Summary PGZ2024
Disease and Prevention
Table of contents
Course opening ......................................................................................................................................................................... 2
Problem 1: ‘Petition’ ................................................................................................................................................ 6
Lecture Prevention by vaccination ................................................................................................................................. 12
Problem 2: ‘The asparagus fields’.................................................................................................................... 19
Lecture Tuberculosis ............................................................................................................................................................ 27
Problem 3: ‘No new goat farm’ .......................................................................................................................... 37
Lecture Introduction to genetics ..................................................................................................................................... 42
Lecture (Re)-emerging infectious diseases .................................................................................................................. 52
Problem 4: ‘Recommendations for the Minister’ ....................................................................................... 56
Lecture Cardiovascular risk management................................................................................................................... 65
Problem 5: ‘An unlikely match?’ ...................................................................................................................... 70
Lecture Prenatal diagnosis & pre-implantation genetic diagnostics ................................................................ 76
Problem 6: ‘To test or not to test?’ .................................................................................................................. 80
Lecture Down syndrome & ethics of prenatal testing.............................................................................................. 85
Problem 7: ‘Tennis friends’ ................................................................................................................................ 89
Lecture Cancer and prevention ........................................................................................................................................ 98
Problem 8: ‘Alzheimer’s disease: just part of ageing?’ ........................................................................... 105
Lecture Dementia ............................................................................................................................................................... 113
Problem 9: ‘The challenge of colorectal cancer survivorship’ ............................................................ 122
Lecture Colorectal cancer survivorship ..................................................................................................................... 127
Problem 10: ‘Taking care of yourself?’ ........................................................................................................ 134
Lecture Diabetes self-management ............................................................................................................................. 142
Problem 11: ‘Chronic back pain’ .................................................................................................................... 145
Lecture Chronic back pain .............................................................................................................................................. 154
Training Health Counseling ..................................................................................................................................... 161
Training Is screening on lung cancer useful? ................................................................................................... 166
Visit Maastricht Study Research Centre ............................................................................................................. 174
1
,Course opening
Public health
“the art and science of preventing disease, prolonging life and promoting health trough the
organized efforts of society” – WHO 1988
Three main approaches in the field of PH
• Health promotion
o Enabling people to increase control over and improve their health trough social and
environmental interventions
• Health protection
o Management of environmental, food, toxicological and occupational safety
• Disease prevention
o Aimed at minimizing the burden of diseases and associated risk factors trough primary
and secondary prevention efforts
PH prevention, management and treatment of
• Communicable diseases: infectious diseases
o Decrease of mortality
• Non-communicable diseases: chronic diseases (e.g. cardiovascular diseases, cancers, mental
disorders)
o Increase of mortality
o Since 2007 cancer is the number one cause of death in the Netherlands
PH has changed
Transition from infectious to chronic diseases, because of
• Developments in society have led to changes in het prevalence of risk factors
• Medical and scientific progress had led to improves detection/screening/treatment
• As a result more people living with chronic diseases
Disease burden
• Mental disorders
• Have their first on set very early in life
• Has an impact during the rest of your life
• Later in life: decrease mental disorders & increase dementia
Life expectancy
• Increasing average life expectancy
• Women: life expectancy in good health isn’t increasing
Successes of PH
Total number of prevented deaths: >16.000 per year!
2
,Disease
• Knowledge on disease is essential for a PH professional
• You have to able to acquire information on diseases
• Disease characteristics determine which interventions possibilities you have
Questions you need to answer before deciding on the right public health intervention:
• How does the disease develop, what are the risk factors?
• What are the symptoms, how is the diagnoses made?
• What are the treatments possibilities, what is the prognosis?
• What are the consequences of the diseases for quality of life and participation (in society)?
Prevention
Classification according to disease stage
Classification according to risk groups
Prevention measures
▪ Monitoring/surveillance
▪ Risk assessment
▪ Identifying the primary source (animal source)
▪ Understanding the virus (human-to-human transmission through droplets, personal contact,
contaminated objects, survival on surfaces)
▪ Isolation and treatment of infected people
▪ Quarantine
▪ Development of vaccine
▪ Public awareness and risk communication (avoid misinformation through social media)
Content of the course
• 11 problems + 11 lectures (12 tutorial group meetings)
o Different diseases
o Different aspects of prevention
• One additional lecture to give an introduction to genetics
• Practicals
3
, o Training sessions and lectures
o One lecture on English Speaking Skills
Subdomains covered by the problems
• Primary prevention of infectious and chronic diseases (4 problems)
o Vaccinations, immunity, mass immunization strategies, the role of social media
o Tuberculosis, outbreak investigation, disease surveillance
o Cardiovascular disease and risk prediction
o (Re-)emerging infections (Q-fever as example), risk communication
• Genetic and prenatal screening (2 problems)
o Carrier screening (cystic fibrosis as example)
o Down syndrome, prenatal screening (NIPT test), preimplantation diagnosis, ethics of
preimplantation diagnosis
• Secondary prevention (2 problems)
o Colorectal, lung, and prostate cancer, cancer risk factors, cancer screening
• (Im)possibilities of early detection
o Dementia, prevention vs treatment
• Living with disease (3 problems)
o Colorectal cancer survivorship, factors influencing quality of life, international
classification of functioning, revisiting study designs (academic skills)
o Diabetes self-care management, diabetes complications (visit “the Maastricht study”)
o Chronis low back pain, pain models
Literature
• Search and read one additional article for the reporting discussion
• Best done after having answered all learning goals to see what dis adds to your knowledge
• Active learning, more discussion & more interaction
Practicals
• Group project: Opt for an intervention
o Tutor will form groups in first tutorial (3-4 persons per group)
o E-mail your top 3 list of topics today (before 16.00h) to M. Schram! She will allocate the
topics
o Gain in-depth knowledge on a specific disease and study various prevention options
(literature)
o Interview an expert in the field (between 18 and 29 feb)
o Determine the best prevention option and give good argumentation (evidence-based)
o Describe how the intervention can be implemented in practice
o Mandatory feedback moment half-way: come prepared with questions to make this
useful
o Present you work during group presentation session
o Hand in group paper (30% course grade)
• Collaboration in teams
o One session with the trainer and your group project team
o Emphasis on conflict management
o Presence is mandatory
o Prepare 1st session by completing online questionnaire
o Group reflection paper
• Health Counseling skills
o Two sessions of three hours each
o One-hour introduction, two-hour training session in subgroups
o Presence is mandatory
• Screening for lung cancer
4
, o One session of two hours
o Epidemiological calculations to determine the usefulness of lung cancer screening
o Presence is mandatory
o Bring laptop or tablet for doing exercises
• Visit to the Maastricht Study
o Introductory talk online please watch before coming
Assessment
• Group project (30%)
o Presentation
o Paper
• Course exam (70%)
o Eight open-ended questions on problems + lectures, you choose six to answer
• You need a pass for both (grade >=5.5)
• 100% attendance and active participation in the tutorial group meetings & group project
5
,Problem 1: ‘Petition’
Primary prevention of infectious diseases
1. How works vaccination (active and passive immunization)?
(Source: Centers for Disease Control and Prevention)
Immunity is the ability of the human body to tolerate the presence of
material indigenous to the body (“self”), and to eliminate foreign (“nonself”)
material. This discriminatory ability provides protection from infectious
disease, since most microbes are identified as foreign by the immune
system. Immunity to a microbe is usually indicated by the presence of
antibody to that organism. Immunity is generally specific to a single
organism or group of closely related organisms. There are two basic
mechanisms for acquiring immunity, active and passive:
• Active immunity is protection that is produced by the person’s own
immune system.
→ This type of immunity usually lasts for many years, often during a
lifetime.
• Passive immunity is protection by products produced by an animal or
human and transferred to another human, usually by injection.
→ Passive immunity often provides effective protection, but this
protection wanes (disappears) with time, usually within a few
weeks or months the antibodies will degrade.
The immune system is a complex system of interacting cells whose primary
purpose is to identify foreign (“nonself”) substances referred to as
antigens. Antigens can be either alive (such as viruses and bacteria) of
inactivated. The immune system develops a defense against the antigen.
This defense is known as the immune response and usually involves the
production of protein molecules by B lymphocytes, called antibodies (or
immunoglobulins), and of specific cells, including Y-lymphocytes (also
known as cell-mediated immunity) whose purpose is to facilitate the
elimination of foreign substances. B-lymphocytes provide mediated immunity: they
produce immunoglobulin; release antibodies to detect antigens and eliminate with the help
of other cells. T-lymphocytes (T-killer cells) help the B-lymphocytes with the elimination of
antigens.
Passive immunity is the transfer of antibody produces by one human or other animal to
another. Passive immunity provides protection against some infections, but this protection is
temporary. The antibodies will degrade during a period of weeks to months, and the
recipient will no longer be protected. The most common form of passive immunity is that
which an infant receives from its mother. Antibodies are transported across the placenta
during the last 1-2 months of pregnancy. As a result, a full-term infant will have the same
antibodies as its mother. These antibodies will protect the infant from certain diseases up to
a year. Protection is better against some diseases (e.g. measles, rubella, tetanus) than others
(e.g. polio, pertussis).
Active immunity is stimulation of the immune system to produce antigen-specific humoral
(antibody) and cellular immunity. Unlike passive immunity, which is temporary, active
immunity usually lasts for many years, often for a lifetime. There are two ways to acquire
active immunity:
• To survive infection with the disease-causing form of the organism: while exceptions
(like malaria) exist, in general once persons recover from infectious diseases, they will
have lifelong immunity to that disease. The persistence of protection for many years
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, after the infection is known as immunologic memory. Following exposure of the
immune system to an antigen, certain cells (memory B cells) continue to circulate in the
blood (and also reside in the bone marrow) for many years. Upon re-exposure to the
antigen, these memory cells begin to replicate and produce antibodies very rapidly to
reestablish protection.
• Vaccination: vaccines interact with the immune system and often produce an immune
response similar to that produced by the natural infection, but they do not subject the
recipient to the disease and its potential complications. Many vaccines also produce
immunologic memory similar to that acquired by having the natural disease.
→ Many factors influence the immune response to vaccination: presence of maternal
antibody, nature and dose of antigen, route of administration, and the presence of an
adjuvant (e.g. aluminum-containing material added to improve the immunogenicity
of the vaccine). Host factors such as age, nutritional factors, genetics, and coexisting
disease, may also effect the response.
General rule: the more similar a vaccine is to the disease-causing form of the organism, the
better the immune response to the vaccine.
There are different types of vaccines:
• Live attenuated vaccines: produced by modifying a disease-producing
(“wild”) virus or bacterium in a laboratory. The wild virus or bacterium is
weakened usually by repeated culturing. The resulting vaccine organism
retains the ability to replicate (grow) and produce immunity, but usually
does not cause illness. A relatively small dose of virus or bacteria is
administered (mostly one dose, except those administered orally), which
replicated in the body and creates enough of the organism to stimulate an
immune response.
→ Anything that either damages the live organism in the vial (e.g. heat,
light) or interferes with replication of the organism in the body
(circulating antibody) can cause the vaccine to be ineffective.
→ When a live attenuated vaccine does cause “disease”, it is usually much
milder than the natural disease and is referred to as an adverse
reaction.
→ The immune response to a live attenuated vaccine is virtually identical
to that produced by a natural infection. The immune system does not
differentiate between an infection with a weakened vaccine virus and
an infection with a wild virus.
→ Live attenuated vaccines may cause severe or fatal reactions as a result
of uncontrolled replication (growth) of the vaccine virus. This only occurs in persons
with immunodeficiency (e.g. leukemia, treatment with certain drugs, or HIV).
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