Population Health And Infectious Disease

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Population Health And Infectious Disease Essay

Assignment Requirements

  1. Utilizing the list below, choose two research methods.
  2. Next, find two articles, one on each of the chosen methods. The articles should be related to population health and infectious disease, chronic health, occupational health, global health, genomics, or environmental health:
    o Randomized Control Trial
    o Cohort Study
    o Case-Control Study
    o Cross-Sectional
    o The articles you choose should be completely in English (this includes the reference list). They should be related to population health and speak to one of the following elements from the course: Infectious disease, chronic health, occupational health, global health, genomics or environmental health.Population Health And Infectious Disease Essay

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  1. Read each article and answer the following questions with detail for each article, include succinct definitions/examples or rationale as fitting to the question. Organize your answers using the number of the question you are answering (1-8). Your answers should provide more than a “yes” or “no”, your answers should provide examples, critical thinking, definitions, and examples.
  2. Does the study design specify a question, goal, of the study? Why is this important?
  3. Explain the methodology (Randomized Control Trial, Cohort Study, Case-Control Study).
  4. Describe the participant information, include recruitment. Is selection bias present?
  5. How is data collected?
  6. Are the variables identified? If yes, discuss. If no, how does this impact your interpretation of the study?
  7. How was the data analyzed, what statistics are provided? What are potential errors related to the study design?
  8. What are the weaknesses of the type of study design/method?
  9. Discuss the outcomes and the implications for implementation. Population Health And Infectious Disease Essay
  10. Your analysis should have in-text citations and utilize a scholarly voice with APA formatting.
    DISCUSSION CONTENT
    Category Points % Description
    Scholarly 13 22% • The student actively stimulates and sustains inquiry by making reflective insightful comments,asking thoughtful questions and/or engaging in a scholarly discussion.
    • The student expresses a clear idea of the topic under discussion and sustains inquiry in order to explore relevant issues.
    • The student recognizes values or values conflict as things that form the assumption basis of arguments and recognizes when it is important to acknowledge these values.
    • The student recognizes the accuracy, logic, relevance, or clarity of statements.
    • The student asks clarifying questions and knows when clarifying questions need to be asked.
    • The student distinguishes fact from opinion.
    Application 20 33% • All components of discussion prompt addressed (met) in posting.
    • The student’s writing conveys an understanding of significant ideas relevant to the issue under discussion. This is indicated by integration of course and weekly objectives, as well as readings from text and articles.
    • All posts should make correct use of terminology, precise selection of the pieces of information required to make a point, correct and appropriate use of examples and counterexamples, demonstrations of which distinctions are important to make, and explanations that are concise and to the point.
    • Information and knowledge are accurate.
    • The student elaborates statements with accurate explanations, reasons, or evidence from the course and/or weekly objectives.
    • All postings integrate scholarly sources to support points consistently.
    Interactive Dialogue 10 16.6% • Responds to ideas in a way that advances discussion with engagement, depth, rigor, and application. Population Health And Infectious Disease Essay
    • Interacts with a professional tone and is able to express opinions with ownership and without judgement.
    • Chooses to include professional experience to the discussion board mindful of appropriateness and boundaries. Experience is integrated as it supports the discussion board topic and utilizes scholarly references to support overall topic.
    DISCUSSION FORMAT
    Category Points % Description
    APA 12 20% • In text citations are formatted per APA currented.
    • Reference list is formatted per APA current ed.
    • Spelling, grammar, and scholarly tone are per APA current ed.
    Spelling / Grammar etc. 5 8% • Posts should utilize correct spelling and grammar(sentence structure and avoidance of slang or casual language).

This course focuses on the strategies available in the twenty-first century to tackle major infectious diseases, including pneumonia, diarrhoea, malaria, HIV/AIDS, measles, tuberculosis and infections of the newborn. Infection poses a major threat to public health all over the world, but it disproportionately affects children in low- and middle-income countries (LMICs), where pneumonia and diarrhoeal diseases are the two largest causes of death among those under five years old.

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 Population Health And Infectious Disease Essay
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 2000.
This OpenLearn course is an adapted extract from the Open University course : SK320 Infectious disease and public health.

Learning outcomes
After studying this course, you should be able to:

define and use, or recognise definitions and applications of, each of the glossary terms for the course

summarise the main features of the current global burden of infectious disease and the public health movement that has evolved to reduce its impact, emphasising the contributions of epidemiology, water quality, sanitation and hygiene, global infectious disease surveillance networks, and evidence-based interventions such as vaccination programmes

use appropriate examples and interpret unfamiliar examples presented to you, to illustrate successful public health strategies that: use education to support behavioural changes that enable people to protect themselves, their children or other community members from infection; 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 Population Health And Infectious Disease Essay

consider a range of public health strategies, including unfamiliar examples, and identify the levels of prevention (primary, secondary, tertiary) involved in their implementation

use or analyse examples of public health interventions to illustrate the importance of international and national prevention programmes, community participation and community health workers in controlling infectious disease.

1 The global burden of infectious disease
In 2008, a total of 8.8 million children died before their fifth birthday – half of them in Sub-Saharan Africa. Pneumonia, diarrhoea, malaria, HIV/AIDS and measles caused 44% of these deaths in children under five years (Figure 1). Newborn deaths from sepsis and tetanus in the first four weeks of life accounted for a further 7%, and many of the 17% of deaths attributed to ‘other causes’ were also due to infection, including TB and meningitis exacerbated by malnutrition, which contributes to over one-third of all child deaths. (Note that the ‘non-infectious neonatal causes’ depicted in the figure refer to deaths resulting from prematurity, birth asphyxia, trauma and congenital abnormalities.)Population Health And Infectious Disease Essay

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Figure 1 Major causes of 8.8 million deaths globally among children under five years in 2008. (Source: based on data in UN, 2010, p. 27.)
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Although the impact of infectious disease episodes and deaths is disproportionately felt among the populations of low- and middle-income countries (LMICs), the richer nations of the world have not escaped. For example, infectious and parasitic diseases were responsible for 201 751 admissions to National Health Service (NHS) hospitals in England in the budget year 2010–2011, an increase of 10% on the previous year – the biggest percentage rise of any disease admission group (Hospital Episode Statistics, 2011). It was largely due to a 29% increase in admissions of children aged under 15 with non-hepatitis, non-influenza viral infections, and it confirms a rising trend. This category of hospital admissions has risen by 84% in England since 2006–2007.

1.1 Acute respiratory infections
Influenza, pneumonia and other acute respiratory infections (ARIs) are often forgotten in the focus on TB, HIV/AIDS and malaria, but they rank first among infectious causes of disease worldwide:

The average global burden of seasonal influenza alone is about 600 million cases per year, of which 3 million result in severe illness, causing between 0.25 and 0.5 million deaths (WHO, 2009a). Pandemic influenza occurs at unpredictable intervals with the emergence of new variant influenza viruses.
The ‘swine flu’ epidemic in 2009 caused by an H1N1 virus spread rapidly to 208 countries; the speed of transmission overwhelmed the capacity for laboratory confirmation of cases, especially in low-resource countries, but clinical diagnosis suggests that several million people were symptomatically infected and at least 12 220 died (WHO, 2009b).Population Health And Infectious Disease Essay
Pneumonia is the largest infectious cause of death among young people globally (see Figure 1), accounting for an estimated 1.5 million deaths in children under 5 years – more than TB, HIV/AIDS and malaria combined in this age group. Pneumonia is mainly due to the bacteria Streptococcus pneumoniae and Haemophilus influenzae type b (Hib), the respiratory syncytial virus (RSV) and parainfluenza viruses, all of which also affect elderly people worldwide. 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 World Health Organization (WHO) estimates that up to 18 million episodes of pneumococcal disease and around 16 million episodes of RSV disease occur globally every year.
1.2 Diarrhoeal diseases
Worldwide, there are about 2 billion cases of diarrhoeal disease every year, including cholera, dysentery (bloody diarrhoea), giardiasis and a long list of bacterial and viral causes. They are the second largest infectious cause of death among young children (Figure 1), killing about 1.4 million annually, 80% of them under two years of age (WHO, 2009c). Even in the USA, the richest nation on Earth, diarrhoeal diseases cause an estimated 38.4 million episodes annually and around 1700 deaths (Scallan et al., 2011).Population Health And Infectious Disease Essay

The pathogens causing diarrhoeal diseases are transmitted in contaminated food and water and from hand to mouth (the faecal–oral route). A major underlying cause is the shaming fact that in 2010 around 780 million people (11% of the global population) lacked access to improved sources of drinking water (Figure 2), and 2.5 billion – 37% of the world’s population – had no access to basic sanitation (UNICEF and WHO, 2012). However, steady progress is being made: in the 20 years from 1990 to 2010, an estimated 2 billion people gained access to improved drinking water and 1.8 billion gained access to improved sanitation (i.e. a covered pit latrine or better). These changes are gradually reducing the impact of diarrhoeal diseases on children’s health.

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Figure 2 (a) A boy collecting water from a stream in the Oromiya region of Ethiopia in East Africa before (b) drinking it. The lack of access to safe drinking water is a major cause of diarrhoeal diseases.
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1.3 Tuberculosis
Tuberculosis (TB) has overtaken HIV/AIDS globally as the largest infectious cause of death by a single pathogen. Kaufmann reports that in 2011:

Every minute of every day, nearly 20 people were infected with Mycobacterium tuberculosis and four people died from TB.
One-third of the global population (well over 2 billion people) were carriers of TB bacteria.Population Health And Infectious Disease Essay
There were over 9 million new or relapsed active cases.
Over 2 million people with chronic TB died.
Although the prevalence of TB is highest in the poorer countries of South-East Asia and Sub-Saharan Africa (Figure 3), it is resurging in Eastern Europe and increasing in the richest parts of the world. For example, there were over 9000 new cases of TB in England and Wales in 2011, most of them in London (HPA, 2012).

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Figure 3 A woman with tuberculosis receiving her DOTS medication (directly observed treatment, short course) from a healthworker in Alem Kitmama, Ethiopia
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1.4 HIV/AIDS
Worldwide, HIV incidence (the number of new cases occurring in a given period, usually one calendar year) has stabilised and deaths have been declining in recent years (UN, 2010). However, the impact on the global burden of HIV-related disease is still huge.

Global HIV incidence stabilised at around 2.7 million new HIV infections annually between 2007 and 2010 (the most recent year for which data are available at the time of writing). AIDS-related deaths fell from 2 million in 2008 to 1.8 million in 2010 due to the expansion of access to effective antiretroviral therapy. One outcome of this success is that HIV prevalence (the number of people living with HIV infection) is steadily increasing – to 34 million in 2010. Just over 2 million of those people were children under 15 years infected via mother-to-child transmission (WHO, UNAIDS and UNICEF, 2011).

People with HIV are primarily in LMICs, but richer parts of the world are also affected. For example, according to the Health Protection Agency, 91 500 people in the UK were estimated to be living with HIV at the end of 2010, of whom 6660 were newly diagnosed in that year and around 24% were unaware of their infection status (HPA, 2011a).Population Health And Infectious Disease Essay

1.5 Malaria
The prevalence and incidence of malaria has also been steadily decreasing worldwide, but 216 million new cases still occurred in 2010, with an estimated 655 000 deaths in that year, mainly among young children and pregnant women. It is a shocking truth that an African child dies from malaria every 60 seconds. Although there were 126 000 fewer deaths globally in 2010 than in 2009, malaria still accounted for 22% of the deaths of African children (WHO, 2011a).

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In October 2011, some progress was announced from large-scale clinical trials of the RTS,S/AS01 malaria vaccine, which reduced the incidence of new infections among young African children by 50% (RTS,S Clinical Trials Partnership, 2011). This is a significant breakthrough, representing the first vaccine with established clinical effectiveness in preventing a human infectious disease caused by a parasite.

However, it is not yet known how long the protection will last, and 50% efficacy is well below the desired 95% achieved by some well-established vaccines, e.g. against measles or diphtheria. But the RTS,S/AS01 vaccine also includes surface antigens from hepatitis B viruses and gives good protection against the latter. Combined (or combination) vaccines such as this one are highly effective because they protect children against two or more diseases at the same time.Population Health And Infectious Disease Essay

Can you identify any other combined vaccines from your own experience?

Reveal answer
1.6 Other infectious disease headlines
Here are some other estimates from the WHO (accessed in 2011).

Over 350 million people are chronically infected with hepatitis B virus (HBV) and 130–170 million with hepatitis C virus (HCV), causing over 1 million deaths from liver disease and hepatic cancer annually (WHO, 2008, 2011b).
Excluding HIV and HBV, there are around 350 million new cases of the major sexually transmitted infections, including gonorrhoea, chlamydia and syphilis, which has a disproportionate effect on infants. Approximately 12 million new infections with Treponema pallidum pallidum occur every year, including 1.5 million babies born with congenital syphilis – the most common infection passed from mother to newborn baby. This is more prevalent even than congenital HIV, but far less publicised. In Africa alone, congenital syphilis causes the death of almost 500 000 babies every year (WHO, 2007).
Around 1.5 billion people are infected with intestinal worms. A typical child in a poor rural environment in a low-income country commonly carries around 1000 hookworms, roundworms and whipworms, causing anaemia, stunted growth and increased vulnerability to other infectious diseases (WHO, 2012a).Population Health And Infectious Disease Essay
The so-called ‘neglected tropical diseases’ include Schistosoma parasites, which infect 207 million people worldwide – 85% of them in Africa, causing an estimated 200 000 deaths annually. Around 12 million people in 88 countries are chronically infected with Leishmania parasites, which cause severe cutaneous (Figure 4a) or visceral (Figure 4b) disease (WHO, 2012b).
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Figure 4 (a) Ulceration on the face due to cutaneous leishmaniasis. (b) A child with severe weight loss and an enlarged abdomen with a huge liver and spleen due to visceral leishmaniasis.
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Around 500 000 people are blinded by the microscopic parasitic worm Onchocerca volvulus (WHO, 2012c) and over 120 million people worldwide are infected with Wuchereria bancrofti, the parasite causing lymphatic filariasis (WHO, 2012d).
The viral haemorrhagic fevers are epidemic-prone diseases, which are increasing their geographical range and the number of people affected. Annually, it is estimated there are:
200 000 cases of yellow fever, causing 30 000 deaths
300 000–500 000 cases of Lassa fever, causing 5000 deaths
up to 50 million dengue virus infections, including at least 250 000 cases of haemorrhagic fever and 24 000 deaths (WHO, 2012e).
With this daunting background in mind, the next section illustrates the diversity of public health approaches to controlling the huge burden of infectious diseases. An additional aim is to demonstrate the importance of addressing local needs and engaging local communities in interventions to improve public health, as you will see particularly in a slidecast on ‘Infectious disease and public health in rural Ethiopia’ in Section 4 (Video 1), and when you read about the guinea worm eradication campaign in Section 5.Population Health And Infectious Disease Essay

2 The public health approach
The term public health refers to the ‘science and art of preventing disease, prolonging life, and promoting health’ (Winslow, 1920) and encompasses everything affecting the health of a population as a whole, rather than the individuals of which it is composed. A population may be all members of a nation or geographical region, or a defined group, for example all children under five years of age, all members of a minority ethnic group, or all women during the potential childbearing years. Public health is also concerned with non-communicable diseases, for example cancers, cardiovascular diseases and diabetes.

Here we focus specifically on the public health approach to infectious disease. 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 Population Health And Infectious Disease Essay
direct intervention to prevent infection, e.g. through vaccination, reducing environmental sources of pathogens, or isolation and treatment of infected individuals
education to promote behaviour change that reduces the risk of infection, or reduces the impact of an infectious disease outbreak
organising and supporting community action to promote and sustain a healthier population and local environment and to coordinate community responses to outbreaks of infectious disease.
All of these areas are addressed in the rest of this course after a very brief review of the origins of the public health movement.

2.1 Threats to public health from urbanisation and industrialisation
Sanitarianism
The public health movement began in England in the nineteenth century in response to the huge toll of deaths from infectious disease in the urban slums and overcrowded tenement buildings that sprang up to house the influx of workers during the Industrial Revolution. An inspirational group of philanthropists founded the ‘sanitary movement’ or ‘sanitarianism’, with the aim of protecting the public health from sickness, which they recognised arose primarily from the polluted urban environment of the period.Population Health And Infectious Disease Essay

The term ‘public’ encapsulates their focus on protecting the health of the population as a whole, rather than on treating or preventing disease in its individual members, and this emphasis characterises the public health approach today.

Quarantine
Quarantine is a period of enforced isolation or restriction of travel or activity. It is one of the oldest forms of public health intervention, pre-dating the germ theory of disease. In the nineteenth and early twentieth centuries, ‘fever’ hospitals and TB sanitariums were built outside major centres of population in Europe and the USA, to quarantine their patients away from the rest of society. This approach is still being applied in modern times: for example, in 2003, an isolation hospital was constructed in Southern China to quarantine people infected with the severe acute respiratory syndrome (SARS) virus.

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. The insistence on evidence led to the gradual development of a new academic discipline – epidemiology – the collection, analysis and interpretation of data on the occurrence, distribution, potential causes and control of diseases, disorders, disabilities and deaths in populations.Population Health And Infectious Disease Essay

Epidemiology remains central to modern public health in the twenty-first century, but the methods of data collection now involve global monitoring and surveillance networks and huge online databases.

2.2 Public health surveillance and response in a globalised world
The rise of holidays abroad, cheap air travel, and the mass population migrations triggered by conflict and economic hardship are characteristics of the modern world. It is not that people did not travel in the past, but that the opportunities and the speed of travel are much greater now, so public health systems are faced with the challenge of controlling new infections that can spread globally in a very short time. Similarly, trade routes still transport infected goods within countries as they have always done, but air freight enables infectious agents in foodstuffs to travel between continents in less than a day.Population Health And Infectious Disease Essay

Globalisation requires global responses to prevent potential infectious disease pandemics. The gradual expansion of global health surveillance and response systems during the twentieth century through the efforts of governments and international organisations, such as the United Nations (UN) and WHO, was given new urgency by the HIV/AIDS pandemic from the mid-1980s onwards (Castillo-Salgado, 2010). This trend was accelerated by the emergence of SARS in 2003 and the identification of at least 30 other previously unknown human pathogens in recent decades. Ongoing concerns about possible pandemic strains of influenza virus and the rapid increase in drug-resistant strains of TB and malaria were additional factors in prompting the 194 member states of the WHO to approve revised International Health Regulations in 2005.

2.2.1 International Health Regulations: IHR (2005)
The main aim of the International Health Regulations (IHRs) or ‘IHR (2005)’ is to ensure early warning and prompt action to contain any public health emergency of international concern. The obligations include the adoption of seven areas of work (Box 1) and the commitment by member states to improve their ‘real time’ reporting of disease outbreaks to WHO via round-the-clock communication channels.Population Health And Infectious Disease Essay

Box 1 Seven areas of work covered by WHO IHR (2005)
Foster global partnerships.
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.g. meningococcal meningitis, cholera, viral haemorrhagic fevers such as dengue and Lassa fever, yellow fever and other vector-borne viral infections, plague, anthrax, human influenza caused by a new subtype, poliomyelitis due to wild-type polio virus, smallpox and SARS).
Strengthen the management of specific risks.
Sustain rights, obligations and procedures.Population Health And Infectious Disease Essay
Conduct studies and monitor progress.
2.2.2 The WHO Global Outbreak Alert and Response Network
The central coordinating body within the WHO’s surveillance function is the Global Outbreak Alert and Response Network. There are now numerous international surveillance and response programmes (ISRPs), networks and online databases recording outbreaks of notifiable diseases, i.e. cases that health workers are legally required to notify (report) to a designated agency or public health officer.

The Global Influenza Surveillance Network illustrates the scope of one of the largest ISRPs: it consists of 111 national influenza detection centres in 83 countries around the world and four influenza reference laboratories in the USA, the UK, Japan and Australia. The reference laboratories collect and analyse influenza strains from the detection centres to give early warning of new variants that could pose a major risk to global health.

The IHRs incorporate the recognition that interventions that affect trade and travel also have the potential to affect the human rights of the individual.

Suggest some examples of interventions that have human rights implications for individual liberty and freedom to travel.

Reveal answer
2.2.3 National surveillance agencies
The ability of national surveillance, response and reporting systems in WHO member states to monitor outbreaks of infectious disease of public health importance are less developed in LMICs where major disease outbreaks most often occur. But strenuous efforts to help them catch up are being made by agencies in wealthier countries.Population Health And Infectious Disease Essay

The UK has four such agencies:

the Health Protection Agency in England
the National Public Health Service Wales
Health Protection Scotland
the Department of Health, Social Services and Public Safety, Northern Ireland.
The functions of the public health agencies in the four nations of the UK are similar and are encapsulated in the Act of Parliament that created the Health Protection Agency (HPA) in England (HM Government, 2004). Principally, the agencies all function to protect the community (or any part of the community) against infectious diseases and other dangers to health through surveillance and data analysis, and to provide advice and information to the general public, health professionals and national and local government.

The HPA also provides expertise to assist the British Commonwealth countries and Brazil, Russia, India, China and South Africa (known collectively as ‘BRICS’) to implement the WHO International Health Regulations – IHR (2005). Projects include:

building meningococcal serology capacity across Sub-Saharan Africa
improving public health emergency preparedness and response in India Population Health And Infectious Disease Essay
developing an influenza surveillance network across South America to detect antiviral drug resistance (HPA, 2011b).
The huge range of outbreaks reported via national infectious disease surveillance networks can be judged from the ‘snapshot’ in Table 1, based on data published in the international journal The Lancet Infectious Diseases in the four months from August to November 2011.

Table 1 Selected infectious disease surveillance notifications from The Lancet Infectious Diseases, August–November 2011
Country, region or town Infectious disease outbreak
Cambodia 6 deaths (all children under 15 years) from H5N1 avian influenza
Canada, Ontario 80 cases of Clostridium difficile in hospitals, causing 21 deaths
Central African Republic 57 cases and 16 deaths from Vibrio cholerae infection Population Health And Infectious Disease Essay
Congo, Brazzaville more than 7000 cases of chikungunya, a mosquito-borne viral disease causing fever and prolonged arthritic inflammation of the joints
India, Eastern Uttar Pradesh and Bihar more than 2000 cases and 400 deaths from mosquito-borne Japanese encephalitis virus and enterovirus infection from contaminated water
France, Vaucluse and Somme districts 8 cases of botulism traced to eating contaminated green olive tapenade or tomato paste from a French food company
Pakistan, Punjab region more than 4000 cases and at least 8 deaths from dengue fever, causing the closure of all schools in Lahore for 12 days
South Sudan, Jur River county 12 new cases of cutaneous anthrax and 777 cases of guinea worm disease
England, Scotland and Wales 250 infections and one death from Escherichia coli O157, possibly originating from leeks and potatoes
USA, Albuquerque, New Mexico 5 cases and 3 deaths from hantavirus pulmonary syndrome, transmitted to humans from rodents
USA (24 states) 109 infections and 23 deaths from listeriosis traced to Listeria monocytogenes in cantaloupe melons and lettuces
Vietnam (national epidemic) more than 42 000 cases and 98 deaths from hand, foot and mouth disease, caused by picornaviruses
Zambia, Chama district 278 cases and 5 deaths from anthrax, thought to have been contracted from contact with infected hippopotamus meat
(Source: Bennet, 2011a, 2011b; Dehnel, 2011; Mohammadi, 2011)Population Health And Infectious Disease Essay
But such high-profile outbreaks are only the tip of the public health ‘iceberg’. Submerged below the level that excites media interest are the day-to-day public health routines of surveillance, direct intervention, education and community action that seek to control infection all over the world. Although these strategies save millions of lives every year and prevent many more episodes of infectious disease, they are largely disregarded outside public health circles.

The rest of this course will give you an insight into their diversity and the success of some public health campaigns to control – and in some cases eliminate – major infectious diseases.

2.3 Public health interventions
Surveillance and reporting are clearly essential to ensure coordinated action to protect public health, but the range of responses can be bewilderingly diverse. A useful way of thinking about direct public health interventions to control infectious disease is to distinguish between strategies that:Population Health And Infectious Disease Essay

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.
For each of the categories 1 to 4, suggest one example of an intervention to control a specific infectious disease.

Reveal answer
Aside from vaccination programmes, what other major public health strategies could have a similarly huge impact on the control of infectious diseases in populations?

Reveal answer
Less visible, but no less significant, contributions to population health come from:

the provision of transport and other infrastructures to enable widespread access to health and social services
controls on the pollution of the environment by traffic, agriculture and industrial processes
an education system that delivers a high rate of literacy in the population, particularly in women, which is strongly associated with reduced morbidity and mortality rates among their children Population Health And Infectious Disease Essay
gender equality in access to the means of subsistence, goods and services, including health care
an economic structure that supports an adequate income, shelter and nutrition for all households
a stable and equitable political system.
3 Levels of infectious disease prevention
The prevention of disease obviously has a potentially greater impact on public health than medical treatment, although – with the exception of vaccination programmes – infectious disease prevention has always been far less well funded or researched.

This section examines a hierarchy of public health interventions, which are traditionally considered to operate at three different ‘levels of prevention’. Although you should be aware that there is some artificiality in separating them in this way, they provide a useful framework to illustrate the diversity of public health strategies for preventing infectious disease.

3.1 Primary prevention strategies
Public health strategies aimed at the primary prevention of infectious disease seek to prevent new cases of infection from occurring by interrupting the transmission of pathogens to susceptible human hosts, or increasing their resistance to infection.Population Health And Infectious Disease Essay

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.
This protective effect is known as herd immunity, and the herd immunity level is reached when the ratio of immune-to-non-immune individuals is high enough to stop the infection circulating in the population because there are so few susceptible individuals.

Educating mothers about the benefits of breast feeding their babies exclusively for the first six months is another example of a primary prevention strategy. Breast feeding is promoted not only for its nutritional benefits but also to protect breast-fed infants against the pathogens that can contaminate feeding bottles, animal milk and infant formula prepared with unsafe water. Breast milk also contains maternal antibodies, so it provides babies with passive immunity against enteric pathogens.Population Health And Infectious Disease Essay

Suggest some other examples of public health interventions aimed at the primary prevention of infectious disease.

Reveal answer
You will see as this course progresses that many other examples of public health interventions operate at the primary prevention level.

3.2 Secondary prevention strategies
Secondary prevention aims to detect new cases of infectious disease at the earliest possible stage and intervene in ways that prevent or reduce the risk of infection spreading further in the population. Some examples of how secondary prevention can be put into practice are described below.Population Health And Infectious Disease Essay

Early treatment
This level of prevention involves infected (or exposed) individuals receiving early treatment to prevent the transmission of pathogens to susceptible hosts. Benefit to the individual may also result from treatment, but the aim from a public health perspective is to protect the community as a whole from further infections, rather than to aid the personal recovery of identified patients.

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. If the disease has the potential to generate an epidemic, it may be necessary to isolate (quarantine) infected individuals, who should also be educated about how they can prevent or reduce the risk of transmission to others.Population Health And Infectious Disease Essay

Suggest examples of how the education of infected individuals could contribute to the secondary prevention of infection.

Reveal answer
Note that even if the condition is not curable by medical treatment, benefit to the community may also result if the education of infected people leads to health-related behaviour modification, i.e. long-lasting changes in behaviour that result in health gains, a reduction in health risks, or an increase in disease prevention. For example, the rates of new HIV infection among gay men in the UK and the USA declined after 1996 due to changes in sexual behaviour, but began rising again after antiretroviral therapy became widely available in high-income countries (CDC, 2001; HPA, 2011c).

Screening
Infected individuals can also be identified even before symptoms develop in systematic screening programmes, i.e. the application of a test or an investigation to large numbers of individuals to identify those at risk of developing a particular disease, or (in the case of infectious disease) those who are already infected. The screening service can target groups assumed to be at high risk; for example, people who are homeless or staying in migrant hostels are at the greatest risk of TB, so TB screening programmes may be directed towards these groups.Population Health And Infectious Disease Essay

Clinical and/or microbiological screening programmes are a vital component of public health initiatives against infectious diseases all over the world, with the aim of secondary prevention as well as the treatment of individuals (Figure 6). If they are coupled with education on prevention among uninfected individuals given the ‘all clear’, screening programmes also contribute to primary prevention.

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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.
Long description
Secondary prevention is most difficult where the infectious disease either has a prolonged asymptomatic (symptom-free) stage (e.g. for HIV this may last several years after infection), or can exist in an asymptomatic carrier state where the person becomes chronically infected but never develops disease symptoms and acts as a persistent reservoir of infection to others.

Suggest some examples (other than TB, HIV and malaria) that fit these criteria.Population Health And Infectious Disease Essay

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3.3 Tertiary prevention strategies
Medical treatment to prevent the worst outcomes of a disease in an individual is known as tertiary prevention. Although this may greatly improve the quality of life for that person, it has at most a limited impact on the spread of infectious disease. For example, physical therapies that support the rehabilitation of children with paralytic polio are at the tertiary level of prevention, i.e. they can reduce the impact of paralysis on the child’s quality of life, but they have no impact whatsoever on the spread of polio virus in a community.

However, tertiary strategies contribute to public health in a more subtle way. By alleviating the pain, distress and disability experienced by individuals, the community as a whole benefits from the input these people are enabled to make to the ‘social capital’ of all (Figure 7).Population Health And Infectious Disease Essay

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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.
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3.4 Combining prevention levels to promote public health
To illustrate how the hierarchy of prevention levels can operate in practice, consider our answers to the following worked example.

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).

Secondary prevention: screening programmes to detect cases of infection early (e.g. from sputum tests); treatment of early non-symptomatic infection with drugs such as isoniazid, or symptomatic TB with a multidrug regimen, ideally in a DOTS programme (see Box 2).Population Health And Infectious Disease Essay

Tertiary prevention: drug treatment of severe complications such as tubercular meningitis, and physical rehabilitation therapy for extrapulmonary TB, e.g. affecting the skeleton and mobility. (Note: ‘extrapulmonary’ means ‘outside the lungs’.)

The same principles can be applied to other examples.

Identify the level of prevention operating in each of the following strategies to control diarrhoeal diseases in children in a rural village in a low-income country.

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.Population Health And Infectious Disease Essay
Reveal answer
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. Failure to do so can lead to a relapse of patient health and the possible development and spread of drug-resistant forms of TB.

In order to improve drug compliance in patients, the WHO devised a five-component TB control strategy called ‘directly observed therapy, short course’ (DOTS). DOTS addresses the problem of drug compliance by having either a designated health worker or some other responsible person directly observe a patient each time they take their antibiotics. 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, 2012f)
4 Public health successes in controlling infectious disease
In this section you will explore some major successes in public health interventions to control infectious disease, and see how these encouraging indicators of progress have been achieved. This will involve studying an additional resource: a slidecast about infectious diseases and public health in Ethiopia (Video 1).Population Health And Infectious Disease Essay

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4.1 Vaccination revisited
In principle, a vaccination is a relatively simple event, because it does not require any changes to social structures or long-term personal behaviour, both of which may be difficult to achieve or sustain. The success of vaccination programmes is not dependent on radical changes in society; it depends on the organisation, funding and delivery of vaccines to populations in need of protection from vaccine-preventable diseases (VPDs).

By comparison with other public health interventions that could have an equal or greater impact, such as the universal provision of clean water and sanitation, vaccination is a relatively cheap disease prevention and health promotion strategy. It has achieved some notable successes, a number of which are briefly summarised here.

When the WHO initiated the Expanded Programme on Immunization (EPI) in 1974, fewer than 5% of the world’s infants were fully immunised during the first year of life against the six main VPDs:

tuberculosis
poliomyelitis
diphtheria
tetanus
pertussis
measles.
In order to track progress towards increasing vaccine coverage, WHO member states agreed to use the proportion of infants (i.e. those under one year) receiving all three scheduled doses of the combined vaccine against diphtheria, tetanus and pertussis (known as ‘DTP3 coverage’, or sometimes ‘DPT3 coverage’) as the main indicator of immunisation programme performance. By 2010, DTP3 coverage in WHO member states was protecting 85% of infants against these three diseases, with a target to reach 90% by 2015 (WHO, 2012g).Population Health And Infectious Disease Essay

Coverage with measles-containing vaccines has also increased worldwide to 83% globally among children aged 12–23 months. This campaign has achieved a reduction from 4 million cases of measles and 2.6 million child deaths in 1980, to fewer than 118 000 cases contributing 1% of deaths in children under five in 2008 (WHO, 2012h).

Polio, measles and neonatal tetanus are the VPDs at the top of the WHO’s target list for global eradication, following the successful campaign to rid the world of smallpox.

4.1.1 The eradication of smallpox
On 8 May 1980, the WHO announced that smallpox had been eradicated from the world. Global eradication refers to the permanent worldwide reduction of cases to zero, with no known sources of infection that could generate a new case.

The declaration that the world was free of smallpox came more than two years after the last recorded cases in the three countries where the smallpox virus had proved hardest to eradicate: Somalia, Ethiopia and Kenya.Population Health And Infectious Disease Essay

The global campaign against smallpox began in 1967. Back then, the estimated prevalence of the disease was 10 million cases, it was endemic in more than 30 countries and was frequently imported to at least 12 further countries. Against this background, how was worldwide eradication achieved in little more than ten years? The answer lies in certain features of the smallpox virus, the efficacy of the vaccine that prevents it, and the manifestations of the disease, as explained in Box 3.

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.
The transmission of the virus from infected to susceptible individuals is relatively infrequent – typically, a person with smallpox infects two to five others (by comparison, a person with measles typically infects 10–20 susceptible contacts), so an outbreak spreads relatively slowly.
Case finding is relatively easy because symptoms develop soon after infection, the smallpox lesions are immediately visible and characteristic in their appearance (Figure 8), and there is no asymptomatic or carrier state.Population Health And Infectious Disease Essay
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Figure 8 A young girl in Bangladesh infected with smallpox in 1973. Freedom from smallpox was declared in Bangladesh in December 1977 when a WHO International Commission officially certified that it had been eradicated from that country.
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The smallpox vaccine is heat-stable, so it could be transported without loss of efficacy for mass vaccination campaigns in locations where refrigeration would have been impossible.
A single vaccination produces long-lasting immunity, so there is no need to locate recipients for repeat vaccinations.
A key aspect of the public health approach to smallpox eradication was the adoption of a case containment policy. Instead of removing smallpox patients to hospitals for treatment, where the disease rapidly spread, most infected people were supported to remain in their own homes. Infected villages were sealed off until the patient recovered or died and all known or suspected contacts had been vaccinated.

4.1.2 The campaign to eradicate polio
Of the three vaccine-preventable diseases on the WHO target list for eradication – polio, measles and neonatal tetanus – the most progress has been made towards eradicating polio, largely because it has some similar characteristics to those already described for smallpox (see Box 3). One difference is that polio is caused by an RNA virus, but it does not generate the high number of variants typical of influenza viruses or HIV.Population Health And Infectious Disease Essay

The global polio vaccination campaign began in 1988, a year in which an estimated 350 000 people – most of them children – developed acute flaccid paralysis (AFP) – the case-defining symptom of polio – as a result of infection with poliovirus. By 2010, the annual number of cases had dropped to 1352 and, in 2012, just three countries reported new cases: Nigeria, Afghanistan and Pakistan (WHO, 2012i). This progress was achieved through systematic mass polio vaccination campaigns (Figure 9) and an increased focus on case finding and case containment.Population Health And Infectious Disease Essay

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Figure 9 Oral polio vaccine (OPV) drops being given to an infant at Malipur Maternity Home, Delhi, India
Long description
However, you might wonder why it is taking so long to eradicate polio, given that a 99% reduction in polio cases worldwide had already been achieved by 2001. Since then, the incidence has increased in some locations, particularly in Pakistan where new outbreaks have occurred. Rumours that fuelled opposition to vaccination in some communities have been the main cause of delay in achieving the WHO eradication target, not only for polio but also for measles and neonatal tetanus. But this delay should not overshadow the success of the polio campaign. In the 1980s, before the advent of mass vaccination, polio was paralysing 1000 children every day.

Activity 1 Infectious disease and public health in rural Ethiopia
Timing:Allow 45 minutes
This is the ideal time to study Video 1, a slidecast entitled ‘Infectious disease and public health in rural Ethiopia’. In addition to illustrating the infectious disease epidemiology of a Sub-Saharan African country, and the principal underlying causes of the high burden of infection, this slidecast will give you an insight into how a routine immunisation programme is organised to reach every child even in remote rural locations. It also serves as an introduction to some key points on non-vaccine interventions to prevent and control infectious disease, which form the focus of the next section of this course.Population Health And Infectious Disease Essay

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Video 1 Infectious disease and public health in rural Ethiopia
If you cannot study the slidecast now, try to do so before you complete this course. Then answer the questions below. There will be other questions on rural Ethiopia later in this course.

Which infectious diseases are covered by the Expanded Programme on Immunization (EPI) in Ethiopia?
What percentage of infants was protected by vaccination in the community served by Almaz? Which of these vaccinations protected newborn babies indirectly?
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4.2 The importance of hygiene
In public health parlance, hygiene behaviour encompasses the wide range of actions taken by individuals to maintain a standard of cleanliness of their bodies, domestic environments and workplaces to prevent the transmission of infection. It includes all the personal actions associated with excretion and the disposal of human and animal waste and refuse, the washing of persons, clothing, implements and structures (e.g. floors, lavatories and latrines), the handling of domestic animals, and the preparation of food.Population Health And Infectious Disease Essay

When clean water and sanitation were installed in London in the nineteenth century, the epidemics of cholera that had claimed thousands of lives rapidly came under control. However, typhoid fever continued to be a problem for several more decades. The eventual reduction in typhoid was ascribed to the increasing availability of piped water and soap inside domestic households, the safe disposal of waste water from houses, and the increasing social imperative for personal hygiene.

Name another infection that can be controlled by personal hygiene.

Reveal answer
Personal hygiene can also alleviate some of the suffering caused by secondary infections of inflamed tissues. For example, careful washing and drying reduces the secondary bacterial infections which often colonise the inflamed skin folds of people with elephantiasis resulting from the blockage of lymphatic vessels by filarial worms Population Health And Infectious Disease Essay

Figure 10 Elephantiasis of the lower limbs and body tissue caused by filariasis
However, although personal hygiene is a matter for the individual, it also requires the provision of certain infrastructures (e.g. covered wells, water mains), the means to purchase certain goods (e.g. soap, domestic cleaning agents) and a culture that is supportive of personal, domestic and public cleanliness. These are all in short supply in the poorest parts of the world.

4.2.1 Hand washing with soap
The importance of the most obvious hygiene behaviour – thorough hand washing with soap – cannot be overestimated. Many intestinal microorganisms and worms are thought of as causing water- or food-borne diseases, and indeed they are often transmitted by these routes. However, they are also transmitted by the faecal–oral route, in which faecal contamination of the hands is transferred directly to the mouth (e.g. when children suck their fingers or people eat with unwashed hands), or indirectly when pathogens on the hands are transferred to food, drinks or utensils. These diseases are also transmitted by flies landing on faeces and then on food.Population Health And Infectious Disease Essay

In most homes in high-income countries, the availability of soap and clean water for washing is taken for granted; but it is a luxury that millions of people elsewhere in the world can rarely afford (Figure 11).

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Figure 11 Hand washing with soap
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Think back to Video 1. What facilities did Asafesh have for washing her hands at her Health Post in rural Ethiopia?

Reveal answer
Public health educators have increasingly understood the potential impact of hand washing on the incidence of many infectious diseases, as described in a major review article entitled ‘Hygiene: New Hopes, New Horizons’ (Curtis et al. 2011). According to the evidence reviewed by the authors, very significant reduction in diarrhoeal-disease episodes can be achieved by hand washing, especially if soap is used. They conclude that hand washing reduces diarrhoeal illness by around 30%, and if soap is used, the reduction is 43–47%. This huge reduction at very little cost per person justifies the authors’ conclusion that hand washing with soap may be ‘the single most cost-effective way of reducing the global burden of infectious disease’ (Curtis et al., 2011, p. 312).Population Health And Infectious Disease Essay

In addition to transferring diarrhoeal pathogens and intestinal parasites, can you suggest any other infectious conditions that can be transferred by poor hand hygiene?

Reveal answer
The article also points to the potential impact of other aspects of personal hygiene that can reduce the risk of infection, one of which was also mentioned in Video 1 (the avoidance of open defaecation in fields and the safe disposal of human faeces in well-constructed latrines). How does this practice reduce the risk of diarrhoeal diseases?

Reveal answer
Another setting in which the importance of hand hygiene has been widely publicised relates to the prevention of infection transmitted between patients and staff in hospitals and other healthcare institutions. It illustrates how relatively simple public health interventions can have a significant impact on an important source of infection, even in high-income countries. This idea is explored in the next section.

4.2.2 Institutional hygiene and healthcare-associated infections (HCAIs)Population Health And Infectious Disease Essay
In the first five years of the twenty-first century, the news media in the UK reported increasing alarm over rising numbers of cases of two bacterial infections believed to have been acquired by patients in hospitals, nursing and residential care homes and rehabilitation centres. The conditions are methicillin-resistant Staphylococcus aureus (MRSA) (Figure 12), which is resistant to the antibiotic methicillin, and ‘C.diff’ or Clostridium difficile infection (CDI). (Note that the antibiotic generally referred to as ‘meticillin’ in the UK, is known as ‘methicillin’ in most other parts of the world.)

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Figure 12 Cultures of MRSA (the blue colonies) growing on a chromogenic agar culture plate; the white colonies are other Staphylococcus species
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MRSA and CDI are not the only healthcare-associated infections (HCAIs), but they are responsible for the most serious, sometimes fatal, cases in the UK. Often overlooked in media reports of HCAIs is the increasing transmission of methicillin-susceptible S. aureus (MSSA) and some other pathogens.Population Health And Infectious Disease Essay

Why are staphylococcal infections a significant problem in healthcare settings, particularly in surgical wounds?

Reveal answer
C. difficile is also found naturally in the large intestine, but only in about 3% of adults in the UK, where it is normally kept in check by competition with commensal gut bacteria. However, C. difficile can ‘overgrow’ in elderly or frail patients who are taking broad-spectrum antibiotics, which destroy competing bacterial species. It is easily spread as spores, which may be hard to eradicate from healthcare institutions where susceptible patients are most at risk of becoming infected. CDI results in severe ulceration of the large intestine (a condition known as pseudomembranous colitis), with painful, copious diarrhoea (NHS Choices, 2012).

The blame for outbreaks of HCAIs is attributed to poor institutional hygiene, including inadequate hand washing by staff in contact with patients. A vigorous campaign to reduce the transmission of HCAIs was initiated in UK hospitals and other healthcare institutions in the late 1990s, and has had significant success. But these infections still cost the NHS an estimated £1 billion per year, in addition to the pain and suffering of patients who acquire an HCAI (DH, 2012).Population Health And Infectious Disease Essay

Surveillance
Surveillance has played a key role in tackling the problems posed by HCAIs.

Mandatory surveillance in England began in 2001 for MRSA and in 2005 for CDI, and all cases in English NHS hospitals have been reported to the Health Protection Agency since April 2007 via a web-based Surveillance Data Sheet. So-called ‘lab returns’ on the number of positive blood cultures (MRSA bacteraemia), and CDI-infected stool samples, are collected from each location.

Patients are now routinely screened for nasal carriage of MRSA before and at admission to NHS hospitals, and all stool samples received from people aged over 65 years with diarrhoea are tested for CDI, including samples sent in by general practitioners or GPs (family doctors in the UK).

Strict surveillance has enabled outbreaks of HCAIs to be tackled quickly by isolating patients, initiating ‘deep cleaning’ regimes of wards and equipment, and installing numerous alcohol-based hand-rub dispensers for use by staff and visitors (Figure 13).Population Health And Infectious Disease Essay

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Figure 13 An alcohol-based hand-hygiene station in the corridor of an English NHS hospital
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Infection Prevention and Control (IPC) service
Every NHS hospital now has an Infection Prevention and Control (IPC) service responsible for the prevention, surveillance, investigation and control of infection. This is achieved through mandatory education and the development and implementation of effective policies and procedures. Data on the rates of MRSA and CDI cases and the standards achieved by the IPC service are regularly reviewed by quality standards bodies in the four UK nations, for example the Care Quality Commission (CQC) in England.Population Health And Infectious Disease Essay

Patients and staff are interviewed on their assessment of cleanliness in the environment, staff hygiene and on the availability of the equipment and services necessary to achieve the prevention and control of infections. If there is a cause for concern, the CQC makes unannounced inspections to ensure that appropriate guidelines are in place and being observed by staff.

Figure 14 illustrates the steady success in reducing the rates of MRSA and CDI in recent years, through the systematic application of two traditional public health measures – hygiene and surveillance.

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Figure 14 All quarterly reported cases in England, from April 2007 to March 2011, of (a) methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and (b) Clostridium difficile infection (CDI). (Source: based on HPA, 2011d, 2011e.)
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4.3 Community action against infectious diseases
Raising the standards of public health is not simply a matter of training more doctors and nurses, building more hospitals and providing more funding for vaccines and treatments – although all of these make substantial contributions. As the earlier examples of mass vaccination campaigns and the promotion of hand washing with soap illustrate, much of the work involved in delivering effective public health strategies against infectious disease occurs in the community, outside the formal healthcare system.Population Health And Infectious Disease Essay

As the famous definition of public health by Winslow (1920) states, ‘organized community effort’ is an essential element of successful strategies against infectious disease. The success of public health strategies all over the world, but especially in low-resource economies, and more particularly in rural areas and slum or shanty settlements, relies crucially on community action, mobilised and directed by community health workers like the Health Extension Workers in Ethiopia (Video 1), often with minimal training. For example, the malaria-screening service shown earlier in Figure 6 is run by a community health worker with basic training and rudimentary equipment.

Give an example of community action in rural Ethiopia based on your study of Video 1.

Reveal answer
However, it is sobering to note that, globally, more than 1.2 billion people still lack basic sanitation and have no alternative but to defaecate in fields and on rubbish heaps and waste ground.Population Health And Infectious Disease Essay

4.3.1 Oral rehydration salts
The importance of community participation in the success of national campaigns to reduce the impact of diarrhoeal diseases is also illustrated by the use of oral rehydration salts (ORS) by parents all over the world to prevent dehydration in children with diarrhoea.

Many low-income countries have established national ‘Control of Diarrhoeal Diseases’ campaigns promoting the use of pre-prepared ORS sachets (over 500 million are distributed free every year), or home-made ‘water with salt and sugar’ rehydration solutions. Bangladesh was the first country to scale up oral rehydration therapy through a national programme to distribute ORS sachets to all affected households. Now many countries give parents the training and confidence as well as the ORS sachets they need to treat diarrhoea in their children Population Health And Infectious Disease Essay