哈医大-流行病学绪论

1,流行病学绪论IntroductionofEpidemiology,哈尔滨医科大学流行病学教研室Departmentofepidemiology，HarbinMedicalUniversity,2,医学Medicine,BasicmedicineClinicalmedicinePreventivemedicineEpidemiologyhasalwaysbeenanecessarypartofmedicinepractice.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Themotherofmedicine,Because,theepidemiologyisfrommacropointofviewtoobservetheanyquestion.e.g.frommacropointofviewtostudythediseaseandhealth.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,HistoryDefinitionMethodsPrincipleApplicationFeaturesProspect,历史定义方法原理应用特点展望,5,BriefHistoryofEpidemiology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-,BeforetheformofEpidemiology-1700sFormingofEpidemiologyEndof1700sbeginningof20centuryDevelopmentofEpidemiology（ModernEpidemiology）40s-50sof20century,6,Earlierstage:-18thcentury,-Hippocrates(460-377BC)AFirstEpidemiologist,EpidemicEpidemicOnAirs,WatersandPlaces-中国：“疫”、“时疫”、“疫疠”,Fromthereisthehumanhistoryofcivilizationtothe18thcentury.Duringthistime,Thisdiscipline(branch)notyetforms,buthaditsembryonicform.,7,Hippocrates(460-377BC)第一个流行病学家,主要的流行病学著作：EpidemicEpidemicOnAirs,WatersandPlaces,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,TheBlackDeathinEuropeca.1300s欧洲黑死病,9,1347-1351年鼠疫导致2400万人死亡,10,Italy-Venice-theearliestquarantine15thCentury:Thepeopleinordertoavoidtheinfectiousdiseasespreading,therequestexternalshipsmustAway(outside)fromtheport40days.Thatis(quadraginta(latin=40).1423:setupfirstinfectiousdiseaseshospital,中国：隋朝开设“疠人坊”(leprosyhospital)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,-JohnGraunt(1620-1674),UsedeathdatatostudydistributionofdiseaseMakefirstlifetablecalculateexpectationoflifeSummarizesdeathprocesswithprobabilityofsurvivalanddeathProduccecontrolgroupideaHiscontributionisthefirsttimetointroduceStatisticstoEpidemiology,NaturalandPoliticalObservationsMadeUpontheBillsofMortality,13,JohnGraunt(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,NaturalandPoliticalObservationsMadeUpontheBillsofMortality,14,GrauntsObservations,ExcessofmalesoverfemalesamongbirthsbuthighermortalityinmalesHighinfantmortalityrateSeasonalvariationinmorbidityAcuteversuschronicdiseasesUrbanversusruralmortalityRuralmigrationtothecityFirstattemptsatalifetable,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.James17161795-AsurgeonofEnglishnavy-BymeansofEpidemiologicexperimentDiscoveredOrangepreventscurvy,2.Formstage,StarttheexperimentalEpidemiology,16,JamesLind(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,-EdwardJenner(1796)Heusedcowpoximmunizationinpreventingsmallpox.,18,EdwardJenner(1749-1823),(1796)接种牛痘预防天花,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,In1979WHOdeclaredthatsmallpoxhasbeeneliminatedinthewholeworld.Smallpoxeradicationshouldbeattributedtohisresearch.,20,SirPercivallPott:1775,EnglishsurgeoninLondonWeallbestknownfor“Pottsfracture”Heisoneofearliestaccountsofcauseandeffectlinkageforanoccupationalcarcinogen.HefoundthatthescrotalcancerwasparticularlyintheworkersofChimney(stovepipe)cleaning,21,SirPercivallPott: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,WilliamFarr(1807-1883),Statistician(English)FirstpersonwhoroutinecollectpopulationanddeathdatainEnglandPutimportantwords:Standardmortality,Personyear、Dose-responserelationship、P=ID,23,WilliamFarr(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一,24,-LondonEpidemiologicalSociety(1850)established,Itisafirstoneintheworld,Itisshowedthatthedisciplinealreadyformed,25,LondonEpidemiologicalSociety(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,-JohnSnow(1848-1854),27,ThegreatFrenchBacteriologistLouisPasteur(1822-1895),HeestablishedtheGermtheoryManufactureanimalvaccine:-anthrax,-fowlcholera,-swineerysipelas-Rabies-virus-vaccinePasteurization600C30thenewusefuldisinfectionmethod,28,伟大的法国微生物学家LouisPasteur(1822-1895),微生物理论(germtheory)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,第一节流行病学发展史,29,3,Developmentstage（发展阶段）(20thCentury40s,50s-now)Features（特点）:(1)Spectrumofdisease:Thestudyareaextendedfromcommunicablediseases-toNon-communicable/chronicdisease-tohealth疾病谱研究领域从传染病非传染病-健康,30,Tenleadingcausesofdeath1900and1990,31,ChildrenofPolio脊髓灰质炎患儿,32,Features（特点）:（2）ResearchmethodfromSurveyandanalysistoqualitativeandquantitativecombined,andmacroscopicandmicroscopiccombined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)Socialbehaviorfactorsisveryimportant社会行为因素非常重要(4)TherearemoreotherrelatedBranchofepidemiologyemerge有更多的流行病学相关分支出现,33,REVIVALOFEPIDEMIOLOGY:BEGINNINGOFMODERNEPIDEMIOLOGY,Maincharacteristic:Fromcommunicablediseasestonon-communicablediseasesTime:Mid20thCenturyFirstRCTs:streptomycinandrespiratorytuberculosisin1948Earlycase-controlstudies:smokingandlungcancerin1950Earlycohortstudies:FraminghamStudyin1948BritishDoctorsStudyin1951,SirAustinB.Hill:TheFatherofModernEpidemiology,SirRichardDoll:TheGodfatherofEpidemiology,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,SirAustinB.Hill:TheFatherofModernEpidemiology,SirRichardDoll:TheGodfatherofEpidemiology,35,KennethRothman:ThePhilosopherinEpidemiology现代流行病学中的哲学家KennethRothman,36,ROTHMANANDMODERNEPIDEMIOLOGY,FromStudyofdistributionstostudyofcausesofdiseaseInhumansandobservational:case-control&cohortstudiesInorderoavoidtheConfoundingbiashesuggested:Bymeansofthe*Restrictionandmatching*Standardization*Stratifiedanalysis*Adjustmentbyregressioncanbecontroltheconfoundingbias,37,1992:BIRTHOFEVIDENCE-BASEDMEDICINE1992年：循证医学诞生,“Anewparadigmformedicalpracticeisemergingin1992”出现医学实践进模式-ANewApproachtoTeachingthePracticeofMedicine医学教育新方法,38,DAVIDSACKETT,Activistinclinicalepidemiology临床流行病学活动家ThepioneerinEBM循证医学先驱ThefirstbookonEBM第一本循证医学书McMasterUniversityHealthScienceCentreChairmanofOxfordCentreforEBM,39,WORLDCOCHRANECOLLABORATION国际COCHRANE合作,In1992,theveryfirstCochranecentrewasestablishedinOxford.Mission:Collecting,summarizinganddisseminatingevidencefromorganizedresearch.,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,Todaythereisatotalof15nationalorregionalCochranecentersandover40reviewgroupsworldwide.ChinesenationalCochrane/EBMCentreisinSichuanUniversity,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,WORLDCOCHRANECOLLABORATION国际COCHRANE合作,41,DefinitionofEpidemiology流行病学定义,Epidemiology:thestudyofthedistributionanddeterminantsandtheoccurrenceofhealth-relatedstatesoreventsinspecifiedandtheapplicationofthisstudytocontrolhealthproblems.(Last),42,themeaningofthisdefinition,DiseasePopulationDistributionprevention&controlSocialmedicine,疾病人群分布预防空中社会医学,43,Therelationshipbetweenepidemiologyandclinicalmedicine,PopulationsStudies/assessmentsPreventionEvaluationPlanning,IndividualsDiagnosisTreatmentCuringCaring,44,Studymethods研究方法-Observation-Experimental-Theoretical,45,STUDY,SurveillanceObservationHypothesistestingAnalyticresearchExperimentsTheoreticalepidemiology,监测观察假设检验分析研究实验理论流行病学,46,Distribution,PlaceTimePersons,47,Determinantsbymeansof:,PhysicalBiologicalSocialCulturalBehavioralFactors,48,Health-relatedstatesandevents健康相关状态和事件,DiseasesCausesofdeathBehavior:Tobacco,Alcohol,DruguseReactionstopreventiveregimensProvisionanduseofhealthservices,49,Epidemiology,PopulationMedicine群体医学TheLanguageofQuantification定量语言,50,Factorsinfluencingthespreadofdisease,SocioeconomicconditionsSanitationNutritionLifestyleAgeGender,社会经济状况卫生营养生活方式年龄性别,51,Principleofepidemiology流行病学原理,DistributionEpidemicprocessRelationshipofhumanandenvironmentCausationCausalinferencePreventionTheoreticalepidemiology,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,Applicationofepidemiology流行病学应用,1.DeterminegreatpublichealthProblems2.Responseanddealwithemergencyevent3.Surveillanceofdiseaserelated,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,Applicationofepidemiology流行病学应用,4.Studythecauseandriskfactorofdisease5.Tostudythenaturalhistoryandprognosisofdisease.6.Evaluatethepreventeffect,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DeterminegreatpublichealthProblems,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1-12005年中国部分市县前十位疾病死亡专率及死亡原因构成,56,表1-22003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Responseanddealwithemergencyevent,SARS人感染猪链球菌病MeningitisCausedbyStreptococcusSuis,58,Firststage1.22.28,Secondstage3.84.23,Thirdstage4.245.31,Fourth6.16.24,图1-2TimedistributionofSARS,59,图1-3,60,图1-4,61,ProportionofpersoncontactedSARStoallisolated61%（630/1028),Table1-5Incidenceofisolatedmedicalobserversof1028,62,Table1-6Incidencesituationof630personclosecontactedwithSARS,ProportionofpersoncontactedwithSymptomperiodSARStototalisolated37%(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Diseaserelatedsurveillance,PurposeofsurveillanceDescribethesituationEmergencyresponseBasisfordecisionmakingEvaluationforintervention,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）,Diseasesurveillance(incidence,death)Biologysurveillance(blood,serum,plasma,saliva)Behaviorsurveillance(smoking,alcoholdrinking,drug.)Environmentalsurveillancenatural，social，EnvironmentVectorsurveillance（mousemosquito）,监测类型Typeofsurveillance,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)Firststage(50sof20century-)ThenotifiableinfectiondiseasesysteminChina(1950),我国的监测系统SurveillancesysteminChina,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）Secondstage(70sof20century-)infectiousdiseasesurveillance(singlediseasesurveillancesystem)birth,deathsurveillancecomprehensivesurveillancesystem(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Thethirdstage（80s20century-）infectiousdiseasesurveillance；birth,deathsurveillanceChronicnon-communicateddisease、behaviorsurveillance第四阶段（21世纪初）整合：国家公共卫生监测体系Thefourthstage（beginningof20century-）integrate：Nationalpublicheal