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JAY

P. JAZUL, RPh, CPS, MSc.


PUBLIC HEALTH PHARMACY

Preven&on
Includes procedures not only to prevent the

occurrence of disease, such as risk factor reduction,


but also to halt its progress and reduce its
consequences once established

Scope

1. Health Problems
1.1 Infectious
1.2 Chronic Disease
1.3 Trauma
1.4 Mental Disorder
2. Health Determinants (risk factor)
2.1 Nutrition
2.2 Environment
2.3 Lifestyle
2.4 Population

Health Problems
1.1 Infectious Disease
Disease resulting from infection
Communicable disease: disease due to a specic

infectious agent or its toxic products that arises


through transmission

Reasons why communicable diseases


persist:
Population explosion
Crowding
Inadequate food, water supply, sewage disposal
Inadequate health care facilities
Ease of transportation
Change in microorganisms (mutations)
Resistance to insecticides
Pop movement
Changes in behavior and attitude

1.2 Chronic Disease


e.g. CVD, cancer

1.3 Trauma
e.g. unintentional injuries, suicide and homicide

1.4 Mental Disorder
Psychoses, neuroses, mental retardation, alcoholism,
dependency disorder, child abuse and learning
disabilities

Health Determinants
2.1 Nutrition
Food safety
Food security

Fifty years ago, the major nutritional problems

throughout the world were lack of adequate, safe and


aordable supplies of food, inadequate understanding
of dietary needs and widespread ignorance
concerning the relationship of nutrition to health and
disease.

Resolved in developed countries but persist in

developing countries

Major nutritional problems in developed countries

now:
Excessive consumption of fats, rened carbohydrates

and salt
Inadequate consumption of ber and cereals

The situation promotes diseases such as coronary

heart disease, diabetes, hypertension and dental


caries

2.2 Environmental and Occupational Hazards


Early part of the 20th century, concerns were provision

of biologically safe water and food to the public, and


the safe removal of sewage and garbage
Major current environmental threats arise from

chemical pollution of water, land and air



2.3 Lifestyle

2.4 Population
Rapid population Growth
Increasing proportion of elderly


2.5 Social Support
Disruption of social support systems may be

associated with poor health


e.g. unemployment, divorce, widowhood

Scope of control (according to level of


applica&on)
1. Individual
Measure/s directed at the individual
Obj: prevention or cure of disease in a person

2. Community (Disease Control)


Measure/s directed at the community
Obj: reduce morbidity and mortality caused by the

disease in the community

Elimination of Disease
Cases of disease no longer exist but one or more

factors important in its occurrence still persist.



Eradication of Disease
Cases of disease and the agent of disease have been

eliminated; transmission of the causative agent has


ceased in an irreversible manner. (global level)

Strategies for Preven&on


1. Risk Assessment
Exposure monitor potential carcinogens in air, water,

soil and the home


Populations at high risk identify and monitor for

prevalence and incidence

Morbidity/Mortality Rates

Surveys (examinations, screening)

Contact Tracing

2. Intervention Measures
Education and health promotion
Control exposure to known etiologic agent
Population trials

Immunization, chemo-prevention and biological markers for


early detection

Genetic testing and psychological support


Early detection (screening)

vAcceptance of measure by the population

3. Evaluation of Intervention Measures


Measure change in risk monitor

Incidence

Stage at diagnosis

Use of healthier lifestyle and prevention practices

Modify intervention strategies

Based on evaluation results

Based on new scientic ndings

Strategy for Preven&on


Modify
Existing
Intervention
Programs

Evaluate
Intervention
Programs

Apply Population-
Based Intervention
Programs

Identify Populations at
High Disease Risk (based

on demography/family history,
host factors)

Assess
Exposure

Conduct Research on
Mechanisms (including the
study of genetic susceptibility

Factors Aec&ng Success of


Preven&ve and Control Measures
Resources
Acceptance of measure by the population
vMust not interfere with any activity, conform with

religion, culture, beliefs, customs, etc.

Must give the most benet with the least expense

Guiding Principles
Understand natural history of disease
Recognize foci of infection (high risk group)
Determine weakest link in the chain of

causation

1. Understand Natural History of


Disease
Course of disease over time from the
EARLIEST STAGE
PREPATHOGENESIS PHASE


TERMINATION
(Recovery, disability or death) unaected by treatment
or prevention

Natural History of Disease


PERIOD

Prepathogenesis

STAGE

Susceptibility

Pathogenesis
Subclinical
Disease

Clinical
Disease

Resolution
Recovery/
Disability/
Death

Exposure
Pathologic
Changes
Onset of
Symptoms Usual Time of
Diagnosis

1. Stage of Susceptibility
Before man is diseased
Factors favoring occurrence of disease are present

i.e. smoking

3. Stage of Subclinical Disease


Disease has occurred but host still has no signs or

symptoms
Pathologic changes have started to occur

3. Stage of Clinical Disease


Sucient anatomical/functional changes have occurred
Presence of recognizable S/S
Usual time of diagnosis

5. Stage of Subclinical Disease


Possible outcomes: recovery, disability, death
There can be residual defect of short or long duration

Induction Period (non-com)

Causal action to disease initiation (cause eect)


Latent Period

Disease occurrence to detection (eect on body detection)

Induction Period

Causal Action

Latent Period

Disease

Detection

Stages in the Natural History of a Disease


Clinical
horizon

Imbalance
Susceptibility
Stage
Interaction
of agent,
host,
environment

Subclinical
Stage
Pathologic
changes

Clinical Stage

Symptoms
present

Resolution
Stage
Problem
resolved
Return to
health, or
chronic state
or death

2. Recognize High Risk Groups


Survey/contact tracing
Examination/screening
Morbidity reports
Mortality reports

3. Determine Weakest Link in the


Chain of Causa&on
Components in the chain of causation of infectious

diseases:
Agent
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Susceptible host

Agent factors
Host range: the extent of the variety of species

susceptible to infection by a specic kind of agent


Reservoirs:
A normal habitat in which an infectious agent lives

and multiplies and depend primarily for survival


Man cases and carriers
Animals ricketsia, leptospirosis, rabies
Environment plants, soil, eater

Portals of Exit
Path by which agents leaves its host
Respiratory, genitourinary, alimentary,

skin, transplancental

Modes of Transmission
Bridge the gap between portal of exit from reservoir and

the portal of entry to a new host


Direct transmission: direct contact; droplet spread
Indirect transmission: vectors; vehicles

Vehicles (air, water, food, inanimate objects)


Droplet nuclei and dust
Dried residue of a droplet (1-5 microns) remain suspended in the air and are
easily drawn into the lungs and retained

Portal of Entry
Essentially the same as those for escape

Susceptible Host
vSusceptibility depends on:
Genetic factors
General factors of resistance

Anatomic and physiologic

Nutrition

Specic acquired immunity

Natural (active, passive)

Articial (vaccines

Preven&ve measures are directed:


1. At the agent when in the reservoir
2. At the agent when in transit to a new host
3. At the susceptible population

Measures against the agent when in the


reservoir:
Eliminate reservoir (destroy)
v Animal: slaughter

Reduce communicability
Treatment to render infected individual non-infectious
Limit Movement

Isolation separation for the period of communicability of infected


persons or animals

Quarantine limitation of movement of well person/animals who have


been exposed to a communicable disease for a period not longer than
longest incubation period

Treatment

For the protection of the case and

community
Shortens course of illness
Shortens period of communicability

Measures Against Agent When It is in


Transit from Reservoir to Host
Consist mostly of environmental control measures aimed

at intermediary agents of transmission


v Vectors (insects, anthropods)
v Vehicles (air, water, food, utensils)
Provision of safe and adequate

Disinfestation

water

Cleaning

Proper sewage and waste disposal Disinfection


Food and Dairy sanitation
Insect and vermin control

Measures Directed at Suscep&ble


Popula&on
Make susceptibles Not susceptible
Minimize exposure to infection

Specic measures: chemoprohylaxis immunization
Non-specic measures

Non-specic
Health education
Change unhealthy behavior
Maintain healthy behavior
Develop responsibility for own health

Adequate nutrition
Prevent fatigue and overexertion
Prevent overcrowding

Emotional health
Promotion of good personal hygiene
Provision of good housing
Improve socio-economic condition
Provide medical facilities

Disease Preven&on
Disease evolves overtime and as this occurs, pathologic

changes may become xed and irreversible


Aim: to push back the level of detection and

intervention to the precursors and risk factors of the


disease
Needs to be based on the natural history of the disease
Levels of prevention:
Primordial

Primary

Secondary

Tertiary

Primordial Preven&on
A relatively new concept, is receiving special attention

in the prevention of chronic diseases


Prevention of risk factors themselves, beginning with

change in social and environmental conditions in


which these factors are observed to develop

Obj: change the milieu that promotes major risk

factor development. Primordial prevention calls for


changing the socio-economic status of society. A
better socio-economic status correlates inversely with
lifestyle factors like smoking, abnormal food patterns
and exercise.

Responsibili&es for Primordial Preven&on:

Government
Professional and non-governmental orgs

Industry
Hospitals, health clinics
Health practitioners and health-care workers

Examples of Primordial Preven&on


National policies and programs on nutrition involving

the agricultural sector, the food industry, and the


food import-export sector
Comprehensive policies to discourage smoking
Programs to promote regular physical activity

Primary Preven&on
Goal:
To remove the precipitating causes and disease determinants

(keep agent away from the host)


To eliminate or reduce host susceptibility

Strategies:
Health promotion the process of enabling people to control

over and improve their health; context of everyday lives,


rather than focusing on at risk pop
Specic protection

Secondary Preven&on
Goal:
To detect and cure disease at its earliest stage
To reduce the more serious consequences of disease

Strategies:
Early diagnosis
Prompt treatment

Ter&ary Preven&on
Goal:
To reduce the progress or complications of established

disease and is an important aspect of therapeutic and


rehabilitation medicine

Strategies:
Treatment
Disability limitation
rehabilitation

Stages in the Natural Hx of a Condi&on and Their


Rela&onships to Levels of Preven&on

Susceptibility
Stage
Agent-host-
environment

Primary
Primordial

Pre-clinical
Stage

Clinical Stage

Pathologic
changes; no
symptoms

Symptoms
present

Secondary

Resolution
Stage
Problem
resolved
Return to
health, or
chronic state
or death

Tertiary

PERIOD

PREPATHOGENESIS

STAGE

Susceptibility

Subclinical
Disease


Levels of
Prevention



PRIMARY



SECONDARY



TERTIARY

Goal

To keep agent away


from the host
Eliminate or reduce
host susceptibility

To detect and
cure disease at
its earliest
stage
To prevent
complications
and disability

To alleviate disability
resulting from the disease
To restore eective
functioning

Intervention

Health promotion
Specic protection

Early
diagnosis
Prompt
treatment

Treatment
Disability limitation
Rehabilitation

PATHOGENESIS

Clinical
Disease

RESOLUTIONS/
EQUELAE

Recovery/
Disability/Death

Levels of Preven&on
Level

Phase of Disease

Target

Primordial

Underlying conditions
leading to causation

Total population

Primary

Prepathogenesis

Total population,
selected groups and
healthy individuals

Secondary

Early stage of disease

Patients

Tertiary

Late stage of disease


(treatment,
rehabilitation)

Patients

Death Rates
for Measles in
Children
Under Age 15,
England and
Wales,
1850-1970

Pneumonia Control

Source: Global Action Plan for Prevention and Control of Pneumonia (GAPP)

Pneumonia Control

Source: Global Action Plan for Prevention and Control of Pneumonia (GAPP)

Pneumonia Control
Use of simple, standardized guidelines for identification and

treatment of pneumonia in the community, at first level health


facilities and at referral hospitals has been shown to substantially
reduce child deaths.

The safety and efficacy of new vaccines against Streptococcus

pneumoniae (Spn) and Haemophilus influenzae type b (Hib), the


two most frequent bacterial agents of childhood pneumonia, has
been established.

Vaccines against measles and pertussis in national immunization

programmes have been shown to substantially reduce pneumonia


morbidity and mortality in children.

Other child survival interventions, including the promotion of

exclusive breastfeeding and improvement of the living


environment to reduce the spread of germs, have also been
demonstrated to play an important role in pneumonia control.

Source: Global Action Plan for Prevention and Control of Pneumonia (GAPP)

Pneumonia Control

Source: Global Action Plan for Prevention and Control of Pneumonia (GAPP)

Preven&ve Measures Against Vehicular


Accidents
Level 1 actions put to use in order to prevent the
accident

Level 2 actions put to use to minimize the consequences
of the accident during its unwinding

Level 3 actions put to use to minimize the consequences
of the accident after the latter has occurred (short/middle
term)

Level 1 Preven&on
Road maintenance
Intelligent road designing/redesigning
Periodic vehicle inspection
Training towards a defensive and UNSURE driving
Expanded speeding controls
Expanded blood alcohol levels controls
Trac education from as early as nursery/elementary

school

Level 2 Preven&on
Safety equipment (driving, work, sports)
Helmets
Safety belts
Child restraints
Head rests
Air bags, etc.

Correct handling and maintenance of the above

Level 3 Preven&on
Adequate treatment
Rehabilitation

The Cost of Preven&on:


Can we aord it?
Can we aord not to do it?