Year 5: Public Health Pg 1

HEALTH INEQUALITIES

DEFINITIONS AND BASIC CONCEPTS

Output number X one can do per year

Outcome only Y (out of X) gain significant health benefits
Equality sameness; but not everyone is the same (e.g. genetics, environmental)
Equity fairness = allocating resources to achieve highest level of health for ALL regardless
of background.
1. Vertical equity: different health care for different needs
E.g. prioritising surgery to pt who cannot manage pain vs one can control it
2. Horizontal equity: equal health care for equal needs
Access aims e.g. everyone can see a GP, regardless of need then sorted
out and put onto different pathways (= go into vertical equity); screening;
vaccinations
All these deal with population
Efficiency allocating limited resources to meet healthcare need to maximise health
outcomes.
1. Balances demand, supply, and needs
2. Needs can be classified as:
Felt (Feel a Sx)
Expressed (Tell doctor of Sx)
Normative (Doctor agree that you need Tx for Sx)
Comparative (Deals with efficiency; doctors compare it with others w similar
Sx can the patient Sx be managed without, say, surgery?)
Health inequality an umbrella term that encompasses equality and equity; refers to any
unfair and unavoidable variations in health e.g. based on socioeconomic status, gender etc.

INVERSE CARE LAW

Availability of good medical care tends to vary inversely with need for it in population
served.
1. E.g. NHS funding formula based on parameters of population; but data lags
behind; USA insurance limits access; Australia requires doctors to work in rural areas
now to address this; LDCs.
Many populations, particularly those in high socio-economic deprivation:
1. Poor quality services
2. Poor access to services too far, too expensive to get there, opening times, cant
speak language
3. Multiple external disadvantage in poor socioeconomic areas, smokers + mental
health problems less likely to seek help.

SOCIAL DETERMINANTS OF HEALTH

The circumstances in which people are born, grow up, live, work, and age in. These are
shaped by other wider forces economics, social policies, and politics.
Dahlgren and Whitehead model (focus on 7 factors)
 Year 5: Public Health Pg 2

GLOBAL INEQUALITIES

Life expectancy lower; maternal mortality higher; and below-5 mortality lower in LDCs
Health and social problems are not correlated to average income of countries however!
BUT correlated and is far worse in more UNEQUAL countries (huge disparity between poor
and rich) e.g. USA ranks worst in terms of life expectancy; infant mortality; mental illnesses;
obesity; etc. index of health + social problems.

HEALTH INEQUALITIES IN ENGLAND

Gap in life expectancy between MEN in most and least deprived group = 9.2 years
Gap in HEALTHY life expectancy between men in most and least deprived group = 19 YEARS!
Gap in life expectancy between WOMEN in most and least deprived group = 7 years
Gap in HEALTHY life expectancy between women in most & least deprived = 20.2 years!
While overall life expectancy increased over 10 years the gap do not

ETHNICITY AND HEALTH

CVD = highest in SEA origin

Infant mortality = higher in women of Pakistani and Black Caribbean origin
Mental health = people from BME (black and minority ethnic) group more likely to be Dx w
mental illness; highest % reported poor mental health in women of Pakistani and Black
Caribbean origin (but smaller differences in Dx rate).
 Year 5: Public Health Pg 3

GENDER AND HEALTH

Females higher life expectancy, higher reported mental health, higher rates disability
Males higher mortality, more suicide & violent death.
Men die quicker, women get sicker

INEQUALITIES: EXPLANATION FROM THE BLACK REPORT

Black report published by Department of Health (1980) and has 4 theories

1. Artefact
Due to the way stats was collected e.g. measurement of class
Comparing apples to oranges
Concerns about quality of data and method of measurement
Numerator = based on occupational distribution of those who die
during period considered.
Denominator = occupational distribution at most recent e.g. census
which is updated every 10 years vs. GP records = annual update
Mostly discredited as an explanation
In fact, underestimates inequalities rather than explaining it.
2. Social-selection
Direction of causation is from health to social position
Vicious circle: sick and cant afford cant complete college cant get job
lower status sick and cant afford

Sick individuals move down social hierarchy, so more likely disadvantaged

Chronically ill and disabled people are more likely to be disadvantaged
Plausible explanation but studies suggest that, at most, it is a minor
contribution to socio-economic differentials in health & mortality.
3. Behavioural-cultural
Ill health is due to peoples choices or decisions, knowledge, and goals
People from disadvantaged BG tend to engage in more health-damaging
behaviours
Limitations
Behaviours are outcome of social processes, not simply individual
choices
Choices may be difficult to exercise in adverse conditions
Choices may be rational for those whose lives are constrained by
lack of resources (coping behaviour).
Largely discredited
4. Materialist
Arise from differential access to material resources.
Low income, unemployment, work environment, low control over
job, poor housing conditions it is a summation of all these
Lack of choice in exposure to hazards and adverse conditions
 Year 5: Public Health Pg 4

Accumulation of factors across lifetime

Most plausible explanation
Limitation = further research needed as to precise routes through which
material deprivation causes ill health.

Other reports of note

1. Acheson report
Commissioned by Labour
39 recommendations only 3 related directly to healthcare.
Implies other social determinants of health and equalising them are more
important
2. Fair society: Healthy lives (Marmot)
Gives every child the best early start; including maternal health + parents
working + in good community + can exercise + fresh air + safety
Implies more to health than healthcare (equalising social determinants of
health more important).
Marmot social inequality, NOT lifestyle, causes early deaths.
Social gradient lower you are in hierarchy, the worse off
So allow child to do better at school graduate etc. breaking
the cycle and leading to fewer overall deaths.

ASSESSING AND RESPONDING TO HEALTH NEEDS

Assessing
1. Health Needs Assessment; Joint Strategic Need Assessment; Health Impact
Assessment; Health Equity Audit
2. How do we know and what do we do?
Define the problem AND magnitude
Identify current services provided & most cost-effective solutions & resource
implications
Make recommendations & plans for implementation. Also identify outcomes
to evaluate.
3. Sources of information (table) quantitative; qualitative; ad-hoc; routine
4. Most evidence about access is about utilisation (receipt of service) and can be
difficult to interpret
 Year 5: Public Health Pg 5

Evaluating
1. Standardised prevalence ratios
2. Standardisation helps compare 2 populations that might differe wrt certain
underlying characteristics e.g. age.
3. Example (prison):

Interpretation: substance misuse = 43 X more likely in prison than in general population etc.

What to work on: prioritise substance misuse (as it leads to other problems + high standardised
prevalence ratio); depression & bipolar disorder (need to overcome for re-enablement).

Hep B (ID spread = individual + other inmates / public health once released) however cannot force
people to be treated e.g. vaccination, HIV PPx. Because not justified that it puts the greater public at
risk (since in prison) vs. notify PHE and use a part 2A order to force people in public with TB and
refuse treatment
 Year 5: Public Health Pg 6

DM+CAD should have more impact but budget in prison for food is only 12 quid a week = means
lots of chips and bad food missed opportunity to target.

Statutory basis for reducing health inequalities

1. NHS Constitution and mandate
2. Equality Act 2010
3. NHS Act 2006 amended by Health and Social Care Act 2012.
4. Guidance for NHS commissioners on equality and health inequalities legal duties,
NHS England 2015.
5. Example: fill in ethnic minority form info feed into NHS noted treatment.

Interventions

Components of unmet need

 Year 5: Public Health Pg 7

Actions to reduce premature mortality

1. 15-20% life expectancy gap can be directly influenced by healthcare interventions
2. A number of evidence-based high impact interventions shown to work in tackling
health inequalities and reducing gap in life expectancy; these include:
Prevention! ALWAYS BETTER THAN CURE.
Early Dx (e.g. screening)
Better disease management
Improving access
Improving acute services
Preventing recurrence.
 Year 5: Public Health Pg 8

OCCUPATIONAL HEALTH

INTRODUCTION

Promotion and maintenance of highest degree of physical, mental, and social well-being of
workers in all occupations by preventing departures from health, controlling risks, and
adaptation of work to people, and people to their jobs.
Quantifying effect
1. Self-reported national surveys Labour Force Survey
2. Large scale epidemiology studies (Scandinavia)
3. Specialist reporting system THOR
Doctors VOLUNTARY reporting
4. Legal requirement Health and Safety Executive (HSE) RIDDOR (Reporting of
Injuries, Diseases, and Dangerous Occurrences Regulations)
LEGAL requirement to report.
HSE = national independent watchdog for work-related health, safety, and
illness. Aim = reduce work-related death and serious injury in GB
workplaces. Via early identification e.g. helpline, online guidelines.
UK employer provided services for OH (not state-provided) e.g. NHS provides OH for HCP
small services dont have = exposure to hazards.
Why detect?
1. Cost to society of occupational ill-health & worklessness
Types of work-related ill health
1. Common health conditions in DCs (caused or made worse by work).
Stress
Not an illness, but perception = can cause depression, anxiety.
Key to Tx is support
Ask why take time off? NOT JUST BIOLOGICAL!!
Need to improve resilience = biopsychosocial e.g. address
depression, culture, carer, family) & encourage
communicate with employer (legislation employers have
to control work place stress and take it seriously)
Musculoskeletal
Let employer know = have to manage this!
Defined pathology e.g. carpal tunnel, tendonitis due to awkward
posture + forceful repetitive actions (drilling/hammer/fish
gutting/plucking feathers)
Unknown pathology cant determine why SNS+ and wasting
(writers cramp) need specialist referral.
Skin & respiratory (discuss in-depth below)
2. Long-latency conditions usually in industrial countries (caused by previous work
activity, with Sx only appearing many years after exposure.
Asbestos usually occurs 20 + years after exposure
Hearing loss
Respiratory fibrosis or COPD
Vibrational loss e.g. polishing or drilling = vascular changes in fingers =
cannot feel vibration.
Cancers dyes and bladder cancer
 Year 5: Public Health Pg 9

OCCUPATIONAL HEALTH HISTORY

What is the problem? Sx, timing, RS of exposure Sx etc. How long did you do the job
for?
What work do you do?
What do you DO in your job? (What were you using? Are you exposed = amounts/type e.g.
mist or fumes? Are there controls?)
Do you have OTHER jobs, or hobbies?
Is anyone else affected?
What other jobs have you done (long latency illness)?

CLINICIAN ROLE IN OH

Consideration of fitness for work

Specific fitness standards (DVLA) do not sign a fit note if drive heavy goods vehicles, or
other transportation e.g. planes, automobiles, trains
o E.g. loss of vision, MI, LOC/syncope
Rehabilitation PT (how can you access, explain active role in exercise)
Adjustments = encourage talking to employer; writing of fit note to employer e.g. can do X
but not Y.
Ill-health retirement if really not fit but have knock-on effect.
o Financial!
o Individual
o Society
o Health effect Waddell = the right work is good for you.
Independent of whatever current health is, those in work are in better
health than those out of work e.g. the latter have more A&E visits, on
more prescribed drugs.
The longer someone is off work, the less likely they are to get back
therefore have to REVIEW every few months (legislation).
80% are better sticking with the same job, 20% better leaving and finding a
new job.
Fit note (key elements written on the back of the fit note)

Adjustments (for employer to consider)

1. Phased return to work
2. Amended duties
3. Altered hours
4. Work place adaptations
o STRICTLY TIME-LIMITED do not write too long, actually people fit to return to work
very quickly.
o Guided by evidence be aware that absence from work, whether justified or not,
lead to negative outcomes (e.g. loss of job skills, social contact, financial stability,
greater risk of not returning to work = Waddells study)
o Even with a Statement of Fitness for Work patient can be dismissed still!
o Any attribution of Sx exclusively to workplace stressors SHOULD BE AVOID unless
very clearly there is evidence to support this
 Year 5: Public Health Pg 10

If you attribute to the employer (and support patients ideas) then it may set
up barriers for patient to go back to work (there is not enough time for
employer to adjust/implement) encourage pt to talk to employer instead!
o Employers now need 3 month proceeding (warning) + HR meeting before dismissal.
Applies to CA + chemotherapy = good prognosis but last a year can still get fired!

Mr X suffered MI 4 weeks ago. He runs a small electronics factory and wants to return to work. He
has requested your advice on this.
1. What do you do at work ladder, drive forklift, mostly desk
2. Amended duties ok stick to desk, dont drive forklift or climb ladder (because cardiac
problems + BP Tx = dizzy)
3. Sick note stick to the desk job (guidelines + common sense)
4. Since he is self-employed, there is no need to report to higher-ups (sick note is for himself
to himself)
5. Review in next month.

OCCUPATIONAL CANCER CAUSES

Asbestos > silica (building, stone-masons) > diesel engine exhaust > mineral oils
(engineering) > shift work (debatable in Denmark, compensated but dont know if
associated) > painters > others
1. Carbon nanoparticles inhaled in lung of rats develop peritoneum with lesions
similar to mesothelioma. So monitor intensely now!
Codes of practice employer is at fault if didnt minimise risk.
Underreported/underestimated, as hard to recognise occupational links

OCCUPATIONAL RESPIRATORY DISEASE

15% men, 5% women = resp tract CA. 17% adult-onset asthma. 10% ILD. 15-20% COPD.
Under-reported (may not connect Sx to previous job; left long ago; cover-up)
1. Long latency silicosis (stonework); lung cancer (welding).
Employer legal duties
1. Health and Safety at Work Act
2. Control of Substances Hazardous to Health (COSHH) if you are an employer, you
need to consider what hazard you are exposing to your employee
Risk assess
Identify hazards and control risk as far as possible
Hierarchy of control:
Eliminate > substitute > enclose > ventilate > PPE (since
user-dependent = dont comply).

Hazard Risk
Biological, chemical, psych, physical Amount, state, controls in place
Example: blood borne virus Small amount; liquid; PPE + sharp box + training
+ immunisation
Train
Record and notify
Health surveillance (see next pg)
3. Lead, radiation etc.
 Year 5: Public Health Pg 11

Occupational asthma
1. Occupational asthmagens certain QUANTITY sensitisation in genetically
predisposed (technically atopy does increase; but it is the quantity exposed that is
the most important factor!)
2. 1 in 6 (17%) people with NEW onset asthma or marked sudden worsening of
asthma have an OCCUPATIONAL cause (including hobbies).
3. DUSTS (solid particles): woodwork dust (machining or sanding or capentry), flour
(and enzyme additives e.g. amylase), grains, animal proteins (zoos, vets) e.g. urine
aeroallergens, saliva fur, scales; plant proteins (agriculture!) e.g. natural rubber
latex, dander, soil, fungal spores!
Powdered latex glove no longer in use in NHS
4. FUMES (metal gas): colophony (pine rosin solder fluxes in electronics industries),
aldehydes, persulphate (bleach)
5. MISTS (liquid): mineral oils, isocyantes (vehicle spray paints = 2-pack pain), MWFs
(metal working fluids)
Biocidal cleaning fluids used for cleaning endoscopes = glutaraldehyde, no
longer used in NHS
6. Controls? Extractor fans, ventilation fans in woodworking

A 40 year old man with surgery + recent onset of cough and wheeze (w reduced peak flow)
presents as your surgery. He had asthma as a child. What factors make you suspect a case of
occupational asthma, and what will you do?
Occupational Hx
1. At-risk occupation?
2. Recent change (particularly in last 6-12 wks = initial sensitisation = need sufficient
exposure) rhinitis or conjunctivitis
Nasal + eye Sx implies reacting to exogenous cause e.g. some organic causes
= animal, insect, pollem. IgE.
3. Anyone else at work have the same problem?
4. Gets better away from work (single most important question).
Get better on holiday? not as good of a question (because may be getting
away from PET at HOME).
Investigations
1. Serial PEFR using OASYS programme to chart
Not everyone do it properly need to train the person
Do it for 4 weeks when at home and work.
GRAPH: fluctuating (variability of >20% = Dx) peak flow that is better at
home and worse at work. Usually there is progressive reduction in peak flow
throughout the week = Monday to Friday. Then it improves from Sat to Sun,
before the cycle continues.
2. Raised specific IgE levels (RAST) only some organic causes, NOT applicable for
non-animal causes
However, it is very sensitive and specific = can rule out organic causes!
3. Challenge testing is the GOLD STANDARD put in hood + inhale different stuff to
see reaction.
Perform peak flow to demonstrate before requesting!
4. Get specialist help e.g. national heart and lung institute (RBH)
 Year 5: Public Health Pg 12

Management
1. Reduce exposure
Inform employer! Employer NEEDS to report to relevant agency e.g. HSE.
Encourage patient to communicate w employer
Reduce through COSHH hierarchy i.e. risk assess then control = eliminate,
substitute, enclose, ventilate >> PPE etc.
This also protects other employees = now legal requirement for
HEALTH SURVEILLANCE = have to monitor employees when you
think your industry have chance to cause OH damage.
But many still lose their job if cannot adjust
R/O asthma
Consider industrial injury compensation if catastrophic (possibility for
allergic asthma and rhinitis!)
Interstitial lung disease extrinsic allergic alveolitis
1. Hypersensitivity pneumonitis, caused by extrinsic cause (bacteria, fungi = moulds,
plants, animals chemicals) that causes inflammation of the alveoli by an allergic type
reaction (type I HS)
2. Farmers aspergillus spores in mouldy hay
3. Common causes:
Farmers lung (grain, straw, mouldy hay)
Bird Fanciers lung (excreta and bloom on feathers, up to 20% keeping bird)
Mushroom workers lung (compost)
Bagassosis (suar cane fibrous residue)
Malt workers lung (mouldy barley)
Ventilation pneumonitis (air-cons!)
4. Present: acute= fever, chills, SOB, cough, myalgia, headache, after 4-8 h of
exposure, and resolve within few days. Chronic = increasing SOB over months/years,
chronic productive cough, weight loss, and malaise.
5. Dx early stages may be attributed/confused w infection.
6. O/E: ?fine inspiratory crackles, tachypnoea.
7. Ix: raised ESR, neutrophilia, PFTs = reduced FEV1 + FVC; CXR (poor SN) = diffused
infilitrates. High res CT scan = multiple changes. IgE to specific allergen.
8. Management avoid = usually resolve. But may be start of progressive fibrosis!!
Steroids. May be eligible for compensation. Must report to HSE.
Pneumoconiosis = ILD from significant respirable mineral dust exposure
1. E.g. coal workers, asbestosis, silicosis (quartz), beryllium, stannosis (tin ore),
siderosis (iron oxide), Bauxite workers lung (aluminium)
CWP coal-laden macrophages, present > 10 years after exposure
Can present LIKE COPD or with coal-related COPD.
BUT reduce lung volume = usually restrictive!!
Supportive Tx. Stop smoking.
Silicosis slateworking, foundary, stonemasonry etc.
Asbestoses need HEAVY exposures. Chronic interstitial fibrosis.
SOB, cough, clubbing.
Nodular basal CXR changes. Gold standard = lung Bx = asbestos
bodies. 40% progress despite removal of exposure.
Increased cancer risk. Compensable.
 Year 5: Public Health Pg 13

OCCUPATIONAL DERMATOLOGICAL DISEASE

Summary is given in separate table.

5% = weird conditions e.g. pustular lesions when exposed to plastics, cancer
95% = contact dermatitis
1. 5% = burns (caustic, H+, OH-)
2. 70-80% = irritant contact dermatitis
E.g. wet work (water); solvent; detergent; soaps; cements; oils; fibreglass.
Is a clinical diagnosis (Hx).
Usually in those with reduced barrier function (waterproofing) e.g. eczema
Management is reduce exposure or substitution e.g. EtOH gel or non-
foaming soap instead of foaming soap. Studies shown they are JUST AS
EFFECTIVE. Add emollients as well. Modify/adjust e.g. prongs or rubber
gloves for cleaners.
3. 15-25% = allergic contact dermatitis (ACD)
10% = type I IgE mediated immediate ACD (within 20 mins urticaria,
pruritus, anaphylaxis (already know they are allergic).
MAY NOT need lots of exposure (1-2 enough to sensitise)
E.g. bee/wasp stings, latex.
Dx = SPT (skin prick test).
Tx = avoid; or desensitisation (to certain ones e.g. bee stings); anti-
histamines + steroids.
25% = type IV T-cell mediated delayed ACD (occurs after ~2d).
Usually requires LOTS OF EXPOSURE (cumulative exposure): so
usually industrial occupation.
E.g. PPD dyes (Henna tattoos, hair dyes); gold + nickel in earrings,
rings, jean studs, watch strap (even if alloy); rubber accelerants (a
lot in nitrile gloves!!); poison ivy (urushiol); neomycin; colophony
(sawdust, sap from spruce or fir tree); chromium;
Related to HAPTEN formation (small molecule)
Dx = patch test (M W F).
Tx = avoid exposure for life.
MSDS = material safety data sheets universal sheets that contains pertinent information
of any chemical, including known to cause
Global harmonised system = exclamation mark in a diamond indicate skin irritation/sens
Highest incidence of drop out in wet work = hairdresser >> nurse > caterer > cleaners.
1. Hairdressing: irritants = wet work, shampoo; sensitizer = legion. PPD, persulphate
dyes, fragrance, perms thioglycolates, nickel, gloves, cosmetic + nails (epoxy resin)
Chronic exposure and no Tx = chronic changes in the skin that is no longer treatable (e.g.
chromate dermatitis: peeling, depigmented, erythematous best his hands can ever get)
LATEX allergy: IgE (type I HS). Can cause anaphylaxis, urticaria, or/and asthma. RAST
sensitivity 80 -90% and specific. SPT better SN/SP but more hazardous. So use RAST. Need to
be specified in medical notes (medic alert) because surgeons may use latex gloves.
Management in general: manage BOTH sensitisers AND irritants as far as possible, with
avoidance of irritants + use emollients + gloves (but can lose grip e.g. roofer, surgeon; need
adequate supply; snagging e.g. hairdresser + metal worker = lose finger; increased dermatitis
from occlusive effect e.g. sweat more; certain chemicals dissolve certain glove). Patch test if
(1) suspicious pattern; (2) severe; or (3) doesnt settle.
 Year 5: Public Health Pg 14

QUIZ

Scrotal lesion SCC. Old days chimney sweeps exposed when young, die of cancer
in 20s. First observed by Percival Pott. Carcinogen = polyaromatic
hydrocarbons. Nowadays, an oily rag left in overalls can seep in and
contact scrotum
Scalp lesion Solar lentigines (keratosis) + some BCC. Related to sun exposure
reducing sun exposure (e.g. shade) is the most important measure; hat
+ sun screen as well.
Giant hogweed The sticky sap contains a psoralen like substance = sensitise one to UVA
(Heracleum = burn (phtotoxicity). Can lead to corneal scarring if eyes contacted.
mantegazzianum) Common in forestry, gardening occupations (brushed the weed
blister = phytophotodermatitis).
Sensitizer in hair dyes PPD dye; perms.
Other (non-sensitiser) water + soap wash = irritant contact
dermatitis. Persulphate bleach asthma.
Wore latex glove after 2 The cause is rubber accelerant in the latex glove (NOT latex) due to the
days develop time frame = delayed allergic contact dermatitis (latex will cause
dermatitis IMMEDIATE allergic reaction). Testing = PATCH.
What has been done to Reduce its use (nitrile gloves instead); no powder.
latex glove to reduce its
allergic response?
Paronychia Bottle washer cellulitis (nail bed infection). Other people who get
this? DM.
Secretary with wrist Patch test found she is allergic to PPD dye. The rubber on her wrist
lesion strap is dyed black using a PPD dye. Where else to look for rubber
accelerant? Waist, bra strap, top of sock, soles (sneakers).
Onion, seafood & chef His non-dominant hand holds the food (sensitister) and so affected by
hands which hand is immediate allergic contact dermatitis (his dominant hand holds the
affected? rubber or nickel in stainless steel of the pots or utensils if his
dominant hand is affected, then it is a DELAYED allergic contact
dermatitis instead).
Nitrile glove, banana, The odd one out is the nitrile glove. The foodstuff contains a latex-like
kiwi, avocado, latex protein in them IgE oral allergy.
gloves odd one out?
Lymes disease Rash = erythema chronicum marginatum (bull eyes rash). Due to Ixodes
ticks found in sheep, deers, but also almost all mammals e.g. pet dogs
and cats. Climate change has caused increased incidence of Lymes in
the UK. If untreated, can develop cardiac + neurological + bilateral CN
VII palsy (mononeuritis; DDx = sarcoid also cause this). Tx =
doxycycline. Usually the tick that cause the disease is small and fell off
(the fat ones that remains usually dont cause the disease).
Uni researcher with Vaccinia vector. Usually inactivated vector no disease, but the
non-infectious small pox researcher has underlying skin problem e.g. eczema (or piercings).
Surfer boards, araldite Any wet plastics e.g. epoxy resins, acrylate glue= mix together and
glue, denture glues, nail solidify can cause allergic dermatitis. Inhalation asthma. Warning
resin labels = global harmonised system.
Mineral oil worker: 3 The person is machining. Solvent, fumes, metal working fluids = mist
sources of irritants? and vapour form. Can cause occupational asthma.
 Year 5: Public Health Pg 15

POPULATION SCREENING

INTRODUCTION

The process of identifying apparently healthy patients who may be increased risk of disease.
Screening is only the first step. Further tests needed for definitive Dx.
Prevention levels
1. Primary (prevents health disease) e.g. education, public health effort like
chlorination, mental health awareness, improve diet + exercise, tobacco public ban.
2. Secondary (prevents disease illness) screening works here.
Disease already there, prevents it from impacting life
3. Tertiary (prevents illness disability)
Already had an impact, prevents further complications (impact).
Types
1. Prior to entering organisation
2. Workforce protection (exposure & disease)
3. Life insurance
4. Early ID of dz
Case finding (opportunitisic)
Selective (based on risk factor)
Population screening
5. NHS check =/= screening not evidence-based on risk factors; no call-recall
system; no set group of people (just age cohort) = hard to determine cost-
effectiveness + not robust.
Effect on doctor-patient R/S
1. Alters it. Changes the nature of risk-benefit R/S.
2. Patients who are ill = more willing to take risks to get better
3. Population who mainly arent ill = no Sx = less willing to take health risks

THE SCREENING PROCESS

NHS screening timeline

Antenatal + newborn 6 programmes from conception newborn.

screen 1. T21, T18, T13 and foetal anomaly USS
2. Sickle cell thalassemia
3. Newborn blood spot
4. ID in pregnancy
5. Newborn and infant physical exam
6. Newborn hearing
7. (Diabetic eye)
Diabetic eye screen From age 12; offered annually to DM.
Cervical screen From aged 25-49; every 3 years.
From 50-64; every 5 years
Breast CA screen From 50-70; every 3 years.
> 70; can self-refer
Bowel CA screen Offered to both genders aged 60-74; every 2 years.
Aged 75+ can request by ringing up.
AAA screen Offered to all men in their 65th year. Above that, can self-refer.
 Year 5: Public Health Pg 16

Screening is a sieve.
1. Eligible cohort (reliant on GP coding the right people)
Decided to take up (others decline)
People caught in the net = offer further Ix (but also FP, FN)
o True disease (aims to rule out FP, but FN missed)

SCREENING: RISK REDUCTION

But is not fool proof it can REDUCE RISK of develop condition or its Cx but not guarantee
protection. In any screening programme there will be FP + FN. Hence, screening process is a
form of risk reduction.
Exception: foetal anomaly screen (no way to risk reduce). But other antenatal care still
screen & risk reduce.
1. Foetal anomaly screen purpose = provides info about structural problems to
enable mum + partner to make choices about pregnancy & future Tx plans.

SCREENING CRITERIA

Wilson and Junger (1968) disease, test, Tx, programme, effectiveness, cost
1. Condition should be important problem
Significant mortality + morbidity
2. Natural history should be well understood
Progression must have identifiable phase (see also 3, 4).
3. Should be recognisable early stage
4. Treatment at early stage more benefit than at later stage
I.e. can risk reduce or prevent. (Non-invasive, accessible see 7, cheap)
5. There should be a suitable test
Accurate, non-invasive
6. Test should be acceptable to population
7. There should be adequate facilities for Dx and Tx of disease detected
8. For diseases w insidious onset, screening should be reported at intervals to
determine natural Hx
9. Chance of physical or psychological harm should be less than chance of benefit
Clinical effectiveness and NNT.
10. Cost of screening programme should be balanced against benefit it provides
Cost-effectiveness on a population cohort e.g. reduce prevalence of dz e.g.
antenatal screen.
 Year 5: Public Health Pg 17

E.g. prostate BAD screening PSA FN+FP; Tx-invasive; most people can LIVE with prostate
CA and die with it.
E.g. cost-benefit of bowel screening pick out at Dukes A cheaper than Sx non-screened
referral.
1. Screen bigger population or eligible cohort should years down the line, reduce
the demand of Sx referral
2. But length of time of effect takes too long so cannot appreciate = hospital dont
like to give up resources e.g. colonoscopy for screening (vs Tx).
3. Cost of screening programme (per head of population = 1.4 quid vs. per eligible
patient = 29.50) therefore screen population.
4. Cost of adding 1 year of life (per quality adjusted life year = QALY gained) < 3000
(threshold QALY is 30,000) therefore worthwhile investment.
5. Prison population cant be screen (foil wrap in the kit dangerous in prison)

PRACTICAL ISSUES OF IMPLEMENTATION

E.g. cervical cancer peak in younger women

Yet uptake rate of younger women lowest
Cervical smear uptake rates in Oxford low (< than national average)
1. Uni town = mobile population (but other Uni town dont have such problems)
2. Accessibility
3. Ethnic population
4. Deprivation
Data shows that Oxford city centre CCG uptake rate the lowest (c.f. elsewhere in
Oxfordshire) so target this.
E.g. AAA screening and Index of Multiple Deprivation (IMD)
1. Those who take up the screen more, are those who are in more affluent areas
E.g. breast cancer screening in different ethnic groups
1. CAUTION: uses Mosaic Origins software = use surnames to determine ethnicity

VALIDITY

Importance of PPV/NPV
1. PPV = what is the chance my patient wo tested
+ve, actually has disease
2. NPV = chance that my patient who tasted ve,
actually DO NOT have disease.

Implications of FP
1. Offered (invasive) test w all anxieties + risks,
when they dont have conditions
2. Turned into patients when they are not ill.
3. If prevalence low, PPV low, lots of FP.

Implications of FN
1. Will NOT be offered Ix = no benefit
2. Disease not Dx early through screening and so
missed opportunity
3. Falsely reassured = late presentation with Sx (+
Cx)
 Year 5: Public Health Pg 18

EVALUATION

Screening is $$ (big cohort) + follow-up (to attain closed episode --> patient needs to know
outcome; cannot lose F/U = screening incidence)
1. Bowel cancer MOST cost-effectiveness (NOW additionally anyone at age 55 can
have ONE-OFF flexi-sig/bowel scope still gradually introducing all over country)
This involves 3x FOBT sample but studies show that only those who
thinks they have disease more likely to do the test others ignore! So try to
phase in 1X sample test (FIT tests).
2. Breast cancer screening is controversial (see OSCE case)
3. Prostate cancer screen just a management programme
4. Rolling out ovarian cancer (RCTs) & SpO2 in newborns.
Potential biases in screening evaluation
1. LEAD TIME (information bias) apparent increased survival time from detecting
disease at an early stage
2. LENGTH (information bias) screening programme more likely to detect slow
developing disease for example a slow-growing cancer.
3. These potential biases are particularly pertinent for evaluation of CA screening
Illustration of lead time (information bias)

Illustration of length (information bias)

Screening identifies slow growing

cancers = more likely to picked up

Vs. fast growing = less likely to pick up

cancer (interval cancers e.g. breast
they occur between the 2 pre-defined
screening ages).

Therefore need helplines to safety net

(-ve screen 1 year ago +Ve Sx now
call helpline).