Preventive Medicine

TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE MAIN DIGITAL HANDOUT BY MARK LOUIE C.
MANN, MD
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Epidemiology 19
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Primary Health Care 44
Development Goals 46
INSTRUCTIONS Universal Health Care Act 46
To scan QR codes on iPhone and iPad
1. Launch the Camera app on your IOS device Phil Health 47
2. Point it at the QR code you want to scan DOH Health Programs 49
3. Look for the notification banner at the top National Tuberculosis Control Program 49
of the screen and tap National Dengue Prevention and Control Program 52
To scan QR codes on Android
Rabies Prevention and Control Program 54
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HEALTH Expanded Garantisadong Pambata Program 59
Please have the following Topnotch materials at hand: Maternal, Newborn and Child Health and Nutrition 59
Antimicrobial Stewardship Program 59
• Topnotch Main Handout will serve as your main reference
Food and Waterborne Diseases Prevention 61
material
National Leprosy Control Program 64
Please buy: Filariasis Elimination Program 64
• (1) Elmore, Joann G.. Jekel's Epidemiology, Biostatistics and HIV/STI Prevention Program 65
Preventive Medicine. Elsevier Health Sciences. Malaria Control Program 65
o This will serve as your main reference material (if you have a Schistosomiasis Control Program 66
hard time understanding the concise information in your main Lifestyle-related Diseases 66
handout) Smoking Cessation Program 66
Please read: Philippine Cancer Control Program 66
Dental Health Program 67
Occupational Health Program 67
Principles of Epidemiology Health Examination for Workers 69
in Public Health Practice Blood Donation Program 69
https://qrs.ly/kbbfx4v Environmental Health Programs 70
Philippine Integrated Disease Surveillance and Response 71
Philippine Herbal Medicinal Plants 72
Never Events 72
WHO Basic epidemiology Hospital Color Coding 72
Types of Leadership Styles 72
https://qrs.ly/6pbqhk5
This handout is only valid for the September 2021 PLE batch. This
will be rendered obsolete for the next batch since we update our
About the Material: This is the fortified and responsive Topnotch handouts regularly.
Preventive Medicine Digital Handout updated specifically for September
PLE 2021. The original material was created by Alvin Arevalo, MD,
subsequently updated by Kenny Taborado, MD, Howell Crisostomo MD,
RESEARCH PROCESS
Rachelle Mendoza, MD, Lean Angelo A. Silverio MD, Lalaine Macalalag Step – 1: Identifying the Problem
Tiongson, MD, Dinky Jao MD, Kurt Asperas MD and most recently by Mark • The first and foremost task in the entire process of scientific
Louie C. Mann MD. Thank you very much Alvin, Kenny, Howell, Rachel, research is to identify a research problem
Gelo, Lala, Dinky, Kurt and Louie! Your contributions are highly • A well-identified problem will lead the researcher to accomplish
appreciated by all doctors taking the med boards! =)
TOPNOTCH
all-important phases of the research process, starting from
setting objectives to the selection of the research methodology
Step – 2: Reviewing of Literature
• A review of relevant literature is an integral part of the research
process. It enables the researcher to formulate his problem in
terms of the specific aspects of the general area of his interest
WELCOME TO that has not been so far researched
PREVENTIVE MEDICINE Step – 3: Setting research questions, objectives, and
AND PUBLIC HEALTH hypotheses
https://qrs.ly/nxbqhox
• After discovering and defining the research problem,
researchers should make a formal statement of the problem
leading to research objectives
• An objective will precisely say what should be researched, to
delineate the type of information that should be collected, and
provide a framework for the scope of the study. The best
expression of a research objective is a well-formulated, testable
research hypothesis.
TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE MAIN DIGITAL HANDOUT BY MARK LOUIE C. MANN, MD Page 1 of 72
TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE MAIN DIGITAL HANDOUT BY MARK LOUIE C. MANN, MD
• A hypothesis is an unproven statement or proposition that can DEFINITION OF TERMS
be refuted or supported by empirical data. Hypothetical
• STATISTICS – science that deals with collection of data,
statements assert a possible answer to a research question.
organization of data, analysis of data, interpretation of data
• BIOSTATISTICS – applications of statistical methods to the life
Step – 4: Choosing the study design
sciences like medicine and public health.
• The research design is the blueprint or framework for fulfilling
• VARIATION – refers to tendency of a measurable characteristic
objectives and answering research questions
to change from one individual or one setting to another.
Step – 5: Deciding on the sample design variation in clinical medicine may be caused by biologic differences or the
• Sampling is an important and separate step in the research presence or absence of disease, it also may result from differences in the
techniques and conditions of measurement, errors in measurement, and
process. The basic idea of sampling is that it involves any
random variation.
procedure that uses a relatively small number of items or Dr. Mann
portions (called a sample) of a universe (called population) to • DATA – the observed values of variable and or collection of
conclude the whole population observations
• VARIABLE – a characteristic of population or sample that is of
Step – 6: Collecting data interest for us
• The gathering of data may range from simple observation to a Independent Variable Dependent Variable
large-scale survey in any defined population. There are many Stimuli that researchers Effect of the action of independent;
ways to collect data manipulate to create Responding behavior that a
effect researcher wants to explain
Step – 7: Processing and Analyzing Data
• Data processing generally begins with the editing and coding of
data. Data are edited to ensure consistency across respondents
and to locate omissions, if any.
Step – 8: Writing the report – Developing Research Proposal, OFFICE OF RESEARCH INTEGRITY
Writing Report, Disseminating and Utilizing Results
• The entire task of a research study is accumulated in a document
called a proposal.
• A research proposal is a work plan, prospectus, outline, an offer,
a statement of intent or commitment from an individual
researcher or an organization to produce a product or render a
service to a potential client or sponsor.
• The proposal will be prepared to keep in view the sequence
presented in the research process. The proposal tells us what,
how, where, and to whom it will be done.
• It must also show the benefit of doing it. It always includes an
explanation of the purpose of the study (the research objectives)
or a definition of the problem.
• It systematically outlines the particular research methodology
and details the procedures that will be utilized at each stage of Office Of Research Integrity
the research process. When a researcher gives an active medication to one group of people and
a placebo, or inactive medication, to another group of people, the
independent variable is the medication treatment. Each person's
response to the active medication or placebo is called the dependent
variable.
Dr. Mann
EXAMPLE
• A scientist studies the impact of a drug A on cancer B
o The independent variables are the administration of the drug
(manipulation of the dosage and the timing)
o The dependent variable is the impact the drug has on cancer
(with cure or no cure)
• Chemoprotective effect of Oral VCO supplementation
against breast cancer development
o The independent variable is the oral administration of VCO
(manipulation of the dosage in ml)
o The dependent variable is the impact of oral VCO
supplementation on breast cancer (preventive, not
preventive)
This is a high yield topic in the boards, you should know what is the
independent and dependent in a given title of a study or scenario.
You can watch this video to further increase your understanding.
INDEPENDENT
VS. DEPENDENT VARIABLES
https://qrs.ly/a8bq4px
BIOSTATISTICS
Dr. Mann
You can watch this video before reading this section of your handout to
prime your reading comprehension about biostatistics. • CONSTANT – a phenomenon whose values remains the same:
e.g. number of second in a minute, Pi, pull of gravity and speed
of light
INTRODUCTION TO STATISTICS A variable is a characteristic or feature that varies, or changes within a
https://qrs.ly/dfbfy4n study. The opposite of variable is constant: something that doesn't
change. In math, the symbols "x" , "y" or "b" represent variables in an
Dr. Mann
equation, while "pi" is a constant
Dr. Mann
• SAMPLING – is the act of studying or examining only a segment

of the population to represent the whole.
• POPULATION SOURCES OF DATA
o refers to entire group of individuals or items of interest in the MOST COMMON LESS COMMON
study • Censuses
o collection of all elements under consideration in a statistical • Sample surveys • Continuing population
inquiry • Registration system registers
• SAMPLE – is a subset of the population • Medical Records • Voter’s registry
• Claims Data • School roster
• Vital Records
• Surveillance
TYPES OF DATA
QUANTITATIVE VS. QUALITATIVE
Quantitative Qualitative
Categorical observation
Numerical observations Provide depth and detail
Computed thru arithmetic through direct quotation and
https://www.omniconvert.com/what-is/sample-size/ calculations careful description of
This is a diagram depicting the relationship between the population and (numerical) situations, events
sample. interactions
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Nominal or ordinal
TYPES OF POPULATION Discrete or continuous (sex, occupation, disease
Target • the group from which representative information status)
Population is desired and to which interference will be made
DISCRETE VS. CONTINUOUS
Sampling • population from which a sample will actually be
Population taken Discrete Continuous
POPULATION CONCEPT • Finite number of values • Usually associated with
• Unit of the population that we select in our possible physical measurement
Sampling sample • Use of whole number • Take on values that are
Unit • Sampling frame or frame: is a list or map fractions or decimals
showing all the sampling units in the population It can assume only integral It can attain any value
Elementary • Is a member of the population values or whole numbers including fraction or decimals
Unit or • an object or a person on which a measurement is • Hospital bed capacity • Birth weight
Element actually taken or an observation is made • Household-size (members) • Arm circumference
• CONFOUNDERS - outside influence that changes the effect of a
SCALES USED TO MEASURE DATA
dependent and independent variable
• Naming or categoric variables that are not based
BRANCHES OF BIOSTATISTICS on measurement scales or rank order.
Descriptive Statistics Inferential Statistics • # or symbols are assigned. Lowest form of
Refers to the different Methods involved in order to variable: (e.g., Gender, Color, Province,
Nominal
methods applied to make generalizations and occupation, skin color and blood group)
summarize and present data conclusions about a target • Dichotomous (binary)- which has only two
in a form to make them easier population, based on result levels (e.g., Yes or No, Normal and Abnormal, Male
to analyze and interpret by from a sample, includes: and Female)
using methods of: • Estimation of parameters • Arranged in rank ordered categories
• Tabulation • Testing of hypothesis Ordinal • (E.g., Social class, Likert scale, Satisfactory scale,
• Graphical representation agree to disagree, murmur range, level of edema)
• Summary measures • Value of zero is arbitrary (E.g., Fahrenheit &
Interval
Celsius)
DESCRIPTIVE STATISTICS • (+) properties of all variables; zero is
DATA COLLECTION Ratio fixed/absolute; Highest form; (E.g., Age, metric
• SOURCE system)
o Primary Invest some time in this topic, malabasin siya sa boards, so I highly
§ data obtained first hand by the investigator for his specific suggest watch this video to fully understand the scales of measurement.
purpose
§ are data documented by the primary resource
§ data collectors themselves documented this SCALES OF MEASUREMENT
o Secondary https://qrs.ly/xxbq5da
§ already existing data
§ data that have been obtained by some other people for Dr. Mann
purposes not necessarily those of the investigators METHODS OF DATA COLLECTION
PRIMARY SECONDARY • Observation – method of collecting data on the phenomenon of
• Information in its original • Provide analysis & interest by recording the observations made about the
form interpretation of event or phenomenon or point of interest
• Reflect the view point of phenomenon o Structured – a researcher designs a rigorous plan and formal
participant or observer of • Subsequent interpretations instruments for recording interest before the actual data
an event or phenomenon or studies that are based on collection
• Has not been previously primary sources o Non-structured – the researcher has complete flexibility in
interpreted, commentated Example: A medical researcher’s performing the study and can modify the original plan at any
or translated documented data for his stage of the study
• Can also be sets of data research paper, which were • Review of documents
which have been tabulated originally collected by the DOH • Enumeration- Census and Sample survey
Dr. Mann
but not interpreted o Survey- a method of collecting data on variable of interest by
Example: National Statistic asking people questions.
Office primary source of data o Census- when data came from asking all the people in the
on population, housing and population then the study is called a census
establishment o Sample survey- when data came from asking a sample of
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people selected from a well-defined population
• Interview – formal or informal • Internal validity is the extent to which the experiment is free from
o In-person interview errors and any difference in measurement is due to independent
o Telephone interview variable and nothing else.
o Online • External validity is the extent to which the research results can be
inferred to world at large – generalizability
o Mailed questionnaire Dr. Mann
o Focus group 4. RELIABILITY
• Experiments and or clinical trials- controlled study of group, o Reliability refers to the extent to which repeated
method of collecting data where there is direct human measurements of a relatively stable phenomenon fall closely
intervention on the conditions that may affect the values of the to each other
variable of interest. o refers to consistency, reproducibility, repeatability of results;
o Registry similar information is supplied when a measurement is
o Case record performed more than once
You measure the temperature of a liquid sample several times under
INSTRUMENTS FOR DATA COLLECTION identical conditions. The thermometer displays the same temperature
• Questionnaire every time, so the results are reliable.
Types: Contents: Valid Measurements = Reliable Measurements
a. Self- Open ended items: subjects use their Reliable Measurements NOT ALWAYS Valid Measurements
administered own words for responses
Suppose your bathroom scale was reset to read 10-pound lighter. The
b. Mailed Close ended Items: have a fixed number
weight it reads will be reliable (the same every time you step on it) but
c. Face-to-face of answer choices for responses will not be valid, since it is no treading your actual weight
interview Rating scale: provides a graded scale Dr. Mann
d. Online survey showing all possible directions and 5. OBJECTIVITY
e. Telephone intensity of attitude of a respondent on a 6. COMPLETENESS
interview particular question or statement o adequacy and representativeness of the sample size
• Test devices – Ex: Weighing scale, BP app, Glucometer o completeness of coverage
• Checklist (for observation) o completeness in accomplishing all items in every form
CHARACTERISTICS IMPORTANT IN DATA SCREENING

COLLECTION • Screening is defined as the presumptive identification of
unrecognized disease in an apparently healthy, asymptomatic
1. ACCURACY/ACCURATE
population by means of tests, examinations or other procedures
o The closeness of a measured or computed value to its true
that can be applied rapidly and easily to the target population
value.
(WHO)
o Trueness of test measurements
• sometimes termed medical surveillance
The true value is sometimes called the theoretical value
Dr. Mann screening tests do not diagnose the illness
2. PRECISION/PRECISE Dr. Mann
o how close measurements of the same item are to each other TYPES OF SCREENING
o Consistency and reproducibility of a test • There are different types of screening, each with specific aims:
o Absence of random variation in a test o mass screening aims to screen the whole population (or
subset);
Remember the definition of VARIATION – refers to tendency of a
measurable characteristic to change from one individual or one setting
o multiple or multiphasic screening uses several screening
to another. tests at the same time;
Dr. Mann o targeted screening of groups with specific exposures, e.g.
SUPPLEMENT: ACCURACY VS PRECISION workers in lead battery factories, is often used in
• A classic way of demonstrating the difference between environmental and occupational health
precision and accuracy is with a dartboard. Think of the bulls- o case-finding or opportunistic screening is aimed at patients
eye (center) of a dartboard as the true value. The closer darts who consult a health practitioner for some other purpose.
land to the bulls-eye, the more accurate they are.
• If the darts are neither close to the bulls-eye, nor close to each CONDITIONS/SITUATIONS FOR A SCREENING PROGRAM TO
other, there is neither accuracy, nor precision (Fig. A). BE ACCEPTABLE AND EFFECTIVE
• If all of the darts land very close together, but far from the • Condition screened must be a vital or important health condition
bulls-eye, there is precision, but not accuracy (Fig. B). that affects majority of the population
• If the darts are all about an equal distance from and spaced • The disease must have a well-developed natural history
equally around the bulls-eye there is mathematical accuracy • There are means to detect the early stages of the disease
because the average of the darts is in the bulls-eye. This • There must be a difference between treatment during the
represents data that is accurate, but not precise (Fig. C). early stage to that of the late stage
• If the darts land close to the bulls-eye and close together, there • The screening test should be acceptable, inexpensive, easy to
is both accuracy and precision (Fig. D). administer, would cause minimal discomfort, reliable, and
valid
• The cost of the test should be outweighed by its benefits
• Adequate health service provision should be made
• Interval for repeating testing is determined
SUPPLEMENT: GOLD STANDARD TEST

Image by Byron Inouye • Screening tests need to be benchmarked against an agreed
Precision is independent of accuracy. That means it is possible to be very “Gold Standard” test
precise but not very accurate, and it is also possible to be accurate without • A gold standard test is a best available diagnostic test for
being precise. The best quality scientific observations are both accurate determining whether a patient does or does not have a disease
and precise. or condition
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Note: random error entails reduced precision in a test while systematic • a diagnostic test that is usually regarded as definitive (e.g. by
error entails reduced accuracy in a test. biopsy or autopsy). The actual gold standard test may be
invasive (e.g. biopsy), unpleasant, too late (e.g. autopsy) to be
3. VALIDITY relevant, too expensive or otherwise impractical to be used
o refers to the extent to which an observation reflects the "truth" widely as a screening test
of the phenomenon being measured
o the data/technique should measure what it is supposed to
measure
SCREENING TEST VALIDITY ADDITIONAL RELEVANT CHARACTERISTICS OF A SCREENING
• is the ability of a screening test to accurately identify diseased TEST
and non-disease individuals. An ideal screening test is • Positive Predictive Value
exquisitely sensitive (high probability of detecting disease) and o (PPV) is the probability that a subject with a positive
extremely specific (high probability that those without the (abnormal) test actually has the disease
disease will screen negative) • Negative Predictive Value
• Sensitivity – is the test's ability to correctly designate a subject o (NPV) is the post-test probability that the subject has no
with the disease as positive disease given a negative test result
• A highly sensitive test means that there are few false negative results; • Likelihood ratio
few actual cases are missed. o it is defined as the probability of a subject who has the disease
• A false negative means that a subject with the disease is misclassified testing positive divided by the probability of a subject who
as not having the disease on the basis of the screening test. The subject does not have the disease testing positive
is given a misleading impression that he/she is free of the disease and
thus does not undergo more suitable diagnostic tests • It is important to remember that the PPV or NPV are dependent on both
Dr. Mann the population under study and the technical characteristics of the
• Specificity – is the test's ability to correctly designate a subject screening test
without the disease as negative • A screening test with relatively high sensitivity and specificity may still
• A highly specific test means that there are few false positive results have a low PPV if the population prevalence is sufficiently low
• A false positive means that a subject without the disease is misclassified • Predictive values are dependent on the prevalence of the disease.
as having the disease on the basis of the screening test. The subject is • The higher the prevalence of a disease, the higher the PPV of a test
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given the misleading impression that he/she has the disease and thus
endures the unnecessary psychological consequences as well has
having to undergo possibly invasive diagnostic or treatment
procedures
Dr. Mann
EXAMPLES OF SCREENING AND DIAGNOSTIC TESTS AND POSSIBLE GOLD STANDARDS

DISEASE SCREENING GOLD STANDARD
Urinary tract infection • Urinalysis • Urine culture
Breast cancer • Mammography • Biopsy result
Colon cancer • fecal occult blood test (FOBT) • Colonoscopy ± biopsy
• Colposcopy with appropriate biopsy or sentinel lymph
Cervical cancer • Pap smear
node biopsy
• IgG and IgM Rapid Antibody Test (RAT)
• Real-time reverse transcription-polymerase chain reaction
COVID-19 (Serum)
(rRT-PCR) assay
• Antigen Test (Swab)
Modified from Maxim, L Daniel et al. “Screening tests: a review with examples.” Inhalation toxicology vol. 26,13 (2014): 811-28. doi:10.3109/08958378.2014.955932
QUICK GUIDE: TEST STATISTICS NOMENCLATURE

•
• It is important for us to define the component of our contingency

TEST STATISTICS NOMENCLATURE
table or 2x2 table, this is a different approach of definition which I
https://qrs.ly/3ccqplp
think you need to be familiar too, iba iba lang chika pero iisa lang
naman point, BTW these exact definitions were asked, TIP memorize
formula using the TP-FP-FN-TN nomenclature.
• Paulit ulit? Aba! Laban!.... daming ganitong tanong so ANO? SAKAY SUPPLEMENT: EVALUATION OF A SCREENING TEST
NA! (Super Ferry) char….!!!!! Hug J
•
• A 2 x 2 table, or contingency table, is used when testing the

Click the link kung bagot ka!
validity of a screening test
https://youtu.be/sbtIFGxjzBA
Dr. Mann CONTINGENCY TABLE
• Definition 1. A true positive test result is one that detects the Test DISEASED/(+) NON-DISEASED/(-) Total
condition when the condition is present. (+) TP (A) FP (B) A+B
• Definition 2. A true negative test result is one that does not (-) FN (C) TN (D) C+D
detect the condition when the condition is absent. Total A+C B+D A+B+C+ D
• Definition 3. A false positive test result is one that detects the I. SENSITIVITY
condition when the condition is absent. o Ability of the test to label positive those who really have
• Definition 4. A false negative test result is one that does not the disease
detect the condition when the condition is present. o Number of true positives (TP) divided by number of all
• Definition 5. Sensitivity measures the ability of a test to people with the disease
detect the condition when the condition is present. Thus, o High sensitivity is desirable for a SCREENING TEST!
Sensitivity = TP/(TP+FN). 𝑇𝑃 𝐴
𝑆𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦 (𝑆𝑛) = 𝑥100 = 𝑥100
• Definition 6. Specificity measures the ability of a test to 𝑇𝑃 + 𝐹𝑁 𝐴+𝐶
correctly exclude the condition (not detect the condition)
when the condition is absent. Thus, Specificity = TN/(TN+FP). II. SPECIFICITY
• Definition 7. Predictive value positive is the proportion of o Ability of the test to label negative those who do not have
positives that correspond to the presence of the condition. the disease
Thus, Predictive value positive = TP/(TP+FP). o Number of true negatives (TN) divided by number of all
• Definition 8. Predictive value negative is the proportion of people without the disease
negatives that correspond to the absence of the condition. o High specificity is desirable for a CONFIRMATORY TEST!
Thus, Predictive value negative = TN/(TN+FN). 𝑇𝑁 𝐷
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐𝑖𝑡𝑦 (𝑆𝑝) = 𝑥100 = 𝑥100
𝑇𝑁 + 𝐹𝑃 𝐷+𝐵
MNEMONIC
SnOUT SpIN
SN-N-OUT = highly SeNsitive test, SP-P-IN = highly SPecific test,
when Negative, rules OUT when Positive,rules IN
disease disease
Value approaching 100% is Value approaching 100% is
desirable for ruling out disease desirable for ruling in
and indicates a low false- disease and indicates a low
negative rate. false- positive rate
Dr. Mann
https://groups.bme.gatech.edu/groups/biml/resources/useful_documents/Test_Statistics.pdf
III. POSITIVE PREDICTIVE VALUE (PPV) • NOMOGRAM

o The probability of having the condition, given a positive o a diagram representing the relations between three or more
test variable quantities by means of a number of scales, so
o Number of true positives divided by number of people who arranged that the value of one variable can be found by a
tested positive for the disease simple geometric construction, for example, by drawing a
𝑇𝑷 𝐴 straight line intersecting the other scales at the appropriate
𝑷𝑃𝑉 = = values
𝑇𝑷 + 𝐹𝑷 𝐴 + 𝐵
By comparing the pre- and post-test probabilities, it is possible to
IV. NEGATIVE PREDICTIVE VALUE (NPV) determine whether the probability of diagnosis has risen (i.e. the post-
o The probability of not having the condition, given a test probability has increased) or fallen (i.e. post-test probability has
negative test decreased). In this way, it is possible to provide comprehensive
information about a screening test in order to enable informed choice.
o Number of true negatives divided by number of people who Dr. Mann
tested negative for the disease.
𝑇𝑵 𝐶 LR INTERPRETATION
𝑵𝑃𝑉 = = LR of <1 decreased likelihood for disease
𝐹𝑵 + 𝑇𝑵 𝐶 + 𝐷
LR of 1 no diagnostic value/no change
For visual and problem-based learners please watch this video: LR >1 increased likelihood for disease
SCREENING TEST VALIDITY

https://qrs.ly/bxbq5sr
PPV AND NPV CORRELATION

https://qrs.ly/1ebq65n
Dr. Mann
SUMMARY OF THE 2x2 TABLE PLUS THE FORMULA
V. LIKELIHOOD RATIOS
• likelihood ratios are used for assessing the value of
performing a diagnostic test. NOMOGRAM FOR LR
Bayes Nomogram: Draw a line connecting the baseline probability (pretest
Likelihood Ratio of a POSITIVE TEST probability) with the value for the likelihood ratio for the test used. Extend
𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑡ℎ𝑎𝑡 𝑡𝑒𝑠𝑡 𝑖𝑠 (+) 𝑎𝑚𝑜𝑛𝑔 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 𝑆𝑛 this line to the right to find the posttest probability.
𝐿𝑅! = = (Adapted from Fagan TJ. Nomogram for Bayes Theorem. N Engl J Med. 1975;293(5):257.)
𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑡ℎ𝑎𝑡 𝑡𝑒𝑠𝑡 𝑖𝑠 (+)𝑎𝑚𝑜𝑛𝑔 𝑁𝑂𝑁 − 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 1 − 𝑆𝑝 https://www.healthknowledge.org.uk/content/pre-and-post-test-probability
Likelihood Ratio of a NEGATIVE TEST LIKELIHOOD RATIO

𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑡ℎ𝑎𝑡 𝑡𝑒𝑠𝑡 𝑖𝑠 (−) 𝑎𝑚𝑜𝑛𝑔 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 1 − 𝑆𝑛 INTERPRETATION
𝐿𝑅" = = https://qrs.ly/btbqhlj
𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑡ℎ𝑎𝑡 𝑡𝑒𝑠𝑡 𝑖𝑠 (−)𝑎𝑚𝑜𝑛𝑔 𝑁𝑂𝑁 − 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 𝑆𝑝
• Likelihood ratios (LR) in medical testing are used to interpret

diagnostic tests. Basically, the LR tells you how likely a patient SUPPLEMENT: ISSUES WITH SCREENING
has a disease or condition. The higher the ratio, the more likely • SELF-SELECTION BIAS
they have the disease or condition. Conversely, a low ratio o people presenting for screening tend to be healthier leading
means that they very likely do not. Therefore, these ratios can to false sense of better outcomes
help a physician rule in or rule out a disease.
• LEAD TIME BIAS
• The pre-test probability o refers to the phenomenon where early diagnosis of a disease
o is simply the prevalence of disease in a population. falsely makes it look like people are surviving longer. This
o Is the proportion of people in the population at risk who have occurs most frequently in the context of screening.
the disease at a specific time or time interval, i.e. the point o survival may appear to be increased among screen-detected
prevalence or the period prevalence of the disease. In other cases simply because the diagnosis was made earlier in the
words, it is the probability − before the diagnostic test is course and yet the outcome of the disease remains
performed unchanged.
• Post-test probability
o This is the proportion of patients testing positive who truly
have the disease. It is similar to the positive predictive value
but apart from the test performance also includes a patient-
based probability of having disease
o pre-test probability refers to the chance that an individual has
a disorder or condition prior to the use of a diagnostic test
PRACTICE SAMPLE COMPUTATION
Question: A researcher develops a new tumor marker for pancreatic
cancer, he then compares it to tissue histology.
There was a total of 300 patients, 100 patients were found to have
pancreatic cancer, of these, 70 tested positives for the tumor marker, the
tumor marker was also positive in 15 patients without pancreatic cancer.
Tumor TISSUE HISTOLOGY
Marker W/DISEASE W/O DISEASE
+ 70 15 85
https://first10em.com/ebm/lead-time-bias/ - 30 185 215
100 200 300
LEAD TIME BIAS When presented with this kind of question, first thing you need to do is to
draw a 2x2 table and supply appropriate data in the cell/box
https://qrs.ly/t5cqpm6 Dr. Mann
𝑇𝑃 70
𝑺𝒆𝒏𝒔𝒊𝒕𝒊𝒗𝒊𝒕𝒚 = = = 𝟕𝟎%
𝑇𝑃 + 𝐹𝑁 70 + 30
For example, a man with metastatic lung cancer dies at age 70. His 𝑇𝑁 185
𝑺𝒑𝒆𝒄𝒊𝒇𝒊𝒄𝒊𝒕𝒚 = = = 𝟗𝟐. 𝟓%
cancer was discovered 1 year ago, when he was 69. Therefore, it 𝑇𝑁 + 𝐹𝑃 185 + 15
appears as if he lived for 1 year with the cancer. However, imagine that 𝑇𝑃 70
𝑷𝑷𝑽 = = = 𝟖𝟐. 𝟑𝟓%
instead his cancer was discovered on a screening CT scan when he was 𝑇𝑃 + 𝐹𝑃 70 + 15
𝑇𝑁 185
65 years old. If he still dies at the age of 70, it now looks like he survived 𝑵𝑷𝑽 = = = 𝟖𝟔. 𝟎𝟓%
for 5 years with the diagnosis of cancer (the 5 year survival rate is much 𝑇𝑁 + 𝐹𝑁 185 + 30
𝑃𝑟𝑜𝑏 𝑜𝑓 + 𝑇𝑒𝑠𝑡 𝑎𝑚𝑜𝑛𝑔 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 70`
better), but in fact there was no real change in his survival 100 = 𝟗. 𝟑𝟑
https://first10em.com/ebm/lead-time-bias/ 𝑳𝑹(+) = =
𝑃𝑟𝑜𝑏 𝑜𝑓 + 𝑇𝑒𝑠𝑡 𝑎𝑚𝑜𝑛𝑔 𝑁𝑂𝑁𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 15`
Dr. Mann 200
• LENGTH BIAS 𝑃𝑟𝑜𝑏 𝑜𝑓 − 𝑇𝑒𝑠𝑡 𝑎𝑚𝑜𝑛𝑔 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 30<
100 = 𝟎. 𝟑𝟐
o refers to the fact that screening is more likely to pick up 𝑳𝑹(−) = =
𝑃𝑟𝑜𝑏 𝑜𝑓 − 𝑇𝑒𝑠𝑡 𝑎𝑚𝑜𝑛𝑔 𝑁𝑂𝑁𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑑 185<
slower-growing, less aggressive cancers, which can exist in 200
!" &.( #$ !" #$&.(
alternative formula: 𝐿𝑅(+) = = = 9.33 𝐿𝑅(−) = = = 0.32
the body longer than fast-growing cancers before symptoms #$!% #$&.)*+ !% &.)*+
develop Magkapit-kapit tayo ng kamay at magdasal sana po walang

o the length of detectable preclinical phase can vary computation sa exam, sana po maging display lang calculator ko sa
substantially from person to person; more slowly exam, YES! kailangan ng calculator sa boards.
progressive disease, with less capacity to prove fatal, may At dahil mahal kita oo, mahal kita! ito yung link ng PRC for allowable
have a longer pre-symptomatic screen-detectable period and calculators, baka kasi dalhin mo pa yung calculator ng nanay mong na
will therefore be more likely to be screen-detected = napakalaki at pag pinipindot eh tumutunog-tunog pa! TINDERA KA
artificial survival advantage to screen-detected cases. GHORL?
https://www.prc.gov.ph/allowable-calculators
P.S. Limang exams na po ang dumaan ng hindi “daw” kailangan ng
calculator #SANAALL #PLE2021
Dr. Mann
SAMPLING DESIGNS
• Is a mathematical function that gives you the probability of any
given sample being drawn
Criteria of a Good Sampling Design: (PERA)
• Practical and feasible
o Practicality and feasibility of the sampling procedure. This
means that the sampling design should be sufficiently simple
• OVER-DIAGNOSIS BIAS and straightforward so that it can be carried out substantially
o An extreme example of length bias as planned.
o aggressive search for abnormalities might actually lead to • Economy and efficiency
harm and great cost without reaping any benefits o Economy and efficiency of the sampling design - that is, it must
o tendency to discover cancer that will not affect the life give the most information at the smallest cost.
expectancy of the patient • Representative
o The sample to be obtained should be representative of the
MNEMONIC
population. This means that it should be reflect both the
• Length-time bias is due to slow cases being detected more
characteristics as well as the variability of the population being
often simply because they are slowly progressing.
studied.
Remember the "g" in length is for slowly progressing.
• Adequate
• Lead-time bias is due to early detection. Remember the "d"
o The sample size should be adequate. Here, the relevant
in lead is for early detection.
question to be answered is, “Is the sample size sufficiently
Dr. Mann large to permit reliable generalizations about the whole
population?’’
PROBABILITY SAMPLING DESIGNS
• Is a method of selecting sample wherein each element in the
population has a known, non-zero chance of being included in
the sample
Sampling Design Description Advantages Disadvantages
• Most basic type of sampling design. • Analysis of data is simple and Sampling frame is necessary
• Every element has equal chance to be easy • Sample chosen may be widely spread,
SIMPLE
included in sample population. • Drawing the sample is easy thus entailing higher cuts
RANDOM
• Used in studies involving relatively small • Probability of obtaining an
SAMPLING (SRS)
populations within readily available unrepresentative sample is higher,
sampling frame especially in studies of small size
• Sampling method where we divide the • Resorted to in order to • High transportation cost if elements
population into nonoverlapping increase the precision of the are widely spread geographically,
STRATIFIED subpopulations or strata, and then select estimates of the parameters unless there are field offices in each
SAMPLING one sample from each stratum being considered geographic area
• The sample consist of all the samples in the
different strata
Sampling Design Description Advantages Disadvantages
• Selection of the first element is at random • Drawing a sample is easier • May give poor precision when
and selection of the other elements is • Easy to administer in the field. unsuspected periodicity is present in
SYSTEMATIC subsequently taking every k • A sampling frame is may not the population
SAMPLING • Sampling interval is represented by k be necessary
DESIGN • kth element of the population is chosen • Gives more precise estimates
(k=N/n, where N is the total population, and than simple random sampling
n is the sample size needed
• The population is first divided into sampling • Does not require a sampling • May need a bigger sample size for the
units called clusters frame of all elementary units; study
• A sample of clusters is selected • Only population list of • Analysis is more difficult
CLUSTER • Every element found in each cluster is clusters is needed • May have bias
SAMPLING included in the study • Listing cost and • Increased rate of homogeneity
transportation are reduced (similarities and or characteristics of
elements) among elements within a
cluster
• There is hierarchical configuration of • Greater efficiency, lower cost • More complex design
sampling units and we select sample of per unit of inquiry • Analysis may become too
these units in stages • Sampling frame is needed in complicated
• The population is 1st divided into a set of first stage sampling units
primary or first stage sampling units
MULTISTAGE
• Each primary sampling unit included in the
SAMPLING
sample is further subdivided into
DESIGN
secondary or second stage sampling
units, from which a sample will again be
taken.
• The procedures continue until the desired
stage is reached
NON-PROBABILITY SAMPLING DESIGNS Type of
Description
• The probability of each member of the population to be selected Table
in the sample is difficult to determine or cannot be specified • number and title of the table is placed above
• Used only for descriptive purposes rather than for making • tables are numbered consecutively
generalizations or interferences about the target population. Formal • Types
o Purposive or judgment – sample selection is based on expert’s table 1. Master table
subjective judgment or on some pre-specified criteria 2. Summary table
o Accidental or Haphazard or convenience – sample selection 3. Dummy table
based on whatever item comes at hand or whoever is available 4. Contingency table
o Snowballing – target population is small or hard to locate;
uses chain referral technique (e.g. IV drug users) 3. GRAPHICAL APPROACH
o Voluntary response – Similar to a convenience sample, a • A graph is a method of showing quantitative data using the x-y
voluntary response sample is mainly based on ease of access. coordinate system.
Instead of the researcher choosing participants and directly • The x-axis is used for classification (independent variable, e.g.
contacting them, people volunteer themselves time)
o Quota - Sample section is based on the given quota to meet, • y-axis is used to show frequency (dependent variable, e.g. no. of
which researchers look for a specific characteristic in their cases)
respondents, and then take a tailored sample that is in
proportion to a population of interest
DATA PRESENTATION
1. TEXTUAL OR NARRATIVE
o Discussion, analysis, and synthesis of data
o Data is simply narrated, story-fashion
o Used for small data sets and limited summaries
2. TABULAR APPROACH
o A table is a brief and concise way of presenting large sets of
detailed information using rows and columns.
o It shows trends, comparisons, and interrelationships among
variables.
o It should be simple, direct and clear
o Tables usually serve as the basis for preparing more visual
presentation of data such as graphs and charts https://www4.uwsp.edu/psych/stat/4/graphing.htm
I know this is very basic, pero baka sa kaba mo makalimutan mo (hehehe)
CHARACTERISTICS OF AN EFFECTIVE TABLE Y axis yung pataas, tignan mo ang letter “Y” patayo (hahahahha) tapos
• Simple with 2-3 variables yung “X” axis siya yung nakahiga na line.
Dr. Mann
• Self-explanatory
• Codes, abbreviations, and symbols should be explained in detail IN CONSTRUCTING A GRAPH, THE FOLLOWING SHOULD BE
in a footnote OBSERVED
• Specific units of measure for the data should be given
• It should be simple and self-explanatory
• Totals should be provided
• Label titles, axes, source, scales and legends
• If the data is not original, source should be provided in a
• Each variable should be clearly differentiated by legends
footnote at the bottom of the table
• Ensure that scales for each axes is appropriate for the data
• Minimize the number of coordinate lines
Type of
Description • Define all abbreviations and symbols
Table
• Note all data exclusions
• Brief and simple
• If the data is not original, source should be provided in a
Informal • Not identified by table number
table footnote at the bottom of the table
• Seen as continuation of text, they have no
ruled frame around them
Type of Graph Nature of Variable Function
Bar Graph
This is the simplest and most effective way to
present comparative data. It uses bars of the Qualitative-categorical or • Comparison of absolute or relative counts, rates
same width to represent different categories Discrete Quantitative etc. bet. Categories
of a factor
Dr. Mann
a. COMPONENT/STACKED bar graph
• Comparison between 2 population or

Qualitative variable
distribution; alternative to pie charts
Rural Urban
HORIZONTAL BAR
• E.g. Leading cause of mortality

Qualitative
• (usually presented as Counts)
VERTICAL BAR GRAPH
Quantitative variable showing • Design with spaces in between bar because

changes with passage of time variable is discrete; use to show trends
9
9
0
0
20
20
20
20
20
1/
1/
1/
1/
1/
1/
2/
3/
4/
5/
PIE CHART • Breakdown of a group or total where the number

of categories is not too many (<6 categories)
• Sum of all proportion must be equal to 100%
• Conventionally, pie charts begin at 12 o’clock.
• The wedges should be labeled and arranged from
largest to smallest, proceeding clockwise,
• A pie chart is a chart in which the sizes of Qualitative although the “other” or “unknown” may be last.
the slices show the proportional • Shading may be used to distinguish between
contribution of each component part slices but is not always necessary.
• Since it is difficult to gauge the area of the • Because the eye cannot accurately gauge the area
slices, it is important to indicate what of the slices, the chart should indicate what
percentage each slice represents. percentage each slice represents either inside or
• The whole chart should total 100 percent
Dr. Mann
near each slice.
HISTOGRAM
• Frequency distribution of continuous variable or

measurement including age group; 1 population,
1 distribution
Continuous quantitative
• E.g.: income
• are used to analyze outbreak data and to show an
a graph wherein the frequency distribution is epidemic curve
represented by adjoining vertical bars where
in the cases are stacked in adjoining columns
Dr. Mann
LINE GRAPH
Quantitative variable
• Trend data or changes with time or age with
Time series respect to other variables
FREQUENCY POLYGON
• Comparison of 2 population
Quantitative continuous
• E.g.: comparison of income in ERAP era as the
a graph created from a histogram by income in GMA era
connecting the midpoints of the interval using
a straight line instead of making a bar or
filling in squares. It is very useful in comparing
frequency distribution from different sets of
data
Dr. Mann
SCATTERPLOT/ SCATTER POINT/ DOT
DIAGRAM
• Correlation between two quantitative
Quantitative variables
• E.g.: comparison of birth weight to AOG
Single blue square represents a single sample. Recent
Board exam question
Dr. Mann
Type of Graph Nature of Variable Function
PICTOGRAPH
• Uses symbols or pictures. Used in showing the

distribution of morbidity across a geographic
area.
SUPPLEMENT: PARETO CHART

• combines a column chart and a line graph
• a vertical bar graph in which values are plotted in decreasing
order of relative frequency from left to right
• the independent variables on the chart are shown on the
horizontal axis and the dependent variables are portrayed as
the heights of bars.
• A point-to-point graph, which shows the cumulative
relative frequency, may be superimposed on the bar graph.
Because the values of the statistical variables are placed in
order of relative frequency, the graph clearly reveals which
factors have the greatest impact and where attention is likely
to yield the greatest benefit. (CRITICAL FEW vs TRIVIAL
MANY)
o PARETO PRINCIPLE: “80% of the output in a given situation
or system is produced by 20% of the input”
• extremely useful for analyzing what problems need attention
first because the taller bars on the chart, which represent http://cec.health.nsw.gov.au/Quality-Improvement-Academy/quality-improvement-tools/pareto-charts
frequency, clearly illustrate which variables have the greatest SAMPLE PARETO CHART
cumulative effect on a given system
PARETO ANALYSIS
https://qrs.ly/26bqcwn
MEASURES OF CENTRAL TENDENCY

MEAN MEDIAN MODE
• Most common measure of central • The value that falls in the middle position • The value that occurs with the greatest
tendency; “average” when the observations are ranked in order frequency in a set of observations
• The sum of all observed values divided from the smallest to the largest. • Used in public health statistics (top 10
by the number of observation • If number of observations is odd, the median mortality and morbidity)
• Not useful on a skewed data (abnormal is the middle number • For bimodal distribution
distribution) • If it is even, the median is the average of the
• For numerical data and symmetric 2 middle numbers.
distribution • Useful on skewed data
• For ordinal or numeric data if skewed
MEASURES OF DISPERSION
MEAN, MEDIAN, & • Measures of dispersion or variation locate the spread of a
MODE frequency distribution. The measures help to describe the
https://qrs.ly/o3bq9uq spread, or how far from the center the data tend to range.
• Describes the variability of the observations
• Homogenous
PRACTICE MEAN, MEDIAN & MODE o Little difference between adjacent observations
• Find the sample mean for the following set of numbers: 12, 13, • Heterogenous
14, 16, 17, 40, 43, 55, 56, 67, 78, 78, 79, 80, 81, 90, 99, 101, o Observations are scattered around the mean
102, 304, 306, 400, 401, 403, 404, 405. • Dispersion
• Step 1: Add up all of the numbers: o Dispersion in statistics is a way of describing how spread out a
• Step 2: Count the numbers of items in your data set. In this particular set of data is. When a data set has a large value, the values in
data set, there are 26 items the set are widely scattered; when it is small the items in the
• Step 3: Divide the number you found in Step 1 by the number you found set are tightly clustered.
in Step 2. 3744/26 = 144. o Very basically, this set of data has a small value/small variance:
https://www.statisticshowto.com/probability-and-statistics/statistics-definitions/sample-mean/
§ 1, 2, 2, 3, 3, 4
If you are given a data set please make sure to arrange/rank it first o …and this set has a wider one/high variance:
from the lowest observation up to highest, so at least you are ready to
§ 0, 1, 20, 30, 40, 100
identify your median value!
Dr. Mann It is better to watch this first before you proceed on reading the definition,
para meron na tayo basehan, I don’t want to burst your bubble (wow soyal
Identify median? 12, 13, 14, 16, 17, 40, 43, 55, 56, 67, 78, 78, may pa burst) but this concept was never asked from previous boards, baka
79, 80, 81, 90, 99, 101, 102, 304, 306, 400, 401, 403, 404, 405. sa inyo palang! Charot! Again. Mag kapit-kapit tayo ng kamay, SANA PO
WALA COMPUTATION!
Since we have an even observation, we need to add 79 and 80 then
divide it by 2 = 79.5
Dr. Mann MEASURES OF
DISPERSION
Identify the mode? 12, 13, 14, 16, 17, 40, 43, 55, 56, 67, 78, 78, https://qrs.ly/crbq9ut
79, 80, 81, 90, 99, 101, 102, 304, 306, 400, 401, 403, 404, 405
The value that occurs in greatest frequency is 78 (unimodal) Dr. Mann
Dr. Mann
COEFFICIENT OF
RANGE VARIANCE STANDARD DEVIATION
VARIATION
• Simplest • Average of the squared deviation of • Square root of variance • Expresses the standard of
• Computed as the difference the mean. • Most common and useful deviation as a % of a mean
between the smallest and the • Each deviation should be squared first measure because it is the • used to compare relative
largest values in a set of data. before taking the sum. average distance of each dispersion in one type of
• Ungrouped data: Highest minus • Always a positive value score from the mean or data with relative
lowest • Statisticians tend to consider variance a how much each data value dispersion in another type
• Grouped Data: True upper class primary measure & use it extensively deviates from the mean of data
limit of the highest class • Affected by outliers • Requires numeric data • Measures relative
interval minus the true lower • Best for symmetric data • Highly affected by outliers variability
limit of the lowest interval • measures how far a set of numbers are • Used when the units of
spread out. measurement of variables
LOW VARIANCE: being compared are
• indicates that the data points tend to be different
very close to the mean (expected value)
and hence to each other
HIGH VARIANCE:
• indicates that the data points are very
spread out around the mean and from
each other.
Disadvantages:
S2= ∑x2- (∑x)2/ n SD/Mean x 100
• Very sensitive to extreme
n-1
observation values. SD= √𝑆2
Not easily interpreted since results are in Standard deviation divided by
• Based only on extreme values.
squared limits the mean multiplied by 100
• Least informative
MEASURES OF LOCATION APPLICATION NORMAL DISTRIBUTION
• QUARTILE 1. Computation of proportion or percentages of values that
o divide the observations into 4 equal parts (if observation belong to different categories of variable of interest
values are 100, then every 25th value is the quartile) 2. Determining the x value that bound a specified area under
• DECILE the normal curve.
o – divide the observations into 10 equal parts (if the
observation values are 100, then every 10th value is the decile) “THE 68-95-99.7% RULE”/EMPIRICAL RULE
• PERCENTILE • 68% of observations fall within 1 SD of the mean
o (1st percentile to 100th percentile) • 95% of observations fall within 2 SDs of the mean
Ito actually yung grade mo sa pa exam natin dito sa Topnotch, so ano nga • 99.7% of observations fall within 3 SDs of the mean
ulit percentile mo? So that’s your “location”/ sa system, NMAT grade also
is good example of this measures of location.
PERCENTILE
https://qrs.ly/q8bqa1r
Dr. Mann
NORMAL DISTRIBUTION
• The normal distribution is the most important probability
distribution in statistics because it fits many natural http://statisticshelper.com/empirical-rule-calculator-mean-standard-deviation
phenomena. For example, heights, blood pressure, Thus, for a normal distribution, almost all values lie within 3 standard
measurement error, and IQ scores follow the normal deviations of the mean
distribution
• The normal distribution is a probability function that describes PRACTICE EMPIRICAL RULE
how the values of a variable are distributed
Among males 44-75 years old in a small community in Tondow Muhnila,
the systolic blood pressure is normally distributed with a mean of
NORMAL 120mmHg, standard deviation of 10. What percentage of males will have
DISTRIBUTION a systolic blood pressure >140mmHg or considered hypertensive?
https://qrs.ly/p3bqa45 Subukan mo muna sagutin ito, try lang then after pwede mo na scan
yung QR code sa baba for the answer J GO GO GO!
Dr. Mann
CHARACTERISTICS:
1. Bell shaped and symmetrical about the mean
2. The mean, median, mode are all equal
3. The total area under the curve and above the x axis is equal to 1
4. It has long tapering tails extending infinitely but never
touching the x axis
5. It is determined by its parameters: its mean(µ) and standard
deviation(σ)
6. The standard deviation becomes a more meaningful quality
than merely being a measure of dispersion
SUPPLEMENT: CENTRAL LIMIT THEOREM
• The central limit theorem in statistics states that, given a
sufficiently large sample size, the sampling distribution of the
mean for a variable will approximate a normal distribution ANSWER TO
regardless of that variable’s distribution in the population. EMPIRICAL RULE
https://statisticsbyjim.com/basics/central-limit-theorem/
PRACTICE
CENTRAL LIMIT https://qrs.ly/2rcqpnp
THEOREM
https://qrs.ly/t1bqa55
SKEWED DISTRIBUTION HYPOTHESIS TESTING
• A distribution is said to be skewed when the data points cluster • simply defined as a statement about the population, based on
more toward one side of the scale than the other, creating a the probability of occurrence of the sample results if the null
curve that is not symmetrical. In other words, the right and the hypothesis were true.
left side of the distribution are shaped differently from each
other. There are two types of skewed distributions.
STEPS IN HYPOTHESIS TESTING
Skewed to the LEFT Skewed to the RIGHT 1. State the null hypothesis and alternate hypothesis
2. State the level of significance
AKA-Negatively skewed AKA- Positively skewed
3. Choose the test statistic
Outlying values are small Outlying values are large
4. Determine the critical region
Mean is smaller than the Mean is larger than the
5. Compute the test statistic
median median
6. Make a statistical decision
Mean<median<mode Mean>median>mode
7. Draw conclusions about the population
1. STATE THE HYPOTHESIS

TYPES OF HYPOTHESIS
• Null Hypothesis (Ho)
o Hypothesis of NO difference
o Statement of equality
o It is framed in hopes of being able to reject it so that the
alternative hypothesis could be accepted.
o “There is no association between the disease and the risk
https://www.statisticshowto.com/probability-and-statistics/skewed-distribution/
factor in the population”
Remember in a graph the left most part has the low value and moving to • Alternative Hypothesis (H1)
the right side of the graph the value is increasing. o The hypothesis that the investigator believes in
Follow the red arrow, tail of the arrow LOW VALUE and the arrow head o Example: There is some association between the disease and
HIGH VALUE the risk factor in the population
Example:
• Suppose we want to test whether the mean (average ) attention
span of topnotch online students is 10 minutes
• Ho - The population mean attention span of topnotch online
students is equal to 10 minutes.
• H1 :
o Two Tailed: The population mean attention span of topnotch
online students is not equal to 10 minutes.
o One-Tailed: The population mean attention span of topnotch
LEFT SKEWED VS online students is greater/less than to 10 minutes.
RIGHT SKEWED
https://qrs.ly/qnbqabw NULL VS
ALTERNATIVE
Dr. Mann HYPOTHESIS
https://qrs.ly/u6bqael
INFERENTIAL STATISTICS
INFERENTIAL STATISTICS 2. STATE THE LEVEL OF SIGNIFICANCE
• A statistical interference makes generalizations and LEVEL OF SIGNIFICANCE (α)
conclusions about a target population from samples. • The significance level, also denoted as alpha or, is a measure of
• Summarizing figures: the strength of the evidence that must be present in
o Parameter – a numerical constant obtained by observing the your sample before you will reject the null hypothesis and
total population (usually unknown) conclude that the effect is statistically significant.
o Statistic – a numerical variable obtained by observing a • The researcher determines the significance level before
random sample from the population. conducting the experiment
• Sampling variation – brought about by the element of chance
• gives the probability of incorrectly rejecting the null hypothesis
which is inherent in random sampling
when it is actually true.
• It is comprised of: o Traditional values for α: 0.05, 0.01, 0.001
o Hypothesis Testing
o Estimation α is typically set at ≤0.05 (but can be set where a study determines), which
allows interpretation with 95% certainty that a detected association is
§ Point Estimate- is a single number
true.
§ Interval Estimate Dr. Mann
TYPE I (Α) ERROR TYPE II (Β) ERROR

Error of rejecting the null Error of NOT rejecting the
hypothesis when it is really null hypothesis when it is
true actually false
Declaring a difference when Failing to declare a
none exists. Similar to false difference that does exist.
positive test Similar to false negative test
If we look at what can happen in a hypothesis test, we can construct the
following contingency table, table sa baba: REALITY
Dr. Mann
REALITY
DECISION H0 is TRUE H0 is FALSE
Type II Error
Do not Reject H0 OK
β -Error
SCHEMATIC DIAGRAM OF THE CONCEPTS OF STATISTICAL Type I Error
INFERENCE Reject H0 OK
α- Error
For more example and application please watch this video.
ONE TAILED TEST OR

TWO TAILED TEST ?
https://qrs.ly/wbbqd1n
Dr. Mann
SUPPLEMENT: DEFINITION OF TERMS

• Parametric tests are used when data follow a normal
distribution (a bell-shaped distribution where the median,
mean, and mode are all equal).
• Nonparametric tests are used when a normal distribution
cannot be assumed; they rank data rather than taking
absolute differences into account.
• Paired tests are performed on paired data; for example,
https://medium.com/@neeraj.kumar.iitg/statistical-performance-measures-12bad66694b7 where the same parameter is measured twice on each study
MNEMONIC subject, often before and after an intervention.
TYPE 1- ART-- ALPHA REJECTING TRUE hypothesis • Unpaired tests compare values from independent samples.
TYPE 2- BNF- BETA NOT REJECTING FALSE hypothesis • Two-tailed tests should be used when an intervention could
Dr. Mann potentially lead to either an increase or decrease of the
3. CHOOSE THE TEST STATISTIC outcome.
• Variance known à z-test • One-tailed tests should be used when an intervention can
• Variance unknown à t-test have only one plausible effect on the outcome.
TWO-TAILED TEST ONE-TAILED TEST • Correlation and regression describe the degree of linear
H1 states that there is a H1 states that there is a association between two quantitative variables, but they do
difference but does not difference and specifies its not imply causation.
specify its direction direction of difference • Correlation measures the strength of association between
Ex: The proportion of Ex: The proportion of two variables; expressed by the correlation coefficient r, also
topnotch reviewees who topnotch reviewees who termed Pearson correlation coefficient.
obtained a grade of >80 obtained a grade >80 among • Regression constructs an optimal straight line illustrating
among those engaged in SGD those engaged in SGD is correlation, and allows for prediction of a dependent variable
is not equal to those who greater than those who self- based on an independent (known) variable.
self-study study
COMMONLY USED STATISTICAL TESTS
NONPARAMETRIC
PURPOSE OF TEST PARAMETRIC TEST EXAMPLE
TEST
Two-sample (unpaired)
Compares two independent samples Mann-Whitney U test To compare girls’ heights with boys’ heights
t test
Compares two sets of observations on a One-sample (paired) t Wilcoxon matched To compare weight of infants before and
single sample test pairs test after a feeding
One-way analysis of
Kruskal-Wallis To determine whether plasma glucose level
Compares three or more sets of variance (F test) using
analysis of variance by is higher 1 hour, 2 hours, or 3 hours after a
observations made on a single sample total sum of squares
ranks meal
(ANOVA)
Test the influence (and interaction) of two Two-way analysis of Two-way analysis of In the above example, to determine whether
different variables variance (ANOVA) variance by ranks the results differ in male and female subjects
Tests the null hypothesis that the
To assess whether male or female
distribution of a variable is the same in χ2 (chi square) test Fisher exact test
adolescents are more likely to smoke
two (or more) independent samples
To assess whether and to what extent
Assesses the strength of the straight-line Product moment Spearman rank
plasma HbA1c concentration is related to
association between two continuous correlation coefficient correlation coefficient
plasma triglyceride concentration in
variables (Pearson r) (rσ)
diabetic patients
Describes the numerical relation between Nonparametric
Regression by least To see how peak expiratory flow rate varies
two quantitative variables, allowing one regression (various
squares method with height
value to be predicted from the other tests)
Describes the numerical relationship Nonparametric To determine whether and to what extent a
Multiple regression by
between a dependent variable and several regression (various person’s age, body fat, and sodium intake
least squares method
predictor variables (covariates) tests) determine his or her blood pressure
Data from Greenhalgh T. How to read a paper. Statistics for the non-statistician. I: Different types of data need different statistical tests. BMJ. 1997; 315(7104): 364-366.
Table 29.1. Molloy M. (2020) Biostatistics and Evidence-based Medicine. K Kleinman et al. (Ed). The Harriet Lane Handbook (22nd ed. 29: p 655). Elsevier Inc.
4. DETERMINE THE CRITICAL REGION Important Values in Statistical Tests
Critical Region P value:
• The critical region is the region of values that corresponds to the • It is the probability of obtaining the result as extreme or more
rejection of the null hypothesis at some chosen probability level extreme than the one observed if the null hypothesis is true. The
• also known as the rejection region probability that the observed result is due to chance alone.
• is a set of values for the test statistic for which the null • is the probability of a difference occurring by chance, and is
hypothesis is rejected. i.e. if the observed test statistic is in the judged against α, the preset level of significance. If p is less than
critical region then we reject the null hypothesis and accept the the significance level α, the detected association is unlikely
alternative hypothesis. to be due to chance alone. For example, if p <0.01, there is less
than a 1 in 100 chance of the detected association being due to
chance alone.
Importante lang na mag ka idea ka
about the critical region and kung ano
basis niya for making a decision, pero 5. COMPUTE THE TEST STATISTIC
MALOLOKA ako kung mag plot ka nito Interpretation is much more important rather than computation sa
sa exam again walang mga ganitong boards, and usually ang computation ngayon ginagamitin na ng software
cases usually… CRITICAL REGION like STATA. SO KALMA LANG TAYO SA PART NA ITO!
Dr. Mann
https://qrs.ly/vcbqd4c
Dr. Mann
6. MAKE A STATISTICAL DECISION POPULATION DYNAMICS
Rejecting or Accepting a Hypothesis DEFINITION OF TERMS
Low P High P
1. POPULATION
p<α p>α o Total number of individuals in a territory or a locality living
Value of sample results are Value of sample results are o at a specified moment of time with an agreed definition of
far from the population close to population residence
parameters parameters o All persons falling within the scope of a census or other inquiry
Unlikely events Likely events 2. POPULATION DYNAMICS
REJECT HO DO NOT REJECT HO o It is the study of changes in size and composition of the
Note: If there is no sufficient evidence to reject the null hypothesis, it is o population and the determinants of population growth such as
RETAINED or cannot be rejected but NOT ACCEPTED.
births, deaths, migration.
Wag malilito makukuha mo ang P-Value after computing your data, so
• Growth
basically magiging guide mo ito together with your alpha (level of
significance.
o Difference between birth rate and death rate
Dr. Mann o Factors:
§ Births or fertility
7. DRAW CONCLUSIONS ABOUT THE POPULATION § Deaths
• Ho - The population mean attention span of topnotch online § Migration
students is equal to 10 minutes. o Net growth rate= birth rate minus death rate plus in-migration
• H1 : rate minus the out migration rate
o Two Tailed: The population mean attention span of topnotch • Size
online students is not equal to 10 minutes. • Composition
The Claim is the The Decision is The Conclusion is o Sex ratio
The evidence is not § Found to be high at birth
Fail to Reject the § Tend to decrease as age increases reaching 99% in middle
sufficient to reject the
Null life
claim
Null Hypothesis § Females were found to have longer life expectancy than
The evidence is
Reject the Null sufficient to reject the males
claim § Sex ratio is higher in rural areas than in urban areas
There is insufficient § It is also higher in frontier communities
Fail to Reject the
evidence to support the
Null • Number of males in the population/number of females in the
Alternative claim population x 100
hypothesis There is sufficient • Interpretation- there are _____ males for every 100 females in the
Reject the Null evidence to support the population
claim Dr. Mann
• Age group
o Dependency Ratio:
ESTIMATION
§ represents the number of dependents that need to be
• The process of computing for measures of population attributes supported by every working individual
based on data from a sample. § Computed by:
(Population 0-14 yo) + (Population ≥65yo) x 100
2 TYPES Population aged 15-64 years
POINT ESTIMATE/ INTERVAL ESTIMATE/
POWER ESTIMATE CONFIDENCE INTERVAL Significance: provides an index of age- induced economic drain on
manpower resources (Recent board exam question)
• A single numerical value • Two numerical values Dr. Mann
used to estimate the defining an interval which POPULATION PYRAMID
corresponding population with ranging degrees of • A population pyramid, or age structure graph, is a simple graph
parameter confidence is expected to that conveys the complex social narrative of a population
include or catch the through its shape
parameter being tested. • important graphs for visualizing how populations are composed
• Interval estimate – consists when looking a groups divided by age and sex
of two numbers, a lower
limit and an upper limit, CHARACTERISTIC OF A POPULATION PYRAMID
which serve as the
bounding values within the
parameter is expected to lie
with a certain degree of
confidence
• Population pyramid special type of histogram

CONFIDENCE INTERVAL • Male population shown at the left
• a range of values so defined that there is a specified probability • Females right
(90%, 95%, 99%)that the value of a parameter lies within it • Youngest at base
• Oldest at top
CONFIDENCE • Chronologically arranged
INTERVAL • And represented by horizontal bar
https://qrs.ly/e6bqdms
TYPES OF POPULATION PYRAMID Parameters
YOUNG
INTERMEDIATE
OLD
1. EXPANSIVE POPULATION POPULATION
Fertility/
High Moderate Low
death rate
Median Age 15-20 years 21-25 26-30+ years
2-3
1:1 (rapid 1-2 (slow
Dependency (moderate
population population
Ratio population
growth) growth)
growth)
Developing Developed
countries countries
Note: The Philippines has a young population.
Dr. Mann
Some Factors affecting age composition:
• Fertility- with high fertility → Young population
• Peace and Order Situation- immediate post war period → babies
boom = younger population
• Social Status
populationeducation.org • Educational Status
• used to describe populations that are young and growing • Urban-Rural differences: Urban population tends to have older
• characterized by their typical ‘pyramid’ shape age composition than rural
• has a broad base and narrow top • Most Filipinos prefer to live in urban areas because of better job
• show a larger percentage of the population in the younger age opportunities, higher educational centers, more advanced
cohorts facilities
• typically representative of developing nations, whose • Cause and Effect Nature - present composition is the effect of
populations often have high fertility rates and lower than previous structure
average life expectancies
2. CONSTRICTIVE ✔GUIDE QUESTION
Q: Increase in the life expectancy is mainly due to?
A: Decrease in mortality in the younger age groups
Q: How can we call declare a place as an “URBAN” area?
A: Definition of Urban area for the Philippines by National
Census and Statistics Office
o All cities & Municipalities having a population of at least
1000 persons per sq. kilometer
o With population density of at least 500 persons per sq. km
o Districts not included in aforementioned criteria regardless
of population size but have the following: street patterns; at
least 6 establishments (commercial, manufacturing,
recreational, personal services); at least 3 of the following:
town hall, church, park, cemetery, marketplace, public
building (school, hospital, library)
o Barangay having at least 1000 inhabitants which meets the
criteria aforementioned and the occupation of the
populationeducation.org
inhabitants is non-farming or fishing
• used to describe populations that are elderly and shrinking
• often look like beehives and typically have an inverted shape SUPPLEMENT OVERPOPULATION/ POPULATION EXPLOSION
with the graph tapering in at the bottom • exists when the economy cannot support the population in the
• have smaller percentages of people in the younger age cohorts face of a rapid population growth.
and are typically characteristic of countries with higher levels of • economic support is measured in terms of:
social and economic development o State of health and nutrition
• Base that is narrower than middle of the pyramid, usually the o Level of unemployment
result of a recent rapid decline in fertility o Level of education
o State of housing
3. STATIONARY
TOOLS OF POPULATION DYNAMICS
1. Estimating population growth
Pt=P0 (1+r) t
Where P0 is population size at the previous census and Pt is the size of the
census t years later, and r is the annual growth rate between now and
the next t years
Population Density
• population per unit of land
• Number of people per square kilometer
• Measure intensity of land use
Why do we need to know this? Because population density can affect rate
of disease transmission and environmental health
Dr. Mann
Population distribution
populationeducation.org • patterns of settlement and dispersal of a population
• Narrow base and a roughly equal numbers in each age group, • How people are distributed in a specified space or geographic
tapering off at the older ages, indicating a moderate proportion area
of children and a slow or zero rate of growth
• The following can affect the population distribution:
• used to describe populations that are not growing o Physical factor
• characterized by their rectangular shape, displaying somewhat o Political
equal percentages across age cohorts that taper off toward the o Social/cultural
top o Economic
• characteristic of developed nations, where birth rates are low Dr. Mann
and overall quality of life is high

• Population Increase – the total population increase resulting
from interaction of births, deaths, and migration in a population
in a given period of time
• Population momentum – the tendency for population growth
to continue beyond the time that replacement level fertility had
been achieved because of relatively high concentration of people
in the childbearing years
• Population optimum – the ideal number of people that can be
sustained in a given area
• Population Policy – explicit or implicit measure instituted by a
government to influence population size, growth, distribution,
or composition
• Population projection – the computation of future changes in
population numbers, given certain assumptions about future
trends in the rate of fertility, mortality, and migration
DEMOGRAPHY
DISTINGUISHING PROPORTIONS, RATES, AND RATIOS
• Empirical, statistical and mathematical study of human med.uottawa.ca
populations MORBIDITY RATES
• Uses: INCIDENCE PREVALENCE
o Planning and administration Numerator No. of NEW cases No. of cases
o Control and prevent health problems No. of people AT RISK
o Study determinants or reasons for occurrence of such Total population at
Denominator (during a time
problems a point in time
PERIOD)
o To know growth and dispersal of population groups in the past Looks at new cases = Look at ALL current
as well as to predict the future developments and their Value
incidents cases
possible consequences
• Tools: A. PREVALENCE
o Counts – absolute # of a population occurring in a specified • Quantifies the proportion of individuals who have the disease at
point in time a specific instant
o Ratio • Provides an estimate of probability (risk) that an individual will
o Proportion – special type of ratio be ill at a point in time
o Rate-frequency- occurrence of events over a given interval of • Can be presented as:
time POINT PERIOD
§ Useful when events are dynamic PREVALENCE* PREVALENCE
§ Measures the amount of change Total cases (old and Total cases (old and
§ More valuable to use when making comparisons between Numerator new) at a FIXED point new) at a PERIOD
and among populations which differ in distribution in time of time
Total population at Total population at
Denominator
LIFE EXPECTANCY OF FILIPINOS that time that period of time
• Chart and table of Philippines life expectancy from 1950 to *More useful than incidence rate in describing the occurrence of chronic
conditions
2021. United Nations projections are also included through the
tear 2100
o The current life expectancy for Philippines in 2021 is 71.41 INCIDENCE AND PREVALENCE
years, a 0.18% increase from 2020 https://qrs.ly/whbqdtp
o The life expectancy for Philippines in 2020 was 71.28 years, a
0.18% increase from 2019
MEASURES OF DISEASE FREQUENCY

SUPPLEMENT BASIC CONCEPT
It is important to review some basic concept:
o The importance of understanding the “numerator” and the
“denominator” [proportions, rates, ratios]
o Defining the numerator [“case”]
o Defining the denominator [“population at risk”]
\
RATIO
• Obtained by dividing one quantity by another 𝑎
(𝑘)
• a single number that represents the relative 𝑏
size of two numbers Gordis Epidemiology, 2013
PROPORTION FACTORS INFLUENCING PREVALENCE RATE
𝑎
• special type of ratio in which numerator is part (𝑘)
Increased by Decreased by
𝑎+𝑏
of the denominator 1. Longer duration of disease 1. Shorter duration of
RATE 2. Prolongation of life of disease
• measure of how quickly something of interest patient without cure 2. High case fatality rate
happens 3. Increase in new case 3. Decrease in new
• frequency of occurrence of events over a given (incidence) cases(incidence)
TIME interval 4. In- migration of cases 4. In-migration of healthy
-
o Time, place and population must be specified 5. Out-migration of healthy people
for each type of rate. people 5. Out-migration of cases
o In a rate, numerator is not a subset of the 6. In-migration of susceptible 6. Improved cure rate of
denominator people cases
o Rate is not a proportion 7. Improved diagnostic
facilities
– CI assumes that the entire population at risk at the
FACTORS beginning of the study has been followed up for the
INFLUENCING specified time period for the development of the outcome
PREVALENCE RATE under investigation
https://qrs.ly/1zcqpov
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑁𝐸𝑊 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝐶𝐼 =
𝑡𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘
B. INCIDENCE B. INCIDENCE DENSITY (ID) or INCIDENCE RATE
• Quantifies the number of NEW events or cases of disease that – a measure of instantaneous rate of development of
develop in a population at risk during a specified time interval disease in a population
o There are two types of incidence measures: – accounts for “lost to follow up”
A. CUMULATIVE INCIDENCE (CI)
– Provides an estimate of the probability (risk) that an 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑁𝐸𝑊 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝐼𝐷 =
individual will develop a disease during a specified 𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑠𝑜𝑛 − 𝑡𝑖𝑚𝑒 𝑜𝑓 𝑜𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛
period of time
VITAL STATISTICAL RATES AND RATIOS
FERTILITY RATES
RATE NUMERATOR DENOMINATOR K
CRUDE BIRTH RATE: Measures how fast people are added to the Number of registered Live births
Midyear population 1,000
population through births in a year
GENERAL FERTILITY RATE: More specific rate than the crude birth
Number of registered live births in Midyear population of
rate since births are related to the segment of population deemed to be 1,000
a year women 15-44 years old
capable of giving birth
AGE SPECIFIC FERTILITY RATE: Number of live births per woman Number of women in a
1,000
Shows variation in fertility by age of a given age groups given age of group
TOTAL FERTILITY RATE:
Standardized index for overall fertility level Sum of all age specific fertility rate Please take note!
Represents the average number that would be born to a women for each year of women from 15- GFR – 15-44 y/o 1,000
throughout her lifetime 49 y/o TFR – 15-49 y/o
Dr. Mann
Indicator of cohort fertility
GROSS REPRODUCTION RATE: Gives an idea about replacement of Total fertility rate restricted to
1,000
females in the population female births only
NATALITY RATES
CRUDE BIRTH RATE:
Number of live births
Affected by accuracy of registration of live births, fertility status of female, Midyear population 1,000
in 1 year
proportion of child bearing females, cultural and social practices
GENERAL FERTILITY RATE: Relates to the segment of population which is Number of live births Number of women (15-
1,000
actually capable of giving birth in 1 year 44 y/o)
MORTALITY RATES
CRUDE DEATH RATE:
Affected by age and sex composition of the population; adverse Number of deaths in a calendar year Midyear population 1,000
environmental condition; peace and order conditions of a place
SPECIFIC MORTALITY RATE:
Midyear population of
Can be made specific according to age, sex, occupation, Number of deaths in a specified group in
the same specified 100,000
education, exposure to risk factors. Graph of age specific a calendar year
group
mortality rates shows a J shaped or U shaped curve
CAUSE OF DEATH RATE:
Affected by completeness of registrations of death; composition Number of deaths from a certain cause in
of population; disease ascertainment in the community which a calendar year
may be used to determine the 10 leading cause of death
INFANT MORTALITY RATE:
• Please remember this as Most sensitive index of assessing
health status in the community. Recent Board Exam Question Deaths under 1 year of age in a calendar Number of live births
Dr. Mann 1,000
High IMR means low level of health standards which maybe year in the same year
secondary to poor maternal and child health care, malnutrition,
poor environmental sanitation, or deficient health care service
Number of deaths from 28 weeks AOG to Number of live births
infant <7 days old and fetal deaths 28
PERINATAL MORTALITY RATES 1,000
(do not confuse this definition to the weeks or more during
perinatal period set by WHO) the same year
NEONATAL MORTALITY RATE:
Cause of death are mainly due to pre-natal or genetic factors Number of deaths among those under 28 Number of live births
1,000
Recent Board Exam Question days of age in a calendar year in the same year
Dr. Mann
POST-NEONATAL MORTALITY RATE: Number of deaths among those 28 days
Influenced mainly by environmental or genetic and nutritional to less than 1 year of age in a calendar 1,000
in the same year
factors as well as infections year
MATERNAL MORTALITY RATE: in the same year
Number of deaths due to pregnancy,
Affected by maternal health practices; diagnostic ascertainment; 1,000
delivery, puerperium in a calendar year
completeness of registration of births (Ideally: Number of
pregnancies)
CHILD MORTALITY RATE:
Reflects the main environmental factors affecting health of a
Total population of
child Number of deaths at 1-4 y/o 1,000
children ages 1-4 y/o
Sensitive indicator of socio-economic development in a
community
Number of deaths from a particular
PROPORTIONATE MORTALITY RATE Total deaths in a year 100
cause /population group in a year
SWAROOP’S INDEX:
• Please remember this as a Sensitive indicator of
standard of health care. Recent Board Exam Question Number of deaths among those 50 years
Total deaths in a year 100
Dr. Mann and older in a calendar year
Developed countries have a higher Swaroop’s index than less
developed ones
CASE FATALITY RATE:
Measures killing power of disease
High CFR means a more fatal disease. Number of cases of
A higher CFR is expected from a hospital statistics than from the Number of deaths from a specified cause 100
the same disease
community
Recent Board Exam Question
Dr. Mann
SUMMARY IMPORTANT LIFE PERIOD PICO/M PROCESS

Age Group Period • P: Describe the patient or problem, deciding whether the
Neonate: <28 days old Perinatal: evidence you seek is regarding therapy, diagnosis, prognosis,
Infant: < 1 yo 22 completed weeks etiology, or cost effectiveness.
Child: 1-4yo AOG – <7days old (WHO) • I: Describe the intervention under consideration.
Fertile: • C: Compare the intervention with an alternative or current
o GFR- 15-44 y/o (Do not confuse this with standard of care.
o TFR- 15-49 y/o perinatal mortality rate) • O: Formulate a specific outcome of interest.
Productive/Working: 15-65yo • M: Methodologies
Post-Neonatal: 28 days
old - <1yo EBM LEVEL OF EVIDENCE
EVIDENCE-BASED MEDICINE
• Evidence-based medicine refers to the method of integrating
individual clinical expertise with the best available evidence
from the literature.
• Evidence based medicine (EBM) is the conscientious, explicit,
judicious and reasonable use of modern, best evidence in
making decisions about the care of individual patients. EBM
integrates clinical experience and patient values with the best
available research information
THE THREE SKILLS OF EBM

• Skill number 1: Acquiring the evidence
• Skill number 2: Appraising the evidence
• Skill number 3: Applying the evidence
https://academicguides.waldenu.edu/library/healthevidence/evidencepyramid
The levels of evidence pyramid provide a way to visualize both the quality
of evidence and the amount of evidence available. For example,
systematic reviews are at the top of the pyramid, meaning they are both
the highest level of evidence and the least common. As you go down the
pyramid, the amount of evidence will increase as the quality of the
evidence decreases.
Meron din variation with the different level of evidence if given sa choices
ang meta-analysis choose that as the highest level of medicine
Dr. Mann
Painless Evidence-Based Medicine John Wiley & Sons, 2008

Recent board exam question
Dr. Mann EBM PYRAMID
https://qrs.ly/sycqpra
STUDY DESIGN COMPARISON

DESIGN TYPE DEFINITION ADVANTAGES DISADVANTAGES
• Define diseased subjects (cases) and non- • Good for rare diseases • Highest potential for biases
diseased subjects (controls); compare • Small sample size (recall, selection, and others)
Case-control (often
proportion of cases with exposure (risk factor) Shorter study times (not • Weak evidence for causality
called retrospective)
with proportion of controls with exposure followed over time) • Unable to determine prevalence,
(risk factor) • Less expensive PPV, NPV
• Expensive
• Defines incidence
• In study population, define exposed group • Long study times
Stronger evidence for
Cohort (usually (with risk factor) and nonexposed group • May not be feasible for rare
causality
prospective; (without risk factor) diseases/ outcomes
• Decreases biases
occasionally • Over time, compare proportion of exposed • Factors related to exposure and
(sampling,
retrospective) group with outcome (disease) with proportion outcome may falsely alter effect of
measurement,
of nonexposed group with outcome (disease) exposure on outcome
reporting)
(confounding)
• In study population, concurrently measure
outcome (disease) and risk factor
• Defines prevalence Short • Selection bias
Cross-sectional • Compare proportion of diseased group with
time to complete • Weak evidence for causality
risk factor with proportion of non-diseased
group with risk factor
DESIGN TYPE DEFINITION ADVANTAGES DISADVANTAGES

• Randomized blinded • Expensive
• In study population, assign (randomly)
trial is gold standard • Risks of experimental treatments
subjects to receive treatment or receive no
Clinical trial • Randomization reduces in humans
treatment
(experiment) confounding • Longer study time
• Compare rate of outcome (e.g., disease cure)
• Best evidence for • Not suitable for rare outcomes/
between treatment and nontreatment groups
causality diseases
• Collates data from multiple independent • Higher statistical power • Possible bias in exclusion of
Meta-analysis studies to maximize precision and power in • Can control for inter- published studies or publication
testing for statistical significance study variation bias
NPV, Negative predictive value; PPV, positive predictive value
Data from Hulley SB, Cummings SR, et al. Study Designs. In: Designing Clinical Research. 4th edition. Philadelphia: Lippincott Williams & Wilkins; 2011:84-207.
Table 29.2. Molloy M. (2020) Biostatistics and Evidence-based Medicine. K Kleinman et al. (Ed). The Harriet Lane Handbook (22nd ed. 29: p 655). Elsevier Inc.
EPIDEMIOLOGY CORE EPIDEMIOLOGIC FUNCTIONS

• Public health surveillance- ongoing, systematic collection,
INTRODUCTION TO EPIDEMIOLOGY analysis, interpretation, and dissemination of health data to help
HIGHLIGHTS IN THE HISTORY OF EPIDEMIOLOGY guide public health decision making and action.
1. Hippocrates (400BC): Role of Environment in health and o Purpose of public health surveillance provides “Information
disease among men for action”
2. John Graunt (1662): First to employ quantitative methods in o Monitoring the pulse of the community
describing population vital statistics - recorded descriptive • Field Investigations
statistics of birth and death data • Analytic studies
3. Edward Jenner (1796) discovered that it is possible to • Evaluations
vaccinate against Small Pox using material from Cow Pox • Linkages
4. John Snow investigated a cholera epidemic in mid-19th century
• Policy development
in London – “Father of MODERN epidemiology”
5. Koch (late 1800s): Some diseases are caused by living
FACTORS OF DISEASE CAUSATION
organisms! Koch’s Postulates!
6. Framing Heart Study (1949): Risk factors for coronary heart • Predisposing factors are the factors which create a state of
disease susceptibility, making the host vulnerable to the agent. These
7. Salk (1954): Polio Vaccine are age, sex and previous illnesses.
8. Doll and Peto (Post WWII): Association between smoking and • Enabling factors are those which assist in the development of
Lung CA (or in recovery from) the disease; e.g. housing conditions, socio-
9. Eradication of small pox economic status.
(Dr. Kurt’s notes, from Dr. Ofelia Saniel’s Intro to Epid Lecture, CPH, UPM) • Precipitating factors are those which are associated with
EPIDEMIOLOGY immediate exposure to the disease agent or onset of disease, e.g.
• The study of distribution and determinants of disease frequency drinking contaminated water, close contact with a case of
in human populations (MacMahon and Trichopoulus, 1996) pulmonary TB.
• The word epidemiology comes from the Greek words: • Reinforcing factors are those which aggravate an already
o Epi-meaning on or upon, existing disease, e.g. malnutrition, repeated exposures.
o Demos- meaning people • Risk factors are the conditions, quality or attributes, the
o Logos-meaning the study of presence of which increases the chances of an individual to have,
• The study of nature, cause, control, and determinants of develop or be adversely affected by a disease process. The risk
frequency and distribution of disease, disability, and death in factor need not necessarily cause the disease but does increase
human populations (Timreck, 1994) the probability that the person exposed to the factor may get the
• It is the backbone of disease prevention disease easily.
Na tanong ito nung nakaraan, yan ang chika so I included this sa handout,
COMPONENTS OF EPIDEMIOLOGY: try to understand lang the different factors in causation
• Population Dr. Mann
https://www.nhp.gov.in/causation-of-diseases_mtl
• Distribution
• “Factors” - risk or protective CONCEPTS ON CAUSATION DISEASES
ANCIENT VIEWS
USES OF EPIDEMIOLOGIC STUDIES: • Demonic theory
• To identify the etiology or cause of the disease o evil spirit entering the body directly and pursuing nefarious
• To determine of natural history and prognosis of the disease action
• Identification of risk factors and high risk groups • Punitive theory
• Determination of the extent of disease found in the community o disease was a punishment meted out by an outraged God for
• Identification of health programs, adequate measures for the sins of the individual or the race
diagnosis and treatment and prevention of diseases • Humoral theory
• Evaluation of effectiveness of existing health programs, therapy o matter is made up of four elements- Earth, Air, Fire and Water
and preventive measures and these elements have the corresponding qualities of
being Cold, Dry, Hot and Moist
CLASSICAL VS. CLINICAL EPIDEMIOLOGY o represented in the body by four humors – Phlegm, yellow
CLASSICAL CLINICAL bile, black bile and blood
• Population oriented • Study patients in health o According to this theory, the equilibrium among these
• Studies the community care settings rather that in humors characterizes health (eucrasia), and disequilibrium
origins of health problems community at large (dyscrasia) characterizes disease
(infectious agents, • Goal is to improve the Hippocrates moved medicine from magic and metaphysics to give it a
nutrition, environment, prevention, early detection, scientific basis. He introduced logic into medical thinking, elaborated the
behavior, social, economic, diagnosis, treatment, theory of humours and recognized the importance of the environment in
health. He also suggested that an excess of one of the humours would
and spiritual prognosis, and care of
result in various idiosyncrasies - hematic, phlegmatic, choleric, and
• Interested in discovering illness in INDIVIDUAL melancholic
risk factors that might be PATIENTS who are at risk Dr. Mann
altered in a population to for, or already affected by, • Miasmatic theory

prevent or delay disease, specific disease o based on the inference that the air arising from certain kinds
injury, and death of ground, especially low, swampy areas, was a cause of
disease
• Contagion theory
o based on the observation that persons could contract
infections even if their humors are normally balanced
o Contagion as a corruption which develops in the substance of
a combination, passes from one thing to another, and is
originally caused by infection of the imperceptible particles.
Particles are called the seminaria (seeds or seedlets) of contagion
Dr. Mann
• MODERN VIEWS
o proposed by Louis Pasteur (1822 –1895) and Robert Koch
(1843 –1910)
o postulates that every human disease is caused by a microbe or
germ, which is specific for that disease and one must be able to
isolate the microbe from the diseased human being
• BEINGS THEORY
o Biologic factors and Behavioral factors
o Environmental factors
o Immunologic factors pitt.edu
o Nutritional factors • THE WHEEL THEORY

o Genetic factors o de-emphasizes the agent as the sole cause of disease
o Services, Social factors, and Spiritual factors o emphasizes the interplay of physical, biological and social
(production) environments. It also brings genetics into the mix
The acronym BEINGS can serve as a mnemonic device for the major o visualizes human disease in the form of a wheel, which has a
categories of risk factors for disease, some of which which are easier to
central hub representing the genetic components and the
change or eliminate than others Currently, genetic factors are among
the most difficult to change, although this field is rapidly developing and peripheral portion representing the environmental
becoming more important to epidemiology and prevention. component.
Immunologic factors are usually the easiest to change, if effective o the outer part (environmental component) has spokes (3 in
vaccines are available. this model) and the environmental component is thus divided
Jekel's Epidemiology, Biostatistics and Preventive Medicine
Dr. Mann into 3 sub components, representing the social, biological and
• MULTIPLE CAUSATION THEORY physical components of the environment
o >1 factor is required to cause the disease
• EPIDEMIOLOGIC TRIANGLE/CHAIN/TRIAD
o In this model, disease results from the interaction between the
agent and the susceptible host in an environment that supports
transmission of the agent from a source to that host.
o Consist of:
§ Host
§ Environment
§ Agent
Principles of Epidemiology in Public Health Practice Third Edition

• COMPONENT CAUSES AND CAUSAL PIE
o An individual factor that contributes to cause disease is shown
as a piece of a pie. Wheel model of human-environment interaction. (Redrawn from Mausner JS, Kramer S: Mausner and Bahn
epidemiology: an introductory text, ed 2, Philadelphia, 1985, Saunders.)
§ Component cause – Individual factors (a piece of pie) • LEVER OR BALANCE
§ Sufficient cause – The complete pie o environment is the fulcrum. Any shift in the leer caused by
§ Necessary causes – It is component cause or a piece of pie either factor will result in disequilibrium (disease)
that appears in every pie, because without it disease does not
occur
SUPPLEMENT DISABILITY
Source: Rothman KJ. Causes. Am J Epidemiol 1976;104:587–592.
• Epidemiologists are concerned not only with the occurrence
• WEB OF CAUSATION of disease, but also with the consequences of disease:
o effects never depend on single isolated cause but rather impairments, disabilities and handicaps. These have been
develop as a result of causation in which each link is the result defined by the WHO International Classification of
of a complex genealogy and antecedents Functioning, Disability and Health (ICF)
The key parameters of ICF are as follows:
• IMPAIRMENT:
o any loss or abnormality of psychological, physiological or
anatomical structure or function
o occur at the level of organ or system function; may be visible
or invisible
• DISABILITY:
o any restriction or lack (resulting from an impairment) of
ability to perform an activity in the manner or within the
range considered normal for a human being
o concerned with functional performance or activity, and 2. ANALYTICAL
limitations therein, affecting the whole person Cross-section Prevalence Individuals
o Does not necessarily lead to a disability, for the impairment Case-Control Case Reference Individuals
may be corrected Cohort Follow-up Individuals
o Refers to the function of the individual (rather than of an EXPERIMENTAL
organ, as with impairment). Randomized Clinical Trials Patients
• HANDICAP: Controlled Trials Therapeutic Trials
o a disadvantage for a given individual, resulting from an Field Trials Prophylactic Trial Healthy people
impairment or a disability, that limits or prevents the Community Trials Community Communities
fulfilment of a role that is normal (depending on age, sex, and Intervention
social and cultural factors) for that individual. Study
o focuses on the person as a social being and reflects the Modified from Basic epidemiology 2nd edition (WHO)
interaction with and adaptation to the person’s

surroundings
o Considers the person's participation in their social context
Schema for assessing non-fatal health condition

Disease → Impairment → Disability → Handicap
Paralyzed Inability to
Polio Unemployed
legs walk
Mild mental Difficulty in Social
Brain injury
retardation learning isolation
Basic epidemiology 2nd edition (WHO)
Example: A person who is born blind (the impairment) is unable to
read printed material, which is how most information is widely
disseminated (the disability). If this person is prevented from attending
school or applying for a job because of this impairment and disability,
this is a handicap.
Dr. Mann
EPIDEMIOLOGIC APPROACH
DESCRIPTIVE Concerned with disease
EPIDEMIOLOGY distribution and frequency
ANALYTICAL Analyze the causes or determinants
EPIDEMIOLOGY of disease by testing hypothesis
Clinical and community trials about
INTERVENTION OR
effectiveness of new methods for
EXPERIMENTAL
controlling diseases
Measure of the effectiveness of
EVALUATION
different health services and
EPIDEMIOLOGY
programs
TYPES OF EPIDEMIOLOGIC STUDIES

Descriptive Studies Analytical Studies
• Describes the distribution • Concerned with DESCRIPTIVE EPIDEMIOLOGY
of cases by the variables of determining causes of • describes community’s reaction to disease:
person, time and place in disease occurrence, o Absence of disease: no cases on record; disease absent from
order to: specifically whether a the beginning or it has been eradicated
o Study and explain acute suspected factor is causally o Sporadic Occurrence: few and unrelated cases; stable
outbreaks of disease associated with disease relationship between agent and host; stable relationship
o Follow secular trends of using observational between agent and host in favor of the latter, which is
disease occurrence over method of testing intermittently disturbed
time hypothesis or cause o Endemic Occurrence: constant occurrence of the disease,
o Develop hypothesis of • goes further by analyzing usually at a low frequency
disease transmission relationships between o Epidemic: occurrence of number of cases of a disease in excess
• limited to a description of health status and other of normal occurrence of expectancy derived from a common
the occurrence of a disease variables or propagated source
in a population and is often o Pandemic: epidemic which is worldwide
the first step in an
epidemiological THE 5W’S OF DESCRIPTIVE EPIDEMIOLOGY:
investigation • What = health issue of concern
• Used if little is known • Purpose is to test the • Who= person
about event or hypothesis because you • Where = place
phenomenon. The purpose already know the • When = time
is to generate hypothesis relationship of events. • Why/how = causes, risk factors, modes of transmission
TIP: One way of knowing if the question warrants for a descriptive study
or analytical study is looking at the construction of the case. If it uses DESCRIPTIVE VARIABLES:
“MAYBE associated” then the use of descriptive study is logical. While if
• Person
the case presents with words like… “With Significant Relationship or Is
related with”. Then, an analytic design is appropriate. • Time
Dr. Mann • Place
ALTERNATIVE UNIT OF
TYPE OF STUDY PERSON
NAME OBSERVATION
OBSERVATIONAL • Age: diseases with different age patterns
1. DESCRIPTIVE o Magnitude decreasing with age: disease confers long lasting
Case Report Single patient immunity
Case Series Group of patients o Magnitude increasing with age: degenerative diseases
Ecological Study Correlational o Magnitude high at both extremes of age: reflects low
resistance of the young and old
Cross-sectional Prevalence Study
o Great exposure during the middle age
• Sex: sex differential because of sexual constitution/make up o Advantage:
o Greater exposure of males, greater health consciousness of § Easy to conduct and less time and financial use
females: early consultation, diagnosis and treatment, more o Disadvantages:
cases recorded § Limited generalizability because of bias, lack of control
• Civil risk factors: group
o Married at higher risk for cervical CA § Absence of comparison, not conclusive
o Greater family support among the married
• Social Class • ECOLOGIC STUDIES (CORRELATIONAL)
• Ethnic and racial groups – Differences in racial, ethnic, or other o The unit of analysis is a group most often defined
group variables may reflect differences in susceptibility or geographically (urban vs. rural; mountainous region, area
exposure, or differences in other factors that influence the risk with wells as major water source)
of disease o Measures that represent characteristics of entire population,
• State of Nutrition used to describe disease in relation to some factors of
o Malnourished at higher risk for opportunistic infections interest.
o Obese at higher risk for CVS diseases o Seeks to determine the extent to which two characteristics
• Occupation are related.
o Aggregate risk factors
TIME (TEMPORAL VARIATION) o Subject to Ecological fallacy bias
Secular • Long term fluctuation of disease occurrence
Trend over many decades • CROSS-SECTIONAL SURVEYS (PREVALENCE SURVEYS)
Declining o A simple descriptive account of interesting characteristics
• Improved preventive measure, expanding observed in a group of patients.
Incidence
health coverage o Case finding, special surveys to establish incidence or
Rate
prevalence
Declining • Declining incidence; improvement in
Mortality o Also called prevalence surveys because they focus on a point
treatment; changing population structures,
Rate in time
changing method of recording cause of death
o Exposure and effect at the same time
• Increase in # of cases more or less regularly
Cyclic o Can also be considered a type of analytical study
every around 5 years due to accumulation of
Intrinsic o It is a study or survey:
susceptible through births; exhibited by
Variation § Of a defined population;
diseases that confer long lasting immunity
§ At a specified point in time;
Seasonal • Fluctuation of disease occurrence during a § On a topic or variables of interest which may include the
Variation year reflecting climactic changes frequency of disease or health disorder, factors associated
Epidemic • Short term fluctuation of disease. with health and disease, attributes of positive health.
o Uses:
PLACE § Assessment of health needs, demands and utilization of
International • Related to geographic variation as well as health care services, planning and evaluation
Variation race, ethnicity and culture § For determining the status of a disease or condition.
• Results from differences in socio economic o Advantages:
National
development as well as cultural and § Relatively simple and rapid;
Variation
geographic differences § Can be extended to a case control or cohort study;
Local • Related to environmental and access to § Allows the study of the association of a disease with a wide
Variation health differences range of factors simultaneously;
§ Feasible as long as prevalence of condition is high
DESCRIPTIVE STUDY DESIGNS § Economical
• CASE REPORT “Interesting Case” § Convenient for sudden outbreaks
o Most basic; brief objective report of a clinical characteristic or o Disadvantages:
outcome from a single clinical subject or event. § Not suitable for rare or acute disease
o Highlights the UNAWARENESS of case (ex: adverse drug § Factors which may prolong or shorten the duration of the
effect; advanced proliferative diabetic retinopathy) condition may not be seen
O Methodology: § Difficult in interpreting temporal sequence of cause and effect
§ Identify single noteworthy case § Provides only a snap shot in time.
§ Retrospective data collection § Selection bias
§ No statistical analysis
o Advantages: ANALYTICAL EPIDEMIOLOGY
§ Address almost all clinical question or issue; commonly used • Common Applications:
to report unusual or unexpected events o Community diagnosis
o Disadvantages: o Investigation of epidemic
§ Only few conclusions can be drawn based on evidence o Determination of diseases etiology
§ Results are rarely generalizable o Evaluations of community interventions and programs
§ Susceptible to bias • May be observational or experimental:
Observational Experimental
• CASE SERIES Cross-Sectional Field/Community Trials
o Objective report of a clinical characteristic or outcome from a Case-Control Clinical Trials
group of clinical subjects with similar diagnosis, collection of Cohort
individual case reports which may occur within fairly short
period of time (>10 patients) OBSERVATIONAL ANALYTIC STUDIES
O Highlights the SIMILARITIES of case Ngayon ka pa ba susuko? DOC!!!!! Please basahin mo ito, kapag may
§ (e.g. typhoid fever: abdominal manifestation with history of tiyaga may linaga! Patience is a virtue, read the whole text please… J)
fever; Intraocular pressure control in 100 consecutive Dr. Mann
patients) • CROSS-SECTIONAL ANALYTIC (PREVALENCE STUDY)

o Methodology: o Examines the relationship between diseases and other
§ Identify subjects with regard to clinical events in question variable of interest as they exist in defined population at one
§ Retrospective or prospective data collection BUT a control particular point in time.
group is usually not included o Subject selection at random.
§ Descriptive statistics are calculated o Employs inferential statistics (p value) to determine
§ Results are strengthened when consecutive series of subjects association or relationship using chi square test.
are included over a period of time
o Uses: § Incident cases preferable to prevalent
§ Determine the magnitude of a disease § Prevalent cases reflect not only determinants of disease but
§ Hypothesis generation those of duration as well.
§ Evaluation of medical care and health service delivery o Selection of controls
§ Establish baseline data § Depends on the characteristics and source of the cases,
§ Studying conditions that are quantitatively measured and practical and economic considerations
that vary over time or relatively frequent diseases that have § Disadvantages using controls from the general
long duration population:
o Advantages: § More costly and time consuming
§ Conducted quickly § Difficulty in contacting healthy people
§ Provides data on a disease rate in a population and § Availability of population
descriptive information on other characteristics of the § Quality of information may not be the same – general
population population may not recall exposures with the same level of
§ Can identify easily stage of disease before it becomes accuracy as that of cases
apparent clinically o Issues:
§ Less costly than cohort § Selection bias
o Disadvantages: § Observation bias – can be avoided by making the procedures
§ Measures the effect of both incidence and duration; to obtain information as similar as possible or by blinding the
§ Cannot identify direction of etiologic association (temporal investigator
sequence) § Recall bias
§ Sensitive to response bias § Misclassification – errors in categorization of either
§ Observation bias can easily occur since both are measured exposure or disease status
simultaneously o Example: Comparison of prior estrogen use, in uterine CA
• CASE-CONTROL patients to that in age-matched controls without CA to assess
o Persons with a given disease (cases) and persons without the possible risk of uterine CA
disease (controls) are selected. The proportion of cases and Ascertainment of disease Ascertainment of exposure
controls of being exposed to a probable risk factor are status to risk factors
determined and compared for presence of association. • Death certificates • Personal interview of the
o Starts with the outcome then researcher will be looking • Medical records subjects
for any exposure or factors. • Hospital admission or • Existing records
discharge records • Physical measurements
OUTCOME → EXPOSURE
• Pathology department
logbook
SUPPLEMENT THALIDOMIDE
A classic example of a case-control study was the discovery of the
relationship between thalidomide and limb defects in babies
born in the Federal Republic of Germany in 1959 and 1960. The
study, done in 1961, compared affected children with normal
children. Of 46 mothers whose babies had malformations, 41 had
been given thalidomide between the fourth and ninth weeks of
pregnancy, whereas none of the 300 control mothers, whose
children were normal, had taken the drug during pregnancy.
DESIGN OF A CASE-CONTROL STUDY
Basic epidemiology 2nd edition (WHO) Accurate timing of the drug intake was crucial for determining
o Done only if there is significant association. relevant exposure.
o Uses: What do you call that condition that involves malformations of the
§ Address issues relating to risk factors arms and legs that is usually associated with thalidomide?
§ Used in clinical decision analysis to assess the differences in Mga besh SAGOT?.............
test positivity between diseased and non-diseased Phocomelia
population. Dr. Mann
O Advantages: • COHORT
§ Provide the opportunity to investigate rare diseases as well o Exposed and non-exposed populations are identified and
as those with long period of latency followed prospectively over time to determine the rate of a
§ Less time consuming and less expensive to carry out specific clinical disease or event.
§ Require smaller sample size o Also used in clinical decision analysis to address the predictive
§ Allow for the evaluation of a wide range of potential etiologic value of test positivity or negativity.
exposure o Starts with the factors/ exposure then researcher will be
§ For diseases with long lag looking for outcome
o Disadvantages: o At the time exposure status is defined, all potential
§ Disease status is measured as a dichotomous categorical subjects must be free from the disease under investigation
variable; o Best information about disease causation
§ Disease status of the subject is likely to influence
EXPOSURE → OUTCOME
ascertainment of exposure factor;
§ Temporal relationship between exposure and disease may
be difficult to establish in some situation;
§ Has to deal with the problem of selective survival,
differential reporting of exposure information between
study groups based on their disease status and differential
selection of either the cases or controls on the basis of their
exposure status;
§ Information on the potential risk factor and confounders
may not be available either from records or the subject’s DESIGN OF A COHORT STUDY
memories Basic epidemiology 2nd edition (WHO)
§ Inferential statistics: ODDS RATIO (OR)!!!! o Types:

o Selection of cases § Retrospect: all relevant events (both exposure and outcome
Hospital- based Population-based of interest) have already occurred when the study is
initiated.
• Convenient • Avoids bias
§ Prospective: relevant exposure may or may not have
• Less expensive • More expensive
occurred at the time the study is begun but the outcome has
• Prone to selection bias
not yet occurred
o Uses: • COMMUNITY/FIELD TRIALS
§ Describe the natural history of disease o Unit of analysis is a group of individuals or a community
§ Identify the number of new cases for planning health care o The selection of population & size depends on prediction of
services & determine effectiveness of preventive measures incidence of disease
§ Determine the etiologic factors associated with the onset of o Field trials, in contrast to clinical trials, involve people who are
disease healthy but presumed to be at risk; data collection takes place
§ Example: The association between low birth weight and “in the field,” usually among non-institutionalized people in the
maternal smoking during pregnancy can be studied by general population
obtaining smoking histories from women at the time of
prenatal visit and then subsequently correlating birth weight • CLINICAL TRIALS
with smoking histories • Individual subjects are used as experimental unit
o Advantages: • The determination of sizes of the groups depends on the
§ Less potential bias in recall & observation expected incidence of the disease or unfavorable outcome
§ Allows for calculation of incidence rate (death) and estimates of differences in outcome in the different
§ Can study the association of one factor and many subsequent groups.
effects • TYPES:
o Disadvantages: o Preventive
§ Requires large sample & long follow-up period § aka Prophylactic
§ More expensive § Interventions given are aimed for disease prevention
§ Attrition- patients are loss to follow up § (-) risk factor
§ Confounders § (-) disease
§ Controls are difficult to identify o Therapeutic
§ Surveillance bias § interventions given are aimed to treat established disease
§ No blinding and randomization
§ Inferential statistics: RELATIVE RISK (RR)!!!! SUMMARY PHASES OF CLINICAL RESEARCH
o Issues: TYPICAL STUDY
TRIAL PURPOSE
§ Selection bias – Most common source is loss to follow-up SAMPLE
§ Information bias “Is it safe?”
§ Confounding Phase Small number of Assess safety, toxicity,
o Example: Follow-up in a population of adults who were 1 HEALTHY volunteers pharmacokinetics, and
exposed or not exposed as children to radiation of the neck to pharmacodynamics
assess risk for thyroid CA. “Does it work?” Assesses
Small number of
Phase treatment efficacy,
patients WITH disease
SUMMARY OBSERVATIONAL-DESCRIPTIVE STUDIES 2 optimal dosing, and
of interest
CROSS- adverse effects
CASE-CONTROL COHORT
SECTIONAL LARGE number of
“Who WILL patients RANDOMLY “Is it as good or better?”
develop the Phase assigned to either Compares the new
“What is 3 treatment or placebo treatment to the current
“What happened?” disease?”
happening?” (usually the best standard of care.
“Who developed
the disease? available treatment)
• Collects data • Compares a • Compares a “Can it stay?” Detects
POSTMARKETING
from a group of group of people group with a rare or long-term
Phase surveillance of
people to with disease to given exposure adverse effects. Can
4 patients AFTER the
assess a group without or risk factor to result in treatment being
treatment is approved
frequency of disease. a group without withdrawn from market.
disease (and • Looks for prior such exposure. SUPPLEMENT RANDOMIZED CONTROLLED TRIALS
related risk exposure or • Looks to see if
• GOLD STANDARD or reference in medicine
factors) at a risk factor. exposure
• Provide greatest justification for concluding causality
particular point increases the
in time. • Best study design to establish efficacy of a treatment or
likelihood of
procedure
disease
• Advantages
Disease
o Subject to the least number of biases
prevalence
• Disadvantages
Can show risk
ODDS RATIO RELATIVE RISK o Expensive and time consuming
factor association
(OR) (RR) o Difficult to obtain approval
with disease, but
does not establish CHOICE OF EXPERIMENTAL DESIGN
causality. a. Procedures to deal with differences in composition of
comparison group
EXPERIMENTAL ANALYTIC STUDIES o Randomization
• RANDOMIZED CONTROLLED TRIALS o Stratified randomization or blocking
o Provide the best evidence for testing any hypothesis or to o Matching
investigate any possible cause and effect relationship o Using each patient as his own comparison
o Resemble cohort studies by follow up of subjects o Restriction
o Involves action or manipulation or intervention on the part of b. Procedures to deal with subject expectations and observer
the investigator bias
o Uses control group for baseline o Open trials: both subjects & investigator are fully aware of
o Difficult to carry out and raise some ethical issues what treatment is being given/ received
o Guides: o Blinding: unawareness of true nature of treatment
§ Randomize treatment A and treatment B to distribute
equally the known and unknown determinants of outcome. Double blind Triple blind
Single blind trial
§ Proper accounting of patients (<20% loss to follow-up) trial trial
§ Blinding Either the subject or Neither subject Subject, data
§ No co-intervention the investigator is nor person collector and
§ Similar characteristics of all participants. unaware of nature of assessing data analyst are
treatment given treatment efficacy all not aware
is aware
c. Procedures to deal with interference between treatment 𝐴𝑅 𝐴𝑅𝑅
o Cross over design: subjects in each group are taken off one = 𝑅𝑖𝑠𝑘$*+%#$, = 𝑅𝑖𝑠𝑘-&$*+%#$, − 𝑅𝑖𝑠𝑘$*+%#$,
treatment and crossed over to the treatment previously given − 𝑅𝑖𝑠𝑘-&$*+%#$, 𝐶 𝐴
to other subjects 𝐴𝑅𝑅 = −
𝐴 𝐶 𝐶+𝐷 𝐴+𝐵
o Latin Square design 𝐴𝑅 = −
𝐴+𝐵 𝐶+𝐷
d. Procedures to deal with sporadic availability of patients e.g., if risk of lung cancer in e intervention as compared to
o Sequential Designs: sufficiency of sample size constantly smokers is 21% and risk in a control (e.g., if 8% of people
being monitored each time a new patient is being included in nonsmokers is 1%, then who receive a placebo vaccine
the trial or fails to respond to treatment. 20% of the lung cancer risk develop the flu vs. 2% of
in smokers is attributable to people who receive a flu
PROBLEMS WITH SAMPLE ATTRITION smoking vaccine, then ARR = 8% − 2% =
• Affects comparability of treatment and control groups 6% = .06)
o Tendency of patient to drop-out related to severity of illness ~ HARM ~TREATMENT
o Severe side effects (treatment group) may lead investigator to
withdraw patient from trial NNH and NNT
o Treatment may be so effective that patient believe themselves NUMBER NEEDED TO HARM NUMBER NEEDED TO
to be cured, ceasing intake of meds → disappear from (NNH) TREAT (NNT)
treatment → treatment appears less effective Number of patients who need to Number of patients who
• Replacement of drop-outs is NOT advisable be exposed to a risk factor for 1 need to be treated for 1
patient to be harmed. patient to benefit.
QUANTIFYING RISK 𝟏 𝟏
𝑵𝑵𝑯 = 𝑵𝑵𝑻 =
𝑨𝑹 𝑨𝑹𝑹
QUANTIFYING RISK BIASES IN CLINICAL EPIDEMIOLOGY

https://qrs.ly/bpbqi0n BIAS IN RECRUITING PARTICIPANTS/SAMPLE POPULATION
• SELECTION BIAS - Comparisons are made between groups of
patients that differ in determinants of outcome other than the
one under the study
WITH 1. Medical Surveillance bias – refers to over-detection of the
NO DISEASE/
Exposure/ DISEASE/ Total disease of interest because one of the groups goes to the
CONTROLS
Intervention CASES doctor (or has a diagnostic test) more often than does
(+) A B A+B another group.
(-) C D C+D 2. Centripetal bias – Occurs when a major clinical center’s
reputation results in part from its particular expertise in a
Total A+C B+D A+B+C+D specialized area of clinical medicine, it will be referred
ODDS RATIO (OR) problem cases likely to benefit from its expertise
• Usually used in CASE-CONTROL studies 3. Popularity bias – Occurs when its experts may preferentially
• the odds of having disease in exposed group (cases) divided by admit and keep track of these cases over other less
odds of having disease in unexposed group (control) challenging or less interesting ones
4. Referral filter bias – The selection that occurs at each stage of
𝐴 the referral process can generate patient samples at
𝑂𝑑𝑑𝑠!"#$# 𝑨𝑫 tertiary care centers that are much different from those
𝑶𝑹 = = 𝐶 =
𝑂𝑑𝑑𝑠!%&'(%)# 𝐵 𝑩𝑪 found in the general population
𝐷 5. Diagnostic access bias – Patients differ in financial and
OR=1 Exposure does not affect odds of outcome/disease geographic access to the clinical technology that identifies
OR>1 Exposure associated with higher odds of outcome them as eligible for studies of the course and prognosis of
OR<1 Exposure associated with lower odds of outcome disease
RELATIVE RISK (RR) 6. Berkson Bias – study population selected from hospital is less
healthy than the general population
• The ratio of incidence of disease among people with risk factor
to incidence of disease among people without risk factor
BIAS IN PERFOMING THE STUDY
• Also known as Risk Ratio
• Typically used in COHORT studies 1. Recall bias – relates to differences in the ways exposure
information is remembered or reported by cases who have
• Risk/probability of developing disease in the exposed group
experienced an adverse health outcome and by controls
divided by risk in the unexposed group
𝑨 who have not.
𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦$*+%#$, 𝑨 + 𝑩 2. Measurement bias – Occurs when the methods of
𝑹𝑹 = = measurement are dissimilar among groups of patients
𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦-.$*+%#$, 𝑪
𝑪+𝑫 3. Diagnostic suspicion bias - The clinician knows that a patient
RR = 1: indicates null value (no effect of exposure or possesses a prognostic factor of presumed importance may
treatment on outcome) carry out more frequent or more detailed searches for the
RR<1: indicates protective effect (protective factor) relevant prognostic outcomes
RR>1: indicates a harmful effect (risk factor) 4. Procedure bias – subjects in different groups are not treated
the same
RELATIVE RISK REDUCTION 5. Observer-Expectancy bias – Pathologist who interpret
• The PROPORTION of risk reduction attributable to the diagnostic specimen can have their judgments dramatically
intervention as compared to a control influenced by prior knowledge of the clinical features of the
case
𝑅𝑅𝑅 = 1 − 𝑅𝑅
• e.g., if 2% of patients who receive a flu shot develop the flu, while
8% of unvaccinated patients develop the flu, then RR = 2/8 = PREVENTIVE MEDICINE
0.25, and RRR = 0.75). “An ounce of prevention is worth a pound of cure.”
AR AND ARR: TO ASSESS FOR RISK DIFFERENCE PREVENTIVE MEDICINE
• Branch of medicine that concentrates on keeping people well
ABSOLUTE RISK REDUCTION
ATTRIBUTABLE RISK (AR) with a goal of disease prevention and health promotion.
(ARR)
• “Science and art of preventing disease, prolonging life and
The difference in risk The difference in risk promoting physical and mental health and efficiency”
between exposed and attributable to the intervention • Seeks to enhance the lives of patients by helping them promote
unexposed groups as compared to a control their health, reduce risk and prevent specific diseases, diagnose
diseases early, improve function, and reduce disability.
BASIC CONCEPTS SOCIAL DETERMINANTS OF HEALTH

HEALTH • Conditions in which people are born, grow, live, work and age.
• These circumstances are shaped by the distribution of money,
• a state of complete physical, mental and social well-being and
power and resources at global, national and local levels.
not necessarily the absence of disease or infirmity. (WHO)
• The social determinants of health are mostly responsible for
HEALTHY LIFESTYLE health inequities - the unfair and avoidable differences in health
• A healthy lifestyle is a way of living that lowers the risk of being status seen within and between countries.
seriously ill or dying early. (WHO) Social determinants of health: also known as “causes of the causes”
WELLNESS Dr. Mann
• Includes:
• an active process of becoming aware of and making choices
o Employment conditions
toward a healthy and fulfilling life
o Working conditions
• a healthy balance of the mind, body and spirit that results in an
o Social exclusion
overall feeling of well-being
o Access to housing
HEALTHCARE o Clean water and sanitation
• is the prevention, treatment, and management of illness and the o Social protection systems (e.g., SSS)
preservation of health through the services offered by health o Access to health care
care organizations and professionals. o Gender equity
• It includes all the goods and services designed to promote o Early childhood development
health, including “preventive, curative and palliative o Globalization, and Urbanization
interventions, whether directed to individuals or to Social determinants impact health through a variety of complex causal
populations” pathways including:
NATURAL HISTORY OF DISEASE 1. Direct causation (e.g., working conditions of miner exposed to high
lead levels can cause impaired recall and cognition)
• Natural history of disease refers to the progression of a disease
2. Changing the likelihood of certain behaviors (e.g., lower availability
process in an individual over time, in the absence of treatment of fresh produce in disadvantaged neighborhoods makes it harder to
• The natural history of disease can be seen as having three stages: provide good nutrition)
o Predisease stage – before a disease process begins in an 3. Impacting cellular function (e.g., stress leads to increased
individual inflammation, blood pressure, and cholesterol).
o Latent (asymptomatic) disease stage – the disease BTW “stress” can be helpful, proper term is “eustress”
producing process is underway, but no symptoms of disease Harmful stress naman ay” distress.”
have become apparent MANTRA IN LIFE: ANG BOARDS AY ISANG EUSTRESS LAMANG!
o Symptomatic disease stage – when the disease is advanced
enough to produce clinical manifestations
SOCIAL DETERMINANTS
Remember the natural history of a disease is its normal course in the OF HEALTH
absence of intervention, this is an important concept for the application https://qrs.ly/uubpowa
of the different levels of prevention.
Dr. Mann
Dr. Mann
LEVELS OF PREVENTION
A useful concept of prevention has come to be known as Leavell levels. Based on this concept, all the activities of clinicians and other health professionals have
the goal of prevention
Dr. Mann
PRIMORDIAL PRIMARY SECONDARY TERTIARY

It addresses broad health determinants Predisease Stage Latent Disease Symptomatic Disease
rather than preventing personal exposure
to risk factors. Prevents onset of disease. It Early diagnosis and Limitation of disability &
aims to reduce incidence of the prompt treatment rehabilitation from disease.
Consists of actions to minimize future disease
hazards to health and hence inhibit the Screening programs and “soften” the impact of an
establishment factors (environmental, Specific disease protection Primary medical care ongoing illness/injury
economic, social, behavioral, cultural)
known to increase the risk of disease. Health education and Aims to reduce the Disability Limitation and
promotion and specific impact of a disease or Rehabilitation
protective measures; injury that has already
environmental modification occurred
and sanitation
Ex: outlawing alcohol in certain countries Ex: MMR, Malaria prophylaxis, Ex: Self-breast Ex: PT and psychological
would represent primordial prevention, immunization, nutritional examination; medication rehab in cases of
whereas a campaign against drinking and supplements and occupational compliance to prevent deformities; cardiac or
would be an example of primary and automobile safety heart attacks or strokes, stroke rehab programs;
prevention measures pap smear, PSA post-op chemotherapy
Level of
Keywords Stages of Disease
Prevention
Primordial “General Risk”
Primary “Protection” Predisease Stage
“Early Detection” -
Secondary Latent Stage
Screening
Tertiary “Complications” Symptomatic Stage
Clinical Epidemiology: The Essentials, 5th Edition, Lippincott Williams & Wilkins, Philadelphia 2013
There are certain scenarios which all level of preventions can be applied,
• Primary prevention prevents disease from occurring. take hypertension as an example: For hypertension, efforts to lower blood
• Secondary prevention detects and cures disease in the pressure can be considered primary, secondary, or tertiary prevention.
asymptomatic phase. • Primary prevention includes efforts to treat prehypertension through
• Tertiary prevention reduces complications of disease increasing physical activity and weight loss.
• Secondary prevention involves treating a hypertensive patient.
• Tertiary prevention involves treating a patient with symptoms from
a hypertensive crisis to prevent a stroke.
Dr. Mann
• In practice, tertiary prevention resembles treatment of established 3 BASIC STRATEGIES FOR HEALTH PROMOTION
disease. The difference is in perspective. Whereas treatment is Advocacy for health for Political, economic,
expressly about “fixing what is wrong,” tertiary prevention looks ahead Advocate social, cultural, environmental, behavioral and
to potential progression and complications of disease and aims to biological development
forestall them. Health promotion focuses on achieving equity
JEKELS
in health and ensuring equal opportunities and
✔GUIDE QUESTION LEVELS OF PREVENTION Enable
resources to enable all people to achieve their
_____1. Abstaining from tobacco
fullest health potential
_____2. Cardiac stress testing
_____3. Tumor debulking for stage 4 cancer Health promotion demands coordinated action
_____4. Practicing stress management by all concerned: by governments, by health
_____5. Colonoscopy and other social and economic sectors, by
Mediate
_____6. Smoking cessation after myocardial infarction nongovernmental and voluntary organization,
_____7. Oral chemoprophylaxis with doxycycline for flood exposure by local authorities, by industry and by the
_____8. Self-breast examination media
_____9. Physical therapy post-ischemic stroke
_____10. Use of condom for STI prevention AREAS FOR PRIORITY ACTION
Secondary 9. Tertiary 10. Primary Build healthy public policy
1. Primary 2. Secondary 3. Tertiary 4. Primary 5. Secondary 6. Tertiary 7. Primary 8.
Create supportive environments
Strengthen community action
Develop personal skills
HEALTH PROMOTION Reorient health services
Mnemonic (“Bad Cats Smell Dead Rats”)
• A planned combination of educational, political, regulatory, and Dr. Mann
organizational supports for actions and conditions of living
conducive to the health of individuals, groups, or communities. HEALTH PROMOTION
• process of enabling people to increase control over, and to AND OTTAWA CHARTER
improve their health. (Health Promotion Glossary, 1998) https://qrs.ly/jebpozh
• It covers a wide range of social and environmental interventions
that are designed to benefit and protect individual people’s
health and quality of life by addressing and preventing the root
causes of ill health, not just focusing on treatment and cure. HEALTH PROMOTION STRATEGIES
• Health-promoting activities usually contribute to the prevention 1. EDUCATIONAL
of a variety of diseases and enhance a positive feeling of health o Stress management classes for middle-management
and vigor. employees in the workplace
Please remember in health promotion activities, it consists of o Educational programs designed to reduce personal
nonmedical efforts such as changes in lifestyle, nutrition, and the vulnerability to crime
environment. 2. ORGANIZATIONAL
Dr. Mann
o Annual hearing and vision screening in schools
OTTAWA CHARTER FOR HEALTH o Automobile, bicycle, and firearm safety programs conducted
SUPPLEMENT:
PROMOTION by law enforcement agencies
It is also important to know the historical background of health 3. LEGISLATIVE
promotion and Ottawa Charter is an important concept o Passage of laws requiring use of helmets while riding
understanding the thrust towards health promotion. motorcycles and bicycles
Dr. Mann
o Legislation requiring environmental polluters to measure
• In 1986, Ottawa was the venue for an international
their pollution and implement effective plans to reduce the
conference sponsored by the WHO to establish the basic
pollution
design principles for health promotion programs
4. COMMUNITY/SOCIAL
• This conference was primarily a response to growing
o Organization and training of out of school youth to reduce
expectations for a new public health movement around the vulnerability to sex or drug crimes
world o Health fairs at shopping malls
• It presents fundamental strategies and approaches for health 5. ECONOMIC
promotion which the participants considered vital for major o Tax incentives to landlords of low-income housing to
progress encourage maintenance of property and reduction of pest
• The charter identified fundamental conditions and resources infestation
for health (Prerequisites for Health) o Incentives from employers to employees who stay healthy and
• The aim of the conference was action to achieve “Health for do not miss work
all by the year 2000 and beyond”
PREREQUISITES FOR HEALTH
• Peace • Income MODEL OF HEALTH PROMOTION
• Shelter • Stable eco-system TANNAHILL’S DESCRIPTIVE MODEL
• Education • Sustainable resources • This model of health promotion is widely accepted by
• Food • Social justice and equity healthcare workers.
• Tannahill talks of three overlapping spheres of activity: health
education, health protection and prevention.
o Health education – communication to enhance well-being
and prevent ill health through influencing knowledge and
attitudes.
o Prevention – reducing or avoiding the risk of diseases and ill
health primarily through medical interventions.
o Health protection – safeguarding population health through
legislative, fiscal or social measures. This is not how the term
‘health protection’ is currently used, which is to control
infections.
HEALTH PROMOTION EMBLEM

https://www.who.int/healthpromotion/conferences/previous/ottawa/en/index4.html
2. HEALTH PROTECTION
• Comprises legal or fiscal controls, other regulation policies, and
voluntary codes of practice, aimed at the enhancement of
positive health and the prevention of ill-health
o Examples:
§ Disability Act
§ RA 6675: Generics Act
§ Senior Citizen Law
§ National Health Insurance Act (see PhilHealth)
§ Child Protection Laws and Policies
§ Clean Air Act
§ Code of Sanitation
§ Universal Health Care Law
§ RA 2382: Philippine Medical Act
Maraming batas for the protection of our health, lumalabas ba sa boards?
YES! They usually give you a description of the law and you will identify
what law is that, seldom magtanong kung anong RA number, just
TANNAHILL’S MODEL OF HEALTH PROMOTION familiarize yourselves sa existence ng isang batas. Must know: Generics
Naidoo, Jennie. Foundations for Health Promotion - E-Book (Public Health and Health Promotion.
Act, Philhealth and Philippine Medical act.
1. Preventive services – e.g. immunization, cervical screening,
You can also check this comprehensive list of Philippine Health Care Laws
hypertension case finding, developmental surveillance, use of
nicotine chewing gum to aid smoking cessation.
2. Preventive health education – e.g. smoking cessation advice Philippine Health Care Laws
and information. https://qrs.ly/56bgu2r
3. Preventive health protection – e.g. fluoridation of water.
4. Health education for preventive health protection – e.g.
Dr. Mann
lobbying for seat-belt legislation.
3. DISEASE PREVENTION
5. Positive health education – e.g. life-skills work with young
people. • Disease prevention, understood as specific, population-based
6. Positive health protection – e.g. workplace smoking policy. and individual-based interventions for primary and secondary
7. Health education aimed at positive health protection – e.g. (early detection) prevention, aiming to minimize the burden of
lobbying for a ban on tobacco advertising. diseases and associated risk factors
1. HEALTH EDUCATION 1. Primary prevention refers to actions aimed at avoiding

the manifestation of a disease (this may include actions to
• It is a planned process
improve health through changing the impact of social and
• Combines a variety of educational experiences, and facilitates
economic determinants on health
voluntary adaptations or establishment of behaviour conducive
o Primary prevention services and activities include:
to health.
§ Vaccination and post-exposure prophylaxis of children,
• Aims primarily at the voluntary actions of people where they can adults and the elderly
take on their own part, individually or collectively, for their own § Provision of information on behavioral and medical health
health or the health of others and the common good of the risks, and measures to reduce risks at the individual and
community. population levels
§ Inclusion of disease prevention programmes at primary and
LEARNING DOMAINS specialized health care levels, such as access to preventive
1. Affective – Focuses on habit formation, new practice and services (ex. counselling)
behavioural change § Nutritional and food supplementation
2. Cognitive – It comprises information and knowledge about a § Dental hygiene education and oral health services
certain aspect of health.
3. Psychomotor – Deals with skill acquisition and reinforcement 2. Secondary prevention deals with early detection when
Learning occurs in three domains, affective, cognitive and psychomotor this improves the chances for positive health outcomes
this is also known as your KSA (Knowledge, Skills and Attitude) o Secondary prevention includes activities such as:
The cognitive domain is very important, because it will address the § Population-based screening programmes for early detection
knowledge that a patient needs regarding his or her illness and how to of diseases
manage it. § Provision of maternal and child health programmes,
The psychomotor domain addresses the skills that the patient will need including screening and prevention of congenital
to acquire to perform specific treatment modalities (e.g., the use of malformations
metered-dose inhalers). § Provision of chemo-prophylactic agents to control risk
The affective domain involves teaching patients about the necessary factors (e.g., hypertension)
attitudes and motivations for successfully living with their diseases.
Dr. Mann
BEHAVIORAL FACTORS IN HEALTH PROMOTION
SUPPLEMENT: METHODS OF HEALTH EDUCATION
• Human behavior is fundamental to health
1. Priming – introduction to establish mood and content and to
stir the imagination (ice breakers, role playing, storytelling, • The primary causes of death in most countries involve
modifiable lifestyle behaviors: cigarette smoking, poor diet, and
etc.)
lack of exercise.
2. Presenting – main content of health education
3. Probing and prying – stretching of the mind by asking • Therefore efforts to change patients’ behavior can have a
patients questions powerful impact on health promotion
4. Pinpointing and pondering – summary and conclusion • The most common theories for health behavior counseling:
where the facilitator highlight the key points of the health A. Health belief model
education program B. Transtheoretical model (stages of change)
5. Pursuing – done after the session, the physician supports C. Theory of planned behavior
action and individuality among participants D. Precaution adoption process model
E. Social cognitive/social learning theory
A. HEALTH BELIEF MODEL o They or their children are personally at risk for the disease
• The Health Belief Model is a theoretical model that can be used o The preventive measure is effective in preventing the disease
to guide health promotion and disease prevention programs. o There are no serious risks or barriers involved in obtaining the
• It is used to explain and predict individual changes in health preventive measure
behaviors • In addition, cues to action are needed, consisting of information
• The health belief model holds that, before seeking preventive regarding how and when to obtain the preventive measure and
measures, people generally must believe the following: the encouragement or support of other people.
o The disease at issue is serious, if acquired • This theory has been used to promote screening interventions.
Concept Definition Application
• Define population(s) at risk and their risk levels
1. Perceived
One's belief of the chances of getting a condition • Personalize risk based on a person's traits or behaviors
Susceptibility
• Heighten perceived susceptibility if too low
One's belief of how serious a condition and its • Specify and describe consequences of the risk and the
2. Perceived Severity
consequences are condition
• Define action to take — how, where, when
One's belief in the efficacy of the advised action to
3. Perceived Benefits • Clarify the positive effects to be expected
reduce risk or seriousness of impact
• Describe evidence of effectiveness
4. Perceived One's belief in the tangible and psychological costs • Identify and reduce barriers through reassurance,
Barriers of the advised behavior incentives, and assistance
• Provide how-to information
5. Cues to Action Strategies to activate "readiness" • Promote awareness
• Provide reminders
6. Self-Efficacy Confidence in one's ability to take action • Provide training, guidance, and positive reinforcement
Aaltonen, Tarja & Laakso, Minna. (2010). Halting Aphasic Interaction. Creation of Intersubjectivity and Spousal
Relationship in Situ. Communication & medicine. 7. 95-106. 10.1558/cam.v7i2.95.
B. TRANSTHEORETICAL MODEL (STAGES OF CHANGE)
1. PRECONTEMPLATION – Not even thinking about changing,
sign of active resistance to change. Main task of a physician is to STAGES OF CHANGE
https://ighhub.org/toolkit/subchapter/stages-change
induce awareness.
C. THEORY OF PLANNED BEHAVIOR
o e.g. I may have a lot of different sexual partners, but I don’t need
to use condoms because my partners are healthy • The theory of planned behavior is a theory used to understand
2. CONTEMPLATION- Thinking about changing, looking for and predict behaviors, which posits that behaviors are
sources of support, balancing the pros and cons, setting goals immediately determined by behavioral intentions and under
o e.g. I know I should wear a condom, but sex isn’t the same when certain circumstances, perceived behavioral control.
I wear one • The key component to this model is behavioral intent;
3. PREPARATION - Getting ready, planning to take action within a behavioral intentions are influenced by the attitude about the
month. likelihood that the behavior will have the expected outcome and
o e.g. I bought some condoms and I’ve decided to talk to my the subjective evaluation of the risks and benefits of that
partner about trying them outcome.
4. ACTION- making a change, learning to control behavior, it is the 1. Attitudes - This refers to the degree to which a person has
time that the patient will deal barriers, time constraints and a favorable or unfavorable evaluation of the behavior of
unrealistic goals. interest. It entails a consideration of the outcomes of
o e.g. we used condoms for the first time, and it wasn’t as bad as I performing the behavior.
thought it would be. We’ll use them again 2. Behavioral intention - This refers to the motivational
5. MAINTENANCE- Maintaining the change, the learner stay factors that influence a given behavior where the stronger
committed by listing barriers during the action stage and the intention to perform the behavior, the more likely the
accepting credit for accomplishment behavior will be performed.
o e.g. I use condoms all the time now with my partner. It’s not a 3. Subjective norms - This refers to the belief about whether
big deal for us.. although I will have to talk to any new partners most people approve or disapprove of the behavior. It
about it relates to a person's beliefs about whether peers and
6. TERMINATION/RELAPSE – Termination of the undesired people of importance to the person think he or she should
behavior or may relapse with abandoning the idea of change engage in the behavior.
reverting to pre-contemplation 4. Social norms - This refers to the customary codes of
Criteria: New self-image behavior in a group or people or larger cultural context.
No temptation in any situation Social norms are considered normative, or standard, in a
Solid self-efficacy group of people.
Healthier lifestyle 5. Perceived power - This refers to the perceived presence of
o e.g. I will use a condom with my partner and with all new factors that may facilitate or impede performance of a
partner. behavior. Perceived power contributes to a person's
perceived behavioral control over each of those factors.
6. Perceived behavioral control - This refers to a person's
perception of the ease or difficulty of performing the
behavior of interest. Perceived behavioral control varies
across situations and actions, which results in a person
having varying perceptions of behavioral control
depending on the situation. This construct of the theory
was added later, and created the shift from the Theory of
Reasoned Action to the Theory of Planned Behavior.
http://sites.bu.edu/ciis/files/2016/06/PRECEDEPROCEED-Model-Cheat-Sheet_CGA.pdf
PRECEDE stands for Predisposing, Reinforcing, and Enabling

Constructs in Educational Diagnosis and Evaluation
https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories3.html Social assessment: Determine the social
Phase 1 problems and needs of a given population and
D. PRECAUTION ADOPTION PROCESS MODEL identify desired results
• The PAPM attempts to explain how a person comes to decisions Epidemiological assessment: Identify the
to take action and how he or she translates that decision into Phase 2 health determinants of the identified problems
action. and set priorities and goals.
• The precaution adoption process model distinguishes seven Ecological assessment: Analyze behavioral and
steps, from unawareness of a problem to behavior change. environmental determinants that predispose,
Phase 3
• People progress from ignorance or unawareness (stage 1) via reinforce, and enable the behaviors and
un-engagement (stage 2) through contemplating the decision to lifestyles are identified.
act (stages 3 and 4). Identify administrative and policy factors that
• If a decision to act has been made (stage 5), the next steps influence implementation and match
Phase 4
involve implementing change (stage 6) and maintenance (stage appropriate interventions that encourage
7) of behavior change. desired and expected changes
• Example
PROCEED stands for Policy, Regulatory, and Organizational
Constructs in Educational and Environmental Development
Implementation: Design intervention, assess
Phase 5 availability of resources, and implement
program.
Process Evaluation: Determine if program is
Phase 6 reaching the targeted population and achieving
desired goals.
Impact Evaluation: Evaluate the change in
Phase 7
behavior.
Outcome Evaluation: Identify if there is a
decrease in the incidence or prevalence of the
Phase 8
identified negative behavior or an increase in
identified positive behavior.
E. SOCIAL LEARNING AND SOCIAL COGNITIVE THEORY
• Acknowledges the constant interaction that exists between the
individual and his or her environment, both structural and
WELLNESS PROGRAMS FOR
social, to shape behavior. DIFFERENT AGE GROUPS
• Three personal cognitive factors that are affected by the Components
environment influence behavior: • History and PE
• Observational learning: Individuals are more likely to perform • Vaccination
a desired behavior if they observe others modeling that • Health Screening
behavior and experiencing the subsequent positive rewards. • Counselling
• Outcome expectations: Individuals are more likely to practice • Chemoprophylaxis
a desired behavior if they believe the benefits of performing that
behavior and outweigh the costs. INFANTS AND CHILDREN
• Self-efficacy: Individuals are more likely to practice a desired • History/PE – growth and developmental milestone (see
behavior if they perceive that they have the necessary skills and pediatrics handout), length, weight, height measurement, signs
capacity to do so of hereditary disorder, hearing and vision test.
https://sbccimplementationkits.org/sbcc-in-emergencies/social-cognitive-learning-theory/
SUPPLEMENT: PRECEDE-PROCEED MODEL • Immunizations – (will be discussed in a separate section – EPI)
• Health Screening
• The Precede-Proceed model has provided moral and practical
o Newborn Screening (will be discussed in a separate section – NBS
guidance for the fields of health education and health promotion
Program)
since Lawrence Green first developed Precede in 1974 and Green
o Hearing Screening (see Universal Newborn Hearing Screening
and Kreuter added Proceed in 1991
Program)
• Precede-Proceed today remains the most comprehensive and
o Developmental: Denver Developmental Screening Test (DDST-
one of the most used approaches to promoting health
• Precede–Proceed provides an eight-phase framework for
II)
practitioners to determine, develop, implement and evaluate o Others:
health promotion programmes § High blood pressure screening starting at age 3
• PRECEDE provides the structure for planning a targeted and § Vision: birth to less than 3y/o: every year
focused public health program § Urinalysis at 5y/o
• PROCEED provides the structure for implementing and § Hyperlipidemia >2 y/o
evaluating the public health program § PPD for high-risk children
• Counseling JNC 8 CLASSIFICATION
Birth to 6 months 3-6 years Lifestyle modification
o Nutritional guidance o Separation issues Normal <120AND <80
only
o Psychological o School readiness S: 120-139 OR Lifestyle mod w/ w/o
development and o Hygiene Pre HTN
D: 80-89 anti-HTN meds
stimulation o Exercise S: 140-159 OR
o Accident prevention 7-12 years St 1 HTN Lifestyle mod with anti-
D: 90-99
7months to 2 years o Self-concept HTN meds
St 2 HTN S: >160 OR D: >100
o Weaning o Relationship with peers
o Toilet training o Healthy lifestyle
BLOOD PRESSURE GOALS (JNC 8)
o Gender Identity o Avoidance of high-risk
<60 yo <140/90
o Oral hygiene behaviors
o Safety issues > 60 yo < 150/90
• Chemoprophylaxis CKD
<140/90
o Vitamin A for young children Diabetes
DENVER DEVELOPMENTAL SCREENING “ROUTINE” HYPERTENSIVE WORK-UP

SUPPLEMENT: • ECG, UA, FBS, lipid profile, CBC, BUN, Creatinine, CXR, Na, K, Ca
TEST (DDST-II)
The DDST-II is a measure of developmental problems in young SUPPLEMENT: BODY MASS INDEX
children. It was designed to assess child performance on various Body Mass Index (For Southeast Asian Countries)
age-appropriate tasks and compares a given child’s Starvation < than 14.9 kg/m2
performance to the performance of other children the same age. Underweight 15- 18.4
The instrument consists of 125 tasks, which broadly reflect the Normal 18.5 to 22.9
following areas: Overweight 23 to 27.5
o Personal-social Obese 27.6 -40
o Fine motor-adaptive Morbidly obese >40
o Language
o Gross motor
DIABETES MELLITUS
• Target Population: Infants and pre-school age children (i.e. •
For adults with hypertension or hyperlipidemia, as well as for
birth to six years of age
all adults aged 40 to 70 years with a BMI ≥25 kg/m2, suggest
ADOLESCENTS screening for type 2 diabetes as part of cardiovascular risk
• History/PE assessment.
o Growth, sexual maturity, mental and psychological status DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS
o BP measurement, skin problems ANY OF THE FOLLOWING:
o Risk Assessment (HEEADSSS) HbA1ca • ≥6.5%
§ Home and Environment Fasting Plasma
§ Education/Employment • ≥126mg/dL (7.0 mmol/L)
Glucose (FPG)b
§ Eating and Exercise
2-hour plasma
§ Activities
glucose during 75-g • ≥200mg/dL (11.1 mmol/L)
§ Drugs
OGTT
§ Sexuality
Random Blood • ≥200mg/dL (11.1 mmol/L) with
§ Suicide/Depression/Self-image
Sugar classic symptoms of hyperglycemia
§ Safety a Perform HbA1C with an assay-standardized method
• Immunization b Fasting: defined as no caloric intake for at least 8 hours
c Random: defined as without regard to time since last meal
• Health Screening For FPG, 2-gour PG, or A1C criteria: in the absence of unequivocal hyperglycemia, these criteria should be confirmed
by repeat testing on a different day.
o Hgb at 15 y/o IM Platinum. 3rd ed. 2018. p. 379
o PPD RISK FACTORS FOR DIABETES

o Chlamydia for sexually active • Family history of diabetes
• Counseling • Obesity (BMI > 25 kg/m2)
o SAFETEENS (sexuality, accident, abuse, firearms, emotions, • Physical inactivity
toxins, environment, exercise, nutrition, shots/Immunization) • Race (Asian, African American)
o Nutrition • Previously identified prediabetes state
o Oral Health • History of GDM or delivery of baby >4kg
o Vaccine Preventable Diseases • Hypertension (BP >140/190)
o Injuries • HDL <35 mg/dl &/or triglycerides >250 mg/dl
o Violence • Polycystic ovary syndrome or acanthosis nigricans
o Mental Health • History of cardiovascular disease
o Sexual and Reproductive Health
§ Family Planning SUPPLEMENT: IM CLINICAL PEARLS
§ Safe Motherhood - HIV and STI • ADA recommends screening all individuals >45 years every 3
o Substance Abuse - Drugs years
o Alcohol • Screening should be earlier if overweight (BMI>25) + one
o Tobacco Use additional risk factors for DM
• Most common pattern of dyslipidemia is hypertriglyceridemia
ADULTS and reduced high-density lipoprotein (HDL)
• History/PE
HYPERLIPIDEMIA
• Vaccination
• patients aged 17 to 21 years undergo one-time screening for
• Health Screening
hyperlipidemia with a non-fasting non-high-density lipoprotein
HYPERTENSION (non-HDL) cholesterol; non-HDL cholesterol is the difference
• screening is recommended for adults ≥18 years of age between total cholesterol and HDL cholesterol
• US Preventive Services Task Force (USPSTF) guidelines • For patients with a normal screen before age 21 who are also at
recommend hypertension screening every year for adults ≥40 high risk* suggest screening for lipid abnormalities starting at
years and for those who are at high risk for high blood pressure age 25 for men and 35 for women
(patients with high-normal blood pressure [130 to 139/85 to 89
*consider patients at high risk if they have more than one risk factor (e.g.,
mmHg] who are overweight or obese diabetes, hypertension, smoking, family history) or a single risk factor
• Adults aged 18 to 39 years with normal blood pressure that is severe (e.g. several siblings with coronary heart disease in their 40s
(<130/85 mmHg) without risk factors should be rescreened or a very heavy smoker)
every three to five years Dr. Mann
• For patients with a normal screen before age 21 who are not at II. COLORECTAL CANCER SCREENING
high risk, suggest screening for lipid abnormalities starting at • average-risk patients aged 50 and older be screened for
age 35 for men and 45 for women colorectal cancer, suggest that screening be continued until the
life expectancy for an individual patient is estimated as less than
OSTEOPOROSIS 10 years
• The goal of osteoporosis screening is to identify persons at • Annual FOBT offers greater reduction in mortality rates
increased risk of sustaining a low-trauma fracture who would • Colonoscopy every 10 years: based on natural history of
benefit from intervention to minimize that risk. adenomatous polyps
• Screening for fracture risk involves: • Sigmoidoscopy and Double contrast barium enema every 5
o appropriate history and physical examination to assess for risk years due to its lower sensitivity
factors For most patients, it is reasonable to stop screening at age 75 years or 85
o measurement of bone mineral density (BMD) years at the latest. One-time screening with colonoscopy (to age 83) or
Clinical risk factors for fracture sigmoidoscopy (to age 84) is advised for adults who have never been
screened for colorectal cancer.
• Advancing age Dr. Mann
• Previous fracture
• Glucocorticoid therapy III. CERVICAL CANCER SCREENING
• Parental history of hip fracture • Women aged 21–29 years should have a Pap test alone every 3
• Low body weight years. HPV testing is not recommended.
• Current cigarette smoking • Women aged 30–65 years should have a Pap test and an HPV
• Excessive alcohol consumption test (co-testing) every 5 years (preferred).
• Rheumatoid arthritis • It also is acceptable to have a Pap test alone every 3 years.
• Secondary osteoporosis (e.g. hypogonadism or premature • Women after hysterectomy with removal of the cervix and with
menopause, malabsorption, chronic liver disease, inflammatory no history of high grade precancer or cervical cancer: Do not
bowel disease screen
• Osteoporosis Screening • Age 21 regardless of the age of onset of sexual activity. Women
o BMD assessment in all women 65 years of age and older aged <21 years should not be screened regardless of age at
o BMD assessment in postmenopausal women less than 65 years sexual initiation and other
if one or more risk factors are present
o For screening BMD, it is suggested to use dual-energy x-ray IV. BREAST CANCER SCREENING
absorptiometry (DXA) of axial sites over peripheral Average risk women
measurements • Monthly breast self-examination (BSE) beginning at age 20 is
optional. Awareness of breast changes is encouraged.
MALIGNANCIES • Annual clinical breast examination (CBE) beginning at age 25.
CANCER PREVENTION • Annual mammography beginning at age 40
• A number of measures can be taken to prevent cancer, including:
o Avoidance of tobacco Women with family history
o Being physically active • Monthly BSE beginning at age 20 is optional. Awareness of
o Maintaining a healthy weight breast changes is encouraged.
o Eating a diet rich in fruits, vegetables, whole grains, and low in • CBE every three to six months starting no later than ten years
saturated/trans fat before the earliest diagnosis in the family.
o Limiting alcohol consumption • Annual mammography starting ten years prior to the earliest
o Protecting against sexually transmitted infections (including diagnosis in the family (but not earlier than age 25 and not later
receiving human papillomavirus [HPV] vaccination) than age 40).
o Avoiding excess sun exposure • Consider annual MRI. (Consider performing MRI and
mammography at alternating six-month intervals. Consult with
I. PROSTATE CANCER SCREENING your physician.)
• Prostate cancer is one of the most frequently diagnosed cancers
and a leading cause of cancer death in men PUBLIC HEALTH
• Prostate cancer screening may reduce the chance of dying from “Public health is what we, as a society, do collectively to assure the
prostate cancer. conditions in which people can be healthy.”
• There is some variability in recommendations by expert groups
“Public health is the science and art of preventing disease, prolonging life,
about the age to begin discussing screening for prostate cancer and promoting physical health and efficiency through organized community
with men efforts for the sanitation of the environment, the control of community
• Average-risk men infections, the education of the individual in principles of personal hygiene,
o suggest initiating discussion of screening for prostate cancer at the organization of medical and nursing service for the early diagnosis and
age 50 years for average-risk men as long as life expectancy is preventive treatment of disease, and the development of the social machinery
at least 10 years which will ensure to every individual in the community a standard of living
adequate for the maintenance of health.”
There is some variability in the age at which expert guidelines (CEA Winslow)
recommend initiating discussion about screening for prostate cancer, • The term public health has the following two meanings:
mostly at age 50 or 55 years or, less commonly, age 45 years o Health status of the public (i.e., a defined population)
Dr. Mann
o Organized social efforts to preserve and improve the health of
• BRCA carriers
a defined population
o Men known or likely to carry BRCA1 or BRCA2 genetic
mutations are at increased risk. Discussing screening for • “Public health aims to provide maximum benefit for the largest
prostate cancer may begin as early as age 40 years number of people.” (WHO)
• Directed at community level that either benefit everyone or
• Other higher-risk men
o suggest initiating discussion of screening at age 40 to 45 years benefit those who are not under the care of physicians.
with other men at higher risk for prostate cancer, including:
o Black men VITAL STATISTICS
o Men with a family history of prostate cancer, particularly in a • Vital statistics are derived from information obtained at the time
first-degree relative who was diagnosed at age <65 years when the occurrences of vital events and their characteristics
• PSA testing are inscribed in a civil register.
o For men who choose prostate cancer screening suggest • Vital acts and events are the births, deaths, fetal deaths,
screening with a PSA blood test alone. Digital rectal marriages, and all such events that have something to do with
examination (DRE) is generally not used as a screening test for an individual's entrance and departure from life together with
prostate cancer the changes in civil status that may occur to a person during his
lifetime.
• Recording of these events in the civil register is known as vital o For the control of infectious diseases
or civil registration and the resulting documents are called vital o Basis for design of programs in public safety, accident
records. prevention and crime eradication
• Vital Statistics System is defined as the total process of: o Mortality surveillance, health and epidemiologic research,
collecting by registration, enumeration or indirect estimation of health planning
information on the frequency of occurrence of certain vital o Study of mortality differentials
events, as well as relevant characteristics of the events o Health decision makers and planners all around the world
themselves and of the persons concerned make extensive use of mortality statistics
o Printing and issuance of certified copies of encoded civil
• Includes the action of compiling, analyzing, evaluating,
registry documents
presenting and disseminating those data o For burial – no human body can be buried without a proper
• Registration of vital events is the responsibility of the Local death certificate, EXCEPT in epidemics wherein death
Government Units (LGUs) through the Local Civil Registrars certificates should be secured within five days from the day of
(LCRs) but under the technical supervision of the Civil Registrar burial
General of the Philippine Statistics Authority (PSA). Please be guided that Presidential Decree No. 856, the burial or
• The hospitals, clinics, rural health units and similar institutions cremation of remains is subject to the following requirements:
including barangay secretaries, practicing physicians, midwives, No remains shall be buried without a Certificate of Death, which shall
nurses, traditional birth attendants who attended births and be issued by the attending physician. If there has been no physician in
deaths, and solemnizing officers from various religious sects and attendance, it shall be issued by the mayor or the secretary of the
municipality where the death occurred. The death certificate shall be
denominations who officiated the marriage ceremonies, are forwarded to the local civil registrar within 48 hours after death.
responsible in causing registration and shall certify to the facts
of the events at the LCR Offices For Muslim Filipinos, however, in accordance with Islamic law and
jurisprudence, the dead body may be buried as soon as possible even
without a Certificate of Death provided that the death shall be
BASIC SOURCES OF VITAL STATISTICS reported by the person who performed the burial rites (or by the
• The PSA maintains an archive of Civil Registration documents. nearest kin) to the local health officer within forty-eight hours after
Several basic forms are needed to record vital events from which the date of burial.
Dr. Mann
vital statistics were generated. These are:
• It should be filed within 48 hours after death (except in
o Marriage Certificate epidemics) by the:
o Certificate of Live Birth o Attending Physician who attended the deceased
o Certificate of Death o Municipal/City Health Officer
o Certificate of Fetal Death o Municipal/City Mayor
CAUSE OF DEATH: Disease or injury that started
SUPPLEMENT: BIRTH CERTIFICATES the physiological process leading to death
• a vital record that establishes the birth of a child Part I: Part II: Part III:
• It is an official form that gives details on the time and place IMMEDIATE ANTECEDENT UNDERLYING CAUSE
of a person's birth, and his or her name, sex, mother's name CAUSE CAUSE
and (usually) father's name. Disease or Sequelae or Root disease;
• The birth certificate is issued shortly after an individual's injury that complications that conditions
birth, after the mother's physician files the required forms directly led to gave rise to the contributing to death
with the appropriate government agency, usually the local the death immediate cause but not actually
civil registrar's office. related to the
• The official birth certificate is stored at LCR where records immediate cause;
are archived at the NSO. most important of the
three parts*
• The birth certificate is used to authenticate one's identity and
Example: 65-year-old male with history of uncontrolled DM had a
nationality, and assist with obtaining government-issued CVD which led to his confinement. During the course of
identity documents, such as a passport or driver's license. hospitalization patient developed pneumonia and subsequently died.
• Holding a birth certificate makes it easier to prove citizenship Immediate Antecedent Underlying cause:
in nations where citizenship depends upon location of birth cause: Cause: CVD DM
• a vital record that establishes the birth of a child pneumonia
• Functions: * If all three lines would be filled up, the “underlying cause” would be
1. To prove the fact of birth, including Date and Place counted in the cause-of-death statistics. In case only two lines were
2. Other uses: patterns of fertility; population estimate; filled up, the entry in the last line would be considered as the
population projection; public health programs underlying.
SUPPLEMENT: DEATH CERTIFICATES MANNER OF DEATH: refers to circumstances that led to death.
Accidents, suicide, homicide and “undetermined” are not causes of
• A Death Certificate is an official document setting forth death; they are manners of death
particulars relating to a dead person, including the name of the Circumstances wherein a normal death certificate cannot be
individual, the date of birth and the date of death issued:
• The certificate of death is a permanent legal record which • Suspicion of unnatural cause of death (Foul play): One should
contains an individual’s death information. perform an autopsy first
• It provides important information and data on the circumstances • DOA – no medical attendant present at the time of death or
surrounding the death. during the last illness
• Uses: • When death occurred before full recovery from a surgical
o Prima facie evidence of death operation or the administration of anesthesia
o Claim of benefits, pensions, insurance, or tax exemption
o Evidence for settlement of estate
o Remarriage purpose of surviving spouse MEDICAL CERTIFICATION OF DEATH
o Designation of a guardian or foster parent for minor https://qrs.ly/n2bpr8w
o Determine health priorities for prevention of deaths due to
similar causes in the future
o The information is also important for family members so that
they know what caused the death and are aware of conditions
that may occur or could be prevented in other family members
o Provide the indicators of existing infectious diseases and
epidemics that need immediate control measures
o Basis for designing programs to promote public safety and
strategies for disease prevention and eradication
o Serve administrative purposes, specifically, in the clearing of
files like disease-case registers, social security, military service
files, electoral rolls and tax registers
SUPPLEMENT: CENSUS FORMULATING THE OBJECTIVES
• Complete enumeration of a population • Health status objective – to decrease mortality or morbidity
• By virtue of Republic Act No. 10625 known as the Philippine • Risk-reduction objective – to decrease the number of smokers
Statistical Act of 2013, censuses in the Philippines are from 20% to 5% in 1 year
administered by the Philippine Statistics Authority (PSA) • Service objective – provision of particular health service (deep
• The population is enumerated every 5 years (beginning on well/excreta disposal facility)
1970, except in 2005 where it was moved to 2007 due to IMPORTANT FEATURES OF COMMUNICATION OBJECTIVES
budgetary constraints) but still we follow the 5-year count so
we had a census enumeration last 2010, 2015 and 2020*
TYPES OF CENSUS
Defacto Census Dejure Census
• physical presence is • assign individuals in their
important regardless of usual residence
where they usually live regardless of where they
were during the census
The POPCEN or Census of Population made use of the de jure concept
of enumeration wherein households and persons are enumerated in
https://www.toolshero.com/personal-development/smart-goals/
the area where they usually reside as of the census reference date.
Dr. Mann SUPPLEMENT COPAR
COMMUNITY ORGANIZING PARTICIPATORY ACTION
HEALTH ASSESSMENT OF THE POPULATION RESEARCH (COPAR)
All efforts to improve public health start with an assessment. • Integral tool in community development follows a systematic
Dr. Mann
and cyclical process.
TOTAL POPULATION OF THE PHILIPPINES • It facilitates the education of the people in part with capability
100,981,437 (2015 PSA Latest File) enhancement activities.
110,803,541 (DECEMBER 2021 Worldometer)
• It nurtures the ability of the society to organize themselves
VITAL STATISTICS (SOURCE: PSA 2018) and to emphasize people involvement in the resolution of
Marriages 449,169 issues and concerns in the community
Births 1,668,120 PHASES OF COPAR
Male 870,832
• 1. Pre-entry phase
Female 870,832
o It involves the selection of the target community.
Fetal Deaths 8,020
o It should at least include 50 families and criteria are utilized
TEN LEADING CAUSE OF DEATH (SOURCE: PSA 2018) to determine their need for community organizing.
1. Ischemic Heart Disease o Some preliminary investigation is conducted through the
2. Neoplasm use of secondary records and ocular inspection is done prior
3. Cerebrovascular Disease to emersion.
4. Pneumonia • 2. Entry phase
5. Diabetes Mellitus o It involves the integration process and the acquisition of
6. Hypertensive Disease relevant information necessary for the conceptualization of
7. Chronic Lower Respiratory Infections the community diagnosis.
8. Respiratory Tuberculosis o It is also during this phase that potential leaders are
9. Other Heart Disease identified.
10. Diseases of the Genitourinary System • 3. Formation phase
TEN LEADING CAUSE OF MORBIDITY (FHSIS 2016) o It is the phase when a core group is created – which then be
1. Acute Respiratory Infection trained to develop their capabilities in leading their
2. Hypertension community.
3. ALRTI & Pneumonia • 4. Organization- building phase
4. UTI o This phase is the most crucial stage since it is during this
5. Influenza time that the people are mobilized through the creation of
6. Bronchitis the community health organization.
7. Acute Watery Diarrhea • 5. Sustenance and strengthening phase
8. TB Respiratory o It is the end portion of COPAR but the most important phase.
9. Acute Bloody Diarrhea It is during this phase by which the community and its
10. Dengue people are being developed to be self- reliant.
COMMUNITY DIAGNOSIS ILLNESS, DEATH, AND DYING

DEFINITION TYPOLOGY/PSYCHOSOCIAL TIME OF ILLNESS
• An example of a descriptive epidemiologic study
• Statement of health situation and health needs of a community,
relating to:
o Demography – population, women’s health
o Ecology – water source, excreta facility
o Health status – mortality, morbidity
o Health resources – facility, worker, doctor
Acute illness
STEPS IN MAKING A GOOD COMMUNITY DIAGNOSIS • Asymptomatic period prior to diagnosis, initial readjustment
1. Definition of the problem (Research Question) and coping takes place
2. Appraisal of existing facts • It is a form of crisis in the family
o Determining factors associated with the problem/disease • Family routine is suspended
o State of knowledge of etiology (literature) • High emotions and sometimes can lead to anger especially if the
o Distribution of disease/ problem in terms of seasonal family perceives that care given by the physician is not
variation, geographic distribution, persons affected satisfactory
3. Formulation of hypothesis – explanation for the existence
and level of the disease/problem
4. Testing of hypothesis
5. Conclusion and practical application – solutions to the
problem
Chronic Illness BEREAVEMENT CARE
• interval between the initial diagnosis and readjustment period • period of mourning after a loss. The hospice care team works
• It promotes prolonged continuation of fear, anxiety and with surviving loved ones to help them through the grieving
desperation process
• Because of stress, it can lead to illness also among the other
family members
• On the part of the patient, feeling of guilt sometimes sets in
specially if he/she is the previous breadwinner of the family
• Tendency for the family members to be overindulgent towards
the patient leading to feeling of overwork and over fatigue
Terminal Illness
• Inevitability of death becomes apparent. Due to possible loss,
grief, and mourning may occur
• Disclosure is the most difficult time of the entire illness
experience Adapted from J Palliat Med
• It can either drawn the family members close together or it can SUPPLEMENT: HOSPICE VS PALLIATIVE
lead to further dysfunction among them HOSPICE PALLIATIVE
KUBLER ROSS’ STAGES OF DEATH AND • is offered and provided for • can be offered and provided
SUPPLEMENT:
DYING patients during their last at any stage of a serious
DENIAL phase of an incurable illness
illness or near the end of • can be provided while the
• common defense mechanism used to protect oneself from the
life, such as in some people patient is receiving active
hardship of considering an upsetting reality
with advanced or treatment. In other words, it
o Initial reaction of shock metastatic cancer. can be given at the same
o Refusal to believe diagnosis • is provided when there is time as chemo, radiation, or
o Thought blocking no active or curative immunotherapy for cancer
o Isolation treatment being given for • A palliative care team is
ANGER the serious illness. separate from the patient's
• commonly experienced and expressed by patients as they "Treatment" during medical care team that's
concede the reality of a terminal illness hospice care involves giving and managing
o Frustration and irritability towards all the members of the managing symptoms and treatment for the illness, but
family and even himself and to god side effects. communicates with the
BARGAINING • A hospice care team medical care team
• typically manifests as patients seek some measure of control coordinates the majority of
over their illness. The negotiation could be verbalized or care for a patient, and
internal and could be medical, social, or religious communicates with the
o Attempt to negotiate (with God or the universe) in return patient's medical care team
https://www.cancer.org/treatment/end-of-life-care/hospice-care/what-is-hospice-care.html
for cure, pledge to fulfill promise or make a deal in order to
get what is wanted
o Guilt is the primary emotion at this stage THE FILIPINO FAMILY
DEPRESSION THE 5-STAR DOCTOR: THE EVOLUTION
• perhaps the most immediately understandable of Kubler- The five-star paradigm started in the early 1990’s as a global strategy to
Ross's stages and patients experience it with unsurprising address the need to promote the “Health for All” advocacy of the Alma-
symptoms such as sadness, fatigue, and anhedonia Ata Declaration. It was later updated by CHED with the end view of
o Reaction to the effects of illness keeping pace with the demands of global competitiveness.
Dr. Mann
o Anticipation of the approaching death THE FIVE-STAR DOCTOR (WHO: DR. BOELEN)
o Lack of hope
1. Care Provider
o Associated with insomnia or hypersomnia, anorexia,
2. Decision-maker
dementia, inability to concentrate, feeling of constant fear
3. Communicator
ACCEPTANCE
4. Community leader
• perhaps the most immediately understandable of Kubler- 5. Manager
Ross's stages and patients experience it with unsurprising
symptoms such as sadness, fatigue, and anhedonia THE FIVE-STAR FILIPINO DOCTOR (CMO-NO.10 S.2006- CHED)
o Realization that death is inevitable 1. Health care provider
o Importance of company 2. Techer/academician
o Going through the process is the best way to cope with a 3. Researcher
cancer diagnosis 4. Social Mobilizer
MNEMONIC: Ang walang kamatayang “DABDA” 5. Administrator/Manager
Dr. Mann Memorize the latest five-star physician, ang kung medyo pagod ka na
mag memorize ito panoorin mo baka sakali makatulong… hehehehe
PALLIATIVE & HOSPICE CARE (PABEBE)
PALLIATIVE CARE
• also known as palliative medicine, is specialized medical care for
THE FIVE STAR PHYSICIAN
people living with serious illness. It focuses on providing relief
https://qrs.ly/26cqpri
from the symptoms and stress of a serious illness—whatever
the diagnosis. The goal is to improve quality of life for both the
patient and the family Dr. Mann
HOSPICE CARE
• special kind of care that focuses on the quality of life for people FAMILY TYPES
and their caregivers who are experiencing an advanced, life- ON BASIS OF SIZE AND STRUCTURE
limiting illness. Hospice care provides compassionate care for
• NUCLEAR – Consists of parents and their still dependent
people in the last phases of incurable disease so that they may
children
live as fully and comfortably as possible
• EXTENDED FAMILY – Unilaterally/Bilaterally extended
• It is a primary concept of care not just a place of care
• SINGLE PARENT FAMILY
• Quality rather than the length of life is the primary emphasis
• BLENDED FAMILY – Includes step parents and step children;
• Composed of multidisciplinary team that is available 24/7
Caused by annulment with remarriage and separation
• Provides follow up bereavement care for up to 1 year after the
• COMMUNAL OR CORPORATE FAMILY – Grouping of individual
patient’s death.
formed for specific ideological or societal purposes
ON THE BASIS OF AUTHORITY THE “FAMILY LIFE CYCLE”

(1) Patriarchal Family: • Represents the composite of the individual developmental
o The family in which all the power remains in the hands of changes of family members
patriach or father is known as patriarchal family. • Presents cyclic development of the evolving family unit
o This type of family is widely found all over the world
(2) Matriarchal family: 2 LEVELS OF ORDERS OF MAGNITUDE OF CHANGE:
o This type of family is just opposite of patriarchal family. • First order Changes- “need to DO”
o In this family power or authority rests on the eldest female o Involve increments of mastery and adaptation
member of the family especially the wife or mother. o Do not involve change in the main structure of the family
(3) Egalitarian family: o Do not involve change in an individual’s identity and self-image
o The family in which power and authority are equally shared • Second Order changes - “need to BE”
between husband and wife is called as egalitarian family. Both o Involve transformation of an individual’s status and meaning
of them take joint decisions or assume joint responsibility. o Change in the very basic attributes of the family system
o That is why it is called as equalitarian family. o Change in the role and identity of family members
ON THE BASIS OF RESIDENCE: SUPPLEMENT: FAMILY SYSTEMS THEORY
(1) Patrilocal family: • Defines the family as a continuous interlocking human
o The family in which after marriage wife comes to reside in the relationship, organized in such a way that when there is a
family of her husband change in one family member, the other family members are
(2) Matrilocal family: affected.
o The family in which after marriage husband comes to reside in o The family is more than a collection of individuals
the family of her wife o Have repeating interaction patterns that regulate member
(3) Bilocal family: behavior
o In this type of family after marriage the married couple change o An individual symptom may have a function within the
their residence alternatively family
o this type of family is also known as family of changing o The ability to adapt to change is the hallmark of healthy
residence. family functioning
(4) Neolocal family: o There are no victims and victimizers in families
o After marriage when newly married couple establish a new
FAMILY LIFE CYCLE
family independent of their parents and settled at a new place
this type of family • UNATTACHED YOUNG ADULT – young adult separates from
(5) Avunculocal family: the family of origin but without abandoning emotional refuge to
o After marriage when the newly married couple reside in that family
maternal uncle’s house the said type of family o extend social contact outside the home
o Avuncu means maternal uncle. o differentiation of self into the family of origin
o Development of intimate peer relationship
o Establishment of self in work
FAMILY RELATIONSHIPS AND INTERACTIONS • NEWLY MARRIED COUPLE – transition stage of the couple from
ORDINAL POSITION their family of origin and their lives as individual to the life of a
FIRST BORN MIDDLE CHILD YOUNGEST couple.
Generally o Establishment a home base of his own
Optimistic Demanding
persevering o Formation of marital system
Serious, Sociable, Outgoing, o Realignment of relationship with extended families
More responsive aggressive, occasionally o Establishing a mutually satisfying system for getting and
to adults, competitive, narcissistic, by spending money and acceptable patterns of accountability
Achievement occasionally nature are o Establishing a continuity of mutually satisfying sexual
oriented manipulative affectionate relationship
o Facing the possibility of children and planning for their
PARENTING STYLE AND CHILDREN BEHAVIOR coming.
1. Democratic parenting EMOTIONAL STAGE CRITICAL
STAGES
• Establish clear rules and expectations and discuss them with ISSUES TASKS
their children. Although they acknowledge the child’s • Differentiation from
perspective, they use both reason and power to enforce their family of origin
standards Honeymoon • Making room for
Commitment to
o Energetic friendly, self-reliant, and cheerful, achievement Stage spouse with family
marriage
oriented child (0-2 years) and friends
2. Authoritarian parenting • Adjusting career
• More rigid rules and expectations are strictly enforced to the demands
children. It demands extreme obedience and loyalty from their • Keeping romance in
children the marriage
o Unfriendly, Conflicting, irritable. Unhappy and unstable child Early Marriage • Balancing
3. Permissive Parenting Maturing of
Stage separateness and
• Parents let the child preferences take priority over their ideals Relationship
(2-10 years) togetherness
and rarely force the child to conform to their standards. Children • Renewing marriage
are in control of the family and not their children commitment
o Impulsive and rebellious, Low achieving child • Adjusting to mid-life
4. Rejecting Parenting changes
• Parents do not pay attention to their children needs and seldom Middle
Post-care • Re-negotiating
have expectations regarding how the child should behave Marriage Stage
review relationship
o Immature, Psychologically troubled child (10-25 years)
• Renewing marriage
5. Uninvolved Parenting commitment
• Parents often ignore the child, letting the child’s preference • Maintaining couple
prevail as long as those preferences do not interfere with the function
parent’s activity. Long Term
Farewells and • Closing or adapting
o Lonely and Withdrawn, Low Achieving child Marriage Stage
planning family home
(25+ years)
Uyyyy! Aminin mo naisip mo kung sino ka diyan? So alin ka diyan? Wag • Coping with death of
na mahiya #PLE2021 spouse
• Dr. Mann
• FAMILY WITH YOUNG CHILDREN - starts with pregnancy for • FAMILIES IN LATER LIFE – begins with the departure of the last
the first child to the emergence of adolescents. child and continuous through retirement of one or both of the
o Supplying adequate space, facilities and equipment for their couple and ends when both are dead.
expanding family o Accepting the shifting of generational goals
o Tapping enough resources o Adjusting to physiologic changes of later life
o Taking on parental roles o Reexamining their living arrangements
o Maintaining mutually satisfying sexual relationships o Participating in group activities
• FAMILY WITH ADOLESCENTS – the stage starts when the first o Maintaining contact with the younger generations
child reaches adolescent age (age 12) o Support for more central role of the middle generation
o Increasing flexibility to boundaries to include children o Making room in the system for the wisdom and experience of
independence the elderly generation without over functioning them
o Changes in the balance of responsibility along with over o Dealing with the loss of spouse, siblings, peers and preparation
functioning and under functioning. for death.
o Marked shifts in intensity of relationship
o Surge of exchange with the community at large FAMILY ILLNESS TRAJECTORY
o Shifting of parent child relationships to permit the adolescent
to move in and out of the system • It is a normal course of the psychological aspects of disease for
o Refocus on midlife, marital and career issues the patient and the family.
o Beginning the shift towards concern for the older generation • Knowledge of the trajectory allows the physician to predict,
o Maintaining contacts with the extended family members anticipate and deal with a family’s response to illness.
• LAUNCHING FAMILY – begins when the first child leaves home • Shows normal and pathologic responses thus enabling family
o Accepting multitude of entries and exits into the family system physicians to formulate special therapeutic plan.
o Adjusting to physiologic changes of middle life
o Discovering new satisfaction in relation with spouse
o Setting up a comfortable home for themselves
o Adjusting to the reality of their own work situation
o Participating in community life
o Sexual relationship with spouse
o Realignment of marital system as a dyad
o Development of adult to adult relationship between grown up
children and their parents
o Realignment of relationships to include in laws and
grandchildren
o Dealing with disabilities and death of parents and
grandparents.
STAGES DESCRIPTION RESPONSIBILITIES OF A PHYSICIAN
Stage I: • The stage experienced prior to contact with the physician. Explore routinely the explanatory model and
Onset of Illness to • Medical beliefs and previous experiences provide influence to fear that the patient brings to the clinical set-up.
Diagnosis the meaning of illness. Most difficult stage for the patient!
Stage II: Anticipate number of problems and help families
2 Phases:
Impact Phase- cope and adapt to the situation.
1. Emotional Plane
Reaction to Interpret findings which are misunderstood.
2. Cognitive Plane
Diagnosis
• Psychological state and preparedness of the patient and the Work in harmony with patient and the family.
family determine the choice of therapeutic plans as well as the Consider all factors in planning.
Stage III: alternative choices. Remain open to the family, indicate they will not
Major • Assumption of responsibility for care be abandoned; provide information.
Therapeutic • Economic impact of illness Most challenging and rewarding stage for the
Efforts • Lifestyle and cultural characteristics of a family are important physician!
in choosing a therapeutic plan.
• Hospitalization gives rise to stressful problem.
• Return from the hospital or major therapy initiates a period of Deal with immediate effects of trauma
gradual movement from one role of being sick to some form of
Stage IV: recovery or adaptation, with corresponding adjustments of Alleviate anxiety and assure adequate rest
Early Adjustment relation within the family.
to Outcome – • 3 types of anticipated outcome: Give psychological support
Recovery 1. Return to full health
2. Partial recovery Explore the level of understanding of patient and
3. Permanent disability-requires acceptance family.
Stage V: Assist the patient and the family in relating to
• It points to the family’s adjustment to crisis.
Adjustment to the health care system
• 2nd crisis occurs as family realizes that they must accept and
permanency of Aid the patient and the family in efficient and
adjust to permanent disability.
outcome functional readjustment
SUPPLEMENT: SPIKES Model for Breaking bad news • Invitation (OBTAINING THE PATIENT’S INVITATION) –
This framework is used in disclosing medical information Asking the patient if they would like to know the details of
particularly regarding to patients with terminal disease. their condition. Although most patients want to know all the
• Setting (SETTING UP the Interview) – must be done in a details about their medical situation, you can’t always assume
private or confidential place, may or may not be accompanied that this is the case. Obtaining overt permission respects, the
by other medical staff. patients’ right to know (or not to know)
• Perception (ASSESSING THE PATIENT’S PERCEPTION) - • Knowledge (GIVING KNOWLEDGE AND INFORMATION TO
This step is the center of the “before you tell, ask” principle. THE PATIENT) - disclosure of the bad news is made
Before you break bad news to your patients, you should glean • Emotions (ADDRESSING THE PATIENT’S EMOTIONS WITH
a fairly accurate picture of their perception of the medical EMPATHIC RESPONSES) - could be addressed by observing,
situation—in particular, how they view the seriousness of the identifying, expressing the emotion.
condition. The exact words you decide to use depend on • Strategy and Summary - summary and checking the patients
your own style understanding of the illness as well as his plans.
FAMILY ASSESSMENT TOOLS Sino ang index patient sa Kineme-Chereret family? Si Chai
FAMILY GENOGRAM Also remember ARROW PO, ulit ARROW PO and marker ng index patient,
hindi triangle.
• a graphic representation of a family tree that displays detailed For more information about genogram symbol,s you can visit this site:
data on relationships among individuals. It goes beyond a
traditional family tree by allowing the user to analyze hereditary
patterns and psychological factors that punctuate relationships GENOGRAM SYMBOLS
• An excellent tool to use in learning about the family structure; https://qrs.ly/bdbqeu8
more dynamic image of the family
• Gives information about family illnesses, family members, Dr. Mann
inheritance patterns, family relationships and significant dates
•
FAMILY APGAR
o 3 or more generations, each generation represented by roman • 5-item questionnaire that has the adequate reliability and
numeral validity to measure one’s level of satisfaction with family
o 1st born for each generation always at the left the left relationship
o Family name is placed above each major family unit • Rapid screening instrument for family dysfunction
o Given names and ages are placed below each symbol
• Has adequate reliability and validity to measure one’s level of
o Index patient is identified with an arrow
satisfaction with family relationship
o Date is indicated when chart is developed
• Needed when:
o Functional Chart
o Family will be directly involved in caring for the patient
§ Family relationship
o Treating a new patient
o Family Illness/History
o Treating a patient whose family is in crisis
§ Heredofamilial diseases
o When patient’s behavior makes you suspect a psychosocial
problem possibly due to family dysfunction
o Components:
§ Adaptation – capability to utilize and share inherent
resources which are either intrafamilial or extrafamilial
§ Partnership – solving problems by communicating, sharing
of decision making
§ Growth – physical and emotional growth, satisfaction in the
available freedom to grow and change
§ Affection – intimacy and emotional interaction within the
family
§ Resolve – members satisfaction with the commitment made
by the members of the family, how time, space, money are
shared
Hypothetical Genogram by Dr. Mann
Almost Some of the Hardly ever

FAMILY APGAR
Always time (1) (0)
I am satisfied that I can turn to my family for help when something is
Adaptation
troubling me
I am satisfied with the way my family talks over things with me and
Partnership
shares problems with me
I am satisfied that my family accepts and supports my wishes to take on
Growth
new activities or directions
I am satisfied with the way my family expresses affection and responds to
Affection
my emotions, such as anger, sorrow, and love
Resolve I am satisfied with the way my family and I share time together
• Scoring: • Facilitates the communication of information about the family
o 8-10 points denotes highly functional family system and its dynamics in order to address psychosocial issues.
o 4-7 points: moderately dysfunctional family • Enmeshment – over involvement of family members with each
o 0-3 points: severely dysfunctional family other
A dysfunctional family has chronic inability to respond to the members or • Disengagement – members are isolated from each other or
to cope with changes and stresses in the environment. have little emotional response to each other
• Dr. Mann
• Triangulation – family members talk directly to each other
about personal matters.
Minuchin Family Map • Coalition – one family member is siding with another family
member
SCREEM (Social, Cultural, Religious, Economic, Educational,

Medical)
• It is an acronym that represents family resources and is a tool
where the family physician helps the family members identify
and assess their resources to meet a crisis. If there is a lack of
resources, it can also serve as a kind of pathology in certain
situations
• Used to assess the capacity to participate in provision of health
care or to cope with crisis
• Relationship of health behavior, practices and utilization of
health services
Resources Pathology OK LET’S HAVE SOME COMMERCIAL PANG TANGGAL STRESS!
Social interaction is The family is socially SABAYAN NIYO AH!!!!
Social evident among family isolated from extra ABOT PA NAMAN SIGURO ITO SA HENERASYON NIYO...
CLICK THE LINK
members. familial groups.
https://youtu.be/6-BPFPwv8RQ
The family has Dr. Mann
Cultural pride or •
feelings of cultural-
Cultural satisfaction can be
ethnic inferiority or COMMUNICABLE DISEASES
identified.
shame.
INFECTIOUS DISEASE
Dogma and rituals are
Religion offers • a disease caused by a microorganism and therefore potentially
so rigid that they limit
Religion satisfying spiritual infinitely transferable to new individuals.
the family’s problem-
experiences. • May or may not be communicable.
solving capacity.
Financial problems o Example of non-communicable: disease caused by toxins from
Ability to meet the food poisoning or infection caused by toxins in the
make it difficult for
economic demands of environment, such as tetanus.
Economic the family to meet
normal life events and
monetary demands of
illness. COMMUNICABLE DISEASE
crisis or illness.
Education of the family Limit the ability of • an infectious disease that is contagious and which can be
members is adequate to family members to transmitted from one source to another by infectious bacteria or
Education allow members to solve comprehend the viral organisms.
or comprehend most of problem or
the problems. recommend solution. CONTAGIOUS DISEASE
Medical care is • a very communicable disease capable of spreading rapidly from
available through Inaccessible and one person to another by contact or close proximity
Medical
channels that are easily under-utilized
established. PHASES OF A COMMUNICABLE DISEASE
PRE-PATHOGENIC PHASE PATHOGENIC PHASE
FAMILY LIFELINE Phase before man is involved; Course of disorder in man
• Used to show significant events among family members over a preliminary interaction of from the first interaction with
period of time in a chronological sequence. potential agent, host and the disease, provoking stimuli
• For exploration of certain family issues environmental factors in to the changes in form and
disease production function which result or until
equilibrium is reached or
Everyone is in the period of recovery, defect, disability or
pre-pathogenesis death ensues
Process in environment Process in man
REQUIREMENTS FOR SUCCESSFUL AGENT INVASION

• Conditions in the environment must be favorable to the agent.
• Suitable reservoir
• Susceptible host
• Satisfactory portal of entry
• Accessibility of portal of exit from the host
• Appropriate means of dissemination and transmission to a new
SAMPLE FAMILY LIFELINE host
SUPPLEMENT: FORMS OF COMMUNICATION ELEMENTS OF A COMMUNICABLE DISEASE

• Verbal Communication
• Non-verbal Communication
o Eye contact – indicates sincerity. Staring continuously might
threaten your patient
o Mannerisms – it might distract the patient during history
taking
o Touch – connotes an establish a sense of personal
relationship with the patient
o Gesture- should be done with ease so that it appears
spontaneous and avoid distractions
o Tone of voice – should be modulated
o Posture –leaning forward –interested, leaning backward –
not interested. AGENT
• Symbolic Communication • Any element, substance, or force whether living or non-living,
o Includes external manifestations of both physician and the presence or absence of which can initiate or perpetuate a
o
patient (hairstyle, dressing, social distance) disease process.
CLASSIFICATION OF AGENTS
PHYSICAL /MECHANICAL CHEMICAL AGENTS NUTRIENT AGENTS BIOLOGIC AGENTS
PHYSICAL: EXOGENOUS: Chemical substances needed to Living Disease Agents:
Can disorganize function within Arise outside of the host sustain life
cells, tissues, organs and the body • Inhalation of pollutants (CHO, CHON, fats, vitamins, Bacteria
as a whole; light; sound; heat; • Ingestion of contaminants, water) Virus
cold; radiation drugs alcohol Fungi
• Skin Contact Protozoa
MECHANICAL:
Chronic friction & other forces ENDOGENOUS
which add unusual stress to body Produced in human
• abnormal products- uremia
• Serum cholesterol
• Hormone disturbance
CHARACTERISTICS OF A LIVING AGENT o Types of carrier:
• INHERENT § Inapparent throughout – polio virus, meningo, hepatitis
o Physical make up virus
o Chemical component § Incubatory carrier – chickenpox, measles and hepatitis
o Antigenic characteristic – ability of an agent to oppose the viruses
effect of chemotherapeutic or antibiotic substance § Convalescent – C. diphtheria, hepatitis B
• BIOLOGIC § Chronic – S. typhi, hepatitis B
o Viability – ability to withstand adverse environmental • MODE OF TRANSMISSION:
influence o Direct Transmission
o Growth Requirements – availability of appropriate nutrition, § Touching, biting, kissing
temperature, etc. § Sexual intercourse
o Host range - spectrum of animals’ w/c an agent can invade or § Droplets
infect § Contaminated dust particles
o Indirect Transmission
CHARACTERISTICS OF AGENTS DIRECTLY RELATED TO MAN: § Vehicle borne objects, food, water
• INFECTIVITY § Vector borne arthropod
o ability of the agent to invade and multiply (to produce § Airborne: dust, droplets
infection; the minimum number of particles or agents required • PORTAL OF EXIT
to establish infection in 50% of a group of hosts of the same o Respiratory tract, GIT, GUT, open lesions
species (ID50); depends on the following factors: FACTORS AFFECTING COMMUNICABILITY OF BACTERIA
§ Viability • Site of lesion of infected host
§ Portal of entry • Size of inoculum
§ Susceptibility of the host • Chance/ accident of coming in contact with bacterial species or
§ Susceptible tissues strain
§ Body defenses of the host • Survival capacity in immune subjects
• PATHOGENICITY – capacity of an agent to induce disease which • Ability to survive outside animal body
is clinically apparent in an infected host • Ability to multiply and survive in intermediate host or vector
• VIRULENCE – Ability of an agent to produce serious illness; • Size of reservoir of infection
measured in terms of fatality HOST
• IMMUNOGENICITY – The ability of an agent to induce
• Individual or other living animal exposed to the agent that
immunity, or to stimulate the host to produce defense
affords subsistence or lodgment.
mechanism
• Final outcome may vary from complete recovery to death of the
• ANTIGENICITY – the ability to combine specifically with the
host.
products or effectors of the immune response
STAGES
SUPPLEMENT: CHAIN OF INFECTION • STAGE OF SUSCEPTIBILITY:
o Disease has not developed but the groundwork has been laid
by the presence of factors that favor its occurrence
o Portal of entry
o Risk factors
• STAGE OF PRE-SYMPTOMATIC DISEASE:
o No manifestation of the disease yet but pathogenic changes
have started to occur
o Incubation period
o Ex: Atherosclerotic changes in coronary vessels prior to any
signs and symptoms
• STAGE OF CLINICAL DISEASE:
o End organ damage has occurred so that there are recognizable
signs or symptoms of the disease
o The clinical horizon
• STAGE OF DISABILITY:
o Any limitation in a person’s activities including psychosocial
role
Breaking a link at any point in the chain will control the risk of
infection by preventing the onward transmission of microorganisms.
• Dr. Mann
CHARACTERISTICS OF AGENT DIRECTLY RELATED TO

ENVIRONMENT:
• RESERVOIR OF INFECTION
o man, animals, plants, soil or inanimate organic matter in
which an infectious agent multiplies; essential component of
the cycle by which an infectious agent maintains and DEFENSE MECHANISM OF THE HOST:
perpetuates itself. • Specific anatomical defenses • Immunity
• SOURCES OF INFECTION • Resistance • Tolerance
o transfer is often direct from reservoirs to host in which the • Allergy • State of nutrition
reservoir is also the source of infection GENERATION TIME
o *Carrier – an infected person who does not have apparent
• Can be used to measure the rate of an epidemic
clinical disease but is, nevertheless, a potential source of
• The period between the receipt of infection by the host and the
infection to others
maximal communicability of that host.
• Roughly equivalent to the incubation period, the interval
between the receipt of infection and the onset of illness.
6. A susceptible host
a. Interruption in any stage of the chain, disease will not develop
b. The reservoir and source are identical when transfer is direct
from reservoir to host
c. Period of communicability - refers to the time during which
an infectious agent can be transmitted directly or indirectly
from an infected person to another person, from an infected
animal to humans, or from an infected person to animals
d. Span of time during which the organism escape from the body
e. The period of communicability varies inversely with the
degree of communicability
SUPPLEMENT: ISOLATION VS QUARANTINE

ISOLATION QUARANTINE
separates sick people separates and restricts the
REFINE DEFINITION with a contagious disease movement of people who were
• Exposure moment refers to point in time when a pathogen from people who are not exposed to a contagious
enters the host sick disease to see if they become
• Latent period is the period between exposure and infection sick
• Incubation period can only be applied to infectious that result in Isolation would last for Lasts only as long as necessary
manifest disease the period of to protect the public by:
• Generation time refers to the time it takes for the first group of communicability of the (1) providing public health
patients to 'generate' the next group illness, which varies by care (such as immunization or
o Measure of RATE OF SPREAD disease and the drug treatment/prophylaxis)
o When one person transmits an infection to another, then the
availability of specific (2) ensuring that quarantined
time that elapses between onset of symptoms in the primary
treatment. persons do not infect others if
case and onset of symptoms of the secondary case
they have been exposed to a
• Timing: the maximal communicability may precede or follow the
end of incubation period
contagious disease = known
incubation period
BRIDGE KIND OF HOST
1. Definitive Host SUPPLEMENT: VECTORS
o a host in which the parasite reaches maturity and, if Vector Disease
possible, reproduces sexually Aedes sp. Dengue, Chikungunya, filariasis, zika
2. Reservoir Host
Anopheles Malaria
o can harbor a pathogen indefinitely with no ill effects
Filariasis, Japanese encephalitis, west
3. Intermediate Host Culex
Nile fever
o host that harbors the parasite only for a short transition
Sand flies Leishmaniasis
period, during which (usually) some developmental stage is
completed. Chagas disease (American
Triatome bugs
4. Paratenic Host trypanosomiasis)
o host is similar to an intermediate host, only that it is not Lice-body louse Typhus fever
needed for the parasite's development cycle to progress. Sleeping sickness (African
o Paratenic hosts serve as "dumps" for non-mature stages of Tse-tse flies trypanosomiasis)
a parasite in which they can accumulate in high numbers.
5. Dead-end host or incidental host Blackflies Onchocerciasis
o is an intermediate host that generally does not allow Lyme disease, rickettsial diseases
Ticks
transmission to the definitive host, thereby preventing the (spotted and Q fever)
parasite from completing its development. Mites Scabies
6. Host of predilection Synanthropic
Dysentery, yaws
o is the host preferred by a parasite flies
7. Amplifying host Diarrheal diseases, Intestinal, skin and
Cockroaches
o is a host in which the level of pathogen can become high eye infections
enough that a vector such as a mosquito that feeds on it will Rodents Leptospirosis
probably become infectious Snails Intermediate host for schistosomiasis
Balikan niyo yung micro niyo! Paulit ulit!... J Pigs Trichinosis
• Dr. Mann Fleas Bubonic plague
Me: Knock knock!
ENVIRONMENT You: Who’s there
• Sum total of an organism’s external surrounding conditions and Me: Balikan mo
influences that affects the life and development of an organism You: Balikan mo who?
Me: Balikan mo mo si micro at para!
3 CATEGORIES OF ENVIRONMENT: #Aning
• Dr. Mann
PHYSICAL BIOLOGIC SOCIO-ECONOMIC
Climate Serve as • Working condition
• Temperature reservoirs • Level of industrialization EPIDEMICS AND SURVEILLANCE
• Altitude and vectors • Disruption: Disaster/ war DEFINITION OF TERMS
• Humidity of disease • Availability of medical • EPIDEMIC - an increase, often sudden, in the number of cases of
agents services a disease above what is normally expected in that population in
Geography/ • Period of prosperity and that area. (There MUST be an increase from the baseline!)
Location depression • OUTBREAK - same definition of epidemic, but is often used for
• Sanitation and Housing a more limited geographic area
THE EPIDEMIOLOGIC CHAIN • PANDEMIC refers to an epidemic that has spread over several
1. A Causative or etiologic agent countries or continents, usually affecting a large number of
2. A reservoir or source of the causative agent people.
3. A mode of escape from the reservoir
4. A mode of transmission from the reservoir to the potential new
host
5. A mode of entry into the new host
SUPPLEMENT: DETERMINANTS OF AN INCREASE There may be more than 1 peak but still there is still clustering
1. Current disease level exceeds the 95th percentile for 2
weeks
2. More than 2x the incidence rate over the specified time
period
3. Dr. Ricardo’s index - comparison of the indices of the
disease with the incidence for the last 5 years by using
median
SURVEILLANCE
• Continued vigilance over the occurrence and distribution of
disease and events & conditions which increase the risk of
disease transmission.
• It entails data collection, consolidation, analysis, and
dissemination!
Objectives:
o Epidemic (outbreak) detection
o Monitoring trends in endemic disease POINT EPIDEMIC
o Evaluation of an intervention • Exposure of susceptible population at the same time (1
o Monitoring progress towards a control objective incubation period) to common source of pathogen.
o Monitoring a program performance • Exposure is brief (single exposure).
o Estimate future disease impact • Epidemic curve rises & fall rapidly usually skewed to the right
• Single, brief exposure that did not persist over time
EPIDEMICS • All cases have single incubation period
• No person to person spread
ESSENTIAL INGREDIENTS OF AN EPIDEMIC
• A recent increase in dosage or change in virulence of the
pathogenic agent
• the recent introduction of the pathogen into a setting where it
has not been before
• an enhanced method of transmission so that more susceptible
are exposed
• some change in the susceptibility of the host response to the
pathogenic agent
• cultural or behavioral factors that increase host exposure or
involve introduction through new portals of entry
EPIDEMIC CURVES
• basic investigative tool because they are so informative
• The epi curve shows the magnitude of the epidemic over time as
a simple, easily understood visual.
• It permits the investigator to distinguish epidemic from endemic
disease. Potentially correlated events can be noted on the graph. PROLONGED- PROGRESSIVE
• The shape of the epidemic curve may provide clues about the • Transfer of the pathogenic agent from one host to another.
pattern of spread in the population, e.g., point versus • The epidemic extends over a number of cases in each successive
intermittent source versus propagated. time period. When all susceptible are exhausted, the outbreak
• The curve shows where you are in the course of the epidemic — ends
still on the upswing, on the down slope, or after the epidemic has • Presents with inverted epidemic curve
ended. o Long ascending limb – longer incubation and more complex
• This information forms the basis for predicting whether more or transmission
fewer cases will occur in the near future. o Short descending limb
• The curve can be used for evaluation, answering questions like: § E.g. Dengue, SARS
How long did it take for the health department to identify a
problem? Are intervention measures working?
• Outliers — cases that don’t fit into the body of the curve — may
provide important clues.
• If the disease and its incubation period are known, the epi curve
can be used to deduce a probable time of exposure and help
develop a questionnaire focused on that time period.
TYPES OF EPIDEMIC PATTERNS

COMMON SOURCE OUTBREAK
• Exposure of susceptible population to common source of
pathogen.
• Few days or weeks exposure the curve is usually symmetrical.
• e.g. Contaminated water supply
• Exposure continues over a longer period
• Many people exposed simultaneously
• No case following termination of exposure MIXED EPIDEMICS
• Involve both single common exposure to an infectious agent and
secondary propagative spread to other individuals, usually by
person to person transmission
ATTACK RATE = ARExposed - ARUnexposed
𝑁𝑜. 𝑜𝑓 𝑃𝑒𝑟𝑠𝑜𝑛 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒

𝐴𝑅/* = 𝑥 100
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑃𝑒𝑟𝑠𝑜𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑡𝑜 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
𝐴𝑅-&$*
𝑁𝑜. 𝑜𝑓 𝑃𝑒𝑟𝑠𝑜𝑛 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
= 𝑥 100
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑃𝑒𝑟𝑠𝑜𝑛 𝑁𝑂𝑇 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑡𝑜 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
o A variety of attack rates can be calculated:

𝐹𝑜𝑜𝑑 𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐴𝑅
𝑁𝑜 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑡ℎ𝑒 𝑓𝑜𝑜𝑑 𝑎𝑛𝑑 𝑔𝑜𝑡 𝑖𝑙𝑙
= 𝑥 100
𝑁𝑜. 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑡ℎ𝑒 𝑓𝑜𝑜𝑑
EXAMPLE: An outbreak was declared in an elementary school with a

population of 40 students. A total of 16 students had the disease. Five food
items were being suspected as the cause of the outbreak.
For example, a common-source epidemic of shigellosis occurred among a

group of 3,000 women attending a national music festival (Figure 1.24).
Many developed symptoms after returning home. Over the next few
weeks, several state health departments detected subsequent generations
of Shigella cases propagated by person-to-person transmission from
festival attendees.
Dr. Mann 16
•
𝑂𝑣𝑒𝑟𝑎𝑙𝑙 𝐴𝑅 =𝑥 100 = 40%

CRITERIA FOR INITIATING AN INVESTIGATION 40
• If the disease is a priority 9
𝐹𝑜𝑜𝑑 𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐴𝑅0 = 𝑥 100 = 42.9%
• When the disease exceeds the usual expected frequency 21
• Cases are due to common sources
ATTACK RATE = ARExposed - ARUnexposed
• When the disease seems to be more severe 𝟗 𝟕
• When a disease has not previously occurred for a long time in a 𝑨𝑹𝑨 = 𝒙𝟏𝟎𝟎 − 𝒙𝟏𝟎𝟎 = 𝟔. 𝟏%
𝟐𝟏 𝟏𝟗
place
WITH
NO DISEASE/
STEPS IN OUTBREAK INVESTIGATION Exposure/ DISEASE/ Total
CONTROLS
1. Field work Intervention CASES
2. Establish existence of an outbreak (+) A =9 B=12 A+B=21
3. Verify diagnosis- uses frequency distributions (-) C=7 D=12 C+D=19
4. Define and identify cases Total A+C B+D A+B+C+D
5. Perform descriptive epidemiology; characterize:
𝐴
a. Time course by frequency polygon or histogram 𝑂𝑑𝑑𝑠!"#$# 𝑨𝑫
b. Place: geographical extent of problem 𝑶𝑹 = = 𝐶 =
𝑂𝑑𝑑𝑠!%&'(%)# 𝐵 𝑩𝑪
c. Person: Population at risk 𝐷
6. Develop hypothesis SECONDARY ATTACK RATE
7. Evaluate hypothesis – uses cohort &case-control studies § incidence of a disease in contacts of a case, often is used to
8. Execute additional studies and refine hypothesis assess contagiousness.
9. Implement control, and prevention measures (Sanitation, § calculated to document the difference between
Prophylaxis, Diagnosis and treatment, and Vector Control) community transmission of illness versus transmission of
10. Communicate findings illness in a household, barracks, or other closed
11. Follow up recommendations population
https://www.cdc.gov/csels/dsepd/ss1978/lesson6/section2.html
𝑁𝑜. 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑎𝑚𝑜𝑛𝑔 𝑐𝑜𝑛𝑡𝑎𝑐𝑡𝑠
This is my source for steps in outbreak investigation, you can read more 𝑆𝑒𝑐𝑜𝑛𝑑𝑎𝑟𝑦 𝐴𝑅 = 𝑥100
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐶𝑜𝑛𝑡𝑎𝑐𝑡𝑠
here:
Example: Consider an outbreak of shigellosis in which 18
persons (primary cases) in 18 different households all became
CDC OUTBREAK INVESTIGATION ill. If the population of the community was 1,000, then the
https://qrs.ly/c7bqhk0 overall attack rate is:
𝑁𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 18
𝑂𝑣𝑒𝑟𝑎𝑙𝑙 𝐴𝑅 = 𝑥 100 = 𝑥100 = 1.8%
𝑇𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 1,000
You can watch this for reinforcement!
One incubation period later, 17 persons in the same households
OUTBREAK INVESTIGATION as these "primary" cases developed shigellosis. If the 18
https://qrs.ly/f4bqhcg households included 86 persons, calculate the secondary attack
rate.
17
𝑆𝑒𝑐𝑜𝑛𝑑𝑎𝑟𝑦 𝐴𝑅 = 𝑥100 = 25%
• Dr. Mann (86 − 18)
SUPPLEMENT: ATTACK RATE Note: (86-18) =subtract the primary cases from the total
Overall AR = Incidence number of people in all of the households to get the “Total
𝑁𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 number of contacts”
𝑂𝑣𝑒𝑟𝑎𝑙𝑙 𝐴𝑅 = 𝑥 100
𝑇𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
o In the outbreak setting, the term attack rate is often used as

a synonym for risk.
§ It is the risk /probability of getting the disease during a
specified period, such as the duration of an outbreak.
SUPPLEMENT: ICEBERG PHENOMENON HISTORY
• A brief history of Primary Health Care is outlined below:
o May 1977. The 30th World Health Assembly adopted
resolution which decided that the main social target of
governments and of WHO should be the attainment by all the
people of the world by the year 2000 a level of health that will
permit them to lead a socially and economically productive life.
o September 6-12, 1978. International Conference in PHC was
held in this year at Alma Ata, USSR (Russia)
o October 19, 1979. The President of the Philippines
o The visible part of the iceberg denotes the clinically (Ferdinand Marcos) issued Letter of Instruction (LOI) 949
apparent cases of disease in the community. which mandated the then Ministry of Health to adopt PHC as
The part of the iceberg below the water level denoted the an approach towards design, development, and
latent, subclinical, undiagnosed and carrier states in the implementation of programs which focus health development
community, which forms the major part. at the community level.
GOALS
• The ultimate goal of primary health care is better health for all.
WHO has identified five key elements to achieving that goal:
o Reducing exclusion and social disparities in health (universal
coverage reforms);
o Organizing health services around people’s needs and
expectations (service delivery reforms);
o Integrating health into all sectors (public policy reforms);
o Pursuing collaborative models of policy dialogue (leadership
reforms); and
o Increasing stakeholder participation.
FOUR PILLARS OF PHC

• Active Community Participation
o the community must share the responsibility and participate
Iceberg Phenomenon, as Illustrated by a Diphtheria
in the following aspects of activity:
Epidemic in Alabama.
§ Defining the health-related needs and problems
• Alabama. In epidemics, the number of people with severe
§ Identifying realistic solutions to priority problems
forms of the disease (part of iceberg above water as shown § Organizing/mobilizing its resources for health activities
here by 2 patients who died and 12 patients with symptoms
§ Evaluating the results of health activities
of clinical illness) may be much smaller than the number of
• Intra and Inter-sectoral linkages
people with mild or asymptomatic clinical disease (part of
o Intersectoral linkages – integration of health plans with those
iceberg below water as shown by the 32 “invisible” cases that
for total community development
would have remained invisible without extensive
o Intrasectoral linkages – within DOH
epidemiologic surveillance).
Elmore, Joann G.. Jekel's Epidemiology, Biostatistics and Preventive Medicine • Use of appropriate technology
o use of methods, procedures, techniques, equipment/materials
that are not only scientifically sound but also suitable to the
PRIMARY HEALTH CARE community; socially and environmentally acceptable level of
• Primary Health Care (PHC) is an essential health care made service or quality product at the least economic cost.
universally acceptable to individuals and families in the • Support mechanism made available
community by means acceptable to them through their full o the need for human resources, financial resources &material
participation and at a cost that the community and country and resources
can afford at every stage of development.
FEATURES OF THE CONCEPT
SUPPLEMENT: DECLARATION OF ALMA-ATA 1. Must be community based with full participation and
• The Declaration of Alma-Ata was adopted at the involvement of the people
International Conference on Primary Health 2. Must be related to the socioeconomic development of the local
Care (PHC), Almaty (formerly Alma- community
Ata), Kazakhstan (formerly Kazakh Soviet Socialist 3. Must be geared to self-reliance towards attaining an adequate
Republic), 6–12 September 1978. level of health
• It expressed the need for urgent action by all governments, Services must be available to all communities, accessible to people,
all health and development workers, and the world affordable at community level
community to protect and promote the health of all people. It
was the first international declaration underlining the COMPONENTS/APPROACHES OF PHC
importance of primary health care. 1. Preventive Health care
• The need for urgent action by all governments, all health and 2. Promotive Health care
development workers, and the world community to protect 3. Curative Health care
and promote the health of ALL people. (by the year 2000) 4. Rehabilitative Health care
You can access the whole script of the alma-ata declaration here: 5. Supportive Health Care
ELEMENTS OF PHC
DECLARATION OF ALMA-ATA
https://qrs.ly/9sbpnki Education for Health
• This is one of the potent methodologies for information
Dr. Mann dissemination. It promotes the partnership of both the family
members and health workers in the promotion of health as well
as prevention of illness.
Locally Endemic Disease Control
• The control of endemic disease focuses on the prevention of its
occurrence to reduce morbidity rate. Example Malaria control
and Schistosomiasis control
Expanded Program on Immunization RESPONSIBILITY OF MOBILIZATION

Level Party Responsible
• This program exists to control the occurrence of preventable
Secretary of health/ Deputy of Public
illnesses especially of children below 6 years old. National Level
Health
Maternal and Child Health and Family Planning Regional Level Regional Health Director
• The mother and child are the most delicate members of the Provincial/City
Provincial Health Director
community. So the protection of the mother and child to illness Level
and other risks would ensure good health for the community. Level Party Responsible
• The goal of Family Planning includes spacing of children and District Level Chief of District Hospital
responsible parenthood. Municipal Level Municipal Health Officer
Environmental Sanitation and Promotion of Safe Water Barangay Level
Rural Midwives/ public health nurse/
Physician of the City Health Department
Supply
• Environmental Sanitation is defined as the study of all factors in
COMPARISON WITH TRADITIONAL HEALTHCARE
the man’s environment, which exercise or may exercise
deleterious effect on his well-being and survival. Water is a basic PRIMARY HEALTH
DIMENSION TRADITIONAL
need for life and one factor in man’s environment. Water is CARE
necessary for the maintenance of healthy lifestyle. Safe Water Development of
Goal Absence of disease
and Sanitation is necessary for basic promotion of health. preventive health care
Focus of
Nutrition and Promotion of Adequate Food Supply care
The sick The well and early sick
• One basic need of the family is food. And if food is properly Urban-based
prepared then one may be assured healthy family. There are Setting for Rural based satellite
hospital, clinics,
many food resources found in the communities but because of services clinics
homes
faulty preparation and lack of knowledge regarding proper food Active recipients in
planning, Malnutrition is one of the problems that we have in the Passive recipients
People health care
country. of health care
development
Treatment of Communicable Diseases and Common Illness Health is isolated
Health is an integral
• The diseases spread through direct contact pose a great risk to Structure part of socioeconomic
from other sectors
those who can be infected.TB is one of the communicable development
diseases continuously occupies the top ten causes of death. Most Decision making is Decision making is
Process
communicable diseases are also preventable. The Government from top to down from bottom-up
focuses on the prevention, control and treatment of these Curative services
Promotive and
illnesses. based on modern
progressive services
medicine
Supply of Essential Drugs Sophisticated
blending traditional
• This focuses on the information campaign on the utilization and with modern medicine
technology
acquisition of drugs Technology
Acceptance of
BASIC REQUIREMENTS FOR A SOUND PHC indigenous
1. Appropriateness 7. Accountability Doctor dominated practitioners
2. Availability 8. Assessibility Appropriate technology
3. Adequacy 9. Completeness for frontline care
4. Accessibility 10. Comprehensiveness Self-reliance
5. Acceptability 11. Continuity Locally and
Reliance on Health
6. Affordability Outcome economically
Professionals
IMPLEMENTATION OF PHC productive
Self-help
1ST level: Awareness
o advocacy and social preparations to make the community LEVELS OF HEALTH CARE
aware of PHC and its advantages 1. PRIMARY HEALTH CARE
2nd level: Organization • The first contact between the individual and the health system;
o community and its organization can develop by identifying Closest to the people
commands • Essential health care (PHC) is provided
3rd level: Project implementation • A majority of prevailing health problems can be satisfactorily
o what projects to pursue, what resources are needed and where managed
to obtain resources • Provided by primary health centers
4th level: Maintenance and Sustainability
2. SECONDARY HEALTH CARE – First Referral Level
o towards self-determination and self-reliance
• More complex problems are dealt with
TYPES OF PHC WORKERS: • Comprise curative services
• Provided by the district hospital
1. Village or Grassroots Health workers
o Trained community health workers, health volunteers, 3. TERTIARY HEALTH CARE
traditional birth attendants • Other specialist care
2. Intermediate Level of Health Workers • Provided by regional/central level institutions
o Provide support to frontline health workers • Provide training programs
o General practitioners or their assistants, public health nurses,
midwives SUPPLEMENT: CONCEPT OF MANAGED CARE
3. First line Level Personnel MANAGED CARE
o Physicians with specialties, Nurses, Dentists, Pharmacists • An organized system of health care delivery, offering a
comprehensive set of benefits, in which members are
SOCIAL MOBILIZATION PROCESS voluntarily enrolled, and paying for a fixed prepaid period
• It is a dynamic process of engaging people in community action A. Health Maintenance Organization
for a common goal. o Prepaid services
• Components: o It is an agreement entered wherein the organization will
o Advocacy shoulder the comprehensive health care service s to patient
o Information, communication and Education enrolled in their plan
o Training o Physician received fixed amount to provide specifically
o Community Organizing defined care and services
o Networking o Fixed payment per enrollee is received regardless of use.
B. Preferred Provider Organizations End hunger, achieve food security and improved nutrition
2
o System that comprises a panel of health care providers and and promote sustainable agriculture
includes physicians, hospitals, diagnostic centers, and other Ensure healthy lives and promote well-being for all at all
3
entities to form a contractual health team concept ages
o Fee schedule for each service is negotiated and agreed upon Ensure inclusive and equitable quality education and
4
before the service is provided promote lifelong learning opportunities for all
o Cost effective health care is encouraged Achieve gender equality and empower all women and
5
girls
Ensure availability and sustainable management of water
DEVELOPMENT GOALS 6
and sanitation for all
MILLENNIUM DEVELOPMENT GOALS Ensure access to affordable, reliable, sustainable and
• Are eight goals that all 191 UN member states have agreed 7
modern energy for all
to try to achieve by the year 2015. Promote sustained, inclusive and sustainable economic
• Some Achievements: 8 growth, full and productive employment and decent work
o Globally, the HIV, TB and malaria epidemics were turned for all
around Build resilient infrastructure, promote inclusive and
o Child mortality decreased by 53% – a great achievement, but 9
sustainable industrialization and foster innovation
fell short of the 67% target 10 Reduce inequality within and among countries
o Deaths related to pregnancy and childbirth (maternal Make cities and human settlements inclusive, safe,
mortality) fell by more than 40% but short of the 75% target 11
resilient and sustainable
o Between 1990 and 2015, the global prevalence of underweight 12 Ensure sustainable consumption and production patterns
among children aged less than 5 declined from 25% to 14%. Take urgent action to combat climate change and its
13
impacts
Conserve and sustainably use the oceans, seas and marine
14
resources for sustainable development
Protect, restore and promote sustainable use of
terrestrial ecosystems, sustainably manage forests,
15
combat desertification, and halt and reverse land
degradation and halt biodiversity loss
Promote peaceful and inclusive societies for sustainable
development, provide access to justice for all and build
16
effective, accountable and inclusive institutions at all
levels
MDG 1: ERADICATE EXTREME POVERTY AND HUNGER Strengthen the means of implementation and revitalize
17
MDG 2: ACHIEVE UNIVERSAL PRIMARY EDUCATION the global partnership for sustainable development
MDG 3: PROMOTE GENDER EQUALITY AND EMPOWER
WOMEN
MDG 4: REDUCE CHILD MORTALITY SDG VISUAL MNEMONIC
MDG 5: IMPROVE MATERNAL HEALTH https://qrs.ly/qhcqqtm
MDG 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
MDG 7: ENSURE ENVIRONMENTAL SUSTAINABILITY
MDG 8: DEVELOP A GLOBAL PARTNERSHIP DEVELOPMENT
UNIVERSAL HEALTH CARE ACT
MDG VISUAL MNEMONIC • Republic Act No. 11223, otherwise known as the Universal
https://qrs.ly/jncqqru Health Care Act
OBJECTIVES OF THE LAW

• Progressively realize universal health care in the country
SUSTAINABLE DEVELOPMENT GOALS through systematic approach and clear delineations of roles of
• In September 2015, more than 150 world leaders gathered at key agencies and stakeholders towards better performance in
United Nations Headquarters to formally adopt the new post- the health system
2015 development agenda – a global plan of action for the next • Ensure that all Filipinos are guaranteed equitable access to
15 years (2030) quality and affordable health care goods and services, and
• 17 Sustainable Development Goals (SDGs) and 169 targets protected against financial risk.
• SDGs seek to build on the MDGs and complete what these did not
achieve, particularly on improving equity to meet the needs of KEY FEATURES OF THE LAW
women, children and the poorest, most disadvantaged people • Financing
• aim to tackle emerging challenges including the growing impact • Service Delivery
of non-communicable diseases, like diabetes and heart • Local Health System
disease, and the changing social and environmental • Regulation
determinants that affect health, such as increasing urbanization, • Governance and Accountability
pollution and climate change
FINANCING
• Membership
o Automatic inclusion of every Filipino into the National Health
Insurance Program
o Simplification of Philhealth membership into:
§ Direct Contributors
§ Indirect Contributors
• Financing Source
o Pooling of funds from Sin Tax, PAGCOR, PCSO, premium, DOH
annual appropriations, and national government subsidy to
DOH and PhilHealth
1 End poverty in all its forms everywhere o Population-based health services financed by the DOH
o Individual-based health services financed by PhilHealth
• Entitlement to Benefits HISTORY
o Free of charge at point services for population-based health • THE call to serve the rural indigents echoed since the early '60s
services when the Philippine Medical Association introduced the MARIA
o Immediate eligibility for health benefit package under National Project which prioritized aid to communities in need of medical
Health Insurance Program assistance.
o No Philhealth Identification Card required • The Project would then be considered a valuable precursor to
o No co-payment for services in basic/ward accommodation the Medicare program, from which a medical care plan for the
entire Philippines was created.
SERVICE DELIVERY o On August 4, 1969, Republic Act 6111 or the Philippine Medical
• Delivery of Health Services Care Act of 1969 was signed by President Ferdinand E. Marcos
o Contracting of province-wide and city-wide health system for which was eventually implemented in August 1971.
population based health services by the DOH with the • The public's clamor for a health insurance that is more
following. Minimum requirements: comprehensive in terms of covered population and benefits led
§ Primary care provider network to the development of House Bill 14225 and Senate Bill 01738
§ Epidemiologic surveillance system which became The National Health Insurance Act of 1995 or
§ Health promotion programs Republic Act 7875, signed by President Fidel V. Ramos on
• Human Resources for Health February 14, 1995.
o Implementation of a National Health Human Resource Master o The law paved the way for the creation of the Philippine
Plan to provide appropriate health workforce based on Health Insurance Corporation (PhilHealth), mandated to
population health needs provide social health insurance coverage to all Filipinos in 15
o National Health Workforce Support System to assist LGU’s in years' time.
human health resource needs
o Expansion of existing and new allied and health-related degree MANDATE
and training programs • The National Health Insurance Program was established to
o Return Service Agreement for all allied and health related provide health insurance coverage and ensure affordable,
government funded scholars for at least three (3) years with acceptable, available and accessible health care services for
compensation all citizens of the Philippines.
• It shall serve as the means for the healthy to help pay for the care
LOCAL HEALTH SYSTEM of the sick and for those who can afford medical care to subsidize
• Integration of health system into province-wide and city-wide those who cannot.
health system
• Pooling and management of all resources intended for health MEMBERSHIP
into a “Special Health Fund” in a province-wide or city-wide
health system PhilHealth Membership Programs
See next page
REGULATION
QUALIFIED DEPENDENTS OF PHILHEALTH
• Establishment of performance-based incentive and scheme for
• Legitimate spouse who is not a member
health facilities
• Child or children - legitimate, legitimated, acknowledged and
• Licensing and regulatory system for stand-alone health facilities
illegitimate (as appearing in birth certificate) adopted or
• Formulation of standards for clinical care in cooperation of DOH
stepchild or stepchildren below 21 years of age, unmarried and
with professional societies and academe
unemployed.
• Institutionalization of Health Technology Assessment for
• Children who are twenty-one (21) years old or above but
development of policies and programs, regulation, and
suffering from congenital disability, either physical or mental, or
determination of range of entitlements
any disability acquired that renders them totally dependent on
the member for support, as determined by the Corporation;
GOVERNANCE AND ACCOUNTABILITY
• Foster child as defined in Republic Act 10165 otherwise known
• Submission of health and health-related data to Philhealth as a as the Foster Care Act of 2012;
requirement for all public and private, national and local health • Parents who are sixty (60) years old or above, not otherwise an
related entities enrolled member, whose monthly income is below an amount to
• Health Impact assessment as requisite for policies, programs be determined by PhilHealth in accordance with the guiding
and projects principles set forth in the NHI Act of 2013
• Health information System as requisite for all health service • Parents with permanent disability regardless of age as
providers and insurers determined by PhilHealth, that renders them totally dependent
Mahirap man, wala parin tatalo sa pagbasa ng buong text ng batas! Kahit on the member for subsistence
isang pasada lang please? Go basahin mo na J… Scan mo na dali!
It is important to remember that qualified dependents must be declared
by the principal member. Their names must be listed under the principal
member's Member Data Record (MDR) to ensure hassle-free benefits
availment.
Dr. Mann
SUPPLEMENT: COVERAGE OF PHILHEALTH BENEFITS

SIGNED UHC ACT IMPLEMENTING RULES
AND REGULATIONS MEMBER: 45 days/calendar year (exclusive for the member)
https://qrs.ly/labpozr
(IRR) DEPENDENTS: Qualified dependents shall be entitled to a
https://qrs.ly/drbpqrc separate coverage of up to 45 days per calendar year.
Dr. Mann However, the 45 days allowance shall be shared among them.
PHILHEALTH SUPPLEMENT: HOW CAN ONE AVAIL BENEFITS

• Philippine Health Insurance Corporation • Must be an active PhilHealth member with updated payment
• Government Owned and Controlled Corporation • Must be attended by an accredited doctor and service must
• It is a “Social Health Insurance” be provided by a PhilHealth accredited Health Care
• Financial Risk Protection Institution (HCI)
• National Health Insurance Act of 2013 • Availment is within the 45-day annual allowance for
• RA 7875 as amended by RA 9241 and 10606 members and another 45 days for qualified dependents
• Tax-exempt Government Corporation
RANGE OF BENEFITS/PACKAGES • Availment condition: Member must have six (6) months
contributions preceding the three months qualifying
A. INPATIENT BENEFITS contributions within the 12-month period prior to the first day
• Benefits for sickness or ailments that need confinement of NOT of confinement
less than 24 hours • Documents needed: copy of Member Data Record or PhilHealth
• These benefits are paid to the accredited Health Care Institution Benefit Eligibility Form (PBEF) and duly
(HCI) through All Case Rates accomplished PhilHealth claim form 1
• The case rate amount shall be deducted by the HCI from the • Subsidies for hospital room and board fees, drugs and
member’s total bill, which shall include professional fees of medicines, x-ray and other laboratory exams, operating room
attending physicians, prior to discharge and professional fees for confinements of not less than 24 hours
• The case rate amount is inclusive of hospital charges and EXCEPT if:
professional fees of attending physician o (1)the case is an emergency
o (2) patient is transferred to another hospital
o (3) the patient expired
MEMBERSHIP
PhilHealth Membership Programs

DIRECT CONTRIBUTORS INDIRECT CONTRIBUTORS
Formal Informal Lifetime Indigent
Sponsored Members Senior Citizen
Economy Economy Members Members
Employees in Workers not Individuals aged Members of the informal Persons who Filipino citizens
the government covered 60 years and economy from the lower have no visible who are residents
and private by formal contracts above * income segment who do not means of income, of the Philippines,
sectors and whose premium qualify for full subsidy under or whose income aged sixty (60)
contributions are Uniformed the means test rule of the is insufficient for years or above and
All other self-paid or personnel aged DSWD, whose premium family are not currently
workers subsidized 56 years and contribution shall be substinence, as covered by any
rendering above* subsidized by the LGUs or shall identified by the membership
services, Migrant workers be through cost-sharing DSWD based on category of
whether in (documented or SSS underground mechanisms between/among specific criteria PhilHealth;
government or undocumented miner-retirees LGUs, and/or legislative
private offices Overseas Filipino aged 55 years sponsors, and/or other Qualified
such as job Workers: Sea-based above* sponsors and/or the member, dependents of
order and Land based) including the National senior citizen
contractors, SSS and GSIS Government members who are
project-based Informal sector- pensioners prior also senior citizen
contractor street hawkers, to March 4, 1995* -Orphans, abandoned themselves
market vendors, (children who have no known
Owners of pedicab and tricycle *Which and have family willing and capable to Qualified
micro drivers, small paid take care of them and are dependents of
enterprises, construction at least 120 under the care of the DSWD, members belonging
workers, and monthly orphanages, churches and to other
Owners of homebased contributions other institutions) and abused membership
small, medium industries and with PhilHealth minors, out-of-school youths, categories, with or
and large services and the former street children, persons with without coverage
enterprises Medicare disability (PWD), senior who are senior
Self-Earning Programs of SSS citizens and battered women citizens themselves
Household individuals and GSIS under the care of the DSWD, or
helpers (Professionals) any of its accredited Senior Citizens who
institutions run by NGOs or are gainfully
Family Drivers Filipinos with dual any non-profit private employed or who
citizenship organizations, whose remain to have
premium contributions shall regular sources of
Naturalized Filipino be paid for by the DSWD income shall
citizens continue to pay
Barangay health workers, their premium
Citizens of other nutrition scholars, barangay contributions to
countries and/or tanods, and other barangay PhilHealth under
residing in the workers and volunteers, the applicable
Philippines whose premium contributions membership
shall be fully borne by the categories
LGUs concerned
Un-enrolled women who are •

about to give birth, whose
premium contributions shall
be fully borne by the National
Government and/or LGUs
and/or legislative sponsors or
the DSWD if such woman is an
indigent as determined by it
through the means test
https://www.philhealth.gov.ph/circulars/2014/circ33_2014.pdf https://www.philhealth.gov.ph/members/#gsc.tab=0
BTW doc kung ikaw ay senior citizen na working pa at contributing to PhilHealth you can continue contributing hanggat kaya, you will be
categorized as a LIFETIME MEMBER kung meron kang at least 120 monthly contributions, iba ito sa category of as SENIOR CITIZEN just
by age. Do not confuse LIFETIME MEMBERSHIP VS SENIOR CITIZEN MEMBERSHIP. Yung lifetime membership na earn mo as a contributor;
Senior Citizen membership, binigay sayo ng Batas which is RA #10645
Dr. Mann
B. OUTPATIENT BENEFITS DOH HEALTH PROGRAMS

1. Day surgeries (ambulatory or outpatient surgeries)
2. Radiotherapy
3. Hemodialysis DOH HEALTH PROGRAMS
4. Outpatient Blood Transfusion https://qrs.ly/8ycqqts
5. Primary Care Benefit (PCB)
6. Expanded Primary Care Benefit (EPCB) Dr. Mann
C. Z BENEFITS NATIONAL TUBERCULOSIS TB CONTROL

• Benefits designed for illnesses that are life- threatening and PROGRAM
requires prolonged hospitalization, extremely expensive
SUPPLEMENT: THE END TB STRATEGY (WHO)
therapies or other treatments that can deplete family’s financial
resources, unless covered by special health insurance policies
o Acute Lymphocytic / Lymphoblastic Leukemia
o Breast Cancer (Stage 0 to IIIA)
o Prostate Cancer
o End-stage renal disease eligible for requiring kidney
transplantation
o Coronary Artery Bypass Graft Surgery
o Surgery for Tetralogy of Fallot in Children
o Surgery for Ventricular Septal Defect
o Cervical Cancer
o Z- MORPH
§ Mobility
§ Orthosis
§ Rehabilitation For more information about the END TB strategy please scan this QR
§ Prosthesis Help code (Recently Identified source for TB exam questions) Tip: try to be
familiar with the PILLARS and PRINCIPLES.
o Expanded Z- MORPH (Orthopedic Implants)
o Peritoneal Dialysis for End stage Renal Disease
o Colon and Rectum Cancer THE END TB STRATEGY
o Prevention of Preterm Delivery https://qrs.ly/nhbpnc7
o Children with Developmental Disabilities
o Children with Mobility Impairment
Dr. Mann
o Children with Visual Disabilities
o Children with Hearing Impairment Perfect attendance lagi ang topic ng TB sa board exam, so it is prudent
for us to study this not just for the boards but also for our future patients.
D. SDG RELATED BENEFITS The latest Manual of Procedures (MOP) was last updated 2020 and this is
adopted based from the END TB strategy of WHO, there is emphasis on
• Benefits in line with 3 Millennium Development Goals of patient-centered care (PCC)
reducing child mortality, improving maternal health and
combating HIV and other infectious disease. MANUAL OF PROCEDURES
o Outpatient Malaria Package OF THE NATIONAL TUBERCULOSIS
o Outpatient HIV-AIDS Package CONTROL PROGRAM 6TH EDITION
o Outpatient Anti-Tuberculosis treatment through DOTS (2020)
Package https://qrs.ly/mebplqj
Dr. Mann
o Voluntary Surgical Contraception Procedures
• Tuberculosis or TB is an infectious disease caused by the
o Animal Bite Treatment Package
bacteria called Mycobacterium tuberculosis.
• It is transmitted from a TB patient to another person through
SUPPLEMENT: NBB: NO BALANCE BILLING
• coughing, sneezing and spitting.
• No other fees or expenses shall be charged or be paid by the • Thus, close contacts, especially household members, could be
indigent patients above and beyond the. Packaged rates infected with TB. Lungs are commonly affected but it could also
during their confinement period affect other organs such as the kidney, bones, liver and others.
• NBB PATIENTS • TB is curable and preventable. However, incomplete or
o Indigents irregular treatment may lead to drug-resistant TB or even death
o Sponsored
o Domestic worker or Kasambahay SUPPLEMENT: POLICIES IN DIAGNOSIS
o Senior Citizen
• A rapid diagnostic test (RDT), such as Xpert MTB/RIF,
o Lifetime members
shall be the primary diagnostic test for PTB and EPTB in
• BENEFITS COVERED adults and children
o All case rates • All presumptive TB patients who are at high risk for MDR-TB
o Z Benefit packages shall be referred for Xpert MTB/ RIF testing. If not accessible,
o Primary care benefit a sputum transport system shall be used or patient shall be
o Other covered benefits referred to the nearest health facility with DR-TB services for
§ MERS-CoV screening
§ Ebola Virus Disease • Smear microscopy/SM (whether brightfield or fluorescence
• Health Care Institution Covered microscopy) or loop mediated isothermal amplification (TB
o All accredited government health care institutions (HCis) LAMP) shall be the alternative diagnostic test if Xpert is not
including all levels of hospitals and other health facilities accessible. Unavailability of Xpert MTB/RIF test shall not be
(e.g., ambulatory surgical clinics, freestanding dialysis a deterrent to diagnose TB disease bacteriologically
clinics, infirmaries, dispensaries, birthing homes, DOTS • TB LAMP may be utilized to process large sample loads
Centers, PD Centers, PCB providers, OHAT providers). especially in ACF activities, but not for children, PLHIV and
MDR-TB risk groups
• If bacteriologic testing is negative or not available/accessible,
THE REVISED IMPLEMENTING RULES
patients shall be evaluated by the health facility physician
AND REGULATIONS OF THE
who shall decide on clinical diagnosis based on best clinical
NATIONAL HEALTH INSURANCE ACT
judgment
OF 2013
https://qrs.ly/4cbpqrx
• Tuberculin skin test (TST), also known as purified protein replace smear microscopy, especially in remote areas. But it
derivative (PPD) test or Mantoux test, shall be used only as cannot detect rifampicin resistance and there is limited
an adjuvant when there is doubt in making a clinical evidence of performance in comparison to Xpert MTB/RIF in
diagnosis of TB in children. Either 5-TU or 2-TU strength children and PLHIV who have more smear negative
may be used (TU- Tuberculin Units) pulmonary TB.
• Trained health workers shall do the testing and reading of • Smear microscopy (SM) is a conventional test that serve as a
TST. An induration of at least 10 mm regardless of bacille basis for the diagnosis of TB cases. This is also used: a) to
Calmette-Guerin (BCG) vaccination status or 5 mm in monitor progress of patients with TB while they are on anti-
immunocompromised children (e.g. severely TB treatment; and, b) confirm cure at the end of treatment in
malnourished) is considered a positive TST reaction drug-sensitive TB cases.
• TB culture and the drug susceptibility test (DST) using solid
• Xpert MTB/RIF assay is a new test that is revolutionizing tuberculosis
(Ogawa or Lowenstein Jensen) or liquid media (MGIT) is used
(TB) control by contributing to the rapid diagnosis of TB disease and
drug resistance. The test simultaneously detects Mycobacterium in diagnosis and monitoring of the treatment response for
tuberculosis complex (MTBC) and resistance to rifampin (RIF) in less DR-TB under the NTP. It is also used for TB prevalence
than 2 hours. In comparison, standard cultures can take 2 to 6 weeks surveys, drug resistance surveillance, research and other
for MTBC to grow and conventional drug resistance tests can add 3 special cases.
more weeks. • Adjuvant diagnostic tools
• Xpert MTB/RIF assay is a nucleic acid amplification (NAA) test that • Chest X-rays are useful tools to aid diagnosis of TB when the
uses a disposable cartridge with the GeneXpert Instrument System. A
sputum sample is collected from the patient with suspected TB. The
TB disease cannot be confirmed with bacteriological
sputum is mixed with the reagent that is provided with the assay, and diagnostic tools. However, it has low specificity and does not
a cartridge containing this mixture is placed in the GeneXpert machine differentiate DS-TB from DR-TB.
• Additionally, the Xpert MTB/RIF assay can quickly identify possible • Tuberculin skin test (TST) is a basic screening tool for TB
multidrug-resistant TB (MDR TB). MDR TB is TB that is resistant to infection among children using purified protein derivative
both isoniazid (INH) and RIF, two of the most effective TB drugs. RIF (PPD) tuberculin solution to trigger a delayed
resistance is a predictor of MDR TB because resistance to RIF, in most hypersensitivity reaction among those previously infected. It
instances, co-exists with resistance to INH. Rapid diagnosis of RIF is also known as the PPD test or Mantoux test. TST may be
resistance potentially allows TB patients to start on effective treatment
used as an adjuvant tool when a physician has doubts in
much sooner than waiting for results from other types of drug
susceptibility testing making a clinical diagnosis of TB in children. However, TST
CDC can be false-positive (e.g. among recently BCG-vaccinated) or
SUPPLEMENT: DIFFERENT TB diagnostic tools false-negative (e.g. in immunocompromised children;
children with HIV/AIDS, severe malnutrition). But it is not a
• Primary diagnostic tools
mandatory tool and the absence of TST test should not be a
• Rapid molecular diagnostic tests endorsed by the WHO will
deterrent in making a diagnosis of TB or in starting TB
be utilized by the NTP. Currently, WHO-endorsed available
preventive treatment. WHO-recommended TST tests are
diagnostic tests in the country are Xpert MTB/ RIF, line probe
either five tuberculin units (TU) of tuberculin-purified
assay (LPA) and TB LAMP. Xpert MTB/RIF is an automated
protein derivative (PPD-S) or 2 TU of tuberculin PPD RT23,
molecular assay and is a rapid test that detects
which give similar reactions in children infected with MTB.
Mycobacterium tuberculosis (MTB) and rifampicin resistance.
An induration of > 5 mm in children with immunosuppressed
Xpert Ultra is a newer generation of Xpert MTB/RIF assay.
conditions, such as HIV or severe malnutrition, or >10 mm in
Due to its higher sensitivity than that of Xpert MTB/RIF,
other children regardless of BCG vaccination status is defined
specificity is slightly lower.
as TST positive.
• TB-LAMP is a manual molecular assay that can be read with
the naked eye under ultraviolet light to detect MTB and can
OLD CLASSIFICATIONS OF TB DISEASE
TB DISEASE CLASSIFICATION BASED ON ANATOMICAL SITE AND BACTERIOLOGICAL STATUS
ANATOMICAL BACTERIOLOGICAL
DEFINITION OF TERMS
SITE STATUS
A patient with at least one (1) sputum specimen positive for AFB,
Smear- positive with or without radiographic abnormalities consistent with active
TB
Bacteriologically- A patient with positive sputum culture for MTB complex, with or
Culture- positive
confirmed without radiographic abnormalities consistent with active TB
A patient with sputum positive for
Rapid diagnostic
MTB complex using rapid diagnostic modalities such as Xpert
test-positive
MTB/RIF, with or without radiographic abnormalities consistent
A patient with two (2) sputum specimens negative for AFB or MTB, or with smear not done
due to specified conditions but with radiographic abnormalities consistent with active TB;
and there has been no response to a course of empiric antibiotics and/or symptomatic
medications; and who has been decided (either by the physician and/or TBDC) to have TB
PULMONARY
disease requiring a full course of anti-TB chemotherapy
(PTB)
OR
A child (less than 15 years old) with two (2) sputum specimens negative for AFB or with
smear not done, who fulfills three (3) of the five (5) criteria for disease activity (i.e., signs
Clinically-
and symptoms suggestive of TB, exposure to an active TB case, positive tuberculin test,
diagnosed
abnormal chest radiograph suggestive of TB, and other laboratory findings suggestive of
tuberculosis); and who has been decided (either by the physician and/or TBDC) to have TB
disease requiring a full course of anti-TB chemotherapy
OR
A patient with laboratory or strong clinical evidence for HIV/AIDS with two (2) sputum
specimens negative for AFB or MTB or with smear not done due to specified conditions but
who, regardless of radiographic results, has been decided (either by physician and/or TBDC)
to have TB disease requiring a full course of anti-TB chemotherapy.
Bacteriologically- A patient with a smear/culture/rapid diagnostic test from a biological specimen in an extra-
EXTRA- confirmed pulmonary site (i.e., organs other than the lungs) positive for AFB or MTB complex
PULMONARY A patient with histological and/or clinical or radiologic evidence consistent with active
Clinically-
(EPTB) extra-pulmonary TB and there is a decision by a physician to treat the patient with anti-TB
diagnosed
drugs
National Tuberculosis Control Program Manual of Procedures, 5th ed
TB PATIENT CLASSIFICATION (2020) • For those with risk for MDR-TB and found to have rifampicin
• Based on bacteriological status: resistance on Xpert, another sputum sample is collected for (1)
o Bacteriologically confirmed – biological specimen yields a baseline culture, (2) phenotypic drug susceptibility testing,
positive result by smear, culture, or rapid diagnostic tests and (3) second-line probe assay (LPA) drug-susceptibility test
(Xpert)
o Clinically diagnosed – a TB patient who fails to fulfill the SUPPLEMENT: GIBBUS DEFORMITY
criteria for bacteriological confirmation, but has been • Form of structural kyphosis typically found in the
diagnosed by a physician and has been decided by that upper lumbar and lower thoracic vertebrae, where one or
physician to take a full course of anti-TB chemotherapy more adjacent vertebrae become wedged.
• Based on drug resistance: • Gibbus deformity most often develops in young children as a
o Monoresistant TB – resistance to one first line anti-TB drug result of spinal tuberculosis and is the result of collapse
only (Isoniazid, Pyrazinamide, or Ethambutol) but not of vertebral bodies.
Rifampicin (also take note that Streptomycin is now
considered a second-line TB drug)
o Polydrug resistant TB – resistance to more than one first line
drug (but not both Isoniazid and Rifampicin)
o Multi-drug resistant TB (MDRTB) – resistance to at least both
Isoniazid and Rifampicin
o Extensively drug-resistant TB (XDRTB) – resistance to any
fluoroquinolone, AND resistance to at least one of three
second-line injectable aminoglycosides (amikacin,
streptomycin), in addition to being MDRTB
o Rifampicin-resistant TB (RR-TB) – resistance to Rifampicin https://www.researchgate.net/figure/Gibbus-formation-in-the-thoraco-lumbar-region-of-a-patient-with-spinal-
tuberculosis_fig1_51835255
detected using phenotypic or genotypic methods, with or
without resistance to other anti-TB drugs Pott disease or Tuberculous spondylitis is a form of skeletal TB: most
commonly affects the lower thoracic and upper lumbar region;
involvement of cervical and upper thoracic region is less common. So
NOMENCLATURE CODE FOR XPERT RESULTS kapag meron kang Pott disease and nag progress siya to affect 2
T MTB detected, Rifampicin resistance not detected adjacent vertebral body, you can have your Gibbus deformity, so
RR MTB detected, Rifampicin resistance detected basically after math siya ng Pott disease.
TI MTB detected, Rifampicin resistance indeterminate Please be reminded that Gibbus is not only associated with Pott
N MTB not detected disease (which is a form of an acquired deformity) pwede siya from
I Invalid/no result/error congenital causes like achondroplasia, cretinism and some
mucopolysaccharidoses.
• For patients with MTB but without rifampicin resistance, they are UpToDate: Skeletal Tuberculosis
classified as DS-TB https://radiopaedia.org/articles/gibbus-deformity
Dr. Mann
OLD RECOMMENDED TREATMENT REGIMEN FOR ADULTS AND CHILDREN

CATEGORY OF
CLASSIFICATION AND REGISTRATION GROUP TREATMENT REGIMEN
TREATMENT
Pulmonary TB, new (whether bacteriologically- confirmed or
clinically-diagnosed)
Category I 2HRZE/4HR
Extra-pulmonary TB, new (whether bacteriologically-confirmed
or clinically-diagnosed) except CNS/ bones or joints
Category Ia Extra-pulmonary TB, new (CNS/bones or joints) 2HRZE/10HR
Pulmonary or extra-pulmonary, previously treated drug-
susceptible TB (whether bacteriologically-confirmed or
clinically- diagnosed)
• Relapse
Category II 2HRZES/1HRZE /5HRE
• Treatment After Failure
• Treatment After Lost to Follow-up (TALF)
• Previous Treatment Outcome Unknown
• Other
Extra-pulmonary, previously treated drug- susceptible TB
Category IIa (whether bacteriologically- confirmed or clinically-diagnosed - 2HRZES/1HRZE /9HRE
CNS/bones or joints)
ZKmLfxPtoCs
• Individualized
Standard Regimen once DST result
Rifampicin-resistant TB or Multidrug-resistant TB
Drug-resistant (SRDR) is available
• Treatment
duration for at least 18 months
Individualized based on DST result and
XDR-TB Regimen Extensively drug-resistant TB
history of previous treatment
Legend: R - Rifampicin, H - Isoniazid, E - Ethambutol, Z - Pyrazinamide, S - Streptomycin, Km - Kanamycin. Lfx - Levofloxacin, Pto - Prothionamide. C - Cycloserine.
Table No. 10. National Tuberculosis Control Program Manual of Procedures, 5th ed.
MANAGING ADVERSE DRUG REACTIONS DURING TREATMENT

Closely monitor the occurrence of minor and major reactions to drugs, especially during the intensive phase. Manage minor reactions appropriately There are
major side effects that necessitate withdrawal of the responsible drug; hence the need to switch to single-dose formulation (SDF).
Dr. Mann
GUIDE IN MANAGING ADVERSE REACTIONS TO ANTI-TB DRUGS
ADVERSE REACTIONS DRUG(S) PROBABLY RESPONSIBLE MANAGEMENT
MINOR
1. Gastro-intestinal intolerance Rifampicin/Isoniazid/ Pyrazinamide Give drugs at bedtime or with small meals.
2. Mild or localized skin reactions Any kind of drugs Give anti-histamines
3. Orange/red colored urine Rifampicin Reassure the patient
4. Pain at the injection site Streptomycin Apply warm compress. Rotate sites of injection
5. burning sensation in the feet due Give Pyridoxine (Vitamin B6): 50-100 mg daily for
Isoniazid
to peripheral neuropathy treatment, 10 mg daily for prevention.
ADVERSE REACTIONS DRUG(S) PROBABLY RESPONSIBLE MANAGEMENT
Give aspirin or NSAID. If symptoms persist, consider
6. Arthralgia due to hyperuricemia Pyrazinamide gout and request for blood chemistry (uric acid
determination) and manage accordingly.
7. Flu-like symptoms (fever, muscle
pains, inflammation of the Rifampicin Give antipyretics
respiratory tract)
MAJOR
1. Severe skin rash due to Any kind of drugs (especially Discontinue anti-TB drugs and refer to appropriate
hypersensitivity Streptomycin) specialist.
Discontinue anti-TB drugs and refer to appropriate
Any kind of drugs (especially Isoniazid,
2. Jaundice due to hepatitis specialist. If symptoms subside, resume treatment
Rifampicin, and Pyrazinamide)
and monitor clinically.
3. Impairment of visual acuity and Discontinue Ethambutol and refer to an
Ethambutol
color vision due to optic neuritis ophthalmologist.
4. Hearing impairment, ringing of the
Discontinue Streptomycin and refer to appropriate
ear, and dizziness due to damage of Streptomycin
specialist.
the eighth cranial nerve
5. Oliguria or albuminuria due to Discontinue anti-TB drugs and refer to appropriate
Streptomycin/ Rifampicin
renal disorder specialist.
Discontinue Isoniazid and refer to appropriate
6. Psychosis and convulsion Isoniazid
specialist.
Discontinue anti-TB drugs and refer to appropriate
7. Thrombocytopenia, anemia, shock Rifampicin
specialist
Table No. 15. National Tuberculosis Control Program Manual of Procedures, 5th ed.
• Renal Failure
MAJOR AND MINOR o Generally, for renal failure, Isoniazid and Rifampicin do not
SIDE EFFECTS OF TB DRUGS require frequency and dosage adjustments because these two
https://qrs.ly/i8cqqty drugs are eliminated by biliary excretion
o Pyrazinamide, Ethambutol and Streptomycin need to be
adjusted for dosage, and will be administered less frequently.
TREATMENT MODIFICATIONS FOR SPECIAL Streptomycin should be avoided if possible
SITUATIONS o Anti-TB drugs are taken after hemodialysis, not before
TB AND SPECIAL SITUATIONS (DS-TB) • HIV
• Pregnancy o If a patient is found to have HIV and TB co-infection on initial
o First line anti-TB drugs are safe for pregnant women, consult, the priority is to treat TB before HIV
o Rifapentine is avoided due to lack of data on safety for the o In severe life-threatening cases, HAART can be given
fetus concomitantly with anti-TB treatment
o Streptomycin is contraindicated due to its ototoxicity to the o If there is no immediate life-threatening condition, the
fetus following are alternative options for treatment regimens, with
o Pregnant women with TB are given Pyridoxine 25mg/day each taking into account potential drug interactions:
• Breastfeeding § 1 – defer ART until completion of TB treatment (6 months)
o Mothers with TB can still breastfeed, and are encouraged to do § 2 – defer ART until completion of the intensive phase of
so before taking the anti-TB drugs TB treatment (2 months), and then using Ethambutol
o Supplemental vitamin B6 can be given for the infants taking and Isoniazid in the continuation phase
Isoniazid § 3 – treat TB with a Rifampicin-containing regimen, and
• OCP intake for HAART, use only Efavirenz + two NRTIs
o Rifampicin stimulates the hepatic metabolism of OCPs
o This results in the lowering of the efficacy of OCPs for PREVENTION OF TB
contraception, potentially leading to unwanted pregnancies
• Prevention of TB depends largely on preventing exposure and
o In order to adjust, patients are given an oral contraceptive
infection. For vulnerable populations such as young children
preparation with higher doses of estrogen (or they may be
(i.e., 0-4 years old) and people living with HIV (PLHIV) who are
advised to use other forms of contraception)
already exposed or infected, the aim is preventing progression
• Acute liver disease to TB disease.
o Isoniazid, Rifampicin and Pyrazinamide are all associated with
• Prevention of TB can be achieved through the following:
hepatitis
• Universal use of BCG (discussed under the Expanded Program on
o If the TB patient is clinically diagnosed to have hepatitis, or if
Immunization)
liver enzymes are elevated, TB treatment is interrupted when:
• Isoniazid Preventive Therapy (IPT)
either:
o IPT for six (6) months shall be given to the following:
(1) ALT > 3x upper limit of normal, and there are clinical signs
§ Children less than five (5) years old without signs and
and symptoms of hepatitis, or jaundice, OR
symptoms of TB and without radiographic findings
(2) when ALT >5x even in the absence of symptoms
o Anti-TB drugs are gradually reintroduced as LFTs normalize suggestive of TB, and who are household contacts21 of –
and clinical symptoms resolve – A bacteriologically-confirmed TB case regardless of TST
o If LFT monitoring cannot be done, the anti-TB drugs are results; or
reintroduced 2 weeks after the resolution of jaundice and – A clinically-diagnosed TB case (if the child has a positive
upper abdominal pain/tenderness TST result).
o Anti-TB drugs are reintroduced one by one, starting with § PLHIV with no signs and symptoms of TB regardless of age
Rifampicin (the least hepatotoxic), followed by Isoniazid
o Pyrazinamide, the most hepatotoxic, is added last (or NATIONAL DENGUE PREVENTION AND CONTROL
alternatively, totally avoided especially if Rifampicin and PROGRAM
Isoniazid are already tolerated)
• Chronic Liver Disease BACKGROUND
o Pyrazinamide is not given, and a number of alternative • Dengue is the fastest spreading vector-borne disease in the
treatment regimens may be used: world endemic in 100 countries
2SHRE/6HR, or • Dengue virus has four serotypes (DENV1, DENV2, DENV3 and
9RE, or DENV4)
2SHE/10HE
• First infection with one of the four serotypes usually is non- 2. Critical Phase
severe or asymptomatic, while second infection with one of • Phase when patient can either improve or deteriorate.
other serotypes may cause severe dengue. • Defervescence occurs between 3 to 7 days of illness.
• Dengue has no treatment but the disease can be early managed o Defervescence is known as the period in which the body
temperature (fever) drops to almost normal (between 37.5 to
TRANSMISSION 38°C).
• Those who will improve after defervescence will be categorized
• Dengue virus is transmitted by day biting Aedes aegypti and
as Dengue without Warning Signs, while those who will
Aedes albopictus mosquitoes.
deteriorate will manifest warning signs and will be categorized
as Dengue with Warning Signs or some may progress
DENGUE CASE CLASSIFICATION AND LEVEL OF to Severe Dengue.
SEVERITY • When warning signs occurs, severe dengue may follow near
• Dengue illness is categorized according to level of severity as: the time of defervescence which usually happens between 24 to
o A. Dengue without warning signs 48 hours.
o B. Dengue with warning signs 3. Recovery Phase
o C. Severe dengue • Happens in the next 48 to 72 hours in which the body fluids go
• Dengue without warning warnings can be further classified back to normal.
according to signs and symptoms and laboratory tests as: • Patients general well-being improves.
o Suspect dengue • Some patients may have classical rash of “isles of white in the
o Probable dengue sea of red”.
o Confirmed dengue • The White Blood Cell (WBC) usually starts to rise soon after
defervescence but the normalization of platelet counts typically
A. DENGUE WITHOUT WARNING SIGNS happens later than that of WBC.
1. Suspect dengue
• a previously well individual with acute febrile illness of 1-7 days STRATEGIES
duration plus two of the following: • Enhanced 4S Strategy
Headache Body malaise Retro-orbital pain o Aksyon Barangay Kontra Dengue in communities (4S)
Myalgia Arthralgia Anorexia § S - earch and Destroy
Nausea Vomiting Diarrhea § S - eek Early Consultation
Flushed skin Rash (petechial, Hermann’s sign) § S - elf Protection Measures
2. Probable dengue § S - ay yes to fogging only during outbreaks
• a suspect dengue case plus laboratory test: • Please Note that 4S strategy also covers for other water related insect
o Dengue NS1 antigen test vector diseases – Zika and Chikungunya
o CBC (leukopenia with or without thrombocytopenia) or • For the sake of completeness other DOH literature proposes the 5S
dengue IgM antibody test (optional) Strategy which includes SUSTAIN HYDRATION as the 5th S.
Dr. Mann
3. Confirmed dengue
• A suspect or probable dengue case with positive result of any: SUPPLEMENT: ZIKA VIRUS AND PREGNANCY
o Viral culture
o Polymerase Chain Reaction(PCR) • Zika virus infection is a mosquito-borne disease caused by a
o Nucleic Acid Amplification Test- Loop Mediated Amplification flavivirus. This occurs in tropical countries with large
Assay (NAAT-LAMP) mosquito population.
o Plaque Reduction Neutralization Test (PRNT) • Zika virus is transmitted to people through the bite of an
infected mosquito from the Aedes genus, mainly Aedes
B. DENGUE WITH WARNING SIGNS aegypti in urban areas and Aedes albopictus in rural areas.
• Aedes bite aggressively during the day.
• A previously well person with acute febrile illness of 1-7 days
plus any of the following: • This is the same mosquito that transmits Dengue and
o Abdominal pain or tenderness Chikungunya.
o Persistent vomiting • Zika virus can also be transmitted through sex carrying Zika
o Clinical signs of fluid accumulation (ascites) virus unprotected.
o Mucosal bleeding • Zika virus has been detected in blood, urine, amniotic fluids,
o lethargy or restlessness semen, saliva as well as body fluids found in the brain and
o Liver enlargement spinal cord.
o Increase in hematocrit and/or decreasing platelet count • Signs and Symptoms
o fever, conjunctivitis, and skin rash.
o Other symptoms include headache, muscle pain, joint pain,
WARNING SIGNS MNEMONIC pain behind the eyes, and vomiting.
https://qrs.ly/cjcqqu8 o The illness is usually mild and self-limiting with symptoms
lasting for 2-7 days.
• Complications
o Neurological type of complication: Guillain-Barre’
C. SEVERE DENGUE syndrome which is the sudden weakening of muscles.
• Severe plasma leakage leading to o Neonatal malformation: Microcephaly which is a condition
o shock (DSS) where a baby’s head is smaller than those of other babies of
o fluid accumulation with respiratory distress the same age and sex.
• Severe bleeding: as evaluated by clinician • Prevention and Treatment
• Severe organ impairment o Avoid infection by preventing mosquito bites.
o Liver: AST or ALT ≥ 1000 § Use insect repellants.
o CNS: e.g. seizures, impaired consciousness § Use window and door screens.
o Heart and other organs (i.e. myocarditis, renal failure) § Wear long-sleeved shirts and long pants or permethrin
treated clothing.
PHASES OF DENGUE INFECTION § Once a week, empty and scrub, turn over, cover, or throw
out items that hold water, such as tires, buckets, planters,
1. Febrile Phase toys, or trash containers.
• Usually last 2-7 days • People sick with Zika virus should get plenty of rest, drink
• Mild hemorrhagic manifestations like petechiae and mucosal enough fluids, and treat pain and fever with common
membrane bleeding (e.g. nose and gums) may be seen. medicines.
• Monitoring of warning signs is crucial to recognize its • People with signs and symptoms of Zika virus infection
progression to critical phase. should undergo diagnostic test (serology)
RECOGNIZE THE CLINICAL SIGNS OF RABIES IN DOMESTIC
The World Health Organization declared Zika Virus (ZIKV) Disease a
Public Health Emergency of International Concern (PHEIC) on ANIMALS
February 1 ,2016, due to increasing case of microcephaly in Brazil and • Withdrawal from and resistance to contact; seeking seclusion
here in the Philippines. • Wide-eyed; reduced frequency or absence of blinking; dilated
Dr. Mann
pupils; photophobia
• Exaggerated, often aggressive, response to tactile, visual, or
ZIKA VIRUS 101 auditory stimuli
https://qrs.ly/n4bps1n • Snapping/biting at imaginary objects
• Pica (eating or mouthing sticks, stones, soil, clothing, feces, etc)
• Aggressively attacking inanimate objects
• Sexual excitement with attempts to mount inanimate objects
RABIES PREVENTION AND CONTROL PROGRAM • Compulsive running or circling, often to the point of exhaustion
• Obsessive licking, biting, or scratching at the site of viral
• Rabies is a human infection that occurs after a transdermal bite
inoculation
or scratch by an infected animal, like dogs and cats.
• Dropped jaw, inability to swallow, excessive salivation
• It can be transmitted when infectious material, usually saliva,
• Change in tone, timbre, frequency, or volume of vocalizations
comes into direct contact with a victim’s fresh skin lesions.
• Flaccid or deviated tail/penis
• Rabies may also occur, though in very rare cases, through
inhalation of virus-containing spray or through organ • Tenesmus (due to paralysis of the anal sphincter)
transplants. • Muscular tremors
• Acute onset of mono-para-,or quadri-paresis; lameness
RABIES IN THE PHILIPPINES • Abnormal, exaggerated gait; ataxia and incoordination
• Rabies is endemic in the Philippines, and remains to be a public • Convulsive seizures
health concern. • Paralysis, prostration, recumbency
• It has a fatality rate of almost 100%. • Death
• However, being the most fatal among infectious diseases, rabies
Reminder lang doc, signs po ito ng rabid animal hindi ng human patient!
too, is 100% preventable J
• One of the measures by which rabies could be prevented is Dr. Mann
through the implementation of the Republic Act No. 9482, also The Burial Requirement under the Philippine Sanitation Code (PD 856)
called the Anti-Rabies Act of 2007, which mandated the creation Section 91 states that “When the cause of death is a dangerous
of a National Rabies Prevention and Control Program (NRPCP) communicable disease, the remains shall be buried within 12 hours after
death. They shall not be taken to any place of public assembly. Only the
COMPONENTS adult members of the family of the deceased may be permitted to attend
• Mass Dog Vaccination the funeral.” It is highly recommended that early disposal of the body by
o This is the most effective measure to control canine rabies. cremation or burial should be done depending on their religious practice.
The Department of Agriculture takes the lead in mass dog Dr. Mann
vaccination campaigns and provision of animal rabies vaccine.

• Post-Exposure Prophylaxis (PEP) and Pre-Exposure (PrEP) MEDICAL MANAGEMENT OF ANIMAL BITES
o Post Exposure Prophylaxis (PEP) – antirabies prophylaxis • Key steps in medical management of bite wounds:
should be administered after an exposure (such as bite, o Wash with soap and water
scratch, lick, etc). o Liberal irrigation
o Pre-Exposure Prophylaxis (PrEP) – vaccination should be o Debridement of devitalized tissue
given to individuals who are at high risk of getting rabies • If signs of infection are present:
• Health Promotion o Swab for culture
o Celebration of Rabies Awareness Month under Executive o Antibiotic therapy
Order No. 84, March is Rabies Awareness Month • Empirical therapy should be directed against those micro-
• SUPPORT SERVICES organisms most likely to be present for dogs and cats pathogen
• MANAGEMENT AND IMPLEMENTATION STRUCTURE OF such as:
THE NATIONAL RABIES PREVENTION AND CONTROL
PROGRAM
4 R’S IN ANIMAL RABIES RISK ASSESSMENT:
• Recognizing
• Recording
• Reporting
• Referral
CATEGORIES OF RABIES EXPOSURE WITH CORRESPONDING MANAGEMENT
EXPOSURE MANAGEMENT
• Feeding/touching an animal
• Licking of intact skin (with reliable history and thorough
physical examination)
Category I
• Wash exposed skin immediately with soap and water.

• Exposure to patient with signs and symptoms of rabies by
• No vaccine or RIG needed
sharing of eating or drinking utensils
• Pre-exposure prophylaxis may be considered for high risk persons
• Casual contact (talking to, visiting and feeding suspected
rabies cases) and routine delivery of health care to patient
with signs and symptoms of rabies
• Wash wound immediately with soap and water for at least 10
minutes.
• Start vaccine immediately
• Nibbling of uncovered skin with or without
o No human rabies vaccine shall be provided, provided that ALL of
Category II
bruising/hematoma
the following conditions are satisfied:
• Minor/superficial scratches/abrasions without bleeding,
§ Dog/cat is healthy and available for observation for 14 days
including those induced to bleed
§ Dog/cat was vaccinated against rabies for the past 2 years
• All Category II exposures on the head and neck area are
• Complete vaccination regimen until day 7
considered Category III and shall be managed as such.
• No RIG needed
o If the biting animal starts to show signs of rabies, immediately
give vaccine and RIG
EXPOSURE MANAGEMENT
• Transdermal bites (puncture wounds, lacerations,
avulsions) or scratches / abrasions with spontaneous
bleeding
• Licks on broken skin or mucous membrane
• Wash wound with soap and water.
Category III
• Exposure to a rabies patient through bites, contamination of

• Start the vaccine regimen.
mucous membranes (eyes, oral/nasal mucosa, genital/anal
• Complete vaccination regimen until Day 7 regardless of the status
mucous membrane) or open skin lesions with body fluids
of the biting Animal
through splattering and mouth-to-mouth resuscitation.
• Administer RIG immediately after vaccination against rabies.
• Unprotected handling of infected carcass
• Ingestion of raw infected meat
• Exposure to bats
• All Category II exposures on head and neck area
Table 11. National Rabies Prevention and Control Program Manual of Procedures 2019: 78
IMMUNIZATION • Administration
ACTIVE IMMUNIZATION o The total computed RIG shall be infiltrated around and into the
wound as much as anatomically feasible, even if the lesion has
Administration
healed. In case some amount of the total computed dose of RIG
• Vaccine is administered to induce antibody and T-cell
is left after all wounds have been infiltrated, the remaining
production in order to neutralize the rabies virus in the body.
volume of RIG that is not infiltrated into the wound does not
It induces an active immune response in 7-10 days after
need to be injected IM. It may be reserved for the next patient
vaccination, which may persist for years provided that primary
who needs RIG, ensuring aseptic retention of the RIG i.e.
immunization is completed
fractionated in smaller individual syringes
o A gauge 23 or 24 needle, 1 inch length shall be used for
Types of Rabies Vaccines
infiltration. Multiple needle injections into the same wound
• The National Rabies Prevention and Control Program (NRPCP) shall be avoided.
shall provide the following anti-rabies tissue culture vaccines
o Equine immunoglobulin s (eRIG) are clinically equivalent to
(TVC)
human rabies immunoglobulins (hRIG) and are considered
o Purified Vero Cell Rabies Vaccine (PVRV) – 0.5 ml/vial and 1.0
safe and efficacious life- and cost-saving biologics. As ERIG
ml/vial
products are highly purified, skin testing is no longer
o Purified Chick Embryo Cell Vaccine (PCECV) – 1.0 ml/vial
recommended.
LIST OF TCV PROVIDED BY THE NRPCP TO ANIMAL MANAGEMENT OF ADVERSE REACTION

BITE TREATMENT CENTERS WITH CORRESPONDING • Anaphylaxis
PREPARATIONS AND DOSE o Give 0.1% adrenaline or epinephrine (1:1,000 or 1mg/ml)
GENERIC NAME PREPARATION DOSE underneath the skin or into the muscle.
Purified Vero Cell ID – 0.1mL § Adults - 0.5 ml
0.5 mL/vial § Children - 0.01ml/kg, maximum of 0.5 ml
Rabies Vaccine (PVRV) IM – 0.5mL
Verorab® ID – 0.1mL o Repeat epinephrine dose every 10-20 minutes for 3 doses
1.0 mL/vial o Give steroids after epinephrine
IM – 1.0 mL
Purified Chick Embryo ID – 0.1mL • Hypersensitivity reactions
1.0 mL/vial • Give antihistamines, either as single drug or in combination
Cell Vaccine (PCECV) IM – 1.0mL
• If status quo for 48 hrs despite combination of antihistamines,
may give short course (5-7 days) of combined oral
PASSIVE IMMUNIZATION antihistamines plus steroids
• Rabies immune globulins or RIG (also called passive • If patient worsens and condition requires hospitalization or
immunization products) shall be given in combination with becomes life threatening, may give IV steroids in addition to
rabies vaccine to provide the immediate availability of antihistamines
neutralizing antibodies at the site of the exposure before it is
physiologically possible for the patient to begin producing his or WOUND TREATMENT
her own antibodies after vaccination. This is especially • Local wound treatment
important for patients with Category III exposures. RIGs have a o Wounds shall be immediately and vigorously washed and
half-life of approximately 21 days flushed with soap or detergent, and water preferably for 10
o Human Rabies Immune Globulin (HRIG) derived from plasma minutes. If soap is not available, the wound shall be thoroughly
of human donors administered at 20 IU per kilogram body and extensively washed with water.
weight. Available preparation is 2 ml/vial; 150 IU/ml o Apply alcohol, povidone iodine or any antiseptic
o Highly purified antibody antigen binding fragments [F(ab’)2] o Suturing of wounds shall be avoided at all times since it may
produced from equine rabies immune globulin (ERIG) inoculate virus deeper into the wounds. Wounds may be
administered at 40 IU per kilogram body weight. Available capitated using sterile adhesive strips. If suturing is
preparation is 5 ml/vial; 200 IU/ml unavoidable, it shall be delayed for at least 2 hours after
administration of RIG to allow diffusion of the antibody to
LIST OF RABIES IMMUNE GLOBULINS occur through the tissues
GENERIC NAME PREPARATION DOSE o Any ointment, cream or wound dressing shall not be applied to
Human Rabies Immune 150 IU/mL at 20 the bite site because it will favor the growth of bacteria and will
Globulin (HRIG) 2mL/vial IU/kg occlude drainage of the wound, if any
Purified Equine Rabies Immune 200 IU/mL at 40 o Anti-tetanus immunization shall be given, if indicated. History
Globulin (pERIG) 5mL/vial IU/kg of tetanus immunization (TT/DPT/Td) shall be reviewed.
Animal bites are considered tetanus prone wounds.
COMPUTATION AND DOSAGE OF RABIES IMMUNOGLOBULIN Completion of the primary series of tetanus immunization is
recommended
GUIDE TO TETANUS PROPHYLAXIS IN ROUTINE WOUND PERFORMANCE OF NEWBORN SCREENING
MANAGEMENT • Newborn screening shall be performed after twenty-four (24)
VACCINATION HISTORY hours of life but not later than three (3) days from complete
Indication for
Unknown or < 3 delivery of the newborn.
TT 3 or more doses
doses • A newborn that must be placed in intensive care in order to
Immunization
Td* TIG/ATS Td* TIG/ATS ensure survival may be exempted from the 3-day requirement
All Animal but must be tested by seven (7) days of age.
YES YES NO** NO
Bites • It shall be the joint responsibility of the parent(s) and the
*TDaP may be substituted for Td if the person has not received TDaP and is 10 practitioner or other person delivering the newborn to ensure
years or older; DPT may be given for patients < 7 years old; TT may be given if Td that newborn screening is performed.
not available
**Yes, if more than 5 years since last dose SIX DISORDERS THAT ARE COMMONLY SCREENED
• Routine Wound Management • Congenital Hypothyroidism (CH)

• The most common organism isolated from dog and cat bites is • Congenital Adrenal Hyperplasia (CAH)
Pasteurella multocida. • Galactosemia (GAL)
• Other organisms include S. aureus, Bacteroides sp, • Phenylketonuria (PKU)
Fusobacterium and Capnocytophaga. Antimicrobials shall be • Glucose-6-Phosphate-Dehydrogenase Deficiency
recommended for the following conditions: • Maple Syrup Urine Disorder (MSUD)
o All frankly infected wounds January 2012: Inclusion of Maple Syrup Urine Disease (MSUD) in the NBS
o All category III cat bites Panel of Disorders
Dr. Mann
o All other category III bites that are either deep, penetrating,
EXPANDED NEWBORN SCREENING PROGRAM
multiple or extensive or located on the hand/face/genital area
• The expanded newborn screening program will increase the
screening panel of disorders from six (6) to twenty-eight (28).
NATIONAL RABIES PREVENTION This will provide opportunities to significantly improve the
AND CONTROL PROGRAM quality of life of affected newborns through facilitating early
https://qrs.ly/9wbpt2p diagnosis and early treatment
If you a hardcore student you can read the Fact sheets: Information for
DOCTORS about the disorders included in the Expanded Newborn
NEWBORN SCREENING PROGRAM (RA 9288) Screening Panel, included here the description of the disease, clinical
• Republic Act no. 9288 otherwise known as Newborn manifestation, testing, pathophysiology and overview of disease
Screening Act of 2004 management.
• OBLIGATION TO INFORM
o Any health practitioner who delivers, or assists in the delivery,
of a newborn in the Philippines shall, prior to delivery, inform NBS FACT SHEETS
the parents or legal guardian of the newborn of the availability, https://qrs.ly/7obpwc6
nature and benefits of newborn screening.
Dr. Mann
EXPANDED NEWBORN SCREENING PANEL

Disorders included in the Expanded NBS panel and the Metabolites Tested
DISORDER GROUP DISORDER METABOLITE TESTED
Congenital Hypothyroidism CH Thyroid Stimulating Hormone (TSH)
Endocrine Disorder
Congenital Adrenal Hyperplasia CAH 17-hydroxy-progesterone (17 𝛼-OHP)
Homocystinuria HCY Methionine
Hypermethioninemia / Methionine Adenosine Transferase
MAT Methionine
Deficiency
Amino Acid Disorder Maple Syrup Urine Disease MSUD Leucine
Phenylketonuria PKU Phenylalanine
Tyrosinemia Type I Succinylacetone (SA)
TYR
Tyrosinemia Type II, III Tyrosine
Carnitine Palmitoyltransferase I Deficiency CPT 1 Hexadecanoylcarnitine + CPT ratio
Carnitine Palmitoyltransferase II Deficiency CPT 2 Hexadecanoylcarnitine + CPT ratio
Carnitine Uptake Deficiency CUD Free carnitine
Glutaric Acidemia Type II GA II Butyrylcarnitine + Isovalerylcarnitine
Fatty Acid Disorder
Long Chain Hydroxyacyl-CoA Dehydrogenase Deficiency LCHAD 3-Hydroxyhexadecanoylcarnitine
Medium Chain-Acyl-CoA Dehydrogenase Deficiency MCAD Octanoylcarnitine
Very Long Chain-Acyl-CoA Dehydrogenase Deficiency VLCAD Tetradecanoylcarnitine
Tri-functional Protein Deficiency TFP Hydroxyhexadecanoylcarnitine
3-Methylcrotnyl CoA Carboxylase Deficiency 3MCC 3-Hydroxyisovalerylcarnitine
Beta Ketothiolase Deficiency BKT Hydroxyisovalerylcarnitine
Glutaric Acidemia Type I GA I Glutarylcarnitine
Isovaleric Acidemia IVA Isovalerylcarnitine
Organic Acid
Methylmalonic Acidemia MMA Propionylcarnitine
3-Hydroxyisovalerylcarnitine +
Multiple Carboxylase Deficiency MCD
Pronionylcarnitine
Propionic Acidemia PA Propionylcarnitine
Citrullinemia CIT Citrulline
Urea Cycle Defect
Argininosuccinic Aciduria ASA Citrulline
Alpha Thalassemia
Beta Thalassemia
Hemoglobin C
Hemoglobinopathies HgB Hemoglobin
Hemoglobin D
Hemoglobin E
Sickle Cell Disease
Galactosemia GAL Total Galactose
G6PD
Glucose-6-Phosphate Dehydrogenase Deficiency G6PD Enzyme Activity
Others Def
Cystic Fibrosis CF Immunoreactive Trypsine (IRT)
Biotinidase Deficiency BTND Biotinidase enzyme activity
www.newbornscreening.ph
Tip try to familiarize yourselves with the new inclusion, this was asked from the previous boards! And YES cystic fibrosis is included in the expanded newborn
screening panel.
Dr. Mann
UNIVERSAL NEWBORN HEARING SCREENING MEASLES ELIMINATION

PROGRAM • Conducted 4 rounds of mass measles campaign: 1998, 2004,
2007 and 2011.
• Republic Act 9709: Universal Newborn Hearing Screening
• Implemented the 2-dose measles-containing vaccine (MCV) in
Program
2009
o The right time to screen is on or after (≥) 24 hours after
o MCV1 (monovalent measles) at 9-11 months old
birth, before the infant is discharged if hospital born
o MCV2 (MMR) at 12-15 months old
o If the infant is out-of-hospital born then he or she should be
• supplemental immunization campaign for measles and rubella
screened not more than (≤) 3 months of age, regardless
(German measles) was done in 2011.
where they are delivered (includes infants who were hospital
• This was dubbed as “Iligtas sa Tigdas ang Pinas” 15.6 million
born but hearing screening was not done before discharge)
(84%) out of the 18.5 million children ages 9 months to 8 years
old were given 1 dose of the measles-rubella (MR) vaccine
EXPANDED PROGRAM ON IMMUNIZATION between April and June 2011.
• The Expanded Program on Immunization (EPI) was • The Department of Health (DOH), launched the National Ligtas
established in 1976 to ensure that infants/children and Tigdas Supplemental Immunization Activity (SIA) to halt the
mothers have access to routinely recommended ongoing transmission of measles especially among unvaccinated
infant/childhood vaccines. children and pregnant women (NCR 2018)
• Six vaccine-preventable diseases were initially included in the HEPATITIS B CONTROL
EPI:
• Republic Act No. 10152 this bill provides for all infants to be
o tuberculosis
given the birth dose of the Hepatitis-B vaccine within 24 hours
o poliomyelitis
of birth.
o diphtheria
• One strategy to strengthen Hepatitis B coverage is to integrate
o tetanus
birth dose in the Essential Intrapartum and Newborn Care
o pertussis
Package (EINC).
o measles
• The goal of Hepatitis B control is to reduce the chronic hepatitis
• Over-all Goal: To reduce the morbidity and mortality among
B infection rate as measured by HBsAg
children against the most common vaccine-preventable
diseases. A FULLY IMMUNIZED CHILD (FIC):
• Specific Goals: • 1 dose of BCG at birth or any time before reaching 12 months
o To immunize all infants/children against the most common • 3 doses each of Pentavalent vaccines
vaccine-preventable diseases. o Pentavalent Vaccine includes the ff:
o To sustain the polio-free status of the Philippines. (not § Diphtheria
anymore L) § Pertussis
o To eliminate measles infection. § Tetanus
o To eliminate maternal and neonatal tetanus § Hepatitis B
o To control diphtheria, pertussis, hepatitis b and German § Haemophilus influenza B (HiB)
measles. • 3 doses each OPV
o To prevent extra pulmonary tuberculosis among children. • One dose of measles before reaching 12 months
• Mandates: Republic Act No. 10152 “Mandatory Infants and
SCHOOL BASED IMMUNIZATION
Children Health Immunization Act of 2011 Signed by President
Benigno Aquino III in July 26, 2010. • MR and Td (Grade 1 and Grade 7)
• Coverage—The mandatory basic immunization for all infants • Measles, Mumps and Rubella (MMR) and Tetanus-diphtheria
and children provided under this Act shall cover the following (Td) (1st year to fourth year 2013 data)
vaccine-preventable diseases: • Human Papillomavirus (HPV) (female, 9-13 years old, Grade 4)
o Tuberculosis; Parental consent must be secured prior to vaccination, MMR shall not be
o Diphtheria, tetanus and pertussis; given to pregnant female
o Poliomyelitis; Additional note:
o Measles; • Live attenuated vaccines are derived from disease-causing pathogens
that have been weakened under laboratory conditions
o Mumps;
• Inactivated vaccines are made from microorganisms that have been
o Rubella or German measles; killed through physical or chemical processes. These killed organisms
o Hepatitis-B; cannot cause disease.
o H. Influenza type B (HIB); and • Subunit vaccines, like inactivated-whole cell vaccines do not contain
o Such other types as may be determined by the Secretary of live components of the pathogen. They differ from inactivated whole-
Health in a department circular. cell vaccines, by containing only the antigenic (fragment) parts of the
pathogen
INTRODUCTION TO NEW VACCINES • Toxoid based on the toxin produced by the microorganism
Dr. Mann
• For 2012, Rotavirus and Pneumococcal vaccines were
introduced in the national immunization program. SUPPLEMENT: HERD IMMUNITY
• Immunization will be prioritized among the infants of families • A vaccine provides herd immunity if it not only protects the
listed in the National Housing and Targeting System (NHTS) for immunized individual, but also prevents that person from
Poverty Reduction nationwide. transmitting the disease to others.
• The mandatory includes basic immunization for children under
5 including other types that will be determined by the Secretary
of Health.
POLIO ERADICATION
• The Philippines has sustained its polio-free status since October
2000. (2019 the Philippines declared an outbreak of polio,
losing the polio-free status of our country L)
• Department of Health recently announced a Supplemental
Immunization Activity (SIA) starting 19 August 2019 aims to Elmore, Joann G.. Jekel's Epidemiology, Biostatistics and Preventive Medicine
provide an extra dose of Oral Polio Vaccine (OPV) to all [A] In the absence of herd immunity, the number of cases doubles each
disease generation. [B] In the presence of 50% herd immunity, the
children under the age of 5 years regardless of previous polio number of cases remains constant. The plus sign represents an infected
immunizations, residing in NCR, Region 3 (Central Luzon) person; the minus sign represents an uninfected person; and the circled
and Region 4A (Calabarzon) minus sign represents an immune person who will not pass the infection
to others. The arrows represent significant exposure with transmission of
infection (if the first person is infectious) or equivalent close contact
without transmission of infection
BASIS FOR CLASSIFYING THE CHILD’S ILLNESS
• When most of a population is immune to an infectious disease, this
provides indirect protection—or herd immunity (also called herd • The child’s illness is classified based on a color-coded triage
protection)—to those who are not immune to the disease. system:
• Look at the picture above, under the assumption of figure A, if there o PINK- indicates urgent hospital referral or admission
is no herd immunity against the disease, everyone is susceptible, the o YELLOW- indicates initiation of specific Outpatient Treatment
number of cases doubles every disease generation. However, if there o GREEN – indicates supportive home care
is 50% herd immunity against the disease, the number of cases is
small and remains approximately constant.
STEPS OF THE IMCI CASE MANAGEMENT PROCESS
• it is not necessary to have a 100% level of herd immunity to prevent
the occurrence of an epidemic • At the out-patient health facility, the health worker should
• At ang hirap ma-achieve ang 100% bakuna noh. WALANG GANON routinely do basic demographic data collection, vital signs
MARS! taking, and asking the mother about the child's problems.
Elmore, Joann G.. Jekel's Epidemiology, Biostatistics and Preventive Medicine.
Dr. Mann Determine whether this is an initial or a follow-up visit.
• The health worker then proceeds with the IMCI process by
checking for general danger signs, assessing the main symptoms
INTEGRATED MANAGEMENT OF CHILDHOOD and other processes
ILLNESS (IMCI) • Take note that for the pink box, referral facility includes district,
• The Integrated Management of Childhood Illness strategy has provincial and tertiary hospitals.
been introduced in an increasing number of countries in the • Once admitted, the hospital protocol is used in the management
region since 1995. of the sick child.
• IMCI is a major strategy for child survival, healthy growth and
development and is based on the combined delivery of essential
interventions at community, health facility and health systems IMCI CHART BOOKLET
levels. https://qrs.ly/9nbpt0x
• IMCI includes elements of prevention as well as curative and
addresses the most common conditions that affect young
children.
• The strategy was developed by the World Health Organization PHILIPPINE FOOD FORTIFICATION PROGRAM
(WHO) and United Nations Children’s Fund (UNICEF). FORTIFICATION AS DEFINED BY CODEX ALIMENTARIUS
• In the Philippines, IMCI was started on a pilot basis in 1996, • “the addition of one or more essential nutrients to food, whether
thereafter more health workers and hospital staff were or not it is normally contained in the food, for the purpose of
capacitated to implement the strategy at the frontline level. preventing or correcting a demonstrated deficiency of one or
PREVENTABLE AND TREATABLE CONDITIONS: more nutrients in the population or specific population groups”
• Pneumonia • Mandatory Food Fortification
• Diarrhea o (1) Rice-with Iron;
• Malaria o (2) Wheat flour - with vitamin A and Iron;
o (3) Refined sugar-with vitamin A;
• Measles
o (4) Cooking oil- with vitamin A; and
• Malnutrition
o (5) Other staple foods with nutrients as may later be required
Three (3) out of four (4) episodes of childhood illness are caused by these by the NNC.
five conditions
Dr. Mann
CHILDREN COVERED BY THE IMCI PROTOCOL VITAMIN A, VITAMIN A DEFICIENCY (VAD) AND ITS
CONSEQUENCES
• Sick children birth up to 2 months (Sick Young Infant)
• Sick children 2 months up to 5 years old (Sick child) • Vitamin A – an essential nutrient as retinol needed by the body
for normal sight, growth, reproduction and immune competence
STRATEGIES/PRINCIPLES OF IMCI • Vitamin A deficiency - a condition characterized by depleted
• All sick children aged 2 months up to 5 years are examined liver stores & low blood levels of vitamin A due to prolonged
for GENERAL DANGER signs and all Sick Young Infants Birth up insufficient dietary intake of vit. A followed by poor absorption
to 2 months are examined for VERY SEVERE DISEASE AND or utilization of vit. A in the body
LOCAL BACTERIAL INFECTION. These signs indicate immediate • VAD affects:
referral or admission to hospital o children’s proper growth
LETHARGY o resistance to infection
UNCONSCIOUSNESS o increased child mortality
o severe deficiency results to blindness, night blindness and
bitot’s spot
VOMITING
DANGER CONVULSIONS IRON AND IRON DEFICIENCY ANEMIA (IDA) AND ITS
SIGNS CONSEQUENCES
• Iron – an essential mineral and is part of hemoglobin, the red
protein in red blood cells that carries oxygen from the lungs to
INABILITY TO DRINK the cells
OR BREASTFEED • Iron Deficiency Anemia – condition where there is lack of iron in
• The children and infants are then assessed for main symptoms. the body resulting to low hemoglobin concentration of the blood
For sick children, the main symptoms include: cough or • IDA results in premature delivery, increased maternal mortality,
difficulty breathing, diarrhea, fever and ear infection. For sick reduce ability to fight infection and transmittable diseases and
young infants, local bacterial infection, diarrhea and low productivity
jaundice. All sick children are routinely assessed for nutritional,
immunization and deworming status and for other problems IODINE AND IODINE DEFICIENCY DISORDERS (IDD)
• Only a limited number of clinical signs are used • Iodine -a mineral and a component of the thyroid hormones
• A combination of individual signs leads to • Thyroid hormones - needed for the brain and nervous system to
a child’s classification within one or more symptom groups develop & function normally
rather than a diagnosis. • Iodine Deficiency Disorders refers to a group of clinical entities
• IMCI management procedures use limited number of essential caused by inadequacy of dietary iodine for the thyroid hormone
drugs and encourage active participation of caretakers in the resulting into various condition e.g. goiter, cretinism, mental
treatment of children retardation, loss of IQ points
• Counseling of caretakers on home care, correct feeding and
giving of fluids, and when to return to clinic is an essential
component of IMCI
POLICY ON FOOD FORTIFICATION EXPANDED GARANTISADONG PAMBATA
• ASIN LAW: Republic Act 8172, “An Act Promoting Salt Iodization PROGRAM
Nationwide and for other purposes”, Signed into law on Dec. 20,
1995 • Comprehensive and integrated package of services and
communication on health, nutrition and environment for
• Food Fortification Law: Republic Act 8976, “An Act Establishing
children available every. day at various settings such as home,
the Philippine Food Fortification Program and for other
school, health facilities and communities by government and
purposes” mandating fortification of flour, oil and sugar with
non-government organizations, private sectors and civic groups.
Vitamin A and flour and rice with iron by November 7, 2004
GP SERVICES PACKAGE
AGE (YR) HEALTH NUTRITION ENVIRONMENT
• Maternal nutrition
• Maternal health care • Iron supplement
0-1 • Essential newborn care • Vitamin A
• Immunization • Early & exclusive breastfeeding
• Complementary feeding • Water
• Breastfeeding • Sanitation
• Immunization • Complementary feeding • Hygiene Promotion
1-5 • Deworming • Vitamin A • Oral health
• IMCI • Iron Supplementation • Child injury prevention
• Iodized salt at home • Treated bed nets
• Deworming • Proper nutrition • Smoke-free homes
6-10
• Booster immunization (Screening) • Iodized salt at home
• Deworming • Proper nutrition
11-14 • Booster immunization (Screening) • Iron supplementation
• Physical activity (Healthy lifestyle) • Iodized salt at home
MATERNAL, NEWBORN AND CHILD HEALTH AND SPECIFICALLY, THE AMS PROGRAM AIMS TO:
NUTRITION • Promote rational and optimal antimicrobial therapy;
• Improve patient outcomes and decrease healthcare cost by
MNCHN Core Package of Services
reducing unnecessary antimicrobial use, adverse drug events,
• Pre-pregnancy: provision of iron and folate supplementation,
and mortality and morbidity from infections (including
advice on family planning and healthy lifestyle, provision of
secondary infections by resistant pathogens);
family planning services, prevention and management of
• Foster awareness on the global and country situation on the
infection and lifestyle-related diseases. Also encompass
threat of AMR and the compelling need to address it;
adolescent health services, deworming of women of
• Effect positive behaviour and/or institutional changes through
reproductive age (to reduce other causes of iron deficiency
educational and persuasive interventions towards improving
anemia), nutritional counseling, oral health
the use of antimicrobials by the prescribers, dispensers, other
• Pregnancy: first prenatal visit at first trimester, at least 4
healthcare professionals, and patients;
prenatal visits throughout the course of pregnancy to detect and
• Establish multi-disciplinary leadership and commitment,
manage danger signs and complications of pregnancy, provision
clinical governance and accountability in antimicrobial
of iron and folate supplementation for 3 months, iodine
supplementation and 2 tetanus toxoid immunization, management to ensure that interventions are sustainable and
well-supported with necessary technical and financial
counselling on healthy lifestyle and breastfeeding, prevention
resources;
and management of infection, as well as oral health services.
• Create an environment where healthcare professionals are
• Delivery: skilled birth attendance/skilled health professional-
assisted delivery and facility-based deliveries including the use supported with monitoring tools and systems to implement
of partograph, proper management of pregnancy and delivery antimicrobial management;
complications and newborn complications, and access to • Conduct research aiming to analyse the progress and challenges
BEmONC or CEmONC services on implementing hospital antimicrobial stewardship program;
• Post-Partum: visit within 72 hours and on the 7th day and,
postpartum to check for conditions such as bleeding or • Prevent or slow down the emergence of AMR
infections, Vitamin A supplements to the mother, and
counselling on family planning and available services. It also
includes maternal nutrition and lactation counseling and
postnatal visit of the newborn together with her visit
• Newborn care until the first week of life: Interventions within
the first 90 minutes such as immediate drying, skin to skin
contact between mother and newborn, cord clamping after 1 to
3 minutes, non-separation of baby from the mother, early
initiation of breastfeeding, as well as essential newborn care
after 90 minutes to 6 hours, newborn care prior to discharge,
after discharge as well as additional care
• Child Care: immunization, micronutrient supplementation
(Vitamin A, iron); exclusive breastfeeding up to 6 months,
sustained breastfeeding up to 24 months with complementary
feeding, integrated management of childhood illnesses, injury
prevention, oral health and insecticide-treated nets for mothers
SIX CORE ELEMENTS OF THE DOH AMS PROGRAM
and children in malaria endemic areas DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures
The national AMS program is based on six core elements that in

ANTIMICROBIAL STEWARDSHIP PROGRAM concordance will form the foundation for its success
Dr. Mann
• AMS program - Antimicrobial Stewardship program is the
program of the DOH tasked with concerted implementation of CORE ELEMENT 1: LEADERSHIP
systematic, multi-disciplinary, multi-pronged interventions in
• A dedicated multi-disciplinary AMS Committee and Team
both public and private hospitals in the Philippines to improve
supported by the hospital administration shall be responsible to
appropriate use of antimicrobials, which is essential for
successfully implement, perform, and monitor the AMS Program
preventing the emergence and spread of AMR.
in each hospital.
CORE ELEMENT 2: POLICIES, GUIDELINES, CLINICAL
PATHWAYS
• Antibiotic policies and standardized clinical guidelines and
clinical pathways on the treatment and prophylaxis of infections
provide evidence-based guidance to clinicians and other
healthcare professionals on the management of infectious
diseases and in the selection of the most appropriate
antimicrobial agent.
CORE ELEMENT 3: SURVEILLANCE OF ANTIMICROBIAL USE

(AMU) AND ANTIMICROBIAL RESISTANCE (AMR)
• AMU and AMR are intricately related. Surveillance of AMU
provides important insights into prescribing patterns that may
explain for the evolution of AMR, and is useful in the
development and evaluation of AMS interventions. AMR
surveillance allows for the development of an antibiogram that CATEGORIES OF ANTIMICROBIALS AND THEIR CORRESPONDING
informs empiric antimicrobial choice, characterizes the impact INTERVENTIONAL STRATEGIES
DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures
of AMS activities on resistance, and identification of specific
AMR problem areas that needs to be addressed notwithstanding
the infection control measures.
Restricted Antimicrobials
1. Cefepime 6. Voriconazole
2. Ertapenem 7. Colistin
3. Meropenem 8. Micafungin
4. Vancomycin 9. Aztreonam
5. Amphotericin B 10. Linezolid
RESTRICTED ANTIMICROBIALS
VISUAL MNEMONIC
https://qrs.ly/vecqqul
• Restricted antimicrobials shall only be utilized by institutions with

tertiary clinical laboratories
• Restricted antimicrobials require approval for use from the AMS
committee of the hospital this is under core element 4: Action
https://www.philhealth.gov.ph/circulars/2018/circ2018-0009.pdf
Dr. Mann
CORE ELEMENTS 4: ACTION
• The AMS Program employs a coordinated multi-pronged, multi-
disciplinary approach to safeguard and optimize use of all
antimicrobials used within the hospital. Active interaction
between the AMS team and prescribers (and other healthcare
professionals) is pivotal in encouraging compliance to AMS
interventions and being able to effectively persuade and
influence change in prescribing practices.
• Action 1. Antimicrobial Restriction and Pre-authorization

o Requires clinicians to obtain approval for use of selected
antimicrobials before prescribing
o This strategy is helpful in minimizing unnecessary patient
exposure to toxicities and cost
• Action 2. Seventh Day Automatic Stop Order

o Infections shall be treated with the shortest effective
treatment duration
o If there is a need to extend antimicrobial therapy for more than
7 consecutive days, the attending resident must complete the
7th day antimicrobial form, indicating reason for continued use
o Upon completion of form the physician shall seek approval
from the designated AMS officer PROCEDURE FOR INTRAVENOUS TO ORAL (IV-TO-PO) SWITCH
DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures
• Action 3. Point-of-Care (POC) Interventions

o Occur routinely at the ward level with direct feedback to the • Action 4. Prospective Audit of Antimicrobial Prescribing &
prescriber/attending physician at the time of prescription or Direct Intervention and Feedback (Audit and Feedback)
laboratory diagnosis, this improves patient management and o Involves the clinical evaluation of individual prescription of
outcomes and an excellent opportunity to educate clinical staff antimicrobials for appropriateness, followed by the immediate
on appropriate prescribing. and direct communication with prescribers to optimize
o Point of care interventions include: treatment for each patient
§ Dose optimization
§ Streamlining or de-escalation of antimicrobial therapy CORE ELEMENT 5: EDUCATION
§ Intravenous to oral (IV-to-PO) antimicrobial therapy switch • AMS practitioners need to gain competency through
comprehensive education and clinical training to effectively and
safely perform AMS interventions. Education of all healthcare
professionals on the principles of judicious use of antimicrobials
is also necessary to enable positive behavioral change.
CORE ELEMENT 6: PERFORMANCE EVALUATION • Co-morbid conditions: HIV/AIDS, diabetes mellitus and other
• Measuring process and clinical indicators to assess the overall metabolic disorders, atopy, pre-existing organ dysfunction,
quality management improvement and effectiveness of AMS obesity, etc.
interventions is fundamental in guiding the progressive • Previous history of adverse drug reactions (e.g., allergy,
implementation of the program towards achieving the goal to intolerance, etc.).
combat AMR. 3. DRUG-RELATED FACTORS
• Pharmacodynamics – “what the drugs does to the pathogen and
GENERAL PRINCIPLES OF ANTIMICROBIAL THERAPY to the body” – antimicrobial spectrum; bacteriostatic vs.
bactericidal; concentration-dependent vs. time-dependent
• The fundamental questions to ask in anti-infective therapy are:
bacterial killing.
• WHAT am I treating?
• Pharmacokinetics – “what the body does to the drug” – includes
o The infectious disease/clinical syndrome and the likely or
the processes of absorption, distribution, biotransformation /
proven pathogen [The MICROBIOLOGIC FACTORS]
metabolism, excretion; the relationship between the
• WHO am I treating?
antimicrobial concentration at the site of action and the
o The patient’s demographic, clinical, and behavioural
minimum inhibitory concentration for the pathogen is the major
characteristics [The HOST-RELATED FACTORS]
determinant of successful therapy; poor antimicrobial
• WHICH antimicrobial (or antibiotic combination) is most penetration of the blood-brain barrier, intraocular tissues and
appropriate? prostate, but increased with inflammation.
o [The DRUG-RELATED FACTORS]
• Adverse effects: risk/benefit ratio.
• HOW do I administer the appropriate antimicrobial(s)?
• Drug interactions – could be pharmaceutical, pharmacodynamic
o Dose, interval/frequency, route of administration, duration of
or pharmacokinetic in nature.
treatment, etc. [The DOSING REGIMEN including duration of
• Cost/benefit ratio – the total cost of the regimen and not the unit
therapy]
cost of the drug, should be considered.
• Others: ease and accuracy of dosing, stability, and acceptability.
FACTORS TO CONSIDER IN THE CHOICE OF ANTIMICROBIALS
1. MICROBIOLOGIC FACTORS: the disease/clinical syndrome
and the likely/proven pathogen(s)
• Site of infection: adequate concentration of the antibiotic at the
site of infection must be attained.
• Severity of infection: serious life-threatening infections (e.g.,
sepsis, meningitis, endocarditis, etc.) require early empiric ANTIMICROBIAL STEWARDSHIP NATIONAL ANTIBIOTIC
therapy after appropriate specimens are obtained to determine MANUAL GUIDELINES
the pathogen involved. https://qrs.ly/qbbpqxp https://qrs.ly/uwbpqy6
• Bacterial load (inoculum size), virulence, regrowth pattern and
susceptibility pattern of the pathogen. FOOD AND WATERBORNE DISEASES PREVENTION
• Infection at sequestered sites, which may not be reached by AND CONTROL PROGRAM
significant levels of the principal antibiotic being used (e.g., • FWBDs refer to the limited group of illnesses characterized by
nasopharyngeal carriage). diarrhea, nausea, vomiting with or without fever, abdominal
• Prior antimicrobial therapy: exert selection pressure for micro- pain, headache and/or body malaise.
organisms resistant to the antibiotic previously given to • These are spread or acquired through the ingestion of food or
outgrow the rest of the microflora, invade and cause infection. water contaminated by disease-causing microorganisms
• Local factors – e.g., presence of pus, devitalized tissue, foreign (bacterial or its toxins, parasitic, viral).
body, pH
2. HOST-RELATED FACTORS influence the efficacy and BASIC CONCEPTS
toxicities of antimicrobials
• Food and water-borne diseases are conditions caused by intake
• Age – a major factor that can influence gastric acidity, renal
of contaminated food and water.
function and hepatic function, as well as propensity to develop
• Across the different stages of food production pathway,
hypersensitivity.
conditions or factors may be present.
• Genetic factors – e.g., glucose-6-phosphate dehydrogenase
• These conditions posed a risk for the growth of bacteria/viruses
deficiency causes hemolytic anemia and jaundice with the
or introduction of food-borne helminths in food/water causing
administration of primaquine, sulfonamides, sulfones,
a disease in humans
nitrofurans, chloramphenicol, etc.; or aplastic anemia from
chloramphenicol as an idiosyncratic reaction. • There are five (5) infectious FWBDs that are under
surveillance in the Philippines.
• Hepatic and renal function – the ability of the patient to
o Acute bloody diarrhea,
metabolize/inactivate or excrete the antimicrobial is one of the
o Cholera,
most important host factors, especially when high serum or
o Rotavirus,
tissue levels are potentially toxic.
o Hepatitis A
• Pregnancy and Nursing Status (Pregnancy Risk Categories by the
o Typhoid
US FDA).
• The most common symptom of food and water-borne
• Host defense mechanisms, both humoral and cellular;
diseases is diarrhea.
immunocompetent vs. immunocompromised host (e.g., HIV
• And the most threatening consequence of diarrhea is
infection, recipients of cytotoxic drugs, transplanted organs,
dehydration
burn patients, with vascular abnormalities, impaired localized
phagocytosis, etc.)
ASSESSMENT OF DEHYDRATION
CLINICAL MANIFESTATION OF DIARRHEA IN CHILDREN ACCORDING TO THE LEVEL OF DEHYDRATION
NO SIGNS OF MILD TO MODERATE
PARAMETERS SEVERE DEHYDRATION
DEHYDRATION DEHYDRATION
Infant <5% 5-10% >10%
1. Fluid deficit
Child 3% 6% 9%
2. General condition* Well; alert Restless; irritable Lethargic; unconscious
3. Thirst Drinks normally; not thirsty Thirsty; drinks eagerly Drinks poorly; not able to drink
Slightly depressed /
4. Fontanel/eyes* Normal Sunken
slightly sunken
5. Tears Present Present or decreased No tears
6. Cutaneous
<2 sec ~2 sec <3 sec
perfusion/capillary time
NO SIGNS OF MILD TO MODERATE
Deep and rapid
2 months – 12 months: ≥ 50 breaths per
7. Respiration Normal Deep, may be rapid
min
>1 year – 5 years: > 40 breaths per min
8. Skin pinch* Goes back quickly Goes back slowly Goes back very slowly
Decreased Minimal (<0.3 mL/kg/hr in 16 hr) OR
9. History of urine output Normal
(<0.5 mL/kg/hr in 8 hr) None(no urine output in 12 hr)
The presence of two or more The presence of two or more of the above
Interpretation
of the above signs signs
Manual of Procedures Food and Water-borne Diseases Prevention and Control Program DEPARTMENT OF HEALTH
CLINICAL MANIFESTATION OF DIARRHEA IN ADULTS ACCORDING TO THE LEVEL OF DEHYDRATION

MILD MODERATE
Fatigue +/- + +
Thirst +/- + +
Sunken eyes - + +
Blood pressure Normal Orthostatic hypertension Shock
Respiratory rate (breaths per
Normal 21-25 >25
minute)
Heart rate (beats per minute) ≥80 >100 Faint or thready pulse
Peripheral circulation Warm Cold, clammy Cold, clammy
Level of consciousness Alert Lethargic Coma or stupor
Oral mucosa Moist Dry Dry
Muscle weakness None Mild to moderate Severe
Skin turgor ≤2 sec ≥2 sec ≥2 sec
Capillary refill time ≤2 sec ≥2 sec ≥2 sec
Urine output (mL/kg/hr) ≥0.5 ≤0.5 ≤0.5
MANAGEMENT OF DIARRHEA CASE • Elderly patients and those at risks of fluid over load (patients with
• Fluid Replacement Therapy heart failure or kidney disease) should be referred to a specialist for
individualized fluid management.
o Fluids and electrolyte replacement are the basic treatment of
• Zinc supplementation is given for acute infectious diarrhea in children
diarrhea to prevent death more than 6 months old at a dosage of 20 mg/day for 10-14 days. This
CONDITIONS FOR ADMISSION OF CHILDREN WITH ACUTE adjunctive therapy shortens the duration of diarrhea and decreases the
INFECTIOUS DIARRHEA: frequency of stool. Zinc supplementation is not routinely given to
• Children who are not able to tolerate oral fluids children less than 6 months of age
• Probiotics is recommended adjunctive therapy because it reduces the
• Children suspected of electrolyte imbalance
severity of the symptoms and duration of diarrhea.
• Children with the following physical findings on examination: • Probiotics are given within the duration of diarrhea and may extend
o altered consciousness for another 7 days after the completion of the antibiotics
o abdominal distention Dr. Mann
o respiratory distress REHYDRATION GUIDE FOR CHILDREN ACCORDING TO THE

o hypothermia (body temperature of < 36 degrees Celsius) LEVEL OF DEHYDRATION
• Children with co-existing medical conditions such as MILD TO
pneumonia, meningitis/encephalitis, sepsis, moderate to severe SEVERE
NO DEHYDRATION MODERATE
malnutrition, and suspected surgical condition DEHYDRATION
DEHYDRATION
Reduced osmolarity Reduced Rapid IV rehydration
CONDITIONS FOR ADMISSION OF ADULT WITH ACUTE oral rehydration osmolarity ORS is recommended with
INFECTIOUS DIARRHEA: solution (ORS) is is recommended plain lactated Ringer’s
• Inability to tolerate oral rehydration recommended to to replace (pLR) solution or
• Moderate to severe dehydration replace ongoing ongoing losses 0.9% sodium chloride
losses (with or without 5%
• Acute Kidney injury
If oral glucose)
• Presence of electrolyte abnormalities If commercial ORS is rehydration is
• Co-morbid conditions such as uncontrolled diabetes, congestive not available, not feasible,
heart failure, coronary artery disease, chronic kidney disease, homemade ORS may administration
chronic liver disease, immunocompromised conditions; be given (4-5 tsp of of ORS via NGT
• Weak or elderly patients (>60 years old) sugar and 1 tsp of is preferred
• Poor nutritional status salt in 1L of clean over IV
drinking water) hydration
• Please note that sport drinks and sodas are not recommended to
replace fluid losses. RHU level Hospital level Hospital level
RECOMMENDED REHYDRATION GUIDE FOR ADULTS ACCORDING TO THE LEVEL OF DEHYDRATION
Mild dehydration Moderate dehydration Severe dehydration
Oral rehydration solution is For Admitted Patients: For Admitted Patients:
recommended at 1.5 - 2 times the 500 to 1,000 ml of plain Lactated Ringer’s 1,000 to 2,000 ml of PLRS within the first hour is
estimated amount of volume solution (PLRS) in the first 2 hours is recommended.
deficit plus concurrent recommended. Once hemodynamically stable, Once hemodynamically stable, give:
gastrointestinal losses. give: • 2-3 ml/kg/hour PLRS for patients with actual or
• 2-3 ml/kg/hour PLRS for patients with actual estimated body weight of <50 kg
or estimated body weight of <50 kg; • 1.5-2 ml/kg/hour PLRS for patients with actual or
• 1.5-2 ml/kg/hour PLRS for patients with estimated body weight of> 50 kg.
actual or estimated body weight of >50 kg; • Use ideal body weight for overweight or obese patients.
Use ideal body weight for overweight or obese Replace ongoing losses volume per volume with PLRS
patients; Replace ongoing losses volume per boluses. ORS is not recommended since patients with
volume with PLRS boluses or ORS (if tolerated). severe dehydration may have compromised mental
status and therefore have high risk for aspiration.
PREVENTIVE MEASURES Cholera vaccine is not meant to replace the provision for clean water and
• Personal Hygiene - Strong promotional and advocacy sanitation and hygiene (WASH), which are the core strategy for
prevention of cholera.
campaign for personal hygiene and proper handwashing Dr. Mann
should be done in the community, health care facility, schools,
day care centers, offices and food establishments
• Safe, clean water - drinking water must be clear and does not FOOD AND WATER-BORNE DISEASES
have objectionable taste, odor and color. It should be free from PREVENTION AND CONTROL PROGRAM
all harmful organisms, chemical substances and radionuclides in https://qrs.ly/ycbpvxa
amounts that could be hazardous to humans
o Simple boiling of water for 3-5 minutes may remove physical FOOD SAFETY
and microbiological impurities.
• Food Safety is the assurance/guarantee that food will not cause
• Proper Food Handling :Some of the regulations from Chapter
harm to the consumers when it is prepared and/or eaten
III of PD 856 are as follows:
according to its intended use
o No food establishment operates for public patronage without
a Sanitary Permit. The permit is renewable yearly and should • Food-borne infection: Produced by living organisms entering
be posted in a conspicuous area. •
the body with the food.
o No person shall be employed in any food establishment • Food poisoning/ food intoxication: produced by toxins or
without a health certificate issued by the city/municipal health poisonous agents present in the food before consumption
officer. This certificate shall be issued only after the required
physical and mental examinations and immunizations. COMMON CAUSES OF FOOD AND WATER BORNE DISEASES
o Requirements for food handlers: • unsafe sources of drinking water
§ Wearing of hair nets (restrain) and clean working garments; • improper disposal of human waste
§ Proper hand washing before handling any food (raw • unhygienic practices like spitting anywhere, blowing or picking
ingredients and cooked), after visiting the toilet, coughing or the nose
sneezing and after smoking; • unsafe food handling and preparation practices i.e. street
§ No person shall be allowed to work as food handlers and be vended foods
engaged in food preparation while afflicted with a
communicable disease. FIVE KEYS TO SAFER FOOD (SOURCE: WHO)
1. Keep Clean.
THE FOLLOWING HEALTHY PRACTICES SHOULD BE o Wash your hands before handling food and often during food
OBSERVED AND FOLLOWED AT HOME OR IN ANY FOOD preparation.
BUSINESS: o Wash your hands after going to the toilet. − Wash and sanitize
• Food preparation: all surfaces and equipment used for food preparation.
o Only safe and wholesome food materials are used. o Protect kitchen areas and food from insects, pests, and other
o Food materials are cleaned with safe water. animals.
o Enough equipment and utensils are provided, properly
2. Separate raw and cooked foods.
cleaned and sanitized.
o Separate raw meat, poultry, and seafood from other foods.
o Food and food materials are prepared, processed and cooked
o Use separate equipment and utensils, such as knives and
in a sanitary manner.
cutting boards, for handling raw food.
• Food storage: o Store food in containers to avoid contact between raw and
o Wet and dry foods are stored separately.
prepared food.
o Proper temperature is maintained.
3. Cook foods thoroughly.
o Food and food materials are protected from contamination by
o Cook food thoroughly, especially meat, poultry, eggs, and
insects and rodents, chemical substances and others.
seafood.
• Food serving: o Bring food, like soups and stews, to boiling to make sure that
o Food and food materials are properly displayed and protected they have reached 70°C. For meat and poultry, make sure that
from all possible contamination. juices are clear, not pink. Ideally, use a thermometer.
o Food are served with clean and sanitized utensils. o Reheat cooked food thoroughly.
Maintenance of proper temperature 4. Keep food at safe temperatures.
o Separate utensils are used for each kind of food. o Do not leave cooked food at room temperature for more than
o Left-over foods are never used 2 hours.
o All contaminated foods of those of doubtful quality are o Refrigerate promptly all cooked and perishable food
condemned. (preferably below 5°C).
• Vaccination o Keep cooked food piping hot (more than 60°C) prior to serving.
o Killed oral cholera vaccine may be given to children and adults o Do not store food too long even in the refrigerator. − Do not
living in endemic areas to prevent outbreaks caused by cholera thaw frozen food at room temperature.
o Rotavirus is an important cause of diarrheal disease 5. Use safe water and raw materials.
particularly in children under 5 years. o Use safe water or treat it to make it safe.
o Rotavirus vaccines are effective in preventing rotavirus o Select fresh and wholesome food.
diarrhea and immunization of infants with rotavirus vaccine is o Choose food processed for safety, such as pasteurized milk.
recommended. o Wash fruits and vegetables, especially if eaten raw.
o Do not use food beyond its expiry date.
ETIOLOGICAL
PROBLEM FOOD INVOLVED PREVENTIVE MEASURES
AGENT
Cook food thoroughly
Salmonellosis Salmonella species Poultry, salads, warmed over foods
Strict personal cleanliness
Moist food, dairy product, water, shell fish,
Dysentery Species of Shigella salad contaminated with excreta of a carrier Strict personal cleanliness, cook food
direct or indirect
Pasteurization of milk and other dairy products,
Typhoid fever S. typhi Same as above
chlorination of water; vaccination
T. saginata (beef)
Insufficiently cooked beef, pork, fresh water
Tapeworm T. solium (pork) Adequate cooking
fish.
D latum
Toxins A,B, or C of C. Home processed CHON food; inadequately Pressure cooking in processed food; adequate
Botulism
botulinum canned foods with pH over 3.5 cooking
Staph food Enterotoxin
Cooked ham, salads of CHON-food Adequate cooking
Poisoning producing staph
NATIONAL LEPROSY CONTROL PROGRAM Diagram representing the different clinical classifications of leprosy using
both the World Health Organization and the Ridley-Jopling system. The
LEPROSY increase in number of acid-fast bacilli and defects in cell-mediated
• Leprosy is a chronic, mildly communicable disease that mainly immunity are represented in the continuum from paucibacillary to
affects the skin, the peripheral nerves, the eyes, and mucosa of multibacillary disease.
Dr. Mann
the upper respiratory tract TREATMENT
CAUSE • Multidrug therapy (MDT) treatment
• Mycobacterium leprae bacillus o Combination of rifampicin, clofazimine, and dapsone for
MODE OF TRANSMISSION Multibacillary (MB) leprosy patients
o Rifampicin and dapsone for Paucibacillary (PB) leprosy
• Transmitted via droplets, from the nose and mouth, during close
patients
and frequent contacts with untreated cases
Treatment of leprosy with only one antileprosy drug will always result in
SIGNS AND SYMPTOMS development of drug resistance to that drug
3 CARDINAL SIGNS OF LEPROSY Dr. Mann
• Skin patch with loss of PREVENTION AND CONTROL

sensation • Treat all leprosy cases to prevent spread of infection.
o The skin lesion can be single or • Avoid direct contact with untreated patients (especially young
multiple, usually less pigmented children).
than the surrounding normal • Practice personal hygiene.
skin. Sometimes the lesion is • Maintain body resistance by healthful living. Practice good
reddish or copper-colored. nutrition.
• Enlarged peripheral nerve • Have enough rest and exercise.
o A thickened nerve is often • Keep environment clean.
accompanied by other signs as a
result of damage to the nerve.
These may be loss of sensation in
FILARIASIS ELIMINATION PROGRAM
the skin and weakness of ETIOLOGY
muscles supplied by the affected nerve. • Roundworms of the Filarioidea type. Lymphatic filariasis is
• Positive slit-skin smear caused by the worm:
o In a small proportion of cases, rod-shaped, red-stained leprosy o Wuchereria bancrofti,
bacilli, which are diagnostic of the disease, may be seen in the o Brugia malayi,
smears taken from the affected skin when examined under a o Brugia timori.
microscope after appropriate staining. • These worms occupy the lymphatic system, including the lymph
Image from McDougall, AC and Yuasa, Y. (2002). A New Atlas of Leprosy. nodes; in chronic cases, these worms lead to the syndrome of
CLASSIFICATION OF LEPROSY elephantiasis.
• Leprosy can be classified on the basis of clinical manifestations
PREFERRED REGIMEN:
and skin smear results.
• In the classification based on skin smears, patients showing • Day 1: Diethylcarbamazine (DEC) 6mg/kg div 3 doses (after
negative smears at all sites are grouped as paucibacillary meals) + Albendazole 400mg
leprosy (PB), while those showing positive smears at any site • Day 2 to Day 12: DEC 6mg/kg div 3 doses
are grouped as having multibacillary leprosy (MB) DEC is free and only available at the DOH Central office and
• Patients with tuberculoid leprosy have limited disease and government health facilities in endemic areas.
relatively few bacteria in the skin and nerves • Comments: Tablets should be taken after meals. Total
o characterized by a few flat or slightly raised skin lesions of cumulative DEC dose of 72 mg/kg for W. bancrofti infections.
various sizes that are typically pale or slightly red, dry, • Precautions:
hairless, and numb to touch o Treatment of pregnant women should be deferred until after
• lepromatous patients have widespread disease and large delivery.
numbers of bacteria o Treatment is contraindicated in individuals with severe
o with a much more generalized disease, diffuse involvement of cardiac and kidney diseases.
the skin, thickening of many peripheral nerves, and at times o Individual with asthma, seizure disorders or severe
involvement of other organs, such as eyes, nose, testicles, and malnutrition should be treated with caution. Do not initiate
bone treatment when patient has asthma attack. Treat asthma first
https://www.who.int/lep/classification/en/ before taking antifilarial drugs.
THE RIDLEY-JOPLING CLASSIFICATION o If patient is less than 2 years of age, refer to specialist.
• Tuberculoid (TT) • Adverse Reactions
• Borderline tuberculoid (BT) o Localized: Pain, inflammation, and tenderness of nodules,
• Mid-borderline (BB) adenitis, lymphangitis due to death of adult filarial worms.
• Borderline lepromatous (BL) Usually begins from 2-4 days after the first dose of DEC.
• Lepromatous (LL) o Systemic: Fever, headache, malaise, myalgia and hematuria
• Indeterminate (I) occur due to death of microfilariae. Usually begin from few to
48 hours after taking DEC and are usually self-limited.
PREVENTION & CONTROL
• The best way to prevent lymphatic filariasis is to avoid mosquito
bites. The mosquitoes that carry the microscopic worms usually
bite between the hours of dusk and dawn . If you live in an area
with lymphatic filariasis:
o At night
§ Sleep in an air-conditioned room or
§ Sleep under a mosquito net
o Between dusk and dawn
§ Wear long sleeves and trousers and
§ Use mosquito repellent on exposed skin.
• Another approach to prevention includes giving entire
communities medicine that kills the microscopic worms — and
controlling mosquitoes. Annual mass treatment reduces the
Jacobson R, and Krahenbuhl JL. Leprosy. Lancet 1999; 353:655. level of microfilariae in the blood and thus, diminishes
TT: tuberculoid; BT: borderline tuberculoid; BB: mid-borderline; BL: transmission of infection. This is the basis of the Global Program
borderline lepromatous; LL: lepromatous; CMI: cell-mediated immunity; to Eliminate Lymphatic Filariasis.
AFB: acid-fast bacilli; PB: paucibacillary; MB: multibacillary
A major strategy of the Elimination Plan was the Mass Annual Treatment
using the combination drug, Diethylcarbamazine Citrate and REPUBLIC ACT NO. 11166
Albendazole for a minimum of 5 years to individuals ages 2 years old and IMPLEMENTING RULES
above living in established endemic areas after the issuance from WHO of AND REGULATIONS
the safety data on the use of the drugs. https://qrs.ly/9rbpsdt
https://www.doh.gov.ph/national-filariasis-elimination-program
Dr. Mann
REVISED POLICIES AND GUIDELINES ON THE
HIV/STI PREVENTION PROGRAM USE OF ANTIRETROVIRAL THERAPY (ART)
PROGRAM ACTIVITIES: AMONG PEOPLE LIVING WITH HUMAN
• With regard to the prevention and fight against stigma and IMMUNODEFICIENCY VIRUS (HIV) AND HIV—
discrimination, the following are the strategies and interventions: EXPOSED INFANTS
o Availability of free voluntary HIV Counseling and Testing Service; https://qrs.ly/qvbpsy3
o 100% Condom Use Program (CUP) especially for entertainment
establishments; MALARIA CONTROL PROGRAM
o Peer education and outreach;
• Malaria is a life-threatening disease caused by plasmodium
o Multi-sectoral coordination through Philippine National AIDS
parasites transmitted by Anopheles mosquito or rarely through
Council (PNAC);
o Empowerment of communities; blood transfusion and sharing of contaminated needles causing
o Community assemblies and for a to reduce stigma; acute febrile illness and symptoms in the form of fever,
o Augmentation of resources of social Hygiene Clinics; and headache and chills.
o Procured male condoms distributed as education materials during REVISED POLICY AND GUIDELINES ON THE DIAGNOSIS AND
outreach. TREATMENT OF MALARIA
PREVENTIVE MEASURES, SAFE PRACTICES AND PROCEDURES • Microscopy will continue to be the "gold standard" for
• Creation of rights-based and community-led behavior diagnosing malaria
modification programs that seek to encourage HIV risk • The Artemether-Lumefantrine (AL) combination will be the first
reduction behavior among PLHIVs; line medicine in the treatment of confirmed uncomplicated and
• Establishment and enforcement of rights-based mechanisms to severe Plasmodium falciparum malaria, replacing CQ+SP
strongly encourage newly tested HIV-positive individuals to combination
conduct partner notification and to promote HIV status • If AL is not available, whether the patient is conscious or
disclosure to partners; unconscious, and in case of treatment failure, quinine (QN) in
• Establishment of standard precautionary measures in public combination with either tetracycline or doxycycline or
and private health facilities; clindamycin (QN+T/D/C x 7 days), will be the second-line
• Accessibility of ART and management of opportunistic treatment.
infections; • In severe malaria cases wherein the patient is unconscious, and
• Mobilization of communities of PLHIV for public awareness the facility has no capacity to adequately manage the patient
campaigns and stigma reduction activities; and (e.g. naso-gastric tube or intravenous therapy), Artesunate (AS)
• Establish comprehensive human rights and evidence-based suppository can be introduced pending transfer of patient to the
policies, programs, and approaches that aim to reduce next level of care."
transmission of HIV and its harmful consequences to members • ACT can be used for all Plasmodium species and mixed
of key affected populations. infections
Art 3, Section 23 REPUBLIC ACT No. 11166 • 2009 : AO 2009-0001 “Revised Policy and Guidelines on the
HIV TESTING Diagnosis and Treatment of Malaria
• HIV testing shall be made available under the following • Chloroquine (CQ)
circumstances: • Sulphadoxine/pyrimethamine (SP)
• if the person is fifteen (15) to below eighteen (18) years of age, • Artemesinin (ACT)
Dr. Mann
consent to voluntary HIV testing shall be obtained from the child
PREVENTION AND CONTROL
without the need of consent from a parent or guardian
• Any young person aged below fifteen (15) who is pregnant or • Strategies to disrupt malaria transmission include effective
engaged in high-risk behavior shall be eligible for HIV testing deployment of antimalarial drugs, personal mosquito
and counseling, with the assistance of a licensed social worker protection, mosquito vector control, and research (including
or health worker. Consent to voluntary HIV testing shall be vaccine development)
obtained from the child without the need of consent from a • Personal protection from infection — Potential tools for
parent or guardian personal protection from infection include use of mosquito
• consent to voluntary HIV testing shall be obtained from the repellants and insecticide treated nets, intermittent preventive
child's parent or legal guardian if the person is below fifteen (15) treatment for selected patient groups
years of age or is mentally incapacitated. In cases when the o Insecticide-treated nets
child's parents or legal guardian cannot be located despite § Pyrethroids are the major insecticides used routinely for bed
reasonable efforts, or if the child's parent or legal guardian net treatment
refused to give consent of the minor shall also be required prior § Long-Lasting Insecticidal Net (LLIN)
to the testing § insecticide treated nets (ITNs)
Art 4, Section 29 REPUBLIC ACT No. 11166
RECOMMENDED PROPHYLAXIS
HEALTH AND SUPPORT SERVICES
• Atovaquone-proguanil
• The DOH shall establish a program that will provide free and o take 1 tablet daily (atovaquone 250 mg + proguanil 100 mg).
accessible ART and medication for opportunistic infections to all o start 1-2 days before entering the malarious area, continue
PLHIVs who are enrolled in the program daily during your stay and continue for 7 days after leaving.
LIST OF ANTIRETROVIRAL DRUGS • Doxycycline
CLASS OF ARV GENERIC NAME OF ARV o take 1 tablet daily of 100 mg.
Tenofovir (TDF) o start 1 day before entering malarious area, continue daily
Nucleotide / Nucleoside
Lamivudine (3TC) during your stay and continue for 4 weeks after leaving.
Reverse Transcriptase
Abacavir (ABC)
(NRTI) • Mefloquine
Zidovudine (AZT)
o take 1 tablet of 250 mg (228 mg base) once a week.
Non-nucleoside Reverse Efavirenz (EFV)
o tart 1-2 weeks before entering the malarious area, continue
Transcriptase Inhibitors Rilpivirine (RPV)
weekly during your stay and continue for 4 weeks after
(NNRTI) Nevirapine (NVP)
Lopinavir / Ritonavir (LPV/r)
leaving.
https://www.cdc.gov/malaria/travelers/country_table/p.html
Protease Inhibitors (PI) Darunavir (DRV)
Chloroquine phosphate or hydroxychloroquine sulfate can be used for
Ritonavir (RTV)
Table 1. AO 2018-0024 or the Revised Policies and Guidelines on the Use of Antiretroviral Therapy (ART) among People
prevention of malaria only in destinations where chloroquine resistance
\
living with Human immunodeficiency virus (HIV) and HIV—exposed infants is not present, here in the Philippines we have chloroquine resistant
malaria
Dr. Mann
PREGNANT PATIENTS
• The major tools for preventing malaria in pregnant women are
mosquito avoidance and preventive drug therapy
• Pregnant travelers should be advised to defer travel to areas
where risk of acquiring malaria is high until after delivery, if
feasible
• Nonimmune pregnant women (i.e., those not living in an
endemic area) who cannot defer travel to an endemic area
should take chemoprophylaxis.
o The agents of choice are chloroquine (for travel to areas with
chloroquine-sensitive malaria
o Mefloquine (for travel to areas with chloroquine-resistant
malaria)
SCHISTOSOMIASIS CONTROL PROGRAM

PROGRAM COMPONENTS
• Schistosomiasis is an acute and chronic disease caused by
parasitic worms called trematodes or blood flukes. SMOKING CESSATION PROGRAM
• It is endemic in the Philippines
THE ROLE OF THE CLINICIAN
• It is transmitted through contact with fresh water infested with
the cercarial schistosome of the parasite that penetrates human • Clinician involvement increases the likelihood that the patient
skin. will successfully quit smoking. The goal is to routinely identify
smokers and offer them evidence-based help to quit
PREVENTION AND CONTROL
THE "5A'S" APPROACH
• Schistosomiasis control strategies for endemic areas include
water sanitation programs, mass treatment, hygiene education, • Ask about tobacco use
snail control and vaccine development. • Advise quitting
• Minimizing contact with fresh water containing infectious • Assess readiness to quit
cercarial larvae is an important control measure • Assist smokers ready to quit
• mass treatment consists of praziquantel administration • Arrange follow-up
(nonpregnant adults, pregnant women, and children ≥4 years:
40 mg/kg orally once; children <4 years: contraindicated) E-CIGARETTE OR VAPING PRODUCT USE
SUPPLEMENT:
ASSOCIATED LUNG INJURY (EVALI)
Praziquantel is the recommended treatment against all forms of
schistosomiasis. It is effective, safe, and low-cost. Even though re-infection “Vaping” is the process of inhaling an aerosol that is created by
may occur after treatment, the risk of developing severe disease is heating a liquid or wax containing various substances, such as
diminished and even reversed when treatment is initiated and repeated nicotine, cannabinoids (eg, tetrahydrocannabinol,
in childhood cannabidiol), flavoring, and additives (eg, glycerol, propylene
Dr. Mann
glycol)
EVALI is the name given by the Centers for Disease Control
LIFESTYLE-RELATED DISEASES and Prevention (CDC) to the dangerous, newly identified lung
• Non-communicable diseases (NCDs) include cardiovascular disease linked to vaping. The name EVALI is an acronym that
conditions (hypertension, stroke) diabetes mellitus, stands for e-cigarette or vaping product use-associated lung
lung/chronic respiratory diseases and a range of cancers which injury
are the top causes of deaths globally and locally. The pathogenesis of EVALI is not known.
• These diseases are considered as lifestyle related and is mostly • To completely avoid one’s risk of developing EVALI, the CDC
the result of unhealthy habits. states, “consider refraining from use of all e-cigarette, or
• Behavioral and modifiable risk factors like smoking, alcohol vaping, products.
abuse, consuming too much fat, salt and sugar and physical • IN JULY 2014, Republic Act No. 10643 or the “Act to Effectively Instill
inactivity have sparked an epidemic of these NCDs which pose a Health Consciousness through Graphic Health Warnings on Tobacco
public threat and economic burden. Products” or the Graphic Health Warnings Law was signed
• Prevention and control measures • Nationwide smoking ban order: executive order no. 26 from the office
of the president entitled "providing for the establishment of smoke-free
PROGRAM COMPONENTS environments in public and enclosed places" (signed May 16, 2017)
You can access the high resolution pdf here:
• Cardiovascular Disease
• Diabetes Mellitus
• Cancer THE TOBACCO BODY (WHO)
• Chronic Respiratory Disease https://qrs.ly/asbpy81
BASIC CONCEPTS
Dr. Mann
Modifiable Risk Factors Non-Modifiable Risk Factors
Diet Family history
Smoking Age PHILIPPINE CANCER CONTROL PROGRAM
Stress Sex • Cancer is one of the four epidemic non-communicable diseases
Birth weight Menopause (NCDs) or lifestyle-related diseases (LRDs) which include
Dyslipidemia Race cardiovascular diseases, diabetes mellitus, and chronic
Body weight Type A personality respiratory diseases.
Alcohol • NCDs are now considered a “silent disaster” of massive
Sedentary lifestyle proportion that is ravaging the Filipino population,
Migration
This is a board favorite, so kailangan familiar kayo kung ano ang
THE SPECIFIC CANCER PROGRAMS OF THE DOH-PCCP
modifiable and non-modifiable risk factors. EASY! • LUNG CANCER CONTROL PROGRAM
Dr. Mann
o focus on anti-smoking campaign
• BREAST CANCER CONTROL PROGRAM
o focus on early detection and treatment, and healthy lifestyle
o Importance of doing a regular monthly breast self-examination
(BSE)
• CERVIX UTERI CANCER CONTROL PROGRAM PREVENTIVE DENTISTRY
o focus on early detection and treatment, and healthy lifestyle SUPPLEMENT: FLUORIDE
• LIVER CANCER CONTROL PROGRAM • Use of fluorides is the primary means of preventing dental
o focus on hepatitis B vaccination, in collaboration with caries across all age groups
Immunization Program of the DOH • Dental fluorosis – which typically presents as white streaks
• COLON/RECTAL CANCER CONTROL PROGRAM in the enamel of permanent teeth – is a result of too much
o Focus on digital rectal exam/ FOBT and healthy diet lifestyle fluoride during tooth development.
• CANCER PAIN RELIEF PROGRAM
o focus on cancer pain relief and support groups, rehabilitation
& hospice care
WHO'S CANCER PAIN LADDER FOR ADULTS

• WHO has developed a three-step "ladder" for cancer pain relief
in adults.
• If pain occurs, there should be prompt oral administration of
drugs in the following order: Reproduced with permission from: Wright JT. Pediatr Clin North Am 2000; 47:975. Copyright © WB Saunders 2000.
• nonopioids (aspirin and paracetamol); • Excess fluoride consumption (generally greater than 0.05
mg/kg per day) can cause fluorosis or hypomineralization of
• then, as necessary, mild opioids (codeine);
the dental enamel
• then strong opioids such as morphine, until the patient is free
• Thus, fluoride should be used judiciously in children,
of pain.
particularly during the critical months of enamel maturation
• To calm fears and anxiety, additional drugs – “adjuvants” –
(up to 48 months), when the developing anterior permanent
should be used.
teeth are most vulnerable to excessive fluoride that can cause
• To maintain freedom from pain, drugs should be given “by the
fluorosis.
clock”, that is every 3-6 hours, rather than “on demand”
• This three-step approach of administering the right drug in the
right dose at the right time is inexpensive and 80-90% OCCUPATIONAL HEALTH PROGRAMS
effective. OCCUPATIONAL HEALTH
• Surgical intervention on appropriate nerves may provide • Branch of medicine concerned in the evaluation of the
further pain relief if drugs are not wholly effective. potential health risk of various toxic substances and physical
• In the case of cancer pain in children, WHO recommends a two factors for the purposes of prevention, treatment and palliation
step ladder. in the living and working environments.
KEY ELEMENTS OF OCCUPATIONAL HEALTH PROGRAM
1. Health protection
o health risk management at work
2. Health promotion
o health risk assessment associated with the environment and
lifestyle
3. Health surveillance
o collection of data for detection and evaluation
o assist in checking effectiveness of control measures
HAZARD
• Any source of potential damage, harm or adverse health effects
on something or someone under certain conditions at work.
HEALTH HAZARDS
• Are environmental factors, agents, or situations that may create
potential harm or injury to one’s physical well-being (Talbott &
Gunther, 1995)
CLASSIFICATION OF HEALTH HAZARDS
Workplace Health Hazards Workplace Safety hazards
A. Physical Hazard A. Vehicles
B. Chemical Hazard B. Workplace violence
https://www.who.int/cancer/palliative/painladder/en/#:~:text=WHO%20has%20developed%20a%20three,patient%2
0is%20free%20of%20pain. C. Biologic Hazard C. Pressure system
D. Ergonomics D. Fire and explosion hazards
WHO'S CANCER PAIN LADDER E. Psychosocial stressors E. Slipping/tripping hazards
FOR ADULTS F. Ejection materials
https://qrs.ly/kmcqqvk See table at next page
HIERARCHY OF CONTROLS TO HAZARDS

The Hierarchy of Controls or risk hierarchy is a system used in
DENTAL HEALTH PROGRAM industry to minimize or eliminate exposure to hazards. It is a
• The prevalence of dental caries on permanent teeth has widely accepted system promoted by safety organizations
generally remained above 90% throughout the years.
• Although preventable, these diseases affect almost every
Filipino at one point or another in his or her lifetime.
• Orally Fit Child (OFC)– Proportion of children 12-71 months
old and are orally fit during a given point of time.
• Is defined as a child who meets the following conditions upon
oral examination and/or completion of treatment :
o caries- free or carious tooth/teeth filled either with temporary
or permanent filling materials,
o have healthy gums,
o has no oral debris,
o No handicapping dento-facial anomaly or no dento-facial
anomaly that limits normal function of the oral cavity
National Institute for Occupational Safety and Health (NIOSH)
PHYSICAL CHEMICAL BIOLOGICAL ERGONOMIC PSYCHOSOCIAL

Involve exposure to various Includes solid, liquid, or gaseous Living organisms Hazards brought about Conditions in the
form of energy substances. that can adversely by the interaction environment and
Presently, there are about 28,000 affect the health of between the worker organization that effects
chemicals (Estrella-Gust, 2003) the worker and his/her working the worker’s mental
used in the different industries in environment. health.
the Philippines. These chemicals
could be used as a raw material,
intermediate products, finished
products or waste products.
• Noise- unwanted sound, • Particulate matter-any solid Microbes, parasites, • Repetitive motions • High level of
sound that bears no particles or liquid droplets viruses, insects, • Improperly concentration at work
information dispersed in the air. Examples snakes, dogs, etc. designed facilities at • Monotony
• Vibration-transmission of include dusts, fumes, and work, • Boredom,
mechanical energy from smoke. • awkward positions • Psychosocial factors at
oscillating force • Gases-aeroform fluids which or postures at work, work like low salary,
• Extremes of have neither shape nor specific • speedy physical lack of recognition, and
temperature-too hot or volume exertions. lack of participation in
too cold • Vapors – gaseous form of planning.
• Extremes of atmospheric substances which are normally • Underuse of skills,
pressure in the liquid or solid state. • Work overload or
• Defective Illumination underload
o Radiation- ionizing • shift working
radiation with enough • Low participation in
energy to break chemical decision making
bonds through non • Poor communication,
thermal process (e.g. X- • Poor relationship with
ray or gamma ray) superiors,
o Non ionizing radiation • Interpersonal conflict
(e.g., ultraviolet, • Bullying
microwave, infrared and • Harassment
laser (Leka & Jain, 2010).
Safety: the condition of being protected from or unlikely to cause danger, risk, or injury.
Dr. Mann
PERSONAL
ENGINEERING
ELIMINATION SUBSTITUTION ADMINISTRATIVE CONTROLS PROTECTIVE
CONTROLS
EQUIPMENT
Elimination is Substitution is
easiest and most
physically removing the replacing a material
Change the way people work common way to
hazard. It is a or process with
mitigate worksite
straightforward another that is Engineering
Related to work practice controls or hazards. However, PPE
strategy that should be considered to be less controls are used to
changes in work procedures through does not eliminate
implemented before all hazardous. To be an isolate workers
written safety policies and supervision hazards and may result
other methods and is effective substitute, from the hazard.
in workers being
considered the most the new process or
This method limits exposure to the exposed if the
effective of the five material must remove
hazard rather than removing it equipment fails
sections of the or at least mitigate
hierarchy of controls. the hazard
Installing machine • include employee training, signs and
guards that shield warning labels, and procedure changes • Gloves
workers from • Working clothing rules • Hard hats not more
For example, using airborne emissions • Personal cleanliness than 0.45 kg
water-based paints in • Washroom time allowance • Foot and eye
Designing/Planning a place of lead-based • Ventilation • Good housekeeping protection,
workplace free of paints is a good way systems • Proper waste disposal • Protective hearing
hazard if possible of substituting out a • Sound dampening • Adequate sanitary facilities device
potential hazard materials • Cleaning procedures outside of • Respirators
• Safety interlocks working hours • Full body suits
• Radiation • Comprehensive information to the • Safety belts and life
protection workers regarding the rules and lines
supervision
National Institute for Occupational Safety and Health (NIOSH)
THRESHOLD LIMIT VALUE SUPPLEMENT: PHYSICAL AGENTS

• Refers to the Philippine Occupational Safety and Health NOISE
Standards set for airborne concentrations of substances and • Intensity is measured in decibels (dB)
represents conditions under which workers may be repeatedly • Frequency- rate of vibration of the sources in Hertz.
exposed for an 8-hours workday at a total of 48 hours per week, Important Ranges for Permissible duration of
without adverse health effects; (OSHS) intensity (dB) and exposure
frequency (Hz) Sound level
Hours/day
TLV categories: Hearing in dB
0 dB
1. Time weighted average (TWA)- amount of chemical that can Threshold 8 85-90
be repetitively exposed to a person over a long duration 20 – 4 90-95
Audible
without causing adverse effects. This is usually based on 20,000 2 95-100
average concentration in a 40-hour workweek. Range
Hz 1 100-105
2. Short term exposure limits (STEL)- amount of chemical that Threshold for ½ 105-110
is allowable for only a short duration (15mins) without 120 dB
pain ¼ 110-115
causing tissue damage, irritation or any adverse effects Speech 500 – 1/8 115
3. Ceiling – amount of chemical or particles that should not be Frequency 2000 Hz
exceeded at any time with no exceptions
NOISE INDUCED HEARING LOSS HEALTH EXAMINATION FOR WORKERS
• Sensorineural deficit results from chronic exposure to CLASSIFICATION OF HEALTH EXAMINATIONS:
excessive sound levels
1. Entrance/pre-employment examination
• Sources: industrial and manufacturing industries
o to determine the physical condition of the prospective
• NIHL is almost always bilateral employee at the time of hiring
• OSHA level 85 dbA for an 8-hour workday o to prevent the placement of a worker on a job where, through
• Permissible Exposure level 90 dBA for 8 hours some physical or mental defects, he may be dangerous to his
fellow workers or to property.
PREVENTION AND CONTROL • Patient classification after examination
• Hearing Conservation Program o Class A- physically fit for any work
• Personal hearing protective devices o Class B- physically underdeveloped or with correctible defects
• Annual hearing tests but otherwise fit for work
• control of the noise source ex: enclosures o Class C-employable but owing to certain impairments or
• control of the noise propagation ex: barriers conditions requires special placement or limited duty in a
• control at the worker level ex: ear plugs, canal caps, ear muffs specified or selected assignment requiring follow up treatment
/periodic evaluation.
HEAT o Class D – unfit or unsafe for any type of employment
Mechanism of Heat Exchange Mnemonic
CONDUCTION CONVECTION RADIATION EVAPORATION
Direct contact Movement of Transfer by Heat transfer Class A: “Ayos!”
without fluid or gas wave by sweat Class B: “… But still employable. ”
interposition particularly motion evaporation Class C: “Conditional”
of air air independent which is the Class D: “Denied!”
of any most important Dr. Mann
conduction and only means 2. Periodic Annual Medical Examinations
medium to maintain o Periodic annual medical examinations shall be conducted in
body order to follow-up previous findings, to allow early detection
temperature of occupational and non-occupational diseases, and determine
the effect of exposure of employees to health hazards
GENERAL SYSTEMIC DISORDERS: § Shall have an interval of no longer than one year between 2
1. Heat Stroke consecutive PE
• failure of thermoregulatory center and suppression of § Allow early detection of disease
sweating. § Determine effect of exposure to health hazards
• S/Sx: temp of 40-430C, disorientation, delirium, coma 3. Transfer examinations
2. Heat exhaustion o Applicants examined for employment and accepted for specific
• results from deficiency of water or salt leading to circulatory work or job shall not be transferred to another work or job
insufficiency. until they have been examined by the physician and certified
• S/Sx: Fatigue, clammy, moist skin, increase temperature, that the transfer is medically advisable
weak pulse and low BP 4. Special exam
3. Heat Cramps o may be required where there is undue exposure to health
painful muscle spasms involving the arms and legs or hazards, such as lead, mercury, hydrogen sulfide, sulfur
abdomen due to excessive sweat loss with high water intake dioxide, nitro glycol and other similar substances.
but without adequate salt replacement 5. Return to Work exam
4. Heat syncope o A return to work examination shall be conducted
Minor disorder characterized by fainting. § (1) to detect if illness of the worker is still contagious
Standing erect and immobile in hot environment due to § (2) to determine whether the worker is fit to return to work
pooling of blood in blood vessels of the skin and lower body § (3) After prolonged absence for health reasons, for the
parts. purpose of determining its possible occupational causes.
Prickly heat (Milaria Rubra) – results from unrelieved exposure to 6. Separation from work exam
humid heat; skin is continually wet with unevaporated areas, imbibing o An employee leaving the employment of the company shall, if
water and plugs sweat duct orifices, resulting in inflammation of the necessary, be examined by the occupational health physician:
sweat gland. § (1) to determine if the employee is suffering from any
Dr. Mann
occupational disease;
ATMOSPHERIC PRESSURE DISORDERS
§ (2) to determine whether he is suffering from any injury or
• DYSBARISM illness which has not completely healed;
o Sudden shift to an environment of lower ambient pressure, § (3) to determine whether he has sustained an injury
as occurs in rapid ascension to the surface from the deep- DOLE OCCUPATIONAL SAFETY AND HEALTH STANDARDS (As Amended, 1989)
sea diving or with loss of cabin pressure while flying at high • OSH standards - mandatory rules and standards set and enforced to
altitudes, causes decompression sickness. eliminate or reduce hazards in the workplace
• OCCUPATIONS AT RISK: Pilots; Stewards; Scuba divers; free • This is a general reference for occupational safety and health
divers standards for every working conditions, sobrang haba nito, so if you
Decrease atm • Decompression sickness (Caisson are curious regarding specific conditions you can refer to this.
pressure disease) – sudden decrease to
causes: approximately 45% of the pressure with OCCUPATIONAL SAFETY
which the subject had been equilibrated AND HEALTH STANDARD
• Hypoxia https://qrs.ly/2zbpwxn
Increase atm • Nitrogen narcosis- nitrogen has
pressure increased solubility in fatty tissues Dr. Mann
causes: • O2 toxicity –retrolental fibroplasia

• Cardiovascular strain BLOOD DONATION PROGRAM
• Republic Act No. 7719, also known as the National Blood
TOP 10 WORK-RELATED ILLNESSES Services Act of 1994, promotes voluntary blood donation to
1. Respiratory diseases 6. Reproductive disorders provide sufficient supply of safe blood and to regulate blood
2. Musculoskeletal diseases 7. Neurotoxic disorders banks.
3. Cancers 8. Noise-induced hearing • This act aims to inculcate public awareness that blood donation
4. Injuries loss is a humanitarian act.
5. CV diseases 9. Dermatological disorders
10. Psychological disorders
SUPPLEMENT: BLOOD DONATION ENVIRONMENTAL HEALTH PROGRAMS
• The most common blood type is Blood Group O followed by PHILIPPINE NATIONAL STANDARDS FOR DRINKING WATER
A, then B and AB.
• Drinking water must be clear and does not have objectionable
• More than 99% of Filipinos are Rh positive while less than
taste, odor and color.
1% has Rh negative blood.
• It must be pleasant to drink and free from all harmful organism,
• After blood is drawn, it is tested for ABO group (blood type)
chemical substances and radionuclides in amounts which could
and RH type (positive or negative). Test for unexpected red constitute a hazard to health of the consumer
blood cell antibodies that may cause problems for the
recipient can be performed upon the request of the patient's Potable water is “free from harmful substances and organisms”
Dr. Mann
attending physician. CHARACTERISTICS OF WATER
o Screening tests performed are listed below:
1. PHYSICAL
§ Hepatitis B surface antigen (HBsAg)
o color and palatability affect behavior & characteristics of water
§ Hepatitis C virus antibody (anti-HCV)/ antigen (HCV Ag)
in its use for commercial, domestic and industrial purposes
§ HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2)
o Analysis of physical attributes:
antigen (HIV-1 and HIV-2 Ag)
§ Turbidity - impurities in suspension
§ Serologic test for syphilis
§ Color - imparted by substances present in solution
§ Nucleic acid amplification testing (NAT) for HIV-1, HCV
§ Taste & odor- expressed only qualitatively
and HBV if available
2. CHEMICAL
• The minimum interval between 2 donations is 12 weeks (3 o Determine and assess behavior of water in pipes and human
months). This interval allows our body to restore it iron body
stock. o Includes:
• Platelet (aphaeresis) donors may donate more frequently § pH - acid <7; Base >7
than - as often as once every two weeks and up to 24 times § Hardness - hard water due to increased Ca & Mg
per year. This is because the body replenishes platelets and § Total Solid content - total mineral impurities present
plasma more quickly than red cells.
3. BIOLOGICAL – Index of pollution
o Determines the kind of microscopic life
BASIC REQUIREMENT OF A POTENTIAL BLOOD DONOR: o Presence of organisms responsible for odor and taste.
• Weight: At least 110 lbs (50 kg). o Biological impurities serve as index of pollution degree of
• Blood volume collected will depend mainly on your body weight. water source
• Pulse rate: Between 60 and 100 beats/minute with regular o Bacteriological Testing
rhythm. § Most important single test to find out if water is potentially
• Blood pressure: Between 90 and 160 systolic and 60 and 100 dangerous; detects “indicator organisms”
diastolic. § Can cause large scale outbreaks!
• Hemoglobin: At least 125 g/L. 4. RADIOLOGICAL
o Testing done when there is a reason to suspect their presence
THREE TYPES OF BLOOD DONORS o Naturally occurring radionuclides in rocks and soils.
• PROFESSIONAL/PAID DONORS: They sell their blood, which is o Principal source of radium & radon: deep-wells, ground water
of very poor quality and can transmit very dangerous diseases & mineral springs
to the recipient. It is illegal to take blood from any professional
or paid donor. TYPES OF WATER EXAMINATION
• REPLACEMENT DONATION: Healthy relatives and friends of 1. Initial- physical, chemical bacteriological and radiological
the patient give their blood, of any group, to the blood bank. In examination are required before a newly constructed system
exchange, the required number of units in the required blood or sources be operated & open for public use
group is given. 2. Periodic-
• VOLUNTARY DONATION: Here, a donor donates blood a. bacteriological exam as often as possible but interval not
voluntarily. The blood can be used for any patient even without more than 6 months
divulging the identity of the donor. This is the best type of blood b. General systemic chemical exam every 12 months
donation where a motivated human being gives blood in an act c. Radioactive contamination exam every year
of selfless service. DRINKING WATER SUPPLY PROTECTIVE MEASURES
• Washing clothes or bathing from source of drinking water is
CONDITIONS THAT PREVENT A PERSON FROM DONATING prohibited within 25 meters.
• Temporary conditions: • No source of water should be constructed within 25 meters
o Pregnancy from any source of pollution
o Acute fever • No radioactive materials shall be stored within 25 meters
o Recent alcoholic intake • Any physical connection between distribution system of a public
o Ear or body piercing and tattooing water supply system to any other water supply is not allowed
o Surgery • Installation of booster pump is not allowed where low water
• Conditions not allowed to donate blood anytime: pressure prevails
o Cancer
The first 3 follows the “25 meters rule”
o Cardiac disease Dr. Mann
o Sever lung disease HOUSEHOLD METHODS OF WATER TREATMENT
o Hepatitis B and C • Boiling- Boil water for 10-20 minutes, two minutes or longer at
o HIV/AIDS/STD 100 degrees Celsius will kill most disease causing germs
o High risk occupation (e.g. prostitution) including cholera
o Unexplained weight loss of more than 5 kg over 6 months • Sedimentation- allows impurities to settle for 30 min- 1 hr. then
o Chronic alcoholism pour the top part in a new clean container
• Aspirin and Ibuprofen will not affect a whole blood donation • Flocculation and sedimentation- use of aluminum sulfate
• Apheresis platelet donors, however, must not take aspirin or aspirin crystals “tawas” to form precipitates of impurities and then
products 36 hours prior to donation allowing the precipitates to settle at the bottom of the container
Dr. Mann
• Aeration- transfer the water from one container to the other or
stir the water to create a turbulence
• Filtration- use of cloth, sand filters
• Chemical disinfection
o Chlorination- chlorination is the most widely used method
for disinfecting drinking water, powerful germicide, combines
with suspended organic matter
o Tincture of iodine- 2 drops/ 1 liter of water
WATER- RELATED DISEASES SOLID WASTE MANAGEMENT
• Water-related diseases can be classified into 4 major REFUSE DISPOSAL
categories: 1. Burial – in pits (1m x 1m deep); pit should be located at
least 25m away from any well used for water supply
1. WATER BORNE DISEASES:
2. Open Burning
o Transmitted by contaminated drinking water
3. Feeding to animals
Bacterial - Typhoid fever,
4. Composting
cholera, bacillary dysentery
5. Grinding and dispersal to sewer
Microbic-specific Viral - Hepatitis A
organisms Protozoan - amoebic dysentery COMMUNITY REFUSE DISPOSAL METHODS:
Helminthic - ascariasis, 1. Dumping in land:
trichuriasis 2. Sanitary Landfill - Aka cut and cover
Non-microbic Heavy metal poisoning • Distribution of refuse in alternate layer of refuse and
Presence or an excess of Nitrate (Infantile earth fill (Soil cover of 2-3 feet cover)
certain chemical methemoglobinemia (< 1yo)) 3. Composting
substances in water Dental Fluorosis (excess • Aerobic – use of air pumps or by frequent turning
Dr. Mann
fluoride) • Anaerobic- burying organic material
2. WATER-WASHED DISEASES 4. Incinerator
• Transmitted from person to person due to inadequate water • Controlled burning with extremely high temperatures
supply for personal hygiene and/ or domestic cleaning (e.g. • Appropriate for hospitals
scabies, lice, typhus, trachoma conjunctivitis and hookworm) • Problems of air pollution may arise
3. WATER- BASED DISEASES 5. Reduction and salvage
• Caused by agents spread by contact with or ingestion of water • Garbage is finally disposed of by applying pressure to
(Schistosomiasis, leptospirosis) remove oils, grease and fats
SUPPLEMENT: RADIOACTIVE WASTE
4. WATER RELATED INSECT-VECTOR DISEASES
• Transmitted by insects harboring in water (Dengue, H-Fever, • The use of Landfills is the only method of disposing
Filariasis, Malaria, Onchocerciasis and Japanese encephalitis radioactive waste safely
Effects of radiation exposure
SOURCES OF WATER SUPPLIES • Acute exposure to ionizing radiation results in:
• SURFACE WATERS - streams, brooks, ponds, lakes, rivers • 100 – 200 rem: mild hematopoietic disturbances, may have
some vomiting after exposure
• GROUND WATER
o Largest source of water; untreated non-saline is normally • 200-600 rem: severe hematopoietic disturbance requiring
safe to drink since deep supplies are biologically pure with transfusions, growth factor and antibiotics
regard to bacteria, algae, protozoa and viruses • 600 – 1000 rem: extreme exposure, high fatality rate (80 to
o Sources: 100% in 2 months), GI and CNS symptoms predominate
o Wells – deep wells are generally >100ft in depth
o Springs – ground water seepages when level of underground SUPPLEMENT: BIOLOGICAL WASTE MANAGEMENT
water comes in contact with surface; usually on the side of a Color of Container/Bag Type of Waste
hill or mountain Black Non-infectious dry waste
• RAINWATER Green Non-infectious wet waste
o Good supply of water since it is basically free from impurities (kitchen, dietary etc)
but contamination may occur at the collection and storage Yellow Infectious and Pathological waste
points Yellow with black
Chemical waste including those
band
TREATMENT OF PUBLIC WATER SUPPLY w/ heavy metals
1. Chlorination- most important single treatment Orange Radioactive waste
2. Complete Standard Water treatment Red Sharps and Pressurized
a. Coagulation- Use of chemical such as alum to form flocus containers
b. Sedimentation- allowing flocus to settle DOH Health Care Waste Management
c. Rapid sand Filtration- settled water is filtered through

sand and rained to filtered water reservoir PHILIPPINE INTEGRATED DISEASE
d. Chlorination- done using an appropriate water reservoir SURVEILLANCE AND RESPONSE
3. Double Treatment - Repeating the treatment methods
Priority Diseases/Syndromes And Conditions Targeted For
Bacterial Quality Surveillance
Degree of treatment
(coliform/ 100ml) DISEASES OTHER DISEASES
<50 Chlorination alone TARGETED FOR OR CONDITIONS
EPIDEMIC-PRONE
Standard complete ERADICATION OF PUBLIC
50-5,000 DISEASES
treatment OR HEALTH
5,000- 50,000 Double treatment ELIMINATION IMPORTANCE
>50,000 Look for another source 1. Acute Viral Hepatitis 1. Poliomyelitis 1. Acute Bloody
2. Anthrax (Acute Flaccid Diarrhea
AIR POLLUTION 3. Bacterial Meningitis Paralysis) 2. Acute
• An act of introducing into the atmosphere substances or 4. Cholera 2. Measles Hemorrhagic Fever
pollutants which may be injurious to public health and cause 5. Dengue 3. Neonatal 3. Acute
nuisance. 6. Human Avian Tetanus Encephalitis
Influenza 4.Rabies Syndrome/Japanese
SUPPLEMENT: RULE OF 1000
7. Influenza-like Illness 5.Malaria Encephalitis
Rule of 1000 - States that a pollutant released indoors is 1000 8. Leptospirosis 4. Adverse Event
times more likely to reach the lungs than a pollutant released 9. Meningococcal Following
outdoors since most people are indoors 70% of their time. Disease Immunization
Particle Size 10. Paralytic Shellfish (AEFI)
• >10um – filtered by nose and pharynx, cleared by nasal secretion Poisoning 5. Diphtheria
• >2um but <10um- deposited in the tracheobronchial tree 11. Severe Acute 6. Hand Foot and
• 1-2um- deposited in the alveolar sacs Respiratory Syndrome Mouth Disease
(SARS) 7. Non-Neonatal
12. Typhoid And Tetanus
Paratyphoid Fever 8. Pertussis
Manual of Procedures for the Philippine Integrated Disease Surveillance and Response 3 rd Edition April 201
HOSPITAL COLOR CODING

PHILIPPINE INTEGRATED DISEASE HOSPITAL CODE COLORS (NOT STANDARDIZED)
SURVEILLANCE AND RESPONSE • Code BLUE –medical emergency
https://qrs.ly/c6bq4pu • Code RED- Smoke or Fire
• Code BLACK –bomb threat
• Code Pink –Infant or child abduction
PHILIPPINE HERBAL MEDICINAL PLANTS • Code Orange- hazardous material or spill incident
• Code SILVER –active shooter
COMMON SCIENTIFIC
USE • Code Violent –Violent or combative individual
NAME NAME
• Code Yellow –Disaster
Scabies, tinea, ringworm,
Akapulko Cassia alata • Code Brown –Severe Weather
athlete’s foot
Momordica • Code White –Evacuation
Ampalaya Anti-diabetes • Code Green –Emergency Activation
charantia
Allium Lowers cholesterol level,
Bawang TRIAGE COLOR CODE
Sativum athlete’s foot
Dizziness, fainting spells, • Red tags - (immediate) are used to label those who cannot
Psidium aromatic bath, diarrhea, survive without immediate treatment but who have a chance of
Bayabas survival.
guajava swollen gum, inflammation,
wound and vaginal wash • Yellow tags - (observation) for those who require observation
Vitex Fever, headache, toothache, (and possible later re-triage). Their condition is stable for the
Lagundi moment and, they are not in immediate danger of death. These
negundo cough, asthma
Niyog- Quisqualis victims will still need hospital care and would be treated
Ascariasis immediately under normal circumstances.
Niyogan indica
Blumea • Green tags - (wait) are reserved for the "walking wounded"
Sambong balsamifera Urolithiasis who will need medical care at some point, after more critical
injuries have been treated.
Tsaang Carmona • White tags - (dismiss) are given to those with minor injuries for
Abdominal pain whom a doctor's care is not required.
gubat retusa
Ulasimang Peperonia • Black tags - (expectant) are used for the deceased and for those
Lowers uric acid level whose injuries are so extensive that they will not be able to
Bato pellucida
Yerba Mentha Gaseous distention, survive given the care that is available.
Buena cordifolia rheumatism
TYPES OF LEADERSHIP STYLES
NEVER EVENTS Democratic Leadership
• The term "Never Event" in reference to particularly shocking • The leader makes decisions based on the input of each team
medical errors member. Although he or she makes the final call, each employee
https://psnet.ahrq.gov/primer/never-events has an equal say on a project's direction
SURGICAL EVENTS Autocratic Leadership
• Surgery performed on the wrong body part/wrong patient/ • inverse of democratic leadership. In this leadership style, the
wrong surgical procedure leader makes decisions without taking input from anyone who
• Retention of a foreign object in a patient after surgery reports to them
Laissez-Faire Leadership
PRODUCT OR DEVICE EVENTS • French term "laissez faire" literally translates to "let them do,"
• Patient death or serious disability associated with the use of and leaders who embrace it afford nearly all authority to their
contaminated drugs, devices, or biologics provided by the employees
healthcare facility Bureaucratic Leadership
• Bureaucratic leaders go by the books. This style of leadership
PATIENT PROTECTION EVENTS might listen and consider the input of employees -- unlike
• Infant discharged to the wrong person autocratic leadership -- but the leader tends to reject an
• Patient suicide, or attempted suicide resulting in serious employee's input if it conflicts with hospital policy or past
disability, while being cared for in a healthcare facility practices.
CARE MANAGEMENT EVENTS

• medication error (e.g., error involving the wrong drug, wrong END OF PREVENTIVE MEDICINE, PUBLIC HEATH
dose, wrong patient, wrong time, wrong rate, wrong
preparation, or wrong route of administration)
• hemolytic reaction due to the administration of ABO-
incompatible blood or blood products Important Legal Information
• Maternal death or serious disability associated with labor or Preparation Incorporated are duly protected by RA 8293 otherwise known as the
delivery on a low-risk pregnancy while being cared for in a Intellectual Property Code of the Philippines, and shall only be for the sole use of the person:
healthcare facility Medical Board Preparation Incorporated Program or c) is the recipient of this electronic
communication. No part of the handout, video or other review material may be reproduced,
ENVIRONMENTAL EVENTS shared, sold and distributed through any printed form, audio or video recording, electronic
medium or machine-readable form, in whole or in part without the written consent of
• Patient death associated with a fall while being cared for in a Topnotch Medical Board Preparation Incorporated. Any violation and or infringement,
healthcare facility whether intended or otherwise shall be subject to legal action and prosecution to the full
• Patient death or serious disability associated with the use of
restraints or bedrails while being cared for in a healthcare DISCLOSURE
facility The handouts/review materials must be treated with utmost confidentiality. It shall be the
responsibility of the person, whose name appears therein, that the handouts/review
materials are not photocopied or in any way reproduced, shared or lent to any person or
CRIMINAL EVENTS disposed in any manner. Any handout/review material found in the possession of another
• Abduction of a patient of any age person whose name does not appear therein shall be prima facie evidence of violation of RA
8293. Topnotch review materials are updated every six (6) months based on the current
• Sexual assault on a patient within or on the grounds of a trends and feedback. Please buy all recommended review books and other materials listed
healthcare facility below.
TOPNOTCH MEDICAL BOARD PREP PREVMED PHASE 2 HANDOUT BY DRS. MANN AND DE LA ROSA
For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/
This handout is only valid for September 2021 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.
When a patient is asked to evaluate his chest pain on
Important Legal Information
The handouts, videos and other review materials, provided by Topnotch Medical Board a scale of 0 (no pain) to 10 (the worst pain), he
Preparation Incorporated are duly protected by RA 8293 otherwise known as the reports to the evaluating clinician that his pain is an
Intellectual Property Code of the Philippines, and shall only be for the sole use of the person: 8. After the administration of sublingual
Medical Board Preparation Incorporated Program or c) is the recipient of this electronic nitroglycerin and high-flow oxygen, the patient
communication. No part of the handout, video or other review material may be reproduced, reports that the pain is now a 4 on the same scale.
shared, sold and distributed through any printed form, audio or video recording, electronic
After the administration of morphine sulfate, given
medium or machine-readable form, in whole or in part without the written consent of 4.
Topnotch Medical Board Preparation Incorporated. Any violation and or infringement, as an intravenous push, the pain is 0. This pain scale
whether intended or otherwise shall be subject to legal action and prosecution to the full is a:
A. Continuous scale
B. Dichotomous scale
DISCLOSURE C. Nominal scale
The handouts/review materials must be treated with utmost confidentiality. It shall be the
responsibility of the person, whose name appears therein, that the handouts/review D. Qualitative scale
materials are not photocopied or in any way reproduced, shared or lent to any person or E. Ratio scale
disposed in any manner. Any handout/review material found in the possession of another
person whose name does not appear therein shall be prima facie evidence of violation of RA
Ten volunteers are weighed in a consistent manner
8293. Topnotch review materials are updated every six (6) months based on the current before and after consuming an experimental diet for
trends and feedback. Please buy all recommended review books and other materials listed 6 weeks. This diet consists of apple strudel,
below.
THIS HANDOUT IS NOT FOR SALE! tomatillo salsa, and gummy bears. (Don’t try this at
home!) The weights are shown in the accompanying
table. The mean weight before the intervention is:
REMINDERS
1. Finish the Phase 0 handout and Phase 1 video before proceeding to the
Phase 2 handout and video.
2. Phase 2 handouts are based on commonly used review books and
previous question feedback from students.
3. Answer the Pre-Test (Guide Questions) first prior to watching the video
lectures.
4. The guided content of the video lectures are in the 2nd part of the Phase
2 handouts and are meant to complement the video lecture.
This handout is only valid for the September 2021 PLE batch. 5.
This will be rendered obsolete for the next batch
since we update our handouts regularly.
PREVENTIVE MEDICINE AND

PUBLIC HEALTH – PHASE 2 A.
(81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
By + 78)/10
B. (81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
Mark Louie C. Mann, MD + 78)/(10 – 1)
Marianne Michelle Q. de la Rosa, MD C. (81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
+ 78)2/10
D. (81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
QUESTIONNAIRE + 78)/102
Stage of subclinical disease, extending from the time E. Not possible to calculate from the given data
of exposure to onset of disease? For distribution A you can conclude that?
A. Incubation period
1. B. Stage of susceptibility
C. Clinical disease stage
D. Recovery stage
E. Symptomatic stage 6.
22 cases of legionellosis occurred within 3 weeks A. The distribution is normal (Gaussian)
among residents of a particular neighborhood B. Mean > median > mode
(usually 0 or 1 per year). From the given scenario C. Mean < median < mode
Identify the level of disease. D. Mean = median = mode
2. A. Sporadic disease E. Outliers pull the mean to the right
B. Endemic disease Which is an example of tertiary prevention?
C. Hyperendemic disease A. Hospice care (end-of-life palliative care)
D. Holoendemic disease B. Occupational therapy after a stroke
E. Epidemic disease 7. C. Post exposure prophylaxis for rabies
What is the prevalence of disease during July in a D. Treatment of essential hypertension
population of 700 people? E. Using nasal steroids with topical
decongestants to prevent rebound congestion
Under what circumstances can primary and tertiary
prevention of medical disease most obviously be
achieved concurrently in different individuals
through the treatment of one patient?
A. Never, because primary and tertiary
prevention are mutually exclusive
8.
3. B. When a patient is treated for a hip fracture
C. When a patient is treated for active
tuberculosis
D. When a patient is treated for cystitis (an
uncomplicated urinary tract infection)
E. When a patient is treated for a heart attack
A. 3/700
B. 4/700
C. 5/700
D. 8/700
TOPNOTCH MEDICAL BOARD PREP PREVMED PHASE 2 HANDOUT BY DRS. MANN & DE LA ROSA Page 1 of 9
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
Identify the family structure in the given scenario: Which of the following is a sensitive indicator of the
Juliana is a widower from White Plains she has a son standard of health care by analyzing the number of
named Robert, after 5 years of being single she deaths over 50 years old?
decided to marry Anselmo a divorcee from Ayala A. Child mortality rate
17.
Alabang, he has 3 kids. B. Age specific proportionate mortality
9.
A. Extended C. Maternal mortality rate
B. Single Parent D. Dependency ratio
C. Blended E. Swaroop’s index
D. Nuclear In a study of a novel antihypertensive drug, the
E. Communal experimental group had a mean systolic blood
Arnold Dolomite is a meat slicer from S en R pressure of 123, 125 and 124 respectively on 3
Alabang, he was rushed to the hospital because of an separate measurement readings using a
injury involving his right index finger, upon sphygmomanometer, the mean was 124 with
examination the finger was hanging only by the skin, intraarterial measurement of BP. Which of the ff.
18.
also it was reported that he was drunk while at statements below best describe the situation?
work. Given this scenario which hazard control A. The measurements are imprecise and
protocol will be best to prevent this kind of injury? inaccurate
10. A. Arnold Dolomite should wear personal B. The measurements are imprecise but accurate
protective equipment C. The measurements are precise and accurate
B. Arnold should follow the policy of no drinking D. The measurements are precise but inaccurate
of alcohol at the workplace What is the formula for sensitivity?
C. The meat slicer should be replaced by a butter A. TP/ (FN + TN)
knife 19. B. TP / (TP + FN)
D. S en R should install automatic meat slicer C. TN/ (FN + TN)
machine D. TN/ (TP + FP)
What is the type of hazard control employed If What sampling method is employed when
Arnold Dolomite followed the no drinking policy at households are selected at random and every
work? person in each household is included in the sample?
A. PPE 20. A. Systematic sampling
11.
B. Administrative B. Simple random sampling
C. Substitution C. Stratified sampling
D. Engineering Control D. Cluster sampling
E. Elimination Which graph is suitable to be used to show the
A group of patients with lung cancer is matched to a increasing cases of dengue from 2009-2021?
group of patients without lung cancer. Their A. Frequency polygon
21.
smoking habits over the course of their lives is B. Pie chart
compared. On the basis of this information, C. Line graph
researchers compute the rate of lung cancer in D. Bar Chart
patients who smoke versus those who never Most common measure of central tendency?
12.
smoked. This is an example of what study A. Mean
A. Case-Control 22. B. Mode
B. Cohort C. Median
C. Cross-sectional D. Range
D. Longitudinal What statistical test should be used in comparing
E. Randomized the serum cholesterol levels of patients before and
Haydeelyn lost his vision because of bilateral retinal after intake of a new lipid lowering drug/agent?
detachment after an encounter with Nestea. Luckily, 23. A. ANOVA
there are braille in the elevator so he has no B. Chi-Square
problem getting around. What is the condition of C. Paired T-test
Haydeelyn? D. Independent T-test
13.
A. Impairment What is the most Sensitive index in assessing health
B. Disability status of the community?
C. Handicap A. Maternal Mortality Rate
D. A and B 24.
B. Infant Mortality Rate
E. All of the above C. Crude Death Rate
Sarah P. undergoes a screening test and a tumor was D. Specific Mortality Rate
discovered. The screening advanced the time of In a local study done in a community hospital in the
diagnosis but no true prolongation of life occurs OB-GYN department, the number of maternal live
because there are no effective treatments available. births via NSD in a year is 5000, CS is 2000/year.
What form of bias is this? Among those who delivered, there was a recorded
14.
A. Length bias 200 deaths in the same year, of the 200, 100 died
B. Lead time bias from complications from hypertension in
C. Information bias pregnancy, 50 from postpartum hemorrhage, 30
D. Recall bias 25. from sepsis, 20 from cardiovascular diseases. In
E. Selection bias relation to the case above, what is the mortality rate
The PLACE of birth is an example of what due to sepsis in the above population?
measurement scale? A. 10%
A. Dichotomous B. 15%
15. B. Nominal C. 20%
C. Ordinal D. 25%
D. Interval E. 30%
E. Ratio All of the ff. increases prevalence rate except?
The blood type is what kind of measurement scale: A. Longer duration of illness
A. Quantitative Interval 26. B. Increase in new cases
16. B. Qualitative Nominal C. High case fatality rate
C. Qualitative Ordinal D. Improved diagnostic facilities
D. Quantitative Ratio
Epidemiological concept stating that the effects Family assessment tool used to assess the capacity
never depend on a single isolated cause but rather to participate in provision of health care / cope with
each link is the result of a complex genealogy and crisis
antecedents 36. A. Family genogram
27.
A. Epidemiologic Triad B. Family APGAR
B. Web of causation C. Minuchin family map
C. Lever or balance D. SCREEM
D. The wheel Tool for family assessment to measure ones level of
Refers to the constant presence of a satisfaction with family relationships usually
very high incidence of disease/infection? needed when family will be directly involved in
A. Hyperendemic caring for the patient?
28. 37.
B. Endemic A. Genogram
C. Epidemic B. Family APGAR
D. Pandemic C. Minuchin family map
Study Design that assigns/manipulates a patient’s D. SCREEM
environment is a: Which of the following is not included in the
A. Cohort expanded newborn screening?
29.
B. Cross Sectional A. Glucose-6-Phosphate-Dehydrogenase
C. Case Control 38. Deficiency
D. Clinical Trial B. Phenylketonuria
A study enrolled 355 participants in a dedicated C. Cystic Fibrosis
weight loss clinic and tracked their health annually D. Hypothyroidism
for an average of 4 years to see whether there is an This presents fundamental strategies and
effect in reduction in atrial fibrillation burden and approaches for health promotion which the
severity, what is the study design? participants considered vital for major progress
30.
A. Cross sectional 39. A. Alma Atta Declaration
B. Case control B. Ottawa Charter
C. Cohort C. MDGs
D. RCT D. SDGs
E. Meta-analysis Formation of neighborhood walking clubs to
Which of the ff. is not included as part of traits and combat hypertension and high cholesterol is what
roles of a 5 star physician? form of health promotion strategy?
A. Teacher/educator A. Educational
31. 40.
B. Researcher B. Organizational
C. Adviser C. Legislative
D. Manager/administrator D. Social
In counseling a patient in smoking cessation, the E. Economic
patient answers “I don’t think smoking half a pack a Regulations aimed at reducing youth access to
day can do so much harm, after all, I’m already 75 tobacco products and alcohol is what kind of health
and I’ve done it for the past 25 years”. Which among promotion strategy?
the ff. is the patient currently in, in terms of capacity 41. A. Educational
32. for change in behavior? B. Organizational
A. Precontemplation C. Legislative
B. Contemplation D. Community
C. Preparation Ability of an agent to produce serious illness;
D. Action measured in terms of fatality?
E. Maintenance A. Infectivity
42.
A family consists of the mother, the father with 3 B. Pathogenicity
children, the eldest is a medical student aged 22, the C. Virulence
middle child is aged 17 taking up an undergraduate D. Antigenicity
degree while the youngest sibling is aged 9 in Which of the ff. interventions is the most effective in
primary school. What stage are they in the family life prevention and control of injuries especially in the
33.
cycle? workplace?
A. Unattached young adult 43. A. Education
B. Launching family B. Law enforcement
C. Family with adolescents C. Engineering
D. Family with young children D. Economic incentives
Patient was discharged from hospitalization after Which among the ff. is true regarding the UN
having a stroke which left him with residual left sustainable developmental goals?
sided weakness. He is regularly being seen by his A. 15 goals to be achieved over the next 10 years
physician for follow up, is compliant with 44. B. 17 goals to be achieved over the next 15 years
medications and attends regular physical therapy, C. Continuation of the millennium development
34. what stage is he in the family illness trajectory? goals for the next 10 years
A. Onset of illness to diagnosis D. 13 goals to be achieved over the next 20 years
B. Early adjustment to outcome Which UN millennium developmental goal does not
C. Impact phase involve maternal health care:
D. Major therapeutic efforts A. 1
E. Adjustment to permanency of outcome 45.
B. 3
The ff. are true about constructing a genogram C. 5
except? D. 7
A. Should have at least 3 generations All of the ff. are part of the millennium development
35.
B. 1st born should be farthest from the left goals except?
C. Family name above each main family A. Eradicate extreme poverty and hunger
D. Index patient marked with a triangle 46.
B. Reduce child mortality
C. Achieve universal primary education
D. Universal health care for all
Which among the ff. vaccines is not part of the EPI When a patient is asked to evaluate his chest pain on
program of the DOH? a scale of 0 (no pain) to 10 (the worst pain), he
A. Hib reports to the evaluating clinician that his pain is an
47. B. Varicella 8. After the administration of sublingual
C. Mumps nitroglycerin and high-flow oxygen, the patient
D. BCG reports that the pain is now a 4 on the same scale.
E. Hepatitis A After the administration of morphine sulfate, given
4.
Definition of a fully immunized child before 1 year as an intravenous push, the pain is 0. This pain scale
old the ff. vaccines must be given except? is a:
A. Hep B x 3 A. Continuous scale
48.
B. BCG B. Dichotomous scale
C. Measles C. Nominal scale
D. MMR D. Qualitative scale
The following are signs of dengue with warning E. Ratio scale
signs except? Ten volunteers are weighed in a consistent manner
A. Lethargy before and after consuming an experimental diet for
49.
B. Ascites 6 weeks. This diet consists of apple strudel,
C. Thrombocytosis tomatillo salsa, and gummy bears. (Don’t try this at
D. Hemoconcentration home!) The weights are shown in the accompanying
All of the ff. are considered under Category II bite table. The mean weight before the intervention is:
wounds for rabies except?
A. Nibbling of uncovered skin
50.
B. Minor abrasions on the face
C. Scratches on the right arm
D. All are category 2 wounds
DISCUSSION
Stage of subclinical disease, extending from the time
of exposure to onset of disease? 5.
A. Incubation period
1. B. Stage of susceptibility
C. Clinical disease stage
D. Recovery stage
E. Symptomatic stage
A.
(81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
+ 78)/10
B. (81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
+ 78)/(10 – 1)
C. (81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
+ 78)2/10
D. (81 + 79 + 92 + 112 + 76 + 126 + 80 + 75 + 68
+ 78)/102
E. Not possible to calculate from the given data
For distribution A you can conclude that?
6.
A. The distribution is normal (Gaussian)
B. Mean > median > mode
22 cases of legionellosis occurred within 3 weeks C. Mean < median < mode
among residents of a particular neighborhood D. Mean = median = mode
(usually 0 or 1 per year). From the given scenario E. Outliers pull the mean to the right
Identify the level of disease.
2. A. Sporadic disease
B. Endemic disease
C. Hyperendemic disease
D. Holoendemic disease
E. Epidemic disease
What is the prevalence of disease during July in a
population of 700 people?
3.
A. 3/700
B. 4/700
C. 5/700
D. 8/700
Which is an example of tertiary prevention? A. Case-Control
A. Hospice care (end-of-life palliative care) B. Cohort
B. Occupational therapy after a stroke C. Cross-sectional
7. C. Post exposure prophylaxis for rabies D. Longitudinal
D. Treatment of essential hypertension E. Randomized
E. Using nasal steroids with topical
decongestants to prevent rebound congestion
Under what circumstances can primary and tertiary
prevention of medical disease most obviously be
achieved concurrently in different individuals
through the treatment of one patient?
A. Never, because primary and tertiary
prevention are mutually exclusive
8.
B. When a patient is treated for a hip fracture
C. When a patient is treated for active
tuberculosis
D. When a patient is treated for cystitis (an
uncomplicated urinary tract infection)
E. When a patient is treated for a heart attack Haydeelyn lost his vision because of bilateral retinal
Identify the family structure in the given scenario: detachment after an encounter with Nestea. Luckily,
Juliana is a widower from White Plains she has a son there are braille in the elevator so he has no
named Robert, after 5 years of being single she problem getting around. What is the condition of
decided to marry Anselmo a divorcee from Ayala Haydeelyn?
13.
Alabang, he has 3 kids. A. Impairment
9. B. Disability
A. Extended
B. Single Parent C. Handicap
C. Blended D. A and B
D. Nuclear E. All of the above
E. Communal Sarah P. undergoes a screening test and a tumor was
Arnold Dolomite is a meat slicer from S en R discovered. The screening advanced the time of
Alabang, he was rushed to the hospital because of an diagnosis but no true prolongation of life occurs
injury involving his right index finger, upon because there are no effective treatments available.
examination the finger was hanging only by the skin, What form of bias is this?
14.
also it was reported that he was drunk while at A. Length bias
work. Given this scenario which hazard control B. Lead time bias
protocol will be best to prevent this kind of injury? C. Information bias
10. A. Arnold Dolomite should wear personal D. Recall bias
protective equipment E. Selection bias
B. Arnold should follow the policy of no
drinking of alcohol at the workplace
C. The meat slicer should be replaced by a butter
knife
D. S en R should install automatic meat slicer
machine
What is the type of hazard control employed If
Arnold Dolomite followed the no drinking policy at
work?
A. PPE
11.
B. Administrative
C. Substitution
D. Engineering Control
E. Elimination
The PLACE of birth is an example of what

measurement scale?
A. Dichotomous
15. B. Nominal
C. Ordinal
D. Interval
E. Ratio
The blood type is what kind of measurement scale:
A. Quantitative Interval
16. B. Qualitative Nominal
C. Qualitative Ordinal
D. Quantitative Ratio
Which of the following is a sensitive indicator of the
standard of health care by analyzing the number of
A group of patients with lung cancer is matched to a deaths over 50 years old?
group of patients without lung cancer. Their A. Child mortality rate
smoking habits over the course of their lives is 17.
B. Age specific proportionate mortality
12. compared. On the basis of this information, C. Maternal mortality rate
researchers compute the rate of lung cancer in D. Dependency ratio
patients who smoke versus those who never E. Swaroop’s index
smoked. This is an example of what study
In a study of a novel antihypertensive drug, the
experimental group had a mean systolic blood
pressure of 123, 125 and 124 respectively on 3
separate measurement readings using a
sphygmomanometer, the mean was 124 with
intraarterial measurement of BP. Which of the ff.
18.
statements below best describe the situation?
A. The measurements are imprecise and
inaccurate
B. The measurements are imprecise but accurate
C. The measurements are precise and accurate
D. The measurements are precise but inaccurate
What is the formula for sensitivity?
A. TP/ (FN + TN)
19. B. TP / (TP + FN)
C. TN/ (FN + TN)
D. TN/ (TP + FP)
Which graph is suitable to be used to show the

increasing cases of dengue from 2009-2021?
A. Frequency polygon
21.
B. Pie chart
C. Line graph
D. Bar Chart
Most common measure of central tendency?
A. Mean
22. B. Mode
What sampling method is employed when C. Median
households are selected at random and every D. Range
person in each household is included in the sample? What statistical test should be used in comparing
20. A. Systematic sampling the serum cholesterol levels of patients before and
B. Simple random sampling after intake of a new lipid lowering drug/agent?
C. Stratified sampling 23. A. ANOVA
D. Cluster sampling B. Chi-Square
C. Paired T-test
D. Independent T-test
What is the most Sensitive index in assessing health
status of the community?
A. Maternal Mortality Rate
24.
B. Infant Mortality Rate
C. Crude Death Rate
D. Specific Mortality Rate
In a local study done in a community hospital in the
OB-GYN department, the number of maternal live
births via NSD in a year is 5000, CS is 2000/year.
Among those who delivered, there was a recorded
200 deaths in the same year, of the 200, 100 died
from complications from hypertension in
pregnancy, 50 from postpartum hemorrhage, 30
25. from sepsis, 20 from cardiovascular diseases. In
relation to the case above, what is the mortality rate Which of the ff. is not included as part of traits and
due to sepsis in the above population? roles of a 5 star physician?
A. 10% A. Teacher/educator
B. 15% 31.
B. Researcher
C. 20% C. Adviser
D. 25% D. Manager/administrator
E. 30%
Revisit this QR Code J
THE FIVE STAR PHYSICIAN

https://qrs.ly/26cqpri
All of the ff. increases prevalence rate except?
A. Longer duration of illness
26. B. Increase in new cases
C. High case fatality rate In counseling a patient in smoking cessation, the
D. Improved diagnostic facilities patient answers “I don’t think smoking half a pack a
Epidemiological concept stating that the effects day can do so much harm, after all, I’m already 75
never depend on a single isolated cause but rather and I’ve done it for the past 25 years”. Which among
each link is the result of a complex genealogy and the ff. is the patient currently in, in terms of capacity
antecedents 32. for change in behavior?
27.
A. Epidemiologic Triad A. Precontemplation
B. Web of causation B. Contemplation
C. Lever or balance C. Preparation
D. The wheel D. Action
Refers to the constant presence of a E. Maintenance
very high incidence of disease/infection?
A. Hyperendemic
28.
B. Endemic
C. Epidemic
D. Pandemic
Study Design that assigns/manipulates a patient’s
environment is a:
A. Cohort
29.
B. Cross Sectional
C. Case Control
D. Clinical Trial
A study enrolled 355 participants in a dedicated
weight loss clinic and tracked their health annually
for an average of 4 years to see whether there is an
effect in reduction in atrial fibrillation burden and
severity, what is the study design?
30.
A. Cross sectional
B. Case control
C. Cohort
D. RCT
E. Meta-analysis
A family consists of the mother, the father with 3

children, the eldest is a medical student aged 22, the
middle child is aged 17 taking up an undergraduate
degree while the youngest sibling is aged 9 in
primary school. What stage are they in the family life
33.
cycle?
A. Unattached young adult
B. Launching family
C. Family with adolescents
D. Family with young children
Patient was discharged from hospitalization after
having a stroke which left him with residual left
sided weakness. He is regularly being seen by his
physician for follow up, is compliant with
medications and attends regular physical therapy,
34. what stage is he in the family illness trajectory?
A. Onset of illness to diagnosis
B. Early adjustment to outcome
C. Impact phase
D. Major therapeutic efforts
E. Adjustment to permanency of outcome
The ff. are true about constructing a genogram Formation of neighborhood walking clubs to
except? combat hypertension and high cholesterol is what
A. Should have at least 3 generations form of health promotion strategy?
35.
B. 1st born should be farthest from the left A. Educational
40.
C. Family name above each main family B. Organizational
D. Index patient marked with a triangle C. Legislative
Family assessment tool used to assess the capacity D. Social
to participate in provision of health care / cope with E. Economic
crisis Regulations aimed at reducing youth access to
36. A. Family genogram tobacco products and alcohol is what kind of health
B. Family APGAR promotion strategy?
C. Minuchin family map 41. A. Educational
D. SCREEM B. Organizational
Tool for family assessment to measure ones level of C. Legislative
satisfaction with family relationships usually D. Community
needed when family will be directly involved in Ability of an agent to produce serious illness;
caring for the patient? measured in terms of fatality?
37.
A. Genogram A. Infectivity
42.
B. Family APGAR B. Pathogenicity
C. Minuchin family map C. Virulence
D. SCREEM D. Antigenicity
Which of the following is not included in the Which of the ff. interventions is the most effective in
expanded newborn screening? prevention and control of injuries especially in the
A. Glucose-6-Phosphate-Dehydrogenase workplace?
38. Deficiency 43. A. Education
B. Phenylketonuria B. Law enforcement
C. Cystic Fibrosis C. Engineering
D. Hypothyroidism D. Economic incentives
This presents fundamental strategies and Which among the ff. is true regarding the UN
approaches for health promotion which the sustainable developmental goals?
participants considered vital for major progress A. 15 goals to be achieved over the next 10 years
39. A. Alma Atta Declaration B. 17 goals to be achieved over the next 15
44.
B. Ottawa Charter years
C. MDGs C. Continuation of the millennium development
D. SDGs goals for the next 10 years
D. 13 goals to be achieved over the next 20 years
Which UN millennium developmental goal does not All of the ff. are part of the millennium development
involve maternal health care: goals except?
A. 1 A. Eradicate extreme poverty and hunger
45. 46.
B. 3 B. Reduce child mortality
C. 5 C. Achieve universal primary education
D. 7 D. Universal health care for all
Which among the ff. vaccines is not part of the EPI
program of the DOH?
A. Hib
47. B. Varicella
C. Mumps
D. BCG
E. Hepatitis A
Definition of a fully immunized child before 1 year
old the ff. vaccines must be given except?
A. Hep B x 3
48.
B. BCG
Revisit this QR Code J C. Measles
D. MMR
The following are signs of dengue with warning
MDG VISUAL MNEMONIC signs except?
https://qrs.ly/jncqqru A. Lethargy
49.
B. Ascites
C. Thrombocytosis
D. Hemoconcentration
All of the ff. are considered under Category II bite

wounds for rabies except?
A. Nibbling of uncovered skin
50.
B. Minor abrasions on the face
C. Scratches on the right arm
D. All are category 2 wounds
END OF PREVMED PHASE 2
TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE PHASE 3 HANDOUT BY DR. LALAINE TIONGSON
Important Legal Information PREVENTIVE MEDICINE

Preparation Incorporated are duly protected by RA 8293 otherwise known as the
It is a branch of medicine that concentrates on keeping
Intellectual Property Code of the Philippines, and shall only be for the sole use of the person: people well with a goal of disease prevention and health
a) whose name appear on the handout or review material, b) person subscribed to Topnotch promotion
Medical Board Preparation Incorporated Program or c) is the recipient of this electronic
communication. No part of the handout, video or other review material may be reproduced, A. Epidemiology
shared, sold and distributed through any printed form, audio or video recording, electronic B. Clinical Epidemiology
medium or machine-readable form, in whole or in part without the written consent of
Topnotch Medical Board Preparation Incorporated. Any violation and or infringement,
C. Health
whether intended or otherwise shall be subject to legal action and prosecution to the full D. Preventive Medicine
extent guaranteed by law. Science and art of preventing disease, prolonging life and
promoting physical and mental health and efficiency
DISCLOSURE A. Epidemiology
The handouts/review materials must be treated with utmost confidentiality. It shall be the B. Clinical Epidemiology
responsibility of the person, whose name appears therein, that the handouts/review
materials are not photocopied or in any way reproduced, shared or lent to any person or C. Health
disposed in any manner. Any handout/review material found in the possession of another D. Preventive Medicine
person whose name does not appear therein shall be prima facie evidence of violation of RA
8293. Topnotch review materials are updated every six (6) months based on the current
Seeks to enhance the lives of patients by helping them
trends and feedback. Please buy all recommended review books and other materials listed promote their health, reduce risk and prevent specific
below. diseases, diagnose diseases early, improve function, and
reduce disability
A. Epidemiology
REMINDERS B. Clinical Epidemiology
1. Phase 3 serves as the final coaching. It is expected that you have finished C. Health
at least the Phase 1 videos prior to watching the Phase 3 videos D. Preventive Medicine
2. The guided content of the video lectures are seen within the handout. In which of the following ways is health promotion
Answers to questions / blanks will be seen in the Phase 3 video.
distinguished from disease prevention?
A. Only health promotion can begin before a disease
This handout is only valid for the September 2021 PLE batch. becomes symptomatic
This will be rendered obsolete for the next batch B. Only health promotion involves materials and
since we update our handouts regularly. methods that are generally nonmedical
C. Only health promotion is applied when a disease has
developed
PREVENTIVE MEDICINE AND D. Only health promotion is targeted at population
PUBLIC HEALTH – PHASE 3 rather than individuals
By Lalaine Macalalag-Tiongson, MD, FPSP PREVENTIVE MEDICINE

• Disease Prevention and Health Promotion
PRIMORDIAL PREVENTION PRIMARY SECONDARY TERTIARY
Consists of actions to minimize Health education & specific Screening programs and Limitation of disability &
future hazards to health and protective measures; Primary medical care rehabilitation from disease.
hence inhibit the establishment environmental modification &
factors (environmental, sanitation Early diagnosis and prompt Maximizing optimal level of
economic, social, behavioral, treatment functioning
cultural) known to increase the General Health promotion,
risk of disease specific protection Aims to reduce the impact of a “soften” the impact of an
disease or injury that has ongoing illness/injury
Prevents onset of disease. It already occurred
aims to reduce incidence of the
disease
Specific disease protection

outlawing alcohol, discouraging Ex: MMR, Malaria prophylaxis, Self-breast examination; PT and psychological rehab in
smoking, promoting regular immunization, medication compliance to cases of deformities; cardiac or
physical activities prevent heart attacks or stroke rehab programs; post-op
strokes, pap smear, PSA chemotherapy
Maintain appropriate weight, blood pressure, lipids, and Which of the following is an example of secondary
glucose. Eating well and exercise. prevention?
A. Primary prevention A. Cholesterol reduction in a patient with asymptomatic
B. Secondary prevention Coronary artery disease
C. Tertiary prevention B. Prescription drug therapy for symptoms of
D. Primordial prevention menopause
What is an example of tertiary prevention? C. Physical therapy after lumbar disk herniation
A. Hospice care D. Pneumococcal vaccine in a patient who has
B. Occupational therapy after a stroke (cerebrovascular undergone splenectomy
accident) The pregnant mother with syphilis is treated with
C. Post exposure prophylaxis for rabies penicillin , what is the level of prevention involved?
D. Treatment of essential hypertension A. Primary
E. Use of nasal decongestants B. Secondary
Immunization, reducing exposure to a risk factor is an C. Tertiary
example of? D. Both primary and tertiary
A. Primary prevention The administration of Human immune globulin after
B. Secondary prevention exposure to Hepatitis B is an example of:
C. Tertiary prevention A. Cross –reactivity
D. Primordial prevention B. Health promotion
C. Hypersensitivity
D. Passive immunity
E. Secondary prevention
TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE PHASE 3 HANDOUT BY DR. LALAINE TIONGSON Page 1 of 24
LEVELS OF PREVENTION CLASSICAL VS. CLINICAL EPIDEMIOLOGY

Disability is permanent, irreversible A. Primary CLASSICAL CLINICAL
and stabilized Prevention • Population oriented • Study patients in health care
Immunizations B. Secondary • Studies the community settings rather that in
Checking for cuts and/blisters on the Prevention origins of health problems community at large
foot of diabetics C. Tertiary (infectious agents, • Goal is to improve the
Encouraging regular checkups Prevention nutrition, environment, prevention, early detection,
BSE, TSE, Mammography behavior, social, economic, diagnosis, treatment,
and spiritual prognosis, and care of illness
Optimal reconstitution
• Interested in discovering in INDIVIDUAL PATIENTS
Regain high –level wellness who are at risk for, or already
risk factors that might be
Environmental sanitation altered in a population to affected by, specific disease
General Nursing assessment at the prevent or delay disease,
hospital, community and the home injury, and death
Prevention of Accidents
Health education on balanced Diet HIPPOCRATES (CIRCA 400B.C.)
Taking of medications for • Hippocrates attempted to explain disease
Hypertension occurrence from a rational rather than a
supernatural viewpoint.
LEVELS OF PROMOTION • Hippocrates suggested that environmental
Vaccinating a health care worker A. Health and host factors such as behaviors might
against Hepatitis B Promotion influence the development of disease
Giving Isoniazid for one year to a 28 B. Secondary • Theory – Four Humors: Blood, Yellow Bile,
year old medical student whose Prevention Black bile, and Phlegm
result in the tuberculin skin test C. Specific
using purified protein derivative Protection JOHN GRAUNT (1662)
recently converted from negative to D. Tertiary • John Graunt, a London haberdasher and
positive Prevention councilman who published a landmark
Performing carotid endarterectomy analysis of mortality data in 1662.
in a patient with transient ischemic • Founder of DEMOGRAPHY
attacks • Quantify patterns of birth, death, and
Recommending regular physical disease occurrence, noting disparities
activity to a patient with no known between males and females, high infant
medical problems mortality, urban/rural differences, and
seasonal variations.
EPIDEMIOLOGY WILLIAM FARR (1800)
Study of factors that influence health of populations. The • William Farr built upon Graunt’s work by
application of epidemiologic findings to decisions in the systematically collecting and analyzing
care of individual patients is: Britain’s mortality statistics.
A. Generally inappropriate • Farr, considered the father of modern vital
B. Known as clinical epidemiology statistics and surveillance, developed
C. Limited to chronic disease epidemiology many of the basic practices used today in
D. Limited to infectious disease epidemiology vital statistics and disease classification.
E. Limited to biologic mechanisms rather than social and • Also worked on Cholera
environmental considerations
This is the branch of medicine that deals with the study of IGNÁZ PHILIPP SEMMELWEIS
the causes, distribution and control of disease in
• First Clinics by Physicians and Medical
populations:
Students had higher rates of Puerperal Fever
A. Family Medicine
than Second Clinics handled by Midwives.
B. Preventive Medicine
C. Epidemiology • Implemented a policy that Physicians and
D. Public Health Medical Students should was hands
thoroughly before touching a pregnant patient.
What is the ultimate aim of Epidemiology?
As a result, PUERPERAL FEVER decreased
A. Reduce morbidity and mortality from disease by
from 12.2% to 2.4%
developing a rational basis for prevention programs
B. Determine the extent of the disease found in the
EDWARD JENNER
community
C. To study the natural history and prognosis of the • Small pox a problem during his time.
disease. • Milk maids who have had COWPOX where
D. Evaluate both preventive and therapeutic measures of somewhat protected from SMALLPOX
health care delivery system • Vaccination against SMALLPOX instead of
E. All of the above variolation(grinding scabs from patients
with mild form and blowing them into the
nose of nonimmune individuals) .
JOHN SNOW (1854) CHARLES STUART –HARRIS (JULY 12, 1909-FEBRUARY 23,
• Anesthesiologist -London 1996)
• “Father of field epidemiology.” • English Virologist and academic; First full-
• Conducted studies of cholera outbreaks time professor of Medicine at the University
both to discover the cause of disease and to of Sheffield
prevent its recurrence. • Received scholarship from Sir Henry Royce
• Descriptive epidemiology to hypothesis (of Rolls-Royce) to conduct research at the
generation to hypothesis testing (analytic National Institute for Medical research into
epidemiology) to application the cause and cure of INFLUENZA;
• In 1854 an epidemic of cholera erupted in Rockefeller scholarship
the Golden Square of London. • Researched Polio and the first OPV
• Created a spot map. underwent trials at Scheffield
• Believed that water was a source of infection for cholera • Identified the difference between
• Marked the location of water pumps on his spot map then looked INFLUENZA Virus and Common Cold
for a relationship between the distribution of households with JOHN OXFORD
cases of cholera and the location of pumps • Was a student of Charles Stuart-Harris
• He noticed that more case households clustered around Pump A, • English Virologist, Professor from Queen
the Broad Street pump, than around Pump B or C. Mary University of London
• NO cases of cholera had occurred in a two-block area just to the • Leading expert on Influenza, including bird
east of the Broad Street pump. flu and the 1918 Spanish Influenza,
HIV/AIDS
• Co –authored Influenza, the Virus and the
Disease, and “Human Virology, a text for
students of Medicine, Dentistry and
Microbiology”
DR ANTHONY FAUCI
• Director of NIAID (National Institute of
Allergy and Infectious Diseases) at the NIH
since 1984 to present
• Expert in Immunology, Basic and applied
research to prevent, diagnose and treat
established infectious diseases such as
HIV/AIDS, respiratory infections, diarrheal
diseases, tuberculosis and malaria and well
as emerging diseases such as Ebola and Zika
• Works include: Coronavirus task force,
Ebola, HIV/AIDs epidemic
MATCHING TYPE
1. Compare food histories between A. Distribution
persons with Staphylococcus food B. Determinants
poisoning and those without. C. Application
2. Compare frequency of brain
cancer among anatomists with
frequency in general population
3. Mark on a map the residences of
all children born with birth defects
within 2 miles of a hazardous waste
site
4. Graph the number of cases of
congenital syphilis by year for the
country
5. Recommend that close contacts
of a child recently reported with
meningococcal meningitis receive
Rifampin
6. Tabulate the frequency of clinical
signs, symptoms, and laboratory
findings among children with
chickenpox in Cincinnati, Ohio
What was the virus that caused the 1918 Pandemic that Timeline
caused one-third of the population (500M) to become • 2019 COVID-19 or SARS –CoV-2
infected with a mortality of at least 50M? o 2009 H1N1 (60.8M cases)
A. H1N1 o 1968 H3N2
B. SARS–CoV o 1957 H2N2
C. Yersinia Pestis • 1918 H1N1 Influenza Pandemic
D. H5N1
https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/milestone-infographic.htm
YERSINIA PESTIS o Transmissible through inhaling infectious droplets, or from
untreated bubonic or septicemic infections. (may occur
separately or in combination)
§ Gram (-) Bacterium
§ Bite of infected flea
CORE EPIDEMIOLOGIC FUNCTIONS

1. PUBLIC HEALTH SURVEILLANCE
• French SUR (over) and VEILLER (watch)
• Public health surveillance is the ongoing, systematic collection,
analysis, interpretation, and dissemination of health data to help
guide public health decision making and action.
• MONITORing the pulse of the community.
• Provides “information for action” (aka)
• Bubonic –
o Acute fever, headache and chills with tender lymph nodes.
o Bite of a flea and localized to the nearest lymph nodes.
o If not treated, can spread to the rest of the body. (does not
spread person to person)
• Pneumonic –
o Fever, chills, abdominal pain, shock, and bleeding into skin
and organs.
o Skin and surrounding tissue may become necrotic and turn
black. Transmissible from a flea bite or handling infected
animals.
• Septicemic –
o Fever, chills, weakness, and a rapid onset of pneumonia
o Secondary symptoms of chest pain, coughing, and bloody
mucous.
Criteria for prioritizing health problems for surveillance 6. POLICY DEVELOPMENT
include which of the following? • Epidemiology is the study of the distribution and determinants of
A. Incidence of the Problem health-related states and events in specified populations, and
B. Resources needed to conduct surveillance the application of this study is to control the health
C. Effectiveness of measures for controlling the disease problems.
under surveillance • Qualified position to recommend appropriate interventions
D. Presence of characteristics of well –conducted regarding disease control strategies, reportable disease
surveillance regulations and health-care policy.
E. All of the above
When analyzing surveillance data by age, which of the MATCHING TYPE
following age groups is preferred? 1. Reviewing reports of test results for A. Public
A. 1-yr age group Chlamydia trachomatis from public health
B. 5-yr age group health clinics surveillance
C. 10-yr age group 2. Meeting with directors of family B. Field
D. Depends on the disease planning clinics and college health investigation
An outbreak of disease should be reported to the local or clinics to discuss Chlamydia testing and C. Analytic
state health department: reporting studies
A. If the diagnosis is uncertain 3. Developing guidelines/criteria about D. Evaluation
B. If the diagnosis is infectious which patients coming to the clinic E. Linkages
C. If the disease is serious should be screened (tested) for F. Policy
D. If the outbreak involves at least 10 people Chlamydia infection development
E. Under all circumstances 4. Interviewing persons infected with
2. FIELD INVESTIGATION Chlamydia to identify their sex partners
• first actions 5. Conducting an analysis of patient flow
• identify a source or vehicle of infection that can be controlled or at the public health clinic to determine
eliminated waiting times for clinic patients
• e.g., STD case tracing 6. Comparing persons with
• identify causes, modes of transmission, and appropriate control symptomatic versus asymptomatic
and prevention measures Chlamydia infection to identify
• “Shoe leather epidemiology” predictors
Criteria for field investigations? CONCEPTS OF DISEASE OCCURRENCE

A. Control or prevention of health problem • Causation
B. Opportunity to learn (research opportunity) o INFECTIOUS
C. Public, Political or legal concerns o Epidemiologic triad or triangle (agent, host, environment)
D. Public health program considerations
• Component causes and causal pies
E. Training
o NON-INFECTIOUS
F. All of the above
o Rothman causal pies
3. ANALYTIC STUDIES
• employing more rigorous methods are needed.
• Descriptive epidemiology
• Analytic epidemiology
o Design
o Conduct
o Analysis
o Interpretation
4. EVALUATION
• Process of determining, as systematically and objectively as
possible, the relevance, effectiveness, efficiency, and impact of
activities with respect to established goals.
o Effectiveness refers to the ability of a program to produce the
intended or expected results in the field; effectiveness differs
from efficacy, which is the ability to produce results under
ideal conditions.
o Efficiency refers to the ability of the program to produce the
intended results with a minimum expenditure of time and
resources.
This (often measurable) ability to avoid wasting materials,

energy ,efforts, money and time in doing something or in
producing a well desired result.
A. Efficacy
B. Effectiveness
C. Efficiency Tim has a severe heart attack at age 58. The near –death
D. NOTA experience so scares him that he quits smoking. Tim’s wife
is also scared into quitting smoking even though she feels
5. LINKAGES fine. Tim’s son resolves to never start smoking, seeing what
cigarettes have done to his dad. The act of not smoking for
• Field epidemiology is often said to be a “team sport.”
Tim, Tim’s wife and Tim’s son represents?
• Do not act in isolation; Collaboration with other sectors,
A. Host, vector, and agent effects, respectively
specialist or health care
B. Herd immunity
• Maintain relationship with staff of other agencies and C. Tertiary prevention for Tim’s son
institutions D. Tertiary prevention, primary prevention, and
• official memoranda of understanding, sharing of published or secondary prevention, respectively
on-line information for public health audiences and outside E. Tertiary prevention, secondary prevention, and
partners, and informal networking that takes place at primary prevention, respectively
professional meetings.
Before quitting smoking, Tim, his cigarettes, and his
tobacco smoke represent:
A. Agent, host, and environment, respectively
B. Agent, environment, and vector, respectively
C. Vector, agent, and vehicle, respectively
D. Host, vehicle, and agent, respectively
E. Vehicle, vector, and agent respectively
BIOLOGIC SPECTRUM OF DISEASE: ICEBERG PHENOMENON

• Floating tip – What the physician sees in the community
• Submerged portion – hidden mass of disease like Pre-
symptomatic and undiagnosed cases or Carriers in the • Necessary cause –component that is needed in every pathway,
Community without it disease cannot occur
• Waterline – the demarcation between apparent and unapparent • Sufficient cause -The complete pie, which might be considered
disease a causal pathway, is called a sufficient cause. A disease may have
• Patients who are at the tip – of the iceberg are more likely to more than one sufficient cause, with each sufficient cause being
have multiple health problems than other composed of several component causes that may or may not
overlap (not a single factor but a minimum set of factors)
• Component cause –Individual factors
What Marks the transition from subclinical to clinical

disease?
A. Exposure
B. Pathologic Changes
C. Onset of Symptoms
D. Usual time of Diagnosis
Most diagnosis are made during this stage?
A. Stage of Susceptibility
B. Stage of Subclinical Disease
C. Stage of Clinical Disease
D. Stage of Disability or Death
Illness range is also called?
A. Spectrum of Disease
B. Recovery
Fig. 1.3 Iceberg Phenomenon, as Illustrated by a Diphtheria Epidemic in C. Disability
Alabama. In epidemics, the number of people with severe forms of the disease D. Death
(part of iceberg above water as shown here by 2 patients who died and 12
patients with symptoms of clinical illness) may be much smaller than the
NATURAL HISTORY AND SPECTRUM OF DISEASE
number of people with mild or asymptomatic clinical disease (part) of
iceberg below water as shown by the 32 “invisible” cases that would have
remained invisible without extensive epidemiologic
surveillance). Source: (Data from Jekel JF, et al: Corynebacterium
diphtheriae survives in a partly immunized group. Public Health Rep 85:310,
1970.)
Elmore, Joann G.. Jekel's Epidemiology, Biostatistics and Preventive Medicine E-Book (p. 10). Elsevier Health Sciences.
Kindle Edition.
• When a new disease emerges, the fist cases that are reported
tend to be the most severe cases.
• Continued investigation reveals that these cases are merely the
“tip of the iceberg”. Many more cases that are generally less
severe are hidden from the view initially, just as the bulk of an
iceberg lies below the water and is not seen initially.
All of the following are non-modifiable risk factors for
• Active surveillance generally is initiated only after the threat of
acquiring diseases or infection except?
a transmissible disease has been exposed, and case finding is an
A. Family history
effort to detect occult disease in a clinical setting as part of
B. Age
medical evaluation.
C. Sex
D. Body weight
An example of iceberg phenomenon would be:
A. The primary prevention of lung cancer
B. Giving medicine that only partially treats illness MODIFIABLE NON-MODIFIABLE
C. Widely publicized fatalities caused by the emerging • Diet • Family history
Coronavirus 19 • Smoking • Age
D. When cold temperatures favor disease outbreaks • Stress • Sex
Widely publicized fatalities associated with an “emerging” • Birthweight • Menopause
disease (e.g., hantavirus pulmonary syndrome) may be an • Dyslipidemia • Race
example of? • Body weight • Type A personality
A. Active surveillance • Alcohol
B. Case finding • Sedentary lifestyle
C. Iatrogenesis • Migration
D. The first responder effect
E. The iceberg phenomenon A 52-year-old generally healthy female patient of yours has
recently been diagnosed with breast cancer. She is
MATCHING TYPE presenting for presurgical evaluation for her breast
1. Hypertension / Stroke A. Necessary cause biopsy. What is the risk category associated with this
2. Treponema pallidum / Syphilis B. Sufficient cause surgery?
3. Type A personality / Heart C. Component A. Extremely low risk
disease cause B. Low risk
4. Skin contact with a strong acid C. Moderate risk
/Burn D. High risk
E. Extremely high risk
You are doing a preoperative clearance for a 60-year-old PAPM (PRECAUTION ADOPTION PROCESS MODEL)
man undergoing an elective knee replacement. He has • PAPM attempts to explain how a person comes to decisions to
diabetes, hyperlipidemia, and a history of poor myocardial take action and how he or she can translate that decision into
infarction (MI) 4 mos ago. After his MI he had triple bypass action
surgery. Since that time, he has done well and has been • Adoption of a new precaution or cessation of risky behavior
asymptomatic from a cardiac standpoint. Which of the requires deliberate steps unlikely to occur outside of conscious
following is true in this case? awareness.
A. Prior to surgery no cardiac evaluation is necessary • The PAPM applies mainly to these types of actions, rather than
given his recent revascularization. to the gradual development of habitual patterns of behavior,
B. He should have and ECG prior to surgery. If that is such as exercise and diet, in which health considerations may
normal, he needs no other cardiac evaluation. play some role. However, the PAPM would apply to the initiation
C. He should have a stress test prior to surgery of new exercise program or new diet
D. He should have a heart catheterization prior to • Proponents of the PAPM hypothesize that there are qualitative
surgery differences among people, and questions whether changes in
E. Surgery should be deferred. health behaviors can be described by a single prediction
equation.
• The PAPM describes a set of categories (stages), defined in terms
of psychological processes within individuals. All stages are
defined in terms of mental states, rather than factors external to
the person, such as current or past behaviors.
CASE • Antigenic drift – most likely the cause of changes in the strain
A large number of people have acquired mild symptoms of that allowed infection despite adequate vaccination.
influenza despite being vaccinated for the appropriate strain • Partial immunity or mutation to a less virulent strain (also
being cultured. due to antigenic drift) à less severe symptoms noted
You find that the cultured strain is the same as that
incorporated into the trivalent vaccine administered
throughout the world.
You also note that the strain had a high case fatality rate in
previous epidemics in China, where most new strains are
isolated and identified for vaccine preparations.
The most likely explanation for the outbreak noted by the
local health department is:
A. Vaccine failure
B. Antigenic drift
C. Antigenic shift
D. Herd immunity
While the pork industry lobbied aggressively against
dubbing the novel H1N1 influenza virus “swine flu,”
substantial evidence supported that this wholly new
genetic variant of influenza developed from confined
animal feed operations associated with commercial pig
farming. The novel H1N1 virus resulted from:
A. Antigenic shift
B. Antigenic drift
IMPORTANCE OF HEARD IMMUNITY NOW?
• Can everyone get vaccinated? No
• Who cannot get vaccinated?
o Previous severe life-threatening allergic reaction
o Pregnant women or Nursing mothers
o People with Weakened immune system
§ HIV/AIDS
§ Cancer
§ Undergoing immunotherapy
§ Using Steroids
§ Undergoing Chemotherapy
VACCINE FAILURE
• Would result in influenza cases with high case fatality rates seen
previously with this strain.
Herd immunity refers to:

A. Genetic resistance to species-specific disease.
B. Immunity naturally acquired in a population after an
epidemic
C. The high levels of antibody present in a population
after an epidemic • 17,200 reported cases of measles cases in the Philippines in
D. The prevention of disease transmission to susceptible 2018
individuals through acquired immunity in others. • 367% increase compared to 2017
E. The vaccination of domestic animals to prevent COVID vaccine table available at next page
disease transmission to humans
Attempts to eradicate a disease through widespread
immunization programs may be associated with potential
adverse effects. Which of the following adverse effects is
correlated with the effectiveness of a vaccine?
A. The emergence of resistant strains of infectious
agents to which the vaccine is targeted
B. The loss of the natural booster effect
C. The occurrence of infection in younger age groups
D. The occurrence of allergic reactions
E. The risk of disorders of the autism spectrum
HERD IMMUNITY
• Would decrease the rate of infection by decreasing the
Fig. 1.2 Effect of Herd Immunity on Spread of Infection. Diagrams illustrate
probability that a susceptible person would come into contact how an infectious disease such as measles could spread in a susceptible
with an infected person. population if each infected person were exposed to two other persons. (A) In
• Would not affect the clinical presentation of those infected. the absence of herd immunity, the number of cases doubles each disease
generation. (B) In the presence of 50% herd immunity, the number of cases
Have you heard of herd immunity? remains constant. The plus sign represents an infected person; the minus sign
represents an uninfected person; the circled minus sign represents an
immune person who will not pass the infection to others. The arrows
represent significant exposure with transmission of infection (if the first
person is infectious) or equivalent close contact without transmission of
infection (if the first person is not infectious).
Elmore, Joann G.. Jekel's Epidemiology, Biostatistics and Preventive Medicine E-Book (p. 6). Elsevier Health Sciences.
Kindle Edition.
ESTIMATED HERD IMMUNITY THRESHOLDS

FOR VACCINE PREVENTABLE DISEASES
HERD
DISEASE TRANSMISSION R0 IMMUNITY
THRESHOLD
Diphtheria Saliva 6-7 85%
Measles Airborne 12-18 83-94%
Airborne
Mumps 4-7 75-86%
droplet
Airborne
Pertussis 12-17 92-94%
droplet
Polio Fecal-oral route 5-7 80-86%
Airborne
Rubella 5-7 83-85%
droplet
Smallpox Social contact 6-7 83-85%
Airborne
The presence of enough immune response in a community droplet,
interrupts transmission of an infectious agent à providing COVID 19 inhalation, 5.7 82%
indirect protection for unimmunized (or susceptible) persons. deposition,
touching
CORONAVIRUS COMMUNITY REACTION TO DISEASE

• Absence of disease
• Crown -like spikes on their surface
o no cases on record
• 4 subgroups
o disease absent from beginning
o Alpha, Beta, Gamma, Delta
o disease has been eradicated, e.g., smallpox
• First identified in the mid-1960s
• Sporadic – occurrence of few and unrelated cases
• Endemic – constant occurrence (low frequency)
[Hyperendemic, Mesoendemic, Hypoendemic]
• Epidemic – occurrence of a number of cases of disease in excess
of normal occurrence of expectancy
• Pandemic – epidemic involving many countries
MATCHING TYPE
1. 22 Cases of legionellosis A. Sporadic Disease
occurred within 3 weeks among B. Endemic Disease
residents of a particular C. Hyperendemic
neighborhood (usually 0 or 1 Disease
per yr) D. Pandemic Disease
2. Average annual incidence was E. Epidemic Disease
364 cases of pulmonary
tuberculosis per 100,000
population in one area,
compared with national average
of 134 cases per 100,000
3. Over 20M people worldwide
died from influenza in 1918-
1919
4. Single case of histoplasmosis
was diagnosed in a community
5. About 60 cases of gonorrhea
THE SEVEN CORONAVIRUSES THAT CAN INFECT PEOPLE ARE: are usually reported in this
• Common human coronavirus region per week, slightly less
o 229E (alpha coronavirus) than the national average.
o NL63 (alpha coronavirus)
o OC43 (beta coronavirus) Which term best describes the pattern of occurrence of the
o HKU1 (beta coronavirus) three diseases noted below in a single area?
• Other human coronaviruses Disease 1: usually 40-50 cases A. Endemic
o MERS-CoV (the beta coronavirus that causes Middle East per week; last week, 48 cases B. Outbreak
Respiratory Syndrome, or MERS) Disease 2: fewer than 10cases C. Pandemic
o SARS-CoV (the beta coronavirus that causes severe acute per yr; 1 case D. Sporadic
respiratory syndrome, or SARS) Disease 3: usually no more
o SARS –CoV-2 (the novel coronavirus that causes coronavirus than 2-4 cases per wk; last wk,
diease 2019, or COVID -19) 13 cases.
EPIDEMIC PATTERNS MATCHING TYPE

Identify whether…
• Classified according to manner of spread:
o Common –source (a group exposed to an infectious 1. Date of Diagnosis A. Nominal
agent/toxin from the same source) 2. Town of residence B. Ordinal
§ Point-source (group brief exposure develops sx within 3. Age (years) C. Interval
incubation period) 4. Sex D. Ratio
§ Continuous 5. Highest alanine aminotransferase
§ Intermittent (ALT)
o Propagated (transmission from one person to another) 6. Lymphocyte Count
o Mixed (have features of both common-source epidemics and
propagated epidemics) A 62-year-old man is rushed to the emergency department
o Other by ambulance during an episode of chest pain. The initial
evaluation is performed by a triage nurse, who reports to
Identify whether… the emergency department attending clinician that the
1. 21 cases of shigellosis among A. Point source patient’s pain is probably angina and seems to be severe.
children and workers at a day care B. Intermittent This characterization of the pain as “severe” is:
center over a period of 6 weeks, no or continuous A. Dichotomous
external source identified common B. Nominal
incubation period for shigellosis is source C. Ordinal
usually 1—3 days) C. Propagated D. Parametric
2. 36 cases of giardiasis over 6 weeks E. Qualitative
traced to occasional use of a What is the appropriate measure of central tendency in
supplementary reservoir qualitative data such as gender, religion or nationality?
(incubation period for giardiasis 3–25 A. Median
days or more, usually 7–10 days) B. Average
3. 43 cases of norovirus infection over C. Mode
2 days traced to the ice machine on a D. Mean
cruise ship (incubation period for All of the ff. are true in a negatively skewed distribution
norovirus is usually 24–48 hours) except?
A. outlying values are small
A propagated epidemic is usually the result of what type of B. mean>median>mode
exposure? C. it is skewed to the left
A. Point source D. all of the above are true
B. Continuous common source
C. Intermittent common source NORMAL DISTRIBUTIONS
D. Person-to-person Remember: “The 68-95-99.7% Rule”
ORGANIZING DATA
• Compiling information in an organized manner
• Method: Line list or Line listing
• Line listing
o Organized like a spreadsheet with rows and columns
§ ROW – one row is called record or observation and
represents one person or case of disease (HORIZONTAL)
§ COLUMN –each column is called a variable and contains
information about one characteristic of the individual, such
as race or date of birth.
Organizing Data: Line list/ Line listing

In nine families surveyed, the numbers of children per
family were 4, 6, 2, 2, 4, 3, 2, 1 and 7. Find the following:
• Mean?
• Median?
• Mode?
MEASURES OF CENTRAL TENDENCY

• Mean – average; the sum of observations divided by the number
of observations
• Median – middle observation in a series of ordered
observations, i.e., the 50th percentile
• Mode – the observation that occurs with greatest frequency
The scores of an IQ Test were normally distributed

(approximately) with a mean of 100 and standard
TYPES OF VARIABLES deviation of 15. Use the 68, 95, 99.7 rule to answer the
• Nominal – values are CATEGORIES without numerical ranking following:
(country of residence, alive or dead, ill or well, eye color) About what percent of the population have IQ scores
• Ordinal – can be RANKED, but not necessarily evenly spaced • A) Above 100?
(cancer stage, level of performance/satisfaction, educ. • B) Above 145?
attainment) • C) Below 85?
• Interval – measured on a scale of equally spaced units, but
without a true zero point (date of birth) STANDARD DEVIATION
• Ratio – an interval variable WITH a true zero (height, duration
• average distance of each score from the mean or how much
of illness)
each data value deviates from the mean
• Normal Curve/Distribution
Are all Filipinos members of PhilHealth?
A. Yes
B. No
All Filipinos are now members of PhilHealth. Families who are not
yet registered/enlisted with PhilHealth will be assisted by their
health care provider with the next steps.
PHILIPPINE HEALTH SYSTEM AT A GLANCE

Membership
NORMAL CURVE/DISTRIBUTION • Automatic inclusion of every Filipino into the National Health
CHARACTERISTICS Insurance Program
• Bell shaped and symmetrical about the mean • Simplification of PhilHealth membership into:
• The mean, median, mode are all equal o Direct contributors
o Indirect Contributors
• The total area under the curve and above the x axis is equal to 1
All the following need to pay a premium based on the UHC
Act, except:
A. Employees
B. Professional Practitioners
C. Migrant workers
D. Senior citizens
E. Self-earning individuals
UHC ACT
• Direct Contributors – have the capacity to pay premiums
o employees, self-earning, professional practitioners, migrant
workers, including their qualified dependents, and lifetime
members.
• long tapering tails never touching the x axis • Indirect Contributors
• It is determined by its parameters: o indigents identified by the DSWD, beneficiaries of the
• its mean(µ) and standard deviation(σ) Conditional Cash Transfer Program, special groups such as
• The standard deviation becomes a more meaningful quality than senior citizens, persons with disabilities, and Sangguniang
merely being a measure of dispersion Kabataan officers.
o Their monthly payment in PhilHealth are covered by the
national government.
What individual based entitlements or “Essential Health

Benefit packages” are covered by PhilHealth?
A. Primary care
B. Medicines
C. Diagnostic and laboratory
D. Promotive services
E. All of the above
PHILIPPINE HEALTH SYSTEM AT A GLANCE: HEALTH CARE

DELIVERY SYSTEM
Health service delivery was devolved to the Local Government
Units (LGUs) in 1991
Which of the following is a good index of severity of Short –

term, acute disease?
A. Cause specific death rate
B. 5-year survival
C. Case- fatality
D. standardized mortality ratio
E. none of the above
UNIVERSAL HEALTH CARE ACT

• Republic Act No. 11223, otherwise known as the Universal PHILHEALTH HOSPITAL
Health Care Act AO 0029, S. 2005 (DOH)
CATEGORY
Primary Level 1
KEY FEATURES OF THE LAW
Secondary Level 2
1. Financing
Tertiary Level 3
2. Service Delivery
3. Local Health System -- Level 4
(Teaching and Training Hospital)
4. Regulation
5. Governance and Accountability
DOH: DON’T JUST REMEMBER, PRACTICE 4S TO PREVENT
DENGUE, ZIKA and other mosquito borne diseases
• Search and Destroy mosquito breeding places
• Use Self-protection measures
• Seek early consultation for fever lasting more than 2 days
• Say YES to fogging when there is an impeding outbreak
The CAGE questionnaire asks the following questions

except?
A. Have you ever felt you needed to Cheat?
B. Have people Annoyed you by criticizing your
drinking?
C. Have you ever felt Guilty about drinking?
D. Have you ever felt you needed a drink first in the
Table 4 Distribution of private and public hospital beds by region. morning (Eye-opener) to steady your nerves or to get
Almost all regions have insufficient beds relative to the population rid of a hangover?
except for NCR, Northern Mindanao, Southern Mindanao and
CAR. Among the seventeen regions, Autonomous Region for Muslim THE CAGE QUESTIONNAIRE ASKS THE FOLLOWING
Mindanao (ARMM) has the lowest bed to population ratio (0.17 beds QUESTIONS:
per 1000 population), far lower than the national average.
• Have you ever felt you needed to Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
UNIVERSAL HEALTH CARE KALUSUGANG PANGKALAHATAN
• Have you ever felt Guilty about drinking?
(KP)
• Have you ever felt you needed a drink first in the morning (Eye-
• Aims to achieve universal health care for all Filipinos opener) to steady your nerves or to get rid of a hangover?
• Seeks to ensure equitable access to quality health care by all Two *YES responses indicate that the possibility of alcoholism should be
Filipinos beginning with those in the lowest income quintiles. investigated further
• GOAL *CAGE questionnaire is considered a validated screening technique with high
o The implementation of KP/Universal Health Care shall be levels of Sensitivity and Specificity
directed towards the achievement of the health system
goals of financial risk protection, better health outcomes and How is a parasitic disease caused by Dracunculus
responsive health system. medinensis (Guinea worm disease) infect humans?
A. By drinking parasite infected water fleas
B. By drinking unfiltered water containing copepods
with L3 larvae
C. By eating foods sources containing copepods
D. By eating larvae infected copepods
The following are part of the 4S program of DOH against

mosquitos except:
A. Safety and Security of children indoors and outdoors
B. Use self-protection measures
C. Seek early consultation for fever lasting more than 2
days
D. Say YES to fogging when there is an impeding
outbreak
• Sensitivity (How many true positives among diseased?)
• Specificity (How many true negatives among well?)
• Positive predictive value (How many diseased among positives?)
A researcher develops a new novel assay for diagnosis of

typhoid fever, he then tests it compared to bone marrow
culture, there were a total of 400 patients, a total of 250
was found to have typhoid, of this only 130 patients tested
positive in the new diagnostic test, the new diagnostic test
was also found to be positive in 5 of the patients without
typhoid, what is the sensitivity of the test?
A. 50%
B. 52 %
C. 92%
Public health policies for the prevention and control of D. 96.67%
schistosomiasis include all the following, EXCEPT: … What is the specificity of the test?
A. Notification of health providers concerning increased A. 50%
cases B. 52 %
B. Adequate treatment of individuals with praziquantel C. 92%
C. Education of the public concerning self-protective D. 96.67%
measures
D. Control of the snail host SENSITIVITY SPECIFICITY
An Intermediate host is a host in which the agent 𝑇𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒𝑠 𝑇𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒𝑠
undergoes: 𝐴𝑙𝑙 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤𝑖𝑡ℎ 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝐴𝑙𝑙 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤𝑖𝑡ℎ𝑜𝑢𝑡 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
A. a sexual phase of its development. • PID = Positive In Disease • NIH – Negative In Health
B. an asexual phase of its development. (Note that PID is a sensitive • SPIN – SPecificity rules IN!
C. a sexual phase then an asexual phase of its topic!) • High specificity is desirable
development • SNOUT = SeNsitivity rules for a confirmatory test, to
D. None of the above OUT! rule in!
• High sensitivity is desirable
A new screening test is applied to a representative sample of 1,000 for a screening test, to rule
people in the population. Based on the data presented in the out!
following table, calculate the requested screening test measures:
• Sensitivity PPV vs NPV
• Specificity • Positive Predictive Value (PPV)
• Positive predictive value o The probability of having a condition, given a positive test (+,+)
• Negative Predictive Value (NPV)
DISEASED WELL o The probability of not having the condition, given a negative
POSITIVE 90 60 150 test (-,-)
NEGATIVE 10 840 850 Note: Predictive values are dependent on the prevalence of the disease. The
100 900 1,000 higher the prevalence of a disease, the higher the PPV of a test
… What is the positive predictive value? “The absence of valvular calcification in an adult suggests
A. 53.36% that severe valvular aortic stenosis is not present.” This
B. 54.72 % means that valvular calcification is/has:
C. 92.34% A. Sensitive
D. 96.3% B. Specific
… What is the negative predictive value? C. High PPV
A. 53.36% D. Low NPV
B. 54.72 % • Sensitive test – one that is positive in most patient with disease.
C. 92.34%
• If the absence of a characteristic rules out a disease, then the
D. 96.3%
test is sensitive.
• Hardly anyone with the disease has a negative test.
• REMEMBER: SNOUT!
TYPE OF COVID-19 TEST KITS
MINIMUM PERFORMANCE
FOR SCREENING OF SARS- REFERENCE
REQUIREMENTS
COV-2
≥95% sensitivity and ≥99% Existing document used by National Regulatory Agencies which
RT-PCR TEST KITS
specificity prescribe value for used sensitivity and specificity
Department Memorandum No. 2020-0439 entitled “Omnibus Interim
COVID-19 ANTIBODY TEST >90% sensitivity and >95%
Guidelines on Prevention, Detection, Isolation, Treatment,
KITS specificity
Reintegration Strategies for COVID 19
COVID-19 ANTIGEN TEST ≥80% sensitivity and ≥97% WHO interim guidance entitled “Antigen-detection in the diagnosis of
KITS specificity SARS-CoV-2 infection using rapid immunoassays”
Latest yearly data in a barangay there is a total of 200,000 All of the ff. increases prevalence rate except?
people, there was a reported total of 985 deaths, 500 were A. longer duration of illness
due to cardiovascular causes, 200 from accidents, 100 B. increase in new cases
from cancer, 185 from infection, a total of 2000 people had C. high case fatality rate
dengue and 50 died from severe dengue hemorrhagic D. improved diagnostic facilities
fever, what is the prevalence rate of dengue? Which graph is suitable to be used to show the increasing
A. 1% cases of dengue from 2009-2015?
B. 2% A. frequency polygon
C. 3% B. pie chart
D. 4% C. line graph
… What is the proportionate mortality rate of dengue? D. histogram
A. 3%
B. 5%
PREVALENCE INCIDENCE
C. 8%
• Number of new cases in a • Total number of cases in a
D. 10%
population per unit time. population at a given time.
… What is the case fatality rate of dengue?
• NEW CASES ONLY • ALL CASES (OLD + NEW)
A. 1.5%
• Acute conditions • Chronic conditions
B. 2.5%
C. 3.5%
D. 5.5%
FERTILITY RATES
Crude Birth Rate: Measures how fast people are added to the Number of registered Live
population through births births in a year
General Fertility Rate: More specific rate than the crude birth rate
Number of registered live Midyear population of
since births are related to the segment of population deemed to be 1,000
births in a year women 15-44 years old
capable of giving birth
Number of live births per Number of women in a
Age specific fertility rate: Shows variation in fertility by age 1,000
woman of a given age groups given age of group
Total fertility rate: Standardized index for overall fertility level. Sum of all age specific fertility
Represents the average number that would be born to a women rate for each year of women 1,000
throughout her lifetime. Indicator of cohort fertility from 15-49 y/o
Gross reproduction rate: Give idea about replacement of females Total fertility rate restricted to
1,000
in the population female births only
NATALITY RATE
Crude Birth Rate: Affected by accuracy of registration of live births, fertility status Number of live
of female, proportion of child bearing females, cultural and social practices births in 1 year
General Fertility Rate: Relates to the segment of population which is actually at Number of live Number of women
1,000
risk of giving births births in 1 year (15-44 y/o)
MORBIDITY RATES
Number of new cases of a Population at risk developing the
Incidence Rate: Measures the rapidity with
disease developing in a disease during the same period of 100 or 1000
which a disease occurs
period of time time(person-years of observation)
Prevalence Rate: Measures the frequency of Number of new and old cases
Midyear population 100 or 1000
all current cases within a period
Point Prevalence: More useful than incidence
Total cases (old and new) at
rate in describing the occurrence of chronic Total population at that time 100
a fixed point in time
conditions
Total cases (old and new) at Total population at that period of
Period Prevalence: 100
a period of time time
Attack Rate: Incidence rate expressed as Number of ill persons with Number of persons attending the
100
percentage disease to a certain event same event
MORBIDITY: TEN (10) LEADING CAUSES In country A there are 35 new cases of breast cancer per
100,000 adult women per year; in country B the number is
90 per 100,000. Which of the following is the most likely
explanation?
A. Women in country A have much higher rate of nursing
their infants.
B. Women in country A are likely to smoke less
cigarettes.
C. Women in country A receive more frequent care such
as mammography.
D. Women in country A are younger.
• The most important risk factor for the development of breast
cancer, like most cancers, is AGE.
• Still the most common cancer for WOMEN
MORTALITY: TEN (10) LEADING CAUSES • Nursing – may have a protective effect on breast cancer, it is of
nowhere near the magnitude of the effect of age.
• Cigarette smoke - NOT a major risk factor for breast cancer.
• Early diagnosis, if it had any effect, would be expected to
increase the incidence rate (since some cases might be
discovered that otherwise might spontaneously resolve or not
be noticed before the woman dies of another cause.)
You are reevaluating a 32-year-old woman in your office.
You started her on combination oral contraceptives (COCs)
3mos ago, and each of three visits since then her blood
pressure has been elevated. Which of the following is the
most appropriate next step?
A. Discontinue the OCP and recommend a barrier
method
INFANT MORTALITY: TEN (10) LEADING CAUSES B. Change to a pill with a higher estrogen component.
C. Change to a pill with a lower estrogen component.
D. Change to a pill with a lower progestin component.
E. Change to a progestin only pill
A 29-year-old woman with type 2 diabetes mellitus is
asking you about progestin-only pills as a method of
contraception. Which of the following is true?
A. Progestin -only pills are contraindicated in woman
with diabetes
B. Progestin -only pills would increase her risk of
thromboembolic events.
You are reading a study that compares cholesterol levels in C. Progestin -only pills are only food and drug
children whose father died from an MI with cholesterol administration (FDA) approved for nursing women
levels in children whose father died from other causes. The D. Progestin only-only pills increase her risk for ectopic
p value obtained in the test was <0.001. what does this pregnancy
value indicate? E. Progestin is-only should be taken every day of the
A. There was no difference in cholesterol levels between month, without a hormone free-period.
the two groups A 28-year-old monogamous married woman comes to you
B. The difference in the cholesterol level was less than for emergency contraception. She and her husband
0.1% typically use condoms to prevent pregnancy but they had
C. There is a less than 0.1% probability that the result sex approximately 36 hours ago, the condom broke, she
obtained in this study were incorrect. does not want to start a family at this time. Which of the
D. There is a less than 0.1% probability that the result following statement is true regarding the use of emergency
obtained in this study occurred because of sampling contraceptive pills (ECPs)?
error. A. She is to late to use ECPs in this case.
E. If the null hypothesis is true, there is less than 0.1% B. ECPs are 90% to 100% effective when used correctly.
probability of obtaining a test statistic equal to or C. There are no medical contraindications to the use of
more extreme than the one obtained. ECPs other than allergy or hypersensitivity to the pill
components.
P value tells us how likely it is to get a result like this if the D. ECPs disrupt pregnancy, if given within days of
Null Hypothesis is true. implantation.
Low P High P E. Clinicians should perform a pregnancy test before
p<α p>α prescribing ECPs.
Value of sample results are Value of sample results are The number of Consult of respiratory illnesses in Tondo vs
far from the population close to population those in Global City is discrepant to the national statistics
parameters parameters of the Philippines. Based on this data we can use the
Unlikely events Likely events A. Inverse Law Care
REJECT HO DO NOT REJECT HO B. Iceberg phenomenon
C. Bad sampling design
NULL VS ALTERNATIVE HYPOTHESIS: WHAT IS P –VALUE? D. None of the above
• H0: Fair Coin INVERSE CARE LAW
• HA: Trick Coin • Proposed by Julian Tudor Hart in 1971 (47 yrs ago) (South
wales)
• The availability of good medical or social care tend to vary
inversely with the need of the population served
• Need of health care and actual utilisation
Kung sinong may kailangn ng Health Care hindi nakakatanggap of
nagpapatingin at ung mga hindi kailangn ang mas nagpapatingin at
tumatanggap ng Health Care
This term refers to the separation of the sick people in a Which of the following will highly decrease transmission of
population to those with a contagious disease from people nosocomial pathogens?
who are not sick. A. Use of air sterilizers
A. Quarantine B. Meticulous handwashing
B. Isolation C. Judicious placement of indwelling catheters
C. Final rule for control of communicable diseases: D. Use of face masks
Interstate and Foreign Which of the following is the most common site of
Which of the following is true about the epidemiology of nosocomial infections?
appendicitis? A. Surgical wound
A. Affects girls nearly 3X as frequently as boys B. Aerodigestive tract
B. Incidence is highest in the 6th and 7th decades of life C. Blood
C. Mortality is increasing in the Western world D. Genito-urinary tract
D. Affects about 1 in 1000 pregnancies
EPIDEMIOLOGY OF NOSOCOMIAL INFECTIONS
APPENDICITIS
• An important cause of morbidity in the Western world, but
mortality is decreasing
• Boys and girls are nearly equally affected
• Most common in 2nd and 3rd decades of life
• During pregnancy, displacement of the appendix by the uterus
can make diagnosis difficult
The bacteria that are involved in nosocomial infections are

transmitted most often by:
A. Airborne material
B. Fomites
C. Direct hand contact
D. Indwelling catheters
NOSOCOMIAL INFECTIONS Which of the ff. is not included as part of traits and roles of
• Transmission of bacteria from patient to patient most a 5-star physician?
commonly occurs via the hands of hospital personnel. A. Teacher/educator
• Airborne transmission, indirect exposure, and common-source B. Researcher
exposure à much less important than direct spread C. Adviser
• Indwelling catheters – important risk factors but are not sources D. Manager/administrator
of transmission of infections
5 –STAR PHYSICIAN
• Health Care Provider
• Teacher/Educator
• Scientist/Researcher
• Administrator/Manager
• Social Mobilizer
IMPAIRMENT, DISABILITY, AND HANDICAP
David is a 4yr old who has a form of cerebral palsy called 5. COMMUNAL OR CORPORATE FAMILY
spastic diplegia. David’s CP causes his legs to be stiff, tight o different families formed for specific ideological or societal
and difficult to move. He cannot stand or walk. purposes
o frequently considered as alternative lifestyle for people who
Identify the: Impairment, Disability and Handicap. feel alienated from a predominantly economically oriented
• Impairment – inability to move legs easily at the joints and society
bear weight on the feet o Ex. Amish community in Lancaster county, Penn
• Disability – inability to walk
• Handicap – prevents him from playing sports or doing certain FAMILY LIFE CYCLE
activities. • represents a composite of the individual developmental changes
of family members
• Impairment – any loss or abnormality of psychological, • presents a cyclic development of the evolving family unit
physiological or anatomical structure or function • shows the evolution of the marital relationship
• Disability – any restriction or lack of ability to perform an
activity in the manner or within the range considered normal for STAGES
a human being. Inability to perform a function due to
1. UNATTACHED YOUNG ADULT
impairment.
o leaving home
• Handicap –disadvantage which results from a disability or o accepting emotional and financial responsibility for self
impairment prevents fulfillment of a role. o differentiation of self in relation to family of origin
This alters the nature of a true relationship between an 2. NEWLY MARRIED COUPLE
exposure and an outcome o joining of families through marriage
A. Biologic plausibility o commitment to new system
B. Confounder o realignment of relationships with extended families and
C. Effect modifier friends to include spouse
D. External Validity
E. Internal validity 3. FAMILY WITH YOUNG CHILDREN
o accepting new members into the marriage and extended
• In contrast to a confounder, an effect modifier does not obscure family
the nature of a relationship between two other variables; rather o joining in child rearing, financial and household task
it changes the relationship.
• Effect modification is about stratification of SUBGROUPS! 4. FAMILIES WITH ADOLESCENTS
Associated with the outcome but not the exposure. o increasing flexibilities to include children’s independence and
• Mean that there’s a difference among the different subgroups of grandparents’ frailties
the population under study. “not a nuisance” o refocus on midlife marital and career issues
• For example, Drug X worked on children but not in older
people.(effect modification) 5. LAUNCHING FAMILY
• Confounding bias is for the ENTIRE POPULATION under the o launching children and moving on
study. “nuisance” o accepting exits from and entries into the family system
• A factor is associated with both the exposure and the outcome o development of adult-to-adult relationships between grown
but does not lie in the causative pathway. children and their parents
• Means you cannot say drug X worked or not because age was a
confounding factor in the sample above. 6. FAMILIES IN LATER LIFE
o accepting the shifting of generational roles
THE FAMILY o maintaining own function in face of physiologic decline
o support for a more central role of the middle generation
Definitions o dealing with loss of spouse, siblings, peers and preparation for
• General - a group of people who are related to each other either own death
biologically, emotionally or legally o life review and integration
• By affinity - a group of people related by blood, marriage or
adoption who live together in one household Mang Salvador was diagnosed 5 years ago with end stage
• By structure, function, composition and affection - a small renal disease and is presently on hemodialysis 3 times a
social system made up of individuals related to each other by week. His children help him with the expenses and his
reason of strong reciprocal affections and loyalties and family prepares food that is suitable for Mang Salvador.
comprising a permanent household (or cluster of households) What stage is he in the family illness trajectory?
that persists over years and decades A. Stage I: Onset of Illness to Diagnosis
B. Stage II: Impact phase-reaction to diagnosis
1. NUCLEAR FAMILY C. Stage III: Major therapeutic efforts
o parents and dependent children D. Stage IV: Early adjustment to outcome-recovery
o separate dwelling E. Stage V: Adjustment to the permanency of outcome
o economically independent It is the most challenging and rewarding stage for the
physician in the family illness trajectory.
2. EXTENDED FAMILY A. Stage I: Onset of Illness to Diagnosis
o parents, children and relatives B. Stage II: Impact phase-reaction to diagnosis
o aggregate of families or part of families from 2 or more C. Stage III: Major therapeutic efforts
generations occupying a single or adjacent dwellings D. Stage IV: Early adjustment to outcome-recovery
E. Stage V: Adjustment to the permanency of outcome
3. SINGLE-PARENT FAMILY
o children <17 y/o living with a single parent, another relative
or non-relative
o due to: loss of spouse by death, separation, imprisonment,
desertion; out of wedlock birth of a child; adoption; one parent
working abroad
4. BLENDED FAMILY
o includes step-parents and step-children
o due to divorce / annulment with remarriage
FAMILY ILLNESS TRAJECTORY
STAGES DESCRIPTION RESPONSIBILITIES OF A PHYSICIAN
• Malaise initiates this stage.
• Explore routinely the explanatory model
Stage I: Onset of Illness • stage prior to contact with the physician.
and fear that the patient brings to the
to Diagnosis • Medical beliefs and previous experiences provide influence
clinical set-up.
to the meaning of illness.
2 PHASES: • Anticipate number of problems and help
EMOTIONAL PLANE families cope and adapt to the situation.
• Initially there is denial, disbelief and anxiety. • Interpret findings which are
• Followed by emotional upheaval (anger, anxiety, depression). misunderstood.
• Last: accommodation, accept the situation.
COGNITIVE PLANE
• Phase 1: tension and confusion arises due to lack of capacity
Stage II: Impact Phase-
for problem solving.
Reaction to Diagnosis
• Phase 2: repeated failure in deriving the diagnosis, may lead
to exacerbation of tension and increase distress (prayers).
• Phase 3: increasing assessment and receptivity of family to
new approach for relief of distress (this is the time for
physician to assist family in re-aligning roles and expectations).
• Phase 4: eventual acceptance of diagnosis will enable them to
mobilize resources and reorganize the family.
• Psychological state and preparedness of the patient and the • Work in harmony with patient and the
family determine the choice of therapeutic plans as well as the family.
alternative choices. • Consider all factors in planning.
• Assumption of responsibility for care (establish and define the • Remain open to the family, indicate they
Stage III: Major
responsibility for each member) will not be abandoned; provide
Therapeutic Efforts
• Economic impact of illness information.
• Lifestyle and cultural characteristics of a family are important
in choosing a therapeutic plan.
• Hospitalization gives rise to stressful problem.
• Return from the hospital • Deal with immediate effects of trauma
• movement from one role of being sick to some form of • Alleviate anxiety and assure adequate
recovery or adaptation rest
Stage IV: Early • Experience of recovery or adjustment to the illness • Give psychological support
Adjustment to Outcome • Explore the level of understanding of
– Recovery 3 types of anticipated outcome: patient and family.
• Return to full health
• Partial recovery
• Permanent disability-requires acceptance
• It points to the family’s adjustment to crisis. • Assist the patient and the family in
Stage V: Adjustment to • 2nd crisis occurs as family realizes that they must accept and relating to health care system
the permanency of adjust to permanent disability. • Aid the patient and the family in efficient
outcome and functional readjustment
• Provide quality care
Which of the following parameters in the APGAR measures According to the WHO the leading cause of mortality
the satisfaction with the commitment made by other worldwide for both men and women is due to:
members of the family A. Respiratory Infections
A. Adaptation B. Ischemic heart diseases
B. Partnership C. Tuberculosis
C. Growth D. Hypertension
D. Affection E. Diabetes Mellitus
E. Resolve Totoy has a history of cryptorchidism. Knowing totoy is a
male. He is most likely to develop what type of cancer?
APGAR A. Testicular CA
• Adaptation – capability to utilize and share inherent resources B. Prostate CA
which are either intrafamilial or extrafamilial C. Penile CA
D. Colon CA
• Partnership – solving problems by communicating, sharing of
The incidence of cholelithiasis is increased in all of the
decision making
following conditions, EXCEPT:
• Growth – freedom to grow and change (physical and emotional)
A. Hypercholesterolemia
• Affection – intimacy and emotional interaction within the family
B. Diabetes
• Resolve – members satisfaction with the commitment made by
C. Chronic hemolytic dyscrasia
the members of the family
D. Female gender
All of the following are included in RA 9288 (newborn
screening) ideally done during the 48th to 72nd hour of life GALLSTONES
except: • Extremely common in about 20% women and and 8% men
A. Phenylketonuria above 40
B. Congenital Adrenal Hypoplasia • Although most gallstones contain cholesterol,
C. Congenital Hypothyroidism hypercholesterolemia is not associated with an increased
D. Galactosemia risk
E. G6PD • Diabetics – have an increased risk for gallstones, as well as
F. Maple syrup Urine Disorder morbidity and mortality associated with the disease
• Chronic hemolysis à calcium bilirubinate
• Other risk factors: age, obesity, chronic biliary infection
There has been increasing age-adjusted mortality in the The major environmental source of lead absorbed in the
past 25 years from cancer of the: human blood stream in adults is:
A. Lung A. Air
B. Uterus B. Water
C. Prostate C. Lead based paint
D. Testis D. Food
The use of oral contraceptives will have the most impact on E. Soil
gynecological mortality by reducing the risk for which of The most commonly described anomalies associated with
the following cancers? congenital rubella include the following, EXCEPT:
A. Ovarian A. Cataracts
B. Breast B. Sensorineural deafness
C. Cervical C. PDA
D. Vulvar D. Hutchinson’s teeth
E. Endometrial
Which of the following is the most important risk factor for • Congenital rubella à ophthalmological, cardiac, auditory and
developing cervical cancer? neurological anomalies
A. Coitarche before age 18 • Congenital syphilis à Hutchinson’s teeth
B. Herpes simplex infection
C. Multiple sexual partners
D. More than 5 years since last pap smear
E. Human papillomavirus type 16
Is it normal to have some vaginal bleeding or spotting after
menopause?
A. True
CONGENITAL RUBELLA SYNDROME
B. False
5 B’s of Congenital Rubella Syndrome
Cigarette smoking increases the risk of acquiring cancers
Bulag (cataracts)
of the following, EXCEPT:
Bingi (sensorineural deafness)
A. Aerodigestive tract
Bobo (mental retardation)
B. Pancreas
Butas ang puso (PDA)
C. Bladder and kidney
Blueberry muffin baby
D. Liver
• Eruption of first deciduous tooth? 6mos
LIVER CANCER • Eruption of first permanent tooth? 6yrs
• Most common risk factor for liver cancer – chronic HBV or HCV
infection.
The most common site for cancer in females in developing

countries is:
A. Lung
B. Cervix and uterus
C. Pharynx
D. Breast
TEN LEADING CAUSE OF MORBIDITY (FHSIS 2016) Upper Primary Teeth Development Chart
1. Acute Respiratory Infection WHEN TOOTH WHEN TOOTH
2. Hypertension EMERGES FALLS OUT
3. ALRTI & Pneumonia Central incisor 8 – 12 months 6 – 7 years
4. UTI Lateral incisor 9 – 13 months 7 – 8 years
5. Influenza Canine (cuspid) 16 – 22 months 10 – 12 years
6. Bronchitis First molar 13 – 19 months 9 – 11 years
7. Acute Watery Diarrhea Second molar 25 – 33 months 10 – 12 years
8. TB Respiratory
9. Acute Bloody Diarrhea The most prevalent mental health disorder in young
10. Dengue children is:
A. Autism
TEN LEADING CAUSE OF MORTALITY (PSA 2018) B. Mental retardation
1. Ischemic Heart Disease C. Behavioral problems
2. Neoplasm D. Depression
3. Cerebrovascular Disease
4. Pneumonia • Behavioral problems (including ADD and learning disabilities)
5. Diabetes Mellitus occur in approximately 10% of children.
6. Hypertensive disease • Autism – 0.05%
7. Chronic Lower Respiratory Infections
• Mental retardation – 1%
8. Respiratory Tuberculosis
9. Other Heart Disease
Parents who abuse their children are correctly
10. Diseases of the Genitourinary System
characterized by the following statements, EXCEPT:
A. They are likely alcoholics
What is the most common reported occupational disease?
B. They are likely to be men than women
A. Dermatitis
C. They are found in all social classes
B. Cardiovascular
D. They are likely to have been abused as children
C. Skeletal work-related problem
D. Abdominal upset
CHILD ABUSE
The most serious manifestation of lead intoxication is:
A. Peripheral neuropathy • The mother is more commonly the abuser, perhaps because
B. Mental retardation of greater contact with the child.
C. Anemia • Abusing parents are usually psychologically immature and have
D. Cerebral edema poor impulse control.
à often noted with blood lead levels exceeding 100 μg/dL
Anabolic steroid use among adolescents is associated with

all of the following EXCEPT:
A. Enhanced school performance
B. Testicular atrophy Tetracycline is contraindicated in pregnancy. Which
C. Aggressive behavior alternative drug will you give to cover for the co-existing
D. Cholestasis chlamydial infection?
School performance usually deteriorates as a result of mood changes and A. Ciprofloxacin
aggressive behavior.
B. Azithromycin
All of the following statements are true of tuberculosis C. Nalidixic acid
EXCEPT: D. Co-trimoxazole
A. Humans are the only reservoir of MTB
Effective means of preventing trichinosis in humans
B. The causative agents of human TB include M. bovis.
include:
C. The time from infection to the development of a
A. Cooking pork and pork products to ensure that all
positive tuberculin skin text is about 6 months.
parts of the meat reach a temperature of at least 40°C
D. HIV infection is an independent risk factor for the
B. Prohibiting the marketing of garbage-fed hogs
development of active TB.
C. Attention to proper disposal of hog feces
D. Skin testing of hogs with Trichinella antigen prior to
Which term best describes the pattern of occurrence of the slaughter
three diseases noted below in a single area?
Dengue, yellow fever, A. Bacterial infections CONTROL OF TRICHINELLA SPIRALIS
chicken pox B. Zoonoses
• Ensure that all garbage and offal fed to hogs are heat-treated to
Scabies, measles, C. Person-to-person destroy the cysts, or preferably by using feed devoid of animal
shigellosis spread meat.
Rabies, psittacosis, D. Viral infections • Prohibition of marketing of garbage-fed hogs is easier to
salmonellosis E. Arthropod-borne enforce than inspection to ensure that all garbage is
Walking pneumonia, infections properly cooked.
brucella, strep throat • Thorough cooking at temperature at least 77°C (171°F) to
destroy the cysts
Which of the following is considered the single most • Freezing
important preventive measure against diseases?
A. Insect vector control Characteristic signs and symptoms of kwashiorkor include
B. Water sanitation all of the following, EXCEPT:
C. Waste management A. Hypoalbuminemia
D. Food sanitation B. Loss of subcutaneous fat
True statements regarding Haemophilus influenzae type b C. Edema
include all of the following, EXCEPT: D. Ulcerated dermopathy
A. It is a more important cause of mortality in children
than adults. VITAMIN DEFICIENCIES
B. Conjugated polysaccharide vaccine should be given to
children beginning at 2 months of age Petechiae, sore gums, A. Vitamin A deficiency
C. It is the most common cause of AOM in children. hematuria, and bone or joint B. Thiamine deficiency
D. It is the major cause of acute epiglottitis. pain C. Vitamin C deficiency
Dermatitis, diarrhea, D. Vitamin B deficiency
HAEMOPHILUS INFLUENZAE TYPE B delirium E. Niacin deficiency
Edema, neuropathy, and
• Meningitis, Epiglottitis, Pneumonia, Periorbital or Facial
myocardial failure
cellulitis à mainly in children
Xerosis conjunctivae,
• 2nd most common cause of AOM in children
hyperkeratosis, and
• Streptococcus pneumoniae – mcc of AOM in children keratomalacia
o (but most cases are due to non-typable strains rather than type
b (bad))
MINERAL DEFICIENCIES
Poor mineralization of bones and teeth; A. Fluorine
osteoporosis B. Copper
Nausea, diarrhea, muscle cramps, C. Zinc
dehydration D. Sodium
Tendency to dental caries E. Calcium
Dwarfism, hepato-splenomegaly, poor
wound healing
PARASITIC INFECTIONS INTERMEDIATE HOSTS A disadvantage of using only the total cholesterol level to
Lung fluke disease A. Snail predict the risk of CVD is that:
Schistosomiasis B. Swine A. HDL is included in the measure
Toxocariasis C. Fish B. The ratio of LDL to VLDL is unknown
D. Crab C. Total cholesterol levels are estimated rather than
Cysticercosis measured.
E. Dog
D. Total cholesterol levels do not correlate with risk
Papanicolaou smears are indicated in: E. In contrast to triglycerides levels, total cholesterol
A. All young women older than 16 yr levels vary with meals
B. A 14-yr-old mother with cervical cancer
C. A 12-yr-old girl exposed to diethylstilbestrol MILLENNIUM DEVELOPMENT GOALS BY 2015
D. All sexually active teenage girls • Eradicate extreme hunger and poverty
• Achieve universal primary education
PAP-arapapa! • Promote gender equality and empower women
• Sexual activity is an absolute indication for a Pap smear. • Reduce Child Mortality
• Examination of two successive cervical scrapings increases the • Improve maternal health
yield and avoids false-negative results. • Combat HIV/AIDS, Malaria and other diseases
• Women should start getting PAP test at age 21 (CDC) • Ensure environmental sustainability
• Develop a global partnership for development
Which vaccine would most likely be dangerous to a person
with immunodeficiency? SUSTAINABLE DEVELOPMENT GOALS BY 2030
A. Diphtheria vaccine • No poverty
B. Hepatitis B vaccine • Zero Hunger
C. Measles vaccine • Good Health and Well-being
D. Tetanus vaccine • Quality Education
E. Typhoid vaccine • Gender Equality
A screening program is designed for the early detection of • Clean water and Sanitation
lung cancer after a clinical study showed promoting • Affordable and Clean Energy
results. The survival time from diagnosis in individuals • Decent work and Economic Growth
whose lung cancer was detected by screening is found to be • Industry innovations and Infrastructure
3 months longer than the survival time in individuals who • Reduced Inequalities
did not undergo screening and presented with symptoms • Sustainable cities and communities
of lung cancer. This difference is most likely due to :
• Responsible consumption and production
A. Better treatment options for those found through
• Climate Action
screening
• Life below water
B. Effect modification
C. Lead –time bias • Life on Land
D. Length bias • Peace, justice, and strong institutions
E. Observer bias • Partnerships for the goals
There is a controversy regarding the use of prostate-
specific antigen to screen for prostate cancer because:
A. Prostate cancer cannot be detected until it is
symptomatic
B. Prostate cancer is a rare disease
C. Prostate cancer is uniformly fatal
D. The appropriate management of asymptomatic
prostate cancer is uncertain
E. There is no effective treatment for prostate cancer
SUSTAINABLE DEVELOPMENT GOALS
MILLENNIUM DEVELOPMENT GOALS
MENTAL RETARDATION DOH PROGRAMS

Mental Retardation • Breastfeeding TSEK
Mental Deficiency
(DSM V) o Tama
• <20 -Profound o Sapat
• 0-25 Idiots o EKsklusibo (birth to 6months)
• 20 -34 Severe
• 26-50 Imbeciles
• 35 -49 Moderate
• 51-70 Morons • Adolescent and Youth Health Program (AYHP)
• 50 -69 Mild
Mental Retardation is now politically incorrect; the correct term • Belly Gud for Health
is: Intellectual Disability (ID), also called Intellectual • Blood Donation Program
development disorder (IDD) • Breastfeeding TSEK
• Cardiovascular Disease
THE PHILIPPINES • CHD Scorecard
• Child Health and Development Strategic Plan Year 2001-2004
• Chronic Obstructive Pulmonary Disease
• Climate change
• Committee of Examiners for Massage Therapy (CEMT)
COLORS OF LIVIDITY
Asphyxia Dark
Carbon Monoxide Bright pink/red “cherry red”
Hemorrhage, Anemia Less dark
Hydrocyanic Acid Bright red
Phosphorus Dark Brown
Potassium Chlorate,
Chocolate or Coffee brown
Potassium dichromate
Snow or ice Bright red
What tool is used by an epidemiologist?

A. Swab
B. Syringe
C. Stethoscope
D. Calculator
END OF PREVENTIVE MEDICINE AND PUBLIC HEALTH PHASE 3
QUESTION ANSWER
BUZZ WORDS Health indicator to evaluate
QUESTION ANSWER and support from and burden Dependency ratio
Family assessment tool: on the working population
depicts family members, their • 5% permethrin lotion from
relationships, and picture of neck to toes including the
the medical, familial and Genogram interdigital webs in adult
social factors that would patients
affect the management of the • Include the face and scalp in
patient the treatment of infants and
Scabies treatment
Stage of family life cycle young children
where children start living Launching family • Active treatment of
home for independence household contact
• Wash off Permethrin lotion
Do no harm Non-maleficence after 8-14 hours (overnight
application)
Most common cause of severe Pain, erythema, plaque-like
emergency illness of the GIT Necrotizing enterocolitis edema with sharply defined Erysipelas
in neonates margin to normal tissues
Most common cause of
Viral
Fat, female, forty, fertile Cholecystitis diarrhea in <28 months
Causative agent most
Active immunity responsible for foodborne
Bacteria
Live-attenuated vaccine disease outbreaks in the
Protection lasts for 20 years Philippines
Vaccination scar is a result of Ability of agent to trigger host
BCG vaccine Immunogenicity
amount of inflammation reaction
caused by the person's Study describes disease in
immune response and the population, accounting for Descriptive studies
person's healing ability basic distribution
Premature uncontrolled • Measures killing power of
death of cells in living tissue Necroptosis disease (how much afflicted
cause by external factors Case fatality rate die from the disease)
• Thalassemia • Higher CFR = more fatal
• Anemia of chronic disease disease
Microcytic hypochromic Leading cause of morbidity
• Iron deficiency anemia Acute respiratory infection
anemia among Filipinos
• Lead poisoning
• Sideroblastic anemia Epidemic started as common
source then secondary Mixed epidemic
Wernicke-Korsakoff person-to-person spread
Thiamine deficiency
syndrome Exact distance between two
• orange or red-orange categories can be determined Interval
discoloration of body fluids but zero is arbitrary
(including urine, sweat, Variable that can be ranked
Ordinal
saliva, and tears). or ordered
• gastrointestinal effects Sampling technique using
(nausea, vomiting, judgement in choosing Purposive
diarrhea) sample population
• central nervous system Denominator of Maternal
effects (headache, fever) mortality rate
Rifampicin side-effects Mean Average of all values
• dermatologic effects (rash,
itching, flushing) Mode Occurring most often
• hematologic effects Median Middle most observation
(thrombocytopenia, RED in biological waste Sharps and pressurized
neutropenia, and acute management containers
hemolytic anemia) Part of CEA counseling when
• Pruritus (with or without doctor speaks in language of
rash) patient, use analogies in Education
• Flu-like syndrome explanations and cites EBM
Family illness trajectory: outcomes
family resources are Sampling technique:
mobilized, medical economics subgroups / strata are each Stratified
Recovery phase adequately represented
applied and reaction to
therapy with necessary YELLOW in biological waste Infectious / pathological
adjustments are made management waste
Family assessment tool: Measure of death in <28 days
measures family function and of age in a calendar year due Neonatal mortality rate
dynamic which elicits to prenatal or genetic factors
APGAR Depicts level of healthcare in
patient’s perception to level
of satisfaction in family community, poor maternal
Infant mortality rate
relationships care, malnutrition, and poor
Hypopigmented plaque with environmental sanitation
absence of sweating and Hansen disease Sensitive indicator of
pinprick sensation standards of healthcare in a Swaroop’s index
• Vasovagal syncope country
Reflex-mediated syncope • Situational syncope
• Carotid sinus syncope
QUESTION ANSWER
Number of illnesses that
occur within a given interval Incidence
over exposed
Direct relationship between
Scatter point / scatterplot
two quantitative variables
Part of research process
where sample size is Construction of research
computed and method of design
subject selection is made
Quality of data shows interval
between date of occurrence timeliness
and time data is used
Blinded in double-blind
All subjects and investigator
randomized controlled study
Refers to output, outcome, or
Dependent variable
response to research problem
Subjects (study and control
Blinded in single-blind
groups)
Testing of hypothesis Inferential statistics
Group of diseased people
identified by SENSITIVITY of True positive
diagnostic test
Intervention group in
Treatment group
experimental study
Measurement close to its true
Accurate
value
Maternal, Newborn, Child
MNCHN strategy by DOH
Health and Nutrition
Occupational hazard: poorly
designed work environment
cause workers to assume Ergonomic
awkward posturing during
work
Health declaration form for • History of exposure
returning workers after • History of travel
COVID quarantine • Presence of symptoms
cause f death counted for
statistical purpose as Immediate
reflected in death certificate
• Flour with Vit A and Iron
• Sugar with Vit A
RA 8976
• Rice with Iron
Food fortification
• Cooking Oil with Vit A
• Salt Iodization
• Exclusive breastfeeding
• Feeding every 4 hours in
day and at least every 6
Lactation amenorrhea hours at night
method (contraception) • Infant less than six months
old
• Mother with menstruation
56 days postpartum

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TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE MAIN DIGITAL HANDOUT BY MARK LOUIE C.

Important Legal Information

• SAMPLING – is the act of studying or examining only a segment

CHARACTERISTICS IMPORTANT IN DATA SCREENING

SUPPLEMENT: GOLD STANDARD TEST

EXAMPLES OF SCREENING AND DIAGNOSTIC TESTS AND POSSIBLE GOLD STANDARDS

QUICK GUIDE: TEST STATISTICS NOMENCLATURE

• It is important for us to define the component of our contingency

• A 2 x 2 table, or contingency table, is used when testing the

III. POSITIVE PREDICTIVE VALUE (PPV) • NOMOGRAM

SCREENING TEST VALIDITY

PPV AND NPV CORRELATION

SUMMARY OF THE 2x2 TABLE PLUS THE FORMULA

Likelihood Ratio of a NEGATIVE TEST LIKELIHOOD RATIO

• Likelihood ratios (LR) in medical testing are used to interpret

develop Magkapit-kapit tayo ng kamay at magdasal sana po walang

• Comparison between 2 population or

• E.g. Leading cause of mortality

VERTICAL BAR GRAPH

Quantitative variable showing • Design with spaces in between bar because

PIE CHART • Breakdown of a group or total where the number

• Frequency distribution of continuous variable or

• Uses symbols or pictures. Used in showing the

SUPPLEMENT: PARETO CHART

MEASURES OF CENTRAL TENDENCY

1. STATE THE HYPOTHESIS

TYPE I (Α) ERROR TYPE II (Β) ERROR

ONE TAILED TEST OR

SUPPLEMENT: DEFINITION OF TERMS

• Population pyramid special type of histogram

and overall quality of life is high

MEASURES OF DISEASE FREQUENCY

SUMMARY IMPORTANT LIFE PERIOD PICO/M PROCESS

THE THREE SKILLS OF EBM

Painless Evidence-Based Medicine John Wiley & Sons, 2008

STUDY DESIGN COMPARISON

DESIGN TYPE DEFINITION ADVANTAGES DISADVANTAGES

EPIDEMIOLOGY CORE EPIDEMIOLOGIC FUNCTIONS

altered in a population to for, or already affected by, • Miasmatic theory

o Nutritional factors • THE WHEEL THEORY

Principles of Epidemiology in Public Health Practice Third Edition

interaction with and adaptation to the person’s

Schema for assessing non-fatal health condition

TYPES OF EPIDEMIOLOGIC STUDIES

patients) • CROSS-SECTIONAL ANALYTIC (PREVALENCE STUDY)

§ Inferential statistics: ODDS RATIO (OR)!!!! o Types:

QUANTIFYING RISK BIASES IN CLINICAL EPIDEMIOLOGY

BASIC CONCEPTS SOCIAL DETERMINANTS OF HEALTH

PRIMORDIAL PRIMARY SECONDARY TERTIARY

HEALTH PROMOTION EMBLEM

1. HEALTH EDUCATION 1. Primary prevention refers to actions aimed at avoiding

PRECEDE stands for Predisposing, Reinforcing, and Enabling

DENVER DEVELOPMENTAL SCREENING “ROUTINE” HYPERTENSIVE WORK-UP

o PPD RISK FACTORS FOR DIABETES

COMMUNITY DIAGNOSIS ILLNESS, DEATH, AND DYING

ON THE BASIS OF AUTHORITY THE “FAMILY LIFE CYCLE”

Hypothetical Genogram by Dr. Mann

Almost Some of the Hardly ever

SCREEM (Social, Cultural, Religious, Economic, Educational,

REQUIREMENTS FOR SUCCESSFUL AGENT INVASION

SUPPLEMENT: FORMS OF COMMUNICATION ELEMENTS OF A COMMUNICABLE DISEASE

CHARACTERISTICS OF AGENT DIRECTLY RELATED TO

SUPPLEMENT: ISOLATION VS QUARANTINE