EPID 600 - Introduction to Public Health Practice - Summer 2017

Communicable Diseases of Public Health Importance
CMG Buttery, Jane L. Moore (VDH).


This presentation covers three models of infectious disease that continue as public health problems, despite advances in epidemiology and microbiology. One of these diseases, Tuberculosis, has been present (seen through anthropological studies) for millennia while HIV infection has only been recognized for the last 30 years.   Look at the UNAIDS Page and its links (particularly the Goals link). Compare the value of knowing that a person is infected with either HIV or TB. What is the expectation of someone with TB infection spreading the disease compared to someone with HIV infection?

deathrates from CD

The discussion on Tuberculosis identifies the populations at risk and the problems of dealing with a well known chronic disease, studied for many years, but  still a significant problem mainly due to resistance developing towards all available antibiotics.

HIV identified only since 1982, provides a model for the positive and negative activities in developing public policies to control an infectious disease, particularly a sexually transmitted infection. Look at these articles from the May 9, 2008 issue of Science relating to HIV vaccine on prevention and vaccine issues You may want to see if you can find new evidence of vaccine development for HIV. Also a very recent editorial from the NEJM reviewing the most recent prevention guidelines (Pages 12-13, 22-34. Box E on p47)

For Immunization we discuss problems with the use of technology to prevent, rather than control, long standing communicable diseases, particularly for infants and children, but also in adults..

Look at the home pages of the Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention and click on each of the topics linked at the bottom of the page to see the depth of information available to you.  Be prepared to discuss how the issues presented by the lecturers might impact on newly emerging diseases. Be prepared to enumerate recently discovered infectious diseases. Look at this video about battling smallpox and Polio by Dr. Larry Brilliant.
As for all sections of the course always check out the VDH web site, In this case the Disease Prevention pages. See this report from Trust for America's Health which is one of a series of state by state evaluations of performance in areas of prevention,


Jane L. Moore, RN, MHSA, Virginia Department of Health

Review the slide show presentation on  Tuberculosis: Slides. Scan this discussion of a recent TB outbreak in New York compared to one in London, UK. Why do you think I selected this topic? Consider why TB persists today with all our antibiotics.  Take a look at the Global Issues defined by the WHO (look at some of the publications on the right side of the screen) . Those of you from outside the U.S. may find the link on this page (4th section) to the Virtual Surveillance Workshop particularly useful. Then look at the WHO global plan to STOP TB, this report on global advances, and the reprint from the NEJM of global TB. You may wish to visit the PBS Deadly Diseases - TB site All of you should watch the 4 minute video (part III).  Also students from outside the US who have seen the effectiveness of BCG in TB prevention, look at this article from the Lancet (April 2006) and try to determine why BCG is not used in the US. A recent article on the planned use of BCG in London is worth reviewing,as is this report in the Guardian. Also look at this editorial on BCG use in Developing Countries (the second editorial). Just in is the latest information on a new test for TB  The [WHO] has endorsed a new rapid test for tuberculosis use worldwide.  Review the articles on the [WHO] website.  How will this new test be a game changer for TB diagnosis and morbidity? Listen to this short blog from Johns Hopkins on Childhood TB.
Blood testing for TB infection - http://www.medscape.com/viewarticle/738519
Program evaluation for TB Control – are we evaluating the right indicators?  Review the 15 national TB Program indicators.  How will improvement on these indicators improve TB Control in the United States?  http://www.cdc.gov/tb/publications/factsheets/statistics/NTIP.htm

During late 2012 and 2013, severe national shortages were reported in Purified Protein Derivative (PPD) solution used for testing individuals to determine the presence of TB infection and Isoniazid, (INH) used to treat active TB disease and latent TB infectio.  Issues with drug shortages persist in the United States with over 81% of TB programs experiencing shortages. 
Research the causes for these shortages.
What are the public health implications of these shortages for US TB Control programs?
If you were responsible for rationing use of these drugs, what recommendations would you make and why?
What are potential long range impacts of these shortages?
What public policy initiatives should be considered to mitigate potential similar shortages in the future?  Do you see barriers in implementing policy initiatives? Is TB still a Killer?

As TB cases in the United States have continued to decline, the CDC has intensified efforts to identify and treat those with latent TB infection.  Review the CDC TB Infection website.  https://www.cdc.gov/tb/publications/ltbi/ltbiresources.htm
What are the challenges facing TB programs in addressing latent TB infection?  What strategies do you think would be most successful?  Besides funding what is needed to implement improved treatment of latent TB infection?
Some experts call for the changing nomenclature to TB infection versus Latent TB infection.  Research opinions both for and against this change.  What is your recommendation for nomenclature going forward?
Review the slide set and presentation “The U-Shaped Curve of Concern 20 Years Later.”
After a small increase in 2015, the number of TB cases in the United States continued its decline in 2016.  The WHO has also launched new efforts in TB Control worldwide.  What is your prediction for TB morbidity in the United States?


Blood testing for TB infection - http://www.medscape.com/viewarticle/738519 This is a free publication even though you are asked to login so they can track how many people review the material.
                Pros and cons of available blood tests over tuberculin skin test
                Do you agree with the current CDC recommendations – if you were making policy what would you change?
Program evaluation for TB Control – are we evaluating the right indicators?  Review the 15 national TB Program indicators.  How will improvement on these indicators improve TB Control in the United States?  http://www.cdc.gov/tb/publications/factsheets/statistics/NTIP.htm. Look at this short editorial from the Lancet. Also a recent report on TB Trends in the USA from the MMWR. Should we treat TB as a social disease, as we do STDs. Also consider this paper on "short treatment' of TB

May 28 in the NEJM, Review of Intervention for Latent TB, Review the section on Epidemiology and Risk Groups and the section on Guidelines and programmatic approach to consider how epidemiology drives intervention.

At present there are a number of problems managing TB infection surveillance and treatment. Look at the following links to see the Virginia and CDC recommendations. If you have difficulty understanding their relevance please email me or Jane Moore for further explanation.






2014 Review of TB progress from the WHO/Gates Foundation:

Recent articles on ending the TB epidemic: Ending TB from the London School of hygiene and tropical medicine. 2015 executive summary from the WHO on the issue.

The BCG Quandary (pdf)
BCG Effectiveness (pdf)
Stopping BCG in the UK
TB & AIDS, Recent JAMA Article
TB among Foreign Born in US, JAMA, July 08
What is Thwarting TB Prevention - Editorial NEJM, July 2011
Atlas of Health & Climate from the WHO (2012).


HIV disease/STDs.

An example of development of Public Policy.

1. Review changes in Sexually Transmissible diseases since W.W. II.     How effective do you believe Condoms are? (See what the CDC site says about condoms and STDs. Where did you look?). Look at this recent article from the British medical Journal concerning failure of US policy in relation to use of condoms. Also the role of Female Condom (toward bottom of page),  Planned Parenthood's Information about female condoms A recent discussion of use of Female Condoms in Washington DC.
Also the following the distribution of condoms from the UK, which we might well copy in the US. Local councils in England should target free condoms at people most at risk of sexually transmitted infections (STIs), guidance from the National Institute for Health and Care Excellence (NICE) recommended. Local authorities and other commissioners should make condoms more freely available through various distribution schemes to cater for the needs of different local populations and help reduce STIs, it said. The guidance has been published against a backdrop of rising rates of syphilis and gonorrhoea, which increased by 76% and 53%, respectively, from 2012 to 2015.I note the several communities in the US have reported significant increase in both syphilis and gonorrhea in the last 12 months.
2. Review Slide show on epidemiology of HIV infection & disease. Also look at the VCU HIV/AIDS center
3. Examine this table and be prepared to discuss why HIV Premarital Blood testing was not passed by the Virginia Legislature. I used this table in 1987 when as Commissioner I had to convince the legislature not to pass a bill to require premarital HIV testing.  We had just managed to remove the requirement for premarital syphilis testing. This is an example of how difficult it is to remove laws passed by a legislature.
4. Look at the PBS info: Deadly Diseases - HIV/AIDS
5. July 2006 Science editorial: Dr. Fauci on 25 years of HIV/AIDS , MMWR June 2, 2006 - 25 Years of HIV/AIDS, USA . Also look at this article about closing on the WHO goals for control of HIV
6. editorial from the NEJM on the "Road to a Vaccine."
7. See these four articles No 1, No 2, No 3, No 4, on the current possibility to achieve an AIDS free world.
8. Treatment as Prevention - Lancet July, 2011 9. CDC Recommendation on PrEP intervention, See page 9-13, Scan rest of document and CDC update on HIV treatment with attention to the boxed information, Also read this recent article on the importance of using Prep now.. Review the MMWR for Nov. 27 2015 for latest data on HIV Prep intervention (See the boxes on Value of data).
10. Can we end AIDS? and 'On the way to a cure'

11. WHO/Gates Foundation review of 2014 Progress.

Take a look at this recent Viewpoints from JAMA on Sex-Ed to prevent STD, this JAMA paper in Syphliis ciontrol and wether the comments relate ro HIV control also., and putting integrating HIV Prevention into practice.

HIV Web Sites
Take a look at the VCU-HIV/AIDS center web (fees for courses are waived for  most students at VCU if you are interested)

Other HIV Web Sites
Aids Clinical Trials Information Services
University of California (SF)
CDC site
Advocates for Youth
STI statement from AMA
How not to have sex!
Physician Education - Use of rapid HIV test (video)

An excellent site for Health Professionals, patients and the general public is The Body.Com

Immunization Programs

C.M.G. Buttery MD MPH

Look at the immunization recommendations for 2016 for children and consider some of the issues when immunizing a population, in particular note the complexity of the schedule and think about the problems in trying to explain this to both patient and immunization provider.  Also, scan the Information on the CDC's National Immunization Program web look at the diseases for which immunogens are available and consider how many of these are present in the childhood immunization program. you  Now consider why the U.S.  immunization levels are so poor compared with many other countries, and what could be done to improve them.. Also read this latest article on the effectiveness of registries, and progress in developing registries.. Review the CDC Publications list for immunization issues and review some of the materials available. Take a look at all the immunizations developed in the last 100 years. Do you think this 'painless' patch may help acceptability of a vaccine? Does social networking have a place for improving immunization rates. After looking at the array of vaccines available it is interesting to look at the role contagious disease have played United States over the last hundred and 40 years. Also look at this recent review of waning immunity. Review this JAMA viewpoint, by Dr. Gostin, on the politics of the measles outbreak. Results of Measles Vaccination worldwide.

The New York Times (1/22/2014) reports, “the latest outbreak(of measles) has renewed a heated debate about an anti-vaccination movement championed largely by parents who believe discredited research linking vaccines to autism, or who believe that the risks of some vaccines, including the measles inoculations, outweigh any potential benefit.” According to infectious disease expert Dr. James Cherry, the outbreak at Disney is, the Times reports, “‘100 percent connected’ to the anti-immunization campaign.” In California, “the vaccination exemption rate among kindergarten students...was 3.1 percent in the 2013-14 school year,” though “health officials said there were pockets across the state, including wealthy neighborhoods in Los Angeles and Orange Counties and enclaves in Northern California, where the exemption rate jumped into the double digits.” Review the CDC Vaccine safety web page to look at more data on safety.. Also consider this repott on Immunization progress in Washington Stateand this one from April 28.2017 in the journal Science.

Look at these slides. Remember that Adult Immunizations are equally important,  particularly for the elderly (>65 )and those with Chronic diseases. Also look at the .pdf article on Parental Attitudes and this Opinion from the "Scientist" on the Risk of avoiding vaccines, As well as this article on talking to parents about the value of vaccines in this Perspective piece from Science.. Also take a look at this short video from the AMA about language barriers. For up to date news about vaccines look at the Brighton Collaborative Web Site, also look at this note and at this interactive map by year & disease and see how the US compares to he rest of the world.. Also Look at the Flu/Pneumonia Fact Sheet..  Finally, scan the All KIDS Count project of the R.W.J. Foundation (when I was director of the RCHD we were one of the initial sites), this was an example of public health practice in community based research.
Look at the discussion of immunization registries as a baseline in primary care. Finally review this summary article from the IOM on development of "smart" vaccines. Then look at this article on Vaccine Development and consider why is was so difficult to provide a vaccine for Ebola and now for the Zika virus.
An interesting piece of history


People likely to be infected by spread of infection from initial (Index) case. Compare Ebola, HIV & Measles. The graphic below shows the number of expected cases from a single sick person.,

Spread of infections


Consider this commentary from Science, and the WHO Immunization Program. Could 'Flu' be a bioterrorism agent?

You may find this recent PBS Frontline show Vaccine War worth watching (Shown in March of 2015.). Also you may find the TED talk (august 2015) on difficulty in developing a vaccine.

Also look at this recent MMWR of vaccine administration prevalence and look at the blue summary boxes, also scan the web site of the Community Guide to a multicomponent action to improve immunization levels.

Other Issues:

When to quarantine (pdf) Jan 2006
Hepatitis-A Vaccine added (pdf)
Kissing & meningitis (pdf)
HPV Cervical Vaccine (KFF Website)
HPV Success - BMJ Editorial
August 25, 2006, Imperial College London, Formalin may not be safe for vaccines
Whom would you believe?
A Multitude of Vaccine Benefits, Yet Controversy Persists (2008)
Alternative Immunization Scheduling
Measles in the 21st Century-Perspective article NEJM May 2012 Look at the interactive graphics and compare the US, Europe and the developing countries.
The IOM recently published a monograph on Adverse Effects of Vaccines, read the Preface, pages 10-12.

For your bookshelf: Autism's False Prophets. Paul A. Offitt MD, 2008, Columbia University Press.