The practices of disease prevention at different levels and the diseases are malnutrition, STI and cancer.

Malnutrition:- “We are what we eat “ Malnutrition, dietary condition caused by a deficiency or excess of one or more essential nutrients in the diet. Malnutrition is characterized by a wide array of health problems, including extreme weight loss, stunted growth, weakened resistance to infection, and impairment of intellect. Severe cases of malnutrition can lead to death. Malnutrition is like an iceberg; remains a serious obstacle to survival, growth and development in Nepal. Malnutrition takes a variety of forms. In Nepal, the most common forms of malnutrition are protein-energy malnutrition, iodine deficiency disorder and deficiencies of iron and vitamin A. 1. Protein-energy malnutrition Current & past status of protein energy malnutrition (PEM): • According to Annual report 2062/63:- o The Nepal demographic and health survey (NDHS) conducted in 2001 showed that 50.5% of children below 5 year of age are affected by stunting (short for their age), which can be a sign of early chronic under nutrition. o Also found that 48.3% of the children are underweight (low weight for age) and 9.6% of the children below 5 years are wasted (thin for their height), an indicator of acute malnutrition. Causes of PEM: • Low birth weight(In Nepal 30-50% of children are born with LBW) • At 18 years of age: the legal age for marriage in Nepal, 40% of the girls are either pregnant or already mothers. • High workload; limited rest; lack of extra food intake and overall inadequate care and support during pregnancy • Inappropriate breastfeeding and complementary feeding: o Nearly nine out of ten children less than 2 months of age are exclusively breastfed. o Almost all mothers initiate breastfeeding and most continue to breastfeed for a long time: 40% of the mothers are still breastfeeding their 3 years old children (NDHS, 2001) o By six to seven months of age, 53% children are given breast milk and complementary feeding. 2. Iodine deficiency disorder:- Current & past status of iodine deficiency disorder (IDD): • According to Annual report 2062/63:- o Most endemic problem in Nepal; especially in Western Mountain and mid hills of Nepal during 1970s.Now, IDD is overcome in the mountain but problem in western terai due to unregulated flow of non-ionized salt from neighboring country. o Introduced a policy to fortify all edible salt with iodine since 1973 AD under universal salt iodization program. o Later in 1998, Ministry of health issued a two-child logo for the quality certification of iodized packet salt with 50 ppm iodine at production level. o Nepal micronutrient status survey (NMSS) report 1998 revealed that the MUIE (Median Urinary Iodine Excretion – biochemical indicator in IDD control program) report 1998 revealed that the MUIE among women were 114.0 mg/l, and the MUIE among school-aged children were 143.8 mg/l. According to between census household information monitoring evaluation survey 2000, there is only 63% household coverage with adequately iodized salt. Causes of IDD: • Lack of iodine in food. 3. Vitamin A deficiency: Current & past status of vitamin A deficiency (VAD): • According to Annual report 2062/63:- o According to Nepal micronutrient status survey 1998, the overall prevalence of current night blindness in women of reproductive age and pregnant women was 4.7% and 6% respectively. o While 16.7% of women showed having night blindness during their last pregnancy. o In the same survey, the prevalence of night blindness was 0.27% among 12-59 month children, and that of bitot’s spots was 0.33% among 6-59 month children. Causes of VAD: • Low intake of vitamin A from daily diets. • Restricted vitamin A absorption. • Worm infestation • Increased vitamin A requirement resulting from infectious disease. 4. Iron deficiency anaemia(IDD):- Current & past status of Iron deficiency Anaemia (IDD):- • According to Annual report 2062/63:- o Prevalence of anaemia was higher in preschool children(78%) than in women(75%). An astonishingly high rate of 90% was found in infants, 6-11 months old. o Iron supplementation during pregnancy has been a key health initiative in Nepal since 1980. According to the government policy, all pregnant women are supplied with iron tablet containing 60 mg. of elemental iron, free of cost. It is provided to all pregnant women since the beginning of second trimester of pregnancy and continued up to 45 days postpartum (225 days in total). o Ministry of health and population had approved a five-year Anemia control plan of action developed by child health division, DoHS. o In order to increase coverage and compliance of iron tablets among pregnant and postnatal mothers, the nutrition section of the child health division has been implementing the ‘Intensification of Maternal and Neonatal Micronutrient program (IMNMP)’ since 2060/61. Causes of Iron Deficiency Anaemia (IDA):- • Inadequate intake of iron from daily diets. • Inadequate absorption of dietary iron. • Infestation such as hookworms and malaria. • High requirements of iron particularly during growth and pregnancy. • Blood loss Achievement: According to Annual report 2062/63:- • The proportion of malnutrition children decreased to 8.6 from 10.5 in last fiscal year. • Vitamin A capsules were distributed to 100% targeted 6 to 59 months children. According to Annual report 2066/67:- • The proportion of malnourished children decreased to 3.77 percent from 4.67 percent in last fiscal year. • 71.91 percent of the pregnant women received the antihelmintic treatment. • Percentage of pregnant women receiving iron tablets during this FY decreased to 58.83 percent from 73.02 in last FY 2065/66. Practices of malnutrition prevention: Here I have talk prevention of given disease in three ways: 1. Action simultaneously at various level: 1. Family level: – Nutrition education to the housewife (manager of the house) to the consumption of food in the family. – Husband and the wife need to be educated on right selection of food. – Family planning and birth spacing; having small family. – Avoid the bad customs, beliefs, traditions and attitudes; some e.g. of bad customs, beliefs, traditions and attitudes: – In Gujarat, valuable foods such as dhals, leaf greens, rich and fruits are avoided by nursing mother. – Hindus do not eat beef, and Muslims pork. – Men eat first and women eat last and poorly. – Promotion of breast feeding and improvement in infant and child feeding practice. 2. Community level: – Community organization should analysis of the nutrition problem. – Community organization should conducted program like supplementary nutrition, immunization, non-formal education for the preschool age children and many others. – Maintain good sanitation of communities. – Advocate for increased home production, consumption and preservation of Vitamin A rich foods at the community level 3. National level: Country should performed following activities:- – Rural development – Increasing agricultural production – Stabilization of the population – Nutritional intervention programmes like Social Marketing Campaign – Nutritional related health activities – Increase the accessibility and market share of iodized packet salt with ‘two-child’ logo 4. International level: International organization like FAO, UNICEF, WHO, World Bank, UNDP and CARE help to those National government for solving this problem by supporting finance, manpower, equipment, supplementary food and many other. 2. Mentioning it in different level of prevention: A. Primary prevention:- – Nutritional and food hygiene education to husband and wife as well as right selection of food. – Distribution of iron, folic acid and vitamin A – Promotion of breast feeding – BCC for Changing the Dietary Practices – Development of low cost weaving food – Measures to improve family diet – Promotion of Home economics – Family planning and birth spacing – Maintaining good family environment – Immunization – Fortification of food – Strengthen the implementation of Iodized Salt Act, 2055 for regulation and monitoring of iodized salt trade to ensure that all edible salt is iodized B. Secondary prevention:- – nutrition surveillance – Growth monitoring for early diagnosis of under nutrition – Early diagnosis and treatment of infectious including diarrhea – Development the program for early dehydration of children with diarrhea – Supplementary feeding program e.g. school feeding programmes. – Regular de-worming of school and preschool children; the child should be made to eat more food at frequent interval. C. Tertiary prevention:- i. Nutrition rehabilitation service ii. Hospital treatment iii. Follow up cases 3. On the basic of different approach: Options for the prevention of malnutrition in emergencies can be classified into 11, often complementary, approaches: (1) Inclusion of nutrient-rich commodities in food assistance rations (2) Provision of fresh food items that are complementary to a general ration (3) Provision of micronutrient-fortified foods (4) Increasing the size of the general food ration to facilitate diet diversification by exchange or trade (5) Distribution of food supplementation products for home fortification (6) Distribution of micronutrient supplements (7) Promotion of home gardening and agricultural development (8) Increasing income generation and improving access to markets (9) Promotion of recommended infant feeding practices (10) Ensuring adequate health care and a healthy environment (11) Ensuring access to adequate non-food items Cancer:-  Cancer is a non-communicable diseases  It is a diseases characterized by an: • Uncontrolled growth of cell i.e., tumor formation • Ability to invade adjacent tissue and even adjacent distinct organ • The eventual death of the patient if tumor has progressed beyond stage that it can successfully removed  Mainly there are two types of tumor they are ; A. Malignant: • It is Cancer cell and one of the dangerous in comparison to benign. • This type of tumor grows rapidly increasing in size spreading to the regional lymph nodes and to the distant organ. B. Benign or Non malignant: • Benign means mild • It is not as much dangerous as malignant TYPES OF CANCER:- A. CARCINOMA: – Carcinoma is a malignant neoplasm of epithelial origin that lines the body organs like; – The nose – The colon – The penis – The breast – The urinary bladder and uterus – About 80% of all cancer cases are carcinomas. B. SARCOMA: – it is a tumorous that originates in bone, muscle, cartilage, fibrous tissues C. LEKUMIAS: – It is cancer of blood. – The abnormal cells are WBC which cannot carry out normal functions. – It helps to suppress immune system. D. Lymphomas: – Affect Lymphatic system – It Can spread to any part of the body, including the liver, bone marrow and spleen Common cancers: a. In male: - lung, stomach liver, colon, esophagus, mouth, prostate, lymphoma. b. In women: - breast, stomach, colon, cervix, lung, ovary, esophagus, liver. Current & past status of cancer:- – In Nepal , there are 60,000 people suffering from cancer – 75 percent of them are deprived of treatment owing to the lack of money. – IN Nepal most Prevalence of cancer in male is: - Lungs, oral, and liver. – In female: - cervical, Breast and lung cancer. RISK FACTOR:- Cancer has multifactorial etiology: 1. Environmental factors:  Use of Tobacco  Harmful Alcohol  Poor Dietary factors  Occupational exposure  Physical inactivity  Viruses  Parasites  Customs habits and life styles 2. Genetic factors: • It includes transference of hereditary Character from parents to offspring e.g. retinoblastoma occurs in children of same parents. WHAT CAUSES CANCER? • Physical carcinogens: such as ultraviolet and ionizing radiation; • Chemical carcinogens: such as asbestos, components of tobacco smoke (a food contaminant) and arsenic (a drinking water contaminant); • Biological carcinogens: such as infections from certain viruses, bacteria or parasites. PREVENTION AND CONTROL: • Cancer prevention is defined as active measures to decrease the incidence of cancer. • Greater than 30% of cancer is preventable via avoiding risk factors including: tobacco, overweight or obesity, low fruit and vegetable intake, physical inactivity, alcohol, sexually transmitted infections, and air pollution. • Spectrum of cancer control activities: – Prevention – Screening – Diagnosis: Staging and consistent specimen evaluation. – Palliative Care – Research – Education – Surveillance – Advocacy: Involvement on councils and boards. – Treatment • Approach to the control of cancer is through different level of prevention:- 1. Primary prevention: Advancing knowledge has increased our understanding of causative factor of some cancers and it is now possible to control these factors in the general population as well as in particular occupational groups. They include the following:  Avoiding risk factors: • Reducing the number of tobacco-induced and alcohol related cancer deaths. • Reducing more taking of fat.  Maintain Personal hygiene  Prevent from Radiation  Occupation hazards: • Measures to protect workers from exposure to industrial carcinogens should be enforced in industries.  Vaccination:- • E.g. hepatitis B vaccine prevents infection with hepatitis B virus and thus decreases the risk of liver cancer.  Foods ,drug and cosmetics  Air pollution  Treatment of precancerous lesions: • Early detection and prompt treatment of precancerous lesion is one of the cornerstones of cancer prevention.  Legislation and restrictive measures: • Control of sales promotion • Health warnings on cigarette pockets and advertisements • Restriction on smoking in public place or places of work. And many other.  Knowledge about Cancer:- • Remind the public of the early warning sign (“danger signals”) of cancer. 2. Secondary Prevention: • Cancer registration: o For assessing the magnitude of the problem and for planning the necessary services. o Basically of two types:  Hospital based registration  Population based registration • Early detection of cancer: Cancer screening is the main weapon for early detection of cancer at a pre-invasive or pre-malignant stage. • Treatment 3. Tertiary prevention  Rehabilitation  palliative care: – Palliative care service development to meet need and the provision of specialized key personnel. – It includes: o A relatively poor knowledge base among providers and the public. o A greater emphasis placed on curing than is placed on the needs of the dying and their families. o Limited access and poor coordination. o Limited capacity. o The need for more support for end-of-life issues and bereavement support. o The need for more education, training and support for volunteers. o The need for better integration with other elements of the cancer program. o The need for earlier referral. o The need for provincial standards for palliative care as well as for pain and symptom control.  Surveys of morbidity and mortality Cancer prevention at national level:- At present more than 150 general hospitals, including medical college hospitals, offers facilities for cancer treatment by surgery, radiotherapy and chemotherapy. The regional cancer centers have the following function:- 1. Diagnosis, treatment and follow up 2. Surveys of morbidity and mortality 3. Training of personnel, both medical and paramedical 4. Prevention measures with emphasis on mass examination, health education and industrial hygiene. STD (Sexual Transmitted disease):- “Women and infants disproportionately bear the long term consequences of STDs.” --Centers for Disease Control Some fact about it: • Venereal disease • Recent analyses show that STDs collectively rank among the five most important causes of years of healthy productive life lost in developing countries. • A group communicable disease transmitted predominantly by sexual contact. It is prevented by the use of condoms. • Age:- Adult and adolescents • Sex:- male > female • Marital status: - single/divorced/separated persons. • Social: - prostitution, Broken homes, sexual disharmony, easy money travel and urbanization. Although there are over 25 diseases spread primarily through sexual activity, this focuses on some of primary public health importance. CHLAMYDIA • Chlamydia is a bacterial disease that can be cured with antibiotics. • If untreated, chlamydia is a major cause of pelvic inflammatory disease (PID) in women, which may lead to ectopic pregnancy, chronic pelvic pain, and infertility. • Men are more likely than women to have symptoms. Left untreated, chlamydia may also cause sterility in men. • Chlamydia infection in pregnant women is of particular concern because it may lead to preterm birth, eye infections or pneumonia in a newborn. GONORRHEA • Gonorrhea is a bacterial disease that can be cured with antibiotics. • Though not all infected individuals show symptoms, about 50 percent of women with gonorrheal infections will have symptoms of an abnormal vaginal discharge or painful urination. • Men usually have a discharge from their penis and painful urination that may be severe. • The bacteria may also cause eye infection, sore throat, or rectal infection, depending on where the bacteria are introduced into the body. • If untreated, gonorrhea can lead to pelvic inflammatory disease (PID) in women, which can result in infertility, ectopic pregnancy and chronic pelvic pain. • The most common complication in men is epididymitis, an infection starting near the testicles. HIV/AIDS • Acquired Immunodeficiency Syndrome (AIDS) is caused by infection with human immunodeficiency virus (HIV), a retrovirus that attacks the immune system and causes a progressive depletion of CD4+ T-lymphocytes, which are crucial for immune function. • HIV can be transmitted when blood, semen, vaginal fluids, or breast milk from an infected person enters the body of an uninfected person. HIV must get into the bloodstream or body in order to cause infection. • Transmission most often occurs during unprotected sex or during injection drug use when equipment is shared. Also, an infected woman who becomes pregnant can transmit HIV to her baby during pregnancy or during birth. • A person infected with HIV can transmit it, whether or not they appear sick, have an AIDS diagnosis, or are successfully treating their infection with antiretroviral drugs. • Without effective treatment, the resulting immunodeficiency causes susceptibility to opportunistic infections and malignancies; immunodeficiency becomes more severe over time and usually ends in death. • Developments in HIV treatment have considerably improved the prognosis for patients with HIV infection, but the side effects of these drugs and the development of resistance to these drugs continue to be problematic. • Some facts:- o Nepal falls in concentrated HIV epidemic category. o Nepal has developed a national strategy (2002-06) for its prevention. o 1 person is infected by AIDS every 10 second. o 5 millions are infected with HIV each year. o HIV infection is highest in heterosexual workers followed by intravenous drug user. o HIV accounts for highest number of death by any single infectious agent. o WHO 3 by 5 target: treat 3 million infected people by HAART by the end of 2005 A.D SYPHILIS • Syphilis infection is caused by the spirochete Treponema pallidum (a type of bacteria). • Syphilis is divided into four disease stages—primary, secondary, early latent and late/late latent. T. pallidum is transmitted through direct contact with lesions of primary or secondary syphilis or from an infected mother to her fetus. • Untreated syphilis is infectious during the first three stages. Untreated late or late latent syphilis may cause damage to the central nervous system, heart or other organs. Similar to other genital ulcer diseases, syphilis can facilitate the transmission of HIV. • The syphilis bacterium can infect the baby of a woman during her pregnancy. • Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth or of giving birth to a baby who dies shortly after birth. • An infected baby may be born without signs or symptoms of disease, but if not treated immediately, the baby may develop serious problems such as developmental delay or seizures. • Death may also occur in rare cases. Practices of STI prevention at different levels in Nepal: To effectively prevent and treat STDs is an enormous challenge. Unlike other communicable diseases, prevention and treatment of STDs naturally involves a discussion of human sexual behaviors. This is a sensitive issue in the public or private area. Yet, these discussions are necessary because the long-term consequences of contracting an STD can be very serious. For instance, some STDs can be passed from mother to baby during childbirth and certain STDs put individuals at greater risk for sterility, pelvic inflammatory disease (PID), and cervical cancer. Therefore, providing effective prevention and treatment options is critical regardless of the challenge. There are other issues that contribute to problems in treating STDs. According to the Centers for Disease Control and Prevention report Healthy People 2010; groups with the highest rates of STDS are often the same groups in which access to health care is the most limited. Some who does seek diagnosis and treatment may travel outside their county of residence to be treated and may choose to use an inaccurate name or address. Thus sexual contact tracing and partner notification may be incomplete, leading to further undiagnosed and untreated cases. Lapses in reporting by health care providers and labs also occur. To further complicate the ability to treat STDs, some individuals do not exhibit any symptoms of certain infections. Despite the challenges associated with STDS, great strides have been made. For instance, sex education, using condoms correctly and consistently, risk reduction counseling, as well as screening and treatment of high risk populations have all been shown to be effective in encouraging more responsible sexual behavior, thus preventing STDs. Working prevention on different levels means addressing all these factors through multiple approaches: individual, couple/family, community, medical and legal. 1. Individual level: • change risky behavior • A randomized trial of an individually-based counseling intervention for men who have sex with men. • Recognized that different men experience different individual, interpersonal and situational factors associated with risk. The program tailored the intervention to each man’s needs. • Counseling modules used motivational interviewing to assess risk behavior, enhance sexual communication, understand substance use and recognize triggers to unsafe sex. • Reported condom use increased in all groups, with significantly greater protection among those in interactive counseling 2. couple/family level • offers comprehensive in-home services to families affected by STDs disease i.e. HIV, substance abuse, sexual abuse and mental illness • Program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. • Helping children deal with anger and resentment towards their parents lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. • Supporting each family member is key to breaking the cycle of dysfunction in the families. • Promote safer sexual behaviors for both members of a couple can also be important. • Relationship-based intervention for women in a heterosexual relationship. Communication, negotiation and how gender roles affect relationship dynamics. Project Connect helped decrease risky behaviors for couples receiving the intervention together and for couples where the woman attended alone. 3. community level • Promoted a norm of safer sex among young gay men through a variety of social, outreach and small group activities designed and run by young men themselves. • A community-level intervention with ethnically-diverse adolescents living in low-income housing, uses skills training, modeling, peer norm and social reinforcement to reduce sexual risk. • Using social events and peer leaders nominated for training and team building, the program attracted neighborhood youth. • Workshops for parents were also offered. • The community intervention was shown to be more effective in delaying onset of first intercourse than education or skills building only 4. medical level • Antiretroviral drugs used to treat STDs disease i.e. HIV have also been used to help prevent mother to child transmission (MTCT) of HIV, and to prevent transmission after accidental exposures (post-exposure prophylaxis or PEP). • Neither of these approaches completely prevents transmission, but MTCT can reduce the risk of transmission by one half to two-thirds. Similarly, because antiretroviral drugs can greatly reduce the viral load in HIV+ persons, it is possible that widespread use could decrease the sexual transmission of HIV. • Hospital community-based prevention organizations to provide an integrated care model for youth with and at high risk for STDs infection • Offered a general medical clinic for youth and psychosocial services such as counseling and case management. • Peer educators also conducted extensive street outreach where high-risk youth congregate • program developed a computerized referral system for local youth services available on the Internet 5. policy/legal level • STDs infection is closely linked to and often fueled by structural factors such as poverty, discrimination and lack of power for women. • Promotes self-sufficiency, community safety and youth advocacy among young women aged 14-18 who are involved in the juvenile justice, foster care systems and/or have lived on the streets. • Provides employment, leadership and training for young women to educate others in their community. • Equipped with the knowledge and opportunity to train others, young women are more likely to incorporate these skills into their own lives. • Political and legislative factors can also hamper STDs prevention. For example, there is currently a ban on federal funding for needle exchange programs in the US. Connecticut addressed the problem of access to clean needles through a program that cost the state nothing and was highly effective. A partial repeal of needle prescription and drug paraphernalia laws resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Needle sharing dropped from 52% before the new laws to 31% after implementation, street purchase fell from 74% to 28%, and pharmacy purchase rose from 19% to 78%. Approach to the control of STI is through different level of prevention: 1. Primary prevention: – Promotion of safer sexual behavior – Provision of condom at affordable – Making the condom accessible – Reduce rates of partner – supportive care to promote and maintain hygiene and nutrition – Social support, including information and referral to support groups, welfare services and legal advice. – A home-based care system, to which people with advanced HIV infection/ AIDS-related illnesses can be discharged from inpatient care, should be established early in refugee situations. – funding for STD-related services – counseling about the disease – Legislature – Empower women – Increase the number of Voluntary Counseling and Testing (VCT) services – Increases antiretroviral treatment programme – Economic and social policies – Educational and employment opportunities for girls – Improved health care service – behavioral change communication for MARPs (FSW, Clients, MSM) and ARPs (prison, Uniform services, youths and adolescents); harm reduction programs (IDUs and HDUs) – expansion and scaling up of the programs for safe migration and mobility – enhance non-discriminatory practices affecting marginalized and most at risk populations 2. Secondary prevention: – Promotion of health care seeking behavior – The provision of accessible, effective and acceptable service. – Screening of blood and its products – Contact tracing – Cluster testing 3. Tertiary prevention – Rehabilitation – Surveys of morbidity and mortality – Hospital treatment – Follow up cases References: – K.PARK, park’s textbook of preventive and social medicine,19th edition feb,2007 – Google search – Annual report of 2062/63 and 2066/67