Concepts of Prevention and Control

Concepts of Prevention

and Control

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"

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.

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.

Prevention; Definition and

Conc e pt

Determinants of Prevention Determinants of Prevention

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

Preventable Causes of Disease

BEINGS

Biological factors and Behavioral

Factors

Environmental factors

Immunologic factors

Nutritional factors

Genetic factors

Services, Social factors, and Spiritual

•

Levels of prevention

Primordial prevention

Primary prevention

Secondary prevention

Tingkat pencegahan

Fase penyakit Kelompok target

primordial Kondisi normal kesehatan Populasi total dan kelompok terpilih

Primary Keterpaparan factor

penyebab khusus Populasi kelompok terpilih total dan dan individu sehat

secondary Fase patogenesitas awal Pasien Tertiary Fase lanjut (pengobatan

dan rehabilitasi) Pasien

Tingkat pencegahan dan kelompok targetnya menurut fase penyakit

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

Riwayat penyakit

Tingkat pencegahan Upaya pencegahan 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

Hubungan kedudukan riwayat perjalanan penyakit, tingkat pencegahan dan upaya pencegahan

Fase sebelum sakit

• Fase pre-pathogenesis dengan

tingkat pencegahan yang disebut pencegahan primer (primary

pre ve ntion). Fase ini ditandai

dengan adanya keseimbangan antara agent (kuman penyakit/ penyebab), host (pejamu) dan

Fase selama proses sakit

• Fase pathogenesis , terbagi dalam 2

tingkatan pencegahan yang disebut pencegahan sekunder (secondary

pre ve ntion) dan pencegahan tersier

(tertiary prevention). 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

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

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

Primary prevention

Specific protection Health promotion

Achieved by

He alth e duc ation

Environmental modifications Nutritional interventions

Life style and behavioral changes

Immunization and seroprophylaxis chemoprophylaxis

Use of specific nutrients or supplementations Protection against occupational hazards 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

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

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

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

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

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.”

• Intervention that should be

accomplished in the stage of tertiary prevention are disability limitation, and rehabilitation.

Disability limitation

disease

impairment

disability

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

Rehabilitation Medical rehabilitation Vocational rehabilitation Social rehabilitation Psychological rehabilitation

Strategy for Prevention Assess Exposure Identify Populations at High Disease Risk (based on demography / family history, host factors..) Conduct Research on Mechanisms

(including the study of genetic susceptibility) Apply Population-Based Intervention Programs Evaluate Intervention Programs Modify Existing Intervention Programs In te rven tion As se ss_m en t Epidemiology Division

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

• Control activities focus on primary

prevention or secondary prevention, but most programs combine both.

control

elimination

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,

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

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 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

Objectives of Surveillance

• The main objectives of surveillance are:

– (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 isolation disinfection treatment follow up release

observation detection Epidemiological Investigation & containment

standard strict protective

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

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

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

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

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

• 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)

– Tingkat pencegahan tersier

• Rehabilitasi

Tahap Pencegahan

• Tingkat pencegahan disesuaikan dengan

riwayat alamiah penyakit:

1. Pencegahan primordial

2. Pencegahan primer

3. Pencegahan sekunder

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

Pencegahan primordial

• Fase penyakit

– Misal: Kondisi yang mengarah penyebab

penyakit jantung koroner

• Target

– Populasi

– kelompok terseleksi

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. Health promotion

2. Specific protection

• Dilakukan melalui 2 strategi: populasi dan

Tingkat pencegahan primer

• Perlindungan khusus

– Imunisasi

– Kebersihan perorangan

– Sanitasi lingkungan

– Perlindungan thdp kecelakaan akibat

kerja

Tingkat pencegahan primer

• Perlindungan khusus

– Penggunaan gizi tertentu

– Perlindungan terhadap zat yang dapat

menimbulkan kanker

– Menghindari zat-zat alergenik

Pencegahan primer

• Fase penyakit

– Faktor-faktor penyebab khusus

• Target

– Total populasi

– kelompok terseleksi

– Individu sehat

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

– Genetika

– Pemeriksaan kesehatan berkala

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

• Target

– pasien

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

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

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:

1. Disability limitation

Pencegahan tersier

• Fase penyakit

– penyakit tahap lanjut (pengobatan dan

rehabilitasi)

• Target

– pasien

Tingkat pencegahan tersier

• Rehabilitasi

– Penyediaan fasilitas untuk pelatihan hingga

fungsi tubuh dapat dimanfaatkan sebaik-baiknya

– Pendidikan pada masyarakat dan

industriawan agar menggunakan mereka yang telah direhabilitasi

Tingkat pencegahan tersier

• Rehabilitasi

– Penempatan secara selektif

– Mempekerjakan sepenuh mungkin

– Terapi kerja di Rumah Sakit

– Menyediakan tempat perlindungan khusus

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!