Eighteen is too Dangerous - 886 Words

Has anyone been harmed from underage drinking that you may know of, whether it’s from over dosing or a severe car accident? The topic of lowering the drinking age to eighteen in the United States is very debatable subject because many people have a difficult time deciding which side to support. Many of the negative issues for the low drinking age would have of an effect on the future, which is why the reform should not be put into action. Reasons include health issues, irresponsibility, and deaths among the youth. Even though there are many pros and cons to lowering the U.S. drinking age to eighteen, it should not be reduced because the effects could be more damaging than what was intended. Because teens are so rebellious, lowering the†¦show more content†¦That I why minors need to learn there will be consequences if they disobey the law because of their restlessness and adults must be more cautious when allowing teens to drink illegally. Children can still be growing all the way up to even eighteen years old. Because minor’s bodies are still growing and developing, consuming alcohol can interfere with the development of a child’s brain. Consuming alcohol can interfere with the development of a young person’s brain. The teen brain is not as developed as twenty-one year olds, which can lead to risks and damages before they are even allowed to drink. As a result, this early set of drinking may lead to addiction, memory loss, violence, and suicide risk is even greater and it would also be medically irresponsible to lower drinking age from twenty-one to eighteen. Select Federal Agencies discovered, â€Å"The brains and bodies of teens are still developing, and alcohol use can cause learning problems.† Children ate the future and we want them to grow up healthy and not have any health issues later on in life. People want them to succeed in life, but if the drinking age is lowered it will result in future health issues and they will not be able to live life to the fullest. There is a reason why poison such as drugs and alcohol have laws. Alcohol makes teens choose wrong decisions and change judgment that could lead to death, diseases, or injuries. Many people have hard about or know someone who has been seriously harmed by theShow MoreRelatedThe Legal Drinking Age Of The United States965 Words   |  4 PagesStates, when a man or women turn eighteen they are considered an adult. Being eighteen, they are not acknowledged as teenagers anymore. They have more freedom and more opportunities to become independent. Some of the opportunities an eighteen years old are given are the right to vote, open bank accounts, lease their own apartment or join the military. They have equal opportunities like adults over the age of twenty-one. However, anyone between the age of eighteen through twenty are not allowed toRead MoreThe Legal Drinking Age Should Be Lowered Essay1548 Words   |  7 Pagestwenty-one to legall y drink alcohol are very scarce. There are many different points, made by people from both sides of the issue about whether or not to lower the drinking age to eighteen, or leave it where it currently stands at twenty-one. Although each side has its own arguments, the legal drinking age should be lowered to eighteen years of age throughout all fifty United States. When you turn the age of 18 in the United States, you are considered an adult. Becoming an adult comes with its rights andRead MoreLowering The Alcohol Drinking Age1602 Words   |  7 Pagesout of trouble. If teens can stay safe while drinking then they should allow eighteen year olds to drink. Eighteen year olds are young adults and are responsible for what they do so they know that they need to be careful while drinking. Even though people do not agree because alcohol is dangerous and some teens can’t control themselves, I personally think they can so they should lower the alcohol drinking age to eighteen. It will help teens stay out of trouble, stay safe, and learn how to be carefulRead MoreUnderage Drinking At The United States916 Words   |  4 PagesAs an eighteen year old in America, you are able to sign housing contracts, join the military, marry a loved one, or even own a firearm but you cannot have a legal drink. We are allowing young American citizens to sign th eir life away to fight for our country yet if they are seen with a beer they will experience legal complications. Also, at the age of eighteen you are able to smoke and purchase cigarettes, why make drinking different? Underage drinking in America is inevitable. Bill H.R 734, EliminatingRead MoreDrinking Age1395 Words   |  6 Pagesage to consume or purchase alcohol has been twenty-one. Before the age was changed to twenty-one it was previously eighteen. This law was not changed to upset those who were between the ages of eighteen and twenty-one at the time or to restrict their freedom. The law was put in place for the safety of the people of the United States from the dangers of alcohol at an age believed to be too young to handle the consequences. Some individuals and groups feel that the drinking age should be lowered becauseRead MoreWhy The Drinking Age Should Be Lowered1237 Words   |  5 Pageslowered to eighteen like most of the world or if it should stay at twenty-one. Un derage drinking has been a major controversial issue for years, yet why is it not under control? Teenagers are continuing to buy alcohol with fake identification cards, drink, get into bars, and drink illegally. As a teen I have proof that these things are going on not only in college but in high school as well. There are a lot of factors that come together to why the drinking age should be lowered to eighteen; the mostRead MoreDrinking Age Should Be Lowered937 Words   |  4 Pagestwenty one to eighteen There is no taboo subject in America quote like underage drinking. The principal problem is not the age of drinking, but the hidden binge side of it. When it comes to the law, there is always an opinion. A reform should be made about the age of drinking for numerous reasons in my personal viewpoint. In the U.S, at the age of eighteen, one can legally vote, buy cigarettes, and join the army, to cite a few things. Going against the law, critics recommend allowing eighteen-year-oldsRead MoreDont lower the drinking Age1229 Words   |  5 PagesDespite the problems that would arise, many people are beginning to feel that the drinking age should be lowered from twenty-one to eighteen. Studies have been made; however, no hard evidence suggesting lowering the minimum drinking age would help have surfaced. Although there are countless studies of how alcohol has many harmful effects on teenagers, there is a great deal of negative criticism about what if the drinking age is lowered. Some would say the morally right decision is to not allow teensRead MoreThe Debate Over A Proper Legal Drinking Age1243 Words   |  5 PagesThe debate over a proper legal drinking age has been ongoing for decades. Some people believe twenty-one is the right age for legally consuming alcohol, while others believe twenty-one is too old. There are many supporters of an age limit of eighteen on alcohol consumption, but it has not been enough to sway Congress away from their set age of twenty-one. One major advocate for the age of twenty-one is the organization MADD, or â€Å"Mothers Against Drunk Driving†. This organization supports the age ofRead MoreDrivers Beware Essay945 Words   |  4 Pagesdebates whether the driving age for teens should be sixteen or eighteen captured the nation. Sixteen year-olds have a legitimate argument for keeping the age where it stands, but statistics show that sixteen year olds are not responsible enough to drive, and that more practice is needed before a nyone should get a driver’s license. However, from the looks of it, it seems that legislation is going to make the legal driving age eighteen. Sixteen year olds do have a valid argument as to why the age

Spectator Violence at Sporting Events Free Essays

â€Å"These people want to hurt you. It†s frightening. You feel like you†re in a cage out there†. We will write a custom essay sample on Spectator Violence at Sporting Events or any similar topic only for you Order Now Reggie Smith, (Berger, 1990). Spectator violence at sporting events has been recorded throughout history. People who have power over the events, often team owners, indirectly influence the amount of spectator violence by encouraging the factors contributing to violence, in order to benefit themselves. Sale of alcohol, encouraging crowd intensity, creating rivalries, and targeting social groups, are factors affecting the degree of spectator violence and can be proven to be influenced by the owner†s actions. Therefore the blame for spectator violence can be attributed to whoever has power over the sport. Many historians suggest that an increase in spectator violence coincides with the commercialization of sports. Anthropologists agree that in societies where games were not for profit, they were enjoyed as celebrations of physical skill without competitiveness or violence between players or spectators (Berger, 1990). However, when people gained power or financially from the sporting events, spectator violence increased (Berger, 1990). Public spectacles and games were part of the Roman Empire. Each emperor had an amphitheater and the size of the crowd reflected the emperor†s wealth or power. The emperor through crowd excitement could influence spectator violence to such an extent that gladiators could be killed or freed depending on the crowd†s effect on the emperor (Robinson, 1998). The emperor encouraged the Roman working class, â€Å"to forget their own suffering, by seeing others suffer,† while the senators, and emperor would benefit financially from gambling profits (Robinson, 1998). With the commercialization of sports, owners† profits increased with alcohol sales. Beer drinking has been an integral part of sports since the late 1870†³s. Chris van der Alie noticed that his saloon did well when St. Louis Brown Stockings were in town. As a result, he decided to sell beer at the games. On February 12, 1880, Alie signed a contract with the Browns allowing him to sell alcohol on their property (Johnson, 1988). During a game on July 6, 1881, the first alcohol related brawl broke out in the crowd, injuring twenty spectators and killing two (Johnson, 1998). The signed contract with the Browns† was a financial bonus for the owner, however permitting alcohol to be sold, might have indirectly contributed to the injuries and deaths. Alcohol sales contribute financial support to teams. â€Å"Without beer companies as sponsors, the teams would have trouble making ends meet. † Bob Whitsitt, president of Seattle Supersonics, (Berger, 1990). The more alcohol consumed, the more revenue for the owners. During the 1987-1988 season the Cincinnati Reds sold 12,610 half-barrels and 35,365 cases of beer. The amount of beer consumed averages out to a pint for every man, woman, and child who attended the 81 games the team played at home (Johnson, 1988). The team†s owner benefited with a financial profit of over 1 million dollars. Sponsorship or ownership of teams by alcohol manufacturers, increases the alcohol sales. The first major partnership of beer and baseball dates from the 1953 purchase of the Cardinals by August A. Busch, Jr. , president of the Anheuser-Busch brewery (Johnson, 1988). In twenty-five years its† sales soared from fewer than 6 million barrels a year to more than 35 million (Johnson, 1988). In addition to direct profit, alcohol also indirectly increases profit through increased attendance. In 1974, when the Cleveland Indians† fan attendance was down, the owner implemented â€Å"Beer Night† where they sold beers for 10 cents at the first game of a three game series against the Texas Rangers (Berger, 1990). Attendance was up by 3500. The night turned out to be the first and last â€Å"Beer Night†. When a brawl occurred during the 5th inning, hundreds of Indian fans charged the field and beat up the Texas Ranger players. Seventy-six people were arrested. All were intoxicated (Berger, 1990). There†s no question that the beer played a great part in the affair† (GM Eddie Robinson). Eddie Robinson did not apologize for the incident, and it took Lee MacPhail, president of American League to intervene and ban the beer nights (Johnson, 1988). The rowdy behavior contributed by alcohol consumption often accompanies the throwing of beverage containers. Cups, bottles, and cans act as stimuli and provide a throwing opportunity. In 1988, Pete Rose of Cincinnati Reds was pelted with full cups of beer and whiskey bottles, when he stormed out of the dugout to dispute a call. It was insane, many of the fans were throwing unopened beer cans† Pete Rose, (Johnson, 1988). To restrain spectator violence, many agree with not selling alcohol at sporting events. â€Å"The selling of alcohol at sporting events should be banned† (Johnson, 1988). Other solutions have been implemented, such as limiting drinking to designated areas, selling low alcohol beer, and making it more difficult to buy. The solution of prohibiting alcohol at games was never implemented (Johnson, 1988) Alcohol sales increase revenue; profits keep the owners satisfied. The owners to increase entertainment and increase attendance often promote other stimulants such as music, hearing obscenities, and aggressive play in the event or in the stands. Since sports are a source of entertainment, loud music and aggressive play in the event pump up the crowds, increasing the fans† enthusiasm. Hearing obscenities can be contagious and escalate into more swearing, name calling and fighting. An obscene cheer starts with two fans, increases to eight and soon a whole section is vibrating to the pulse. If fans take exception to the obscenities individual fights break out building into group fights, as friends come to assist. Owners are often able to control the crowd†s involvement in the game with the type of music they play and how loud they control the volume (Robinson, 1998). An excited, participatory crowd heightens the atmosphere and increases future ticket sales, benefiting the owner. However, the same atmosphere can increase hostility leading to fan violence. Basketball games attract anywhere from twenty to thirty thousand fans, whereas a gymnastic competition may attract a few hundred (Robinson, 1998). This is party due to the loud, exciting atmosphere at a basketball game. Goldstein did a study comparing crowd hostility before and after a basketball game to before and after a gymnastic competition. He proved that the hostility increased considerably for the basketball fans, and also discovered that hostility occurred no matter if the fan was rooting for the winning or the losing team (Robinson, 1998). Large sport events like basketball often use music to increase the crowd†s hostility and competitive awareness of the game. Owners often don†t realize at what point hostility turns to fan violence. This may have been the situation for Dan Goodenow, organizer of the 1988 Martin Luther King Classic basketball tournament where 5 fans were arrested, a man’s face slashed, and a police officer injured during a riot (Atyeo, 1979). Coaches and game officials blamed the rap group Public Enemy, who played before the game shouting obscenities, carrying plastic guns, and working up the crowd to an extent of raucous excitement (Chapman, 1988). Owners or school leaders help create team rivalry by encouraging fans, through city or school patriotism, to support their team. With media support, owners use historical team rivalry, competitive stories, propaganda and team loyalty to promote high-ticket sales and increase profits. Excessive promotion of rivalry changes crowd cheers to jeers that can lead to violence. The most common rivalries are school rivalries. Starting as far back as 1899 the students of Colorado School of Mines and those of Colorado College would celebrate victory by using dynamite to blow up the rival†s goal posts (Taylor, 1992). During one game the presidents of the universities promoted the final game, as â€Å"The top college in Colorado will win† (Taylor, 1992). By game time, most students from both schools were there to cheer their teams on. When Colorado College was down their fans, frustrated by the score and the name-calling, stormed the field at half time where a riot broke out. When rivalry was claimed to be a factor it was no longer promoted, and violence diminished (Taylor, 1992). A similar example of rivalry leading to hostility occurred in the 1999 Red Feather game Banting vs. Westminster. To encourage attendance and raise money for charities both schools had pep rallies to pump up the students by using music, videos and chants. During half time the two schools emerged towards the center of the field taunting each other. The organizers of the rallies intent on boosting ticket sales inadvertently encouraged spectator violence. There is an increase in violence following sporting events promoting rivalry as compared to regular promotion, as seen in professional boxing following a highly talked about match. The promoters in boxing do everything they can to make sure the matches turn out violent to satisfy the crowd. David C. Phillips a sociologist studied the rate of homicides following highly publicized heavyweight championship fights. The survey was done the 3 weeks following each of 18 highly publicized bouts from 1973-1978 compared to those bouts with normal publicity (Davidson, 1983). Phillips found that there were 193 more murders, in the surrounding areas, after the promoted fights as compared to the norms (Davidson, 1983). After the highly promoted Muhammad Ali vs. Joe Frazier fight on October 1, 1975, the murder rate shot up thirty-two percent (Davidson, 1983). Phillips theory is â€Å"people see how violence is prized in the boxing ring and come to believe that violence outside the ring will also be rewarded† (Davidson, 1983). The rewards however, are the financial rewards to the owners, through increased ticket sales and media advertising. Spectator violence may be parallel to violence in the society. For example in a violent society, play will be violent, whereas in a peaceful society play will be more peaceful. The make up of the social group contributes to the possibility of violence. Spectators can be divided into different social classes and the event advertised in areas where a particular social group is targeted for ticket sales. Often working class males are targeted, as their values and attitudes of aggressiveness, fearlessness and toughness are well suited to competitive sports (Bonney Giulianotti, 1994). They are likely to be the fans that are betting on the game or are there for the thrills (Berger, 1990). These fans are more likely to attend contact sporting events such as rugby and to be violent, compared to the upper class fans who analyze the game are more likely to attend a cricket match. In the sport soccer, hooligans who dominate the crowds are mainly males who generally act in rough, noisy behavior (Taylor, 1992). They have lawless fun, fighting spectators, throwing objects and vandalizing property. Most hooligans are from the working class. They have low ambitions, violent behavior and high stress levels (Bonney Giulianotti, 1994). They act out their frustrations, like the Roman working class, by attending sporting events where they loose their individualities. Fans in Glasgow, Scotland, trampled sixty-six persons to death when they tried to return to the stadium they had just left upon hearing that a last-minute goal had been scored. Berger, 1982). â€Å"Hooliganism gives the organization of a team motivation with their traditional cheers and it builds the atmosphere which builds a team† Lesie Davis, management of Peru†s soccer organization (Taylor, 1992). Major soccer teams target this low-income social class because it brings atmosphere to the game and alcohol sales and profits increase (Shumacher, 1975). In marketing ticket sales for most team sports, owners target males nineteen to forty-five. Sixty three percent of males and twenty percent of females in that age range are involved with sports whether they participate in them, or follow them (Oliver, 1971). Team owners often exclusively target males, resulting in an increase of ticket sales and merchandise. However, when males are bonded they often act violently emphasizing their masculinity, machismo, bravery and fighting skills (Tiger, 1970). Many teams in the American Baseball League in the 1970†³s were having problems concerning fan violence, and found the main instigators were males. They changed the games to Sunday, traditionally a family day and encouraged female fans by admitting them free. With women and family present the men were less likely to loose their individuality and act violently as a group. The results for the next 5 years were positive as fan violence decreased by 30 percent (Berger, 1990). By studying the occurrences, degrees, and causes of fan violence over history, owners are able to decrease the incidents of fan violence while maintaining profits and entertainment value of their organization. Slowly but effectively owners, teams, coaches and professional leagues are creating solutions to minimize fan violence. The American Baseball League, National Baseball League and the National Basketball Association participate in TEAM (Techniques for Effective Alcohol Management), which is a program for training everyone from vendors to ushers in handling people who have had too much to drink (Berger, 1982). Many of the NFL teams have moved their tailgate parties outside the stadium to eliminate the hostility caused by loud rock bands on the premises (Berger. 1990). Security cameras have been installed in many of the soccer stadiums and transportation centers to games, spotting the fans that cause the violence, and acting as deterrents for others. Controlled drinking areas, entrance controlled security checks, and increased visible security personnel are measures, which have helped to reduce fan violence in all sports. Most important, the owners need to be aware that some of their actions to benefit their organization have an indirect influence on the factors for fan violence. Sport is a basic feature of Australian culture. The achievements of Australian athletes have enhanced our image as a nation. Participation in sporting activities contributes to the health of millions of Australians; the teamwork and fair play which Australians learn on the playing field provide the basis for a good society. But Australian sport is not without shortcomings. Whilst sporting violence, on the part of both participants and spectators, is less frequent and less severe in Australia than in many overseas locations, it remains grounds for concern. Violence on the playing field sets a bad example for impressionable young Australians. Unruly crowd behaviour can spoil a pleasant family outing. How to cite Spectator Violence at Sporting Events, Essay examples

Kids These Days A Study of the Millennial Generation free essay sample

You are art of this group, and its unclear if this is a good thing or not. Its hard to tell everything about a generation until theyre all dead, but there are a few characteristics that Millennials are pretty obvious. Technologically Savvy Millennials have never had to use word processors†Just word processing software on computers. Millennials dont really remember a time without cell phones, and probably own one now. Millennials gasp when you tell them Facebook is only nine years old†that there was a time when they didnt document every second of their life ith selfies and status updates. Millennials grew up playing games on CD-ROMs, spent their middle school years on Club Penguin, are now hooked on Candy Crush on their iPhones. You live in the time that technology is commonplace and will only get bigger and better. In the early days of their lives, many of Millennials used floppy disks. We will write a custom essay sample on Kids These Days: A Study of the Millennial Generation or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page By the time they hit middle school, it was all about USB flash drives. Now, they just upload it to a cloud of information on the internet and pray they have wifl when they need it. Unlike their parents, Millennials have been exposed to technology from very young age and have developed along with it. They can adapt to technology without question, while a good deal of older generations are still struggling along. Narcissistic and Optimistic Another characteristic of the Millennials is entitlement. Because of the way we were raised, we believe that we deserve the best, even when we dont do the best. We were raised on participation trophies and competitions where everybody wins! This stemmed from parents obsession with making sure their children had proper self-esteem; but self-esteem cant really be given as a prize. In soccer and baseball leagues, everyone got a trophy†the winner got the biggest trophy, but everyone got some sort of prize. A good effort prize. Every post-game meeting of any sports team, the coach starts out with we did our best, or we gave it our all before going on to gently criticize performances. And its Just now that its really starting to make a difference. A lot of younger Millennials are applying for their first Jobs and becoming appalled when they have to apply for five, ten different Jobs†why didnt the first one hire me, huh? The seniors are applying for college, and theyre going to be sorely disappointed when they dont get into their number one choice. And their parents have not prepared them for that. According to them and the way they raised their children, every single one ot the Millennials will nave a Job†its Just a matter ot now g job it will be. Even more, everyone believes that they can make a difference†that they will be the exception to the rule, the one in a million that has a crazy success story and makes it to the top on dreams and pluck alone. A survey by Telefonica hows that 83% of American Millennials believe they can make a local difference, and 52% believe they can make a global difference. Open-minded Recent studies have shown that Millennials are automatically more accepting than any previous generation. Baby Boomers are still a little bit racist, which partially may have passed onto their children. But it would be much harder to find a Millennials who would purposefully discriminate against someone because of their skin color. President Obama was elected for the first time in 2008†some Millennials were old nough to vote in this election. While they might not always agree with someones lifestyle, the rising trend of Millennials is to not interfere with anyone elses personal life, as long as theyre not hurting anybody else. An approximated 81% of Millennials believe that same sex marriage should be legally recognized, according to the Advocates for Youth study; 65% of Millennials support the legalization of marijuana according to the Pew Research Poll. What Will Millennials Become? Generation X, usually defined as anyone born from the late 60s to the early 80s, was haracterized as a group of lazy, passive slackers in their youth, but they are currently defined as well-educated, cynical, and confrontational. So it is projected that each Millennial will develop into someone more than Just a narcissistic, accepting techie. But theres even a trend that teenagers attempt to define themselves at a younger age. Most people are fairly certain of who they are by the time they graduate (or at least make a good show of saying they are). Whatever happens, remember that you dont have to be defined only by your generation.

Pandemic free essay sample

TuberculosisWe are entering the third decade of what may be the most devastating epidemic in human history: HIV/AIDS. The HIV/AIDS Pandemic is a large-scale epidemic affecting more than one country. AIDS was first clinically diagnosed in the early 1980s but retrospective diagnosis suggests it existed well before this date. AIDS is a syndrome, which develops from an impaired ability to fight diseases. It undermines the body’s defenses against viruses, infections and malignancies. Here, we describe the origins and evolution of these viruses, and the circumstances that led to the AIDS pandemic. Pandemic Assignment Since scientists identified the HIV as the cause of AIDS in 1983, it has spread insistently, causing one of the most harmful pandemics ever recorded in human history. However, concerted global efforts to fight the pandemic are making a significant difference. More than nine million people living with HIV in low and middle-income countries now have access to life-saving antiretroviral treatments. We will write a custom essay sample on Pandemic or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page HIV/AIDS Overview Human immunodeficiency virus (HIV) invades the body through the exchange of certain body fluids. The virus invades cells such as T helper cells and begins to replicate itself in the human body. Acquired immunodeficiency syndrome (AIDS) of humans is caused by two lentiviruses, â€Å"HIV-1 and HIV-2; HIV-1 accounts for the majority of infections in the world, and has at least 10 genetic subtypes† (Lamptey, Wigley, Carr, Collymore, 2002). Both HIVs are the result of multiple cross-species transmissions of simian immunodeficiency viruses (SIVs) naturally infecting African primates. However, as according to Sharp Hahn (2011), one transmission event, involving SIVcpz from chimpanzees in southeastern Cameroon, gave rise to HIV-1 group M—the principal cause of the AIDS pandemic† and noted that by â€Å"tracing the genetic changes that occurred as SIVs crossed from monkeys to apes and from apes to humans†. AIDS Pandemic and the Efforts to Stop HIV/AIDS According to Merson â€Å"on June 5, 1981, few suspected a pandemic of AIDS when the Centers for Disease Control reported five cases of Pneumocystis carinii pneumonia (PCP) in young homosexual men in Los Angeles† (2006). Morbidity and Mortality Weekly Report (MMWR) reported that all the men had other unusual infections as well, indicating that their immune systems were not working; two had already died by the time the report was published. In a timeline created by AIDS. com, â€Å"this edition of the MMWR marks the first official reporting of what will become known as the AIDS epidemic† (2014). Although â€Å"after pandemic HIV-1 first emerged in colonial west central Africa, it spread for some 50 to 70 years before it was recognized† (Sharp Hahn, 2011) because phylogenetic and statistical analyses have dated the last common ancestor of HIV-1 to around 1910 to 1930. For a while the American government completely ignored the emerging AIDS pandemic. The first attempt to treat HIV was in â€Å"September 1986, when early results from clinical trials involving AZT (zidovudine) – a drug that was first investigated as a cancer treatment – showed that it might slow the attack of HIV† (AVERT, 2013). Although AZT could slow progression to AIDS in HIV positive individuals with no symptoms, a year’s supply for each person would cost around seven-thousand dollars and many did not have adequate health insurance to cover the cost. In 1995, â€Å"FDA announced that the drug 3TC (lamivudine) had been approved for use in combination with AZT in treating AIDS and HIV† (AVERT, 2013) after a number of studies had shown that HIV could quickly become resistant to AZT and that the drug had no benefit for those in the early stages of the disease. On April 5th 1990 Ryan White, schoolboy who had become infected with HIV via a blood transfusion for his haemophilia, died. He was known for his fight to return to public school after he was banned due to fears of spreading of AIDS to other children. â€Å"Following Ryan’s death, the American government implemented a new programme named after him – the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act† (AVERT, 2013). Its aim was to improve the quality and availability of care for low-income, uninsured and underinsured individuals and families affected by HIV. In 2000, the government funded programs such as needle exchange services and abstinence-only education and in 2001 the Centers of Disease Control (CDC) set a goal to halve the number of people infected with HIV each year in the USA to 20,000 by the end of 2005 but by 2003 it was already clear that the CDC’s goal would be missed, the number of new infections had shown no sign of declining. In 2006, President Bush signed the reauthorisation of the Ryan White HIV/AIDS Program, â€Å"since its creation in 1990 the program had provided federal funding for thousands of Americans living with HIV/AIDS unable to pay for their treatment themselves† (AVERT, 2013). In 2007, raltegravir – was approved by the FDA which according to AVERT â€Å"Raltegravir was the first of a new class called integrase inhibitors† and â€Å"the significant progress in treatment proved to be particularly important to thousands of HIV positive Americans whose treatment had been failing due to drug resistance (2013). It was believed to provide extended years of meaningful survival to patients. In July 2010, â€Å"the USAs first HIV/AIDS Strategy was released† (The White House Office of National AIDS Policy, 2010) and reducing new HIV infections was included as one of the Strategys three core aims. According to AVERT (2013), â€Å"in order to reduce new infections without an increase in funding, the Strategy recommended that HIV prevention efforts be intensified in the communities where HIV is the most heavily concentrated†. MedlinePlus concluded that â€Å"there is no cure or vaccine to prevent HIV/AIDS, but early detection through HIV testing and treatment can frequently turn this fatal disease into a manageable chronic disease† (2009). The HIV-1 pandemic is a complex mix of diverse epidemics within and between countries and regions of the world. â€Å"AIDS remains the fourth leading cause of death in low-income countries† (International AIDS Vaccine Initiative, 2014). While there will never be a solution to HIV and AIDS, a preventive vaccine would do a great deal to curb the pandemic. But unfortunately, the problem with developing a vaccine is that the HIV genome mutates very quickly. Stowell (2006) explains that all organisms vary a little throughout the centuries. The HIV genome mutates around 1000 times more quickly than the human genome around 1000 times more mutations accumulate in a single year, relative to the length of the genome. Antiretroviral treatment has transformed AIDS from an inevitably fatal condition to a chronic, manageable disease in some settings.

How to Write Headlines and Subheads

How to Write Headlines and Subheads How to Write Headlines and Subheads How to Write Headlines and Subheads By Mark Nichol The first thing most readers notice in print or online is a headline. Think of it as a virtual handshake. If your headline is the text equivalent of a cold, dead fish, you’ll make a poor first impression. Or think of it as analogous to a cover letter or a request for a date. You only get one chance to introduce yourself make it good. Various types of headlines exist, and some are more suitable than others for various types of content. Here are eight categories appropriate for selling something, whether it’s a product or an idea, along with a sample headline of that type: 1. Direct: â€Å"Lawn Mowers on Sale† Such an approach may seem dull, but consider that no single reader personality prevails; some people like an unadorned statement. Many people looking for lawn mowers on sale will be gratified to see the headline â€Å"Lawn Mowers on Sale† â€Å"Ah, just what I was thinking.† 2. News: â€Å"Remote-Control Lawn Mower to Debut in April† A journalistic headline conveys authority and is straightforward without being plain. 3. How-To: â€Å"How to Select the Best Lawn Mower for Your Yard† The words â€Å"how to† have launched a million headlines (many of them right here on this site), and for good reason: What do you type into a search engine when you want to learn how to do something? â€Å"How to† tells readers that somebody out there wants to help them. 4. Question: â€Å"Is Your Lawn Mower the Right One for the Job?† A query to readers is an invitation, a promise that they’ll get something out of the experience; all they have to do is pick up the magazine or click on the link and read. 5. Command: â€Å"Go to Lawn Mowers R Us for the Best Deals† You don’t have to be a current or former military service member to know that a directive gets one’s attention. Of course, it’s more likely to succeed in a marketing pitch if it aligns with the target audience’s desires. 6. List: 7 â€Å"Things to Look for in a New Lawn Mower† The next-best approach to a how-to headline is a list. Look in the archives here at Daily Writing Tips and notice how many headlines start with a number. People like enumeration; it offers a promise that they will come away from the reading experience with quantifiable results. 7. Testimonial: â€Å"I Got a Great Deal on a New Lawn Mower† A testimonial, an authentic or fictional statement about the value of a good or service, is a time-honored advertising strategy. People are drawn to anecdotal evidence especially if it is accompanied by a photograph of a celebrity or an attractive model who has ostensibly offered the claim even though such overtures are notoriously unreliable. But if you routinely employ testimonials that stand the test of trust, even readers who practice critical thinking will find them appealing. 8. Teaser: â€Å"The Most Important Purchase You’ll Make This Year† Take care with this approach, because you can easily overextend yourself. â€Å"My most important purchase of the year will be a lawn mower? Really?† If you can back up the tease a survey of real estate agents concludes that good lawn care drives up property values and is a significant factor in home sales over the asking price then by all means use it. But be careful: One unsubstantiated teaser headline can drive a reader away forever. Conciseness Notice that none of the sample headlines above is more than ten words long. Many effective headlines are half that long, or even shorter. Make sure your headlines are no longer than they need to be, but nail the technique or catch the vibe you want first, then reduce the word count if possible. Take care, however, not to truncate unnecessarily: You might think, for example, that â€Å"How to Select the Best Lawn Mower for Your Yard† has three extraneous words at the end, but the best lawn mower overall may not be the best lawn mower for your yard, and the use of the word your personalizes the message hey, reader, I to help you! Originality Copy and paste your final draft into a search engine. If it comes up, consider altering one or more words or starting over again. There’s nothing wrong with using an existing headline there are only so many ways to string together a handful of words about a topic but you may not want your article to be associated with the content beneath that existing one, especially if it’s of inferior quality. And don’t hesitate to use a basic, functional headline, or to assume that it’s already been taken: In an online search, the headline for this post (the most fundamental wording I can think of for the topic) came up only in a single extent reference, and was in an obscure video tutorial. Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Freelance Writing category, check our popular posts, or choose a related post below:Using "a" and "an" Before Words10 Colloquial Terms and Their MeaningsPrepositions to Die With

7 derechos de los indocumentados si son arrestados

7 derechos de los indocumentados si son arrestados Si eres uno de los 11 millones de indocumentados que viven en los Estados Unidos, estos son tus derechos en los casos de arresto o si la Policà ­a te para en la calle o te ordena parar mientras manejas un auto. Derechos de los indocumentados La policà ­a no puede entrar en una vivienda sin que tenga orden judicial (warrant). La excepcià ³n es si tiene motivos fundados de que se est cometiendo un delito (atacando a una persona, traficando con drogas, etc.). Si la policà ­a llama a la puerta, pedir el warrant muy educadamente y sin perder los nervios. Si no la tienen sà ³lo pueden ingresar si se les da permiso, pero se les puede decir que no. Si la policà ­a para a un inmigrante en la calle o cuando est manejando o en el trabajo recordar que se tiene el derecho a permanecer en silencio. La à ºnica excepcià ³n son algunos estados en los que se est obligado a decir el nombre. Verifica si resides en uno de esos estados. Si es asà ­, se dice. Si la policà ­a lo para a uno se le puede preguntar si se puede ir (free to leave, en inglà ©s). Si la respuesta es afirmativa (hay que oà ­r el yes), se puede ir, pero sin movimientos bruscos. Nunca perder la calma (aunque por dentro se està © muy nervioso). Si se es arrestado se tiene el derecho a pedir hablar con un abogado. Es muy conveniente cargar siempre con el nombre y el nà ºmero de telà ©fono de un abogado de inmigracià ³n con buena reputacià ³n (o incluso ms de uno, por si no contesta o no puede hacerse cargo del caso). Si se est como indocumentado en Estados Unidos no cargar con documentos como el pasaporte u otros como la matrà ­cula consular que puedan probar que se est ilegalmente en el paà ­s. Si se tienen se guardan en un lugar seguro, pero no se les lleva con uno. La razà ³n de lo anterior es que para que el gobierno pueda deportar a una persona es necesario que pruebe que est aquà ­ ilegalmente (o que ha hecho algo que amerita la deportacià ³n). Si no se dice nada, si no hay rà ©cords de ninguna clase entonces tiene difà ­cil probar su caso. Lo ms aconsejable es no hablar ni mostrar documentos y esperar por el abogado. Si se est ilegalmente en el paà ­s y se tienen personas dependientes como por ejemplo hijos menores, tomar la precaucià ³n de hablar con personas de confianza quià ©n debe hacerse cargo de ellos, cules son las instrucciones, cà ³mo acceder al dinero ahorrado para gastos, etc. Es incluso muy conveniente hacer un escrito ante notario. Jams firmar algo que no se entiende. Esto puede ser porque est en inglà ©s y sà ³lo se habla espaà ±ol o porque no se acaba de entender las consecuencias del documento que se le pone delante. Tampoco firmar ningà ºn papel si no se est de acuerdo con lo que dice, aunque se entienda. En estos casos esperar por el abogado. Una vez que se firma es muy difà ­cil dar marcha atrs. NO importa lo mucho que insistan. Si no se quiere firmar o no se entiende, no se firma. Muy importante Jams dar o enseà ±ar a la Policà ­a un documento falso. Jams decir que se es ciudadano americano si es una mentira. Esto es muy grave. Permanece callado, si asà ­ se desea. Pero no mentir, si se habla. Si la policà ­a lo para a uno, permanecer siempre en calma. Jams mostrarse violento, muy nervioso, hacer movimientos extraà ±os o salir huyendo, esto à ºltimo es considerado como una violacià ³n migratoria que amerita la deportacià ³n. Saber que existen en las carreteras retenes migratorios internos en algunas partes del paà ­s. A tener en cuenta De los estimados 11 millones de indocumentados presentes en Estados Unidos, aproximadamente menos de cinco podrn beneficiarse de las medidas anunciadas por el presidente Obama que les protege frente a la deportacià ³n. Si crees que puedes calificar para esas medidas, infà ³rmate con abogados u organizaciones de apoyo a inmigrantes que sean reputados. Evita ser và ­ctima de un fraude migratorio y considera reportar los casos que sepas. No  pagues a personas que ofrecen cosas que simplemente no existen o que cobran por sus gestiones cantidades completamente desorbitadas. Y ten presente que por ahora DAPA y DACA extendido no se estn aplicando. Y si recibes una carta para presentarte en Corte es el momento de buscar abogado. Tener presente que puede haber una demora grande en los casos en las Cortes migratorias. De interà ©s En algunos estados, como por ejemplo Nueva York o California, algunos indocumentados podrà ­an ser considerados PRUCOL. En estos casos, tendrà ­an derecho a algunos beneficios sociales de los que generalmente los indocumentados estn excluidos. Y es que hay importantes diferencias entre estados en lo que afecta a indocumentados: unos son muy estrictos y otros han pasado medidas para hacerles la vida un poco menos difà ­cil. Finalmente, la presidencia de Donald Trump est teniendo un  gran impacto en las comunidades migrantes. Esos son 9 asuntos migratorios sobre los que ya se ha pronunciado y conviene estar familiarizados. Adems, conviene saber cules son las 7 nuevas prioridades de deportacià ³n, segà ºn orden ejecutiva de enero de 2017. Este artà ­culo es meramente informativo. No es asesorà ­a legal.

Multi-national organization that is an ideal candidate for acquisition Research Paper

Multi-national organization that is an ideal candidate for acquisition - Research Paper Example According to Miller, Vandome and John (2010) have reported that the company has furthered its growth in the foreign market and has branches in Sweden, United States, UK and other 100 countries. It is headquartered in London, UK. AS of 23rd December 2011 it had a market capitalization of approximately ? 39.5 billion. It has an operating income of US $8.15, a net income of US$ 6.33 billion, and 57,200 employees in the year 2012. AstraZeneca is involved in the development, manufacturing, and selling of pharmaceutical and biotechnological products. According to Magidibe (2011) reported that the pharmaceutical industry is also risky because to develop a drug requires huge investments and out of the many thousands of discovered compounds. As a result, only one might be approved drug for sale with the failure rate being high and very difficult to get the return on investment. To venture into a foreign market requires a consideration of various factors. Cultural diversity plays a crucial rol e in the organizational structure of the business. Cross-cultural diversity is emphasized as it helps create cohesion in the organization. To attain international business success, the organization must employ the services of the people in the nation you have established your business. This is leads to product diversity. According to McDowell (2011) found out that productive diversity refers to the business benefits that emerge through the employment of many different people. Such advantages are referred to as diversity dividend and comprise of: expanded global opportunities; an improved business to business relations; enhanced innovation and creativity; advanced communication between the parties; superior teamwork skills; quality customer service; and reduced workplace conflict. For an organization to be effective in their translation of goals into results there must be an alignment between organizational structure and the business strategy. Alignment is attained when the shared be liefs, ways of working and values within the organization drive towards the realization of strategic objectives and goals. The pharmaceutical industry has many challenges if you want to establish the organization globally. It therefore needs a strategy in order for it to survive in the foreign environment. According to Afuah (2009) is of the opinion that strategy is the actions taken by managers to attain certain goals and objectives of the firm. The key aspects of global strategies include: treating the global market as a domestic market; creation of a global marketing mix; creation of production and distribution systems; concentrating on the power brands. With my pharmaceutical company investing in a nation that we were not aware of the pharmaceutical industry, therefore the need to align with AstraZeneca. The conduction of business analysis found out that pharmaceutical industry is characterized by rising consumer expectations and an ageing population which continues to create un met medical needs. Cherubini (2013) argues that there are the enormous needs of the developing nations nearby a fundamental driver behind continued research and development (R&D) investment so as to create novel drugs. However, the costs of healthcare have consistently raised faster than GDP thus creation of an unsustainable situation in healthcare systems, whether it is publicly or privately funded. Entry into a foreign market requires a strategy. The probable strategy to enter the European market is by utilizing

The Burgelman Case Study Essay Example | Topics and Well Written Essays - 1000 words

The Burgelman Case Study - Essay Example Surveys and exploratory studies are examples of descriptive research designs, which are more quantitative than qualitative and have more aspects of this type of theory. Quantitative studies tend to rely on hard data and statistics that can provide generalizable results about a population, whereas qualitative studies could be more of a case example or subjective viewpoint. Bergemann's case study states having a qualitative method in place: â€Å"A qualitative method was chosen as the best way to arrive at an encompassing view of ICV project development has a ten- to twelve-yeartime horizon (Biggadike, 1979), and a truly longitudinal study was thus beyond the available resources† (Burgelmann, 2009). In terms of statistics, the single case study is not very representative. Another disadvantage in reference to flexible designs could be their lack of scientific credibility when compared to fixed designs using inferential statistics, which Burgelmann addresses explicitly as a possib le drawback. Of course, it is fitting at this level of research for authors to be forward with possible limitations of the study; however, this admission does not make the study more statistically or empirically viable, just because of this admission.   #2 Since this is a qualitative study, it tends to focus more on theory forming, rather than theory testing.

Traveling in the New Kingdom of Egypt Essay Example for Free

Traveling in the New Kingdom of Egypt Essay Life on the road to Thebes is hard for anyone, not the least for a foreigner from the land of Egypt’s former enemy. Not that it makes much difference if you have money. The poor walk; the rich take horses or camels. If you are walking along the roads and are suspected of being a foreigner, be prepared to be harassed. As for me, I am fortunate. I am neither poor, nor rich for I have some skills of value. These skills I would consider modest in comparison to the military conquests of other men which have defined most of my life. My name is Jakarob, the son of a stone mason from the land of Syria, but that land has long been abandoned by my family. The Hittite invasion swept away my father’s house. As a result, I received very little knowledge of stonemasonry and instead, survived by learning the art of languages such as Akkadian, Sumerian, and Egyptian. My knowledge of the surrounding regions, languages, and eventual journey into Egypt has made me a valuable asset to the court of Pharaoh Ahmose I. The caravan I ride with is apart of a group of professionals answering the request of the pharaoh; many of them have military expertise. These men are like me in ancestry. We are Semites who came across the Sinai into the land of Egypt seeking refuge in the land of Egypt from the Hittites. Our kings are referred to by the Egyptians as Hyksos, or â€Å"rulers of foreign lands† (Kishlansky, p. 22). We settled throughout the land of Egypt, taking up their customs, traditions, and assimilating into their culture. My father was among the first Semites to arrive in Egypt and settle. However, regardless of how assimilated our people have become in Egypt, we will never fully be accepted as Egyptian. To them we will always be foreigners. The most important innovation our people brought to the Egyptians was military technology, and hence the reason the caravan I am in consists of primarily military men. Before the Semites, the Egyptians had an army which was not very mobile. We introduced the chariot, along with a variety of tactics associated with using the chariot in combat. Then around 1552 B. C. E. , Ahmose I was able to expel the Hyksos and begin again the reign of Egyptian pharaohs (p. 23). Now it seems that no matter what Ahmose does, he will never get rid of his need for Semite military expertise, not to mention translators like myself. The chariot has become a symbol of Egyptian power, and in order for them to continue dominating local dissenters, the pharaoh must rely on our knowledge of chariot methods and tactics. Personally I have no qualms with helping the pharaoh build his base of power. Life under the Egyptians is much more preferable to life under the Hittites. Before coming to Egypt, my family spent a number of years fleeing the Hittites in Babylon and southern Mesopotamia. In this region I learned how to use the character system of writing of â€Å"cuneiform† and the language of Akkadian (p. 14). With this knowledge I was also able to learn how to write characters in my native tongue of Sumerian. The reason for this similarity I learned was that â€Å"for over a thousand years, scribes used the same symbols to write not only in Sumerian but also in the other languages of Mesopotamia, such as Akkadian, Babylonian, and Persian† (p. 15). Thus, culturally the peoples of Mesopotamia and Egypt share a common link in their system of languages. In contrast, the Hittites do not share in this cultural similarity. Instead, they originate from the Indo-European people with writing traditions vastly different than the cuneiform system. At one time, part of the Hittites’ land was of the Akkadian Empire under King Sargon and the Hittite influence was minimal (p. 16). Alas, that time has long since past, as well as the later period in which the Babylonian Hammurabi ruled his strong empire and prevented the Hittites from forming theirs. Over a period of time, Hammurabi’s successors were unable to deter the rise of the Hittites, and Babylon was overrun. Now on the road to Thebes, the threat of Hittite invasion is very far away. The Sinai desert protects Egypt from incursions by Hittite chariots. Egypt is a land of great wonder and ancient power, for the reign of the pharaohs has stretched back for generations. The source of Egyptian power comes from multiple sources, including religious authority, strong government bureaucracy, and the magnificent pyramids. Each of these pillars of Egyptian strength supports the other. King Zoser, â€Å"the founder of the Old Kingdom who built the first of the pyramid temples, the Step Pyramid at Sakkara,† could not have done so without an efficient bureaucracy and religious legitimacy (p. 21). Likewise, the pyramids reinforce a pharaoh’s power and religious significance, for the pyramids is the resting place for pharaohs in the afterlife. In other words, â€Å"the pyramids strengthen the image of the living king by honoring the physical remains of his predecessors† (p. 21). This focus on the afterlife is partially the reason for their early downfall. As I make each step closer to Thebes, I think about how the focus of Ahmose I have changed since his predecessors. Men from a multitude of backgrounds can contribute to the pharaoh’s court, even peasants (p. 22). I have no doubt my contribution will expand its power and that the second rise of Egypt’s power has just begun.

Rhetorical Analysis of an Advertisement :: Advertising, Marketing

Rhetorical Analysis of an Advertisement Advertisements are all over the place. Whether they are on TV, radio, or in a magazine, there is no way that you can escape them. They all have their target audience who they have specifically designed the ad for. And of course they are selling their product. This is a multi billion dollar industry and the advertiser’s study all the ways that they can attract the person’s attention. One way that is used the most and is in some ways very controversial is use of sex to sell products. For me to analyze this advertisement I used the rhetorical triangle, as well as ethos, pathos, and logos. The target audience is both males and females in their late teens to mid twenties. This company gets the male side of the equation by getting their attention and interest drawn to the attractive woman on the right with bright colors drawing your attention there as well as the bottle of whiskey which is right in the middle of the page. Then what gets these peoples attention to stay there is the fact they have an incredibly good looking female who is posing in next to nothing. Then a way that they try and get the females to look at the advertisement and read it is by showing a very plain girl who seems to be very typical of girls during their younger years. Then beside they show the same girl who now has become a women who is very attractive and just seems so much more powerful and sure of herself. One way that you can achieve that is if you drink Evan Williams Kentucky straight bourbon whiskey. The purpose is to get young adults even ones that are under age to drink their whiskey. One piece of specific information that is sent across to you is that the whiskey is aged for seven years before it is sold. The writer’s whole purpose of this advertisement is to try and sell Evan Williams Kentucky Straight Bourbon Whiskey. The reason that I think that it advertises to people that are under age because the girl that is on the left in my opinion seems to be under age. Then they got that bottle of whisky which is in between each of the pictures. The author of this advertisement is all about sexual stereotypes such as blonde hair blue eyes and a very large breast size.

Introduction to Epidemiology

Aug 17 2011 Introduction to Epidemiology Epidemiology is considered the basic science of public health, and with good reason. Epidemiology is: †¢ †¢ †¢ A quantitative basic science built on a working knowledge of probability, statistics, and sound research methodology A method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality A tool for public health action to promote and protect the public’s health based on science, causal reasoning, and a dose of practical common sense (2).As a public health discipline, epidemiology is instilled with the spirit that epidemiologic information should be used to promote and protect the public’s health. Hence, epidemiology involves both science and public health practice. The term applied epidemiology is sometimes used to describe the application or practice of epidemiology to address public health issues.Examples of applied epidemiology include the following: †¢ †¢ †¢ †¢ the monitoring of reports of communicable diseases in the community the study of whether a particular dietary component influences your risk of developing cancer evaluation of the effectiveness and impact of a cholesterol awareness program analysis of historical trends and current data to project future public health resource needs ObjectivesAfter studying this document and answering the questions in the exercises, you should be able to do the following: †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ Define epidemiology Summarize the historical evolution of epidemiology Describe the elements of a case definition and state the effect of changing the value of any of the elements List the key features and uses of descriptive epidemiology List the key features and uses of analytic epidemiology List the three components of the epidemiologic triad List and describe Hill’s criteria of causation Understand the natural history of disease and the three types of prevention Understand infectivity, pathogenicity, and virulence List and describe primary applications of epidemiology in public health practice List and describe the different modes of transmission of communicable disease in a population 1 Page 2 Applied Epidemiology I A number of exercises are provided. It is suggested you attempt to answer these questions and then compare your answers with those at the end of this document. Introduction The word epidemiology comes from the Greek words epi, meaning â€Å"on or upon,† demos, meaning â€Å"people,† and logos, meaning â€Å"the study of. Many definitions have been proposed, but the following definition captures the underlying principles and the public health spirit of epidemiology: â€Å"Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the cont rol of health problems. † (17) Key terms in this definition reflect some of the important principles of epidemiology. Study Epidemiology is a scientific discipline with sound methods of scientific inquiry at its foundation. Epidemiology is data-driven and relies on a systematic and unbiased approach to the collection, analysis, and interpretation of data.Basic epidemiologic methods tend to rely on careful observation and use of valid comparison groups to assess whether what was observed, such as the number of cases of disease in a particular area during a particular time period or the frequency of an exposure among persons with disease, differs from what might be expected. However, epidemiology also draws on methods from other scientific fields, including biostatistics and informatics, with biologic, economic, social, and behavioral sciences. In fact, epidemiology is often described as the basic science of public health, and for good reason. First, epidemiology is a quantitati ve discipline that relies on a working knowledge of probability, statistics, and sound research methods.Second, epidemiology is a method of causal reasoning based on developing and testing hypotheses grounded in such scientific fields as biology, behavioral sciences, physics, and ergonomics to explain health-related behaviors, states, and events. However, epidemiology is not just a research activity but an integral component of public health, providing the foundation for directing practical and appropriate public health action based on this science and causal reasoning. Determinants Epidemiology is also used to search for determinants, which are the causes and other factors that influence the occurrence of disease and other health-related events.Epidemiologists assume that illness does not occur randomly in a population, but happens only when the right accumulation of risk factors or determinants exists in an individual. To search for these determinants, epidemiologists use analytic epidemiology or epidemiologic studies to provide the â€Å"Why† and â€Å"How† of such events. They assess whether groups with different rates of disease differ in their demographic characteristics, genetic or immunologic make-up, behaviors, environmental exposures, or other so-called potential risk factors. Ideally, the findings provide sufficient evidence to direct prompt and effective public health control and prevention measures. Health-related states or eventsEpidemiology was originally focused exclusively on epidemics of communicable diseases3 but was subsequently expanded to address endemic communicable diseases and non-communicable infectious diseases. By the middle of the 20th Century, additional epidemiologic methods had been developed and applied to chronic diseases, injuries, birth defects, maternal-child health, occupational health, and environmental health. Then epidemiologists began to look at behaviors related to health and well-being, such as amount o f exercise and seat belt use. Now, with the recent explosion in molecular methods, Introduction to Epidemiology – Epi 592J Page 3 epidemiologists can make important strides in examining genetic markers of disease risk.Indeed, the term health related states or events may be seen as anything that affects the well-being of a population. Nonetheless, many epidemiologists still use the term â€Å"disease† as shorthand for the wide range of healthrelated states and events that are studied. Specified populations Although epidemiologists and direct health-care providers (clinicians) are both concerned with occurrence and control of disease, they differ greatly in how they view â€Å"the patient. † The clinician is concerned about the health of an individual; the epidemiologist is concerned about the collective health of the people in a community or population. In other words, the clinician’s â€Å"patient† is the individual; the epidemiologist’s â⠂¬Å"patient† is the community.Therefore, the clinician and the epidemiologist have different responsibilities when faced with a person with illness. For example, when a patient with diarrheal disease presents, both are interested in establishing the correct diagnosis. However, while the clinician usually focuses on treating and caring for the individual, the epidemiologist focuses on identifying the exposure or source that caused the illness; the number of other persons who may have been similarly exposed; the potential for further spread in the community; and interventions to prevent additional cases or recurrences. Application Epidemiology is not just â€Å"the study of† health in a population; it also involves applying the knowledge gained by the studies to community-based practice.Like the practice of medicine, the practice of epidemiology is both a science and an art. To make the proper diagnosis and prescribe appropriate treatment for a patient, the clinician comb ines medical (scientific) knowledge with experience, clinical judgment, and understanding of the patient. Similarly, the epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well as experience, epidemiologic judgment, and understanding of local conditions in â€Å"diagnosing† the health of a community and proposing appropriate, practical, and acceptable public health interventions to control and prevent disease in the community. SummaryEpidemiology is the study (scientific, systematic, data-driven) of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (patient is community, individuals viewed collectively), and the application of (since epidemiology is a discipline within public health) this study to the control of health problems. Evolution Although epidemiologic thinking has been traced from Hippocrates (circa 400 B. C. ) through Grau nt (1662), Farr, Snow (both mid-1800’s), and others, the discipline did not blossom until the end of the Second World War. The contributions of some of these early and more recent thinkers are described next. Hippocrates (circa 400 B. C. ) attempted to explain disease occurrence from a rational instead of a supernatural viewpoint. In his essay entitled â€Å"On Airs, Waters, and Places,† Hippocrates suggested that environmental and host factors such as behaviors might influence the development of disease.Another early contributor to epidemiology was John Graunt, a London haberdasher who published his landmark analysis of mortality data in 1662. He was the first to quantify patterns of birth, death, and disease occurrence, noting male-female disparities, high infant mortality, urban-rural differences, and seasonal variations. No one built upon Graunt’s work until the mid-1800, when William Farr began to systematically collect and analyze Britain’s mortalit y statistics. Farr, considered the father of modern vital statistics and disease surveillance, developed many of the basic practices used today in vital statistics and disease classification. He extended the epidemiologic analysis of morbidity and mortality data, looking at Page 4 Applied Epidemiology I he effects of marital status, occupation, and altitude. He also developed many epidemiologic concepts and techniques still in use today. Meanwhile, an anesthesiologist named John Snow was conducting a series of investigations in London that later earned him the title â€Å"the father of epidemiology. † Twenty years before the development of the microscope, Snow conducted studies of cholera outbreaks both to discover the cause of the disease and to prevent its recurrence. Because his work classically illustrates the sequence from descriptive epidemiology to hypothesis generation to hypothesis testing (analytic epidemiology) to application, we will consider two of his efforts.It is important to mention that at the time of John Snow’s investigations the most widely accepted cause of diseases, including cholera, was due to miasma, or foul air. Therefore most believed that cholera was transmitted by air, especially foul-smelling air near water. The germ theory, that disease was transmitted by microbes, did not gain acceptance until later in the 1800s. Snow conducted his classic study in 1854 when an epidemic of cholera developed in the Golden Square of London. He began his investigation by determining where in this area persons with cholera lived and worked. He then used this information to map the distribution of cases on what epidemiologists call a spot map. His map is shown in Figure 1. 1.Because Snow believed that water was a source of infection for cholera, he marked the location of water pumps on his spot map, and then looked for a relationship between the distribution of cholera case households and the location of pumps. He noticed that more cas e households clustered around certain pumps, especially the Broad Street pump, and he concluded that the Broad Street pump was the most likely source of infection. Questioning residents who lived near the other pumps, he found that they avoided certain pumps because the water they provided was grossly contaminated, and that other pumps were located too inconveniently for most residents of the Golden Square area.From this information, it appeared to Snow that the Broad Street pump was probably the primary source of water for most persons with cholera in the Golden Square area. He realized, however, that it was too soon to draw that conclusion because the map showed no cholera cases in a two-block area to the east of the Broad Street pump. Perhaps no one lived in that area, or perhaps the residents were somehow protected. Upon investigating, Snow found that a brewery was located there and that it had a deep well on the premises where brewery workers, who also lived in the area, got th eir water. In addition, the brewery allotted workers a daily quota of malt liquor. Access to these uncontaminated rations could explain why none of the brewery’s employees contracted cholera.To provide further evidence that the Broad Street pump was the source of the epidemic, Snow gathered information on where persons with cholera had obtained their water. Consumption of water from the Broad Street pump was the one common factor among the cholera patients. According to legend, Snow removed the handle of the Broad Street pump and aborted the outbreak. Snow’s second major contribution involved another investigation of the same outbreak of cholera that occurred in London in 1854. In a London epidemic in 1849, Snow had noted that districts with the highest mortalities had water supplied by two companies: the Lambeth Company and the Southwark and Vauxhall Company. At that time, both companies obtained water from the Thames River, at intake points downstream of London.In 18 52, the Lambeth Company moved their water works upstream from London, thus obtaining water free of London sewage. When cholera returned to London in 1853, Snow realized the Lambeth Company’s relocation of its intake point would allow him to compare districts that were supplied with water upstream from London with districts that received water downstream from London. Table 1. 1 shows what Snow found when he made that comparison for cholera mortality over a 7-week period during the summer of 1854. Introduction to Epidemiology – Epi 592J Page 5 Figure 1. 1 Distribution of cholera cases in the Golden Square area of London, August-September 1854 Table 1. Mortality from cholera in the districts of London supplied by the Southwark and Vauxhall and the Lambeth Companies, July 9-August 26, 1854 Districts with Water Supplied by Population Deaths from Mortality Risk per (1851 Census) Cholera 1,000 Population 167,654 844 5. 0 Southwark and Vauxhall Co. only Lambeth Co. only Both c ompanies Source: 27 19,133 300,149 18 652 0. 9 2. 2 Page 6 Applied Epidemiology I The data in Table 1. 1 show that the risk of death from cholera was more than 5 times higher in districts served only by the Southwark and Vauxhall Company than in those served only by the Lambeth Company. Interestingly, the mortality risks in districts supplied by both companies fell between the risks for districts served exclusively by either company.These data were consistent with the hypothesis that water obtained from the Thames below London was a source of cholera. Alternatively, the populations supplied by the two companies may have differed on a number of other factors which affected their risk of cholera. To test his water supply hypothesis, Snow focused on the districts served by both companies, because the households within a district were generally comparable except for which company supplied water. In these districts, Snow identified the water supply company for every house in which a deat h from cholera had occurred during the 7-week period. Table 1. 2 shows his findings. Table 1. Mortality from cholera in London related to the water supply of individual houses in districts served by both the Southwark and Vauxhall Company and the Lambeth Company, July 9August 26, 1854 Water Supply of Individual House Population Deaths from Mortality risk per (1851 Census) Cholera 1,000 Population Southwark and Vauxhall Co. 98,862 419 4. 2 Lambeth Co. Source: 27 154,615 80 0. 5 This further study added support to Snow’s hypothesis, and demonstrates the sequence of steps used today to investigate outbreaks of disease. Based on a characterization of the cases and population at risk by time, place, and person, Snow developed a testable hypothesis. He then tested this hypothesis with a more rigorously designed study, ensuring that the groups to be compared were comparable. After this study, efforts to control the epidemic were directed at changing the location of the water intake of the Southwark and Vauxhall Company to reduce sources of contamination.Thus, with no knowledge of the existence of microorganisms, Snow demonstrated through epidemiologic studies that water could serve as a vehicle for transmitting cholera and that epidemiologic information could be used to direct prompt and appropriate public health action. More information on John Snow can be found at: www. ph. ucla. edu/epi/snow. html In the mid- and late-1800’s, many others in Europe and the United States began to apply epidemiologic methods to investigate disease occurrence. At that time, most investigators focused on acute infectious diseases. In the 1900’s, epidemiologists extended their methods to noninfectious diseases.The period since the Second World War has seen an explosion in the development of research methods and the theoretical underpinnings of epidemiology, and in the application of epidemiology to the entire range of health-related outcomes, behaviors, and even kno wledge and attitudes. The studies by Doll and Hill (13) linking smoking to lung cancer and the study of cardiovascular disease among residents of Framingham, Massachusetts (12), are two examples of how pioneering researchers have applied epidemiologic methods to chronic disease since World War II. Finally, during the 1960’s and early 1970’s health workers applied epidemiologic methods to eradicate smallpox worldwide.This was an achievement in applied epidemiology of unprecedented proportions. Today, public health workers throughout the world accept and use epidemiology routinely. Epidemiology is often practiced or used by non-epidemiologists to characterize the health of their communities and to solve day-to-day problems. This landmark in the evolution of the discipline is less dramatic than the eradication of smallpox, but it is no less important in improving the health of people everywhere. Introduction to Epidemiology – Epi 592J Page 7 Uses Epidemiology and t he information generated by epidemiologic methods have many uses. These uses are categorized and described below. Population or community health assessment.To set policy and plan programs, public health officials must assess the health of the population or community they serve and determine whether health services are available, accessible, effective, and efficient. To do this, they must find answers to many questions: What are the actual and potential health problems in the community? Where are they? Who is at risk? Which problems are declining over time? Which ones are increasing or have the potential to increase? How do these patterns relate to the level and distribution of services available? The methods of descriptive and analytic epidemiology provide ways to answer these and other questions.With answers provided through the application of epidemiology, the officials can make informed decisions that will lead to improved health for the population they serve. Individual decision s. People may not realize that they use epidemiologic information in their daily decisions. When they decide to stop smoking, take the stairs instead of the elevator, order a salad instead of a cheeseburger with French fries, or choose one method of contraception instead of another, they may be influenced, consciously or unconsciously, by epidemiologists’ assessment of risk. Since World War II, epidemiologists have provided information related to all those decisions.In the 1950’s, epidemiologists documented the increased risk of lung cancer among smokers; in the 1960’s and 1970’s, epidemiologists noted a variety of benefits and risks associated with different methods of birth control; in the mid-1980’s, epidemiologists identified the increased risk of human immunodeficiency virus (HIV) infection associated with certain sexual and drug-related behaviors; and, more positively, epidemiologists continue to document the role of exercise and proper diet in reducing the risk of heart disease. These and hundreds of other epidemiologic findings are directly relevant to the choices that people make every day, choices that affect their health over a lifetime. Completing the clinical picture. When studying a disease outbreak, epidemiologists depend on clinical physicians and laboratory scientists for the proper diagnosis of individual patients.But epidemiologists also contribute to physicians’ understanding of the clinical picture and natural history of disease. For example, in late 1989 three patients in New Mexico were diagnosed as having myalgias (severe muscle pains in chest or abdomen) and unexplained eosinophilia (an increase in the number of one type of white blood cell). Their physicians could not identify the cause of their symptoms, or put a name to the disorder. Epidemiologists began looking for other cases with similar symptoms, and within weeks had found enough additional cases of eosinophilia-myalgia syndrome (EMS) t o describe the illness, its complications, and its risk of mortality.Similarly, epidemiologists have documented the course of HIV infection, from the initial exposure to the development of a wide variety of clinical syndromes that include acquired immunodeficiency syndrome (AIDS). They have also documented the numerous conditions associated with cigarette smoking—from pulmonary and heart disease to lung and cervical cancer. Search for causes. Much of epidemiologic research is devoted to a search for causes, factors which influence one’s risk of disease. Sometimes this is an academic pursuit, but more often the goal is to identify a cause so that appropriate public health action might be taken. It has been said that epidemiology can never prove a causal relationship between an exposure and a disease. Nevertheless, epidemiology often provides enough information to support effective action.Examples include John Snow’s removal of the pump handle and the withdrawal o f a specific brand of tampon that was linked by epidemiologists to toxic shock syndrome. Another example is the recommendation that children not be given aspirin due to its association with Reye syndrome. Just as often, epidemiology and laboratory science converge to provide the evidence needed to establish causation. For example, a team of epidemiologists were able to identify a variety of risk factors during an outbreak of pneumonia among persons attending the American Page 8 Applied Epidemiology I Legion Convention in Philadelphia in 1976, called â€Å"Legionnaire’s disease. However, the outbreak was not â€Å"solved† until the Legionnaires’ bacillus was identified in the laboratory almost 6 months later. Disease control, elimination, and eradication. The ultimate goal of epidemiology is to improve the health of populations and through the reduction in disease. The definitions of disease control, elimination, and eradication as applied to infectious diseases are given below. (Dowdle WR. The principles of disease elimination and eradication. MMWR 48(SU01);23-7, 1999. ): Control: The reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction. Example: diarrheal diseases.Elimination of disease: Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Examples: neonatal tetanus. Elimination of infections: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent reestablishment of transmission are required. Example: measles, poliomyelitis. Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate effor ts; intervention measures are no longer needed. Example: smallpox.Extinction: The specific infectious agent no longer exists in nature or in the laboratory. Example: none. The above definitions are specific to infectious disease, but some of the concepts can carry over to other conditions, such as nutritional disorders, inborn errors of metabolism, and chronic diseases. Introduction to Epidemiology – Epi 592J Page 9 Exercise 1. 1 In the early 1980’s, epidemiologists recognized that AIDS occurred most frequently in men who had sex with men and in intravenous drug users. Describe how this information might be used for each of the following: a. Population or community health assessment b. Individual decisions c. Search for causes Page 10 Applied Epidemiology I The Epidemiologic ApproachLike a newspaper reporter, an epidemiologist determines What, When, Where, Who, and Why. However, the epidemiologist is more likely to describe these concepts in slightly different terms: c ase definition, time, place, person, and causes. Case Definition (â€Å"What? †) The identification of disease can be based on symptoms, signs, and diagnostic tests. A symptom is a sensation or change in health experienced by an individual. Examples of symptoms reported by an individual are a cough, fatigue, anxiety, and back pain. Signs, or signs of disease, are an objective evidence of disease observed by someone other than the affected individual, such as a physician or nurse.A case definition is a set of standard criteria for deciding whether a person has a particular disease or other health-related condition. By using a standard case definition we attempt to ensure that every case is diagnosed in the same way, regardless of when or where it occurred, or who identified it. We can then compare the number of cases of the disease that occurred in one time or place with the number that occurred at another time or another place. For example, with a standard case definition, we can compare the number of cases of hepatitis A that occurred in New York City in 1991 with the number that occurred there in 1990. Or we can compare the number of cases that occurred in New York in 1991 with the number that occurred in San Francisco in 1991. With a standard ase definition, when we find a difference in disease occurrence, we know it is likely to be due to a real difference or due to the quality of the disease reporting system rather than the result of differences in how cases were diagnosed. A case definition consists of clinical criteria and, sometimes, limitations on time, place, and person. The clinical criteria usually include confirmatory laboratory tests, if available, or combinations of symptoms (subjective complaints), signs (objective physical findings), and other findings. For example, see the case definition for rabies below; notice that it requires laboratory confirmation. Rabies, Human Clinical description Rabies is an acute encephalomyelitis that almos t always progresses to coma or death within 10 days of the first symptom.Laboratory criteria for diagnosis †¢ Detection by direct fluorescent antibody of viral antigens in a clinical specimen (preferably the brain or the nerves surrounding hair follicles in the nape of the neck), or †¢ Isolation (in cell culture or in a laboratory animal) of rabies virus from saliva, cerebrospinal fluid (CSF), or central nervous system tissue, or †¢ Identification of a rabies-neutralizing antibody titer greater than or equal to 5 (complete neutralization) in the serum or CSF of an unvaccinated person Case classification Confirmed: a clinically compatible illness that is laboratory confirmed Comment Laboratory confirmation by all of the above methods is strongly recommended. Source: 3 Compare this with the case definition for Kawasaki syndrome provided in Exercise 1. 3 on page 12. Kawasaki syndrome is a childhood illness with fever and rash that has no known cause and no specifically d istinctive laboratory findings.Notice that its case definition is based on the presence of fever, at least four of five specified clinical findings, and the lack of a more reasonable explanation. A case definition may have several sets of criteria, depending on the certainty of the diagnosis. For example, during an outbreak of measles, we might classify a person with a fever and rash as having a Introduction to Epidemiology – Epi 592J Page 11 suspect, probable, or confirmed case of measles, depending on what additional evidence of measles was present. In other situations, we may temporarily classify a case as suspect or probable until laboratory results are available. When we receive the laboratory report, we then reclassify the case as either confirmed or â€Å"not a case,† depending on the lab results.In the midst of a large outbreak of a disease caused by a known agent, we may permanently classify some cases as suspect or probable, because it is unnecessary and wast eful to run laboratory tests on every individual with a consistent clinical picture and a history of exposure (e. g. , chickenpox). Case definitions may also vary according to the purpose for classifying the occurrences of a disease. For example, health officials need to know as soon as possible if anyone has symptoms of plague or foodborne botulism so that they can begin planning what actions to take. For such rare but potentially severe diseases, where it is important to identify every possible case, health officials use a sensitive, or â€Å"loose† case definition.On the other hand, investigators of the causes of a disease outbreak want to be certain that any person included in the investigation really had the disease. The investigator will prefer a specific or â€Å"strict† case definition. For instance, in an outbreak of Salmonella agona, the investigators would be more likely to identify the source of the infection if they included only persons who were confirmed to have been infected with that organism, rather than including anyone with acute diarrhea, because some persons may have had diarrhea from a different cause. In this setting, a disadvantage of a strict case definition is an underestimate of the total number of cases. Exercise 1. 2In the case definition for an apparent outbreak of trichinosis, investigators used the following classifications: Clinical criteria Confirmed case: signs and symptoms plus laboratory confirmation Probable case: acute onset of at least three of the following four features: myalgia, fever, facial edema, or eosinophil count greater than 500/mm3 Possible case: acute onset of two of the above four features plus a physician diagnosis of trichinosis Suspect case: unexplained eosinophilia Not a case: failure to fulfill the criteria for a confirmed, probable, possible, or suspect case Time Onset after October 26, 1991 Place Metropolitan Atlanta Person Any Assign the appropriate classification to each of the person s included in the line listing below. (All were residents of Atlanta with acute onset of symptoms in November. ) Page 12 Applied Epidemiology I ID # 1 2 3 4 5 Last name Abels Baker Corey Dale Ring myalgia yes yes yes yes yes fever yes yes yes no no facial edema no yes no no no eosinophil count 495 pending 1,100 2,050 600 Physician diagnosis trichinosis trichinosis ? trichinosis EMS ? trichinosis Lab confirm yes pending pending pending not done Classification __________ __________ __________ __________ __________Exercise 1. 3 The following is the official case definition for Kawasaki syndrome that is recommended by CDC: Kawasaki Syndrome Clinical case definition A febrile illness of greater than or equal to 5 days’ duration, with at least four of the five following physical findings and no other more reasonable explanation for the observed clinical findings: †¢ Bilateral conjunctival injection †¢ Oral changes (erythema of lips or oropharynx, strawberry tongue, or fis suring of the lips) †¢ Peripheral extremity changes (edema, erythema, or generalized or periungual desquamation) †¢ Rash †¢ Cervical lymphadenopathy (at least one lymph node greater than or equal to 1. cm in diameter) Laboratory criteria for diagnosis None Case classification Confirmed: a case that meets the clinical case definition Comment If fever disappears after intravenous gamma globulin therapy is started, fever may be of less than 5 days’ duration, and the clinical case definition may still be met. Source: 3 Discuss the pros and cons of this case definition for the purposes listed below. (For a brief description of Kawasaki syndrome, see Benenson’s Control of Communicable Diseases in Man). a. Diagnosing and treating individual patients b. Tracking the occurrence of the disease for public health records c. Doing research to identify the cause of the disease Introduction to Epidemiology – Epi 592J Page 13 Numbers and RisksA basic task of a he alth department is counting cases in order to measure and describe morbidity. When physicians diagnose a case of a reportable disease they are suppose to report the case to their local health department. For most reportable conditions, these reports are legally required to contain information on time (when the case occurred), place (where the patient lived), and person (the age, race, and sex of the patient). The health department combines all reports and summarizes the information by time, place, and person. From these summaries, the health department determines the extent and patterns of disease occurrence in the area, and attempts to identify clusters or outbreaks of disease.A simple count of cases, however, does not provide all the information a health department needs. To compare the occurrence of a disease at different locations, during different times, or in different subgroups, a health department converts the case counts into risks, which relates the number of cases to the size of the population. Risks are useful in many ways. With risks, the health department can identify groups in the community with an elevated risk of disease. These so-called high-risk groups can be further assessed and targeted for special intervention; the groups can be studied to identify risk factors that are related to the occurrence of disease.Individuals can use knowledge of these risk factors to guide their decisions about behaviors that influence health. Descriptive Epidemiology In descriptive epidemiology, we organize and summarize data according to time, place, and person. These three characteristics are sometimes called the epidemiologic variables. Compiling and analyzing data by time, place, and person is desirable for several reasons. First, the investigator becomes intimately familiar with the data and with the extent of the public health problem being investigated. Second, this provides a detailed description of the health of a population that is easily communicated . Third, such analysis identifies the populations at greatest risk of acquiring a particular disease.This information provides important clues to the causes of the disease, and these clues can be turned into testable hypotheses. Time (â€Å"When? †) Disease risks usually change over time. Some of these changes occur regularly and can be predicted. For example, the seasonal increase of influenza cases with the onset of cold weather is a pattern that is familiar to everyone. By knowing when flu outbreaks will occur, health departments can time their influenza vaccination campaigns effectively. Other diseases may make unpredictable changes in occurrence. By examining events that precede a disease increase or decrease, we may identify causes and appropriate actions to control or prevent further occurrence of the disease.We usually show time data as a graph (Figure 1. 3). We put the number or risk of cases or deaths on the vertical, y-axis; we put the time periods along the horizo ntal, x-axis. We often indicate on a graph when events occurred that we believe are related to the particular health problem described in the graph. For example, we may indicate the period of exposure or the date control measures were implemented. Such a graph provides a simple visual depiction of the relative size of a problem, its past trend and potential future course, as well as how other events may have affected the problem. Studying such a graph often gives us insights into what may have caused the problem.Depending on what event we are describing, we may be interested in a period of years or decades, or we may limit the period to hours, days, weeks, or months when the number of cases reported is greater than normal (an epidemic period). For some conditions—for many chronic diseases, for example—we are interested in long-term changes in the number of cases or risk of the condition. For other conditions, we may find it more revealing to look at the occurrence of t he condition by season, month, day of the Page 14 Applied Epidemiology I week, or even time of day. For a newly recognized problem, we need to assess the occurrence of the problem over time in a variety of ways until we discover the most appropriate and revealing time period to use. Some of the common types of time-related graphs are further described below. Secular (long-term) trends.Graphing the annual cases or risk of a disease over a period of years shows long-term or secular trends in the occurrence of the disease. We commonly use these trends to suggest or predict the future incidence of a disease. We also use them in some instances to evaluate programs or policy decisions, or to suggest what caused an increase or decrease in the occurrence of a disease, particularly if the graph indicates when related events took place, as depicted in Figure 1. 3 (note the scale of the y-axis). Figure 1. 3 Malaria by year, United States, 1930-1990 Works Progress Administration Malaria Control Drainage Program Relapses from Overseas Cases 1000 Reported Cases per 100,000 Population 100Relapses from Korean Veterans Returning Vietnam Veterans 10 Foreign Immigration 1 0. 1 0. 01 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 Source: 9 Year Seasonality. By graphing the occurrence of a disease by week or month over the course of a year or more we can show its seasonal pattern, if any. Some diseases are known to have characteristic seasonal distributions; for example, as mentioned earlier, the number of reported cases of influenza typically increases in winter. Seasonal patterns may suggest hypotheses about how the infection is transmitted, which behavioral factors increase risk, and other possible contributors to the disease or condition.The seasonal pattern of an unknown disease is shown in Figure 1. 4. What factors might contribute to its seasonal pattern? From only the single year’s data in Figure 1. 4, it is difficult to conclude whether the peak i n June represents a characteristic seasonal pattern that would be repeated yearly, or whether it is simply an epidemic that occurred in the spring and summer of that particular year. You would need more than one year’s data before you could conclude that the pattern shown there represents the seasonal variation in this disease. Introduction to Epidemiology – Epi 592J Page 15 Figure 1. 4 Cases of an unknown disease by month of onset 450 400 350 300 Cases 50 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Source: 14 Month of Onset Day of week and time of day. Displaying data by days of the week or time of day may also be informative. Analysis at these shorter time periods is especially important for conditions that are potentially related to occupational or environmental exposures, which may occur at regularly scheduled intervals. In Figure 1. 5, farm tractor fatalities are displayed by days of the week. Does this analysis at shorter time periods suggest any hypothesis? In Figure 1. 5 the number of farm tractor fatalities on Sundays is about half the number on the other days. We can only speculate why this is.One reasonable hypothesis is that farmers spend fewer hours on their tractors on Sundays than on the other days. Figure 1. 5 Fatalities associated with farm tractor injuries by day of death, Georgia, 1971-1981 Source: 15 Page 16 Applied Epidemiology I Examine the pattern of fatalities associated with farm tractor injuries by hour in Figure 1. 6. How might you explain the morning peak at 11:00 AM, the dip at noon, and the afternoon peak at 4:00 PM? Figure 1. 6 Fatalities associated with farm tractor injuries by time of day, Georgia, 1971-1981 Source: 15 Epidemic period. To show the time course of a disease outbreak or epidemic, we use a graph called an epidemic curve.As with the other graphs you have seen in this section, we place the number of cases on the vertical axis and time on the horizontal axis. For time, we use either the time of onset of symptoms or the date of diagnosis. For very acute diseases with short incubation periods (i. e. , time period between exposure and onset of symptoms is short), we may show time as the hour of onset. For diseases with longer incubation periods, we might show time in 1-day, 2-day, 3-day, 1-week, or other appropriate intervals. Figure 1. 7 shows an epidemic curve that uses a 3-day interval for a foodborne disease outbreak. Notice how the cases are stacked in adjoining columns. By convention, we use this format, called a histogram, for epidemic curves.The shape and other features of an epidemic curve can suggest hypotheses about the time and source of exposure, the mode of transmission, and the causative agent. Figure 1. 7 Date of onset of illness in patients with culture-confirmed Yersinia enterocolitica infections, Atlanta, November 1, 1988-January 10, 1989 8 7 6 Thanksgiving Christmas New Year’s Cases 5 4 3 2 1 0 1 4 7 10 13 16 19 22 25 28 1 4 7 10 13 16 1 9 22 25 28 1 4 7 10 November December January Source: 18 Date of Onset Introduction to Epidemiology – Epi 592J Page 17 Place (â€Å"Where? †) We describe a health event by place to gain insight into the geographical extent of the problem. For place, we may use place of residence, birthplace, employment, school district, hospital unit, etc. , epending on which may be related to the occurrence of the health event. Similarly, we may use large or small geographic units: country, state, county, census tract, street address, map coordinates, or some other geographical designation. Sometimes, we may find it useful to analyze data according to place categories such as urban or rural, domestic or foreign, and institutional or noninstitutional. Not all analyses by place will be equally informative. For example, examine the data shown in Table 1. 3. Where were the malaria cases diagnosed? What â€Å"place† does the table break the data down by? Would it have been more or l ess useful to analyze the data according to the â€Å"state of residence† of the cases?We believe that it provides more useful information to show the data in Table 1. 3 by where the infection was acquired than it would have to show where the case-patients lived. By analyzing the malaria cases by place of acquisition, we can see where most of the malaria cases acquired their disease. Table 1. 3 Malaria cases by distribution of Plasmodium species and area of acquisition, United States, 1989 Species Area of Acquisition Vivax Falciparum Other Total Africa 52 382 64 498 Asia 207 44 29 280 Central America & Caribbean 107 14 9 130 North America 131 3 13 147 (United States) (5) (0) (0) (5) South America 10 1 2 13 Oceania 19 2 5 26 Unknown 6 2 0 8 Total 532 448 122 1,102 Source: 6By analyzing data by place, we can also get an idea of where the agent that causes a disease normally lives and multiplies, what may carry or transmit it, and how it spreads. When we find that the occurrence of a disease is associated with a place, we can infer that factors that increase the risk of the disease are present either in the persons living there (host factors) or in the environment, or both. For example, diseases that are passed from one person to another tend to spread more rapidly in urban areas than in rural ones, mainly because the greater crowding in urban areas provides more opportunities for susceptible people to come into contact with someone who is infected.On the other hand, diseases that are passed from animals to humans often occur in greater numbers in rural and suburban areas because people in those areas are more likely to come into contact with disease-carrying animals, ticks, and the like. For example, perhaps Lyme disease has become more common because people have moved to wooded areas where they come into contact with infected deer ticks. Although we can show data by place in a table—as Table 1. 3 does—it is often better to show it pictorial ly in a map. On a map, we can use different shadings, color, or line patterns to indicate how a disease or health event has different numbers or risks of occurrence in different areas, as in Figure 1. 8. Page 18 Applied Epidemiology I Figure 1. 8 AIDS cases per 100,000 population, United States, July 1991-June 1992 Source: 4For a rare disease or outbreak, we often find it useful to prepare a spot map, like Snow’s map of the Golden Square of London (Figure 1. 1), in which we mark with a dot or an X the relation of each case to a place that is potentially relevant to the health event being investigated—such as where each case lived or worked. We may also label other sites on a spot map, such as where we believe cases may have been exposed, to show the orientation of cases within the area mapped. Figure 1. 9 is a spot map for an outbreak of mumps that occurred among employees of the Chicago futures exchanges. Study the location of each case in relation to other cases and to the trading pits. The four numbered areas delineated with heavy lines are the trading pits.Does the location of cases on the spot map lead you to any hypothesis about the source of infection? Figure 1. 9 Mumps cases in trading pits of exchange A, Chicago, Illinois, August 18-December 25, 1987 #1 #3 #2 #4 Key: Pit areas are numbered and delineated by heavy lines. Individual trading pits within pit areas are outlined by light lines. Affected person (N= 43) Desk areas Source: CDC, unpublished data, 1988 Introduction to Epidemiology – Epi 592J Page 19 You probably observed that the cases occurred primarily among those working in trading pits #3 and #4. This clustering of illness within trading pits provides indirect evidence that the mumps was transmitted person-to person. Person (â€Å"Who? ) In descriptive epidemiology, when we organize or analyze data by â€Å"person† there are several person categories available to us. We may use inherent characteristics of people (for example, age, race, sex), their acquired characteristics (immune or marital status), their activities (occupation, leisure activities, use of medications/tobacco/drugs), or the conditions under which they live (socioeconomic status, access to medical care). These categories usually determine, to a large degree, who is at greatest risk of experiencing certain undesirable health conditions, such as becoming infected with a particular disease organism. We may show person-related characteristics in either tables or graphs.In analyzing data by person, we often must try a number of different categories before we find which are the most useful and enlightening. Age and sex are most critical; we almost always analyze data according to these. Depending on the health event we are studying, we may or may not break the data down by other attributes. Often we analyze data by more than one characteristic simultaneously; for example, we may look at age and sex simultaneously to see if the sex es differ in how they develop a condition that increases with age—such as with heart disease. Age. Age is probably the single most important â€Å"person† attribute, because almost every health-related event or state varies with age.A number of factors that also vary with age are behind this association: susceptibility, opportunity for exposure, latency or incubation period of the disease, and physiologic response (which affects, among other things, disease development). When we analyze data by age, we try to use age groups that are narrow enough to detect any agerelated patterns that may be present in the data. In an initial breakdown by age, we commonly use 5-year age intervals: 0 to 4 years, 5 to 9, 10 to 14, and so on. Larger intervals, such as 0 to 19 years, 20 to 39, etc. , may conceal variations related to age which we need to know to identify the true ages at greatest risk.Sometimes, even 5-year age groups can hide important differences, especially in children less than five years of age. Take time to examine Figure 1. 10, for example, before you read ahead. What does the information in this figure suggest health authorities should do to reduce the number of cases of whooping cough? Where should health authorities focus their efforts? You probably said that health authorities should focus on immunizing infants against whooping cough during the first year of life. Now, examine Figure 1. 11. This figure shows the same data but they are presented in the usual 5-year intervals. Based on Figure 1. 11 where would you have suggested that health authorities focus their efforts?Would this recommendation have been as effective and efficient in reducing cases of whooping cough? You probably said that health authorities should immunize infants and children before the age of 5. That recommendation would be effective, but it would not be efficient. You would be immunizing more children than actually necessary and wasting resources. Sex. In general, mal es have higher risks of illness and death than females do for a wide range of diseases. For some diseases, this sex-related difference is because of genetic, hormonal, anatomic, or other inherent differences between the sexes. These inherent differences affect their susceptibility or physiologic responses.For example, premenopausal women have a lower risk of heart disease than men of the same age. This difference is attributed to higher estrogen levels in women. On the other hand, the sex-related differences in the occurrence of many diseases reflect differences in opportunity or levels of exposure. For example, Figure 1. 12 shows that hand/wrist disorders occur almost twice as often in females than in males. What are some sex-related differences that would cause a higher level of this disorder in females? Page 20 Applied Epidemiology I Figure 1. 10 Pertussis (whooping cough) incidence by age group, United States, 1989 Source: 9 Figure 1. 11 Pertussis (whooping cough) incidence by a ge group, United States, 1989 Source: 9 Figure 1. 2 Prevalence of hand/wrist cumulative trauma disorder by sex, Newspaper Company A, 1990 Source: NIOSH, unpublished data, 1991 Introduction to Epidemiology – Epi 592J Page 21 You may have attributed the higher level of disorders in females to their higher level of exposure to occupational activities that require repetitive hand/wrist motion such as typing or keyboard entry. With occupationally-related illness, we usually find that sex differences reflect the number of workers in those occupations. You may also have attributed the higher level of disorders in females to anatomical differences; perhaps women’s wrists are more susceptible to hand/wrist disorders. Ethnic and racial groups.In examining epidemiologic data, we are interested in any group of people who have lived together long enough to acquire common characteristics, either biologically or socially. Several terms are commonly used to identify such groups: race, nationality, religion, or local reproductive or social groups, such as tribes and other geographically or socially isolated groups. Differences that we observe in racial, ethnic, or other groups may reflect differences in their susceptibility or in their exposure, or they may reflect differences in other factors that bear more directly on the risk of disease, such as socioeconomic status and access to health care. In Figure 1. 13, the risks of suicide for five groups of people are displayed. Figure 1. 3 Suicide death rates for persons 15 to 24 years of age according to race/ethnicity, United States, 1988 Source: 22 Clearly this graph displays a range of suicide death rates for the five groups of people. These data provide direction for prevention programs and for future studies to explain the differences. Socioeconomic status. Socioeconomic status is difficult to quantify. It is made up of many variables such as occupation, family income, educational achievement, living conditions, and social standing. The variables that are easiest to measure may not reflect the overall concept. Nevertheless, we commonly use occupation, family income, and educational achievement, while recognizing that these do not measure socioeconomic status precisely.The frequency of many adverse health conditions increases with decreasing socioeconomic status. For example, tuberculosis is more common among persons in lower socioeconomic strata. Infant mortality and time lost from work due to disability are both associated with lower income. These patterns may reflect more harmful exposures, lower resistance, and less access to health care. Or they may in part Page 22 Applied Epidemiology I reflect an interdependent relationship which is impossible to untangle—does low socioeconomic status contribute to disability or does disability contribute to lower socioeconomic status? Some adverse health conditions are more frequent among persons of higher socioeconomic status.These condition s include breast cancer, Kawasaki syndrome, and tennis elbow. Again, differences in exposure account for at least some of the differences in the frequency of these conditions. Exercise 1. 4 The following series of tables (Exercise 1. 4, Tables 1-4) show person information about cases of the unknown disease described in Figure 1. 4 on page 15. Look again at Figure 1. 4, study the information in the four exercise tables and then describe in words how the disease outbreak is distributed by time and person. Exercise 1. 4, Table 1 Incidence of the disease by age and sex in 24 villages surveyed for one year Males Females Age Group Population* # Cases Risk per Population* # Cases Risk per (years) 1,000 1,000