Chapter 8 Person

Benfu Yang,
Dept. Epidemiology,
Jining Medical College
bfyangs@163.com

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Distribution of Disease
 Person

 Place

 Time

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Person

 Age
 Gender
 Race and Ethnic
 Socioeconomic
 Occupation
 Marital Status
 Religion

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Age – the most fundamental factor to consider
when describing disease occurrence.

--- The incidence of most chronic diseases

increases with age.

--- However, the incidence of many infectious

diseases is highest in childhood.

--- Some disorders show bi-modal (two peak)

distributions (i.e. Hodgkin’s disease). This
may reflect different underlying etiologies.

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Age
Age as a Confounding Variable
 In most disease the variation in frequency that

occurs with age is greater than that with any other

variable.

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Technical Influences on Age Curves
 There are a number of sources of error that vary with age
and may affect the shape of observed age-risk curves, E.g.,
accuracy of diagnosis varies with age, a fact that is
particularly likely to affect the newborn and the oldest age
groups and that is probably more significant in the context
of mortality than of incidence data.
 The shape of an age-risk curve will also depend on whether
it is based on rates of incidence, prevalence, or mortality,
and on the stage of the disease at which incidence or
prevalence is measured.
 A cross-sectional age curves declined in the older age
groups.Cohort age curves continued to increase throughout
the life span.
 such patterns are now known to be common in other
cancers and in other noninfectious diseases. They must be
considered when interpreting patterns of association
between age and disease rates.
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Interpretation of Age Associations
 Early Mortality

 The Diseases of Aging

 Evidence:
 The potential for the control of lung cancer and an even
larger number of deaths due to other diseases attributable to
cigarette smoking,
 The steady decline in mortality from ischemic heart disese
that has occurred in the last two decades for reasons that are
not clearly understood but are probably multiple.
 Tobacco company executive might characterize as “only
statistical”.

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 Irregularities in Age Curves
 Sometimes irregularities in overall age curves, may indicate age groups in need
of further investigation.

 Bimodality
 The occurrence of two separate peaks in the age-incidence curve of a disease is
always of interest.
 E.g., age curves for tuberculosis are bimodal, showing one mode in the 0-4 age
group and a second in the 20-29 age group. Tuberculosis is defined in terms of
exposure to the tubercle bacillus, so that both these modes affect the same
“disease.” The existence of the two modes, however, suggests that two distinct
sets of other component causes must be taken into account to explain the age
distribution.
 Another example:deaths in motor vehicle crashes. Although the motor vehicle is
a common facor in the deaths of young adults and the elderly, it is likely that
there are substantial differences in the other components of the causal web in

these two age groups.

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Gender – biological and non-biological factors related to
gender may impact disease risk.

--- In all developed countries, life expectancy is higher in

females and males – principally
due to lower heart disease mortality.

--- However, many chronic diseases occur

more frequently in women (depression,
lupus, etc.)

--- As lifestyles continue to become more

similar, a question is whether mortality
rates will become more similar (i.e.
environment vs. biology).

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Gender
 The Gender Ratio
 associations between gender and a disease are most convincingly
demonstrated by comparing disease rates between males and females.
 Gender Differences in Mortality
 more males are born alive than females—a ratio that is generally about
106:100.
 the mean age of females commonly being higher than that of males.
 ratio of male to female rates is close to 1.0 (including hypertensive
heart disease, cerebrovascular disease, and diabetes mellitus) actually
show higher crude mortality rates for females than for males, but, as
seen in the table, when the rates are age standardized they are higher
for males than for females.
 Explanations: much earlier onset of heavy cigarette smoking in males
(beginning in the first quarter of the century); the later epidemics of
deaths due to firearms and motor vehicle crashes (both affecting males
primarily); and, most recently, the epidemic of AIDS, which up to this
point has affected males predominantly.
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 Gender Differences in Morbidity
 The ratios of male to female incidence rates for
individual diseases cover a wide range of values.
Women have higher morbidity rates than men for many
chronic disease. In some instances the differences are
striking, for example, thyrotoxicosts, diabetes mellitus,
cholecystitis and biliary calculi, obesity,arthritis, and
psychoneuroses. In contrast, other diseases are
predominantly diseases of males when examined in
morbidity data. These include ischemic heart disease,
malignant and nonmalignant respiratory disease, peptic
ulcer, inguinal hernia, gout, and accidents.

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 Men do experience fewer acute conditions and associated bed days
than women, and they apparently have fewer physician office visits.
Table 8-3. Selected measures of Morbidity in Adult Males and Females,
United States,1993
Per 100 persons
Measure Ratio M/F
Male(M) Female(F)
Acute conditions reported

Annual incidence 126 169 0.72

Associated bed days 262 387 0.68
Associated work-loss days 267 326 0.82
Prevalence of impairment due to chronic conditions

Some activity limitation 29.8 30.2 0.99

Unable to carry on major activity 10.3 8.7 1.18
Bed days due to acute and chronic conditions in 890 1190 0.74
previous year
Physician office contacts per year 293 421 0.70
Physician office contacts per year 415 489 0.85
One or more short-stay hospitalizations,previous 7.2 7.6 0.95
year
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Annual hospital days 73 69 1.05
 Interpretation of Gender Differences
 Race and Ethnic Group
 Race and ethnic group are descriptors that are widely used
but inconsistently defined.
 Inconsistencies in Racial Classification
 Hispanic Origin
 An ethnic group of increasing societal and epidemiologic
importance in the United States comprises immigrants and
their descendants from Spanish language countries south of
the US mainland, particularly Mexico, Cuba, Puerto Rico,
and other Central American nations.

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 Religion
 Cultural background and religious belief are so strongly
associated that religion sometimes serves as an indicator of
ethnic group. For example, persons of Irish and Italian
ancestry in the United States are predominantly Catholic in
religion, and those of British and Scandinavian ancestry are
predominantly
 The Jewish religion, however, does currently appear to
identify groups that are more homogeneous than the
population at large with respect to some characteristics
(e.g.,eastern European ancestry, male circumcision,
moderation in use of alcohol, genotype).

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 Whereas religion may be the classificatory item used to
identify population groups, it is clear that explanation for
observed differences in disease rates between religious
groups may or may not be found in a feature of the religious
practice. Specific methods of birth control, circumcision,
and abstinence from tobacco are features of, respectively,
Catholics, Jews, and Seventh Day Adventists that may be
thought of as part of religious practice.
 A great deal of interest in religious differences has been
focused in the field of cancer, most recently in the hope of
discovering from the dietary practices of groups such as the
Mormons and the Seventh Day Adventists clues about
dietary factors related to cancer etiology, as referred to in
Chapter 5. Originally, however, this interest was stimulated
by the well-known rarity of cancer of the cervix in Jewish
women and its possible relationship to the circumcision of
Jewish males, a relationship for which there now appears to
be only limited support.
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 Local Reproductive and Social Units
 the addition of accurate medical data to
anthropological studies has produced some
interesting findings. The identification of the
probable role of cannibalism in the dissemination of
Kuru in the Fore people of New Guinea, and indeed
the entire story of the elucidation of the etiology of
this disease, provides a good example of the
usefulness of the combination of anthropologic and
epidemiologic information.

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 Interpretation of Racial and Ethnic Patterns of Disease
 Mutations in Single Major Genes
 A number of important diseases are determined by
mutations in single major genes, the inheritance of which
has been limited, or essentially limited, to certain groups.
These include:
 Sickle cell anemia:Common in West African blacks and their
descendants in the United States and elsewhere.
 Cystic fibrosis of the pancreas: High in Europeans and US
Caucasian populations.
 Tay-Sach’s disease:Essentially restricted to Ashkenazi
Jews.
 Alcohol dehydrogenase deficiency in Japanese and some
other Asian populations.
 Thalassemia, which occurs mainly in persons of Greek or
Italian descent and in other areas around the Mediterranean
Sea.
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 Polygenic Inheritance
 susceptibility to tuberculosis, diabetes mellitus,
hypertension, and many other diseases. Although the
influence of such factors is undoubted , the specifics are
poorly understood at the present time.
 Geography
 Any feature of that geographic congregation that is
associated with disease susceptibility may be reflected in an
apparent association of the disease with an ethnic group.

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 Socioeconomic Status
 Associations between ethnic groups and socioeconomic
status in a community are common.
 This is reflected in trend in infant mortality rates, one of the
most sensitive health indicatitors of economic status, which
have fallen dramatically in both groups, but remain more
than twice as high in the black as in the white population.
 Cultural Practices
 Migration
 The Role of Genes
 Multigeneration Studies

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 Biases in Migrant Studies
 A comprehensive account of the potential biases in migrant studies has
been assembled by Parkin. They include:
 1.Diagnostic, reporting, and coding practices may be different in the
country of origin from those in the host country.
 2.Migrants are not representative samples of the populations of their
home countries of origin and may be selected in terms of geographic
area (important if the disease of interest varies by geography within the
country of origin), age, gender, race, socioeconomic, and, perhaps
most important, health status.
 3.The stresses of migration may in some circumstances pose disease
risks not present, or present to a lesser degree, in either the country of
origin or the host country.
 4.Biases may be introduced by inaccuracies in denominator data
because the accuracy of numbers and levels of information on such
variables as age, gender, and race will vary according to statistical
resources available in both the countries of origin and the host country.
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 Socioeconomic Status
 Socioeconmic status (SES) is one of the most important
demographic determinants of disease risk.
 SES is a concept that is not uniformly defined. Indeed, the concept
has so many components—income, occupation, living conditions,
social prestige—that in practice a single variable that can be
defined objectively is often used as a surrogate for the whole, as
shown in Table 8-6.
 Another variable that is frequently used as a measure of SES is
occupation.
 Years of schooling (education) received, or in the case of children,
years of education of a parent, also correlates well with the general
concept of SES.
 Occasionally, and investigator will devise an index combining a
number of variables by an arbitrary formula to fit with his or her
own concept of social class. The index might be based on a
weighted combination of some or all of such items as income,
rental, family size, occupation, and residence.
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 Interpretation
 For public health purposes we must endeavor to identify the attributes
of social class that are most strongly related to disease risk and that
can be altered. F
 For example, the crowded and unsanitary living conditions that aid the
spread of infectious disease and the many known diseases associated
with undernutrition.
 Other mechanisms for social class effects are strongly suspect but
effective counteractions are not yet known; for example, it is doubtful
that the diet favored by the rich over the last 200 years is the most
beneficial in terms of health, but the changes that would improve it
from the point of view of health are controversial. As another example,
the educational underpinnings of a proclivity to violence, although
undoubtedly related to social class, are not understood.
 There are other relationships of disease risk to SES of which the
mechanisms remain totally mysterious.
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 An Example : Coronary Heart Disease
 The prospective cohort studies described earlier, and many
others not mentioned, have consistently shown a strong
inverse relationship of SES, however it is measured, to risk
of coronary heart disease (CHD). Generally speaking, the
rate ratio for the lowest compared to the highest classes is
greater than three and sometimes higher.
 In the 1930—1932 analysis of the Registrar General noted
earlier, the mortality from CHD in men in the highest
economic class was 3.5 times that of those in the lowest
class.
 this reversal in the trend with SES has not been seen in
women.

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 Occupation
 Occupation has been so important in the development of knowledge of
disease causation.
 Purpose of use.
 1.occupation as a surrogate for socioeconomic status.
 2. approach is to identify occupations at high risk for specific diseases
and search for the noxious agents or processes to which persons in
these occupations are exposed. Probably about half the chemicals and
chemical processes known to be carcinogenic to humans have been
identified in this way. They include soot, lead, acrylonitrile, asbestos,
aniline derivatives , arsenic, benzene, cadmium, coal tar fumes,
chromates, mineral oils, nickel, radium, radon, vinyl chloride, and wood
dust. The associations of silica and other dusts with chronic obstructive
lung disease were also identified in this way, as was the association of
heavy exposure to carbon disulphide with coronary heart disease.
 3. as an index of factors associated with working conditions, rather than

specific exposures associated with the occupation.

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 Marital Status
 Most diseases mortality rates are lowest among married people
and highest among the widowed and divorced.
 Major difficulty in interpreting these differences is in
differentiating the hypothesis that some factor associated with
marital status is a risk factor for a disease from the hypothesis
that marital status depends to some extent on the presence or
absence of chronic disease.
 There are lifestyle differences according to marital status. Yet,
this provides no more information than everyday observation and
leaves unanswered the question of the directionality of the causal
path.
 Religtion
 Religion has been of use in identifying groups with particular
dietary or other practices.
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Race/ethnicity – difficult to define, and to
identify which characteristics may relate to
disease occurrence. Remarkable variation
exists in rates of disease occurrence across
racial and ethnic groups.

--- Genetics?
--- Socioeconomic status?
--- Environmental exposures?
--- Access to health care?
--- Lifestyle factors?

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 100
Motality D 1949~1950

C 1939~1941
1\105

10 1930~1932
B
1914
1
A 、 B 、 C 、 D for 1880
A birth cohort

0.1
0 10 20 30 40 50 60 70 80 90
age （ yrs ）

1914~1950 lung cancer Mortality for Male （ by MacMahon ）

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