Investigation, Primary Health Care ( Phc )

Presented by DR. Nihal salah Shihab

Professor in Public Health and Preventive Medicine

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

Prevention 1ry 2nd 3rd prevention prevention prevention

What will you learn in this course of public health this month? Linear Vaccination EPI

Urban health center, Chest hospital, health inspectors

MCH, Child care

Nutrition

Occupational medicine + Pollution

Samples, tables, sequence, statistics, study designs

on Port Stephens Council Website: http://portstephens.local-e.nsw.gov.au/community/35624/35630.html

Rural health, units Communication

Co-producingwiththeDivisions

Primary health care ( PHC )  Definition:  It

is the essential health care based on practical, scientifically sound and socially acceptable methods and technology.  It is universally accessible to all the community,  It is at a cost that the community and the country can afford .

Levels of the health services in any health care system 1.

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

2nd level  2.

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

3rd level  3.

Tertiary health services: It requires a high degree of skills and advanced technology. It is provided in large hospitals which posses complex surgical operations and complex diagnostic procedures such as computerized tomographic scanning. It is costly and consume a high % of the national health expenditure.

Developed & non-developed countries Health expenditure 

3rd

3rd

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2nd

2nd 1ry

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1ry

1ry

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

1.) It’s the first contact between Patient & System. 2.) It’s the base on which 2nd and 3rd health care are built. 3.) It’s the key to achieving acceptable level of health throughout the world. 4.) The health status of the community depends mainly on the availability of good PHC than on advanced technical resources of modern hospitals. 5.) Its cheap .

Objectives of P.H.C:  1.

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

Elements: 1. Promotive and preventive:      

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

2. Curative elements:

 Appropriate

treatment of common diseases

and injuries.  Provision of some essential drugs .

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

Continue principles 3. It should involve health related sectors e.g. agriculture (surrouding environment), education, municipality, social affairs. This is to achieve coordination and avoid duplication ( multi-sectoral approach). 4. It should depend on a good system of referrals to the secondary level of health care with a detailed report on each referred case. 5. It may be free charge as in the health centers, governmental hospitals or paid services as in private clinics.

What are the guidelines for referral of a case?

Primary health care in urban areas:  1-

Health offices: they are responsible for monitoring of environmental sanitation, registration of births and deaths, compulsory immunizations for infants and children, prevention and control of infectious diseases (notification, isolation, etc..) and sick leaves for governmental employees.

 {Health

inspectors are the personnel responsible for infection and epidemics control

Vaccination setting

Continue  2-

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

5- Urban health centers: they provide integrated health services 

Maternal and child health services

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{< 5 years children are insured},while older are insured inside schools Health office services Monitoring of the environment for sanitation Outpatient clinic: it provides treatment of common diseases and Emergency medical care. Health education Health registration Dental care Family planning

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Health team of P.H.C in urban centers comprise: Ten physicians, Two dentists, One pharmacist, 15 nurses, Three sanitariums, One statistical technician, One laboratory technician, Two assistant laboratory technicians, Two social workers, Two statistical clerks

Primary health care in rural areas: a). The rural health units.  b). Recently, integrated hospitals have been built to provide primary and secondary levels of care in some rural communities. The rural health unit services:  They are the same as in the urban centers but the staff is much lower in number includes only one physician, two nurses, one laboratory technician, a sanitarian, a dentist. (see rural health). 

What are the programs delivered by the ministry of health (MOH) through the P.H.C : Maternal

and child health program (MCH)  Family planning program  Rural health program  Geriatric health program  School and Adolescent health programs  Health education programs  Occupational health program • Solitary programs as in diarrhea and acute respiratory infection (ARI) control programs.

Job description of P.H.C. team: 1-Medical officer “MO” He is responsible for:  Ensuring implementation of the national polices and strategies of health services delivery.  Organizing, Staffing and Training of the health team on the different activities set by the P.H.C center or unit ( as vaccinations, health education..) Why ?,,to deliver effective and comprehensive health services and ensuring a sanitary environment in his community.

Continue MO Job  Supervising

and participating in the collection and analysis of all the data needed for survey studies.  Medical examination for all the family members and proper management for the diseased with a proper referral system.  continuous updating for his knowledge and skills.  The accuracy of notifications, referral, reports and records.

Continue job description 2- The dentist:

He is responsible for:  Dental health education and routine dental examination for all. Attention must be paid for pre-school and school children, also pregnant ladies.  Accurate records and proper reports specially with referral.

3- The nurse midwife She is responsible for A- The mothers:  History taking during pregnancy from the mother or relatives  The basic measurements in initial examination and subsequent visits  Simple laboratory tests [Hb % & urine analysis].  Health education and home visits. B- the child:  Vaccinations and oral rehydration therapy  Sterilization of instruments and Keeping health records.

4- The health inspector:  He

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

Continue  Taking

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

Continue  Arranging

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

with PHC team in health education activities.

5-The laboratory technicians He is responsible for:  taking specimens and carry out Blood , Urine and stool simple analytic tests  If more investigations are needed , send the specimens to the hospital  Monthly reports on laboratory activities.  keeping the laboratory always tidy and ready for work and supervise its cleanliness

Merits and constrains of Egypt health care system: A): the Merits: 1-

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

Continue Merits  4-

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

Continue merits  7-

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

B.) The Constrains 1.

Health outcome: Maternal mortality

was {67.6 / 100.000 live births} in 2004, still high. High infant mortality rate [ 22.4 /1000 live births ] in 2004, while the agespecific mortality rate of children under 5 years was {28.6 / 1000 live births.

Map of Maternal Mortality, Worldwide 2000 Maternal deaths per 100,000 Live Births

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

Continue health outcome  Preventive

programs must be set up and or improved for  Non-communicable diseases,  Communicable diseases and  Life style induced illness caused by overnutrition, smoking and sedentary life.

2. Accessibility and equity:  

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Only 40% of the population has formal coverage Poorer individuals spend relatively more of their income on health care and paying relatively more in taxes than wealthier individuals . There are 3:1 disparities in infant and child mortality among governorates and 5:1 geographic disparities in maternal mortality Health infrastructure is mal-distributed as evidenced by 5:1 differential in beds between wealthier urban and other governorates and 6:1 differential in physicians .

3. Efficiency {resources}  Total

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

Continue efficiency  Egypt

has too many specialists(over 60%) relative to primary health care physicians.  The extensive network of MOHP primary care facilities is under-utilized as over 60% of all primary care visits take place in private sector facilities.  Drug spending and consumption is high with little use of lower cost generic drugs .

4. Quality, effectiveness and consumer satisfaction:  The

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

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

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

Read the followings and give the suitable answers. Q2)  In

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

Continue Q2 

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1-Fix a canula with intravenous fluids and try to deliver the lady in the health unit. 2-Refer her immediately in the ambulance to the nearest hospital. 3-Fix a canula and refer her immediately in the ambulance with a proper report about her case including any data or investigations { as RH or ABO blood group} from her record kept in the unit. 4-Try to deliver the lady with the assistance of the midwife.

2nd problem: In an urban health center, there was a notification about 2 persons in a family complained of symptoms and signs suspected to be of cholera.  A-Which

sector (or service) in the center is responsible for controlling this epidemic?  B-Who are responsible for the control measures { name the job of the persons in charge}.?  C-The previous personnel are responsible for – – –

The curative services. Curative and promotive Preventive services.

Continue D-In the previous problem, infection could be terminated by controlling:  The agent  The agent and the host  The host and environment  The agent and the environment  The agent, the host and the environment

3rd problem:- In the rural health unit one day the physician faced the following situations. Find the correct answer. 

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A two years child with a fever 39˚c , rhinitis and a sore throat. A one year infant with fever, cough, tachypnea (RR is > 40/min) and chest indrawing. A 1.5 year child with severe diarrhea and vomiting, drowsy with very dry skin. A pregnant lady who was healthy during the antenatal care and seemed to be in normal labour. An adult male complained of itching at night. A female suspected to be leprotic.

Continue Q4 1- Which cases can be managed at the unit and which couldn’t and must be referred to the hospital specialists. 2- Write down if the referred cases would be sent to a 2nd care level or a 3rd care level

Investigation of infectious disease epidemics Or outbreaks

What Is an Outbreak? 

An outbreak, or an epidemic, exists when there are more cases of a particular disease: in an area, – among a specific group of people, or – over a particular period of time Also, Epidemic can be prescribed If a certain disease reemerged after long time of disappearance in the locality, Or an index case of a new disease appeared in the locality. –

Uncovering Outbreaks: How can we discover outbreaks?  Health

departments learn about most outbreaks in one of two ways: – –

Calls from a physician or other healthcare provider. Public heath surveillance

Influenza pandemics in the 20th century

1918: “Spanish Flu”

1957: “” Asian Flu

deaths 1-4 million deaths expected from Avian Flu 21st century ???

1968: “Hong Kong Flu”

Before any investigation, keep in your mind the followings:  The

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

The epidemiological triangle Agent

host

Environment

Steps of the investigation: 

1- verification of diagnosis by clinical and laboratory methods (two labs) for the cases (index cases) and the suspects. Why 1st?

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2- Demonstrate the existence of an epidemic:

 The

investigator or the clinician should determine first the diagnosis of the cases.  Compare between the present incidence and the previous incidence of the suspected disease.

Continue steps  3-

Demonstrate the characteristics of the present epidemic or outbreak:

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

The Time represented by: The epidemic curve   

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

Continue the curve –

Shape of the curve gives you clues: agent

known: use incubation period to look back at exposure agent unknown, but common event likely: postulate the agent by determining the incubation period

a). If the agent is known and all cases occur within one incubation period of the disease, it suggests a point source of exposure.

Initial case (s), then rapid upstroke and down stroke

A Typical Common source epidemic (point source)

b). If the cases occur over several incubation periods, it suggests either person-to-person transmission or a continuing common source of exposure.

A propagated curve in person to person transmission

Point source then a person to person transmission

Continue the time 

c). If the agent is unknown but the time of exposure is known, the incubation period can be used to establish a diagnosis as in food borne outbreaks.

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d). If the incubation period is known, the curve could tell the probable time and possible source of infection.

Salmonellosis in passengers on a flight from London to the United States, by time of onset, March 13--14, 1984 The time of exposure is suspected, so the I.P could tell the diagnosis

Continue studying the characteristics  Place:

the geographical distribution of the diagnosed cases, using a proper types of maps as: street, maps, spot maps and transportation route maps.  Persons: Determine the characteristics of the cases as follows: – – – – –

Age distribution, age specific rates. Sex distribution according to age. Occupational distribution. Residence. Other characteristics as required.

The Spot Map

A

B

C

D

Distribution of cholera cases and implicated water well - Golden Square area of London, AugustSeptember, 1848

Culture-positive cases of shigellosis, by sites along the Mississippi River where each case swam within three days of onset of illness - Dubuque, Iowa, September 1974

Continue the steps  4-

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

Continue the steps  7- Caiculate the attack rates:  In

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

Definition of the Attack Rate The number of new cases of a specific disease during a specific time interval -----------------------------------------------Total population at risk during the same time period X 100. It is an incidence rate calculated during an epidemic situation using particular population observed for a limited period of time.

Secondary attack rate  It

is calculated as before but we subtract the initial index case(s) from both the numerator and the denominator.  Ill people – [index cases]  --------------------------------- Total people – [index cases]

Continue the steps    

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

continue         

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

continue  

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