foundations of public health ph-200 fall 2009 week 3
TRANSCRIPT
Foundations of Public HealthPH-200 Fall 2009
Week 3
Agenda• 9:30 AM – 9:45 AM : Questions and Review
• 9:45 AM – 11:00 AM : Public Health Milestones Revisited– Case studies on disease eradication; Injury / Environmental Health– World Health Organization – Disease Eradication and the Global
Burden of Diseases
• 11:00 AM – 11:15 AM : Recess
• 11:15 AM – 12:15 PM : The Centers for Disease Control and Prevention.
• 12:15 PM – 12:30 PM : Review
Pop-quiz
• “Causation” is a very contentious word in public health research. Explain why?
– Discuss the contributions of Austin Bradford Hill to the description of disease causation.
– Based on recent understandings of the molecular basis of disease and the ecological model of public health, are there limitations to applying Hill’s guidelines?
Established 7 April 1948 (Annual World Health Day – April 7th)
http://www.who.int/about/brochure_en.pdf
The World Health Organization• http://www.who.int/about/agenda/en/index.html
Dr Margaret Chan, from the People's Republic of China, obtained her medical degree from the University of Western Ontario in Canada. She joined the Hong Kong Department of Health in 1978, where her career in public health began.
In 1994, Dr Chan was appointed Director of Health of Hong Kong. In her nine-year tenure as director, she launched new services to prevent the spread of disease and promote better health. She also introduced new initiatives to improve communicable disease surveillance and response, enhance training for public health professionals, and establish better local and international collaboration. She effectively managed outbreaks of avian influenza and of severe acute respiratory syndrome (SARS).
In 2003, Dr Chan joined WHO as Director of the Department for Protection of the Human Environment. In June 2005, she was appointed Director, Communicable Diseases Surveillance and Response as well as Representative of the Director-General for Pandemic Influenza. In September 2005, she was named Assistant Director-General for Communicable Diseases.
Dr Chan was appointed to the post of Director-General on 9 November 2006. Her term will run through June 2012.
WHO Six Regional Offices
The role of W.H.O. in public health• W.H.O. fulfils its objectives through its core functions:
– providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
– shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
– setting norms and standards and promoting and monitoring their implementation;
– articulating ethical and evidence-based policy options;
– providing technical support, catalyzing change, and building sustainable institutional capacity; and
– monitoring the health situation and assessing health trends.
The real causes of death and disability
• “The Global Burden of Diseases” – World Health Organization’s GBD project
• (http://www.who.int/topics/global_burden_of_disease/en/)
http://www.who.int/healthinfo/bodproject/en/index.html
• The disease-adjusted life year is a composite indicator of the time lived with a disability (YLD) and the time lost due to premature mortality (YLL) (Murray & Lopez, 1996).
• DALYi [0,0] = YLLi + YLDi
Where:• YLLi = Years of Life Lost due to disease i
– (# deaths x standard life expectancy at age of death)
• YLDi = Years of Life lived with Disability due to disease i– # incident cases x disability weight x average duration of disease case
until remission or death.
Measuring Burden of Diseases
Estimating Years of Life Lost (YLL)
YLLsKCera
(r )2e (r )(La) (r )(L a) 1 e (r )a (r )a 1 1 K
r(1 e rL )
Where:r = discount rate (.03, rate used in GBD, 1997) = parameter from the age weighting function (.04)K = age-weighting modulation factor (1)C = constant (0.1658)a = age at deathL = standard expectation of life at age “a”
Years Lived with Disability (YLDs)
YLDsDKCera
(r )2e (r )(La) (r )(L a) 1 e (r )a (r )a 1 1 K
r(1 e rL)
Where:a = onset of disabilityL = duration of disabilityr = discount rate (r = .03) = age-weighting parameter ( = 0.04)K = age-weighting modulation factor (K = 1)C = adjustment constant necessary because of unequal age-weights = 0.1658D = Disability weight
0
2000
4000
6000
8000
10000Major Depression
Alcoholism
Osteoarthritis
Dementia
Schizophrenia
Bipolar disorder
Cerebrovascular
COPD
Car Accidents
Diabetes
Diseases
YLD
Global Disease-Adjusted Life Years (DALYs)
2002 Worldwide Disability Adjusted Life Years (DALYs)
0.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
Neuro
psyc
hiat
ric co
nditio
ns
Cardio
vasc
ular d
iseas
es
Uninte
ntion
al inj
uries
Respi
rato
ry in
fecti
ons
HIV/A
IDS
Diarrh
oeal
dise
ases
Respi
rato
ry d
iseas
es
Inte
ntion
al in
jurie
s
Mal
aria
Digesti
ve d
iseas
es
Tuber
culos
is
Nutrit
iona
l def
icien
cies
Diabet
es m
ellitu
s
STDs e
xclu
ding
HIV
Mill
ion
s
Disease Category
DA
LY
s
Future projections of disease burden
ln M = C + b1lnY + b2lnHC + b3T
Where:M = projected mortality levelC = constant termY = GDP per capitaHC = Human capital (including population growth)T = Time
Global Demographic Divide Widens
© 2008 POPULATION REFERENCE BUREAU
Source: United Nations Population Division, World Population Prospects: The 2006 Revision.
World Population (in Billions): 1950-2050
© 2008 POPULATION REFERENCE BUREAU
Continued Population Growth Sets the United States Apart From Other Developed Countries Around the World.
Source: Carl Haub and Mary Mederios Kent, 2008 World Population Data Sheet.
Percent Change in Population, Selected Countries: 2008-2050
Global projections for selected causes, 2004 to 2030
0
2
4
6
8
10
12
2000 2005 2010 2015 2020 2025 2030
De
ath
s (
mil
lio
ns
)
Updated from Mathers and Loncar, PLoS Medicine, 2006
Cancers
Stroke
Perinatal
Road trafficaccidents
HIV/AIDSTBMalaria
Acute respiratoryinfections
Ischaemic HD
Projected deaths by cause and income, 2004 to 2030
0
5
10
15
20
25
30
2004 2015 2030 2004 2015 2030 2004 2015 2030
De
ath
s (
mill
ion
s)
High income Middle income Low income
HIV, TB, malaria
Other infectious
Mat//peri/nutritional
CVD
Cancers
Other NCD
Road traffic accidents
Other unintentionalIntentional injuries
Ten leading causes of burden of disease, world, 2004 and 2030
Scaled World Population by
Region
Danny Dorling of the University of Sheffield: Worldmapper Project – PLOS-Medicine 2007
Public Health Spending
Number of working
physicians
Preventable Deaths
Estimating “Attributable Risk”
• Attributable Risk is assessed, using published data on relative risks for each cause of death and disability related to the exposure, levels of exposure (prevalence), and burden of disease due to each cause of death and disability in the population:
• AB = ∑ AFj Bj = ∑Pj (RRj – 1) ÷ ∑Pj (RRj – 1) + 1• Where
– AB = Attributable Burden for a risk factor – AFj = Fraction of Burden from cause j – Bj = population level burden of cause j– P = Prevalence of exposure– RRj = Relative Risk of disease or injury for cause j in exposed versus unexposed
group.– n = Maximum exposure level
Environmental burden of disease
• http://www.who.int/quantifying_ehimpacts/national/countryprofile/intro/en/index.html
Burden of Disease Attribution to Environmental Factors in the U.S.
Angola
Infant mortality = 260/1000
Environmental Health at the Global and National Levels
• The history of child lead poisoning in the past century in this country is a good example of how powerful economic interests can prevent the implementation of a ‘useful Truth’.”
1706 - 1790
Movement Toward Institutional Environmental Health
• “For each of us, as for the robin in Michigan, or the Salmon in the Miramichi, this is a problem of ecology, of interrelationships, of interdependence….We spray our elms and following springs are silent of robin song…”
1907 - 1964
Fact sheets: environmental health
• Air pollution
• Use of the air quality guidelines in protecting public health: a global update October 2006
Use of the air quality guidelines in protecting public health June 2005
Children• The environment and health for children and their mothers
February 2005
What happens when children live in unhealthy environments? April 2003
Climate• Climate and health
July 2004
http://www.who.int/topics/environmental_health/en/
Occupational health
Radiation
• Electromagnetic fields and public health: base stations and wireless technologies May 2006
Health effects of the Chernobyl accident: an overview April 2006
Electromagnetic fields and public health: static electric and magnetic fields March 2006
Electromagnetic fields and public health: electromagnetic hypersensitivity December 2005
Radon and cancer June 2005
Sunbeds, tanning and UV exposure March 2005
Depleted uranium January 2003
Ultraviolet radiation: global solar UV index August 2002
Electromagnetic fields and public health: extremely low frequency fields and cancer October 2001
Protecting children from ultraviolet radiation July 2001
Electromagnetic fields and public health: mobile telephones and their base stations June 2000
Water
• Health-care waste management October 2004
• Arsenic in drinking water May 2001
Bottled drinking water October 2000
Legionellosis
World’s Worst Polluted SitesBlackwell Institute. 2006. The Worlds Worst Polluted Sites – The Top Ten.
http://www.blacksmithinstitute.org/ten.php
• Kabwe, Zambia• Lead, cadmium
Source of Pollution: Lead mining and processing
Sex n Mean [BPb] Range SD % > 10 ug/dL
Female 138 8.9 (2.1,23.8) 4.2 32.5
Male 168 9.8 (2.2,31.8) 4.8 35.0
Total 306 9.4 (2.1,31.8) 4.2 34.3
Summary of Blood Lead Levels in Children, Ages 1-6, Otukpo
100 IQ
Per
cen
tag
e o
f su
bjec
ts
908070
72.6 73.5
50
Mild mental retardation
Attributable Risk:
Shift to mild mental retardation due to Pb-induced loss of IQ points
Shift to mild mental retardation due to loss of
IQ points
Normal curve of distribution of intelligence
Fewtrell et al., [2002]
Childhood Health Costs of Lead Exposure Children Variable $(M) GNI-PPP Adjusted Million Naira
Medical Costs Average blood lead concentration 9.8 ug/dL
Number of children requiring chelation therapy 160,909
Cost of chelation therapy 1,920
Total Medical Costs 309 7 888
Compensatory Education Number of children who receive education 162,231
Cost of education 4,902
Total Compensatory Education Cost 795 18 2,286
Earnings Number children, age 6 3,515,600
Increase in earnings of a 1 ug/dL reduction in BLL 1,920
Total Earnings Lost 6,750 155 19,406
Infant Mortality IMR 75/1000
1 ug/dL reduced maternal blood – IMR 74.9/1000
Value of statistical life 4,429,840
Number of live births, 2002 5,192,000
Number of reduced deaths 519
Total IMR Cost 2,299.09 52.88 6,609.88
Neonatal Care # of NICU admissions 1,752,300
Reduced NICU admissions 1,749,960
Number of fewer NICU admissions 2,340
Cost of NICU 86,661
Total Neonatal Cost 202.79 4.66 583.01
Total Costs 10,356.03 238.19 29,773.58
Cost of Lead Abatement
Cost ($/liter) ‡Cons. (106 l/year) Cost (M$/yr1995)
Cost (M$/yr2003)
Cost (†MN/yr,2003)
Abatement Factors Unleaded Gasoline 0.01 6,837 68 82 10,250
Non-Pb Additive 0.01 6,837 68 82 10,250
Refinery Retooling 0.006 6,495 39 47 5,875
Tetraethyl Lead (TEL) 0.002 6,837 14 17 2,125
Gasoline Source Domestic Gasoline 0.16 6,495 1,039 271 33,821
Foreign Gasoline 0.16 342 55 66 8,250
Total Gasoline 0.16 6,837 1,094 1,313 164,148
Low Estimate
Total annual cost of abatement *75.6 24,250
Pb abatement cost / Pb health cost 0.189 0.189
Abatement as % of health cost 18.9% 18.9%
Medium Estimate
Total annual cost of abatement 194 24,250
Pb abatement cost / Pb health cost 0.485 0.485
Abatement as % of health cost 48.5% 48.5%
High Estimate
Total annual cost of abatement *227 24,250Pb abatement cost / Pb health cost 0.567 0.567
Abatement as % of health cost 56.7% 56.7%*Low estimate = ($.01/L)(Liters consumed/year) (11). **High Estimate = ($.03/L)(Liters consumed/year) (11). ‡Consumption, †Million Naira
Asbestos
• Mesothelioma
Irvin Selikoff
National-Level Programs in Public Health
• Department of Health and Human Services
• Public Health Service
• Centers for Disease Control and Prevention
• National Institutes for Health Science
• CDC s Mission is to collaborate to create the expertise, ′information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.
• The Centers for Disease Control and Prevention is the nation s premier public health agency—working to ensure ′healthy people in a healthy world
• Organization Chart: http://www.cdc.gov/maso/pdf/cdc.pdf
• Coordinating Center for Global Health:• http://www.cdc.gov/maso/pdf/COGH.pdf
Thomas Frieden
Sub-agencies• Health & Environment• Air Quality• Asbestos• Asthma• Biomonitoring• Carbon Monoxide Poisoning• Childhood Lead Poisoning Prevention• Climate Change• Cruise Ship Health• Extreme Weather Conditions• Health Studies• Healthy Places• Mold• Natural Disasters• Protect Yourself from the Sun• Radiation Studies• Rodent Control• Smoking and Tobacco Use• Water Quality
• Toxic Substances• Chemical Agent Briefing Sheets• Hazardous Waste Sites• Managing Hazardous Materials Incidents• Minimal Risk Levels• Public Health Assessments and Health Consultation
s• Toxic Substances FAQs• ToxGuides• Toxicological Profiles
• Education & Training• Case Studies in Environmental Medicine• Environmental Public Health Leadership Institute• Recognition of Illness Associated with Chemical Exposure (August 5,
2004)• Recognition, Management and Surveillance of Ricin-Associated Illness• Toxicology Curriculum
• Publications• Case Studies in Environmental Medicine• Handwashing Tips• Healthy Housing Reference Manual• National Exposure Report• Public Health Assessments and Health Consultations• Selected Information on Chemical Releases within Great Lakes Counties
Containing Areas of Concern• ToxProfiles• Vessel Sanitation Program Operations Manual (PDF, 206 pages)
Emergency Preparedness
• Centers at Accredited Schools:• http://www.cdc.gov/media/pressrel/2008/r081006.htm
• October 2008 ($10.9 Million)