Mieh 400 exam 1

normal life expectancy

80 years for males 82 years for females

Why Should We Care?

Risk factors does not recognize boundaries Collective effort makes a difference.

•Sources of Ambient air pollution

1.Naturally occurring 2.Anthropogenic (stationary and non stationary)

Fecal-oral: Diarrheal disease

2 million deaths/year from diarrhoea, mostly under 5 • 4.3% of Burden of Disease DALYs, 88% attributable to inadequate WASH

• 1/3 of developing world carry intestinal worms

200 million infected by schistosomiasis. (causes liver damage, kidney failure, infertility, poor growth) • 6-9 million blind from trachoma (1/4 reduced by adequate water supply)

Water "stress"

<1,700 cubic meters per person per year • 40% of the world's population does not have adequate water for basic hygiene An area is experiencing water stress when annual water supplies drop below 1,700 m3 per person. Different than actual water consumption.

"Acute water scarcity"

<500 cubic meters per person per year

100,000 adult Japanese females are stricken with a disease making them sick for 2 years (disability weight* = 0.6); 20% die at the age of 80 years.

= YLL + YLDYLL = {20,000 x (82-80)} YLD = {(100,000-20,000) x 2 x 0.6) = {20,000 x (82-80)} + {(100,000-20,000) x 2 x 0.6) = 40,000 + (80,000 x 1.2)= 136,000 DALYs

Global Burden of Disease

A gap measure between the current health of the global population and the "perfect health experience" scenario- where full life expectancy and full health is realized by all. GBD measures total burden of disease

open defecation

Estimated 2.6 billion people worldwide lack access to improved sanitation nearly 60% total people who practice open defecation live in India largely rural problem leads to water contamination (unprotected source)

DALY Assumption

Everyone in the world has a right to the best life expectancy in the world. Differences in the rating of a death or disability should be due to age and sex and not to income, culture, location or social class.

stage 3 of demographic transition

Fertility rates drop and cause a more even distribution of the population according to age and sex. (STATIONARY)

Gaps in Population Growth (watch video)

Hans Rosling explains why ending poverty - over the coming decades - is crucial to stop population growth. Only by raising the living standards of the poorest, in an environmentally-friendly way, will population growth stop at 9 billion people in 2050.

What is global health

Health problems, issues, and concerns that transcend national boundaries, which may be influenced by circumstances or experiences in other countries, and which are best addressed by cooperative actions and solutions

South East Asia

non comm, cd close behind

western pacific, AMR, EUR

non communicable

Nutritional transition

High vegetable/grain/non-processed food àProcessed foods with added sugar, saturated fats and sodium

•The three Key determinants of exposure to hazards

I.Duration II.Frequency III.Intensity

Water Scarcity

occurs when the demand for water from all sectors (agricultures, human consumption etc) is higher than the available resource It is fast becoming one of he most serious resources issue • Water "scarcity"• <1,000 cubic meters per person per year

measurement of GBD allows us to address

preventable diseases in each region of the world - how much risks to health can be avoided in future years.

Impairment

problem in body function or structure, e.g., broken leg

WHO Immediate objective WASH

raise awareness and change existing perceptions about the importance of WASH

In less than 3 months, a major international city will likely run out of water

In Cape Town, South Africa, they're calling it "Day Zero" -- the day when the taps run dry.City ocials had recently said that day would come on April 22. This week, they moved up the date to April 12. They're recycling bath water to help flush toilets. They're being told to limit showers to 90 seconds. And hand sanitizer, once somewhat of an afterthought, is now a big seller. It's been a slow-motion crisis, exacerbated by three factors: The worst drought in more than a century, which has pushed Cape Town's water scarcity into a potentially deadly horizonThe metro area's population, which is 4 million and growing quickly.A rapidly changing climate.

•Which sector in the United States is considered the top "water user" as well as top "water polluter"?

Industrial sector (46%)

How to Measure Disease at Global Level

Life expectancy another common and useful measure of disease burden

water supply systems in rural areas

Women may spend several hours each day hauling water from a distant source Water-hauling activities divert time and effort from more economically rewarding activities

Years Lived With Disability

YLD = I x D x DW YLD: Years of life lived with disability I: Number of incident cases in the population DW: Disability weight D: Duration of disability

GBD

a global estimate of disease, disability/injuries, and death. Collective impact of disease on the world population.

Health Benefits of Hand Washing

reduction in diarrheal disease, respiratory disease such as colds, school absenteeism Access to water - Critical first step for hand washing.

Human and Animal Fecal Contamination of Community Water Sources, Stored Drinking Water and Hands in Rural India Measured with Validated Microbial Source Tracking Assays

Abstract. We examined pathways of exposure to fecal contamination of human and animal origin in 24 villages in Odisha, India. In a cross-sectional study during the monsoon season, fecal exposure via community water sources (N = 123) and in the home (N = 137) was assessed using human- and nonhuman-associated Bacteroidales microbial source tracking (MST) markers and fecal coliforms (FCs). Detection rates and marker concentrations were examined to pinpoint path- ways of human fecal exposure in the public and domestic domains of disease transmission in study communities. Human fecal markers were detected much more frequently in the domestic domain (45% of households) than in public domain sources (8% of ponds; 4% of groundwater drinking sources). Animal fecal markers were widely detected in both domains (74% of ponds, 96% of households, 10% of groundwater drinking sources), indicating ubiquitous risks of exposure to animal feces and zoonotic pathogens. This study confirms an often suggested contamination link from hands to stored water in the home in developing countries separately for mothers' and children's hands and both human and animal fecal contamination. In contrast to MST markers, FCs provided a poor metric to assess risks of exposure to fecal contamination of human origin in this rural setting.

WHO regions

Africa, The Americas, South-East Asia, Europe, Eastern Mediterranean, Western Pacific

Africa pop growth

Africa....reductions in death rate because of infectious disease control (example: widespread spraying with DDT brought rapid control over mosquito borne killers such as malaria and yellow fever) and also because of fertility rates that remain high (lack of access to contraceptives) Nigeria predicted to grow 215 million

•Which sector uses the most water at a global scale?

Agriculture (70%)

Megacity

Any urban area with a population of ≥10 million 1900: None 1950: 2 (Tokyo and New York) 2017: 37 megacities 19 megacities, 13 of which are in developing countries Slum areas and shanty towns built without regard to local regulations

Global Health solutions

Approaches to tobacco control Polio eradication Containment of avian influenza Containment of Ebola

Investigation of a community outbreak of typhoid fever associated with drinking water

Background: This report is about the investigation of an outbreak of typhoid fever claimed three human lives and left more than 300 people suffered within one week. The aim of this report is to draw the attention of global health community towards the areas that are still far from basic human essentialities. Methods: A total of 250 suspected cases of typhoid fever were interviewed, out of which 100 were selected for sample collection on the basis of criteria included temperature > 38°C since the onset of outbreak, abdominal discomfort, diarrhea, vomiting and weakness. Food and water samples were also collected and analyzed microbiologically. Results: Inhabitants of village lived in poor and unhygienic conditions with no proper water supply or sewage disposal facilities and other basic necessities of life. They consumed water from a nearby well which was the only available source of drinking water. Epidemiological evidences revealed the gross contamination of well with dead and decaying animal bodies, their fecal material and garbage. Microbiological analysis of household and well water samples revealed the presence of heavy bacterial load with an average total aerobic count 106-109 CFU/ml. A number of Gram positive and Gram negative bacteria including Escherichia coli, Klebsiella, Bacillus species, Staphylococcus species, Enterobacter species, and Pseudomonas aeruginosa were isolated. Lab investigations confirmed the presence of multidrug resistant strain of Salmonella enterica serovar Typhi in 100% well water, 65% household water samples and 2% food items. 22% of clinical stool samples were tested positive with Salmonella enterica serover Typhi Conclusions: This study indicated the possible involvement of well water in outbreaks. In order to avoid such outbreaks in future, we contacted the local health authorities and urged them to immediately make arrangements for safe drinking water supply.

WHO 2030 Agenda for WASH

By 2030, achieve universal and equitable access to safe and affordable drinking water for all By 2030, achieve access to adequate and equitable sanitation and hygiene for all By 2030, end open defecation

Africa

CD

Health effects of air pollution?

Cardiovascular, upper respiratory, premature death]

Water Shortage in Nepal

Challenges: Getting water from its source to where people live Harvesting water that come down all at once See: Merchant of Thirst from NY Times Same area, different time of year. Flooding during monsoon, waiting for dinking water during winter

Growth rate:

Change in population size represented by the difference between the birth rate and the death rate

Participation restriction

Changed interaction with others at the social/environmental level, restricts participation in social environments e.g., cannot work

Global Health Issues Affected by transnational determinants

Climate change Urbanization Malnutrition - under or over nutrition

Purpose of DALY

Compare burden associated with different health outcomes Compare health burden among several populations/countries Estimate health trends of one population over time Provide balanced attention to the effects of fatal and non-fatal outcomes on overall population health Develop priorities for health services planning and research

Disability-Adjusted Life Years

DALY= YLL + YLD Years of Lost Life (due to premature mortality) Years Lost to Disability (due to injury or illness) single indicator of total disease burden combines years lost to premature mortality and the number of productive years lost to disability. 1 DALY = 1 lost year of healthy life. Combines information about mortality and morbidity in a single number. Allows the losses due to disability and the losses due to premature death to be expressed in the same unit.

Perinatal mortality rate

Death occurring in the fetus or infant between the twenty-eight week of pregnancy and seven days after birth/total birth x1000

Public Health Historical Development

Developed as a discipline in the mid 19th century. Focus - national issues. Data and evidence to support action, focus on populations, social justice and equity, emphasis on preventions vs cure.

ØIn your own words interpret the concept of DALY in global health setting

Disability Adjusted Life Years; 1 DALY = 1 Year lost of healthy life

Epidemiological transition

Epidemics (infectious disease & war and famine)à receding pandemics (improved nutrition, sanitation, and medical care)àNCD (degenerative diseases experienced by older adults

Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis

Many studies have reported the results of interventions to reduce illness through improvements in drinking water, sanitation facilities, and hygiene practices in less developed countries. There has, however, been no formal systematic review and meta-analysis comparing the evidence of the relative effectiveness of these interventions. We developed a comprehensive search strategy designed to identify all peer-reviewed articles, in any language, that presented water, sanitation, or hygiene interventions. We examined only those articles with specific measurement of diarrhoea morbidity as a health outcome in non-outbreak conditions. We screened the titles and, where necessary, the abstracts of 2120 publications. 46 studies were judged to contain relevant evidence and were reviewed in detail. Data were extracted from these studies and pooled by meta-analysis to provide summary estimates of the effectiveness of each type of intervention. All of the interventions studied were found to reduce significantly the risks of diarrhoeal illness. Most of the interventions had a similar degree of impact on diarrhoeal illness, with the relative risk estimates from the overall meta-analyses ranging between 0·63 and 0·75. The results generally agree with those from previous reviews, but water quality interventions (point-of-use water treatment) were found to be more effective than previously thought, and multiple interventions (consisting of combined water, sanitation, and hygiene measures) were not more effective than interventions with a single focus. There is some evidence of publication bias in the findings from the hygiene and water treatment interventions.

Limitations of Mortality Rates and Life Expectancy

Metric does not tell us anything about disease burden among people living with disability/illness. quality of life loss of productivity HIV prevalence or maternal mortality rates Access to sufficient health care and coverage

Question: Which country has the highest under five mortality in North America?

Mexico? 10-49 per 1000

Global Health Historical Development

More recent in its origin, a greater scope of health problems and solutions that transcend national boundaries requiring greater inter-disciplinary approach

stage 2 of demographic transition

Mortality rates drop and fertility rates remain high. There is a rapid increase in population, particularly among the younger age groups. (EXPANDING)

Birth of the "Megacity"

Most population growth in cities in developing countries is occurring in "illegal settlements" u30-60% of people living in developing country cities live in substandard housing Poverty is increasingly an urban phenomenon Today, ~50% of the world's poorest people are living in urban settlements

in order to improve WASH

Need to raise mass awareness make the identified audiences more conscious about issues related to the importance of sanitation and hygiene (Awareness raising) § Need to influence decision makers and opinion leaders to advocate for improved sanitation and hygiene standards (Advocacy) § Increase public demand for quality sanitation services and adoption of hygiene practices (Social/behavioural change).

•Why is this metric superior to other metrices such as mortality rate or life expectancy rate?

Not only quantifies death but measures the quality of life accounting for pain & suffering

What is Meant by "Disability?"

Objective alteration of behavior or activity at the individual level, e.g., cannot walk

population currently live in countries where there isn't enough water or the quality has been compromised

One third of world UN estimates that by 2025 • 2/3s world populationàwater stress • 1. 8 billion peopleàacute water scarcity

stage 1 of demographic transition

Population mostly young, and fertility and mortality rates are high. Overall, the population remains small. (EXPANDING)

Reasons Behind the Population Explosion?

Reductions in death rates over time Advances in agriculture Improvements in public sanitation Control of infectious diseases (antibiotics) gains (or reductions in death rates) were gradual until about 200-300 years ago... Resulted in precipitous declines in death rates, particularly in terms of infant and child mortality

Human Population Growth

Since the 20th century, humans have experienced unprecedented population growth Annual increase in the world's total population is > 80 million This explosive growth of the human species is arguably the most significant development, dating back thousands of years

DALYs can be calculated for

Specific environmental diseases OR Specific environmental risk factors (exposures)

Merchant of Thirst from NY Times

Tanker water costs on average 10 times more than government-supplied pipeline water Locals tell tales of frequent underhand deal making, pipeline sabotage and egregious environmental destruction. World Health Organization recommends that households spend no more than 3 to 5 percent of their income on water, but tanker-dependent Nepalis shell out up to 20 percent of their earnings,

Death rates

The annual number of deaths per 1,000 population.

Total fertility rate (TFR):

The average number of children each woman within the population is likely to bear during her reproductive lifetime.

Birth rates

The number of babies born per 1,000 people per year. High income countries tend to have lower birth rates

infant mortality rate

The total number of deaths in a year among infants under one year old for every 1,000 live births in a society.

Doubling time

Time required for population to double

Unimproved Drinking Water Sources

Unprotected dug well ØUnprotected spring Ø Surface water (river, dam, lake, stream, irrigation channel) Ø Vendor-provided water (cart with small tank/drum) ØBottled waterØ Tanker truck water

Unreliable water supply systems in urban areas of LMIC

Water available only a few hours a day Personal hygiene and basic sanitation frequently neglected Vendors sell water at high price, burdening family incomes [see Merchant of Thirst]

Disease burden

can be attributed to either specific diseases (e.g. HIV, TB, obesity, diabetes) and risks for ill health (unsafe sex, overcrowding, smoking, excess cholesterol).

WHO long term objective WASH

change social norms § make open defecation unacceptable § promote practice of safe disposal of child faeces, handwashing with soap § safe storage and handling of drinking water

most populous countries 2015

china, india, u.s.

Primary source of indoor air pollution

cook smoke ●Source materials? ○Solid Fuels ■Crop Waste, Dung, Wood, Charcoal, Coal ●Dangers of burning such? ○Poor ventilation, half of world's population dependent on burning solid fuels ○Volatile Organic Compounds and Polycyclic Aromatic Hydrocarbons = known carcinogens ○Adverse health effects such as low birth weight, pneumonia in children, Lung Cancer, COPD, etc.

DISABILITY WEIGHTS

disability weight is a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (equivalent to death). Years Lost due to Disability (YLD) are calculated by multiplying the incident cases by duration and disability weight for the condition.

DALYs provides a balanced attention to

effects of non- fatal as well as fatal diseases on overall health. In the absence of such assessments, conditions which cause decrements in function but not mortality tend to be neglected.

Improved sanitation:

facilities that hygienically separate human excreta from human contact

CAN inform debates on priorities

hould not be the only metric): Compare the health of one population with another - and allow decision makers to focus on health systems with the worst performance Compare the health of the same population at different points in time Compare the health of subgroups within a population - to identify health inequalities ↑↑ DALY, the worst it is

Examples of health problems

include infectious diseases (SARS, TB, avian influenza, malaria,) non infectious diseases (diabetes mellitus, tobacco related diseases) and other health risks (global warming, conflict, nuclear power) etc.

Classification of Causes of Death Group I

includes communicable, maternal, and perinatal causes and nutritional deficiencies.

Classification of Causes of Death Group II

includes the non-communicable causes including cancers, diabetes, cardiovascular disorders and chronic respiratory diseases

Classification of Causes of Death Group III

includes unintentional and intentional injuries.

most populous countries 2050

india, china, u.s., nigeria

What would a full healthy life would look like?

max health, max life expectancy

life expectancy varying

monaco: 89.5 chad: 50.2 look at discussion post

International Health Historical Development

more concerned with the diseases (e.g. malaria) and conditions (e.g. natural disasters) of low and middle income countries (LMICs). Approach typically involves uni-direction flow of 'good ideas' and foreign aid efforts from industrialized countries to developing countries always been linked with nongovernmental action, focusing on locally developed, sustainable solutions.

Ending Open Defecation and Achieving a Clean and Healthy Rural India

mproving sanitation in India's villages, where three out of five people defecate in the open, has proved to be one of the country's greatest development challenges. A new $1.5 billion World Bank project will now support the rural component of India's Swachh Bharat - or Clean India - Mission, the country's largest-ever drive to improve sanitation. World Bank support will help accelerate results in India's states by giving them performance-based incentives. The project will promote behavior change among rural communities and help accelerate results in India's states by giving them performance-based incentives

EMR

non comm, cd close behind

Share of World Population by Major Geographical Region, 1950 and 2050

virtually all of the increase in human numbers over the next several decades will be in developing countries Africa and Asia pop growth Changes in population growth rates are not equally distributed across the planet. Industrialization à in general leads to falling birth rates and death rates...this is called demographic transition, a trend that accelerated throughout the 20th century Reasons for demographic transition are still being debated: realization by couples in industrial societies that children are expensive

•Who are the two vulnerable groups mostly exposed to indoor air pollution ???

women and children

WHO GBD Intro Main Issues

· The GBD study is the most comprehensive and consistent set of estimates of morbidity and mortality by age, sex and region. · The DALY is a summary measure of population health, combining mortality and disability. · The DALY measures a health gap, relative to an "ideal" life expectancy of 80 years for men and 82.5 years for women. · The DALY is the sum of years of life lost and years of life lived with disability. · A disability weight is used to characterize each disease or sequelae. · Social preferences for the point in time or age at which a death or disability occurs are incorporated into DALY calculations.

Improved Drinking Water Sources

ØPiped household water ØPublic standpipe ØBorehole ØProtected dug well ØProtected spring ØRainwater collection

Next 10 years, many countries important to the United States will experience water problems

ØWill risk instability and state failure, increase regional tensions, and distract them from working with the United States. ØBetween now and 2040, fresh water availability will not keep up with demand absent more effective management of water resources. ØWater problems will hinder the ability of key countries to produce food and generate energyàrisk to global food markets and economic growth. ØNorth Africa, the Middle East, and South Asia will face major challenges coping with water problems.

Air Quality Index

• Air quality indicator related to potential health effects

Criteria Air Pollutants (NAAQS)

○Carbon Monoxide (CO) ○Nitrogen Dioxide (NO2) ○Lead ○Ozone ○Particulate Matter (PM10 and PM2.5) ○Sulfur Dioxide

Potential air pollution Solutions

●Energy Conservation ●Renewable energy ●Technological Controls ●Public transportation ●International coordination efforts ○Kyoto Protocol ○Copenhagen Accord ○Paris Agreement

Ground Based Monitoring

●Measures elevation we breath, accurate ●Expensive, can only measure where stationed

Model Data

●Scientific models based on the aggregate of ground based and satellite data

Satellite Data

●Widespread coverage, continuous data collection, data is accessible ●Measures entire vertical column of atmosphere and is susceptible to atmospheric interruptions