CPH 201 - Introduction to Public Health
CPH 201 - Introduction to Public Health CPH 201
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Monday August 31 2015 Public Health Science Politics and Preventions Public Health Science Politics and Preventions What is Public Health The science and art of preventing disease prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment the control of community infections the education of the individual in principles of personal hygiene the organization of the medical and nursing services for the early diagnosis and preventative treatment of disease and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health Charles Edward A Winslow a theoretician and leader of American public health during the first half of the 20th Century Three core functions of public health 1 Assessment The diagnostic function in which a public health agency collects assembles analyzes and makes available information on the health of the population 2 Policy Development The use of scientific knowledge to development a static approach to improving the community s health 3 Assurance Public Health has the responsibility of assuming that the services needed for the protection of public health in the community are available and accessible to everyone The Ten Essential Public Health Services Assessment 1 Monitor health status to identify community health problems 2 Diagnose and investigate health problems and health hazards in the community Policy Development 3 Inform educate and empower people about health issues 4 Mobilize community partnerships to identify and solve health problems Monday August 31 2015 5 Develop policies and plans that support individual and community health efforts Assurance 6 Enforce laws and regulations that protect health and ensure safety 7 Link people to needed personal health services and assure the provision of health care when otherwise unavailable 8 Assure a competent public health and personal healthcare workforce 9 Evaluate effectiveness accessibility and quality of personal and populationbased health services Serving All Functions 10 Research for new insights and innovative solutions to health problems Public Health Versus Medical Care Medical care is focused on an individual patient while public health is concerned for a whole community as its patient Medical care focuses on healing patients who are ill public health focuses on preventing the disease Effective public health programs save money on medical costs in addition to saving lives We can see this in the rise in life expectancy thanks to increases public health efforts Public Health has a focus in environmental health and social and behavioral sciences Social and behavioral includes studies in how moderne societies are dying of diseases caused by their behavior and the social environment Ex Heart Disease Obesity Prevention and Intervention Public health s approach to health problems in a community Step 1 Define the health problem Step 2 Identify the risk factors associates with the problem Monday August 31 2015 Step 3 Develop and test communitylevel interventions to control or prevent the cause of the problem Step 4 Implement interventions to improve the health os the population Step 5 Monitor those interventions to access their effectiveness Epidemiology Basic study of public health study of epidemics aims to control spread of infectious diseases seeks causes of chronic disease and ways to limit harmful exposures Statistics Collection of data on the population these numbers are diagnostic tools for the health of the community the science of statistics is used to calculate risks and benefits Biomedical Sciences CDC Infectious diseases pathogens Chronic diseases gene cs Environmental Health Science Health effects of environmental exposure airquality waterquality solid and hazardous wastes Monday August 31 2015 Safe food and drugs global environmental change Social and Behavioral Sciences Behavior is now the leading factor in affecting people s health Theories of health behavior social environment affects people s behavior Major health threats tobacco poor diet and physical inactivity injuries Maternal and child health a social issue Health Policy and Management role of medical care in public health cost of medical care in US is out of control US still has a percentage of population without health insurance quality of medical care can be measured and os often questionable Three Levels of Prevention Primary Prevention Prevents an illness or injury from occurring at all by preventing exposure to risk factors Ex vaccinations drunk driving laws child safety lids Secondary Prevention Seeks to minimize the severity of the illness or the damage due to an injury causing event once the event has occurred Ex seatbelt laws road median barriers mammograms motorcycle helmet laws Tertiary Prevention Seeks to minimize disability by providing medical care and rehabilitation services Ex PTOT facilities cancer centers ambulance Monday August 31 2015 Chain of Causation H031 Hon Agent Environment Vector not required 1 190M o o nnronmont o Example Malaria Agent virus so you kill all of the mosquitos Host person at risk Environment outside in a mosquito invested area Vector the living mosquito that moves the agent to the host Public Health and Terrorism Events of the 911 and the anthrax letters highlighted the importance of public health The public Health Response to disasters both natural and manmade helps to control the damage and prevent further harm to survivors and rescuers bioterrorism is recognized primarily through classical public health measures similar to those used in natural epidemics Wednesday September 2 2015 Why is Public Health Controversial Why is Public Health Controversial Mission of Public Health as defined by the Institute of Medicine report The Future of Public Health Fulfilling society s interest in assuring conditions in which people can be healthy Early History of Public Health Closely tied to social reform movements sanitary science public hygiene 19th century reformers moved for improved housing trade unions the abolition of child labor maternal and child health and temperance whole populations mobilized for the great war against preventable disease Winslow Public Health as a Broad Social Movement public health should be a way of doing justice a way of asserting the value and priority of all human life Dan E Beauchamp a noted public health philosopher Market Justice powerful forces of environment heredity and social structure prevent a fair distribution of of the burdens and benefits of society Fundamental right to be left alone Social Justice suggests that that minimal levels of income basic housing employment education and health care should be seen as fundamental rights Conservatives favor a more limited approach to public health concerned about government encroachment on their economic and professional independence 1930s and 1940s physicians use their political power to limit federal health funding most were locally run health depts focused on child health venereal disease control tuberculosis and dental health 1960s concerns were voiced about health threats from environment pollution were addressed independently Social problems such as homelessness drug abuse and violence were not thought of as public health problems despite their adverse health consequences 1988 Institute of Medicine declared Public Health in disarray Wednesday September 2 2015 Ideas that the government has an obligation to provide healthy conditions for citizens who are unable to do so for themselves provide healthcare has been attacked as socialist Three Issues in Public Health debates economic libertarian moral Thursday September 3 2015 Powers and Responsibilities of Government Powers and Responsibilities of Government Federal Versus State Authority For the most part public health has been a responsibility of the state Health is mentioned nowhere in the constitution therefore making matters of public health a state delegated power State Laws include Mandates to collect data about population to immunize children before they enter school to regulate environment for sanitation purposes to regulate safety Other public heath matters may be delegated to smaller local governments The interstate commerce provision gives the power to the FDA Food and Drug Administration to monitor products that are distributed across state lines This way the producers only have to comply with one set of guidelines rather than 50 different state administrations Motorcycle Example Federal Government mandates that any state that wanted highway construction funds must mandate that all motorcycle drivers must wear a helmet motorcycle related deaths plummeted When the offer was taken back states removed the law and death rates rose again How the Law Works Its hard for the government to draw a line between public health policys that are okay and those that violate the rights of the citizens to make their own decisions regarding their health There are many Health Departments that are either state or local that help delegate some of these policies Thursday September 10 2015 Chapter 4 Epidemiology The Basic Science of Public Health John Snow Father of Modern Epidemiology Conducted epidemiological research on a rise in cases of Cholera in London 1848 concluded that the disease was being spread through drinking water polluted with sewage from two water sources Epidemic an increase in the frequency of a disease above the usual and expected rate Epidemiologic Surveillance the requirement of certain notifiable diseases to be reported as soon as they are diagnosed in order to prevent or recognize an epidemic before it becomes out of control Typical Epidemiologic Investigation Hepatitis Outbreak Notifiable Disease in all 50 states because it is caused by a virus that contaminates food or water Incubation period of 30 days Virus traced back to a single source such as a restaurant where all of the patients had eaten ionnaires Disease July 1976 Philadelphia Pennsylvania 4day convention at Hotel Bellevue Stratford 150 cases 20 deaths by early August Was concluded that the source of the disease was a bacteria thriving in the water cooling tower of the airconditioning system Cases were reported all over the US New Federal AirConditioning standards were mandated Eosinophilia Myalgia Syndrome First reported in New Mexico by patients reporting high while blood cell counts eosinophils Thursday September 10 2015 All patients reported using the natural drug Ltryptophan a component of proteins that had been publicized as treatment for insomnia depression and premenstrual symptoms New cases were found all over the US Tests on the recalled tablets indicated a toxic contaminant formed as a result of a recent change in one factory s method of production Epidemiology and the Causes of Chronic Diseases Studies have been done that evaluate risk factors for diseases that develop over time with no known vaccine or prevention method Heart Disease Framingham Study After WW2 in 1948 over 5000 healthy people were examined and data was recorded on their weight blood pressure smoking habits various blood tests and other characteristics The patients were reexamined ever 2 years for the rest for their lives In only 10 years it was found that high blood pressure high cholesterol and smoking significantly increased their risk of heart disease Results caused many people to change their eating exercise and smoking habits Rates in the contraction of heart disease decreased dramatically Framingham Offspring Study launched in 1971 included about 5000 of the original participant s children More advanced technology was used to examine them and genetic factors were evaluated as well New studies including the grandchildren of the participants have begun as well Lung Cancer In 1950 and 1952 2 major epidemiological studies were conducted by British Epidemiologists Richard Doll and A Bradford Hill that directly linked lung cancer to smoking Death rates from lung cancer was 20 times higher among smokers than nonsmokers The death rate among exsmokers was lower than that of smokers and declined as the length of time increased since the patient had quit smoking Similar study in the US done by E Cuyler Hammond and Daniel Horn concluded that cigarette smokers were 10 times more likely to die of lung cancer than nonsmokers Thursday September 10 2015 Smokers were also 5 times more likely to die of cancer of the lip tongue mouth pharynx larynx and esophagus than nonsmokers Doctors involved in both studies quit smoking during the study In the 20 years that the studies were ongoing the average number of cigarettes smoked per day by the physicians was less than half of what it was at the beginning Thursday September 10 2015 Ecological Principle and Methods Epidemiological Principles and Methods Epidemiology the study of the distribution and determinants of disease frequency in human populations Frequency study of the number of cases and their relation to the size of the population being studied yielding a rate In calculating a rate the denominator is generally the population at risk Number of cases total population at risk Incidence Rates the rate of new cases of a disease in a defined population over a defined period of time Measures the probability that a healthy person in the population will develop the disease during that time Useful in identifying the cause of a disease Prevalence Rates the total number of cases existing in a defined population at a specific time Measured by doing a survey Related to incidence rates but the relationship depends on how long people live with the disease Low prevalence if people recover quickly or die quickly from the disease Much higher for chronic diseases arthritis Changes slowly not useful for epidemiological studies Death Mortality Rate the incidence of death used as a measure of frequency for diseases that are usually lethal Death rates and incidence rates are close for extremely lethal diseases such as pancreatic cancer Distribution is comprised of the answers to the who when and where questions Who characterizes disease victims by factors such as age sex race and economic status When looks for trends in disease frequency over time is incidence increasing decreasing or remaining stable Crucial in tracking an outbreak Where looks at comparisons of disease frequency in different countries states counties or other geographical divisions Thus giving clues about the determinants of the disease Thursday September 10 2015 Kinds of Epidemiological Studies Intervention Studies Usually done to test a new treatment for a disease One group is exposed to the intervention while the control group is not exposed They are observed to see if the treatment is effective or harmful Sometimes the control group is given a placebo an inactive substance similar in appearance to the drug or vaccine being tested Subjects do not know if they were exposed to the treatment Up to 13 of placebo subjects respond to the inactive substance placebo effect If the drug being test is more successful than the placebo then it is considered e ec ve Randomized double blind clinical trials neither the doctor nor the completely random patients know whether the real drug or the placebo was administered Therapeutic Trial both the experimental and control group are composed of patients who have the disease for which the drug is being tested Cohort Studies Investigators link exposures to results by observation alone without actively intervening in the lives of the study subjects Large numbers of healthy individuals are questioned concerning their exposures They are observed over a period of time to determine whether or not those exposed are more likely to develop the disease than those who were not exposed Ex Framingham Heart Study DollHill and HammondHorn studies of smoking and lung cancer Case Control Studies Start with people who are ill with the disease and look back to determine their exposure More efficient than cohort studies because they focus on a smaller amount of people and can be done relatively quickly Investigator asks all participants the same questions in order to determine the exposure in a common factor between the participants Thursday September 17 2015 Statistics Making Sense of Uncertainty Statistics Making Sense of Uncertainty The Science of Epidemiology rests on statistics All of public health relies on statistics to provide and interpret data What is statistics The numbers that describe the health of the population The science used to interpret these numbers The science of statistics is a set of concepts and methods used to analyze data in order to extract information Statistics makes possible the translation of data into information about causes and effects heath risks and disease cures Health is determined by many factors genes behavior exposure to infectious organisms or environmental chemicals interacting in in complex ways with each individual so it is often not obvious when or whether specific factors are causing specific health effects Ethical and logistical limits to the kinds of studies that can be conducted on human populations there are also limits to the conclusions that can be drawn from biomedical studies on animals Statistics sometimes indicate that a health effect is simply a random occurrence The Uncertainty of Science Most science is of a probable nature Science in ongoing studies may contradict each other Thursday September 17 2015 The science of statistics can quantify the degree of uncertainty Example When to screen for Breast Cancer While we do have a considerable amount of data from which we can draw many conclusions science does not always provide us with the degree of certainty necessary to say that something will definitely happen or not happen Contradictory results from epidemiological studies are very common sources include bias and confounding Probability The probable is what usually happens Aristotle Statisticians know that the improbable happens more often then most people think BUT The most improbable things are bound to happen occasionally Pvalue ps005 is usually taken to mean a result is statistically significant However when p005 there is still a 5 chance that the result is wrong Confidence interval a range of values within which the true result probably falls o The narrower the confidence interval the lower the likelihood of random error Bias or confounding data Law of small probabilities The most improbable things are bound to happen occasionally throwing heads 99 times terminal patients recover many people randomly contract a disease Power of a study The probability of finding an effect if there is in fact an effect The larger the sample size the greater the power p value expresses the probability that the result could have occurred by chance alone Thursday September 17 2015 The Statistics of Screening Tests Examples of screening Mammography for breast cancer HIV test Newborn screening The best public health measure is to screen the population at risk so as to detect the disease early when it is most treatable Ale and HIV patients can be counseled as how how not to spread the disease Babies can be screened and diagnosed before any permanent damage is done Sensitivity vs Specificity Highly Sensitive yield few false negatives Highly Specific yield few false positives Sensitive tests are desirable in order to avoid missing any individual with a serious disease who could be helped by some intervention Specific Tests can be used to make sure the sensitive test was accurate Sensitive Test Example If it is not human and lives in your house it is a dog False Positive it could be a cat Specific Test Example If it lives in your house walks on four legs has fur and barks it is a dog False Negative you could have a three legged dog false positives vs false negatives When testing for rare conditions false positives may be as high or higher than the number of true positives lead times bias and over diagnosis bias Lead Time Bias occurs when increased survival time after diagnosis is counted as an indicator of success Overdiagnosis Bias occurs when the tumors that are detected by the screening are not likely to progress to the stage that they cause symptoms and be lifethreatening Thursday September 17 2015 The only way to be sure that screening actually saves lives is to conducts a randomized control trails comparing mortality among patients who are screened with that of patients who are not screened Studies with low power are likely to produce false negative results to find a result even when there is not one False positive results occur when the study finds an effect that is not real when a random variation appears to be a true effect Rates Relate the raw numbers to size of population Birth rates Number of live births per 1000 people Mortality rates Generally expressed as deaths per 1000 people Crude rates Regular rates per 100 people Adjusted rates Eg age adjusted Florida vs Alaska Mortality Rates Rates may also be adjusted for other relevant to health such as gender race ethnicity and so forth EX males have a higher mortality rates at all ages than females it may be useful to calculate a genderadjusted mortality rate for a population that has a higher proportion than average Group specific rates Eg gender specific males alone or females alone This would inform us that males have a higher mortality rate than females in the same age group or that black have a higher mortality rate than whites of the same gender and age Thursday September 17 2015 Years of potential life lost YPLL Eg Accidents cancer heart disease Gives weight to the deaths of young people appropriate to the priorities of public health which has the goal not of eliminating death entirely but of enabling people to live out their natural lifespan with a minimum of illness and disability Risk Assessment and Risk Perception For wellknown risks can be calculated from historical data Motor vehicle accident trends can be calculated based on the numbers the previous year either increasing or decreasing depending on the trend from previous years Risks that contain chemicals cause cancer in humans are usually estimated by analogy with data obtained from animal studies For poorly understood risks must make many assumptions Various possible chains of events are considered and a risk is calculated for each step that something could go wrong during then added to calculate the risk for the whole Risk perception involves psychological factors The public s perception of a risk proves to be more accurate than original thought People s concern about a risks affected by pertaining associate factors Familiar risks are more acceptable than those that are not familiar Risks that people believe they have control over are more acceptable Risks with catastrophic results is less acceptable even though it is highly unlikely to occur o Examples driving in cars flying in planes nuclear power youth smoking Cost Benefit Analysis Costs are easier to calculate than benefits Estimated cost of implementing a policy against the estimated benefit Thursday September 17 2015 What monetary value can we put on a life saved often calculated by the cost of the policy vs the cost of care if the policy is not implemented Often controversial Costeffectiveness analysis efficiency of different methods of attaining the same objective Monday September 28 2015 Chapter 8 The Role of Data in Public Health Why do we need data to assess the health of a community as raw material for research Vital Statistics Local Records Birth certificates Filed with the local registrar by the attendant contains information about the child such as the child s family including names addresses ages race and ethnicity and education levels Medical information is supplied by the hospital doctor or other birth attendant concerning prenatal care birth weight medical risk factors complication of labor and delivery obstetrical procedures and abnormalities Main use is public health research providing data that can be used to relate features of the mother and her pregnancy to the health of the child Death certificates Subject to many uncertainties Includes information on parents education occupation circumstances of the death autopsy report Notifiable Diseases Other vital statistics marriages divorces spontaneous fetal deaths and abortions Transmitted from local governments to states Transmitted from State Governments to the National Center for Health Statistics NCHS part of the CDC Monday September 28 2015 The Census Serves as denominator for most public health data Age sex race ethnicity Conducted every 10 years Every American must be counted no statistical corrections allowed Short form vs long form American Community Survey ACS began in 2005 More intrusive done in between censuses to gather more information after the short form was used for the nation census done in between on an ongoing basis Education housing health insurance Is there too much data Never How can we make an assessment of our nation s health without data How would we know our areas of concern How do we know if disparities exist How do we know an epidemic is beginning Confidentialitv Governments have safeguards to protect individual Use of data may involve removal of identifying information on individuals Use of data requires institutional review boards or data protection committees Exception when people must be notified that they have been exposed to a communicable disease HIV used to be an exception to the exception Monday September 28 2015 Accuracy The government is very keen on amassing statistics They collect them add them raise them to the nth power take the cube root and prepare wonderful diagrams But you must never forget that every one of those figures comes in the instance from a village watchman who just puts down what he damn well pleases Sir Josiah Stamp 1929 Data collection is imperfect Census there are over counts and undercounts Information technology increases accuracy and availability All scientific research is based on probabilities and even the least probable thing sometimes happens Monday September 28 2015 Chapter 9 The Conquest of Infectious Diseases Bubonic Plague Wiped out 75 of of the population of Europe and Asia 14th Century Tuberculosis 1 killer in England in 19th century Small Pox and Cholera o swept through NYC every few years killing many people in the mid 19th Century Many diseases were largely conquered through purification of water proper disposal of sewage pasteurization of milk immunizations the discovery and introduction of antibiotics in the 1940s By the 19603 infectious diseases were just a minor nuisance Infectious Agents Epidemic diseases are caused by bacteria viruses or parasites 18803 established that each type of disease is caused by a specific microbe Robert Koch German Physician developed techniques to classify bacteria by their shape and their propensity to be stained by various dyes Koch s Postulates 1 The organism must be present in every case of the disease 2 The organism much be isolated and grown in the laboratory 3 When injected with the laboratorygrown culture susceptible test animals must develop the disease Monday September 28 2015 4 The organism must be isolated from the newly infected animals and the process repeated identified the bacteria responsible for tuberculosis cholera Types of Bacteria Bacilli rod shaped vibrio cholera cause of cholera Cocci round shaped streptococci cause of strep throat and scarlet fever staphylococci cause of staph infections pneumococci cause of pneumonia Spirochete spiral shaped Cause of syphilis 1935 American Scientist W M Stanley crystalized tobacco mosaic virus nature of viruses discovered Undetectable and deemed filterable agents before this point Virus complexes of nucleic acid and protein that lack the machinery to reproduce themselves Infect animal and plant hosts Able to survive in very extreme conditions such as treatment with alcohol and drying with a vacuum and become active again when they are injected into a living cell Reproduce by taking over a living cell often killing the cell in the process Human diseases include small pox yellow fever polio hepatitis influenza measles rabies and AIDS as well as the common cold Human Diseases can also be caused by protozoa singlecelled animals that can live as parasites in the human body Examples include Malaria spread by mosquitos Cryptospiridiosis the cause of the Milwaukee diarrhea epidemic Giardiasis beaver fever Monday September 28 2015 Types of Parasites Roundworm round shape Hookworm hook shaped Pinworm long push pin shaped only one still common in the US Tapeworm circle shaped Means of Transportation Diseases spread in a variety of ways directly from one person to another or indirectly by way of water food or vectors such as insects or animals Bacterias and viruses that cause respiratory infections colds influenza tuberculosis transmitted through aerosols water droplets produced when an infected person sneezes or coughs indirectly through objects touched by an infected person transferred from object to hand to nose Smallpox given to native americans by blankets from European settlers Gastrointestinal infections cholera cryptospridiosis diphtheria are transmitted by the fecaloral route fecal matter from an infected person reaches the mouth of an uninfected person because of poor hygiene or sanitation Vectorborn diseases malaria yellow fever and West Nile encephalitis use a complex route such as an insect Every disease has its own pattern of transmission after a person is infected including a set time that the person is contagious Some diseases can spread even when the person is not showing symptoms Typhoid Mary Linn v Ly Chain of Infection 5 0 Famine 1 Pathogen virus bacterium parasite that causes the 345 be Hui disease In humans 35227 W 39J393939 Mquot quotUquot MT 2 Reservorr The place where the pathogen lives and 3153 m multiplies some spread directly and have no reservoir Example Rats are the reservoir for the plague 3 Method of transmission Example Food insect vectors I H 3931 399 aerosol sexual contact 313 m 3913 as fluxu mnclw gnu 1 cu Jlly PM 5 n quotnag1 newtw 4 Susceptible host A host without immunity to the pathogen Example a person not vaccinated for chicken 420 I T 151517 gin vttn Lc39faJ Van Monday September 28 2015 pox will contract chicken pox when exposed Public Health measures to control the spread of disease are aimed at interrupting the chain of infection at whichever links are most vulnerable Measures to control the spread of disease may be routine prevention measures or emergency measures to control an outbreak once it has begun Surveillance is used to watch disease threats so that public health practitioners may step up when it becomes a problem Common responses include immunization medical treatment and quarantine in extreme cases Contact tracing often used in sexually transmitted disease to find out who is infected who infected them and so on and discretely alerting those potentially infected m Fatal disease of the nervous system caused by a virus Kills an estimated 55000 people around the world each year Usually contracted through a dog bite Vaccine available but not recommended for everyone Rabies only infects mammals Bats are the most dangerous rabies threat to humans because they are nocturnal and very elusive The rabies surveillance system is very effective Smallpox Measles and Polio Small Pox One of public health s greatest victories Feared disease that is believed to have first emerged in Asia at the time of Christ and tended to spread in major epidemics that claimed millions of lives in China Japan the Roman Empire Europe and the Americas Highly contagious transmitteed through aerosols or touch Concept of vaccination originated with small pox Monday September 28 2015 1796 practice of immunization was less dangerous when British physician Edward Jenner proved that inoculation with cowpox matter which was harmless to humans provided immunity against small pox 1958 routine immuniztion eliminated small pox in the United States and other industrialized countries 19671977 teams traveled all over the world vaccinating for small pox Small pox only exists in 2 places currently stored in laboratories in the CDC and in a Russian laboratory in Siberia There was fear that the Soviet Union had been working on smallpox as a bioweapon m lnfects humans only Has the potential to be eradicated 1988 350000 children were being paralyzed each year WHO set a goal of eradicating polio by 2000 Only Southern Asia and SubSaharan Africa still have a significant incidence of polio there were thoughts that the vaccine had been contaminated with AIDS or infertility among Muslims in 2003 Harder to eradicate because there are invisible cases the vaccine must be administered multiple times in order to be effective Measles Viral disease that could be eradicated Before the vaccine was available almost all children contracted measles causing 400500 health s a year in the US and 1000 cases of chronic disability from measles encephalitis 1963 vaccine becomes available number of cases drops 1978 US Department of Health and Human Services sets goal to eradicate disease in the US by 1982 It was found that the immunity wears off during infancy so it is necessary that children be vaccinated between the ages of 46 Too many children were being vaccinated too late Monday September 28 2015 Surveillance system was doing poorly 1991 study in NYC found that up to 50 of cases were not being reported Public Health officials hoped to set their sights on measles after the eradication of polio Fear of Vaccination Parental and Religious concerns often stop people from vaccinating their children Monday September 28 2015 Chapter 10 The Resurgence of Infectious Diseases Appearance of AIDS in the early 19803 antibiotic resistance and the popping up of other diseases were making people question the belief that infectious diseases were underconUoL The Biomedical Basis of AIDS Turn of the 21 st Century disease striking only gay men turned into a worldwide scourge HIV now infects over 33 million people and kills almost 2 million a year Retrovirus a virus that used RNA as its genetic material instead of DNA RNA infects cells by copying their RNA into the DNA of the host cell penetrating the genetic material like a mole The target of HIV is a specific white blood cell called the CD4T lymphocyte or the T4 cell It makes the T4 cell attack itself making it unable to attack other foreign invaders compromising the host s immune system At the beginning of infection the host may experience cold or flu like symptoms for a few weeks then they will not show symptoms again until the T4 cells begin to lose their battle When the number of of T4 cells drops below 200 per cubic millimeter of blood symptoms will appear they are more capable of transmission and the person meets the criteria for AIDS 1985 development and licensing of screening tests The test measures antibodies to the virus which begin to appear 36 weeks after the original infection Pathways of HIV Homosexual relations between men leading cause Injection drug use 9 Heterosexual relations Greatest hope for controlling AIDS is to develop a vaccine Monday September 28 2015 Other Emerging Viruses Ebola 1976 Zaire and Sudan Virus that includes a fever and severe bleeding from various bodily orifices 90 of victims died New outbreak in 1995 Estimated to have killed 800 Africans since 1995 lnfects monkeys as well anirlenr nrm Responsible for the death of hundreds of American soldiers in Korea in the 1950s Causes kidney failure and acute respiratory distress Rodents are carriers of many hemorrhagic fevers 1999 West Nile in the US Environmental factors are responsible for the recent emergence of many new pathogens Influenza 19181919 the flu kills 20 million to 40 million people worldwide Retrovirus that is constantly changing so vigilance in necessary Flus with features of avian flu viruses are what make them particularly dangerous they are what caused the epidemics in both 191819571968 2003 The US Government has developed a vaccine against bird flu and has stock piled some doses in the event that the virus were to begin spreading easily from person to person 2009 H1 N1 declared a pandemic by the WHO New Bacterial Threats Legionnaires disease and Lyme Disease have become common enough to be recognized as distinct entities and for their bacterial causes to be identified Monday September 28 2015 Streptococci the bacteria that causes strep throat usually treated with penicillin has developed a more deadly strain called groupA streptococci It is a flesh eating bacteria that infects open wounds and often leads to the amputation of limbs Escherichia Coli usually found in the human digestive tract has developed a more deadly strain that has been infecting people through hamburgers unpasteurized apple cider and alfalfa sprouts Many bacteria have developed antibiotic resistance MultidrugResistant Tuberculosis Spread by aerosol used to be a major killer in the US responsible for 1 in 5 deaths While steps that have been taken have dramatically decreased the incidence of tuberculosis the development of MDR TB has meant that the disease is much more difficult and expensive to treat It can be a threat to many demographics not just the traditionally poor demographic Wednesday October 7 2015 Chapter 11 The Biomedical Basis of Chronic Disease Chronic Diseases Leading cause of death and disability Multiple causes risk factors Long period of onset Possibility of secondary prevention importance of animal models Cardiovascular Disease Heart disease and stroke two of the three leading causes of death in the United States risk for dying of cardiovascular disease increases with age risk is higher in men than women higher in African Americans than whites Causes include through Framingham Study and others high blood cholesterol high blood pressure smoking Atherosclerosis hardening arteries part of the development of cardiovascular diseases within the innerwall lining of the deceased s arteries was a buildup of plaque composed of fat and cholesterol blood cells and clotting materials Animal studies show that diet has a large role in the formation of plaque Wednesday October 7 2015 Rabbits fed milk meat and eggs were found to develop atherosclerotic arteries High cholesterol and fat in the blood interact with other risk factors such as smoking high blood pressure and diabetes to form plaque in the arteries Causes chronic injury of the artery s inner wall which leads to the body trying to heal itself through a healing process that runs wild and leads to the disease itself Atherosclerosis may have an infectious component caused by bacteria found in the plaque quue begins at an early age in the US American diet raises risk Total cholesterol level Low density lipoprotein LDL bad cholesterol High density lipoprotein HDL good cholesterol Hypertension Essential Hypertension Causes Obesity smoking and stress Dietary Salt raises blood pressure Secondary prevention possible m Not a single disease many disease with their own risk factors and treatments Arises through mutations in DNA All cancers occur when a the activities of a cell are transformed and the cells begin to multiply out of control so their daughter cells do as well Metastasize when cells detach from the tumor and spread to other parts of the body Other causes include chemicals viruses and radiation Diet and hormones also influence whether or not a mutation processes to the development of a tumor Wednesday October 7 2015 Tobacco use causes 13 of cancer related deaths Testing chemicals for carcinogenicity is a complex process millage Major cause of death and disability tripled in the last 20 years Type 1 childhood onset Failure of insulin production Type 2 Adult onset insulin resistance Closely correlated with obesity prevelence in rising int he US along with obesity Treatable but needs longterm monitoring needs good access to medical care Complications include Blindness kidney failure poor wound healing amputations of the extremities Mental Illness 1 in 5 suffer from mental illness 1 in 20 have a disabling disability o Mental illness has an early onset 75 by age 24 Thursday October 8 2015 Chapter 13 Do People Choose Their Own Health Compared to the leading causes of death in the 1900 s which consisted mainly of infectious diseases today s leading causes of death are preventable diseases with risk factors that are highly controllable such as tobacco poor diet and physical activity and alcohol Obesity is one of the US s leading cause of death Infectious disease does not come into play until number 4 on the list 7 of the 9 top leading causes of death are behavioral choices of individuals The other 2 are microbial agents and toxic agents what Public Health is traditionally known for Educa on Information provided by the federal government has traditionally been what has spread awareness about health conditions and taking preventative measures The FDA also plays a large part in the output of educational materials including the requirements for labeling foods which must accurately identify the percentage of the daily value provided by each serving Information on the risks of smoking has decreased the number of smokers however 1 in 5 adults continue to smoke despite knowing the risks involved Sexual education in schools has been proven to to delay the initiation of sex reduce the number of partners and students are more likely to use contraceptives when they do decide to have sex Regulation Most states have laws concerning alcohol and tobacco use aimed at protecting the public s health including laws against drunk driving regulation of smoking in public places age restrictions on buying and use of alcohol and tobacco States have different laws requiring vaccinations Some regulations include sexually transmitted disease screenings Thursday October 8 2015 Does Prohibition Work After the failure of the alcohol prohibition in 1919 we have been focusing more on illegal drugs There is no definitive answer for whether or not it works but it has been very expensive so the government has shifted from imprisonment as a punishment to treatment of addicts Tuesday December 1 2015 How Psychosocial Factors Affect Health Behavior Health of Minority Populations Race and Ethnicity greatly affect health in the United States The health of African Americans 13 of the population is poorer than that of white Americans Hispanics are heterogeneous and their health status varies among different subgroups American Indians typically have poorer health statuses than white Americans Asian Americans typically have better health statuses than White Americans 2009 Life Expectancy of Whites 788 Life Expectancy of Blacks 748 Infant mortality rate was blacks 24 times that of whites Infant mortality rate of American Indians 15 times that of whites Mortality from diabetes 17 times as high as American Indians as in whites and more than twice as high in blacks as in whites Black men die of prostate cancer 23 times the rate of white men Death rate from HIVAIDS is 9 times higher among blacks than whites 2010 Over 27 of blacks living in poverty compared to 1 out of 10 white non Hispanics Conclusion Minorities who have not been favored economically educationally and politically tend to reside in a lower SES and have poorer health statuses Stress and Social Support Stress due to the adverse physical and social conditions associated with a lower SES which may act both directly by affecting physiological processes and indirectly by influencing individual behavior Example widows and widowers are more likely to pass away shortly after the death of their spouse according to several studies in the 19603 and 19703 Mortality rates of widows and widowers are 5060 o higher in the 6 months following the death of a spouse than that of married people Other stressful life events such as death of a family member divorce and loss of a job were found to increase the risk of illness or death Tuesday December 1 2015 Stress contributes to heart disease Bank example Two banks that were extremely similar one bank switched management to become commercial and took on stress due to competition risk and responsibility for investing funds employees of the commercial ban over ten years were found to have a 50 higher rates of heart attacks and sudden death Many studies have concluded that psychosocial stress induces physiological changes such as decreased immune response and increases atherosclerosis in both baboons and humans Money education family friends and social support have been found to decrease levels of stress Absence of social support has been related to an increase in coronary heart disease complications in pregnancy and delivery suicide and other unhealthy outcomes Psychological Models of Health Behavior Health Belief Model specific factors that determine whether a person in likely to change behavior when faced with a health threat 1 The extent to which the individual feels vulnerable to the threat 2 The perceived severity of the threat 3 Perceived barriers to taking action to reduce the risk 4 The perceived effectiveness of taking an action to prevent or minimize the problem So in order to convince people to change their behavior they must be convinced that they are very vulnerable the threat is severe and that certain actions are effective preventative measures SelfEfficacy the sense of having control over one s life often added as a fifth factor to the Health Belief Model People are more likely to change if they are confident that they have the ability to do so Lowest selfefficacy is seen in humans or animals who have the experience of being unable to avoid noxious events especially if they have repeatedly tried and failed SelfEfficacy is increased by successful performance of the behavior in question or by seeing others perform it successfully Tuesday December 1 2015 Example the most effective school drug prevention programs include rolemodeling small group exercises and skills practice to teach students how to identify and resist the internal and external pressures to use drugs Transtheoretical Model envisions change as a process involving progress in five stages 1 pre contemplation no intent on changing 2 contemplation aware of the benefits of change not ready to take action 3 preparation decides to make change 4 action behavior is modified 5 maintenance makes change prevents relapse The Health Belief Model and the Trantheoretical Model are not contradictory but just alternative ways of looking at what may be the same psychological factors Both are e ec ve Ecological Model of Health Behavior An ecological model looks at how the social environment including interpersonal organizational community and public policy factors supports and maintains unhealthy behaviors The model proposes that changes in these factors will produce changes in the individual behavior Five Levels of Influence 1 Interpersonal knowledge attitudes and ad skills of the individual 2 Interpersonal Relations family friends and coworkers Application of the ecological model at the interpersonal level would lead to different strategies in teen drug prevention program depending on the nature of the teens social relationships 3 Institutional Settings schools and workplaces 4 Community Organizations can work together in a community to jointly promote healthy goals 5 Public Policy encompasses the regulations and limitations on behavior smoking restrictions age limits on alcohol sales seatbelt laws Tuesday December 1 2015 Changing the Environment Public Health programs to be effective must concentrate less on individual behavior and more on changing the environment Wednesday October 14 2015 Chapter 15 Public Health Enemy Number One Tobacco Cigarette Smoking is the actual leading cause of death in the United States responsible for approximately 400000 deaths each year Understanding and dealing with tobaccocaused illness embodies all aspects of public heaHh Epi provided the first solid evidence that smoking caused cancer and heart disease and continues to yield results Biomedical Research provided information on the role of tobacco in the causation of cancer and heart disease Environmental provided information on tobacco as an environmental threat producing indoor air pollution that has been proven to cause adverse health effects to nonsmokers Social and Behavioral Sciences understanding why people smoke despite the health effects and how they can be persuaded to quit What is the role of a democratic government in confronting this behavior Biomedical Basis of Smoking s Harmful Effects In 2010 44 of smokers tried to quit 4 o7 o succeeded Nicotine is absorbed into the blood stream through the linings of the mouth and respiratory tract traveling quickly to the heart producing a sense of enhanced energy and alertness and a calming effect on addicted smokers When smokers try to quit they experience intense physical and psychological withdrawal symptoms Tar residue from burning tobacco that condenses in the lungs of smokers and is a major source of its carcinogenicity Tar damaged cilia tiny hairs lining the respiratory tract that usually sweep the lungs and bronchi clear of microbes irritants and toxic substances therefore leaving the respiratory tract virtually unprotected and susceptible to infectious diseases such as bronchitis influenza and pneumonia as well as diseases brought on by chronic irritation such as emphysema and asthma Wednesday October 14 2015 Cigarettes also contain other known carcinogens such as arsenic and benzene Cardiovascular effects of smoking take place very rapidly raising blood pressure and heart rate causing spasms in the blood vessels of the heart and increasing the risk of sudden cardiac death Carbon Monoxide in cigarette smoke interferes with the oxygen carrying capacity of red blood cells leading to oxygen shortages in the hearts of patients suffering from coronary artery disease Smoking increases the risk of stoke and heart attacks by altering the clotting properties of blood and has been shown to raise total blood cholesterol levels and reduce the levels of HDL good cholesterol Historical Trends in Smoking in Heath Cigarette smoking became very popular after 1913 when Camel and other brands began mass marketing campaigns Though frowned upon in the beginning of the century by 1960 34 of women smoked First disease clearly linked to smoking was Lung Cancer which was very uncommon until smoking became popular Lung cancer deaths correlated directly with the increase of cigarette smoking 1964 US Surgeon General released Smoking and Health including information from 10 renowned scientists all claiming that cigarette smoking caused lung cancer and chronic bronchitis and was strongly associated with the cancer of the mouth and larynx as well 1980 Health Consequences of Smoking for Women New study issued by the US Surgeon General that said smoking had the same health effects on women as men Prevalence of smoking is higher among black men than white men historically Now blacks are at a slightly lower risk than whites while American Indians and Alaskan Natives are at a much higher risk averaging 364 overall 83 among male and female college graduates 27 of those without a high school diploma Wednesday October 14 2015 Regulatory Restrictions on Smoking New Focus on Environmental Tobacco Smoke 1964 Surgeon General report carried great credibility its publication led to a number of government actions aimed at restricting cigarette marketing including Federal Trade Commission requirements that every package have a warning label Federal Communications Commission mandate in 1968 that radio and television advertisements for cigarettes must be balance by public service announcement about their risks Tobacco companies began to target advertising in magazines newspapers billboards products giveaways and sponsorship of sporting and cultural events Secondhand smoke has led to some of the most effective nonsmoking actions Children of smokers are more likely to suffer from asthma respiratory infections and sudden infant death syndrome 1992 Enviromental Protection Agency issued a report that environmental tobacco smoke to be a carcinogen causing 3000 lung cancer deaths a year 1974 Connecticut was the 1st state to enact restrictions on smoking in restaurants 1975 Minnesota passed a comprehensive statewide clean indoor air law 1983 San Fransisco passed a law against smoking in the workplace including private work places 1989 Congress bans smoking on all domestic flights 2012 24 states and the District of Columbia banned or severely restricted smoking in in all public places All but one state Wyoming had enacted some limitations on indoor smoking Avriin Emh i nY h Tobacco companies target the teenage demographic the most important age for smoking initiation They have doubled their advertising budget in order to bring in new business They also target women and minorities All states have laws prohibiting the sale of tobacco to minors Wednesday October 14 2015 Taxes as a Public Health Measure One of the most effective ways to discourage young people from smoking is to raise the tax because they are so sensitive to price It also has been very effective in discouraging adults from smoking as well State and local governments have found that raising taxes on cigarettes is a painless way of closing budget shortfalls California s Tobacco Control Program 25 cent tax increase on cigarettes in California has proved to be successful in maintaining ow smoking rates Per capita cigarette consumption fell by 59 between 1988 and 2004 California s campaign included an aggressive advertising component Second hand smoke information was included The Master Settlement Agreement 1994 a class action lawsuit against American tobacco companies was filed in federal district court in Louisiana on behalf of all nicotinedependent persons in the US It was dismissed but followed by many other lawsuits 1997 tobacco industry began settlement negotiations with the attorney general in an effort to protect themselves against further lawsuits and financial ruin Companies agreed to pay 3685 billion over a 25 year period to compensate states for treating smoking related illnesses and to set up a fund to pay damage claims for I smokers as well as for other purposes including financing nationwide antismoking programs They also agrees to a number of restrictions on advertising and promotion to allow the FDA to regulate the nicotine in cigarettes Congressional approval was not passed 1998 Companies agreed to pay 46 states 206 billion over 25 years and accepting restrictions on advertising including a ban on billboards as well as a 17 billion over a 5 year period to create the American Legacy Foundation which used the funds for public education and the tobacco control activities The MSA was somewhat of a disappointment as most states used the money to close budgetgaps FDA Regulation 2009 President Obama signed the Family Smoking Prevention and Tobacco Control Act giving the FDA authority to regulate tobacco products and to restrict advertising and promotion Wednesday October 14 2015 Tuesday December 1 2015 Injuries Are Not Accidents Epidemiology of Injuries Injuries are the fifth leading cause of death in the US Number one cause of death for ages 144 o Unintentional injuries 13 of deaths in children Intentional Homicidesuicide 30 of deaths in ages 1524 o Higher injury rates in groups with lower SES o More likely to have high risk jobs low quality housing and defective cars Males have higher injury rates than females Blacks have lower injury mortality than whites Exception being higher homicide rates Injuries and the Chain of Causation Interrupt the Chain Agent examples car firearm swimming pool Environment examples road conditions weather bully gangs nonfenced pool Host examples depressed individual drunk individual gang member person who can t swim Injuries and Levels of Prevention Primary Prevention Preventing injury eg drunk driving laws safety latches on bottleswindows Secondary Prevention Tuesday December 1 2015 Reduce harmearly detection eg seatbelts airbag highway road dividers Tertiary Prevention Quality treatment and rehab Ambulance ER Rehab facilities The Public Health Approach Regulation is typically more effective than education Speed limits Seatbelts helmets o The Three E s of Injury Prevention Educa on Enforcement o Engineering o Example Children Can t Fly in NYC Leading Causes of Injury Related Death 1 Poisoning Leading cause of injury death as of 2009 Over 40000 deaths per year Recent increase largely from unintentional deaths recreational use of prescription pain relievers and illegal drugs Rx drug abuse doubled from 1999 2008 Most commonly occurring in middle aged men o Prevention Strict regulation Drug tracking 2 Motor Vehicle Crashes 2nd leading cause of injury death 34000 deathsyear Congressman Kenneth Rogers 1950s Ralph Nader Unsafe atAny Speed the DesignedIn Dangers of the American Automobile published 1966 Tuesday December 1 2015 NHTSA created amp empowered to set standards for auto safety The power of regulation safer cars safer roads Motor vehicle fatalities decreased by gt40 o since 1968 despite more cars and more miles driven Engineering changes to make cars and highways safer Education and enforcement Speed limits Seat belts MADD Alcohol plays a major role in fatal crashes Second leading factor youth and inexperience Graduated driver s licenses Zero tolerance for blood alcohol Distracted driving Pedestrians gt4000 deaths per year 19 are over 65 years old Motorcyclists 4500 deaths 19 states and DC require helmets 28 states require helmets for younger riders Bicyclists about 600 deaths per year 11 are under age 16 21 states and DC require helmets for children 3 Firearms 3rol leading cause of injury death 31000 deaths annually 200 Americans each day in the ER with gunshot wounds Almost 60 suicides 37 homicides 3 unintentional Homicide rates 2 4 times higher in US than other developed countries Tuesday December 1 2015 34 of Americans own a gun There are 89 guns per 100 people in the United States Mass Shootings o 1 method of homicide666 1 method of suicide 522 80 of men and women feel safer with a gun in their home Owning a gun has been linked to higher rates of homicide suicide and accidental death Women are 500 more likely to be killed during a domestic dispute if there is a gun in the home 43 of homes with guns and kids have at least one unlocked firearm private sales online sales education and gun safety The power of the NRA 4 Falls 5 Suffocation 6 Drowning 7 FiresBurns 8 Cuts Occupational Injuries Occupational Safety and Health Administration OSHA Regulatory agency 1970 Over 4600 deaths per year Motor vehicle injuries are the leading cause of work related death Falls falling objectequipment caught in equipment electrocution Tuesday December 1 2015 Domestic Violence Child abuse gt1 500 children dieyear 80 younger 4 years old gt740000 treated in emergency departments due to violence Intimate partner violence Includes rape physical violence and stalking gt12 million affected 2300 deathsyear Violence on College Campuses 1 in 4 women impacted by violence during their time in college 7 of men impacted by violence Public health has a successful formula for reducing injury related deaths It has worked and continues to work with motor vehicle accidents We now must find ways to do this for drug abuse gun violence and other types of injuries in America Tuesday December 1 2015 Maternal and Child Health as a Social Problem History of Child Health Programs New York City milk stations starting in 1893 US Children s Bureau beginning in 1912 Child labor regulated by US beginning in 1930s Ongoing conflicts over the role of government in protecting children Infant mortality rate has fallen over 20th century Importance of Infant and Child Health Foundation of health throughout life Children are most vulnerable group in society Infant mortality rate IMR is an indicator of health status of population US ranks 27th internationally IMR higher for blacks than whites indicator of health disparity Social Factors in Mortality Number one risk factor is poverty Reasons why low SES increases risk Environmental hazards Poor nutrition Maternal risk behaviors smoking alcohol illegal drugs Social factors young maternal age violence stress lack of social support Lack of prenatal care Prenatal Care Provides women with information Diagnose problems early Can often link low SES women with social services Tuesday December 1 2015 Most states try to remove financial barriers States and federal government collect data on prenatal care Causes of Infant Mortality Birth defects leading cause overall Prematurity and low birth weight Was leading cause overall until recently Still leading cause among African Americans Sudden infant death syndrome SIDS Prevention Genetic and newborn screening FDA regulation of drugs Warnings against alcohol for pregnant women Immunization of all children against rubella protects infants Dietary supplementation with folic acid Preventing Low Birth Weight Smoking drinking and drug use Prenatal care Maternal Age Recent increases in low birth weight due to multiple births because of reproductive technology Preventing SIDS Maternal smoking The Power of Prenatal Care Breastfeeding Back to Sleep campaign SIDS rate has fallen by over 50 Family Planning and Adolescent Pregm Adolescent pregnancy has physical and social risks for mother and child Tuesday December 1 2015 Planned pregnancy leads to healthier outcomes Affordable Care Act requires insurance companies to cover birth control at no cost increasing access Comprehensive sex education most effective Delays sexual initiation amp increases safer sex practices when sexually active Contraception Sterilization commonly used but permanent Hormonal pill patch ring depo shot implants lUDs Barrier condom diaphragm cervical cap Often used inconsistently and unreliany Condoms reduce risk of STls Emergency Contraception Plan B Government Nutrition Programs 0 WlC provides vouchers for nutritious foods for pregnant women lactating mothers children up to 5 very effective 0 Encourage breastfeeding 0 School Meals Program 0 Supplemental Nutrition Assistance Program formally called Food Stamp Program 0 Food insecurity is still common in the US Children s Health and Safety Immunizations required before entering school Public health efforts to vaccinate younger children Controversy over HPV vaccine for girls to prevent cervical cancer CDC tracks immunization rates Well baby care and screenings in school Childhood asthma is growing Fluoridation of water to prevent tooth decay Regulation of day care centers Tuesday December 1 2015 US Consumer Products Safety Commission regulates toys and children s furniture Public health campaigns for child safety seats bicycle helmets Governments also provide diagnostic treatment and rehabilitative services for children with special needs Public Health begins before birth There are many inherited poor health outcomes which we are constantly trying to fight and one of the best ways to do that is to look at the entire lifespan and intervene as early and as often as possible Tuesday December 1 2015 A Clean Environment Role of Government in Environmental Health The three basic requirements for human life o Air Food Water o Environment is beyond the control of individuals As early as 2000 BC in cities in India Egypt Greece and South America clean water and sewage drainage was built First known public health measures Local governments provide clean water and disposal of wastes As population grew environmental problems transcended local government 1960s and 1970s state and federal governments took more responsibility With population growth and urbanizationsuburbanization the number of environmental concerns have grown The Environmental Protection Agency EPA Radiation Ultraviolet light from the sun Radon gas Early scandals Radioactive ingredients added to patent medications X rays used in medicine and dentistry Radon Girls Lessons on health effects of radiation learned from atomic bombings in Japan Tuesday December 1 2015 Mercury Neurological damage Mad hatter Japan in 1950s Iraq in 1972 Current cause of Mercury levels Coal burning power plants Concern about fever thermometers school laboratory equipment Lead Harmful to brain and nervous system especially of children Single most important environmental threat to American children lead pipes Air pollutant from use in gasoline banned in the 1980s Was used in paint until 1977 still a threat in old housing peeling paint or contaminated dust Toys made overseas Lead screenings Asbestos Was widely used because of fire resistance Used in insulation still used in roofing gaskets brake linings Was required in schools between 1940 and 1973 Lung cancer Libby Montana and asbestos mines World Trade Center cleanup and rescue workers Pesticides and Industrial Chemicals Rachel Carson s Silent Spring 1962 o beginning of environmental movement DDT and other pesticides banned in 1972 2 Tuesday December 1 2015 PCBs Hudson River Most widespread chemical contaminant world wide Skin rash discoloration of newborns headaches fatigue joint ache endocrine and immune system defects increase cancer risk Japan 1968 Endocrine Disruptors Bisphenol A BPA component of hard plastics used in baby bottles amp can linings Phthalates component of soft plastics used in water bottles Both leach into liquids and found at low levels in humans o Interfere with normal hormone action in wildlife and maybe in humans FDA had declared them safe but is now reconsidering Potentially affect reproduction nervous system immune system maybe cancer Occupational Exposures Workers are often the first to suffer effects of an exposure Carcinogens recognized through occupational cancers Scrotal cancer in chimney sweeps bladder cancer in dye factory workers lung lymphatic cancer from arsenic copper smelters etc Neurotoxins also recognized through occupational illness Deterioration of vision muscle weakness failure of memory Factory Farms Animals crowded together and tended by automated systems Produce huge volumes of wastes lagoons 500 million tons of manure each year Air pollution ammonia hydrogen sulfide methane and water pollution after rain Political power makes environmental regulation difficult Tuesday December 1 2015 Climate Change Greenhouse effect from burning fossil fuels Rise of 1 degree during 20th century Predict 3 to 7 degree rise during 21st century US has 5 of world s population contributes 18 of greenhouse gases China with 20 of world s population has become the leading emitter with 24 No success in reaching an international plan for improvement Setting Standards Most chemicals have not been tested for health effects Occupational Safety and Health Act gave government authority to set standards for workers exposure to toxic substances Toxic Substances Control Act allowed government to require testing of potentially hazardous substances before they go on the market Clean Air Act 1970 required the EPA to develop a list of industrial pollutants that can cause serious health damage and set emission standards for them Process of standard setting is slow and always controversial Risk Analysis Absolute safety is impossible Overregulation can cause underregulation Must balance risk against other societal goals including economic wellbeing Political groups sometimes favor economic amp business interests over environment amp public health Tuesday December 1 2015 Population The Ultimate Environmental Health Issue Overpopulation Population Biology Carrying capacity number of organisms that I I r4 a l can be supported wrthout degrading environment Thomas Malthus predicted in about 1800 that I I population growth would outgrow food supply 5 z I Paul Ehrlich The Population Bomb 1968 1 Current World Population Seven Billion 4quot 39 39 WC 5M Lot O d UN predicts the world population will be 93 Billion in 2050 Public health has contributed to population growth by reducing death rates especially among children in developing countries Birth rates tend to fall as a result of falling death rates demographic transition Excess population settles in cities HIVAIDS shortening life expectancies in Africa Prevalence rate as high as 26 in some African countries Depletion of Global Resources Fresh water Drinking cooking washing Agriculture Unevenly distributed Ogallala Aquifer 13 of the world population currently live in regions with water shortages Fuel Deforestation leads to degradation of land Tuesday December 1 2015 Food 14 of the world s population are chronically or acutely malnourished 75 of the major marine fish stocks are exploited or significantly depleted 10 of earth s vegetated surface is at least moderately degraded Decline of harvests of fish and shellfish Prospects for Population Control United Nations Conferences on Population every ten years Opposition to contraception by Catholics and Muslims Rich and poor countries blame each other 1994 UN Conference 20 year Program of Action Education for women o Empowering women to choose fewer children and providing family planning options Reducing infant mortality rates Population stabilization comes with modernization and economic viability Tuesday December 1 2015 Emergency Preparedness Post 911 Types of Disasters Disasters cause death injury disease and property damage on a scale beyond the routine emergencies to which the health system is accustomed Natural disasters many are predictable Prior evacuation when possible Technological disasters less predictable Include terrorism industrial explosions hazardous material releases bridge collapses etc Response for all types of disasters Search and rescue Treatment and evacuation of injured Food water shelter for survivors Minimize environmental hazards All types of disasters require response planning September 11th 2001 819am flight attendant notify flight control that Flight 11 is being hijacked 837 am military notified of hijacking 846am Flight 11 crashes into 9399 floor of North Tower and emergency services mobilize 850am President alerted 902 am South Tower ordered to evacuate 903am Crash of Flight 175 into South Tower 905am President informed of second crash 910am Increased emergency response in NYC 912am Flight attendant on Flight 77 notifies that plane is hijacked 930am evacuation of NYC Office of emergency management 937am Flight 77 crashes into Pentagon 942am all flights are grounded Tuesday December 1 2015 957am Flight 93 passengers and crew alert of hijacking 959am South Tower collapse 1003am flight 93 crashing when passengers and crew attempt to take control of plane 1028am North Tower Collapse 1102am Lower Manhattan evacuation 830pm President Bush addresses the nation 13000 to 15000 people evacuated from towers 2801 people died during terrorist attacks Many failures of communication and coordination radio tower for Office of Emergency Management was on top of North Tower Agencies communicated on different channels so there was confusion Stairway to roof was locked Failure to protect rescue and cleanup workers from environmental hazards Public Health Response Issued death certificates and burial permits Monitored safety of food and drinking water served to emergency workers Cleaned up food in abandoned restaurants Sampled dust and debris to assess risk Surveillance of cleanup workers and area residents for symptoms Arranged for mental health counseling Victim location services shelters for displaced residents Monitoring for biological agents Changes after 911 Money provided by federal government to improve county city and state emergency preparedness 9 Billion dollars since 2002 o Used for planning training improving communication and coordination strengthening hospitals and labs and improving epi surveillance CDC set up a Strategic Nationwide Stockpile which includes medical supplies vaccines antibiotics and antidotes for chemical agents which can be delivered to anywhere in the US in twelve hours Tuesday December 1 2015 Hurricane Katrina Friday August 2611 Path looks to possibly impact Louisiana National Guard deployed Saturday August 27th Category 2 storm voluntary evacuations for New Orleans Pres Bush declares state of emergency in order to begin federal aid Sunday August 28th Category 5 storm 10am New Orleans issued mandatory evacuation We are facing the storm most of us have feared Superdome opened Had food and water for 15000 for three days 20000 people entered superdome Monday August 29th Katrina makes landfall as Category 3 storm Levees begin to breach Flood water over 10 feet high Tuesday August 30th Order to evacuate New OrleansSuperdome made Wednesday August 31st 85 of New Orleans under water Police and national guard ordered to focus on looting Thursday September 181 Congress passes relief package Canadian troops enter New Orleans Buses and food began arriving at Superdome Red Cross attempted to enter city to provide food and water but were told they could not until Friday Friday September 2nd Bush signs relief package All sick and injured people removed from superdome Roof rescues over 6500 boat rescues over 2500 Sunday September 4th Superdome evacuation complete September 56th nearly 28000 people rescued from flooded areas 1800 deaths Lack of planning for populations with special needs hospital patients people without cars low SES Poor communication lack of clear directions on evacuation until too late The issue of race and SES in the response 68 of survivors believe the response would be different if those impacted were wealthy andor white Too little help from outside New Orleans Major failure by FEMA After the storm passed damaged housing contaminated air in FEMA trailers large displaced population Population prior to storm 485000 2010 census 343829 Tuesday December 1 2015 Current Natural Threats Natural Disasters Tsunami Hurricanes Floods Forest Fires Tornados Earthquakes Volcanoes SnowIce storms Current Technological Threats Domestic vs International terrorism in the US Unrest abroad Mass shootings EMP Nuclear Disaster Infrastructureengineering disasters o Bioterrorism Principles of Emergency Preparedness o Importance of advance planning involving all agencies Practicemrill Importance of good communication Incident Command System puts a single person in charge at the scene Federal government has provided funding to states and metropolitan areas for planning Strategic National Stockpile of medical supplies antibiotics vaccines antidotes for chemical agents Bioterrorism Preparedness Same as preparedness for epidemics Challenge to recognize an attack is occurring surveillance is important Need for laboratory capability Tuesday December 1 2015 Need for public health laws enabling authorities to take action Problem of whether uninsuredunderinsured will seek care Need for coordination between public health and law enforcement Possible Bioterrorism Agents Smallpox Highly contagious no immunity in population 30 mortality rate Vaccination campaign before Iraq war military and health workers Resistance by civilians because of side effects and uncertainty of risk Anthrax Plague Botulinum toxin Surveillance Activities Emergency room visits Calls to 911 and poison control centers Pharmacy records Veterinary diseases The uninsured and undocumented immigrants Both 911 and Hurricane Katrina were defining moments in our nation s history and their tie to public health cannot be overstated They have shown our weaknesses and have shown us how we must improve
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