Health protection entails the disciplines and services that protect members of the society from INFECTIOUS DISEASES or ENVITONMENTAL THREATS to their health, such as radiation, chemicals, contamination of resources, dangers at the workplace, industrial accidents, natural disasters and terrorist acts. It aims to control threats by developing national, local or individual policies for vaccinations, isolation PROCEDURES or emergency protocols and carries out SURVEILLANCE of health threats, in order to allow rapid response in case of an outbreak. •  STAGES Gather information regarding the health threat (ID and quantify) => implement measures (prevention, treatment, control, education, short or long term) => monitor / carry out surveillance.

•  COMMUNICABLE DISEASES Infectious diseases declining in Western world while non-infectious/chronic conditions are increasing. New challenges: Pandemics, nosocomial infections, Abx resistance, new diseases (CJD, SARS, influenza strains)

•  TARGETING INFECTIOUS DISEASES MODE: direct – indirect – droplet; need to know MECHANISM: target agent – reservoir – transmission - infection – treatment – treatment resistance AIM OF INTERVENTION: containment – eradication

•  VACCINATIONS WHEN TO VACCINATE: high spread, high burden, high incidence/prevalence, high complications, good vaccine, good process, cheap, rest similar to WHO criteria for screening. WHOM TO VACCINATE: population vs. targeted TYPES OF VACCINES: live, attenuated, killed, inactivated, toxoid, subunit, passive (Ig) REQU. VACCINATION PROPORTION: to prevent spread

RVP = 1 – 1 / R0 R0 = number of 2* infections caused by single case 1/R0 = 1* cases needed to cause one 2* infection

RVP = remaining people need vaccination to break chain Know UK vaccination schedule.

•  SURVEILLANCE. Ongoing systematic collection, collation and analysis of risk factors, incidence, distribution, morbidity and mortality of diseases of public interest in order to take appropriate quick action.

METHODS: real time evaluation, surveys, representative samples, reporting (voluntary vs. mandatory) OUTBREAK INVESTIGATION: (outbreak = disease occurrence > expected) Descriptive study, then analytical study to ID cause Members of outbreak control team: environmental health officer, microbiologist, consultant in health protection/communicable disease (head), consultant epidemiologist, treating physicians (GP, hospital), spokes person, secretariate, infection control nurse, food standards agency representative, regional repre- sentative,

•  ENVIROMENTAL THREATS Source => pathways => receptor => effects / aim is : break chain! METHODS: evacuation, decontamination, legislation, safety measures

•  DISASTER CONTROL Disaster = disruption of functioning of a community with detrimental consequences for humans, the environment, the economy and the resources. Emergency = threat to human welfare and environment or security METHODS: prevention, preparation for the case of failed prevention, enabling the response, enabling the recovery A health needs assessment is an objective and systematic analysis of the health issues facing a population leading to agreed priorities and resource allocation that will improve health and reduce inequalities. Action is taken where measures have a high / the highest impact, where changes are acceptable and can be integrated into current practice and are feasible in terms of resource implications.

WHAT IS HEALTH NEED? •  A medical service that is wanted or required as patient/society would benefit from it.

Health needs are complex to define objectively and depend on who formulates their need. Considering health needs, remember that health is more than just absence of illness, healthcare comprises more than just treatment.

•  HEALTH = physical, social and emotional well-being of an individual, group or community, not just absence disease. Ability to function normally within society

•  HEALTH NEEDS: health definition plus education, social services, housing, environment, social policies

•  HEALTHCARE NEEDS: treatment, prevention, diagnosis, continuing care, rehabilitation, palliative care

•  BRADSHAW’s types of NEED: Expressed (by action), normative (expert-defined), comparative, felt (subjective)

(Need DOES.NOT.EQUAL demand DOES.NOT.EQU. Supply - Health need DOES.NOT.EQUAL healthcare need Individual need DOES.NOT.EQUAL societal need - Patient’s need DOES.NOT.EQUAL clinician’s opinion of it)

WHO CARRIES OUT THE HNA •  Commissioning organisations, e.g. PCTs, ID need, define priorities (demand) and

purchasing/procurement of supply •  “Joint strategic needs assessment” by local governments for health and social care

HOW TO PERFORM HNA •  PROCESS: Gather information/analyse data, plan and prioritise (ID services required),

allocate resources and involve stakeholders (fairly/maximise equity), assess efficiency •  METHODOLOGY 1. COMPARATIVE NEEDS ASSESSMENT: Define population of interest and collect data, e.g. routine data (see under “Health Status”). Compare local statistics to other areas, compare local variables to set standards. 2. CORPORATE NEEDS ASSESSMENT: Involvement of other agencies – professionals, local governments, voluntary sector, the public, communities, stakeholders via surveys, citizen’s juries or appraisals. 3. EPIDEMIOLOGIAL NEEDS ASSESSMENT: Quantify particular health needs and relate to the current services available, quantify their effectivity => able to prioritise health needs and decide on reallocation of resources keeping in mind:

•  PRIORITIES What would have highest gain/IMPACT? Is implementation into services possible? CHANGEABILITY Are changes ACCEPTABLE? Is it feasible? Consider RESOURCE IMPLICATIONS Involve all interested/affected/useful parties.

•  Study designs – 1* research, 2* research, study hierarchies •  Critical appraisal of research papers (mainly 2*) •  Evidence-based medicine –use of current best evidence to inform decisions and

procedures and attempting to integrate individual expertise in order to improve outcome.

WHAT IS PUBLIC HEALTH ?

Health improvement comprises PREVENTATIVE measures and strategies for health promotion with the goal of improving population health, at an individual or POPULATION level. Prevention is facilitated by targeting individual behaviour in order to avoid contraction or manifestation of a disease or limit its outcome. Health promotion targets the entire population through education, legislation, community development and public policy regarding the prerequisites of health.

How to improve the health outcomes by health services and ensure processes are up to date. •  What is QUALITY: Subjective to patients, docs, managers MAXWELL: accessibility, effectiveness, efficiency, acceptability, equity NHS: clinical effectiveness, patient safety and experience •  What is a PROBLEM in the health service: Underuse, misuse, overuse, errors. •  How to perform an EVALUATION: DONABEDIAN’s elements: structure, process, outputs (results), outcome (long term) •  STRATEGIES FOR IMPROVEMENT: ** Regulations/standards (minimum) NHS, GMC, NICE, QCC ** Improving best practice (beyond min) Audit cycle: define, monitor, ID divergence, change practice, evaluate change The audit checks what is supposed to be done is done. ** Financial strategies ** System-level approaches Clinical governance (corporate strategies), lean (best value for patient), six sigma (aim for smallest error), root cause analysis (learn from mistakes) STANDARD PROVISION IMPLE MENTA TION MONITORING

CLINICAL GOVERNANCE is a systematic approach to improving quality of care in the NHS.

The QUALITY CARE COMMISSION is the public body of the department of health (since 2009) ton monitor the NHS.

•  LEVELS: Macro (% of all resources), Meso (distribution of budget), micro (decisions between patients) •  DECISION MAKERS: clinicians up to Dept. of Health (government) •  FRAMEWORK FOR PRIORITISATION: ID service in question Assess: need, quality, economic evaluation Decide on changes Implement changes Evaluate results Re-prioritise

•  ECONOMIC EVALUATION: * Costs: direct, indirect, opportunity, marginal, incremental * Cost-utility (quality and quantity) QUALITY ADJUSTED LIFE YEARS = QALYS Qualitative = % of full health Quantitative = life expectancy Measure of disease burden or number of years in full health gained by particular intervention. => comparison * Cost-effectiveness (quantity) * Cost-benefit (more subjective) * STRATEGIES FOR RATIONING Exclusion (some get nothing), dilution (all get less), delay (have to wait), termination (processes shorter) •  Policy refers to the decisions of governments which are not always evidence

based but also take political and cultural considerations into account. MODELS •  WALT-GILSON model for policy analysis Context of policy: situation, structure, culture, environment, professionalism Process/implementation: top-down, bottom-up Content Implementors •  Other models: rational/sequential (like audit or prioritisation), incrementalist: carry

out small steps in agreement with groups of competing interest CONCERNS •  Cost, efficacy, efficiency, effectiveness, quality of care, access, equity, patient-

centered care, information management, workforce development PRIORITIES •  Improving LE, best start for children, employment, standard of living, sustainability,

disease prevention, addressing inequalities, disease prevention STRATEGIES •  Market incentives (financial incentives, choice, including independent sector,

liberalisation) •  Structural reorganisations: top-down, bottom-up, Care Quality Commission, NICE •  Whole systems approach, inter-dependency of agencies with central vision and

avoiding duplication •  Specific to public health policy: BIOETHICS LADDER describing level of

intervention, aim at lowest effective level by enabling choice, guiding by default, incentives, restriction, disincentives, elimination

•  Management skills (mainly managing change) •  Leadership skills •  Prioritisation skills, see above •  Decision-making skills

INDIVIDUAL LEVEL •  Disease prevention: 1* = avoid contraction Address risk factors: lifestyle, environment, genes, exposure 2* = prevent outbreak/manifestation Address knowledge, behaviour, individual/population health 3* = prevent complications Provide education, care, accessibility, address co-morbidities •  Factors to change behaviour: will,

belief in possibility and outcome, knowledge

•  Stages of behavioural change: pre-contemplation, contemplation, action, maintenance, relapse

•  Methods of targeting the individual: Mass media campaigns, social marketing, legislation, nudging (indirect / +ve reinforcements)

POPULATION LEVEL Main routes •  Education Schools, professionals, authoriarian, client-led •  Legislation Law, taxes, regulations, pricing •  Communities Empowerment, support groups, school initiatives •  Public policy Provide baseline •  Private sector •  Advocacy action UN, organisations, professional groups, unions, individuals OTTAWA CHARTER for health promotion 1986 •  Public policy •  Supportive environments •  Strengthening communities •  Improving health services •  Developing knowledge and skills SCREENING

Systematic testing of a defined sub-group for risk factors or signs of an illness in its pre-symptomatic stage with the aim of prevention or reduction in morbidity/mortality. Action will be taken in those individuals more likely to be helped than harmed by further investigation or treatment. •  Advantages: reduced morbidity, reduced mortality, economic benefit •  Disadvantages: false reassurance, unnecessary psychological harm, costs,

treatment side-effects; opportunity costs, requires high coverage, difficult to put in place, plan and implement, evaluate.

•  WHO CRITERIA ** 4. reg. test: available, acceptable, inexpensive, valid (predictive value, sensitivity, specificity), continuous ** 3 reg. disease: important condition, known progression, identifiable early stage ** 4 reg. treatment: available, acceptable, adequate cost, know how/whom to treat ** 4 reg. screening process: program of known effectiveness, benefits > harms, cost justified within budget, adequately resourced •  UK PROGRAMMES PREGNANT (FBC, infectious diseases, urine, foetus), BABIES/CHILDREN (Guthrie=hypothyroidism, Pku, CF, Sickle, MCAPD; Babycheck=hips, heart,eyes; hearing test, growth charts, vision checks), ADULTS (Cervical CA, Breast CA, Colorectal CA, AAA, sight-threatening retinopathy in diabetics). Note: prostate CA is voluntary as PSA bad test, lung CA CXR not sensitive enough and risk of radiation, cost. •  PREVENTION PARADOX Most cases identified from population at low/moderate

risk, the minority of cases come from the righ risk population. The health status of a population is determined by carrying out a study/survey named “HEALTH PROFILE”, in which the mortality, morbidity and other factors affecting health and disease in the population of interest (including determinants and inequalities) are statistically/stystematically analysed. At obtained from •  Statistical organisations (national surveys), hospitals (hospital episode statistics

HES), 1* care •  Public health organisations, e.g. notif. disease data, specialist disease registers •  Ideally also some subjective data from population itself regarding their needs •  NOTE: Finangle’s law of dynamic negatives. And time lags until data available.

MORTALITY •  Crude death rate = deaths /100k per year (age is confounder) •  Directly standardised death rate DSR = mortality rate of the population of

interest if it had the same age-distribution as the population of interest, obtained by multiplying the crude death rate of each age group with proportion of the standard population of that group, then summed up. Can divide by standard population death rate to see difference.

•  Indirect standardised mortality ratio SMR = don’t have age-specific data for population of interest. Apply age-specific death rates of standard population to population of interest an calculate total number of expected deaths, relate to actually observed deaths.

•  Proportional mortality = disease deaths/y : tot. deaths*100 •  Perinatal mortality = (still births + deaths < 1w)/ total births •  Neonatal mortality rate = deaths in 28d / 1000 live births •  Post-neonatal m.r. = deaths 28d-1y / live births •  Maternity m.r. = maternal deaths / live births •  Infant mortality rate = deaths < 1 / live births •  Under five m.r. = deaths < 5 / live births per year x 1000 •  Life expectancy LE •  Years of life lost YLL = sum all years lost <75 / population •  QALYs

MORBIDITY •  Information from notifiable diseases, hospital episode statistics HES, 1* care data,

disease registers, national surveys or censuses, surveillance and reporting, local government data, commercially available data, office of national statistics, WHO global observatory, Joint Strategic Needs Assessment by UK local governments

•  QALYS => see under prioritisation •  INEQUALITIES, e.g. slope index of inequality SII = gap between best and worst

deciles

DATA •  How good is data? Completion, categorisation/coding/consistency, accuracy, •  Discrimination in terms of age, sex, time, location, population?

•  Children •  Women •  Adults •  Ageing

•  Statistics – inferring trends from large amounts of data •  Demography – analysing the size, structure and distributions of populations. •  Epidemiology – statistical analysis of the risk factors, incidence, morbidity and

mortality of diseases as well as the determinants of health and the control of disease.

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PUBLIC'HEALTH'TOOLBOX'

Policy'Public Health efforts aim to advise the government on:

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Scien1fic'Methods' Research'Methods' Execu1ve'Skills'

Public Health is the science of promoting health, preventing disease and premature death of a population by systematic efforts of society, communities or individuals, usually in the presence of limited financial resources. It covers three key areas (but overlapping):