Concepts of Prevention and Control

(I) Prevention
The goals of medicine are to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress. These goals are embodied in the word "prevention"

Prevention; Definition and Concept

Actions aimed at eradicating (mengakhiri), eliminating or minimizing the impact of disease and disability, or if none of these are feasible, retarding the progress of the disease and disability.

Pencegahan penyakit adalah

Tindakan yang ditujukan untuk mencegah, menunda, mengurangi, membasmi, mengeliminasi penyakit dan kecacatanm dgn menerapkan sebuah atau sejumlah intervensi yg telah dibuktikan efektif. (Kleinbaum, et al., 1982; Last, 2001).

Prevention; Definition and Co nc e pt

Determinants of Prevention

The concept of prevention is best defined in the context of levels, traditionally called primary, secondary and tertiary prevention. A fourth level, called primordial prevention, was later added.

Determinants of Prevention

Successful prevention depends upon:

a knowledge of causation, dynamics of transmission, identification of risk factors and risk groups, availability of prophylactic or early detection and treatment measures, an organization for applying these measures to appropriate persons or groups, and

Preventable Causes of Disease

BEINGS Biological factors and Behavioral Factors Environmental factors Immunologic factors Nutritional factors Genetic factors Services, Social factors, and Spiritual factors

Levels of prevention
Primordial prevention

Primary prevention

Secondary prevention

Tertiary prevention

Tingkat pencegahan dan kelompok targetnya menurut fase penyakit

Tingkat pencegahan
primordial Primary Kondisi normal kesehatan Populasi total kelompok terpilih Keterpaparan penyebab khusus factor Populasi total kelompok terpilih individu sehat Pasien dan dan dan

Fase penyakit

Kelompok target

secondary Tertiary

Fase patogenesitas awal

Fase lanjut (pengobatan Pasien dan rehabilitasi)

Sumber : Beoglehole, WHO 1993

Stage of disease Pre-disease

Leavells Levels of Prevention

Level of prevention Type of response Primary Prevention Health promotion and Specific protection Secondary prevention Pre-symptomatic Diagnosis and treatment Disability limitation for early symptomatic disease Rehabilitation for late Symptomatic disease

Latent Disease

Symptomatic Disease

Tertiary prevention

Hubungan kedudukan riwayat perjalanan penyakit, tingkat pencegahan dan upaya pencegahan Riwayat penyakit Pre-patogenesis Primordial prevention Primary prevention Underlying condition Health promotion Specific protection patogenesis Secondary prevention Tertiary prevention Early diagnosis and prompt treatment Disability limitation Rehabilitation Tingkat pencegahan Upaya pencegahan

Fase sebelum sakit

Fase pre -pathoge ne s is dengan tingkat pencegahan yang disebut pencegahan primer (prim ary pre ve ntion ). Fase ini ditandai dengan adanya keseimbangan antara age nt (kuman penyakit/ penyebab), hos t (pejamu) dan e nvirontm e nt (lingkungan).

Fase selama proses sakit

Fase pathoge ne s is , terbagi dalam 2 tingkatan pencegahan yang disebut pencegahan sekunder (s e condary pre ve ntion ) dan pencegahan tersier (te rtiary pre ve ntion ). Fase ini dimulai dari pertama kali seorang terkena sakit yang pada akhirnya memiliki kemungkinan sembuh atau mati.

Primordial prevention

Primordial prevention consists of actions and measures that inhibit the emergence of risk factors in the form of environmental, economic, social, and behavioral conditions and cultural patterns of living etc.

It is the prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared For example, many adult health problems (e.g., obesity, hypertension) have their early origins in childhood, because this is the time when

Primordial prevention (cont.)

Primordial prevention (cont.)

In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles The main intervention in primordial prevention is through individual and mass education

Primary prevention

Primary prevention can be defined as the action taken prior to the onset of disease, which removes the possibility that the disease will ever occur. It signifies intervention in the prepathogenesis phase of a disease or health problem. Primary prevention may be accomplished by measures of

Primary prevention (cont.)

It includes the concept of "positive health", a concept that encourages achievement and maintenance of "an acceptable level of health that will enable every individual to lead a socially and economically productive life".

Primary prevention (cont.)

Primary prevention may be accomplished by measures designed to promote general health and well-being, and quality of life of people or by specific protective measures.

Primary prevention

Achieved by

Health promotion

Specific protection
Immunization and seroprophylaxis chemoprophylaxis Use of specific nutrients or supplementations Protection against occupational hazards

He alth e duc atio n Environmental modifications Nutritional interventions Life style and behavioral changes

Safety of drugs and foods Control of environmental hazards, e.g. air pollution

Health promotion

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

Approaches for Primary Prevention

The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established:

a. Population (mass) strategy b. High -risk strategy

Population (mass) strategy

Population strategy" is directed at the whole population irrespective of individual risk levels. For example, studies have shown that even a small reduction in the average blood pressure or serum cholesterol of a population would produce a large reduction in the incidence of cardiovascular disease The population approach is directed towards socio-economic, behavioral and lifestyle changes

High -risk strategy

The high -risk strategy aims to bring preventive care to individuals at special risk. This requires detection of individuals at high risk by the optimum use of clinical methods.

Secondary prevention

It is defined as action which halts the progress of a disease at its incipient stage and prevents complications. The specific interventions are: early diagnosis (e.g. screening tests, and case finding programs.) and adequate treatment.

Secondary prevention

Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.

Secondary prevention

It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

Early diagnosis and treatment WHO Expert Committee in 1973

defined early detection of health disorders as the detection of disturbances of homoeostatic and compensatory mechanism while biochemical, morphological and functional changes are still reversible.

Early diagnosis and treatment

The earlier the disease is diagnosed, and treated the better it is for prognosis of the case and in the prevention of the occurrence of other secondary cases.

Tertiary prevention

It is used when the disease process has advanced beyond its early stages. It is defined as all the measures available to reduce or limit impairments and disabilities, and to promote the patients adjustment to irremediable conditions.

Disability limitation
disease

impairment

disability

handicap

Impairment

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

Disability

Disability is any restriction or lack of ability to perform an activity in the manner or within the range considered normal for the human being.

Handicap

Handicap is termed as a disadvantage for a given individual, resulting from an impairment or disability, that limits or prevents the fulfillment of a role in the community that is normal (depending on age, sex, and social and cultural factors) for that individual.

Rehabilitation

Rehabilitation is the combined and coordinated use of medical, social, educational, and vocational measures for training and retraining the individual to the highest possible level of functional ability.

Rehabilitation

Medical rehabilitation

Vocational rehabilitation

Social rehabilitation

Psychological rehabilitation

Strategy for Prevention

Modify Existing Intervention Programs Identify Populations at High Disease Risk
(based on demography / family history, host factors..)

me sess nt As

Intervent ion

Evaluate Intervention Programs

Assess Exposure

Apply Population-Based Intervention Programs

Conduct Research on Mechanisms

(including the study of genetic susceptibility)

Epidemiology Division

(II) Control

Control

Concept of control:

The term disease control describes ongoing operations aimed at reducing:

The incidence of disease The duration of disease and consequently the risk of transmission The effects of infection, including both the physical and psychosocial

Control activities focus on primary prevention or secondary prevention, but most programs combine both.
control

elimination

eradication

Disease Elimination

Between control and eradication, an intermediate goal has been described, called "regional elimination" The term "elimination" is used to describe interruption of transmission of disease, as for example, elimination of measles, polio and diphtheria from large geographic regions or areas

Disease Eradication

Eradication literally means to "tear out by roots". It is the process of Termination of all transmission of infection by extermination of the infectious agent through surveillance and containment. Eradication is an absolute process, an "all or none" phenomenon, restricted to termination of an infection from the whole world. It implies that disease will no longer occur in a population. To-date, only one disease has been eradicated,

Monitoring

Monitoring is "the performance and analysis of routine measurements aimed at detecting changes in the environment or health status of population" (Thus we have monitoring of air pollution, water quality, growth and nutritional status, etc).

Monitoring

It also refers to on -going measurement of performance of a health service or a health professional, or of the extent to which patients comply with or adhere to advice from health professionals.

Surveillance

surveillance means to watch over with great attention, authority and often with suspicion According to another, surveillance is defined as "the continuous scrutiny (inspection) of the factors that determine the occurrence and distribution of disease and other

Objectives of Surveillance

The main objectives of surveillance are:

(a) to provide information about new and changing trends in the health status of a population, e.g., morbidity, mortality, nutritional status or other indicators and environmental hazards, health practices and other factors that may affect health

The main objectives of surveillance are:

Objectives of Surveillance

(b) to provide feed-back which may be expected to modify the policy and the system itself and lead to redefinition of objectives, and (c) provide timely warning of public health disasters so that interventions can be mobilized.

Control of infectious diseases (the 4 Cs

Control

Cases
Diagnosis notification standard isolation strict disinfection protective treatment follow up release

Contacts

Carriers

Community

observation

detection

Epidemiological Investigation & containment

Evaluation of control

Evaluation is the process by which results are compared with the intended objectives, or more simply the assessment of how well a program is performing. Evaluation should always be considered during the planning and implementation stages of a program or activity.

Evaluation of control

Evaluation studies may also be carried out to generate information for other purposes, e.g., to attract attention to a problem, extension of control activities, training and patient management, etc.

Evaluation of control

Evaluation can be useful inidentifying performance difficulties. Evaluation studies may also be carried out to generate information for other purposes, e.g., to attract attention to a problem, extension of control activities, training and patient management, etc.

To summarize

The goals of medicine are to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress. These goals are embodied in the word "prevention"

To summarize

Successful prevention depends upon a knowledge of causation, dynamics of transmission, identification of risk factors and risk groups, availability of prophylactic or early detection and treatment measures, an organization for applying these measures to appropriate persons or groups, and continuous evaluation of and development of procedures applied

To summarize

The objective of preventive medicine is to intercept or oppose the "cause" and thereby the disease process. This epidemiological concept permits the inclusion of treatment as one of the modes of intervention

Thank You

Pencegahan mengambil tindakan terlebih dahulu sebelum kejadian Peran epidemiologi dalam pencegahan:

identifikasi faktor risiko yang dapat dimodifikasi konsep dasar penyakit upaya pencegahan sesuai dengan riwayat alamiah penyakit r a p

Riwayat alamiah penyakit dan tingkat pencegahan

Periode prepatogenesis

Tingkat pencegahan primer

Promosi kesehatan Perlindungan khusus

Periode patogenesis

Tingkat pencegahan sekunder

Diagnosis dini dan pengobatan segera Pembatasan ketidakmampuan (disability)

Riwayat Alamiah Penyakit 58

Tahap Pencegahan

Tingkat pencegahan disesuaikan dengan riwayat alamiah penyakit:

1. 2. 3. 4.

Pencegahan prim ordial Pencegahan prim er Pencegahan sekunder Pencegahan tersier

1. Pencegahan Primordial

Tujuan: menghindari terbentuknya pola hidup sosial ekonomi dan kultural yang diketahui mempunyai kontribusi untuk meningkatkan risiko penyakit Pencegahan primordial yang efektif memerlukan adanya peraturan yang ketat dari pemerintah Contoh:

Pencegahan primordial

Fase penyakit

Misal: Kondisi yang mengarah penyebab penyakit jantung koroner Populasi kelompok terseleksi

Target

Riwayat Alamiah Penyakit

61

2. Pencegahan Primer

Adl Upaya pencegahan yg dilakukan saat proses penyakit belum mulai (pd periode pre-patogenesis) dengan tujuan agar tidak terjadi proses penyakit Tujuan: mengurangi insiden penyakit dengan cara mengendalikan penyebab penyakit dan faktor risikonya Upaya yang dilakukan adalah untuk memutus mata rantai infeksi agent host environment

Terdiri dari:
1. 2.

Health promotion Specific protection

Dilakukan melalui 2 strategi: populasi dan individu

Tingkat pencegahan primer

Perlindungan khusus

Imunisasi Kebersihan perorangan Sanitasi lingkungan Perlindungan thdp kecelakaan akibat kerja
Riwayat Alamiah Penyakit 64

Tingkat pencegahan primer

Perlindungan khusus

Penggunaan gizi tertentu Perlindungan terhadap zat yang dapat menimbulkan kanker Menghindari zat-zat alergenik

Riwayat Alamiah Penyakit

65

Pencegahan primer

Fase penyakit

Faktor-faktor penyebab khusus Total populasi kelompok terseleksi Individu sehat

Target

Riwayat Alamiah Penyakit

66

Tingkat pencegahan primer

Promosi kesehatan

Pendidikan kesehatan, penyuluhan Gizi yang cukup sesuai dengan perkembangan Penyediaan perumahan yg sehat Rekreasi yg cukup Pekerjaan yg sesuai Konseling perkawinan Riwayat Alamiah Penyakit
67

3. Pencegahan Sekunder

Adl Upaya pencegahan yg dilakukan saat proses penyakit sudah berlangsung namun belum timbul tanda/gejala sakit (patogenesis awal) dengan tujuan proses penyakit tidak berlanjut Tujuan: menghentikan proses penyakit lebih lanjut dan mencegah komplikasi Bentuknya berupa deteksi dini dan pemberian pengobatan (yang tepat)

Pencegahan sekunder

Fase penyakit

tahap dini penyakit pasien

Target

Riwayat Alamiah Penyakit

69

Tingkat pencegahan sekunder

Diagnosis dini dan pengobatan segera

Penemuan kasus (individu atau masal) Skrining Pemeriksaan khusus dengan tujuan

Menyembuhkan dan mencegah penyakit berlanjut Mencegah penyebaran penyakit menular Mencegah komplikasi dan akibat lanjutan Memperpendek masa ketidakmampuan
Riwayat Alamiah Penyakit 70

Tingkat pencegahan sekunder

Pengobatan yang cukup untuk menghentikan proses penyakit mencegah komplikasi dan sekuele yg lebih parah Penyediaan fasilitas khusus untuk membatasi ketidakmampuan dan mencegah kematian Riwayat Alamiah Penyakit 71

Contoh

PMS kultur rutin bakteriologis utk infeksi asimtomatis pd kelompok risti Sifilis tes serologis utk infeksi preklinis pd kelompok risti Kanker leher rahim hapusan pap Kanker payudara skrining dgn mammografi

4. Pencegahan Tersier

Adl Pencegahan yg dilakukan saat proses penyakit sudah lanjut (akhir periode patogenesis) dengan tujuan untuk mencegah cacad dan mengembalikan penderita ke status sehat Tujuan: menurunkan kelemahan dan kecacatan, memperkecil penderitaan dan membantu penderita-penderita untuk melakukan penyesuaian terhadap kondisi yang tidak dapat diobati lagi Terdiri dari:

Pencegahan tersier

Fase penyakit

penyakit tahap lanjut (pengobatan dan rehabilitasi) pasien

Target

Riwayat Alamiah Penyakit

74

Tingkat pencegahan tersier

Rehabilitasi

Penyediaan fasilitas untuk pelatihan hingga fungsi tubuh dapat dimanfaatkan sebaikbaiknya Pendidikan pada masyarakat dan industriawan agar menggunakan mereka yang telah direhabilitasi

Riwayat Alamiah Penyakit

75

Tingkat pencegahan tersier

Rehabilitasi

Penempatan secara selektif Mempekerjakan sepenuh mungkin Terapi kerja di Rumah Sakit Menyediakan tempat perlindungan khusus

Riwayat Alamiah Penyakit

76

Contoh

Peny vaskuler diabetik pd kaki perawatan kaki (podiatric cure) rutin pasien diabetes Fraktura & cedera memasang rel pegangan tangan (handrails) di rumah orang yg mudah jatuh Ulserasi kulit kronis penyediaan matras khusus utk penyandang cacat berat

Latihan

Seorang ibu membawa bayinya untuk diimunisasi Polio.

Tindakan imunisasi Polio tersebut termasuk pencegahan apa? Tahap yang mana dari riwayat alamiah penyakit yang akan dicegah dengan tindakan imunisasi tersebut? Mengapa? Jelaskan!