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Introduction
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The Field of Epidemiology
Epidemiology is the study of the frequency and deter-
minants of morbidity and mortality in populations.
Besides being a discipline in its own right, the science
of epidemiology is one of the foundational sciences of
public health and of evidence-based medicine. The
Centers for Disease Control and Prevention (CDC) esti-
mate that of the more than 30 years increase in life span
experienced by Americans between the years 1900 and
1998, approximately 25 of those years can be attributed
to improvement in public health. Epidemiology played
a key role in these improvements by identifying risk
factors and causal agents for disease and by aiding in
the development and evaluation of public health and
educational programs designed to reduce morbidity and
mortality. Epidemiology has proved equally useful in
the drive to prevent and control infectious disease
through measures such as provision of clean water, the
institution of widespread vaccination programs, and in
the reduction of morbidity and mortality from chronic
disease through identification of risk factors such as
tobacco smoking, consumption of a high-fat diet, and
lack of physical activity.
Epidemiologic studies often begin by describing
variation in disease occurrence or other health out-
comes according to the variables of person, place, and
time. Person variables describe who is becoming ill—
their gender, ethnic group, usual diet, and so on. Place
Copyright 2008. SAGE Publications, Inc.
variables may describe where the individual was
exposed to the disease-causing agent, the location
where they became ill, or where the agent (such as a
rodent or mosquito) became infected with the disease.
Time variables may relate either to measurements such
as the age or birth cohort of those infected, the dura-
tion of an infection or disease, or to cyclical or secular
trends in disease occurrence. Descriptive studies of
disease occurrence often suggest hypotheses that may
xxxv
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be investigated further in analytic studies that examine
many variables to discover causal or risk factors related
to disease occurrence.
Epidemiologic studies have led to massive
improvements in public health, sometimes even before
the mechanisms of disease causation are completely
understood. For instance, Ignaz Semmelweis’s obser-
vations of the differing rates of puerperal fever within
different wards of the Vienna General Hospital in the
mid-19th century led him to institute antiseptic proce-
dures that drastically lowered both morbidity and
mortality rates, years before the germ theory of disease
was accepted. Similarly, Joseph Goldberger was able
to demonstrate that pellagra, a disease epidemic in the
American South in the early 20th century, was not an
infectious disease but was related to poor nutrition.
Goldberger was also able to prevent outbreaks of
pellagra by having individuals consume small amounts
of brewer’s yeast, a breakthrough achieved a decade
before niacin deficiency was definitively identified as
the cause of pellagra. And the first recognition that
cigarette smoking was a primary risk factor for lung
cancer came from observational epidemiologic studies
conducted by Sir Richard Doll and Sir Austin Bradford
Hill in Great Britain in the 1950s, studies conducted
before any specific mechanism relating smoking and
lung cancer had been proposed.
The scope of epidemiology is continually widening
to accommodate expanded definitions of health and
to accommodate our ever-broadening understanding
of the influence of diverse factors on health. Although
epidemiologic thought may be traced back to ancient
times, growth and development of epidemiology as a
profession began in the 19th century, when the science
of epidemiology was developed partly in response to
public health concerns such as the cholera epidemics
that regularly occurred in many large cities. So suc-
cessful were the interventions devised in this early
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xxxvi———Encyclopedia of Epidemiology
period that many infectious diseases that still plague
the developing world are almost unknown in the
industrialized world, thanks to public health measures
such as the provision of potable tap water, control of
mosquitoes and other pests, and institutions of wide-
spread vaccination programs. Infectious diseases
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still remain a concern in industrialized countries, how-
ever, and the emergence of diseases such as HIV and
multidrug-resistant tuberculosis pose new challenges
for the science of epidemiology.
The first great expansion in the scope of epidemiol-
ogy was the inclusion of chronic as well as infectious
diseases. This is a logical development since, partly due
to greater control of infectious disease, the greatest
causes of morbidity and mortality in developed coun-
tries today are chronic diseases such as cancer, cardio-
vascular disease, and stroke. These diseases are also
significant health factors in the developing world: In
fact, the World Health Organization estimates that 80%
of deaths due to chronic disease now occur in develop-
ing countries. Increased study of chronic diseases has
brought with it a massive increase in complexity, since
most such diseases do not have a single causal factor or
solution. While cholera is caused by ingestion of the
bacterium Vibrio cholerae and effective prevention
requires the public health measure of preventing the
bacterium from polluting drinking water or removing or
killing it through filtration, chemical treatment, or boil-
ing, heart disease may be influenced by many things,
including genetics, obesity, tobacco smoking, and
comorbid conditions, and prevention and treatment are
likely to require an individualized combination of
behavioral and lifestyle changes as well as medical
intervention. In fact, many of the risk factors for chronic
diseases are individual behaviors, and epidemiology’s
growing awareness of the importance of individual
health behaviors on morbidity and mortality led to the
establishment, in the 1980s, of the Behavioral Risk
Factor Surveillance System. It has also led to numerous
public health campaigns aimed at lowering chronic dis-
ease morbidity and mortality by inducing individuals to
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make alterations in their lifestyle, such as increasing
physical activity, eating more fruits and vegetables, and
quitting smoking and moderating alcohol consumption.
An even newer focus of concern for epidemiology
is the influence of social and geographical factors on
health. We now realize that not only individual behav-
ior but also the material facts of a person’s life may be
major determinants of their health. Geographical influ-
ence on health includes not only obvious factors such
as living in a polluted region or in a high-crime area
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Page xxxvi
but also more elusive qualities such as the type and
strength of social relationships that typify a given
neighborhood. Social influences also range from the
obvious to the remarkable: It’s easy to see how poverty
could negatively affect health through lack of access to
health care or inability to purchase nutritious food,
or how the regular experience of discrimination could
harm one’s mental and physical health, but recent
studies indicate that even in affluent societies where
health care is available to all, a person’s place within
the social hierarchy can be a major influence on their
health. Sorting out the influence of the many variables
involved remains a challenge for epidemiology.
Epidemiologists are concerned not only with dis-
ease but also with injury. This includes accidental
injuries, such as those caused by motor vehicles or by
falling off a ladder, as well as injuries deliberately
caused by oneself or other persons. The inclusion of
topics such as suicide, child abuse, and intimate part-
ner violence within the scope of epidemiology repre-
sents a commonsense broadening of scope, as does
the study of risk factors such as the presence of
firearms in the home. War and terrorism have also been
included within the scope of epidemiology, which is
entirely appropriate given the great toll they extract in
human life and suffering.
Another expansion of scope for epidemiology,
which was originally concerned with the health of
human populations, has been the development of the
science of veterinary epidemiology that studies the
occurrence of health and disease of animal popula-
tions. This expansion is entirely logical because not
only are many diseases communicable between ani-
mals and humans, but animal husbandry also plays an
essential role in securing both the food supply and
economic welfare of many human populations.
Organization of the Encyclopedia
As the study of epidemiology may potentially incor-
porate information about anything that affects human
health, it incorporates descriptive and analytical tech-
niques borrowed from many areas of study. However,
a two-volume encyclopedia cannot include detailed
discussions of every topic relevant to epidemiology,
so we took the approach of including overview arti-
cles on many topics relevant to epidemiology, with
their length proportional to the centrality of the topic
to epidemiology. Anyone studying epidemiology will
need to know something about biostatistics, for
instance, but not so much as a full-time biostatistician.
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Similarly, a basic knowledge of health economics is
relevant to the practice of many epidemiologists,
although that knowledge need not be as extensive or
detailed as someone working as a health economist.
We have organized this material into almost 500
entries, which may be viewed as belonging to a
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number of broad categories. One way to look at the
content of this Encyclopedia is by major topics and
representative entries included within each:
Behavioral and Social Science. This deals with topics
such as acculturation, community health, demogra-
phy, health behavior, health communication, network
analysis, and social epidemiology.
Branches of Epidemiology. This includes 20 fields of
study, based on methodological approach or content
studied, from applied epidemiology to veterinary
epidemiology.
Diseases and Conditions. This deals with the incidence,
prevalence, prevention, and control of 40 major infec-
tious, chronic, and psychiatric diseases and conditions,
from Alzheimer’s disease to zoonotic diseases.
Epidemiological Concepts. This deals with topics that
form the basis of the science of epidemiology, including
fundamental concepts such as attack rate, attributable
fractions, incidence and prevalence, effect modification
and interaction, morbidity and mortality rates, herd
immunity, and direct and indirect standardization.
Epidemiologic Data. This deals with topics related to
important data sets and the acquisition and manage-
ment of data, including administrative data, cancer
registries, notable epidemiologic studies such as the
Framingham Heart Study and the Harvard Six Cities
Study, publicly available data sets, sampling techniques,
and secondary data.
Ethics. This deals with standards of ethics in health
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care, public health and human subjects research, and
when doing epidemiology in developing countries,
and related topics such as definitions of health, eugen-
ics, and genocide.
Genetics. This deals with topics related to the bur-
geoning science of genetic epidemiology, including
epigenetics, family studies, genetic counseling, gene-
environment interaction, linkage analysis, molecular
epidemiology, and twin studies.
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Page xxxvii
Introduction———xxxvii
Health Care Economics and Management. This deals
with topics such as biomedical informatics, economic
evaluation, functional status, health economics, man-
aged care, and quality-of-life measurement.
Health Risks and Health Behaviors. This deals with
what is known about the influence of numerous agents
and conditions on health and disease from Agent
Orange to urban sprawl and individual health behav-
iors from alcohol use to tobacco.
History and Biography. This deals with the history of
epidemiology and public health, and biographies of
pioneers in the field, from William Budd to John Tukey.
Infrastructure of Epidemiology and Public Health.
This deals with epidemiologic and public health orga-
nizations, governmental and nongovernmental agen-
cies, major journals, and the publication process.
Medical Care and Research. This deals with topics at
the intersection of medicine and epidemiology, includ-
ing clinical epidemiology; evidence-based medicine;
the International Classification of Diseases and the
International Classification of Functioning, Disability
and Health; medical anthropology; and screening.
Specific Populations. This deals with major threats to
health and patterns of disease and disability within
specific populations, as defined by race or ethnicity,
gender, age category, urban or rural residence, immi-
grant or refugee status, and sexual identity.
Statistics and Research Methods. This deals with the-
oretical background and applied techniques of epi-
demiology and statistics, including categorical data
analysis, bias, causation and causal inference, classi-
fication and regression trees, cluster analysis, factor
analysis, geographical and spatial analysis, multilevel
modeling, nonparametric statistics, qualitative meth-
ods, regression, sequential analysis, and structural
equation modeling.
The Growth of the
Field of Epidemiology
The demand for epidemiologists is growing faster
than the available supply of trained personnel,
although enrollment in both public health programs in
general, and epidemiology programs in particular,
has been steadily expanding for years. In the United
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xxxviii———Encyclopedia of Epidemiology
States, most formal epidemiologic study takes place at
the graduate (master’s and doctoral) level at one of
37 accredited schools of public health, who enroll
students from all parts of the world. University study
in epidemiology and public health is offered in many
other countries as well, including Canada, Japan, and
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numerous European countries.
Epidemiology is truly an international science, and
epidemiologic research today is conducted in all parts of
the world. The international growth of epidemiology
as a science is demonstrated by the expansion of the
International Epidemiological Association, which began
as an “International Corresponding Club” founded by
three British and American researchers in 1954, that
now has members from more than 100 countries and
whose triennial Congress in 2002 was attended by more
than 1,200 people. Regional epidemiologic conferences
also regularly draw participants from outside their
geographic region; for instance, the 2004 European
Congress of Epidemiology accepted individuals from
38 countries, representing all six continents.
In 2004 to 2005, U.S. schools of public health pro-
duced 6,656 graduates, a 43.6% increase from 1994
to 1995. Epidemiology was the most popular field of
study, with 19.5% of students choosing this concentra-
tion. Despite this increase in graduates, there is a short-
age of epidemiologists in the United States and
worldwide. Many people who are currently working
in epidemiology without formal training, such as the
Council of State and Territorial Epidemiologists
(CSTE), estimates that almost half the individuals
working as epidemiologists in state and territorial health
departments are not academically trained in the subject,
with the largest gaps in those working in infectious dis-
ease epidemiology and injury epidemiology. Of course,
many of these individuals are not able to stop working
and enroll in a full-time course of study; even if they
were, there are not sufficient places in university epi-
demiology programs to accommodate them. This situa-
tion led to development by the CDC and the CSTE
of the Competencies for Applied Epidemiologists in
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Governmental Public Health Agencies, which specify
what topics should be included in competency-based,
on-the-job training for epidemiologists in government
public health agencies.
Rationale for the Encyclopedia
The extraordinary growth of the field of epidemiology
in the past several decades, coupled with an ever-
increasing demand for people with epidemiologic
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Page xxxviii
training, has created a void in the literature. There are
several highly technical encyclopedias directed to
trained epidemiologists and biostatisticians and basic
dictionaries that define key terms in the field, but there
is no single reference work that describes basic epi-
demiologic concepts in sufficient depth for practition-
ers and that is accessible to the nonspecialist also. In
addition, there is no reference that combines technical
information about the techniques used in epidemiol-
ogy with substantive information about the epidemiol-
ogy of specific diseases and conditions or about the
health status of particular population groups.
The Encyclopedia of Epidemiology is designed
to be comprehensive in its coverage of topics but
not exhaustive in its treatment of any one topic. Basic
information about epidemiology is presented in a man-
ner that is appropriate for both a student beginning uni-
versity study in the field and the interested general
reader. Technical articles such as those on biostatistical
techniques are presented in a nontechnical manner so
that they may be understood without advanced statisti-
cal training. Particular emphasis has been placed
on communicating with individuals outside the field.
Epidemiology plays too important a role in the modern
world to be left to epidemiologists alone, and many
people working outside the field need a working
knowledge of at least some aspects of epidemiology.
Such persons include health care professionals such as
nurses and physicians, researchers in other social sci-
ence fields, social workers, and journalists.
Content and Organization
This Encyclopedia was designed to include every
topic that would be of major concern to persons study-
ing or working epidemiology; thus, many topics from
related fields such as biostatistics, health psychology,
and health economics are included. Because many
topics are interrelated, and to avoid redundancy, all
topics include cross-references to related topics. In
some cases, a topic was completely covered within
an article on another topic; in that case, the smaller
topic is listed in its alphabetical position with a cross-
reference to the entry in which it is discussed.
To help the reader navigate the Encyclopedia, a
Reader’s Guide is provided that organizes the content into
the 14 large topics previously enumerated. Additionally,
a list of the entries is presented in alphabetical order.
The content of each article is intended to provide a
concise and nontechnical summary of the major aspects
of the topic, providing the reader with a fundamental
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Introduction———xxxix

understanding of the area. Following each entry is a
Further Readings section that presents the interested
reader with a carefully selected set of references should
they wish to inquire more deeply into the topic.
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in approach, and balanced in the presentation of dif-
ferent views on any controversial issue.
Step 5. The Editor in Chief and Advisory Board mem-
bers, who are all subject experts in epidemiology and
related fields, reviewed all articles and requested revi-

How the Encyclopedia of sions as necessary.

Epidemiology Was Created
The Encyclopedia was developed in seven basic steps.
Step 1. Leading epidemiologists and public health sci-
entists were invited to serve on the Advisory Board.
The Advisory Board includes faculty members from
major epidemiology programs, in addition to a biostat-
istician and a health economist from two of the lead-
ing medical schools in the United States. Together
they present broad and varied experience in the field,
including considerable overseas research and training.
Step 6. A Sage Developmental Editor, who was not an
epidemiologist, reviewed entries once they had been
passed by the subject experts, with an eye to consis-
tency and comprehensibility for the general reader.
Further revisions were requested at this stage if
necessary.
Step 7. The volumes were finalized and the extra mate-
rial was compiled, including the Reader’s Guide and
final matrix of cross-references and blind references.

Step 2. A master list of topics for the Encyclopedia

was created. First an initial list of topic headwords Acknowledgments
was created by the Editor in Chief, using as a guide
A number of people played major roles in producing
the content of major epidemiologic textbooks, epi-
this Encyclopedia. First I would like to thank my
demiology and public health journals, and the cur-
Advisory Board, who went far beyond the call of duty
ricula of accredited epidemiology and public health
in suggesting current topics, locating authors, and par-
programs in the United States. This list was revised by
ticipating in the manuscript review process. I would
the Advisory Board, with a particular effort made to
also like to thank my editorial team at Sage, in partic-
include topics of current relevance, such as bioterror-
ular, my developmental editor, Diana Axelsen, and my
ism, SARS (severe acute respiratory syndrome), and
production editor, Melanie Birdsall. And of course
violence as a public health issue.
I would like to thank all the scholars and profession-
als who authored the entries.
Step 3. Contributors were identified and invited, based
I would also like to thank my literary agent, Neil
on personal knowledge of their expertise, references
Salkind at Studio B, for his guidance and support.
from colleagues, and publication record. The authors
On a personal level, I would like to thank my hus-
represent a mix of academics and practitioners from
band, Dan Peck, for his unwavering love and support,
around the world and include people from all career
my professors at City University of New York and
stages, from new researchers with particular subject
Saint Louis University for setting me down the path
expertise in an emerging field to emeritus faculty
that led to this Encyclopedia, and my colleagues at
drawing on many years of experience.
Washington University Medical School and BJC
HealthCare in Saint Louis for sharing their collective
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Step 4. Contributors were given basic instructions and

wisdom and experience.
guidelines regarding their entries. In particular, they were
encouraged to be thorough in coverage, nontechnical —Sarah Boslaugh

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