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Global Public Health Impact of Vaccines in Children  

Peter McIntyre and Tony Walls

From the first vaccine (cowpox, developed by Edward Jenner in 1796), more than 100 years elapsed before additional vaccines for broad population use (diphtheria toxoid, tetanus toxoid, and whole cell pertussis) became available between 1920 and 1940. Then followed inactivated polio vaccine in the 1950s, and live attenuated vaccines for measles, mumps, rubella, and polio in the 1960s. In 1979, global elimination of smallpox was formally certified, with the last human case occurring in Somalia, almost 200 years after Jenner administered cowpox vaccine to James Phipps. In 2019, global elimination is tantalizingly close for maternal and neonatal tetanus and polio. Despite recent outbreaks, elimination has also been achieved at country and regional levels for measles and rubella and, if achieved globally, will offer, as it has for smallpox, large reductions in child mortality and morbidity and in health system costs. Short of elimination, it is important to define the public health impact of vaccines broadly and at the population level. These broader impacts include benefits to families flowing from prevention of long-term sequelae of infection in children, and to populations and health systems from reduced transmission of infection. Importantly, well-delivered vaccination programs will have a substantial impact by improving equality in health outcomes across populations. Broader impacts include reductions in syndromic disease beyond laboratory-proven infection (e.g., diarrhea and pneumonia), indirect reductions in disease in those not immunized (within and beyond age cohorts targeted by vaccine programs), and improvements in other health services driven by the infrastructure for vaccine delivery. Measurement of these broader impacts can be challenging and must also acknowledge the potential for trade-offs, such as replacement disease due to non-vaccine strains, as documented for pneumococcal infection. The realization of the benefits of vaccines globally for all children began with the Expanded Program on Immunization (EPI) initiated by the World Health Organization (WHO) in 1974. The EPI focused on improving coverage of six already available but grossly underutilized vaccines—diphtheria–tetanus–pertussis (DTP), polio, measles, and Bacille Calmette–Guerin (BCG). Through the EPI, estimated global coverage for 3 doses of DTP increased from around 20% to over 85%. Subsequent to the EPI, the Global Alliance for Vaccines and Immunization (GAVI), the Global Immunization Vision and Strategy (GIVS), and, most recently, the Global Vaccine Action Plan (GVAP) have aimed to improve access to additional vaccines in the poorest countries. These include Haemophilus influenzae type b (Hib), hepatitis B, pneumococcal conjugate, rotavirus, and human papillomavirus (HPV) vaccines, all introduced in high-income countries from the 1990s. In this chapter, the scope and methodological issues in measuring public health impact are reviewed, and estimates of the global public health impact of individual vaccines in children summarized, concluding with potential future benefits to global child health from expanded maternal vaccination and vaccines under development.


The Implications of Informal Settlement Upgrading Programs for Access to Water, Sanitation, and Public Health  

David Satterthwaite and Alice Sverdlik

Most cities in low- and middle-income countries have substantial proportions of their population living in informal settlements—sometimes up to 60% or more. These also house much of the city’s low-income workforce; many informal settlements also concentrate informal economic activities. These settlements usually lack good provision for water, sanitation, and other essential services. The conventional government responses were to bulldoze them or ignore them. But from the 1960s, another approach became common—upgrading settlements to provide missing infrastructure (e.g., water pipes, sewers, drains). In the last 20 years, community-driven upgrading has become increasingly common. Upgrading initiatives are very diverse. At their best, they produce high-quality and healthy living conditions and services that would be expected to greatly reduce illness, injury or disablement, and premature death. But at their worst, upgrading schemes provide a limited range of improvements do nothing to reduce the inhabitants’ exclusion from public services. There is surprisingly little research on upgrading’s impact on health. One reason is the very large number of health determinants at play. Another is the lack of data on informal settlement populations. Much of the innovation in upgrading is in partnerships between local governments and organizations formed by informal settlement residents, including slum/shack dweller federations that are active in over 30 nations. Community-driven processes can deal with issues that are more difficult for professionals to resolve—including mapping and enumerations. Meanwhile, local government can provide the connections to all-weather roads, water mains, sewers, and storm drains into which communities can connect.


Health Problems in the European Alps Under Climate Change  

Lisbeth Weitensfelder, Hans-Peter Hutter, Kathrin Lemmerer, Michael Poteser, Peter Wallner, and Hanns Moshammer

The Alpine region in Central Europe and its populations in principle face the same types of threats to their health due to climate change as those in other parts of the world. But special geographical and climatic aspects of that region warrant closer and special examination of the connections between health and climate change in the Alps. These include small-scale variation, in some instances steep mountain slopes, and, above all, a larger-than-average increase in near-surface temperatures. To that end, there are main pathways between climate change and health: “Direct effects” describe rather short-term health effects of extreme weather events. Such events have occurred in the past, and therefore ample epidemiological evidence is available for the assessment of their impact. With climate change, such extreme events are predicted to change in frequency and intensity. “Indirect effects” refer to a more complex pathway where long-term changes of various natural and anthropogenic systems in reaction or adaptation to climate change exert adverse or sometimes also beneficial impacts on health. Such systems include ecosystems in which, for example, the prevalence of disease vectors or the allergenicity of pollen will change. But agriculture and forestry or the built environment are also affected by climate change and in turn affect the health of people. “Distant effects” are also rather indirect in nature. But in this pathway, changes due to climate change in other parts of the world affect the health in the Alpine region. Increasing migration into the Alpine region and changing migration patterns are important examples of this pathway. In some instances, most importantly regarding mental health, there is still a need for more studies focusing on the Alpine environments. But apart from these especially understudied topics, as the climate crisis evolves, there is generally a need for continuous research on the health effects of climate change and the potential of health promotion to create co-benefits.


The Impacts of Environmental Regulation on the U.S. Economy  

Ann E. Ferris, Richard Garbaccio, Alex Marten, and Ann Wolverton

Concern regarding the economic impacts of environmental regulations has been part of the public dialogue since the beginning of the U.S. EPA. Even as large improvements in environmental quality occurred, government and academia began to examine the potential consequences of regulation for economic growth and productivity. In general, early studies found measurable but not severe effects on the overall national economy. Although price increases due to regulatory requirements outweighed the stimulative effect of investments in pollution abatement, they nearly offset one another. However, these studies also highlighted potentially substantial effects on local labor markets due to the regional and industry concentration of plant closures. More recently, a substantial body of work examined industry-specific effects of environmental regulation on the productivity of pollution-intensive firms most likely to face pollution control costs, as well as on plant location and employment decisions within firms. Most econometric-based studies found relatively small or no effect on sector-specific productivity and employment, though firms were less likely to open plants in locations subject to more stringent regulation compared to other U.S. locations. In contrast, studies that used economy-wide models to explicitly account for sectoral linkages and intertemporal effects found substantial sector-specific effects due to environmental regulation, including in sectors that were not directly regulated. It is also possible to think about the overall impacts of environmental regulation on the economy through the lens of benefit-cost analysis. While this type of approach does not speak to how the costs of regulation are distributed across sectors, it has the advantage of explicitly weighing the benefits of environmental improvements against their costs. If benefits are greater than costs, then overall social welfare is improved. When conducting such exercises, it is important to anticipate the ways in which improvements in environmental quality may either directly improve the productivity of economic factors—such as through the increased productivity of outdoor workers—or change the composition of the economy as firms and households change their behavior. If individuals are healthier, for example, they may choose to reallocate their time between work and leisure. Although introducing a role for pollution in production and household behavior can be challenging, studies that have partially accounted for this interconnection have found substantial impacts of improvements in environmental quality on the overall economy.



Funmilola M. OlaOlorun and Wen Shen

Menopause is the natural senescence of ovarian hormonal production, and it eventually occurs in every woman. The age at which menopause occurs varies between cultures and ethnicities. Menopause can also be the result of medical or surgical interventions, in which case it can occur at a much younger age. Primary symptoms, as well as attitudes toward menopause, also vary between cultures. Presently, the gold standard for treatment of menopause symptoms is hormone therapy; however, many other options have also been shown to be efficacious, and active research is ongoing to develop better and safer treatments. In a high-resource setting, the sequelae/physiologic changes associated with menopause can impact a woman’s physical and mental health for the rest of her life. In addition to “hot flashes,” other less well-known conditions include heart disease, osteoporosis, metabolic syndrome, depression, and cognitive decline. In the United States, cardiac disease is the leading cause of mortality in women over the age of 65. The growing understanding of the physiology of menopause is beginning to inform strategies either to prevent or to attenuate these common health conditions. As the baby boomers age, the distribution of age cohorts will increase the burden of disease toward post-reproductive women. In addition to providing appropriate medical care, public health efforts must focus on this population due to the financial impact of this age cohort of women.


A Historical Perspective of Unconventional Oil and Gas Extraction and Public Health  

Erin N. Haynes, Lisa McKenzie, Stephanie A. Malin, and John W. Cherrie

Technological advances in directional well drilling and hydraulic fracturing have enabled extraction of oil and gas from once unobtainable geological formations. These unconventional oil and gas extraction (UOGE) techniques have positioned the United States as the fastest-growing oil and gas producer in the world. The onset of UOGE as a viable subsurface energy abstraction technology has also led to the rise of public concern about its potential health impacts on workers and communities, both in the United States and other countries where the technology is being developed. Herein we review in the national and global impact of UOGE from a historical perspective of occupational and public health. Also discussed are the sociological interactions between scientific knowledge, social media, and citizen action groups, which have brought wider attention to the potential public health implications of UOGE.


Impacts of Megacities on Air Quality: Challenges and Opportunities  

Luisa T. Molina, Tong Zhu, Wei Wan, and Bhola R. Gurjar

Megacities (metropolitan areas with populations over 10 million) and large urban centers present a major challenge for the global environment. Transportation, industrial activities, and energy demand have increased in megacities due to population growth and unsustainable urban development, leading to increasing levels of air pollution that subject the residents to the health risks associated with harmful pollutants, and impose heavy economic and social costs. Although much progress has been made in reducing air pollution in developed and some developing world megacities, there are many remaining challenges in achieving cleaner and breathable air for their residents. As centers of economic growth, scientific advancement, and technology innovation, however, these urban settings also offer unique opportunities to capitalize on the multiple benefits that can be achieved by optimizing energy use, reducing atmospheric pollution, minimizing greenhouse gas emissions, and bringing many social benefits. Realizing such benefits will, however, require strong and wide-ranging institutional cooperation, public awareness, and multi-stakeholder involvement. This is especially critical as the phenomenon of urbanization continues in virtually all countries of the world, and more megacities will be added to the world, with the majority of them located in developing countries. The air quality and emission mitigation strategies of eight megacities—Mexico City, Beijing, Shanghai, Shenzhen, Chengdu, Delhi, Kolkata, and Mumbai—are presented as examples of the environmental challenges experienced by large urban centers. While these megacities share common problems of air pollution due to the rapid growth in population and urbanization, each city has its own unique circumstances—geographical location, meteorology, sources of emissions, human and financial resources, and institutional capacity—to address them. Nevertheless, the need for an integrated multidisciplinary approach to air quality management is the same. Mexico City’s air pollution problem was considered among the worst in the world in the 1980s due to rapid population growth, uncontrolled urban development, and energy consumption. After three decades of implementing successive comprehensive air quality management programs that combined regulatory actions with technological change and were based on scientific, technical, social, and political considerations, Mexico City has made significant progress in improving its air quality; however, ozone and particulate matter are still at levels above the respective Mexican air quality standards. Beijing, Shanghai, Shenzhen, and Chengdu are microcosms of megacities in the People’s Republic of China, with rapid socioeconomic development, expanding urbanization, and swift industrialization since the era of reform and opening up began in the late 1970s, leading to severe air pollution. In 2013, the Chinese government issued the Action Plan for Air Pollution Prevention and Control. Through scientific research and regional coordinated air pollution control actions implemented by the Chinese government authority, the concentration of atmospheric pollutants in several major cities has decreased substantially. About 20% of total megacities’ populations in the world reside in Indian megacities; the population is projected to increase, with Delhi becoming the largest megacity by 2030. The increased demands of energy and transportation, as well as other sources such as biomass burning, have led to severe air pollution. The air quality trends for some pollutants have reduced as a result of emissions control measures implemented by the Indian government; however, the level of particulate matter is still higher than the national standards and is one of the leading causes of premature deaths. The examples of the eight cities illustrate that although most air pollution problems are caused by local or regional sources of emissions, air pollutants are transported from state to state and across international borders; therefore, international coordination and collaboration should be strongly encouraged. Based on the available technical-scientific information, the regulations, standards, and policies for the reduction of polluting emissions can be formulated and implemented, which combined with adequate surveillance, enforcement, and compliance, would lead to progressive air quality improvement that benefits the population and the environment. The experience and the lessons learned from the eight megacities can be valuable for other large urban centers confronting similar air pollution challenges.


Risk Perceptions and Risk Characteristics  

Hye-Jin Paek and Thomas Hove

Risk perception refers to people’s subjective judgments about the likelihood of negative occurrences such as injury, illness, disease, and death. Risk perception is important in health and risk communication because it determines which hazards people care about and how they deal with them. Risk perception has two main dimensions: the cognitive dimension, which relates to how much people know about and understand risks, and the emotional dimension, which relates to how they feel about them. Several theoretical models have been developed to explain how people perceive risks, how they process risk information, and how they make decisions about them: the psychometric paradigm, the risk perception model, the mental noise model, the negative dominance model, the trust determination model, and the social amplification of risk framework. Laypeople have been found to evaluate risks mostly according to subjective perceptions, intuitive judgments, and inferences made from media coverage and limited information. Experts try to base their risk perceptions more on research findings and statistical evidence. Risk perceptions are important precursors to health-related behaviors and other behaviors that experts recommend for either dealing with or preventing risks. Models of behavior change that incorporate the concept of risk perception include the Health Belief Model, Protection Motivation Theory, the Extended Parallel Process Model, and the Risk Perception Attitude framework. Public awareness and perceptions of a risk can be influenced by how the media cover it. A variety of media factors have been found to affect the public’s risk perceptions, including the following: (1) amount of media coverage; (2) frames used for describing risks; (3) valence and tone of media coverage; (4) media sources and their perceived trustworthiness; (5) formats in which risks are presented; and (6) media channels and types. For all of these media factors, albeit to varying degrees, there is theoretical and empirical support for their relevance to risk perceptions. Particularly related to media channels and genres, two hypotheses have emerged that specify different kinds of media influences. The impersonal impact hypothesis predicts that news media mainly influence how people see risks as affecting other individuals, groups, nations, or the world population in general (societal-level risk perceptions). By contrast, the differential impact hypothesis predicts that, while news media influence people’s societal-level risk perceptions, entertainment media have stronger effects on how people see risks as affecting themselves (personal-level risk perceptions). As the media environment become increasingly diverse and fragmented, future research on risk perception needs to examine more of the influences that various media, including social media, have on risk perception. Also, the accounts of how those influences work need to be further refined. Finally, since people’s risk perceptions lead them to either adopt or reject recommended health behaviors, more research needs to examine how risk perceptions are jointly affected by media, audience characteristics, and risk characteristics.


Children: Overview  

Dorinda N. Noble

Children are interesting, resilient people, whose lives are often perilous. Social workers deal extensively with children and families, and with policies that affect children, to help children and families overcome family disruption, poverty, and homelessness. Social workers also provide mental health care while working to ensure that children get medical care. Schools are areas of practice for social workers dealing with children. The issues of ethical practice and social justice for children are complex.