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Public health

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defined by Charles-Edward Winslow: science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education

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Public health areas

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epidemiology( epidemics, human population, outbreaks), stats (prevalence, calculate risk), biomedical sciences (clearer understanding of disease for epidemiologists) , environmental health sciences (disease causing agents and potential to harm air, food; channels of transmission), social/behavioral sciences (control by modifying behavior/prevent contraction); all work together to achieve success

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5 step process

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define health problem, identify risk factors, develop & test community-level interventions to control or prevent the cause, implement interventions, monitor & assess their effectiveness

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core functions of public health

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Assessment: diagnostic function in which PH agency collects, assembles, analyzes, and makes available info on health of population; Policy development: use of scientific knowledge to develop strategic approach to improving community's health; assurance: assuring public that services needed for protection of PH including environmental, educational, medical services in community are available/accessible to everyone

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primary prevention

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prevent injury from occurring by preventing exposure to risk factors (examples: discourage teens from smoking/encourage smokers to quit; build divided highways and install traffic lights

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secondary prevention

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seek to minimize severity of illness or damage due to injury causing event once event has occurred (early detection/diagnosis, keep it at treatable stage) example: mammogram, design cars with stronger bumpers, seat belt laws

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tertiary prevention

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seeks to minimize disability by providing medical care/rehab services (911, hospitals)

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James Lind

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conducted first ever clinical trial, found citrus fruits cure scurvy, Scottish physician, hypothesized that fresh water could be obtained by distilling seawater

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John Snow

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father of modern epidemiology, british physician, concerned about cholera outbreaks so he tested the water from two different water companies and found that people in a specific area getting water from the southwark/Vauxhall company; cholera was spread by polluted water, shoe leather epidemiology (# houses, # deaths, per 10,000 houses, moved handle of water pump)

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Edward Jenner

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british physician, proved that inoculation with cowpox matter which is harmless to humans provided immunity against smallpox

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Ignaz Semmelweiss

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Hungarian physician, early pioneer of antiseptic procedures, found that washing of hands could decreases incidence of puerperal fever (childbed fever), savior of mothers

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Epidemic

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A sudden increase in the number of cases of a disease above what is normally expected in population in that area

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Endemic

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amount of particular disease that is usually present in a community

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Pandemic

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worldwide epidemic(baseline of the disease)

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Local public health agency

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most common is the county health department, day to day responsibility for PH, collect health stats, conduct communicable disease control programs, provide screening/immunizations, provide health education services and chronic disease control programs, conduct sanitation, sanitary engineering, inspect programs, run school health programs, mental health may or may not be a separate agency; funds comes from state/federal, local property/sales taxes, fees for some services

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State public health agency

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state health departments, some are centralized while others delegate to the local departments, depend heavily on federal money for many programs, coordinates activities of local agencies and collect/analyzes data provided by the local agencies, lab services provided, maintain standards competence and quality of care, funding from state taxes and federal grants, responsible for people who lack health insurance

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Federal public health agency

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fall under jurisdiction of department of health and human services, agencies include CDC, NIH, FDA, surgeon general is nation's leading spokesperson on PH, CDC does main assessment/epidemiology agency for the nation, NIh is greatest biomedical research complex in the world, FDA ensures food supply is safe and nutritious/evaluates new drugs/ regulates vaccines/cosmetics, EPA is included, departments of education/agriculture/homeland security

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Analytic epidemiology

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hypotheses generated in descriptive phase are tested (prospective-start in present/monitor groups into future, or start in past and look forward, retrospective- look into past for causes of diseases for which people currently suffer)

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Analytic epidemiology--observational

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no intervention implemented, no randomization (ecological cross sectional, case control, cohort)

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Analytic epidemiology--experimental

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test an intervention, groups randomized to eliminate differences between 2 groups (RCT's, group randomized trials)

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Descriptive epidemiology

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answers who, when and where questions to provide clues about the causes of a disease or the source of an outbreak

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Purpose of descriptive epidemiology

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hypotheses tested by formal epidemiological studies to confirm or disprove

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Descriptive epidemiology--Who?

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age, gender, race, sex, SES

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Descriptive epidemiology--When?

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disease frequency over time (season, year or long term trends, elapsed time since exposure or epidemic curve)

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Descriptive epidemiology--Where?

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comparison of disease frequency by geographic region; neighborhood (clusters), latitude (climate), urban vs. rural, national variations

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Prevalence

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- Number of existing cases, depends on incidence and prognosis; # of affected persons present in population at specified time divided by # of persons in population at that time; less useful because rate changes slowly - New + current divided by total

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Incidence

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- Rates of new cases in a defined population over defined period of time; cases reported to local/state health departments divided by population at risk (probability that healthy person will develop disease during that time) - New divided by total - Incidence rates close to death rates; survival rates less than that

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Relationship between prevalence and incidence

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- if causes/risk factors increase, both will increase - if ability to diagnose increases, both will increase -disease with high incidence could have a low prevalence if people recover from it rapidly or if they die from it in a short period of time

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Crude rates

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actual rate of events (birth, death, cases of disease/injury)

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Adjusted rates

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way of comparing 2 groups that differ in some important variable (age ) by mathematically eliminating effect of the variable; uses statistical calculation to make the groups equivalent to each other

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P-value

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Used to express degree of probability or improbability of a certain result in an experiment; represents probability of experimental result occurring by chance alone; interpret 0.05

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Confidence Interval

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Range of values within which true result probably fall, expressed as margins of error; placed around relative risks or odds ratios; crosses 1= not considered significant

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Case report study

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physician reports unusual disease/condition, in depth descriptions of factors related to illness/injury of individual in which new possible relationships/causes found by history, exam, or testing (descriptive, not analytic)

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Case series study

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group of individuals with same/similar illness/injury and with same/similar factors that may be related to disease/injury (descriptive); HIV/AIDS first description doing 5 chest x-rays on young man with rare pneumonia

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Ecologic Studies

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-Examine relationship with disease and exposure with population level rather than individual data; large segments of population are the units of study (countries, communities, schools families) -Provide idea of trends and associations but difficult to link cause/effect -Examples are= air quality samples taken throughout cities in US and hospital records available for researchers for ER visits (investigating asthma ER visits and air quality) ; good for hypothesis generating, inexpensive, can serve as alert system when new exposures introduced

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Fallacy

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stating an association at individual level based on data at group or population level (do not know if people who are dying from heart disease are the same who are individually drinking less)

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Aggregate measures

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proportion/mean of observations derived from individuals in each group (smokers/medial family income, mean saturated fat intake)

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Environmental measures

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physical characteristics of place in which members of each group live or work

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Cross-sectional study

answer

-Determine prevalence -Used to infer causation to some extent; assessed one point in time to determine whether they were exposed to relevant agent and whether they developed outcome of interest -Neither deliberately exposed or treated so less ethical issues; one group- one set of data collected relatively cheaply where multiple outcomes can be studied; cannot provide relationship

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Case control study

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-Looks at people who are already ill and investigates backwards to determine exposures (retrospective); more efficient than cohort studies because focuses on smaller number of people and can be completed relatively quickly -Produces an odds ratio; looks at cases of interest and then ask about previous exposures, good for rare diseases/outcomes, good for assessing many exposures, less expensive, not as good as showing causality

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Cohort study

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-Prospective -Link exposures by observation and without actively involving in lives of human subjects (prospective) ; large groups observed over long period of time and interviewed again to see how many developed diseases/did not -Looks at whether exposed are likely to develop disease as compared to those who were not; produces relative risk -Good for rare exposures, good for assessing many outcomes, provide greater evidence for causality, often expensive, take a long time Exposed, sees if they develop disease or not; most accurate -People choose whether they belong to the exposed group or control group -Finds relative risk

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Randomized controlled trial (RCT)

answer

-Most rigorous form of intervention studies; each subject assigned to treatment group or control group at random (control group may be given placebo); used to test new treatment for disease -Gold standard, rely on some intervention

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Community Trial

answer

Clinical trial in the community? By doctors/clinics not academic researchers; provide access to new meds, etc.

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Intervention Study

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-Is the only type of experiments that epidemiologists conduct. Usually done to test new treatment for a disease, like chemotherapy for a cancer, or a preventative measure like a vaccine. -In a clinical trial, one group is exposed and the control group is not. -The control group may be given a placebo, an inactive substance similar in appearance ot the drug or vaccine being tested. This is to make sure that the participants do not know whether that are getting the treatment. -most convincing clinical trials are the randomized, double blind. randomized meaning each subject is assigned to the treatment group of control group at random. double blind, means that both the patient and the doctor are blind to which participants have the drug or the placebo.

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What to know/look for in all study designs

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-Unit of study -Design (when exposure/outcome are assessed): Identify exposures/outcomes of interest and then formulate your research question/hypothesis -Best uses -Potential problems -Measures of association (Cohort and Case control)

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Exposure

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variable hypothesized to be related to outcome, exposure could be smoking

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Outcome

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any disease state, condition, or other variable examined as end point, could be prostate cancer

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Case Control Study

answer

The Long Island Breast Cancer Study tested the hypothesis that environmental pollution was causing the relatively high rates of breast cancer among residents of Suffolk and Nassau counties of New York. Epidemiologists identified a group of 1,420 women who were diagnosed with breast cancer between 1984 and 1986 and compared their residential histories over a 20 year period with those of a matched group of healthy women. What kind of epidemiologic study was this?

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Relative risk

answer

-cohort studies -Probability of event occurring when exposed divided by probability of event occurring when not exposed(20/100 / 1/100=20); 1.0=no association between exposure & disease; greater than 1.0= increased risk; less than 1.0= exposed less likely to have disease (decreased risk)

question

Odds Ratio

answer

calculates what relative risk would have been if cohort study was performed (case-control) A b C d odds ratio: (a/c)/(b/d) = ad/bc

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Causal inference

answer

Process of drawing conclusion about a causal connection based on conditions of the occurrence of an effect

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Confounding variable

answer

Factors associated with exposure & that may independently affect the risk of developing the disease

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Bias

answer

-Systematic error; selection= when choosing subjects for a case control study; getting participants from randomized digit dialing or choosing control as people recovering from digestive disorder in a study about heart disease (may suggest exaggerated effect of dietary fat effect on heart disease) -Reporting= recall, common problem in case control studies; if study group and control group systematically report differently even if exposure was the same; underweight individuals overreport fat intake while obese underreport

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Factors that support causality

answer

Large number of subjects, high relative risk or odds ratio (stronger association between exposure and disease measured), dose=response relationship between exposure/risk of disease , known biological explanation for association between exposure and disease, consistent with other investigations

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Limitations & advantages of observational studies

answer

advantages: real life situations, explaining meaning and context, strong on validity & in-depth understanding difficult to avoid or assess causality, because treatment exposure is not assigned, it occurs by chance or choice, possible that exposed/unexposed differ in other ways other than exposure

question

Limitations & advantages of experimental studies

answer

limitations are loss to follow up, noncompliance, generalizability, ethical considerations, time consuming and expensive, strict exclusion criteria; advantages are greatest control over amount of treatment, timing/frequency of treatment, period of observation, helps decrease bias, confounding can be reduced with randomization, helps to understand what needs to be controlled for

question

Experimental studies

answer

RCT or quasi experimental (lacks random assignment to treatment or control) studies like a group trial Determine best measures of treatment based on evidence

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Placebo

answer

Control group may receive this; inactive substance similar in appearance to drug/vaccine given to intervention group)

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Randomiztion

answer

Assignment random (participant does not know which group ); assigned to exposure status independent of other factors; each participant assignment is unpredictable, reduces selection bias, increases likelihood that both groups will be comparable

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Blinding

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Do not tell patient which group/what will be receiving; double blind means patient and doctor are blind to who is getting what treatment/placebo; decreases potential bias, placebos are used to mask

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Epidemiologic triangle

answer

3D triangle, each corner is host, vector, agent and environment. -Host: where organism lives -Vector: animal/insect that transmits pathogen to -human host -Environment: food, water

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Infectivity

answer

-ability of a pathogen to establish an infection & how frequently it spreads among hosts that are not in a parent-child relationship.

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Pathogenicity

answer

ability of an organism to cause disease (harm the host).

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Virulence

answer

harmful quality possessed by microorganisms that can cause disease; virus spreads diseases, virulence is the quality possessed by viruses that are on the loose and spreading.

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Antigenicity

answer

capacity of a chemical structure to bind specifically with a group of products that have adaptive immunity

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Pathogen

answer

microorganism that causes illness; bacteria, virus or parasite

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Reservoir

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place where pathogen lives & multiplies before invading a non-infected person. Some infect only humans, some have animal reservoirs & infect humans only occasionally. Contaminated food or water may serve as a reservoir for waterborne or foodborne illnesses.

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Method of transmission

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the way a pathogen travels from one host to another, or reservoir to new host

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Susceptible host

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susceptibility to specific viruses varies among individuals; host may not be susceptible if they have immunity to the pathogen; immunity may develop as result of previous exposure to pathogen, or host may naturally lack susceptibility; most microorganisms are specifically adapted to infect certain species (canine distemper virus, HIV)

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Types of immunity

answer

-Natural: without human intervention -Artificial: when antigens or antibodies are given to person by artificial means (injection) -Herd immunity: Resistance of group to an attack of a disease to which a large population of members of group are immune, if large percentage of population immune, then entire population is likely to be protected; prevents chance of infected person coming into contact with unprotected person

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Disease reservoirs

answer

animal, soil, anthropod (insect, spider), substance, or any combo

question

Modes of transmission

answer

body surface to body surface, touching infected object, droplets by coughing or sneezing, aerosols that contain organisms in droplet nuclei or dust (ventilation systems), contaminated source (food poisoned), vectors

question

Incubation period

answer

the time between infection of an individual by pathogen and the manifestation of the disease it causes; time needed for organism to multiply/reach critical mass that could result in infection

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Infectious period

answer

when you can transmit the disease

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Symptomatic period

answer

when you're actually showing symptoms

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Attack rate

answer

proportion of non-immune exposed individuals who become clinically ill; different from incidence because it uses a specific population & usually refers to an outbreak

question

case fatality rate

answer

proportion of deaths within designated population cases (people with medical condition) over course of the disease; represents a measure of risk; usually used for outbreaks as well.

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cardiovascular disease

answer

leading cause of death, risk increases with age, higher for blacks, higher for men; risk factors are high cholesterol (HDL, not LDL), high BP, atherosclerosis, diet of milk, eggs and meat; difficult to recognize significant risk factors/establish preventative measures; multiple causes for long periods of time, gradual onset

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Cancer

answer

2nd overall leading cause of death, many different manifestations-chemicals, radiation, viruses, diet, smoking, alcohol, inactivity, occupational; recurrence is major issue; mutations; long period from risk exposure to disease; increased risk for 2nd form

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Diabetes

answer

6th overall leading cause of death, increased risk for CVD, treatable, controlled over long periods, major causes of disability; blindness, kidney disease, poor wound healing, amputations; type 1--insulin production, type 2--obesity, rapidly rising in US

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Studying causes of chronic health

answer

-to learn how to prevent them, single vs multiple causes, identify risk factors -long period over which they develop makes it hard to find causative factors -Animal models, epidemiologic study designs, lab cultures

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risk factors of chronic disease

answer

socioeconomic status, culture, age, heredity, smoking, diet, inactivity, cancers, diabetes

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Factors that increase risk of developing disease

answer

single risk factor can lead to many diseases; one disease can have multiple risk factors; risk factors not necessarily causal factors

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Screening

answer

Purpose: decreases morbidity, mortality, detect in earliest stages so treatment can be more successful; helps for those who don't show signs or symptoms of disease

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Sensitivity

answer

ability of test to correctly identify those who have disease, high sensitivity will have few false negatives

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Specificity

answer

specificity is the ability of the test to correctly identify those who don't have the disease, test with high specificity will have few false positives

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10 greatest pubic health achievements

answer

Vaccine preventable diseases, prevention & control of infectious diseases, tobacco control, maternal & infant health, motor vehicle safety, cardiovascular disease prevention, occupational safety, cancer prevention, childhood lead poisoning prevention, public health preparedness & response

question

Maternal & infant health

answer

Labeling of folic acid on food to prevent defects, newborn screenings for metabolic & heritable disorders, reduction in neural tube defects, improvements in technology

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Vaccine preventable diseases

answer

17 diseases targeted by immunization policy, prevents 42,000 deaths & 20 million new cases, pneumococcal conjugate vaccine, routine rotavirus vaccination, improvements in varicella & hepatitis

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Occupational safety

answer

Lower back injuries from patient lifting: mechanical equipment; childhood agriculture injury prevention: match chores with child's development & physical capabilities; crab fishing: correct stability hazards so boats don't overturn

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Motor vehicle safety

answer

Prevent crashes: safer vehicles, safer roadways, safer road use, seat belt, child safety seat

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Prevention and control of infectious diseases

answer

Improvements in PH infrastructure, innovative & targeted prevention efforts, lab techniques, disease surveillance, technology, contaminated foods, HIV testing, West Nile Virus through blood transmission-blood donation screening, canine rabies

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Cardiovascular disease prevention

answer

Heart disease & stroke: controlling hypertension, cholesterol, quit smoking; improvements in treatments, medications, quality of care

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