CONCEPTS OF

PREVENTION AND
CONTROL
R. Venkitachalam
OF DISEASES

Seminar No: 5
 CONTENTS
• Concepts of prevention of disease
– Definition
– Timeline of approaches to prevention
– Levels of prevention
– Levels of prevention for dental diseases

• Concepts of control of disease

– Disease control
– Disease elimination and eradication
– Monitoring
– Surveillance

• Conclusion
• References
 CONCEPTS
OF
PREVENTION
 Disease prevention: Definition
• Activities designed to protect patients and other members of
the public from actual or potential health threats and their
harmful consequences
-Mosby’s Medical Dictionary, 8th edition.2009

• Disease prevention covers measures not only to prevent the

occurrence of disease, such as risk factor reduction, but also
to arrest its progress and reduce its consequences once
established.
• Reference: adapted from Glossary of Terms used in Health for
All series. WHO, Geneva, 1984
• Successful prevention depends upon:

– Knowledge of causation
– Dynamics of transmission
– Identification of risk factors and risk groups
– Availability of prophylactic or early detection and
treatment measures
– Facilities for these treatment procedures
– Evaluation and development of these procedures
 Levels of prevention
• The concepts of prevention can be best defined in the context
of “levels of prevention”.

But how many levels of prevention??

 Timeline
1953 – Leavell and
Clark

1957 – Commission of chronic illness

1958 – Leavell and Clark 1965 – Leavell and
Clark
1983 – Gordon
1985 – Tannahill

2001 – Froom and Benbassat

 1953 – Leavell and Clark
• Book: Textbook of preventive medicine

• 5 levels of application
1. Health promotion
2. Specific protection
3. Early recognition and prompt treatment
4. Disability limitation
5. Rehabilitation

• Based on his paper on the disease syphilis

 1957 – Commisssion on chronic
illness
• Prevention of chronic illness : Volume 1

• First use of the words primary and secondary prevention

• Primary prevention: averting the occurrence of disease

• Secondary prevention: halting the progression of disease from

its early unrecognized stage to a more severe one and
preventing complications
 1958 – Leavell and Clark
• Second edition retitled: Preventive Medicine for the Doctor
and the Community

• Defined five levels into three categories

– Primary prevention
• Health promotion (serving to further general health and well-
being)

• Specific protection (measures applicable to a particular disease or

group of diseases in order to intercept the causes before they
involve man )
• Secondary prevention
– early recognition and prompt treatment (preventing spread to others
if the disease is communicable, complications or sequelae, and
prolonged disability).

• Tertiary prevention
– disability limitation (prevention or delaying of the consequences of
clinically advanced disease)

– rehabilitation (aiming at prevention of complete disability after

anatomic and physiologic changes are stabilized).
 1965 – Leavell and Clark
• Third edition: Preventive Medicine for the Doctor and the
Community

• Referred levels of prevention as “phases of prevention” and

• Disability limitation was transferred to secondary phase of

prevention
 1983 - Gordon
• Public Health Reports

• Limited the use of word prevention to persons who have not

yet suffered and discomfort or disability due to the disease

• Classification – target population

– Universal measures : for everyone
– Selective measures : for above-risk demographies
– Indicated measures : for individuals at risk
 1985 - Tannahill
• Reviewed the usages of primary, secondary and tertiary by
different authors, and proposed a new classification

• Foci of prevention
1. Prevention of the first occurrence of an illness or unwanted
phenomenon
2. Prevention of avoidable consequences of illness or other unwanted
state through early detection when this favorably affects the
outcome
3. Prevention of avoidable complications of established disease or
other unwanted state
4. Prevention of recurrence.
 2001 – Froom and Benbassat
• Expanded categories of prevention from three to seven
– Level 1: reducing exposure to an etiologic agent
– Level 2: increasing resistance to the disease
– Level 3: defining it as screening for risk factors for disease (in
asymptomatic individuals) in order to reduce them.
– Level 4: prevention of recurrence (in asymptomatic individuals after a
disease-related event)
– Level 5: treatment aimed at prevention of complications (in
asymptomatic individuals after a disease-related event)
– Level 6: treatment of symptomatic patients for cure, palliation, or
reduction of mortality
– Level 7: rehabilitation for “adjustment to irremediable conditions.
2008 – 2009: Ronald Hattis (draft stage as on 2012)

• Classification according to stages of disease

Stages of Disease Development Corresponding Stages of Prevention
1 Exposure Avoidance of Exposure
2 Acquisition Reduction of Acquisition
3 Advancement/Progression Interruption of Progression
4 Complications Avoidance of Complications

a) Delay of Mortality
5 Death or Disability b) Rehabilitation of Disability
c) Palliative Care for Inevitable Death
 Stages Disease I Disease II Disease III
    Type 2 Diabetes HIV Dental caries
Abstinence from
Healthy eating, limit sex (or screening and
Exposure simple carbohydrates, monogamy of Avoidance of sticky
1 fermentable carbohydrate
Avoidance: maintain healthy weght, seronegative diet
exercise partners), no injection
drug use
Condom promotion
Disease Weight loss, consider and programs to Sealing of pit and fissure,
2 Acquisition metformin if insulin discourage drug use of fluorides and plaque
Reduction: resistance/pre-diabetes abuse, needle control
sharing

Antibody
Anti-diabetic drugs,
Interruption or screening, Preventive resin restorations,
monitor hgb A-1C, FBS,
3 Delay of Disease monitoring CD4, conservative restorations,
proteinuria, lipids; bariatric ART
Advancement: viral load; treatment
surgery if indicated
with antiretrovirals

ACE Inhibitor/ARB to
Prophylactic
Avoidance or prevent renal sequelae,
treatment for Indirect pulp capping, deep
4 Delay of Disease strict glucose control caries restorations
opportunistic
Complications: (insulin if necessary), lipid
infections
control, foot and eye care

Delay of Intensive treatment

Renal Dialysis,
Mortality from for severe Root canal treatment and
5 coronary stent or prosthetic rehabilitation
Disease opportunistic
bypass
complications infections
 Beyond disease prevention . . .
• Breslow proposed in 1999 moving “beyond disease
prevention and aiming for “the energy and reserves of health
that permit a buoyant life, full of zest the eager ability to
meet life’s challenges.”

• Thus a supplementary paradigm consisting of four stages of

health promotion/wellness was developed . .
 Stages of wellness
– Stage 1: Exposure to positive health influences.

– Stage 2: Adoption of positive health practices (such as healthy diet,

exercise, recreation, adequate sleep, etc.).

– Stage 3: Increase in indicators of health and wellness due to the

healthy practices (such as increased strength and flexibility,
immunity, optimal BMI, etc.).

– Stage 4: Achievement of specific defined health and wellness goals,

both
• subjective (e.g., sense of wellbeing and energy, fulfilling social relationships)
• objective measures (e.g., high cognitive function, productivity, capacity for
role fulfillment or achievement)
 LEVELS
OF
PREVENTION
 LEVELS OF PREVENTION
• The concept of prevention is best defined in terms of levels of
prevention. Traditionally,

1. Primordial prevention
2. Primary prevention
3. Secondary prevention
4. Tertiary prevention
5. Quaternary prevention
 PRIMORDIAL PREVENTION
• Prevention of emergence or development of risk factors in
countries or population groups in which they have not yet
appeared.

• it consists of actions and measures that inhibit the emergence

and establishment of environmental, economic, social and
behavioral conditions, cultural patterns of living known to
increase the risk of disease.
- John Last’s dictionary
 Primordial prevention . . .

• Mainly associated with chronic diseases

• Intervention – Individual and mass education

• Has to start in childhood when health risk behaviour begins

 Primordial prevention . . .

• Examples of primordial prevention

– National programmes and policies on:
• Food and nutrition
• Against smoking and drugs
• To promote regular physical activity
 Primordial prevention . . .

• Responsibility of primordial prevention:

– parents, teachers and peer groups: imparting health
education
– Government: legislating and enacting laws
– Professional and nonprofessional organisations
– Industry
– Hospitals, health practitioners, health care workers
 PRIMARY PREVENTION
• Action taken prior to the onset of disease, which removes the
possibility that a disease will ever occur

• Intervention – prepathogenesis stage of disease

• Concept of positive health: an acceptable level of health that

will enable every individual to lead a socially and
economically productive life
 primary prevention . . .

• Approaches for primary prevention for chronic diseases

(WHO):

A. Population (mass) strategy:

 Directed at whole population irrespective of individual risk levels
 Directed towards socio-economic, behavioral and lifestyle changes

B. High risk strategy:

 To individuals at special risk
 Population approach
ADVANTAGES DISADVANTAGES
• Recognises influence of • Less effective in situations
society where there is no dose-
• Risk reduction can be response relationship
achieved at population level
• Effective in dose-response
relationship of diseases
 High risk approach
ADVANTAGES DISADVANTAGES

• Cost effective • Fails to address public

• Motivation level is higher health problems which
• Easier for health arise from small risks
professionals to promote • Tends to medicalise
change prevention
• Individuals would have • Does not focus on what
been aware and exposed influences behaviour
to the risk • Little overall impact on
control of disease
POPULATION
AND
HIGH RISK
STRATEGIES
 primary prevention . . .

• Achievements of primary prevention:

– Controlling diseases like cholera, typhoid, dysentry, plague,
tuberculosis, by raising standard of living

• Holistic approach

• Modes of intervention:
– Health promotion
– Specific protection
 Health promotion
• Process of enabling people to increase control over and to
improve health

• Not directed against any particular disease

• Interventions in this area:

– Health education
– Environmental modifications
– Nutritional interventions
– Lifestyle and behavioural changes
• Values in health promotion

– Equity and social justice

– A holistic definition of health
– Covers a full range of health determinants
– Recognizes influence of environment on health
– Seeks to enhance people’s social participation
– Involves intersectoral collaboration (ottawa reference)
 Specific protection
• Efforts directed toward protection against specific diseases

• Interventions
– Immunization
– Use of specific nutrients
– Chemoprophylaxis
– Protection against occupational hazards
– Protection against accidents
– Protection from carcinogens
– Avoidance of allergens etc.
 SECONDARY PREVENTION
• Action which halts the progress of the disease at its incipient
stage and prevents complications

• Intervention – early pathogenesis stage

• It is the domain of clinical medicine

• Drawback
– Patient already subjected to mental anguish & physical pain
– More expensive than primary prevention
 secondary prevention . . .

• Modes of intervention:
– Early diagnosis (screening tests, case finding programs)
– Adequate/prompt treatment

• Effects:
– Seeks out unrecognized disease
– Provides treatment before irreversible changes occur
– Reverses communicability of infectious diseases
– Protects community
 Early diagnosis and prompt
treatment
• Earlier diagnosed – better prognosis

• Reduces morbidity and mortality

• Effective in acute conditions

 TERTIARY PREVENTION
• All measures available to reduce or limit impairments and
disabilities, minimize suffering caused by existing departures
from good health and to promote the patients adjustment to
irremediable conditions

• Intervention – late pathogenesis stage

• Modes of intervention:
– Disability limitation
– Rehabilitation
 Disability limitation
• To prevent or halt the transition of disease process from impairment to
handicap

• Disease impairment disability handicap

• Impairment: any loss or abnormality of psychological, physiological or

anatomic structure or function

• Disability: any restriction or lack of ability to perform an activity in the

manner considered normal for a human being

• Handicap: disadvantage for a given individual, resulting from impairment

or disability, that limits or prevents the fulfillment of a role that is normal
for that individual
 ACCIDENT Impairment: Loss of an
anatomical structure

Disability: Lack of ability to Handicap: Prevents

perform an activity fulfillment of normal role
Disease - dental caries Impairment – loss of
tooth

Disability – cant talk Handicap – cant socialize

 Rehabilitation
• The combined and coordinated use of medical, educational,
social and vocational measures for training and retraining the
individual to the highest possible level of functional ability

• Types of rehabilitation
– Medical: restoration of function
– Vocational: restoration of capacity to earn a livelihood
– Social: restoration of family and social relationships
– Psychological: restoration of personal dignity and confidence
• Examples of rehabilitation
– Establishing schools for blind
– Provision of aids for crippled
– Exercises in neurological disorders
– Prosthetic restoration of lost tooth

• Requires cooperation from different sections of

society
Principles of tertiary prevention
Enable
timely
recovery

Re-integrate Re-stabilize

TERTIARY
PREVENTION

Re-socialize Re-train

Re-motivate
 QUATERNARY PREVENTION

 The action taken to identify patient at risk of over-medicalisation, to

protect him from new medical invasion, and to suggest to him
interventions, which are ethically acceptable.
 Quaternary prevention is the set of health activities to mitigate or avoid
the consequences of unnecessary or excessive intervention of
the health system.
 Quaternary prevention should take precedence over any alternative
preventive, diagnostic and therapeutic, as is the practice version
‘primum non nocere’
 Intervention types:

Healthcare professionals must be aware of the consequences of

their decisions, and include quaternary prevention interventions in
their daily clinical practice with each patient

• Do not mistake risk factor with disease.

• To avoid check ups or unnecessary exams.
• To avoid technical interventionism in healthcare.
• To avoid the indiscriminate use of antibiotics (very often unnecessary,
with the subsequent unjustified increase of bacterial resistances)
 Individual and mass
Primordial education
Health education

N Environmental modification
O Health promotion
TI Nutritional interventions

EN Lifestyle changes
EV Primary
PR Immunization

OF Specific protection Chemoprophylaxis

LS
Early diagnosis and Avoidance of risk factors
VE Secondary prompt treatment
LE Medical
Disability limitation
Tertiary Vocational
Rehabilitation
Social

Quaternary Psychological
 EXAMPLES OF
LEVELS OF PREVENTION
OF
COMMON ORAL DISEASES
 EXAMPLES OF PREVENTIVE STRATEGIES FOR DENTAL CARIES
Levels of PRIMARY SECONDARY TERTIARY
prevention
Modes of Health Specific Early diagnosis Disability Rehabilitation
intervention promotion protection and prompt limitation
treatment
Services provided Diet planning, Use of Self-examination Use of dental Use of dental
by individual demand for fluoride/fluoridat and referral; use services services
dental care ed water, fluoride of dental services
dentifrice, oral
hygiene practices
Services provided Dental health Community or Periodic Provision of Provision of
by community education, school water screening and dental services dental services
promotion of fluoridation, referral;
research school fluoride provision of
mouthrinse/table dental services
t/sealant
program,
Services provided Patient Topical Complete Complex Removable and
by the dental education, application of examination, restorations, fixed
professional plaque control fluoride, fluoride prompt pulpotomy, RCT, prosthodontics,
program, diet supplements; pit treatment of extractions minor tooth
counselling, and fissure incipient lesions, movements,
recall sealants PRR, simple implants
reinforcement, restorations, pulp
caries activity capping
tests
 EXAMPLES OF PREVENTIVE STRATEGIES FOR PERIODONTAL DISEASE
Levels of PRIMARY SECONDARY TERTIARY
prevention
Modes of Health Specific Early diagnosis Disability Rehabilitation
intervention promotion protection and prompt limitation
treatment
Services provided Periodic visits to Oral hygiene Self-examination Use of dental Use of dental
by individual dental office; practices and referral; use services services
demand for of dental services
preventive
services
Services provided Dental health Supervised Periodic Provision of Provision of
by community education, school tooth- screening and dental services dental services
promotion of brushing referral;
research; programs provision of
provision of oral dental services
hygiene aids
Services provided Patient Correction of Complete Deep curettage, Removable and
by the dental education, tooth examination, root planing, fixed
professional plaque control malalignment, scaling and splinting, prosthodontics,
program, recall prophylaxis curettage, periodontal minor tooth
reinforcement corrective surgery, selective movements
restorative and extractions
occlusal services
 EXAMPLES OF PREVENTIVE STRATEGIES FOR ORAL CANCER
Levels of PRIMARY SECONDARY TERTIARY
prevention
Modes of Health Specific Early diagnosis Disability Rehabilitation
intervention promotion protection and prompt limitation
treatment
Services provided Periodic visits to Avoidance of Self-examination Use of dental Use of dental
by individual dental office; known irritants and referral; use services services
demand for of dental services
preventive
services
Services provided Dental health Periodic Provision of Provision of
by community education, screening and dental services dental services
promotion of referral;
research provision of
dental services
Services provided Patient education Removal of Complete Chemotherapy, Maxillofacial and
by the dental known irritants in examination, radiation therapy, removable
professional oral cavity biopsy, oral surgery prosthodontics,
cytology, plastic surgery,
complete speech therapy
excision and counselling
Understanding prevention through
disease pathogenesis
Eg: understanding dental caries

Loss of teeth, difficulty

in chewing, esthetics,

pain

Sensitivity, food lodgement

Tooth + Bacteria = Demineralization

Acid

Sensitivity and Pits and Deep cavities,

white spots cavitation pulp invl.
Eg: understanding dental caries
CONCEPTS
OF
DISEASE
CONTROL
DISEASE CONTROL
 Describes (ongoing) operations aimed at reducing:
 The incidence of disease
 Duration of disease (risk of transmission)
 Effects of infection (both physical and psychosocial)
 Financial burden to the community

 Mainly focused on primary and secondary prevention

Public health approach to disease control
Disease control includes . . .
The specific infectious
agent no longer exists in
nature or in the laboratory

Termination of all transmission of infections

by extermination of infectious agents

Eradication Reduction to zero of the incidence of a specified disease in a

Extinction
defined geographical area as a result of deliberate efforts

public policy intervention

Control that restricts the circulation of an
Elimination
infectious agent beyond the level that would result from
spontaneous, individual behaviors to protect against infection
Disease eradication
 All or none law

 Only one disease has been eradicated so far: Small pox

 Eradication underway for:

 Poliomyelitis
 Dracunculiasis
 Yaws
 Malaria
 Measels
Framework for eradication
Scientific
considerati
ons

Economic Operational
considerati considerati
ons ons
 Framework for eradication

Scientific considerations

Geographic and environmental controls

Potential reservoirs

Transmissibility

Natural resistance to reinfection

Laboratory containment

Operational considerations

Economic considerations
Framework for eradication
Scientific considerations

Operational considerations
Disease surveillance

Intervention

Certification

Economic considerations
 Framework for eradication
Scientific considerations

Operational considerations

Economic considerations
Private vs Social net benefit

Short term vs long term benefits

Local vs international benefits

 Framework for eradication
Scientific considerations
Geographic and environmental controls

Potential reservoirs

Transmissibility

Natural resistance to reinfection

Laboratory containment

Operational considerations
Disease surveillance

Intervention

Certification

Economic considerations
Private vs Social net benefit

Short term vs long term benefits

Local vs international benefits

Monitoring
 Monitoring: it is the performance and analysis of routine
measurements aimed at detecting changes in the
environment or health status of a population

 Eg: monitoring of air pollution, water quality, growth and

nutritional status

 Also refers to performance of health service or health

professional or the extent of patient’s compliance
Surveillance
 Surveillance: continuous scrutiny of the factors that
determine the occurrence and distribution of disease and
other conditions of ill-health

 Objectives of surveillance:
 To provide information about new and changing trends in
health status of a population
 To provide feed back which may be expected to modify policy
and system
 Provide timely warning of public health disasters so that
interventions can be mobilized
 surveillance . . .

 Surveillance is a continuous process which involves three

primary activities:

i. Collection of relevant data for a specified population, time

period and/or geographic area;

ii. Meaningful analysis of data;

iii. Routine dissemination of data with accompanying

interpretation.
Duties of health care professionals in surveillance

 Identify and describe each individual having an infection as

quickly as possible after exposure.
 Determine the source of infection.
 Identify exposed individuals to whom the infection may have
been transmitted.
 Specify the frequency of occurrence of infection in
population groups at risk by person, place and time.
 Identify populations that are experiencing, or might
experience, an increased frequency of infection.
 Prepare and distribute surveillance reports to health care
professionals participating in disease prevention and control
activities.
Types of surveillance
 Passive surveillance: receipt of reports of
infections/disease from physicians, laboratories and other
health care professionals required to submit such reports
as defined by public health legislation

 Active surveillance: Active disease surveillance is also

based on public health legislation and refers to daily,
weekly or monthly contacting of physicians, hospitals,
laboratories, schools or others to “actively” search for cases
 Usually seasonal or done during disease outbreaks
CONCLUSION
 Understanding disease pathology is the first step towards
formulating preventive measures

 Prevention can be achieved in any stage of disease

 Primordial or primary prevention is most effective and

economical

 Disease control is also a part of prevention which is achieved

by means of continuous monitoring and surveillance of disease
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