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Authors: Wendy Huebner , Asif Patel,  Andrea Polk-Stephenson , Howell Sasser  and Erica E. Smith

From the Chair: Ebola—The New Normal
From the Secretary: Leading by Example—The Importance of Risk Communication
Fall 2014 Update in Epidemiology Education
Polio Eradication: Progress and Challenges
One of the Greats: A Tribute to Mervyn Susser

From the Chair: Ebola: The New Normal

The news today reports that a Liberian man who developed symptoms of Ebola fever after flying to Texas has died. Various other “mini-outbreaks” in the U.S. and Europe – as well as the still-growing index event in West Africa – continue to appear on front pages and TV screens around the world. And just this morning, my employer’s Employee Assistance Program sent me an email entitled, “Ebola: What You Need to Know to Protect Yourself.”

I will leave it to my readers to fill in appropriate thoughts about the case-to- coverage ratio, and about what might happen if similar attention were directed toward any of many public health problems that are much larger but which routinely go begging for prevention and treatment dollars, let alone face time on MSNBC AND Fox News. Instead, I will offer a few thoughts on what this and other high-profile communicable disease events mean for how we work and how we think.

Numerators and denominators are largely imaginary numbers. It is perhaps a bit ironic that this year’s APHA Annual Meeting theme is “Healthography” (subtitled, “How where you live affects your health and well-being”). Place nowadays seems to have less to do with the traditional combination of agent, host and environment, than with things like proximity to airports and interstate freeways. Ease – and rapidity – of movement puts a large but poorly defined portion of the population in

the (potential) hot zone. Counting cases and calculating rates becomes a vexed topic, and forecasting is little better than guessing.

Public health becomes a police issue (again). It has been announced again lately that airport security screens in various places would begin to include remote temperature measurement, presumably by infrared sensing, as a means of identifying carriers of communicable diseases. The impulse is understandable, and it is probably too much to expect that available technology not be used when disease may be prevented and perhaps lives saved. Still, the lack of specificity, the lack of professional training and discretion on the part of those doing the screening, and the coercive nature of the whole process seems at odds with the public health ethos. Can anyone imagine doing something similar for HIV, or HPV, or anything else not getting 24/7 coverage? Ask me again when we have remote scans for pre-diabetes or prostate cancer…

Prevention gets lost, and then found again. In the heat of the moment, the public health heroes are all wearing inflatable plastic suits. “What do we do now?” drowns out “What could we have done to prevent this?” When patients are already in the beds, a multi-thousand-dollar treatment sounds a lot more reasonable than it does when public health budgets are being discussed. But all of this passes. When the news cycle moves on, a return to a focus on prevention is the — reassuring — constant. May the present outbreak burn itself out rapidly and become less a parade of plastic suits and more a topic for education.

From the Secretary
Leading by Example: The Importance of Risk Communication

On Sept. 30, 2014, the Centers for Disease Control and Prevention, the Texas Department of State Health Services and the Dallas County Health & Human Services announced the first laboratory-confirmed Ebola case diagnosed in the United States (http://www.cdc.gov/media/releases/2014/s930-ebola-confirmed-case.html). The hours that followed exemplify the 24-hour news cycle in which we currently live. In some cases, media consultants and experts provided clear and accurate commentary on the situation at hand. In others, a variety of factors contributed to misinformation and speculation. In the new age of “viral” stories, sound bytes and social media, an “outbreak” of misinformation can be almost as dangerous as the true outbreak being described.

As epidemiologists, we are often in a unique position during public health emergencies — one that can become particularly relevant in the early hours of any outbreak investigation, when publicly available information may be limited, and fear and speculation can spread quickly. We understand public health and epidemiologic principles, as well as outbreak investigation and contact tracing. We frequently negotiate the delicate balance between agency transparency and patient confidentiality. This is where grassroots communication comes into play. Even in

our own social circles, we can lead by example to promulgate more accurate information and try to quell rumors and speculation.

Although many of us have no direct role in the current case follow-up and contact tracing in Texas, risk communication is key in any emergency situation. Staying informed is crucial, and an excellent source “related to emergency preparedness and response and emerging public health threats” is CDC’s Clinician Outreach and Communication Activity, or COCA) “COCA prepares clinicians to respond to emerging health threats and public health emergencies by communicating relevant, timely information related to disease outbreaks, disasters, terrorism events and other health alerts.” For more information and to subscribe,

visit http://www.bt.cdc.gov/coca/. Not all of us are specialists in risk communication, but CDC also provides some excellent resources on Crisis and Emergency Risk Communication (http://emergency.cdc.gov/cerc/index.asp) and Social Media Tools, Guidelines and Best Practices (http://www.cdc.gov/socialmedia/tools/guidelines/socialmediatoolkit.html).

As CDC DirectornTom Frieden, MD, MPH, stated in the CDC’s September 30 news release, “Ebola can be scary. But there’s all the difference in the world between the U.S. and parts of Africa where Ebola is spreading. The United States has a strong health care system and public health professionals who will make sure this case does not threaten our communities. While it is not impossible that there could be additional cases associated with this patient in the coming weeks, I have no doubt that we will contain this.”

Without clairvoyance we cannot predict the future of Ebola in the United States or the world, but an emphasis on good risk communication strategies can benefit all of us, whether we are talking about Ebola or any other situation.

Cheers,
Erica Smith,
Secretary, Epidemiology Section

Fall 2014 Update in Epidemiology Education

The Epidemiology Education Committee welcomes you to our corner. The Committee’s goal is to support efforts to increase and enhance epidemiology education for key target groups. These groups include the public health workforce, public health policymakers, the media, the general public, and our youth and their teachers. We will report activities and events that address one or more of these groups. Let us know if you have any such news to include in the EE Corner.

Using Smartphone Technologies in Undergraduate Epidemiology Classes

This article is written by Jeffrey Bethel, PhD, assistant professor of epidemiology at Oregon State University, College of Public Health and Human Sciences. As a member of the Epidemiology Education Committee, he is responding to the Committee’s desire to share information about using technology in the epidemiology classroom.

I was looking for a way to better engage the roughly 80 students in my undergraduate introduction to epidemiology course. Having heard of a few student engagement and response systems used by colleagues, I wanted to use one that utilized cell phones since cell phones had been a point of contention in the classroom. If you can’t get students off their phones, use the phones in class! I decided to use Top Hat (https://tophat.com/), which was touted as a way to transform students’ mobile devices into powerful classroom engagement tools. Students took their weekly quizzes on Top Hat rather than in paper form. This eliminated manual grading, saved paper, provided me with instant feedback, allowed students to view their scores in a timely manner, and stored all quizzes online for students to review at their leisure. No passing back quizzes that students may misplace. I also used Top Hat to assess student comprehension during lectures and used the instant feedback to review certain concepts in greater detail. Students also completed in-class exercises in groups and submitted their responses using Top Hat. These exercises were also available online for students to review in preparation for exams. After some difficulty getting students registered for Top Hat, the class quickly became adept at using the software that was available on smartphones, tablets, and laptops. Connectivity was rarely an issue. Student feedback was generally positive — they liked having access to quizzes and in-class exercises and really liked that it saved a large amount of paper. The consistent criticism was that they felt the added cost, while quite modest ($20), was unfair given they had already paid tuition and fees. Overall, my first experience using student engagement and response systems was positive. With a few tweaks, I believe I can more effectively use Top Hat to improve student learning in the future. Looking ahead, I am hoping to incorporate additional technology that could be used for data collection exercises in the epidemiology classroom to simulate real world experience in administering surveys. Contact: Jeff.Bethel@oregonstate.edu

High School Standards For Epidemiology — Update on Tennessee’s program

In the Spring 2013 and Summer 2014 newsletters, we reported that there were three states that have adopted high school standards focused on public health and epidemiology. Here is more about what is happening in Tennessee, written by Sheila Carlton, RN, MSN, who is at the Tennessee Department of Education’s Division of Career and Technical Education, and is working at the forefront of developing these standards as the Health Science, Law, Public Safety, Correction and Security, Government and Public Administration Career Cluster Consultant.

The Tennessee Department of Education’s Division of Career and Technical Education is excited to provide health science students and teachers the opportunity to expand the knowledge of public health across our state’s high schools. Our research found Americans’ overall health is on the decline in all areas, from very rural to dense metropolitan communities. To ensure that we were preparing our

students to meet the needs in this field, the Public Health program of study, or POS, was developed.

Within this POS, students will examine why and how the increase in chronic conditions impact and influence not only individuals, but also the health of their communities and the public. Course content includes: knowledge and skills to help communities prepare for and respond to disaster; public health problems and strategies for alleviating them; tools to evaluate the rise in mental health diseases and disorders; and the examination of how the health of the United States is related to larger global health issues. Upon completion of this POS, students will be prepared for advanced study at the postsecondary level in the areas of epidemiology, health policy and similar public health-related fields.

Currently, four schools will be offering the public health POS in the first year it is available. Three schools are located in small rural communities and one in a metropolitan area. “We are seeing unhealthily individuals in our community,” says one health science teacher, “If our students can become disease detectives in the Epidemiology course, possibly they can change their own community’s health.” The department is currently developing a resource toolkit to support teachers of these new courses. To share resources that will be valuable for these teachers, or learn more about the courses, please

visit http://www.state.tn.us/education/cte/HealthScience.shtml or email Sheila Carlton, Tennessee Career Cluster Consultant for Health Science Education,
at Sheila.Carlton@tn.gov.

Looking for epidemiology teaching materials for the Undergraduate and Graduate level? Here are a few URLs that link to epidemiology education resources suitable for post-secondary students. For a more extensive list of links to this and other target student groups, go to http://www.epiedmovement.org and click on “Links for Teaching Material.”

  • Deadly Outbreaks — How medical detectives save lives threatened by killer pandemics, exotic viruses and drug-resistant parasites — A book by Alexandra M Levitt in conjunction with the Council of State and Territorial Epidemiologists. This book project is “intended to provide the next generation of young people attracted to the fields of math and science with an exciting and worthwhile career option…”
  • North Carolina Center for Public Health Preparedness — University of North Carolina
  • Tephinet — A professional alliance of field epidemiology training programs, or FETP, in 32 countries, Centers for Disease Control and Prevention
  • Epidemiology Case Studies, Epidemiology Intelligence Sevice (EIS) — Centers for Disease Control and Prevention
  • Understanding the Fundamentals of Epidemiology — an Evolving Text, Victor J. Schoenbach, Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill (versión en

español: Comprendiendo los Fundamentos de la Epidemiología — un

Texto en Desarrollo)
• Epiville — Developed by the Mailman School of Public Health, Columbia

University

Polio Eradication: Progress and Challenges

As a consultant to the Centers for Disease Control and Prevention Center for Global Health, Global Immunization Division, I was privileged to be a part of a worldwide initiative to eradicate polio. I wanted to share some of what I learned so we can better understand polio epidemiology, prevention and the efforts to stop transmission of this cruel and preventable disease.

Polio is a viral infection that is usually recognized by the acute onset of flaccid paralysis caused by poliovirus types 1, 2 and 3.1 Less than 1 percent of cases result in flaccid paralysis, and the vast majority of cases go undetected.1 Poliovirus can be isolated from stool, cerebrospinal fluid, or CSF, and oropharyngeal samples, and from environmental (sewage) sampling. Transmission is generally through the fecal-oral route.1

Polio transmission has never been interrupted in Afghanistan, Nigeria and Pakistan. In 2013 and 2014, outbreaks occurred in the Horn of Africa, Cameroon, Equatorial Guinea, Syria and Iraq — all previously polio-free countries.2

Poliovirus can invade the brain and spinal cord of infected individuals and can result in permanent paralysis and, rarely, death. There is no cure, but safe and effective vaccines are available. Therefore, the strategy to eradicate polio is based on preventing infection by immunizing every child through routine immunization, supplemental immunization activities and/or “mop-up” vaccination campaigns in geographically-restricted areas following the identification of a case. Another cornerstone of the eradication effort is timely and sensitive clinical surveillance so that every case can be detected.2

There has been great progress since 1988 when the Global Polio Eradication Initiative was launched, and the number of annual polio cases has decreased by >99 percent. The World Health Organization, Rotary International, CDC, and the United Nations International Children’s Emergency Fund are spearheading GPEI partners.3 The Bill & Melinda Gates Foundation is also a critical partner in polio eradication activities. CDC activated its Emergency Operations Center in response to the 2012 World Health Assembly declaration that the completion of polio eradication was a programmatic emergency for public health.

In the United States, the CDC recommends the following:
The poliovirus vaccine used in the U.S. is inactivated poliovirus vaccine, or IPV. IPV is injected into the leg or arm and often given when other vaccines are administered.

It is routinely administered to children who get four doses at 2 months, 4 months, 6- 18 months, and a booster dose at 4-6 years.4

The polio program has made extraordinary progress, “The number of worldwide polio cases has fallen from an estimated 350,000 in 1988 to 407 in 2013 — a decline of more than 99 percent in reported cases.”5 Additionally, four regions of the world are certified polio free — the Americas, Europe, Southeast Asia and the Western Pacific. Within the remaining regions, only three polio-endemic countries (countries that have never interrupted the transmission of wild poliovirus) remain — Afghanistan, Nigeria and Pakistan.

However, there are challenges to the program in a number of countries. Difficulties persist in finding chronically missed children, obtaining parental consent to vaccinate children, and accessing children in areas of insecurity.

GPEI partners and other organizations continue to deploy staff, vaccine and other resources to countries around the world. As travel and trade have been globalized, we must be vigilant at home and abroad.

Further information on the Polio Eradication Initiative can be found at http://www.polioeradication.org/Home.aspx.

References:
1. Heyman, David L, Ed, Control of Communicable Diseases Manual, 19th ed.

APHA Press, 2008 p 484.
2. http://www.cdc.gov/polio/
3. http://www.polioeradication.org/AboutUs.aspx
4. http://www.cdc.gov/vaccines/vpd-vac/polio/dis-faqs.htm 5. http://www.cdc.gov/polio/progress/index.htm

One of the Greats: A Tribute to Mervyn Susser

One of the important chapters of epidemiology ended with the passing of Dr. Mervyn Susser on August 14, 2014. Dr. Susser’s work influenced a whole generation of epidemiologists and will no doubt inspire many generations in the future.

Dr. Susser’s contributions to public health began in the 1950s in South Africa, where he was a supporter of Nelson Mandela during the anti-Apartheid movement. Dr. Susser had many publications with his wife, Dr. Zena Stein; both were vocal opponents of Apartheid, and in 1955 they co-published “Medical Care in a South African Township,” which focused on community-oriented primary care in South Africa and was published in the Lancet.

Because of political pressure and his outspoken opposition to Apartheid, Dr. Susser moved from South Africa to England and then to the United States, where he joined Columbia University as the chair of the division of epidemiology in 1966. Dr. Susser’s most influential work, “Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology,” was published in 1973 and focused on the emerging discipline-wide paradigm shift from infectious disease to chronic disease epidemiology. Later contributions of Dr. Susser and Dr. Stein during the 1980s focused on the then newly emerging disease HIV/AIDS and included the identification of women, not just men who have sex with men, as at-risk for HIV/AIDS. Dr. Susser was also the editor of the American Journal of Public Health between 1992 and 1998. Recognizing his numerous contributions to epidemiology, the APHA Epidemiology Section bestowed him with the John Snow Award. He will be long remembered for his many contributions to the fields of epidemiology and public health.

To read the entire New York Times obituary, please visit: http://www.nytimes.com/2014/08/27/us/mervyn-susser-92-dies-studied-illness- and-society.html?_r=0

 

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I have a huge respect for dedicated and hardworking researchers; they serve for community, humanity and make life easier . After a long time, I visited Columbia University and attended important lecture by Dr.Nash. Actually it was the same topic what I attended two months ago. I wondered how much time both researchers Dr.Nash and Dr.Irvine have invested in this research which has immense potential to influence policies centering around HIV. I again used an opportunity to ask question. Since viral load is the clinical outcome, my follow up question to the presentation had logical substance.  I haven’t read their recent publication, but will go through it next week. I am keeping my curiosity intact to read specially methods, sample size, and type of study, setting, strength and limitations of this study.

Research study the past, lives in present and predict the future when they get all information about past and present. Applying predictor models they keep past and present in proper places, and building on both , they postulates theory. To prove the theory again, they apply their all skills. Researchers gives us a wisp of possibility, or wisp of uncertainty, it also gives us a hint of potential danger or potential calamity. Ongoing research in medicine and health definitely brought mortality, morbidity, and disability rates down significantly. In old scripture, there is mentioning of plague, which used to annihilate big towns and cities in very short duration. Thanks to scientific research, there is no any major outbreak since world war second where death numbers could have piled up in hundred thousands.

We CUNY SPH stakeholders fortunately have umbrella of wonderful research. Here I would like to give examples of quite of few researchers from CUNY School of Public Health. Dr.Freudenberg has taken CUNY healthy initiative and now we have smoking policy implemented in all CUNY campuses. Dr.Nash research on HIV is giving new hope to people in Sub-Saharan Africa, especially Rwanda. Dr.Jessie Daniel has been using technology to the hilt for her innovative research. Dr.Johnson and Dr.Maroko are applying GIS KNOWDEGE to improve the environment. Dr.Thorpe is also contributing to the positive aspect of health by doing research on pests and insects, which are triggering factor for asthma. Dr.Molina and Dr.Borrell are working on reducing disparity and making health equitable to all. A month ago I received survey about toys in MacDonald, and now I heard that McDonald has removed toys from its facilities as toys can cause choking among children .Dr.Freudenbeurg’s and Dr.Poppendick’s   crusade against fast food is really commendable. Dr.Platkin is adding the layer of his judicial knowledge make it happen. Dr.Huynh is investing her time in maternal/child health and Dr.Tsui, who happens to be my inspiration in light of research, is facilitator of qualitative research and program designing.

I like asking question and stimulating discussion. Question usually comes out of curiosity and desire, it also comes out of passion for gaining knowledge and desire to use opportunity to the hilt. So far I might have asked more than thousands questions in the United States. Honestly, it has really helped me to  work on communication skills. I think it is my hobby, so to further nourish it; I have started working in the Department of Health where I deal with interviews.

Death of Liberian patient in the Texas hospital, and the infection of health care worker have opened holes in fight against Ebola. It conveys defeat at two fronts- first,  we could not eliminate Ebola from the main source, and 2) Ebola successfully traveled all the way to the land of the United States. It is off course a great matter of concern, and it is logical  why people of country should get panic. Keeping these entire things in mind, Center for Diseases Control and Prevention (CDC) has to give the live update on Monday morning. Since I received email on updates, I followed it online.

Now I am crippled with many questions: how nurse got infected with Ebola, did she break any protocol? How our hospitals are prepared to tackle any cases? How can we stop Ebola at the main source? Does travel ban on people coming from Ebola stricken countries will work? How our front-line healthcare providers, especially doctors and nurses are enough trained to treat patients with Ebola? Since Ebola’s case fatality rate is very high, how potent enough we are to avoid mortality? how successfully we will be able to break the transmission? How much funding is assured from federal government and how fast it will be disbursed to healthcare emergencies?

Is travel ban feasible, more importantly is it worth? Recent survey showed that 58 percent of Americans are in favor of travel ban on three Ebola stricken African nations, and few of Democrats and Republicans support that same echo.  However, Dr.Freiden, CDC chief, was little reluctant to buy travel ban theory which is quite both fathomable and logical in light of transnational interest.

The main source of infection is Western African countries including Liberia, Sierra Leone and Guniea. Why not stopping the Ebola at the source? Why not stopping patient harboring infection or potentially infected or the person at risk before boarding the plain? Why not working hard to stop Ebola menace in Africa only, once source is eliminated, there wont be any further infection. However, it is time taking process. According to World Health Organization, it is road-map of between six to nine months. Does it mean we should keep ourselves at risk till Ebola get eradiated from Africa? And if we want to impose travel ban, what about our citizens working in those countries and would like to return the USA is also point of concern. Travel ban won’t work, because the person who want to visit USA may chose other routes too reach Untied States. While incubation period of Ebola is two to three weeks, patient can transmit to other person (if comes in contact with fluid) during that period. If we want to impose ban, then effective international collaboration will be needed, which though seem apparently possible, but not practically possible. And again, how many countries we are going to impose travel ban, are we ready to include Nigeria? 150 detectives are already working in Western Africa on the behalf of CDC.

The engagement of non-profit organization like doctors without borders in training physicians and nurses makes greater sense.There is need to break the transmission chain. We can divide population at risk into two categories: 1) finding out the people with whom index patient had contact before getting hospitalized, 2) finding out the people index patient came in contact in hospital.Starting isolated clinic for suspected patients in every hospital ,or in emergency room. JFK has started screening patients even  from last Thursday.

 

When I contacted one of my friends in Nebraska University and when I disclosed to her that we have new dean for student affairs from her school, she told me one word about Dr.Ashish Joshi, ‘implementer. His brief speech at our alumni meeting (1st October) was flowing of ideas and I found him proactive, charismatic, energetic, innovative, encouraging, open-minded, warm, responsible, outstanding, ambitious, progressive, logical, diligent, enterprising, prideful and inspiring. He is highly accomplished and is also good at oral, written and visual communication.

Our Alumni meeting was well attended by 15 members, mostly represented by board members.  I express my thanks to president Dr.Welch, board members and other members. I also express my gratitude to Attiqa for arranging things well before time. This meeting, in a sense, was interplay of ideas!

Dr.Joshi has numerous publications to his name; and he has been mentoring many students. Also, by giving his own example to motivate us, he mentioned how he had published eleven papers during his maters degree, which is itself a staggering number. To underline his helping nature and his fund generating capacity through grants, he told us that he funded three PhD students and twelve master students. One of his student, just 9, had even published paper on music. To improve health outcomes at global level, Dr.Joshi has been part of many innovative interventions and has been recipients of many grant (recent R21). He has been blending clinical experience with technology.

He updated us about his initiatives for our school and he illustrated how things have been changing. Important areas of concerns he has noted down in our CUNY SPH schools are 1) There is no support from career services, which is absolutely right.. 2) Most of students have to commute a long distance to reach school. 3) There is lack of communication among alumni.

Since he has taken an initiative to start various concentration (stream) clubs (total ten clubs are on the card) and   few of those clubs  have already started functioning. To make things easier for access, he has started even virtual clubs. He also shared his own innovative idea of  HealthATM smart card. It was one of the first preventive health care initiatives. He is also considering to start dietary helpline. Quick results are already on plate. Last week I attended lecture by Dr.Johnson  on walkability and neighborhood at Hunter College and honestly, I was astonished by students followup question to Dr.Johnson, which reflects their interest in innovative technology.

One of major issues Dr.Joshi threw light on included mentoring program for students. One of Alumni members shared her experience how one of the students asked her about bio-statistics while doing internship with Epidemiology. I think offering mentors-ship is also an art and it also depends how interested you are to provide mentor-ship. Its not mandatory either! Besides, Dr.Joshi also insisted on electronic portfolio of students/alumni, that is interesting and potentially helpful idea. He is contemplating to hold career job fairs for students and alumni.

“Obstruction is an opportunity, innovation is struggle.” Well said during talk. When I thought of starting nutrition program, I met few challenges (May 2012). I then contacted MPH advisory board member, Stefania Patinella, who guided me later (October 2013), after more than one year.

We are nine hundred alumni, so big number, can’t we create potentially relevant platform? Can’t we make our voice louder through numbers?  We all need to coalesce into one unit. Yes, we are embarked on ambitious path under the inspiring leadership of Dr.Joshi, Dr.Welch and Dr.Lucretia Jones! In my words, Dr.Joshi is innovative officer for CUNY SPH.

 

 

 

It was timely and overdue presentation, ” The imperative of Immediate Action ,Here and Abroad ” by Dr.Jay Verma and Dr. Widney Brown on Ebola. Dr.Jay Verma  is the Deputy Commissioner for Disease Control at the New York City Department of Health and Mental Hygiene (NYCDOHMH). Dr. Verma’s division is one of the largest division in the department, employing more than 1100 employees and operating 17 clinical facilities. He attended Harvard, and the University of california.From 2003-2011, he worked in infectious disease control in Bangkok and Beijing. Windney Brown is Director of Programs for Physicians for Human Right (PHR). She is a JD from New York University School of Law where she was Root-Tilden Scholar. I feel pride in meeting Dr.Farley while I was interning at DOH in 2012. Trained as pediatrician, Dr.Farley is also co-author of prescription for a Healthy Nation.

Considering the gravity of the problem in Western Africa; and the recent death of Western African, Mr.Duncan, in the Texas; realizing the global fabric of New York City; understanding the population dynamic of New York; fathoming its diversity and underlining two major airports in City, this presentation holds meaningful spot in policy issues. How does Ebola infect, how does it transmit, what is the source of infection, what precautions should be taken, what treatment is available and more importantly what is the response of NYCDOH so far. Most of these queries were addressed well by Dr.Verma and Dr.Brown. During panel discussion Dr.Thomas Farley asked few interesting and engaging questions which really stimulated audiences to ask curious questions about Ebola. He updated us about the ongoing airport services to examine people coming from West Africa. Dr.Brown stressed that quarantine is not a human right violation, as speculated by few organizations.

I picked up an opportunity to ask  about the United States resolve to eradicate Ebola as it successfully did for polio.  President Roosevelt personally took initiative since he was himself inflicted with polio. He provided all way help to Dr.Salk to advance research on developing vaccine. Since my sister has polio , I can feel the importance of vaccine for the following generation. Responding to my question, Dr.Verma added that the United States helped and took efforts on prioritized basis such as HIV, malaria and cancer. Thanks to international generosity, fight against many infectious challenges are ongoing at global level.

Dr.Verma termed anxiety among people about Ebola as epidemic of hysteria. At the end of session I asked him about the New York city’s response to Ebola so far. He was very polite and detailed in his reply where he told me about the programs already started by DOH with involvement of communities. Adding further, there are even mental health programs in place for relatives of people  stuck in affected areas in Africa. I am looking forward to meet Dr.Verma again!

Though we have left infectious disease era long time back, global dynamic population, increased number of travelers, increased interdependence among nations and global trade growth put us at a risk to global infectious diseases. Whether it is SARS, or flu, whether it is Ebola or cholera; we need to prepare for any health emergency and outbreak. We are equal stakeholders for those health problems. Taking all pieces together, it can be concluded that United States , being superpower in both economy and resources, being global health leader, have an opportunity-cum- responsibility to invest in infectious diseases related research. Since there have been collaboration between CDC and World Health Organization (WHO) on many global health projects, it would be interesting to see how both work on Ebola together.

Thanks DR.Lawrence Moss!

 

 

 

 

 

 

 

I am not sure whether I will attend next year National Comprehensive Cancer Network (NCCN) conference, but I went through its few of topics, potentially part of conference. agenda.  While revising glial cell tumor yesterday,  I am left  with many question : Where is curative intervention for malignant glial cell tumors? Combination of surgery, chemotherapy and radiation therapy improves the survivial, but unfortunately nor more than two years. Even worse, Glioblastoma multiforme, one of the types of astrocytoma, has prognosis of less than one year. What is the role of public health professionals in  glial cell tumors, what is the role of oncologists/oncosurgeons,  what policies can bring down the number of incidence of such tumors? Annually 10,000 cases of malignant glial cells tumors are reported in the United States annually. Half of them lose their battle in one year, and only 25% cross two years.  Former senator, and champion of equal healthcare, Ted Kennedy was also the victim of this dreadful cancer.

Neurons are the structural and functional unit of nervous system; glial cells are the supporting cells for neurons. Glial cells are present in both central and peripheral nervous system. Astrocytes, microglia, olegodendrocytes and ependymal cell are the types og glial cells [resent in the central nervous system, whereas shchwan cell and stellate cells are in the peripheral nervous system.

Estimating the burden of disease is also component of epidemiology. Survival rates for astrocytomas may vary according to geographic region. The presence of astrocytoma in genetically conditions like tuberous sclerosis supports the role of genes in the etiology of glial cell tumors. Children with ALL treated with radiation are at higher risk for developing gliomas. Several genetic mutations has been suspected in the etiology of gliomas. Tumor p53 gene mutation, and EGFR mutation is believed to play role in the fast division of cancer cells.

Having bad prognosis, second and advance-staged astrocytoma have higher mortality rates. Astrocytoma in pediatric age group is mostly benign, but adult astrocytoma is usually malignant. Primary cell lymphoma is one of the most common tumors in HIV patients, especially when CD4 count is less than 50. Oligodendriglioma is not common. Ependymoma is the cause of hydrocephalous. Shwannoma is mostly benign tumor, and it usually involve eith cranial nerve. Surgical removal is advised. Neurofibromatosis is seen to have shwannoma.

Astrocytoma was shown in John Travolta’s movie, in which Travolta develops astrocytoma. The movie rightly shows the fatality of the tumor, however, over intelligence and extra power in the character because of the tumor is not digestible.

There is need of more investment in genetic centric intervention research when it comes to glial cell tumors. Temazolide has improved the survival rate marginally, but I hope extensive research in that direction would come up with substantial cure. National Cancer Institute (NCI) has a division of cancer control and population sciences which support various grants for epigenetics related studies. For example, Dr.Wiencke of university of California received the grant to study the biomarkers of survival in glioma epidemiology.

 

CUNY SPH has recently started the EPI seminar series, and a part of it, Dr.Denis Nash and Dr. Mary Irvin presented their research work. HIV is community problem, major public health issue, clinical challenge for physicians and  broader research field for epidemiologists. Dr.Nash travelled us through his epidemiology slides, (slide showed the map of HIV global prevalence)  , HIV cases in New York city in graphical presentation (good example of visualization), and many useful references. Few cohort studies, which showed hoe several factors determined the outcome of interest: viral load suppression. Dr.Nash also highlighted the engagement of clients with primary care.On this collaboration between department of health and public health school, Dr.Aymen El-mohandes, once reportedly said “This is an example of the collaborative work that our faculty are engaged in with the practice community. Implementation science that expands the relevance of evidence-based to practice-based success is aligned with the School of Public Health’s mandate.” (*)

Taking a leaf from his presentation, I studied Dr.Nash research work for all night, went through the most of his (abstracts).  I also revised cox regression analysis with SAS and SPSS. In between I discussed viral load and other parameters with my classmate from medical school(Internal medicine resident at Baltimore medical center). To make my interest flowing and more engaging, I went through the setting of his studies, type of study, analysis, predictor and variable in studies, and conclusion part. Most of his studies have setting of Sub-Saharan Africa, and specially Rwanda, and New York City. When it comes to the analysis, many of studies has used cox-regression model and adjusted odd ratios. I could locate one study using survival analysis. Finding out the reason behind the non-compliance to treatment was goal of few studies.

Dr. Mary Irvine described Ryan White Care Coordination program in far systematic way; it was well divided into components and tracks.).  I was also interested to know excel adherence calculator.Dr.Nahs and Dr.Irvine, both are joint investigator for this project.It even reminded me of the program planning course  Professor Tsui instructed us, which I tried to correlate with the program discussed by Dr.Irvine.

I asked the question on second slide of Dr.Nash’s presentation. Since it shows the prevalence of HIV and his 7th slides talk about HIV1, so I was curious to know the epidemiology of HIV1 and HIV2, and since the outcome of interest was viral load suppression, I was interested in knowing the federal guidelines for viral load measurement in HIV2 patients. Other student asked the question on difference between hospital based and community based setting and their advantages/disadvantages. Dr.Thorpe asked about the alternate source of data other than e-share. Responding to Dr.Thorpe. Dr.Irvine spoke on HOUSA data.

In nutshell, this presentation was full of knowledge and information, and I enjoyed it to the hilt. Dr.Nash is wonderful researcher and we CUNYites are fortunate to have him. Also, one topic crossed my mind when Dr.Nash was presenting his findings, and that inspired me to write literature review on something related to viral load. I hope I will get to see Dr.Nash again so that I can learn more from him and his enriched experienced would nourish my passion for epidemiology, research, and global work.

Thanks very much for cheese and wine, Professor Thorpe J

Epidemiology of esophageal cancer has been undergoing significant change over the past 30 years; it wont be extra-aggregate to term it one of the biggest epidemiological shifts in the cancer domain in the Unites States. Squamous cell carcinoma used to be the most common histological type of  esophageal cancer, but it was replaced by adeno-carcinoma. Esophageal adenocarcinoma is one of the most lethal cancers in the US with a five-year survival of less than 20%. The relative rarity and high lethality of esophageal adenocarcinoma make this a challenging yet crucial malignancy to study. It highlights the importance of prevention when compared to the effect and cost of cure. The risk of esophageal cancer is greatest among those with the lowest socioeconomic status (SES). In case-control studies, income, education and occupation are assessed to measure the SES. Gastroesophageal reflux is proved to be the culprit of adenocarcinoma. Do you have heartburn? How long and how often determines the magnitude of the risk of developing esophageal adenocarcinoma in individuals.

Despite investment of many years and lot of resources including money, we are not succeed to say certainly which patients are going to get what cancer. But recent study by leading investigators at National Cancer Institute, Dr. Michael Cook , is somewhat right step in that direction, which found monotonic relationship between the duration of the symptom of heartburn and the magnitude of the risk of getting adenocarcinoma of esophagus.

The international Barrett’s and Esophageal Adenocarcinoma Consortium (BEACON) was formed in 2005. The primary aim of BEACON is to provide an open scientific forum for epidemiological research into the etiology and prevention of both Barrett’s esophagus and esophageal adenocarcinoma by facilitating the sharing of data across population-based studies. Although previous studies have provided evidence for the positive association between GERD and esophageal adenocarcinoma risk, it was unknown to what extent these associations vary by sex, BMI, and cigarette smoking, or whether duration and frequency of GERD symptoms confer risk independent of each other. In this study of BEACON data, Cook et al not only found strong associations between GERD and esophageal adenocarcinoma, but also found that the relationship between GERD duration and esophageal adenocarcinoma was monotonic: Odds ratios (ORs) were 2.80, 3.85, and 6.24 for symptom durations of <10 years, 10 to <20 years, and ≥20 years, each compared with no GERD symptoms. Researchers also observed that both frequency and duration of GERD were independently associated with higher risk; individuals who had both high frequency (≥weekly) and long duration (≥20 years) were at a much higher risk of developing esophageal adenocarcinoma (OR=9.27, 95% CI: 5.02, 17.10), compared to those without GERD. Results were not notably altered when stratified by sex, BMI or cigarette smoking.Limitations of this analysis include the moderate-to-high heterogeneity associated with a majority of summary estimates presented–cautious interpretation as to the magnitude of these estimates is therefore warranted.

(I interviewed Dr. Michael Cook , scientist at National Cancer Institute, on his recent study: Gastroesophageal Reflux in Relation to Adenocarcinomas of the Esophagus: A Pooled Analysis from the Barrett’s and Esophageal Adenocarcinoma Consortium (BEACON).)

Smoking has various dimensions: cultural, political, religious, geographical, racial, ethnic, health, corporate and gender. To counter smoking,  public health also had to use multi-dimensional approach. In the February edition of 2006, American Journal of Public Health (AJPH ) discuss the status and perception of smoking among physicians in the earliest twentieth century. Tobacco companies exclusively used doctors to market their brands as pharmaceuticals companies do today to sell its drugs. For example, to advertise camel brand cigarette, Reynolds Company in 1940s,used catchy quotation, “More doctors smoke Camels than any other cigarette.” Advertisements of various cigarettes brands kept medial journals and organizations solvent. It finally came to rest when American  Medical Association (AMA) publicly disapproved the Kent Ad campaign. . In short, smoking cigarette was fashion and was believed  healthy those days. Manufacturer Allen and Ginter were even offered prize for innovative work of building machine to fasten the process of producing cigarettes at higher rates. First world war also helped in popularizing smoking among soldiers. They believed that smoking relieved them from stress. And they even considered tobacco as important as guns in war.

Those days, stomach cancer was the leading cause of cancer deaths. Lung cancer was rapidly taking the second position because of increasering reports of new lung cancer cases. Fritz Lickint,German physician first published the possible association between smoking and lung cancer. Few years later, Muller reported the finding of case control study, which underlined smoking as the cause of lung cancer. In the United States, Hammond and Wynder provided evidence for the causation link.

More than 50 carcinogens have been reported in cigarette ingredients as potential carcinogens. Smoking causes elastin damage and cause peri-acinar emphysema, it also damages cilia epithelium. It hastens multiple sclerosis and other white matter degeneration disorders. The association between lung cancer anf smoking is well established. However, not every lung cancer is related to smoking, for example bronchoalveolar cancer and carcinoid are not associated with smoking. Smoking is strong risk factor for cardiovascular diseases. It is also concluded from the analysis that if with zero smolers in the United States, one in three cancers are completely avoidable. Smoking  effect is highly perceived  in head neck cancer studies; it is routine independent variable for many multivariate model. Smoking also has effect on the pregnant women and their babies. There are more cases of still births, preterm births and ectopic pregnancy in pregnant women who are smokers. Risk of developing diabetes is high in smokers compared to non-smokers. Smoking even decreaes the productivity at work place, and increase utilization of health care services, resulting in increase health care cost.

Center for disease control and prevention (CDC) estimates that 42 million adult Americans are smokers, which stands at 18% (declined from 20% to 18% from 2005 to 2012) of  adult population of country and prevalence of smoking is more in men than women. Adding further, people who are below poverty lines are more likely to smoke (27% vs 18%). Applying GIS knowledge, Midwest of United States has higher prevalence of 26% while west has far less prevalence of 14%. Prevalence of smoking in Harlem is 22%, which is more than national average of 18% and far more than northeast region 16.5%. 20% of children in Bronx have asthma, and smoking prevalence in the area is the key reason. Globally,Russia has one of the highest prevalence of smoking, around 40% population of Russia smokes. Cigarettes shortage triggered riots in Russia some twenty years ago.It is 29% in Europe. Indonesia and East Timor has more than two third men indulge in smoking, which elucidates the dangerous trend in these countries. In developing countries, smoking is more common in men than women. But for few years, percentage of new smokers among women has been increasing.

I lived in more than 20 neighborhoods in New York, and generally I observe smoking pattern on the street or open space. So in my observation, I found that there could be high prevalence of smoking in the Flushing area. Further supporting my  observation, I am also adding my experience of living in the Flushing neighborhood. Wonderful place for food , great diversity  and good nightlife!  I was sharing apartment with Chinese friends . I don’t know why that house didn’t have the smoke detector in place. I became public health officer for our apartment.  My African friend also moved from DC to stay in our house. It was African, Chinese and Indian staying under same roof. We had always-friendly altercation on smoking issue. My observation was apparently right; except for Native Americans (ritual value for smoking), Chinese American has the highest prevalence rate of smoking than all other ethnicities.

Native Americans have used tobacco for religious/ceremonial reasons. Judaism and other religions prohibited smoking once its harmful effects were established. For example, Rabbi Kagan prohibited smoking on the basis of health effects. Zorastrism prohibit smoking but with different rationale. It actually termed it abuse of fire. Sikhism is the religion, which clearly denounced smoking on the basis of Gurus teaching.

Few examples of the past witness the  policy of smoking ban, for instance,  Roman catholic banned smoking in mexican church, but I didn’t get any evidence that it was because of any health concern. Policy in United States has taken a long miles journey to reach the situation where we are comfortably placed. New York City reflects successful story in the framework of public health to counter smoking. Ex-mayors  Bloomberg’s work was exemplary, and perhaps why many people termed him public health mayor. It wasn’t easy walk. It wasn’t cakewalk. Corporate interests were fought first time in the history for the cause of public health. Corporate were the interest group and pressure group for every government, but public health advocacy made biggest impact. It is the biggest victory when we think in terms of health policy.  Now even CUNY has anti-smoking polic in place. Restaurants and bars do not allow smoking now.  Policy included increasing prices of cigarettes, researched found that with every 10 cent increases, smoking reduced by 2 to 5 percent. Banning at public places, and issuing harsh fine also work. New Yorks clean air indoor act has resulted in positive changes. Eight percent of population favored the law where one their to one half of adult smokers. As a result of strong policy in place, significant drop was noted in nicotine by-products in the air at restaurants and bars. New York city extended this ban to Beeches and parks.As a result of policy, smoking rates in the city has come dramatilly down.

 While  visiting Facebook profiles of African American friends,  displeasure (anger) over the recent incident in the state of Missouri is quite palpable. After pondering over this issue in light of public health, I think economic disparity is the root cause;  economic gap is the root cause; and even when if we think of stereotyping, it is also somewhat related with economic differences. There might be many angles involved, but solution lies in reducing this disparities. And coupling it with closing  educational gap!

According to the US census, the poverty rate among African American has increased from 25% to 28% in last ten years between 2005 and 2014. Single mother with children is the most suffered group in the framework of poverty. Statistics reveal shocking layer of the truth when poverty rates among single mothers with children is compared to married couple black families. (its 47% vs 8%). There is need to find out the reason behind this sordid condition of single mothers.  There are 43 million American living under poverty line, of which almost 10 million are African Americans, which means 25% of poor Americans are represented by African Americans. Doesn’t this statistics tell the crux of story? However, everything is not like discouraging, rates have dramatically come down from 1960 statistics.

According to US Bureau of Justice Statistics, nearly 40 percent prison population is non-hispanic blacks, if we imagine its implications such as what happen to their families, who take care of them, what happen to their children, are they more prone to fall into crime like their father (the crime for he was arrested) or sibling committed? Do we have such program in place to observe (just observation) the living condition of relatives or dependent of the person who is in jail? 40% of black population of jails is there for drug and robbery related crimes compared to 30% of others.

It’s a complex issue, it can’t be sorted out overnight, however, sincere and honest initiatives by government and active participation from rich educated members of the community can definitely help in tailoring required program and its effective implementation. Such program, if in place and effectively executed, have potential to produce desirable outcome and long sustaining impact.

It is not that government has closed its eyes ( based on the statistics). Many assistance programs are running well, for example.39% of African Americans are on Medicaid, 25 percent of them are recipients of food stamps, 13% get cash assistance and 11 percent get housing help. Deeper insight into Medicaid reveals that major chunk of Medicaid beneficiaries are children.

In the context of health, African Americans are not only more prone to get disease; they are more likely to die from it. I attended one lecture by family medicine practitioner (also health activist) at Hunter college auditorium, who told surprising fact that African Americans are least likely to obtain retirement social security benefits even though they contribute during their working years. Why? Life expectancy of black is 73, which is five years less than white counterparts. There are few more disturbing stat: almost 80% of black women above 20 are overweight and 40 percent of black men above 20 are living with hypertension.

(Special note: I apologize if there is any statistics or sentence, which is wrongly placed, or convey message that, in case, if hurt someone. This is my sincere attempt to present reality in the context of public health)

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