Social medicine, epidemiology and medical law

Analytical interventional studies (EP6)

Analytical interventional studies involves the manipulation of independent variables and observing the effect. Here the researcher controls the intervention for each group. It primarily focus on the effectivity of preventive or therapeutic methods. - The most common type of study is the randomized controlled trial. - The purpose is to test the effect of exposure/intervention on the outcome. - It involves randomly allocating participants to receive either the intervention or a placebo, tracking each group over time and assessing the effects of the intervention. - It allows determination of the number needed to treat, absolute risk reduction and relative risk. - In order for an analytical interventional study to be valid, it requires randomization, blinding and compliance.

Determinants of health: (SM4/5) - Biology and genetics

Biology and genetics are internal determinants of health which cannot be change. The age, sex, genetic cargo (including genetic mutations such as BRCA), race all influence health. - Ex: Men have higher risk of CVD, whereas women have higher risk of autoimmunity

Epidemiology of EBV infections (EP15)

EBV infections is a herpesvirus that is commonly transmitted through bodily fluids and is associated with IFM, oral hairy leukoplakia, Burkitt's lymphoma and Nasopharyngeal carcinoma. -Chain of infection: The source of infection is a person who is shedding the virus through saliva or other bodily fluid. Transmission occurs through close contact, such as kissing or sharing food. Once the virus enters the body, it infects B cells, leading to production of infectious virions that shed into bodily fluids. - Occurance: EBV infections are very common, infecting primarily adolescents and young adults. Most people who are infected with EBV do not develop symptoms (asymptomatic). - Prevention: There is no specific vaccine for EBV but preventive measures include avoiding close contact with infected individuals, avoid sharing food or drinks and practice good hygiene. - Repressive measures: Treatment is mostly supportive with fluids, analgesics and antipyretics. Prevention and early detection of EBV-associated cancers is important in reducing morbidity and mortality.

Epidemiological studies (EP4/5/6) - Types and subdivisions - Basic characteristics

Epidemiological studies are divided into descriptive and analytical studies. The descriptive studies are used to generate an hypothesis. The researchers describe what they find from observing groups. These studies are limited to describing the occurance of a possible correlation in a population. - They answer to who, where, when and what. However, they lack a comparison group (there is no case or control groups). - Includes Case studies, Case series, Cross-sectional studies and Ecologic studies. The analytic studies are used to test hypothesis. The researchers analyse data from case and control groups to measure association between factor and outcome. - They answer to how and why. They involve the use of a case and control group. - Observational analytic studies: Cohort studies and Case-control studies. - Interventional analytical studies: Randomized control trial.

Measures of diease burden (SM3) - Years of life lost (YLL) - Years lost due to disability (YLD) - Disability adjusted life year (DALY)

Disease burden refers to impact disease has on health. - YLL: estimation of how many years a person has lost due to the disease. It accounts for the life-expectancy minus the age of premature death. - YLD: The amount that a person has lived with a disability. - DALY: Number of years lost due to ill-health, disability or premature death. YLL + YLD

Epidemiology of HAI (EP23)

HAI, also known as nosocomial infections, are infection acquired within the hospital environment. - The prevalence of HAI is an indicator of healthcare quality and is usually lower in developed countries and higher in developing countries. - Criteria for HAI: New symptoms developing 48 hours after admission or within 3 days of discharge or within 30 days of surgery. Risk factors for HAIs: - Immunosupression: Patients with weakened immune system, such as those receiving chemo or after organ transplantation, are at higher risk - Invasive procedures: Patients who undergoo invasive procedures are at higher risk - Lenght of stay: The longer a patient stays in the hospital, the higher the risk - ATB use: Prolonged use of ATB may lead to the development of DR bacteria. - Staffing levels: Lower staffing numbers are associated with higher risk of HAIs. Chain of infection of HAI: Pathogen: pathogens that cause HAI are generally more aggressive since they are often ATB resistant. - Examples include bacteria (MRSA, VRSA, VRE, Legionella, Pseudomonas, C- dificile), Viruses (Influenza, Coronavirus), Fungus (Candidia) or parasites (sabies and cimex) Reservoir: Persons or equipment - Endogenous infections: patient him/herself carrier an infectious pathogen - Exogenous infections: acquired from other patients, from equipment or from health care workers. Transmission: - Direct: direct contact (skin-to-skin, injection, ingestion), respiratory droplets - Indirect: aerosol, vehicles (food, water, blood, fomites) or vectors. Portal of entry: - invasive procedures, open wounds and catheters offer pathogens a portal of entry - The highest risk occurs in the OR and ICU due to open wounds and many catheter attached to the patient. Host: Hospitalized patients are more susceptible to infections due to many factors: - Age - Comorbidities - Drugs Types of HAI: - UTIs (most common, associated with the regular use of urinary catheters) - Surgical site infections - Pneumoniae (associated with the use of a ventilator) - Blood stream infections (associated with the use of central line, IV catheters) - GI infection Burden of HAIs: - Prolonged hospitalization, decreased productivity of the patient, financial burden to both the family and the health system and cause unnecessary morbidity and mortality. Prevention of HAIs: Eliminate a reservoir: - Maintaining healthcare sanitation and hygiene - Disinfection and steralization of medical equipments; Reduce the transmission: - Good hygiene practices, including proper hand hygiene. - Use of PPE before contact with patients. - Isolation of infective patients. - Proper use of ATBs to reduce the development of resistance Protect the portal of entry: - Using sterile equipment and following sterile guidelines for invasive procedures. - Thorough disinfection of insertion sistes for catheters - Prevention of any prolonged use of catheters Reduction of host susceptibility: - Vaccination, good nutrition, encouraging physical activity. Survaillance: - Survaillance is an essential component of infection prevention and control in healthcare settings. It helps to identify outbreaks, trends and evaluate the effectivness of infection prevention and control measures. - Active survaillance, passive survaillance, Sentinel survaillance.

Public health domains (SM1)

- Health protection: Focuses on serious public health threats with potential to spread beyong borders. Based on the international health regulations (IHR 2005) by WHO. - Health promotion: Adresses the leading risk factors and underlying determinants of health, promoting health changes so as to reduced morbidity and mortality. - Disease prevention. Aims at preventing or delaying the onset of diseases via a set of medical and non-medical practices.

Brucellosis, Psitaccosis and Tularemia (EP20)

Brucellosis: - Etiology: Multiple species of brucella genus (melitensis, abortus). - COI: Reservoir is sheep, goasts, catle and pigs. Transmission occurs via the ingestion of contaminated food such as raw meat or unpasteurized milk products. - Groups at risk: occupational exposure to infected animals and animal products (farmers, vets). - CF: Brucellosis, which presents with flu-like symptoms, night sweats, undulating fever and lymphadenopathy. - Diagnosis: serology and blood cultures. - Treatment: doxycycline plus rifampin. Psitacosis: - Etiology: C. psitacci - COI: Transmission occurs via inhalation of feces or dander from infected birds. - Groups at risk: Mainly includes those with contact with birds. - CF: flu-like symptoms and atypical pneumoniae. - Diagnosis: culture, PCR and serology - Treatment: Doxycyline or Azithromycin Tularemia: - Etiology: F. tularensis - COI: Reservoir is rabbits and rodents and transmission occurs via tick bites - CF: Causes flu-like symptoms, fever, tender regional lymphadenopathy and a variety of localising signs (eg. ulceroglandular type presents with ulcer at the bite site). - Diagnosis: based on positive culture and serology findings - Treatment: Streptomycin or gentamycin.

5As model of EBM (EP2)

EBM is based on the 5As model - Asking the right question: A good question helps identifying keywords for database searching. To ask the right question, we use the PICO-SD framework. - Acquire evidence: Search relevant studies in databasesand identify a list of studies that may include the answer to your question. -Apraise the evidence: evaluate the studies to assess which one is the ebst and most useful. This should include assessment of the quality of the study (based on the pyramid of evidence), the validity of the study (based on Rambo) and applicability of the study (cost/benifit, availability, patient's preferance). - Apply the evidence: involves the creation and application of a change based on the evidence. - Assess the results.

Determinants of health (SM4/5) - Lifestyle and behaviour

Individual lifestyle and behaviour plays a role in health outcomes, In fact, this is the determinant of health with the greatest impact (50-60%). - Individual specific lifestyle including diet, physical activity, alcohol or drug intake, smoking all influence the health of a person.

Legionelosis (EP16)

Legionellosis is an infection caused by L. pneumophilla (gram -). Chain of infection: - Source: Contaminated water (especially water distribution systems such as AC, colling towers, spas) - Transmission: Inhalation of aerosols from contaminated water - Incubation period of 5-6 days. Clinical features: - Pontiac fever: acute flu like illness (headache, fatigue, myalgia, fever and chills) - Legionaires disease: Severe atypical pneumoniae with very high fever, hyponatremia, diarrhea, headache. Diagnosis: Silver stain of sputum sample, urine antigen tests, serology Treatment: ATBs (erythromycin, fluoroquinolones) Prevention: - Survaillance: Regularly testing water deposits for legionella. - Disinfection of water distribution systems by using Na hypochlorite or specific filters.

Epidemiological measures of frequency (EP3)

Measure of frequency describe how often morbidity and mortality from a disease occur Morbidity refers to the number of people affected by a certain disease. - Incidence: number of new cases of a disease in a population per unit of time. - Prevalence: Refers to the total number of people affected by a disease in a certain time period. Point prevalence: number of people affected by a disease at a specific time Period prevalence: number of people affected by a disease in a time period. Mortality refers to the frequency of death from a specific disease in a population: - Crude death rate: the total number of deaths pepopulation - Case fatality rate: the number of deaths from a specific disease divided by the total number of cases of that disease.

Epidemiology of parasitic infections (EP24)

Parasite is an organism that lives on or in a host and gets its nutrition from or at the expense of the host. - Parasitism is a common form of life and parasitic infections are among the most common human infections. - They have worldwide distribution but specific etiologies ar elinked to specific geographic locations. - The majority of parasitic infections does not generate long-term immunity, thus we are at constant risk of infection. Parasites can live temporarily or permanently in a host (defnitive hosts vs intermediate host) There are three main classes of parasites: Protozoa: Single cell organisms with a nucleus. They have a short and rapid life cycle. They pathogenicity may include their abbility to invade cells, form cysts and to exchange surface antigens. - GIT: Giardia Lamblia, Entamoeba hystolitica - Blood: Plasmodium - CNS: Toxoplasma gondii, Naeglaria Fawleri, Trapanossoma cruzei - UGT: Trichomonas vaginalis - Other: Leishmaniasis Helminths: refers to parasitical worms. - Roundworm (noodle-shaped): GIT (Enterobius, Ascaris, Ancylostoma) - Flatworms: can be a fluke (non-segmented - Schistossoma) or tapeworm (segmented- Taenia solium from pork, Taenia sagianta from beef or Echinoccocus. Ectoparasites (insects): They can cause disease themselves, but they can also act as vectors for other infections - Scabies - Flea: Vector for Plague - Louse: Body louse (acts as a vector for , pubic louse or head louseepidemic typhus, trench fever and relapsing fever) - Ixodes tick: vector for Lyme disease, tick-borne encephalitis. Transmission: human to humans, animals to animals or animals to humans - Direct: through skin penetration (necator), Ingestion (fecal-oral route) or inhalation (enterobius) - Indirect: through vehicles (contaminated food or water, fomites) or vectors (ectoparasites) Epidemiology: - 3 most common protozoal infections: Plasmodium, Entamoeba, Trypanosoma brucei - 3 most common helminth infections: Enterobius, Ascaris, taenia - Most common ectoparasite in children: head lice Non-specific prevention measures: WASH strategy, use of protective clothing and repellants, and eleminating carriers.

Epidemiology of Salmonela (EP 18)

There are two serotypes of S. enterica: - S. Enterica serotype enteriditis (Salmenellosis and reactive arthritis) - S. Enterica serotype typhi (Typhoid and paratyphoid fever, osteomyelitis) Salmonellosis is a diarrheal disease caused by S. Enterica serotype enteriditis. - It is one of the 4 key glocal causes of diarrhea. In CZ there are >10000 cases per year. - Source: Human or animal - Transmission: ingestion of contaminated raw or undercooked meat, eggs, mild and other dairy products. - Clinical features: Fever, chills, headache, myalgia, abdominal pain, watery-bloody diarrhea. - Diagnosis: stool testing - Treatment: supportive (most cases are mild and self-limited) - Prevention: improving WASH and food hygiene

Definition of public health (SM1)

"the art and science of preventing disease, prolonging life and promting health through the organized efforts of society" Public health focuses on the entire spectrum of health and not only on treating the disease. It also focuses on the causes of the disease and how to intervene and prevent the disease from happening.

Factors causing health inequalities: (SM6)

- Economical status - Geographical area, culture and environment. - Living and working conditions - Age - Education - Acess and quality of healthcare.

Global conferances and charters on health promotion: (SM10)

1st international conferance on health promotion (Ottawa 1986): - It identified the concepts, principles and actions in the area of health promotion. - It identified social determinants as a route of health problems. - The Ottawa charter established the health for all by 2000. 4th international conferance (Jakarta 1997): - The theme was Leading health promotion into the 21st century. - It reviewed health promotion strategies outlined in the Ottawa charter and adresses new threats to health in the 21 st century. - It was the first charter mentioning health literacy 8th international conferance (Helsinki, 2013) - Reviewed the experiences in practicing the "Health for all" approach and established guidance for how countries can do so regardless of their level of development. 9th interation conferance (Shangai, 2016) - Two documents were written: Shangai declaration on health promotion and the Shanghai consensus on healthy cities. - Both documents adress the determinants of health through good governance, healthy cities and health literacy.

Epidemiology of communicable diseases (EP9):

A communicable disease is a disease caused by the transmission of a pathogen to a susceptible host. - A contagious disease is an infectious diseases that can spread between humans without a vector or vehicle. - The study of epidemiology allows us to understand the epidemiological triad, understand the chains of infection and aplly this knownledge to control and treat infections. - Around 20% of all global deaths are caused by infectious diseases with the top 3 causes being LRTIs, diarrheal diseases and TB. Types of infection include colonization, sub-clinical infection, latent infection and clinical infection.

Epidemiology of Alimentary infections (EP21)

Alimentary infections occurs when the pathogen enters the susceptible host through the digestive tract. - In the majority of cases, diarrhea is the most common symptoms. - However, some alimentary infections, such as botulism, Typhoid fever, hepatitis A and E, poliovirus, may not cause diarrhea. Source of this infection: - Human or animal. Transmission: - Direct: Fecal-oral route (via contaminated hand) - Indirect route: Ingestion of contaminated food or water. Risk factors: Poor hygiene and sanitation conditions, contaminated water supply and improper food handling. Populations at risk: - Children, pregnant women, elderly and immunosupressed. Etiology: - Bacterial: E. coli, Salmonella, Shigella, Campylobacter, Botulism, V. Cholera, C. dificille, Listeria - Virus: HAV and HEV, Rotavirus, Norovirus - Parasites: Giardia Lablia or Entamoeba histolitica.

Entamoeba histolitica and Plasmodium (Ep24)

Amebiasis: - Epidemiology: very common infection in tropical and subtropical regions. Infection occurs when travelling to endemic regions. - Etiology: E. histolitica - COI: Transmission occurs via fecal-oral route. - CF: Intestinal amebiasis (loose stools with mucus and blood, tenesmus, abdominal cramps and pain) and extraintestinal amebiasis (amebic liver abcess, fever, RUQ pain) - Diagnosis: stool analysis and RUQ US. - Treatment: paromomycin. Malaria: - The disease is endemic to tropical and subtropical areas of Africa and South America. - Etiology: Parasites of the Plasmodium family (P. falciparum, P. ovale, P. vivax) - COI: The host of the infection is humans and it is transmitted via the bite of a female anopheles mosquito. - CF: Flu-like symptoms, headache, diaphoresis, fever with regular spikes, hemolytic anemia, thrombocytopenia, N/V, diarrhea - Diagnosis: Thick and Thin smear - Treatment: Antimalarian medication - Prevention: Malaria chemoprophylaxis before travelling to endemic regions, limit outdoor stay, wear appropriate clothing with long sleeves, apply repellent products on the skin, install insect nets.

Analytical observational studies (EP5)

Analytical observational studies focus on hypothesis testing relating to exposure and outcome. It involves division into case and control groups but, in contrast to analytical interventional studies, it does not involve intervention. Cohort studies assesses the future incidence of a disease in an exposed group in related to an unexposed group. - Indicated to find outcomes from a single exposure. - It involves finding two groups (one with the factor being tested and another without), follow-up of these two groups over time and determine and compare the outcomes. - I allows the calculation of the relative risk (how much more likely is a person with exposure to a factor to develop the disease in comparison to those without exposure). - Example: Framingham study - Prospective vs Retrospective Cohort studies. - Advantages include a stronger association than case-control study and can study a variety of factors. - Disadvantage is that counfounding may occur, unknown factors may be responsible for the disease and the cost and duration. Case control studies assess the percentage of cases of a disease where there was exposure to a factor in comparison to those without. - Indicated for rare diseases, multiple exposures, outbreak investigation. - It involves enrolling one group with the disease and another without the disease and look back in time to measure exposure. - Case control studies allows the measurement of the odds ratio (how much more likely is a person with a disease to have exposure to the factor in comparison with those without the disease). - Advantages is that it is less costly and can be used for rare or long diseases. - Disadvantages include recall bias, counfounding, selection bias.

Epidemiology of bacterial respiratory tract infections (Ep16)

Bacterial respiratory tract infections are among the most common and most deadly infections. They are also among the most relevant HAI. Chain of infection: - Reservoir: In the majority of cases the reservoir are humans (either infected humans or via collonization), water (Legionella) - Transmission: Occurs through inhalation of respiratory droplets, aerosols or via direct contact. Risk factors: - Viral infections: Viral URTI weaken the mucocilliary clearance (increase the risk of 2nd bacterial infection) - Immunisation status: Non-immunized individuals are at increased risk. - Environmental factors: Air pollution, smoking and contaminated water may predispose to infections. - Immunecompromise: HIV, immunodeficiency, cystic fibrosis, Kartagener syndrome - Allergy Prevention measures: - Primordial prevention: Prevention fo exposure to risk factors ( smoking cessation, measures to improve air quality) - Primary prevention: Prevention of the onset of the disease with Vaccination (vaccines are available for pneumoccocus, meningoccocus, HiB, Diphteriae, Pertussis and TB (BCG vaccine)) and measures to prevent the spread (proper hygiene practices, disinfection and sterilization, use of PPE, isolation) The most relevant bacterial RTI are: - TB, Legionelosis, S. aureus, S. pneumoniae, S. pyogenes, H. Influenza, N. meningitidis.

Breast cancer (Ep13)

Breast cancer is the most common cancer in women with more than 2 million new cases every year. - Trend: Incidence and mortality has been increasing for 25 years. Incidence is higher in developed countries due to the use of screening programs. Mortality is higher in low and middle income countries. - Risk factors: Age, female gender, hereditary factors (positive family history, BRCA1 and BRCA2), exposure to estrogen (early menarche, late menopause, hormonal therapy), positive medical histrory of breast cancer and exposure to radiotherapy, alcohol and smoking. Prevention: - 1º prevention: Lifestyle modification (mainting a healthy weight, exercise, limit alcohol and cigarrete, limit hormonal therapy) - 2º prevention: Breast cancer screening starts at the age of 40 with annual mammography or MRI.

COVID-19 (EP15)

COVID-19 is a viral respiratory infection first identified in Wuhan, China in december 2019. - Properties: Enveloped RNA virus of the same family as SARS and MERS. - Transmission: Initially, it is thought that the virus was transmitted to humans from bats (zoonotic infection). Human-to-human transmission primarily occured through respiratory droplets and aerosols. Incubation period of 1-14 days. - Manifestations: Fever, dry cough, fatigue, sore throat, diarrhea, loss of taste and smell, dyspnea, chest pain. - Complications: ARDS, pneumoniae, viral sepsis Prevention: - Personal protective equipment (wearing masks , social distancing nad hand washing) - Community measures (quarentine and contact tracing) - Vaccination (Moderna, Pfizer-BionTech, Jansen)

CRC (EP13)

CRC is the 3rd most commonly diagnosed cancer in the world. - Trend: The overall incidence is increasing, with the highest incidence occuring in Western countries and the lowest in Asia (probably associated with dietary factors). Mortality rate has been decreaing in developed countries due to early screening and removal of polyps. - Risk factors: Age, family history, personal history of polyps, genetic syndromes (FAP, Lynch syndrome), IBDs and lifestyle (obesity, high fat and low fat diet, smoking, alcohol intake) Prevention: - 1º Prevention: Lifestyle modifications (exercise, diet, smoking and alcohol cessation) - 2º Prevention: CRC screening (starts at the age of 50 with annual FOBT or FIHT or colonoscopy every 5 years), colectomy (prophylactic colectomy for those with FAP)

Epidemiology of CV and metabolic disease (EP12)

CVD refers to a group of disorders involving blood vessels and the heart. - It includes CHD (MI), Cerebrovascular disease (TIA, stroke, aneurysms), PAD, Rheumatic heart disease, Congenital heart disease, DVT and PE. Metabolic disease refers to a group of diseases that affects metabolic processes of the body (Wilson's, PKU, DM). Epidemiology: - CVD is the most common cause death worldwide, causing 18 million deaths a year (31% of deaths worldwide) - 4/5 CVD related deaths are due to MI and stroke - >75% of CVD related death occurs in low/middle income patients - CVD also cause significant economical burden - The incidence of CVD is increasing, but with low mortality in developed countries. - DM is another growing public health concern - In PT, 17% of population are obese, 9,3% have DM, 127.9/100000 deaths annually from CVD and 14.7/100000 deaths annually from DM. Risk factors for CVD: - Non-modifiable: genetic predisposition, increasing age, male sex, race (black) - Modifiable: smoking, obesity, physical inactivity, unhealthy diet, hypertension, dyslipidemia - Novel risk factors: elevated homocysteine, CRP and fibrinogen levels. - Environmental risk factors: pollution, infection, low socioeconomic factors and education. To assess the risk for CVD, algorithms were developed based on the Framingham study. They calculate the risk of CVD in the next 10 years based on age, gender, race, total and HDL levels, BP, HTN, DM and smoking status Prevention of CVD - Primordial prevention: aimed at prevention exposure to risk factors of CVD. It may involve health policies (prohibiting indoor smoking, higher taxation for alcohol and tobacco), city planning (to promote healthier lifestyles) and health promotion (by educating patients on CVD, DM and healthy lifestyle). - Primary prevention: aimed at preventing onset of CVD and DM despite exposure to risk factors. Includes prevention of smoking, mainting healthy lifestyle and diet, limit alcohol consumption and physical activity. - Secondary prevention: aimed at prevention progression of CVD and MD. Includes prevention of smoking, aspirin and antiplatelet therapy, statins and anti-hypertensives. - Tertiary prevention: aimed at preventing the development of complications of CVD and improving quality of life. Includes surgical procedures (CABG, PCI, valve repair/replacement surgeries), cardiac rehabilitation

Epidemiology of cancer (EP13)

Cancer is the 2nd leading cause of death worldwide after CVD. It causes an estimated 10 million deaths each year. Epidemiology of cancer in males (excluding skin cancer): - Incidence: Prostate cancer > Lung cancer > CRC > Stomach cancer - Prevalence: Prostate cancer > CRC > Lung cancer - Mortality: Lung cancer > Prostate cancer > CRC > Pancreatic cancer Epidemiology of cancer in women (excluding skin cancer): - Incidence: Breast cancer > Lung cancer > CRC > Cervical cancer - Prevalence: Breast cancer > CRC > Lung cancer - Mortality: Lung cancer > Breast cancer > CRC > Pancreatic cancer Incidence in both sexes: - Lung cancer (2,20 million), Prostate cancer ( 1,4 million), Breast cancer (2,26 million), CRC (1,93 million) Mortality in both sexes: - Lung cancer (1,79 million), Prostate cancer (375 thousand), Breast cancer (684 thousand), CRC (1,06 million)

Chain of infection: (EP9)

Chain of infection refers to the sequence of events that culminates in infection -Reservoir -> portal of exit -> transmission -> portal of entry -> susceptible host. Reservoir is the habitat where the pathogen lives, grows and multiplies. - It can be human (syphyllis, measles, mumps), animal reservoir (zoonosis - brucellosis, plague, tularemia) or environmenral reservoir (water in legionella or giardia) Portal of exit is the pathway by which a pathogen leaves its reservoir. Usually refers to the site where the pathogen is localised. - It may be the respiratory system, GIT (feces) and bodily fluid (semen, saliva). Transmission refers to how a pathogen spreads from the reservoir to the host. We can have direct trasmission (direct contact, droplet transmission, vertical transmission) or indirect transmission (aerosol transmission, vehicle or vector). Portal of entry refers to the pathway by which a pathogen enters a susceptible host. It may include natural orifices (nose, mouth, ear, anus, vagina) or artifical opening (wounds, surgical incisions or through direct penetration). Host susceptibility: Susceptibility of the host determines whether an infection develops. Susceptibility depends on the determinants of health.

Epidemiology of Cholera (EP18) and other pathogens

Cholera is an acute watery diarrhea that can kill within hours if left untreated. It is caused by V. Cholerae. Cholera is an indicator of inequelity and lack of social development (primarily develops in developing countries). Epidemiology: - 1-4 million cases of cholera per year with 10-100 thousand deaths. 80% of cholera cases are treated sucessfully with an oral rehydration solution. - Cholera is endemic is more than 50 coutries (Africa and Southeast asia) - Outbreaks of cholera tend to occur in places after disruption of clean drinking water (Haiti after the tsunami). Latest outbreak was in Yemen and Sudan. - Source: Human (strictly human pathogen shed in the feces) - Transmission: direct (fecal-oral route) or indirect (contaminated water and food, especially seafood) - Diagnosis: Based on dipstick test and stool culture - Treatment: Supportive with aggresive rehydration - Prevention: Improving WASH, Food hygiene, survaillance systems and Vaccine (oral vaccine) Other pathogens: - Campylobacter: One of the most common pathogens for food-borne gastroenteritis. Transmited through fecal-oral route or via the consumption of contaminated or raw meat and water. Causes bloody diarrhea. - Listeria: Transmitted via the ingestion of contaminated food (including pre-packed foods) - E. coli: Transmitted via the ingestion undercooked beef. Cause of traveler's diarrhea. - Shigella: Transmitted through contaminated food or water. Cause of dysenteriae. - C. dificille: Causes severe diarrhea after intake of ATBs - Norovirus: Transmitted between humans via contaminated food and water (especially shellfish)

Demography (SM7) Demographic statics vs dynamics Sources of demographical data

Demography refers to the statistical study of population changes and its measurment. - Demographic statics: the study of the size, distribution and structure of the population of an area in a specific time - Demographic dynamics: the study of the changes in population size, disribution and structure over time and the factors behind these changes There are multiple sources for demographical data: - Census: snapshot of the population at a given point in time. Allows us to get a picture of the size, distribution and structure of the population - Registers, population projections, migration documentation.

Epidemiology of diarrheal diseases (EP18)

Diarrhea is defined as the passage of three of more loose or liquid stools per day. It presents the biggest threat to children, because these patients are more prone to dehydration. Epidemiology: - Leading cause of malnutrition in children under 5 - Second leading cause of death in children under 5 - 1.7 billion cases of diarrhea worldwide every year Classification diarrhea based on duration: - Acute diarrhea (lasts <15 days, doesnt require diagnostics) - Persistent diarrhea (lasts 15-30 days, requires diagnostics) - Chronic diarrhea (lasts >30 days, requires diagnostics). Types of diarrhea: - Acute watery diarrhea (Cholera, Rotavirus, Norovirus, ETEC) - Acute bloody diarrhea (EHEC, EIEC, Shigella, Entamoeba) Risk factors: - Poor sanitary conditions, dirty water, poor hygiene, poor handling of food. Etiology: E. coli and Norovirus are the 2 most common causes. - Bacteria: Campylobacter jejuni, Salmonella, Shigella, Listeria, Yersinia, E. Coli, C. dificile, V. Cholera - Viral: Norovirus, Rotavirus - Protozal: Entamoeba hystolitica, Giardia lamblia (protozoal diarrhea has a slower onset than bacterial and viral) - Toxin-mediated: S. Aureus, B. cereus, C. perfrigens, ETEC. Chain of infection: - Source: Animal (zoonosis), human or contaminated food or water - Transmission: Direct transmission (fecal-oral route through contaminated hands), indirect transmission (ingestion of contaminated water or food). - Susceptible hosts: children, elderly immuno-compromise, travelers. Clinical features: - N/V, diarrhea, malaise, dehydration (sunken eyes, thirst, slow capilalry refill) Diagnosis: - Clinical diagnosis (most diseases are self-limited) Treatment: - Supportive care with oral rehydration solutions, oral nutrition Prevention: A large proportion of infectious diarrhea can be prevented through proper sanitary conditions - WASH strategy: improving water, sanitation and hygiene through health promotion and policies. - Food hygiene: proper storing, handling and preparing food. - Vaccination: Rotavirus, Typhoid fever, Cholera

Prevention and its levels: (EP1)

Disease prevention refers to the act of stopping a disease from happening of from progressing. Prevention has 5 levels: - Primordial prevention: Prevention of the exposure to risk factors. It aims at producing environments with reduce risk factors for disease. It targets the entire population. Example is health policies such as prohibition of smoking in public places to reduce passive smoking. - Primary prevention: Prevention of the onset of a disease, despite exposure to risk factors. It aoms at reducing incidence of the disease by targeting the healthy population. Most important example is vaccination and mainting BMI and BP levels. -Secondary prevention: Prevents the progression of an ongoing disease. It aims at reducing prevalence of the disease through early diagnosis and treatment. Targets whole population. Most important example is screening programs. - Tertiary prevention: Prevents the complications of a well-established disease and tries o improve the quality of life. It is targeted for a specific patient. Examples include rehabilitation programs for chronic diseases, regular follows with a specialist. - Quaternary prevention: Preventio of any unnecessary treatments and risks of interventions. Aim is to reduce the overutilizatio of medical resources. Example is the rsection of tumours in a patient with metastatic disease.

Definitions: (SM3) - Disease - Illness - Injury - Impairment - Disability - Etiology - Pathologenesis

Disease: an abnormal condition that negatively affects the structure or function og an organism. It may be caused by internal and/or external factors. Ilness: A subjective perception of lack of physical or mental well- being. It leads to illness behaviour. Injury: refers to a damage to the body by an external force (one of the most common causes of disease during travelling) Impairment: refers to an abnormality of the psychologica, physiological or anatomical structure or function. Disability: refers to the lack of the ability to perform an activity considered normal for a human being. Etiology: the cause of the condition Pathogenesis: the process of disease development.

Evidence based medicine (EP2)

EBM refers to the use of the best available evidence together with clinical experience and patient preferances to make health related decisions. In other words, it refers to the integration of clinical expertise, patient's values and best evidence to make the best decision for the patient. It is based on three components: - Clinical experience - Patient's values - Best evidence available Importance of EBM - Allows improvement of quality of care - Allows EBPH (helps to guide the establishment of effective guidelines) - Allows the incorporation of patient's values

Evidence-based public health (SM19)

EBPH refers to the process of using the beast evidence to improve the health of the population. - Similarly to EBM, it uses the best current evidence to make decisions. In EBPH, these decisions are usually in the form of health policy that aims to change the social determinants of health and affect the whole population rather than an individual person. Framework of EBPH: 1st- Assess the community to find the health status of the population 2nd- Set goals by laying down desired changes. 3rd- Search for evidence related to the objective. 4th- Apraise the evidence 5th- Adapt the evidence to the population by creating a specific policy 6th- Implement the health policy 7th- Evaluate how well the policy works Difficulties of EBPH are related to the fact that there are lots of stakeholders, each with different interests. - Funding: New health policy requires health funds. - Training: Now everyone involved in the new health policy has the same training. Culture and geographic differences: In certain regions of the world, implementation of certain health policies is unfeasible.

Epidemiology of Ebola (EP22)

Ebola - Etiology: Ebola Zaire, Ebola Sudan or others. Enveloped RNA virus. Epidemiology: - The source of infection is primates, bats or infection humans. Transmission occurs via direct contact with blood or body fluid from an infected source, sexual contact, contact with an infected animal. - Ebola virus disease outbreaks occurs mainly in central and west Africa, with the largest ever outbreak occuring in West Africa in 2014. The most recent outbreak occured in November 2021, which started in Guinea. Pathogenesis: - Direct contact -> viremia -> infects all organs. - Infection of endothelial cells -> vascular instability -> hemorrhage (petechial rash) ->hypovolemic shock -> MOF -> Shock - Fever, headache, joint and muscle pain, sore throat, diarrhea, vomiting, petechial rash Treatment is only supportive. Prevention: - Early detection and reporting of suspected cases. - Isolation of infected individuals to prevent the spread - Use of PPE and strict adherance to infection control measures - Contact tracing and quarentine of individuals with exposure. - Vaccination (oral vaccine is available for Ebola Zaire) - Movement restrictions to prevent spread of the disease - Safe burial practices.

Emerging diseases (EP25)

Emerging diseases refers to: - Outbreaks of a previously unknown disease; - Known diseases that are rapidly increasing in incidence or geographic range in the last 20 years. - Persistance of infectious diseases that cannot be controlled. Examples: - Emerging: HIV, Lime disease, COVID 19, West Nile virus - Re-emerging: Measles Reasons for emergence: - Environmental changes (including climate change): can lead to increased exposure of humans to certain pathogens. For example, deflorestation causes an increased chance of human exposure to wild-life and, therefore, increased risk of transmission of diseases. - Social instability: Social conditions such as war, economic crisis or non-functional governments may lead to deteoration of health services and emergence of diseases. Additionally, some social factors may promote migration of populations and emergence of infections. - ATB overuse: leads to the development of MDR bacteria with increased infective capacities. - Decrease in vaccine adherance: Measles is re-emerging due to decreased vaccination associated with anti-vaxxers. - Pathogen mutation: Mutation of certain pathogen may lead to emergence of new strains, fow which humans do not have immunity (eg. Influenza epidemics) - Bioterrorism: Emerging infections can be the result of deliberate release into humans.

Enterobius, Ascaris (EP24)

Enterobius: - Epidemiology: Most commonly affects children and people that take care of children. - Etiology: E. vermicularis. - COI: It is a strictly human pathogen, which is transmitted via the fecal-oral route. - CF: Pruritus ani - Diagnosis: Scotch tape and microscopy - Treatment: Albeldazole Ascariasis: - Epidemiology: Most common helminth infection worldwide. - Etiology: Ascaris lumbricoides. - COI: Transmission occurs via the fecal-oral route. - CF: dry cough, blood tinged sputum, wheezing, N/V, diarrhea and bowel obstruction. - Diagnosis: stool sample analysis - Treatment: bendazoles.

Evaluation of epidemiological situation (EP11)

Epidemic investigations are a critical aspect of epidemiology. They involve the systemic collection, analysis and interpretation of data on the occurance and distribution of a particular disease outbreak. The underlying aim is to identify the underlying causes and implement effective control measures. Epidemiological investigations involve the following steps: - Establish the existence of an outbreak: involves identifying cases of the disease and determine whether they represent an unusual increase in the number of cases. - Define the outbreak: Involves describing the affected population, affected geographic area and time period. - Collecting data: Involves gathering information about the cases, including demographic characteristics, clinical symptoms and lab results. - Analyzing the data: involves the use of statistical methods to identify patterns and associations in the data. - Implement control measures: Based on the findings of this epidemiological investigation, control measures should be implemented to prevent the spread of the outbreak. One of the key tools in epidemiological evaluation is the epidemic curve, which is a graphical representation of the number of cases of a particular disease over time. - The shape of the epidemic curve can provide important information about the pattern of disease transmission, such as rate of spread, peak of the epidemic and duration.

Epidemiological measures of association (EP3)

Epidemiological measures of association asses the association between two measured values. Relative risk describes how much more like is a person with esposure toa factor of developing a disease in comparison to those without exposure. - It uses cohort studies (factor -> disease. assess the future incidence of disease in an exposed group in relation to disease in the unexposed group). Odds ratio describes how much more likely a person with a disease is going to have exposure to a factor in comparison with those without the disease. - It uses Case-control studies (Disease -> factor. Assess the % of disease cases in which there was exposure to the examine factors) Pearson's correlation coefficient describes how strongly the two variables are related. - It only works for linear trends - Correlation does not equal causation.

Epidemiology and its purpose (EP1)

Epidemiology refers to the study of the distribution and determinants or health related states in specific populations and the application of this study to the control of health problems. Its purpose: - Study the agent, host and environmental fatcors that affect health - Study the natural history and prognosis of the disease - Identify populations at risk and determine the extent of the disease in the population - Evaluate the effectivness of both new and existing health problems in improving the health of the population - Support decision making (both individual and health policy).

Global health and health protection (SM11)

Global health refers to the health of the populaiton in a global context. Involves the collaboration between countries to promote health for all and to protect aggainst threats that transcend national borders. An important part of global health is health protection. Health protection refers to the protection of people and populations aggaints potential threats. It has 3 main domains: - Control of communicable diseases: detection, investigation and control of infections. - Emergency preparedness resilience and control: involves preparing, preventing an dcontrolling health care emergencies. - Environmental public health: Involves the identification of any kinds of environmental threats to health.

H. Influenza, N. Meningitidis (EP16)

H. Influenza: - Chain of infection: the bacterium can be found on the nasopharynx of humans. It is transmitted through respiratory secretions (aerosol ransmission). - Ocurrance: H. influenza can cause a range of infections, including otitis media, conjunctivitis, epiglottitis, pneumoniae and meningitis. - Prevention: Vaccination, proper hygiene practices - Repressive measures: ATBs (Amoxiclav, 3rd gen cephalosporins) N. meningitidis: - Chain of infection: Bacterium is found in the nasopharynx of humans (humans are the only hosts). It is transmitted through respiratory secretions or close contact with an infected person. - Occurance: It causes meningitis and bloodstream infections (meningoccocemia with petechiae) - Prevention: Vaccination (Subunit vaccine), proper hygiene practices. - Repressive measures: ATBs (3rd gen cephalosporins)

Epidemiology of viral hepatitis A and E (EP 17)

HAV is a naked RNA virus - Endemic to Sub-Saharan Africa and Asia (Mongolia). It causes around 7000 deaths annually. - Transmitted via fecal-oral route (primarily via contaminated seafood) and has an incubation period of 15-50 days. - Clinical features: acute hepatitis, rarely fulminant hepatitis - Does not cause Chronic infection nor Carrier state. - Treatment is supportive. - Prevention: Vaccine (Killed or LAV), WASH strategy, food safety (avoiding raw food) HEV is a naked RNA virus. - Endemic to east and south Asia. Causes around 20 million cases annually. - Transmitted via the fecal-oral route (primarily via contaminated raw pig meat) and has an incubation period of 15-60 days. - Clinical features: acute hepatitis, fulminant hepatitis in pregnant women (high mortality at 20%) - Does not cause Chronic infection nor Carrier status. - Treatment is supportive - Prevention: Vaccine (only available in china), WASH strategy and food safety.

Epidemiology of viral hepatitis B and D (EP17)

HBV is a enveloped DNA virus. - Endemic in Sub-Saharan Africa and Southeast Asia. Around 260 million people have hepatitis B. - Transmitted via unprotected sexual relations, parenteral trasnmission (contaminated needles, blood), vertical transmission and has an incubation period of 2 weeks to 6 months. - Clinical features: Acute heaptitis, Fulminant hepatitis, Carrier state, Chronic hepatitis - Complications: HCC, liver cirrhosis, fulminant hepatitis - Can cause chronic infeciton and carrier state - Treatment involves a combination of supportive care plus anti-virals (IFN-a, tenofovir and Entecavir) - Prevention includes vaccination (Subunit vaccine), safe injection policies, screening of blood donations, safe sexual practices HDV is a naked RNA virus. - Endemic in Sub-Saharan Africa and Southest Asia. Seen in around 5% of patients with HBV. - It is an incomplete virus which requires a co-infection with HBV. - Transmission involves unprotected sexual relationships, parenteral transmission (contaminated blood products or infected needles) and has an incubation period of 2 months - Clinical features: co-infection with Hep B (typically a more severe hepatitis) or a superinfection. - Can cause fulminant hepatitis and HCC. - Treatment is based on treating HBV. - Prevention is also similar to HBV.

Epidemiology of high consequence infectious diseases (EP22)

HCID are diseases that have the potential to cause severe infection, death and significant social and economial distuption. - HCID are a heterogenous group of diseases with high contagiousness (high potential for spread n the human population) - Reasons for being classified as high consequence is that these diseases have rapid interhuman transmission and a severe clinical course with high lethality. - HCIDs can be caused by bacteria, viruses, fungi and parasites, can spread from person to person and through various modes of transmission including direct contact, droplets, airborne particle and contaminated objects or surfaces. Important examples of HCID: - Avian Influenza, Ebola, SARS, MERS, Monkey pox (epidemics in Africa), Marburg fever (outbreaks in Equatorial Guinie), Plague (endemic in Madagascar) and Anthrax. Epidemiological characteristics: - Source: can be both human or animal - Both direct or indirect modes of transmission may be involved - Incubation period is usually in the range of 2-21 days - In the majority of cases, these diseases are zoonosis that have crossed the interspecies barrier. Their development may be associated with changes in the ecosystem which allow transmission. Importance: - HCIDs can lead to very severe illness, leading to a high number of deaths and mortality , with the potential to cause social and economic disruption. - Early detection and response to these infections is critical to prevent and minimize tha impact on public health.

Epidemiology of viral hepatitis C (EP17)

HCV is enveloped RNA virus. - Endemic to Eastern Europe, Africa, Middle East and Central Asia. High rate of chronicity with 70 million cases of chronic Hep C worldwide. - Transmitted via unprotected sexual intercourse, parenteral transmission (contaminated needles, contaminated blood products), vertical transmission - Clinical features: Acute hepatitis, carrier status, chronic hepatitis. - Complications: HCC, liver cirrhosis. - Treatment involves a combination of antiviral medications. - Prevention: There is no vaccination for HCV. Prevention involves safe injection policy, blood screening programs, safe sexual practices.

HIV and AIDS (EP19)

HIV/AIDS is currently a global pandemic. Epidemiology: - 38 million people in the world have HIV - 33 million people have died from HIV so far - >2/3 of affected individuals live in Sub-Saharan Africa - There are around 3500 cases in CZ and around 41000 cases in PT - Etiology: HIV is a retrovirus. HIV-1 is the most prevalent, whereas HIV-2 is mainly found in Africa - Transmission: Sexual route (semen, vaginal secretions), contaminated blood transfusions, needle injuries and vertical transmission - Risk population: Young people, transgender, men who have sex with other men, IV drug users, Sex workers and their clients. - Risk factors: Unprotected sex, having other STIs, sharing injection material, acidental needle stick and receiving contaminated blood. Pathogenesis: HIV infects CD4+ T cells -> cells die over time -> acquired immunodeficiency (if CD4 counts < 200 ul) - 1st: Window period (1st month): Incubation period - 2nd: Acute Infection (2nd month): Flu like Illness. - 3rd: Seroconversion (12 weeks to up to 10 years): development of specific immunity aggainst HIV (individuals become seropositive) - 4th: Immunodeficiency: occurs when CD4 < 500 ul and presents innitially on mucous menbranes (eg. chronic candidiasis) - 5th: AIDS is defined as CD4 < 200 ul or development of an AIDS defining illness (CMV retinitis, PCP, HIV-related encephalopathy, TB, primary CNS lymphoma) - Diagnosis: ELISA and Western bloting - Treatment: HAART Prevention: - Safe sexual practices: avoiding multiple sexual partners, use of barrier methods (condoms) - Use of sterile equipments - Testing for HIV and STI - ARV therapy prevention: including pre-exposure and post-exposure prophylaxis . - Prevention of HIV spread to baby from HIV-positive mother: C-section, pre-exposure prophylaxis and no breastfeeding.

Health care quality (SM16)

Health care quality refers to providing the healthcare the patient needs, when the patient needs in an affordable, safe and efefctive manner. - Patient´s safety is the cornerstone of healthcare quality . The most important parameter to judge healthcare quality is patient satisfaction. Indicators or healthcare quality: These include measurable indicators of the quality of healthcare. - Effectivness - Afficiency - Equity - Acessability - Safety - Timeliness To assess healthcare, the Donabedian models are used. This modules measure quality of care by evaluation its structure, processes and outcomes. Important to improving healthcare quality is the implementation of clinical guidelines. - These are recommendations intended to optimize patient care, which are based on systemic reviews of evidence and an assessement of the benifits anf harms of alternative care options. - They improve quality of care, reduce legal accusation and aid in decision making.

Health economy (SM13)

Health economy and financing refers to how health funds are obtained and used to cover the health needs to a health system. - Health funds are require for the provision of health services (salaries, procedures), for the administration of health care and for the promotion of health through public health and promotion programs. - Health funds may be obtained as part of the government budget, through insurance (either private, social or national health insurance), from the patients pocket or through NGOs and charities. Health care payment models: - Bundled payment: hospital receives a set amount per service, regardless of the ultimate cost - Capitation method: Hospital and insurance companies agree to a price per patient that is paid monthly - Fee for service method: The patient or insurance company pays for each service. - Discounted fee for service: The patient pays portion of the service and the other portion is provide by the insurance company - Global payment: The patients pay everything. Important metrics of healthcare efficiency: Cost-to-effectivness analysis and Cost-to-benefit analysis.

Health inequalities (SM6)

Health inequalities refers to systematic differences in the health status of different populational groups. - Inequalities have no boundiries, meaning it can happen between countries, cities or within the same city. - Health inequalities are associated with the differances among the determinants of health. Human biology and genetics can be populational specific, and individual lifestyle and behaviour, health services and social determinants of health can vary widely between populational groups leading to inequalities in the healthy status. - Health inequalities are associated with significant socail and economic costs.

Health information systems (SM15)

Health information system is an informatical system that collects, stores and retrives health data. There are multiple levels of HIS: - Local level: includes the systems used in different hospitals, such as electronical medical records, practice management software, patient portals. - National level: includes the Institute of health information and statistics (UZIS in CZ) and National institute of statistics (PT) - International level: includes the Global health observatory of the WHO and the OECD health at glance from OECD. The major advantage of HIS is that it improves quality of care by facilitating acess to information and by improving collaboration. Additionally, it is an important source of information for epidemiological studies.

Health policy (SM8)

Health policy refers to the decisions, plans and actions taken to improve the health status of a population. - Since health is related to everything, WHO proposed the "Health in All approach" which states that health should be incorporated in policy across all areas. - The major aims of health policy are to define a vision for future health, outiline priorities and roles of different groups, outline changes to be implemented as a means to improve health. Some of the top health policy priorities currently include: - ATB resistance due to misused, disease epidemics, mental health, health worker shortages, air pollution, refugee and migration crisis and climate changes Examples of health policies: - Internation health regulations: set of policies that focuse on seriousb health threats with the potential to cross borders. - Health 2020: European policy framework and strategy for the 21st century. It was design by the WHO regional office for europe in 2012.

Health promotion (SM10)

Health promotion is the process of enabling people to increase control over their health and its determinants, thereby improving their health. - Health promotion can be directed towards health resource enhancement or health-risk reduction. - Since health is envolved in every sector, the WHO suggested the Health in all approach, which states that health should be involved in all policies. - Health promotion healtht o reduce excess mortality, adress risk factors, and helps streghtening health systems.

Health status and its indicators (SM9)

Health status refers to the description of the health of a population at a particular point in time. It is reflected via health indicators. Health indicators are provided by specific institutes. - CZ: Data comes from the Institute of health information and statistics (UZIS) - International sources include the Global health observatory of the WHO and OECD health at glance. Multiple health indicators exist, but the most important are: - Life expectancy - Crude death rate - Infant mortality rate - Maternal mortality rate - Leading cause of death - Stilbirth rate - Fertility rate - Under 5 mortality rate. - Prevalence of certain diseases - Case fatality rate

Health system models (SM12)

Health system consists of all organizations, people and associations whose primary intent is to promote, restore or maintain health. Beveridge model (UK) - In this model, health care is provided and financed by the government through tax. - Health services are provided mostly by public services (but private providers also exist) Bismarck model (czech): - This health system uses insurance systems financed through a combination of payroll deductions from emplyoers and employes and government. - This model insures everyone. National health insurance model (Portugal) - This model uses private sector providers, but payment also comes from a government-run insurance program that every citizen pays into. Free market model (USA) - In this model, each person has its own private insurance and medical care is primarily through private hospitals. - The major con is that not everyone is covered in this model.

Health workforce (SM17)

Health workforce refers to all people engaged in the delivery of healthcare. A health system cannot function without health workers and a well-functioning health system is based on having well-trained and well-motived health workers. - Direct services providers, including physicians, nurses and physiotherapists - Indirect service providers: include tecniqtions, drivers and administrative workers. Health workforce indicatoors: - Doctor to population ratio (number of doctors per 1000 people) - Graduates per 100000 population - Physicians pby specialities per 100000 population - Nurse to physician ratio

Healthcare accreditation (SM16)

Healthcare acredittation is the act of oficially recognizing a hospital as having met the standard of care quality defined by the accreditation organization. Internal accreditation: occur when the hospital conducts quality assessment on itself. It is done every 3 years in CZ. External accreditation: occurs when am external accreditatio organization conducts a quality check. - It serves as a proof the the hospital has quality care, making it more attractive for patients. However, hospital accreditation is time and resource consuming. - Important accreditation associations: Joint commision on Accreditation of Healthcare Organizations (JCAHO), Czech Accreditation institute and Department of health quality (PT, part of DGS).

Determinants of health (SM4/5) - Healthcare

Healthcare services, including both the acess to and the quality of healthcare, can impact health. - In general, limited acess to healthcare is associated with poorer health outcomes and may be associated with lack of availability, high cost, lack of insurance and/or language barriers.

Hipocrathic oat and declarations reguarding medical ethics (SM20)

Hipocratic aoth is a medical text written by Hippocrates. It includes many ethical principles that are still used today, includoing the principle of confidentiallity and non-malificence. Declaration of Geneva: - Modern version of the Hipocratic oath since many things mentioned there are no longer suitable for modern medicine. - It was drafted by the World medical association in Geneva in 1948. - It includes many ethical principles such as respecting autonomy and dignity, respecting confidentiality and prohibits the use of medical knowledge aggainst human rights. Declaration of Helsinki (1964): - Approaches the ethical principles for medical reasearch involving human subjects. Declaration of Lisbon (1981) - Adress the rights of the patients.

International classification of functioning, disability and health (SM3)

ICF is a classification system of body function and disability. It focuses on body function, structure, activity and participation. - It allows evaluation of disability for physiotherapy, handicap pension and insurance purposes.

Definitions (SM3): Incidence Prevalence Morbidity Mortality Crude death rate Case fatality rate Infant mortality rate Life expectancy

Incidence: Number of new cases of a disease within a certain population in a certain time period. Prevalence: number of total cases within a population. Morbidity: Frequency of a disease in the population. Associated with incidence and prevalence. Mortality: Frequency of deaths in a population. Associated with crude-death rate, case fatality rate and infant mortality rate. Crude death rate: number of deaths divided by the population size. Case-fatality rate: number of deaths from a specific cause divided by the the total cases of that disease Infant mortality rate: Number of deaths of infants <1 yoa reported during a certain time period. Life expectancy: Number of years a newborn is expected to live, based on selected time and area.

Main indicators of health inequality: (SM6)

Infant mortality rate: Number of deaths among children < 5 yoa during a certain time period. - Children in poorest countries are associated with 2x the risk of mortality than those of developed countries. Maternal mortality rate: Maternal deaths due to complications from pregnancy or childbirth per 100000 live births. - 99% of maternal deaths worldwide are seen in developing countries - Chad (11140 d/100000) vs portugal (8 d/100000) Tuberculosis mortality rate: TB mortality is primarily seen in developing countries. Life expectancy: Life expectancy differs considerably between countries. - Sierra Leoa (50 years) vs Portugal (82 years). Crude death rate

Epidemiology of Influenza (EP15)

Influenza is a viral respiratory tract infection first isolated from a pig in 1931. Properties: - It is caused by enveloped RNA virus which can be divided into 4 strains (A, B, C, D -> only A and B can cause seasonal epidemics) - Two important antigens exist on the surface of influenza virus: Hemaglutinin and Neuraminidase. This antigens are used to classify different epidemics of the disease (Eg. A/sydney/05/97 (H3N2). - The genome of influenza commonly undergoes changes which are responsible for the development of influenza epidemics (antigenic drift) and influenza pandemics (antigenic shifts). Influenza virus has a 1-4 days incubation period. It is transmited via respiratory droplets or aerosols released when an infected individual coughs of sneezes. Clinical features: Flu.like symptoms (fever, chills, myalgias, sore throath, cough, headache. Prevention: - Non-specific measures: Wearing masks, social distancing and hand washing - Specific measures: Flu vaccines - Post-exposure prophylaxis: oseltamivir. Seasonal epidemics of influenza cause around 3-5 million cases of severe illness and thousands of deaths annually. Influenza pandemics, occurs when a new strain of influenza virus is transmitted to humans: - 1918 Spanish flu (H1N1): estimated to cause 50-100 million deaths. - 1957 Asian flu (H2N2): originated in china - 1968 Hongkong flu (H3N2): originated in Hongkong and caused 1 millhion deaths - 2009 Swine flu (H1N1): originated in Mexico.

Informed consent (SM15 and ML2)

Informed consent is teh process of getting permission before conducting a healthcare intervention or when bridging patient confidentiallity. - Before any consent is signed, informations should be provided to the patient via both speaking and via a document. - Consent is given via the signature of the patient. - Main needs for consent: Examination of a patient, before any procedure, when using certain examinaion methods, when bridging patient confidentiality.

Population approach to health (SM2)

Is defined as the promotion of health through actions that influence the entire population, rather than a single individual. - Focuses on improving the social determinants of health. - Ex. Increasing the price of cigarrests and increasing the adds on the adverse effects of cigarrests. This will stop more people from smoking than teling each smoker to stop.

Internation classification of disease and related health problems (ICD) (SM3)

It is a disease and injury classification system developed by the WHO. - Revised every 10 years and is mandatory to be used in countries that accept it. - Currently ICD-11 is used. - It provides a universal classification system for collecting, stroing and retriving medical data.

Leptospirosis, Plague (Ep 20)

Leptospirosis is the most common zoonotic disease worldwide. - Etiology: L. interrogans. - COI: Transmission occurs via teh contact of brokin skin or mucous menbranes with soil, food or water contaminated with the urine of infected animals (rodents). - Groups at risk: farmers, sewer workers and water sports enthusiasts. - CF: fever, headache, diarrhea, conjunctival suffusion, photophobia and rash - Diagnosis: dark field microscopy, serology and PCR. - Treatment: Doxycycline or Azithromycin. Plague: - Etiology: Y. pestis. - COI: Reservoir is prairie dogs, squirrles and rodents and transmission occurs via flea bites. - CF: Bubonic plague which presents with fever, headaches, myalgias, chills and painfull lymphadenopathy. - Diagnosis: culture and microscopy - Treatment: Isolation, droplet precautions, IV gentamycin or fluoroquinolones

Listeriosis (EP21)

Listeriosis is a rare disease with high mortality, which is caused by L. monocytogenes. - Source: Listeria are ubiquitous (can survive everywhere) - Transmission: Ingestion of contaminated food (chilled, ready to eat products, deli meat, raw milkd products) and water, transplacental or perinatal transmission (congenital listeriosis) - Risk populations: Pregnant women, children, elderly and immunocompromised Clinical features: - Non-invasive listeriosis (febrile gastroenteritis): fever, diarrhea, headhace and myalgia. - Invasive listeriosis: Fever, myalgia, septicemia and meningitis - Congenital infection: miscarrigae, stillbirth, neonatal meningitis. Diagnosis: Combination of clinical suspicion and detection of the bacteria in blood, CSF, meconium of newborns. Treatment: ampicilin, penicilin G Prevention: Food safety (keep clean and seperate raw and cooked meat, use safe water), Avoid eating high risk foods for high risk people (pregnant and immunocompromised).

Lung cancer (EP13)

Lung cancer is the most commonly diagnosed cancer (when both genders are taken into account) and the most lethal cancer. - Trend: Worldwide, the incidence and mortality of lung cancer are decreasing. Prevalence is low but mortality is high - Risk factors: Smoking, exposure to radon, asbestos and arsenic, family history, pulmonary scarring, radiation Prevention: - Primordial prevention: Tobacco control policies (ex. increasing the taxes on tobacco, prohibition of indoor smoking) - 1º prevention: Quit smoking, maitain a healthy lifestyle and reduce occupational exposure - 2º prevention: Cancer screening (Low dose CT scan for patients >50 years and >20 pack years of smoking)

Lyme disease (EP 20)

Lyme disease is a zoonotic disease caused by B. Burgdorferi. - Epidemiology: The incidence of Lyme's disease is increasing in Europe. It is primarily found in forested areas of Asia, Central Europe and North America. Around 4000 cases per year in CZ. - Source: Deer or mouse - Transmission: Tick bites (Ixodes tick) (This tick also transmits Tick born encephalitis, Babesia and Anaplasia) Clinical features: it has 3 stages and each stage has progressively worst symtpoms - 1st stage: Flu-like ilness, Erythema migrans - 2nd stage: Migratory arthralgia, CN palsies (especially Bell's palsy), carditis and AV block and erythema migrans. - 3rd stage: Migratory polyarthritis, encephalomyelitis, aseptic meningitis, cognitive impairments and Acrodermatitis chronica Atrophicans. - Diagnosis: clinical features and serological testing - Treatment: Amoxicillin or Doxycycline, Ceftriaxone Prevention: - Wearing long pants and long sleeves to protect aggainst the tick bite. - Use of insect repellants on the skin and clothes - Check the skin for ticks and removing immediately - Vacciantion for TEBV.

Epidemiology of MMR infections (EP15)

Measles is a highly contagious viral infection that spreads through respiratory droplets or contact with contaminated surfaces and is associated with development of fever, Koplik's spots, generalized lymphadenopathy and erythromatous maculopapular, blanching exanthema. - Chain of infection: The source of the virus is an infecting person who is sheeding the virus. It is transmitted through the air as respiratory droplets or aerosol. - Occurrance: Measles is still a significant health problem in areas with low vaccination rates (Ukraine). In 2019, there was an estimated 207500 mealses death globally,, with most deaths occuring in children under 5. - Preventive measures: The measles vaccine (MMR vaccine) is highly effective. People who has been exposed to measles may be given post-exposure prophylaxis, such as vaccine or immunoglobulin. - Repressive measures: Treatment is primarily supportive and may include Vit. A. Outbreaks of measles may require public health interventions, such as case tracing and quarentine measures to contain the spread of disease. Mumps is a viral infection that primarily affects the salivary glands, is spread through respiratory secretions or direct contact with contaminated surfaces and is associated with development of low grade fever, malaise and inflammation of salivary glands. - Chain of infection: The source of the virus is a person who is activily shedding the virus through their saliva and respiratory secretions. It is transmitted through as respiratory droplets released when an infected person coughs or sneezes. Once the virus enters the body it infects the salivary glands. - Occurance: Mumps was a common childhood disease, but is now less common due to widespread vaccination. Outbreaks still occur. - Prevention: Mumps vaccine (MMR vaccine) is highly effective. People who have been exposed to mumps may be given post-exposure prophylaxis, such as mumps vaccine or immunoglobullin. - Repressive measures: Treatment is supportive, including bed rest, fluids, analgesics and antipyretics. Outbreaks may require public health interventions, such as case investigation, contact tracing and quarentine measures to contain the spread of the disease. Rubella is a viral infection that is spread through respiratory droplets and is associated with the development of auricular and sub-occipital lymphadenopathy, low grade fever, sore throat, pink maculopapular rash and polyarthritis. - Chain of infection: The source of the virus is an infected person who is shedding the virus in their respiratory secretions. It is transmitted via respiratory droplets. Additionally, it can also be transmitted from a pregnant women to her unborn baby (vertical transmission). - Occurance: Rubella was once a common childhood illness, but widespread vaccination has reduced its occurance. It primarily affects children aged 5-9 years. - Prevention: The rubella vaccine (MMR vaccine) is highly effective and maintaining high coverage rate is important in preventing Rubella epidemics. - Repressive measures: Treatment is supportive and includes bed rest, fluids, analgesics and antipyretics. Outbreaks of Rubella may require public health interventions, such as case tracing and quarentine measures to contain the spread of infection.

Medical ethics (SM20)

Medical ethics is a set of moral principles that health workers should follow when providing medical care. The purpose of medical ethics is to guide the conduct of a medical personal. Basic principles of ethics: - Autonomy: Patients have the right to make their own decisions, and health care workers must respect them. - Beneficience: Physicians have the duty to act in the patient's best interest. This may conflict with autonomy or with what is best for society. - Non-malificence: The duty to not harm. The harm must not outweight the benifit. Principle of double effect states that is ethically ok to provide a treatment with side-effects if these are not intended. - Justice: Treat all patients with the same quality of care. - Patternalism: the doctor knows whats best for the patient. - FIdelity: Docotr's obligation to keep promises and to not deceive. - Confidentiality: States that ny information reguarding a patient is not to be shared.

Epidemiology of neurodegenerative diseases (EP14)

Neurodegenerative diseases is an umbrella term for diseases that are characterized by the irreversible and progressive loss of neurons. The main symptom is dementia. - Dementia refers to the progressive decline of cognitive functions that impairs daily function. Although it mostly affects the elderly, it is not part of the normal development. - Dementia may present with memory loss, difficulty concentrating, confusion about time and place, mood changes, sleep disturbances. Behaviour disturbances commonly develop in the afternoon (sundowing). Epidemiology: - NDD affect 50 million people worldwide, with 10 million new cases every year. - Azheimer's is the most common form and accounts for 60-70% of total cases. - Around 60% of cases are seen in low/middle income countries. - It is estimated that 5-8% of people over 60 have dementia. - Prevalence of dementia is increasing. Etiology: - Alzheimer's disease > Vascular dementia > Lewy body's dementia and Parkinson's disease > Frontotemporal dementia. Risk factors: - Non-modifiable risk factors: Aging, female gender, genetics (such as ApoE e4 allele), and family history - Modifiable risk factors: Education (lower education status is associated with high risk), lifestyle and physical activity, smoking, alcohol and obesity. Prevention of NDD: - 1º prevention: Nutrition (vit. E, unsaturated fat, omega 3), lifestyle modification (decreased alcohol and smoking, physical activity and cognitive training) - 2º prevention: Early diagnosis (only 20-30% are diagnosed early due to the asymptomatic course of the disease) - 3º prevention: Maximizing functionality and quality of life (eg. practice daily skills), educate the patient's family.

Prostate cancer (ep13)

Prostate cancer is the most common cancer in males by incidence and prevalence (due to high incidence and low mortality). - Trend: Incidence of PC is increasing, probably since the use of PSA serum and more expensive prostatic biopsy are increasing detection. - Risk factors: Age, race (black > other races), family history, obesity Prevention: - Dietary modification, exercise and PC screening (screening of prostatic cancer with DRE + PSA is controversial).

Provision of health services (SM15)

Provision of health services refers to the delivery of affordable, high quality and effective health interventions to the population. It is achieved through a proper combination of funding, staff, equipments and medications. Health may be provided by: - Direct health providers: includes medical professionals such as doctors or nurses - Indirect health providers: Includes everyone involved in the functioning of the hospital but not in the treatment of patients (tecnitions)

Determinants of health (SM4/5)

Refers to the 4 major factors that act together to determine the health status of an individual. - Human biology and genetics - Lifestyle and behaviour - Health services - Environment and social determinents

Health legislation (SM15)

Refers to the law concerned with the health of individuals and populations, the provision of health care and operation of health care systems. - In CZ, this law is called Health service act (Zakon C. 372/2011) -

Determinants of health (SM4/5) - Environment and social determinants of health

Refers to the social and environmental factors that are involved in determining health. It includes: - Environment: The environment where a person is introduced influences her health. Acess to clean water, air, healthy work places, etc all contribute to better health. - Education - Child development - Emplyoment and income - Culture - Politics

Rights and obligations of patients: (SM15)

Rights of patients (Outlined in the Declaration of Lisbon - 1981): - Right to medical care - Right to freedom of choice - Right to self-determination (patient's autonomy) - Right to information - Right to confidentiality Obligations of the patient: - Provide full cooperation with the provider - Pay for the service - Respect the hospital rules and equipments - Responsible for the consequences of your own decisions.

S. Aureus, S. pneumoniae (EP 16)

S. aureus: - Chain of infection: The bacterium can be found colonizing the skin, nares and nasopharynx. It is transmitted through direct contact, contaminated objects or food. - Ocurrance: It can cause a range of infections including skin and soft tissue infections (cellulitis and impetigo), abcesses, acute bacterial endocarditis, pneumoniae, septic arthritis, osteomyelitis, nosocomial infections and toxin mediated infections (TSS, SSSS and food poisoning). - Prevention: Proper hand hygiene (hand washing, cleaning wounds), isolation precautions and use of PPE. - Repressive measures: ATBs (Antistaphyloccocal penicillins such as oxacillin, Vancomycin for MRSA). S. pneumoniae: - Chain of infection: The bacterium can be found in the nasopharynx. It is transmitted through respiratory secretions from an infected person (respiratory droplets). - Occurrance: It can cause a range of infections including otitis media, sinusitis, pneumoniae and meningitis. - Prevention: Vaccination (pneumococcal conjugate vaccine with 13 or 23 serotypes), proper hygiene measures - Repressive measures: ATBs (penicillin, ceftriaxone, macrolides)

Epidemiology of SARS and MERS (EP22)

SARS and MERS - Are enveloped RNA viruses of the Coronaviridae family of viruses. Epidemiology: - The infection is more common in the winter and spring. - Source: Infected humans or animals (Civet cat and bat for SARS and camel for MERS) - Transmission occurs through inhalation of respiratory droplets but also via contact with contaminated surfaces. - SARS: was first identified in China in 2002 and spread to other countries in Asia, NA and Europe. -MERS: was first identified in Saudi Arabia in 2012 and has since been reported in other Middle eastern and Asian countries. Pathogenesis: - Inhalation -> lytic infection of the epithelial lung cells -> damage to the lung, kidney, liver and GIT -> High fever, headache, dizziness, malaise, myalgia, cough and dyspnea. - SARS causes severe lung injury -> ARDS -> death Diagnosis: PCR of stool or respiratory sample, serology Treatment: supportive care Prevention: - Early detection and reporting suspected cases. - Isolation of infected individuals to prevent spread - Use of PPE and strict adherance to infection control measures in healthcare setting - Public health education Repressive measures: - Contact tracing and quarentine of individuals who may have been exposed. - Movement restrictions to prevent spread of the disease

Epidemiology of AIDs and STDs (EP 20)

STD refers to a group of diseases transmitted via unprotected sexual intercourse. General epidemiology: - >1 million cases are acquired everyday worldwide. - The top 4 most common STIs are chlamydia, gonorrhea, syphillis and trichomoniasis. - > 590 million people have herpes and >290 million women have HPV infection. Risk factors: Young people (1/2 of STI cases occur between 15-25 years of age), risky sexual behaviour (unprotected sexual practices, multiple sexual partners), history STIs. Etiology: - Bacterial: Syphyllis, Gonorrhea, Chlamydia - Viral infections: HBV, HCV, HDV, HSV, HIV and HPV - Parasitic: Trichomoniasis Transmission: - Sexual contact - Vertical transmission - Blood or blood products - Unsafe injection Long-term impact and consequences of STIs: - Increase the risk of HIV infection - Vertical transmission may lead to stillbirth, neonatal deaths, congenital deformitis. - Cancer: 70% of cervical cancer is associated with HPV, 60% of HCC is associated with chronic HBV or HCV - PID and infertility: Chlamydia and Gonorrhea are the main causes for PID and infertility in developing countries Diagnosis: Acurate diagnostics tests are widely available in developed countries, but remain a challange in low and middle income countries. Treatment: - ATBs are curative for all bacterial and parasitic STIs. - Antivirals for STIs are not curative, but slow down or stop disease progression Prevention of STDs: - Health promotion programs: including sex education and safe sexual practices (condoms) - Vaccination: vaccines for HBV and HPV exist and are very effective - Screening - Treatment of both the affected individual and sexual partner. - Survaillance program - Circumcision: associated with a reduction in the risk of HIV, HSV and HPV

Screening and screening programs: - Examples; - Purpose of screening - Disadvantages of screening - Types of screening - Criteria for screening - Evaluation of screening tests

Screening refers to the indentification of an ongoing disease during its pre-clinical stages, using a relatively simple test. It is used to detect disease in people who do not have symptomsbut are at high risk. - The goal is early detection of the disease and early intervention (part of secondary prevention). A positive screening tests, however, does not equal a confirmed diagnosis, but does require individual follow-up with a confirmatory test. - Important examples include the screening of CRC, prostate cancer, breast cancer and cervical cancer. Purposes of screening: - To identify undiagnosed diseases during their pre-clinical stages (uncover the iceberg) - 2º prevention - To plan health care resources - For research - To protect the society Disadvantages of screening include the possibility of false positives (associated with unnecessary additional tests and phychological stress), false negatives (which provide false relief) and risk of the screening test itself. Types of screening: - Mass screening (aims to screen the whole population) - Multiple screening (involves the use of several screening tests at the same time) - Targeted screening (screening of a target group due to its exposures) - Opportunistic screening (additional screening tests done to patients who consult a healt practitioner for another reason) Criteria for screening: 1st- the disease must be well defined 2nd- there must be an effective intervention 3rd- early intervention must improve outcome 4th- must have an effective screening test 5th- the test must be available and appropriate for the target population 6th- the disease must be important 7th- there must be a benifit greater then the cost Screening tests must be safe, acceptable to the population, must have high sensitivity (and ideally specificity), should be simple and cheap and effective in reducing morbidity and mortality. Screening tests are commonly evaluated by: - Sensitivity (true positive rate) - Specificity (true negative rate) - Positive predictive value (probability that a person with a positive result will have the disease) - Negative predictive value (probability that a person with a negative result will not have the disease - Likelihood ratio

Theory of the Iceberg (SM3)

States that for most diseases the number of undiscovered or misdiagnosed cases outweighs the number of visible cases. It forms an analogy between an iceberg and medical diseases. - The undiscovered or misdiagnosed cases include the latent, inapparent, asymptomatic and undiagnosed cases. - The cases may remain invisible because people may not have acess to healthcare, dont known where to seek proper healthcare or due to underestimation of symptoms. - Screening is done to identify these cases.

Tuberculosis (EP16)

TB is an infection caused by M.tuberculosis, an acid fast bacteria. Epidemiology: - Leading cause of deaths by infection causing 1.4 million deaths a year. - It is estimated that 10 million people obtain the infection every year and that 1/4 of the world population has an asymptomatic infection. - 8 countries with the highest incidence - India, Indonesia, China, Phillipines, Pakistan, Nigeria, South africa - MDR TB is a public health crisis. - Incidence of 18/100000 per year in PT. 1600 cases per year. Chain of infection: The source of the infection is a human and transmission occurs through inhalation of respiratory droplets. it has an incubation period of 2-12 weeks. Clinical features: Hemoptysis, chest pain, weakness, weight loss, fever and night sweats. Diagnosis: Clinical suspicion, acid fast stain and PCR of sputum samples Treatment: Antituberculotic regimens RIPE for 2 months followed by RI for 4 months Prevention: - Vaccination: BCG vaccine - Measures to prevent the spread of the infection (cough etiquette, hand hygiene, disinfection and sterilisation, PPE, isolation and quarentine).

Descriptive studies (EP4) - Basic characteristics - Types - Advantageous and disadvantageous - Hypothesis formulation

The descriptive studies are used to generate an hypothesis. The researchers describe what they find from observing groups. These studies are limited to describing the occurance of a possible correlation in a population. - They answer to who, where, when and what. However, they lack a comparison group (there is no case or control groups). Types of descriptive studies: - Case studies: reports on <10 clinical cases with similar characteristics to describe associations. - Case series: reports on more than 10 clinical cases with similar characteristics to describe associations. - Cross-sectional studies: describes the characteristics of a population at a given time. - Ecological studies: reports on the characterisyics of a population (using population data rather than individual data). Advantageous: - Cheaper, easier and faster than analytical studies - Measures disease prevalence - Identifies risk factors and suggests associations which may be used to create an hypothesis Disadvantages: - Cant confirm any association due to the lack of comparison group. - No control of evidence, low piramyd of evidence - Subjective Hypothesis formulation is the basis of descriptive studies. An hypothesis is an educated guess about an association that is testable. - Epidemiologists use descriptive studies to generate hypothesis and use analytical studies to test hypothesis. - Hypothesis can be formulated when you observe similarities (there is a common factor), differances, analogy and correlation.

Tools for infection control (EP10)

The incidence and prevalence of many infections has decreased due to effective elimination and erradication programs. Elimination: Refers to the presence of 0 cases of a disease in a location, but cases are still seen elsewhere Erradication: Refers to the development of 0 cases in the whole world. - Key elements for erradication include no natural reservoir, no vector, no asymptomatic cases, effective vaccine, long lastingimmunity - The major exemple of an erradicated diseases are smallpox and cat plague - Dissapearing infections include pertussis, diphteriae, tetanus, polio, MMR, rabies. Epidemiological survaillance refers to the ongoing systematic collection, analysis and interpretation of health data. - Active survaillance involves the active collection of health data (but is more expensive), whereas passive survaillance involves waiting for reports sent by health facilities. - Epidemiological survaillance is an important part of erradication programs since it allows survaillance of the infection status and to assess how the infection is reacting. Knowledge of the chain of infection allows epidemiologists to devise epidemiological measures for disease control. These measures are seen at all levels of the chain of infection. - Control the reservoir: treating any affected patient to stop transmission, eliminate the reservoir (disinfection or sterelization), identity and treat carriers - Block the portal of exit: via using facial masks or condoms - Reduce transmission: via physical distancing, avoiding physical contact, isolation, quarentine, disinfecting fomites, improving sanitation and reducing the vector population. - Protect the portal of entry: usually carried out as physical barrier that stops the infectious agent from coming into contact with the host (covering the nose and mouth with a facial mask, disinfecting wounds, use of protective clothes, use of bed nets) - Increasing the hosts defenses: throught health promotion measures including vaccination, promotion of a healthy lifestyle and use of prophylactic drugs (such as anti-malarians).

Tick-borne encephalitis and Rabies (EP20)

Tick borne encephalitis: - Etiology: TBE virus - COI: Reservoir includes animals such as rodents and transmission occurs via a tick bite. Primarily seen in eastern Europe and Asia. - CF: Fever, malaise, headache, N/V, myalgias and neurological symptoms (meningitis, encephalitis and meningoencephalitis) - Treatment: supportive - Vaccination for individuals at risk Rabies: - Etiology: Menbers of the Lyssa viridea - COI: Mostly affected developing countries due to lack of animal vaccination. Reservoirs include dogs, bats, raccons and foxes. Transmission occurs through the saliva of an infected animal after a bite injury. - CF: Encephalitic rabies (hydrophobia, anxiety, agitation, hallucinations, seizures, coma and death) or Paralytic rabies (ascending flacid paralysis, paraplegia, resp. failure and death). - Diagnosis: PCR and serology - Treatment: cleaning and debridment of wounds, tetanus shots and ATB prophylaxis and indicated, Rabies Ig and Rabies vaccine

Toxoplasmosis and Giardia Lamblia (EP24)

Toxoplasmosis is the leading cause of death attributed to foodborne illness. - Epidemiology: Prevalent in South America - Etiology: Toxoplasma gondii - COI: The reservoir includes humans and animals such as cats. The infection is transmitted via ingestion of contaminated food, fecal-oral route, contact with contaminated soil and vertical. - Risk factors: Cat sandbox, uncooked meat. - CF: Asymptomatic or flu-like symptoms in healthy individuals, mononucleosis like symptoms in the nodal form, headache, confusion, seizures and multiple ring like enhancing lesions in immunocompromised - Congenital toxoplasmosis (chorioretinitis, hydrocephalus, seizures) - Dignosis: Serology - Treatment: TMP-SMX, pyrimethamine.+ sulfadiazine Giardiasis: - Etiology: Giardia lamblia - It is widespread diseases throghout the world affecting 200 million people per year. It is endemic to the tropics and sub-tropics. - COI: Transmission occurs through ingestion of contaminated water or food and fecal oral route. - CF: foul-smelling and fatty diarrhea, abdominal cramps and pain. - Diagnosis: stool analysis and immunoassay - Treatment: tinidazol

Type of disease occurance (Ep9)

Types of disease occurance in the population: - Endemic disease: refers to a disease that is consistentlypresent at low/moderate levels in a population or geographical area. - Epidemic disease: refers to a disease that develops in greater numbers than would be normally expected in a particular area or population. - Pandemic disease: refers to an epidemic disease that has spread across multiple countries or continents, affecting a large proprotion of the global population. It is usually a highly contagious disease. - Sporadic disease: disease that occurs infrequently or irregularly - Hyperendemic disease: refers to a persistent, high levels of disease occurance.

Typhoid fever (EP21)

Typhoid fever is caused by S. enterica serotype typhi. Epidemiology: - Around 11-21 million cases per year and hundreds of thousands of deaths every year. - Endemic to resource limited countries with poor sanitation in Africa, Central and South America and South-east Asia (Bangladesh, China, India, Indonesia, Nepal) Chain of infection: Strictly human disease transmitted via fecal-oral route. The bacteria is shed in the feces and may establish latent infection in the gallbladder. Manifestation: The course of typhoid fever is usually divided into 3 stages, each one lasting one week. The disease regresses after the 3rd week. - 1st week: fever, headache, bradycardia, diarrhea - 2nd week: persistent fever, rose colored spots, typhoid tongue, abdominal pain, headache, diarrhea, delirium - 3rd week: Similar to 2nd week but may be complicated by GI ulceration and/or perforation, hepatosplenomegaly. Diagnosis: Based on stool and blood culture Treatment: ATBs (fluoroquinolones, 3rd gen cephalosporin, azithromycin) Prevention: - WASH strategy - Vaccination (parenteral killed vaccine, or oral LA vaccine) - Epidemiological survaillance: Report, isolation, disinfection and vaccination of contacts

Vaccination (EP8) - Basic principles and importance - Types of vaccines - Immunization schedules

Vacination refers to the administration of a vacine to develop protection aggainst a disease. It act as part of primary prevention. - We distinguish between passive immunization (administration of a preformed Ab to provide temporary protection -> tetanus or rabies Ab) and active immunization (administration of an antigen to stimulate the immune system). - Vaccines may be monovalent or polyvalent based on the number of strains covered. Types of vaccines: - Live attenuated vaccines (BCG, MMR, Smallpox and Sabin) - Killed vaccines (Hep.A, Influenza, Salk) - Subunit vaccines (HPV, pneumococcal and meningoccocal) - Toxoid vaccines (Diphteriae and tetanus toxoids) - Conjugate vaccine (Hib and pneumococcal vaccines) - Recombinant vaccines (Hep. B) Benifits of vaccination: - Prevent communicable diseases - Provides herd immunity - Controls/erradicates diseases (smallpox erradication occured due to succesfull vaccination) - Protects from related diseases - Cost-effectivness: The cost of the vaccination is less than the cost of morbidity - Reduces ATB resistance: by decreasing ATB use. Immunisation programs are schedules of vaccination created by the government to achieve maximmum effectivness of vaccination. There are mandatory vaccines, emergency vaccines and optional vaccines Commonly used vaccinations: - Hexavaccine: DPT + Salk (inactivated polio) + HiB + Hepatitis B - MMR: Measles, mumps and rubella - Pneumococcal vaccine (2 versions - one with 13 and another with 23 strains) - Chickenpox vaccine - BCG vaccine - Rotavirus vaccine Difficulties of vaccination programs include cost, logistics, social instability, training, survaillance and refusal.

West Nile fever and Yellow fever (EP20)

West Nile fever: - Etiology: West nile virus - COI: Reservoir is mosquitos, birds and horses and it is transmitted via mosquito bites. Endemic in parts of Afriaca and South-east Asia. - CF: mostly asymptomatic but may present with fever, headahce, myalgias, N/V, rash and orbital pain - Diagnosis: Serology and PCR - Treatment: supportive Yellow fever: - Etiology: yellow fever virus - COI: The virus is endemic to tropical regions of sub-Saharan Africa and South America. The reservoir is primates and transmission occurs via mosquito bite. - CF: Most patients are asymptomatic but the may present with fever, headaches, N/V, hemorrhagic diathesis, MOF and abdominal pain and jaundice. - Diagnosis: PCR - Treatment: Supportive - Prevention: vaccination of people travelling to endemic areas (single dose of LAV).

Global health organizations: (SM11) - WHO - EU/EC - OECD

World health organization is an internation health organization established in 7th of april, 1948. It is headquartered in Geneva and has 194 member states divided into 6 regions. - Its overall mision is "Health for all" - better health for everyone, everywhere. - World health assembly: every year the WHO delegations meet in geneva to discuss and determine policies, programs and budgets of WHO. - WHO objectives: Providing universal healthcare, set IHR, enhance acess to health care, deal with healthcare shortage, define health determinants EU/EC: European union refers to the political and economic union of 27 member states that are located in europe. The EC is the executive branch of the EU, responsible for managing EU business. - Decision 1082/2013 - adressed cross border threats. Oorganization for economic co-operation and development is an international organization of 37 menber states. Its mission is to improve the economic and social well-being of people around the world. Other organizations: - UNICEF - Food and agriculture organization - World food program - World bank - International commite of the red cross - Gavi, the vaccine alliance - World medical association Example of global health cooperation is the IHRs (a legal document that defines the countries rights and obligations in handling public health events that have the potential to cross borders.

Epidemiology of zoonotic and natural focal infections (EP20):

Zoonotic infection is an infection that is transmissible under natural conditions from animals to humans. In many cases, the occurance of these diseases are associated with nutrition. - Epizoonotic: zoonosis that is epidemic in animals - Enzoonotic: zoonosis that is endemic in animals - Anthroponosis: an infectious disease of humans that can be transmitted to animals Risk factors: - Occupational exposure: certain occupations are associated with increased exposure to animals (animal control workers, biologists, farmers, vets) - Food: vehicle for zoonosis (eg. raw meat in salmonella or E. coli) - Pets: Pets can act as mechanical vectors (dogs and roundworm, cats and toxoplasmosis) - Recreational activities: certain activities are associated with increased risk (camping and Lyme disease, water sports and leptospira) - ATB use: Mass use of ATBs for animals is associated with the creation of drug-resistant bacteria. - Urbanization: Deflorestation and destruction of habits increases the risk of zoonotic diseases by increasing contact between animals and humans. Sources of infection: - Cattle: Tb, brucellosis, Q fever, Salmonellosis - Pig: Salmonellosis, taenisis - Poltry: Salmonelosis - Sheep: Q fever - Dogs: Rabies - Cats: toxoplasmosis Route of transmission: - Direct: Respiratory droplets, direct contact (eg. petting zoos, bites or scratches) - Indirect: through a vehicle (contaminated food - food-borne) or vector (ticks, mosquitos) Prevention: In general, prevention of zoonotic diseases is difficult due to animal reservoirs. As a result, most zoonotic diseases cannot be eradicated. - Vector control programs: for ticks, fleas and mosquitos - Survaillance systems for animals: testing all imported animals, culling infected animals and restricting animal movement - Animal vacciantion: Mass rabied vaccination is made through bait laden with oral rabied vaccine. - WASH strategy: improving water, sanitation and hygiene measures - Food safety: proper storing and handling of food - Protective clothing: Use of insect repellants and protective clothing when going to the wild. Repressive measures: - Quarentine: Isolation of any infected individual or population can help prevent further transmission of the disease. - Vaccination - Treatment Etiologies of Zoonotic infections: - Bacteria: Salmonella, Campylobacter, Lyme disease, Leptospira, Plague, Brucellosis, Psitacosis, Bartonella, Tularemia - Virus: Tick borne encephalitis, HEV, Rabies, Incluenza, Ebola, Yellow fever virus - Parasitic: Trypanosoma, Leismaniosis, Toxoplasmosis - Fungus: Aspergillosis, Blastomycosis Most common zoonosis in CZ: Toxoplasmosis, Lyme disease and Salmonellosis Most common zoonosis in PT: Salmonellosis, Lyme disease, Leptospirosis Natural focus infection is one that is linked with a specific biotope (a specific area which contains all the requirments for the infection - reservoirs, environment and host). Importance of natural focus of infection: - Natural focus of infection serves as a reservoir for the pathogen. - Identification of natural focus is important in the control of the disease. - Pathogens with a natural focus of infection are difficult to control and impossible to erradicate (we cant kill or vaccinate all animals in that focus) - Pathogens without a natural focus of infection are subject to eradication (eg. smallpoc does not contain a natural focus of infeciton).