Choosing a future for epidemiology: I. Eras and paradigms.

To inform choices about the future of epidemiology, the present condition of epidemiology is examined, in terms of its evolution through three eras, each demarcated by its own paradigm: (1) the era of sanitary statistics with its paradigm, miasma; (2) the era of infectious disease epidemiology with its paradigm, the germ theory; and (3) the era of chronic disease epidemiology with its paradigm, the black box. The historical context in which these eras arose is briefly described. In each era, the public health was at the center of the concerns of the founders and early protagonists of the prevailing paradigm. Around this intellectual development we weave a further theme. We argue that in the present era, the public health has become less central a concern. At the same time, in epidemiology today the dominant black box paradigm is of declining utility and is likely soon to be superseded.  

HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action

Internationally, there has been a recent resurgence of interest in HIV and AIDS-related stigma and discrimination, triggered at least in part by growing recognition that negative social responses to the epidemic remain pervasive even in seriously affected communities. Yet, rarely are existing notions of stigma and discrimination interrogated for their conceptual adequacy and their usefulness in leading to the design of effective programmes and interventions. Taking as its starting point, the classic formulation of stigma as a 'significantly discrediting' attribute, but moving beyond this to conceptualize stigma and stigmatization as intimately linked to the reproduction of social difference, this paper offers a new framework by which to understand HIV and AIDS-related stigma and its effects. It so doing, it highlights the manner in which stigma feeds upon, strengthens and reproduces existing inequalities of class, race, gender and sexuality. It highlights the limitations of individualistic modes of stigma alleviation and calls instead for new programmatic approaches in which the resistance of stigmatized individuals and communities is utilized as a resource for social change.  

Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology.

Part I of this paper traced the evolution of modern epidemiology in terms of three eras, each with its dominant paradigm, culminating in the present era of chronic disease epidemiology with its paradigm, the black box. This paper sees the close of the present era and foresees a new era of eco-epidemiology in which the deployment of a different paradigm will be crucial. Here a paradigm is advocated for the emergent era. Encompassing many levels of organization--molecular and societal as well as individual--this paradigm, termed Chinese boxes, aims to integrate more than a single level in design, analysis, and interpretation. Such a paradigm could sustain and refine a public health-oriented epidemiology. But preventing a decline of creative epidemiology in this new era will require more than a cogent scientific paradigm. Attention will have to be paid to the social processes that foster a cohesive and humane discipline.  

Does risk factor epidemiology put epidemiology at risk? Peering into the future

The multiple cause black box paradigm of the current risk factor era in epidemiology is growing less serviceable. This single level paradigm is likely to be displaced. The signs are that the growing strength of molecular epidemiology on the one side, and of a global epidemiology based on information systems on the other, will come to dominate epidemiology and segregate it into separate disciplines. At the same time, the links with public health interests grow weaker. A multilevel ecoepidemiology has the potential to bind these strands together.  

Antiseptic impregnated endotracheal tubes for the prevention of bacterial colonization

The effect of endotracheal tubes (ETTs) impregnated with chlorhexidine (CHX) and silver carbonate (antiseptic ETTs) against Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacter aerogenes [organisms associated with ventilator-associated pneumonia (VAP)], was evaluated in a laboratory airway model. Antiseptic ETTs and control ETTs (unimpregnated) were inserted in culture tubes half-filled with agar media (airway model) previously contaminated at the surface with 10(8) cfu/mL of the selected test organism. After five days of incubation, bacterial colony counts on all ETT segments were determined. Swabs of proximal and distal ends of the agar tract in antiseptic and control models were subcultured. The initial and residual CHX levels, (five days post-implantation in the model) were determined. Cultures of antiseptic ETTs revealed colonization by the tested pathogens ranging from 1-100 cfu/tube, compared with approximately 10(6) cfu/tube for the control ETTs (P < 0.001). Subcultures from proximal and distal ends of the agar tract showed minimal or no growth in the antiseptic ETTs compared with the control ETTs (P < 0.001). The amount of CHX retained in the antiseptic ETTs after five days of implantation was an average of 45% of the initial level. Antiseptic ETTs prevented bacterial colonization in the airway model and also retained significant amounts of the antiseptic. These results indicate that the effectiveness of antiseptic-impregnated ETTs in preventing the growth of bacterial pathogens associated with VAP may vary with different organisms.  

Infant survival, HIV infection, and feeding alternatives in less-developed countries.

OBJECTIVES: This study examines, in the context of the human immunodeficiency virus (HIV) epidemic, the effects of optimal breast-feeding, complete avoidance of breast-feeding, and early cessation of breast-feeding. METHODS: The three categories of breast-feeding were weighed in terms of HIV transmission and infant mortality. Estimates of the frequency of adverse outcomes were obtained by simulation. RESULTS: Avoidance of all breast-feeding by the whole population always produces the worst outcome. The lowest frequency of adverse outcomes occurs if no HIV-seropositive women breast-feed and all seronegative women breast-feed optimally, given infant mortality rates below 100 per 1000 and relative risks of dying set at 2.5 for non-breast-fed compared with optimally breast-fed infants. For known HIV-seropositive mothers, fewer adverse outcomes result from early cessation than from prolonged breast-feeding if the hazard of HIV transmission through breast-feeding after 3 months is 7% or more, even at high mortality rates, given relative risks of dying set at 1.5 for early cessation compared with optimal duration of breast-feeding. CONCLUSIONS: The risk of HIV transmission through breast-feeding at various ages needs to be more precisely quantified. The grave issues that may accompany a possible decline in breast-feeding in the less developed world demand evaluation.  

The effect of lead exposure on behavior problems in preschool children.

OBJECTIVES: Interpreting associations between lead exposure and child behavior problems is difficult because studies have not controlled for sociodemographic confounders or have used shed teeth to mark exposure. This study explored associations between blood lead and preschool behavior. METHODS: Children from a smelter town and a non-lead-exposed town in Yugoslavia were followed up prospectively from pregnancy through age 3. The Child Behavior Checklist was used to assess behavior problems in 379 3-year-olds, controlling for sociodemographic factors and difficult infant temperament. RESULTS: Multiple regression revealed the expected significant associations between checklist subscales and sociodemographic factors, which explained 7% to 18% of the variance on the subscales. Concurrent blood lead explained a significant 1% to 4% of the variance on the Destructive and Withdrawn subscales. Earlier difficult temperament explained an additional 2% to 5% of the checklist variance. Scores on the Destructive subscale were consistently associated with blood lead. As blood lead increased from 10 to 20 micrograms/dL, subscale scores increased by approximately 0.5 points. CONCLUSIONS: Lead/behavior associations are significant but small compared with the effects of social factors.  

Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice

BACKGROUND: Most research on the prevalence of mental disorders in primary care has been conducted in practices that serve middle- and upper-income patients. OBJECTIVE: To determine the prevalence of major mental disorders in a primary care practice that serves a predominantly low-income immigrant patient population. DESIGN: Cross-sectional survey; criterion standard. SETTING: Urban general medicine practice. PARTICIPANTS: Systematic sample of consecutive adult patients with scheduled appointments. Of 1266 approached eligible patients, 1007 (80%) participated. MAIN OUTCOME MEASURES: PRIME-MD Patient Health Questionnaire major depression, generalized anxiety disorder, panic disorder, alcohol use disorder, and suicidal ideation; drug use disorder; functional status; work loss; family distress; and mental health treatment. RESULTS: Major depression (18. 9%), generalized anxiety (14.8%), panic (8.3%), and substance use (7. 9%) disorders and suicidal ideation (7.1%) were highly prevalent. Many patients had more than 1 disorder (range, 36.3% [substance use disorder] to 76.9% [panic disorder]). In multivariate analyses, each disorder was significantly associated with an increase in impairment after controlling for demographic characteristics, perceived health, and the other disorders. A minority of patients with each disorder (range, 22.5% [substance use disorder] to 46.4% [panic disorder]) reported receiving mental health treatment in the last month. CONCLUSIONS: Clinically significant depression, anxiety, substance use, and suicidal ideation are quite common in this practice and associated with significant functional impairment. Primary care practices that serve poor urban immigrant populations have a critical need to provide access to mental health services. Arch Fam Med. 2000;9:876-883  

Racial/ethnic differences in cigarette smoking initiation and progression to daily smoking: a multilevel analysis

OBJECTIVES: We sought to identify individual and contextual predictors of adolescent smoking initiation and progression to daily smoking by race/ethnicity. METHODS: We used data from the National Longitudinal Study of Adolescent Health to estimate the effects of individual (adolescent, family, peer) and contextual (school and state) factors on smoking onset among nonsmokers (n = 5374) and progression to daily smoking among smokers (n = 4474) with multilevel regression models. RESULTS: Individual factors were more important predictors of smoking behaviors than were contextual factors. Predictors of smoking behaviors were mostly common across racial/ethnic groups. CONCLUSIONS: The few identified racial/ethnic differences in predictors of smoking behavior suggest that universal prevention and intervention efforts could reach most adolescents regardless of race/ethnicity. With 2 exceptions, important contextual factors remain to be identified.  

Residential pesticide use during pregnancy among a cohort of urban minority women

Residential pesticide use is widespread in the United States. However, data are limited specific to use among minority populations. Nor are data available on the extent of pesticide exposure resulting from residential use during pregnancy. We have gathered questionnaire data on pesticide use in the home during pregnancy from 316 African-American and Dominican women residing in northern Manhattan and the South Bronx. Additionally, 72 women underwent personal air monitoring for 48 hr during their third trimester of pregnancy to determine exposure levels to 21 pesticides (19 insecticides and 2 fungicides). Of the women questioned, 266 of 314 (85%) reported that pest control measures were used in the home during pregnancy; 111 of 314 (35%) reported that their homes were sprayed by an exterminator, and of those, 45% said the spraying was done more than once per month. Most (>or= 90%) of the pesticide was used for cockroach control. Use of pest control measures increased significantly with the level of housing disrepair reported. Of the women monitored, all (100%) had detectable levels of three insecticides: the organophosphates diazinon (range, 2.0-6,010 ng/m3) and chlorpyrifos (range, 0.7-193 ng/m3) and the carbamate propoxur (range, 3.8-1,380 ng/m3), as well as the fungicide o-phenylphenol (range, 5.7-743 ng/m3). We also frequently detected the following four insecticides (47-83% of samples) but at lower concentrations: the pyrethroid trans-permethrin, piperonyl butoxide (an indicator of exposure to pyrethrins), and the organochlorines 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane and chlordane. Thirty percent of the women had detectable levels of all eight pesticides. Exposures were generally higher among African Americans than among Dominicans. We detected other pesticides in 相似文献