History of Public Health

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• History of Public Health
• and Its Role in Addressing
• Emerging Disease Threats
• MMI 554
• September 8, 2009
• Peter A. Shult, Ph.D.
• Director, Communicable Disease Division
• and Emergency Laboratory Response
• Wisconsin State Laboratory of Hygiene
• shult_at_slh.wisc.edu

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History of Public Health and Its Role in
Addressing Emerging Disease Threats

• The student should be able to
• Discuss the history and reasons for the current
  emerging infectious diseases (EID) crisis
• Understand what public health is and discuss the
  history of the public health response to
  infectious diseases
• Discuss in broad terms the strategies employed by
  the CDC to counter the EID threat
• Discuss continuing challenges to the public
  health response to the EID threat

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Emerging Infectious Diseases

• What Is Your Perception?
• More infectious diseases affecting us?
• Greater perception/detection of what
• always was?
• Are we hypersensitive to any threat?
• All of the above?

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Recent EID Threats and the list
continues to grow

• Pandemic Influenza swine flu
• E.coli O157H7/Salmonella
• Norovirus
• MDR, XDR tuberculosis
• Community-acquired MRSA/ Epidemic C. difficile
• Mumps, Measles, Rubella
• Pertussis (Whooping Cough)
• Monkeypox
• SARS
• West Nile Virus
• Anthrax, ricin and other bioterrorism agents

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Key Resources
www.cdc.gov
www.promedmail.org
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Novel H1N1 Influenza Resources

• www.cdc.gov/h1n1flu

www.pandemic.wisconsin.gov
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Key Factors in Infectious Disease Emergence
-Historical Perspective-

• Population Growth
• Urbanization
• Travel/Trade
• The importance of the Far East
• Goods, people and rodents
• Virgin populations
• Wars
• Changes in Land Use
• Microbial Adaptation

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WHAT IS PUBLIC HEALTH?

• The art and science of preventing
• disease and disability, prolonging life,
• promoting health of populations, and
• ensuring a healthful environment
• through organized community effort

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Public Health in Antiquity

• Waste removal/ fresh water
• Romans, 1st century B.C.
• Variolation
• China, 1000 A.D.
• Quarantine/Isolation
• Europe, 14th century
• Vaccination
• Late 18th - early 19th century

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THE ROAD TO MODERN PUBLIC HEALTH

• 1850s.The birth of Epidemiology as a science
• 1850s-90s..Germ theory and cellular biology,
  etiology of many bacterial diseases
• 1866-1919..Municipal and state boards of health
• 1887-1919..State public health labs opened
• 1890s-1900sArthropod-borne infections, sewage
  treatment, chlorination, pasteurization, garbage
  collection, refrigeration, pure food practices,
  pest control
• 1930s-present..Discovery and development of
  antibiotics
• 1950s-60sEtiology of viral diseases, viral
  vaccines, effective insecticides

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Comparison of Maximum and Recent Reported
Morbidity, Vaccine-Preventable Diseases United
States
Disease Pre-vaccine
Era 2001
change
Smallpox                         
48,164                   
0        100Diphtheria 175,885 2
99.99 Measles 503,282
108 99.98 Mumps 152,209
226 99.80 Pertussis 147,271
5,420 96.30 Polio
(paralytic) 16,316 0
100.00 Rubella 47,745
20 99.95 Cong. Rubella Synd.
823
2 99.80 Tetanus 1,314 27
97.90 H.influenzae type b
20,000
290 98.60

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FIGURE 1. Crude death rate for infectious
diseases - United States, 1900 - 1996.
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U.S. Life Expectancy Change

• 80 attributed to public health interventions
• 20 attributed to medical advances

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What is going on here?http//books.nap.edu/catalo
g.php?record_id10636 (online readable/searchable
version)
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EMERGING INFECTIOUS DISEASES SINCE 1970

• 1973 - Rotavirus
• 1975 - Parvovirus B-19
• 1976 - Cryptosporidium
• 1977 - Ebola
• 1977 - L. pneumophilia
• 1977- Hantaan virus
• 1977 - C. jejuni
• 1980 - HTLV-1
• 1981 - S. aureus - Toxic Shock
• 1982 - E. coli O157H7
• 1982 - HTLV-2
• 1982 - B. burgdorferi
• 1983 - HIV
• 1983 - H. pylori

• 1986 - Cyclospora cayatanensis
• 1988 - HHV-6
• 1988 - Hepatitis E
• 1989 - Erlichia chafeensis
• 1989 - Hepatitis C
• 1991 - Guanarito virus
• 1991 - Babesia species
• 1992 - Vibrio cholerae O139
• 1992 - Bartonella henselae
• 1993 - Sin nombre virus
• 1993 - Encephalitozoon cuniculi
• 1994 - Sabia virus
• 1995 - HHV-8
• 1995 - vCJD

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Factors in Infectious Disease Emergence
- 1992 -

• Ecological Changes
• Human Demographics and Behavior
• International Travel and Commerce
• Technology and Industry
• Microbial Adaptation and Change
• Breakdown in Public Health Infrastructure

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Factors in Infectious Disease EmergenceBreakdown
in Public Health Infrastructure

• HISTORICALLY
• Societal change or disruption
• RECENTLY- circa. 1970 - 1992
• Re-defining health risks
• Complacency
• Treatment vs. prevention mind set
• Decrease in to public health
• Lack of surveillance networks
• Lack of trained personnel
• Reduction in prevention programs

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Public Awareness of Disease Threats
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Emerging Infectious Diseases The Public
Health Response

• Targets
• Surveillance and Response
• Applied Research
• Infrastructure and Training
• Prevention and Control
• The Outcomes
• Raised awareness of public health deficiencies
• We understood what needed to be done however,
  minimal funding to do it

http//www.cdc.gov/ncidod/diseases/eid/index.htm
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A Defining Event
Anthrax 2001
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Anthrax 2001 The Outcome

• Mild contamination of other US postal facilities
• 22 human cases in US
• 11 inhalation
• (5 deaths)
• 11 cutaneous
• 10,000 people prophylaxed
• Nationwide Effects
• Concerns/panic

• 4-5 letters containing anthrax spores sent in
  mail
• 4 regions initially affected in US
• Florida
• New York City / New Jersey
• Washington Metro
• Connecticut

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CDC Program Announcement 99051Public Health
Preparedness Response to BioterrorismEMERGENCY
SUPPLEMENTAL 2002-2009

• Preparedness Planning and Readiness Assessment
• Surveillance Epidemiology Capacity
• Laboratory Capacity - Biological Agents
• Laboratory Capacity - Chemical Agents
• Health Alert Network
• Communication and
• Health Info Dissemination
• Education and Training

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Another Defining Event
Avian Influenza

• The Spread of Avian Flu
• Status - Summer 2009

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Pandemic Influenza Planning
http//www.pandemicflu.gov/

• National Strategy
• Stopping, slowing or limiting the spread of a
  pandemic to the U.S.
• Limiting the domestic spread of a pandemic, and
  mitigating disease, suffering and death
• Sustaining infrastructure and mitigating impact
  to the economy and the functioning of society

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Enhancing Public Health Response
to Emerging Infectious Diseases

• 2009HAVE WE ELIMINATED THE
  THREAT?

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A Reason for Optimism?
Summer 2007
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THE EID THREAT IS A GLOBAL ONE
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Enhancing Public Health Response
to Emerging Infectious Diseases

• 2009WHY DOES THE THREAT
  STILL EXIST?

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WHAT IS PUBLIC HEALTH?

• The art and science of preventing
• disease and disability, prolonging life,
• promoting health of populations, and
• ensuring a healthful environment
• through organized community effort

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Factors in Infectious Disease Emergence

• Human demographics and behavior
• International travel and commerce
• Technology and industry
• Human susceptibility to infection
• War and famine
• Lack of political will
• Poverty and social inequality
• Intent to harm

• Breakdown in
• public health

• Microbial
• adaptation
• and change

Emergence

• Ecological factors
• Zoonotic diseases
• Economic development and land use
• Climate and weather

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ADDRESSING THE THREAT OF
EMERGING INFECTIOUS DISEASES

• The Publics Role in Public Health