The Role of Public Health - DR. KATIE A. CAHILL OCT. 2018
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The Role of Public Health DR. KATIE A. CAHILL OCT. 2018
What is health?
u Health is a dynamic state of complete physical, mental, and social well-
being.
Top 10 Causes of Death (CDC, 2016) 1. Heart disease (635, 260) 2. Cancer (598,038) 3. Accidents-unintentional injury (161,374) 4. Chronic lower respiratory disease (154,596) 5. Stroke (142,142) 6. Alzheimer’s disease (116,103) 7. Diabetes (80,058) 8. Influenza and pneumonia (51,537) 9. Nephritis, nephrotic syndrome, and nephrosis (50,046) 10. Suicide (44,965)
Public Health
u Public Health is what society does to create conditions in which people
can be healthy.
u Public health problems are diverse and can include infectious diseases,
chronic diseases, emergencies, injuries, environmental health
problems, as well as other health threats.
Key Point: medicine is focused on individuals,
while public health is focused on populations.
Public Health u prevents epidemics and the spread of disease u protects against environmental hazards u prevents injuries u promotes and encourages healthy behaviors u responds to disasters and assists communities in recovery u assures the quality and accessibility of health services
Health Impact Pyramid Frieden TR. Framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590–5.
Health Impact Pyramid Frieden TR. Framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590–5.
Life Expectancy
u since 1900, average life
expectancy at birth increased by
30 years
u public health innovations have
been responsible for 25 of those
years
u still, some US counties live 20
years longer than residents of
other areas
Map: Journal of American Medical Association (2017)
Top 10 Public Health Achievements 1. Immunization 2. Safer Workplaces 3. Safer and Healthier Food 4. Motor Vehicle Safety 5. Control of Infectious Diseases 6. Decline in Deaths from Coronary Heart Disease and Stroke 7. Family Planning 8. Tobacco Use as a Health Hazard 9. Healthier Mothers and Babies 10. Fluoridation of Drinking Water
Essential Services of Public Health 1. Monitor Health Status 2. Diagnose and Investigate 3. Inform, Educate, and Empower 4. Mobilize Community Partnerships 5. Develop Policies and Plans 6. Enforce Laws and Regulations 7. Link People to Needed Services/Ensure Care 8. Ensure a Competent Workforce 9. Evaluate Health Services 10. Research
Sanitation and Environmental Health
500 BCE 1840s 1970
Greeks and Romans The Public Health The Environmental
practice community Act of 1848 was Protection Agency
sanitation measures established in the was founded
United Kingdom
11Founders of Modern Epidemiology u John Snow u Ignaz Semmelweis u Reasons: introduced hypothesis testing, analyses, and explanation.
John Snow, Physician
John Snow is best known for
his work tracing the source of
the cholera outbreak and is
considered the father of
modern epidemiology.
Photo: London School of Hygiene
and Tropical MedicinePandemics
Influenza Polio HIV
500 million infected Vaccine introduced 34 million living with
worldwide in 1918 in 1955; eradication HIV worldwide; 20%
initiative launched in decline in new
1988 infections since 2001
14Preparedness for Disaster Response
Biologic September Hurricane
Warfare 2001 Katrina
Plague used as a Public health Emergency services,
weapon of war during surveillance public health
the Siege of Kaffa conducted after surveillance, and
the 9/11 attacks disease treatment
providedPrevention Through Policy Book Tobacco of Leviticus Laws Obesity The world’s Laws banning smoking Food labeling and first written in public places promotion of physical health code activity
A Public Health Approach
Risk Factor Intervention
Surveillance Implementation
Identification EvaluationCholera — A Public Health Approach 18
Cholera, a fatal intestinal
disease, was rampant during
the early 1800s in London,
causing death to tens of
thousands of people in the
area. Cholera was commonly
thought to be caused by bad
air from rotting organic
matter.
Photo: TJ Kirn, MJ Lafferty, CMP Sandoe, and R Taylor,
Dartmouth Medical SchoolEpidemiology — What is the Problem?
Cluster of Cholera Cases, London — 1854
Image: The Geographical Journal
19Risk Factor Identification — What Is the Cause?
Cluster of Cholera Cases and Pump Site Locations
Image: The Geographical JournalIntervention Evaluation — What Works?
Through continuous research, Snow understood what
interventions were required to:
• stop exposure to the contaminated water supply
on a larger scale, and
• stop exposure to the entire supply of
contaminated water in the areaImplementation — How Do You Do It?
John Snow’s research convinced the
British government that the source of
cholera was water contaminated with
sewage.
Photo: Justin CormackPublic Health Structure
u Community Partners, Providers, and Non-Profit Organizations (e.g.,
National Academy of Medicine (NAM))
u Local Health Departments and Local Boards of Health
u State Health Agency (SHA), State Health Departments, and State
Boards of Health
u Federal: Department of Health and Human Services (HHS) and
Environmental Protection Agency (EPA)
u International Health Agencies (WHO, Unicef)State and Local Health Departments
u states retain primary responsibility under US Constitution
u screening and treatment for diseases and conditions
u technical assistance and training
u state laboratory service
u epidemiology and surveillance
•Health •Improved
Department Every Health
•Public Health •Operational Community Outcomes
Investment System Builds Capacity Impacts and Public Leads To •Reduced
•Community •Infrastructure Health Disparities
Partners Program •Better
•Workforce PreparednessHealth Boards
u a health board is a legally designated body whose role is to protect and
promote the health of the community.
u Most:
u provide oversight to the public health agency/public health
department
u foster activities such as community health assessments,
assurance, and policy development
u review public health regulations and recommend public health
policies, priorities, and programs.Core Functions at Government Levels 26
Policy
Assessment Development Assurance
Federal National tobacco Smoking ban Federal grants
public health on commercial flights for antismoking
surveillance research
State Monitor state Increase
Funding
for campaign
tobacco use tobacco tax
through
Proposition 99
Resources to help
Local Report on local County laws smokers quit
tobacco use prohibiting in multiple languages
smoking in barsState and Local Health Governance
u Centralized: all local health departments are units of the state
government, which makes most fiscal decisions.
u Shared: all local health departments are governed by both state and local
authorities.
u Decentralized: local health departments are units led by local
governments and make most fiscal decisions.
u Mixed: some local health departments are led by state government, and
some are led by local government; no arrangement dominates.Health and Human Services (HHS)
u The mission is to enhance and protect the health and well-being of all
Americans.
u Secretary is a cabinet-level position (Alex Azar, 2019)
u Provides for effective health and human services by fostering advances in
medicine, public health, and social services.
u 11 operating divisions; 8 public health agencies; 3 human service agencies
u Includes: AHRQ, CDC, CMS, FDA, NIH, and SAMHSA
u More information here.Federal Public Health Responsibilities
u Act when:
u health threats may span more than one state, a region, or the
entire nation.
u solutions may be beyond the jurisdiction of individual states.
u states lack the expertise or resources to effectively respond in a
public health emergency (e.g., disaster, bioterrorism, or an
emerging disease).
u Ensure all levels of government have ability to provide essential public
health services.
u Facilitate the formulation of public health goals.Federal Government
u Provides leadership, through regulatory powers in setting health goals,
policies, and standards.
u Contributing operational and financial resources.
u Financing research and higher education.
u Supporting the development of scientific and technological tools
needed to improve public health infrastructure at all levels.Emergency Management
Public Health Surveillance
u Epidemiology is the study of the distribution and determinants of disease
frequency and injury/disability in human populations.
u Purpose:
u to study the etiology (origin) of diseases, disorders, and disabilities
u to identify agents (germs, pollutants, etc.) associated with diseases
u to assist in the development of population-level health initiatives,
services, and programs
u to prevent/protect and control diseasesDistribution
First key word in the definition of epidemiology.
u Person: refers to demographic variables such as gender, age, race, sex,
socio-economic, and martial status
u Place: a specific geographic location
u Time: a specified period of timeTerms Related to Distribution u Sporadic u Endemic u Hyperendemic u Holoendemic u Outbreak u Epidemic u Pandemic
Classifying Terms
Term Distribution Criteria
Outbreak Localized 2 or more cases (foodborne)
Epidemic Community No. of observed cases are greater than expected
State
Region
Pandemic Country No. of observed cases are greater than expected
Continent
WorldDeterminants
Second key word in the definition of epidemiology.
u Variables that affect the distribution of a disease. Such as age, sex, race,
genetics, biology, environment, seasons, etc.Disease
Third key word in the definition of epidemiology.
Assumptions:
u diseases do not occur at random
u diseases have causal factors (determinants), which often make them
preventable and controllableFrequency
The fourth key word in the definition of epidemiology.
u Determinants are related to disease frequency (f)
u What does (f) tell us?
u How often a disease occurs during a specified period of time (e.g.,
magnitude)
u Tells us whether we have an outbreak, epidemic, or pandemic
u Helps to think about prevention/protection, control, and treatment
strategiesPrevention
u Primary Prevention: stop the disease from happening
u Secondary Prevention: modifies the extent or severity of a disease by early
detection and prompt treatment
u Tertiary Prevention: damage control
u SKIT: stop it from happening, keep it from getting worse, treat it once it
has developed.Investigating Outbreaks
u Reservoir: any organism or substance where an infectious agent lives and
multiplies
u Mode of Transmission: how an infectious agent is spread
u Period of Communicability: the time during which an infectious agent
may be transmitted
u Susceptible: easily infected
u R0 (r nought): the number of cases one case generates on average over
the course of its infectious period in an otherwise uninfected individualDisease Transmission
u Direct transmission: pathogen transmitted via direct contact between a
diseased and non-diseased subject
u Indirect transmission: pathogen transmitted via an intermediate
u vehicle borne: fomites (e.g., door knobs, table tops/desks, etc.)
u food borne: contaminated food (e.g., raw or undercooked
chicken/eggs)
u vector borne: intermediate organism (e.g., mosquito)Investigating an Outbreak u https://www.youtube.com/watch?v=kUlKRIMxpZQ&t=26s
Investigating an Outbreak 1. Verify the diagnosis: know the criteria for a case 2. Verify the distribution: how does the incidence rate compare to the endemic state? 3. Define the distribution: cases (numerator) and population at risk (denominator) 4. Examine the distribution of cases in terms of person, place, and time 5. Consider variables: incubation period, transmission mode, etc. 6. Develop hypotheses based on existing knowledge and information collected 7. Recommend prevention/protection and control measures 8. Review best practices 9. Report the investigation 10. Prevent future outbreaks
Outbreaks u National Outbreak Reporting System (NORS)
Pandemic
u The CDC has developed a Pandemic Severity Index, with categories of
increasing severity (Category 1 to Category 5).
u It uses a ratio to estimate the number of expected deaths.
u Similar to preparing for a hurricane, this index helps communities with
pandemic preparedness and planning.Pandemic
u The World Health Organization (WHO) provides an influenza pandemic alert
system, with a scale ranging from Phase 1 (a low risk of a flu pandemic) to
Phase 6 (a full-blown pandemic).
u Phase 1: A virus in animals has caused no known infections in
humans.
u Phase 2: An animal flu virus has caused infection in humans.
u Phase 3: Sporadic cases or small clusters of disease occur in
humans. Human-to-human transmission, if any, is insufficient to cause
community-level outbreaks.
u Phase 4: The risk for a pandemic is greatly increased but not certain.
u Phase 5: Spread of disease between humans is occurring in more
than one country of one WHO region.
u Phase 6: Community-level outbreaks are in at least one additional
country in a different WHO region from phase 5. A global pandemic is
under way.What if something goes wrong?
u Isolation separates sick people with a contagious disease from people
who are not sick.
u Quarantine separates and restricts the movement of people who were
exposed to a contagious disease to see if they become sick.
Isolation and quarantine help protect the public by preventing exposure. In
addition to serving medical functions, these represent the “police power” of
the state.Public Health Ethics
u identifying and clarifying the ethical dilemma posed
u analyzing it in terms of alternative courses of action and their
consequences
u resolving the dilemma by deciding which course of action best
incorporates and balances the guiding principles and valuesFederal Isolation and Quarantine
Federal isolation and quarantine are authorized for these communicable
diseases:
u Cholera
u Diphtheria
u Infectious Tuberculosis
u Plague
u Smallpox
u Yellow Fever
u Viral Hemorrhagic Fevers
u Severe Acute Respiratory Syndromes
u Flu that can cause a Pandemic
Federal isolation and quarantine are authorized by Executive Order of the
President. The President can revise this list by Executive Order.Federal Law
u isolation and quarantine are derived from the Commerce Clause of the
US Constitution
u Under Section 361 of the Public Health Service Act (42 U.S. Code §
264), the US Secretary of Health and Human Services is authorized to
take measures to prevent the entry and spread of communicable diseases
from foreign countries into the United States and between states.
u The authority for carrying out these functions on a daily basis has been
delegated to the Centers for Disease Control and Prevention (CDC).The Power of the CDC
u Under 42 Code of Federal Regulations parts 70 and 71, CDC is
authorized to detain, medically examine, and release persons arriving
into the United States and traveling between states who are suspected of
carrying these communicable diseases.
u CDC routinely monitors persons arriving at US land border crossings and
passengers and crew arriving at US ports of entry for signs or symptoms
of communicable diseases.
u When alerted about an ill passenger or crew member by the pilot of a
plane or captain of a ship, CDC may detain passengers and crew
as necessary to investigate whether the cause of the illness on
board is a communicable disease.State and Local Government
u States have police power functions to protect the health, safety, and
welfare of persons within their borders.
u To control the spread of disease within their borders, states have laws to
enforce the use of isolation and quarantine.
u These laws can vary from state to state and can be specific or broad. In
some states, local health authorities implement state law. In most states,
breaking a quarantine order is a criminal misdemeanor.Enforcement
u If a quarantinable disease is suspected or identified, CDC may issue a
federal isolation or quarantine order.
u Public health authorities at the federal, state, local, and tribal levels may
sometimes seek help from police or other law enforcement officers to
enforce a public health order.
u US Customs and Border Protection and US Coast Guard officers are
authorized to help enforce federal quarantine orders.
u Breaking a federal quarantine order is punishable by fines and
imprisonment.
u Federal law allows the conditional release of persons from quarantine if
they comply with medical monitoring and surveillance.Solve the Outbreak u https://www.cdc.gov/mobile/applications/sto/web-app.html
Communicating u Simple u Timely u Accurate u Relevant u Credible u Consistent
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