Table Of ContentPIDPR 5/21/04 11:21 AM Page i
Lecture Notes: Epidemiology and
Public Health Medicine
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Lecture Notes
Epidemiology
and Public Health
Medicine
Richard Farmer
MB, PhD, FFPH, FFPM
Professor of Epidemiology
Postgraduate Medical School
University of Surrey
Stirling House
Surrey Research Park
Guildford
Surrey, UK
Ross Lawrenson
MRCGP, FAFPHM, MD
Dean of Medicine & Professor of Primary Health Care
Postgraduate Medical School
University of Surrey
Stirling House
Surrey Research Park
Guildford
Surrey, UK
Fifth Edition
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© 2004 by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
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The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the
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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK
Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
First published in 1977 under the title Lecture Notes on Epidemiology and Community Medicine
Second edition 1983
Third edition 1991
Fourth edition 1996
Reprinited 1997, 1998
Fifith edition 2004
Library of Congress Cataloging-in-Publication Data
Farmer, R. D. T.
Lecture notes on epidemiology and public health medicine / Richard D.T. Farmer, Ross Lawrenson.—5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-4051-0674-3
1. Epidemiology. 2. Public health.
[DNLM: 1. Epidemiologic Methods. 2. Health Services. 3. Preventive Medicine. WA 950 F234L 2004] I. Title:
Epidemiology and public health medicine. II. Lawrenson, Ross. III. Title.
RA651.F375 2004
614.4—dc22
2004000864
ISBN 1-4051-0674-3
A catalogue record for this title is available from the British Library
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Printed and bound in India by Replika Press Pvt. Ltd.
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Contents
Preface, vi 13 Health promotion and health
List of Abbreviations, viii education, 96
14 Control of infectious disease, 103
15 Immunization, 114
Part 1 Epidemiology
16 Environmental health, 127
1 General principles, 3 17 Screening, 133
2 ‘Cause’ and ‘risk’ and types of
epidemiological study, 7
Part 3 Health Services
3 Descriptive studies, 14
4 Surveys, survey methods and bias, 24 18 History and principles, 143
5 Cohort studies, 32 19 The National Health Service, 153
6 Case–control studies, 38 20 Health targets, 162
7 Intervention studies, 45 21 Evaluation of health services, 173
8 Health information and sources of data, 51
9 Indices of health and disease, and
Appendices: Further Reading and
standardization of rates, 63
Useful Websites
10 Medical demography, 69
11 Evidence-based medicine, 82 Appendix 1: Suggested further
reading, 181
Appendix 2: Useful websites, 182
Part 2 Prevention and Control of Disease
12 General principles, 91 Index, 183
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Preface
The UK Government is committed to improving is relevant effective and efficient are evident
the nation’s health and reducing health inequali- within the NHS in the UK as in many other coun-
ties. Whilst the provision of health care is in a state tries. This is exemplified in the NHS plan The New
of constant change it is important to remember NHS; modern, dependable (1997).
that the key objective is to maintain and improve This new edition of Lecture Notes: Epidemiology
the health of the population. This was recognized and Public Health Medicine, as before, covers
by Derek Wanless in his report Securing Good Health the basic tools required for the practice of epidemi-
for the Whole Populationpublished on 25th Febru- ology and preventive health. The chapters in the
ary 2004. This document focused on prevention first section of the book outline the principles of
and the wider determinants of health. To prevent epidemiology and lead the reader to some classic
disease and improve health it is essential to under- examples from the medical literature. A new chap-
stand why diseases arise;and conversely why, in ter has been included on the practice of evidence-
many cases, they do not. To do this it is necessary based medicine. The second section of the book
to study the distribution and natural history of dis- covers the areas of prevention and control of dis-
eases in populations and to identify the agents re- ease—in particular the chapter on health promo-
sponsible; effective strategies can then be planned. tion has been updated to reflect the advances that
In the same way that the provision of health care have occurred over the last eight years. The chapter
should be evidence based, the introduction of new on occupational health has been dropped from
preventive strategies should be rigorously evaluat- this edition.
ed and researched. The application of evidence- The final section has been updated to reflect the
based medicine is applicable to both clinical and changes in the provision of health care. Change is
public health practice. now a constant in the health services and the shift
In the past the importance of public health between central control and devolution of respon-
medicine and the related basic medical sciences, in sibility will continue to ebb and flow. At the time of
particular medical statistics and sociology applied writing we are seeing more devolution of responsi-
to medicine, was not emphasized in the under- bility and the primary care trusts have a tremen-
graduate medical education. This relative neglect dous opportunity to deliver health services that are
changed in the 1990s with the GMC's recommen- truly responsive to patient needs. We should also
dation on undergraduate medicine Tomorrow’s recognise the successes brought about through the
Doctors. This publication recommended that the introduction of health targets—the incidence of
theme of public health medicine should figure heart disease is falling; the mortality from breast
prominently in the undergraduate curriculum, en- and cervical cancer has fallen as screening for these
compassing health promotion and illness preven- diseases has increased; and many infectious dis-
tion, assessment and targeting of population needs eases, for practical purposes, have been eliminated.
and awareness of environmental and social factors We still have many challenges—obesity and dia-
in disease. This explicit and forceful advocacy for betes are increasing rapidly, alcohol abuse has been
the discipline from a body as influential as the recognized as a growing social problem and the
GMC undoubtedly gave added momentum to spread of sexually transmitted disease and HIV still
the development of medical education. Similar poses challenges.
changes emphasising the importance of disease We hope readers will find that this new edition
prevention and the need to ensure that health care continues to provide a basic structure to under-
vi
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Preface
standing epidemiology and public health and that diseases and immunization. We must also recog-
many of our readers will be encouraged to delve nise the contribution of Emeritus Professor David
deeper into the subject. Miller who was the co-author of the first four
editions of this book. We would also like to thank
Mrs Pat Robertson, our PA at the University, for her
Acknowledgements
help and support.
We are greatly indebted to Dr Peter English of the
Health Protection Agency for his help and support Richard Farmer
in the updating of the chapters on infectious Ross Lawrenson
vii
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List of Abbreviations
AHA Area Health Authority
AIDS acquired immune deficiency syndrome
BCG bacille Calmette—Guérin (vaccine)
BMA British Medical Association
CCDC Consultant in Communicable Disease Control
CDSC Communicable Disease Surveillance Centre
CEHO Chief Environmental Health Officer
CHAI Commission for Healthcare Audit and Inspection
DHA District Health Authority
DoH Department of Health
DTP diphtheria/tetanus/pertussis (vaccine)
EBM evidence-based medicine
FHSA Family Health Service Authority
GMC General Medical Council
GPRD General Practic Research Database
HEA Health Education Authority
HES hospital episode statistics
Hib haemophilus influenzaetype b (vaccination)
HIV human immunodeficiency virus
HPA Health Protection Agency
HSE Health and Safety Executive
ICD International Classification of Diseases
IHD ischaemic heart disease
IPV injected polio vaccine
ITT intention to treat
MMR measles/mumps/rubella (vaccine)
MRC Medical Research Council
NHS National Health Service
NHSME National Health Service Management Executive
NICE National Institute for Clinical Excellence
OPCS Office of Population Censuses and Surveys
OPV oral polio vaccine
PCT primary care trust
PHLS Public Health Laboratory Service
PMR perinatal mortality rates
RAWP Resource Allocation Working Party
RCT randomized controlled trial
RHA Regional Health Authority
SARS severe acute respiratory syndrome
SMR standardized mortality ratio
STD sexually transmitted disease
WHO World Health Organization
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Part 1
Epidemiology
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