Preventive Medicine

and Public Health

Ramon Jason M. Javier, MD, MSTM, FPAFP

Department of Preventive and Community Medicine
College of Medicine
UERMMMCI
PRC Board of Medicine
Dr. Clarita C. Maano Dr. Miguel L. Noche, Jr.
Chairperson Member
PRC Board of Medicine
Dr. Eleanor B. Amoro Dr. Ma. Graciela G. Gonzaga
Member Member
PRC Board of Medicine
Dr. Eleanor J. Galvez Dr. Edgardo T. Fernando
Member Interim Member
 Review Outline
• Concepts of Health and Disease
– Ecologic Triad of (Communicable*) Diseases
– Natural History of Disease
– Levels of Prevention
 Review Outline
• Epidemiology and Research Methods
– Descriptive Epidemiology: Time, Place, Person
– Epidemiologic Research
 Descriptive Studies
 Analytical Studies – Observational
 Analytical Studies – Experimental / Trials
 Other Designs
– Disease Outbreak / Epidemic Investigation
– Evidence Based Medicine
 Critical Appraisal of Medical Journal
 Review Outline
• Biostatistics
– Descriptive Statistics
– Inferential Statistics
 Review Outline
• Public Health and Community Medicine
– Common Health Indices in the Community
– Primary Health Care
– Alma Ata Declaration and Other Health Fora
– Level of People’s Participation
– UN Millennium Development Goals (UN-MDGs)
– UN Sustainable Development Goals (UN-SDGs)
– W.H.O. Building Blocks of Healthcare System
 Review Outline
• Public Health and Community Medicine
– Philippine Health Agenda 2010-2016 (Universal
Health Care / Kalusugan Pangkalahatan): Pres.
Benigno S. Aquino
– Philippine Health Agenda 2016-2022 (All for
Health Towards Health for All): Pres. Rodrigo R.
Duterte
– National Health Insurance Program (PhilHealth)
– Government Health Programs (Department of
Health)
– Health Legislation
 Review Outline
• Special Topics
– Family Medicine and the Biopsychosocial
Paradigm (i.e., patient-centered, family-
focused, community-oriented health care)
– Occupational Safety and Health / Occupational
Medicine / Industrial Medicine
– Environmental Health and Sanitation
– Complimentary and Alternative Medicine
Health and Disease
 Health and Disease
• Epidemiologic Models of Disease
1. Ecologic Triad / Triangle of Disease
2. Epidemiologic Lever
3. Web of Causation
 Health and Disease
H A
A H
E E
Agent becomes more A H The proportion of susceptible
pathogenic. in population decreases.

E
H
at equilibrium A
steady rate
A
H
E
E
There are environmental There are environmental
changes that affect the agent. changes that affect the host.
Health and Disease
Health and Disease
 Health and Disease

Frank Illness Chronic Stage

Prodrome
consists of mild, non- signs and symptoms disease is prolonged
specific signs and are now more (e.g., development of
symptoms specific anemia due to chronic
(e.g., generalized body (e.g., icteresia, kidney disease secondary to
weakness, weight loss, hemoptysis, uncontrolled hypertension or
fever, etc.) paroxysmal diabetes; development of
nocturnal dyspnea, left-sided residuals due to a
etc.) cerebrovascular disease /
accident, etc.)
 Health and Disease
PRC Sample Exam:

The following are the CONSTITUTIONAL RISK

FACTORS for the development of ISCHEMIC
HEART DISEASE, EXCEPT:
A. age
B. gender
C. genetics
D. hypertension
 Health and Disease
PRC Sample Exam:

HEPATITIS B SPREAD is NOT known to occur

in:
A. sexual intercourse
B. vertical transmission in perinatal period
C. intimate household contact
D. sharing food with infected patients
 Health and Disease
PRC Sample Exam:

Which of the following communicable diseases has

an INTERMEDIATE HOST?
A. syphilis
B. schistosomiasis
C. Japanese encephalitis
D. dengue
 Health and Disease
PRC Sample Exam:

How long is the INCUBATION PERIOD of

HEPATITIS A?
A. 2 weeks
B. 4 weeks
C. 6-8 weeks
D. 10-12 weeks
 Health and Disease

Quaternary
Prevention
Tertiary
Prevention - Late
Secondary Pathogenesis
Prevention - Early • Disability
Primary Pathogenesis Limitation*
Prevention - • Early Diagnosis • Rehabilitation
Primordial Prepathogenesis (Screening)
Prevention • Health • Prompt
Promotion Treatment
• Specific
Protection
 Health and Disease
Primordial Quaternary
Prevention Prevention
• avoid the emergence • set of health activities
and establishment of to mitigate or avoid
the social, economic, the consequences of
and cultural patterns unnecessary or
of living that are excessive intervention
known to contribute of the health system
to an elevated risk of • to avoid patient over
disease diagnosis and
overtreatment
 Health and Disease
PRC Sample Exam:

A group of doctors decided to do a SCREENING

TEST to detect colon cancer. Those diagnosed
with colon cancer were SUBSEQUENTLY
TREATED. What type of prevention is this?
A. primary prevention
B. secondary prevention
C. tertiary prevention
D. quaternary prevention
 Health and Disease
PRC Sample Exam:

Which among these ANTI-DIABETIC DRUGS

increases the risk of developing BLADDER
CANCER?
A. Pioglitazone (Thiazolinedione)
B. Glimepiride (Sulfonylurea)
C. Sitagliptin (DPP-4 Inhibitor)
D. Acarbose (α-Glucosidase Inhibitor)
 Health and Disease
PRC Sample Exam:

A 5 year old boy, known case of SEIZURE

DISORDER, was brought by her mother to you
clinic due to SUSPECTED HELMINTHIC
INFECTION. Which among the following drugs
should NOT be given in this patient?
A. Pyrantel Pamoate
B. Praziquantel
C. Ivermectin
D. Piperazine
 Health and Disease
PRC Sample Exam:

Patients who had acute stroke were enrolled in a

REHABILITATION PROGRAM to minimize any
LONG-TERM DISABILITY. This is an example
of:
A. primary prevention
B. secondary prevention
C. tertiary prevention
D. quaternary prevention
 Health and Disease
PRC Sample Exam:

The use of an ANTIBIOGRAM by the hospital

INFECTIOUS CONTROL COMMITTEE to monitor
drug resistance is an example of what LEVEL OF
PREVENTION?
A. primary prevention
B. secondary prevention
C. tertiary prevention
D. quaternary prevention
 Health and Disease
PRC Sample Exam:

PINGGANG PINOY is a food guide that uses a familiar

food plate model to convey the right food group
proportions on a per-meal basis, to meet the body’s
energy and nutrient needs of Filipino adults. It shows
the following, EXCEPT:
A. The fruit portion is represented by banana which should make up
about 17%.
B. The vegetable portion is represented by malunggay which is
about 33%.
C. The rice and alternatives are represented by cooked rice, making
up 17%.
D. The meat portion is represented by fish, which is 17%.
 Health and Disease
Fish and
Alternatives:
17%
Fruits:
17%

Rice and
Alternatives:
33%
Vegetables:
33%
Health and Disease
Health and Disease
Health and Disease
 Health and Disease
PRC Sample Exam:

Which of the following is NOT an ADVERSE EFFECT

of immunization with DIPHTHERIA-PERTUSSIS-
TETANUS?
A. abscess formation
B. fever
C. reactive adenitis
D. seizures
 Health and Disease
PRC Sample Exam:

The MOST COMMON COMPLICATION associated

with BCG vaccination is:
A. suppurative lymphadenitis
B. convulsions
C. encephalitis
D. osteomyelitis
 Health and Disease
PRC Sample Exam:

An 8-year old child with NO PREVIOUS

IMMUNIZATION stepped on a rusty nail. The
child should receive:
A. no immunization / prophylaxis required
B. DTwP
C. DTaP
D. Tdap / Td
 Health and Disease
PRC Sample Exam:

A 5-year old male was noted to have FEVER of five days

duration which is rapidly increasing to 39-40oC. It is
accompanied by FRONTAL HEADACHE and was noted to
have BACK PAIN. After two days of defervecence of
fever, RASHES appear at the lower and upper extremities
that are GLOVES AND STOCKINGS IN
DISTRIBUTION. The MOST PLAUSIBLE DIAGNOSIS
is:
A. measles
B. typhoid fever
C. varicella
D. dengue
 Health and Disease
National Immunization Program 2016
 Health and Disease
Japanese Dengue*
Encephalitis
• given 1.0 ml • school-based
subcutaneously immunization
• given 0.5 ml
• given at a minimum age
subcutaneously
of 9 months
• given at a minimum age
• children 9 months to 17 of 9 years
years of age should • given as 3-dose series at
receive one primary dose 0, 6, and 12 months
followed by a booster • recommended age
dose 12-24 months after indication is from 9 to 45
the primary dose years --- optimal safety
• individuals 18 years and and efficacy within these
older should receive a age group
single dose only
 Health and Disease
PRC Sample Exam:

VACCINE for this disease (in the previous 5-year

old patient) may be given AS EARLY AS:
A. 6 months
B. 9 months
C. 12 months
D. no vaccine available
 Health and Disease
Some Important Concepts
• infectivity: ability to gain access into host
• pathogenicity: ability to set up a specific
reaction, local or general, clinical or subclinical
• virulence: severity of reaction produced,
measured in terms of mortality
• antigenicity: ability to stimulate the host to
produce antibodies
 Health and Disease
PRC Sample Exam:

Which of the following is the best indicator of a

high degree of hepatitis B virus (HBV)
REPLICATION and hence a MARKER OF
"INFECTIVITY"?
A. HBcAg
B. HBeAg
C. HBsAg
D. HBV DNA
Health and Disease
 Health and Disease
• Agents with high infectivity and
pathogenicity but low antigenicity will cause
a relatively high disease prevalence in the
community.

• Agents with high infectivity but low

pathogenicity usually produce mild or sub-
clinical symptoms and disease carriers.
 Health and Disease
Wellness Program
• Philippine Periodic Health Examination
(PHEX), UP Philippine General Hospital, 2004
• Guide to Clinical Preventive Services, US
Preventive Services Task Force, 2014
Health and Disease
 Health and Disease
PRC Sample Exam:

A 30-year-old woman has had a negative clinical

breast examination. She has a family history of
BREAST CANCER IN HER MOTHER, who
contracted the disease at the age of 48. At what
age should she commence having ROUTINE
SCREENING MAMMOGRAMS?
A. 30 years old
B. 38 years old
C. 48 years old
D. 60 years old
 Health and Disease
PRC Sample Exam:

A 45-year old male, diabetic, smoker, who has a

sedentary lifestyle came in for advise regarding
WEIGHT LOSS REGIMEN. The patient weighs 160
lbs. and he is 5'5" tall. What will be your advice?
A. diet, exercise, behavioral therapy, pharmacotherapy,
and surgery
B. diet, exercise, behavioral therapy, pharmacotherapy
C. diet, exercise, behavioral therapy
D. diet, exercise
 Health and Disease
PRC Sample Exam:
A 32-year old female was diagnosed with CERVICAL INTRAEPITHELIAL
NEOPLASIA, GRADE II (CNII), three years ago. The diagnosis was
confirmed with a biopsy and loop electrosurgical excision procedure (LEEP)
was performed. Her past medical history is otherwise insignificant. She
does not smoke or consume alcohol. She is currently not taking any
medications. She has been sexually active with one partner for the last
two years. She has been undergoing cytologic screeing and colposcopy
every 6 months after the LEEP. The LAST THREE EXAMS WERE
NEGATIVE. Which of the following is the best management for this
patient?
A. Continue cytologic screening and colposcopy every 6 months.
B. Continue cytologic screening every 6 months.
C. Order the biopsy in order to exclude the recurrence.
D. Perform annual cytologic screening.
Health and Disease
 Health and Disease
PRC Sample Exam:

Based on the PHILIPPINE INTEGRATED

DISEASE SURVEILLANCE AND RESPONSE
(PIDSR), the following diseases are targeted for
ERADICATION or ELIMINATION, EXCEPT:
A. poliomyelitis
B. neonatal tetanus
C. meningococcemia
D. measles
 Health and Disease
PRC Sample Exam:

Which of the following is NOT included in the role

of the QUARANTINE PROGRAM?
A. disease surveillance
B. inter-island vessel sanitation
C. medical clearance of migrants
D. mass media communication
 Health and Disease
PRC Sample Exam:

What does the HERD IMMUNITY depend on?

A. degree to which an affected individual is
capable of transmitting the infection
B. the length of time during which an individual
is infectious
C. number of non-immunized individuals in the
community
D. virulence factors of the etiologic / causative
agent
 Health and Disease
Herd Immunity
 Health and Disease
Herd Immunity
 Epidemiology
Epidemiology may be defined as the study of the
distribution and determinants of diseases and
injuries in human populations.

That is, epidemiology is concerned with the

extent and types of illnesses and injuries in
groups of people and with factors which
influence their distribution.
 Epidemiology
This implies that disease is not randomly
distributed throughout a population, but
rather that groups differ in the frequency of
different diseases.

Knowledge of this uneven distribution can be

used to investigate etiologic factors and to lay
the groundwork for programs of prevention and
control.
 Epidemiology
The core of epidemiology is the use of
quantitative methods to study disease and risk
factors in human populations.

Epidemiology is a relatively young science dating

back to John Graunt and possibly a hundred year
later to James Lind (1794).
 Epidemiology
John Graunt (1620-1674) is considered
by many historians to have founded the
science of demography, the statistical
study of human populations. He analyzed
the vital statistics of the citizens of London
and wrote a book regarding those figures
that greatly influenced the demographers
of his day and those in the centuries that
followed. Graunt was honored for his
work by being made a charter member of
England's Royal Society, which was
composed of prominent scientists.
 Epidemiology
James Lind was a British navy doctor. He is
credited with designing first ever clinical trial. He
had the hypothesis that scurvy, a debilitating
disease affecting sailors on long sea journeys, was
caused by lack of fruit intake.
oranges and lemons
cider
sea water
vinegar
 Epidemiology
Epidemiologic work may be divided into two main
categories:
• Descriptive Epidemiology: includes activities
related to characterizing the distribution of
diseases within a population
• Analytic Epidemiology: concerns activities
related to identifying possible causes for the
occurrence of disease
 Epidemiology
Both types of epidemiology are fundamental to the
prevention and control of diseases and to the
advancement of medical knowledge. Descriptive
patterns of disease occurrence often lead to
hypotheses (hypothesis generation) about
disease causation that are tested (hypothesis
testing) in analytic investigations. Analytic
studies may yield findings that help to explain
descriptive patterns and to improve surveillance
efforts.
 Epidemiology
For almost all diseases / illnesses, three basic
epidemiologic questions may be asked:
1. Who develops the disease? (PERSON)
2. When does the disease occur? (TIME)
3. Where does the disease occur? (PLACE)

A basic tenet of epidemiology is that diseases do

not occur at random. Thus, not all individuals
in a given population are equally likely to develop
a particular condition.
 Epidemiology
Person Variables
• Variation of occurrence in relation to personal
characteristics may reflect differences in level
of exposure to causal factors, susceptibility
to the effects of causal factors, or both exposure
and susceptibility.
age, gender, race
level of education and income, marital status,
occupation
 Epidemiology
PRC Sample Exam:

TRUE statements about SOCIAL DETERMINANTS

OF HEALTH include all the following, EXCEPT:
A. Persons with few social ties have greater mortality from
coronary heart disease than do persons with many social
ties.
B. Persons of lower socioeconomic status have greater
mortality from diabetes than do persons of higher socio-
economic status.
C. After correcting for race and access to medical care, there
is still a relationship between socioeconomic status and
mortality.
D. Female sex is associated with increased mortality from
most diseases.
 Epidemiology
PRC Sample Exam:

CORRECT statements about OBESITY include all

the following, EXCEPT:
A. A woman whose body fat is greater than 30% of
her total body mass is obese.
B. The average body weights of men and women
are increasing with no proportionate change in
stature.
C. Obesity is a major risk factor for coronary heart
disease.
D. Genetic factors contribute to obesity.
 Epidemiology
PRC Sample Exam:

Compared with the general population, all the

following patients are at an INCREASED RISK OF
FOLATE DEFICIENCY, EXCEPT:
A. a 20-year-old man with sickle cell anemia
B. a 20-year-old woman who is a strict vegetarian
C. a 60-year-old man on hemodialysis
D. a 70-year-old woman who drinks a quart of gin
a day
 Epidemiology
PRC Sample Exam:

The incidence of MALNUTRITION in the Philippines

is reported to be HIGHEST in the following:
A. pre-school children
B. school children
C. pregnant women
D. geriatric population / elderly
 Epidemiology
PRC Sample Exam:

Most common CANCER IN CHILDREN AND

ADOLESCENT:
A. leukemias
B. CNS and spinal cord tumors
C. lymphomas
D. retinoblastoma
 Epidemiology
Time / Temporal Variables
• Three major kinds of change with time may be
identified:
1. secular trends: long-term variations
2. cyclic changes: periodic fluctuations on
an annual basis (seasonal variations);
recurrent alterations in the frequency of
disease
3. epidemics: short-term fluctuations
 Epidemiology
• The usual rate of occurrence for a disease in a
population is referred to as the endemic rate.
A rapid and dramatic increase over the endemic
rate is described as an epidemic rate.

• A rapidly emerging outbreak of disease that

affects a wide range of geographically
distributed populations is described as a
pandemic.
 Epidemiology
PRC Sample Exam:

Which pattern/s of disease distribution according

to TIME would be most appropriate to monitor for
CHRONIC NON-COMMUNICABLE DISEASES,
like hypertension?
A. secular trend
B. short term fluctuation
C. seasonal pattern
D. all of the above
 Epidemiology
PRC Sample Exam:

CYCLIC SEASONAL CHANGES in disease patterns

could be influenced by:
A. changing environmental conditions
B. changes in the fauna and flora
C. variations in people’s behavior
D. all of the above
 Epidemiology
PRC Sample Exam:

This is known as the SILENT EPIDEMIC OF THE

21ST CENTURY:
A. coronary artery disease
B. chronic liver disease
C. chronic obstructive lung disease
D. Alzheimer’s disease
 Epidemiology
Place Variables
• Frequency of disease can be related to place of
occurrence in terms of areas set off either by
natural barriers (e.g., mountain ranges, rivers,
desserts; tropical versus temperate regions) or
by political barriers (e.g., rural-urban
differences; migration of people).
 Epidemiology
PRC Sample Exam:

URBAN-RURAL VARIATIONS in disease

occurrence can be brought about by which of the
following?
A. difference in the inherent physical
characteristics of the place
B. variation in the exposure factors of the
inhabitants
C. both A and B
D. neither A nor B
 Epidemiology
PRC Sample Exam:

Which among the following choices regarding

PULMONARY TUBERCULOSIS is CORRECT?
A. Prevalence of TB was 2.0 per 1,000 for smear-
positive TB, and 4.7 per 1,000 for culture-
positive TB.
B. The Philippines is the eighth out of the 22
highest TB-burden countries.
C. TB is the 8th leading cause of illness as of
2010.
D. all of the above
Epidemiology
Epidemiology
 Epidemiology
Vector-Borne Food and Water
Diseases Borne Diseases
• Suspect Dengue • Typhoid
• Probable Dengue • Acute Bloody Diarrhea
• Chikungunya • Confirmed Rotavirus
• Confirmed Dengue • Hepatitis A
• Confirmed Cholera

Epidemiology Bureau / PIDSR, 2017 Report

 Epidemiology
Zoonotic Diseases Vaccine Preventable
• Leptospirosis Diseases
• Rabies • Rubella
• Measles
• Pertusis
• Neonatal Tetanus
• Diphtheria

Epidemiology Bureau / PIDSR, 2017 Report

 Epidemiology
Other Diseases Diseases Target
• Influenza-Like Illnesses for Eradication
• Hand-Foot-Mouth Disease • Acute Flaccid
• Hepatitis B Paralysis
• Bacterial Meningitis
• Non-Neonatal Tetanus
• Influenza
• Meningococcal Disease
• Hepatitis C
• Acute Hemorrhagic Fever
Epidemiology Bureau / PIDSR, 2017 Report
 Research Methods
Epidemiologic Research Study Designs
A. Descriptive
1. Case Report / Case Series
2. Ecologic Study / Correlational Study
3. Cross-Sectional Study* / Prevalence Study
 Research Methods
Correlation Pearson’s r
• Ecologic studies Spearman’s rho (ρ)
describe the • 0.00-0.25: little or
magnitude and no relationship
direction of • 0.26-0.50: fair
correlation (i.e., a degree of relationship
change in one
• 0.51-0.75: moderate
variable is noted with
to good relationship
a change in another
variable). • >0.75: good to
excellent relationship
 Research Methods
Scatter Plot
 Research Methods
Epidemiologic Research Study Designs
B. Analytical
1. Observational
a. Cross-Sectional Study*
b. Case-Control Study
c. Cohort Study
– Concurrent (Prospective)
– Non-Concurrent (Retrospective / Trohoc
Study)
 Research Methods
110 Study Designs
Cross-Sectional Study, Analytical

Sample

Risk
Risk
Population factor;
factor;
No
Disease
disease

No risk No risk
factor; factor;
Disease No disease

FIGURE 8.1. I n a cross-sectional study, the

investigator (a) selects a sample from the population
and (b) measures predictor and outcome variables
(e.g., presence or absence of a risk factor and disease).
 Research Methods
Case-Control Study Chapter 8  Designing Cross-sectional and Case–Control Studies 113

THE PAST OR PRESENT THE PRESENT

Sample Larger
with disease population
Risk Risk with disease
factor factor Cases
present absent

Sample Larger
without disease population
Risk Risk without disease
factor factor Controls
present absent

FIGURE 8.2. I n a case–control study, the investigator (a) selects a sample from a population
with the disease (cases), (b) selects a sample from a population at risk that is free of the disease
(controls), and (c) measures predictor variables.
 Research Methods
Case-Control Study and the Odds Ratio (OR)
(+) Disease = (-) Disease =
Cases Controls
(+) Exposure
A B
(-) Exposure
C D
AD
OR = ------
BC
 Research Methods
Interpretation of OR:
• OR = 1: risk factor is not related with disease
• OR > 1: risk factor is positively related with
disease
• OR < 1: risk factor is negatively related with
disease

Conclusion Formulation:
• Among patients with “outcome,” there is …
 Research Methods
98 Study Designs
Cohort Study, Concurrent
THE PRESENT THE FUTURE

Population
Risk factor No
Disease
present disease

Risk factor No
Disease
absent disease

Sample

FIGURE 7.1. I n a prospective cohort study, the investigator (a) selects a sample
from the population (the dotted line signifies its large and undefined size)
(b) measures the predictor variables (in this case whether a dichotomous risk
factor is present [shaded]), and (c) measures the outcome variables during
follow-up (in this case whether a disease occurs [outlined in bold]).
 RETROSPECTIVE COHORT STUDIES
Research
Structure
Methods
Thedesign of aretrospectivecohort study(Fig. 7.2) differsfrom that of aprospective
one in that the assembly of the cohort, baseline measurements, and follow-up have
Cohort Study, Non-Concurrent
THE PAST THE PRESENT

Risk factor No
Disease
present disease
Population
Risk factor No
absent Disease
Sample disease

FIGURE 7.2. I n a retrospective cohort study, the investigator (a) identifies a

cohort that has been assembled in the past, (b) collects data on predictor
variables (measured in the past), and (c) collects data on outcome variables
(measured in the present).
 Research Methods
Cohort Study and the Risk Ratio / Relative
Risk (RR)
(+) Disease (-) Disease
(+) Risk Factor
A B
(-) Risk Factor
C D

A / (A + B)
RR = -----------------
C / (C+ D)
 Research Methods
Interpretation of RR:
• RR = 1: risk factor is not related with disease
• RR > 1: risk factor is positively related with
disease
• RR < 1: risk factor is negatively related with
disease

Conclusion Formulation:
• Among patients with “risk factor”, there is …
 Research Methods
Cross-Sectional Study, Analytical
Interpretation of Prevalence Rate Ratio (PRR)
and Prevalence Odds Ratio (POR):

AD A / (A + B)
POR = ----- PRR = --------------
BC C / (C + D)

• PRR = for acute diseases / non-disease outcomes

• POR = for chronic diseases
 Research Methods
Epidemiology Research Study Designs
B. Analytical
2. Experimental
a. Randomized Clinical (Controlled) Trial
b. Preventive / Vaccine / Field Trial
c. Community Trial
d. Quasi-Experimental (Non-Randomized) Trial
 Time Series Design (Before-After Trial)
 Cross-Over Study Design
 Research Methods
Randomization / Random Allocation
• Randomization is usually used in clinical trials. It
is an important technique for achieving internal
validity in a study because it reduces the
possibility of bias.

Random Sampling
• Random sampling helps to ensure external
validity because it seeks to ensure a
representative sample of people.
 Research Methods
Experimental Study / Trial
 Research Methods
Quasi-Experimental Trial – Time Series
 Research Methods
Quasi-Experimental Trial – Cross-Over Design
 Research Methods
Epidemiology Research Study Designs
C. Other Designs – Pharmacoepidemiology /
Pharmacoeconomics
1. Cost Effectiveness Analysis
2. Cost Benefit Analysis
3. Cost Utilization Study
4. Cost Minimization Study
 Research Methods
Epidemiology Research Study Designs
D. Mixed Methods Design – Qualitative
Study
1. Ethnography
2. Phenomenology
3. Grounded Theory
4. Participatory Action Research
5. Case Study
 Pharmacoeconomics
• Cost Effectiveness Analysis provides a way of
comparing different proposed solutions in terms
of the most appropriate measurement units.
 death / mortality
 disease / morbidity
 costs
 longevity
 disease-free time
 savings
 Pharmacoeconomics
• Cost Effectiveness Analysis involves a more
comprehensive look at drug costs. While cost is
measured in monetary terms, effectiveness is
determined independently and may be
measured in terms of a clinical outcome
such as number of lives saved (i.e., NNT),
complications prevented or diseases cured.
• Cost Effectiveness Analysis thus measures
the incremental cost of achieving an incremental
health benefit expressed as a particular health
outcome that varies according to the indication
for the drug.
 Pharmacoeconomics
• Cost Benefit Analysis measures the costs and
the benefits of a proposed course of action in
terms of the same units, usually monetary units
such as dollars / pesos.
• Incorporating concepts such as the dollar value
of life, suffering, and the quality of life into such
an analysis is difficult. Cost Benefit Analysis
is useful, however, if a particular budgetary
entity (e.g., government or business) is trying to
determine whether the investment of resources
in health would save money in the long run.
 Pharmacoeconomics
• Cost Benefit Analysis is used to value both
incremental costs and outcomes in monetary
terms and therefore allows a direct calculation of
the net monetary cost of achieving a health
outcome. A gain in life-years (survival) may
be regarded as the cost of the productive value
to society of that life-year using, for example,
the average wage.
 Pharmacoeconomics
• The methods for valuing gains in quality of life
include techniques such as willingness to
pay, where the amount that individuals would
be willing to pay for a quality-of-life benefit is
assessed. However, the techniques used to
value health outcomes in monetary terms
remain somewhat controversial, with the result
that Cost Benefit Analysis is so far not widely
used in pharmacoeconomic analyses.
 Pharmacoeconomics
• A subtype of Cost Effectiveness Analysis is Cost
Utility Analysis, which has the outcome of the
cost / quality-adjusted life year, also called the
cost-effectiveness ratio (CER).
• A recent comparison of the CER of various
preventive measures with treatments for existing
conditions found that both preventive and
curative measures span the cost effectiveness
spectrum; both can be cost-saving, favorable, or
unfavorable.
 Pharmacoeconomics
• Cost Utility Analysis expresses the value for
money in terms of a single type of health
outcome. The CER in this case is usually
expressed as the incremental cost to gain an
extra quality-adjusted life-year (QALY).
This approach incorporates both increases in
survival time (extra life-years) and changes
in quality of life (with or without increased
survival) into one measure.
 Pharmacoeconomics
• An increased quality of life is expressed as
a utility value on a scale of 0 (dead) to one
(perfect quality of life). An increased duration
of life of one year (without change in quality of
life), or an increase in quality of life from 0.5 to
0.7 utility units for five years, would both result
in a gain of one QALY. This allows for easy
comparison across different types of
health outcome, but still requires value
judgments to be made about increases in the
quality of life (utility) associated with different
health outcomes.
 Pharmacoeconomics
• The use of incremental cost utility ratios enables
the cost of achieving a health benefit by
treatment with a drug to be assessed
against similar ratios calculated for other
health interventions (e.g., surgery or
screening by mammography). It therefore
provides a broader context in which to make
judgments about the value for money of using a
particular drug.
 Pharmacoeconomics
• Cost Minimization Analysis is a method of
calculating drug costs to project the least
costly drug or therapeutic modality. Cost
minimization also reflects the cost of
preparing and administering a dose. This
method of cost evaluation is the one used most
often in evaluating the cost of a specific drug.
Cost minimization can only be used to compare
two products that have been shown to be
equivalent in dose and therapeutic effect.
 Pharmacoeconomics
• Cost Minimization Analysis is most useful for
comparing generic and therapeutic
equivalents. In many cases, there is no
reliable equivalence between two products and if
therapeutic equivalence cannot be
demonstrated, then Cost Minimization Analysis is
inappropriate.
 Pharmacoepidemiology
DISABILITY ADJUSTED LIFE YEARS (DALY)
and QUALITY ADJUSTED LIFE YEARS (QALY)
are both measurements used in order to weigh the
cost per healthy unit measure.

DALY, in essence, measures health loss in the

quality of life.

On the other hand, QALY measures the same

quality of life in health gain.
 Pharmacoepidemiology
QALY is usually used in measuring the QUALITY
AND QUANTITY OF CARE AND LIFE when
considering OPTIONS FOR HEALTH TREATMENTS
for a particular illness.

In measurements, both DALY and QALY only produce

a single number (either 1 or 0) to express DEATH or
PERFECT HEALTH in the extension of describing the
quality and quantity of health.
 Pharmacoepidemiology
Disability Adjusted Life Years (DALY)
 0: perfect health
 1: death

Quality Adjusted Life Years (QALY)

 0: death
 1: perfect health
 Pharmacoepidemiology
Economic Burden of Illness is the sum of all
costs associated with the condition which would
not otherwise be incurred if the disease did not
exist.
• Direct Costs
 involve monetary exchange (e.g., physician services, medications,
hospital services, rehabilitation / therapy)

• Indirect Costs
 reflect economic value of health state consequences (e.g., work
absenteeism, lost productivity, premature death)

• Intangible Costs
 value of decreased enjoyment of life because of illness
 Pharmacoepidemiology
Direct Medical Costs Direct Non-Medical
 medical consultations Costs
and clinic visits  transportation costs
 drugs and medicine  services of informal
 hospital admissions caregivers
 diagnostics and
ancillary services:
laboratory tests and
imaging studies
 equipment and
medical supplies
 Pharmacoeconomics
PRC Sample Exam:

Which of the following use/s QUALITY-

ADJUSTED LIFE YEAR (QALY) as the unit of
measurement?
A. cost-effectiveness analysis
B. cost-minimization analysis
C. cost-benefit analysis
D. cost-utility analysis
 Research Methods
Other Topics Related to Research:
• Sampling Methods / Techniques
– Non-Probability
– Probability
• Sample Size Estimation
• Ethics in Medical Research
• Bias and Confounders
 Research Methods
PRC Sample Exam:

A SURVEY was conducted on knowledge, attitudes, and

practices related to the risk of acquiring HIV/AIDS
AMONG INJECTING DRUG USERS (IDUs) in Cebu
City. The survey was self-administered and focus
group discussions were also conducted. This describes
what RESEARCH DESIGN?
A. correlational study
B. cross-sectional study
C. case-control study
D. cohort study
 Research Methods
PRC Sample Exam:

To investigate the relationship between history of cigarette

smoking and heart disease, a group of patients admitted to
the hospital WITH MYOCARDIAL INFARCTION were
questioned about their PAST SMOKING HISTORY. A group
of age and sex matched patients admitted to a different clinic
for ANY REASON OTHER THAN HEART DISEASE was also
questioned about their smoking history using an identical
protocol. What TYPE OF STUDY DESIGN should be used?
A. correlational study
B. cross-sectional study
C. case-control study
D. cohort study
 Research Methods
PRC Sample Exam:

In a study conducted in a private hospital, 99 OF

150 PATIENTS WITH BLADDER CANCER had a
positive exposure to aromatic amines, while 70 OF
150 PATIENTS WITHOUT BLADDER CANCER
had positive exposure to aromatic amines.
Compute for the ODDS RATIO.
A. 2.2
B. 2.4
C. 2.6
D. 2.8
 Research Methods
PRC Sample Exam:
Which of the following is an example of a COHORT
STUDY?
A. Men are grouped as to whether or not they have had
radioactive exposure; then their existing medical
records are evaluated for a diagnosis of lung cancer.
B. Women are grouped as to whether or not they have
chronic obstructive lung disease; then they are asked
about their occupational history.
C. Women are given a questionnaire assessing weight and
menstrual symptoms.
D. A group of elderly veterans are followed for adverse
reactions to the flu vaccine.
 Research Methods
PRC Sample Exam:

The following is/are TRUE regarding COHORT

STUDIES:
A. Prospective cohort can lead to high attrition
rate due to a long follow-up period.
B. This study design is used for rare exposure
factors.
C. It is important to ensure that the study
population is disease-free at the time of
selection.
D. all of the above
 Research Methods
PRC Sample Exam:

A researcher wishes to conduct a survey on the knowledge

and attitude on disaster preparedness among nurses in a
selected government hospital. A list of 1,000 NURSES
was provided by the Nursing Service Department. If the
sample size requirement was 200, and the sampling
strategy employed was SYSTEMATIC SAMPLING, what
was the respondent number of the 13th SAMPLE using #3
as the random start?
A. #38
B. #39
C. #58
D. #63
 Disease Outbreak
Investigation
• In 1848, a British
physician, Dr. John
Snow (Father of
Modern Epidemiology)
noted a high
incidence of cholera
in London.
 Disease Outbreak
Investigation
The Bradford Hill Criteria,
otherwise known as Hill's
Criteria for Causation, are a
group of minimal conditions
necessary to provide adequate
evidence of a causal
relationship between an
incidence and a consequence,
established by the Sir Austin
Bradford Hill in 1965.
 Disease Outbreak
Investigation
• Strength of Association
• Specificity of Association
• Biological Gradient (Dose-Response Relationship)
• Consistency of Association
• Temporal Relationship (Temporality)
• (Biologic) Plausibility
• Confirmation by Other Studies*
• Coherence
• Experiment (Reversibility)
• Analogy (Consideration of Alternate Explanations)
 Disease Outbreak
Investigation
PRC Sample Exam:

Studies in medicine are designed to identify causes

of disease. The ultimate goal of such studies is to
alter the frequency or severity of these diseases.
All the following are considerations in the
DETERMINATION OF CAUSALITY, EXCEPT:
A. temporal sequence
B. biological gradient
C. concurrency
D. consistency
 Disease Outbreak
Investigation
Centers for Disease Control and Prevention
(CDC)
1. Prepare for field work.
2. Establish the existence of an outbreak.
3. Verify the diagnosis.
4. Define and identify “cases”.
5. Describe and orient the data, in terms of time,
place, and person.
 Disease Outbreak
Investigation
Centers for Disease Control and Prevention
(CDC)
6. Develop (a) hypothesis / hypotheses.
7. Evaluate the hypothesis / hypotheses.
8. Refine hypotheses and carry out additional
studies.
9. Implement control and prevention measures.
10. Communicate findings.
Disease Outbreak
Investigation
 Disease Outbreak
Investigation
WHO Pandemic
Stages

Level of
Alert

Time
Evidence Based Medicine
• Evidence Based Medicine (EBM) refers to
the judicious use of current best evidence in
making decisions about the care of individual
patients.
• Evidence Based Medicine (EBM) integrates a
medical practitioner’s own clinical experience or
expertise with the results of medical research
into clinical practice.
Evidence Based Medicine
patient

clinical dilemma /
question on management

literature search

appraisal of literature

decision-making / execution of management

Evidence Based Medicine
User’s Guide to Medical Literature
A. Primary Studies
– Prevention or Therapy or Therapeutics
– Diagnosis or Diagnostics
– Harm
– Prognosis
Evidence Based Medicine
User’s Guide to Medical Literature
B. Integrative Studies
– Overview / Systematic Review
– Meta-Analysis
– (Clinical) Practice Guidelines
– Decision Analysis
– Economic Analysis
Evidence Based Medicine
Critical Appraisal of Medical Literature
1. Relevance Question*
2. Validity Guides
3. Results
4. Applicability
5. Resolution of the Clinical Dilemma
Evidence Based Medicine
• P: population • P: population
• E: exposure • I: intervention
• O: outcome • C: comparison*
• M: methodology • O: outcome
• M: methodology
Evidence Based Medicine
Errors and Research Validity
• Errors are likely to be committed during the
planning or conduct of the study and even
in the analysis, thus leading to wrong
interpretation of research results.
• Specifically, systematic errors or biases result
in erroneous estimate of association between
exposure and an outcome.
• Thus, bias can compromise the validity (i.e.,
internal and external) of the study.
Evidence Based Medicine
Internal Validity refers to the soundness of
the methods utilized in the selection of the
study subjects, and the lack of error in
measurement of exposure / outcome and the
association between variables under investigation

External Validity refers to the study’s ability to

extrapolate the inferences and findings from
a sample to the target population. This
highlights the ability of the study to generalize
beyond a set of observations to some
universal statement.
Evidence Based Medicine
• The internal validity of an epidemiological study
can be affected by random error and
systematic error.
• The internal validity is a must for the study to
have external validity.
Evidence Based Medicine
Selection Bias Information Bias
1. Non-Response Bias 1. Misinformation Bias –
2. Incidence-Prevalence Differential and Non-
Bias Differential
3. Loss to Follow-Up / 2. Recall Bias
Drop-Out Bias 3. Interviewer /
4. Berksonian Bias Abstractor Bias
5. Sample Size Bias 4. Observer Bias
5. Prevarication Bias
6. Regression-Dilution
Bias
Evidence Based Medicine
PRC Sample Exam:
This threat to INTERNAL VALIDITY results from the fact that
subjects change during the course of the experiment or even
between measurements. Permanent changes (i.e., physical growth
and aging) and temporary ones (i.e., fatigue) provide "natural"
alternative explanations; thus, they may change the way a subject
would react to the independent variable. So upon completion of the
study, the researcher may not be able to determine if the cause of
the discrepancy is DUE TO TIME or the INDEPENDENT
VARIABLE. This represents what type of BIAS?
A. Maturation Bias
B. Historic Bias
C. Hawthorne Bias
D. Berksonian Bias
Evidence Based Medicine
PRC Sample Exam:

Events outside of the study or between repeated measures of

the dependent variable may affect participants' responses to
experimental procedures. Often, these are LARGE-SCALE
EVENTS (e.g., natural disaster, political change, etc.) that
affect participants' attitudes and behaviors, such that it
becomes impossible to determine whether any change on the
dependent measures is due to the independent variable. This
THREAT TO INTERNAL VALIDITY is referred to as:
A. Maturation Bias
B. Historic Bias
C. Hawthorne Bias
D. Berksonian Bias
Evidence Based Medicine
PRC Sample Exam:

Which of the following statements best describe/s

BERKSONIAN BIAS?
A. Increase admission rates to hospital, leading to a
systematically higher exposure rate among the
hospital cases than the hospital controls.
B. Systematic error due to differences in accuracy or
completeness of recall to memory of past events or
experiences.
C. Systematic difference between how information is
solicited, recorded, or interpreted.
D. both A and B only
Evidence Based Medicine
PRC Sample Exam:
Suppose that investigators are interested in the effect
of oral contraceptive use on the incidence of
myocardial infarction among women of reproductive
age. The investigators decided to allot the SAME
AMOUNT OF INTERVIEW TIME between the cases
and the controls. This minimizes which BIAS?
A. recall bias
B. misclassification bias
C. interviewer bias
D. attrition bias
Evidence Based Medicine
User Guide for Articles on Prevention /
Therapy / Therapeutics:
• P: __________
• I: test drug / test intervention
• C: drug of choice / intervention of choice
• O: __________
• M: clinical trial
comparability of study subjects
randomization versus non-randomization
blinding procedure
attrition rate / lost to follow-up
Evidence Based Medicine
User Guide for Articles on Prevention /
Therapy / Therapeutics:
• Measuring Treatment Effect
 Risk in Control Group (RC)
 Risk in Treatment Group (RT)
 Relative Risk (RR)
 Relative Risk Reduction (RRR)
 Absolute Risk Reduction (ARR)
 Number Needed to Treat / Harm (NNT / NNH)
 Cost Effectiveness (CE)
Evidence Based Medicine
Relative Risk (RR) Relative Risk (RR)
If the outcome of If the outcome of
interest is negative interest is positive
(e.g., death): (e.g., cure):
• RR < 1: treatment is • RR > 1: treatment is
beneficial beneficial
• RR = 1: no • RR = 1: no
significant difference significant difference
• RR > 1: treatment is • RR < 1: treatment is
harmful harmful
Evidence Based Medicine
User Guide for Articles on Diagnosis /
Diagnostics:
• P: __________
• I: new diagnostic test / modality
• C: gold standard in the diagnosis
• O: accuracy of new diagnostic test
• M: cross-sectional study / diagnostic trial
complete spectrum of patients with disease =
representative sample
accuracy versus precision
Evidence Based Medicine
• Sensitivity Screening Tool
• Specificity • high sensitivity
• Positive Predictive • high negative
Value predictive value
• Negative Predictive
Value Confirmatory Tool
• Positive Likelihood • high specificity
Ratio • high positive
• Negative Likelihood predictive value
Ratio
Evidence Based Medicine
Clinical Decision-Making
Line
• Diagnostic Threshold
• Therapeutic Threshold
• Pre-Test Probability
• Post-Test Probability
Evidence Based Medicine
PRC Sample Exam:

A new test for hyperthyroidism is administered to 5,000

people. Out of 900 people who test POSITIVE, 450
truly have diabetes, and out of 500 who truly have
DIABETES, 450 test positive. Which of the following
statement is TRUE about this new test?
A. The sensitivity is 90% and the positive predictive value is
50%.
B. The specificity is 90% and the negative predictive value is
95%.
C. The sensitivity is 95% and the positive predictive value is
50%.
D. The specificity is 95% and the negative predictive value is
99%.
Evidence Based Medicine
PRC Sample Exam:

This describes ability of a study to demonstrate an

association or causal relationship between two
variables, given that an association exists. A high
value for this parameter means that there is LESS
CHANCE OF COMMITTING A TYPE II ERROR.
A. 1 – alpha
B. 1 – beta
C. alpha error
D. beta error
Evidence Based Medicine
PRC Sample Exam:

Using any SCREENING TEST with a given

sensitivity and specificity, the POSITIVE
PREDICTIVE VALUE of the test typically
INCREASES as DISEASE PREVALENCE ____:
A. decreases
B. increases
C. remains the same
D. no specific relationship between the two
 Biostatistics
Descriptive Statistics
• method to summarize and present data in a
form which will make it easier to analyze and
interpret

Inferential Statistics
• method to make generalizations and conclusions
about a target population based on results from
a sample
 Biostatistics
Descriptive Analysis Inferential Analysis
• tables • estimation
• graphs – point estimate
– interval estimate
• summarizing figures
• hypothesis testing
– qualitative – mean
measures – proportion
 frequency
 location
– quantitative
measures
 central tendency
 dispersion
 Biostatistics
Types of Graphs
• pie graph
• bar graph
– vertical bar graph (for quantitative variables)
– horizontal bar graph (for qualitative variables)
– component bar graph
– histogram
• line graph
• frequency polygon
• scatterplot
 Biostatistics
Quantitative Variables Qualitative Variables
• variables can be • categories are simply
measured and ordered used as labels to
according to quantity or distinguish one group
amount, or whose from another and not
values can be expressed for comparison (i.e.,
numerically greater or less)
• discrete (i.e., whole
numbers / integers) or
continuous (i.e.,
fractions / decimals)
Biostatistics
 Biostatistics
NATURE
GRAPH OF PURPOSE
VARIABLE
Histogram or Quantitative - graphic representation of a
Frequency Continuous frequency distribution
Polygon
Bar Graph Qualitative or comparison of absolute or
(Horizontal or Quantitative - Discrete relative counts between
Vertical) categories
Pie Qualitative breakdown of a group or total
where the number of categories
is not too many
Line Graph Time Series shows trend of data or changes
with time
Scatter Plot Quantitative correlate data between two
variables
 Biostatistics
Measures of Frequency

Count absolute number of persons / elements with

the characteristic
Ratio single number representing the relative size of
two numbers
Proportion special type of ratio where the numerator is
part of the denominator
Rate frequency of occurrence of events in a given
interval of time
 Biostatistics
Measures of Location

Percentile one of the 99 values of a variable which

divides the distribution into 100 equal parts

Decile one of the 9 values of a variable which divides

the distribution into 10 equal parts

Quartile one of the 3 values of a variable which divides

the distribution into 4 equal parts
 Biostatistics
Measures of Location

P25 P50 P75

P10 P20 P30 P40 P60 P70 P80 P90

D1 D2 D3 D4 D5 D6 D7 D8 D9

Q1 Q2 Q3
Median
 Biostatistics
Measures of Central Tendency
Ungrouped Data
MEAN • average

MEDIAN • middlemost observation, if “n” is odd

• mean of the two middlemost
observations, if “n” is even
MODE • most frequently occurring value in a
set of observations
 Biostatistics
Patient Weight Mean
Number in kgs.
= average of 10 values
1 7.0
2 17.0
= 14.38 ~ 14.4 kgs
3 12.6
4 15.7
5 17.7
6 16.0
7 16.0
8 11.7
9 17.5
10 12.6
 Biostatistics
Patient Weight Ranking Median
Number in kgs.
= (n + 1) / 2
1 7.0 1
2 17.0 8
= (10 + 1) / 2
3 12.6 4 = 5.5
4 15.7 5
5 17.7 10 Median = mean of
6 16.0 6 values between “5”
7 16.0 7 and “6”
8 11.7 2 = (15.7 + 16.0) / 2
9 17.5 9 = 15.85 ~ 15.9 kgs
10 12.6 3
 Biostatistics
Patient Weight Mode
Number in kgs.
= 12.6 kgs. and 16.0 kgs.
1 7.0
(bimodal distribution)
2 17.0
3 12.6
4 15.7
5 17.7
6 16.0
7 16.0
8 11.7
9 17.5
10 12.6
 Biostatistics
Symmetric Distribution
mean = median = mode
 Biostatistics
Skewed to the Left (Negative Skewness)
mean < median < mode
 Biostatistics
Skewed to the Right (Positive Skewness)
mode < median < mean
 Biostatistics
Measures of Dispersion (for ungrouped data)
• range: highest observation minus lowest
observation
• variance: average of the squared deviations of
the individual observations from the mean
• standard deviation: square root of variance
 Biostatistics
Patient No. Weight in kgs (Xi) X i2
1 7.0 49.00
2 11.7 136.89
3 12.6 158.76
4 15.7 246.69
5 15.9 252.81
6 16.0 256.00
7 16.0 256.00
8 17.0 289.00
9 17.5 306.25
10 17.7 313.29
Total 147.1 2,264.49
 Biostatistics
• Range = 17.7 kgs – 7.0 kgs = 10.7 kgs

2,264.49 – [(147.1)2 / 10]

• Variance = --------------------------------- = 11.18
(10 – 1)

• Standard Deviation = √11.18 = 3.34

Biostatistics
 Biostatistics
PRC Sample Exam:

All of the following statements regarding the

NORMAL (GAUSSIAN) DISTRIBUTION are
TRUE, EXCEPT:
A. About 95% of observations fall within 2 standard deviations
of the mean.
B. Approximately 68% of observations fall within 1 standard
deviation of the mean.
C. The number of observations between 0 and 1 standard
deviation from the mean is the same as the number
between 1 and 2 standard deviations from the mean.
D. The shape of the curve does not depend on the value of the
mean.
Biostatistics
 Biostatistics
PRC Sample Exam:

Which of the following results gives the reader the

most information concerning STATISTICAL
SIGNIFICANCE, SAMPLE SIZE, and
STRENGTH OF ASSOCIATION?
A. a relative risk of 2.5 with a 95% confidence interval
of 2.0 to 3.1
B. a p-value of 0.0004 and an alpha (α) = 0.05
C. a relative risk of 5.0 with a 95% confidence interval
of 0.1 to 9.8
D. a relative risk of 5.0 and a statistical power of 0.70
 Biostatistics
PRC Sample Exam:

The 95% CONFIDENCE INTERVAL for a

sample mean value represents:
A. The range in which the true population mean
most likely to exists.
B. The author’s belief that the presented data
are true.
C. The range in which 95 percent of the sample
values fall.
D. A test for statistical significance of the mean
value.
Public Health
 Public Health
Fertility Rates:
• Crude Birth Rate
• General Fertility Rate

Morbidity Rates:
• Incidence Rate
• Prevalence Rate
• Attack Rate
 Public Health
INCREASED DECREASED
Prevalence Prevalence
• longer duration • shorter duration
• prolongation of life • high case fatality
without cure • decreased incidence
• increased incidence • in-migration of healthy
• in-migration of cases people
• out-migration of healthy • out-migration of cases
people • improved cure rates
• in-migration of
susceptible people
• better diagnosis /
reporting
 Public Health
Mortality Rates:
• Crude Death Rate
• Specific Death Rate
• Cause Specific Death Rate
• Proportionate Mortality Rate
• Case Fatality Rate

• Maternal Mortality Rate

• Maternal Mortality Ratio
• Puerperal Mortality Ratio
 Public Health
Mortality Rates:
• Infant Mortality Rate
• Neonatal Mortality Rate
• Fetal Death Rate
• Fetal Death Ratio
• Perinatal Mortality Rate
 Philippine Health Picture,
1993-2013
PROJECTED CRUDE BIRTH RATE
POPULATION • decreased from 25.1
• increased from to 18.0
66,981,614 to • 28% decrease
98,011,951
• 46% increase CRUDE DEATH RATE
• increased from 4.8 to
MATERNAL 5.4
MORTALITY RATE • 12% increase
• remained at 0.9
• no change
 Philippine Health Picture,
1993-2013
INFANT MORTALITY
RATE
• declined from 20.6 to
12.5
• 39% decrease

FETAL DEATH RATIO

• declined from 5.6 to
4.2
• 25% decrease
 Public Health
PRC Sample Exam:

Which of the following is often used as an indicator

to measure the OVER-ALL HEALTH AND WELL-
BEING OF A NATION?
A. Crude Birth Rate
B. Crude Death Rate
C. Infant Mortality Rate
D. Maternal Mortality Rate
 Public Health
PRC Sample Exam:

The following indices use LIVEBIRTH in the

denominator, EXCEPT:
A. Crude Birth Rate
B. Neonatal Mortality Rate
C. Infant Mortality Rate
D. Maternal Mortality Rate
 Public Health
PRC Sample Exam:

A community with a HIGH SWAROOP UEMURA

INDEX would suggest the following:
A. old population
B. poor economic status
C. poor control of communicable diseases
D. shorter life expectancy
 Public Health
PRC Sample Exam:

The Philippines, as a developing country, exhibits

HIGH BIRTH AND DEATH RATES. The
MEDIAN AGE IS 15-20 YEARS, and
DEPENDENCY RATIO IS 1:1. The Philippines
exhibits this type of POPULATION PYRAMID:
A. beehive-shaped
B. bell-shaped
C. triangular
D. inverted triangle
 Public Health

expanding stationary contracting

less
developed developing developed
countries countries countries
 Public Health
Population

If the population changes (increases or decreases)

by a FIXED AMOUNT PER UNIT TIME (for
example, ten units per year), the quantity is said
to be changing LINEARLY or
ARITHMETICALLY.

If the quantity is increasing, we have GROWTH; if

it is decreasing, we have DECAY.
 Public Health
Population

If a quantity changes (increases or decreases) by a

FIXED FRACTION PER UNIT TIME, (for
example, ten percent per year), the quantity is
said to be changing EXPONENTIALLY or
GEOMETRICALLY.

An example would be a population that increases

(or decreases) by five percent each month.
 Public Health
Population

If a quantity is always increasing (or decreasing),

but the changes do not have the regularity of
either linear or exponential change, the growth (or
decay) is said to be MONOTONIC or
CONTINUOUS.
• Linear growth or decay, and exponential growth
or decay are monotonic.
• Monotonic growth or decay need not be either
linear or exponential.
 Public Health
Natural Growth Rate (Natural Increase)
• NGR = CBR – CDR

Arithmetic Method of Projecting Population

• Pt = P0 + bt
t = projected date (time interval)
b = absolute population increase per year
May 1, 2017 and July 1, 2022
(2022 07 01)
(2017 05 01)
5 years 2 months 0 days
t = 5.17
 Public Health
Geometric Method of Projecting Population
• Pt = P0 (1 + r)t
 r = rate of growth is given (decimal, not %)

Exponential Method of Projecting Population

• Pt = (P0)ert
 The assumption is that the population is
continuously increasing at very small
amounts.
 Public Health
PRC Sample Exam:

The PHILIPPINE POPULATION as of April 2016

is:
A. 101.2 M
B. 104.7 M
C. 102 M
D. 108 M
 Public Health
PRC Sample Exam:

A medical team went to a nearby province where they

randomly selected a SAMPLE OF 1,500 FROM THE
POPULATION OF WOMEN aged 55 and above. Of
the 1,500, 75 were assigned a diagnosis of
RHEUMATOID ARTHRITIS. Choose the
appropriate parameter that should be used.
A. incidence ratio
B. incidence density
C. point prevalence
D. cumulative prevalence
 Public Health
PRC Sample Exam:

What is the RATE OF RHEUMATOID ARTHRITIS

in the sample population?
A. 5.0%
B. 5.1%
C. 6.2%
D. 7.7%
 Public Health
PRC Sample Exam:

What if aside from the 75 NEWLY DIAGNOSED

CASES, the medical team found out that there were
approximately 40 other women who have already
been diagnosed and treated for rheumatoid
arthritis. What then would be the INCIDENCE RATE
of rheumatoid arthritis in the sample population?
A. 5.0%
B. 5.1%
C. 6.2%
D. 7.7%
 Public Health
Standardization of Rates:
• Direct Method
• Indirect Method

Other Indices of Public Health Relevance:

• Disability Adjusted Life Years (DALYs)
• Quality Adjusted Life Years (QALYs)
 Public Health
STANDARDIZED / ADJUSTED RATES are
summary rates for the total population but they
are fictitious rates. Statistical techniques are used
to calculate summary rates for populations
differing in some important characteristics, the
most important of which is age. Thus, adjusted
rates equalize the differences in the population at
risk so that the rates are comparable.
 Public Health
However, adjusted rates are difficult to calculate
because the demographic composition of the
population must be known.

AGE-ADJUSTED RATES are most frequently

used to compare mortality in different populations.
 Public Health
The DIRECT METHOD calculates the rate that
would have been observed if the populations being
compared had the same age distribution.

The INDIRECT METHOD calculates the number

of events that would have been observed in the
two populations being compared had the same
age-specific rates. The indirect method is used
when the age-specific rates are unknown, as in
developing countries or unstable because of small
numbers in the population being studied.
Public Health
Public Health
Public Health
 Primary Health Care
Alma Ata Declaration
• E: (health) education
• L: (control of) local and endemic diseases
• E: expanded program on immunization
• M: maternal health, including reproductive health
• E: (provision for) essential drugs
• N: nutrition and adequate food supply
• T: treatment of common illnesses / injuries
• S: sanitation, including adequate water supply
 Primary Health Care
PRC Sample Exam:

All are program components of the D.O.H.

HEALTHY LIFESTYLE PROGRAM, EXCEPT:
A. tobacco control program
B. lifestyle physical activity program
C. stress management program
D. food fortification program
 Primary Health Care
PRC Sample Exam:

A 36 year old female presented with two-day

history of LOW GRADE FEVER, DYSURIA, and
SUPRAPUBIC PAIN. Initial urinalysis from
another hospital revealed PYURIA OF 40-
60/HPF. What is your initial impression?
A. acute pyelonephritis
B. uncomplicated cystitis
C. asymptomatic bacteriuria
D. acute glomerulonephritis
 Primary Health Care
PRC Sample Exam:

On further investigation, patient complained of

URINARY FREQUENCY, FLANK PAIN, and
GROSS HEMATURIA. What is the most likely
diagnosis?
A. acute pyelonephritis
B. uncomplicated cystitis
C. asymptomatic bacteriuria
D. acute glomerulonephritis
 Primary Health Care
Complicated Urinary Tract Infection
 Primary Health Care
W.H.O. Four Pillars for “Health for All”
1. political and societal commitment and
determination
2. community participation
3. inter-sectoral cooperation
4. systems support
 Primary Health Care
Level of People Participation
• Clinic / Hospital Based
– health TO the people = NO CHANGE
• Community Oriented
– health FOR the people = BEHAVIORAL CHANGE
• Community Based
– health WITH the people = SOCIAL CHANGE
• Community Managed
– health BY the people = STRUCTURAL CHANGE
 Primary Health Care
Ottawa Conference – Five Health Promotion
Action Areas:
1. building healthy public policy
 legislation, taxation, organizational change
2. creating supportive environments
 reciprocal maintenance (communities and
environment)
 work and leisure = source of health
 technology, work, energy production,
urbanization
 Primary Health Care
Ottawa Conference – Five Health Promotion
Action Areas:
3. strengthening community action
 empowerment of communities: ownership
4. developing personal skills
5. re-orienting health services
 clinical and curative services
 health research
 professional education and training
 Primary Health Care
PRC Sample Exam:

In PRIMARY HEALTH CARE, the FOCUS OF

CARE is:
A. the well members of the community
B. the asymptomatic disease carriers
C. the acutely ill individuals
D. the terminally ill patients
UN-MDGs
 UN-MDGs
PRC Sample Exam:

According to United Nations Millennium

Development Goals (UN-MDGs), which is included
in the BIG THREE DISEASES OF GLOBAL
IMPORTANCE?
A. lung cancer
B. pulmonary tuberculosis
C. pneumonia
D. chronic bronchitis
UN-SDGs
 W.H.O. Framework
WHO Building Blocks of Healthcare Systems
Philippine Healthcare
Philippine Healthcare
Kalusugang Pangkalahatan
• The Kalusugan Pangkalahatan (KP) seeks to
ensure equitable access to quality health care by
all Filipinos beginning with those in the lowest
income quintiles.
1. Investing in the people, reducing poverty
and building national competitiveness;
2. Advancing and protecting public health;
3. Building of capacities and creation of
opportunities among the poor; and
4. Increasing social protection.
Kalusugang Pangkalahatan
• The implementation of
Kalusugang
Pangkalahatan /
Universal Health Care
(UHC) shall be directed
towards the achievement
of the health system
goals of financial risk
protection, better
health outcomes, and
responsive health
system.
Kalusugang Pangkalahatan
Financial Risk Protection
• To protect all Filipinos, especially the poor,
against the catastrophic cost of ill health, KP
shall strengthen the National Health
Insurance Program (PhilHealth) as the
prime mover in improving financial risk
protection, generating resources to modernize
and sustain health facilities, and improving the
provision of public health services to achieve the
UN Millennium Development Goals (UN-MDGs).
Kalusugang Pangkalahatan
Responsive Health System
• Kalusugang Pangkalahatan aims to enhance the
responsiveness of the health system and client
satisfaction by improving the quality hospitals
and health care facilities. Government
owned and operated hospitals and health
facilities will be upgraded to expand capacity
and provide quality services to help attain UN-
MDGs, attend to traumatic injuries and other
types of emergencies, and manage non-
communicable diseases and their complications.
Kalusugang Pangkalahatan
Better Health Outcomes
• Kalusugang Pangkalahatan aims for the
attainment of health-related UN-MDGs by
focusing on the reduction of maternal and
child mortality, morbidity and mortality
from TB and malaria, and the prevalence of
HIV/AIDS, in addition to being prepared for
emerging disease trends, and prevention and
control of non-communicable diseases.
Kalusugang Pangkalahatan
PRC Sample Exam:

The three thrusts of the AQUINO HEALTH

AGENDA are as follows, EXCEPT:
A. improve financial risk protection through
improvements in National Health Insurance
Program benefit delivery
B. achieve health related UN-MDGs targets
C. improve quality of education via K-12 program
D. improve access to quality health care facilities
All for Health Towards
Health for All
 All for Health Towards
Health for All
Goals:
• attain health related SDG targets
• financial risk protection
• better health outcomes
• responsiveness
Values:
• equity
• efficiency
• quality
• transparency
 All for Health Towards
Health for All
Guarantee #1:
• all life stages and triple burden of disease
--- services for both the “well” and the “sick”
communicable diseases
non-communicable diseases
diseases of rapid urbanization and
industrialization
 All for Health Towards
Health for All
Guarantee #2:
• service delivery network --- functional
network of health facilities
fully functional: facilities, medicine, health
work force
compliant with clinical practice guidelines
practices gate-keeping
located close to the people
available 24/7 (i.e., disasters)
enhanced by tele-medicine
 All for Health Towards
Health for All
Guarantee #3:
• universal health insurance --- financial
freedom when accessing health services
National Health Insurance Program
(PhilHealth)
 All for Health Towards
Health for All
Communicable Non-Communicable
Diseases: Diseases:
• H.I.V. / A.I.D.S. • cancer / malignant
• (pulmonary) tuberculosis neoplasms
• malaria • diabetes mellitus
• dengue fever • cardiovascular diseases
• ebola (hemorrhagic  obesity
fever)  sedentary lifestyle
• zika  smoking
• infections target for • malnutrition
elimination
• (neglected / emerging
and re-emerging tropical
 All for Health Towards
Health for All
Diseases of Rapid
Urbanization and 59 Programs of the
Industrialization: Department of Health
• mental health
• injuries / accidents
• substance abuse
• pandemics and
travel medicine
• consequences of
climate change
 All for Health Towards
Health for All
Simplify PhilHealth Rules:
• no balance billing for the poor in basic
accommodation
• fixed co-payment for non-basic
accommodation
 All for Health Towards
Health for All
PhilHealth = Main Revenue Source for All
Healthcare Facilities:
• expand benefits to cover comprehensive
range of services with high support value
• contracting networks of providers within
Service Delivery Networks
Gateway to Free or Affordable Care:
• all Filipinos as members
• formal sector premium paid through payroll
and non-formal sector premium paid through
tax subsidy
 All for Health Towards
Health for All
D.O.H. Strategy for 2016-2022:
• A: advance health promotion, primary care, and quality
• C: cover all Filipinos against financial health risk
• H: harness the power of strategic health human resource
• I: invest in e-health and date for decision making
• E: enforce standards, accountability, and transparency
• V: value clients and patients
• E: elicit multi-stakeholder support for health
All for Health Towards
Health for All
All for Health Towards
Health for All
 Health Legislation
• Philippine Medical Act of 1959 (RA 2382)
and Physician’s Act of 2012 (Senate Bill
3137)
• National Health Insurance Program of the
Philippines / PhilHealth (RA 7875)
• Generics Act of the Philippines 1988 (RA
6675) and Universally Accessible Cheaper
and Quality Medicine Act of 2008 (RA 9502)
 Health Legislation
• Responsible Parenthood and Reproductive
Health Act of 2012 (RA 10354)
• Sin Tax Reform Law (RA 10351) and Graphic
Health Warnings Law (RA 10643)
• Comprehensive Dangerous Drugs Act of
2002 (RA 9165) and Compassionate Use of
Medical Cannabis Act (House Bill 4477)
 Health Legislation
PRC Sample Exam:

Which of the following is NOT considered a LEGAL

DEPENDENT of a SENIOR CITIZEN PhilHealth
member?
A. legitimate spouse
B. children who are twenty-one (21) years old or
above but suffering from congenital disability,
or any disability acquired that renders them
totally dependent on the family member for
support
C. foster child
D. none of the above
 Family Medicine
Biopsychosocial Factors and Health =
Family as a Unit of Care
• Biological Factors
• Psychological Factors
• Social Factors
 Family Medicine
Types of Family and Clinical Correlates
• Nuclear Family
• Extended Family
• Blended Family
• Single Parent Family
• Corporate Family
 Family Medicine
Family Assessment
Tools
• Family Genogram
• Family Map
• Family APGAR
• Family SCREEM
• Family Resource
SCREEM
 Family Medicine
Family Life Cycle Orders of Magnitude
1. Unattached Young of Change
Adult • First Order Change:
2. Newly Married a need to DO
Couple something new
3. Family with Young • Second Order
Children Change: a need to BE
4. Family with something new
Adolescents
5. Launching Family  emotional process
6. Later Years of transition
 Family Medicine
Family Illness Trajectory / Impact of Illness
on the Patient and the Family
1. Onset of Illness
2. Impact Phase
3. Major Therapeutic Efforts
4. Recovery
5. Adjustment to Permanency of Outcome*

Primary Care Counseling ---

Mental Health and C.E.A. Method:
• non-verbal communication / active listening skills
 Family Medicine
Sub-Specialties of Family Medicine and
Other Related Fields:
• Hospice Care and Palliative Medicine
• Toxicology
• Geriatrics and Gerontology
• Tropical and Infectious Medicine
• Occupational Medicine
• Non-Urgent Ambulatory (Emergency) Medicine
• Primary Care Diabetology
• Sports Medicine
• Developmental Family Medicine
 Family Medicine
PRC Sample Exam:

Which of the following features characterizes

families in which SPOUSE ABUSE occurs?
A. Husbands of battered women are frequently
substance abusers.
B. Women who were abused as children are more
likely to be abused as adults.
C. Women whose mothers suffered abuse are
unlikely to be abused by their own husbands.
D. Men who batter women are prosecuted in 25%
of cases.
 Family Medicine
PRC Sample Exam:

PARENTS WHO ABUSE THEIR CHILDREN are

correctly characterized by all the following
statements, EXCEPT:
A. They are more likely to be alcoholics than are
non-abusive parents.
B. They are found in all social classes.
C. They are more likely to have been abused as
children than are non-abusive parents.
D. They are more likely to be men than women.
 Hospice Care and
Palliative Medicine
PRC Sample Exam:

This concept refers to CARING FOR

TERMINALLY ILL by allowing patients to have a
GOOD QUALITY OF DEATH by DYING WITH
DIGNITY:
A. physician assisted suicide
B. dysthanasia
C. euthanasia
D. hospice care and palliative medicine
 Geriatrics
PRC Sample Exam:

Which of the following statements regarding FALLS

in “OLDER ELDERLY” PERSONS (i.e., >75 years
of age) is FALSE?
A. Most falls occur outside of the home environment.
B. The risk of falls is directly related to the number
of medications the elderly patient is taking.
C. Alcohol is a contributing risk factor for accidental
falls.
D. Falls often occur in mentally competent elderly
people.
 Geriatrics
PRC Sample Exam:

Nanding is an 80-year old retired college professor

who has a history of ischemic heart disease (post
coronary artery bypass graft) and prostate cancer
with possible bone metastasis. The following
VACCINES are recommended for Nanding, EXCEPT:
A. tetanus, diphtheria, acellular pertusis vaccine
B. conjugate pneumococcal vaccine
C. quadrivalent influenza vaccine
D. varicella vaccine
 Tropical Medicine
PRC Sample Exam:

In evaluating a patient with ACQUIRED IMMUNE

DEFICIENCY SYNDROME (AIDS) for visual
disturbance, you notice PERIVASCULAR
HEMORRHAGES and WHITE FLUFFY
EXUDATES on routine funduscopy. Which of the
following is the MOST LIKELY CAUSE?
A. cytomegalovirus
B. herpes virus
C. Toxoplasma gondii
D. Candida albicans
 Tropical Medicine
PRC Sample Exam:

Most common form of infection of HIV,

particularly in DEVELOPING COUNTRIES:
A. by blood and blood products
B. heterosexual transmission
C. male-to-male sexual transmission
D. by infected mother to infants intrapartum
 Tropical Medicine
PRC Sample Exam:

This is the PRIMARY DETERMINANT of HIV-1

TRANSMISSION:
A. mode of transmission
B. quantity of HIV-1 in the plasma
C. anti-retroviral therapy
D. immunity of the recipient
 Tropical Medicine
PRC Sample Exam:

Which of the following drugs is the first choice for

MALARIA PROPHYLAXIS in an area of the
world in which the Plasmodium is known to be
RESISTANT TO CHLOROQUINE?
A. Doxycycline
B. Mefloquine
C. Pyrimethamine
D. Halofantrine
 Tropical Medicine
PRC Sample Exam:

A young black male exchange student with SICKLE CELL

TRAIT was traveling to the Philippines from North America.
While obtaining his visa, he was told to update his
immunization records. The health inspector also told him that
his chances of getting a certain tropical disease were low.
Sickle cell trait has been shown to convey PROTECTION
AGAINST WHAT TROPICAL DISEASE?
A. pulmonary tuberculosis
B. malaria
C. histoplasmosis
D. Hansen’s disease
Tropical Medicine
 Tropical Medicine
PRC Sample Exam:

A 10 year old male was admitted for FEVER AND SEIZURES.

History revealed he had three-day history of fever with
PRODUCTIVE COUGH, HEADACHE, and YELLOWISH NASAL
DISCHARGE. Few hours PTA, he developed generalized tonic
seizures for 15 minutes followed by loss of consciousness. On
admission, he was febrile with VIOLACEOUS, PURPURIC
RASHES ON THE TRUNK, POSITIVE KERNIGS, HYPERACTIVE
REFLEXES, and with GLASCOW COMA SCALE of 6. The most
probable diagnosis:
A. fungal meningitis
B. meningococcemia
C. dengue encephalitis
D. tuberculous meningitis
 Tropical Medicine
PRC Sample Exam:

What PROPHYLACTIC ANTIBIOTIC may be

given to a PREGNANT MOTHER AFTER
MENINGOCOCCEMIA EXPOSURE?
A. Rifampicin
B. Ciprofloxacin
C. Ceftriaxone
D. Penicillin
 Tropical Medicine
PRC Sample Exam:

Which of the following is/are TRUE regarding

SEVERE ACUTE RESPIRATORY SYNDROME
(SARS) :
A. MERS-CoV belongs to the same genus of virus
as SARS-CoV.
B. No additional cases of SARS have been
reported since 2004.
C. It is caused by coronavirus.
D. all of the above
 Tropical Medicine
PRC Sample Exam:

This drug may be given to out-patients diagnosed

with COMMUNITY-ACQUIRED PNEUMONIA
who are previously healthy and with no antibiotics
use in past three months:
A. Tetracycline
B. Fluoroquinolone
C. Cephalosporin
D. Aminoglycosides
 Tropical Medicine
CAP, Low Risk
 Sports Medicine
PRC Sample Exam:

In helping a patient to recognize moderate

exercise in his individual case, what PULSE RATE
would a 45-year old patient need to achieve to be
reaching at least MODERATE PHYSICAL
ACTIVITY?
A. 100 beats per minute
B. 122 beats per minute
C. 154 beats per minute
D. 175 beats per minute
 Occupational Medicine
Occupational Safety and Health (OSH) /
Occupational Medicine should aim at:
• promotion and maintenance of the highest degree of
physical, mental, and social well-being of workers in
all occupations
• prevention among workers of departures from health
caused by their working conditions
• protection of workers in their employment from risks
resulting from factors adverse to health
• placing and maintenance of workers in an
occupational environment adapted to his physiological
and psychological ability
 Occupational Medicine
OSH Legislation: OSH standards require
1. Labor Code (PD conditions or the adoption
442) of one or more practices,
 O.S.H. Standards means, methods,
operations or processes
2. Sanitation Code (PD
reasonably necessary or
856)
appropriate to provide
safe and healthful
employment in the
workplace.
 Occupational Medicine
Important Principles of Occupational Safety
and Health / Occupational Medicine
• recognition of health hazards
• evaluation of health hazards, including
prioritization of identified problems
• control --- selection of appropriate intervention,
implementation, and monitoring of effectiveness
of interventions
 Occupational Medicine
Occupational Health Physical Agents:
Hazards: 1. Noise
1. physical agents (25%) 2. Vibration
2. chemical agents (34%) 3. Defective Illumination
 threshold limit values 4. Extremes of
(TLVs)
Temperature
 material safety data
sheets (MSDS) 5. Extremes of
3. biological agents (6%) Atmospheric Pressure
4. ergonomics (35%) 6. Radiation
• Ionizing
• Non-Ionizing
 Occupational Medicine
Evaluation and Hierarchy of Categories
Monitoring of Control
1. environmental 1. Elimination
monitoring 2. Substitution
• MSDS, TLV 3. Engineering Control
2. biological monitoring 4. Administrative Control
• body fluids (e.g.,
blood, sputum, urine,
5. Use of Personal
etc.) Protective Devices and
3. medical monitoring Equipment (PPD /
• annual physical
PPE)
examination
 Occupational Medicine
OSH Rule 1960: Occupational Health Services
 Occupational Medicine
PRC Sample Exam:

A man who works in a factory that manufactures

STORAGE BATTERIES consults at the infertility
clinic due to OLIGOSPERMIA. This is most
probably due to chronic exposure to:
A. chromium
B. nickel
C. lead
D. antimony
 Occupational Medicine
PRC Sample Exam:

The following OCCUPATIONAL HAZARDS and

associated MEDICAL DISORDERS are correctly
paired, EXCEPT:
A. paint: urinary bladder CA
B. ultraviolet radiation: cataract
C. mixed solvent: non-Hodgkin’s lymphoma
D. ionizing radiation: sterility
 Occupational Medicine
PRC Sample Exam:
A 45-year old male comes to you with complaints of throbbing pain
over the pulp of right index finger to the last two days. He says
that he has been feeling warm also for three days. On examination,
he has swollen, soft, and tender distal pulp space of the right index
finger with some non-purulent vesicles. TZANCK SMEAR of
VESICLES show MULTINUCLEATED GIANT CELLS. He has
never had any sexually transmitted disease or cold sores in the past.
Which of the following is most likely the occupation of this patient?
A. dentist
B. commercial sex worker
C. gardener
D. cook
 Occupational Medicine
Herpetic Whitlow:
 Toxicology – Drug Abuse
Types of Substance Abuse:
1. Stimulant / “Upper”
2. Depressant / “Downer”
3. Hallucinogen / “Psychedelic”
4. Dissociatives
5. Opioids
6. Inhalant
7. Cannabis
 Environmental Health
Environmental Health
• Water Purification Process
• Food Handling, Storage, Processing
• Housing Sanitation
• Waste Management
• Pollution = Air, Land, Water
• Vector and Vermin Control
 Environmental Health
DENR Administrative Order No. 34, Series of
1990: Water Usage and Classification
Environmental Health
 Environmental Health
PRC Sample Exam:

Which of the following statements about WATER

SANITATION is TRUE?
A. To ensure potability, chlorination of water
removes bacteria present in it.
B. Hardness of water is primarily due to calcium
and magnesium content.
C. Bacteriologic quality examination of water is
done regularly every six months.
D. A and B only
 Environmental Health
PRC Sample Exam:

What is the MINIMUM REQUIRED DISTANCE

between a SEPTIC TANK and DRINKING
WATER SOURCE?
A. 15 meters
B. 20 meters
C. 35 meters
D. 40 meters
 Environmental Health
PRC Sample Exam:

Which is an IMPROVED SANITATION FACILITY?

A. pit latrine without slab
B. flush toilet to an open sewer
C. hanging latrine
D. composting toilet
 Environmental Health
IMPROVED SANITATION FACILITY
• flush or pour-flush to:
 piped sewer system
 septic tank
 pit latrine
• ventilated improved pit latrine
• pit latrine with slab
• composting toilet

NOTE: Only facilities which are not shared or are

not public are considered “improved”.
 Environmental Health
UNIMPROVED SANITATION FACILITY
• flush or pour-flush to elsewhere (i.e., excreta is
flushed to the street, yard or plot, open sewer, a
ditch, a drainage way or other location )
• pit latrine without slab or open pit
• bucket
• hanging toilet or hanging latrine
• no facility or bush or field
 Environmental Health
PRC Sample Exam:

A COMMUNAL FAUCET SYSTEM that is

described as a system composed of a source, a
reservoir, a piped distribution network and stand
posts represents what type of water supply?
A. Level I
B. Level II
C. Level III
D. Level IV
 Environmental Health
Minimum Frequency of Sampling for Drinking-
Water Supply Systems for Microbiological
Examination
 Environmental Health
Minimum Frequency of Sampling for Drinking-
Water Supply Systems for Physical and
Chemical Analysis
 Environmental Health
PRC Sample Exam:

Which VECTOR is IMPROPERLY PAIRED with

its corresponding COMMUNICABLE DISEASE?
A. Culex mosquito and Japanese encephalitis
B. Anopheles mosquito and Zika infection
C. Musca housefly and cholera (Vibrio cholera)
D. Xenopsylla flea and plague (Yersinia pestis)
Epidemiology of Disaster
International Disaster Database:
Center for Research on the Epidemiology of
Disaster
A. Natural
B. Technological
1. Industrial Accident (e.g., chemical spill,
explosion, radiation, fire, gas leak, poisoning,
collapse)
2. Transport Accident
3. Miscellaneous Accident (e.g., fire)
Epidemiology of Disaster
Epidemiology of Disaster
Epidemiology of Disaster
National Disaster Risk
Reduction and
Management
• Philippine Disaster Risk
Reduction and
Management Act (RA
10121): May 27, 2010
• NDDR Framework: June
16, 2011
• Approval of NDDR Plan:
February 7, 2012
Epidemiology of Disaster
Epidemiology of Disaster
Epidemiology of Disaster
 Complimentary and
Alternative Medicine
Traditional and Alternative Medicine Act
(RA 8423)
• Philippine Institute of Traditional and
Alternative Health Care (PITAHC)
 Complimentary and
Alternative Medicine
D.O.H. Scientifically Validated
10 Halamang Gamot:
• primary and secondary indications
 Good Luck!

“Believe in
yourself and
all that you
are. Know
that there is
something