Prevention is better than cure

It is not necessary (although desirable) to know everything about the natural history of a disease to initiate preventive measures. Often times, removal or elimination of a single known essential cause may be sufficient to prevent a disease. The objective of preventive medicine is to intercept or oppose the "cause" and thereby the disease process. The epidemiological concept permits the inclusion of treatment as one of the modes of intervention.

1. prevention is better than cure

2. Sensitive issue Akin to Comparing Preventive Medicine with Curative Medicine

3. OXFORD ENGLISH Dictionary PREVENTION = PREVENTING FROM OCCURENCE

4. Concepts of prevention It is not necessary (although desirable) to know everything about the natural history of a disease to initiate preventive measures. Often times, removal or elimination of a single known essential cause may be sufficient to prevent a disease. The objective of preventive medicine is to intercept or oppose the "cause" and thereby the disease process. The epidemiological concept permits the inclusion of treatment as one of the modes of intervention.

5. Levels of prevention In modern day, the concept of prevention has become broad-based. It has become customary to define prevention in terms of four levels: Primordial prevention Primary prevention Secondary prevention Tertiary prevention

6. Primordial prevention This is primary prevention in its purest sense, that is, prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared. For example, many adult health problems (e.g., obesity, hypertension) have their early origins in childhood, because this is the time when lifestyles are formed (for example, smoking, eating patterns, physical exercise). In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles.

7. Primary prevention Action taken prior to the onset of disease, which removes the possibility that a disease will ever occur. It signifies intervention in the pre-pathogenesis phase of a disease or health problem (e.g., low birth weight) or other departure from health. Primary prevention may be accomplished by measures designed to promote general health and well-being, and quality of life of people or by specific protective measures.

8. Primary prevention The concept of primary prevention is now being applied to the prevention of chronic diseases such as coronary heart disease, hypertension and cancer based on elimination or modification of "risk factors" of disease. The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established: a. population (mass) strategy b. high-risk strategy

9. Secondary prevention Action which halts the progress of a disease at its incipient stage and prevents complications. The specific interventions are early diagnosis (e.g., screening tests, case finding programmers) and adequate treatment. By early diagnosis and adequate treatment, secondary prevention attempts to arrest the disease process; restore health by seeking out unrecognized disease and treating it before irreversible pathological changes have taken place; and reverse communicability of infectious diseases. It may also protect others in the community from acquiring the infection and thus provide at once secondary prevention for the infected individuals and primary prevention for their potential contacts.

10. Tertiary prevention It signifies intervention in the late pathogenesis phase. All measures available to reduce or limit impairments and disabilities, minimize suffering caused by existing departures from good health and to promote the patient's adjustment to irremediable conditions". For example, treatment, even if undertaken late in the natural history of disease may prevent squeal and limit disability. When defect and disability are more or less stabilized, rehabilitation may play a preventable role. Modern rehabilitation includes psychosocial and medical components based on team work from a variety of professions. Tertiary prevention extends the concept of prevention into fields of rehabilitation.

11. Rehabilitation Rehabilitation has been defined as "the combined and coordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability". Rehabilitation medicine has emerged in recent years as a medical specialty. It involves disciplines such as physical medicine or physiotherapy, occupational therapy, speech therapy, audiology, psychology, education, social work, vocational guidance and placement services.

12. Backend vs. Frontend measures Frontend event measures are like Pruning the branches of disease tree while Backend event measures uproot the tree

13. Why big denominator? The disease causative agent is not considered as a component. It is assumed that it is the whole story Diseases are really complex http://www.wordinfo.info/words/index/info/view_unit/1/?letter=B&spage=3

14. Prevention is better than cure … or universal truth? Scurvy, "limeys" and vitamin C James Lind 1716-94 A Treatise of the Scurvy

15. Smallpox: what value eradication? Day 3 Synchronous eruption of lesions Day 5 Rash turns to vesicles and pustules Day 7 Large lesions with central well Case fatality 30%

16. From inoculation to vaccination to eradication Edward Jenner (1749-1823) Lady Mary Wortley Montague (1689-1762) DA Henderson WHO Eradication campaign (1966-1977)

17. Smallpox inoculation: tools of the trade

18. Cost of eradication in external funding $125 million "Just eradicate the disease, and let the skeptics talk to each other" UNICEF

19. 1967 About 10,000 cases per month 1977 Last case 26 October 1977

20. Cure is cleverer than prevention? 186 Nobel Prizes for Medicine, 1901-2006 Basic science 172 Cure/therapy 12 Prevention 2 Theiler 1905 Ehrlich 1908 + Mechnikov 1908

21. Paul Ehrlich's (1854-1915) "magic bullets" Prevention: "side-chain" theory of immunity based on antibody Cure: drugs selectively targeting pathogens -- arsenic-based Salvarsan to treat syphilis Smoking one of his "25 strong cigars a day" Died of stroke

22. Aspirin reduces strokes in women (17%) and heart attacks in men (32%) women have slightly more strokes than heart attacks, men tend to have more heart attacks than strokes ( JAMA vol 295, p 306 , 2005) Sir John Vane, Nobel Prize 1982

23. Is prevention better than cure? In formal analysis, not necessarily… Aetiology of some diseases unknown some conditions unpreventable Prevention vs cure is not always the right question both are needed and feasible e.g. child mortality in LDCs We value more than is captured in formal analysis which gives guidance, not rules

24. PREVENTION VS CURE: A STRAW POLL AT WHO 1 2 3 4 Vaccination Clean water Handwashing Nutrition The pill Seatbelts Sterilization Covered cough Vitamins Votes for prevention 1 2 3 4 5 Antibiotics Surgery Good doctors ORT diarrhea Votes for cure

25. of aged 15 and over are insufficiently active 31% Physical inactivity- 6% of deaths , main cause for 21–25% of breast and colon cancers, 27% of diabetes, 30% of ischaemic heart disease adolescent boys use tobacco 18% 50% continue to smoke 7% deaths 30% NCDs due tobacco use adolescent are obese 11% Overweight & obesity - 44% of diabetes, 23% of ischaemic heart disease and 7-41% of certain cancers of adolescents experience a mental health problem 20% Antisocial personality disorder- greater than 50% of first diagnoses across the life course are ONLY by age 25 years 47% experience alcohol dependence of adolescent girls and 14% of boys reported use alcohol. 18% 9% of all deaths in 15 and 29 age group due to alcohol-related causes Behaviors formed in adolescence influence health & morbidity across life continue to be overweight 50% Source: WHO 2008; WHO 2009; WHO 2011

26. UK Fire Services have long known that prevention is better than cure This is why fires have reduced by more than 50% in the last decade We are keen to ensure that despite reform and budget cuts, prevention remains at the heart of everything we do. From Home Fire Safety Visits to working to educate children and young people. Prevention is better and less costly than cure Keeping the focus on prevention

27. Poliomyelitis: prevention far better than cure

28. Polio vaccines Sabin & Salk

29. Polio eradication? > 1600 cases in 2006 Total external spending ~ $4 bn Initial estimate $300 million India Pakistan Afghanistan Nigeria

30. Polio Eradication & End game strategic plan (2013 – 2018) has been developed to capitalize on a unique opportunity to eradicate polio only the second time in the history. Cost = $5.5 billion + additional resources from the countries 1980s: polio crippled 3.5 lakh children every year ~~ fewer than 250 in 2012 Global Polio Eradication Initiative (GPEI) initiated in 1988. An investment of $9 billion has already generated net benefits of $27 billion.

31. Two alternatives Relying solely on the existing routine immunization and control policy, to keep the number of polio cases below certain level

32. World Health Report 2013 15 th August ‘13: margaret Chan, DG, who World is spending more than USD100 billion on health research A lions share goes to the discovery and development of pharmaceutical and biotechnology products. A tiny proportion goes into research into health systems and service delivery. Syphilis is easily screened, diagnosed and treated each costing less than $1, yet about 2 million pregnant women are infected and half of them transmit to newborns; not to mention the dire consequences… Cervical cancer being the third leading cause of cancer among women, it is indeed impressive to note that there are effective vaccines: which undoubtedly lessen the burden in the future generations!!!

33. Thank you