Basic concepts of Health Planning

Planning is making current decisions in the light of their future effects.

Health planning is a process culminating in decisions regarding the future provisions of health facilities and services to meet health needs of the community.

Dental Fluorosis

Epidemiology

Dental fluorosis is a developmental disturbance of dental enamel caused by the consumption of excess fluoride during tooth development. It's caused by overexposure to fluoride during the first eight years of life more commonly, the time when most permanent teeth are being formed. 

Dental Fluorosis

Common sources of fluoride includes, toothpaste (if swallowed by young children), drinking water in fluoridated communities, beverages and food processed with fluoridated water, dietary prescription supplements that include fluoride (e.g., tablets or drops) and other professional dental products (e.g., mouth rinses, gels, and foams). Increases in the occurrence of mostly mild dental fluorosis were recognized as more sources of fluoride became available to prevent tooth decay. These sources include drinking water with fluoride, fluoride toothpastes (if swallowed by young children) and dietary prescription supplements in tablets or drops. Moderate-level chronic exposure (above 1.5 mg/litre of water - the WHO guideline value for fluoride in water) to drinking water is typically the most significant source. 

Dental fluorosis can occur among persons in all communities at different severities, even in those with a low natural concentration of fluoride in the drinking water. However fluoride in water is mostly of geological origin. Waters with high levels of fluoride content are mostly found at the foot of high mountains and in areas where the sea has made geological deposits. Known fluoride belts on land include: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In these areas fluorosis has been reported. Various studies from all over the world on the disease burden of different populations reveals different figures. But As of 2005 surveys conducted by the National Institute of Dental and Craniofacial Research in the USA between 1986 and 1987 and by the Center of Disease Control between 1999 and 2002 are the only national sources of data concerning the prevalence of dental fluorosis.

Data from the National Health and Nutrition Examination Survey, 1999-2004 and the 1986-1987 National Survey of Oral Health in U.S. School Children reveals that there were less than one-quarter of persons aged 6-49 in the United States had some form of dental fluorosis. The prevalence of dental fluorosis was higher in adolescents than in adults and highest among those aged 12-15. Adolescents aged 12-15 in 1999-2004 had a higher prevalence of dental fluorosis than adolescents aged 12-15 in 1986-1987. Another survey conducted in Indian subcontinent shows that fluorosis is an endemic disease prevalent in 20 states out of the 35 states and Union Territories of the Indian Republic.

Signs and symptoms

Symptoms of fluorosis range from tiny white specks or streaks that may be unnoticeable to dark brown stains and rough, pitted enamel that is difficult to clean. The severity of the condition depends on the dose (how much), duration (how long), and timing (when consumed) of fluoride intake. Since the 1930s, dentists have rated the severity of fluorosis using the following categories:

·

• Questionable -The enamel shows slight changes ranging from a few white flecks to occasional white spots.
• Very mild      -Small opaque paper-white areas are scattered over less than 25% of the tooth surface.
• Mild               - White opaque areas on the surface are more extensive but still affect less than 50% of the surface.
• Moderate        -White opaque areas affect more than 50% of the enamel surface.
• Severe             -All enamel surfaces are affected. The teeth also have pitting that may be discrete or may run together.

Classification of Dental Fluorosis

Treatment options

Depending upon severity of the disease, treatment option varies. Micro/Macro abrasion, Bleaching, Composite restorations, Veneers, Full crowns are the main options available. These are described in detail in another article.

Disease prevention

Removal of excessive fluoride from drinking-water is difficult and expensive. The preferred option is to find a supply of safe drinking-water with safe fluoride levels. If you rely on well water or bottled water, your public health department or a local laboratory can analyze its fluoride content. Where access to safe water is already limited, de-fluoridation may be the only solution. Methods include: use of bone charcoal, contact precipitation, use of Nalgonda or activated alumina (Nalgonda is called after the town in South India, near Hyderabad, where the aluminium sulfate-based defluoridation was first set up at a water works level).

Health education regarding appropriate use of fluorides and parental vigilance is a key measure to prevent fluorosis. Keeping all fluoride-containing products such as toothpaste, mouth rinses, and supplements out of the reach of young children and monitoring your child’s use of fluoridated toothpaste are key facts. Only place a pea-sized amount of toothpaste on your child’s toothbrush. Also teach your child to spit out the toothpaste after brushing instead of swallowing it. To encourage spitting, avoid toothpastes containing flavors that children may be likely to swallow. Adult supervision of tooth brushing by children younger than 6 years of age and changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.

Teething in Infants

Teething is the phenomena accompanying growth of teeth through the gums. The effect of teething on infant health has been debated for at least 5000 years, and traditional beliefs on the issue have still not been entirely superseded by scientific findings. Sumerians believed teething and worm infestation were associated. Hindu writings, as well as work by Aristotle, Homer, Celsus, and others, describe associations between teething and illness. Many of these authors implicated tooth emergence in childhood mortality. The belief that teething led to childhood mortality, seizures, diarrhea, fever, or other serious conditions was criticized as early as the 17th century by Francois Ranchin. Yet in 1839, 5016 deaths in England and Wales were attributed to teething. Illingworth wrote in 1975 that “teething produces nothing but teeth.” However, as recently as 1979, parents and physicians were identifying teething as a cause of presenting symptoms in children admitted to the hospital. A medical evaluation of 50 of these children showed that in 48 cases the symptoms, ranging from upper respiratory infection to bacterial meningitis. Most medical professionals now agree that teething does not cause life-threatening illness, but they disagree about which symptoms may be associated with tooth eruption.

Teething in Infants

However several studies with different study designs has revealed symptoms believed to be associated with teething such as loss of appetite for solids and liquids, drooling, biting or chewing various objects, congestion or runny nose, cough, sleep disturbances, restlessness and irritability, rash, spitting up or vomiting, and diarrhea and fever or mild temperature elevation. Anyhow It is important to inform parents that none of these symptoms consistently and accurately predict when teething is about to occur and any of other organic disorders should be ruled out in infants with these symptoms.

The recommended intervention for teething is the use of cold items because the cold acts as an anesthetic for the gums. Refrigerated pacifiers, Spoons, Clean wet washcloths, Frozen bagels or bananas, refrigerated teething rings can be offered to the infants at this stage.Topical teething gels sold over-the-counter (OTC) are often used for teething but may carry serious risks, including local reactions, seizures with overdose, and methemoglobinemia. Benzocaine containing teething gels should not be used in infants or children under 2 years of age. If necessary, parents should be instructed on proper dosing of analgesic medications, such as acetaminophen or ibuprofen.

Ebola Virus [Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) ]

What is Ebola?

Ebola is a virus which causes rare but deadly disease Ebola virus disease (EVD) or Ebola

hemorrhagic fever (EHF) which is a disease of humans and other primates. Symptoms start two days to three weeks after contact with the virus. Symptoms area fever, sore throat, muscle pain, and headaches. Typically nausea, vomiting, and diarrhea follow, along with decreased functioning of the liver and kidneys. Around this time, affected people may begin to bleed both within the body and externally.

Ebola’s natural reservoir is unknown.Non human primates have been the source of human infections but are not thought to be the reservoirs.

Ebola Taxonomy or Scientific Classification

Order: Mononegavirales

  Family: Filoviridae

  Genus: Ebola like viruses

  Species: Ebola 

Subtypes  

Ebola-Zaire, Ebola-Sudan,Ebola-Ivory Coast-disease in humans

Ebola-Reston-disease in nonhuman primates

Filoviridae or “Filoviruses”

•          Most mysterious virus group

•          Pathogenesis poorly understood

•          Ebola

–        Natural history/reservoirs unknown

–        Exist throughout the world

–        Endemic to Africa

–        Filamentous ssRNA^- (antisense) viruses

History

Named after the Ebola River in the Democratic Republic of the Congo (formerly Zaire), near the first epidemics.

Two species were identified in 1976:

• Zaire ebolavirus (ZEBOV)
• Sudan ebolavirus (SEBOV)

Case fatality rates of 83% and 54% respectively.

A third species, Reston ebolavirus (REBOV), was discovered in November 1989 in a group of monkeys (Macaca fascicularis) imported from the Philippines.

Ivory Coast ebolavirus – Only one case. Unlucky scientist.

Outbreaks of EBOLA

Most Recent Incident

April 25 – June 16 2005 total of 12 cases including 9 deaths were reported in Etoumbi and Mbomo in the Cuvette Quest Region

Ebola Pathogenesis

•          Enters Bloodstream

–         Skin, membranes, Open wounds

•          Cell Level

–         Socks with cell membrane

•          Viral RNA

–        Released into cytoplasm

–        Production new viral proteins/ genetic material

•           New viral genomes

–        Rapidly coated in protein

–        Create cores

•          Viral cores

–        Stack up in cell

–        Migrate to the cell surface

–        Produce trans-membrane proteins

–        Push through cell surface

–        Become enveloped by cell membrane

•          ssRNA^- Genome Mutations

–        Capable of rapid mutation

–        Very adaptable to evade host defenses and environmental change

•          Theory

–         Virus evolved to occupy special niches in the wild

Modes of Transmission

There are 3 modes of infection

1. Unsterilized needles
2. Suboptimal Hospital conditions
3. Personal contact

Symptoms and Diagnostic Tests

•          Early symptoms

–        Muscle aches, fever, vomiting

–        Red eyes, skin rash, diarrhea, stomach pain

–        Acute symptoms

–        Bleeding/hemorrhaging from skin, orifices, internal organs

–        Onset of fever.

–        Intense weakness.

–        Muscle Pain.

–        Headache.

–        Soar Throat.

–        Vommitting, Diarrhoea.

–        Impaired Kidnay and liver function

•          Early Diagnosis

•          Very difficult

•          Signs & symptoms very similar to other infections

•          Laboratory Test for the diagnosis of Ebola Virus

•          PCR detection

•          ELISA (enzyme-linked immuno-absorbant) assay

Is there a cure for Ebola?

•          There are no known curative medications for Ebola.

•          However, there have been very recent developments in preventative medications.

•          No Standard Treatment available

•          Patients receive supportive therapy

•          Treating complicating infections

•          Balancing patient’s fluids and electrolytes

•          Maintaining oxygen status and blood pressure

•          No vaccines!

•          Patients are isolated

•          Medical Staff Training

•          Western sanitation practices

•          Intake

•          Care during stay

•          After patient dies

•          Infection-control Measures

•          complete equipment and area sterilization

Vaccines

•          In June, Jones and his colleagues, Dr. Heinz Feldmann of Winnipeg and Dr. Thomas Geisbert at Fort Detrick, Maryland announced that they had successfully vaccinated monkeys against the deadly Ebola virus

•          The Ebola vaccine is based on the 1976 strain of the Zaire species and protects from the 1995, but not the other 2 species that affect humans.

Risk of Bioterrorism?

Airborne transmission of Ebola Zaire has been demonstrated in monkeys in a controlled laboratory experiment

Plum Island…?

Prevention

After Death

Virus contagious in fluids for days

•          Burial use extreme caution

–        Handling and transport

–        Cultural practices/ religious belief

–        Incinerate all waste!!!!

–        Protective clothing

–        Body sealed in body bag and coffin

–        Sanitation of all equipment before and after

–        Risk for exposure special steps need to be taken to protect the family and community from illness.

–        Family only

–        Why open casket not possible

–        Some practices cannot be done

Conclusion

•          Reservoirs in Nature

–        Largely unknown

–        Possibly infected animals (primates?)

•          Transmission

–        Direct contact blood/secretions of infected person

–        Possible airborne (Reston primate facility)

•          Onset of illness abrupt

–        Incubation period:  2 to 21 days

–        Infections are acute and mostly deadly

Latest Morbidity and Mortality Reports

Ebola-Reston Virus Infection Among Quarantined Nonhuman Primates -- Texas, 1996

Report describes death and blood testing of cynomolgus monkey imported from the Philippines held in a private quarantine facility in Texas

•          Outbreak of Ebola Hemorrhagic Fever ---Uganda, August 2000--January 2001

–        Report describes surveillance and control activities related to the EHF outbreak

–        Presents preliminary clinical and epidemiologic findings

Ebola Information Posters

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