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)