Вы находитесь на странице: 1из 21

Chapter1:PublicHealth:Science,Politics,andPrevention

WhatisPH?

WhatisHealth?
Thefutureofpublic
health

Definitionofpublichealth

Corefunctionsofpublic
health

Thefulfillmentofsocietysinterestinassuringtheconditionsinwhich
peoplecanbehealthy.
Organizedcommunityeffortsaimedatthepreventionofdiseaseandthe
promotionofhealth.(Forexample:drinkingwaterinUS/othercountries)
Astateofcompletephysical,mental,socialandspiritualwellbeingand
notmerelytheabsenceofdiseaseWHOdefinition
Healthrepresentsadynamicstatewithhabitsthatpromotehealthand
loweringriskofanydiseases
Mission:Thefulfillmentofsocietysinterestinassuringtheconditionsin
whichpeoplecanbehealthy
Substance:Organizedcommunityeffortsaimedatthepreventionofdisease
andthepromotionofhealth.
OrganizationalFramework:Activitiesundertakenwithintheformalstructure
ofgovernment,andtheassociatedeffortsofprivate/voluntary
organizations/individuals.
CoreFunctions:Assessment,Policydevelopment,Assurance
DreamofPublicHealth:Preventdiseaseanddeathincidencesandworkfora
commongood,butunfortunatelythisisnotalwaysanumberonepriority
forthegovernmentadministration,ortheeconomy,orpublicopinionofthe
time.
PublicHealthisthescienceofprotectingandimprovingthehealthof
communitiesthrougheducation,promotionofhealthylifestyles,and
researchfordiseaseandinjuryprevention.Publichealthprofessionals
analyzetheeffectonhealthofgenetics,personalchoiceandtheenvironment
inordertodevelopprogramsthatprotectthehealthofyourfamilyand
community.
Assessment:Identifieseventsandexposuresthatmaybeharmfulto
humansandestimatestheprobabilitiesoftheiroccurrenceandextentof
harm

PolicyDevelopment:Formulatingpublicpolicies,incollaborationwith
communityandgovernmentleaders,designedtosolveidentifiedlocal
andnationalhealthproblemsandpriorities.

Assurance(protecthealthandpreventdisease):Assuringthatall
populationshaveaccesstoappropriateandcosteffectivecare,including
healthpromotionanddiseasepreventionservices,andevaluationofthe
effectivenessofthatcare.

Comparewithamedicaldoctor:
Diagnosticprocessforhealth/disease,
Strategicapproach/treatmentplan,
Actualtreatmentservicesavailable
Boldones=coreones!

Rectangularizingthelife
curve

Publichealthdisciplines

Aboveimage:theactivitiesarejustdecreasingduetoageyourfunctionis
decreasingNATURALLY.
Epidemiology(epidemics/obesity,prostatecancerinwesterncountries
andAsia),newdiseases:firstindications,preventingspreadofdisease,
identifyingchronicdiseases

Ex:Tracebackeveryonewhohasbeenincontactwithacollegestudent
diagnosedwithMeningitis
o Thebasicscienceofpublichealth
o Thestudyofepidemics
o Aimstocontrolspreadofinfectiousdiseases
o Seekscausesofchronicdiseaseandwaystolimitharmfulexposures.
o Showsconnectionwithconsumptionoflikegreenteaetc.
o Thecommondenominatorofthedisease,whereisitfound?What
populationusesitthemost?
Statistics(calculaterisks,testingthenewdrug):diagnostictools;how
healthyorsick?
Ex:U.Sisranked28thininfantmortalityamongtheworld,thisisone
indicationthatPublicHealthmaynotbeasgoodasothercountries.
o Collectionofdataonthepopulation
o Thesenumbersarediagnostictoolsforthehealthofthecommunity
o Thescienceofstatisticsisusedtocalculaterisks,benefits.
BiomedicalSciences(AIDS,flu,Hantavirus.Cancer):howagentsare
spreadandhowtheyaffectthehumanbody?
Ex:AIDS,andnoninfectiousdiseasesCancer
o Infectiousdiseasespathogens
o Chronicdiseases
o Genetics
EnvironmentalHealthScience(newchemicals)
o Healtheffectsofenvironmentalexposures
o AirQuality
o WaterQuality
o Solidandhazardouswastes
o Safefoodanddrugs
o Globalenvironmentalchange
o Howtopreparesafefood
SocialandBehavioralSciences(Latinoparadox):manypeopleare
dyingofdiseasecausebytheirbehaviorandsocialenvironments
Ex:Nutritionandexercisepatterns.FormsofCancercausedby
smoking

Primaryprevention
Secondaryprevention
Tertiaryprevention
Chainofcausation

WhatisChronicFatigue
Syndrome(CFS)?

o Behaviorisnowtheleadingfactorinaffectingpeopleshealth
o Theoriesofhealthbehavior:socialenvironmentaffectspeoples
behavior
o Majorhealththreats:tobacco,poordietandphysicalinactivity,
injuries
o Maternalandchildhealthasocialissue
o LatinoParadoxcomparepregnantwomaninLatinopopulation
o Whyarepeopledoingthebehaviortheyaredoing?
o Education&promotion
HealthPolicyandManagement:preventingdiseasethroughwater,air
andfood
Ex:Safedrinkingwaterduetowastedisposal
o Roleofmedicalcareinpublichealth
o CostofmedicalcareinU.S.isoutofcontrol
o U.S.hasahighpercentageofpopulationwithouthealthinsurance
thesepeopleoftenlackaccesstomedicalcare
o Qualityofmedicalcarecanbemeasured,andisoftenquestionable.
Preventdisease
Minimizetheseverityoftheillness
Minimizethedisability,rehabilitations
Agent
Host
Environment
Interventionscanfocusonanyofthesetargets.
Malaria,WestNilevirus,Hantavirus,
Highdietaryfat/typeoffood/schools/education,cookingclass(prevent
obesity)

Immunesystemcompromised

Marginaldeficiencies:
i. Folicacid
ii. VitaminB12andVitaminBgroup
iii. VitaminC
iv. Magnesium
v. Zinc
vi. LTryptophanserotonin
vii. Essentialfattyacidsomega3andratio
viii. Sodium
ix. Water
Underlyinghealthproblems
i. Depression
ii. Cholestasis/impairedliverfunction..(sat.fat,ref.sugar,low
fiberdiet,drugs)
iii. Obesity
iv. Diabetes
v. Medication/drugs/alcohol
vi. Cancer
vii. Constipation
viii. Chronicstressoveruse
ix. Chroniclackofsleep

Whatwerethe5Questions
Shakespeareaddressed?

Differencesbetween

PublicHealthSciences&

Politics
PublicHealthApproach

x. Hypoglycemia
xi. Chemicalsensitivity
Sleep:howmanyhours/day?
Exercise:howmanyminutes/hours/day?
Stress:howmanyminutes/daydoyoulaugh?
Coffee&caffeinateddrinks:howmanycups/daydoyoudrink?
Fruits&vegetables:doyouliketoeat?
Scienceishowweunderstandthreatstohealth,determinewhatinterventions
mightwork,andevaluatewhethertheinterventionsworked
Politicsishowweasasocietymakedecisionsaboutwhatpoliciesto
implement
Example:tobaccolungcancer/policyofnonsmokingarea
Definethehealthproblem
Identifytheriskfactorsassociatedwiththeproblem
Developandtestcommunitylevelinterventionstocontrolorpreventthe
causeoftheproblem
Implementinterventionstoimprovethehealthofthepopulation.
Monitortheinterventionstoassesstheireffectiveness.
Howyouapproachdifferentproblems:doanassessment,dorisks,develop
promotionprogram,intervention.,applyandobserve

BookDefinition:
1.Definehealthproblem
2.Identifyriskfactors
3.Developandtestcommunitylevelinterventionstocontrolor
preventproblem
4.Implementinterventionstoimprovehealthofpopulation
5.Monitorthoseinterventionstoassesstheireffectiveness

Howdothesefunctions
comparewiththe
functionsofmedicalcare?
Howarethesixdisciplines
ofpublichealthusedto
accomplishthecore
functions?

Diagnosis,treatmentplanning,therapy

Epidemiology,Statistics,BiomedicalSciences,EnvironmentalHealth
Science,Social&BehavioralSciences,HealthPolicyandManagement

Chapter2:WhatisPublicHealthControversial?
Marketjusticevs.Social
Justice

Publichealthshouldbeawayofdoingjustice,awayofassertingthevalue
andpriorityofallhumanlife
PublicHealthasasocialjustice
Dreamofpublichealth:preventabledeathanddisabilityshouldbe
minimized
Politicalconservatives:limitpublichealthtoatechnicalenterprise,focused
oncontrollingcommunicabledisease,orsafetynetthatprovidesmedical
caretotheindigent

Costvs.BenefitinPublic
Health

TragedyoftheCommons

Paternalism
Politicalinterferencewith
Science

ThisrestrictiveviewofPHwasencouragedbyphysicians,concernedabout
governmentencroachmentontheireconomicandprofessionalindependence
Limitationsonfederalfundingtolocalpublichealthdepartments19301940
Thecommongood(thevalueandpriorityofhumanlife)
Individualresponsibility
Questionsaboutthescopeofpublichealth
Importanceofeconomicfactorsforhealthpoliticallycontroversial
Peoplewithhigherincomestendtobehealthierforavarietyofreasons.
Businessesoftenresistpublichealthmeasuresbecausetheyaffectprofits
Thosewhomustpaymaynotbetheoneswhobenefit
Costsmaybeshortterm,whilebenefitsmaybelongterm
Costseasiertocalculatethanbenefits
Milkproducersresistedpasteurization
Landlordsresistedbuildingcodes,
Automobilemanufacturesresisteddesignchangestoimprovesafety
Cigarettesalesalsoareasignificantincomeforsmallbusinesses
Ownersofbarsandrestaurantsfoughtlawsrestrictingsmokingontheir
premises,fearingthattheywouldlosepatronageofsmokers
Intimesofeconomicdifficulty,peopleareoftenunwillingtopayshortterm
costinordertoobtainabenefitinthelongterm.
Fishing&lumberindustrysourcesdepletedriskofkillingallfish,
cuttingdownallthetimber
Examples:
o Companiesresisttoughpollutioncontrol
o Madcowoutbreak,(USAnotesting,Americanbeefbannedinmany
countries)
SmoginLA:tocalculatethecostofreductioneasy,howtocalculatewhether
thisbenefitisworththecoastdifficult,alsotimelineproblem
Exemplifiedinmanyenvironmentallaws
Freedomtopollute
Behavioronindirectharm:tragedyofthecommons
Inindustrialworldcommonsisair,water.
abanonagasdrivenlawnmovers(1versusmany)
Eliminationofdrivethroughwindowsinbankandfastfoodrestaurants(cut
pollutionfromidlingcarengines).1versusmany
ExampleinEurope:stopcarenginenoidlingcarengines
Ithastobeacceptableforchildren
Thereisalwaysthepossibilityoftension
Currentconservativecontroloffederalgovernmentintensifiestheconflict
CriticismofBushadministrationforgoingtoofarinmisrepresentingscience
tosupportitspolicies.
2004USC(UnionofConcernedScientist):morethan60leadingscientists
&20NobelPrizeWinnerssignedareport:
administrationsmisrepresentationorsuppressionofscientificinformation
toobscurethefactthatpolicydecisionsarebasedonitspoliticalagenda.
Examples:
o PRESSUREON:CenterforControlDiseaseandPrevention(CDC):

topromoteabstinenceonlyprogramforpreventingteenpregnancy
o 2003:NationalCancerInstituteswebinformationsuggestingthat
havingabortionincreasedawomensriskofbreastcancer
o ThePresidentsCouncilonBioethics:wascreatedtoconsider
researchonembryonicstemcells..early2004twomembers,
scientistswhoweresupportersoftheresearch,weredismissed
o AdvisorycommitteeonChildhoodleadpoisoningpreventionact:
recommendstrictfederalstandardsforexposuretolead,thehighly
qualifiedscientistreplacedwithmemberswhohadfinancialtiesto
theindustry

Chapter3:PowersandResponsibilitiesofGovernment
Administrativeagencies

Roleofthecourts

OSHA(Occupational
safetyandhealth
administration)

CDC

NIH

PublicHealthatthelocal,
state,&federallevel
(federalvs.state)

Departmentofhealthandhumanservices(HHS)
CentersforDiseaseControl&Prevention(CDC)
NationalInstitutesofHealth(NIH)
EnvironmentalProtectionAgency(EPA)
InBranchesofgovernment:
Legislativepassesstatutes
Executivepublichealthagenciescarryoutthelaw;mayissueregulations
consistentwithstatutes
Judiciallawsandregulationscanbechallengedincourt
Coordinateactivitiesoflocalhealthagenciesandprovidefunding
Collectandanalyzedata
Laboratoryservices
ManageMedicaid
Licenseandcertifymedicalpersonnel,facilities,andservices
Environment,mentalhealth,socialservices,andagingmaybehandledby
separateagencies
CentersforDiseaseControlandPrevention
Mainepidemiologicandassessmentagencyforthenation
PublishesMorbidityandMortalityWeeklyReport(MMWR)
CenterforHealthStatisticscollectsdataonU.S.populationconcerningall
aspectsofhealth
Centersoninfectiousdiseases,chronicdisease,injuryprevention,andothers
NationalInstitutesofHealth
Biomedicalresearchagency
Institutesoncancer,heartandlungdisease,diabetes,aging,childhealthand
humandevelopment,andothers.
NationalLibraryofMedicine
HaslaboratoriesinBethesda,MDandprovidesgrantfundingtoresearchers
inuniversitiesandresearchcenters.
ClinicalCenterwheremedicalresearcherstestexperimentaltherapies
U.S.Constitution:Topromotethegeneralwelfare
Reserveclause:sincehealthisnotmentionedintheConstitution,primary
responsibilitybelongstothestates
Interstatecommerceclausejustifiesfederalroleinsomecases
Powertotaxandspendiswidelyusedbyfederalgovernmenttocontrol
publichealthpolicy

NGOs(nongovernmental
roleinpublichealth)

Chooseaspecifichealth
problem.Howmight
federal,state,andlocal
levelsofgovernment
divideresponsibilityfor
addressingit?

AmericanCancerSociety,AmericanHeartAssociation,AmericanDiabetes
Association,AlzheimersDiseaseandRelatedDisordersAssociation,and
others
AmericanMedicalAssociation,AmericanNursesAssociation,American
PublicHealthAssociation,andothers
Consumergroups
LungCancer,etc.

Chapter4:EpidemiologyTheBasisofPublicHealth
Epidemiology

JohnSnow

Vauxhall&Lambeth
watercompanies
Epidemiologicsurveillance

Thediagnosticdisciplineofpublichealth
Amajorpartofpublichealthsassessmentfunction
Investigatescausesofdiseases
Identifiestrendsindiseaseoccurrence
Evaluateseffectivenessofmedicalandpublichealthinterventions
Anobservationalscience
o Prettymuchwhatkindofdiseaseyouhaveandthetrendsthatareinvolvedin
Observationalscience
PatternsofDiseaseOccurrence
Whoisgettingthedisease?
Whendidtheygetthedisease?
Whereisthediseaseoccurring?
Fromthisinformation,epidemiologistscaninferwhythediseaseisoccurring.
CholeraepidemicsinLondon,mid1850s
Suspectedanassociationwithwatersupply,whichcamefromtheThames
River
Naturalexperiment
Questionedhouseholdswhereacholeradeathhadoccurred
Mostdeathsassociatedwithonecompany
JohnSnowfatherofepidemiology
o Wentdoortodoorandaskedwhowhatwhenwherehewas
tryingtofindacommondenominatorandcametoaconclusionthat
inacertainneighborhoodwaterhadcholeraandtheother
neighborhooddidnt.

Endemicvs.Epidemic
Notifiablediseases
Recognitionofnewdisease
Increasedimportancewiththreatofbioterrorism
Patternsofthedisease,factorsthatinfluencethesepatterns
Increaseinthefrequencyofadiseaseabovetheusualandexpectedrate
Notifiablediseases:toreportadiseaseHepatitisAinthebook.pg56

NotifiableDiseases
Legionnairesdisease

Eosinophiliamyalgia
syndrome

Chronicdisease&
Epidemiology

Heartdisease,Lung
Cancer,Tobacco

Recognitionofnewdisease
Increasedimportancewiththreatofbioterrorismthedangeramountofthedisease
HepatitisA
July1976:AmericanLegion4dayconventioninPhiladelphia
HotelBellevueStratford
Symptoms:fever,muscleaches,andpneumonia
August150cases
Airborne,nopersontopersoninpatientsfamilies
Legionellabacteriainthewaterofcoolingtower
Federalairconditioningstandardschanged
Infectiousortoxicdisease
1989inNewMexico/SantaFe
Symptoms:fatigue,debilitatingmusclepain,rashes,shortnessofbreath,bloodtest:h
LTryptophandietarysupplement
NewMexicoStateHealthDepartment
Toxiccontaminationrecentchangeofproductioninonefactory
1981:Madrid/SpainsimilartoEMS
Morethan20000people/morethan300died
Householdsboughtoilforcookingfromsalesperson(oilforindustrypurposes)

Identifyriskfactors
Observelongtermtrends
HeartdiseaseleadingcauseofdeathinU.S.
FraminghamStudystartedin1948
Lungcancerandsmokingearly1950s
BritishPhysiciansStudy
HammondHornstudyinU.S.
LungCancer
o 1950/1952:lungcancerandtobaccosmoking
o QuestionnairetophysiciansinUK:smokers,pastsmokers,nonsmokers(age
smoking)
o Deathratefromlungcancer20xhigheramongsmokers
o Deathrateamongnonsmokerswaslowerthanofsmokers
o Anddeclinedasthelengthoftimeincreasedsincetheyhadquitsmoking
o Cigarettesmokers:5xmoretodiefromothercancerstongue,pharynx,laryn
o Heavysmokers(2ormorepacks/day)were2.4xmorelikelytodiefromheart
HeartDisease
o 1920:heartdiseaseleadingcauseofdeathinUSA
o 1948:firstmajorepidemiologicstudy:Framingham,Massachusetts

FraminghamStudy

o 5000healthypeople,examinedanddatarecorded:weight,BP,smokinghabits
o Every2yearstestsrepeated
o 10years:identificationmajorrisksfactors:highBP,highbloodcholesterol,sm
o HDL,LDL,
Majorriskfactorsforcardiovasculardiseasesidentified
Abetterunderstandingofeffectoflifestyle

BritishPhysiciansStudy
Whyisepidemiologic
Topreventdiseases
surveillanceimportantfor
publichealth?Whatrole
woulditplayiftherewere
abioterroristattack?
Heartdisease?LungCancer?Allarecorrelationwithheartdiseases.
Whathasepidemiology
contributedtopeoples
understandingof?

Chapter5:EpidemiologicPrinciplesandMethods
Incidence

Prevalence
Who,when&where

InterventionStudy

Thenumberofnewcasesoveradefinedperiodoftime
Incidenceisusedforstudyingcausesofdisease
Ifcausesorriskfactorsincrease,incidenceandprevalenceincrease
Ifabilitytodiagnoseincreases,incidenceandprevalenceincreases.
Numberofexistingcasesataspecifictime
Prevalencedependsonincidenceandprediction
Whosex,age,occupation,race
Whenseason,year(longtermtrends),elapsedtimesinceanexposure
(epidemiccurve)
Whereneighborhood(e.g.clusters),latitude(climate),urbanvs.rural,
nationalvariations
Howthediseasedistributed
Closestthingtoanexperiment
Startwithtwogroups:
o Experimentalgroup(getstheinterventionorexposure)and
o Controlgroup
o Compareboththegroups^^^
Watchthemovertimeandcompareoutcomes
Experimenterchooseswhoisinwhichgroup
Twogroupsshouldbeassimilaraspossiblesothatinterventionistheonly
difference
Randomized,doubleblind,placebocontrolistheideal
Pharmaceuticalcompaniesconductmanyclinicaltrialsfornewdrugs
PhysiciansHealthStudypreventionstudy
Aspirintopreventheartdisease
Betacarotenetopreventcancer
Fieldtrialofpoliovaccine1954
KingstonNewburghstudyoffluoridationtopreventtoothdecay
Problemsthatoccurred:
o Interventionstudy:subjectsmaynotfollowprescribedbehavior

Cohortstudy

Casecontrolstudy

throughoutstudyperiod
Noteveryonefollowsyourrecommendation
Overreportorunderreportsoyouhavetomakesure
Forsituationswhendoinganinterventionstudywouldbeunethicalortoo
difficult
Consideredthenextmostaccurate
Choosealargenumberofhealthypeople,collectdataontheirexposures,
andtrackoutcomesovertime
Theonlydifferencefrominterventionisthatpeoplechoosetheirown
exposures
o Examples:FraminghamHeartStudy
o NursesHealthStudy
o Britishphysiciansstudyonsmokingandlungcancer
o HammondHornstudyonsmokingandlungcancerinU.S.
Problemsthatoccurred:
o Cohortstudy:sometimeshardtoisolatewhichofmanyfactorsare
responsibleforhealthdifferences
Youcanhavemanybodyangles
CaseControlStudy
o Choosepeoplewhoalreadyhavedisease
o Chooseahealthycontrolgroupofindividualsassimilaraspossible
tocases
o Interviewthemallandaskfortheirpreviousexposures
o Advantage:fasterandcheaper
o Leastaccurateapproach
Problemsthatcanoccur:
o Casecontrolstudy:controlgroupmaynotbetrulycomparable;also
errorsinreportingorrecall
Sometimesitdependsonitsreportinghowtheyreportthe
exposure
Youhavetomakesureitscomparable

Chapter6:ProblemsandLimitsofEpidemiology
RandomVariation
Errors
Cofoundingvariables
Bias
Selectionbias
Reportingbiasorrecall
bias
Provingcause&effect
(largenumberofsubjects)

Informedconsent,ethics

Resultsbychance
Newsreports
Coffee,smoking,pancreaticcancer
Lookbelow.
(Heartdiseasepatient,controldigestiveproblems,dietaryfat)
Peoplewhodrinkheavilyunderreportconsumption..

Drugcompaniesarerequiredtoconductrandomizedcontrolledtrialsonany
newdrugbeforeitcanbeapproved
Harmfulsideeffectshavefrequentlybecomeobviousafterdrugswere
approved
Thereisevidencethatdrugcompaniessometimessuppressnegativefindings
Allclinicaltrialsmustnowberegisteredinadvanceinapublicdatabase
Naziexperimentsonhumans

Institutionalreview
boards(IRB)

Tuskegeesyphilisstudy(toobservepeoplewhodidntreceivetherapy)
Newrulesinformedconsent
Newrulesinstitutionalreviewboards
Importanceofclinicaltrials
Possibilityofconflictofinterestbymedicalproviderswhostandtoprofit
Newrules

Chapter7:Statistics:MakingSenseofUncertainty
Probability

Power(largenumberof
cases)
Sensitivityvs.specificity

Rates(crude,adjusted)
pg108

Lifeexpectancy(Florida,
Alaska)

YPLL(YearsofPotential
LifeLost)
RiskAssessment

RiskPerception
ExampleofFalsevs.
Negative

Acalculationofwhatmaybeexpectedbasedonwhathashappenedinthe
pastundersimilarconditions.
Theprobableiswhatusuallyhappens
Theprobabilityoffindinganeffectifthereis,infact,aneffect
Largenumbersconferpower
Sensitivity:abilityofatesttodetectadiseaseifthediseaseistrulypresent
o Theabilityofatesttoavoidfalsenegatives;itsabilitytoidentifya
diseaseorconditioninthosewhohaveit.
Specificity:abilityofatesttonotdetectadiseasewhennotpresent
o Theabilityofatesttoavoidmistakenidentificationsfalse
positives.
Cruderate:Theactualrateofevents(births,deaths,casesofadiseaseor
injury,etc.)inapopulation,withoutadjustment.
Adjusted:Awayofcomparingtwogroupsthatdifferinsomeimportant
variable(e.g.,age)bymathematicallyeliminatingtheeffectofthatvariable.
Thenumberofadditionalyearsoflifeexpectedataspecifiedpointintime,
suchasatbirthoratage45.

Ameasureoftheimpactofdiseaseorinjuryinapopulation,YPLLisyears
oflifelostbeforeaspecificage(usuallyage75).Thisapproachplaces
additionalvalueondeathsthatoccuratearlierages.
Aquantitativeestimateofthedegreeofhazardtoapopulationpresentedby
someagentortechnologyordecision.Ariskbenefitassessmentattemptsto
weighpossiblerisksagainstpossiblebenefits.
Wellknownriskscanbecalculatedfromhistoricaldata
Forpoorlyunderstoodrisks,mustmakemanyassumptions
Riskperceptioninvolvespsychologicalfactors
Inthearenaofspousalrelations:awifenoticeslipstickonahusband's
shirtcollar(a"positive"test)andworriesaboutmaritalinfidelity.Butshe
laterverifiesthatherhusbandactuallyencounteredhisAuntJaneatalunch
breakatalocalfastfoodoutlet.OldAuntJanepartlymissedherhusband's
neckwithherlipstickkissandhithiscollar...acaseofafalsepositive
finding(whichwaspositiveforfemalekissbutnegativeforinfidelity...wife

"walkedtheline"ofpossibilitiesofthesignificance...theinterpretation...of
thefindingandgottothetruthofit).

Chapter8:RoleofDatainPublicHealth
Data(Whyweneeddata
inPublicHealth)
Census(VitalStatistics)

Accuracy&Availabilityof
data

Assessthehealthofacommunity
Rawmaterialforresearch
Servesasdenominatorformostpublichealthdata
o Age,sex,race,ethnicity
Every10years
AmericanCommunitySurveydoneinbetween,onanongoingbasis
o Education,housing,healthinsurance
Datacollectionisimperfect
Censusismostaccurate;stillthereareovercountsandundercounts
Informationtechnologyincreasesaccuracyandavailability

Chapter9:TheConquestofInfectiousDiseases
Kochspostulates

Infectiousagents

Meansoftransmission

Kochpostulates:
o Organismmustbepresentineverycaseofthedisease
o Theorganismmustbeisolatedandgrowninthelab
o Wheninjectedwiththelagrownculture,susceptibletestanimalmust
developthedisease
o Theorganismmustbeisolatedfromthenewlyinfectedanimalsand
processrepeated
Bacteria(singlelivingorganism)
Tuberculosis(rodshape)
Cholera(vibriocholera,rodshape)
Typhoid
Tetanus
Diphtheria
Dysentery
Syphilis
Streptococci
Staphylococci(roundshapebacteria,
cocci)
Shyphilis(spirochete,corkscrewshape)
Viruses(notcompletecells,complexof
nucleicacidandprotein,cansurvive
extremeconditions,reproducethemselves
bytakingcontrolofthecellsmachinery,
killingthecell)
Smallpox,poliomyelitis,hepatitis,measles,
rabies,AIDS,yellowfever
Parasites(protozoa,singlecelledanimals)malaria,cryptosporidiosis,
giardiasis,roundworms,tapeworms,hookworms,pinworms
Howwecangetthediseases
o Aerosol(cold,influenza,TBC)
o Touchingcontaminatedobjectandputtinghandstomouth,nose,or
eyes

Chainofinfection

Fearofvaccination

RobertKoch

Whyweretheyableto
eradicatesmallpox?

o Contaminatedwaterorfood:fecaloralroute(Cholera,Diphteria,
HepatitisA)
o Vectors(Malaria,WestNileEncephalitis)
o Sexual contact
Pathogen(infectiousagent)
Reservoir(pathogencanlive,rodents,flea
plague,racoon,batsrabbies)
Meansoftransmission(apersoneatsfood,
sexualcontact,tickbite)
Susceptiblehost(lowimmunity)
Interruptchainofinfectionatanylink(1
4)
KNOWCHARTBELOW
PointofEntrySusceptible
HostPathogenReservoirPlaceof
ExitMeansofTransmission
Rumorsofvaccinescausingautism,SIDS
Sideeffectsdoexistforsomevaccines
Someparentsrefusetoacceptrisks
Herdimmunitylostifmanypeopledonotgetvaccinated
Pharmaceuticalcompaniesreluctanttodevelopvaccines
o Lowprofits
o Riskoflawsuits
Germanphysician
Developedtechniquestoclassifybacteria
o Identifiedwhatwascausingtuberculosis
o Famousforthat^^^
o Hedevelopedsteroid
o HealsowantedtomakesureitwastruesoKochblastulator
Nowusedtoidentifynewdiseases
o Byshapeandtheirpropensitytobestainedbyvariousdyes
Theyalwaysknewwherethediseasewassoitwaspossibletoremoveit
immediately.
Itwasvisible
Persontopersonthediseasewillbeending
Nohoax
Nowayoftransmittingthedisease
Theyhadvaccinations
Communicatingwiththevillages
Heartimmunitydidthevaccinationsandthiswastheprotection
Diseasedoesntoccurheartimmunity

Chapter10:TheResurgenceofInfectiousDiseases
AIDS

Acquiredimmunedeficiencysyndrome:
o Themostseverephaseofinfectionwiththehuman
immunodeficiencyvirus(HIV).PeopleinfectedwithHIVaresaidto
haveAIDSwhentheygetcertainopportunisticinfectionsorwhen
theirCD4+cellcountdropsbelow200.

Enza

NewBacterialthreats

Antibioticresistance

ResistanceTuberculosis

Directlyobservedtherapy
Prions

FirstrecognizedinU.S.in1981.Nowaworldwidekiller
Causedbyaretrovirus(copyingRNAintotheDNAofthecell)
Attackstheimmunesystem(CD4T)
Afterexposure:mildflulikesymptoms,weeks,easilytransmitted
Latentperiod,virushiddenintheDNAoftheT4cells,personquitehealthy,
lesslikelytransmit
Screeningtestrecognizesantibodies(26monthsaftertheoriginal
exposure),sensitivity
Window:initialtwomonthperiodafterinfection,falsesenseofsecurity
Canmeasurevirusesintheblood(moreaccuratetests)
Nowmanydrugsareavailable,butnocure
Virusisconstantlymutating
Vaccinemustbechangedfrequently
New,lethalstrainsappearperiodically
Epidemicof19181919killed20millionto40millionworldwide
ConcernaboutbirdfluinAsia
INFLUENZA
LegionnairesDisease
LymeDisease(1982,reservoirismouse,deertickfeeds,infecteddeartick)
StreptococcusA,(strainBmilder)
E.ColiO157:H7infood(shigatoxin)
Antibioticresistance
o Fromimpropermedicaluse
o Useinagriculture
o Example:ATBuseinEurope
Antibioticresistance
o Fromimpropermedicaluse
o Useinagriculture
o Example:ATBuseinEurope
Leadingcauseofinfectiousdiseasedeathworldwide;onethirdofworld
populationisinfected
TherewasaresurgenceintheU.S.inearly1990s
MuchhigherriskforpeoplewithHIV
Transmittedbyaerosol
50%fatalityrateforuntreatedTB
Antibioticsareeffective,butmustbetakenforseveralmonths
Improperuseofantibioticsleadstoresistance,includingmultidrug
resistance,whenmortalityratecanbe50%
Directlyobservedtherapyworksbestapproachtopreventingantibiotic
resistance
Bestapproachtopreventingantibioticresistance
Prionsparticlescontainprotein
o CreutzfeldJacobdisease(CJD)sporadic,inolderpeople
(dementia,examplefromEurope)
o Bovinespongiformencephalopathy(BSE)ormadcowdiseasein
Britain
o NewvariantCJDinBritaininyoungerpeople,thoughttobecaused

Bioterrorism

byeatinginfectedbeef
o Regulationshavebeentightenedonanimalfeed
ThreatofBioterrorism
o Approachtobioterrorismisthesameasthatfornaturaldisease
outbreaks
o Willprobablyfirstberecognizedbysurveillance
o Bestdefendedagainstbysamemethodsasnaturaloutbreaks

Chapter11:TheBiomedicalBasisofChronicDiseases
Cardiovasculardisease

Atherosclerosis

Cancer

Diabetes

Diseaseoftheheartandbloodvessels,mostcommonlycausedby
atherosclerosis,depositsoffattysubstancesintheinnerlayerofthearteries.
Coronaryheartdiseaseaffectsthearteriesoftheheartandmayleadtoa
heartattack.Cerebrovasculardiseaseaffectsthearteriesofthebrainandmay
leadtoastroke.
Totalcholesterollevellowisbetter
Lowdensitylipoprotein(LDL)lowisbetter
Highdensitylipoprotein(HDL)highisbetter
Geneticsareamajorfactor(BUTifweknowit..)
ExerciselowerstotalcholesterolandincreasesHDL
SmokinglowersHDL
WidespreaduseofStatinsforsecondaryprevention
Atherosclerosis
Heartdiseaseandstroke
PlaquebeginsatanearlyageinU.S.
Americandietraisesrisk
Diet,highbloodpressure,diabetes,smokinginteracttocauseinjuryofartery
walls
Itsadiseasewhichplaquebuildsupinsideyourarteriesthatcancause
cardiovasculardisease.
Couldbecausedby:
o Highlevelsofcholesterol
o Highbloodpressure
o Cigarettesmoke.
Diseasesinwhichabnormalcellsdividewithoutcontrol.Cancercellscan
invadenearbytissueandcanspreadthroughthebloodstreamandlymphatic
systemtootherpartsofthebody.
Notonedisease,butmany;eachhasdifferentriskfactors,treatments,etc.
ArisesfrommutationsinDNA
Mutationscausedbychemicals,viruses,radiation.lifestyle???
Dietandhormonesplayarole
Tobaccousecausesonethirdofcancerdeaths
Testingchemicalsforcarcinogenicity
Achronicdiseaseduetoinsulindeficiencyand/orresistancetoinsulinaction
andassociatedwithhighlevelsofsugarintheblood.Overtime,unless
properlytreated,organcomplicationsrelatedtodiabetesdevelop,including
heart,nerve,foot,eye,andkidneydamageandproblemswithpregnancy.
Majorcauseofdisability

HDL&LDL

PrevalenceisrisinginUSalongwithobesity
Deficiencyinthebodysabilitytometabolizesugar
Type1diabeteschildhoodonset;failureofinsulinproducingcellsof
pancreas
Type2diabetesadultonset;insulinresistance
Type2diabetescloselycorrelatedwithobesity
Treatable,butneedlongtermmonitoring;needgoodaccesstomedicalcare
LOWDENSITYLIPOPROTEIN(LPL)lowisbetter
HIGHDENSITYLIPOPROTEIN(HDL)highisbetter

Chapter12:GeneticDiseasesandOtherInbornErrors
Environmentalteratogens

Geneticdiseases

Autosomaldominant

Autosomalrecessive

Xlinked
Screening
Carrierscreening

Newbornscreening

Humangenomeproject
(examplebreastcancer)

Infectiouspathogens
Syphilis(bacteriapassedthroughplacenta),blindnessandmentalretardation
Rubella(deafness),vaccination
Toxoplasmosis(parasiticdisease,neurologicaldamage),catsarereservoirs
EnvironmentalchemicalsMercury
1950:Minamatadisease,Japan(braindamage,neurologicalproblems)
Chromosomalabnormalitiese.g.,downsyndrome(mentalretardation)
Mendeliangenetics
o Autosomaldominant
o Autosomalrecessive
o Xlinked
MaybecausedbyNEWMUTATIONS
Whenoneparenthasit,nonsexchromosome50%only
Examples:
o Huntingtonsdisease
o Marfanssyndromeextremehigh,cardiovascularabnormalities
Whenbothparentshaveit
Youinherittwocopiesofthegene
Example:
o TaySachsdisease
Hemophilia,Duchennesmusculardystrophy)
Checkingforadiseasewhentherearenosymptoms.
ScreeningforRECESSIVEgenesinhighriskpopulations
TaySachsdiseaseinJews
o EncouragedbyJewishleaders
Newbornscreeningonlywhenbenefitsthenewborn,whencanconfirm
diagnosisandwhentreatmentandfollowupsareavailableforinfants
Testdropofbloodfromnewbornsformetabolicabnormalities
AllnewbornsinUSarescreenedforatleasttwoconditions:
o PKUphenylketonuria,metabolismofaminoacidphenylalanine
o Hypothyroidismriskofmentalretardation
Statesvaryinconditionsscreenedfor
Earlydiagnosiscanpreventorreducepermanentdamage
Forexample,somescientistsstudywhatmutationsinthehumangenome
causecertaindiseases,saycancers.Becausethehumangenomewas
sequenced,scientistscannowlookforcluesinthisgenomeastowhatparts

Ethicalissueswith
screening

ofitarechangedwhenadiseaseisbroughtforth.Thisallowsforthe
possibilityofmedicinestobedesignedbecauseitallowsscientiststosee
whatmutationsinthegenometheymustaddressoratleasttheycanstudy
thatpartofthegenometofigureoutinthecorrespondingbiological
pathway,howtheycandevelopmedicinesoastotreatordelaythese
diseases.Abigexampleofthesecouldbewithcancerdrugssuchas
Tarceva,orcancerdrugsingeneralthataredesignedforothercancerslike
breastcancer(Herceptin)orothers.
Newbornscreeningonlywhenbenefitsthenewborn,whencanconfirm
diagnosisandwhentreatmentandfollowupareavailableforinfants
Carrieridentificationshouldbevoluntaryandconfidentialandinclude
counseling
Prenataldiagnosisshouldincludeeducationandcounseling
Alltestsofhighquality,evaluatedbyFDA;governmentoversightof
laboratoryproficiency
Moreeducationforthegeneralpublicaboutgenetics

Chapter13:DoPeopleChooseTheirOwnHealth?
Actualcausesofdeath

Healthpromotion
strategies
Educationandregulation

Tobacco
o Cancer
o Cardiovasculardisease
o Chronicobstructivelungdisease
o Infantdeathsduetolowbirthweigh
o Burns
Poordietandphysicalinactivity
o Obesity
o Heartdiseaseandstroke
o Diabetes
o Cancer
Alcoholconsumption
Microbialagents
Toxicagents
Motorvehicles
Firearms
Sexualbehavior
Illicitdruguse
Accountforalmosthalfofalldeaths
Mostarepreventable
Mostarepremature
Mostarecausedbyindividualbehavior
Targetsforpublichealthintervention
Education
Regulation
Prohibition
Education:
Provideinformation:
http://www.healthiergeneration.org/engine/renderpage.asp?pid=s017
Smokingisbad

Prohibition

Recommendeddietaryallowances
Healtheducationinschools
Physiciansrecommendationscanbeeffective
Regulation:
Lawsagainstmurderandassault
Trafficregulations
Restrictionsonalcohol,drugs,andtobacco
Agerestrictionsonmanybehaviors
Sexualbehaviorishardtoregulate
Whensomethingisofficiallyforbidden,oranorderforbiddingsomething:

Chapter14:HowPsychologicalFactorsAffectHealthBehavior
Socialenvironment

SES
SOCIOECONOMIC
STATUS
Socialsupport

Healthbeliefmodel

Locusofcontrol(self
efficacy)
Ecologicalmodel

Transtheoreticalmodel
Dr.Prochaska

Mostimportantpredictorofhealthissocioeconomicstatus(SES):less
accesstomedicalcare,morestress,nothealthynutrition,airpollution,lead
paint,crime,violence
Healthalsoaffectedbygender,maritalstatus,raceandethnicity
InU.S.,racialandethnicminoritieshavepoorerhealththanwhites
Healthdisparitiesareabigconcernofpublichealth
Nutrition
Sanitation
Conditionsofthephysicalenvironment
HigherSESleadstomorehealthybehavior
Accesstomedicalcare
Alamedastudy,pg237,1965:associationbetweencertainunhealthy
behaviorsandhighermortalityrates,
strongassociationwithsocialnetwork
Socialsupportcanbufferstress
Iamvulnerabletothethreat
Thethreatisserious
BytakingactionIcanprotectmyself
Selfefficacyisincreasedbyprevioussuccessfulperformance
Selfefficacyisincreasedbyseeingotherssuccessfullyperform,especiallyif
modelisapeer
Intrapersonallevel(psychology)
Interpersonallevelfamily,friends,coworkers
Institutionallevelschool,workplace
Communitylevelchurches,communityorganizations
Publicpolicylevelgovernmentregulations
Thetranstheoreticalmodelofbehaviorchangeassessesanindividual's
readinesstoactonanewhealthierbehavior,andprovidesstrategies,or
processesofchangetoguidetheindividualthroughthestagesofchangeto
ActionandMaintenance.

Chapter15:TobaccoPublicHealthEnemyNumberOne
1954smokingandhealth
1980healthconsequences
ofsmokingforwomen

Firstmedicalresearchonconnectionbetweensmoking&lungcancer
Fallacyofwomensimmunity
Womenstartedsmokinglaterthanmen
Womenslungcancerratesbeganrisinglater

Occurrenceofsmoking

Biomedicalbasisof
harmfuleffects

Healthimprovementswith
smokingcessation

Serotonin

Nonsmokersrights

Lungcanceramongwomensurpassedbreastcancerinthe1980s
Blackmenhadhigherratesbuthavedeclined
HighratesinAmericanIndiansandAlaskaNatives
Strongassociationwithlackofeducation
NowinU.S.,about23%ofadultssmoke
Decreasedlungfunction
Shortnessofbreath
Naggingcoughs
Tireeasilyduringphysicalactivity
Diminishedabilitytosmellandtaste
Prematureagingoftheskin
Increasedriskofimpotenceformen
Nicotineisanaddictivedrug
Raisesbloodpressureandheartrate
Maycausespasmsinbloodvesselsofheart
Tarsprovideflavor
Damageciliaandirritaterespiratorytract
Carbonmonoxide
Interferewithoxygencarryingcapacityofblood
Otheringredients
Arsenic,benzene,arealsocarcinogenic
Alterclottingpropertiesofblood
RaisebloodcholesterolandreduceHDL
Within20minutesofsmokingthebodybeginstorestoreitself
After20minutes
Bloodpressuredropstoalevelclosetothatbeforethecigarette
Temperatureinhandsandfeetincreasestonormal
After8hours
Carbonmonoxidelevelinblooddropstonormal
After24hours
Chanceofheartattackdecreases
After3months
Circulationimprovesandlungfunctionincreaseupto30%
Inonetoninemonths
Coughing,sinuscongestion,fatigueandshortnessofbreathdecrease
Regainnormalfunctionofthelungs
Afteroneyear
Excessriskofcoronaryheartdiseaseishalfthatofasmokers
Afterfiveyears
Strokeriskisreducedtothatofanonsmoker
After10years
Lungcancerdeathrateusabouthalfthatofacontinuingsmoker's
Riskofcancerofthemouth,throat,esophagus,bladder,kidneyand
pancreasdecreases.
After15years
Riskofcoronaryheartdiseaseisthatofanonsmokers
Serotoninergicsystemmaybeinvolvedinsmokingbehavior:Nicotine
increasesbrainserotoninsecretionandnicotinewithdrawaldecreases
serotoninlevels/Ishikawaetal.,1999/
TheFederalGovernmenthasenactedseverallawsprotectingnonsmokers

movement

Mastersettlement
Agreement

CAtobaccocontrol
program

fromsecondhandsmoke.Federallawsrequirethatalldomesticairline
flights,aswellasallscheduledflightsbetweentheUnitedStatesandforeign
destinations,besmokefree.AnExecutiveOrder,ineffectsince1998,
providesthatallbuildingsowned,rented,orleasedbytheexecutivebranch
oftheFederalGovernmentmustbesmokefree,exceptfordesignated
smokingareasthatareenclosedandseparatelyventilated.Also,under
federallaw,smokingisnotallowedinenclosedareasofagenciesreceiving
federalfundingthatprimarilyserveyouth,suchasschools.
19971998agreedonasettlement
$206billionto46statesover25years
Industryagreedtorestrictionsonadvertising
$1.7billiontoAmericanLegacyFoundationtruthcampaign(tolearn
manipulationsbythetobaccocompanies)usedlessonslearnedfrom
Californiacampaign
Disappointingly,statesusedverylittleofsettlementmoneyfortobacco
control
Fundedby1989taxincreaseof25centsperpack
Cigaretteconsumptionimmediatelybegantodecline
Mediacampaignin1990and1991
1994smokingbaninallworkplaces
Cigaretteconsumptiondeclinedby60since1988
Lessonsoneffectiveantitobaccomessages

Summary:
Pleasenote:audiosandvideoschapters115areavailableonyourclasswebsite
Book1:Chapters115
Book2readings(SLIDES):Chapter15,PHprofessionsbasicinformation
PHagenciesbasicinformation
Grouppresentations17and15,16
Reviewquestionsonlectureslides:basicinfo
PHnewsweek15:basicinfo
Videoclips:vaccinationPasteur,Epi+statistics,WestNilevirus,SmallPox,Polio,TBinPeru,
RoadMap:linksthere
GuestSpeakersinfoifthereareduringthereviewperiod

Вам также может понравиться