Public Health Flashcards
What is bias?
- The results of a study do not represent the truth
- inherent limitation in design/conduct
- several tools to rate risk of bias in RCTs
What is imprecision?
- Focuses on 95% CI around best estimate of absolute effect
- Certainty lower if clinical decision likely to be different if true effects at upper end of CI
What is indirectness?
- Certainty highest when studies directly compare interventions of interest in relevant populations
- Report outcome critical for decision making
What is publication bias?
- missing evidence
- More common in:
-> observational data
-> commercial studies
What is inconsistency?
- Certainty of evidence highest when several studies show a consistent effect
What is primary vaccine failure?
Person doesn’t develop immunity from vaccine
What is a secondary vaccine failure?
Initially responds but protection wanes over time.
What are the symptoms of tetanus?
- Clostridium tetani bacteria
- toxins cause painful muscle contraction
What bacteria causes pertussis and the symptoms?
- Bordetella pertussis bacteria
- whooping cough
What causes polio and its symptoms?
- poliovirus
- bad water
- attacks nerves, then causes muscle wasting
What causes Haemophilus influenza type B and its symptoms?
- haemophilus influenza bacteria
- acute epiglottis –> swells up stopping you form breathing
What is meningococcal disease caused by and symptoms?
- Neisseria meningitides bacteria
- Meningococcal sepsis
What is your legal obligation as a doctor?
- to notify on infectious diseases
- to stop outbreak of disease
Why are these diseases notifiable?
- very scary
- horrible complications
- very infectious
- vaccine preventable
- need specific control measures
What is the role of surveillance with infectious diseases?
- Detection of any changes in a disease
- outbreak detection
- early warning
- forecasting - Track changes in disease
- extent and severity of disease
- risk factors - Allows development of interventions targeted at vulnerable groups
How do we protect the community?
- Investigate: contact tracing, partner notification, lookback exercises, etc…
- Identify and protect vulnerable persons: e.g. chemoprophylaxis, immunisation, isolation
- Exclude high risk persons or from high risk settings
- Educate, inform, raise awareness, health promotion
- Coordinate multi-agency responses
What are the 3 steps on route of disease transmission?
- Source
- pathway
- receptor
What to think about when someone is infected with scarlet fever?
- risk settings e.g. schools
- co-infections e.g. chickenpox
What factors to think about when someone is infected with typhoid fever?
- risk factors e.g. travel
- risk groups e.g. food handlers, health & care staff, young children, hygiene
What factors to think about when someone has Hep B?
- Risk factors e.g. travel, medical procedures, infected mothers, blood products
- Risk groups e.g. sex workers
What vaccines do you get at 8 weeks old?
- 6in1
- diptheria
- tetanus
- pertussis
- polio
- haemophilus influenza type b
- hep B - Meningococcal group B
- Rotavirus gastroenteritis
What vaccines are given at 12 weeks old?
- 6in1
- pneumococcal
- rotavirus
What vaccines are given at 12 weeks old?
- 6in1
- pneumococcal
- rotavirus
What vaccines are given at 16 weeks old?
- 6in1
- Men B
What vaccines are given at 1yrs old?
- Haemophilus Influenza type B (Hib) & Men C
- pneumococcal
- measles, mumps and rubella
- Men B
What vaccine is is given at 3yrs 4 months?
- 4 in 1 –> diphtheria, tetanus, pertussis, polio
- measles, mumps, rubella
What vaccine is given at 12/13 yrs old?
Human papillomavirus (HPV)
What vaccine is given at 14 yrs old?
- Tetanus, diphtheria and polio
- Men ACWY
What are the steps in a virus spreading in the population?
- sporadic case
- cluster
- outbreak
- epidemic
- pandemic
- endemic
What are some public health countermeasures?
- Hygiene
- social distancing
- isolation/quarantine
- personal protective equipment
- treatment vs prevention
- chemoprophylaxis
- vaccination
How many genera of influenza are there?
A, B and C
Why does influenza change very year?
- gene reassortment
- gene swapping (between human and avian flu virus)
- no proof reading mechanism so prone to mutation
- minor antigenic variation (antigenic drift)
How in influenza transmitted?
- aerosol (cough & sneezes)
- also hand to hand contact
Who is more likely to be affected by the flu?
Mortality risk higher in persons with underlying medical conditions:
- Chronic cardiac and pulmonary diseases
- Old age
- Chronic metabolic diseases
- Chronic renal disease
- Immunosuppressed
What are the symptoms of influenza?
- upper and/or resp tract symptoms
- fever
- headache
- myalgia
- weakness
bacterial pneumonia
What is avian influenza?
- avian pathogen can pass from birds to humans
- due to close proximity of poultry and people
How do we control avian flu?
Cull affected birds
Biosecurity and quarantine
Disinfecting farms
Control poultry movement
Vaccinate workers – seasonal influenza vaccine
Antivirals for poultry workers
Personal Protective Equipment (PPE)
Try to reduce chance of co-infection
What is pandemic flu?
- virus mutates markedly (antigenic shift)
- large proportion of population is susceptible
- virus usually jumps from one species to another
- high morbidity
- excess mortality
- social disruption
- economic disruption
What is an example of a pandemic flu?
Spanish flu 1918/19
- 40% of the worlds population became ill
What characteristics do we expect from pandemic flu?
- Short incubation period 1-4 days
- Infectious from onset of symptoms to 4-5 days after
- 10% infectious before symptom onset.
- Little warning? 2-4 weeks from first case to first introduction to UK??
- First wave last 3-5 months. Subsequent waves may be worse
- What age groups will be affected?
- Will take 4 – 6 months (or more) before vaccine available
- Effectiveness of anti-virals??
- Unknown attack rate and case fatality rate
What increases and decreases likelihood of pandemics?
Increases
- more travel
- more people
- intensive farming
(more animal contact with people & factory farming)
Decreases
- better nutrition, healthier
- better supportive care options
- vaccination
- antivirals
What are infection controls?
Hand hygiene, cough etiquette
Universal precautions and PPE (mask, apron, gown, gloves)
Surgical masks OK for non aerosol generating procedures
Segregation of patients
Reduce social contact
Flu surgeries
Environmental cleaning
What are the goals of medical optimisation?
- Improve their outcomes
- Take their medicines correctly
- avoid taking unnecessary medicines
- improve medicine safety
- reduce wastage of medicine
Define adherence.
- Patient following a doctors advise and medication prescribed
- acknowledges importance of patients belief instead of just ‘compliance’
What are the examples of non-adherence in pharmacology?
- not taking prescribed medication
- taking bigger/smaller doses than prescribed
- taking medication more/less often than prescribed
- stopping the medicine without finishing the course
- modifying treatment to accommodate other activities
- continuing with behaviours against medical advice
What are intentional and unintentional reasons to non-adherence?
Unintentional
- difficulty understanding instructions
- problems using treatment
- inability to pay
- forgetting
intentional
- patients belief about their health/condition
- beliefs about treatments
- personal preferences
What is the necessity concerns framework?
necessity beliefs = perceptions of person need for treatment
Concerns = about a range of potential adverse consequences
helps predict patient adherence
What are the impacts of good Dr patient communication?
- Better health outcomes
- Higher adherence to therapeutic regimens in patients
- Higher patient and clinician satisfaction
- Decrease in malpractice risk
Why is type 2 diabetes a public health issue?
It is preventable!!
1. increasing in prevalence
2. lack of effective global, national or local policy
3. major inequalities - higher prevalence in BME and deprived communities
What are the 3 things that trends in diabetes prevalence depend on?
Primary prevention = incidence of condition
Secondary prevention = % of incident cases diagnosed
Tertiary prevention = survival from diagnosis
How can we reduce the impact of type 2 diabetes from a public health approach?
- Identifying people at risk of diabetes - diet, sedentary job/lifestyle
- Preventing diabetes - primary prevention
- diagnosing diabetes earlier - secondary prevention
- effective management and supporting self-management - tertiary prevention
What are the 3 features of the obesogenic environment?
- Physical environment; car, TV remote, lifts
- Economic environment: e.g. cheap fast food
- sociocultural environment e.g. safety fears, family eating patterns
What are the 3 mechanisms that maintain people being overweight?
- physical/physiological - more weight, more difficult to exercise, dieting
- psychological - low self-esteem, comfort eating
- socioeconomic - cheaper food, employment, relationships
What are the effective ways of preventing diabetes?
- sustained increase in physical activity
- sustained change in diet
- sustained weight loss
Who does NICE recommend focusing on for preventing type 2 diabetes?
- focus on ethnic minority and socio-economically deprived communities at increased risk
- focus on culturally appropriate interventions (diet and activity)
What are the 3 approaches to diagnosing diabetes earlier?
- Raising awareness of diabetes and possible symptoms in the community
- Raising awareness of diabetes and possible symptoms in health professionals
- Using clinical records to identify those at risk and/or using blood tests to screen before symptoms develop
How is NHS England investing in type 2 diabetes prevention?
“Healthier You: The NHS Diabetes Prevention Programme”
Programme of lifestyle education, weight loss support, and group physical exercise
From 2016, 20,000 places available in 27 areas (including Sheffield)
National roll out by 2020, with 100,000 referrals available annually
What is the four quadrants approach to ethics?
- Medical indications
- clinical encounters, review of diagnosis and treatment options - Quality of Life
- objective of all clinical encounters is to improve, or a least address quality of life for the patient - Patient Preferences
- patient autonomy + values essential to encounter - Contextual features
-encounters include family, law, hospital policy, insurance companies etc.
What are the health impacts of climate change?
- temperature related illness or death
- air pollution
- water + food Bourne diseases
- effects of food and water shortages
What is the role of public health in climate change challenges?
- health protection
- prevention = vaccinations, food hygiene
- disaster preparedness
- community resilience
- early warning systems
- mitigation of health risks in natural disasters
- advocate for sustainable practices
What are the 3 policy recommendations to prevent alcohol use disorders?
1: Price - Make alcohol less affordable
2: Availability - licensing & import allowances
3: Marketing - limit exposure, esp.to children and young people
What are the 4 recommendations for practise to prevent alcohol use disorders?
- licensing = license to sell alcohol
- screening + brief interventions
- supporting = children + young people aged 10-15 yrs
- Referral = consider referral for specialist treatment
What policies in the UK ‘restrict choice’ to try and prevent alcohol harm?
Minimum Unit Pricing
Restriction on alcohol advertising (appeal to young people, sexual content & irresponsible or antisocial behaviour)
What campaign in the UK ‘enable choice’ to try and prevent alcohol harm?
Dry January
How is information provided to try and prevent alcohol harm?
Alcohol labelling (industry self-regulation)
Drinking guidelines
Media campaigns
What secondary prevention is there to reduce alcohol harm?
- Exploring alcohol consumption with patients
- Ask about it routinely
- Ask about it using screening questions/tools
- Think of it as an explanation for presenting symptom
- Think of it in relation to lifestyle change (violence, unemployment, depression or anxiety)
- Detect problem drinking (incl. laboratory tests – liver enzymes, macrocytosis, high carbohydrate-deficient transferrin)
- Feed back whether or not drinking is a problem
Define at risk drinking.
A pattern of drinking which brings about the risk of physical or psychological harm – Screening tools
Define harmful drinking (/alcohol abuse)
a pattern of drinking which is LIKELY TO CAUSE physical or psychological harm.
Define alcohol dependence.
Substance dependence is defined as a set of behavioural, cognitive and physiological responses that can develop after repeated substance use
(International Classification of Diseases and related health problems, ICD-10)
What screening tools are there for alcohol harm?
A Clinical Interview – a single question about heavy drinking days
FAST - Fast Alcohol Screening Test
AUDIT - Alcohol Use Disorders Identification Test
CAGE Questions
What alcohol dependence treatments are there?
Psychosocial:
Therapy – cognitive & behavioural
Social support – one to one or group
e.g. Alcoholics Anonymous
Medical/Pharmacological:
Acamprosate Calcium (Campral)
Disulfiram (Antabuse).
Nalmefene (Selincro).
Naltrexone also in drug dependence
What 3 things must consent be?
- voluntary
- informed
- made by someone with capacity
What is the Mental Capacity Act 2005?
A person must be presumed to have capacity unless it is established that he/she lacks capacity.
An act done, or a decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made in his best interests.
What are the causes of reduced capacity?
- learning disabilities
- dementia
- mental illness
- impaired consciousness
Who makes the decision if the patient lacks capacity?
- NO-ONE can give consent on behalf of another adult
- Unless Lasting Power of Attorney which specifies can consent - Independent Mental Capacity Advocate
- Should be appointed if no family/friend to advise and support patient - Doctor in charge of care usually makes the decision
What is the Deprivation of Liberty Safeguards?
DoLS an amendment to the Mental Capacity Act 2005
- protect people who do not have the mental capacity to consent to treatment e.g. live in a care home, hospital, supported living environment
- given treatment that is appropriate and in their best interests
What are the 7 domains of liberty?
- Movement
- Eating and drinking
- Washing and appearance
- living environment
- family and social life
- privacy
- healthcare
What is Gillick Competence?
Whether children below the ages of 16 years old having the understanding and intelligence to consent for themselves
What are the rules on a patient under 16 years old refusing treatment?
- parents can’t refuse treatment
- young person can refuse if competent
- involve MDT and often helpful to take legal advice
Define primary prevention
reduce prevalence of risk factors
Including role of physical activity and nutrition through life course
Define Secondary prevention
screening
[Specific conditions inc. congenital hip dislocation; osteoporosis]
Define tertiary prevention.
management of conditions to reduce impact
[Common conditions including back pain, joint pain, minor injuries]
What health prevention support is needed at different stages of life?
Maternal health – smoking, diet, vitamin D (related to infant bone density)
Child health – physical activity, diet (bone density and healthy body weight)
Adult health – injury prevention, workplace health, healthy weight/weight loss
Healthy ageing – dietary protein, calcium, vitamin D, strength and balance exercises
How does physical activity play apart in prevention and management of MSK conditions?
Prevention = ensures people have good bone health and strength, preventing them from getting conditions in the future
Management = may feel painful to exercise at first but will help them of they keep doing it
What are social determinants of health?
- good work
- our surroundings
- money + resources
- housing
- education and skills
- the food we eat
- transport
- family, friends and communities
What is medical ethics?
critical evaluation of assumptions and arguments
Inquiry into norms and values; what is good or bad, right or wrong in the context of medical practice
What is clinical truth?
- clinical truth is contextual, circumstantial and personal
- it cannot ignore objective truth
- it mustn’t be relegated to it either
Define deontology
Based on the belief that we owe a duty of care to each other
Define virtue ethics
- virtues are characteristics that promote human flourishing
- compassion, patience, kindness, fidelity
- derives from the notion that it is the character of the person that is central
- a person of good character will necessarily act in the right way
What are the pros and cons of virtue ethics?
Pros:
- centres ethics on the person and what it means to be human
- it includes the whole of a person’s life
Cons:
- doesn’t provide clear guidance on what to do in moral dilemmas
- no general agreement on what the virtues are
- changes depending on culture
What are the 5 C’s in practicing ethics?
Candour - open and honest
Consent
Capacity
Confidentiality
Communication
Define Aleatory and Epistemic.
Aleatory = chosen by chance, rather than according to plan
Epistemic = understanding knowledge given
Define teamwork
Work done by several associates with each doing a part but all subordinating personal prominence to the efficiency of the whole
What problems can arise in teamwork?
- lack of working together
- lack of leadership
- lack of effort
- lack of communication
- lack of challenge
What are the 6 components of teamwork?
- Communication / SBARR
- Leadership & followership
- Authority gradient
- Situational awareness
- Declaring an emergency
- Training together - simulation
What is the definition of health?
being in a state of complete physical , social and mental wellbeing. Not just the absence of disease.
