Which activities are involved in providing a secondary level of preventive care

Secondary Prevention

Secondary prevention activities traditionally entail chemoprophylaxis and involve the identification of early or asymptomatic infection with subsequent treatment so that the infection is eradicated and sequelae are prevented. Although most secondary prevention programs involve intervention at the individual level through the use of chemoprophylaxis, such programs often operate within the context of a population-based or institutional-based screening effort. Routine screening programs for sexually transmitted diseases such as Chlamydia infection are examples of secondary prevention strategies.129,130 Contact investigations for partners of persons with sexually transmitted diseases are also part of a secondary prevention strategy focused on those at highest risk of infection (i.e., those with known exposure). Another example of a secondary prevention program using chemoprophylaxis is screening of high-risk populations for tuberculosis infection and subsequent therapy with an antimicrobial drug, such as isoniazid, to prevent active disease.

Although most secondary prevention strategies involve chemoprophylaxis (and, rarely, immunoprophylaxis), the concept can be broadened to other prevention efforts aimed at intervention and correction of a recognized specific health hazard. Most such efforts occur at the community level. Examples of community-based secondary prevention efforts include the early identification of contaminated products through outbreak investigations and subsequent removal of such products from the market to prevent additional illnesses and restore “the community's health.” A boil-water order for a waterborne disease outbreak of cryptosporidiosis is another example of a secondary prevention strategy aimed at correcting an existing community-wide problem.

Secondary Prevention

Secondary prevention of CRS is concerned with detecting a disease in its earliest stages, and restoring normal health by intervening to achieve disease and symptom control and preventing future exacerbations. Implicitly, secondary prevention takes place when primary prevention fails. Early diagnosis and selection of the optimal treatment is central to secondary prevention. Recent data suggest that there is still a large portion of the population with CRS not receiving treatment; as above, it is estimated from population studies that CRS affects approximately 5%–15% of the general population both in Europe and the United States in contrast with 2%–4% prevalence of doctor-diagnosed CRS [8,52]. It is unclear whether patients are unable to access care or effectively self manage their symptoms of CRS.

Secondary Prevention

Secondary prevention of H. pylori–associated ulcer disease is mandatory and consists of successful bacterial eradication. Testing to ascertain H. pylori status after eradication therapy is indicated in patients with prior complicated ulcer disease or with persistent or recurrent symptoms after therapy, as well as in patients who fail to complete the therapeutic course.

Secondary prevention of NSAID-related ulcer disease is preferentially achieved by the withdrawal of NSAIDs. In patients who must continue taking NSAIDs, a change to a selective COX2 inhibitor in combination with a proton pump inhibitor at a dose equivalent to esomeprazole 20 mg twice daily is advocated, especially for patients with complicated ulcer disease.9 This combination is associated with a lower risk of secondary peptic ulcer complications than treatment with a COX2 inhibitor alone.

Secondary prevention of recurrent ulcers in patients who use aspirin may depend on H. pylori status. In H. pylori–positive patients, H. pylori eradication is as effective as a proton pump inhibitor for the prevention of recurrent ulcers.6 In H. pylori–negative patients, additional acid suppressive therapy at a dose equivalent to esomeprazole 20 mg twice daily should be prescribed. Secondary prevention of idiopathic ulcer disease consists primarily of maintenance therapy with a proton pump inhibitor and treatment of the underlying condition.

Secondary Prevention

Secondary prevention is directed at diseases where there are measurable risk factors or an abnormal condition that predates the emergence of disease. It aims to intervene before the disease arises either by reducing the risk factors or by treating the underlying abnormality. This is the task of preventive medicine.

Secondary prevention can be applied only where the natural history of a given disease includes an early period when it is easily identified and treated, thereby allowing interrupting the progression to a more serious stage. Appropriate secondary prevention strategies require safe and accurate methods of disease detection, preferably at a preclinical stage, and effective methods of intervention.

Important examples include screening for the early detection of cervical cancer and breast cancer. While the efficacy, specifically of breast screening programs based on mammography, continues to be debated, cumulating evidence suggests that cytological screening for cervical cancer is associated with a decline in associated mortality. With advances in medical technology, screening tests for different cancer sites have become available and are being introduced at the population level, such as screening for colorectal cancer.

Other forms of screening measures include programs for the early detection of congenital disorders in newborn children such as phenylketonuria (PKU) or galactosemia. PKU can be identified by measuring the level of phenylalanine in neonatal blood and thus identified children, when treated appropriately, i.e., with special diet, will develop normally.

Further examples of secondary prevention include measures to prevent the spread of infectious diseases by tracing, and subsequently treating, contacts; antiretroviral prophylaxis of perinatal transmission of HIV-infected pregnant women and their babies; identification of hypertension to lower the risk of stroke; prophylactic treatment of asthma; provision of antenatal care to reduce complications in pregnancy; and early treatment and monitoring of diabetes. Measures of secondary prevention may also include interventions to promote early health-care seeking behavior.

Detect Risk Factors and Start Preventive Measures for Avoiding Recurrences

Secondary prevention should start as early as possible or on admission to the stroke unit at the latest. Aspirin should be given early after ischemic stroke if thrombolysis is not administered or 24 hours after thrombolysis. Early mobilization of stable patients is strongly recommended. Adequate secondary prevention of stroke may reduce the risk of recurrent stroke substantially even by 80%.126 Anticoagulation alone in patients with atrial fibrillation reduces ischemic stroke recurrence by about two-thirds and antiplatelets in non-cardioembolic ischemic stroke approximately by one-fourth. Carotid endarterectomy, when indicated, must be performed early. All risk factors must be systematically searched and treated.

Home measurements of arterial blood pressure, blood sugar, and international normalized ratio are widely available and reliable. A major challenge is patient compliance in regular use of medications, but even more challenging is changing lifestyle habits and maintaining the improved lifestyles (cessation of smoking, alcohol abuse and illicit drug use, increased exercising, weight-control, implementing a diet rich in vegetables, salt restriction). These measures are effective in all stroke subtypes. So far, there is little evidence that long-term nursing staff-facilitated close follow-ups would improve maintaining secondary prevention.

IV.B.7. Secondary Prevention

Secondary prevention of obesity, aimed at children, appears to be a promising approach for the treatment of obesity. In 1990, Leonard H. Epstein and colleagues found that when comparing a therapy program attended by both child and parent (in which both were reinforced for weight loss and behavior change), the children lost more weight than those children who attended a child only program, without a parent (in which only the child was reinforced for behavior change), or a nonspecific control treatment (which reinforced families for their attendance). At 5- and 10-year follow-ups, the children in the child and parent treatment program had significant decreases in overweight when compared to the nonspecific control group, and the children in the child only group were midway between these two groups. These findings suggest that early interventions with overweight children may be a useful method of preventing chronic obesity in adulthood. Because obese children are 6.3 times more likely to be overweight adults than are nonobese children, Wing has advocated secondary prevention targeting obese children as an important public health initiative.

4.2 Polyphenols in Secondary Prevention

Secondary prevention is designed to reduce the progress of a disease.5 Polyphenols have been shown in various studies to change lipid and energy metabolism and potentially facilitate weight loss and prevent weight gain, all of which improves the condition of obesity.11 Polyphenolic compounds in tea have also been shown to possess anti-obesity effects, including changes in fatty acid oxidation and metabolism, modification in appetite control, and decreased nutrient absorption.8,15 In reducing the progress of type 2 diabetes and preventing the development of long-term complications of diabetes, potential health benefits include improving blood glucose and lipid profiles, reducing insulin resistance, adiposity and obesity.6,7,8,11

Secondary Prevention

Secondary prevention is early diagnosis and management to prevent complications from a disease. Public health interventions to prevent the spread of disease include the identification of sources of the disease and the implementation of steps to stop it, as shown in Snow’s closure of the Broad Street pump. Secondary prevention includes steps to isolate cases and treat or immunize contacts so as to prevent further cases of meningitis or measles, for example, in outbreaks. For current epidemics such as HIV/AIDS, primary prevention is largely based on education, abstinence from any and certainly risky sexual behavior, circumcision, and treatment of patients in order to improve their health and to reduce the risk of spread of HIV. For high-risk groups such as intravenous drug users, needle-exchange programs reduce the risk of spread of HIV, and hepatitis B and C. Distribution of condoms to teenagers, military personnel, truck drivers, and commercial sex workers helps to prevent the spread of STIs and AIDS in schools and colleges, as well as among the military. The promotion of circumcision is shown to be effective in reducing the transmission of HIV and of HPV (the causative organism for cancer of the cervix).

All health care providers have a role in secondary prevention; for example, in preventing strokes by early identification and adequate care of hypertension. The child who has an untreated streptococcal infection of the throat may develop complications which are serious and potentially life-threatening, including rheumatic fever, rheumatic valvular heart disease, and glomerulonephritis. A patient found to have elevated blood pressure should be advised about continuing management by appropriate diet and weight loss if obese, regular physical exercise, and long-term medication with regular follow-up by a health provider in order to reduce the risk of stroke and other complications. In the case of injury, competent emergency care, safe transportation, and good trauma care may reduce the chance of death and/or permanent handicap. Screening and high-quality care in the community prevent complications of diabetes, including heart, kidney, eye, and peripheral vascular disease. They can also prevent hospitalizations, amputations, and strokes, thus lengthening and improving the quality of life. Health care systems need to be actively engaged in secondary prevention, not only as individual doctors’ services, but also as organized systems of care.

Public health also has a strong interest in promoting high-quality care in secondary and tertiary care hospital centers in such areas of treatment as acute myocardial infarction, stroke, and injury in order to prevent irreversible damage. Measures include quality of care reviews to promote adequate long-term postmyocardial infarction care with aspirin and beta-blockers or other medication to prevent or delay recurrence and second or third myocardial infarctions. The role of high-quality transportation and care in emergency facilities of hospitals in public health is vital to prevent long-term damage and disability; thus, cardiac care systems including publicly available defibrillators, catheterization, the use of stents, and bypass procedures are important elements of health care policy and resource allocation, which should be accessible not only in capital cities but also to regional populations.

Secondary Prevention

Secondary prevention of HNSCC implies that a person has developed genetic, molecular, and/or histologic evidence of the disease and that the disease can be diagnosed as early as possible in the cascade of events. Thus, early detection or secondary prevention can include a serum, salivary, or tissue-based molecular test that reveals the disease. Further detection techniques can include population screening, routine physical examination, radiographic studies, and biopsy.

Early detection by screening is discussed in detail in Chapters 3 through 5Chapter 3Chapter 4Chapter 5 with techniques including molecular studies, markers, public health approaches, clinical examinations, and radiographic studies.

Molecular relationships to the onset and diagnosis of HNSCC are described in the aforementioned section on molecular genetics. Screening for HPV has also been described as a potential primary and secondary prevention technique.

The oral cancer examination has been advocated by many groups as an opportunity for dentists and physicians to identify the disease early (see Fig. 10-7). A recent study in India is the first prospective study to provide confirmation of survival improvement in a large population of at-risk individuals.278

New visualization-enhancing technologies are being developed and used. A chemoluminescent light (ViziLite, Zila Pharmaceuticals, Inc, Phoenix, AZ) can improve visualization of the premalignant and malignant oral lesions. Unfortunately, the early reports using this technology do not provide enough support for its use as a general screening device for oral lesions.279,280 The Velscope (LED Dental, Inc, White Rock, BC, Canada) is an instrument that has been marketed as an aid in the diagnosis of early oral cancer and precancerous lesions without published prospective or controlled trials to date. It is hoped that future studies with both trained and untrained clinicians will further elucidate the usefulness and indications for these techniques.

Other studies have assessed the role of autofluorescence and fluorescence visualization in the clinical setting and the operating room to assess for premalignant and malignant areas of the oral cavity. Although interest in these technologies is increasing, the exact role and indications for their use are yet to be defined.281,282

Studies also support the use of a brush biopsy technique to assess the level of risk or suspicion of lesions of the oral cavity and to promote early detection.283 OralCDx (OralCDx Laboratories, Inc, Suffern, NY) is a commercially available brush for performing these types of biopsies. Further studies are necessary to identify which patients and lesions should be assessed with this technique. The role of staining methods has also been promoted to assess patients at risk for the development of oral cancer and/or to determine the most appropriate location for biopsy using a toluidine blue rinse. Oratest (Zila Pharmaceuticals, Inc, Phoenix, AZ) is a commercially available mixture that has been studied and is currently used in some centers for these indications.

Radiographic techniques including CT scans, MRI, and CT/PET scans continue to play a role in assessing primary, regional, and distant disease in HNSCC while also providing information related to staging.284 Many of these techniques for secondary prevention are covered in greater detail in Chapters 1–5Chapter 1Chapter 2Chapter 3Chapter 4Chapter 5 and 12 (Box 10-1).