Whatever you call them, immunizations are one of the best weapons we have against a number of serious diseases. Syringe Access and Disposal Information about the Minnesota law that allows pharmacies to sell a limited number of sterile syringes to people without a prescription, how to access sterile syringes, storage or destruction of needles, and the North American Syringe Exchange Network.
Refugee and International Health Minnesota's Refugee and International Health Program RIHP partners with local health departments, private health care providers, and community organizations to offer each new refugee arrival a comprehensive screening examination, appropriate follow-up or referral, and community-based health education.
Minnesota One Health Antibiotic Stewardship Collaborative Issues like antibiotic stewardship require a collaborative effort across multiple disciplines. The association of the worm with a dragon may be due to the fiery, burning pain experienced at the site where the worm emerges from the body, most often in the lower leg or foot. Like smallpox, it has been known since antiquity and evidence of guinea worms has been found in Egyptian mummies.
The campaign to eradicate guinea worms from the world has been chosen as the final example in this course because it illustrates many of the key features of the public health approach to controlling infectious disease — but particularly the importance of community action and the power of low-cost interventions. Dracunculiasis was once endemic in many parts of the world but, by the s, the provision of piped water in towns and cities had eradicated it from North Africa, Egypt, Iraq, Brazil, the West Indies and Uzbekistan.
However, attitudes gradually changed as a number of research studies evaluated the human cost of a disease with a global burden estimated in to be affecting at least 3. Although the case fatality rate is less than 0. Around half of all cases become infected, which greatly increases the disabling effects of the parasite, in terms of both pain in the affected limb, which can reduce mobility for several weeks, and the fever, nausea and debility associated with an acute inflammatory reaction against secondary bacterial infection.
How could guinea worm infection have a serious impact on life in rural communities in endemic countries? An immobilising condition impacts heavily on rural economies where people earn their livelihoods from working on the land. They often walk long distances to reach their fields, herd livestock, collect firewood and drinking water, and — in the case of children — attend school.
The economic impact is particularly severe because the highest rates of infection occur in the rural working population i. Recognition of the seriousness of the guinea worm problem led the Indian government to initiate the first national dracunculiasis-elimination programme in The features of the campaigns will be described shortly but, for the moment, we will concentrate on the evidence of their success. It took several more years before it was eradicated in Uganda , Nigeria and Ghana — bringing the total to previously endemic regions and territories certified as free of dracunculiasis by the end of In the whole of there were reported cases of the disease worldwide, and the number fell to just cases in the whole of in only four countries — Chad, Ethiopia, Mali and South Sudan WHO, j.
The community actions that have interrupted guinea worm transmission so successfully can only be understood by first describing its complex life cycle. Dracunculiasis is the only human disease in which the causative agent is transmitted exclusively in drinking water. The life cycle of D. Until recently, all the species that transmit guinea worm larvae were classified in a single genus, Cyclops , which has since been subdivided, but for simplicity the traditional term will be used. People become infected when they drink water contaminated with cyclops containing infective Dracunculus larvae.
None of the drugs used in the treatment of other parasitic worms has any therapeutic effect against guinea worms. At best, antibiotics or antibacterial ointment rubbed into the worm eruption site may reduce the risk of secondary bacterial infections. No vaccine has yet been developed to protect people who ingest the larvae, and infected people do not develop a protective immune response to the adult worms, so they can be infected again and again.
Thus, attempts to control dracunculiasis have had to rely entirely on community action and low-cost interventions rather than on medical treatment. The features listed in Box 4 underlie the strategies that have succeeded in eradicating guinea worms from most countries and greatly reducing their incidence in the few remaining endemic areas. The eradication campaign illustrates several features of the public health approach to the control of infectious diseases, particularly in remote regions with high levels of poverty and low literacy rates. It has relied primarily on three simple, low-technology strategies, operated within the affected communities by local people: the protection of drinking-water sources from reinfection; the routine filtering of water at the point of use; and the case containment of infected people.
Drinking water sources can be protected from reinfection by persuading people with emerging worms not to enter the water until the lesion has healed. A second important control measure is the routine filtering of water at the point of use, just before drinking it, to remove the infected cyclops. This initiative has been supported by the donation of hundreds of thousands of square metres of fine mesh nylon cloth. Case containment has also been practised in the later stages of a campaign it is too labour intensive to be used on a large scale.
It involves the controlled release of worm larvae by plunging the affected limb into a bucket of cold water, followed by simple palliative treatment e. The infected person agrees not to remove the bandage or enter sources of drinking water, and the procedure is repeated every few days until the worm has completely emerged. The important health education messages have largely been delivered by one or two volunteers from each village. They are each given basic training and provided with a few educational aids, e.
Community participation in the eradication programme is central to its success — without it, no progress would have been made.
It demonstrates that combined community action can persuade individuals to change behaviour that damages their health. The success of this low-cost approach has been striking, not only in reducing the number of cases to the threshold of eradication, but also in empowering local people and reducing poverty and the loss of education due to the disabling effects of guinea worm disease. The main steps are as follows. The dracunculiasis maps have also proved to be highly effective advocacy tools, both for informing governments of the progress of the campaign and for persuading commercial donors and aid agencies to support it.
In , the system was extended to HIV and other sexually transmitted infections, tuberculosis, and complex emergencies involving infectious diseases such as SARS. Of course, the most effective way to eradicate guinea worms would be to provide safe drinking water, which would also reduce the risk of many other important infectious diseases that are also endemic in the same geographical areas.
Attempts have been made to achieve this aim using both mechanical and chemical means, although both strategies have drawbacks. In the early years of the global eradication campaign, considerable emphasis was placed on improving water quality by drilling boreholes and installing a hand-pump in villages in endemic areas. Also, the pumps need regular maintenance and many have fallen into disuse.
In the s, some additional help in the final stages of an elimination campaign came from the donation of a water-treatment chemical temephos. This can be added safely to drinking water to kill infected cyclops, provided the volume of water can be accurately measured. At the correct concentration, temephos is harmless to fish and humans, but its application is labour intensive and accurate dosing is a major problem. Figure 22 illustrates the difficulty of dosing a natural pond effectively, when the water volume can change rapidly with the seasons and the chemical treatment must be repeated at least once a month.
To conclude Section 5, you should consider the following ethical problem that may indeed have already occurred to you.
As the deliberately targeted extinction of D. Very few female worms have been collected in a suitable condition for research and no males have ever been recovered from humans. The fourth meeting of the International Commission for the Certification of Dracunculiasis Eradication WHO, recommended that strenuous efforts be made to collect intact specimens and send them to European laboratories for genome sequence analysis and the preservation of a D.
While there have been enormous strides in improving public health in all countries worldwide during the twentieth century, through the approaches described and illustrated in this course, there is still a huge gap between the health of the poorest people and the rest. Note that the MDGs summarised in Box 5 cannot be separated into those that relate to infectious disease and those that do not.
People who live in poverty in urban slums and shanty towns cannot protect themselves from sources of infection; children who are frequently ill cannot complete their schooling. The World Bank estimated that there were 1. In , this estimate was confirmed as still the most accurate measure of the number considered to be living in absolute poverty.
Aside from the obvious threats to health that poverty entails, the lack of the means of subsistence drives impoverished rural populations into already overcrowded cities. Despite the undoubted progress of recent decades, the prospects for meeting the MDG targets in relation to infectious disease and public health are constrained by many factors in addition to poverty. They include:. Vaccination, the provision of clean drinking water and improved sanitation, the promotion of personal and institutional hygiene particularly the importance of handwashing with soap , and the organisation of surveillance and response strategies to detect and control disease outbreaks are integral to the public health approach.
Raising sustainable living standards, improving the quality of housing, nutrition and education, and promoting gender equality and personal security are also important public health goals. Community participation and community health workers with minimal training and equipment are central to the success of infection-control campaigns in many parts of the world, and particularly in low- and middle-income countries. Despite the undoubted progress of recent decades, the prospects for meeting international targets in relation to infectious disease and public health are constrained by many factors.
In addition to poverty, poor housing and food insecurity, they include:. However, there are hopeful signs: the advances that delivered such large improvements in public health in high-income countries in the twentieth century are being applied in low- and middle-income countries with substantial success, as several of the examples in this course have demonstrated. The following questions allow you to assess your understanding of the content of this course.
Each one relates to one or more of the intended learning outcomes of the study. If you are unable to answer a question, or do not understand the answer given, then reread the relevant section s of the course and try the question again. Suggest at least one example of a public health measure that can be taken to control malaria at each of the primary, secondary and tertiary levels of prevention.
Tertiary prevention refers to treatment of the life-threatening complications of malaria e. You might have thought first of the common approach to increasing awareness of hand hygiene in both locations. The Ethiopian programme has promoted the installation of yellow plastic canisters of clean water near latrines to facilitate hand washing ideally with soap ; this is similar to the programme in English hospitals to install alcohol-based hand-hygiene stations in all wards and corridors. Secondly, both of these initiatives require community mobilisation and the full participation of staff, patients and community members in order to reduce the incidence of infectious agents transmitted on the hands.
Explain why the type of water source available is a key factor in determining the areas where guinea worms are endemic and the areas where they have spontaneously disappeared. Even in endemic countries, dracunculiasis does not occur in urban areas where piped water is supplied, and it is rare in rural communities where the principal sources of drinking water are fast-running streams or deep wells, because the intermediate host cyclops cannot survive in these environments.
It inhabits still, shallow water, such as natural pools and step wells, where people are most likely to stand as they draw water, or seek relief from the burning pain of a guinea worm as it emerges. Find out more about all our free courses. If you are new to university study, you may be interested in our Access Courses or Certificates. Sign up to our newsletter or view a sample. Except for third party materials and otherwise stated see terms and conditions , this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.
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Public Health Approaches to Infectious Disease. The aim of the course is to give you clear insights and memorable examples of: the importance of surveillance and mapping of infectious disease outbreaks in human populations and their impact on human lives the biological, socioeconomic and other circumstances influencing the transmission of pathogenic disease-causing bacteria, viruses and parasites the success of some low-cost, community based public health campaigns to prevent, treat or control infections, illustrated by a video of a unique rural health programme in Ethiopia and a case study of how guinea worm disease has been brought to the brink of global eradication the challenges that must be overcome in order to make further progress in reducing the burden of infectious disease and meeting the associated Millennium Development Goals MDGs agreed by the international community in Figure 1 Major causes of 8.
Source: based on data in UN, , p. Long description. Pandemic influenza occurs at unpredictable intervals with the emergence of new variant influenza viruses. A major underlying cause of susceptibility to these pathogens is inflammation of the lungs due to atmospheric pollution; this is a major problem particularly among women, children and elderly people who are persistently exposed to indoor smoke from cooking fires in poor rural communities. The lack of access to safe drinking water is a major cause of diarrhoeal diseases.
Kaufmann reports that in Every minute of every day, nearly 20 people were infected with Mycobacterium tuberculosis and four people died from TB. There were over 9 million new or relapsed active cases. Over 2 million people with chronic TB died. Figure 3 A woman with tuberculosis receiving her DOTS medication directly observed treatment, short course from a healthworker in Alem Kitmama, Ethiopia. Can you identify any other combined vaccines from your own experience? This is more prevalent even than congenital HIV, but far less publicised. Around 1.
Figure 4 a Ulceration on the face due to cutaneous leishmaniasis. This encompasses four broad areas of work: surveillance, monitoring and reporting of disease outbreaks and analysis of epidemiological data to shed light on the underlying causes, and inform actions to bring outbreaks under control direct intervention to prevent infection, e. Quarantine Quarantine is a period of enforced isolation or restriction of travel or activity.
Epidemiology From its earliest period, the advocates of public health strategies for tackling infectious disease promoted an evidence-based approach, collecting systematic data on the incidence and prevalence of disease, the geographical location, socio-economic circumstances and behaviour of cases, and the impact of interventions on subsequent disease rates.
Strengthen national disease prevention, surveillance, control and response systems. Strengthen public health security in travel and transport, particularly at designated airports, seaports and ground crossings. Strengthen the WHO global alert and response GAR systems and standardised approaches to contain outbreaks of major epidemic-prone diseases and dangerous and emerging pathogens with the ability to cause serious health impact and to spread rapidly across borders e. Strengthen the management of specific risks. Sustain rights, obligations and procedures.
Conduct studies and monitor progress. Projects include: building meningococcal serology capacity across Sub-Saharan Africa improving public health emergency preparedness and response in India developing an influenza surveillance network across South America to detect antiviral drug resistance HPA, b. Source: Bennet, a, b; Dehnel, ; Mohammadi, A useful way of thinking about direct public health interventions to control infectious disease is to distinguish between strategies that: use education to support behavioural changes that enable people to protect their own health or that of their children or other community members from infectious disease promote resistance to infection in the human host isolate a source of infection to prevent it from being passed on tackle an environmental source of infection.
You may have chosen other examples, but here are some that illustrate the general principles. Vaccination programmes against a range of infectious agents are estimated to save the lives of over 2. Quarantine of infectious individuals has been practised for centuries, for example, in the isolation hospitals and TB sanitariums of the late nineteenth and early twentieth centuries, and during outbreaks of swine flu, bird flu and SARS. ITNs not only protect the individuals sleeping under the nets, but they also reduce the local mosquito population by contact with the insecticide.
Figure 5 Insecticide-treated mosquito nets erected over sleeping mats offer effective protection from the mosquitoes that transmit malarial parasites Plasmodium species. Vaccination operates at the level of primary prevention: directly, by increasing the resistance of the uninfected population to the pathogens from which the vaccine was prepared indirectly, by decreasing exposure to pathogens, because it reduces the proportion of infected individuals in the community who could transmit the infection to its unvaccinated members.
You might have thought of many other examples in addition to our suggestions below. Food safety legislation, inspection of catering premises and slaughterhouses, and education about hygienic food-handling practices to prevent outbreaks of food poisoning. Training community members to drain mosquito breeding sites near homes in endemic malaria areas, and distributing ITNs to cover beds at night. Education of community members who lack access to safe sources of water so that they know they should boil unsafe water before using it for drinking, cooking or mixing formula feeds for infants.
Early treatment This level of prevention involves infected or exposed individuals receiving early treatment to prevent the transmission of pathogens to susceptible hosts. Education and health-related behaviour modification Secondary prevention relies partly on educating the population about signs of illness that require prompt referral to the health service, coupled with systematic surveillance to detect and report cases quickly and respond with effective treatment.
Some examples we thought of are: People with active TB counselled to cover their mouth when they cough, to avoid coughing close to other people, particularly in enclosed spaces, and to take their medication regularly. Pregnant women with HIV counselled about the importance of receiving antiretroviral therapy to reduce the risk of transmitting the virus to their baby. People with chlamydia infection counselled about abstinence and safer sex practices to avoid transmitting the bacteria to sexual partners. Screening Infected individuals can also be identified even before symptoms develop in systematic screening programmes , i.
Eradication of Diseases
Figure 6 Villagers in Ethiopia at a local health clinic giving blood smears for the malaria-screening programme. Screening helps to protect other people in the community: early treatment of uncomplicated malaria prevents the parasites from developing to the stage where mosquitoes can ingest them with a blood meal and transmit the infection to new hosts.
Figure 7 Tertiary prevention can benefit the community as well as the individual. This man with elephantiasis in both legs, caused by lymphatic infection with filarial worms, follows a rigorous hygiene regime daily, washing with soap and water and applying antibiotic cream. This has enabled him to work at a local coir factory in India. Example Question What measures can be taken against TB at the primary, secondary and tertiary levels of prevention?
Answer Primary prevention: BCG vaccination and improved living standards, including better housing reduction in crowding and nutrition improved host immunity. Drilling a deep tube well to access clean water and pumping it to standpipes. Digging cesspits and building latrines. Vaccinating children against rotaviruses. Teaching parents how to make and administer oral rehydration salts ORS to children with acute diarrhoea.
Educating parents and children about the importance of hand washing before preparing food and after defaecation or urination. Administering intravenous fluids to children with severe dehydration caused by persistent diarrhoea. Strategy 6 is tertiary prevention, aimed at saving lives. Box 2 Directly observed therapy, short course DOTS In order to control TB, patients must regularly take antibiotics over a prolonged period of several months. This simple observation strategy listed below as item 3 is further supported by an additional four aspects of medical and political infrastructure: political commitment with increased and sustained financing case detection through quality-assured bacteriology standardised treatment with supervision and patient support an effective drug supply and management system monitoring and evaluation system and impact measurement Based on WHO, f.
Box 3 Special features of smallpox as an eradication target Smallpox is a DNA virus with a relatively stable genome, which does not generate variant strains; therefore, the same vaccine could be used everywhere. Humans are the only host — there is no reservoir of smallpox virus in other animals or in the natural environment. Figure 8 A young girl in Bangladesh infected with smallpox in Freedom from smallpox was declared in Bangladesh in December when a WHO International Commission officially certified that it had been eradicated from that country.
Activity 1 Infectious disease and public health in rural Ethiopia Allow 45 minutes. Download this video clip. Video 1 Infectious disease and public health in rural Ethiopia. Skip transcript: Video 1 Infectious disease and public health in rural Ethiopia Transcript: Video 1 Infectious disease and public health in rural Ethiopia. Slide 1 This slide cast will introduce you to the realities of infectious disease in rural Ethiopia and how it is being tackled in every village by local health workers with basic training in disease prevention, diagnosis, treatment and control.
Slide 2 Ethiopia is in the horn of East Africa. Slide 3 Notice the huge expanse of Lake Tana in the north and the chain of lakes that mark the start of the Great Rift Valley, beginning in central Ethiopia — not far from the capital Addis Ababa — and extending south into Kenya. Slide 4 This slide cast focuses on infectious disease in rural Ethiopia. Slide 7 Animals are vital to the rural economy, but close proximity to their domestic animals exposes the rural population to infectious diseases with reservoirs in animal hosts, particularly intestinal parasites and the bacteria causing diarrhoeal diseases.
Slide 8 Most farming is done by hand or with simple ploughs pulled by oxen. Slide 9 This is a map of Fura kebele , a rural area with a population of approximately people in the Southern Nations, Nationalities and Peoples Region of Ethiopia. Slide 10 There are no paved roads, no piped water, and no electricity supply to the houses, so they are dark inside and difficult to photograph. Slide 11 This road in Fura is typical of how people get around in rural kebeles — mostly on foot, walking long distances, sometimes on a bicycle or in a donkey cart.
Slide 12 Many of the causes of infection in Ethiopia are related to the lack of clean water, which is a constant problem for many rural communities.
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Slide 12 Some rural communities have deep communal wells, like this one in Fura. Slide 14 People and their animals competing for scarce drinking water also increases the risk of water contamination by human and animal urine and faeces. Slide 15 This chart shows the main causes of death in Ethiopia in children aged under five years.
Slide 16 An idea of the challenges in rural communities can be gauged from this wall chart from a Health Centre in the small town of Modjo. Slide 17 Inadequate food hygiene standards and the practice of eating kitfo — raw beef or ox meat — at important festivals is another major source of infection.
Slide 18 Ethiopia is commonly associated with famine, but such deep crises of absolute food insecurity are relatively rare. Slide 19 These data come from the last national survey in Ethiopia conducted in and published in Slide 21 Faced with all these challenges to public health, in the government of Ethiopia began an ambitious programme to bring basic disease prevention and health promotion services to the entire population, now totalling over 83 million people.
Slide 22 Here are two of them — Asafesh on the left and Almaz on the right. Slide 22 The vital importance of the Health Posts and their Health Extension Workers to the delivery of health services in Ethiopia is well illustrated by the pie chart on the left. Slide 23 So what health services do Asafesh and Almaz provide for their communities?
Slide 25 The scales are for weighing adults mainly pregnant women attending for antenatal care and there is a delivery couch in a side room. Slide 26 Asafesh also a spirit burner, boxes of disposable syringes, packets of oral rehydration salts to treat diarrhoea, and sachets of PlumpyNut an energy-rich paste given to malnourished children. Slide 27 Health Extension Workers have a very small stock of medicines for the people they serve. Slide 28 Every Health Post has a kerosene, gas or electric refrigerator for storing vaccines and an insulated vaccine carrier lined with ice packs.
Slide 30 Inside the Health Post, wall charts help Asafesh to keep track of her public health targets for the local population, including immunisations. Slide 31 This wall chart shows how Almaz has been achieving her targets for childhood immunisation coverage in her kebele , which is called Shera Dibandiba. Slide 32 Immunisation clinics are mainly held at the Health Post, but all Health Extension Workers spend four out of five days visiting families in the surrounding area and teaching them about disease prevention and health promotion, for example in food preparation, breastfeeding, hand washing, waste disposal and digging latrines.
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Ray R. Arthur Search for more papers by this author. Abstract To better track public health events in areas where the public health system is unable or unwilling to report the event to appropriate public health authorities, agencies can conduct event-based surveillance, which is defined as the organized collection, monitoring, assessment, and interpretation of unstructured information regarding public health events that may represent an acute risk to public health. References 1 World Health Organization. Interim Version. Accessed July 27 , The Global Health Security Agenda.
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Public health burden of infectious diseases in Africa
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