Epidemiological

Impacts of
Environmental
Pollution

Dr. Carol Lau

Lecturer
School of Science and Technology
Hong Kong Metropolitan University
Contents

1. Introduction of Hygiene and Environmental Health

2. Epidemiological studies: theories, practices and applications
3. Global burden of disease due to environmental health risk factors

2
1. Hygiene and Environmental Health

Hygiene 衛生情況:
• It generally refers to the set of practices
associated with the preservation of health and
healthy living.
• The focus is mainly on personal hygiene that
looks at cleanliness of the hair, body, hands,
fingers, feet and clothing, and menstrual
hygiene.

https://www.oneeducation.org.uk/personal -hygiene-for-kids/

3
Sanitation 衛生設備
• Sanitation refers to public health conditions related to clean
drinking water and treatment and disposal of human excreta
and sewage.
• It focuses on management of waste produced by human
activities.
• There are 4 types of sanitations:
▪ Excreta management
▪ Solid waste management
▪ Wastewater management
https://www.unicef.org/syria/water-sanitation-and-hygiene ▪ Drainage system

4
What is Environmental Health?

• The World Health Organization’s (WHO) definition is as follows:

• Environmental health addresses all the physical, chemical, and
biological factors external to a person, and all the related
factors impacting behaviors.
• It encompasses hygiene, sanitation and many other aspects of
the environment such as global warming, climate change,
radiation, gene technology, flooding and natural disasters.
• It also involves studying the environmental factors that affect
health.

5
5 Key Areas of Environmental Health

There are several environmental health issues that can negatively affect us:
1. Water and sanitation
2. Chemicals and radiation
3. Air pollution
4. Built environments
5. Climate change

6
 Examples of
Environmental Health

• Air pollution:
• Living near factories or heavy traffic worsens air quality
and leads to health impacts on the lungs and heart such
as asthma 哮喘 and increased risk of heart attacks or
stroke 中風.
• Water contamination:
• Drinking lead-contaminated water can cause IQ loss,
behavioral issues, learning disabilities and more.
• Infants and young children are most at risk.

7
• Drinking water at a commercial
building in Wan Chai has been found
to contain an excessive amount of
lead.
• From the weekly monitoring data for
consumers’ taps under the Enhanced
Water Quality Monitoring
Programme, the department said that
out of 15 samples, 17 mg of lead
were found in one taken from the
premises.
• HK follows the WHO's standard,
which caps the amount of lead in tap
water at 10 mg/L, more stringent
than the 15 mg/L in the US, or 50
mg/L in mainland China.

8
Examples of Environmental Health

• Toxic chemicals: Phthalates 鄰苯二甲酸鹽 are a

group of chemicals used to make plastics more
durable.
• Phthalates are in hundreds of products, such
as lubricating oils, and personal-care products
(soaps, shampoos, hair sprays).
• They affect hormones and can cause a wide
array of health impacts, increased risk of cancer
and fertility issues.
• Video for Environmental Hygiene: Scope
and Challenges (3:10) https://youtu.be/a4hwZ25ALFw

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Components of Hygiene and Environmental Health

Description Concerns
Personal hygiene Hygiene of body and clothing
Adequacy, safety (chemical, bacteriological, physical) of water for
Water supply
domestic, drinking and recreational use
Human waste disposal Proper excreta disposal and liquid waste management
Proper application of storage, collection, disposal of waste.
Solid waste management
Waste production and recycling
Control of mammals (rats) and arthropods (flies and mites) that
Vector control
transmit disease

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Components of Hygiene and Environmental Health

Description Concerns
Food safety and wholesomeness 衛生in its production, storage,
Food hygiene preparation, distribution and sale, until consumption
https://youtu.be/qCDLHRpd1bI

Physiological needs, protection against disease and accidents,

Healthful housing
psychological and social comforts in residential and recreational areas
Communal hygiene in schools, prisons, health facilities and settlement
Institutional hygiene
areas
Water pollution Sources, characteristics, impact and mitigation

Occupational hygiene Hygiene and safety in the workplace

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 Major Environmental Risk Factors and Related Diseases

Environmental risk factors Related diseases and conditions

Contaminated water, lack of latrines, poor hand Diarrhoeal diseases 腹瀉, trachoma 顆粒性結膜炎,
washing, inappropriate solid waste management, schistosomiasis 血吸蟲病, ascariasis 蛔蟲病, trichuriasis 鞭蟲
open defecation, vector infestation 侵擾 病, hookworm, typhoid fever 傷寒, and relapsing fever 回歸熱
Chronic obstructive pulmonary disease, lower respiratory
Indoor air pollution
infections, and lung cancer
Outdoor/ambient air pollution Respiratory infections, cardiovascular diseases, lung cancer
General environmental hazards Diarrhoeal diseases, malnutrition, malaria and other vector-
(climate, mosquitoes, nutrition) borne diseases, and heat exhaustion 中暑
Environmental hazards in workplaces (excess Injuries, hearing loss, cancer, asthma, back
noise, heat, dust, chemicals) pain, and chronic obstructive pulmonary disease

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Common Environmental
Hygiene Problems 1

Accumulation of refuse
Cause:
Many irresponsible people and business operators
treat rear lanes as common dumping grounds for
refuse and unwanted articles as well as areas for
dish-washing and other activities.

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Common
Environmental Hygiene
Problems 2

Canopies
• Cause: Torn and rusty canopies
are common. They hold refuse
and stagnant water and pose
risks of dengue fever and other
health hazards.
• Throwing objects from height is
also a major cause of
accumulated refuse on these
canopies.

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Common Environmental Hygiene
Problems 3

Damaged and illegal drain-pipes

• Cause: Illegally connected or defective drain-
pipes discharge untreated sewage directly into
open channels at the surface of rear lane and
streets or onto storm water drains.
• It causes water pollution, pest infestation, the
breeding of mosquitoes, foul smell,
slippery surfaces and other public health
hazards.

15
Common Environmental Hygiene
Problems 4

Water cooling towers and air-conditioners

and associated ventilation systems
• Cause: Illegally installed by shops and restaurants for their
business operations, many of these structures are not
properly maintained and leak profusely.
• Because of their size, most water-cooling towers protrude
over the rear lane and affect illumination, turning the
lanes into dark and wet alleys.

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Common
Environmental Hygiene
Problems 5
Defective underground drainage system
• Cause: Defective and collapsed
underground drains of rear lanes and
streets cause choked drains
and backflow of effluent onto the lanes,
causing serious environmental hazard.

17
8th September 2023 – Wong Tai Sin district in Hong Kong has been
severely affected by the ongoing Black Rainstorm Warning Signal.
Heavy rainfall has led to extensive flooding in several areas, with
Wong Tai Sin being one of the hardest-hit regions.

18
Common
Environmental Hygiene
Problems 6

Water seepage
• Damp patches as a result of water
seepage and leaking drains are commonly
found in housing units.

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Summary of Hygiene and Environmental Health
• There are differences between hygiene, sanitation and environmental health.
• While hygiene focuses on individual personal hygiene/cleanliness, sanitation often refers
to waste management, and environmental health has a broader meaning beyond
hygiene and sanitation, referring to where we live, work and play.
• The focus of environmental health is on how environmental risk factors affect human
health.
• Environmental health plays a major role in the prevention and control of communicable
diseases caused by pathogens, such as diarrhoea, and other diseases such as chronic
obstructive pulmonary disease caused through inhalation of polluted air.
• There are various environmental health risks that affect our health.
• These include water and air pollution, food contamination and the disposal of wastes
into our environment.

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Audio (4:55) https://hongkongfp.com/2022/08/12/hong-kong-govt-to-
tackle-over-600-hygiene-black-spots-in-bid-to-beautify-public-space/
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2. Definition of Epidemiology

• Epidemiology is the study of

the distribution and determinants 決定因素 of health-related
states or events in specified populations, and the application of
this study to the control of health problems.
• Environmental epidemiology involves studies of existing
human population groups that have been
inadvertently exposed to one or more chemical and/or physical
agents.
• Its principal aim is to identify risk factors that can be reduced
so as to prevent or reduce the risk of future disease and
promote public health.

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Key Terms
in Epidemiology

A. Distribution
B. Determinants
C. Health-related States Or Events
D. Specified Populations
E. Application

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A. Distribution

• Epidemiology is concerned with the frequency and pattern of health events in a population.​
• Frequency refers not only to the number of health events such as the number of cases of
meningitis 腦膜炎 or diabetes in a population, but also to the relationship of that number to
the size of the population.​
• The resulting rate allows epidemiologists to compare disease occurrence across different
populations.

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Distribution

• Pattern refers to the occurrence of health-related events by time, place, and person.
• Time patterns may be annual, seasonal, weekly, daily, hourly, weekday versus weekend, or
any other breakdown of time that may influence disease or injury occurrence.
• Place patterns include geographic variation, urban/rural differences, and location of work
sites or schools.
• Personal characteristics include demographic factors which may be related to risk of illness,
injury, or disability such as age, sex, marital status, and socioeconomic status, as well as
behaviors and environmental exposures.

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B. Determinants 決定因素

• Any factor, whether event, characteristic, or other definable entity, that brings about a change in a
health condition or other defined characteristic.
• Epidemiologists assume that illness does not occur randomly in a population, but happens only when
the right accumulation of risk factors or determinants exists in an individual.
• To search for these determinants, epidemiologists use epidemiologic studies to provide the “Why” and
“How” of such events.
• They assess whether groups with different rates of disease differ in their demographic characteristics,
genetic or immunologic make-up, behaviors, environmental exposures, or other so-called potential risk
factors.
• The findings may provide sufficient evidence to direct prompt and effective public health control and
prevention measures.

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 • Epidemiology was originally focused exclusively on
epidemics of communicable diseases but was
subsequently expanded to address endemic
communicable diseases and non-communicable diseases.
• Epidemiologic methods have been applied to chronic
diseases, injuries, birth defects, maternal-child health,
C. Health-related occupational health, and environmental health.
• Behaviors related to health and well-being, such as
States or Events amount of exercise and seat belt use.
• With the recent explosion in molecular methods,
epidemiologists can examine genetic markers of disease
risk.
• The term health-related states or events may be seen as
anything that affects the well-being of a population.

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D. Specified Populations

• The clinician is concerned about the health of an individual,

while the epidemiologist is concerned about the collective
health of the people in a community or population.
• Epidemiologist focuses on:
• Identifying the exposure or source that caused the illness;
• The number of other persons who may have been similarly
exposed;
• The potential for further spread in the community; and
• Interventions to prevent additional cases or recurrences.

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E. Application

• Epidemiology is not just “the study of” health in a population; it also involves
applying the knowledge gained by the studies to community-based practice.
• Epidemiologists use the scientific methods of descriptive and analytic
epidemiology as well as experience, epidemiologic judgment, and
understanding of local conditions in “diagnosing” the health of a community.
• They propose appropriate, practical, and acceptable public health interventions
to control and prevent disease in the community.

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30
 A Classic Example
• John Snow (practicing physician) is often considered to be the founder
of epidemiology.
• Based on his classic studies of the transmission of cholera 霍亂 in
London in the mid- 1800s (Monson, 1990).
• Snow observed that people working with cholera patients did not
always contract the disease, and yet people who did not have contact
with infected patients often did.
• In this case, the cause of the disease was known; what was not known
was the pathway through which people were being infected.
• Snow postulated the existence of some vehicle that transmits the
disease and hypothesized that one possibility was the presence of
sewage (fecal) contamination in their drinking water.

Spot map of deaths from cholera in Golden Square area, London,

1854 (redrawn from original) 31
A Classic Example
• To determine the source, Snow conducted a study of population
groups in different parts of the city who obtained their drinking water
from different suppliers.
• He analyzed the mortality rates in a single subdistrict, where the only
observable difference was that one portion of the population
obtained its drinking water from one supplier and the other obtained
its water from a second supplier.
• He found that a difference in the chloride content of the two water
supplies, and he was able to identify the supplier of each individual
household.
• Using these data, he confirmed that the disease was transmitted by
sewage in the drinking water supplied by one of the companies.

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 Number of Cholera Death
Water Supply of Population Deaths from Rate per 1,000
Individual House (1851 Census) Cholera Population

Southwark and 98,862 419 4.2

Vauxhall Only

Lambeth Only 154,615 80 0.5

Mortality from Cholera in London Related to the Water Supply of

Individual Houses in Districts Served by Both the Southwark and
Vauxhall Company and the Lambeth Company, July 9–August 26,
1854.
Source: Snow J. Snow on cholera. London: Humphrey Milford: Oxford
University Press; 1936.
33
Interpretation of the Study

• This study demonstrated a higher death rate from cholera among households served
by the Southwark and Vauxhall Company in the mixed districts, added support to
Snow’s hypothesis.
• It also established the sequence of steps used by current-day epidemiologists to
investigate outbreaks of disease.
• After this study, efforts to control the epidemic were directed at changing the
location of the water intake of the Southwark and Vauxhall Company to avoid
sources of contamination.
• Snow demonstrated through epidemiologic studies that water could serve as a
vehicle for transmitting cholera and that epidemiologic information could be used to
direct prompt and appropriate public health action.
• Video for What is Epidemiology? (2:10) https://youtu.be/q-17icRTMyY

34
 A. Source Activities
Industry & energy Transport Domestic activities Waste management Agriculture Nature

B. Emission

Transport Environmental concentrations

Links between Transformation Air Water Food Soil
Fate
Environmental Population

Pollution and C. Exposure distribution

Time-activity
Health
Dose
Absorbed dose
Target organ dose

D. Health Effects
Subclinical
Morbidity Adapted from Briggs D. Environmental pollution
and the global burden of disease. Br Med Bull.
Mortality 2003;68:1-24. 35
A. Sources of Pollutants
Most pollutants are of human origin:
• They derive from human activities such as industry,
energy production & use, transport, domestic
activities, waste disposal, agriculture & recreation.
Natural sources of pollution may also be significant:
• Radon 氡, released through the decay of radioactive
materials in the Earth’s crust,
• Arsenic 砷 released into groundwaters from natural
rock sources,
• Heavy metals accumulating in soils and sediments
derived from ore-bearing rocks, & particulates,
• Sulphur dioxides released by wildfires or volcanic
activity.

36
Natural Sources of Pollution: Radon

• Radon is a radioactive gas that forms naturally when

uranium 鈾, thorium 釷, or radium 鐳, which are
radioactive metals break down in rocks, soil and
groundwater.
• People can be exposed to radon primarily from breathing
radon in air that comes through cracks and gaps in buildings
and homes.
• Because radon comes naturally from the earth, people are
always exposed to it.
• Over time, breathing in high levels of radon can cause lung
cancer.

Source: http://www.lifetimeradon.com/
37
Natural Sources of Pollution: Arsenic
• Arsenic, a naturally occurring element, can combine with either
inorganic or organic substances to form many different compounds.
• Inorganic arsenic compounds are in soils, sediments, and
groundwater.
• These compounds occur either naturally, or as a result of mining, ore
smelting, or when using arsenic for industrial purposes.
• Organic arsenic compounds exist mainly in fish and shellfish.
• People are most likely exposed to inorganic arsenic through drinking
water, in areas with water sources that naturally have higher levels of
inorganic arsenic.
• Other sources of inorganic arsenic exposure include contact with
contaminated soil or dust, or with wood preserved with arsenic
compounds.

Source: https://edition.cnn.com/

38
B. Estimation of Emission

• Estimates of emission by source & environmental

medium are inevitably only approximate, for they
can rarely be measured directly.
• Instead, most emissions inventories derive from
some form of modelling, either based on emission
factors for different processes or source activities,
• Or based on input–output models by calculating
the difference between quantities of the material
input into the process & quantities contained in the
final product.

39
Atmospheric Emissions

• Emissions to the atmosphere tend to be more closely modelled

& measured, and more generally reported, than those to
other media.
• Partly because of their greater importance for environmental
pollution and health,
• Partly because of the existence of better established policy
& regulation.

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Emissions to Surface Water, Groundwater and Soil

• Releases to other media, such as surface waters, groundwaters and soil, also occur through a range of
processes.
• Deliberate discharge, spillage (e.g. from storage, during transport, or during processing & usage),
• leakage and runoff (e.g. of agricultural chemicals) are all important in terms of aqueous pollutants.
• Legal limits for discharges to streams are set for many industries, aimed at keeping levels of
contamination within accepted limits.
• Illegal discharges, or accidental spillage accounted for the majority of reported surface water pollution
incidents.
• Dumping (both legally in landfill sites and illegally) represents a major source of emission of solid wastes.
• Landfill sites may thus be responsible for emissions of a wide range of pollutants, via different pathways,
especially when these sites are inadequately sealed or poorly maintained.

41
C. Exposure and Dose

• Exposure is defined as the contact between a hazardous agent (a pollutant) and

an organism.
• Three main forms of exposure are generally recognized: dermal contact, inhalation and
ingestion.
• Dose refers to the quantity of the substance in the body.
• The absorbed dose refers to the amount of the substance entering the body as a whole;
• Target organ dose refers to the amount reaching the specific organs that are affected.

42
D. Health Effects: • Health effects: a relationship exists between the level of
exposure (or dose) and the degree of effect.
Dose-response • By the type of effect or by its severity, or the probability of its
Relationships occurrence (often termed the ‘response’).

(B) For many pollutants

(A) Associations are (C&D) At high levels of
have health effects, at least
generally assumed to be exposure, responses may
over a wide range of
broadly linear, the effect or weaken, so that the dose-
exposures and responses.
response increases with response relationship is
Thresholds may exist,
each increment of exposure essentially curvilinear
below which no detectable
to a pollutant convex or S-shaped.
health effects occur. Graphs from Briggs D. Environmental
pollution and the global burden of
43
disease. Br Med Bull. 2003;68:1-24.
Health Effects

• Health effects can be short-lived (acute)

or prolonged (chronic).
• Many acute effects are almost
immediate & have latencies typically of
no more than a few minutes to a few
days.
• Many chronic effects can have latencies
of several years-up to 20 years or more,
e.g. in the case of some cancers &
diseases such as asbestosis 石棉沉著病 .

44
Human Health Risk Assessment

45
Types of Questions Human Health Assessments Address
To explain this better, a human health risk assessment addresses questions such as:
• What types of health problems may be caused by environmental stressors such as chemicals & radiation?
• What is the chance that people will experience health problems when exposed to different levels of
environmental stressors?
• Is there a level below which some chemicals don't pose a human health risk?
• What environmental stressors are people exposed to and at what levels & for how long?
• Are some people more likely to be susceptible to environmental stressors because of factors such as age,
genetics, pre-existing health conditions, ethnic practices, gender, etc.?
• Are some people more likely to be exposed to environmental stressors because of factors such as where
they work, where they play, what they like to eat, etc.?
The answers to these types of questions helps decision makers, whether they are parents or public officials,
understand the possible human health risks from environmental media.
• Video for Environmental burden of disease approach (8:39) https://youtu.be/V2zBiMO6qOQ

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Environmental-Epidemiological Studies: Study Design

Environmental
epidemiology

Descriptive Analytic
studies studies

Cross-
Ecological Case-control
Sectional Cohort studies
studies studies
Studies

47
 Descriptive Studies Vs Analytical Studies

Descriptive studies describe general Analytical studies are used to test specific
characteristics of the distribution of an outcome in hypotheses & infer 推斷 that exposure precedes 先
relation to person, place, & time. 於 outcome.

48
 Descriptive Epidemiology
The 5W’s of descriptive epidemiology:

What = health issue of concern

Who = person

Where = place

When = time

Why/how = causes, risk factors, modes of transmission

49
 Seasonal Pattern of Rubella 德國麻疹, Influenza, & Rotavirus 輪狀病毒

Time
• The occurrence of disease changes over time. Some of
these changes occur regularly, while others are
unpredictable.
• Two diseases that occur during the same season each
year include influenza (winter) and West Nile virus 西尼
羅河病毒 infection (August–September).

• In contrast, diseases such as hepatitis B and

salmonellosis can occur at any time.
• For diseases that occur seasonally, health officials can
anticipate their occurrence and implement control and
prevention measures, such as an influenza vaccination
campaign or mosquito spraying.
• For diseases that occur sporadically, investigators can
conduct studies to identify the causes and modes of
spread, and then develop appropriately targeted
actions to control or prevent further occurrence of the
disease.
Source: Dowell SF. Seasonal Variation in Host Susceptibility and Cycles
50of
Certain Infectious Diseases. Emerg Infect Dis. 2001;5:369–74.
 Place
Mortality Rates for Asbestosis, by State — United
• Describing the occurrence of disease by States, 1968–1981 and 1982–2000
place provides insight into the geographic
extent of the problem and its geographic
variation.
• Characterization by place refers not only to
place of residence but to any geographic
location relevant to disease occurrence.
• Such locations include place of diagnosis
or report, birthplace, site of employment,
school district, hospital unit, or recent
travel destinations.
• The unit may be as large as a continent or
country or as small as a street address,
hospital wing, or operating room. Source: Centers for Disease Control and Prevention. Changing patterns
of pneumoconiosis mortality–United States, 1968–2000. MMWR 2004;53:627–32.
• Sometimes place refers not to a specific
location at all but to a place category such
as urban or rural, domestic or foreign, and
institutional or noninstitutional.
51
Descriptive Studies: Ecological Studies

• In an ecological study data from entire populations are used to compare outcome
frequencies between different groups during the same time period or in the same
population at different points in time.
• Ecological studies are particularly useful to conduct when individual-level data
would either be difficult or impossible to collect, such as the effect of air pollution
or of legislation.
• It is not possible to link exposure information to the occurrence of outcome
in a particular individual.
• The studies are unable to control for confounding. They cannot be used
to test hypotheses or infer causality 因果關係.
• However, they are quick and inexpensive and use already available information.

52
Examples of the Use of Ecological Studies

1 2 3
Correlating population Demonstrating Comparing the
disease rates with changes in mortality prevalence of a disease
factors of interest, over time (time series) between different
such as healthcare use regions at a single
point in time
(geographical studies).

53
 Design: Ecological study
Outcome: Preterm delivery and birthweight
An Example of Ecological Studies Exposure: Arsenic in drinking water
Reference: Yang et al. (2003).

• Birthweight distributions in two different regions of Taiwan with

different levels of arsenic in drinking water are compared.
• Children from the arsenic-endemic area had on average a 30-g* lower
birthweight and the rate of preterm deliveries was increased by 9%.
• No individual exposure information was collected and the place of birth
determined the exposure status.
• The women may have moved to that area just before the delivery &
therefore not have been exposed to the drinking water of that region in
pregnancy at all.
• No information about the actual intake of water in pregnancy was
available and it was not known whether the women with high
water intake were those who delivered prematurely.
• In addition, no information on how much water the women drank at
home was available, and the study was unable to control for
confounding as e.g. the women’s smoking habits.
• The study is, however, good for generating hypotheses to be tested in
analytical studies.

54
Descriptive Studies: Cross-Sectional Study

• In cross-sectional studies the status of an individual with respect to the presence or

absence of both exposure & outcome is assessed simultaneously.
• Thus, a cross-sectional study provides information about the frequency
and characteristics of an outcome by a “snapshot” of the population at a specific
time.
• As exposure and outcome are assessed at the same point in time, cross-sectional
surveys cannot always distinguish whether the exposure preceded the outcome
development or whether the presence of disease affected the individual’s level of
exposure.
• It is not possible to determine whether the exposure preceded or was caused
by the disease.

55
An Example of Cross-Sectional Studies

• Cross-sectional studies have found that infertile

couples report more psychological distress symptoms,
which implies that stress therefore causes infertility.
• It is, however, not known whether the couples became
infertile because of the stress,
• Or whether the infertility & its consequences and
treatment caused the stress.
• Cross-sectional studies are valuable for raising a
question of the presence of an association rather than
for testing a hypothesis.

56
Analytic Epidemiology

• Key feature of Analytic Epidemiology is Comparison group.

• When investigators find that persons with a particular characteristic are more
likely than those without the characteristic to contact a disease, the characteristic
is said to be associated with the disease.
• The characteristic may be a:
• Demographic factor such as age, race, or sex;
• Constitutional factor such as blood group or immune status;
• Behavior or act such as smoking or having eaten salsa 辣醬; or
• Circumstance such as living near a toxic waste site.

57
 Analytic studies: Case-control study

• In a case-control study, investigators start by enrolling a group of people with disease.

• As a comparison group, the investigator then enrolls a group of people without disease (controls).
• Investigators then compare previous exposures between the two groups.
• The control group provides an estimate of the baseline or expected amount of exposure in that
population.
• If the amount of exposure among the case group is substantially higher than the amount you
would expect based on the control group, then illness is said to be associated with that exposure.
• The key in a case-control study is to identify an appropriate control group, comparable to the
case group in most respects, in order to provide a reasonable estimate of the baseline or
expected exposure.

58
 Design: Population-based case-control
An Example of Case-Control Studies study
Outcome: Confirmed primary lung cancer
Exposure: Indoor radon concentration
Reference: Barros-Dios et al. (2002)
• It is an example of a population-based, case-control study where lung cancer
patients were compared with healthy controls from the same area in Spain.
• A total of 163 cases of primary lung cancer & 241 cancer-free controls were
included.
• Cases were on average 8 years older than controls and had a 40% higher rate
of cancer within the family.
• Close to 92% of cases were smokers as compared to 55% of the controls.
• Residential radon was measured in 98% of the homes for an average of 150
days.
• Residential radon exposure was close to 20% higher among cases than
controls.
• This study concludes that residential radon exposure at levels below official
guidelines of 148–200 Bq/m3 may lead to a 2.5-fold increase in lung cancer
risk.
• Further, synergy between residential radon exposure and smoking was
demonstrated.
59
Analytic studies: Cohort Studies

• In a cohort study the epidemiologist records whether each study participant is exposed or not, and
then tracks the participants (a type of longitudinal study) to see if they develop the disease of interest.
• After a period of time, the investigator compares the disease rate in the exposed group with the
disease rate in the unexposed group.
• The unexposed group serves as the comparison group, providing an estimate of the baseline or
expected amount of disease occurrence in the community.
• If the disease rate is substantively different in the exposed group compared to the unexposed group,
the exposure is said to be associated with illness.
• Most often, the follow-up period must be at least several years to allow an adequate number to
develop the outcome so that meaningful comparisons of disease frequency between exposed and
unexposed individuals can be made.
• Cohort studies allow the examination of multiple outcomes of a single exposure.
60
Cohort Studies: Retrospective cohort study Prospective cohort study
Retrospective And Relates a complete set of outcomes In which current exposure is directly
Prospective already observed in a
defined population to exposures
measured & individuals are
then followed, have a potential
that occurred earlier. for more accurate measurements
Data on both exposure and but may suffer from loss of
outcomes must be available at the subjects to follow up or
time the study is undertaken. bias in ascertainment of end points.
It may be necessary to wait for
many years or even for the time of
follow up to exceed the latent
period between exposure and effect
or for sufficient outcome events
to occur.

Source: www.nottingham.ac.uk/

61
 Design: Cohort-study
An Example of Cohort Studies Outcome: Malignant pleural mesothelioma
Exposure: Inhalation of dust from asbestos in soil
Reference: Metintas et al. (2002).
• In a cohort of 1886 villagers in a rural area in Turkey, the
incidence of malignant pleural mesothelioma (MPM) 惡性胸膜間
皮瘤 was studied.

• The villagers were environmentally exposed to asbestos dust

due to the use of asbestos-contaminated white soil.
• The soil was used as a whitewash or plaster material for walls,
as insulation, and in pottery.
• Exposure was assessed on a subgroup level
through measurement of airborne fiber concentrations both
indoors & outdoors.
• During a 10-year observation period, 24 cases of MPM were
diagnosed within the cohort corresponding to an annual
incidence rate close to 130/100,000.
• This incidence rate exceeds the expected in the general
Turkish population by more than 100-fold & is comparable
to risks of MPM observed in occupational settings with much
higher exposures.
62
Study type Ecological study Cross-sectional study Case-control study Cohort study

Quick and inexpensive Quick and inexpensive Optimal for evaluation of rare Valuable for rare exposures
often using already diseases
available information Provide information about Can examine multiple etiologic Can examine multiple effects
health status of great public factors for a single disease of a single exposure
health relevance Relatively quick and Can elucidate temporal
Strengths inexpensive compared to relationship between
cohort studies exposure and disease
Well suited for evaluation of Minimizes bias in exposure
diseases with long latency assessment
periods Allows direct incidence rates
to be calculated
Unable to link exposure Cannot determine whether Inefficient for evaluation of Inefficient for evaluation of
with disease in exposure preceded or resulted rare exposures rare diseases
particular individuals from the disease
Unable to control for Considered prevalent and will Cannot compute incidence Prospective: extremely
confounding reflect determinants of rates in exposed and expensive and time
Limitations etiology as well as survival unexposed individuals consuming
No individual exposure The temporal relationship Retrospective: requires the
information between exposure and disease availability of adequate
may be difficult to establish records

Prone to bias, particularly recall Losses of follow-up can

and selection bias affect results
•Video for Epidemiological Studies (9:42) https://youtu.be/Jd3gFT0-C4s 63
3. Estimation of the Global Burden of Disease

• Since the early 1990s, largely motivated by WHO, increasing attention has been given
to constructing indicators on environmental health at all levels from the local to the
global scale.
• Exposure-side indicators: which use information on exposures to imply degrees of
health risk.
• Health-side indicators: which use information on health outcome to suggest
attributable effects.
• To make interpretations of the link between pollution & health, & thus to assess the
contribution to the burden of disease.

64
Estimation of the Global Burden of Disease

Disability Adjusted Life

Mortality Years of Life Lost (YLL)
Years (DALYs)
• It was a traditional • It is estimated as the • It Incorporates an
method because data difference between age allowance for the
on deaths tended to be at death and the life number of years lived
more reliable and expectancy in the with a disability due to
widely available, & absence of the disease, disease or injury,
mortality is directly based on an advanced weighted according to
comparable in terms of developed country its severity.
health outcome (82.5 years for women,
80 years for men at
that time).

65
Disability-adjusted life years (DALYs)

• Mortality does not give a complete picture of the burden of disease borne by individuals in different
populations.
• The overall burden of disease is assessed using the disability-adjusted life year (DALY),
• Years of life lost due to premature mortality (YLLs) and
• Years of life lost due to disability (YLDs)
• One DALY represents the loss of the equivalent of one year of full health.
• Using DALYs, the burden of diseases that cause premature death but little disability (such as drowning
or measles) can be compared to that of diseases that do not cause death but do cause disability (such
as cataract causing blindness).

66
67
68
The Organisation for Economic Co-operation and Development (OECD)
經濟合作暨發展組織

69
70
71
72
73
 Global burden of
disease due to • Each subsequent level includes more-detailed risk factors
that are nested within the broader category above it (adapted
environmental health from Stanaway et al. 2018).
risk factors

Level 1 Level 2 Level 3 Level 4

Unsafe water source
Unsafe water, sanitation, and
Unsafe sanitation
handwashing
No handwashing with soap
Ambient particulate
matter pollution
Environmental risks Particulate matter pollution
Air pollution
Household air pollution
from solid fuels
Ambient ozone pollution
Residential radon
Other environmental risks
Lead exposure

74
Diseases with the highest
preventable disease burden from
environmental risks, in disability-
adjusted life years (DALYs) 2012
• DALYs due to preventable
environmental risks
• Proportion of disease
attributable to the environment
• Main areas of environmental
action to prevent disease

Source: Preventing disease through healthy environments: towards an estimate of the environmental burden of disease, 2016 75
Ambient Air Pollution
• Ambient air pollution accounts for an
estimated 4.2 million deaths per year due to
stroke, heart disease, lung cancer, lung cancer,
acute and chronic respiratory diseases.
• Around 99% of the world’s population live in
places where air quality levels exceed WHO
limits.
• The major outdoor pollution sources include
residential energy for cooking and heating,
vehicles, power generation, agriculture/waste
incineration, and industry.

Source: https://www.pulmonologyadvisor.com/76
 Source: https://www.humanosphere.org/

• Household air pollution is one of the leading causes of disease and

premature death in the developing world.
• Exposure to smoke from cooking fires causes 3.8 million premature deaths
Household Air each year, mostly in low- and middle-income countries.
Pollution • Burning fuels such as dung 糞 , wood and coal in inefficient stoves or open
hearths 壁爐 produces a variety of health-damaging pollutants, including
particulate matter (PM), methane, carbon monoxide, polyaromatic
hydrocarbons (PAH) and volatile organic compounds (VOC).

77
Source: https://www.who.int/

• Safe and readily available water is important for public health, whether it is used for
drinking, domestic use, food production or recreational purposes.
• 2.2 billion people without safely managed services in 2017.
Drinking-water • Globally, at least 2 billion people use a drinking water source contaminated with
faeces.
• Contaminated water can transmit diseases such diarrhoea, cholera, dysentery 痢疾 ,
typhoid, and polio 小兒麻痹症.
• Contaminated drinking water is estimated to cause 485 000 diarrhoeal deaths each
year. 78
 • 74% of the world’s population (5.5 billion people) used at least a basic sanitation
service.
• 2 billion people still do not have basic sanitation facilities such as toilets or latrines.
• Of these, 673 million still defecate in the open, for example in street gutters街道排水溝,
behind bushes or into open bodies of water.
Sanitation And • Poor sanitation is believed to be the main cause in some 432 000 of these deaths.
Health • Diarrhoea remains a major killer but is largely preventable. Better water, sanitation, and
hygiene could prevent the deaths of 297 000 children aged under 5 years each year.
• Video for Preventing disease through healthy environments (2:00)
Source: https://www.who.int/ https://youtu.be/tupJDf13jBo
79