**Health Seminar Series - Emerging Diseases**

**February 11, 2000**

Session 3 -- Emerging Infectious and Non-Infectious Disease in the
United States

Dr. Arnauld Nicogossian introduced the third session in the Health
Seminar Series on Emerging Diseases, the sixth of a series of continuing
education programs sponsored by NASA's Occupational Health Program,
Office of Health Affairs (OHA), in cooperation with the Uniformed
Services University of the Health Sciences (USUHS). He introduced the
speakers for this session: Dr. James M. Hughes, Assistant Surgeon
General, Director of the National Center for Infectious Diseases,
Centers for Disease Control and Prevention (CDC); and Dr. Diane Rowley,
Assistant Director for Science, National Center for Chronic Disease
Prevention and Health Promotion, CDC.

Dr. Hughes discussed the burden of infectious diseases in the U.S., the
factors contributing to disease emergence and re-emergence, and the
strategies for addressing these problems. The CDC priorities are: to
strengthen the science base for public health action; to collaborate
with health care partners for prevention; to promote healthy living at
every stage of life; and to work with partners to improve global health.
Dr. Copeland is the first CDC Director to enunciate global health as a
high priority. Dr. Hughes showed the cover of a recent issue of the
*Morbidity and Mortality Weekly Report* that talked about achievements
in public health during the 20^th^ century, focusing on the control of
infectious diseases. The graph on the cover showed the tremendous
progress that has been made during the 20^th^ century in terms of
reduction of infectious disease mortality. The large peak in 1918-1919
was the first influenza pandemic of the 20^th^ century. This is relevant
to the issues today because we are constantly threatened with the
reoccurrence of an influenza pandemic. Subsequent to that event, there
was a continuing decline in infectious disease mortality. Progress has
been made because of improvements in sanitation, the introduction of
effective vaccines, and the introduction of many effective antibiotics.
However, this progress has led in some quarters to a mood of
complacency, and it is illustrated in a quotation from Nobel Laureate
Sir Macfarland Burnett, who wrote in 1962 "...one can think of the
middle of the twentieth century as the end of one of the most important
social revolutions of history, the virtual elimination of the infectious
disease as a significant factor in social life." This is misplaced
complacency. The microbes continue to challenge us today.

Infectious diseases are the leading cause of death worldwide. When you
look at aggregated infectious disease mortality in the U.S., infectious
diseases rank number three behind heart disease and cancer. A recent
article in the *Journal of the American Medical Association* reported on
trends in infectious diseases mortality in the U.S. between 1980 and
1992. During that period, there was a 58% increase in infectious disease
mortality in this country. When the data was age-adjusted, there
remained a 39% increase. That increase was most dramatic in the 25-44
age group, primarily as a result of HIV infection and AIDS. There was
also a 25% increase in mortality in people 65 years of age and above.
Important contributors to the overall increase in mortality are
septicemia (83% increase) and respiratory tract infections (20%
increase). In a smaller graph, between 1980 and 1995, infectious disease
mortality has continued to increase.

Dr. Hughes turned to the issue of emerging infectious disease. A very
important report by the Institute of Medicine (IOM)---*Emerging
Infections: Microbial Threats to Health in the United States,* published
in 1992, was developed under the leadership of Dr. Joshua Lederberg and
Dr. Robert Shope. The report is important in a number of ways. It called
attention to the complacency about infectious diseases and provided a
definition of emerging infections---new, reemerging or drug resistant
infections whose incidence in humans has increased within the past two
decades, or whose incidence threatens to increase in the near future.
The Committee identified six major factors that contribute to the
emergence of infectious diseases: human demographics and behaviors;
advances in technology and industry; economic development and changes in
land use patterns; dramatic increases in international travel and
commerce (both speed and volume, both people and food stuffs); microbial
adaptation and change (drug resistance in this context); and the
breakdown of public health measures (at national and local levels). In
many cases, emergence of infectious disease is due to a combination of
these factors. At CDC, the IOM report was taken very seriously. Of the
fifteen recommendations that it contained, ten or eleven were directed
primarily at CDC. In 1993-1994, CDC moved to develop an initial Emerging
Infections Plan, which CDC has been incrementally implementing. An
updated version of this Plan (1998) currently drives the CDC efforts.

The four goals of the Plan focus on: strengthening public health
surveillance and response capacity at the local, state, and national
level; addressing important applied research questions raised by
emerging and reemerging infectious diseases; the need to rebuild the
public health system, particularly focusing on the training needs; and
strengthening prevention and control programs at all levels. Dr. Hughes
commented briefly on several things that the CDC has started to do and
how these contribute to overall national effort to deal with emerging
infections. Since 1994, CDC has, through cooperative agreements with
state health departments, put in place nine Emerging Infections
Programs. These are active, population-based, surveillance sites that
involve partnerships between state health departments, local health
departments, state chapters of infection control practitioners, schools
of public health, schools of medicine, schools of managed care
organization, and state medical examiners. These programs share three
projects in common so that data can be pooled across sites; they focus
on invasive bacterial diseases (pneumococcal disease being one example),
the causes of unexplained deaths and severe illnesses in previously
healthy young people between the ages of one and 49 years, and
food-borne disease. In addition, these sites have the opportunity to
focus on infectious disease issues of local priority, which vary from
site to site. This has helped strengthen capacity in these nine areas,
but obviously there is a need to rebuild the capacity across the
country. The CDC has used a second mechanism, referred to as
Epidemiology and Laboratory Capacity Cooperative Agreements, which are
now in place in 43 states and large cities; eventually, the CDC would
like to have these in place in all 50 states, the territories, and large
cities. These have financial awards with fewer "strings" attached to
them; they give people flexibility at the state and local level to
rebuild their local infrastructure as they see fit, with emphases on
improving surveillance, enhancing lab capacity (with focus on molecular
sub-typing), training and technical assistance, developing electronic
disease registries, developing partnerships with managed care
organizations, and special projects of local priority.

Dr. Hughes spent some time on three topics: food-borne disease,
drug-resistance disease, and an interesting experience with an emerging
vector-borne disease in the U.S (West Nile encephalitis). Estimates of
the magnitude of food-borne disease were contained in a paper by Paul
Mead and colleagues in the CDC *Emerging Infections Journal* late last
year. Each year, there are about 76 million cases of acute food-borne
diseases that result in an estimated 325,000 hospitalizations and about
5,000 deaths. Three organisms are responsible for a substantial part of
the infectious disease mortality---salmonella, listeria, and toxoplasma.
We do not yet know the full range of food-borne disease pathogens in
this country. Molecular sub-tying, or fingerprinting, is a very
important part of infectious disease surveillance. A paper a few years
ago in the *New England Journal of Medicine* focused on a Minnesota
experience (1995) with an emerging food-borne pathogen, e. coli 0157:H7,
that causes severe bloody diarrhea and sometimes kidney failure in
health young children. When molecular sub-typing was done and the
molecular fingerprints of the organisms were matched, it was found that
there are multiple small clusters that are likely to be related to each
other. Of the 344 cases reported to the state, 92% were available for
sub-typing by PFGE. That technique identified 143 distinct patterns and
10 outbreaks involving 18% of the total strains. Four of the 10
outbreaks were identified only as a result of the molecular
fingerprinting. This modern laboratory capacity is essential to perform
infectious disease surveillance in a timely way to facilitate public
health action. A *Newsweek* cover story in 1997 reported on a food-borne
disease outbreak caused by this e. coli organisms in Colorado. Fifty-six
% of the isolates between June 1 and August 7 had highly related PFGE
patterns. These isolates came from people all over the state. However,
the fifteen patients had onset of illness between June 14 and July 14;
five people were hospitalized but there were no deaths. When the state
public health lab reported this information to their epidemiologist,
they found that 11 of the 14 had eaten pre-formed hamburgers a week
before the onset of illness; 8 of the 11 recalled the specific brand and
it was the same; 3 additional people recognized the specific brand when
they were shown it. That led investigators to obtain samples of the
meat, and the PFGE patterns of beef isolate matched the patient
isolates. This food product was distributed nationally, and these
results led to a huge nationwide recall in a timely way. Only one
additional case was identified outside of the state of Colorado. This is
an example of effective public health action based on timely results.

We now have in place a national molecular sub-typing network for
food-borne disease surveillance called PulseNet. This network is a
partnership between CDC, the Food and Drug Administration, the U.S.
Department of Agriculture, and state and public health laboratories.
These networks enter data in a timely way into a national database which
can be screened for matching patterns. This is a vision of what modern
infectious disease surveillance should be. In 1998, three outbreaks were
identified as a result of PFGE typing: salmonella agona in contaminated
toasted oats cereal; shigella sonnei in parsley; and listeria
monocytogenes in hot dogs and cold cuts.

Dr. Hughes included a few comments about the emergence of antimicrobial
resistance. There have been several media reports about this issue.
Antimicrobial resistance occurs in part due to selective pressures
resulting from antimicrobial usage. We don't know as much about
antimicrobial usage in the U.S. as we would like to, either in the human
or the animal population. Estimates are that about 60% of overall
antimicrobial usage occurs in humans and about 40% in animals. Of that
occurring in animals, about 80% is for growth promotion and about 20%
for therapeutic use. Dr. Hughes shared some data from Drs. Smith and
Osterholm who looked at the Minnesota state experience with another
food-borne pathogen, campflobacter jejuni, focusing on the frequency of
quinolone-resistant infections. From 1992 to 1998, the proportion of the
resistant campflobacter jejuni increased during that period. The high
peak during the winter months result from travel abroad (primarily
Mexico). The lower peaks (summer) were not associated with foreign
travel. Emergence of resistance in locally acquired strains as well as
introduced strains is a complicated problem. Overall, resistance
increased from 1.3% in 1992 to about 10.2% in 1998.

Dr. Hughes discussed the emergence of West Nile encephalitis in the U.S.
It is a member of a group of viruses called flaviviruses. These viruses
cause one of two types of illnesses---either hemorrhagic fever (Dengue
and yellow fever), or encephalitis (St. Louis, West Nile, and Japanese).
West Nile virus is transmitted by mosquitoes, primarily mosquitoes that
are members of the genus *Culex*; birds are the reservoir for the virus.
It was first isolated in West Nile Province, Uganda, in 1937. It has an
incubation period of five to 15 days. The West Nile experience in NY in
1999 was initially recognized by an alert physician in Queens, who was
taking care of some encephalitis patients with some unusual clinical
features. She reported this to the NYC health department. At this time,
crows were dying in NY, and subsequently zoo birds were becoming ill and
dying. Eventually, 61 cases of the infection were identified; there were
seven deaths (all 68 years and above). Dr. Hughes showed a graph
depicting early onset, high of onset, and latest cases. Molecular
studies of the virus indicate that it is most closely related to a virus
isolated in 1998 in Israel from a goose. How this virus was introduced
into the U.S. remains a mystery and is the focus of continuing
investigation. This is a clear reminder of the fact that we live in a
global village. Dr. Hughes noted another aspect of this outbreak.
Questions about bioterrorism were raised during the course of the
outbreak, and we need to be prepared for the fact that this question
will surface. There are some take-home messages from this outbreak:
people involved in clinical medicine and public health should keep an
open mind; the importance of the linkages between clinical medicine and
human public health; the importance of linkages between people involved
in human medicine public health and people involved in veterinary
medicine; the need for public health laboratory capacity; the importance
of people who are trained in entomology and wildlife biology; and the
importance of communications between all the people involved in the
various aspects, as well as communication with the public. From this
outbreak and some other outbreaks we have learned some more general
lessons: the importance of surveillance, prompt epidemiologic
investigation and laboratory capacity; the disruption of travel and
commerce that can result; and the global implications of local problems.

Dr. Hughes emphasized the issue of public health laboratory capacity, at
the local, state, national, and international levels. CDC has placed
particular emphasis on human resource needs around public health
laboratory capacity. CDC has put in place an Emerging Infectious
Diseases Laboratory Fellowship Training Program to provide young people
with training and experience in public health laboratory science, in the
hope that they will be interested in pursuing careers in this area.
Information on this training program is available through the CDC
Website. The outbreaks remind us of another important point---the media
interest in these emerging infections is sometimes inversely
proportional to the overall disease burden. There were 61 cases of West
Nile encephalitis identified in the outbreak last fall; when an outbreak
of *ebola* occurs in central Africa, there is intense media interest.
However, the real global killers are HIV and AIDS, tuberculosis,
malaria, pneumonia, diarrhea, and measles.

What does the future hold? A quote from the *Lancet* said: "While future
epidemics of infections are impossible to predict, the conditions for
these epidemics---high population density and poverty---are entirely
forseeable." Some of the principal future challenges are: antimicrobial
resistance (a major national and global threat); the constant threat of
the next pandemic of influenza; the reemergence of urban yellow fever in
Latin America; continued experience of international foodborne disease
outbreaks; the role of microbial agents in chronic diseases (e.g.,
hepatitis B and C are major causes of chronic liver disease and liver
cancer; human papilloma virus is a major cause of cervical cancer); and
the need to be prepared to confront the unexpected (naturally occurring
or the threat of bioterrorism). Dr. Hughes referred those interested in
emerging infectious disease issues, and particularly the issue of
bioterrorism, to the CDC *Emerging Infectious Diseases Journal*, which
is available on-line. The Website for the National Center for Infectious
Diseases can be reached through the CDC Website: www.cdc.gov. On July
16-19, 2000, the CDC will be sponsoring in Atlanta the second
international conference on emerging infectious diseases.

Dr. Nicogossian noted that NASA has a joint research program with the
CDC in vector borne disease remote sensing.

The next speak, Dr. Diane Rowley discussed the emergence of obesity as a
disease of epidemic proportions and the policies and strategies for
addressing Type 2 Diabetes. She proposed broadening the definition of
disease even beyond what the IOM report recommended in terms of looking
at emerging infectious diseases. A few years ago, the Director of
Disease Prevention for the U.S. suggested that the actual cause of
disease is not adequately defined. We talk about cardiovascular disease
or cancer, but we don't talk about the exposure or the vector that might
be the actual cause of disease. The actual cause of disease might need a
new way of classification, and that in this instance, smoking and
tobacco products might be the leading cause of disease. With that in
mind, Dr. Rowley talked about what might be another leading cause of
disease---obesity. She showed the trends of in obesity beginning in
1991, taken from the CDC surveillance program. The data shows the spread
of obesity in the nation over a seven year period. Throughout the
1990's, there has been a substantial spread of obesity throughout the
U.S. This cross-sectional survey conducted by CDC and state health
departments asked a series of questions concerning personal behaviors
that increase the risk of one or more of the causes of death, like
chronic diseases or cancer. An important strategy for monitoring and
preventing these diseases is to intervene on these risk factors. By
1997, no state had an obesity rate less than 10%. The obesity rate
increased by nearly one-third, from 12% of the population in 1991 to
16.4% of the population in 1997. The study adjusted for age, sex, and
race; although the rates are higher after adjustment, there has been a
steady increase for both sexes across age groups, all races, and all
educational levels. The greatest magnitude of increase was found among
three groups: those 18-29 years of age, those with some college
education, and those of Hispanic ethnicity. This rising prevalence of
obesity is considered to be an epidemic because of its potential
contribution to the burden of chronic disease. Already, obesity-related
morbidity may account for close to 7% of health care costs. Consumers
spend \$33 billion annually for weight loss products, but long-term
weight loss is difficult to maintain. For losing weight, both the U.S.
Department of Agriculture and the National Heart, Lung, and Blood
Institute recommend decreasing caloric intake and increasing physical
activity. Both guidelines recommend at least 30 minutes or more of
moderate physical activity on all or most days of the week. The risk
factor surveillance survey also provides data on weight control
strategies. Sixty percent of obese men and 70% of obese women reported
that they were trying to lose weight, but only 20% of these men and 15%
of these women exercised more than 150 minutes per week and consumed
fewer calories. Whether this reflects a lack of knowledge about weight
control methods or an inability to implement these methods effectively,
or both, cannot be assessed by the surveillance program. The NIH
guidelines also recommend that health care professionals advise obese
patients to lose weight. The surveillance on the number of obese people
who recall receiving advice on weight loss or exercise in a visit to a
physician in the previous 12 months shows only 42% received advice to
loose weight. Women, people with higher education, and people perceived
to be in poorer health, or those who had diabetes were most likely to
receive advice.

The epidemic is not restricted to adults. The percentage of overweight
youth (6-17) has increased dramatically since 1980. The increase is
probably due to an increase in energy intake combined with a decrease in
physical activity brought about by environmental and societal changes
(the use of automobiles, labor-saving devices, television and video
entertainment, and the ready availability of fast foods). Reversing this
trend will require a cultural change at the environmental and societal
level. Some of the broad societal forces influencing this poor health
risk are often unintentional consequences of policy and commercial
interests that were developed for other reasons (convenience, value for
money, relaxation, good taste, etc.). The original purpose was not to
help the American people get fat or become inactive, but the increase in
obesity over the last two decades was not due to the loss of a thinness
gene, or a lack of appetite suppressant drugs. The epidemic is not even
due to the society-wide loss of motivation to control weight. The
implications of this mean that individual-level interventions in trying
to encourage the decline in obesity simply by physical activity and
change in dietary practices will not reverse these trends. We have to
recognize that public health policy must embrace a bigger vision of how
to influence behavior and improve health.

CDC has started to look at environmental interventions that create
social trends, and policies that foster health and healthy behaviors.
CDC is looking outside the public health community to enlist a variety
of partners. Dr. Rowley provided some examples. In the Ozark Project,
85% of the people supported zoning regulations, 77% supported local
government funds for physical activity, and half supported work policies
that give time off for physical activity. In addition, there is
overwhelming support for physical education in the schools as a
requirement. In order to test some of these strategies, CDC is working
on Smartraq---Strategies for Metropolitan Atlanta's Regional
Transportation and Air Quality---that supports transportation patterns
that encourage walking and biking. Over the next several years, the CDC
hopes to expand its relationship with this group to determine if
practices such as land use and air quality will increase physical
activity. In addition, CDC has begun a study with some of the Health
Maintenance Organizations to determine if their attempt to maintain
Medicare patients in enrollment in health clubs is successful. Another
partner is the National Park Service (social marketing of physical
activity by designing activity trails that are user friendly).

In addition to the environmental approaches, the CDC has been involved
in one community-based clinical trial---the Child and Adolescent Trial
for Cardiovascular Health, otherwise known as CATCH. CATCH reduced the
fat content of school lunches, increased moderate to vigorous physical
activity in physical education classes, and improved eating behaviors in
children over a three-year period. CDC has worked with educators to
develop a series of programs to improve school health, and has developed
a number of guidelines to provide adequate information for schools that
want to build physical activity programs and improve nutrition.

Dr. Rowley discussed what may be the first consequence of the epidemic
of obesity---Type 2 diabetes among children and adolescents. Type 2
diabetes, characterized primarily by insulin resistance and a relative
decrease in insulin secretion, has typically been considered a disease
of adults. However, during the last two decades, pediatric Type 2
diabetes has appeared in American Indian youth and among the First
Nation people in Canada, and, more recently, among African American,
Hispanic, and Caucasian children. CDC will soon be publishing the
results of its first epidemiological review that describes the emergence
of Type 2 diabetes among youth as a health problem. Dr. Rowley
summarized some of the findings: (1) the mean age of diagnosis was close
to the age of puberty (12-14); (2) girls were more likely to be affected
than boys; (3) the majority of reported cases were from minority
children; (4) a strong family history of diabetes or obesity; (5)
acanthosis nigricans was common; (6) most cases were referred to a
physician because of symptoms or acute illness. In general, glucose
control was poor after the diagnosis. The few prospective studies on
these children showed hypertension, high triglycerides. A more thorough
study showed high prevalence of microalbuminuria, high triglycerides,
and hypertension.

When is a disease a public health problem? The CDC applied the criteria
suggested by Dr. Frank Vinicor, et. al. to answer this for Type 2
diabetes. Does Type 2 diabetes affect lots of youth? There are few
estimates, except for American Indians; this group meets this criteria.
Type 1 is already considered one of the most prevalent pediatric
diseases in the U.S., and the CDC anticipates an increasing prevalence
for Type 2. Has Type 2 diabetes among youth increased, or is it likely
to increase in the future? Among many racial and ethnic populations,
there is an increasing prevalence. It is also likely to increase in the
future because of increasing obesity among children and because patterns
of population growth will continue. Does Type 2 diabetes among children
pose a large burden? Much of the future population burden from Type 2
diabetes in children will result from complications, such as
cardiovascular disease, retinopathy, etc. An earlier age at onset will
lead to an earlier onset of diabetic complications. Preliminary data
have indicated poor glucose control among teenagers. Data has shown a
clustering of cardiovascular risk factors during teenage years.
Potentially, there is high impact on cost and quality of life. Are the
needs of the affected population important? The realization that Type 2
diabetes, already a serious adult disease, now affects children and
adolescents, has generated much public concern, especially in the media.
The media has stressed that Type 2 diabetes is linked to the way we
live, and the public may well conclude that the disease reflects
societal patterns favoring obesity and physical inactivity. Public
concern will also be raised by the realization that Type 2 diabetes is a
costly disease, and its cost will escalate because of the growing burden
among younger people with subsequent loss of their productivity as
adults due to premature morbidity. An increase in the prevalence of Type
2 diabetes among youth should be a particular concern considering the
disparities in adult Type 2 diabetes, the general health status, and
access to care that already exists among minority and low socioeconomic
populations. This is another compelling argument that diabetes and its
complications have a legitimate public health dimension. Is it feasible
to act at a community or public health level? Among children, Type 2
diabetes is probably as closely linked to modifiable risk factors (e.g.,
obesity, poor nutrition, and lack of physical activity) as it is among
adults. Increasing physical activity and decreasing obesity can probably
reduce Type 2 diabetes and help prevent other chronic diseases. A public
health approach to prevention of Type 2 diabetes and its risk factors
that targets all children and adolescents and their environment,
particularly the media, schools, communities, and families, should
improve health at the population level. Additional approaches are needed
to target high-risk groups. Even though primary prevention would be
ideal, we cannot ignore the evidence that several efficacious secondary
prevention strategies for adult Type 2 diabetes exist, including
glucose, lipid, and blood pressure control, and aspirin treatment.
Interventions in younger populations are likely to be more cost
effective. The efficacy of glucose treatment for insulin control has
also been demonstrated for adolescents with Type 1, but not Type 2
diabetes. Hypoglycemic drugs other than insulin have not been tested and
approved for youth with Type 2 diabetes. In addition, population
mobility, lack of symptoms, and denial; absence of family support; and
inadequate health care insurance coverage may be major barriers to
adherence to treatment and follow-up, and to successful clinical
management. There is a large potential for improving the current health
care management of Type 2 diabetes among North American children and
adolescents. CDC will continue to monitor this disease and will be
engaging with several health maintenance organization and public health
departments and other groups to screen and track children with this
illness.

Dr. Rowley discussed an age-old problem which is reemerging---tobacco
use. While cigarette smoking among adults has declined by 14% over the
past 10 years, smoking among high school seniors has increased by 24%.
The prevalence of cigarette smoking among student in grades 9-12
increased from 27.5% in 1991 to 36.4% in 1997. In 1995, only 24.7% of
adults reported current cigarette use. This is a reversal of a previous
trend, when in the 1970's and 80's, incidence of first cigarette use
decreased among people 12-17 years old. Although smoking declines were
greater for black youth, the trend in increasing daily smoking among
high school seniors is present for both whites and blacks. The same is
true for both males and females. CDC is hoping that the trend in
increasing smoking patterns has leveled off. For 1999, there has been a
slight decline. If the 1996 trend continued, CDC estimated that
approximately 5 million people less than 18 years old would eventually
die from smoking-attributed disease in the U.S. Two weeks ago, the
American Legacy Foundation released the findings from their first youth
tobacco survey. This is the first time that we have national data on
tobacco use among students in the middle school (grades 6-8). CDC was
very disappointed to find out that by this age, over 9% of students
smoke. The data shows that there is equal opportunity among all ethnic
groups for smoking in middle school. This is a very disturbing trend. In
addition, CDC has begun to document that although cigarettes may be the
more popular use of tobacco, it is not the only form. Cigars are quite
popular. The survey documented the emergence of two very novel tobacco
products---bidis and kreteks. These are flavored tobacco products. Bidis
seem to be growing in popularity and are an easy way of introducing
smoking to middle and high school students. The continuum of smoking
behavior among youth can be described in several well-known stages:
preparation, trying, experimentation, and regular smoking and addiction.
Adolescents are difficult to recruit for formal smoking cessation
programs, and when enrolled, it is difficult to retain them in the
programs. The optimal public health strategy is to prevent tobacco use
completely, or to intervene as early as possible in smoking behavior.
Proven tobacco prevention programs should begin in elementary school
with intensive instruction in grades 6-8. In fact, sixth grade may be
too late for intensive intervention. Programs are most effective when
they are supported by community-wide activities that involve parents,
peers, mass media, and community organizations.

Dr. Rowley showed the linkage between cigarette consumption and major
smoking and health events in the U.S. from 1900 through 1998. In the
late 1950's people became concerned about the effect of cigarette
smoking on health. There were a series of scientific studies released
and more attempt to ban cigarette advertisements. There was a growing
interest by non-smokers to protect their own rights, and a broad media
campaign (the Great American Smokeout) to encourage people to stop
smoking. These interventions, along with more and more information on
the extensive impact of tobacco on health, have led to an increasing
overall decline in tobacco use. Beginning in the late 1980's and
throughout the 1990's, there has been a broader concerted effort to
reduce smoking. One of the additional approaches has been continuing to
increase the cigarette tax. Price particularly influences the use of
certain populations (young adults between 18-24, low income populations,
and among certain racial and ethnic groups). Tax dollars have been used
in some states to develop strong anti-smoking campaigns and to support
treatment of people with cigarette-related disease. Within the last year
or two, there has been an agreement between the cigarette industry and
many State Attorney Generals to provide funding as compensation for
problems with cigarette smoking. CDC would like to continue to use and
expand several of these strategies---to encourage increasing tobacco
prices; to continue to reduce access to smoking; to reduce the appeal of
tobacco products by restricting advertising and promotion of the
products; to conduct targeted mass media campaigns specifically for
youth; and to continue to establish health-oriented social norms, by
increasing smoke-free indoor spaces and decreasing the modeling of
tobacco use by celebrities.

Dr. Rowley again presented the concept of extending what an emerging
disease is. With the publication in the last month of the "2010 goals
for health," CDC has acknowledged that a disproportionate societal
burden of disease is an important public health problem to attack. Death
rates have fallen tremendously over the past century, but improvements
have not been shared equally. Eliminating burden of disease based on
race, ethnicity, and social economic status or occupational classes
suggest that there is another set of causes. What if the causes of
diseases also have social determinants? We acknowledge that social
disadvantage can cause higher rates of disease and a lot of the original
work in this area comes from Great Britain and Europe, where studies
have demonstrated that disparities in occupational class cannot be
explained by lifestyle factors alone. There is a social gradient of
mortality and disease for every level of occupation and income. In the
U.S., this social gradient of disparity is magnified by racial and
ethnic groups. The majority of the work that the CDC will be doing over
the next 5-10 years will be to examine how to intervene at a social
level in reducing the burden of disease among populations.

Questions:

Dr. Nicogossian asked both speakers about their view of the future with
respect to the effects of tobacco use.

Dr. Rowley: CDC is very concerned about the export of tobacco use across
the globe; it has recently started a collaboration with WHO to help
monitor tobacco use and to look at appropriate interventions that might
work in other countries. In addition, there has been a lot of work
sponsored by the WHO that examines the global burden of disease. It is
clear that an epidemiological transition, or shift, from infectious
diseases to non-infectious diseases has already started occurring
outside of the U.S. and Europe. We are now seeing cardiovascular
disease, cancer, and diabetes account for more and more of the burden of
disease in developing countries. HIV is a major contributor to that. The
concern is how to develop a health care system that will accommodate
those diseases in countries where it has already been difficult to
respond to an infectious disease problem.

Dr. Hughes: In terms of microbes, they can move into and out of the U.S.
with equal ease. It is important to remember the concept of the global
village when you think of infectious diseases today. There is a need to
continue research programs related to these issues, including research
to better permit us to anticipate future trends and challenges.

Moscow: What about infections associated with health care facilities?
Are there prevention programs in this area?\
Dr. Hughes: Infections that occur in association with health care are
very important, both clinically and from a public health standpoint. The
data suggests that about 5% of people admitted to acute care hospitals
develop a pneucicomial infection. We have learned over the years that
well-staffed and well-organized hospital infection control programs are
effective in preventing many of these infections. This is something that
CDC has worked with the American Hospital Association to promote. Key
elements of effective programs are: surveillance of infections;
monitoring of infections; having an infection control practitioner
working in the hospital collecting information on infections that occur;
analyzing that data in connection with a hospital epidemiologist; and
providing feedback of infection rates to practitioners in the hospital
setting so that infection rates can be controlled and procedures can be
optimized. CDC has developed a number of guidelines that are targeted
toward hospitals in an effort to improve procedures and reduce
infections. In the U.S., we are seeing an every broadening range in
which health care is delivered; we are no longer focused on just the
acute care hospital or the nursing home, but even beyond that into
out-patient care settings and home care settings. The CDC Website
contains a lot of information on the hospital infection program and its
recommendations.

HQ: What is the major cause of obesity---is it the intake of food or the
lack of physical activity?

Dr. Rowley: What we are finding is that it is probably both. We have
clearly established that physical activity is declining among adults and
children. Some studies suggest that we don't even fidget the way we used
to. In addition to that, it is quite clear that there have been changes
in food consumption patterns; CDC will be working with the Department of
Agriculture to document some of those. Over 70% of high school students
report that they do not eat five servings of fruit and vegetables a day
(the recommended amount). This is one of the reasons that there is so
much focus on school-based programs---they learn how to eat foods in
school. In order to modify weight, people need to be involved in some
type of moderate to vigorous activity about 30 minutes a day. Rather
than only focusing on decreasing fat intake, CDC is focusing on
decreasing portions and ensuring that fruits and vegetables are added
adequately to the diet. Adequate nutrition provides an important
intervention for a lot of diseases.

HQ: What is the average turnaround time for the molecular typing
technique? Is it fast enough to influence the intervention strategy?

Dr. Hughes: Yes, it is fast enough to influence the intervention
strategy. It is on the order of a day or two. The computerized network
(PulseNet) immediately transfers the fingerprint pattern data from the
site of collection into a national database where it can be instantly
analyzed and similar strains from different parts of the country can be
picked up. Delays are more related to the incubation period of the
illness, the patient seeing the physician, the initial culture being
collected, and the isolate being referred to a public health lab. Once
it get to the lab, things move very quickly.