HAP 350 Test #2

+ The important role of data and surveillance in epidemiology

+ A major line of defense in protecting the public against disease. Endemic vs Epidemic ~ Epidemic: the term used to describe a situation where a disease spreads rapidly to a large number of people in a given population over a short time period. ~ Endemic: describes a disease that is present permanently in a region or population + Statistics are the vital signs of public health. Local, state, and federal governments collect data on their citizens, starting with birth certificates and ending with death certificates. The U.S. census, conducted every 10 years, provides information on the age, sex, and ethnic composition of communities, information that allows the calculation of birth rates, death rates, infant mortality rates, life expectancies, and other data that form the basis for public health's assessment function. + The NCHS is the repository for the vital statistics data received from the states. The NCHS also conducts a number of periodic and ongoing surveys to collect additional information on Americans, including information on family structure, specific health conditions, behavioral risk factors, and other data useful in planning public health intervention programs. +Health statistics are used for all aspects of public health policy development and evaluation. Uses of the data include health needs identification, analysis of problems and trends, epidemiologic research, program evaluation, program planning, budget preparation and justification, administrative decision making, and health education. + Increasingly, electronic means are being used to collect, transmit, store, and analyze data and to make the data available to public health workers and the general public. Strict precautions are taken to ensure confidentiality of information about individuals.

Key features in the story of the fight against tobacco in the U.S.

+ Cigarette smoking—the leading actual cause of death in the United States—is clearly the nation's most significant public health issue. The problem of tobacco-caused disease embodies the complex interactions by which psychological, social, cultural, economic, and political factors influence individual behavior to cause over 480,000 deaths each year. + The struggle to understand and deal with tobacco-caused illness involves all areas of public health. Epidemiology provided the first solid evidence that smoking caused cancer and heart disease and has continued to yield information on the health effects of this very human habit. Biomedical studies were slow to provide evidence because laboratory animals could not be persuaded or forced to smoke cigarettes, but eventually they yielded valuable information on the role of tobacco in the causation of cancer and heart disease. + Public health faces a fundamental dilemma in confronting the current epidemic of tobacco-caused disease: What should be the role of a democratic government in confronting a behavior that is practiced by nearly one out of five adults and will kill up to half of them? Political and economic forces that favored tobacco have opposed strong government measures against cigarettes. Public health efforts involving education and health promotion campaigns have persuaded many people to stop smoking but seem to have reached the limit of their effectiveness in bringing smoking prevalence down to about 18 percent among adults. + However, the 1990s saw a major shift in federal and state governments' attitudes toward smoking. Recognition that the nicotine in tobacco is addictive, together with evidence that cigarette companies have purposely manipulated nicotine levels in cigarettes to keep people hooked, has forced politicians to look with suspicion on what was previously considered a freely chosen behavior. Moreover, evidence of the high economic costs paid by government-financed programs, including Medicare and Medicaid, for the treatment of tobacco-caused disease has forced governments to question their previous assumptions about the economic advantages of supporting the tobacco industry. + In addition to nicotine, an important component of tobacco smoke is tar, the residue from burning tobacco that condenses in the lungs of smokers. Tars provide the flavor in cigarette smoke; they are also a major source of its carcinogenicity. As early as the 1930s, experiments were done in which these tars were painted on the ear linings of rabbits or the shaved backs of mice and found to cause tumors. Decades of studies by biomedical researchers—and clandestinely by tobacco companies, which did not wish to publicize their results—have confirmed the carcinogenicity of the tars as well as other ingredients of the smoke, including arsenic and benzene. When filters were added to cigarettes with the ostensible purpose of removing tars and other harmful ingredients, it turned out that they tended also to remove the taste and "satisfaction" from smoking. Thus filter cigarettes, to be acceptable to smokers, had to deliver significant levels of tar and nicotine, meaning that there were limits to how "safe" a cigarette could be. + Although it has been smoked and chewed for hundreds of years, tobacco was not used intensively enough to cause widespread illness until the 20th century. Before then, almost all tobacco was smoked in pipes and cigars or used as chewing tobacco and snuff. Cigarette rolling machines and safety matches were invented in the 1880s, but cigarette smoking began to increase dramatically only after 1913, when Camel, followed by other brands, began mass marketing campaigns. The distribution of free cigarettes to soldiers during the two world wars further stimulated smoking among men. Smoking among women was frowned on early in the century, but women began to take up the habit during and after World War II, and by 1960 about 34 percent of American women smoked. + The first disease clearly linked to smoking was lung cancer, which is caused predominately by smoking and is relatively rare in nonsmokers. Lung cancer was virtually nonexistent in the United States and Britain in 1900. In the 1930s, the increase in deaths from lung cancer began to attract attention, and a link to cigarette smoking began to be suspected. This link was confirmed in the epidemiologic studies published in the 1950s. Cigarette consumption dropped as a result of these reports (as shown in Figure 15-2) but began to climb again when tobacco companies promoted filter cigarettes as a safer alternative. + In 1964, the U.S. Surgeon General released a report, Smoking and Health, a summary of the evidence to date, the result of an exhaustive deliberation by a panel of ten renowned scientists.5 The panel unanimously agreed and wrote that cigarette smoking caused lung cancer and chronic bronchitis and was strongly associated with cancer of the mouth and larynx. It also reported that smoking increased the risk of heart disease. The Surgeon General's report was very influential, convincing many smokers to quit and providing ammunition for advocates wishing to impose controls on the tobacco industry. + Women were hardly mentioned in the 1964 Surgeon General's report. Lung cancer was rare in women, and all the studies had been done on men. However, women soon began to catch up. In 1980, the Surgeon General issued another report that focused entirely on women. Health Consequences of Smoking for Women addressed "the fallacy of women's immunity."6 The report points out that the first signs of an epidemic of smoking-related diseases among women were just beginning to appear, because women had only begun smoking intensively 25 years after men had. Indeed, lung cancer was about to surpass breast cancer and become the leading cause of cancer death in women, as it is today.7 The report noted that, in addition to suffering the same ill health effects as men, female smokers are at increased risk for complications of pregnancy and that infants of female smokers are more likely to be premature or lagging in physical growth. + Historically, the prevalence of smoking among black men was higher than that for white men; accordingly, lung cancer mortality rates have been higher among black men. Rates of smoking among blacks have declined and are now slightly lower than those among whites. American Indians and Alaskan Natives smoke at much higher rates than other ethnic groups, averaging 19.1 percent overall. Very large differences in smoking rates are seen among groups of different socioeconomic status, and there is a particularly strong association with lack of education. Prevalence of smoking is only about 7.7 percent among male and female college graduates, while 25.8 percent of those without high school diploma are smokers. + Public health efforts at discouraging smoking have had to contend with the enormous economic and political power of the tobacco industry. Congress, which until recently provided subsidies to tobacco growers, has been very reluctant to pass legislation opposed by the industry. However, the 1964 Surgeon General's report carried great credibility, and its publication led to a number of government actions aimed at restricting cigarette marketing. These included Federal Trade Commission requirements that cigarette packages contain warning labels and a Federal Communications Commission mandate in 1968 that radio and television advertisements for cigarettes be balanced by public service announcements about their harmful effects. The latter requirement, called the Fairness Doctrine, was so effective in countering the tobacco companies' ads, as seen in the drop in cigarette consumption shown in Figure 15-2, that in 1971 the industry submitted to a total ban on cigarette advertising on radio and television. In return, the public service announcements ceased. The tobacco companies shifted their advertising efforts to magazines, newspapers, billboards, product giveaways, and sponsorship of sporting and cultural events. + Over the past four decades, new awareness of the harm caused by "second-hand smoke" has led to some of the most effective actions against smoking. Studies began to show that exposure to environmental tobacco smoke caused some of the same health problems as active smoking. For example, the nonsmoking spouses of smokers have an increased risk of lung cancer and heart disease, and children of parents who smoke are more likely to suffer from asthma, respiratory infections, and sudden infant death syndrome. In 1992, the Environmental Protection Agency issued a report that declared environmental tobacco smoke to be a carcinogen, causing 3000 lung cancer deaths a year. Evidence of the harm caused by passive smoking inspired the non-smokers rights movement, which largely bypassed the Congress and focused political pressure on state and local governments. + Over the objections of the tobacco industry, a ban on smoking on all domestic airline flights was passed by Congress in 1989.4 Restrictions on indoor smoking became more widespread in the 1990s. By January 1, 2015, 28 states and the District of Columbia had banned or severely restricted smoking in all public places, including work sites, restaurants, and most bars. All other states had enacted some limitations on indoor smoking, although Wyoming was the least restrictive, with restrictions applied only to government offices, not schools. Many counties and municipalities have passed legislation to promote clean indoor air. + While smoking rates among adults have fallen, public health advocates are especially concerned about smoking among youth. Teenagers tend to be less worried about their health in the distant future than they are with their image and social status among their peers. Tobacco companies exploit those concerns in their attempts to win over young people to smoking. In order to maintain a constant number of customers over time, the tobacco industry must persuade 2 million people to take up the habit each year to balance the number of smokers who die or quit.11 Cigarette advertising and promotional expenditures amounted to $9.2 billion in 2012.12 Because the teen years are the critical period for smoking initiation—90 percent of adult smokers started when they were teenagers, and the average age at which they took up the habit is 14.5—tobacco companies have targeted their advertising toward children and young people.4 For example, Joe Camel ads were strongly appealing to children. A 1991 study found that 91 percent of 6-year-olds recognized the cartoon character, the same percentage that recognized the Mickey Mouse logo of the Disney channel. Some 98 percent of high school students recognized Joe Camel, compared with only 72 percent of adults.13 Between 1988, when the Joe Camel ad campaign was introduced, and 1990, it is estimated that Camel cigarette sales to minors went from $6 million to $476 million.4 In response to an outburst of negative publicity and public anger at the tobacco companies, Joe Camel was retired in 1997. + As part of the 1998 Master Settlement Agreement (MSA), discussed later in this chapter, major tobacco companies agreed to stop advertisements targeted at children, including some promotional activities. Although the most blatant appeals to youth are gone, the companies began running ads that, while ostensibly antitobacco public service ads, were actually more sophisticated messages designed to encourage youth smoking.14 The messages were that smoking is for adults only, and that parents should talk to their children about not smoking. Analyses of their impact on teens have shown that these ads were ineffective in discouraging young people from smoking and may have increased their intention to smoke. This may have been the intention when the ads were designed. Nevertheless, a combination of public health efforts, including the MSA, have contributed to a decline in the number of teens who smoke. The CDC's biannual survey of high school students found in 2013 that 15.7 percent had smoked in the previous month, down from 36.4 percent in 1997, the year when the highest number of students reported having smoked.15 All states have laws prohibiting the sale of tobacco to minors, but enforcement of the laws varies. The CDC's 2013 survey found that 18 percent of the student smokers bought cigarettes from a store or gas station. There is evidence that increasingly, youths are buying cigarettes via the Internet, making age laws difficult to enforce. A 2007 Institute of Medicine committee has recommended that Congress pass legislation to prohibit all online tobacco sales and shipment of tobacco products directly to consumers. + As advertising to children and teens has become increasingly restricted, tobacco companies have focused their efforts on young adults, who are still receptive to social pressures, may smoke occasionally, and may be vulnerable to advertising. The companies use promotional activities in bars and nightclubs, such as distributing free cigarette samples or brand-labeled articles of clothing, with the goal of turning occasional smokers into addicts. Social events at college campuses are other occasions where companies can gain access to young adults. A study in 2000-2001 of 119 colleges found that events at which free cigarettes were distributed occurred at all but one of them. Many of the events took place at bars and nightclubs, but fraternities and sororities were also popular sites for the events.17 Indoor smoking bans, which have become more widespread in recent decades, have blocked the effectiveness of this kind of marketing. Portrayal of smoking in movies and on television has been shown to exert a powerful influence in inspiring adolescents to smoke, and the Institute of Medicine has recommended that the movie rating system take this into consideration when G, PG, PG-13, or R ratings are assigned. However, the recommendation has had little effect. + The tobacco industry has targeted advertising at women and minorities, groups identified as promising sources of new smokers. Young women have been attracted by suggestions that smoking will help them lose weight, beginning with the Lucky Strike ads of the 1920s that advised, "Reach for a Lucky instead of a sweet." More recently, Virginia Slims ads have taken a similar approach. Shortly after the Virginia Slims advertising campaign began in the 1960s, the proportion of 14- to 17-year-old girls who started smoking nearly doubled.4 African Americans historically had higher rates of smoking—and of lung cancer—than whites, though the difference has shrunk over the past decade.8 Tobacco companies try to win over black leaders by donating to black causes, such as the National Association for the Advancement of Colored People and the United Negro College Fund, and by sponsoring black cultural events such as jazz festivals. They advertise heavily in African American publications and, before the MSA, blanketed neighborhoods with billboards. + increase in price reduces the number of teenagers who smoke by approximately 7 percent to 12 percent.20 "Raising tobacco taxes is our number one strategy to damage the tobacco industry," an American Cancer Society executive was quoted as saying. "The industry has found ways around everything else we have done, but they can't repeal the laws of economics."20(p.293) Raising taxes on cigarettes is effective in reducing smoking among adults as well. In 1989, California increased cigarette taxes from 10 cents to 35 cents per pack. The law specified that 20 percent of the proceeds were to be designated for programs designed to prevent and reduce tobacco use, especially among children. + In recent years, state and local governments have found that raising taxes on cigarettes is a painless way of closing budget shortfalls, and many states have followed this policy.22 In 2015, for example, New York had the highest rate, with a tax of $4.35 per pack. By contrast, tobacco-producing states have low cigarette taxes: Virginia's rate was 30 cents per pack, and Missouri's rate, the lowest, was 17 cents.10 California, a leader in raising cigarette taxes for public health goals, had fallen to a rank of 32nd among states, with a tax of 87 cents per pack. In June 2012, California voters rejected a proposed $1 a pack increase, the proceeds of which would have been used to finance cancer research. The tobacco industry spent nearly $50 million to defeat the measure.23 The federal tax on cigarettes, last raised in 2009, is $1.01.per pack. + Despite California's failure in recent years to maintain its leadership in tobacco control efforts, its voter-initiated program begun in 1989 with a 25-cent tax increase on cigarettes, has proved successful in maintaining low smoking rates statewide. The initiative mandated mass media antitobacco advertising as well as school and community education and intervention activities. It also mandated that the effectiveness of the program be evaluated after a decade. Thus, the California experience has provided evidence on what methods are effective in reducing smoking. + In California, according to the CDC's Behavioral Risk Factor Survey, the prevalence of smoking was 13.7 percent in 2011, compared to 21.2 percent in the nation as a whole.25 California's antitobacco campaign suffered budget cuts after the first few years, and tobacco companies stepped up their political efforts to oppose the state's control measures, as well as their advertising and promotion of cigarettes; but the permanent changes in policy, as well as additional tax increases, have helped California to maintain its lead over all other states except Utah in keeping smoking levels relatively low. + California's campaign included an aggressive advertising component, which contributed significantly to the campaign's overall success. Studies of the effectiveness of antismoking messages have shown that some messages are much more effective than others. In fact, some programs sponsored by the tobacco industry, which are presented as smoking prevention efforts, have been shown to make smoking more attractive to youths. Examination of industry documents, discussed in the next section, has found that the industry has purposely used these "forbidden fruit" messages to generate good public relations and fight restrictive legislation without actually discouraging youth smoking. + Researchers found that the message most effective in reaching both youths and adults is that "Tobacco industry executives use deceitful, manipulative, dishonest practices to hook new users, sell more cigarettes and make more money."27(p.774) One such successful ad, called "Nicotine Soundbites," showed the actual footage of tobacco executives testifying before Congress in 1994, raising their right hands and swearing that nicotine is not addictive. Ads with this message made both adults and teenagers angry, because no one likes to learn that they are being manipulated. + Another message that was found to be effective among both adults and teens was that second-hand smoke harms others. One ad portrayed a boy smoking, sitting with his little sister watching television. The little girl begins coughing and smoke comes out of her mouth + Researchers concluded that, to be effective, antitobacco advertisements need to be " ambitious, hard-hitting, explicit, and in-your-face."27(p.776) The industry recognized the effectiveness of the ads and worked hard to limit them. R. J. Reynolds threatened to sue the California Department of Health and the television stations that ran the Nicotine Soundbites ad; the lawsuit was not filed, but the ad was later dropped. During the state campaign, the tobacco industry tried to counter the antitobacco efforts by increasing spending in California on advertising, incentives to merchants, and promotional items. One study calculated that after 1993, the industry spent nearly $10 for every $1 spent by the state. + The 1990s saw dramatic developments in the battle against smoking, and suddenly it seemed possible that effective tobacco control measures would be enacted at the federal level. The changes resulted from several separate political and legal events, as well as public revelations that have discredited the tobacco industry. In February 1994, David Kessler, then Commissioner of the Food and Drug Administration (FDA), launched an offensive against the tobacco industry by asserting that his agency had the authority to regulate tobacco. Kessler, who was appointed by the first President Bush but now had the support of an antismoking president, Bill Clinton, based his claim on thoroughly documented evidence that nicotine is an addictive drug and cigarettes are drug delivery systems. He proposed a series of measures aimed to protect children and teenagers against tobacco company efforts to get them hooked. + The MSA has been something of a disappointment for public health advocates. It was hoped that the states would use some of the settlement dollars for tobacco control programs. Smoking cessation programs that include counseling and nicotine-replacement therapy, such as nicotine gum or patches, can double or even triple a smoker's chance of quitting.32 Telephone quit lines, sponsored by some states and sometimes by voluntary organizations, can be effective at motivating people to quit. However, most states have used little of the MSA funds for such programs, using the windfall to close state budget gaps. On the other hand, tobacco companies have had to increase the price of cigarettes by 45 cents a pack to pay for the settlement. As discussed previously, higher prices discourage people from smoking, especially young people. + The original agreement negotiated by the state attorneys general and the tobacco companies contained a provision allowing the FDA to regulate tobacco. Because that agreement was not approved by Congress, the MSA did not contain such a provision. There are many advantages to giving regulatory authority over tobacco to the FDA. Until 2009, there were no legal restrictions concerning ingredients in tobacco smoke or on labeling or advertising concerning health claims by the companies. There is evidence, for example, that companies manipulated nicotine levels in tobacco to promote addiction, and they added ammonia to increase the effect of the nicotine. Tobacco smoke contains toxic chemicals such as nitrosamines and arsenic in addition to the tars known to be carcinogenic.30 It also contains radioactive polonium, which is not widely recognized.37 In fact, the American Legacy Foundation has focused on some of these toxic ingredients in their antismoking ads. + In 2009, Congress passed and President Obama signed a law authorizing the FDA to regulate tobacco products. It is hoped that the agency will devise ways to rein in the industry's deceptive practices, wean smokers off their addiction to nicotine, and reduce demand for cigarettes. Electronic cigarettes are a recent addition to the repertoire of nicotine-delivery systems. They have not been studied enough yet to understand their potential risks. The FDA does not currently regulate electronic cigarettes, but that situation may change. The battle continues. It seems that progress is being made, but prospects for victory in public health's battle against the powerful tobacco industry are uncertain.

Why "upstream" solutions to health issues make sense but are often difficult to conceive and implement.

+ Complexity of causal links and duration of causal processes makes definitive research difficult + Funding for research prioritizes single diseases, but upstream social determinants are not linked to single diseases + The benefits and beneficiaries of preventive medicine are unknown (in contrast immediate results of medicine). + it's really hard to change people's lifestyles, and it's really hard to have the resources to do that sort of work --> it often requires major governmental, political change and waay tooo much effort

The challenge of proving causation (e.g., that smoking causes lung cancer)

+ Epidemiologic studies are susceptible to many sources of error. Confounding factors may influence the results, suggesting an association where none exists. Bias may be introduced in the selection of cases or controls, in the reporting of exposures or outcomes, or in the disproportionate loss to follow-up of exposed and unexposed groups. Nevertheless, epidemiology is the basic science of public health. It is the only science of disease that focuses on human experience. + Epidemiology cannot prove cause and effect. However, certain characteristics of well-designed studies can make them very convincing. Studies with large numbers of subjects are more likely to be valid than smaller studies. A strong measure of association between exposure and disease, in the form of a high relative risk or odds ratio, is likely to indicate a true cause-and-effect relationship. A dose-response relationship that shows increasing risks from higher exposures adds to the validity of a study. A known biological explanation for an association between an exposure and a disease makes epidemiologic evidence more convincing than in situations when there is no known mechanism. + While observational studies have little potential for harming people, many ethical questions have been raised about clinical trials. In response to well-publicized abuses of the past, clinical trials and many other epidemiologic studies are required to be approved by committees, called institutional review boards, which ensure that the subjects' rights are protected. Other ethical concerns have been raised about the availability of treatments that have not been tested in clinical trials. On the other hand, conflicts of interest in the clinical trials for testing safety and efficacy of new drugs, which are required of pharmaceutical companies, have raised questions about the integrity of the research. Drug companies, which have vast amounts of money at stake in the outcomes of these trials, have found ways to manipulate the research to make drugs look better than they are. + Despite its flaws, epidemiology is still of necessity the basic science of public health. Epidemiologic data, when confirmed by repeated, well-designed studies and supported by the results of biomedical experiments in the laboratory, provide the best certainty as to the causes and cures of human disease. + The ultimate goal of many epidemiologic studies is to determine the causes of disease. This is generally done first by observing a possible association between an exposure and an illness, second by developing a hypothesis about a cause and effect relationship, and third by testing the hypothesis through a formal epidemiologic study. While the formal study can strongly support the conclusion that a certain exposure causes a certain disease, there are many potential sources of error in drawing such a conclusion. Studies of chronic diseases, which often have multiple determinants and develop over long periods of time, are especially prone to error. + One of the most common reasons for a study to lead to a wrong conclusion is that the reported result is merely a random variation and that the association is merely due to chance. As a general rule, epidemiologic studies of chronic diseases require large numbers of subjects to draw valid conclusions. Causes of these diseases are usually complex, and there are usually long periods between exposures to possible causes and the development of illness, making it difficult to draw conclusions about associations between exposure and disease. The cause-and-effect relationship is not obvious—as it is, for example, when a bullet in the heart causes death, or exposure of an unvaccinated child to the measles virus causes the child to develop measles in 10 to 12 days. The weaker the relationship between exposure and disease, the larger the group of people that must be studied for the relationship to be evident. + One and Hammond-Horn results concerning SMOKING AND LUNG CANCER are so convincing is that they involved such large numbers of subjects. + There are a number of other possible sources of error that well-designed studies may be able to avoid. For example, the cohort study of a low-fat diet proposed previously may be invalidated by the presence of confounding variables, like smoking and exercise. Confounding variables are factors that are associated with the exposure and that may independently affect the risk of developing the disease. Such an error may have occurred in a 1980s study that suggested coffee drinking could cause pancreatic cancer, a finding that has not been replicated in other studies. Since many heavy coffee drinkers were also smokers, there are suspicions that the cancer was caused by the smoking rather than the coffee.1 To eliminate the errors caused by smoking as a confounding variable, researchers might conduct the study only on nonsmokers. Alternatively, there are statistical techniques for adjusting the results to compensate for confounding variables as long as the investigator is clever enough to think of possible factors that may affect the result and to take them into consideration when collecting the data and calculating the results. While the investigators in the study of coffee corrected for smoking over the 5-year period before the cancer was diagnosed, the correction may have been inadequate. + Bias, or systematic error, may be introduced into a study in a number of ways. Selection bias is a particular problem in choosing subjects for a case-control study. For example, if the cases of heart disease are chosen from hospitalized patients recovering from heart attacks, and the controls include hospitalized patients being treated for a digestive disorder that causes extreme discomfort from eating fatty foods, the study may suggest an exaggerated effect of dietary fat on heart disease. The results would probably be different if the controls were patients recovering from the effects of motor vehicle crashes, whose diet might be more like the average American's. + The most important indication that an epidemiologic result is valid is that it is consistent with other investigations. If several independently designed and conducted studies lead to the same conclusion, it is unlikely that the conclusion resulted from bias or other error. If the reports are conflicting, however, people must be wary of accepting any of the results.

Global Smallpox Eradication Campaign (basic facts about the smallpox epidemic and about how it was eradicated)

+ In 1796 in Gloucestershire, England, Dr. Edward Jenner discovered the first vaccine for smallpox. Jenner used material from a skin pustule which contained live vaccinia virus, a virus believed to be spread by cows to milkmaids, causing cowpox. Milkmaids who contracted cowpox, a mild disease in humans, seemed to be immune to smallpox, a virulent disease in humans. Jenner inoculated 24 children with the vaccinia virus and, like the milkmaids, they became immune to smallpox. Despite its success, the smallpox vaccine never became widespread enough to fully control the disease until late in the 20th century. It was especially problematic in the tropics, where suspensions could not be kept cool enough to be effective. + Smallpox was still widely prevalent in the United States at the beginning of the 20th century + A vaccine is formally defined as "a preparation of killed, weakened, or fully infectious microbes that is given to produce or increase immunity to a particular disease." It can be given as an injection or in a form that can be swallowed (such as the polio vaccine).Vaccine researchers are inventing other means of safely and effectively delivering vaccines, such as nasal sprays. + Vaccines fall into three broad categories: Live (Attenuated) Vaccine: This type of vaccine uses a live, although weakened, version of the virus; it usually provides lifelong immunity to the recipient. Measles, mumps and rubella vaccines are examples of the live vaccine type. Killed (Inactivated) Vaccine: This vaccine uses a pathogen exposed to Formalin, a chemical that kills its genetic material, leaving just its shell. This form of vaccination usually requires several injections. The typhoid and Hib vaccines are examples. Toxoid Vaccine. This type of vaccine uses protein toxins that have been secreted by pathogenic bacteria but are inactivated. These vaccines also require several injections; diphtheria and tetanus vaccines are examples. + The story of vaccines begins with smallpox. Over thousands of years, hundreds of millions of people contracted the disease. The mummified body of Pharaoh Ramesses V of Egypt, who died in 1157 BC, shows a pustular rash, the earliest physical evidence of smallpox. During the next thousand years, traders carried the disease from Egypt to India, and from there it swept into China. It reached Japan by the 6th century and Europe by the 11th century, spread by returning crusaders. In the20th century alone, an estimated 300 million people are believed to have died from it. Although smallpox was declared eradicated in 1980, the threat that it might be distributed by a terrorist has created fear. + Smallpox was particularly contagious and deadly in populations exposed for the first time to explorers from Europe. It paved the way for Spanish conquests in Latin America. Historians say that smallpox made the Spanish conquest of Mexico possible when Cortés and his conquistadors unintentionally introduced it to the Aztec population in Techotitlan in 1520. Smallpox ravaged theAztecs, who had no natural immunity. Cortés and his men then proceeded to conquer a vastly weakened Aztec empire. During the French and Indian War, Lord Jeffrey Amherst deliberately infected blankets with smallpox and distributed them to Indians outside Fort Ticonderoga, the first known example of germ warfare. + Smallpox affects only humans. Transmission occurs when the variola virus(an orthopox virus) is inhaled in droplets or aerosols from the respiratory tract. Transmission also occurs through contact with skin lesions of infected patients or their bedding or clothing. The incubation period lasts seven to 17 days, with an average of 12 days. The disease presents first with fever for two to four days, followed by a rash lasting for weeks. The rash evolves slowly from papules to vesicles, then pustules and finally scabs, all at the same stage in any one area. + Transmission occurs mainly during the rash phase and diminishes as the lesions scab. Historically, about 50 percent of unvaccinated family members became infected. The mortality rate was 20 percent to 30 percent in unvaccinated populations, but many survivors were left with severe scarring and some with blindness. + Noting that survivors enjoyed lifelong immunity from any recurrence of the disease, physicians in China and India in the 10th century began to experiment with inoculation. In a process called variolation, these physicians introduced pus from smallpox pustules on infected people into non-infected people. Usually, the person who was inoculated would develop only a few pustules and a fever. However, in up to two percent of the cases, a virulent or aggressive form of the disease developed, causing death. Nonetheless, the odds were great that an inoculated person would survive and, thereafter, enjoy lifelong immunity. The idea of variolation spread to Europe. + Variolation: the deliberate inoculation of an uninfected person with the smallpox virus (as by contact with pustular matter) that was widely practiced before the era of vaccination as prophylaxis against the severe form of smallpox + In 1796, Dr. Jenner vaccinated 24 children with pus he had extracted from a milkmaid's cowpox pustule. First, he experimented with James Phipps, an eight-year-old boy, by introducing the cowpox strain through a cut in the arm. After purposely exposing the young boy to smallpox, Jenner followed the boy's status closely and concluded that the introduced vaccinia virus conferred immunity from smallpox. Next, Jenner inoculated his own 11-month-old son with the same result. The cowpox vaccine proved effective with all 24 children, conferring lifelong immunity from smallpox. By today's standards, Jenner's experiments on human subjects would not be considered ethical. Fortunately, the fact that his cowpox vaccine worked is not in dispute, and his discovery would protect millions of lives in the future. + Smallpox continued to appear in outbreaks throughout the world into the 20th century. In fact, a deadly smallpox outbreak in the United States between 1900 and 1904 caused an average of 48,164 cases in each of those years and resulted in an average of 1,528 deaths annually. Due to improved tracking and containment, outbreaks of the severe form of the disease (variola major)ended abruptly in 1929 in the U.S.; outbreaks of variola minor, the milder form, declined in the 1940s with the last U.S. case reported in 1949. + One scare in New York City in 1947 resulted in the city vaccinating more than six million residents. A Mexican businessman who traveled by bus to the city, unaware that he was incubating smallpox, spread the disease to 12 people, two of whom died, including him. + Fearing the worst in the densely populated city, health authorities took no chances and ordered the mass vaccination, which took place within one month at hundreds of stations in hospitals, police stations and firehouses. + A resolution proposed by a delegate from the former USSR at the 11th World Health Assembly in 1958 and passed by the assembly in 1959 paved the way for a worldwide effort to eradicate smallpox. In 1966 at the 19th World Health Assembly, the World Health Organization (WHO) called upon all the world's governments to support and give financial backing to a newly created Global Smallpox Eradication Campaign. + Why did smallpox, of all diseases, become a candidate for worldwide eradication? An important reason was that it remained a powerful killer throughout the world. In the year prior to the start of the WHO eradication program, an estimated 15 million people contracted the disease and an estimated two million people died from it. Smallpox lent itself to the possibility of complete eradication for other reasons as well. Only humans are hosts; no animal reservoir exists, so smallpox cannot jump from animals to humans. A prompt antibody response allows exposed people to be protected. The vaccine is very inexpensive, easy to administer, does not require refrigeration, and provides long-term protection. Smallpox has no subclinical infection, or hidden carrier state, to contend with. The disease is always overt and can, therefore, be traced and contained. + The Global Smallpox Eradication Campaign became a worldwide public health program like no other. The WHO chose Donald Ainslie (D.A.) Henderson to head the campaign. He moved to Geneva, Switzerland, from Atlanta, where he had headed the CDC's Infectious Diseases Surveillance Unit. - He pioneered improved methods for disease control that emphasized better reporting of infectious diseases so that control measures could begin sooner to control the diseases. This became the most important strategy in smallpox eradication - surveillance to detect cases as early as possible and vaccination of all contacts of patients by specialized teams so that the outbreak would not spread. + n 1967, the campaign got under way using D.A. Henderson's methods. The WHO worked with health workers in all the infected countries to form surveillance teams ready to track down smallpox outbreaks and armed with "recognition cards" that explained the disease simply. As the number of smallpox cases decreased, the teams offered rewards to encourage reporting. The earliest successes came in western and central Africa. Smallpox turned out to spread less readily than had previously been thought, and the world began to understand that prompt detection and containment could lead to the eradication of the disease. Although the western African countries reporting endemic cases at the beginning of the campaign were among the poorest in the world and had heavy infection rates, all but one of them became free of smallpox within three years. Brazil recorded the last casein the Western Hemisphere in April 1971. Well-executed eradication programs eliminated smallpox transmission in East Pakistan (now Bangladesh) in 1970 and in Indonesia and Afghanistan in 1972. In eastern and southern Africa, smallpox had been eliminated in all but three countries by the end of 1971. + The introduction of potent, freeze-dried vaccine and the bifurcated needle had remarkable effects on smallpox prevalence, even in countries where eradication programs stalled. The freeze-dried version solved the problem of the vaccine losing potency in the heat of the tropics. The bifurcated needle, which was easy to transport, simplified administering the vaccine. + bifurcated Needle: It holds a dose of reconstituted smallpox vaccine in its prongs and punctures a person's skin easily to the ideal depth for delivery. The needle was a cost-effective alternative to a clunky, unreliable jet injector that had been slowing down vaccination campaigns. + Unfortunately, setbacks did occur. In 1972, refugees returning to Bangladesh after its war for independence reintroduced the disease. In Botswana, introduction of the disease from South Africa created an epidemic, and in Iran, Iraq and Syria, cases were imported, and epidemics occurred. However, by late 1973 outbreaks had been contained except in Bangladesh. That year, intensified campaigns began in the five countries with remaining endemic cases - Bangladesh, India, Nepal, Pakistan and Ethiopia. India alone reported 64 percent of the cases worldwide. + By 1976, only Ethiopia remained with smallpox, and all attention turned to it. The milder strain, variola minor, spread tenaciously across a vast, sparsely settled region made destitute by civil war. The last outbreak was finally contained in the Ogaden Desert in August 1976.However, an affected nomad population had already migrated into Somalia, and it was there that the last known outbreak occurred on October 26, 1977. + In 1980, the WHO declared smallpox eradicated. The steps taken to get to that point illustrated how the surveil-lance and containment programs could be adapted to individual countries to allow teams to succeed in very different populations. The combination of a persistent, coordinated international effort, spearheaded by the WHO, and innovative approaches at local levels led to success. Lessons learned from the eradication campaign are relevant in the 21st century as the threat of weaponized smallpox forces the public health community to confront a scourge it hoped had been conquered.

Reasons why we need a moral/ethical foundation for public health

+ In certain situations, it is imperative that we have an ideology to work towards public health + In the absence of good, ethical, moral principles, upon what will public health principles be made? BY WHOEVER IS IN POWER (whichever dominant ideologies, institutions) AT THAT TIME, WHICH CAN BE PROBLEMATIC. + If the ideologies, political and economic institutions that weild power in the world today, are how we make decisions for public health, what are the potential problems with that? -- The nature of people in power, is to act on their own self-interest, so typically when people in power make decisions they tend to not take into account people who are vulnerable, but that is MOST what public health needs to focus on --> this is why we need an ethical foundation rather than just letting the dominant people in power make those decisions + Decisions aren't being made in a centralized way, so more susceptible to corruption from outside sources -- NO ethical code: Dominant ideologies make decisions .... -- Potential dangers: = Not all members of population included = People of power are not a part of those marginalized groups that need public health attention + We should want some sort of ethical principles to guide public health + Relational ethic -- interconnected instead of the individual: From "us" to "us all" + Catholic Social Teaching --Every human has dignity + Common Good -- Individual well-being is related to everybody's wellbeing

Confounding variable

A factor or explanation other than the one being studied that may affect a result or conclusion. Congenital Present at birth.

How does OHKA demonstrate this "future structure of public health"

Assessment/Intervention •Healthy Home Assessments •Construction •Supplies provision •Environmental testing Education/Outreach •Outreach events •In-home education •Curriculum development •Websites, video games, PSA's •Marketing campaigns Collective Impact •Collaborative efforts •Conference attendance •Presenting to community •Advocacy efforts •Research Public Health in Practice •Upstream problem solving •Accessible services and education •Scrappy mentality (in all aspects!) •Thick skin: healthcare isn't always pretty •Actually data-driven •Advocacy for people, policies, and ideals •Understanding of "common good" What's next for OHKA? Household conversation •Advocacy •Branching out to new communities •Educating on systematic issues •Creating a market for Healthy Housing

The Cure Violence strategy for intervention and how it exemplifies the idea of using epidemiological principles to address violence.

Cure Violence stops the spread of violence in communities by using the methods and strategies associated with disease control - detecting and interrupting conflicts, identifying and treating the highest risk individuals and changing community norms

The definition, mission, and substance of public health

Definition: Public health is the science of protecting and improving the health of people and their communities Mission: The fulfillment of society's interest in assuring the conditions in which people can be healthy. Substance: Organized community efforts aimed at the prevention of disease and the promotion of health

+ The Integrated Model that combines levels of prevention, chain of causation, and the three E's; apply this model to examples.

Host ➞ Education, Enforcement, Engineering Agent ➞ Education, Enforcement, Engineering Environment ➞ Education, Enforcement, Engineering ~ Primary and secondary Prevention •The primary domain of public health is primary and secondary prevention (ideal is to focus more effort upstream). •We can think of primary and secondary prevention strategies being targeted to: host, agent, and environment. •These targeted interventions at the host, agent, and environment could be accomplished by means of: education, enforcement, or engineering. •Primary/secondary prevention targeting the host (education, enforcement, engineering) •Primary/secondary prevention targeting the agent •Primary/secondary prevention targeting the environment

Understand and be able to apply the logic of the Tragedy of the commons

Illustrates why common resources are used more than is desirable from the standpoint of society as a whole The Tragedy optimizing for self in the short term is not optimal for anyone in the long term. Principle — What's good for all of us is good for each of us. Solution — Policy is critical for solving this problem.

Different ways of measuring rates of disease in a population

Incidence: The rate of new cases of a disease in a defined population over a defined period of time, usually a year Prevalence: The total number of cases existing in a defined population at a specific time. + A disease with high incidence (new cases) could have a low prevalence (proportion of cases in a population) if people recover from it rapidly or die from it quickly. + However, for chronic diseases that are not lethal -- like arthritis, the prevalence will be much higher than the incidence + For most diseases, prevalence rates change slowly and are less useful for epidemiologic studies --> more useful for addressing societal impact and planning for healthcare services

+ The nature of infectious diseases, chronic diseases, and injury-causing events—how they are similar/different and implications for intervention in these three domains.

Infectious = chain of causation chronic = levels of prevention injury = levels of prevention

Complex causal chains that link "upstream" causes to health outcomes

Look on powerpoint Example: Adult attention to child --> Development of neurological pathways in the Brain --> Cognitive ability --> Educational ability and attainment --> Multiple pathways to health (see Figure 4)

+ Market vs. social justice and how this relates to public health

Market Justice: + Market Justice is focused on individualism + Places the responsibility for fair distribution of health on market forces in a free economy. + Goods and (medical) services are distributed on the basis of people's willingness and ability to pay. Social Justice: + Focused on the common good + Emphasizes the well-being of the community over that of the individual + The inability to obtain health or health care due to a lack of financial resources is seen as unjust. How this relates to public health: Market Justice makes it harder for people to access healthcare services, as not everyone has the same resources. This lowers the overall health of the population as not everyone is healthy.

Compare and contrast the core functions of public health with the function of medical treatment.

Medical practice: -patient is the individual -diagnostic process for health/disease -strategic approach/treatment plan -goal is to cure Public health: -patient is the community -diagnoses the health of the community using public health sciences -treatment involves new policies and interventions -goal is to prevent disease and disability -Summarize the core

random variation

Natural variation in the output of a process, created by countless minor factors The way a coin will successively turn up heads or tails if flipped in just the same way.

Dose-response relationship

The relationship between the dose of some agent, or the extent of some exposure, and a physiological response. A dose-response effect means that the effect increases with the dose.

chain of infection

infectious agent (pathogen), reservoir, portal of exit, mode of transmission, portal of entry, susceptible host •Eradication is possible if there is no nonhuman reservoir and if a vaccine exists. •Smallpox was eradicated in 1977. •Polio was eradicated from the Western Hemisphere. •Now it is only in a few countries. •There is religious opposition in some countries. •Measles is the next target. •Now it is no longer endemic in the U.S.

The main tasks of the science of epidemiology

•Investigate causes of diseases •Identify trends in disease occurrence that may influence the need for medical and public health services •Evaluate the effectiveness of medical and public health interventions. Definition: Study of patterns of disease occurrence in human populations and the factors that influence these patterns.

+ Understand the three basic types of epidemiological studies and be able to identify strengths and weaknesses of each.

+ Intervention, Cohort, Control + Intervention ~ Start with Two groups: Experimental group (gets intervention or exposure), and control group (gets nothing) ~ Watch two groups overtime and compare outcomes ~Experimenter chooses who is in which group ~ Randomized, double-blind, placebo control is ideal Pros: that they are the most effective way to reduce confounding Cons: May be unethical, expensive, time-consuming, difficult Examples: • Field trial of polio vaccine in 1954 was randomized and double-blind. • Kingston-Newburgh study of fluoridation to prevent tooth decay was a community trial. + Cohort Study: ~Common when doing an intervention study would be unethical or too difficult. ~Considered the next most accurate kind of study. ~Choose a large number of healthy people, collect data on their exposures, and track outcomes over time. ~What is the key difference between intervention and cohort studies? ~In Cohort studies, people choose their own exposures. Pros: Cohort studies provide the best information about the causation of disease, because you follow persons from exposure to the occurrence of the disease, and you can examine a range of outcomes/diseases caused by one exposure (e.g. heart disease, lung disease, renal disease caused by smoking). Cons: They may require long periods of follow-up since disease may occur a long time after exposure. Therefore, it is a very expensive study design, not simple to conduct, slow and don't get results quickly Examples •Framingham Heart Study •Nurses' Health Study •British study of physicians on smoking and lung cancer •Hammond-Horn study on smoking and lung cancer in the U.S. + Case-control Study •Choose people who already have disease. •Choose a healthy control group of individuals, as similar as possible to cases. •Interview them all and ask for their previous exposures. •Estimate the strength of the association between exposure and disease by calculating an odds ratio. Pros: Faster and cheaper Cons: more likely to be inaccurate

* The two basic approaches to public health prevention/intervention: levels of prevention and chain of infection. Be able to apply these approaches to various diseases/health outcomes.

+ Levels of prevention approach ~ Primary prevention: {PREVENTING} prevents an illness or injury from occurring at all by preventing exposure to risk factors. (Example [modern Oral Health Strategy] -- Primary: fluoridation of water supply) ~Secondary Prevention: {TRIES TO STOP} Seeks to minimize the severity of the illness or the damage due to injury-causing event once the event has occurred. (Example [modern Oral Health Strategy] -- Secondary: education and incentives for regular dental checkups, daily dental care, etc. in order to catch cavities early) ~ Tertiary prevention: {TREATMENT/MEDICAL CARE} Seeks to minimize disability by providing medical care and rehabilitation services. (Example [modern Oral Health Strategy] -- Tertiary: dental technologies/procedures such as crowns, root canals, implants, etc. to minimize the damage/disability associated with neglected tooth decay) + Chain of Causation Approach: • Illness or injury is the result of a chain of causation involving an agent (e.g., virus), a host (the person), and the environment (means of transmission). Agent -->Environment-->Host -- Agent: Causative factors, risk factors, environmental exposures --Environment: Place characteristics, biological, physical, psychosocial environments --Host: Person characteristics, group and population demographics

Why should we focus upstream?

+ Upstream interventions address multiple (not individual) health outcomes + A reorientation toward upstream prevention would, ultimately, be more cost effective. + Downstream focus will never eliminate disparities (might improve overall health, but not disparities) •Fundamental cause theory (Link and Phelan 1995)

"Snowball effect" principle that has allowed us to divert resources to new threats

+ Whenever we start preventing certain problems, we can snowball resources and manpower into solving new problems. + Successful victories in public health allow us as a human race to reinvest our energy and attention into other problems -- once there is success in one area, you can reinvest that energy in other things

The three E's (means of intervention)

+Engineering +Education +Enforcement Example -- Motorvehicles Engineering - air bags, seatbelt installations Education - benefits of using a seatbelt, costs of not using one Enforcement - seatbelt laws, speeding laws

The "nutshell" model of epidemiological research, and how the Green et al. study demonstrates the steps of this model.

1. Counting frequencies of disease (who, when, where) Leads to the description of some pattern 2. Create a formal hypothesis about cause and effect 3. Use appropriate research study design to test the theory Green et al: + Counting Frequencies: They counted how many people were exposed to or affected by gun violence from this network of individuals in Chicago that were arrested for the same offense. + Created a formal hypothesis: When someone becomes a victim of gun violence, your risk of becoming a subject of gun violence temporarily increases. Predictive models like social contagion can help predict future gunshot subjects + Use appropriate research study design to test the theory: This study was an epidemiological analysis of a social network of individuals who were arrested during an 8-year period in Chicago, Illinois, with connections between people who were arrested together for the same offense. Modeling of the spread of gunshot violence over the network was assessed using a probabilistic contagion model that assumed individuals were subject to risks associated with being arrested together, in addition to demographic factors, such as age, sex, and neighborhood residence. Participants represented a network of 138 163 individuals who were arrested between January 1, 2006, and March 31, 2014 (29.9% of all individuals arrested in Chicago during this period), 9773 of whom were subjects of gun violence. Individuals were on average 27 years old at the midpoint of the study, predominantly male (82.0%) and black (75.6%), and often members of a gang (26.2%).

Understand the common "ingredients" in major public health victories and be able to apply them to other public health threats

1. good, well-funded epidemiological research (ex: funding the NIH) 2. Public Policies to implement those evidence-based interventions 3. Education of the public -- specifically education on changed social norms 4. Integration of macro-level strategies of preventing with individual treatment

Hemenway's reasons we don't spend more on public health

1.The benefits of public health programs lie in the future 2.The beneficiaries of public health are unknown. 3.The benefactors (those who work in public health) are also unknown. 4.Some Public health effort encounter not just disinterest, but outright opposition.

Case-control study

An epidemiologic study that compares individuals affected by a disease with a comparable group of persons who do not have the disease to seek possible causes or associations

Bias

The influence of irrelevant or even spurious factors or associations—commonly called confounding variables—on a result or conclusion.

The difference between "upstream" and "downstream" causes of health.

UPSTEAM: Upstream Social determinants of health refers to the macro factors that comprise social-structural influences on health and health systems, government policies, and the social, physical, economic and environmental factors that determine health. Upstream approach asks us to consider the social, economic and environmental origins of health problems that manifest at the population level, not just the symptoms or the end effect. ADDRESSING CONDITIONS IN WHICH PEOPLE ARE BORN, GROW, LIVE, AND PLAY(Ex: Economic and social opportunities and resources) DOWNSTREAM: Chronic disease treatment—emergency services, pharmacology, surgery, and dialysis. Downstream interventions and strategies focus on providing equitable access to care and services to mitigate the negative impacts of disadvantage on health. Toxic River: Contaminated water, factories are polluting water, and people are drinking it downstream. Downstream solutions: Providing a water filter to everyone in town that it is drinking it Upstream solution: Find out where the toxic water is coming from, and try to stop it from coming. + Toxic River illustration: Economic opportunities and resources | | Living and working conditions in homes and communities | | Medical Care --> personal behavior | | HEALTH + Health is downstream and economic opportunities and resources are upstream

Ways that the work of Partners in Health exemplifies the historical "ingredients" for public health success, the importance of working "upstream," and the ethical argument for public health.

Upstream:

Who is primarily responsible for organizing and funding public health in the U.S.?

WHO

The social contagion theory of gun violence.

social contagion is a type of social influence. It refers to the propensity for a person to copy a certain behavior of others who are either in the vicinity, or whom they have been exposed to. Social Contagion Model (example: gun violence) We modeled the contagion of violence over the network using a stochastic model in which the probability of future shoot- ings depended on the history of past shootings.11,42-45 Indi- viduals are susceptible to gunshot violence through the fol- lowing 2 means: (1) social contagion, reflecting the increased probability to be shot immediately after a person with whom one associates has been shot, and (2) a seasonal factor that re- flects the persistent rate of violence episodes within the net- work. The model expressed the social contagion component of susceptibility via 2 factors, namely, time and network struc- ture (section 4 of the eMethods and eFigure 4 in the Supple- ment). Consistent with previous models and epidemiological research, we assumed that gun violence is most likely to spread immediately after another shooting44-46 and between people who are closely linked in the network.47,48 Regarding this lat- ter point, we set the influence of contagion to weaken farther away from the source according to the inverse square of net- work distance and to disappear beyond 3 degrees of separa- tion (ie, >3 edges away in the network).

Core functions and essential services of public health

•Assessment (diagnosis) ~Essential Service #1: Monitor health status to identify community health problems. ~Essential Service #2: Diagnose and investigate health problems and health hazards in the community. •Policy Development (identify causes and plan treatment) ~Essential Service #3: Inform, educate, and empower people about health issues. ~Essential Service #4: Mobilize community partnerships to identify and solve health problems. ~Essential Service #5: Develop policies and plans that support individual and community health efforts. •Assurance (treatment and follow up) ~Essential Service #6: Enforce laws and regulations that protect health and ensure safety. ~Essential Service #7: Link people to needed personal health services and assure the provision of health care when otherwise unavailable. ~Essential Service #8: Assure competent public health and personal healthcare workforce. ~ Essential Service #9: Evaluate effectiveness, accessibility, and quality of personal and population-based health services. ~Essential Service #10: Research for new insights and innovative solutions to health problems.