Another goal of secondary prevention is to prevent the spread of communicable diseases (illnesses that can be transmitted from one person to another). In the community, early identification and treatment of people with communicable diseases, such as sexually transmitted diseases, not only provides secondary prevention for those who are infected but also primary prevention for people who come in contact with infected individuals.
Like primary prevention, individual health care practitioners and public health agencies and organizations perform secondary prevention. An example of secondary prevention that is conducted by many different professionals (physicians, nurses, allied health professionals) in a variety of settings (medical offices, clinics, health fairs) is blood pressure screening to identify people with hypertension (high blood pressure). An example of mental health secondary prevention is the effort to identify young children with behavior problems in order to intervene early and prevent development of, or progression to, more serious mental disorders.
Table 2.6 shows preventive measures, recommended by the U.S. Preventive Services Task Force, that should be taken by healthy adult men, women, pregnant women, and children. The recommended preventive services include screening to detect and identify a wide range of conditions including high blood pressure, depression, obesity, and sexually transmitted diseases such as chlamydia and syphilis infection.
Secondary prevention plays an important role in diseases such as diabetes (a condition in which the body does not properly metabolize sugar), glaucoma (a disorder caused by too much fluid pressure inside the eyeball), breast cancer, and cancer of the cervix (the opening of the uterus). State and local health departments, voluntary health agencies, hospitals, medical clinics, schools, and physicians often conduct screenings for these conditions during which people with no signs or symptoms are tested to uncover these diseases in their earliest stages.
Screening and Early Detection of Breast and Cervical Cancers
Early detection through screening is our best defense against morbidity and mortality from breast and cervical cancers and precancers.
—Julie L. Gerberding, MD, MPH, Director, Centers for Disease Control and Prevention
The American Cancer Society (ACS) in Breast Cancer Facts and Figures 2005–2006 estimates that in 2005, 211,240 women were diagnosed with breast cancer and 40,410 died of the disease (2005, http://www.cancer.org/downloads/STT/CAFF2005BrF.pdf). And in Cancer Facts and Figures 2005, the ACS estimated that 10,370 new cases of cervical cancer were diagnosed in 2005 and 3,710 women died of the disease (2005, http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf). As with many other cancers, treatment for these types of cancer is most likely to be successful when the disease begins, before the cancer has metastasized (spread from its original site to other parts of the body).
Mammography screening, or breast x-rays that find cancers too small to be detected by self-examination or manual examination by a health practitioner, could
TABLE 2.6 Table of recommended preventive services| TABLE 2.6 | ||||
|---|---|---|---|---|
| Table of recommended preventive services | ||||
| Adults | Special populations | |||
| New | Women | Pregnant women | Children | |
| aAdults at increased risk for coronary heart disease. | ||||
| bDiscuss with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. | ||||
| cMammography every 1-2 years for women 40 and older. | ||||
| dStructured education and behavioral counseling programs. | ||||
| eWomen who have been sexually active and have a cervix. | ||||
| fSexually active women 25 and younger and other asymptomatic women at increased risk for infection. | ||||
| gAsymptomatic pregnant women 25 and younger and others at increased risk. | ||||
| hMen and women 50 and older. | ||||
| iPrescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months whose primary water source is deficient in fluoride. | ||||
| jIn clinical practices with systems to assure accurate diagnoses, effective treatment, and follow-up. | ||||
| kAdults with hypertension or hyperlipidemia. | ||||
| lAdults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. | ||||
| mPregnant women at first prenatal visit. | ||||
| nMen 35 and older and women 45 and older. | ||||
| oYounger adults with other risk factors for coronary disease. Screening for lipid disorders to include measurement of total cholesterol and high-density lipoprotein cholesterol. | ||||
| pIntensive counseling and behavioral interventions to promote sustained weight loss for obese adults. | ||||
| qWomen 65 and older and women 60 and older at increased risk for osteoporotic fractures. | ||||
| rBlood typing and antibody testing at first pregnancy-related visit. | ||||
| sRepeated antibody testing for unsensitized Rh (D)- negative women at 24-28 weeks gestation unless biological father is known to be Rh (D) negative. | ||||
| tPersons at increased risk and all pregnant women. | ||||
| uTobacco cessation interventions for those who use tobacco. | ||||
| vAugmented pregnancy-tailored counseling to pregnant women who smoke. | ||||
| wTo detect amblyopia, strabismus, and defects in visual acuity. | ||||
| SOURCE: "Table of Recommended Preventive Services," in The Guide to Clinical Preventive Services 2005, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, June 2005, http://www.ahrq.gov/clinic/pocketgd.pdf (accessed December 14, 2005) | ||||
| Alcohol misuse screening and behavioral counseling interventions | 3 | 3 | 3 | |
| Aspirin for the primary prevention of cardiovascular eventsa | 3 | 3 | ||
| Bacteriuria, screening for asymptomatic | 3 | |||
| Breast cancer, chemopreventionb | 3 | |||
| Breast cancer, screeningc | 3 | |||
| Breastfeeding, behavioral interventions to promoted | 3 | 3 | ||
| Cervical cancer, screeninge | 3 | |||
| Chlamydial infection screeningf,g | 3 | 3 | ||
| Colorectal cancer, screeningh | 3 | 3 | ||
| Dental caries in preschool children, preventioni | 3 | |||
| Depression, screeningj | 3 | 3 | ||
| Diabetes mellitus in adults, screening for typek | 3 | 3 | ||
| Diet, behavioral counseling in primary care to promote a healthyl | 3 | 3 | ||
| Hepatitis B virus infection, screeningm | 3 | |||
| High blood pressure, screening | 3 | 3 | ||
| Lipid disorders, screeningn,o | 3 | 3 | ||
| Obesity in adults, screeningp | 3 | 3 | ||
| Osteoporosis in postmenopausal women, screeningq | 3 | |||
| Rh (D) incompatibility, screeningr,s | 3 | |||
| Syphilis infection, screeningt | 3 | 3 | 3 | |
| Tobacco use and tobacco-caused disease, counseling to preventu,v | 3 | 3 | 3 | |
| Visual impairment in children younger than age 5 years, screaningw | 3 | |||
FIGURE 2.1 Number of women served in National Breast and Cervical Cancer Early Detection Program, fiscal years 1991–2003
prevent 16% of all breast cancer deaths in women older than age forty, according to the CDC in The Burden of Chronic Diseases and Their Risk Factors: National and State Perspectives (2004, http://www.cdc.gov/nccdphp/burdenbook2004/pdf/burden_book2004.pdf). Moreover, the risk reduction associated with screening increases as women age. The Papanicolaou test, also called Pap smear or Pap test, is a screening examination for cancer of the cervix that has the potential to prevent practically all deaths from cervical cancer by detecting cervical cancer at an early stage, when it is most curable, or even preventing the disease if precancerous lesions found during the test are treated. The incidence of cervical cancer has decreased dramatically in the past forty or so years thanks largely to screening and early treatment.
Although a new vaccine to immunize women against contracting the strain of human papilloma virus (HPV) that causes cervical cancer will be available in late 2006, it will only work in females who have not yet become sexually active and contracted the virus. For this reason cervical cancer screening will continue to be important for several generations after widespread immunization has occurred.
In 1990 Congress passed the Breast and Cervical Cancer Mortality Prevention Act, establishing the CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The NBCCEDP provides breast and pelvic examinations, screening mammography, and Pap tests to women at greater risk of death from breast or cervical cancer—racial and ethnic minorities, those who live below the poverty level, older women, and women with less than a high school education.
By June 2003 NBCCEDP had screened nearly two million women, provided more than 4.6 million screening examinations, and diagnosed 17,009 breast cancers, 61,474 precancerous cervical lesions, and 1,157 cervical cancers. Figure 2.1 shows the numbers of women served by NBCCEDP for the years 1991–2003. A significant component of the NBCCEDP effort is community education and outreach. Health educators must not only communicate the life-saving benefits of screening and early identification of disease but also overcome barriers to access to care, such as lack of transportation or child care.
To inform and encourage women to seek screenings, public health workers present health education programs to women's groups, distribute brochures describing how and why women should be screened, and enlist the media to help spread the message. Print advertisements appear in newspapers and magazines to promote the NBCCEDP.
The NBCCEDP also funds follow-up care for women who have abnormal screening results to enable them to receive needed services. These may include biopsy (surgical removal of a sample of cells for microscopic examination) to confirm the diagnosis and visits with surgeons and other medical specialists to receive timely treatment. The provision of follow-up care and treatment is a fundamental principle underlying screening programs.
Screening programs that do not provide facilities for diagnosis and treatment are unlikely to be effective, especially when they are serving populations unable to pay for medical care. Further, many public health professionals believe it is unethical to offer screening without plans and provisions to care for disease identified through the screening process.
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