Division of Disease Control and Health Protection

For June 3, 1999

The March 11, 1999 issue of the New England Journal of Medicine includes an article entitled "Rising Incidence of Hepatocellular Carcinoma in the United States" by Hasem B. El-Serag and Andrew C. Mason. This article describes the trends in liver cancer incidence and mortality rates by race and gender for the U.S. The authors found that both incidence and mortality rates for liver cancer (hepatocellular carcinoma) have generally increased in the last 20 years. The age-adjusted incidence rate was 1.4 per 100,000 for the period 1976 to 1980 and rose to 2.4 per 100,000 for the period 1991 to 1995. The authors cite hepatitis B and hepatitis C infection as contributing factors in the increase.

The liver cancer data in Florida follow almost the same pattern as the national data. The age-adjusted incidence rate per 100,000 in Florida was 1.60 in the 1983 to 1987 period and rose to 2.25 in the 1993 to 1997 period. Likewise, the mortality rate was 2.04 in the 1983 to 1987 period and rose to 2.63 for the period 1993 to 1997. The table below gives the average annual cases and deaths by race and gender for liver cancer for the period 1995 through 1997. The number of deaths exceed the number of cases probably because: 1) Some of the liver cancer deaths were metastatic liver cancer, 2) some were of cell types other than hepatocellular carcinoma and 3) some people died in Florida of liver cancer originally diagnosed while living elsewhere.

The graphs of the age adjusted incidence rates and mortality rates by race and gender display the same pattern as the national data in the article, with the exception of the rates for Non-White Males. In the article, the national trend for Black Males continues to increase in both incidence and mortality. In Florida, as shown in the graphs below, the age-adjusted incidence and mortality rates decreased for Non-White Males in 1995-1997 compared to the previous period 1992-1994.

The increases in liver cancer incidence and mortality rates could be a result of the large number of persons infected with hepatitis B and C virus and the 10 to 30 year latency period for liver cancer. These trends could continue for some time since many of the persons currently infected with the hepatitis B and C viruses are probably still in the latency period. Alternatively, it may be that the increases in liver cancer rates are near the peak and may begin following the downward trend in hepatitis B and C incidence. Possible evidence for this can be seen in the recent decreases in the rates of liver cancer for Non-White Males. If the rates for the other race and gender categories follow the same pattern in upcoming years as the rates for the Non-White Males, it might be an indication that the declines in hepatitis B and C incidence rates are beginning to be reflected in the liver cancer rates.

Nearly 200,000 children were born in Florida in 1998.

• If we keep on doing what we are doing – if we do nothing differently – if the current trends continue… then 27,000 of our children born last year will be overweight in elementary school.
• IF WE DO NOTHING differently – if we end up where we’re headed, then 40,000 of our children born last year will be using some form of tobacco in the 6^th grade and 52,000 will be regular smokers by age 18.
• IF WE DO NOTHING - at age 25, 50,000 of our children born in 1998 will abuse alcohol.
• At age 35, 60,000 will lead sedentary lives - IF WE DO NOTHING.
• At age 45, 6,600 will have diabetes and ten-fold more (62,000) will have high blood pressure.
• Between the ages of 45 and 54, these children will have been discharged from the hospital 21,000 times for heart attacks or strokes.
• And by age 64, IF WE DO NOTHING, nearly 10,000 of our children born in 1998 will have died as a result of cardiovascular disease, cutting their lives short by at least 10 years.

This is where we are headed; and if we don’t change direction soon, this is where we will end up.

How do we change direction?

I suggest to you that we change direction -- from a focus on treatment to a focus on prevention, from a focus on the individual to a focus on the community, from a focus on individual choices to a focus on a re-engineered community landscape and a restructured social context.

The question we need to ask ourselves, as public health professionals, is how can we contribute to the construction of heart healthy communities, communities that encourage, indeed require, us to lead heart healthy lives?

In an April 2 article in the Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention published their list of the 10 Great Public Health Achievements in the United States from 1900 to 1999. Most of those listed required no individual initiative or voluntary behavior change. Most of the major public health successes of this century have resulted from changes in the social, physical, or legal environment that improved our health status by community action, in spite of ourselves.

Topping the list were improvements in motor-vehicle safety resulting from engineering changes to vehicles and roads, and legal constraints on individual behavior including seatbelt and infant restraint laws. Improvements in work place safety were next, resulting from engineering and equipment improvements along with better safety laws and regulations. Half way down the list: safer and more healthful foods, and then fluoridation of drinking water, neither requiring individual effort.

In areas where individual behavior change is required, we’ve changed or reinforced social norms to enhance the adoption of improved behaviors, and made the new behaviors easy to implement, providing both incentives and coercion. We make vaccines widely available free or at reduced cost and then adopt laws requiring their use before other social services like day care or education become available. The Clean Indoor Air Act enhances the non-smoker’s right to breathe indoor air free of tobacco smoke and restricts the smoker’s ability to engage in this unhealthful behavior at work or in public places.

The recognition of tobacco use as a health hazard and the recognition of environmental tobacco smoke as an important health problem, along with legal restrictions on the use of tobacco, alter community perceptions about what is acceptable behavior. As the social acceptability of tobacco use declines, so does tobacco use itself, further reinforcing and extending the social norms against tobacco use and the decline in tobacco use – setting up a "virtuous cycle" of behavior change.

We need to begin or extend such a cycle for other heart healthy behaviors.

You already know that we can, and we have, altered social norms and redesigned the community landscape. We have succeeded in changing behaviors and altering health status. Over the past 40 years, we have replaced accessible stairwells with escalators and elevators. We have eliminated common greenways and moved work and shopping to areas better suited to driving than walking. We’ve made car travel more convenient and often safer than walking or biking or using public transportation (which usually involves some walking). We’ve introduced nearly every conceivable human energy saver into our homes, from washing machines and garage door openers to TV remote controls and battery powered watches. We have drive-through fast food restaurants, drive-through banks, and drive-through drug stores. We can order in meals and movies. And more than ever, we rely on processed, packaged foods and snacks that require a minimum of effort to prepare and consume, and pack few nutrients and fiber, and a lot of calories.

The result: Overweight and obesity have reached epidemic levels; adequate physical activity has reached its lowest level ever, and type 2 diabetes has been on the rise since World War II and is affecting people at younger ages.

We’ve made some gains too. We have experienced declines in cardiovascular disease mortality; in cigarette use; in cholesterol levels; and in the percentage of the population that has high cholesterol and high blood pressure. Per capita consumption of butter, consumption of fat as a percentage of total calories and salt intake are all down. Alcohol use is at its lowest level in decades.

Since when? Since the American Heart Association issued its first statement on diet and coronary heart disease in 1961; since the 1964 Surgeon General’s Report on Smoking and Health; since the inception of the National High Blood Pressure Education Program in 1973; and the National Cholesterol Education Campaign in 1985. And in the 1990s we have improved dietary guidelines, user-friendly nutrition labels on nearly all foods, and the "5 A Day for Better Health" and "Exercise: It’s Every Where You Go" campaigns.

In short, since we educated the public and launched campaigns designed to improve the behavior of everyone in the community -- not just those at highest risk.

But we still have a long way to go.

• In our society, when a child is born with congenital syphilis, we call it a public health failure. But when a newborn is exposed to second-hand smoke, we say, "smokers have rights too."
• In our society, when a child gets measles in kindergarten, we call it a public health failure. But when a kindergarten child gets a high fat, high sugar, low fiber, non-nutritious "treat" at the end of each week, we call it "Friday surprise."
• In our society, when a 64 year old woman dies of cervical cancer, we say "that death should have been prevented." But when a 64 year old woman dies of heart disease, we say "everybody dies of something."
• In our society, we’d rather go to a physician for a cure than take responsibility for prevention.

We still have a long way to go to change community perceptions and alter community norms – and it’s going to take a generation to get there.

If we were holding this cardiovascular health conference 35 years ago, in 1964, we would have had all the basic information about preventing heart disease that we have today.

The key difference – if this meeting were held 35 years ago – is that one-third to one-half of you here in this audience would have been smokers and some of you would be smoking right now in this room. Now, I would guess, fewer than 5% of you are smokers, and those of you who are smokers wouldn’t dream of lighting up in a public place like this.

We need that kind of 'sea of change' in the other cardiovascular disease risk factors and even greater reductions in tobacco use. 35 years from now architects won’t dream of hiding staircases in the remote, dimly lit corners of buildings – they’ll put the elevator there instead. 35 years from now, processed and packaged foods will contain 10% to 15% less salt; and "whole" milk will contain 2% milk fat instead of 4%. 35 years from now teachers won’t be modeling poor nutrition behaviors by handing out candy in the classroom and physical activity will return to our daily lives. Maybe we’ll be vaccinating against chlamydia.

But only if we do something differently, if we change social norms and transform the community environment to encourage and require heart healthy living.

What does all this have to do with data and translating data into action?

How we use data and what we think of as data determines the questions we ask, the priorities we set, the programs we implement, and the attention we get.

I presented a report yesterday on trends in cardiovascular disease mortality, hospitalizations, and risk factors. That’s how we tend to quantify the burden of disease in our society. I presented the data at the state level, not at the level of county or zip code or census block, again because in our society that’s most often the level of surveillance that we can afford and the level that gives us numbers and rates that we can be confident about.

When we think about mobilizing communities to action, however, cardiovascular disease mortality rates are rarely shocking enough, and state or even county level data aren’t close enough to home.

We need these data – don’t be confused on that point. We need to know what the burden of disease is and we need to track it over time. We need to know where we’ve been and where we are headed; where we are making progress and where we are not. But we need to translate the data into something meaningful in our communities. We do that by linking what happens in our communities – what we have control over – to the abstract rates and numbers that ultimately quantify the burden of disease in our society.

At the end of the twentieth century, we know enough about individual behaviors, we know enough about the disease process, and we know enough about the links between behavior and disease to look critically at our communities and figure out what needs to change. We have a basic set of recommendations for healthful living that for the most part have not changed in the past 40 years:

• Don’t smoke (don’t use tobacco)
• Eat a healthful diet
• Exercise regularly
• Achieve and maintain ideal weight
• If you drink, do so only in moderation (0-2 drinks/day)

What we need to do as we think about interventions to improve cardiovascular health in our communities is to take a critical look at our community and ask ourselves: What do I see that is not directly contributing to the health of this community? If we need to narrow it down, ask: What do I see that is not directly contributing to the cardiovascular health of this community. And if we need to narrow it down even further, ask: What do I see that is not directly contributing to the adoption of the behaviors that contribute to cardiovascular health?

What we might see are

• Public places out of compliance with the Clean Indoor Air Act
• Schools that lack a physical activity program
• Parks and recreation areas that are underutilized, outdated or unsafe
• Restaurants and fast food establishments that lack heart healthy menu choices
• Lack of education
• Grocery stores that show-case high fat, low nutrition foods
• Work places that are not smoke-free
• Advertisements for alcohol
• Senior centers serving high fat high salt meals
• Roadways that lack sidewalks
• Substandard housing in unsafe neighborhoods that lack access to affordable healthful foods and inviting recreation areas
• Stores that sell tobacco products to minors
• Snack areas where soda and potato chips are easier to find than juice and carrot sticks.

These are empowering sights. These are empowering sights because…

Each of these obstacles presents an opportunity for intervention, an intervention that can be linked, through a network of prevention pathways, to the disease outcome we want to avoid and that we have so much data to describe.

When we talk about translating data into action, take the data I presented yesterday, and work backwards through what you know about risk factors and disease prevention, to what is going on in your community that you can change, at the community level and at the individual level, to enhance cardiovascular health.

Translating data into action means making the link between abstract numbers that tell the story of disease and death, to what goes on in my kitchen, in my school, in my community that sets the whole disease process in motion.

We have our work cut out for us because we have already picked the "low hanging fruit." In the data in our report, you see the behavior change. As you look around, you see the change in social norms.

But behavior change has occurred among those who were easiest to reach, whose attitudes and behaviors were easiest to change, and who had the resources to make heart healthy choices.

We are a very diverse state in a very diverse country. Now more than ever, we need to reach out to all population groups and communities in all geographic areas with messages and interventions that are meaningful and practical to the diverse lives we lead.

When we re-engineer the social landscape, when we add bike paths, and walking trails, and heart healthy school lunches, let us not ignore the structural and social obstacles that stand in the way of those who want and need to change: Poverty, violence, ignorance, lack of access to health care, lack of access to child care…

As we embark on "Cardiovascular Health – The Next Generation, " these are our phantom menace.

Legionellosis was first recognized in 1976 after an explosive outbreak of pneumonia (with 182 cases and 29 deaths) among participants of the American Legion’s convention in Philadelphia¹ The source of the bacteria, Legionella pneumophilia, was apparently in the cooling system of the hotel where the convention was held. By 1978 researchers had found the organism growing in cooling towers or evaporative condensers of air-conditioning systems at the sites of several outbreaks and hypothesized that the equipment may aid in disseminating the organism into the air².

There are two forms of the disease: Legionellosis and Pontiac disease. For Legionellosis, pneumonia is the most common clinical manifestation. However, the symptoms are nonspecific and can vary from a mild cough with low-grade fever to stupor, respiratory failure and multi-organ failure³. The incubation period is 2-10 days. As with other types of pneumonia, the disease is more severe in elderly and patients with other health problems such as chronic lung disease, immune disorders and cancer⁴.

Pontiac fever is a milder, self-limiting form of the disease without pneumonia. The symptoms are influenza-like with respiratory signs, fever and myalgia. The incubation period is 1-2 days. Laboratory testing is needed to distinguish Legionellosis and Pontiac disease from other causes of respiratory illness.

It has been estimated that 1-5% (ca 13,000) of all cases of community-acquired pneumonia in the United States each year are caused by Legionella³. More than 80% of these are caused by L. pneumophilia serotype 1. Most cases are sporadic, but outbreaks have been reported from several different environments including cruise ships, office buildings, hotels and hospitals. Exposure to construction sites has also been linked to some outbreaks. Hot tubs, hot water heaters, shower nozzles and spray equipment in grocery stores have all been implicated in clusters or outbreaks. In Florida, on average 41 cases were reported each year between 1987-1998. Most of the patients were white (88%), and the average age was 61.7 years. An outbreak caused by bacteria growing in a decorative water fountain was reported from Orlando in 1992⁵. Environmental investigation of the source of clusters of cases is often indicated, while it is usually not indicated for individual or sporadic cases.

References:

1. Fraser, D.W., Tsai, T.R., Orenstein W et.al 1977. Legionnaires’ disease, description of an epidemic of pneumonia. NEJM 297 (22) 1189-1197.

2. Eickhoff, T.C. 1979. Epidemiology of Legionnaires’ disease. J. Int. Med. 90: 499-502.

3. Stout, J.E., Yu, V.L. 1997. Current concepts: Legionellosis. NEJM 337: 682-687.

4. Breiman R.F., Butler, J.C. 1998. Legionnaires’ disease: Clinical, epidemiological, and public health perspectives. Seminars in resp. inf. Vol 13. 1998. pp. 84-89.

5. Hlady, W.G., Mullen, R.C., Mintz, C.S., Shelton, B.G., Hopkins, R.S., Daikos, G.L. 1993. Outbreak of Legionnaire’s disease linked to a decorative fountain by molecular typing. Am. J. Epidemiology 138: 555-562.

An interactive satellite teleconference entitled "Health Effects of Harmful Algal Blooms In Florida" and produced by the Department of Health’s Marine Toxin Program will be broadcast on June 8, 1999 from 1:00 p.m. to 2:30 p.m. (EDT) at Department of Health Satellite Teleconference Sites. The content of this teleconference is most appropriate for physicians, nurses, epidemiologists, toxicologists, environmental health scientists, and other personnel interested in marine toxins, occupational health, or emergency medicine.

Calling all writers! Anyone interested in submitting articles for inclusion in the Epi Update should send their article(s) and attachment(s) (if applicable) to Don Ward.

During the past decade, several County Health Departments were finally able to move to new buildings specifically designed to serve public health interests. The following brief history of the Hernando County Health Department, penned by Gina Dowler, is but one example of how much our CHDs have improved their physical facilities over time.