The Future of Public Health Shattuck Lecture Massachusetts Medical Society May 1, 215 Thomas R. Frieden, MD, MPH Director Centers for Disease Control and Prevention Areas where public health works Domestic Communicable HIV HCV Antimicrobial resistance Healthcare associated infections And more. Non-Communicable Cardiovascular disease Cancer Diabetes Prescription drug overdose Environmental risks Road crashes And more. Global HIV Tuberculosis Malaria Polio Emerging infections (Ebola, etc.) Vaccine-preventable infections Parasitic infections And more. Cardiovascular disease Cancer Diabetes Road crashes Environmental risks And more. 1
Factors that affect health Smallest Impact Largest Impact Counseling & education Clinical interventions Long-lasting protective interventions Changing the context To make individuals default decisions healthier Socioeconomic factors Examples Eat healthy, be physically active Medication for high blood pressure, high cholesterol, diabetes Immunizations, brief intervention, cessation of treatment, colonoscopy Fluoridation, g trans fat, iodization, smoke-free laws Poverty, education, housing, inequality Number of Infections Antibiotic Resistance Initiative could reduce many infections Projected burden of healthcare-associated invasive MRSA, healthcare-associated CDI, healthcare-associated CRE, and hospital-onset MDR Pseudomonas infections 4, 35, 3, 25, 2, 15, 1, 5, Maintaining status quo Aggressive multisectoral intervention Over 5 years prevention will result in: > 1/2 million AR infections averted Thousands of AR infection attributable deaths averted Billions in medical costs averted 211 212 213 214 215 216 217 218 219 $5. 5,,, Bn 4,5,, Attributable medical costs ($ in billions) $4. 4,,, Bn 3,5,, $3. 3,,, Bn 2,5,, $2. 2,,, Bn 1,5,, $1. 1,,, Bn 5,, $ 2
The continuum of HIV care Of the 1.1 million Americans living with HIV, less than a third are virally suppressed Percent of all people wth HIV 1% 8% 6% 4% 2% 86% 4% 37% 3% % Diagnosed Received Medical Care Prescribed ART Viral Suppression MMWR Vital Signs, Nov 28, 214. Globally, the TB mortality rate fell ~1/3 between 199 and 213 4 TB + HIV-TB TB Only HIV-TB Only Rate per 1, population per year 35 3 25 2 15 1 5 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 Includes TB deaths in both HIV-negative and HIV-positive people. 3
Estimated vaccine-preventable disease deaths averted and still occurring Annually among children <5 years, 28 75, 1.5M deaths 2.2M deaths averted 5, 25, -25, -5, -75, -1,, -1,25, Pneumonia* Rotavirus Diarrhoea Measles Pertussis Tetanus Other (Polio, Diphtheria, * vaccine preventable component caused by Streptococcus pneumoniae, Haemophilus influenzae type b, JE^, Japanese Encephalitis Yellow Fever, JE^) WHO, Global Burden of Disease 28. Updated estimates Vaccination saves >3 million lives worldwide each year Categories Vaccines Lives saved/globally/year Existing, widely used vaccines Measles Pertussis Polio Lives saved, compared to pre-vaccine era Measles: 2.5M Pertussis: 687, Polio (paralytic cases prevented): 35, Vaccines being scaled up Human papillomavirus (HPV) Pneumococcus Rotavirus Potential additional lives saved per year HPV: 275, women Pneumococcus: 1.6M Rotavirus: 45, Sources: All sources from WHO HPV and rotavirus source: GAVI Alliance, 212 4
Measles vaccine prevented 15.6M deaths and reduced infant mortality rates by 25% 2-213 MMWR, Nov 14, 214. Global malaria deaths have declined since 25, primarily by reducing death among children <5 years in Africa 198-21 Murray JLC et al. Lancet 212;379:413-431. 5
A safer US and a safer world US CDC works directly with countries to Prevent avoidable catastrophes Biosafety & biosecurity Immunization Surveillance of zoonotic disease in humans Antimicrobial resistance Detect threats early Surveillance Laboratory Information systems Disease detectives and other public health staff Respond rapidly and effectively Emergency Operations Centers Medical countermeasures Linking public health and law enforcement Improved cardiovascular care could save 1, lives/year in U.S. Number of deaths prevented (per year) 8 7 6 5 4 3 2 1 Smoking cessation Blood pressure control Cholesterol control Aspirin 2% 5% 1% 25% 3% 15% 35% 4% 45% 5% 55% 6% 65% 7% 75% 8% 85% 9% 95% Percent eligible using service Source: Farley TA, et al. Am J Prev Med 21;38:6-9. 6
72 million US adults have hypertension But many are not aware or treated (hiding in plain sight) and barely half have it controlled 1% 8% 72M 59M 54M 6% 37M 4% 2% 52% % Have high blood pressure Aware Treated Controlled CDC/NCHS, National Health and Nutrition Examination Survey, 211-212. Potential public health actions of a responsive government Promoting free and open information Protecting individuals from harm caused by other people or by groups Taking societal action to protect and promote health Longstanding Newer Truth-in-advertising laws Nutrition-facts panel Pharmaceutical package inserts Public reporting of health care provider performance Calorie labeling at chain restaurants Graphic tobacco pack warnings Non-adulteration of food Laws against alcohol-impaired driving Infectious-disease reporting Worker safety Tobacco excise tax Alcohol excise tax Smoke-free laws Alcohol ignition interlock devices for people convicted of drunk driving Restrictions on sales and marketing of tobacco and alcohol (especially to children) Elimination of artificial trans fat Vaccination mandates Water fluoridation Micronutrient fortification of manufactured foods Clean water, air, food Elimination of lead in paint and gasoline Zoning promote physical activity (e.g., walking and bicycle paths) School policies (e.g., food, physical activity, safe transportation) Reduction of sodium in packaged and restaurant foods Frieden TR. NEJM, Apr. 17 213. 7
Tobacco is the world s leading single agent of death Global Deaths per Year (millions) 6 5 4 3 2 1 6. Tobacco (incl. secondhand smoke) 3.9 Acute Resp Infect 2.2 Diarrheal Disease Tobacco kills more people worldwide each year than HIV, TB and malaria combined 2. 1.8 1.2.9.2 AIDS TB Traffic Injuries Malaria Measles World Health Organization 8
Effective clinical systems improvement program Centers for Disease Control and Prevention 16 Clifton Road NE, Atlanta, GA 3333 Phone: 1-8-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov 9