Figure 1:

During specific data collection for Public Health Surveillance in rural community

PUBLIC HEALTH SURVEILLANCE

Public health and health care practitioners are concerned with a wide spectrum of health issues including infectious diseases, chronic conditions, reproductive outcomes, environmental health, and health events related to occupation, injuries, and behaviors. This array of problems requires a variety of intervention strategies for populations in addition to the need to provide clinical preventive services for individuals. Some critical examples are the provision of prophylactic measures (e.g., vaccination or post exposure rabies prophylaxis), educational services (e.g., public health messages to diverse populations or counseling and prophylaxis for contacts of persons with certain infectious diseases), inspection of food establishments, and control of infectious and noninfectious conditions.

For these activities, the rational development of health policy depends on public health information. For example, information on the age of children with vaccine-preventable diseases has been used to establish policy on appropriate ages for delivering vaccinations (Centers for Disease Control and Prevention [CDC] 1994a). Documentation of the prevalence of elevated levels of lead (a known toxicant) in blood in the US population has been used as the justification for eliminating lead from gasoline and for documenting the effects of this intervention (Annest et al. 1983), and information on the rate at which breast cancer is detected has led to new policies regarding the ages at which to recommend mammograms (Day 1991).

Public health information is understood most basically in terms of time, place, and person. Descriptive analysis of surveillance data over time shows patterns which generate hypotheses or merely reflect patterns in reporting behavior rather than underlying disease incidence. Furthermore, the approach to the prevention and control of disease and injury is often determined by circumstances unique to the place or geographic distribution of the disease or of its causative exposures or risk-associated behavior. For example, elevated blood-lead levels in children may represent exposure to lead hazards in their environment and may require both medical and environmental interventions. Distributions of some forms of cancer (e.g., melanoma of the skin) show a definite spatial distribution (Pickle et al. 1987).

Finally, the characteristics of the person or groups who develop specific diseases or who sustain specific injuries are important in understanding the disease or injury, identifying those at high risk, and targeting intervention efforts. For example, disparities in health (incidence or severity of disease) among members of different population groups highlight the need to identify cultural, economic, or social factors associated with these health problems (CDC 1993a).

Definition and Brief History

Public health surveillance (in some literature called epidemiological surveillance) is the ongoing systematic collection, analysis, and interpretation of outcome-specific health data, closely integrated with the timely dissemination of these data to those responsible for preventing and controlling disease or injury (Thacker and Brekelman 1992). Public health surveillance systems should have the capacity to collect and analyze data (Cates and Williamson 1994), disseminate data to public health programs (Langmuir 1963), and regularly evaluate the effectiveness of the use of the disseminated data (Klaucke et al. 1988). Public health information systems, on the other hand, have been defined to include a variety of data sources essential to public health and are often used for surveillance; however, historically, they lack some critical elements of surveillance systems (Thacker 1992). For example, they may not focus on specific outcomes (e.g., vital statistics), are not ongoing (e.g., a one-time or occasional survey), or are not linked directly to public health practices (e.g., insurance claims data).

DATA COLLECTION IN REMOTE AREA OF NEPAL

The history of public health surveillance can be traced back to efforts to control the bubonic plague in the 14^th century and includes and includes such key figures as von Leibnitz, Graunt, Shattuck, and Farr (Thacker 1992). Following the discoveries of infectious disease agents in the late 1800s, the first use of scientifically based surveillance concepts in public health practice was the monitoring of contacts of persons with serious communicable diseases such as plague, smallpox, typhus, and yellow fever to detect the first signs and symptoms of disease and to begin prompt isolated. For many decades, this was the function of foreign quarantine stations throughout the world.

In the late 1940s, Alexander D. Langmuir, then the chief epidemiologist of the Communicable Disease Center (now the Centers for Disease Control and Prevention [CDC]), began to broaden the concept of surveillance. Although surveillance of persons at risk for specific disease continued at quarantine stations, Langmuir and his colleagues changed the focus of attention from individuals to diseases such as malaria and smallpox. They emphasized rapid collection and analysis of data on a particular disease with quick dissemination of the findings to those who needed to know (Langmuir 1963). As latter started by Foege et al. (1976): “The reason for collecting, analyzing, and disseminating information on a disease is to consume resources if action does not follow”. Although surveillance was originally concerned with protection of the population against infectious disease (Langmuir 1963), more recently a wide variety of health events, such as childhood lead poisoning, birth defects, injuries, and behavioral risk factors, have been included in surveillance activities (Thacker and Stroup 1994).

Unless those who set policy and implementation programs have ready access to data, the use is limited to archives and academic pursuits, and the material is therefore appropriately considered health information rather than surveillance data (Terris 1992). Thus, the boundary of surveillance practice meets with-but does not extend to actual research and implementation of intervention programs (Ballard and Duncan 1994). For example, although patient identifiers are not collected for most surveillance activities, state and local health departments may need this information for effective prevention of the spread of sexually transmitted diseases (i.e., contacting the partners of infected persons to deliver treatment and prevention information). A central difference between public health work and other biomedical research is that the boundary in public health between research and non-research activities is ill-defined (Last 1996). Specially, state and local health departments use surveillance information for control and prevention of disease, and most surveillance activities are mandated (or permitted) by state statute (CDC 1990b). If persons with contagious diseases were allowed to refuse appropriate intervention, this would have an adverse effect on the health of communities (Chorba et al. 1989). At the same time, surveillance is more than the collection of reports of health events, and data collected for other purposes may enhance surveillance activities. This extension of activities can be seen in the 1957 national weekly influenza surveillance system established by CDC which used morbidity and laboratory data from state health departments, school and industrial absenteeism, morbidity data from 108 US cities, and acute respiratory illness rates from the National Health Interview Survey (Langmuir 1987).

Uses

The uses of surveillance information can be organized on the basis of three categories of timeliness: immediate, annual, and archival (Thacker and Stroup 1994) (Figure 4-2).

• Immediate detection of:
• Epidemics
• Newly emerging health problems
• Changes in health practices
• Changes in antibiotic resistance

• Annual dissemination for:
• Estimating the magnitude of the health problem, including cost
• Assessing control activities
• Setting research priorities
• Testing hypothesis
• Facilitating planning
• Monitoring risk factors
• Monitoring changes in health practices
• Documenting distribution and spread

• Archival information for:
• Describing natural history of diseases
• Facilitating epidemiologic and laboratory research
• Validating use of preliminary data
• Setting research priorities
• Documenting distribution and spread

Immediate

For detecting epidemics, a surveillance system should allow public health officials immediate access to new information (Kilbourne 1992). For example, detection of a disease related to contaminated food or biological products should immediately trigger intervention and control efforts. As soon as, say, unusual clusters of specific birth defects or geographic clusters or pedestrian injuries [Kilbourne 1992], public health officials should respond (CDC 1990a).

In hospital and health department laboratories, various infectious agents are monitored for changes in bacterial resistance to antibiotics or antigenic composition. The detection of penicillinase-producing Neisseria gonorrhea in the United States through surveillance activities has provided critical information for the proper treatment of gonorrhea (CDC 1976). The National Nosocomial Infection Surveillance System monitors the occurrence of hospital-acquired infections, including changes in antibiotic resistance. Surveillance of influenza monitors the continual changes in the influenza virus structure, information vital to vaccine formulation (Emori et al. 1991).

Annual

Timely annual data summaries would provide immediate estimates of the magnitude of a health problem, thus assisting policy-makers to modify priorities and plan intervention programs. These same data would be useful to those assessing control activities and would help researchers establish research priorities in applied epidemiology and laboratory research.

Surveillance data are used to assess control activities programs. For example, they have demonstrated the decrease in poliomyelitis rates following the introduction of both the inactivated and oral polio vaccines and the effect on motor vehicle-associated injury of broad-based community interventions such as increased legal age of driving and seat-belt laws (Loeb 1993).

The traditional use of surveillance was to quarantine persons infected with or exposed to a particular disease and to monitor isolation activities. While this measure is rarely used today, isolation and surveillance of individuals is done for patients with multidrug-resistant tuberculosis and patients suspected of having serious, imported diseases such as the hemorrhagic fevers.

Surveillance has been used to monitor health practices such as hysterectomy, cesarean delivery, mammography, and tubal sterilization (Thacker et al. 1995). In the United States, a sociological trend is shifting in the health care industry from one dominated by a large number of small offices to one characterized by a small number of large managed-care organizations with computerized patient records. For example, as of June 1995, 32% of Medicaid beneficiaries were enrolled in managed-care organizations, compared with 14% in 1994 (CDC 1995a). Data systems developed for managed-care activities will have tremendous potential for public health surveillance.

Surveillance data serve as the cornerstone of epidemiologic and public health practice. Representative and relevant health surveillance data give the necessary framework to facilitate planning and management of public programs. For example, Missouri health officials used existing chronic disease surveillance data to develop a cardiovascular disease health plan (Thacker et al. 1995). Data used were from existing sources, including mortality, data on behavioral risk factors, and data on population distribution. The resulting plan included a task force to establish priorities and monitor progress, a plan for chronic disease control, a resource directory, and training in cardiovascular disease control strategies. As discussed later in the case study section of this chapter, officials cite the appropriate use of surveillance data as the integral component in local coalition development (Brownson et al. 1992).

The health of populations may be adversely affected by time required to do special studies. Although surveillance information has limitations, it can often be used to test hypotheses. For example, the reported occurrence of lung cancer in the United States over the past 50 years has shown the impact of changes in the prevalence of smoking behaviors in women. For example, the passage of smoking legislation in the United States was shown to increase the age of initiation of smoking (United States Department of Health and Human Services 1994). Surveillance data on cancer from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (Gloeckler-Ries et al. 1990) has been used as the basis of etiologic studies (Tejeda et al. 1996).

Archival

Surveillance data should be retained in readily accessible archival form, not only to document the evolving health status of a population but also to help us understand the predictors of disease and injury. For example, as we better understand spatial spread of infectious diseases such as influenza or measules, more effective prevention strategies may be possible (Longini et al. 1986; Cliff et al. 1992a). Carefully maintained archival data can provide the most accurate portrayal of the natural history of a disease in a population (Thacker and Berkelman 1992), effective measurements of the long-term effects of public policies or social changes (CDC 1991), and validation of interim data (CDC 1992; Thacker 1996).

Archival surveillance data can be used at the local, and to a lesser degree national, level to develop prevention and control activities. Missouri investigators used surveillance data to provide quantitative estimates of the magnitude of heart disease and to demonstrate an epidemic in that population. As a result, policy-makers adopted a cardiovascular health plan, enhancing its disease control program (Thacker et al. 1995). Conversely, surveillance data suggested that diabetic patients using continuous subcutaneous insulin infusion pumps suffered excess mortality; an investigation triggered by these data showed that this important technology was not associated with mortality (Teutsch et al. 1984).

Figure 3: Changes in health practice through the Micro Health Project (MHP) in rural area of Nepal.

Major Public Health promblem in Great Britain

Latest Data of Road Traffic Accident in Britian

The number of deaths and injuries on British roads is falling. In 2005 there were 3,201 deaths on the roads in Great Britain. Just over half (52%) of people killed in road accidents in 2005 were in cars. Pedal cyclists and motor cyclists represented 5 and 18% of those killed respectively. Pedestrian deaths are at a 40 years low of 671 or 21%. Occupants of buses, coaches, goods and other vehicles accounted for the remaining 4% of road deaths.

Total casualties of all severities fell by 3% between 2004 and 2005 to approximately 271,000 in Great Britain. The decline in the casualty rate, which takes into account the volume of traffic on the roads, has been much steeper. In 1964 there were 240 casualties per 100 million vehicle kilometres. By 2005 this had declined to 55 per 100 million vehicle kilometres.

The UK has the lowest rate of road accident fatalities in the EEC. It is lower than Japan or Australia and just over a third of the rate in the USA.

These figures are falling and are a great achievement but they still represent an enormous burden. The aim here is to reduce the morbidity and mortality of those who are injured before they reach hospital.

Assessment

If there has been an enormous accident with many people injured and perhaps fatalities too, the principles outlined in major disaster plans are appropriate.

When attending an accident, check that the scene of the accident is safe. Your personal safety is paramount or you may add to the problem rather than contributing to the solution. If you have access to high visibility clothing, wear it.

Hazards

There are a number of hazards that may need to be considered for personal safety and that of others.

Passing traffic

One risk is that oncoming traffic may plough into those there. It may be best to park obliquely behind the incident to fend off oncoming traffic. Leave on hazard lights and if you have one, a green beacon. The problem is discussed further in Road traffic accidents - attending as a passing doctor.

Fire

Fewer than 5% of RTAs result in fire, and less than 1 in 500 results in significant burns. The world's worst ever road traffic accident was in the Salang tunnel, Afghanistan, in November 1982 and involved a petrol tanker explosion with an estimated 1,100 to 2,700 killed. Unleaded petrol is far more inflammable than 4-star. Diesel is difficult to burn without a wick. LPG (liquid petroleum gas) in dual fuel cars is potentially explosive. If the engine is still running, turn it off.

Electricity

If electricity cables are brought down, the power may be restored after 20 minutes without investigation. It is necessary to telephone the power company to ensure that the source is turned off. High tension cables can be lethal, even when standing several metres away.

Rail

Accidents on level crossings can kill or injure occupants of cars and even derail trains. An electrified rail may be short circuited by a bar carried in the guard's van. Cutting power does not stop diesel locomotives that may also operate on the same line. Trains may be stopped by signal lights, red flags, or a series of charges placed on the rail. The noise warns the driver.

Chemical

Lorries carrying hazardous loads are required to display an orange HAZCHEM board. This contains information on how to fight a fire, what protective equipment to wear, if the chemical can be safely washed down the storm drains, and whether to evacuate the area.

As a concession to freight carriers, mixed loads of <500kg need only be identified by a plain orange square at the front and rear.

To obtain information about the chemical at the scene of an accident look at the transport emergency card (TREM card) carried in the driver's cab. The fire tender may be equipped with CHEMDATA - a fax service with the national chemical information centre at Harwell. Alternatively phone a Poison's Information Centre (eg 0131 229 2477 or 01132 430715), or the company. Do not approach a chemical incident until declared safe by the fire service.

Assess the situation

If there are many people injured, triage will be necessary to order priority
Read the wreckage and relate the damage of the vehicle to potential injuries:
Steering wheel deformed = chest injury
Dashboard intrusion = patella/femur fracture ± posterior dislocation of the hip
Bodies are softer than metal, so major bodywork distortion = major injury
Talk to the patient or patients if conscious. Come over as competent and reassuring as they will be very anxious
Ask where it hurts to get an idea of injuries
They may well be in severe pain. Parenteral opiates are often appropriate. Give IV if possible as peripheral circulation is probably shut down
Fractures and abdominal trauma may produce considerable concealed haemorrhage. Check for signs of hypovolaemic shock. Unless injuries are minor get venous access sooner rather than later, before peripheral circulation collapses. If you are unsuccessful at cannulation do not persevere. Two attempts is regarded as reasonable.
Identify the time-critical patient. Some will die unless rapidly removed from the vehicle, at whatever cost. Entrapped patients should be removed in less than half an hour.
When the patient is unconscious remember the ABC of airways, breathing, circulation. If there is sudden deterioration check ABC again for a possible cause.
Whether the person is conscious or not beware of neck injuries and spinal cord compression. Many head restraints are unsatisfactory. If there is any doubt at all apply a collar if you have one but still there is need to support the neck as even a well fitted and applied collar allows some movement.
If a car has rolled over onto a person, there may be crush injuries. Crush syndrome is discussed elsewhere.

Principles of extrication

Stabilize the vehicle where it lies as movement may exacerbate injury
Make the vehicle safe. Switch off the ignition, disconnect the battery, swill away any petrol.
The easiest way to enter a car is through the door, so try this before removing the windscreen or the roof.
Remove the wreckage from the casualty, not the casualty from the wreckage. Do not try to manoeuvre the casualty through too small a hole.
Do not move from one entrapment situation straight into another. If necessary spend a short time stabilising the patient before moving into the back of the ambulance.
Stabilization or evacuation?

Some texts refer to this as scoop and run or stay and play. Scoop and run refers to rapid evacuation of casualties to hospital. Stay and play entails detailed resuscitation at the scene of trauma. The question is whether it is better to arrange immediate transfer to hospital, wasting no time, or if resuscitation first would improve the patient's chance of surviving the journey and prognosis once there. In deciding which is better, take the following into account:

There is no single answer for all circumstances. Local geography, such as the distance to the hospital, plays a part, as does the fitness of the casualty.
Scoop and run and stay and play are two ends of a spectrum of activity. Often a minimal amount of resuscitation can be done without causing too much delay. A consensus paper from Birmingham in 2002 highlighted a number of issues. One is that there should not be undue delay in getting the patient to hospital.
Penetrating chest injuries have been studied in a pseudo-randomized trial of 289 patients. Full randomization was impossible but scoop and run operated for one day, and stay and play for the next. This showed that the balance of benefit probably lies in scoop and run for this type of injury.

Fluid resuscitation aiming for normotension without an operating theatre to hand may be dangerous, as clot may be displaced by the rising BP. There may be consequent fatal haemorrhage, which could only have been prevented by major surgery.
In another study, 70% in the delayed-resuscitation group survived, compared with 62% who received immediate fluid resuscitation. Duration of hospital stay was shorter for survivors in the delayed-resuscitation group. A computer model showed that if the rate of bleeding is slow there is not much difference in giving fluid or not but if bleeding is profuse it is beneficial.
The consensus statement advice was that fluid should not be administered to trauma victims before haemorrhage control if a radial pulse can be felt. Judicious aliquots of 250 ml should be titrated for other patients. If the radial pulse returns, fluid resuscitation can be suspended for the present and the situation monitored. In penetrating torso trauma the presence of a central pulse should be considered adequate. In children less than 1 year old, the use of a brachial pulse is more practical as it is easier to feel.
Vicarious liability

In the United Kingdom there is no legal obligation for anyone to stop and help at a road accident. The GMC states, "In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care."

If you stop you are legally responsible for your actions and omissions. The "Good Samaritan" is not covered by NHS trust indemnity but both the Medical Protection Society and the Medical Defence Union include medico-legal cover for accidents in their basic policies. It is recognised by most authorities that a doctor willing to stop is acting out of beneficence for the casualties and in this country legal repercussions are fortunately rare.

When was HIV discovered, and how is it diagnosed?

In 1981, homosexual men with symptoms of a disease that now are considered typical of the acquired immunodeficiency syndrome (AIDS) were first described in Los Angeles and New York. The men had an unusual type of lung infection (pneumonia) called Pneumocystis carinii (now known as Pneumocystis jiroveci) pneumonia (PCP) and rare skin tumors called Kaposi's sarcomas. The patients were noted to have a severe reduction in a type of cell in the blood that is an important part of the immune system, called CD4 cells. These cells, often referred to as CD4 T cells, help the body fight infections. Shortly thereafter, this disease was recognized throughout the United States, Western Europe, and Africa. In 1983, researchers in the United States and France described the virus that causes AIDS, now known as the human immunodeficiency virus (HIV) and belonging to the group of viruses called retroviruses. In 1985, a blood test became available that measures antibodies to HIV that are the body's immune response to the HIV. This blood test remains the best method for diagnosing HIV infection. Recently, tests have become available to look for these same antibodies in blood and saliva, some providing results within 20 minutes of testing.


How is HIV spread (transmitted)?

HIV is present to variable degrees in the blood and genital secretions of virtually all individuals infected with HIV, regardless of whether or not they have symptoms. The spread of HIV can occur when these secretions come in contact with tissues such as those lining the vagina, anal area, mouth, or eyes (the mucus membranes), or with a break in the skin, such as from a cut or puncture by a needle. The most common ways in which HIV is spreading throughout the world include sexual contact, sharing needles, and by transmission from infected mothers to their newborns during pregnancy, labor (the delivery process), or breastfeeding. (See the section below on treatment during pregnancy for a discussion on reducing the risk of transmission to the newborn.)

Sexual transmission of HIV has been described from men to men, men to women, women to men, and women to women through vaginal, anal, and oral sex. The best way to avoid sexual transmission is abstinence from sex until it is certain that both partners in a monogamous relationship are not HIV-infected. Because the HIV antibody test can take up to six months to turn positive after infection occurs, both partners would need to test negative six months after their last potential exposure to HIV. If abstinence is out of the question, the next best method is the use of latex barriers. This involves placing a condom on the penis as soon as an erection is achieved in order to avoid exposure to pre-ejaculatory and ejaculatory fluids that contain infectious HIV. For oral sex, condoms should be used for fellatio (oral contact with the penis) and latex barriers (dental dams) for cunnilingus (oral contact with the vaginal area). A dental dam is any piece of latex that prevents vaginal secretions from coming in direct contact with the mouth. Although such dams occasionally can be purchased, they are most often created by cutting a square piece of latex from a condom.

The spread of HIV by exposure to infected blood usually results from sharing needles, as in those used for illicit drugs. HIV also can be spread by sharing needles for anabolic steroids to increase muscle, tattooing, and body piercing. To prevent the spread of HIV, as well as other diseases including hepatitis, needles should never be shared. At the beginning of the HIV epidemic, many individuals acquired HIV infection from blood transfusions or blood products, such as those used for hemophiliacs. Currently, however, because blood is tested for both antibodies to HIV and the actual virus before transfusion, the risk of acquiring HIV from a blood transfusion in the United States is extremely small and is considered insignificant.

There is little evidence that HIV can be transferred by casual exposure, as might occur in a household setting. For example, unless there are open sores or blood in the mouth, kissing is generally considered not to be a risk factor for transmitting HIV. This is because saliva, in contrast to genital secretions, has been shown to contain very little HIV. Still, theoretical risks are associated with the sharing of toothbrushes and shaving razors because they can cause bleeding, and blood can contain large amounts of HIV. Consequently, these items should not be shared with infected people. Similarly, without sexual exposure or direct contact with blood, there is little if any risk of HIV contagion in the workplace or classroom.

What is Public Health

Public health:

The approach to medicine that is concerned with the health of the community as a whole. Public health is community health. It has been said that: "Health care is vital to all of us some of the time, but public health is vital to all of us all of the time."

The mission of public health is to "fulfill society's interest in assuring conditions in which people can be healthy." The three core public health functions are:

•The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities;
•The formulation of public policies designed to solve identified local and national health problems and priorities;
•To assure that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care.
There are many distinctions that can be made between public health and the clinical health professions. While public health is comprised of many professional disciplines such as medicine, dentistry, nursing, optometry, nutrition, social work, environmental sciences, health education, health services administration, and the behavioral sciences, its activities focus on entire populations rather than on individual patients.

Doctors usually treat individual patients one-on-one for a specific disease or injury. Public health professionals monitor and diagnose the health concerns of entire communities and promote healthy practices and behaviors to assure our populations stay healthy.

One way to illustrate some of the breadth of public health is to look at some of the notable public health achievements in the 20th century. The following were selected as the "Ten Great Public Health Achievements -- United States, 1900-1999" by the U.S. Centers for Disease Control and Prevention (CDC).

Vaccination Vaccination has resulted in the eradication of smallpox; elimination of poliomyelitis in the Americas; and control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae type b, and other infectious diseases in the United States and other parts of the world.

Motor-vehicle safety Improvements in motor-vehicle safety have resulted from engineering efforts to make both vehicles and highways safer and from successful efforts to change personal behavior (e.g., increased use of safety belts, child safety seats, and motorcycle helmets and decreased drinking and driving). These efforts have contributed to large reductions in motor-vehicle-related deaths.

Safer workplaces Work-related health problems, such as coal workers' pneumoconiosis (black lung), and silicosis -- common at the beginning of the century -- have come under better control. Severe injuries and deaths related to mining, manufacturing, construction, and transportation also have decreased; since 1980, safer workplaces have resulted in a reduction of approximately 40% in the rate of fatal occupational injuries.

Control of infectious diseases Control of infectious diseases has resulted from clean water and improved sanitation. Infections such as typhoid and cholera transmitted by contaminated water, a major cause of illness and death early in the 20th century, have been reduced dramatically by improved sanitation. In addition, the discovery of antimicrobial therapy has been critical to successful public health efforts to control infections such as tuberculosis and sexually transmitted diseases (STDs).

Decline in deaths from coronary heart disease and stroke Decline in deaths from coronary heart disease and stroke have resulted from risk-factor modification, such as smoking cessation and blood pressure control coupled with improved access to early detection and better treatment. Since 1972, death rates for coronary heart disease have decreased 51%.

PUBLIC HEALTH SURVELLIENCE

Figure 1:
During specific data collection for Public Health Surveillance in rural community


PUBLIC HEALTH SURVEILLANCE

Public health and health care practitioners are concerned with a wide spectrum of health issues including infectious diseases, chronic conditions, reproductive outcomes, environmental health, and health events related to occupation, injuries, and behaviors. This array of problems requires a variety of intervention strategies for populations in addition to the need to provide clinical preventive services for individuals. Some critical examples are the provision of prophylactic measures (e.g., vaccination or post exposure rabies prophylaxis), educational services (e.g., public health messages to diverse populations or counseling and prophylaxis for contacts of persons with certain infectious diseases), inspection of food establishments, and control of infectious and noninfectious conditions.

For these activities, the rational development of health policy depends on public health information. For example, information on the age of children with vaccine-preventable diseases has been used to establish policy on appropriate ages for delivering vaccinations (Centers for Disease Control and Prevention [CDC] 1994a). Documentation of the prevalence of elevated levels of lead (a known toxicant) in blood in the US population has been used as the justification for eliminating lead from gasoline and for documenting the effects of this intervention (Annest et al. 1983), and information on the rate at which breast cancer is detected has led to new policies regarding the ages at which to recommend mammograms (Day 1991).

Public health information is understood most basically in terms of time, place, and person. Descriptive analysis of surveillance data over time shows patterns which generate hypotheses or merely reflect patterns in reporting behavior rather than underlying disease incidence. Furthermore, the approach to the prevention and control of disease and injury is often determined by circumstances unique to the place or geographic distribution of the disease or of its causative exposures or risk-associated behavior. For example, elevated blood-lead levels in children may represent exposure to lead hazards in their environment and may require both medical and environmental interventions. Distributions of some forms of cancer (e.g., melanoma of the skin) show a definite spatial distribution (Pickle et al. 1987).

Finally, the characteristics of the person or groups who develop specific diseases or who sustain specific injuries are important in understanding the disease or injury, identifying those at high risk, and targeting intervention efforts. For example, disparities in health (incidence or severity of disease) among members of different population groups highlight the need to identify cultural, economic, or social factors associated with these health problems (CDC 1993a).





Definition and Brief History
Public health surveillance (in some literature called epidemiological surveillance) is the ongoing systematic collection, analysis, and interpretation of outcome-specific health data, closely integrated with the timely dissemination of these data to those responsible for preventing and controlling disease or injury (Thacker and Brekelman 1992). Public health surveillance systems should have the capacity to collect and analyze data (Cates and Williamson 1994), disseminate data to public health programs (Langmuir 1963), and regularly evaluate the effectiveness of the use of the disseminated data (Klaucke et al. 1988). Public health information systems, on the other hand, have been defined to include a variety of data sources essential to public health and are often used for surveillance; however, historically, they lack some critical elements of surveillance systems (Thacker 1992). For example, they may not focus on specific outcomes (e.g., vital statistics), are not ongoing (e.g., a one-time or occasional survey), or are not linked directly to public health practices (e.g., insurance claims data).
Figure 2:
DATA COLLECTION IN REMOTE AREA OF NEPAL

The history of public health surveillance can be traced back to efforts to control the bubonic plague in the 14th century and includes and includes such key figures as von Leibnitz, Graunt, Shattuck, and Farr (Thacker 1992). Following the discoveries of infectious disease agents in the late 1800s, the first use of scientifically based surveillance concepts in public health practice was the monitoring of contacts of persons with serious communicable diseases such as plague, smallpox, typhus, and yellow fever to detect the first signs and symptoms of disease and to begin prompt isolated. For many decades, this was the function of foreign quarantine stations throughout the world.

In the late 1940s, Alexander D. Langmuir, then the chief epidemiologist of the Communicable Disease Center (now the Centers for Disease Control and Prevention [CDC]), began to broaden the concept of surveillance. Although surveillance of persons at risk for specific disease continued at quarantine stations, Langmuir and his colleagues changed the focus of attention from individuals to diseases such as malaria and smallpox. They emphasized rapid collection and analysis of data on a particular disease with quick dissemination of the findings to those who needed to know (Langmuir 1963). As latter started by Foege et al. (1976): “The reason for collecting, analyzing, and disseminating information on a disease is to consume resources if action does not follow”. Although surveillance was originally concerned with protection of the population against infectious disease (Langmuir 1963), more recently a wide variety of health events, such as childhood lead poisoning, birth defects, injuries, and behavioral risk factors, have been included in surveillance activities (Thacker and Stroup 1994).

Unless those who set policy and implementation programs have ready access to data, the use is limited to archives and academic pursuits, and the material is therefore appropriately considered health information rather than surveillance data (Terris 1992). Thus, the boundary of surveillance practice meets with-but does not extend to actual research and implementation of intervention programs (Ballard and Duncan 1994). For example, although patient identifiers are not collected for most surveillance activities, state and local health departments may need this information for effective prevention of the spread of sexually transmitted diseases (i.e., contacting the partners of infected persons to deliver treatment and prevention information). A central difference between public health work and other biomedical research is that the boundary in public health between research and non-research activities is ill-defined (Last 1996). Specially, state and local health departments use surveillance information for control and prevention of disease, and most surveillance activities are mandated (or permitted) by state statute (CDC 1990b). If persons with contagious diseases were allowed to refuse appropriate intervention, this would have an adverse effect on the health of communities (Chorba et al. 1989). At the same time, surveillance is more than the collection of reports of health events, and data collected for other purposes may enhance surveillance activities. This extension of activities can be seen in the 1957 national weekly influenza surveillance system established by CDC which used morbidity and laboratory data from state health departments, school and industrial absenteeism, morbidity data from 108 US cities, and acute respiratory illness rates from the National Health Interview Survey (Langmuir 1987).


Uses

The uses of surveillance information can be organized on the basis of three categories of timeliness: immediate, annual, and archival (Thacker and Stroup 1994) (Figure 4-2).

Immediate detection of:
Epidemics
Newly emerging health problems
Changes in health practices
Changes in antibiotic resistance

Annual dissemination for:
Estimating the magnitude of the health problem, including cost
Assessing control activities
Setting research priorities
Testing hypothesis
Facilitating planning
Monitoring risk factors
Monitoring changes in health practices
Documenting distribution and spread

Archival information for:
Describing natural history of diseases
Facilitating epidemiologic and laboratory research
Validating use of preliminary data
Setting research priorities
Documenting distribution and spread

Immediate

For detecting epidemics, a surveillance system should allow public health officials immediate access to new information (Kilbourne 1992). For example, detection of a disease related to contaminated food or biological products should immediately trigger intervention and control efforts. As soon as, say, unusual clusters of specific birth defects or geographic clusters or pedestrian injuries [Kilbourne 1992], public health officials should respond (CDC 1990a).

In hospital and health department laboratories, various infectious agents are monitored for changes in bacterial resistance to antibiotics or antigenic composition. The detection of penicillinase-producing Neisseria gonorrhea in the United States through surveillance activities has provided critical information for the proper treatment of gonorrhea (CDC 1976). The National Nosocomial Infection Surveillance System monitors the occurrence of hospital-acquired infections, including changes in antibiotic resistance. Surveillance of influenza monitors the continual changes in the influenza virus structure, information vital to vaccine formulation (Emori et al. 1991).




Annual

Timely annual data summaries would provide immediate estimates of the magnitude of a health problem, thus assisting policy-makers to modify priorities and plan intervention programs. These same data would be useful to those assessing control activities and would help researchers establish research priorities in applied epidemiology and laboratory research.

Surveillance data are used to assess control activities programs. For example, they have demonstrated the decrease in poliomyelitis rates following the introduction of both the inactivated and oral polio vaccines and the effect on motor vehicle-associated injury of broad-based community interventions such as increased legal age of driving and seat-belt laws (Loeb 1993).

The traditional use of surveillance was to quarantine persons infected with or exposed to a particular disease and to monitor isolation activities. While this measure is rarely used today, isolation and surveillance of individuals is done for patients with multidrug-resistant tuberculosis and patients suspected of having serious, imported diseases such as the hemorrhagic fevers.

Surveillance has been used to monitor health practices such as hysterectomy, cesarean delivery, mammography, and tubal sterilization (Thacker et al. 1995). In the United States, a sociological trend is shifting in the health care industry from one dominated by a large number of small offices to one characterized by a small number of large managed-care organizations with computerized patient records. For example, as of June 1995, 32% of Medicaid beneficiaries were enrolled in managed-care organizations, compared with 14% in 1994 (CDC 1995a). Data systems developed for managed-care activities will have tremendous potential for public health surveillance.

Surveillance data serve as the cornerstone of epidemiologic and public health practice. Representative and relevant health surveillance data give the necessary framework to facilitate planning and management of public programs. For example, Missouri health officials used existing chronic disease surveillance data to develop a cardiovascular disease health plan (Thacker et al. 1995). Data used were from existing sources, including mortality, data on behavioral risk factors, and data on population distribution. The resulting plan included a task force to establish priorities and monitor progress, a plan for chronic disease control, a resource directory, and training in cardiovascular disease control strategies. As discussed later in the case study section of this chapter, officials cite the appropriate use of surveillance data as the integral component in local coalition development (Brownson et al. 1992).

The health of populations may be adversely affected by time required to do special studies. Although surveillance information has limitations, it can often be used to test hypotheses. For example, the reported occurrence of lung cancer in the United States over the past 50 years has shown the impact of changes in the prevalence of smoking behaviors in women. For example, the passage of smoking legislation in the United States was shown to increase the age of initiation of smoking (United States Department of Health and Human Services 1994). Surveillance data on cancer from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (Gloeckler-Ries et al. 1990) has been used as the basis of etiologic studies (Tejeda et al. 1996).

Archival

Surveillance data should be retained in readily accessible archival form, not only to document the evolving health status of a population but also to help us understand the predictors of disease and injury. For example, as we better understand spatial spread of infectious diseases such as influenza or measules, more effective prevention strategies may be possible (Longini et al. 1986; Cliff et al. 1992a). Carefully maintained archival data can provide the most accurate portrayal of the natural history of a disease in a population (Thacker and Berkelman 1992), effective measurements of the long-term effects of public policies or social changes (CDC 1991), and validation of interim data (CDC 1992; Thacker 1996).

Archival surveillance data can be used at the local, and to a lesser degree national, level to develop prevention and control activities. Missouri investigators used surveillance data to provide quantitative estimates of the magnitude of heart disease and to demonstrate an epidemic in that population. As a result, policy-makers adopted a cardiovascular health plan, enhancing its disease control program (Thacker et al. 1995). Conversely, surveillance data suggested that diabetic patients using continuous subcutaneous insulin infusion pumps suffered excess mortality; an investigation triggered by these data showed that this important technology was not associated with mortality (Teutsch et al. 1984).

Figure 3: Changes in health practice through the Micro Health Project (MHP) in rural area of Nepal.


















Figure 3 Presentation on the preparation of Sarbottam Pitho












Figure 4 Demonstration Method of Sarbottam Pitho














Sources of Public Health Surveillance Data

Langmuir’s credo of rapid reporting, analysis, and action now applies to over 100 infectious diseases and health events of noninfectious etiology nationally (Osterholm et al. 1996). Some ongoing systems of reporting have resulted from national emergencies such as contaminated lots of polio vaccine (Langmuir 1987), the Asian influenza epidemic of 1957, shellfish-associated hepatitis type A in 1961, and toxic-shock syndrome in 1980. Following the investigation of l-tryptophan-associated eosinophilia-myalgia syndrome (EMS) in 1990, within days a national surveillance system was put into place (Philen et al. 1993).

For such activities, public health agencies need several categories of information: (1) reports of health events affecting individuals; (2) vital statistics on the entire population; (3) information on the health status, risk behaviors, and experiences of populations; (4) information on potential exposure to environmental agents; (5) information on existing public health programs; (6) information useful to public health but obtained by organization not directly involved in public health practice; and (7) information on the health care system and the impact of the health care system on health.

Reports of Health Events

Reports of cases of specific diseases of public health importance serve as the basis of many national surveillance programs in the United States (e.g., the National Notifiable Disease Surveillance System [NNDSS]; CDC 1991; Koo and Wetterhall 1996). Public health information needs may dictate the level of detail needed in data collection. For example, on a weekly basis, the NNDSS seeks reports on all cases of more than 40 conditions in the United States but collects only a small amount of information for each case, in order to minimize the burden placed on those who report. NNDSS data are used to monitor trends in disease, to evaluate public health programs, and to identify unusual occurrences of conditions that may require further epidemiologic investigation at the local level.

For some public health purposes, however, effective action requires additional detail on each case. For this reason, supplemental data collection systems have been developed for some of the diseases involved in the NNDSS. Such supplemental systems are sometimes less comprehensive in terms of the population represented but provide more detailed information on characteristics of the occurrence of disease (CDC 1991). For example, cases of hepatitis are reported weekly to NNDSS for population in the Morbidity and Mortality Weekly Report (MMWR). In addition, the Viral Hepatitis Surveillance Project collects data on specific risk factors for different types of viral hepatitis in selected geographic areas. These data have been used to evaluate the importance of behavior associated with sexual activity and drug use as risk factors for transmitting hepatitis type B and to target educational and vaccination programs. Other uses of data may require the ability to identify the patient whose case is reported and sometimes persons in contact with the patient, as in the identification and treatment of persons in contact with cases of sexually transmitted disease or tuberculosis.

Intervention and control of some conditions require more detailed information than can be obtained from a large group of clinicians or institutions. As a result, networks of selected health care providers have been organized to meet these targeted information needs. For example, CDC’s Sentinel Event Notification System for Occupational Risks (SENSOR) targets select groups of health care providers as a component of a comprehensive approach that uses multiple data sources to provide information used in directing efforts to prevent workplace-related morbidity (Maizlish et al. 1995). Data from this system were used by states to institute intervention programs for occupational asthma. As a result, investigations of workplaces where occupational asthma cases have occurred have identified substantial numbers of symptomatic co-workers and inadequacies in engineering controls and work practices. These finding

CLINICAL EPIDEMIOLOGY
Clinical Epidemiology is the science of making predications about individuals patients by counting clinical events in similar patients, using strong scientific methods for studies of groups of patients to ensure that the predications are accurate. The purpose of clinical epidemiology is to develop and apply methods of clinical observation that will lead to valid conclusions by avoiding being misled by systemic error and chance.The term clinical epidemiology is derived from its two parent disciplines: clinical medicine and epidemiology. It is clinical because it seeks to answer clinical questions and to guide clinical decision making with the best available evidence.It is epidemiologic because many of the methods used to answer these questions have been developed by epidemiologists and because the care of individual patients is seen in the context of the larger population of which the patient is a member.

Basic principles
Clinical questions
Issue Question

Abnormality Is the patient sick or well?
Diagnosis How accurate are tests used to diagnosis disease?
Frequency How often does a disease occur?
Risk What factors are associated with an increased risk of disease?
Prognosis What are the consequences of having a disease?
Treatment How does treatment change the course of disease?
Prevention Does an intervention on well people keep disease from arising? Does early detection and treatment improve the course of disease?
Cause What conditions lead to disease? What are the pathogenic mechanisms of disease?
Cost How much will care for an illness cost?
Outcomes of disease (the Five Ds)

Death A bad outcome if untimely
Disease A set of symptoms, physical signs, and laboratory
abnormalities
Discomfort Symptoms such as pain, nausea, dyspnea, itching
Disability Impaired ability to go about usual acitivities at home, work or recreation
Dissatisfaction Emotional reaction to disease and its care, such as sadness or anger.
Uses of clinical Epidemiology
Clinical epidemiology is the application of epidemiological principles and methods to the practice of clinical medicine.
The central cores of clinical epidemiology are: definition of normality and abnormality, accuracy of diagnostic tests, natural history and prognosis of disease, effectiveness of treatment and prevention in clinical practice.
Uses of Clinical Epidemiology
It helps to understand the strengths and weakness of clinical evidence.
It can increase efficiency in acquiring sound information by allowing one to decide quickly, from basic principles, which articles or sources of clinical information are credible.
By relying on clinical epidemiology, clinicians of all backgrounds are all depending mainly on the interpretation of the same set of strong studies.
Finally, clinical epidemiology gives clinicians a perspective on the extent to which their efforts, relative to other factors, such as the biology of disease and the physical and social environment, determine health outcomes, so that they can know what they can and cannot change.




RESEARCH
Research is a quest for knowledge through diligent search or investigation or experimentation aimed at the discovery and interpretation of new knowledge.
Simply it can be defined as a careful, systematic and critical investigation/experimentation to discover new facts or to verify and test existing facts, principles, theory and scientific tools for facilitating human welfare.
Research is the systematic collection, analysis and interpretation of data to answer a certain question or to solve a problem.




Purpose of research
Generating new knowledge i.e uncovering new facts or phenomenon or establishing new relationship of various variables
Improving understanding i.e helping to explain situation or shed light on misunderstood phenomenon or concepts
Application testing i.e trying out concepts and approaches in the real world to see if they work
Comparing best practices i.e that is gathering information about successful of subject in different circumstances and looking for explanation of their success and
Helping with decision making i.e generating information, concepts, framework and approaches that help executives and planners make better and more effective decisions.

Categories of research
1. Empirical and Theoretical Research
The philosophical approach to research is basically of two types: empirical and theoretical. Health research mostly follows the empirical approach, i.e it is based upon observation and experience more than upon theory and abstraction.

2. Basic and Applied
Research can be functionally divided into basic (or pure) research and applied research. Basic research is usually considered to involve a search for knowledge without a defined goal of utility or specific purpose. Applied research is problem oriented, and is directed toward a purposeful end; it is frequently generated by a perceived need, and it directed toward the solution of an existing problem.

3. Health Research Triangle
Health research, be it empirical or theoretical, basic or applied, generally falls under three operational interlinking categories of biomedical, health services and behavioral research, the so called health research triangle.
Health System Research
The systematic investigation and evaluation of the functioning and development of health services and their interrelationship with health-related factors.

Major steps in research
Selecting and formulation of a research problem
Selecting a topic for research
Formulating the research problem
Formulating objectives
Formulating hypothesis
Defining concepts
Establishing working definitions
Review of relating material
Methodology
Study design
Sampling
Methods of data collection
Tools of data collection
Training to investigators
Actual data collection
Analysis and interpretation of data
Research report

Health system research
The systematic investigation and evaluation of the functioning development of health services and their interrelationship with health related factors.
Health system research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to healthcare, the quality and cost of healthcare, and ultimately our health and well-being.
Health System Research: Focus Area
Poverty and Health
Utilization of Health Services
Research Based On Caste, Ethnicity and Gender
Topography and Its Effects on Health
Equity Issues
Cultural Differences and Health Effects
Resource Allocation
Public Vs Private Health Services
Quality of Care
Ethical Aspects of Care
Alternative Health Care
Maternal Health
Child and Neonatal Health
HIV and AIDS
Right Based Issues-Women, Children and Indigenous People
Perceptions on risk factors related to Non-Communicable Disease

EPIDEMIOLOGY AS A TOOL FOR PLANNING
The systematic use of epidemiological methods and principles is for the planning and evaluation of health services. Epidemiological methods are widely applied in health services and even the health professionals who do not themselves carry out surveys often find that health and clinical practices are influenced by epidemiological observations. Planning of health services is necessary for setting priorities and allocating scare health care resources. Health service planning is a process of identifying key objectives and choosing among alternative means of achieving them.
Epidemiology is involved in all stages of planning of health service. The health care planning process includes:
Measurement or assessment of the burden of illness
Identification of the cause of illness
Measurement of the effectiveness of different community interventions
Assessment of their efficiency in terms of resources used
Implementation of interventions
Monitoring of activities
Reassessment of the burden of illness to determine whether it has been altered.

Burden of illness
Measurement of overall health status of the community is the first step in planning process. The measurements include prevalence rates, incidence rates, different measures of mortality and the number of cases of different diseases. Rapid epidemiological assessment is a defined field of epidemiological methods for planning of burden of illness in community.
Causation
Once the burden of illness in the community has been measured, it is necessary to try to identify the major preventable causes if disease so that intervention strategies can be developed.
Measuring effectiveness of different interventions
The effectiveness of interventions in the community is determined by the following factors:
Efficacy of interventions i.e how well an intervention works under ideal conditions.
The ability to screen for and diagnose the disease accurately; both the health care provider and the consumer must be compliant with the necessary actions.
The appropriate use of intervention by all who could benefit; this means that the intervention has to be acceptable to the community.
Efficiency
Efficiency is a measure of the relationship between the results achieved and the effort expended in terms of money, resources and time. It provides the basis for the optimal use of resources and involves the complex interrelationship of costs and effectiveness of an intervention. There are two main approaches to the assessment of efficiency.
Cost effectiveness analysis
Cost benefit analysis



Implementation
The fifth stage in the planning process begins with decisions on specific interventions and takes into account the problems likely to be faced in and by the community.

Monitoring
Monitoring is the continuous follow-up of activities to ensure that they are proceeding according to plan. Monitoring must be directed to requirements of specific programmes, the success of which may be measured in a variety of ways using short, intermediate and long term criteria.
Reassessment of the burden of illness
Reassessment is the final step in the health care planning process. It requires a repeat measurement of the burden of illness in the population.

Control programs
In Nepal Division (EDCD)/ Department of Health Services (DHS) works with prevention and control of vector borne diseases such as Malaria, Kala-azar, Japanese Encephalitis JE) and lymphatic filariasis, food and water borne diseases like; Diarrhoeal Disease, Typhoid, Cholera, zoonoses like; Post exposure treatment of rabies and poisonous snakebites, communicable diseases outbreaks management and EWARS (Early Warning Reporting System) surveillance of selected diseases from sentinel sites.
Vector Borne Disease Control

Malaria
The first attempt to control malaria in Nepal was initiated in 1954 hrough the Insect Borne Disease Control Programme. Currently malaria control services are being provided free of cost to approximately 17.3 million people of 65 districts at risk of malaria.
Kala-azar
Kala-azar is a major problem in the eastern and central terai and is still confined to 12 districts. More than 5.5 million people are believed to be a risk of disease.
Japanese Encephalitis (JE)
Twenty four districts of Terai and inner Terai are affected by Japanese Encephalitis putting 12.5 million people at risk of the disease.
The major control actions of all the above programmes
· BCC, surveillance, epidemic preparedness and response
· Supply of essential medicines, vaccines and other commodities
· Zoonoses control, early diagnosis and prompt treatment
· Transmission risk reduction
· Epidemiological capacity empowerment
· Mapping of risk population and areas
· Strengthening diagnostic facility
· Monitoring and implementation of the cross boarder collaborative actives.
Communicable disease control

Tuberculosis Control
Tuberculosis contributes 7 % burden of disease. The NTP continues to make progress with DOTS expanded to 462 treatment centres and 2,428 sub centres.
Main strategies include
· Continue expansion of DOTS, so as to make available to all patients in NTP and to community level
· Continue expansion in diagnostic and treatment sites (public and private) ti improve access and coverage and maintain quality.
· Establish treatment centre and sub centre in HP and SHP and /or partnership at a community level.
· Implement collaborative action with HIV/AIDS programme with TB/HIV co-infection.
· Conduct studies to deal emerging issues such as drug resistance
· Focus TB control activities in rural areas and urban poor communities.

Leprosy control
Nepal is one of the 9 countries in the world that has not yet been able to eliminate leprosy despite all efforts. Leprosy contributes 1 % of the total burden of diseases.
Main strategies include
Provision of leprosy elimination services to the people nearest to their door step (up to SHP) through PHC system and by transferring the retained patients from referral centres to the health centres/district clinics.
Provision of MDT to all registered cases for treatment in the country
Prevention of disability by early case detection and treatment and
Reduction of social stigma by increasing awareness about the disease through appropriate HE.

HIV/AIDS/STDs
HIV/AIDS and sexually transmitted diseases (STDs) are emerging as major threats to Nepal’s socio-economic and health sectors. Nepal has responded to the threat by developing a national strategy for HIV/AIDS prevention and has identified priority areas that need addressing.
Major strategies include (National HIV/AIDS Strategy, 2003)
Prevention of STIs and HIV infection among vulnerable groups
Prevention of new infections among young people
Ensuring care and support for person infected and affected by HIV/AIDS
Expansion of monitoring and evaluation
Establishment of an effective and efficient management system.

CDD/ARI
Diarrhoeal diseases are still a major problem for Nepalese children even though its ranking as the most prevalent diseases in outpatient services has slipped from third to second place.
The ARI control Programme covers 75 districts, ten of which have a special strengthening programme of Community based ARI/CDD.
Main strategies include
Steady expansion of the CB-IMCI model to additional districts to achieve national coverage with five years.
Maintenance of high coverage in currently covered districts
Refinement and institutionalisation of the model and studies of potential gaps in coverage.
HEALTH SERVICES
Services that are performed by health care professionals, or by others under their direction, for the purpose of promoting, maintaining, or restoring health. In addition to personal health care, health services include measures for health protection, health promotion, and disease prevention.
It comprises of courses and/or programs related to planning, managing, and providing diagnostic, therapeutic, and information and environmental services in health care.
The purpose of health cares services is to improve health status of the population. In the light of Health for all by 2000 AD, the goals to be achieved have been fixed in terms of mortality and morbidity reduction, increase in expectation of life, decrease in population growth rate, improvement in nutritional status, provision of basic sanitation, health manpower requirements and resources development and certain other parameters such as food production, literacy rate, reduced levels of poverty e.t.c.
There is now broad agreement that health services should be comprehensive, accessible, acceptable, provide scope for community participation and available at a cost the community and country can afford.

HEALTH CARE SYSTEM
It is the organization by which health care is provided. It includes everyone who needs health care and everyone who delivers health care.
Types of Health Care Systems
· Allopathic system or modern medicine
· Oriental or traditional medicine e.g Ayurveda
· Homeopathy
· Sino-Tibetan system-Acupuncture and Amchi
· Others-Naturopathy
Health care by advance level of services
· Primary medial care system includes district hospitals up to 25 beds
· Secondary medical care-regional and general hospital
· Tertiary medical care
Health care system at district level
· Hospital
· Primary health care center
· Health post
· Sub health post
· Outreach clinics
· Community health volunteers and mothers group
Characteristics of public sector health services
· Nepal’s health care system is primary health care based
· Primary health care is delivered on the basis of the essential health care packages
· Most of the essential health care services are free
· Health service delivery is by non-physician.

ESSENTIAL HEALTH CARE SERVICES
Essential health care services in Nepal are priority public health measures and essential curative services that will be available to the total population. Currently there are 20 elements and out of them 11 are prioritized elements, related to improvement in maternal health and child health and control of communicable diseases.
Essential Health Care Services for Modern System of Medicine
1. Appropriate Treatment of Common Diseases and Injuries
2. RH Services
3. EPI + Hepatitis B Vaccination
4. Condom Promotion and Distribution
5. Leprosy Control
6. Tuberculosis Control
7. Integrated Management of Childhood Illness (IMCI)
8. Nutritional Supplementation, Enrichment, Nutritional Education and Rehabilitation
9. Prevention and Control of Blindness
10. Environment Sanitation
11. School Health Services
12. Vector Borne Disease Control
13. Oral Health
14. Prevention of Deafness
15. Substance Abuse among Tobacco, Alcohol Control
16. Mental Health Services
17. Accident Prevention And Rehabilitation
18. Community Base Rehabilitation
19. Occupational Health
20. Emergency Preparedness and Management