Presented

by

DR. Nihal salah Shihab

Professor in
Public Health
and Preventive Medicine
 What is the Preventive Medicine ?
In any Health C.S, Prevention is better
than treatment.

Prevention

1ry 2nd 3rd

prevention prevention prevention
 What will you learn in this course of
public health this month?
Linear Urban health Occupational medicine
Vaccination Nutrition + Pollution
EPI center, Chest
MCH, Child
hospital, health
care
inspectors

Samples, tables, sequence,

on Port Stephens Council Website: http://portstephens.local-e.nsw.gov.au/community/35624/35630.html statistics, study designs
Rural health, units

Communication
Co-producingwiththeDivisions
Primary health care ( PHC )

 Definition:
 It is the essential health care based on
practical, scientifically sound and socially
acceptable methods and technology.
 It is universally accessible to all the
community,
 It is at a cost that the community and the
country can afford .
 Levels of the health services in any
health care system

1. Primary health services

(PHC): in which many health
problems can be diagnosed and
treated by the general practitioner
doctor in the primary health care
unit. More sophisticated or
complicated health problems are
referred to the 2ry or 3ry care.
2nd level

 2. Secondary health services : these

services applied for the referred cases
from the PHC service. They need
procedures for diagnosis and treatment
beyond the scope of primary
practitioner. The health providers need
some degree of specialization. It is
provided in hospitals, and it is costly.
3rd level

 3. Tertiary health services: It

requires a high degree of skills and
advanced technology. It is provided in
large hospitals which posses
complex surgical operations and
complex diagnostic procedures such as
computerized tomographic scanning. It
is costly and consume a high % of the
national health expenditure.
Developed & non-developed countries
Health expenditure

 3rd 3rd


 2nd 2nd

1ry
1ry
 1ry
Significance of primary health care
(P.H.C):

1.) It’s the first contact between Patient & System.

2.) It’s the base on which 2nd and 3rd health care
are built.
3.) It’s the key to achieving acceptable level of
health throughout the world.
4.) The health status of the community depends
mainly on the availability of good PHC than on
advanced technical resources of modern
hospitals.
5.) Its cheap .
Objectives of P.H.C:

 1. Health promotion of the community.

 2. prevention and control of health hazards,
illnesses and accidents in the community.
 3. Early detection and prompt treatment of
health hazards.(Example----)
 4. Rehabilitation and disability limitation.[ex.
In geriatric programs, + occupational
program]
Elements:

1. Promotive and preventive:

 Promotion of food supply and proper nutrition.

 Health education.
 Immunization of children against major communicable
diseases.
 Monitoring of sanitary environment including safe water supply
and sewage & waste disposal.
 Prevention (1ry, 2ry, and 3ry prevention ) of locally
endemic diseases.
 Improving the quality of life in the local community.
2. Curative elements:

 Appropriate treatment of common diseases

and injuries.
 Provision of some essential drugs .
Principles of PHC :[by the MOH]

1. It should be:-
 accessible to all.
 acceptable by the people.
 comprehensive [ preventive and curative
services].
2. It should involve all the community through
arousing the people interest in their health
needs, (community participation).
Continue principles

3. It should involve health related sectors e.g.

agriculture (surrouding environment),
education, municipality, social affairs. This is
to achieve coordination and avoid duplication
( multi-sectoral approach).
4. It should depend on a good system of
referrals to the secondary level of health care
with a detailed report on each referred case.
5. It may be free charge as in the health
centers, governmental hospitals or paid
services as in private clinics.
What are the guidelines for referral of a
case?
 Primary health care in urban areas:

 1- Health offices: they are responsible for

monitoring of environmental sanitation,
registration of births and deaths, compulsory
immunizations for infants and children,
prevention and control of infectious diseases
(notification, isolation, etc..) and sick leaves
for governmental employees.
 {Health inspectors are the personnel responsible
for infection and epidemics control
Vaccination setting
Continue

 2- Maternal and child health centers: They

provide primary health care programs for
mothers [during pregnancy, labor and
puerperium] and their children [ health
promotion, lowering child mortality and
infection control] and family planning.
 3- School health units and polyclinics:
They provide preventive and curative
services for the school population.
 4- governmental hospitals .etc
5- Urban health centers: they provide
integrated health services

 Maternal and child health services

 {< 5 years children are insured},while older are insured inside
schools
 Health office services
 Monitoring of the environment for sanitation
 Outpatient clinic: it provides treatment of common diseases and
Emergency medical care.
 Health education
 Health registration
 Dental care
 Family planning
 Health team of P.H.C in urban centers comprise:
 Ten physicians, Two dentists, One pharmacist, 15 nurses, Three sanitariums, One
statistical technician, One laboratory technician, Two assistant laboratory technicians,
Two social workers, Two statistical clerks
Primary health care in rural areas:

 a). The rural health units.

 b). Recently, integrated hospitals have been built to
provide primary and secondary levels of care in
some rural communities.
The rural health unit services:
 They are the same as in the urban centers but the
staff is much lower in number includes only one
physician, two nurses, one laboratory technician, a
sanitarian, a dentist. (see rural health).
What are the programs delivered by the
ministry of health (MOH) through the P.H.C :-

 Maternal and child health program (MCH)

 Family planning program
 Rural health program
 Geriatric health program
 School and Adolescent health programs
 Health education programs
 Occupational health program
• Solitary programs as in diarrhea and acute
respiratory infection (ARI) control programs.
Job description of P.H.C. team:
1-Medical officer “MO”

He is responsible for:
 Ensuring implementation of the national
polices and strategies of health services
delivery.
 Organizing, Staffing and Training of the
health team on the different activities set by
the P.H.C center or unit ( as vaccinations,
health education..) Why ?,,to deliver effective
and comprehensive health services and
ensuring a sanitary environment in his
community.
Continue MO Job

 Supervising and participating in the collection

and analysis of all the data needed for survey
studies.
 Medical examination for all the family
members and proper management for the
diseased with a proper referral system.
 continuous updating for his knowledge and
skills.
 The accuracy of notifications, referral,
reports and records.
Continue job description
2- The dentist:

He is responsible for:
 Dental health education and routine dental
examination for all. Attention must be paid for
pre-school and school children, also
pregnant ladies.
 Accurate records and proper reports
specially with referral.
3- The nurse midwife
She is responsible for
A- The mothers:
 History taking during pregnancy from the mother or
relatives
 The basic measurements in initial examination and
subsequent visits
 Simple laboratory tests [Hb % & urine analysis].
 Health education and home visits.
B- the child:
 Vaccinations and oral rehydration therapy
 Sterilization of instruments and Keeping health
records.
4- The health inspector:

 He is responsible for:
 1. Supervising and controlling the
spread of endemic diseases (e.g
bilharziasis) and infectious diseases as
follows:
 Receiving notification of cases of
endemic and infectious diseases.
Continue

 Taking case history, conducting

surveillance, enlisting contacts, notifying
health authorities, preparing specimens,
spraying and disinfections and lastly
preparing the possible vaccines for
prevention of the disease.
 Weekly and the monthly reports of
infectious diseases reported to the health
center .
Continue

 Arranging for routine vaccination activities in

the health center, follow up of defaulters and
record keeping .
 Participating with municipal staff in promotion
of standards of environmental sanitation
 Participating in all community surveys ,
demography ,house marking, ….

 Participating
with PHC team in health
education activities.
5-The laboratory technicians

He is responsible for:
 taking specimens and carry out Blood , Urine
and stool simple analytic tests
 If more investigations are needed , send the
specimens to the hospital
 Monthly reports on laboratory activities.
 keeping the laboratory always tidy and ready
for work and supervise its cleanliness
Merits and constrains of Egypt health care
system:
A): the Merits:-

 1- access to health care is a basic right

for all Egyptians
 2- Physical access to health care is
available to all citizens within 5 km of a
health care facility
 3- All Egyptians are insured either
through MOHP or health insurance
organization
Continue Merits

 4- There is an extensive infrastructure

of physicians, clinics and hospitals /
1000 of population, there are 2.1 beds,
2.1 nurses and 1.1 physicians.
 5- Medical schools are learning more
than 4000 new physicians per year.
 6- Medical technology, pharmaceuticals
and immunization are available
Continue merits

 7- Population growth has been brought

down significantly .
 8- Over 80% of the population has
access to safe water and sanitation.
 9- Per capita share for health is $ 38
that is at the lower end of range for
comparable income countries.
B.) The Constrains

1.
Health outcome:
Maternal mortality was {67.6 / 100.000
live births} in 2004, still high.
High infant mortality rate [ 22.4 /1000
live births ] in 2004, while the age-
specific mortality rate of children
under 5 years was {28.6 / 1000 live
births.
Map of Maternal Mortality, Worldwide
2000
Maternal deaths per 100,000 Live Births

Source: WHO, UNICEF, and UNFPA, Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and
UNFPA, 2004.
Continue health outcome

 Preventive programs must be set up and or

improved for
 Non-communicable diseases,
 Communicable diseases and
 Life style induced illness caused by over-
nutrition, smoking and sedentary life.
2. Accessibility and equity:

 Only 40% of the population has formal coverage

 Poorer individuals spend relatively more of their income
on health care and paying relatively more in taxes than
wealthier individuals .
 There are 3:1 disparities in infant and child mortality
among governorates and 5:1 geographic disparities in
maternal mortality
 Health infrastructure is mal-distributed as evidenced by
5:1 differential in beds between wealthier urban and
other governorates and 6:1 differential in physicians .
3. Efficiency {resources}

 Total health spending is low compared to

international standards.
 At 2.1 beds / 1000 population, Egypt has a
surplus of hospital beds compared to other
smaller income countries
 Egypt has four times physicians per capita than
other comparable income countries.
 Egypt has 1.3 physicians per occupied hospital
bed . it’s one of the highest ratios in the world.
Continue efficiency

 Egypt has too many specialists(over 60%)

relative to primary health care physicians.
 The extensive network of MOHP primary
care facilities is under-utilized as over
60% of all primary care visits take place in
private sector facilities.
 Drug spending and consumption is high
with little use of lower cost generic drugs .
4. Quality, effectiveness and consumer
satisfaction:

 The quality of many facilities is poor since

insufficient funds are spent on maintenance
(less than 1% of recurrent expenditures
compared to 10-15% internationally.
 Physician training needs to be improved through
clinical training .
 Shortage of skilled nurses.
 Medical nursing education needs to be
upgraded at both the university and in service
level.
Problems in P.H.C

1- First problem:
A primary care physician was working in a rural
health unit. There were two nurses and a
sanitarian. The laboratory technician was
sick in one day and didn’t come.
 Read the followings and give the suitable
answers.
Read the followings and give the
suitable answers.

Q1).
 A-The doctor can wait till the technician return and
postpone all the investigations needed..
 B-The doctor should acts and perform all the needed
investigations by himself, because this is one of his
duties.
 C-The doctor can direct the nurse to carry out only
the simple urine analysis tests for pregnant women
and Hb%, while the other investigations are delayed
till the technician’s arrival.
Read the followings and give the
suitable answers.

Q2)
 In the former health unit, a pregnant
female came in labour, she was
bleeding, her pulse rate was 55/min
and blood pressure was 90/60 Hg.
What do you recommend as a primary
care physician?
Continue Q2

 1-Fix a canula with intravenous fluids and try to

deliver the lady in the health unit.
 2-Refer her immediately in the ambulance to the
nearest hospital.
 3-Fix a canula and refer her immediately in the
ambulance with a proper report about her case
including any data or investigations { as RH or ABO
blood group} from her record kept in the unit.
 4-Try to deliver the lady with the assistance of the
midwife.
2nd problem: In an urban health center, there was a
notification about 2 persons in a family complained of
symptoms and signs suspected to be of cholera.

 A-Which sector (or service) in the center is

responsible for controlling this epidemic?
 B-Who are responsible for the control
measures { name the job of the persons in
charge}.?
 C-The previous personnel are responsible for
– The curative services.
– Curative and promotive
– Preventive services.
Continue

D-In the previous problem, infection could be

terminated by controlling:
 The agent
 The agent and the host
 The host and environment
 The agent and the environment
 The agent, the host and the environment
3rd problem:- In the rural health unit one day
the physician faced the following situations.
Find the correct answer.

 A two years child with a fever 39˚c , rhinitis and a sore

throat.
 A one year infant with fever, cough, tachypnea (RR is >
40/min) and chest indrawing.
 A 1.5 year child with severe diarrhea and vomiting,
drowsy with very dry skin.
 A pregnant lady who was healthy during the antenatal
care and seemed to be in normal labour.
 An adult male complained of itching at night.
 A female suspected to be leprotic.
Continue Q4

1- Which cases can be managed at the

unit and which couldn’t and must be
referred to the hospital specialists.
2- Write down if the referred cases would
be sent to a 2nd care level or a 3rd
care level
Investigation of infectious
disease epidemics

Or outbreaks
What Is an Outbreak?
 An outbreak, or an epidemic, exists when there
are more cases of a particular disease:
– in an area,
– among a specific group of people, or
– over a particular period of time

Also, Epidemic can be prescribed If a certain disease re-

emerged after long time of disappearance in the
locality,
Or an index case of a new disease appeared in the
locality.
Uncovering Outbreaks:
How can we discover outbreaks?

 Health departments learn about most

outbreaks in one of two ways:
– Calls from a physician or other healthcare
provider.
– Public heath surveillance
 Influenza pandemics in the 20th
century

1957: “” Asian Flu

1918: “Spanish Flu” 1968: “Hong Kong Flu”

deaths
1-4 million deaths
expected from Avian
Flu
21st century ???
Before any investigation, keep in your
mind the followings:

 The epidemiological triangle :-- the agent----

the host----the environment.
 The possible channels of transmission
between the agent and the host through the
surrounding environment .
 Be a good observer.
The epidemiological triangle

Agent

host Environment
Steps of the investigation:
 1- verification of diagnosis by clinical and
laboratory methods (two labs) for the cases
(index cases) and the suspects.
Why 1st?

 2- Demonstrate the existence of an epidemic:

 The investigator or the clinician should

determine first the diagnosis of the cases.
 Compare between the present incidence and
the previous incidence of the suspected
disease.
Continue steps

 3-Demonstrate the characteristics of the

present epidemic or outbreak:

This requires studying the cases as regards

time, place and personal characteristics as
follows:
 A-Time:
 Arrange cases by date of onset of their
symptoms and then make a graph ( epidemic
curve ), in which the horizontal axis refers to
the time and the vertical axis refers to the
number of cases.
The Time represented by:
The epidemic curve

 The curve could tell the possible:-

 Etiological agent, [time of exposure is known]
 Mode of transmission or, possible source of
infection.
 The shape of the curve may be type I epidemic
curve which suggest a common-source outbreak ,
or type II epidemic curve (propagated) which
suggest [person-to-person transmission or
continued common source].
Continue the curve

– Shape of the curve gives you clues:

agent known: use incubation period to
look back at exposure
agent unknown, but common event
likely: postulate the agent by
determining the incubation period
a). If the agent is known and all cases occur within
one incubation period of the disease, it suggests a
point source of exposure.

A Typical Common
source epidemic (point
Initial case (s), then rapid
upstroke and down stroke
source)
b). If the cases occur over several incubation
periods, it suggests either person-to-person
transmission or a continuing common source of
exposure.

Point source then a person

A propagated curve in
to person transmission
person to person
transmission
Continue the time

 c). If the agent is unknown but the time of exposure is

known, the incubation period can be used to establish a
diagnosis as in food borne outbreaks.

 d). If the incubation period is known, the curve could tell

the probable time and possible source of infection.
Salmonellosis in passengers on a flight from London
to the United States,
by time of onset, March 13--14, 1984

The time of exposure is suspected, so

the I.P could tell the diagnosis
Continue studying the characteristics

 Place: the geographical distribution of the

diagnosed cases, using a proper types of maps
as: street, maps, spot maps and transportation
route maps.
 Persons: Determine the characteristics of the
cases as follows:
– Age distribution, age specific rates.
– Sex distribution according to age.
– Occupational distribution.
– Residence.
– Other characteristics as required.
The Spot Map

A B

C D
Distribution of cholera cases and implicated water
well - Golden Square area of London, August-
September, 1848
Culture-positive cases of shigellosis, by sites along the
Mississippi River where each case swam within three days of
onset of illness - Dubuque, Iowa, September 1974
Continue the steps

 4- Determination of individual
epidemiologic histories.
 What is meant by the epidemiological
history?
 5- Study of the environmental condition in
the identified place.
 6- Human or animal sources of infection.
Continue the steps

 7- Caiculate the attack rates:

 In case of food poisoning:
 For the people who ate the food:
 Attack rate = Number of people who ate the
food & become ill / Total number of people
who ate suspected food X 100
 For people who didn’t eat the food:
 Attack rate = number of people ill and didn’t
eat that food / Total number of people who
didn’t eat suspected food X 100
Definition of the Attack Rate

The number of new cases of a specific disease

during a specific time interval
------------------------------------------------
Total population at risk during the same time period
X 100.
It is an incidence rate calculated during an
epidemic situation using particular population
observed for a limited period of time.
Secondary attack rate

 It is calculated as before but we subtract the

initial index case(s) from both the numerator
and the denominator.
 Ill people – [index cases]
 ----------------------------------
 Total people – [index cases]
Continue the steps

 8- Suggest the origin of the epidemic ( Formulation of

hypothesis )
 This will depend on the collected data, Tabulation and
analysis of these data
 9- Testing hypothesis:
 {use either case-control or a cohort study to collect and
analyze data}. For example, In an outbreak due to
contamination of food, All patients within the outbreak
should have shared this food but it isn’t essential that all
who shared should become ill. This is because the frank
illness depends not only on the dose of infection but also
on the resistance of the host.
continue

 10- Conclusion and proposal for immediate action:

 The control measures will depend on local circumstances
and the resources available.
 11- Summarization:
 Knowledge of disease agent.
 Epidemiologic features.
 The vehicle of transmission.
 The source of contamination.
 Reservoir and host susceptibility
 Steps can be taken to manage the epidemic and reduce
the possibility of future outbreak.
continue

 12- Management of the epidemic.

 13- After control of the epidemic , keep the entire
community under surveillance to detect further rises in
incidence and ensure the effectiveness of the selected
control measures.
 14- In case of food poisoning, there is a common
vehicle epidemic characterized by:
 Explosiveness within a specified incubation period.
 Restriction to groups with a common exposure to food
[ with a high attack rate].