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Volume 7 (1); June 1985
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Original Articles
IUD-associated hospitalization after postpartum insertions in less-developed countries: a study of the host risk factors
I-cheng Chi, Sandra E Reid, Rebecca A Teeter, Susan M Rogers, Lynne R Wilkens
Korean J Epidemiol. 1985;7(1):143-145.
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A study on 10 major causes of death in Korea, 1980
Jae Yeon Kang, Sam Sup Choi
Korean J Epidemiol. 1985;7(1):133-142.
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To investigate the 10 major causes of death in Korea in 1980 by sex, age grouped and residential area among all death recorded on death registration form in Economic Planning Board, the 58,187 deaths diagnosed by doctors were classified in accordance with the Korean Standard Classifications of Diseases, Mortality List of 50 Causes. The results are as follows: 1) The 10 major causes of death in Korea were cerebrovascular disease, hypertensive disease, poisoning and toxic effects, malignant neoplasm of stomach, chronic liver disease and cirrhosis, tuberculosis, motor vehicle traffic accident, suicide, bronchitis emphysema and asthma, and pneumonia in that order. 2) The 10 major causes of death of male in Korea were cerebrovascular disease, hypertensive disease, poisoning and toxic effects, chronic liver disease and cirrhosis, malignant neoplasm of stomach, tuberculosis, motor vehicle traffic accident, suicide, bronchitis emphysema and asthma, and pneumonia in that order. 3) The 10 major causes of death of female in Korea were cerebrovascular disease, hypertensive disease, poisoning and toxic effects, malignant neoplasm of stomach, tuberculosis, suicide, chronic liver disease and cirrohosis, bronchitis emphysema and asthma, motor vehicle accident, and pneumonia in that order. 4) The 10 major causes of death of 0~14 age group in Korea were motor vehicle traffic accident, pneumonia, congenital anomalies, poisoning and toxic effects, meningitis, cerebrovascular disease, burns, tuberculosis, leukaemia, and bronchitis emphysema and asthma in that order. 5) The 10 major causes of 15~44 age group in Korea were poisoning and toxic effects, suicide, motor vehicle traffic accident, cerebrovascular disease, tuberculosis, chronic liver disease and cirrhosis, hypertensive disease, malignant neoplasm of stomach, nephritis nephrotic syndrome and nephrosis, and pneumonia in that order. 6) The 10 major causes of death of 45~64 age group in Korea were hypertensive disease, cerebrovascular disease, chronic liver disease and cirrhosis, malignant neoplasm of stomach, tuberculosis, poisoning and toxic effects, suicide, motor vehicle traffic accident, malignant neoplasm of trachea bronchus and lung, and diabetes mellitus in that order. 7) The 10 major causes of death of 65 and over age group in Korea were cerebrovascular disease, hypertensive disease, malignant neoplasm of stomach, bronchitis emphysema and asthma, chronic liver disease tand cirrhosis, uberculosis, pneumonia, poisoning and toxic effects, malignant neoplasm of trachea bronchus and lung, and diabetes mellitus in that order. 8) The 10 major causes of death in urban area were cerebrovascular disease, hypertensive disease, poisoning and toxic effects, malignant neoplasm of stomach, chronic liver disease and cirrhosis, tuberculosis, motor vehicle traffic accident, suicide, bronchitis emphysema and asthma, and pneumonia in that order. 9) The 10 major causes of death in rural area were cerebrovascular disease, poisoning and toxic effects, hypertensive disease, suicide, chronic liver disease and cirrhosis, malignant neoplasm of stomach, motor vehicle traffic accident, tuberculosis, bronchitis emphysema and asthma, and pneumonia in that order.
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Analytical studies of internal quality control status in clinical chemistry
Chang Kyou Lee
Korean J Epidemiol. 1985;7(1):125-132.
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An internal quality control status analysis some biochemistries tested in a University Hospital Laboratory, a participating member of the External Quality Control Program, but not maintaining the internal quality control program regularly. The test items were blood glucose, urea nitrogen and creatinine, and the period of collective data accumulated was from January to December of 1982. 1) The quality control status of blood glucose in months of August, September, October, November and December exceeded the allowable error of 4.95, and consequently, lowered its precision, though the accuracy was in the acceptable range. 2) The quality control status of urea nitrogen in months of January, August, September, October, and December exceeded the allowable error of 1.31, and therefore, the precision was unstable, and the accuracy was unsatisfactory because there was the constant error in the systematic error. 3) In creatinine test, it had shown unstable tendency in months of January, March, April, August, October, November and December exceeding the allowable error of 0.132, consequently, lowering the precision. Its accuracy, with the constant error in the systematic error, was also unsatisfactory. 4) The standards of the allowable errors of 3 chemistry items was established for the domestic reference. 5) Regressive order of the CV mean values were glucose (5.12%), urea nitrogen (7.80%), and creatinine (13.19%) respectively. 6) The results of tested items that fall out of acceptable range were 3 in August, October and December, 2 in January, September and November, 1 in March and April.
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A case-control study on the relationship between anemia and dietary factors among middle school children
Sug Yeong Lee, Joung Soon Kim
Korean J Epidemiol. 1985;7(1):106-124.
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This case-control study was carried out on anemia group (≤31% of Hct) and healthy control group (≥40% for male, ≥37% for female) selected from the middle school pupils in Korea as a part of the research “Physical and Mental Development of Korean Children in Relation to Family Formation Pattern” from march to July 1984. The objective of this study was to pursue risk factors of the anemia by estimating ∅(odds ratio), and by the dose-response relationship between major factors and ∅(estimated odds ratio), and by identifying the important variables through pear-son's correlation coefficient and multiple regression analysis on the variables which have been considered to effect on Hct value directly or indirectly. In this study, 47 pupils in case group were match with 94 students in control group. The matched variables were age, sex and school. The results summarized are as followings; 1) In comparison of two groups for the variables, such as the economic status, MB score, FD score, iron, vitamin A, thiamin, vitamin B12 and pantothenic acid, showed statistical significant difference, whereas the other variables revealed no difference between the case and control group. 2) Among the variables that showed statistical association with anemia, MB score, FD score, irno, protein, folate, vitamin B12, vitamin A also showed a significant dose-response relationship with the estimated relative risk ratio when the socioeconomic status was controlled. Therefore, anemia in this study group was largely due to iron-deficiency, folate and vitamin BI2 deficiency. 3) In addition, it was identified that iron was the most significant variable influencing Hct value directly, and food behavior and socioeconomic status influencing Hct value indirectly according to multiple regression analysis. —This study was partially supported by WHO, Special Programme of Research in Human Reproduction.—
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An evaluation study on the Korean national tuberculosis control program by literature reviews
Joung Soon Kim, Gill Han Bai, In Sook Lee
Korean J Epidemiol. 1985;7(1):59-105.
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The Korean national tuberculosis control program reduced the prevalence rate of tuberculosis from 5.1% in 1965 to 2.5% in 1980, for which many people including the responsible policy makers tend to think the tuberculosis is no more health problem to deal with seriously, and there has been an argument whether the program should be continued futher or not. At this crucial point of time this study was carried out in an attempt to evaluate the tuberculosis control program in terms of effort, performance, adequacy of performance, efficiency and process by reviewing all the available literatures relevant to the control program, particularly the national tuberculosis prevalence survey data collected every five-year from the 1965. Despite the long term effort to control tuberculosis as a priority national intervention program tuberculosis is still major health problem in Korea; currently the deaths due to tuberculosis count about 15,000 per year ranking 4th among all causes of death and tuberculosis patients count about 852,000 when projected the prevalence rate 2.5% of 1980 to the total population. Moreover only 340,000 (40%) patients out of 850,000 estimated patients have been identified and under the treatment, and that among these identified patients less than half would complete the full course of the treatment until they become free from the disease. Thus in summary one fifth of the patients estimated achieved ultimate goal of the program. Taking the reduction trend of death and prevalence rate of tuberculosis during last 15 years into account, it may take around 20 years to reduce the prevalence rate to 1% or under 1% even when the control program in current scale goes on. From the results of the study it is concluded that reinforcement of the control program is indispensable, reinforced budgetary and legal input. Detailed data used for the evaluation are presented in tables and some strategies to increase the efficiency of the program are discussed.
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An outbreak of Legionellosis (Pontiac fever) in ICU of K hospital, Korea
Joung Soon Kim, Sung Woo Lee, Han Soup Shim, Dae Kyu Oh, Min Kee Cho, Hee Bok Oh, Je Hong Woo, Yun Sop Chong
Korean J Epidemiol. 1985;7(1):44-58.
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Early in the morning of July 21,1984 three ICU patients out of eleven died within three hours, and also several medical as well as nursing staff working in ICU of K hospital became seriously ill. The hospital has about 500 beds and located in the middle of Seoul City with good reputation. The hospital started remodeling of the building from the middle of July with an extensive ground excavation to bury cables, particularly around the ICU. The hospital is furnished with central heating/cooling system but for some reason there was a box air-conditioning attached to the window facing to outside where the ground excavation was going on. An epidemiological investigation was carried out from July 25, 1984 in order to identify the entity of the outbreak by the governmental epidemiology team although the hospital insistingly incriminated the deaths of the ICU patients to their serious conditions and clustered occurrence of the illness among the staff to influenza-like croup. The epidemiologic investigation consisted of interview and blood collection for the ICU staff, medical record reviews for the deceased, and environmental survey of the hospital including the ICU. Also an additional study was conducted following the initial study from which legionellosis was suspected as the cause of the outbreak; the interview survey was extended to the entire nursing staff of the hospital, medical record review to all ICU patients and specimen collections for the agent isolation such as water collection from tap water, cooling tower of the central cooling system and the box air-conditioning, and dust from the ICU and its vicinities. Unfortunately, however, any autopsy of the deceased was not performed because they had been hurried already when the investigation started; also the effort of the team to collect blood specimen for the serological test from the ICU patients discharged and the entire nursing staff interviewed failed due to hospital’s reluctance for the additional study. Therefore the investigation had to rely upon the interview survey on the whole nursing staff in identifying the focus of exposure to the legionella and the serological test results on ICU staff only. In order to confirm the peculiarity of the outbreak to that particular place, ICU of K hospital, the ICU nursing staff of S hospital located in Seoul were also interviewed and serologically tested. The results of the epidemiological investigation summarized are as followings: 1) The clinical and epidemiological characteristics of the illness that had occurred among the ICU staff were so typical that there was no alternative to consider but non-pneumonic legionellosis (pontiac fever). 2) There were 23 legionellosis patients diagnosed clinically among 26 hospital staff who had been exposed to the ICU environment more than two hours during 32 hour-period between 08 hour of July 19, 1984 and 24 hour of July 20, 1984 ; the attack rate was 88.5%. 3) In serological test by means of IFA test on paired sera against antigens of fourteen serogroups, 14 person’s sera out of 19 reacted positively only against the antigen of L. gormanii. Two out of 14 clinical legionellosis reacted negatively, and two persons out of five healthy staff exposed showed positive results. Accordingly inapparent infection rate among positives of the serological test was 14.3%. The infection rate based on result of serological test among those who were exposed to the ICU during the estimated duration of Legionella contamination and serologically tested (17 persons) was 94% ; one nurse whose serological test revealed negative had serious and typical feature of legionellosis clinically. 4) The most frequent symptoms of the non-pneumonic legionellosis among serologically confirmed cases were fever (100%), malaise (92%), chills (83%), headache (83%), generalized myalgia (83%), and anorexia (83%). The duration of the illness was 2~3 days in most of the cases. 5) The expired three patients in the early morning, July 21, 1984 with admission diagnosis of bleeding gastric ulcer, liver cirrhosis and acute myocardial infarction had abnormal chest X-ray findings; one with increased density on RLL and two with pulmonary edema before the death. Among seven survivals who had been exposed to the ICU environment during the risk period five patients had revealed abnormal chest X-ray, two of them with definite pneumonia. 6) The duration of exposure to the Legionella contaminated environment estimated from the association between the disease occurrence and the time of exposure was most likely from around midnight of July 19 to that of July 20, 1984. 7) The incubation period that was estimated from the duration of exposure and onset time of the illness ranged from 20 hours to 42 hours. 8) The clinical pathological laboratory results between serology positives and negatives revealed no difference except the CBC; electrolyte, liver and kidney functions were all within normal limits, however, about the half the confirmed cases showed leucocytosis with relative increase of segmented white cells and lymphocytes. 9) The interview survey on clinical manifestation of the illness for all nursing staff of the hospital showed prominant clustering at a point of time only for the ICU staff, which, implies the occurrence of the legionellosis was peculiar to the ICU within the hospital. The interview and serological survey on the same illness during the same period for the ICU nursing staff of S hospital located in Seoul as a control yielded negative results of serological test against the L. gormanii. One of ten nurses, however, showed 1 : 128 antibody titer to L. pncumophila serogroup 1 suggesting there had been sporadic legionella infection in Korea although this is the first report on legionellosis outbreak in Korea. 10) The effort to isolate the legionella organism from water and dust specimens collected in ICU itself and its vicinities was failed; probably well-planned experiment such as aerosol exposure of guinea pigs with water from box airconditioner and the soil extract from the ground excavated might have produced positive results. 11) It was inferred that the source of ICU contamination by the Legionella could have been the box airconditioner attached to the window outside of which an extensive ground excavation was going on to bury cables; L. gormanii had been aspirated to the airconditioner, multiplied in the water of airconditioner, and aerosol sprayed into the ICU.
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Familial clustering of hepatitis B virus
Hyuk Han Kwon
Korean J Epidemiol. 1985;7(1):28-43.
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Abstract
The study of viral hepatitis type B has progressed much for the last decade, but the infection of hepatitis B virus is still prevalent all over the world. Especially in Korea, it is earnestly needed to study the immunology and epidemiology for HBV, to examine closely the cause for a familial clustering and to prevent it from spreading. Therefore the author sampled the students of 6 middle schools in Seoul from June 1984 till Septembre of the same year, measured the HBsAg with micro-Ouchterlony doubleimmuno diffusion modified method, and then detected HBsAg and anti-HBs in the serum by selecting families (total 898 persons) of 198 members (153 members of the HBsAg positive and 45 members of the HBsAg negative group) with the RPHA modified method. The results which were analyzed and compared with each other were as follows: 1. Familial clustering of HBV infection in the families which have chronic carriers (positive group) of Hepatitis B surface antigen (HBsAg). 1) The HBsAg positive rate of 701 family members of 153 carriers was 53.92%, higher than 3.05% of the control group, and the anti-HBs positive rate was 13.41% against 12.69% of the control group. But there was no significant difference statistically. The HBsAg positive rate (57.31%) of the families of female carriers was higher than that (50.01%) of the families of male carriers. The anti-HBs positive rate (15.65%) of the families of male carriers was higher than that (9.49%) of the families of female carriers. 2) The HBsAg positive rate in the parents (260 members) of carriers was 34.62%, and was significantly higher than that (2.78%) of the control group, but the anti-HBs positive rate was 16.92%, which was lower than that of the control group (19.44%). The HBsAg positive rate of parents in the case where the carrier was a son was 31.03%, and in the case where the carrier was a daughter showed higher value (41.68%). The HBsAg positive rate was significantly higher in the case of the mother (47.62%) than that in the case of the father (17.70%) and the anti-HBs positive rate was higher in the case of the father (23.89%) than that in the case of the mother(11.56%). 3) The HBsAg positive rate of the brothers and sisters of the carrier was 49.27%, which was higher than that of the control group (5.26%), and the anti-HBs positive rate was higher in the case group (17.52%) than that in the control group (9.21%). The HBsAg positive rate of the siblings was 59.06%, which was higher than that of the sisters (40.82%). The anti-HBs positive rate was 18.11% in the siblings and 17.01% in the sisters, which appeared to be similar. In the case of the male carriers, the HBsAg positive rate (61.97%) was significantly higher in their siblings (homosexual) than that (38.30%) in their sisters (heterosexual). But in the case of the female carriers, it (55.30%) was a little higher in the siblings (heterosexual) than that (45.28%) in their sisters (homosexual), which was statistically insignificant. 4) In the case of the grand parents of carriers, there was no HBsAg positive and the anti-HBs positive rate was 7.14%, But it was statistically insignificant because of the small sample cases. 2. In the sample cases (107) where parents of carriers existed, the cases where both of the parents were HBsAg positive was 8.41%, and the HBsAg positive rate was significantly higher in the case of the mother (50.47%) than that in the case of the father (17.76%). The anti-HBs positive rate was 2.80% in the case where both of the parents were positive, and the anti-HBs positive rate was significantly higher in the case of the father (24.30%) than that in the case of the mother (13.08%). 3. When the HBsAg positive rates were classified according to the number of family members, the case where all of the family members were HBsAg positive rate was 54.54% in the 2 member family group, 26.67% in the 3 member family group, 18.60% in the 4 member family group, and was 6.12% in the 5 member family group. In the family group of 6 members, the case where only 5 members in the family were HBsAg positive rate 17.86%, and in the family group of 7 members, the case where only 6 members in the family were HBsAg positive rate was 14.29%. The smaller the number of family members, the larger the probability that all family members are HBsAg positive. 4. HBsAg positive rates in relation to the related factors including liver diseases. 1) The HBsAg positive rate of members in the case where someone of their family died of liver disease was significantly higher (77.27%) than that (50.50%) in the counter case. When the causes of death were classified according to their frequencies, they were shown to be hepatoma, liver cirrhosis, and hepatitis in descending order. 2) HBsAg positive rate of the group whose members had experienced liver disease was 51.72%, and that of the counter group was 53.80%. There was no significant difference between the two groups. 3) HBsAg positive rate of the group whose members had experienced blood transfusion was 51.72% and that of the counter group was 53.80%. There was no significant difference between the two groups. 4) HBsAg positive rate of the group whose members had experience hospitalization or medical operation was 52.40% and that of the counter group was 34.44%. There was no significant difference between the two groups. 5) HBsAg positive rate of the group whose members experienced other diseases excepting liver diseases at that time was significantly higher (58.72%) than that of the counter group (50.00%). 6) HBsAg positive rate of the group whose members thought themselves healthy at that time was 54.48%, that of the group whose members thought themselves normal was 51.60%, and that of the group whose members thought themselves weak was 50.00%. But there was no significant difference among the groups. 5. HBsAg positive rates in relation to human living environment and related factors. 1) HBsAg positive rate of the group whose members owned house was 56.19%, that of the group whose members leased house on a deposit basis was 51.50%, and that of the group whose members leased house on a monthly rent basis was 45.90%. There was significant difference among these groups. 2) HBsAg positive rate of the group whose members used a single room by themselves was the highest (66.25%), and that of the group whose members used one room with other 4 persons was the lowest (45.00%). But there was no significant difference between the two groups. 3) HBsAg positive rate of the group whose members lived in 4 household houses was the highest (65.52%), and the group whose members lived in 6 household houses was the lowest (36.67%). But there was no statistically significant difference. 4) HBsAg positive rate of the group whose members used pump water as drinking water was 72.73%, that of the group whose members used well water was 63.16%, and that of the group whose members used tap water was 52.28%. But there was no statistically significant difference. 5) HBsAg positive rate of the group whose members used flush toilets was 55.42%, and that of the group whose members used conventional toilets was 51.13%. But there was no statistically significant difference. 6) In relation to religion, HBsAg positive rate of the Catholic group was the highest (58.33%), and Buddhist group was the lowest (45.58%). But there was no statistically significant difference. 6. The frequency that both the HBsAg and anti-HBs were detected in the same person was about 1%, which was detected in only 7 members among 701 members.
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An epidemiological study on HBsAg and anti-HBs prevalence in relation to liver function tests among farmers in Korea
Joung Soon Kim, Won Young Lee, S.W Lee, Hee Sup Yoon, Sook Ja Yang, D.H Lee, H.C. Kim
Korean J Epidemiol. 1985;7(1):16-27.
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Abstract
This study was carried out in a rural area for the adult population older than 20 years of age to find out the prevalence of HBsAg and Anti-HBs among the population, and particularly the relationship between the presence of HBsAg and liver function tests during November 1984. Six hundred fourteen persons were interviewed according to structured questionnaire, examined by physician, and blood was drawn for the tests. For the detection of HBsAg and Anti-HBs Eliza method was used. The liver function test including SGOT, SGPT, alkaline phosphatase, total bilirubin and albumin was done in an university hospital laboratory of clinical pathology. The results summarized are as followings: 1. The prevalence rate of HBsAg positive was 13.0% and Anti-HBs positive was 43.6% among the population studied. The age adjusted positive rate by sex showed higher rate in males(14.6%) than females(12.7%) for HBsAg, whereas the positive rate was higher in females than males for anti-HBs although these differences by sex were not statistically significant (p〉0.05). 2. The age specific positive rate for both HBsAg and anti-HBs revealed peaks on 30~39 yrs. age group even though the Anti-HBs showed a slight increase for the age group older than 60 years. 3. The HBsAg positive rate was the highest (17.6%) among simple labourers accompanied by the highest positive rate of anti-HBs (58.8%) and then farmers, sales worker, clerical workers showed higher positive rate in order when the positive rates were compared by occupation. Also the lower socioeconomic class revealed higher positive rate. 4. The positive rates of both HBsAg and Anti-HBs were not different statistically between alcohol drinkers and non-drinkers, cigarette smokers and non-smokers, and the group with past history of liver disease and that without the history. 5. The HBsAg positive group when compared with HBsAg and Anti-HBs negative group showed 1.9 times more in family history of liver disease, 1.5 times in surgical operation, 1.4 times in blood transfusion. 6. The abnormal liver function test was found to be much more frequent among persons with past or present history of liver disease than those without; 84.2% versus 17.9%. By each item of the liver function test the HBsAg positive group had 1.6 times more abnormal value of bilirubin, 1.3 times of SGPT, and 1.2 times of SGPT than those who were negative for both HBsAg and Anti-HBs. The SGOT/SGPT ratio was not statistically different between two groups HBsAg positive and negative.
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A study on hepatitis B virus markers and formation of anti-HBs after hepatitis B vaccination in healthy Korean population
Young Sik Kim, Joung Soon Kim, Bong Yul Huh
Korean J Epidemiol. 1985;7(1):8-15.
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Abstract
The positive rate of Hepatits B Virus markers and Anti-HBs formation after Hepatitis B-Vaccination were studied by RPHA or RIA technique in 1,015 (male 502, female 513) healthy Koreans, from May 1983 to April 1985 at the Department of Family Medicine, Seoul National University Hospital. And the following results were obtained; 1) The HBsAg was detected in 92 among 1,015 with positive rate of 9.0%. The positive rate of HBsAg was higher in male (11.8%) than in female (6.4%) 2) The positive rate of Anti-HBs was 27.7% (289/1,015) and difference between sexes was insignificant. 3) The positive rate of one or more markers among HBsAg, Anti-HBc, Anti-HBs was 57.6% (345/599). 4) The positive rate of HBeAg among HBsAg positives was 47.6% (20/42). 5) Elevated SGOT(>25 IU/L) or SGPT (>29 IU/l) was significantly higher in HBsAg positives (15.2%) than that of Anti-HBs positives (3.9%) and both negatives (2.6%). 6) The Anti-HBs became positive in 72.9% (70/96) of the vaccinated group and 7.7% (2/26) of the unvaccinated control group according to the 21-raonth follow-up test. 7) After 7.9 months follow up, the positive rate of HBsAg among initial HBsAg positives was 89.2% (33/37), and two cases of HBsAg positives developed acute viral hepatitis and improved, and the other two cases were revealed chronic hepatitis clinically.
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Controversy
Controversies in epidemiology: matching in case-control studies
Kwang Ho Meng
Korean J Epidemiol. 1985;7(1):4-7.
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Abstract
During the last decades, the scholarly development and empirical findings of epidemiology have contributed immensely to the understanding of a range of diseases. It goes without saying that this growth has been driven by the development and utilization of highly advanced study design methods with diverse goals. However, most epidemiological findings and study designs are subject to different analyses and/or conclusions due to the size or diverse characteristics of the samples, as well as problems inherent to the accuracy and reliability of all study designs. Although some of these controversies involve subjective bias on the part of researchers, most of them reflect legitimate differences in academic viewpoints, and thus may be of particular interest and utility to scholars in the field of epidemiology. In this paper, the opposing views in some epidemiological controversies will be introduced and their progress will be reviewed, in order to provide better insights into epidemiology for those who wish to obtain a deeper understanding of this field.
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Special edition
Current issues in epidemiology
Abdel R. Omran
Korean J Epidemiol. 1985;7(1):1-3.
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Abstract
Current issues of epidemiology are a reflection of its continuing interface with other sciences, and expanding of its frontiers. But the more epidemiology changes, the more it remains the same. From a descriptive beginnings in the old civilizations, to reflective functions in the Greek period, to the evolution of a theory of contagion by the Arabs in the 10th~14th centries to the suppression of the theory and its replacement by the miasma hypothesis in the Dark ages, all the way to the brilliant epidemiologic work by Snow, Panum, Budd, Pateur and Koch. Thence more rigorous interface with other sciences occurred. With biostatistics analytical techniques evolved including cohort analysis, life table approach, survival analysis, risk analysis, multivariate analysis and use of models and, of course, the development of the case-control approach. With social sciences there were interactions between threats to internal validity and bias, the expansion of experimental designs and their use in clinical trials, the use of qualitative methods, and, by interface with behavioral sciences, other study facets evolved such as acceptability and compliance. With, demography, a new area of emphases was established namely population epidemiology including the theory of epidemiologic transition, family formation patterns and health, the child survival hypothesis and forecasting patterns of health and disease. Finally, by interface with management and administrative science and operations research thence evolved the area of operational epidemiology and health science research. The challenges to epidemiology will never wane and epidemiologists will always find ways of meeting these challenges and going even beyond them.
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Epidemiol Health : Epidemiology and Health