Practice Exercises on Surveillance PDF

 Practice Exercises SURVEILLANCE Q1- Prevention of road traffic accidents among school children is viewed as a priority public health problem by Egypt national health authority. In response to this concern, all data regarding this issue were collected and repo...

 Practice Exercises SURVEILLANCE Q1- Prevention of road traffic accidents among school children is viewed as a priority public health problem by Egypt national health authority. In response to this concern, all data regarding this issue were collected and reported by the attendant physicians in all school student’s hospitals organized by age, sex, cause, severity of injury and outcome of treatment. A weekly report was submitted to the affiliated districts health authority, then to the Directorates of Health Affairs, and finally to the preventive sector of the Ministry of Health. For situation analysis, a yearly report was sent to the regional office of the World Health Organization. A- Arrange the levels of data collection and reporting mentioned in this situation 1. 2. 3. 4. 5. 6. B- The method of data collection in this situation is 7. Active ( ) Passive ( ) 8. State why…………………………………. C-The regional office of the World Health Organization noticed that the magnitude of road traffic accidents in Egypt is underestimated. So, desighnated health of- ficers have been trained to make outreach visits to all school student’s hospitals ,emergency department and orthopedic hospitals to collect data for all cases of road traffic accidents. The method of data collection in this situation is Active ( ) Passive ( ) State why…………………………………. Q2- Write down the appropriate type of data collected in each of the following surveillances of communicable diseases. a) The number of infants vaccinated with the compulsory doses of oral polio vaccine in country (A) is 15,000 infants. 4  Practice Exercises …………………………………… b) 90% of the houses in country (B) are supplied by clean water ……………………………………… c) 95% of female anopheles mosquitoes in village (C) are night biters. ……………………………………… d) The male to female ratio in country (D) is 1: 2. ……………………………………….. e) 60% of contacts of open pulmonary tuberculosis cases received chemopro- phylaxis (INH). ……………………………………….. f) 15 cases of meningitis were laboratory confirmed in community (F) in 2008. All of them were males recently recruited in military service. Five of them died. ……………………………………….. ……………………………………….. g) Water samples testing in community (G) reveals presences of E – Coli. …………………………………………. h) A Malaria control program sprayed 90% of houses in village (H) with insecti- cides. ………………………………………….. Q3- Data of typhoid fever in community (X) was represented in the following fig- ures: Figure (a) 5  Practice Exercises 80 No. of typhoid cases 70 60 50 40 30 20 10 0 5 10 15 20 25 30 Age in years Figure (b) Comment on the following: Fig (a): represents……………………………..,that denotes………………………………, and….……. Fig (b): represents……………………………., that denotes……………………………………. To whom these data will be disseminated ……………………………… …………………………… Q4- Match each use of surveillance in column (A) with appropriate situation in column B Column (A) Column (B) Uses of surveillance Situations 1) Evaluation of ( ) The incidence of breast cancer in Egypt is 2) preventive and control raised during the last decade. measures 3) Identify the population at ( ) Smoking during pregnancy is associated risk with delivery of low birth weight babies. 4) Identify disease trend ( ) Dentists are vulnerable to infection with hepatitis B virus. 5) Formulate hypothesis ( ) SARS cases were first identified in China in the year 2002. 6) Investigate and control ( ) 90% reduction of malaria cases in village outbreaks (X) was due to use of DDT impregnated bed nets in 1997, compared to 50% reduction due to swamp filling in 2000. 7) Identify new emerging ( ) Unexpected excess number of typhoid diseases cases occurs in district (X) due to a contami- nated water source. 6  Practice Exercises Q5- Read the following statement about measles, and then state the criteria that made it a suitable candidate for surveillance. “Measles is one of the most common infectious diseases of childhood. It is en- demic in many communities. When the disease is introduced into a virgin com- munity, more than 99% of persons in that community will be affected. Despite the presence of an efficient vaccine, it was estimated that the global number of cases of measles in the year 2001 was 30-40 million and a three quarters of a million deaths of measles that represents about 60% of deaths attributed to vaccine pre- ventable diseases. Although the disease is mild, it can causes severe complica- tions; such as diarrhea and dehydration, pneumonia, encephalitis, corneal ulcer- ations and blindness due to vitamin A deficiency”. Write down the criteria that made measles a suitable candidate for surveillance: Q6- Complete the following 1. The proportion of total cases being detected by the system is ---------------------- 2. The extent to which a surveillance system accurately portrays the incidence of the health event in the population by person, time and place is--------------------------- ------------ 3. The proportion of cases reported to the system that actually has the health event. The appropriate indicator is ------------------------------ 4. How many days after the onset of a health event is the information reported to the surveillance system and action taken? ------------------------------------------------------- ------ 5. The willingness of persons and organizations to participate in the surveillance system. The appropriate indicator is---------------------------------------------------------------- ------------ 6. the survelliance system collects too much useless and copmlex informations. The appropriate indicator is ---------------------------------------------------------------- 7. The system can respond to new diseases, health conditions, changes in case definitions and variations across data sources. The appropriate indicator is-------- ------------ 7  Practice Exercises Elimination and Eradication Q1- Match the best preventive measure with the suitable disease and mention the point of attack at the cycle of infection (Agent, reservoir, Mode of transmis- sion). 1- Cholera epidemic.Health education ) ( 2-HIV. Vaccination ) ( 3-Malaria.Super chlorination of water ) ( 4-Measles.Insecticides ) ( Q2- Match the best preventive measure with the suitable disease and mention the point of attack at the cycle of infection (Agent, reservoir, Mode of transmission). 1- Measles. Vaccination and seroprophy ) ( laxis 2-Contacts of Meningococcal meningitis Vaccination ) ( 3- Contacts of hepatitis A patients Chemoprophylaxis ) ( 4-Newborn of hepatitis B HbsAg +ve Seroprophylaxis ) ( mother 5- Contacts of neonatal tetanus Nothing ) ( Q3- Match the best preventive measure with the suitable condition 1- A person travelling to endemic area for.Vaccination ) ( malaria 2-Severely injured person not immune to. Chemoprophylaxis ) ( tetanus. 3- The best preventive measure for polio Seroprophylaxis ) ( eradication. 4-The best control measure for T.B Case finding and treatment ) ( Q4- Draw the cycle of infection of typhoid with its 3 links: -Can this disease be eradicated? Yes ( ) No ( ) -Give your reasons 8  Practice Exercises Q5- Can you repeat the above exercise for meningitis? -Can this disease be eradicated? Yes ( ) No( ) -Give your reasons Q6- Hepatitis B has an effective vaccine. Is it enough to eliminate the disease? Yes ( ) No ( ) -Give your reasons Diseases suitable for eradication / elimination: I- Infectious diseases: a-Viral. b-Bacterial. c-Parasitic. II-Non infectious diseases. I-a- Infectious viral disease: 1-a-1- Small pox: I) small pox has been eradicated. the factors that enabled its eradica- tion are: a. Smallpox is an evident disease and can be recognized easily even by non-medical personnel. b. Course of the disease is limited (3 weeks). c. Incubation period is long. This allows time for containment. d. Absence of animal reservoir of infection. e. Absence of human carrier state. f. Absence of subclinical cases. g. The patient is not infectious during incubation period. h. Rarity of second attacks of the disease (solid post infection immunity). i. Availability of a stable, potent vaccine. II) What are the strategies used for its elimination? 1- ………………………………………………………………………….. 2- ………………………………………………………………………….. 9  Practice Exercises I-a-2-Measles: Measles is a suitable candidate to be eliminated. I) Draw the cycle infection of measles. II) Mention the favorable factors for its elimination. …………………………………………………………….........................................……… …………………………………………………………….........................................……… ………………………………….........................................………………………………… III) Mention the factors that make it difficult to be eradicated. ……………………………………………………….........................................…………… ……………………………………….........................................…………………………… …………………………………………….........................................……………………… I-a-3-Rubella: Rubella resembles measles not only in having generalized rash but also in being specifically human, acute self limiting disease, except that, the rare cases of con- genital infection may continue to excrete the virus for years. I) Effective surveillance is difficult because ……………………….......................….. ………………………………………………………………………............................……… II) However …………………………… is a cost effective strategy in rubella elimination. I-a-4-Poliomyelitis: I) Polio, like small pox, could be eradicated, why? …………………………………………………….........................................……………… …………………………………………………….........................................……………… ……………………………………………….........................................…………………… ………………………………………….........................................………………………… II) Mention the primary strategies for polio eradication ………………………………………........................................……………………………. …………………………………………….......................................……………………….. III) What are the difficulties that hinder polio eradication? ……………………………………….......................................…………………………….. ……………………………………………………………………..…………………………….... ……………………………………………………………………………………………............ ……………………………………………………………………..……………………….......... 10  Practice Exercises I-b-Infectious bacterial diseases: I-b-1-Neonatal Tetanus: I) Neonatal tetanus is a potential candidate for elimination, why it can not be eradi- cated? ………………………………………………………………………….. …………………………………………………………………………. ………………………………………………………………………….. ………………………………………………………………………….. II) What are the strategies that can be used for its elimination? ………………………………………………………………………….. …………………………………………………………………………. ………………………………………………………………………….. I-b-2-Tuberculosis I) What are the factors that make pulmonary T.B liable to be eliminated? a-………………………………………………………………………….. b-…………………………………………………………………………. c-………………………………………………………………………….. II) Mention the strategies for TB elimination ? a-…………………………………………………………………………... b-…………………………………………………………………………… c-…………………………………………………………………………… II-Non infectious diseases: There are four non-infectious diseases suitable to be eliminated, these are: 1-Vitamin A deficiency. 2-Iodine deficiency disorders. 3-Iron deficiency anaemia. 4-folic acid deficiency. N.B. Elimination of micro-nutrient deficiencies will facilitate the elimination and eradication of some infectious diseases. 11  Practice Exercises SCREENING Q1- Define screening and mention its goals. Q2- Compare between Screening and diagnostic tests. Q3- Enumerate uses of screening programs. Q4- Mention types of screening programs. Q5- Enumerate characteristics of a disease that makes it a suitable target for screening. Q6- Enumerate characteristics of the screening test or procedure that affect its suitability for screening Q7- A comparison of “clinically diagnosed” versus “autopsy-confirmed” myo- cardial infarction (MI) was performed among 1000 consecutive diseased pa- tients, as shown in the following table: Autopsy findings Total MI No MI 160 80 240 MI Clinical )a( )b( )a+b( Diagnosis 40 720 760 No MI )c ( )d( )c+d( 200 800 1000 Total )a+c( )b+d( )a+b+c+d( From these data, calculate the following: The prevalence of myocardial infarction at autopsy. ………………………………………………………………………….. The “Positive Predictive Value” of the clinical diagnosis. ………………………………………………………………………….. The “Negative Predictive Value” of the clinical diagnosis. ………………………………………………………………………….. Q8- The table below is a 2 X 2 table, in which screening test results for disease Y are tabulated in relation to the true disease status of the population being tested. 12  Practice Exercises Disease Y Screening test Total Yes No Positive 200 100 300 Negative 50 600 650 Total 250 700 950 Match each measurement listed below to its appropriate numerical value: 1-Sensitivity ( ) 250/950 or 26% 2-Specificity ( ) 200/300 or 67% 3-Positive predictive value ( ) 200/250 or 80% 4-Negative predictive value ( ) 600/700 or 86% 5-Disease prevalence ( ) 600/650 or 92% Q9- For each of the numbered items below, select the most appropriate mea- sure from the following lettered options. Each option can be used once, more than once, or not at all. a- Sensitivity 1. Among 100 patients with Alzheimer’s disease, 15 subjects score within the normal range on a b- Specificity battery of tests of cognitive performance. 2. Among 500 persons with positive screening tests c-Positive predictive for antibodies to the human HIV, 492 are infected value with the virus. 3. Among 1000 women without breast cancer, d- Negative predictive screening mammograms are normal for 920 value women. 4. Among 750 persons with normal screening test e- False-positives results for serum cholesterol, 50 actually have elevated serum cholesterol. f- False-negatives 13  Practice Exercises INVESTIGATION OF OUTBREAKS Reminder Basic steps of epidemiologic outbreak investigation : The order presented in this learning guide reflects the logical process of most outbreak investigations. However, each outbreak is unique and the investigation should be conducted in a way that ensures that all steps are completed. Several steps may be and sometimes should be conducted si- multaneously, emphasizing the importance of a teamwork approach. 1. (Confirm the diagnoses): Clinical and laboratory findings in reported cases should be reviewed close- ly, either directly, by examining the patients, or indirectly, by detailed re- view of the medical records and discussion with the attending health-care provider(s). 2. (Confirm outbreak): Utilize existing surveillance data at local, region- al, and national levels to determine the background rate of occurrence of the disease. (attack rate and relative risk). 3.(Case definition):Contact cases and obtain the following information -Demographics (age, sex, occupation) - Date of onset of illness - Clinical symptoms and signs - Potential risk factors for infection 4. (Case finding): Ascertain all cases via active surveillance to determine the extent of the outbreak. Create line list of possible cases and confirmed cases. 5. Put a descriptive epidemiological profile: Develop a case definition based on person, place and time to reduce misclassification of disease sta- tus. 6.Plot and interpret epidemic curves to determine some characteristics of the epidemic/outbreak that is being investigated. 7.Formulate a preliminary hypothesis about the cause of the outbreak. 8.Test the hypothesis by analyzing data and Performing epidemiologic study: cohort or case-control. Compare risk factors among ill (cases) vs. not ill (controls) 9.Additional environmental studies: according to needs 10.implement preliminary control measures. - Control the source of the pathogen. - Interrupt the transmission. Control or modify the host response to exposure. 11.Draw conclusions (epidemiologic andcausal inference) ,make recom- mendations to prevent further transmission of the disease and prevent a new outbreak. 12.Write a report of investigation and control measures and disseminate as appropriate (Communicate findings). 14  Practice Exercises ExercisesExercise (1) Part 1 On April 18, 46 people reported an acute episode of gastrointestinal illness characterized by nausea, vomiting, diarrhea and abdominal pain. All 46 people say that they attended the same supper before becoming ill. Their family members who did not attend the supper did not become ill. A total of 80 people were at the supper. You confirm the findings of the local health officer and suspect that something in the supper was responsible for all these cases of illness. You also know from recent National Health Survey data that, on average, a person experiences ap- proximately two episodes of acute gastrointestinal illness per year. Questions: 1. Would you declare the situation an outbreak ? Why or why not? 2. List the steps of an outbreak investigation. 3. You plan to interview the people who attended the supper. What information will you want to collect? 4. Will you use a cohort or a case or a case-control study to investigate the outbreak? Why? What measure of association is most appropriate to compute for this type of study? 15 Practice Exercises 16  Practice Exercises 17  Practice Exercises Part 2 You learn that the supper was held in the village school and lasted from 6 PM to 11 PM. The food contributed by the members, was spread out on a table and con- sumed throughout the evening. You are able to interview 75 of the 80 people who attended the supper. Your find- ings on food and beverage consumption are detailed in the line listing, along with the time of onset of symptoms for people who become ill. Unfortunately, only about half of those who become ill reported the time when they had eaten. Approximately 20% of the people who were sick were treated by a doctor. No fecal specimens were obtained for bacteriologic testing. 5. What number will you use for the population at risk in this study? Why? 6. As soon as epidemiologists have the necessary data, they develop an epidemic curve How does an epidemic curve help in an investigation? 7.Draw the epidemic curve using the information given in the line listing.What does this epidemic curve tell you? Exercise (2) Read the following table and respond to the questions Table -A- Food eaten and drinks consumed at lunch by fifth grade classes, El- ementary school campus, in Alexandria, July 1999. Ate Not Ate Food Ill Well Total Ill Well Total Salad 16 15 31 10 8 18 Chicken 16 11 27 10 12 22 Potatoes 25 8 33 1 15 16 Bread 22 13 35 4 10 14 a. Name the risk estimate you can calculate for incriminating a food type and write its formula. b. Using data in the table, which consumed item(s) are most likely to have been associated with the risk of gastroenteritis. 18  Practice Exercises Exercise (3) Plot the following data of an epidemic of viral hepatitis. What type of epidemic does this appear to be? Date of onset of an epidemic of viral hepatitis, city X (in August and September 1978) no of cases no of cases Aug 1978 21 1 Sept 1978 3 13 22 0 4 12 23 1 5 11 24 0 6 11 25 0 7 3 26 0 8 1 27 2 9 3 28 4 10 3 29 0 11 2 30 2 12 0 31 7 13 2 Sept 1 7 14 0 2 13 Total 98 19 Practice Exercises 20  Practice Exercises Exercsie (4) At least 70 people attending a conference in a city X became ill with what appeared to be food poisoning. 48 participants who complained of nausea and vomiting were treated and released from hospital. Others with similar symptoms were hospitalized overnight. A health official noted that all of the patients had eaten snack at the hotel. The hotel snack menu included roast chicken, roast beef, and a vegetable dish. Because some of the people who become ill were vegetarian, there was particular interest in determining whether the vegetable dish might be contaminated. The health officials were looking for the source of the outbreak and the hotel stopped food service for the time being. Questions 1- Explain why you might consider the problem important enough to investigate. 2- Briefly describe the initial steps that you would take in investigating this problem. Indicate the type of data needed to accomplish each step. 3-Develop probable hypotheses to explain the source and mode of transmission of the outbreak. 4- Develop suitable recommendations and interventions for controlling the problem. 21  Practice Exercises COMMUNICABLE DISEASES Case Studies Case 1: A 35 years old school bus driver had been recently released from prison came to the hospital with a 6 week history of cough, fever, night sweating, weakness, fatigue, and shortness of breath. The patient lives with his wife and three young children. A test was done to each of the family members at the time of the patient’s initial diagnosis. The results were positive for the patient’s wife and the two years old daughter. No evidence of clinically active disease was found in either the wife or the other children. 1. What is the most probable diagnosis of the driver ?............................................................................... 2. The investigations that lead to this diagnosis include: ………………………………………………………… ………………………………………………………… 3. Suggest the possible site from which the patient acquired the disease. ………………………………………………………… 4. Explain why this site has higher rate of the disease. …………………………………………………………. …………………………………………………………. 5. In the previous situation who else should be investigated for infection? …………………………………………………………… 6. Mention briefly control measures that should be undertaken in this situa- tion...................................................................................... …………………………………………………………….. Case 2 In village ( X ) three newly born having symptoms and signs of twitching of the face ,rigidity, and convulsions presented to the health center. This occurred during the period from mid March to 1st of May 2003. Records of the health center showed that there have been two other cases with the same diagnosis during the previous two years.The 3 cases were home deliveries. The time of onset of symptoms after birth for the 3 cases was as follows: Case 1: after 9 days, Case 2: after 4 days, Case 3: after 7 days Only one of these 3 cases had survived after the attack 22  Practice Exercises 1. What is the possible diagnosis? …………………………………………………………. 2. Why this disease is more commonly found in rural areas? …………………………………………………………. …………………………………………………………. 3. What are the possible malpractices during delivery that caused the infec- tion?................................................................................. 4. Which case was the survivor among the 3 babies and why? …………………………………………………………… 5. If you were the managing doctor, what are the treatment steps you would take for controlling the infection in the 3 cases? …………………………………………………………….. …………………………………………………………….. 6. Does the survivor from this disease need to be vaccinated against it during his infancy? Why? ……………………………………………………………… 7. All the 3 neonates have children contacts in their families. Are these contacts in danger of having the disease? Why? ………………………………………………………………….. Case 3: At January 2003, Mona nine years old complained of headache, nausea and vomiting. She was feverish. On examination the doctor noticed neck stiffness. 1. What is the possible diagnosis of this case?.................................................................................... 2. How to confirm this diagnosis?.................................................................................... 3. Mona was referred to the fever hospital, the school directory decided to close the school for 3 days, fumigated the school classes using disinfec- tants. What is your opinion about action done by the school directory? ……………………………………………………………… ……………………………………………………………… 4. If you were the school physician, what do you have to do to school chil- dren and the school environment? ………………………………………………………………….. ………………………………………………………………….. 23  Practice Exercises Case 4: Hossam is a 19 years old food server in a beach resort in Hurrghada. He is residing in a dormitory with 10 other workers in the resort (two are working in the kitchen). He spent two weeks vacation in his village in Monoffia Governorate. Three days after returning to his work he started to suffer from malaise, gradual rise of temperature which soon became sustained decreasing but not reaching the base line with abdominal discomfort and relative bradycardia and no neck rigidity. The physician took a blood sample and started to give Hossam antibiotic and instructed him to abstain from work. The physician declared other measures on getting the result of the blood examination. 1- What is the provisional diagnosis of Hossam’s illness? Give reasons ……………………………………………………………… ……………………………………………………………… 2- Why did the physician take a blood sample? ………………………………………………………………. 3- Should he take other samples at this stage of illness? What are these samples?................................................... Yes ( ) Give reasons. ……………………………………………………………… No ( ) Give reasons. ……………………………………………………………… 4- Hearing about Hossam’s illness, some of the guests in the resort were afraid of becoming ill as Hossam. Is there reason for their fear? Why ? ……………………………………………………………… ……………………………………………………………… 5- Do you think that Hossam acquired the infection in the resort? Yes ( ) No ( ) State why and mention the possible place of acquiring the infection if the answer is No. ……………………………………………………………… ……………………………………………………………… 6- What are the measures to be taken by the resort’s physician? Measures for Hossam: ……………………………………………………………… Measures for his work mates: ……………………………………………………………… Measures for the resort in general: 24  Practice Exercises ……………………………………………………………… Measures for guests: ……………………………………………………………… After how long Hossam could return to work as a food server? ……………………………………………………………… Is there a possibility that Hossam could not work as a food server in spite of becoming well? Why? ……………………………………………………………… Is this possibility high? Why? ……………………………………………………………… Case 5: An infant born to a mother who known -prior to delivery- to be a surface antigen carrier (HbsAg+), For prevention of hepatitis B in this infant: Write the followings: a. Immunizing agents used: ………………………………………………………….. b. Timing of immunization: ………………………………………………………….. c. Any follow-up testing to be done: ……………………………………………………………………….. 25  Practice Exercises Health education Planning Objectives By the end of the practical session the learner will be able to a) State the different steps in planning health education intervention b) Carry out the steps c) Plan a health education session Part I- Introduction Answer the following questions 1- What do we mean by planning? 2- What will be the aim of the health education program to be planned? 3- What do we mean by a behavior? 4- Give two examples for preventive behavior and treatment behavior 3- What are the steps to be carried out in planning a health education interven- tion? Part II – Planning 1- Social diagnosis Questions Q.1.What are the steps to be carried out in planning a health education interven- tion? Q.2. How to carry out social diagnosis? Exercises 1-In threes select 5 social indicators to assess the quality of life in Egypt and com- ment on them. 2- In threes draw a line indicating the quality of life as shown 0 100 Ask them to put an X on the line Then discuss what are the obstacles faced. 2- Epidemiologic diagnosis Exercise The situation analysis carried out by planners indicated the following health prob- lems affecting infants: Diarrhea, Acute respiratory infections, Congenital heart, Injuries and Protein malnutrition 26  Practice Exercises In threes, use the following table and prioritize them Each item is given a score from 1- 5.  Add the scores Compare the scores The problem with the highest score is the priority problem. Problem Magnitude Seriousness Demand Cheap Total score 1-5 1-5 1-5 1-5 1-5 Diarrhea ARI Cong ht Injuries PEM The priority problem is ……………………………………………….. Developing objectives Criticize the following objectives A- Reduce incidence of measles and German measles in 6 months. - - - - - B- “Eradicate poliomyelitis by the year 2000 in Egypt” - - - - C-“Reduce mortality of children under 5 from diarrhea in Egypt by 50% within 5 years” - - - - Exercise Develop two program objectives for diarrhea 1- To reduce deaths from disease 2- To reduce incidence of disease 27  Practice Exercises 3-Behavioral diagnosis Exercise In small groups of threes A. Use a figure to illustrate how one can analyze the problem B. List possible causes of diarrhea among infants - - - - - - C. List possible outcomes for diarrhea - - - D. List possible causes for the outcome - - - - E. From the analysis carried out, develop a list of behaviors (use your answers in B and D. Use the following tables. Behaviors Non Behaviors Preventive behaviors Treatment behaviors Look at your program objective If it is to reduce incidence of disease, you have to focus on preventive behaviors. If it is to reduce mortality of disease, you have to focus on both pre- ventive and treatment behaviors. 28  Practice Exercises Exercise: Prioritize behaviors Use the following Matrix and rate selected behaviors in terms of I-Importance If the behavior is directly linked to the health problem. If the behavior occurs frequently. II- Changeability In the developmental stage.  Recently been established.  Superficially tied to established cultural patterns or life-styles. MATRIX Important Not/less important Changeable Not/Less Changeable The high priority behaviors are: (write them in action verbs):- - - - - - Developing Behavioral Objectives For the two program objectives written earlier, write down a related pri- ority behavioral objective. 1-Program objective to reduce deaths from disease Behavioral objective related 2-Program objective to reduce incidence of disease Behavioral objective related 29  Practice Exercises 4- Educational Diagnosis Exercise For the behavior, Mother prepares ORS, data indicated that:  70% of mothers heard about ORS.  90% do not know how ORS works.  80% perceive that antibiotics not ORS are the ideal treatment.  80% of mothers do not believe that infants could be treated by ORS.30% of mothers heard that they can use any drink instead of water in prepar- ing ORS.  50% of mothers have a negative attitude to ORS.  100% of mothers value their infant’s health.  90% of mothers prepare ORS wrongly.  100% of mothers have access to ORS.  100% of mothers can afford buying ORS.  95% of doctors and 98% of nurses have a positive attitude towards ORS.  90% of doctors prescribe ORS.  3% of grandmothers encourage their daughters to administer ORS. 1-Sort the data provided under the following titles Predisposing Knowledge - - - Perception - Beliefs - Attitudes - Values - Enabling - - - Reinforcing - - - 2-Rate the selected predisposing factors according to importance and Changeability using the following matrix 30  Practice Exercises Important Not/less important Changeable Not/Less changeable 3-Rate the selected enabling factors according to importance and Changeability using the following matrix Important Not/less important Changeable Not/Less changeable High priority factors related to the behavior (Mother prepares ORS) Knowledge Beliefs Skill Developing educational objectives Developing Educational Questions objectives 1-What will be the focus of an educational objective? a- b- 2- State which of these objectives are educational: A. Eliminate tetanus in Alexandria in 10 years B. By the end of the program 80% of drivers in Alexandria will believe in the merits of using a belt during driving C. By the end of the program 70% of school pupils in Alexandria will respect street lights D. By the end of the program 80% of school pupils in Alexandria will strictly respect street lights according to health education guidelines E. By the end of the program 95% of mothers in Alexandria will list signs of dehydration 31  Practice Exercises Exercise Develop educational objectives for factors identified previously for the behavior: mother prepares ORS. I-Knowledge II-Beliefs III-Skills Selection of Health Education Strategies and Channels Questions 1-What are the health educational strategies? 2-What methods one should use in this strategy? Give examples - - - - - - - - - - - - 3-When do you use training strategy? 4-What methods one should use in this strategy? Give examples of methods for training Manual skill: a- b- Thinking skill: a- b- Communication skill: a- b- 5- When do you use the organization strategy? 6-What methods one should use in this strategy? - - - Questions 1- If you are dealing with lack of resources, which strategy you should use? 2-If you want to build abilities and skills for social development, which method you should use? 3-If your efforts are directed towards a disadvantaged segment and distribution of resources is needed, which method you should select? 32  Practice Exercises 4-If you want to solve social problems detected, which method you should use? Questions 1-What are the levels of evaluation? i. ii. iii. iv. v. 2-State which level of evaluation will assess the following objectives: A- Program objective? B- Educational objective? 3-State which level (s) of evaluation assess (es) the implementation of services? 4-State which level (s) of evaluation assess (es) the plan developed? 33  Practice Exercises CASE STUDY Health Education Learning objectives By the end of the case, learners will be able to a. Criticize prioritization of the problem carried out in the case study. b. Identify wrong behaviors. c. Develop a behavioral objective. d. Identify predisposing and enabling factors for the behavior identified. e. Develop an educational objective related to skill. f. Select the proper strategy and methods to achieve the written objective. CASE STUDY 1 A school physician proposed to carry out a health education program for prevention of road traffic in 10 primary schools in Alexandria. He selected this problem as a priority problem on basis of its importance, seriousness, demand of the educational authority as well as his own interest in the subject. Q.1 What was the wrong criterion selected by the school physician? Q-2 State what is the behavior that he should focus on ? Q-3 Write down a behavioral objective? Q- 4 State 2 predisposing factors discovered in the survey? 1- 2- Q-5 State 2 enabling factors ? 1- 2- 34  Practice Exercises Q-6 State 2 areas other than skill that educational objectives should focus on? 1- 2- 7- Write down one educational objective related to skill needed for achieving the behavior? 8. Select the strategy and methods to be used to achieve the developed objective ? 35  Practice Exercises DEMOGRAPHY Question 1: The crude birth rate (CBR) in Egypt 1995 was 29/1000 population and the crude death rate (CDR) was 9/1000 population. The net migration rate was – 0.1%. Calculate the RNI and the GR of Egypt in 1995. Question 2: If the RNI and GR in Egypt 2000 were equal, suggest two possibilities. Question 3: The following tables show distribution of population of country A and country B by age and sex. From the tables: Compare between both pyramids regarding: Items Community (A) Community (B) 1- The median age (High or …………………… …………………… low). …………………… …………………… 2- The dependency ratio (DR) …………………… …………………… …………………… …………………… a) The young DR. …………………… …………………… b) The old DR. c) The total DR. 36  Practice Exercises Distribution of country (A) population by Age and Sex (1986 Census) Male Female Total Age No. % No. % No. % Less than 5 3753848 7.6 3608333 7.7 7362181 15.3 5- 327658 6.6 3070428 6.5 6341086 13.1 10- 293638 6.0 2647282 5.6 5577920 11.6 15- 2692898 5.5 2370734 5.0 5063632 10.5 20- 2222672 4.5 2024869 4.3 4247541 8.8 25- 1788443 3.7 1909065 4.0 3697508 7.7 30- 1514610 3.1 1530714 3.2 3045324 6.3 35- 1491751 3.0 1433555 3.1 2925306 6.1 40- 1054937 2.1 1073015 2.3 2127952 4.4 45- 972484 2.0 942756 2.0 1915240 4.0 50- 796138 1.6 899538 1.9 1695676 3.5 55- 673137 1.3 579157 1.3 1252294 2.6 60- 554010 1.1 577203 1.2 1131213 2.3 65- 352264 0.7 330227 0.7 682491 1.4 70- 293308 0.6 226808 0.5 530116 1.1 75+ 195037 0.4 190880 0.4 385917 0.8 Missed 152441 0.3 120400 0.3 272841 0.6 Total 24709274 50 23544964 50 48254238 100 37  Practice Exercises Does not include people outside the country Distribution of the Country (B) by Age and Sex (1986 Census) Male Female Total Age No. % No. % No. % Less than 5 123257 6.2 118943 8.1 242200 14.3 5- 107091 5.3 103296 7.1 210387 12.4 10- 87864 4.4 84634 5.8 172498 10.2 15- 72697 3.6 72499 5.0 145196 8.6 20- 76900 4.0 71488 4.7 148388 8.7 25- 114995 6.2 72261 4.9 187257 11.0 30- 110977 5.8 62746 4.4 173723 10.2 35- 88466 4.6 49095 3.4 137561 8.1 40- 64808 3.5 33272 2.3 98080 5.8 45- 48948 2.6 23490 1.7 72438 4.3 50- 31368 1.6 14856 1.1 46224 2.7 55- 18237 1.0 9086 0.6 27323 1.6 60- 9040 0.5 6131 0.4 15171 0.9 65+ 10649 0.6 10207 0.6 20856 1.2 Total 965297 50 732004 50 1697301 100 38  Practice Exercises 39 Practice Exercises 40  Practice Exercises Question 4: Use data below to calculate the dependency ratio for country x. 0 - 14 = 11.252 million 15 - 64 = 37.690 million 65 + = 9.156 million Question 5: The following figure shows population pyramids of a developed country and a less developed country. 1- State the main differences in the structure of the two populations shown and suggest reasons for the differences stated. 2- Describe the main changes you would expect in the shape of the population pyramid for both countries after 50 years if both the birth rate and death rate were to fall. 41 Practice Exercises 42  Practice Exercises Question 6: Look at the population pyramids below State problems of country A and problems of country B resulting from their popu- lation structure. Question 7: 1- In the Demographic Transition Model below, in which one of the four stages is the rate of natural increase greatest? 2- In which two stages shown in the figure is the rate of natural increase low? 3- Having studied the population statistics for Singapore, into which state or stages of the Demographic Transition Model would you place Singapore? Give one reason for your answer. 43  Practice Exercises Population statistics for Singapore Death rate Natural in- Year Birth rate Per 1000 )%( crease 1960 36 6 3.0 1970 27 6 2.1 1985 17 5 1.2 Question 8: The following figure shows the birth and death rates for a country from 1900 to 2000. Using the information in the figure answer the following: 1- State the year with the highest birth rate. 2- Describe two ways in which the death rate between 1900 and 1935 dif- fered from that between 1960 and 2000. 3- In which one of the following years was the natural rate of population growth at its highest? 4- State how life expectancy in 1900 most likely differed from that in 2000. 44  Practice Exercises Question 9: Study the following figure showing stages of population development (Demo- graphic Transition Model) and population pyramids A, B, C and D. a) Write down A, B, C, and D as a list and state in which stage of population development each of the pyramids would be found. b) Give reasons for the rapid fall in the death rate in stages 2 and 3. c) Describe stage 4 of the Demographic Transition Model. 45  Practice Exercises Question 10: From the following table: Age groups No. of females Live births.Age sp. F.R 15- 100 8 20- 250 80 25- 200 96 30- 300 84 35- 200 40 40- 150 24 49 – 45 250 20 Total 1450 352 Calculate: - General fertility rate. - Age specific fertility rate. - Total fertility rate. - Gross reproduction rate (Female % = 48%). Question 11: In a community (X) the total population = 30000000 persons in 2005, if 60000 deaths from TB occurred in the same year, calculate a suitable rate. Question 12: The total deaths in a village (X) in 1960 were 100. Of these, 16 were due to pneu- monia. If the total population is 10000, calculate three rates. Question 13: In a village of 5000 person, the following was registered: 200 births, 80 deaths, of these 20 were below 1 year and one female died from maternal causes. Calculate four rates and a ratio. 46  Practice Exercises Question14: Study the following figure, which shows the population pyramid for Botswana, a developing country in Africa, in a recent year. a) Describe the absentees (migrant workers) shown on the pyramid and suggest reasons. (b) What are the consequences for developing countries such as Botswana of such a large number of absentees? 47  Practice Exercises Question 15: What are the effects of internal migration to highly populated cities (e.g. Cairo)? 48  Practice Exercises The Expanded Program on Immunization MMR Vaccine Measles Rubella Mumps Clinical Fever ≥38.5 fever˃37.2 Unilateral or presentation lasting ≥3 days generalized bilateral swelling generalized maculopapular of parotid or other maculapapular rash salivary glands rash lymphadenopathy cough, running nose, conjunctivitis Complications Diarrhea arthralgia and Orchitis in post- respiratory tract arthritis in young pubertal males but infection and otitis adults sterility is rare media Congenital rubella Oopharitis encephalitis syndrome: occur Pancreatitis blindness (by in ≥90% of infants causing vitamin A born to women who acquire deficiency) rubella during the first trimester with decreasing frequency therafter Cycle of infection: Agent Viral infection Reservoir Only man Only clinical cases Clinical and Clinical and (mild to severe) subclinical cases subclinical cases Exit Nose and mouth Mode of Contact transmission (droplet, direct, indirect) transmission +air borne transmission + Transplacental Inlet Nose and mouth Susceptibility o Susceptibility is general o Post infection immunity is life long o Infants born to mothers immune against measles or german measles will acquire natural passive immunity fot the first 6 to 9 months of age Communicability Highly Moderate Moderate communicable communicability communicability MMR vaccine: Type: live attenuated vaccine Dose and route of administration: 0.5 ml subcutaneous injection at the deltoid region 49  Practice Exercises Schedule: It is given to all infants as a single dose vaccination at the age of 12 months with a revaccination dose at the age of 18 months post immunization immunity: life long Contraindication to vaccination: 1. As a live attenuated vaccine, it is contraindicated to be given to immune-com- promised children (Except in case of HIV infection measles vaccine should be given) 2. Pregnancy (German measles vaccine is contraindicated to be given to pregnant women and those who intend to be pregnant after 3 months) N.B: 1. Post exposure prophylaxis against measles can be carried out using the mea- sles vaccine or immunoglobulin. In case of using the vaccine, it is found to be ef- fective in aborting the attack of disease if it is given in the first 3 days following exposure. But if it is given in the second 3 days (second half of the incubation period) the attack will be in a mild clinical form. 2. In case of exposure of a non immune pregnant woman to german measles infec- tion (especially in first trimester), laboratory investigations should be carried out. If she has IgM or rising IgG, it is an indicator of recent infection, so abortion should be done or immunoglobulin should be given. DPT Vaccine Pertussis infection is acute bacterial infection of the respiratory tract caused by Bordetella pertussis. It has an initial stage of irritating cough that gradually becomes paroxysmal and lasts for 1 to 2 months or longer. It has a high morbidity and mortality especially among infants. Complications include pneumonia, atel- ectasis, seizures, encephalopathy, hernias and death. Diphtheria is acute bacterial infection primarily involving the mucous membrane of the upper respiratory tract with a characterizing grayish white adherent mem- brane. Bacteria release a potent exotoxin. Absorption of this exotoxin can lead to myocarditis with heart block as well as neurological complications in the form of polyneuropathies that can mimic Guillian-Barre syndrome. The disease has a high fatality rate even with treatment. Tetanus (back to the lecture book) DPT Vaccine: Type: - Diphtheria toxoid - Pertussis killed whole cell vaccine - Tetanus toxoid 50  Practice Exercises Dose and route of administration: 0.5 ml intramuscular injection in the anterolat- eral aspect of the thigh Schedule: The recommended schedule include 3 primary doses at the ages of 2,4,and 6 months and a booster dose at the age of 18 months Side effects: There are 4 groups of side effects that may occur within 48 hours following vaccination Type of side Clinical Frequency Management/ effects presentation recommendations 1. Systemic - fever ≤38.5 Very common All vaccinated reaction - dizziness, (≥80% of infants should a) General malaise vaccinated) receive: reaction - analgesic and antipyretic for 48 hours following vaccination b) CNS The whole cell Rare side effect For subsequent irritability killed vaccine but the frequency doses of the of pertusssis is of its occurrence vaccine the infant the incriminated increase markedly should receive DT component. after the age of 6 only manifestations years -For those above may be in the form 6 years of age any of: booster doses of - high persistent the vaccine should fever ˃38.5 be in the form of dT. - convulsions - shock - persistent cry for ≥3 hours without apparent cause 2. Local reaction - pain, tenderness, Very common redness, and swelling at site of injection 3. Allergic - unpredictable Very rare -The infant should reaction and it can be mild NOT receive this to severe reaction vaccine (DPT) again 51  Practice Exercises A new preparation of pertussis vaccine (acellular pertussis aP) become available now and start to replace the whole killed pertussis vaccine. Administration of acellular pertussis vaccine do Not associated with CNS irritability manifestations compared to the whole cell killed vaccine. Exercise Vaccination Coverage Table: from the following data calculate and interpret the vaccination coverage of Measles vaccine of infants by health office X in 2003 Months No. of vaccinated infants Cumulative frequency January 120 ……………………………… February 80 ……………………………… March 110 ……………………………… April 120 ……………………………… May 90 ……………………………… June 130 ……………………………… July 120 ……………………………… August 80 ……………………………… September 130 ……………………………… October 130 ……………………………… November 120 ……………………………… December 120 ……………………………… Total 1350 ……………………………… The total no of target infants = 1500 The vaccination coverage = ……………………………………… 1- Write your comment: 3- Draw the curve and write down its title. 52  Practice Exercises 53  Practice Exercises Exercise Estimation of monthly supply of vaccines: 1- Calculate the monthly supply of measles vaccine in the health office pro- vided that the population size is 20.000, the crude birth rate is 30 live births per 1000 population, the coverage rate of measles vaccination is 85%, the reserve of vaccine is 20%, the wastage is 25%, and the vaccine is provided in 10 doses vials. 2- Calculate the monthly supply of OPV vaccine for the health office provided that the population size is 40.000, the crude birth rate is 20 live birth / 1000 population, the coverage of OPV vaccination is 95 %, the wastage is 20%, the reserve is 20% and the vaccine is provided in 20 doses vials. 3- Calculate the monthly supply of DPT vaccine for the health office provided that the population size is 10.000, the crude birth rate is 40 live birth / 1000 population, the coverage rate of DPT is 90%, the wastage for DPT vaccine is 20%, and its reserve is 25%, the vaccine is provided in 20 doses vials. Vaccines Dose needed Vials needed DPT.………………….………………… Polio.………………….………………… Measles.………………….………………… 54  Practice Exercises Reproductive Health Learning objectives By the end of the case, learners will be able to 1. Point to risk pregnancies. 2. Diagnose level of anemia. 3. Select a proper place of delivery for the case. 4. Diagnose puerperal sepsis. 5. Identify that puerperal sepsis is a direct cause of death. 6. Point to the several factors that led to death of the case that could be avoided. Case study1: - Mona is 29 years old, had only one baby girl 6 months old. She did not experience any obstetric problems whether in this pregnancy or its outcome. She is illiterate and her husband was a manual worker who was a heavy smoker. She lived in small two rooms with her husband, in laws, her husband sister and her baby. She has chronic piles and anemia. She is now 5 months pregnant. She went only once to antenatal visit complaining of easy fatigability. Her hemoglobin level was 10 gm/dl. The doctor prescribed iron tablets but she refused to take them thinking that it will lead to constipation. Besides, she was afraid that the Iron tablets will harm the baby. Her mother-in-law disapproved of antenatal care. She declared that pregnancy and delivery are normal processes that need no fuss. In her initial visit the health team did not give her any information about her condition or its management. They did not discuss the importance of antenatal care, or danger signs. They did not give her any nutritional advice. 1. What are the different pregnancies risks in this case study? 2. What is Mona’s level of anemia ? 3. What place of delivery you recommend for this woman and why? - She delivered at home by a retired midwife. The midwife left immediately after re- ceiving her fee. After delivery she complained of fever and had bad odor vaginal discharge. She ignored these symptoms and after seven days she died. 1. What is the possible cause (s) of Mona’s death? 2. Do you classify these causes as maternal deaths? 55  Practice Exercises 3. What are the factors that may have caused puerperal sepsis? 4. What factors that led to Mona’s death that could be avoided in this case study? Objectives : By the end of this case study, the learner will be able to : (1) Identify normal weight gain during pregnancy. (2) Diagnose abnormal weight gain. (3) Recommend proper management for the case. Case study2: A woman, at 35 wks gestation, is visiting the center for a routine prenatal visit. On assessment, the nurse finds that she has gained 5 Kg in the past month. Q.1: What is the significance (if any) of this weight gain? Q.2: What other assessments should be carried out at this time? Q.3: What are the required preventive measures for this client? Exercise1: In the following table, for each case study identify the different pregnancy risks: Case study Biological Social Medical Obstetric risk risk risk risk 1) A 34-year-old who is in her second pregnancy is seen for prenatal care at 24 weeks gestation. Her blood pressure is 130/80 mmHg. 10 years ago she had her first baby. Her family history reveals that her mother has type 2 diabetes mellitus. A urine dipstick shows 3+ glycosuria and negative ketones. 2) a 15-year-old mother is pregnant with twins, on testing blood she was proved to be Rh negative ,her husband was Rh positive 56  Practice Exercises Exercise 2: Complete the followings regarding maternal mortality: 1- High maternal mortality rate indicates:-…………………………………… 2- Calculation of accurate maternal mortality rate is difficult in underdevel- oped countries because ………………………………….. 3- if a pregnant woman has a severe antepartum hemorrhage and dies of Hy- povolaemic shock, the primary cause of death is …………… And the final cause of death is …………………. 4- If a woman has eclampsia and dies of a brain hemorrhage, ………. is the primary cause and the …………..is the final cause of death. 5- A woman who had rheumatic heart disease and became pregnant she had complication of heart failure and died.This is …………….cause of death. 6- A woman who was pregnant and died due to car accident. This is ………..………….in calculation of maternal mortality rate. 7- In a large maternity service consisting of one small hospital and six Clin- ics, there have been 10,000 live births and 35 women died in the past year. These deaths include women who died as a result of septic abortions as well as women who died of sepsis following delivery. a. According to the definition of maternal mortality, are these deaths belonging to maternal deaths or not? …………………………… b. Calculate a suitable rate or ratio from given figures 57  Practice Exercises Exercise 3: The following table shows some of the Avoidable Factors contributing to ma- ternal morbidity and mortality. Measures could be done to avoid Avoidable factors these factors 1- Young age at pregnancy ……………………………….. 2- Inability to recognize dan- ……………………………… gerous signs and symptoms 3- Inability to reach hospital ……………………………………………… 4- Inability of doctors to early diagnose and refer patients ………………………………………… 5- Patients dying from hemor- ……………………………… rhage 6- Patients dying from sepsis ……………………………… 7- Deaths from abortions of unwanted pregnancies ……………………………… 8- Deaths due to underutilized ………………………………. services 9- Deaths due to anemia 10- Anesthetic accident 58  Practice Exercises UNDER-FIVE HEALTH CARE SERVICES Tutorial class Learning objectives 1. Review the components of under-five health care services provided at MCH or Family heath centeres (preventive, follow up, curative services) for in- fants and preschool children) 2. Identify measures/tools commonly used to monitor growth and develop- ment of underfive children 3. Explain the concept and utility of the growth chart in growth monitoring 4. Plot a weight-for-age growth curve and interpret its findings 5. Interpret different patterns of normal and abnormal growth curves 6. Identify children at special risk of under-nutrition 7. Formulate key health education messages (to be used for counseling the mothers about feeding problems of their children) 8. Calculate and interpret different health indicators used to evaluate the quality of Under-five Health Services Learning activities 1. Some data will be provided to plot a growth curve, and interpret its findings. 2. Different examples of normal and abnormal growth curves will be displayed. A group discussion will be carried out for interpretation. 3. Practice exercises Growth monitoring What to look for in the child’s weight-for-age growthcurve Is the child’s weight outside the normal range? Is it below the 3rd percentile or above the 97th percentile? If the weight is below the 3rd percentile, is it far below? Is the child’s growth curve rising, flat or falling? If the child’s growth curve is rising, is it parallel to the reference curve? Is the child’s growth curve rising faster or slower than the reference curve, or at the same rate? How has the child’s growth curve changed? The following data provided are for a baby boy who was followed-up in serial monthly visits to measure his weight. Draw and interpret the growth curve of this child. 59 Practice Exercises Age in months Weight measurements 1 4 kg 2 5.50 kg 3 6.25 kg 4 7 kg 5 8 kg 6 8.50 kg 7 9.75 kg 8 10 kg 9 10.50 kg 10 10.75 kg 11 11 kg 12 15 11.50 kg 11.75 kg 60  Practice Exercises Interpretation: ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………..... Different examples of normal and abnormal growth curves A slow growth curve means growth faltering 61 Practice Exercises A flat growth curve means growth failure, i.e. the childhas stopped growing. 62  Practice Exercises A growth curve that turns downward denotes under- nutrition and weight loss. It calls for urgent action A growth curve that rises faster than the reference curves. This might be a sign of recovery from under nutrition and illness (catch up growth) or it might be a warning sign of overweight due to over nutrition. 63 Practice Exercises 64  Practice Exercises 65  Practice Exercises A. A child aged less than 12 months who has not gained weight for 1 month specially if the weight is below the 3rd percentile. B. A child who has not gained weight for 3 months especially if the weight is below the 3rd percentile. C. A child who has just lost a parent specially the mother. Practice exercises on Under-five health care services The most sensitive measure of underfives’ growth is: D. Height E. Head circumference F. Weight G. Developmental milestones 66  Practice Exercises Below is the weight-for-age growth chart of a child aged 22 months, Qs 1-4: Match each direction of growth curve (in column A) with its appropriate interpretation (in column B). Column A Column B Direction of growth curve Interpretation of growth line Q1 Arrow A A. The child is in dangerous condi- tion and urgent action is needed (weight loss) Q2 Arrow B B. The child’s growth became nor- mal again (catch up growth) Q3 Arrow C C. Not satisfactory and action should have been taken (growth faltering) Q4 Arrow D D. Normal growth pattern In the above growth chart, the most likely cause of the downward movement of the growth line in this child (aged 22 months) is: A. Inadequate breast milk B. Faulty feeding practices C. Infections (e.g., ARI and Gastroenteritis) D. Low birth weight 67  Practice Exercises In the growth chart, the zone which reflects abnormal growth lies: A- Above the 3rd percentile and below the 50th percentile. B- Below the 3th percentile and below the 50th percentile. C- Below the 3rd percentile and above the 97th percentile. D- Between the 50th percentile and the 97th percentile. Which of the following is INCORRECT about interpretation of the growth chart? A. The direction of the growth curve is more important than the position of the dots B. In the first 6 months of life, a leveling off or a downward movement of the growth line is a serious matter C. After 2 years, a small variation over one or two months is not so serious D. A growth curve of a LBW child that is parallel to, but below, the lower reference line (3rd percentile) denotes normal growth pattern E. None of the above Numerator for calculating neonatal mortality rate is all: A- Infant deaths less than or equal to 7 days of age B- Infant deaths less than or equal to 28 days of age C- Infant deaths less than or equal to 1 year of age D- Infant deaths between 28 days to 1 year of age Which of the following is the commonest cause of infant mortality rate in Egypt? A- Acute respiratory infections B- Diarrhea and dehydration C- Congenital anomalies D- Low birth weight Post-neonatal Mortality Rate has been most closely linked to: A- Maternal health prior to pregnancy B- Maternal health during pregnancy C- Events during delivery D- Environmental sanitation E- Events during the early neonatal period 68  Practice Exercises The most sensitive indicator of maternity and newborn care services is: A- Stillbirth rate B- Post-neonatal mortality rate C- Perinatal mortality rate D- Under-five mortality rate Post neonatal mortality rate refers to: A. Mortality during the first 28 days of life. B. Mortality from 28 days of life up to one year. C. Mortality during the first year of life. D. Mortality during the first 7 days of life Qs 1-4: Match each mortality rate in column (A) with its appropriate description in column (B) Mortality rate Description Column (A) Column (B) Q1 Infant mortality rate A) No. of deaths from 1-4 years per 1000 child in the same age Q2 Under-five mortality rate B) No. of deaths from 0-< 28 days of life per 1000 live birth Q3 Child death rate C) No. of deaths from 28 days - < 1year per 1000 live birth Q4 Post-neonatal mortality rate D) No. of deaths from 0-< 5 years of life per 1000 live birth E) No. of deaths from 0-< 1 years of life per 1000 live birth 69  Practice Exercises OCCUPATIONAL MEDICINE Prerequisites: Read chapter on “Occupational Health” in the thaoretical book. Session 1 Accident Prevention Learning Objectives: At the end of this session students will be able to: 1. Classify accidents 2. Identify main causes of workplace accidents 3. Measure accident rates and present them efficiently 4. Work systematically, to develop an “injury control program” I. Classification of accidents Situation 1: An explosion of a pressure vessel resulted in a lacerated wound to the right arm of a nearby worker. Type of injury: Lacerated wound Body part: Right arm Source of injury: Explosion of a pressure vessel Type of accident: Struck by a flying object Hazardous condition: ------------------------------- Agent: Pressure vessel Agent part: ------------------------------- Unsafe act: ------------------------------- Situation 2: While a worker was sawing a wooden frame, a foreign body injured his left eye (he was not wearing his protective goggles). Type of injury: …………………………………….. Body part: …………………………………….. Source of injury: …………………………………….. Type of accident: …………………………………….. 70  Practice Exercises Hazardous condition: …………………………………….. Agent: …………………………………….. Agent part: …………………………………….. Unsafe act: …………………………………….. Situation 3: A worker collapsed while paving a street on an extremely hot day, this resulted in brain concussion. Type of injury: Body part: …………………………………….. Source of injury: …………………………………….. Type of accident: …………………………………….. Hazardous condition: …………………………………….. Agent: …………………………………….. Agent part: …………………………………….. Unsafe act: …………………………………….. II. Accident rates Accident rates are specifically designed to: a. Provide data for comparisons between industries and coun- tries b. Identify the factors responsible for accidents c. Provide background for convincing policy-makers of the need for change. d. Evaluate preventive measures applied. Accident incidence rate: is usually presented as number of accidents per 100 employees. Total number of accidents Accident incidence rate = -------------------------------------------x 100 Number of exposed employees Accident Frequency Rate: is usually presented as number of accidents per 1000000 men -hours worked. Total number of accidents Accident frequency rate =-----------------------------------------------x1000000 Total number of man-hours worked 71  Practice Exercises Accident Severity Rate: is used to measure the severity of injuries. Total number of days lost Accident severity rate =--------------------------------------------- x1000 Total number of man-hours worked Example 1: An industry undertaking with 850 employees had 100 disabling accidents in one year. Assuming that there were 300 working days in a year, each of 8 working hours, and a total of 40,000 working days were lost through holidays, absenteeism, sickness and accidents. What would be the annual frequency rate? Answer: Total number of man-hours worked = …………………………………………………………………………………………… ………………………………………………………………………… Frequency rate=............................................................................................................................................................................................................................................ Example 2: Taking the same figures as in example 1, assuming that the 100 accidents caused a loss of 3000 days, calculate the severity rate. Answer: Severity rate= …………………………………………………………………………………………… ……………………………………………………………………………………. 72  Practice Exercises III.A systematical approach to injury control measures by using the “Haddon’s Matrix”: It is working in a step by step manner. Each injury problem is considered as resulting from an interaction between several discrete factors, occurring over distinct phases in time. This can be done if divide all time into 3 phases: before the injury producing event, during the event and after the event. The physical universe can be divided into 3 factors: man, the vehicles and equipment potentially involved in an injury event and the environment which consists of everything else. These different phases and factors can be used to create the 3*3 MATRIX. Factors Human Environment Vehicle and Equipment phases Pre-Event 1 2 3 Event 4 5 6 Post-Event 7 8 9 In developing a program of injury control measures for a particular injury problem, we can go systematically through each cell of the matrix and think up all possible countermeasures applicable to that cell. The usefulness of the matrix is as a tool for generating ideas, at this stage every possible strategy should be documented and nothing held back because of political or financial considerations. Session 2 Medical screening for occupational diseases Learning Objectives: At the end of this session students will be able to: 1. Identify main environmental hazards in a workplace 2. Perceive medical screening programs for preventing prevailing occupa- tional diseases 3. Interpret audiogram results with special emphasis on occupational hearing loss 4. Detect early noise induced hearing loss 5. Recognize the importance of spirometry in diagnosing occupational lung diseases 73  Practice Exercises 6. Interpret spirometry results and differentiate between occupational obstructive and restrictive lung disease Learning Activities: -Practical demonstration -Case studies i.Screening for noise induced hearing loss Audiometery is used to assess hearing acuity in noise exposed workers. Situation A: A male worker age 42 years, works in a textile company for the last 20 years, exposed to noise level of 90 dB. He complains of hearing loss and tinnitus. Audiometry revealed the following values for right and left ear conduction: )Freq. (Hz 500 1000 2000 3000 4000 6000 8000 )Rt (dB 10 5 15 10 40 0 20 )Lt (dB 15 10 20 20 50 10 20 Situation B: A male worker age 53 years, works in a food processing company for the last 30 years. He is exposed to noise level of 60 dB. He complains of hearing loss and tinnitus. Audiometry revealed the following values for right and left ear conduction: )Freq. (Hz 500 1000 2000 3000 4000 6000 8000 )Rt (dB 40 50 40 40 30 60 80 )Lt (dB 20 15 10 20 10 5 15 Which worker is suffering from occupational deafness? …………. Why? 1. ………………………………………………………………………. 2. ………………………………………………………………………. 3. ………………………………………………………………………. 74  Practice Exercises Complete the following audiogram according to situation (A) Comment on: - Pattern: ………………………………………………………………………................….. - Affection of speech frequencies: ……………………………………..............………. - Presence of deafness: ………………………………………………………...............… - Type of deafness: …………………………………………….........................………… 75  Practice Exercises Complete the following audiogram according to situation (B) Comment on: - Pattern: ………………………………………………………………………….. - Affection of speech frequencies: ……………………………………………. - Presence of deafness: ………………………………………………………… - Type of deafness: ……………………………………………………………… II. Screening for occupational lung diseases Lung Function Tests: (Practical demonstration) Forced expiration using a portable spirometer is widely used to assess the early impairment of lung function of workers exposed to respiratory hazardous substances. 1. Give examples of Occupational obstructive lung diseases: …………………………………………………………………. …………………………………………………………………. 2. Give examples of Occupational restrictive lung diseases: …………………………………………………………………. …………………………………………………………………. 76  Practice Exercises Situation A: A male worker aged 48 years, employed in a textile industry for the last 28 years, he works in the carding ward and is continuously exposed to cotton dust. He suffers from chest tightness on exposure to cotton dust; this symptom occurs on the first working day of the week only. Lung function assessment revealed the following data: FEV1= 2.4L; FVC=4L; FEV1/FVC= 60%. a. Provisional diagnosis: ………………………. b. Why? : - …………………………………………………………………. - …………………………………………………………………. - …………………………………………………………………. - …………………………………………………………………. c. From the given Lung function data, what is the type of impairment? …………………………………………………………………. d. What are the expected X-ray findings? …………………………………………………………………. e. What are the clinical stages of byssinosis? …………………………………………………………………. …………………………………………………………………. Situation B: A male worker aged 50 years, employed in a glass factory. He is exposed to fine silica dust ( range 2 µm in diameter)for the last 30 years. He complains of dry irritant cough, and shortness of breath on exertion; his lung function data are: FEV1=1.8L; FVC= 2L; FEV1/FVC=90%. a. Provisional diagnosis: ………………………………….. b. Why? : - …………………………………………………………………. - …………………………………………………………………. - …………………………………………………………………. - …………………………………………………………………. c. From the given Lung function data, what is the type of impairment? …………………………………………………………………. d. What are the expected X-ray findings? 77  Practice Exercises 79  Field Training Field Visit of the Fever Hospital Infectious\Communicable Disease Hospital 81  Field Training Field Visit of the Fever Hospital Infectious\Communicable Disease Hospital Learning Objectives: After completing this session, the, students will be able to 1. Identify the key symptoms and signs of infectious\communicable dis- ease cases commonly admitted to the hospital. (Based on case defini- tion). 2. Identify the basic adopted preventive and control measures for patients and the immediate environment. 3. Identify some of the adopted infection control procedures through as- sessment of: o Procedure and frequency of hand washing as well as availability of hand washing facilities inside patient wards. o Waste management process inside patient wards. o Infection control procedures adopted in the Central Sterilization and Supply Department. 4. Determine steps of data collection in the hospital surveillance unit and notification of detected new cases to health authority (notification form of Meningitis, Viral Hepatitis and Gastrointestinal Infections). 5. Identify risk factors of an infectious\ communicable disease (Meningitis, Viral Hepatitis and Gastrointestinal Infections). Learning activities: Students will be exposed during their visit to the hospital on the following three main groups of activities: 1. A round with the consultant of the fever hospital to: (Appendix I,II,III) Identify the key signs and symptoms infectious\ communicable disease cases admitted to the hospital Identify the basic measures for isolation adopted for cases ad- mitted in the different wards. 2. Recoginize risk factors of an infectious \communicable disease (Meningitis, Viral Hepatitis and Gastrointestinal Infections) by filling case investigation form (Appendix I,II,III) 3. Utilize the enclosed observational checklists to assess: (appendix IV) 82  Field Training The infection control procedures adopted in the patient wards ( Appendix IV ) Field (Visit Waste management of the Appendix V) Fever Hospital Infectious\Communicable The Central Disease Sterilization and Supply Department Hospital ( Appendix VI) 4. Attend a session with the responsible staff of the surveillance unit, to identify the activities related to data collection and notifcation of newly detected cases to health authority considering rules of notification ( Appendix VII) and the levels of data collection and reporting (Appendix VIII) Currently online notification is going on beside regular notification Time Table of the Visit Activity Duration Time Responsible person )From-To( Attendanceand welcoming min 15 08:45-09:00 Community M