Community Health - Lecture notes

Community Health (University of Nairobi)

Studocu is not sponsored or endorsed by any college or university

COMMUNITY HEALTH

1 |

COMMUNITY HEALTH

Community health is a major field of study within the medical and clinical sciences which focuses on the maintenance, protection and improvement of the health status of population groups and communities as opposed to the health of individual patients. It is a distinct field of study that may be taught within a separate school of public health or environmental health.

It is a discipline which concerns itself with the study and improvement of the health characteristics of biological communities. While the term community can be broadly defined, community health tends to focus on geographical areas rather than people with shared characteristics. The health characteristics of a community are often examined using geographic information system (GIS) software and public health datasets. Some projects, such as InfoShare or GEOPROJ combine GIS with existing datasets, allowing the general public to examine the characteristics of any given community in participating countries.

Because 'health III' (broadly defined as well-being) is influenced by a wide array of socio- demographic characteristics, relevant variables range from the proportion of residents of a given age group to the overall life expectancy of the neighborhood/community. Medical interventions aimed at improving the health of a community range from improving access to medical care to public health communications campaigns. Recent research efforts have focused on how the built environment and socio-economic status affect health.

Community health may be studied within three broad categories:

• Primary healthcare which refers to interventions that focus on the individual or family such as hand-washing, immunization, circumcision, personal dietary choices, and lifestyle improvement.

• Secondary healthcare refers to those activities which focus on the environment such as draining puddles of water near the house, clearing bushes, and spraying insecticides to control vectors like mosquitoes.

• Tertiary healthcare on the other hand refers to those interventions that take place in a hospital setting, such as intravenousrehydration or surgery.

2 |

The success of community health programmes relies upon the transfer of information from health professionals to the general public using one-to-one or one to many communication (mass communication). The latest shift is towards health marketing.

Role of Community Health Workers How Will CHWs

Affect Change?

The Initiative provides CHWs with creative strategies, materials, and tools for training, educating, and changing lifestyle behaviors so CHWs can be active promoters of health in their community.

Community health workers (CHWs) are lay members of the community who work either for pay or as volunteers in association with the local health care system in both urban and rural environments. CHWs usually share ethnicity, language, socioeconomic status, and life experiences with the community members they serve. They have been identified by many titles, such as community health advisors, lay health advocates, promotoras, outreach educators, community health representatives, peer health promoters, and peer health educators. CHWs offer interpretation and translation services, provide culturally appropriate health education and information, help people get the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening.¹

Since CHWs typically reside in the community they serve, they have the unique ability to bring information where it is needed most. They can reach community residents where they live, eat, play, work, and worship. CHWs are frontline agents of change, helping to reduce health disparities in underserved communities.

HRSA CHW National Workforce Study Findings¹

CHW-specific work activities involved:

• Culturally appropriate health promotion and health education 82%

• Assistance in accessing medical services & programs 84%

• Assistance in accessing non-medical services & programs 72%

• “Translation” 36%

• Interpreting 34%

3 |

• Counseling 31%

• Mentoring 21%

• Social support 46%

• Transportation 36%

Related to work activities, employer-reported duties:

• Case management 45%

• Risk identification 41%

• Patient navigation 18%

• Direct services 37%

Among the many known outcomes of CHWs’ service are the following:

• Improved access to health care services.

• Increased health and screening.

• Better understanding between community members and the health and social service system.

• Enhanced communication between community members and health providers.

• Increased use of health care services.

• Improved adherence to health recommendations.

• Reduced need for emergency and specialty services.¹

CHWs Take Action to Promote Heart Health in the Community

The Initiative’s health education materials are designed to be taught by CHWs, who are trained to use these materials to help community residents improve their quality of life by adopting heart healthy behaviors.

With the help of the Initiative, CHWs are able to:

• Help families understand their risk for developing heart disease.

• Help community members get appropriate screenings and referrals for health and social services.

• Track an individual’s progress toward meeting health goals.

• Hold workshops and group discussions to learn about ways the community can promote heart health.

4 |

• Teach people how to prepare heart healthy meals, get more physical activity, and stop smoking.

COMMUNITY HEALTH

The term "community health" refers to the health status of a defined group of people, or community, and the actions and conditions that protect and improve the health of the community. Those individuals who make up a community live in a somewhat localized area under the same general regulations, norms, values, and organizations. For example, the health status of the people living in a particular town, and the actions taken to protect and improve the health of these residents, would constitute community health. In the past, most individuals could be identified with a community in either a geographical or an organizational sense. Today, however, with expanding global economies, rapid transportation, and instant communication, communities alone no longer have the resources to control or look after all the needs of their residents or constituents. Thus the term "population health" has emerged. Population health differs from community health only in the scope of people it might address. People who are not organized or have no identity as a group or locality may constitute a population, but not necessarily a community. Women over fifty, adolescents, adults twenty-five to forty-four years of age, seniors living in public housing, prisoners, and blue-collar workers are all examples of populations. As noted in these examples, a population could be a segment of a community, a category of people in several communities of a region, or workers in various industries. The health status of these populations and the actions and conditions needed to protect and improve the health of a population constitute population health.

The actions and conditions that protect and improve community or population health can be organized into three areas: health promotion, health protection, and health services. This breakdown emphasizes the collaborative efforts of various public and private sectors in relation to community health. Figure 1 shows the interaction of the various public and private sectors that constitute the practice of community health.

Health promotion may be defined as any combination of educational and social efforts designed to help people take greater control of and improve their health. Health protection and health services differ from health promotion in the nature or timing of the actions taken. Health

5 |

protection and services include the implementing of laws, rules, or policies approved in a community as a result of health promotion or legislation. An example of health protection would be a law to restrict the sale of hand guns, while an example of health services would be a policy offering free flu shots for the elderly by a local health department. Both of these actions could be the result of health promotion efforts such as a letter writing campaign or members of a community lobbying their board of health.

FOUNDATIONS OF COMMUNITY HEALTH

The foundations of community health include the history of community health practice, factors that affect community and population health, and the tools of community health practice. These tools include epidemiology, community organizing, and health promotion and disease prevention planning, management, and evaluation.

History of Community Health Practice. In all likelihood, the earliest community health practices went unrecorded. Recorded evidence of concern about health is found as early as 25,000 b.c.e., in Spain, where cave walls included murals of physical deformities. Besides these cave carvings and drawings, the earliest records of community health practice were those of the Chinese, Egyptians, and Babylonians. As early as the twenty-first century b.c.e., the Chinese dug wells for drinking.

Figure 1

Between the eleventh and second centuriesb.c.e., records show that the Chinese were concerned about draining rainwater, protecting their drinking water, killing rats, preventing rabies, and building latrines. In addition to these environmental concerns, many writings from 770 b.c.e. to the present mention personal hygiene, lifestyle, and preventive medical practices. Included in these works are statements by Confucius (551–479 b.c.e.) such as "Putrid fish … food with unusual colors… foods with odd tastes … food not well cooked is not to be eaten." Archeological findings from the Nile river region as early as 2000 b.c.e., indicate that the Egyptians also had environment health concerns with rain and waste water. In 1900 b.c.e., Hammurabi, the king of Babylon, prepared his code of conduct that included laws pertaining to physicians and health practices.

During the years of the classical cultures (500 b.c.e.–500 c.e.), there is evidence that the Greeks were interested in men's physical strength and skill, and in the practice of community sanitation. The Romans built upon the Greek's engineering and built aqueducts that could transport water

6 |

many miles. Remains of these aqueducts still exist. The Romans did little to advance medical thinking, but the hospital did emerge from their culture.

In the Middle Ages (500–1500 c.e.), health problems were considered to have both spiritual causes and spiritual solutions. The failure to account for the role of physical and biological factors led to epidemics of leprosy, the plague, and other communicable diseases. The worst of these, the plague epidemic of the fourteenth century, also known as the Black Death, killed 25 million people in Europe alone. During the Renaissance (1500–1700 c.e.), there was a growing belief that diseases were caused by environmental, not spiritual, factors. It was also a time when observations of the sick provided more accurate descriptions of the symptoms and outcomes of diseases. Yet epidemics were still rampant.

The eighteenth century was characterized by industrial growth, but workplaces were unsafe and living conditions in general were unhealthful. At the end of the century several important events took place. In 1796 Dr. Edward Jenner successfully demonstrated the process of vaccination for smallpox. And, in 1798, in response to the continuing epidemics and other health problems in the United States, the Marine Hospital Service (the forerunner to the U.S. Public Health Service) was formed.

The first half of the nineteenth century saw few advances in community health practice. Poor living conditions and epidemics were still concerns, but better agricultural methods led to improved nutrition. The year 1850 marks the beginning of the modern era of public health in the United States. It was that year that Lemuel Shattuck drew up a health report for the Commonwealth of Massachusetts that outlined the public health needs of the state. This came just prior to the work of Dr. John Snow, who removed the handle of the Broad Street pump drinking well in London, England, in 1854, to abate the cholera epidemic. The second half of the nineteenth century also included the proposal of Louis Pasteur of France in 1859 of the germ theory, and German scientist Robert Koch's work in the last quarter of the century showing that a particular microbe, and no other, causes a particular disease. The period from 1875 to 1900 has come to be known as the bacteriological era of public health.

The twentieth century can be divided into several different periods. The years between 1900 and 1960 are known as the health resources development era. This period is marked by the growth of health care facilities and providers. The early years of the period saw the birth of the first voluntary health agencies: the National Association for the Study and Prevention of Tuberculosis

7 |

(now the American Lung Association) was founded in 1904 and the American Cancer Society in 1913. The government's major involvement in social issues began with the Social Security Act of 1935. The two world wars accelerated medical discoveries, including the development of penicillin. In 1946, Congress passed the National Hospital Survey and Construction Act (Hill- Burton Act) to improve the distribution and enhance the quality of hospitals.

The social engineering era (1960–1975) included the passage of amendments to the Social Security Act that set up Medicare (payment of medical bills for the elderly and certain people with disabilities) and Medicaid (payment of medical bills for the poor). The final period of the twentieth century is the health promotion era (1974–1999). During this period it was recognized that the greatest potential for improving the health of communities and populations was not through health care but through health promotion and disease prevention programs. To move in this direction, the U.S. government created its "blueprint for health" a set of health goals and objectives for the nation. The first set was published in 1980 and titled Promoting Health/Preventing Disease: Objectives for the Nation. Progress toward the objectives has been assessed on a regular basis, and new goals and objectives created in volumes titled Healthy People 2000, and Healthy People 2010. Other countries, and many states, provinces, and even communities, have developed similar goals and targets to guide community health.

Factors that Affect Community and Population Health. There are four categories of factors that affect the health of a community or population. Because these factors will vary in separate communities, the health status of individual communities will be different. The factors that are included in each category, and an example of each factor, are noted here.

Figure 2

1. Physical factors—geography (parasitic diseases), environment (availability of natural resources), community size (overcrowding), and industrial development (pollution).

2. Social and cultural factors—beliefs, traditions, and prejudices (smoking in public places, availability of ethnic foods, racial disparities), economy (employee health care benefits), politics (government participation), religion (beliefs about medical treatment), social norms (drinking on a college campus), and socioeconomic status (number of people below poverty level).

3. Community organization—available health agencies (local health department, voluntary health agencies), and the ability to organize to problem solve (lobby city council).

8 |

4. Individual behavior—personal behavior (health-enhancing behaviors like exercising, getting immunized, and recycling wastes; see Figure 2).

Three Tools of Community Health Practice. Much of the work of community health revolves around three basic tools: epidemiology, community organizing, and health education. Though each of these is discussed in greater length elsewhere in the encyclopedia, they are mentioned here to emphasize their importance to community and population practice. Judith Mausner and Shira Kramer have defined epidemiology as the study of the distribution and determinants of diseases and injuries in human populations. Such data are recorded as number of cases or as rates (number per 1,000 or 100,000). Epidemiological data are to community health workers as biological measurements are to a physician. Epidemiology has sometimes been referred to as population medicine. Herbert Rubin and Irene Rubin have defined community organizing as bringing people together to combat shared problems and increase their say about decisions that affect their lives. For example, communities may organize to help control violence in a neighborhood. Health education involves health promotion and disease prevention (HP/DP) programming, a process by which a variety of interventions are planned, implemented, and evaluated for the purpose of improving or maintaining the health of a community or population. A smoking cessation program for a company's employees, a stress management class for church members, or a community-wide safety belt campaign are examples of HP/DP programming.

COMMUNITY AND POPULATION HEALTH THROUGH THE LIFE SPAN

In community health practice, it is common to study populations by age group and by circumstance because of the health problems that are common to each group. These groupings include mothers, infants (less than one year old), and children (ages 1–14); adolescents and young adults (ages 15–24); adults (ages 25–64); and older adults or seniors (65 years and older). Maternal, infant, and child (MIC) health encompasses the health of women of childbearing age from prepregnancy through pregnancy, labor, delivery, and the postpartum period, and the health of a child prior to birth through adolescence. MIC health statistical data are regarded as important indicators of the status of community and population health. Unplanned pregnancies, lack of prenatal care, maternal drug use, low immunization rates, high rates of infectious diseases, and lack of access to health care for this population indicate a poor community health infrastructure. Early intervention with educational programs and preventive medical services for

9 |

women, infants, and children can enhance health in later years and reduce the necessity to provide more costly medical and/or social assistance later in their life.

Maternal health issues include family planning, early and continuous prenatal care, and abortion. Family planning is defined as the process of determining and achieving a preferred number and spacing of children. A major concern is the more than 1 million U.S. teenagers who become pregnant each year. About 85 percent of these pregnancies are unintended. Also a part of family planning and MIC is appropriate prenatal care, which includes health education, risk assessment, and medical services that begin before the pregnancy and continue through birth. Prenatal care can reduce the chances of a low-birthweight infant, and the poor health outcomes and costs associated with it. A controversial way of dealing with unintended or unwanted pregnancies is with abortion. Abortion has been legal in the United States since 1973 when the Supreme Court ruled in Roe v. Wade that women have a constitutionally protected right to have an abortion in the early stages of pregnancy. According to the Centers for Disease Control and Prevention (CDC), approximately 1.6 million legal abortions were being performed in the United States each year during the late 1990s.

Infant and child health is the result of parent health behavior during pregnancy, prenatal care, and the care provided after birth. Critical concerns of infant and childhood morbidity and mortality include proper immunization, unintentional injuries, and child abuse and neglect. Though numerous programs in the United States address MIC health concerns, one that has been particularly successful has been the Special Supplemental Food Program for Women, Infants, and Children, known as the WIC program. This program, sponsored by the U.S. Department of Agriculture, provides food, nutritional counseling, and access to health services for low-income women, infants, and children. Late-twentieth-century figures indicate that the WIC program serves more than seven million mothers and children per month, and saves approximately three dollars for each tax dollar spent.

The health of the adolescent and young adult population sets the stage for the rest of adult life. This is a period during which most people complete their physical growth, marry and start families, begin a career, and enjoy increased freedom and decision making. It is also a time in life in which many beliefs, attitudes, and behaviors are adopted and consolidated. Health issues that are particularly associated with this population are unintended injuries; use and abuse of alcohol, tobacco, and drugs; and sexual risk taking. There are no easy, simple, or immediate

10 |

solutions to reducing or eliminating these problems. However, in communities where interventions have been successful, they have been comprehensive and communitywide in scope and sustained over long periods of time.

The adult population represents about half of the U.S. population. The health problems associated with this population can often be traced to the consequences of poor socioeconomic conditions and poor health behavior during earlier years. To assist community health workers, this population has been subdivided into two groups: ages twenty-five to forty-four and ages forty-five to sixty-four. For the younger of these two subgroups, unintentional injuries, HIV (human immunodeficiency virus) infection, and cancer are the leading causes of death. For the older group, noncommunicable health problems dominate the list of killers, headed by cancer and heart disease, which account for almost two-thirds of all deaths. For most individuals, however, these years of life are the healthiest. The key to community health interventions for this population has been to stress the quality of life gained by good health, rather than merely the added years of life.

The senior population of the United States has grown steadily over the years, and will continue to grow well into the twenty-first century. In 1900 only one in twenty-five Americans was over the age of sixty-five, in 1995 it was one in seven, and by 2030 it is expected to be one in five. Such growth in this population will create new economic, social, and health concerns, especially as the baby boomers (those born between 1946 and 1964) reach their senior years. From a community and population health perspective, greater attention will need to be placed on the increased demands for affordable housing, accessible transportation, personal care created by functional limitations, and all segments of health care including adult day care and respite care. Though many communities have suitable interventions in place to deal with the issues of seniors (including meal services like congregate meals at senior centers, and Meals-on-Wheels), the demands will increase in all communities.

HEALTH PROMOTION

The three strategies by which community health practice is carried out are health promotion, health protection, and the provision of health services and other resources. Figure 3 presents a representation of these strategies, their processes, their objectives, and anticipated benefits for a community or population.

11 |

As noted earlier, health promotion includes educational, social, and environmental supports for individual, organizational, and community action. It seeks to activate local organizations and groups or individuals to make changes in behavior (lifestyle, selfcare, mutual aid, participation in community or political action) or in rules or policies that influence health. Community health promotion lies in the areas in which the spheres of health action, as shown in Figure 1, overlap. Two areas in which communities employ health promotion strategies are mental and social health, and recreation and fitness. Though both of these health concerns seem to be problems of individuals, a health concern becomes a community or population health concern when it is amenable to amelioration through the collective actions noted above. Action to deal with these concerns begins with a community assessment, which should identify the factors that influence the health of the subpopulations and the needs of these populations. In the case of mental and social health, the need will surface at the three levels of prevention: primary prevention (measures that forestall the onset of illness), secondary prevention (measures that lead to an early diagnosis and prompt treatment), and tertiary prevention (measures aimed at rehabilitation following significant pathogenesis).

Primary prevention activities for mental and social health could include personal stress management strategies such as exercise and meditation, or school and workplace educational classes to enhance the mental health of students and workers. A secondary prevention strategy could include the staffing of a crisis hot line by local organizations such a health department or mental health center. Tertiary prevention might take the form of the local medical and mental health specialists and health care facilities providing individual and group counseling, or inpatient psychiatric treatment and rehabilitation. All of these prevention strategies can contribute to a communitywide effort to improve the mental and social health of the community or population. During and after the implementation of the strategies, appropriate evaluation will indicate which strategies work and which need to be discontinued or reworked.

As with mental and social health promotion, community recreation and fitness needs should be derived via community assessment. The community or population enhances the quality of life and provides alternatives to the use of drugs and alcohol as leisure pursuits by having organized recreational programs that meet the social, creative, aesthetic, communicative, learning, and physical needs of its members. Such programs can provide a variety of benefits that can contribute to the mental, social, and physical health of the community, and can be provided or

12 |

supported by schools, workplaces, public and private recreation and fitness organizations, commercial and semipublic recreation, and commercial entertainment. As with all health- promotion programming, appropriate evaluation helps to monitor progress, appropriate implementation of plans, and outcomes achieved.

HEALTH PROTECTION

Community and population health protection revolve around environmental health and safety. Community health personnel work to identify environmental risks and problems so they can take the necessary actions to protect the community or population. Such protective measures include the control of unintentional and intentional injuries; the control of vectors; the assurance that the air, water, and food are safe to consume; the proper disposal of wastes; and the safety of residential, occupational, and other environments. These protective measures are often the result of educational programs, including self-defense classes; policy development, such as the Safe Drinking Water Act or the Clean Air Act; environmental changes,

Figure 3

such as restricting access to dangerous areas; and community planning, as in the case of preparing for natural disasters or upgrading water purification systems.

HEALTH SERVICES AND OTHER RESOURCES

The organization and deployment of the services and resources necessary to plan, implement, and evaluate community and population health strategies constitutes the third general strategy in community and population health. Today's communities differ from those of the past in several ways. Even though community members are better educated, more mobile, and more independent than in the past, communities are less autonomous and more dependent on those outside the community for support. The organizations that can assist communities and populations are classified into governmental, quasi-governmental, and nongovernmental groups. Such organizations can also be classified by the different levels (world, national, state/province, and local) at which they operate.

Governmental health agencies are funded primarily by tax dollars, managed by government officials, and have specific responsibilities that are outlined by the governmental bodies that oversee them. Governmental health agencies include: the World Health Organization (WHO), the

13 |

U.S. Department of Health and Human Services, the various state health departments, and the over three thousand local health departments throughout the country. It is at the local level that direct health services and resources reach people.

Quasi-governmental health organizations have some official responsibilities, but they also operate in part like voluntary health organizations. They may receive some government funding, yet they operate independently of government supervision. An example of such a community health organization is the American Red Cross (ARC). The ARC has certain official responsibilities placed on it by the federal government, but is funded by voluntary contributions. The official duties of the ARC include acting as the official representative of the U.S. government during natural disasters and serving as the liaison between members of the armed forces and their families during emergencies. In addition to these official responsibilities, the ARC engages in many nongovernmental services such as blood drives and safety services classes like first aid and water safety instruction.

Nongovernmental health agencies are funded primarily by private donations or, in some cases, by membership dues. The thousands of these organizations all have one thing in common: They Figure 4

arose because there was an unmet need for them. Included in this group are voluntary health agencies; professional health organizations and associations; philanthropic foundations; and service, social, and religious organizations.

Voluntary health organizations are usually founded by one or more concerned citizens who felt that a specific health need was not being met by existing government agencies. Examples include the American Cancer Society, Mothers Against Drunk Driving (MADD), and the March of Dimes. Voluntary health agencies share three basic objectives: to raise money from various sources for research, to provide education, and to provide services to afflicted individuals and families.

Professional health organizations and associations are comprised of health professionals. Their mission is to promote high standards of professional practice, thereby improving the health of the community. These organizations are funded primarily by membership dues. Examples include the American Public Health Association, the British Medical Association, the Canadian Nurses Association, and the Society for Public Health Education.

14 |

Philanthropic foundations have made significant contributions to community and population health in the United States and throughout the world. These foundations support community health by funding programs or research on the prevention, control, and treatment of many diseases, and by providing services to deal with other health problems. Examples of such foundations are the Robert Wood Johnson Foundation, the Henry J. Kaiser Family Foundation, and the W. K. Kellogg Foundation.

Service, social, and religious organizations have also played a part in community and population health by raising money and funding health-related programs. For example, the Lions Clubs has worked to help prevent blindness, Shriners have helped to provide free medical care through their hospitals, and many religious organizations have worked to feed, clothe, and provide shelter for those in need.

The health services and resources provided through the organizations discussed above are focused at the community level. However, a significant portion of the resources are aimed at personal health care. Figure 4 presents the spectrum of health care delivery in the United States. Some refer to this as the U.S. health care system; others would debate whether any system really exists, referring to this network of services as an array of informal communications between health care providers and health facilities. The spectrum of care begins with public health (or population-based) practice, which is a significant component of community and population health practice. It then moves to four different levels of medical practice. The first level is primary, or front-line or first-contact, care. This involves the medical diagnosis and treatment of most symptoms not requiring a specialist or hospital. Secondary medical care gives specialized attention and ongoing management for both common and less frequently encountered medical conditions. Tertiary medical care provides even more highly specialized and technologically sophisticated medical and surgical care, including the long-term care often associated with rehabilitation. The final level of practice in the spectrum is continuing care, which includes longterm, chronic, and personal care.

What is Primary Health Care (PHC)?

Primary health care (PHC) is essential health care made universally accessible to individuals and acceptable to them, through full participation and at a cost the community and country can afford. It is an approach to health beyond the traditional health care system that focuses on health

15 |

equity-producing social policy. Primary health-care (PHC) has basic essential elements and objectives that help to attain better health services for all.

Primary health care elements

Essential Elements of Primary Health Care (PHC):

There are 8 elements of primary-health care (PHC). That listed below-

1. E– Education concerning prevailing health problems and the methods of identifying, preventing and controlling them.

2. L– Locally endemic disease prevention and control.

3. E– Expandedprogramme of immunization against major infectious diseases.

4. M– Maternal and child health care including family planning.

5. E–  Essential drugs arrangement.

6. N– Nutritional food supplement, an adequate supply of safe and basic nutrition.

16 |

7. T– Treatment of communicable and non-communicable disease and promotion of mental health.

8. S– Safe water and sanitation.

Extended Elements in 21st Century:

1. Expended options of immunizations.

2. Reproductive health needs.

3. Provision of essential technologies for health.

4. Health promotion.

5. Prevention and control of non-communicable diseases.

6. Food safety and provision of selected food supplements.

Principles of Primary Health Care (PHC):

Behind these elements lies a series of basic objectives that should be formulated in national policies in order to launch and sustain primary health-care (PHC) as part of a comprehensive health system and coordination with other sectors.

1. Improvement in the level of health care of the community.

2. Favorable population growth structure.

3. Reduction in the prevalence of preventable, communicable and other disease.

4. Reduction in morbidity and mortality rates especially among infants and children.

5. Extension of essential health services with priority given to the undeserved sectors.

6. Improvement in basic sanitation.

7. Development of the capability of the community aimed at self-reliance.

8. Maximizing the contribution of the other sectors for the social and economic development of the community.

9. Equitable distribution of health care– according to this principle, primary care and other services to meet the main health problems in a community must be provided equally to all individuals irrespective of their gender, age, and caste, urban/rural and social class.

10. Community participation-comprehensive healthcare relies on adequate number and distribution of trained physicians, nurses, allied health professions, community health workers and others working as a health team and supported at the local and referral levels.

17 |

11. Multi-sectional approach-recognition that health cannot be improved by intervention within just the formal health sector; other sectors are equally important in promoting the health and self- reliance of communities.

12. Use of appropriate technology- medical technology should be provided that accessible, affordable, feasible and culturally acceptable to the community.

1. Sources of Health Information

1. Census

2. Registration of Vital Events

3. Sample Registration System (SRS)

4. Notification of Diseases

5. Hospital Records

6. Disease Registers

7. Record Linkage 8.Epidemiological Surveillance

9.Other Health Service Records 10.Environmental Health Data

11.Health Manpower Statistics 12.Population Surveys

13. Other routine statistics related to health

14. Non-quantifiable information

1. Census

Census is taken in most countries of the world at regular intervals

Definition of Census (UN): ‘The total process of collecting, compiling and publishing demographic, economic and social data pertaining at a specified time or times, to ALL persons in a country or delimited territory’.

It is massive undertaking to contact every member of the population in a given time and collect a variety of information

It needs

• Massive preparation and

• Several years to analyze the results after census is taken

• This is the main problem of census as a data source i.e. that the results are not available quickly

18 |

2. Registration of Vital Events.

Definition (UN): ‘legal registration, statistical recording and reporting of the occurrence of and the collection, compilation, presentation, analysis and distribution of statistics pertaining to vital events’

Vital events include:

a. Live births

b. Deaths

c. Fetal deaths

d. Marriage

e. Divorce

f. Adoptions

g. Legitimations

h. Recognitions

i. Annulments and

j. Legal separations

3. Sample Registration System (SRS)

The civil registration system has a lot to be improved and would require a huge effort and time. A need for having an alternate source of such information was felt. SRS aims to provide reliable estimates of birth and death rates for the States and also at All India level. Following features of SRS ensure the completeness of vital events reporting:

1. A representative sample of the population is covered and NOT the WHOLE population

2. It is based on Dual – record system:

a. First a baseline survey of sampled units is done

b. This is followed by continuous enumeration of vital events of the areas by an enumerator (who is a volunteer from the community)

c. Independent retrospective 6-monthly surveys are done for recording births and deaths which occurred in the preceding 6 months and the number is matched with the one reported by the enumerator

Not only the numbers of vital events should match, it is also verified if the births and deaths reported by the enumerator are the same ones which the survey has found out. This is called as ‘Matching of events’ by the observer. At present, the Sample Registration System (SRS) provides

19 |

reliable annual data on fertility and mortality at the state and national levels for rural and urban areas separately. In this survey, the sample units, villages in rural areas and urban blocks in urban areas are replaced once in ten years

4. Notification of Diseases

Disease notification is a practice of reporting the occurrence of a specific disease or health- related condition to the appropriate and designated authority. A notifiable disease is any disease that is required by law to be reported to government authorities. Effective notification allows the authorities to monitor the disease, and provides early warning of possible outbreaks

A notifiable disease is one for which regular and timely information regarding individual cases is considered necessary for the prevention and control of the disease.

Reasons for Declaring a Disease as Notifiable may be:

a. It is of interest to national or international regulations or control programs

b. Its National/ State/ District incidence

c. Its severity (potential for rapid mortality)

d. Its communicability/ Its potential to cause outbreaks

e. Significant risk of international spread

f. The socio-economic costs of its cases

g. Its preventability

h. Evidence that its pattern is changing

In other words, diseases which are considered to be serious menaces to public health are included in the list of notifiable diseases.

5. Disease Registers

A registry is basically a list of all the patients in the defined population who have a particular condition. It is different from ‘notification’ where the case is reported and is counted once.

A register requires that a permanent record be established that the cases be followed up and that basis statistical tabulation be prepared both on frequency and on survival. Hence mostly for chronic conditions.In addition the patients on a register are frequently be the subjects of special studies

• Morbidity registers are a valuable source of information such as the

– duration of illness, case fatality and survival

– Natural history of disease especially chronic diseases

20 |

There are two types of registries:

A. Hospital based:

It involves recording of information on the patients seen in a particular hospital. The primary purpose of hospital based registries is to contribute to patient care by providing readily accessible information on the patients, the treatment received and its results. The data is also used for clinical research and for epidemiological purposes.

The objectives of hospital based registry:

• Assess patient care

• Participate in clinical research to evaluate therapy

• Provide an idea of the patterns of cases

• Contribute to follow up of the patients

• Epidemiological research through case control studies

• Show time trends in the stage of diagnosis

• Help study the quality of care for the patients in the hospitals

B. Population-Based Registry:

A population-based disease registry contains and tracks records for people diagnosed with a specific type of disease who reside within a defined geographic region (i.e., a community, city, or state-wide)

The major concern of Population Based Registries is to calculate the incidence rates. Population Based Registry systematically collects information on all reportable cases occurring in a geographically defined population from multiple sources.

The comparison and interpretation of population based incidence data support population-based actions aimed at reducing the burden in the community. The systematic ascertainment of incidence from multiple sources can provide an unbiased profile of the burden in the population and how it is changing over time.

6. Record Linkage

• Record linkage means bringing together information that relates to the same individual or family, from different data sources. In this way it is possible to construct chronological sequences of health events for individuals. The records may originate in different time or places. Medical record linkage implies the gathering and maintenance of one file for each individual in a population, with records relating to his/her health.

21 |

• The events commonly recorded are

o birth, marriage, death,

o hospital admission and discharge

o sickness absence from work,

o prophylactic procedures

o use of social services, etc.

Record linkage is a particularly suitable method of studying association between diseases; these associations may have etiological significance.

7. Epidemiological Surveillance

Surveillance systems are set up for select diseases under the respective control/eradication program as a procedural matter. The purpose of this surveillance is to keep an eye on the incidence, prevalence and changing pattern of the particular disease so as to adjust the control measures accordingly.

PRIMARY AND SECONDARY USES OF HEALTH INFORMATION

In most cases, your personal health information comes into the system from you or from other sources on your behalf, for the main reason of giving you health care. This is called the “primary purpose” (“primary” means “first”).

Once your health information is in the health care system, it is sometimes used for other “secondary” purposes. In general, you must be told about these secondary purposes, but sometimes you don’t have to be told, if the secondary purpose is reasonably connected to the primary purpose or is required by law.

For example, when you go to your doctor, you talk about a health problem you may have. Your doctor collects your information by writing it down in the paper file or entering into a computer file. Some of that information will be given to Medical Services Plan ("MSP") so that the doctor can be paid for the visit. If you have to see a specialist, some of your personal health information might be sent to the specialist, and information about your visit to the specialist will be given to MSP so that the specialist can be paid. The information collected by the doctor and the specialist is collected for the primary purposes of giving you health care, and billing MSP.

Health information is also used for secondary purposes such as health system planning, management, quality control, public health monitoring, program evaluation, and research.

22 |

Sometimes health information will be “de-identified” or “anonymized” before it is used for these secondary purposes.

There has in the past few years been some confusion about when identifiable personal health information can be used for secondary purposes. This is one of the reasons why the Ministry of Health Act was recently changed to let the Minister collect, use and disclose identifiable personal information for “stewardship purposes”, so that these uses and disclosures are no longer against the law.

The new law does not allow a person to limit access to their health records that are collected by the Ministry of Health Services from health authorities or other public bodies for a stewardship purpose.

For more discussion of this issue, see Laws that Apply to the Public Health System

Opinion of this new law

There are many people in BC who feel that making this change to the law was a good thing, because it is important and beneficial for government to be able to use personal health information for these types of secondary purposes, even when it still has a name or other identifier (such as a personal health number) attached to it.

Many other people are concerned that this law has significantly weakened privacy protection for personal health information in BC because it allows privacy and security to be ignored or minimized in favour of other values.

Emerging health issues: the widening challenge for population health promotion SUMMARY

The spectrum of tasks for health promotion has widened since the Ottawa Charter was signed. In 1986, infectious diseases still seemed in retreat, the potential extent of HIV/AIDS was unrecognized, the Green Revolution was at its height and global poverty appeared less intractable. Global climate change had not yet emerged as a major threat to development and health. Most economists forecast continuous improvement, and chronic diseases were broadly anticipated as the next major health issue.

23 |

Today, although many broadly averaged measures of population health have improved, many of the determinants of global health have faltered. Many infectious diseases have emerged; others have unexpectedly reappeared. Reasons include urban crowding, environmental changes, altered sexual relations, intensified food production and increased mobility and trade. Foremost, however, is the persistence of poverty and the exacerbation of regional and global inequality.

Life expectancy has unexpectedly declined in several countries. Rather than being a faint echo from an earlier time of hardship, these declines could signify the future. Relatedly, the demographic and epidemiological transitions have faltered. In some regions, declining fertility has overshot that needed for optimal age structure, whereas elsewhere mortality increases have reduced population growth rates, despite continuing high fertility.

Few, if any, Millennium Development Goals (MDG), including those for health and sustainability, seem achievable. Policy-makers generally misunderstand the link between environmental sustainability (MDG #7) and health. Many health workers also fail to realize that social cohesion and sustainability—maintenance of the Earth's ecological and geophysical systems—is a necessary basis for health.

In sum, these issues present an enormous challenge to health. Health promotion must address population health influences that transcend national boundaries and generations and engage with the development, human rights and environmental movements. The big task is to promote sustainable environmental and social conditions that bring enduring and equitable health gains. INTRODUCTION

The Ottawa Charter (1986) was forged only 8 years after the historic Alma Ata meeting, which had declared Health for All by 2000. With hindsight, the goal of shaping a new and healthier world was already in jeopardy (Werner and Sanders, 1997). Perhaps, aware of this nascent weakening of the prospects for population health, the global health promotion community called for the revitalization of ambitious large-scale thinking. New strategies were devised to energize healthy individual and community behaviours, reflected in phrases such as ‘healthy choices should be easy choices’ and ‘healthy public policy’.

Nevertheless, over the ensuing two decades, the adverse social, economic and environmental trends that were already beginning to jeopardize, Health for All in 1986 have strengthened. Further, economic globalization, with increasingly powerful transnational companies shaping global consumer behaviours, has tended to make unhealthy choices the easier choices, including

24 |

cigarettes, fast-food diets, high-sugar drinks, automated (no-effort) domestic technologies and others. These changes have occurred despite an increased understanding of the fundamental determinants of population health. Some of these foundations of health are at risk, and in some regions, hard-won health gains have recently been reversed. Recent attempts to re-focus attention on global public goods, such as in the Millennium Development Goals (MDGs), are weak in comparison to the scale of today's problems.

There is an urgent strategic need for health promotion to engage with the international discourse on ‘sustainability’. To date much of the discussion and policy development addressing ‘sustainable development’ has treated the economy, livelihoods, energy supplies, urban infrastructure, food-producing ecosystems, wilderness conservation and convivial communal living as if they were ends in themselves: the goals of sustainability. Clearly, those are all major assets that we value. But their value inheres in their being the foundations upon which the health and survival of populations depend. The ultimate goal of sustainability is to ensure human well- being, health and survival. If our way of living, of managing the natural environment and of organizing economic and social relations between people, groups and cultures does not maintain the flows of food and materials, freshwater supplies, environmental stability and other prerequisites for health, then that is a non-sustainable state.

In this paper, we discuss several of the emerging health issues. Lacking space to be comprehensive, we focus upon infectious diseases, the decline in life expectancy in several regions, the increasingly ominous challenge of large-scale environmental change and how globalization, trade and economic policy relate to indices of public health. Other emerging health issues not discussed here also reflect major recent shifts in human ecology. They too pose great environmental or social risks to health. They include urbanization, population ageing, the breakdown of traditional culture and relations and the worldwide move towards a more affluent diet and its associated environmentally damaging food production methods (McMichael, 2005). There are two fundamental causes for the selected emerging health risks. First, most important, is the global dominance of economic policies which accord primacy to market forces, liberalized trade and the associated intensification of material throughput at the expense of other aspects of social, environmental and personal well-being. For millions in the emerging global middle class, materialism and consumerism have increased at the expense of social relations and leisure time. The gap between rich and poor, both domestically and internationally, has increased substantially

25 |

in recent decades (United Nations Development Program, 2005). Inequality between countries has weakened the United Nations and other global institutions. Foreign aid has declined, replaced by claims that market forces will reduce poverty and provide public goods, including health care and environmental stability.

The second fundamental threat to the improvement and maintenance of population health is the recent advent of unprecedented global environmental changes. The scale of the human enterprise (numbers, economic intensity, waste generation) is now such that we are collectively exceeding the capacity of the planet to supply, replenish and absorb. Stocks of accessible oil appear to be declining. Meanwhile, the global emissions of carbon dioxide from fossil fuel combustion, and of other greenhouse gases from industrial and agricultural activities, are rapidly and now dangerously altering the global climate. Worldwide, land degradation, fisheries depletion, freshwater shortages and biodiversity losses are all increasing. The human population, now exceeding 6500 million, continues to increase by over 70 million persons per annum. The number of chronically undernourished people (over 800 million) is again increasing, after gradual declines in the 1980s and early 1990s (Food and Agricultural Organization, 2005).

Famines in Africa remain frequent, and 300 million undernourished people live in India alone. Meanwhile, hundreds of millions of people are overnourished and, particularly via obesity, will incur an increasing burden of chronic diseases, especially diabetes and heart disease.

The scale of these health risks is unprecedented. The global food crises of the 1960s were averted by the subsequent Green Revolution. Today, a broader-based revolution is required, not only to increase food production (again), but also to promote peace and international cooperation, slow climate change, ensure environmental protection, eliminate hunger and extreme poverty, quell resurgent infectious diseases and neutralize the obesogenic environment. This enormous population health task goes well beyond that envisaged by the MDGs.

It is, of course, difficult to get an accurate measure of these emerging risks to health. Some, such as climate change, future food sufficiency and the threat from weapons of mass destruction, may prove soluble. However, because of the inevitable time lag in understanding, evaluating and responding to these complex problems, the health promotion community should now take serious account of them. There is an expanding peer-reviewed literature on these several emerging problem, areas. To constrain health promotion by sidestepping them would be to risk being ‘penny wise but pound foolish’.

26 |

EMERGING AND RE-EMERGING INFECTIOUS DISEASES

In the early 1970s, it was widely assumed that infectious diseases would continue to decline: sanitation, vaccines and antibiotics were at hand. The subsequent generalized upturn in infectious diseases was unexpected. Worldwide, at least 30 new and re-emerging infectious diseases have been recognized since 1975 (Weiss and McMichael, 2004). HIV/AIDS has become a serious pandemic. Several ‘old’ infectious diseases, including tuberculosis, malaria, cholera and dengue fever, have proven unexpectedly problematic, because of increased antimicrobial resistance, new ecological niches, weak public health services and activation of infectious agents (e.g. tuberculosis) in people whose immune system is weakened by AIDS. Diarrhoeal disease, acute respiratory infections and other infections continue to kill more than seven million infants and children annually (Bryce et al., 2005). Mortality rates among children are increasing in parts of sub-Saharan Africa (Horton, 2004).

The recent upturn in the range, burden and risk of infectious diseases reflects a general increase in opportunities for entry into the human species, transmission and long-distance spread, including by air travel. Although specific new infectious diseases cannot be predicted, understanding of the conditions favouring disease emergence and spread is improving.

Influences include increased population density, increasingly vulnerable population age distributions and persistent poverty (Farmer, 1999). Many environmental, political and social factors contribute. These include increasing encroachment upon exotic ecosystems and disturbance of various internal biotic controls among natural ecosystems (Patzet al., 2004). There are amplified opportunities for viral mixing, such as in ‘wet animal markets’. Industrialized livestock farming also facilitates infections (such as avian influenza) emerging and spreading, and perhaps to increase in virulence. Both under- and over-nutrition and impaired immunity (including in people with poorly controlled diabetes—an obesity-associated disease now increasing globally) contribute to the persistence and spread of infectious diseases. Large-scale human-induced environmental change, including climate change, is of increasing importance.

These causes of infectious disease emergence and spread are compounded by gender, economic and structural inequities, by political ignorance and denial (particularly obvious with HIV/AIDS in parts of sub-Saharan Africa). Iatrogenesis (as with HIV in China and partial tuberculosis treatment in many developing countries), vaccine obstacles and the ‘10/90 gap’ (whereby a

27 |

minority of health resources are directed towards the most severe health problems) add to this unstable picture.

We inhabit a microbially dominated world. We should therefore frame our relations with microbes primarily in ecological (not military) terms. The world's infectious agents, perhaps with the exceptions of smallpox and polio, will not be eliminated. But much can be done to reduce human population vulnerability and avert conditions conducive to the occurrence of many infectious diseases. This is an important focus for health promotion.

DECLINING REGIONAL LIFE EXPECTANCY

The upward trajectory in life expectancy forecast in the 1980s has recently been reversed in several regions, especially in Russia and sub-Saharan Africa (McMichael et al., 2004b). These could, in principle, be either temporary aberrations or unconnected to one another. However, identifiable factors appear to link these declines.

The fall in life expectancy since 1990 in Russia is unprecedented for a technologically developed country. Many proximal causes have been documented, including alcoholism, suicide, violence, accidents and cardiovascular disease. Multiple drug-resistant tuberculosis is widespread in Russian prisons. Collectively, these factors reflect social disintegration and crisis (Shkolnikovet al., 2004).

In sub-Saharan Africa, HIV/AIDS has combined with poverty, malaria, tuberculosis, depleted soils and undernutrition (Sanchez and Swaminathan, 2005), deteriorating infrastructure, gender inequality, sexual exploitation and political taboos to foster epidemics that have reduced life expectancy, in some cases drastically. Adverse health and loss of human capital, caused by disease and the out-migration of skilled adults, have helped to ‘lock-in’ poverty. More broadly, indebtedness and ill-judged economic development policies, including charges for schooling and health services, have also impaired population health in Africa, following decades of earlier improvement. The intersectoral implications for health promotion are clear.

Conflict, most notoriously in Rwanda (André and Platteau, 1998), has also occurred on a sufficient scale to temporarily reduce life expectancy for some populations in sub-Saharan Africa. Age pyramids skewed to young adults have almost certainly played a role in this violence (Mesquida and Wiener, 1996), together with resource scarcity, pre-existing ethnic tensions, poor governance and international inactivity when crises develop.

GLOBAL ENVIRONMENTAL CHANGE

28 |

Sustainable population health depends on the viability of the planet's life-support systems (McMichael et al., 2003a). For humans, achieving and maintaining good population health is the true goal of sustainability, dependent, in turn, on achieving sustainable supportive social, economic and environmental conditions. Today, however, human-induced global environmental changes pose risks to health on unprecedented spatial and temporal scales. These environmental changes, evident at worldwide scale, include climate change, biodiversity loss, downturns in productivity of land and oceans, freshwater depletion and disruption of major elemental cycles (e.g. environmental nitrification) (McMichael, 2002). In coming decades, these long-term change processes will exact an increasing health toll via physical hazards, infectious diseases, food and water shortages, conflict and an inter-linked decline in societal capacity.

We currently extract ‘goods and services’ from the world's natural environment about 25% faster than they can be replenished (Wackernagelet al., 2002). Our waste products are also spilling over (e.g. carbon dioxide in the atmosphere). Hence, there is now little unused global ‘biocapacity’.

We are thus bequeathing an increasingly depleted and disrupted natural world to future generations. Although the resultant adverse health effects are likely to impinge unequally and, often, after time lag, this decline could eventually harm, albeit at varying levels, the entire human population.

Global climate change now attracts particular attention. Fossil fuel combustion, in particular, has caused unprecedented concentrations of atmospheric greenhouse gases. The majority expert view is that human-induced climate change is now underway (Oreskes, 2004). The power of storms, long predicted by climate change modellers to increase (Emanuel, 2005), appears (in combination with reduced wetlands and failure to maintain infrastructure) to have contributed to the 2005 New Orleans flood. WHO has estimated that, globally, over 150 000 deaths annually result from recent change in the world's climate relative to the baseline average climate of 1961– 1990 (McMichael et al., 2004a). This number will increase for at least the next several decades. The most direct risks to future health from climate change are posed by heatwaves, exemplified by the estimated 25 000 extra deaths in Europe in August 2003, storms and floods. Climate- sensitive biotic systems will also be affected. This includes: (i) the vector–pathogen–host relationships involved in transmission of various infections, vector-borne and other, (ii) the production of aeroallergens and (iii) the agro-ecosystems that generate food. Recent changes in infectious disease occurrence in some locations—tickborne encephalitis in Sweden (Lindgren

29 |

and Gustafson, 2001), cholera outbreaks in Bangladesh (Rodóet al., 2002) and, possibly, malaria in the east African highlands (Patzet al., 2002)—may partly reflect regional climatic changes.

Changes in the world's climate and ecosystems, biodiversity losses and other large-scale environmental stresses will, in combination, affect the productivity of local agro-ecosystems, freshwater quality and supplies and the habitability, safety and productivity of coastal zones. Such impacts will cause economic dislocation and population displacement. Conflicts and migrant flows are likely to increase, potentiating violence, injury, infectious diseases, malnutrition, mental disorders and other health problems.

These and other categories of global environmental changes, often acting in combination, pose serious health risks to current and future human societies (Figure 1). The important message here is that, increasingly, human health is influenced by socio-economic and environmental changes that originate well beyond national or local boundaries. The major, perhaps irreversible, changes to the biosphere's life-support system, including its climate system, increase the likelihood of adverse inter-generational health impacts.

Fig. 1:

View largeDownload slide

Major pathways by which global and other large-scale environmental changes affect population health (based on McMichael et al., 2003b, p. 8).

EMERGING HEALTH ISSUES AND THE MDGs

In 2000, UN member states agreed on eight MDGs, with targets to be achieved by 2015. Four MDGs refer explicitly to health outcomes: eradicating extreme poverty and hunger, reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other infectious diseases. Figure 2 shows how the MDG topic areas relate to the emerging health issues discussed here.

Fig. 2:

View largeDownload slide

30 |

Relationships between: (i) social and environmental conditions and their underlying economic and demographic influences and (ii) the MDG topics. (Two of this paper's main issues, environmental changes and infectious diseases, are explicitly represented as boxes.)

Many of the MDG targets are already in jeopardy. Although all are inter-linked, the ‘environmental sustainability’ MDG has fundamental long-term importance. Without it, the other concomitants of sustainability—economic productivity, social stability and, most importantly, population health—are unachievable. An additional reason to advance the MDGs is because that will slow population growth rates and thus reduce our collective ecological footprint (Wackernagelet al., 2002).

THE FALTERING DEMOGRAPHIC AND EPIDEMIOLOGICAL TRANSITIONS

Both the demographic and epidemiological transitions are less orderly than predicted. In some regions, declining fertility rates have overshot the rate needed for an economically and socially optimal age structure. In other countries, population growth has declined substantially because of the reduced life expectancy discussed earlier (McMichael et al., 2004b). Relatedly, the future health dividend from recent reductions in poverty may be lower than that once hoped because of the emergence of the non-communicable ‘diseases of affluence’, including those due to obesity, dietary imbalances, tobacco use and air pollution.

In the 1960s, there was widespread concern over imminent famine, affecting much of the developing world. This problem was largely averted by the ‘Green Revolution’ during the 1970s and 1980s. Meanwhile, the earlier view that unconstrained population growth had little adverse impact upon environmental amenity and other conditions needed for human wellbeing gained strength. However, in the last few years, this position has been re-evaluated (United Nations Department of Economic and Social Affairs Population Division, 2005). There is an increasing recognition of the adverse effects of rapid population growth, especially in developing countries, including from high unemployment when population increase outstrips opportunity.

Some argue that unsustainable regional population growth is characterized by age pyramids excessively skewed to young age, high levels of under- and unemployment and intense competition for limited resources. These circumstances jeopardize public health. Where there is also significant inequality and/or ethnic tension, catastrophic violence can result (André and Platteau, 1998; Butler, 2004).

31 |

Although Russia and parts of sub-Saharan Africa have vastly different demographic characteristics, there are important similarities in their recent declines in life expectancy. Both regions have a significant scarcity of public goods for health (Smith et al., 2003). In Russia, there is a lack of equality, safety and public health services. In many parts of sub-Saharan Africa, there is inadequate governance and food security as well as public safety and public health services.

Viewed on an even larger scale, the miserable conditions for millions of people in these regions accord with a global class system, in which privileged groups in both developed and developing countries act (often in concert) to protect their own position at the expense of others (Butler, 2000: Navarro, 2004).

The growth of the global population and its environmental impact means that we may now be less than a generation from exhausting the biosphere's environmental buffer, unless we can rein in our excessive demands on the natural world. If not, then the demographic and epidemiological transitions, already faltering, will be further affected. Population growth may then slow not only because of the usual development-associated fertility decrease but also because of persistently high death rates elsewhere.

Meanwhile, the growing awareness of these issues, the publicity of the MDGs, the ongoing campaigns against poverty and Third-World debt, calls for public health to address political violence and the renewed vigour of social movements for health (McCoy et al., 2004) affords new potential resources and collaborations to the global health promotion effort. These should be welcomed and acted upon.

GLOBALIZATION, TRADE, ECONOMIC POLICY AND FALTERING GLOBAL PUBLIC HEALTH: TOWARDS A UNIFYING EXPLANATION

The health benefits of the complex social, cultural, trade and economic phenomena that comprise ‘globalization’ are vigorously debated. Although differing viewpoints (Bettcher and Lee, 2002) are inevitable, the strength of this debate signifies that the net gain for population health from globalization is uncertain.

Several important health dividends often attributed to globalization have plausible alternative explanations. Many health gains in developing countries may be the time-lagged result of development policies and technologies introduced before the era of structural adjustment and partial economic liberalization, which heralded modern globalization. The accelerated

32 |

demographic transition in China is a greatly under-recognized role in that country's rapidly growing wealth, as were China's earlier investments in health and education.

Proponents of gobalization assert that free trade, via ‘comparative advantage’, will benefit all populations. In reality, wealthy populations have long tilted the economic and political playing field in ways that ensure a disproportionate flow of trade benefits towards privileged populations (Mehmet, 1995). A powerful real-politic impediment to the complete removal of trade-distorting national subsidies is that this would probably entail a relatively greater loss for wealthy populations than for the poor. In contrast, the economic disadvantages incurred to date through partial market deregulation have largely been confined to relatively poor and politically weak populations in developed countries.

The pre-eminence of modern economic theory presents a major obstacle for health promoters. The narrow focus of the World Trade Organization, which largely discounts the often adverse social, environmental and public health impacts of trade, underscores the problem. Dominant economic theory evolved when environmental limits were considered remote (Daly, 1996).

These theories assume that increased per capita income will offset the non-costed losses, whether these affect social welfare, environmental resources or public health. Critiques of these theories note that the harshest costs of modern economic practices fall upon ecosystems and populations with little current economic power or value, including generations not yet born.

Mobility of capital brings development, but capricious capital flight can create great hardship, including for public health. Deregulated labour conditions facilitate cheap goods, but they concentrate occupational health hazards among powerless workers. Increased labour mobility and steep economic gradients weaken family and community structures, contribute to ‘brain drain’ and promote inter-ethnic tensions. Many indices of inequality, including in health, income and environmental risk, have risen in recent decades (Butler, 2000; Parry et al., 2004).

Most critical commentary of globalization (George, 1999) is conceptual, emphasizing the adverse experiences of the disadvantaged and unborn. In contrast, the experiential feedback of the main beneficiaries of modern economic policy is largely positive. A major challenge for the promoters of health (and other forms) of justice is to adduce stronger evidence to convince policy-makers (themselves largely beneficiaries of globalization) to promote public goods, even though this may diminish the relative privilege of policy-makers and their constituencies. This is a difficult but essential task for health promotion.

33 |

EMERGING HEALTH ISSUES: THE CHALLENGES FOR HEALTH PROMOTION

In sum, global and regional inequality, narrow and outdated economic theories and an ever- nearing set of global environmental limits endanger population health. On the positive side of the ledger, there have been some gains (e.g. literacy, information sharing and food production, and new medical and public health technologies continue to confer large health benefits). Overall, though, reliance on economic, especially market-based, processes to achieve social goals and to set priorities and on technological fixes for environmental problems is poorly attuned to the long- term improvement of global human well-being and health. For that, a transformation of social institutions and norms and, hence, of public policy priorities is needed (Raskinet al., 2002).

Population health can be a powerful lever in that process of social change, if health promotion can rise to this challenge.

Many of these contemporary risks to population health affect entire systems and social–cultural processes, in contrast to the continuing health risks from personal/family behaviours and localized environmental exposures. These newly recognized risks to health derive from demographic shifts, large-scale environmental changes, an economic system that emphasizes the material over other elements of well being and the cultural and behavioural changes accompanying development. Together, these emerging health risks present a huge challenge to which the wider community is not yet attuned. The risks fall outside the popular conceptual frame wherein health is viewed in relation to personal behaviours, local environmental pollutants, doctors and hospitals. In countries that promote individual choice and responsibility, there are few economic incentives for the population's health.

Health promotion must, of course, continue to deal with the many local and immediate health problems faced by individuals, families and communities. But to do so without also seeking to guide socio-economic development and the forms and policies of regional and international governance is to risk being ‘penny wise but pound foolish’. Tackling these more systemic health issues requires multi-sectoral policy coordination (Yachet al., 2005) at community, national and international levels, via an expanded repertoire of bottom-up, top-down and ‘middle-out’ approaches to health promotion.

CONCLUSION

The essential principles of the Ottawa Charter remain valid. However, today's health promotion challenge extends that foreseen in 1986 and requires work at many levels. There is need for

34 |

proactive engagement with international agencies and programs that bear on the socio-economic fundamentals in disadvantaged regions/countries. Many low- and middle-income countries require financial aid from donor countries to achieve the health-related MDGs, to deal with emerging and re-emerging infectious diseases and to counter the emerging health risks from human-induced global environmental problems. Linkages between the health sector and civil society, including those struggling to promote development, human rights, human security and environmental protection, should be strengthened.

We need to understand that ‘sustainability’ is ultimately about optimizing human experience, especially well-being, health and survival. This requires changes in social and political organization and in how we design and manage our communities. We must live within the biosphere's limits. Health promotion should therefore address those emerging population health influences that transcend both national boundaries and generations. The central task is to promote sustainable environmental and social conditions that confer enduring and equitable gains in population health.

CHAPTER TWO COMMUNITY NUTRITION

Community nutrition Definition

Community nutrition is the process of helping individuals and groups develop healthy eating habits in order to promote wellness and prevent disease.

Purpose

Americans increasingly eat a diet that is high in saturated fat and refined sugars and lacking in fruits, vegetables, and whole grains. Poor dietary habits are linked to health conditions such as obesity , diabetes, heart disease , strokes, and some forms of cancer . With more than half of Americans classified as overweight or obese, organizations including the American Dietetic Association strive to increase awareness about the importance of a healthy diet and exercise . The goal of community nutrition is to educate individuals and groups so that they adopt healthy eating habits. Dieticians and nutritionists work with many other health care professionals in promoting improved community nutrition. Their efforts emphasize a preventive approach in

35 |

educating individuals in how a change in dietary habits will reduce the risk of illness. Community nutrition focuses on all age groups. The groups targeted range from babies to pregnant women to older adults. For example, a young pregnant woman may not realize how poor eating habits affect her developing fetus or she may be unaware of the importance of breastfeeding. Older adults may lose interest in eating due to loneliness, inability to prepare meals, or a physical condition such as difficulty chewing. Individuals with diabetes may not understand the need to control their blood glucose levels through diet as well as medication. Obesity is an issue for many age groups. Causes include lack of physical education programs in schools and an overly busy lifestyle for adults. The availability of fast food and “supersized” items are regarded positively because of their cost and convenience. Their accessibility and convenience often prompts people to make unhealthy food choices. In a school cafeteria, for example, a child may bypass a salad in favor of fries and a soda. A moviegoer may choose to buy a tub of buttered popcorn because the purchase price includes a free refill.

Community nutrition programs attempt to change attitudes so that a diet rich in fruit, vegetables, and whole grains is more appealing than diet high in fats and sugars. While sweet, high fat foods may be an occasional treat, community nutrition emphasizes a lifetime of routine healthy eating. Precautions

Since the objective of community nutrition is for people to adopt healthy eating habits, there are usually no reasons that a person would be prevented from participating in a community nutrition program. Some individuals such as those with diabetes who participate in community nutrition programs may have special dietary needs.

Description

Community nutrition programs are administered by organizations such as public health agencies, public schools, residential facilities for the elderly, hospitals, social service organizations, and health-care systems. Programs range from lunch programs for school children and senior citizens to health fairs and “5-A-Day” public awareness promotions that urge the public to eat least five fruits and vegetables every day.

Health care professionals may develop a community nutrition project aimed at groups such as new immigrants or the elderly. They may implement an existing project such as a food distribution program. Nutritionists and dietitians may work as part of a team with representatives

36 |

from other groups such as businesses, schools, or churches. Sometimes nutrition programs are linked with exercise programs.

Participants may need to meet eligibility requirements for some programs. These projects may be limited to people of a certain age or income level. Some community nutrition programs, such as lunch programs, are ongoing. Others such as a diabetic cooking class have an established duration. Costs for programs vary. There is often no cost for public agency programs; however, classes offered by a health maintenance organization may not be covered by insurance.

Community nutrition projects may also be operated by groups such as social service agencies and churches.

Community nutrition addresses health conditions such as obesity and economic conditions such as poverty, which limit access to healthy food, lack of nutritional information, and cultural traditions that promote unhealthy eating. Community nutrition programs strive to improve eating habits through food banks that distribute food as needed. Some cities have monthly food distribution programs. Distributors provide discounted packages that contain healthy foods such as meat, eggs, vegetables, fruit, bread and rice.

Shasta County community nutrition

The California County Public Health Department's community nutrition projects provide an example of the scope of available nutrition services. In 2005, Shasta County projects included obesity prevention for children, a food security coalition, breastfeeding education, and promotion of 5-A-Day Week and National Nutrition Month.

Obesity prevention efforts include working with schools to develop healthier choices to be offered in their cafeterias and to aid them offering healthier alternatives in their fundraising efforts. Food security pertains to a person's access to healthy food. The public health department also works with other agencies to reduce hunger in the county. Another county goal is to help mothers overcome barriers to breastfeeding.

The promotional campaigns bring together registered dietitians, health professionals, and community organizations. They work with the county to plan activities such as Get Healthy Shasta. The event, held in a park, features entertainment and activities to promote healthy eating, physical activity, and wellness.

37 |

Shasta County's projects are tied to Healthy Eating 2010, a county strategic plan with goals that include increasing the number of residents who eat five servings of fruit and vegetables. The objective is to raise that number from 26% in 2002 to 40% by December of 2010.

Preparation

Preparation for participating in a community nutrition program varies from program to program. An individual with a medical condition may need to consult a physician before entering a program. Registration is required for some community nutrition projects, and an assessment interview is often required to determine eligibility to participate in some programs.

Aftercare

Some programs require follow-up classes or meetings. A nutritionist may do an assessment interview to determine whether or not a program is effective. Surveying is one method of determining whether participants understood concepts and helps determine if they have adopted healthier eating habits.

In addition, some weight-loss programs offer maintenance classes. Health care providers may offer ongoing support groups or cooking classes that feature healthy recipes.

Complications

Complications in community nutrition programs may be demonstrated by a lack of change in the eating habits and food choices made by participants.

Results

The anticipated outcome of community nutrition programs is that participants will eat healthy food on a regular basis. Improved health is another anticipated result. Some positive outcomes are related to educational efforts. Others are due to a change in behavior. For example, a young mother may recognize the benefits of breastfeeding. A diabetic individual may enjoy ethnic cooking classes and seek additional healthy ethnic recipes. An older adult may find companionship and healthy meals at a senior lunch program. Sometimes positive outcomes are the result of changes beyond an individual's control. When schools change cafeteria offerings and increase physical education requirements, improvements in diet and exercise may occur.

Community nutrition programs may fail because of inadequate funding, program cancellation, poor participation, cultural barriers between program personnel and clients, lack of consistent access to healthy food, and lack of desire on the part of individuals to change.

38 |

Caregiver concerns

Community nutrition programs are often coordinated by registered dietitians and nutritionists. These health care professionals have bachelor degrees, and registered dietitians have been certified by the American Dietetic Association. In some states, licensing is required for these professions. Furthermore, some professionals have graduate degrees in specialty areas such as food safety, nutrition science, sports nutrition, or public health.

INTRODUCTION TO HIV AND AIDS

Specific Objection

By the end of this topic the trainee should be in a position to;

a) Explain the meaning of HIV and Aids

b) Discuss the origins of HIV And AIDS

c) State the misconception of HIV and AIDS

d) Discuss the impacts of HIV and Aids in the Various sectors DEFINITION

H-human I-immune V-virus A-acquire I-immune

D-deficiency S-Syndrome

Meaning of HIV / AIDS

HIV-human immune deficiency virus called human because the virus can survive in human in body and also virus can be traced in fresh human blood.

HIV survives in human blood but be transmitted by mosquitoes.

Because its immune deficiency it incapacitate weakness body immunity thus reduce the natural ability to defend protect itself against diseases . it can be transmitted from one person to another (replicate

39 |

HIV is the acronym for the human immunodeficiency virus. HIV is virus that causes the incurable acquired immunodeficiency syndrome (AIDS). Over time, HIV destroys the helper T cells of the body's immune system, resulting in a critical deterioration of the immune system and the ability of the body to fight infection.

HIV is most often a sexually transmitted virus. It is passed from one person another during sexual contact that involves vaginal, oral, or anal sex. HIV can also be passed to another person through other means, such as through contact with blood or body fluids. This can occur through such processes as blood transfusions or sharing needles contaminated with HIV. HIV can also be passed from an infected mother to her baby during pregnancy, childbirth or breastfeeding.

Early infection with HIV often produces no symptoms. When there are symptoms, they can include flu-like symptoms that occur about four to eight weeks after infection. These symptoms generally go away within several weeks. There then may be no symptoms for months to years. The most serious complication of HIV infection is AIDS.

Treatments

Treatment of HIV starts with prevention. Preventive measures include seeking regular medical care throughout the lifetime. Regular medical care allows a health care professional to best evaluate symptoms and the risks of catching HIV and regularly test for it as needed. These measures greatly increase your chances of catching and treating HIV in its earliest stages ORIGIN OF HIV/ AIDS

No clear cause origin of aids / HIV, however there is several theories that have been propounded to help us understand among the theories include: L

- Comment and curse

- Monkey meat theory

- Accidental emergency theory

- Conspiracy theory.

(i) Comet and curse

Viral material arrived in the tail curse of a come passing toward to the earth was deposited and subsequently infecting people nearby gods wrath sees the scripture condemned sexual sin such as homosexual. God sent HIV/ aids an incurable disease. The bible also talks about the disease which has no cure except define intervention.

40 |

(ii) Monkey meat theory.

The monkey family carries serian / immune virus (sir) similar to HIV found in human being. It’s believed that as a result of human eating monkey meat or monkey blood, sir cross to human being and mutilated itself to become HIV which was more infectious.

(iii) Accidental emergence

During the 1970 there was an outbreak of small pox in southern African and central with sent doctors on an anti- pox campaign / vaccination.

During this vaccination its believed that the vaccine of small pox and polio were accidentally mixed and hence to their contamination which in turn lead to mutation of this respective virus to HIV .

(iv) Conspiracy theory,

During this era biological weapon have been manufactured as a weapon of mass destruction. Just like anthrax weapon the developing world believed that HIV was manufactured or created by the developed world as chemical biological weapon through which the developing world could be examinee / done a way with so that the developed world could have total control of the whole world . Propone for this theory argue that despite the fact that HIV was first diagnosed in developed world.

It’s first diagnosed in the developed world. Its prevalence rate is quite high in the developing world as opposed to the developed world.

REVISION QUESTIONS

1. Define HIV and Aids

2. Discuss the origins of HIV And AIDS

3. State the misconception of HIV and AIDS

4. Discuss the impacts of HIV and Aids in the Various sectors

IMMUNITY

SPECIFFIC OBJECTIVES

By the end of this topic the trainee should be in position to;

• Define immunity

• State the various types of immunity

• Discuss the effects of immunity on the body

• Explain the viral implication

41 |

Introductions

The body has a two –part Immune system which workers together to protect it from harmful micro organism such as bacteria, fungi, viruses and parasites, it is divided in to two:

Innate Immunity

This is the front-line defense which equips us from before birth to deal with the various microorganisms that we are likely to meet in our normal everyday lives

Innate Immunity Include:

-Antibodies formed by a mother and passed on to the developing fetus and through infant breasting feeding

Tears containing the enzyme lysosome, to protect one eye from bacteria Saliva in the mouth, also containing the anti-bacterial lysosome

Mucus and chemicals co-existing but with quite differing functions in the urethra Ureter (water tubes) and vagina

When the barriers of the innate immunity are penetrated ,while blood cells leukocyte.(phagocytes or devouring cells) and other while cells (principally serotoxin or natural cell-Killing cells)surround and a number of other naturally-produced substances such as interfere and a range of blood proteins (called the complement system combine to help in the destruction process.

Adaptive Immunity

Adaptive Immunity is the second line of defense and is called into service when the defenses of the innate immunity are breached well beyond the capability of its response, Its defense, instead of being a general reaction is much more specific as it adapts to the particular organism present hence adaptive immunity is often referred to as specific immune system to identify the invading micro-organism as being foreign to any of the body’s own protein these foreign or devouring cells) and other while cells (principally serotoxin or natural cell-killing cells) surround and attempt to destroy the invader. At the same time a number of other naturally-produced substances such as interferon and a range of blood proteins called the complement system) combine to help in the destruction process.

Adaptive Immunity

Adaptive Immunity is the second line of defense and is called into service when the defenses of the innate immunity are breached well beyond the capability of it response. It defence,instead of

42 |

being a general reaction is much more specific as it adapts to the particular organism present hence adaptive immunity is often referred to as specific immunity.

Body immunity is the ability of the body o define itself against foreign bodies ( antigens) its commonly associated with the blood cells which comprise the soldier cells of the body. Body immunity system it’s important because it equips as our bodies with the ability to control act foreign invaders.

We have two types of immunity

• Innate

• Adaptive

Innate immunity- natural ability of the body to defend itself against micro –organism and it’s always transmitted from parent to children. Example of innate immunity

i) Lysosome –protect eyes and mouth from being infected by bacteria.

ii) hairs-in nose help trap inhaled matter.

iii) mucus)has cilia hairs found in trachea and wind pipe when by they protect the lungs by ensuring that foreign matters don’t affect.

iv) Skin - its layer protect the body surface, serviced by (sweat glands) sebaceous gland providing bacterial killing chemical s.

v) acids – in stomach and intestine (HCl) which destroy harmful microorganism and also permit the present of helpful bacteria.

ADAPTIVE IMMUNITY

This is artificially induced attenuation ( inoculation) this is type of immunity called intro service when the inmate immunity is destroyed beyond response .

There are around 7 days between immune response as one part of the system takes over from the either.

The response can either be cellular or hormonal based on the type of invader. Hormonal immunity response to bacteria while cellular responds to virus and parasite. Effects of HIV/ aids on the body immunity

1. Weaken the body immunity leading to opportunistic infection.

2. Inhibit the production of CD4 cells.

3. Destroy immune system.

43 |

T- Killer cells termed as cytolysis t- lymphocytes.

Upon entry in the body HIV moves n migrates to the lymph nodes in different parts of the body

e.g. neck, groins and armpits.

The lymphatic system which include the lymph nodes act as a reservoir for the virus it then moves other parts of the body where it infect and destroy white blood cells (t- lymphocyte or CD4 cells)

The lymph nodes normally trap bacteria , fungi and virus to allow easier destruction by the WBC they are contracted by there but as the virus concentration increases there s both breakdown in the ability of the lymphocyte to hold back.

Infection and the destruction of the CD4 cells

The breakdown of the lymph nodes barrier allow rapid spread of the virus into the blood stream and other parts of the body.

According to the diamond HIV / aids research centre (US) says that infected die on average every two days and that unto 100 billion new viruses are released daily. When the virus enter CD4 cell, it takes unto 30 hrs to cope with genetic material produce new enzyme and other viral component then they are assembled into new viruses.

Steps in viral replication

The HIV virus first defined in the US in 1983 is classified in the family of tentrovidae within genus retrovirus. Retrovirus has RNA genome which also poses a unique transcriptase (reverse transcriptase)

Steps

Attachment (fusion)

HIV virus itself to human cell so as to inject its genetic materials into the cell on the surface of the cell through molecules called receptors

Using receptors the HIV cells attaches itself and fuses into the cell membrane. a process called fusion to do this HIV uses GP120 to attach itself to human cell and GP 41 to fuse into the human cell.

Step 11

Transcription process

44 |

After fusion with the cell, the virus transfers its instruction which reprogram the cell to produce copies of the cell. This instruction is known as RNA are similar to DNA contained by all cells of the body. An enzyme reversed transcriptase convert the single stranded HIV RNA to double stranded HIV DNA. A class of drugs known as transcriptase inhibitors

Step111

Once HIV has converted itself to HIV DNA moves towards the host cell nucleus which is the command center of the cell It does so through the use of enzyme called intergraded inside the cell nucleus. HIV hides its DNA in the host cell DNA when does two things i.e.

- Stays in the cell

- Once activated uses the host cell DNA to make more copies of it. Intergraded inhibitors are drugs used to inhibit the interrogation process. Step I

Cleavage

The cell nucleus when activated commands the cell to reproduce HIV. The building block for the new HIV viruses reproduced in form of chain using an enzyme called process act as scissor, the long chain is cut into pieces and this process is called cleavage.

Packaging

This cut pieces packed together by the help of the protease enzyme to form new virus protease inhibitors are drugs used to inhibit the process.

Budding

After packaging HIV moves to the outer part of the cell to escape process called budding.

Maturation

HIV uses the part of the cell outer membrane to complete its final structure. The new HIV particles leave the cell in search of new cell to infect and start the process again.

Clinical stage in HIV

Modes and non modes of transmission of sexually transmitted disease and infection

HIV transmission is the spread of HIV virus from one person to another by different routes. HIV is spread when an infected individual comes into contact with infected body fluids or cells. The virus is found in blood, breast milk, semen and virginal secretion. In high concentration and saliva in low conclusion

45 |

HIV can be transmitted through various modes sexual contact - the commonest mode, any unprotected penetration sex whether virginal , anal or oral can transmit the virus from an infected individual to uninfected .

Sexual contact accounts for 70-80 percent transmission. Homosexual accounts for 10-15% HIV infection by sexually account for between 1-3%.

Oral sex is associated with a lower risk but gonorrhea and genital cancer and syphilis do but the risk of transmission.

Deep kissing weak ‘oral saliva is exchanged causes some risk of HIV transmission especially when one or both partners have bleeding gums , shivering of tooth brush and toothpicks have small risk.

Factors influencing the risk of HIV transmission

- No of sexual partners. The higher the number off sexual partners one has the higher the chances of contracting HIV.

- The level of virus in the body fluid. The higher level of risk in body fluid (blood, semen, virginal secretion) the higher the risk of transmission.

- Sexual orientation. Being homosexual , homo sexual or unprotected sex influence a great deal of HIV transmission , unprotected guys sex causes great risk.

- Gender. the chances of a woman contracting the virus from an infected man is statistically higher than the chances of uninfected man can contract the virus s from an infected woman.

- Age. Younger women are at higher risk as opposed to other women this is because during sexual intercourse virginal tissue tears and get fractured because they are not fully developed.

1. Sexually transmitted disease. Presence of STDS increases chances of HIV infection because they cause ulcer and lesions that open up the skin.

2. Mother to child transmission disease. World wide rate of HIV infection from mother to their children ran from 13-40% i.e. 4% out of 10% children born to HIV positive e mothers contract HIV.

Ways of mother to child transmission

46 |

i) The child can be infected before birth by virus crossing from the mother blood to the child through placenta. About 35% of newly born infant which are HIV infected at birth.

ii) The child can contract HIV through exposure to mother blood and other expulsion during birth. This account for about 05% of newly born HIV infected at birth is most of mother to child transmission occur during birth.

iii) The child can contract HIV positive mother that get infected with HIV contract virus as a result of breast feeding.

The following factors increase the chances of MTCT.

- High level of HIV in mother blood and other body fluid and secretions.

- Premature babies more prone to infection

- Low birth weight

- Prolonged membrane rapture

- Traditional birth delivery.

3. Blood transfusion. Use o blood products that have not been screened for HIV or have been poorly screened can lead to HIV transmission. It constitutes 3-5 % of all HIV infection.

4. Intravenous drug use / contact with contaminated instruments. its the administering of drugs of addiction e.g. heroine into blood stream by injecting into veins most of the group members often shave with some needless of their r chances of infection , account 5-10% HIV infection. procedures such as ear piercing , circumcision when done with poorly cleaned and unspecialized instrument can lead to transmission for previous person used on was HIV positive. Rape/ occupational exposure. Exposure to HIV can also be as a result of rape or occupational exposure to healthcare providers such as doctors and nurses. Occupational exposure is the accidental exposure of healthcare worker to body fluid form a positive infected person in their care. Can be due to needle pricks or cut with surgical instruments.

Rape an sodomy victim could also get infected with HIV if the attacker is HIV thus its important that the victim seek prompt medical attention as early treatment with ARVS could reduce chances of HIV infections.

47 |

The HIV epidemic in sub Saharan Africa has had a far more damaging societal impact not only because of extremely high number of people infected but also heterosexual transmission.

Way HIV is not transmitted

- Mosquito bites

- Sharing utensils

- Living with infected person

- Touching an infected person

- Having your hair cut

- Sharing drinks

- Wearing second hand clothes

- Sitting next to an infected person

- Using the same toilet with infected person

- Coughing and sneezing

- Swimming

General trend of HIV

• HIV is spreading very rapidly globally

• No of orphans and vulnerable children are increasing more and more women and children are being infected.

• More and more women and children are being infected

• Between 4-5 girls and young women are infected with HIV for every one young man infected.

• People who are living in poverty are more vulnerable to HIV infections.

• Aids has no cure

• HIV is preventive QUESTIONS

• Define immunity

• State the various types of immunity

• Discuss the effects of immunity on the body

• Explain the viral implication

48 |

RELATIONSHIP BETWEEN HIV /AIDS AND OTHER STDS

SPECIFIC OBJECTIVES

By the end of this topic the learner should be in a position to;

• Define sexually transmitted infection

• State the symptom of STDS

• Discuss the various examples of STDS

Sexually transmitted infection (STDs) vulnerable group of disease or infection whose predominant mode of transmission is through sexual intercourse

Stds makes one more vulnerable to HIV infection e.g. gonorrhea and genital herpes thus early treatment to aspect of HIV infection.

When one is infected by STDs he/ she depict the following symptoms

- Urethral discharge

- Virginal discharge

- Genital ulcers

- Long abdominal pain

- Eye infection in new born

- Swelling of scrotum Examples of STDs Gonorrhea

Causative agent

- Neisseria gonococcus Signs

- Burning when passing urine

- Discharge of pus through the urethra of the virginal or sore growth incase of oral sex, Complication and treatment

- Damage of fallopian duct in female and epididymis in male leading to sterility

- Inflammation of joint, liver, heart and peritoneum may occur.

Treatment By use of effective antibiotic as the organism is resistant to several times. Noflocin is a useful anti biotic.

49 |

SYPHILIS

Bacterium Treponema palladium

Signs and symptoms

- Sore in the genitalia and body rush

- After some years it damages the heart aorta and the brain leading to a condition known as paralysis of the insane.

Complication and treatment

Can cause re-current miscarriage, heart problems and brain damage Easily failed with infection of penicillin or cephalosporin’s LYMPOGRANULOMA

Causative agent – Chlamydia Signs and symptoms

- Swelling and ulceration of lymph nods in the grain Complication

Narrowing of rectum and destruction of urethra

Treatment Tetracycline’s TRICHOMONIASIS

Causative agent- protozoa dichotomous virginals Signs and symptoms

- Burning in the virginal and urethra

- Greenish - yellow discharge

Complication and treatment

Treated with fasigyn (tinidazolepessarics) or cream

Candidiasis

Causative agent – a fungus called Candida albicans Signs and symptoms

- Burning in the virginal and the urethra

- White thick discharge sometimes tiredness with blood.

50 |

Complication and treatment

May lead to pre cancer condition of the neck and womb (cervix cancer) Treated with anti fungalpassure or cream e.g. doctrimazole.

GENITAL Herpes. Causative agent Herpes simplex agent Signs and symptoms

Painful vascular rushes in the genitals Complication and treatment

- Figia damage unborn baby eventually treating to death.

- Cancer of the neck of the womb  no nearly the effective treatment.

- Acyclorin may be harmful. HEPATITIS

Causative agent Hepatitis ‘B’ virus Signs and symptoms

Yellow less of eyes (juridical ) due to liver damage

- Pain around right upper abdomen

- Lead to cancer of the liver. Complication and treatment

- Cancer of the liver.

- No treatment, vaccine, available also transmitted by blood transfusion.

AIDS

Causative agent HIV Signs

Many different signs but dominated by weight less and opportunistic infections. Complication and treatment

Much complication eventually leading to death i.e. no cure CLAMIDIA SIS

51 |

Causative agent

Chlamydia trichomatis (virus)

- Very common in adolescence

- Pain when passing urine

- Discharge and abdominal pain

Complication and treatment

- Damage to fallopian duct

- Inflation and sterility in both male and female

- Treatment doxycycline Cause by human popilloma virus Signs and symptoms

- Marks around genital area

- Invasion of the neck of the womb. Complication and treatment

Cancer of neck of the womb

Treatment is very difficult burning the wart with podophilingetc Relationship between STDS and HIV AIDS

- Both are sexually transmitted

- Both don’t have cure

- Both require psychotherapy (counseling) for individual to cope with them.

- In all of them individual s experience stigmatization

- In both of them the victim should always be educated on ways of avoiding re infection for it will worsen the situation

Clinical staging of HIV / aids

Clinically HIV/ AIDS infection has been categorized into five stages

1. Transmission stage

2. Primary infection

3. Asymptomatic phase.

4. Intermediate / asymptomatic stage

52 |

5. Advance disease

Transmission stage

Transmission of HIV/ AIDS with the 1st stage without, with non of the subsequent stage can occur

- Basically HIV virus is transmitted through contact with body fluids e.g sexual intercourse. accounting 80% of HIV transmission intravenous drug use 10% unscreened blood transfusion accounting 5% of HIV transmission and exposure to contaminated instrument accounting 0.1% e.g. needle . Mother to child transmission accounting 10% of HIV transmission.

- Primary injection. The symptoms of injection occur normally 2-6 weeks after exposure to the virus. In 50-80% of patient the symptom are normally mild and patient might dismiss them as mild through symptoms. this might be accompanied by swelling of the glands , sore throats which may persist up to 14 days .CD4 will decline as immune system come into attack from the virus but will recover as the immune system land to fight injection through production of antibodies.

Antibodies may become detectable 10-14 days after the onset of symptoms however depending on the sensitivity of the test and level of A HIV test may still be negative once natural viral suppression due to immune function occur the level of virus reaches a plateau 3-6 months after the injection has taken place.

Its during zero conversion that the patient is tightly infectious and transmission of virus is very likely while viral level remains high in the body fluids.

The plateau in the viral level is called viral sets.

Point and may indicate this rate of viral replication e.g. disease progression is likely to be faster in those in those with high viral subsequent.

ASSYMPTOMATIC PHASE

During the phase the patient remain asymptomatic (no signs of HIV / aids) although enlarged gland may characterize the phase with minor complication which the patients ignore as not no medical attention . Oral lesion may be represented as ulcers and the patients may have increased sinuses and other respiratory tract.

Many patients may take this normal cause infection if they are unaware of their status and treat with over the counter medicine.

53 |

SYMPTOMATIC STAGE

Here cd4 count has fallen below 500 and remain above 200. Patients begin manifesting symptom of HIV / aids and may develop a risk of bacteria pneumonias or, pulmonary TB. Also during this stage mouth infection may also show itself as oral thrush an d oral leukoplakia.

ADVANCED DISEASE

During this stage the cd4 counts fails below 200 patients may develop a variety of opportunistic infection of which include

- Non – pulmonary TB

- Pneumocytic pneumonia and may be accompanied by weight loss , fatigue and extreme headache and the patient may sometime become bad ridden . As the CD4 count drop below 50. The condition?

QUESTOIONS

Define sexually transmitted infection State the symptom of STDS

Discuss the various examples of STDS

IMPACT OF HIV/AIDs IN THE VARIOUS SECTORS

SPECIFFIC OBJECTIVES

By the end of this topic the learner should be in position to;

• State and explain the various impacts of HIV and AIDS on various sectors

• Explain the impact of HIV on education

• Explain the disadvantages of each

IMPACT OF HIV/AIDs IN THE VARIOUS SECTORS

1. Education. Negative impact

✓ Loss of skills as a result of death of teachers and student

✓ Reduces and declines performance of both teachers and students.

✓ High dropout of student especially for girls who take care of sick at home

54 |

✓ A large proportion of funds are ghptowards recruitment of new staff to replace the weak and the dying staff.

✓ The rate of absenteeism for teachers and staff is high i.e. it reduces lab our productivity

2. Industry and trade sector

Loss of productivity due to reduced labour

Reduces capacity for investment as resources are channeled towards the treatment and care of the sick employees

Reduces opportunity for overseas employees

3. Agricultural sector

Reduced productivity fund that need to be directed towards enhancing the agricultural sector as form of incentive which are challenged towards treatment and management of HIV/AIDs Reduced capacity for investment by industries in the agriculture sector due to loss of skills Reduces output because subsistence forming is practiced as opposed to large scale farming

4. Health sector

Funds that could be directed to preventive medicine are channeled towards treatment and management of HIV/AIDs

A mention is generated towards treatment and management of HIV/AIDs at the expenses of a terminal disease e.g. cancer.

A strain on the medical facilities mainly because a large proportion of the hospital beds are occupied by the related diseases

A lot of funds in the health sector are channeled towards purchasing ARVs at the expense of drugs for treating diseases.

Home Individual Loss of lives

Reduced purchasing due to reduction of income

Orphans are forced to dropout from school as they are forced to work to cater for their needs.

SOCIAL / ECONOMIC IMPACTS

There is reduction of life expectancy

Retarded economic growth resulting from loss of human capital this is due to management of HIV/Aids instead of out bed patients.

55 |

Loss of income due to death of parents and reduction in the productivity of this working which ultimately translate to increase in the number of dependency

Many orphans are left to be cared for by elderly thereby unable to access quality education Stigmatization of the affected and infected

Compulsory HIV/AID testing without prior consent of the patient undermines the dignity of those being served.

Quarantine / separation of people suffering from HIV/AIDs contributed to stigmatization of the people.

MYTHS MISCONCEPTION OF HIV/AIDS

Sexual intercourse with a virgin cure HIV/AIDs

Sexual intercourse with a virgin does not cure AIDs but it increases chance of infecting the virgin with AIDs

Sexual Intercourse with a animal cures HIV/AIDs HIV/AIDs is transmitted by mosquitoes

Showering after sexual intercourse with a person who infected with HIV prevents HIV/Aids Sharing of items like cloths food etc

HIV Aids is transmitted by a Mosquito

Since many of the areas of infection, immunity and treatment overlap, we have already encountered the general principle of HIV/AIDs transmission in other lesson. It is now placed to discuss transmission of HIV/Aids in details

HIV is transmitted through body fluids. The fluids. The fluids include:

i) semen

ii) vaginal fluid

iii) blood

The modes of transmission include.

i. Sexual intercourse. This is Intercourse with an infected person.

ii. Infected blood produce. This is when someone comes in to contact with the blood i.e. during blood transfusion that is contaminated blood.

iii. Receiving an injection from unsterilized useof syringes or surgical instrument have not been properly sterilized

56 |

iv. Mother to child transmission-During pregnancy child birth and breast feeding one can not get HIV/AIDs from

v. Casual contact with infected person. This include handshaking, hugging caring for people with HIV/Aids

vi. Food prepared or served by HIV/Positive people or using their utensils

vii. Saliva or tears (that include the intimate contact of kissing

viii. People with HIV coughing or splitting

ix. Toilet or toilet seat and hand wash basins

x. Swimming pools or public showers

xi. Visiting your doctor or dentist

xii. Donating blood

xiii. Using an infected person’s telephone

xiv. Contact with animals.

Factors responsible to the spread of HIV/Aids

i. Growth of shanty structures around town as a result of high cost of housing in urban areas hence making others to engage in prostitution as to get money

ii. Workers relocation cases where a spouse has to work away from each other.

iii. Minimal access to HIV information or education especially for people living in remote areas

iv. Under employment

v. Instability politically

vi. Inadequate or inequality between men and women which denies women the power to make decision

Vulnerable routes

i) Vagina:

Thinner tissue lining of the vagina in ad descent girls and the position of a zone of cells around the cervix which are more exposed in younger women and progressively less exposed during the ageing and progressively less during the ageing process less profuse mucus in the vagina

HIV also targets lymphocytes and macrophages this may be present in the vagina as a result of any inflammation however caused

57 |

ii) Foreskin

Has less Keratin than the penis so while intact easily allows HIV to penetrate the skin and affects semen directly and indirectly

Liable to tears and ulceration but even without this the uncircumcised is 8 time move vulnerable to HIV Aids

iii) Anus

The extreme thinners of protective tissue lining the rectum makes it easily to damage Unprotected anal intercourse carries the greatest HIV risk with homosexual men having a higher prevalence than receptive women because of both passive and active roles.

Vulnerable group for HIV/Aids

This refers to people with higher chances of contracting HIV virus The military people

Those people living around the roads The commercial sex workers Specific objectives

By the end of this of this chapter the trainee should be in a position to: Explain the meaning of body Immunity

Effect of HIV and Aids of on body Immune system

INTRODUCTIONS

The body has a two –part Immune system which workers together to protect it from harmful micro organism such as bacteria, fungi, viruses and parasites, it is divided in to two:

Innate Immunity

This is the front-line defense which equips us from before birth to deal with the various microorganisms that we are likely to meet in our normal everyday lives

Innate Immunity Include:

-Antibodies formed by a mother and passed on to the developing foetus and through infant breasting feeding

Tears containing the enzyme lysosome, to protect one eye from bacteria Saliva in the mouth, also containing the anti-bacterial lysosome

58 |

Mucus and chemicals co-existing but with quite differing functions in the urethra Uretes (water tubes) and vagina

When the barriers of the innate immunity are penetrated ,while blood cells leukocyte.(phagocytes or devouring cells) and other while cells (principally serotoxin or natural cell-Killing cells)surround and a number of other naturally-produced substances such as interfere and a range of blood proteins (called the complement system combine to help in the destruction process.

Adaptive Immunity

Adaptive Immunity is the second line of defense and is called into service when the defenses of the innate immunity are breached well beyond the capability of its response, Its defense, instead of being a general reaction is much more specific as it adapts to the particular organism present hence adaptive immunity is often referred to as specific immune system to identify the invading micro-organism as being foreign to any of the body’s own protein these foreign or devouring cells) and other while cells (principally serotoxin or natural cell-killing cells) surround and attempt to destroy the invader. At the same time a number of other naturally-produced substances such as interferon and a range of blood proteins called the complement system) combine to help in the destruction process.

Adaptive Immunity

Adaptive Immunity is the second line of defense and is called into service when the defenses of the innate immunity are breached well beyond the capability of it response. It defense, instead of being a general reaction is much more specific as it adapts to the particular organism present hence adaptive immunity is often referred to as specific immunity.

The role of the adaptive immune system to identify the invading micro-organism as being foreign to any of the body own protein (these foreign to any of the body own proteins these foreign protein are called antigens (antibody regenerators) from Greek works meaning against and engender)

The response can be either humeral or cellules based on the type of invade

Humoral Immunity

Deals infections arising in the inter-cellular body fluid or humors Deals infection arising in the inter-cellular body fluid or humors Is primarily a response to bacteria?

59 |

As the B-lymphocytes multiply they form plasma cell which in turn makes antibodies which bind to the antigens

Cellular Immunity

Responds mainly to virus and parasite that hide inside the cells. As we have seen, some viruses provoke a reaction that brings lasting protection

Questions

State and explain the various impacts of HIV and AIDS on various sectors Explain the impact of HIV on education

Explain the disadvantages of each sector

HIV AIDs COUNSELLING

Specific objectives

By the end of this chapter the learner should be in a position to:

• Understand HIV/Aids counseling

• Discuss the areas of counseling. INTRODUCTION

The possibility that one might have an illness bring it own anxieties especial where the person has enjoyed good health previously .If the illness has long term implication then a number of anxieties will surface incase of HIV infection these might include shock

On hearing the diagnosis and considering its implication Through disappointment on not hearing good news Anxiety fear due to.

Not knowing what course the infection will take Worrying about the effects of the treatment /medication Rejection by family /friends community

Isolation through sexual rejection because of the tears of others concerning infection Anticipating the partner /family inability to cope with the situation

Concerns about job and or skill losses Despairs because of

60 |

Little hope of cure

Persistent worries about ones inevitable physical decline Recriminations about being infected and /or spreading the infecting The limiting effects of the virus

The effect on ones family of being infected The stigma of being HIV infected

Areas Of counseling.

The two main areas of HIV counseling are;

Educating the infected person so that they will understand the nature of their problems explanation of the available treatment options; outlining ways to prevent others from being infected by them and

Support through anxieties and other physical need meets by people in the cause of their illness. Counseling opportunities will exist at different stage and provided by different individuals.

Appropriate counseling intervention include

Initial attendance at a clinic or medical centre where the at risk person will have the HIV testing procedures explained.

Personal counseling of the HIV-positive person and the partner family where this is possible and applicable

Available treatment regimes Instruction is safer sexual practices

Explanation of the development and effect of opportunistic infection and their delay /treatment Counseling the family of bereaved

Support Networks

Counselors and counseling facilities vary from country to country so there is hardly a standard approach

All community agencies should be alert to their opportunities to provide support to the sick in their midst and to help people with HIV/Aids and their dependants.

This network of support will include: Families, friends work colleagues Medical and paramedical staff

61 |

Social service charitable organizations Professional counselor/psychologists Faith communities

Special organization working specifically with HIV Aids infected people and their families. Counseling material and messages will need to be particularly relevant to specific target groups whether these be families, women sex workers or youth

Prevention and control of HIV /AIDs

HIV prevention services seem to work best when all the stakeholders are involved in implementation of the strategies .In. Kenya the Interpersonal donor partners local and international NGO’s faith –best organization are involved in activities and service to prevent HIV/Aids

Some of the activities implemented by this organization include:

❖ Basic evaluation and dissemination of information about HIV.

❖ Communication about behavior change.

❖ Community mobilization to change social norms

❖ Training youths and adolescent in life skill and behavior change e.g. being assertions responsibility accountability social skill ways of relating to others developing a positive mage.

❖ Peer education and youth to youth initiatives

❖ Voluntary counseling and testing (V.C.T)

❖ Prevention and treatment of other sexually transmitted diseases.

❖ Prevention of mother to child transmission

❖ Prevention of transfusion in medical settings including are blood transfusion and proper injection control

❖ Condom education and distribution promotion. Prevention and control strategies used in Kenya.

l. V.C.T as a prevention strategy it is a powerful weapon in the fight against HIV/AIDs since it is associated with behavior change that reduces HIV transmission and serves as a point of entry into care for those testing positive through the joint effort of stakeholders

There has been rapid increase of V.C.T sites in Kenya in the year 2008

62 |

V.C.T services are offered through site registration by the ministry of health as an effort to increase the number of people who are tested and to expand access to Aids case and treatment.

The National V.C.T programme use for models of services delivery.

Intergrated-Intergarded site are V.C.T centre which are located within the ground of health facilities such as hospital health centers or dispensaries .There are main advantages include. Easier referral to medical care service

Low start up cost that allows for an increasing number of people being tested and accessing AIDs core and treatment.

Short coming of integrated sites includes Health workers

They may have more urgent medical problems to attend to and cannot develop enough time to VCT

Stand alone site –This sites are not usually with existing medical Institution usually have staff denoted to V.C.T, They largely operated by NGOs agencies and they usually located at intensely populated urban areas.

Advantages

They staff can work full time on VCT service

They have donor funds that facilitate their community approach site.

Are V.C.T centers either intergraded into other social service or implanted as a souls activity of a local community based organization (CBOS)

Mobile sites

V.C.T services are provided as an outreach to remote to reach communities. Benefits of V.C.T

Helps in prevention of transmission of HIV serves as a flat form for care and treatment of Aids

Helps in planning for individual organization as well as the government

Help in identifying the number of HIV infected persons and ways of addressing or promoting prevention of transmission

It is enhancing referral of HIV position client for proper care and T.B prevention.

63 |

Prevention of transmission through blood

Blood transfusion often is a life saving intervention but it comes with a risk because it can transmit Infection if safety mercies are not followed

Safety measures include Blood screening

Sterilization of needle and syringes before using and discarding after each subsequent use Prevention of mother to child transmission (PMTC)

Mother to child transmission of his is responsible for most HIV infection in children a pregnant. Women who is HIV infected is 30-45% likely to transmit HIV to her newbornchild. The baby can be infected during pregnancy labor and delivery or through breast milk.

Intervention to reduce transmission of HIV include Prevent HIV infection in women.

The best way to prevent mother to child is to prevent the women from being affected this include engaging in sex.

For women to have a single and uninfected sexual partners

For young women pregnant women and lactating women to use condoms consistently and properly

Reduce the number of HIV exposed pregnancy women who are HIV infected can use family planning methods to prevent pregnancy

QUESTION

Define HIV counseling?

Discuss the procedure of HIV counseling? What are the roles of client in the session? HIV & AIDS Vulnerable Groups

AIDS is caused by HIV, a virus that can be passed from person to person through sexual fluids, blood and breast milk.

Worldwide, the majority of HIV infections are transmitted through sex between men and women, and half of all adults living with HIV are women. Certain groups of people have been particularly affected and these include people who inject drugs, sex workers and men who have sex with men.

64 |

HIV particularly affects adolescents and young people, who accounted for 39 percent of all new infections and 15 percent of all people living with HIV in 2012. 1 AIDS-related deaths among young adults have an especially damaging impact on their families and communities: skills are lost, workforces shrink and children are orphaned.

In some countries in sub-Saharan Africa, life expectancies have fallen below 40 years, whereas they would have been above 60 without the epidemic. Roughly 17.8 million children have lost at least one parent to AIDS-related illnesses. 2

Apart from inadequate funding, other major obstacles to reducing the vulnerability of these populations to HIV include weak infrastructure and shortages of healthcare workers in the worst affected countries. Political or cultural attitudes are also significant. For example, some authorities are opposed to condom promotion, while others refuse to support needle exchanges for people who inject drugs. Many are also reluctant to provide young people with adequate education about sex and sexual health.

Stigma and discrimination particularly affects these vulnerable groups. People known to be living with HIV are often shunned or abused by community members, employers even healthcare workers. As well as causing much personal suffering, this sort of prejudice discourages people from seeking HIV testing, treatment and care, undermining efforts to tackle the epidemic.

AIDS Stake holders- Institutions Involved in HIV/AIDS Reponses

At the national level, the state policy in the area of HIV/AIDS is implemented through the National Programme on Prevention and Control of HIV/AIDS and STI, which determines national strategies of priority for prevention, epidemiological surveillance and treatment. The structure of the institutional framework of the NAP is rather complex. The main executors of the state policy in the area of HIV/AIDS and STI are the Government, local public administration authorities, Ministry of Health and Social Protection and other Ministries, NGOs, mass media, etc. An important contribution is carried out by international organizations, such as UNAIDS and most UN agencies, GFATM/WB, Soros Foundation Moldova, SIDA, etc.

65 |

National AIDS Stakeholders and their Role

National Coordination Council and NCC Secretariat

- Development, integration, correlation and monitoring of activities under the NAP

Government and its Ministries

- Capacity building related to national response to HIV/AIDS/STI;

- Support to the consolidation of NGO networks which are working in the field of HIV/AIDS/STI and people living with HIV/AIDS;

- Priority financing, political support of HIV/AIDS activities;

- Focal points and HIV related responsibilities under several ministries;

- M&E

Local Public Administration Authorities

- Regional interdepartmental, multisectoral HIV/AIDS/STIs committees;

- Earmarking in local budgets for HIV/AIDS activities;

- Contribution to regional programmes in the field.

Mass Media

- Promote and make use of non-discriminatory language in HIV/AIDS/STIs

- Communication activities.

National Centre for Public Health

- Evaluation of population health, prognosis as to the evolution of basic indicators and sanitary-epidemiological statistics;

- Elaboration of prevention programmes at national and territorial levels;

- Fighting negative effect of harmful environment and production factors;

- Cooperation with other medical-sanitary national and international institutions of common and global interest;

- Exchange of experience and information.

Public Institution "UCIMP"

- Strengthening of the public health through reforming the health system;

- Development of the institutional capacities;

- Fighting negative effect of harmful environment and production factors;

66 |

- Support to the National Programmes on Prevention and Control of HIV/AIDS/STI and TB and National Programmeon Blood Transfusion Safety.

Rayon Centres for Preventive Medicine

- Epidemiological surveillance in territories;

- Elaboration and implementation of preventive measures;

- Organization and coordination activities with other medical institutions.

National AIDS Centre

- Analysis of the epidemiological situation, maintenance of official statistics;

- Elaboration of methods in all the areas of activity;

- Confirmation and reference tests for HIV/AIDS;

- Training and seminars on HIV/AIDS for family doctors.

Republican Dermato-Venerological Dispensary

- ARV treatment;

- Treatment of opportunistic infections.

National Centre for Health Management

- Health system strengthening;

- Scientific research coordination in the field of public health;

- Development of the legislative framework in public health.

Monitoring and Evaluation Unit on HIV/AIDS

- Development of M&E plans for the National AIDS Programmes, UNGASS reports, etc.

NGOs

- Grassroots activities;

- Wide range of prevention, care, support and rehabilitation projects in HIV/AIDS related areas;

- Lobby and advocacy.

International organizations

- Financial and technical assistance.

Association “Positive initiative”

67 |

“Positive initiative” is a new created association that represents a network within the organizations with a reach experience in the field of HIV, especially working and providing services for MARPS (Most at Risk populations), people living with HIV, IDU, women and children HIV+ or affected by HIV.

Association "Youth for Right to Life", Balti

Association "Youth for Right to Life", Balti is an NGO from Balti, Republic of Moldova, that more than one decade works in the field of HIV prevention, drug abuse and social assistance HIV Strains: Types, Groups and Subtypes

HIV types, groups and subtypes

HIV is a highly variable virus which mutates very readily. This means there are many different strains of HIV, even within the body of a single infected person.

Based on genetic similarities, the numerous virus strains may be classified into types, groups and subtypes.

What is the difference between HIV-1 and HIV-2?

There are two types of HIV: HIV-1 and HIV-2. Both types are transmitted by sexual contact, through blood, and from mother to child, and they appear to cause clinically indistinguishable AIDS. However, it seems that HIV-2 is less easily transmitted, and the period between initial infection and illness is longer in the case of HIV-2.

Worldwide, the predominant virus is HIV-1, and generally when people refer to HIV without specifying the type of virus they will be referring to HIV-1. The relatively uncommon HIV-2 type is concentrated in West Africa and is rarely found elsewhere.

How many subtypes of HIV-1 are there?

The strains of HIV-1 can be classified into four groups: the "major" group M, the "outlier" group O and two new groups, N and P. These four groups may represent four separate introductions of simian immunodeficiency virus into humans.

68 |

HIV types, groups and subtypes

Group O appears to be restricted to west-central Africa and group N - a strain discovered in 1998 in Cameroon - is extremely rare. In 2009 a new strain closely relating to gorilla simian immunodeficiency virus was discovered in a Cameroonian woman. It was designated HIV-1 group P. More than 90 percent of HIV-1 infections belong to HIV-1 group M and, unless specified, the rest of this page will relate to HIV-1 group M only.

Within group M there are known to be at least nine genetically distinct subtypes (or clades) of HIV-1. These are subtypes A, B, C, D, F, G, H, J and K.

Occasionally, two viruses of different subtypes can meet in the cell of an infected person and mix together their genetic material to create a new hybrid virus (a process similar to sexual reproduction, and sometimes called "viral sex"). Many of these new strains do not survive for long, but those that infect more than one person are known as "circulating recombinant forms" or CRFs. For example, the CRF A/B is a mixture of subtypes A and B.

The classification of HIV strains into subtypes and CRFs is a complex issue and the definitions are subject to change as new discoveries are made. Some scientists talk about subtypes A1, A2, A3, F1 and F2 instead of A and F, though others regard the former as sub-subtypes.

What about subtypes E and I?

One of the CRFs is called A/E because it is thought to have resulted from hybridization between subtype A and some other "parent" subtype E. However, no one has ever found a pure form of subtype E. Confusingly, many people still refer to the CRF A/E as "subtype E" (in fact it is most correctly called CRF01_AE).

A virus isolated in Cyprus was originally placed in a new subtype I, before being reclassified as a recombinant form A/G/I. It is now thought that this virus represents an even more complex CRF

69 |

comprised of subtypes A, G, H, K and unclassified regions. The designation "I" is no longer used.

Where are the different subtypes and CRFs found?

The HIV-1 subtypes and CRFs are typically associated with certain geographical regions, with the most widespread being subtypes A and C. As studies have shown, individuals are increasingly presenting with sub-types not native to the country of diagnosis. For example, a rise of non-B sub-types among men who have sex with men (MSM) in the UK has been identified.

• Subtype A and CRF A/G predominate in West and Central Africa, with subtype A possibly also causing much of the Russian epidemic.

• Historically, subtype B has been the most common subtype/CRF in Europe, the Americas, Japan and Australia and is the predominant sub-type found among MSM infected in Europe. Although this remains the case, other subtypes are becoming more frequent and now account for at least 25 percent of new HIV infections in Europe.

• Subtype C is predominant in Southern and East Africa, India and Nepal. It has caused the world's worst HIV epidemics and is responsible for around half of all infections.

• Subtype D is generally limited to East and Central Africa. CRF A/E is prevalent in South- East Asia, but originated in Central Africa. Subtype F has been found in Central Africa, South America and Eastern Europe. Subtype G and CRF A/G have been observed in West and East Africa and Central Europe.

• Subtype H has only been found in Central Africa; J only in Central America; and K only in the Democratic Republic of Congo and Cameroon.

As a Belgium study highlighted, local epidemics can be better understood if sub-types, patient demographics and transmission routes are recorded. Furthermore, the availability of this data can be used to target risk groups more accurately and to improve the effectiveness of prevention strategies.

Are more subtypes likely to "appear"?

It is almost certain that new HIV genetic subtypes and CRFs will be discovered in the future, and indeed that new ones will develop as virus recombination and mutation continue to occur. The current subtypes and CRFs will also continue to spread to new areas as the global epidemic continues.

70 |

The implications of variability

Does subtype affect disease progression?

A study presented in 2006 found that Ugandans infected with subtype D or recombinant strains incorporating subtype D developed AIDS sooner than those infected with subtype A, and also died sooner, if they did not receive antiretroviral treatment. The study's authors suggested that subtype D is more virulent because it is more effective at binding to immune cells.This result was supported by another study presented in 2007, which found that Kenyan women infected with subtype D had more than twice the risk of death over six years compared with those infected with subtype A. An earlier study of sex workers in Senegal, published in 1999, found that women infected with subtype C, D or G were more likely to develop AIDS within five years of infection than those infected with subtype A.

Several studies conducted in Thailand suggest that people infected with CRF A/E progress faster to AIDS and death than those infected with subtype B, if they do not receive antiretroviral treatment.

Are there differences in transmission?

It has been observed that certain subtypes/CRFs are predominantly associated with specific modes of transmission. In particular, subtype B is spread mostly by homosexual contact and intravenous drug use (essentially via blood), while subtype C and CRF A/E tend to fuel heterosexual epidemics (via a mucosal route).

Whether there are biological causes for the observed differences in transmission routes remains the subject of debate. Some scientists, such as Dr Max Essex of Harvard, believe such causes do exist. Among their claims are that subtype C and CRF A/E are transmitted much more efficiently during heterosexual sex than subtype B.However, this theory has not been conclusively proven. More recent studies have looked for variation between subtypes in rates of mother-to-child transmission. One of these found that such transmission is more common with subtype D than subtype A. Another reached the opposite conclusion (A worse than D), and also found that subtype C was more often transmitted that subtype D. A third study concluded that subtype C is more transmissible than either D or A. Other researchers have found no association between subtype and rates of mother-to-child transmission.

71 |

Is it possible to be infected more than once?

Until about 1994, it was generally thought that individuals do not become infected with multiple distinct HIV-1 strains. Since then, many cases of people coinfected with two or more strains have been documented.

All cases of confection were once assumed to be the result of people being exposed to the different strains more or less simultaneously, before their immune systems had had a chance to react. However, it is now thought that "superinfection" is also occurring. In these cases, the second infection occurred several months after the first. It would appear that the body's immune response to the first virus is sometimes not enough to prevent infection with a second strain, especially with a virus belonging to a different subtype. It is not yet known how commonly super infection occurs, or whether it can take place only in special circumstances.

Do HIV antibody tests detect all types, groups and subtypes?

Initial tests for HIV are usually conducted using the EIA (or ELISA) antibody test or a rapid antibody test.

Compared with first generation EIA antibody tests that were initially developed, third and fourth generation EIA antibody tests are significantly more accurate. Unlike previous tests, the fourth generation test detects HIV antibodies and antigens simultaneously. The WHO recommends that tests should have an accuracy rate of 99 percent and whilst most do, this may vary slightly between the test brands.

The most-up-to date (fourth generation) EIA tests detect both HIV-1 and HIV-2 infections. Although most HIV infections are HIV-1 group M, EIA tests are also able to detect infections with rare groups and subtypes.

However, as HIV-2 and group O infections are extremely rare in most countries, routine screening programs might not be designed to test for them.Anyone who believes they may have contracted HIV-2, HIV-1 group O or one of the rarer subtypes of group M should seek expert advice.

What are the treatment implications?

An HIV positive man sitting at home before taking his antiretroviral drugs

72 |

Although most current HIV-1 antiretroviral drugs were designed for use against subtype B, there is no compelling evidence that they are any less effective against other subtypes. Nevertheless, some subtypes may be more likely to develop resistance to certain drugs, and the types of mutations associated with resistance may vary. This is an important subject for future research. The effectiveness of HIV-1 treatment is monitored using viral load tests. It has been demonstrated that some viral load tests are sensitive only to subtype B and can produce a significant underestimate of viral load if used to process other strains. The latest tests do claim to produce accurate results for most Group M subtypes, though not necessarily for Group O. It is important that health workers and patients are aware of the subtype/CRF they are testing for and of the limitations of the test they are applying.

Not all of the drugs used to treat HIV-1 infection are as effective against HIV-2. In particular, HIV-2 has a natural resistance to NNRTI antiretroviral drugs and they are therefore not recommended. As yet there is no FDA-licensed viral load test for HIV-2 and those designed for HIV-1 are not reliable for monitoring the other type. Instead, response to treatment may be monitored by following CD4+ T-cell counts and indicators of immune system deterioration.

More research and clinical experience is needed to determine the most effective treatment for HIV-2.

What are the implications for an AIDS vaccine?

The development of an AIDS vaccine is affected by the range of virus subtypes as well as by the wide variety of human populations who need protection and who differ, for example, in their genetic make-up and their routes of exposure to HIV. In particular, the occurrence of super infection indicates that an immune response triggered by a vaccine to prevent infection by one strain of HIV may not protect against all other strains. The increasing variety of sub-types found within countries suggests that the effectiveness of a vaccine is likely to vary between populations, unless an innovative method is developed which guards against many virus strains. Inevitably, different types of candidate vaccines will have to be tested against various viral strains in multiple vaccine trials, conducted in both high-income and developing countries OPPORTUNISTIC INFECTIONS

• WHAT ARE OPPORTUNISTIC INFECTIONS?

• TESTING FOR OIs

• OIs AND AIDS

73 |

• WHAT ARE THE MOST COMMON OIs?

• PREVENTING OIs

• TREATING OIs

WHAT ARE OPPORTUNISTIC INFECTIONS?

In our bodies, we carry many germs – bacteria, protozoa, fungi, and viruses. When our immune system is working, it controls these germs. But when the immune system is weakened by HIV disease or by some medications, these germs can get out of control and cause health problems. Infections that take advantage of weakness in the immune defenses are called “opportunistic”. The phrase “opportunistic infection” is often shortened to “OI”.

TESTING FOR OIs

You can be infected with an OI, and “test positive” for it, even though you don’t have the disease. For example, almost everyone with HIV tests positive for Cytomegalovirus (CMV). But it is very rare for CMV disease to develop unless the CD4 cell count drops below 50, a sign of serious damage to the immune system.

To see if you’re infected with an OI, your blood might be tested for antigens (pieces of the germ that causes the OI) or for antibodies (proteins made by the immune system to fight the germs). If the antigens are found, it means you’re infected. If the antibodies are found, you’ve been exposed to the infection. You may have been immunized against the infection, or your immune system may have? cleared? the infection, or you may be infected. If you are infected with a germ that causes an OI, and if your CD4 cells are low enough to allow that OI to develop, your health care provider will look for signs of active disease. These are different for the different OIs.

OIs AND AIDS

People who aren’t HIV-infected can develop OIs if their immune systems are damaged. For example, many drugs used to treat cancer suppress the immune system. Some people who get cancer treatments can develop OIs.

HIV weakens the immune system so that opportunistic infections can develop. If you are HIV- infected and develop opportunistic infections, you might have AIDS.

In the US, the Center for Disease Control (CDC) is responsible for deciding who has AIDS. The CDC has developed a list of about 24 opportunistic infections. If you have HIV and one or more

74 |

of these “official” OIs, then you have AIDS. The list is available at http://www.aidsmeds.com/lessons/StartHere8.htm.

WHAT ARE THE MOST COMMON OIs?

In the early years of the AIDS epidemic, OIs caused a lot of sickness and deaths. Once people started taking strong antiretroviral therapy (ART), however, a lot fewer people got OIs. It’s not clear how many people with HIV will get a specific OI.

In women, health problems in the vaginal area may be early signs of HIV. These can include pelvic inflammatory disease and bacterial vaginosis, among others. See fact sheet 610 for more information.

The most common OIs are listed here, along with the disease they usually cause, and the CD4 cell count when the disease becomes active:

•  Candidiasis (Thrush) is a fungal infection of the mouth, throat, or vagina. CD4 cell range: can occur even with fairly high CD4 cells.

•  Cytomegalovirus (CMV) is a viral infection that causes eye disease that can lead to blindness.CD4 cell range: under 50.

•  Herpes simplex viruses can cause oral herpes (cold sores) or genital herpes. These are fairly common infections, but if you have HIV, the outbreaks can be much more frequent and more severe. They can occur at any CD4 cell count.

•  Malaria is common in the developing world. It is more common and more severe in people with HIV infection.

•  Mycobacterium avium complex (MAC or MAI) is a bacterial infection that can cause recurring fevers, general sick feelings, problems with digestion, and serious weight loss. CD4 cell range: under 75.

•  Pneumocystis pneumonia (PCP) is a fungal infection that can cause a fatal pneumonia. CD4 cell range: under 200. Unfortunately this is still a fairly common OI in people who have not been tested or treated for HIV.

• Toxoplasmosis (Toxo) is a protozoal infection of the brain. T-cell range: under 100.

•  Tuberculosis (TB) is a bacterial infection that attacks the lungs, and can cause meningitis. CD4 cell range: Everyone with HIV who tests positive for exposure to TB should be treated.

PREVENTING OIs

75 |

Most of the germs that cause OIs are quite common, and you may already be carrying several of these infections. You can reduce the risk of new infections by keeping clean and avoiding known sources of the germs that cause OIs.

Even if you’re infected with some OIs, you can take medications that will prevent the development of active disease. This is called prophylaxis. The best way to prevent OIs is to take strong ART. See Fact Sheet 403 for more information on ART.

The Fact Sheets for each OI have more information on avoiding infection or preventing the development of active disease.

TREATING OIs

For each OI, there are specific drugs, or combinations of drugs, that seem to work best. Refer to the Fact Sheets for each OI to learn more about how they are treated.

Strong antiretroviral drugs can allow a damaged immune system to recover and do a better job of fighting OIs. Fact Sheet 481 on Immune Restoration has more information on this topic Complications

HIV infection weakens your immune system, making you highly susceptible to numerous infections and certain types of cancers.

Infections common to HIV/AIDS

• Tuberculosis (TB). In resource-poor nations, TB is the most common opportunistic infection associated with HIV and a leading cause of death among people with AIDS. Millions of people are currently infected with both HIV and tuberculosis, and many experts consider the two diseases to be twin epidemics.

• Salmonellosis. You contract this bacterial infection from contaminated food or water. Signs and symptoms include severe diarrhea, fever, chills, abdominal pain and, occasionally, vomiting. Although anyone exposed to salmonella bacteria can become sick, salmonellosis is far more common in HIV-positive people.

• Cytomegalovirus. This common herpes virus is transmitted in body fluids such as saliva, blood, urine, semen and breast milk. A healthy immune system inactivates the virus, and it remains dormant in your body. If your immune system weakens, the virus resurfaces — causing damage to your eyes, digestive tract, lungs or other organs.

76 |

• Candidiasis. Candidiasis is a common HIV-related infection. It causes inflammation and a thick, white coating on the mucous membranes of your mouth, tongue, esophagus or vagina. Children may have especially severe symptoms in the mouth or esophagus, which can make eating painful.

• Cryptococcal meningitis. Meningitis is an inflammation of the membranes and fluid surrounding your brain and spinal cord (meninges). Cryptococcal meningitis is a common central nervous system infection associated with HIV, caused by a fungus found in soil. The disease may also be associated with bird or bat droppings.

• Toxoplasmosis. This potentially deadly infection is caused by Toxoplasma gondii, a parasite spread primarily by cats. Infected cats pass the parasites in their stools, and the parasites may then spread to other animals and humans.

• Cryptosporidiosis. This infection is caused by an intestinal parasite that's commonly found in animals. You contract cryptosporidiosis when you ingest contaminated food or water. The parasite grows in your intestines and bile ducts, leading to severe, chronic diarrhea in people with AIDS.

Cancers common to HIV/AIDS

• Kaposi's sarcoma. A tumor of the blood vessel walls, this cancer is rare in people not infected with HIV, but common in HIV-positive people.

Kaposi's sarcoma usually appears as pink, red or purple lesions on the skin and mouth. In people with darker skin, the lesions may look dark brown or black. Kaposi's sarcoma can also affect the internal organs, including the digestive tract and lungs.

• Lymphomas. This type of cancer originates in your white blood cells and usually first appears in your lymph nodes. The most common early sign is painless swelling of the lymph nodes in your neck, armpit or groin.

Other complications

• Wasting syndrome. Aggressive treatment regimens have reduced the number of cases of wasting syndrome, but it still affects many people with AIDS. It's defined as a loss of at least 10 percent of body weight, often accompanied by diarrhea, chronic weakness and fever.

77 |

• Neurological complications. Although AIDS doesn't appear to infect the nerve cells, it can cause neurological symptoms such as confusion, forgetfulness, depression, anxiety and difficulty walking. One of the most common neurological complications is AIDS dementia complex, which leads to behavioral changes and diminished mental functioning.

• Kidney disease. HIV-associated nephropathy (HIVAN) is an inflammation of the tiny filters in your kidneys that remove excess fluid and wastes from your bloodstream and pass them to your urine. Because of a genetic predisposition, the risk of developing HIVAN is much higher in blacks.

Regardless of CD4 count, antiretroviral therapy should be started in those diagnosed with HIVAN.

AIDS Stakeholders – Institutions Involved in HIV/AIDS Response in Moldova

At the national level, the state policy in the area of HIV/AIDS is implemented through the National Programme on Prevention and Control of HIV/AIDS and STI, which determines national strategies of priority for prevention, epidemiological surveillance and treatment. The structure of the institutional framework of the NAP is rather complex. The main executors of the state policy in the area of HIV/AIDS and STI are the Government, local public administration authorities, Ministry of Health and Social Protection and other Ministries, NGOs, mass media, etc. An important contribution is carried out by international organizations, such as UNAIDS and most UN agencies, GFATM/WB, Soros Foundation Moldova, SIDA, etc.

78 |

National AIDS Stakeholders and their Role

National Coordination Council and NCC Secretariat

- Development, integration, correlation and monitoring of activities under the NAP

Government and its Ministries

- Capacity building related to national response to HIV/AIDS/STI;

- Support to the consolidation of NGO networks which are working in the field of HIV/AIDS/STI and people living with HIV/AIDS;

- Priority financing, political support of HIV/AIDS activities;

- Focal points and HIV related responsibilities under several ministries;

- M&E

Local Public Administration Authorities

- Regional interdepartmental, multisectoral HIV/AIDS/STIs committees;

- Earmarking in local budgets for HIV/AIDS activities;

- Contribution to regional programmes in the field.

Mass Media

- Promote and make use of non-discriminatory language in HIV/AIDS/STIs

- Communication activities.

National Centre for Public Health

- Evaluation of population health, prognosis as to the evolution of basic indicators and sanitary-epidemiological statistics;

- Elaboration of prevention programmes at national and territorial levels;

- Fighting negative effect of harmful environment and production factors;

- Cooperation with other medical-sanitary national and international institutions of common and global interest;

- Exchange of experience and information.

Public Institution "UCIMP"

- Strengthening of the public health through reforming the health system;

- Development of the institutional capacities;

- Fighting negative effect of harmful environment and production factors;

79 |

- Support to the National Programmes on Prevention and Control of HIV/AIDS/STI and TB and National Programmeon Blood Transfusion Safety.

Rayon Centres for Preventive Medicine

- Epidemiological surveillance in territories;

- Elaboration and implementation of preventive measures;

- Organization and coordination activities with other medical institutions.

National AIDS Centre

- Analysis of the epidemiological situation, maintenance of official statistics;

- Elaboration of methods in all the areas of activity;

- Confirmation and reference tests for HIV/AIDS;

- Training and seminars on HIV/AIDS for family doctors.

Republican Dermato-Venerological Dispensary

- ARV treatment;

- Treatment of opportunistic infections.

National Centre for Health Management

- Health system strengthening;

- Scientific research coordination in the field of public health;

- Development of the legislative framework in public health.

Monitoring and Evaluation Unit on HIV/AIDS

- Development of M&E plans for the National AIDS Programmes, UNGASS reports, etc.

NGOs

- Grassroots activities;

- Wide range of prevention, care, support and rehabilitation projects in HIV/AIDS related areas;

- Lobby and advocacy.

International organizations

- Financial and technical assistance.

Association “Positive initiative”

80 |

“Positive initiative” is a new created association that represents a network within the organizations with a reach experience in the field of HIV, especially working and providing services for MARPS (Most at Risk populations), people living with HIV, IDU, women and children HIV+ or affected by HIV.

Association "Youth for Right to Life", Balti

Association "Youth for Right to Life", Balti is an NGO from Balti, Republic of Moldova, that more than one decade works in the field of HIV prevention, drug abuse and social assistance. UN Groups on HIV/AIDS

Coordination, cohesion and effectiveness of the UN contribution to the national response to HIV/AIDS

More information on UN TG and UN JT

UNAIDS

Advocacy, Capacity building (NCC, TWG, NGOs, PLH, etc), Promotion of best practices, Support of PLH

WHO

Advocacy, ARV Treatment, Technical norms and guidelines, Promotion of research into health service delivery

UNICEF

Advocacy, Children made vulnerable or orphaned because of HIV, Prevention of Mother to Child Transmission, Life skills based education, Prevention among young people

UNFPA

Advocacy, Reproductive Health, Condom Promotion, Peer education, VCT

UNDP

Advocacy, Coordination, HIV Prevention in the Armed Forces

IOM

HIV and Migrants

UNHCR

HIV and Refugees

ILO

HIV at the workplace

81 |

UNESCO

HIV Prevention education

WFP

Nutrition and food security for PLHIV and their families

UNODC

HIV prevention among IDU and in penitentiaries

WB

Advocacy, Financial support

UNIFEM

Prevention of HIV among women

Other Stakeholders

AFEW – AIDS Foundation East West

Campaign on Stigma and Discrimination against PLH, HIV Prevention Campaign

Soros Foundation – Moldova

Harm Reduction, Palliative Care

Center for Health Policies and Studies

Contribute to health system development, support reforms and capacity building in HIV/AIDS and TB area

SIDA – Swedish International Development Agency

Strengthening Civil Society, Prevention of Social Exclusion and Promotion of Public Health

MSF – MédecinsSansFrontières

Setting up operations in Moldova that will address the needs of both TB and HIV patients

USAID Moldova

Prevention of HIV/AIDS and Viral Hepatitis B&C Positive Initiative

A network within the organizations with a reach experience in the field of HIV

Youth-friendly Health Centre "ATIS"

Youth friendly services, IEC activities

82 |

UOHR – Union of Harm Reduction Organizations

Coordinating, building capacity, and providing support to organizations operating in the field of harm reduction

League of People Living with HIV of Republic of Moldova Advocacy and support for people living with HIV Moldova AIDS Network

Transfer of experience and capacity building in the field of HIV/AIDS, STI and Drug-abuse prevention

Non-governmental Organization "New Life" Promote the healthy life style and rehabilitation MCA – Moldavian Christian Aid

Foster ecumenical cooperation, increase the role of the Churches in Moldavian modern society

MIHR – Moldova Institute for Human Rights

Education, promotion and defense of rights and freedoms foreseen by the national and international legislation

NYRC – National Youth Resource Centre

Network to promote services targeting young people Charity Social-Medical Foundation "Angelus Moldova" Palliative care and psychological support

CRS – Catholic Relief Services

Hope, security and opportunity

GTZ – German Technical Cooperation Bureau

Sustainable development, improvement of people’s living conditions

WAC – World AIDS Campaign

Advocacy, campaigning activities and lobby

Association "TineretulPozitiv"

Protection of rights of young people affected by HIV/AIDS

Information Center "GenderDoc-M"

Lobby and protection of rights of LGBT community representatives

83 |

Moldova Youth Peer Education Network Promotion of peer to peer education Association "Youth for the right to live"

HIV Prevention, drug abuse and social assistance COMMUNICABLE DISEASES

TERMS

✓ Communicable diseases - An illness due to specific infections agent or its toxic product which arise through transmission of the agent or its toxin form a reservoir susceptible host either directly, indirectly as an infected animals or person or indirectly through the agency of intermediate plant or animals host vector or in animate environment.

✓ Infection-Invasion of the body by dx causing organism.

✓ Cross infection – Normally occurs in the hospital btn patient due to their cross proximity or carelessness of the staff.

✓ Drop infection –Organism are spread by minute particle of moisture especially in coughing or sneezing.

✓ Mass infection- Infection of the blood extremely large no. of the organism.

✓ Secondary infection –Prefers to the super-imposed second infection that occurs while one is already present i.e. re-infection

✓ Incubation period –Is the time taken from the time of infection 2 the time the signs and symptoms of illness appear.

✓ Clinical infection –Where the organism or agent produce signs & symptoms.

✓ Sub-clinical infection (Asymptomatic)-This is where the sign & symptoms are not showed up clear. There is no usual clinical diagnosis.

✓ Health carrier –A person carrying diseases, agent but is not affected but can transmit it to other person.

✓ Susceptible host-Refer to one who has no or has less resistance to disease or infection.

✓ Host – The organism, man or animals on which a parasite lives & multiplies.

✓ Intermediate host-One that shelter parasite during the non –productive period (larval stage)

84 |

✓ Pandemic-This is when a disease spread in many countries through the world.

✓  Epidemic-When a disease spreads out attacking a large no. of people. It’s a rapid outbreak of diseases.

✓ Endemic – A term used to describe any disease prevalent in a particular area.

✓ Sporadic – Refers to a disease occurring here and there (scattered).

✓ Incidence- Refers to new cases occurring at a particular time in a place.

✓ Fatality- Death due to a certain disease.

✓ …………………………… INTRODUCTION

Most of the common diseases in Africa are environmental diseases and are due to infection by living organisms which are viruses, bacteria, Chlamydia, ricketsiae, fungi, protozoa, metazoan or Helminthes. These are called communicable diseases because they spread from person to person or from animals to people. Together with malnutrition they are today the major cause of illness in Africa. The communicable diseases occur at all ages but are most serious in childhood due to an increased intensity of exposure and a poorly developed immunity. These diseases are to a great extent preventable.

In countries where they have been largely eliminated, other conditions such as degenerative and malignant diseases have taken place. This process is known as the Epidemiological transition.

Infections that have increased in incidence during the last couple of decades and whose incidence is predicted to increase in the near future have appeared. They are called “emerging infectious diseases”. The reasons behind these emerging infections are not known but likely factors

include:-

1. Societal events

• Economic impoverishment

• War or civil conflicts

• Population growth and migration

• Urban decay

2. Health care

• New medical devices

85 |

• Organ or tissue transplantation

• Drugs causing immunosuppression

• Widespread use of antibiotics

3. Food production

• Globalization of food supplies

• Changes in food processing and packaging

4. Human behavior

• Sexual behavior

• Drug use

• Travel

• Diet

• Outdoor recreation

• Use of childcare facilities

5. Environmental changes

• Deforestation/reforestation

• Changes in water ecosystems

• Flood/drought

• Famine

• Global warming

6. Public health

• Curtailment or reduction in preventive programmes

• Infrastructure and communicable disease surveillance inadequate

• Lack of trained personnel

7. Microbial adaptation

• Changes in virulence and toxin production

• Development and change of drug resistance

• Microbes as co-factors in chronic diseases

More simplified, the factors to emerging and re-emerging of infections are:-

• Agricultural practices and consumption of exotic animals-genetic recombination

• Change of land use-forest land to agricultural land causing deforestation

86 |

• Rapid international travel

• Poverty and disease

• Urbanization

• Forced displacement due to war or civil strife

• Human morality and disease

• Overuse of antibiotics-resistance

• Biblical perspective-unclean animals, unclean environments, sexual immorality e.g. homosexual and lesbians and broken relationship with God.

Communicable diseases are very important in Africa because:-

1. Many of them are very common

2. Some of them are very serious and cause death and disability

3. Some come as widespread outbreaks, i.e epidemics

4. Many of them are fairly preventable by fairly simple means

5. Many are particularly serious (and more common) in infants and children.

I. BROAD CLASSIFICATION OF DISEASES

1. Metabolic disorders-Chemical and physical processes within the body-disordered biochemistry in the body i.e. cholesterol imbalance e.g. diabetes

2. Congenital diseases-Mental or physical abnormalities that are present at, and usually before birth, some may be medically insignificant and may not appear for some time. In other cases they may pose a direct threat to life and requires immediate attention. Examples are cataract, cleft palate, cretinism, down’s syndrome, congenital heart disease, hemophilia, joints disorders, spinal bifida. Blindness, deafness, hydrocephalus can also be due to congenital disorders.

3. Hereditary diseases-This is the transmission of mental and physical characteristics from parents to their children, and also the total genetic constitution of any individual. Examples are hemophilia, sickle cell anemia, etc

4. Allergy diseases-A condition in which the body reacts with unusual sensitivity to a certain substance(s).These substances which are usually proteins are called antigens. They stimulate the body to produce antibodies which weaken or destroy the invading

87 |

antigens. In some cases, when an antibody reacts with an antigen, the organic compound histamine is released from special body cells called mast cells. It is an excess of histamine that results in allergy symptoms e.g. hay fever, asthma.

5. Traumatic diseases-A medical term for an injury ,could be physical or psychological e.g. shock, Accident

6. Nutritional/deficiency diseases-In adequate, lack of essential nutrients e.g. Obesity, marasmus, kwashiorkor, nutritional anemiaetc

7. Occupational diseases-Diseases associated with one’s occupation e.g. silicosis, asbestosis, Lung fibrosis etc

8. Toxic diseases-Due to contact with toxic substances e.g. poisoning, snake venom, etc

9. Degenerative diseases-Wear and tear of the body tissues e.g. arthritis, arteriosclerosis, rheumatism,etc

10. Addictive diseases-Due to desire/urge to use some substances e.g. alcoholism, smoking etc

11. Mental disorders-Refers to a broad range of psychiatric disorders that reflect a deviation from normal thought and behavior patterns e.g. psychosis, schizophrenia, etc

12. Neoplastic disorders-The medical name for any abnormal new growth commonly referred to as tumors e.g. cancers

13. Psychosocial disorders-Refers to a mental illness caused or influenced by life experiences as well as maladjusted cognitive and behavioral processes. They can be due to psychological and social factors that influence mental health. Social influences such as peer pressure, parental support, cultural and religious background, socioeconomic status and interpersonal relationship e.g. juvenile delinquency, rapists, stress etc

14. Communicable diseases-Diseases spread from one person to another or from animal to person

II. CLASSIFICATION OF COMMUNICABLE DISEASES (BASED ON HOW THE DISEASE IS TRANSMITTED)

1. Contact diseases-The means of transmission is through:-

• Skin to skin contact

• Direct touch of infected person

88 |

• Indirect-handling contaminated articles (fomites) e.g. clothing.

They tend to occur in places of:-

• Overcrowding

• Clusters within the family

• Children’s playgrounds-schools,etc

• Work

Communicability occurs in the following situations:-

• High population density e.g. urban centers

• Overcrowding

• Poor housing

• Close personal contact including sexual contact

• Inadequate water supply

Examples are scabies, pediculosis, fungal skin infections, candidiasis, trachoma, etc

2. Sexually transmitted diseases/infections-Usually transmitted during sexual intercourse hence the name STDs/STIs.During sexual intercourse there is close body contact which is an ideal situation for transmission e.g. gonorrhea,etc

3. Vector-borne diseases-The insect vectors usually acquire the disease organisms by sucking blood from infected persons and later pass it on by the same route. There are other transmission routes however. Infection may enter skin cracks or abrasions either from infected insect feces deposited when feeding or from body fluid when an insect is crushed. Examples are malaria,onchocerciasis ,etc

4. Feacal contamination diseases-The causative organisms of the diseases in this group are excreted in the stools of infected persons (or less commonly animals).The portal of entry for these diseases is the mouth. Therefore the causative organisms have to pass through the environment from the feces of an infected person to the gastrointestinal tract of a susceptible person. This is known as the faeco-oral transmission route which occurs mostly through contamination of food, water and hands with faeces.Examples are bacillary

89 |

dysentery,amoebiasis,viralhepatitis,cholera,enteric fevers, food poisoning,poliomyelitis,etc

5. Helminthic diseases-Due to worms. Examples are ascariasis,enterobiasis,etc

6. Airborne diseases-Can be transmitted through the air. Examples are measles,mumps,chickenpox,whoopingcough,meningitis,pneumonia,tuberculosis,com moncolds,influenza,etc

7. Animals and their products contact diseases. Examples are rabies,tetanus,anthrax,brucellosis,etc

CLASSIFICATION BASED ON CAUSATIVE/INFECTIOUS AGENTS

1. Bacterial diseases-bacillary dysentery(Shigellosis),cholera,enteric fevers,tetanus,anthrax,brucellosis,meningitis,tuberculosis,leprosy,plague,gonorrhea,et c

2. Viral diseases-yellow fever,rabies,measles,chickenpox,poliomyelitis,viral hepatitis,mumps,AIDS,etc

3. Helminthic diseases- Ascariasis,hydatidosis,filariasis,schistosomiasis,taeniasis,dracunculosis,etc

4. Protozoan diseases- malaria,leishmaniasis,trypanosomiasis,giardiasis,amoebiasis,trichomoniasis

5. Chlamydia diseases-trachoma,non-gonococci (non-specific)urethritis,etc

6. Spirochetes diseases-pinta,syphilis,relapsing fever,yaws,etc

7. Rickettsia diseases-typhus fever,Q-fever,trench fever,scrub typhus,Dengue fever.

8. Fungal diseases-candidiasis, banalities,Ringworm etc

9. Mychotic diseases-Otomychisis,Histoplasmosis,Aetinomycosis ANOTHER CLASSIFICATION

1. Water washed diseases

• Diarrhea and dysenteries

• Scabies and other skin diseases

• Trachoma and other eye diseases

2. Water borne diseases

90 |

• Typhoid fever and paratyphoid fever

• Cholera

• Poliomyelitis

• Amoebiasis

• Hepatitis A

3. Water related diseases

• Malaria

• Schistosomiasis

• Onchocerciasis

• Etc

FACTORS CONTRIBUTING TO SPREAD OF DISEASES (DETERMINANTS OF DISEASES)

PATTERN OF COMMUNICABLE DISEASES (EPIDEMIOLOGICAL TRIAD)

91 |

Different diseases are common in different places and at different times. To understand why this is so, we need to consider the living organism of disease (agent), the people they infect (host) and the surrounding in which they live (environment)

Agent Environment

The agents need a suitable environment in which to grow and multiply and thus be able to spread and infect another host. If they are not successful in doing this they die out.

Hosts (people) are affected by their environment e.g. they may live in hot and wet climate in which there are many mosquitoes. But people can also change this environment by draining swamps, changing the vegetation and adding competing hosts such as animals. If the balance is shifted against the agent, the disease will be controlled and the number of cases will go down.

When the balance between the agent, the host and the environment is fairly constant, we tend to see approximately the same number of cases of the disease every month. When this happens the disease is said to be ENDEMIC.

When the balance is shifted in favour of the agent (organism), e.g. when many non- immune children have been born in an area since the last measles epidemic, a large number of cases of measles may occur in a short time. This is called an EPIDEMIC. Epidemic diseases occur during certain periods or seasons and cause sudden deaths and much suffering in the community.

In some parts of the country, some disease outbreaks occur only occasionally without a regular pattern. Such diseases are said to be SPORADIC in their occurrence.

• Predisposing factors are factors which create a state of susceptibility, so that the host becomes vulnerable to the agent or to necessary cause, e.g. age, sex, previous illness.

92 |

• Enabling factors are those which assist in the development of(or in recovery from)the disease, e.g. housing conditions, socio-economic status

• Precipitating factors are those which are associated with immediate exposure to the disease agent or onset of disease, e.g. drinking contaminated water, close contact with open case of pulmonary TB

• Reinforcing factors are those which aggravate an already existing disease e.g.

malnutrition, repeated exposures, etc

• Risk factor is a condition, quality or attribute, the presence of which increases the chances of an individual to have, develop or be adversely affected by a disease process. A risk factor is thus not necessarily the cause of a disease but does increase the probability that a person exposed to the factor may get the disease.

WHAT HAPPENS ONCE AN INFECTING ORGANISM ENTERS A PERSON’S BODY AND CAUSE DISEASE-THE HOST AND INFECTION

A person who is invaded by a disease causing micro-organism is called a HOST. An infection occurs when this microorganism begins to reproduce (multiply) and grow. When an organism infects a person, there are three possible stages to consider:-

• Incubation period

• Clinical infection

• Sub-clinical infection

INCUBATION PERIOD

Is the time between infection and appearance of signs and symptoms of an illness.During the incubation period the host does not realize that she/he has an infection until several days later when detectable signs and symptoms of the illness occur.

CLINICAL INFECTION

This is the period when the host develops detectable signs and symptoms of an illness.

93 |

SUB-CLINICAL INFECTION

At this stage, infection does not produce clear signs and symptoms.

It is important for you to understand these stages because people with signs and symptoms are easier to find as they come to our health facilities for treatment. But people with subclinical infections do not know they are infected and hence are a danger to other people. They are also difficult to detect in the general population without special tests.

Individuals who suffer from this stage are also likely to infect others as in the case of HIV infection which leads to AIDS after a long period. They are therefore known as CARRIERS.

An individual who develops a clinical or subclinical infection is said to be susceptible to the disease. A susceptible individual is one whose body lacks resistance to the disease.

Resistance of the body to a disease occurs due to various immunity mechanisms.

DISEASE TRANSMISSION CYCLE

Disease causing organisms are living things. Living things need somewhere to live and reproduce. This place may be an animal, insect or the human body and is known as the RESERVOIR of infection. The human being is the main reservoir of most of the communicable diseases that affect man. When an infection spread to a new host, the place, animal or human from which the organisms come from is called the source of infection. The way in which an organism leaves the source (the infected host) and passes to a new susceptible host is called the route of transmission. Each disease causing organism has particular routes which play a large part in how these organisms spread in the community. For example, some organisms are spread through water and food, while others are spread by vectors like mosquitoes and snails. The cycle through which an organism grows, multiplies and spread is called transmission cycle. In some cases, the human beings may be the only host, in which cases the infection spreads directly from person to person e.g. measles. Transmission cycle is made up of:-

• The source

• Transmission route

94 |

• Susceptible host SOURCE

This is where the disease causing organisms spread from. It could be an infected person, animal place or object. The reservoir is the source of infection.

TRANSMISSION ROUTE

The main routes of transmission are:-

✓ Direct contact e.g. sexual contact, contact with skin or mucous membranes

✓ Vectors i.eonchocerciasis , malaria

✓ Faecal-oral ,i.e. ingesting food or water contaminated with feces

✓ Airborne

Examples are

➢ Measles

➢ Smallpox

➢ Common cold

➢ Streptococci

➢ Tons line

➢ Diphtheria

➢ Whooping cough

➢ Tuberculosis

➢ Meningitis

➢ Influenza

➢ Chickenpox

➢ Mumps

✓ Tran placental (mother to fetus)

✓ Blood e.g. .transfusion, surgery, injection

✓ Contact with animals or their products

95 |

SUSCEPTIBLE HOST

An individual who has low resistance to a particular disease is said to be a susceptible host to that host. There are a number of factors which lower the body’s resistance to a disease. Some of the factors are:-

• Not having met the disease causing organisms before and therefore not having any immunity to it. For example passive immunity against measles is lost at the age of 6-12 months. Therefore if a child comes into contact with the measles virus after this age ,he or she may develop the disease

• Having a serious illness which suppresses a person’s immunity. Such people have

a high risk of developing tuberculosis

• Malnutrition.

• Certain drugs such as those used to treat cancer can lower one’s resistance to disease

• 

METHODS OF COMMUNICABLE DISEASES CONTROL/PRINCIPLES OF CONTROLLING COMMUNICABLE DISEASES IN THE COMMUNITY

Communicable diseases can be controlled and eradicated from the community. When thinking about the control of diseases it is always good to think of all the possible methods. Very often, one or two methods are more important and sometimes one or other method does not apply at all to a particular disease. The aim of control is to tip the balance against the agent. The control and eradication can be done by:-

• Attacking the source of the disease causing organism

• Interrupting the transmission route

• Protecting the susceptible host

a. ATTACKING THE SOURCE

There are various specific measures which can be used to attack the source of the infecting organism with the aim of eliminating the organism. They include:-

➢ Treatment of cases

96 |

• Treating the infected person or animal with the appropriate antibiotics that destroy the disease causing organism.

• Treating the carriers and subclinical cases after carrying on screening tests among suspected individuals or groups.

➢ Mass treatment

• When a high % age of the people is known to have a diseases. It is sometime advisable to treat everybody without checking whether individuals have the disease or not.

• Treating specific groups of persons who are at high risks of being infected(mass

treatment).This is called chemoprophylaxis

➢ Isolation

• Isolating those persons who are infected with highly infectious diseases such as Ebola, Marburg fever, Lassa fever, so as to prevent the spread of the organism to other healthy people.

➢ Reservoir control

• Treating sick animals such as cattle suffering from brucellosis, immunizing animals such as cows from anthrax and dogs from rabies, killing animals such as rats to control plague and dogs to prevent rabies, separating humans from animals.

➢ Notification & reports

• Although these do not directly affect the source. Notification is an essential means of keeping a watch (Surveillance) on the no. of new cases & thereby monitoring the effectiveness of the control programme.

• Notifying the local health authorities immediately you suspect a patient is suffering

from an infectious disease. Though this does not directly affect the source, it is an essential way of keeping watch on the number of new cases and thereby monitoring the effectiveness of the control programme. (WHO) International notification diseases is Cholera ,Teller fever, plague, Ebola e.t.c

• National ministries of Health also require notification of certain diseases in their own

countries e.g. meningococcal meningitis & acute polio.

All these are methods of controlling the reservoir.

97 |

If cases can be treated with drugs that destroy the organism, then fewer (or none) are available to spread to new hosts. The effectiveness of treatment as a control measure depends on how many of the cases in the area can be reached and whether the treatment affects the agent’s capacity to reproduce.

Treatment is an important method in the control of tuberculosis and leprosy and most sexually transmitted infections.

For treatment to be effective subclinical cases and carriers must also be treated. However, special efforts have to be made to find them first as they do not usually present with any apparent illness, e.g. subclinical infections of cholera, or asymptomatic sexually transmitted infections.

Where a high percentage of the population is known to have a disease, it is sometimes advisable to treat everybody without checking whether individuals have the disease or not. This is called mass treatment and has been used for example, in the treatment of schistosomiasis in children.

Isolation means that the person with the disease is not allowed to come into close contact with other people except those who are looking after him. Therefore the organisms cannot spread. Isolation is used to control highly infectious and serious conditions such as Ebola. (Tuberculosis cases used to be isolated but not anymore, why?).Isolation is very difficult to enforce, and has a number of disadvantages. In particular, people are frightened of being isolated and this stops them coming for treatment and so increases the spread of the disease.

b. INTERRUPTING THE TRANSMISSION ROUTE

A number of methods are used to interrupt the transmission cycle. They include:-

• Personal hygiene & behavioral changes

• Environmental sanitation

• Water and sanitation

• Vector control

• Good and adequate housing

• Food handling

98 |

• Sterilization of medical equipments and the use of sterile surgical equipments( disinfection & sterilization)

c. PROTECTING THE HOST

This is the third principle of controlling the spread of communicable diseases in the community. Any person who is not yet infected by a specific disease-causing organism is known as a susceptible host. This is because they are at risk of contracting the infection. All susceptible hosts must be protected from contracting the infection. There are various specific and general measures for protecting the host:-

Specific measures:-

• Immunization using vaccines such as the KEPI vaccines

❖ Immunization increases host resistance by strengthening the internal defenses- antibodies, killer cells, etc. It is one of the most effective methods of control for some communicable diseases. Immunization plays a critical role in the control of many diseases in Africa. For example, it was responsible for the worldwide eradication of smallpox. Diseases in Africa which are now being controlled through immunization include measles, polio, whooping cough, diphtheria, tuberculosis, tetanus, hepatitis B and influenza.

• Better Nutrition

❖ Malnourished children get infections more easily and suffer more severe complications e.g.diarrhoea. Also, infections occur during famine where people crowd together for assistance making it easy for the disease to spread and result in epidemics. .

• Chemoprophylaxis use Drugs that protect the host be used to suppress infection.

e.g.paludrine to suppress malaria parasites, tetracycline during cholera outbreaks, and cotrimazole during plague outbreaks.

• Personal protection (PPDs)

❖ The spread of some diseases may be limited by use of barrier against infection

e.g shoes to prevent dust & hookworms from soils , use of nets & insect repellant 2 prevent bites e.t.c

99 |

General measures:-

• Use of bed nets and insect repellants to prevent mosquito bites.

• Wearing shoes to prevent penetration of hookworm larvae from the soil.

• Adequate space/housing to reduce overcrowding.

• Improved nutrition.

• Adequate lighting and ventilation.

• Health education.

The most effective way of controlling communicable diseases is to use a combination of methods.

OTHER CONTROL MEASURES

There are other useful measures that can be taken to control spread of communicable diseases. Among the measures is the notification of diseases. Notification requires you to keep watch (surveillance) on the number of new cases in your area of work and to immediately inform the local health authority when you come across a patient suffering from an infectious disease. One of the main reasons for notification is to help the health authorities take measures to confirm your suspicion and to control the spread of the disease. Notification of the infectious communicable diseases is the responsibility of all health care workers. It is also a legal requirement according to the Public Health Act cap.242 sec.8 of the laws of Kenya. Some notification diseases in Kenya include:-

• Plague

• Poliomyelitis

• Anthrax

• Whooping cough(Pertusis)

• Cholera

• Diphtheria

• Trypanosomiasis

• Meningococcal meningitis

• Measles

• Tuberculosis

100 |

• Typhoid fever

• Yellow fever

• Etc

Some diseases spread so quickly that they need international control measures, they include cholera, plague and yellow fever. These diseases are reported by the Ministry of Health (MOH) to the World Health Organization (WHO).

APPLICATION OF COMMUNICABLE DISEASE CONTROL NMEASURES

The actual application of the control methods we have just discussed can be undertaken by different groups of people. These are individual and villages, dispensaries and health centers and the district and central ministry.

CONTROL MEASURES AT INDIVIDUAL AND VILLAGE LEVEL

• Completing the immunizations

• Personal hygiene

• Food hygiene and adequate nutrition

• Using bed nets and protective wear

• Abstaining from casual sex ,being faithful to one sexual partner or using condoms

• Protecting water supply and using clean water

• Digging and using pit latrines

• Controlling vectors

CONTROL MEASURES AT DISPENSARY AND HEALTH CENTRE LEVEL

The healthcare workers should support and encourage their clients and community to establish and sustain community based disease control programmes. In addition the healthcare workers should:-

• Increase immunization coverage

• Participate in vector and reservoir control

• Emphasize water protection and purification

101 |

• Inspect food ,markets and eating places

• Encourage sanitation and refuse disposal

• Promote health and prevent diseases using information ,education and communication(IEC)

• Notify diseases

CONTROL MEASURES AT DISTRICT, REGIONAL AND NATIONAL LEVEL

At this higher level, healthcare workers are responsible for:-

• Vector control schemes

• Mass communication campaigns

• Mass treatment and chemoprophylaxis

• Mass media IEC programmes

• Health registration research on disease control methods

• Emergency ,epidemiology and control teams

• Manpower training and continuing education for staff

VARIOUS METHODS OF PREVENTING DISEASES (VARIOUS LEVELS OF PREVENTING DISEASES)

1. PRIMARY PREVENTION (PRIMARY LEVEL)

a) Personal methods i.Immunization ii.Chemoprophylaxis iii.Nutrition

Iv.Personal hygiene V.Good health behavior Vi.Child spacing

b) Environmental methods

102 |

I. Safe water supply

II. Food hygiene

III. Excreta and refuse disposal IV.Disinfection and sterilization V.Reservoir and vector control Vi.Good living and working conditions

SECONDARY PREVENTION (SECONDARY LEVEL)

I. Early detection of disease by screening

Ii. Contact tracing followed by prompt and effective treatment

iii. Surveillance

TERTIARY PREVENTION (TERTIARY LEVEL)

i. Diagnosis

ii. Treatment

iii. Management

iv. Rehabilitation

DISEASE DESCRIPTION FORMAT

❖ Identify the disease (definition)

❖ Aetiological agent (causative agent )

❖ Incubation period

❖ Predisposing factors

❖ Occurrence – epidemic, endemic, sporadic form

❖ Distribution – where found localized /cosmopolitan

103 |

❖ Reservoir of service

❖ Susceptibility of resistance

❖ Mode of transmission

❖ Chemical manifestation ( signs & symptoms)

❖ Prognosis-severely (fatal) possible outcome

❖ Management of individual

❖ Prevention

MALARIA

Def: An acute infection of the blood with plasmodium parasite characterized by chills fever, pyrexia, nausea and anorexis.

Aetiological agent- A protozoan of genus plasmodium 4 species are implicated ; these are

❖ P. falciparum-12 days

❖ P. vivax-14days

❖ P.ovale-14 days

❖ P.malariae-30 days

NBIncubation period is reduced if transmission is by inoculation through blood transfusion.

Occurrence: Appear either as hypo endemic (low transmission) especially during the day season hyper endemic (some incidents) throughout.

Distribution: Equatorial & humid tropical region with low activities (16⁰c-21⁰c) Susceptibility & Resistance: All susceptible through people living in endemic region tend 2 acquire partial immunity (tolerance due to development of antibodies)

Reservoir: Man

Source: Infected female anopheline mosquito.

Pathogencity: Occurs in two phases i.e

104 |

❖ Schizogony ( sexual)

❖ Sporogony (a sexual) forms in the blood cell

1. SEXUAL FORM ( schizogony)

The mosquito picks gametocytes from the human blood during its feeding process fertilization of female & male gametocytes take place 2 form zygote they penetrate mosquito stomach wall & change into cyst which multiply & change into cyst which multiply into sporozoite , that burst through the wall enter the salivary gland.

2. A SEXUAL FORM ( Sporogony)

Sporozoites are introduced into the body by a bite of a mosquito. They enter into the liver, multiply, develop R.B.C which multiply by binary fission and burst the rest cells realizing them as gametocytes.

CLINICAL PICTURE:

1. COLD STAGE

Temp rises but the patient shivers red B.C are bursting (lasts for 1-2 hours)

2. HOT STAGE

48⁰c the skin is dough and not there be severe headache, nausea and vomiting (lasts for 3hrs)

3. SWEATING STAGE

Temp. goes down , patient sweat profusely (lasts for 1-3 days)

4. THERE IS GENERAL MALAISE, JOINT PAINS, JAUNDICE & ANAEMIA

COMPLICATION

❖ Anaemia

❖ Obstruction of capillaries

✓ Brain psychosis (insanity/ meningitis) ikesign

105 |

✓ Kidney tubular, necrosis leading to anaemia& uremia.

✓ Spleen –spleenomegaly-prognosis(p1ossible outcome) –fatality rate are high – death

MANAGEMENT

1) Chloroquin is one of the drug of choice – 4 tabs start, 2 after 6 hrs, the 2 for 3 days (however MOH kicked it out since malaria responding to it very well.

2) Comaquin

3) Fansider

4) Metakelfin

5) Quinine & Tabs

6) Amodlaquin

7) Altan

8) Dual cortex each

9) Intravascular injection

10) Coaxtem

11) Coartefam

12) AL

13) …………………

PREVENTION

  Health education on mode of spread, clinical picture & control.

 Physical measure by destruction of vectors e.g. draining stagnant water e.t.c  Mechanical methods by screening houses & use of nets.

  Chemicals – Application of larvacide& insecticides

 Chemoprophysis –Taking 2 tabs of ofcoatem or any suitable drugs a weak before visiting Malaria prone area.

  Biological method- use of natural predator to destroy vector.

First Aid.

106 |

Introduction.

First-Aid is the assistance given to a person suffering from sudden illness or injury, with care to preserved life, prevent the condition from worsening and promote recovery. It includes initial interventions in a serious condition prior to professional medical help being available.

Interventions include performing CPR(Cardiopulmonary resuscitation) while awaiting an ambulance and complete treatments for minor conditions such as applying a plaster to a cut. First-Aid is generally performed by the lay person with many people trained in providing basic levels of First-Aid and others willing to do so from acquired knowledge.

Mental Health is an extension of the concept of first aid to cover mental health.

Aims of first aid.

The key aims of first aid are;

I. Preserve life: The aim of all medical care which include first aid it to save life and minimize deaths.

II. Prevent further harm. This is also called prevent condition from worsening or danger from further injury. This covers external factors such as moving away from the cause of harm and applying pressure to stop bleeding from becoming dangerous.

III. Promote recovery. First-Aid also require trying to start the recovery process from the illness or injury and in some cases it might invoke completing a treatment such as applying plaster to a small wound.

Certain skills are considered essential to provision of First-Aid. Particularly the ABC (Airway, Breathing, Circulation.) which focuses on critical lifesaving.

Specific disciplines.

There are several types of first Aid and First-Aider which may require specific additional training. These are usually undertaken to fulfill the demands of the work or activity undertaken.

I. Aquatic/marine first aid. This is usually practiced by professional such as lifeguards. Professional marine, or in a diver rescue and covers a specific problems which may be faced after water based rescue.

II. Battlefield first aid. It takes into account the specific need of treating wounded combatants and non-combatants (person or nation engaged in fighting war.) during armed conflict.

107 |

III. Oxygen first aid. This is the provision of First-Aid under conditions where the arrival of emergency responders or the evacuation of the injured person may be delayed due to constraints of terrain, weather, and available persons or equipment. It may be necessarily to care for a person for several hours.

IV. Mental health first aid. It is taught independently of physical first aid on how to support someone experiencing mental health problems or in a crisis situation. It also involves how to identify the first signs of someone developing mental ill health and guides a person to appropriate help.

Symbols.

The internationally accepted symbol for first aid is the white cross on a green background.

Conditions that require first Aid.

I. Altitude sickness. It may begin in a susceptible people at altitude as low as 5000 can cause potentially fatal.

II. Anaphylaxis. This is a life threatening condition in which the airway can become constricted and the patient may go into shock. This reaction may be caused by allergic reactions to allergens such as insect bites. It is treated with injections of epinephrine.

III. Battlefield. It refers to treating gunshots, burns, bone fracture.

IV. Cardiac Arrest. This may lead to death unless a CPR is started within minutes. There is no time to wait for the emergency services to arrive as 92% of people die before reaching the hospital.

V. Chocking. This is blockage of airway which can result to death due to lack of oxygen if the patients trachea is not cleared. For example by Heimlich maneuver.

VI. Childbirth.

VII. Cramps. This occurs due to accumulation of lactic acid in muscles caused by either inadequate oxygenation of muscles or lack of water or salt.

VIII. Road accidents, drowning or asphyxiation.

IX. Heat stroke(hypothermia)

X. Heavy bleeding

XI. Hyperglycemia and hypoglycemia.

XII. Insects and animal bites.

108 |

XIII. Joint dislocation

XIV. Poisoning

XV. Seizures

XVI. Stroke. Temporary loss of blood in the brain.

XVII. Toothache First-Aid kit.

Many accidents can happen at home, office, school, laboratories, which require immediate attention before the patient is attend to by a doctor.

Contents of first aid.

First-Aid manual, adhesive tape, adhesive bandage, elastic bandages, a splint, antiseptic wipes, soap, antibiotic ointment, antiseptic solution (hydrogen peroxide), acetaminophen and ibuprofen, extra prescribed medication, tweezers, sharp scissors, safety pins, disposable instant cold PP, calming lotion, alcohol wipes, thermometer, tooth preservation kit, plastic and nonlatex gloves, flashlight and extra batteries, thermal shock blanket, First-Aid card (contains emergency personal information, phone number, medication, manual)

First aid is the initial assistance or treatment given to a person who is injured or suddenly becomes ill. The person who provides this help may be a first aider, a first responder, a policeman or fireman, or a paramedic or EMT. This chapter prepares you for being a first aider, psychologically and emotionally, as well as giving practical advice on what you should and should not do in an emergency situation.

The information given throughout this book will help you give effective first aid to any casualty in any situation. However, to become a fully competent first aider, you should complete a recognized first aid course and receive certification. This will also strengthen your skills and increase your confidence. The American Red Cross and the American Heart Association teach a variety of first aid courses, at different educational levels.

Aims and objectives

■ To understand your own abilities and limitations.

■ To stay safe and calm at all times.

■ To assess a situation quickly and calmly and summon the appropriate help if necessary.

■ To assist the casualty and provide the necessary treatment, with the help of others if possible.

109 |

■ To pass on relevant information to the emergency services, or to the person who takes responsibility for the casualty.

■ To be aware of your own needs.

WHAT IS A FIRST AIDER?

First aid refers to the actions taken in response to someone who is injured or has suddenly become ill. A first aider is a person who takes action while taking care to keep everyone involved safe (p.28) and to cause no further harm while doing so. Follow the actions that most benefit the casualty, taking into account your own skills, knowledge, and experience, using the guidelines set out in this book.

This chapter prepares you for the role of first aider by providing guidance on responding to a first aid situation and assessing the priorities for the casualty. There is advice on the psychological aspect of giving first aid and practical guidance on how to protect yourself and the casualty.

One of the primary rules of first aid is to ensure that an area is safe for you before you approach a casualty (p.28). Do not attempt heroic rescues in hazardous circumstances.

If you put yourself at risk, you are unlikely to be able to help casualties and could become one yourself and cause harm to others. If it is not safe, do not approach the casualty, but call 911 for emergency help.

FIRST AID PRIORITIES

Assessing an incident

When you come across an incident stay calm and support the casualty. Ask him what has happened. Try not to move the casualty; if possible, treat him in the position you find him.

■ Assess a situation quickly and calmly.

■ Protect yourself and any casualties from danger—never put yourself at risk (p.28).

■ Prevent cross-contamination between yourself and the casualty as best as possible (p.16).

■ Comfort and reassure casualties.

■ Assess the casualty: identify, as best as you can, the injury or nature of illness affecting a casualty (pp.38–53).

■ Give early treatment, and treat the casualties with the most serious (life-threatening) conditions first.

110 |

■ Arrange for appropriate help: call 911 for emergency help if you suspect seriousinjury or illness; take or send the casualty tothe hospital; transfer him into the care of ahealthcare professional, or to a higher levelof medical care. Stay with a casualty untilcare is available. HOW TO PREPARE YOURSELF

When responding to an emergency you should recognize the emotional and physical needs of all involved, including your own. You should look after your own psychological health and be able to recognize stress if it develops (pp.24–25).

A calm, considerate response from you that engenders trust and respect from those around you is fundamental to your being able to give or receive information from a casualty or witnesses effectively. This includes being aware of, and managing, your reactions, so that you can focus on the casualty and make an assessment. By talking to a casualty in a kind, considerate, gentle but firm manner, you will inspire confidence in your actions and this will generate trust between you and the casualty.

Without this confidence he may not tell you about an important event, injury, or symptom, and may remain in a highly distressed state.

The actions described in this chapter aim to help you facilitate this trust, minimize distress, and provide support to promote the casualty’s ability to cope and recover. The key steps to being an effective first aider are:

■ Be calm in your approach

■ Be aware of risks (to yourself and others)

■ Build and maintain trust (from the casualty and the bystanders)

■ Give early treatment, treating the most serious (life-threatening) conditions first

■ Call appropriate help

■ Remember your own needs

Be calm

It is important to be calm in your approach to providing first aid. Consider what situations might challenge you, and how you would deal with them. In order to convey confidence to others and encourage them to trust you, you need to control your own emotions and reactions.

People often fear the unknown. Becoming more familiar with first aid priorities and the key techniques in this book can help you feel more comfortable. By identifying your fears in

111 |

advance, you can take steps to overcome them. Learn as much as you can, for example, by enrolling in a first aid course, asking others. how they dealt with similar situations, or talking your fears through with a person you trust.

Stay in control

In an emergency situation, the body responds by releasing hormones that may cause a “fight, flight, or freeze” response. When this happens, your heart beats faster, your breathing quickens, and you may sweat more. You may also feel more alert, want to run away or feel frozen to the spot.

If you feel overwhelmed and slightly panicky, you may feel pressured to do something before you are clear about what is needed. Pause and take a few slow breaths. Consider who else might help you feel calmer, and remind yourself of the first aid priorities (opposite). If you still feel overwhelmed, take another breath and tell yourself to be calmer. When you are calm, you will be better able to think more clearly and plan your response.

The thoughts you have are linked to the way you behave and the way you feel. If you think that you cannot cope, you will have more trouble determining what to do and will feel more anxious: more ready to fight, flee, or freeze. If you know how to calm yourself, you will be better able to deal with anxiety and help the casualty.

When you give first aid, it is important to protect yourself (and the casualty) from infection as well as injury. Take steps to avoid cross-contamination—transmitting germs or infection to a casualty or contracting infection from a casualty. Remember, infection is a risk even with relatively minor injuries. It is a particular concern if you are treating a wound, because blood- borne viruses, such as hepatitis B or C and Human Immunodeficiency Virus (HIV), may be transmitted by contact with blood. In practice, the risk is low and should not deter you from carrying out first aid. The risk increases if an infected person’s blood makes contact with yours through a cut or scrape.

Usually, taking measures such as washing your hands and wearing disposable gloves will provide sufficient protection for you and the casualty. There is no known evidence of these blood-borne viruses being transmitted during resuscitation. If a face shield or pocket mask is available, it should be used when you give rescue breaths (pp.68–69 and pp.78–79).

Take care not to prick yourself with any needle found on or near a casualty, or cut yourself on glass. If you accidentally prick or cut your skin, or splash your eye, wash the area thoroughly and

112 |

seek medical help immediately. If you are providing first aid on a regular basis, it is advisable to seek guidance on additional personal protection, such as immunization. If you think you have been exposed to an infection while giving first aid, seek medical advice as soon as possible.

PROTECTION FROM INFECTION

Minimizing the risk of cross

■ Do wash your hands and wear latex-free disposable gloves (in case you or the casualty are allergic to latex). If gloves are not available, ask the casualty to dress his or her own wound, or enclose your hands in clean plastic bags.

■ Do cover cuts and scrapes on your hands with waterproof dressings.

■ Do wear a plastic apron if dealing with large quantities of body fluids, and wear glasses or goggles to protect your eyes.

■ Do dispose of all waste safely (p.18).

■ Do not touch a wound or any part of a dressing that will come into contact with a wound with your bare hands.

■ Do not breathe, cough, or sneeze over a wound while you are treating a casualty.

WHEN TO SEEK MEDICAL ADVICE

Take care not to prick yourself with any needle found on or near a casualty, or cut yourself on glass. If you accidentally prick or cut your skin, or splash your eye, wash the area thoroughly and seek medical help immediately. If you are providing first aid on a regular basis, it is advisable to seek guidance on additional personal protection, such as immunization. If you think you have been exposed to an infection while giving first aid, seek medical advice as soon as possible.

A. THOROUGH HAND-WASHING

If you can, wash your hands before you touch a casualty, but if this is not possible, wash them as soon as possible afterward. For a thorough wash, pay attention to all parts of the hands— palms, wrists, fingers and thumbs, and fingernails. Use soap and water if available, or rub your hands with alcohol gel.

HOW TO WASH YOUR HANDS

I. Wet your hands under running water. Put some soap into the palm of a cupped hand. Rub the palms of your hands together.

113 |

II. Rub the palm of your left hand against the back of your right hand, then rub the right palm on the back of your left hand.

III. Interlock the fingers of both hands and work the soap between them.

IV. Rub the back of the fingers of your right hand against the palm of your left hand, then repeat with your left hand in your right palm.

V. Rub your right thumb in the palm of your left hand, then your left thumb in the right palm.

VI. Rub the fingertips of your left hand in the palm of your right hand and vice versa. Rinse thoroughly, then pat dry with a disposable paper towel.

B. USING PROTECTIVE GLOVES

In addition to hand washing, gloves give added protection against infection in a first aid situation.

If possible, carry protective, disposable, latex-free gloves with you at all times. Wear them whenever there is a likelihood of contact with blood or other body fluids. If in doubt, wear them anyway.

Disposable gloves should be used to treat only one casualty. Put them on just before you approach a casualty and remove them as soon as the treatment is completed and before you do anything else.

When taking off the gloves, hold the top edge of one glove with your other gloved hand and peel it off so that it is inside out. Repeat with the other hand without touching the outside of the gloves.

Dispose of them in a biohazard bag (below).

Ideally, wash your hands before putting on the gloves.

Hold one glove by the top and pull it on. Do not touch the main part of the glove with your fingers.

Pick up the second glove with the gloved hand. With your fingers under the top edge, pull it onto your hand. Your gloved fingers should not touch your skin.

Always use latex-free gloves. Some people have a serious allergy to latex, and this may cause anaphylactic shock (p.223). Nitrile gloves (often blue or purple) are recommended.

C. USING PROTECTIVE GLOVES

114 |

a. DEALING WITH WASTE

Once you have treated a casualty, all soiled material must be disposed of carefully to prevent the spread of infection.

Place items such as dressings or gloves in a plastic bag—ideally a biohazard bag—and give it to the emergency services. Seal the bag tightly and label it to show that it contains clinical waste. Put sharp objects, including needles, in a plastic container known as a sharps container, which is usually red. If no sharps container is available, put used needles in a jar with a screw top and give it to the EMT for disposal.

b. DEALING WITH A CASUALTY

Casualties are often frightened because of what is happening to them, and what may happen next. Your role is to stay calm and take charge of the situation—but be ready to stand back if there is someone better qualified. If there is more than one casualty, use the primary survey (pp.44–45) to identify the most seriously injured casualties and treat in the order of priority.

DIVERSITY AND COMMUNICATION

Consider the age and appearance of your casualty when you talk to him, since different people need different responses. Respect people’s wishes; accept that someone might want to be treated in a particular way.

Communication can be difficult if a person speaks a different language or cannot hear you. Use simple language or signs or write questions down. Ask if anyone speaks the same language as the casualty or knows the person or saw the incident and can describe what happened.

BUILDING TRUST

Establish trust with your casualty by introducing yourself. Find out what the person likes to be called, and use his name when you talk to him. Crouch or kneel down so that you are at the same height as the casualty. Explain what is happening and why. You will inspire trust if you say what you are doing before you do it. Treat the casualty with dignity and respect at all times. If possible, give him choices, for example, whether he would prefer to sit or lie down and/or who he would like to have with him. Also, if possible, gain his consent before you treat him by asking if he agrees with whatever you are going to do.

Reassure the casualty

115 |

When treating a casualty, remain calm and do not do anything without explanation. Try to answer any questions he may have honestly.

SPECIAL CASE TREATING CHILDREN

You will need to use simpler, shorter words when talking to children. If possible, make sure a child’s parents or caregivers are with him, and keep them involved at all times.

It is important to establish the caregiver’s trust as well as the child’s.

Talk first to the parent/caregiver and get his or her permission to continue to treat the child. Once the parent/ caregiver trusts you, the child will also feel more confident.

LISTEN CAREFULLY

Use your eyes and ears to be aware of how a casualty responds. Listen by showing verbal and nonverbal listening skills.

■ Make eye contact, but look away now and then so as not to stare.

■ Use a calm, confident voice that is loud enough to be heard but do not shout.

■ Do not speak too quickly.

■ Keep instructions simple: use short sentences and simple words.

■ Use affirming nods and “mmms” to show you are listening when the casualty speaks.

■ Check that the casualty understands what you mean—ask to make sure.

■ Use simple hand gestures and movements.

■ Do not interrupt the casualty, but always acknowledge what you are told; for example, summarize what a casualty has told you to show that you understand.

WHEN A CASUALTY RESISTS HELP.

If someone is ill or injured he may be upset, confused, tearful, angry, and/or anxious to get away. Be sensitive to a casualty’s feelings; let him know that his reactions are understandable.

Also accept that you may not be able to help,or might even be seen as a threat. Stay at a safe distance until you have gained the person’s consent to move closer, so that he does not feel crowded. Do not argue or disagree. A casualty may refuse help, for example because he is suffering from a head injury or hypothermia. If you think a person needs something other than what he asks for, explain why. For example, you could say, “I think someone should look at where you’re hurt before you move, in case moving makes it worse.” If someone still refuses your help and you think he needs urgent medical attention, call 911 for emergency help.

116 |

A casualty has the right to refuse help, even if it causes further harm. Tell the dispatcher that you have offered first aid and have been refused. If you are worried that a person’s condition is deteriorating, observe from a distance until help arrives.

When treating a casualty

When treating a casualty, always relate to him calmly and thoughtfully to maintain trust. Think about how he might be feeling. Check that you have understood what the casualty said and consider the impact of your actions, for example, is the casualty becoming more (or less) upset, angry, and tense? A change in emotional state can indicate that a condition is worsening.

Be prepared to change your manner, depending on what a person feels comfortable with; for example, ask fewer questions or talk about something else. Keep a casualty updated and give him options rather than telling him what to do. Ask the casualty about his next-of kin or friends who can help, and help him make contact with them. Ask if you can help make arrangements so that any responsibilities the casualty may have can be taken care of.

Stay with the casualty. Do not leave someone who may be dying, seriously ill, or badly injured alone except to go to call for emergency help.

Talk to the casualty while touching his shoulderor arm, or holding a hand. Never allow a casualty to feel alone.

ENLISTING HELP FROM OTHERS

In an emergency situation you may be faced with several tasks at once: to maintain safety, to call for help, and to start giving first aid. Some of the people at the scene may be able to help. you do the following:

■ Make the area safe; for example, control traffic and keep onlookers away.

■ Call 911 for emergency help (p.23).

■ Obtain first aid equipment, for example an AED (automated external defibrillator).

■ Control bleeding with direct pressure, or support an injured limb.

■ Help maintain the casualty’s privacy by holding a blanket around the scene and encouraging onlookers to move away.

■ Transport the casualty to a safe place if his life is in immediate danger, only if it is safer to move him than to leave him where he is, and you have the necessary help and equipment (p.234).

117 |

The reactions of bystanders may cause you concern or anger. They may have had no first aid training and feel helpless or frightened themselves. If they have seen or been involved in the incident, they too may be injured and distressed. Bear this in mind if you need to ask a bystander to help you. Talk to people in a firm but gentle manner. By staying calm yourself, you will gain their trust and help them remain calm too.

CARE OF PERSONAL BELONGINGS

Make sure the casualty’s belongings are with him at all times. If you have to search belongings for identification or clues to a person’s condition (medication, for example), do so in front of a reliable witness. If possible, ask the casualty’s permission before you do this. Afterward, ensure that all of the clothing and personal belongings and medication accompany the casualty to the hospital or are handed over to the police.

KEEPING NOTES

As you gather information about a casualty, write it down so that you can refer to it later. A written record of the timing of events is particularly valuable to medical personnel.

Note, for example, the length of a period of unconsciousness, the duration of a seizure, the time of any changes in the casualty’s condition, and the time of any intervention or treatment. Hand your notes to the emergency services when they arrive, or give them to the casualty. Useful information to provide includes:

■ Casualty’s details, including his name, age and contact details

■ History of the incident or illness

■ Brief description of any injuries

■ Unusual behavior, or a change in behavior

■ Treatment—where given and when

■ Vital signs—level of response, breathing rate, and pulse (pp.52–53), if the first aider is trained

■ Medical history

■ Medication the casualty has taken, with details of the amounts taken and when

■ Next-of-kin contact details

■ Y our contact details as well as the date, time, and place of your involvement Remember that any information you gather is confidential. Never share it with anyone not involved in the casualty’s care without his agreement. Let the casualty know why you are

118 |

recording information and who you will give it to. When you are asking for such information, be sensitive to who is around and of the casualty’s privacy and dignity.

REQUESTING HELP

Further help is available from a range of sources. If help is needed, you must decide both on the type of help and how to access it. First, carry out a primary survey (pp.44–45) to ascertain the severity of the casualty’s condition. If it is not serious, explain the options and allow him to choose where to go. If a casualty’s condition is serious, seek emergency help. Throughout the book there are guidelines for choosing the appropriate level of help.

Call 911 for emergency help if the casualty needs urgent medical attention and should be transported to the hospital in an ambulance, for example, when you suspect a heart attack.

■ Take or send the casualty to a hospital.

Choose this option when a casualty needs hospital treatment, but his condition is unlikely to worsen; for example, with a finger injury. You can take him yourself if you can arrange transportation—either in your own car or in a taxi.

■ Seek medical advice. Depending on what is available in his area, the casualty should be advised to call his own physician or nurse practitioner. He would do this, for example, when he has symptoms such as earache or diarrhea.

CALLING FOR HELP

You can call for help from:

■ Emergency services, including police, fire and ambulance services, by calling 911

■ Utilities, including gas, electricity or water—the phone number will be in the telephone directory

■ Health services, including doctor, dentist, and hospital—this varies in different areas. The phone numbers will be in the telephone directory

Calls to the emergency services are free from any phone, including cell phones. On some roadways, emergency phones have been placed at regular intervals to enable people to call for help. To summon help using these telephones, pick up the receiver and your call will be answered. However, the density of these phones can vary widely by state and area. You may do better with a cell phone than these highway phones.

119 |

Keep time away from the casualty to a minimum. Ideally, tell someone else to make the call for you while you stay with the casualty.

Ask the person to confirm that the call has been made and that help is on the way. If you have to leave a casualty to call for help, first take any necessary vital action (primary survey pp.44–45). MAKING THE CALL

When you dial 911, you will be asked which service you require. If there are casualties, ask for the ambulance service (EMS); the dispatcher will alert other services if they are required.

Always remain on the telephone and let the dispatcher hang up first, because you may be given important information about what to do for the casualty while you wait, and/or asked for further information as the situation develops. If someone else makes the call, make sure that he is aware of the importance of his call and that he reports back to you after making the call.

TALKING TO THE EMERGENCY SERVICES

State your name clearly and say that you are acting in your capacity as a first aider. It is essential to provide the following:

■ Your telephone number and/or the number you are calling from.

■ The exact location of the incident; give a road name or number. It can also be helpful to mention any intersections or other landmarks in the area. In many cases your call can be traced if you are unsure of your exact location. If you are on a highway, say in which direction the vehicles were traveling.

■ The type and gravity of the emergency. For example, “Traffic accident, two cars, road blocked, three people trapped.”

■ Number, gender, and age of casualties.For example, “One man, early sixties, breathing difficulties, suspected heart attack.”

■ Details of any hazards, such as gas, toxic substances, power-line damage, or adverse weather conditions, such as fog or ice.

WHEN THE EMERGENCY SERVICES ARRIVE

Once the emergency services arrive, they will take over the care of the casualty. Tell them what has happened and any treatment given. Hand over any notes you made while attending the casualty. You may be asked to continue helping, for example, by assisting relatives or friends of the casualty while the paramedics provide emergency care.

120 |

You should also follow instructions given to you by the medical team. Remain until you are told you can go, since they may need to ask you more questions or the police may want to speak to you. Help maintain a clear and clean environment and preserve the dignity and confidentiality of those involved.

You may be asked to contact a relative.

Explain as simply and honestly as you can what has happenened and where the casualty has been taken. Do not be vague or exaggerate because this may cause unnecessary alarm.

It is better to admit ignorance than to give someone misleading information

However, the information you give may cause distress; if so, remain calm and be clear about what to do next.

THE USE OF MEDICATION

In first aid, administering medication is largely confined to relieving general aches and pains. It usually involves helping a casualty take his own medicines.

A variety of medications can be bought without a doctor’s prescription. However, you must not buy or borrow medication to administer to a casualty, or give your own.

If you advise the casualty to take any medication other than that stipulated in this manual, he may be put at risk and you could face legal action as a consequence. Whenever a casualty takes medication, it is essential to make sure that:

■ It is for the condition

■ It is not out of date

■ It is taken as advised

■ Any precautions are strictly followed

■ The recommended dose is not exceeded

■ You keep a record of the name and dose of the medication as well as the time and method of administration

REMEMBER YOUR OWN NEEDS

Most people who learn first aid gain significantly from doing so. In addition to learning new skills and meeting new people, by learning first aid you can make a real difference in peoples’ lives. Being able to help people who are ill or injured often results in a range of positive feelings. However, you may also feel stressed when you are called upon to administer first aid, and feel

121 |

emotional once you have finished treating a casualty, whatever the outcome. Occasionally, that stress can interfere with your physical and mental well-being after an incident. Everyone responds to stressful situations in different ways, and some people are more susceptible to stress than others. It is important to learn how to deal with any stress in order to maintain your own health and effectiveness as a first aider. Gaining an understanding of your own needs can help you be better prepared for future situations.

IMMEDIATELY AFTER AN INCIDENT

An emergency is an emotional experience.

Many first aiders experience satisfaction, or even elation, and most cope well. However, after you have treated a casualty, depending on the type of incident and the outcome, you might experience a mixture of the following:

■ Satisfaction

■ Confusion, worry, doubt

■ Anger, sadness, fear

You may go through what has happened again and again in your mind, so it can be helpful to talk to someone you trust about how you feel and what you did. Consider talking to someone else who was there, or who you know has had a similar experience. Never reproach yourself or hide your feelings. This is especially important if the outcome was not as you had hoped. Even with appropriate treatment, and however hard you try, a casualty may not recover.

LATER REACTIONS

Delivering first aid can lead to positive feelings because you notice new things about yourself, such as your ability to deal with a crisis.

However, occasionally, the effect of an incident on you will depend on your first aid experience as well as on the nature of the actual incident.

The majority of the incidents you will deal with will be of a minor nature and they will probably involve people you know. If you have witnessed an incident that involved a threat to life or you have experienced a feeling of helplessness, you may find yourself suffering from feelings of stress after the incident. In most cases, these feelings will disappear over time

WHEN TO SEEK HELP

If, however, you experience persistent or distressing symptoms associated with a

122 |

Stressful incident, such as nightmares and flashbacks, seek further help from someone you trust and feel you can confide in.

See your doctor or a mental health professional if you feel overwhelmed by your symptoms. You can talk through them with the professionals and together decide what is best for you. Seeking help is nothing to be embarrassed about, and it is important to overcome these feelings. This will not only help you deal with your current reactions, but it will also help you learn how to respond to situations in the future.

Talking things over

Confiding in a friend or relative is often useful. Ideally, talk to someone who was also present at the incident she may have the same feelings about it as you. If you are unable to deal with the effects of the event you were part of or witnessed, seek help from your doctor

MANAGING AN INCIDENT

The scene of any incident can present many potential dangers, whether someone has become ill or has been injured, whether in the home or outside at the scene of an incident. Before any first aid is provided you must make sure that approaching the scene of the incident does not present unacceptable danger to the casualty, or to yo or anyone else who is helping.

This chapter provides advice for first aiders on how to ensure safety in an emergency situation. There are specific guidelines for emergencies that pose a particular risk. These include fires, traffic accidents, and incidents involving electricity and drowning.

The procedures that are used by the emergency services for major incidents, where particular precautions are necessary and where first aiders may be called on to help, are also described here.

■ To protect yourself from danger and make the area safe.

■ To assess the situation quickly and calmly and summon help if necessary.

■ To assist any casualties and provide necessary treatment with the help of bystanders.

■ To call 911 for emergency help if you suspect serious injury or illness.

■ To be aware of your own needs.

ACTION AT AN EMERGENCY

In any emergency it is important that you follow a clear plan of action. This will enable you to prioritize the demands that may be made upon you, and help you decide on your best response.

123 |

The principle steps are: to assess the situation, to make the area safe (if possible), and to give first aid. Use the primary survey (pp.44–45) to identify the most seriously injured casualties and treat them in the order of priority.

ASSESSING THE SITUATIONv

Evaluating the scene accurately is one of the most important factors in the management of an incident. You should stay calm. State that you have first aid training and, if there are no medical personnel in attendance, calmly take charge.

Identify any safety risks and assess the resources available. Action for key dangers you may face, such as fire, are dealt with in this chapter, but be aware, too, of tripping hazards, sharp objects, chemical spills, and falling debris.

All incidents should be managed in a similar manner. Consider the following:

■ Safety What are the dangers and do they still exist? Are you wearing protective equipment? Is it safe for you to approach?

■ Scene What factors are involved at the incident? What are the mechanisms of the injuries (pp.42–43)? How many casualties are there? What are the potential injuries?

■ Situation What happened? How many people,are involved and what ages are they? Are any of them children or elderly?

MAKING AN AREA SAFE

The conditions that give rise to an incident may still present a danger and must be eliminated if possible. It may be that a simple measure, such as turning off the ignition of a car to reduce the risk of fire, is sufficient.

As a last resort, move the casualty to safety.

Usually specialist help and equipment is required for this.

When approaching a casualty, make sure you protect yourself: wear high-visibility clothing, gloves, and head protection if you have them. Remember, too, that a casualty faces the risk of injury from the same hazards that you face. If extrication from the scene is delayed, try to protect the casualty from any additional hazards.

If you cannot make an area safe, call 911 for emergency help before performing first aid.Stand clear until the emergency services havesecured the scene.

GIVING EMERGENCY HELP

124 |