PH, NCD, CD, and Concept of Control and Prevention PDF

PUBLIC HEALTH DEFINED
Public health can be defined as

An approach to health that aims to improve the health of an
entire nation
The way in which the country monitors, analyzes, and draws
conclusions about health concerns
Things that can pose a threat to public health range from
infectious disease outbreaks (e.g., influenza or Ebola viruses), to
chronic illnesses (e.g., heart disease, cancers, or diabetes), to
environmental disasters (e.g., hurricanes, tornadoes, or
earthquakes), to
biologic or chemical terrorism.
PH Department Unnes Lukman Fauzi (c) 2016 2

A Public Health Approach
Risk Factor Intervention

Surveillance Implementation
Identification Evaluation

PUBLIC HEALTH CORE SCIENCE

SOLVING HEALTH PROBLEMS
Step 1 -
Step 1 Step 1 -
Data Surveillance; determine
collection time, place, and person
Step 2 Step 2
Assessment Inference
Solving health
problems
Step 3 Step 3
Hypothesis
Determine how and why
testing
Step 4 Step 4
Action Intervention
Action
EPIDEMIOLOGICAL TRANSITION

Communicable Disease (Emerging and Re-

Emerging Comm Disease)
Non-Communicable Disease
DOUBLE Disease Burden for Developing Country

TRIPLE Disease Burden for Certain Country

Emerging comm diseases are diseases that:

1. have not occurred in humans before
2. have occurred previously but affected only small
numbers of people in isolated places
3. have occurred throughout human history but have only
recently been recognized as distinct diseases due to an
infectious agent
(http://www.ncbi.nlm.nih.gov/books/NBK20370/)

Re-emerging comm diseases are diseases that:

once were major health problems globally or in a particular country
then declined dramatically
but are again becoming health problems for a significant

proportion of the population
(http://www.ncbi.nlm.nih.gov/books/NBK20370/)

GLOBAL MORTALITY DUE TO NCD
(WHO, 2011)
A total of 57 million deaths occurred in the world

during 2008
36 million (63%) were due to NCDs, principally

cardiovascular diseases, diabetes, cancer, and
chronic respiratory diseases
NCD deaths are projected to increase by 15% globally

between 2010 and 2020. The greatest increases will be
in Africa, the Eastern Mediterranean, and South-East
Asia, where they will increase by over 20%
GLOBAL MORTALITY BY SEX

INDONESIAN DISEASE BURDEN

RISK FACTOR
A risk factor is a variable associated with an increased risk

of disease or infection.
Sometimes, determinant is also used, being a variable
associated with either increased or decreased risk.
Risk factors or determinants are correlational and not
necessarily causal, because correlation does not imply
causation.
(Indriani, 2012)

NI HON SUN STUDY
CHD in Japanese Men: Marmot, et al. (1975)

Compared CHD rates among men of
Japanese ancestry living in Japan, Honolulu,
and San Francisco.
Rates lowest in Japan, highest in San
Francisco, intermediate in Honolulu.
Possibly due to variations between the two
countries in terms of diet, occupation, and the
social and cultural milieu.
(Global Health Risk,2009)
RISK TRANSITION

Global Health Risk,2009

GRAND CHALLENGE IN NCD
1. Raise public awareness

2. Enhance economic, legal, and environmental policies
3. Modify risk factors
4. Engage business and community
5. Mitigate health impact of poverty and urbanization
6. Re-orientate health system
http://www.nature.com/nature/journal/v450/n7169/fig_tab/450494a_T1.html

PREVENTION
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"

CONCEPT OF PREVENTION
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.

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

PREVENTABLE CAUSE 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]

THE THREE-CATEGORY CLASSIFICATION
OF PREVENTION: LEAVELL AND CLARK
Leavell and Clark: first authors to develop and gradually
evolve a classification system
In 1953, their Textbook of Preventive Medicine described five
levels of application of preventive medicine:
(a) health promotion
(b) specific protection
(c) early recognition and prompt treatment
(d) disability limitation
(e) rehabilitation.
Later, divided these into 3 levels of prevention

THE THREE-CATEGORY CLASSIFICATION
OF PREVENTION: LEAVELL AND CLARK
Stage of disease Level of prevention Type of response
Pre-disease Primary Prevention Health promotion and

Specific protection
Latent Disease Secondary prevention Early recognition/

diagnosis and prompt
treatment
Symptomatic Disease Tertiary prevention Disability limitation for

early symptomatic disease
Rehabilitation for late
Symptomatic disease
PH Department Unnes 27 Lukman Fauzi (c) 2016

LEVELS OF PREVENTION
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention

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.

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).

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

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

PRIMARY PREVENTION
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.

Primary prevention
Achieved by
Health promotion Specific protection
Immunization and seroprophylaxis

Health education
chemoprophylaxis
Use of specific nutrients or supplementations
Environmental modifications
Protection against occupational hazards
Nutritional interventions Safety of drugs and foods
Life style and behavioral changes Control of environmental hazards,
e.g. air pollution

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
PH Department Unnespotential contacts.
Lukman Fauzi (c) 2016 35
EARLY DIAGNOSIS AND PROMPT 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.

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.

DISABILITY LIMITATION
disease
impairment
disability
handicap

REHABILITITION
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.

Rehabilitation
Medical Vocational Social Psychological

rehabilitation rehabilitation rehabilitation rehabilitation

ALTERNATIVE PROPOSAL OF FROOM AND BENBASSAT:
SUBSTITUTE 7-LEVEL CLASSIFICATION
Level 1, reducing exposure to an etiologic agent

Level 2, increasing resistance to the disease.
Level 3, screening for risk factors for disease (in asymptomatic
individuals) in order to reduce them.
Level 4, prevention of recurrence (in asymptomatic individuals
after a disease-related event)
Level 5, treatment aimed at prevention of complications (in
asymptomatic individuals after a disease-related event)
Level 6, treatment of symptomatic patients for cure, palliation, or
reduction of mortality
Level 7, rehabilitation for adjustment to irremediable
conditions.

A NEW PARADIGM: 5 STAGES OF DISEASE DEVELOPMENT
(Hattis and Law, 2009, unpublished)
The development of diseases (esp. chronic) generally

involves 5 stages, and each lends itself to preventive
interventions:
1. Exposure to agents/causes/risk factors of disease
2. Acquisition of early disease due to exposure
3. Progression of acquired disease from early to
advanced
4. Complications resulting from advanced disease
5. Death or Disability, generally from complications

A NEW PARADIGM: 5 STAGES OF DISEASE DEVELOPMENT
(Hattis and Law, 2009, unpublished)
Stage # Disease Development Prevention of the Respective

Stage
1 Exposure Avoidance of Exposure
2 Acquisition Reduction of Acquisition
3 Advancement/Progression Interruption of Progression
4 Complications Avoidance of Complications
5 Death or Disability a) Preventing (Delaying)
Mortality
b) Rehabilitation of Disability
c) Palliative Care for Inevitable
Death

APPLICATION OF MODEL TO SPESIFIC DISEASE
STAGES TYPE 2 DIABETES HIV/AIDS BREAST CANCER
1 Exposure Avoidance: Healthy eating, limit simple Abstinence from sex (or Avoid known carcinogens
carbohydrates, maintain healthy screening and monogamy of (smoking, drinking ETOH), limit
weight, exercise seronegative partners), no exogenous estrogens, avoid
injection drug use obesity, regular exercise
2 Disease Acquisition Weight loss, consider metformin if Condom promotion and Tamoxifen, raloxifene or
Reduction: insulin resistance/pre-diabetes programs to discourage drug mastectomy as prophylactic
abuse, needle sharing treatment if BRCA gene (genetic
exposure)
3 Interruption or Delay Anti-diabetic drugs, monitor hgb A- Antibody screening, Detection of cancer by exams,
of Disease 1C, FBS, proteinuria, lipids; bariatric monitoring CD4, viral load; mammograms, other imaging;
Advancement: surgery if indicated treatment with antiretrovirals biopsy; surgery; hormone
antagonism or ovarectomy if
estrogen receptor
4 Avoidance or Delay of ACE Inhibitor/ARB to prevent renal Prophylactic treatment for Chemo/radiation therapy,
Disease sequelae, strict glucose control opportunistic infections mastectomy, follow up biannual
Complications: (insulin if necessary), lipid control, mammogram post surgery, PET
foot and eye care scan
5a Delay of Mortality Renal Dialysis, coronary stent or Intensive treatment for severe Full body radiation, bone
from Disease: bypass opportunistic infections marrow transplant
Complications

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.

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

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

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.
CONTROL OF INFECTIOUS DISEASE (THE 4 Cs)
Control
Cases Contacts Carriers Community
Diagnosis
notification standard
strict Epidemiological
isolation observation detection
protective Investigation &
disinfection containment
treatment
follow up
release

INTERACTIVE EXERCISE: WHAT STAGE OF PREVENTION
(OR OF HEALTH PROMOTION)?
Condoms
Needle exchange programs , and syringe/needle purchase
at pharmacies
HIV screening with referral
Antiretroviral drugs for patients with HIV/AIDS (or exposed)
Low-dose aspirin for patients with hypertension or coronary
disease
Coronary care unit after myocardial infarction
Passenger restraints
Immunization
MMR
Rabies, for veterinarians
Joining a gym

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PUBLIC HEALTH DEFINED

Public health can be defined as

PH Department Unnes Lukman Fauzi (c) 2016 2

Risk Factor Intervention

PH Department Unnes Lukman Fauzi (c) 2016 3

PH Department Unnes Lukman Fauzi (c) 2016 4

PH Department Unnes Lukman Fauzi (c) 2016 6

Communicable Disease (Emerging and Re-

DOUBLE Disease Burden for Developing Country

PH Department Unnes Lukman Fauzi (c) 2016 7

Emerging comm diseases are diseases that:

PH Department Unnes Lukman Fauzi (c) 2016 8

Re-emerging comm diseases are diseases that:

then declined dramatically

but are again becoming health problems for a significant

PH Department Unnes Lukman Fauzi (c) 2016 9

A total of 57 million deaths occurred in the world

36 million (63%) were due to NCDs, principally

NCD deaths are projected to increase by 15% globally

PH Department Unnes Lukman Fauzi (c) 2016 12

PH Department Unnes Lukman Fauzi (c) 2016 13

A risk factor is a variable associated with an increased risk

PH Department Unnes Lukman Fauzi (c) 2016 14

CHD in Japanese Men: Marmot, et al. (1975)

PH Department Unnes Lukman Fauzi (c) 2016 19

PH Department Unnes Lukman Fauzi (c) 2016 20

1. Raise public awareness

PH Department Unnes Lukman Fauzi (c) 2016 21

The goals of medicine are to promote health,

These goals are embodied in the word

PH Department Unnes Lukman Fauzi (c) 2016 22

Actions aimed at eradicating, eliminating or

PH Department Unnes Lukman Fauzi (c) 2016 23

Successful prevention depends upon:

PH Department Unnes Lukman Fauzi (c) 2016 24

PH Department Unnes Lukman Fauzi (c) 2016 25

PH Department Unnes Lukman Fauzi (c) 2016 26

Stage of disease Level of prevention Type of response

Pre-disease Primary Prevention Health promotion and

Latent Disease Secondary prevention Early recognition/

Symptomatic Disease Tertiary prevention Disability limitation for

PH Department Unnes 27 Lukman Fauzi (c) 2016

PH Department Unnes Lukman Fauzi (c) 2016 28

Primordial prevention consists of actions and

PH Department Unnes Lukman Fauzi (c) 2016 29

It is the prevention of the emergence or development

For example, many adult health problems (e.g.,

PH Department Unnes Lukman Fauzi (c) 2016 30

In primordial prevention, efforts are directed

The main intervention in primordial

PH Department Unnes Lukman Fauzi (c) 2016 31

Primary prevention can be defined as the action

PH Department Unnes Lukman Fauzi (c) 2016 32

It includes the concept of "positive health", a

PH Department Unnes Lukman Fauzi (c) 2016 33

Health promotion Specific protection

Immunization and seroprophylaxis

PH Department Unnes Lukman Fauzi (c) 2016 34

The specific interventions are: early diagnosis (e.g.

Secondary prevention attempts to arrest the disease

It thus protects others from in the community from

WHO Expert Committee in 1973 defined early

The earlier the disease is diagnosed, and treated the