Levels 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, eliminating or

minimizing the impact of disease and
disability, or if none of these are feasible,
retarding the progress of the disease and
disability.
• 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
– continuous evaluation of and development of
procedures applied
Preventable Causes of Disease

BEINGS
Biological factors and Behavioral Factors
Environmental factors
Immunologic factors
Nutritional factors
Genetic factors
Services, Social factors, and Spiritual
factors
Leavell’s Levels of Prevention

Stage of disease Level of prevention Type of response

Pre-disease Primary Prevention Health promotion and

Specific protection

Latent Disease Secondary prevention Pre-symptomatic

Diagnosis and
treatment

Symptomatic Disease Tertiary prevention •Disability limitation for

early symptomatic disease
•Rehabilitation for late
Symptomatic disease
Levels of prevention

Primordial prevention

Primary prevention

Secondary prevention

Tertiary prevention
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.
Primordial prevention (cont.)
• 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 lifestyles are formed (for
example, smoking, eating patterns,
physical exercise).
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 pre-
pathogenesis phase of a disease or health
problem.
• Primary prevention may be accomplished by
measures of “Health promotion” and
“specific protection”
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 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

Health education
chemoprophylaxis
Use of specific nutrients or supplementations
Environmental modifications
Protection against occupational hazards
Nutritional interventions Safety of drugs and foods
Life style and behavioral changes 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 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.

• 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.
Secondary prevention (cont.)

• 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.

• 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.”

• 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.”
• Intervention that should be accomplished in
the stage of tertiary prevention are disability
limitation, and rehabilitation.
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 Vocational Social Psychological

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

Assess
Evaluate Exposure
Intervention
Programs

Conduct
Research on
Apply Mechanisms
(including the study of
Population-Based genetic susceptibility)
Intervention
Programs
–(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 complications
– The financial burden to the community.
• 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
• Regional elimination is now seen as an
important precursor of eradication
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,

that is smallpox.
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).

• 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
conditions of ill-health"
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

– (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 “C”s)
Control

Cases Contacts Carriers Community

Diagnosis
notification
Epidemiological
isolation observation detection
Investigation &
disinfection containment
treatment
follow up
release
 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 may be crucial in identifying the health benefits

derived (impact on morbidity, mortality, sequelae, patient
satisfaction).

• Evaluation can be useful in identifying 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"

• 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

• 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
Quiz
• Match the following statements. Each option may
be selected once, more than once, or not at all:
• (a) performing carotid endarterectomy in a patient
with transient ischemic attack
• (b) recommending regular physical activity to a
patient with no known medical problem
• (C) vaccinating a health care worker against
hepatitis B
• (d) giving isoniazid for 1 yr to a 28-year-old
medical student with a positive PPD tuberculin
skin test.
• 1. primary prevention 2. secondary prevention
• 3. tertiary prevention 4. health promotion
Thank You