Top 10 Public Health Issues

Every year, the Centers for Disease Control and Prevention (CDC) publishes a report called the Prevention Status Report (PSR), which highlights the status of public health policies and practices that address the top ten most important public health issues that the United States is facing today. These include: (1) alcohol related harm or injury, (2) food safety, (3) healthcare-associated infections (or nosocomial infections), (4) heart disease and stroke, (5) HIV, (6) motor vehicle injuries, (7) nutrition, physical activity and obesity, (8) prescription drug overdose, (9) teen pregnancy, and (10) tobacco use.

(1) Alcohol Related Harm

Binge drinking, the main route alcohol related harm takes to occur, affects one in six adults in the United States, and is most common among younger adults aged 18-34 years. Binge drinking has been associated with many health issues, including: (1) unintentional injuries (car accidents, falls, burns, alcohol poisoning), (2) violence (murder, suicide, domestic violence, sexual assault), (3) STDs, (4) unintended pregnancies, (5) fetal alcohol spectrum disorders, (6) sudden infant death syndrome, (7) chronic diseases (high blood pressure, heart disease, liver disease), (8) cancers of the breasts, mouth, throat, esophagus, liver and colon, (9) memory and learning problems, and (10) alcohol dependence.

Prevention Strategies: Based on evidence-based policies recommended by the Community Preventive Services Task Force (CPSTF), alcohol related harm can be prevented by increasing the state excise taxes on beer, distilled spirits, and wine, in addition to having host commercial liability laws. Host commercial liability  mean that if a customer buys a drink, leaves the location and causes harm elsewhere, the owner of the place the drink was served at is legally responsible for that harm. These agencies have also suggested (1) regulating alcohol outlet density (i.e. the amount of alcohol-selling entities within a given area), (2) avoiding further privatization of retail alcohol sales, and (3) providing adults (especially pregnant women) with screening and a brief intervention for excessive alcohol use as appropriate prevention strategies.

Statistics: With the most current data, 42 states have beer excise taxes of less than 0.50 cents per gallon, 20 states have distilled spirits excise taxes of less than $4.00 a gallon, and 29 states have wine excise taxes of less than $1.00 per gallon. Six states have no commercial host liability laws and 25 states have major limitations added to the law that make it harder to find the commercial entity responsible for alcohol harm outcomes.

(2) Food Safety

It is estimated that one in six individuals in the United States get sick from contaminated food every year. From the 31 known pathogens that cause foodborne diseases, 37.2 million individuals will become infected, 228,744 will be hospitalized due to illness, and 2,612 will perish due to complications caused by the disease per year. Food can be contaminated with bacteria, viruses, parasites, chemical toxins, or other toxic substances. Contamination can occur before the product reaches its distribution center or during its preparation.

Prevention Strategies: Recommendations from the Council to Improve Foodborne Outbreak Response and the US Food and Drug Administration (FDA) are based on scientific evidence that supports the improved effectiveness of foodborne disease surveillance, detection, and prevention. This includes increasing the speed of DNA fingerprinting used to identify all reported cases of Shiga toxin-producing Escherichia coli (E. coli) O157 (i.e. identification within 4 days of the sample being taken), increasing the completeness of the DNA fingerprinting, and adopting provisions recommended in the FDA Food Code into state food regulations. These regulations include: (1) excluding ill food service staff from working until at least 24 hours after symptoms, such as vomiting and diarrhea, have ended, (2) prohibiting bare hand contact with ready-to-eat food, (3) requiring at least one employee in a food service establishment to be certified in food protection management, and (4) requiring food service employees to wash their hands. Other strategies to improve the prevention of foodborne illnesses include: (1) using trained staff and standardized questionnaires to interview individuals with suspected cases of foodborne illness soon after the disease is reported and (2) conducting environmental assessments as a routine component in outbreak investigations.

Statistics: With the most recent data, 18 states only follow 2 or fewer of the FDA’s Food Code regulations and 16 states only follow 3 of the 4 regulations.

(3) Healthcare-Associated Infections (HAIs)

HAIs are infections that individuals can get while receiving medical treatment in any healthcare facility and are often preventable. Examples of infections include pneumonia, gastrointestinal illness, urinary tract infections, primary bloodstream infections, and surgical site infections. On any given day in the United States, 1 in 25 hospital patients have at least one healthcare-associated infection. In 2011, there was an estimated total of 721,800 HAIs reported in the United States. Some of these infections can be treated and only result in an increased hospital bill, but others can cause further complications, or, if patients become septic due to one of these infections, it can result in death.

Prevention Strategies: Prevention strategies for reducing the instance of HAIs and antibiotic resistant (AR) bacteria are priorities of the CDC, the US Department of Health and Human Services (USDHHS) and the White House. These strategies include: (1) implementing state activities to build capacity for HAI prevention (e.g. building and maintaining partnerships, building proper infrastructure to aid in HAI outbreaks, HAI training for staff, and validating HAI data) and (2) implementing stewardship programs to improve antibiotic use in acute care settings (e.g. leadership commitment, accountability, drug expertise, actions to improve antibiotic use, tracking antibiotic use and outcomes and reporting it to staff, and education). The White House’s National Strategy for Combating Antibiotic Resistance Bacteria and the National Action Plan stresses the cautious use of antibiotics to prevent the transmission of AR bacteria. Other strategies include: (1) optimizing infection control practices within healthcare facilities, (2) using a coordinated regional approach to preventing infections, and (3) implementing the CDC’s Targeted Assessment for Prevention (TAP) strategy.

Statistics: With the most recent data, 14 states address only 3 of the HAI prevention areas in their acute care hospitals. Currently, less than 50% of acute care hospitals in 40 United States have antibiotic stewardship programs available.

(4) Heart Disease and Stroke

Heart disease is the leading cause of death in the United States for both men and women. Approximately 630,000 individuals die from heart disease each year and costs the United States about $200 billion per year. Stroke is the fifth leading cause of death, resulting in 140,000 deaths each year. Each year, approximately 795,000 individuals in the United States have a stoke, and each year, they cost the nation $34 billion dollars.

Prevention Strategies: Recommendations provided by the CPSTF, the US Public Health Service, the Institute of Medicine, and the American College of Clinical Pharmacy include implementing the use of certified electronic health records and establishing state collaborative drug therapy (CDTM) policies that authorize pharmacists to provide certain patient services. Other strategies for reducing heart disease and stoke include: (1) promoting team-based care, (2) implementing clinical decision-support systems, (3) using interventions that engage community health workers (cessation of smoking and drinking, increased physical activity, eating healthier, etc.), (4) reducing out-of-pocket costs for cardiovascular disease prevention strategies, and (5) reducing sodium consumption at the community level.

Statistics: Most recent data show that there are still 3 states that have no policies in place for following CDTM protocols and 9 states have limited services provided under an existing protocol.

(5) HIV

HIV is a virus that weakens a person’s immune system by destroying immune cells that are used to fight off infection. This means individuals with this disease are unable to fight any infection once the disease has progressed far enough. In 2015, 38,500 individuals were diagnosed with HIV, with an estimated 1.1 million individuals living with the disease during that year. An estimated 6,456 individuals died from complications due to HIV in 2015 and is the 9th leading cause of death for those aged 25 to 44.

Prevention Strategies: Four policies have been determined to aid in the advancement of the prevention in HIV and medical care that can reduce new HIV infections and related illnesses and death. These include (1) facilitating state Medicaid reimbursement for HIV screening, (2) making state HIV testing laws compatible with the CPSTF testing recommendations, (3) reporting all CD4 and all HIV viral load data to the state HIV surveillance program and complete lab reporting to the CDC, and (5) increasing the percentage of HIV-infected individuals who have a suppressed viral load. Another strategy is the use of antiretroviral medical in infected individuals to prevent transmission of the disease to unaffected partners.

Statistics: Most recent data show that 8 states still do not have Medicaid reimbursement for HIV screening and 1 state has limited Medicaid reimbursement. In 7 states, either there is no requirement for reporting CD4 and viral load levels to the state or no policy exists at all. In 16 states, there is a requirement for reporting, but incomplete data is shown to be reported to the CDC. In the 28 states that reported the data, less than 80% of individuals with HIV had evidence of viral suppression.

(6) Motor Vehicle Injuries

More than 32,000 individuals are killed, and another 2 million individuals are injured each year from motor vehicle crashes, which cost the United States $380 million in direct medical costs. One in three car accidents involve alcohol and almost one in three involve speeding.

Prevention Strategies: Strategies for preventing motor vehicle injuries come from recommendations provided by the CPSTF and the National Highway Traffic Safety Administration. These include (1) implementing primary enforcement of seat belt laws, (2) mandating the use of car seats and booster seats for individuals 8 years of age or younger, (3) implementing comprehensive graduated driver licensing systems for individuals 16 years or older, and (4) requiring the use of ignition interlock devices for everyone convicted of alcohol-impaired driving. Other strategies include (1) enhanced seat belt enforcement campaigns, (2) the 0.08% blood alcohol concentration laws, (3) the minimum drinking age laws, (3) publicized sobriety checkpoint programs, (4) alcohol impaired driving mass media campaigns, (5) increased alcohol taxes, and (6) car and booster seat distribution education campaigns.

Statistics: With the most current data, 16 states either have secondary enforcement laws for seat belts or no laws at all, with another 16 that only enforce seat belt laws in the front seats. Ten states only require car seats for children 5 years of age or younger, and 39 states only require them for ages 6 or 7 years. In 8 states, a learner’s permit can be given to those 14 years of age or younger, and in 34 states, 15-year-old individuals can obtain their learner’s permit. In 5 states, ignition interlocks are not required for anyone convicted of alcohol impaired driving, and 20 states only require interlocks for repeated offenders or first-time offenders with an abnormally high blood alcohol level at the time of arrest.

(7) Nutrition, Physical Activity and Obesity

Childhood obesity has become an issue in the United States, with 13.7 million individuals between 2 and 19 years of age being considered obese. This disease, in turn, affects 93.3 million adults in the Unites States. Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer that cause premature death in individuals.

Prevention Strategies: Strategies for reducing the obesity and increasing the consumption of nutritious food and participation in physical activity are provided by the Institute of Medicine, CPSTF, US Surgeon General, and the CDC. These strategies include (1) limiting the availability of less nutritious foods and beverages sold in schools, (2) implementing nutrition standards for foods and beverages sold on government property, (3) include obesity prevention standards in state regulation of licensed childcare facilities, and (4) promoting practices that support breastfeeding in hospital and birth centers. Other strategies include (1) requiring daily physical education in schools, (2) designing communities to support physical activity, and (3) improving the availability and promotion of healthier foods in the retail environment.

Statistics: In 14 states, less than 50% of secondary schools allowed students to purchase less nutritious foods and beverages, and in 20 states, 50%-65% of secondary schools allowed the purchase of less nutritious foods and beverages. In 47 states, the states’ nutrition standards policy for foods and beverages did not provide or reference quantifiable nutrition standards, did not apply to state executive bench properties, or no policy existed at all for nutrition standards. All fifty-one states were found to include less than 24 of the 47 components of national standards considered to have a high impact for obesity prevention into state licensing regulations of childcare facilities.

(8) Prescription Drug Overdose

Prescription opioids are used to treat chronic condition and acute pain, but they come with serious risks, including addition to the medication. Over-prescribing painkillers is the main reason why there is an epidemic currently occurring in the United States, with the number of opioids being prescribed per person ranging from 1 to 3. In 2016, 63,632 drug overdose deaths occurred in the United States, with 42,249 being caused by prescription opioids.

Prevention Strategies: The two strategies provided by the CDC to reduce the instance of prescription drug overdose include (1) requiring timely data submission to the Prescription Drag Monitoring Programs (PDMPs) (e.g. within 24 hours of medication being dispensed) and (2) requiring universal PDMP use by prescribers. Other important strategies that go hand-in-hand with these policies is: (1) making sure PDMP practices are easy to use and access, (2) PDMP records can be linked to electronic health records, (3) PDMP information is accessible to public health agencies for tracking trends, and (4) the institution that is using PDMP has the capacity to proactively notify users of high-risk behaviors. The USDHHS has also provided strategies to reverse the prescription drug overdose epidemic, which include (1) improving opioid prescribing practices, (2) expanding the use and distribution of naloxone, and (3) expanding medication-assisted treatment to reduce opioid reduce disorders and overdose.

Statistics: With the most recent data, 4 states either report dispensing data a week after the medication has been prescribed, or there is no reporting requirement at all. Another 23 states require reporting within a week after medication being prescribed. In 43 states, prescribers are not required to consult the PDMP before initial opioid prescriptions are made or such a requirement does not exist. There is no required subsequent check, and/or the policy includes subjective standards or broad exceptions in these same 43 states.

(9) Teen Pregnancy

Teen pregnancy and childbearing have significant social and economic costs through immediate and long-term impacts on teen parents, their children, and the parents of these teenagers. In 2010, teen pregnancy and childbirth costed about $9.4 billion in taxpayer money. From a social aspect, pregnancy is a significant contributor to high school dropout rates among girls. The children of these teen parents are also (1) more likely to drop out of high school when they are older, (2) have more health problems as they age, (3) be more likely to be incarcerated at some time during their teenage years, (4) give birth as teenagers, and (5) face unemployment in their adult years. In 2015, there were a total of 229,715 babies that were born to women between 15 and 19 years of age.

Prevention Strategies: Key policies that are in effect to reduce the instance of teen pregnancy in the United States include policies that involve increasing access to contraceptive counseling and services by expanding the age and income eligibility for Medicaid coverage of family planning services to increase teens’ access to healthcare services. States can expand access to Medicaid by: (1) extending coverage to teens under age 18 years and (2) setting the income eligibility level for family planning coverage to at least the same income level required for pregnancy care coverage. Other strategies include (1) providing sexual health education for adolescents, (2) using positive youth development approaches, and (3) improving parent-child communication and parental monitoring of youth behavior.

Statistics: The most recent data show that 7 states still have not expanded Medicaid to include teens under the age of 18 to be set to at least the income eligibility for coverage of pregnancy care, and another 30 states have set limited family planning eligibility that excludes some teens from receiving care when they are pregnant.

(10) Tobacco Use

Smoking is the leading cause of preventable death in the United States. Tobacco use leads to disease (e.g. lung cancer) and disability (e.g. emphysema) and can harm almost every organ in the body. In 2016, 17.8 million adults considered themselves to be current smokers, with thousands of young individuals starting to smoke every day.

Prevention Strategies: Strategies for reducing tobacco use are recommended by the Institute of Medicine, the World Health Organization, the CPSTF, the US Surgeon general, and the CDC. These strategies include (1) increasing the price of tobacco products, (2) establishing comprehensive, state-wide smoke-free policies to protect all nonsmokers from exposure to second hand smoke, and (3) sustaining comprehensive tobacco control program funding. Other strategies include (1) hard-hitting media campaigned and (2) systematic changes to increase access to and use of cessation services.

Statistics: In the most recent data, 18 states have tobacco excise taxes that are less than $1.00 per pack, and another 17 states have taxes that are less than $2.00 per pack. In 14 states, there are no state laws that prohibit smoking in all indoor areas of private workplaces, restaurants, and bars with no exceptions, with another 10 states having only some locations covered by these state smoke-free policies. Forty-four states use less than 50% of the recommended funding from the CDC for state comprehensive tobacco control activities.

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