1. PREVENTION Saudi board family medicine Sunday 18\10\2015
13:00-15:00 pm
Brig.Gen.DR.KHALID ALHARBI
MBBS,DAM,DAMS,DPHC,ABFM,SBFM
CONSULTANT FAMILY MEDICINE

2. The goals of medicine are to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress.
These goals are embodied in the word "prevention"

3. Prevention; Definition and Concept
Actions aimed at eradicating, eliminating or minimizing the impact of disease and disability, or if none of these are feasible, retarding the progress of the disease and disability.
The concept of prevention is best defined in the context of levels, traditionally called primary, secondary and tertiary prevention. A fourth level, called primordial prevention, was later added.

4. Disease Prevention Overview
Prevention is a cornerstone concept in public health
If it cannot be prevented, try to reduce its impact
Often tailored to a specific disease or risk
Prevention may occur at individual or population levels
Prevention as a cornerstone concept in public health.
“If it can be prevented, it should be.”
This concept is applied to disease, injury, and premature death.
It is the central theme of many public health interventions, policies, and laws.
Examples: seatbelt and helmet laws for automobiles and motorcycles; mandatory vaccinations for school children, and safety caps on prescription vials.
Reducing impact of disease and injury
If disease or injury cannot be avoided, disease prevention will focus on reducing its impact on the individual and the community. This is usually done with early diagnosis, treatment, and rehab.
Tailored to a specific disease or risk
A difference between health promotion and disease prevention is this specificity. While general measures to improve health can be used (e.g., better nutrition, exercise, sleep), prevention activities are often tailored to the disease that is being targeted. A prevention program for skin cancer will have very different activities than one designed to reduce injuries from medication errors, yet both are technically disease prevention programs.
May occur at many levels
Interventions or policies may target individuals in an at-risk population or the entire community where the at-risk populations are found. Unlike pharmacy, where we often focus on the individual and their risks, a public health approach could also focus on an entire community, or communities across the nation or world. Text has examples including one about sun exposure and skin cancer risk that may be worth emphasizing. This will also be emphasized in subsequent slides.
Bullet point not on slide: worthwhile distinguishing it from health promotion which is focused on overall improvement in health and not specific disease states.

5. A child riding a bicycle falls because of a pothole.
imagine the following situation :
A child riding a bicycle falls because of a pothole.
Dr. Bandage would treat the child.
Dr. Protective Helmet would tell the child to be more careful and would suggest the child ride his bicycle on safer roads.
Dr. Supportive Environments would instead wonder if potholes cause a significant number of accidents. If so, he would wonder how potholes come about and how to mitigate them.

6. To restore health or to alleviate disease
According to their respective approaches, these doctors have different positions on the following continuums:
To maintain health
Dr. Protective
Helmet
Dr. Supportive
Environments
Individual-centered
Population-based
Dr. Bandage
To restore health or to alleviate disease
and its consequences
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003

7. To restore health or to alleviate disease
One of these continuums relates to the purpose of the approach taken:
To maintain health
For healthy people
For sick people
To restore health or to alleviate disease
and its consequences
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003

8. To restore health or to alleviate disease
Health promotion and disease prevention mainly aim to maintain health.
To maintain health
Health
Promote
Risk
Prevent
Disease
Cure
Chronicity
Treat
To restore health or to alleviate disease
and its consequences
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003

9. The other continuum relates to the health approach’s subject of interest:
The Individual
The Community
Their immediate environment
Their families
Their friends
Etc.
The region
The neighborhood
The age group
The risk group
Etc.
Individual-centered
Population-based
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003

10. As shown in the diagram, health approaches may be individual or population-based. The process used in either case remains similar. Here are a few examples:
APPROACH
PROCESS
Individual-centered
Population-Based
INVESTIGATION AND DIAGNOSIS
Medical history and physical examination
Notifiable disease surveillance
Laboratory examination
Environmental risk assessment
Imaging
Diagnostic tests
Outbreak investigation
Mass screening
Opportunistic screening
Monitoring health status and determinants of health

11. Individual-centered Population-Based
APPROACH
PROCESS
Individual-centered
Population-Based
TREATMENT
FOLLOW-UP
Programs, projects, promotion, prevention and protection activities
Recommendations and prescriptions
Legislation and regulation support
Evidence-based
Evidence-based
Follow-up on investigation and treatment
Program, project and activity evaluation
Ongoing monitoring of the population’s health status
Yearly follow-up
Inspired by Kennedy et al. DSP Saguenay, Lac St-Jean, 2003

12. The difference between these two approaches lies mainly in the unique vision and expertise of each of them. Note that, typically, a clinical physician will have an individual-centered approach while the public health and preventive medicine physician will have a population-based approach.
APPROACH
Individual-centered
Population-Based
SUBJECT OF INTEREST
The patient
The population
Inspired by Kennedy et al. DSP Saguenay, Lac St-Jean, 2003

13. Health promotion and disease prevention can be integrated to each approach. However, disease prevention can be easier to apply and more common in the individual setting. It is at the heart of prevention in clinical practice.

14. Leading Causes of Death
Deaths from infectious diseases have declined markedly in the U.S. in the 20th century. In the 1900’s the leading cause of death was pneumonia, tuberculosis and diarrhea and enteritis. Together with diphtheria these caused one third of all deaths. In 1997, 54.7% of all deaths were attributable to heart disease and cancer, while 4.5% were attributable to pneumonia, influenza, and HIV.
In spite of these success infectious disease is the leading cause of death worldwide. Infectious disease is the third leading cause of death in the U.S. In the U.S. deaths from infectious disease increased from 1980 through 1995.
Source: Ten Public Health Achievements -United States, MMWR 4/2/99/48(12);

15. Death Rate for Infectious Diseases
Public health action to control infectious disease in the 20th century is based on the 19th century discovery of microorganisms as the cause of many serious diseases. Despite overall progress in control of infectious disease the 1918 influenza pandemic resulted in 20 million deaths, including 500,000 in the U.S. in one year, more than have died in any year due to famine or war. HIV infection, first recognized in 1981, has caused a pandemic that is still in progress, affecting 33 million people, and causing 13.9 million deaths. These episodes illustrate the volatility of infectious disease death rates and the unpredictability of emerging infections.
Source: Achievements in Public Health, : Control of Infectious Diseases. MMWR 7/30/99/48(29);

16. Health-to-Death Continuum
Think about various levels of healthiness, sickness, and death
Activities to reduce disease and increase health by where they are initiated on the continuum
INTRO
This is the big picture. Disease prevention, which is the focus of this presentation, will focus on the RIGHT hand side of the continuum. Health promotion, which is covered in a different chapter and presentation, tends to focus on the LEFT side of the continuum. Activities for both tend to overlap in the middle where exposures and lifestyle risks are found.
CONTINUUM
At any given time, a person’s state of health lies somewhere on this continuum. Throughout their lifetime, their health may fluctuate between states of health and states of disease. Most people fall into the moderate health area of the continuum for most of their lives.
Aging does not automatically mean a person will develop disease; however, many diseases do appear as people age. This may be in part to lifestyle choices, exposures over time to harmful chemicals, genetics, or other diseases. Diseases often shorten the lifespan; some may be treated successfully and a person is considered healthy again (e.g., cancer that is in remission).
Death may occur at any time. If a person lives a long life and their death comes in old age that may be considered a natural lifespan. However, deaths that occur earlier than the average lifespan are considered premature. Premature deaths that can be avoided will be one of the targets of prevention activities.
USING CONTINUUM TO IDENTIFY AT-RISK POPULATIONS
In addition to using the continuum to describe how an individual’s health can fluctuate over time, the continuum can be used to identify subsets of the population that are at increased risk of poor health or disease.

17. Relationship between Continuum and Health Promotion & Disease Prevention
Health Promotion – optimize overall health. LEFT side
Disease Prevention – reduce occurrence and impact of specific diseases. RIGHT side
Here’s another view of the continuum that shows the relative locations of health promotion and disease prevention.
In a population, the circles represent different at-risk groups that may be targeted by an intervention. This explicit grouping underscores the idea that we would create interventions for folks who have lifestyle risks like tobacco use differently than we would approach folks who have advanced respiratory illnesses like COPD or emphysema.
GENERAL HEALTH IMPROVEMENT v. SPECIFIC DISEASE PREVENTION
Health Promotion – covered in chap 8.
Recall that the goal of health promotion is to optimize overall health. This may involve some reduction of lifestyle or exposure risks, but should focus mainly on improving health in general (e.g., good nutrition, exercise, sleep)
Because it is a general approach, it will tend to focus on larger populations than the more disease-specific prevention interventions. (There can still be subsets such as health needs by age or gender.)
DISEASE PREVENTION
On the other hand, disease prevention targets more specific populations. This specificity tends to increase as you go towards the RIGHT side of the continuum.
In addition, the interventions tend to vary quite a bit as you target the different populations. This has led to describing prevention activities as three levels of prevention: primary, secondary, and tertiary.

18. Free translation from: D. Lafortune, M
Free translation from: D. Lafortune, M. Kiely; Santé mentale au Québec, 1989; XIV, 1.

19. Determinants of Prevention
Successful prevention depends upon:
a knowledge of causation,
dynamics of transmission,
identification of risk factors and risk groups,
availability of prophylactic or early detection and treatment measures,
an organization for applying these measures to appropriate persons or groups, and
continuous evaluation of and development of procedures applied

20. Preventable Causes of Disease
BEINGS
Biological factors and Behavioral Factors
Environmental factors
Immunologic factors
Nutritional factors
Genetic factors
Services, Social factors, and Spiritual factors
[JF Jekel, Epidemiology, Biostatistics, and Preventive Medicine, 1996]

21. Prevention in clinical practice
combines a set of various types of effective individual interventions offered in a clinical setting, for example:
counseling on lifestyle choices and habits,
screening or identifying cases of certain diseases or risk factors,
immunization,
chemoprophylaxis (prescription of medication for preventive purposes).
MSSS (2008), Programme national de santé publique updated 2008, Québec, 103p.

22. Three Levels of Prevention
Define levels by:
Goal
Rationale
Target population
Typical activities
Outcome measure
Late
Disease
To identify the level(s) of prevention being used by an intervention, there are some characteristics that can be used.
What is the goal of the intervention?
Goals are related to the ultimate outcomes – prevent new cases of disease (morbidity) and premature death (mortality)
What is the implicit rationale of the intervention?
Or – how will interventions at this level ultimately reduce morbidity and mortality?
Rationales will center on avoiding new cases of the disease, reducing the time people with the disease are sick, reducing the severity of illness to increase survival, and returning the ill back to health. All of these will contribute to lower incidence (new cases) and prevalence (all cases) of a disease and its related mortality.
TARGET POPULATION: See figure. As level of prevention progresses from those at risk of exposure to those with late disease, the size of the population tends to get smaller.
TYPICAL ACTIVITIES: These can overlap some, but there do tend to be some distinctive interventions based on level. This makes sense – would you provide education about seasonal flu vaccine to individuals who are currently experiencing influenza or risks of lung disease from tobacco use to people who are dying from lung cancer or chronic lung disease? Looked at another way, you would not take every person who smoked and treat them for lung cancer or a chronic lung disease.
OUTCOME MEASURE:
These outcome measures will trend from reducing the number of new cases (incidence rates) to reducing overall number of cases (prevalence rates) and mortality rates in the populations at risk or with the disease.
Time to look at each level.
Early Disease
Exposed / risk factors
Whole population

23. Leavell’s Levels of Prevention
Stage of disease
Level of prevention
Type of response
Pre-disease
Primary Prevention
Health promotion and
Specific protection
Latent Disease
Secondary prevention
Pre-symptomatic
Diagnosis and treatment
Symptomatic Disease
Tertiary prevention
Disability limitation for
early symptomatic disease
Rehabilitation for late
Symptomatic disease

24. Primordial prevention
Levels of prevention
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention

25. Primordial prevention
Primordial prevention consists of actions and measures that inhibit the emergence of risk factors in the form of environmental, economic, social, and behavioral conditions and cultural patterns of living etc.

26. Primordial prevention (cont.)
It is the prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared
For example, many adult health problems (e.g., obesity, hypertension) have their early origins in childhood, because this is the time when lifestyles are formed (for example, smoking, eating patterns, physical exercise).

27. Primordial prevention (cont.)
In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles
The main intervention in primordial prevention is through individual and mass education

28. Primary prevention
Primary prevention can be defined as the action taken prior to the onset of disease, which removes the possibility that the disease will ever occur.
It signifies intervention in the pre-pathogenesis phase of a disease or health problem.
Primary prevention may be accomplished by measures of “Health promotion” and “specific protection”

29. Primary prevention (cont.)
It includes the concept of "positive health", a concept that encourages achievement and maintenance of "an acceptable level of health that will enable every individual to lead a socially and economically productive life".
Primary prevention may be accomplished by measures designed to promote general health and well-being, and quality of life of people or by specific protective measures.

30. Primary prevention Specific protection Health promotion Achieved by
Health education
Environmental modifications
Nutritional interventions
Life style and behavioral changes
Immunization and seroprophylaxis
chemoprophylaxis
Use of specific nutrients or supplementations
Protection against occupational hazards
Safety of drugs and foods
Control of environmental hazards,
e.g. air pollution

31. Health promotion
Health promotion is “ the process of enabling people to increase control over the determinants of health and thereby improve their health”.

32. Approaches for Primary Prevention
The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established:
a. Population (mass) strategy
b. High -risk strategy

33. Population (mass) strategy
“Population strategy" is directed at the whole population irrespective of individual risk levels.
For example, studies have shown that even a small reduction in the average blood pressure or serum cholesterol of a population would produce a large reduction in the incidence of cardiovascular disease
The population approach is directed towards socio-economic, behavioral and lifestyle changes

34. High -risk strategy
The high -risk strategy aims to bring preventive care to individuals at special risk.
This requires detection of individuals at high risk by the optimum use of clinical methods.

35. Primary Prevention Goal: Rationale: Target population:
Reduce number of new cases
Rationale:
By reducing exposure rates and increasing resistance, can reduce number of new cases
Target population:
Those who are most likely to be exposed and/or could increase their resistance
Typical activities:
Remove or reduce source of the risk
Educate and make aware of disease risk
Include behavioral changes to reduce exposure
Improve general health
Outcome measure: incidence of exposure; incidence of disease
Of the three levels, the target population that will be the focus of primary prevention will be relatively larger than the populations in other levels. Note that many of these activities will overlap with health promotion activities.
GOAL: Preventing new cases of a disease (reducing incidence of disease) is the ultimate goal of primary prevention.
RATIONALE: Reducing exposure risk will reduce incidence of disease.
This may involve removing the exposure risk so it is not encountered. EXAMPLE: Chlorinating the city water supply to reduce the number of enteric pathogens present in the drinking water; spraying for mosquitoes to reduce risk of exposure to malarial plasmodia; using netting over bed to reduce nocturnal mosquito bites.
May involve removing population so it is not in contact with risk. EXAMPLE: Forbidding public access to sewage treatment water and area; restricting travel to areas where malaria is endemic.
OTHER PART OF RATIONALE: Increasing resistance to disease if exposed will also reduce incidence of disease
If exposure risk cannot be entirely eliminated, may seek ways to strengthen natural defenses. EXAMPLE: Vaccination to promote the development of antibodies so body can prevent the development of disease if it is exposed.
TARGET POPULATION: This will change depending on disease.
TYPICAL ACTIVITIES: Keeping the two rationales in mind, activities will focus on efforts to remove or reduce source of risk as well as prepare the target population to avoid and resist its effects.
Remove source of risk – for malaria, which is transmitted via a mosquito vector, this may include draining standing water where mosquitoes may breed.
Educate about risk/change behaviors – provide exposure risk information along with tips for how to reduce exposures. Netting for bedding, staying indoors during morning and evening hours when mosquitoes are most active, and using a DEET mosquito repellant when outdoors. Other general tips for contagious diseases include handwashing and keeping hands away from eyes or mouth.
Improve general health – this is where disease prevention and health promotion overlap. In general, a healthier person is better able to mount an immune response and avoid disease. Should the person become exposed and sick, they will often have a better chance of recovering.
OUTCOME MEASURE:
Number of exposures to a causative agent or risk factor
Final outcome would be number of new cases of disease (incidence)
Be sure students understand what incidence (incidence rate) means.
Incidence = the number of new cases in a given time period
Incidence rate = ratio of new cases to total population at risk for a given period of time. Allows comparison of incidence to other diseases or other populations.

36. Secondary prevention
It is defined as “ action which halts the progress of a disease at its incipient stage and prevents complications.”
The specific interventions are: early diagnosis (e.g. screening tests, and case finding programs….) and adequate treatment.
Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.
It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

37. Secondary prevention (cont.)
Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.
It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

38. Early diagnosis and treatment
WHO Expert Committee in 1973 defined early detection of health disorders as “ the detection of disturbances of homoeostatic and compensatory mechanism while biochemical, morphological and functional changes are still reversible.”
The earlier the disease is diagnosed, and treated the better it is for prognosis of the case and in the prevention of the occurrence of other secondary cases.

39. Secondary Prevention Goal: Rationale: Target population:
Reduce number of new cases; reduce number of severe cases
Rationale:
By reducing number of exposures and early disease that progress to more severe disease, mortality and morbidity can be reduced
Target population:
Those who have been exposed to the disease-causing agent or have early symptoms of the disease
Typical activities:
Screening for exposure and/or disease
Post-exposure prophylaxis
Early treatment to reduce impact of disease/reverse course
Outcome measure: incidence of disease
GOAL: Reducing the severity of a disease (reducing morbidity) and new cases (incidence) are the ultimate goals of secondary prevention. This may apply to the individual case (reduce severity of symptoms or duration of illness) and the community (reduce severity of outbreak – or said another way – reduce the spread of the disease and shorten the length of time the outbreak exists).
RATIONALE: Early detection of a disease-causing exposure or identifying a disease in its early stages can lead to early treatment to either stop the progression of the disease or reduce its severity which will reduce complications. Identifying those who are sick can also aid in reducing the spread of the disease to others in the community.
EXAMPLE: Detecting exposure to lead through blood tests can lead to the removal of the lead source. Screening interviews can be used to identify who has been in close contact with a person diagnosed with an infectious disease and the timely use of post-exposure prophylaxis to “nip” the possible infection in the bud. For chronic diseases like diabetes, early detection via A1c levels can lead to earlier control of blood sugar and a reduction in both short and long term complications of the disease.
TARGET POPULATION: This now becomes the individuals who were in the “risk of exposure” or “risk of disease” group who have been exposed or have early disease. So it is a subset of the primary prevention population for that specific disease.
TYPICAL ACTIVITIES: Like primary prevention, secondary prevention has two key types of activities that help you identify it. SCREENING to detect exposure or early disease is one; the other is EARLY TREATMENT to either prevent or reverse the disease process entirely or reduce the severity of the illness. Another type of early interventions at the population level would be quarantining those who have been exposed so they are not in contact with others; for those with early symptoms of the illness, isolation would be used to minimize contact with healthy folks.
EXAMPLES:
For exposure to a toxic chemical, secondary prevention would use decontamination to remove exposure before it caused harm and/or an antidote to counteract the effects of the toxin. An exposure to an organophosphate pesticide would be treated in both of these ways. If decontamination and the administration of atropine did not completely counteract the effects of the poisoning, then the severity would probably be reduced. At the population level, interventions may involve preventing people from entering a contaminated area and offering methods for removing contaminants.
For an infectious disease like Varicella (chickenpox), screening interviews can be used to determine if a person has likely been exposed. Questions like did they share a drinking glass or kiss? Were they close together for four or more hours? Did they care for someone who had chickenpox, or did they already have immunity to chickenpox through a vaccine or prior illness can be used to identify good candidates for vaccination? Another group would be those who are just beginning to show symptoms – they may be a good candidate for early treatment with an antiviral. At the population level, would encourage sick folks to stay home (self-imposed isolation) and their caregivers to seek vaccination if not already immune.
OUTCOME MEASURE:
Number of cases of disease (compare to number of exposures in primary level)
Be sure students understand what incidence (incidence rate) means.
Incidence = the number of new cases in a given time period
Incidence rate = ratio of new cases to total population at risk for a given period of time. Allows comparison of incidence to other diseases or other populations.

40. Tertiary prevention
It is used when the disease process has advanced beyond its early stages.
It is defined as “all the measures available to reduce or limit impairments and disabilities, and to promote the patients’ adjustment to irremediable conditions.”
Intervention that should be accomplished in the stage of tertiary prevention are disability limitation, and rehabilitation.

41. Tertiary Prevention Goal: Rationale: Target population:
Reduce number of complications, deaths
Rationale:
By reducing disease severity and increasing recovery, can reduce number of premature deaths or complications
Target population:
Those who have disease and need treatment
Typical activities:
Treatment tailored to the patient
Rehabilitation to promote recovery
Outcome measure: incidence of death and long-term disability
GOAL: Reducing the risk of disease-related premature mortality or long-term morbidity and increasing likelihood of returning to a state of health.
RATIONALE: Once disease occurs, need to work to cure patient and avoid long-term illness or complications. Doing so will reduce mortality and morbidity rates and reduce prevalence rates.
EXAMPLE: Lead poisoning that has resulted in symptoms now requires treatment to address lead toxicity illness and end organ complications. For chronic diseases like diabetes, tertiary prevention will focus on controlling the disease so premature death and complications are avoided. For an infectious disease, the tertiary levels of prevention will use antibiotics or anti-microorganism (viral, protozoan, fungal, etc) medications if available to directly treat infection causing disease and supportive care to allow the disease to run its course while reducing risks of complications created by the infective agent or its by-products (e.g., shock due to toxins released during a gram negative infection).
TARGET POPULATION: This now becomes the individuals who develop the illness. It is a subset of the population identified for secondary prevention.
TYPICAL ACTIVITIES: For individuals, these activities are best described as clinical or THERAPEUTIC interventions – something that should be/will be very familiar to pharmacy students. In addition to treatment, there are REHABILITATION activities that are used for individuals who have permanent or long-term disabilities due to the disease. The goal of rehabilitation is to resume as normal a lifestyle as the person had prior to the disease. At the population level, tertiary activities may include ensuring individuals has access to care sites or professionals, research to find more effective treatments, and support groups for recovering individuals.
EXAMPLES:
Using the toxic exposure example, tertiary prevention would concentrate on supportive care if antidotes were not available or not effective. If the exposure were a venomous snake bite that was not promptly treated with anti-venom, it is possible that the injured person may have surgical intervention to reduce pressure building up in the muscle bundles (fasciitis) or even amputation if damage to a limb is too extensive. Post surgical rehabilitation would be used to help the person resume many of their usual activities. At the population level, ensuring access to anti-venom may be important – because it is so expensive, hospitals
For an infectious disease like varicella (chickenpox), the goal of tertiary prevention will be recovery from the immediate infection without the development of complications. One long-term complication of a varicella infection called shingles would best be addressed through primary prevent efforts involving vaccination of older adults who are at risk of shingles. If this is confusing, consider the development of shingles as a separate disease from chicken pox and it may be easier to think about primary prevention.
OUTCOME MEASURE:
Prevalence rates for disease (cures should lower it)
Mortality rates
Morbidity rates

42. Levels of Prevention Table
Table 9.1 from textbook – Students may want to review it for trends.
The Table shows relative information for the three levels of prevention.
The previous slides covered the PRIMARY - TERTIARY columns.
TRENDS:
As you read across a row from Primary to Tertiary:
Population size: large to small;
Goal: avoiding disease to avoiding death
Rationale: avoiding exposure to minimizing impact of disease
Interventions: proactive and general to reactive and specific (population level to patient level)
Evaluation: reduced exposures to reduced deaths
Terms:
Morbidity = long-term disease or disability
Mortality=death
Prevalence=total number of cases of a disease in a population at a given point in time or during a specific period of time. When compared to the total population, it becomes a rate.

43. Example Infectious Disease
Disease: Seasonal influenza
Primary prevention:
target population – everyone; all ages
Goal – reduce number of cases of flu
Rationale – reduce exposures; bolster immune system
Actions
Education: cough and sneeze etiquette, hand washing, know risk groups
Immunization: vaccination to develop antibodies
Interventions at the individual level:
vaccinate; good nutrition, sleep, and exercise to optimize health; good cough/sneeze etiquette; frequent hand washing; avoid others who are sick
Interventions at the community/population level:
Provide access to vaccines
Use Public Service Announcements (PSAs) to educate public
Prepare plans for schools, worksites, and hospitals/clinics for outbreak
Another way to use this slide would be to save the headings and have the students suggest who the target population, goal, etc. are.
The last bullet presents population-level interventions that should be emphasized to help students focus on activities that may occur outside the pharmacy.

44. Example: Infectious Disease
Disease: Seasonal influenza
Secondary prevention:
target population – everyone who has been exposed to the virus
Goal – reduce number and severity of cases of flu
Rationale – early treatment to reduce severity of disease
Actions
Screening: identify those who are most likely exposed from those who are not
Early treatment
Immunization: vaccination to develop antibodies
Interventions at the individual level:
Post flu symptoms and suggestions for self-care
Provide antiviral within 48 hours of symptom onset
Interventions at the community/population level:
Use quarantine or isolation measures; ban gatherings of large groups; travel restrictions
Send sick children home from school; enforce sick leave at work
For seasonal influenza there are not really any post-exposure prophylaxes available, but early treatment of symptoms with an antiviral drug could reduce length of illness and severity of illness.
See if students know the symptoms of influenza (compare with cold symptoms). CDC website has a handy comparison chart that may be worth showing.
Population-level activities will be focused on containing and controlling the spread of the disease among the residents of the community. These measures do not affect risk of disease in people already exposed or ill; they protect those who have not yet been exposed.
Students should distinguish between quarantine (restrict movement of people who have been EXPOSED to an infectious agent) and isolation (restrict movement of people who have the INFECTION).
Other approaches designed to reduce spread are banning large gatherings especially in enclosed spaces such as schools, theaters, and churches.

45. Example: Infectious Disease
Disease: Seasonal influenza
Tertiary prevention:
target population – everyone who has influenza
Goal – reduce number and severity of flu-related complications and deaths
Rationale treatment and rehabilitation can reduce deaths and help return individual to a normal lifestyle
Actions
Provide supportive care and early treatment of complications
Use rehabilitation to increase recovery of normal lifestyle
Interventions at the individual level:
Tailor treatment to symptoms; monitor and treat complications
Interventions at the community/population level:
Ensure access to treatment (health insurance, local clinics available)
Protect employees who are out sick from losing jobs
Research to find better treatments; monitor resistance patterns
For this level of prevention, the individual interventions should remind the students of clinical practice.
As with the previous slides, it may be good to focus on the population level interventions.
Students may not realize that a majority of the un- and under- insured adults in the U.S. are employed. They often work for a small business or in a minimum wage position that either do not offer or the employee cannot afford insurance. A population intervention may involve using community health centers that treat all patients and adjust charges using a sliding fee scale that is based on income.
Many of the minimum wage jobs also do not have sick leave for employees, so staying home sick usually means loss of income, but may also mean unemployment. Population interventions may be in the form of employee protection laws.
Research to monitor resistance patterns or find new methods for treating influenza would be another example of population tertiary prevention.

46. Factors related to the patient
Many factors can influence the application of preventive clinical practices!
Factors related to the patient
Fear, expectations, beliefs, ability to ask, comments from loved ones
Factors related to the physician
Beliefs, personal lifestyle, expertise, training, support from colleagues
Factors related to the preventive clinical practice
Effectiveness, safety, discomfort 1 2 3

47. Disability limitation
disease
impairment
disability
handicap

48. Impairment
Impairment is “any loss or abnormality of psychological, physiological or anatomical structure or function.”

49. Disability
Disability is “any restriction or lack of ability to perform an activity in the manner or within the range considered normal for the human being.”

50. Handicap
Handicap is termed as “a disadvantage for a given individual, resulting from an impairment or disability, that limits or prevents the fulfillment of a role in the community that is normal (depending on age, sex, and social and cultural factors) for that individual.”

51. Rehabilitation
Rehabilitation is “ the combined and coordinated use of medical, social, educational, and vocational measures for training and retraining the individual to the highest possible level of functional ability.”

52. Rehabilitation
Medical
rehabilitation
Vocational
Social
Psychological

53. Epidemiology Division
Strategy for Prevention
Identify A
Populations s
at High s
Modify Existing e
Disease Risk s
Intervention s
(based on demography /
family history,
host factors..)
Programs m e n n o t i t n
Assess e v
Evaluate
Exposure r e
Intervention t n
Programs I
Conduct
Research on
Mechanisms
Apply
(including the study of
genetic susceptibility)
Population-Based
Intervention
Programs
Epidemiology Division

54. Control Concept of control:
The term disease control describes ongoing operations aimed at reducing:
The incidence of disease
The duration of disease and consequently the risk of transmission
The effects of infection, including both the physical and psychosocial complications
The financial burden to the community.

55. Control activities focus on primary prevention or secondary prevention, but most programs combine both.
control
elimination
eradication

56. Disease Elimination
Between control and eradication, an intermediate goal has been described, called "regional elimination"
The term "elimination" is used to describe interruption of transmission of disease, as for example, elimination of measles, polio and diphtheria from large geographic regions or areas
Regional elimination is now seen as an important precursor of eradication

57. Disease Eradication
Eradication literally means to "tear out by roots".
It is the process of “Termination of all transmission of infection by extermination of the infectious agent through surveillance and containment”.
Eradication is an absolute process, an "all or none" phenomenon, restricted to termination of an infection from the whole world. It implies that disease will no longer occur in a population.
To-date, only one disease has been eradicated, that is smallpox.

58. Monitoring
Monitoring is "the performance and analysis of routine measurements aimed at detecting changes in the environment or health status of population" (Thus we have monitoring of air pollution, water quality, growth and nutritional status, etc).
It also refers to on -going measurement of performance of a health service or a health professional, or of the extent to which patients comply with or adhere to advice from health professionals.

59. Surveillance
surveillance means to watch over with great attention, authority and often with suspicion
According to another, surveillance is defined as "the continuous scrutiny (inspection) of the factors that determine the occurrence and distribution of disease and other conditions of ill-health"

60. Objectives of Surveillance
The main objectives of surveillance are:
(a) to provide information about new and changing trends in the health status of a population, e.g., morbidity, mortality, nutritional status or other indicators and environmental hazards, health practices and other factors that may affect health
(b) to provide feed-back which may be expected to modify the policy and the system itself and lead to redefinition of objectives, and
(c) provide timely warning of public health disasters so that interventions can be mobilized.

61. Control of infectious diseases (the 4 “C”s
Cases
Contacts
Carriers
Community
Diagnosis
notification
isolation
disinfection
treatment
follow up
release
observation
detection
Epidemiological
Investigation &
containment
standard
strict
protective

62. Evaluation of control
Evaluation is the process by which results are compared with the intended objectives, or more simply the assessment of how well a program is performing.
Evaluation should always be considered during the planning and implementation stages of a program or activity.
Evaluation may be crucial in identifying the health benefits derived (impact on morbidity, mortality, sequelae, patient satisfaction).
Evaluation can be useful inidentifying performance difficulties.
Evaluation studies may also be carried out to generate information for other purposes, e.g., to attract attention to a problem, extension of control activities, training and patient management, etc.

63. The concepts of health promotion and disease prevention overlap a lot, although they are distinct. They can both be applied to the individual-centered approach and the population-based approach to health, although disease prevention is more common than health promotion in the individual clinical setting. Although the individual-centered approach and the population-based approach involve a similar thought process for health professionals, they are distinguishable from one another by the vision and expertise that they require. Clinicians typically use the individual-centered approach for which the subject of interest in the patients. On the other hand, public health and preventive medicine physicians usually use the population-based approach in their practice. They are interested in populations.

64. Illustrating the concepts of disease prevention and health promotion
Prevention in clinical practice must be adapted to patients’ needs. There are many of these practices (counseling, screening, immunization, chemoprophylaxis, etc.) and they are effective. Expert groups such as the Canadian Task Force on Preventive Health Care (CTFPHC) publish guidelines and grade their effectiveness provide recommendations for clinicians. There are different levels of disease prevention, defined as follows:
Primary prevention
Improving resistance and decreasing risk factors
Secondary prevention
Early detection of disease at a stage when the disease is easily curable.
Tertiary prevetion
Reducing complications, chronic disability and premature mortality

65. Illustrating the concepts of disease prevention and health promotion
It is important to always keep in mind that many factors influence the population’s health positively or negatively. These factors are the determinants of health. The can be divided as such:
Individual characteristics
Individual behavior
Physical environment
Socio-economic environment
Health care services
Free translation from: Éric Litvak et al., Guide de planification populationnelle, 2005

66. Illustrating the concepts of disease prevention and health promotion
With regards to health promotion, the Ottawa Charter is a well recognized tool. The charter presents 5 major strategies in health promotion:
Developing personal skills
Creating supportive environments
Building healthy public policy
Strengthening community action
Re-orienting health services

67. Explaining the public health and preventive medicine physician’s role in disease prevention and health promotion
The public health and preventive medicine physicians are interested in disease prevention as well as health protection and promotion at the individual and population levels. As previously mentioned, their practice focuses mostly on populations. They mainly address the determinants of health. They often work in an interdisciplinary setting. The analysis of needs, the investigation of health problems, the development and implementation of solutions to address them are amongst their tasks. These physicians can offer support to clinicians interested in integrating preventive measures to their professional practice.

68. Identifying strategies to apply disease prevention and health promotion to your future clinical practice.
Many factors related to patients, physicians and to preventive clinical practices influence the application of the concept of prevention in clinicians’ professional practice. However, various strategies, of documented effectiveness, enable us to optimize the application of such concepts. These strategies’ effectiveness is optimal when they are combined and when they include the organization of the clinic. In a population setting, the control of risk factors, immunization and screening are amongst the effective prevention strategies.

69. Identifying strategies to apply disease prevention and health promotion to your future clinical practice.
At the population level, the Ottawa Charter’s five strategies for health promotion can be adapted to the health professionals’ practice setting. Communication campaigns, development of bicycle paths, anti-tobacco laws, inter-sectorial action and support for prevention in clinical practice are amongst the many examples of such strategies.

70. To summarize
The goals of medicine are to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress.
These goals are embodied in the word "prevention"
Successful prevention depends upon a knowledge of causation, dynamics of transmission, identification of risk factors and risk groups, availability of prophylactic or early detection and treatment measures, an organization for applying these measures to appropriate persons or groups, and continuous evaluation of and development of procedures applied
The objective of preventive medicine is to intercept or oppose the "cause" and thereby the disease process. This epidemiological concept permits the inclusion of treatment as one of the modes of intervention