流行病学（epidemiology) 公共卫生学院 流行病与卫生统计学研究所

第一章 绪论 （Introduction of Epidemiology) 流行病学的简史 流行病学的定义 流行病学的原理和应用 流行病学的研究方法 流行病学的特征 流行病学与其他学科的关系及其展望

第一节 流行病学的简史 （现代流行病学时期） 一、流行病学的发展史 学科形成前期(~18世纪) 第一节 流行病学的简史 一、流行病学的发展史 学科形成前期(~18世纪) 科形成期（成长期） (18世纪末~20世纪初) 现代发展期(20世纪40、50年代~) （现代流行病学时期）

（一）学科形成前期 时间：18世纪以前 特点：科学的学科尚未形成，但对疾病的认识从无知到认识到由外界物质引起；意识到疾病可以传播并可以预防；有了防并要求，采取了一定法规和个别措施。 事件： 迷信阶段：疾病是妖魔、鬼神、瘴气引起 朴素唯物主义：阴阳五行学说 Hippocrates “Airs，waters and place” 《内经素问》 “黄帝曰，余闻五疫之 至，皆相染也”

●1736年云南师道南《鼠死行》诗： 东死鼠，西死鼠，人见死鼠如见虎， 鼠死不几日，人死如圻堵。 昼死人，莫问数，日色惨淡愁云护， 三人行，未几步，忽死两人横截路。 ●隋朝“疬人坊”隔离麻风病人 ● 11世纪宋朝天花流行，娥眉山人创造人痘接种预防之 ● 15世纪中叶，意大利威尼斯规定外来船只必须在港外留验40天，guarantine（检疫）

学科形成前期 Hippocrates (460-377 BC) 第一个流行病学家 主要的流行病学著作： 《Epidemic Ⅰ》 《On Airs, Waters and Places》 The essentials of epidemiology noted by Hippocrates included observations on how diseases affected populations and how disease spread. He further addressed issues of diseases in relation to time and seasons, place, environmental conditions, and disease control, especially as it related to water and seasons. The broader contribution to epidemiology made by Hippocrates was that of epidemiological observation. His teachings about how to observe any and all contributing or causal factors to a disease are still sound epidemiological concepts. 《论气、水和地区》 《论瘟疫》，共7册，其中第一和第三册无疑是希伯克拉底的手笔 主要贡献： 流行病学观察 环境在疾病发生中起着很重要的作用

quadraginta (拉丁语，意思为40) → quarantine 学科形成前期 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) → quarantine 1423年成立了首家传染病隔离医院

学科形成前期 John Graunt (1620-1674) 将统计学引入流行病学领域 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

（二）学科形成期（成长期） 时间：18世纪末至20世纪初 特点：以防制传染病为主要任务，以独特的调查分析方法为特点，结合实行具体措施，成长为一门独立学科—传统流行病学。 事件： 1796年英国Jenner发明接种牛痘预防天花 1848年至1854年英国John Snow伦敦霍乱调查 1850年在伦敦首次成立流行病学会

学科形成期 James Lind (1716-1794) VitC缺乏 – 坏血病 (1747)

学科形成期 Edward Jenner (1749-1823) (1796) 接种牛痘 预防天花

学科形成期 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＝发病率×病程

学科形成期 John Snow (1813-1858) 伦敦宽街－霍乱爆发 标点地图法 霍乱是介水传播 流行病学现场调查、 分析与控制的经典实例

London Epidemiological Society (1850) 学科形成期 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 John Snow was a founding member of the London Epidemiological Society, one of the first professional organizations  devoted to the field of epidemiology.  The seal of the organization (see figure) includes the Latin phrase penned by the Roman poet Persius (34-64 AD), venienti occurrite morbo, translated into English as confront disease at its onset. How did this important movement get started?  What were their contributions during Snow's life, and in the years that followed?  ORIGIN OF SOCIETY In February 1848, three and a half years after John Snow received his MD degree, an intriguing letter to the editor appeared in The Lancet.  England at the time was very concerned with the possible appearance of a second cholera epidemic (the first ever occurred in 1831-32). The letter started, "Will that dreadful scourge the cholera visit our island again?  If so, are medical men prepared to wage a war against it?" The letter proceeded to suggest that "meetings [to address this disease] should be held in different localities."  Finally the letter concluded with the suggestion that medical journals should report "a statistical account of deaths and recoveries."  The signer was mysteriously identified as "Pater" (a British term for father).  In July 1849, after cholera had again appeared in England, the same Pater wrote once more to The Lancet, but this time to propose "...the formation of a new society, which might be styled the Asiatic-Cholera Medical Society, or the Epidemic Medical Society, the object of which would be to investigate epidemics..."  The identity of Pater was finally revealed in The Lancet as J. H. Tucker, a concerned physician practicing in London.  His stimulating words lead to a meeting on March 6, 1850 in Hanover Square, within walking distance of the Broad Street pump in the Soho region of London.  It was here that the London Epidemiological Society was born, perhaps in the building shown to the right. A second meeting was held in Hanover Square on July 30, 1850 to create a constitution and appoint the founding members and officers. The first president was Dr. Benjamin G. Babington (shown here),  a prominent physician at Guy's Hospital in London and member  of the medical board that was expected to advise the London government on ways to address the cholera epidemic.  John Snow (shown below) attended this organizing meeting of the London Epidemiological Society and is considered one of the founding members.  He was 37 years old. After another four months had past, Dr. Babington held on December 2, 1850 the first professional meeting of the London Epidemiological Society, 33 months after the initial Pater letter appeared in The Lancet.  About 100 members and visitors were present.  Among the most famous were Thomas Addison (1793-1860), the British physician who discovered pernicious anemia (now termed Addison's anemia) and adrenal cortex deficiency (now called Addison's disease); and Richard Bright (1789 -1858), his British colleague who first described the disease characterized by edema and presence of albumin in urine, now termed Bright's disease.  For others, including John Snow, fame would come later. Notable in this latter group was Dr. John Simon (later to become Sir John Simon) who in 1848 had become the first medical officer of health of London (he remained in that position until 1855); and Gavin Milroy who in 1864 on Babington's retirement, would become the second president of the London Epidemiological Society.  ORIGINAL PURPOSE OF THE ORGANIZATION When the constitution of the London Epidemiological Society was created, the founders had three major purposes all related to epidemics as a broad notion, not specific to a cholera epidemic, the threat of which had stimulated the earlier letters of Pater.  to institute rigid examination into the causes and conditions which influence the origin, propagation, mitigation, and prevention of epidemic diseases; to institute...original and comprehensive researches into the nature and laws of disease; and to communicate with government and legislature on matters connected with the prevention of epidemic diseases. The founders also recognized that having ideas without public or professional communication is a self-centered undertaking.  To avoid this end they advocated: to publish original papers;  to issue queries;  to publish reports;  to form statistical tables;  to prepare illustrative maps; and  to collect works relative to epidemic diseases. These purposes and undertakings remain appropriate today. ACTIVITIES OF THE ORGANIZATION Papers were regularly presented at the monthly meeting of the London Epidemiological Society such as one in 1851 on the use of statistics and statistical methodology in the study of epidemic diseases. Between 1851 and 1853, most meetings had considerable discussion about whether or not a specific disease was caused by a contagion, . with cholera and yellow fever being common example cited by both opponents and proponents of the germ theory (i.e., disease is caused by a microorganism or germ).  In 1853, John Snow (shown here) presented a paper on "The Comparative Mortality of Large Towns and Rural Districts, and the Causes by Which it is Influenced" which featured the application of statistics to epidemiology.    In 1852, Dr. Benjamin W. Richardson (shown below), a close friend of Snow's, joined the London Epidemiological Society.  Being an intellectual comrade, Dr. Richardson supported Snow in his theory of water propagation of cholera, an idea that was quickly accepted by the medical community.  Later after the death of his friend in 1858, Richardson would write the lengthy account of Snow's life that enriches our current understanding of the life and times of the man.  Richardson founded the Journal of Public Health in 1855, where the transactions of the London Epidemiological Society were first published.  Four years later, however, the journal was discontinued for financial reasons.  Thereafter the Society published its own proceedings as the Transactions of the Epidemiological Society of London, which remained until 1907. In 1861, three years after the death of John Snow, Gavin Milroy presented "The Influence of Contagion on the Rise and Spread of Epidemic Diseases."  In this important work he joined John Snow in dismissing the miasmatic theory of disease causation (i.e., the idea that poisonous atmosphere rises from swamps and putrid matter and cause disease) because of its inconsistency with the spread of epidemics.  DEMISE AND REBIRTH At end of the century as infectious diseases continued their inevitable decline, the London Epidemiological Society came to a temporary end.  Its successor was the Section on Epidemiology and State Medicine of the Royal Society of Medicine.  Later still this became the Section on Epidemiology and Preventive Medicine, also of the Royal Society of Medicine.  In more modern times, emphasis was placed on prevention of such non-infectious conditions as accidents involving motor vehicles, heart disease, cancer and even mental illness.  In addition, this new section of the Royal Society of Medicine stressed the use of quantitative epidemiological methods and principles, and held discussions on topics such as ethical questions relating to public health. Likely if John Snow had lived another 142 years, he would have approved, and enthusiastically participated in the continuing drama of epidemiology. Sources:  Babington, BG. The Lancet 2, 639-642, 1850. Hunting, P. The History of the Royal Society of Medicine, 2002. Lilienfeld, D. Bulletin Hist Med 52(4), 503-28, 1978. Paul JR. Yale J Biology Med 46(1), 29-31, 1973. Pater. The Lancet 1, 242, 1848. Pater. The Lancet 2, 301-302, 1849. Tucker, JH. The Lancet 2, 592, 1849. Simon, J. English Sanitary Institutions, Cassell, London, 1890.

（三）现代发展期 时间：20世纪40年代至今（现代流行病学） 特点：任务扩大为人群的一切疾病和健康状态；方法扩展为利用多种资料来源进行整套定型的统计分析研究。 事件： 20年代开始应用病例对照研究 50年代开始应用队列研究（Doll & Hill 关于吸烟与肺癌关系的研究） 51年Cornfield提出RR、OR等指标 59年Mentel-Haenszel分层分析法 60年布拉格国际流行病学会议

现代发展期 第二次流行病学革命(现代流行病学) －非传染性疾病 第一阶段 (1946~20世纪60年代中期) 第二阶段 (20世纪60年代中期~80年代早期) 第三阶段 (20世纪80年代中期~至今) 第一次流行病学革命－针对传染病 现在看来，针对传染病的战斗还没有结束，也不可能结束。我们需要的是第三次流行病学革命，将研究和控制传染病、非传染病的方法整合起来，探索它们的共同病因及解决方法。

现代发展期 特点 传染病→所有疾病、健康问题 传统的调查分析→定量+定性、宏观+微观 “流行”→“分布”、“动态”+“静态” 三环节两因素→社会行为因素 分支学科↑、应用范围↑

Richard Doll & Austin Bradford Hill 吸烟-肺癌的研究 Sir Austin Bradford Hill and Sir Richard Doll More than anybody else Richard Doll has stopped doctors pontificating without any evidence. Together with the father of medical statistics, Austin Bradford Hill, he introduced the randomised controlled trial: a method of assessing a treatment or procedure that is one of the most important medical developments of the century. Doll and Hill were also the first to show the connection between cigarette smoking and many serious diseases, particularly lung cancer and heart disease. Austin Bradford-Hill. He was a professor of statistics at the London School of Hygiene and Tropical Medicine.

Nathan Mantel & William Haenszel 分层分析法 Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959; 22 (4): 719-748.

代表性的流行病学教科书/专著 MacMahon B and Pugh TF. Epidemiology Principles and Methods. Boston: Little, Brown and Company. 1970. Lilienfeld AM and Lilienfeld DE. Foundations of Epidemiology (2nd ed.). New York: Oxford University Press. 1980 Last JM. A dictionary of epidemiology. Oxford University Press. 1983. Kenneth J. Rothman Rothman KJ. Modern Epidemiology. Boston: Little, Brown and Company. 1986

二、我国流行病学的成就 伍连德（1877-1960）我国流行病学先驱者和奠基人； 对鼠疫、霍乱的防制做出巨大贡献，确定旱獭为鼠疫的传染源之一。 1911年任国际鼠疫会议主席；1937年任中华医学会公共卫生学会首任会长。 苏德隆（1906－1985）我国流行病学先驱者和奠基人之一 1、血吸虫及霍乱的研究 2、1972年上海桑毛虫皮炎研究 3、原发性肝癌病因研究

何观清 （1911－1995）我国流行病学先驱者和奠基人之一 1、早年发现中华白蛉为我国黑热病的传播媒介 2、否认痢疾噬菌体对痢疾的预防作用 3、证明鼠脑制成的乙脑疫苗有严重不良方应 4、70年代建立以急性传染病为主的全国疾病监测网 1949年后我国传染病控制取得伟大成就，控制了人鼠疫、霍乱、性病（64年）、血吸虫病、丝虫病、疟疾等。 1960年消灭天花（77年全球消灭天花）

50年代初建立卫生防疫站、流行病学教学科研系统 58年出版了前苏联学者主编的教科书 60年出版卫生专业用《流行病学》教材 70年代起开始非传染病流行病学研究 74年出版卫生专业用《流行病学》教材 80年成立全国流行病学会并出版《中华流行病学》杂志 89年首次举办国际流行病学会议 89年颁布《中华人民共和国传染病防治法》 90年代开始伤害流行病学研究 00年代开始突发事件流行病学研究 03年公布实施《突发公共卫生事件应急条例》

第二节 流行病学定义 流行病及流行病学 传染病 非感染性慢病 生活习惯病 健康相关现象 Epidemiology 第二节 流行病学定义 流行病及流行病学 传染病 非感染性慢病 生活习惯病 健康相关现象 Epidemiology Upon people science

(一)定义的演变(1) Stallybrass(1931) 流行病学是关于传染病的传染源、传播途径及预防的科学 苏联流行病学家(1936) 流行病学是关于流行的科学，它研究发生流行的原因、规律及扑灭的条件，并研究与流行作斗争的措施。 Maxcy(1951) 流行病学是医学的一个分支，它研究那些决定人群中传染过程的因子及影响疾病和生理状态的频度和分布的条件。

定义的演变(2) MacMahon(1970) 流行病学是研究人类疾病的分布及决定疾病频率的决定因子的科学。 全苏医学院校教材(1971) 流行病学是研究人类社会中传染病的发生、传播和停止的科学。 Lilienfeld(1978) 流行病学是一门通过观察人群中疾病现象而对病因进行生物学推理的方法。

定义的演变(3) 钱宇平主编《流行病学》(1979) 流行病学是研究疾病在人群中发生、发展和分布的规律，以及制定预防控制和消灭这些疾病的对策和措施的科学。 WHO流行病学教育专题会议定义(1980) 流行病学是研究健康和疾病在人群中的分布和决定因素，以保证合理地计划卫生服务，有效地进行疾病监测，并使预防和控制规划得以实现。 Last主编《流行病学词典》定义(1983) 流行病学研究在人群中健康有关状况和事件的分布及决定因素，以及应用这些研究以维持和促进健康的问题。

定义的演变(总结) 研究对象：即人群。EPIDEMIOLOGY，希腊词EPI（在……之中）；DEMO（人群）；OLOGY（学科）。即“研究在人群中发生（事件）的学科。” 研究方法： 研究范围： 传染病 疾病 疾病＋ 健康 卫生相关 事件

现代定义 流行病学(Epidemiology)是研究人群中疾病与健康状况的分布及其影响因，并研究防制疾病及促进健康的策略和措施的科学。 —连志浩主编《流行病学》(1994) —李立明主编《流行病学》(1999；2004）

二、流行病学定义的诠释 伤害 疾病 健康 找出原因 提供措施 揭示现象 流行 分布 原因 影响因素 策略 措施 描述流行病学方法 分析性流行病学方法 实验流行病学方法

第三节 流行病学原理与应用 一、基本原理 1、分布：疾病与健康的分布及疾病流行 2、发病过程：感染过程与流行过程 3、生态学：人与环境 第三节 流行病学原理与应用 一、基本原理 1、分布：疾病与健康的分布及疾病流行 2、发病过程：感染过程与流行过程 3、生态学：人与环境 4、病因论：多病因学说 5、病因推断：疾病原则 6、疾病防治原则和策略：三级预防 7、数学模型：理论流行病学

二、 实际应用 一、疾病预防与健康促进 ★两次全国结核病调查（79；84-85年）：84年发现活动性TB、菌阳和涂阳病例的登记率为23、11、10/10万 ★全国恶性肿瘤死亡回顾性调查（75-85年）：食道癌高发于河南、河北、山西交界的太行山区；肝癌高发与江苏、福建 ★12地区精神病调查（82年）：总患病率12.67‰，全国＞千万 ★三次全国吸烟与健康调查（84；91；96年）96年总吸烟率上升为为37%（男69%，女4 . 2%） ★ 14省市糖尿病流行特点调查（94年）：20-7-岁组II型糖尿病总患病率为3.2%，比81年提高了5倍 ★ 两次全国病毒性肝炎调查（79、92年）92年HBsAg 9.75% ；抗-HAVIgG 80.9 %；抗-HCVIgG 3.2 %；抗-HEV 17.2 %

二、疾病监测 长期连续动态地过程 三、疾病病因与危险因素的研究 四、疾病自然史的研究 五、疾病防制的效果评价 ★40年代Gregg提出孕妇早期患风疹与儿童先天性白内障关系 ★50年代Doll & Hill关于吸烟与肺癌关系的研究 ★“未明原因”： 58年新疆“察布查尔病”——肉毒杆菌毒素中毒 59年“烧热病”——长期进食生棉籽油 72年上海皮炎流行——桑毛虫 四、疾病自然史的研究 五、疾病防制的效果评价

第四节 流行病学研究方法 观察法 研 究 实验法 方 法 理论与方 法研究 observation method experiment 第四节 流行病学研究方法 普查(census) 抽样调查 现况研究 (Prevalence) 描述流行病学 Descriptive epi. 纵向研究 (Longitudinal) 筛检(census) 观察法 observation method 生态学研究 (ecological) 病例对照研究(case control) 分析流行病学 Analytical epi. 队列研究 (cohort study) 研 究 方 法 临床试验(clinical trial ) 实验法 experiment method 现场试验(field trial ) 社区试验(community trial ) 类试验(quasi-experiment ) 理论流行病学 theoretical epi. 理论与方 法研究 流行病学方法 Methodology study

第五节 流行病学的特征 一、群体的特征：一切流行病学的起点 二、对比的特征：研究方法的核心 三、概率论与数理统计学的特征： 第五节 流行病学的特征 一、群体的特征：一切流行病学的起点 二、对比的特征：研究方法的核心 三、概率论与数理统计学的特征： 流行病学＝分母的科学 四、社会医学的特征：社会环境 五、预防为主的特征：根本目的和宗旨 六、发展的特征：一切学科的特征

第六节 流行病学与其他学科的 关系及其展望 一、流行病学与其他学科的关系 预防医学 基础医学 临床医学 流行 病学 临床流行 分子流行 病学 第六节 流行病学与其他学科的 关系及其展望 一、流行病学与其他学科的关系 预防医学 流行 病学 临床流行 病学 分子流行 病学 基础医学 临床医学

二、 流行病学面临的挑战与展望 1、宏观与微观并举 2、传染病与非传染病并重 3、人群健康研究提上日程 4、发展应急流行病学 二、 流行病学面临的挑战与展望 1、宏观与微观并举 2、传染病与非传染病并重 3、人群健康研究提上日程 4、发展应急流行病学 5、重视流行病学研究中的伦理问题 6、强化流行病学在循证浪潮中的作用