Perie public health

SECTION I

Cases and Discussion Questions

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HIV/AIDS DETERMINANTS AND CONTROL OF THE EPIDEMIC

A report appeared in the CDC’s “Morbidity and Mortality Weekly Report” (MMWR) on June 5, 1981, describing a previously unknown deadly disease in five young homosexual males, all in Los Angeles. The disease was characterized by dramatically reduced immunity, allowing otherwise innocuous organisms to become “opportunistic infections,” rapidly producing fatal infections or cancer. Thus, acquired immune deficiency syndrome (AIDS) first became known to the public health and medical communities. It was soon traced to rectal intercourse, blood transfusions, and reuse of injection needles as methods of transmission. Reuse of needles was a common practice in poor nations. It was also widespread among intravenous drug abusers. Within several years, the disease was traced to a previously unknown retrovirus, which came to be called the human immunodeficiency virus (HIV).

A test was developed to detect the disease and was first used in testing blood for transfusion. Within a short period of time, the blood supply was protected by testing all donated blood, and transmission of HIV by blood transfusion became a rare event. Diagnostic tests for HIV/AIDS soon became available for testing individuals. For many years, these were used by clinicians only for high-risk individuals. In recent years, HIV testing has become more widely used, as the testing no longer requires blood drawing and the results are rapidly available. The CDC has put increasing emphasis on testing as part of routine health care.

In subsequent years, much has been learned about HIV/AIDS. Today, it is primarily a heterosexually transmitted disease with greater risk of transmission from male to females than females to males. In the United States, African Americans are at the greatest risk. Condoms have been demonstrated to reduce the risk of transmission. Abstinence and monogamous sexual relationships likewise eliminate or greatly reduce the risk. Even serial monogamy reduces the risk compared to multiple simultaneous partners. Male circumcision has been shown to reduce the potential to acquire HIV infection by approximately 50%.

In major U.S. cities, the frequency of HIV is often greater than 1% of the population, fulfilling the CDC definition of “high risk.” In these geographic areas, the risk of unprotected intercourse is substantially greater than in most suburban or rural areas. Nearly everyone is susceptible to HIV infection, despite the fact that a small number of people have well documented protection on a genetic basis.

Maternal-to-child transmission is quite frequent and has been shown to be largely preventable by treatments during pregnancy and at the time of delivery. CDC recommendations for universal testing of pregnant women and intervention for all HIV-positive patients have been widely implemented by clinicians and hospitals and have resulted in greatly reduced frequency of maternal-to-child transmissions in the developed countries and in developing countries in recent years.

Medication is now available that greatly reduces the load of HIV present in the blood. These medications delay the progression of HIV and also reduce the ease of spread of the disease. These treatments were rapidly applied to HIV/AIDS patients in developed countries, but it required about a decade before they were widely used in most developing countries. Inadequate funding from developed countries and controversies over patent protection for HIV/AIDS drugs delayed widespread use of these treatments in developing countries.

New and emerging approaches to HIV prevention include use of antiviral medications during breastfeeding, postcoital treatments, and rapid diagnosis and follow-up to detect and treat those recently exposed.

Discussion Questions

1. Use the BIG GEMS framework to examine the factors in addition to infection that have affected the spread of HIV and the control or failure to control the HIV/AIDS epidemic.

2. What roles has health care played in controlling or failing to control the HIV/AIDS epidemic?

3. What roles has traditional public health played in controlling or failing to control the HIV/AIDS epidemic?

4. What roles have social factors (beyond the sphere of health care or public health) played in controlling or failing to control the HIV/AIDS epidemic?

SMOKING AND ADOLESCENTS—THE CONTINUING PROBLEM

The rate of smoking in the United States has been reduced by approximately one-half since the 1960s. However, the rate of smoking among teenagers increased in the 1980s and 1990s, especially among teenage females. This raised concerns that young women would continue smoking during pregnancy. In addition, it was found that nearly 90% of those who smoked started before the age of 18, and in many cases at a considerably younger age.

In the 1980s and most of the 1990s, cigarette smoking was advertised to teenagers and even preteens, or “tweens,” through campaigns by companies such as Joe Camel. In recent years, a series of interventions directed at teenagers and tweens was put into effect. These included elimination of cigarette vending machines, penalties for those who sell cigarettes to those under 18, and elimination of most cigarette advertising aimed at those under 18. In addition, the Truth® campaign aimed to convince adolescents, who often see smoking as a sign of independence from their parents, that not smoking is actually a sign of independence from the tobacco companies who seek to control their behavior. Evaluation studies concluded that these interventions have worked to reduce adolescent smoking by about one-third.

Despite the successes of the early years of the 2000s in lowering the rates of cigarette smoking among adolescents, the rates have now stabilized at over 20%. Evidence indicates that adolescents who smoke generally do not participate in athletics, more often live in rural areas, and are more often white and less often African American. Males and females smoke about the same amount overall, but white females smoke more and Asian females smoke less than their male counterparts.

New drugs have recently been shown to increase the rates of success in smoking cessation among adults with few side effects. Evidence that the benefits are greater than the harms in adolescents is insufficient to recommend them for widespread use because of increased potential for adverse effects, including suicide. A series of interventions has been suggested for addressing the continuing problem of adolescent smoking. These include:

• Expulsion from school for cigarette smoking

• Focus on adolescents in tobacco warning labels

• Selective use of prescriptions for cigarette cessation drugs

• No smoking rules for sporting events, music concerts, and other adolescent-oriented events

• Fines for adolescents who falsify their age and purchase cigarettes

• Higher taxes on tobacco products

• Rewards to students in schools with the lowest smoking rates in a geographic area

• Higher auto insurance premiums for adolescents who smoke

• Application of technology to reduce the quantity of nicotine allowed in tobacco products to reduce the potential for addiction

• Testing of athletes for nicotine and exclusion from competition if they test positive

• Encouragement of the use of e-cigarettes, which utilize smokable nicotine but not cancer-causing components of cigarettes

• Provision of tobacco counseling as part of medical care covered through insurance

Discussion Questions

1. How does this case illustrate the P.E.R.I.E. process?

2. Which of these interventions do you think would be most successful? Explain.

3. How would you classify each of these potential interventions as education (information), motivation (incentives), obligation (required), or innovation (technological change)?

4. What other interventions can you suggest to reduce adolescent smoking?

REYE’S SYNDROME: A PUBLIC HEALTH SUCCESS STORY

Reye’s Syndrome is a potentially fatal disease of childhood that typically occurs in the winter months at the end of an episode of influenza, chicken pox, or other acute viral infection. It is characterized by progressive stages of nausea and vomiting, liver dysfunction, and mental impairment that progress over hours to days and result in a range of symptoms, from irritability to confusion to deepening stages of loss of consciousness. Reye’s Syndrome is diagnosed by putting together a pattern of signs and symptoms. There is no definitive diagnostic test for the disease.

Reye’s Syndrome was first defined as a distinct condition in the early 1960s. By the 1980s, over 500 cases per year were being diagnosed in the United States. When Reye’s Syndrome was first diagnosed, there was over a 30% case-fatality rate. Early diagnosis and aggressive efforts to prevent brain damage were shown to reduce the deaths and limit the mental complications, but there is no cure for Reye’s Syndrome.

In the late 1970s and early 1980s, a series of case-control studies compared Reye’s Syndrome children with similar children who also had an acute viral infection, but did not develop the syndrome. These studies suggested that use of aspirin, then called “baby aspirin,” was strongly associated with Reye’s Syndrome, with over 90% of those children afflicted with the syndrome having recently used aspirin.

Cohort studies were not practical because they would require observing very large numbers of children who might be given or not given aspirin by their caretakers. Randomized controlled trials were neither feasible nor ethical. Fortunately, it was considered safe and acceptable to reduce or eliminate aspirin use in children because there was a widely used alternative—acetaminophen (often used as the brand name Tylenol)—that was not implicated in the studies of Reye’s Syndrome.

As early as 1980, the CDC cautioned physicians and parents about the potential dangers of aspirin. In 1982, the U.S. surgeon general issued an advisory on the danger of aspirin for use in children. By 1986, the U.S. Food and Drug Administration required a Reye’s Syndrome warning be placed on all aspirin-containing medications. These efforts were coupled with public service announcements, informational brochures, and patient education by pediatricians and other health professionals who cared for children. The use of the term “baby aspirin” was strongly discouraged.

In the early 1980s, there were over 500 cases of Reye’s Syndrome per year in the United States. In recent years, there have often been fewer than 5 per year. The success of the efforts to reduce or eliminate the use of “baby aspirin” and the subsequent dramatic reduction in the frequency of Reye’s Syndrome provided convincing evidence that aspirin was a contributory cause of the condition and its removal from use was an effective intervention.

Discussion Questions

1. How does the Reye’s Syndrome history illustrate the use of each of the steps in the P.E.R.I.E. process?

2. What unique aspects of Reye’s Syndrome made it necessary and feasible to rely on case-control studies to provide the evidence to help reduce the frequency of the syndrome?

3. What types of methods for implementation were utilized as part of the implementation process? Can you classify them in terms of when, who, and how?

4. How does the Reye’s Syndrome history illustrate the use of evaluation to demonstrate whether the implementation process was successful?

SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden infant death syndrome, or SIDS, was first recognized as a distinct public health problem in the late 1960s when over 7,000 infants each year were found to die suddenly and unexpectedly. “Crib deaths” have been recognized for centuries, but until they were formally recorded and investigated, little was known about their cause, leading some to conclude that intentional or unintentional suffocation by parents or caregivers played an important role.

Data from the investigations of SIDS indicated that the syndrome was very rare before babies’ first month of life, increased during the second month, and peaked during the third month, before rapidly declining in frequency to again become rare after the fourth month of life. The timing of SIDS suggested that the condition occurs after infants begin to sleep for extended periods but prior to the time in which children can raise themselves up and roll over on their own. Additional evidence suggested a seasonal trend, with more cases of SIDS occurring during cold weather months than during warm weather months.

In the 1980s, several case-control studies of SIDS cases and similar infants without SIDS established that infants who slept on their stomachs were at substantially increased risk of dying from SIDS. The studies indicated that the chances increased four to seven times, suggesting that if a cause-and-effect relationship exists, a clear majority of SIDS cases could be prevented if infants slept on their back. Many parents and clinicians remained skeptical because the traditional teaching emphasized sleeping prone, or on the stomach, to reduce the possibility of choking on regurgitation and vomit. Despite the lack of evidence for this hazard, generations had been raised on this practice and belief.

Additional evidence of the effectiveness of a “back-to-sleep” intervention was provided by the experience of New Zealand, which was the first country to begin a program to encourage caretakers to put infants to sleep on their backs. The rates of SIDS in New Zealand declined rapidly in parallel with the increased rate at which infants were put to sleep on their back. Similar declines in SIDS did not occur in other countries that had not yet instituted similar back-to-sleep programs.

In 1992, the American Academy of Pediatrics made a recommendation that infants be placed on their back to sleep. The initial recommendations also endorsed side sleeping. In 1994, with the support of the American Academy of Pediatrics, the National Institutes of Health (NIH), and the U.S. Public Health Service, the Back-to-Sleep campaign was launched. The educational campaign included public service announcements, brochures and other publications, including information accompanying new cribs, plus efforts for pediatricians and others who care for infants to educate parents and caretakers about the importance of having infants sleep on their backs.

The frequency of infants sleeping prone in the United States was found by survey data to be reduced from approximately 70% to less than 15% during the years immediately following the initiation of the Back-to-Sleep campaign. During these years, the rates of SIDS fell by approximately 50%, an impressive change but less than expected by the initial data. The rate of prone sleeping among African Americans was found to be over twice as high as the rate among whites, and African American infants continued to have higher rates of SIDS than whites.

Continuing studies suggested that the side position was being commonly used. It was found that many infants moved from the side to the prone position, and movement from the side to the prone position carried a high risk of SIDS. Additional case-control studies suggested that soft objects and loose bedding as well as overheating were associated with SIDS. These relationships are consistent with the initial finding of an increase of SIDS in colder weather months.

Studies of the infants who slept on their back indicated an increasing in flattening of the head, or plagiocephaly. These changes were shown to be reduced by increasing the amount of “tummy time,” or play periods in which infants are placed prone under supervision. Guidelines for tummy time are now part of the evidence-based recommendations.

SIDS continues to be an important cause of infant mortality, and new contributory causes continue to be investigated. SIDS reflects the use of evidence-based public health and the importance of continuing to study and develop new approaches to public health problems.

Discussion Questions

1. Discuss how the problem description component of the evidence-based public health approach suggested hypotheses for the etiology of SIDS.

2. Discuss the types of evidence used to support the relationship between sleeping prone and SIDS as well as the limitations of the evidence.

3. Discuss how the evidence-based recommendations incorporated potential benefits and harms.

4. Discuss how implementation and evaluation worked to establish sleeping on the back as a standard intervention to prevent SIDS.

5. Discuss how the continuing presence of the problem of SIDS has produced a new round of use of the evidence-based public health approach.

OXYGEN USE IN PREMATURE INFANTS AND BLINDNESS

Oxygen seemed like just what premature infants needed to address the underdevelopment of their lungs, which often led to pneumonia and death. Thus in the 1940s, after effective means were developed to administer oxygen to pilots in World War II, physicians began to routinely administer high-dose oxygen to nearly all premature infants. The unexpected association between high-dose oxygen and blindness only became established after over 10,000 premature infants, including its most famous victim, Stevie Wonder, developed blindness.