Transcript POPULATION HEALTH: CLINICAL PRESENTATIONS

Back to Basics, 2008
POPULATION HEALTH (2):
CLINICAL PRESENTATIONS
N Birkett, MD
Epidemiology & Community Medicine
Based on slides prepared by Dr. R. Spasoff
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THE PLAN(2)
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About 1.5-2 hours of lectures
Review MCQs for 60 minutes
A 10 minute break about half-way through
You can interrupt for questions, etc. if
things aren’t clear
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THE PLAN (4)
• Session 2 (April 18)
– Clinical Presentations
• Periodic Health Examination
– More in session after this one (Dr. Wooltorton)
– Focus here is on key conditions, risks and general issues
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Immunization
Occupational Health
Health of Special Populations
Disease Prevention
Determinants of Health
Environmental health
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077 PERIODIC HEALTH
EXAMINATION (1)
• “Determine patient’s risks for common gender/age specific
conditions”
• This would involve knowing something about prevalence
of condition, as well as patient’s risk factors for it.
• Objectives identify certain common conditions for each
age group
• Use periodic health exam for health promotion/disease
prevention interventions.
• Case-finding and screening for disease & risky behaviours
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Conditions identified by MCC
as examples (1)
• Infant/Toddler <3 years
– Delayed growth & development
– Abuse/neglect
• Child 3-12 years
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Vision/hearing defect
“Accidents”
Delayed development
Abuse/neglect
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Conditions identified by MCC
(2)
• Youth 13-24 years
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MVA
Substance abuse
STDs
Contraception
Sedentary lifestyle
Female: rubella/HPV immunization
Eating disorders (don’t know why not included)
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Conditions identified by MCC
(3)
• Adult 25-44 years
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Substance abuse
Eating disorders
Family violence
Hypertension
Female: cervical cancer
Male: elevated cholesterol, MVA
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Conditions identified by MCC
(4)
• Middle age 45-64 years
– Lung cancer
– Colon cancer
• Method of screening is controversial
• Screening colonoscopy has serious potential risks and low
patient acceptance but can treat adenomas
– Skin cancer
– Female: osteoporosis, breast cancer
– Male: IHD, prostate cancer (55 and up)
• Role of PSA screening is controversial
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Conditions identified by MCC
(5)
• Seniors >64 yrs
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Elder abuse
Falls
Drug-related morbidity
Nutrition
Cancer
Dementia (Should be on MCC list)
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077 PERIODIC HEALTH
EXAMINATION (2)
• “Elicit information about ethnic, family,
socio-economic, occupational, and
lifestyle characteristics that are known
to be at high risk for a particular
condition.”
• Presumably means “…known to convey
a high risk…”
• MCC provides a list for each age group
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Risk factors identified by MCC
(1)
• Infant, Toddler, Child:
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Risk factors at conception, pregnancy, birth
Familial factors
Existing signs of illness
Environment (missed immunization, diet,
passive smoke inhalation, skin protection)
– Height, weight, head circumference, medical
status, developmental milestones
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Risk factors identified by MCC
(2)
• Youth
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Nutrition
Physical activity
Drug use
Sexual/social/peer activities
Emotional concerns
Communication with parents
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Risk factors identified by MCC
(3)
• Adults:
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Lifestyle patterns
Psychological, social and physical functioning
Symptoms of any illness
Situational factors affecting mood
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Risk factors identified by MCC
(4)
• Seniors:
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Past illness
Lifestyle factors
Mental function
Drug use
Physical and social activity
Emotional concerns
Social relations and support systems
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Risk factors identified by MCC
(5)
• General:
– Use lab tests only for specific to age and sex
concerns. Do not use the same battery of tests
in all patients.
– Interpret results taking into account age/gender,
etc.
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077 PERIODIC HEALTH
EXAMINATION (3)
• “Conduct an effective plan of management”
• All patients:
– Encourage patient control over health
– Follow recommendations of CTFPHC
(http://www.ctfphc.org/ )
• Patient with risk factors:
– Counsel about risk factor reduction, using
health belief model, stages of change model,
etc.
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077A NEWBORN
ASSESSMENT/NUTRTION
• Developmental surveillance
– Anticipatory guidance to new parents
• Nutritional issues
– Importance of breast-feeding
– Bottle feeding; solid foods
• Well-newborn care
– Bathing, skin care
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077B INFANT & CHILD
IMMUNIZATION (1)
• “Discuss the population health benefits of immunization
programs”
• Probability of contracting communicable disease depends
on probability that contacts have the disease, or are carriers
• If sufficient proportion of population is immune, then
disease will not spread (herd immunity)
• Prevention is usually cheaper and more effective than
treatment (if treatment even exists)
• Possibility of eradicating some diseases
• Implications for school attendance (Ontario)
– Mandatory choice vs. mandatory immunization
– Exclusion from school for non-immunized children
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Standard immunizations(2007)
Age 0-16
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Diphtheria
Tetanus
Pertussis
Polio
H. influenzae
Mumps
Measles
• Rubella
• Hepatitis B
• Chickenpox
(varicella)
• Pneumococcus C
• Meningococcus C
• Influenza
• HPV (girls only)
Taken from: Canadian Immunization Guide, 2007
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IMMUNIZATION: HPV
• Protects against 4 strains of HPV
– Type 16/18 (linked to 70% of cervical cancer)
– Type 6/11 (linked to 90% of anogenital warts)
• Approved for use in women aged 9-26.
• Need three doses (0, 2 and 6 months)
• 1st dose prior to initial sexual contact
– Age 9-13
• Ontario
– Offered free on voluntary basis to all Grade 8 girls
• Why only women?
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NO RCT’s in men (drug companies)
Rectal cancer
Genital warts
STD & shared responsibility for interrupting transmission
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077B INFANT & CHILD
IMMUNIZATION (2)
• “State that a lapse in immunization
schedule does not require re-instituting the
initial series, merely giving it at the next
visit”
• Done!
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077B INFANT & CHILD
IMMUNIZATION (3)
• “Communicate to patients and parents about vaccine
benefits and risks”
• Obtain an immunization history on all children
• Late immunization is still very effective
• Immigrants require special attention
– Depends on availability of good records
– Countries have different immunization coverage
– Were the previous vaccines ‘potent’?
• Travel
– Update regular vaccinations
– Follow legal requirements
• Yellow fever
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077B INFANT & CHILD
IMMUNIZATION (3)
• “Discuss misconceptions about immunization
contraindications”
• Following are not contraindications:
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Mild/moderate local reactions to previous dose
Mild acute illness with or without fever
Taking antibiotics
Allergy to penicillin, duck, molds, pollens
Positive Mantoux TB skin test
Breast feeding
Asplenia
Prior febrile seizure reaction (consider prophylactic
acetaminophen)
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077B INFANT & CHILD
IMMUNIZATION (4)
• “List possible complications of immunization”
• Seizures (secondary to fever)
• Anaphylaxis
• Neurological damage (rarely, if ever)
– Most evidence is due to diagnostic correlations, not
causation
– Use acellular pertussis
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077B INFANT & CHILD
IMMUNIZATION (5)
• “Discuss immunization of immuno-compromised children
(e.g., asplenia, chronic diseases or seizures)”
• Avoid live (attenuated) vaccines; use killed vaccines
• Splenectomy (surgical or congenital/functional)
– Not a contra-indication to vaccination
• Immuno-suppression
– Avoid live vaccines
– Follow regular immunization schedule
– High dose steroids can mute immune response
• Congenital immunodeficiency
– Read the Guide!
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Communicable disease control
Time scale
Exposure
Incubation period
(personal surveill.)
Clinical onset
Period of infectivity
(isolation)
“Cure”
time
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Communicable disease control
Approaches
• Enhance host resistance
– Active or passive immunization
• Interrupt transmission
– Isolate cases until no longer infectious
– Contact tracing; observe until incubation period
is over
– Individual measures (hygiene, barriers)
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077C PRE-OPERATIVE
MEDICAL EVALUATION
• Come on … This is population health?
• Opportunity for case-finding/screening
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077D WORK-RELATED
HEALTH ISSUES
• “Elicit history of patient’s occupation and possible
exposure and identify potential relationship to patient
presentation
• “Counsel patients about safety issues and report findings
to affected patients as well as employers (considering
medical confidentiality issues)”
• Consider underlying medical conditions and work risk
• Importance in Canada
– 920 work place deaths in 2001
– 373,216 lost time injuries in 2001
Well covered in UTMCCQE, except 2 topics
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Work-related Health Issues (2)
• Under provincial jurisdiction except for 16 federal
regulated industries (e.g. banks, airports, highway
transport).
– 90% of workers are under provincial jurisdiction
• Ontario: Occupational Health and Safety Act
– Defines rights of workers: participate, know, refuse and stop.
• Ontario: Workplace Safety and Insurance Act
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Establishes WSIB to oversee work-site injuries/disease
Funded by employers
Non-fault protection but no right to sue
MD must submit medical report to WSIB; no need for patient
waiver.
– MD must report exposure to designated substances
• Asbestos, arsenic, benzene, lead, mercury, vinyl chloride, etc.
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Essential responsibilities of an
Occupational Health Program
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Health evaluation of employees
Diagnosis/treatment of occup injuries or illnesses
Emergency treatment of other injury or illness
Education of employees re: occupational hazards
Evaluation of programs for the use of indicated
personal protective devices
• Assist management in providing a safe and
healthful work environment. Inspect workplace.
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WHMIS
Workplace Hazardous Materials
Information System
• Informs workers of hazards that they face
• Labels
• MSDS (Materials Safety Data Sheets)
• Worker education
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Work-related Health Issues (3)
• Categories of occupational hazards
– Chemical
• Dusts, heavy metals, gasses, second-hand smoke
– Physical
• Noise, temperature, air pressure, radiation
– Biological
– Mechanical
• Repetitive strain, trauma
– Psychosocial stress
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Work-related Health Issues (4)
• Work place safety issues can affect family
members as well as the workers.
• Asbestos
– Causes asbestosis and lung cancer in miners
and other workers.
– Asbestos in the air adheres to work clothing,
even if the clothes are brushed
– Cleaning of clothes at home liberates asbestos
fibers and has been shown to cause cancer in
family members.
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077E HEALTH OF SPECIAL
POPULATIONS
“When providing periodic health
examination to a person belonging to
one of the [following] groups, evaluate
conditions common to the group and
determine whether evidence exists that
the individual has such a condition”
MCC lists four populations and several
conditions
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Special populations (1)
• Aboriginal peoples
– Trauma/poisoning/SIDS/ALTE (Apparent Life
Threatening Event Syndrome)
• also suicide, substance use
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Circulatory diseases (incl rheumatic fever)
Neoplasms
Respiratory diseases
Infection (gastroenteritis, otitis media, infectious
hepatitis)
– Diabetes
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Special populations (2)
• Seniors:
– Musculoskeletal
• includes falls & injuries
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Hypertension/heart diseases
Respiratory diseases
Dementia
Polypharmacy
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Special populations (3)
• Children in poverty
– Low birth weight
– trauma/poisoning
– Mouth problems (abnormalities in teeth and
jaws)
– Fever/infectious diseases
– Psychiatric problems
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Special populations (4)
• People with disabilities
– No specifics listed
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Two priests, a Dominican and a Jesuit met
for their regular Monday morning walk.
They got into a discussion about whether it
was a sin to smoke and pray at the same
time. The Jesuit was sure that it wasn’t a sin
while the Dominican was sure that it was.
Unable to resolve it, they decided to ask their
superiors.
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The next week, they met again.
Dominican: What did your
superior say?
Jesuit:
He said that it
definitely was not a sin.
Dominican: That’s strange because mine
said that it was a sin.
Jesuit:
What did you ask him?
Dominican: Whether it was a sin to smoke
while praying.
Jesuit:
I asked if it was a sin to pray
while smoking.
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077F POPULATION (1)
Disease Prevention
• “Discuss the 3 levels of disease
prevention and strategies for health
promotion (e.g., education,
communication/behaviour change,
social marketing, healthy public policy,
community development and
organization, community-wide
prevention, and diffusion of innovation)”
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Levels of Prevention
• Categories are not black and white.
• Primary prevention:
– Strategies applied BEFORE disease starts.
– E.g. Immunization
• Secondary prevention:
– Early identification of disease
– Screening; thrombolytic therapy of MI
– Some people suggest secondary prevention relates to reducing the
severity of disease.
• Tertiary prevention:
– Treatment and rehabilitation of disease
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Screening
• Can either:
– Detect pre-disease states (e.g. dysplasia)
– Detect the disease at an early stage
• Criteria for when screening is useful
– Disease related
• Significant cause of ‘illness’
• Early detection can alter the course of the disease
– Test related
• High sensitivity (and specificity if possible)
• Safe, rapid, cheap, acceptable
– Healthcare System related
• Adequate capacity for follow-up/treatment
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Strategies for Prevention (1)
High Risk Approach
• Identify individuals at high risk and attempt
to reduce their risk
• Requires testing entire population (costs,
false positives)
• Asks targeted people to act differently from
their peers
• Misses most cases (which occur in lower
risk people)
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Strategies for Prevention (2)
High Risk Approach
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Strategies for Prevention (3)
Population Approach
• Attempts to shift distribution of risk factor
in whole population
• Gets to root of the problem
• Shades into health promotion
• Benefits everyone
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Strategies for Prevention (4)
Population Approach
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077F POPULATION (2)
Determinants of Health
• “Explain that factors such as geographic
location, gender, and ethnic origin
influence some of the determinants of
health, but health status is in turn
influenced by differential allocation and
distribution of some of the determinants of
health”
See below…
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Determinants of Health
(Useful list from MCC Objectives)
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Income and social status
Social support network
Education
Personal health practices and coping skills
Healthy child development
Health services (access and barriers to access)
Employment and working conditions
Physical environment
Biology and genetic endowment
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Differential distribution of
determinants of health
• Poverty is associated with increased
occurrence of nearly all health problems,
often working through known
determinants/risk factors, e.g.., smoking
• Income inequality appears to be associated
with worse overall health in the population,
perhaps through decreased social cohesion,
community investment, etc.
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077F POPULATION (3)
Health Promotion
• “Select (identify) population health
issues better managed by means of
health promotion rather than traditional
medical interventions”
• Physical or social environmental
hazards, (e.g., pollution, poverty)
• Environmental interventions are usually
more effective than behavioural ones
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077G ENVIRONMENT (1)
• “Describe clinical presentations caused or
aggravated by environmental exposures that
are virtually indistinguishable from ones
caused by other conditions (e.g., headache
from CO poisoning is similar to tension
headache or migraine; asthma)”
• Done. You have to identify them from the history.
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077G ENVIRONMENT (2)
• “In patients whose immediate (e.g. allergic
reaction), subacute (e.g. asthma) or delayed
(e.g. pneumoconiosis) presentation may be
linked to environmental exposure, elicit and
environmental history and identify a/the
potential source of the problem”
• Need to know when presentation may link to
environmental agent.
• Consider list of candidate agents (later)
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077G ENVIRONMENT (3)
Four areas to focus on for environmental history
1. Determine whether symptoms are worse:
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at home,
at work
at leisure activities
on weekends or week days
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And what is relationship to recent or past
exposures (e.g. fumes, dusts, chemicals, radiation,
etc.)
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077G ENVIRONMENT (4)
2. Determine whether an illness is occurring
in an unexpected person (e.g. lung cancer
in a non-smoker) or whether symptoms
developed without a clear etiology
3. Determine presence of nearby industrial
plants, commercial businesses or dump
sites.
– ‘nearby’ needs to consider hydrology,
weather patterns, etc.
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077G ENVIRONMENT (5)
4. Obtain information about:
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Home insulation (UFI),
Home heating and cooling systems
Cleaning agents used
Pesticide use
Water supply and leaks
Recent renovations
Air pollution
Hobbies
Hazardous waste contamination, spills, etc.
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077G ENVIRONMENT (6)
• “Interpret critical clinical and laboratory
findings which were key in the
processes of exclusion, differentiation
and diagnosis.
• Doesn’t really say a whole lot.
• Main point is to learn where to get
information and help in dealing with
environmental issues (next 2 slides)
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077G ENVIRONMENT (7)
• “Select and consult labels or Material Safety
Data Sheets (MSDS), poison control centers,
consultants, agencies, and other references
for information.”
• Sources of help: Ministry of Labour, occupational
health clinics (not many freestanding ones)
• MSDS are available on the web. Find one you
like and book-mark it for use in your practice.
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077G ENVIRONMENT (8)
• “Select consultants (environmental
medicine specialists, toxicologists,
governmental agencies, industrial
hygienists, etc.) for the purpose of
documenting and quantifying exposure.”
• Industrial (occupational) hygienists: usually
chemical engineers with post-graduate
training in measurement and control of
environmental hazards
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077G ENVIRONMENT (9)
• “Select laboratory tests for the patient
to establish exposure or select
investigations to establish the presence
of adverse health effects in target
organs:
– Blood lead levels to access exposure
– Serum creatinine to look for effect on kidney
function.
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077G ENVIRONMENT (10)
• “If evidence supports, or a strong suspicion
exists for, a causal connection between
exposure and the clinical presentation, notify
the appropriate authorities to inspect the site
and thereafter to decrease and eliminate
exposure.
• Your responsibility lies beyond the specific
patient.
• Who do you contact? Next slide 
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ENVIRONMENT (11)
• Environmental Health Jurisdiction
– Public Health Unit
• Sanitation, reportable diseases, local hazard assess
– Municipal
• Garbage disposal, recycling
– Province/territory
• Toxic waste disposal, air/water standards
– Federal
• Food regulations, designating toxic substances
– International
• Treaties like Kyoto
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ENVIRONMENT (12)
• Risk assessment/management
• Epidemiology vs. toxicology
– Air
• Includes climate change
– Water
• Biological & chemical risks
– Soil
– Food
• Biological & chemical risks
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ENVIRONMENT (13)
• AIR
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Particulates
Ground-level ozone
Carbon monoxide
Sulphur dioxide, nitrogen dioxide
Biological agents (e.g. moulds, mites)
Organic compounds (e.g. benzene)
Heavy metals
Radiation
Global warming
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ENVIRONMENT (14)
• WATER
– Biological agents
• Mainly animal and human waste
• Very high risk in aboriginal Canadians
– Chemical agents
• Organic compounds
• Chlorination byproducts.
• SOIL
– Lead, pesticides, industrial waste
– Infants/toddlers are at highest risk
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ENVIRONMENT (15)
• FOOD
– Biological Contaminants
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Salmonella
Campylobacter
E. Coli
Listeria monocytogenes
Clostridium botulinum
BSE
Avian flu
Viruses, mould, parasites
– Chemical Contaminants
• PCBs, dioxins/furans, pesticide residues (e.g. DDT), endocrine
disruptors, food additives
• antibiotics
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