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Sunday, September 03, 2006

Tuskegee II? An Interview with Peter Lurie of Public Citizen

Peter Lurie, MD, MPH, is a Health Researcher with Public Citizen, a non-profit consumer advocacy organization founded by Ralph Nader in 1971. Public Citizen fights for safe foods, drugs and medical devices; greater consumer control over personal health decisions; and universal access to quality health care.
Currently Public Citizen is involved in speaking out against US funded HIV trials being conducted in developing countries which deny effective drug therapy to participants and are in violation of the Nuremberg Code. Dr. Lurie has played a central role in bringing this issue to the attention of the public. His findings have been published in the New England Journal of Medicine and presented to both President Clinton and Secretary Shalala. Public Citizen has joined with leading health experts including Wilbert Jordan, MD, MPH, Chairman of the Black Los Angeles AIDS Consortium; Michael Grodin, MD and George Annas, JD, MPH of Boston University’s Health Law Department; and George Silver, MD of Yale School of Medicine; to demand an investigation by the Department of Health and Human Services Office of the Inspector General. The group has also appealed to Secretary Shalala to order the researchers to provide participants immediate access to AZT in order to prevent further loss of life. Furthermore, Public Citizens recommends a referral to the National Bioethics Advisory Commission and is supported by Dr. Philip Lee, former Assistant Secretary for HHS; Dr Thomas Murray, a member of the NBAC and Director of the Center for Biomedical Ethics; Case Western Reserve University School of Medicine; Dr. Richard Humphrey, of the John Hopkins University Medical School and School of Public Health; and Dr. Author Caplan, Director of the Center for Bioethics, University of Pennsylvania.
Dr. Lurie spoke to me in his capacity as Health Researcher with Public Citizen on November 11, 1997 from his office in Michigan.

Interview
Perez: I’d like to start at the beginning--what lead you into the field of HIV research; specifically your interest in the socioeconomic and ethical issues surrounding HIV?
Lurie: I am originally from South Africa and was always interested in ethical and socioeconomic issues. In 1984, as a student, I began working with Pubic Citizen examining the double standards of the Pharmaceutical industry in developing countries. I went back to medical school and obtained my MD while continuing to pursue my interest in the socioeconomic implications of health. People are not generally interested in socioeconomic issues but if you look at all causes of morbidity and mortality, socioeconomic status is the strongest predictor. All causes of morbidity and mortality are very strongly correlated with socioeconomic status. In America we shrug this off, but it is a stronger association than many other things we obsess about. It’s one of those things that you start off with in Public Health but then forget about. The assumption is that it can’t change, but some of the biggest success stories in Public Health are due to these changes; for example, better housing conditions. I saw a big gap - especially on the international level. Also, if you are interested in HIV, you have to be interested in what is happening in developing countries. It is estimated that 90% of all HIV is in developing nations... economics and politics play a large role in the health of the citizens.
Perez: I couldn’t help but notice you are no stranger to controversy; you strongly support Needle Exchange Programs which are often an unpopular idea in this country; what is your opinion on the role of education and research in the prevention of HIV?
Lurie: Most public opinion polls show the public does support Needle Exchange Programs (NEP), the problem is not with the public but rather the politicians. They are seized by hysteria with the war on drugs...at which we are failing miserably. I saw a recent article that estimated over 57 Billion dollars of drugs were being brought into this country -- we only seize about 1/5 -- the problem is so large...but they can’t be seen as soft on drugs so it pollutes the ability to debate NEP’s because of the absolutist way NEP draws into ideologies such as giving away pure Heroine when in fact that is not the proposal. It is not radical to say in Public Health, “lets balance the risk vs the benefit”. NEP’s have been shown to reduce HIV transmission; we are not advocating giving away drugs but that is what gets drawn into the argument. So, while politicians are saying there can be absolutely no increase in drug use and demanding assurance of this...basically a zero tolerance on drugs... the ability to intervene with a demonstrated and effective way to reduce HIV transmission is being overlooked.
Perez: Speaking of controversy, you are in the midst of one at the moment. In affiliation with Public Citizen, you have openly charged the National Institute of Health and the Centers for Disease Control of funding and conducting unethical HIV trials in developing countries. How did you become involved in speaking out against these trials and why?
Lurie: In February I was presenting at a meeting exploring the relationship between research and journalism in South Africa. The CDC came in to present work being conducted on these trials and the audience objected. Much of the opposition centered on the medication regimen being used. I feel the use of shorter trials are a legitimate research question and highly dependent upon what drugs the shorter trials are being compared to. When I questioned the speaker as to what drugs they were comparing... in this case it was a placebo. I knew this was important right away but I had no idea of the total number involved until further investigation showed studies either being conducted or funded by the NIH and CDC in several developing countries. We went public with the information in April. Of course the trials have been in existence since 1994 and have gained momentum. I wish I had learned of them before.
I am not opposed to randomized controlled trials to determine the effectiveness of different interventions, but there are several problems associated with these trials. First of all, the use of a placebo denies women access to an effective HIV intervention which has already been shown to reduce the transmission of HIV from mother to baby. This is not tolerated in the US but is being supported for use abroad. Alternatives are available. We know that AZT can reduce HIV infection in babies by about two-thirds... of those which are infected, approximately 65% are transmitted during delivery and 95% of the remaining cases are transmitted in the first few months after birth. The NIH and CDC argue that the differences in duration and means of administering the drugs (oral or intravenous) justify the use of a placebo but this does not account for the availability of alternative means of drug therapy. For example, research on shorter drug regimens suggests they may be equally effective in reducing the transmission of HIV if given during critical risk periods. Also, the use of oral or intravenous administration has already demonstrated similar blood levels for each group. Given the availability of alternatives, it is difficult to justify the use of placebo controlled studies.
Perez: Why do you believe the general public should be concerned?
Lurie: For several reasons. Any time there is needless suffering and death there is a need for compassion. Also, as Americans, there is a concern for any such study with American money behind it. Morally, and as international policy, it is offensive to adhere to lower standards and ethics abroad than what is deemed appropriate for our own citizens.
Perez: According to a statement by the CDC and NIH, it is estimated that more than 1 million children (worldwide) are already infected and 5-10 million will become infected through perinatal transmission in the coming decade. Given these statistics it is obvious intervention is needed as soon as possible. The CDC and NIH claim these studies are warranted by the need to quickly identify a drug regimen available to poorer nations and the respective countries supported the use of placebos in the trials. How do you respond to this argument?
Lurie: It is a stupid argument. The charting is irrelevant and implies we don’t understand the problem. It’s nonsense. Obviously we would like to see fewer die - not more. The facts stipulate alternatives are available. It is simply not a winning argument. They say placebo trials are the best way to find a quick intervention, but it is not true that placebo trials are any faster than equivalency trials. The sample sizes are comparable and the small difference that does exist could be easily overcome by recruiting less than 20% more people in order to reach the needed sample size. It is not as if we are asking them to build a state of the art heart institute costing millions of dollars. The argument that researchers must comply with the standard of care in the sponsoring country is being distorted to create a double standard that permits a research design that is unacceptable in this country. It is for this reason, a single international standard of ethical research must be developed.
Finally, the trials are unnecessary because there is little guess that a shorter version of AZT is better than nothing-- we have a good working knowledge of when transmission occurs; most often during labor...and we can prevent 65% of those infections from occurring. No, there is no question that this is better than nothing, the data from 076 shows this. As for the support of the countries, there are several problems. First of all the ethic committees are young and often lack support. In fact, some do not even have ethicists on the board, only researchers who may be involved in the research. This is potentially a conflict of interest as funding for research is often difficult to obtain. It becomes difficult to screen out unethical research. Also, you must keep in mind that approval and informed consent is not the same as an ethical review. If the studies are unethical in the United States, you cannot make them ethical by review or informed consent in another country. In a way it is even more unethical.
{Note: 076 refers to a demonstration of the AIDS Clinical Trial Group (ACTG) to the World Health Organization in the summer of 1994 that showed positive results in the AZT drug regimen. The WHO called for the immediate use of the 076 regimen in the industrialized world where it is feasible...and the immediate exploration of alternative regimens to be used in developing countries where cost is a factor}.
Perez: In “1,000 Foreign Infants to Die...” and again in a letter you co-authored to Secretary Shalala, a comparison between the current HIV trials and Tuskagee was drawn. Do you feel the comparison is warranted?
Lurie: Yes. Although the analogy is not perfect, it is afterall an analogy, it is close enough to warrant the comparison. Both studies withheld effective therapy, both involved members of a minority group, and although there is informed consent in these studies where there was none in the Tuskegee experiments, the informed consent is terrible and problematic; countries often must decide between a placebo controlled trial or no trial at all. Interviews with the women reveal that many of the women believe that at least one of the pills they received would treat HIV or that they agreed to participate in the trial simply to obtain access to medical care in any form. In an environment where many cannot read or write and where poverty, sickness, hunger, and homelessness is rampant; where the powerful, the rich or the expatriate is a semi-god, how can you talk of informed consent? Also, both have attempted to argue that in the absence of the studies the subjects would not have been treated. But, there is opportunity for effective treatment, it does exist, but they are choosing to do this instead. They CHOOSE not to give treatment and it is death for these children. Part of what is going on is the slavish adherence to clinical trials....they have sacrificed to the Holy Grail of randomized trail by placebo rather than redesign the study to include treatment.
Perez: How would you respond to those who feel 1,000 infant deaths are a small price to pay in order to save millions?
Lurie: I believe it is the Neuremburg Code that states the interest of society does not take precedent over the rights of the individual. Research cannot justify theoretical and unproven future benefits of life savings in view of certain death. The choice these researchers have made will result in certain death for these children. The benefits are debatable; at this point they are just proving the obvious.
Perez: Dr. Lurie, you co-authored a letter to President Clinton in addition to that of Secretary Shalala...what official response, if any, have you received?
Lurie: Secretary Shalala, the NIH and CDC, and others have released public statements regarding these trials but at this time the debate is still on-going.
Perez: What can other concerned citizens do to help?
Lurie: People of color, especially African Americans, can play an extremely important role by becoming actively involved in taking a stand against this research...as should we all. I encourage anyone who is interested to begin a letter writing campaign, voicing their opposition to these trials, to Secretary Shalala with a copy of the letter sent to Public Citizen. The address is;
Secretary Shalala
Dept. HHS
200 Independence Ave SW
Washington DC, 20201
FAX: 202.690.7203

Public Citizen
1600 20th Street NW
Washington DC, 20009

Learning and Technology

The ability to effectively communicate is widely recognized as an essential component of health education, however, effective communication is difficult (National Cancer Institute, no date/online). Students present different backgrounds, experiences, and ability levels; health information can be complex and controversial; and peers, family, and media often reinforce misinformation. Additionally, health is often an emotional subject. Diseases such as AIDS or cancer may elicit fear, topics such as birth control and sexuality are often sensitive issues, and each individual presents unique personal beliefs (NCI, ). Given the complexity of effective communication, methods to enhance expression and increase learning are needed.
The role of communication in health education
Communication can increase awareness, affect attitudes, demonstrate skills, increase demand, and reinforce knowledge, attitudes, or behaviors (NCI, ). The PRECEDE model developed by Lawrence Green proposes health behavior is influenced by predisposing factors such as knowledge, attitude, and behavior; enabling factors including community and environment; and reinforcing factors which influence the likelihood of continuing the behavior. (Green, ?). Commercial media uses these principles. Examining the psychology of media production, Bernard Luskin, states "Producing media software is a communications craft. The successful producer must combine the knack of thinking visually, drawing upon a myriad of techniques taken from communications arts…" (Luskin, 1998). Imagine the impact of an anti-drug campaign as effective as a Nike advertisement! The "success" of commercial endeavors is not a mystery but rather the result of applying effective communication techniques through the use of available technology. This article will attempt to demonstrate how technology can enhance communication in the classroom and improve learning.
Communication
Traditional classrooms use an Aristotelian model of communication where a speaker presents an issue in the form of speech directed toward the listener(s). It is characterized by one-way communication or what is commonly known as a lecture. If questions are posed (such as in the Socratic method), communication still exists in a singular form. Issues related to individual perception, background, learning style, noise, distractors, and other factors are not addressed. In an attempt to account for these factors, the Shannon-Schramm Communication Model demonstrates the communication process as related to perception, field of experience, noise, feedback, and the sender/encoder- decoder/receiver. This model provides a working foundation for the inclusion of educational technology into the school health curriculum. As society becomes more complex, the field of experience also becomes more complex. This is especially true of health information (NCI, online no date). Media and other forms of communication capitalize on the ability to "create" a uniform schema or foundational knowledge base, however, an individuals field of experience is shaped by more than media. It is important to assess this information when designing learning activities.
Learning Styles
Drawing on theoretical foundations for how people learn provides a framework for enhancing learning through improving communication. Cognitive learning styles refer to "the preferred way an individual processes information" (TIP Concepts, 199?). Several theories provide guidance based upon multiple intelligence, developmental stages, learning strategies, and other criteria. Most acknowledge the need to assess student learning and experience in order to create a common field of experience capable of enhancing communication and understanding.
Technology has the potential to positively impact learning by communicating information in a different modality than print or traditional lectures by "individualizing" the rate, progression, feedback, and duration of instruction (Owston, 1997). Drawing on the premise that students learn in different ways, at different rates, and from different perspectives, the ability of technology to "individualize" instruction is promising.
Technology creates a common field of experience
The example of individual experience as related to perception can be demonstrated by the reference to "a tree". It is expected that everyone is familiar with the term, but individual experience dictates the "meaning" inferred by each person. Even if a more descriptive explanation is provided (for example, a Mesquite tree), individual experience directs the process. If a student has never seen a Mesquite tree, the label alone does little to assist in the learning process. Technology enhances this stage of communication by quickly creating a common field of experience through the use of other medium…in this case a photograph.
In addition to creating a common field of experience, technology is capable of providing a more exact interpretation of information. For example, positive or negative connotations are associated with specific words, gestures, or even intonations. Once again, by providing information in a variety of formats, desired meaning is more likely to be communicated and understood. Media recognizes semantics as powerful tools in the communication process; "Managing language is fundamental to communication and central to our ability to understand…Words, their use and articulation, alliteration, intonation and patterns are central to media communications." (Luskin, 1998).
A common field of experience may be created for an individual or a group further reducing potential communication problems. The importance of creating a common field of experience is clearly demonstrated when communicating with an individual who is blind or deaf…the ability to use alternative formats such as auditory or visual information bypasses barriers experienced as a result of the disability. Cognitive barriers based on learning style, ability, previous experience, expectations, and preference are less obvious variations on different methods of acquiring information but no less important to effective communication.
Technology provides inclusive communication
Studies in the field of educational technology have found students are most commonly "active-concrete" learners while "the majority of faculty prefer the IN pattern, creating a disparity between teacher and learner" (Twigg, 1997). Twigg poses the question; "How can our faculty respond to diverse learning patterns when their primary pedagogy consists of classroom lecture?". This concern is a repeated theme among advocates of educational reform and the use of instructional technology. Howard Gardner (1983) proposed the Theory of Multiple Intelligences which recognizes seven distinct forms of intelligence; logical, mathematical, linguistic, spatial, musical, bodily, and personal. Implications for the classroom are profound; "The theory states all seven intelligences are needed to productively function in society. Teachers therefore, should think of all intelligences as equally important. This is in great contrast to traditional education systems which typically place a strong emphasis on the development and use of verbal and mathematical intelligences." (Brunaldi, 1996).
Technology not only provides a means to create a common field of experience, but is capable of delivering information in a manner that decreases "noise" or extraneous information the decoder is unable or not inclined to process. Media software recognizes the need to address these issues. For example, the editing and sequencing of events and information can greatly impact perception…" We all perceive and experience events… driving to the market, we experience certain perception edits…The car's engine and radio provide context, continuity, and language. Music may influence mood…When we enter a building by passing through doors, or climb a stairway or look up at a light, we change points of view." (Luskin, 1998). Not only does technology allow students to access information in non-linear format while controlling pace and duration, but it also provides a means to incorporate visual and auditory components to a lesson. This uniting of senses is referred to as "synesthetics"; the study of the uniting of the senses or the response that occurs when one sense is added to another. "Adding one sense to another facilitates an experience of higher intensity. This concept is central to stimulation strategy in media" (Luskin, 1998).
By individualizing instruction, technology promotes communication centered on the learner rather than forcing the learner to adjust to the instructor. Strategies designed to address various types of intelligences and learning styles can be incorporated into a lesson while increasing the likelihood of communicating the information in the method most likely to be received by the student.
Technology promotes dialog
Technology promotes dialog by providing students the opportunity to express opinions and communicate understanding more effectively. Communication becomes two-way rather than one-way as students incorporate technology into projects and presentations, thereby enhancing communication between student and teacher and between student and peers. An example of the interactive nature of publishing on the Internet can be found in the article "Me and my hyptertext" by Reinking. In Digress2a, Reinking introduces the author (himself) and in so doing demonstrates the authoritative nature of traditional educational communication where an "expert" imparts information to a static audience void of "democratic dialog". The less formal, but highly democratic dialog available on-line creates an environment where information is discussed, argued, and subject to question as well as revision. Reinking astutely states, "electronic reading and writing invite a much less formal, honest approach to writing, because whether authors like it or not, they are ( I am) much less remote" (Reinking, 1997).
In conclusion
Communicating about health is difficult due to the complexity, social and emotional factors surrounding health related issues, competing information, and the prevalence of misinformation (NCI, …). The ability of effective communication to increase awareness, affect attitudes, demonstrate skills, increase demand, and reinforce knowledge, attitudes, or behaviors is in keeping with the PRECEDE model of health theory and practice.
Technology provides a method of enhancing communication by creating a common frame of reference and incorporating various learning styles into lesson planning, providing inclusive communication, and promoting diaglog.
References
Brualdi, Amy C. (1996). Multiple Intelligences: Gardner's Theory. ERIC Digest. [On-line]. Available: http://www.ed.gov/databases/ERIC_Digests/ed410226.html

Green, Lawrence (?)………Find something

Luskin, Bernard J. (1998). Media Out of Your Mind: The Psychology of Media Production. T.H.E. Journal. [On-line]. Available: http://www.thejournal.com/journal/magazine/98/sept/specrep..html

Takahashi, Junjro. Models of Communication. Digital Media Ambience and Collaborative Research. [On-line]. Available: http://www.sfc.keio.ac.jp/~masanao/Mosaic_data/com_model.html


National Cancer Institue. Theory at a Glance. [On-line]. Available: http://rex.nci.nih.gov/NCI_PUB_INDEX/PUB_INDEX_DOC.html

National Cancer Institute. The Role of communication in Disease Prevention and Control [On-line]. Available: http://rex.nci.nih.gov/NCI_PUB_INDEX/PUB_INDEX_DOC.html


Owston, R. The world-wide web: A technology to enhance teaching and learning. [On-line]. Available: http://www.edu.yorku.ca/~rowston/article.html

Reinking, D. My and my hyptertext: A multiple digression analysis of technology and literacy. [On-line]. Available: http://www.readingonline.org/literacy/hypertext/index.htm

Thornburg, David. (1997). 2020 Visions for the Future of Education. [On-line]. Available: http://www.tcpd.org/

TIP Concepts. [On-line]. Available: http://www.gwu.edu/~tip/

Twigg, Carol. (1994). The Changing Definition of Learning. [On-line]. Available: http://www.educom.edu/web/pubs/review/reviewArticles/29422.html

Coffee and Caffeine : More than You Ever Wanted to Know

Coffee is an integral component of many societies, not only from an ingestable standpoint, but also due to the psychological and socio-economic significance of the substance. Beginning with the historical narrative of Coffee, this paper examines the physical composition of coffee, short and long term physiological effects, and the current status of health related coffee/caffeine research. Issues of dependency, addiction, real and perceived benefits, side-effects, and possible long term consequences will also be examined.
History
According to the Arcade Dictionary of Word Origins, the word “coffee” originated from the middle east .... from where it is believed the coffee tree is descended. Early translations do not distinguish between the beverage as it is known today and an ancient form of wine, however, by the 17th century the Italian word “caffe” is easily distinguished (Ayto, 1990). This European historical narrative correlates the origins of the word with the emergence of coffee into Europe via Arabia and Turkey. However, sources familiar with the botanical origin of coffee dispute this traditional view and report that coffee originated not from Arabia but rather Ethiopia (Kowalchik, C., and Hylton, W., 1987). Coffee as it is now known in North America, is an herbal concoction (actually it is a decoction...where large pieces of a plant are simmered in water in order to draw out the essential properties) derived from the fruit of the Coffea Arabica plant. Coffee trees are evergreens which grow to a height of 15 to 40 feet and may live to be 100 years old given the proper conditions (Kowalchick, C., and Hylton, W., 1987).
During the 17th century, Italian fleets actively traded around the world. It is speculated that during this time the widespread use of coffee was popularized. Within a century, coffee was introduced throughout Europe and an established industry of trade. Soon coffee peddlers increased the fame of coffee beyond the supply capacity of Arabia. Coffee smugglers began stealing the beans in order to re-introduce the plants into favorable climates around the globe. The West Indies, Java, India, and Brazil soon produced enough coffee to meet demand; with an “unlimited” supply of coffee available, the “golden era” of coffee was born. Coffeehouses became popular in Europe and North America by catering to intellectuals, artists, politicians, and “thinkers”...an association still strongly linked to coffee consumption. As American settlers began moving west, coffee spread as a drink among “common” persons.
Today coffee is one of the most widely used beverages in the world and spawns entire economies through the growth, production, and distribution of the substance. In Europe and North America, as before, coffeehouses are again increasing in popularity...this time with themes such as computer linked stations or poetry recitals. Roadside stands at outdoor events, kiosks in malls, and sections of franchise bookstores have taken advantage of the latest wave of coffee enthusiasm...as well as coffee manufacturing industries who offer a variety of blends, styles, and choices of coffee.
In the midst of this trend it is easy to find persons who spend more time selecting and preparing coffee than meals; in fact, for many persons coffee has taken the place of breakfast and afternoon snacks. Due to the high rate of coffee consumption among segments of the population the composition, metabolism, and safety of the substance has been thoroughly researched.
Description
The principle active ingredient of coffee is caffeine and therefore the primary research subject when observing the physical or physiological effects of coffee consumption. It may be noted however, sociological factors have not adequately addressed the differentiation between coffee consumption and other methods of caffeine ingestion in regard to the societal attitudes and expectations surrounding “coffee-breaks” and other associated coffee rituals.
It is recognized that caffeine is “the worlds most common drug”. Despite years of ingestion, it was not until 1820 that caffeine was first isolated from coffee. According to the Alcoholism and Drug Addiction Research Foundation, (1991):
The caffeine content of coffee beans varies according to the species of the coffee plant. Beans from Coffea arabica, grown mostly in Central and South America, contain about 1.1% caffeine. Beans from Coffea robusta, grown mostly in Indonesia and Africa, contain about 2.2% caffeine...In North America, the caffeine content of a cup of coffee averages about 75 mg, but varies widely according to cup size, the method of preparation, and the amount of coffee used. Generally cups prepared from instant coffee contain less caffeine (average 65 mg) and cups prepared by drip methods contain more caffeine (average 110 mg.). (p. 1)
In comparison, cups of tea average approximately 30 mg, cola averages about 35 mg, and hot chocolate contains 4 mg of caffeine. Although coffee is the main source of caffeine for persons over the age of 25, it is by no means the only source. Caffeine is present/routinely added to pain relievers, colas, chocolate, and numerous food products.
Consumption Patterns
The average daily consumption of caffeine among American adults is estimated at 280 mg...the equivalent of three cups of coffee per day with 80 percent of the adult population using some form of caffeine on a regular basis ( Fenton, 1995).
Caffeine
Short Term Effects
Short term effects of a drug are those which appear after the ingestion of a single dose and disappear within hours. The effects of caffeine appear as early as 15-45 minutes after ingestion, with peak central nervous system inclusion reached at approximately 30 minutes after ingestion. Caffeine is a central nervous system stimulant resulting in increased heartbeat, respiration, basal metabolic rate, and the production of stomach acid and urine. Caffeine does not accumulate in the body and is excreted within several hours. The “half-life” of caffeine is the amount of time it takes the body to eliminate one-half of the consumed caffeine from the body, generally three to four hours in most adults.
According to the Alcoholism and Drug Addiction Research Foundation, 1991, the short term effects of ingesting one to two cups of coffee cause several physiological responses:
As the general metabolism increases it is expressed as an increase in activity or raised temperature, or both. The rate of breathing increases, as does urination and the levels of fatty acids in the blood and of gastric acid in the stomach. Caffeine may increase blood pressure. Caffeine stimulates the brain and behavior...caffeine elevates neural activity...postpones fatigue, and enhances performance at simple intellectual tasks and at physical work that involves endurance but not fine motor coordination. (p. 2)
Tolerance and Dependence
Tolerance refers to the body’s increased need for a substance in order to achieve the same desired effect. It is often the first stage of a dependence or addiction to a substance. Caffeine is considered a psychoactive substance and as such, the most widely used drug in the world (ADARF, 1991). However, it is difficult to assess the impact/effect of caffeine on a comprehensive basis because most adults consume caffeine in one form or another. Research has demonstrated that individuals are able to build a tolerance to caffeine thereby increasing the amount consumed in order to achieve the same desired effect. After the individual use of caffeine reaches 350 mg (or more) per day, physical dependency results (ADARF, 1991). Interruption of the source of caffeine ( coffee for most adult Americans) results in withdrawal syndrome symptoms.
Caffeine withdrawal is characterized by “headache, drowsiness, irritability, fatigue, nausea, and even vomiting...symptoms start about 12 to 24 hours after the last regular “dose”...peak at about 20 to 38 hours, and last for about a total of one week” (Fenton, 1995).
Psychological dependence is also a common observation among heavy coffee users who often “feel” or “think” it is necessary to drink coffee in order to get through the day. Social coffee drinkers often relate experiences similar to alcoholics regarding the discontinuation of coffee and the use of decaffeinated substitutes. For these individuals specific rituals, social expectations, and activities are strongly associated with the consumption of coffee and the corresponding manifestations. Despite these superficial similarities, the Presidents Office of National Drug Control Policy (1992):
does not view caffeine as a “gateway drug”...linking caffeine to drugs of abuse...undermines the effectiveness of a drug prevention program...most caffeine consumers do not demonstrate dependent, compulsive behavior, characteristic of dependency to drugs of abuse. Although pharmacologically active, the behavioral effects of caffeine typically are minor. (Rigby, 1992)
This view is supported by the American Psychiatric Association which states “drugs of dependence cause occupational or recreational activities to be neglected in favor of drug-seeking activity” (Hughes, J.R., Higgins, S.T., Bickel, W.K. et al., 1988).
Overdose
Although unlikely, it is possible to overdose or even die from caffeine. Large doses of caffeine may produce what is termed “caffeinism”. Symptoms of caffeinism may appear after 250 to 750 mg (approximately 2 to 7 cups of coffee) and include restlessness, nausea, headache, tense muscles, sleep disturbances, and irregular heartbeats. Doses over 750 mg may produce delirium, tinnitis, and visual hallucinations as well as caffeine induced mental disorder (Lopez-Ortiz, 1995). According to the DSM-3-R of the American Psychiatric Association (1987), the guidelines for caffeine induced organic mental disorder include:
1. Recent consumption of caffeine, usually in excess of 250 mg.
2. At least five of the following signs:
1. Restlessness
2. Nervousness
3. Excitement
4. Insomnia
5. Flushed face
6. Diuresis
7. Gastrointestinal disturbances
8. Muscle twitching
9. Rambling flow of thought and speech
10. Tachycardia or cardiac arrhythmia
11. Periods of inexhaustibility
12. Psychomotor agitation

According to the Alcoholism and Drug Addiction Research Foundation:
Near fatal doses cause a crisis resembling the state of a diabetic without insulin, including high levels of blood sugar and the appearance of acetone-like substances in urine. The lowest known dose fatal to an adult has been 3,200 mg-administered intravenously by accident. The fatal oral dose is in excess of 5,000 mg- the equivalent of 40 strong cups of coffee taken in a very short space of time. (1996)
Long Term Effects
The International Food Information Council Foundation states that caffeine was placed on the Food and Drug Administration (FDA) list of Generally Recognized as Safe (GRAF) in 1958. In 1978 the FDA recommended additional research be conducted into the safety of caffeine. The Alcoholism and Drug Addiction Research Foundation (1991) states:
...long term effects of caffeine usage do not appear evident when regular caffeine use is below 650 mg per day-equivalent to eight or nine average cups of coffee. Above this level, users may suffer from chronic insomnia, persistent anxiety and depression, and stomach ulcers. Caffeine use appears to be associated with irregular heartbeat and may raise cholesterol levels...the evidence is unclear concerning caffeine and cancer.
Caffeine and some of its metabolites can cause changes in the cells of the body and in the way in which they reproduce themselves, and caffeine certainly enhances this kind of action by some known carcinogens. However, although caffeine is suspected as a cause of cancer, the evidence is contradictory and does not allow a clear conclusion...Caffeine certainly has the ability to cause a variety of reproductive effects in animals, including congenital abnormalities and reproductive failures, reduced fertility, prematurity, and low birth weight. What is unknown is whether these findings are relevant to the use of ordinary amounts of caffeine containing beverages by pregnant women. (p.2-3)
Despite the FDA’s placement of caffeine on the GRAS list, concern regarding the safety and acceptable dosage of caffeine intake remains. This is especially true in regard to pregnant women. Conflicting interpretation of research findings and the inability to determine strictly defined limits of usage have perpetuated the confusion regarding caffeine consumption. The following represent the most common health related concerns and findings.
Cancer
Caffeine related research previously suggested a relationship between ingestion of caffeine and some forms of cancer (bladder, rectal, colon or pancreatic ). Following the FDA’s call for further research into the safety of caffeine, numerous studies demonstrate “no association between caffeine consumption and the incidence of cancer” (IFIC, 1993). The IFIC cites research by Rosenberg who reviewed 13 epidemiologic and clinical studies consisting of over 20,000 subjects, which “failed to establish a relationship between coffee or tea consumption and the incidence of bladder, rectal, colon or pancreatic cancers” (Rosenberg, L., 1990). Research conducted by Lubin and Ron (1990) was cited by the IFIC in response to the concern of increased risk of breast cancer due to caffeine consumption. In this research, 11 total case controlled studies were reviewed with no link between caffeine and breast cancer established. In summary, the IFIC, 1993, concluded:
Overall, the universal scientific research does not support a relationship between caffeine consumption and cancer development. As a result, the American Cancer Society’s Guidelines on Diet, Nutrition, and Cancer state there is not indication that caffeine is a risk factor in human cancer and the National Academy of Sciences’ National Research Council reports there is not convincing evidence relating caffeine to any type of cancer. (P. 3)
Cardiovascular Disease
Findings presented by the IFIC in regard to recent research into caffeine and cardiovascular disease are almost to good to be true. In fact, consumers and health practitioners alike continue to question the relationship between caffeine and cardiovascular disease. It is recognized that large doses of caffeine may cause transient symptoms of cardiovascular disease including elevated blood pressure and/or arrhythmia’s. However, the relationship between normal usage of caffeine and the causation or progression of cardiovascular disease/disorders has been
re-evaluated in recent years.
A number of studies were cited by the IFIC including the 45,589 subject Framingham Heart Study which concluded that caffeine consumption caused “no substantial increase in the risk of coronary heart disease or stroke” (Grobee, D.E., Rimm, E.B., Giovannuci, E. Et al, 1990). In regard to blood pressure, Dr. Myers of the cardiology division in Toronto reviewed the scientific literature of caffeine and blood pressure and concluded, “caffeine does not cause any persistent increase in blood pressure”(Myers, M.G., 1988). Finally, the effects of caffeine on cardiac arrhythmia’s was also reviewed... “The American Medical Association’s (AMA) Council on Scientific Affairs concluded that abstaining from caffeine did not significantly influence the occurrence or frequency of arrhythmia’s”(AMA, 1984). The IFIC concludes, “Despite continued consumer questions on caffeine and heart disease, there is a significant amount of data that demonstrates there is no link between moderate caffeine consumption and cardiovascular disease” (IFIC, 1993).
Fertility
In 1988 a study conducted by Wilcox, Weinberg and Baird of the National Institute of Health found the caffeine equivalent of 1-2 cups of coffee per day may affect fertility in women (Wilcox, A., Weinberg, C. & Baird, D., 1988). Research conducted by the Centers for Disease Control and Harvard University in 1990, as well as an epidemiological study of 11,000 Danish women published in 1991, failed to confirm these findings.
Pregnancy
Perhaps the most conservative area in regard to caffeine consumption is the impact of caffeine upon fetal growth and development. In the early 1980’s, animal studies conducted by the FDA reported an increased risk of birth defects associated with caffeine consumption during pregnancy. Later this study was criticized due to the large doses of caffeine administered to the animal subjects. In 1993, the National Institute of Health published results which concluded “moderate caffeine consumption during pregnancy did not increase the risk of spontaneous abortion or abnormal fetal growth” (Mills, J.L., Holmes, L.B., Aarons, J.H. et al., 1993). The FDA currently recommends women consume no more than two cups of coffee or two units of caffeine per day while pregnant.
Benign Breast Disease
In the 1970’s the relationship between symptoms of fibrocystic breast disease and caffeine suggested that eliminating caffeine from the diet may alleviate or reduce symptoms. In 1986, the National Cancer Institute conducted a study of 3,000 women which demonstrated “no evidence of an association between caffeine intake and benign tumors, fibrocystic breast disease or breast tenderness” (McDonald, A.D., Armstrong, B.G., & Sloan, M., 1993). This conclusion is corroborated by the AMA Council on Scientific Affairs.

Osteoporosis
Caffeine is known to increase the excretion of calcium in the urine thereby hypothetically increasing the risk of Osteoporosis. Separate studies conducted by Pennsylvania State University, Creighton University School of Medicine, and the Mayo Clinic each concluded that despite a slight increase in urinary calcium excretion due to caffeine consumption, caffeine intake had no significant impact upon overall bone density and was not considered an important risk factor for osteoporosis. The minimal impact of caffeine was adequately compensated by the inclusion of 600 mg of calcium per day (Lloyd, T., Schaeffer, J.M., Walker, M.A. et al., 1991; Barger-Lux, M.J., Heaney, R.H., & Stegman, M.R., 1990; and Cooper, C., Atkinson, E.J., Wahner, H.W. et al., 1992).
Interactions With Other Drugs/Substances
Caffeine is such a widely used substance it is often mistakenly overlooked in the examination of drug interactions. Commonly used drugs including oral contraceptives are known to increase the effect of caffeine whereas caffeine is known to increase the effect of thyroid hormone supplements. Other drugs such as sedatives may prove less effective while illegal substances including Marijuana and Cocaine may result in over stimulation. (Griffith, W., 1988).
Therapeutic and Beneficial Uses
With the concern surrounding the safety of caffeine intake, the beneficial aspects are often forgotten or overlooked. Medicinally caffeine is frequently used to enhance the effectiveness in analgesic preparations both oral and topical as well as the performance of stimulants. The use of caffeine as a cardiac and respiratory stimulant has been of particular interest in the treatment of apnea in newborn babies. Caffeine is a known diuretic and at times has also been used as an enema in alternative cancer therapy. Other controversial caffeine therapies include the treatment of skin fungi, fertility problems in men, enhancement of the toxic effects of chemicals used in cancer therapy, and promotion of seizures during electroconvulsive therapy (ADARF, 1991).
Future Trends
The economic future of coffee consumption appears bright. According to the Specialty Coffee Association of America, the specialty coffee market has increased 30 percent for three years in a row and is expected to reach $3 Billion dollars by 1999. Combined with foodservice shares, the total retail sales are projected to reach $5 Billion by the year 2000. The number of coffeehouses and outlets has grown from approximately 250 in the 1970’s to an anticipated 10,000 in 1999 (LaPoint, K., 1997). These statistics reflect the rise in specialty coffee alone. As a nation, America consumes over one-third of the worlds coffee...no small feat when you realize “in the entire world, coffee is second only to petroleum as the most important legal export commodity”(Parrish, J., 1997). In the United States, coffee ranks third in imports, behind oil and steel, with an estimated 80 percent of Americans drinking coffee daily, and 10 percent consuming more than ten cups of coffee per day (Parrish, J., 1997). As small countries in Latin America attempt to “cash in” on the latest craze in coffee production, new concerns regarding long term environmental effects upon land use, production techniques, and chemical exposure have become areas of concern. Economically and socially, coffee is a significant contribution to worldwide affairs.
Conclusion
The history of coffee reflects significant economic and social impact on a worldwide basis with near universal appeal. Caffeine and the “addictive” nature of the substance is partially responsible for such abundant use, but does not adequately address social and psychological factors associated with consumption. Health related concerns regarding the safety of caffeine prompted research into various factors including short and long term effects, tolerance and dependence, overdose, and associated risk of selected disease/disorders. Finally, the future trend and economic impact of coffee virtually ensures the continued consumption of coffee on a global scale.

Notafiable Infectious Dieases and Conditions

Infectious Diseases and Conditions Designated as Notifiable at the National Level 1997

1. AIDS
2. Acute Pesticide Poisoning
3. Anthrax
4. Botulism
5. Brucellosis
6. Chancroid
7. Chlamydia trachomatis
8. Cholera
9. Coccidiodomycosis
10. Diphtheria
11. Elevated Blood levels (adult)
12. Elevated Blood levels (child)
13. Encephalitis (western equine)
14. Encephalitis (California serogroup)
15. Encephalitis (St. Louis)
16. Encephalitis (eastern equine)
17. Escherichia coli 0157:H7
18. Gonorrhea
19. Haemophilus influenza
20. Hansen disease (leprosy)
21. Hantavirus
22. Hemolytic uremic syndrome
23. Hepatitis A
24. Hepatitis B
25. Hepatitis C/non A, non B
26. HIV infection, adult
27. HIV infection, child
28. Legionellosis
29. Lyme disease
30. Malaria
31. Measles
32. Meningococcal disease
33. Mumps
34. Pertussis
35. Plague
36. Poliomyelitis
37. Prevalence of tobacco use
38. Psittacosis
39. Rabies, animal
40. Rabies, human
41. Rocky Mountain spotted fever
42. Rubella
43. Rubella, congenital syndrome
44. Salmonellosis
45. Shigellosis
46. Silicosis
47. Streptococcal disease, invasive, group A

Healthy People 2000 Objectives

Healthy People 2000
Healthy People 2000 was adopted by the U.S. Department of Health and Human Services in 1990 in order to:
1. Increase the span of healthy life for Americans.
2. Reduce health disparities among Americans.
3. Achieve access to preventive services for all Americans. (CDC, 1997).
To achieve these goals, 22 priority areas were identified with 300 specific objectives set. The Healthy People 2000 Consortium is composed of 330 member organizations. Each priority area is overseen by a Lead Public Health Service (PHS) agency. (Appendix A).
Priority area 22:
Year 2000 Objectives:
· Develop and implement common health status indicators
· Create national data sources to track the year 2000 objectives
· Develop and disseminate among Federal/State/local agencies procedures for collecting comparable data for the year 2000 objectives.
· Improve related data for blacks, Hispanics, American Indians and Alaska Natives, Asian Americans, people with disabilities and with low incomes.
· Expand state-based activity to track progress toward year 2000 objectives.
· Improve information transfer capabilities among Federal/State/local agencies.
· Provide more timely processing of survey and surveillance data. (CDC, 1998).
The Lead PHS is the Centers for Disease Control and Prevention (CDC).
· The CDC Prevention Strategy as related to data includes;
· Secure networks for the transmission of sensitive information.
· Automatic and direct reporting from physicians offices, hospitals, and private and public laboratories.
· Computer based patient record technology.
· Strategies to integrate existing and planned information systems.
· Field applications of computer technology.
· Geographic information systems (GISs) and satellite imagery.
· New statistical and mathematical modeling methods.
In addition, an international database is being developed to improve data collection, surveillance, and dissemination of information globally.

Priority 22 Challenges
On February 18, 1997, the Department of Health and Human Services held a review on surveillance and data systems progress toward Healthy People 2000 objectives. When the first national health promotion and disease prevention objectives were published, 35% of the 226 objectives had no baseline data. (HP 2000, 1998). Despite major progress in obtaining baseline data, several areas of concern still exist.
· Infectious diseases and conditions designated as notifiable at the national level may not be notifiable at the state level (Appendix B).
· There is no unified statistical program implemented across states.
· Variations in Case Definitions for infectious conditions impede tracking of data.
· Local budget limitations may not provide technology capable of disseminating timely information.
· The use of passive surveillance reporting (provider-based) remains incomplete even when used in conjunction with laboratory-based reporting.

Current status of priority 22
Surveillance and data system objectives are supported primarily through the National Electronic Telecommunications Systems for Surveillance (NETSS). The NETSS is a computerized public health surveillance system that provides data on all cases of notifiable disease.
The Development of NETSS
The CDC in cooperation with the Council of State and Territorial Epidemiologist (CSTE) developed NETSS in 1984. In 1985 the system was deemed operable and by 1989 all 50 states had begun to participate in the reporting system, however, participation in NETSS is not mandated. Currently the CDC Division of Public Health Surveillance and Informatics (DPHSI) supports the NETSS. All information must be reported in ASCII format, however, there is no requirement as to the specific statistical/other software to be utilized. Reporting must be made by designated staff of local health departments or other authorized persons.
In addition to the use of telecommunications for the collection and dissemination of data, other suggestions are proposed in order to reach target goals. These include (but are not limited to…) the implementation of active surveillance, the use of a Unified Medical Language System (UMLS), and CDC Health Information and Surveillance Systems Board Proposed Standards.

Active Surveillance
One method of improving the completeness of reporting is to implement active surveillance. Active surveillance refers to the practice of making contact with all providers and institutions responsible for reporting on a regular basis to solicit reports rather than relying solely on passive reporting. Studies demonstrate increased reporting of measles, rebella, salmonellosis, and hepatitis when active surveillance is used.
Unified Medical Language System
The Unified Medical Language System is an “offshoot” of the numerical medical coding we have all become acquainted with. In 1986 the National Library of Medicine began a long-term research project to build a Unified Medical Language System (UMLS) to retrieve and integrate electronic biomedical information. These machine-readable “knowledge sources” assist in retrieval problems brought about by differences in terminology, coding, and the “scattering” on information across several databases.
There are four UMLS “knowledge sources”;
1. UMLS Methathesaurus
2. SPECIALIST ™ Lexicon
3. UMLS Semantic Network
4. UMLS Information Sources Map
The Methathesaurus is the most commonly used. It provides “a uniform, integrated distribution format for more than 30 biomedical vocabularies and classifications, …and links to many different names for the same concept”. The Lexicon contains “syntactic information for many Metathesaurus terms component words, and English words that do not appear in the Metathesarus”. The Semantic Network contains “information about the types of categories to which all Metathesaurus concepts have been assigned and the relationship between the types”, and finally, the Information Sources Map contains “both human readable and machine processable information about the scope, location, vocabulary, syntax rules, and access conditions of biomedical databases”. (NLM, 1998).
Proposed CDC Health Data Standards
The CDC often requires grant recipients to use CDC developed software for data transmission or develop software in compliance with CDC standards…which are complex (Example for DATE: Appendix D). Standards for Health Information and Surveillance Systems have been proposed but not yet mandated. A major barrier is the CDC developed software itself. As states integrate surveillance data into one system to be accessed by various routes and integrated with other software, the CDC developed software appears inflexible as it does not promote the exchange/integration of information with other systems. As a result, data is unavailable to different state organizations or entities.
Traditional Resources
For General Information on Healthy People 2000:
Office of Disease Prevention and Health Promotion
U.S. Public Health Services, 330 C Street, SW, Room 2132
Washington, DC 20201
202.205.5968


For Healthy People 2000 Publications:

ODPHP National Health Information Center
POB 1133
Washington, DC 20013



For information on Surveillance and Data Systems:

Centers for Disease Control and Prevention
National Center for Health Statistics
(Note: Diane Wagener or Richard Klein)
6525 Belcrest Road
Room 630
Hyattsville, MD 20782
301.436.3548
301. 436.3572 (FAX)
http://www.cdc.gov/

Division of Public Health Surveillance and Informatics
EPO, Mailstop C-08
Centers for Disease Control and Prevention
1600 Clifton Road, NE
Atlanta, GA 30333
404. 639.3761
404.639.1546 (FAXA)

CDC WONDER/PC
To register to use CDC WONDER/PC contact customer support @ 404.332.4569 (phone) or 404. 488.7593 (FAX). The software and users guide is available for $50.00 or FREE if you work for a local or state health dept..

Healthy People 2000 Surveillance and Data Systems
1600 Clifton Road, NE
Mailstop A23
Atlanta GA 30333
404.639.3534
404.639.1537 (FAX)

National Institute of Health
National Library of Medicine
MEDLARS Management
8600 Rockville Pike
Bethesda, MD 20894
1.800.638.8480
301.496.6193
301.496.4450 (FAX)
publicinfo@nlm.nih.gov






National Sources

Association of State and Territorial Health Officials
415 2nd St. NE
Suite 200
Washington DC 20002
202.546.5400
202.544.9349 (FAX)

National Academy of Sciences
Institute of Medicine
2101 Constitution Av NW
Washington DC 20418
202.334.2352
202.334.2158 (Fax)

Public Health Foundation
1220 L St. NW
Suite 350
Washington DC 20005
202.898.5600
202.898.5609 (FAX)












Appendix A
Healthy People 2000 Priority Areas and Lead PHS Agencies
Physical Activity and Fitness
Presidents Council on Physical Fitness and Sports 202. 272.3421

Nutrition
National Institutes of Health 301.594.8822
Food and Drug Administration 202.205.5483

Tobacco
Centers for Disease Control and Prevention 770.488.5709

Substance Abuse: AOD
Substance Abuse and Mental Health Services Administration 301.443.7790

Family Planning
Office of Population Affairs 301.594.4000

Mental Health and Mental Disorders
Substance Abuse and Mental Health Services Administration 301.443.4111
National Institutes of Health 301.443.4513

Violent and Abusive Behavior
Centers for Disease Control and Prevention 770.488.4276

Educational and Community Based Programs
Centers for Disease Control and Prevention 770.488.5080
Health Resources and Services Administration 301.443.2460

Unintentional Injuries
Centers for Disease Control and Prevention 770.488.4652

Occupational Safety and Health
National Institutes of Health 919.541.5723

Food and Drug Safety
Food and Drug Administration 301.443.1382

Oral Health
National Institutes of Health 301.594.5579
Centers for Disease Control and Prevention 770.488.5080

Maternal and Infant Health
Health Resources and Services Administration 301.443.2170

Heart Disease and Stroke
National Institute of Health 301.496.1051

Cancer
National Institutes of Health 301.496.9569

Diabetes and Chronic Disabling Conditions
National Institutes of Health 301.654.3327
Centers for Disease Control and Prevention 770.488.5080

HIV Infection
Office of HIV/AIDS Policy 202.690.5560

Sexually Transmitted Diseases
Centers for Disease Control and Prevention 1.800.27.8922

Immunization and Infectious Diseases
Centers for Disease Control and Prevention 404.639.8200

Clinical Prevention Services
Health Resources and Services Administration 301.443.5277
Centers for Disease Control and Prevention 404.637.7075

Surveillance and Data Systems
Centers for Disease Control and Prevention 301.436.3548





















Appendix B

Infectious Diseases and Conditions Designated as Notifiable at the National Level 1997

1. AIDS
2. Acute Pesticide Poisoning
3. Anthrax
4. Botulism
5. Brucellosis
6. Chancroid
7. Chlamydia trachomatis
8. Cholera
9. Coccidiodomycosis
10. Diphtheria
11. Elevated Blood levels (adult)
12. Elevated Blood levels (child)
13. Encephalitis (western equine)
14. Encephalitis (California serogroup)
15. Encephalitis (St. Louis)
16. Encephalitis (eastern equine)
17. Escherichia coli 0157:H7
18. Gonorrhea
19. Haemophilus influenza
20. Hansen disease (leprosy)
21. Hantavirus
22. Hemolytic uremic syndrome
23. Hepatitis A
24. Hepatitis B
25. Hepatitis C/non A, non B
26. HIV infection, adult
27. HIV infection, child
28. Legionellosis
29. Lyme disease
30. Malaria
31. Measles
32. Meningococcal disease
33. Mumps
34. Pertussis
35. Plague
36. Poliomyelitis
37. Prevalence of tobacco use
38. Psittacosis
39. Rabies, animal
40. Rabies, human
41. Rocky Mountain spotted fever
42. Rubella
43. Rubella, congenital syndrome
44. Salmonellosis
45. Shigellosis
46. Silicosis
47. Streptococcal disease, invasive, group A

Bioethics and The Human Genome Project: Implications for Health Science Education

Bioethics is perhaps one of the most important and controversial subjects in health care today. Advances in technology are challenging society’s ability to assimilate and use available information resulting in fear, misinformation, poor program planning, and failure to proactivily meet future needs. The Human Genome Project is a prime example of the need for bioethical discourse.
The Human Genome Project (HGP) is an international 15 year effort begun in 1990 to discover the 60,000 to 80,000 human genes and the structure, organization, and function of DNA in chromosomes. Medical practice is rapidly changing as clinical technologies based on DNA diagnostics are combined with biotechnological advances capable of forming new treatment alternatives. Emphasis is shifting from the treatment of disease to a prevention based approach as the ability to test and treat genetic disease is usurping the long held belief that genetics cannot be altered. This is having a profound impact upon society and the delivery of Health Education programs. Historically health education has emphasized the behavioral and environmental aspects of health and prevention of disease. However, rapid biotechnological changes resulting from work such as the HGP promise to place genetics close beside exercise or diet in the choices facing the average American health consumer. This paper explores the issue of bioethics through a synopsis of the HGP, critical issues and concerns related to the project, future trends, and the implication for health education.




Introduction:
According to the University of Pennsylvania Center for Bioethics, bioethics is defined as “the study of moral issues in the fields of medical treatment and research...(or) more generically to describe ethical issues in the life sciences and the distribution of scarce medical resources.” (McGee and Coelho, 1997). Over the years ethics have evolved from the original Hippocratic Oath which required physicians to “do no harm” to the Nuremberg Code established at the end of W.W.II in response to abusive medical experimentation by Nazi Germany. Other landmark cases include the Tuskegee Study which resulted in directives for informed consent, Roe vs. Wade which began the still raging debate as to when life begins, and the Quinlin case which questioned when life ends.
Today, bioethical debates center around several broad topics; each with numerous legal, emotional, and social implications:
· Defining Life and Death: Including life-support and abortion.
· Reproductive Medicine: Including abortion, RU-486, “test-tube” babies, surrogate parents, artificial insemination, fetal tissue research, genetic testing, and in vitro fertilization.
· Economic Issues: Including managed care, access to affordable treatment, international disparity in resources, cost to society, and scarcity in organs/transplantation.
· Society vs. The Individual: Including physician assisted suicide, the right to refuse treatment, and the right to die.
· Technological Advances: Including the Human Genome Project, gene therapy, organ and tissue transplantation and others listed separately.
Bioethics is not a philosophical mental exercise, but rather the cornerstones of medical and health interventions. History presents a grim example of how the lack of discourse on bioethics can lead to not just poor planning but the death of innocent victims.
The Human Genome Project exemplifies the bioethical debate surrounding several of the above issues and in many cases, actually involves decisions ranging from quality of life issues or abortion to the right to die. It is one of the most daring undertakings of this century with profound results expected far into the next century.
The Human Genome Project
The Human Genome Project (HGP) is an international 15-year effort begun in 1990 to discover the 60,000 to 80,000 human genes and the structure, organization, and function of DNA in chromosomes. By “mapping” the gene sequence it is possible to diagnose, treat, or alter the course of a disease through early detection, proactive treatment regimens, the avoidance of environmental “triggers”, and the possible replacement of defective genes through gene therapy.
Initially genetic mapping appears to have little in common with behavioral, social, and environmental approach to disease prevention and health promotion used by health education, but surprisingly the HGP was formed in response to an environmental stimuli. The development and use of the atomic bomb resulted in the need to analyze genetic mutations resulting from radiation damage. The Department of Energy realized the best way to study the effects of radiation damage was to compare mutated genes to a baseline. The HGP has focused on three major areas; gene identification, physical mapping, and Sequencing. While the three areas compliment each other, each serves a distinct purpose. For example, simply identifying the gene does not disclose its function whereas correlating a gene to a particular disease does not account for the specific “triggers” or corresponding factors needed to produce the disease or condition. Despite these limitations, the HGP has dramatically expanded the scientific knowledge of genetically based diseases. Currently it is estimated that over 4,000 diseases are known to be genetically transmitted, with numerous others resulting from genetic alterations or mutations caused by environmental stimuli (National Center for Human Genome Project, 1997).
Genetic Testing and Health Education
As the identification of disease related genes continues so does the number of available genetic tests. Although genetic testing offers the potential to discover the cause...and possible cure...for thousands of the most devastating diseases and conditions known, the usefulness of the results is debated. The reliability of the tests the interpretation of results is problematic due to the inability to identify the genetic marker and fully understand the function and possible mutations caused by environmental triggers.
According to the Institute for Health Policy Studies, diagnostic kits for the detection of genetic markers is available within months or even weeks after the initial identification of the disease gene (1997). This “Drive-Through” approach to medical testing is only one area of concern for the medical field. Dr. McGee at the Center for Bioethics, reports that whereas five years ago genetic testing required a medical geneticist and genetic counselor, today technology companies are offering genetic testing for any adult patient whose doctor requested it...even for tests whose reliability has not been established (McGee, 1997). The confusion surrounding genetic testing can be seen in legislation drafted in response to the issue. For example, as one insurance company lamented, “what once described tests identifying specific genetic mutations (e.g., Huntingtons’ disease) now includes tests uncovering any medical problem related to or influenced by one’s genes (coronary artery disease).” (Linde, 1997). While the insurance industry attempts to maintain profit margins by mandating access to genetic test results, the impact on the field of health education is just as profound.
Health Education
Health education supports the individuals right to make informed decisions regarding their own health through the availability of information and experience. By assuming responsibility for behavioral changes such as diet and exercise, the individual is able to prevent, minimize, or delay many diseases or conditions. The role of genetics has been limited in the discussion of health education programs because there has been little control over hereditary factors; this is no longer true.
Genetic testing...done properly...can empower the individual and society to make informed decisions regarding their health and lives. Health education routinely addresses lifestyle and behavioral changes which may not demonstrate disease for 30 years; for example diet, smoking, and exercise. Similarly, knowledge of a predisposing genetic marker may allow an individual to make intelligent lifestyle or behavioral changes, or even surgical preventative measures. One example of this can be found in family patterns of breast cancer. Some women insist the choice is theirs to be tested or opt for a preventative mastectomy rather than face a potentially life threatening illness later in life. Physicians are agreeing in record numbers. Legally, there are questions regarding patients right to have all available medical information at their disposal. At the same time, Dr. McGee has found the average physician spends less than 13 minutes per check-up (McGee, 1997). This leaves the patient responsible for not only deciding whether or not to have the test performed, but also responsible for attempting to interpret the test results.
Test Results
There are several concerns in regard to the interpretation of test results.
· Genetic tests may give the impression that a disease can be predicted.
· It is difficult to define disease much less anticipate the degree or severity associated with onset.
· A person who carries a genetic marker or shows mild symptoms may be unable to secure insurance, experience unwarranted anxiety, or elect unnecessary treatment.
· Treatment or cure for the disease may not be available.
Questions for Health Education
· What, if any, role will health education play in the education and prevention of disease as it relates to genetic testing?
· Who will be responsible for assisting individuals in the decision to be tested and the
consequences of the test results?
· How will “prevention” be defined in the future?
· How will a “patient” be defined in the future?
· What is being done to address these concerns?
Again, these are not simply rhetorical questions. Health education is in a unique position to address the educational, informational, and preventative aspects of the genetic testing issue. Medicine is not structured to deal with disease BEFORE it is manifested, nor address the behavioral and lifestyle changes that may be associated with maintenance or prevention of disease. Furthermore, individuals seeking information are not yet “patients” per se...and may not ever become patients. Similarly, psychology and counseling is a vital component to genetic counseling with the necessity of addressing the emotional impact of potential disease, but of little use for health related maintenance or preventative behaviors. Currently this void is being filled by the technology firms responsible for marketing the genetic test kits, for example, Myriad and OncorMed...among others...provide short courses for physicians and CD-ROM aids for the patients. Not only are these considered ineffective means to address such a complex issue; conflicts of interest are becoming commonplace. These same companies use the data collected during the testing and training to patent mutations and outcomes justifying the effectiveness of the tests. This type of clinical trials has been virtually unheard of previously (McGee, 1997).
Curriculum Infusion
Without adequate education and information, the health consumer is left to decide whether or not to be tested, interpret the results, and decide on treatment options with little assistance other than a few educational CD-ROMS available from the manufacturer of the tests. Genetic testing and education without understanding can reinforce the misperception that genes alone prescribe individual health destiny. In order to assist the consumer, it is necessary to first infuse the information into the formal educational requirements for health educators.
While a concerted effort is being made in many high schools across America to instill the findings and implications of the Human Genome Project into the curriculum, millions of adults remain totally uninformed and those outside of genetic or biological training at the college level have been slow to consider the implications. The curricula that does exist often lacks a clear conceptual framework for ethical analysis and structure for class discussion and learning. According to the American Institute of Biology “if cherished tenets of medical ethics such as informed consent and nondirective counseling are to be more than topics of discussion...public education must acquaint potential consumers of genetic medicine with some basic principles of technology” (McInerney, 1995). Currently, only 16% of patients receive genetic counseling before undergoing genetic testing for cancer (McGee, 1997); of those patients who do receive educational or genetic counseling, it is most likely to be requested from an internist (90% of request) as compared to a surgeon (9% of request); however, the total number of patients who receive any education or counseling remains small (Paola and Barten, 1995).
The American Society of Human Genetics Board of Directors and the American College of Medical Genetics Board of Directors has issued guidelines for professional consideration in the implementation of educational or counseling services related to genetic counseling. These include:
· Treatment and Prevention: Tests that offer therapeutic benefit, preventative advice for high risk individuals, and/or aid in reproductive decisions.
· Surveillance: Tests that can identify early disease states.
· Reduction of Surveillance: Tests that are able to exclude the possibility of a disease and result in the discontinuance of medical surveillance.
· Refinement of Prognosis: Tests that offer a precise diagnosis which indicate the severity of a known disease.
Although the issue of genetic testing is far from resolved in the medical field, a framework is being developed to address this fast growing area. Health educators are in a unique position to take a proactive stance in regard to this important area. Without the ability to educate consumers on these issues, health education will fail to serve the best interests of society. Having shared many of these experiences with a spouse who has a genetically based condition, I can unequivocally state there is a great need for comprehensive information and education. If indeed health education is designed to assist individuals in making informed decisions about their health, the issue of genetic testing and bioethics is vital. The time to begin is now.








References
American Society of Human Genetics Board of Directors and the American College of Medical Genetics Board of Directors. (1995). Points to Consider: Ethical, Legal, and Pschosocial Implications of Genetic Testing in Children and Adolescents. The American Society of Human Genetics. 0002-9297/95/5705-0031
Boyd, Kenneth. (1995). What can medical ethics learn from history? Journal of Medical Ethics. V21n4, pp 197-198. Aug 1995.
Cho, Mildred. (1997). Genetic technologies: issues for ethics committees. Mid-Atlantic Ethics Committee Newletter.
Human Genome Project Information. (1997). Human Genome Project Frequently Asked Questions. http://www.ornl.gov/figmis/faq/faqs1.html.
Linde, Greg. (1997). Getting Frentic about genetics. Best’s Review: Life/Health. V98n4. Pp 63. Aug. 1997.
McGee, Glenn. (1997). To Your Health: NPR All Things Considered Commentary.
McGee, Glenn. (1997). Drive-Through genetic testing poses new ethical dilemmas. Academic Physician and Scientist. Center for Bioethics. University of Pennsylvania.
McGee, Glenn and Coelho, Danial. (1997). Center for Bioethics. University of Pennsylvania.
McInerney, Joseph. (1995). The Human Genome Project and biology education. Bioscience. V45n11. Pp 786-791. Dec 1995.

National Center for Human Genome Research. (1997). Understanding Gene Testing. http://www.gene.com/ac/AE/AEPC/NIH//gene01.html.

Epidemiology of HIV / AIDS Long Term Survival Rates : Who Lives the Longest and Why?

Introduction To address the question “What is the epidemiology of people who live the longest with the HIV virus?” it is necessary to specify operational definitions. While HIV/AIDS has received a great deal of media attention over the years, variations in concepts related to long-term survivorship exist.
HIV and AIDS
The first concept is that of the AIDS (Acquired Immune Deficiency Syndrome) virus itself. HIV ( Human Immunodeficiency Virus) is the virus responsible for AIDS (According to the Centers for Disease Control although there are those who disagree). The term AIDS refers to the last stage(s) (generally stages 4 to 5) of HIV infection. The AIDS virus is actually two separate viruses: HIV-I and HIV-2. HIV-1 was formerly known as HTLV-3 and is associated with the development of AIDS in Africa, North and South America, and Europe. HIV-2 is found predominately in West Africa. There is speculation that variations in the form of the virus may account for some instances of long-term survivalship or that less aggressive sub-types exist.
Although media often uses the terms HIV and AIDS interchangeable, from a clinical perspective a person infected with the HIV virus does not have AIDS until specific criteria are met. In fact, some persons who test positive for HIV remain asymptomatic for years without AZT or protease inhibitors. To address the question “What is the epidemiology of people who live the longest with the HIV virus?” it is important to differentiate between persons who remain asymptomatic for longer than average and those who live longer once diagnosed with full-blown AIDS.

Long-Term Survivors
Five broad categories or stages of HIV infection exist:
ü Initial HIV infection.
ü PGL: Persistently enlarged lymph glands.
ü ARC: AIDS-related complex.
ü Full-blown AIDS
ü AIDS dementia.
The term “long-term survivor”(LTS) in relation to AIDS generally refers to a person surviving three or more years once diagnosed with AIDS. An AIDS diagnosis is made when the immune system fails as represented by one or more opportunistic infections or T-cell (a lymphocyte responsible for immune functioning) count below 200. Increasingly, viral load is used in addition to, or in place of, T-cell count.
The LTS criteria in relation to HIV is less consistent. Stable immuniological markers and high CD 4 and CD 8 counts (CD refers to “cluster determinant”: a cluster of antigens that antibodies react to and characterize the surface markings of a cell) over a 7 to 10 year period generally fall within the HIV LTS criteria. In addition, a separate LTS category exists: Long-Term Non-Progressors. Long-term non-progressors are generally defined as persons infected for 7-10 years who remain asymptomatic without the use of AZT or other medications. Estimates of long-term non-progressors range from less than one percent to approximately ten percent of affected individuals.
The Epidemiology Triangle
The epidemiology triangle serves as a useful example of major factors influencing the survival rates of HIV seropositive persons. In this case, time is the factor in question. The agent, in this case the presence of either HIV-I or HIV-2, is associated with LTS. The host, or the person infected, provides unique genetic material and psychological hardiness associated with LTS; and finally, the environment plays a major role in determining access to medication, health care, and support associated with LTS.
Psychological Hardiness
Consistent with other research into psychoimmunology, several studies have found a positive correlation between “hardy” personality/psychological characteristics and LTS. Long term survivors (LTS) take a more proactive role in treatment, exercise, nutrition, and lifestyle than short term survivors. Stress reduction, interpersonal relationships, coping skills, and realistic disease concept is associated with LTS. Realistic disease concept involves recognizing the diagnosis of HIV not as a death sentence, but rather a long term chronic condition with “highs and lows” which must be managed for optimum health. Termination of poor health habits and involvement in spiritual guidance, volunteer work, or other activities self reported to “give meaning to life” are also positively correlated with LTS.
Conversely, hopelessness; the feeling of powerlessness; continuation of poor health habits such as alcoholic consumption, multiple sexual partners, and drug usage; and social isolation are associated with increased acquisition of opportunistic infections and lower overall immune functioning. However, it should be noted, research in this area is far from conclusive. Psychological “hardiness” is closely related to environmental and physical functioning. Disparities in social support, resources, availability to medical care, and poor health itself may exacerbate the negative aspects of the HIV diagnosis.

Genetic Factors
Some LTS are genetically more “hardy” and naturally secrete proteins (cytokines) that inhibit HIV replication in much the same manner as protease inhibitors. Other LTS are believed to have a less aggressive form of HIV. A strong immune function, the existence of greater numbers of cytokines, neutralizing factors, and specific allele sequences are associated with LTS by providing a natural resistance to HIV. By slowing the replication of HIV in the body, “blocking” the receptor sites, and successfully minimizing the amount of “free floating” virus; the individuals immunity remains functional for longer periods of time. This is particularly interesting when taken with non-use of AZT or other medications as exhibited by many of the LTS. However, protection afforded these individuals is relatively rare. Neutralizing factors apparently provide some degree of protection from the virus but can not be replicated in the laboratory or outside of the individual. Research on specific allele sequences capable of deterring the binding and replication of the virus are intriguing genetic variations which provide a degree of protection to the few individuals with this specific mutation. Currently the production of cytokines is one of the more promising areas of research with protease inhibitors attempting to mimic the genetic hardiness exhibited by LTS.
Despite variations in psychological and environmental attributes, LTS and asymptomatic non-progressors are identified in all cohorts of HIV seropositive populations. It is unknown if asymptomatic non-progressors are a unique subset of individuals possessing a “natural immunity” to HIV, or if they are simply extended LTS who will manifest symptoms at some point in the future. Originally researchers hoped to eradicate HIV through protease inhibitors or naturally induced immune functions, however, the virus continues to reside in the lymph glands after blood levels are indectable. Once protease inhibitors or the immune response is inhibited, the virus begins replicating almost immediately. Still, protease inhibitors and so called “drug cocktails” have proven the most effective treatment for the majority of HIV seropositive individuals. In fact, the use of these drug regimens is now one of the major factors associated with LTS.
Socio-environmental Factors
Socio-economic aspects influence LTS. Although asymptomatic and slow progressors are found in all cohorts of HIV seropositive populations, access to medical care, medications, and education remain major determinants of LTS for the majority of HIV patients. Early detection of opportunistic infections or other health problems, the availability of protease inhibitors and strong social support are positively associated with LTS.
As the use of “drug cocktails” has extended the life of many HIV persons, the environment has become of greater concern than ever. Access to medications is expensive (Approximately $20,000 per year) and unavailable to many clients whose only medical care is state provided. Low income and subsidized housing can further compromise nutritional and environmental stressors. Clients dependent on food stamps are often incapable of providing grooming and other essential necessities for daily living not allocated/allowed in the food stamp program.
Internationally this becomes even more apparent. Countries disproportionately affected by HIV are associated with greater levels of poverty, drug usage, and sexual commerce while least able to address the spiraling effects of the disease.
Summary
My response to the question “What is the epidemiology of people who live the longest with the HIV virus?” is threefold:
1. Long term survivors are more likely to exhibit psychological “hardiness”. Rather than considering the disease in a fatalistic manner, the diagnosis as HIV positive is likely to encourage a LTS to “take stock” in their life to find meaning and fulfillment. They are more likely to engage in exercise and nutrition programs designed to promote health and well-being, educate themselves on treatment options and factors influencing their health, and take a proactive role in their own medical care. Likewise, these individuals are more likely to deliberately attempt to eradicate stress…both physical and mental… from their lives.
2. Long term survivors are often characterized by genetic “hardiness”. Some HIV seropositive individuals have been found to produce more cytokines which inhibit the replication of HIV, have less aggressive forms of HIV, strong immune systems, neutralizing factors, or specific allele sequences associated with LTS. These genetic variations have been shown to inhibit the replications or mutation of HIV thereby delaying onset of symptoms. In a small percentage of HIV positive individuals, the virus seems to have little effect. These non-progressors are not yet clearly understood. The use of AZT and other medications is not a statistically significant variant among this group.

3. Long term survivors are associated with positive socioeconomic variables. Although asymptomatic and slow progressors are found in all cohorts of HIV seropositive populations, access to medical care, medications, and education remain major determinants of LTS. Protease Inhibitors are perhaps the single greatest determinant of LTS for the majority of HIV positive individuals today, yet many persons cannot afford the high cost of life sustaining medications. Early detection of opportunistic infections, adequate nutrition, provision of necessities for daily living, and strong social support are all associated with LTS.

Epidemiology Notes - Quick Study Review

EPI=UPON DEMO=POPULACE OLOGY=THE PROCESS OF STUDY

EPIDEMIOLOGY= A SCIENTIFIC METHODOLOGY USED TO DETECT THE CAUSE OR SOURCE OF DISEASES, DISORDERS, SYNDROMES, CONDITIONS, ETC. WHICH RESULT IN DISABILITY OR DEATH IN A POPULATION.

THREE GENERAL PURPOSES OF EPIDEMIOLOGY
1. EXPLAIN THE ETIOLOGY (STUDY THE CUASE OF DISEASE)
2. DETERMINE IF EPIDEMIOLOGIC DATA ARE CONSISTENT WITH PROPOSED HYPOTHESIS AND CURRENT MEDICAL KNOWLEDGE.
3. PROVIDE A BASIS FOR DEVELOPING CONTROL MEASURES AND PREVENTION PROCEDURES FOR GROUPS AT RISK
Develop PREVENTION AND TREATMENT PRACTICES,
MEASURING THE SUCCESS OF INTERVENTION STRATEGIES.

OR ANOTHER WAY TO PUT IT…
1. TO PREVENT/PREDICE
2. TO TARGET
3. TO JUSTIFY
The main purpose of all these is to eradicate in order to
ü Save money
ü Altruism
ü Describe the clinical picture
ü Syndromes
ü Diagnosis
ü Risk behavior
ü Other factors
ü Demonstrate most effective measures/treatment


Traditional Epidemiology
The epidemiological triangle:

Agent=cause of disease
Host=carrier or suscept ind.
Environment=where you find the host and agent
(time is in the middle)
Epidemiology is attempting to break the relationship between any of these factors.
Most commonly used for infectious disease.

Web of causation:

(looks like dr. chens notes)
Multiple causes each interrelated to explain the “cause”. More complex than the epi tri.
Persons in biostats would assign a relative importance and give a weighted mean.


Other general:
The wheel: not common.
Each disease has a genetic core surrounded by physical, biological. And social env. Depending on the situation, each factor may be smaller or larger

The gordon model:
Agent versus host with the fulcrum of the environment in the center.

See handout: The natural history of disease process. Used child abuse example.


4 categories of agents:
1. Biological (protozoa, bacteria, virus, etc)
2. Physical (noise, light, heath, radiation, cold, vibration)
3. Chemical (lead, abestos, food additives, smoke
4. Nutritional (lack of (usually), or imbalance).

Characteristics of agents:
Infective=ability to infect host
Pathogenic=capacity to cause disease
Virulence= degree of pathogenicity
Invasive=ability to enter body and spread
Antigenicity=ability of agent to stimulate production of antibodies
Toxicity=degree to which cause harm to host.

Factors that influence spread of disease:
Age (most important)
Gender (disease specific)
Race (sickle cell)
Religion (diet)
Customs (female circumcision)
Occupation (exposure to noise, lead, stress)
Heredity
Marital status (women primary physician interfact…married men more likely to go)
Family background
Previous disease (more or less suscept)










Environmental factors that influence disease causation or progression
Temperature
Humidity
Altitude
Crowding
Housing
Neigborhood
Water supply
Milk and food
Radiation
Air and noise pollution


Chain of infection:
1. Etiologic agent (that which causes the diease
2. Reservoir (animate or inanimate)
Clinical (acute) or Carrier
Carrier: Active (individual exposed to and harboring disease organism for an extended time after recovering)
Convalescent (exposed to and harboring pathogen in the recovery phase but still infectious.
Healthy and Passive (exposed to and harboring pathogen without becoming ill.
Incubatory (exposed to and harboring pathogen in the beginning stages.
Intermittent (exposed to and harboring pathogen who can intermittently spread the disease.
3. Portal of exit (skin, transplacental, respiratory, gentourinary, ailementary etc)
4. Mode of transmission (direct versus indirect)
5. Portal of entry (generally same as exits)
6. Susceptible host (degrees of suscep dependent upon immunity of host).

Hyperendemic=persistent level of activity beyond the expected prevalence associated with small poulations.
Holoendemic=disese that is highly prevalent in a population and commonly acquired early in life (chickenpox)
Epidemic=outbreak of one specific disease form a single source in a give population or area in excessof the usual level of expectancy. The seriousness and severity influence the definition of an epidemic. New cases exceed the prevalence of a disease.
Pandemic=and epidemic that is worldwide.





Measures of sickness:
Incidence=The number of new cases or a specific period of time.

Prevalence=the number of people in a pop. With the disease/cond. At a given point in time. There must be incidence to be prevalence.

Point prevalence: total number of cases at a specific moment in time

Period prevalence: Total number of cases in a prescribed period of time…from/to
When assessing period prevalence, a recurring case is treated as a new case.

Rate=the amt or number of one thing measured in units of another

Morbidity= the frequency of illness or disability in a pop.

Attack rate=an incidence rate expressed in percentage form.

Measures of death: Mortality

CDR=crude death rate: the actual number of deaths in a given time

Cause specific mortality rate=total number of death for a given disease in a given year.

Case fatality rate= the number death by a certain cause in a given time over the number of diagnosed cases.

Infant mortality rate= the number of children death less than one year old over the number of live births.

Infant death rate=the number of child deaths less than one year over the total pop.

Neonatal mortality rate=the number of infant deaths less than 29 days old over the number of live births in one year.

Post neonatal mortality rate=the number of infant death s from 28 days to one year over the number of live births in the same year.

Fetal death rate: the number of stillborn in one year over the total number of births in one year x 1000.

Fertility rate=probability rate of birth

Rate formula= numerator: number of cases of a disease over the denom. Which is the population in a given period of time. Then multiplied by a given value (say K) relevant to the population under study.

A rate in epi is the frequency/number of disease per unit size of population

Adjusted rates=used to allow for a fair comparison between groups which differ in some important characteristics (say age or gender). Adjust for a skewed rate.

Ratio=the raltion of a number, degree, event, etc between 2 similar things. Generally mutually exclusive to compare one to another. Try to always use 1:….

Ratio formula: dividing one quantity by another as expressed by a fraction.

Proportions= percentages. The relationship between the amount, size, and degree of one thing to another.

Proportion formula: divide the numerator by the denominator and mult by 100 to get a percentage.

Sensitivity and specificity: ensure reliability.

Sensitivity: Correctly id those who have the disease.

Specificity: Correctly id those who do not have the disease.

Sources for Epi info:

Mortality stats
Mobidity stats
Lab. Reports
Case study investigations
Vector studies
Special surveys


Definitions:

Fomites: inanimate objects that serve in disease transmission.

Vector: non-human living carrier of disease

Reservois: any organic thing in which organism live and multiply.
Zoonoses: animal transmission to human

Case: a person diagnosed with the disease

Primary case: the fist case introduced into the population

Index case: the first case brought to the attention of the epidemiologist

New case: first occurrence or a new case of the same disease

Suspect case: not yet diagnosed.

Case fatality ratio: the number of deaths due to specific disease per 100 episodes of dis.

Case severity: determined by several variables including avg length of stay in hosp, how disabling, chances of recovery, etc.


Levels of prevention:
Primary: halting disease or disorder before it happens.
Secondary: discovering pathogenic states/conditions in a population.
Tertiary: block the progression of a condition.

Pathogens:organisms capable of causing disease
Pathogenesis: the process of generating disease
Pathogenicity: ability of a pathogenic substance to cause disease.

Infective: those where the pathogen can enter, survive, and multiply in the host.

Virulence: the strength of different organism or degree of pathogenicity.

Invasiveness: the capacity to enter and grow on tissues of the host.

Etiology: cause of disease.

Three levels of disease:
Acute
Subacute
Chronic

Five classifications of disease
Congenital and heredity
Allergies and inflammatory
Degenerative or chronic
Metabolic
Cancer/neoplastic

Communicability: ability to be spread.

Classification by cause:
Airborne/Respiratory
Intestinal discharge
Open sores/lesions
Zoonosis or vector born
Fomite born

Classification by microbe source:
Bacteria
Virus
Fungus/mold/yeast
Protozoan
Worms
Arthropods

Classification by formite:
Dusts
Funes
Smoke
Chemicals
Electric
Noise
Radiation
Thermal
Bites,
Stings


Herd immunity: if most of the people in a population are protected, the chances or an epidemic are minimized. (immunizations)

Three factors to controlling communicable disease:
Remove, eliminate or contain the cause or source
Disrupt and block the chain of transmission
Protect susceptible populations.

Environmental controls:
Providing clean water, sewage, nutrition, animals and public utilities, etc.

Host related controls:
Quarantines
Isolation
Sanitaion
Hygiene
Immuniztions
Chemoprophylaxis

4 levels of quarantine:
segregation
surveillance
modified quarantine
complete quarantine


People to know:

Hippocrates: recognized airborne disease, atomic particles, etc.

Syndenham: (1600’s) advocated hygiene principles and began classifying disease states.

Lind: (1700’s) Scurvey epidemic in sailers. By identifying nutritional effects on disease he also observed the sources of causation, place, time, and season.

Jesty: (1774) Smallpox.
Jenner: (1700’s) Smallpox. More widely known.

Semmelweis: (1800’s) Childbed fever.

Snow: (1800’s) Cholera epidemic

Pasteur: (1800’s) vaccine

Koch: (1800) Methodology. Showed world first picture of microorganism. Pioneered the identification of microorganisms….

Leuwenhooek and Drebel: Microscope

Graunt: Drew up bill or mortality and other vital statistics.

Ramazzini: Italian guy who was interested why certain workers went blind. Advent of occupational health and industrial hygiene epidemiology.

Typhoid Mary: Early 1900’s cook responsible for large outbreak of typhoid. Illustrated the need to track carriers and control food supplies etc..

Note: nutrition one aspect of early epidemiology as deficiencies were correlated with disease such as ricketts, night blindness, etc.


Two types of epidemics:

Common source epidemic: where everyone gets it from the same place such as food poisoning at a picnic from bad potatoe salad.

Propagated or progressive source epidemic: where an outbreak occurs and then is spread from person to person, fomite, vectors, etc. Cannot chart a clean curve.

Vital statistics include all major life events combined with health and other status information such as on the census.
Vital events registrations include births, marriage, divorce, death.

Sources for vital stats include:

National vital stats center
National survey of family growth
National health interview survey
National health and nutrition exam survey
Natinal master facility inventory
National hospital discharge survey
National nursing home survey
AIDS surveillance
National notifiable diseses surveillance system.
Abortion surveillance x 2 sources
US immunization survey
National occupational exposure survey
National survey on drinking and drug abuse
Mental health organizations.
Medicaid/Medicare
Census
National health expenditures
Surveillance, epidemiology and end results program
Consumeer price index
Employment and earnings
Environmental protection agency
World health org.



Types and osurces of data for descriptive stats

Nominal: classify using categories that lack numbers such as age, gender, race. Parametric

Ordinal: Heiarchial classification of categories such as a ligert scale 1-5.
Parametric

Interval: No zero point. Tells absolute value between categories or units of measurment
Nonparametric

Ration: Has a zero point and tells value between categories.
Nonparametric