Community & Preventative Medicine

Front 1

What accounts for gains in life expectancy?

Back 1

Clinical medicine ~ 5 years
Public Health ~ 25 years

Front 2

Factors Contributing to Gains in Life Expectancy

Back 2

1. Clean water and air
2. Improved sanitation
3. Safer foods, improved nutrition
4. Expanded immunizations
5. Safer environment and workplaces
6. Improved medical care.

Front 3

Preventive Medicine

Back 3

- To protect, promote, maintain health and well-being and prevent disease, disability, and premature death.
- in US, it is its own medical specialty and own Board Certification
- The principles of preventive medicine are used in most clinical specialties
- The field of Preventive Medicine covers both clinical preventive care and public health.

Front 4

Community vs. Preventive Medicine
(US Perspective)

Back 4

Community - promote health in populations thru application of organized community efforts
(Public Health)

Preventive - enhances lives of individuals by helping them improve own health
(on individual level. What Clinicians do)

Front 5

Community vs. Preventive Medicine
(UK Perspective)

Back 5

Integrated approach to Preventive and Community Medicine.

- Branch of medicine concerned with total health of individual, at home and in the community. Applying comprehensive care to prevent and treat illnesses in entire community

Front 6

Public Health Services to Clinicians

Back 6

– Laboratory testing
– Public health surveillance results
– Health alerts, e.g., anthrax, influenza
– Selected vaccines, antitoxins, etc.
– Prevention materials

Front 7

Clinicians' responsibilities to agencies

Back 7

– Public health surveillance reporting
– Completing death certificate
– Reporting of suspected child or elder abuse

Front 8

Core Aspects of Preventive Medicine

Back 8

Screening
Counseling
Immunization

Front 9

Screening

Back 9

testing in persons without evidence or suspicion of disease to identify early disease or susceptibility when it is more easily / more successfully treated

(secondary prevention)

Front 10

Goals of Preventive Medicine

Back 10

To advance health by
– promoting health-enhancing policies, environments, and behaviors,
– preventing disease and injury
injury,
– making possible early diagnosis and treatment
– fostering rehabilitation to minimize
disabilities.

Front 11

Primary Prevention

Back 11

prevention of disease by eliminate causes of disease or by increasing resistance to it
- before it happens
ie. vaccines
Stage of Disease: Pre-disease

Front 12

Secondary Prevention

Back 12

- Early detection and prompt treatment before it becomes symptomatic.
- Treat it before it becomes serious
ie. Screening and treatment
Stage of Disease: Latent

Front 13

Tertiary Prevention

Back 13

Limitation of impact (eg. disability)
- damage control
ie. treatment, disability limitation, rehabilitation
Stage of Disease: full swing. Symptomatic

Front 14

Health Promotion

Back 14

- efforts to prevent disease and enhance health in general
- multiple applications (exercise, don't smoke)
type of primary prevention

Front 15

Specific Protection

Back 15

- efforts aimed at specific disease, deficiencies, injuries, toxic exposures
ie. get tested for HIV, Don't Drink and Drive

Front 16

Elements of Health Promotion

Back 16

Social Marketing
Counseling
Environmental Modification
Other Structural changes

Front 17

Social Marketing

Back 17

applications of commercial marketing principles to programs designed to influence behavior and improve personal and societal welfare.

Ie. MADD - mothers against drunk driving
Know your numbers - your systolic, diastolic
A.B.C. - Abstinence, Be Faithful, Condoms (Strategy for HIV Prevention)

(Primary Prevention)

Front 18

Specific Protection

Back 18

Prevention of:
- specific disease (mostly infectious)
- specific deficiencies
- injuries
- toxic exposures
- latrogenic disease and injuries

Front 19

Latrogenic

Back 19

Caused by physicians

Front 20

Nosocomial Infections

Back 20

Hospital-Acquired Infections
- #1 problem = handwashing by healthcare workers

Front 21

Screening

Back 21

Test a healthy population
Goal: to identify disease or susceptibility in it is easier/more successfully treatable
- Classifies people as likely or unlikely to have disease. if they are likely referred to → Diagnostic test

Front 22

Diagnostic

Back 22

testing among individuals suspected to have the disease to confirm presence or absence of disease
(secondary)

Front 23

Screen If

Back 23

- Important health problem
- Decent acceptable Test
- Available effective early treatments
- Based on best available data and unbiased reviews (USPSTF)

Front 24

Criteria for Screening Program: Characteristics of Disease ( A CURE)

Back 24

1. Condition is important public health problem
2. Understanding of natural history of condition (need to know what to look for)
3. Recognizable latent or early symptomatic stage
4. Accepted treatment
5. Early treatment influences course and prognosis of disease (Does catching it early make a difference)

Front 25

Criteria for Screening Program: Characteristics of Screening Test (ASS R&D)

Back 25

Suitable Screening Test or Examination
1. Relatively Sensitive and Specific
2. Detects Disease at Latent or Early symptomatic Stage
3. Simple and Inexpensive
4. Safe
5. Acceptable to Population and Providers

Front 26

Criteria for Screening Program: Health Care System

Back 26

1. Available facilities for diagnosis and treatment
2. Screening costs are economically balanced with possible expenditure on medical care
3. Is the treatment/diagnostic test worse than the disease?
4. Ongoing case-finding. Not one time shot

Front 27

Reliability

Back 27

Findings can be replicated

Front 28

Validity

Back 28

ability of test to detect who has the disease and who doesn't

Front 29

True Negative

Back 29

Healthy with normal test

Front 30

Sensitivity

Back 30

Among those with disease, probability of a positive test
(True Positive / True Positive + False Negative)

Front 31

Specificity

Back 31

Among those without disease, probability of a negative test
(True Negative / True Negative + False Positive)

Front 32

Screening

Back 32

Test a healthy population
Goal: to identify disease or susceptibility in it is easier/more successfully treatable
- Classifies people as likely or unlikely to have disease. if they are likely referred to → Diagnostic test

Front 33

Diagnostic

Back 33

testing among individuals suspected to have the disease to confirm presence or absence of disease
(secondary)

Front 34

Criteria for screening

Back 34

- Important public health problem
- Decent acceptable Test
- Available effective early treatments
- Based on best available data and unbiased reviews (USPSTF)

Front 35

WHO Criteria for Screening Program: Characteristics of Disease (A CURE)

Back 35

1. Condition is important public health problem
2. Understanding of natural history of condition (need to know what to look for)
3. Recognizable latent or early symptomatic stage
4. Accepted treatment
5. Early treatment influences course and prognosis of disease (Does catching it early make a difference)

Front 36

WHO Criteria for Screening Program: Characteristics of Screening Test (ASS R&D)

Back 36

Suitable Screening Test or Examination
1. Relatively Sensitive and Specific
2. Detects Disease at Latent or Early symptomatic Stage
3. Simple and Inexpensive
4. Safe
5. Acceptable to Population and Providers

Front 37

WHO Criteria for Screening Program: Health Care System

Back 37

1. Available facilities for diagnosis and treatment
2. Screening costs are economically balanced with possible expenditure on medical care
3. Is the treatment/diagnostic test worse than the disease?
4. Ongoing case-finding. Not one time shot

Front 38

Reliability

Back 38

Findings can be replicated

Front 39

Validity

Back 39

ability of test to detect who has the disease and who doesn't

Front 40

True Positive

Back 40

Sick with abnormal test

Front 41

False Positive

Back 41

Health person with abnormal test

Front 42

False Negative

Back 42

Sick with a normal test

Front 43

How does Prevalence affect Predictive Value of Positive Test

Back 43

If ↑ Prevalence, ↑ Predictive Value of Positive Test
↓ Prevalence, ↓ Predictive Value of Positive Test

Front 44

Who makes recommendation on Screening?

Back 44

US Preventive Services Task Force
- independent panel of private sector experts in primary care and prevention
- Recommendations are "the gold standard"
- Evidence Based recommendations

Front 45

Prophylaxis

Back 45

medical or public health procedure to prevent, rather than cure of treat a disease

(Primary Prevention)

Front 46

Chemoprophylaxis

Back 46

administer drug for purpose of preventing disease or infection
ie. Anti-malarial, Antibiotics prior to surgery, Aspirin, Vaccines

Front 47

What is the only disease to be eradicated worldwide?

Back 47

Smallpox

Front 48

Vaccine

Back 48

biologically derived substance that elicits a protective immune response when administered to susceptible host

Front 49

Vaccination

Back 49

administration of vaccine

Front 50

Immunization

Back 50

Development of immunity of vaccine (your body's response to the vaccine → making antibodies)

Front 51

Antigen

Back 51

Substance that stimulates immune response
ie. production of antibodies
eg. toxins, microorganism, foreign blood cells

Front 52

Antibody (immunoglobulin)

Back 52

Protein produced by B Lympocytes in response to antigen stimulus
- destroys foreign substances

Front 53

Immunological Memory

Back 53

After exposure to antigen, specific memory B cells circulate are able to antibodies upon re-exposure
- Don't need to be exact. ie. Cowpox vaccine was good for smallpox

Front 54

Vaccine Preventable Rash Illnesses

Back 54

- Chickenpox/Varicella
- Measles
- Rubella

Front 55

Vaccine Preventable Childhood Disease

Back 55

- Mumps
- Diphtheria
- Pertussis (Whooping Cough)

Front 56

Vaccine Preventable Neuromuscular Disease

Back 56

- Polio
- Tetanus

Front 57

Passive Immunity

Back 57

- immunity products (antibodies) given to a person, rather than producing it themselves
- Short Term = body breaks down the proteins
- EG. maternal antibodies in milk or across placenta
- Immune globulin (immune blood)
- Hyperimmune globulin - specialized blood with specific antibodies
- Antitoxins (antibodies formed in response to poisonous substances. usually made from horses)
- Anti-venoms

Front 58

Active Immunity

Back 58

- Producing antibodies from your own immune system
- Long lasting

Front 59

Live Attenuated Vaccine

Back 59

- live virus that is weakened in a lab (by physical or chemical processes) so it will elicit an immune response without causing the clinical disease
- must replicate in host to be effective
- needs to stay cold (maintain cold chain)
- culture viruses so they become accustomed to the lab environments and evolve away from human body
- Interference from circulating antibodies
- need fewer doses
- Rare: can convert back to virulent strain (OPV-associated Polio in Dominican Republic)

e.g. influenza / measles / mumps / rubella / yellow fever / BCG / **oral Polio **
** if not handled carefully, may revert back to virulent strain -> OPV **

Front 60

BCG

Back 60

Live attenuated vaccine
- made from cow form of Tuberculosis
- Not used in US/Canada
- will test positive for TB Skin Test

Front 61

Inactivated Vaccines

Back 61

- Inactivated by heat or chemicals
- Cannot replicate or revert
- Not as effective as Live-attenuated vaccines
- Less interference from circulating antibody than live vaccines
- Fewer side effects (localized, if any)
- Requires 3-5 doses
- Immune response usually humeral
- Antibody may dimish over time, requiring boosters

e.g. HepA / polio / rabies / HepB / HPV / cholera / anthrax / plague / tetanus

** may be given as whole OR fractional (protein or sugar based) **

Front 62

Inactivated Polio Vaccine (IPV)

Back 62

- Given by Intramuscular injection
- Can be used for immunocompromised persons
- Used in U.S., Canada, UK
- Very low risk of getting polio

Front 63

Live Attenuated Oral Polio Vaccine (OPV)

Back 63

- Given orally - on a sugar cube
- no health professional needed (Cheap, Easy)
- Provides longer lasting immunity than IPV
- Used in developing countries
- can lead to Vaccine-induced polio

Front 64

Combination Vaccine

Back 64

- Combination of two or more vaccines
ie. Diphyheria/tetanus/Pertussis (whooping Cough)

Front 65

conjugate vaccine

Back 65

Vaccine in which a polysaccharide antigen is chemically joined with a protein molecule to improve immunogenicity of polysaccharide

Front 66

Adjuvant

Back 66

- substance that is used in vaccine to improve the immune response so that less vaccine is needed to produced a non-specific stimulator of the immune response

Front 67

Polysaccharide Vaccine

Back 67

- not consistent in children <2 years of age
- No booster response
- Antibody with less functional activity
- Immunogenically improved by conjugation to a protein
- ie. Meningococcal and pneumococcal

Front 68

Recombinant Vaccine

Back 68

- Genetic modified organism to make live attenuated or inactivated vaccines
- Insert antigen-producing gene into yeast to produce large quantities of antigen
- Delete or modify pathogenicity (rotavirus)

Front 69

WHO Vaccines Recommended for Children

Back 69

- DTP (Dipheria, Tetanus, Pertussis)
- Hepatitis B
- Haemophilus influenzae type B (HIB)
- Human Papillomavirus (HPV)
- Measles or MMr
-Pneumococcal (Conjugate)
- Oral Polio Vaccine (Live)
- BCG, Japanese Encephalitis, Yellow Fever

Front 70

US Vaccines Recommended for Children

Back 70

- Hepatitis B
- Haemophilus influenzae type B (HIB)
- Human Papillomavirus (HPV)
- Measles or MMr
-Pneumococcal (Conjugate)

Differences from WHO recommended
- DTaP (Dipheria, Tetanus, acellular form of pertussis)
- Inactivated Polio Vaccine (Live)
- (no BCG, Japanese Encephalitis, Yellow Fever)
+ Varicella
+Influenza
+ Rotavirus
+ Hepatitis A

Front 71

Vaccines recommended for adolescents (11-12 yrs old)

Back 71

- Meningococcal (MCV4)
- Booster against Tetanus, Diphtheria, Pertussis (Tdap)
- Human Papillomavirus (for girls)
- Influenza (annual)

Front 72

Vaccines Recommended for Adults

Back 72

- Catch up on HPV, MCV, VZ, MMR
- Every 10 years - Booster agains Td or Tdap
Annually - Influenza
Age 60 years - Zoster
Age 65 - Pnemococcal (polysaccharide)

Front 73

Vaccines Recommended for Healthcare workers

Back 73

- Hepatitis B
- Influenza (annually)
- Measles, Mumps, Rubella*
- Varicella*
Tetanus, Diphtheria, Pertussis
Meningococcal (only for microbiologists
- only if no evidence of immunity

Front 74

Uses for a Death Certificate

Back 74

1. Burial Permit
2. Settlement of Deceased Estate
3. Life Insurance Claim
4. Obtain Death Benefits
5. Termination of Govt services or obligations
6. Closure, Peace of mind

ie. determine official cause of death. - Michael Jackson (homicide) vs. Heath Ledger (OD)

Front 75

Physician's responsibility in signing death certificate

Back 75

- legal document
- (Liberace was gay, had AIDs but doctor wrote down pneumonia -> lost license)
- Must be familiar with state/local regulations regarding medical certifications
- complete relevant portion of death certificate
- deliver death certificate to funeral director
answer questions from state or local registrar if asked
-provide supplemental report if autopsy reveal different cause of death

Front 76

What level of government can modify the death certificate outline?

Back 76

States

Front 77

Who signs the death certificate

Back 77

Physician and Funeral Director

Front 78

Why is a death certificate important in public health?

Back 78

- Characterize and access general health of population
-Target and measures results of interventions
- Follow up on infant, maternal, and other deaths
-Calculate life expectancy

Front 79

What is included in the "Cause of Death Section" of a death certificate?

Back 79

1. Sequence of Events leading up to death
- Immediate Cause (not mode of death - ie. cardiac arrest/respiratory arrest)
- As A Consequence of
- Other Significant Conditions

2. Underlying cause of death
(Disease or injury that initiated events resulting in death listed LAST)

3. Only one cause per line

4. Duration of each

Front 80

What is an ICD code is used for?

Back 80

ICD = International Classification of Diseases
- Published by WHO
- Codes for every cause of death worldwide

Front 81

Nosologist

Back 81

someone who is an expert at ICD Codes

Front 82

What are the most common causes of death?

Back 82

1. Heart Disease
2. Cancer
3. Stroke

Same in Caribbean, UK and US

Front 83

The top 3 causes of death can be attributed to what?

Back 83

Behaviors.
1. Tobacco
2. Poor Diet/Non-Activity
3. Alcohol

Front 84

Death (Mortality) Rate

Back 84

Frequency of death in a defined population during a specified period of time

Front 85

Crude Death Rate

Back 85

NOTE: Grenada has a lower mortality rate because younger population

Front 86

Cause Specific Death Rate

Back 86

Front 87

Age-Specific Death Rate

Back 87

Front 88

Infant Mortality Rate

Back 88

Used around the world to measure health and healthcare
U.S. = 43rd in the world.
Cuba = above us.

Front 89

How to Deliver Prevention in the Clinical Setting? (5 A's)

Back 89

1. Assess/Ask - about behavior risk and factors affecting those behaviors

2. Advise - give personalized, clear, specific advice on behavior change. talk about harms/benefits.

3. Agree - work with the patient to find things they are willing to do to change their behavior.

4. Assist - support the patient in achieving the agreed upon behavioral changes.

5. Arrange - schedule on-going follow ups. check their progress. adjust treatment as needed.

Front 90

What has the greatest potential of decreasing morbidity/mortality?

Back 90

Changing Behaviors:
esp.
1. Smoking
2. Exercise
3. Alcohol

Front 91

What 3 Behaviors are linked to the most mortality?

Back 91

1. Smoking
2. Not enough Exercise/Poor Diet
3. Alcohol Abuse
...
4. Illicit Drug Use
5. Risky Sexual behaviors

Front 92

Health risk profiles

Back 92

are tools to help office staff and clinicians identify whether age, gender, or health-related behaviors put the patient at risk for cardiovascular disease, diabetes, certain types of cancer, certain infectious diseases, and other conditions.

The identification of risk factors guides the clinician in deciding which screenings, immunizations, patient education, and follow-up to provide each patient.

ie. RealAge.com
(The HRP is not a patient health history.

Front 93

Transtheoretical Model
(Stages of Change Model)

Back 93

Note: Relapse is often a natural part of the change process, and can happen at any point along the continuum

1. Change is a process that takes time
2. Patients may benefit from different messages, depending upon where they are

Front 94

Ready (for change)

Back 94

Recognition on the part of the individual that there is a need to make the desired behavior change and that he or she is mentally prepared to attempt the behavior change.

Front 95

Willing (for change)

Back 95

The strong desire and the decision of an individual to make the behavior change.

Front 96

Able (for change)

Back 96

The actual ability and confidence an individual has about his or her potential to accomplish the desired behavior change and the commitment and planning to make it happen.

Front 97

Motivational Interviewing

Back 97

Definition:
A directive, patient-centered counseling style
- enhances motivation for change by helping patients clarify
- resolve ambivalence about behavior change.

Goal:
To identify and resolve discrepancies between current behavior and broader values and goals.

Front 98

3 Components of Motivational Interviewing

Back 98

Collaboration – working together with patients in a partnership

Evocation – eliciting thoughts and feelings from patients about what they want and need

Autonomy – respecting the patient’s ability and right to make his or her own decisions about health behaviors.

Front 99

4 Principles of Motivational Interviewing

Back 99

Express Empathy -

Support Self-Efficacy - a client's belief that change is possible is an important motivator to succeeding in making a change

Roll with Resistance - accept setbacks. don't let it get you off the bandwagon.

Develop Discrepancy - a discrepancy between where they are and where they want to be

Front 100

Advice on behavioral changes need to be:

Back 100

1. Clear
2. Personalized
3. Strong

Front 101

Purposes of Public Health Surveillance

Back 101

To portray the ongoing pattern of health-related states and events, to
- Assess public health status
- Trigger public health action (ie. Swine Flu)
- Define public health priorities
- Evaluate Programs

Front 102

Health Insurance Portability and Accountability Act (HIPAA)

Back 102

- protects the privacy of individually identifiable health info
- regulates how health plans, hospitals, docs, use and disclose individually identifiable health info
- specifically does not interfere with state public health reporting, investigations, interventions

Front 103

WHO's Quarantine-able Diseases

Back 103

- small pox
- poliomyelitis (wild-type)
- human influenza caused by new subtype (ie. avian flu, swine flu)
- severe acute respiratory syndrome (SARS)

Unexpected or “impactful” cases of
- cholera
– pneumonic plague
– yellow fever
– viral hemorrhagic fevers
– West Nile fever
– diseases of regional concern, e.g., dengue, rift valley fever, meningococcal disease
- Any event of potential international PH concern

Front 104

What data must be reported? (if found with a flagged diseased)

Back 104

- Identifying info (name, address, phone)
- Demographic info (age, sex, occupation)
- Clinical info (disease, date of onset, lab results)
- Epidemiological info (usually disease specific risk factors)
- Reporter info (name of doctor, facility)
+/- Contact info

Front 105

Process of Public Health Surveillance

Back 105

1. Data Collection – PCP, hospital, etc.
2. Data Tabulation/Analysis – descriptive/analytic/by place
3. Data Interpretation – crosses epidemic threshold
4. Data Dissemination – to those who need to know
5. Link to Action – case investigation/disease control/development of policies

Front 106

Uses of Public Health Surveillance

Back 106

1. Describe the burden of or potential for disease
2. Monitor trends and patterns in disease, risk factors, agents
3. Detect sudden changes in disease occurrence and distribution
4. Provide data for program, policies, priorities
5. Evaluate prevention/control efforts

Front 107

Do physicians need informed consent to report data?

Back 107

No, they don't need informed consent or notification of patients, even if sensitive info

Front 108

Health Agencies uses info to

Back 108

1. monitor health of community
2. feed info back to clinicians about:
- current trends in disease occurrence
- antibiotic resistance
- treatment
- prevention

Front 109

Other than disease, what do physicians need to report?

Back 109

- Impaired driving (DUIs)
- Abuse
(child abuse, elder abuse, rape)
- Injuries
(from weapons, crimes)
- Burns over 5% of the body

Front 110

What does the ap in DTap stand for?

Back 110

ap = acellular Pertussis vaccine. (reduced dose - doesn't use the whole cell. only parts of the cell)
both DTap and DTP are inactivated vaccines.

Front 111

10 Great Achievements in Public Health:

Back 111

1. Vaccination
2. Motor-Vehicle Safety
3. Control of Infectious Disease
4. Decline of CHD and Stroke
5. Safer/Healthier Foods
6. Safer Work Places
7. Healthier mothers/babies
8. Family planning
9. Fluoridation of drinking water
10. Recognition of tobacco use as health hazard

Front 112

Healthy People 2010

Back 112

U.S. National Prevention Initiative
2 overachieving goals:
1. Increase quality of years of healthy life
2. Eliminate health disparities

Front 113

What is different about prevention services?

Back 113

- Future oriented
- lag time between program & health effects
- program for all regardless of need
- program usually in absence of medical crisis
- quality of life: current participation vs. future benefits

Front 114

Describe the goals of preventative medicine

Back 114

- To advance health by promoting health enhancing policies, environments, & behaviors
- Preventing disease & injury
- Making possible early diagnosis & treatment
- Fostering rehabilitation to minimize disabilities

Front 115

Isolation vs. Quarantine vs. Social Distancing

Back 115

Isolation - separation/restriction of movement of persons who are ILL

Quarantine - separation/restriction of movement of persons who are NOT ILL
(asymptomatic but may be exposed)

Social Distancing - prohibit large groups gathering.

Front 116

WHO Prerequisites for successful screening program:

Back 116

1. Condition is important public health problem
2. Decent acceptable test
3. Available effective early treatment based on the best available data and unbiased review

Front 117

Describe the attributes of a good screening test

Back 117

- Relatively sensitive & specific
- Detects disease at latent or early symptomatic stage
- Safe
- Simple and inexpensive
- Acceptable to population and providers

Front 118

Predictive value positive (PVP)

Back 118

– among those testing +ve, prob. of actually having disease (= TP / TP + FP)

Front 119

Predictive value negative (PVN)

Back 119

among those testing -ve, prob. of not having disease (= TN / TN + FN)

Front 120

List 5 sources of screening recommendations

Back 120

1. Government agencies
2. Panels convened by government agencies
3. Medical specialty associations
4. Special interest organizations
5. Individual experts

Front 121

Assess

Back 121

ask about behavior health risks and factors affecting choice of behavior change goals

Front 122

Advise

Back 122

give clear, specific, & personalized behavior change advice, including information about personal health harms/benefits (express empathy/support self-efficacy / roll with resistance)

Front 123

Agree

Back 123

collaboratively select appropriate treatments goals & methods based on patient’s interest & willingness to change the behavior

Front 124

Assist

Back 124

using behavior change techniques to aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environment supports for behavior change

Front 125

Arrange

Back 125

schedule follow-up contacts to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment

Front 126

Pre-contemplation

Back 126

unaware of problem / increase awareness of need for change

Front 127

Contemplation

Back 127

thinking about change but hasn’t / motivate, weight pro’s and con’s

Front 128

Decision

Back 128

making a plan to change / assist in developing concrete action plans

Front 129

Action

Back 129

new change or implementation of specific action plan / assist with feedback, problem solve

Front 130

Maintenance

Back 130

maintained change / assist in coping, reminders, avoiding relapse

Front 131

Naked DNA

Back 131

antigen-producing gene injected, incorporates host DNA -> produce antigen
--- Edible vaccines or skin-patch vaccines
--- vaccines against HIV, TB, Malaria, HSV, other STDs
--- more combination vaccines (MMR + VZV)

Front 132

Occupational Hazards:

Back 132

1. Physical: awkward posture, prolonged static posture, high repetition, vibration, noise, temp extremes

2. Chemical: toxins, asphyxiates, mutagens, teratogen (effects group of cells), carcinogens

3. Biological: viral infections agents (AIDS, SARS), vector-borne diseases (malaria, dengue fever)

4. Safety: struck by, caught in, struck against, fall from

5. Psychosocial: stress, organization structure, shift work

Front 133

Occupational Health

Back 133

multidisciplinary approach to the
- recognition
- diagnosis,
- treatment,
- prevention
- control
of work-related diseases, injuries, & other conditions

Front 134

5 Key Parts of Occupational History: Questions to ask patient

Back 134

1. Description of all jobs held
2. Work exposure history
3. Timing of symptoms in relation to work
4. Epidemiology of symptoms or illness among coworker
5. Non-occupational exposures and other factors

Front 135

Initiating Preventative Action:

Back 135

1. Advise the patient
2. Contact the patient’s union or other labor org.
3. Contact the patient’s employer
4. Inform the appropriate gov. authority
5. Contact appropriate research/expert group

Front 136

Death Certificate:
Part I Line (a) Immediate Cause

Back 136

- final disease, injury, or complication directly causing death
- NOT mode of dying or terminal event
- Cannot be left blank
- List duration


- if immediate cause due to complication/error in medical/surgical treatment, report complication or error, procedure and condition being treated

Front 137

Death Certificate:
Part I Line (b) Due to (or as a consequence of)

Back 137

- Report any disease, injury, or complication that gave rise to or prepared way for cause of death

- Underlying cause of death should be listed LAST

- If immediate cause arose as complication of/error in medical treatment, report complication or error, procedure, and condition being treated

Front 138

What are the 3 subspecialties of Preventive Medicine?

Back 138

- Public health and general preventive medicine
- Occupational Medicine
- Aerospace Medicine

Front 139

Food Fortification Against Dental Caries?

Back 139

Fluoride in water

Front 140

Food Fortification against rickets?

Back 140

Vitamin D in milk

Front 141

Food fortification against neural tube defects?

Back 141

folic acid in cereal grain products

Front 142

Food fortification against goiter?

Back 142

iodine in salt

Front 143

What are the interventions used to reduce the risk of diabetes or its complications?

Back 143

1. Screening using fasting plasma glucose (II°)

2. Measurement of glycosolated hemoglobin (HbA1c) every 3–4 months in diabetic patients (III°)

3. Counseling obese non-diabetic patient to lose weight (I°)

4. Annual eye exam in diabetic patients to look for diabetic retinopathy (III°)

Front 144

Diagnosis

Back 144

testing among individuals suspected to have the disease to confirm presence or absence of disease

Front 145

Consequences of false-positive test result

Back 145

– Unnecessary follow-up tests
(inconvenience, morbidity, expense)
– Labeling, anxiety
– Over-treatment of questionable
abnormalities
– Fear of future tests

Front 146

Consequences of false-negative test result

Back 146

– Delayed diagnosis, more advanced disease,
premature death / disability
– Disregard of early signs / symptoms
– False reassurance
– Exposure of others to infection

Front 147

Is smoking and intravenous drug use listed as Part I or Part II on a death certificate?

Back 147

Part II.
- Smoking is a RISK FACTOR for bronchitis, emphysema, lung cancer.

- Intravenous drug use is a RISK FACTOR for HIV and Hepatitis B

Front 148

Is alcohol abuse listed as Part I or Part II on a death certificate?

Back 148

Part I.
Alcohol abuse is the CAUSE of Alcoholic Cirrhosis

Front 149

What is the importance of reporting Part II on a death certificate?

Back 149

1. Report conditions that co-existed or pre-existed AND contributed to death

2. Report conditions that resulted from underlying cause of death and contributed to death, but was parallel to the immediate cause of death.

3. To report risk factors
(ie. smoking, intravenous drug use)

Front 150

What is the single most used measure to measure health around the world?

Back 150

Infant Mortality Rate

= measure deaths in children under 1 year.

- not all countries measure death rate. But all countries Infant Mortality.

Front 151

Where is the U.S. ranked for infant mortality? How do we compare to other countries?

Back 151

43rd - infant mortality rate = 6.4
- we are below Cuba (41st, 6.1)

Good = below 5.
UK (29th, 5.0)
Canada (24th, 4.6)

Developing country = in teens and 20s not bad.

BAD = above 50.
Pakistan = 68.5
Afghanistan = 157.4

Infant mortality rate = deaths per 1000 live births

Front 152

What is a "good" infant mortality rate for a developing country? What is a "bad" infant mortality rate for a developing country?

Back 152

Developing country =

Good = 10-20s
91. Grenada = 13.9
134. Trinidad & Tobago = 24.3
152. Guyana = 31.4

BAD = above 50.
194. Pakistan = 68.5
226. Afghanistan = 157.4
228. Angola = 184.4

Infant mortality rate = deaths per 1000 live births

Front 153

What is a "good" infant mortality rate for a developed country?

Back 153

5.0

UK = 29th with 5.0
Canada = 24th with 4.5
Singapore = 1st with 2.3

Infant mortality rate = deaths per 1000 live births

Front 154

Where does the data for mortality rates come from?

Back 154

Death certificates

Front 155

Describe the authority that physicians report reputable diseases to. What do they report?

Back 155

Authority = States or Province (Canada)

- Physican/Hospital => Local Health Agency
- Local health agency will do investigation, action if necessary.
- Local health agency forwards up to state.

- Mostly communicable diseases, animal bite, occupational illness, others

- Every other state has similar request

- Some states specify penalty for failing to report, some do not

Front 156

Health is a ____________ rights issue.
(Level of Govt)

Back 156

State's
ie. federal govt (CDC) has to ask permission to enter a state to investigate

Front 157

Thyrotoxicosis

Back 157

Overactive thyroid from elevated levels of
- thyroxine (T4)
- triiodothyronine (T3)
- or both

- more common in women than men
Symptoms:
- rapid pulse, weight loss, palpitations, heat intolerance, tremors, moist skin

Front 158

Endemic

Back 158

The amount of disease that is normally present in a community.

Front 159

Epidemic

Back 159

Amount of disease greater than expected number.
-over a particular period of time

Front 160

Role of clinician in an outbreak investigation

Back 160

– see and diagnose patients
– report cases to health department
– provide medical records as needed to
– health department investigators
– incorporate health department alerts, findings, etc. into his/her clinical practice

Front 161

What is the importance of comparison (control) in analytical studies?

Back 161

Need a control group. Just because something is common doesn't mean it is the culprit.

ie. how many people drink water? how many of them breathe the air?

Need a control group to infer causation.

Front 162

Odds Ratio

Back 162

compares exposure and illness.

Odds ratio of 1 = no diff between control and diseased. No association.

Odds ratio below 1 = protective. prevents you from getting the disease

Odds ratio of above 1 = bad for you. causes the disease.

Front 163

Outbreak

Back 163

An epidemic limited to localized increase in the incidence of disease
(eg. village, town)

Front 164

Describe the approach and list the key steps of an outbreak investigation

Back 164

1. Confirm existence of an outbreak: endemic v. epidemic / outbreak v. epidemic

Epidemic: occurrence of more cases of disease than expected in a given area or
among a specific group of people over a particular period of time

Outbreak: an epidemic limited to localized increase in the incidence of disease

2. Verify the diagnosis (need field investigation?) – rule out lab error/review med record

3. Prepare for field work

4. Construct a working case definition – loose (sensitive) versus tight (specific) case def.
Categories of certainty: e.g. confirmed, probable, possible

5. Find cases systematically and record information – try to identify all cases / collect data on
case-patients / create line listing

6. Perform descriptive epidemiology – time, place, person, “person data” (transmission method)

7. Develop Hypotheses – subject matter knowledge / review / outliers / talk to patients

8. Evaluate Hypotheses epidemiologically – key = comparison group

9. Refine Hypotheses and execute additional studies as necessary

10. Reconcile with lab/environmental studies

11. Implement control / prevention measures – the earlier, the better!
- create mechanisms to evaluate both short and long-term effectiveness of control

12. Initiate or maintain surveillance – monitor for additional cases/evaluate
effectiveness of control

13. Communicate findings – legal documentation / justify recommendations

Front 165

Risk Factors for Diabetes

Back 165

- obesity
- poor diet and physical activity
- family history and genetics
- history of gestational diabetes
- impaired glucose metabolism
- Dyslipidemia (elevated lipids in blood)
- History of gestational diabetes (or baby > 9 lbs)
- race/ethnicity (African American, Asian American, Pacific Island, Hispanic/Latinos)

Front 166

Secondary Prevention for Diabetes

Back 166

SCREEN adults who are overweight (BMI > 25) and have at least one risk factor:
- physical inactivity
- 1st degree relative with diabetes
- members of high risk popn (Black, Hispanic, Asian, Native American, Pacific Islander)
- Women who delivered a baby >9 lbs or diagnosed with gestational diabetes
- Hypertension (>140/90)
- HDL < 35 and TG > 250

Front 167

Gestational Diabetes

Back 167

diagnosed glucose intolerance during pregnancy

frequently diagnosed in:
- obese pregnant women
- Pregnant Black, Hispanic, Native Americans
- requires treatment to normalize in infants
- 5-10% will develop type 2 soon after pregnancy
-40-60% will develop type 2 within 5-10 years post delivery

Front 168

1-5% of diagnosed diabetes results from:

Back 168

- genetic conditions
- surgery
- drugs
- malnutrition
- infections
- pancreatic disorders

Front 169

Impaired Fasting Glucose (IFG) - Pre-Diabetes

Back 169

condition where fasting blood glucose is elevated (100-125 mg per dL) after an overnight fast

Front 170

Impaired Glucose Tolerance (IGT)
- Pre-Diabetes

Back 170

condition where fasting blood glucose is elevated (149-199 mg per dL) after a 2 hour oral glucose tolerance test

Front 171

Tertiary Prevention for Diabetes

Back 171

Screen person with diabetes for:
- yearly eye exam
- Periodic foot exam
- HbA1c levels
- Psychosocial assessment

Vaccination - influenza, pneumococcal

Exercise, Diet counseling

(Damage Control)

Front 172

Complications of Diabetes

Back 172

- Heart Disease and Stroke
- High Blood Pressure
- Blindness
- Kidney Disease
- Nervous system neuropathy (impaired sensation to hands, feet, slow digestion of food in stomach, erectile dysfunction, carpal tunnel)
- Amputations
- Dental disease (Periodontal Gum disease)
- Pregnancy Problems
- Susceptibility to Infection

Front 173

metformin

Back 173

- Diabetes Prevention Program
- reduced risk of getting diabetes
- most effective in younger and more overweight people
(25-40 years and 50-80 lbs overweight)

Front 174

acarbose

Back 174

STOP-NIDDM Trial
- treatment of people with Impaired Glucose Tolerance (IGT)
- reduced risk of developing diabetes by 25%
- lifestyle changes and medication works to bring it back to normal glucose tolerance

Front 175

Antigen "drift"

Back 175

minor mutations in flu virus
ie. point mutation

Front 176

Antigenic "shift"

Back 176

larger immunological change (reassortment) of flu virus
-new virus subtype
- ie. genetic reassortment (human and animal viruses)
or direct animal (poultry) to human transmission

Front 177

What does H stand for in H1N1?

Back 177

Hemagglutinin - surface antigens (glycoproteins)
-protein that allows virus to attach to respiratory cells.

Front 178

What does N stand for in H1N1?

Back 178

Neuraminidase - surface antigens (glycoproteins)
- helps release newly formed virons from infected cell.

Front 179

Pandemic

Back 179

epidemic occurring in multiple continents

Requirements:
1. A new influenza type A subtype
2. Causes serious illness
3. Spreads easily from human-to-human

Front 180

Influenza has what "shaped pattern" for hospitalizations and death?

Back 180

J-Shaped Pattern. Mostly young children and elderly (65+) affected.

Front 181

What are the 2 types of influenza virus? What are the hosts for each?

Back 181

Type B. is very mild.
Type A is very virulent

Front 182

What is the distribution of Influenza A subtypes in humans, swine, horses, and birds?

Back 182

Birds can host all subtypes. Humans only have H1-3, N1-2

Front 183

H5N1

Back 183

Avian flu
- very lethal but not very contagious
- need direct contact with birds
- 60% mortality rate
- No J-shaped curved. mostly <40 year olds.

- wild birds - carriers
- domestic birds - affected

Front 184

panzootic

Back 184

pandemic in animals

Front 185

What is the best way to not get the flu?

Back 185

get vaccinated

Front 186

Describe the flu vaccines

Back 186

- WHO meets twice a year to decide
- Influenza is very specific = need to decide what strains to make vaccines against
- Northern hemisphere - makes it in spring for following season

Typical vaccine -
trivalent (Type A: H1N1, H3N2, and Type B)

6-8 months to make it
- inactivated for intramuscular
- live attenuated nasal spray

Front 187

What is the current concern over avian influenza (H5N1) and swine flu (H1N1)?

Back 187

The concern is there will be a strain with:
- contagiousness of H1N1
- deadliness of H5N1

(ie. 1918 Pandemic)

Front 188

What is the difference between the seasonal flu and the outbreaks of influenza?

Back 188

Seasonal Influenza
- in the Fall
- Contagious but not deadly
- J-shaped curve (very young and elderly)

Novel Influenza-
- In Spring,
- deadly but not contagious
- affects mostly young people. no J-shaped curve

Front 189

H1N1

Back 189

Swine Flu
- 8 genes (avian, human, swine)
- contagious (human to human transmission)
- does not cause severe disease
- 1.1% mortality rate
(most death had underlying conditions)
- no vaccine yet
- Antivirals available - but have side-effects. shorten duration of illness by 1 day
- Mostly affects younger people <40 year olds

Front 190

CH2OPD2

Back 190

Taking an Environmental Exposure History?
1. Community
2. Home
3. Hobbies
4. Occupation
5. Personal Habits
6. Diet
7. Drugs

Front 191

Occupational Exposure

Back 191

1. Jobs and Tasks
2. Exposures (Physical, Chemical, Biological, Psychosocial)
3. Protection.

Front 192

What are the modifiable risk factors for heart disease?

Back 192

- high blood pressure
- high cholesterol
- smoking
- obesity
- diabetes
- physical inactivity

Front 193

Risk factors for Coronary Heart Disease?

Back 193

1. Cigarette Smoking
2. Overweight and Obesity
3. Hypertension
4. Dyslipidemia
5. Diabetes Mellitus

+Male Sex (Gender)
+Increasing age (>55 for men, >65 for women)
+family history of CHD (men <55, women <65)
+diet and nutrition

Front 194

Novel Risk factors for Coronary Heart Disease

Back 194

1. Excess homocysteine in Blood

2. Inflammatory markers (C-reactive protein)

3. Abnormal blood coagulation (elevated levels of fibrinogen)

Front 195

Non-modifiable risk factors for CHD

Back 195

- Increasing Age
- Heredity or family history
- Gender
- Ethnicity or Race
(Low socioeconomic status)

Front 196

Lesser Modifiable Risk Factors

Back 196

- Mental Ill Health (Depression)
- Psychosocial Stress
- Heavy Alcohol Use
- Use of Certain Medications
- Lipoprotein A

Front 197

Primary Prevention for Coronary Heart Disease

Back 197

- Maintain healthy lifestyle
- Exercise
- Healthy Diet
- Regular Exercise
- Normal weight
- Non-smoking
- Control of Stress

Front 198

Secondary Prevention of Coronary Heart Disease

Back 198

Screening (Early Detection) and treatment of symptomatic patients.

- medication to lower blood pressure

Front 199

Tertiary Prevention for Coronary Heart Disease

Back 199

- Beta Blockers
- Stop Smoking
- Treat for hyperlipidemia
- Recommend low dose aspirin
- ACE inhibitors
- Revacularization (bypass surgery)
- Thrombolytic drugs
- Heart transplant

Front 200

Community Intervention for Coronary Heart Disease

Back 200

- Organization based fitness and diet control
- Marketing healthy practices
- Integration of traditional healing practices
- Expanded clinic-based fitness and diet control interventions

Front 201

What are interventions used to reduce the risk of heart disease?

Back 201

- Restricting sale of cigarettes to minors (I)
- Avaliabilty of playgrounds, sports, recreation (I)
- Screening for hypertension (II)
- Exercise Treadmill Test for ppl with diabetes and 3 other risk factors (II)
- Daily Aspirin after having myocardial infarction (III)

Front 202

What are interventions used to reduce the risk of diabetes?

Back 202

- Counseling obese patients about weight loss (I)
- Screening using fasting plasma glucose (II)
- Measurement of glycosolated hemoglobin (HbA1c) (III)
- Annual eye exam for diabetic retinopathy (III)

Front 203

Expected consequences of screening

Back 203

True Positive Result
- early diagnosis
- early (possibly less radical) treatment
- reduce morbidity, mortality, disability
- reduced cost
- "labeling effect"

True Negative Result
- Reassurance