Community

0105068372 Rural health program Mortality

Objectives

- Prevention of diseases by establishing maternal & child health serises, school health services. - Curative services By clinics, labs, 1st aid services

Achieved by Morbidity

Occupational Health Occupational Health: is the science & art that aim at achieving optimum state of physical, mental & social wellbeing of workers.

Types of occupational diseases: - Occupational diseases: during doing the occupational work. - Work related diseases:

by occupational stresses as  HTN, CHD. Prevention of diseases

Occupational health services achieved by

Early detection of diseases Promotion of health

Occupational health team: Physician, Nurse, Hygienist Occupational health Team Duties: 1. Preplacement Examination: must be place in a suitable place 2. Prevention of accidents 3. Protective clothing 4. Rehabilitation: following injury, need physiotherapy. 5. Records: concerned diseases, accidents …

Noise

6. Supervision of the work environment: by measuring level of

Heat

7. Therapeutic services

Radiation

8. Health education 9. Nutrition of workers

Prevent diseases

10. Periodic medical Examination: every 6 months to

detect early stages of diseases

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Occupational Health Diseases A) Diseases caused by physical agents

1. Exposure to extremes of temperature Heat disorders

Causes:

In building Mining Ovens Improper ventilated areas

Clinical Picture

A) Heat Exhaustion exposure to heat VD of BV  Blood loss from vessels to tissues  Blood goes to brain  loss of consciosness. Treatment: removing the patient to cool place. Water

B) Heat Cramps excessive sweating  loss of

NaCl

Treatment: Water & NaCl

C) Heat Pyrexia Exposure to extreme heat damage to the heat regulatory center Treatment: immersion of the patient into ice cold water.

D) Miliary Rubra (Sweat rash) Blocking of orifices of sweat gland accumulation of sweat red popular eruptions.

Prevention of Heat disorders A) Environmental measures

B) Medical Measurements

Community Oct. Med.

Insulation of hot machines Prevention of steam leakage Proper ventilation Protective clothing Pre-employment examination Periodic medical examination Salts & fluids intake

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0105068372 B) Diseases caused by Noise A) Air conduction deafness exposure to noise > 150 decibels  rupture of drum e.g. in military explosions. B) Nerve conduction deafness Prolonged exposure to noise level > 90 d.b. Prevention:

echo

1. Environmental control: 2. Medical control:

Proper maintenance of machines.

Periodic examination Use of ear plugs

Occupational Health Diseases caused by abnormalities in pressure Decompression thickness can affect  diving, building under water … Problems that the workers suffer from: 1. During Descent: (Harmless process), it harms only if bleeding from close cavities 2. During Stay: 3. During Ascent

N2 & O2 dissolving in tissues  toxicity Slow compression (gradual compression)  no hazards Rapid compression (Sudden compression)  Pain around joints, dyspnea & chock.

Dyspnia: decompression illness occurring in aeroplanes during rapid ascent to upper atmosphere Prevention of decompression illness A) Environmental measures

B) Medical Measurements

Community Oct. Med.

Gradual decompression Inhalation of helium to avoid level of dissolved N2

Pre-employment examination Periodic medical examination

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Diseases caused by exposure to ionizing radiation Occupational Exposure - Mining

- Use of radium, uranium

- Accidental leakage of radiation.

- Exposure in medical field.

Effects of exposure to ionizing radiation Acute effects Affect the rapidly divided cells as bone marrow & intestine

Treatment supportive Delayed effects lung cancer, Cataract, Premature aging, skin cancer, leukemia Prevention environmental measures: - Isolation

- use of radiation proof containers

- protective clothing

Medical measures: - pre-employment examination - Periodic medical examination - Health education

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Occupational respiratory diseases caused by dust (pneumoconiosis) Silica, Asbestos, talc, coal

Silicosis A fibrotic lung disease produced by inhalation of dust containing Silicon dioxide.

Etiology It is present in sand, sand stone & granite. In these occupations: Mines, Porcelain manufacture & Glass industry.

Predisposing factors: 1. Duration of exposure (long period 5 — 10 years). 2. Size: Smaller dust particles are more injurious. 3. Concentration: the higher the conc. of dust  the more injurious. 4. The presence of free silica in the dust. 5. Personal susceptibility.

Pathogenesis Silica particles are ingested by alveolar macrophages  carry them to lung tissue  macrophages disintegrate  stimulate fibroblast function & collagen formation, - Damaged macrophages attract others that ingest released silica particles

Pathology Silicosis  nodular fibrosis, layers of collagen (ONION RING APPEARANCE) Clinical picture DYSNEA Complications: Tuberculosis. Corpulmonale as a result of pulmonary hypertension, chronic bronchitis & emphysema

Diagnosis: 1. History of exposure 2. Radiological examination: Nodular shadow 3. Pulmonary function testing FVC, FEV1 below normal levels.

Prevention: A) Environmental measures to reduce dust below TLV (Threshold Limit Value). 1. Substitution

2. Segregation.

3. Enclose of machines releasing dust.

4. Ventilation

5. Wetting Water is sprayed to precipitate dust.

6. Cleanliness

7. Protective clothes

B) Medical measures: 1. Pre-emp1oyment examination 2. Periodic medical examination Community Oct. Med.

3. Health education. 5

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Asbestosis Asbestos is a fibrous material obtained from mines; it has an insulating & fire protecting characters & can resist chemicals.

Hazards: Cement Asbestos industry (used in roofs, buildings & pipes manufacture) During manufacture, fixation, or removal of car breaks.

Pathology Asbestos fibers can be found in the terminal bronchiols or penetrate lung tissue  irritation & injury of lung tissues

- When coated with iron rich protieneanous material  Asbestos Bodies (found in sputum)

Predisposing Factors: 1. Duration of exposure  after 5-10 years. 2. Dose response relationship. 3. Smoking has synergistic effect in production of lung cancer & mesothelioma.

Clinical picture Dysnea, cough & expectoration (Chest pain is an indication of involvement of pleura)

On examination Cyanosis, clubbing of fingers Diagnosis: 1) History 2) X-RAY of the chest Early stages  Frosted glass of cob web appearance. Late stages  opacities appear in lower lobes, pleural fibrosis & calcifications, pleural effusion (in mesothelioma) 3) Sputum examination: ASBESTOS BODIES, Malignant cells may also be seen. 4) Pulmonary function tests: FVC & FEV1 are reduced 5) Bronchoscopy, Lung & Pleural biopsy: to diagnose lung cancer & mesothelioma of pleura.

Complications: 1. Bronchogenic carcinoma. 2. Mesothelioma of pleura or peritoneum. 3. cor-pulmonale.

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Occupational Diseases caused by exposure to Cotton Dust A) Mill Fever Workers in cotton mills for the 1st time suffer the first week fever, muscle aches and malaise. (Diagnosed as common cold or influenza) Cause is unknown; may be Endotoxins of E-coli.

B) Byssinosis Tightness of the chest on the day following a holiday, (called MONDAY FEVER)

Exposure hazards of byssinosis 1) Ginning of cotton dust 3) Carding

2) Bale opening & bale breaking  large amounts of 4) Spinning

5) Weaving

Predisposing Factors 1) Duration of exposure  5-10 years

2) Intensity of exposure

3) Personal susceptibility.

Pathogenesis A) The allergic theory: On exposure to cotton dust antigen antibody reaction develops. B) The chemical theory: assumes presence of histamine releasing substance in cotton dust  BRONCHOSPASM

Pathology: NON SPECIFIC Mucous metaplasia in small airways, Mucious hyperplasia in larger bronchi

Clinical Picture: STAGE 1/2: Tightness of chest occurring OCCASIONALLY in the day following holiday STAGE 1: Tightness of chest occurring on EACH DAY following holiday STAGE 2: Tightness of chest occurring on each day following holiday & EXTENDING FOR FEW DAYS AFTER.

DIAGNOSIS 1. History of exposure

2. Clinical picture

3. Pulmonary function testing: FVC & FEV1 are reduced

Prevention

Environmental measures Community Oct. Med.

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0105068372 Medical measures: 1) Pre-employment examination. 2) Periodic medical examination

Epidemiology of cardiovascular diseases Congenital heart diseases An abnormality in cardio-circulatory structure or function that is present at birth, even if it is discovered much later.

Risk factors: 1. Host factors (Genetic factors)

Offsprings of parents with CHD have malformation rates ranging from 1.4% to 16.1%.

2. Environmental factors:

1. Maternal viral infections: Rubella accounts for 2% to 4% of all CHDs. 2. Maternal X-ray exposure: especially of pelvis  ↑ incidence of Down’s syndrome. 3. Teratogenic drugs as: - Thalidomide & folic acid antagonist - Lithium chloride. - Alcohol

- Anti-convulsion drugs.

- Progesterone / estrogen: acting in the 1st trimester.

4. Acute hypoxia 5. Cigarette smoking  uterine vascular changes 6. Maternal metabolic defects: diabetes mellitus. 7. Obstetric problems association of advanced maternal age with Down’s syndrome 8. Dietary deficiencies during pregnancy  congenital malformation.

Preventio n 1. Genetic counseling of parents & families with CHD. 2. Rubella immunization programs through premarital care. 3. Avoidance of exposure to viral diseases during pregnancy 4. Physician should avoid Teratogenic drugs & radiological influence on the fetal & newborn heart during prenatal care. 5. Family planning services 6. Health education of mothers: to avoid cigarette smoking, alcohol consumption or any drugs without prescription.

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Hypertension The elevation of arterial blood pressure over 140 / 90 in adults

Risk factors a) Host factors 1. Genetic - Heredity interacting with the environmental role  not all hypertensive patients have diseased offspring. - So children of hypertensive parents should be screened & advised to avoid environmental factors that aggravate hypertension (e.g. smoking, physical inactivity, and excess sodium) 2. Low birth weight Low birth weight due to fetal under- nutrition followed by  ↑ B.P. later in life 3. The role of sodium salt in essential hypertension - ↑ sodium intake in diet  ↑ B.P… 4. Obesity: HTN is common among obese individuals  ↑ risk of ischemic heart disease 5. Physical inactivity: Physical fitness  prevent HTN 6. Alcohol intake 7. Smoke: Cigarette smoking  ↑ B.P., through nicotine  release of nor-epinephrin. 8. Hyperuricemia: Present in 25 - 50 % of individuals with untreated 1ry HTN. 9. Ethnic group: Adult blacks have HTN  to higher rises of morbidity and mortality. 10. Sex: Before menopause, HTN is less common in women than in men, but after that HTN is equally common & dangerous in elderly males & females. 11. Age: At old age  more HTN cases & age related atherosclerosis. 12. Diabetes mellitus: HTN & diabetes coexist commonly

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0105068372 Diabetics are susceptible to adverse effects of HTN therapy, because diuretics & βblockers  ↑ insulin resistance.

Environmental factors Tension, anxiety & continuous exposure to external stress factors  ↑ blood pressure in normo-tensives but high ↑ in hypertensives.

Prevention of Hypertension 1. Life style modification: A) Weight reduction: - ↑ exercise

- Use ↓ caloric supplement

B) Avoidance of tobacco C) Dietary Na restriction B) K supplementation: Patients should ↓ K depletion & ↑ dietary K intake E) Mg & Ca supplementation: ↓ B.P. F) Prevent alcohol consumption G) Physical exercise H) Relaxation exercises: ↓ stress & anxiety.

2. Anti-hypertensive drug therapy: Drugs are used if: - life style modification is not followed or ineffective with the patient - ↑ HTN at the onset

3. Management of etiology of 2ry hypertension.

Bronchial asthma Asthma cannot be cured, but could be controlled.

CAUSES 1. Indoor allergens (e.g. domestic mites, carpets & furniture, cats) 2. Family history of asthma or allergy.

3. Tobacco smoke.

4. Exposure to chemicals in the workplace. 5. Drugs: aspirin & NSAIDs. Community Oct. Med.

6. Low birth weight & respiratory infection. 10

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0105068372 7. Weather (cold air) 8. Extreme emotional expression & physical exercise. 9. Urbanization.

Preventio n 1. Increase public awareness 2. Organize global epidemiological surveillance to monitor asthma 3. Develop & implement a strategy for its prevention 4. Stimulate research into the causes of asthma to develop new control strategies & treatment techniques.

Cancer Descriptive epidemiology Cancers arise from undifferentiated stem that are capable of mitotic division & differentiation. 1. Age: most cancers develop in the 6th, 7th, 8th decades of life. 2. Sex: cancers of non-sexual sites occur in men than women, except in gallbladder & bile ducts. 3. Race & Geography: Cancers varies among racial groups in the same country.

This variation is due to: - Cultural patterns

- genetic difference among the races - social behavior

- economic status.

4. Time Trends: - The high ↑ in rates of lung cancer is largely due to cigarette smoking. - Decline in rates of stomach cancer is unknown but may be related to dietary habits, (consumption of less preserved & more fresher foods) - Decline in mortality from uterine cancer is probably due to combination of 3 factors: 1. ↓ number of women who still have a uterus 2. ↑ cytological screening

3. Decline in the incidence of new cases

Etiology & 1ry prevention Initiators - Agents cause the genetic damage to the stem or intermediate cells. - Ionizing radiation, chemicals & certain viruses Community Oct. Med.

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0105068372 Initiators  rearrangements in DNA  ↑ expression of normal genes (ONCOGENES) Promotors  ↑ rate of growth & number of stem & intermediate cells (targets for initiators)  to enhance growth of tumor cells Estrogens  ↑ proliferation of endometrium  endometrial cancer

Risk factors 1. Tobacco - Compared to non-smokers, risk in the average cigarette smoker is - ↑ 10 fold  lung cancer,

- ↑ 8 folds  laryngeal cancer

- ↑ 4 folds  mouth & pharynx - ↑ 3 folds  esophageal cancer - ↑ 2 folds  bladder, renal pelvis, ureter & pancreas - Risk is increased by about 30% in non-smoking members with a resident smoker.

2. Alcohol - Risk of neoplasms is associated with alcohol consumption. - Hepatocellular carcinomas develop at ↑ rate in alcoholics with macro-nodular cirrhosis. - ↑ Risk for carcinomas of mouth (buccal cavity & pharynx) & esophagus

3. Industrial exposures Specific exposure

Site or tumor type

Arsenic & arsenic compounds

Lung, skin

Asbestos

Lung, mesothelioma

Benzene

Leukemia

4. Drugs not an important cause of cancer (account for less than 1% of neoplasms) 5. Ionizing radiation - Among the atomic bomb survivors in Japan there were - High ↑ in rates of carcinomas of thyroid & mammary glands & of leukemias - Lesser ↑ in rates of lymphomas & carcinomas of stomach, esophagus, & bladder - Risk of leukemia ↑ in early radiologists who took few precautions against radiation

6. Non-ionizing radiation Community Oct. Med.

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0105068372 Sunlight cause squamous & basal cell carcinomas of skin (occur on exposed parts of body)

7. Exogenous hormones - ↑ endometrial cancer in women receiving estrogens for menopausal conditions

8. Infectious agents: EBV  nasopharvnea1 carcinomas HBV  Hepatocellular carcinoma (Hepatoma) HBV viral DNA  cervical cancers Human immunodeficiency virus (HIV)  AIDS An RNA virus  Kaposi sarcoma & non Hodgkin’s lymphomas

9. Nutrition Aflatoxins produced by fungi  liver cancers it some parts of the world. Food additives May be carcinogenic, the evidence is weak - ↑ artificial sweeteners  ↑ risk of bladder cancer - ↑ fat diet  cancers of colon, breast & prostate Over-nutrition  obesity  associated with endometrial & postmenopausal breast cancers N.B. - Fibers in diet ↑ bulk of bowel contents & ↓ intraluminal carcinogens by ↓ contact of colonic mucosa with carcinogens. - ↑ Fresh fruits Diets & raw vegetables  ↓ carcinomas risks in GIT & RT.

10. Reproductive factors Single women (specifically nulliparous)  at ↑ risk of ovary, endometrium & breast cancers.

11. Genetic factors Some individuals exposed to a carcinogen  develop cancer & others with identical exposure do not, Due to differences in genetic susceptibility to carcinogens - Carcinomas of breast & prostate. - Malignant melanomas occur in light skinned individuals with blond or red hair & blue eyes. - Stomach cancers occur more in persons with blood gp A.

Hazards of blood transfusion 1. Infection

2. Blood incompatibility.

3. Sensitization of Rh

4. Fever due to pyrogens.

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n 1. Precautions with blood donors: 1. Must be healthy & not addicts. 2. Must be free of infection: no history of recent disease, especially viral hepatitis & testing blood for any existing infection. 3. Blood grouping: ABO & Rh to be registered in the identity cards.

2. Precautions with blood recipients: 1. Blood grouping: ABO & Rh, if not already registered in identify card. But if not available, & no facilities or time for pre-transfusion grouping, group 0 (RH -ve for females) blood is used. 2. Supervision of the case during & after the process of transfusion, for any reaction Family Planning Service It is a basic need of reproductive health, safe motherhood & child health & survival

Aim of family planning services 1. Avoid pregnancy outside the safe childbearing period (20 —34 years). 2. Allow for having the suitable no. of children & avoid unwanted pregnancy 3. For proper pregnancy spacing. 4. For mothers having chronic disease.

Methods for family planning 1. Natural methods: Safe period, lactation, isolation 2. Mechanical: Condom, vaginal diaphragm, cervical cap, IUD 3. Chemicals: Vaginal foam, tablets & vaginal creams 4. Hormonal: Contraceptive pills

Benefits of Proper inter-pregnancy spacing For the sake of mother: 1. Protection of mothers from risk of multiple pregnancies & labour 2. ↓ maternal mortality ratio. 3. Malnutrition including teeth decay & osteomalacia. 4. ↓ health hazards of pregnancy & labour: e.g. toxemia & puerperal sepsis. 5. ↓ hazards related to urogenital system e.g. fistulae, uterine prolapse. 6. ↓ hazards of illegal abortion to get rid of unwanted child.

For the sake of foetus Community Oct. Med.

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0105068372 ↓ Infant mortality rate & ↓ congenital Abnormalities & pregnancy wastage, lethal sublethal. - Mother give better care nutritional, psychological, education & medical care for smaller number of children.

For the sake of husband 1) Better psychological & emotional states. 2) Better working for the non loaded father.

For the community 1. Better educational level. 3. Increased percapita share.

2. Better housing. 4. Improvement of health services.

5. The public resources is allotted to industrial & national promotion program.

Care of the Newborn - Neonatal care contributes to maternal health, reproductive health & safe motherhood. - Neonatal care aims at: health promotion of newborn, prevention of morbidity & mortality.

Outcome of Pregnancy: 1. Favorable: delivery of a healthy live born. 2. Unfavorable i.e. dead baby (called pregnancy wastage), It is of two types: • Lethal i.e. abortion, miscarriage, stillbirth, neonatal death & postneonatal deaths • Sublethal: e.g. congenital anomalies, mental retardation, cerebral palsy, Also prematurity.

Factors affecting the outcome of pregnancy 1. Age of mother, risk is below [6 and above 40 years 2. Parity risk is lowest with parity 1-4 3. Pregnancy spacing, most suitable 2-3 years 4. State of maternal health including: - Body built (height) - Syphilis and malaria - Drugs & radiations

- Nutritional status - Smoking - Outcome of previous pregnancy.

5. Factors related to labour: Analgesic or anesthetic drugs given during labour  Prolonged labour, malposition Community Oct. Med.

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0105068372 6. Infection acquired by the foetus during labour 7. Social factor: Poor living conditions and lack of medical care

Maternal mortality Maternal mortality: a biostatistical index which monitors the safety of the reproductive process through which mothers in the reproductive age might pass through. The interaction between the maternal fitness & environmental factors would determine the process of maternity and its outcome part of which is the maternal survival - Maternal mortality is death of women during performing their maternity function at pregnancy, delivery or puerperium. Maternal Mortality is one of the main indicators of the health status & welfare of a community.

Ecology of maternal mortality Agent - Failure of adaptation to pregnancy, delivery or puerperium. - Occurs when the stress of the maternity process exceeds the vital reserve of the mother.

Host - Mothers who are intolerant to maternity stress might be due to: 1. Limited vital reserve due to constitutional factors 2. Incomplete recovery of their vital reserve due to previous maternity or other stressing factor (recovery needs 2 years at least). 3. Morbid condition whether limiting her vital reserve to the maternity process. • Endocrine Balance: Pregnancy & delivery are the stresses to which mothers are exposed. Community Oct. Med.

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0105068372 • Nutrition: Proper nutrition makes mother more tolerant to stress of maternity process. • Age: Excess of deaths among older women & excess among women younger than 20. - Risk of maternal death was higher in mothers aged more than 40 years • Parity: Maternal mortality is high among primipara then it drops & reincreases again among those who had five or more children.

Time of maternal death The 2000 NMMS found that most maternal deaths took place during delivery or postpartum: Maternal deaths in 2000 were more likely to occur during delivery (49% compared to 39% in 1992-93) and less likely to occur during the postpartum period (27% compared to 35% in 1992-93).

Causes of maternal mortality” - There are three groups of causes which lead to maternal mortality”

1. Direct causes These are the causes due to complications of pregnancy, delivery & puerperium & trials to manage the case during this maternity process including abortion. The three leading causes of maternal mortality in Egypt: haemorrhage, toxemia & sepsis. - Hemorrhage before & after delivery (43%of maternal death), with most hemorrhage deaths due to postpartum hemorrhage. - Other direct causes: hypertensive disease of pregnancy (22%), sepsis (8%), ruptured uterus (8%), cesarean section (7%) & obstructed labor (5%).

2. Indirect causes - These are causes due to aggravation of pre-existing conditions as rheumatic heart during pregnancy, delivery & purperium. - Cardiac disease: the indirect cause of maternal deaths (13%) - Anemia was the second most important indirect cause of maternal death (11 %).

3. Causes not related to the mortality process: as traffic accidents

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Interventions to reduce maternal mortality 1. Setting up maternal mortality committees on national, regional & local levels & keeping them operative. 2. Improving the system for the registration & capture of information of all heath actions relating to pregnancy, delivery & family planning. 3. Ensuring the existence of a national system for the epidemiologic surveillance of mortality of women of reproductive age that provides data of sufficient quantity & quality to determine the real scope of the problem, the structure of its causes & the social determinants of maternal mortality. 4. Incorporate the investigation of maternal mortality within the routine work of personnel working in MCH Units. 5. Formulate maternal mortality panel at district level so as to be able to thoroughly revise the causes of conditions of every maternal health. 6. Training Obs/Gynophysician at hospitals on accurate diagnosis of direct & underlying causes of maternal deaths. 7. Establishment of system for accurate diagnosis of maternal deaths in death certificate in the health office. 8. Set monthly audits to discuss any case of death due to pregnancy & labor to determine the cause of death 9. Community education and mobilization is essential so that women & their families learn about the need for special care during pregnancy & childbirth.

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0105068372 10. Community education must address traditional beliefs about pregnancy-related complications that are often blamed on a woman’s behavior, fate, evil influences & other factors beyond the reach of the health system. 11. Dialogue among communities, policy-makers, and health system staff is essential to identify ways of overcoming barriers to women seeking maternal care.

Child Health Care - MCH centers are responsible for care of under 5 years children (from birth to school age), & include infants & preschool children.

Objectives of the child health care program 1. Monitoring of growth & development of children. 2. Implementation of the program of compulsory (obligatory) vaccination to prevent diseases. 3. Treatment of common diseases & early detection of critical cases to be referred to specialized clinics. 4. Control of infectious diseases. 5. Minimization of under 5 years mortality. 6. Prevention of diarrhoeal diseases as well as respiratory tract infection. 7. Health education. 8. Rehabilitation.

Health problems among children (1) Morbidity

(2) Mortality

(1) Morbidity problems I. Infectious diseases.

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III. Malnutrition.

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V. Social disorders.

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0105068372 II. Parasitic infections

IV. Accidents.

VI. Handicapping (disability).

I. Infectious diseases - Infection is a health problem in developing countries. - It may be congenital or acquired.

(a) Congenital infection It is in utero infection (vertical infection) - Transmitted from the mother to her - embryo (during the 1st trimester) before formation of placenta - fetus (trans-placental infection) N.B. Congenital infection lead to unfavorable outcome of pregnancy which is lethal (abortion, still birth) or sublethal (congenital anomalies or congenital diseases e.g. Syphilis, Rubella syndrome, , AIDS) Forms of congenital infection: Syphilis, rubella, cytomegallo inclusi5n virus, hepatitis B virus infection, AIDS, Toxoplasma gondii.

(b) Acquired infections (classification acc. to the age of the child) 1. Neonatal infections: Infections acquired during the 1st 4 weeks after birth. - These infections are acquired during the process of delivery from the birth canal of the mother or faulty practices after birth, environment has very little contribution to acquired neonatal infection. Important forms of neonatal Infections: Opthalmia neonatoruan, conjunctivitis, Otitis media, Pneumonia, Herpes simplex, Tetanus neontorum, diarrhoeal diseases of new born, AIDES, cytomegallo inclusion virus. 2. Prenatal infection: infections occur in the prenatal period (from the 28th week of intrauterine life till the 1St week neonatal period). 3. Infections occurring in infants: (Children during the 1st year of life) They are exposed to: a. Diarrhoeal diseases it was the 1st killer for infants accounting for half of deaths of infants.which before the introduction of ORT, b. Acute respiratory tract infections (Upper & lower). c. Infective conjunctivitis & infective skin diseases. 4- Infections of childhood Community Oct. Med.

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0105068372 - Many infectious diseases are endemic in the developing countries. - Susceptibility begins from the 6th month of infancy due to the fade out of maternally acquired immunity except for pertussis & T.B. in which there is no maternally acquired immunity. - Pertussis: Big molecule of immunoglobulin “M”, that can not pass through the placenta. - Tuberculosis: cell-mediated immunity. The risk of infection is aggravated by faulty breast feeding practices, malnutrition & faulty weaning practices. Infectious diseases occur in sporadic cases, epidemics or outbreaks.

Forms of infectious diseases: 1. Poliomyelitis: sporadic cases in endemic areas like Egypt (no epidemics). 2. Diarrhoea 3. Acute respiratory tract infections (ARI). 4. Measles. 5. infective conjunctivitis & skin diseases. 6. Tuberculosis: (milk borne) intestinal TB.

Prevention of infectious diseases in childhood 1. Maternal measures a) Health education of mothers & girls b) Premarital care: active immunization & treatment of any infection. c) Prenatal care: Health appraisal, active immunization by tetanus toxoid (no live vaccines during pregnancy). d) Intra-natal care: Asepsis is the rule

2. Child care measures: a) Neonatal care: 1. Aseptic cutting of the cord & slump dressing. 2. Antibiotic eye drops immediately after birth 3. Early initiation of breast feeding within half an hour after birth & establish good breast feeding practices. b) Health appraisal  for diagnosis & management of morbidity that may predispose to infection. c) Proper nutrition. d) Prevention of infection in low birth weight units, incubators & paediatric units Community Oct. Med.

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II- Parasitic diseases Some parasitic diseases are endemic in developing countries particularly in rural areas e.g. Entrobius vermicularis (most prevalent), Schistosoma (infrequent in preschool children),

Ascaris lumbercoids, giardia lamblia, Hymenolepis nane, Entamoeba histolytica, Ancylostorna, Malaria Impact of parasitic diseases on child health: a) Impairment in physical & mental development. b) Predispose to malnutrition.

IIIMalnutrition About 50% -60% of under 5 years mortality is at attributed to or associated with malnutrition. Important forms of malnutrition: Iron deficiency anaemia, Protein-energy malnutrition Rickets, Vit A deficiency, Riboflavin deficiency, I2 deficiency (endemic goiter). The government compat vit A deficiency by its adminstration to pregnant females (600.000 iu) & to infants at the 9th month l00000 iu) also, iodinization of table salt to combat iodine deficiency

IVAccidents Below-five-year children are exposed to Varity of injuries starting from birth injuries, home & road injuries.

V- Social disorders Contributing factors 1) Big family size & low percapita income. 2) Poor housing & high crowdness index 3) Low socioeconomic standards 4) Separation of parents (loss of love & security) 5) Mother’s Employment (lack of close with mother)

VI- Handicapping (Disability) Definition: Any physical, mental, social or psychological morbidity that interferes with leading normal life & activities. Community Oct. Med.

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0105068372 - It is classified according to its etiology into: a) Congenital

b) Acquired

a) Congenital handicapping Examples: Mental retardation — Microcephaly — Hydrocephalus — cleft lip or palate. Causes: 1. Genetic factor: Gene mutation & chronomosomal abrasion e.g down’s syndrome. 2. Inutero Exposure to adverse condition: a. Maternal infection acquired during pregnancy e.g. toxoplasma gondii, hepatitis B infection, syphilis, measles, mumps, rubella. b. Live vaccines administered to pregnant mothers during or shortly before (less than 3 months) pregnancy. c. Teratogenic agents (drugs, heavy metals, radiation). d. Smoking: risk factor for low birth weight & prematurely. e. Air pollution & Malnutrition of the mother may play a role: Examples i. Iodine deficiency predispose to congenital cretinism. ii. Severe protein deficiency may predispose to LBW

Prevention: Congenital disability could be prevented through premarital, preconceptional & pre- natal care. 1. Premarital care a. Premarital counseling & examination for diagnosis & treatment of sexually transmitted diseases, genetic counseling to avoid hereditary diseases. b. Vaccination in non immune couples; females are vaccinated at least 3 months before pregnancy. c. Health education for healthy life & avoid any harmful practices that may affect pregnancy. 2. Prenatal care: to ensure healthy safe intrauterine growth & development & to avoid adverse intrauterine. 3. Health education: It is a continuous process to preparation of girls to be the future mothers. It is continued till child birth. Community Oct. Med.

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Control - Case finding: It is better to be carried out at birth. - Management of case: Once diagnosed start medical, social & educational care & rehabilitation of the case physically, mentally, psychological & socially to lead independent life.

b) Acquired handicapping - It is disability acquired at any age of childhood, adolescence or geriatric age group. - Acquired disability during child hood is due to either or as complications for some infectious diseases. 1) Accidents: a. The 1st accident that might occur is birth injury that may lead to neurological damage. b. Home accidents e.g fall, swallowing of caustic materials that lead to permanent oesophageal fibrosis. c. Road accidents: traffic accidents. 2) Complications of infectious diseases: a) Streptococcal pharyngitis: improperly treated case may be complicated with: a. Impaired hearing & conductive deafness. b. Rheumatic heart disease.

c. Glomerulonephritis.

d. Conjunctivitis (purulent) is the most common cause of blindness in Egypt (corneal opacity as a result of corneal ulceration). - Corneal opacity has no treatment except corneal transplantation. e. Poliomyelitis: paralytic form lead to paralysis. f. Meningococcal meningitis: it is complicated by paralysis of cranial nerves subnormal mentality. h. Diphtheria.

i. Leprosy.

j. Tuberculosis

k. Syphilis,

Forms of handicapping - Impaired hearing, vision, blindness, paralysis, rheumatic heart disease, skeletal deformity & mental retardation.

Prevention 1- Primary prevention - Prevention of infections diseases by general or specific measures e.g. vaccination & chemoprophylaxis. Community Oct. Med.

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0105068372 2- Secondary prevention - Early case finding & management of infectious diseases through health appraisal. - 1st aid, emergency services for early management of infection & accidents. 3- Tertiary prevention: - Rehabilitation of cases suffering from any disability. - It is comprise of physical, mental social rehabilitation.

Quality of health care

Quality It defined as “Fitness for purpose”. Or as “conformance to specification” Or as "a degree or standard of achievement”. - The British standards Institute defines quality as the totality of feature & characteristics of a product or service that bear on its ability to satisfy stated needs. - Quality of technical care consists of: application of medical science & technology in a manner that maximizes its benefits to health without increasing its risks. - Degree of quality is, the extent to which the care provided is expected to achieve the most favorable balance of risks & benefits. - Quality of health care is a process of change or fully meeting requirements of lowest cost or more specifically full meeting the needs of consumers Quality:- Doing the right thing  Appropriate. - Doing the right thing right  Effective. - Doing the right thing for 1st time & every time  Efficient. Community Oct. Med.

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0105068372 How Can we improve? - We must change:

Change  Improvement  Quality

How change? 1. Cooperation 2. Involvement 3. Education Resources - The costumer: Expectation & rights & satisfaction, • Measuring Quality? - Structure - Process - Outcome

4. Management

5.

Total Quality Management (TQM)

Definitions: • Definitely customer focused. • Philosophy, concepts, tools & techniques focused. • Emphasis in employee involvement. • Continuous improvement and TQM a never ending journey. • Organization wide-all departments function and level. • Everyone responsible for quality. • Involves process and culture change. The quality control proces 1. Evaluate actual operating performance. 2. Compare actual performance to goals. 3. Act on the difference.

TQM • Total Quality management is about improvement. • Improvement requires change • The change process requires consensus between all concerned. • Education & training may assist the process of change but it is not sufficient by itself changes in the organization’s policies, structures & technical systems are also likely to be necessary.

Practical approach of TOM

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0105068372 Quality Improvement in Health Care • Quality council • Team work • Information system • Reducing deficiency in the services • Adding new services • Better care under limited budgets • Attract new customer • Lower the cost of services • Customer satisfaction — Internal (health team provider). — External (population & patients)

Total quality management

— Quality planning: adding new services

— Quality improvement: removed deficiencies

— Quality control: establish standard for structure and process, measure actual performance & corn pare to standard & regulate the process.

Family Medicine

Principles of Family Medicine 1. Continuity of care 3. Coordinated care 5. Health care in the community context.

2. Comprehensive care 4. Care of patient in the family context

1. Continuity of care

Family practice is defined as the medical specialty that provides continuity and comprehensive health care for the individual & the family.

2. Comprehensive care

Family practitioners can provide independent care for 85 90% of problems encountered in daily practice. - Comprehensive care may be synonymous with personal medicine. - Personal medicine is a process of providing broad-based health care which both physician & patient recognize that the relationship extends beyond that of provider and client. - When providing personal medicine, the physician may act as advisor, advocate, confidant or healer. Community Oct. Med.

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0105068372 - The specialty of family physician including adolescent health care, sports medicine, addiction medicine and geriatrics.

3. Coordinated care

- Family physician have traditionally served as the patient’s first contact and point of entry into the health care system. - Hence, care is provided for all problems. - This physician serves as the patient’s or family’s advocate in all health-related matters, including the appropriate use of consultants and community resources. - His training and experience qualify him to practice in the several fields of medicine & surgery.

4. Health care of the patient in the family environment

Family is part of family physician and family practice is integral to their definitions.

5. Family practice

- is a people —oriented specialty physicians today choose family practice because they wish to be people doctors not doctors for organs, machines or age groups. General guidelines for family medicine 1. Provide personal care for individual & family 2. Manage acute & chronic medical problems in the community. 3. Provide anticipatory (predicted) health care using education, risk reduction, & health enhancement strategies. 4. Provide continuous health care, not limited by a specific disease 5. Provide comprehensive care of complex and sever problems. 6. Establish physician-patient relationships by using interpersonal communication skills to provide quality health care. Five Star Doctor - The concept of the “five-star doctor” is an ideal profile of a doctor possessing a mix of aptitudes to carry out the range of services that health settings must deliver to meet the requirements, quality, cost-effectiveness & equity in health. - The five sets of attributes of the “five-star doctor” are summarized as follows: - Care provider - Community leader

1. Care-provider

- Decision-maker - Manager

- Communicator

- Besides giving individual treatment “five- star Doctors” must take into account the total (physical, mental & social) needs of the patient. - They must ensure that a full range of treatment — curative, preventive will be dispensed in ways that are complementary, integrated & continuous. - And they must ensure that the treatment is of the highest quality.

2. Decision-maker

“Five-star doctors” have to take justified & efficient decisions. 28 Community Oct. Med.

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0105068372 - In treating a given health condition, the one that seems most appropriate in the given situation must be chosen.

3. Communicator

- The doctors of tomorrow must be excellent communicators in order to persuade individuals, families & the communities in their charge to adopt healthy lifestyles & become partner in the health effort.

4. Community leader

The needs and problems of the whole community- in a suburb or a district — must not be forgotten. By understanding the determinants of health inherent in the physical and social environment “five-star doctors” will not simply be treating individuals who seek help but will also take a positive interest in community health activities which will benefit large numbers of people.

5. Manager

- To carry out all these functions, it will be essential for “five-star doctors” to acquire managerial skills. - This will enable them to initiate exchanges of information in order to make better decisions.

Vaccination Schedule

Vaccine or Toxoid

Dose

First 3 months

• BCG for tuberculosis,

0.1 ml intradermally in deltoid region (without tuberculin test).

2nd month

• Sabin (poliomyelitis). • Hepatitis B vaccine. • Quadruple vaccine (OPT + polio salk)

- 3 drops on tongue - 0.5 ml IM - 0.5 ml IM or deep subcutaneous.

4th month

• Sabin (poliomyelitis). • Hepatitis B vaccine. • OPT.

- 3 drops on tongue. - 0.5 ml IM. - 0.5 ml IM or deep subcutaneous.

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0105068372 6th month

• Sabin (polio). • Hepatitis B vaccine. • OPT.

- 3 drops on tongue. - 0.5 ml IM. - 0.5 ml IM or deep subcutaneous.

9tb month

• Measles.

- 0.5 ml subcutaneous.

18 to 24th month

• DPT. • MMR (measles, mumps, Rubella) • Sabin (polio).

- 0.5 ml IM. 0.5 ml subcutaneous. - 3 drops on tongue.

Ten steps to successful breast feeding

1. Have a written breast feeding policy communicated to all health care staff 2. Train all health care staff necessary to implement the policy. 3. Inform all pregnant women about the benefits and management of breast feeding. 4. Help mothers initiate beast feeding within a half-hour of birth. 5. Show mothers how to breast feed 6. Give new born babies no food or drink other than breast milk unless medically indicated. 7. Practice rooming in-allow mothers and babies to remain together-24 hrs a day. 8. Encourage breast feeding on demand. 9. Give no artificial teats. 10. Establishment of breast feeding support groups.

What is Optimal for Breastfeedinr Practice?

1. Initiation of breastfeeding within about one hour of birth.

newborn should be offered the breast as soon after delivery as possible, preferably within one hour of birth. Nothing, nothing all except breast milk, should be given to a young infant. Early initiation stimulates breast milk production. Community Oct. Med.

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0105068372 - It fosters mothers—child bonding and serves the baby’s first immunization with antibodies present in colostrums (the 1st milk).

Early initiation of breastfeeding is beneficial

For the mother • Early suckling promotes the release of a hormone that reducing the risk of mother’s haemorrhage after labor. - It helps the uterus to shrink back to normal size. - The suckling action can help expel the placenta & reduce postpartum hemorrhage. • Establishment of emotional bond between mother and child. For the child • It is important to receive the colostrums which contains antibodies that protect infant against illnesses & enhances the baby’s immune system. - Early & frequent feeding may bring in mother’s milk more quickly. - The infant will immediately benefit from the protective effect of the concentrated amounts of antibodies present in colostrum. The colostrums is like a first immunization.

2. Frequent, on-demand feeding (including night feeds)

Why young infants should suckle frequently? An infant should suckle frequentlr, both day and night. Frequent feeds are needed because: • An infant’s stomach is small and can only take in a limited quantity of breast mild at any one time. The small stomach needs to be refilled often. • Breast milk is perfectly adapted to the baby. - This means Ms more easily and quickly digested than other foods, and the infant will need to feed often. • Since the supply of breast milk is dependent on demand, frequent feeds are needed to keep up a mother ‘s milk supply. • Frequent suckling maximizes the contraceptive benefit to mothers and helps delay the return of menses. N.B. An infant should be put to the breast 8-12 times per 24 hours, for about 10-20 minutes on each breast. - Infant should sleep with the mother so that it can feed “on demand”. Reproductive health A state of complete physical, mental, & social wellbeing & not merely the absence of disease or infirmity (‫)عجز‬, in all matters related to the reproductive system & to its function & processes. Components of Reproductive Health I. Health promotion of females, from birth, childhood, adolescence & childbearing period. II. Safe motherhood. III. Family planning service. IV. Prevention & management of: • Complicated abortion. Community Oct. Med.

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0105068372 • Infections of reproductive system, including STDs. • Noninfectious hazards of reproductive system. • Infertility. • Management of menopause. V. Elimination of harmful practices for girls & women. VI. Care of the Newborn Basic Requirements for Safe Motherhood 1. Preconceptional Care: 1- Health promotion • Proper nutrition • Prevention of infectious diseases • Health education 2- Premarital guidance Education includes: • Family life • Family planning • Child bearing 3- Premarital immunization • Mumps for males and females not affected before • German measles for females not affected before. 4- Premarital examination Includes: • Complete family and medical history • Systematic medical examination • Investigations X-ray of chest, RH factor & Wasserman reaction 2. Obstetric Care A. Prenatal care for safe childbirth a) Early, regular, & good antenatal care including: 1. Nutrition 2. Screening for high risk 3. 1ry & 2ry prevention of certain conditions as anemia. 4. Health education: to make women understand nature of maternity process, how to care for themselves, the service resources available around & how to benefit of it. 5. Treatment of mild diseases if occur 6. Immunization: against tetanus to prevent tetanus of child & post partum tetanus of mother. b. Recognition of & early care seeking for danger signs. c. Birth preparedness d. Plan for emergencies e. Immunization against Tetanus With Tetanus Toxoid. Immunization of Pregnant Women Against Tetanus With Tetanus Toxoid (TT) - Tetanus Toxoid protects all women of child-bearing age, including pregnant women during & after labour. Child must be vaccinated with the 1st dose of DPT at 2 months of age. The reasons underlying the female malpractice: 1. Psychosexual reason reduction or elimination of the sensitive tissue of the outer genitalia, particularly the clitoris, in order to attenuate sexual desire in the female. 2. Sociological reason identification with the culture heritage, initiation of girls into womanhood. 3. Hygiene reason the external female genitalia are considered dirty & unsightly and should be removed to promote hygiene. 4. Religious reason there is no substantive evidence that it is a religious requirement. 5. Myths (‫)خرافة‬enhancement of fertility & promotion of child survival. Community Oct. Med.

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0105068372 Levels & Trend of the Problem in Egypt - Maternal Mortality is measured through the maternal mortality ratio = = no. of mothers who died due to pregnancy, delivery and puerperium 1000 live Births at the Same Period & Locality - There is a definite drop of maternal mortality rate. “National Maternal Mortality in Egypt during 1992-93”, determined the mortality to be 174/100.000 live births). - In the 2000, National Maternal Mortality Study of maternal death carried out in Egypt, maternal mortality decreases to 84/100,000 live births. - This direct reduction of more than 50% is a remarkable achievement Egypt’s efforts to improve the quality of obstetric care, ↑ access to family planning, & educate women about see medical care.

Non-human resources (to decrease maternal mortality) 1. Transportation & communication 2. Drugs 3. Blood & plasma expanders 4. Hospital & maternity homers 5. Reproduction regulators 6. Training facilities & resources 7. Research facilities & funds 8. Health education resources Main Avoidable Factors contributing to maternal Death 1. Health Provider Factors General practitioners contributed disproportionately to maternal deaths, due to delays in referral of woman with obstetric complications & misuse of drugs used to speed up labor. 2. Woman & Family Factors Failure by the woman or her family to recognize danger signs and consequently delay in seeking care, was the second most 3. Health Facility Factors Shortage of blood was the most frequent health facility factors, contributing to 16% of maternal deaths. 4. Main Medical Care of Maternal Death Medical causes of death were classified in direct causes and indirect causes. Community Oct. Med.

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0105068372 - Direct causes were responsible for 77% of maternal deaths - Indirect causes for 20% of maternal deaths. For 3% it Health record It is a file initiated at birth of any child & follows him (her) to school & through the whole life, for registration of all concerning health & morbidity. Contents of health record 1. Birth data (date, weight, length, head circumference and any detected abnormality. 2. Results of health appraisal at the periodic visits to the MCH center as. a- General health status & body built. b- Growth monitoring by anthropometric measurements plotted on growth chart for early detection of any deviation from normal to be managed. c- Criteria of developmental milestones according to age. 3. Vaccinations given, by date & age. 4. Curative services provided on morbidity & referral if any value of health record. Value of health record 1. Follow-up and growth monitoring. 2. a data for statistical analysis for comparison between countries, current & past states. Health hazards of smoking Health hazards 1. Malignancy: Cancer lung & other parts of the body (mouth, larynx, Pharynx, esophagus) 2. Cardiovascular disease: - CHD & Cerebrovascular disease. - stroke. * Peripheral vascular disease. 3. Respiratory hazards other than cancer: - Bronchitis, emphysema, Asthma. 5. Unfavorable outcome of pregnancy: risk of abortion, & Congenital Hazards. 4. Peptic ulcer. 6. Others, e.g. gingivitis, heart burn, and indigestion. Particular hazards to which females smokers are exposed 1. Unfavorable outcome of pregnancy. 2. Cardiovascular hazards in contraceptive pill users. 3. Increased incidence of CHD and lung cancer. Control of smoking 1. Extensive education program. 2. Management of smokers, and helping them to give up. 2. Restriction of manufacture, sale and advertising of Cigarettes

Vital & Morbidity Statistics Functions & Purpose of Vital and Health Statistics 1. Research: (diagnosis & treatment) in medicine, surgery and public health researches. 2. Organization: in prevention and control of diseases. 3. Planning health program 4. Evaluation of Health program 5. For comparison between one country & another and with one country over the years.

Mortality Statistics Community Oct. Med.

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0105068372

Death: It is the postnatal cessation of vital function without capability of resuscitation. Crude Death rate C.D.R. =

Specific Death Rates: rates calculated by taking in consideration one or more of characteristics of population like age, sex, occupation, religion Specific Death Rate =

Sex Specific Mortality rate =

Case fatality rate =

Infant mortality rate IMR: The infant is the baby in his first year

Causes of infant deaths A) Biological: • Congenital malformation • Prematurity • Rh factor • Birth injuries and birth complication. B) Environmental • Respiratory infection • Gastroenteritis • Malnutrition • Accidents C) General Factors: • Ignorance • Low income • Big family Leading causes of infant mortality in Egypt Bronchitis, pneumonia and bronchopneurnonia, gastroenteritis, prematurely constitutes (90%) of death. Other causes constitutes (10%) of deaths. Causes of death (other cause 10%) of infant in the first year of life are. Tetanus, Pertussis, Measles, Diphtheria, T.B., Poliomyelitis, Meningitis, PEM and accidents Neonatal Mortality Rate = Post-neonatal mortality rate =

Morbidity Statistics Incidence Rate = Prevalence Rate = Measures of fertility Community Oct. Med.

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0105068372 1- Crude birth rate C.B.R. =

2- General fertility rate (G F R)= 3- Age specific fertility rate (ASFR) = Basic Hospital Medical Records a. Diagnostic summary index: listing of admissions with dates, diagnosis and operations. b. Admission and discharge records. c. History and physical examination. d. Progress notes. e. Discharge summary. f. Physician’s orders. h. Nurses note. i. Vital signs record Temp, pulse, respiration, blood pressure, state of consciousness. Uses of Medical Records 1. Document the course of the patient’s illness and medical treatmentt inpatient or an outpatient. 2. Serves as a basis for planning individual patient care. 3. Provide continuity of patient care on subsequent admission of the patient. 4. Review, study and evaluate patient care by hospital or medical staff committees. 5. Provide data for fluid parties concerned with the patient e.g. governmental agencies. 6. Communicates between the physician and other professionals contributing to patient care.

FEV1: Forced Expiratory Volume in the first second. The volume of air that can be forced out in one second after taking a deep breath, an important measure of pulmonary function. Fibroblasts cells of connective tissue play a critical role in wound healing.

They are the most common cells of connective tissue in animals. Emphysema is a type of cshronic obstructive lung disease. It is often caused by exposure to toxic chemicals or long-term exposure to tobacco smoke. Emphysema is caused by loss of elasticity (increased compliance) of the lung tissue, from destruction of structures supporting the alveoli, and destruction of capillaries feeding the alveoli. Lungs overworking your heart Cor pulmonale is failure of the right side of the heart caused by prolonged high blood pressure in the pulmonary artery and right ventricle of the heart.

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0105068372 Forced vital capacity (FVC) measures lung volume which will be reduced if the lungs are stiffened by scar. Mesothelioma is a rare form of cancer (malignancy) that most frequently arises from the cells lining the sacs of the chest (the pleura) or the abdomen (the peritoneum). Appraisal: ‫تقييم‬ Asepsis: ‫خلو من الجراثيم‬ infrequent ‫نادر‬ Prevalent: ‫منتشر‬

Percapita: each person Microcephaly: the condition of having a small head or having reduced space for the brain in the skull, often associated with learning difficulties Hydrocephalus: an increase of cerebrospinal fluid around the brain, resulting in an enlargement of the head in infants, because the bones of the skull are still unfused. The fluid is blocked by a congenital condition or a disease, and can be drained into the abdominal cavity. Mumps: an acute contagious disease, usually affecting children, that causes a fever with swelling of the salivary glands and sometimes also affects the pancreas and ovaries or testes. It is caused by a virus and can be prevented through vaccination. It may cause sterility if contracted by a man. Rubella: a highly contagious viral disease, especially affecting children, that causes swelling of the lymph glands and a reddish pink rash on the skin. It can be harmful to the unborn baby of a pregnant woman who contracts it.

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