THE CONSEPT AND THE LEVEL OF PREVENTION

Dr.Sidarta S. Department of IKM-IKKOM Faculty of Medicine UNDANA

History of Disease (Ancient Civilizations: Theories of Disease Causation) • Egyptian Medicine

– The early Egyptians (4000-1000 B.C.) had many remedies for illness. Spells, incantations, and magic were integral parts of their medicine.

– Among early races, illness and death were attributed to actions of the gods and demonic possession.

History of Disease (Ancient Civilizations: Theories of Disease Causation) cont…

• Egyptian Medicine cont…– Despite their lack of scientific knowledge, some of the treatments they used were effective and still used today.

– Egyptians are recognized as the first to treat disease systematically.

Greece: The Teachings of Hippocrates• Hippocrates believed in the healing

power of nature and thought that disease developed from natural causes.

• Hippocrates prescribed diets, rest, fresh air, massage, and baths as treatments.

• Hippocrates’s approach to disease and research were the first steps on the way to the prevention and control of disease.

The Immune System• The immune system is a complex protection mechanism that functions by protecting the body from harmful microorganisms (bacteria, viruses, fungi, and parasites) and foreign materials (toxins and venoms), while recognizing and eliminating foreign pathogens.

The Immune System (Two Parts)

Innate• The body’s first line

of defense against disease.

• Skin—outer protective barrier

• Macrophages, Natural Killer Cells & Neutrophils kill infectious agents

Adaptive• Second Line of defense

• White blood cells & Lymphocytes

• Antibodies formed when there is a pathogen

What is Infectious Disease?

•A disease caused by organisms that enter the body and multiply within the human body.

What is Noninfectious Disease?•Diseases that are not transmitted by means of a pathogen (foreign invaders on in the human body).

What Are Some Examples of Chronic Infectious Diseases?

• HIV—virus that attacks the immune system making it difficult to fight disease

• Tuberculosis—Bacterial infection of the lungs.

• Meningitis—Inflammation of the membranes that cover the brain and spinal cord.

• Encephalitis—Inflammation of the brain• Poliomyelitis (Polio)—caused by a virus of the CNS

• Others?

What are Some Examples of Acute Infectious Diseases?

• The cold virus—causes inflammation in the mucous membranes lining the nose and throat.

• Influenza—a viral infection of the respiratory tract.

• Mononucleosis— Known as “the kissing disease,” common in teens; it’s a virus that multiplies in the lymphocytes changing lymphocyte appearance.

• Others?

What are Some Examples of Chronic Noninfectious Diseases?

• Diabetes• Osteoporosis • Arthritis • Heart (cardiovascular) Disease• Cancer• Hypertension• Others?

What are Some Examples of Acute Noninfectious Diseases (This is a hard one)?

• Heart Attack• Stroke• Cardiac Arrest• Hypoglycemia—Too low blood sugar levels

• Hyperglycemia—Too high blood sugar levels

• Others?

• 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"

(I) Prevention

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.

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 Causes of Disease

BEINGS Biological factors and Behavioral FactorsEnvironmental factorsImmunologic factorsNutritional factorsGenetic factorsServices, Social factors, and Spiritual factors

[JF Jekel, Epidemiology, Biostatistics, and Preventive Medicine, 1996]

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 DiseaseTertiary prevention•Disability limitation forearly symptomatic disease•Rehabilitation for lateSymptomatic disease

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.

Primordial prevention• 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).

Primordial prevention

• 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

Specific protectionHealth promotion

Achieved by

Health education

Environmental modifications

Nutritional interventions

Life style and behavioral changes

Immunization and seroprophylaxis

chemoprophylaxisUse of specific nutrients or supplementations

Protection against occupational hazards

Safety of drugs and foods

Control of environmental hazards, e.g. air pollution

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

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

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

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.

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.

Secondary prevention• 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.

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.

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

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

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.”

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.”

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.”

Rehabilitation

Medicalrehabilitation

Vocationalrehabilitation

Socialrehabilitation

Psychologicalrehabilitation

Strategy for Prevention

Assess Exposure

Identify Populations at High

Disease Risk(based on demography /

family history, host factors..)

ConductResearch on Mechanisms

(including the study of genetic susceptibility)

Apply Population-BasedIntervention

Programs

Evaluate Intervention

Programs

Modify Existing Intervention

Programs

Inter ve ntion

Assessment

Epidemiology Division

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 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.

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.

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"

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.

Control of infectious diseases (the 4 “C”s

Control

Cases Contacts Carriers Community

Diagnosis notificationisolationdisinfectiontreatmentfollow uprelease

observation detection EpidemiologicalInvestigation &containment

standardstrictprotective

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.

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

Scenarios—What’s the Level of prevention? • Wanda stays at home all day in fear that she will catch a disease. She is always in the restroom washing her hands and when someone sneezes, she runs away like there’s no tomorrow. What’s the level of prevention?

• If you said primary…you’re right!!!

Scenarios—What’s the Level of prevention?

• Hector has been diagnosed with mouth & throat cancer because of his continual use of chewing tobacco. His doctors say that he has little chance of survival without medication and surgery. Hector had the surgery but eventually dies six months later.

• What’s the level of prevention?• If you said primary…you’re so wrong.• If you said tertiary…(congratulations!) you are correct!!!

What are the Three Most Meaningful Words in The Dictionary?• 1: Choice• 2: Choice• 3: Choice• You have the power to choose. Making the wrong choices could negatively affect your health. Remember: You ARE responsible for you’re own actions. So, be healthy and always make the right choices—your life depends on it!

The End? The End of this PowerPoint, the beginning of your journey in disease prevention…I wish you all the best!