HEALTH NEWS

To answer this question, it is necessary to estimate the total resources and costs involved in screening ,diagnosis, and effective intervention. The estimate will be based in part on the direct and indirect costs of each screening procedure ,multiplied by the estimated number of persons to be screened . this includes the initial investment required to put in place the capacity to perform screening ,as well as the recurrent costs of performing each screening procedure . indirect costs are difficult to calculate ,but should include at least the costs of the required planning, public education, and staff training . Costs also include the costs of definitive diagnosis, based on the estimated number of people who will have abnormal results on screening , and the direct and indirect costs of performing the relevant confirmatory tests, as well as expenses for transport, record keeping, and communication. The estimate of the costs of treatment should be based on the number of persons who

Screening or diagnostic procedures or treatments that are inconvenient, uncomfortable, or invasive , violate cultural taboos, or result in social stigmatization or economic hardship are likely to be insufficiently used by the public. The best way to avoid introducing unacceptable services is to involve menders of the community in decisions about which services, if any , to introduce, and how . the preferences and convenience of the population to be screened and treated on the basis of screening results are frequently not considered, with predictable consequences. For example, workers need preventive services they can receive without loss of pay. Maternal and child health services, including family planning, need to be organized so as to take account of problems of child care, transport, and the responsibilities of working mothers . the maximum integration of screening activities into established, locally available services used by the population will tend to minimize inconvenience.

The burden of suffering that the condition represents for the society should be large enough to warrant special effort. Priority should be given to conditions having a significant impact on the quality of life and survival of a large proportion of the population. Devastating but rare conditions should receive attention only after common causes of significant suffering or disability have been dealt with. Are there effective preventive or curative measures to deal with the condition when it is detected at an early stage Effective intervention may be carried out wholly or primarily within the health sector, may require intersectoral  coordination, or may depend largely on action in other sectors, agriculture . I may require action at the policy or programme level, involve community mobilization, or consist primarily of clinical treatment of individuals.  In some cases, there is no benefit to be derived from intervening before symptoms occur. Is there a safe, ethical , and efficacio

Screening for skin cancer in the general population is not recommended . in areas of high prevalence, education of the public in primary prevention (use of sunscreen products, hats  and other protective clothing ) and in early detection (self-referral for suspicious lesions )in more rational. Resource levels required. Low for screening by inspection of exposed skin by primary car workers, but the technique needs validation ; high for biopsy and surgery. Liver cancer Screening is not recommended . no accurate screening test exists, and there is no evidence of any benefit from early detection. Emphasis should be on primary prevention through community-wide action for the prevention of hepatitis B infection, especially in infants .

Screening of asymptomatic men is not recommended as a priority at the present time.  Many false positives are obtained on screening by digital examination of rectum. Definitive diagnosis is expensive (serum tumour markers, ultrasound , biopsy ) . recent studies raise serious questions regarding the benefits of early detection and surgical intervention before symptoms develop (USPSTF,1989; brawer et al., 1992). In studies in the USA , men of African origin and men with a family history of prostate cancer appeared to be at greater risk; these groups should therefore be given priority for screening (USPSTF,1989) Resource levels required. Medium for detection by digital rectal examination, high for biopsy; high for surgery.

Screening of asymptomatic persons for colorectal cancer is not recommended as a priority at present. Many false positives and false negatives are yielded by affordable screening tests (ahlquist et sl ., 1993)and evidence for the benefits of screening is inconclusive (USPSTF,1989).while screening by sigmoidos copy may be efficacious (Levin, 1992;selby et al., 1992)it is expensive and of low acceptability in many cultures. Emphasis should be on primary prevention through a high-fibre diet. Resource levels required. Medium for screening by testing for faecal occult blood or digital rectal examination, but results are inconclusive; high for sigmoidoscopy, radiological studies, and biopsy; high for surgery. 

Why. cancer of the breast is the leading cause of cancer deaths in women in many developing countries, as well as in most developed countries .early detection can significantly improve the chances of survival (Stanley et al., 1987)as well as quality of life, making far less radical therapy necessary. current use of lumpectomy rather than mastectomy in many cases makes treatment more acceptable than in previous years. Who and how .the USPSTF (1989) recommends annual clinical examination of the breasts in women aged 35 and older with a family history of premenopausal breast cancer in a first-degree relative, and of all women aged 40 and over. They recommend mammohraphy every 1-2years in the high –risk group, and every 1-2 years for all women aged 50-75. The Canadian task force recommended an annual clinical examination and mannography for all women between the ages of 50 and 59 and only an annual clinical examination for those aged 40 to 49 (CTF, 1986;Morrison, 1986).the WHO collabora

Why. cervical cancer is the most common cancer in women in developing countries and is curable if detected early. Targeted screening for cervical cancer is highly recommended within a primary health care strategy when the capacity exists, preferably at the district level, for reaching the women at highest risk. Targeted screening and treatment should be combined with action for primary prevention through the provision of access to safe family planning methods, the prevention and control of STD , and the prevention of smoking which is an important risk factor for cervical carcinoma. the woman at highest risk are those over 35 years of age and those with STDs. Who, how , and when. Who has developed recommendations for cervical caner screening that are relevant to the needs of developing countries (WHO meeting, 1986; Stanley et al , 1987; stjernsward et al , 1987). WHO collaborating centres have made important contributions in that area (habbema, 1990). The following comments are a sum

Why , to identify people at risk of cerebrovascular accidents, for medical (anticoagulant)or surgical (carotid endarterectomy)intervention. How , auscultation (stethoscope)or Doppler ultrasound. Definitive diagnosis requires arteriography. Resource levels required. Medium, high , or very high for detection. very high for intervention with carotid endarterectomy. Recommendation on use of screening. Screening of asymptomatin adults is not recommended . accurate detection involves invasive tests that are expensive and have serious associated risks. intervention is extremely expensive and of uncertain long-term benefit. A recent large clinical trial in the USA found no evidence that vascular surgery prevents stroke in patients with asymptomatic carotid stenosis demonstrated on screening(pierce,1992).emphasis should be on primary prevention through reduction of risk factors for cerebrovascular disease (smoking prevention or cessation, diet, exercise)in the community.

Why , opportunistic screening has been recommended to health care providers in north America, so that patients whose behavior is damaging to their health can be counseled . tobacco , alcohol, high-salt diet, and sedentary habits are major risk factors for hypertension and ischaemic heart disease, which are now important causes of suffering  and premature mortality in most developing countries . it appears that advice from a sympathetic health care provider can help individuals change their behavior, leading to health-promoting changes;such advice may be especially effective when the care provider is well known to the patient. Who , all adults. How and when , enquiry (verbal; questionnaires with literate population).optimal frequency of screening and counseling is not established. How and when . enquiry (verbal; questionnaires with literate population). Optimal frequency of screening and counseling is not established. Resource levels required . low for detection (enquiry ); low

Recommendation on use of screening. Uncertain recommendation on routine screening of general population regarding occupational exposures. Opportunistic screening may be reasonable, especially in areas where it is known that the population is exposed to occupational hazards. The benefit of questioning individuals during routine health care is uncertain. It appears reasonable to ask about potential occupational hazards when completing an adult s health history . however, this may not lead to effective action. The most rational strategy is one that emphasizes primary prevention and routine monitoring of workplaces. Workers in high-risk occupations should be screened for relevant immunization status on starting employment. There should be routine surveillance of workplaces to detect and minimize hazards. This ,along with training workers and ensuring that they are properly equipped, should be at the centre of a preventive strategy, with screening only an adjunct. Certain persons may be

Why . glaucoma is an important cause of irreversible blindness; effective treatment exists for high levels of intraocular pressure, but this condition is rare in the general population under the age of 65. No clear evidence exists that early intervention for moderately increased levels of intraocular pressure in asymptomatic persons leads to improved outcome (W@HO,1984;USPSTF,1989). How and resource levels required .screening and definitive diagnosis by means of tonometry , ophthalmoscopy, and perimetry  (all requiring medium or high resource levels); screening by non –specialists is of uncertain efficacy. Intervention medium (medication to reduce intraocular pressure)or high (surgery). Recommendation on use of screening . screening of the general population is not recommended as a priority. Persons at special risk should be under special surveillance (eddy et al ., 1989 ; gottlieb et  al., 1983;USPSTF, 1989). The elderly should be screened for visual problems; those with p

Why, cataracts are a leading cause of preventable blindness in the elderly. New methods of cataract surgery do not require a hospital stay. Many elderly people consider limited visual acuity a normal part of the aging process and thus not symptomatic of any disease, despite significant reversible disability. Who. Elderly people . How . screening by enquiry and observation, ideally making use of a visual chart or appropriate pictorial substitute . When . frequency uncertain. Resource levels required. Low for initial screening by enquiry or simple assessment of acuity, which can be done by trained primary care workers (venkataswamy, 1972;  medium for optometric examination; high for cataract extraction or corrective lenses, but there are ways in which this secondary-level medical care can be provided at relatively low cost in developing countries (WHO, 1984b) Recommendation on use of screening early detection. Screening early detection is recommended in the elderly, not only

Why . increased life expectancy has made the health of the elderly an issue of concern in most countries. Changes in society also make the social isolation of the elderly a problem not restricted to the industrialized world . the elderly are vulnerable, and it should be possible to design appropriate ways of promoting an optimum quality of life for the elderly in a primary health care context . screening for cataracts, a common and treatable cause of blindness in the elderly , addressed below. How , a recent essay aimed at general practitioners in the united kingdom urges that screening (of the elderly ) should be oriented to the patient s functioning and not to disease (freer, 1990). Periodic assessment is recommended, including  assessment of mobility, social and mental functioning, hearing, vision, and continence, and a review of medication, the author also recommends an annual home visit. The USPSTF (1989)has stressed assessment of functional status as an essential component of

Psychosocial problems, including problems of mental health ,alcohol and drug abuse, and domestic violence Patients whose mental disorders are presented somatically are frequent users of medical services and form a substantial proportion of all patients seen in developing countries. There is evidence that provision of psychiatric care reduces subsequent use of medical services, so there would appear to be economic as well as humanitarian reasons for improving the detection and treatment of mental disorders in medical settings (hamburg, 1989). On the other hand , according to the USPSTF(1989),it has not been demonstrated in a controlled setting that the detection and treatment after signs and symptoms become apparent…however…some studies support the efficacy of counseling once the signs or symptoms of problem drinking…are detected. Screening for psychological problems may be desirable under certain circumstances, for example, where it is suspected that such problems account for a hi