremely difficult to follow due to the cluttered and disorganized nature of the course website (there was a BlackBoard site AND a class website . . .)”

“I was expecting to take an Epid class that discussed the prevalence and spread of major (and less known) diseases throughout the world . . .”

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What students say about EPID600

“I’ve heard horror stories about EPID 600, and I fear taking it.”

“. . . Make Bios and EPID more challenging, we can take it . . .”

“I don’t feel at all prepared with regard to my knowledge of epidemiology . . .”

“I basically taught myself the material . . .”

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What students say about EPID600

“I do not feel that I have a good grasp of concepts still.”

“I almost feel like I need to take it again to really absorb all the information.”

“I don’t feel confident about any of the material.”

“The course was great. My main problem was that I already knew everything.”

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Thank you

Xie xie ni Asante

Gracias, grazie Dhanyawad

Spacibo Merci, Danke

Naishitz Arigato, Shohkrahn

Gàn xìe Multu^mesc

Hvala Ngiyabonga

Cám o*n Kamsa hamnida

2/21/2011

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