HEALTHY PEOPLE

1. HEALTHY PEOPLE Promoting health and preventing disease

2. What do we need to learn ? The GP should be able to demonstrate an understanding of: The epidemiology of problems presenting in primary care The risk factors for disease including alcohol and substance abuse, accidents, child abuse, diet, exercise, genetics, occupation, social deprivation and sexual behaviour. The principles of prevention and preventative strategies The principles of immunisation and vaccination, and the UK’s immunisation programmes The benefits and risks of immunisation and vaccination in order to reassure parents effectively The benefits and risks of screening programmes The importance of excellent communication and effective teamwork, the role of the public health specialist how to access specialist public health advice The structure of the healthcare system and the function of primary care within the wider NHS The principles of health surveillance.

3. FEELING OVERWELMED ?? Sounds complicated !

4. Take a Step Wise Approach ….. Epidemiology Risk factors quiz New curriculum /domains Immunisation Screening Access public health

5. Epidemiology in Primary Care The application of epidemiological principles and methods to the study of health problems encountered in primary care, including their aetiology, prevention and diagnosis, and with a view to improving their management. Most clinical research has focused on the aetiology and management of defined diseases, or their associated risk factors. Comparatively little research has examined the epidemiology of symptoms themselves. Symptoms presented to primary care practitioners are undifferentiated, multifactorial in origin, diverse in spectrum and frequently of short duration.

6. Epidemiology in Primary Care • Often only a small proportion of presented symptoms can be attributed to physical or psychological disease, even after detailed investigation. • For example, in a study of primary care attendees in North America, 15% had an identifiable organic cause for their presenting symptoms, 10% a psychological explanation and 75% an unknown cause. • Much of the work of primary care practitioners involves the management of symptoms rather than discrete, well-defined diagnoses, especially when treatments are often independent of any specific attributable diagnostic labels used (as, for example, with most back pain).

7. Epidemiology in Primary Care Primary care epidemiology is needed to describe: the incidence, prevalence, severity and natural history (duration, remission and recurrence) of symptoms and signs, and of defined illnesses occurring in the community. An understanding of how these problems vary among different groups within the community (e.g. by age, gender, socio-economic status, ethnicity, place of residence); and how these problems cluster or relate to each other. The long-term continuous nature of primary care, often to whole families, highlights both the need for, and opportunities available, to consider the complex genetic, physical, psychological, social and cultural influences on the onset and natural history of common symptoms and illnesses.

8. Epidemiology in Primary Care Knowledge about the natural history of symptoms can inform the development of effective evidence-based interventions, for instance leaflets about cough that reduce re-consultation rates. Understanding of the psycho-social factors associated with beliefs about back pain and its primary care management, has led to public health education campaigns that reduce work-related absenteeism and improve beliefs, effects that remain apparent after three years. Chronic pain is an example of a common, disabling condition whose epidemiology was, until recently, only understood through hospital clinic attendees. These patients represent a small, atypical proportion of all those experiencing the problem in the community, with very different levels of pain severity, duration and aetiological factors. Recent primary care-based research has provided better understanding of the prevalence and determinants of chronic pain in the community, offering new opportunities to target potentially useful interventions in primary care (including more efficient secondary care referral).

9. Take a common scenario …. Frustrated patient waiting operation and told cannot be done until BP control improved. How can you positively influence this patient in order to improve her health and prevent disease ? Run through this case in small groups and consider all the RCGP domains of competence.

10. Varicella zoster risk in pregnancy. 19 week pregnant teacher exposed to chicken pox 1 week ago and is not immune herself to this disease. She attends asking you should she be concerned and do you need to take any action ?

11. How do you tackle this ? Gain information from Green Book . VZIG is recommended for VZ antibody-negative pregnant contacts exposed at any stage of pregnancy, providing VZIG can be given within ten days of contact. However, when supplies of VZIG are short, issues to pregnant women may be restricted. Clinicians are advised to check availability of VZIG. Ring HPA – Leeds and speak to a clinician who authorises the immunoglobulin supply.

12. Varicella zoster risk in pregnancy. Those with a negative history must be tested for VZ antibody before VZIG is given . The outcome in pregnant women is not adversely affected if administration of VZIG is delayed up to ten days after initial contact. There is still time to test for VZ antibody even when the woman presents relatively late after contact. The majority of adults and a substantial proportion of children without a definite history of chickenpox will be VZ antibody positive. One UK study found that 11% of children aged 1 to 5 years, 37% aged 6 to 16 years and 89% of adults given VZIG on the basis of a negative history of chickenpox were VZ antibody positive.

13. Next scenario 26 year old attends for a consultation about her sore throat but you can see that she has not has a cervical smear yet and has defaulted from two invitations. How do you address this ? Does cervical screening fulfil Wilson’s criteria ?

14. CRITERIA FOR SCREENING • These are defined by the WHO as follows: • The condition screened for should be an important one. • There should be an acceptable treatment for patients with the disease. • The facilities for diagnosis and treatment should be available. • There should be a recognised latent or early symptomatic stage. • There should be a suitable test or examination which has few false positives - specificity - and few false negatives – sensitivity. • The test or examination should be acceptable to the population. • The cost, including diagnosis and subsequent treatment, should be economically balanced in relation to expenditure on medical care as a whole.

15. Pertusis Risk to Neonates Telephone consultation Pregnant patient has been called to have a pertusis vaccination in her last trimester but is really anxious about it and wants your advice. She has already declined an influenza vaccine but is actually now unsure what to do.

16. Pertusis Risk to Neonates There has been a considerable increase in pertussis activity in the UK starting in mid-2011. The current national outbreak is the largest seen in the UK for over a decade with a total of 4791 cases confirmed so far this year in England and Wales. The greatest numbers of cases are in adolescents and young adults but the highest rates are in infants less than three months of age. The latter are at highest risk of complications and death and are too young to be protected through routine vaccination programmes. There have been nine deaths in England up to 1st September this year – all in infants below the age of vaccination.

17. Pertusis Risk to Neonates A recent rise in whooping cough has been reported from a number of other countries, including the USA where deaths in infants have also been seen. In June 2011, the US Advisory Committee on Immunisation Practices recommended that pregnant women who have not been previously boosted as adults are offered a dose of pertussis containing vaccine.

18. Pertusis Risk to Neonates The Joint Committee on Vaccination and Immunisation (JCVI) has agreed that a temporary programme of immunisation of women in later stages of pregnancy be implemented. The purpose of the programme is to boost antibodies in the vaccinated women in late pregnancy, so that pertussis specific antibodies are passed from the mother to her baby. This aims to protect the infant before routine immunisation can be started at eight weeks of age. The committee has reviewed the epidemiology of the disease and the safety and effectiveness of the proposed approach. The committee was convinced that vaccinating pregnant women is likely to be the most effective strategy to provide protection to newborn infants and that there is no evidence of risk to the mother or her baby. However, while providing vital protection for infants, this programme will not have any effect on transmission of pertussis across the population.

19. Pertusis Risk to Neonates Vaccination against influenza is also recommended for all pregnant women and pertussis vaccination can be given at the same time. However, vaccination against influenza should not be delayed to be given alongside the pertussis vaccination. Where influenza vaccination has been given before 28 weeks of pregnancy, pertussis vaccine should be given separately after 28 weeks.

20. What next ? Read up on common childhood immunisations Principles of health surveillance Any questions ????