Download Lecture 14: SDL Occupational Lung Dz

Epi Exam 2
Lecture 12: Occupational Medicine Essentials (Stoner)
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Occupational medicine = Medical specialty focusing on detection, diagnosis, and prevention of diseases that
arise from the work environment
Occupational Disease = Health outcomes that are caused or influenced by exposure to general conditions or
specific hazards encountered in the work environment
Discuss the significance of the occupational environment for health
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Direct costs of injuries and illnesses during the 2002 were estimated at $45.8 billion. Indirect costs were
estimated to be $229 billion.
Make signif changes to workplace policies to better employee health
List physical and psychological effects of occupational hazards. State five categories of health impacts of occupational
hazards.
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Agents of occupational dz
a. Noise
b. Dusts
c. Toxic heavy metals and their fumes
d. Carbon monoxide
e. Chemicals
f. Ionizing radiation
g. Microbial agents
h. Lifting heavy weights
i. Repetitive motion
j. Workplace accidents
k. Work-related stress
Effects – 3 different patterns
a. The effects of occupational and environmental exposures occur after a biologically predictable latent interval
following exposure.
b. Agents or chemicals capable of causing direct and acute injury to the body will typically exert their effects either
immediately or soon after exposure.
c. Other substances initiate insidious disease processes that may become clinically apparent only after a latent
interval for many years.
Effects – specific
a. Allergic/Irritant Dermatitis
i. skin is one of the most common sites of contact with industrial chemicals in the workplace.
ii. Manufacturing, construction, food production, and activities such as metal plating and engine service
put workers at highest risk for skin diseases.
b. Resp Dz
i. Many of the work-related respiratory diseases are chronic conditions that have long latency periods.
ii. Asbestosis, coal workers’ pneumoconiosis, silicosis, byssinosis, mesothelioma, and lung cancer are
examples of work-related respiratory diseases.
iii. COPD and asthma
1. About 30% of cases of COPD and asthma can be linked to occupational exposures.
2. COPD is related to workplace exposure to dusts.
3. Asthma has become the most frequently diagnosed occupational respiratory disease in the U.S.
c. Fertility/pregnancy abnormalities
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i. birth defects, prematurity, low birth weight, spontaneous abortions, and developmental disabilities.
ii. A total of 4 million chemicals in use commercially have not been tested for their reproductive effects.
iii. Most of the 1,000 chemicals used in the work environment that have been demonstrated to cause
adverse reproductive effects among animals have not been tested with humans.
Hearing Loss from noise
i. As many as 10 million workers in U.S. suffer from noise-induced hearing loss.
ii. Prolonged exposure to noise may result in psychological reactions that adversely impact the immune
system and physical well-being.
1. Cardiovascular effects (exacerbation of HBP)
2. Stress
3. Sleep deprivation
Noise in the workplace
i. Construction industry—bulldozers, heavy trucks, and loading machines
ii. Healthcare industry—high-speed bone-cutting drills and suctioning devices – Noise levels in some
operating rooms has reaching 118 dB
Infectious Dz
i. Healthcare workers
ii. Public utility workers
iii. Agricultural workers
iv. Social service workers and corrections personnel
v. Clinical laboratory specialists
vi. Mortuary workers
vii. Adult film industry workers
MSK – SPRAINs, STRAINs, TEARs are LEADING CAUSE OF OCCUPATIONAL INJURIES AND ILLNESS
i. Soreness, pain, hurt, except the back
ii. Back pain, hurt back
iii. Hernia
iv. Carpal tunnel syndrome
v. Tendonitis
vi. Musculoskeletal system and connective tissue diseases and disorders, except tendonitis
Traumatic Injury
i. Highest risk occupations are: Construction, Transportation and warehousing, Agriculture, forestry,
fishing, and hunting
Stress
i. Health impacts
1. Anxiety,
2. Neurotic disorders
3. “Going postal”
4. Critical Incident stress
ii. Sources
1. Work overload
2. Job dissatisfaction
3. Job insecurity/fear of layoff
4. Lock of control over environment; shift work
5. Assembly line work with repetitive tasks
6. Dealing with abusive members of the public
7. Inadequate compensation/benefits
List three methods for the prevention of occupationally related disease. State the purpose of engineering controls and
reporting requirements for workplace injuries
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Engineering Control Methods
Worker education and training are key components of effective primary prevention programs for workplace injuries
and illnesses.
Substitute materials for less hazardous substances.
Modify the work environment that contains the source of the hazard.
Isolate the worker from the hazardous environment.
Personal Protective Equipment – last line of defense
a. Devices to protect against airborne hazards - Respirators
b. Devices to protect hearing - Ear muffs and ear plugs
c. Protective eyewear - Goggles, face shields, safety glasses, and full-face respirators
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Recall legislation related to occupational health and workers compensation at national and state level
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OSHA 1970
a. Occupational Safety and Health Act (OSH Act) to assure “so far as possible, every working man and woman in
the United States safe and healthful working conditions”.
b. Under the OSH Act employers are responsible for providing a safe and healthful workplace.
c. A separate commission oversees the Labor Department enforcement.
i. Hence the creation of Occupational Safety and Health Administration (OSHA)
NIOSH (National Institute for Occupational Safety and Health) charged with:
a. Identifying the causes of work-related diseases and injuries.
b. Evaluating the hazards of new technologies and work practices.
c. Studying industrial hygiene and hazard control.
d. Making recommendations for occupational safety and health standards
Exposure Limits
a. threshold limit value (TLV) “Refers to airborne concentrations of substances and represents conditions under
which it is believed that nearly all workers may be unaffected.”
COFI(Census of Fatal Occupational Injuries) for Public Health Surveillance
a. CFOI is considered the most accurate and reliable source for national data, however it only goes back through
1992
b. Multiple data sources (death certificates, state workers’ compensation fatality reports, federal compensation
fatality reports, various OSHA reports, newspaper reports)
c. Unique in that it requires confirmation of a work-related death from 2 separate sources
OSHA Form 300 Log of Injuries and Illness
a. The OSHA law requires most employers with 10 or more full-time employees to keep a yearly log of all workrelated injuries and illnesses
b. Employers must record all new cases of work-related fatalities, injuries, and illnesses if they involve:
i. death
ii. days away from work
iii. restricted work or job transfer
iv. medical treatment beyond first aid
v. loss of consciousness or
vi. a significant injury or illness diagnosed by a physician or other licensed health care professional.
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SUMMARY
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Occupational injuries can pose a major health threat for some populations
Disease can result from many agents in the workplace and occur in higher concentrations
Measures of prevention should be taken wherever possible
Physicians should consider occupational exposures whenever examining a patient
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Lecture 13: Occupational Exposure Hx
Importance of an Occupational and Environmental History
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To increase awareness of occupational and environmental factors.
To make accurate medical diagnosis.
To prevent the development of occupational and environmental diseases.
To prevent the aggravation of underlying medical conditions by occupational and environmental factors.
To identify potential workplace hazards.
To detect new associations between exposures and disease.
To establish the basis of compensation for occupational and environmental diseases.
To establish rapport with patients.
Know how the organ systems may be affected by toxic exposures
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Note the nonspecific Sx
a. Headache
b. Difficulty concentrating
c. Behavioral problems
d. Rashes
e. Asthma
f. Angina
g. Myalgia
h. Difficulty conceiving
i. Spontaneous abortion
COMMON EXPOSURE RISK
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State the components of an exposure history
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General: incorporate in
a. Ask about hobbies
b. Ask about work exposures
c. Ask about the home environment
Exercise judgment in choosing which questions to ask
a. Extent of detail depends on clinician’s level of suspicion that occupational or environmental factors
contributed to disease
b. Further elaboration is helpful when:
i. Exercise judgment in choosing which questions to ask
ii. Extent of detail depends on clinician’s level of suspicion that occupational or environmental
factors contributed to disease
iii. Further elaboration is helpful when:
COMPONENTS of EXPOSURE HX
a. Three main components (all explained in next objective)
i. Exposure Survey
ii. Work History
iii. Environmental History
b. Positive response - Indicates need for further inquiry
c. Negative response - Does not rule out a toxic exposure etiology or previous exposure
Identify specific questions asked in the environmental history
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General
a. What kind of work do you do?
b. Are your symptoms better or worse when you are at home?
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c. Are you not or have you previously been exposed to dust, fumes, chemicals, radiation, or loud noise at
your workplace?
d. Do you think your health problems are related to your work?
EXPOSURE HX: Past and current exposures
a. Changes in routines and work site characteristics
b. Details about known toxicant exposure
c. Known exposure to metal, dust, fibers, fumes, chemicals, physical agents, and biologic hazards
d. Other persons affected
e. Protective equipment use
f. Temporal patterns and activities in relation to work
g. Dose and concentration
WORK Hx
a. Comprehensive inventory of the patient’s occupations, employers, and current and potential exposures
in the workplace
i. Note every job regardless of duration
b. Ask patient to describe a typical work shift
c. Ask patient to simulate performance of work tasks
d. Ask about routine task and unusual or overtime tasks
e. Other co workers
ENVIRONMENTAL HX
a. Questions regarding patient’s home and surrounding environment
i. Location of the house
ii. House water supply
iii. Changes in air quality
iv. Patient hobbies and other household members’ hobbies
v. Travel
Role of Clinicians is preventative.
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Advise the patient
Contact an appropriate labor or environmental organization
Contact the responsible party such as an employer or landlord (with permission of the patient)
Inform appropriate governmental regulatory agency
Contact an appropriate research or expert group
Other objectives
Recall a possible temporal relationship between patient’s symptoms and patient’s home and surrounding environment
State why patients need to provide detailed information about their past and current exposures from their jobs and
homes
Recall how temporal relationships between patient’s symptoms and patient’s home or work environment are identified
Identify the possible sources of toxicants from indoor air pollution
Identify the possible sources of toxicants in the home and environment
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Lecture 14: SDL Occupational Lung Dz
List common occupational illnesses and injuries, causes and their relationship to industry
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Worker Protection
a. Occupational Safety & Health Administration
i. Extensive information regarding occupational lung diseases
ii. Epidemiologic data, workplace safety guidelines
iii. Minimum exposure standards are all published for specific exposure types.
b. National Institute for Occupational Safety and Health (NIOSH)
i. conducts research and makes recommendations to prevent worker injury and illness
Occupational Respiratory Dz Surveillance
a. Surveillance
i. Systematic collection, analysis & dissemination of health and hazard data
ii. monitors the extent & severity of occupationally related lung disease & workplace exposure
b. National Statistics
i. Work-Related Lung Disease Surveillance System (eWoRLD)
ii. National Occupational Respiratory Mortality System (NORMS)
c. State-Based Surveillance
i. Programs available through NIOSH funding
d. Worker Medical Monitoring
e. Coal Workers’ Health Surveillance Program
i. Federally mandated medical monitoring programs
Recall how to take an occupational history
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most important step in diagnosing work-related asthma is to suspect it in all adults who present with newonset asthma or recent clinical deterioration.
a. Work-related asthma is incorrectly diagnosed as bronchitis because most physicians do not inquire
about the work relatedness of symptoms
Once the cause of your symptoms is identified, you and your employer can work together to assure that you
avoid exposure to the substance that triggers your asthma symptoms
Recall common occupation lung diseases
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major classifications of occupational lung diseases are hypersensitivity pneumonitis (HP) and
pneumoconiosis.
a. HP refers to lung diseases caused by inhalation of organic materials/irritation/inflammation/allergic rx.
b. Pneumoconiosis is the term for lung diseases caused by inhalation of mineral dust/a foreign body.
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Two Categories:
a. Diseases related to a specific occupation, such as asbestosis, coal worker’s pneumoconiosis (black lung),
berylliosis (brown lung), and farmer’s lung
b. Diseases that are not occupation-specific, but are aggravated at work, such as occupational asthma
i. OLDs all lead to progressive deterioration in lung function that can cause severe respiratory
compromise if appropriate measures are not undertaken.
Most occupational lung diseases are caused by repeated, long-term exposure
a. Acute
b. Sub-acute
c. Chronic
Occupational lung diseases are preventable
a. What effect does smoking have on lung cancer?
i. Increases severity
ii. Increases risk
Dx
a. TAKE A GOOD WORKPLACE HX
b. Pulmonary function tests - diagnostic tests that help to measure the lungs' ability to exchange oxygen
and carbon dioxide appropriately.
c. Microscopic examination of tissue, cells, and fluids from the lungs
d. Biochemical and cellular studies of lung fluids
e. Measurement of respiratory or gas exchange functions
f. Examination of airway or bronchial activity
List types of OLD based on classification of hypersensitivity pneumonitis and pneumoconiosis
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HYPERSENSITIVITY PNEUMONITIS - causes extensive inflammation and fibrosis. an inflammatory disease of
the lung parenchyma caused by inhalation of organic dusts.
a. Some types (this is not all of them. The most common antigens are thermophilic actinomyces species
and avian proteins. The most common diseases are farmer's lung and bird fancier's lung)
i. Farmer's lung is caused by the inhalation of thermophilic Actinomyces or Aspergillus species in
decomposing compost, hay, or sugar cane. Exposure to large quantities of contaminated hay is
the most common source.
ii. Bird fancier's lung is the most common type of HP in children. It has been associated with a
wide variety of different birds including pigeons, pheasants, turkeys, geese, and parakeets.
b. Sx:
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i. fever, chills, malaise, cough, dyspnea, and headaches 4-6 hours after heavy exposure to an
inciting agent in acute HP.
ii. Subacute and chronic forms are characterized by cough, progressive dyspnea, fatigue, anorexia,
and weight loss.
c. Imaging
i. Chest radiographs may show micronodular or reticular opacities (shown) in acute or subacute
HP and progressive fibrosis with lung volume loss in chronic HP.
d. Prognosis
i. Most patients will recover the majority of lung function, but it may take several years. Patients
with significant fibrosis have a poorer prognosis.
PNEUMOCONIOSIS types
a. Asbestosis
i. High levels of asbestos fibers can lead to an increased risk of lung cancer:
mesothelioma (a cancer of the lining of the chest and the abdominal cavity)
ii. Asbestos-related diseases may develop after a latency of up to 20 years.
iii. On physical examination, persistent and dry inspiratory crackling/rales are the most important
finding. As fibrosis worsens, shortness of breath occurs even at rest
iv. risk of asbestos exposure is not just limited to the workplace. Since many homes were built with
asbestos products (especially those homes built before 1978)
v. The mere presence of asbestos in the home is not hazardous.
vi. The best thing to do with asbestos material that is in good condition is LEAVE IT ALONE!
vii. Disturbing it can create a health hazard where none existed before.
viii. Imaging
1. Computed tomography may show intralobular opacities (black arrow), thickened septa
(white arrows), subpleural curvilinear lines, parenchymal bands, peribronchial fibrosis,
honeycombing, and calcified diaphragmatic pleural plaques (red arrow
2. Classic chest xray findings include reticulonodular infiltrates at the lung bases (shown),
shaggy heart borders (shown), and calcified diaphragmatic pleural plaques that are
commonly called "holly leaf."
ix. Where Asbestos Hazards May Be Found In The Home
1. Some roofing and siding shingles are made of asbestos cement
2. Insulation (houses built between 1930 and 1950)
3. Textured paint and in patching compounds used on wall and ceiling joints (banned in
1977)
4. Artificial ashes and embers sold for use in gas-fired fireplaces
5. Stove-top pads
6. Walls and floors around woodburning stoves may be protected with asbestos paper,
millboard, or cement sheets
7. Vinyl floor tiles and adhesives
8. Hot water and steam pipes may be coated with an asbestos blanket or tape
9. Oil and coal furnaces and door gaskets
x. Tx
1. Corticosteroids and immunosuppressive drugs do not alter the course of the disease.
2. Treatment focuses on removal of any ongoing asbestos exposure, but asbestosis is often
a progressive disease, even in the absence of a continued exposure
3. Patients are advised to quit smoking
4. Prompt treatment of any subsequent respiratory infections
5. Immunizations against influenza and pneumococcal pneumonia are warranted
6. Some patients may require supplemental home oxygen therapy
xi. Death rates
1. Deaths from asbestosis are increasing due to the long latency period
2. Cases that are being seen now result from exposure to asbestos dust in the 1950s, 60s &
70s.
b. Silicosis
i. What = lung disease caused by inhalation of dust containing crystalline silica. It is perhaps the
oldest known occupational lung disease. Crystalline silica is a basic component of soil, sand,
granite, slate and other common building materials.
ii. Physical examination findings are typically benign with respiratory difficulty and signs of
hypoxemia only in severe cases.
iii. Diagnosis is based on a history of exposure, clinical symptoms, physical examination findings,
and chest radiographic appearance.
iv. Treatment focuses on exposure avoidance, smoking cessation, immunization, and prompt
treatment of respiratory infections.
v. Corticosteroids may benefit individuals with acute silicosis. Overall mortality is quite low
c. Berylliosis
i. Beryllium – metallic agent found in rocks, soil, coal, volcanic dust
ii. 2 dz types
1. Acute inhalation causes chemical pneumonitis where the metal acts as a direct chemical
irritant causing an inflammatory reaction.
2. Exposure occurs over 2-4 weeks
3. Complete recovery is possible
4. Chronic inhalation causes granulomatous lung disease known as berylliosis.
iii. Sx: cough, chest pain, arthralgias, fatigue, and weight loss. Other than inspiratory crackles,
physical examination findings are uncommon.
iv. Treatment focuses on exposure avoidance and corticosteroid therapy for 4-6 weeks.
v. Prognosis is highly variable and ranges from complete recovery to lung transplantation
d. Coal Worker’s Lung – Pneumoconisosis
i. What - fibrotic pulmonary condition caused by the accumulation of coal dust in the lungs.
1. causes thickening and scarring making the lungs less efficient in supplying O2 to the
blood.
ii. Pt w/ early disease are typically asymptomatic but may eventually report productive cough and
dyspnea.
iii. Dx: history, physical examination findings (do PFT), and evidence of fibrosis on radiographic
imaging.
iv. Treatment is largely supportive and preventative. Mortality is related to the degree of fibrosis
and oxygen requirement.
v. Prevention
1. Hazard exposure limits
2. Dust suppression
3. Personal protective equipment
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vi. Prevention Surveillance - Evaluation of exposed workers to detect potential health problems at
an early stage; To prevent the development/progression of occupationally-related respiratory
disease
1. Important b/c Despite control measures individuals can continue to be affected via
a. Excessive exposure
b. Unusually susceptible to the hazard
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State the difference between occupational asthma and asthma not associated with occupational illness
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WORK-RELATED asthma is divided into
a. Work aggravated asthma
i. Pt has Hx of preexisting asthma.
ii. They have recurrent asthmatic episodes that are triggered by a nonspecific mechanism such as
cold temperatures, excessive exertion, or exposure to irritant aerosols including dusts, fumes,
vapors, and gases.
b. Occupational asthma develops as a direct result of workplace exposure.
i. Two forms of occupational asthma:
1. Reactive airway dysfunction syndrome (RADS)
a. Develops within minutes-hours after a single or high dose exposure to a variety
of chemicals generated as gases or aerosols, particulates or smoke.
b. HAS NO LATENCY PERIOD
2. Allergic occupational asthma
a. Develop sensitization to a specific chemical agent in the workplace
i. ammonia, chlorine gas, baking enzymes, animal proteins, powdered
proteins
b. Develops over time (latency period)
Lecture 15: SDL Counseling Skills for Behavioral Change
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Why Epi goes w/ counseling
a. Leading causes of morbidity and mortality in the US are attributed primarily to behavior
b. Awareness and internal locus of control impact wellness and prevention
c. Ultimate goal is to help patients make healthy life choices
Counseling = Professional relationship that empowers diverse individuals, families, and groups to accomplish
mental health, wellness, education, and career goals
a. Uses a team approach and is goal oriented
b. Strength-based
c. Not always the same as psychotherapy
i. Counseling skills used with both well populations and those with clinical disorders
ii. Psychotherapy generally used to treat mental health issues
Pt Need Support to Change
a. Natural consequences such as a heart disease, jail time, and diabetic complications are often not enough
to motivate people to change on their own
b. Sometimes we are unaware of the impact of our own behavior
c. Sometimes we are aware and are unsure about how to change
d. Sometimes we get to the point of indifference and lack self-efficacy
Counseling Skills for Physicians
a. Communication skills are imperative
i. Active listening
ii. Clarification
iii. Reflection-goal is to both check and communicate you understand correctly
1. Statements that accurately reflect the patient’s meaning
2. Often a guess at what the patient thinks/feels based on what he/she is telling you
b. Use of empathy
i. Seeing the patient’s perspective as if it were your own
ii. Keep your opinions and judgments separate from those of patient
c. Unconditional positive regard (Carl Rogers)
i. Communicate respect regardless of patient’s responses
ii. Does NOT mean you are expressing agreement
d. Validation: legitimize patient’s experience
i. Show acceptance of patient’s belief system and experiences even if they are not based in reality
or contain errors
e. Educate instead of lecture
i. Provide relevant facts in an objective and non-judgmental way
f. Redirection: refocus conversation to something productive
i. First validate to avoid patient feeling dismissed
g. Problem solving with solution-focused approach
i. Help patients identify strengths
ii. Discuss what they are ALREADY doing right
h. Motivational Interviewing (MI) skills
i. Physicians can integrate MI principles and strategies to help with patient resistance and/or
ambivalence
Motivational Interviewing Overview
a. Goal-directed, client-centered counseling style used to address ambivalence about behavioral change
b. Originally developed to treat problem drinking and now commonly used for health promotion, medical
treatment compliance, and mental health issues
c. Collaborative approach
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d. Encourages the patient to voice arguments for change rather than the provider
e. Aims to elicit “change talk” vs “sustain talk”
Stages of Change: Prochaska and DiClemente
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4 Basic MI (medical interview?) Skills
a. Open-ended questions
b. Affirmations
c. Reflection
d. Summary
Eight Stages In Learning MI
a. The spirit of MI
b. OARS – Client-centered counseling skills
c. Recognizing change talk
d. Eliciting and reinforcing change talk
e. Rolling with resistance
f. Developing a change plan
g. Consolidating client commitment
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h. Integrating MI with other intervention methods
Questions to ask
a. Listen carefully with a goal of understanding the dilemma; Give no advice
b. Ask these four open questions:
i. Why would you want to make this change?
ii. How might you go about it, in order to succeed?
iii. What are the three best reasons for you to do it?
iv. On a scale from 0 to 10, how important would you say that it is for you to make this change?
v. Follow-up: And why are you at __ and not zero?
c. Give a short summary/reflection of the speaker’s motivations for change
d. Then ask: “So what do you think you’ll do?” and just listen with interest
e. Think of something about yourself that you:
i. want to change
ii. need to change
iii. should change
iv. told to change
v. have been thinking about changing but you haven’t changed yet
vi. E.g. something you’re ambivalent about
How to work through clinical cases
a. Prioritize presenting issues
b. Inquire about patient’s perspective and level of understanding of current complaints
c. Approach patient by first assessing level of motivation for making change and any previous attempts
d. Choose the appropriate strategies and counseling skills based on the severity of the issue and patient’s
willingness to discuss change
e. Use a collaborative approach to treatment
f. Patient should fully understand the “how” and “why” of any treatment plan
Physician Self-Awareness
a. Physicians need to be aware of any countertransference
i. Separate personal beliefs from professional responsibilities
ii. Use a non-judgmental approach
b. Use of mindfulness skills can help physicians be more present during patient encounters
c. Assess patient’s tone and body language for uncertainties or hesitancy to share information
d. Convey respect and unconditional positive regard at all times
i. Note: This does not mean you are agreeing with their choices and/or behavior
Case Studies on slides 18-30
Lecture 16: Zoonosis (Stoner)
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Zoonosis = An infection or infectious disease transmissible under natural conditions from vertebrate animals
to humans
a. CDC def - contagious diseases spread between animals and humans. These diseases are caused by
bacteria, viruses, parasites, and fungi that are carried by animals and insects
Methods of Transmission
a. Contact with the skin
b. A bite or scratch from an animal
c. Aerosol - Direct inhalation
d. Oral - ingestion
e. The bite of an arthropod vector
f. Reproductive
Vectors and Dz
a. Vector - An insect or any living carrier that transports an infectious agent from an infected individual or
its wastes to a susceptible individual or its food or immediate surroundings
1. Examples
ii. Various species of rodents (rats and mice)
iii. Arthropods (mosquitoes, ticks, sand flies, biting midges)
b. Vector-Borne Dz
i. Malaria (Parasitic)
ii. Leishmaniasis (Parasitic)
iii. Plague (Bacterial)
iv. Lyme disease (Bacterial)
v. Rocky Mountain spotted fever (Rickettsial)
PARASITIC DZ
a. MALARIA
i. Host - Mosquito
ii. Agent - Parasite: plasmodium
iii. Common symptoms: Fever and flu-like, headache, muscle ache fatigue, shaking chills, jaundice,
kidney failure, seizures, coma, death
iv. Health burden of malaria
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1. A disease found in more than 100 countries, with more than 40% of the world’s
population at risk
2. Endemic regions include Central and South America, Africa, India, Southeast Asia, the
Middle East, and Oceania.
3. The World Health Organization estimates that in 2012 malaria caused 207 million clinical
episodes, and 627,000 deaths.
4. An estimated 91% of deaths in 2010 were in the African Region
b. CUTANEOUS LEISHMANIASIS
i. Host = Sand fly. Carried by includes wild rodents, human beings, and carnivores (e.g., domestic
dogs
ii. Agent - Parasite: Leishmania
iii. Common symptoms: No symptoms to sores on the skin
iv. Endemic in a total of 82 countries
c. TOXOPLASMOSIS
i. Host - Domestic cats and their relatives
ii. Agent - Parasite: Toxoplasma gondii
iii. Transmission - Usually from eating undercooked meat or not washing hands
iv. Common symptoms: Usually flu-like, severe can lead to damage to brain, eye, or other organs
BACTERIAL ZOONOSIS
a. PLAGUE
i. Host – Fleas. Harbored by rodents
ii. Agent - Yersinia pestis Transmission
iii. Symptoms
iv. Historians believe that the plague epidemic during the Middle Ages (the “black death”) was
caused by fleas from infested rats.
b. LYME DZ
i. Host - Blacklegged ticks. Carried by deer
ii. Agent - Borrelia burgdorferi
iii. Symptoms: Fever, headache, fatigue, and a characteristic skin rash called erythema migraine. If
left untreated, infection can spread to joints, the heart, and the nervous system
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c. Foodborne Risk Factors
i. Animal Husbandry
ii. Transportation
iii. Slaughter, Processing & Packing
iv. Retail
v. Home
d. ANTHRAX
i. Host - Commonly found in soil. Affects domestic and wild animals when they breathe in the
spores
ii. Agent -Bacillus anthracis
iii. Transmission - Inhalation spores, eat food or drink water that is contaminated with spores, or
get spores in a cut or scrape in the skin.
iv. Symptoms
1. Cutaneous - Blisters, sore with a black center
2. Inhalation - Flu-like, chest discomfort, cough, extreme fatigue
v. Gastrointestinal - Flu-like, swelling of neck, sore throat, hoarseness, fainting, abdominal
swelling, vomiting, diarrehea
VIRAL ZOONOSIS
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a. RABIES
i. Host - Dog, Cat, Bat, Racoon
ii. Agent - Rabies Virus
iii. Transmission - Saliva of infected animals
iv. Common symptoms: Encephalopthy, seizures, paralysis, fever, headache, hallucinations
v. Almost all persons infected by rabid animals will die if not treated.
b. WEST NILE VIRUS
i. Host –Birds. Mosquitoes are carriers
ii. Agent - Flavivirus Transmission
iii. Common symptoms
iv. Health effects vary from no symptoms (70-80%)to very severe symptomatology (1%)
encephalitis or meningitis
c. DENGUE FEVER
i. Host - Aedes aegypti mosquito.
ii. Agent - Four dengue viruses
iii. Transmission - Saliva of infected animals
iv. Common symptoms
1. High fever, headache, eye pain, joint pain, muscle and bone pain, rash, mild bleeding
v. The proportion of deaths can be as high as 40% to 50% when the disease is untreated.
vi. Occurs primarily in tropical subtropical areas of the world, for example, Southeast Asia, tropical
Africa, and South America
vii. In the US
1. In the U.S., most cases of dengue are imported by travelers who are returning from
endemic areas or by immigrants.
2. Occurrence of dengue fever that originated in the continental U.S. has been
documented.
3. Southern Texas and the southeastern states are at theoretical risk for transmission of
dengue and for sporadic outbreaks
FUNGI
a. Dermatophytoses
i. Superficial mycoses that may be acquired from infected animals and affect the skin, hair and
nails of humans, causing itching, redness, scaling and hair loss.
b. Histoplasmosis - Bat stool
c. Cryptococcosis - Wild pigeon stool
EMERGING ZOONOSES = to zoonotic diseases that are caused by either apparently new agents or by known
agents that occur in locales or species that previously did not appear to be affected by these known agents
a. Risk Factors
i. Ecological changes that result from agricultural practices (e.g., deforestation, conversion of
grasslands, and irrigation)
ii. Changes in the human population and human behavior (e.g., wars, migration, and urbanization).
b. Examples of emerging zoonoses & their contributing factors
i. Non-conventional agent:
1. Bovine spongiform encephalopathy
a. Changes in rendering process
ii. Viral:
1. Hantaviruses
a. Ecological/environmental changes
2. Increasing rodent contacts
iii. Bacterial:
IX.
X.
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1. Escherichia coli O157:H7 (hemolytic-uremic syndrome)
a. Mass food processing technology allowing contamination of meat
iv. Parasitic:
1. Cryptosporidium and other pathogens
a. Contaminated surface water, faulty water purification
GLEWS (Global Early Warning System for Major Animal Diseases, including Zoonoses)
a. What = is a joint system that builds on the added value of combining and coordinating the alert and
disease intelligence mechanisms of OIE, FAO and WHO for the international community and
stakeholders to assist in prediction, prevention and control of animal disease threats, including
zoonoses, through sharing of information, epidemiological analysis and joint risk assessment.
i. Since many infectious diseases are zoonotic it is clear that information of zoonotic disease
occurrence in animals is important also to public health officials.
b. Considerations
i. Is the public health impact of the event serious?
1. High morbidity and/or high mortality in humans and/or animals.
2. Emerging disease with significant mortality and/or morbidity or zoonotic potential.
ii. Is the event unusual or unexpected?
1. First occurrence or reoccurrence of a disease/strain.
2. Unusual event for the area or season.
3. Event associated with an unknown agent.
iii. Is there significant risk of international spread or interference with international travel or
trade?
c. Prevention
i.
Summary slide
a. Understanding how zoonotic diseases & emerging infectious diseases are transmitted will help in the
prevention of these diseases
b. Understanding the drivers of zoonotic diseases & emerging infectious diseases will help in the
prevention of these diseases
c. Understanding the risk factors of exposure will help in the prevention of these diseases
d. Understanding the need to prevent emerging zoonotic diseases due to their potentially serious human
health and economic impacts
e. Understanding prevention control measures helps in the prevention of these diseases
Lecture 17: Essentials of Global Community Health and Community Oriented Primary Care (stoner)
I.
II.
III.
IV.
V.
VI.
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Health Definitions
a. Health - state of complete physical, mental, and social well-being and not merely the absence of disease
or infirmity(WHO)
b. Public Health - science and art of preventing disease, prolonging life, and promoting physical health and
mental health and efficiency through organized community efforts to ensure to every individual in the
community a standard of living adequate for the maintenance of health.
c. Global Health - application of the principles of public health to health problems and challenges that
transcend national boundaries and to the complex array of global and local forces that affect them
Why study global health?
a. Understand the progress that has already been made
b. Understand the challenges that still remain
c. Diseases are not limited by national boundaries (West Nile, Dengue Fever(
d. Significant health disparities among groups
e. Link between health and development
Millenium Development Goals
a. Countries signed pledge to meet goals by 2015
b. Explicit statement of goals for development efforts
c. All relate to health, whether directly or indirectly
d. Important to understanding global health issues
Key global Health Principles
a. Countries do not need to be high-income to enjoy good health status
b. Burden of disease is evolving in light of economic and social changes, the aging of populations, and
scientific and technical progress
c. Some issues can only be solved through cooperation
d. People and communities have the ability to enhance their own health status
e. Each of us should be concerned with the health of others for health, security and humanitarian reasons
Global Public Health Efforts
a. Enormous progress in improving health status over last 50 years
b. Much of the progress due to improvements in public hygiene, better water and sanitation, and better
education
c. Progress in health status has been very uneven across countries
d. Influencing factors
i. The factors that influence health status most
ii. The indicators used to measure health status
iii. The key trends that have occurred historically
Determinants of Community Health - interconnected factors that determine an individual’s health status
a. Personal Level
i. SES
ii. Genetics
iii. Behaviors
b. Community Level
i. Societal environment
ii. Culture and acculturation
iii. Physical environment
iv. Health care
c. Societal Level
i. Policies and Politics
ii. Urbanization
iii. Migration
iv. Demographic Transition
VII.
Health Indicators
a. uses
i. Finding which diseases people suffer from
ii. Determining the extent to which the disease causes death or disability
iii. Practicing disease surveillance
iv. To perform these functions, it is important to use a consistent set of indicators
b. Measuring the Global Burden of Disease
i. Two indicators used to compare how far countries are from a state of good health
ii. Health-Adjusted Life Expectancy (HALE)- summarizes expected number of years to be lived in
what might be termed the equivalent of good health
iii. Disability-Adjusted Life Year (DALY)- a unit for measuring the amount of health lost because of a
particular disease or injury
1. Composite measure of premature deaths and losses due to illnesses and disabilities in a
population
c. Burden of deaths and Dz w/in countries
i. Most low- and middle-income countries
1. Rural people will be less healthy
2. Disadvantaged ethnic minorities will be less healthy
3. Women will suffer from their weak social positions
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VIII.
IX.
21
4. Poor people will be less healthy
5. Uneducated people will be less healthy
ii. Higher income countries tend to have a greater burden of noncommunicable disease
iii. Lower income countries to have a greater burden of communicable disease
iv. Africa and South Asia are set apart by their large burdens of communicable disease
v. Children in low- and middle-income countries often die of communicable disease
vi. HIV/AIDS and TB are among the leading causes of death among adults in low- and middleincome countries
Demography and Health
a. Gen
i. Population Growth - Creates need for more infrastructure and services
ii. Aging Population - People will be living longer with morbidities and disabilities
iii. Urbanization - Majority of the world’s population lives in urban areas for the first time
1. Enormous pressure on urban infrastructure like water and sanitation
b. Demographic Transition
i. Shift from pattern of high fertility and high mortality to low fertility and low mortality
ii. Mortality declines due to better hygiene and nutrition
iii. Population grows with younger share of population increasing
iv. Fertility declines
v. Population growth slows and older share of population increases
c. Epidemiologic Transition
i. Shift from burden of disease dominated by communicable disease to burden of disease
dominated by noncommunicable disease
ii. Most low-income countries are in ongoing transition so they face large burdens of
communicable and noncommunicable disease
Burden of Dz: Looking forward
a. Economic development
i. Economies of low-income countries need to grow in order to invest in health
ii. Impact of economic development will depend on countries investing in areas that improve
health such as water, sanitation, and education
b. Scientific and Technological Change
i. Development of vaccines, drugs, and diagnostics
ii. Country’s ability to adopt these changes will determine their effect on health
c. Climate Change
i. Impact not entirely clear
ii. Possible migration from places that become inhabitable
iii. Adverse weather
X.
XI.
22
iv. Possible change in populations of disease vectors
d. Political Stability
i. Necessary for long-term gains in health
ii. Instability causes illness, disability and death as well as breakdown of infrastructure and services
e. Emerging and Re-emerging infectious disease
i. Occurrence and impact difficult to predict
ii. Pandemic flu
iii. Anti-microbial resistance
f. Culture
Addressing Local and Global Health issues through Community Health Care
a. The collective expression of the health of individuals and groups in a defined community
b. Determined by the interaction of personal and family characteristics, the social, cultural and physical
environments, as well as health services and the influence of societal, political, and globalization factors.
COPC (community-oriented primary core)
a. Way of practicing medicine and nursing or providing primary care, which is focused on care of the
individual who is well or sick or at risk for illness or disease while also focusing on promoting the health
of the community as a whole or any of its subgroups
i. Individual and community care
ii. Integration of primary care and public health
iii. Care to defined entire populations based on needs
iv. Community participation and interdisciplinary collaboration
b. Principles of COPC
i. Responsibility for the health and health care of a defined population
ii. Health care based on identified health needs at the population level
iii. Prioritization
iv. Interventions covering all stages of the health–illness continuum of a selected condition
v. Community participation
c. Framework
i. COPC places primary care at the core of community programs.
ii. COPC is not only where care takes place, it is also the care that considers individuals and their
micro- and macro- environments well as their interrelations with the collective state of health.
iii. The person, not the disease, is at the center of attention in the community context.
iv. The coordination and cooperation with other levels of care and health-related services or
sectors and professionals is an essential component in the delivery of COPC
v. Framework uses epidemiology for assessing health needs & determinants and the identification
of risk groups.
vi. Six-step process
1. Community definition and
characterization
2. Prioritization
3. Detailed problem assessment
4. Intervention planning and
implementation
5. Evaluation
6. Reassessment
f.
Example of COPC – 1940s Roots in Rural South Africa
i. Behavioral, cultural, social characteristics were crucial components of health assessment and
planning of care
ii. Extended to 44 Community Health Centers
iii. The approach Improved the state of health and promoted community development
iv. were responsible for health assessments at the individual, family and community level.
1. The family diagnosis was part of the community diagnosis, upon which health
promotion and preventive and curative services were provided.
g. Goals of COPC and Health care
i. healthcare team should attend to the needs of individuals and families and also to the
community as a whole.
ii. It should address not only sick people, but also promote the health of the community members
and prevent the development of disease.
h. Challenges in COPC – Factors influencing participation
i. Economic level of the community
ii. Geographic location (urban/rural)
iii. Sociocultural & political context
iv. Population coverage
i. Enhancing Participation
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XI.
24
i.
Summary Slide
a. Global health is essential to study as disease are not limited by international boundaries
b. Each country faces vastly different health issues
c. Community health can be measured and expressed through health indicators
d. Global Community health is largely dependent on the personal, community, and societal level
determinants of health
e. Global health is changing due to the demographic and epidemiologic transition
f. COPC is based on providing primary care to well and sick individuals and also focusing on promoting the
health of the community as a whole.
Lecture 18: SDL Zoonosis in the Bedroom
I.
Review questions
a. Based on the review by Drs. Chomel and Sun, which of the following statements about transmission of
plague by pets living in very close contact to their owners is most likely correct?
i. Pets infested with infected fleas may transmit plague to their owners
b. Your patient is a 6-month-old boy admitted with irritability and fever. Lumbar puncture reveals
cerebrospinal fluid profile consistent with meningitis. Upon questioning, the mother admits that while the
infant was in a bassinet, she ran to answer the phone, and when she returned to her son, her pet dog was
licking his nose and mouth. Based on the above review, which of the following statements is most likely
correct?
i. Being licked by pets is a common source of human infection by P. multocida
c. Based on the review, which of the following statements about parasitic zoonoses associated with pets is
most likely correct?
i. Transmission of toxocariasis to humans may occur from contact with embryonated eggs on a
II.
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dog's hair coat
Notes from the Reading
a. Dz
i. Plague outbreak 1974 –from fleas on cat/dog – from sleeping in same bed as sick pet
ii. Chagas Dz - dogs and cats infected with the Chagas disease agent, Trypanosoma cruzi, increased
risk for domestic transmission of T. cruzi to the Chagas disease vector, Triatoma infestans bugs
(rates much higher in shared sleeping areas)
iii. Cat-Scratch Dz - transmitted to humans when they are scratched by a cat that harbors
Bartonella henselae–infected fleas and flea feces. scratched or bitten by a kitten, licked on the
face by a kitten, slept with a kitten, or combed a kitten.
iv. Pasteurella spp & Capnocytophaga canimorsus infxn – kissing pets, licking, sleeping in shared
area
v. Staph intermedius infxn - common commensal bacterium in dogs and cats and has rarely been
identifi ed as causing human infection. Rare but happens.
vi. MRSA infxn – recurrent infxn from dog licking and sleeping in bed
vii. Rabies - being licked by dogs that are rabid or suspected to be rabid is considered to pose a
major risk. Still a big problem in SE Asia
viii. Parasitic Infxn –
1. In United States, the most common parasitic zoonoses associated with dogs are caused
by hookworms (Ancylostoma spp.) and roundworms (Toxocara canis)
2. The Netherlands, prevalent parasitic zoonoses are caused by Toxocara spp., Giardia
spp., Cryptosporidium spp., and Toxoplasma spp.
ix. Others - keeping dominant and possessive dogs in a bedroom where young infants are sleeping
b/c RISK FACTOR FOR BITING BABY
b. Recommendations
i. Zoonotic infections acquired by sleeping with a pet are uncommon
ii. More zoonotic agents that are transmitted by kissing a pet or being licked by a pet have been
identified
iii. Our review suggests that persons, especially young children or immunocompromised persons,
should be discouraged from sharing their bed with their pets or regularly kissing their pets.
iv. Any area licked by a pet, especially for children or immunocompromised persons or an open
wound, should be immediately washed with soap and water.
v. Pets should be kept free of ectoparasites (especially fl eas), routinely dewormed, and regularly
examined by a veterinarian.
vi. Preventive measures such as anthelmintic drug intervention for puppies within the first few
weeks after birth or, even better, for bitches during the last few weeks of pregnancy, could
help prevent most cases of human toxocariasis.
vii. Evaluation of patients with recurrent MRSA colonization or infection or Pasteurella spp.
infection with no obvious source should prompt queries about any regular contact with pet
dogs, particularly in household settings.
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Lecture 19: SDL Case study – read article. Discussion questions mirror objectives, so if you can
answer them, then test questions on exam should be fine. HERE ARE THE ANSWERS
1. A. In what ways is the Agincourt project a model of COPC? B. What areas still need to be developed?
A.





Had the responsibility for the health of a defined population, including healthy and sick individuals
Integrated primary care (trained for primary care providers and nurse practitioners) and public health
Care is based on identified health needs and determinants of health
Intervention covers all the states of health-illness continuum
Community participation



Clinical intervention planning and implementation
Evaluation
Reassessment
B.
2. How did COPC shape the health priorities in this subdistrict from what had previously been assumed?

Through the work of COPC , the conducted a survey assessment and determined trends were changing in
the community revealing new patterns of morbidity and mortality. This brought about a realization that
while deaths from noncommunicable disease were increasing particularly in older adults, communicable
diseases were the main cause of ill health, were rising exponentially and needed to become a focus for
intervention.
3. In what ways is the community involved in this project? In what ways could this be strengthened (For you to think
about on your own)?



Findings were communicated to the community used a theater program of which generated a great deal
of audience participation. This also provided the opportunity for community members to provide ideas
for future interventions
All information collected was shared with community members and data entry was completed on site to
be visible to the public.
Directories of resources for health, development, and education were compiled to be used by local
communities
4. Why has COPC, which has its roots in South Africa, struggled to realize its full potential? What needs to develop
further before COPC can have its full impact?

COPC has struggled to reach its full potential due to rising costs of health care, governmental policy, lack of
health sciences professionals training in community orientation. Feasibility is also affected by a lack of interest
and motivation of primary care workforce ,the role of a strong primary care infrastructure availability
of primary care settings, a lack of knowledge about the role of social determinants of health

The COPC in Agincourt has collected enough information and prioritized the greatest health need but have not
yet translated this into direct interventions. While they have directed a few interventions such as the theater
education program, they can improve by direct the interventions to clinical care and services.
I.
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