Public health frameworks

A SUMMARY OF PUBLIC
HEALTH FRAMEWORKS
- By Dr Mithilesh Dronavalli
I Am An INDIAN!

A Summary of Public Health Frameworks Jaya Bhaarathi (Great is Mother India)
29/09/2019 Dr Mithilesh Dronavalli Page 1 of 32
Table of Contents
Overview of Frameworks ..........................................................................................................................4
Frameworkof Frameworks:.......................................................................................................................5
IID and CERT..............................................................................................................................................6
HealthPromotion/ Prevention/ ImprovementFramework.......................................................................7
Communityparticipation/ EngagementFramework .................................................................................9
Indigenouscentered Scenarios–framework ...........................................................................................10
Outbreakinvestigationframework ..........................................................................................................11
RiskAssessment&ManagementFramework...........................................................................................12
HealthImpactAssessmentFramework....................................................................................................13
Plain Language Framework.....................................................................................................................14
Epidemiology Question:..........................................................................................................................15
Biostatistics (2X2 Tables and Regression)...............................................................................................16
Screening(versusdiagnostic)frameworks...............................................................................................19
PublichealthSurveillanceframework......................................................................................................20
EconomicEvaluation and DecisionFramework .......................................................................................21
Disastermanagementframework ...........................................................................................................22
18/09/2019 – Summary Of NSW Health Guidelines for Hepatitis A/ Meningitis/ Measles/ Pertussis/
Influenza/ Gastro/ STI Spread.................................................................................................................23
Quick Dot points......................................................................................................................................23
MEASLES..................................................................................................................................................24
Introduction ........................................................................................................................................24
Measles Specifications ........................................................................................................................24
Diagnosis: ........................................................................................................................................24
Vaccination:.....................................................................................................................................24
Period of Communicability:.............................................................................................................24
Incubation period:...........................................................................................................................24
DDx:.................................................................................................................................................24
Control Measure .................................................................................................................................24
Cases: ..............................................................................................................................................24
Contact Tracing: ..............................................................................................................................24
Contact Management: ....................................................................................................................24
Team&Media.......................................................................................................................................25
PERTUSSIS ...............................................................................................................................................26
Introduction ........................................................................................................................................26
Pertussis Specifications.......................................................................................................................26
Vaccinate:........................................................................................................................................26
Diagnosis: ........................................................................................................................................26

Incubation: Max: 4-21 days Avg: 7-10 days................................................................................26
Control.................................................................................................................................................26
Team&Media: .....................................................................................................................................26
INFLUENZA ..............................................................................................................................................27
Case Definition:...............................................................................................................................27
Outbreak Definition: ...........................................................................................................................27
Special Groups requiring Vaccination .................................................................................................27
Special outbreak situations:................................................................................................................27
ATSI remote communities...............................................................................................................27
Aged Care Facilities: ........................................................................................................................27
Cruise Ship:......................................................................................................................................27
Flight/Public Transport:...................................................................................................................27
MENINGOCOCCAL DISEASE.....................................................................................................................28
Introduction: .......................................................................................................................................28
Presentation....................................................................................................................................28
Complications..................................................................................................................................28
Vaccination......................................................................................................................................28
Meningococcal Specifications.............................................................................................................28
High Risk Groups and Contact Tracing:...........................................................................................28
Case Definition ................................................................................................................................28
Meningitis Control...............................................................................................................................28
Contacts Clearance..........................................................................................................................29
Team and Media .................................................................................................................................29
Outbreak .............................................................................................................................................29
Food-Borne and Gastro Outbreak epidemiological investigations.........................................................29
ACFs and CCCs (Roughly the Same): ...............................................................................................30
Salmonellosis:..................................................................................................................................30
Milk..................................................................................................................................................30
Campylobacter................................................................................................................................31
STEC/VTEC:......................................................................................................................................31
Cryptosporidium .............................................................................................................................31
Listeriosis.........................................................................................................................................31
Rotavirus .........................................................................................................................................31
Protozoa and Helminths..................................................................................................................31

E.coli................................................................................................................................................31
HEPATITIS A.............................................................................................................................................31
Intro and Education:............................................................................................................................31
Risk Factors in Australia ..................................................................................................................31
HEPATITIS A Specifications..................................................................................................................31
Dangerous .......................................................................................................................................31
Case Definition:...............................................................................................................................31
Control.................................................................................................................................................32
Case Treatment:..............................................................................................................................32
Exclude and Contact Tracing:..........................................................................................................32
Educate Contacts.............................................................................................................................32
PEP: .................................................................................................................................................32
Prevention of Hep A........................................................................................................................32
Team and Media: ................................................................................................................................32
SEXUALLY TRANSMITTED INFECTIONS....................................................................................................32
Epidemiology of Infectious Diseases.......................................................................................................32

Overview of Frameworks
CONCEPTS
Ottawa+3 / Community Engagement / Health Pyramid
Haddon’s Matrix: Levels(0/1/2/3)- Host/Agent/Vector
Health System Planning and IID and CERT
FRAMEWORKS:
1) Health Promotion
2) Health Evaluation
3) Needs Assessment
4) Health Policy
IID + CERT + POLICY + DITME
5) Community Consultation:
IID CERT + Why/Who/How/Sensitivites/Outcome
6) Indigenous
IID + CERT +Engage (Aboriginal{Current Scenario +Good
Practice}) + Engage(Government)
7) Plain Language: Excellent Teaching
8) Epidemiology Question: IMRAD+Bradford-Hill+ Appraisal
9) Outbreaks: (Gastro + Non-Gastro)
IID + CERT + Define&Collect Data→Investigate→Intervene
→Communicate
10) Environmental Risk Assessment
IID + CERT + Risk=Hazard*Exposure →Manage->Communicate
11) Health Impact Assessment Framework
IID + CERT +Screen and SPADE
12) Screening (versus diagnostic) frameworks
IID + CERT +DTTP
13) Public health Surveillance framework
IID + CERT + (Why/Which One/Data/Evaluate)
14) Economic Evaluation and Decision Framework
IID + CERT + Health Eco Evaluation + Non-Health Eco Decision Making
15) Disaster Management/ Emergency Response
IID + CERT + PREVENT/PREPARE/RESPOND/RELIEF/RECOVERY

Framework of Frameworks:
1) Evaluation
2) Health Promotion
3) Needs Assessment
4) Health Policy
1) Issue Identification(IID) = (Scenario/Public Health
Significance/Context)
2) CERT=
a) Communication (Internal/External/Communication-
Media-Team/Media-Public)
b) Evidence (Qualitative and Quantitative, new vs old,
appraisal)
c) Resources (Staff/Time Available/Expertise /Cost/
Milestones &Deadline)
d) Team:1 Steering Committee: Guidance
2 Team: Co-ordination (Includes You)
3 Working Group: Gather and Supply Evidence
POLICY=
1)Rational vs. Strategic tools (R vs S)
2)Pros and Cons of Different Policy
3)Context of Policy
DITME--> (DESIGN):
Prioritise Needs:CommunityWants, Prevalence&Burden
Levels (0/1/2/3-Ottawa+Tech+Intersectoral+Poverty)
Logic Model (DIPOO: Design Input Process Output
Outcome)
Features: Social Inequity, Strengths/Barriers,
Politics/Culture, Sustainability
Evaluation: Aim / Logic Model / (Qual&Quant) / Metrics)
4)Implement, Test, Monitor and Evaluation

IID and CERT
Issue Identification:
Scenario / Public Health Significance / Context
Communicate with Stakeholders:
WHO? WHY? INFLUENCE on PLAN!
Engage: Indigenous/Internal (Vertical (Minister’s office for
further info/ Horizontal / Whole of Government)/
External/SIGs/CALD Groups/Role Models
Evidence:
Quantitative: (Levels of Evidence, Bradford Hill Criteria
(Causation), Critical Appraisal)
Qualitative: (Survey, Focus Group, Delphi Method,
(Anonymously Guided Converging Focus Group), Narrative,
Semi-structured interview)
Appraisal
Old vs New (Gathering vs Generating Evidence)
Resources: Time/Money/Staff/Expertise/Deadline
Team
Steering committee : Prominent policy makers and
advocates to guide policy process.
Team to co-ordinate evidence gathering, appraisal and
reporting.
Working Group: Gathers and Supplies Evidence for
consideration by team.
Task force: Temporary team with special powers to address
a transient critical issue.
Media: To shape public opinion and seek public
participation.
Media Communications Team (Comms): For government
To communicate to media effectively.

Health Promotion/ Prevention/ Improvement
Framework
Haddon’s Matrix:
Pre-Disease/Disease/Post-Disease
1. Primordial - Lifestyle
2. Primary – Risk Factor Management
3. Secondary – Screening for early disease and
treating
4. Tertiary - Treating the full-blown disease
versus
Host-Agent-Environment
Ottawa Charter+ 3:
1. Personal Choice: PC
2. Building Community: BC
3. Community Attitudes: CA
4. Health Services: HS
5. Health Policy: HP
6. Technology: Tech
7. Alleviate Poverty: Pov.
8. Inter-sectoral Intervention: IS
Health (system) pyramid framework
1. Inter-Sectoral
2. Health Sector
3. Models of Care (Prevention/Education/Treatment)
4. Health Need – Burden of Disease
5. Health Outcomes

Health System Planning
Main PH issue / PH Solutions/ Desirable Outcomes
Stakeholders and decision-makers?
Who wins and looses?
Regional/Rural/Remote Health Service Planning:
• Health Issues by Target Groups
• Accessibility/Discrimination
• Health Service Delivery
• Staffing (Sticks vs Carrots)
o Constitution: Prohibition of Civil Conscription
• Impact of Health Services on SES of community
Hospital Quality Improvement
o Evidence Base
o Risk Management: Why Error and Reduce Risk?
o Compliable Safety Goals / Avoid Risk / Local vs State
Standards
o System issue, not an individual problem
o Co-ordinating team and all-inclusiveness
Using Political Will to benefit society:
• Overcoming the inertia towards social change,
stigmatising philosophies and inequality.
• Fight for the left (socialist causes) and frame
socialist issues to inspire populist opinion to the left.

CommunityParticipation/ Engagement/Consultation/Participatory
Action Research Framework
IID + CERT
1. Why Communicate with the Community?
a. Acceptability
b. Effectiveness
c. QOL
d. Community Capacity Building
• Support and Plan to Improve Independence
• For Social Change: with people, not on people
2. Engage Stakeholders
a. Individual/Elders/Role Models/ Experts/ Special Groups /
Multicultural Societies
b. Geographical Boundaries
c. Ownership and Inclusion
3. Methods of Engagement
a. Quantitative / Qualitative/ Survey/Focus Group/Delphi
Method/Community Meeting/ Committee/Social
Media/Photo Diary/Mixed Methods/Self Reflection
b. Multiple Sources and be flexible
c. Local knowledge more than “generalisable truth”
d. Responsive and Evolving (Iterative)
e. Plan →Action → Reflection → Improve Action → Plan
4. Sensitivities
a. Barriers
b. Outsiders
c. Broad representation vs Special Interest Groups
d. Language/Cultural
5. Outcomes
a. Transformative
b. Change in communication to/within the community
c. Change in action to/within the community
d. Change in social/organisation co-operation

Indigenous centered Scenarios – framework
IID + CERT +Engage (Aboriginal{Current Scenario
+Good Practice}) + Engage(Government)
ENGAGING WITH THE ABORIGINAL COMMUNITY
***Current Scenario for Aboriginal Health and
Wellbeing
1. Past: Colonialism/Stolen Generation/Destruction of
culture/Genocide
2. Present Situation: Social Inequity: Poor –
Stigmatised – Sicker (Mental
Health/Addiction/Infection/Illness) -Unemployment –
Lower Education – Isolation
3. Present Approach: Corruption/Exploitation/Neglect
4. Leading to Distrust/Alienation and Present Situation
***Good Practice for Working Alongside
Aboriginal Communities
1. Representation of local champions, elders,
leaders, men’s and women’s business, local
service providers (teacher/GP etc.)
2. Community Priorities, Ownership,
Upskilling & Empowerment
3. Evidence – “Closing the Gap”
4. Utilize Ottawa Charter +Tech+ Poverty+
Intersectoral+
a. Equitability
b. Accessibility
c. Culturally Appropriate
ENGAGE WITH HEALTH AND GOVERNMENT
SERVICES
- Using any other framework in this document.
Monitor and Evaluate

Outbreak investigation framework
IID + CERT +
Define and Collect Data
→Investigate→Intervene→
Communicate
1. Immediate Measures
2. Define: Case Definition
3. Collect Data: Case and Contact
Finding→Line Listing
4. Investigate: Epi Curve, Hypothesize
and Test (P-value)
5. Intervene with Control Measures
a. Environmental Measures
b. Case and Contact Management
• Follow-up
• Educate
• Exclude
• Treatment
(Antibiotics/Vaccinate/NHIG)
6. Communicate

Risk Assessment & Management Framework
IID + CERT + Risk = Hazard*Exposure
→Communicate
Precautionary Principle: Prevent harm from
suspected hazard in the absence of causation.
1. Hazard and Potential Harms
2. Exposure (Dose) (Internal /External /Noise-
Radiation-Light-Air-Soil-Water-Food-Meds/Route of
Ingestion/Organ Affected/Sense Affected)
3. Dose Response
a. Evidence/Safe Level/Vulnerable Subgroups
4. Risk Characterizations and Uncertainties
5. Manage Risk (Remove/Reduce/Accept)
a. Elimination
b. Substitution
c. Isolation
d. Containment
e. Removal of point source
f. Personal protective equipment.
6. Communicate Risk at all stages
a. Know Topic/Evidence
b. Involve Public -2-way, transparent, ongoing
c. Engage (Perceive Risk, Involve Expert, Local
(GP-Teacher))
d. Communication Style (Clarity/Integrity/Pre-
empt and Answer Questions)
e. Risk in Political Context
7. Write a Report
8. Monitor and Evaluate

Health Impact Assessment Framework
IID + CERT +Screen and SPADE
Screening: Need HIA: Yes or No
Scoping: 1. Goals 2. Team 3. Plan 4. Detail
Profiling:
1.Demographics
2.Evidence (Q&Q, new & old)
3.Community Consultation
4.Domains
1. Socio-Economic
2. Sustainable
3. Cultural
4. Health
5. Lifestyle
6. Transport
7. Education
8. Employment
Assessment:
1.Appraise Evidence
2.Assess Risk vs Benefit
Risk( vs Beneft) = Hazard ( vs Therapy) * Exposure
Decision making and recommendations
1.Prioritise impacts
2.Health Eco vs Non-Health Eco:
3.Moral Values, Political/Cultural context
4.List recommendations
Evaluation and HIA management plan

Plain Language Framework (EXCELLENT
TEACHING):
1)Re-frame the question so anyone can
understand.
2)Think systematically and break it down to
components
3)Attack the question from different angles
4)Use an example, preferably in Health
5)Re-iterate or summarise
6)Check understanding

Epidemiology Question:
IMRAD+Bradford-Hill+Appraisal
Introduction: The Specific Topic in the wider context. The
Research Question.
Method: Study Design, Predictors and Exposures, Statistical
Methods.
Results: Describe the findings, step by step
And
Discussion:
Strengths and Flaws
Context: Findings in relation to the Literature
Future: Further-Info required or future directions for research
Impact: Impact on Public Health/Policy/ Clinical Guidelines
Critical Appraisal (STROBE/PRISMA/CONSORT) &
Bias: Measurement Error/Confounding/Selection Bias/
Chance T1 Error: Falsely rejecting the null hypothesis (False Claim)
(alpha) ||| T2 Error: Rejecting true finding (Power)
2X2 Tables:
Levels of Evidence: MA/SR/RCT/Cohort/Case Control/Cases
Bradford Hill Criteria+(Reversibility/Study-Design/Appraisal):
1) Strength: Exposure leads to high level outcome change
2) Temporality: Exposure → Outcome across time.
3) Gradient: Increasing Exposure & Effect or Inverse
4) Consistency: all regions and populations
5) Coherence: Lab→ Clinical→ Public
6) Specificity: Minimal confounders
7) Plausibility: Mechanism
8) Experiment: RCT or animal experiment.
9) Analogy: Similar Scenarios lead to Similar outcomes

Biostatistics (2X2 Tables and Regression)
Formulas: Sensitivity: A/(a+c) Specificity: d/(c+d) PPV: a/(a+b) NPV: d/(c+d).
Sensitivity: Screening program, Aim: don't miss potential cases. Not missing
Illness.
Specificity: Ability to Pick up "normals no disease". Poor specificity leads to
more expensive and intrusive followup that causes unnecessary anxiety.
Identifying Healthy among Sick.
Sensitivity and specificity are part of a trade-off as seen in a receiver
operator curve.
Practical Benefits:
Sensitivity is good for screening program as no one with possible disease
should be left behind.
Specificity is important as specificity prevents misdiagnosing normal
patients, which leads to anxiety, unnecessary treatment and treatment's
complications.
Sensitivity and specificity are vertical. PPV and NPV are horizontal where
test status is horizontal and diseases status is vertical in a 2*2 table. Disease is
Case. Exposure is Test
PPV/NPV: Probability of disease where test is positive/negative - for
clinicians.
PPV and NPV are affected by the prevalence of the disease in the target
population ( diseased or health individuals) and the pre-test probability.
Sensitivity and Specificity are not affected by prevalence of the disease or
pre-test probability.
Likelihood Ratio
Pre-test probability * Likelihood Ratio = Post Test Probability
Can be for a positive test or a negative test.
for positive test LR = sensitivity / (1-specificity)
for negative test LR = (1-sensitivity)/specificity
Screening Program:
Mortality: is the best measure of effectiveness of a screening program but
expensive to measure. 5 year survival rate is inflated by lead time and length
time bias and is not effective in measuring the effectiveness of screening.
Survival is a clinical measure where mortality is a population measure.
Lead Time Bias: 5 yr survival inflated as treating early pre-disease which is
easier to treat and has better outcomes anyway.

Length Time Bias: Early attrition of diseases individuals after which screening
occurs (by age intervals)
Healthy User Bias: People are more likely to volunteer to screen programs if
they have a healthy lifestyle which usually prevents disease making the
program look good when it might not be.
In regression there is an outcome (y) and a predictor (x) and confounders
(z1,z2,z3)
Usually in the format:
y= m_1x + m_2z1 + m_3z2 + m_4z3 + constant
m is the effect size.
It can be a coefficient: one unit rise in x leads to so much rise in y eg one-foot
rise in height is associated with 30 kg increase in weight
m can be an odds ratio.
m can be a relative risk
m can be a hazard ratio (for survival analysis)
m can be an incident risk ratio (for Poisson regression)
Linear Regression: For continuous outcomes consider linear regression.
Assumptions:
1) normally distributed error terms,
2)random-scatter of standardised residuals vs fitted y values.
3) No multi co-linearity. Don't use same or similar predictors (correlated)
twice in a regression.
Logistic/Binomial Regression For binary outcomes consider logistic
regression for odds ratio (check goodness of fit) or certain glms for relative
risk.
Relative risk is times likely - easy to interpret needs a cohort
RR for cohorts: Risk in Exposed/Risk in Unexposed ((a/a+b)/(c/c+d)).
Odds ratio difficult to interpret multiple of the odds - can do with a case
control or a cohort
OR: Odds of Exposed / Odds of unexposed (ad/bc)
Poisson Regression with rates (deaths per year) requires Poisson regression
which is a type of generalised linear model (beyond continuous outcomes
but still using a linear framework). Assumption: The model variance less than
mean, if not satisfied use a negative binomial regression.
Longitudinal Regression: - to account for repeated measures over time.

Each subject will have similar results which are correlated compared to other
subjects. This means outcomes are not independent of each other. 2 main
models - Random/Fixed Effects and Marginal Models (Advanced)
Time Series Regression: Looking at trends over time of single outcome such
as number of prescriptions of a drug each month for years.
To make sense of trends you need to adjust for cyclical trends:
- Seasonality
- Confounders
- Residual Correlation (Lack of independent of outcomes after adjusting for
other factors.
Can evaluate sudden changes in prescriptions due to a new policy or media
release etc. This is known as an interrupted time series analysis (ITSA)
Meta-Regression
When there is a possible time trend in the result of a meta-analysis (change
of prevalence of antibiotic resistance over time).
Each study is a row of data, with outcome, year and other characteristics
which could be confounding the outcome
The outcomes of each study are data points for the meta-regression they are
adjusted for study characteristics and time is the main predictor.
The effect size of time is the time trend of change in results over tiem for the
studies collected.
Survival analysis is carried out using Kaplan Meier Curves (Descriptive graph
of time to failure). To measure the effect of a variable on the time to failure
(eg smoking on time to death) you need to do a Cox regression.
The effect size is the Hazard Ratio which is a measure of the hazard of
smoking throughout the time period.
The assumption that the risk of smoking is the same throughout the time
course of the person's survival. Proportional Hazards Assumption.

Screening (versus diagnostic) frameworks
IID + CERT +DTTP
1. Disease
a. Why relevant
b. Known Natural History
c. Long Latency
d. Targets of Screening and Reach
2. Treatment
a. Easy Access
b. Good NNT
c. Need Early Treatment Advantage
d. Who to Treat
3. Test
a. Accurate &Culturally Appropriate Test
b. Evidence Based Screening Interval
4. Program
a. Sustainable
b. Cost-Utility
c. Stakeholder Support

Public health Surveillance framework
IID + CERT + (Why/Which One/Data/Evaluate)
1. Why Surveillance?
a. Case Management
b. Curbing Outbreaks
c. Planning
d. Research
2. Which one? Surveillance Types
a. Passive (Routine Notification)
b. Active
i. Enhanced (e.g. During Outbreaks)
ii. Sentinel (in Special Groups)
3. Data Analysis
- Collect/Clean/Analyse/Report (Data)
4. Evaluate Surveillance
a. Usefulness
b. Accuracy

Economic Evaluation and Decision Framework
IID + CERT + Health Eco Evaluation + Non-Health
Eco Decision Making
1. IID + CERT + Upstream Determinants Analysis
2. Feasibility of an Evaluation
3. Approach (Type of Efficiency / Level of Evaluation for
LOGIC model)
a. Cost is Direct/Indirect/Intangible:
Program/ Treatment (Cost) vs Averted (Cost of Illness)
b. Cost-Minimization (Comparing on $)
c. Cost-Benefit (Outcome: $)
d. Cost-Utility (Outcome: DALY)
e. Cost-Effectiveness (Comparing Interventions on
DALY)
4. Accurate Data
5. Discounting and Uncertainty
6. Cost Effectiveness Plane
7. Make Decision
a. Consider Alternatives
b. Model Consequences
c. Opportunity Cost
d. Combine Evidence and Moral Values
e. Maximize Benefit
f. Sensitivity Analysis-Check Assumptions
8. Report, Monitor and Evaluate

Disaster management framework
IID + CERT +
PREVENT/PREPARE/RESPOND/RELIEF/RECOVERY
CERT + IID , Status, plan and phase of disaster
PREVENT:
1. Pre-disaster proofing (community awareness, power-backup
2. ICS Plan, Vertical-Horizontal
3. Plan for All Major Hazards
4. Plan using all Agencies(Government, Charity, Utility,etc)
5. Plan for intersection of other departments with health (eg.
electricity→no AC → Heat Stroke)
PREPARE
1. Prioritize
2. Setup Surveillance and 2-way communications
3. Liaise with other Emergency providers
4. Review Surge Workforce Capabilities
5. Triage
RESPOND & RELIEF
1. Attend to necessities (food, water, clothing etc.)
2. Ameliorate threat and Evaluate
3. Control Outbreaks.(Quarantine/Medical prophylaxis/Immunize)
Post disaster RECOVERY of Service/Mental Health

18/09/2019 – Summary Of NSW Health
Guidelines for Hepatitis A/ Meningitis/
Measles/ Pertussis/ Influenza/ Gastro/ STI
Spread
Quick Dot points
Hepatitis A: Orofaecal route (sexual and food bourne)
Meningitis: Can die in 24 hours. very close contacts Abx
moderately close contacts (Abx/Vacc)
Measles: 0-3 MMR , 4-6 NHIG , 7-9 partially effective NHIG
Pertussis: Prevent Exposure in less than 6m olds and
pregnant women in their last month of pregnancy
Influenza: 3 ILIs with at least 1 definitive diagnosis is
outbreak, infection control plus oseltamivir treatment or
prophylaxis. 8days free of ILI outbreak closed.
Gastro: red flag, collect and analyse data intervene and
communicate.
STI spread: people with STIs must take reasonable
precautions to prevent spread or can get fined or go to jail.

MEASLES
Introduction
Measles is a Moribilli Virus which is highly contagious air-borne small droplet
infection that requires urgent PHU action. Complications include middle ear
infection and bronchopneumonia, rare encephalitis (SSPE), miscarriage,
premature delivery, permanent blindness, deafness and death.
Measles Specifications
Diagnosis: Clinical: Fever and Rash and (Cough or Coryza or conjunctivitis or
Koplik's spot (white spots on buccal mucosa)
Vaccination: 12m vaccine and 18m vaccine
Lab Investigation using NAT is mandatory as is notification.
Period of Communicability:
The case is infective for 24 hours prior to the prodromal period when
symptoms arrive or 4 days prior to rash till 4 days after rash.
Incubation period: exposure to symptoms is 10 days or from exposure to
rash is 14 days.
DDx: Rubella, Roseola, Scarlet Fevel, Human Papiloma Virus, Adenovirus,
Enterovirus, Kawasaki Disease, Arbovirus
Control Measure
Cases: needs supportive treatment:
Contact Tracing: (Household contacts and sharing airspace (same shop,
classroom)
Trace Source - Get travel history - look for secondary cases.
Exclude suspected cases and susceptible contacts from schools child care
centres, work environment and health care settings (ED, hospital, General
Practice unless isolated.) - Home isolation required.
Contact Management: Contacts need vaccination if not vaccinated. Do not
vaccinate immunocompromised (Live Virus), pregnant women and infants
below 6months. MMR within 72 hours of exposure to a case or NHIG within
144 hours - partially effective 7-9 days after 10 days no effect.
Educate and Isolate as needed.
NHIG is only given to vulnerable people: Unvaccinated AND (Infants above
9m| pregnant women| immunocompromised| ATSI <5 yrs and > 20yrs|
Malnourished (Low Vitamin A))
Measles included in rubella vaccination after 1989.

Before 1966 no need to vaccinate.
AIRS record present after 1990 (roughly).
Team&Media
As required to check for vaccination records, to provide info regarding
measles and to test case specimens (PCR, IgM (current infection and IgG (past
infection), see IgG and IgM curve). Using media to inform potential contacts
about precautions.

PERTUSSIS
Introduction
High priority -investigate within 24 hrs
B. Pertussis (bacteria), reservoir humans, large droplet or mucous discharge,
Coryzal --> Paroxysmal Cough --> Vomiting-Cyanosis-whoop(absent in infants
instead: gagging gasping cyanosis apnoea, poor feeding seizures).
Complications: Pneumonia or Rare Encephalitis.
Pertussis Specifications
Vaccinate: (8w,6m,4yr,15yr)
Diagnosis:
Confirmed required Lab Def (NAT/Isolation/Seroconversion)
Suggestive: Ig Change + Clinical (cough >2weeks/paroxysm/post-tussive
vomiting/whoop).
Probable: Clinical + Epi (one infectious case: 1wk before catarrhal to 3 weeks
after coughs
and 2nd
case develops illness 6-20 days after exposure to first case and at-
least one epi-linked case confirmed by NAT).
Incubation: Max: 4-21 days Avg: 7-10 days
Period of Communicability: Not Communicable: >21d cough (14d:
paroxysmal) 5d after Abx
Control
FUP children <2yr, contacts of: 6m and pregnant ladies in last month of
pregnancy
Notify CD Branch of case info(demo/hx/vacc hx/lab/source/FUP) and NNDD
for deaths
Prevent in <6m old. 0.5% fatality (esp in household, Child Care & Health
Care).
Antibiotics mainly for prophylaxis and recommend to update vaccine. Abx
prophylaxis to those near <6m esp. in households.
Give Abx for treatment early in Catarrhal Stage: (Macrolide/Trimethoprim-
Sulfamethoxazole).
NHIG not effective
Proactive case finding for suspected pertussis: HCW in maternity ward or
newborn nursery
Active Case Finding/Epi/Media(community alert), promote community wide
vaccination)
Educate. Inform Clinician/Investigation as per form/check Vacc Hx for <5yo.
Outbreak: 2 or more cases with shared epi link.
Team&Media: HCF case finding need a team/Inform Media in an outbreak

INFLUENZA
Case Definition: Only Lab notifications are required for Confirmed Case
Definition: Ig G seroconversion/antigen detection/culture/ NAT
ILI: Fever>38C Coryzal symptoms myalgia/Elderly: no fever confusion
anorexia, SOB
Incubation period: 1-7 days.
Period of Communicability: Fever indicates viral shedding. 1day prior to
symptoms to 7 days post symptoms. 10 days for children and weeks for
immunocompromised patients.
Outbreak Definition: 3 cases within 72 hours where at least one is
diagnosed as test positive for influenza.
Special Groups requiring Vaccination
• >65
• >6m with comorbidity cardio/resp/neuro/immunocompromised
• pregnant women
• ATSI >6m to <5yo and 15yo and over
• Anyone can get vaccinated.
Special outbreak situations:
ATSI remote communities
Consider vaccination especially close contacts
Educate
Work with the community
Accessible Affordable and Available Health Care with point of care testing
and treatment in a primary care setting
Control Measures, reduce overcrowding and environmental health concerns
Aged Care Facilities:
Can lead to hospitalisation and death
Treat cases with oseltamivir treatment early
Oseltamivir prophylaxis for healthy patients around ill patients
Infection Control Measures
Sending HCWs home, need to vaccinate HCWs.
Cruise Ship: Isolate, Educate, Control Measures
Flight/Public Transport: Avoid travel

MENINGOCOCCAL DISEASE
Introduction:
Meningococcal from Neisseria meningitides is a Gram-negative diplococcus
bacteria of urgent priority with 6 major strains where in Australia B and W are
predominant. Neisseria meningitidis is a commensal only found in humans
with increased prevalence in youth <24yrs and in low socioeconomic status.
Neisseria is spread through respiratory droplets.
Presentation: Meningitis and Septicaemia. Starts as fever, myalgia,
vomiting, Nil rash or Late Haemorrhagic rash and non-blanching. Mottling,
cold extremities, leg pain.
Complications: Death can occur in 24 hours. Early diagnosis is a must. Long
term: deafness, neuro sequellae, skin grafts, amputation.
Vaccination available for (ABCW and Y), MenCCV is 12 months age. Quad
Vaccine (A, C, W, Y): occ exp, travel, household contacts.
HIV-coinfection and outbreaks are dangerous.
Meningococcal Specifications
Incubation period: 1-7 days.
Period of Communicability: Infectious until coryza stops and with Abx
disappears in 24 hrs.
High Risk Groups and Contact Tracing: Prolonged exposure to an
asymptomatic carrier/household/intimate kissing-STI. Lab workers,
immunocompromised, asplenia, travel to hyperendemic/epidemic countries
Case Definition:
In sterile areas Lab Definitive (isolate Neisseria Meningitidis/DNA sequence).
Lab: PCR/ CSF PCR/ Detect the virulent strain of the organism) or
Lab Suggestive (IgM or IgG to Neisseria/Gram-neg dip) and Clinical Evidence
Meningitis Control
1. Active case findings.
2. Discuss with treating doctor to get contact history.
3. Educate/Clarify understanding of case and caregiver.
4. Is the Onset of symptoms/signs consistent with Invasive Meningococcal
Disease?
5. Do not vaccinate cases. Give Clearance Abx to cases
6. Contact Clearance: Give info/clearance Abx/vaccinate to "high-risk
groups"
7. Isolation as per Respiratory Droplets.

Contacts Clearance: Clarify the degree of contact
Household (Abx/Vacc) / intimate kissing-sexual contacts (ABx)/CCC-workplace
for 16-20 hours (Abx/Vacc) // unmasked HCW or Mouth to Mouth
resuscitation (Abx)
Provide info to allay anxiety and advice when to take action for surveillance
Check guidelines for Abx( Ciprofloxain/Ceftriaxone.Rifampicin)
Use Quadravalent Vacc.
Team and Media
Data Mangement: notify NDD and Notify CDB within 24 hours and for ATSI to
the jurisdictional database. Record serogroup and outcome.
Outbreak
1. Check if outbreak
2. The site visit by the team
3. Heightened surveillance
4. Calculate subgroup attack rates
5. Info to all affected and media for wider public
6. clearance Abx to household contacts and chronic contacts and
contacts of infants
7. Review and report
8. Low threshold for ATSI: Utilise Aboriginal Health Liaison Worker.
Foodborne and Gastro Outbreak
epidemiological investigations
1)Red Flag(Signal)
2)Collect Data
3)Test Hypothesis
4)Intervention
5)Evaluate/Media/Monitor

Rotavirus (50%), cryptosporidiosis (38%), giardiasis (26%), salmonellosis
(22%), are reported among 0-4 year olds.
ACFs and CCCs (Roughly the Same):
1. Is it an Outbreak?
2. Communicate with staff and residents
3. Contact Resident's GPs
4. Additional Control Measures:
i) Hygiene & Hand-washing (including Signage) & Cleaning with Bleach
solution
ii) PPE/ Restrict (Staff & Residents) movement and contact (from outside).
Exclude children and staff if sick until G clearance is provided.
iii) Safe Food Handling
4. Case Listing/Notify/Collect Specimens
5. Review and Update Plans
Salmonellosis: Chicken/Egg, Turtle, Bandicoots
Chickens that are infected with Salmonella only lay eggs which are infected
salmonella. Amphibia and orofaecal route. 10,000,000 bacteria are needed to
cause diarrhoea.
When Chickens are not infected eggs may get infected with salmonella where
the egg shells have not hardened and there is chicken poo infecting the egg.
Nests need to be cleared and cleaned regularly.
Don’t eat egg sunny side up, make sure egg is cooked thoroughly to reduce
the risk of salmonellosis.
For mayonnaise use pasteurised eggs. Infants, elderly and IC are at risk.
Milk need to be pasteurised to prevent TB, Brucellosis, Mycobateria and
anthrax

Campylobacter can come from raw diary, chickens, eggs, meat is 100%
food borne and from cross-contamination/utensils, pets-babies. Requires
greater than 10,000 organisms to cause gastro. Bloddy diarrhoea – can use
Azithromycin.
STEC/VTEC: Shigella Toxic E-coli/ Very Toxic E-coli – Can lead to Haemolytic
Uraemic Syndrome → acute kidney failure and death.
Cryptosporidium – need hyperchlorination – difficult to eliminate due to
oocysts. /Giardiasis: Water-borne.
Listeriosis Milk/Cold Meats(Sushi)/Dangerous in Pregnancy/Frozen
Salads/Rockmellon
Rotavirus: Orofecal route: 2 doses 2month and 4 months. No catchup or
doses after 6months, risk of intussusception
Protozoa and Helminths – Have a very low infectious dose.
E.coli that is not STEC/VTEC is usually self limiting and does not need
antibiotics.
HEPATITIS A
Intro and Education:
High Priority <24hrs: Respond + Notify to NDD
Surveillance is important to prevent new cases. CFR: 0.1-2.1%
Hepatovirus. Immunity is long lasting. Human reservoir in faces, water and
soil
oral-faecal route/sexual activity. Infectivity is high with diarrhoea and in <6
yrs.
Risk Factors in Australia: frozen berries, shellfish, semi-dried vegetables,
CCC (disabled), ATSI prior to the funded vaccine, food handlers, MSM,
homeless youth, Injecting drug users (IDU), homeless youth, Hep Endemic
countries, sex workers,
Outbreak: 2 linked cases.
HEPATITIS A Specifications
Time of Contact, onset of symptoms and jaundice
28-day infectious period, Infectious period 2 weeks before symptoms and
2 weeks after symptoms.
14 day incubation period, prodromal then jaundice.
Dangerous: Elderly, Hep Co-infection, immunosuppressed, liver disease,
Case Definition:
Confirmed: Lab Def or Lab Sug + (Cllinical or Epi)
Clinical: Jaundice, dark urine ALT 10X, nausea, LOA, Fever, abdo pain, malaise
Lab Definitive : NAT/PCR:qual+ Genotyping Lab Suggestive: Ig M without

recent prior vaccination
Control
Case Treatment: supportive, avoid liver harmful products,
Exclude and Contact Tracing: from CCC, cooking, carers or cared for
(esp. disabled), belongings, sex, Blood transfusion, sewage (Envt Health)
Educate Contacts, PEP<2wks of exposure, nature and period of infection,
rare complications, hygiene and need for exclusion, water
PEP: Provide PEP within 2 weeks of exposures to contacts within the
infectious period of cases: NHIG and/or Vaccine
Prevention of Hep A: Potable Water, hand hygiene and clean cooking,
sewage disposal, vaccinate as needed,
Team and Media: Environmental, Microbiologist, Public Health Unit Team
(Physician/Nurse) for organisation and contact tracing. Use the media for
inter-jurisdictional cases to avoid exposure to causative agents.
SEXUALLY TRANSMITTED INFECTIONS
Case or jail penalty if reasonable precautions are not used by people with
STIs and “sex on premises” owners knowingly permitting sex by people with
STIs:
Reasonable Precautions:
+ taking Abx or
+ use of a condom or
+ have HIV treated and managed or
+ for HIV taking PrEP and open disclosure to partner or
+ for hepatitis B open disclosure and vaccination of potential partner
Epidemiology of Infectious Diseases
• R0 = beta*c*d = infectivity per contact * number of contacts/days *
duration of outbreak (in days)
• R0<1 outbreak will end.
• R0 >1 outbreak will grow.
• R0 = 1 infection will sustain and be endemic.
• R1 refers to a closed population model: susceptible--> exposed -->
infected --> removed. (SEIR)
• R1<1 R1 >1 andR1=0 also apply

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