1. Public Health Priorities CDC Orientation for New Health Officials May 13, 2015 Thomas R. Frieden, MD, MPH Director Centers for Disease Control and Prevention

2. CDC strategic directions Improve health security at home and around the world Better prevent the leading causes of illness, injury, disability, and death Strengthen public health/ health care collaboration

3. Key winnable public health battles for the United States Nutrition, Physical Activity, Obesity and Food Safety Healthcare- Associated Infections HIV Motor Vehicle Injuries Tobacco Teen Pregnancy

4. Each area is a leading cause of illness, injury, disability, or death, and/or represents enormous societal costs Evidence-based, scalable interventions already exist and can be broadly implemented Our effort can make a difference We can get results within 1 to 4 years – but it won’t be easy Winnable battles

5. Tobacco

6. Adult smoking rates vary widely Nearly 3x higher in some states than in others Behavioral Risk Factor Surveillance System, 2013; http://apps.nccd.cdc.gov/statesystem/InteractiveReport/InteractiveReports.aspx

7. Adult smoking rates have fallen in recent years Prevalence of current smoking among adults age 18+, U.S., 1997–2013 CDC/NCHS, National Health Interview Survey, 1997–2013, Sample Adult Core component; preliminary analysis; www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201406_08.pdf 0% No significant decrease 25% 21% 18%

8. Many states have passed smoke-free laws in worksites, restaurants, and bars Laws in effect as of 2014. CDC State Tobacco Activities Tracking and Evaluation (STATE) System; www.cdc.gov/tobacco/statesystem

9. 2015 Tips From Former Smokers campaign Profiles people who are living with the significant adverse health effects due to smoking www.cdc.gov/tobacco/campaign/tips/

10. Nutrition, physical activity, obesity, and food safety

11. Rates of obesity are high in all states among adults Source: Behavioral Risk Factor Surveillance Systems, CDC Prevalence of self-reported obesity among U.S. adults, 2013

12. Core interventions to prevent obesity Leverage federal, state, community, and other resources Rigorous monitoring SchoolsWorksites Provide high quality PE programs Increase physical activity opportunities before, during, and after school Reduce screen time Increase walking/cycling to school Implement nutrition standards Ensure only nutritious foods are sold and marketed on school campuses Establish worksite wellness programs to increase physical activity and improve nutrition Ensure that health care benefits include nutrition and weight counseling Increase availability/affordability of healthier food and beverages in cafeterias and vending CommunitiesHealth care Increase access to healthier/affordable food through corner stores and farmers markets Support purchase of locally produced food Promote physical activity and active transport through community design Adopt food service guidelines in cafeterias, vending, and concessions Provide BMI screening and counseling Increase support for breastfeeding Provide referrals to structured lifestyle change programs such as the Chronic Disease Self Management Program and the National Diabetes Prevention Program

13. Progress in nutrition, physical activity, obesity, and food safety

14. Healthcare-associated infections

15. CAUTI* has improved in some states, but further prevention is needed

16. Progress in healthcare- associated infections

17. Motor vehicle injuries

18. Motor vehicle crash death rates nearly 5x higher in some states than others www.iihs.org/iihs/topics/t/general-statistics/fatalityfacts/state-by-state-overview/2013

19. Progress in motor vehicle injuries

20. Teen pregnancy

21. Teen birth rates lowest in Northeast, upper Midwest, upper Northwest, and highest in South www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf (page 37)

22. Progress in teen pregnancy

23. HIV/AIDS

24. The continuum of HIV care Of the 1.2 million Americans living with HIV, less than a third are virally suppressed MMWR Vital Signs, Nov 28, 2014.

25. New HIV diagnosis rates are higher in the Southeast and Northeast US (2013) Note: Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data includes adults and adolescents only. Data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Source: www.cdc.gov/hiv/library/slideSets/index.html

26. Progress in HIV/AIDS

27. Priorities evolve and need to resonate within the context of your community Identify your own focus areas – recognizing the winnable battles framework: Address public health priorities that have large-scale impact on health Implement existing evidence-based interventions Focus on efforts that can have a significant impact in a relatively short time Finding your own winnable battles

28. Heart disease and stroke are leading killers in the US

29. 72 million US adults have hypertension But many are not aware or treated (hiding in plain sight) and barely half have it controlled 72M 59M 54M 37M 52% CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012

30. Million Hearts: Prevent 1M heart attacks and strokes by 2017

31. Million Hearts will mean…

32. Prescription drug abuse is a public health epidemic 4X The more than 4-fold increase in opioid overdose deaths parallels the 4-fold increase in sales since 1999 Prescription opioid overdoses have claimed more than 145,000 lives over the past decade

33. Public health, law enforcement & communities working together cut crash deaths in half We can do the same for overdoses Source: NCHS.

34. Death rates from heroin overdose are increasing rapidly as death rates from prescription opioids are leveling off CDC Vital Statistics Heroin Rx Opioids All opioids (Heroin and Rx)

35. Two groups of people, two different sets of needs Addicted/Dependent Need access to services At risk for addiction/dependence Protect from dangerous drugs

36. State-based interventions are improving outcomes

37. Technical package Selected group of related interventions that, together, will achieve and sustain substantial improvements in specific risk factor or disease outcomes Ensures focus on specific interventions known to be most effective, feasible, sustainable, and scalable Avoids using large number of interventions, many of which may have only a small impact Can sometimes achieve synergy among intervention elements Simplicity is key to success

38. Possible technical package elements for Rx opioid misuse/abuse and OD prevention Improve prescribing PDMPs, pain clinic laws, prescribing defaults in EHR software, prior authorization for risky prescriptions, more Involve payors including Medicaid/Medicare, health systems, PBMs; clinicians; patients Treatment of opiate addiction and overdose: Increase access, quality, and accountability Reduce availability of illicit drugs Promote social awareness & economic development to reduce initiation and continuation of drug use Rigorous, real-time monitoring and appropriate action

39. Factors that affect health Socioeconomic factors Changing the context To make individuals’ default decisions healthier Long-lasting protective interventions Clinical interventions Counseling & education Largest Impact Smallest Impact Examples Poverty, education, housing, inequality Fluoridation, 0g trans fat, iodization, smoke-free laws Immunizations, brief intervention, cessation of treatment, colonoscopy Medication for high blood pressure, high cholesterol, diabetes Eat healthy, be physically active Frieden TR. AJPH. 2010;100:590-595.

40. Potential public health actions of a responsive government Promote free & open information Protect individuals from harm caused by other people or by groups Take societal action to protect & promote health Long- standing Truth-in-advertising laws Nutrition-facts panel Pharmaceutical package inserts Non-adulteration of food Laws against alcohol-impaired driving Infectious-disease reporting Worker safety Protection against naturally occurring health threats (e.g., West Nile virus) Tobacco excise tax Alcohol excise tax Vaccination mandates Water fluoridation Micronutrient fortification of manufactured foods Iodization of salt Clean water, air, food Elimination of lead in paint & gasoline Newer Public reporting of health care provider performance Calorie labeling at chain restaurants Graphic tobacco pack warnings Anti-tobacco advertising Sex education for teens Laws requiring smoke-free workplaces & other public places Alcohol ignition interlock devices for people convicted of drunk driving Restrictions on sales & marketing of tobacco & alcohol (especially to children) Elimination of artificial trans fat Zoning laws to promote physical activity (e.g., walking & bicycle paths) School policies (e.g., food, physical activity, safe transportation) Reduction of sodium in packaged & restaurant foods Frieden TR. NEJM, Apr. 17 2013

41. Necessary steps to implement public health programs Frieden TR. AJPH. 2014; 104:17-22.