Exam 2 Flashcards
Economics
concerned with the production, distribution, and consumption of goods and health services
Health economics
Concerned with how scarce resources affect the healthcare industry
Public health economics
Focuses on the production, distribution, and consumption of goods and services as related to public health
Greatest good for the greatest number
Public health finance
A growing science and process that looks at acquisition, management, and use of money to improve the health of populations
Doing this through disease prevention and health promotion strategies
Evaluates the use of money and impact on public health system
Goal is to be able to provide population-focused preventative health services
General economics of healthcare systems
Public funded are paid by taxes, private funded are paid individually (like collective funds or insurance companies)
US uses all four
Beveridge model
Healthcare is paid for almost entirely with taxation and delivered through the government.
Healthcare facilities are government-owned, and the government employs healthcare providers.
Deduct from taxes to help fund the healthcare system and the government has control
In addition to the U.K., other countries that follow the Beveridge model include New Zealand, Finland, and Spain.
Bismarck Model
Financing and delivery of healthcare are privately funded.
In Germany, employees and employers pay premiums to insurance companies, termed “sickness funds,” through mandatory payroll deductions. Those sickness funds then reimburse the facilities that deliver care.
Government owned agencies and healthcare facilities, we get taxed, and we get deductions from payroll
In the US, we use insurance companies.
Other countries that use this model include Japan, France, the Czech Republic, and South Korea.
National health insurance model
Mixture between the Beveridge and the Bismarck model.
In this system, the government funds healthcare services, which are paid for through taxation, like the Beveridge model.
However, healthcare service delivery is provided mainly through private organizations, like the Bismarck model.
Perhaps the most notable country using this model is Canada (National health insurance)
Trying to get as much access and insurance as possible and we need a national health insurance model for this
Long wait lines but that’s what we do anyways!!
Socialized medicine
Uninsured model
provides healthcare services to people who can pay for those services out of pocket.
Residents and citizens who can afford to pay receive healthcare, while those who cannot afford care do not receive it.
An exception includes nonprofit institutions that might provide charitable care to the uninsured, or the government might provide vaccines free of charge.
Comprehensive care, however, goes primarily to those who can afford to pay.
This system is found in many low-income countries that lack the resources to fund a robust healthcare system.
Seen in the US
People who can pay get good service, those who can’t pay not as much
Private or personal care
Funded through insurance companies, employers, managed care organizations, and individuals paying for care
Primary care system
Those who have insurance get superior care
Public care
Includes broad public health system
Financed through public support
Depend on public funds
Large segment of under/uninsured
The working poor: People who make too much for government assistance and their job doesn’t give them health insurance (hope you don’t get sick)
Financing healthcare
The US Healthcare system is influenced by federal and private organizations as well as global health organizations.
How is US healthcare funded
Public support
Private support
Public health
Federal agencies
Veterans Health Administration
US Department of Health & Human Services
It falls under the Secretary of Health and is funded through federal taxes
Have hold on every initiative related to healthcare
11 examples of federal agencies
*Centers for Medicare and Medicaid Services (CMS)
*Centers for Disease Control (CDC)
Food and Drug Administration (FDA)
Indian Health Services
National Institutes of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Administration for Children & Families (ACF)
Administration for Community Living (ACL)
Agency for Toxic Substances & Disease Registry (ATSDR)
Health Resources and Service Administration (HRSA)
Substance Abuse & Mental Health Services Administration (SAMHSA)
State agencies
Receives funds from the state level to implement community-level programs at the state level
Focused on the health of its citizens
Offers various services and programs
Identify problems and intervene to meet citizens’ health needs
Funded through local taxes with support from federal and state funds
Local agencies
Same as state responsibilities but local
Includes local health departments—nassau county dept of aging (commissioner) oversees all senior centers in nassau that fall under local health dept
Receives funds from the state level to implement community-level programs
Their focus is on the health of its citizens
Offers various services and programs
Identify problems and intervene to meet citizens’ health needs
Funded through local taxes with support from federal and state funds
Health departments
International Health
World Health Organization (WHO)
Provides daily information regarding the occurrence of internationally important diseases
Establish worldwide standards for antibiotics and vaccines
Focuses on healthcare workforce and education, environment, sanitation, infectious diseases, maternal and child health, and primary care
Public support in financing US healthcare
Support funded by the US Federal Government
Dates to 1978 - Marine Hospital Service – considered the “1st national health insurance plan in the US.”
Providing care for sailors at sea ports and protecting borders from internationally infectious disease from coming in
Established what was considered US healthcare plan
What does public support in finance include
Public Health Service (PHS)
Department of Defense
Veterans Administration
Medicare & Medicaid
Managed Care
Medicare
Federally funded
Covers people 65+ who get social security, people with disabilities receiving services for two years, end-stage renal disease/kidney transplant, maintenance dialysis, ALS
Forms are confusing, help them!
Medicare part A
original, emergency care, inpatient services, hospital stays, skilled nursing facilities limited, some home care, hospice, NOT vision and hearing which are common problems in this population
Medicare part B
original, doctors services, durable medical equipment, outpatient services, mental health services, preventative services, x rays, lab tests, limited home health and ambulance transportation services, NOT vision and hearing which are common problems in this population
Medicare part C
Combination of A and B but provided through private health insurance companies that give advantages of both A and B, more expensive, Medicare Advantage, vision, dental, and hearing
Medicare part D
prescription drug plan/coverage, provided only through private insurance companies that have contracts with the government and provide different coverages for different drugs, limitations with A and B if you don’t have this
Medicaid
Federally and State Funded (Federal gov says some things are mandatory and state decides the rest)
Income is not just how much you make, it’s also how many people in the household you pay for, income for that amount of people. Not just what they cover, also who meets the criteria.
Covers low socioeconomic status, children, eligibility based on household size and income, priority are children, pregnant women, and disabled
They can also determine income criteria
Advantages of medicaid
Inpatient and outpatient, lab stuff, x ray and radiology, home health care, vaccines for children, family planning and pregnancy related care
Copay costs are lower and affordable
Reaches vulnerable populations including low income, elderly, and disabled
Financial protection because many expenses are covered by program
Recipients are entitled to receive care through privately managed care organizations
Disadvantages of medicaid
Not all low-income individuals qualify
Each state has its own guidelines for eligibility
Sometimes people receive lower quality care when they have medicaid simply because they can’t always undergo and receive services
Some people face discrimination in terms of sdoh
Not all physicians actually accept medicaid. Tendency to drop medicaid patients due to reimbursements and costs
Doesn’t always pay for certain medical interventions. Usually denied after treatment conducted
Diagnosis related groups (DRGs)
patient classification scheme that defines 468 illness categories and the corresponding healthcare services that are reimbursable under Medicare
Directly linked to medicare reimbursement
Classification system, contains 468 illness categories, each with a list of services and treatments that can be done that are reimbursable
Prospective payment system
diagnostic-related group payment mechanism for reimbursing hospitals for inpatient health care services through Medicare
How they get paid when they utilize a DRG
Utilize illness category, follow services reimbursable, medicare reimburses through PPS
TRICARE
Department of Defense’s health care program for members of the uniformed services
Veterans administration
finances health services for active and retired military persons and dependents
Indian health service
promotes tribal health for American Indians and Alaskan Natives
Third party payers
occur when reimbursement is made to health care providers by an agency other than the client for the care of the client.
Insurance companies, government agencies, managed care organizations, employers
Client is not reimbursing HCP, outside person is
Managed care
a type of health insurance designed to control costs by influencing the ways, type, and amount of care clients receive.
Payment by individual
HMOs and PPOs
Medical savings plans
tax-exempt accounts available to individuals, enabling individuals to save money for future medical needs and expenses
HMO
lower copays, only paying for care that occurs in the network, MUST choose and list on your account a PCP, can’t go to a specialist without referrals from primary care because they’re responsible for coordination of care. Lower monthly payments and smaller copayments each visit. Not a lot of doctors take this, many services denied. Costs employers less so it is offered to employees at lower cost
PPO
allows people to choose 2 different ways of care (in network, lower cost and everything covered or out of network, see any doctor, pay more, and not everything is covered)
Financing in private support
Funded privately when paying for healthcare services or goods
Insurance
Employers
Managed care (HMOs and PPOs)
Individuals
Financing in public health
Seeks to ensure that the health of the community is protected, promoted, and ensured
Overlaps with the primary care system
It is mandated through laws that are developed and organized at the national, state, or local level.
What does public health financing consist of
Health insurance
Employee benefits
Managed Care (HMO and PPO)
Medical savings accounts
WIC programs (women and children, medical savings plan)
Health Departments
Public Health Related Organizations
Centers for Disease Control and Prevention (CDC)
World Health Organization (WHO)
CDC
Research to enhance disease prevention
Detect and investigate infectious disease problems
Develop and advocate public health policies
Assists in healthcare economics
Look at the economic costs of chronic diseases and health problems and how preventing or managing symptoms can reduce costs.
WHO
Provides daily information on disease occurrences
Establishes international standards for antibiotics and vaccines
Assists in healthcare economics
Regarding economics, the World Health Organization’s Economic Evaluation and Analysis (EEA) team assists countries in collecting, evaluating, and introducing economic evidence into health policy
Goals of WHO
Increase life expectancy and quality of life
Improve equity in health between and within countries
Access for all to sustainable health services and systems
How are all sectors involved in managed care
Managed care can fall under both public and private support and is also related to public health
Public support–Managed care is a key part of Medicaid. It assists millions in gaining access to healthcare
Private support–Managed care plans are a type of health insurance program
Public Health–share an interest in ensuring the health of a defined population. Managed care and public health organizations do this
Primary care
Care provided by a healthcare professional
Care is provided on an individual level
Refers to personal health care that provides first contact and continuous, comprehensive, and coordinated care
Managed care (HMOs and PPOs)
-Medicare and Medicaid
-Private insurance
Primary healthcare
Care is made universally accessible to individuals and families in a community.
Emphasis is on prevention
Care is provided at the community level
Includes a comprehensive range of services
Encourages self-care and self-management in health and the social welfare of daily life
Declaration of Alma Alta (1978)
Healthy People 2030–want to improve health by focusing on health equity and eliminating disparities
Context of the US healthcare system
The U.S. healthcare system is a diverse collection of industries that directly or indirectly provide healthcare services.
Current system is in crisis
No longer affordable and many are left under or uninsured
Full time employees may not have health insurance
Part time is NOT offered but if it is, it’s expensive
Working long hours may cause medical errors, leading to increased cost in healthcare organizations and increased cost of coverage
Can lead to increased cost to hospitals and healthcare organizations and cost of coverage
Demographics in healthcare economics
Approximately 12% of the U.S. population was born in a different country.
Hispanics are the largest minority group population.
Mortality for both genders in all age groups declined.
Citizens are appreciating the quality of life enjoyed in the United States.
Massive and unexpected social and economic changes have occurred.
The aging population is expected to have the most significant influence on national healthcare spending.
The government inadvertently encourages low-income persons to use emergency departments as their primary care providers because, legally, EDs must see clients even if clients can’t pay (but where do they follow-up/get meds filled if they don’t see a PCP?)
Forces stimulating change in the US healthcare system
Demographic Trends
Social and Economic Trends
Health Workforce Trends
Technological Trends
Demographic trends
Population growth of the world
Aging Baby Boomer generation
Change in largest minority group
The U.S. household composition is changing
Declining mortality for both genders in all age groups
Social/economic trends
Changing lifestyles
Growing appreciation of the quality of life
Family and living patterns changing
Changing household incomes (slowly going up, don’t meet rapidly increasing living expenses)
Revised definition of quality healthcare
Any economic downturn experienced by the country
Affordable Care Act (will we improve it or take it away?)
Health workforce trends
Not enough primary care providers (advanced practice nursing (APN) specialties, rural areas have this problem more)
Move to contain costs and move to community-based care (services out of hospital since hospital is expensive!)
Current nursing shortage (covid made old nurses retire and new nurses quit)
Need to increase the number of minority nurses to help decrease health disparities
Positive technology trends
More accessible and efficient, less medication errors
Less costly because more efficient
Telehealth
Negative technology effects
Costly! Machines are costly and it takes money to train people to use the machines
Replacing machines even if they’re not outdated because they want the newest, cutting edge technology
Digital divide
Some people are great and some really aren’t comfortable with technology
Electronic medical records effects
Don’t walk away from open computer!
Doctors from different organizations don’t talk to each other
factors influencing the healthcare system of the future and resource allocation
Consumer desires higher quality care for lower cost and ability to choose doctor
Employer wants decent low cost insurance for employees
Health care system needs better balance between consumer desires and employer wants (combination)
Needed policy development and legislation in terms of access and quality
uninsured persons in 2017, 2018, 2023, and 2024
1st quarter 2024 - 8.2%.
2023 - 7.7%.
2018 – 8.5%
2017 – 7.9%
Low income and mortality
those earning less than $10,000 per year have a mortality rate three times higher than those with incomes of more than $30,000
LINK BETWEEN POOR HEALTH AND SOCIOECONOMIC STATUS
Access to healthcare (we want to improve it)
Healthcare rationing (short on supplies, see who really needs them, less supplies for everyone)
factors affecting health
- Personal behavior or lifestyle
- Environmental factors (including physical, social, and economic environments)
- Human biology
- Medical services
Medical services have the least effect and the rest have the greatest effect
Even though there’s a big impact of behavior and environment on health, estimates show that most healthcare dollars are spend on secondary and tertiary care (medical services)
We know what it takes to be healthy but our focus of how we treat them/prevent problems are skewed
Trends affecting healthcare spending
Population- people living longer
Immigration–affects how we spend healthcare dollars
Change in nuclear family
Technology–costs
Chronic illness
Consumer desire for lower cost and higher quality–how do we get that without increasing cost
Limit excessive and insufficient use of goods and services
Challenges for the 21st century
Reemergence of infectious diseases
More extensive foodborne illnesses and outbreaks
Chronic diseases
Acts of terrorism
Electronic medical records
Labor force changes
Affordable Care Act
Nursing education – introduction of DNP
Economics and the future of nursing practice
Become aware of nursing service costs
Identify areas for cost savings
Understand how nursing practice affects and is affected by economics
Focus on improving the nation’s health (health for all)
Ensure economic viability within the healthcare marketplace
How have disaster stats changed
The number of disasters, both human-made and natural, continues to increase
As does the number of people affected by them (population also increasing)
The cost to recover from a disaster has risen sharply because of the amount of technology and infrastructure that must be restored (most costly part of a disaster)
Nurses are increasingly getting involved in disaster planning, response, and recovery through their local health department or local government and disaster organizations
How does the WHO define a disaster
A situation or event, which overwhelms local capacity, necessitating a request to national or international level for external assistance; an unforeseen , unpredictable, and often sudden event that causes great damage, destruction and human suffering
Facts about disasters
Range in size
Are expensive
Cause premature deaths, illnesses (communicable infectious disease, and social well-being of the people , those affected directly or disaster workers from recovery efforts)
Destroy the local health care infrastructure and prevent an effective response to the emergency (people went to bathroom in bags and bags were on the street, hospitals were not safe)
Create environmental imbalances, thereby increasing the risk of communicable diseases and environmental hazards
Cause shortages of food and water
Displace populations of people
Why are earthquakes bad
kill quickly and lead to many injuries with other long-term effects
Why are volcanoes bad
deaths due to mud and ash inhalation
Why are tsunamis bad
immediate drowning, few injuries because people just die
Why are floods bad
increase in diarrheal disease, respiratory infections (mold), and skin diseases
U.S. Department of Homeland Security
through FEMA, directly responsible for emergency response, management, and recovery
National Preparedness Guidelines
prepare for threats and hazards that pose the greatest risk to the US
National Response Framework (formally National Response Plan)
a national plan to respond to emergencies such as natural disasters or terrorist attacks
National Incident Management System
framework or set of guidelines to improve coordination among responders (more communication=better response)
Public Health and Medical Preparedness and the National Health Security Strategy
provide a vision for strengthening prevention, detection, assessment, preparation, mitigation, response, and recovery
All levels of disaster management from before to after the disaster (recovery period)
Healthy people 2030 and disasters
focuses on making sure individuals, communities, and organizations are prepared for disasters, disease outbreaks, and medical emergencies.
American Red Cross in disasters
Implement shelters and work in every stage. Working after a disaster to help people get on their feet. They work at individual and community level
Pan american health organization
Stress Management in Disaster program (disaster response workers)
disaster management cycle
Prevention/Mitigation (way before the disaster)
Preparedness
Response
Recovery
prevention/mitigation
actions towards reducing the severity, seriousness, or painfulness of disasters
Prevent identified risks from causing a disaster
Achieved through risk analysis for a community/population and then helping to offset or mitigate problems
Examples of prevention/mitigation
surveillance/monitoring for potential disasters/monitoring disasters as they’re approaching
inspections and security
immunizations, isolation, and quarantine (spread of disease during disasters, know who is immunized and what they have)
strengthening levees/barriers
Teaching methods of prevention
Preparedness
Advanced preparation to cope with a disaster.
The first component of the disaster management cycle
Although disasters do not occur with frequency, planning with vulnerability assessment can reduce the impact on the community
How do we assess vulnerability of a community during preparedness stage
Identification of hazards - Identify all existing or potential dangers before a disaster occurs
Analysis of vulnerability – predict the most affected & identify resources for a community for disaster response
Assessment of Risk – uses data from hazard identification + vulnerability assessment to determine probability of adverse health effects to a specific disaster. Makes us better prepared
Personal preparedness
Checklist (plan for you an family)
Emergency supplies kit
CASH (singles)
Snacks, nonperishable food, chargers
IDs
1 gallon of water per person per day for 3 days
ICE (in case of emergency on phones)
highway emergency local patrol (HELP) roadside assistance
Professional preparedness
Know disaster plans
Disaster medical assistance teams (DMAT)-response teams deployed in emergencies/disasters to provide medical assistance to those in need (Field hospitals, can be deployed whenever)
Professional Preparedness Checklist (copy of license nearby, especially if volunteering. Specialized training certificates)
Community preparedness
Nurses should be familiar with written disaster plans if they exist for a community (if not then create a realistic and easy one)
be familiar with the disaster history of the community where they work
Having realistic, easy-to-follow plans, enacting community-wide drills, and having an adequate warning system
Disaster and Mass Causality Exercises
iRescU
Pinpoints nearest AED
I’m OK
Family Locator – location app. It allows you to track the location and send SOS messages
I’m okay
allows users to have automatically scheduled texts sent to their phone to check in on them. If they don’t respond, the app alerts a list of cell phones, emails, and Facebook contacts
FEMA
advises how to prepare before and what to do after a major catastrophe
Response
THINK TRIAGE!!! In terms of mass casualty events
Levels of Disaster and Agency Involvement
Levels determined by number of casualties
3 ways to classify a disaster
type: the agent that produced the event
level: anticipated or actual Red Cross disaster response and relief cost
scope: The basic characteristics of the event’s magnitude and the number of Red Cross units affected and responding (family, local, state, major, presidentially declared)
National Incident Management System
Structures and flexible framework guiding the response to disasters
Done at all levels of governments, private companies, and nongovernmental organizations
Incident command system
Common organizational structure implemented to improve emergency response
Common in hospitals
Different levels of response based on different events
Point of Distribution or Point of Dispensation (POD)
Units deployed after disaster occurs to an accessible, central location where the community can obtain specifically determined emergency supplies.
Examples of supplies include food, water, blankets, vaccines, and/or prophylactic medications following a disaster
The type of disaster drives the type of supplies dispensed
Shelter management
Local Red Cross Chapter
Can be set up before or after disaster
What do shelter nurses do
assessments and referrals (intake and registration when someone comes)
healthcare needs like glasses, meds, first aid, and diet adjustments
Need to know what resources are available in the community and communities outside of the affected area so they can determine what is available, what they can give, pharmacies, what hospitals are open and taking patients
client records
emergency communications
safe environment (physical and from violence)
Stress reactions in the community
Heroic (right after impact. Want to help with recovery)
Honeymoon (everyone loves each other and bands together)
Disillusionment (trigger events, people aren’t as helpful)
Reconstruction (new beginning)
Recovery
returning to the new normal with the goal of reaching a level of organization that is as near the level prior to the disaster as is possible (will not always return to old normal)
Hardest and most expensive step
occurs as all involved agencies pull together to restore the economic and civic life of the community and its members
role of nurse during preparedness stage
initiate or update disaster plan and educate on importance
educational programs regarding disasters (know what disasters you’re prone to based on where you are)
disaster drills (plans)
Updated record of vulnerable populations
Review individual strategies
role of nurse during response stage
The role of the nurse in disaster response depends on the nurse’s experience, professional role in a community disaster plan, specialty training, and special interest (MCR is less abrupt of a leave)**
Advocate for members and get response efforts to them quicker
assessment
know what resources are available
First responder (case finding and referring, prevention, health education, surveillance, triage)
Role of the nurse during recovery stage
proper hygiene and immunization
referrals to mental health professionals (workers!)
Be alert for environmental hazards
Watch affected animals (can show presence of disease)
case finding and referral
role of nurses in disaster management
Public health nurses as first responders
Just in time training
Field triage
Point of distribution plans in responding to disasters
PPE—always have gloves!
Documentation in a disaster (very different, more autonomous and doesn’t need to be done right away)
Skill building for disaster response
evaluation in disaster
Foundation for evidence-based disaster response
Following a thorough review of the responses, a final report is prepared with recommendations for improving emergency response in the future
adverse health effects after a disaster
Continuing death, chronic illness, and/or disability
Population shift if recovery is prolonged
Contamination of food and water supplies, with an increased risk of infectious diseases
Collapse of local and regional health care access
Increased need to provide mental health services— “psychological first aid” for disaster victims and responders
Passive surveillance system
Case reports of symptomatology are sent to local health departments by healthcare providers (nurses usually in ER who see pts with same symptoms and share same characteristics. Exposure to biological, chemical or radiological agents)
Laboratory reports of disease occurrence are sent to local health departments by hcps that find them through patient clientele
Active surveillance system
The nurse, as an employee of the health dept, may begin a search for cases through contacts with local healthcare providers and healthcare agencies
Employee of health dept (RN) looks for cases of disease or is sent case report and now want to reach out to others to check for uptick of same symptoms
when is bioterrorism used
utilized by countries during war time when they’re studying it for treatments and vaccines because there’s threats of exposure OR they’re studying it to use as a biological weapon
facts about bioterrorism agents
Can be easily disseminated or transmitted from person to person
high mortality and illness rates
Have the potential for a significant public health impact
It might cause public panic and require unique action for public health preparedness
Results of a biological attack (symptoms) to be made known several hours or days after the attack
aerosol route of bioterrorism
Easiest to disperse
Highest number of people exposed
Most infectious and contagious, causing most dangerous diseases
Undetectable to humans
Most common and most likely
Odorless, colorless
food/waterborne route of bioterrorism
less likely
Larger volumes required
More technically difficult
Psychological impact bigger than clinical effects because of filtration and how much is needed to actually infect people
Weapons of bioterrorism
Anthrax
Botulism
Smallpox virus
Plague
Tularemia
anthrax
Acute disease caused by spore forming bacterium B anthracis
An organism that perpetuates itself by forming spores (very fast rate)
Spread from handling products from infected animals or eating undercooked meat from infected animals
Most people who get sick do so by coming in contact with infected animals or animal products like wool, hide, and hair
four types of anthrax
Cutaneous—workers handle contaminated animal products and have broken skin
GI—eating raw or undercooked meat of infected animal
Respiratory/inhalation—from breathing in spores, seen in 9/11 when anthrax was white powder in envelopes
Intravenous—not as common
Prevention of anthrax
60-day treatment with antibiotics approved for adults and children (ciprofloxacin, doxycycline, and levofloxacin)
A three dose series of anthrax vaccine
In some cases, treatment with monoclonal antibodies — raxibacumab and obiltoxaximab
treatment for anthrax
IV antibiotics, antitoxin
The vaccine isn’t intended for the general public. Instead, it’s reserved for military personnel, scientists working with anthrax, and people in other high-risk professions
cutaneous anthrax
Most common form; least dangerous
Usually 1-7 days after exposure
A group of small blisters or bumps that may itch
A painless sore (ulcer) with a black center (looks necrotic) that appears after the small blisters or bumps
Swelling can occur around the sore
Most often the sore will be on the face, neck, arms, or hand
GI anthrax
Rarely reported in the US due to FDA investigating food preparation and sources
Usually 1-7 days after exposure
Fever and chills
Swelling of the neck or neck glands
Sore throat
Painful swallowing
Hoarseness
N/V, especially bloody vomiting
Diarrhea or bloody diarrhea
Headache
Flushing (red face) and red eyes
Stomach pain
Fainting
Swelling of abdomen (stomach)
Inhalation anthrax
Considered the deadliest form of anthrax
Infection usually develops within a week or two of exposure, but can take up to 2 months
Headache
Fever
Aches
Respiratory symptoms
Drenching sweats
Injection anthrax
Never reported in the US
Identified in heroin-injecting drug users in Northern Europe
Spreads through the body faster and may be harder to recognize and treat
Fever and chills
A group of small blisters or bumps that may itch, appearing where the drug was injected (are these symptoms from infection or from anthrax?)
A painless skin sore with a black center that appears after the blisters or bumps
Swelling around the sore
Abscesses deep under the skin or in the muscle where the drug was injected
botulism
Serious illness caused by the C. Botulinum toxin that causes paralysis
Very small amount needed, making it optimal for biological attack
A biological attack that releases the toxin into the food supply or air might make many people sick very quickly
Rapid appearance of symptoms (~6h)
Paralysis in face and towards limbs
Resp failure and death possibly
S/S, prevention, and treatment of botulism
Blurred or double vision, slurred speech, dry mouth, dysphagia, drooping eyelids, resp and muscle weakness
No prevention
Treatment is airway management and antitoxin when appropriate
Tularemia
A rare, infectious disease that affects mammals by attacking the skin, eyes, lymph nodes, and lungs
Developed into aerosol biological weapon
SUPERRR infective
Aerosol Dissemination=abrupt onset in large number of cases of acute nonspecific febrile illness beginning 3-5 days after exposure
Incubation range 1-14 days
Also called rabbit fever or deer fly fever
How is tularemia transmitted?
insect bites and direct exposure to an affected animal
manifestations, prevention, and treatment of tularemia
Manifestations- fever, headache, aches, dry cough, diarrhea
Prevention- FDA reviewing vaccine
Treatment- Streptomycin, gentamicin
Smallpox
VERY infectious and devastating
An infectious disease caused by one of 2 variants, variola major and variola minor
Eradicated! Nobody gets vaccinated anymore
High attack rate (how many people affected by contagious person)=3-4 but can be 10-20 secondary cases
droplet, aerosol, or clothing
Remains a bioterrorism threat
S/S, prevention, and treatment of smallpox
S/S: fever, aches, rash from face down
Can look like chickenpox at first. People don’t worry because it’s eradicated. No protocol to make sure it’s not smallpox
Prevention- contact and airborne precautions? Vaccine?
Treatment- no cure, supportive care
Plague
The plague bacterium (Yersinia pestis) is transmitted by fleas and cycles naturally among wild rodents (common in western states). It can also infect humans and their pets
Transmission of plague
Bites of infected fleas
Touching or skinning infected animals (such as prairie dogs, squirrels, rats, and rabbits)
Inhaling droplets from the cough of an infected person or animal (esp. sick cats)
three types of plague
bubonic
septicemic
pneumonic
Prevention and treatment of plague
Prevention- contact and droplet precautions
Treatment- Gentamicin, fluoroquinolones
Bubonic plague
Most common
Least deadly
Usually occurs after the bite of infected flea; illness occurs 1-6 days after being infected
Key Feature – swollen, painful lymph node, usually in groin, armpit or neck
Other symptoms – fever, chills, headache, and extreme exhaustion
If not treated early, can spread and cause septicemic or pneumonic plague
Septicemic plague
100% death
Occurs when plague bacteria multiply in bloodstream
Symptoms: high fever, exhaustion, light-headedness, and abdominal pain
Quickly causes shock and organ failure
No treatment
Pneumonic plague
Occurs when plague bacteria infects lungs
High fever, chills, cough, difficulty breathing, and coughing up bloody mucus
Almost always fatal if not treated rapidly
Least to most serious forms of plague
Bubonic
Septicemic
Pneumonic
Chemical disaster presence
Presence is known immediately through observation (explosion), self-admission, or the occurrence of rapidly emerging symptoms (burns, convulsions, SOB).
Chem-agents may be solid, liquid, or gas
Health effects of chemical disasters
Disorientation
Dizziness
Nausea
Blindness
Serious injury
Immobilization
Death
2 steps of mitigation of chemical disaster
- Minimize exposure: avoid chemical cloud and filter breathing
- Get medical assistance (skin decontamination and antidote if applicable and available
Nerve agents
disrupt the nervous system (convulsions), cause paralysis, and are fatal quickly. Reactions occur minutes after inhalation or hours if through skin
MOST LETHAL AND REQUIRE SMALLEST QUANTITIES
Sarin and VX
Sarin: used by cult in Tokyo subway bombing, non persistent nerve agent
VX (persistent)
Vary in persistence from hours to weeks
Blister agents
Can be felt within minutes depending on what was used
Felt as oily droplets that can penetrate clothes.
Eye contact: blindness
Inhalation: respiratory damage/failure
Example - Mustard gas (liquid, common in chemical warfare stockpiles)
2nd smallest quantity needed
Choking agents
not persistent, lung fills with fluid, causing choking and quick or delayed fatality (up to 3 hours). Irritation can give warning
Example - Chlorine gas (transported in bulk)
Blood agents
not persistent interfere with oxygen at the cellular level, which can become fatal quickly. Causes headache, nausea, and vertigo. Example - Hydrogen cyanide
3rd smallest quantity needed
Riot controlled agents
not persistent skin and breathing irritations, rarely fatal. Example – pepper spray/tear gas
factors of a chemical disaster
The hazardous material involved
The population threatened
The time span involved from chemical release to symptoms or people coming in with them
The current and predicted weather conditions (aerosol + wind is bad)
The ability to communicate emergency information
shelter-in
used for short-duration incidents when moving would result in a greater hazard or evacuation is impractical
Example is covid. Stay inside small place and cover entrances to outside
Evacuation
occurs when there is potential for massive explosions, fire, and long–duration events
People need to leave homes and communities
Radiological disasters effects
Skin reddening
Headaches
Nausea & vomiting
Hair loss
Weakened immune system
Health outcome after radiological disaster depends on
The amount or dose of radiation absorbed
The type of radiation
The route of exposure
The length of time exposed to the dose
radiological attack
Explosions and symptoms of high radiation doses indicate a radiological attack.
Explosive release of fine powder or solid material
3 rules of protection from radiation
Minimize time
Maximize Distance
Maximize Shielding
chemical agent detection
Some can be seen
Some can be smelled
Some can be tasted
Most can be felt (e.g. burning sensation, choking)
Instruments and paper tests can detect these
In chemical attack, agents r usually vapor, solid aerosol, or liquid drops. Can be inhaled and come into contact with skin or eyes. Many agents have antidotes but some don’t and treatment options are limited
Radiation detection
Can not be seen
Can not be smelled
Can not be tasted
Can not be felt
Can be rapidly detected by instruments!
Clues of epidemiologic attack
Won’t know something happened until patients access the medical system
ER or Family Practice Clinic/Office-
Unusual trend in patient population
Pharmacy-
Intuition or “hunch” that something is not right
Increase in abx prescriptions
Large epidemics of acutely ill patients or multiple, simultaneous epidemics
Unusual or impossible pathogen
The prior or current threat of bioterrorism
Unexplained numbers of dead animals
Increased and severe morbidity and mortality especially in previously healthy population
Increase in severe respiratory illnesses
Look for change or trend in your population baseline!!
Levels of prevention in disaster management
Primary- Planning, drills, vaccines, develop protocols
Secondary- Early recognition, screenings, monitor mortality and morbidity
Tertiary- Rehabilitation of survivors, monitor meds, evaluate effectiveness of plan
Initial response to bioterrorism
Early detection through surveillance/rapid assessment of reports
Mobilize laboratory
Rapid confirmation of agent, site, initial at-risk population, prophylaxis and/or treatment
Alert medical community, ERs, labs, tell them to watch for big influx of patients with same symptoms
Implement disease specific plans (e.g. Smallpox)
Determine resource needs and possible quarantine
Coordinate with partner agencies (local/state/national)
Provide immunizations as required
Army Surgeon Dominique Jean Larrey
Triage system
MPI
multiple person incident = <25 victims
MCI
multiple casualty incident = 25-100 victims
Disaster (victims)
> 100
MOI
mechanism of injury (cause/how?)
MVC
Motor vehicle collision
START SMART triage
START – Simple Triage and Rapid Treatment
SMART – triage tag system used with the START process
Why use SMART START and how was it developed
It is fast, simple, easy to use, easy to remember, consistent
Developed by the Newport Beach (CA.) Fire and Marine Department to quickly identify and sort patients during a multiple patient incident
What to assess with start
Initial victim assessment and treatment should take less than 30 seconds for each patient
Assess airway, respiration, pulse, and LOC
SHOULD TAKE LESS THAN 30 SECONDS
SMART triage system: green
Minor injury (fractures, wounds, or burns)
Walking wounded
direct them to gathering place
Think: “If you can walk, move to green”
SMART triage system: yellow
Delayed
Most victims in this category
Includes significant MOI but whose RPM is intact
Shock risk (e.g., heart attack, abdominal trauma)
Open fractures
Femur or pelvis fracture
Burns (recommended 5-50% TBSA)
Head trauma but responsive to verbal or painful stimuli
Uncertain diagnoses
SMART triage system: red
Immediate stabilization required
Patients whose RPM is altered
Shock due to any cause
Breathing difficulty with possible respiratory failure
Profuse external bleeding
Burns (50-90% TBSA)
Head trauma with signs of altered consciousness
Disorientation (cannot obey simple commands)
Unconsciousness (cannot respond to verbal and/or painful stimuli)
Asymmetrical pupils (sign of cerebral hernia)
SMART triage system: black
deceased/expectant
Respirations = absent -> reposition airway -> still absent
Perfusion = absent
Mental status = unconscious
Injuries too severe to live
Mortally wounded, will probably die
Burns 95% TBSA
Resources are wasted here, hard decision
Triage process
Clear walking wounded with verbal instructions (speak loud, may be hearing impaired from incident)
Direct them to treatment areas for assessment and treatment
Check RPMs (respirations, pulse, mental status)
Mnemonic for RPM
R-30
P-+2
M-Can do
RPM: respirations
Absent? Open the air way
If still none, black tag. If restored, red tag
Above 30: red tag
Below 30: check perfusion
RPM: pulse/perfusion
Radial pulse absent or cap refill over 2 seconds: red tag
Radial pulse present or cap refill under or equal to 2 seconds: check mental status
RPM: mental status
Can’t follow simple commands (unconscious or altered MS): red tag
Can follow simple directions: yellow tag
3 treatments in triage
open airway
stop bleeding
elevate extremities
triage priorities
find and transport red tag
Reassess yellow ASAP and see if they deteriorate to red tag (serious MOI, age, or history)
Don’t move green tag
FOCUS ON RED TAG! EVERYONE ELSE CAN WAIT
ped triage vs adult
Apneic child more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable
RR +/- 30 may over or under triage a child depending on age
Cap refill not accurate when it is cold
Obeying commands not appropriate for small children
why do kids need a different triage system
Pediatric multi-casualty triage may be affected by the emotional state of triage officers.
To optimize triage effectiveness to benefit all victims, not just children
Introducing JUMPSTART
JumpSTART triage
For ages 1-8, could be less but not really since babies can’t walk
Pediatric physiology (specifically, the airway) approaches that of adults by approximately eight years of age
If the child is over 8, we use jumpstart, if they’re a young adult, use START
JumpSTART respirations
Not breathing: open airway, if they breath it’s red
If apneic AND no pulse, black tag
Apneic with pulse, 5 rescue breaths. Still apneic, black. Breathing again, red
Pulse in JumpSTART
No distal pulse: red
Present: mental step
Mental status in JumpSTART
AVPU
Alert, responds to verbal or pain (yellow)
Inappropriate response, posturing, or unresponsive, red
JumpSTART for babies under 1
Either yellow or red (JumpSTART to determine)
NO GREEN BABIES
JumpSTART for ambulatory minor
Get them to green area
Assess non-ambulatory patients
Children carried to green area by walking victims need to be assessed first
Secondary triage
uses refined physiological scoring systems and anatomical examination.
It is carried out as and when resources become available. This normally is at the casualty clearing station.
Evaluates GCS, respiratory rate, and SBP
Again, can be done within 30 – 60 seconds
Epidemiology
Factors that influence health and disease
The study of disease, causes, distribution/spread, incidence, prevalence, etc
The study of Health Phenomena (disease, condition, etc)
distribution and determinants of health and diseases, morbidity, injuries, disability, and mortality in populations/aggregates, health phenomena
Study characteristics of those who have disease and compare to those who don’t have the disease
Why does disease affect one group more than another?
Helps determine what’s occurring, cause of illness, possible treatments, cures, preventative efforts
A tool for examining the “signs and symptoms” of the community’s health
Population medicine
What kinds of health outcomes are studied by epidemiology
Infectious diseases
Chronic diseases (patterns)
Disability, injury, limitation of activity
Mortality (leading causes of death in a population)
Active life expectancy (infant mortality, increasing lifespan)
Mental illness, suicide, drug addiction
3 assumptions of epidemiology
- Disease doesn’t occur at random, and we need to look for root causes and how to prevent it from occurring
- Disease has causal and preventive factors
- Disease is not randomly distributed throughout a population
Purpose of epidemiology
Control and prevention
How do epidemiologists use information
To control health problems
Interdisciplinary team works in collaboration and uses data collected to evaluate local health problems and act to promote health and prevent disease
Epidemiology uses data to
Monitor Disease Trends & The Health of the population (where diseases occur, who they occur in, symptomatology, how we can prevent it)
Identify the determinants of health and disease in communities
Investigate and evaluate interventions to prevent disease and maintain health
Determinants
Also referred to as the how and why of health events
Factors or events that can bring about a change in health
Cause and how it occurs
Genes and biology, behaviors, access to and quality of medical services, ecology, social/societal characteristics
Closely related to sdoh
Demonstrate how disease occurs and why some people are more affected than others
Distribution in epidemiology
Frequency or number of cases of disease occurrence.
These may vary from one population group to another
Disease mapping, where is disease more frequent and where does it occur most
John Snow
father of epidemiology
Utilized door-to-door investigation and disease mapping to determine the origins and characteristics of the Cholera outbreak in London in 1854
Florence Nightingale in epidemiology
Focused on Soldiers and the environment & carefully tracked and reported rates of illness
Demonstrated that a safer environment resulted in decreased mortality rate during the mid-1800’s
Pick up careful records of what was done and what were the results
She focused on soldiers and their environment.
Thus, nursing’s roots in epidemiology started with Florence’s efforts during the Crimean War
Epidemiologic description
indicates variation by age groups, time, geographic location, and other variables
Health phenomena
Health outcome of interest (looking at cancer, diabetes, etc)
Epidemiology investigates many kinds of health outcomes:
Infectious diseases
Chronic diseases
Disability, injury, limitation of activity
Mortality
Active life expectancy
Mental illness, suicide, drug addiction
Epidemiology has contributed to
Understanding the factors that contribute to health and disease;
The development of health promotion and disease prevention measures;
The detection and characterization of emerging infectious agents;
The evaluation of health services and policies;
The practice of community and public nursing
How do nurses use epidemiology
Nurses working in the community look at health and disease causation and ways they prevent and treat illness, we are case finders.
Surveillance and monitoring of disease trends
Nursing documentation is a source of data for epidemiologic reviews
School Nursing–autonomous, reporting and finding diseases
Communicable Disease
Environmental Health
Infection Control
Community Oriented nursing (keep well population well)
Occupational and school nurses
Analyze, interpret, report
Epidemic
Increase in disease rate in a certain population in a certain timeframe
Communicable or infectious disease
Outbreak
Endemic
Constant presence of a disease (usually in smaller numbers) in a certain population or area.
HIV, bubonic plague, flu when it’s not flu season, ebola
Pandemic
Worldwide epidemic, only classified as pandemic when WHO says so
Swine flu was worldwide but never declared a pandemic. COVID is a pandemic
MMWR weekly report, morbidity and mortality, different cases, world health system saying if this is sporadic, epidemic, endemic, or pandemic
Sporadic disease
No discernable pattern, infrequent with occasional pop-up cases. No population at risk because not many cases at a time
Acute vs chronic
Acute: usually revolves by itself or with treatment in about 3-4 weeks
Chronic: lifelong, has fluctuations
Sources of data in epidemiology
Surveillance data put out by CDC
Routinely collected data (census data, vital records)
Data collected for other purposes (medical records, insurance records)
Original data collected for specific epidemiologic studies
Comparison groups
To decide if the rate of disease is the result of a suspected risk factor, compare the exposed group with a group of comparable unexposed persons
Ex. Black and white ppl with breast cancer
Descriptive epidemiology
What is occurring, who is affected, where it’s occurring, when is it occurring?
Provides a way of organizing and analyzing these data in order to understand variations in disease frequency geographically and over time, and how disease (or health) varies among people based on a host of personal characteristics (person, place, and time (seasonal).
Person in epidemiology
characteristics that affect susceptibility to a disease: age, gender, ethnicity
Analytic epidemiology
How is it occurring, differences and relationships
Why are certain people more affected/at risk than others
Investigate potential causes or relationships between health conditions and other factors or events
Examines the how and why of observed patterns of health and disease
Rates and calculations to describe severity
Research approaches to analytic epidemiology (the 4 studies)
The epidemiological triangle
Interrelationships between host, agent, and environment
Host in epidemiological triangle
living species capable of being infected/affected by an agent
Susceptible by age, comorbidities, etc.
Agent in epidemiological triangle
infectious microorganism capable of bringing about disease
Has to be present for disease to occur but its presence isn’t the only thing to diagnose a disease (other factors like environment and how severe/how many numbers of pathogen involved to create disease)
Just because we have an agent and somebody’s exposed to it, doesn’t mean they’re gonna come down with disease. But to have disease you need an agent
Environment in epidemiological triangle
characteristics of an environment that precede an infectious disease process leading up to disease (physical like geology/climate that influence risk and disease, also biological environment like insects, rodents, also socioeconomic environment like overcrowding with TB or sanitation or availability of healthcare services and goods
Web of causation
Also called web of causality
Demonstrates the complex interrelationships of many factors interacting with each other to influence the risk for or distribution of health outcomes
Identifies causal relationships
Associations can be mutual with lines of causation going in both directions
Simple to complex
Ecological model of public health
New paradigm that goes beyond the two-dimensional causal web and considers multiple levels of factors that affect health and disease
Treats the multiple determinants of health as interrelated and acting synergistically (or antagonistically) with onset of a disease or illness, rather than as discrete factors
Encompasses determinants at many levels
Includes policy enactment, legislation, culture, and economic environments
Includes lifespan perspective (young to old)
Epidemiology looks at the distribution of health states and events (rates, proportions, and risk)
Epidemiological measures
Think numbers and calculations!!
Counts or ratios
Proportion- Ratio
Rate- Frequency
Risk – probability
Incidence- new cases
Prevalence- all cases
Attack Rate (morbidity)
Mortality Rate (deaths)
best indicators of the probability that a specific state of health will occur
Rate
Ratio
Simple to calculate but very important
The value obtained by dividing one quantity by another
Consists of a numerator and a denominator
Rates, proportions, and percentages are also ratios
Compares two amounts to each other
In epidemiology, ratios are often used to determine priority in terms of needs and resource allocation
Proportions
Primary measurement used to describe the occurrence of a state of health in a specific group
In proportion a subpopulation is divided by the total population
May be expressed as a percentage
Ex. 50 students in dorm and 20 have mono, what % is contagious
Can demonstrate the magnitude of a problem, how serious is the problem
Rate
Think frequency
Most common statistic used in epidemiology, expresses probability/risk of disease or other events in a defined population over a specified period.
Rates deal with change*
Use rates in gaining attention for problems, to obtain funding if problem is serious, to assess for intervention impact (did interventions help decrease rate)
Attack rate
exposed & get sick (most prominent)
Specifically linked to people who get exposed to a problem (usually foodborne) and how many people get sick
Crude rate
All causes of death
Case fatality rate
% of people who die from a disease, among all with the dx in a specific period of time
Adjusted rates
used when we want to try to control for differences such as age, or known conditions
Fertility rate
Live births
Infant mortality rate
Die at <1 year
The infant mortality rate is commonly referred to as a general indicator of overall health because they’re vulnerable but also don’t have a bunch of comorbidities and stuff
Rate most often used to determine quality of healthcare systems
Least viable healthcare systems have greatest risk of infant mortality
Looking at this, then age of <5 (usually die from various diseases [infectious or diarrheal])
This is a crude rate- because it is not CAUSE-specific (all deaths)
Perinatal mortality rate
stillbirths and deaths <7 days
Neonatal mortality rate
<28 days
Incidence
the number or proportion of individuals developing (new cases) the disease during a specific time
Assesses whether health condition is getting better or worse
Compares frequency of diseases in diff communities when populations are different
Useful when determining if a nursing intervention worked**
Prevalence
Think ALL
the number of existing cases of a disease or health condition in a population at some designated time.
Prevalence- time can be calendar date, age, life event
Prevalence measures disease status, not disease onset
It is used to present a ‘snapshot’ view of the disease or health condition of interest.
We frequently obtain prevalence data from surveys or surveillance databases.
Prevalence is a proportion (or percentage).
at a given point in time.
This is of particular use when planning health services
Not useful in determining cause/determinants
Incidence and prevalence with acute vs chronic
Chronic: High Prevalence compared to Incidence (keeps getting added to total number)
Acute: High Incidence compared to prevalence
Due because of recovery or death (no longer part of prevalence, now they’re part of mortality stat)
Attack rate
A form of incidence that measures the proportion of persons in a population who experience an acute health event during a limited period (i.e., during an outbreak)
Attack rate equation
The total number of new cases (number of ill people exposed to a specific agent) / the total population (total number of people exposed whether they get diagnosis or not).
Risk
Probability that an event will occur within a specified period
There are some outcomes for which certain people would never be at risk (i.e., men can’t be at risk of ovarian cancer; women can’t be at risk of testicular cancer)
Men can be at risk for breast cancer though so include them!
A high-risk population would include those persons who, because of exposure, lifestyle, family history, or other factors, are at a greater risk for disease than the population at large
What do we do with epidemiologic information
Find relationships
Look for differences in diseases and outcomes
Share what is learned with providers and general public (education)
Primary prevention in epidemiology
Health Promotion and Education
Improving Host, Agent, and Environment conditions
Adequate provision for basic needs
Anticipatory action = Health Protection
Classic epidemiological model
Secondary prevention in epidemiology
Screening and Monitoring
Detection = Early Diagnosis
Screening programs- regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer)
Prompt treatment, arrest progression
daily aspirin, modified work so ill workers can return
Tertiary prevention in epidemiology
Functional Adaptation & Rehabilitation
Reducing degree of disability/damage from crisis
Reducing risk of future crisis
Cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.)
Support groups that allow members to share strategies for living well
Vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible
Florence Nightingale in environmental health
“Mother of Biostatistics”
Lilian Wald in environmental health
worked to improve the environment of the Henry Street Settlement neighborhood
When did environmental health become a discussion
Quality of the environment became a popular topic in the mid- to late 20th century.
Environmental Health is one of priority areas of Healthy People 2010/2020//2030
Why should nurses know about environmental health?
Environmental factors have an impact on health (examples)
Nurses are good about teaching about health (supports work in protecting individuals, families, and communities from environmental hazards)
Nurses are largest professional group in healthcare (we can be powerful together in improving environment)
Toxicology
The basic science that studies the health effects associated with chemical exposures
Epidemiology
the science that helps us understand the strength of the association between exposure and health effects in human populations
Biomonitoring
the process of using medical tests such as blood or urine collection to determine if a person has been exposed to a contaminant and how much exposure he or she has received
Bioavailability
the amount of a contaminant that ends up in the systemic circulation
Environmental health
the branch of public health science that focuses on how the environment influences human health
Exposure
occurs when there is contact between people and an environmental contaminant
Environmental justice
The belief that no group of people should bear a disproportionate burden of the negative effects of pollution regardless of race, culture, or income
How is environment and its effect on human health often considered
How do environmental contaminants, such as asbestos, lead, or radon, influence human health?
How does the entire environment surrounding the community, such as neighborhood safety, climate, access to grocery stores, and community design, affect health?
Questions about environmental health
How do specific contaminants affect human health?
How do we assess exposure to contaminants?
How does the environment influence health?
How do we live as a population while maintaining a healthy environment?
Environmental health assessments
Assess home, school, workplace, and community
Key questions should cover past as well as present conditions
Determine whether an exposure is in the air, water, soil, or food
Methods of environmental health assessments
Windshield survey
Environmental databases
Environmental assessment forms
Exposure Pathways - A method by which people are exposed to an environmental containment that originated from a specific source
Exposure assessments
Exposure pathway and history
Exposure pathway
method by which people are exposed to an environmental contaminant that originates from a specific source (skin, oral, inhalation)
Exposure history
the process to help determine whether an individual has been exposed to environmental contaminants (amount of exposure [dose]); duration of exposure; to whom (animals, humans, environment)
What should exposure history aim to do
Identify current or past exposures.
Eliminate exposures
Try to mitigate or reduce a client’s adverse health effects from exposures.
“I PREPARE” Mnemonic
Precautionary principle - Maintains that if something has the potential to cause harm to the environment or humans, then precautionary measures should be taken if there is a lack of scientific evidence concerning cause and effect
Assessing for and constructing an exposure pathway
Source of contamination
Environmental media and transport
Point of Exposure
Route of exposure
Receptor population
Knowing if there is a completed exposure pathway
Interrupting the exposure pathway before it is complete is key
Determining the Health Impact of a Completed Exposure Pathway
An exposure estimate determines a person’s level of exposure to a contaminant.
How much exposure to a chemical or agent will cause what effect?
Dose-Response
iPrepare mnemonic
Investigate potential exposure
Present work
Residence (homes before 1978=lead risk)
Environmental concerns
Past work
Activities
Referrals and resources
Educate
Evaluation exposure/exposure risk questions to consider
Has the exposure pathway been interrupted?
What does the community think about the intervention— are people satisfied?
How has people’s health improved?
How many people did the intervention affect?
Can the intervention demonstrate any cost savings?
Is the evaluation sustainable?
Major Challenges to Environmental Epidemiology
Limited availability of data on many contaminants and their effect on health
Limited understanding about how exposures to multiple contaminants may sicken people
Latency between exposure and illness can be very long
Time consuming to perform
Resource intensive in terms of personnel and money
Inconclusive in determining if X contaminant caused Y illness
Where can environmental hazards be found
Air
Water
Land
Food
Biological agents
bacteria, protozoa, viruses, fungi. Algae, dust mites, pollen, molds
Chemical contaminants
Organic and inorganic
Organic chemical contaminants
fluorine, chlorine, bromine, iodine, nitrogen, sulfur, phosphorus, Polychlorinated Biphenyls (PCBs), DDT, dioxins, benzene, malathion, toluene
Inorganic chemical contaminants
ozone, nitrogen oxides, sulfur dioxide, lead, mercury, cadmium, arsenic, etc.
Radiation
microwaves, UV rays, noise
Particulate matter
dust, smoke, asbestos, ETS (Environmental tobacco smoke)
Air as an environmental hazard
Significant contributor to health problems
Point source and nonpoint source
Major culprits contributing to poor indoor air quality
Carbon monoxide
Dusts
Molds
Dust mites
Cockroaches
Pests and pets
Cleaning and personal care products (particularly aerosols)
Lead
Environmental Tobacco Smoke (ETS)
Examples of water hazards and why it’s so bad
Water is necessary for all life forms
People’s lives are tied to a safe and adequate water supply
Water-borne diseases such has giardia, cryptosporidium, cholera, dysentery, Hepatitis A
Wastewater and sewage
Agricultural and storm runoff
Oil pollution and radioactive substances
Lead
Land in environmental hazards
Local governments determine land use through their zoning laws
“Urban sprawl and the built community” - uncontrolled development around the edges of a city, can have many negative effects on the built community,
Sources of land environmental hazards
Manufacturing, mineral extraction, abandonment of mines, national defense activities, waste disposal, accidental spills, illegal dumping, leaking underground storage tanks, hurricanes, floods, pesticide use, and fertilizer application
Examples of land environmental hazard
Lead in the soil
Pesticide poisoning
Community configuration and obesity
Food environmental hazard
Usually E.coli or salmonella (bacteria)
Food-borne illness is defined as 2 or more cases of similar illness resulting from ingestion of a common food
Prevented by health department inspections of restaurants and supermarkets
Early 1900s with food
Contaminated food, milk, and water caused many foodborne illnesses
Sanitary revolution
Sewage and water treatment
Hand-washing, sanitation
Pasteurization of milk - 1908
Refrigeration in homes – 1913
Where can transmission/contamination occur
On the farm or in the field
At the slaughter plant
During processing
At the point of sale
In the home
Irradiation and why it’s done
Prevention of foodborne illness
Preservation
Control of insects
Delay sprouting and ripening
Sterilization
Controversial topic
Food safety in the home
Drink pasteurized milk and juices
Wash hands carefully
Wash raw fruits and vegetables before eating
Defrost meats in the refrigerator
Cook meats thoroughly
Beef – internal temp 160 F
Poultry and eggs – internal temp 170-180 F
Eat cooked food promptly
Refrigerate leftovers within 2 hours after cooking
Store leftovers in shallow containers
Don’t always use antidiarrhea
Malaria
serious and sometimes fatal disease caused by a parasite that commonly infects a certain type of mosquito which feeds on humans.
People get malaria by being bitten by an infective female Anopheles mosquito.
Symptoms of malaria
People who get malaria are typically very sick with high fevers, shaking chills, and flu-like illness.
For most people, symptoms begin 10 days to 4 weeks after infection, although a person may feel ill as early as 7 days or as late as 1 year later
2 special types of malaria
P. vivax and P. ovale
can occur again (relapsing malaria),
Remains dormant in the liver for several months up to about 4 years after being bitten by infected mosquito
West Nile Virus
Leading cause of mosquito-borne disease in the continental United States
Most commonly spread to people by the bite of an infected mosquito
Cases occur during mosquito season, (starts in the summer and continues through fall)
Symptoms of WNV
Most people infected with WNV do not feel sick.
About 1 in 5 people who are infected develop a fever, swollen lymph nodes, nausea/vomiting, muscle aches, joint pain and rash
About 1 out of 150 infected people develop a serious, sometimes fatal, illness
Treatment of WNV
No vaccine or specific medicines are available for West Nile virus infection
Over-the-counter pain relievers can be used to reduce fever and relieve some symptoms
Chikungunya
A viral infection transmitted by mosquitoes.
Extremely rare
Chikungunya is found worldwide, particularly in Africa, Asia, and India
Symptoms of chikungunya
Symptoms usually appear within a week of infection. Fever and joint pain come on suddenly. Muscle pain, headache, fatigue, and rash also may occur.
Treatment is aimed at relieving symptoms. Most people feel better within a week or so, after the virus runs its course.
Pain medications and fluids
Preventing mosquito diseases
Repellants
-DEET (up to 50% concentration; 10% in children)
-Permethrin on clothing and fabrics
Reduce mosquito breeding sites
Long sleeves and pants
Stay indoors when mosquitoes are biting
Mosquito nets
Bug zappers, sonic devices, CO2 devices (mosquito magnet); no proven efficacy
Before going to endemic areas of malaria
Prophylactic use of chloroquine (Aralen hydrochloride)***
Tick bites
Not poisonous but can transmit disease
Rocky Mountain spotted fever
Lyme diseaseBite into skin, embed mouth parts
If not detected, may remain for days
What to do if you see a tick
Remove tick by grasping close to skin with tweezers, pull gently until tick lets go.
Wash area with soap and water.
Put antiseptic on site and apply antibiotic cream if not allergic.
Seek medical attention if rash appears or flu-like symptoms
Lyme Disease and incubation period
A bacterial infection you get from the bite of an infected tick
Incubation Period: 3-30 days
Early localized stage of lyme
Erythema migrans (EM) – bullseye rash
Early disseminated stage of lyme
Multiple secondary annular rashes
Flu-like symptoms - malaise, headache, fever, myalgia, arthralgia
Swollen lymph nodes
Late disseminated stage of lyme
Rheumatologic Manifestations, Cardiac Manifestations, and Neurologic Manifestations
Prevention of lyme
Wear light-colored clothes (easier to spot tick), long pants, long sleeves
Use tick repellent: Permethrin on clothes; DEET on skin
Check for ticks after being outside
Remove ticks immediately by the head
Treatment for lyme
for adults and children includes Doxycycline, Cefuroxime Axetil, and Amoxicillin
Rocky Mountain Spotted Fever
American dog tick in the Eastern, Central and Western United States
Rocky Mountain wood tick in the Rocky Mountain states
Brown dog tick in the Southwestern United States, along the U.S.-Mexico border
Can be rapidly fatal if not treated within the first 5 days of symptoms
Incubation, early, and late periods of rocky mountain
Incubation Period: 3–12 days
Early (1–4 Days)
Late (5 Days and Beyond)
Rocky mountain rash
Typically appears 2–5 days after onset of symptoms; approximately 10% of RMSF patients never develop a rash.
Decision to treat should not be based on presence of rash
Rocky mountain treatment
doxycycline for all ages
4 types of poisonous snakes
Rattlesnakes
Copperheads
Water moccasins (cottonmouths)
Coral snakes
What to do about snake bites
Have the victim lie down and stay calm.
Keep the bitten area immobile and below the level of the heart.
Call 9-1-1.
Wrap extremities with a clean cloth.
DO NOT apply a tourniquet.
**DO NOT follow the movies and suck the venom out
Spider/scorpion bites (where are they found and what to do)
In the U.S., black widow and brown recluse spider bites are serious and sometimes fatal
Spiders are commonly found in woodpiles, sheds, and debris piles. Closets, rarely used cabinets, attics, crawl spaces
If the victim has difficulty breathing – call 9-1-1. Call 9-1-1 immediately for a brown recluse bite.
Keep the bite area below the level of the heart.
Wash the area with soap and water
Insect stings
Not poisonous but can cause anaphylaxis in those allergic
Bees of all types and fire ants
Someone allergic may carry EpiPen or other emergency epinephrine auto-injector
Remove stinger from skin.
Call 9-1-1 if known allergy.
Wash area with soap and water.
Watch victim for 30 minutes for signs or symptoms of anaphylaxis
Examples of chemical hazards
Pesticides
Environmental Tobacco Smoke (ETS)
Lead
Mercury
Physical hazards
includes airborne particles, humidity, equipment design and radiation (including radon)
Health risks of pesticides
Skin, eye, and lung irritation
Hormone disruption
Brain, nervous toxicity, and nerve disorders
Cancer
Blood disorders
Birth defects
Reproductive effects
Effects to children in heavy pesticide areas
impaired hand-eye coordination, decreased physical stamina, short-term memory impairment, and trouble drawing
environmental tobacco smoke (ETS)
From someone else’s smoking
also described as the material in indoor air that originates from tobacco smoke
S/S of ETS in children
Brain tumors, middle ear infections, lymphoma, respiratory symptoms, impaired lung function, asthma, lower respiratory illness, leukemia, SIDS
S/S of ETS in adults
Stroke, nasal sinus cancer, nasal irritation, coronary heart disease, breast cancer (women), lung cancer, COPD, asthma, chronic respiratory symptoms, impaired lung function, atherosclerosis, reproductive effects in women, including low birth weight and pre-term delivery
Lead exposure
Health problems associated with overexposure to lead are anemia, birth defects, bone damage, neurological damage, kidney damage, and others
Exposure is by ingestion and inhalation
Children are particularly at risk from eating peeling lead paint
Lead poisoning effects
lower IQ, growth problems, kidney damage, hyperactivity, reading problems, anemia, hearing loss
Sources of lead poisoning and who’s at risk
exposure to lead-based paint or dust, drinking water, hobbies, foods, cosmetics
children under the age of 6, children living in older housing
Treatment for lead poisoning
Chelation therapy.
In this treatment, a medication given by mouth binds with the lead so that it’s excreted in urine.
Chelation therapy might be recommended for children with a blood level of 45 mcg/dL or greater and adults with high blood levels of lead or symptoms of lead poisoning
Mercury exposure
A toxic metal that comes in different forms within the environment
The most common cause of mercury poisoning is from consuming too much methylmercury or organic mercury, which is linked to eating seafood
There is no cure, stop exposure and start chelation therapy if certain levels
Mercury poisoning s/s in adults
anxiety, depression, irritability, memory problems, numbness, tremors, pathologic shyness
If advanced: hearing and speech difficulties, lack of coordination, muscle weakness, nerve loss in hands and face, trouble walking and vision changes
Mercury poisoning s/s in children
problems in cognition, fine motor skills, speech and language development, visual-spatial awareness
Mercurialism
acrodynia (pink disease – pain and pink skin); Minamata disease (ataxia, impairment of hearing and speech)
Radon exposure
Naturally occurring radioactive gas produced when uranium, thorium, and radium break down in soil, rock, and water and is then released in the air
High amounts of radon can be found in the workplace, school, or any building
Most likely to be exposed in your home (spending most time in house)
Radon comes up through the ground and into the home through cracks in the foundation
Tasteless, odorless, and invisible
Global Environmental Health Challenges
Clean water and sanitation
Air quality
Climate change
Why are children vulnerable to environmental risk
Body systems are still rapidly developing
Eat more, drink more, and breathe more in proportion to their body size than adults
The breathing zone is closer to the ground than adults
Bodies may be less able to break down and excrete contaminants
Behaviors can expose them to more contaminants
