Foundations of Public Health
PH-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
Measuring Burden of Diseases
•
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.
Estimating Years of Life Lost (YLL)
KCe ra (r  )(L  a)
1 K
(r  )a
YLLs 
e

(r


)(L

a)

1


e

(r


)a

1


(1 e rL )


2
(r  )
r
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 death
L = standard expectation of life at age “a”
Years Lived with Disability (YLDs)


 KCera (r  )(L  a)
1 K
(r  )a
rL 
YLDs  D
(r  )(L  a)  1  e
(r   )a  1
(1 e )
2 e


r
(r  )

YLD
Where:
a = onset of disability
L = duration of disability
r = 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 = 0.1658
D = Disability weight
10000
Major Depression
8000
Alcoholism
Osteoarthritis
Dementia
6000
Schizophrenia
Bipolar disorder
4000
Cerebrovascular
COPD
2000
Car Accidents
Diabetes
0
Diseases
Global Disease-Adjusted Life Years (DALYs)
Millions
2002 Worldwide Disability Adjusted Life Years (DALYs)
180.00
160.00
140.00
DALYs
120.00
100.00
80.00
60.00
40.00
20.00
0.00
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Future projections of disease burden
ln M = C + b1lnY + b2lnHC + b3T
Where:
M = projected mortality level
C = constant term
Y = GDP per capita
HC = Human capital (including population growth)
T = Time
Global Demographic Divide Widens
World Population (in Billions): 1950-2050
Source: United Nations Population Division, World Population Prospects: The 2006 Revision.
© 2008 POPULATION REFERENCE BUREAU
Continued Population Growth Sets the United States Apart From Other
Developed Countries Around the World.
Percent Change in Population, Selected Countries: 2008-2050
Source: Carl Haub and Mary Mederios Kent, 2008 World Population Data Sheet.
© 2008 POPULATION REFERENCE BUREAU
Global projections for selected causes,
2004 to 2030
12
Cancers
Deaths (millions)
10
Ischaemic HD
Stroke
8
6
Acute respiratory
infections
4
Road traffic
accidents
Perinatal
HIV/AIDS
TB
Malaria
2
0
2000
2005
2010
2015
2020
2025
2030
Updated from Mathers and Loncar, PLoS Medicine, 2006
Projected deaths by cause and income, 2004 to 2030
30
Intentional injuries
Other unintentional
Road traffic accidents
Deaths (millions)
25
Other NCD
20
Cancers
15
CVD
10
Mat//peri/nutritional
5
Other infectious
HIV, TB, malaria
0
2004
2015
2030
High income
2004
2015
2030
Middle income
2004
2015
2030
Low income
Ten leading causes of burden of disease,
world, 2004 and 2030
Scaled World
Population by
Region
Public Health
Spending
Danny Dorling of the University of Sheffield: Worldmapper Project – PLOS-Medicine 2007
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
http://www.who.int/topics/environmental_health/en/
•
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
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 Sites
Blackwell 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
Summary of Blood Lead Levels in Children, Ages 1-6, Otukpo
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
Sex
Attributable Risk:
Shift to mild mental retardation due to Pb-induced loss of IQ points
Percentage of subjects
Normal curve of
distribution of
intelligence
Shift to mild mental
retardation due to loss of
IQ points
Mild mental
retardation
50
70
72.6
80
90
100
IQ
73.5
Fewtrell et al., [2002]
Childhood Health Costs of Lead Exposure
$(M)
Children
Variable
Medical Costs
Average blood lead concentration
9.8 ug/dL
Number of children requiring chelation therapy
160,909
Cost of chelation therapy
Total Medical Costs
Compensatory Education
Number of children who receive education
Cost of education
Total Compensatory Education Cost
Earnings
Infant Mortality
Neonatal Care
Number children, age 6
Million Naira
1,920
309
7
888
18
2,286
155
19,406
52.88
6,609.88
162,231
4,902
795
3,515,600
Increase in earnings of a 1 ug/dL reduction in BLL
1,920
Total Earnings Lost
6,750
IMR
GNI-PPP Adjusted
75/1000
1 ug/dL reduced maternal blood – IMR
74.9/1000
Value of statistical life
4,429,840
Number of live births, 2002
5,192,000
Number of reduced deaths
519
Total IMR Cost
2,299.09
# of NICU admissions
1,752,300
Reduced NICU admissions
1,749,960
Number of fewer NICU admissions
2,340
Cost of NICU
86,661
Total Neonatal Cost
202.79
4.66
583.01
10,356.03
238.19
29,773.58
Total Costs
Cost of Lead Abatement
Cost ($/liter)
Abatement Factors
Gasoline Source
‡Cons.
(106 l/year)
Cost (M$/yr
1995)
Cost (M$/yr
2003)
Cost (†MN/yr,
2003)
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
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
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%
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%
Total annual cost of abatement
*227
24,250
Pb abatement cost / Pb health cost
0.567
0.567
Low Estimate
Medium Estimate
High Estimate
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
•
•
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•
•
•
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•
•
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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
Consultations
• 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)