Lafluer Trading Company

Lafleur Trading Company Lafleur Trading Company was founded in 1975 and has been supplying fine foods and wines to countries all over the world (Apollo Group, 2009). The founders of Lafleur Trading Company believe their products meet the needs of consumers for their lifestyle, health, and ethics. Company leaders offer only products that have passed Canada’s strictest guidelines for organic products (Apollo Group, 2009). The Lafleur Trading Company teams members stand by their company ethics, believe in the company mission, and stand by the values on which the company was founded. Organizational Analysis â€Å"Whether a firm is developing a new business or reformulating direction for an ongoing business, it must determine the basic goals and philosophies that will shape its strategic posture† (Pearce & Robinson, 2009, p. 25). To accomplish this effectively, the leaders of Lafleur must have clarity on the organization’s mission, vision, values, and goals. These fundamental concepts serve as the foundation for why and how the organization will do business. Lafleur Trading Company has clearly identified the mission of the organization, which is providing high quality, organic products at competitive prices (Apollo Group, 2011). A company’s mission embodies the unique purpose it serves to meet and is developed with the values the leadership intends to infuse in the execution of its business. At Lafleur, they are committed to a high quality product, which meets the needs of their customers in an ethical manner. The importance for any business to identify its mission is to describe the expectations it plans to meet on a daily basis, expressing the organizational attitude to all its stakeholders. The values the leadership holds dear, like seeking out the most reputable producers of products and certifying those products meet the highest standards, provides insight into the commitment of Lafleur’s leadership to their values and mission. A vision, unlike the mission, is forward-thinking and identifies what the company’s leaders aspire for it to become. Lafleur Trading Company seeks to become the premier supplier of fine foods and wines in the world. This vision cannot be accomplished without clearly expressed goals. Its already impressive list of trading partners indicates the vision and goals for Lafleur was determined early in the organization’s conception. By continuing to make strategic decisions with the mission, vision, values, nd goals in mind, Lafleur is sure to attain a desirable future. Organizational Structure Lafleur Trading Company implemented a divisional organizational structure that allows the Chief Executive Officer to delegate responsibilities to separate department leaders. The decision to use a divisional organizational structure provides Lafleur Trading Company the ability to create departments that consists of experienced individuals in specific duties related to the department. This method creates additional accountability for employees because the department manager delegates a task to an individual or team who is responsible for the competition of that task (Apollo Group, Inc, 2011). Creating individual departments also creates an environment where Lafleur Trading Company can focus on providing customers with quality products at the lowest price because employees in his or her departments focus on his or her assigned task without interruption form other unrelated tasks. This structure allows Lafleur Trading Company to make decisions with better information and in less time because of the concentrated focus in each department. The divisional organizational structure at Lafleur Trading Company consists of four main positions the Chief Executive Officer (CEO), the Chief Information Officer (CIO), the Chief Financial Officer (CFO), and the Chief Operations Officer COO) (Apollo Group, Inc, 2011). The CEO oversees the total operation of the company using information from the CIO, CFO, and COO to determine what actions are appropriate. The CIO is responsible for the information technology aspect of the company, and the CFO oversees the accounting and legal aspect of the company. The COO maintains the general operations of the business that consists of sales, purchasing, warehouse operations, and human resources. Each department manages the responsibilities assigned to them and reports to the CEO who can use the information to make decision with more information about each department involved (John A. Pearce, 2009). Collaboration Process The collaboration process is a process in itself. It involves the process of parties coming together to work through the project. Each party should bring the project together; provide the scope of the project and the expectations. The parties need to understand and be clear on the success and the results of the project and then discuss the specifics. The framework offers the general components of collaboration. The elements include grounding, core foundation, outcomes, process and contextual factors. Grounding is the foundation of collaboration in which the parties get together and share the idea. Core foundation is the mutual idea of the collaborative efforts. Outcomes are the efforts achieved by collaboration and process and contextual factors are what effect the each day actions of the collaboration. Once the process is complete and it has been implemented, the parties are on their way to getting results that they would have not got otherwise. It is important to understand that the process is not for all situations and teamwork is the only way to achieve it. It is important to select the right people, for the right reason, and with the support of management. References Apollo Group, Inc. (2011). Lafleur Trading Company. Retrieved 12 8, 2011, from https://ecampus. phoenix. edu/secure/aapd/cist/vop/Business/Lafleur/intranet. htm Pearce, J. A. II, & Robinson, R. B. (2009). Strategic management: Formulation, implementation, and control (11th ed. ). New York: McGraw-Hill.

Florence Nightingale Leadership in Nursing Essay

Nursing has never been simple profession and it is not an easy task to quantify the contributions nurses have made in shaping healthcare. Modern nursing is complex, ever changing and multi focused; requiring nurses to evolve personally and professionally as leaders in healthcare. What is leadership? Leadership is defined by what it is, as much as what it is not. Leadership has nothing to do with titles, age, seniority, education or status, but rather associated with the characteristics that define a leader. Per Forbes Magazine (April, 2013) â€Å"Leadership is a process of social influence, which maximizes the efforts of others, towards the achievement of a goal. An effective leader must inspire the group to follow in their lead, to guide them to accomplish a mutual goal.† Florence Nightingale, the innovative leader and pioneer of modern nursing, is the person I selected as the leader I most admire and one who continues to inspire me to continue to grow professionally. Read more:  The person you admire the most essay Nightingale, who lived from 1820-1910 was a visionary, healer, reformer, environmentalist, feminist, practitioner, scientist, politician and global citizen. Her achievements are astounding considering the Victorian era, and the submissive role of women in her time. Her contributions to nursing theory, research, statistics, public health, and health care reform are invaluable and inspirational. Florence Nightingale demonstrated the characteristics of leadership such as, mission conscious, tenacity, solution oriented and commitment by her ability to establish nursing as professional practice, separate from medicine, while practicing in a male dominated world. Secondly, she was intentional and focused in her efforts as an advocate for the advancement of nursing into leadership positions and not one of just servitude, by fostering an environment of continued education and training for nurses. She formalized an educational program and founded the first nursing school in England that helpe d to formulate standards of practice evident in nursing care today. Florence far reaching visionary concepts of nurses contribution to healthcare ,leadership and the transformational aspects of nursing has continued to propel nurses into the forefront of modern healthcare . According to, Selanders & Crane, (2012) â€Å"Today ANA states that high quality practice includes advocacy as an  integral component of patient safety. Advocacy is now identified both as a component of ethical nursing practice and as a philosophical principle underpinning the nursing profession and helping to assure the rights and safety of the patient.† If the true test of leadership is measured by the outcomes, Florence is a proven leader. It has been my experience that nursing is a transformational experience, it shapes you as much as your values and philosophies shape your practice. Florence Nightingale herself was a true visionary, who was also transformed into a leader by her courage, advocacy, focus and intentional pursuits, in advancing the practice of nursing. Her leadership style is aligned with that of a transformational leader, integrated with some democratic and authoritarian leadership styles of her time. Per Selander & Crane (2012) â€Å"Nightingale understood the value of and the methods for achieving visionary leadership. She repetitively utilized techniques which have been developed as the stair step leadership development model. This paradigm blends the ideas of Nightingale with the current leadership terminology of Burns (1978, 2003), who identified the relative merit of leadership outcomes, with the ‘novice-to-expert’ concept of Benner (2000) which focuses on the necessity of building leadership skills. â€Å"Her ability to empower and inspire others to follow in her path, is the ultimate pinnacle of success for a leader. Florence Nightingale embodies the true characteristics and spirit of leadership, one that has proven the test of time and continues to evolve with time, as nurses forge a path in the 21 century healthcare. Selanders. L, Crane.P, (2012), 17(1).The voice of Florence Nightingale on Advocacy. Online J.of Nursing Issues Kruse. (April, 2013).The Definition of Leadership in the 21 Century, Forbes Magazine.www.forbesmagazine.com

African American Culture Reflection Response Essay

African American Culture Reflection Response - Essay Example African American culture has been growing independently from the standard American culture given craving of African American to hone their traditions, and additionally the racial isolation determination in America. As a result, African American culture has turn out to be a critical piece of American society, though then, for a certain period, it will be an unmistakable culture, which can be separated from it. One of the examples that can be used to understand African American Culture is naming; how they use to name people. African American culture considers names to be regularly have some connection with the same dialect group as other mainstream names found in American culture. The act of embracing neo-African or Islamic names did not pick up prevalence in anticipation of the Civil Rights period. This wilk be the last period. Endeavors to recoup African legacy roused determination of names with more profound social importance. Preceding this, the use of African names, which for two reasons, it was not considered to be pragmatic. First, some African Americans were a few eras expelled from the final predecessor to posses an African name. Moreover, African American practiced naming, which originates before the invention of African names. While trying to come up with their particular names, African American parents’ growth (regarding numbers), beginning in the post-World War II period, started making new names given sounds they discovered satisfying, for example, Marquon, DaShawn, LaTasha, or Shandra.

Assignment 2 Example | Topics and Well Written Essays - 750 words - 6

2 - Assignment Example Therefore, I will have to respond to the review publicly and make it professional (Couzin and Grappone 14). In my response, I will thank the client for the feedback and explain why the cafe allows children events. I will then explain to other clients or readers of the review page that they will not face the same issue because the cafe has worked out a solution to the issue. This will be to ensure that child minders, parents and all the other responsible parties keep all children under the control at all times. Therefore, it is not expected that presence of the children in Broadways Cafe will cause any problem to adults. Clients, who do not want to visit when children are there, can avoid such moments. I will also try to point out indirectly that the client who provided the review was wrong by including a statement which creates a doubt whether the origin of the problem is the Broadways Cafe or the client’s personal viewpoint. I will explain that the cafe is inclusive because it allows families with children to visit, but ensures that children are under control to avoid any inconvenience to other clients. The client’s viewpoint is unethical. Children cannot be eliminated from visiting the cafe just because of their age. They also have a right to enjoy the public place with their parents, as long as their behaviour, while they are within the cafe, is put under check. However, the customer has a right to air his view too, and to address the issue, it will be upon the cafe’s personnel to ensure that children do not cause any inconvenience to other clients. An open line of communication for Broadways Cafe can be encouraged, while still maintaining an open forum on the cafe’s Web site by making a corporate community on the Web site, which allows feedback to clients. To ensure that communication is open, the Web site will have to be user friendly and interactive so that clients can

Yiddish Literature Essay Example | Topics and Well Written Essays - 1000 words

Yiddish Literature - Essay Example ‘Joy’ is the story of a Rabbi who loses faith in his God with the adversities in his life. The Rabbi loses his children to death through sickness. His wife’s nagging and the tragedy makes him to question the existence of God. His faith trembles and he talks of shifting his belief to religion that believe in idol worship (Singer 32). He realizes that everything exist because his body makes him to feel the existence. Through the touch of the Berries and the cold water, he understands that the existence is momentary and so he does not have to worry about anything as he can’t do anything about it (Singer 33). This is the fact of life. When you experience difficulties that goes beyond your capacity of suffering, you start losing faith in your religious beliefs and question the existence of God. The absurdity of the situation is realized by the Rabbi in his deathbed. He sees the figures of his four sons, two daughters, grandfather and his father in the form of light and realizes that even when they are trying to come close to him, there is a restraint exercised on them which looks like fence. He becomes enlightened and just before dying tells Reb Abraham Moshe that one should always be joyous (Singer 37). The grotesque element makes him realize there is no point in missing the opportunity of being joyous on earth in hope of getting the joy or freedom after death in heaven. Vasil is a boy who hates and fears violence in his childhood but grows to be a soldier who resorts to violence and kills hundreds of his enemies himself. As a child he suppresses his fears

Battle of Fredericksburg Essay Example | Topics and Well Written Essays - 1250 words

Battle of Fredericksburg - Essay Example It started December 11, 1862 and ended four days later. The importance of the battle for both sides is paramount. The outcome, for instance, could prop up the Lincoln administration’s campaign for public support, which has suffered a great loss in public confidence owing to the failure of the Union forces to crush the Confederate army and defeat General Lee once and for all. On the other hand, for the Confederacy, the battle, though did not have any significant strategic import, achieved a psychological boost that trumpeted the might and capability of their forces. According to Eckenrode and Conrad, the battle is the culmination of the peak of the confederate strength in the course of the Civil War.1 How Fredericksburg came to be the battleground for this winter war was explained by Longstreet and Piston who wrote: Before the end of November it became evident that Fredericksburg was to be our winter station and the scene of a severe battle before it could be relieved†¦ To wards the latter part of the month General Jackson was called down and assigned position on the right near Hamilton’s Crossing and the Massaponax. ... Under cover of this fire, the Yankees attempted to construct two pontoon bridges opposite the city, but were repeatedly driven off by our sharpshooters in the rifle pits along the shore and in the houses.3 In the beginning the battle was expected to be a victory for the Union forces because they outnumbered Lee’s men. Under the command of General Ambrose Burnside, the Union army was 120,000 strong. General Longstreet wrote about the fateful day before the assault took place: â€Å"The flags of the Federals fluttered gaily, the polished arms shone brightly in the sunlight, and the beautiful uniforms of the buoyant troops gave to the scene the air of a holiday occasion rather than a spectacle of a great army about to be thrown into the tumult of battle.†4 But the attempt to rebuild a destroyed bridge necessary to cross into the city cost the Union Army a month, allowing Lee’s Confederate forces to receive reinforcements such as James Longstreet’s 41,000 men who began fortifying Marye’s Heights, which overlooked a wide canal and drainage ditch that the Union troops had to cross; â€Å"Stonewall† Jackson’s 39,000 soldiers who were positioned in Longstreet’s right flank; and, Lee’s 90,000 assembled army, who with the time wasted by the Union forces rebuilding the bridge, was able to secure the heights that covered most of the ground river. As events unfolded, the tides were turned and the expedition became a debacle for the Union army. The difficulty of the assault was recounted no less than General Burnside who later wrote about the bloody ambush: The stone wall [commanded by Longstreet’s men] proved too strong for the valor of our troops. Never did a hotter fire greet an advancing party. The plain in

Chase Management and Leadership Paper Term Example | Topics and Well Written Essays - 2000 words

Chase Management and Leadership - Term Paper Example me time, JPMorgan must determine the best method to satisfy foreign customers with vastly different needs and lifestyle values in an ever-changing and adaptable work environment. This requires dedication to setting up a healthier organizational culture built on teamwork and trust as primary principles for the business. This paper describes the role of manager versus leader at JPMorgan Chase, the process of maintaining a healthy organizational culture, and offers strategies on how to support a vigorous and dedicated team of professionals. The roles of traditional manager and that of an internal leader are significantly different in today’s fast-paced, international business environments. The role of manager is that of planning new operational activities and delegation of employee responsibilities, including assessment of financial data through management accounting. In the role of manager at JPMorgan Chase, this would include reviewing strategic plans, developing risk management policies, and considering the scope of major capital investments (Epstein & Roy, 2010). This role is primarily operational and strategic in nature, assessing long-term strategies and then aligning internal staff to meet these mandated goals. The role of manager in this financial institution is also setting a series of control practices, such as new employee policies, to ensure that all members of the organizational staff are performing their job roles effectively and considering proper allocation of organizational resources both budget ary and human resources-related. Management is a process-minded and procedural role with considerable employee oversight. In an organization like JPMorgan Chase, it involves a transactional focus, which is offering contingent reward to high performers based on their individual or group performance for meeting corporate goals (Judge & Piccolo, 2004). In this role, at a company like JPMorgan, these activities include monitoring changes in financial

Influence of Winthrop and Hobbes Essay Example | Topics and Well Written Essays - 1000 words - 4

Influence of Winthrop and Hobbes - Essay Example Hobbes also espouses ideas concerning equality stating that despite people living in different conditions in life, nature has made all men equal and because of this, no one should be superior to another. A result of the viewpoints espoused by these individuals is that they have become an essential part of developing a system of governance that not only embraces democracy but also guarantees the rights of all individuals in society. When one makes a study of Winthrop and Hobbes’ works, one will find that they are quite similar to the modern conventions concerning human rights as well as the rights of children. Hobbes states that all men have the liberty to do as they wish and this is an ability which has been given to them by nature and as a result it an inalienable right.   All men have control over their own lives and they can do everything that they believe is right according to their own judgment, thus ensuring that they remain completely free. An echo of Hobbes’ sentiments appears in the Universal Declaration of Human Rights (UDHR) which also declares that all human beings are born equal in dignity and in rights and that they are free to do what they think is right according to their own conscience. This declaration shows Hobbes’ influence on it despite its having been written some four hundred years before the UDHR was formally declared and implemented. This belief in the right of a ll men to equality as well as is based on a belief that human liberty has its origins in nature and that no man has the right to deny others the right to choose what they want to do with their lives.

How Diversity of Faith is Effectively Used in Nursing Care Essay Example for Free

How Diversity of Faith is Effectively Used in Nursing Care Essay Even though medical healing is mainly based upon scientific beliefs, one cannot discount the effect of religious beliefs in the healing of a patient. For many people with a strong religious conviction, the simple belief in the power of prayer is enough to create signs of healing even in the most critical of patients. Even though the effects of prayer are undocumented, there is a growing belief among many that faith plays a significant role in healing a patient when science has given him up for dead. In the medical field, nurses are slowly realizing that a diversity of faith among their patients has them in a bind. Not all nurses are religious, nor do they share the same religious traditions as the patient. In such instances, it is up to the nurse to find a middle ground where they can honor the religious beliefs of individual patients without losing sight of their own religion. Nursing is a highly technical occupation. This is why even though nurses realize that each patient has a spiritual need, the nurse may not always be trained to respond to it. So this job is usually relegated to the hospitals pastoral care workers even though nurses would be better placed to deliver such patient needs. It is not for a nurse to question the religious beliefs of her patients, but it is her job to insure that these beliefs are fully utilized in the process of helping a patient to heal both physically, mentally, and spiritually. Unfortunately, the nursing shortage in the country does not leave the nurses with much to connect on a personal basis with their patients. Patient care and comfort are forgone in lieu of time management and getting the job done. Though nurses have traditionally been viewed as both medical and spiritual healers because of the personal connection they have with their wards, the lack of time and instruction as to how to combine patient care and religion are sending our nurses off the original objectives of why they became nurses. Roberta Bube, RN, PHN currently works part time as nurse at the Marion Medical Center in Santa Maria, Calif. According to her interview in Nurseweek for the article You Gotta Have Fait, she realized that You have to address mind, body and spirit, I always found time to do it [in a hospital]. I did have to be cautious. Id have to do it quietly. Everybodys beliefs are different. So, how can a nurse integrate the religious aspect and its various differences in their daily dealings with their individual patients? Firstly, a nurse can typically start by incorporating the patients religious belief into her basic daily care routine for the patient. At the Saint Francis Medical Center in Santa Barbara, California, clinical coordinator Jan Ingram, RN, explains in the same article that Whether youre giving them a sponge bath or putting them on the commode, if youre really there with them-mindfully present-that is a spiritual action. Nurses have to realize that listening and communicating with their patient is of vital importance in helping a patient heal. This includes developing ways and means for the patient to be able to effectively practice their beliefs and be able to assist in the patients personal spiritual care. Once a nurse learns to approach a person holistically, the nurse will now be in a very good position to accept the various faiths of their patients and convert the same or varied belief amongst the patients she is in charge of. Secondly, the nurse must be willing to set aside her own personal spiritual beliefs and instead be open minded and willing to accept the faith of the patient while she is caring for him or her. A patient may request for a bible reading, a short prayer, or simply letting the patient talk with the nurse listening and prepared to reassure her at the end that God has not abandoned him or her. If need be, a nurse must not hesitate to accommodate a patients request to join him in a religious activity. Such activities tend to reassure a patient and keep him calm throughout the healing process. Lastly, it is highly imperative that nurses know and understand the religious beliefs of their patients as these beliefs can affect their medical decisions pertaining to procedures such as operations or end of life decisions. So, a nurse is encouraged to discuss and explore their patients religious beliefs if a patient is comfortable doing so with the nurse. This will allow a nurse to develop and gain the trust of the patient because the patient will be comfortable in the knowledge that the nurse in charge of her care understands her religious belief and will always respect its role in their lives. Such support systems between patient and nurse usually prove vital in the therapeutic alliance of the two parties. Â  It is also highly important that a nurse, even though not a devout practitioner of her religion, believes in God and knows how to pray. Even though a nurse is taught how to compartmentalize her feelings and not be affected by the events of the day at the hospital, one cannot help but be affected. There will be times in the course of performing her duty that she will call science into question and why it failed certain patients, or why it cannot seem to heal a patient who has no reason to be ill. During those situations, when science seems to fail her, the only thing she will find herself clinging to is her belief in god or her religion. It is this faith that she will take with her as she tries to heal her patient and help him cope with his medical situation. This will be the common denominator binding them. Faith in religion regardless of what the religion is commonly called. At the end of the day, nurses will have to learn to accept and integrate the diversified cultures and religious beliefs of their patients. The nurse will have to turn to her own personal faith for support as well. All of this because healing a patient is not all a matter of science. It is also a matter of spiritual belief in a Supreme Being who can heal us all of our aches and pains in any form or guise. Work Cited Hebert Randy S. ; Jenckes., Mollie W. ; Ford, Daniel E.; OConnor, Debra R. $ Cooper, Lisa A. (2001). Patient Perspectives on Spirituality and the Patient-Physician Relationship. Journal of Internal General Medicine. Retrieved May 25, 2007 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1495274 Hemilla, Donna. (2002). You Gotta Have Faith. Nurseweek. Retrieved May 20, 2007 from http://www.nurseweek.com/news/features/02-09/faith.asp Mitchell, Joyce Haroun, Lee. (2005). Healthcare. Singapore. Thomson Delmar. Wensley, Michelle. Spirituality in Nursing. Retrieved May 21, 2007 from http://www.ciap.health.nsw.gov.au/hospolic/stvincents/1995/a04.html

The Study On Nokia S Utilizing Of Communications Mix Marketing Essay

The Study On Nokia S Utilizing Of Communications Mix Marketing Essay 1 Introduction When it comes to modern international marketing, it is not just confined in developing a good product, pricing it attractively, and making it available to target customers. Firms need also communicate with current and potential customers. For most companies, the question is not whether to communicate, but how much to spend and in what ways. This is what the communications mix is good at. Communications mix is comprised of sales promotion, personal selling, public relations, advertising, and direct marketing tools which the firm uses to fulfill its marketing objectives and strategy. Here the theory of communications mix is primarily analyzed related with the case of Nokias. The international company Nokia takes full advantage of the theory of communications mix to fulfill its strategic goal. Under the guidance of the theory of communications mix, the concrete marketing measures or activities taken by Nokia are analyzed. It mainly includes: how Nokia makes full use of advertising, publ ic relation, promotion and direct marketing in its international marketing, cultural influences on the communication, and the recommendations, etc. 2 Communication Mix Marketing, as a concept with specific meaning, has come into being for about one hundred years. Marketing is a social and managerial process by which individuals and groups obtain what they need and want through creating, offering, and exchanging products of value with others (Kotler, 1967). It is a definition grounded upon human needs and wants, which are satisfied through products or services. When marketing crosses borders, it is called international marketing. There are literally dozens of marketing methods, for instance, customer segmentation, product/service offering, market research activity or part of their communication mix. Communication mix is emphatically discussed hereinafter. The communication is comprised of direct marketing, advertising, personal selling, promotion and public relations. Communication mix is mainly used to promote the new products. It is an effective method to attract consumers and increase the selling (Gatignon, 1993). 3 The Background of Nokia In 1865 when Nokia was established in southwestern Finland, it was a little company. At that time, Nokias business covered mainly following sectors, such as televisions, personal computers, shoes, electricity production, communications cables, capacitors, paper products, etc. In the 1960s, the electronics section of the cable division was founded and it witnessed a modern Nokia. In 1967, this section was divided from into its former division and became independently, and started to produce telecommunications equipments. In this period, Nokia got itself more involved in the telecommunications industry and began to develop its network equipment products. In 1992, Nokia changed its name and began to use the name of Nokia Telecommunications, which is todays name. Since 2000, Nokia has begun to expand its business and cooperation with other companies. In 2006, Nokia and Siemens made an unprecedented cooperation in the fixed line and mobile phone network equipment businesses and built one of the largest network companies all over the world. The two companies jointly held a fifty percent stake in this infrastructure firm and built Nokia Siemens Networks. About 20, 000 Nokia employees had been transferred to this new company. Nokia is the leading mobile phone manufacture around the world. Its logo Technology Connecting People has been deeply rooted in customers mind. Nokia House was constructed between 1995 and 1997. Nowadays, there have been more than 1000 Nokia employees in its company. At the same time, Nokia is a customer oriented company. There has been a continuous and progressive increase contact in technology and communications all over the world. Nokias strategy is to build trusted consumer relationships by offering compelling and valued consumer solutions that combine beautiful devices with context enriched services. And, Nokia promises to connect people in a better and new way. 4 The Communication Mix of Nokia 4.1 Advertising It is any paid form of no personal presentation and promotion of ideas, goods or services by an identified sponsor. It is a widely-used means of publicity. The major media types for advertising are: newspapers, television, magazines, radio, internet and so on (Rao, 1993). Advertisements help to draw the publics attention and make people aware of this product. As a result, it undoubtedly could promote a companys sales. However, it is also kind of double-edged sword as advertisements can be very money-consuming. What is more, advertisements may mislead consumers if they are not properly designed or contain any exaggerated information. Therefore, when a firm chooses advertisements as it means for promotion, it must be very careful to select a advertising company and be clear the messages and the image that it wants to convey to it current and perspective customers. Technology Connecting People is Nokias distinguished brand concept. Through TV advertisements, magazine advertisements and leaflets; the concept has been deeply rooted in consumers mind. Except some traditional promotion ways, Nokia adopts some new ways to announce its new products. When selling classical mobile phone Nokia 8810, Nokia sold the products on Internet and became the first firm adopting interactive advertisement in Asia. Nokia held celebrity salon with the theme the upper life to push its new product Nokia 8800 in 2006. Its target consumer was the top end consumer who paid attention to life quality and adored elegant product design. 4.2 Public Relations Public relations mean establishing good relations with the publics by earning a good reputation, shaping a favorable image and dealing with the companys rumors and events (Doyle, 1994). It mainly contains keeping good relations with the firms different social groups by getting favorable publicity and setting up a healthy and good corporate image in public and at the same time, tackling or heading off stories, rumors, and events which damage its reputation. As a result, consumers get a good impression with this kind of firms and, therefore trust and purchase products manufactured by them. From the perspective of enterprises social obligations, especially in modern times, companies can be condemned and eventually be abandoned by consumers if they fail to perform their social responsibilities. Therefore, today, it is not whether firms should build good relations with the public, but how to construct it in a better and more impressive way. In order to develop public relationship promotion, Nokia tries best to be all excellent enterprise citizen in China and makes its effort to sponsor the development of the society, sports and education through series of innovation activities. The first series of activities are donations. In 1998, it donated RMBl0 million to the districts suffered from flood in China. From 2000 to 2001, N0kia launched the planting trees activities in China with its cooperators. Up to now, Nokia still takes these activities as all important components of its marketing methods. The second series of public activities ale gym support activities. By gym support activities, Nokia builds a stylish, leading, and creative brand among the young generation. In 1995, Nokia sponsored Beijing international tennis match. In 1997, Nokia sponsored the No8 national chess match. In 2000, it donated mobile phones to sports meeting for the disable. In 2001, Nokia sponsored No 21 national university match. In 2005, it supported China international diving match. In 2006, it supported NBA China Jam Van and Basketball without Borders activities. The third series are education activities. From 1999 to 2000, Nokia held series of activities in theme of innovation is the source of wisdom to promote teenagers innovation abilities. In 2000, it organized Nokia 2000, flew ideas match with the theme of advancing to future in Beijing University. In recent years, Nokia paid more attention to develop the campus marketing. In order to ease the university enter exam pressure, Nokia held campus activities named communication crates happiness. By humors pictures and creative attempts, these activities added fun to campus life, also set up a good brand image among the campus. 4.3 Promotion Promotion refers to activities or performances taken by companies in a short term to stimulate the purchase or sale of the product or service using varieties of formats such as premiums, coupons, contests, etc (Brick, 1982). Through a serial of activities or performances, it can promote people to purchase more. And sales promotion is targeted at final buyers, wholesalers and retailers, other business customers and members of the sales force (Schall, 1983). It can be effective especially for introducing new products or services. In order to announce its new product, Nokia cooperated with the famous star Wang Lihong and pushed its new product Nokia 3230 to the youth. Nokia 3230 was a music smart phone, which embodies the demands of the youth at that time. In December 2006, Nokia cooperated with Hunan TV Station, and held a concert named Music let me feel happy to push its middle end products. In July 2007, Nokia held a concert named Nokias stylish trend night to announce its new product Nokia 7500 prism, which was the unique design for Chinese market that month. 4.4 Direct Marketing It refers to direct contacts with carefully targeted individual customers in order to acquire a reply in time as well as cultivate permanent consumer relationship, for example, using telephone, mail, fax, e-mail, the Internet, and other tools to communicate directly with specific consumers. Direct marketing is very useful helps companies obtain the first hand information directly from consumers. And companies can give an immediate reply to their customers if there are any questions. Through this way, customers obtain a sense of being respected and cared by firms and, therefore, consumers can be loyal to this kind of companies. However, there are also negative effects brought by direct marketing. Firstly, it undoubtedly costs a lot of money, time and human resources. Secondly, companies may not draw any useful conclusions for decision-makers at all if information is processed in a scientific way. Therefore, to make full use of direct marketing, firms must make sufficient preparations. When it comes to the contour design, Nokia appears to be rather conservative and backward. Especially in China, consumers pay a lot of attention to it. Compared with its competition rivals such Motorola and Samsung, Nokia seems stubborn in reaction to market. However, by directing contacts with its consumers and obtaining the relevant information from the Chinese market, Nokia finally produced its freshly designed foldaway mobile phone 7200. However, any one aspect of the communications mix is not enough to guarantee a good marketing. Instead, a successful promotional strategy should adopt the concept of integrated marketing communications widely by coordinating the promotion channels and tools. Through putting together and reinforcing all the images and messages, it constructs a famous brand in public. Integrated marketing communications requires that all the messages, positioning and images, and identity from the corporate are harmonized across all marketing communications venues. Under this concept, to deliver a clear, unchangeable, and convincing message about the organization and its products, the company should be careful to integrate and bring into line its many communications methods. In terms of this aspect, Nokia really excels in. 5 How Culture Affects the Communications Mix of Nestle 5.1 The Introduction of Culture Since 1871 when the founder of cultural anthropology E.B. Taylor put forward the definition of culture in his works Primitive Culture, scholars have raised hundreds of definitions about culture from different perspectives. The definition of culture given by Taylor is that the so-called culture or civilization is an internal integration of knowledge, beliefs, art, morals, laws, customs and other capabilities and habits acquired by human beings as community members(Taylor, 1871 ). His view has a deep influence on the later research and has been accepted by many scholars. In the West, the origin of the word culture is cultura in Latin. In English, the very beginning meaning of the word culture referred to agriculture and raising of plants. Since the 15th century, it has been extended to cultivate peoples morals and competences. And culture is also a basic definition in both sociology and anthropology. In broad sense, culture is the sum of material wealth and spiritual wealth created by human beings; in narrow sense, it refers specifically to spiritual wealth including language, literature, art and other ideologies. Based on the analysis above, the thesis adopts the definition of culture in large sense, that is, culture is composed of three aspects: material culture, spiritual culture and behavioral culture. 5.2 How It Affects the Communications Mix of Nokia As an international company, Nokia needs to handle cross-cultural problems and culture plays a significant role in Nokias application of communications mix. Undoubtedly, Nokia is a firm sensitive to cultural differences and adapts varied cultural counter-measures in varied regions. Advertising is the most commonly utilized promotional method. Companies must be very clear who their potential customers are probably to be, make effective contacts with those consumers, and be aware of the relationship between the culture and advertising, i.e. .cultural impacts. Various cultures reaction to communications and messages are quite different. Companies which realize these differences may succeed; those that totally neglect them fail. In Korea, consumers often recommend the suitable and good products to their friends, relatives and workmates. Therefore, the word-of-mouth advertising is very popular: a consumers testimony works more effectively than advertisements on television or in newspaper. In the same way, Chinese are also dependent on this form of communications. The Chinese consumers value and trust their family and this is justified by their purchasing products through their families recommendations. Thus, Nokia have noticed that and put a great emphasis on this i n East Asia. For example, Nokias advertising message is technology is people-oriented. As everyone knows, people-oriented thought is put forward by ancient Chinese two thousand years ago. Therefore, Nokias advertisement is rather successful. It is a typical example of Nokias combination of its own enterprises culture and local culture. Many companies today use marketing public relations to support their marketing departments in corporate/product promotion and image making. The Japanese have little concept of public relations in the American sense. Since the Japanese are very modest and self-effacing, they cannot understand self-promotion. They have little need for corporate public relations. The tendency o f the Japanese conservative and low profile way of doing their business results from many economic and cultural factors. From the ancient times, Japanese society has been comprised of exclusive groups and even within groups there are smaller ones. Each one is cared about its living, obligations, and powers and is generally hostile to the other. Therefore, when Nokia operates its business in Japan, it also adapts the way Japanese companies take and keep a low profile in public relation. Although it still seems to make a better job than Japanese firms. Culture also has a deep influence on Nokias promotion. When Nokia notice that todays youth are passionate for fashion, music and sports, it adapts the concept of youth marketing and cooperates sports and music stars to promote its new product. For example, in China, as Nokia 3230 was a music smart phone, it cooperated with the famous star Wang Lihong and Wang especially wrote a song for publicizing the new phone. 5.3 Recommendations International companies must objectively know and learn the diversity of the culture, turn the cross-cultural awareness to the cross-cultural marketing skills and develop cultural sensitivity (Schwartz, 1981). Culturally sensitive companies understand that differences exist and make corresponding accommodations for them. Advertising is a key tool in international marketing, and it is required to accurately position the product as desired for multinational companies. For an international company like Nokia, firstly, it needs to emphasize one characteristic that caters for local culture. Therefore, in the United States, Nokia should focus on durability and economy; in France, it could be leisure and power; in Germany, utilization; in Mexico, price; and in Venezuela, quality. Secondly, it must be aware of local taboos and idioms when selecting the advertising message. Otherwise, it could be at least embarrassing and even hurt local consumers trust and respect towards Nokia. For example, an advertising campaign used by Pepsi-Cola-Come Alive with Pepsi-translated too literally in some countries. The German translation of come alive became come out of the grave, while in Chinese it read Pepsi brings you ancestors back from the dead. In Spanish, the very word for advertising poses a problem since the corres ponding Spanish word means propaganda, which has other connotations in English. Public relations are designed to promote and/or protect a companys image or its individual products. However, under different cultural background, there are different skills in carrying out it. For example, in China, Nokia needs to focus on such activities as lobbying and counseling-the former aims to improve the relationship with legislators and government officials, and the later, connected with public confidence and loyalty. In this respect, Amway set a good example-through out the seven years after its entry into Chinas market, it has always been concerned with the Chinas children, and it has sponsored nearly one hundred charity campaigns to help these children, such as Chinas Hope Project or Spring Bud Project, through which it obtain sanction from the government and popularity from the citizens. 6 Conclusions It has been proved by many international companies that a good quality of products does not certainly guarantee companies successful sales, and that a proper and wise application of communications mix is indispensible in this respect. Communications mix is essential to help a company maintain its market share and even obtain more, build its good image such as innovation, responsibility and so on, stimulate consumers to buy more products, and also get people to know its new products. However, a firm may be end with a loss if it fails to know positive and negative aspect of each method and choose the right one or ones in the right time and in the right place. Especially when the firm selects more than one method, it needs to make sure that all these methods are to convey a consistent, clear message about its image and products. If it fails to do so, consumers can get confused and therefore, there be will no loyalty customers. Besides, culture has a substantial influence on communicatio ns mix. For those companies which are not sensitive to cultural differences, they cannot obtain the result they have expected by using communications mix in better and even worsen their selling. The international company Nokias leading role in mobile phone market tells us that a successful is the result of the combination of a good quality of product and of proper using of marketing strategy.

Symmetric Key Utilized for EasySMS Convention

Symmetric Key Utilized for EasySMS Convention Conceptual SMS (Short Message Service) is a generally utilized correspondence between the end clients. SMS is being utilized as a part of our diverse  applications. The Short Message Service (SMS) normally whatever we trade the first configuration, now and then we used to send the some mystery  message like our email secret word, pass code and bank watchword. We send SMS is in unique organization, our customary SMS does not secure this  trusted data, so the proposed convention called EasySMS it will give exceptionally secure and ensure the trusted data between the end  clients. Pivotal words part; Authentication, Security, Secrete Key, Mobile Phone I. Presentation These days, the Short Message has turn into a standout amongst the most quick  furthermore, solid correspondence on the planet to transmit the  message from two persons. The Short Message Service called  SMS is a correspondence stage that sends the message  through a versatile cell system. At the point when the delicate data in our messages (SMS), it is  extremely hard to shield the data from the  meddlers furthermore exceptionally hard to recognize the root  from the specific sender. The cellular telephone correspondence  is great experience and an incredible acknowledgement from among all  human culture. The GSM is aviation route activity correspondence between the two  portable stations called Mobile Station (MS) and the Base  Handset Station (BTS) is an encryption between two feeble  also, stream figure (A5/1 or A5/2). The validation is an one  sided furthermore unprotected. In spite of the expanding force of cell phones with the  approach of Advanced mobile phones, a critical division of portable  gadgets in creating districts are still basic minimal effort gadgets  with constrained handling and correspondence capacities. A. Research Problem Infrequently, we used to send trusted data to our crew  individuals like secret key, credit number additionally bank pass book  number. This private data from one cellular telephone  to another through system. While sending the dataover the system meddler can read the data  since that will be in the first configuration. SMS use is  undermined with security concerns, for example, SMS exposure,  man-in-center assault and replay assault. SMS messages are  transmitted as plaintext between portable client and the SMS  focus utilizing remote system. B. Key Contribution The above convention called EasySMS is proposed to  anticipate and secure the end-to-end correspondence  between the clients, the convention EasySMS is going to  keep the different assault are Man-in-center assault,  Replay assault, SMS exposure and it is additionally message  trade amid the confirmation process, less  calculation overhead and decreases the data transfer capacity. II. RELATED WORK As indicated by the different creators have proposed distinctive sorts  of procedures and security to secure data amid  transmiision of the message. A usage of an open  key cryptosystem for SMS in a cell telephone system has  been exhibited, yet the security for convention is not talked about. Shared trade scrambled utilizing open key  cryptography by A structure secure extensible and  effective SMS(SEEMS). Another convention called SSMS is  used to give the application layer structure to the  wanted security traits in SMS. Amid the transmission  of message to give the security to the message by utilizing  carrier for m-installment. Because of physical constraints of the  cellular telephones it is exceptionally neccesary to offer the convention which  would make least utilization of assets and would improve  security. The proposed convention called SMSSec is utilized to secure SMS  correspondence between a customer furthermore used to the  encryption between end clients. The convention SMS based  structure gives a low-transmission capacity, solid, effective  answer for restorative information acquistion. The mutual session key  era is profoundly utilization correspondence and it is too  inadmissible for genuine eord application. Accordingly in this proposed convention EasySMS contrasted and two  convention called SMSSec and PK-SIM conventions. _______________________________________________________________________________________ III. EXISITNG SYSTEM In Existing System, the SMS based structure gave a  low-transmission capacity, solid, effective and savvy arrangement  for medicinal information procurement. The created shared key for  every session produced an enormous overhead. This structure  neglected to forestall SMS against different assaults. SMS messages are transmitted as plaintext between versatile  client (MS) and the SMS focus (SMSC), utilizing remote  system. SMS substance are put away in the frameworks of system  administrators and can be read by their work force.   An assault model depicts diverse situations for the  potential outcomes of different assaults where a pernicious MS can  access the legitimate data, or deceive the honest to goodness  MS. Since, the SMS is sent as plaintext, along these lines system  administrators can undoubtedly get to the substance of SMS amid the  transmission at SMSC. Fig1. Existing Architecture IV. PROPOSED SYSTEM The purpose behind picked these conventions for correlation is that  these are the main existing conventions which dont propose to  change the current structural planning of cell systems. We needed to contrast our proposed convention and some  existing conventions gave to give end-to-end SMS security  with symmetric key cryptography, however there is no such  convention exists. Both conventions are having two stages comparable  to the proposed convention and are in view of symmetric also  as hilter kilter key cryptography while the proposed convention  is totally in view of symmetric key cryptography. To defeat the above expressed assaults, different figure  calculations are actualized with the proposed confirmation  convention. We suggest that the figure calculations ought to be  put away onto the SIM (some piece of MS) and in addition at AS. Since  giving security needs to do some additional exertion which is  measured regarding expense, consequently giving or including additional  security means expanding more cost. Creators propose to  incorporate one more administration as Secure Message in the menu of  portable programming grew by different versatile organizations. Portable administrators can add some additional charges to send secure  message by their clients over the systems. At whatever point a  client needs to send a protected message to other client, the  proposed convention in particular EasySMS is executed which makes  accessible the symmetric shared key between both MS and afterward  figuring of message happens utilizing a symmetric key  calculation. We propose another convention named EasySMS with two  distinctive situations which give end-to-end secure  transmission of data in the cell.   Is the Secret Key SK Safely Stored? Since the malignant client  does not know the structure of cryptographic capacities like  f1() and f2(), so he/she can neither create the right MAC1  nor right designation key DK1. Further, the mystery key SK is  put away on the validation server/focus and also implanted  onto the SIM at the season of assembling. In this way, it is very nearly  difficult to concentrate the SK. The capacity situation of SK key  we introduced is same as these days utilized for the voice  correspondence in the conventional cell systems. In the event that some  administration suppliers dont wish to utilize real SK in the convention  execution. The EasySMS convention keeps the SMS data from  different assaults including SMS assault, telephone capture, SMS  spam, man-in-the-center assault, and GSMA. This EasySMS  sends lesser number of transmitted bits, produces less  reckoning overhead, and diminishes transmission capacity utilization  furthermore, message traded when contrasted with SMSSec and PK-SIM  conventions. V. CONCLUSION The EasySMS convention is ordinarily used to outline for  assurance of different assaults furthermore give end-to-end  secure correspondence. Symmetric key is effectively overseen by the proposed  convention called EasySMS furthermore it is correspondence  overhead amid execution, contrasted with SMSSec and PK-SIM  convention verification of trade of messages is less. VI. REFERENCES [1] H. Rongyu, Z. Guolei, C. Chaowen, X. Hui, Q. Xi,  also, Q. Zheng, A PK-SIM card based end-to-end  security structure for SMS, Compute. Standard  Interf. vol. 31, no. 4, pp. 629–641, 2009 [2] M. Densmore, Encounters with mass SMS for  wellbeing financing in Uganda, in Proc. ACM CHI,  2012, pp. 383–398.   [3] D. Risi and M. Teà ³filo, MobileDeck: Turning SMS  into a rich client experience, in Proc. 6th MobiSys,  no. 33, 2009.   [4] R. E. Anderson et al., Encounters with a  transportation data framework that uses just GPS  also, SMS, in Proc. IEEE ICTD, no. 4, Dec. 2010. [5] J. L.-C. Lo, J. Minister, and J. H. P. Eloff, SMSSec:  An end-to end convention for secure SMS, Compute.  Security, vol. 27, nos. 5–6, pp. 154–1

Hamlet :: essays research papers

After Hamlet has discovered the truth about his father, he goes through a very traumatic period, which is interpreted as madness by readers and characters. With the death of his father and the hasty, incestuous remarriage of his mother to his uncle, Hamlet is thrown into a suicidal frame of mind in which "the uses of this world"seem to him "weary, stale, flat, and unprofitable." No man in his right state contemplates suicide and would take his life due to human frailty. Ophelia tells us that before the events of the play Hamlet was a model courtier, soldier and scholar, "The glass of fashion and the mould of form,/ The observed of all observers." A modern boy scout to say the least, but as the play unwinds, his actions and thoughts catch him and slowly turn him insane. Not to say that he was a crazed madman out of touch with reality as was Ophelia, but a man driven crazy by thought. Hamlet's behavior throughout the play, especially towards Ophelia is inconsistent. He jumps into Ophelia's grave, and fights with Laertes in her grave. He professes "I loved Ophelia. Forty thousand brothers/Could not, with all their quantity of love,/ Make up my sum" [Act V, scene I, lines 250-253], during the fight with Laertes in Ophelia's grave, but he tells her that he never loved her, when she returns his letters and gifts, while she was still alive. Hamlet subtly hints his awareness of his dissolving sanity as he tells Laertes that he killed Polonius in a fit of madness [Act V, scene II, lines 236- 250] Once Ophelia meets Hamlet and speaks with him her love abandons him. Hamlet realizes that his mother and step father are aware of this love and might use this to end his threat. Hamlet must end their thoughts of using Ophelia to rid him of his condition. To do this he must destroy all the current feelings Ophelia has for him and he does so very well, perhaps too well. Either his love for Ophelia was never as strong as he said, which I doubt, or he has really gone insane by assuming every situation is going to happen and he sacrifices her love for revenge. An honest man would not have done so. Hamlet has violent outbursts towards his mother. His outburst seems to be out of jealousy, as a victim to the Oedipus complex.

Radio in the New Age Essay -- Writing Cyberculture Technology Essays

Radio in the New Age The essay is a popular form for writers to express their ideas. It can be found in many sources: newspapers, magazines, and journals. The essay is no longer limited to these mediums, and as communication technology develops, the essay has extended into new arenas. What was once an exclusively paper-and-ink technology is now available over the airwaves and through the phone lines. The essay has found its way to new formats through the radio and internet. We were once readers, but have now become listeners and spectators through the cyberculture revolution. The term "cyberspace" was invented by writer William Gibson to describe the interconnection of society and its technology (Tribble 162). Cyberculture implies a computer-literate segment of society. Our American culture relies heavily on the automobile industry, fast food, instant communication, and the movie industry, yet not all of these aspects of our culture make up cyberspace. Cyberculture narrows its definition to cover only those aspects of technology that instantly connect person to person or person to machine via other machines. This includes telephone, satellite, television, radio, and internet systems and allows us to uplink, download, tune in, channel surf, surf the web, dial up, and ring nearly anything, anywhere, and anyone at anytime. Steven Johnson, in his article "Links", considers two attitudes toward interactions with this technology. Comparing channel surfing to web surfing, Johnson views TV surfing as a passive act requiring only that the viewer accept what is bei ng shown. Web surfing, however, is a n interactive process that allows for inquiries and searches along a line of interest (Johnson 196-7). Similar to TV viewing, listenin... ..., a print version of the broadcast, ready for purchase or to download. The sound quality is significantly worse than the original, and sounds like the radio has de-evolved fifty years. Our advances in technology have, unpredictably, given us a sound experience of the radio medium when it was king of the airwaves. Our new is old again. Works Cited Birkerts, Sven. "Into the Electronic Millennium." Writing Material. Ed. Tribble, Evelyn B. and Anne Trubek. New York: Longman Publishers, 2003: 62-73. Johnson, Steven. "Links." Writing Material. Ed. Tribble, Evelyn B. and Anne Trubek. New York: Longman Publishers, 2003: 195-212. Tribble, Evelyn B. and Anne Trubek, ed. Writing Material. New York: Longman Publishers, 2003. National Public Radio. www.npr.org/ This American Life. www.thislife.org/ All Songs Considered. www.npr.org/programs/asc/index.html

Financial Analysis of Ted Baker & Burberry Essay

INTRODUCTION Burberry is a global luxury brand offering menswear, womenswear, childrenswear, coats, dresses, shoes, accessories, bags, scarves, beauty and fragrance. The quintessentially British brand was first founded as an outerwear brand, well known for it’s iconic Burberry trench coat and distinct tartan print. The brand has over 497 directly operated stores and concessions operating in 32 countries; and via a third-party distribution network- 70 franchise stores in an additional 28 countries and approximately 1,400 wholesale department and specialty store doors in over 80 countries (as at 31 March 2014). The brand continues to develop its presence in existing and  under-penetrated markets. THE BASICS Burberry was founded by Thomas Burberry in 1855 in Hamphire England and remained an independent company until 1955, when it was taken over by Great Universal Studios (GUS). In 2005, GUS divested its remaining interest in Burberry. Burberry Group PLC was initially floated on the London Stock Exchange in July 2002. In 2013/2014, Burberry had a turnover of  £2,330 million (up 16.5% from the previous year), recording a profit before tax of  £461 million (up 7.7% from the previous year). The company employs 9698 employees across 34 countries and is headquartered in London. The accounts are presented in GBP, which is Burberry’s functional currency. It is listed on the London Stock Exchange under the ticker BRBY with a market capitalization of GBP6822.43 Million. The consolidated financial statements have been prepared in accordance with IFRSs as adopted by the EU. The accounts have been audited by PricewaterhouseCoopers LLP with no reservations. MANAGEMENT CHANGES On the management side, the most significant change is the departure CEO Angela Ahrendt in April 2014 who left Burberry (to join Apple). Ahrendt the CEO since 2006 has lead the successful transformation of the company, tripling revenue three-fold during her tenure. Ahrendt was succeeded by Christopher Bailey, Chief Creative Officer (CCO) who has been with Burberry since 2001. Bailey holds the roles of CEO and CCO and his appointment as CEO is considered a natural progression. Other important changes include, the changes of the CFO and COO, and the appointment of three new non-executive directors. The new board appointments focus on evolving the Board’s relevant skills and competencies for the future under its succession plan. THE BUSINESS ENVIRONMENT After three years of double digit growth, analyst estimated that the luxury sector growth slowed to 2% in 2013. This was in part due to a slowdown in China (the world’s 4th largest luxury market), in light of government policy changes on gift giving and the Chinese consumer increasingly shifting luxury consumption abroad (which has in turn help drive luxury sales in the rest of Asia and Europe). Whilst Burberry is a luxury brand, note that it’s growing beauty and fragrance lines are â€Å"attainable† luxury and has the capacity for resilience in unfavourable economic conditions. Burberry’s five strategic themes which have sustained its growth during the period include:[1: Claudia D’Arpizio, Bain Report: Luxury Goods Worldwide Market Study Spring 2014 ]

Introduction to Epidemiology

Aug 17 2011 Introduction to Epidemiology Epidemiology is considered the basic science of public health, and with good reason. Epidemiology is: †¢ †¢ †¢ A quantitative basic science built on a working knowledge of probability, statistics, and sound research methodology A method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality A tool for public health action to promote and protect the public’s health based on science, causal reasoning, and a dose of practical common sense (2).As a public health discipline, epidemiology is instilled with the spirit that epidemiologic information should be used to promote and protect the public’s health. Hence, epidemiology involves both science and public health practice. The term applied epidemiology is sometimes used to describe the application or practice of epidemiology to address public health issues.Examples of applied epidemiology include the following: †¢ †¢ †¢ †¢ the monitoring of reports of communicable diseases in the community the study of whether a particular dietary component influences your risk of developing cancer evaluation of the effectiveness and impact of a cholesterol awareness program analysis of historical trends and current data to project future public health resource needs ObjectivesAfter studying this document and answering the questions in the exercises, you should be able to do the following: †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ Define epidemiology Summarize the historical evolution of epidemiology Describe the elements of a case definition and state the effect of changing the value of any of the elements List the key features and uses of descriptive epidemiology List the key features and uses of analytic epidemiology List the three components of the epidemiologic triad List and describe Hill’s criteria of causation Understand the natural history of disease and the three types of prevention Understand infectivity, pathogenicity, and virulence List and describe primary applications of epidemiology in public health practice List and describe the different modes of transmission of communicable disease in a population 1 Page 2 Applied Epidemiology I A number of exercises are provided. It is suggested you attempt to answer these questions and then compare your answers with those at the end of this document. Introduction The word epidemiology comes from the Greek words epi, meaning â€Å"on or upon,† demos, meaning â€Å"people,† and logos, meaning â€Å"the study of. Many definitions have been proposed, but the following definition captures the underlying principles and the public health spirit of epidemiology: â€Å"Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the cont rol of health problems. † (17) Key terms in this definition reflect some of the important principles of epidemiology. Study Epidemiology is a scientific discipline with sound methods of scientific inquiry at its foundation. Epidemiology is data-driven and relies on a systematic and unbiased approach to the collection, analysis, and interpretation of data.Basic epidemiologic methods tend to rely on careful observation and use of valid comparison groups to assess whether what was observed, such as the number of cases of disease in a particular area during a particular time period or the frequency of an exposure among persons with disease, differs from what might be expected. However, epidemiology also draws on methods from other scientific fields, including biostatistics and informatics, with biologic, economic, social, and behavioral sciences. In fact, epidemiology is often described as the basic science of public health, and for good reason. First, epidemiology is a quantitati ve discipline that relies on a working knowledge of probability, statistics, and sound research methods.Second, epidemiology is a method of causal reasoning based on developing and testing hypotheses grounded in such scientific fields as biology, behavioral sciences, physics, and ergonomics to explain health-related behaviors, states, and events. However, epidemiology is not just a research activity but an integral component of public health, providing the foundation for directing practical and appropriate public health action based on this science and causal reasoning. Determinants Epidemiology is also used to search for determinants, which are the causes and other factors that influence the occurrence of disease and other health-related events.Epidemiologists assume that illness does not occur randomly in a population, but happens only when the right accumulation of risk factors or determinants exists in an individual. To search for these determinants, epidemiologists use analytic epidemiology or epidemiologic studies to provide the â€Å"Why† and â€Å"How† of such events. They assess whether groups with different rates of disease differ in their demographic characteristics, genetic or immunologic make-up, behaviors, environmental exposures, or other so-called potential risk factors. Ideally, the findings provide sufficient evidence to direct prompt and effective public health control and prevention measures. Health-related states or eventsEpidemiology was originally focused exclusively on epidemics of communicable diseases3 but was subsequently expanded to address endemic communicable diseases and non-communicable infectious diseases. By the middle of the 20th Century, additional epidemiologic methods had been developed and applied to chronic diseases, injuries, birth defects, maternal-child health, occupational health, and environmental health. Then epidemiologists began to look at behaviors related to health and well-being, such as amount o f exercise and seat belt use. Now, with the recent explosion in molecular methods, Introduction to Epidemiology – Epi 592J Page 3 epidemiologists can make important strides in examining genetic markers of disease risk.Indeed, the term health related states or events may be seen as anything that affects the well-being of a population. Nonetheless, many epidemiologists still use the term â€Å"disease† as shorthand for the wide range of healthrelated states and events that are studied. Specified populations Although epidemiologists and direct health-care providers (clinicians) are both concerned with occurrence and control of disease, they differ greatly in how they view â€Å"the patient. † The clinician is concerned about the health of an individual; the epidemiologist is concerned about the collective health of the people in a community or population. In other words, the clinician’s â€Å"patient† is the individual; the epidemiologist’s â⠂¬Å"patient† is the community.Therefore, the clinician and the epidemiologist have different responsibilities when faced with a person with illness. For example, when a patient with diarrheal disease presents, both are interested in establishing the correct diagnosis. However, while the clinician usually focuses on treating and caring for the individual, the epidemiologist focuses on identifying the exposure or source that caused the illness; the number of other persons who may have been similarly exposed; the potential for further spread in the community; and interventions to prevent additional cases or recurrences. Application Epidemiology is not just â€Å"the study of† health in a population; it also involves applying the knowledge gained by the studies to community-based practice.Like the practice of medicine, the practice of epidemiology is both a science and an art. To make the proper diagnosis and prescribe appropriate treatment for a patient, the clinician comb ines medical (scientific) knowledge with experience, clinical judgment, and understanding of the patient. Similarly, the epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well as experience, epidemiologic judgment, and understanding of local conditions in â€Å"diagnosing† the health of a community and proposing appropriate, practical, and acceptable public health interventions to control and prevent disease in the community. SummaryEpidemiology is the study (scientific, systematic, data-driven) of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (patient is community, individuals viewed collectively), and the application of (since epidemiology is a discipline within public health) this study to the control of health problems. Evolution Although epidemiologic thinking has been traced from Hippocrates (circa 400 B. C. ) through Grau nt (1662), Farr, Snow (both mid-1800’s), and others, the discipline did not blossom until the end of the Second World War. The contributions of some of these early and more recent thinkers are described next. Hippocrates (circa 400 B. C. ) attempted to explain disease occurrence from a rational instead of a supernatural viewpoint. In his essay entitled â€Å"On Airs, Waters, and Places,† Hippocrates suggested that environmental and host factors such as behaviors might influence the development of disease.Another early contributor to epidemiology was John Graunt, a London haberdasher who published his landmark analysis of mortality data in 1662. He was the first to quantify patterns of birth, death, and disease occurrence, noting male-female disparities, high infant mortality, urban-rural differences, and seasonal variations. No one built upon Graunt’s work until the mid-1800, when William Farr began to systematically collect and analyze Britain’s mortalit y statistics. Farr, considered the father of modern vital statistics and disease surveillance, developed many of the basic practices used today in vital statistics and disease classification. He extended the epidemiologic analysis of morbidity and mortality data, looking at Page 4 Applied Epidemiology I he effects of marital status, occupation, and altitude. He also developed many epidemiologic concepts and techniques still in use today. Meanwhile, an anesthesiologist named John Snow was conducting a series of investigations in London that later earned him the title â€Å"the father of epidemiology. † Twenty years before the development of the microscope, Snow conducted studies of cholera outbreaks both to discover the cause of the disease and to prevent its recurrence. Because his work classically illustrates the sequence from descriptive epidemiology to hypothesis generation to hypothesis testing (analytic epidemiology) to application, we will consider two of his efforts.It is important to mention that at the time of John Snow’s investigations the most widely accepted cause of diseases, including cholera, was due to miasma, or foul air. Therefore most believed that cholera was transmitted by air, especially foul-smelling air near water. The germ theory, that disease was transmitted by microbes, did not gain acceptance until later in the 1800s. Snow conducted his classic study in 1854 when an epidemic of cholera developed in the Golden Square of London. He began his investigation by determining where in this area persons with cholera lived and worked. He then used this information to map the distribution of cases on what epidemiologists call a spot map. His map is shown in Figure 1. 1.Because Snow believed that water was a source of infection for cholera, he marked the location of water pumps on his spot map, and then looked for a relationship between the distribution of cholera case households and the location of pumps. He noticed that more cas e households clustered around certain pumps, especially the Broad Street pump, and he concluded that the Broad Street pump was the most likely source of infection. Questioning residents who lived near the other pumps, he found that they avoided certain pumps because the water they provided was grossly contaminated, and that other pumps were located too inconveniently for most residents of the Golden Square area.From this information, it appeared to Snow that the Broad Street pump was probably the primary source of water for most persons with cholera in the Golden Square area. He realized, however, that it was too soon to draw that conclusion because the map showed no cholera cases in a two-block area to the east of the Broad Street pump. Perhaps no one lived in that area, or perhaps the residents were somehow protected. Upon investigating, Snow found that a brewery was located there and that it had a deep well on the premises where brewery workers, who also lived in the area, got th eir water. In addition, the brewery allotted workers a daily quota of malt liquor. Access to these uncontaminated rations could explain why none of the brewery’s employees contracted cholera.To provide further evidence that the Broad Street pump was the source of the epidemic, Snow gathered information on where persons with cholera had obtained their water. Consumption of water from the Broad Street pump was the one common factor among the cholera patients. According to legend, Snow removed the handle of the Broad Street pump and aborted the outbreak. Snow’s second major contribution involved another investigation of the same outbreak of cholera that occurred in London in 1854. In a London epidemic in 1849, Snow had noted that districts with the highest mortalities had water supplied by two companies: the Lambeth Company and the Southwark and Vauxhall Company. At that time, both companies obtained water from the Thames River, at intake points downstream of London.In 18 52, the Lambeth Company moved their water works upstream from London, thus obtaining water free of London sewage. When cholera returned to London in 1853, Snow realized the Lambeth Company’s relocation of its intake point would allow him to compare districts that were supplied with water upstream from London with districts that received water downstream from London. Table 1. 1 shows what Snow found when he made that comparison for cholera mortality over a 7-week period during the summer of 1854. Introduction to Epidemiology – Epi 592J Page 5 Figure 1. 1 Distribution of cholera cases in the Golden Square area of London, August-September 1854 Table 1. Mortality from cholera in the districts of London supplied by the Southwark and Vauxhall and the Lambeth Companies, July 9-August 26, 1854 Districts with Water Supplied by Population Deaths from Mortality Risk per (1851 Census) Cholera 1,000 Population 167,654 844 5. 0 Southwark and Vauxhall Co. only Lambeth Co. only Both c ompanies Source: 27 19,133 300,149 18 652 0. 9 2. 2 Page 6 Applied Epidemiology I The data in Table 1. 1 show that the risk of death from cholera was more than 5 times higher in districts served only by the Southwark and Vauxhall Company than in those served only by the Lambeth Company. Interestingly, the mortality risks in districts supplied by both companies fell between the risks for districts served exclusively by either company.These data were consistent with the hypothesis that water obtained from the Thames below London was a source of cholera. Alternatively, the populations supplied by the two companies may have differed on a number of other factors which affected their risk of cholera. To test his water supply hypothesis, Snow focused on the districts served by both companies, because the households within a district were generally comparable except for which company supplied water. In these districts, Snow identified the water supply company for every house in which a deat h from cholera had occurred during the 7-week period. Table 1. 2 shows his findings. Table 1. Mortality from cholera in London related to the water supply of individual houses in districts served by both the Southwark and Vauxhall Company and the Lambeth Company, July 9August 26, 1854 Water Supply of Individual House Population Deaths from Mortality risk per (1851 Census) Cholera 1,000 Population Southwark and Vauxhall Co. 98,862 419 4. 2 Lambeth Co. Source: 27 154,615 80 0. 5 This further study added support to Snow’s hypothesis, and demonstrates the sequence of steps used today to investigate outbreaks of disease. Based on a characterization of the cases and population at risk by time, place, and person, Snow developed a testable hypothesis. He then tested this hypothesis with a more rigorously designed study, ensuring that the groups to be compared were comparable. After this study, efforts to control the epidemic were directed at changing the location of the water intake of the Southwark and Vauxhall Company to reduce sources of contamination.Thus, with no knowledge of the existence of microorganisms, Snow demonstrated through epidemiologic studies that water could serve as a vehicle for transmitting cholera and that epidemiologic information could be used to direct prompt and appropriate public health action. More information on John Snow can be found at: www. ph. ucla. edu/epi/snow. html In the mid- and late-1800’s, many others in Europe and the United States began to apply epidemiologic methods to investigate disease occurrence. At that time, most investigators focused on acute infectious diseases. In the 1900’s, epidemiologists extended their methods to noninfectious diseases.The period since the Second World War has seen an explosion in the development of research methods and the theoretical underpinnings of epidemiology, and in the application of epidemiology to the entire range of health-related outcomes, behaviors, and even kno wledge and attitudes. The studies by Doll and Hill (13) linking smoking to lung cancer and the study of cardiovascular disease among residents of Framingham, Massachusetts (12), are two examples of how pioneering researchers have applied epidemiologic methods to chronic disease since World War II. Finally, during the 1960’s and early 1970’s health workers applied epidemiologic methods to eradicate smallpox worldwide.This was an achievement in applied epidemiology of unprecedented proportions. Today, public health workers throughout the world accept and use epidemiology routinely. Epidemiology is often practiced or used by non-epidemiologists to characterize the health of their communities and to solve day-to-day problems. This landmark in the evolution of the discipline is less dramatic than the eradication of smallpox, but it is no less important in improving the health of people everywhere. Introduction to Epidemiology – Epi 592J Page 7 Uses Epidemiology and t he information generated by epidemiologic methods have many uses. These uses are categorized and described below. Population or community health assessment.To set policy and plan programs, public health officials must assess the health of the population or community they serve and determine whether health services are available, accessible, effective, and efficient. To do this, they must find answers to many questions: What are the actual and potential health problems in the community? Where are they? Who is at risk? Which problems are declining over time? Which ones are increasing or have the potential to increase? How do these patterns relate to the level and distribution of services available? The methods of descriptive and analytic epidemiology provide ways to answer these and other questions.With answers provided through the application of epidemiology, the officials can make informed decisions that will lead to improved health for the population they serve. Individual decision s. People may not realize that they use epidemiologic information in their daily decisions. When they decide to stop smoking, take the stairs instead of the elevator, order a salad instead of a cheeseburger with French fries, or choose one method of contraception instead of another, they may be influenced, consciously or unconsciously, by epidemiologists’ assessment of risk. Since World War II, epidemiologists have provided information related to all those decisions.In the 1950’s, epidemiologists documented the increased risk of lung cancer among smokers; in the 1960’s and 1970’s, epidemiologists noted a variety of benefits and risks associated with different methods of birth control; in the mid-1980’s, epidemiologists identified the increased risk of human immunodeficiency virus (HIV) infection associated with certain sexual and drug-related behaviors; and, more positively, epidemiologists continue to document the role of exercise and proper diet in reducing the risk of heart disease. These and hundreds of other epidemiologic findings are directly relevant to the choices that people make every day, choices that affect their health over a lifetime. Completing the clinical picture. When studying a disease outbreak, epidemiologists depend on clinical physicians and laboratory scientists for the proper diagnosis of individual patients.But epidemiologists also contribute to physicians’ understanding of the clinical picture and natural history of disease. For example, in late 1989 three patients in New Mexico were diagnosed as having myalgias (severe muscle pains in chest or abdomen) and unexplained eosinophilia (an increase in the number of one type of white blood cell). Their physicians could not identify the cause of their symptoms, or put a name to the disorder. Epidemiologists began looking for other cases with similar symptoms, and within weeks had found enough additional cases of eosinophilia-myalgia syndrome (EMS) t o describe the illness, its complications, and its risk of mortality.Similarly, epidemiologists have documented the course of HIV infection, from the initial exposure to the development of a wide variety of clinical syndromes that include acquired immunodeficiency syndrome (AIDS). They have also documented the numerous conditions associated with cigarette smoking—from pulmonary and heart disease to lung and cervical cancer. Search for causes. Much of epidemiologic research is devoted to a search for causes, factors which influence one’s risk of disease. Sometimes this is an academic pursuit, but more often the goal is to identify a cause so that appropriate public health action might be taken. It has been said that epidemiology can never prove a causal relationship between an exposure and a disease. Nevertheless, epidemiology often provides enough information to support effective action.Examples include John Snow’s removal of the pump handle and the withdrawal o f a specific brand of tampon that was linked by epidemiologists to toxic shock syndrome. Another example is the recommendation that children not be given aspirin due to its association with Reye syndrome. Just as often, epidemiology and laboratory science converge to provide the evidence needed to establish causation. For example, a team of epidemiologists were able to identify a variety of risk factors during an outbreak of pneumonia among persons attending the American Page 8 Applied Epidemiology I Legion Convention in Philadelphia in 1976, called â€Å"Legionnaire’s disease. However, the outbreak was not â€Å"solved† until the Legionnaires’ bacillus was identified in the laboratory almost 6 months later. Disease control, elimination, and eradication. The ultimate goal of epidemiology is to improve the health of populations and through the reduction in disease. The definitions of disease control, elimination, and eradication as applied to infectious diseases are given below. (Dowdle WR. The principles of disease elimination and eradication. MMWR 48(SU01);23-7, 1999. ): Control: The reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction. Example: diarrheal diseases.Elimination of disease: Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Examples: neonatal tetanus. Elimination of infections: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent reestablishment of transmission are required. Example: measles, poliomyelitis. Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate effor ts; intervention measures are no longer needed. Example: smallpox.Extinction: The specific infectious agent no longer exists in nature or in the laboratory. Example: none. The above definitions are specific to infectious disease, but some of the concepts can carry over to other conditions, such as nutritional disorders, inborn errors of metabolism, and chronic diseases. Introduction to Epidemiology – Epi 592J Page 9 Exercise 1. 1 In the early 1980’s, epidemiologists recognized that AIDS occurred most frequently in men who had sex with men and in intravenous drug users. Describe how this information might be used for each of the following: a. Population or community health assessment b. Individual decisions c. Search for causes Page 10 Applied Epidemiology I The Epidemiologic ApproachLike a newspaper reporter, an epidemiologist determines What, When, Where, Who, and Why. However, the epidemiologist is more likely to describe these concepts in slightly different terms: c ase definition, time, place, person, and causes. Case Definition (â€Å"What? †) The identification of disease can be based on symptoms, signs, and diagnostic tests. A symptom is a sensation or change in health experienced by an individual. Examples of symptoms reported by an individual are a cough, fatigue, anxiety, and back pain. Signs, or signs of disease, are an objective evidence of disease observed by someone other than the affected individual, such as a physician or nurse.A case definition is a set of standard criteria for deciding whether a person has a particular disease or other health-related condition. By using a standard case definition we attempt to ensure that every case is diagnosed in the same way, regardless of when or where it occurred, or who identified it. We can then compare the number of cases of the disease that occurred in one time or place with the number that occurred at another time or another place. For example, with a standard case definition, we can compare the number of cases of hepatitis A that occurred in New York City in 1991 with the number that occurred there in 1990. Or we can compare the number of cases that occurred in New York in 1991 with the number that occurred in San Francisco in 1991. With a standard ase definition, when we find a difference in disease occurrence, we know it is likely to be due to a real difference or due to the quality of the disease reporting system rather than the result of differences in how cases were diagnosed. A case definition consists of clinical criteria and, sometimes, limitations on time, place, and person. The clinical criteria usually include confirmatory laboratory tests, if available, or combinations of symptoms (subjective complaints), signs (objective physical findings), and other findings. For example, see the case definition for rabies below; notice that it requires laboratory confirmation. Rabies, Human Clinical description Rabies is an acute encephalomyelitis that almos t always progresses to coma or death within 10 days of the first symptom.Laboratory criteria for diagnosis †¢ Detection by direct fluorescent antibody of viral antigens in a clinical specimen (preferably the brain or the nerves surrounding hair follicles in the nape of the neck), or †¢ Isolation (in cell culture or in a laboratory animal) of rabies virus from saliva, cerebrospinal fluid (CSF), or central nervous system tissue, or †¢ Identification of a rabies-neutralizing antibody titer greater than or equal to 5 (complete neutralization) in the serum or CSF of an unvaccinated person Case classification Confirmed: a clinically compatible illness that is laboratory confirmed Comment Laboratory confirmation by all of the above methods is strongly recommended. Source: 3 Compare this with the case definition for Kawasaki syndrome provided in Exercise 1. 3 on page 12. Kawasaki syndrome is a childhood illness with fever and rash that has no known cause and no specifically d istinctive laboratory findings.Notice that its case definition is based on the presence of fever, at least four of five specified clinical findings, and the lack of a more reasonable explanation. A case definition may have several sets of criteria, depending on the certainty of the diagnosis. For example, during an outbreak of measles, we might classify a person with a fever and rash as having a Introduction to Epidemiology – Epi 592J Page 11 suspect, probable, or confirmed case of measles, depending on what additional evidence of measles was present. In other situations, we may temporarily classify a case as suspect or probable until laboratory results are available. When we receive the laboratory report, we then reclassify the case as either confirmed or â€Å"not a case,† depending on the lab results.In the midst of a large outbreak of a disease caused by a known agent, we may permanently classify some cases as suspect or probable, because it is unnecessary and wast eful to run laboratory tests on every individual with a consistent clinical picture and a history of exposure (e. g. , chickenpox). Case definitions may also vary according to the purpose for classifying the occurrences of a disease. For example, health officials need to know as soon as possible if anyone has symptoms of plague or foodborne botulism so that they can begin planning what actions to take. For such rare but potentially severe diseases, where it is important to identify every possible case, health officials use a sensitive, or â€Å"loose† case definition.On the other hand, investigators of the causes of a disease outbreak want to be certain that any person included in the investigation really had the disease. The investigator will prefer a specific or â€Å"strict† case definition. For instance, in an outbreak of Salmonella agona, the investigators would be more likely to identify the source of the infection if they included only persons who were confirmed to have been infected with that organism, rather than including anyone with acute diarrhea, because some persons may have had diarrhea from a different cause. In this setting, a disadvantage of a strict case definition is an underestimate of the total number of cases. Exercise 1. 2In the case definition for an apparent outbreak of trichinosis, investigators used the following classifications: Clinical criteria Confirmed case: signs and symptoms plus laboratory confirmation Probable case: acute onset of at least three of the following four features: myalgia, fever, facial edema, or eosinophil count greater than 500/mm3 Possible case: acute onset of two of the above four features plus a physician diagnosis of trichinosis Suspect case: unexplained eosinophilia Not a case: failure to fulfill the criteria for a confirmed, probable, possible, or suspect case Time Onset after October 26, 1991 Place Metropolitan Atlanta Person Any Assign the appropriate classification to each of the person s included in the line listing below. (All were residents of Atlanta with acute onset of symptoms in November. ) Page 12 Applied Epidemiology I ID # 1 2 3 4 5 Last name Abels Baker Corey Dale Ring myalgia yes yes yes yes yes fever yes yes yes no no facial edema no yes no no no eosinophil count 495 pending 1,100 2,050 600 Physician diagnosis trichinosis trichinosis ? trichinosis EMS ? trichinosis Lab confirm yes pending pending pending not done Classification __________ __________ __________ __________ __________Exercise 1. 3 The following is the official case definition for Kawasaki syndrome that is recommended by CDC: Kawasaki Syndrome Clinical case definition A febrile illness of greater than or equal to 5 days’ duration, with at least four of the five following physical findings and no other more reasonable explanation for the observed clinical findings: †¢ Bilateral conjunctival injection †¢ Oral changes (erythema of lips or oropharynx, strawberry tongue, or fis suring of the lips) †¢ Peripheral extremity changes (edema, erythema, or generalized or periungual desquamation) †¢ Rash †¢ Cervical lymphadenopathy (at least one lymph node greater than or equal to 1. cm in diameter) Laboratory criteria for diagnosis None Case classification Confirmed: a case that meets the clinical case definition Comment If fever disappears after intravenous gamma globulin therapy is started, fever may be of less than 5 days’ duration, and the clinical case definition may still be met. Source: 3 Discuss the pros and cons of this case definition for the purposes listed below. (For a brief description of Kawasaki syndrome, see Benenson’s Control of Communicable Diseases in Man). a. Diagnosing and treating individual patients b. Tracking the occurrence of the disease for public health records c. Doing research to identify the cause of the disease Introduction to Epidemiology – Epi 592J Page 13 Numbers and RisksA basic task of a he alth department is counting cases in order to measure and describe morbidity. When physicians diagnose a case of a reportable disease they are suppose to report the case to their local health department. For most reportable conditions, these reports are legally required to contain information on time (when the case occurred), place (where the patient lived), and person (the age, race, and sex of the patient). The health department combines all reports and summarizes the information by time, place, and person. From these summaries, the health department determines the extent and patterns of disease occurrence in the area, and attempts to identify clusters or outbreaks of disease.A simple count of cases, however, does not provide all the information a health department needs. To compare the occurrence of a disease at different locations, during different times, or in different subgroups, a health department converts the case counts into risks, which relates the number of cases to the size of the population. Risks are useful in many ways. With risks, the health department can identify groups in the community with an elevated risk of disease. These so-called high-risk groups can be further assessed and targeted for special intervention; the groups can be studied to identify risk factors that are related to the occurrence of disease.Individuals can use knowledge of these risk factors to guide their decisions about behaviors that influence health. Descriptive Epidemiology In descriptive epidemiology, we organize and summarize data according to time, place, and person. These three characteristics are sometimes called the epidemiologic variables. Compiling and analyzing data by time, place, and person is desirable for several reasons. First, the investigator becomes intimately familiar with the data and with the extent of the public health problem being investigated. Second, this provides a detailed description of the health of a population that is easily communicated . Third, such analysis identifies the populations at greatest risk of acquiring a particular disease.This information provides important clues to the causes of the disease, and these clues can be turned into testable hypotheses. Time (â€Å"When? †) Disease risks usually change over time. Some of these changes occur regularly and can be predicted. For example, the seasonal increase of influenza cases with the onset of cold weather is a pattern that is familiar to everyone. By knowing when flu outbreaks will occur, health departments can time their influenza vaccination campaigns effectively. Other diseases may make unpredictable changes in occurrence. By examining events that precede a disease increase or decrease, we may identify causes and appropriate actions to control or prevent further occurrence of the disease.We usually show time data as a graph (Figure 1. 3). We put the number or risk of cases or deaths on the vertical, y-axis; we put the time periods along the horizo ntal, x-axis. We often indicate on a graph when events occurred that we believe are related to the particular health problem described in the graph. For example, we may indicate the period of exposure or the date control measures were implemented. Such a graph provides a simple visual depiction of the relative size of a problem, its past trend and potential future course, as well as how other events may have affected the problem. Studying such a graph often gives us insights into what may have caused the problem.Depending on what event we are describing, we may be interested in a period of years or decades, or we may limit the period to hours, days, weeks, or months when the number of cases reported is greater than normal (an epidemic period). For some conditions—for many chronic diseases, for example—we are interested in long-term changes in the number of cases or risk of the condition. For other conditions, we may find it more revealing to look at the occurrence of t he condition by season, month, day of the Page 14 Applied Epidemiology I week, or even time of day. For a newly recognized problem, we need to assess the occurrence of the problem over time in a variety of ways until we discover the most appropriate and revealing time period to use. Some of the common types of time-related graphs are further described below. Secular (long-term) trends.Graphing the annual cases or risk of a disease over a period of years shows long-term or secular trends in the occurrence of the disease. We commonly use these trends to suggest or predict the future incidence of a disease. We also use them in some instances to evaluate programs or policy decisions, or to suggest what caused an increase or decrease in the occurrence of a disease, particularly if the graph indicates when related events took place, as depicted in Figure 1. 3 (note the scale of the y-axis). Figure 1. 3 Malaria by year, United States, 1930-1990 Works Progress Administration Malaria Control Drainage Program Relapses from Overseas Cases 1000 Reported Cases per 100,000 Population 100Relapses from Korean Veterans Returning Vietnam Veterans 10 Foreign Immigration 1 0. 1 0. 01 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 Source: 9 Year Seasonality. By graphing the occurrence of a disease by week or month over the course of a year or more we can show its seasonal pattern, if any. Some diseases are known to have characteristic seasonal distributions; for example, as mentioned earlier, the number of reported cases of influenza typically increases in winter. Seasonal patterns may suggest hypotheses about how the infection is transmitted, which behavioral factors increase risk, and other possible contributors to the disease or condition.The seasonal pattern of an unknown disease is shown in Figure 1. 4. What factors might contribute to its seasonal pattern? From only the single year’s data in Figure 1. 4, it is difficult to conclude whether the peak i n June represents a characteristic seasonal pattern that would be repeated yearly, or whether it is simply an epidemic that occurred in the spring and summer of that particular year. You would need more than one year’s data before you could conclude that the pattern shown there represents the seasonal variation in this disease. Introduction to Epidemiology – Epi 592J Page 15 Figure 1. 4 Cases of an unknown disease by month of onset 450 400 350 300 Cases 50 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Source: 14 Month of Onset Day of week and time of day. Displaying data by days of the week or time of day may also be informative. Analysis at these shorter time periods is especially important for conditions that are potentially related to occupational or environmental exposures, which may occur at regularly scheduled intervals. In Figure 1. 5, farm tractor fatalities are displayed by days of the week. Does this analysis at shorter time periods suggest any hypothesis? In Figure 1. 5 the number of farm tractor fatalities on Sundays is about half the number on the other days. We can only speculate why this is.One reasonable hypothesis is that farmers spend fewer hours on their tractors on Sundays than on the other days. Figure 1. 5 Fatalities associated with farm tractor injuries by day of death, Georgia, 1971-1981 Source: 15 Page 16 Applied Epidemiology I Examine the pattern of fatalities associated with farm tractor injuries by hour in Figure 1. 6. How might you explain the morning peak at 11:00 AM, the dip at noon, and the afternoon peak at 4:00 PM? Figure 1. 6 Fatalities associated with farm tractor injuries by time of day, Georgia, 1971-1981 Source: 15 Epidemic period. To show the time course of a disease outbreak or epidemic, we use a graph called an epidemic curve.As with the other graphs you have seen in this section, we place the number of cases on the vertical axis and time on the horizontal axis. For time, we use either the time of onset of symptoms or the date of diagnosis. For very acute diseases with short incubation periods (i. e. , time period between exposure and onset of symptoms is short), we may show time as the hour of onset. For diseases with longer incubation periods, we might show time in 1-day, 2-day, 3-day, 1-week, or other appropriate intervals. Figure 1. 7 shows an epidemic curve that uses a 3-day interval for a foodborne disease outbreak. Notice how the cases are stacked in adjoining columns. By convention, we use this format, called a histogram, for epidemic curves.The shape and other features of an epidemic curve can suggest hypotheses about the time and source of exposure, the mode of transmission, and the causative agent. Figure 1. 7 Date of onset of illness in patients with culture-confirmed Yersinia enterocolitica infections, Atlanta, November 1, 1988-January 10, 1989 8 7 6 Thanksgiving Christmas New Year’s Cases 5 4 3 2 1 0 1 4 7 10 13 16 19 22 25 28 1 4 7 10 13 16 1 9 22 25 28 1 4 7 10 November December January Source: 18 Date of Onset Introduction to Epidemiology – Epi 592J Page 17 Place (â€Å"Where? †) We describe a health event by place to gain insight into the geographical extent of the problem. For place, we may use place of residence, birthplace, employment, school district, hospital unit, etc. , epending on which may be related to the occurrence of the health event. Similarly, we may use large or small geographic units: country, state, county, census tract, street address, map coordinates, or some other geographical designation. Sometimes, we may find it useful to analyze data according to place categories such as urban or rural, domestic or foreign, and institutional or noninstitutional. Not all analyses by place will be equally informative. For example, examine the data shown in Table 1. 3. Where were the malaria cases diagnosed? What â€Å"place† does the table break the data down by? Would it have been more or l ess useful to analyze the data according to the â€Å"state of residence† of the cases?We believe that it provides more useful information to show the data in Table 1. 3 by where the infection was acquired than it would have to show where the case-patients lived. By analyzing the malaria cases by place of acquisition, we can see where most of the malaria cases acquired their disease. Table 1. 3 Malaria cases by distribution of Plasmodium species and area of acquisition, United States, 1989 Species Area of Acquisition Vivax Falciparum Other Total Africa 52 382 64 498 Asia 207 44 29 280 Central America & Caribbean 107 14 9 130 North America 131 3 13 147 (United States) (5) (0) (0) (5) South America 10 1 2 13 Oceania 19 2 5 26 Unknown 6 2 0 8 Total 532 448 122 1,102 Source: 6By analyzing data by place, we can also get an idea of where the agent that causes a disease normally lives and multiplies, what may carry or transmit it, and how it spreads. When we find that the occurrence of a disease is associated with a place, we can infer that factors that increase the risk of the disease are present either in the persons living there (host factors) or in the environment, or both. For example, diseases that are passed from one person to another tend to spread more rapidly in urban areas than in rural ones, mainly because the greater crowding in urban areas provides more opportunities for susceptible people to come into contact with someone who is infected.On the other hand, diseases that are passed from animals to humans often occur in greater numbers in rural and suburban areas because people in those areas are more likely to come into contact with disease-carrying animals, ticks, and the like. For example, perhaps Lyme disease has become more common because people have moved to wooded areas where they come into contact with infected deer ticks. Although we can show data by place in a table—as Table 1. 3 does—it is often better to show it pictorial ly in a map. On a map, we can use different shadings, color, or line patterns to indicate how a disease or health event has different numbers or risks of occurrence in different areas, as in Figure 1. 8. Page 18 Applied Epidemiology I Figure 1. 8 AIDS cases per 100,000 population, United States, July 1991-June 1992 Source: 4For a rare disease or outbreak, we often find it useful to prepare a spot map, like Snow’s map of the Golden Square of London (Figure 1. 1), in which we mark with a dot or an X the relation of each case to a place that is potentially relevant to the health event being investigated—such as where each case lived or worked. We may also label other sites on a spot map, such as where we believe cases may have been exposed, to show the orientation of cases within the area mapped. Figure 1. 9 is a spot map for an outbreak of mumps that occurred among employees of the Chicago futures exchanges. Study the location of each case in relation to other cases and to the trading pits. The four numbered areas delineated with heavy lines are the trading pits.Does the location of cases on the spot map lead you to any hypothesis about the source of infection? Figure 1. 9 Mumps cases in trading pits of exchange A, Chicago, Illinois, August 18-December 25, 1987 #1 #3 #2 #4 Key: Pit areas are numbered and delineated by heavy lines. Individual trading pits within pit areas are outlined by light lines. Affected person (N= 43) Desk areas Source: CDC, unpublished data, 1988 Introduction to Epidemiology – Epi 592J Page 19 You probably observed that the cases occurred primarily among those working in trading pits #3 and #4. This clustering of illness within trading pits provides indirect evidence that the mumps was transmitted person-to person. Person (â€Å"Who? ) In descriptive epidemiology, when we organize or analyze data by â€Å"person† there are several person categories available to us. We may use inherent characteristics of people (for example, age, race, sex), their acquired characteristics (immune or marital status), their activities (occupation, leisure activities, use of medications/tobacco/drugs), or the conditions under which they live (socioeconomic status, access to medical care). These categories usually determine, to a large degree, who is at greatest risk of experiencing certain undesirable health conditions, such as becoming infected with a particular disease organism. We may show person-related characteristics in either tables or graphs.In analyzing data by person, we often must try a number of different categories before we find which are the most useful and enlightening. Age and sex are most critical; we almost always analyze data according to these. Depending on the health event we are studying, we may or may not break the data down by other attributes. Often we analyze data by more than one characteristic simultaneously; for example, we may look at age and sex simultaneously to see if the sex es differ in how they develop a condition that increases with age—such as with heart disease. Age. Age is probably the single most important â€Å"person† attribute, because almost every health-related event or state varies with age.A number of factors that also vary with age are behind this association: susceptibility, opportunity for exposure, latency or incubation period of the disease, and physiologic response (which affects, among other things, disease development). When we analyze data by age, we try to use age groups that are narrow enough to detect any agerelated patterns that may be present in the data. In an initial breakdown by age, we commonly use 5-year age intervals: 0 to 4 years, 5 to 9, 10 to 14, and so on. Larger intervals, such as 0 to 19 years, 20 to 39, etc. , may conceal variations related to age which we need to know to identify the true ages at greatest risk.Sometimes, even 5-year age groups can hide important differences, especially in children less than five years of age. Take time to examine Figure 1. 10, for example, before you read ahead. What does the information in this figure suggest health authorities should do to reduce the number of cases of whooping cough? Where should health authorities focus their efforts? You probably said that health authorities should focus on immunizing infants against whooping cough during the first year of life. Now, examine Figure 1. 11. This figure shows the same data but they are presented in the usual 5-year intervals. Based on Figure 1. 11 where would you have suggested that health authorities focus their efforts?Would this recommendation have been as effective and efficient in reducing cases of whooping cough? You probably said that health authorities should immunize infants and children before the age of 5. That recommendation would be effective, but it would not be efficient. You would be immunizing more children than actually necessary and wasting resources. Sex. In general, mal es have higher risks of illness and death than females do for a wide range of diseases. For some diseases, this sex-related difference is because of genetic, hormonal, anatomic, or other inherent differences between the sexes. These inherent differences affect their susceptibility or physiologic responses.For example, premenopausal women have a lower risk of heart disease than men of the same age. This difference is attributed to higher estrogen levels in women. On the other hand, the sex-related differences in the occurrence of many diseases reflect differences in opportunity or levels of exposure. For example, Figure 1. 12 shows that hand/wrist disorders occur almost twice as often in females than in males. What are some sex-related differences that would cause a higher level of this disorder in females? Page 20 Applied Epidemiology I Figure 1. 10 Pertussis (whooping cough) incidence by age group, United States, 1989 Source: 9 Figure 1. 11 Pertussis (whooping cough) incidence by a ge group, United States, 1989 Source: 9 Figure 1. 2 Prevalence of hand/wrist cumulative trauma disorder by sex, Newspaper Company A, 1990 Source: NIOSH, unpublished data, 1991 Introduction to Epidemiology – Epi 592J Page 21 You may have attributed the higher level of disorders in females to their higher level of exposure to occupational activities that require repetitive hand/wrist motion such as typing or keyboard entry. With occupationally-related illness, we usually find that sex differences reflect the number of workers in those occupations. You may also have attributed the higher level of disorders in females to anatomical differences; perhaps women’s wrists are more susceptible to hand/wrist disorders. Ethnic and racial groups.In examining epidemiologic data, we are interested in any group of people who have lived together long enough to acquire common characteristics, either biologically or socially. Several terms are commonly used to identify such groups: race, nationality, religion, or local reproductive or social groups, such as tribes and other geographically or socially isolated groups. Differences that we observe in racial, ethnic, or other groups may reflect differences in their susceptibility or in their exposure, or they may reflect differences in other factors that bear more directly on the risk of disease, such as socioeconomic status and access to health care. In Figure 1. 13, the risks of suicide for five groups of people are displayed. Figure 1. 3 Suicide death rates for persons 15 to 24 years of age according to race/ethnicity, United States, 1988 Source: 22 Clearly this graph displays a range of suicide death rates for the five groups of people. These data provide direction for prevention programs and for future studies to explain the differences. Socioeconomic status. Socioeconomic status is difficult to quantify. It is made up of many variables such as occupation, family income, educational achievement, living conditions, and social standing. The variables that are easiest to measure may not reflect the overall concept. Nevertheless, we commonly use occupation, family income, and educational achievement, while recognizing that these do not measure socioeconomic status precisely.The frequency of many adverse health conditions increases with decreasing socioeconomic status. For example, tuberculosis is more common among persons in lower socioeconomic strata. Infant mortality and time lost from work due to disability are both associated with lower income. These patterns may reflect more harmful exposures, lower resistance, and less access to health care. Or they may in part Page 22 Applied Epidemiology I reflect an interdependent relationship which is impossible to untangle—does low socioeconomic status contribute to disability or does disability contribute to lower socioeconomic status? Some adverse health conditions are more frequent among persons of higher socioeconomic status.These condition s include breast cancer, Kawasaki syndrome, and tennis elbow. Again, differences in exposure account for at least some of the differences in the frequency of these conditions. Exercise 1. 4 The following series of tables (Exercise 1. 4, Tables 1-4) show person information about cases of the unknown disease described in Figure 1. 4 on page 15. Look again at Figure 1. 4, study the information in the four exercise tables and then describe in words how the disease outbreak is distributed by time and person. Exercise 1. 4, Table 1 Incidence of the disease by age and sex in 24 villages surveyed for one year Males Females Age Group Population* # Cases Risk per Population* # Cases Risk per (years) 1,000 1,000