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

Bioterrorism

Introduction:- Bioterrorism is terrorism involving the intentional release or dissemination of biological agents. These agents are bacteria, viruses, or toxins, and may be in a naturally occurring or a human-modified form. For the use of this method in warfare, see biological warfare. A bioterrorism attack is the deliberate release of viruses, bacteria, toxins or other harmful agents used to cause illness or death in people, animals, or plants. These agents are typically found in nature, but it is possible that they could be mutated or altered to increase their ability to cause disease, make them resistant to current medicines, or to increase their ability to be spread into the environment. Biological agents can be spread through the air, water, or in food. Terrorists tend to use biological agents because they are extremely difficult to detect and do not cause illness for several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread from person to person and some, like anthrax, cannot. Bioterrorism is an attractive weapon because biological agents are relatively easy and inexpensive to obtain, can be easily disseminated, and can cause widespread fear and panic beyond the actual physical damage they can cause.Military leaders, however, have learned that, as a military asset, bioterrorism has some important limitations; it is difficult to employ a bioweapon in a way that only the enemy is affected and not friendly forces. A biological weapon is useful to terrorists mainly as a method of creating mass panic and disruption to a state or a country. However, technologists such as Bill Joy have warned of the potential power which genetic engineering might place in the hands of future bio-terrorists. The use of agents that do not cause harm to humans but disrupt the economy have been discussed.[A highly relevant pathogen in this context is the foot-and-mouth disease (FMD) virus, which is capable of causing widespread economic damage and public concern (as witnessed in the 2001 and 2007 FMD outbreaks in the UK), whilst having almost no capacity to infect humans. History Early use Biological terrorism dates as far back as Ancient Rome, when faeces were thrown into faces of enemies. This early version of biological terrorism continued on into the 14th century where the bubonic plague was used to infiltrate enemy cities, both by instilling the fear of infection in residences, in hopes that they would evacuate, and also to destroy defending forces that would not yield to the attack. The use of disease as a weapon in this stage of history exhibited a lack of control aggressors had over their own biological weapons. Primitive medical technology provided limited means of protection for the aggressor and a battle's surrounding geographical regions. After the battle was won, the inability to contain enemies who escaped death led to widespread epidemics affecting not only the enemy forces, but also surrounding regions' inhabitants. Due to the use of these biological weapons, and the apparent lack of medical advancement necessary to defend surrounding regions from them, widespread epidemics such as the bubonic plague quickly moved across all of Europe, destroying a large portion of its population. The victims of biological terrorism in fact became weapons themselves. This was noted in the Middle Ages, but medical advancements had not progressed far enough to prevent the consequences of a weapons use. Over time, biological warfare became more complex. Countries began to develop weapons which were much more effective, and much less likely to cause infection to the wrong party. One significant enhancement in biological weapon development was the first use of anthrax. Anthrax effectiveness was initially limited to victims of large dosages. This became a weapon of choice because it is easily transferred, has a high mortality rate, and could be easily obtained. Also, variants of the anthrax bacterium can be found all around the world making it the biological weapon of choice in the early 19th century. Another property of anthrax that helped fuel its use as a biological weapon is its poor ability to spread far beyond the targeted population. Anthrax could not be spread from person to person. 20th century By the time World War I began, attempts to use anthrax were directed at animal populations. This generally proved to be ineffective. Shortly after the start of World War I, Germany launched a biological sabotage campaign in the United States, Russia, Romania, and France. At that time, Anton Dilger lived in Germany, but in 1915 he was sent to the United States carrying cultures of glanders, a virulent disease of horses and mules. Dilger set up a laboratory in his home in Chevy Chase, Maryland. He used stevedores working the docks in Baltimore to infect horses with glanders while they were waiting to be shipped to Britain. Dilger was under suspicion as being a German agent, but was never arrested. Dilger eventually fled to Madrid, Spain, where he died during the Influenza Pandemic of 1918. In 1916, the Russians arrested a German agent with similar intentions. Germany and its allies infected French cavalry horses and many of Russia’s mules and horses on the Eastern Front. These actions hindered artillery and troop movements, as well as supply convoys. American biological weapon development began in 1942. President Franklin D. Roosevelt placed George W. Merck in charge of the effort to create a development program.[8] These programs continued until 1969, when by executive order President Richard Nixon shut down all programs related to American offensive use of biological weapons. US President Richard M. Nixon announced his new policy on biological warfare at a press conference in the Roosevelt Room of the White House on November 25, 1969. “Biological weapons have massive, unpredictable, and potentially uncontrollable consequences,” he declared. “They may produce global epidemics and impair the health of future generations.” He then stated that, in recognition of these dangers, the United States had decided to destroy its entire stockpile of biological agents and confine its future biological research program to defensive measures, such as vaccines and field detectors.As the 1970s passed, global efforts to prevent the development of biological weapons and their use were widespread. On August 10, 1972, President Richard M. Nixon formally transmitted the Biological Weapons Convention to the United States Senate for ratification. In his transmittal, he states: "I am transmitting herewith, for the advice and consent of the Senate to ratification, the Convention on the Prohibition of the Development, Production, and Stockpiling of Bacteriological (Biological) and Toxin Weapons, and on their Destruction, opened for signature at Washington, London and Moscow on April 10, 1972. The text of this Convention is the result of some three years of intensive debate and negotiation at the Conference of the Committee on Disarmament at Geneva and at the United Nations. It provides that the Parties undertake not to develop, produce, stockpile, acquire or retain biological agents or toxins, of types and in quantities that have no justification for peaceful purposes, as well as weapons, equipment and means of delivery designed to use such agents or toxins for hostile purposes or in armed conflict. In 1972 police in Chicago arrested two college students, Allen Schwander and Stephen Pera, who had planned to poison the city's water supply with typhoid and other bacteria. Schwander had founded a terrorist group, "R.I.S.E.", while Pera collected and grew cultures from the hospital where he worked. The two men fled to Cuba after being released on bail. Schwander died of natural causes in 1974, while Pera returned to the U.S. in 1975 and was put on probation. Since that time, efforts to use biological warfare has been more apparent in small radical organizations attempting to create fear in the eyes of large groups. Some efforts have been partially effective in creating fear, due to the lack of visibility associated with modern biological weapon use by small organizations. 1984 - USA - Rajneeshee bioterror attack In Oregon in 1984, followers of the Bhagwan Shree Rajneesh attempted to control a local election by incapacitating the local population. This was done by infecting salad bars in 11 restaurants, produce in grocery stores, doorknobs, and other public domains with Salmonella typhimurium bacteria in the city of The Dalles, Oregon. The attack infected 751 people with severe food poisoning. However, there were no fatalities. This incident was the first known bioterrorist attack in the United States in the 20th century.[12] 1993 - Japan - Aum Shinrikyo anthrax release in Kameido In June 1993 the religious group Aum Shinrikyo released anthrax in Tokyo. Eyewitnesses reported a foul odor. The attack was a total failure, infecting not a single person. The reason for this, ironically, is that the group used the vaccine strain of the bacterium. The spores recovered from the attack showed that they were identical to an anthrax vaccine strain given to animals at the time. These vaccine strains are missing the genes that cause a symptomatic response.[13] 21st century 2001 - USA - Anthrax Attacks In September and October 2001, several cases of anthrax broke out in the United States in the 2001 anthrax attacks, caused deliberately. Letters laced with infectious anthrax were delivered to news media offices and the U.S Congress. The letters killed 5. Tests on the anthrax strain used in the attack pointed to a domestic source, possibly from the biological weapons program. Still the attacks provoked efforts to define biodefense and biosecurity, where more limited definitions of biosafety had focused on unintentional or accidental impacts of agricultural and medical technologies. Bioterrorism Agent Categories Bioterrorism agents can be separated into three categories, depending on how easily they can be spread and the severity of illness or death they cause. Category A agents are considered the highest risk and Category C agents are those that are considered emerging threats for disease. Category A These high-priority agents include organisms or toxins that pose the highest risk to the public and national security because: • They can be easily spread or transmitted from person to person • They result in high death rates and have the potential for major public health impact • They might cause public panic and social disruption • They require special action for public health preparedness. Category B These agents are the second highest priority because: • They are moderately easy to spread • They result in moderate illness rates and low death rates • They require specific enhancements of CDC's laboratory capacity and enhanced disease monitoring. Category C These third highest priority agents include emerging pathogens that could be engineered for mass spread in the future because: • They are easily available • They are easily produced and spread • They have potential for high morbidity and mortality rates and major health impact. Planning and response Planning may involve the development of biological identification systems. Until recently in the United States, most biological defense strategies have been geared to protecting soldiers on the battlefield rather than ordinary people in cities. Financial cutbacks have limited the tracking of disease outbreaks. Some outbreaks, such as food poisoning due to E. coli or Salmonella, could be of either natural or deliberate origin. Preparedness Biological agents are relatively easy to obtain by terrorists and are becoming more threatening in the U.S., and laboratories are working on advanced detection systems to provide early warning, identify contaminated areas and populations at risk, and to facilitate prompt treatment. Methods for predicting the use of biological agents in urban areas as well as assessing the area for the hazards associated with a biological attack are being established in major cities. In addition, forensic technologies are working on identifying biological agents, their geographical origins and/or their initial son. Efforts include decontamination technologies to restore facilities without causing additional environmental concerns. Early detection and rapid response to bioterrorism depend on close cooperation between public health authorities and law enforcement; however, such cooperation is currently lacking. National detection assets and vaccine stockpiles are not useful if local and state officials do not have access to them. Biosurveillance In 1999, the University of Pittsburgh's Center for Biomedical Informatics deployed the first automated bioterrorism detection system, called RODS (Real-Time Outbreak Disease Surveillance). RODS is designed to draw collect data from many data sources and use them to perform signal detection, that is, to detect the a possible bioterrorism event at the earliest possible moment. RODS, and other systems like it, collect data from sources including clinic data, laboratory data, and data from over-the-counter drug sales.In 2000, Michael Wagner, the codirector of the RODS laboratory, and Ron Aryel, a subcontractor, conceived of the idea of obtaining live data feeds from "non-traditional" (non-health-care) data sources. The RODS laboratory's first efforts eventually led to the establishment of the National Retail Data Monitor, a system which collects data from 20,000 retail locations nation-wide. On February 5, 2002, George W. Bush visited the RODS laboratory and used it as a model for a $300 million spending proposal to equip all 50 states with biosurveillance systems. In a speech delivered at the nearby Masonic temple, Bush compared the RODS system to a modern "DEW" line (referring to the Cold War ballistic missile early warning system). The principles and practices of biosurveillance, a new interdisciplinary science, were defined and described in the Handbook of Biosurveillance, edited by Michael Wagner, Andrew Moore and Ron Aryel, and published in 2006. Biosurveillance is the science of real-time disease outbreak detection. Its principles apply to both natural and man-made epidemics (bioterrorism). Data which potentially could assist in early detection of a bioterrorism event include many categories of information. Health-related data such as that from hospital computer systems, clinical laboratories, electronic health record systems, medical examiner record-keeping systems, 911 call center computers, and veterinary medical record systems could be of help; researchers are also considering the utility of data generated by ranching and feedlot operations, food processors, drinking water systems, school attendance recording, and physiologic monitors, among others. Intuitively, one would expect systems which collect more than one type of data to be more useful than systems which collect only one type of information (such as single-purpose laboratory or 911 call-center based systems), and be less prone to false alarms, and this appears to be the case. In Europe, disease surveillance is beginning to be organized on the continent-wide scale needed to track a biological emergency. The system not only monitors infected persons, but attempts to discern the origin of the outbreak. Researchers are experimenting with devices to detect the existence of a threat: • Tiny electronic chips that would contain living nerve cells to warn of the presence of bacterial toxins (identification of broad range toxins) • Fiber-optic tubes lined with antibodies coupled to light-emitting molecules (identification of specific pathogens, such as anthrax, botulinum, ricin) New research shows that ultraviolet avalanche photodiodes offer the high gain, reliability and robustness needed to detect anthrax and other bioterrorism agents in the air. The fabrication methods and device characteristics were described at the 50th Electronic Materials Conference in Santa Barbara on June 25, 2008. Details of the photodiodes were also published in the February 14, 2008 issue of the journal Electronics Letters and the November 2007 issue of the journal IEEE Photonics Technology Letters. The United States Department of Defense conducts global biosurveillance through several programs, including the Global Emerging Infections Surveillance and Response System. Response to bioterrorism incident or threat Government agencies which would be called on to respond to a bioterrorism incident would include law enforcement, hazardous materials/decontamination units and emergency medical units. The US military has specialized units, which can respond to a bioterrorism event; among them are the US Marine Corp's Chemical Biological Incident Response Force and the U.S. Army's 20th Support Command (CBRNE), which can detect, identify, and neutralize threats, and Objective of the study General objective To analysis of Bioterrorism in public health aspects Specific objective • To explain about public health aspect on Bioterrorism in global context • To describe about the challenges of Bioterrorism. Methodology For collection of data the tools used are internet search, library search, reference books. The collected information was analyzed and compiled. For these procedures many software used are Internet Explorer, Adobe Reader, Ms. Office, etc. Result:- • Definition of Terrorism o ‘Terrorism’ - derives from the Latin ‘terrere’  Means to frighten o There are different types of terrorism  Instrumental:  To force a group into taking some action or complying with a demand  Example:-National Republic Army’s desire to end British control  Retribution:  Perpetrators are primarily interested in destroying their enemies  Target is hated not because of what they do but for the very fact that they exist  Examples:-Radical Islamic terrorists, White supremacists • The Terrorist Mind:- The terrorist mind uses 3 basic forms of rationalization: o Rationalization #1  No target population is entirely innocent, because they are evil by association with the enemy group o Rationalization # 2  Victims may be innocent, but war is hell, and in all noble struggles there is always collateral damage o Rationalization #3  The greater the number on innocent lives lost, the better  Targeting innocent is not a side effect, but in fact is their goal • Comparing Psychological Profiles o Street Criminal  Decreased verbal IQ  Poor planning  Frequent substance abuse  Early developmental antisocial pattern o Political Terrorist  Normal verbal IQ  Well-organized  Rare substance abuse, if any  No such pattern seen • Terrorist Typologies o Crusaders:  Most ideologically driven of terrorist  Motivated by their devotion to their cause  Example - Islamic Jihad, Neo-Nazism o Criminals:  Essentially violent individuals  In search of an excuse to express their antisocial impulses in the name of a ‘noble cause’ o Crazies:  May have some mental disorders  They easily revert their loyalties to the group  Result in dangerous instability in their commitment and behavior • Secret Service Profiles of Terrorists o Crusading Terrorists o Ideologically motivated by their religion or political convictions o Ultraconservative Political Terrorist o They believe in individual rights over the repressive or ultraliberal government o Often involved in militia groups o Religious Terrorists o Believe that they are accountable to no one but God o Therefore justify killing in His name and for His purpose o Criminal Terrorist o More of an opportunist than an idealist o Act for personal gain rather than for a cause o Theories behind terrorism have either: o Completely ignored individual psychological factors o Conceptualized the terrorist mind as mentally disturbed o Psychological insight into personality theory o APA defines personality disorder as: o “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” o There are 10 different personality disorders, divided into 3 categories o Terrorist leaders tend to have a narcissistic or paranoid personality disorder • Terrorist Personalities: Narcissistic Personality o Traits include: o Grandiosity, entitlement, and arrogance o Need for admiration o Lack of empathy for others’ feelings and opinions o Classic terrorist leaders convinced of their own authority and infallibility o Regard themselves as above the law • Terrorist Personalities: Paranoid Personality o Traits include: o Pervasive distrust and suspiciousness o Others’ actions and motives are almost invariably interpreted as deceptive, persecutory, or malevolent o Philosophy here is to have a racial or religious exclusionary focus • Terrorist Personalities: True Believers and Unstable Deceivers o Borderline Personality o Traits include: o Erratic and intense relationships o Alternates between over-idealization and devaluation of others o Self-damaging impulsiveness o Emotional instability o Inappropriately intense anger and/or mood swings o Chronic feelings of emptiness  This may lead to the quest for stimulation through provocation or escalation of conflict • Terrorist Personalities: Borderline Personality o They form powerful allegiances to group leaders and ideologies o But their behavioral patterns of changeability makes them unreliable long-term loyalists o Devotion to take great risks makes them useful for dangerous terrorist missions o Example - suicide bombers o Unpredictability of their attachment may work to the advantage of law enforcement authorities • Terrorist Personalities: True Believers and Unstable Deceivers o Antisocial Personality o Traits include: o Consistent disregard for, and violation of, the rights of others o Impulsivity o Criminal behaviors o Sexual promiscuity o Substance abuse o Parasite and/or predatory lifestyle o May possess some similar qualities of entitlement ad self-importance as a narcissist • Terrorist Personalities: Antisocial Personality vs. others o However, antisocial have a complete lack of empathy and conscience o Often become skilled assassins and bombers of their group o Unlike narcissists and paranoid types, they are not true loyalists o This is all a game for them!! o When pressured by authorities they easily betray their group psychology to save their own skin o They are very manipulative so information has to be checked carefully • Terrorist Personalities: Good Soldiers and Worker Bees o Avoidant personality o Traits include: o Pattern of social inhibition o Feelings of inadequacy o Hypersensitivity to criticism o Makes them feel important by the admiration from the people and fellow group members o The organized and ideological certainty of these organizations provide them opportunities to work behind the scenes o They are never on the front lines • Terrorist Personalities: True Believers and Unstable Deceivers o Dependent personality o Traits include: o Pattern of submissive and clinging behavior o Excessive need for care and nurturance o They cling to others to receive guidance and direction • Terrorist Personalities: Dependent Personality o A charismatic cult leader is the perfect object of their desire o Their nature of being loyal and perseverance is very strong and is exploited by the terrorists o Dependents and Borderline get their “meaning and validation” from these groups hence they are fiercely loyal • Terrorist Personalities: Limelight Seekers and Loose Cannons o Histrionic Personality o Traits include: o Pattern of excessive emotionality o Attention-seeking behaviors o Need for excitement o Flamboyant and theatrical in speech and behavior o Impressionistic and impulsive • Terrorist Personalities: Histrionic Personality o These are the “showboats” of any organization o Enjoy being center of attention o Terrorist organizations use them as the frontline in the legitimate worlds of entertainment, the media, and politics o Hunger for recognition may make them change their loyalties o They can become a liability to the organization • Terrorist Personalities: Loose Cannons Traits include: o Pattern of severe deficits in social skills o Generalized withdrawal from life o Sometimes impairment in perceptual and cognitive skills Schizoid personality o Detachment from social interaction o Restricted range of emotional expressions o They are happy when left by themselves Schizotypal personality o More serious disturbances of thinking and more bizarre behavior • Terrorist Personalities: Schizoid and Schizotypal Personalities o We think these two personality disorders really represent a point in a continuum from schizoid to schizotypal to outright schizophrenia o Their psychology may lead them in a philosophical and spiritual quest that end up in a social and religious movement with terrorist ties o They keep to themselves - but show fierce commitment • Introduction:-Bioterrorist event o Release of biological agent into civilian population o Purpose  Creating fear  Illness  Death  Disruption of social and economic infrastructure • Biological agents o Infectious agents  Contagious  Noncontiguous o Biologically produced toxins  Act as chemical agents within human body • Agents of Concern o Agent selection 1. Potential for public health impact 2. Delivery potential  Estimation of ease for development and dissemination  Potential for person-to-person transmission of infection 3. Public perception (fear) of the agent 4. Special requirements for public health preparedness o Ranking category o Class A agents: most severe potential for widespread illness and death  Variola major (small pox)  Bacillus anthracis (anthrax)  Yersinia pestis (plague) o Class B agents: less potential o Class C agents: future threats  Class A Agents • Variola major (small pox) o Incubation: 12-14 days o S&S:  Initially: fever, severe myalgias, prostration  Within 2 days: papular rash on face spreading to extremities → rash on palms and soles → trunk  Lesions progress at same rate • Vesicular → pustular → scabs • Bacillus anthracis (Cutaneous anthrax) o Incubation: usually < 1 day, up to 2 weeks o S&S:  Macule or papule enlarging into eschar  Surrounding vesicles and edema  Sepsis possible • Bacillus anthracis (GI anthrax) o Incubation: usually 1-7 days o S&S:  Abdominal pain  Vomiting  GI bleeding leading to sepsis  Mesenteric adenopathy on CT • Bacillus anthracis (Oropharyngeal anthrax) o Incubation: usually 1-7 days o S&S:  Sore throat  Ulcers on base of tongue  Marked unilateral neck swelling • Bacillus anthracis (Inhalational anthrax) o Incubation: usually < 1 week o S&S:  1st stage: fever, dyspnea, cough, headache, vomiting, abdominal pain, chest pain  2nd stage: dyspnea, diaphoresis, shock  Hemorrhagic mediastinitis with widened mediastinum on CXR • Yersinia pestis (Bubonic plague) o Incubation: 2-8 days o S&S:  Fever, chills, painful swollen lymph nodes  Nodes progress to bubo (possibly suppurative) • Yersinia pestis (Pneumonic plague) o Incubation: 2-3 days o S&S:  Fever, chills, cough, dyspnea, nausea, vomiting, abdominal pain  Clinical condition consistent with gram-negative sepsis • Yersinia pestis (Primary septicemic plague) o Incubation: 2-8 days o S&S:  After bubo formation, clinical condition consistent with gram-negative sepsis, DIC • Clostridium botulinum (Food-born botulism) o Incubation: 1-5 days o S&S:  GI symptoms  Followed by symmetric cranial neuropathies, blurred vision  Progresses to descending paralysis • Clostridium botulinum (Inhalational botulism) o Incubation: 12-72 hours o S&S:  Symmetric cranial nerve palsies  Progresses to descending paralysis • Francisella tularensis (Tularemia) o Incubation: 2-5 days o S&S:  Abrupt nonspecific febrile illness  Progressing to pleuropneumonitis  May have mucocutaneous lesions • Filoviruses and arenaviruses (Ebola virus) o Viral hemorrhagic fevers o Incubation: 2 days – 3 weeks, depending on the virus o S&S:  Initial: nonspecific febrile illness, sometimes with rash  Progresses to hematemesis, diarrhea, shock  Class B Agents • Coxiella burnetii (Q fever) o Incubation: 2-3 weeks o S&S:  Fever, myalgias, headache  30% develop pneumonia • Brucella spp (Brucellosis) o Incubation: 2-4 weeks o S&S:  Fever, myalgias, back pain  Possible CNS infections, endocarditis • Burkholderia mallei (Glanders) o Incubation: 10-14 days o S&S:  Suppurative ulcers  Pneumonia  Pulmonic abscesses  Sepsis • Alpha viruses (VEE, EEE, WEE) o Encephalitis o Incubation: variable o S&S:  Fever  Headache  Aseptic meningitis  Encephalitis  Focal paralysis  Seizures • Rickettsia prowazekii (Typhus fever) o Incubation: 7-14 days o S&S:  Fever  Headache  Rash • Chlamydia psittaci (Psitticosis) o Incubation: 6-19 days o S&S:  Fever  Headache  Dry cough  Pneumonia  Endocarditis • Toxins o Ricin, Staphlococcus, Enterotoxin B • Food safety threats o Salmonella, Eschericia coli O157:H7 • Water safety threats o Vibrio cholera, Cryptosporidium parvum  Class C Agents • Emerging threats o Nipah virus o Hanta virus • Recognition of Bioterrorist Event 1. Patient presents with signs, symptoms, or immediately available diagnostic results that obviously indicate a suspect disease process. 2. Patient presents with protean symptoms, but an astute clinician establishes enough criteria (suspicious historical information, signs, symptoms, short turn-around lab results, public health corroborative information, etc.) to designate the patient as a presumptive case until diagnostic confirmation can be accomplished. 3. Patient presents, is evaluated and admitted or released, but not suspected as being a victim of bioterrorism. Diagnostic test results (blood cultures, immunoassays, etc.) subsequently establish a diagnosis, potentially even post mortem. 4. Multiple patients present over a defined period with similar symptoms or historical characteristics, raising the suspicions of a practitioner and causing that individual to report the concern. Further investigation with diagnostic testing and/or public health epidemiological investigation of the cohort establish the cause. 5. Public health surveillance systems establish unusual patterns of signs, symptoms, or disease in the community and correlate with further investigation to establish the etiology. • Recognition of Bioterrorist Event o Emergency physician should know o Basic pathological principles for each agent o Modes of dissemination and transmission o Disease signs and symptoms o Recommended diagnostic testing o Recommended therapy  Immunizations, medicines, or prophylaxis o Infectious control practices o Pictorial resources o Confirmatory tests o Respond to notification of potential disease by another health or medical professional o Querying the source for methodology of testing that produced the concern o Exposure to an unidentified substance o Source substance and where obtained o Coordination with outside agencies, such as law enforcement and public health o Patient exposure risk stratification • Design and Implementation of Community Surveillance Systems o Clinical duties are minimally affected - Does not consume valuable clinician or support staff time and attention o Financial investment is not carried by the hospital or professional staff o Patient privacy and hospital proprietary issues are addressed appropriately o Participation in the system provides direct benefit to the acute care medical community - All pertinent epidemiologic information is disseminated in real time to the practitioners • Initial Response to a Potential Bioterrorist Threat • Within hospital environment o Infection control procedures o Notification of hospital departments  Administration  Infectious disease  Infection control  Laboratory services  Security  Environmental services o Activation of Emergency Operations Plan (EOP)  Preplanned surge capacity configuration  Security dept – aid in protection of facility and staff  Media relations o Notification of jurisdictional public health department • Information that needs to be conveyed to public health department 1. Diagnosed or suspected agent of concern 2. Whether it is a presumed or definitive diagnosis and how many diagnoses were made 3. Patient demographics (including occupation) 4. Recent history of travel or participation in special events (i.e. mass gatherings, high-profile events, or at- risk gatherings) 5. Patient condition 6. Initial testing performed and further diagnostic testing being conducted 7. Treatment being provided 8. Public health assistance required (including testing) 9. Preferred method of contacting hospital or treating physicians for follow-up • Protective equipment o Gowns, gloves, respiratory masks • Patient isolation • Patient decontamination o Removal of clothing o Soap and warm water o NO bleach • Integration with Local Department of Health • Development of community wide patient evaluation and treatment protocol o Screening o Testing o Treatment methodologies o Patient and public education • Clear and concise definition for the suspicious agent • Reporting requirements (surveillance) for suspected or diagnosed cases o Type of information o Method of reporting (e.g. phone, fax, Internet) o Contact methods (e.g. 24 hr access for technical advice) • Treatment, Prophylaxis, and Immunizations • Agent: Variola major • Vaccination: Vaccinia vaccination o Not recommended for general public use o Contraindicated in immunocompromised pts and pts with eczema o Useful in preventing disease if given within 4 days of exposure • Prophylaxis: Vaccinia immunoglobin o Within 2-3 days of exposure o Limited supplies available o Consider giving it to those with contraindications to the vaccine • Treatment: o Mainly supportive • Treatment, Prophylaxis, and Immunizations • Agent: Bacillus anthracis • Vaccination: Anthrax vaccination o 6 part series at 0,2, and 4 week, then 6,12, and 18 months o Annual boosters required o Not available to the public o Animal models: efficatious in inhalational anthrax • Prophylaxis: o Cipro or doxy for 60 days o Amoxicilin if strain not resistant to treatment • Treatment: o Cipro or doxy (amoxicillin if strain not resistant) in combo with 2 others, including clindamycin, rifampin, imipenem, aminoglycoside, chloramphenicol, vancomycin, streptomycin, and some macrolides • Agent: Yersinia pestis • Vaccination: none • Prophylaxis: o Cipro or doxy for 7 days o Alt: chloramphenicol • Treatment: o Streptomycin or gentamycin o Alt: doxy, cipro, chloramphenicol • Treatment, Prophylaxis, and Immunizations • Agent: Clostridium botulinum • Vaccination: o Not available to public o Pentavalent toxoid of C botulinum toxin types A-E o 3-part series, with yearly booster • Prophylaxis: none • Treatment: o Antitoxin: from local public health agency o Antitoxin may preserve remaining neurologic function, BUT does not reverse paralysis o May require prolonged, assisted mechanical ventilation and supportive care • Agent: Francisella tularensis • Vaccination: o Live, attenuated vaccine under FDA investigation • Prophylaxis: o Cipro or doxy for 14 days • Treatment: o Streptomycin or gentamycin o Alt: doxy, cipro, chloramphenicol • Agent: Filoviruses and arenaviruses (e.g. Ebola virus) • Vaccination: none • Prophylaxis: none • Treatment: o Supportive therapy o Ribavirin may have applicability in arenaviruses • Treatment for Bioterrorism • General Emergency Operation Plans o Need to have enough staff to handle large surge in general patient volume • Specialty requirements o Patient with unusual medical conditions o Patients who may be contagious o Contamination risks to staff and other patients • Disease containment o Isolation o Designation of staff to care for infected vs. noninfected patients o Proper personal protective equipment • Management of personnel o Need more personnel to care for more patients o Staff reluctance to care for potentially infectious patients • Logistics o Limited supply of drugs and medical supplies o Sharing of critical supplies, staff, and equipment among local hospitals o National Pharmaceutical Stockpile • Patient Management o Addressing requirements of each patient encounter o Preprinted instructions  Category of risk stratification  Why patient placed in that category  How disease transmitted  Measures to prevent spread  Early signs and symptoms of disease  Appropriate steps if symptoms occur • Patient Management o Appropriate follow-up o Proper record keeping o Organization of charts • Vaccinations o Not to be given in a pre-event setting to general public • Recommended therapies o Usually not for pregnant or lactating women o Usually not approved for children o Should be given if risk of infection and its consequences exceeds risks of the medications or vaccines • Fatality Management o Bodies are considered evidence o Processed through coroner or medical examiner • WHY PUBLIC HEALTH? • CHEMICAL o effects immediate and obvious o victims localized by time and place o overt o illicit immediate response o first responders are police, fire, EMS • BIOLOGICAL o effects delayed and not obvious o victims dispersed in time and place o no first responders o unless announced, attack identified by medical and public health personnel • Tokyo subway 1995 / Sarin o Effects within minutes o Victims self-reported to authorities, self- transported to hospitals o First responders  fire, police, EMS o Agent identified: 3 hrs o Event over: 12-24 hrs • Oregon USA 1984 / Salmonella o County Health Department  first reports of foodborne illness: several days  two waves of illness over 5 weeks o County Health Department and CDC  751 victims and 10 restaurants identified: weeks - months o Criminal investigation  source identified: 12 months  criminal charges: 18 months • PUBLIC HEALTH • Examples of biological assaults: Note: all incidents were discovered by public health officials and initially presented as an unusual cluster in time and place of an uncommon disease o 1996 Shigella dysenteriae USA o 1984 Salmonella USA o 1970 Ascaris suum Canada o 1966 Typhoid Japan o 1965 Hepatitis USA • Announced attack o Primary response: law enforcement, EMS • Hoax o Variation on announced attack o Increasing occurrence  1992: 1 event affecting 20 people  1998: 37 events affecting 5529 people • Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management -- United States, 1998 o MMWR February 5, 1999 48(04);69-74 o http://www.cdc.gov/epo/mmwr/preview/ mmwrhtml/rr4904a1.htm • Preparedness and prevention • Detection and surveillance • Diagnosis and characterization of agents • Response • Communication • Preparedness and prevention o Coordinated preparedness plans o Coordinated response protocols o Performance standards  self-assessment, simulations, exercises • Detection and surveillance o Develop mechanisms for detecting, evaluating, and reporting suspicious events o Integrate surveillance for illness and injury resulting from WMD terrorism into disease surveillance system • Diagnosis and characterization of agents o Multilevel laboratory response network  link clinical labs and public health agencies in all states, districts, territories, and selected cities and counties to CDC and other labs o Transfer diagnostic technology from federal to state level o CDC Rapid Response and Technology Lab • Response o Epidemiologic investigation  if requested by state health agency, CDC will deploy response teams to investigate unexplained or suspicious illness o Medical treatment and prophylaxis  vaccine / antibiotic stockpile and transportation o Environmental decontamination • Communication o Effective communication with the public  use news media to limit panic and disruption of daily life o Effective communication with health care and public health personnel  coordination of activities  access emergency information  rapid notification and information exchange • Issues: o Existing local, regional, and national surveillance systems  Adequate to detect traditional agents  Inadequate to detect potential bio-warfare agents o Specific training for health care professionals  clinical personnel will be “first responders” o Civilian biodefense plans are usually based on HAZMAT models  Assumes responders enter a high exposure environment near the source  Assumes site of exposure is separate from the health care facility  Assumes no time pressure for decontamination  Maximum protection is provided for a minimum number of workers / rescuers o HAZMAT  OSHA mandates use of PPE based on site hazard, but site hazards are more easily defined at the point of release  Traditional HAZMAT products are expensive, take time to set up, and are inadequate for large numbers of patients  Difficult to train and maintain proficiency in a civilian work force with high turnover Conclusions o Preparation for a biological mass disaster requires coordination of diverse groups of medical and non-medical personnel o Preparation cannot occur without support and participation by all levels of government o Preparation must be a sustained and evolutionary process References 1. CDC. Norwalk-like virus--associated gastroenteritis in a large, high-density encampment---Virginia, July 2001. MMWR 2002;51:661--3. 2. CDC. Public health aspects of the Rainbow Family of Living Light annual gathering---Allegheny National Forest, Pennsylvania, 1999. MMWR 2000;49:324. 3. Wharton M, Spiegel RA, Horan JM, et al. A large outbreak of antibiotic-resistant shigellosis at a mass gathering. J Infect Dis 1990;162:1324--8. 4. CDC. About extreme heat. Atlanta, GA: US Department of Health and Human Services, CDC; 2004. Available at http://www.bt.cdc.gov/disasters/extremeheat/about.asp. 5. CDC. Heat-related illnesses and deaths: United States, 1994--1995. MMWR 1995;44:465--8. 6. CDC. Heat-related deaths---Dallas, Wichita, and Cooke counties, Texas, and United States, 1996. MMWR 1997;46:528--31. 7. McGeehin MA, Mirabelli M. The potential impacts of climate variability and change on temperature-related morbidity and mortality in the United States. Environ Health Perspect 2001;109(Suppl 2):185--9.

history of health promotion

History 1948 The World Health Organisation (WHO) was established in 1948. Two important statements came out of the World Health Organisation. Health is a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity. Governments have a responsibility for the health of their people, which can be fulfilled only by the provision of adequate health and social measures. 1978 The WHO and the United Nations Children's Fund (UNICEF) held a major conference at Alma Ata in the USSR which was attended by 134 nations. The outcome was the Alma Ata Declaration The declaration acknowledges that health is more than the absence of disease and expands the notion of people as being more than independent biological units to one which encompasses the idea that people are affected by their social, economic and natural environments. 1981 The Alma Ata Declaration prompted the development of the Global Strategy for Health for All by the Year 2000 (1981). The major themes of this were: Equity in health Health promotion The need to develop Primary Health Care to enhance preventative activity in primary health care settings Cooperation between government, community and the private sector The need to increase community participation 1986 The Australian Commonwealth Government established the Better Health Commission which reviewed the nation's health from a social perspective. The findings were published in three volumes of Looking Forward to Better Health (1986). WHO identified little change in the eight years since the Alma Ata Declaration particularly in the area of Primary Health Care. The Alma Ata provided a sound theoretical base, and ethical/moral imperative to develop a primary health care approach, but there was no identifiable framework for action. The 1st International Conference on Health Promotion was held in Ottawa, Canada. The outcome was the Ottawa Charter for health promotion which was the action framework for primary health care to be implemented. 1988 The Australian Commonwealth Government produced the Health for All Australians document. This resulted in a number of key developments including: The National Better Health Program which provided money for innovative approaches to meeting health priorities within the states. The Government sought to develop comprehensive goals and targets for decision makers in health, to assist the refocusing of their organisations. The National Goals and Targets document was released in 1993. The 2nd international conference on Health Promotion was held in Adelaide, Australia and produced the Adelaide Recommendations on Healthy Public Policy 1991 The 3rd international conference on Health Promotion was held in Sundsvall, Sweden and produced the Sundsvall Statement on Supportive Environments. 1993 The Australian Commonwealth Government produced Better Health Outcomes which designated targets in health gain to be measured and met within stated time frames. 1997 The 4th international conference on Health Promotion was held in Jakarta, Indonesia where the Jakarta Declaration was developed. This lists the 5 priority areas to lead Health Promotion into the 21st Century. 1999 The 52nd World Health Assembly amended the definition of health included in the World Health Organisation's constitution. The new WHO definition of health states: Health is a dynamic state of complete physical, mental, spiritual and social wellbeing, and not merely the absence of disease or infirmity. 2000 The 5th Global Health Promotion Conference was held in Mexico City. The conference focused on how health promotion, by addressing the social determinants of health, helps to improve the lives of economically and socially disadvantaged populations. The Ministers of Health from 87 countries, including Australia, signed the Mexico Ministerial Statement on Health Promotion - From Ideas to Actions. This Ministerial Statement affirms the contribution of health promotion strategies to the sustainability of local, national and international actions in health, and pledges to draw up a country-wide plan of action to monitor progress made in incorporating strategies which promote health into national and local policy and planning. 2005 The 6th Global Conference on Health Promotion was held in Thailand. Participants agreed to the Bangkok Charter on Health Promotion in a Globalised World which identifies actions, commitments and pledges required to address the determinants of health in a globalised world through health promotion.

HEALTH EDUCATION METHOD

HEALTH EDUCATION METHOD Health education is carried out in three levels: individual, group, mass method. They are as follow: 1. Individual method a) Counseling b) Interview 2. Group method a) Group discussion b) Role play c) Brain storming d) Work shop/ seminar e) Demonstration f) Mini lecture g) Problem solving h) Panel discussion i) Field trip/ educational tour j) symposium 3. Mass method a) Lecture b) Exhibition 1. Individual Method: There are plenty of opportunities for individual health education. It may be given in personal interview and counseling in the consultation room of the doctor or in the health services centre or in the home of the people. Individual method involves person to person or face to face communication which provides maximum opportunities for two ways communication of ideas, knowledge and information. a) Counseling: Counseling is a means by which one person helps another through purposeful conversation. When an individual comes to the doctor or health centre because of illness then opportunity is taken in educating him on matters of interest- diet, causation and nature of illness and its prevention, personal hygiene, environmental hygiene etc. counseling is done to solve the patients’ problem. The responsibility of the counselor whether he or she is a physician or a pharmacist or a staff nurse or other health care personal is high because the patient will listen carefully to them during counseling. A hint from the doctor and health workers may have more lasting effect than volume of printed word. What is counseling? Counseling is the process of helping a person with problems to discover and develop his or her own capacity to solve the problems. Counseling is……. Counseling is not…….  Client centered: Specific to the needs, issues and circumstances of each individual client  An engaging, collaborative and respectful process  Goal centered and developing action plans  Developing autonomy and self-responsibility in clients  Considerate of interpersonal situation, socio cultural context, readiness to change  Asking question, eliciting information and reviewing options.  Telling or directing  Giving advice  A conversation  An interrogation  A confession  praying Counseling helps people to:  Feel listened to and supported  Understand their situation more clearly  Identify a range of options for improving the situation  Makes choices which fit their values, feelings and needs  Make their own decisions and act on them  Cope better with problems Qualities of a good counselor:  Self confident, self aware and self disciplined  Caring, warm and genuine  Knowledgeable / informed about subject and awareness of resources available within the community  Demonstrates professionalism  Tolerates values that differ from one’s own  Culturally sensitive  A sense of humor  Supportive attitude towards clients, positive regard or respect for people  Non-judgmental and accepting  Trustworthy  Ethical Steps in counseling for problem solving  Develop a trusting relationship with your client  Learn with client about their situation by talking, listening and asking open-ended, non-leading questions  Identify problems and strengths of the client  Make plan, set goals, select strategies with client  Implement plan with client  Follow-up, review and modify plan as needed Do and don’t in counseling Do in counseling Don’t in counseling  Remain calm and stable. Allow clients to express their feelings.  Encourage the person to tell his/her problem  Remove the hesitation to accept the problem  Listen and establish precipitating factors as the clients relates their story  Appreciate the person having disclosed his/her problem  Help the client generate alternatives to solve the problem  Assist the client and identify those areas that something can be done about  If needed and possible refer the client to the right place  Accept their feedback seriously and use them properly  Don’t interrupt the client  Don’t confront  Don’t challenge  Don’t laugh at client  Don’t loose temper in any circumstances  Don’t boast of yourself  Don’t show attitude of counselors superiority  Don’t order your client  Don’t use technical words or many acronyms  Don’t criticize  Don’t threaten your client  Don’t give advice  Don’t argue with your client How is counseling different from health education? Counseling Health Education  Confidential  Usually a “one to one process  Evokes strong emotions/relation in counselor and client  Focused, specific, goal targeted  Issue oriented  Based on needs of client  May not be confidential  Small or large groups of people  Emotionally neutral in nature  Content oriented  Based on public health needs Advantages: • Even illiterate people can be taught by this method. • Provides maximum opportunity for feedback and helps to maintain two way communication process. • Easy to conduct with less cost and limited facilities. • Easy to make follow-up studies on the basis of counseling records. • Different counseling aids can be used to demonstrate the process. Disadvantages: • Time consuming • Difficult to cover wide range of target people with limited manpower. b) Interview method: Interview is an effective technique of investigation of disease diagnosis as well as giving health education as it is a method of finding internal view on his/her health related problems. The main purpose of interview is: I. To gain information through face to face association and to gain social and psychological background. II. To perform hypothesis. III. To collect personal data for quantitative purpose. Advantages: • Helpful to know individuals knowledge, attitude and behavior. • Easy to conduct with less cost and limited facilities. • Helpful to reach to a better conclusion for the solution of the problem. • Easy to make follow-up studies on the basis of interview to find out the impact of teaching. • Even illiterate people can be taught by this method. Disadvantages: • Time consuming • Difficult to cover wide range of target people with limited manpower. Advantage of Individual Method The advantage of individual method of health education is that we can discuss, argue and persuade the individual to change his/her behavior. It also provides the opportunity for asking question, expressing fears and learning more. Disadvantage of Individual Method The disadvantage or limitation of the individual method is that the numbers of person who are given health education are small and health education is given only to those who come in contact. 2. Group Method: In a society there are many kinds of group: school children, mothers, industrial workers, patient etc. The choice of subject in a group health teaching is very important. For example, school children may be taught about oral hygiene and industrial workers about accident. Different methods about group teaching are: a) Group Discussion: A group is an aggregation of people interacting in a face to face situation. It is a two way communication where people learn by exchanging their views and experiences. This method is useful when the group have common interest and similar problems. For an effective group discussion, the group should comprise not less than six and not more than twelve members. In a group discussion, there should be a group leader who initiates the subject, helps the discussion in proper manner, prevents side conversation, encourages everyone to participate and sums up the discussion in the end. There should be a person to record whatever is discussed and agreement reached. In group discussion, the members should observe the following rules: I. Express ideas clearly and concisely II. Listen to what others say III. Do not interrupt when others are speaking IV. Make only relevant remarks V. Accept criticism gracefully VI. Helps to reach conclusions Advantages: • Develops creativity, confidence and ability of judgment in the members of learners. • Helps learners to come to a group decision and solve their common problem. Group decision is better than individual decision. • Helps members to become active learners and learn new knowledge, ideas and experiences about their subject of concern through a cooperation process. • Provides adequate communication among all the members with exchange of ideas and experiences. Their potentialities can be explored through discussion. Person-to person influence in small group is the stepping stone to change or develop attitude. • The health educator can make a closer study of the members of target group regarding their need, interest, attitude, ability and other potentialities. He can identify their real problems and help them to solve them. Disadvantages: • Some self conscious members may not venture to bring forth their valid idea for fear of disapproval by other members. • Sometimes discussion may be prolonged without any fruitful result, or it may take longer time to come to the conclusion or decision. • Somebody may not feel personally responsible for the result of discussion. So, they may not participate well. b) Role Play: Role playing is a process of acting of any imaginary person and conditions by own knowledge, ideas and experiences. Role playing or socio-drama is based on the assumption that many values in a situation cannot be expressed in words and the communication can be more effective in the situation is dramatized by the group. The size of the group is a useful technique to use in providing discussion of problems of human relationship. Role playing consists of the acting but of real situation and problems. By acting out of a real situation people can better understand the cause of their problems and the result of their own behavior. Advantages: • Gives learners opportunity to express their ideas based on real life situation and can learn from each other. • Develop careful listening habit. • It is not expensive and can easily be conducted at different situations. • Enables the learners to see things through the eyes of others. Disadvantages: • Not every body can successfully act like somebody else due to shyness, lack of experience, lack of confidence and expression skills. • Sometimes it may turn into a recreational activity and may not achieve educational objectives. c) Brain Storming: This is a method to draw out the idea and solution from participants on current problems. The participants are encouraged to make a list of all the ideas that come to their mind regarding some problem in a short period of time. Then, the list of ideas is passed on to the chairman or secretary of the group. Then the selected persons discuss about the idea given by different participants and try to get the best idea for the solution of problems. Whatever may be the idea given by participants, they are not criticized. Advantages: • Provides varieties of useful ideas in a short time for quick group decision. • Enable individuals to think and response quickly. • Decision made by group thinking is better than by individual thinking. Disadvantages: • Ideas pulled out may not always be relevant and helpful to make group decision. It may happen especially with the new learners. • It might take some longer time and may not be appropriate for packed program. d) Workshop: To work and to learn from practical experience is the theme of workshop. It consists of a series of meeting with emphasis on individual work within a group with the help of consultants and resource personnel. The total workshop may be divided in to small group and each group will choose a chairman and recorder. In workshop, the individuals work, solve a part of problem through their personal effort with the help of consultants which will contribute to the group work for solving problems. Learning in workshop takes place in a friendly, happy and democratic atmosphere under expert guidance. Advantages: • Helps to provide up-to-date knowledge and skills as well as to develop appropriate attitude. • Provide varied learning experiences like listening, speaking, discussion etc. • Enhances participant’s power of thinking and critical learning. Disadvantages: • Take long time to organize the workshop. It might take weeks or even months. • Needs more money, materials and physical facilities. • Sometimes it may be difficult to get appropriate consultant. e) Seminar: In seminar, several expertises from different discipline meet to deliberate on particular field. The members or participants of the seminar come together to exchange views on current problems or to share with others their own problems, experiences and new encounter experiments. Usually seminars are conducted by research institution or organizations which are interested in pooling experiences, this method do not find much applicability in the usual type of health education. f) Demonstration: A demonstration is a carefully prepared presentation to show how to perform a skill or procedure. Demonstration is carried out step by step before the audience assuring that the audience understands how to perform it. Demonstration is found to have a high educational value in programmes like environmental sanitation (construction of sanitation latrine), mother and child health (demonstration of oral rehydration therapy). A demonstration leaves a visual impression on the mind of people and is more effective than the printed word. Advantages: • It is effective method which involves varied learning experiences like seeing, hearing, feeling, tasting and smelling depending upon the subject of demonstration. • It is interesting and draws attention of the learners because of the active learning process. • It helps to develop not only knowledge and attitude but also skills for required work performance. • Provides concentrate and realistic visual picture of what is being taught resulting in more lasting impression. Disadvantages: • Sometimes it may be difficult to get necessary equipment and materials for certain demonstration. • Sometimes it may not be appropriate to conduct demonstration on certain topic especially when there will be only cognitive gain. g) Problem Solving Method: In this method, the problem is identified and different ideas and methods are used to solve that problem. A problem is an obstruction or some short of difficulty which does not enable the individual to reach a goal easily. Problem solving is the purposeful activity that will remove the difficulty through a process of reasoning. All the participants in this method are given equal chance to express freely and exchange their ideas and experiences. So it is a collective thinking process to solve the problem. The seven steps of problem solving methods are: I. Selection of a problem II. Definition of the problem III. Collection of data IV. Interpretation of data V. Drawing conclusion VI. Applying the conclusion to the solution of problem VII. Evaluating the result. Advantages: • Helps to reach goal within a period of time by solving problem on the way. • Participants get equal chance to express freely. Disadvantages: • Sometimes the solution given may not solve the problem effectively. • Sometimes it may be difficult to get appropriate person for discussion. h) Panel Discussion: A panel discussion is a conversational exchange of ideas by selected participants on a topic, problem, question or issues. In this method 4-8 persons who are qualified to talk about the topic sit and discuss in front of a large group or audience. The panel comprises a chairman from 4-8 speakers who opens the meeting, welcomes the group and introduces the panel speakers. He introduces the topic briefly and invites the panel speakers to present their points of view. After the main aspects of the subject are explored by the pane speakers, the audience is invited to take part. The audience reacts to the views given by the panel speakers. Advantages: • Provides varied knowledge, ideas and experiences about the subject of concern to the learners. • Interesting and can draw attention of the audience or learners. • Learners get opportunity to ask questions and pass comments which help in teaching-learning process. Disadvantages: • Sometimes it is difficult to get the appropriate experts. • Difficult to set definite time to suit the experts. i) Symposium: A symposium is a series of speeches on a selected subject. Each person or expert present an aspect of the subject briefly. In symposium, there is no discussion among the members but in the end, the audience may raise questions. The chairman makes a comprehensive summary at the end of the entire session. Advantages: • It is interesting and draws attention. • Student speakers can develop the techniques of finding information as well as the techniques of presentation. • Students get opportunity to explore their potentialities. • Students get opportunity to learn from concerned experts and get up-to-date knowledge. • Develops the habit of listening and critical thinking. • Does not require special kind of materials and equipments. Disadvantages: • Difficult to get the appropriate experts. • May be time consuming. • Difficult to adjust time at the convenience of the experts. 3. Mass Method: a) Lecture: Lecture is an oral presentation of information and ideas by a person to a large group of people or mass at a particular place. So it is a popular method of health education. Lecture is organized at a particular time usually for the people who come together for common purpose. Though it is face to face presentation there is no adequate opportunity for interpersonal reaction between the speaker and audience. Techniques of giving lecture effectively: • The subject of the lecture should be related to the needs and interest of the target audience. • The speaker should get a thorough and up to date knowledge of the content. • The language should be correct, simple, clear and understandable. • Avoid monotony in voice. The speaker can raise his voice while expressing important points. The lecturer should try to know the feedback of the audience by watching their gestures. • The speaker should be sincere, pleasing and properly dressed up. b) Health Museums: A good museum can be a very effective media for health education since it display material covering various aspect of health. The best example of popular health museum in Nepal is at Chhauni, near Buddha temple, Kathmandu. HEALTH EDUCATION MEDIA Media are the teaching aids by which knowledge, information and ideas are communicated. They provide varieties of learning experiences. They are used in different situations of individuals, group and mass teaching. Media are of different types. They are audio aids, visual aids and audio-visual aids. 1. Audio aids: In this type, learning occurs by hearing. The examples of audio aids are radio, tape recorder or cassette player etc. Radio is most widely used in mass teaching where cassette player is used in individual and group teaching. Audio aids are considered less effective for providing health education. 2. Visual aids: Visual aids are the media through which people learn by seeing. Poster, bulletin board, flannel graph, slides, pamphlets, diagram etc are the example of visual aids. Visual aids are more effective than audio as we know that learning by seeing is better than learning by hearing. 3. Audio-Visual aids: In this type of media, learning occurs both by seeing and hearing. Television, Video Tape, Movie film with sound etc are the example of audio-visual aids. These are more effective to give health education than audio or visual media alone because the process of hearing and seeing takes place at a time. Classification of different health education media 4. Auditory aids Radio, tape recorder, microphones, amplifiers, earphones 5. Visual aids a) Non projected: Chalk board, bulletin board, black board, whit board, leaflets, posters, flip charts, flannel graph, specimens, flash cards, newspapers, magazine, photograph etc. b) Projected: Over head projector, slide projector, film strips, bell and howel projector etc. 6. Audio-visual aids: a) Non projected: Drama, puppet show, role play etc b) Projected: Television, cinema (sound film), documentary/videos etc. 1. Audio aids: a) Tape recorder: Tape recorder is a small portable machine or equipment which operated with the help of electricity or batteries. Circular tape can be recorded with the necessary message and be played with the help of the tape recorder. It is used for the purpose of providing health education to a group of audience. Cassettes can be labeled by the title of the subject to identify appropriate and necessary cassette. Tape recorder can be used in direct group teaching followed by discussion. In the beginning, the health educator should give the introduction about the subject of teaching. During the teaching period, he should pause the tape whenever needed in order to explain the point. The program shouldn’t exceed more than 30 minutes. Advantage: • It can be used to open a discussion which gives health education to a group. • It can be played at learner’s speed of learning by stopping in between or by playing over and over repeatedly as needed. • The recorded message can be presented before using for actual teaching and make necessary alteration to meet the need and interest of the target people. • It can be played with the help of batteries where there is no electricity supply. • Message can be recorded and played easily at various places at home, in the office, in the school, in the community place etc. • It is portable and easy to carry at different places of teaching and can be kept without any difficulty. Disadvantage: • Management for recording may take more time. • Learning by hearing only is not effective. • Cassette player or tape recorder may be little costly to afford. There is added problem of repairing. • Break of electricity supply or lack of batteries might cause problem. b) Radio: Radio is the audio aid through which message is relayed to a heterogeneous and large group of people. It is a mass media which provide one sided communication. Sometimes the concerned audience are informed and asked to attend the broadcast at a particular time and place. The audience can be encouraged to have some discussion after listening to the program to avoid doubts and confusions. The health educator can encourage them to put into practice what they have learnt from the program. From radio health message can be relayed in the form of lecture, story, song, news, dram, or dialogue etc. 2. Visual aids: a) Poster: A poster is a picture or drawing designed for public display to convey message on certain subject. A poster must contain the following four basic parts: • Caption • Picture • Course of action suggested • Logo (official symbol or name of the office for validity of the poster) Sometimes, poster can be made even without picture but they are not useful for illiterates. A good poster should carry only one unit of message. Colored poster is more natural, attractive and clear to understand. Posters are usually displayed on the side walls of busy streets, community centre, waiting halls or places, school complex and other public gathering places. Advantages: • Pictorial and colored posters are attractive and effective. • Posters can be carried easily from one place to another to distribute and display widely. • Many people (both literate and illiterate) can learn something from limited number of posters on display. • Can be used to motivate or to open discussion on health education. • Helps to develop creativity in the learners by involving them in designing and making posters. • Helps to communicate ideas quickly. Disadvantages: • Poster provides only one-way communication. It may create misunderstanding and confusion. • Takes time to print in large scale. • Coloured posters are expensive to print. • Printing services may not available in rural places and small towns. • Can’t be sure if the intended group have seen or read the display posters. b) Pamphlet: Pamphlets are visual media which are considered as mass media of health education. It gives short description of different aspects of a specific topic. Pamphlets can be produced in the form of leaflets or folders to convey the message. Pamphlets can be distributed to the learners of a training group, to family members, in clinic, hospital OPD etc. Advantages: • Helps in propagating message rapidly in the mass scale through wide distribution. • People can read them at their free time and understand the message well. • The first reader can pass the read pamphlet to the others. • Can be kept safe to read again which help as remainder of the message. • Easier to prepare and produce in large scale at low cost. Disadvantages: • Provide only one way communication. • Not useful for illiterates. • Printing services may not available in rural places and small towns. • Can’t be sure if the intended group have read and understood the distributed pamphlet. c) Flash cards: Flash card is a set of visual aid. It consists of simple message in series or steps by consecutive pictures which convey certain message about a specific topic. For example, the kind of vitamins and their sources, the steps of making a pit latrine etc. Flash cards are used in group teaching especially the illiterates. It can be used in giving health education in different situations like home visiting, classroom teaching, community group teaching, community group teaching, clinic, hospital etc. Advantages: • It is interesting and attractive, especially when the pictures are coloured. • It is easy to carry and use at different teaching situations like home, school etc. • Limited number of sets will be enough for group teaching and won’t be expensive. • Useful and effective even for illiterate audience. d) Flip chart: It is also called flip book or turnover chart. It consists of a series of sequential charts which are fastened together at the top so that as one chart is viewed it can be flipped back to see the next one. The flip chart as a whole describes about a subject or topic. As set of flip chart normally consists of six to eight, the number may slightly vary depending upon the message to be conveyed. Advantages: • It is helpful to make systematic presentation. • It helps to show abstract information visually. Pictorial explanation is better and more effective. • It is easy to carry from one place to another for providing health education at different situation – clinic, classroom, community group etc. • A health educator can make flip chart by himself. Disadvantages: • Expensive to produce in a large scale. • There may be problem of drawing appropriate picture. • Some ready made flip chart may not suit the objective. e) Flannel graph: A flannel graph consists of flannel board and a series of cut pieces or cutouts. It can be prepared by the health educator himself if ready made flannel graph is not available which will help him to illustrate the points of teaching. Advantages: • The pictorial explanation is interesting and attractive. • Organized and systematic display of cut pieces can make the teaching impressive and effective. • It is easy to carry the sets of cut pieces and a sheet of flannel cloth to distance places. • It is not expensive to make a flannel graph and can be used again and again to give health education. Disadvantages: • There may be problem of drawing appropriate pictures. Also appropriate picture may not be available in the magazine for cutting. • Sometimes the cut pieces may not properly stick on the flannel board and fall down. It happens especially with repeatedly used flannel graph. f) Chalk board: A health educator can provide health message to the audience with its help. The chalk board can help to provide visual explanation of important health message in the form of diagram, chart, graph etc to make the message easier to understand. The health educator can write important points of message, can draw the cycle of infection etc. Chalk boards are commonly used in group teaching. Advantages: • Cheap to make and durable. It is highly used in schools and training centers. • Can write and erase things immediately according to the need. • Students and trainers can go to the chalk board, write facts and processes and try to explain them. Disadvantages: • Takes time in writing on the chalk board. • Difficult to take from one place to another. It may not be available for every kind of teaching situations like in community places, home etc. • The message written on the board will be wiped cut and can not be stored for future use. g) Model: Model is the representation of original reality. It helps to provide health education effectively, so it is commonly used by health educator. Different models like model of an apple, model of a well, the model of an ideal village etc. Advantages: • It is the representation of real object and so provides clear and concrete knowledge of the thing. • It is attractive and interesting, so it helps to draw attention of the learners. • There can be better retention of what is learnt through the use of model. Disadvantages: • Sometimes it may be problem to make or collect or purchase the appropriate model. • Some models may be expensive to make or purchase. h) Photographic slides: A photographic slide is a negative picture cutout from a 35mm filmstrip and mounted on a cardboard or plastic frame. Photographs or written message can be snap shot with the help of a camera. Then each snap are separated from the film strip to make individual slide. A slide set will normally have twenty to thirty pictures prepared in series for teaching purpose. The slides are loaded on a projector serially and are projected on a screen to teach about something. Advantages: • Could be projected and explained for desirable time period. The speed of presentation can be adjusted. • Coloured pictures are attractive and give clear picture of what is presented causing good learning and retention. • Slides can be explained verbally or with the help of tape recorder. • Discussion can be made in between the slide show, or at the end of presentation. • Can be kept safe for future use. Disadvantages: • There may be problem of obtaining the projector, appropriate slide set. • Can not be arranged where there is no electricity supply and also has problem in getting the batteries. • It is expensive and difficult to prepare colour slides. Colour films and developing services are not available in many towns. i) Film strip: Film strip is a continuous strip of film consisting of a series of individual picture or message arranged in sequence to convey certain message. The negative pictures or messages are projected on the screen with the help of the projector. The pictures and messages are commonly explained orally. Advantages: • The speed of the presentation can be adjusted according to the learner’s speed of the interpretation and understanding. • The sequence of picture can be skipped if needed. • The systematic and pictorial presentation of message makes it interesting and effective. • It can provide opportunity for questions and answers on the subject of teaching. • The film strip can be prepared at low cost and can be stored safely for future. Disadvantages: • No sound with picture. • There may be problem of obtaining appropriate filmstrip, projector, electricity or batteries etc. • It may be problem to make filmstrip in terms of time period available, money etc. j) Transparency: A transparency is a transparent plastic sheet on which words and pictures can be written by special marking pen or can be printed to get the required materials. Transparencies are very often used in educational classes or training sessions. Simple message are written on transparencies and projected on the screen with the help of a overhead projector. Advantages: • Message can be planned and written on the transparencies ahead of time. • Written message can be wiped out when needed and write other appropriate message. • Written transparencies can be saved for future use. • Keeps the teacher in a comfortable situation and help him/her to explain message systematically. Disadvantages: • There may be problem of obtaining the overhead projector or transparencies. • It is expensive to maintain. Even the bulb of the projector is expensive and rare. • It is not useful where electricity is not available. 3. Audio – Visual Aids: 1. Film: Film consists of a series of negative pictures which are prepared to convey information by projecting them on the screen with sound and motion. Because of its motion, film is also called movie or motion picture. It can be made black and white or coloured. Though it is expensive, colour film is attractive and provides natural view of things as they look. Documentary films are generally made for educational purposes. They are different from commercial entertainment films. Educational film is made short of about 30 minutes. The length of time may vary slightly depending upon the nature of health topic. Advantages: • The motion pictures can be presented in a natural way and represent reality. It provides education through a real life situation with actions and reactions of people, natural process. • A film provides learning through hearing and seeing. • Can present different kinds of action and events in a short period of time which otherwise take long time to learn. E.g. pattern of water pollution in river, construction procedure of a well etc. • Is interesting, attractive and effective especially when the film is coloured. • Carefully prepared film for special group of people may be self explanatory and so will be useful even for illiterates. • Can be kept for future use. Disadvantages: • It is difficult to prepare film in terms of time, money, appropriate situation. • Needs different kinds of the equipments like projector, screen, generator or electricity supply etc. which may be difficult to obtain and conduct the show. • Film mostly provides only information and idea but not actually teach them which need real observation and practice. • Difficult to transport the hard-ware like film reels, projector and loudspeaker. Criteria for selecting appropriate methods and media of health education A particular method or media may get failure to achieve its educational objective simply because of its inappropriateness and impracticability in certain situation. The appropriateness of particular method or media should be determined on the light of certain criteria. These criteria should be well considered in choosing and applying a particular method or media. The criteria are described below: 1. Feasibility or practicability: A method or media should be feasible to apply from the point of view of transportation, economic factor, availability of necessary equipment and other facilities. 2. Nature of the audience: A method or media should be chosen to suit the educational status, culture etc of the target group. Teaching about the importance of eating meat will mean nothing to the vegetarian group who has taboo against taking meat. In the same way distributing pamphlets to illiterate people will not help to provide information to them. 3. People’s attitude and belief on the method or media: People have different kinds of interest for different kinds of methods or media. So, each method or media should be chosen according to the interest and belief of people on them. People take radio broadcasting, television telecast, government published pamphlets, etc as valid messages and tend to ignore individual lectures. 4. Accessibility: The method or media that a health educator chooses must be able to reach to the people concerned. In fact a health education program or message should be accessible to each member of the target group in the community. 5. Subject or purpose of teachings: The purpose of teaching also affects in the selection of particular method or media. The subject and purpose of the teaching will be based on audience need. If it is for conveying some health message or knowledge a lecture can help but when there is a need of skill and attitude development, demonstration method has to be applied.