Professional Documents
Culture Documents
4 5976285849506022679
4 5976285849506022679
Textbook of
Preventive and Social Medicine
In their Esteemed Opinion....
“ I congratulate you for your bold and strenuous effort in bringing out the Textbook of
Preventive and Social Medicine for medical students in India. This book would definitely
become popular very soon in India.”
— Dr M Sudarshan, Professor and Head, Department of Community Medicine,
Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
“This book is very informative and well written and can be used as reference by community
health personnel engaged in health care delivery.”
— Dr Deoki Nandan, Professor, Department of Social and
Preventive Medicine, SN Medical College, Agra, Uttar Pradesh, India
“I congratulate you for writing a good Textbook of Preventive and Social Medicine.”
— Dr VN Mishra, Professor and Head, Department of Social and
Preventive Medicine, LLRM Medical College, Meerut, Uttar Pradesh, India
“It was a pleasure to go through this book. The contents have been brought out at the
desired standard.”
— SD Gaur, Professor and Head, Department of Preventive and
Social Medicine, BHU, Varanasi, Uttar Pradesh, India
“The Textbook of Preventive and Social Medicine by Dr Mahajan and Dr Gupta is a very
good attempt.”
— Dr Abdul Rauf, Professor and Head, Department of Social and
Preventive Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India
Mahajan & Gupta
Textbook of
Preventive and Social Medicine
Fourth Edition
Revised by
Rabindra Nath Roy MBBS MD (PSM)
Associate Professor
Department of Community Medicine
Burdwan Medical College and Hospital
Burdwan, West Bengal, India
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: jaypee@jaypeebrothers.com
Overseas Offices
J.P. Medical Ltd. Jaypee-Highlights Medical Publishers Inc.
83, Victoria Street, London City of Knowledge, Bld. 237, Clayton
SW1H 0HW (UK) Panama City, Panama
Phone: +44-2031708910 Phone: + 507-301-0496
Fax: +02-03-0086180 Fax: + 507-301-0499
Email: info@jpmedpub.com Email: cservice@jphmedical.com
Jaypee Brothers Medical Publishers (P) Ltd. Jaypee Brothers Medical Publishers (P) Ltd.
17/1-B, Babar Road, Block-B, Shaymali Shorakhute, Kathmandu
Mohammadpur, Dhaka-1207 Nepal
Bangladesh Phone: +00977-9841528578
Mobile: +08801912003485 Email: jaypee.nepal@gmail.com
Email: jaypeedhaka@gmail.com
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the
publisher.
This book has been published in good faith that the contents provided by the authors contained herein are original, and is
intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the
authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of
the contents of this work. If not specifically stated, all figures and tables are courtesy of the authors. Where appropriate, the
readers should consult with a specialist or contact the manufacturer of the drug or device.
MC Gupta
Preface to the Fourth Edition
The last few years have witnessed a rapid progress in the field of Community Medicine. There was a felt need
for publication of an updated fourth edition of this book after a gap of couple of years. Many new concepts
have arisen and much more modifications have been incorporated over the past strategies. We think this edition
will also meet the expectations of the medical and nursing students, as well as the students of Public Health,
teachers of Community Medicine and the program implementers of health services.
Almost all the chapters have been thoroughly revised and updated; notably among those are epidemiology,
communicable and noncommunicable diseases, MCH and family planning, management, demography and vital
statistics, disaster, biomedical waste management, food and nutrition, immunization, geriatrics, communication,
etc. National Health Programs have also been thoroughly revised and updated. New data have been incorporated,
wherever applicable. Latest SRS and census data have also been included. Various domains that are of
importance, both in theory, practical and viva of MBBS examination have been highlighted with examples and
justification. Many postgraduate study materials have also been incorporated with references for further reading.
Various flow charts, diagrams and pictures have been introduced for clarity of understanding. Students will be
benefited for their preparation in answering MCQ for their Postgraduate Entrance Examination.
It is our earnest hope that fourth edition of this textbook will help the MBBS, Postgraduate aspirants,
Postgraduate students and the students of other public health disciplines. We will be grateful to the students and
the teachers for their valuable feedback, comments and constructive criticism. We will acknowledge and will try
our best to address those issues in the subsequent editions.
Preventive and social medicine is one of the most important subjects in the curriculum of a medical student.
Unlike other subjects, preventive and social medicine, community medicine and community health are the concern
not only of those specializing in these fields but of all others in the medical profession, including those engaged
in active clinical care as well as the health administrators. As a matter of fact, the subject is of serious concern
to all interested in human health and welfare, whether in the medical profession or not. The present book is
patterned on the earlier book Preventive and Social Medicine in India by Professor BK Mahajan, published in
1972. However, the marked developments in the subject during the last 20 years have necessitated extensive
changes and additions. Hence, this volume is presented as a new book in its first edition. The entire approach
is epidemiological and the subject matter is presented in a linked and continuous manner. The language and
style are simple, and attractive with emphasis on practical aspects which may be of utility not only to PHC medical
officers and health administrators but even to general practitioners.
The whole book is divided into four parts. The first part deals with the general aspects of preventive and
social medicine and its scope. The second part, comprising two-thirds of the book, is built around the
epidemiological triad. The third part deals with demography, vital statistics and biostatistics. The fourth part is
devoted to health care of different groups, and includes detailed discussion of primary health care, health policy
and the relation between health and development. The above division is objective and purposeful. It makes
the reader familiar with the essential course content of community medicine, inculcates in him the epidemiological
approach to health and disease, and prepares him to practise family medicine as a family physician. A chapter
on general practice has been added for this purpose.
Though the book is primarily written for the undergraduate students, it would be of use to the postgraduate
students as well. The number of references has been kept to a minimum. Only those references have been
included which substantiate a controversial or less widely-known point, or which relate to recent work or review.
Inter-relation between health and development, health manpower planning, communicable disease
epidemiology in natural disasters, mental health program and the program for control of acute respiratory infections
have been discussed in detail. The national ICDS program has been given adequate coverage. Care has been
taken to include practical aspects in relation to diagnosis and management of leprosy, which may have to be
tackled by many PHC medical officers and general physicians. Special attention has been paid to the chapters
on social environment, host factors and health, noncommunicable diseases, food and nutrition, demography
and vital statistics, health policy, planning management and administration, primary health care, health education,
information and communication, maternity and child health, school health, geriatrics, mental health and health
service through general practitioners so as to present the concerned topic in a most up-to-date and easily
comprehensible manner.
Some sections, such as those relating to water supply and disposal of wastes, could have been reduced further
by omitting certain details; the latter have been retained in view of the requirement of public health administrators.
The existing curricula of various universities, as also the suggestions from eminent professors, have been given
due consideration while preparing this book. We shall feel amply rewarded if this book is found useful for students,
teachers, public health administrators and PHC medical officers.
We are grateful to a large number of colleagues in different parts of India, who spared their valuable time
and effort to go through the manuscript, offered constructive suggestions and incorporated appropriate changes
wherever necessary. These include Professor YL Vasudeva and Professor Sunder Lal (Rohtak), Professor RD
Bansal and Professor SC Chawla (LHMC, Delhi), Professor OP Aggarwal (UCMS, Delhi), Professor G Anjaneyulu
(Hyderabad), Dr GS Meena (MAMC, Delhi), Professor IC Verma, Dr Bir Singh and Dr Ravi Gupta (AIIMS, Delhi),
Dr GVS Murthy and Dr K Madhavani (Wardha), Dr LN Balaji (UNICEF) and Professor KK Wadhera (CMC,
Ludhiana). Professor Bansal, Professor Anjaneyulu and Professor Wadhera, in particular, took special pains to
Textbook of Preventive and Social Medicine
go through the entire manuscript critically at various stages of preparation. We owe special gratitude to Professor
G Anjaneyulu, for writing a foreword to the first edition for the book after going through the entire manuscript.
We are thankful to the American Public Health Association, Washington, and the Institute of Health and
Nutrition, Delhi, India for permission to reproduce certain portions of the text from their publications. Reference
to original source has been made wherever this has been done. We must thank to M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, India, who have done a marvellous job in record time, in spite of delay from
our side. We must also acknowledge the contribution of our typists Shri Rameshwar Dayal and Shri Murli Manohar,
whose excellent typing skills greatly reduced the drudgery associated with drafting and redrafting of a manuscript.
Lastly, we must express our heartfelt thanks and indebtedness to our wives who silently, and sometimes not
so silently, suffered—their husbands continuously lost in books, papers and proofs in utter disregard of their
domestic responsibilities.
MC Gupta
(Late) BK Mahajan
x
Acknowledgments
We would like to thank the people without whom this book would not have been possible, they are our colleagues,
students and our family. We are thankful to the Almighty for the ability, circumstances and health that were
needed to write the book. Last but not the least both the editors thankful to M/s Jaypee Brothers Medical Publishers
(P) Ltd, Kolkata and New Delhi, India to give this special opportunity to update and revise
Mahajan & Gupta Textbook of Preventive and Social Medicine.
Contents
PART I: GENERAL
4. General Epidemiology 28
• Types of Epidemiological Study 28; • Study Design 29; • Cohort Study (Follow-up Study) 34;
• Types of Therapeutic or Clinical Trials 38
xv
Textbook of Preventive and Social Medicine
xvi
Contents
38. Anthrax and Bioterrorism 671
• Anthrax 671; • Bioterrorism 673
Index 693
xvii
PART I: General
Preventive and Social Medicine is comparatively a improvement in economic condition or education and
newcomer among the academic disciplines of medicine. vice versa.
Previously it was taught to medical students as hygiene Among the developing countries, India gave a lead
and public health. This name was later changed to for bringing about the total well being of rural people
preventive and social medicine when it was realized that by instituting the remarkable Community Development
the subject encompassed much more than merely the Program (1951). For intensive all-round development,
principles of hygiene and sanitation and public health the country was divided into Community Development
engineering. The name preventive and social medicine Blocks in which ill-health was to be fought through the
emphasizes the role of: (a) disease prevention in general agency of primary health centers as recommended by
through immunization, adequate nutrition, etc. in the Bhore Committee. It may be mentioned that the
addition to the routine hygiene measures, and (b) social concept of public health was fairly well developed in
factors in health and disease. ancient Indian. Adequate proof of community health
The name preventive and social medicine has gained measures adopted during Harappa Civilization as far as
wide acceptance in the past twenty-five years or so 5000 years ago has been found in the old excavations
because of its broader and more comprehensive at Mohenjo-Daro and at Lothal near Ahmedabad in the
outlook on medicine, integrating both prevention and form of soakpits, cesspools and underground drainage.
cure. Today, it implies a system of total health care
delivery to individuals, families and communities at the
clinic, in the hospital and in the community itself.
Public Health, Preventive
Medicine, Social Medicine and
Historical Background Community Medicine
Traditionally, a young man planning to enter the medical
During last 150 years, there have been two important
college has in mind the picture of a patient in agony,
“revolutions”. The industrial revolution in 1830 was in relieving whose suffering by medicines he considers
associated with the discovery of steam power and led himself to be amply rewarded. He always thinks of
to rapid industrializations, resulting in concentration of alleviating the suffering of a patient but rarely about the
wealth in the cities and, consequently, migration from prevention of such suffering at the level of the individual
rural to urban areas. The net result was that on the one patient, his family or his community. No doubt he has
hand the villages were neglected and, on the other, the to play a very important role in meeting the curative
towns and cities witnessed rapid haphazard expansion, needs of society but that is not all. The community in
often leading to creation of urban slums. These changes the past has felt satisfied with that curative role. But now
brought in their wake and more complex health the developing society, in India and elsewhere, expects
problems in rural as well as urban areas which ultimately much more from the doctor, and the people are
led to development of the concept of public health. The gradually becoming more and more conscious of their
social revolution occurred around 1940, during the health needs. These varied expectations are reflected
Second World War. The social revolution brought into in the fact that the subject has been practised in the past
force the concept of ‘Welfare State’. It envisaged the under different names as discussed below.
total well being of man, paying major attention to the
forgotten majority living in the villages. It was aimed at
Public Health
fighting the three enemies of man—poverty, ignorance
and ill-health on a common platform. This followed the It was defined by Winslow (1851) as the science and
realization that health was not possible without art of preventing disease, prolonging life and promoting
PART I: General health and efficiency through organized community With the advent of the specialty of preventive medicine,
measures such as control of infection, sanitation, health emphasis was also given to prevention of diseases.
education, health services and legislation, etc. Public These included not only infective diseases but also others
Health developed in England around the middle of the such as nutritional deficiency diseases.
nineteenth century. Edwin Chadwick, a pleader, the
then Secretary of Poor Law Board (constituted under Social Medicine
Poor Law Act passed in 1834) championed and cause
of community health and the first Public Health Act was It is defined as the study of the man as a social being
passed in 1848. This signified the birth of public health. in his total environment. It is concerned with the health
Public Health in India followed the English pattern of groups of individuals as well as individuals within
but the progress was extremely slow during the British groups. The term social medicine gained currency in
regime. It started after 1858 when a Royal Commission Europe around 1940.
was sent to find the reasons for heavy morbidity and In 1949, a separate department of Social Medicine
mortality among European troops in India due to was started at Oxford by Professor Ryle. The concept
malaria and some other preventable diseases. The of social medicine is based upon realization of the
Public Health Departments started as vaccination following facts:
departments and later as Sanitation Departments at the • Suffering of man is not due to pathogens alone. It
Center as well as in the Provinces around 1864. There can be partly considered to be due to social causes
was a long tussle whether the Sanitation or Public Health (social etiology).
Department should be responsible directly to the • The consequences of disease are not only physical
Government or to the Surgeon General-in-Charge of (pathological alterations due to pathogens) but also
Hospitals and Medical Education. It took almost 40 social (social pathology).
years for the British Government to decide in 1904 that • Comprehensive therapeutics has to include social
Public Health Departments should function separately. remedies in addition to medical care (social
The designations of Sanitary Commissioner and Assistant medicine).
Sanitary Commissioner were changed to those of • Social services are often needed along with medical
Director and Assistant Director of Public Health. Thus care services.
curative and preventive departments worked separately Interest in social medicine began to decline with the
as Medical and Public Health Departments. This conti- development of epidemiology. The Royal Commission
nued in India even after independence for some time, on Medical Education substituted in 1968 the term
though the idea of integration started at the beginning social medicine by community medicine in its report
of the Second World War. A recommendation to this (Todd Report).
effect was made by the Bhore Committee in 1946.
Preventive and Social Medicine
Preventive Medicine
As clarified above, preventive medicine and social medi-
Preventive medicine developed as a specialty only after cine cover different areas, though both are concerned
Louis Pasteur propagated in 1873 the germ theory of with health of the people. This is why the combined
disease followed by discovery of causative agents of name Preventive and Social Medicine was suggested to
typhoid, pneumonia, tuberculosis, cholera and provide a holistic approach to health of the people. This
diphtheria within the next decade. It gained further name was preferred to the earlier name public health
impetus during subsequent years from the following because the former had come to be visualized as a
developments: discipline dealing mainly with sanitation, hygiene and
• Development of several specific disease preventive vaccination. However, the term public health has now
measures before the turn of the century (antirabies once again become fashionable in England.1
treatment, cholera vaccine, diphtheria antitoxin and
antityphoid vaccine).
Community Medicine
• Discovery and development of antiseptics and
disinfectants. It has been defined as “The field concerned with the
• Discovery of modes of transmission of diseases study of health and disease in the population of a
caused by germs. Transmission of malaria, yellow defined community or group. Its goal is to identify the
fever and sleeping sickness had been elucidated health problems and needs of defined populations
before the turn of the century. (community diagnosis) and to plan, implement and
It may be said in retrospect that when public health evaluate the extent to which health measures effectively
2 gained roots with the passage of the Public Health Act, meet these needs”. 2 Broadly, one could state that
the emphasis was on environmental sanitation alone. community medicine, while encompassing the broad
scope of preventive and social medicine, lays special
3
Basic Concepts in
2 Community Medicine
In this chapter, we will first consider why should a detailed information about the medication. When the
medical student study community medicine. Then we child and woman come back a few months later in
shall discuss the basic concepts related to health, disease a worse condition with the same recurrent problem,
and prevention. your conscience is pricked. Now it becomes obvious
that there is something wrong with the system. Medical
care itself is not sufficient. Individual illness is itself
Why to Study Community symptomatic of a wider social malady afflicting the
Medicine? individual, the family and the community.
3. Let us now look at the situation existing in many of
Before the student starts studying community medicine,
our remote, ill connected villages. In a small hamlet
he must have motivation to study it. Motivation can follow
cut off from modern civilization, a male infant aged
only when he can get a clear answer to the question—
eight months, the only child of his parents and the
“I want to become a doctor, treat patients and reduce their
fond hope of his grandparents, suffers from diarrhea.
suffering. Why should I study community medicine at all”?
There are no trained health functionaries in the
Let us try to answer this question. Some of the reasons village. The nearest hospital is 35 kilometers away.
why a medical student should take interest in community The parents, being landless laborers, have no means
medicine and study it seriously are given below: to reach the nearest hospital. Within 12 hours the
Treatment of patients: A doctor’s aim should be to child’s condition becomes critical. The mother gives
treat a patient, not to treat a disease. For example, a the child some herbal decoctions as advised by the
patient may present to a doctor with malnutrition, local dai. The result: no improvement. Within another
tuberculosis or diarrhea. The doctor’s responsibility does six hours the child takes his last breath. With all its
not end with prescribing nutritious diet, antitubercular technological sophistication, does modern medicine
drugs or fluid therapy. If he does so, he would merely have an answer for this unwarranted death? Unless
be treating a disease episode, not the patient. In order technological breakthroughs are supplemented by
to understand this better, let us imagine three scenarios. “social revolution” to communicate information
1. Imagine yourself sitting in a busy pediatric outpatient effectively to the thousands who need them, they are
clinic. A mother has just brought in her fifth child, of no avail. Cheap interventions like ORS can
a boy aged two years. He has sunken eyes, wizened become meaningful only if people are armed with
appearance, wasted muscles, pot belly, bow legs and knowledge about them and put this knowledge into
a skin and bones appearance. You chide the mother practice whenever needed. This is an area where
for her “uncaring attitude” and ignorance and scold community medicine practice can help.
her for coming so late. You prescribe a dose of It is clear from the above three realistic examples
vitamin A and an antihelminthic, give cursory advice that for treating a patient in the real sense of the word,
on nutrition and send her away. The case sheet is a doctor has to know more than clinical medicine; he
closed and you call out the next patient. You learn has to know the preventive and social aspects of disease.
after 6 months that the child died some time ago. Social equity: Resources for health care are limited. These
2. Imagine a different scenario. This time you are sitting resources must be equitably distributed among the people.
in a busy medical OPD. A 30-year-old mother of For the cost of one big hospital, it is possible to create 50
three children presents with cough of three months small accessible health posts in the community. For one
duration, loss of weight, hemoptysis and continuous patient needing coronary bypass surgery, there are
fever. You put your stethoscope to her chest and thousands in need of treatment for diarrhea, skin disease,
before you have time to blink your eyes, the diagnosis respiratory infection, fever and hepatitis, etc. Who should
stares you in the face. You prescribe antitubercular get priority when it comes to providing free medical care
drugs, record the notes and send her to the through the country’s health system—the bureaucrat or
dispensary, expecting the staff there to give her politician who needs sophisticated cardiac care or the
thousands of unimmunized, malnourished children and discipline of community medicine. Knowledge of
Health services planning: The needs of the many Health team leadership: Health practice is a team
should take precedence over those of the few. This issue effort and the doctor is the team leader. The varied
becomes even more complex and critical by our knowledge encompassed within the ambit of community
knowledge that those who are in the greatest need of medicine will make the doctor a strong team leader and
health care may not even know about their need; even an able health administrator.
if they do, they may not be able to seek health care.
How can we come to know what the population’s health Concepts of Health
needs are? Do we even know whether health is a priority
for most people? And what are the reasons which prevent Health is one of the most difficult terms to define. Health
them from seeking help at designated health facilities? can mean different things to different people. To some
Such questions must be answered before health services it may mean freedom from any sickness or disease while
are planned for people. Experience of community to some it may mean harmonious functioning of all body
medicine can considerably help in this regard. systems. It may be construed as a feeling of “wholeness”
and a happy frame of mind. At the center of the debate
Doctor’s responsibility: At the center of a moralistic is whether health denotes a positive quality or whether
debate is the question of a doctor’s responsibility. To it should be understood or defined in terms of the
whom is a doctor responsible? Only to those who absence of a negative quality, i.e. freedom from disease.
come to the clinic or also to those who need his Modern medicine or modern medical practice tends to
services but cannot come to the clinic? Where does view health as simply the state of absence of all known
the responsibility end? We must realize that the health diseases. Doctors are too busy fighting disease to be
sector in a country cannot be divorced from the unduly bothered about health. Even when they are
country’s economic or social fabric. Sitting in an ivory caring for well babies, the parameter chosen to so define
tower may isolate us but cannot insulate us from a baby is in terms of absence of congenital abnormalities
reality—the situation existing in the country. Thus or postnatal deleterious effects. When doctors spend time
modern medicine has to extend itself outside the to screen adult populations for carcinoma of the cervix,
confines of the four walls of a hospital and seek hypertension or the like, their focus of interest is on
solutions at an affordable cost. It is not enough to absence of these morbid conditions. Thus the emphasis
have theoretical knowledge and the pharmaceutical in modern medicine has been on freedom from disease.
prescriptions to promote health and manage disease If this be the yardstick, then what does one strive for?
in the community. We must also necessarily have a If the best is to be the goal, health necessarily needs to
system of health care delivery that can implement the be defined in a positive fashion.
feasible solutions and make them available to as many The WHO (1948) has attempted to construct a
as possible at a cost that the country and the positive definition of Health and has described Health
community can afford. Community medicine strives as “a state of complete physical, mental and social well-
to provide the appropriate solutions in this regard. being and not merely an absence of disease or infirmity.1
Examples are the national programs for malaria, filaria, Later on (1978), it has been added as to lead a “socially
tuberculosis, AIDS, iodine deficiency diseases, diarrheal and economically productive life”. This is an all-
disease, anemia, vitamin A deficiency, etc. encompassing definition and clearly places health on a
Patient’s queries: Many a time a doctor is confronted higher pedestal in comparison to disease. This definition,
with the question—“Doctor, what is the chance that I however, refers to an ideal state which one strives to
may get carcinoma of the lung since I smoke 20 achieve, though one may not be able to do so. There
cigarettes a day”? or, “Doctor, I am suffering from has been criticism that using such a yardstick, very few
tuberculosis. Can I breastfeed my child”? Answers to people would be categorized as healthy since almost
these questions are only possible if one is familiar with everyone whould have some grade of ill health or
the natural history of disease, its etiology and the myriad abnormality, may be in a clinical, subclinical,
risk factors and their interactions. These are addressed pathological or biochemical sense. It is perhaps best to
by community medicine. talk of the WHO ideal of positive health as the top of
the ladder while other categories of health status may
Interaction with patients: Even doctors who have occupy lower rungs. A diseased state may be categorized 5
decided to set up private practice can benefit from the at the lowest rung of the ladder.
Such a categorization of health is skin to a spectrum,
PART I: General family and community spheres and is not unduly
with positive health at one end and a diseased state at aggressive. However, there may be transient digression into
the other end. This conceptualization permits one to talk the zone of the abnormal, especially under stress or duress.
of health as a dynamic state capable of moving up or Tests have been developed in recent decades which indicate
down the ladder, rather than a static state in equilibrium. the mental health status of individuals. These include tests
This is appropriate because the health status cannot for IQ, personality tests, thematic appreciation tests and
remain constant for an individual, family, community projective techniques.
or country over a period of time. Spiritual health may be construed as a component
Let up now look at the components of the WHO of mental health. In societies like the Indian society,
definition, i.e. physical, social and mental well-being. religion has played an important role in shaping the
Physical well-being is most easily understood by all cultural ethos. Many individuals strongly believe in the
of us. Physical health relates to the anatomical, supernatural. In such situations a positive mental health
physiological and biochemical functioning of the human embraces spiritual health. Spiritual health may help to
body. Thus the attributes of physical health denote resolve both internal as well as external conflicts.
normalcy of the body structure and organs and their Many a time doctors are approached by patients
proper functioning. One should remember that a with vague complaints like generalized aches, disinterest
“normal state” in medicine is based on the law of in work, easy fatiguability, etc. However, no abnormality
averages and the extent of deviation from the average is detected on examination. Are these individuals to be
or the mean. Thus the normal state for a European may classified as “healthy” or in poor health? Though they
be different as compared to the Asians. If the deviation may not be actually diseased, they may also not be
is excessive, it may constitute an abnormal situation. The labelled as healthy because they perceive themselves as
selection of the limits of “normalcy”, even in statistical not being in good health, and their mental health is
terms such as 2 standard deviations from the mean, is thus compromised. Health, therefore, is not a constant
an arbitrary cut off point. Thus the line dividing normal entity but a relative state. It is relative to time as well
and abnormal is very thin near the preselected limits. as to individuals. The threshold of pain is not the same
It should also be remembered that these limits of in any two individuals and so their perception of a
normalcy can change over time or generations. healthy state is obviously different. Therefore health
Various modes of assessment of physical health are appears to be a matter of degree. Almost every
available, e.g. height, weight, muscle mass, head circum- individual’s state of health can potentially improve.2
ference, serum estimations, physiological tests of func-
tioning such as forced expiratory volume, etc. but all of
them define normalcy in statistical terms and in relation
Determinants of Health
to the risk of developing a particular disease, e.g. What is it that results in good health, optimum health
elevated serum cholesterol related to cardiac disease, etc. or positive health? It is certain that the health status
Social well-being is more difficult to define. In its cannot be the result of one particular activity. Many
simplest connotation, social health means that level of influences have a bearing on health. The influences
health which enables a person to live in harmony with which affect health and well-being are called
his surroundings. Man is, after all, a social animal. He determinants of health. Some of these determinants are:
both learns from and contributes to society. Health is Genetic configuration: The health of a population or
both a product of and a determinant of social values. an individual is greatly dependent upon the genetic
The cultural and ethnic background, the traditions and constitution of populations. These genetic factors may
mores, the economic and literacy levels, the needs and be overshadowed by other factors but still play a sub-
perceptions are all important in the consideration of social stantial role. Genetic traits related to certain enzymes
health. To measure social health is much more difficult (e.g. G-6-PD deficiency) or HLA markers (e.g. diabetes)
but social scientists have tried to make such measure- can lead to a change in health status.
ments more objective. Thus social health can be
measured by attitude scales, socioeconomic status, level Level of development: Economic and social
of literacy, employment status, etc. All these measures, development helps to improve health status. Such
however, are indirected measures of social health. development potentially removes many deleterious
Mental well-being is perhaps the most abstract compo- factors in the external environment of man. However,
nent to describe. Recent developments in psychiatry and affluence can also bring many problems in its wake.
psychology have helped in defining features of mental These are related to the lifestyle adopted by the affluent.
health in a better fashion. A positive mental health state Lifestyle: Contemporary Western society is nearing the
indicates that the individual enjoys his routine; there are pinnacle of socioeconomic development. This has led
6 no undue conflicts, nor frequent bouts of depression or to improved health facilities and increased health
elevation of mood, he has harmonious relations within the awareness. With improved literacy and better
employment opportunities now available, many of the Precise: Reliability, reproducibility and repeatability are
10
PART II: Epidemiological Triad
Epidemiological Approach in
3 Preventive and Social Medicine
Dictionaries define epidemiology as the scientific basis epidemiology was considered to be a science of
for public health and, especially, preventive medicine.1 epidemics and its application was limited to prevention
In keeping with this concept, the present book is and control of a few communicable diseases such as
patterned on the epidemiological approach, which is cholera, smallpox, plague, etc. which occurred in
symbolized in the triad of host, agent and environment. epidemic form. Gradually, the epidemiological method
To put it rather picturesquely, just as there are three of studying a disease by devoting attention to its
components in a drama on the stage, there are three occurrence and distribution, etiology, prevention and
components in the drama of disease as well. The stage control was extended to communicable diseases in
drama or a movie is built around a hero, a villain and general. During last few decades, the epidemiological
the life circumstances in which they operate and interact. approach has been used in the study of
The disease drama has similar components of hero (the noncommunicable diseases also, such as hypertension,
host), villain (the agent of disease) and circumstances coronary artery disease, diabetes, cancer, mental
(the environment). To summarize, the three disorders and even accidents and burns. As a result,
epidemiological components of a disease situation are: diseases are now broadly classified into two groups—
1. The host or the man who enjoys health or suffers from communicable and noncommunicable—for the
disease (The World Health Organization defines health purpose of epidemiological study.
as a state of complete physical, mental and social well-
being and not mere absence of disease or infirmity.
2. The agents, whether living (such as bacteria and Definition of Epidemiology
viruses) or nonliving (such as radiation, temperature As the scope of epidemiology has enlarged over the
and minerals, e.g. lead, fluorine). years, the definition of epidemiology has also changed
3. The environment comprising of food, air, water, from the previous narrow definition as “the branch of
housing, place of work, etc. which surround both medical science dealing with epidemics” as suggested by
the host and the agent and in which both interact. Parkin in 1873. Some broader definitions are given below:
The host, the agent and the environment are discussed • It is an orderly study of incidence in human society
in detail later in this chapter. The outcome of the host- of any morbid state (communicable and non-
agent environment interaction may be in the nature of communicables disease, accidents, injuries and
health, discomfort, disability, disease or death. Thus all abnormalities of medical importance).
individuals in a population group may be equally exposed • It is a study of the role of the agent, host and
to the same agent and environment, yet some may totally environment in the natural history of disease.
escape the disease, others may get only a mild attack while • It is the study of relationship among various factors
yet others may develop the full blown disease which may and conditions in the agent, host and environment
culminate in death. This is so because the exact outcome that determine the frequency of occurrence and
is determined by host factors inherent in each individual. distribution of an infectious process; a disease or a
These are described detail in Chapter 14. physiological state in a population.
• According to Lilienfeld, “Epidemiology is the study
of the distribution of a disease or a physiological
Concept of Epidemiology condition in human populations and of the factors
Epidemiology is a scientific study of factors and that influence this distribution”.2
conditions related to disease as they occur in people. • The study of the frequency, distribution and deter-
The word epidemiology is derived from epi (in, on, minants of disease (International Epidemiological
upon); demos (people) and logos (science). Formerly, Association).
PART II: Epidemiological Triad • The study of the distribution and determinants of
health related states and events in populations and
the application of this study to control health
problems.3
Out of the above definitions the last one is the most
modern. To put it even more simply, “epidemiology is
the study of distribution and determinants of health
related events in population.”4 The meaning of four
words in this definition needs to be explained for a Fig. 3.1: The epidemiological triad
proper understanding of this definition.
The Agent The known agents in relation to food and nutrition are
energy, protein, carbohydrate, fat, vitamins, minerals,
12 The agent is defined as an organism, a substance or a water and fibre. Their nature and role in health and
force, the presence or lack of which may initiate a disease are discussed in detail in Chapter 22.
Chemical Agents Genetic endowment: The genetic constitution either
TABLE 3.2: Reported deaths from plague in India4 Cause Percentage of deaths
Year No. of deaths 1. Diseases of digestive system 41.2
1948 23191 2. Senility 14.7
1950 18813 3. Fevers 11.8
1952 3894 4. Prematurity 11.8
1954 705 5. Diseases of respiratory system 5.9
1958 206 6. Diseases of circulatory system 5.9
1962 200 7. Accidents 5.9
1966 8 8. Others 2.9
1970 NIL
23
Note: The above data are based upon study of a representative
1994 53 sample of 6025 out of a total population of 1,03,676.
PART II: Epidemiological Triad cular disease or as regards outcome of diseae. As an such as rainfall. Such trend forecasts are currently being
example, it has been calculated that the lifespan of an made in respect of AIDS.
American male having 20 percent extra weight is 4 years
shorter than his normal weight counterpart. Other TO IDENTIFY SYNDROMES
examples are the risk of bearing a mongol child in relation A syndrome refers to association of two or more
to mother’s age and the risk of developing lung cancer medical phenomena. Syndromes can be identified
and coronary disease in relation to smoking. While the risk when it is discovered through epidemiologic studies that
of bearing a mongol child is less than one in thousand for apparently unrelated phenomena have the same cause.
mothers below 30 years, it rises steeply thereafter to about Examples are Plummer-Vinson syndrome (koilonychia
1 in 45 for mothers above 45 years of age. and esophageal cancer) thiamine deficiency (Wernicke’s
encephalopathy, peripheral neuritis and wet beri-beri),
TO PLAN HEALTH SERVICES and vitamin B 12 deficiency (anemia and subacute
Health services—preventive, curative as well as rehabi- combined degeneration of spinal cord). Conversely
litative—must be commensurate with the health prob- epidemiologic investigations may reveal that what had
lems in a region. Adequate epidemiological data base been lumped together earlier as one syndrome or
regarding the incidence and prevalence of various disease entity needs to be taken apart. An example is
diseases and disabilities is essential for planning proper the distinction between gastric and duodenal ulcer,
health services in a community. Examples are—health which was facilitated by the epidemiologic observation
manpower planning, hospital planning (number of beds that the former is more common among poor people.
per thousand population for particular diseases) and Another example is Sydenham’s uniform and consistent
planning of immunisation campaigns. Such planning is distinction of measles from other specific fevers. Other
essential for preventing wastage of resources, minimizing examples are distinction of gout from rheumatoid
costs and improving the effectiveness and acceptability arthritis, gonorrhea from syphilis and infective hepatitis
of health services. (hepatitis A) from serum hepatitis (hepatitis B).
Proportional mortality Number of deaths assigned to a specific Total number of deaths from all causes 100 or 1,000
cause during a given time interval during the same interval
Neonatal mortality rate Number deaths under 28 days of age Number of live births during the same 1,000
during a given time interval time interval
Postneonatal Number of deaths from 28 days to, Number of live births during the same 1,000
mortality rate but not including, 1 year of age, time interval
during a given time interval
Infant mortality rate Number of deaths under 1 year of Number of live births reported during 1,000
age during a given time interval the same time interval
Maternal mortality rate Number of deaths assigned to Number of live births during the same 100,000
pregnancy-related causes during time interval
25
a given time interval
PART II: Epidemiological Triad PERSON-TIME RATE 1. Definition of the problem, such as relationship of
A person-time rate is a type of incidence rate that directly cancer and smoking.
incorporates time into the denominator. When a 2. Statement of existing facts by tabulating all available
person or an event is observed for variable length of information as per age, sex, class, profession, habits
time we use person time as denominator for calculation and other characteristic features.
of such rate. The denominator is the sum of the time 3. Formulation of hypothesis, such as smoking causes
each person is observed, totalled for all persons and lung cancer.
numerator is still the number of new cases. 4. Testing the hypothesis by making observations, trials
or investigations to see if the hypothesis holds good.
Number of cases during
the period of observation 5. Statistical analysis and drawing of logical conclusions.
Person-time rate = ————————————— × 10n 6. Recommendations, if any.
Sum of time each person is
It may be mentioned that four things are needed
observed (total person time)
for carrying out a good field epidemiological study.
These are a field unit, a statistical unit, a laboratory and
Risk Ratio (Refer General Epidemiology—
an efficient transport system. The field unit consists of
Chapter 4, Page 35) interrogators, technicians, enumerators, social workers,
A risk ratio, or relative risk, is the ratio of incidence public health nurse, etc. with an epidemiologist as the
of disease among exposed to risk factor and that among head who should either be a good clinician himself or
non-exposed to risk factor. It compares the risk of some should have one in his team.
health-related event such as disease or death in two
groups. The groups may be differentiated by INTERNATIONAL CLASSIFICATION OF DISEASES
demographic factors such as sex (e.g. males versus
The essence of epidemiology lies in comparison of
females) or by exposure to a suspected risk factor (e.g.
health and disease related data with reference to time,
high fat vs low fat intake) or by other factors. A risk
place and person. Comparisons can be meaningful only
ratio of 1.0 indicates identical risk in the two groups.
when different people understand a particular health
Incidence of disease among exposed to risk factor term to mean the same thing all over the world. This
RR= ————————————————————————— is made possible through a system of “International
Incidence of disease among non-exposed to risk factor
Statistical Classification of Diseases and Related Health
ATTRIBUTABLE RISK (AR) Problems. 20 This is briefly referred to as ICD-10,
denoting that it is the tenth revision of the International
It indicates excess risk of a disease that can be ascribed Classification of Diseases. The first classification was
to exposure over and above that experience by non- published in 1893 as the Bertillon Classification of
exposed. It is also known as the ‘Attributable Risk International List of Causes of Death. During last ten
Percent’/Attributable Proportion or ‘Risk Difference’. It is decades, there have been as many revisions. From Sixth
a measure of the public health impact of a causative Revision (1948) onward, the ICD has been coordinated
factor and predict about the expected reduction in disease by WHO. The ICD-10 came into effect on 1.1.1993.
if the exposure could be removed (or never existed). It is essential for all doctors to understand the concept
Incidence among exposed – Incidence among non-exposed of ICD-10, its role and its limitations.
AR =—————————————————————————
Incidence among exposed
BASIC STRUCTURE OF ICD
POPULATION ATTRIBUTABLE RISK
The ICD-10 differs from ICD-9 in that it uses an
It is a measure of excess risk of disease in a population alphanumeric code instead of a purely numeric code.
that can be solely attributed to a particular risk factor. The basic or core code is a three character code,
It provides an estimate of the amount by which disease comprizing a letter of the alphabet (excluding U) followed
could be reduced in that population if the suspected by two digits from 0-9. When finer classification is needed,
risk factor is withdrawn. a fourth character, a digit, is added after a decimal.
Incidence of the disease in total population – Letter U is reserved for provisional classification of new
Incidence in non-exposed population diseases of uncertain etiology.
PAR = —————————————————————— The total ICD-10 is divided into 21 Chapters, each
Incidence of the disease in total population
chapter having a few blocks of disease categories. For
example, chapter 1 is titled “Certain infectious and para-
Methodology of Epidemiological Studies sitic diseases”. It covers entries from A00 to B99 spread
26 Any epidemiological study consists of the following six over 21 blocks. The block for viral hepatitis (B+15 to
methodical steps: B19) has the following three character categories:
B 15 Acute hepatitis A References
27
4 General Epidemiology
Diseases have afflicted mankind since days of yore. causes with a aim to suggest remedial measures for those
Alterations in growth, disturbances of metabolism, problems are called epidemiology. The word ‘study’
degenerative changes with advancing years, accidents, denotes scientific inquiry on some problem or event. The
poisons, tumors, cancers, and invasions of body by epidemiological investigation to health problem involves
microorganisms, all seem to have occurred with varying following two basic approaches.
extent and distribution with the changing environment 1. Asking questions: Availability of data is prerequisite
in which man has lived.1 for any systematic investigation on health problem
Epidemiology has been recognized as “the multi- in population; key information can be approached
disciplinary study of the distribution (person, place, through a series of questions:
time) and determinants (cause) of health-related • What is the health problem, condition, what are
states or events in specified populations and the its manifestation and characteristics?
applications of this study to control of those health • Who are affected, with reference to with age,
problems”.2-4 Epidemiology has evolved over a few sex, social class, etc.?
centuries. It has bor rowed from sociology, • Where does the problem occur, in relation to
demography, statistics, as well as other fields of study geographical distribution, residence, place of
and it is still considered as neonate or budding exposure, etc.?
science.5 It was not until the 19th century that the • When does it happen in terms of day, months,
fabric of epidemiology was finally woven into a seasons, etc.?
distinct discipline with its own philosophy, concepts • Why does it occur, in terms of the contributing
and methods. 6 Epidemiological principles and or causative factors?
knowledge of distribution of disease may be utilized • So what can be done? What intervention may
to describe the natural history of disease as well have been implemented? Have there been any
causal factors.7 Thus, it is useful to know how the improvement following any action?
duration of a disease and the probability of the 2. Making comparisons: The next basic approach is
various possible outcomes (recovery, complication, to make comparison and draw inference. Such
death) var y by age, gender, and so on. Such comparison may be made between different
knowledge is useful not only for prognostic purposes population at a given time, between subgroup of
but also in advancing hypotheses as to what specific population, or between various periods of
factors may be more directly involved in determining observation. By making comparisons, the
the course of disease in an individual.8 investigator attempt to find out the difference related
Epidemiology is the basic science of public health to study variables among study and comparison
that deals with health and disease in population. It has group, which help to draw inference on contributing
been defined various way by different epidemiologist. factor or etiology of a disease. To ensure the
‘comparability’ between the groups (i.e. study group
and control group), both the groups should be as
Definition similar as possible to all factors that may relate to
‘Study of the distribution and determinants of health the disease except to the variable under the
related states or event in a specified population and investigation. In other word we can say that ‘the like
application of this study to the control of health problems’ can be compared with like’.
(Jhon M Last, 1988). Last’s in his definition emphasized
that epidemiological study is not only concerned with the
disease but also with ‘health related events’. The term
Types of Epidemiological Study
‘epi’ means among and ‘demos’ means people; any Epidemiological studies can be broadly classified as
study undertaken among population to find the observational and experimental study with further
magnitude of health problems and their distribution, subdivision, however, these studies cannot be regarded
as watertight compartment; they complement one – Program trial
Evaluative study are those that appraise the value of Retrospective (Backward Looking Study)
health care; they are setout to measure the effectiveness
of different health services. They are of two main types: Here the investigator start with effect and goes back to
review and trials. find the cause.
• Program review In this study the investigator start with causative factor
• Trials and goes forward to the effect. The term prospective
29
– Clinical trials not necessarily mean that the study is carried out in
PART II: Epidemiological Triad which allows valid comparisons across different
populations. Pattern refers to the occurrence of health-
related events by time, place, and personal characteristics.
Fig. 4.1: Schematic presentation of prospective Sometimes we can study association between variables,
and retrospective study design which help in formulation of hypothesis.
A particular research question may be addressed using Periodic Trend (Cyclical Fluctuation)
different epidemiological approach; the choice depend
Periodic fluctuation in occurrence of diseases is known
upon nature of the disease, type of exposure and
as periodic trend, e.g. upsurge in influenza activity every
availability of resources, as well as result from previous
2 to 3 years result from antigenic drift of virus. Cause
studies and gap in knowledge. The descriptive studies
of periodic variation: (a) Variation in herd immunity, (b)
are primarily carried out for measuring frequency and
Antigenic variation in agent.
describing pattern of disease or health related problem
and for formulation of etiological hypothesis. On the
other hand both case-control and cohort study can be Seasonal Trend
used to test a hypothesis. For rare disease a case control
Annual variation in the disease incidence that is related
study design is useful and for common diseases cohort
in part to a season is called seasonal trend, e.g.
study is suitable (large no of subjects available and need
community acquired infections and nosocomial infections
follow-up to get sufficient number of case).
show increased incidence in winter months because
people inhale closed unfiltered air with droplet nuclei.
Descriptive Epidemiology
The distinctive feature of this approach is that its primary Acute (Epidemic) Trend
concern is with description rather than with the testing of
Short-term fluctuation is seen with epidemic outbreak.
hypotheses or proving causality. This study is concerned
Epidemic is portrayed by epidemic curve, which is a
with disease distribution and frequency in human
graphical presentation of number of cases plotted
population in relation to time, place and persons and
against time.
identifies the characteristics with which the disease in the
question is related. In this study the investigator tries to
PLACE DISTRIBUTION
get the answer of questions about a disease or health
related events. What is the problem and its frequency? World is not uniform in its characteristics, it varies in
Who are affected (person distribution)? When the disease culture, standard of living, genetic makeup, etc.
occurs (time distribution)? Where (place distribution)? Relative importance of these factors in etiology of a
Descriptive studies are useful to formulate hypothesis. disease can be studied due to difference in place
Distribution is concerned with finding the frequency distribution, e.g. migration study can distinguish genetic
and pattern of disease or health related events in a and environmental factor in disease aetiology. To analyze
30 population. Rate (number of events divided by size of by place, we usually organize data into a table, a map,
the population) may be used to measure frequency, or both. Variation may be classified under various levels.
• Formulation of new hypothesis concerning possible
TABLE 4.1: Strength, weakness and main difference between case control cohort study
Case control Cohort
• Proceed from effect to cause • Proceed from cause to effect
• Start with diseased population • Start with people exposed to the factor under study
• Case control provide information about one outcome only • Useful for evaluating more than one outcome related to single
exposure
• Allow to study the range of exposure • Usually focus on one exposure only
• Suitable for study of a rare disease • Impractical to consider cohort study for rare diseases
• For rare exposure study, case control may not suitable one • Suitable for rare special exposure study
• Cannot estimate the incidence of a disease, so only can give • Can provide accurate estimate of incidence of a
estimate of relative risk (odd’s ratio) disease—possible to find RR and attributable risk
• Time, cost, involvement is more • Time, cost, involvement is more, more
32 • No problem of drop-out but record based information • Being a follow-up study there is more chance of drop-out
may be a problem
Features of a case control study: be desirable method of control selection.
44
5 Physical Environment: Air
The word ‘environment’ is derived from an French word • There is direct relation between sunshine and conce-
‘environ’ meaning ‘encircle’. Earth’s environment is a ption. An eight-year survey in Sussex showed that
rich heritage handed over to us by previous generations. conception occurred mostly, during May to August,
Environment may be classified as physical, biological when sunshine is more. Regardless of season,
and social for the purpose of studying its role in health conceptions throughout the year occurred more on
and disease. In this chapter, a few general comments those days when there were more sunshine hours.
about human health and physical environment will be • An analyses of 2000 murders in Florida between
made before describing the role of air in health. 1956 and 1970 showed high peaks in homicide rates
Cleanliness or sanitation of physical environment such coinciding with phases of full and new moon.
as air, water, food and dwelling place is essential for • A survey of 10,000 women with regular menstrual
healthy living. According to WHO, environmental cycles in Germany revealed that an unduly high
sanitation means “The control of all those factors in man’s proportion of cycles commenced at the time of full
environment which exercise or may exercise a deleterious or new moon.
effect on his physical development, health and survival”.
It is due to the sanitation measures that there has been
spectacular reduction in water and food borne diseases in Air
USA and other Western countries. Control and eradication
of malaria, filaria, yellow fever and other vector borne Air forms the most immediate environment of man with
diseases is also attributed to the same. It has made a which he is in constant contact throughout his life. The
substantial contribution to positive health and longevity of importance of clean air for man’s health is thus self-
life. In developing countries like India, where environment evident. Even from a symbolic point of view, it is well
is still not clean, water, food and vector borne diseases such to keep in mind that while a man consumes 1.2 kg of
as cholera, typhoid, food poisoning and malaria are solid food and drinks 1.8 kg of liquids, he breathes as
responsible for significant morbidity and mortality. much as 14 kg of air per day.1a
The important components of the physical environ- The air atmosphere with which man comes into
ment are: contact is of two types:
• Air 1. External atmosphere, i.e. air space outside the room.
• Water 2. Internal atmosphere, i.e. air space inside the room
• Soil and housing of a building.
• Place of work, such as office and factor (occupational They are certain agents in the atmosphere to which
health) man is constantly exposed. These agents affect his
• Wastes such as refuse and human excreta physical well-being and may cause discomfort, injury or
• Food. disease. They may be divided into physical, chemical
These components should be in such a state that they and biological agents, as follows:
are favorable for the host (man) and unfavorable for the
survival and growth of agents (microbes). These will be
PHYSICAL AGENTS
described in the present and the next five chapters. The
role of food as part of man’s environment will be • Temperature
discussed in the chapter on “Food and Nutrition”. • Humidity
It has been known for long that physical factors influ- • Wind velocity
ence human body in several ways, though the • Pressure of atmospheric air.
concerned mechanisms are not clear. Some of the
effects listed 25 years ago are as follow:1 CHEMICAL AGENTS
• 81 percent fatal and 75 percent nonfatal car
accidents in Ontario between June and Sept. 1968, Dust, soot, smoke, other organic and inorganic particles
occurred when barometric pressure was falling. emanating from houses, factories and vehicles, etc.
PART II: Epidemiological Triad BIOLOGICAL AGENTS fully saturated air at same temperature
Humidity is commonly measured by using dry and
Bacteria and viruses, etc.
wet bulb hygrometers. Relative humidity can be found
from specially constructed psychrometric charts. RH
Factors Affecting Atmospheric Environment below 30 percent indicates that the air is too dry causing
METEOROLOGICAL VARIABLES drying of nasal mucosa. RH above 65 percent indicates
excessive humidity, causing the room air to feel
• Degree of sunshine uncomfortable and sticky. However, excess humidity is
• Atmospheric pressure not known to cause any ill effects on physical health.
• Humidity
• Rainfall Rain: Rainfall is measured with the help of raingauge.
• Velocity and direction of wind Symon’s raingauge has a funnel of 5 inches diameter
• Air temperature. for receiving the rainfall.
The sum of these variables over a period of months Air motion: Direction of the prevailing wind is indi-
or years is referred to as the climate of a place (weather, cated by wind vane. The velocity is measured by an
on the other hand, denotes these conditions at a anemometer. Wind up to 0.5 meter per second (m/s)
particular moment or time). Good climate and pleasant is calm air when smoke can be seen rising vertically.
weather are soothing and health promoting. Wind at 0.5 to 1.5 m/s is called light air. Light breeze,
breeze and strong breeze have velocities of 1.75 to 3,
GEOGRAPHICAL CONDITIONS 3 to 9 and 9 to 14 m/s respectively. Gale and storm
• Distance from the equator have velocities of 14 to 28 and 28 to 32 m/s
• Distance from the sea and height above sea level respectively. Beyond that it is a hurricane. Wind direction
• Nature of soil (rocky, sandy, loamy or clayey) and and velocity modify the air temperature, which in turn
• Terrain (plain or hilly). affects the power of body to gain or lose heat.
The above factors modify the climate by bringing Atmospheric pressure: It is measured by Fortin’s
about changes in temperature, rainfall, humidity, direction mercury barometer or aneroid barometer. The latter is
and velocity of winds and atmospheric pressure. convenient, though less sensitive.
HUMAN ACTIVITIES AND INDUSTRIES
Acclimatization to Physical Agents in the Air
Man adds heat, humidity, microorganisms and odors
to the air around him through various physiological HIGH TEMPERATURE
functions of the body. Household activities and
industries add noise, radiation, smoke, soot and various Heat loss from the body occurs mainly through the skin
types of dusts to the atmosphere which may become by convection, radiation and evaporation. Hot, humid
detrimental to healthy living. and stagnant air takes less heat from the skin than cool,
dry and moving air.
Exposure to sudden and prolonged heat without
Physical Agents in Atmosphere prior acclimatization leads to ill-effects which may be
i. Temperature local or general. These ill-effects are accentuated in the
presence of high humidity and lack of air movement.
ii. Sunshine: This can be measured with the help of
Campbell-Stoke sunshine recorder.
Local Effects
iii. Humidity: Absolute humidity is the actual weight of
These include darkening of skin, prickly heat, sunburn,
moisture or water vapor in a unit volume of air at
dermatitis.
a particular temperature and is expressed as gram
per cubic meter of air. Relative humidity (RH) is the
ratio of absolute humidity at a particular temperature General Effects
to the weight of water vapor, when the air is fully Heatstroke: It is characterized by hyperpyrexia
saturated at the same temperature. It is calculated (108°–112°F) along with giddiness, anorexia and fre-
as a percentage. It tells how much more moisture quency of micturition followed by unconsciousness.
can be taken by the air at a particular temperature There is sudden cessation of seating, the cause of
and thus indicates comparative dryness or wetness which is not known. This leads to failure of heat regu-
of the air. lating mechanism. Mortality is more in young children
Weight of water vapor in one cubic and old people, especially if they are ill-nourished.
46 metre of air say at 30°C
RH = ____________________________________________________________ × 100 Heatexhaustion: It is due to profuse sweating chloride
Weight of water vapor in one cubic meter (between 0.2 and 0.5 percent) with specific gravity
1.002 to 1.003 and pH 4.2 to 7.5. The fluid loss may oxygen taken by RBCs is decreased, to compensate for
Water is not only an environment but an essential • Natural lakes and impounded reservoirs
requirement for life. Water purification was done as early • Rivers and streams
as 2000 BC as mentioned in Sanskrit literature. The 3. Groundwater
methods used were: (i) keeping water in copper vessels; • Wells: Shallow, deep, artesian
(ii) exposing water to sunlight; (iii) filtering water through • Springs: Shallow, deep, intermittent or seasonal,
sand and gravel; (iv) boiling; (v) dipping hot iron in water. hot springs or sulfur springs.
Provision of safe and adequate water to human popu- It may be mentioned that sea water can also be used
lations is essential for health. Polluted water is known as a source of drinking water after desalination. The
to have caused several epidemics of water-borne diseases technology is presently very costly and is used only in
in India, one of the most severe being the epidemic of a few oil rich Arabian countries.
infective hepatitis in Delhi in 1955 which was caused It may be mentioned that 80 percent of water needs
by contamination of water of the river Yamuna. The of rural India are met by groundwater and 20 percent
Government of India launched the National Water from surface water. The situation is just the reverse in
Supply and Sanitation Program in 1954 as an overall urban areas, where 80 percent needs are met by surface
part of the National Health Plan. However, the water and 20 percent from groundwater. It may be
achievements in this direction have been slow. mentioned that 50 percent irrigation of the country is
Only 77.7 percent urban population and 31 percent done with groundwater.
rural population in India was estimated to have safe
drinking water supply in 1981.1 The International Water RAINWATER
and Sanitation Decade (1981-90) aimed at providing
“Water for All” by 1990. Rainwater from roofs of houses may be collected and
stored in small tanks below the ground in scarcity areas
CRITERIA OF POTABLE WATER for future use. This is done in Dwarka (Gujarat) and
Churu (Rajasthan). This water is soft and clean, but has
The water is said to be potable when it devoid of
to be protected against contamination. Rainwater is an
pathogenic agents, harmful chemical substances, and
important source of water in some countries like
free from color, odor and usable for domestic purposes.
Indonesia and Gibralter.
The above requirements add up to 150 liter per day. • Excess of soluble salts like sulfates may cause
Allowing for an excess margin of 20%, the Environmental diarrhea. Hardness due to sulfates and chlorides of
Hygiene Committee of Government of India recommen- calcium and magnesium may cause digestive upsets.
ded provision of water at the rate of 180 day for large Fluorides in excess may cause symptoms of fluoro-
communities and at a lesser rate for smaller communities sis. Fluorine and iodine deficiency may be associated
as given below.6 with caries and goitre respectively.
• Lead or other metals such as iron, zinc and copper
Population Quantity per head Quantity per head may cause poisonous symptoms. Insoluble matter
(without sewerage) (with sewerage)
such as sand, clay and mica may cause irritative
1,000-5,000 60 liters 80 liters diarrhea when present in excess.
5,000-20,000 80 liters 100 liters
20,000-50,000 100 liters 120 liters
• Insecticides used in agriculture may pollute water and
50,000-2,00,000 160 liters 180 liters cause poisoning.
Greater than 2,00,000 180 liters 180 liters
Physical
National drinking water requirements have been
targeted at 40 liters per capita per day in rural areas and Water containing radioactive wastes may be hazardous
110 liters in urban areas. The requirement in Chennai to health.
and Hyderabad has been fixed at 140 to 170 liters and
in Delhi at 270 liters per capita. Delhi gets only half this Standards of Quality
amount at present. In comparison, per capita consump- These may be classified as physical, chemical and micro-
tion of drinking water in US cities is 540 liters. biological standards, as described below.
As pointed out by the World Bank, as much as
40 percent of the per capita water supply in urban areas
PHYSICAL STANDARDS
is used for no useful purpose other than flushing away
56 wastes.7 The water needs for a community would thus Wholesome water should be odorless, tasteless and clear
be almost halved if alternative appropriate technology without any turbidity.
CHAPTER 6: Physical Environment: Water
Color Toxic Substances
A large collection of water may be apparent as pale blue These are lead, selenium, arsenic, cyanide and mercury.
or pale green, otherwise water is colorless. However, it
may be reddish when iron salts are present in it. A dilute Substances that may Affect Health
solution of K2CrO7 and cobalt sulfate in the tintometre
is used to measure the color. There is a standard series • Fluorine: It should be present in a concentration of
or colored tubes. The color of good water is 0.5 on Hazen 0.5 to 0.8 mg/l to prevent caries. Concentration less
scale. It should not be more than 5 units as per the than 0.5 mg/l is associated with caries in the
platinum cobalt scale. population. Excess fluoride (more than 1.5 parts per
million) causes chalky discoloration of teeth, seen first
on incisors as transverse patches. Levels above 3.5
Odors
PPM may be associated with skeletal fluorosis. High
They are imparted by algae and organic and mineral matter fluoride content has been found in Punjab (up to 44
that reaches water through seepage or from industries. Algae PPM and beyond), Andhra Pradesh, Tamil Nadu,
give a fishy or putrescent odor on decomposition. Tar, peat Kerala and Junagadh district of Gujarat.
and gases impart their typical smells. No disagreeable smell • Nitrates: Some water samples may be too rich in
is permissible in portable water. nitrates. Amounts in excess of 45 mg/l (as NO3) may
cause methaemoglobinemia in infants. No harmful
Taste effects are seen in adults.
• Polynuclear aromatic hydrocarbons (PAH): These
A pleasant taste is due mainly to dissolved O2 and CO2. may be carcinogenic. They should not be present in
That is why boiled, distilled or rainwater has a flat or water in excess of 0.2 mg per liter.
insipid taste. The taste can be regained by shaking. Well
water may sometimes be brackish in taste. Substances that may Affect
Water Acceptability
Reaction These include—iron, calcium, copper, zinc, etc. Their
Sour taste is due to acids (excess of CO2) and bitter taste presence affects water acceptability due to changes in
is due to alkalies (such as ammonia) from decaying color, taste, etc.
organic matter like dead animals, leaves, rotten wood The levels of various chemical substances permissible
and dead marsh plants. pH should be 7 to 8.5. in drinking water have been given by WHO8 as “highest
permissible levels” and by Indian Standards Institute9a as
Turbidity “desirable upper limit”. These are shown in Table 6.1.
Besides the above, other BIS standard for drinking
It is due to fine particles of mud, sand, slime, clay, loam, water (upper limit) are: Color (10 Hazen units), Turbi-
and organic matter and a large variety of aqueous dity (10 NTU), pH (6.5 to 8.5).
microorganisms including plantation suspended in water. It may be mentioned here that tube-well water in
They settle down by storage or on adding alum. Turbidity some parts of Delhi has excessive levels of iron and
can be measured by Jackson-Candle turbidimeter. The chlorides. It is also too hard in some areas.
permissible limit is up to 5 units.
Hardness of Water
Radiological Quality Water is said to be hard when it destroys soap because
10
Increasing pollution of water sources with radioactive of the dissolved salts. These salts are bicarbonates, sul-
wastes from nuclear reactors has become a problem fates and chlorides of calcium and magnesium. The
during recent years. Another source is the radioactive hardness due to the presence of bicarbonates was earlier
debris from nuclear fall ou ts. This debris, usually from labelled as temporary hardness as compared to
a nuclear detonation, is deposited on the earth after permanent hardness due to other salts. These terms are
having been blown by the winds. International standards no longer used now. Hardness is expressed as
for the upper limit of radioactivity in water are as follows: milliequivalents per liter of the hardness producing ion.
Gross alpha activity—3 picocurie/l Thus a sample of water having 50 mg of calcium
Gross beta activity—30 picocurie/l. carbonate per liter would have 1 mEq/L of hardness.8
Water can be categorized as soft or hard as follows:
CHEMICAL STANDARDS mEq/L
The WHO had laid down water standards under three Soft 0-0.9
Moderately hard 1-2.9
categories.8 Hard 3-5.9
57
Very hard 6 and above
PART II: Epidemiological Triad TABLE 6.1: Chemical standards for water bacteria in water to know whether water is being
WHO BIS polluted by human excreta which may contain
pathogens. Most authorities now insist that water should
• Toxic substances
Lead (as Pb) 0.05 0.1
be free from all sorts of E.coli as well as fecal
Selenium (as Se) 0.001 0.01 streptococci. The WHO has recommended the following
Arsenic (as As) 0.05 0.05 criteria of safety for large water supplies:
Cadmium (as Cd) 0.005 0.01 • No sample should have E.coli in 100 ml.
Cyanide (as Cn) 0.05 0.05
Mercury (as Hg) 0.001 0.001
• No sample should have more than 3 coliforms per
• Substances that may 100 ml.
affect health • Not more than 5 percent samples throughout the year
Fluoride (as F) 0.6–1.2 should have coliforms in 100 ml.
Nitrates (as NO3) 45
• No two consecutive samples should have coliform
• Substances that may
affect acceptability organisms in 100 ml.
Iron (as Fe) 0.1 0.3 The above standards may have to be relaxed in case
Calcium (as Ca) 75 75 of small water supplies from wells, etc. In such cases
Copper (as Cu) 0.05 0.05
isolated samples should not have more than 10 coliforms
Zinc (as (Zn) 5 5
Manganese (as Mn) 0.05 0.1 per 100 ml. Persistent presence of coliforms, especially
Magnesium (as Mg) 30 30 of E.coli, would indicate that the water is unsafe for
Total dissolved 500 500 drinking.
solids
While detailed microbiological techniques are to be
Chloride (as Cl) 200 250
Sulfate (as SO4) 200 150 found in appropriate textbooks, a brief description of the
Phenolic (as C6H5OH) 0.001 0.001 method used for surveillance of water quality is given
substances here. These methods are of four types: presumptive coli-
Total hardness (as CaCO3) 100 300 form test, colony count, test for fecal streptococci and
Mineral oil 0.01
Residual free chlorine 0.02 Clostridium perfringens and tests for pathogens.
NB—All values are in mg/liter. BIS = Bureau of Indian Standards
Presumptive Coliform Count
(Multiple Tube Technique)
Too soft water is insipid in taste. Drinking water
should be preferably moderately hard. It is done on lactose bile salt medium (MacConkey’s broth),
Hardness is objectionable for the following reasons: which is a selective medium for coliform bacteria which
• Hard water precipitates soap forming curds. Hardness produce acid and gas. Acid is indicated by the medium
causes wastage of soap and difficulty in laundering, turning red. Gas gets collected in the Durham’s tube.
bathing and hair washing. Method: Sterilize 16 tubes containing single or double
• Hard water affects the durability of textiles. strength MacConkey’s fluid medium. Add different
• Hard water causes encrustation in boilers and utensils quantities of water to be tested as follows:
which might crack on sudden heating. Encrusted • 50 ml water to 50 ml double strength medium in one
utensils require more fuel for heating. Hard water also tube.
causes scaling, encrusting, occlusion and bursting of • 10 ml water to 10 ml double strength medium in each
water pipes. of 5 tubes.
• Hard water is unsuitable for certain industries. • 1 ml water to 5 ml single strength medium in each
There is no conclusive evidence that hardness affects of 5 tubes.
health. Some people get digestive upsets when they are • 0.1 ml water to 5 ml single strength medium in each
not used to hard water. On the other hand, coronary of 5 tubes.
artery diseases has been found to be more common in • Incubate for 48 hours and read the result.
areas with soft water supply. This has been attributed The probable number of coliform bacilli per 100 ml
to magnesium deficiency.11 of water is found by referring to McCrady’s table. It is
called presumptive count because the actual number of
organisms in the sample of water is not counted. It is
MICROBIOLOGICAL STANDARDS
presumed that each of the tubes in the test showing
Ideally, drinking water should not contain any micro- fermentation contains coliform organisms.
organism at all. This ideal is unattainable. Natural waters Further confirmation of the type of coliform organisms
contain various types of bacteria that may be is done by the Eijkman’s test. In this test the typical fecal
saprophytes, coliforms (typical, atypical and Escherichia coli are differentiated from nonfecal
intermediate atypical coliforms, IAC) and pathogens for coliforms by incubating the tubes at two different
58 cholera, typhoid, dysentery, etc. The main aim of testing temperatures, viz., 37°C and 44°C. The E. coli grow
for water quality is to look for the presence of coliform at 44°C while the other coliforms do not.
CHAPTER 6: Physical Environment: Water
Colony Count DISSOLVED OXYGEN
The aim here is to have an estimate of the general Low levels of dissolved oxygen in water indicate that
microbiological quality of water. The standard count it contains organic matter. Dissolved oxygen should not
involves inoculating nutrient agar plates with 1 ml water be less than 5 mg/l.
and inoculating them at two different temperatures—
22°C for 72 hours and 37°C for 48 hours. The number
of colonies is then counted. The growth at 22°C Collection of Water Samples
indicates the presence of saprophytes. The following For physical and chemical analysis, about 2 liters of water
guidelines for safe water are used for interpretation: is collected in a Winchester bottle after it has been rinsed
Disinfected water—Plate count 0 at 37°C and upto twice. The bottle is stoppered and sent to the laboratory.
20 at 22°C. In case of a tank or river the sample should be taken
Undisinfected water—Plate count up to 10 at 37°C 1 to 2 meters away from the shore without disturbing
and not more than 100 at 22°C. the mud and should be filled from below the surface.
A high total count at 22°C has no value. However, From a well, the sample should be taken after the day’s
sudden changes from low to high may indicate pollution. pumping is over. While collecting from a tap the sample
Uncontainated well water may have a total count of 100 should be taken after letting the water run off for some
to 200 per ml. Surface waters have high count, especially time.
after rains, while groundwaters usually have a low count. For bacteriological analysis a 230 ml sterilized bottle
with a glass stopper, covered with a rubber cap, is taken.
Fecal Streptococci and Clostridium Perfringens The bottle is packed in ice and sent to the laboratory
within 6 hours. The following details about the source
Since these bacteria are of fecal origin, their presence may of water should be forwarded with the sample for the
be looked for and may provide confirmatory evidence opinion of the expert:
when fecal pollution of water is suspected but is doubtful. • Date and time of collection
• Purpose of analysis
Pathogens • Source of water and address
• Nature of soil and source of pollution, if any, with distance
When indicated, specific tests may be performed to look • Condition of the well and the method of drawing water
for the presence of pathogenesis like Vibrio cholerae. • Recent rainfall or flood
Some chemical criteria are also useful for determining • Any existing water-borne disease
the microbiological quality of water. These are described
• Any other particulars.
below:
FILTRATION
On a large scale, filtration was started in the beginning
of 19th century. There are two types of filters.
1. Slow sand filter, biological filter or English filter.
2. Rapid sand filter, mechanical filter or American filter,
which is again of two types: Paterson filter (Gravity Fig. 6.3: Section of slow sand filter
filter) and Candy filter (Pressure filter). The slow sand
filter was the one used initially. Nowadays the rapid takes about 2 hours to pass through the slow filter. One
sand filter is also in common use. cubic centimeter of sand in the filter bed provides 150
sq cm surface area to the water passing through it.
Slow Sand Filter12
Rapid Sand Filter
The slow sand filter essentially consists of four elements:
• Water head, which is a layer of raw water 1 to 1.5 This is the filter commonly used nowadays. Before the
mete1rs deep. water comes to the filter it is subjected to a process of
• Sand bed (1.25 meter thick, composed of sand coagulation. The coagulant used is alum in a dose of
particles 0.15 to 0.35 mm in diameter), supported 5 to 80 mg per liter depending on turbidity. In the
on a layer of fine and then coarse gravel. presence of calcium carbonate, alum forms ‘floc’ as per
• Drainage system for filtered water consisting of perfo- the following reaction:
rated pipes. Al2(SO4) + 3CaCO3 + 3H2O = 2Al(OH)3 + 3Ca2SO4 + 3CO2
• Filter control valves in the outflow pipe with the help The floc is a flocculent precipitate of aluminium
of which the outflow of water is regulated in such a hydroxide which clarifies the water. It entangles all
way that a constant water head of 1 to 1.5 meter is particulate, suspended and colloidal matter along with
maintained. The first three elements together constitute bacteria and forms ‘floc’ balls’ which, being heavy, settle
the filter box, which is an open rectangular box 2.5 down to the bottom. Thus the bacterial content of water
to 4 meters deep. The different layers in the filter box decreases and any undesirable colour and odours are
from bottom upwards are listed below (Fig. 6.3). removed or reduced.
As the water enters the purification works from the
Drains at the bottom with perforations 5 cm raw source, it is mixed rapidly and thoroughly with alum
Layer of bricks with gaps 10 cm
in the mixing chamber. From there it goes to a
Small stones about 1 cm in size 10 cm
Gravel pieces about 0.5 cm in size 10 cm flocculation chamber where it rests for half an hour.
Fine sand (coarse sand in case of rapid sand filter) 75 cm During this period, it is gently stirred with the help of
Water head above the sand 150 cm slowly rotating paddles. As a result, a copious precipitate
Total 3.6 meters of aluminum hydroxide forms. Next, the water moves
to the sedimentation tank. Here the puffy balls of floc
Within 2 to 3 days after the fresh sand layer is laid settle down along with the bacteria and suspended
down, a slimy vital layer or filtering membrane is formed matter. The water rests in the sedimentation tank for
at the top of the sand bed. This consists of multiple forms 2 to 6 hours. The clear water above the precipitated
sludge now goes to the filter bed.
of microorganisms, including bacteria, diatoms, plankton
The filter bed in rapid s and filter is essentially similar
and algae embedded in silt and organic matter. This
to that in the slow sand filter, with two differences.
biological layer helps in purifying water by holding back Firstly, the sand is coarser (diameter 0.6-2 mm).
bacteria and by oxidising the organic matter. The Secondly, the biological membrane is replaced in the
formation of the biological layer is referred to as ripening rapid filter by the layer of “alum floc” which escapes
of the filter. When fully formed, it is 2 to 3 cm thick. settling in the sedimentation tank and is held at the top
When this becomes too thick, it has to be scraped. The of the sand bed as a slimy layer capable of holding back
new layer takes 24 hours to develop, during which bacteria. When this layer becomes too thick, there is
period proper filtration cannot occur and the filtrate has “loss of head”, i.e. the water level above the filter bed
to be discarded. Thus the slow sand filter does not rises due to slowing of filtration. The filter is then back
permit continuous water supply. washed by agitating the sand by bubbling of air from
60 The rate of filtration through slow filter is 0.1 to 0.4 below in the reverse direction. After back washing the
cubic meters per sq meter of surface per hour. Water slimy layer again forms within 5 minutes. The total time
taken for revitalization (back washing plus settling of • Amount of free or residual chlorine or chloramines.
Note: Majority of the treatment procedures are capable of reducing virus content. Efficacy may vary depending upon design, operation, water
64 quality and temperature. Prechlorination treatments like slow and or biological filtration, flocculation with rapid filtration and lime flocculation
are highly effective and may reduce viruses by 90%. Storage and rapid filtration may also remove viruses up to certain extent. However, all
these alone are not adequate and disinfection is the most effective treatment for removal of viruses.
India organized in 1990, in collaboration with UNDP,
66
7 Physical Environment: Housing
70
Physical Environment:
8 Wastes and their Disposal
Wastes constitute an important part of the environment – Mosquitoes that transmit insect-borne diseases
to which man is continuously exposed. Wastes are of like malaria and filaria
three types. – Common house flies which transmit infections
mechanically
REFUSE OR SOLID WASTE – Many other insects and worms that cause
nuisance, e.g. cockroaches, crickets and ants
This includes all unwanted or discarded waste material – Rats, thriving on refuse.
arising from houses and streets and from commerical, • Sullage water, refuse and nightsoil, all create intole-
industrial and agricultural activities of man.1 In other rable nuisance of sight and smell.
words, the term ‘refuse’ is applied to all solid waste • Dust may harbor tubercle bacilli and other germs
from human habitations that is not carried by the which cause diseases if inhaled.
sewers, i.e. all waste other than sullage and nightsoil. • Soil polluted with nightsoil may be rich in tetanus
It includes public refuse (originating from homes, spores.
hotels, institutions, streets, stables and markets) and
industrial refuse. The refuse originating from homes
or domestic refuse consists of garbage, rubbish and Recycling of Wastes
ash. Garbage is the waste from food during its handling
at various stages including preparation, cooking and Wastes, despite their name, are not so. The so called
serving. Rubbish comprises dirt, dust and bits of paper, wastes contain plenty of useful substances which can be
wood clothing, glass, rubber, plastic, metal, etc. Ash refused with advantage. Let us have a look at different
is the residue after burning of fuel. The term liter is types of wastes.
sometimes used in place of refuse for solid waste in
rural areas. Refuse or Solid Waste
Pit Latrines
SHALLOW PIT LATRINE
74
It is about one meter in depth and 0.5 to 1 meter wide Fig. 8.1: VIP latrine: Basic components (Sectional view)
with a wooden squatting plate. Nightsoil has to be covered Source: Worldbank
disease carrying insects. The VIP latrine (Ventilated
AQUA PRIVY
Sometimes called septic toilet, it consists of a squatting
plate with a long drop pipe, extending into a water tight
tank to a point well below the water level (Fig. 8.5).
The tank is usually below the seat. Feces and urine decom-
pose anaerobically and there is three fourth reduction in
the solid mass which settles as sludge at the bottom. Liquid
Fig. 8.3: Handflush water seal latrine (PRAI type) effluent undergoes further treatment in a seepage pit or
subsoil irrigation system. Solid of the pit residue has to be
76
Fig. 8.4: Septic tank Fig. 8.5: Aqua privy
removed periodically. A vent pipe, 7.5 cm in diameter, The sewerage system can be divided into 3 parts:
Septic tanks: Large circular or rectangular tanks are At the end of secondary treatment, the effluent, though
provided through which sewage passes slowly and is clear, still has pathogenic organisms. If it is to be
held for 8-24 hours. Both sedimentation and septic tank discharged into a river, it must be disinfected by the
action take place here. There is formation of scum on traditional or newer methods described below:
the top; the effluent enters and leaves the tank below
the surface without disturbing the scum. Sludge and Chlorination
scum have to be removed intermittently or continuously
Chlorine or bleaching powder is added in a proportion
by mechanical means. The sludge needs further
of 2-5 PPM.
digestion and the effluent, still having suspended matter
with high biological oxygen demand, needs further The residual chlorine content before discharge into
treatment such as bioaeration. the river must be 0.5 PPM.
Many types of sedimentation and septic tanks are
in use. The anaerobic or septic action decomposes the Sewage Disinfection by Irradiation
organic matter consisting of proteins, fats, cellulose, This is a new method based upon nuclear technology.
soaps, urea and mineral matter. Ammonia, phenols, This technique is already being used in five countries.
aromatic and fatty acids are released. Ammonia is partly India is sixth country in the world and the first in Asia
let off, and part of it combines with nitrous acid to form to use this method. The Sludge Hygienization Research
nitrites. Carbohydrates are fermented to alcohol or Irradiator (SHRI) established at Gajerwadi, Baroda by
changed to butyric acid, and lactic acid, etc. Fats are the Bhabha Atomic Research Center in 1992, can take
ultimately hydrolysed to carbon dioxide and water.
care of half of the city’s sewage. It uses gamma
irradiation from a Cobalt-60 source, which reduces the
SECONDARY TREATMENT concentration of coliforms from 100 million/ml to
After primary treatment, the effluent still contains lot of negligible levels.12a
organic decomposable matter that can be further
broken down by aerobic bacteria. The aim of secondary OTHER METHODS OF SEWAGE DISPOSAL
treatment is bio aeration of the effluent from primary These are as follows:
treatment. This can be done by two methods, viz. the • Direct chlorination
Trickling filter method and the Activated sludge method. • Sewage farming
Biological trickling filter method: The trickling filter • Oxidation pond (stabilization pond)
is a bed of crushed stones. It is about 15-30 m in • Oxidation ditch. 79
diameter and 1-2 m deep. The effluent from primary These are briefly discussed below.
PART II: Epidemiological Triad Direct Chlorination this is not done, mosquitoes may cause a menace. The
If the four phases of sewage treatment described above pond must be located in an area with abundant sunlight.
cannot be used, the least that can be done is to Ideally, a stabilization pond should consist of three
chlorinate the raw sewage directly to a level of 5-10 PPM sequential ponds, water flowing from one to the other
by adding chlorine or bleaching powder before as follows.1a
discharging it into the river. 1. Anaerobic pond: It is 2-5 meters deep and
functions essentially as one open septic tank. It
Sewage Farming (Surface or Broad Irrigation) requires desludging after every 3-5 years. It receives
strong raw waste with high BOD. Digestion here is
This method can be used for small communities where
almost completely anaerobic.
lot of land is available and soil is porous. After prelimi-
2. Facultative pond: It is 1-2 meter deep. It receives
nary treatment (screening and sedimentation), the
water from anaerobic pond. Its deeper part is
sewage is made to flow onto land on which ridges and
anaerobic. The upper layer is aerobic during day
furrows have been made. The sewage flows in the
due to intense photosynthesis of phytoplankton,
furrows while the ridges are used for growing fodder
whereby oxygen is released. This layer is anaerobic
grass and suitable crops (which are not eaten raw). The
during night due to respiratory oxygen demand.
discharge in an area has to be intermittent. One acre
3. Maturation pond: It is 1-2 meter deep. It receives
land is sufficient for sewage form 100-300 persons.
facultative pond effluent. The main function
achieved here is reduction of excreted pathogens and
Stabilization Pond nutrients. Some reduction of BOD also takes place
Also called Oxidation pond, it is an old method, the here. It is aerobic at all times.
importance of which has been only recently Aerobic and facultative ponds are used
recognized.13 This method enables sewage purification independently also, without the sequential flow system.
by forces of nature at very low cost. It is being used These two are primarily designed to reduce BOD, while
at more than 50 places in India. Two examples are the maturation pond is primarily designed to destroy
oxidation pond at Sevagram, Wardha and Bhilai. The excreted pathogens.1a Fish can be cultured only in
latter is a large one, catering to a population of one maturation ponds, which are aerobic all the time.
lakh. As a rule of thumb, if the overall retention time over
Principle: The oxidation pond is characterized by the a series of ponds is at least 20 days, the effluent is safe
presence of the following three attributes: for fish culture from the point of view of public health.
• Presence of bacteria feeding on organic matter The area of stabilization ponds reported in literature
• Presence of algae, and varies from 400 m2 nightsoil fed ponds in Jawa to 10
• Presence of abundant sunlight. hectare sewage fed ponds in Munich. The most
The main action of the bacteria is aerobic. They desirable size of sewage fed ponds in China has been
degrade the organic matter to carbon dioxide, ammonia found to be 3.3-6.6 hectare. Ponds in tropics are usually
and water. These products are in turn utilized by the smaller, about 0.2-0.5 hectare.1a
algae for their own growth. During the process of The effluent may be used for irrigation or may be
photosynthesis the algae utilize carbon dioxide and discharged into river or sea after appropriate treatment.
produce oxygen. This oxygen is the major source for They may also be used for fish farming as already men-
the bacteria, making the aerobic decomposition of tioned.1a Since there is no fecal odor associated with
organic matter possible. Thus, it is clear that the aerobic these ponds they are an acceptable and suitable method
bacteria and the algae are in a state of symbiotic for small communities.
relationship. In the deeper layers of the pond, where Stabilization pond can be an economically sound
algal growth is minimal, and especially in late hours of proposition. Water hyacinth, a plant with scavanging
night, some anaerobic decomposition by anaerobic potential, can help in water purification in a stabilization
bacteria also occurs. Thus, the oxidation pond purifies pond. This plant grows very fast. It can be removed and
the sewage not only by oxidation (aerobic process) but used for production of manure rich in nitrogen, phos-
also by reduction (anaerobic process). For this reason phorus and potassium (NPK).
the name redox pond is technically more correct than
the term oxidation pond. The most appropriate term, Oxidation Ditch
however, is “waste stabilization pond”.13 This is a method working on the same principle as an
Construction: It is an open, shallow pool with a depth oxidation pond with the difference that mechanical
of 1-1.5 m. There is an inlet for sewage and an outlet rotors are utilized for proper and continuous aeration
80 for the effluent. The surroundings of the pond should of sewage. The land area needed is hence less, about
be kept free from growth of vegetation and weeds. If one twentieth of that for an oxidation pond.
CHAPTER 8: Physical Environment: Wastes and their Disposal
Sullage Disposal
In towns and cities, sullage water is disposed of either
in the sewer system or by the surface drainage system.
In villages and isolated domestic habitations, proper
arrangement for disposal of sullage water is needed to
avoid haphazard water collections with the attendant
problems of fly and mosquito breeding as also of
nuisance of sight and smell.
SOAK PIT
In the absence of a drainage system in rural areas,
sullage water spills and stagnates along open streets,
leading to nuisance and unhygienic conditions, apart
from acting as breeding source for mosquitoes. The soak Fig. 8.7: Soak pit
pit is a cheap, simple and sanitary method of disposing
sullage water. Besides acting as a sanitary sullage
disposal system, the soak pit also acts as a device for • Cover the gunny cloth with a similar sized ploythene
recharging of ground water. Improvements in soak pit sheet having a similar hole in the center.
have been suggested by the Safai Vidyalaya, the Central • Cover the polythene sheet with soil and fill the pit.
Building Research Institute, Roorkee, and the Compact the soil properly. The soak pit is now
Consortium on Rural Technology, Delhi. The steps in ready.
constructing an improved soak pit as suggested by the • Make a pucca drain 7 cm (3") wide and 10 cm (4")
latter are given below:14 deep from the water outlet to the soak pit inlet. It
• Choose a proper site which should be away from should have a slope of about 8 cm per meter, i.e.
a house wall and at least 10 m distant from any well. about 1" per foot. The drain should be covered by
The water table should not be very high. Its water bricks or flat stones without joining them. This helps
is present 3-4 m below ground level, this technology in checking the entry of solid waste and rain water.
may not be appropriate. • Provide a trap near the middle of the drain to check
• Dig a pit about 1 meter long, broad and deep. The the entry of suspended solid wastes from entering
bottom of the pit must have a slope of about 15 the pit. Dimensions of the trap are: length 35 cm
cm, the direction of the slope being away from the (14"), breadth 25 cm (10") and height, progressively
house. sloping along the flow of water, so as to be 25 cm
• Divide the depth of the pit into roughly four equal (10") in beginning, 22.5 cm (9") in the middle and
parts. Fill the lowermost part with stones or bricks 20 cm (8") at end. At the middle is provided a
the size of a coconut. Fill the second part with stones partition with a 7.5 cm × 7.5 cm (3" × 3") hole
or bricks the size of a big apple. The third part is at the bottom.
to be filled with stones of the size of an average • Cover the trap and the inlet chamber of the pit with
lemon. The fourth or uppermost part is for the inlet a flat stone.
chamber. • Cover the top surface of the soak pit with soil so as
• The inlet chamber is constructed as follows (Fig. 8.7): to raise it 5 cm above the surrounding ground level.
– At the center, lay the foundation of the chamber
in the form of 4 bricks arranged as shown, laid References
with a gap of 5 cm between the bricks, leaving
1. WHO. Tech Rep Ser No. 484, 1971.
a central space of 12.5 × 12.5 cm (5" × 5").
1a. Edwards P. Reuse of Human Wastes in Aquaculture.
– Lay over these bricks a second layer of bricks Washington: World Bank 1, 1992.
without leaving any space between the joints. 1b. Rao TS. Ambio 1977;6:134-36.
– If necessary, similarly lay a third or fourth layer 1c. Hanumanulu V. J Instt Eng 1978;58:66-75.
of bricks. This will depend upon the slope of the 1d. AIT. Reuse of wastes. ENFO News 1989;11(4):6-10.
drain from the source outlet of waste water to 2. NEERI. Technical Digest No. 15, 1971.
3. Chandra Jagpravesh. Electricity from domestic waste.
the inlet chamber of the soak pit.
Hindustan Times March 23, 5, 1986.
• Take a 1 sq m gunny cloth with a hole in the center 4. WHO. Tech Rep Ser No, 367, 1967.
about the size of the inlet chamber. Cover the stone 4a. Kawata K. Environmental sanitation in India. Ludhiana:
layer of the pit with this gunny cloth. CMC 104, 1963.
81
PART II: Epidemiological Triad 5. Acharya CR. Preparation of Compost Manure from Town 11. Morgan PR. The pit latrine revived. Central African Journal
Wastes. An ICAR Monograph. Delhi: ICAR, 1950. of Medicine 1974;23:1-4.
6. Bopardikar MV. Environmental Health 1967;9:349. 11a. Whittington D, et al. Household Demand for Improved
7. ICMR. Review of Work done on Rural Latrines in India. Sanitation Services: A case study of Kumasi, Ghana,
Spl Rep Ser No. 54, 1966. Washington: World Bank, 1992.
8. Kalbermatten JM, et al. Appropriate Technology for Water 12. Okum and Ponghis. Community Waste Water Collection
supply and Sanitation—Technical and economic options. and Disposal. Geneva: WHO, 1975.
Washington: World Bank, 1980. 12a. Indian Express, 10.1.1992
9. WHO. The Community Health Worker. Delhi: Jaypee 13. Arceivala SJ, et al. Waste Stabilisation Ponds design,
Brothers, 1990. construction and operation in India. Nagpur: NEERI, 1970.
10. Mara DD. The Design of Ventilated Improved Pit Latrines. 14. Om Prakash. Soak pit—Do it yourself. Delhi: Consortium
Technical Advisory Group Technical Note No. 13. of Rural Technology. D-320, Laxmi Nagar ND-1100092,
Washington: World Bank, 1984. Sponsored by IDRC, Canada, 1990.
82
Physical Environment: Place of Work
9 or Occupation (Occupational Health)
Like the home and the school, the place of work is also radiant energy, injurious force and friction from
an important part of man’s environment. The physical, machinery parts.
chemical and biological agents and the work • Chemical agents such as toxic substances and dusts.
environment at place of work may affect the health and • Biological agents such as B. anthraces, leptospirae,
efficiency of the worker. A man is exposed to these for fungi, and scabei.
at least six to eight hours daily at his place of work or • Social factors related to work environment such as
occupation. This environment, therefore, should be tension and worry related to coworkers and employers,
healthy and free from any harmful agents as far as job security and the conditions of employment.
possible. A healthy occupational environment, in
addition to being beneficial for the workers, is Physicochemical Agents
conductive to higher work productivity.
Occupational Health is an important branch of In this chapter, we shall discuss the following:
preventive medicine. It deals with: (i) promotion and • Physical (including chemical) agents in occupational
protection of the health of the worker, (ii) early environment
diagnosis and prompt treatment of occupational diseases • Offensive trades and occupations
and (iii) rehabilitation in case of disablement. The term • Occupational diseases and hazards
‘occupational health’, being more comprehensive, has • Prevention of occupational diseases
replaced the old terms industrial hygiene, industrial • Occupational health legislation
health and industrial medicine. The subject envisages • Worker absenteeism
health, safety and welfare of all the workers alike such • Biological agents and social factors in occupational
as office goes, farmers, unskilled laborers, teachers and health.
workers in the cottage industry, etc. and not only those
engaged in an industry. Factory workers, however, need Physical Agents
and are paid special attention by the government
because they work in hazardous environments and are Temperature and Humidity
exposed to special risks. In its first session held in 1950,
the Joint ILO/WHO Committee on Occupational Health Exposure to extremes of temperature: Workers in
stated that the general aims of occupational health the field, such as farmers, road builders and those
should be the promotion and maintenance of the engaged in house construction, are exposed to external
highest degree of physical, mental and social well-being heat from the sun. Fishermen and workers at high
of workers in all occupations; the prevention among altitudes are exposed to cold.
workers of departures from health caused by their Many workers are exposed to high temperatures
working conditions; the protection of workers in their inside the workrooms, such as those employed in
respective employments from risks resulting from factors engine rooms, metal works, cement, asbestos and
adverse to health; the placing and maintenance of the abrasives factories, bakeries, brick kilns and potteries,
workers in an occupational environment adapted to etc. Workers in ice factories, cold storage rooms, milk
their physiological and psychological needs, or, in other dairies and cold laboratories are exposed to cold.
words, the adoption of work to man and of each man Effects of extremes of temperature include prickly
to his job. heat, heat stroke, heat exhaustion and muscle cramps
Most physicians are nowadays confronted with in case of heat and frostbite and respiratory diseases in
occupational diseases. They should hence be conversant case of exposure to cold.
with occupational health hazards. The various factors Exposure to high humidity: It accompanies extremes
in occupational environment that may affect health are: of temperature in many industries and aggravates the
• Physical agents such as extremes of temperature and heat or cold effects on body such as in textiles, paper
humidity, abnormal air pressure, vibrations, noise, factories, ice factories, etc.
PART II: Epidemiological Triad Air Pressure EFFECTS ON HEALTH
Aviators, balloonists and mountaineers are exposed to Noise has wider ranging ill effects than the effect on
low pressure while deep sea divers, caisson workers and hearing alone. There is enough evidence to show that
workers in submarines and deep mines are exposed to noise has undesirable effects on cardiovascular, respi-
high pressure. ratory, endocrine and nervous systems. For example,
Acclimatization to heat, humidity and pressure has abnormal cardiac rhythms have been found in workers
already been discussed in the Chapter on Air. exposed to intense noise in steel mills and ball bearing
factories. Overexposure to noise is associated with high
Vibrations blood pressure, peptic ulcer, and, in general, a higher
environmental stress.2,3 A noise of 140 decibels is suffi-
Industrial exposure to vibration occurs while operating cient to drive a person insane. As regards acoustic
machines and hand tools that impart vibrations. damage, prolonged exposure to noise levels greater
Common examples are grinding, burning, hammering, than 85 decibels can impair hearing permanently.
breaking concrete, cutting, chipping and scaling of Studies conducted in USA in the fifties showed that the
metals, hole boring, drilling and tailoring, etc. Vibrations noise level in several prison industries varied from 75
may cause general symptoms such as nervousness and to 110 decibels and the prisoners developed impairment
fatigue or local symptoms such as injury and of hearing within three months, which was permanent
inflammation of bones and joints. The surrounding soft to some extent.1 The temporary impairment of hearing
tissues such as nerves, muscles, tendons, ligaments and due to noise trauma usually occurs in a frequency range
blood vessels may also be affected. As a preventive of 4000 to 6000 Hz. (One Hertz denotes a frequency
measure, hand held vibrating tools should be replaced of one wave per second. Human ear can perceive
by automation processes. Suitable job placement, sound between 20 and 20000 Hz).
periodic medical check up, rest and proper exercises are
also necessary. NOISE CONTROL
The control of noise pollution and prevention of noise
Noise
trauma can be achieved by using the following
Like hypertension, noise has also been called a silent killer. measures:
This is so because the effects of noise are very insidious. • Reduction of noise production: By using less noisy
It is estimated that 6 to 16 million workers in the USA machines and by fitting noise mufflers and silencers.
work in noisy surroundings that may impair hearing.1 • Reduction of noise transmission: By enclosing noise
Figures for India are not available. However, a study by producing machines in thick walled sound proofed
the National Physical Laboratory indicated that Mumbai chambers. Noise in cities and towns can be markedly
is ‘the noisiest city in India’, the biggest source of noise reduced by green belts having plantations of dense
for a person there being vehicular traffic.1 A recent survey shrubs and trees like neem, banyan, casuarina and
in noise-prone industries (oils, textiles and steel mills, tamarind.1
automobiles industry and railway workshops) revealed • Protection of persons exposed: To noise above 85
a noise level of 95 to 102 decibels.1 Industrial noise decibels at frequency above 150 Hz. Ear plugs and
ranging from 81 to 102 decibels numbs the efficiency ear muffs can be used for this purpose. The workers
of a worker besides being injurious to his health. It may in noisy environment should be rotated to avoid
be mentioned that as demonstrated by Theodore Wacks prolonged exposure and their hearing should be
at Purdue University in 1982, ordinary household noise checked by periodic audiograms.
also can retard the cognitive development of children aged • Suitable legislation: To prevent noise pollution and
7 to 24 months. 1 Even the foetus may suffer from to award compensation for noise trauma.
undesirable effects of noise. A recent study advocated that • Appropriate health education: To workers, employers
pregnant women avoid prolonged exposure to noise.1 and the general public about the effect of noise on
Industrial noise may be classified into four categories health and the related preventive measures.
as follows: Noise pollution is also briefly discussed in the Chapter
1. Steady wide band noise from continuously on Environmental Pollution.
operating motors or machines. The center has changed rules to prohibit or regulate
2. Steady narrow band noise from saws, lathes and noise from myriad sources, including the modern day
pneumatic hand tools. menace of construction and blowing horns at night. The
3. Impact noise (lasting less than 1/10th of a second) rules ban the use of vehicle horns, sound emitting fire-
from drop hammers. crackers, sound emitting equipment, noisy construction
84 4. Repeated impact noise from pneumatic hammers, equipment in residential areas at night. Night time has
riveting, etc. been specifically defined as 10 pm to 6 am. Loud noise
from the neighbor’s music system and parties has also tubes has no ill effect within reasonable limits of
Environment pollution may be described as the tants may be primary (those emitted into the
unfavorable alteration of our surroundings and occurs atmosphere as such) or secondary (those produced by
mainly because of the actions of man.1 These actions interaction of primary pollutants with the atmosphere).
are of two types—those relating to reproduction and Of the five gaseous pollutants described below, the first
those relating to industrialization. Population growth is four are primary while ozone is secondary.
really the most important cause of pollution. The world Hydrocarbons are also primary pollutants.
is overcrowded with people who consume resources
and create wastes. As regards industrialization, the CARBON MONOXIDE
actions of man include excess energy consumption using
the earth fuels (coal and oil), synthesis and use of This is one of the most abundant air pollutants. Its major
various chemicals, and use of radioactive substances. It source is automobile exhaust. Hence, its concentration
is in view of the above that the two general indicators shows marked diurnal variation in urban areas.
of sources of pollution in various countries are the
population density and the gross national product SULFUR DIOXIDE
(GNP).1 It is one of the principal air pollutants. It is produced
Well-known environmental tradegies, like the cases by combustion of sulfur bearing fossil fuels and coal.
of mercury poisoning in Minamata (Japan), severe It is also produced in certain industries where sulfur ore
smoke pollution episodes in London and the massive is roasted (copper, zinc, lead smelting industries), as also
oil spill caused by the Terrey Canyon accident reinforced in oil refineries and industries producing fertilizers,
in people's mind, the sense that the quality of air, water paper, pulp and sulfuric acid. Sulfur dioxide is readily
and a wide range of other natural resources was being absorbed by soil, plants and water surfaces. It causes
seriously degraded. deterioration and corrosion of metal, cement, paints,
Pollution can be studied under the following six leather, paper, textile, etc.
headings:
1. Air pollution HYDROGEN SULFIDE AND ORGANIC SULFIDES
2. Water pollution
3. Soil and land pollution Sulfides are very foul smelling. They are produced in
4. Radioactive pollution industries like paper, rayon, tar distillation, coke and
5. Thermal pollution natural gas refining. However, they do not cause much
6. Noise pollution. harm because effluents from these industries are usually
adequately processed in purifiers. Municipal workers
entering large sewers have died of hydrogen sulfide
Air Pollution poisoning.
Air pollutants are the materials that exist in the air in
such concentrations as to cause unwanted effects. Air OXIDES OF NITROGEN
pollution may be described as the imbalance in the
These are very abundant air pollutants, second only to
quality of air so as to cause ill effects.1 Air pollutants may
carbon monoxide. Their chief source is automobile
be natural (e.g. smoke from forest fires or volcanoes)
exhaust, the other source being chemical industries manu-
or man-made. We are concerned here mainly with the
facturing nitric acid, sulfuric acid and nylon intermediates.
latter. These are of two types—gaseous and particulate.
OZONE
Gaseous Pollutants
It is a secondary pollutant. The chief culprit is
These are substances that are gaseous at normal tempe- automobile exhaust. The nitrogen oxides produced
rature and pressure. Substances with boiling point below during petroleum combustion yield ozone in the
200°C are also included in this category.1 Gaseous pollu- presence of sunlight. Ozone and hydrocarbons undergo
PART II: Epidemiological Triad photochemical reactions that produce aldehydes, STATIONARY COMBUSTION
ketones, organic acids, acylnitrates and peroxy
An example is that of thermal power based upon
compounds. These reactions particularly occur in the
combustion of coal or oil. It may be mentioned that
smog, which is a combination of smoke and fog. The
the safest combustion is that of natural gas. This is
sozone levels in atmosphere have not decreased in spite
because of the low particulate content and minimal
of substained efforts.
sulfur content of natural gas.
Soil pollution can be described under four groups as Bacteria and parasites in human and animal excreta
103
follows.1 contaminate the soil when hygienic excreta disposal
PART II: Epidemiological Triad facilities are not available. Open defecation in the fields increase above natural background radioactivity can place
in rural and slum areas is the single most common a person at risk. The maximum permissible doses of
source. Discharge of untreated or incompletely treated radiation as recommended by the International Commis-
sewage on land and dusmping of sewage sludge also sion on Radiation Protection (ICRP), are as follows:1
cause soil pollution. The pollution, this, can cause be Total lifetime dose: 200 rem. One rem (Roentgen
rather long lasting. Ascaris eggs and Salmonella organisms equivalent man) is the amount of radiation that will
can survive on soil for 2 years and 70 days respectively. produce an energy dissipation in man that is biologically
In conclusion, one may say that soil pollution, some- equivalent to one roentgen of radiation of X-rays or
times referred to the third pollution (after air and water approximately equals 1000 ergs/g. In turn, Roentgen (r)
pollution), is certainly widespread and needs to be is a unit of X-ray or gamma-radiation intensity. It is the
curbed. Solid wastes constitute the major cause of soil amount of radiation (gamma or X-ray) that produces one
pollution. The remedy lies in promoting hygienic habits electrostatic unit of electricity in one cubic centimeter of
and use of biodegradable material. dry air at normal temperature and pressure.
Weekly dose: The above lifetime dose amounts to 0.1
Radioactive Pollution rem per week. The ICRP has recommended the limit
of 0.3 rem per week for a radiation worker with the
Radioactive emissions are of three types, i.e. alpha, beta
condition that the dose in any 13 weeks period should
and gamma rays, consisting of particles carrying positive,
not exceed 13 rem.
negative and no charge respectively. The gamma rays
are identical to X-rays. Radioactive pollution is defined Yearly dose: 5 rem.
as “Increase in natural background radiation emerging It is important to clarify that rem is a unit of radiation
from the activities of man involving the use of energy while curie is a unit of radioactive disintegration.
radioactive materials, whether naturally occurring or One picocurie (micro-micro curie) means 3.7 × 10–2
artificially produced.” The naturally occurring disintegrations per second. According to the Federal
radioactivity is of two types—cosmic radiation from outer Radiation Council, drinking water should not have gross
space and terrestrial radiation from radioisotopes in beta radiation above 1000 picocurie in the absence of
earth’s crust. Cosmic radiation produces Carbon-14 and alpha emitters and strontium-90.
Hydrogen-3 which reach earth in the form of carbon
dioxide and water. Naturally occurring radioactivity in PREVENTIVE MEASURES
the earth’s crust is found in the form of ores of uranium Storage and Discharge of Radioactive Waste
and thorium, potassium-40 and rubidium-87.
Environmental pollution occurs through the follow- • Low activity wastes—These can be discharged into
ing activities. sewers or streams. These should be stored for
• Processing of uranium and thorium ores sometime before discharge so as to reduce activity.
• Operation of nuclear reactors • High activity wastes—These cannot be discharged as
• Testing of nuclear weapons such. The radionuclides from such wastes are
• Use of radiotracers in medicine, biology, agriculture segregated by coagulation, precipitation, or ion
and industry. exchange. The concentrated nuclide in solid form is
Radioactivity from the polluted environment may stored or buried. Waste water remaining behind can
reach man directly or indirectly. Direct route includes be discharged.
exposure to radioactive gases and radioactive particles, • Very strongly active wastes—These cannot be trea-
X-rays, color TV sets, luminous dials of clocks and ted and have to be stored indefinitely. These may
watches, etc. Indirect route includes consumption of be buried under the ground or may be stored in
radioactive particles through food chain. This may occur sea at a depth of 6000 feet in concrete filled stool
through ingestion of (i) plants that have acquired drums. The latter is a cheaper method.
radioactivity from contaminated soil or water, (ii) animals
that have fed on such plants, (iii) animals living in conta- Limitation of Emission of Radioactive Pollutants
minated water, (iv) irradiated foods, and (v) conta- Appropriate techniques during handling of radioactive
minated water having radioactive particles. material can reduce the amount of emission. For
Radioactive pollution is distinct from other types of example, such handling may be carried out under a jet
pollution in that the effects are confined not only to the of soil or water.
exposed persons but also to the future generations. This
is so because of the genetic mutations caused by radiation.
Dispersal
Other major harmful effect of radiation is malignancy,
104 particularly leukemia. It may be mentioned that there When emission can not be reduced, dispersal of
is no threshold or safe dose for radiation. Even a small pollutants over a large area dilutes the pollutant and
decreases the risk. Proper ventilation and use of high 100 years due to huge industry and automobiles the
106
11 Biological Environment
Biological environment is intimately related to infective and Gunomys kok have become domesticated and
disease and its components can act a reservoir, (e.g. susceptible to plaque because the erstwhile field areas
cattle, rodents and man), vector (e.g. mosquito, ticks) have become inhabited.
and agents of infection (e.g. bacteria). The biological
environment consists of plants and animals. The DAMAGE DONE BY RATS
discussion in this chapter will be limited to the latter, with Rats are voracious eaters. One rat consumes its own
a major focus on medical entomology. However, this weight of food per month. Rats eat 1/5th of the food
does not mean that the components of vegetable grown by the farmer. Besides, they damage common
kingdom are not important for human health. Thus household articles. Rats serve as reservoirs of infection
bacteria and fungi are responsible for several diseases also. Bandicoots and other field rodents can exchange
while the food eaten may impair health if it is deficient, plague infection with domestic rodents. Thus, they may
excessive or toxic. Examples of food toxicity are serve as reservoirs of infection and maintain the disease
mushroom poisoning, ergot poisoning and lathyrism. in interepidemic periods. Tatera indica has been found
These aspects are discussed elsewhere in this book. to be a natural reservoir of plague. Various diseases
Animals constituting the biological environment may transmitted by rodents are listed in Table 11.1.
be divided into vertebrates and invertebrates. Among The magnitude of damage that rats can cause is evi-
vertebrates, birds, especially parrots, can transmit psitta- dent from an interesting incident in 1938. Thousands
cosis and ornithosis while fish may be responsible for of rats burrowed tunnels under the Mohul Bhim
allergy and fish tapeworm infection. Among inverte- airport, 100 miles from Karachi in undivided India. The
brates, protozoa, helminths and arthropods are well ground yielded to the slightest pressure and no plane
known as agents and vectors of infection. In this chapter, could land safely. Rat trapping, poisoning and gassing
attention will be focussed on rodents and arthropods were all ineffective. The airport had ultimately to be
along with the methods for destroying them as they abandoned.
play a very vital role in epidemiology of many important Common rodents that live close to man are:
communicable diseases. Rodents will be described first, • Rattus rattus, the gray or black domestic rat that lives
followed by arthropods. In the end, control of insects in inland districts.
will be described. • Rattus norvegicus, the brown rat that lives mostly in
seaport towns.
• Mus. musculus, the ubiquitous mouse.
Rodents Rats are larger than mice. Figure 11.1 shows the
Rodents include rats, mice, and some field rodents such difference between the two types of rats. The lower
as Bandicoots, Gunomys kok, marmots, Tatera indica, diagram shows the difference between a mouse and a
etc. In Mumbai, some of the rodents like Bandicoots young rat.
RAT CONTROL
It should be in the form of an all out mass campaign
rather than piecemeal efforts. Assessment of infestation
should be made by special surveys by counting the
dropping, runs, fresh knowings and rat burrows. This
is also done by weighing of plain baits and an estimate
is made on the basis of consumption of flour at 10 g
per rat per day. Infestation is considered to be light if
the number is 20 rats per house, medium if 21 to 50
and heavy if over 50. Two main methods of control
are elimination and destruction.
Rat Elimination
• All food should be kept covered, or placed in wire-
net cupboards. The garbage tins should have well
fitting covers. Food grains and flour should be
stored in metal containers.
• Gutters should be trapped and windows closed at
Fig. 11.1: Common rodents. “The upper portion compares the two night to prevent entry of rats.
types of rats. The lower portion compares a mouse and a young rat” • All existing rat burrows should be closed.
• Floors, roofs and walls of the house should be pucca
HABITS and should not provide hiding or breeding places.
Normally nocturnal; during the day the rats remain in • Household articles should be arranged in such a way
their nests near the food. There is seasonal migration that no hiding places are created.
of fields. They run along the walls and narrow passages • Food grain godowns should be so constructed that:
and move long distances. Mice move in the range of – The floor of the godown is raised one metre
3 to 7.5 meters and are not shy of new environments. above the ground level
Rats can cut through hard surfaces including – No staircase connects the ground to the floor at
concrete. They can pass through holes bigger than 1.25 the gate of the godown
cm. Burrow size is usually not more than 45 cm. Norway – A one metre wide ledge protrudes out from the
rat is a good swimmer but the other two types cannot floor in front of the gate and
swim. Some comparative characteristics of the three – Roof should be a slopping one and should pro-
species are given in Table 11.2. trude out one meter from the walls.
TABLE 11.2: Comparative characteristics of sewer rat, house rat and domestic mouse
*
The characteristic feature of order Acarina is that the head and abdomen are all fused into a single sac. The ticks (Family Ixodoidae) are
110 large and macroscopic. They possess few small hair and have an exposed hypostome with teeth. The mites are small and microscopic. They
possess plenty of long hair and their hypostome is hidden.
listed in Table 11.4. They will hence be described in trumpets on the thorax. It develops into an adult in
111
Fig. 11.2: Life cycle of mosquito Fig. 11.3: Characteristics of Anopheles, Aedes and Culex
PART II: Epidemiological Triad TABLE 11.6: Distinguishing characters of Anophelini and Culicini
attached to the rootlets. They have a long siphon tube METHODS OF CONTROL
with a spine with which they pierce the plant and draw Integrated Vector Management (IVM)
the air required, never coming to the surface. The
adults, when mature, come out from below the surface Ideally, malaria vector control activities should be part
of water. They have speckled wings and legs. The palps of a broader vector control management program. IVM
in the female are 1/4th of the proboscis in length. The entails the use of a range of biological, chemical and
important Indian species are—M. annulifera, physical interventions of proven efficacy, separately or
M. uniformis, M. longipalpis and M. indiana in combination, in order to implement cost-effective
(Fig. 11.3). They are mostly found in rural areas. control and reduce reliance on any single intervention.
Forty-six species of Anopheles have been found in Combinations of a number of methods will compensate
India. Only the following seven of these are vectors for for the deficiencies of each individual method. It includes
malarial parasite: safe use of insecticides and management of insecticide
1. A. stephensi resistance. Rotation of insecticides may be done so as
2. A. culicifacies to prolong their effectiveness. It is based on the premise
3. A. fluviatilis that effective vector control is not the sole preserve
4. A. philippinensis responsibility of the health sector but requires the
5. A. sundaicus collaboration of various public and private agencies and
6. A. minimus community participation.
7. A. leucosphyrus.
Antilarval Measures
Of the above species, A. stephensi is found mainly
in towns. A. culicifacies and A. fluviatilis are mainly rural, • Elimination of breeding places (Source Reduction):
the former with indoor and the latter with outdoor It includes permanent measures such as—
resting habits. – Filling of low lying places where water may accu-
The important Aedes (Stegomyia) species are A. mulate. This is particularly important for control-
aegypti, A. vittatus and A. albopictus. These are mainly ling breeding of Anopheles.
found in the rainy reason and are sometimes called tiger – Weekly emptying of household collections of
mosquitoes because of the stripes on their legs. Among water, particularly to prevent breeding of Aedes.
the culex (the common nuisance mosquito), the most – Covering drains, ditches, cess pools and sewers
important species is C. fatigans. near the houses, where Culex breeds.
– Removal of vegetation on shores of slow moving
DISEASES TRANSMITTED BY MOSQUITOES IN INDIA streams where A. fluviatilis breeds.
– Removal of water plants such as Pistia stratiotes
• Anopheles: They transmit malaria. and water hyacinth, manually or by herbicides,
• Culex: They transmit Bancroftian filariasis (W. checks the breeding of Mansonoides.
bancrofti), Japanese encephalitis and West Nile • Larvicidals: The breeding of mosquitoes can be
fever. reduced by a variety of physical, chemical and
• Mansonia: They transmit Brugian or Malayan filariasis biological methods. Residual effect of larvicides
(caused by B. malayi) and Chikungunya fever. varies considerably with the water quality. The
• Aedes: They transmit viruses of dengue and chikun- higher dosages are indicated for polluted water.
gunya fever in India. Yellow fever, not found in India, Larvivorous fish are widely used in urban areas,
is also transmitted by Aedes. peri-urban areas and freshwater bodies in rural
112 Mosquitoes also transmit disease from animal to animal areas. Following methods are being used to control
such as monkey malaria and avian (bird) malaria. larval stage.
– Mineral oils: Kerosene, diesel, fuel oil and 1. Space spray: Space spraying has been defined as
DDT 1 or 2 6 to 12
Dieldrin 0.5 6 to 12
Antiadult Measures
Lindane 0.5 3
Killing: The mosquitoes are killed in two ways by Malathion 2 3 113
contact poisons: OMS-33 (Propoxur) 2 3
PART II: Epidemiological Triad Current policy of insecticide use in India: DDT should stand out erect, forming a V. Flights are short and jerky
be the insecticide of choice for residual spray where it as they are too weak to fly against wind (Fig. 11.4).
is sensitive. If resistance is noted with DDT then The sandflies breed in cracks in the walls and in stone
Malathion is the alternative choice; in case of resistance heaps where there is enough nitrogenous waste. They
to DDT and Malathion both then synthetic pyrethroids sting at night and the bite is painful. Itching persists for
is the choice. The use of HCH was banned in India in sometime. Out of about 39 species of sandflies found
1997 due to environmental concerns and partly due in India, those of medical importance are Phlebotomus
to resistance. argentipes, P. papatasii, P. sergenti and Sergentomyia
For Mansonia, in addition to insecticides, herbicides punjabensis.
have to be used to destroy the weeds whose roots
support the larvae. Diseases Transmitted
The various types of formulations used for sprays
are described later under the section Insecticides. The sandflies are responsible for the transmission of kala-
azar (P. argentipes), oriental sore (P. papatasii and P. sergenti)
and sandfly fever (P. papatasii and P. punjabensis).
Genetic Control 4,5
Males sterilized by gamma irradiation and Control
chemosterilants are released. They mate with females
but the later produce unfertilized eggs which do not • Breeding is prevented by filling cracks and cervices
develop further. This is a potentially useful method that on the walls and removing any stone or rock piles.
has yet to be tried on a large scale. • The adults are killed by indoor residual spray
insecticides like DDT and lindane in concentrations
of 1-2 and 0.25 g per square metre respectively.
Prevention of Mosquito Bites
• Repellents used on clothes or applied to skin such
• Use of repellents: Diethyl toluamide (deet) and butyl as deet, DMP, etc. are effective against bites.
ethyl propanediol applied on clothes repels Culex
for 6-13 hours. Others in use are DMP, indalone, TSETSE FLIES
dimethyl carbate and ethyl hexanediol. They are
applied to the exposed parts of the body. They belong to family glossinae and are limited to
equatorial Africa. They are brown in color and have the
• Preventing entry into houses: Mosquito-proof wire
same size as a house fly. Both male and female bite man
gauze (6 mesh) is used for this purpose on doors,
and suck blood. They attack domestic animals as well.
windows and ventilators.
Two species transmit trypanosomiasis:
• Sleeping in mosquito nets: (6 mesh) and using veils,
1. Glossina palpalis—It transmits Trypanosoma
socks and gloves, etc. as necessary.
gambiense and lives along water courses (hence
In regard to wire gauze and mosquito nets, it
called wet fly).
should be ensured that the number of holes should
2. Glossina morsitans—It transmits T. rhodesiense and
be at least about 25 per sq cm (i.e. 5 holes or 5
is sometimes called dry fly.
mesh per cm). It is preferable to use a net with 6
mesh per cm (15 mesh per inch).
Flies
Though less important than mosquitoes as vectors of
disease, the flies have a large variety of species. They
may be divided into two groups, the biting and
nonbiting flies. The biting flies include sandfly, tsetse fly,
blackfly and deer fly. Of these the sandfly is the most
important. The common example of a nonbiting fly is
the domestic fly.
SANDFLIES
They belong to order Diptera, family Psychodidae and
subfamily Phlebotominae. The proboscis of sandflies is
like a blade and not like a stylet as in case of
114 mosquitoes. Minute in size (1.5-3 mm), they have lot
of hair on the wings and body. The wings are hard and Fig. 11.4: Phlebotomus
motile, white, legless, 1.2 cm in length, with a distinct
Fleas
They belong to the order Siphonaptera and have
laterally flattened body but no wings. Thus they differ
from lice and bugs which are compressed dorsoventrally.
They feed on a number of hosts such as rodents, cats,
dogs, etc. Important fleas are those that migrate from
the animal hosts to attack man. These are listed below:
Pulex irritants or human flea: It is cosmopolitan in
habitat. It causes dermatitis and may transmit human
plague and endemic typhus. It is characterized by an
ocular bristle below the eye.
Xenopsylla cheopis, X. astia and X. braziliensis:
These are oriental rat fleas responsible for transmitting
plague and endemic typhus. They are characterized by
an ocular bristle in front of the eye.
Nosopsyllus fasciatus: This is the rat or squirrel flea
of temperate regions. It has got a prenatal comb only.
116 Ctenocephalus canis and felis: These are the dog
and cat fleas. They possess pronotal and genal combs. Fig. 11.6: Developmental stages of a flea
Diseases Transmitted Life Cycle
117
Fig. 11.7: Human lice Fig. 11.8: Eggs of lice
PART II: Epidemiological Triad Control Measures Control
Prevention of Infection Bugs have become resistant to organochlorine insecticides
• Contact with infested person, often a servant or a like DDT, gammexane and dieldrin. Diazinon in kerosene
fellow school child, should be avoided. Hat, cap, oil is most effective but toxic. Other organophosphorus
comb, hair brush and clothes of an infested person insecticides and carbamates are effective. Malathion
should not be used. resistance has also been reported.4 Synergised pyrethrum
• The bedlinen and under clothes should be properly spray (with piperonyl butoxide, sesame oil and lindane)
washed and the hair combed as a part of personal is effective against bedbugs.
hygiene. If necessary, clothing may be dusted with
carbaryl powder in highly lousy surroundings. Scorpions
Delousing Measures
These octapods belonging to class Arachnida do not
Applying 2 percent DDT emulsion or dusting with
transmit any disease. Their medical importance is limited
10 percent DDT were very effective previously. With
the emergence of DDT resistance, 0.2 percent to scorpion bite which is painful and may sometimes be
lindane in coconut oil should preferably be used. In poisonous. The bite of poisonous varieties of scorpions
case of resistance to this also, 0.5 percent malathion may produce severe systemic reactions such as lymph-
lotion (1% in case of body louse) is effective. The adenitis, twitching of muscles, spasm and convulsions.
lotion should be allowed to act for 12 to 24 hours Patients may die of respiratory failure with pulmonary
before the hair is washed. It kills both lice and nits. edema within two to three hours of the sting. The venom
Carbaryl dust may also be used as louse powder.3 is probably a neurotoxin which acts peripherally.
An emulsion designated NBIN (68 percent benzyl
benzoate, 6 percent DDT, 12 percent benzocaine Treatment for Scorpionism
and 14 percent Tween-80) applied after 1:5 dilution
A tourniquet is applied above the bite to prevent
in water is also effective against lice as well as nits.7
Leather, wool and silk may be deloused by soaking systemic spread of the poison. The wound is incised and
them in 2 percent cresol and 50 percent soap the poison is sucked. Pain is relieved usually by a drop
emulsion for one hour. of strong or dilute ammonia solution poured directly.
If necessary, 0.3 to 0.6 ml of 2 percent novocaine
Bugs solution with epinephrine is injected near the puncture
would to combat pain. If systemic dissemination occurs,
The common bedbugs (Cimex lectularius and C. hemip- (indicated by profuse sweating, salivation, vomiting,
terus) are not known to transmit any disease. The Redu- myoclonic twitching or abdominal pain), specific
viid bugs are known transmitters of Chagas disease in antivenom should be given. Cortisone may have to be
South and Central America. Several species of these administered.
bugs are known to transmit Trypanosoma cruzi, the
causative agent. Though Reduviid bugs have been Control
described in India, 8 they do not act as vectors of
infection. Sprays with 2 percent chlordane, 10 percent DDT and
The bedbugs (Fig. 11.9) are nocturnal in habit and 0.2 percent pyrethrum in kerosene are useful to kill
reside in the clothing and seams of linen. They emit a scorpions. Dieldrin, BHC and organophosphorus
stinking odor. Their bite is very painful. They feed on compounds are also effective as surface spray or dust.
blood, the feeding lasting for about 15 minutes. They
can fast for up to six months. Ticks
Ticks are blood sucking parasites. Their natural hosts are
domestic animals such as cats, dogs and cattle. They
attack man only accidentally. The two families of medical
importance are Ixodidae (hard ticks) and Argasidae (soft
ticks, Fig. 11.10). The hard ticks remain attacked to
the host while the soft ticks leave the host after feeding.
LIFE CYCLE
It consists of four stages (egg, larva, nymph and adult)
and is completed in two years (Fig. 11.11).
118 1. Eggs: They are laid on the ground in batches of
Fig. 11.9: Bedbug thousands and take 2 weeks to one month for hatching.
CHAPTER 11: Biological Environment
ITCH MITE (SARCOPTES SCABIEI)
The scab or itch mite is the causative agent for scabies.
It is found allover the world. Infestation is more
common when living is congested.
All the four stages of the parasite (egg, larva, nymph
and adult) are completed in the skin, the development
from egg to the adult occurring in about two weeks.
The female makes zig-zag burrows and lays eggs deep
in the horny layers of the skin. Eggs develop into three
Fig. 11.10: Hard and soft ticks legged larvae, which enter hair follicles and grow into
nymphs and adult. The adult is 0.4 mm in length and
oval in shape with flat ventral and convex dorsal surface.
The spines and bristles on its body given it the
appearance of a hedgehog (Fig. 11.12).
The male dies after mating, leaving behind the ferti-
lized female to cause the disease. Places of predilection
for burrows are: interdigital webs, wrists, elbows, feet,
penis, scrotum, buttocks and armpits. Face, palms and
soles are always free in adults but may be involved in
children. The scabies mite can be located in the skin
with the help of the hand lens.
Clinical picture appears after sensitisation of the skin
Fig. 11.11: Life cycle of tick
over a period of a month or two. This can be called
the incubation period. To start with, erythematous
2. Larvae: Smaller than adults, they have only 3 pairs
patches are seen around the burrows. These develop
of legs. They jump about to feed on small rodents,
into papules and vesicles. Itching is intense at night,
then leave them, shed skin and develop into
which leads to scratching and secondary infection.
nymphs.
Personal contact of prolonged nature, such as sharing
3. Nymphs: They are octapods like adults adults are
the same bed, is needed for infection. However,
sexually immature. They remain unfed for about a
transmission through bedlinen is not likely as mites
year. Later on they feed on rodent or man, then
prefer the warm body. Off the host, the parasite dies
fall to ground and change into adults.
within two days.
4. Adults: They hibernate for one year before sucking
blood of larger animals or man.
Prevention and Control
DISEASES TRANSMITTED • Direct contact with the infested person, or indirect
Hard ticks: Tick typhus (Rocky mountain spotted fever), through undergarments, should be avoided. Proper
Q fever, viral encephalitis, viral hemorrhagic fevers (e.g. personal hygiene should be observed including bath
KFD) and tularemia. They transmit babesiosis in animals with soap and water.
and may also sometimes cause human babesiosis. In
addition, they also cause tick paralysis.
Soft ticks: They mainly transmit relapsing fever.
CONTROL MEASURES
Dimethyl phthalate (DMP) is a good tick repellant,
especially against larvae. Clothes dipped in 5 percent
DMP and 2 percent soap solution retain the repellant
effect for one to two months. Infested animals may be
dusted with lindane, malathion or DDT.
Mites
Mites are parasitic to man and animals and produce
irritation of skin (acariasis). The mites of public health 119
importance are the itch mite and the trombiculid mite. Fig. 11.12: Sarcoptes scabiei
PART II: Epidemiological Triad • The infested persons and contacts should be treated (deet, benzyl benzoate). Clothes impregnated with DBP
thoroughly with 3 to 5 percent sulfur ointment or remain effective for two to four weeks even if washed.
20 to 25 percent benzyl benzoate emulsion. The
patient should take hot bath with soap and water, CYCLOPS
scrub the affected parts with brush, dry the body
with rough towel, and rub the medicine all over, Cyclops or water flea is found in fresh water. It is
especially over the affected parts. He should then pyriform in shape and is dorsally convex. The head and
put on clean clothes and take no bath for 48 hours. thorax are fused to form a bulbous cephalothorax while
The old clothes should be sterilised by boiling. the abdominal portion is narrowed. The head has two
Second application may be necessary. pairs of antennae and small pigmented eyes. The size
• Tetmosol 5 to 10 percent in soap is a good does not exceed one mm and it is just visible to a
prophylactic. Five percent tetmosol solution is a good trained eye. Average life is three months. It is
sarcopticides and can be applied three times a day. responsible for transmission of guinea worm infection.
• 0.5 to 1 percent BHC or Gamma HCH (lindane)
in coconut oil is a good sarcopticide when applied
on the affected part two or three times at interval
Insect Control
of two to three days. Insecticides
TROMBICULID MITE (REDBUGS OR CHIGGERS) Insecticides are substances that kill insects. The term
pesticides is a general term including, besides insecticides,
Redbugs (Fig. 11.13) are the six legged larvae of mites rodenticides, herbicides, fungicides, disinfectants and
belonging to family Trombiculidae. They alone are repellents. Till 1936, the major emphasis was on
parasitic to man while the adults or nymphs live in the inorganic chemicals such as arsenicals (Paris green),
soil. The parasitic larvae are called redbugs, chiggers, fluorides, mercurials, hydrocyanic acid, sulfur dioxide
harvest mites or scrub mites. Leptotrombidium and methyl bromide. However, their use was restricted
akamushi is found in Japan and L. deliens in India. Their because they are injurious to man and pets. Vegetable
larvae are called red bugs because of their brick red poisons and chlorinated hydrocarbon were found to be
color. less toxic to man. From 1936 to 1945, plant insecticides
L. akamushi larvae, when anchored to the skin, such as pyrethrum, rotenone, nicotine and certain
inject saliva that produces irritation and causes tissue petroleum oils were widely used. They were effective
reaction. They transmit Rickettsia orientalis, the causative against insects but practically nontoxic to man. From
organism of scrub typhus, or tsutsugamushi fever. The 1945 to 1955 chlorinated hydrocarbons such as DDT,
transmission is transovarial—the larva bites and becomes BHC and dieldrin were put to extensive use but
infected and passes on the infection to nymph and adult resistance to them developed over a period of time.
stages. The female transmits the infection to the ovum Later on organophosphorus compounds such as
from which the larva emerges and bites the fresh host, diazinon, malathion, parathion and dichlorvos became
thereby passing on the infection. popular. Though they are more expensive and more
toxic to man, they are effective against insects that have
Prevention become resistant to organochlorine compounds.
Use of repellents protects against larval bites when sitting However, insects have started showing resistance to
on infected grass. Such repellents may be used on the them also. Some other chemical insecticides such as
exposed parts (DBP or dibutyl phthalate) or on clothes OMS-33 (baygon), and OMS-29 (carbaryl) were later
developed. These are safer than organophosphorus
compounds if general precautions are taken.9
Increasing reports of resistance of insects to chemical
insecticides and their toxicity to man (direct and through
food contamination) is causing great concern.
Consumer hazards due to the increasing use of
pesticides in food and agriculture have been evaluated
by several expert committees. Organochlorine
compounds have been found to be persistent and
cumulative and there is evidence of their effect on liver
even in low doses.10 According to one study “Indians
ingest more pesticides through their food than any other
120 nation studied. The level of DDT in the body fat of
Fig. 11.13: Trombiculid mite residents in Delhi has been found to be in the region
of 26 ppm on average—well above the maximum • It should be economical, easily available and should
An insecticide, to be useful, should have the following Pyrethrum: This is an instantly acting insecticide but is
characteristics: effective for only a short duration being highly photo
• It should be highly toxic to insects and not to verte- degradable. It is extracted from flower heads of
brates. Chrysanthemum cineariafolium which originated in East
• It should have persistent action or residual effect. Africa but is now successfully grown in Kashmir, Shimla,
• It should not be too slow in killing or paralysing the and Nilgiri Hills.
insects. Pyrethrum is the main insecticide used for space
• Insects should not develop resistance against it. spray and kills insects on their wings in rooms or other
125
12 Social Environment
• Though the relationship starts after a particular specified rules of conduct are technically known as social
disease, it is often continuous in nature. Illness keeps norms. Various social norms and their origins are
on occurring frequently and, by and large, patients explained in Figure 12.1.
have a tendency not to change the doctor. Most Various types of norms, can be considered according
people have their family doctors, the relation with to– Range of acceptance and Range of enforceability.
whom is continuous.
Folkways: They refer to customary ways of behavior.
• The doctor-patient relation is more than a mere
People conform to these ways not out of fear of being
professional or money relation. Without an element
penalised but because it is obligatory in the proper
of emotion on the part of the doctor and without
situation. They are enforced by informal social controls
an element of faith on the part of the patient, the
like gossip and ridicule. Their origin is usually unplanned
treatment cannot be fully unsuccessful.
and obscure. Examples of such expected forms of
• The relation is not transferable from the patient’s
behavior include the ways of greeting, dressing, eating,
point of view. For example, a patient wishes to see
etc. Folkways vary from society to society and culture
the same doctor on a follow-up visit even in a
to culture. Certain folkways may be common, but
government hospital. If his own doctor is not
otherwise they lend uniqueness to a culture. They are
available, a patient would prefer to visit again and
necessary for the group solidarity. Vitality of a group is
see his earlier doctor rather than be seen by a new
indicated by the extent to which people follow or abide
doctor on each visit.
by folkways.
FUNCTIONAL ASPECTS OF SOCIETY Mores: Mores are socially acceptable ways of behavior
that involve moral standards. There is greater feeling
We have already said that society is an organization
made by man for himself. So he has framed the of horror about violating mores and greater unwilling-
procedures also. Every living organism has some basic
requirements and tries its best to satisfy them. In
animals, these needs give rise to the basic desires or
instincts which the animal tries to satisfy without
inhibition. In man, the biological forces trigger the desires
but, contrary to animals, there are social standards
which guide man. The resultant of these two forces is
the actual behavior, which we perform in society. A
newly born child is equivalent to an animal. Whenever
he feels hungry, he starts crying and keeps on crying
till his desire is fulfilled. As the child grows, he can tole
or can be made to understand that “please wait, food
is not ready” and the child can resist his hunger. The
day to day teaching and learning constitutes an
important functional aspect of society.
Social Norms
128 Every society specifies certain rules of conduct to be
followed by its members in certain situations. These Fig. 12.1: Types of norms
ness to see them violated. While each folkway is not
Socioeconomic Status
Socioeconomic status (SES) is an important determinant
of health and nutritional status as well of morbidity and
mortality. The variables that affect socioeconomic status
are different in case of urban and rural societies. For
example, the influence of caste on social status is very
strong in rural communities but not so much in the cities.
Separate scales are hence used for measuring the SES
in rural and urban areas.
The SES scale (rural) developed by Pareek5 attempts
to measure the socioeconomic status of a rural family.
It is based upon nine items as follows:
1. Caste 133
Fig. 12.2: Different types of families 2. Occupation of head of family
PART II: Epidemiological Triad 3. Education of head of family TABLE 12.2: Kuppuswamy socioeconomic scale
4. Level of social participation of the head of family Components Weightage
5. Land holding
Education of head of the family
6. Housing
• Professional degree, postgraduate and above 7
7. Farm power (drought animals like bullocks, prestige • Bachelors’ degree 6
animals like camel, elephant, horse and mechanical • Intermediate or post high school diploma 5
power like tractor) • High school certificate 4
• Middle school completion 3
8. Material possessions • Primary school completion or literate 2
9. Family (type of family, family size and distinctive • Illiterate 1
features of family in respect of persons other than
the head of family). Occupation of head of family
137
13 Health and Law
We have seen in the previous chapter that sociopolitical Muslim, Christian and Parsi Marriage and Divorce Acts,
environment is a crucial determinant of health. An the Special Marriage Act, 1954 and the Medical
important component of this environment is the legal Termination of Pregnancy Act, 1971. The
system. Many laws have been specifically enacted to Environmental Acts, include Factories Act, 1948,
protect and promote people’s health. In addition, the Industries (Development and Regulation) Act, 1951,
general civil and criminal law can also be invoked to Mines and Minerals (Regulation and Development) Act,
protect the health interests of people. Every physician, 1947, Prevention of Food Adulteration Act, 1954,
especially a community physician, should be aware of Water (Prevention and Control of Pollution) Act, 1974,
such laws. This topic will be briefly discussed in this Air (Prevention and Control of Pollution) Act, 1981,
chapter. Medicolegal aspects related to forensic medicine Environmental Protection Act, 1986, and Motor Vehicles
will not be touched upon. Act, 1988. However, another potent legislation affecting
Poor health in rural areas is essentially a mani- health services is essentially a non-health Act, the
festation of their poor resources, bargaining power and Consumer Protection Act, 1986 (CPA). This act has
access to centers of policy and decision making. To that been widely welcomed but has also generated
extent, the discussion of legal aspects of rural health will controversy as regards its application to the medical
have to touch upon wider social issues. We shall first profession. The Monopolistic and Restrictive Trade
have an overview of health laws in general. Then we Practices Act, 1969, is another potent law which, though
shall discuss in some detail the legal issues of particular general in nature, can be used for health issues.
relevance for the rural poor followed by a discussion
about how law can be used as a tool to improve health.
This will be followed by a discussion on law and the Law and the Rural Masses
medical profession and, in the end by some thoughts In the context of the rural people, it is basic inequality
about future legislation. between the rural and urban areas that has been
perpetuated, both before and after independence. A
single example will suffice. Hospital bed availability per
Laws Related to Health 1000 population in urban areas is 16 times that in the
Merely having a law is not sufficient. What is important rural areas. This is so in spite of the fact that morbidity
is to ensure that the laws enacted are implemented. and mortality is higher in rural areas, underlining the
There is frequent flouting of laws all around, especially need for better health care facilities there. The adverse
in relation to environment, food adulteration and doctor population ratio in rural areas, as compared to
population. As an example of the latter, child marriages urban areas, is a reflection of the same trend. As a
are still common. matter of fact, almost all parameters, including job
Health related laws concern three major areas, viz. opportunities and education, housing, communication
health care, population and environment. In addition, facilities, etc. show an urban bias.
there are some laws which are not specific to health but When social inequity becomes too much, people
have crucial bearing on health issues. Only the more revolt. However, revolutions often have disastrous
important laws will be discussed. As regards health care, effects. It is better to bring change in society through
the important acts are the Drugs and Cosmetics Act, planned legislation rather than unplanned revolution.
1940, Drugs and Magic Remedies (Objectionable It needs to be underlined, of course, that legislation by
Advertisement) Act, 1954, Drugs Control Act, 1956. itself cannot bring change. Legislation must be
Indian Medical Council Act, 1956, Medical Degrees Act, implemented to act as an engine of change. In a
1916, Employees State Insurance Act, 1948 and Indian democratic system, legislation can be effective only
Factories Act 1948. The Population Acts include the when people are literate and know and demand their
Registration of Births and Deaths Act, 1969. The Hindu, rights, as also perform their duties.
Some constitutional and statutory provisions related Child Marriage Restraint Act, last amended in 1978,
The state of health or disease is the end result of An aspect of sexuality getting particular attention these
interactions that occur in the environment between days is sexual orientation, earlier referred to as sexual
the agent and the host (man). The role of various preference, in relation to homosexuality or heterosexuality.
environmental factors has already been discussed in There appears to be a genetic basis for sexual orientation.
the chapters on “Environment”. The role of host It may be mentioned that gays are more prone to get
factors that help in the promotion and maintenance certain infections, including HIV infection.
of health and in prevention and defence against Sex differences in disease may have a cultural basis. For
disease is described in this chapter. example, Chutta cancer (cancer of hard palate caused by
The host factors that influence health can be reverse smoking, i.e. smoking a cigar with the lighted end in
grouped as follows: the mouth) is more common in women in Andhra Pradesh.
• Age, sex, marital status, parity and race The reason is that reverse smoking is used by women as
• Physical state of the body a mark of respect to men with the result that 36 percent
• Psychological state and personality women compared to 20 percent men use this
• Genetic constitution technique.1a
• Defense mechanisms
• Nutritional status Marital Status and Parity
• Habits and lifestyle.
Cancer of cervix is rare in nuns and far more common
in married women. Gallstones disease is classically des-
Age, Sex, Marital Status and Race cribed to be common in fat, fertile females. Obesity in
Age and Sex women is similarly common in those who are multiparous.
On the other hand, breast cancer and cancer of the body
Infectious diseases like measles, whooping cough and of uterus are more common in multiparous women.
nutritional deficiencies are common in childhood, Marital status is well known to affect lifespan. Accor-
cancer and venereal disease in middle age and ding to a Soviet study,2 staying single can cut short a man’s
arteriosclerosis and coronary heart disease in old age. lifespan by more than nine years and a woman’s lifespan
However, an increasing trend towards early by more than four years. This does provide scientific
occurrence of coronary disease has been found justification for men marrying in old age.
during the last few decades. Certain neoplastic
diseases like leukemia, breast cancer and Hodgkin’s Race
disease show bimodal age incidence, indicating
thereby that two different sets of factors may be Racial or ethnic differences are combined manifestations
operative in their causation. For example, Hodgkin’s of genetic and environmental factors to which a popu-
disease shows one peak at 15 to 35 years and lation is exposed. Thus some races have innate resistance
another beyond 50 years.1 Chromosomal anomalies to malaria, syphilis, tuberculosis, leprosy and perhaps to
like Down’s syndrome are more common in the AIDS (Acquired Immune Deficiency Syndrome) infection.
offspring of women conceiving after 35 years of age. As an example, it may be mentioned that acne vulgaris,
Women in general have higher longevity than man. so common among caucasians, is uncommon in blacks
Certain diseases are exclusive to males and females. and rare in the Japanese. Parsis have a higher incidence
Examples are cancer of prostate and testes and of G-6-PD deficiency.
cancer of breast and cervix. Some diseases are more
common in men (atherosclerosis, coronary heart
disease, lung cancer) while others are more common Physical State of the Body
in women (obesity, diabetes mellitus,
hyperthyroidism). A few diseases show difference in Fasting, fatigue and cold, lower the body resistance against
severity between the two sexes. Thus syphilis is more disease agents. On the other hand, a well fed person with
severe in males, probably because of anatomical and adequate rest and clothing is less prone to fall ill. For
hormonal differences. example, acute respiratory infections are more common
during the winter season. Similarly, persons with at birth. Nongenetic Birth Defects are due to conditions
Principles of Immunization
In the process of immunization the body’s immune
system is actively stimulated by the antigen used for
immunization. This leads to the production of specific
antibody (humoral immune response) or specifically
sensitized cells (cell mediated immune response), which
specifically combine or react with the pathogens and
148 destroy them. The immunization procedure which Fig. 14.1: Relationship between nutrition and infection
CHAPTER 14: Host Factors and Health
TABLE 14.1: How infection results in malnutrition?
Habits and Lifestyle
• Reduced food intake
– Decreased appetite While community health is the concern of the state, the
– Altered sensory perception health of an individual is his own responsibility. The
– General malaise government can only ensure that all individuals have
• Reduced nutrient absorption access to adequate food, clothing, shelter, immunization
• Increased caloric expenditure
• Utilization of glucose in preference to fatty acid as source energy facilities and treatment for disease. But no government
– Increased gluconeogenesis Negative can force the people either to use these facilities or not
– Decreased synthesis of muscle protein nitrogen to indulge in practices injurious to health. Herein lies
– Decreased albumin synthesis balance the importance of lifestyle and healthy habits, including
• Hypovitaminosis
personal hygiene. In course of time hygienic and
healthy habits become a natural way of life and thus
TABLE 14.2: How malnutrition aggravates infection?
help to maintain life-long health.
• Mechanisms involved In a narrow sense, the term personal hygiene
– Increased predisposition to and severity of infection
impaired tissue integrity
implies observance of personal body cleanliness. In a
– Impaired immune response (cellular as well as humoral) wider sense, it implies the observance of healthy
– Endocrine and metabolic effects practices by an individual in his daily life.
• Effects of specific deficiencies
– Protein deficiency: Synergistic with all bacterial infections
including tuberculosis. Helminthic infections more severe Healthy Habits
in protein deficient animals.
– Vitamin C deficiency: Synergistic with almost all infections
studied.
ORAL HYGIENE
– Vitamin A deficiency : Synergistic with many bacterial Eat some fibrous fruit or vegetable (such as apple,
diseases, also with several helminthic infections in animals.
– Energy deficiency: Synergistic with infections in general.
orange, carrot, salad) at the end of a meal. This helps
in proper cleaning of teeth. Refined sugar is not good
for teeth. Drinking water should contain at least one
PPM of fluorine as prophylactic against carries. Rinse
priate to discuss here the effect of host nutrition upon
the mouth well after eating something. Use a good
host immunity.
quality tooth brush. Any tooth paste or tooth powder
is good enough for use. However, the powder should
Nutrition and Immune Response not be too coarse. Teeth must be brushed before retiring
for the night. Visit a dentist regularly.
Recent studies have shown that the immune system,
like other systems in the body, also shows malfunction
DIGESTIVE SYSTEM
in persons with malnutrition. Thus in mild and
borderline malnutrition, cell mediated immunity is • Do not eat in a hurry and under stress or worry.
decreased to some extent. It is usually compensated by Chew the food well.
humoral immunity with consequent increase in serum • Do not eat too much sugar and fat.
gamma globulin levels. In moderately severe • Fasting is good for all ages. It gives rest to stomach
malnutrition, even the humoral immunity is decreased when there is indigestion. It also helps build up will
and the capacity to produce antibody goes down. In power and thus contributes to sound mental health.
the most severe forms of malnutrition, even the • Take meals at regular timings. The interval between
primitive body functions like phagocytosis and two meals should not be unduly long, especially in
inflammatory response are decreased. Recent studies case of infants and children.
have shown the importance of trace elements in • Eat enough vegetables and fruits.
immune response. Thus, even mild to moderate zinc
deficiency may lead to profound malfunction of the RESPIRATORY SYSTEM
immune system of the body. A recent review suggests Ventilate the lungs well with deep breathing exercises.
that zinc deficiency may facilitate occurrence of leprosy Avoid chills, dust, irritating fumes and overcrowding. Do
through impairment of the immune response.5b It is not smoke and avoid passive smoking.
obvious that malnourished individuals show increased
susceptibility and response to infections because of
CIRCULATORY SYSTEM
depressed functioning of the immune system. This leads
to further malnutrition, thus starting a vicious cycle Avoid coronary risk factors like smoking, overweight,
(Fig. 14.1). There is also evidence that the “take” of mental tension and excessive intake of salt and cho-
immunization is decreased in malnourished persons lesterol. Take daily physical exercise. Get blood pressure 149
because of depressed immune function.3 checked at least once a year after 40 years of age.
PART II: Epidemiological Triad EYES of tobacco.6a In France also, about 0.1% population dies
annually due to smoking. Out of the 58000 smoking
Eyes should be kept clean and well protected from dust
related deaths in France in 1985, 29000 (50%) were
and irritating atmosphere. Errors of refraction should
due to cancer, 17,500 (30%) due to cardiovascular
be corrected. While reading a book, it should be kept
illness and 7,000 (12%) due to chronic respiratory
at a distance of about 30 cm from the eyes. The light
illness.7 Data from India on similar lines is not available,
should be adequate and should preferably come from
the left. Do not read in a running vehicle. Do not look but is likely to reflect the same trend.
directly at the sun, are light or solar eclipse, otherwise Smoking a cigarette means inhaling about 1.7 mg
nicotine and about 20 mg tar. The former causes addic-
retinal burns may be caused. It is advisable to perform
tion while the latter causes cancer. Besides cancer, there
ocular convergence exercises daily for four to five minutes.
are several other harmful effects. Statistically significant
This is done by holding the hand in front of the eyes,
association between smoking and development of
fixing the gaze at the tip of the index finger and moving
pulmonary tuberculosis has been reported.7a Smoking
the finger slowly towards the face to ultimately touch the affects all body systems adversely including the nervous,
nose, keeping the gaze fixed at the tip of the finger unless gastrointestinal and reproductive systems. Even the skin
one sees two fingers for one. Then slowly take away the is affected: blood flow to skin decreases due to smoking,
finger and fully stretch the hand as earlier. Repeat the causing early wrinkling. As regards reproductive system,
process eight to ten times at each sitting daily. With some the effects are quite obvious in case of women smokers.
practice, it should be possible for the finger tip to touch Smoking during pregnancy causes low birth weight and
the nose without the occurrence of diplopia. fetal death. Smoking also decreases the movement in
the fallopian tubes, increasing the risk of ectopic
NERVOUS SYSTEM pregnancy and infertility. It is also related to an increased
risk for cervical cancer due to interaction of the cancer
Avoid use of addictive narcotic substances such as causing agents in tobacco smoke with the HPV virus.
alcohol, opium, cocaine, cannabis, nicotine and The other well known problem for women who smoke
tobacco. Use tea, coffee and cocoa in moderation. is the interaction with oral contraceptives in increasing
Minimize worries, mental strain and overwork. the risk of heart disease. Women who are over 35 years
who smoke and take the pill are much more likely to
Lifestyle have a fatal heart attack than women of same age who
do not smoke and do not take the pill.6
Lifestyle has emerged during last two decades as a If tobacco smoking is to be minimized as a host
major modifiable determinant of health and disease. The factor, it involves two types of actions on the part of the
peculiarity of this determinant is that control mechanisms human host.
have to be applied not in the external environment but
within one’s internal mental domain. As such, the Avoiding active smoking: Starting or stopping smoking
adoption of a particular lifestyle is a direct reflection of is a personal decision which depends on several factors
inner control or will power. It is in this context that besides enjoyment derived from cigarettes. For example,
spirituality is also included in the seven major components about half the smokers smoke even when they do not
of lifestyle from the point of view of health as listed below: enjoy doing so.7b The health professionals can help in
1. Dietary intake, including beverages like tea and dissuading people from starting smoking and
coffee (discussed in Chapter 22) encouraging smokers to stop doing so. Research in USA
2. Alcohol intake (discussed in Chapter 34) shows that 5 to 20 percent patients who quit smoking
3. Drug addiction (discussed in Chapter 34) are advised to do so by their doctor. According to a
4. Smoking recent survey,7c one third Indian smokers tend to consult
5. Sexual behavior their family physician for problems arising out of
6. Physical fitness and exercise smoking. The responsibility of the medical profession in
7. Spirituality this direction is obvious. The antismoking campaign has
Only the last four aspects will be discussed here.
already started showing results in USA. Between 1976
and 1987, the number of adult male smokers dropped
SMOKING by nine percent. The decrease in case of women was
Smoking is a pernicious scourge of the world today. only four percent. Unfortunately, more women than men
According to data from USA, smoking is number one are taking to smoking in USA at present. It is feared that
cause of premature death. It kills more people every if this trend continues, women smokers will outnumber
year than alcohol, heroin, cocaine, homicide, suicide men in USA by mid-nineties.6
and AIDS combined.6 It is reported that one million Avoiding passive smoking: Passive or involuntary
150 Indians (0.1% of total population) die every year from smoking has been recognized as a definite health
tobacco related diseases including smoking and chewing hazard. A passive smoker is a person who is exposed
to tobacco smoke exhaled by a smoker in the vicinity. body” certainly has scientific basis.
152
General Epidemiology of
15 Communicable Diseases
Communicable diseases in endemic or epidemic form The major communicable diseases in India are:
have been taking a very heavy toll of human lives • Tetanus
throughout history. Their incidence has reduced consi- • Rabies
derable due to better understanding of their epidemio- • Cholera
logical features, availability of specific chemotherapeutic • Enteric fever
agents and application of effective methods of • Amebiasis
prevention and control. The progress made in control • Ankylostomiasis and ascariasis
of communicable diseases in India is reflected by the • Infective hepatitis
fact that smallpox has been eradicated from the world • Tuberculosis
and guineaworm is almost eradicated from India. It is • Diphtheria
the control of communicable diseases which, to a large • Whooping cough
extent, has been responsible for the increase in life • Measles
expectancy at birth in India from 19.4 in 1911 to 20, • Influenza
through 41.9 in 1951 to 60 to 58.6 in 1986 to 91. • Filariasis
The relation between communicable diseases and life • Arthropod borne virus infections
expectancy is clearly demonstrated in Figure 15.1 • Leprosy
where data from 20 Latin American countries in • Polio
graphically presented. It is seen that as the proportion • Malaria
of deaths caused by infectious and parasitic diseases • Trachoma
decreases from around 21 to 5 percent, there is marked • STD
increase in lifespan from 42 to 68 years. • Scabies.
The environmental forces affecting the host and the
agent are constantly changing the balance between the
two. Disease occurs when the balance is in favor of the
agent. Lodgement of the causative agent in the human
host is only the initial requirement for occurrence of an
infectious disease. The infection in the community is
maintained through a chain of five events:
1. Entrance of the agent into skin or mucous
membranes of alimentary canal, respiratory passages
or genitourinary tract by direct or indirect contact.
2. Multiplication in a favorable site, organ or tissue of
predilection.
3. Exit through body secretions or excretions or
through blood sucking arthropods.
4. Survival in physical environment (such as air, water
and soil) or biological environment (such as rats and
arthropods).
5. Propagation to another host through man, animal,
arthropod, food, air, water, etc.
Group I: Bolivia, Guatemala, Haiti, Honduras, Nicaragua and Paraguay
Group II: Columbia, Costa Rica, Ecuador, El Salvador, Peru, and Transmission of Infectious Agents
Dominican Republic
Group III: Brazil, Chile and Mexico Transmission implies any mechanism by which an
Group IV: Argentina, Cuba, Panama, Uruguay and Venezuela infectious agent is spread from a source or reservoir to
Fig. 15.1: Relation between communicable diseases and lifespan a person. The various mechanisms of transmission as
PART II: Epidemiological Triad described by the American Public Health Association are Air-borne
given below.
The dissemination of microbial aerosols to a suitable
portal of entry, usually the respiratory tract. Microbial
DIRECT TRANSMISSION
aerosols are suspensions of particles in the air consisting
It is direct and essentially immediate transfer of an partially or wholly of microorganisms. They may remain
infectious agent to a receptive portal of entry through suspended in the air for long periods of time, some
which human or animal infection can take place. This retaining and others losing infectivity or virulence.
may be by direct contact, as by touching, biting, kissing Particles in the 1 to 5 micron range are easily drawn
or sexual intercourse, or by the direct projection into the alveoli of the lungs and may be retained there.
(droplet spread) of droplet spray onto the conjunctiva Examples are droplet nuclei, and small dust particles.
or onto the mucous membranes of the eye, nose or Large droplets and other large particles which promptly
mouth during sneezing, coughing, spitting, singing or settle out are examples not of airborne transmission but
talking (called droplet spread, usually limited to a rather of direct transmission of the droplet spread type.
distance of about 1 meter or less).
Droplet nuclei: These are usually the small residues
which result from evaporation of fluid from droplets
INDIRECT TRANSMISSION
emitted by an infected host as described. They usually
Vehicle-borne remain suspended in air for long periods of time. They
The examples of vehicles are contaminated inanimate may also be created purposely by atomizing devices or
materials or objects (fomites) such as toys, may arise accidentally in microbiological laboratories, etc.
handkerchiefs, soiled clothes, bedding, cooking or Dust: This includes small particles of widely varying size
eating utensils, surgical instruments or dressings (indirect which may arise from soil (as, for example, fungus
contact); water, food, milk, biological products including spores separated from dry soil by wind or mechanical
blood, serum, plasma, tissues or organs; or any agitation), clothes, bedding, or contaminated floors.
substance serving as an intermediate means by which
an infectious agent is transported and introduced into CONTROL MEASURES
a susceptible host through a suitable portal of entry. The
agent may or may not have multiplied or developed From the point of view of control measures the commu-
in or on the vehicle before being transmitted. nicable diseases can be classified into three categories.
1. Diseases requiring constant surveillance only:
Vector-borne Their preventive measures are known and effective.
Examples are smallpox, typhoid, yellow fever,
Mechanical: Includes simple mechanical carriage by malaria, epidemic typhus, cholera and plague.
a crawling or flying insect through soiling of its feet or 2. Diseases well understood but requiring more
proboscis, or by passage of organisms through its intensive application of the known preventive
gastrointestinal tract. This does not require multiplication measures: Examples are amebiasis, ascariasis,
or development of the organism. brucellosis, trachoma, diphtheria, guinea worm,
Biological: Propagation (multiplication), cyclic ankylostomiasis, food poisoning, poliomyelitis,
development or a combination of these (cyclopro- pneumonias, rabies, relapsing fever, ringworm,
pagative) is required before the arthropod can trans- scabies, tapeworm infections, venereal diseases and
mit the infective form of the agent to man. An tuberculosis.
incubation period (extrinsic) is required following 3. Diseases requiring development of more
infection before the arthropod becomes infective. The effective preventive measures: Examples are
infectious agent may be passed vertically to succeeding chickenpox, common cold, encephalitis, influenza,
generations (transovarian transmission). Transstadial leprosy, leptospirosis, mumps, meningitis, rheumatic
transmission indicates its passage from one stage of life fever and streptococcal infections.
cycle to another, as from nymph to adult. Transmission
may be by injection of salivary gland fluid during biting, Definitions in Communicable
or by regurgitation or deposition on the skin of feces
Disease Epidemiology
or other material capable of penetrating through the
bite wound or through an area of trauma from If a microorganism, on entry into the body, produces
scratching or rubbing. This transmission is by an infected disease, it is called a pathogen as against a commensal
nonvertebrate host and not simple mechanical carriage which lives in symbiosis and does not produce disease.
by a vector as a vehicle. However, an arthropod in Infection means entry, development and multiplication
154 either role is termed a vector. of a particular living pathogen in the body. It occurs in
three forms.
1. Subclinical or latent infection, when no definite or its products from an infected person, animal, or
A quotient (rate), with the number of new cases of a For persons or animals, the lodgement, development
specified disease diagnosed or reported during a defined and reproduction of arthropods on the surface of the
period of time as the numerator, and the number of body or in the clothing. Infested articles or premises are
persons in a stated population in which the cases those which harbor or give shelter to animal forms,
occurred as the denominator. This is usually expressed especially arthropods and rodents.
as cases per 1,000 or 100,000 per annum. This rate
may be expressed as age or sex-specific or as specific INFESTATION
for any other population characteristic or subdivision For persons or animals, the lodgment, development and 157
(see Morbidity rate and Prevalence rate). reproduction of arthropods on the surface of the body
PART II: Epidemiological Triad or in the clothing. Infested articles or premises are those 3. Respiratory isolation: To prevent transmission of
which harbor or give shelter to animal forms, especially infectious diseases over short distances through the
arthropods and rodents. air, a private room is indicated but patients infected
with the same organism may share a room. In
INSECTICIDE addition to the basic requirements, masks are
Any chemical substance used for the destruction of indicated for those who come in close contact with
insects, whether applied as powder, liquid, atomized the patient, gowns and gloves are not indicated.
liquid, aerosol, or as a “paint” spray; residual action is 4. Tuberculosis isolation (AFB isolation): For patients
usual. The term larvicide is generally used to designate with pulmonary tuberculosis who have a positive
insecticides applied specifically for destruction of sputum smear or chest X-rays which strongly suggest
immature stages of arthropods; adulticide or imagocide, active tuberculosis. Specifications include use of a
to designate those applied to destroy mature or adult private room with special ventilation and the door
forms. The term insecticide is often used broadly to closed. In addition to the basic requirements, masks
encompass substances for the destruction of all are used only if the patient is coughing and does
arthropods, but acaracide is more properly used for not reliably and consistently cover the mouth.
agents against ticks and mites. More specific terms, such Gowns are used to prevent gross contamination of
as lousicide and miticide are sometimes used. clothing. Gloves are not indicated.
5. Enteric precautions: For infections transmitted by
ISOLATION direct or indirect contact with feces. In addition to
As applied to patients, isolation represents separation, the basic requirements, specifications include use of
for the period of communicability of infected persons a private room if patient hygiene is poor. Masks are
or animals from others in such places and under such not indicated, gowns should be used if soiling is likely
conditions as to prevent or limit the direct or indirect and gloves are to be used for touching contaminated
transmission of the infectious agent from those infected materials.
to those who are susceptible or who may spread the 6. Drainage/secretion precautions: To prevent infections
agent to others. In contrast, quarantine (qv) applies to transmitted by direct or indirect contact with purulent
restrictions on the healthy contacts of an infectious case. material or drainage from an infected body site. A
Recommendations which are made for isolation of cases private room and masking are not indicated, in
are the methods recommended by CDC. The recom- addition to the basic requirements, gowns should be
mendations are divided into 7 categories. used if soiling is likely and gloves used for touching
Two basic requirements are common for all 7 categories. contaminated materials.
• Hands must be washed after contact with the patient 7. Blood/body fluid precautions: To prevent infections
or potentially contaminated articles and before that are transmitted by direct or indirect contact with
taking care of another patient infected blood or body fluids. In addition to the basic
• Articles contaminated with infectious material should requirements, a private room is indicated if patient
be appropriately discarded or bagged and labeled hygiene is poor, masks are not indicated but gowns
before being sent for decontamination and should be used if soiling of clothing with blood or
reprocessing. body fluids is likely. Gloves should be used for
The seven categories are: touching blood or body fluids.
1. Strict isolation: This category is designed to prevent
A recent CDC recommendation states that blood
transmission of highly contagious or virulent
and body fluid precautions be used consistently for all
infections that may be spread by both air and
patients (in-hospital settings as well as outpatient settings)
contact. The specifications, in addition to those
regardless of their bloodborne infection status. This
above, include a private room and the use of masks,
extension of the blood and body fluid precautions to
gowns and gloves for all persons entering the room.
all patients is known as “Universal blood and body fluid
Special ventilation requirements with the room at
precautions” or “Universal precautions”. In this, blood
negative pressure to surrounding areas is desirable.
2. Contact isolation: For less highly transmissible or and certain body fluids (any visibly bloody body
serious infections, for diseases or conditions which secretion, semen, vaginal secretions, tissue, CSF, and
are spread primarily by close or direct contact. In synovial, pleural, peritoneal, pericardial, and amniotic
addition to the basic requirements, a private room fluids) of all patients are considered potentially infectious
is indicated but patients infected with the same for HIV, HBV, and other bloodborne pathogens.
pathogen may share a room. Masks are indicated Universal precautions are intended to prevent
for those who come close to the patient, gowns are parenteral, mucous membrane, and nonintact skin
158 exposures of health care workers to bloodborne
indicated if soiling is likely, and gloves are indicated
for touching infectious material. pathogens. Protective barriers include gloves, gowns,
masks and protective eyewear or face shields. Waste purposes by others, away from the mouth, nose, eyes,
to further spread of infection. Flies and dust can also Venereal Nonvenereal
provide a link between feces and food. Viral Lymphogranuloma Trachoma
The infecting organism may not have its breeding inguinale
ground in the intestine, and may not always enter by Molluscum
contagiosum
mouth or leave through anus in case of some worms. Spirochetal Syphilis Yaws
Hookworm infection enters through the skin instead of Bacterial Gonorrhea Leprosy
the mouth while guinea worm infection comes out of Soft chancre Erysipelas
the skin and not the anus. Nonintestinal infections like Donovaniasis or Impetigo
Granuloma
poliomyelitis and infectious hepatitis also fall in this group inguinale
because of their mode of spread. Fungal Candidiasis Ringworm
Protozoal Trichomonas
vaginalis infection
CONTACT OR SURFACE INFECTIONS Arthropods Scabies
In this group Table 15.4 the infection comes out of
the skin or mucous membrane of the patient and enters TABLE 15.5: Arthropod-borne infections
through the skin and mucous membrane of a healthy
• Flies
person through bodily or sex contact. The infection may
– Common housefly: Mechanical carrier of many infections, e.g.
also be carried indirectly through fomites, such as kajal amebiasis, shigellosis, typhoid, trachoma, yaws
– Sandfly: Leishmaniasis, (visceral and dermal), sandfly fever
TABLE 15.3: Water and food-borne infections – Tsetse fly: African trypanosomiasis (sleeping sickness)
– Blackfly: Onchocerciasis
Viral Bacterial Protozoal Worms • Mosquitoes
Enterovirus infections Cholera Amoebiasis Flukes – Anopheles: Malaria
Infective hepatitis Food poisoning Giardiasis Tapeworms – Culex: Filaria
– Aedes aegypti: Yellow fever, dengue
Poliomyelitis Enteric fever Balantidiasis Trichinellosis
Brucellosis Threadworm • Fleas: Plague, endemic typhus
Bacillary dysentery Roundworm • Louse: Epidemic typhus, relapsing fever, trench fever
Diarrhea Whipworm • Bugs: (Reduvid bug) Chagas’ disease or American trypanosomiasis
Hookworm • Ticks: Relapsing fever, typhus, kyasanur forest disease (KFD) 167
Guinea worm • Mites: Typhus
PART II: Epidemiological Triad Zoonoses material and human resources of health programs
to improvized emergency programs (for example,
These are infections or infectious diseases transmissible immunization campaigns against typhoid) which are
under natural conditions from vertebrate animals to expensive and of uncertain benefit.
man. There are over 150 diseases common to man and
animals. As per causative agents, they fall into 8 classes— RECEPTIVITY OF THE POPULATION
viral, rickettsial, bedsonial (psittacosis), bacterial, fungal,
protozoal, helminthic and arthropod diseases. But as per The importance of the host-agent relationship cannot
mode of transmission they permeate in all the four be overestimated. No further proof is needed than the
groups mentioned earlier, as described below. synergism between malnutrition and infections. In
famines, infectious diseases are the major immediate
Airborne infection Anthrax, psittacosis, ornithosis.
causes of death. However, while it is a fact that mortality
Water and food-borne infections Man contracts them from these diseases rises considerably, it is still a matter
from animals through milk or meat. Examples are liver of controversy whether their incidence also increases.
fluke, T.solium, T. saginata, intestinal tuberculosis, Paradoxically, natural sudden onset disasters, such as the
brucellosis and salmonellosis. Foot and mouth disease cyclones in Bangladesh, have left behind a surviving
can also rarely occur in animal handlers. population that is temporarily more resistant to
Contact infections Glanders and some types of communicable diseases. This resistance can be
ringworm and scabies primarily found in animals. attributed to a selectively high mortality among the
Arthropod-borne infections: Plague, typhus, yellow young, the very old and the sick.
fever and KFD.
In addition, some diseases are transmitted directly INTRODUCTION OF A NEW PATHOGEN
through bites of animals, e.g. Rabies and rat-bite fever. Natural disasters may be associated with widespread
Still others have varied modes of transmission such as massive migration of population over long distances,
anthrax, leptospirosis, histoplasmosis and actinomycosis. with the risk or introduction of new pathogens or new
The zoonotic diseases which do not fit into a clear strains into areas of low prevalence or immunity.
pattern as per the four modes of transmission Close epidemiological surveillance for communicable
mentioned above are described in the chapter on disease is essential in disaster situations. As a first step,
Miscellaneous Zoonoses. the authorities should list in advance the diseases already
under surveillance and should identify those which will
Epidemiological Approach to Communicable need enhanced surveillance during the disaster. For this
Diseases after Natural Disasters purpose, it must be ensured that reports are rapidly
despatched to the control center on a daily basis.
Natural disaster like flood, famine and earthquakes are Any unusual event detected by the surveillance
usually associated with increased occurrence and even system must be immediately investigated in order to
epidemics of communicable diseases. There are three determine its nature and magnitude and to take
ways in which an epidemic can be triggered by a appropriate and specific control measures. In addition,
disaster: by increasing transmission of local pathogens, unofficial rumours of epidemic outbreaks also must be
by changing the receptivity of the population, or by officially investigated so that they may not nullify the
introducing a new pathogen into the environment. benefits of surveillance. If such rumours are not
investigated, there is risk of excessive or improper action
by the highest authorities under public pressure.
INCREASE IN TRANSMISSION
Disasters may increase the transmission of DISEASE PREVENTION AND CONTROL
communicable diseases through three mechanisms. IN EMERGENCIES
1. An increase in promiscuity which often results when There are two major categories of measures to prevent
refugee camps are set up and become quickly and control diseases after disaster: sanitary measures and
overcrowded. medical measures. Medical measures often have less
2. A deterioration in sanitary conditions in the environ- long-term impact than sanitary measures and should not
ment. This deterioration can be caused by abrupt be undertaken without good reason. Vaccination
changes in the quantity and quality of the water campaigns are frequently resorted to in disaster
supply and the creation of more favorable conditions situations, but new massive campaigns should not be
for the proliferation of vectors. The vulnerability of encouraged. However, the emergency may provide the
the community, however, will be determined by the opportunity of extending normal immunization
level of sanitation prior to the disaster. programs to people in the temporary disaster relief
168 3. A partial or total disruption of control programs, settlements and camps, who might earlier have been
compounded by the tendency to divert available scattered and difficult to reach.
Bibliography 10. Kundsin RB, Walter CW. The Practitioner 1968;200:
169
16 Respiratory Infections
TRANSMISSION
The spread of infection is mainly by droplet infection have one of these manifestations, or may present earlier
and direct contact. A person is infective for two weeks— with neonatal signs; laboratory confirmation of the
about one week before and one week after the diagnosis is therefore recommended. Rubella virus may
appearance of skin rash, the maximum infectivity being be isolated for 6 to 12 months following birth, and
at the time of appearance of rash.2 The virus is present occasionally longer, from nasopharyngeal swabs, urine
in throat, nose, pharynx, urine, stools and blood.3 The specimens, or cerebrospinal fluid, or less commonly
incubation period ranges from 12 to 23 days, with an from tissues obtained by biopsy, autopsy, or surgical
average of 18 days. In pregnant women the virus procedures. Rubella-specific IgM is readily detected in
infects the placenta and the developing fetus. Humans the first six months of life, and among a decreasing
are the only known host. It may be mentioned that proportion of cases up to one year of age. Its detection
subclinical infections may be one to six times as usually indicates prenatal rather than postnatal infection.
common as clinical infection.4 The persistence of rubella-specific IgG beyond six
months (the age when maternally derived IgG would
CONGENITAL RUBELLA SYNDROME (CRS) usually have waned) can be detected in 95 percent of
infants with CRS. However, the presence of IgG in a
When a woman is infected with the rubella virus early child over six months of age may indicate either prenatal
in pregnancy (first trimester), she has a 90 percent or postnatal infection; and identification of low-avidity
chance of passing the virus on to her fetus that may IgG1 will indicate prenatal infection.5
result in multiple fetal defects and there is an
approximately 50 percent increase in risk of Differential Diagnosis of Rubella
spontaneous abortion. CRS manifestations in surviving
infants may be transient (e.g. purpura); permanent Rubella causes mild fever and maculopapular rash, often
structural manifestations (e.g. deafness. congenital heart with occipital and postauricular lymphadenopathy.
disease, cataract); or late-emerging conditions (e.g. Arthralgia/arthritis is common in adults, particularly women.
diabetes mellitus) Table 16.4. Sensorineural deafness The differential diagnosis includes measles, dengue,
may occur following maternal infection up to the 19th parvovirus B-19, human herpesvirus-6, coxsackievirus,
week of pregnancy, while cataract and heart disease only echovirus, adenovirus, and Streptococcus group A (beta
occur after infection prior to the ninth gestational week.5 hemolytic). Because of the difficulty in clinical diagnosis,
studies that use serological confirmation are the most
reliable, either by detecting rubellaspecific IgM, which is
Diagnosis of CRS
usually positive for up to six weeks after rash onset, or by
184 CRS may be diagnosed by its classic triad: cataract, demonstrating a fourfold rise in rubella-specific IgG
heart disease, and deafness. However, many infants only antibody titre between acute and convalescent specimens.
If a woman in early pregnancy is found to have
Streptococcal Sore Throat (ICD-J02.0) • Sore throat, mild fever, grayish-white membrane in
throat.
It is an acute inflammation of throat due, most • Exposure to a suspect case of diphtheria in the
186 commonly, to Streptococcus hemolyticus, group A (beta previous one week or a diphtheria epidemic in the
hemolytic) which also causes scarlet fever, impetigo, area.
per year.4 It is high between August and November, with
No age is exempt. Highest incidence is in children • Early detection and notification: Active search for
between 1 and 15 years with a peak in the four to seven cases in contacts and schools is a must. Notification
years group, after which there is a sharp decline because is compulsory in most places.
of natural immunization by subclinical infection. Case • Isolation: It should be done in the house or hospital
fatality has been estimated to be ten percent in untreated to the extent possible. Young children should not
cases and five percent in treated cases.5 The highest case come in contact with the case. The case should be
fatality rate is in the age group two to five years. isolated till two nasal and throat swab cultures, taken
The natural immunity passively acquired from the not less than 24 hours apart and not less than 24
mother is retained upto six months of age. Thus there hours after the cessation of antibiotic therapy, are
is very low incidence in infants below 6 months. The negative. When culture is not possible, isolation
disease is rare in adults. Common cold, chronic rhinitis should be continued for 14 days after appropriate
and tonsillitis increase proneness to infection. Suscepti- antibiotic treatment.
bility or immunity is tested by Schick test which deter- • Quarantine: Contacts whose work involves exposure
mines the presence or absence of antibodies in the blood. to children should be excluded from such work till
When antibodies are present, they neutralise the antigen bacteriological examination shows that they are not
injected and hence the latter fails to produce a reaction. carriers. Often it is not practicable.
• Diagnosis: One should depend on clinical features
and antidiphtheric serum (ADS) should be
Schick Test
administered without waiting for laboratory report
It is done by giving 0.2 ml (1/50 MLD) of Schick test if the suspicion is strong.
antigen or toxin intradermally in one forearm, and • Treatment: Cases, contacts and carriers, all have to
heated toxin in the other for control. As an alternative, be treated promptly:
0.1 ml fluid diphtheria toxoid vaccine in 1:10 dilution Cases: Treatment should be started as early as
may be injected intradermally.7 The arms are inspected possible without waiting for laboratory confirmation
at 24 to 48 hours. The test is interpreted as follows: as it affects the prognosis and mortality. The sheet
• No reaction on either arm—Negative reaction. The anchor of treatment is the administration of
person tested has enough antitoxin (0.03 units per antidiphtheric serum. The dosage varies from
ml serum) to neutralize the antigen. 20,000 to 100,000 units depending upon the
• Test arm develops a circumscribed red flush, 1 to 5 severity of disease. A single intramuscular injection
cm in diameter, at 24 to 48 hours while the control is usually sufficient but a part of the total dose may
arm does not show any reaction—Positive reaction. be given intravenously in urgent situations. Care
The flush is most marked on the fourth day. It then should be taken to rule out sensitivity to the
fades, becomes brown and desquamates on 5th to antitoxin, which is of equine origin, before the same
7th day. A person with positive reaction is susceptible is administered. For this purpose, the past history
to diphtheria and needs immunization. of serum sensitivity should be asked for and a
• Both arms develop an equal flush, less circumscribed conjunctival or intradermal skin test should be
than in a positive case—False positive reaction. The performed using a 1:10 saline dilution of the
flush fades quickly and disappears by fourth day. antitoxin. In case of sensitivity, desensitization has
This occurs due to allergic reaction to the foreign to be done. In addition to the antitoxin, an
protein in the toxin. The test is read as negative and appropriate antibiotic must be given. This may be
indicates adequate immunity. in the form of procaine penicillin 400,000 units
• Test arm shows true positive reaction and control arm intramuscularly every 12 hours for 10 to 12 days
shows false positive reaction—Combined reaction. or erythromycin 30–40 mg/kg body weight orally
Such a person is susceptible to diphtheria as well as for 10 to 12 days.
188 allergic to the antigen. He should be vaccinated Contacts: If the contact of a diphtheria case has
cautiously, using very small but multiple doses.7 been previously immunized, he should be given a
booster dose of the toxoid. If the contact has not of DPT because almost all children are already
IDENTIFICATION EPIDEMIOLOGY
The disease involves trachea, bronchi and bronchioles. Prevalence is worldwide. The disease is more common
It occurs in two stages: in temperate climate and in winters. It is caused by Borde-
• Catarrhal stage: It lasts for five to ten days. The child tella pertussis which is viable at 0 to 10°C but cannot
has mild fever and catarrh with irritating cough which survive long in external environment. B. parapertussis
is worse at night. may also be responsible for an occasional case. Incidence
• Paroxysmal stage: This is characterized by bouts or in India has declined from 698 per million population
paroxysms of cough. During each bout, the child in 1978 to 124 per million in 1987.2 Incidence and
coughs five to ten times in rapid succession followed mortality are both higher in females. Most deaths occur
by holding of breath, stimulation of respiratory center below one year age. Case fatality ratio is 15 per 1000.3
and forced inspiration associated with a whooping There is no subclinical case and no chronic carrier.
sound. This restores color and strength to the child Secondary attack rate is about 90%.
exhausted by the bout of cough. The child may
experience five to ten paroxysms per day. The child SOURCE OF INFECTION
may pass urine or stools during an attack of cough Infected humans, whether typical, mild or missed cases.
and may bite his tongue. Whooping cough may be
complicated by occurrence of hernia, rectal prolapse
Spread
and superadded pulmonary infection. The
190 paroxysmal stage may last for up to six weeks. Mainly by droplets but also, to a small extent, through
• Convalescent stage: It lasts for 1–2 weeks. fomites. The disease is most communicable during the
later part of incubation period and in early catarrhal prophylactic erythromycin for ten days. If the infant
DIAGNOSIS Susceptibility
Diagnosis can be confirmed by: It is low. Children are more prone than adults. Mortality
• Demonstration of the typical organisms in a gram- rate in meningitis should be less than 10 percent if
stained smear of the spinal fluid or the fluid from diagnosis is early and modern therapeutic and support
the petechiae. measures are used.1
• Culture of the organisms from blood or CSF.
• Demonstration of group specific meningococcal
Incubation Period
polysaccharides in the spinal fluid by latex
agglutination, counter immuno-electrophoresis or Two to ten days; average three to four days.
coagglutination techniques.1
Prevention and Control
OCCURRENCE
Isolation: This is needed up to 24 hours after the start
The disease is prevalent allover the world. In India, it of appropriate chemotherapy.1
occurs more in March and April. Characteristic features Protection of contacts: Sulphadiazine for five days
of an epidemic are: or rifampicin for two days (adult dose: 600 mg bd)
• It occurs in sporadic form, not more than one case
given as a chemoprophylactic measure.
in a family. The prevalence is higher in jails, schools
and hostels, etc. because of mass contact.
• A large number of healthy carriers are found. The TREATMENT
percentage of carriers may be as high as 50 percent In view of the high prevalence of sulphonamide resistant
in military recruits.1 This testifies to the low virulence strains, the antibiotic of choice at present for treatment
of the organism. of meningitis is penicillin G2. Intramuscular penicillin
• Some cases get only nasopharyngitis; they spread should not be used in patients who are in shock or on
the disease but themselves remain undetected.
the verge of shock. The dose for adults is 100,000 units
• Susceptibility to clinical disease is very low as testified
every two hours intramuscularly or 3,000,000-
by the fact that there is a high ratio of carriers to
5,000,000 units intravenously every six hours.
cases. That is why even nurses, doctors and contacts
Ampicillin may be used as an alternative to penicillin.
do not get meningitis2.
In case of sensitivity, chloramphenicol can be used with
due precaution towards its toxic effects. It may be
Causative Agent
mentioned that the epidemiological pattern of disease
Neisseria meningitidis is a gram-negative Diplococcus is not influenced by treatment.3
appears as kidney-shaped pairs with adjacent sides
flattened in gram stains. In most persons, meningococci Vaccine
are commensal colonizers of the nasopharynx. Humans
192 are the only natural reservoir. Mueller-Hinton media is The meningococcal polysaccharide vaccine consists of
used to culture in laboratories. group-specific purified capsular polysaccharides from
serogroup A, serogroup C, serotype Y and serogroup the United States since its introduction in 2005 through
201
Fig. 16.2: Diagnostic algorithms for pulmonary TB
PART II: Epidemiological Triad X-ray chest: Used as a supportive tool to microscopy. Diagnosis of TB in Children:
X-rays are necessary for the diagnosis of smear negative Standard Case Definition 21
cases if both the samples of a repeat sputum
examination after a two weeks course of antibiotic SUSPECT (HISTORY)
therapy are negative.
A child with fever and/or cough for more than two
Tuberculin test: May be useful as an additional tool
weeks, with or without weight loss or no weight gain;
for diagnosing pediatric TB.
and history of contact with a suspected or diagnosed
Patients suspected of having extrapulmonary TB, and case of active TB disease within the last two years.
patients who are contacts of sputum smear-positive
patients, should have their sputum examined for AFB PROBABLE (HISTORY AND
if they have cough of any duration. CLINICAL EXAMINATION)
A combination of clinical presentation, sputum examina-
Definitions Under RNTCP tion wherever possible, chest X-ray, mantoux test (1 TU
PPD RT23 with Tween 80, positive if induration >10 mm
PULMONARY TUBERCULOSIS after 48–72 hours) and history of contact.
Smear-positive Patient
Confirmed (Laboratory Tests)
TB in a patient with at least one initial sputum smear A patient with culture positive for the Mycobacterium
examinations (direct smear microscopy) positive for
tuberculosis or a patient with one or two sputum smears
acid-fast bacilli (AFB)
positive for acid-fast bacilli.
Or: TB in a patient with one sputum specimen positive for
AFB and radiographic abnormalities consistent with active
pulmonary TB as determined by the treating physician. Definition of Types of Cases
Or: TB in a patient with one sputum specimen positive NEW
for AFB and culture positive for M. tuberculosis.
A TB patient who has never had treatment for tuber-
Smear-negative Patient culosis or has taken anti-tuberculosis drugs for less than
one month.
A patient having symptoms suggestive of TB with at
least two sputum examinations negative for AFB, and
RELAPSE
radiographic abnormalities consistent with active
pulmonary TB as determined by the treating MO, A TB patient who was declared cured or treatment
followed by a decision to treat the patient with a full completed by a physician, but who reports back to the
course of anti-TB therapy health service and is now found to be sputum smear-positive.
Or: A patient whose diagnosis is based on positive
culture for M. tuberculosis but sputum smear TRANSFERRED IN
examinations negative for AFB. A TB patient who has been received for treatment into
a Tuberculosis Unit, after starting treatment in another
Extrapulmonary Tuberculosis unit where s/he has been registered.
• Meningitis • Miliary TB
• Pericarditis • Extensive parenchymal infiltration
• Peritonitis • Coinfection with HIV
• Bilateral or extensive pleural effusion • Cavitary disease
• Spinal TB with neurological involvement • All forms of pediatric sputum smear negative
• Intestinal pulmonary TB except primary complex
• Genito-urinary
• Coinfection with HIV
• All forms of pediatric extra-pulmonary TB other
than lymph node TB and unilateral pleural
effusion are considered to be seriously ill
* The number before the letters refers to the number of months of treatment. The subscript after the letters refers to the number of
doses per week. The dosage strengths are as follows: H: Isoniazid (600 mg), R: Rifampicin (450 mg), Z: Pyrazinamide (1500 mg), E:
Ethambutol (1200 mg), S: Streptomycin (750 mg). Patients who weigh 60 kg or more receive additional rifampicin 150 mg. Patients who
are more than 50 years old receive streptomycin 500 mg. Patients who weigh less than 30 kg, receive drugs as per body weight.
Patients in Categories I and II who have a positive sputum smear at the end of the initial intensive phase receive an additional month of
intensive phase treatment.
** Those who are new in DOTS; might have taken anti TB drugs from private practitioners clinic in a scientific dosage (other than DOTS
regimen) as advised by him and they do not fall into relapse, failure or default category.
*** In rare and exceptional cases, patients who are sputum smear-negative or who have extrapulmonary disease can have Relapse or
204 Failure. This diagnosis in all such cases should always be made by an MO and should be supported by culture or histological evidence
of current, active TB. In these cases, the patient should be categorized as ‘Others’ and given Category II treatment.
**** Patients who refuse SCC or can not comply with the regimen, adverse reaction to rifampicin and pyrazinamide.
third month. Thereafter, the patient is put on the
within a week of missing a dose in continuation The first sputum smear examination is done at three
phase. All the empty blister packs (of IP and CP) months, i.e. end of intensive phase. If both smears are
are retained in the patient-wise boxes (PWB). negative, the patient will be put on the continuation
• For adults, drugs will be given in the recommended phase. If either of the samples is positive, the intensive
number of pills/capsules irrespective of body weight phase of treatment will be extended by one more month,
(now adults with very low body weights can be and another smear examination will be done at the end
treated with paediatric PWBs). However, for patients of the fourth month of treatment. Thereafter, the patient
weighing more than 60 kg an additional capsule of is put on the continuation phase regardless of his sputum
rifampicin 150 mg will be added to the treatment status at the end of four months of the intensive phase.
regimen. Patients who are more than 50 years old Subsequent follow-up sputum examinations are
done after two months into continuation phase.
receive streptomycin 500 mg and patients who
Irrespective of the results of the follow-up smear
weigh less than 30 kg receive drugs as per body
examinations, the patient continues and completes the
weight. For children, the drugs will be given
treatment when a final follow-up sputum smear is done.
according to body weight.
Special Situations
Drugs and their Dosage
Hospitalization
The most important drugs used in the treatment of TB In RNTCP, patients are treated on ambulatory basis. But
are rifampicin (R), isoniazid (H), pyrazinamide (Z), when the general condition of patient is serious enough
streptomycin (S) and ethambutol (E). The like patients with pneumothorax or large accumulations
recommended dosage for thrice weekly regimen in of pleural fluid leading to breathlessness; massive
adults and children is given follow: Table 16.9. haemoptysis etc. then they are treated in hospitals.
Treatment of TB during pregnancy and
Follow-up Smear Examination (Table 16.10) postnatal period
Follow-up of the patients is done as detailed below: • Streptomycin is never given, but all other drugs are
safe during this period.
• Breast feeding is advised irrespective of the mother’s
CATEGORY I
TB status and mother is advised to cover her mouth,
Two smears are examined each time during follow-up. if she is smear-positive, while breastfeeding the baby.
The first follow-up sputum examination is done at the • Chemoprophylaxis with INH is recommended for
end of two months of intensive phase. If both smears the baby if mother is sputum smear-positive.
are negative, the patient will be put on the continuation Treatment in patients with renal failure
phase. If either of the smears is positive, the intensive Streptomycin and ethambutol, if given, should be closely
phase will be extended by one more month, and monitored with reduced dosage under the supervision
sputum examination will be repeated at the end of the of the treating physician.
Treatment in women taking oral contraceptive pills
TABLE 16.10: Follow-up sputum smear Rifampicin decreases the efficiency of oral contraceptives;
examination during treatment
thus women are advised to use another method of
Category SS –ve at end of IP SS +ve at end of IP
contraception.
Category I 2, 4, 6 months 2, 3*, 5, 7 months
Category II 3, 5, 8 months 3, 4*, 6, 9 months
TB and HIV
TB is the most common opportunistic infection in people 205
* Irrespective of sputum smear result, patient is put on to CP phase living with HIV virus. HIV- infected people are at increased
PART II: Epidemiological Triad risk of TB, and again HIV is also the most powerful risk of DOTS and DOTS-Plus activities under the RNTCP,
factor for progression from TB infection to TB disease. so that patients with MDR-TB are both correctly
TB in turn accelerates the progression of HIV to AIDS. identified and properly managed under the recommen-
However, even among HIV-infected people, TB can dations set out in this document.23
be cured by Directly Observed Treatment, Short-course
chemotherapy (DOTS). Service linkages between ICTC Components of DOTS Plus
and RNTCP diagnostic and treatment centres are the
most important area of coordination between the HIV/ • Sustained political and administrative commitment
AIDS and TB Control program. • Diagnosis of MDR-TB through quality-assured
culture and drug susceptibility testing (DST)
Achievements of RNTCP • Appropriate treatment strategies that utilize second-
line drugs under proper management conditions
RNTCP has consistently achieved treatment success rate • Uninterrupted supply of quality assured anti-TB drugs.
of more than 85 percent, and case detection close to • Recording and reporting system designed for DOTS-
the global target. However, in 2007 RNTCP for the first Plus programmes that enable performance monito-
time has achieved the global target of 70 percent case ring and evaluation of treatment outcome.
detection while maintaining the treatment success rate
of more than 85 percent.
Treatment of MDR-TB
Multi-drug-Resistant Tuberculosis (MDRTB) RNTCP will be using a Standardized Treatment
Regimen (Cat IV) for the treatment of MDR-TB cases
MDRTB refers to strains of the bacterium which are
(and those with rifampicin resistance) under the
proven in a laboratory to be resistant to at least isoniazid
program. Cat IV regimen comprises of six drugs-
and rifampicin. DOTS has been proven to prevent the
emergence of MDRTB, and also to reverse the incidence kanamycin, ofloxacin (levofloxacin)†, ethionamide,
of MDRTB where it has emerged.22 pyrazinamide, ethambutol and cycloserine during six to
nine months of the Intensive Phase and four drugs-
ofloxacin (levofloxacin), ethionamide, ethambutol and
Causes of Drug-resistant Tuberculosis cycloserine during the 18 months of the Continuation
Drug-resistant TB has microbial, clinical, and program- Phase. p-aminosalicylic acid (PAS) is included in the
matic causes. From a microbiological perspective, the regimen as a substitute drug if any bactericidal drug (K,
resistance is caused by a genetic mutation that makes Ofl, Z and Eto) or two bacteriostatic (E and Cs) drugs
a drug ineffective against the mutant bacilli. An are not tolerated (Table 16.11).23,24
inadequate or poorly administered treatment regimen
allows drug-resistant mutants to become the dominant TABLE 16.11: Treatment regimens
strain in a patient infected with TB. However it should
Category of Type of Patient Regimen
be stressed that MDR-TB is a man-made phenomenon Treatment
– poor treatment, poor drugs and poor adherence lead
to the development of MDR-TB.23 Category IV MDR-TB cases 6 (9) Km Ofx (Lvx) Eto Cs Z E
+ 18 Ofx (Lvx) Eto Cs E
211
PART II: Epidemiological Triad TABLE 16.13: Treatment of pneumonia at home or subcenter treatment alone will be recommended in such cases.
with contrimoxazole Examples are locally accepted remedies made from
Age/ Weight Pediatric tablet Syrup (Each 5 ml contain household ingredients (honey, ginger, tulsi, hot
(Trimethoprim 20 mg Trimethoprim 40 mg and water) or a suitable bulk cough mixture made in the
and Sulfameth- Sulfamethoxazole
dispensary. Fever control with paracetamol, conti-
oxazole 100 mg) 200 mg)
nued feeding and adequate fluids should be
<2 months One tablet twice daily Half spoon ensured.
(2.5 ml) twice daily
• In the event that respiratory rates are above the
2–12 months Two tablets twice daily One spoon indicated levels, the following action should be taken:
(5 ml) twice daily
Infants aged zero to two months, with a respiratory
1–5 years Three tablets twice daily Three spoon rate of 60 per minute or more should be referred
(7.5 ml) twice daily
immediately to a health care facility where a doctor
is available for further evaluation and treatment. No
home or subcenter with cotrimoxazole according treatment should be offered by paramedical workers
to following schedule. for these young children in view of the high danger
Give the first dose at the clinic and teach the mother of respiratory disease in this age group. The dose
how to give the other doses at home (Table 16.13). of cotrimoxazole (pediatric) in this age group is 1
tablet twice a day for five days (Table 16.14).
FOLLOW-UP
It is important to remember that in a child with
Encourage the mother to feed the child. Advise her to severe pneumonia, the respiratory rate may actually
bring the child back after two sdays, or earlier if the child slow down as a result of exhaustion and advanced
becomes sicker or is not able to drink or breastfeed. If disease. Therefore, the presence of chest indrawing and
the breathing has improved (slower), there is less fever, other dangerous signs should take precedence over
and the child is eating better, complete the three days respiratory rate as diagnostic criterion.
of antibiotic treatment. If the breathing rate, fever and At the PHC, after further evaluation, parenteral anti-
eating have not improved, change to the second-line biotic is started. If the case is very severe, the child should
antibiotic and advise the mother to return again in two be sent onward to another hospital facility where round
days. If there are signs of severe or very severe the clock nursing, oxygen, intravenous drugs and
pneumonia need institutional care. laboratory or radiological investigations are available.
Viewed in the light of the strategy of the national
ARI control program, the findings of a recent survey
Criteria for Diagnosis
are alarming.6 The survey was conducted by the Indian
• The basic criterion for diagnosis of pneumonia is Medical Association to study the practices of its
based on the counting of respiratory rate. A members in relation to ARI. Out of 891 physicians
breathing rate of 60 per minute or more in an infant studied, 71 percent relied primarily on auscultation and
less than two months of age, 50 or more in an infant only 19 percent on counting of respiratory rate for
2 to 12 months of age and 40 or more in children diagnosing ARI. 54 percent used antibiotics even in URI.
1 to 5 years of age suggests pneumonia. In each More than half did not use cotrimoxazole which is the
case respiratory rate should be carefully counted in cheapest and most effective agent with the broadest
a resting child for a full minute. In a child whose spectrum. The urgent need for proper orientation and
respiratory rate exceeds these limits, a second count training of doctors is obvious. Along with this, it is also
should be done before a diagnosis is made. important that mothers understand the appropriate
• Children breathing at rates lower than mentioned management decisions. The health education measures
above are considered to have no pneumonia. Home aim at propagating the following meassages:
TABLE 16.14: Dose schedule for cotrimoxazole(*) in a suspected case of pneumonia
213
Water and Food-borne
17 (Alimentary) Infections
The mode of spread of the alimentary infections in Asia, China, Middle East, USSR, Europe and Africa. The
general and their classification have already been third phase, starting in 1923, was once again marked
described in Chapter 12. In this chapter will be by confinement of cholera to India and the East. To
described the alimentary infections caused by bacteria, these three phases may be added the fourth phase
protozoa, viruses and worms, in that order. A general which started in 1961 with the onset of the still
classification of various diseases related to water is given continuing seventh pandemic.
in Table 17.1. The list of food-borne diseases is given The seventh pandemic started from an endemic focus
in Table 17.2. on an island in Indonesia in 1961. It was caused not by
the classical cholera vibrio but by El Tor vibrio. By 1965,
El Tor completely replaced classical V. cholerae in India.2
Cholera and Diarrhea The worst year of this pandemic was 1970 when it
involved some parts of all the continents except America.
Cholera (ICD A00.9) From 1948 onwards 98 percent of the world cases
HISTORY AND PREVALENCE have occurred in India, Pakistan and Bangladesh.
RATIONALE COVERAGE
Diarrheal diseases are a major cause of morbidity and • Correct case management at home and all health
mortality among children under five years (0 to 5 facilities.
years). It has been estimated that diarrhoea accounts • Improve ORT use rate to 60 percent.
for 28 percent of deaths in this age group, i.e. 1 million
deaths every year. Most of the deaths in diarrhoea are Identification Guidelines
due to dehydration (loss of water and electrolytes) What is Diarrhea?
caused due to frequent passage of loose watery motions.
Diarrhea is defined as passage of liquid or watery stools.
A child, on an average, suffers from 2 to 3 attacks of
These liquefied stools are usually passed more than
diarrhea each year. Prevention of diarrhea itself is not three times in a day; however, it is the recent change
an easy task and remains a long-term goal to be in consistency and character of the stools rather than
achieved. The program, therefore, presently aims at the number of stools that is the more important feature.
reducing deaths due to diarrheal diseases among the Passage of even one large watery motion among
0 to 5 years age group. children may constitute diarrhea. When stools contain
mucus or blood it is known as dysentery.
GOAL
What is not Diarrhea?
To reduce deaths due to dehydration caused by diarrhoeal
• Passage of frequent formed stools.
disease through promotion of Oral Rehydration Therapy
• Passage of pasty stools in a breastfed child.
(ORT) by 30 percent in 1995 and by 70 percent in the • Passage of stools during or immediately after
year 2000. feeding. 221
PART II: Epidemiological Triad • Passage of frequent loose greenish yellow stool in • Ensure availability of ORS packets through govern-
the 3rd and 4th day of life (Transitional diarrhea). ment outlets and in villages through village level
In most situations, mothers know better what is an functionaries including Anganwadi Workers (AWW)
abnormal stool of her child. wherever possible.
• Eliminate irrational use of drugs in the management
Three Types of Diarrhea of diarrheal diseases.
1. Acute watery diarrhea starts suddenly and may The strategy is based on the following observations:
continue for a number of days but not more than – Ninety percent of all diarrheal episodes do not
14 days. Most of these are self limiting and will last develop dehydration. These can be managed at
for 3 to 7 days. home by mothers with the use of home available
2. Dysentery is diarrhea with visible blood in stools. fluids (HAF) and continued feeding.
3. Persistent diarrhea begins acutely but is of unusually – Nine percent of all episodes will develop some
long duration, i.e. lasting more than 14 days. dehydration. These need to be managed at
health facilities with the use of ORS solution.
Why Diarrhea is Dangerous? – One percent of episodes will develop severe
• Diarrhea leads to loss of water and electrolytes. If dehydration needing intravenous infusion
untreated, dehydration leads to death. therapy. These need to be referred to the nearest
• Diarrhea leads to undernutrition because— facility where intravenous infusion could be given.
(i) nutrients are lost from the body, (ii) a child with
diarrhea may be anorexic, and (iii) mothers often ASSESSMENT OF A CHILD WITH DIARRHEA
reduce food for some more days even after diarrhea
A child with diarrhea should be assessed to determine
is treated or has stopped.
the nature and pattern of diarrhea, the degree of
dehydration (No signs, some or severe dehydration)
STRATEGY and the presence of any other problems (i.e. Blood in
• Correct case management at all levels enabling stool or severe undernutrition) so that appropriate
mothers at home to use home available fluids treatment can be started without delay.
(HAF) for diarrhea without dehydration followed History should be taken from the patient or a family
by Oral Rehydration Salts (ORS) solution member. ASK questions to obtain information on: Dura-
whenever a child gets dehydration. Two things will tion of diarrhea, consistency of stool, presence of blood
have to be ensured for this (i) Mothers should be in stool, presence of fever, convulsions or other problems,
able to recognize dehydration so that they can preillness feeding practices, type and quantity of fluids
start Oral Rehydration Therapy (ORT) and can (Including breast milk), food consumed during illness and
seek help when the condition of the child worsens, drugs or other remedies taken. However, answers to
(ii) Correct and improved management of cases many of these questions will not decide the degree of
depending on degree of dehydration at all health dehydration. Degree of dehydration will be determined
facilities. by the signs as described in Table 17.8.
TABLE 17.8: Look, feel, decide chart for assessment of dehydration in diarrhea
A B C
• Look: Condition Well, alert Restless, irritable Lethargic or unconscious; floppy
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth and Tongue Moist Dry Very dry
Thirst Drinks Thirsty, drinks Drinks poorly or not able to
normally, eagerly drink
not thirsty
• Feel: Skin Pinch Goes back Goes back slowly Goes back very slowly
quickly
• Decide: The patient If the patient has two or If the patient has two or more
has no more signs, including at signs, including at least one
signs of least one sign, there sign, there is severe
dehydration is some dehydration
dehydration
• Treat: Use Weigh the patient, if Weigh the patient and use
222 Treatment possible and use Treatment Plan C
Plan A Treatment Plan B urgently
Rule 3 (Watch for signs of dehydration): Explain to the
dehydration status. Patients with many or more marked nearby facility for IV treatment. If ORS packet is not
signs of dehydration will require more solution than those available, treatment with ‘Home Available Fluids’ should
with fewer or less marked signs. If the patient wants more be started.
ORS solution than the volume shown on the chart and
there are no signs of overhydration, give more. INTRAVENOUS THERAPY FOR SEVERE DEHYDRATION
WHEN THERE IS SEVERE DEHYDRATION Solutions for Intravenous Infusion
(TREATMENT PLAN C)
A number of solutions are available for IV infusion;
Treatment Plan C deals with treatment of severe dehy- however, some do not contain appropriate or adequate
dration Community based health staff should be advised amounts of the electrolytes required to correct the deficits
not to attempt IV treatment in these cases. They should, found in dehydration associated with acute diarrhea.
224 however, start immediate treatment with ORS as per The preferred solution is Ringer’s Lactate Solution
Treatment Plan B and at once refer the case to the which supplies adequate concentration of sodium and
CHAPTER 17: Water and Food-borne (Alimentary) Infections
TABLE 17.11: Treatment plan B for diarrhea with some dehydration24
Approximate amount of ORS solution to give in the first 4 hours:
Age* Less than 4 months 4-11 months 12-23 months 2-4 years 5-14 years 15 years of older
Weight in ml Less than 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg or more
in local measure 200-400 400-600 600-800 800-1200 1200-2200 2200-2400
Use the patient’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated
*
After 4 hours, reassess the child using the assessment chart. Then select plan A, B or C to continue treatment:
• If there are no signs of dehydration shift to Plan A. When dehydration has been corrected, the child usually passes urine and may also be
tired and fall asleep.
• If signs indicating some dehydration are still present, repeat Plan B, but start to offer food, milk and juice as described in Plan A.
• If signs indicating severe dehydration have appeared, shift to Plan C.
If the mother must leave before completing treatment plan B:
• Show her how much ORS to give to finish the 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration, and for 2 more days as shown in Plan A.
• Show her how to prepare ORS solution.
• Explain to her the three rules in Plan A for treating her child at home:
– To give ORS or other fluids until diarrhea stops.
– To feed the child.
– To bring the child back to the health worker, if necessary.
potassium and the lactate yields bicarbonate for correc- • After 6 hours (infants) or 3 hours (older patients),
tion of acidosis. An acceptable solution is normal saline evaluate the patient using the assessment chart. Then
which is readily available. It will not correct the acidosis choose the appropriate Plan (A, B or C) to continue
and will not replace potassium losses. If used, this treatment.
solution should be accompanied by ORS solution orally.
Providing IV therapy for severe dehydration: The
POLICY ON USE OF ZINC IN THE NATIONAL
purpose is to give the patient a large quantity of fluids PROGRAM FOR MANAGEMENT OF DIARRHEA
quickly to replace the very large fluid loss which has
resulted in severe dehydration. Zinc is a very safe drug and the window between thera-
Plain glucose dextrose solutions should not be used peutic and toxic dose of zinc is large. A stable
as they provide only water and sugar. They do not formulation (stable at room temperature for 3 years)
contain electrolytes and thus they do not correct the is available and is well accepted by children and mothers
electrolyte losses causing the acidosis. without any side effects. Zinc (20 mg/day for 14 days)
Begin intravenous therapy quickly in the amount is to be used in the national program as an adjunct to
specified in Treatment Plan C (Table 17.12). ORS in the management of diarrhea in children older
• Start IV fluids immediately. If the patient can drink, than 2 months.
give ORS by mouth while the drip is set up. Give
100 ml/kg Ringer’s Lactate solution (or, if not Recommendations
available, Dextrose saline). 20 mg zinc sulfate dispersible tablet is to be used in
• Repeat once if radial pulse is still very weak or not childhood diarrhea. Children aged 2 to 6 months to be
detectable. advised 1/2 tablet per day dissolved in breast milk.
• Reassess the child every 1 to 2 hours. If hydration Those older children aged more than 6 months will be
is not improving, give the IV drip more rapidly. advised 1 tablet a day dissolved in breast milk or water.
• Also give ORS (about 5 ml/kg/hour) as soon as the The duration of therapy will be 14 days beginning from
patient can drink: Usually after 3 to 4 hours (infants) the day the child sought care. But zinc fortified ORS is
or 1 to 2 hours (older patients). not recommended, since zinc intake would not be 225
PART II: Epidemiological Triad TABLE 17.12: Treatment plan C for diarrhea with severe dehydration24
Follow the arrows. If answer is “Yes”, go across. If “No”, go down
Start here
Can you give intravenous Yes Start IV fluids immediately. If the patient can drink, give ORS by mouth
(IV) fluids immediately? while the drip is set up. Give 100 ml/kg Ringer’s lactate solution (or, if not available,
normal saline), divided as follows:
standardized, because of variable amounts of ORS To achieve this goals, an effective communication
consumed by children.25 strategy is required. It is recommended that all professional
bodies and institutions be engaged to promote the use
Rationality of adding Zinc in Management of Diarrhea of zinc along with ORS in treatment of diarrhea.
Apart from reducing duration and severity of the treated
MANAGEMENT OF A CHILD WITH DYSENTERY
episodes of acute diarrhea, Zn treatment in programmatic
condition has the potential to decrease hospital admission When the child has diarrhea with blood, treat with
rates by 15 to 20 percent, decrease child mortality by cotrimoxazole. Give paracetamol for fever. Also give
3 to 5 percent and decrease the incidence of subsequent ORS and advise early feeding. Observe the child for two
episodes of diarrhea and possibly pneumonia over days and proceed as follows:
ensuing 3 months. Zn addition to ORS for treatment • Child well or definitely improving (as indicated by
of diarrhea has been shown to substantially reduce use disappearance of fever and blood in stools)—
of unwarranted drugs during acute diarrhea. This is likely Continue treatment and monitor weight response.
to help reduce emergence of drug resistant entero • Child not well or improving—Treat with nalidixic acid
bacteria, a major public health problem. The critical issues and monitor weight response.
to enable Zn to be effective are that it must be freely
MANAGEMENT OF A CHILD WITH PERSISTENT
available and accessible round the year in every village
DIARRHEA (TABLE 17.13)
226 and all health personnel, including private practitioners
and AWW, must be included in the network of Zn • Persistent diarrhea begins as acute diarrhea and
distribution through intersectoral coordination. continues for more than 14 days.
CHAPTER 17: Water and Food-borne (Alimentary) Infections
TABLE 17.13: Managing other problems associated with diarrhea
Ask about blood in the stool If blood is present:
• Treat for 5 days with an oral antibiotic recommended for Shigella in your area—Cotrimoxazole
• Teach the mother to feed the child as described in Plan A.
• See the child again after 2 days if:
– Under 1 year of age
– Initially dehydrated
– There is still blood in the stool
– Not getting better.
• If the stool is still bloody after 2 days, change to a second oral antibiotic recommended for
Shigella in your area.
Give it for 5 days—Nalidixic acid
Ask when this episode of diarrhea began If diarrhea has lasted at least 14 days:
• Refer to hospital if:
– The child is under 6 months old
– Dehydration is present (Refer the child after treatment of dehydration)
• Otherwise, teach the mother to feed her child as in Plan A, except:
– Dilute any animal milk with an equal volume of water or replace it with a fermented milk
product, such as yoghurt
– Assure full energy intake by giving 6 meals a day of thick cereal and added oil, mixed
with vegetables, pulses, meat, or fish
• Tell the mother to bring the child back after 5 days:
– If diarrhea has not stopped, refer to hospital
– If diarrhea has stopped, tell the mother to:
i. Use the same foods for the child’s regular diet
ii. After 1 more week, gradually resume the usual animal milk
iii. Give an extra meal each day for at least 1 month.
Look for severe undernutrition If the child has severe undernutrition:
• Do not attempt rehydration: refer to hospital for management.
• Provide the mother with ORS solution and show her how to give 5 ml/kg/hr during the trip.
Ask about fever and take temperature If temperature is 39°C or greater:
• Give paracetamol
If there is Falciparum malaria in the area, and the child has any fever (38° or above) or history of fever
in the past 5 days:
• Give an antimalarial (or manage according to your malaria program recommendation)
Salmonella Abdominal pain, diarrhea, Patients and convalescent Microorganisms multiply 12-24 hours up to 5 days
vomiting, fever carriers; more commonly in foods, more so in animal
rodents, infected cattle foods like milk and milk
and other livestock such preparations, meat, fish,
as cats, dogs, pigs, ducks eggs, icecream, puddings,
and turkeys; eggs and egg pastries sausages, meat pies.
powdes Infection may be transmit-
ted through milk and meat
of infected animals or the
cooked food gets infected by
droppings of rodents
Bacterial intoxication by Salivation, nausea, vomit- Usually man. S. aureus Staph aureus infects the 1-6 hours (short because
S. aureus enterotoxins ing, abdominal pain, pros- transiently colonises the foods, especially milk, ice- the toxin is preformed)
tration and subnormal nasopharynx of 70-90% cream, custard and jelly
temperature, not fatal persons and resides during preparation and
permanently in 10-30% handling. Organisms multi-
ply and produce an exo-
Nasal carriage often leads toxin called enterotoxin
to skin colonization as which is heat stable and is
well5 not destroyed by boiling.
Refrigeration prevents
multiplication
Cl. perfringens type A Abdominal pain, diarrhea The organism can be easily The infection can usually 8-12 hours
(explosive) without nausea grown from soil, water, air be traced to contamination
and vomiting. Not fatal and animal and human of food by soil or feces.
feces Microorganisms multiply
and produce toxin in the
contaminated food
Cl. botulinum (Botulism) Change of voice, diplopia, Spores from soil and intes- Tinned food, if infected, 12-36 hours
ptosis, cranial nerve pal- tinal tract of animal infect decomposes under anaerobic
sies, obstinate constipa- the food conditions. Food may be
tion. Death in 3-7 days, atlered physically the exo-
mortality high, up to 40% toxin produced is heat labile,
Death due to cardiac or destroyed in half an hour at
respiratory failure 80°C
B. cereus Vomiting type: Contaminated food. The Traced to raw, uncooked or 1-6 hours in emetic type,
Vomiting with nausea, organism is commonly partially cooked food and 12-24 hours in diarrheal
salivation, abdominal pain found in soil and in raw, tinned foods type
Diarrheal type: Diarrhea, dried and processed foods
lower abdominal pain
nausea with little vomiting
Campylobactor jejuni Vomiting Poultry, Traced to poultry, raw milk, 3-5 days
(most common) bloody diarrhea, raw milk, known to cause epidemics
C. coli Abdominal pain, raw meat of food poisoning in
C. Laridis fever. Self limiting, nurseries, Pediatric wards
non fatal and communities in deve-
loped countries
Vibrio Diarrhea (blood mucus), Sea food like Traced to improperly 12-18 hours
parahemolyticus Vomiting, abdominal pain, shell fish, cooked sea foods
fever crabs, lobsters
E. coli 0157– Bloody diarrhea, Beef, raw milk, raw Traced to beef raw milk, 3-4 days
H7 most common abdominal pain. apple juice raw apple juice
Usually self limiting.
Some people develope
Hemolytic uremic
syndrome
As a measure of individual safety, the following • Food items should not be left overnight in warm
precautions should be observed: pantries. Not eaten items should be kept
• Foodstuffs should be selected properly and cooked immediately in cold storage to prevent bacterial
well. The cooked food should be properly stored in multiplication and toxin production.
refrigerators or hot cases and not exposed to dust, • The kitchen should have enough space, light, 229
flies or rats. ventilation and washing facilities. All garbage or waste
PART II: Epidemiological Triad food should be kept covered. Rodent and insect 2. Macleod J. Davidson’s Principles and Practice of Medicine
control. Edinburgh: Churchill Livingstone, 1984.
3. Mandal BK. Medicine International 1981;2:56.
• Cooking staff should not be carriers of salmonellae
4. Carpenter CCJ. In: Isselbacher KJ, et al (Eds). Harrison’s
and should not have obvious staphylococcal Principles of Internal Medicine (9th edn). New York:
infection. McGraw Hill, 1980.
• Frequent washing of hands with soap, especially after 5. Truck M, Stamm W. In: Isselbacher KJ, et al (Eds). Harrison’s
visit to latrine, should be insisted upon. Principles of Internal Medicine (9th edn). New York:
• Food should be served hot. It is safer to heat the McGraw Hill, 1980.
cold food again before serving. Food with unusual
smell should be discarded.
Enteric Fevers
This group includes typhoid and paratyphoid A, B and
Control
C. In India typhoid and paratyphoid A only are found.1
When there is a report of case(s), of food poisoning,
the remains of food, empty containers, stools and vomit Typhoid (ICD-A01.0)
should be seized and sent immediately in an ice box
for bacteriological and chemical examination. Organs IDENTIFICATION
removed after postmortem may be sent in 30 percent
glycerine solution. It is necessary to trace the source of Typhoid is a continuous fever lasting 3 to 4 weeks,
contamination and to deal with it properly. The usually with headache, bronchitis and gastrointestinal
containers used for cooking the suspected food should symptoms. Onset is slow. In a classical case, the fever
be disinfected and the remaining food should be rises daily in a step ladder pattern during the first
destroyed. week, remains continuously high during the second and
third weeks and comes down gradually by the fourth
TRACING THE SOURCE OF INFECTION week.
The patient becomes much more ill, appearing
• Find the extent of the outbreak, i.e. the total exhausted and often prostrated. In early part of the disease,
number of persons who took the food and of those there may be marked constipation or ‘pea soup’
who suffered. diarrhea, along with marked abdominal distention.
• Study the clinical picture of each case. Make a special During the early part, physical signs are few. Later,
note of the nature of onset, incubation period and
splenomegaly, abdominal distention, tenderness,
involvement of nervous system, if any.
relative bradycardia and occasionally meningismus
• Trace the evidence implicating a particular food. Note
appear. The rash (rose spots), is a pink papule 2 to
the time of the last meal and ascertain the persons
3 mm in diameter that fades on pressure is found
who developed symptoms or remained symptom
principally on the trunk which commonly appears
free after consuming a particular item of food.
during the 2nd week of disease and disappears by 3
• Confirm the nature of the toxic agent on the basis
to 4 days.
of chemical, bacteriological and postmortem reports.
Death may occur in the third week due to
• Investigate the source of infection, the means of
perforation or hemorrhage from ulcers in the intestine.
contamination and the circumstances responsible for
High fever, bronchopneumonia or heart failure may
the same during storage.
• Assessment of environmental factors: kitchen, dining also lead to death.
hall, storage of food grains and cooked food, The classical presentation described above is seen
presence of rodents. only in a minority of patients. Kamat 1 has found
• Record the history of any illness among food hand- continuous fever only in 10 to 15 percent and some
lers and examine their stools, urine and blood for authors have described rates as low as 5 percent. The
carrier state. fever is often intermittent or remittent and is often
• Laboratory report: Vomitus, stool of patients for simply irregular. Also, respiratory symptoms are found
culture, sample of suspected food, serological test of in one-third to half of the patients. One-fourth cases of
blood for antibody titre. enteric fever may, in fact, present with upper respiratory
• Draw conclusions and make appropriate recom- tract infection and the diagnosis may be missed without
mendations. a blood culture. As many as 45 percent patients of
enteric fever have cough and 32 percent have rhonchi.1
Convalescence is prolonged. Relapse may occur
References after a week or 10 days of afebrile period, lasting for
230 1. Benenson AS (Ed). Control of Communicable Diseases 10 to 15 days. Blood shows leukopenia. Blood culture
in Man (15th edn). Washington: APHA, 1990. during initial 7 to 10 days may reveal the causative
organism. Widal agglutination test showing higher titres There are 3 antigens; O or somatic antigen, specific
238
been identified in Malaysia, but there is no evidence of ting others from contact with the patient’s stools. This
240
Fig. 17.2: Outcomes of hepatitis B virus infection8
is true of homo as well as heterosexual partners. Simple
RESERVOIR
Occurrence
Man has been transmitted experimentally to chimpa-
Worldwide, with marked variation in prevalence. Occurs
nzees.
epidemically or endemically in populations at high risk
of HBV infection.
MODE OF TRANSMISSION
As in case of hepatitis B. MODE OF TRANSMISSION AND METHODS
OF CONTROL
INCUBATION PERIOD
Similar to that of HBV.
Ranges from 2 weeks to 6 months; most commonly,
within 6 to 9 weeks.
INCUBATION PERIOD
PERIOD OF COMMUNICABILITY Approximately 2 to 10 weeks for experimental infections
From one or more weeks before onset of the first symp- in chimpanzees; not firmly established in man.
toms through the acute clinical course of the disease,
and indefinitely in the chronic carrier states. Hepatitis E
cases of polio occur between the ages of 7 to 12 months. Moradabad district is a densely populated region
90 percent of children aged up to 5 years show the in western Uttar Pradesh that has had continuing wild
presence of neutralising antibodies to all the three types polio virus transmission despite ongoing polio
of polioviruses. There is an ominous trend towards eradication efforts; including supplemental
increase in the number of cases of paralytic poliomyelitis immunization activity (SIA) targeting all children aged
along with an improvement in the standard of living.4 This < 5 years roughly every 6 weeks. The low OPV
is related to the fact that the first exposure to poliovirus coverage achieved through routine immunization
is delayed in countries with a higher standard of living and activities (~38%), and the combination of crowding,
that the incidence of paralytic polio following poliovirus high diarrhea rates, poor sanitation as well as a warm
infection increases with increasing age (Table 17.18). and humid climate have contributed to persistent
The WHO regions that have been certified as polio- poliovirus transmission.6 In 2011, India reported a
free are Americas (certified in 1994), Western Pacific single case of polio in a 2-year-old girl in West Bengal
Region (certified in 2000) and European region on 13th January 2011.
(certified in 2001).
In 2009, globally 40.4 percent cases came from RESERVOIR
India, followed by 30.9 percent cases from Nigeria and
5 percent cases from Pakistan. This year there has been Man is the only reservoir. Paralytic patients as well as
sudden increase in the number of cases in two countries, mild, missed and inapparent cases discharge the virus
e.g. in Benin (1.6 %) and Sudan (3.6%), compared to in oropharyngeal secretions and stools. The virus is
previous years. demonstrable in the throat as early as 36 hours after
In India, initially most cases were due to Type 1, but infection and persists for about 1 week. It can be
for the last three years, there has been change in demonstrated in feces 72 hours after infection and
serotype from Type 1 to Type 3 (Fig. 17.3). In India, persists for 3 to 6 weeks or longer. 2 In tropical
majority of the cases (79.7%) came from Uttar Pradesh countries the virus does not survive in environment
in the year 20095 (Table 17.19). outside the human body for more than few days.
246
Cases are probably most infectious during the first few
S. haematobium
PREVENTION AND CONTROL OF SCHISTOSOMIASIS
Initially a parasite of Nile Valley, it has now spread to
It is important to prevent schistosomal infections from
other countries also. A focus was found in Ratnagiri dis-
entering India and from gaining foothold here. General
trict in Maharashtra and the infection was imported to
control measures include the following:
Punjab from the Middle East two decades ago. The snail
• Prevention of pollution of water with excreta
identified in Ratnagiri focus is Ferrissia tenuis. Some
• Molluscicides to kill molluscs
monkeys are naturally infected. Rat, mouse and sheep
• Cercariae may be killed by storage and chlorination
can also get the infection.
• Mass treatment with schistosomicidal drugs.
Life cycle (Fig. 17.6): The adults lodge in portal, Praziquantel is the drug of choice for all the 3
vesical, hemorrhoidal and uterine veins and live for species.
2 to 5 years. The male is 1.2 cm long and carries the
slender female, 2.5 cm long, in a ventral canal called Food Animal Transmitted Helminths
gynecophoric canal. Eggs are 0.16 mm long, oval, with
a terminal spine. They are found in urine and CESTODES OR TAPEWORMS
occasionally in feces. Eggs are laid in veins and pierce
Tapeworms resemble a ribbon (tenia), hence their
through the small venules to enter the bladder or
name. The adult form is found in the small intestine of
rectum. They are thus discharged in urine, and
carnivorous animals such as man and dog (teniasis). The
occasionally, in stools.
On reaching water the eggs form miracidia. The larval form is found in herbivorous animals such as cattle
latter enter the snail and form sporocysts and daughter and the infection in them is called cysticercosis.
sporocysts. The tadpole like cercariae with bifid tails that
come out enter the body through skin or buccal mucous LIFE CYCLE IN GENERAL
membrane when a person is taking bath. Then they enter The adults are attached to the mucous membrane of
the circulation, lodge in the veins of predilection and the small intestine by suckers on the head. They have
develop into adults. It may be mentioned that storage 3 distinct parts: head, neck, and a segmented body.
of water for 48 hours before use provides protection Each segment is hermaphroditic and produces eggs after
against infection (Fig. 17.6). The reason is that the copulation with another segment of the same worm or
cercariae survive in water only for 24 to 48 hours. another worm.
S. mansoni: It is found mainly in Brazil, Puerto Rico Eggs are passed in the stools and are infective. Each
and Venezuela. The adult lives in mesenteric vein and egg contains a ciliated spherical embryo known as hexa-
the branches of mesenteric and portal veins. The eggs canth because it has six hooklets. The eggs are
pierce the venules under the mucous membrane of the swallowed by the intermediate host along with feces or
rectum and are passed out in stools. The eggs have a fodder or food. The hexacanth, on coming out of the
252 lateral spine. egg, burrows through the wall of the intestine into
CHAPTER 17: Water and Food-borne (Alimentary) Infections
Fig. 17.7: Life cycle of T. saginata Fig. 17.8: Life cycle of T. solium
submucous blood vessels and goes to the organs of cycticercosis, is caused when man gets infected either by
choice, such as liver and muscles. There it loses the cilia autoinfection or by ingesting eggs in contaminated food
and hooklets to form a germinal disk, at one end of and salad. The last mode explains why many patients of
which develops the invaginated scolex while the neurocysticercosis are strict vegetarians.1a
remaining portion gets filled with fluid, giving rise to T. solium is particularly common along the east coast
what is called a cysticercus. This is the larval stage which of India. It is rare in Muslims because they do not eat
is swallowed by the definitive host with meat. The scolex pork. Life cycle is similar as in case of T. saginata except
evaginates in the intestine of the host and develops into that the intermediate host is pig. The adult is 4 meters
the adult tapeworm. The five species of tapeworms of long. The head is 1 mm in diameter and possesses a
medical importance are described below. short rostellum, two rows of hooklets and four suckers.
It is usually found singly, though rarely 25 to 30 worms
Taenia saginata (Beef Tapeworm) ICD-B 68.1 may be found in a person. The adult lives for may
years. The eggs passed in the stools are eaten by pigs,
The adult worm is 4 to 10 meters long and has about in whom they form cysticercus cellulosae (Fig. 17.8).
1000 segments. The head is 2 mm long, bears no He then develops cysticercus in brain, eye muscles and
hooklets or rostellum and has four elliptical suckers on subcutaneous tissues (cysticercosis).
the sides. The segments are broader than longer. Usually Cysticercosis is a more important problem than
there are less than 4 worms in one host and they live teniasis as such.1b In man, cysticercosis can manifest in
for several years (Fig. 17.7). brain, spinal cord, eye, muscles and subcutaneous
The eggs are 30 to 40 microns in diameter. The tissues. Neurocysticercosis in an important manifestation.
cysticercus bovis (larval stage of T. saginata) is formed In a recent series of 317 cases of neurocysticercosis, 70
in the liver and muscles of cattle. It is 0.5 cm in diameter percent presented with epilepsy and 20 percent with
and is yellowish in color, looking like a split pea. Within increased intracranial pressure. It tends to be common
the cysticercus is the larva, which can live for about 6 in north India, may be because of a higher preference
months. Cows get infected by eating human feces or to consume salad and raw foods in the north.
contaminated grass. T. saginata infection is rare in Neurocysticercosis is currently responsible for 0.4
Hindus since they do not eat beef. percent of all pediatric admissions and 2.5 percent of
Diagnosis is done by finding mature segments (pro- all space occupying lesions at the All India Institute of
glottids), rarely eggs, in the stools. Medical Sciences.1a More cases are being diagnosed
now with the help of CT and MRI. Treatment is based
upon use of praziquantel and albendazole, with other
Taenia solium (Pork Tapeworm) ICD-B 68.0 supportive and symptomatic drugs like steroids and
T. solium is similar to T. saginata except that while the latter antiepileptics.
causes only enteric infection (adult worm), T. solium can Diagnosis is made by finding proglottids and eggs
also cause somatic infection. Enteric infection by T. solium in the stools. The proglottids disintegrate soon and hence
253
is caused by eating infected pork containing the cycticercus may not be seen. Calcified cysts may be seen in the
form of the parasite. Somatic infection, manifested by X-ray. Eosinophilia may be present.
PART II: Epidemiological Triad raising countries such as Australia, New Zealand, Middle
East, Turkey, etc.1c In India it is particularly common in
Tamil Nadu and Andhra Pradesh.1d
Hydatid cyst: The ingested eggs hatch in man’s
intestine, liberating larvae. The latter lodge in liver
(67%), spleen (1.3%), kidneys (3%), brain, bones, joints
and muscles. There the larva changes into a cellular
mass called morula which develops fluid in it, forming
a cyst. It has two layers, an outer fibrous layer called
ectocyst and an inner germinal layer called endocyst.
A number of secondary and tertiary morulas with fluid
are formed from the germinal layer, known as daughter
and granddaughter cysts. The smallest cysts inside the
endocyst are called brood capsules in which a number
of invaginated headends or scolices are formed.
Sometimes, a part of germinal layer pushes out of the
ectocyst and produces a new cyst called exogenous cyst.
Free bits of germinal layer may fall out on the pleura
Fig. 17.9: Life cycle of T. echinococcus
or peritoneum to form implantation cysts. Cysts may
be unilocular or multilocular. Some may get calcified.
It is obvious that the hydatid is a very complicated cyst.
PREVENTION AND CONTROL OF
Diagnosis of the cyst is made by X-rays. Puncture
T. SAGINATA AND T. SOLIUM
of cyst should be avoided to prevent infection of other
• Regular inspection of meat. Infested beef or pork organs. Casoni’s skin hypersensitivity test may be done
(“measly pork”) should be discarded. with the antigen prepared from cyst fluid. Pet dogs
• Prolonged cooking of meat. Raw meat should be should be regularly treated with a vermifuge as a
avoided. prophylactic measure. It is important to wash hands
• Cattle should not be allowed to eat human excreta after patting a dog in order to avoid infection. It is best
or contaminated grass. not to eat raw vegetables.
• Proper disposal of human excreta.
• Treatment of all cases with niclosamide as the drug Diphyllobothrium latum (Fish Tapeworm)
of choice. Praziquantel has been recently found to
be very effective. If these drugs are not available, It is not found in India. Man is the definitive host, while
mepacrine can be used. cylops and fish form the intermediate hosts. One should
nor eat raw fish in order to avoid infection.
Echinococcus granulosus (Dog Tapeworm) ICD-B 67.4 Trichinella spiralis
Dog is the natural definitive host. The adult worm is only
It is an intestinal roundworm found in several mammals,
4 mm long and lives in dog intestine. It has only 4 to
especially canines, pig and rat. Animals get infected by
5 segments. The last segment is big and gravid and is
eating flesh of infected animals containing larvae
about 2 mm long.
encysted in muscle and other tissues (Figs 17.10A to C).
The head has a rostellum with 2 rows of hooklets
In the intestine, the larvae are released. They penetrate
and 4 suckers as in case of T. solium. The whole worm
the lymphatics, enter the blood stream and are
looks like a wheat grain (Fig. 17.9). Eggs are passed
disseminated to all parts of the body, especially the
in the stools of the dog and contaminate grass, which
striped muscles. The organs most commonly involved
is eaten by sheep, the intermediate host. The hydatid
are diaphragm, ribs, larynx, tongue and eye, i.e. the
cyst or cysticercus is formed in the liver and muscles of
sheep. It is also found in cattle, deer, horse and zebra. muscles which are very active and rich in glycogen.
The dog gets infected by eating the cysticercus in sheep Cardiac muscle may also be involved. The larva coils
meat. The larval stage within the cysticercus grows into up in the muscle fibers into loose spirals, hence the
adult worm and the cycle is thus completed. Man is an name. It grows from 0.1 to 1 mm, gets encysted and
accidental intermediate host. He is infected through does not develop further. When the flesh is eaten by
vegetables or food contaminated with infected dog’s another animal, the encysted larvae are liberated and
excreta. Dog lovers and shepherds may contaminate develop into adults in the intestinal mucosa within three
days. The cycle ends in the man for obvious reasons.
254 their fingers while handling the dog and may thus get
infected. Human infection is more common in sheep The reservoirs of infection are pigs, dogs, cats, rats and
CHAPTER 17: Water and Food-borne (Alimentary) Infections
Figs 17.10A to C: Life cycle of Tr spiralis: (A) Adult worm (paralia Fig. 17.11: Life cycle of H. nana
(3 mm female 3 to 6 mm); (B) Larva, before reaching tissues (0.1 mm
size); (C) Larva in muscle before and after encystment
many wild animals such as fox, wolf, etc. Almost 75 HYMENOLEPSIS NANA
percent rats living near the slaughter houses are infected. It is cosmopolitan in distribution. The prevalence rate
Man gets infected by eating undercooked or uncooked in children in the tropics is 5 to 10 percent. Infection
or uncooked pork in which the cysts can be seen as chalky occurs from man to man, there being no intermediate
deposits. The disease is obviously rare in those who do host. The adult worm is 1 to 3 mm long and 0.55 mm
not eat pork, especially Muslims and Jews. Necropsy surveys broad and resides in the intestine. The head has a
in USA in the 1950’s revealed a prevalence rate of 16.7 retractile rostellum with 24 hocklets. Thousands of
percent. This has now fallen to 2 percent or less 2 percent.2 worms may be found in the intestine at a time but the
Clinical picture depends upon the intensity of infec- lifespan is short. Immunity develops soon, hence
tion. When the number of larvae ingested is small, there infection is rare in adults (Fig. 17.11).
may be no or few symptoms. Heavier infection can Diagnosis is made by finding the characteristic two
cause immediate symptoms like nausea and vomiting knobbed eggs in the stools. The drugs of choice in
24 to 48 hours after the infected meal. These are due niclosamide. Paromomycin may also be effective. If they
to intraintestinal activity of adult worms. Late symptoms are not available, mebendazole, mepacrine or
occur 1 to 6 weeks later. These are due to larval chloroquine may be used.
invasion of body tissues. Characteristic and early
symptoms are muscular pain and soreness along with ENTEROBIUS VERMICULARIS
edema of upper eyelids. Fever may be present. Severe
infection may be accompanied by muscular, cardiac and This worm is commonly known as threadworm or
neurological symptoms. Fatal infections can occur. pinworm. The infection, called enterobiasis or oxyuriasis,
Diagnosis depend upons eosinophilia, serological is found worldwide and is more common in children.
tests and demonstration of encysted larvae in muscle The eggs are 40 to 50 microns long and 20 to 25
biopsy. The biopsy should be done not earlier than 10 microns broad and are planoconvex in shape. They
days after exposure to infection. The larvae live in the have a thick, clear, double walled shell. The eggs are
tissues for 6 months. They get calcified in 2 years. rarely seen in stools. The female comes out of the anus
Control measures: Rats should be eliminated from onto the perineum of the host to lay eggs. This process
slaughter houses and meat markets. Regular meat causes irritation and itching, causing an urge to scratch
inspection should be carried out. Infested meat, called the perineum. The larva develops within a few hours
measly pork, should be discarded. The discarded meat of egg laying. After the eggs are swallowed, the larvae
should be destroyed and not fed to hogs or other are liberated in the small intestine and develop into
animals. adults in about ten days. The adult female is one cm
long with a thick anterior end like a pin head, tapering
at the back. The male is a quarter cm long and dies
Contagious or Fecal-borne Helminths
after copulation. It is, therefore, seldom seen except in
These include one cestode H. nana and one nematode autopsies. The lifespan of the adult is 2 to 4 weeks. The 255
(Enterobius). whole life cycle require 3 to 6 weeks (Fig. 17.12).
PART II: Epidemiological Triad
Fig. 17.12: Life cycle of E. vermicularis Fig. 17.13: Life cycle of A. lumbricoides
259
18 Contact Diseases
These are also referred to as surface infections. India in March 1998 was estimated to be 5.3 per 10,000
Common factors in their epidemiology are direct or compared to 57 per 10,000 in 1981. About 15 to 20
indirect contact and low hygienic standards. Direct percent patients are children. The proportion of
contact implies that the skin or mucous membrane of multibacillary cases is 42 percent among total cases and
a healthy person comes in contact with the sufferer or 30 percent among new cases. The deformity rate is
carrier of the infection through means such as touching, 6 to 8 percent and 3.9 percent among total and new
rubbing, kissing or having sexual intercourse. Indirect cases respectively. 20 percent of the leprosy patients at
contact is brought about through fomites like clothes, present are of infectious type.1 For the first time in 1997
shaving brushes, towels, fingers and kajal sticks. to 98, the newly detected cases were less than the
Because of direct contact, the contact diseases are discharged cases, the number being 5.2 lakh and 5.5
also called contagious diseases. However, this term is lakh respectively.1
not very appropriate since it also includes droplet
infections like diphtheria, influenza and whooping Epidemiology
cough contracted by sitting face to face but not in actual
contact of skin or mucous membrane. It may, however, Prepathogenesis (agent, host and environment factors),
be mentioned that droplet infection has also been pathogenesis and prevention and control of leprosy are
suggested lately as a possible mode of spread of leprosy. described below in detail.
In case of contact diseases, the contagion or infection
comes out of the skin or mucous membrane of the AGENT FACTORS
infected person and enters through the skin or mucous The causative agent, Mycobacterium leprae is a gram
membrane of the healthy person. positive, acid fast bacillus that is rapidly decolourised by
Classification of the diseases in this group has been alcohol. The leprosy bacillus is a very hardy organism.
given in Chapter 15. The main diseases described here It needs more than two hours exposure to direct
will be Leprosy, Sexually transmitted diseases, sunlight to kill the bacilli. In hot, humid conditions, the
Trachoma, Ringworm and Yaws. bacilli have been shown to remain viable for about 1½
months, may be even for a greater period.
promptly diagnose and manage reaction or relapse of How do we manage a patient with type-1 reaction?
the disease. The patient will need corticosteroids in addition to rest
If a patient, sometime after he has been declared and analgesics. The drug of choice is prednisolone in
as cured (RFT) comes with reappearance or increase the case of type 1 reaction. The usual course begins with
in the number of lesions he should be considered a case 40 to 60 mg daily (up to a maximum of 1 mg/kg of
of relapse and given MB regimen whatever might be body weight), and the reaction is generally controlled
the grouping of the disease. within a few days. The dose is then gradually reduced
weekly or fortnightly and eventually stopped. Proper
Reaction in Leprosy and their Management precaution should be taken in patients with diabetes,
What is reaction in leprosy? peptic ulcer, hypertension, etc.
It is an acute inflammatory event occurring in the course A suggested schedule for prednisolone therapy for
of the disease. It can occur at anytime before, during an adult patient is as follows:
or after treatment. It must be promptly diagnosed and • 40 mg once a day for the first 2 weeks, then
treated to prevent any disability. Patients with following • 30 mg once a day for weeks 3 and 4
characteristics are more likely to develop lepra reactions. • 20 mg once a day for weeks 5 and 6
• Many lesions • 15 mg once a day for weeks 7 and 8
• Lesions close to the nerve • 10 mg once a day for weeks 9 and 10
• Lesions on the face. • 5 mg once a day for weeks 11 and 12
These patients should be monitored more frequently It is also important to provide rest to the affected
by doing clinical examination including VMT and ST for nerve until symptoms clear by applying a padded splint
early detection of reaction and its prompt management. or any suitable alternative material to immobilize the
joints near the affected nerve. The aim is to maintain
What are the types of lepra reaction?
the limb and the affected nerve in the resting position
There are two principal types of lepra reactions: Type
to reduce pain and swelling and prevent worsening of
1 and Type 2. Type 1 lepra reaction also known as
the nerve damage.
Reversal Reaction may occur both in PB and MB
leprosy. Type 2 reaction is also known as Erythema In case of a type 1 reaction not responding to
Nodosum Leprosum (ENL) and occurs only in severe treatment after 4 weeks of treatment with prednisolone
forms of MB leprosy. or at any time showing signs of worsening, the patient
Skin or nerves or both may be affected in reaction. should be referred to the nearest referral center.
Skin or nerves or both may be affected in reaction. Type 1 reactions, which occur after the completion of
What are the features of lepra reactions? treatment, should also be managed as mentioned above.
These are given in Table 18.7. Continue MDT if the patient is under treatment.
Common side effects Signs and symptoms What to do if side effects occur
Dapsone
Anemia Paleness inside the lower eyelids, mouth and finger- Give anti-worm treatment and
nails. Tiredness, edema of feet and breathlessness iron tablets. Continue dapsone
Severe skin complication Extensive scaling, itching, ulcers in the mouth and stop dapsone. Refer to hospital
(Exfoliative dermatitis) eyes, jaundice and reduced urine output immediately. Never restart
Abdominal symptoms Abdominal pain, nausea, and vomiting on high symptomatic treatment.
doses Reassure the patient
Liver damage Jaundice (yellow color of, skin, eyeballs and urine) Stop dapsone. Refer to hospital.
(Hepatitis) Loss of appetite and vomiting Restart after the jaundice subsides
Kidney damage Edema of face and feet Stop dapsone. Refer to hospital
(Nephritis) Reduced urine output
Rifampicin
No significance Redish coloration of urine, saliva and sweat Reassure the patient
Hepatitis (Liver damage) Jaundice (yellow color of skin, eyeballs and urine) Stop rifampicin. Refer to hospital
Loss of appetite and vomiting Restart after the jaundice subsides
Flu like illness Fever, malaise and bodyache Symptomatic treatment
Allergy Skin rash Stop rifampicin
Clofazimine
Ofloxacin*
Minocycline*
IDENTIFICATION EPIDEMIOLOGY
A small red lesion appears on the genitals as a papule Occurrence is worldwide, more so in tropics and sub-
or vesicle which becomes a pustule and ulcerates. Ulcers tropics. It is caused by Chlamydia trachomatis of
are often multiple and painful with soft bleeding surface immunotypes L-1, L-2 and L-3. It is akin to the
276 and ragged undermined edges, in contrast to the hard organisms of Trachoma and Inclusion Conjunctivitis
sore of syphilis. Lymph glands are enlarged, tender and (TRIC agents). There has been an increase in the
incidence of this disease in India. Two to three decades • Planning
In about 15 percent of the persons getting HIV CD4 Cell Count Common Clinical Features
infection, an acute viral illness develops about 6 weeks 150 to 500/ml Oral and vaginal candidiasis, oral hairy
after the entry of the virus into the body. Clinically it leukoplakia, sinusitis, gingivitis, seborrheic
resembles infectious mononucleosis (glandular fever) dermatitis, psoriasis, warts, molluscum
contagiosum, recurrent varicella-zoster and
with high fever, skin rash, headache, muscle pains, joint herpes simplex infection, cervical dysplasia,
pains and enlarged lymph nodes in the neck and axillae. tuberculosis, fever, sweats, weight loss
Encephalitis and aseptic meningitis can also occur. On
< 150/ml Pneumocystis jiroveci pneumonia, Kaposi’s
an average, the illness clears up within 2 weeks. If tested sarcoma, oesophageal candidiasis, cerebral
for HIV, the person would show a positive serological toxoplasmosis, lymphoma, HIV dementia,
test during the recovery phase, hence the name cryptococcal meningitis
“seroconversion illness.” < 50/ml Cytomegalovirus retinitis, cerebral lymphoma,
Mycobacterium avium complex infection
Asymptomatic Carrier Stage
After acute seroconversion stage, the individual become
asymptomatic and remain in this stage for long periods • Generalized and aggressive form of Kaposi’s sarcoma
(average 7 to 9 years). But the person is fully infectious • High grade B-cell lymphoma of the brain.
during this stage and is capable of spreading the disease
through his blood and body fluids.
Central Nervous System HIV Disease
Persistent Generalized Lymphadenopathy During the terminal stages of the illness the CNS also
(PGL) Syndrome gets involved. The following CNS diseases caused by
HIV are known:
Some asymptomatic persons infected with HIV develop • AIDS dementia complex: It consists of clumsiness
big lymph glands in their neck and axillae for no and slowing down of movements, disturbances in
obvious reasons. These glands may persist for months thought process, memory judgment and behavioral
without any change. This rather stable clinical stage in abnormalities.
HIV illness is called PGL syndrome. • AIDS myelopathy: It is a special type of spinal cord
damage (vacuolar myelopathy) with a form of
AIDS Related Complex (ARC) and HIV sensory-motor paralysis.
Constitutional Disease • AIDS neuropathy: It causes severe pins and needles
On an average, 7 to 9 years after infection with HIV, sensation on the tips of fingers and toes.
the seropositive individuals start developing recurrent
bouts of diarrhea, night sweats, fever and weight loss. Common Infections at Different CD4 Levels
This clinical stage is identified as ARC. Some of these
individuals may also develop minor opportunistic The degree of immune suppression (measured as the
infections like oral candida (thrush). This clinical stage CD4 cell count) predisposes to the development of
of ARC associated with minor opportunistic infections certain illnesses. Tuberculosis is the only opportunistic
is identified as “constitutional disease”. This clinical stage infection that may appear at any CD4 level (Table
heralds the onset of the terminal phase of HIV illness. 18.11).16
Within a few months of ARC, the immune system of Testing for HIV
the HIV infected person undergoes further deterioration. Testing without explicit consent may prove counter
The CD4+ cells fall below 200 per cmm. At this stage productive and has put people away from HIV testing
these patients start showing severe and life-threatening and it is also violation of human rights. Complete
opportunistic infections. These include: procedure consists of four stages.
• Fungal infections: Candida, Histoplasma, Cryptococcus
• Protozoal infections: Pneumocystis carinii, Crypto-
A. Pretest counseling
sporidium isospora, Toxoplasma
• Bacterial infections: Typical and atypical mycobacte- 1. Impairing awareness on how infection is acquired,
rial infections, Salmonella, Shigella different risk factors and its prevention.
• Helminthic infections: Generalized strongyloidosis. 2. Explaining implications of positive or negative results.
282 These persons may also show opportunistic cancers 3. Explaining window period.
including: 4. Obtaining informed consent.
the env and the gag proteins are detected. This test has
• Asymptomatic
• Persistent generalized lymphadenopathy
Clinical stage 2
Clinical stage 3
Clinical stage 43
1
Assessment of body weight in pregnant woman needs to consider expected weight gain of pregnancy.
2
Unexplained refers to where the condition is not explained by other conditions.
3
Some additional specific conditions can also be included in regional classifications (e.g. reactivation of American
trypanosomiasis (meningoencephalitis and/or myocarditis) in Americas region, Penicilliosis in Asia)
Source: Antiretroviral Therapy Guidelines for HIV-infected Adults and Adolescents Including Postexposure Prophylaxis.
May 2007. NACO, National AIDS Control organization. Ministry of Health and Family Welfare. Government of India.
285
PART II: Epidemiological Triad TABLE 18.13: Different classes of ARV drugs
Nucleoside reverse transcriptase Nonnucleoside reverse Protease inhibitors (PI)
inhibitors (NRTI) transcriptase inhibitors (NNRTI)
Nucleotide reverse transcriptase CCR5 Entry Inhibitor (new) Integrase Inhibitors (new)
inhibitors (NtRTI)
Tenofavir (TDF)
• Blood transfusions should be given only when strictly TABLE 18.14: ART criteria for adults and adolescents:
indicated. WHO clinical stage CD4 count (cells/mm3)
• Hemophiliacs should be given heat treated prepa-
rations instead of coagulation factor concentrates. I Treat if CD4 count < 250 (If between 251 – 300,
II Repeat CD4 count after 4 weeks)
• Appropriate health education should be given to III Treat if CD4 count < 350
public and to school and college students. IV Treat irrespective of CD4 count
• Treatment facilities for drugs users should be expan-
Specific situations
ded to include AIDS related health education, parti-
• HIV and tuberculosis (start efavirenz based regimen)
cularly as regards use of safe needles.
• Free and anonymous or confidential HIV testing, – Pulmonary TB and HIV: Start ART within 2 weeks of initiation
of ATT for all patients with CD4 < 350 cells/mm3 (For patients
counselling and referral services should be routinely
CD4 > 350, defer ART)
made available at places such as (i) STD clinics, (ii)
– Extrapulmonary TB and HIV: Start ART within 2 weeks of
Drug treatment clinics, (iii) Antenatal clinics, (iv) Family initiation of ATT in all patients irrespective of CD4 count
planning centers, (v) Facilities for gay men, pros- (Monitor hepatotoxicity).
titutes and hijras (eunuchs), and (vi) Communities • HIV and pregnancy (avoid efavirenz in first trimester)
or places frequented by persons at high risk of HIV
– WHO stage I and II: Start ART at CD4 < 250 cells/mm3
infection (such as high way resting points for truck (If between 251–300, repeat CD4 after 4 weeks).
drivers). – WHO stage III: Start ART at CD4 < 350 cells/mm3 (Strictly
• Health care workers should be careful in handling monitor adverse effects of nevirapine).
needles, sharp instruments and blood. Latex gloves – WHO stage IV: Start ART irrespective of CD4 count.
should be used whenever one has to handle blood
or fluids that are visibly bloody. If patient’s blood
because a pool of latently infected CD4 cells are
comes in contact with the health worker’s skin, it should
established during the earliest stages of acute HIV
be immediately washed away with soap and water.
infection and persists with a long half-life, even with
prolonged suppression of plasma viremia to <50
Control of Patients, Contacts and the
copies/ml (Table 18.13).
Immediate Environment
Antiretroviral therapy (ART) effectively suppresses
• Report to health authorities. replication, if taken at the right time. Successful viral
• Isolation: Precautions should be taken to avoid suppression restores the immune system and halts onset
contact with blood and body fluids of the patient. and progression of disease as well as reduces chances
• Concurrent disinfection of all equipment of conta- of getting opportunistic infections. It also reduces the risk
minated with blood, all excretions and secretions of of sexual transmission, mother to her child transmission
the patient.14 (MTCT), transmission after an accidental needle stick injury
• Quarantine: None. But HIV infected persons and and in cases of sexual assault and rape etc. Medication
their sex partners should not donate blood for thus enhances both quality of life and longevity (Table
transfusion, semen for artificial insemination and 18.14).
body organs for transplantation.14 Adherence to ART regimen (Highly active
• Immunization of contacts: None antiretroviral therapy–HAART) is therefore very vital
• Investigation of contacts: Not feasible as a routine. in this treatment. Any irregularity in following the
286 • Specific treatment: The currently available prescribed regimen can lead to resistance to HIV drugs,
antiretroviral drugs can not cure HIV infection, and therefore can weaken or negate its effect.
CHAPTER 18: Contact Diseases
TABLE 18.15: Recommended first-line antiretroviral regimens
Recommendation Regimen Comments
Preferred first-line Zidovudine + AZT may cause anaemia, which requires Hb monitoring, but is preferred over d4T
regimen Lamivudine + because of d4T toxicity (lipoatrophy, lactic acidosis, peripheral neuropathy)
Nevirapine * Patients who develop severe anemia while on an AZT-based regimen should not
be re-challenged with AZT. In such cases, the patient should receive either d4T
or TDF in place of AZT
For women with CD4 > 250 cells/mm3, monitor for
hepatotoxicity closely if started on the NVP-based regimen
Alternative first- Zidovudine + EFV is substituted for NVP in cases of intolerance to the latter or if patients are
line regimens Lamivudine + receiving rifampicin-containing anti-TB treatment
Efavirenz EFV should not be used in patients with grade 4 or higher elevations of ALT
Stavudine + Lamivudine + If the patients have anemia, a d4T-based regimen should be prescribed
(Nevirapine or efavirenz)
Other options Tenofovir disoproxil TDF is supplied on a case-to-case basis by SACS after evaluation by the SACS
fumarate + Lamivudene + clinical expert panel
(Nevirapine or efavirenz)
or
Zidovudine + Lamivudine +
Tenofavir (TDF)
* Substitute NVP with EFV, for patients with TB or toxicity to NVP.
Genetic diversity due to env gene. HIV vaccine clinical trial are long, difficult
and expensive.
Lack of formation of neutralizing antibody Recruiting volunteers for the clinical trials
against the globally diverse and circulating are difficult.
strain of HIV.
Lack of proper animal model for preclinical testing. Lack of political commitment.
Three principles are being maintained for selecting 2. Perinatal vaccine: To vaccinate HIV-infected pregnant
the first-line regimen: (1) lamivudine is chosen in all women, in order to protect the fetus or the newborn
regimens, (2) one NRTI (Zidovudine or Stavudine) is child from being infected.
chosen to combine with Lamivudine (3) one NNRTI 3. “Therapeutic” or post-infectious vaccine: To delay the
(Nevirapine or efavirenz) is also selected (Table 18.15). progression to AIDS in HIV-positive persons.
Fixed-dose combinations (FDCs) are preferred Background: The first phase I trial of an HIV vaccine
because they are easy to use, have distribution was conducted in 1987 using a gp160 candidate
advantages, improve adherence to treatment and thus vaccine. Subsequently, more than 30 candidate
reduce the chances of development of drug resistance. vaccines have been tested in over 60 phase I/II trials,
The current national experience shows that bid (twice involving approximately 10,000 healthy volunteers.
a day) regimens of FDCs are well tolerated and Most of these trials have been conducted in the USA
complied with. EFV is contraindicated in pregnant HIV- and Europe, but several have also been conducted in
infected women during the first trimester of pregnancy developing countries. The first phase III trials began in
because of concerns of teratogenicity. the USA in 1998 and in Thailand in 1999 to assess the
ART is now available free to all those who need it. efficacy of the first generation of HIV vaccines (based
ART centers are located in medical colleges, district on the HIV envelope protein, gp120).22
hospitals and non-profit charitable institutions providing An HIV vaccine could either prevent disease onset
care, support and treatment services to people living or progression to AIDS. According to mathematical
with HIV/AIDS (PLHA). ART centers also provide estimates by the International AIDS Vaccine Initiative
counseling and follow-up on treatment adherence and (IAVI) – provided that other programs for treatment and
support through community care centers (CCC). prevention have been scaled up – an HIV vaccine with
an efficacy as low as 30 percent and coverage as low
HIV VACCINE as 20 percent could avert as many as 5.5 million new
infections between the year 2015 to 2030. 23 The
There are three different aproaches to HIV vaccination:21 development of an effective vaccine has posed a wide
1. Preventive vaccine: To prevent HIV-negative persons range of challenges, as HIV has proven to be a uniquely
287
from being infected. complex virus.24 An effective vaccine against HIV would
PART II: Epidemiological Triad have to elicit protection against both free virus and virus- development of vaccines. Out of the 24 candidate
infected cells (Table 18.16). vaccines in different stages of development, 18 are in
phase I trial, 3 are in phase I/II trial, 2 are in phase II
Types of HIV Vaccines24 trial, and only 1 is in the phase III trial which is VaxGen’s
gp120 based AIDSVAX that is being tested in Thailand.
Live attenuated vaccine: Although it has been tested
in animals with high level of protection; but they are Indian scenario
not being developed for use in humans because of ICMR, NACO, their partner International AIDS Vaccine
safety concerns. Initiative (IAVI), Department of Biotechnology (DBT)
Inactivated vaccine: Because of the serious nature of are involved in vaccine development in India. The
the disease and the ability of retroviruses to induce Indian HIV vaccine has been designed to prevent HIV
latency, it is unlikely that live attenuated or inactivated 1c subtype. The first ever conducted trial in India was
virus will ever be accepted for human use. Adenoassociated virus based vaccine expressing gag,
protease, delta-RT HIV 1 subtype c gene, given
Subunit vaccine: The first AIDS vaccine developed and intramuscularly to 30 healthy uninfected adult
tested was designed by using the subunit concept. volunteers. This trial was initiated in February 2005 at
Subunit vaccine (AIDSVAX gp 120) was the first vaccine National AIDS Research Institute (NARI), Pune and the
that underwent complete testing in humans. This vaccine vaccine was found to be safe, well tolerated and
contains small protein or piece of pathogen, which elicits modestly immunogenic. Another phase I trial in Chennai
B cell mediated humoral response against the antigen. (January 2006) with Modified Vaccinia Ankara (MVA)
Synthetic peptide vaccine: Neutralizing and T cell vaccine suggests safety, tolerability and 100 percent
epitopes are included in this vaccine. The problems with immunogenicity.24
synthetic peptides are related to the tertiary structures
which may be different from those of native proteins.
DNA vaccines: This vaccine uses copies of single or National AIDS Control Program
multiple genes from the pathogen. The gene from the National AIDS Committee was formed in 1986 and
pathogen integrates with the human gene resulting in National AIDS Control Program was started in 1987. The
the formation of protein that acts as an antigen to activities were HIV screening in sexually promiscuous
produce the antibody. DNA vaccine will not cause HIV group and among blood donors along with increased
infection, since it does not contain all the genes of the educational activities. Then in 1992 National AIDS
live pathogen. Many of the current AIDS vaccine Control Organization (NACO) was established as a
candidates are DNA vaccine. separate wing by Department of Health, Ministry of
Recombinant vector vaccines: This adopts a same Health and Family Welfare. At present, National AIDS
strategy like DNA vaccines, but except that the genes Control Program is in its third phase (2007–2012) of
are carried by a harmless or a much weakened activity. The first two phases of activity NACP I (1992–
bacterium or virus called vector. Many of the current 2001) and NACP II (2001–2007) built up the infra-
AIDS vaccine candidates are vector vaccines. Like DNA structure required for providing comprehensive services
vaccine, vector vaccine will not cause HIV infection since for prevention, care and treatment. India through its
it contains copies of one or several HIV genes, not all National AIDS Control Program stands committed to
of them. They carry a high immunogenicity since virus Millennium Development Goal (MDG) of reversing the
replication results in large quantities of virus antigen. spread of HIV/ AIDS by 2015.25
Both humoral and cellular immunity can be induced.
Some of the candidate recombinant virus vectors GOALS AND OBJECTIVES OF NACP III
include adeno and adeno-associated viruses, pox viruses The overall goals of NACP-III is to halt and reverse the
like Modified Vaccinia Ankara (MVA) and alphaviruses epidemic in India over the next five years by integrating
like Venezuelan Equine Encephalitis (VEE) virus. A programs for prevention, care and support and
disadvantage of this approach is possible adverse effects treatment through the following strategies.
observed after inoculation of vaccinia virus. • Prevention of infection through saturation of cover-
Other type of the following approaches has also age of high-risk groups with targeted interventions
been studied like anti-idiotypes antibodies and
(TIs) and scaled up interventions in the general
passive immunization. Passive immunization may
population.
be helpful for postexposure protection.
• Provision of greater care, support and treatment to
larger number of persons living with HIV and AIDS
Status of AIDS Vaccine
(PLHA).
Global scenario • Strengthening the infrastructure, systems and human
288 The International AIDS Vaccine Initiative, WHO, UNAIDS resources in prevention, care, support and treatment
and others including vaccine industry are involved in the programs at district, state and national levels.
• Strengthening the nationwide Strategic Information environment, and linking prevention to HIV related care
on the knowledge, awareness and behaviours related Urethral stricture, Pelvic Inflammatory Disease
to HIV/AIDS among general population, youth as well Phimosis/paraphimosis, (PID), Infertility, Chronic pelvic
Infertility, Disfigurement of pain, Spontaneous abortion,
as among different high risk group communities. It also genitals, Cardiovascular Ectopic pregnancy, Low birth
throws light on the impact of the intervention efforts complications (syphilis), weight baby, Stillbirth, Increased
being undertaken through NACP. Neurosyphilis susceptibility to opportunistic
infection, Cervical cancer
293
PART II: Epidemiological Triad Flow chart 18.1: Management of urethral discharge/burning micturition in males26
294
Flow chart 18.2: Management of scrotal swelling26
295
PART II: Epidemiological Triad Flow chart 18.3: Management of inguinal Bubo26
296
Flow chart 18.4: Management of genital ulcers26
297
PART II: Epidemiological Triad Flow chart 18.5: Management of vaginal discharge in females26
298
Flow chart 18.6: Management of lower abdominal pain in female26
299
PART II: Epidemiological Triad Flow chart 18.7: Management of oral and Anal STIs26
300
References
standard of personal hygiene, malnutrition and over- ointment. Sulfacetamide eye drops are no longer the
crowding favor susceptibility. Infection does not confer treatment of choice for trachoma. When individuals
immunity and no vaccines are available. have lid deformities such as entropion, necessary surgical
correction needs to be done to prevent blindness.
INCUBATION PERIOD Surveillance of the community which has been given
mass treatment should be continued for several years
5 to 12 days as determined from experience on human after the active disease has been controlled.
volunteers.
References
PREVENTION AND CONTROL
1. WHO. Eye Health in South East Asia. Delhi: SEARO, 1976.
Health Education 2. WHO. Techn Rep Ser No. 330, 7, 1966.
3. Dawson CR, et al. Guide to Trachoma Control. Geneva:
People should be told about the mode of spread and
WHO, 1981.
asked to avoid use of common towels, fingers, hand-
kerchiefs and other articles for cleaning or wiping the
eyes. They should take early specific treatment. Dust
Fungus Infections
and smoke should be controlled. Dark glasses should There are two types of fungus infections or phytoses.
be used while moving in the sun. Dermatomycoses affect the skin. Common examples are
ringworm and favus. Systemic mycoses affect the
Early Diagnosis internal organs where infective granulomata are formed.
Examples are actinomycosis (Ray fungus infection),
Cases should be detected by mass surveys and given maduramycosis (Madura foot), moniliasis or candidiasis
treatment. In a difficult case, diagnosis is confirmed by (thrush) and histoplasmosis.
demonstration of intracytoplasmic inclusion bodies in
conjunctival scrapings stained by Geimsa or immuno- Ringworm (Tinea) (ICD-B35.9)
fluorescent stain. However, mass surveys for detection
and treatment pose complex organisational problems. CLINICAL FEATURES
It is hence recommended2,3 that if 5 percent or more
children below 10 years in a community have moderate It is a low grade infection that grows in the horny layers
or severe trachoma, a blanket or mass treatment should of skin, in hair and in nails where it induces an inflam-
be instituted. matory reaction. The lesion is seen in patches which
have a healing scaly center and a ring like spreading
edge. They are not produced by mere implantation of
Treatment
the fungus on the skin; allergy and sensitization of skin
SAFE strategy has been adopted (S: Surgery, A: are prerequisites. The lesions are given various names
Antibiotic, F: Facial cleanliness, E: Environmental as per the site involved as described below:
sanitation). Tetracycline ointment is the sheet-anchor of • Tinea pedis (Athlete’s foot): It affects the toes,
treatment. It is highly effective when applied in the eyes especially 4th and 5th, and is transmitted through
thrice daily for at least five weeks. Erythromycin and common bath, shoes and socks, especially when
rifampicin eye ointments are also effective. Systemic sweating is profuse.
302 tetracycline, erythromycin or sulfamethoxazole (30 mg/ • Tinea cruris (Dhobie’s itch): It affects genitocrural skin
kg per day) for 3 weeks are as efficient as topical and, sometimes, the under surface of breasts. It may
be transmitted through underwears, toilet seats and Africa, Malaya, Philippines. Fiji, India, Burma, Ceylon,
Mode of transmission can be by direct contact with Yaws is amenable to eradication. This is possible
secretions of infectious lesions, by fomites or by certain through interruption of transmission. The YEP has been
vectors like flies and insects which spread the disease initiated with this objective.3 It was started in 1996 to
by mechanical contact. 97 in Koraput district, Orissa, as a central sector health
scheme. In 1997-98, it was extended to MP, AP,
INCUBATION PERIOD Maharashtra and Gujarat. The National Institute of
Communicable Diseases, New Delhi, is the nodal agency
3 to 5 weeks.
for the program. The program strategies include:
• Manpower development
METHODS OF CONTROL • Case detection
These include mass surveys, case finding and specific • Simultaneous treatment of cases and contacts
treatment and continuous surveillance. Health education • IEC.
about personal cleanliness and the mode of spread is The program is implemented by the state authorities
necessary. Measures to improve environmental utilizing the primary health care infrastructure.
sanitation are also important.
Scabies
Treatment
It occurs allover the world in the poor strata of society,
A single injection of benzathine penicillin G 1.2 million living in unhygienic conditions. It has already been
units is usually enough. The dose for children below 10 discussed in detail in Chapter 11.
years of age is 0.6 million units.
In areas where yaws is hyperendemic, (more than References
10% of clinically active yaws), mass treatment with
penicillin in the above dose is recommended for the 1. Narain JP, et al. J Com Dis 1986;18(2/128).
2. Hopkins DR. Am J Trop Med Hyg 1976;25:860.
entire population. If the area is in a mesoendemic zone 3. Ministry of Health and Family Welfare: Govt of India
(5 to 10% prevalence), treatment is given to all cases Annual Report 1998-99
and to all children under 15 years of age. In 4. WHO. Techn Rep Ser No. 1982;674.
304
19 Arthropod-borne Diseases
Arthropods are responsible for transmitting a large – Intestinal malaria: There is vomiting or diarrhea,
number of diseases as already described in Chapter 11. with or without blood.
These diseases will now be described in the following – Blackwater fever: There is intravascular hemolysis.
sequence: mosquito-borne diseases, (malaria, filariasis, Urine contains blood. Its color varies from dark
yellow fever, dengue, chikungunya fever, Japanese red to black, hence the name.
encephalitis) fly-borne disease (sandfly fever, leishma- – Renal malaria: Glomerulonephritis and nephrotic
niasis), flea-borne diseases (plague), tick-borne diseases syndrome have also been described.
(KFD) and diseases transmitted by more than one type • Quartan malaria: It is caused by P. malariae and pre-
of arthropod, such as certain rickettsial infections (epide- sents with mild symptoms. The bouts come in three
mic typhus, trench fever, endemic typhus, scrub typhus, stages as in the benign tertian malaria, but occur
rocky mountain spotted fever) and relapsing fever. every 4th day.
• P. ovale malaria: It is caused by a relatively rare mala-
rial parasite found in Africa. The symptoms are simi-
Malaria (ICD-B54) lar to P. vivax infection.
Identification
RELAPSES
The symptoms and signs of malaria depend upon the
Plasmodium vivax and ovale may persist in man for a
type of plasmodium, the infecting protozoal parasite in
blood that causes the disease. long time in the liver in the form of dormant forms
• Benign tertian malaria: It is caused by P. vivax. In called hypnozoites. These exoerythrocytic forms may be
some cases, continuous fever may occur for a few responsible for recrudescence of infection after a lapse
days before typical bouts of fever on every third day of months or even years following mosquito bite or
set in. There are three stages in a typical attack: after incomplete treatment of malaria (Table 19.1).
– In cold stage, the patient has marked shivering, The exoerythrocytic forms do not persist for long in case
lasting for about half an hour. of P. malariae and P. falciparum infections. In case of
– In hot stage, there is fever up to 39.5 to 40.5°C, P. vivax and P. ovale, the relapses keep on occurring
lasting for 1 to 5 hours without fresh infection from outside. Hypnozoites left
– In sweating stage, the temperature falls. The behind in the liver reach blood and start new cycles of
patient feels comfortable and falls asleep. infection. Eventually, immunity is established in 1 to 2
• Malignant tertian malaria: It is caused by P. falciparum. years and relapses cease.
Onset is insidious, the fever being prolonged and irregu-
lar, but not very high. Sometimes the patient may RECRUDESCENCE
be afebrile, even with heavy infection. The three typical
The phenomenon of reappearance of clinical malaria
stages described above are rare. Vomiting and
or Malaria parasite in blood, due to reactivation of
headache are common. Falciparum malaria is known
to mimic many febrile conditions. It is characterized
TABLE 19.1: Characteristics of disease caused by two
by heavy invasion of RBCs so that, in severe cases,
major species of malaria parasites
every 10th cell may be parasitized.
Serious complications due to interference with Characteristic P. falciparum P. vivax
capillary circulation, destruction of RBCs and toxemia Exoerythrocytic cycle 6-7 days 6-8 days
may occur in falciparum infection. The following Incubation period 9-14 days (12) 12-17 days (15)
presentations of falciparum malaria may be fatal: Severity of primary attack Severe Mild to severe
Duration of untreated infection 1-2 years 1.5-5 years
– Cerebral malaria: There may be sudden coma, Relapse No Yes
mental changes, aphasia and hemiplegia or CNS and other complication Frequent Infrequent
monoplegia. Anemia Frequent Common
PART II: Epidemiological Triad parasites, which remain dormant in the RBC itself. The Rapid diagnostic test (RDT): An antigen-based stick,
parasite some times remain in silent stage due to increase cassette or card test for malaria in which a colored line
host resistance which may reactivate when immunity indicates that plasmodial antigens have been detected.
decline. This simple test is used when laboratory facilities are not
available. The results of the test are available instantly.
CHRONIC MALARIA RDTs for detection of parasite antigen are generally
more expensive. The sensitivity and specificity of RDTs
It is common in endemic zones where reinfection conti- are variable under the influence of high temperatures
nues. Anemia, ill health, cachexia, enlarged spleen, slight and humidity. In India the test can be done by ASHA
icterus, butterfly pigmentation of the face, variable after receiving training.
degree of fever and parasitemia are the common While taking blood smears for diagnosis of malaria,
features. Repeated episodes produce a variety of there is no need to waste time by trying to synchronies
immune response as well as parasitic tolerance. Large blood smear with parasitemia. Such timing is irrelevant.
amounts of IgG and IgM are produced together with What is important is the number of smears examined.
an enlargement of the spleen. These are the features Two or three smears collected every 8 to 12 hours are
of the Tropical Splenomegaly syndrome. usually sufficient for diagnosing malaria. This is true of
Infants and the young are very susceptible and may even the falciparum type, which is more difficult to detect.
die of fever and gastrointestinal or pulmonary compli-
cation. Growth and development are retarded. By adult
INFECTIOUS AGENT
age, relative immunity has developed. The enlarged
malarial spleen is very friable and may rupture due to The malarial parasite was discovered in 1880 in human
a light thrust on the abdomen. Abortion may occur blood by Laveran. Manson (1894) postulated that
because of infection of the placenta. Malaria in malaria was transmitted by mosquitoes. Ronald Ross
pregnancy is associated with LBW delivery and increase found oocysts in the stomach of mosquitoes fed on
risk of deaths of mother and baby. patient’s blood in 1897. The whole cycle of the malarial
parasite in man as well as in mosquito was thoroughly
studied in the subsequent years.
Laboratory Diagnosis
The causative agent is a unicellular protozoan belon-
All fever cases should preferably be investigated for ging to class sporozoa, order hemosporidium and genus
malaria by Microscopy or Rapid Diagnostic Test (RDT). plasmodium. P. vivax, falciparum and malariae are
The results of parasitological diagnosis should be roughly responsible for 50 to 55 percent cases in India
available within a short time (less than 2 hours) of the and are found in all regions. P. malariae is more common
patient presenting. If this is not possible, the patient in tribal areas and accounts for 5 percent cases. P. ovale
must be treated on the basis of a clinical diagnosis. is not found in India. Mixed infections are found in 4
to 5 percent cases of malaria. P vivax invades only the
Blood Smear Examination/Microscopy young RBCs, which constitute 1 to 2 percent of the total.
Hence it is benign in nature. P falciparum, on the other
Both thick and thin films are made and examined for hand, can affect all red cells and hence produces a greater
malarial parasite. Repeated microscopic examination degree of hemolysis. The prevalence of falciparum
may be necessary, especially when the patient has malaria is increasing in most countries, including India.
received partial treatment. This is particularly so in case Man is the intermediate host in whom the parasite
of P. falciparum, in which case the parasites are often undergoes asexual cycle called schizogony and early
scanty in blood. Mixed infections are quite common. sexual cycle called gametogony. Mosquito is the definitive
Indirect fluorescent antibody technique is of help in host in which sexual forms or gametes complete and
diagnosing malaria. The test is positive after a week of sexual cycle called sporogony and produce sporozoites.
infection and may remain so for years. It is possible to
distinguish the various species of malaria parasite and Vectors of malaria in India: Several species of Anopheles
their different stages. It can be used to assess response mosquitoes are found in India Anopheles culicifacies is the
to antimalarial treatment. The test requires relatively main vector of malaria. It is a zoophilic species. Most of
high degree training and supervision for reliable results. the vectors, including Anopheles culicifacies, start biting
Under optimal conditions the sensitivity and specificity soon after dusk and rests during daytime in human
of the test is >90 and 100 percent respectively but dwellings and cattle sheds (Table 19.2).
under typical field conditions the sensitivity and
specificity of the test is 25 to 100 percent and 56 to Cycle in Man
100 percent respectively. The form of parasite detected This occurs in four phases:
306 in slide includes ring form (mostly), tophozoite, schizont 1. Sporozoites enter the human blood through the bite
and gametocyte. of a female mosquito. They disappear from blood
CHAPTER 19: Arthropod-borne Diseases
TABLE 19.2: Malaria vectors in India
• A. fluviatilis Foothills of South Irrigation channels, shallow Usually feeds before mid-night
India and UP, wells, rice-fields, tanks Major foothill vector of South India
J and K, Rajasthan
• A. minimus UP, foothills, As above Feeds mainly between mid-night
Bengal, Assam and 02.00 hours
• A. philippinensis Deltaic Bengal, tanks, pools Major foothill vector of UP,
Assam, UP Bengal, Assam
• A. stephensi Peninsular and Wells, fountains, cisterns, Commences to bite at dusk or soon
North West India pools, sluggish streams after. Chief urban vector of India.
Important rural vector in North
West India
• A. sundaicus Coasts of Orissa, Brackish water, lagoons and Coastal vector. Brackish water
North Tamil Nadu, tanks. May breed in fresh water breeder
Bengal, A and N island
• A. annularis Orissa coastal plains, Stagnant water Vector of local importance only
Jhansi (UP), Garo
hills (Assam)
• A. balabacensis East Assam, Burma Forest pools and streams
• A. varuna Travancore and East Rainwater pools, tanks,
peninsular India wells irrigation channels
Note: No. 1-6 are major vectors, of which Number 1 and 2 are most important. 70% malaria in India is caused by A. culicifacies.
within half an hour and reach the reticuloendothelial mosquito into ookinete, oocyst, sporocyst and sporozoite
system, mostly liver, to undergo preerythrocytic phase. stages. This cycle takes 7 to 20 days and the period is
In the parenchymal cells of liver, the sporozoites pass sometimes referred to as the extrinsic incubation period.
through schizont stages, called cryptozoites, which
develop into merozoites. Merozoites may further PROBLEM STATEMENT
repeat proliferative cycles in the liver and thus multiply The 109 countries and territories classified as endemic
in number. This phase lasts for 8 days or more in for malaria, or previously endemic with the threat of
vivax and for 6 days in falciparum infection. reintroduction of infection in year 2008. About half the
2. From liver, the merozoites escape into blood and world’s population (3.3 billion) in live in areas that have
undergo the erythrocytic phase or asexual cycle some risk of malaria transmission. There were an
consisting of ring, ameboid or trophozoite, schizont estimated 247 million malaria cases (5th to 95th centiles,
and merozoite stages. Merozoites again enter fresh 189 to 327 million) worldwide in 2006, of which 91
RBCs and complete the cycle every 2 or 3 days, percent or 230 million (175 to 300 million) were due
depending on the species. to P. falciparum. The percentage of cases due to P.
3. After 7 to 10 days, some merozoites develop into falciparum exceeded 75 percent in most African
sexual forms known as male and female countries but only in a few countries outside Africa. The
gametocytes. This part of the cycle is called number of cases reported by national malaria control
gametogony, sexual phase or infective phase. programs (NMCPs) was only 37 percent of the estimated
4. Exoerythrocytic phase—All preerythrocytic forms global incidence. There were an estimated 881 000
come out of the liver in case of P. falciparum. In case deaths worldwide in 2006, of which 90 percent were
of P. vivax however, they persist in the liver (tissue in the African Region, and 4 percent in each of the
phase) and are responsible for relapes. These persis- South-East Asia and Eastern Mediterranean regions.
tent forms are called hyprozoites and are capable World Malaria Day - 25th April—which was instituted
of developing into merozoites months or years later. by the World Health Assembly at its 60th session in May
2007 - is a day for recognizing the global effort to
Cycle in Mosquito provide effective control of malaria.
The gametocytes are sucked in with blood when the
female mosquito bites the patient or carrier. They BURDEN IN SEA REGION
change to male and female gametes and unite to form Around 40 percent of the global population at risk of 307
a zygote which develops in the stomach, wall of the malaria resides in SEA Region and accounts for 8.5
PART II: Epidemiological Triad percent of the global and around 4.1 percent (Fig. India: Before 1953 the incidence of malaria was very
19.1) of the global mortality due to malaria. WHO high (75 million / year). With introduction of NMCP and
estimates that globally 33.96 million DALYs lost due to followed by NMEP the incidence was brought down to
malaria in which SEA Region contributes around 1.34 50,000/ year in 1961. However, this success was not
million. The malaria situation in the region remains highly long lasting and resurgence of malaria was noted in
dynamic and evolving, and likely to be further 1970. With introduction of MPO in 1997 upsurge of
aggravated by climate change. There is an evidence to malaria cases dropped and reached a plateau after
show that warming of the earth’s temperature and 1984. About 1.65 million cases and 933 deaths was
increasing precipitation will hasten maturation of the reported in 2003, aproximately 22 percent of these
parasite in mosquitoes, increase the biting frequency and cases were Falciparum malaria.
create conditions more conducive to mosquito breeding. Malaria is prevalent in all the parts of the country
During 2000 to 2008, in SEA Region, malaria except in areas more than 5000 feet above sea level.
incidence remains between the range 2.19 to 2.83 Some of the states are highly endemic for malaria and
millions. The countries showing significant reduction in contribute about 90 percent of the total malaria in the
malaria incedence are Bhutan, Korea (DPR), Sri Lanka country (Fig. 19.2). During 2008, the malaria
and Thailand. About 95 percent of the population of incidence was around 1.53 million cases, 0.78 million
moderate to high risk of malaria in SEA region is living Pf cases and 1055 eaths. About 88 percent of malaria
in India, Indonesia, Myanmar and Thailand. More than cases and 97 percent of deaths due to malaria were
90 percent of the confirmed malaria cases and deaths reported from high disease burden states namely
are reported from India, Indonesia and Myanmar. Northeastern (NE) States, Chhattisgarh, Jharkhand,
During 2008 total 2.5 million laboratory confirmed Madhya Pradesh, Orissa, Andhra Pradesh, Maharashtra,
malaria cases and 3088 malaria deaths were reported in Gujarat and Rajasthan, West Bengal and Karnataka.
the region where as the estimated malaria cases and deaths However, other States are also vulnerable and have
were around 21 million cases and 29,000 respectively. Sri local and focal outbreaks. Malaria problem has assumes
Lanka and DPR now entered in to malaria preelimination serious dimension in NE states because of perennial
phase where as rest of the countries are still in control malaria transmission, predominance of falciparum
phase. In Maldives, there is no indigenous transmission infection and development of drug resistance in the area
since 1984 (World Malaria Report, 2008). Table 19.3.
Fig. 19.1: Global malaria burden. Source: World Malaria Report 2008, WHO
TABLE 19.5: Drug schedule for treatment of malaria under NVBDCP 2010 in India
Diagnosis Treatment
P. vivax cases § Chloroquine: 25 mg/kg body weight divided over three days (10 mg/kg on day 1,
10 mg/kg on day 2 and 5 mg/kg on day 3)
§ Primaquine: 0.25 mg/kg body weight daily for 14 days.
Uncomplicated Artemisinin based Combination Therapy (ACT)
P. falciparum cases § Artesunate 4 mg/kg body weight daily for 3 days plus
§ Sulfadoxine (25 mg/kg body weight) and Pyrimethamine (1.25 mg/kg body weight)
on first day and
§ Single dose primaquine preferably on day 2
Pregnant women with 1st Trimester: Quinine salt 10 mg/kg 3 times daily for 7 days
uncomplicated Pf infection 2nd and 3rd Trimester: ACT as per dosage given above.
Treatment of mixed Full course of ACT and Primaquine 0.25 mg per kg body weight daily for 14 days
infections (Pv + Pf)
Clinical malaria (where Suspected malaria cases will be treated with full course of chloroquine, till the results
parasitological diagnosis of microscopy are received. When parasitological diagnosis is available, species-specific
313
not available or delayed) treatment should be administered.
PART II: Epidemiological Triad TABLE 19.7: Age-wise dosage schedule for treatment of P. falciparum cases
Age Day 1 Day 2 Day 3 Day 4
(Years) Artesunate Artesunate Artesunate Primaquine
(50 mg)(50 mg) SP* (50 mg) (50 mg) (7.5 mg base)
<1 ½ ¼ ½ ½ Nil
1-4 1 1 1 1 1
5-8 2 1½ 1 2 2
9-14 3 2 1½ 3 4
15 and above 4 3 4 4 6
Before 1953 there was 75 million cases ‘National Malaria Control Program’ (NMCP) 1953
and 0.8 million deaths in India. Objectives: To bring down malaria transmission to a level at which it would cease to be a major
Introduced NMCP (1953) to combat public health problem and hold down malaria transmission at low level.
problem of malaria Strategies: 1) Anti-malarial treatment for institutional cases, 2) Residual insecticide spray with
DDT of human dwelling and cattle sheds
Encouraged by success of NMCP (2 ‘National Malaria Eradication Program’ (NMEP) attempted ending transmission of malaria by
million cases per year in 1958) killing entire vectors and elimination of reservoir of infections.
eradication program was take-up in Strategies: 1) Two round of DDT spray in all area, 2) Active and passive surveillance, 3)
1958 Presumptive and Radical treatment
NMEP reduced cases to 0.1 million in ‘Modified Plan of Operation’ (MPO) 1977 was launched. Vertical approach was replaced by
1966, but set back resulted sub- horizontal approach.
sequently due to technical, operational Objectives: Elimination of deaths, reduction of morbidity from malaria and maintenance of the
and administrative failures. Resurgence gains achieved so far by reducing transmission of malaria
of malaria cases and deaths were noted. Strategies: 1) Stratification of rural area based on API and differential vector control measures
Attempt of malaria eradication was given 2) Active and passive surveillance, 3) Presumptive and radical treatment
up and introduced MPO.
Annually 2-3 million cases were ‘Enhanced Malaria Control Project’ (EMCP) 1997
reported during 1984 –1998. The area Objectives of EMCP: Prevention of death and reduction of morbidity from malaria, consolidation
with adverse epidemiological of the gain achieved so far.
parameter were selected for Strategies: Early case detection and prompt treatment, vector control by appropriate insecticide,
implementation of EMCP health education and community participation.
In 1999 name of national program was National Anti Malarial Program (NAMP) 1999: Objectives and strategies remained same as
changed MAP
Though NAMP successfully reduced The Intensified Malaria Control Prject (IMCP), 2005 was introduced with special inputs in the
the average national API but some form of Rapid Diagnostic Tests (RDTs), Artesunate Combination Therapy (ACT), Insecticide
areas continue to register high API. Treated Bed Nets (ITNs) and Health Systems Strengthening (HSS) were provided.
2003-04 Convergence of numbers of vector borne programs: Malaria, Filaria, JE and Dengue under
National Vector Borne Disease Control Programme (NVBDCP).
Strategies: Integrated vector control and promotion of insecticide treated bed net
316 2006 ACT introduced in areas showing Chloroquine resistant falciparum malaria.
Malaria Control Activities and • Epidemiological investigation
National program for malaria in India has been evolved Community Participation
over the year salient features of which has been • Sensitizing and involving the community for
described in the following Table 19.8. detection of Anopheles breeding places and their
elimination
• NGO schemes involving them in program strategies
National Anti Malaria Programme
Behavior Change Communication (BCC)
National Anti Malarial Program (NAMP) 1999 has many BCC has been defined as a process of learning that
common features to earlier program. Presently the empowers people to take rational and informed
antimalarial activities are being carried under National decisions through appropriate knowledge. BCC as a
Vector-Borne Disease Control Program (NVBDCP), supportive strategy should be an integral part of malaria
which an umbrella programmes for prevention, and control program. It enhances awareness regarding
control of Vector-Borne Diseases (VBDs). The overall transmission risk reduction, treatment and availability of
strategy under NVBDC on prevention and control of services at different levels. Communicating messages for
malaria is outlined below. behavioral changes are formulated after analysis of
health behavior of people. Clear messages,
Two Objectives of the Program are:
communicated through different, credible channels are
1. Prevention of deaths and morbidity due to malaria
most likely to bring about change. It inculcates necessary
2. Maintenance of ongoing socioeconomic development skills and optimism; facilitates pertinent action through
Specific Objectives: changed mindsets, modified behavior.
• To bring down API to 1.3 or less in the 11th Five Monitoring and Evaluation of the program
Year Plan Monitoring is ongoing follow-up of the planned program
• At least 50 percent reduction in mortality due to malaria activities / processes to examine whether the program
by the year 2010, as per National Health Policy (2002) is being implemented as planned. Monitoring provides
• To halt and reverse the incidence of malaria by 2015 feedback information for corrective action. Evaluation
(as per Millenium Development Goals) indicate the extent of achievement of the stated
Strategies: The strategies for prevention and control of objectives goals in defined time-periods, and why it may
malaria and its transmission are: have succeeded or failed. Evaluations are expected to
lead to modification of program design and policies.
Surveillance and Case Management
• Case detection (passive and active)
SURVEILLANCE AND CASE DETECTION
• Early diagnosis and complete treatment
• Sentinel surveillance It relied on surveillance of fever cases in the community
Integrated Vector Management (IVM): refer vector by means of active fortnightly case detection based
control for details mainly on slide results conducted mainly by the multi
purpose worker or other health functionaries. There are
Stratification of the problem: Under Modified Plan of different approaches to search for cases:
Operation the malarious areas of the country have been • Passive case detection: Collection of blood slides
stratified according to Annual Parasite Incidence (API) from all fever cases in all medical or health units to
as follows. detect malaria cases. This is followed by appropriate
• Area with API < 2 treatment. This also includes notification of all
• Area with API ≥ 2 confirmed or suspected cases of malaria.
The approach was used to define population at risk • Active case detection: It is the system of detecting
and for judicial use of resources. malaria cases by domiciliary visits. Under
Selective application of transmission control antizmalarial program the health workers collect
measures in these strata were as follows: blood slide from all fever cases by fortnight visits in
community (secondary cases occur within two weeks
Intervention in area with API ≥ 2:
following primary cases). A patient with fever and
• Residual insecticide spray with 2 round DDT or
no other obvious cause of fever is considered a case
3 round BHC/ Malathion
of “suspected malaria. The health worker during
• Surveillance/ Treatment of cases
house-to-house visits inquires about fever cases in
• Entomological assessment
the family and initiates a diagnostic test (slide
Intervention in area with API < 2: microscopy, RDT) if he or she encounters a
• Focal spray around house with Falciparum suspected case of malaria; the health worker also 317
• Surveillance/ Treatment of cases provides case management.
PART II: Epidemiological Triad • Mass blood survey: Examination of blood from all is given along with investigation for the case but in DDC
persons in a community. This is carried out during there is only provision of distribution of antimalarial drug.
epidemiological investigation around positive cases. Details diagnosis and treatment have been described in
This is also done to detect asymptomatic previous sections.
parasitemia.
URBAN MALARIA CONTROL ACTIVITIES
Sentinel Surveillance
About 7.8 percent of the total cases of malaria are
Sentinel surveillance is necessary for events which are
reported from urban areas. Anopheles stephensi is the
not being captured by the regular system of reporting
viz. severe cases of malaria, their management and on important vector of Urban Malaria. The mostly breeds
malaria deaths and effectiveness of the antimalarial in container, piped water supply system, overhead and
drugs being used. The objective of sentinel surveillance storage tanks, water storage at construction sites, wells,
is to capture trends on in-patient malaria, severe malaria etc. Aedes aegypti and Culex quinquefasciatus are also
and malaria deaths. It will also enable the program to important vectors in urban area.
estimate the malaria burden in the country. Medical
college or any other hospital with required facilities and Factor Responsible for Urban Malaria Problem
staff may act as sentinel site.
• Unplanned developmental activities
• Increasing migration leading to dissemination of
DIAGNOSIS AND TREATMENT OF MALARIA
infection: The movement may lead to permanent
Any fever suspected as case malaria, must be change of residence known as migration or there
investigated by Microscopy of blood for malarial may be temporary change of residence and followed
parasites and/or Rapid Diagnostic Test and antimalarial by return to the original location which is termed as
treatment is given only on the basis of a positive circulation. Both these phenomena can influence
diagnosis. A patient with fever in an endemic area local malaria epidemiology, i.e. transmission and its
during transmission season, or who has recently visited seasonal pattern.
an endemic area, without any other obvious cause of • Proliferation of slums with no basic amenities leading
fever as stated below should be considered as suspected to abundant mosquitogenic conditions.
case of malaria: • Anti larval activities are restricted to chemical control.
• Cough and other signs of respiratory infection The focus is not on integrated source reduction
• Running nose and other signs of cold measures.
• Pelvic inflammation indicated by severe low back- • Area and population of the towns/cities have
ache, with or without vaginal discharge and urinary increased manifold without commensurate increase
symptoms in manpower for delivery of services including health
• Skin rash suggestive of eruptive illness care.
• Burning micturition Urban Malaria Scheme (UMS) was sanctioned
• Skin infections, e.g. boils, abscess, infected wounds in 1971 after the recommendations of Madhok
• Painful swelling of joints Committee in 1969. The main activity of UMS is
• Diarrhea reduction of vector population in urban areas through
• Ear discharge recurrent anti larval measures.
In practice the ascertainment of an “obvious cause”
can only be expected from well-trained and experienced Two main objectives:
health staff. A volunteer or health activist working in a 1. To prevent deaths due to malaria.
high-risk area should be taught to consider any fever 2. Reduction in transmission and morbidity
case in the absence of specified symptoms as suspected The control measures recommended under UMS
malaria. are as follows:
The area lacking timely microscopic services (result • Early diagnosis through passive institutional
is not available within 24 hours of testing) and reporting surveillance (malaria clinic, dispensary and hospital)
> 30 percent of Pf, SfR >1 percent, consistently high and treatment.
API and deaths, difficult to access area are provided with • Vector control strategy:
Rapid Diagnosis Test kit for prompt diagnosis of Pf cases. – Antilarval! Malarial oil, Malathion, Fenthion,
To ensure the accessibility of service and availability of Abate
antimalarial drugs to people DDC (Drug Distribution – Engineers, measure like filling, under ground
Centre), FTD (Fever Treatment Depots), MLV (Malaria drainage
318 Link Volunteers) have been established through – Biological control by Larvivorous fish (Gambusia
community involvement. At FTD antimalarial treatment affinis and Pecilia reticulata)
• IEC: • Physical disabilities due to obstructional defects (such
Culex quinquefasciatus is the vector of nocturnally The prevalence of microfilaremia usually increased
periodic bancroftian filariasis in all parts of the country with age. In some regions prevalence plateaus in early
in 99.3 percent cases. Though no natural vector has adult life while in others it rises steadily with age. There
so far been incriminated for the diurnal bancroftian is also a consistent increase in the disease rate with
infection in Nicobar, a species of Aedes group of increasing age. Infection at earlier age is reported more
mosquitoes have been found to be highly susceptible— commonly with B. malayi, perhaps due to the shorter
Aedes (Finlaya) niveus group. incubation period. However, microfilaremia below one
Mansonia annulifera is the principal vector of year of age has been reported in both infections.3 the
Brugian filariasis while M. uniformis is the secondary earliest age at which disease manifestations have been
vector. The Mansonia require water plants like Pistia, reported is one and two years with B. malayi and
Eichornia, etc. for their development. W. bancrofti respectively.11
Since the biting rate remains constant for all ages,
and a plateau is seen in adult age, this implies that after
INCUBATION PERIOD
the age of 20 years immune mechanism are effective
The duration of the clinical incubation period (from against the acquisition of new infection. The immunity
invasion of infective larvae to development of chronic probably functions against the infective stage rather than 323
manifestation) is variable. The shortest period for esta- against the adult worms or microfilariae.12
PART II: Epidemiological Triad It has been observed that in areas where genital infective larvae in mosquitoes and alterations in the
manifestations predominate, males invariably show frequency and severity of clinical manifestations of
higher disease rates than females while the reverse holds filariasis. Mf counts come down by 80 percent while
true for areas with predominant extremity lesions. mean density of circulating Mf decreases through
more than 90 percent.
METHODS OF CONTROL • Mass treatment: DEC has been used for mass
treatment in China, Japan, Brazil, Tanzania and India.
These may be discussed with reference to the host The reasons for undertaking mass treatment are:
(man), the agent (microfilaria) and the environment – If all members in a specified population are not
(vector). treated, it would necessitate night blood exami-
nation of every member of the community. This
Measures for the Host is a daunting task.
These relate to personal protection against mosquito – A single blood examination may not reveal infec-
bite and are similar to those outlined under malaria ted persons if concentration techniques are not
prevention. used.
– Carriers of Mf are often asymptomatic and are
Measures against the Agent unlikely to come for blood examination.
Common salt medicated with DEC in 0.2 to 0.4
These relate to the use of antifilarial drugs. Two anti- percent concentration for six months has been
parasitic drugs are available for chemotherapy: successfully tried for mass treatment.5 DEC citrate has
Diethylcarbamazine (DEC) and Ivermectin. been found to be quite stable and can withstand
Diethylcarbamazine (DEC) has been the conventional prolonged heating. However, the long-term impact of
therapeutic mode employed. DEC has significant large scale programs has been limited.
microfilaricidal but only limited macrofilaricidal activity. DEC only has a limited impact on established disease.
It reduces filarial transmission as it reduces the number It is only partially effective against adult worms. It is excreted
of circulating microfilariae. Administration of DEC in urine as well as stools and is a strong vermifuge for
reduces prevalence and intensity of microfilaremia. roundworms. Rarely, untoward effects may be seen after
DEC has been used both for individual treatment DEC administration. They occur due to sudden killing
and for mass treatment of populations. of microfilariae in large numbers. These include fever,
• Individual treatment: DEC given in a daily dose of urticaria, bullae formation, swelling of joints and in some
5 mg/kg for 10 days rapidly reduces Mf density within cases, orchitis. Other side effects such as nausea, vomiting,
a few days but the effect is not sustained. When a headache, drowsiness and anemia may also occur.
total dose of 72 mg/kg is given over an extended
Ivermectin
period, the decrease in Mf density is much slower
but eventually reaches the same level as with 10 day This semisynthetic agent has recently emerged as the
regimens and the effect lingers on for a longer period. drug of choice in treatment of onchocerciasis. It has
Alternatively, an intense 5 to 7 day short course can been tried in bancroftian filariasis but not found to be
be given for rapid reduction in the number of micro- very useful.
filariae and this can be followed up smaller doses
given at wider intervals for achieving a persistent reduc-
tion in prevalence and intensity of microfilaremia. Measures Against the Vector
Various doses that have been used include 6 mg/ • Antilarval measures: Larvae are the preferred target
kg for 12 days and 9 mg/kg for 4, 6, 8, or 12 days. for Culex quinquefasciatus. In addition to petroleum
Toxic reactions to DEC are frequent, occurring oils, organophosphate insecticides like temephos,
in 25 to 100 percent of medication acceptors. These malathion, chlorvinphos, chlorpyrifos and diazinon
reactions are more common during the first few days are very useful in low concentrations. They remain
of treatment and are more frequent in patients with effective for several weeks in polluted stagnant water
high Mf counts. The reactions are thought to be due so that frequent treatment is not necessary. For
to rapid destruction of Mf and liberation of toxins petroleum oils like MLO (Malarial Larvicidal Oil) or
from killed Mf. The adverse reactions are endured kerosene, 15 ml/m 2 at 7 to 10 day intervals is
by sick people but discourage the normal or required. The application of organic oils to the water
asymptomatic persons and populations from drug surface is effective in suffocating the culex larvae
compliance. which breathe air through the water surface.
The effectiveness of DEC may be assessed by However, since these oils are biodegradable, they
324 change in the number of Mf in humans, number of need repeated application.
Recently polystyrene beads have been effectively
RESERVOIR Short-term
• Areas with SSG sensitivity >90 percent: SSG IM/
Man is the only known reservoir in India. Dogs and IV 20 mg/kg/day × 30 days.
rodents act as reservoir hosts in the Mediterranean and • Areas with SSG sensitivity <90 percent:
in Brazil, where they cause infantile kala-azar in age Amphotericin B 1 mg/kg b.w. IV infusion daily or
group 1 to 4 years. alternate day for 15 to 20 infusions. Dose can be
increased in patients with incomplete response with
Mode of Transmission 30 injections.
Phlebotomus argentipes, a sandfly, is the vector in India. Long-term
It becomes infected when it bites a patient with • Areas with high level of SSG resistance (>20%):
Leishman Donovan bodies in the blood and transmits Miltefosine 100 mg daily × 4 weeks.
the same to a healthy person at the next bite. • Areas with SSG sensitivity >80 percent: SSG IM/
IV 20 mg/kg/day × 30 days or Miltefosine 100 mg
daily x 4 weeks.
Incubation Period
1 to 4 months, varies up to 18 months; may be as short Second Line Drugs
as 10 days.
• SSG Failures: Amphotericin B 1 mg/kg b.w. IV
infusion daily or alternate day for 15 to 20 infusions.
Period of Communicability
Dose can be increased in patients with incomplete
As long as parasites persist in blood. Man may be infec- response with 30 injections.
tive for sandfly even after clinical recovery. • SSG and Miltefosine Failures: Liposomal
Amphotericin B.
Susceptibility and Resistance General rule for taking Miltefosine capsule
Susceptibility is general. Long lasting immunity develops • Have to take strictly for 4 weeks
to kala-azar after the first infection. • Do not have capsule in empty stomach
• During treatment keep the treatment card of
Methods of Control Miltefosine give from health center carefully
• Miltefosine is contraindicated in child below 2 years
These may be described in relation to the host, the and pregnant mother
vector and the parasite. • If doses of Miltefosine are not completed, then
Measures to Protect the Host: Endemic zones should relapse of kala-azar and even death also might
334 be demarcated and residence in infected homes and occur.
occur in the past. It was well under control but an out-
References Reservoir
342
Miscellaneous Zoonoses, Other
20 Infections and Emerging Infections
• Single or multiple transdermal bites or scratches Nervous tissue Semple’s sheep brain*
• Contamination of mucous membrane with saliva Suckling mice brain
Duck embryo Duch embryo vaccine (DEV)
(i.e. licks) Purified duck embryo vaccine (PDEV)
• Exposure to bats, whatever the nature of contact Tissue culture Human diploid cell vaccine (HDCV)*
Primary chick embryo cell vaccine (PCECV)*
Management: Wound treatment, rabies immunoglobulin Purified Vero cells rabies vaccine (PVRV)*
(RIG) and modern tissue culture vaccine. Fetal rhesus cells (rabies vaccine adsorbed-RVA)
Local treatment is described in two parts—the first Fetal bovine kidney cell rabies vaccine
aid to be rendered by the victim himself or his attendant, Primary hamster kidney cell rabies vaccine 345
and the measures to be taken by a doctor. *
Available in India
PART II: Epidemiological Triad Duck Embryo Vaccine (DEV) TABLE 20.2: Regimens for post-exposure prophylaxis
(Intradermal route)
It has been in use in many countries, but not in India,
since 1956. It is economical and easy to prepare, with Route Regimen Dose Schedule (Days)
less side effects compared to neural tissue vaccine. A Intradermal Two-site* 0.1 ml Day 0, 3, 7, 28†
purified vaccine (PDEV) is now available which is Intradermal Eight-site‡ 0.1 ml Day 0 (8 doses§),
7 (4 doses#), 28¶, 90¶
claimed to have a level of safety and immunogenicity
comparable to tissue culture vaccines including human * Two site regimen signifies right and left upper arm (total 2 sites)
diploid cell vaccine.9 † On each day, one injection is administered in right and left upper
arm
‡ Eight site regimen signifies both upper arms, both lateral thighs,
Tissue Culture Vaccines both suprascapular regions and both sides of the lower quadrant
region of the abdomen (total 8 sites)
Being derived from cells of nonneural origin, these § One injection each in both upper arm, both lateral thigh, both
vaccines are safe as well as potent. Human diploid cell suprascapular region, and on both sides of the lower quadrant
vaccine (HDCV) was the first to be prepared. Primary region of the abdomen (total 8 doses)
Chick Embryo Cell (PCEC) rabies vaccine is also now # One injection each in both upper arm and both lateral thigh (total
4 doses)
available worldwide. The least in the international ¶ One dose in one upper arm only
market is purified vero cell rabies vaccine (PVRV) which
is produced in VERO cells procured from African green
monkey kidneys. PVRV has now replaced HDCV as the
WHO reference vaccine for rabies. The three vaccines Intradermal Schedule11
HDCV, PCEC and PVRV are similar in most respects Eight out of India’s 28 states and seven Union Territories
except that the dose of PVRV is 0.5 ml per injection had announced plans to introduce intradermal regimen
compared to 1 ml for the other two. Each dose has a from 2009.5 Only PCEC and PVRV has been accredited
minimum vaccine content of 2.5 IU. An oral antirabies for ID use by WHO and DCGI (Table 20.2).
vaccine for dogs has been developed and tried The 2 site ID schedule is known as Updated Thai
successfully in Germany.10 An oral antirabies vaccine for Red Cross Schedule, where 0.1 ml each (total 0.2
human use will be a major breakthrough. ml in two sites) tissue culture ARV is administered on
Meanwhile Government is doing more to promote both deltoid areas (alternative site is anterior aspect of
rabies awareness with initiatives such as a pilot project both thigh) ID route involving two different lymphatic
to prevent human rabies death launched by the area drainage sites. For ID route 1 ml insulin syringe
National Center for Disease Control (NCDC) – formerly with 28 G fixed needle is required and 70 percent
NICD in five Indian cities.5
ethanol or isopropyl alcohol is used as skin disinfectant.
Dosage Schedule3
ADVANTAGE OF INTRADERMAL SCHEDULE
Practice varies as regards number of doses, route and
• Low dosage is necessary – only a fraction of
amount of vaccine per dose.
intramuscular dose is required.
• This is a vaccine saving schedule.
Tissue Culture or Duck Embryo Vaccines • It is cost effective, thus economical.
The potency is at least 2.5 IU per dose. The following • Less number of doses are required, so patient
schedules are used: compliance is better. Thus saving of man days,
expenses and clinic hours.
Intramuscular schedule: One dose of the vaccine is • Immune response is developed early, so better
administered on days 0, 3, 7, 14 and 30. All intra- efficacy.
muscular injections must be given in the deltoid region • Less or no dilution in blood after dermal inoculation.
or, in small children, in the anterolateral area of the vii. It yields stronger immune status even in
thigh. Vacine should never be administered in the compromised persons.
gluteal region. • It yields stronger immune status even in
In the abbreviated multisite schedule referred to as compromised persons.
the 2 to 1 to 1 regimen spanning over 21 days instead However intradermal route is not preferred in the
of the 30 days schedule described above, one dose each situations like diabetes mellitus, hepatic insufficiency,
is given in the right and left arms on day 0, followed malnutrition, antimalaria therapy, steroid or antiviral
by a dose on day 7 and one on day 21. The 2 to 1 therapy and HIV infection. Mixed schedule involving ID
to 1 schedule induces an early antibody response and and IM route is also not recommended.
may be particularly effective when post-exposure In the following situations the first dose of the
346 treatment does not include administration of rabies vaccine is given in double doses (whatever
immunoglobulin. schedule is used):
• Patients with chronic diseases like cirrhosis of liver Communicable Diseases12 show that one-fourth of cases
References The disease is found in Japan, China and India but cases
are also reported from Europe, Africa and Australia.
1. Benenson AS. Control of Communicable Diseases in Man Rats and mice allover the world have been found to
(16th edn). Washington: American Public Health be healthy carriers. Infection occurs when an infected
Association, 1995.
2. Chugh ML. Bharat Med J (July issue) 120-7,1969.
rat bites a healthy person and introduces the germs
3. WHO. Techn Rep Ser 824,1992. through the skin wound.
4. Dutta JK. JIMA 91: 3-4,1993.
5. Chatterjee P. India’s ongoing war against rabies. Bull World Susceptibility and Resistance
Health Organ 2009;87:890-1
6. Sudarshan MK, Mahendra BJ, Madhusudana SN, Rahman There is general susceptibility. Mortality is 10 percent
SA, Ashwathnarayana DH. An Assessment of Rabies Free in untreated cases.
Status of the Island of Andaman, Nicobar and
Lakshadweep: Results of the WHO Sponsored National
Multicentric Rabies Survey. Indian Journal of Public Health, Incubation Period
2006; 50 (1):11-4. 2 to 6 weeks.
7. Rao KNA, Stephen S. In: Ahuja MMS (Ed) “Progress in
Clinical Medicine, Series 4”, Delhi: Arnold-Heinemann,
31-56,1981, Methods of Control
8. Houff SA, et al. New Engl J Med 300: 573,1979.
9. Bhatia R, Ichhpujani RL. Immunization against Infectious
Anti-rat measures and curative treatment with penicillin.
Diseases. Delhi: Jaypee Brothers, 1994.
10. Wilhelm U, Schneider LG. Bull WHO 68: 87-92,1990. Leptospirosis (Weil’s Disease) (ICD-A27.9)
11. Expert Group of the Association of Physicians of India on
Adult Immunization in India. The Association of Physicians IDENTIFICATION
of India Evidence-Based Clinical Practice Guidelines on
Adult Immunization. JAPI. 2009;57:351-3. • Stage of invasion: Fever and prostration for 4 to 5
12. National Institute of Communicable Diseases: Annual days; muscular twitchings; pain in calf muscles;
Report, 142,1980. intense injection of conjunctiva.
13. Anonymous: Medical Times (Sandoz) Vol. VII, No. 2,1977.
• Icteric stage: Jaundice in 60 percent cases for 5 to
7 days with enlarged and tender liver. Hemorrhages
Rat Bite Fever (ICD-A25.0 and A25.1) may occur. Death occurs in about 10 percent cases.
Urine shows albumin, bile and leptospira organisms
IDENTIFICATION
since the infection becomes localized in the
There is a history of rat bite. The wound heals but pain kidneys.
and swelling appear at the site of wound after two to
six weeks. The scar breaks down and lymphadenitis and DIAGNOSIS
lymphangitis occur. General symptoms appear after
some time in the form of fever and a specific rash Blood culture is positive during the first week of illness.
(purple red spots over the neck, trunk and face) which Urine culture is positive after the first week. Serological
slowly disappear. The temperature comes down after tests reveal rising titer.
3 to 4 days. Relapses and remissions may occur for
months and years. OCCURRENCE
The disease is found worldwide including Japan, USA,
Causative Agent
France, Germany and Sweden. In India, cases have
Rat bite fever can be the result of two different infections, been reported from Andamans and Kolkata.
both producing almost similar clinical picture. These are Prevalence is higher in miners, sewer workers,
spirillosis (ICD-A25.0) caused by a spirochete Spirillum fishermen, swimmers and dock workers due to higher
minor and Streptobacillosis (ICD-A25.1) caused by risk of exposure. Scores of persons reportedly died of
348 Streptobacillus moniliformis. The variety found in Asia leptospirosis in Ernakulam district of Kerala in 1993
is spirillosis. The description given below pertains to this. and 1994.1
Bacillus anthracis, the largest of all bacteria in size.
Emerging Infections1 •
•
Insecticide resistance
Weak public health system
The theme of the World Health Day on 7th April 1997
was “Emerging infectious diseases-Global response,
TABLE 20.7: Potentially emerging diseases
global alert”. The reemergence of diseases thought to
be well under control in large parts of the world and Infection Reported in
emergence of new infections with high case fatality rates Hanta virus Myanmar, Sri Lanka, USA
and the potential of their rapid spread has led the WHO Yellow fever Kenya, many African and Latin American countries
to issue a wake up call. The eradication of smallpox and Ebola virus Zaire, South Africa
E. coli O 157:H7 Australia, South Africa, Japan, USA
effective control of many communicable diseases, has
led to a false sense of security and complacency in many
countries. Resources for public health were curtailed as
more immediate priority areas were identified for humans has either increased during the last two decades
financial support. or threatens to increase in near future. The term
The outbreaks of plague in 1994, cholera in 1995 includes newly-appearing infectious diseases or those
and dengue hemorrhagic fever in 1996, among many spreading to new geographical areas. It also refers to
others, have highlighted the urgency for strengthening those diseases which were previously easily controlled
the disease surveillance system so that early warning by antimicrobials but have now developed resistance
singals are recognized and appropriate control measures to these drugs.
are initiated in a timely manner. Reemerging infectious diseases are those that have
Various factors are responsible for the emergence reappeared after a significant decline in their incidence.
and reemergence of communicable diseases. These Appearance of plague in an explosive form in 1994 after
multisectoral factors will need to be addressed while a period of quiscence of almost 27 years is an important
developing strategies for their prevention and control. example of reemerging infections.
Some of these factors, apart from weak public health List of some emerging diseases is given in Table
system, include rapid urbanization, industrial and other 20.5. Main reasons for emergence are given by Table
developmental activities, encroachment by humans of 20.6. Some potentially emerging diseases are listed in
areas so far uninhabited leading to ecological changes Table 20.7.
and rapid means of transportation to and from any part
of the world. Improvements in living standards are
sometimes accompanied with potential health hazards. Reference
Emerging infectious diseases have been defined by 1. NICD: CD Alert, 1: Issue 1, 1 to 2. Delhi: National Institute
WHO as those infections the incidence of which in of Communicable Diseases, 1997.
352
Epidemiology of
21 Noncommunicable Diseases
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 355
PART II: Epidemiological Triad Inorganic chemicals like nickel, arsenicals, asbestos and demonstrate gross deficiency of thiamine and moderate
chromates are also well known carcinogens. Lime in deficiency of riboflavin in patients of oral cancer in the
betel is supposed to condition the oropharyngeal 1950’s.3 Iron deficiency has been incriminated in the
mucosa to the carcinogenic action of tobacco and areca.3 etiology of cancer; the Plummer-Vinson syndrome
Carcinogens are found in insecticides, cosmetics and (sideropenic anemia with epithelial lesions) in rural
food additives also. The example of the latter are the North Sweden was known to be associated with cancer
various nonpermitted dyes used as coloring agents in of upper alimentary tract. The syndrome and the cancer
food. Brominated vegetable oil (BVO), used in cold have both declined after the Swedesh government
drinks as a stabilizing agent for cloudiness, is a known started iron and vitamin fortification of flour.3 Dietary
carcinogen whose use has been banned in most fibers has now emerged as a major factor associated
countries, including India. with cancer of the bowel, a high fiber intake protecting
Intrinsic carcinogens have not been studies as against colonic carcinoma. On the other hand, a higher
thoroughly as the extrinsic ones. The former include than optimal intake of energy and fats has been found
hormones and smegma. Hormones like estrogen and to be associated with higher incidence of cancer of the
androgen play a possible role in breast, prostate, and breast and colon. In view of the association of diet with
endometrial cancers. Unwise and prolonged use of cancer and cardiovascular disease, Wynder has
hormones such as estrogen and progesterone in recommended the so called prudent diet providing 2500
contraceptive pills may cause cancer. Smegma is a well to 2800 kilocalories per day, of which not more than
known carcinogen in the etiology of penile and cervical 35 percent should come from fats, the presence of
cancer. The incidence of this cancer is markedly low in animal fat being so limited as not to provide more than
circumcised males and their spouses. The prevalence rate 300 mg cholesterol.14
of cervical cancer in Indian Muslims is half compared to A recent study in Chennai observed that Indian
that in the Hindus.6 The major risk factors associated with women with cancer of the breast or of other sites might
cervical cancer are early age at marriage and at first have low intake of green-yellow vegetables rich in fibre
pregnancy, low economic status and multiparity. Other and carotenoids such as beta-carotene, zeaxanthin and
factors of importance are sexual promiscuity and lutein.15 Another case control study in Gujarat showed
cohabitation with uncircumcised male partners.3 a protective effect of fibre for both oral submucous
Physical carcinogens: These may be in the forms of fibrosis and leukoplakia. Ascorbic acid was thought to
radiation energy and mechanical agents. Radiations be protective against leukoplakia as was consumption
include ultraviolet rays, corpuscular rays (alpha and of tomoto.16
beta), electronic rays (gamma-rays, X-rays) and heat Biological carcinogens: A large number of animal
radiation. Sufficient data linking radiation to development tumors are known to be caused by viruses. No human
of various types of cancer are available. A steep rise in cancer has been definitely provided to be viral in
the incidence of leukemia in the West is attributed to etiology. However, there is strong evidence linking
increased diagnostic and therapeutic exposures. It is much hepatitis B virus (HBV) with hepatocellular carcinoma
higher in doctors, particularly radiologists, compared to and Epstein-Barr virus (EBV) with Burkitt’s lymphoma.
the general public. The atom bomb tragedy in Nagasaki Besides viruses, Schistosoma hematobium infection is
and Hiroshima in 1945 results in a crop of radioisotope believed to be associated with bladder cancer.
induced malignancies, including leukemia. Continuous Studies undertaken at the Institute of Cytology and
heat applied to skin can be carcinogenic as in the cause Preventive Oncology (Delhi) indicate a significant role
of kangri cancer in Kashmir. of Human Papillomavirus in the causation of cervical
Mechanical agents such as chronic irritation and trauma cancer. HPV is a sexually transmitted agent that infects
do not usually initiate cancer formation but may the cells of the cervix and slowly causes cellular changes
promote carcinogenesis if an irritating carcinogen has (dysplasia) that can result in cancer.8
produced its effect already; such as a projecting tooth
in buccal mucosa, birth injuries in cervix and stones in HOST FACTORS
gallbladder. Burn scars undergo malignant changes The diverse host factors, though very important, are not
when exposed to constant friction. Dhoti cancer is a yet fully understood. These are described below.
good example of cancer attributable to constant
mechanical friction.3 Age: Relationship of age and cancer is interesting as well
as bewildering. The known facts are summarized here.
Nutritional agents: More and more evidence is • The most common general pattern is that of a marked
accumulating that nutritional factors play an important increase in incidence of cancer with increase in age.
part in etiology of cancer. As far back as 1933, Ian This pattern is seen in general in case of carcinomas
356 Morrison Orr incriminated low dietary vitamin A intake of skin, gastrointestinal tract and urinary tract, as well
in the etiology of oral cancer. Khanolkar was able to as in case of some nonepithelial cell cancers such as
chronic lymphatic leukemia and myelomastosis. The between Parsis and nonparsis in Mumbai.3 For example,
hypercoagulability of blood (high plasma levels of factor Rheumatic Fever (RF) and
VII, factor VIII and fibrinogen) are also associated with Rheumatic Heart Disease (RHD)
IHD.5
Acute Rheumatic fever is predominantly a disease of
Physical inactivity: Epidemiological studies6 have children aged 5 to 14 years and generally does not affect
shown a clear inverse relation between vigorous exer- children less than 3 years old or adults. However, people
cise and IHD. It has been found that exercise reaching can have recurrent episodes well into their forties. The
maximal energy output level may be more beneficial prevalence of RHD peaks in the third and fourth
than overall total energy output at low intensity of effort.5 decades.10,11
Vigorous exercise may be regarded as one involving an In the 2004 WHO Technical Report it was estimated
energy expenditure of 5 kcal/minute or more. that worldwide, there were 5.5 deaths per 100,000
population in 2000.12 In 2005, it was estimated that
Smoking: Heavy smokers have three-fold risk of IHD
over 2.4 million children aged 5 to 14 years are affected
compared to nonsmokers. with RHD and 79 percent of all RHD cases come from
Socioeconomic factors: IHD is more common in the less developed countries. Further, the annual number
upper socioeconomic classes. of new ARF cases in children aged 5 to 14 years was
more than 336,000. Similar to RHD, 95 percent of
Psychological stress: Stressful situations predispose
cases come from less developed countries.13 From there,
to IHD. For example, it has been found that widowers
they estimated that of all cases of ARF, 60 percent would
have a higher mortality from IHD during the six go on to develop RHD each year.
months after the death of the wife compared to In India, prevalence figures over the past five years
married men of similar age. Also, persons with type have been derived almost entirely from school surveys.
‘A’ or ‘Coronary prone’ behavior pattern have been Between 1940 and 1983, the prevalence rate for RHD
shown to have more than twice the risk of developing varied from 1.8 to 11 per 1000 (national average 6
IHD compared to those without it. 5 It may be per 1000), while between 1984 and 1995 the rate
mentioned that the type A individual is described as varied from 1 to 5.4 per 1000. During the same periods
an aggressive, striging, ambitious and restless person of time, the prevalence of rheumatic fever ranged from
bothered with deadlines. Those without such pattern 0.06 to 5.01 and 0.32 to 0.54 per 1000, respectively.14
are labelled as type B. In the south Indian population, Vellore in Tamil Nadu
had a 0.3 percent prevalence of RHD during 1982 to
Water hardness: Studies in England have shown that 90, which declined to 0.068 percent during 2001 to
IHD occurs less in those areas where water is hard. Such 02. The incidence estimates are predominantly in north
water tends to have a higher content of nitrate, Indian population. It ranges from 0.17 to 0.75 per 1000
carbonate, calcium and silica. population.15 In the year 2000 in Kanpur the incidence
Alcohol: Heavy drinking is associated with high IHD was estimated as 0.750 per 1000 population in a
mortality, but moderate drinking (upto three drinks per sample size of 3963 among 7 to 15 years of age
day) has been shown to protect against IHD in the group.16 Because of the different methods of collecting
the data it is not possible to be certain that these figures
West.5 However, such protective effect may be related
represent a fall in the prevalence of RHD. By
to the fact that alcohol intake raises serum HDL comparison, in western countries the prevalence of
cholesterol. Also, moderate drinking may relieve RHD in children aged between 5 and 15 years is below
mental stress, thereby lowering the risk of IHD related 0.5 per 1000, and for rheumatic fever it is below 1 per
to stress. 1000.14
Two generalizations need to be made about the risk Rheumatic heart disease is the most significant
factors of coronary disease. Firstly, the role of genetic sequelae of Rheumatic Fever. Although the exact causal
factors has yet to be fully appreciated. It is the genetic pathway is unknown it seems that some strains of group
code that determines which patient will get the disease A Streptococcus are “rheumatogenic” and that a small 363
and who will respond to which treatment.7 Secondly, proportion of people in any population (3-5%) have
an inherent susceptibility to acute rheumatic fever
PART II: Epidemiological Triad TABLE 21.3: Criteria for diagnosis of rheumatic fever
(ARF).10 Acute rheumatic fever (ARF) is an autoimmune
Major manifestations Minor manifestations
consequence of infection with group A streptococci. It
causes an acute generalized inflammatory response and Carditis Clinical
an illness that selectively affects the heart, joints, brain Polyarthritis Fever
Chorea Arthralgia
and skin. Despite the dramatic nature of an acute Erythema marginatum Previous rheumatic fever or
episode, ARF leaves no lasting damage to the brain, Subcutaneous nodules rheumatic heart disease
joints or skin. However, damage to the heart valves, Laboratory
particularly the mitral and aortic valves, may persist after Acute phase reactions:
an acute episode has resolved. This involvement of the Abnormal erythrocyte
sedimentation rate
cardiac valves is known as rheumatic heart disease. C-reactive protein
People who have had ARF previously are much more Leukocytosis
likely to have subsequent episodes, and these Prolonged P-R interval.
recurrences may cause further damage to the cardiac
The presence of two major, or one major and two minor,
valves. Thus RHD steadily worsens in people who have manifestation plus evidence of a preceding streptococcal infection
multiple episodes of ARF.11 indicates a high probability of rheumatic fever. Previous infection is
Group A streptococci can be subdivided into more indicated by: increased antistreptolysin O or other streptococcal
than 70 distinct types on the basis of M protein. Certain antibody; positive throat culture for group A Streptococcus and recent
scarlet fever. Manifestations with a long latent period, such as chorea
types of group A streptococci (including M types 1, 3, and late onset carditis, are exempted from this last requirement.
5, 6, 14, 18, 19, 24, 27, and 29) appear to be more
frequently, but not exclusively, associated with rheumatic
fever. The M type refers to the M protein of the cell Heart Association. The WHO recommended that strict
wall or the opacity factor antigens produced by the adherence to the criteria mentioned in Table 21.3 can
strain.17 be waived in the following three instances:
Joint involvement is the most common manifestation • Insidious or late onset carditis
of RF. In an ICMR survey of school children aged 5 to • Chorea
15 years, RHD patients had a history of polyarthritis in • Rheumatic recurrence.
18 percent cases, migrating polyarthralgia in 26 percent In the above 3 categories, the diagnosis of rheumatic
cases and chorea in 3 percent cases.18 In cases of first fever can be accepted even when two major (or one
attacks of acute rheumatic fever, the following major and two minor) manifestations are not present.
frequency of various signs and symptoms was reported: In the first two, however, the requirement for a prior
Polyarthralgia 50 percent streptococcal infection can also be waived.
Polyarthritis 36 percent
Carditis 14 percent
Corea 4 percent Primordial and Primary Prevention
Subcutaneous nodules 0.9 percent Primordial prevention generally requires significant
History of sore throat 1 to 5 weeks earlier is present improvements in the social determinants of health such
in about two-thirds cases of rheumatic fever. Such sore as improvement in housing, hygiene infrastructure and
throat is caused by group A hemolytic streptococci. access to health care.
Prevention of RHD after an attack of rheumatic fever Primary prevention is defined as the adequate
depends to a large extent upon long-term prophylactic antibiotic therapy of group A streptococcal upper
use of penicillin. This is because of the fact that each respiratory tract infection. 12 Primary prevention is
subsequent attack of rheumatic fever increases the risk administered only when there is group A streptococcal
of cardiac damage. One attack of rheumatic fever, in upper respiratory tract infection. Primary prevention has
fact, raises manifolds the risk of subsequent attack. been shown to be effective in reducing the frequency
Girls and women in particular seem to be severely of subsequent cases of RF, however has not to date
affected, possibly as a result of being housebound and been proven to be cost-effective, resulting in secondary
having to live in overcrowded conditions. Overpopula- prophylaxis remaining the mainstay of RF/RHD
tion, overcrowding, poverty, and poor access to medical management.19
care are undoubtedly the main reasons for the high
prevalence of RHD in India. Another reason may be
ANTIBIOTIC TREATMENT OF ACUTE
the inadequate use of penicillin by general practitioners
RHEUMATIC FEVER11
because of fears over allergic reactions.
The WHO 17 has recently issued guidelines for There is general consistency in the literature that the acute
diagnosis of rheumatic fever. These are reproduced in RF should be treated with intramuscular benzathine
364 Table 21.3 and are essentially based upon the Jones benzylpenicillin. However there is some debate about at
criteria revised in 1982 and approved by the American what weight the does should increase from 600,000 IU
to the adult does of 900,000 IU. With the accepted oral
and child health programs. However, new challenges 9. Prevention of Child Abuse and Neglect: Making the links
threatening child health are emerging. Child abuse and between human rights and public health. Geneva: World
Health Organization. World Health Organization 2001.
neglect is one of them. Child abuse is an emotional, 10. Silverman AB, Reinherz HZ, Giaconia RM. The long-term
physical, economic and sexual maltreatment meted out sequelae of child and adolescent abuse: A longitudinal
to a person below the age of eighteen.7 The Centers community study. Child Abuse and Neglect 1996;20:709-
for Disease Control and Prevention (CDC) define child 723.
maltreatment as any act or series of acts of commission 11. Brown J, Cohen P, Johnson JG, Smailes EM. Childhood
abuse and neglect: specificity of effects on adolescent and
or omission by a parent or other caregiver that results
young adult depression and suicidality. Journal of the
in harm, potential for harm, or threat of harm to a American Academy of Child and Adolescent Psychiatry
child.8 Most incidents of child abuse occur in a child’s 1999;38:1490-1496.
home, but instances of abuse occurring in school or the 12. Sidhartha T, Jena S. Suicidal Behaviors in Adolescents.
community with whom the child interacts with are also Indian Journal of Pediatrics 2006;73:783-788.
not uncommon.
Worldwide about 40 million children under the age Blindness
of 14 years are estimated to suffer from abuse and
neglect. 9 One of the most important long-term Blindness is now a major public health problem both
consequences of childhood abuse is suicidal behavior in the developed and the developing countries. A
in adolescence.10 Adolescents and young adults with a blindness prevalence rate of more than 1 percent is
history of childhood maltreatment were 3 times more widely acknowledged as indicative of a significant
likely to become depressed or suicidal compared with public health problem.1 The past few decades have
individuals without such a history.11 Physical abuse and seen an upsurge in the number of the blind. This is
neglect by parents is found as one of the main reason due to increase in total population and increase in
for suicidal behavior among Indian adolescents.12 life expectancy resulting in increase in geriatric
population. It is well known that the aged suffer 20
References to 100 times more from blindness compared to
children.
1. WHO: Tech Rep Ser No. 322,1986.
2. Indian Express 20.9.91.
3. Roberts I et al: Effect of environmental factors on risk of Definition
injury of child pedestrians by motor vehicles: a case control
study. BMJ 1995,310:91-94. No standard definitions existed earlier for defining the
4. Govt of India. Ninth Plan Document, 1997-2002. magnitude. The WHO in 1979 defined categories of
5. Christoffel T, Gallagher SS. Injury Prevention and Public
visual impairment2 as a first step to obtain comparable
Health. 2nd edn Jones & Bartlett, 2005.
6. Haddons Matrix. Available from: http://www.ihs.gov/ data (Table 21.11).
m e d i c a l p r o g r a m s / p o r t l a n d i n j u r y / Wo r d d o c s /
Getting%20Started/Haddon%20Matrix/Haddon TABLE 21.11: Categories of visual impairment and blindness3
MatrixBasics.pdf
Category Visual acuity
7. Study on Child Abuse: India 2007. Ministry of Women
(with both eyes, using best possible correction)
and Child Development. Ministry of Women and Child
Development, Government of India. New Delhi 2007. 1 Below 6.18 to 6/60 to 3/60 or more
8. Leeb RT, Paulozzi LJ, Melanson C, Simon TR, Arias I. Child 2 Below 6/60 to 3/60 or more
Maltreatment Surveillance: Uniform Definitions for Public 3 Below 3/60 to 1/60 or more (Finger counting at 1 M)
Health and Recommended Data Elements. Centers for 4 Below 1/60 to Light perception alone
376 Disease Control and Prevention. 2008. Available from 5 No light perception
http://www.cdc.gov/ncipc/dvp/CMP/CMP-Surveillance. 6 Undetermined or unspecified.
The WHO recommends that categories 3,4 and 5 and diabetic retinopathy are the other major causes,
383
PART II: Epidemiological Triad TABLE 21.17: List of core diseases
TABLE 21.18: Clinical sydromes and diseases under Fever less than seven days with:
each syndrome • Rash and running nose or conjunctivitis (suspected
Syndromes Diseases
Measles)
• Altered sensorium (suspected JE)
Fever with and without Malaria, Typhoid, JE, Dengue,
• Convulsions (suspected JE)
localizing signs Measles
Cough more than 3 weeks Tuberculosis • Bleeding from skin, mucus membrane, vomiting
duration blood or passing fresh blood through nose or ear
Acute Flaccid Paralysis Polio or black motion (suspected dengue)
Watery Diarrhea Cholera
Jaundice Hepatitis, Leptospirosis,
• With none of the above (suspected malaria)
Dengue, Malaria, Fever more than seven days (suspected typhoid)
Unusual Events causing Anthrax, Plague, Emerging
While entering the diagnosis for fever, care must be
death or hospitalization epidemics
taken to record it as one of the following categories:
• Only fever/Fever with rash/Fever with altered
Syndrome is group of symptoms and/or signs consciousness or convulsions/Fever with bleeding/
attributable to particular disease condition (e.g. fever Fever more than 7 days.
with skin rash indicative of measles.
Methods of Surveillance
Syndromes Under Surveillance
The following are the main sources of data under IDSP:
The paramedical health staff will undertake disease • Routine reporting (passive surveillance): It is most
surveillance based on broad categories of presentation. major form of data collection and universalized, while
The following are the clinical syndromes and diseases other methods are need and area specific. Health
under each syndrome (Table 21.18). Worker/ANM reports all patients fulfilling the clinical
Surveillance of fever: Fever is the most common syndrome from area covered by the sub-centre.
presenting symptom among patients at the periphery. Medical Officers at Primary Health Centre (PHC) or
Fever may be accompanied by other symptoms, e.g. Community Health Centre (CHC) level will report
as probable cases or confirmed cases as applicable.
384 fever with cough/ muscle pain, a patient is considered
to be suffering from fever, if his/her main symptom is It is suggested that each of the units report at weekly
that of fever. intervals.
• Sentinel surveillance: a hospital, health center, Feedback and Sharing Information
387
22 Food and Nutrition
TABLE 22.2A: Protein requirement for normal Indian adults and allowances for pregnant and lactating womena
Group Body weight kg Protein* g/kg/d Daily additional requirement* (g) Total daily requirement* (g)
Adult
Male 60 1.0 60
Female 55 1.0 55
Pregnant women
(3rd trimester, 10 kg GWG) 23b 78
Lactating women
0-6 months 19b 74
6-12 months 13b 68
a b
Terms of mixed Indian diet protein; High quality protein, GWG: Gestational weight gain
* Sources: ICMR 2010
The daily requirement for Indian children, computed for their growth, is given in Table 22.2B.
TABLE 22.2B: Protein requirement and dietary allowances for infants, Boys and Girls
Age Group Requirementa,b Body weight Total daily Requirementa,b Body weight Total daily
g protein kg/d (kg) requirement g protein/kg/d (kg) requirement
(g protein/d) (g protein/d)
Infantsc (Months)
6-9 1.69 7.9 13.4
9-12 1.69 8.8 14.9
Pre-school Children(y) Boys Girls
1-2 1.47 10.3 15.1 1.47 9.6 14.1
2-3 1.25 12.8 16.0 1.25 12.1 15.1
3-4 1.16 14.8 17.2 1.16 14.5 16.8
4-5 1.11 16.5 18.3 1.11 16.0 17.8
School Children (y) Boys Girls
390 5-6 1.09 18.2 19.8 1.09 17.7 19.3
6-7 1.15 20.4 23.5 1.15 20.0 23.0
Contd...
CHAPTER 22: Food and Nutrition
Contd...
Age Group Requirementa,b Body weight Total daily Requirementa,b Body weight Total daily
g protein kg/d (kg) requirement g protein/kg/d (kg) requirement
(g protein/d) (g protein/d)
7-8 1.17 22.7 26.6 1.17 22.3 26.1
8-9 1.18 25.2 29.7 1.18 25.0 29.5
9-10 1.18 28.0 33.0 1.18 27.6 32.6
Adolescents (y) Boys Girls
10-11 1.18 30.8 36.3 1.18 31.2 36.8
11-12 1.16 34.1 39.6 1.15 34.8 40.0
12-13 1.15 38.0 43.7 1.14 39.0 44.5
13-14 1.15 43.3 49.8 1.13 43.4 49.0
14-15 1.14 48.0 54.7 1.12 47.1 52.8
15-16 1.13 51.5 58.2 1.09 49.4 53.8
16-17 1.12 54.3 60.8 1.07 51.3 54.9
17-18 1.10 56.5 62.2 1.06 52.8 56.0
a
In terms of mixed Indian vegetarian diet protein.
b
Requirements for each age band taken as the protein requirement for the lower age limit at that age band.
Source: ICMR 2010
Table 22.3: Protein content in 100 gm of some foods again during frying with oil especially when same oil
used repeatedly.
Cow’s milk 3.2% Poly unsaturated fatty acids (PUFA) are essential
Human milk 1.1%
Buffalo milk 4.3% components of cell membranes. The n-6 PUFAs are
Meat 22.5% predominant in all cells, while the nerve tissue has high
Egg 13.3% levels of long chain n-3 PUFA. The two most important
Fish 22.0% polyunsaturated essential fatty acids namely, linoleic
Groundnuts 25.3%
Atta raw, handpounded 12.1% (n-6) and linolenic acid (n-3) are metabolized at various
Rice 7.5% sites in the body to generate a group of biologically-
Pulses 20.25% active compounds, which perform several important
Soybean 43%
physiological functions. Further, PUFAs reduce total
cholesterol; influence peripheral glucose utilization,
insulin action and decrease adiposity and hence are anti
Fats are distinguished from oils by their different atherogenic. On the other hand saturated fatty acids
melting points; fats are solid and oils liquid at room are known to increase serum total, LDL cholesterol
temperature. Fat is one of the major sources of calorie levels, reduce insulin sensitivity and increase CVD risk.
to the body, which provides 9 calories of energy per Excessive fat in the diet increases the risk of obesity,
gram. It helps in digested, absorbed, and transportation heart disease, stroke and cancer.8 Replacing SFA with
of fat soluble vitamins A, D, E, and K. MUFA reduces LDL cholesterol concentration and total/
The dietary fatty acids have been subdivided into HDL cholesterol ratio.
three broad classes according to the degree of
unsaturation; saturated fatty acids (SFA) have no double
SOURCE OF FAT
bonds, monounsaturated fatty acids (MUFA) have one
double bond and polyunsaturated fatty acids (PUFA) Dietary fats can be derived from plant and animal
have two or more double bonds. sources. Fats that are used as such at the table or during
A cis configuration means that the hydrogen atoms cooking are termed as “visible” fats; and that present
attached to the double bonds are on the same side. If as an integral components of various foods are referred
the hydrogen atoms are on opposite sides, the to as “invisible” fat. Fats, in processed and ready to eat
configuration is termed trans. Each broad classification foods are known as hidden fats. Cereals contain only
of fatty acids may have unique biological properties and 2 to 3% of invisible fat. A typical Indian diet contain
health effects.8 Trans fatty acids are produced during significant amount of invisible fat. Major sources of
the partial hydrogenation of PUFA. Trans fatty acids dietary SFA are from animal fat and especially from
have been associated with adverse effects on lipoprotein ruminant dairy fats. Appreciable levels of SFA are also
status by elevating LDL and depressing HDL. Trans fatty present in some tropical oils, such as palm oil, coconut
acid formation occur when oil is heated over and over oil, etc.
391
PART II: Epidemiological Triad synthesized by humans. The minimum intake levels for
essential fatty acids to prevent deficiency symptoms are
estimated to be 2.5% of total energy from LA plus 0.5%
of energy from ALA.
Higher dietary cholesterol increases blood
cholesterol. Therefore, cholesterol intake should be
maintained below 200 mg/day.
which the husk has been removed. Food groups Mean iodine contents
• Fruits and vegetables that can be eaten with the skin (microg/kg weight)
intact should be eaten as such. However, fruits and Sea fish 832
vegetables are poorer sources of fiber than cereals Fresh water fish 30
Vegetables 29
and pulses.
Meat 50
Eggs 93
Minerals Legumes 29
Cerebral grains 47
Minerals, like vitamins, are micronutrients. The minerals Fruits 18
which are most commonly deficient are iron and iodine.
Calcium
Calcium deficiency may also occur sometimes.
Deficiency of other minerals is either rare or not well It forms 1.2 to 2% of body weight, 99% being present
documented. in bones and teeth. Its serum level is about 10 mg per
100 ml. The proportion in blood and bone is maintained
Iron by the interaction of vitamin D, calcitonin and
parathyroid hormone. Calcium controls neuromuscular
It is the essential constituent of hemoglobin in the red action, including cardiac muscle contraction. It is essential
blood cells. Out of the total estimated 3 to 4 gm in the for coagulation of blood.
body, 75% is present in blood.
SOURCES
SOURCE
Main dietary sources are milk, eggs, fish, green leafy
Main dietary sources of iron are cereals, pulses, meat, vegetables and cereals. Rice is a poor source. Phytic acid
eggs and green leafy vegetables. Gur (jeggery) also has in cereals and oxalates in some leafy vegetables decrease
394 significant amounts of iron. Milk is a poor source. Vitamin the bioavailability of calcium because of formation of
C helps in iron absorption. calcium phytate and oxalate which are not absorbed.
Phytase destroys phytic acid in wheat during yeast vitamin A content of human milk, cow milk and eggs
TABLE 22.5: Nutritive value of milk and milk products per 100 gm
Products Moisture Proteins Fat CHO Minerals Calcium Vit A Energy
g g g g g mg iu kcal
Milk
Human 88 1.1 3.4 7.4 0.1 28 137 65
Cow’s 87.5 3.2 4.1 4.4 0.8 120 174* 67
Buffalo’s 81.0 4.3 6.5 5.0 0.8 210 160 117
Goat’s 86.8 3.3 4.5 4.6 0.8 170 182 72
Skimmed milk 92.1 2.5 0.1 4.6 0.7 120 — 29
Milk powder
Skimmed milk powder (cow’s) 4.1 38.0 0.1 51.0 6.8 1370 0 357
Whole milk powder (cow’s) 3.5 25.8 26.7 38.0 6.0 950 1400 496
Channa (buffalo’s) 54.1 13.4 23.0 7.9 1.6 480 — 292
Cheese 40.3 24.1 25.1 6.3 4.2 790 273 348
Khoa or mawa (buffalo’s) 30.6 14.6 31.2 20.5 3.1 650 — 421
Cal. caseinogenate + lactic acid = casein + calcium a. Animal must be healthy and clean;
lactate. b. Premises where the animal is housed and milked
Fats are present in emulsion as glycerides of fatty must be sanitary
acids, mainly butyric, oleic, stearic and palmitic acids. c. The milk vessels must be sterile and kept covered
Milk fat is easily digestible. d. The water supply must be safe
Carbohydrate is present in milk as lactose. On fer- e. Milk handlers’ must be free from communicable
mentation, it is converted into lactic acid by Lactobacillus diseases
lactis; the acid coagulates casein, forming curd. f. Milker must wash their hands and arms before
Milk contains most vitamins and all minerals but vita- milking
min C and iron are present only in very small quantities. g. Strict control of milk and milk product processing
It is a rich source of assimilable calcium. h. The distribution of milk must be done under
hygienic condition.
Adulteration of Milk Products
Milk Standards
Adulteration of milk may be defined as addition of any
material to the milk, or removal of any constituent of Detailed food standards have been prescribed under the
milk. The common adulterants in milk include addition Prevention of Food Adulteration Act, 1954, for milk and
of water, sugar, cereal flour, skim milk powder, gelatin, milk products. Some of these are given below.
urea, etc. and removal of fat. The water adulterated • Cow milk: It should not contain less than 3.5% of
milk tests less lactometer reading and less solid not fat milk fat. Solids not fat (nonfat solids) should not be
content (SNF). Adulteration of milk is a punishable less than 8.5%.
offence under the Prevention of Food Adulteration Act • Buffalo milk: Milk fat at least 6% and solids not fat
(PFA Act. 1954). The PFA standards, which are 9%.
mandatory, prescribe minimum compositional • Skimmed milk: Solids not fat at least 8.5%.
standards, standard for levels of residues of chemical • Toned milk: Fat 3%, solids not fat 8.5%.
contaminants and various other provisions. The Milk • Dahi: Standards are same as for the milk from which
and Milk Products Order, 1992 sets sanitary it is prepared.
requirements for dairies, machinery, and premises, and • Khoa: Fat 20%. Should not contain any ingredient
includes quality control, certification, packing, marking other than those in milk.
and labeling standards for milk and milk products. • Icecream: Fat 10%, total solids 36%.
• Cream: Fat 23%, no added substance.
Milk Hygiene
Milk Borne Diseases
Milk is an efficient vehicle for a great variety of disease
agents. The sources these infection may be (i) the diary Diseases which can be directly transmitted through milk
of animal (ii) the human handler or (iii) the environ- are brucellosis, Q fever and anthrax. However,
ment, e.g. contaminated vessels, polluted, water, flies, contaminated milk can also act as a vehicle for other
dust, etc. Following factors should be taken into pathogens and can be responsible for enteric fever,
consideration production processing and distribution of food poisoning and diphtheria.13 Dysentery, diarrhea, 399
milk and milk product. and, potentially, even poliomyelitis and infective
PART II: Epidemiological Triad hepatitis might be transmitted through infected milk. Tests for Freshness
There is no evidence for occurrence of bovine
• Candling: An egg is translucent when sunlight or
tuberculosis in India.
electric light is passed through it. A spoiled egg is
opaque and if there is gas, it is transparent. When
Pasteurization held against light, the yellow is seen floating in the
It is a process by which milk is made free from all white in a fresh egg.
pathogens, including tubercle bacillus, which is killed at • A fresh egg sinks in 10% saline or water and remains
63°C. Most nutrients are preserved during in horizontal, not a tilted or vertical position. If
pasteurization. There are two methods. decomposed, it floats.
1. Holding or holder process: This is the British method
in which milk is heated to and maintained at a MEAT
temperature of 65.5°C or 150°F for half an hour.
Then it is cooled down to 50°F or 10°C. It is a slow The term meat includes all flesh foods such as beef,
method. pork, mutton, poultry, liver, etc.
2. Flash process or high temperature short time
process (HTST): This American method is fairly General Composition
quick. Milk is heated to 71° or 72°C, kept at this
Muscle proteins consist mainly of myosin and small
temperature for 15 seconds, and then suddenly
amounts of albumin and myoglobin. Some meats such
cooled to 10°C.
as pork are rich in fat. Meats, in general, are rich in
Sterilization by boiling. It is a common practice in
vitamin B2, iron and protein (Table 22.7).
India to boil milk. Boiling and pasteurization are
Consumption of infected meat may lead to various
compared in Table 22.6.
diseases. The more important meat borne diseases are
brucellosis, anthrax, food poisoning and infection by
MILK PRODUCTS helminths like Taenia solium, T. saginata and Trichinella
• Cheese: It is a nutritious food consisting mainly of spiralis.
protein (24.1%) and fat (25.1%).
• Butter: It consists of 81% fat, a trace of protein, Cereals and Millets
2.5% minerals and 16 to 20% water. It is rich in
vitamins A and D. In India, cereals like wheat, rice and maize form the
• Ghee: It is clarified butter with less than 0.5% staple food of people. Millets (smaller grains that are
moisture. eaten without removing the outer layer) are also used
• Butter milk: It is the product obtained after removal to a fair extent by some segments of the population.
of butter from curds by churning. More common among the millets are jawar and bajra.
Ragi and kodri are also used by the poor.
Eggs and Meat Cereals and millets are rich in carbohydrates. Being
the staple food, they form the major source of dietary
EGGS protein. They are a good source of minerals and several
An average hen’s egg weighs 50 gm. It consists of 3 parts: B complex vitamins.
1. Shell, 12% by weight.
2. White, 58% by weight, consisting mainly of albumin. WHEAT
3. Yellow, 30% by weight consisting mainly of lecithin,
a phospholipid in finely emulsified form and vitellin, It contains more protein than any other cereal (12%),
a phosphoprotein. but is deficient in lysine which is made up by eating
Egg contains 13.3% protein, 13.3% and 73.7% chapatis with legumes. When milled whole wheat flour
water. Its energy value is 173 kcal per 100 gm. Its is sieved, about 5% bran is removed and the remaining
calcium and iron contents are 60 and 2.1 mg per flour of 95% extraction (atta) is used for making
100 g respectively. Consumption of raw egg may lead chapatis. On straining through cloth, about 10% is
to infection with Salmonella organisms. Boiling removed and the remaining refined flour of 90%
destroys these germs and inactivates avidin (a potent extraction (maida) is used for making bread. Highly
antibiotic factor) as also a trypsin inhibitor found in refined flour is poorer in proteins, minerals and vitamins.
raw egg white. Egg can be preserved by blocking the The high extraction wheat flour is fortified in the western
pores in the shell. This is done by smearing the egg countries with calcium and thiamin to make up for the
with oil or grease, or by immersing it in a solution loss. Semolina (suji), prepared from the outer part of
400 of sodium silicate (glazing). This prevents bacteria wheat, is richer in minerals and vitamins and is used
from entering the egg. for making puddings. Wheat flour contains gluten, a
CHAPTER 22: Food and Nutrition
TABLE 22.7: Nutrient value of different meats per 100 gm
Name of food stuffs Protein Fat CHO Minerals Vit A Thiamine Moisture Energy
gm gm gm gm iu mg gm kcal
Beef (muscle) 22.6 2.6 — 1.0 18 0.15 74.3 114
Fowl 25.9 0.6 — 1.3 — — 72.2 109
Liver, sheep 19.3 7.5 1.3 1.5 690 0.36 70.4 150
Mutton (muscle) 18.5 13.3 — 1.3 9 0.18 71.5 194
Pigeon 23.3 4.9 — 1.4 — — 70.4 137
Pork (muscle) 18.7 4.4 — 1.0 0 0.54 77.4 114
Fish (pomfret) 17.0 1.3 1.8 1.5 — — 78.4 87
sticky protein that makes the dough spongy and Pulses, Oil Seeds and Nuts
stretchable. Maida is rich and suji is poor in gluten.
PULSES (LEGUMES)
RICE Pulses include grams, peas, lentils and beans. They
The grain consists of three parts—embryo, endocarp and contain globulin and a protein called legumin. In
pericarp. The pericarp and embryo contain most of the combination with cereals, they form a good source of
protein, fat, minerals and vitamins. The endocarp mainly all essential amino acids. The protein content of pulses
contains starch. The protein content of rice is 6 to 8.5 is 20 to 22% in general. They supply good amounts
per cent. Though rice contains less protein than wheat, of iron and calcium, as well as thiamine and riboflavin.
rice protein is qualitatively better than wheat protein. Khesari dal (Lathyrus sativus): If taken for a long
The nutrient value of rice depends on the way the time, it gives rise to lathyrism characterized by spastic
husk is removed. Hard milling removes a good part paralysis of lower limbs. The symptoms are due to toxic
of pericarp along with husk (Fig. 22.1). This reduces factor in dal called Beta oxalyl alpha amino oxidase
the nutrient value. Undermilling and hand pounding (BOAA). This cheap dal is mainly consumed by poor
are less damaging. Nutrient loss can be minimized by people in Madhya Pradesh. The toxic principle can be
parboiling of rice. In this process, rice is soaked in removed by parboiling.14 Efforts are being made to
water for 2 to 3 days, boiled or steamed, dried and develop toxin free strains of Lathyrus sativus.
then dusked by hand or machine. As a result of
parboiling, the nutrient rich outer layer (Pericarp) sticks OILSEEDS AND NUTS
to the endocarp and some nutrients diffuse into the Oilseeds and nuts are grouped with pulses because, like
latter. The color and odour are improved if paddy is them, they are a rich source of protein. Oil seeds,
soaked in water at 65 to 67° for 2 to 3 hours only except gingelly or sesame (til), are not consumed as
instead of in cold water for 2 to 3 days. Parboiled rice such. Oil is extracted from them and the oil cake rich
is harder than ordinary rice but is less vulnerable to in protein is fed to cattle. Nuts, on the other hand, are
nutrient loss during cooking. taken as such. They are rich in protein and fat.
Cereals
Wheat atta 12.1 1.7 69.4 2.7 0.49 0.17 341
Maida 11.0 0.9 73.9 0.6 0.12 0.07 348
Rice
raw (milled) 6.8 0.5 78.2 0.6 0.06 0.06 345
parboiled (hand pounded) 8.5 0.6 77.4 0.9 0.27 0.12 349
Maize, dry 11.1 3.6 66.2 1.5 0.42 0.10 342
Jawar 10.4 1.9 72.6 1.6 0.37 0.13 349
Bajra 11.6 5.0 67.5 2.3 0.33 0.25 361
Barley 11.5 1.3 69.6 1.2 0.47 0.20 336
Oat 13.6 7.6 62.8 1.8 0.98 0.16 374
Ragi 7.3 1.1 72.0 2.7 0.42 0.11 328
Pulses
Bengal gram Dal 20.8 5.6 59.8 2.7 0.48 0.18 372
Black gram Dal 24.0 1.4 59.6 3.2 0.42 0.20 347
Green gram (whole) 24.0 1.3 56.7 3.5 0.47 0.27 334
Lentil 25.1 0.7 59.0 2.1 0.45 0.20 343
Rajmah 22.9 1.3 60.6 3.2 — — 346
Redgram 22.3 1.7 57.6 3.5 0.45 0.19 335
Soybean 43.2 19.5 20.9 4.6 0.73 0.39 432
Oil seeds and nuts
Almonds 20.8 58.9 10.5 2.9 0.24 0.57 655
Cashewnut 21.2 46.9 22.3 2.4 0.63 0.19 596
Coconut dry 6.8 62.3 18.4 1.6 0.08 0.01 662
Sesame (til) seeds 18.3 43.3 25.0 5.2 1.01 0.34 563
Groundnut 25.3 40.1 26.1 2.4 0.90 0.13 567
Linseeds 20.3 37.1 28.9 2.4 0.23 0.07 530
Walnut 15.6 64.5 11.0 1.8 0.45 0.40 687
Vegetables form an important part of daily diet. They They include roots and tubers like beet, potato, sweet
fall into three groups—leafy, non-leafy, and starchy. potato, colocasia (ari), yam and tapioca. They are rich
in starch. Most of them are fair sources of vitamin C.
LEAFY VEGETABLES Nutrient values of some vegetables are given in
Table 22.9.
They are cheap protective foods, being rich in minerals
like calcium and iron and vitamins like vitamin A
(carotene), vitamin C, riboflavin and folic acid. It is to Fruits
be noted that green leafy vegetables can also be a fairly Fruits in unripe state are sour because they contain
good source of protein. This is so for two reasons. Firstly, certain acids (tartaric acid in grape and tamarind, citric
the biological value of leaf proteins is quite high. in tomato, lemon, orange and mango, malic acid in
Secondly, though the protein content of fresh leafy apple). On ripening, the acids are converted into sugars
vegetables is low, it is so because of the relatively high (fructose and sucrose) and the fruits become sweet.
water content. This means that dried green leafy Fresh fruits, specially citrus fruits, are good source of
vegetables can be a rich source of protein. For example, vitamin C. Guava and Indian gooseberry (amla) are rich
the protein content of fresh and dried colocasia leaves sources of vitamin C. Papaya, mango and other yellow
is 3.9% and 13.7% respectively.6 Similarly, the values fruits are rich in carotene.
for fenugreek leaves are 4.4% and 19.5% respectively. Most fruits have laxative action because of high fiber
content. About 30 to 40 gm fruits should be included
NON-LEAFY VEGETABLES in daily diet according to the season.6 It is not necessary
They include gourds, bringal (bengan), lady finger to eat costly fruits. In spite of their palatability, the
(bhindi), tomato, cauliflower, pumpkin, carrot, turnip, nutritive value of fruits is low. They mainly provide
radish, etc. (Their leaves in addition, may also form a vitamin C, which, of course, can be obtained from
vegetables, especially the leafy ones. Nutrient values of
402 part of diet). Their carbohydrate content is low (3 to some fruits are given in Table 22.9.
8%) as compared to starchy vegetables.
CHAPTER 22: Food and Nutrition
TABLE 22.9: Nutrient values of vegetables and fruits per 100 gm
Name of foodstuff CHO Protein Ca Fe Vitamin B1 Vitamin B2 Energy
gm mg mg mg mg mg kcal
Leafy vegetables
Bathua 2.9 3.7 150 4.2 0.01 0.14 30
Cabbage 4.6 1.8 39 0.8 0.06 0.09 27
Coriander leaves 6.3 3.3 184 1.42 0.05 0.06 44
Lettuce 2.5 2.1 50 2.4 0.09 0.13 21
Fenugreek leaves 6.0 4.4 395 1.93 0.04 0.31 49
Rape leaves 5.9 5.1 370 12.5 0.01 0.03 48
Spinach 2.9 2.0 73 1.14 0.03 0.26 26
Ash gourd 1.9 0.4 30 0.8 0.06 0.01 10
Bitter gourd 4.2 1.6 20 0.61 0.07 0.09 25
Brinjal 4.0 1.4 18 0.38 0.04 0.11 24
Calabash cucumber (Bottle gourd) 3.5 0.2 20 0.46 0.03 0.01 12
Cluster beans 10.8 3.2 130 1.08 0.09 0.03 16
Cucumber 2.5 0.4 10 0.60 0.03 0.00 13
Drumstick 3.7 2.5 30 0.18 0.05 0.07 26
Knol-khol 3.8 1.1 20 1.54 0.05 0.09 21
Ladies fingers 6.4 1.9 66 0.35 0.07 0.10 35
Pumpkin 4.6 1.4 10 0.44 0.06 0.04 25
Rhubarb stalks 4.3 1.1 120 2.2 — — 26
Carrot 10.6 0.9 80 1.03 0.04 0.02 48
Colocasia 21.1 3.0 40 0.42 0.09 0.03 97
Onion, big 11.1 1.2 47 0.60 0.08 0.01 50
Potato 22.6 1.6 10 0.48 0.10 0.01 97
Radish, white 3.4 0.7 35 0.4 0.06 0.02 17
Sweet potato 28.2 1.2 46 0.21 0.08 0.04 120
Turnip 6.2 0.5 30 0.4 0.04 0.04 29
Fruits
Apple 13.4 0.2 10 0.660 — — 59
Apricots, fresh 11.6 1.0 20 2.2 0.04 0.13 53
Banana, ripe 27.2 1.2 17 0.36 0.05 0.08 116
Ber (Zizyphus) 17.0 0.8 4 0.50 0.02 0.05 74
Dates, fresh 33.8 1.2 22 0.96 — — 144
Grapes (pale green) 16.5 0.5 20 0.52 — — 71
Guava, country 11.2 0.9 10 0.27 0.03 0.03 51
Lemon 11.1 1.0 70 0.26 0.02 0.01 57
Musambi (sweet lime) 9.3 0.8 40 0.7 — — 43
Malta (sweet lime) 7.8 0.7 30 1.0 — — 36
Mango, alphonso
Melon (musk) 3.5 0.3 32 1.4 0.11 0.08 17
Orange 10.9 0.7 26 0.32 — — 48
Orange juice 1.9 0.2 5 0.7 0.06 0.02 9
Papaya ripe 7.2 0.6 17 0.5 0.04 0.25 32
Pears 11.9 0.6 8 0.5 0.06 0.03 52
Pineapple 10.8 0.4 20 2.42 0.20 0.12 46
Pomegranate 14.5 1.6 10 1.79 0.06 0.10 65
Energy intake recommendations are made based on the The energy needs varies with number of factors such
reference man and women whose profile have been as age, sex, body size, physical activity and, climate and
described as follows. altered physiological status such as pregnancy and
According to Indian standard, the reference man lactation. According to Indian standard, the total calorie
is between 18 and 29 years of age and weighs 60 kg intake for an Indian man has been fixed at 2,320 kilo-
with a height of 1.73 m with a BMI of 20.3 and is free calories if he leads a sedentary life. For those with
from disease and physically fit for active work; on each moderate or heavy work, it should be 2,730 kilo-
working day, he is engaged in 8 hours of occupation calories and 3,490 kilocalories respectively. The
which usually involves moderate activity, while when corresponding figures for women are 1,900 kcal, 2,230
not at work he spends 8 hours in bed, 4 to 6 hours kcal and 2,850 kcal. The ideal man (or woman) should
in sitting and moving about, 2 hours in walking and in work for eight hours, sleep eight hours, spend 4 to 6
active recreation or household duties. hours sitting or moving about and two hours in walking/
Reference woman is between 18 and 29 years of active recreation or household duties. Energy needs of
406 age, non-pregnant non-lactating (NPNL) and weighs 55 children and adolescents have been computed for
kg with a height of 1.61 m and a BMI of 21.2, is free reference children and adolescents; these reference
children were assumed to have a moderate daily physical
TABLE 22.11B: Energy requirement of Indian men and women at different ages and body weights
Sex Body Age 18-30 yrs Age 30-60 yrs Age > 60 years
weight
kg Sedentary Moderate Heavy Sedentary Moderate Heavy Sedentary Moderate
work work work work work work work work
kcal kcal kcal kcal kcal kcal kcal kcal
Male 45 1986 2336 2985 2026 2383 3045 1590 1870
50 2096 2466 3151 2078 2444 3123 1688 1985
55 2208 2597 3319 2196 2579 3296 1786 2101
60 2318 2727 3485 2275 2671 3420 1883 2216
65 2430 2858 3652 2359 2736 3547 1981 2331
70 2540 2988 3818 2442 2873 3671 2079 2446
75 2716 3191 4078 2526 2971 3797 2177 2565
Female 40 1577 1856 2371 1714 2016 2576 1477 1737
45 1685 1982 2532 1778 2092 2673 1553 1627
50 1792 2108 2693 1841 2165 2767 1630 1917
55 1899 2234 2854 1905 2241 2864 1706 2007
60 2006 2360 3015 1966 2315 2958 1782 2097
65 2113 2486 3176 2032 2390 3054 1860 2187
70 2220 2612 3337 2095 2464 3149 1936 2277
TABLE 22.14: Consumption units according to age, gender, physiological status and activity
Age group and sex Consumption Units (CU) Age group, gender and Consumption Units (CU)
physical activity
1–3 years (B + G) 0.5 ≥ 18 years Female – Non Pregnant Non Lactating
4–6 years (B + G) 0.7 Sedentary 0.8
7–9 years (B + G) 0.9 Moderate 0.9
10–12 years (Boys) 1.0 Heavy 1.3
10–12 years (Girls) 0.9 ≥ 18 years Female - Pregnant
13–15 years (Boys) 1.1 Sedentary 0.9
13–15 years (Girls) 1.0 Moderate 1.0
16–17 years (Boys) 1.2 Heavy 1.4
16–17 years (Girls) 0.9
≥ 18 years Male ≥ 18 years Female - Lactating
Sedentary 1.0 Sedentary 1.0
Moderate 1.2 Moderate 1.1
Heavy 1.6 Heavy 1.5
408
CHAPTER 22: Food and Nutrition
TABLE 22.15A: Recommended dietary allowances for Indians (Macronutrients and Minerals)
Group Particulars Body Net Energy Protein Visible Fat Calcium Iron
wt. kg kcal/d a g/d g/d mg/d mg/d
Man Sedentary work 2320 25
Moderate work 60 2730 60 30 600 17
Heavy work 3490 40
Woman Sedentary work 1900 20
Moderate work 2230 25 21
Heavy work 2850 30
Pregnant woman 55 +350 82.2 30 35
Lactation
0-6 months +600 77.9 30 25
6-12 months +520 70.2 30
Infants 0-6 months 5.4 92 1.16 - - -
kcal/kg/d g/kg/d
6-12 months 8.4 80 1.69 - 500 46
kcal/kg/d g/kg/d µg/kg/d
Children 1-3 years 12.9 1060 16.7 27 600 09
4-6 years 18 1350 20.1 25 13
7-9 years 25.1 1690 29.5 30 16
Boys 10-12 years 34.3 2190 39.9 35 800 21
Girls 10-12 years 35.0 2010 40.4 35 800 27
Boys 13-15 years 47.6 2750 54.3 45 800 32
Girls 13-15 years 46.6 2330 51.9 40 800 27
Boys 16-17 years 55.4 3020 61.5 50 800 28
Girls 16-17 years 52.1 2440 55.5 35 800 26
a
Rounded off to the nearest 10 kcal/d
Group Particulars Vit. A µg/d Thiamin Riboflavin Niacin Pyridoxin Ascorbic Folate Vitamin Magnesium Zinc
mg/d mg/d equivalent mg/d acid µg/d B12 mg/d mg/d
mg/d mg/d µg/d
Reti- β caro-
nol tene
Man Sedentary 1.2 1.4 16
work
Moderate 600 4800 1.4 1.6 18 2.0 40 200 1 340 12
work
Heavy 1.7 2.1 21
work
Woman Sedentary 1 1.1 12
work
Moderate 600 4800 1.1 1.3 14 2.0 40 200 1 10
work
Heavy 1.4 1.7 16
work
310
Pregnant 800 6400 +0.2 +0.3 +2 2.5 60 500 1.2
woman
12
Lactation +0.3 +0.4 +4 2.5
0-6 months 950 7600 80 300 1.5
6-12 +0.2 +0.3 +3 2.5
months
Contd...
PART II: Epidemiological Triad Contd...
Group Particulars Vit. A µg/d Thiamin Riboflavin Niacin Pyridoxin Ascorbic Folate Vitamin Magnesium Zinc
mg/d mg/d equivalent mg/d acid µg/d B12 mg/d mg/d
mg/d mg/d µg/d
Reti- β caro-
nol tene
Boys 10-12
years 1.1 1.3 15 1.6 40 140 120 9
Girls 10-12
years 1.0 1.2 13 1.6 160 9
Boys 13-15
years 600 4800 1.4 1.6 16 2.0 40 150 0.2 165 11
Girls 13-15 to 1.0
years 1.2 1.4 14 2.0 210 11
Boys 16-17
years 1.5 1.8 17 2.0 195 12
Girls 16-17 40 200
years 1.0 1.2 14 2.0 235 12
410
nutritional status of the child we can use weight for age
Source: WHO38
iron nutrition and prevent iron deficiency anemia. Since • Incorporating heme iron in diet: Iron absorption
2 ml spoon of vitamin A contains 200000 IU and marked * Adolescent girls are given priority
level of 1 ml inside the spoon contains 100000 IU of
In pregnancy IFA tablets are prescribed during the
vitamin A. Vitamin A concentrated solution are kept away
second half of pregnancy. If the mother is diagnosed
from direct sunlight and stored at room temperature in
anemic then 100 mg elemental iron + 500 mcg folic
a cold dark room for a minimum of 1 year. Once the
acid are given twice daily per day for 100 days; one
bottle has been opened, it must be utilized within 6–8
tablet after lunch and one tablet after dinner. The tablet
weeks.
should be taken after meal and warm food or drinks,
especially tea should be avoided for 2 hours after the
Bibliography
intake of tablet. These IFA tablets are also given to family
1. Government of India. Ministry of Health and Family planning IUD (intrauterine device) acceptors.
Welfare, Department of Family Welfare, Child Health Multiple channels and strategies are required to
Division. Nirman Bhawan. New Delhi. address the problem of iron deficiency anemia. Double
fortified salts, sprinklers, ultra rice and other
National Nutritional Anemia micronutrient candidates or fortified candidates are to
Prophylaxis Program (NNAPP) be explored as an adjunct or alternate supplementation
strategy. Two different technologies of fortification of
The National Nutritional Anemia Prophylaxis Program common salt were developed at the NIN, Hyderabad
(NNAPP) was initiated in 1970 to control iron as a long-term strategy to control and prevent iron
deficiency anemia in the vulnerable groups through deficiency anemia in the population. These are (i) iron
daily supplements of iron-folic acid tablets. The fortified salt – common salt fortified with iron; and (ii)
suggested prophylactic doses of iron and folic acid double fortified salt – common salt fortified with iron
tablets were distributed to the high risk groups by the and iodine.58
local health workers. Other sustainable approaches to In depth studies carried out with this strategy have
control anemia are food fortification and dietary clearly shown that fortified salts improve hemoglobin
diversification. status. Dietary diversification to improve absorption of
Infants between 6 and 12 months, school children iron by lowering inhibitor and increasing promoter
6 to 10 year old and adolescents 11 to 18 years old concentrations has been suggested. This may need
have also been included in this program, since sufficient nutrition education and changes in dietary habits of the
evidence shows that iron deficiency affects this age group population.
also. For children 6 to 60 months ferrous sulphate and
folic acid are to be provided in a liquid formulation
containing 20 mg elemental iron and 100 mcg folic acid
Food Hygiene
per ml of liquid formulation. Dispersible tablets have an Apart from diseases due to deficient or excess intake of
advantage over liquid formulation in programmatic food, there are diseases due to food contamination that
conditions.57 occurs during production, storage, transport, cooking
or feeding. In addition, there are diseases due to idio-
DEWORMING AND FOLIFER TABLET syncracy or allergy to certain foods in some individuals.
There may be areas where iron folate tablets may not Food-borne or Food-related Diseases
be effective due to heavy worm infestation. Whenever
there is a history of worm infestation in mother or child, • Diseases due to naturally present poisons in plants
the iron folate tablets should be given after deworming. and animals: Examples are ergot, khesari dal, certain
For pregnant mothers deworming should be done in mushrooms and shellfish. 423
the 2nd or 3rd trimester, but never in 1st trimester. • Diseases due to chemical poisoning of food:
PART II: Epidemiological Triad – Accidental: As in use of insecticides like sodium temperature from 6-7° to 45°C, so refrigeration can
fluoride used for killing cockroaches, ants, etc. prevent their growth. Salmonella, staphylococci and Cl.
The poison resembles flour in appearance. welchii poisoning can be avoided by proper cooking of
– Due to adulteration: For example mixing of food and serving it hot. The time between cooking and
mineral oils and argemone oil to edible oils. serving should be short so as to prevent the growth of
– Intentional: Done with malice (homicidal), e.g. these organisms. If food is stored after cooking, this
mixing of arsenic in milk or other food, or fore- should be done at low temperature or above 50°C. In
thought (suicidal), e.g. taking of potassium order to destroy exotoxins of Cl. botulinum, food should
cyanide, diazinon, etc. be heated to 80°C for 15 to 30 minutes before serving.
• Disease due to biological agents: They may be due This is particularly so in case of canned non-acid foods.
to specific infections, bacterial toxins or parasites. The formation of Cl. botulinum toxins is inhibited in acid
– Due to specific infections: Common ones are foods with pH less than 4.5.
enteric fever, amebiasis, giardiasis and brucellosis. The exotoxin of Staphylococcus is heat stable an is
– Due to bacterial toxins: Food gets contaminated destroyed at 191°C for 30 minutes, which is no possible
with microorganisms, which grow in the food and in practice. Cream and custard filled pastries and dahi
produce toxins. Such food produces symptoms from contaminated milk may cause such poisoning.
of food poisoning. Common contaminants are Hence it is advisable to boil milk and to keep it free
Staphylococcus, Cl. welchii and Cl. botulinum. from growth of germs by refrigeration. Staphylococcal
– Due to parasites: Tapeworms, flukes, roundworm, carriers (often nasal and skin carriers) should not handle
whipworm and trichinellosis spread through food milk and meat preparations.
contamination.
• Diseases due to food allergy: Some persons have in-
Prevention of Adulteration
herent or acquired idiosyncracy to certain foods, i.e.
some foods do not agree with them and if they take Prevention of Food Adulteration Act, 1954 and Preven-
such foods, they get digestive upsets, urticaria or tion of Food Adulteration Rules, 1955 provide for
asthma. The foods to which a person is allergic are prevention of adulteration and inspection of food by
mostly protein in nature such as eggs, fish, shellfish, Inspectors and Health Officers. Poisoning due to
milk and less commonly, pulses and some vegetables commercial fraud is often reported in newspapers. The
and fruits. Act should be strictly explained and regular inspection
of all foods and food establishments should be done.
PREVENTION AND CONTROL
Diseases due to contamination of food can be Control over Food Establishments
prevented by proper food sanitation or hygiene, the
Slaughter houses, flour mills, bakeries, confectioneries,
principles of which are given below. Hygienic
creameries, sweetmeat shops, biscuit factories, icecream
preparation of milk and meat and preservation of eggs,
plants, pasteurizing plants and ice and aerated water
fish and vegetable food has already been discussed
factories are often found in small towns without any
under respective headings.
control whatsoever. In bigger towns, they are controlled
through a licensing procedure but the control is poorly
Protection against Contamination
exercised. The owners, managers and workers are often
Foods, drinks and milk, when produced, stored, indifferent and apathetic to or ignorant of hygienic
transported, cooked or served, should be free from principles. To make them observe or follow the same,
all sorts of contamination with germs or any other harmful the food law administration needs to be strengthened
material. The workers should observe strict cleanliness. by providing more staff as well as stringent punishment.
The utensils should be clean. The kitchen should be
insect-free, rodent-free, dust-free and otherwise clean
in general. Medical examination of workers should be National Nutrition Policy
done to find if they are carriers of some disease like The Government of India announced the National
typhoid and dysentery. If so, they should be stopped Nutrition Policy (NNP) in the second half of 1993. It
from handling food and should be given appropriate is a 22 page document consisting of 12 pages in text
treatment. and 10 pages in annexure and tables, etc. The policy
has been published by the Deptt. of Women and
Protection against Toxins Children, Ministry of Human Resource Development.
Cl. botulinum cannot produce toxin at temperature An extract of the policy is given below. Numbering of
424 below 10°C. Salmonella and staphylococci do not grow the paras and subparas has been retained as in the
at temperature below 5° to 6°C. They can grow at original for purpose of reference.
Introduction country. Nutrition has to be tackled independently, along
433
PART III: Health Statistics, Research and Demography
23 Biostatistics
Any branch of science demands precision for its • To locate, define and measure the extent of
development and medical science is no exception. With morbidity and mortality in the community.
the scientific advances in modern medicine, including • To evaluate the achievements of public health pro-
public health, there has been felt an increasing need grams.
for objectivity, so that data may be properly processed • To fix priorities in public health programs.
and correctly interpreted, leading to conclusions that
may stand the tests of significance. Even before the Sources of Data
observations are made and data collected, experiments
have to be designed and surveys planned keeping in • Experiments performed in the laboratory or in the
mind the subsequent statistical analysis of data. That is wards.
why it is very important for all students and practitioners • Surveys and epidemiological investigations carried
of medicine, especially those of community medicine, out by trained teams in the field to investigate health
to have a working knowledge of biostatistics. The problems.
present chapter can at best be regarded as an • Records like birth and death registers and other
introductory overview of statistics as used in medicine. medical records in hospitals.
It is strongly recommended that the more serious The figures from the above sources are obtained
student should read an appropriate textbook suitable either by measurement or by enumeration. The data
to his taste and needs.1-4 collected by measurement are called continuous data
Statistics is the science of compiling, classifying and as in case of height, weight, blood pressure, etc. The
tabulating numerical data and expressing the results in data collected by counting are called discrete data, e.g.
a mathematical or graphical form. Biostatistics is that the number of persons dying or cured of a particular
branch of statistics concerned with mathematical facts disease. Continuous data are numerically measurable,
and data relating to biological events. Medical statistics such as the height of persons. The term continuous
is a further specialty of biostatistics when the mathe- indicates that there is no natural demarcation between
matical facts and data are related to health, preventive different categories. Thus two persons may be 165 cm
medicine and disease. Vital statistics is that branch of and 166 cm tall respectively, but there may be persons
statistics that deals mainly with births, deaths, human 165.3 cm and 165.7 cm tall between these two values.
populations and the incidence of disease.5 On the other hand, data having an inbuilt natural
First of all, we shall enumerate the uses of biostatistics demarcation are called discrete, such as blood groups
and the sources of data. The subsequent discussion in A, B, O and AB.
this chapter will be related to six topics, viz. Presentation
of statistics, Variability and error, Analysis and interpre- Different Scales of Measurement
tation of data, Sampling, Sampling variations and Tests
of significance. There are four different measurement scales, i.e.
(i) Nominal (ii) Ordinal (iii) Interval and (iv) Ratio scales.
Uses of Biostatistics
NOMINAL SCALE
• To define normalcy
• To test whether the difference between two popu- Nominal scale is the least powerful among all the
lations, regarding a particular attribute, is real or a measurement scales. It is simply a system of assigning
chance occurrence. number to events in order to label them, i.e. assignment
• To study the correlation or association between two of numbers to cricket players in order to identify them.
or more attributes in the same population. Here data is divided into qualitative categories or group
• To evaluate the efficacy of vaccines, sera, etc. by (thus counted data), in other words nominal data can
control studies. be grouped but not ranked. For example, male/female,
urban/rural, right/left, yes/no and 0/1 are examples of
HISTOGRAM
It is a graphic presentation of a frequency distribution
(Figs 23.1 and 23.2). The character of different
groups is indicated on the horizontal axis or abscissa,
while frequency is indicated on the vertical axis or
ordinate. The frequency of each group forms a column
or rectangle. The heights of frequency rectangles vary
and the area of a rectangle represents the frequency.
Such a diagram is called histogram and is made use
of in presenting quantitative data (such as of height in
the frequency Table 23.2).
Frequency Polygon
It is simply a derivation from the histogram obtained
by joining the midpoints of various histogram blocks.
This is clear from (Fig. 23.3). Fig. 23.1: Histogram of height of 100 boys
Frequency Curve
When the number of observations is large, the polygon
loses angulations and it becomes a frequency curve
(Fig. 23.4).
√
∑{x – x}2 TABLE 23.3: Standard deviation of incubation period of a disease
SD or σ = ______________
formula (a)
n–1 Incubation period Deviation from Squares of
mean x = 12 deviations
Summing up the above steps: x x – x = x ( x – x)2 = x2
Where S denotes the sum of series of readings, is 14 2 4
the mean and n is the number of observations. It is seen 10 –2 4
12 0 0
in the formula (a) that the sum of squares has been
11 –1 1
divided by (n – 1) in place of n. This is so because if 13 1 1
we use n as the divider we get the variance and standard
60 0 10
deviation of the universe or the population, while if we
divide by (n – 1), we get the sample variance or standard Using formula (a),
deviation. In medical statistics we are almost always con-
√ √
∑{x – x}2 10
cerned with the sample standard deviation. In a SD = _______________
= ______
n–1 4
statistical sense, the term universe or population refers
to all the different individual values, measurements or
persons, etc. that may potentially exist. A sample is
= √ 2.5 = 1.58
Using formula (b),
drawn from such a population or universe. Thus 100
√
guinea pigs used in an experiment constitute a sample, (∑ x)2
___________
while the universe or population of guinea pigs consists ∑ x2
√
n 730 – 3600/5
of all the guinea pigs of that particular type in the world. SD =
_________________
= __________________
n–1 5–1
√
(∑ x)2
∑ x2 ___________
√
n 10
440 _________________ = _____
= √ 2.5 = 1.58
SD = formula (b)
n–1 4
Example 2. Compare the variability of systolic blood
12
CV in adults = _______ × 100 = 10
120
Thus, variability of blood pressure is found to be more
in adults.
units ( Z =
–X
_________
SD ) from the mean. Z is 0 at the mean.
Z 0.00 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09
0.0 0.5000 0.4960 0.4920 0.4880 0.4840 0.4801 0.4761 0.4721 0.4681 0.4641
0.1 0.4602 0.4562 0.4522 0.4483 0.4483 0.4404 0.4364 0.4325 0.4286 0.4247
0.2 0.4207 0.4168 0.4129 0.4090 0.4052 0.4013 0.3974 0.3936 0.3897 0.3859
0.3 0.3821 0.3783 0.3745 0.3707 0.3669 0.3662 0.3594 0.3557 0.3520 0.3483
0.4 0.3446 0.3409 0.3372 0.3336 0.3300 0.3264 0.3228 0.3192 0.3156 0.3121
0.5 0.3085 0.3050 0.3015 0.2981 0.2946 0.2912 0.2877 0.2843 0.2810 0.2776
0.6 0.2743 0.2709 0.2676 0.2643 0.2611 0.2578 0.2546 0.2514 0.2483 0.2451
0.7 0.2420 0.2389 0.2358 0.2327 0.2297 0.2266 0.2236 0.2206 0.2177 0.2148
0.8 0.2119 0.2090 0.2061 0.2033 0.2005 0.1977 0.1949 0.1922 0.1894 0.1867
0.9 0.1841 0.1814 0.1788 0.1762 0.1736 0.1711 0.1685 0.1660 0.1635 0.1611
1.0 0.1587 0.1562 0.1539 0.1515 0.1492 0.1469 0.1446 0.1423 0.1401 0.1379
1.1 0.1357 0.1335 0.1314 0.1292 0.1271 0.1251 0.1230 0.1210 0.1190 0.1170
1.2 0.1151 0.1131 0.1112 0.1093 0.1075 0.1056 0.1038 0.1020 0.1003 0.0985
1.3 0.0968 0.0951 0.0934 0.0918 0.0901 0.0885 0.0869 0.0853 0.0838 0.0823
1.4 0.0808 0.0793 0.0778 0.0764 0.0749 0.0735 0.0721 0.0708 0.0694 0.0681
1.5 0.0668 0.0655 0.0643 0.0630 0.0618 0.0606 0.0594 0.0582 0.0571 0.0559
1.6 0.0548 0.0537 0.0526 0.0516 0.0505 0.0495 0.0485 0.0475 0.0465 0.0455
1.7 0.0446 0.0436 0.0427 0.0418 0.0409 0.0401 0.0392 0.0384 0.0375 0.0367
1.8 0.0359 0.0351 0.0344 0.0336 0.0329 0.0322 0.0314 0.0307 0.0301 0.0294
2.0 0.0228 0.0222 0.2197 0.0212 0.0207 0.0207 0.0197 0.0192 0.0188 0.0183
2.1 0.0179 0.0174 0.0170 0.0166 0.0162 0.0158 0.0154 0.0150 0.0146 0.0143
2.2 0.0139 0.0136 0.0132 0.0129 0.0125 0.0022 0.0119 0.0116 0.0113 0.0110
2.3 0.0107 0.0104 0.0102 0.0099 0.0096 0.0094 0.0091 0.0089 0.0087 0.0084
2.4 0.0082 0.0080 0.0078 0.0075 0.0073 0.0071 0.0069 0.0068 0.0066 0.0064
2.5 0.0062 0.0060 0.0059 0.0057 0.0055 0.0054 0.0052 0.0051 0.0049 0.0048
2.6 0.0047 0.0045 0.0044 0.0043 0.0041 0.0040 0.0039 0.0038 0.0037 0.0036
2.7 0.0035 0.0034 0.0033 0.0032 0.0031 0.0030 0.0929 0.0028 0.0027 0.0026
2.8 3.0026 0.0025 0.0024 0.0023 0.0023 0.0022 0.0021 0.0021 0.0020 0.0019
2.9 0.0019 0.0018 0.0018 0.0017 0.0016 0.0016 0.0015 0.0015 0.0014 0.0014
3.0 0.0013 0.0013 0.0013 0.0012 0.0012 0.0012 0.0011 0.0011 0.0010 0.0010
Vertical column headed Z gives the Z values up to one decimal point such as 0.1, 0.2, etc. while horizontal values to the right of Z give
the Z values up to two decimal points such as 0.00, 0.01, 0.02, etc.
To know the area or percentage of observation lying beyond the Z value of 1.96, find 1.9 in the Z column at the extreme left and then
read across to the column headed 0.06. The area is 0.025 and hence the percentage of observations will be 2.5%.
Single-tail means the area or observations lying to only one side of the curve mean beyond a defined point.
When Z is +1.5, the area of the curve beyond or the percentage of observation above the value corresponding to Z = 1.5 will be 0.0668
or 6.68%. Similarly, when Z is –1.5 the proportion of observations below the value corresponding to Z will be 6.68%.
Example: If the mean height is 160 cm with SD of 5 cm, calculate the Z value for an observation X 172.9 cm and interpret the result
in the light of UND.
172.9 – 160
Z = _____________ = 2.58
5
The table value for Z = 2.58 is 0.0049. It means only 0.49% observations will exceed height 172.9 cm if heights are normally distributed.
147.1 – 160
Conversely, if the observed X is 147.1 cm, then Z = ______________ = – 2.58
5
The table value for Z = 2.58 is 0.0049. It means only 0.49% observations will be less than height 147.1 cm.
The probability values corresponding to, different Z values (both tails, i.e. probability of an observation being higher or lower than the mean)
are given below:
Z: 1.645 1.960 2.326 2.576 3.291
444 P: 0.10 0.05 0.02 0.01 0.001
Mathematically, it is the root of the sum of the Applications: The ‘t’ test is an accurate method to test
√
(S )2 (S )2
√
For unpaired sample
s2
1 2 s2 1 – 2
= _________ × ___________ _________________________________________
t=
n1 n2 SE of difference between means
2.4 cm while another group of 75 children had mean For paired samples
height 61 cm and SD of 3.1 cm. Is the difference d
between the two means statistically significant? t = _______________
SE of d
The difference between the two means in terms
Where
d = difference in the two values for each pair (total
number of pairs being n).
√
S2 S2 d = mean of the n values for d.
1
_________ 2
= + ________
n1 n2 SD of d
It may be remembered here that SE of d = ________________
√n
√√
{2.4}2 {3.1}2
= ________ + _________ In paired series, the two sets of observations are
50 75 made on the same individuals and the difference is
compared before and after exposure to some factor
= 0.2533 = 0.51 such as a drug. In unpaired series, the observations are
made on two different groups of individuals and the
difference between the two groups is compared.
61 – 59 2
of SE = ____________ = _________ = 3.92 In case of unpaired series, degrees of freedom df =
0.51 0.51 n1 + n2 – 2 while in paired series, df = n – 1. If the
The observed difference is more than 3 times the estimated or calculated ‘t’ value is higher than the tabu-
SE, hence it is highly significant. The area of the normal lated ‘t’ value, the difference is statistically significant; if
curve beyond + 3.92 SD is 0.00005. Hence this it is less, the difference is insignificant.
implies that there is a probability of only 0.00005 or
0.005 percent that the difference of 2 cm between the Standard Error of Proportions
two sample means could be by chance if they were Information is not always quantitative and all data cannot
drawn from the same universe. In other words, there be expressed as measured values. If a quality, attribute
is only a 0.005 percent probability that the two groups or character of a series of persons is described as vacci-
of children belong to the same universe. More simply, nated or unvaccinated, alive or dead, etc. such data,
it might be stated that the difference between the two being qualitative in nature, is presented simply as the
sample means is real and that growth is significantly number counted to be positive or negative for the
more in the second group than in the first (p = attribute. For example, out of 100 persons whose blood
0.00005). groups were typed, 10 were negative. This type of data
is expressed as a proportion by saying that the proportion
‘t’ Test of Rh negativity in the sample is 10/100 or 0.1.
If a sample is divided into two classes only such as
The two tests described above are applicable only to successes and failures, vaccinated and not vaccinated,
large samples. WS Gossett observed that the normal polymorphs and nonpolymorphs, etc. it is called a
distribution gives biased results in case of small samples. binomial sample having binomial classification (binomial
He demonstrated that the ratio of the observed means divided into two classes.). If the sample is divided
difference between ‘two values to the SE of difference into more than two classes such as blood groups A, B,
follows a distribution called ‘t’ distribution and such a O and AB or WBC types polymorphs, lymphocytes, 445
ratio is denoted as ‘t’. eosinophils, etc. the sample is called multinomial.
PART III: Health Statistics, Research and Demography APPENDIX 23.2: Table of ‘t’ Example 5. 30 out of 100 persons in a sample had
Probability of larger value of ‘t’ blood group A. Find the SEP and the 95 percent limits
DF 0.10 0.05 0.02 0.01 0.001 of confidence. Could this sample be from a universe in
1. 6.31 12.71 3.82 63.66 636.62 which the prevalence of blood group A is 40 percent ?
2. 2.92 4.30 6.97 9.93 31.60 p = 0.3 q = 1 – 0.3 = 0.7 n = 100
3. 2.35 3.18 4.54 5.84 12.92
√ _______ = √
pq 0.3 × 0.7
4. 2.13 2.78 3.75 4.60 8.61 ________
SEP = = 0.0458
5. 2.02 2.57 3.37 4.03 6.87 n 100
6. 1.94 2.45 3.14 3.71 5.96
95% confidence limits = 0.3 + 2 × 0.0458
7. 1.90 2.37 3.00 3.50 5.41
8. 1.86 2.31 2.90 3.36 5.04 i.e. 0.3916 and 0.2084
9. 1.83 2.26 2.82 3.25 4.78
Since the proportion 0.4 is outside the 95 percent
10. 1.81 2.23 2.76 3.17 4.59
confidence limits we can say with 95 percent confidence
11. 1.80 2.20 2.72 3.11 4.44
that the sample is not drawn from a universe having
12. 1.78 2.18 2.68 3.06 4.32
40 percent prevalence of blood group A.
13. 1.77 2.16 2.65 3.01 4.22
14. 1.76 2.15 2.62 2.98 4.14
15. 1.75 2.13 2.60 2.95 4.07 Standard Error of Difference
16. 1.75 2.12 2.58 2.92 4.02 between Two Proportions
17. 1.74 2.11 2.57 2.90 3.97
18. 1.73 2.10 2.55 2.88 3.92 This test measures the probability of chance occurrence
19. 1.73 2.09 2.54 2.86 3.88 of a particular difference between two sample propor-
20. 1.73 2.09 2.53 2.85 3.85 tions. If the observed difference between two
21. 1.72 2.08 2.52 2.83 3.82 proportions (p 1 – p 2) is more than twice the SE of
22. 1.72 2.07 2.51 2.82 3.79 difference, it is significant at 95 percent confidence
23. 1.71 2.07 2.50 2.81 3.77 level.
24. 1.71 2.06 2.49 2.80 3.75 The appropriate formula for calculating the SE of
25. 1.71 2.06 2.49 2.79 3.73 difference between proportions is as follows:3
}
26. 1.71 2.06 2.48 2.78 3.71
{
√
1 1
27. 1.70 2.05 2.47 2.77 3.69 SE of difference between proportions = pq ___ + ___
28. 1.70 2.05 2.47 2.76 3.67 n1 n2
29. 1.70 2.05 2.46 2.76 3.66
30. 1.69 2.04 2.46 2.75 3.65
40. 1.68 2.02 2.42 2.70 3.55
Where n1 and n2 represent the total number in each
60. 1.67 2.00 2.39 2.66 3.46
120. 1.66 1.98 2.36 2.62 8.37
sample and
∝ 1.65 1.96 2.33 2.58 3.29
r1 + r2
p = _____________
The table gives the probability of observing a higher ‘t’ value by chance n1 + n2
at particular degrees of freedom. The probability of observing a value off
greater than 2.95 at 15 degree of freedom is 0.01 or 1%. Once this formula is applied and the null hypothesis
is rejected, then the formula for SE of difference
The proportions of positive and negative attributes between proportions for fixing the confidence limits is
or classes in a binomial sample are expressed as: as follows:3
√
pq Pq
1 1 2 2
SE of difference in proportions = _________ + __________
r Number having a specific character n1 n2
p =___________ =_______________________________________________
n Total number in the sample
However, both these methods give closely similar
p is the probability of occurrence of the positive results. It is common to use only the second formula
attribute such as attacked, vaccinated, etc. and q (= given above for both purposes since it is often more
1 – p) is the probability of non-occurrence of the same convenient, though not logical.2
attribute such as not attacked, unvaccinated, etc. Example 6. Suppose cholera mortality in one
The concept of standard error of proportion (SEP) and sample of 50 is 7 and in another sample of 50 it is 18.
its derivation is similar to that of standard error of the mean. Find SE of difference between proportions. Is the
Sample proportions also follow normal distribution. difference in mortality rates significant?
7
√
pq ________
_______ For sample 1, p1 = = 0.14 q1 = 1 – 0.14 = 0.86
SEP = where p is the positive attribute 50
446 n
For sample 2, p2 = 18 ÷ 50 = 0.36
and q = 1 – p. q2 = 1 – 0.36 = 0.64
SE of difference between p1 and p2 III and IV among smokers and nonsmokers.
√
p1 × q1 P2 × q 2
= + the number of columns (c) and rows (r) in a table by
n1 n2 the formula: DF = (c – 1) (r – 1)
In a 2 × 2 table the degrees of freedom will be
√
0.14 × 0.86 0.36 × 0.64 (2 – 1) × (2 – 1) = 1.
= ×
50 50 Example 7: An experiment was carried out aimed
at assessing the efficacy of neomycin in preventing
= √ V.00241 + 0.00461 = √ 0.00702 = 0.0838 staphylococcal cross-infection during first 14 days after
burns. Infection developed in 18 of 30 patients whose
It may be mentioned that using the formula
burns were dressed with penicillin cream compared to
{ }
√
1 1 5 out of 33 patients in whom both penicillin and
pq ___ + ___
n1 n2 neomycin were used. What conclusion will you draw
from this data?
First we prepare the contingency in Table 23.4 as
It may be mentioned that using the formula the SE below:
of difference between proportions p 1 and p 2 is In the four-cell contingency table above, the
computed as 0.0866 which is close to 0.0838. The observed frequency 0 in the cells a, b, c, d is 5, 28,
difference in mortality rates is more than twice the SE 18 and 12 respectively. The expected frequency E,
of difference, hence it is significant at 95 percent assuming no association (i.e. no effect of neomycin) for
confidence level. each cell, is calculated by using the following formula:
The above two tests related to proportions are row total × column total
applicable in case of large samples. For small samples, E = ____________________________________
the Chi-square test is usually applied. However, the results total no. in the sample
of both tests are the same. Thus E in cell (a) = 33 × 23 ÷ 63 = 12.05
The chi-square value for each cell is calculated
(O – E)
χ2) Test
Chi-Square (χ by using the formula χ2 = ___________
E
χ is a Greek letter, written as chi and pronounced as
The total of chi-square for all the four cells is then
Kye. χ2 test was developed by Karl Pearson and is an
calculated as follows:
important test of significance. It involves calculation of
a quantity called χ2. This test is applied to rule out {O – E}2 {5 – 12.05}2 {28 – 20.95}2
χ2 = _____________ = ________________ + __________________
chance or to estimate the probability of chance E 12.05 20.95
occurrence of a difference as described below. {18 – 10.95}2 {12 – 19.05}2
+ ______________________ + ______________________
1. To find if the difference between two proportions is 10.95 19.05
real or by chance as described above.
= 4.1247 + 2.3724 + 4.5390 + 2.6090 = 13.6451
2. To find any association between two attributes occur- To find the significance of the calculated χ2 value,
ring together such as cancer and smoking, age and blood we refer to the χ2 table and find the tabulated χ2 value
pressure, parity of mother and weight of the newborn, corresponding to a given probability like 0.05 or 0.01
etc. The test measures the probability of association by against the appropriate degrees of freedom. The
chance. According to null hypothesis the assumption of tabulated value of chi square at probability 0.05 (5%
no association or independence is made. If the χ2 value level) and 0.01 (1% level), against 1 DF is 3.84 and
is higher than that given in the χ2 table against a
probability of 0.05, for the particular degrees of TABLE 23.4: An experiment showing the contingency of
freedom, the association is not apparent but real, at 5 the application of antibiotics
percent level of significance. Then null hypothesis is Antibiotic Staphylococcal Infection not Total
rejected and we conclude that the two attributes or applied infection acquired
events are dependent on each other. acquired
The first requirement for the application of chi- (a) (b)
square test is making a contingency table of the Penicillin cream O 5.00 O 28.00 33
observed frequencies. Expected frequencies are plus neomycin E 12.05 E 20.95
calculated on the assumption of no association. If there (c) (d)
are only two events and 2 groups or classes it is called Penicillin cream O 18.00 O 12.00 30
a 2 × 2 or four-fold or four-cell contingency table. alone E 10.95 E 19.05 447
Often the groups are more, such as social classes I, II, Total 23.00 40.00 63
PART III: Health Statistics, Research and Demography 6.64 respectively, while the calculated value is 13.64 in It is very important to remember that the chi square
our example. It is much higher than the tabulated χ2 test is applied to actual numbers and not to percentages.
value at both the levels, so the null hypothesis is The reason would be clear from the following: Suppose
rejected. The difference between the effect of two drugs the town referred to in the above example were a fairly
combined and that of penicillin alone is significant and big one so that 5200 male and 4800 female babies were
we conclude that addition of neomycin is more born, the expected frequency in each case being 5000,
prophylactic against staphylococcal infections. assuming null hypothesis. Then:
(Interpretation: There are two classes, hence degrees The table gives the highest values of χ2, at particular degrees of
freedom, corresponding to probability P of occurrence by chance in
of freedom = 2–1 =l. χ2 with 1 degree of freedom at nature. For example, at 10 degrees of freedom, χ2 value larger than
5 percent level of significance = 3.841. The calculated 18.31 will occur less than 5 times in 100 (P) and is interpreted as
448 value of χ2 is much less and is hence insignificant. The significant at 5% level.
observed difference in sexes is by chance).
Correlation Coefficient Regression Coefficient
449
24 Research Methodology
Research is a systematic process aimed at obtaining new activities? Because, health is serious business and a
knowledge through verifiable examination of data and costly one. Interventions related to people’s health
empirical testing of hypothesis. Research activities are must be based upon sound principles and practices
directed towards finding answers, seeking solutions or which must be continuously and critically evaluated.
looking for improved designs of functioning. Very often, Knowledge of research methodology is important for
no positive results emerge and a probable hypothesis a doctor because in his professional career at a later
may be negated. This in no way undermines the effort. date, he is often called upon to evaluate and sit in
In general, research activities in community medicine are judgment whether in a teaching role, services role or
more concerned with ‘applied’ aspects but basic research administrative role.
can also be undertaken. Research tends to minimize or negate bias. Scientific
As against research in many subjects which are techniques help one to perceive the true dimensions
undertaken on a philosophical or intellectual level, i.e. of a problem or a situation. Research pinpoints
concerned with knowledge for its own sake, research in reasons for observed differences between two
community medicine is warranted only for the purpose populations or groups. Research provides answers to
of gathering knowledge or information for improving the questions relevant to daily living. Is there any danger
health of the community or for improving the service if I consume iodised salt everyday? What should be
delivery network, i.e. operations research. This research the level of fluoridation of water supplied? Can I have
should not be carried out just for the sake of collecting two pegs of whisky every evening? At what age should
data. Medical sciences in general, and community my daughter be given a dose of MMR? Is there any
medicine in particular, deal with human beings. Hence benefit of substituting coconut oil with cotton seed oil
ethical considerations demand that research procedures for my cooking? And many more. There is no end to
are benign and harmless. The importance of ensuring research applications.
this will be obvious if one remembers that very often the
subjects are diseased people in their natural community
environs. Purpose of Research and
The basic unit of interest in community medicine is Broad Areas of Research
the community or a population group. This implies that
research priorities and interests often centeron health As already mentioned, the reasons for undertaking
problems and perceptions of population groups. In research are manifold. The broad research area is
contrast, hospital or laboratory data are sufficient for determined by the purpose of undertaking research.
designing research related to other medical disciplines. Generally speaking, there are two broad areas of medical
Critical thinking, the quality of inquisitiveness, a desire research.
to examine and verify statements rather than accepting
everything at face value as true and correct, are crucial Exploratory Research
for undertaking research in all fields. It should also be
remembered that there is no end point or finite limit Exploratory research is undertaken to gain new insights
for research horizons. Science is a logical discipline and or to standardize procedures for more widespread
unravels the rationale of phenomena. Thus each application. This is often undertaken to formulate a more
research solution throws up new challenges. As Max precise research problem or to develop a hypothesis.
Webber said, ‘Every scientific fulfilment raises new Examples of such types of research in medical sciences
questions—it asks to be surpassed and outdated’. A are standardization of reagents, chemicals, procedures
research scientist should always keep his third eye open; (Fluorescein angiography in diabetic retinopathy, Sputum
he should be observing even when asleep. microscopy in tuberculosis, Standardization of OPV),
Why should anybody concerned with the health of etc. where the accent is on augmenting skills or
population groups bother himself about research procedures.
Observational Research based research methods. Epidemiological studies, which
This is the most important section of the research These relate to operational aspects of a health program
protocol as it explicitly sets out how the protocol is to or facility. Observational element is an important aspect
be implemented. The following items of research design of these. Time-motion studies are a good example.
have to be carefully addressed:
SELECTION OF RESEARCH SETTING
SELECTION OF RESEARCH STRATEGIES
This includes all pertinent aspects such as characteristics
This is probably the single most important decision that of the study population, the place and time of the study
has to be made. Various strategies are described below. and the ethical considerations. The latter are described
The appropriateness of a particular strategy will depend a little later.
upon the problem to be researched.
SAMPLING CONSIDERATIONS
Descriptive Strategies
The best method of studying a population is by complete
These generate hypotheses rather than test them. Their enumeration of all units. This is not operationally feasible
nature will become clear by having a look at the because of financial and time constraints. Hence
following examples: adequate samples are drawn which are representative
• Descriptive cross sectional surveys including KAP of all units in a population. A consideration of sampling
studies. techniques deals with the following:
• Disease description by time, place and person. • Selection of appropriate sampling methods: Simple,
Changing patterns of health and disease over time. random, systematic or stratified random sampling,
• Community diagnosis of a health problem. multiphase, multistage, cluster sampling, etc.
• Assessment of community perceptions and needs. • Determination of appropriate sample size: It is the
• Studies of existing data—case series, disease smallest number of units that is required to be
registries, surveillance records, hospital inpatient studied for getting statistically valid results. Sample
data, etc. size depends upon the parameter measured and the
• Studies on the natural history of disease. research design chosen. As a general rule more the
variance or standard deviation, more the sample size.
Observational Analytical Strategies • Minimizing sampling errors: By ensuring represen-
tativeness and reliability of the sample.
These are useful in testing formulated hypotheses. These
may be of the following types: CONTROLS
• Prospective study (cohort study)
• Historical cohort study Controls are used to increase the validity of results.
• Retrospective study (casecontrol study) Controls are comparable units drawn from similar popu-
• Analytical cross-sectional studies lation groups which are similar in most respects except
• Follow-up studies (either longitudinal studies or that exposure to the risk factor or disease condition is
cross-sectional studies repeated at intervals). lacking. Controls should be matched on as many of the
confounding variables as possible. For example, they
may be drawn from the general population, other family
Experimental Strategies
members or hospitalized patients not afflicted by the
The experimental setting may vary from a closed same disease.
laboratory background to an open-field background as In experimental situations, “controls” are those indi- 457
listed below: viduals who are not administered an experimental
PART III: Health Statistics, Research and Demography stimulus (for example, individuals given placebo in A pilot study can also be utilised for determining the
contrast to individuals receiving the trial drug, who sample size. In many situations, information on the
constitute the experimental group). When cause and prevalence and other variables of a disease (which is
effect relationships are not being considered, there is essential for determining the sample size) is not available.
no need for a control group. The pilot study can be used to obtain such information.
If a pilot study shows that certain components are
DESCRIPTION OF STUDY INSTRUMENTS not feasible, a modification should be incorporated in
the research design. The modified research plan should
The study instruments used in research protocols have again be validated through a pilot study before the
already been discussed. The questionnaires, interview main research protocol is implemented.
schedules, other methods of observation and the
recording forms, etc. should be explained in detail. DESCRIPTION OF PLANS FOR DATA ANALYSIS
AND INTERPRETATION OF RESULTS
DESCRIPTION OF DATA COLLECTION
The plan for analysis of data is an integral part of the
The method of collection of data should also be spelled research design and should be incorporated into the
out in full detail. How the community would be research proposal itself. Preparing such plan helps the
approached, how investigators would be selected, how investigator in avoiding several pitfalls, such as,
their training needs would be assessed and how they discovering at the end of the study that some needed
would be trained — all these aspects need to be information has not been collected, or that the
described. So also, there is a need to specify job information collected is not appropriate for statistical
responsibilities of each member of the data collection
analysis. The description should include the following:
team, methods of supervision and cross checking and
• Design of the forms for data processing.
the logistic support and supplies. Persons responsible for
• Overall data processing plan and a statement
field verification of data should be identified. Large
whether the data will be processed by hand or by
studies should be preceded by a pilot study which
computer.
should include pretesting of forms and schedules.
• Pretests: Pretesting is the system of validating the • Coding plan in case of computer processing.
study instruments and procedures. It is a method of • Personnel to be involved in verification of data, data
standardization of the instrument as well as the entry and handling and data retrieval.
personnel who will administer the instrument. • Choice of statistical methods to be employed.
Pretesting helps in the following ways:
– It tests the clarity of the framed questions. It REPORTING AND PUBLISHING OF RESULTS
examines whether the questions in the form are The prime aim of undertaking research is to validate
understood similarly by many people or whether selected hypotheses and to disseminate information
their perceptions vary greatly. In India, question- which will be useful for future research. The scientific
naires and schedules have often to be translated community at large should be able to benefit from the
into local languages. Hence it is desirable to see research results. Hence a comprehensive report is
whether the translation agrees with the original. desirable and wide dissemination, using all available
– It tests acceptability of the questions. It looks into channels of communication, is essential.
whether people answer the questions happily or
whether they take offence to some questions.
– It tests logical sequencing of questions. Ethical Considerations in Research
After pretesting, the questionnaire should be
modified in the light of the experience gained. Any research activity conducted in a human population
• Pilot studies: A pilot study is akin to a fulldress has to be carefully reviewed in terms of ethical
rehearsal. It can be defined as a program of implications. Once a community participates in a
predetermined duration and on a restricted scale research project, it logically expects some corollary
which should serve as a model for extended or medical benefits to accrue. Some part of the budget
general application, if it proves to be feasible, should be earmarked for this purpose.
effective and sufficiently efficient. A pilot phase helps Since most persons in a general population do not
to validate whether all components of the system are suffer from a disease condition, it is essential that the
functioning smoothly or not. The pilot phase should examination procedures used in the study are completely
have a duration long enough to detect weaknesses harmless and noninvasive.
and constraints in the system. Pretesting of the A careful consideration of what is to be done for
instruments and procedures should have been those people who were not selected in the final sample
458 completed before embarking on the pilot is also important. Any intervention in the community
study. should not be restricted solely to those who were
sampled or who participated in a trial. At the information on procedures, risks and affects should
459
25 Demography and Vital Statistics
Growth of population can be measured by growth rate, DOUBLING TIME OF WORLD POPULATION
which is calculated by the difference between the crude (TABLE 25.3)
birth rate and crude death rate expressed as percentage.
The three most populous countries of the world today
are China, India and USA, with populations of 1285
Population Trends in the World million (2001), 1027 million (2001) and 286 million
World population was about 250 million 2000 years ago (2001) respectively. Four fifths of the world population
and 1000 million 200 years ago. Thus it took 1800 years lives in the developing countries of Asia, Africa and Latin
for a four times increase. Interestingly, the further America. The high growth rate in developing countries
quadrupling of population to 4000 million took only 75 accounts for the major portion of population increase
years. World population reached 6.1 billion by mid 2000 in the world as seen in Table 25.4 on World Population
and is currently growing at an annual rate of 1.2% or Growth Trends.
77 million people each year. Six countries account for The annual world population growth rate was
around 0.5% during the last two centuries, and
half of this annual growth—India for 21%, China for
increased to about 1% during the middle of the present
12%, Pakistan for 5%, Nigeria for 4%, Bangladesh for
century. It reached its peak in 1970, at 1.92%. It has
4% and Indonesia for 3%. By 2025 AD, the world
been gradually declining since then. In 2001 it has come
population is expected to be between 7.9 billion (low
down to 1.2%.
projection) to 10.9 billion (high projection). The
population of the more developed countries which is
currently 1.2 billion, is not expected to change much over Population Trends in India
the next 50 years. In fact, for 39 countries, including
Growth of population in India since the beginning of
Japan, Germany, Hungary, Italy, Russia, Ukraine,
this century is seen in Table 25.5 “Population of India
Georgia, the population is expected to decrease. At the
(1901-2001)”. It is obvious that we are adding 1.6
same time, the population of the less developed countries
corer people every year, equivalent to the combined
is projected to rise steadily from 4.9 billion in 2000 AD
population of Haryana and Himachal Pradesh.
to 8.2 billion by 2050 AD. If fertility levels do not come
Some important features in the population profile
down, it may increase to 11.9 billion.2
of India are summarized below. The urgency of
reducing population growth is obvious from the fact that
ESTIMATES OF WORLD POPULATION (TABLE 25.1) India has only 2.4% of world’s land area, yet sustains
What is the cause of this rapid increase in population 16% of world population.
in the present century from 1.6 billion in 1900 to more
TABLE 25.2: Relation between population growth rate and
than 6 billion estimated in 2000 AD? For understanding doubling time
this, the concept of “doubling time” is useful. Doubling
Annual growth rate (%) Doubling time (years)
time implies the time needed for the population to
double. More the growth rate of population, less the 1.5-2.0 35-47
doubling time. It is seen from the table above that 1.0-1.5 47-70
0.5-1 70-139
annual world population growth rate had always been
TABLE 25.1: Estimates of world population TABLE 25.3: Doubling time of world population
Population (billions) and years Doubling time (years)
Years Population (Billions) Annual growth rate (%)
From To
1750 0.8 —
0.8 1.6 150
1800 1.0 0.4
(1750) (1900)
1850 1.3 0.5
1.25 2.5 100
1900 1.6 0.6
(1850) (1950)
1950 2.5 1.1
2.5 5.0 37
1975 4.1 1.89
(1950) (1987)
1987 5.0 1.63
3.0 6.1 40
2000 6.1 1.2
(1960) (2000)
461
Note: 1 billion = 1000 million
PART III: Health Statistics, Research and Demography TABLE 25.4: Comparison of population characteristic between developed and developing countries
Sharing of population About 80% of world popn live in developing 20% of world popn live in this area
countries (Asia, Africa and latin America) India
(16%) and China (20%)
Age sex composition Young age group (<14 year) constitute 39 % of Young age group (<14 yr ) constitute 23 % of population.
(Population pyramid ) population. High working group of population 15- 50 yrs consist of 12 %. Grater proportion of geriatric
(low dependency ratio) represent both a popn Narrow base with bulge in middle
challenge and opportunity.Broad base with
tapering tip (India)
Sex ratio Adverse to female (940/1000 male as Favorable to females
per 2011 census)
population density Higher Low
Family size ( TFR ) Fairly high in India (4.5) Smaller, Switzerland (1.5)
Population Profile of India3 • Low death, though high infant and child
• Large population base mortality.
[2.4% of land area and 16% of world population]. • High morbidity of mothers and children
• Rapid population growth and low economic • High rate of urbanization
development • Sex ratio unfavorable to females.
• Young age distribution – 940 females per 1000 males in 2011.
• Low female age at marriage In view of this urgency, definite demographic
[1981:% married, 10 to 14 years 6.2, targets to be achieved were fixed at the national level
15 to 19 years 43.4]. for 1990 and 2000. These targets, and the extent to
462 • High fertility and typical reproductive pattern which these have been realized, are shown below in
[4.0 births; too early and too frequent]. Table 25.6.
change in the marital status. The concerned events are
Approximate interval
CAUSE OF DEATH between onset and death
I
Disease or condition directly leading to death* a. Bronchopneumonia due to (or as consequence of)
Antecedent causes b. Due to (or as a consequence of)
c. Strangulated hernia
Morbid conditions, if any, giving rise to the above
cause, stating the underlying condition last
II
Age group Mid-year’s Deaths during Age-specific Standard population in Expected deaths
population the year death rate per 1000 thousands (proportionate to in standard
(Study area) (Study area) all India pattern) population
0-4 12000 120 10.0 14500 145.00
5-14 6000 20 3.7 27500 101.75
15-19 8000 25 3.1 8700 26.97
20-24 6000 25 4.1 7900 32.39
25-34 12000 40 3.3 14000 46.20
25-44 13000 75 5.8 11200 64.96
45-54 12000 150 12.5 7900 98.75
55-64 10000 200 20.0 4900 98.00
65+ 6000 500 83.3 3400 283.22
A B C D E
Age group (years) Mid-year population Deaths during Age-specific death rates in Estimated no. of deaths in the
in the area studied the year the standard population* study population (B × D)
0-14 12000 120 38.4 460.8
5-14 6000 20 2.8 16.8
15-19 8000 25 2.3 18.4
20-24 6000 25 3.1 18.6
25-34 12000 40 3.3 39.6
35-44 13000 75 4.9 63.7
45-54 12000 150 10.6 127.2
55-64 10000 200 26.1 261.0
65 + 6000 500 77.9 467.4
All ages 85000 1155 1493.5
TABLE 26.1: Health related investment pattern in various five-year plans (in crores of rupees)6
Plan Years Health Family welfare 3 + 4 Water supply Total plan 5 as % of 7 5 + 6 as % of 7
and sanitation expenditure
1 2 3 4 5 6 7 8 9
I 1951-56 65.2 0.1 65.3 11.0 1960.0 3.3 3.9
II 1956-61 140.8 2.2 143.0 74.0 4672.0 3.1 4.7
III 1961-66 225.9 24.9 250.8 110.2 8576.5 2.9 4.2
IV 1969-74 335.5 278.0 613.5 548.0 15778.8 3.9 7.4
V 1974-79 760.8 491.8 1252.6 1107.5 39426.2 3.2 5.99
VI 1980-85 2052.2 1387.0 3412.2 3996.9 109291.7 3.1 6.7
VII 1985-90 3688.6 3120.8 6809.4 7093.1 218729.6 3.1 6.4
VIII 1992-97 7575.9 6500.0 14075.9 2514.4 798000.0 1.76 6.2
IX 1997-2002 5118.2 15120.2 20238.4 39538.0 859200.0 2.35 4.6
Note:
• In addition to the above, the Planning Commission made a special allocation of Rs.1740.2 crores for nutrition in the VII Plan
(Rs. 238.1 crores in the VI Plan).
• The periods 1966-69, 1979-80 and 1990-92 were covered by Annual Plans 479
PART IV: Health Care and Services TABLE 26.2: Per capita public health care expenditure 7. Streamlining of the Public Distribution System with
States Male Female focus upon the poor.
1996-2001 2001-2006 1996-2001 2001-2006
Performance in States with Poor Health Indices: Chapter 1: Objectives, Targets and Strategy
There are substantial differences in performance between
States. The performance of the four demographically INTRODUCTION
poor states is shown in the given figures. In UP there
has been a decline in the number of sterilizations but The Tenth Five-year Plan (2002-07) is being prepared
Rajasthan has shown an increase in the number of against a backdrop of high expectations arising from
acceptors of terminal methods. The acceptors of spacing some aspects of the recent performance. GDP growth
methods have also increased in the state of Rajasthan; in the postreforms period has improved from an average
remained almost at the same level in Bihar and of about 5.7 percent in the 1980s to an average of
marginally declined in MP and UP in 1998-99 as about 6.5 percent in the Eighth and Ninth Plan
compared to the previous year. periods, making India one of the ten fastest growing
developing countries. Encouraging progress has also
It is noteworthy that these four states have the
been made in other dimensions. The percentage of the
largest proportion of unmet needs for family planning,
population in poverty has continued to decline, even
both for terminal and spacing methods: This unmet
if not as much as was targeted. Population growth has
need has to be met by improving availability, access and decelerated below 2 percent for the first time in four
quality of care of family welfare services. decades. Literacy has increased from 52 percent in
Containment of population growth is not merely a 1991 to 65 percent in 2001 and the improvement is
function of couple protection or contraception but is evident in all States. Sectors such as software services
directly correlated with female literacy, age at marriage and IT enabled services have emerged as new sources
of the girls, status of women in the community, IMR, of strength creating confidence about India’s potential
quality and outreach of health and family planning to be competitive in the world economy.
services and other socioeconomic parameters. This is
illustrated in Table 26.3. OBJECTIVES OF THE TENTH PLAN
Traditionally, the level of per capita income has been
INDIAN SYSTEMS OF MEDICINE
regarded as a summary indicator of the economic well
AND HOMEOPATHY
being of the country and growth targets have therefore
The Indian Systems of Medicine and Homeopathy focused on growth in per capita income or per capita
consist of Ayurveda, Siddha, Unani and Homeopathy, GDP. In the past, our growth rates of GDP have been
and therapies such as Yoga and Naturopathy. Some of such as to double our per capita income over a period
these systems are indigenous and others have over the of 20 years or so. Recognizing the importance of making
years become a part of Indian tradition. It is estimated a quantum jump compared with past performance, the
that there are over 6 Indian Systems of Medicine and Prime Minister has directed the Planning Commission
Homeopathy. to examine the feasibility of doubling per capita income
States CBR (1999) IMR (1998) Female literacy Population% Female Female Median age at first
rate (2001) below poverty Mean age Median age at cohabitation with
line (1993-94) at marriage marriage (1998-99) husband (1998-99)
(1) (1) (2) (3) (4) (5) (5)
Bihar 31.1 67 33.57 54.96 18.6 14.9 16.6
Kerala 18.2 16 87.86 25.43 22.3 20.2 20.3
MP 30.6 97 50.28 42.52 18.8 14.7 16.0
Maharashtra 22.3 49 67.51 36.56 19.1 16.4 16.7
Rajasthan 31.5 83 44.34 27.41 18.4 15.1 16.4
Tamil Nadu 18.9 53 64.55 35.03 20.2 18.7 18.8
UP 32.4 85 42.98 40.85 19.5 15.0 16.3
India 26.1 72 54.28 36.00 19.4 16.4 17.0
1. Annual Report, Ministry of Health and Family Welfare 2. Census of India; Registrar General of India, 2001.
484 3. Planning Commission IX Plan Volume 1; 1996 4. SRS, 1994
5. National Family Health Survey-II; 1998-99.
in the next ten years. With population expected to grow well-entrenched infrastructure in the public health
Years No. of medical No. of students No. of students This has been already emphasized earlier. What we need
colleges* admitted qualified today is not to produce more doctors but to deploy
them in such a way as to remove the regional and
1947 25 1983 959
urban rural imbalances.
1960-61 60 5874 3387
1965-66 87 10620 5387
1970-71 95 12029 10407 ANOMALIES REGARDING JOB OPPORTUNITIES
1975-76 106 11213 11982 A good manpower policy should ensure that only that
1980-81 109 11431 12170
much number of professionals are trained as are needed
1985-86 122 12017 11470
1990-91 128 11389 —
and can be gainfully employed. An idea of the
2000-01 175 18000 — proportion of unemployed doctors can be had from the
ratio of those registered with the employment exchanges
*Till 1980-81, only those recognized by MCI From 1980-81 onward to those registered with the respective professional
includes unrecognized colleges also.
council. This ratio is 8.6 percent in case of doctors
(33,583 out of 3,91,226) and 3.2 percent in case of
TABLE 26.5: Physician and beds per 1000
population in selected countries
nurses.6 It is important that job opportunities should be
created in rural areas where the population: doctor ratio
Countries No. of physicians/1000 No. of beds/1000
is very high compared to urban areas.
population (1990-1998) population (1990-1998)
India 0.4 0.8
Australia 2.5 8.5 Health Administration and
Bangladesh 0.2 0.3
Myanmar 0.3 0.6 Management
Canada 2.1 4.2
China 2.0 2.9 The field of organization, administration and manage-
Japan 1.9 16.5 ment has become immensely important not only in
Mexico 1.6 1.1 public administration and corporate sector but, also,
Pakistan 0.6 0.7
in the field of health. No health administrator or
Singapore 1.4 3.6
Sri Lanka 0.2 2.7 public health specialist can afford to be ignorant in
Sweden 3.1 3.8 this area. However, this field is a speciality in itself.
USA 2.7 3.7 Only introduction to certain principles can be given
here. This section will be dealt within the following
(Source: World Development Indicators; 2001)18
subsections:
• Administration
TABLE 26.6: Population served per doctor • Management
engaged under government agencies*
• Organization
Population per doctor States /UTs • Principles of organization
Below 1000 Chandigarh • Organizational behavior
1001-3000 Goa, Lakshadweep, Manipur, Pondicherry • Overview of management, administration and
3001-5000 Arunchal Pradesh, Sikkim, Tripura, A and N organization
Islands
• Management techniques
5001-10,000 Assam, HP, Kerala, Meghalaya, Nagaland,
Orissa, Punjab, Daman and Diu, Delhi • Characteristics of good health service
10,001-20,000 Gujarat, Haryana, Karnataka, Tamil Nadu, • Challenges in health care administration.
UP, D and N Haveli
*Including hospitals and public sector undertakings. Data not available
Administration
for all states.
Administration is closely related to management but has
Committee. In fact, the doctor:population ratio in India a wider scope. The concept is manifest in the following
is higher than Sri Lanka where, incidentally, the infant definitions:
mortality rate is about one-third of that in India. It must • Administration is the direction, coordination and
be realized that more doctors do not mean more control of many persons to achieve some purpose
health. The health of the community, in fact, depends or objective (LD White).
more upon its nursing manpower than upon the • Administration is the organization and direction of
number of doctors available. This point is well illustrated human and material resources to achieve desired
in Table 26.7. It is seen that Japan and Egypt have ends (Pfiffiner and Presthus).
a comparable number of doctors per unit population, • Administration, in its broadest sense, is defined as
but Egypt has a high IMR along with a high the activities of groups cooperating to accomplish 489
population:nurse ratio. common goals (Herbert A Simon).
PART IV: Health Care and Services TABLE 26.7: Health personnel per lakh population and IMR in various countries
Country Doctor /100,000 Nurse /100,000 No. nurses / No. midwives/ No. dentists/ Infant
population* population* doctors* 100,000 population* 100,000 population* mortality rate**
• Administration is determined action taken in pursuit achieve certain objectives.2 Health administration is a
of conscious purpose. It is the systematic ordering branch of public administration which deals with matters
of affairs and calculated use of resources, aimed at relating to promotion of health, preventive services,
making those things happen which we want to medical care, rehabilitation, development of health
happen and simultaneously preventing develop- manpower and medical education and training. The
ments that fail to square with our intentions. It is the purpose of public health administration is to provide
marshalling of available labor and materials in order total health services to the people with economy and
to gain that which is desired at the lowest cost of efficiency. 2 Health administration must use the
energy, time and money (John A Vieg). knowledge of health economics to achieve proper
• Administration is a variety of component elements economy.
which together in action produce the result of getting The efforts of public health administration are
done a defined task with which a group of people directed towards raising the level of health of the
is charged. Administration, primarily, is the direction community. A good public health administrator is one
of people in association to achieve some goal who carries out this task with maximum efficiency and
temporarily shared. It is the inclusive process of minimum delay.
integrating human efforts so that a desired result is
obtained (Ordiway Tead). Management21
According to Henri Fayol, the enunciator of the
formal organization theory, administration comprises The term management is generally understood as a
the following five elements: forecasting and planning, process of getting things done through others. A
organizing, commanding, coordinating, and controlling. manager in an organization manages to realize the
To administer is to forecast and plan, to organize, to established aims of the organization by directing its
command, to coordinate and to control. To forecast and operations and coordinating the efforts of people
plan means examining the future and drawing up the working in it. So, management is the effective use and
plan of action. To organize means building up the dual coordination of resources such as money, materials and
structure, material and human, of the undertaking. To manpower, to achieve defined objectives with maximum
command means maintaining activity among the efficiency. The success of an organization depends on
personnel. To coordinate means binding together, its management. The productiveness of the resources,
unifying and harmonising all activity and effort. To control i.e. men, money and materials, depends to a large
means seeing that everything occurs in conformity with extent upon the quality and performance of the
established rules and expressed command. In simple manager and the effectiveness of his direction.
words, administration may be defined as the There are a variety of views about management. In
490 management of affairs with the use of well thought out its traditional interpretation, the term ‘management’
principles and practices and rationalized techniques to refers to the activities (and often the group of people),
involved in four general functions—planning, organi- • Management is a distinct process consisting of plan-
There are 28 States in the country. Health, as stated There are three types of local self government in urban
earlier, is a State subject. Therefore, the pattern of areas of a district, depending upon the size of
organization, state of integration, level of health services, population:
public health laws and scales of pay for health personnel 1. Town areas committees (5 to 10,000)
differ from state to state. The aim, however, of all States 2. Municipal Board or Municipality (10 to 200,000)
and their Public Health Administration is the same— 3. Corporation (Above 200,000)
health, happiness and longevity for all the people. All the above three are elected bodies.
The town area committee is like a Panchayat in the
rural areas. Its functions are primarily limited to
STATE MINISTRY OF HEALTH
provision of sanitary services. The Municipal Board or
The Ministry has a Minister and Deputy Minister of municipality has more diverse functions. These include
Health. The Bhore Committee recommended that the regulations regarding construction of houses, latrines
post of Secretary to the Health Ministry should be held and urinals, hotels, and markets; provision of water
by the Director of Health Services, but this has not been supply, drainage and disposal of refuse and excreta,
put into practice, barring exceptions. The Secretary and disposal of the dead, registration of births and deaths,
Joint Secretary, etc. in the Ministry continue to be keeping of dogs and control of communicable diseases.
appointed from the IAS cadre. The Municipal Corporation is also an elected body. The
people elect the Councillors, who then elect a Mayor.
STATE HEALTH DIRECTORATE The executive staff of the corporation includes the
Commissioner, the health and engineering wings and
Till the time of independence, there were separate medi- the secretariat. The corporation provides essentially the
cal and public health departments in the States. The same services as the municipality, but on a larger scale.
Bhore Committee 4 recommended integration of It also maintains hospitals and dispensaries.
curative and preventive services. The lead was taken by
West Bengal which created a post of Director of Health
HEALTH ORGANIZATION IN RURAL AREAS
Services in 1947.
The process of integration has now been completed In order to understand the health set up in the villages,
in most States. The usual pattern now is that the State it is essential to appreciate the existing system of
Health Directorate is headed by a Director, usually administration and its historical background. This can
known as Director of Health Services (in some States, be described in four phases.
known as the Director of Health and Family Welfare or Up to 1923: District Administration alone: The
as Director of Medical and Health Services). He is Collector or Deputy Commissioner acted as the chief
assisted by a suitable number of deputies (Joint Director, administrative head of the district as well as the District
Deputy Director, Assistant Director, etc.) to look after Magistrate before independence. He was assisted by
various public health and medical services. Some states 2 to 3 Assistant or Deputy Collectors incharge of
also have a separate Director of Medical Education. Subdivisions and 5 to 10 Mamlatdars or Tehsildars
There is a move that the public health engineering incharge of Talukas or Tehsils into which the district was
department of the state should also be placed under divided. He coordinated the activities of heads of
the State Health Directorate. departments in the district, such as the Civil Surgeon,
District Health Officer, Executive Engineer and
District Level Agriculture, Education and Veterinary Officers, etc.
1923-1951: District Administration plus Local
Each state in Indian union is divided into districts. Total
Boards: There was no local autonomy till District Local
population in each district, urban as well as rural, varies
Boards came into existence in 1923, after the visit of
from one to three million. Just as in case of states,
Simon Commission in 1920. These Boards were given
some autonomy has been given to urban and rural
some powers for self-government in rural areas of the
areas in the district as well. The autonomous bodies
district.
or local self-government are called Corporations and
Municipal Committees in the cities, Zilla Parishads in 1952-1961: Community Development: After inde-
rural districts and Gram Panchayats and Nagar pendence, the Government adopted the goal of
Panchayats (Town Area Committees) in villages and “Welfare State” and launched a scheme called
small towns. ‘Community Development Program’ on 2nd October,
498
1952 for comprehensive and intensive development of turn elect a Sarpanch, Deputy Sarpanch and
Government of India will handover the running of the The Constitution directs the State to regard the raising
rural job scheme to a nationwide network of NGOs, of the level of nutrition and the standard of living of
sidelining the panchayats and Gram Sabhas that its people and the improvement of public health among
managed the program till now. Failure of local level its primary duties. It is felt that an integrated,
political system with allegation of corruption and comprehensive approach towards the future
inefficiency has led to this. Many NGOs had been development of medical education, research and health
monitoring the National Rural Employment Guarantee services requires to be established to serve the actual
Scheme but now they will be paid for their work. health needs and priorities of the country. It is in this
According to a draft note prepared by the rural context that the need has been felt to evolve a National
development ministry, the NGO will spread awareness Health Policy.
about the scheme, train the workforce, monitor the
muster rolls and all documents relating to the work done, PARA 2: OUR HERITAGE
ensure that grievances are redressed and finally evaluate “India has a rich heritage of medical and health sciences.
the scheme’s implementation. The Panchayats will be The approach of our ancient medical systems was of
500 kept in the loop but will no longer be the decision a holistic nature.”
CHAPTER 26: Health Planning, Administration and Management
TABLE 26.9: Goals for Health and Family Welfare Programs (as quoted in National Health Policy) vis-a-vis achievements
Sl. Indicator Level as quoted Goals Achievements
No in NHP Latest Ref.
1985 1990 2000 1985 1990 available No.
1 2 3 4 5 6 7 8 9 10
Note:
• The Planning Commission set the following goals in addition to the above30
1985 1990 2000
Vitamin A distribution 50% 50% 50%
Iron folic acid distribution to 50% 50% 50%
children up to 12 years
Population with protected water supply
Rural 60% 100% 100%
Urban 90% 100% 100%
Population with safe human excreta disposal
Rural 10% 25% 100%
Urban 60% 80% 100%
Malaria API 2.7 1.9 Below 0.5
•
Goiter reduction 50% 75%
According to the seventh plan document, the target date for achieving net reproduction rate of 1 was 2000 AD. This has been now
95%
targeted for 2011-2016.
501
• Measles immunization coverage in 1999 was 89.6%
PART IV: Health Care and Services PARA 3: PROGRESS ACHIEVED prevention of food adulteration, maintenance of
prescribed standards in the manufacture and sale of
Since independence, considerable progress has been
achieved, especially in reference to smallpox, plague drugs and the conservation of the environment. In sum,
and cholera. Mortality has decreased from 27.4 to the contours of the National Health Policy have to be
evolved within a fully integrated planning framework
14.8 and life expectancy at birth has increased from
which seeks to provide universal, comprehensive
32.7 to over 52.
primary health care services, relevant to the actual needs
and priorities of the community at a cost which the
PARA 4: THE EXISTING PICTURE
people can afford, ensuring that the planning and
The demographic and health picture of the country implementation of the various health programs is
constitutes a cause for serious and urgent concern, with through the organized involvement and participation of
special reference to the following: the community, adequately utilizing the services being
• High rate of population growth. rendered by private voluntary organizations active in the
• High mortality rates for women, children and infants. health sector.
• Malnutrition. It is also necessary to ensure that the pattern of
• High prevalence of communicable and noncommu- development of the health services infrastructure in the
nicable diseases, especially diarrheal diseases, leprosy, future fully takes into account the revised 20-point
tuberculosis and blindness. Program. The said program attributes very high priority
• Poor access of rural population to potable water promotion of family planning as a people’s program on
supply (31%) and basic sanitation 0.5 percent. a voluntary basis; substantial augmentation and
• Poverty. provision of primary health care facilities on a universal
• Ignorance. basis; control of leprosy, TB and blindness; acceleration
• Almost wholesale adoption of health manpower of welfare programs for women and children; nutrition
development policies based on the Western models, programs for pregnant women, nursing mothers and
resulting in the development of a cultural gap children, especially in the tribal, hill and backward areas.
between the people and the personnel providing The program also places high emphasis on the supply
care. of drinking water to all problem villages, improvements
• Establishment of curative centers based upon in the housing and environments of the weaker sections
of society; increased production of essential food items;
Western models, which are inappropriate and irrele-
integrated rural development; spread of universal
vant to the real needs of our people and their socio-
elementary education; expansion of the public distri-
economic condition.
bution system, etc.
• Emphasis on hospital based, cure oriented approach
and neglect of preventive, promotive, public health
PARA 6: POPULATION STABILIZATION
and rehabilitative aspects of health care.
• Failure to involve the community in the identification Improvement in health status of people cannot be
of health needs and priorities, as well as in achieved without achieving success in “securing the
implementation and management of various health small family norm, through voluntary efforts and
related programs. moving towards the goal of population stabilization. It
is necessary to enunciate, separately, a National
PARA 5: NEED FOR EVOLVING A HEALTH Population Policy.”
POLICY—THE REVISED 20-POINT PROGRAM
PARA 7: MEDICAL AND HEALTH EDUCATION
India is committed to attaining the goal of “Health for
All by the year 2000 AD” through the universal “The effective delivery of health care services would
provision of comprehensive primary health care depend very largely on the nature of education, training
services. The attainment of this goal requires a thorough and appropriate orientation towards community health
overhaul of the existing approaches to the education of all categories of medical and health personnel and
and training of medical and health personnel and the their capacity to function as an integrated team. Towards
reorganization of the health services infrastructures. this end, it is necessary to formulate, separately, a
Furthermore, considering the large variety of inputs into National Medical and Health Education Policy which:
health, it is necessary to secure the complete integration • Sets out the changes required to be brought about
of all plans for health and human development with in the curricular contents and training program of
the overall national socioeconomic development medical and health personnel, at various levels of
process, specially in the more closely health related functioning.
502 sectors, e.g. drugs and pharmaceuticals, agriculture and • Takes into account the need for establishing the
food production, rural development, education and extremely essential interrelations between function-
social welfare, housing, water supply and sanitation, aries of various grades.
• Provides guidelines for the production of health the functioning of the field stations. These stations
Sector Population IMR/per 100 < 5 Mortality Weight for age % of MMR/Lakh Leprosy cases Malaria +ve cases
Live births per 1000 children under 3 yrs (Annual report per 10000 in years 2000
(1999 SRS) (NFHSH) (< –2 SD) 2000) population (in thousands)
India 26.1 70 94.9 47 408 3.7 2200
Rural 27.09 75 103.7 49.6 — — —
Urban 23.62 44 63.1 38.4 — — —
Better
Performing
States
Kerala 12.72 14 18.8 27 87 0.9 5.1
Maharashtra 25.02 48 58.1 50 135 3.1 138
TN 21.12 52 63.3 37 79 4.1 56
Low Performing
States
Orissa 47.15 97 104.4 54 498 7.05 483
Bihar 42.60 63 105.1 54 707 11.83 132
Rajasthan 15.28 81 114.9 51 607 0.8 53
UP 31.15 84 122.5 52 707 4.3 99
MP 37.43 90 137.6 55 498 3.83 528
TABLE 26.12: Differentials in health status among if, while framing a new policy, it is not acknowledged
socioeconomic groups that the existing public health infrastructure is tar from
Indicator Infant Under 5 % Children
satisfactory. For the outdoor medical facilities in
Mortality/1000 Mortality/1000 Underweight existence, funding is generally insufficient; the presence
of medical and paramedical personnel is often much
India 70 94.9 47
Social Inequity less than required by the prescribed norms; the
Scheduled Castes 83 119.3 53.5 availability of consumables is frequently negligible; the
Scheduled Tribes 84.2 126.6 55.9 equipment in many public hospitals is often obsolescent
Other Disadvantaged 76 103.1 47.3
Others 61.8 82.6 41.1
and unusable; and the buildings are in a dilapidated
state. In the indoor treatment facilities, again, the
equipment is often obsolescent; the availability of
health programmes exists with the Central Government essential drugs is minimal; the capacity of the facilities
in a considerable degree; this expertise can be gainfully is grossly inadequate, which leads to overcrowding, and
utilized in designing national health programmes for consequentially to a steep deterioration in the quality
implementation in varying socioeconomic settings in the of the services. As a result of such inadequate public
status. health facilities, it has been estimated that less than 20
percent of the population seeks the OPD services and
Over the last decade or so, the Government has less than 45 percent avails of the facilities for indoor
relied upon a ‘vertical’ implementational structure for treatment in public hospitals. This is despite the fact that
the major disease control programs. Through this, the most of these patients do not have the means to make
system has been able to make a substantial dent in out of pocket payments for private health services
reducing the burden of specific diseases. However, such except at the cost of other essential expenditure for items
an organizational structure, which requires independent such as basic nutrition.
manpower for each disease program, is extremely
expensive and difficult to sustain. Over a long time-
Extending Public Health Services
range, ‘vertical” structures may only be affordable for
diseases, which offer a reasonable possibility of While in the country generally there is a shortage of
elimination or eradication in a foreseeable time-span. medical manpower, this shortfall is disproportionately
In this background, the NHP-2001 attempts to define impacted on the less-developed and rural areas. No
the role of the Central Government and the State incentive system attempted so far, has induced private
Governments in the public health sector of the country. medical manpower to go to such areas; and, even in
the public health sector it has usually been a losing battle
The State of Public Health Infrastructure to deploy medical manpower in such under-served
areas. In such a situation, the possibility needs to be
The delineation of NHP-2001 would be required to be examined for entrusting some limited public health
based on an objective assessment of the quality and functions to nurses, paramedics and other personnel
508 efficiency of the existing public health machinery in the
from the extended health sector after imparting
field. It would detract from the quality of the exercise adequate training to them.
India has a vast reservoir of practitioners in the Indian health expertise is nonexistent in the private health sector,
516
populace of the country. Further, it has to be recognized
Fig. 26.1: Analytical model showing how improper or excessive pace of development can have harmful consequences for health through
environmental degradation. Three main causes of environmental degradation are identified: Poverty, affluence and short-term policy perspectives.
It may be noted that mass poverty forces people to adopt means of economic “development” that result in environmental degradation and are
ultimately counter-productive.
HFC: Hydrofluorocarbons
Prepared on the basis of data in Ref. No. 44
Two projects currently under cloud because of their potential harmful effects upon environment are the Sardar Sarovar Project on river Narmada
and the Tehri Dam Project in Garhwal.
High consumption is the basic cause leading to Table 26.15. Comparing the per capita consumption
depletion of natural environment. The pattern ratio in USA and India (given in parentheses), the
of consumption in different countries is given in following comments may be made:
520
CHAPTER 26: Health Planning, Administration and Management
TABLE 26.15: Per capita consumption pattern in different countries16a
Daily Annual
Name of GNP per capita Fat protein Energy Sugar commercial energy Crude Newsprint
country (1986, US $) g g Kcal kg as oil, kg steel, kg kg
FAT (RATIO 4.56) causing global warming, the consequences of which are
often catastrophic.
US consumption too high, constituting about 40
It is in view of the disastrous effects of the CFCs that
percent of total calories intake. Needs to be
it has been decided by international agreement to
halved.
substitute CFCs by safer refrigerants such as
hydrochlorofluorocarbons and hydrofluorocarbons.
SUGAR (RATIO 2.92)
US consumption too high, constituting about 40 percent Current Trends in Development
of total calorie intake. High consumption is associated
with caries. According to a recent decision of the development
committee of the World Bank and IMF, the development
ENERGY (RATIO 34.58) priorities for the nineties have been fixed to be (i)
Reduction of poverty, (ii) Sustainable growth (i.e., avoi-
High oil burning in US causes excessive air pollution. ding environmental damage) and (iii) Human resources
development through greater attention to education
NEWSPRINT (RATIO 103.6) and health.
The high consumption of newsprint simply means high
degradation of forests, and must be reduced. Physical Quality of Life Index
A good example of harmful effects of economic and
industrial development is the chlorofluorocarbons Physical Quality of Life Index (PQLI) measures the quality
(CFC). These were synthesized in 1930 by Thomas of life or well-being of a country. PQLI encompasses
Midgley in USA and were hailed as a wonder invention. three indicators like literacy rate, infant mortality and
These are noncorrosive, nontoxic, noninflammable, life expectancy at age one, giving equal weightage to
colorless, odorless compounds with a low boiling point, all of them. PQLI value ranges from 0 to 100.
making them suitable for use as refrigerants and as
constituents of cosmetics, such as shaving creams. Human Development Index
Today, sixty years after their discovery, they stand
discredited as a major threat to the survival of mankind Human Development Index (HDI) measures well-being,
because of the ecological damage caused by them. This especially the child welfare, and was developed by
damage occurs in two ways: (i) CFCs have a tendency Indian economist Amartya Sen and Pakistani economist
to drift high into the atmosphere. There they are broken Mahbub ul Haq in the year 1990. HDI combines three
down by sunlight and chlorine atoms are released. dimensions like life expectancy, literacy, education and
These chlorine atoms convert ozone into oxygen. As a standards of living for countries worldwide. Population
result the ozone layer around the earth gets depleted. health and longevity is expressed by life expectancy at
Ozone serves the important purpose of filtering out birth, Knowledge and education is measured by the
excess ultraviolet radiation which is responsible for skin adult literacy rate (with two-thirds weighting) and the
cancer and cataract. An ozone hole was discovered for combined primary, secondary, and tertiary gross
the first time in 1947 and such findings have been enrolment ratio (with one-third weighting), and
repeatedly reported since then. (ii) CFCs, along with standard of living, as indicated by the natural logarithm
other “legacies” of the industrial revolution, such as of gross domestic product per capita at purchasing
power parity.45 521
carbon dioxide and sulphur dioxide, are capable of
PART IV: Health Care and Services HDI value ranges from 0 to 1. According to HDI TABLE 26.16: Top five states of India according
value, countries fall into four categories, e.g. very high to GDI and GEM for 2006
(HDI value 0.900-1.000), high (0.800-0.899), medium Ranking States
(0.500-0.799) and low (0.000-0.499). The first
GDI GEM
category is referred to as developed countries and the
last three are all grouped in developing countries. 1 Chandigarh Andhra Pradesh
2 Goa Goa
Previously, gross national income (GNI) in purchasing 3 Kerala Haryana
power parity (PPP) per capita, was included in 4 Delhi Kerala
calculating HDI, but now it has been replaced by gross 5 Puducherry Maharashtra
domestic product (GDP) in purchasing power parity per
capita. India’s rank is 134 and belongs to medium HDI of people with access to health services and to safe
category with a score of 0.612.46 water, and the percentage of malnourished children
under five.
Human Poverty Index
Gender Development Index (GDI) and
If human development is about enlarging choices, Gender Empowerment Measure (GEM)
poverty means that opportunities and choices most basic
to human development are denied: to lead a long, Gender Development Index is calculated by comparing
healthy, creative life and to enjoy a decent standard of the infant mortality, life expectancy at age one, literacy
living, freedom, dignity, self-respect and the respect of rates, average years of education and estimated income
others. From a human development perspective, per capita for girls and boys. The higher the GDI, the
poverty means more than the lack of what is necessary greater the gender equality. India’s GDI has improved
for material well-being. from 0.568 in 1996 to 0.633 in 2006.
For policy-makers, the poverty of choices and opportu- Gender Empowerment Measure is calculated by
nities is often more relevant than the poverty of income, measuring political and economic participation and
for it focuses on the causes of poverty and leads directly control wielded by women in different Indian States.
to strategies of empowerment and other actions to Like GDI, higher GEM represents greater empower-
enhance opportunities for everyone. Recognizing the ment of women. Political participation is calculated by
poverty of choices and opportunities implies that poverty taking into consideration the number of women
must be addressed in all its dimensions, not income alone. legislators – at the center, assembly and the
The Human Development Report 1997 introduced Panchayati Raj Institutions (PRI), the number of
a human poverty index (HPI) in an attempt to bring women candidates fielded by parties and the
together in a composite index the different features of percentage of women voters in election. Economic
deprivation in the quality of life to arrive at an aggregate participation has been calculated by evaluating the
judgment on the extent of poverty in a community. share of jobs held by women in the civil services of
professionals graduating from medical; and
engineering colleges and judges of high courts and
THE THREE INDICATORS OF THE HUMAN POVERTY
INDEX (HPI)
the Supreme Court.
India has improved gender equality and empower-
Rather than measure poverty by income, the HPI uses ment by over 10 percent each over the past decade, but
indicators of the most basic dimensions of deprivation: traditional laggard states remain virtually stagnant, the
a short life, lack of basic education and lack of access Center’s first ever official quantitative rating of gender
to public and private resources. The HPI concentrates development has revealed. Kerala has lost its tag as the
on the deprivation in the three essential elements of country’s most gender equal state to Chandigarh, while
human life already reflected in the HDI: longevity, women in Andhra Pradesh are the most empowered.
knowledge and a decent living standard. Bihar is at the bottom of both GDI and GEM indices for
The first deprivation relates to survival: The vulne- both 1996 and 2006 (Table 26.16).
rability to death at a relatively early age and is represen-
ted in the HPI by the percentage of people expected References
to die before age 40.
The second dimension relates to knowledge: It is 1. WHO. Modern Management Methods and the Organisation
of Health Services. Public Health Papers No. 1974;55.
being excluded from the world of reading and
2. Goel SL. Public Health Administration. Delhi: Sterling
communication and is measured by the percentage of Publishers 1984;20:47.
adults who are illiterate. 3. WHO. Planning and Programming for Nursing Services.
The third aspect relates to a decent standard of living, Public Health Papers No. 1971;44.
522 in particular, overall economic provisions. This is repre- 4. Govt. of India. Report of the Health Survey and Development
sented by a composite of three variables: the percentage Committee. Shimla: Govt. of India Press, 1946.
5. Malhotra S, Zodpey SP. Operations Research in Public 26. WHO. WHO Chronicle 1977;31:123-5.
523
27 Health Economics
organizing information so that the costs of alternatives A Rs. 25,000 100 lives saved Rs. 250 per life
and their effectiveness in meeting a given objective can B Rs. 25,000 15 lives saved Rs. 1677 per life
be compared systematically. CEA involves three distinct
subprocesses: (a) Developing comprehensive cost TABLE 27.2: The approaches for an alternative strategy
stream data and analysis of cost of each alternative; Approaches for Effectiveness Cost (Rs.) CE ratio
(b) An analysis of effectiveness of each alternative; (c) strategy ‘A’
An analysis of the relationship between the costs and which was found
cost effective
effectiveness of each alternative.
Cost-effectiveness (CE) ratio is calculated by dividing • Campaign 15,000 Rs, 75,000 Rs. 5 per
cost of an alternative, expressed in monetary terms, by immunizations immunization
• MCH clinic 15,000 Rs. 45,000 Rs. 3 per
the effectiveness of that alternative, usually expressed immunizations immunization 527
in nonmonetary terms. CEA measures health benefits • Mobile clinic 15,000 Rs. 65,000 Rs. 4.33 per
in natural units such as life years saved or improvements immunizations immunization
PART IV: Health Care and Services A practical example is a recent study undertaken budgeting, which is defined as the process that links
to compare the cost effectiveness of directly observed budgeting to programming Health budgeting and
treatment (DOTS) in tuberculosis with the program budgeting are essential components of the
conventional treatment of tuberculosis. Cure rates Managerial Process for National Health Development
were used as the measure of effectiveness in this study. (MPNHD).
All patient costs, community costs and treatment costs
were calculated using standard procedure. Cost Allocations
effectiveness was calculated in three ways. First, the
proportion of patients who completed treatment was In Health Economics the term ‘allocations for health
multiplied by the cost of managing a patient upto the care’ at a given point in time or over a period of time,
completion of treatment. Secondly, the cost of patients refers to the distribution of resources, both in monetary
not completing treatment was calculated by multiplying and non-monetary sense, within a program. This
the patient management costs (assuming that default general term covers such specialized expressions as
would occur at the time of discharge from hospital) apportioning or apportionment, allotment, etc.
by the proportion of patients not completing
treatment. Thirdly, the cumulative costs of both types Health Financing
of patients were divided by the cure rate. It was
concluded that DOTS was 2.7 times cheaper for the There are several macro and micro aspects of economics
health system, 3 times cheaper for the patient and 2.8 relevant to the health sector. Out of these, the aspect
times cheaper overall. DOTS was foynd to be 2.4 to of Financing of Health Care is particularly important.
4.2 times more cost effective compared to conven- Health financing, in general, refers to raising of
tional treatment. It was therefore concluded that DOTS resources to pay for goods and services related to
should replace conventional treatment of tuberculosis.7 health. These resources may be in the form of “cash”
or “kind”. Financing of health care is viewed within the
framework of scarcity of resources, their sustainability
Cost Utility Analysis and their efficiency. A broad categorization of the
This is an adaptation of CEA which measures an sources of health care financing is as follows:
intervention’s effect on both the qualitative and • Public sources (Government sources)
quantitative aspects of health (morbidity and mortality) • Private sources (including nongovernment, corpo-
using a utility based measure such as QALY. An rate and private bodies)
intervention is deemed efficient, relative to an alternative • External cooperation or aid (bilateral or
if it results in higher (or equal) benefits at a lower cost. international)
The use of a single measure of health benefit enables • Individual or household
diverse health care interventions to be compared.6 • Mixed sources.
In summary, it can be seen that the three types of Besides the above, another category of financing
evaluations use three different types of outcomes could be through health insurance, both compulsory
measurement:8 and voluntary. Major problems in health financing are
1. Cost effectiveness—clinical end points as follows:
2. Cost benefit—condition specific outcome measures • Lack of funds
3. Cost utility—mortality; years of life. • Unequal distribution of health finances
• Rising health costs
• Lack of coordination in health financing units
Budget • Wastage and inefficiency in spending the funds or
In the context of health, the budget is a systematic resources available.
economic plan for a specific period of time. It
incorporates politically and technically determined Some Practical Considerations
appropriations indicating in what way and for what
purpose various health resources are to be used. Cost of Medical Care:
Budgeting refers to the process by which the budget
comes into being. Budgeting is a means of ensuring that
Government System vs Privatization
program decisions become budget decisions. The next Medical care is costly business. The American health
stage after budgeting is control on budget or budgetary industry is $900 billion strong. Bill Clinton, President of
control. This involves designating the spending authority the USA, described American health care as the “costliest
for delivering the health program and ensuring that the and the most wasteful system on the face of the earth”
528 budget is spent judiciously for various aspects of the and vowed, to revamp it as part of his election manifesto
program. The latter is done through program in 1993.8
Health care is highly privatised in USA. The result disability. On the other hand, the number of DALYs lost
530
28 Health Care of the Community
537
PART IV: Health Care and Services Rural Health Scheme principles of health education. At the end of the training,
the health guides are given a certificate, a manual and
The Rural Health Scheme emerged out of the recom- a kit. The manual tells them in simple words what to
mendations of the Shrivastav Committee and was intro- do and what not to do in the situations they might face.
duced in 1977. It is based on a 4-tier system of services The kit contains common medicines (modern as well
provided at the level of the village, the subcenter, the as indigenous) needed in the community. After the
PHC and the CHC as described below: training, the health guide attends to people’s problems
in his spare time, while continuing to attend to his other
VILLAGE LEVEL normal vocation. He is paid Rs. 50/- per month as
honorarium for this voluntary work. His stock of
73.9% of India’s population lived in nonurban areas
medicines is also periodically replenished, the annual
in 1991.8 37.3% of the rural population lives below the
supply being Rs. 600/- worth of medicines.
poverty line in contrast to 32.4% in urban areas.8 As
The health guide is to be selected by the Gram
per the provisional totals of the 2001 census, the literacy
Panchayat. He reports to a Village Health Committee,
rate for males is 75.96% and for females it is 54.28%.10
consisting of 5 members, on all matters except technical
23% villages in India still do not have electricity.4 In these
ones, which are referred to the concerned Medical
conditions, it is not surprising that health facilities are
Officer. Usually oneVHG is provided for 1000
meagre in the villages. It is not possible for a physician
population (500 in case of tribal, hilly or remote areas).
to be available in each village for providing health care
If the population of a village is more than 2000, two
to the villagers. The Rural Health Scheme was hence
guides can be provided. One of these should be a
envisaged to enlist local people in the health service set-
woman, and one should be from a Scheduled Caste/
up. Two types of functionaries were sought to be
Tribe. The government took a policy decision in 1986
developed for this purpose, viz., the Health Guide and
to replace male VHGs by female VHGs.
the Trained Dais.
Preference is to be given to practising dais. The health
Village Health Guides guide cannot administer injections and cannot prescribe
outside the list of drugs provided to him. He should not
On October 2, 1977 the Community Health Workers treat any case for more than 2 days if there is no
Scheme was launched in India to provide health services improvement.
to people in the villages by enlisting people’s partici-
pation. The name of this cadre of worker was later Trained Dais
changed from Community Health Worker (CHW) to
Village Health Guides (VHG). This scheme is in Almost all deliveries in the villages are conducted in the
operation in all states and Union Territories except in homes, unattended by a doctor or a properly trained
four states where alternative rural health schemes are health functionary. The high maternal mortality rate and
in progress. These states and their schemes are as neonatal tetanus mortality rates are largely due to lack
follows: Jammu and Kashmir (Rehbar-e-Sehat), of proper antenatal, natal and postnatal care. If the basic
Arunachal Pradesh (Medics), Tamil Nadu (Mini Health concepts of such care are imparted to the local
Centres) and Kerala (strengthening of PHCs). indigenous village dai, high maternal morbidity and
The health guide is envisaged as a person from mortality can be reduced. This is the idea behind the
within the community who provides primary health care dai training scheme. The target is to train one local dai
to the people in the village. As such, following guidelines per village or per 1000 population. The training lasts
for appointing the health guides are observed: for one month. The trainees get a stipend of Rs. 300/-
• He or she should be a permanent resident in the during this period. The training is imparted 2 days in
village. a week at the PHC/subcenters and 4 days in a week
• He or she should be acceptable to all sections of the in the field, when the dai accompanies the Health
community. Worker (Female) to the village. During the one month
• He or she should have had formal education up to training, the dai has to conduct at least 2 deliveries under
at least sixth standard. This criterion can be relaxed the supervision of the Health Worker (Female). At the
if the candidate is otherwise suitable. end of the training, she is given a Dai’s Kit which she
• He or she should be able and willing to spare 2 to can use for conducting deliveries. There is a provision
3 hours daily for community health work. to pay her Rs. 2/- per delivery, provided the case has
The health guide is given 3 months training at the been registered at the subcenter or the PHC”. This is
PHC. During the training period, he gets Rs. 200 per only to facilitate registration of births. The Dai is free
month and is taught basic health concepts including to charge the community for her services.
538 treatment of minor ailments, first aid, environmental A new scheme for training of dais has been initiated
sanitation, family planning, personal hygiene and in January 2001 to tackle the problem of unsafe
deliveries in 142 districts in 17 States, where safe and improve functioning of the subcenter. Currently the
547
PART IV: Health Care and Services TABLE 28.6: Types of health parts TABLE 28.8: Pattern of staff at each type of center
Name of the post A B C D Type Population No of Staffing pattern
Lady doctor – – – 1 covered units
Public health nurse – – – 1
Type I 10000-25000 326 ANM-1, FP field worker-1
Nurse midwife 1 1 2 3–4 Type II 25000-50000 125 FP extension educator/LHV-1;
Male MPW* – 1 2 3–4 FP field worker (Male)-1; ANM
Class IV – – – 1
Type III Above 50000 632 Medical Officer-1 (Pref. Female)
Computer-cum clerk – – – 1 ANM-2, LHV-1, FP field worker
Voluntary woman health worker* – – – 1 (Male)—1, Storekeeper-cum-
*At present, there is a ban on these categories of staff17 clerk—1
Source: Annual Report 1999-2000. Ministry of Health and Family
Welfare, GOI17
TABLE 28.7: Functioning of health parts in the states and
union territories
TABLE 28.9: National health programs in various chapters
Type of health post No. of health posts
Program Chapter
A 65
B 76 • National Tuberculosis Program 16
C 165 • Program for Control of Acute Respiratory Infections 16
D 565 • Guinea Worm Eradication Program 17
Ref:17 • Diarrheal Disease Control Program 17
• National Leprosy Eradication Program 18
• Sexually Transmitted Disease Control Program 18
URBAN FAMILY WELFARE CENTRES • National AIDS Prevention and Control Program 18
• National Malaria Eradication Program (NMEP) 19
Urban Family Welfare Centres are on ground since First • National Filaria Control Program (NFCP) 19
Five-year Plan to provide family welfare services in • Iodine Deficiency Disorders (IDD) Program 22
urban areas. Most of UFWCs are equipped to provide • National Nutrition Program 22
contraceptive supplies. At present 1083 centres are • Universal Immunization Program 30
functioning. There are three types of Urban Family • National Family Welfare Program 31
Welfare centres based on the population covered by • School Health Program 32
each centre. The staffing pattern at each type of centre
is given in Table 28.8. Initially there were 8 components of the MNP. In the
6th Plan, adult education was added to MNP while in
the 7th Plan, the following were also added to MNP.
National Health Programs • Rural domestic energy
Some health problems are present on a large scale • Rural sanitation
allover the country. In order to tackle them, not only • Public distribution system.
huge expenditure but also elaborate planning and A Chief Ministers Conference in 1996 decided that
coordination are required. Hence they have to be full coverage of the country by 7 basic services should
organized at the Central or National level, though their be achieved by 2000 AD. These are:
implementation is done at the state level. These are, • 100% coverage of provision of safe drinking water
in rural and urban areas.
hence, called National Health Programs. Fourteen of
• 100% coverage of primary health service facilities in
these have been described in various chapters as
rural and urban areas.
indicated in Table 28.9.
• Universalization of primary education.
The remaining three programs are described below: • Provision of public housing assistance to all
Minimum needs program: This is not basically a shelterless poor families.
national health program in the usual meaning of the • Extension of mid-day meal program in primary
term. However, it is described here because many of its schools to all rural blocks and urban slums and
components have a direct or indirect bearing on health. disadvantaged sections.
It was started in 1974 at the beginning of the Fifth Plan • Provision of connectivity to all unconnected villages
in order to fulfill certain basic needs and thereby raise and habitations.
the standard of living. It has the following components: • Streamlining of the Public Distribution System with
• Rural health focus upon the poor.
• Rural water supply The Program of Nutritional Support to Primary
• Nutrition Education popularly known as Mid-day Meal Program
• Elementary education was launched in 1995 as a fully funded Centrally
• Adult education sponsored Scheme. All primary school children in
Government and Government Aided schools are to be
548 • Houses for landless laborers covered. Ideally a hot meal is provided to the children
• Environmental improvement of slums
• Rural electrification. at school for 10 months in a year.
In the Ninth Plan the target is that 85% of village
OBJECTIVES
TABLE 28.10: Achievements under NPCB
• Intensification of educational activities through use S.No. Parameter Achievement
of all available channels.
• Augmenting ophthalmic services at the periphery for 1. Central mobile units 80
2. District mobile units 301
restoring sight and relieving eye problems by adop- 3. State ophthalmic cells established 18
ting an eye camp approach. 4. Eye banks established 166
• Establishing permanent facilities for eye care as an 5. District hospitals strengthened 423
integral part of general health services at peripheral, 6. Medical colleges augmented 82
intermediate and central levels. 7. Regional institutes established 11
• Orientation of paramedical personnel, teachers, 8. PHC’s strengthened 5441
social workers and community leaders on the 9. Ophthalmic assistant training schools established 39
10. District blindness control 482
problem of visual impairment. 549
PART IV: Health Care and Services Universal Precautions It is proposed that countries should be categorized
The universal precautions should be practiced by all in the following manner with regard to the targets:
medical and paramedical workers involved in providing • Countries that have already achieved this target
health services.11 The basic components include: • Countries for which the global target is achievable
i. Hand washing thoroughly with soap under running and challenging
water • Countries that find the global target hard to achieve
– Before carrying out the procedure and therefore “demotivating”.
– Immediately if gloves are torn and hand is The first group needs stricter target levels, and the
contaminated with blood or other body fluids third group less stringent ones. If a breakdown of this
– Soon after the procedure, with gloves on and kind is made for each target, some countries may be
again after removing the gloves classified in different groups for different targets. In this
ii. Barrier precautions: Using protective gloves, mask, way, the targets will provide an insight into the health
waterproof aprons and gowns. status of the population and could be useful for policy
iii. Strict asepsis during the operative procedure and makers in member states in encouraging action and
cleaning the operative site. Practice the “no touch allocating their resources.
technique” which is: any instrument or part of
instrument which is to be inserted in the cervical GLOBAL HEALTH TARGETS20
canal must not touch any nonsterile object / surface
Health Outcome
prior to insertion.
iv. Decontamination and cleaning of all instruments Health equity: childhood stunting: By 2005, health
immediately after each use. equity indices will be used within and between countries
v. Sterilization/high level disinfection of instruments with as a basis for promoting and monitoring equity in
meticulous attention. health. Initially, equity will be assessed on the basis of
– Instruments and gloves must be autoclaved a measure of child growth.
– In case autoclaving is not possible, the Survival: maternal mortality rates, child mortality
instruments must be fully immersed in water in rates, life expectancy: By 2020, the targets agreed
a covered container and boiled for at least 20 at world conferences for maternal mortality rates
minutes. (< 100/1,00,000 live births), under 5 years or child
vi. Appropriate waste disposal. mortality rates (< 45/1000 live births), and life
expectancy (> 70 years) will be met.
HEALTH FOR ALL IN 21ST CENTURY
Reverse global trends of five major pandemics: By
In May 1998, the World Health Organization adopted 2020, the worldwide burden of disease will be reduced
a resolution in support of the new global Health for All substantially. This will be achieved by implementing
policy. The new policy, Health for All in the 21st Century, sound disease control programs aimed at reversing the
succeeds the Health for All by the Year 2000 strategy current trends of increasing incidence and disability
launched in 1977. In the new policy, the worldwide call caused by tuberculosis, HIV/AIDS, malaria, diseases
for social justice is elaborated in key values, goals, related to tobacco, and violence or trauma.
objectives, and targets. The 10 global health targets are
Eradicate and eliminate certain diseases: Measles
the most concrete end points to be pursued. They can
will be eradicated by 2020. Lymphatic filariasis will be
be divided into three subgroups—four health outcome eliminated by the year 2020. The transmission of
targets, two targets on determinants of health, and four Chagas’ disease will be interrupted by 2010. Leprosy
targets on health policies and sustainable health systems. will be eliminated by 2010, and trachoma will be
All member states are supposed to set their own targets eliminated by 2020. In addition, vitamin A and iodine
within this framework, based on their specific needs and deficiencies will be eliminated before 2020.
priorities.20
There are two main aims behind the Health for All
Determinants of Health
in the 21st Century program. Firstly, the WHO wants
to develop a shared vision by listing the 10 most Improve access to water, sanitation, food, and
important health issues. Secondly, the organization shelter: By 2020, all countries, through intersectoral
wants to formulate 10 targets to motivate all member action, will have made major progress in making available
states to take action and to set priorities for resource safe drinking water, adequate sanitation, and food and
allocation. To fulfill these aims the WHO sought to shelter in sufficient quantity and quality, and in managing
include in the new targets components that were risks to health from major environmental determinants,
550 inspirational and achievable. including chemical, biological, and physical agents.
Measures to promote help: By 2020, all countries The role of national administrations in primary
554
Information, Education,
29 Communication and
Training in Health
Preservation of good health depends upon adopting worth to him. Information affects the perspective of the
good health practices and avoiding practices that are recipient person. The facts and figures that are received
harmful to health. Out of the practices prevalent in a by humans have to be true and factual to be labeled
community, some are conducive to good health, some as information. Lies, falsehood or counterfactual
to bad health and some are inconsequential to health. ‘information’ is not information itself but is called
The aim of health education is to bring about a change ‘misinformation’. Information is therefore that
in health behavior of the people in such a manner that ‘intangible’ news and facts, which an individual uses to
the harmful health practices are given up while the good bridge discontinuities and gaps that are prevalent in his
ones are reinforced. Such change cannot come about mind. It is therefore a process of creating meaning from
simply because people are ordered to do so by the things that are seen or perceived by an individual.
authorities, exhorted to do so by leaders and politicians,
advised to do so by health professionals or rewarded
for doing so by the government or nongovernment
organizations. People, whether literate or illiterate, do
not change their behavior unless they understand and
feel the need for the same. To accomplish this is the
task for health education.
The importance of health education has been
increasingly realized during the last three decades, so
much so that health education has now emerged as Education
a speciality in itself. The reason why so much
It is the process by which behavioral change takes place
attention is being focussed on health education lies
in an individual as a result of experience which he has
in the realization that health care delivery systems,
undergone.1 Education is a learning process or a series
though elaborately planned and provided, remain
of learning experiences through which an individual
ineffective if unsupported by health education aimed
informs and orients himself to develop skills and intelli-
at motivating people to use these services and
gent action.2
cooperate with the concerned health programs. The
Webster defines, Education as the process of educa-
importance of health education has been strongly
ting or being educated; the knowledge or skill
highlighted by the Alma Ata conference. The
developed by a learning process; a program of
conference pointed out that community participation
instruction and an instructive or enlightening experience.
is crucial to ensure optimum utilization of the services
provided by a health care delivery system. It is
stressed that health is an individual responsibility and Communication
that it must be ensured that every individual is health Communication is the process of attempting to change
conscious, so that he may observe healthy living the behavior of others. The communicator’s job is
practices and seek appropriate medical help at
chiefly helping people learn to look at things in a new
appropriate time.
way by sharing ideas and information. When people
exchange ideas and information, they can work together
Definitions and Concepts better. Sharing entails parting with information that gives
power. Health secrets are the most closely guarded
Information secrets of the medical profession. Sharing this
knowledge helps overcome the imbalance in the power
One of the most common ways to define information of society over its health and promotes self-reliance.2a
is to describe it as one or more statements or facts that Communication is a general term for the flow of
are received by a human which have some form of information linking people or places. It is therefore the
PART IV: Health Care and Services process of exchanging news, facts, opinions and facilitate this goal and conducts professional training
messages between individuals. and research to the same end.4
In communication, initially rapport or relationship is • Health education is the education for identifying
built up. Then information is provided and the final step health needs and matching them with suitable
is to promote ideas into action. behavior.5 The entire process of involving people in
learning about health and disease and aiding them
to act suitably for overcoming illness and preserving
a positive health is health education.3
• Health education is that part of health care that is
concerned with promoting healthy behavior.
Through health education we make people under-
stand their behavior and how it affects health. We
do not force people to change—Rather, we enco-
urage them to make their own choices for a healthy
life. Health education is also needed to promote the
proper use of health services.
• Health education is any combination of learning
experiences designed to facilitate voluntary actions
conducive to health (Green and Kreuter, 1991).
• Health education is a practical endeavor focused on
improved understanding about the determinants of
health and illness and helping people develop the
skills they need to bring about change (French,
1990).
Health • It is the process that assists individuals, small groups
and larger populations to identify their health needs
It is a state of complete physical, mental and social well- and priorities, obtain information and resources to
being and not merely the absence of disease or infirmity meet those needs and mobilize action aimed at
(WHO, 1948). achieving desired change. It focuses on creating an
The very definition of health encompasses the environment in which there are strong individual
essence of health education by making the individuals and structural supports for informed and voluntary
and communities equal partners in the process of decision making about personal health and
ensuring freedom from sickness and attaining the highest community well-being (Berkeley School of Public
plane of physical, mental and social health. Spreading Health, University of California).
the word that what people should do to remain healthy • It is the combination of planned social actions and
is important, but this is not sufficient to ensure health. learning experiences designed to enable people gain
In many situations, it is not only the individual who control over the determinants of health and health
needs to change because there are other things that behaviors, and the conditions that affect their health
influence the way people behave and react. The status and the health status of others (XIV World Health
physical surroundings, people with whom they live and Conference on Health Education, WHO, IUHE).
interact, the work they do and the resources available All definitions of health education emphasize the
to them must all be taken into consideration for central role of an individual and the community in
improving health. bringing about the desirable change.
Health education is not the same as health infor-
HEALTH EDUCATION mation. Correct information is certainly a basic part of
• Definition adopted by WHO: “Health education, like health education but health education must also
general education, is concerned with changes in address the other factors that affect health behavior
knowledge, feelings and behavior of people. In its such as the availability of resources, effectiveness of
most usual forms, it concentrates on developing such community leadership, social support from family
health practices as are believed to bring about the members and the levels of self-help groups. Health
best possible state of well-being”.3 education is therefore incomplete unless it encourages
• Definition adopted by the National Conference on involvement and choice by the people themselves.5a
Preventive Medicine in USA: “Health education is a
process that informs, motivates and helps people to HEALTH PROMOTION
556 adopt and maintain healthy practices and lifestyles, Health promotion is the combination of educational and
advocates environmental changes as needed to environmental supports for actions and conditions of
living conducive to health (Green and Kreuter, 1991).
Fig. 29.2: Sociogram showing examples of Not a good discussion and Good discussion
conference, is an excellent example of the case method.
World Health Day 2005: Make Every Mother and Child Count
Maternal and Child Health societies in big towns, such as holding of mothers’
classes and training of indigenous dais. Lady
Family Welfare covers both Family Planning and MCH. Chelmsford was much interested in this work and she
Family Planning will be discussed in the next chapter. established the All India League for maternal and child
MCH services are described here. welfare in 1919 and opened Health Schools for
training of health visitors in many big towns. Later on
Mothers and Children as a Special Group the League became incorporated with the Red Cross
Society. Training of midwives, assistant midwives and
Public health activities are concerned with the well-being dais was also conducted at some places.
of all people irrespective of age, sex, race or other Till 1953, the MCH services in the districts were
characteristics. However, two groups, i.e. women in the patchy and were rendered through maternity homes
reproductive age group and children, especially under or trained midwives. The latter were under the control
fives merit special attention There are three reasons for of the civil surgeon and their services were mostly
this: curative and institutional. From 1955 onwards, MCH
1. By virtue of their numbers, mothers and children services were linked with primary health centers in the
are major consumers of health services. They rural areas. In urban areas, these services are rendered
comprise approximately two-thirds of the population through MCH centers or maternity homes run by the
in the developing countries. In India, women in the
Local Bodies.
childbearing age (15 to less than 45 years) constitute
Remarkable progress has been made in the saving
21.7% and children under 15 years of age 37.3%
of lives of expectant mothers and infants through the
of the total population. Thus, together they
MCH services. This is particularly noticeable in the
constitute nearly 60% of the total population (1991
advanced countries. These services were initially started
census).
with the sole aim of reducing infant and maternal
2. These groups are subjected to marked physical and
mortality. At present, these services definitely play a
physiological stress, which, if not cared for, may cause
serious deviation from normal health. positive role in the welfare and health of the mother
3. They are exposed to unusual risks of widespread and the child. The present scope of these services is
infection, poor nutrition and hazardous delivery, which therefore very broad.
may cause death or impairment of health. The high
occurrence of morbidity among women and children Mother and Child as One Unit
is reflected in the fact that in a seven village study, The mother and the child should be considered as one
two-thirds of the total morbidity in the entire scheduled unit for providing health services because of the
caste population studied was due to MCH related following reasons:
cases.1 • During the antenatal period the fetus is part of the
The protection of the health of the expectant mother mother. The period of development of the fetus is
and her children is of prime importance for building of about 40 weeks. During this period, it obtains all
a sound and healthy nation. In spite of this, the concept necessary supplies of nutrients and oxygen from the
of maternal and child health was put into practice only mother’s blood.
recently (after 1900 in the West and after 1950 in • The health of the child is intricately linked to the
India). mother’s health.
The maternal and child welfare movement in India • Certain diseases afflicting the mother during preg-
started with attempts to train the indigenous ‘dai’ nancy can have their deleterious effects on the
(Traditional Birth Attendants, TBA) by Miss Hewlett of health of the fetus.
the Church of England Zenana Mission in India in • Even after birth, the child is dependent for its
1866. Wives of officials returning from foreign feeding upon the mother, at least in the first year
countries started some services through voluntary of life.
• During the first few years of life, the child usually The Nature of MCH Problem
Educational
The boys and girls at high school or in college have to
be imparted knowledge about hygiene of genitals,
physiology of reproduction, HIV/AIDs and dangers of
venereal diseases. They should also be given education
about planned parenthood, family welfare and
mothercraft. Fig. 30.1: Urine pregnancy test card.
Informational
Benefits of medical supervision during maternity and
infancy and facilities available for the same should be
made adequately known to married in women, even
before they conceive.
Eugenics
Eugenics refers to improvement of the genetic stock of
the race. Eugenic aspects of services to the mother include
prevention of births of children with serious genetic disease,
e.g. Down’s syndrome, muscular dystrophies, hemophilia,
etc. This may be achieved through nonterminal or terminal
methods of contraception or through medical termination
of pregnancy.
Fig. 30.2: Urine Reagent stripes for urinanalysis.
ANTENATAL CARE
An antenatal care should have contact with the health
facility as early as possible. This could be either at home
or in the clinic once a month in the first 7 months, twice
a month during the eighth month and weekly in the
9th month. Under the antenatal program, each
registered antenatal case is expected to receive a
minimum of 4 physical examinations, of which at least
one is to take place at more than 36 weeks gestation.
Each antenatal case is also expected to receive at least
one home visit prior to delivery.
Source: Indicators for assessing infant and young child feeding practices. Part 1. Definitions
Conclusions of a consensus meeting held 6–8 November 2007 in Washington, DC, USA.
of breast milk depends upon age, nutrition and mental Adequacy of Breast Milk
status of the mother. On an average, an Indian mother
secretes 600 ml of breast milk per day with 1.2 g% If the following conditions are met, then breast milk is
protein in the first year of lactation. 100 ml breast milk adequate.
gives 71 kilocalories. Breast feeding should be initiated • Baby is gaining weight, as documented by growth
as early as possible preferably within ½ hours. of birth chart at periodic intervals.
in normal delivery and within 4 hours in Cesarian section. • Baby is feeding and sleeping well.
The mother should be encouraged to breast feed the • Baby urinates about six times a day.
child up to 2 years or more if baby wishes. Also, different
criteria for the infant feeding are listed in Table 30.4. Complimentary Feeding
Gradual introduction of semisolid foods to the infants
Advantages of Breastfeeding at the age of 6 months of age in addition to usual
• To baby: breast-feeding is known as complimentary feeding.
– Anti-infective properties. The ideal time to introduce semisolid feeds to babies
– Easily digestible and meet all the nutritional need is about 6 months of age, because of the following reasons:
for growth and development. • Baby needs food and water in addition to breast
– Protect against allergic reaction and future milk for further development, since activity of the
development of coronary heart disease. baby increases. Baby has good appetite and accepts
– Nurture bonding between mother and baby. food readily.
– Reduce the incidence of dental caries. • Baby’s stomach is ready to digest outside food in
– Breast fed babies have a higher IQ and have less addition to breast milk.
chance to develop hypertension, obesity, CHD,
• After the age of 6 months of the baby, milk secretion
DM in later years.
is also gradually decreased.
• To mother:
– Reduce postpartum hemorrhage and help early Desirable quality of foods to be introduced in
postpartum uterine involution. complimentary feeding:
– Lower the risk of breast and ovarian cancer. • High energy density
– This mode of feeding is more convenient for the • Easily digestible
mother. • Semisolid consistency
• To family and society: • Low in bulk and viscosity
– Economical. • Fresh, clean and easy to prepare
584 • Should be affordable, available and culturally
– Help delaying child birth.
– Do not causes environmental pollution. acceptable
2. Train all health care staff with necessary skill to
Service for the school age child (5 to 14 years) are But this chart was not representing the growth of infants
described under School Health Program in Chapter 32. very faithfully. In comparison with the weight of
Only the services for the preschool child will be described breastfed infants in Europe and the United States, the
here. These will be discussed as per the five levels of weight for age of the NCHS/WHO charts was shown
prevention, viz. health promotion, specific protection, to be unduly low in the first 6 months of life, whereas
early diagnosis and treatment, disability limitation and in the second 6 months NCHS weight tended to be
rehabilitation. higher than that of breastfed infants. These shortcomings
were thought to be due to anthropometric data during
HEALTH PROMOTION the first year of life were spaced too widely (every 3
months). Secondly, few of the infants were fully
This is basically achieved through health education to breastfed, and of those who were breastfed many were
the mother as follows: breastfed for only a short period.
• Guidance and demonstration on various aspects of
baby care, such as toilet training, bathing and Other Growth Charts
dressing the baby.
• Information about milestones in growth and The NCHS 1977 Growth Curves: This was based
development, such as lifting of head, walking, talking on longitudinal data from birth to 3 years collected by
and cutting of teeth, etc. the Fels Institute between 1929 and 1975.
• Education regarding infant and child feeding, inclu- The CDC 2000 Charts: This chart is a modification
ding breastfeeding. of the NCHS chart, was prepared by cross-sectional data
• Convincing the mother about the need for immuni- from birth to 3 years from 5 nationally representative
zation and family planning. surveys conducted in the US between 1963 and 1994.
• Mothercraft classes on various aspects of child care.
Euro-Growth 2000 Charts: Data were collected from
Growth Monitoring subjects born between 1990 and 1993 were followed
longitudinally from birth to 5 years.
Growth monitoring means keeping a regular track of
the growth and development of the child with the help New WHO Growth Standards
of key nutrition indicators related to their age like weight
and height. To overcome different shortcomings of early NCHS/
Growth monitoring is a useful tool for the following WHO growth chart, a multicentre growth reference
reasons: study was carried out between 1997 and 2003 at 6 sites
• To detect early growth faltering and prevent under in 6 countries (Brazil, Ghana, India, Norway, Oman,
nutrition. USA) with the objective of describing the growth of
• To identify underweight children who need special children living under conditions that posed no
care and feeding at home. constraints on growth. The study consisted of two parts,
• To identify severely underweight children who need a longitudinal study in which subjects were followed
special care and feeding at home and referral from birth to 2 years of age, and a cross-sectional study
advice. of children between 1.5 and 5 years of age. It is worth
• To find out different causes of weight loss, i.e. illness noting that, as all other charts, the WHO charts from
like diarrhea, ARI, etc. birth to 2 years represent recumbent length and only
• To educate, counsel and support mothers and from 2 years on do they represent standing height. The
families for optimal nutrition, health care and new WHO Growth Standards for global use were
development of their children. released in 2006.
• Between 2 and 5 years of age, WHO weight tends The month axis of each growth chart has five boxes,
to be at the lower end of the spectrum, especially representing five years. Each box contains 12 small
at the lower percentiles, whereas Euro-Growth squares representing 12 months, i.e. each small square
occupies the top end for weight at all percentiles. on month axis represents 1 month. Overall, month axis
• Functional assessment shows that the WHO charts of each growth chart has 60 squares and can be used for
identify fewer 1- to 2-year-old as underweight and a child for 5 years or 60 months. White rectangles below
more 2- to 5-year-old as overweight than other charts. the month axis are for writing months and years as per
the date of birth of the child. Age is recorded in completed
NEW ICDS GROWTH CHART weeks/months/years. It is recorded in completed weeks
only for a child below 1 month. Similarly on weight axis,
Presently in ICDS, growth monitoring is done with the lines are marked for recording weight in kilograms and
help of growth charts, separate for girls and boys, using grams. Each thick extended line represents 1 kg. each line
weight-for-age index, which is based on new WHO extended from a small square represents 500 gm. And
Child Growth Standards (2006). Growth chart is used the very thin line represents 100 gm.
to identify normal growth as well as early growth On each growth chart, there are 3 preprinted growth
faltering of a given child. curves. These are called reference lines or Z score lines
Pink border growth chart is for girls and blue border and are used to compare and interpret the growth
chart is for boys. Each growth chart has two axes. The pattern of the child and assess the baby’s nutritional
horizontal line at the bottom of the chart is the X axis, status. The first top curve line on the growth chart is the
which is for recording the age of the child for five years median which is generally speaking, the average. The
and is also known as ‘month axis’. The vertical line at other two curve lines are below the average and are at
the far left of the chart is the Y axis – meant for a distance. Weight of all normal and healthy children,
recording the weight of the child from birth onwards plotted on the growth chart, fall above 2nd curve (dark
and is called ‘weight axis’. green band); weight of moderately underweight children 587
fall below the 2nd curve to 3rd curve (yellow band); and
PART IV: Health Care and Services
weight of severely underweight children fall below the earlier standards are no more applicable for Indian
3rd curve (orange band). children.
One information box has also been provided on the • Exclusive breastfeeding for first 6 months of life is
upper left hand side of each growth chart. Name of the now the recommendation.
child, father’s name, mother’s name, registration
number and birth weight has to be written in this box. Rationale Behind the Adoption of New WHO
A point on a growth chart, where a line extended Child Growth Standards in ICDS
from a measurement on the month axis, i.e. age,
intersects with a line extended from a measurement on • Earlier standards were based on infants receiving
the weight axis, i.e. weight, is called a plotted point. A bottle and mixed feeding. New standards have been
growth curve is formed by joining the plotted points on developed on infants exclusively breastfed for 6
a growth chart. Direction of the growth curve is more months.
important rather than a single plotted point. From • We must know how children should grow, rather
direction of the curve it will be evident whether a child how they are growing.
is growing or not. • Children below six years have same potential to
grow and develop as long as their basic needs of
Justification of New WHO Child nutrition, environment and health are met.
Growth Standards in ICDS • Previous chart was unisex. But new charts are
separate for boys and girls, since boys and girls grow
• Earlier, the Indian Academy of Paediatrics used differently.
rightly Harvard Standards based on the experience
of the growth of Indian children by using percentage STEPS OF GROWTH MONITORING
rather than percentile.
• The growth of the children now over a period of The following are the five steps of growth monitoring
588 (Figs 30.5 and 30.6):
three decades through ICDS has shown that the
Interpretation of the position of the plotted point
UNDER-FIVES CLINIC
In recent times, the “Well Baby Clinics” are giving way
to the concept of the under-fives clinics. The well baby
clinics were entirely restricted to preventive pediatrics.
On the other hand, the under-fives clinics aim to
provide preventive, promotive, curative and
rehabilitative health care services to the under five
children. In fact, the symbol for under-fives clinics in
India depicts these aspects clearly (Fig. 30.7). In the
590 case of so-called well baby clinics, there is a risk that Fig. 30.7: Symbol for under-fives clinic. (Note that health education
those running the clinic may concentrate too much on encompasses all four components in the triangle)
1. Prophylaxis against nutritional anemia in mothers
National Immunization Program vaccine, 2nd dose is given along with DPT and OPV – booster
dose and thereafter every 6 monthly upto age of 5 years.
Routine Immunization is one of the most cost effective For Pregnant Women
Early in pregnancy – TT–1 or booster *
public health interventions. The WHO launched the
One month after – TT–1 – TT–2
Expanded Program of Immunization (EPI) in 1974 with
* 1 booster dose is needed if a mother becomes pregnant within 3
the objective of reducing morbidity and mortality due years of the previous pregnancy, when she received 2 TT 595
to six common preventable childhood diseases, viz. injections (documented).
PART IV: Health Care and Services one month before the expected date of delivery. It is Program error: An event caused by an error in vaccine
recommended that the first dose be given on first preparation, handling or administration. The most
contact during pregnancy, the second dose being given common program error is infection as a result of nonsterile
not earlier than one month after the first. If the woman injection or poor injection technique. The infection can
has received TT previously, one dose during the current manifest as a local reaction (e.g. suppuration, abscess),
pregnancy will be sufficient. If a pregnant woman systemic effect (e.g. sepsis or toxic shock syndrome), or
reports late and there is not time to complete 2 doses, blood-borne virus infection (e.g. HIV, Hepatitis B or
only one dose may be given. Hepatitis C). Use of reconstituted vaccines beyond the
In India, children get the diseases at an early age. stipulated 4 hours, reuse of reconstituted vaccine at
For example, in communities with low immunization subsequent sessions, reuse of disposable syringe and
coverage levels, 25 to 33% of all cases of polio occur needle, reconstitution error/wrong vaccine preparation,
in children under one year and more than two-thirds injection at incorrect site/route (BCG given sub-
in children under two years of age.30 Hence the timing cutaneously), contraindications ignored like administration
of the first dose has been reduced from 3 months, of DPT vaccine after having reaction with the first dose
recommended earlier, to 6 weeks. The interval between are some examples of program error.
the doses of polio or DPT should be 4 to 6 weeks. Coincidental: An event that occurs after immunization
However, if the child is brought later than the due date but is not caused by the vaccine. This is due to a chance
for the next dose, it can still be given without starting temporal association. There is clinical/laboratory
all over again. Malnutrition, low grade fever, mild evidence that the event is not related to immunization.
respiratory infections, diarrhea and other minor illnesses Once an event is established as coincidental (e.g.
are not contraindications to vaccination. It may have pneumonia after administration of OPV) no further
to be deferred only in critically ill children with high investigation is required, other than what would be
fever (38°C or more) and in those requiring needed for the clinical management of the case.
hospitalization.30
Injection reaction: Event caused by anxiety or pain
Proposed Changes in the National Immunization from the injection itself rather than the vaccine. This
Schedule in 2009-1031 reaction is unrelated to the content of the vaccine.
• In select well-performing states, MR to be given with Examples being fainting, lightheadedness, dizziness,
DPT Booster at 16 to 24 months (Dose: 0.5 ml; tingling around the mouth and breath-holding in
Route: Subcutaneous; Site: Right Upper Arm) younger children, etc.
• DPT and Hep-B vaccines at 6, 10 and 14 weeks to Unknown: Unknown AEFIs imply that the cause of the
be replaced by DPT-HepB-Hib (Pentavalent) vaccine. event cannot be determined. The other possible above
mentioned causes must be excluded before reaching this
ADVERSE EVENT FOLLOWING IMMUNIZATION (AEFI)
conclusion.
An adverse event following immunization is defined as
a medical incident that takes place after an Investigating of AEFIs
immunization, causes concern, and is believed to be
caused by immunization. AEFIs, particularly when they On receiving reports of AEFIs, investigations must be
are not properly managed, represent a genuine threat started immediately with the following steps:
to the immunization program and, in some cases, to • Confirmation of the reported diagnosis of AEFI and
the health of the beneficiaries. It is important that AEFIs clarification of the details and outcomes.
are detected, investigated, monitored and promptly • Searching of the unimmunized persons, whether
responded to for corrective interventions. The AEFI they are experiencing the same medical events or not.
have been classified as following:31 • Determination whether a reported event was isolated
or part of a cluster.
Classifications of AEFIs • Investigation of any link between the vaccine given
and the development of AEFI.
Vaccine reaction: An event caused or precipitated by • Finding out any contribution of operational aspects
the active component or one of the other components of the program to the reported AEFI.
of the vaccine (e.g. adjuvant, preservative or stabilizer). • Ascertain the cause of the AEFI to provide the best
This is due to the inherent properties of the vaccine. medical care and take further actions as necessary.
Examples being common, minor vaccine reactions like
local reaction (pain, swelling, redness), fever and
systemic symptoms (e.g. vomiting, diarrhea, malaise) COLD CHAIN
that may result as a part of the immune response. An The cold chain is a system of transportation and storage
596 ideal vaccine reduces these reactions to a minimum while of vaccine at recommended temperature from the
producing the best possible immunity. manufacturer to the point of use.26,31
CHAPTER 30: Maternal and Child Health
There are three essential elements of cold chain like top portion, there is a basket. Current recommendation
• Personnel: to organize and manage vaccine distribution is to store all vaccines on the basket. If baskets are not
• Equipment: to store and transportation of vaccine available, store vaccines (other than OPV and Measles)
• Procedures: to ensure vaccines are stored and over two rows of empty ice-packs kept on the platform
transported at recommended temperature. of the ILR. Measles and OPV can be kept over two rows
of empty ice-packs on the floor of the ILR. Twice daily
COLD CHAIN EQUIPMENTS temperature recording (morning and evening) is done
with hanging thermometer placed in basket.
Cold chain equipments (both electrical and nonelectri-
At the District level vaccines are stored for 3 months
cal) are used for storage and transportation of vaccines
and at PHC level stored for 1 month.
at recommended temperature.
General principles for proper functioning of all Deep Freezers (DFs)
electrical cold chain equipments:
• These should be kept in a cool room, away from Under the program, top opening DFs are provided. At
direct sunlight or any heat source. the PHC level, DFs are used only for preparation of
• Should be locked and key is accessible to one ice packs and are never used for storing any vaccines
designated personnel. and at district level it stores OPV in addition to
• Should be placed at least 10 cm away from walls. preparation of ice packs. About 20 to 25 icepacks can
• Should be leveled, preferably on wooden blocks. be prepared by a 140 Liter DF in 24 hours with at least
• Should be properly connected to one voltage 8 hours of continuous electricity supply. The
stabilizer per equipment. temperature in DF is between – 15ºC and – 25ºC.
• Should be defrosted periodically, when there is more
than 0.5 cm of frost in ILR and Deep freezer. Domestic Refrigerators
Whenever a thick layer of ice is formed inside the They also maintain a cabinet temperature between
freezer, the inside temperature goes up, thus +2ºC to +8ºC with a holdover time of only 4 hours.
decreasing the efficiency of refrigerator. Therefore, they are not recommended for common use
• A paper should be pasted outside the refrigerator in the national program. However, they are used in
containing the name and contact number of the urban dispensaries and by private practitioners in urban
concerned person in case of a problem or failure. areas due to more assured power supply and
• Have to record the temperature regularly. nonavailability of ILRs and DFs.
At regional level vaccines are stored here. The These are insulated vans used for transporting the
temperature being + 2ºC to + 8ºC. vaccines in bulk. The vaccines should be transported
to the last cold storage point only through vaccine vans.
Vaccines should be transported only in Cold boxes with
Ice Lined Refrigerator (ILR)
the desired number of conditioned ice packs.
Ice lined refrigerators are lined with tubes or ice packs
filled with water which freezes and keeps the internal Cold Boxes
temperature at a safe level despite electricity failure. ILRs These are thick walled, thermally insulated boxes, used
can keep vaccine safe with as little as 8 hours continuous for transportation and emergency storage of vaccines
electricity supply in a 24-hour period. Since ILRs are and icepacks. Conditioned ice packs are placed at the
top-opening, they can hold the cold air inside better bottom and sides of the cold box before loading the
than a front-opening refrigerator. vaccines in cartons or polythene bags. A thermometer
Ice lined refrigerator has two sections—top and is also kept in the cold box. DPT, DT, Hep B and TT vials 597
bottom. Bottom of the ILR is the coldest part and in are not kept in direct contact with conditioned ice packs.
PART IV: Health Care and Services Vaccine Carriers sensitive vaccines. An icepack is adequately
It is a thermally insulated box. At PHC level they are conditioned when it sweats, i.e. beads of water cover
used for carrying vaccines (16-20 vials) and diluents its surface and the sound of water is heard on
from PHCs to session sites like subcenter or outreach shaking it.
sessions. Vaccines can be kept for a period of 12 hours, • Vaccines sensitive to heat (in increasing order of
heat stability): BCG (after reconstitution) > OPV >
if not opened frequently. Four conditioned ice packs are
Measles > DPT > BCG (before reconstitution) >
placed inside the four side walls of vaccine carriers.
DT, Hep B, JE, TT.
• Vaccines sensitive to freezing (in increasing
Day Carriers order): Hep B > DPT > DT > TT. Thus Hep B is
It is also a thermally insulated box, to carry small most sensitive to freezing.
quantities of vaccines (6 – 8 vials) to nearby sessions. • Cold chain sickness rate is the proportion of cold
Two conditioned ice packs are placed inside the day chain equipment out of order at any point of time.
carrier above and below. Nowadays these day carriers It should be kept to the minimum acceptable level
are not recommended under UIP. of less than 2%.
• Response Time is the period between sending
Ice Packs information regarding breakdown to actually
attending by a mechanic. Response Time should be
These are flat plastic containers filled with water, up to 48 hours for plains and 72 hours for hilly terrain.
the level marked on their sides. These are frozen in the • Down time refers to the time between breakdown
deep freezer and when placed in nonelectrical cold of equipment and its repair or the period for which
chain equipments such as vaccine carriers and cold an equipment remains out of service. An efficient
boxes, help increase the holdover time. They are also Sickness reporting system contributes greatly to
used to keep reconstituted measles and BCG vaccine reduce the cold chain sickness rate by reducing the
on the hole during an immunization session. Down Time of the equipment. The down time
should be less than 2 weeks for plains and 3 weeks
Thermometers
for hilly terrain.
Either dial or stem (alcohol) thermometers are used to • Bundling is the simultaneous availability of a
measure the temperature during storage of vaccines. number of related supplies, which ensures that
Alcohol thermometers are more sensitive and accurate vaccines are always supplied with diluents, droppers,
as they can record temperatures from – 50ºC to + 50ºC AD syringes and reconstitution syringes, in
and can be used for ILRs and deep freezers. corresponding quantities, at each level of the supply
Some terminologies and general principles chain.
related to cold chain31 • Any used and date expired vials are never kept in
• FIFO: First In First Out, i.e. vaccines received first cold chain. All opened vaccine vials must be
should be dispensed first and EEFO – Earliest Expiry discarded. Keep these vials in the red bag for
First Out, i.e. early expiry date vaccines should be disinfection and disposal. DPT, DT, Hep B and TT
given first are the two important principles that are vials are not kept in direct contact with conditioned
maintained. ice packs.
• Holdover time is the time taken for increasing the • Diluents do not need to be stored in cold chain as
temperature of vaccines at the time of power failure usual, but they are kept with the vaccines so that
from its minimum range to its maximum range, proper temperature could be maintained while
subject to the condition that the equipment is reconstitution and also not to be misplaced
functioning well. For example, if the inside elsewhere. Diluents are stored in baskets of ILR for
temperature of an ILR is 2ºC at the time of power
24 hours before next session.
failure, the time taken up to reach 8ºC will be the
• Unused vaccine vials from session sites must be
holdover time of that ILR. Holdover time depends
returned to the PHC on the same day by the cold
on the frequency of opening the lid, the quantity
chain and kept in ILR with a marking. It is sent for
of vaccines kept inside with adequate space between
the boxes, exposure to direct sunlight, different the next immunization session, but has to be
seasons and in the case of nonelectrical cold chain discarded after unopened more than thrice.
equipments, the condition of icepacks placed inside. • Shake test: The shake test is used to determine
• Conditioned Icepacks: When icepacks are whether adsorbed vaccines (DPT, DT, TT or
removed from a freezer, say about – 25°C, they Hepatitis B) have been frozen at some point of
need to be kept at room temperature for long time in the cold chain. Once the vaccine is frozen
598 enough to allow the temperature of the ice at the it tends to form flakes which gradually settle to the
core of the icepack to rise to 0°C. This process is bottom after the vial is shaken. Sedimentation
called conditioning. It prevents freezing of freeze- occurs faster in a vaccine vial which has been frozen
as compared to a vaccine vial which has not been
implementation amongst the various departments to Preschool Education Children 3-6 years AWW
promote child development. Nutrition and Health Women (15-45 years) AWW / ANM / MO
• To enhance the capability of the mother to look after Education
the normal health and nutritional needs of the child
*AWW assists ANM in identifying the target group.
through proper nutrition and health education.
600
A number of new initiatives have been taken up malnutrition. Immunization of pregnant women against
use of weighing scales and arm bands, conducting home RECENT INITIATIVES
visits, maintenance of records, monitoring immunization
coverage and other important support. She acts as a • Revision in Population norms for setting up of AWCs/
liaison between the Anganwadi Workers and the Mini-AWCs.
Primary Health Center staff, which delivers the basic • Universalization and 3rd phase of expansion of the
health services of the ICDS Program between Scheme of ICDS Special focus on coverage of SC/
Anganwadi Workers and the Child Development Project ST and Minority population.
Officer (CDPO), who is incharge of each ICDS Project. • Introduction of cost sharing between Center and
The CDPO coordinates and implements the ICDS States, with effect from the financial year 2009-10,
program and is responsible for managing the project. in the following ratio: (a) 90:10 for all components
The CDPO supervises and guides the entire project including SNP for North East; and (b) 50:50 for SNP
team, including the Mukhya Sevikas and Anganwadi and 90:10 for all other components for all States
Workers, making field visits and calling staff meetings other than North East.
for this purpose. • Provision of Uniform for Anganwadi Workers and
All the Anganwadi areas in a project are divided into Helpers.
Mukhya Sevika Circles. The Anganwadi areas are also • Introduction of new WHO child growth standards
divided among Auxiliary Nurse Midwives or Multi- in ICDS: Following the adoption of new WHO
purpose Female Health Workers. Ideally, the Health growth chart there has been increase in total of
Worker’s service area will correspond to that of the normal weight children, increase in severely
Mukhya Sevika in order to facilitate joint visits to the underweight children and increase in underweight
Anganwadis. On an average, an ANM looks after five children (mild/moderate and severe) in age group
Anganwadis. A lady Health Visitor looks after the works of 0 to 6 months.
of about four ANMs. The entire project areas is also
geographically divided among the total number of PHC ACHIEVEMENTS
Medical Officers in the block. Each Medical Officer is There has been significant progress in the
responsible for all the PHC activities included in the implementation of ICDS Scheme during X Plan both
ICDS Program in his area. The organizational structure and during XI Plan (up to 2008-09), in terms of increase
of an ICDS Project is given in Figure 30.9. in number of operational projects and Anganwadi
Centers (AWCs) and coverage of beneficiaries.
WHEAT BASED NUTRITION PROGRAM (WBNP)
References
The Government of India allocates food grains (wheat
and rice) at BPL rates to the States, on their demand, 1. Trakroo PL, Kapoor JD. Utilization of Health Care Services
for meeting their requirement for supple- by Scheduled Caste Population in Rural Area. Delhi:
NIHFW, 1990.
mentary nutrition to beneficiaries under the ICDS 1a. WHO. International Classification of Diseases, 1977.
Scheme. 2. Baker SJ. Bull WHO 1978;56:659.
3. WHO. Sixth Report on the World Health Situation. Part One:
INTERNATIONAL PARTNERS Global analysis 1980;127.
4. Govt of India: Health Information India, 1995 and 1996.
Government of India partners with the following Central Bureau of Health Intelligence, Ministry of Health
international agencies to supplement interventions and Family Welfare, 1998.
5. Sinha K. Despite 59% drop, India tops maternal mortality
under the ICDS:
list. The Times of India. Sep 16, 2010.
• United Nations International Children’ Emergency 6. Maternal and Child Mortality and Total Fertility Rates.
Fund (UNICEF). Sample Registration System (SRS). Office of Registrar
• Cooperative for Assistance and Relief Everywhere General, India. 2011.
(CARE). 7. Jansankhya Sthirata Kosh. National Population
Stabilisation Fund. Available from http://jsk.gov.in/
603
• World Food Program (WFP). maternal_mortality _ratio.asp
PART IV: Health Care and Services 8. WHO systematic review of causes of maternal death. 23. Govt of India. Plan of Operation for the All India Hospital
Available at www.countdown2015mnch.org/documents/ (Postpartum) Family Planning Program. Dept of Family
2010 report Welfare, Ministry of Health and Family Welfare, 1971.
9. Annual report (2009 -10). Health and Family Welfare. 23a. Min of Health and FW. National CSSM Program: Module
Government of India, New Delhi. for Health Workers, 1992.
10. WHO. Risk Approach for MCH Care. Geneva: WHO. Offset 24. Integrated Child Development Services. Growth
Publication No. 1978;39. Monitoring Chart Register. 2008. Ministry of women and
11. Anonymous. Mothers and Children. American Public child development. Government of India.
Health Association 1984;4(2):5. 25. Jelliffe DB, Hofvander Y. The Health of Mother and Child.
12. Jelley D, Madelay RJ. J Epid Comm Health 1983;37: In: Hobson W (Ed). Theory and Practice of Public Health
111-16. (5th edn): Oxford: Oxford University Press.
13. Ministry of Health and FW. National Child Survival and 26. Reproductive and Child Health. Module for Medical Officer
Safe Motherhood Program: Program Interventions, 1992.
(Primary Health Centre). National Institute of Health and
14. Jelliffe DB. Diseases of Children in the Sub-tropics and
Family Welfare. Munirka, New Delhi.
Tropics (3rd edn). London: Edward Arnold, 1978;15.
27. Ministry of Health and FW. Govt of India. Annual Report
15. Tandon BN. Monograph on Integrated Training on
1999-2000.
National Programs for Mother and Child Development.
28. Indian Public Health Standards (IPHS) for Primary Health
Delhi: Central Technical Cell of ICDS, AIIMS, 1990.
16. Menon PSN. Ind J Comm Med 1987;12:58. Centers. Directorate General of Health Services. Ministry
17. Ghai OP. Management of Primary Health Care. Delhi: of Health & Family Welfare. Government of India. Revised
Interprint 1985;97-98. 2010.
18. Lechtig A, et al. Am J Dis Child 1975;129:553-56. 29. International Institute for Population Sciences (IIPS) and
19. Rush D. In M Enkin, I Chalmers (Eds): “Effectiveness and Macro International. 2007. National Family Health Survey
Satisfaction in Antenatal Care.” Clinics in Developmental (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS.
Medicine Series. London: Spastics International Medical 30. Sokhey J. National Immunisation Program. Delhi: NIHFW,
Publications, 1982;92-113. National Health Program Series No 1, 1988.
20. WHO. Tech Rep Ser No. 1966;331. 31. Immunization Handbook for Medical Officers. Department
21. WHO. Tech Rep Ser No. 1969;428. of Health and Family Welfare, Government of India.
22. Coverage Evaluation Survey. All India Report 2009. 32. Tandon BN, et al. Lancet 1981;1:650-52.
UNICEF, UNICEF House, 73, Lodi Estate, New Delhi – 33. Tandon BN, et al. Ind J Med Res 73: 385-94, 1981.
110003. INDIA 34. Integrated Child Development Services Scheme. Available
at www.wcd.nic.in/icds.
604
Family Planning and
31 Population Policy
The family in its literal sense, is a unit consisting of planning. The idea of limiting or planning the family is
husband, wife and children. It is a well-knit permanent now new. In olden times, the attempts at birth control
unit of society and the members are dependent on each were based on coitus interruptus, douches, postures, safe
other for all-round health and welfare—physical, period and the insertion of cotton, lemon or other odd
mental, social and economic. things in the vagina to prevent the union of germ cells.
Abortion and infanticide were also resorted to self-
What is Family Planning? restraint or abstinence was also advocated.
Birth control services involve guidance about the
Most parents in India have limited physical, social and timing, spacing and number of children, education regar-
economic resources, adequate only for a limited number ding contraceptive methods and the provision of facilities
of children. Too frequent conceptions may be incom- for the same. The aim should be to produce children
patible with health and socioeconomic resources of the by choice and not by chance. Unwanted pregnancies in
parents. If there are too many children in a poor family, married or unmarried women are associated with higher
they are deprived of adequate care and tend to be illno- morbidity and mortality in mothers and children. A high
urished and unhealthy. Large family size adversely affects abortion rate clearly indicates a high rate of unwanted
the health and happiness of each member of the family. pregnancies.
Family planning would thus mean planning the size of
the family in a manner compatible with physical and TIMING OF BIRTHS
socioeconomic resources of the parents and conducive
to health and welfare of all members of the family. It It implies the age at which women should conceive.
has been defined by WHO as, “a way of thinking and Maternal morbidity, mortality, complications of preg-
living that is adopted voluntarily, upon the basis of nancy and delivery are highest when the mother’s age
knowledge, attitudes and responsible decisions by is below 20 and over 35 years. Neonatal and fetal deaths
individuals and couples, in order to promote the health are lowest for mothers in their twenties. Congenital
and welfare of the family groups and thus contribute anomalies are more common in children born to elderly
effectively to the social development of a country”.1 mothers. Thus the safest time for conception is when the
Another descriptive definition by WHO2 is as follows: woman is in her twenties.
Family Planning refers to practices that help
individuals or couples to attain certain objectives: SPACING OF BIRTHS
• To avoid unwanted births Closely spaced pregnancies are associated with anemia
• To bring about wanted births and various complications during pregnancy and deli-
• To regulate the intervals between pregnancies very. Late fetal and early neonatal mortality are lowest
• To control the time at which births occur in relation when the interval between the termination of one
to the ages of the parent pregnancy and the beginning of the next is not less than
• To determine the number of children in the family. 2 to 3 years. Epidemiological studies in Punjab have
shown that the infant mortality rate was highest when
Scope of Family Planning Services the birth interval was less than 24 months.
The aim of family planning is much wider than merely
NUMBER
preventing births. The full scope of family planning is
discussed below. Maternal mortality risk is slightly less with the second
and third pregnancy than with the first. It rises beyond
Birth Control the third and significantly so beyond the fifth. A small
family norm would thus bring down maternal mortality.
This term was coined by Margaret Sanger, the great Two or three children per couple is an ideal number
American lady who championed the cause of family from the point of view of health and welfare of the
PART IV: Health Care and Services family. A two-child norm is currently advocated in India for family planning. These included allocating sufficient
while China advocates a one child norm. funds for the family planning program, raising the age
of marriage (from 14 to 18 years for girls and from 18
Management of Sterility and Low Fertility to 21 years for boys) and liberalising abortion. Average
age of marriage in India in 1971 was 17.2 years for
It should not end with the clinical examination, females and 22.4 years for males. This increased to 19
laboratory tests and prescription of medicines. Efforts and 24 respectively in 1991.3
should continue till a child is born to the couple or till It is estimated that the world population was about
they decide to adopt a child or to terminate their efforts. 5 million in 6000 BC, a number that is added to the
world population every month at present. The world
Education about Sexuality population had risen to 250 million by the time of
Christ and doubled to 500 million by 1650.4 Then an
This includes educating the persons of both sexes at acceleration began. By 1750, it was 791 million, by
different ages as regards anatomical, physiological, 1850, 1262 million and by 1950, 2486 million. In
psychological, hygienic, social and ethical aspects of 1987, it was estimated to be 4998 million with annual
sexuality. growth rate of 1.9 percent. The current estimate (2000)
of world population is 6 billion with annual increase of
Advice Regarding Wise Parenthood 1.7 percent. It is likely to reach 8.5 billion in 2050 and
may not stabilize till 2150, when it is projected to be
This consists of educating the couples and unmarried
11.6 billion.5 However, the rate of increase is not the
young persons, the future parents, about the
same in all parts of the world. It varies from minus 0.4
relationship between their reproductive behavior and
percent per year in Romania to 3.4 in Angola. It is 1.8
their own health and welfare, as also that of their
percent in India.6
children, community and the country.
The population in India is estimated to be 102.7 crores
as per 2001 census. A baby is born every two seconds,
Other Aspects
about 50,000 a day. Crude death rate (sample registration
• Genetic counseling survey data) is 9.0 per thousand7 (SRS 1998). The global
• Premarital advice and examination population was 6 billion in 2000. 1.5 billion women across
• Marriage guidance the world are in the reproductive age group. 133 million
• Maternal and child health care births occur ever year in the world, which means that 247
• Early diagnosis of gynecological troubles such as births occur every minute or roughly 4 babies are born
cancer cervix every Second, somewhere in the world.8
• Termination of pregnancy, if indicated
• Services to unmarried mothers.
Qualities of a Good Contraceptive
Demographic Considerations The wide variety of contraceptives available today
in Family Planning reflects the fact that an ideal contraceptive is yet to be
developed. The desirable qualities in a good contra-
In most of the developing countries, including India, the ceptive are listed below.9
family planning services have developed on account of • Reliability, i.e. 100 percent effectiveness.
the imbalance between population growth and • Safety, i.e. freedom from associated side effects or
economic development. The National government complications.
agreed to family planning by scientific methods through • Reversibility, i.e. complete return to fertility when the
government agencies as early as 1956, when Rs. 5 method is discontinued.
crores were provided in the Second Five-year Plan. This • Low cost
was done on demographic and economic • Convenience: Long acting methods are generally
considerations, since it was realized that though the convenient for the user. Methods which are difficult
country had made all-round progress in the fields of to understand or use, those which must be used at
education, health, economy, communications and social the time of coitus, those which must be used daily
welfare, the fruits of this progress had not percolated and those which need availability of supplies at hand
down to the masses because of the simultaneous are usually inconvenient.
increase in population. India has only 2.4 percent of • Consumer control: Most present day contraceptives
the world’s land and less than 1.4 percent of world’s are meant for use by women. Only temporary male
gross domestic product but one-sixth of the world’s contraceptive in use today is the condom, over which
606 population. The government realized that development the user has full control. Development of female
of resources fell far short of the population increase and contraceptives, which they can safely use themselves,
hence decided to make all efforts to promote facilities will go a long way in promoting family planning.
• Cultural acceptability: Some methods needing contact
Each method has its own merits and drawbacks. The Source: *Combined pill is more effective than progestogen only pill.10
user may make his or her own choice according to
individual requirements and preferences (cafeteria
Coitus Interruptus or Withdrawal
approach). The effectiveness of contraceptive methods
is measured in terms of pregnancies per 100 users per It was recommended by Francis Place, who started the
year. Various methods are listed in Table 31.2 along birth control movement in England in 1823. The failure
with their effectiveness. rate is high.
It is seen that sterilization is the most effective
method. Oral contraceptives and IUD are
Periodic Abstinence (Safe Period Method)
approximately equally effective.9 The different methods
of family planning are described below. Periodic abstinence requires the couple to refrain from
TABLE 31.1: Methods of family planning sexual intercourse during the estimated time of fertility.
Ways to determine the approximate time of ovulation
• Terminal Methods
– Vasectomy and the fertile period include: a calendar method; a
– Tubectomy basal body temperature method; a cervical mucus
• Spacing or Nonterminal Methods method (Billings ovulation method); and a sympto-
– Periodic abstinence
– Barrier methods thermal method. Each of these methods requires careful
i. Physical instruction. Users of the calendar method, record the
Condom length of their menstrual cycles and calculate the time
Diaphragm
ii. Chemical
of fertility by subtracting 20 days from the length of
Foam tablet their shortest cycle (this indicates the first day of the
Jellies, creams, suppositories fertile period) and 10 days from the length of their
Soluble films longest cycle (this indicates the last day of the fertile
iii. Combined
Vaginal sponge period). The day of start of menstruation is counted as
• Intrauterine Devices (IUD) the first day of the cycle. Users of the temperature
• Hormonal Methods method take and record their working temperature and
– Oral pills
– Depot formulations
interpret the rise in temperature which follows ovulation;
• Postconceptional Methods or Medical Termination of Pregnancy abstinence is required until the 3rd day of the rise in
(MTP) temperature. Since this method denotes only the
– Menstrual regulation
– Menstrual induction
postovulatory safe period, it is rarely used now in
– Abortion isolation. Users of the cervical mucus or Billings ovul-
• Miscellaneous ation method monitor and record the sensation and
– Male contraceptives appearance of mucus at the vulva; abstinence is 607
– Antifertility vaccines
– Female condoms required during menstruation, on all days of noticeable
PART IV: Health Care and Services mucus and for 3 days afterwards (mucus becomes thin the mostly widely used contraceptive in India today. It
and profuse during ovulation and thick and scanty after also prevents venereal diseases. Its acceptability has
ovulation). The sympto-thermal method is a increased with the availability of ultrathin condoms
combination of the temperature method, the mucus available nowadays. The three types of condoms
method, the calendar method and other signs of marketed today are the ordinary type (thick,
ovulation (e.g. midcycle pain and bleeding). nonlubricated), deluxe type (thick, lubricated) and
super deluxe type (thin, lubricated). Condom
manufacture has increased to cover both family
Spermicidal (Chemical) Methods planning and prevention of HIV transmission.
• Foam tablets have been widely used for this
purpose. The tablet has to be inserted high up in Intrauterine Devices (IUD)
the vagina sometime before intercourse. The foam
They are foreign bodies introduced into the uterus and
formed locally kills the sperms when discharged.
retained as long as sterility is desired. Grafenberg in Germany
Success rate is low.
used gold and silver rings in the 1920s. A new device
• Spermicidal jelly: It is supplied along with a vaginal
(Ota ring) was introduced by Ota in Japan in 1934. The
applicator. Failure rate is high.
interest in IUDs was revived after Oppenheimer from Israel
and Ishihama from Japan published their excellent results
Diaphragm Method on Grafenberg and Ota rings around 1960.
The Lippes loop was devised by Dr Lippe (1962)
A diaphragm is a soft rubber cup with a stiff but flexible
in the USA. It is made of polyethylene but also contains
rim around the edge. Contraceptive cream or jelly is put
barium sulphate to make it opaque to X-rays. This helps
on the surface facing the cervix and the diaphragm is
in location of the loop when required. It was recom-
inserted into the vagina before intercourse. The dia-
mended in 1965 by the ICMR for large scale use.
phragm covers the entrance to the uterus and the cream
However, Copper-T has now replaced Lippes loop. The
or jelly blocks sperm movement. It must be ensured that Copper-T is a T or Y shaped IUD made of copper having
the diaphragm fits properly. The user should be properly a surface area of 200 sq mm. The copper contained
instructed about how to insert it and take it out. The dia- in it has a strong antifertility effect. The various IUDs
phragm must be checked periodically to determine that are shown in Figure 31.1.
the rubber has not deteriorated or ripped, and that the
size is still correct (the size of the uterus may change after
a full-term pregnancy, abortion or miscarriage beyond
the first 3 months of pregnancy, pelvic surgery, or a
weight change of 10 pounds or more). Because of such
constraints, the diaphragm is suitable only for urban
areas. It found great favor with the educated class in the
early years of the Family Planning Program. The failure
rate is low.
Vaginal Sponge
This has been marketed in USA and India under the
trade name “Today.” It is a small polyurethane foam
sponge measuring 5 cm × 2 cm, saturated with a
spermicide nonoxynol-9. It is less effective than the
diaphragm.
Condom
The condom is a sheath of thin rubber (latex) which
is put on man’s erect penis before intercourse to collect
the semen, keeping the sperm from entering woman’s
vagina. About ½ inch of the condom is left slack to hold
the semen. After climax, but before losing his erection,
the man must hold the rim of the condom against the
608 penis as he withdraws, so that the condom does not
slip off and the semen is not spilled. A new condom
must be used for each act of intercourse. Condom is Fig. 31.1: Commonly used intrauterine devices
The IUD’s have been labeled as first, second or third • The Copper-T is very cost-effective over time.
Miscellaneous CONTRAINDICATIONS
The Central Drug Research Institute, Lucknow, has • Absolute: Recent history of jaundice or liver disease,
developed a nonhormonal, nonsteroidal contraceptive polycystic ovarian disease, chronic cervicitis or
by the name Centchroman. It is marketed under the cervical hyperplasia.
brand name Saheli. Its uniqueness lies in its being a • Others: Severe allergic conditions, chronic illnesses
postcoital agent which is taken as a once-a-week tablet like tuberculosis and renal disease, and first six
instead of continuous administration required with months of lactation.
steroidal contraceptives. Less frequent administration of In comparison to hormonal pills, Centchroman is
Saheli makes it safer and more economical. Its effect free from several side effects, both minor and common
is reversible. It is being produced and marketed by (headache, nausea, soreness of breasts, weight gain,
Hindustan Latex Ltd. spotting and dizziness) as well as rare and serious (hyper-
Centchroman exhibits its contraceptive efficacy tension, thromboembolism and coronary or cerebral
through embryouterine asynchrony resulting from: infarction). Delayed menses occur only in 8 percent
(i) Hastened tubal transport of embryo; (ii) Accelerated cycles.
blastocyst formation; (iii) Suppression of uterine decidua-
lisation and biochemical markers of implantation;
(iv) Delayed zona shedding and, most important of all; National Family Welfare Program
(v) Inhibition of nidation in the uterus. India was one of the first countries in the world to start
Centchroman is supplied in 30 mg tablets. The first a national family planning program, officially launched
tablet should be taken orally on the first day of menstrual in 1953. Steady progress has been made in this direction
period and twice-a-week thereafter, 3 and 4 days apart, since then. The salient features of the program are given
on the same day every week for 3 months followed by below.
once-a-week, same day every week, for as long as The Family Planning Program is being implemented
protection is desired. under the Target Free Approach since 1996. This
In case a tablet is missed, it should be taken as soon approach has been renamed as Community Needs
as possible and the normal schedule should be Assessment Approach since 1997.
continued. As an added precaution, condom should be
used.
If a tablet is missed for more than 7 days, the whole Objective
schedule should be restarted like a new user, i.e. bi- The main objective of the program is to reduce the birth
weekly for first 3 months and weekly thereafter. Cent- rate. The task of achieving such an objective involves
chroman is marketed in India under the trade names dealing with individuals in delicate matters of their
Centron 2 and Saheli 2. The pregnancy rate as calculated intimate and personal life. The number of married
by Pearl Index was 2.84. The only reported adverse effect couples, with the wife aged 15 to 44 years, is 170 per
was delayed menstruation which occurred in 8 percent 1000 population. As such, for a population of 1000
of the users.46 million, 170 million couples have to be approached to
Based on the limited data available, this novel non- help them plan their families. It has been estimated that
steroidal chemical may become an extremely important if family planning could limit the number of children per
620 new oral contraceptive. Evidence indicates that Cent-
couple to 3, 2 or 1, the birth rate would fall to 25, 17
chroman is highly effective (only 1.63 pregnancies per or 9 respectively.
Steps to Achieve the Target and 100 percent effective, IUCDs 95% and conventional
TABLE 31.6: The performance of Family Planning Methods Reproductive and Child Health Program
during the last five years
On the recommendations of the international conference
(Figures in Millions) on population and development held in 1994 at Cairo
Year Sterilization IUD Condom Oral pills (Egypt), the Government of India launched the Repro-
users users ductive and Child Health (RCH) program on
1995-96 4.42 6.86 17.30 5.00 15.10.1997 for implementation during 9th Plan period
1996-97 3.87 5.68 17.21 5.25 by integrating and strengthening all the existing inter-
1997-98 4.24 6.17 16.80 6.39 ventions under the Child Survival and Safe Motherhood
1998-99 4.18 6.07 17.31 6.87
1999-2000 4.44 6.08 18.70 6.87 (CSSM) interventions of fertility regulation and adding
the component of Reproductive Tract Infection (RTI) and
Newer Initiatives Sexually Transmitted Infections (STI). The concept of
RCH Program is to provide need based, client centers,
Following announcement of the country’s population demand driven, high quality and integrated RCH services
policy in February, 2000, the National Commission on to the beneficiaries. The program is being implemented
Population was constituted. It was decided to have a on a differential approach basis and in a phased
National Population Stabilization Fund with a seed money manner.56
of Rs 100 crore from the Central Government, with support All the districts of the country have been covered
from the corporate sector, NGOs, etc. and an Empowered under the program during 1999-2000. The main
Action Group, attached to the Ministry of Health and highlight of the RCH Program are:
Family Welfare, to give focussed attention to the five • The Program integrates all interventions of fertility
States of Uttar Pradesh, Madhya Pradesh, Rajasthan, regulation, maternal and child health with reproduc-
Bihar and Orissa. The Empowered Action Group will tive health of both men and women.
be charged with the responsibility of preparing area- • The services to be provided will be client centered,
specific programs, with special emphasis on States that demand driven, high quality and need based.
have been lagging behind in containing population growth • The program envisages upgradation of the level of
to manageable limits and will account for nearly half the facilities for providing various interventions and
country’s population in the next two decades.33 quality of care. The First Referral Units (FRUs) being
Achievements since inception: Birth rate, death rate set up at subdistrict level will provide comprehensive
and infant mortality rate have declined over the periods. emergency obstetric and newborn care. Similarly
The achievements of the family welfare program have RCH facilities in PHCs will be substantially upgraded.
been quite significant as may be seen from the • It is proposed to improve facilities for obstetric care,
indicators33 in Table 31.5. MTP and IUD insertion in the PHCs and for IUD
Maternal Mortality Ratio (per 1000 live births): 4.37 insertion in subcenters.
(1992-93) (NFHS-I);4.08 (1997) (SRS) 4.07 (1998) (SRS).
PHN/STAFF NURSES
PERFORMANCE DURING LAST FIVE YEARS On the same rationale, the PHCs/CHCs with adequate
The performance of Family Planning Methods during infrastructure for conducting deliveries will be able to
the last five years is given in Table 31.6.33 engage PHN/Staff Nurse on contract basis during the
project period or till the State Government is able to
make a regular arrangement.
ESSENTIAL OBSTETRIC CARE AND ADDITIONAL
ANM IN CATEGORY ‘C’ DISTRICTS HIRING OF PRIVATE ANESTHETIST
Essential obstetric care includes those items of obstetric 623
Emergency obstetric care is an important intervention
care, which any pregnant woman requires during for preventing maternal mortality and morbidity. One
PART IV: Health Care and Services of the deficiencies identified for providing emergency THE RCH OUTREACH SERVICES
obstetric care at FRU is nonavailability of anesthetist for
The RCH household surveys conducted in 252 districts
surgical interventions. To tide over the immediate needs,
have shown that only 53.5 percent of all children are
the States have been permitted to engage the anesthetist
fully immunized with a range of 16.8 percent in Bihar
from the private sector on a payment of Rs 1,000 per
to 89.5 percent in Tamil Nadu. The situation in the eight
case and this facility is available at subdistrict and CHC
large northern and eastern States has been a cause of
level but only for emergency obstetric care.
concern with the coverage for fully immunized children
in most of these States being below the national
24 HOURS DELIVERY SERVICES AT PHCS/CHCS average. Coverage levels for other services also followed
Institutional deliveries have beneficial impact on mater- similar pattern. For improving the maternal and child
nal mortality and morbidity as also on the health and health coverage in these States, it has been decided to
well-being of the newborn. One of the reasons demoti- strengthen outreach services by providing inputs to
vating people from seeking deliveries in the health insti- increase coverage and improve quality of immunization,
tution is nonavailability of medical/paramedical/ child health interventions and maternal health services
cleanliness staffs, especially beyond normal working by addressing gaps in service delivery and improving
hours. Therefore, the RCH program has made provi- outreach and creating demand through IEC and social
sion to provide honorarium to the PHC/CHC doctors, mobilization both in urban and rural areas within the
nurses and cleaners @ of Rs. 200, 100 and 50 districts.
respectively, per delivery, conducted by him/her
between 8 pm to 7 pm provided they are not on night Child Health
shift duty. The program will attempt to set up 24 hours
delivery services in CHCs/PHCs in as many districts as Improvement in child health and survival are important
becomes feasible. The project will be monitored on the aspects of the family welfare program. Low birth weight,
basis of implementation report for individual districts.33 diarrheal diseases, acute respiratory infections, vaccine
preventable diseases and inadequate maternal and
newborn care have been identified as major causes of
REFERRAL TRANSPORT TO INDIGENT
FAMILIES THROUGH PANCHAYATS high infant and child mortality rates in the country.
Under the RCH program, interventions like antenatal
This is sought to be provided in view of the fact that care, safe deliveries, essential newborn care, immu-
one of the causes of high maternal mortality and morbi- nization against six vaccine preventable diseases, control
dity in the weakly performing eight states, particularly of deaths due to diarrhea and acute respiratory infec-
in ‘C’ category districts of these States is weak tions are being implemented. As a result of these inter-
communication infrastructure and low economic status ventions deaths due to vaccine preventable diseases
of many families. Because of this, even if there is a have come down significantly.
complication identified during pregnancy or delivery, the
women have the delivery conducted in the village and RECANALIZATION SERVICES
frequently by untrained dais. (CENTERS OF EXCELLENCE)
This scheme was initiated in 1987 as an UNFPA and
SAFE MOTHERHOOD CONSULTANT
AVSC assisted project with Government of India contri-
To supplement the regular arrangement, provision have bution. Under the scheme training is conducted in
been made for engaging doctors trained in MTP as SM Standards for Male and Female Sterilization and in
Consultant who will visit to the PHC (including CHCs Micro-surgical Recanalization. A total of 16 Centers of
in NE States) once a week or at least once in a fortnight Excellence were set-up in Medical Colleges in different
on a fixed day for performing MTP and other Maternal parts of the country.
Health care services.
SUPPLY OF LAPAROSCOPES AND TUBAL RINGS
DAI TRAINING In order to ensure quality of laparoscopes and tubal
Reduction in maternal mortality and morbidity is one Rings, this Ministry under the Laparoscopic Sterilization
of the main goals of National Population Policy, 2000. Program of Government of India procures and supplies
Unsafe deliveries conducted at home by relatives and these items to the States/UTs.
dais are an important cause of maternal mortality and
TESTING FACILITY AT IIT, NEW DELHI
morbidity and most of these dais are illiterate, poor and
624 do not have adequate skills in conducting safe deliveries In order to ensure that quality equipments are utilized
or in identifying high risk among pregnant women in the program, a National Center for testing of IUD
during the antenatal period. and Tubal Rings was set up at the Biomedical Engineering
Wing at IIT, New Delhi, in 1986-87 with financial assistance in the country. It functions at referral center for Peripheral
632
32 School Health Services
School health is an important aspect of any community from less than 1 percent to around 10 percent. Hardly
health program. The school health program is a more than 40 percent of the school children are found
powerful, yet economical approach towards raising the to be reasonably healthy and free from defects.9 An
level of community health. Its basic aim is to provide evaluation of the School Health Program in 9 PHCs by
a comprehensive health care program for children of the NIHFW showed that 24 percent of the school children
school going age.1 medically examined had some disease or defect. Eleven
It would be more correct to use the term ‘Health Care percent of those found to have such defect had to be
of School Age Children’ rather than School Health. The referred to a specialist.10
former term indicates that school health is not something
new in itself but rather a part of the overall community
plan for child health, which should begin in the prenatal School Health Service in India
period and continue throughout childhood up to the No authentic records are available in India regarding
school years. initiation of these services. Way back in 1909, medical
School health services are not well organized in our examination of school children is reported to have been
country, especially in the rural areas. School health carried out in Baroda city for the first time in India. The
services tend to be neglected since morbidity and morta- Health Survey and Development Committee (popularly
lity are comparatively much lower at school age than known as the Bhore Committee) in 1946 noted that
in the preschool years and other periods of life. In the school Health Services were practically nonexistent in
West, the importance of this service was recognized when India.11 In 1960, the Government of India constituted
deficiencies in health status were found in soldiers at the a School Health Committee to assess the standards of
time of recruitment for the First World War. These defi- health and nutrition of school children. This Committee
ciencies were noticed too late for correction but would was also assigned the task of suggesting ways and means
have been remedied easily if they had been detected and to improve the health status of school going children.
treated during the school period. In 1961, this Committee submitted its report which con-
tained many useful suggestions and recommendations.
In view of the crucial’ importance of school health,
Health Status of School Children and the grossly inadequate inputs in it, the Government
Health surveys in Indian schools indicate that morbidity of India constituted a Task Force to propose an Intensive
and mortality rates of children are among the highest School Health Service Project which could be imple-
in the world. Morbidity of school children has been mented on a trial basis. The Task Force submitted its
studied in small surveys in Tamil Nadu, 2,3 Kerala,4 report9 in Jan 1982. According to this report, only 14
Andhra Pradesh, 5 Madhya Pradesh, 6 Punjab,7 and of the 22 states had made efforts at establishing a school
Delhi.8 Most of these surveys yielded more or less similar Health Program through their own health budgets. The
findings, the general prevalence of morbidity being as program covered only 1337 out of total 3614 PHCs in
follows:9 these states. Even in these States, the response and
Dental ailments 70-90%
performance has not been encouraging. The Task Force
Malnutrition 40-75% identified the following reasons for the poor state of
Worm infestations 20-40% school health program:
Skin diseases 10% • Lack of transport facilities for the PHC medical officer
Eye diseases 4-8%
Pulmonary TB 4-5% • Lack of budget for printing health cards, etc.
• Lack of properly trained school teachers, multi-
In addition to the above, diseases of cardiovascular, purpose workers, and other education and health
respiratory, gastrointestinal and urogenital systems were personnel who can ensure effective functioning of
also detected to varying extent in different surveys, ranging the school health program.
PART IV: Health Care and Services • Lack of proper documentation and evaluation. There are two special needs in school years:
• Lack of coordination between: 1. Health guidance: Children are continuously under-
– Different schemes and health programs within the going change—physical, mental, emotional and
health department. social. In the absence of such guidance, their growth
– Health department and outside agencies, parti- and development may be affected.
cularly the education department. 2. Education in group-living: The child plays, travels and
The Task Force suggested that an Intensive Pilot learns things with others. He has to learn to adjust
Project, fully sponsored by the Central Government, and adapt to school environment, which is quite
should be started on an experimental basis in 25 blocks different from that at home.
in the country. Choosing a block from the remote and
underdeveloped areas of different States and Union School Health Program
Territories, the pilot project was started in the year 1982-
83. During the year 1984-85, it was extended to 75 more
blocks. Objectives1
An evaluation of the Intensive Pilot School Health • Health consciousness among school children.
Project was undertaken by the NIHFW. It made the • Providing health instruction in a healthy environment.
following suggestions for the improvement of School • Prevention of disease; early diagnosis, treatment and
Health Program in order of priority:10 follow-up of defects.
• School health education needs to be intensified. • Promotion of positive health.
• School buildings and school sanitation need to be • Recognising the child as a “change-agent” in the
improved. family.
• Nutritional status of primary school children should
be improved through midday meal program,
Components
providing 50 percent of daily energy requirement and
30 percent of daily protein requirement. The school health program has three major
• Immunization services should be provided to ensure components: Health education, healthy environment
that the following goals are reached: and health service.
– 85 percent coverage of children in class I in
relation to DT and typhoid immunization. HEALTH TEACHING AND HEALTH EDUCATION
– 100 percent coverage of children in class VI and
This is the most important element of a school health
X as regards TT.
program. It does not merely imply inclusion of health
• Arrangements should be made for medical exami-
lessons in the textbooks but also includes the following:
nation of children and provision of treatment for the
• Insisting on high standards of cleanliness in the school.
morbidity detected. The guiding principle should be
• Improving water supplies and latrines and inculcating
that no medical examinations should be conducted
habits for their proper use.
unless a system of referral and follow-up has been
• Introducing healthy practical diets into the school
organized.
lunch program.
The Central Government’s School Health Project is • Demonstrating personal hygiene, such as cutting of
a step in the right direction, but it suffers from the major nails, dressing of hair, bathing with soap and water,
drawback that it is essentially a project of the Health etc.
Department, there being very little coordination with the Visits to observe community health problems should
Education Department. In contrast, the comparatively be arranged and opportunities for actual participation
much more successful ICDS, though essentially an MCH in health projects and tasks should be provided. In
activity, is a project of the Department of Women and developing countries, every school child should be
Child Development with active technical support from considered a health worker. School age children
the health sector.12 constitute an easily accessible and adaptable segment of
the population. They can contribute much towards attack
on community health problems. They take home to
Special Needs of the School Child parents all the instructions on health that they receive
The school age is a formative period, physically as well at school and can, in fact, act as health leaders in the
as mentally, transforming the school child into a promi- family.13 Even more important, they apply this know-
sing adult. Health habits formed at this stage will be ledge to their own families when they become adults.
carried to the adult age, old age and even to the next The teacher plays a very vital role in all elements of
634 generation. Thus school health service is a forum for the the school health program, especially in health education.
improvement of the health of the nation. Efforts should be made to strengthen the health
content of teacher training courses by including such ventilation and other items of environmental sanitation
MAINTENANCE OF Playground
HEALTH GIVING ENVIRONMENT It is a must for recreation and physical education.
This should include not only the sanitation of the school
premises but also the surroundings, which have moral, COMPREHENSIVE HEALTH CARE
physical and mental effect on the school child. The site It should be promotive, protective and curative, as well
should be carefully selected. It should be dry, on raised as rehabilitative.
ground, situated at a distance from the road so as to
minimize the nuisance of dust, noise and too much traffic. Health Promotion
Proper maintenance of the school building is even
more important than the site and actual construction. Health is promoted through environmental sanitation
The medical officer or sanitary inspector should advise and health education as discussed above, and by good
school authorities on different items of sanitation as nutrition, recreation, exercise and personal hygiene.
below: Nutrition plays a very vital role in physical growth and
development of the school child. Poor nutrition affects
education achievement as well. The relationship between
Water Supply
scholastic performance and nutritional status of children
If tap water is not available and the source of water is has been established. 14 A midday meal helps in
a well, proper chlorination of the well should be ensured. supplementing nutritional intake of school children.
Also, water for drinking should be available to children Physical exercise and activities in the school promote
in a proper container with a tap and a glass. In case of musculoskeletal development and inculcate team spirit.
earthenware containers, a ladle must be provided. Each Promotion of mental health can be facilitated by school
student should learn to drink water either directly from teachers. Because of direct contact with students, they
the tap or by pouring it into the mouth from a glass. can help in release of mental tension.
The waste water should drain into a soakpit or a garden. It should be done through environmental sanitation,
nutrition, immunization and guidance about safety
against accidents (especially those on the road, by
Urinals
instilling traffic sense).
They are absolutely necessary. Cheap soakpit or trench
type urinals can be provided in rural schools. The habit Curative Services
of passing urine anywhere should be curbed. They include regular medical check-up and preparation
of health cards; prompt treatment of defects; follow-up;
Latrines and referral for special problems.
Each school must have a latrine. The provision of a Medical check-up: The Medical Officer should carry
latrine in rural schools, besides being desirable for other out a detailed examination of each child in the school
reasons, is also a source of practical education to children and should fill the school health card. He may be
in appreciating the need for proper disposal of excreta. assisted by a school health assistant or a teacher for
recording general and family history, weight and height,
Refuse etc. A minimum of three examinations should be carried
out as follows:
Each room should have a refuse basket to be emptied
• On school entry at the age of 5 to 6 years.
into a compostpit. The rooms should be swept and
• On passing out from primary school at age 10 to
cleaned and all dust, paper and other refuse should be
11 years.
collected into the basket. The refuse may also be
• On passing out from middle school at age 13 to 14
disposed of by burning.
years.
In addition, periodic (twice a year) testing of
Ventilation
weight, height, vision and hearing may be done by
Enough windows, doors and ventilators should be health auxiliaries and teachers oriented towards 635
provided to admit fresh air and light. Good light and school health. Daily observations made by the class
PART IV: Health Care and Services teacher are also very useful in detecting any devia- their teachers should be instructed to pay special
tions from normal health. attention to them.
Treatment: Minor ailments may be treated at school.
All defects should be treated at the central school health HOW TO START A SCHOOL HEALTH PROGRAM1
clinic or at the PHC or dispensary. Expert help for Step 1: Organize the principals of the schools.
diagnosis and treatment should be made available. Step 2: Motivate and involve the teachers.
Follow-up of cases with defects must be done and the Step 3: Provide health education to teachers.
parents should be informed about it. Step 4: Develop resource materials and child-to-child
Special Problems activities.
• Teeth services of a full or part-time dentist should Step 5: Implement the program. It is essential to form
be available. Dental health education and a coordinating health committee for this
knowledge about caries and gingivitis should be purpose, consisting of the principal, teachers,
imparted. community leaders, parents and children.
• Eyes defective vision and squint need the services of
a specialist who should prescribe glasses and treat References
squint.
1. Rama Rao. Amla. School Health Program. Delhi: Voluntary
• Ears wax, discharge and hearing defects should be
Health Association of India, p. I, 1987.
attended to.
2. Subramaniam PTK. Indian Pediatrics 1979;16:109.
• Communicable diseases: These should be promptly 3. Sundram MV. Indian Pediatrics 1978;15:725.
treated and also notified for mass measures, if 4. Joseph MV. Indian Pediatrics 1977;14:243.
necessary. Examples of important communicable 5. Indira Bai, Ratna Malik. Indian Pediatrics 1976;13:571.
diseases are leprosy, tuberculosis, diphtheria, scabies, 6. Srivastava IK, et al. Indian Pediatrics 1978;15:667.
ring worm, etc. 7. Prabhakar, Nayar: Indian Pediatrics 1975;12:1083.
8. Dhingra DC. Indian Pediatrics 1977;14:103.
Rehabilitative Care 9. Govt. of India, Ministry of Health and Family Welfare.
Handicapped children need special care. The handicap Report of the Task Force on School Health Services.
Mimeographed document 1982; p. I.
may be:
10. Sapru R, Pandey DC. Evaluation Study of Government of
• Physical, such as serious heart disease, high myopia, India’s Intensive Pilot Project on School Health Services.
partial or complete blindness, deafness, deaf-mutism, Delhi: NIHFW, 1988.
stammering and crippling of body or limbs 11. Govt. of India: Report of the Health Survey and
• Mental, such as subnormal intelligence, mental defi- Development Committee. Govt. of India Press, Shimla,
ciency, epilepsy or delinquency. 1946.
Those with marked defects should be trained in 12. Gupta MC. Indian J Prev Soc Med 1983;14:92-7.
special institutions and rehabilitated. Those with minor 13. Bhalerao VR. World Health Forum 1981;2(2):209-10.
defects may be kept in the normal schools. However, 14. Van Rensberg. S Afr Med J 1977;52:644.
636
Geriatrics:
33 Care and Welfare of the Aged
Old age is mainly a social problem. A person, retired from Mental Problems
active job, loses status. He might have lost his spouse,
other near and dear ones and good friends. The sons, Mental changes are an inevitable accompaniment of old
daughters and young friends get busy in their own affairs. age. A certain degree of cerebral atrophy is universal
There is a painful feeling of futility and genuine loneliness, in the elderly and is associated with loss of memory and
which becomes all the more acute because of the slowing of reflexes. Sexual changes, such as menopause
increasing number of small nuclear families nowadays. in women and decrease of sexual activity in men,
The old person wants to be useful to society, to mix up aggravate mental tension. As a result, some elderly
with friends and relatives and to play with children. He persons may become irritable and high strung.
also needs security and love. These needs were, to a large Senile dementia is a well-known entity. However,
extent, fulfilled in large joint families earlier. The solution there is evidence that it is more common in USA than
lies in inculcating a feeling in the elderly that they are in China and Japan.12 A quarter of all suicides in UK
wanted and needed by others and are useful to society. occur in the elderly13 and the majority of these occur
The following suggestions are useful in this direction: in those with mental illness, usually depression,
• An elderly person should keep himself “too busy to associated with social isolation.14
be ill and too healthy to be old”. According to an Apart from appropriate psychiatric management
old saying, the panacea for old age is “Satat Udyog, when indicated, mental problems of the elderly can be
Shant Man” (Be busy, be calm). Raising the age of mitigated to a large extent through sympathetic under-
retirement would help people to be active and busy standing and sincere affection rather than through pity.
in their later years. The retirement age is 58 to 60 Loneliness has to be decreased by suitable job, hobbies,
in India in comparison to 65 in UK and USA. social service and club life, etc. As far as possible, an
Formerly, large joint families used to provide elderly person should live with or near his blood
opportunities to most old people to remain busy in relations and not be removed to old age homes. His
some suitable tasks according to their capabilities. dignity and self-respect have to be preserved. The
These opportunities are declining now with the motto should be, ‘add life to years and not merely years
gradual breakdown of the joint family system. to life’.
• They should know how to utilize leisure time when the It should be remembered that sleep is important for
active working phase of life comes to an end. Read- mental health. Contrary to general belief, the need for
638 ing, writing, and club visits, etc. are good pastimes. sleep is not reduced with age.
Physical Problems Nutritional Status
641
34 Mental Health
Mental Health is one of the three important aspects of there is no universally accepted definition of what
health (others being physical and social) incorporated constitutes mental illness. Surveys in different parts of
in the WHO definition of health. Just as physical health the country have revealed a prevalence of 1.8 percent
is subject to a lot of variations and fluctuations, so also to 10.2 percent in rural areas and 2.5 percent to 14
is mental health. Mental health is generally equated with percent in urban areas.2 The prevalence of psychiatric
happiness, satisfaction and normal behavior. It shows illness is almost same in India and the West, about 8 to
in one’s ways of thinking, adjustment in life, relationship 10 per 1000 population. During the whole life time,
with others and effective functioning in the different about 25 percent persons suffer from psychological stress
roles of daily life.1 Mental health means a harmonious or illness some time in their life. Also, one-fourth of
working of the mind, which results in a well adjusted patients seen by medical practitioners have a
personality that can: psychological basis. It is obvious that the prevalence of
• Adjust to one’s environment pleasantly without being mental illness is fairly high in both urban, and rural areas.
disturbed. In spite of the wide difference in findings of the different
• Fully utilize one’s talents in creative work and help surveys, the prevalence rates of schizophrenia and
others to do the same. organic psychoses are constant at about 2 per 1000 and
• Realize one’s own limitations and also those of others 1 per 1000 population respectively. A representative
• Be realistic in outlook, confident of one’s own analysis of admission to the psychiatry department of
capacity and able to find meaning in life. a general hospital shows the following pattern.2
• Enjoy one’s work and marital and other social
relationships, and Schizophrenia 58.3%
Affective disorders 9.8%
• Provide love and affection. Other psychoses 2.3%
Mental ill-health is one of the most disturbing and Neuroses 12.2%
disabling conditions of life. It affects not only the person Organic brain syndrome 5.2%
concerned but also his family and the community and Mental retardation 3.8%
Miscellaneous 8.5%
is made worse by the social stigma attached to it. A large
number of persons are affected, many of whom are
For comparison, the US figures for hospitalization for
children. As many as 20 percent of all patients attending
mental illness are presented below.3
general health care facilities in both developed and
developing countries do so because of psychological Schizophrenia 45.6%
Manic-depressive psychosis 7.6%
symptoms. The problem is gradually on the increase due Psychosis with mental deficiency 6.0%
to such factors as urbanization, industrialization and Alcoholic psychosis 3.0%
increase in lifespan, together with breakup of the joint Involutional psychosis 3.0%
family system, which has increased the psychiatric Senile psychosis 12.2%
Personality disorders (nonalcoholic) 4.0%
problems of the elderly. To this is added the problem Psychoneuroses 6.0%
of population explosion which has led the problem of Miscellaneous 12.6%
population explosion which has led to an increase in
poverty, disease, crime, unemployment, etc. all of which Mental ill-health is a worldwide problem. The majority
are stressful situations precipitating mental illness. It is also of cases (80%) are to be found in the developing
one of the few problems that impose a very heavy burden countries. Children below 15 years constitute one-third
on the family.1 of the global cases. Worldwide, there are about 40 million
cases of severe mental illness, 20 million cases of epilepsy
and 200 million cases incapacitated by other minor
Prevalence of Mental Illness
mental and neurological conditions. In India, mental
The prevalence of mental illness shows wide variation illness contributes to 30 percent of all causes of disability.
in various surveys. This is partly because of the fact that Roughly 1 to 2 percent (7-14 million) of the population
is affected, of which 30 percent are children, the emotional states of nervous or mental tension**. This
A drug is any substance (other than food) that produces An addict may die due to any complication, but the
changes in the physical or mental functioning of an factor which induces the complication itself is the abuse
individual. of drug which is also the real agent behind the death.
Drug use is taking a drug for medical purposes like IT IS A PERMANENT DISEASE
treating an illness, protecting the body against a disease
or to relieve pain or tension. The disease cannot be cured but can be successfully
arrested by totally abstaining from the drug. Even if an
Drug abuse is taking a drug for other than medical addict has remained sober (drug-free) for many years,
reasons in amount, strength, frequency and manner that he should not take even small doses of the drug. This
damages the physical and mental functions. will lead him to obsessive drug-taking. Hence addiction
Addiction is the result of drug abuse, which produces is considered to be a permanent disease.
both dependence and drug tolerance.
Types of Drug Abuse
Dependence
Any drug can be abused intentionally in the following
Physical dependence: It occurs when a drug user’s body ways:
becomes so accustomed to a particular drug that he • Too much: Taking too much of any drug at one time
requires the drug in order to function normally. When or taking small doses too frequently can cause prob-
a person who is physically dependent on a drug abruptly lems ranging from fatal overdose to addiction. For
stops taking it, he experiences a variety of adverse effects example, taking an overdose of sleeping pills can
which are collectively known as withdrawal symptoms. result in death.
These withdrawal symptoms are specific to the type of • Too long: A drug can be abused if it is taken regularly
the drug abused. for a long period of time. Some medicines, such as
pain killers (e.g. pethidine), can cause serious
Psychological dependence: It occurs when a drug is so
problems if they are taken after they are no longer
central to a person’s thoughts, emotions and activities
needed.
that it is extremely difficult to stop using it, or even stop
• Wrong use: A drug can be abused if it is taken for
thinking about it. Psychological dependence is marked
the wrong reasons or taken without following proper
by an intense craving and an abnormal obsession for
instructions. For example, taking phenobarbitone, an
the drug and its effects.
antiepileptic drug, for reasons other than the
Tolerance: Tolerance to a drug means requiring more and prescribed reason.
more of a drug to get the same effects. Tolerance • Wrong combination: A drug can be abused if it is
increases the physical health hazards of any drug, simply taken in combination with certain other drugs
because the amount taken increases over time. knowingly or unknowingly. Some combinations can
prove to be fatal. For example, barbiturates with
Addiction as a Disease alcohol can cause death.
• Wrong drug: With some drugs like brown sugar, the
In the year 1956, addiction was declared a disease by potential damages are extremely high and there are
the American Medical Association. It is a disease which no legitimate uses. These drugs can cause serious
can be treated and arrested. The characteristic features problems, no matter how or when they are taken.
of the disease are: With such drugs, there is no difference between use
and abuse. To use them is to abuse them.
IT IS A PRIMARY DISEASE
Addiction as such is a disease and not a symptom of Reasons for Using Drugs
a psychological disorder. It can cause mental, emotional
A person may have more than one reason to start using
and physical problems. These associated problems
drugs. People may start using drugs for one reason
cannot be treated effectively unless addiction is treated
(curiosity, pleasure, social pressure or medical reason)
first.
and may continue using it for quite another (such as
psychological dependence or group pressure).
IT IS A PROGRESSIVE DISEASE
• Curiosity: Young people are especially tempted to
The disease progresses from bad to worse. Sometimes, experiment with drugs.
there may be intermittent periods of improvement. • Emotional pressure: Some people use psychoactive 645
However, the disease invariably follows a course of drugs (those which affect the mind or behavior) to
serious deterioration over a period of time. relieve various emotional problems such as anxiety,
PART IV: Health Care and Services nervousness or depression. Others use drugs simply – Odor on breath and clothing
because they are bored. Insecure people may take – Presence of needles, syringes, strange packets, etc.
drugs to boost their self-confidence. Some young at home
people may use drugs as an expression of alienation – Preference of solitude, especially spending long
or rebellion. hours in the toilet.
• Social pressures: The social pressures for using drugs The control of drug addiction essentially involves a
can be very strong. Young people may be influenced two-pronged strategy—diminishing the supply of narco-
by popular songs glorifying the effects of drugs or by tics and diminishing; the demand for them. The former
famous singers, musicians or athletes who are known is essentially to be tackled by the government, using
to use drugs. Children are specially influenced by their various strategies such as stricter enforcement of the Nar-
parents whose casual use of alcohol, nicotine cotic Drugs and Psychotropic Substances Act. The latter
(cigarettes) and other drugs may make drug-taking strategy is primarily the responsibility of voluntary
seem normal or safe or even justifiable. organizations.
• Group pressures: In some groups, drug-taking is the
fashionable thing to do. It is the badge of belonging Mental Health Care
and the key to social acceptance. Abstainers are
excluded. There have been three major revolutions in the mental
• Availability: Drugs, both legal and illegal, are now health care in the world, the first was brought about by
more easily available. More people than ever before Phillipe Pinel in 1975 when he introduced a humane
are directly or indirectly exposed to them. approach to the mentally ill, who were earlier kept
• Previous drug use: For most people, trying a drug chained and were treated like animals. The second
for the first time is a major step. A single experiment followed the work of Sigmund Freud and his psycho-
does not mean a person will become a regular drug analysis. The third, that of community psychiatry, is
user, but it may remove some of the barriers against largely a synthesis of the first two.8 The third phase has
trying drugs again. It is also true that people who are just begun in India. The earlier policy of establishing
regular users of one drug are more likely to use other mental hospitals or asylums is now no longer followed.
drugs as well. Out of the 42 such hospitals in India, the last one at
• Dependence: Some people use drugs because they Shahdara, Delhi, was established in 1966. The present
have become phyically or psychologically dependent trend is to have psychiatry beds as part of a general
on them. It does not matter whether the drug is legal hospital under the care of departments of psychiatry.8
or illegal, mild or strong or whether it was first used
for medical or nonmedical purposes. When people Prevention and Control of
continue using a certain drug because they do not
feel right without it, they can be said to be drug Mental Illness
dependent. Primary Prevention
This relates to prevention before mental disorder
How to Identify Drug Abusers?
actually occurs. Mentals stress is probably the
Some probable signs are: commonest cause of mental ill health. Three
• Academic changes fundamental psychological needs of an individual are
– Poor attendance at school or college love, security from want and understanding of his
– Decline in academic performance difficulties by others. Stress results when these wants are
• Physical changes not fulfilled. The measures conducive to good mental
– Slurring of speech health are described below.
– Sweating at night • Personality development: For development of a strong
– Loss of appetite and well adjusted personality, a proper, pleasant,
– Reddening of eyes affectionate but disciplined environment is necessary,
– Unsteady gait both at home and school and in the society. Parents,
– Fresh injection sites teachers, religious leaders, priests and social workers
– Temper tantrums play an important role in producing such an
– Puffiness under eyes environment and helping in formation of good
• Withdrawal symptoms personality. Scouting, NCC and other such activities
• Other changes foster team spirit in the young and inculcate the
– Blood stains on clothes quality of conforming to discipline and adjusting to
646 – Disappearance of articles from home. Addicts adverse situations.
often sell articles to obtain money for the • Youth welfare: Counseling, information and
purchase of drugs employment services for the youth, who are at the
threshold of adult responsibilities, will save frustration the patient’s family. Patients who require support or
Services MOs
The service component includes three activities: Treat- • Diagnosis and management of severe mental
ment, Rehabilitation and Prevention. disorder, both acute and chronic
• Referral of difficult cases for specialist opinion to
TREATMENT district hospitals and receiving them back for further
The focus is on the following morbidity conditions: follow-up
• Acute psychoses of schizophrenia, affective or • Supervision and guidance of multipurpose workers.
unknown etiology, paranoid reactions and psychosis
resulting from cerebral involvement (e.g. malarial, Budget
alcoholic and epileptic psychosis) The Planning Commission allocated Rs. 1.00 crore for
• Chronic or frequently recurring mental illness, such implementing the program during the 7th plan.
as some cases of schizophrenia, cyclic affective psy- National Institute of Mental Health and Neuro
chosis, epileptic psychosis, dementia and encephalo- Sciences (NIMHANS), Bangalore, has been entrusted
pathies associated with intoxication and chronic the job for preparing the necessary manuals related to
organic diseases the program.
• Emotional illness like anxiety, hysteria and neurotic
depression. World Mental Health Day: 10th October
Specific forms of treatment to be administered by
various levels of auxiliaries and doctors are set out for To enhance treatment and promote mental health, the
this purpose. following initiatives have been taken under National
Mental Health Program:11
REHABILITATION • District Mental Health Program extended to 123
districts.
Maintenance treatment of epileptics and psychotics at • Upgradation of psychiatric wings of 86 medical
community level is an important rehabilitative activity. colleges or general hospitals.
Wherever practical, the rehabilitation centers would be • Modernization of 29 mental hospitals.
developed at the district level as well as at higher referral • Mass media awareness campaigns.
centers. • Research in mental health.
• Short-term training in mental health.
PREVENTION
648 • Manpower development by establishment of centers
In the initial phase, the main focus will be upon preven- of excellence and postgraduate training departments
tion and control of alcohol related problems. Later on, in mental health.
References 5. Hanlon JJ, Pickett GE. Public Health (7th edn). St. Louis:
649
Health Services through
35 General Practitioners
General practice forms the backbone of the health care General Practitioners, ‘A General Practitioner is directly
delivery system. The private doctor and hospital are the responsible for the complete and continuous medical
biggest providers of health services in India. Today there care of a patient and his family in all its aspects,
are more than 7 lakh doctors (Allopathic, RMPs, Ayurvedic, providing technical services, when necessary, with the
Unani, etc.) in India, out of which about 6 lakh work assistance of the appropriate consultant. To discharge
in the private sector. this responsibility fully, the General Practitioner must
About two-thirds of allopathic doctors are in general understand and give attention to the mental, social
practice. In addition, the majority of the medical practi- and physical factors which determine the patient’s
tioners registered with State Councils of Homeopathy, reaction to his environment.’
Ayurveda, Unani, Sidha, etc. are in general practice. Also,
there are a large number of traditional healers of medicine General Practice vs Family Medicine
rendering some sort of health care to the people.
In a comprehensive study of health care practices in Till recently, general practice implied treatment of the
Jalgaon rural and urban area, it was found that when individual. Over the last few years, it has been redesig-
persons fell ill, 77 percent went to a private doctor or nated as family medicine and general practitioners are
hospital and only 13 percent went to a government now known as family physicians. The practitioner in
family medicine treats the family as a ‘unit of living’ or
facility (hospital, dispensary, PHC or subcenter). Out of
‘unit of illness’.
the remaining 10 percent, 2 percent went to traditional
The family physician or family doctor knows all details
healers (including Vaidya, Hakim, folk healer, etc.). Two
above the family. Thus, he is in a unique position to base
percent took self medication and 6 percent took no
his approach to comprehensive care, including pro-
treatment.
motive, preventive, curative and rehabilitative aspects,
upon his knowledge of the family environment. It should
What is General Practice? be remembered that the family is the smallest unit of
social organization or community and it is here that the
The Indian Medical Association has defined general maximum interaction occurs between a person and his
practice in medicine as a discipline adopted by a surroundings. For the purpose of discussion in this
qualified medical man, called a General Practitioner chapter, the term general practice and family medicine
(GP’s), who for the purpose of alleviation of human will be used as synonyms.
ailment and suffering and for the promotion of human
health, makes use of all branches of medical science, General Practice vs Community Medicine
without restricting to any particular speciality.
According to the American Academy of General Community medicine has been defined in the first
Practice, a General Practitioner is a legally qualified doc- chapter. As a discipline of medicine, it teaches the study
tor of medicine who does not limit his practice to a of man in health or disease (not of disease in man)
particular field of medicine. He refers the patient to a and helps in finding solutions to health or disease
particular specialist or consults him when the situation problems not only in the setting of a clinic or hospital
exceeds the capacities of his own training and compe- but also in the community setting. General practice and
tence. community medicine are thus overlapping and not
The College of General Practitioners of Great exclusive of each other. However, while Community
Britain describes a General Practitioner as—“A doctor Medicine/Preventive and Social Medicine places much
in direct touch with patients who accepts continuing emphasis upon epidemiology and health services
responsibility for providing or arranging their general administration, the emphasis, instead, in Family
medical care which includes prevention and treatment Medicine/General Practice is upon primary health care,
of any illness or injury affecting the mind or any part both preventive and curative, management of
of the body.” According to the Australian College of emergencies and referral in time.
General practitioner, the doctor of first contact, plays medicine specialist must be potentially a good general
PREVENTIVE ASPECTS
Components of Family Medicine or
General Practice • The general practitioner should be able to give correct
advice to the public regarding various immunizations
The three essential components are primary care, emer- and to administer (or to arrange for administration
gencies and referrals. These are described here in detail, of) the same.
so as to give an idea about how much clinical medicine • He should know the procedure for registration of
a student of MD in Community Medicine or Preventive births and deaths.
and Social Medicine must know. This is based on the • He should be able to give suitable advice on
premise that every public health man or community maternal and child care. 651
PART IV: Health Care and Services • The general practitioner should give suitable advice COMMON MEDICAL EMERGENCIES
about methods of family planning and should help
• Anaphylactic shock: This can follow administration
his clients to get these services free through state
of sera and vaccines and certain parenteral or even
agencies.
oral drugs. The general practitioner can save pre-
• He should be familiar with the provisions and objec-
cious lives if he is familiar with immediate adminis-
tives of the Medical Termination of Pregnancy Act
tration of adrenaline, hydrocortisone and amino-
and should help women to avail of this facility in an
phylline, etc. The patient should be asked to wait
easy and graceful way.
for 15 to 30 minutes if there is possibility of
• He should make use of all services available under
anaphylaxis following the administration of a
National Health Programs, such as those for control
particular substance.
of malaria, tuberculosis, leprosy and goiter. General
• Coma: It could be a medical or surgical emergency
practitioners are often ignorant about their role in
or both and may be due to cardiovascular accidents,
passive surveillance of malaria; this is a glaring
diabetes, poisoning, hepatic failure, uremia, menin-
example of their poor skill as GP. Any patient will
gitis and electrolyte imbalance. A general practitioner
be impressed if his blood slide is examined free and
can be quite helpful in such a situation if he tries to
he is given radical treatment. Similarly, a GP will
correctly diagnose the cause of coma using his own
make a good impact on the community and the
knowledge, clinical acumen and common sense. In
patients if he gets for them the drugs for treatment
addition to putting the patient in lateral position,
of tuberculosis and leprosy.
pulling out the tongue and giving artificial respiration,
• He should have a practical knowledge about
he can administer IV fluid in dehydration and can
nutrition and its role in promotion of health and
perform stomach wash for poisoning.
prevention and control of disease, especially in the
• Myocardial infarction: Morphine (15 mg), pethidine
vulnerable groups.
(100 mg), sedatives and oxygen are the immediate
• The general practitioner should know whom to
needs. The general practitioner should know when
notify the cases of certain communicable diseases.
and how to give these and when and where to refer.
• Last, but not the least, is his vital role in health
• Bronchial asthma.
education. He should strike the iron when it is hot.
• Cerebrovascular stroke.
The patient and the family are most receptive at the
• Poisoning due to chemicals, drugs, etc.
time of illness. A general practitioner can deliver
• Encephalitis, meningitis, tetanus.
health education in a more effective manner than
• Status epilepticus.
a public health man.
• Snake and scorpion bites.
• Miscellaneous: urticaria, hyperpyrexia, heat stroke, etc.
Emergencies
The General Practitioner should be trained in handling COMMON OBSTETRIC EMERGENCIES
all types of emergencies—medical, surgical or obstetric—
till the patient gets cured, relieved or removed to a Common ones that a general practitioner may come
specialist or hospital. across are: vaginal bleeding, incomplete abortion,
toxemia of pregnancy, sepsis, prolapsed cord or hand
and abnormal presentation and position. Obstructed
COMMON SURGICAL EMERGENCIES
labor may result in tear of cervix and rupture of uterus.
• Accidents and injuries: He should be able to treat A general practitioner should be trained in carrying out
vasovagal or neurogenic shock, give IV fluids, apply normal delivery, forceps delivery and episiotomy, as also
stitches and, of course, render first aid of all sort. in management of other obstetric conditions till the case
• Acute abdomen: He should be able to decide how is referred to hospital.
to give immediate management and when and how
urgently to send the patient to the surgeon. For COMMON PEDIATRIC EMERGENCIES
example, severe pain lasting more than 6 hours, rigid
abdomen, silent abdomen, distension and low blood These include diarrhea, dehydration, hyperpyrexia,
pressure are pointers for immediate referral to a sur- convulsions and severe dyspnea associated with acute
geon while acute abdomen associated with diarrhea, respiratory infection.
dysentery, indigestion, intestinal colic and renal colic
can be managed by antispasmodics, etc. Referrals
• Foreign bodies: Foreign bodies in the ear, nose and
throat, as well as in the eyes, are a common emer- A patient may have to be referred to higher level for
652 gency, especially in children. The general practitioner proper diagnosis and management. This may be neces-
must be able to deal with them. sary in the following types of cases:
• When emergency treatment in hospital is required. early social environment at home or school and later
653
36 International Health
Health of the people in a country cannot be isolated with cholera, plague and yellow fever.1 This code was
from health of mankind in general. This is clear from ratified by only three countries and hence never came
the following examples: into force. Ten more conferences between 1851 and
• Diseases spread from one country to another. 1902 tried to reach an agreement in this direction, but
Examples are syphilis, plague, cholera, influenza and all resulted in failure.
AIDS. Syphilis was earlier known as ‘Firangi Rog’
because it was believed to have been brought to Pan American Sanitary Bureau (1902)
India by the Europeans.
• Research, knowledge and developments in the field This was the first international health agency of the world
of health should not be confined to any one country established in 1902 to coordinate quarantine
but should, rather, be freely available to the whole procedures among the various American countries. The
mankind. Pan Amercian Sanitary Code evolved by it in 1924 is
• Poor health conditions in a country are associated still in force. In 1947, the PASB was renamed as Pan
with and lead to poor development. The marked Amercian Sanitary Organization (PASO). In 1940, it was
disparity between the developed and underdeve- agreed that the PASO would function as the WHO
loped countries is a danger for world peace. Regional Office for the Americas. In 1958, the name
• Population explosion in the world has to be con- was changed from PASO to Pan American Health
tained if the human race has to survive. There are Organization.
countries in the world with near zero population
growth, while there are many countries with very International Health
high rates. The former cannot remain silent spec-
tators to the high birth rates in many parts of the PAHO is based in Washington DC. PAHO member
world when the survival of mankind itself is at stake. states include all 35 countries in the America. A major
Hence international cooperation in health, including effort of PAHO was the launch of polio eradication in
joint efforts at pollution control, is desirable. 1985. In September 1994, the Americans were officially
It is obvious from the above that health and disease declared polio-free.
of people in one country are related to health and
disease in other countries. This necessitates the need for Office Internationale d’Hygiene
international cooperation in the area of health. Attempts
Publique (1907)
at such cooperation have been made through different
agencies before the creation of the WHO after the After the American countries formed the PASB, other
Second World War. At present, the international countries also felt the need to have a permanent health
cooperation in health is being largely effected through agency to disseminate information about communicable
the WHO and other UN agencies. Bilateral government diseases and to evolve uniform quarantine procedures.
agencies and several non-government organizations also This resulted in the establishment of the Office Inter-
play a significant role in international health. nationale d’Hygiene Publique in Paris in 1907 comprising
more than 60 countries.2 The OIHP was wound up in
1950, after the WHO was established in 1948.
Pre-WHO Efforts
International Sanitary Conference (1851) Health Organization of the League of
Nations (1923)
The first international efforts, directed towards evolving
uniform quarantine regulations, were in the form of the The League of Nations was established after the First
International Sanitary Conference, 1851, in which many World War to ensure peace and stability in the world.
European countries participated, along with Turkey. The However, it was unable to prevent the Second World
conference lasted six months and resulted in an inter- War and was thus a political failure. It established a
national sanitary code comprising 137 articles dealing Health Organization in 1923 which carried out
commendable work in the field of health, hygiene, everywhere, but less-developed countries are witnessing
UNICEF FAO
The United Nations International Children’s Emergency The Food and Agricultural Organization, with its
Fund was established by the UN in 1946 to provide help headquarter in Rome, was established in 1945 with the
and relief to children in countries where the Second main objective of raising food production and ensuring
World War had caused wide damage. In 1953, it was adequate food availability in the face of increasing popu-
renamed as United Nations Children’s Fund but the lation. It plays special attention to the rural areas, where
abbreviation UNICEF was retained. it aims at increasing the efficiency of farming, fisheries
The UNICEF has the following offices: and forestry. In order to combat malnutrition, the FAO
• UNICEF Headquarter Office at New York launched in 1960 the Freedom from Hunger campaign.
• UNICEF Regional Office for Europe at Geneva The FAO is also linked to the World Food Program
• UNICEF Regional Office for Eastern and Southern (WFP) and works in close collaboration with the WHO.
Africa at Nairobi The WHO and FAO have jointly sponsored a large
• UNICEF Regional Office for West and Central Africa number of expert committees on food and nutrition,
at Abidjan the recommendations of which have been published as
• UNICEF Regional Office for the America and the Technical Report Series of the WHO/FAO. The FAO also
Caribbean at Bogota shares interest in control of brucellosis and other
• UNICEF Regional Office for East Asia and the Pacific zoonoses.
at Bangkok Since 1994, FAO has undergone major
• UNICEF Regional Office for the Middle East and restructuring. The reforms include increased emphasis
658 North Africa at Amman on food security, increased use of experts from
• UNICEF Regional Office for South Asia at developing countries and broadened links with the
Kathmandu private sector and nongovernmental organization.
UNDP of helping the poorest people in the poorest
662
37 Biomedical Waste Management
Environmental pollution has been discussed in Chapter biologicals and including human anatomical waste,
10 of the book in detail. This additional write up is animal waste, microbiology and biotechnology waste,
meant to focus on the newly emerging concern of waste sharps, discarded medicines and cytotoxic drugs,
biomedical waste management with special reference to solid wastes, liquid waste, incineration ash, chemical
medical waste management, which has assumed special waste, etc.1-3
importance because of the fear of spread of certain
infections, particularly HVB, HVC and HIV infections. Medical Wastes
A special attribute of biomedical waste is that even
though it forms only a small part of the total solid waste, Medical waste includes the various types of biomedical
if not taken care of properly, it can pollute the whole wastes related to medical use. These are as follows:
of the solid waste and thereby transfer infectivity to the • Pathological waste (human tissues such as limbs,
whole of the municipal solid waste. Once that happens, organs, fetuses, blood and other body fluids).
all the waste must be considered infected and treated • Infectious waste (soiled surgical dressing, swab
as such. Not only this, if the biomedical waste finds material in contact with persons or animals suffering
access to air and water, it has the potential of infecting from infectious diseases, waste from isolation wards,
the ambient environment as well as water sources and cultures or stocks of infectious agents from
channels. laboratory, dialysis equipment, apparatus and
disposable gowns, aprons, gloves, towels, etc.).
• Sharps (any item that can cut or puncture such as
Concept and Definition needles, scalpels, blades, saws, nails, broken glass, etc.).
• Pharmaceutical waste (drugs, vaccines, cytotoxic
Health Care Wastes drugs and chemicals returned from wards, outdated
drugs, etc.).
Waste that is generated from any health care establish-
• Chemical waste (any discarded solid, liquid or
ments, research facilities and laboratories due to various
gaseous chemicals from laboratories, cleaning,
health care activities is known as health care waste.
disinfection, etc. hazardous chemicals that are
Majority, i.e. 75 to 80% of health care wastes are
corrosive, flammable, reactive, genito-toxic, etc. non-
general wastes and nonhazardous; but rest 10 to 25%
hazardous chemicals such as inorganic salts, buffer
wastes are hazardous, which is referred as biomedical
chemicals, amino acids, sugars, etc.).
waste.
• Aerosols and pressurized containers
• Radioactive waste.
TABLE 37.4: Color coding and type of container for disposal of biomedical wastes
Color coding Type of container Waste category Treatment options as per schedule I
Yellow Plastic bag Cat. I, Cat. 2, and Incineration/deep burial
Cat. 3, Cat. 6
Red Disinfected container/ Cat. 3, Cat. 6, Autoclaving/Microwaving/Chemical
plastic bag Cat. 7 Treatment
Blue/White Plastic bag/puncture Cat. 4, Cat. 7. Autoclaving/Microwaving/Chemical
translucent proof container Treatment and Destruction/Shredding
Black Plastic bag Cat. 5 and Cat. 9 and Disposal in secured landfill
Cat. 10 (solid)
Notes:
1. Color coding of waste categories with multiple treatment options as defined as Schedule I, shall be selected depending on treatment option
chosen, which shall be as specified in Schedule I.
666 2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics.
3. Categories 8 and 10 (liquid) do not require containers/bags.
4. Category 3 if disinfected locally need not be in containers/bags.
noninfectious, and then disposal by domestic landfill. The advantage of a common facility over individual
Safety Pit or Tank for Disposal of Treated vat. Ultimately from the black vat it is disposed off with
Needles and Broken Vials municipal garbage.
The treated needles and broken vials are disposed off
in a circular or rectangular pit. It is a dug pit, having Biomedical Wastes (Management
a length 1 to 2 m and depth 2 to 5 m and is lined
with brick, masonry or concrete rings. The pit is covered and Handling) Rules, 1998
with a heavy concrete slab, which is penetrated by a The Government of India under the provision of the
galvanized steel pipe projecting for about 1 meter above Environment Act 1986 notified the Biomedical Waste
the slab, with an internal diameter of up to 50 Management and Handling rules on 20th July 1998
millimeters or 1.5 times the length of vials, whichever (BMW Rules’98). The Rules regulate the disposal of
is more. The top opening of the steel pipe have a biomedical wastes, including human anatomical waste,
provision of locking after the treated waste sharps have blood and body fluids, medicines and glassware, soiled,
been disposed in. When the pit is full it can be sealed liquid and biotechnology wastes and animal wastes. The
completely, after another pit has been prepared.11 objective is to take all steps to ensure safety of health
Use of Syringe Hub Cutter (Fig. 37.1) and environment.
After the use, needle and hub of autodisabled (AD) or The rules delineate the duty of occupiers in the
disposable syringe is inserted into the insertion hole. By treatment and disposal of Biomedical Wastes.
holding the syringe in same position, the hub is Biomedical Wastes (BMW) have been classified into 10
completely cut by using the clamp in other hand. The categories and the treatment and disposal options for
cut needle and hub will drop automatically inside the each of the categories are specified in Schedule I. The
syringe hub cutter. In addition, broken vials and treatment and disposal should be in compliance with
ampoules are also kept inside the container of hub the standards prescribed in Schedule V. Schedule V gives
cutter. These are ultimately disposed off in safety pit.11 standards for incinerators (operating and emission
standards), for waste autoclaving, for liquid waste, of
microwaving and for deep burial.
Prescribed authorities such as State Pollution Control
Boards and Pollution Control Committees to grant
authorization to hospitals are defined in the rules. An
Advisory Committee is to advise the prescribed authority
on the implementation of the rules. A schedule for
implementation of BMW rules has been laid down in
Schedule VI.
Authorization has been made mandatory to all
occupiers generating biomedical wastes excluding
occupiers of clinics, dispensaries, pathological laborato-
ries, blood bank, by whatever name called, providing
treatment/service to less than 1,000 (one thousand)
patients per month which need not obtain authorization.
DISPOSAL OF GENERAL WASTE
The Rules also provide for provisional authorization for
General waste that is being generated in the health care a trial period for one year.
668 settings is collected in a black bin followed by black bag. The Biomedical Waste Rules make the generator of
Then it is transported by black trolley and stored in black wastes liable to segregate, pack, store, transport and
CHAPTER 37: Biomedical Waste Management
dispose off the biomedical wastes in an environmentally The details pertaining to the types of containers to be
sound manner. used, their color coding and labeling have also been
The agency responsible for implementation of the provided in these rules. Recycling and reuse of
Rules is the prescribed authority to be constituted by each biomedical wastes except plastics and glassware have
State Government/UT. The tasks of the administering been prohibited.
agencies include the grant of authorization, record The advisory committee will advise the prescribed
keeping, monitoring the handling of wastes and authority as and when required. This will ensure the
accidents, and of supervising the implementation of rules. participation of medical and health, animal husbandry 669
PART IV: Health Care and Services and veterinary sciences, environment management, Awareness campaigns are necessary to inform small
municipal administration and NGOs. The committee will clinics and dispensaries to undertake proper
also ensure participation of the State Pollution Control management of BMW. Several states have successfully
Boards (SPCBs) and Pollution Control Committees. This launched such awareness drives through audio-visual
will help in the implementation of these rules. media. Ministry of Environment and Forests has also
The Rules have been formulated as a framework for appointed professional agencies to launch mass
handling and management of biomedical wastes. The awareness campaign through electronic and print media
Rules are applicable to all persons handling biomedical on a number of subjects including BMW. Training of
wastes. The duty of the occupiers is absolute. hospital staff towards proper segregation of biomedical
In order to comply with the Biomedical Waste wastes is also necessary.
(Management and Handling) Rules, 1998, a policy on
hospital waste management which lays down the References
requirements for hospital waste management form the 1. Palnitkar S. Manual on Solid Waste Management, AIILSG:
point of generation to its final disposal and establishes Mumbai. 2000;9.
managerial responsibilities should be formulated. 2. Kewalramani N, Karande A, Palnitkar S. Training module
Article 21 of the Constitution of India guarantees the on hospital waste management, Brihanmumbai Mahanagar
Palika: Public Health Department, 1999.
right of life and personal liberty. The expansive 3. Biomedical Waste (Management and Handling) Rules,
interpretation given to it by the judiciary includes the 1998.
fundamental right to clean environment with health and 4. Rao HVN. Disposal of Hospital Wastes in Bangalore and
medical care within its ambit. their impact on environment. Technical papers, Volume II,
Published by 3rd International Conference [25-26
The Central Legislations on this subject are: - February, 1995] on Appropriate Waste Management
• The Water (Prevention and Control of Pollution) Act, Technologies for Developing Countries, 1995.
1974 5. http://www.medwasteind.org/random1.htm
• The Air (Prevention and Control of Pollution) Act 6. Drucker EM, et al. The Injection Century. Lancet December
8, 2001.
1981. 7. Report of the Committee constituted by the Hon. Supreme
• The Environment (Protection) Act 1986 Court of India. Solid Waste Management in Class I cities in
• The Hazardous wastes (Management and Handling) India, 1999.
Rules 1989 8. Bennett N, Calder I, Forsyth M, Moore A, Cheng T. National
Guidelines for the Management of Clinical and Related
• The Biomedical Wastes (Management and Handling) Wastes, AGPS Press: Canberra, 1989.
Rules 1998 9. http://www.gimkerala.com/Common %20 Bio-medica l%20
• Municipal Solid Wastes (Management and Handling) Facilities.pdf
Rules 2000 for Municipal Wastes 10. Manila Times, Internet Edition, Monday, July 7, 2003.
11. Immunization Handbook for Medical Officers. Department
As per the feedback given by CPCB, the implemen- of Health and Family Welfare, Government of India.
tation of various provisions of the BMW Rules is far from Ministry of Health and Family Welfare, Government of
satisfactory. India, 2008.
670
38 Anthrax and Bioterrorism
INHALATIONAL ANTHRAX
What are the Types of Anthrax Infection?
Although case-fatality estimates for inhalational anthrax
Anthrax infection can occur in three forms: cutaneous are based on incomplete information, the rate is
(skin), inhalation, and gastrointestinal. extremely high, approximately 75 percent, even with
all possible supportive care including appropriate
CUTANEOUS antibiotics. Estimates of the impact of the delay in
postexposure prophylaxis or treatment on survival are
Most (about 95%) anthrax infections occur when the
not known.
bacterium enters a cut or abrasion on the skin, such as
when handling contaminated wool, hides, leather or
hair products (especially goat hair) of infected animals. GASTROINTESTINAL ANTHRAX
Skin infection begins as a raised itchy bump that For gastrointestinal anthrax, the case-fatality rate is
resembles an insect bite but within 1 to 2 days develops estimated to be 25-60 percent and the effect of early
into a vesicle and then a painless ulcer, usually 1 to 3 antibiotic treatment on that case-fatality rate is not
cm in diameter, with a characteristic black necrotic defined.
(dying) area in the center. Lymph glands in the adjacent
area may swell. About 20 percent of untreated cases What are the Symptoms for Anthrax?
of cutaneous anthrax will result in death. Deaths are
rare with appropriate antimicrobial therapy. These symptoms can occur within 7 days of infection:
Fever (temperature greater than 100 degrees F): The
INHALATION fever may be accompanied by chills or night sweats.
Initial symptoms may resemble a common cold— Flu-like symptoms: Cough, usually a nonproductive
sorethroat, mild fever, muscle aches and malaise. After cough, chest discomfort, shortness of breath, fatigue,
several days, the symptoms may progress to severe muscle aches.
breathing problems and shock. Inhalation anthrax is
Sorethroat, followed by difficulty swallowing,
usually fatal.
enlarged lymph nodes, headache, nausea, loss of
appetite, abdominal distress, vomiting, or diarrhea.
GASTROINTESTINAL A sore, especially on face, arms or hands, that starts
The intestinal disease form of anthrax may follow the as a raised bump and develops into a painless ulcer with
consumption of contaminated meat and is characterized a black area in the center.
PART IV: Health Care and Services In most cases, anthrax can be distinguished from the Another reason not to use nasal swabs is that most
flu because flu has additional symptoms like running nose. hospital laboratories cannot fully identify anthrax spores
from nasal swabs. They are able to tell only that bacteria
What is Postexposure Prophylaxis for that resemble anthrax bacteria are present.
Prevention of Inhalational Anthrax after
Intentional Exposure to B. Anthracis? If Patients are Suspected of Being Exposed
to Anthrax, should they be Quarantined or
Prophylaxis for inhalational anthrax exposure lies in should Other Family Members be Tested?
the use of either ciprofloxacin or doxycycline as first
line agents. High-dose penicillin (e.g. amoxicillin or Direct person-to-person spread of anthrax is extremely
penicillin VK) may be an option for antimicrobial unlikely and anthrax is not contagious. Therefore, there
prophylaxis when ciprofloxacin or doxycycline are is no need to quarantine individuals suspected of being
contraindicated.2 exposed to anthrax or to immunize or treat contacts of
persons ill with anthrax, such as household contacts,
Is There a Vaccine for Anthrax? friends, or coworkers, unless they also were also
exposed to the same source of infection.
A protective vaccine has been developed for anthrax;
however, it is primarily given to military personnel. What should be the Management When a
Vaccination is recommended only for those at high risk,
Person has been Exposed to Anthrax?
such as workers in research laboratories that handle
anthrax bacteria routinely. The antibiotics used in post Identification of a patient with anthrax or a confirmed
exposure prophylaxis are very effective in preventing exposure to B. anthracis should prompt an
anthrax disease from occurring after an exposure. epidemiologic investigation. The highest priority is to
identify at risk persons and initiate appropriate
Who should be Vaccinated Against Anthrax? interventions to protect them. The exposure
circumstances are the most important factors that direct
The US Advisory Committee on Immunization Practices decisions about prophylaxis. Persons with an exposure
(ACIP) has recommended anthrax vaccination for the or contact with an item or environment known, or
following groups: suspected to be contaminated with B. anthracis:
Persons who work directly with the organism in the regardless of laboratory tests results: should be offered
laboratory. antimicrobial prophylaxis. Exposure or contact, not
Persons who work with imported animal hides or laboratory test results, is the basis for initiating such
furs in areas where standards are insufficient to prevent treatment.
exposure to anthrax spores. Culture of nasal swabs is used to detect anthrax
Persons who handle potentially infected animal spores. Nasal swabs can occasionally document
products in high-incidence areas. exposure, but cannot rule out exposure to B. anthracis.
Military personnel deployed to areas with high risk
As an adjunct to epidemiologic evaluations, nasal swabs
for exposure to the organism.
may provide clues to help assess the exposure
circumstances.
What is a Nasal Swab Test? Rapid evaluation of contaminated powder, including
particle size and characteristics, may prove useful in
A nasal swab involves placing a swab inside the nostrils
assessing the risk for inhalational anthrax.
and taking a culture. The CDC and the US Department
of Health and Human Services do not recommend the
use of nasal swab testing by clinicians to determine What Antimicrobial Treatment
whether a person has been exposed to Bacillus should be Given?
anthracis, or as a means of diagnosing anthrax. At best,
a positive result may be interpreted only to indicate A high index of clinical suspicion and rapid administra-
exposure; a negative result does not exclude the tion of effective antimicrobial therapy is essential for
possibility of exposure. Also, the presence of spores in prompt diagnosis and effective treatment of anthrax.
the nose does not mean that the person has inhalational Limited clinical experience is available and no controlled
anthrax. The nose naturally filters out many things that trials in humans have been performed to validate
a person breathes, including bacterial spores. To have current treatment recommendations for inhalational
inhalational anthrax, a person must have the bacteria anthrax. Based on studies in nonhuman primates and
672 deep in the lungs, and also have symptoms of the other animal and in vitro data, ciprofloxacin or
disease. doxycycline should be used for initial intravenous
therapy until antimicrobial susceptibility results are
673
39 Nosocomial Infections*
Nosocomial infections (Hospital Acquired Infections) to a breach in host defense. Exogenous source involves
refer to all types of infections acquired by the patients transmission from patient to patient or from health care
while being treated in hospital, as also by hospital staff worker to patient. It can also occur after exposure of
members, volunteers, visitors, workers, salespersons and a susceptible patient to a contaminated environmental
delivery personnel, etc. visiting the hospital or working source like inadequately disinfected medical devices.
there.1 The concept of nosocomial infections may be Center for disease control (CDC) has come up with
related to the realization, almost around 150 years ago, certain specific criteria including clinical and pathological
in 1847, of Ignac F Semmelweis, then a young assistant findings, laboratory tests and imaging data for correct
to Johann Klein, a Professor of Obstetrics at University diagnosis and management of nosocomial
of Vienna, through a series of sharp clinical observations, infections.1
that identified medical practices within hospitals are a
major source and mode of spread of infections. He
demonstrated that modification of such practices led to Control Measures
control of such infections. • Handwashing with disinfectants—detergents.
Nosocomial infections continue to be a significant public • Hygienic handrubs—rubbing fast acting antiseptic
health problem worldwide because of their frequency and preparations on to both hands.
the associated morbidity and mortality, as also the increase
• Surgical hand disinfections
in cost of health care. In affluent countries the incidence
• Perioperative antibiotic prophylaxis.5
of nosocomial infections ranges between 5 and 10
percent.2 Urinary tract infections (UTIs) are the most
common type of nosocomial infections in both acute care References
hospitals and long-term care facilities. These infections 1. Garner JS, Jarvis WR, Emori TG, et al. CDC definitions
regularly account for about 40 percent of all hospital for nosocomial infections. Am J Infect Control
acquired infections and are a major source of nosocomial 1988;16:128-40.
septicemia and related mortality.3 Nososcomial pneumonia 2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG.
is the next major group of infections after UTI.4 In the early The nationwide nosocomial infection rate: A new need for
1990s, nosocomially acquired multidrug resistant vital statistics. Am J Epidemiol 1985;121:159-67.
tuberculosis (MDR-TB) presented a serious public health 3. Lohar JA, Donowitz LG, Sadler JE III. Hospital acquired
urinary tract infections. Pediatrics 1989;83:193-99.
problem, initially in the USA, and soon thereafter, in
4. Kumar P, Clark M. Pneumonia. In: Kumar P, Clark M (Eds).
Southern European Countries. Clinical Medicine (5th edn), WB Saunders 2002;891.
Nosocomial infections can occur from endogenous 5. Haley RW, Culver DH, White JW, et al. The efficacy of
as well as exogenous source. Endogenous source infections surveillance and control programme in US
involves translocation of resident microflora secondary Hospitals. Am J Epidemiol 1985;121:182-205.
679
41 Disaster Management
The initial assessment should be followed up with more detailed assessment during the rehabilitation
and recovery phase as shown in the following flow diagram3-5
681
PART IV: Health Care and Services done, feeding is done by cup rather than a bottle emotional and physical pressure, and in conditions and
because it is easy to clean/sterilize and the risk of environments, that they might not be familiar with.
infection is low.
Sanitary facilities: Adequacy and cleanliness of Management Aspects
toilets are ensured. If inadequate, trench latrines are
constructed in a suitable place away from the COMMAND POST
cooking site. Proper disposal of stools are ensured.
Proper garbage disposal The purpose of a command post is to coordinate activities
– Garbage are collected, sorted and disposed off at the disaster site. Lack of organization coupled with the
in a suitable place. presence of various rescue squads and relief groups that
– Flies are controlled by wet mopping of all rush to the disaster site (the fire department, the police,
surfaces (floors, furniture) with cleaning solution Red Cross brigades, mobile hospital units, emergency
and insecticide spraying. medical services, and volunteers) cause chaos. In order
– Cleanliness in and around the camp is to avoid this, a single authority for operations must be
maintained by health education and supervision. established to coordinate activities at the disaster site,
• Many people with chronic diseases have lost their including health actions. This role is usually assigned to
drugs and records, and do not have access to clinics. a ranking officer of the police or fire department.
These areas need special attention.
• Injuries are among the commonest health problems FUNCTION OF THE COMMAND POST
immediately after a natural disaster.
• The psychological impact of trauma on children is The essential functions of a command post are to provide
more severe than in adults, but children are unable a preliminary evaluation of the magnitude of the
to express their negative thoughts. Policy planners disaster, coordinate emergency medical care, delimit the
must play an active role to relieve the psychological affected area, establish safety measures and a network
impact on the community. of emergency communications, regulate traffic, and set
• Infections are common in overcrowded camps: up a public information post for the press. The relief
dysentery, acute gastroenteritis, upper respiratory agencies or brigades working at the disaster area should
tract infections, vector borne infections (especially assign a representative to the command post. All staff
dengue and malaria), exanthemata (especially assigned to the command post should wear a badge to
chickenpox), scabies, ringworm and head lice, etc. identify themselves clearly.
• Deaths due to disaster often require medico-legal
investigation, especially for identification. MEDICAL COORDINATOR AT THE COMMAND POST
A physician with experience in mass casualty
Medical Care at the Disaster Site management should be responsible for coordinating
Experience has shown that there is usually much health activities at the disaster site. In the absence of a
confusion and disorganization in handling victims at a physician, a qualified nurse or paramedic with broad
disaster site. The convergence of numerous relief experience could be assigned to this position.
agencies tends to cause competition and results in An organized community that has a plan for disaster
ineffective action. Frequently observed problems include situations predesignates a medical authority to this role.
insufficient organization and stabilization of patients, The medical coordinator, as part of the command post,
inadequate training for providing timely medical care, is responsible for organizing and coordinating
inappropriate distribution of patients to hospitals, emergency medical care and for mobilizing and
deficiencies in communication coordination, and an transporting victims from the disaster site to hospitals.
absence of a person in authority and command. This coordinator should be a professional with sufficient
authority over the medical and paramedical personnel
Potential Risks at the Disaster Site to assign tasks and areas of action. The medical
coordinator works closely with the physician responsible
Health staff (physicians, paramedics, and rescue squads) for classifying the patients by degree of urgency and with
can potentially be at risk for accidents at the scene of the assistant responsible for transportation.
the disaster, owing to toxic gas leaks, asphyxiation by
smoke, secondary fires, explosions, collapses, electric
TRIAGE
discharges, and others. Although these risks are not
common to all disasters, personnel must be adequately The word triage is of French origin and means selection
prepared for safety measures. Carelessness could lead or categorization. The concept of triage in a disaster
682 to a secondary disaster. It is also important to point out situation means classifying victims in order to assign
that personnel at the disaster site work under high priorities for medical care and transportation.
treatment and transportation to hospitals. Emergency
691
PART IV: Health Care and Services State Level International Day for Disaster Reduction:
14th October
Usually a Joint Director or a Deputy Director of Health
Services under Director of Health Services in the state This day is dedicated to strengthening of pre-disaster
is responsible for crisis management, coordination, prevention, preparedness and steps for mitigation
monitoring and implementation. He has information measures and prompt and efficient response, National
about key personnel involved in disaster management Disaster Management Authority (NDMA) has strived to
at the Center, State and District Level. train the community to face challenges of both natural
and man-made disasters.
District/PHC Level
At district level, the chief medical officer/Civil Surgeon References
is responsible to implement and coordinate health 1. Govt. of India, DGHS, Min. of H & FW [1995]. Health
sector activities. He has details of information about Sector Contingency Plan. Also available at http://
officers involved in disaster management at state, district www.whoindia.org/SDE/EHA/EHAHome.asp
and PHC level. 2. Govt. of India, DGHS, Min. of H &FW [1995]. ]. Health
Sector Contingency Plan, Part III: Guidelines For Mass
Casualty Management Hospital Contingency Plan. Also
Non-governmental Organizations available at http://www.whoindia.org/SDE/EHA/
HealthContingency/Part%20III.pdf]
There are a number of NGOs which are functioning 3. Guidelines on Disaster Management. A compilation of
in the field of disaster management. Most of them are expert guidelines on providing Healthcare.
small and work locally. However, Indian Red Cross 4. Dualeh M, Shears P. Refugees and other displaced
Society and Ramakrishna Mission are the two populations. In: Detels R, McEwen J, Beaglehole R, Tanaka
organizations, which take very active part in disaster H (Eds) Oxford Text Book of Public Health, 4th edition.
management. As a matter of fact, these two Oxford University Press, 2002; pp. 1737-53.
5. Shmona K. A typical course of disaster, Community Stress
organizations supplement government efforts. They
Prevention Centre, 2005; Tel Hai College, Israel.
have sufficient infrastructure to provide immediate 6. WHO. Myths and realities in disaster situations. 2005.
facilities within shortest possible time. Details of the role Available: http://www.who.int/hac/techguidance/ems/
played by Indian Red Cross in disaster management myths/en/
are given below. 7. WHO. Handbook on emergency field operations, Geneva,
World Health Organization. 1999.
Indian Red Cross Society 8. Govt. of India, DGHS, Min. of H & FW [1995]. Health
Sector Contingency Plan, Part II:Planning For Natural
Besides its activities related to mother and child Disaster. Also available at http://www.whoindia.org/SDE/
welfare, including nutrition program, arrangements of EHA/HealthContingency/Part%20II.pdf]
relief to the victims of epidemics, earthquakes, cyclones, 9. Govt. of India, DGHS, Min. of H & FW [1995]. Health
droughts, floods and natural and industrial calamities Sector Contingency Plan, Part I: Planning for Biological
Disaster. Also available at http://www.whoindia.org/SDE/
is also a function of the Red Cross. They also provide
EHA/HealthContingency/Part%20I.pdf
paramedical education in fields like first aid, nursing 10. National Disaster Management Authority. Government of
and blood banking. Promotion of voluntary blood India. Available at www.ndma.gov.in
donation is an important activity of the society. There 11. Govt. of India, DGHS, Min. of H &FW [1995]. Health
is a network of 51 blood banks run by Red Cross in Sector Contingency Plan, Part V: Planning For Chemical
11 states. Medical relief is extended to the community Disasters. Also available at http://www.whoindia.org/SDE/
through their static and mobile units. EHA/HealthContingency/Part%20V.pdf
692
Index
Index
boxes 598 Congenital Cycle in
chain malaria 311 man 306
equipments 597 rubella syndrome 184 mosquito 307
monitor 600 syphilis 274 Cyclones 690
sickness rate 599 varicella syndrome 177 Cysts of Entamoeba histolytica 56
Collection of Consequences of iron deficiency anemia
sputum 202 417
D
vital statistics 463 Conservation of nutrients 405
water samples 59 Constipation 230 Dai training 594, 625
Colombo plan 660 Consumer Protection Act 140 Danish
Color coding scheme 665 Contact International Development Agency
Coma 652 diseases 260 382
Combination of cold cloud duration 331 infections 168 Save Children Fund 270
Combined isolation 158 Dapsone 266
extraction and propulsion system 51 poisons 121 Death rates 471, 472
pill 612 survey 263 Deep
Common time 61 freezers 598
cold 170 tracing 277 well 53
medical emergencies 652 transmission 166, 261 Deer fly 115
nutrition problems in India 413 Content of primary health care 552 Definition of
obstetric emergencies 652 Control of disaster 680
pediatric emergencies 652 communicable diseases 483, 536 epidemiology 11
surgical emergencies 652 diarrheal diseases 220 poliomyelitis 245
Communicability period 187 disease in dogs 347 surveillance 383
Communicable infection 417 types of cases 203
disease 153, 155, 161, 168, 507 influenza 173 Degree of sunshine 46
program 541 local endemic diseases 541 Dehydration 217
period 155 maternal morbidity and mortality 579 Delivery of National Public Health
Communications skills 567 noncommunicable diseases 483 Programs 509, 514
Community Controlled fertilization 127 Delphi technique 455
education 278 Copper Demographic
level interactions 541 acetoarsenite 113 considerations in family planning 606
medicine 2 sulfate 64 gap 460
mobilization 431 T intrauterine device 615 stages 460
participation 317, 430 Cor pulmonale 368 transition 460
in primary health care 552 Corea 364 Demonstration of viral nucleic acid 283
surveys 465 Corneal pathology 378 Dengue 329
Complement system 148 Coronary hemorrhagic fever 329
Complicated measles 180 artery disease 644 Density of infection in mosquito 322
Complications of disease 147 Dental caries 393, 677
delivery 577 Corynebacterium diphtheriae 187 Deprofessionalization of medicine 3
gonorrhea 275 Cost Dermacentor andersoni 341
hypertension 367 benefit analysis 526 Dermal leishmaniasis 335
Complimentary feeding 584 effectiveness analysis 527 Dermatitis 117
Components of methods 495 Determinants of health 6, 551
antenatal checkups 582 utility analysis 528 Determinate leprosy 262
dots plus 206 Cowie’s sign 182 Developing innovative partnerships 372
family medicine 651 Crude death rate 471, 475 Development of
MCH care 581 Cryptic malaria 311 brain 127
primary health care 533 Cryptococcal meningitis 284 human resources for health 482
syndromic case management 293 Culex 112 Dharmendra’s scale 266
Composition of cow’s milk 398 fatigans 322 Dhobie’s itch 303
Comprehensive quinquefasciatus 310, 323 Diabetes 174, 369, 372, 393, 394
health care 635 tritaeniorhynchus 331 Control Program 483
primary health care 552 Curative services 540, 635 Diaphragm method 608
Compressed natural gas 49 Curb parking 375 Diarrhea 220, 221, 228, 318
Concentration method 322 Current Dibutyl phathalate 124
Concepts of contraceptive prevalence 622 Dichloro diphenyl trichlorethane 122
disease 8 estimates of TFR 470 Dieldrin 122
health 5 flaccid paralysis 249 Dietary
prevention 8 Policy of Insecticide Use in India 114 fiber 393
Concurrent disinfection 156, 162 status of poxvirus disease 176 improvement 416
Condom 608 Cutaneous anthrax 349, 671 sucrose 678 695
promotion 290 Cyanocobalamin 397 Diethyl stilbesterol 37
Textbook of Preventive and Social Medicine Diethylcarbamazine 324 Elimination of breeding places 112, 115 Father of
Diethylstilbestrol 615 Emergency Indian
Different scales of measurement 434 contraception 615 medicine 3
Digestive system 149 immunization 687 surgery 3
Dihydrofolate reductase inhibitors 312 Emerging infections 352 medicine 3
Dilemma of adolescent hypertension 366 diseases 352 public health 3
Dimethyl Employees State Insurance Act 95 surgery 3
carbate 124 Endemic typhus 340 Fats soluble vitamins 395
phthalate 119, 124 Energy 406, 523 Fecal streptococci 59
Diphtheria 153, 170, 186, 687 rich foods 398 Female condom 615
Diphyllobothrium latum 255 Entamoeba histolytica 236 Fenthion 123
Direct Fertility rates 469
Enteric fever 153, 230
chlorination 79, 80 Fertilizer 103
Enterobius vermicularis 256
droplet transmission 166 Filariasis 153, 319
Environmental
fluorescence assay 178 Final treatment of disinfection of sewage
health 657
standardization 473 79
pollution 99
transmission 154, 160 Financial allocation 325
Disablement benefit 97 protection 505 First
Disaster sanitation and safe water supply 536 aid appliances 94
Assessment 680 Epidemic line drugs 334
Management Structure in measures 162 stage larva 321
Health Sector 691 typhus 117, 339 vaccine developed 3
India 691 Equivalent sterilizations 623 Fish tapeworm 255
Disease Eradicate and eliminate certain diseases Fixed-dose combinations 287
surveillance 382, 541 551 Flat type of smallpox 175
under Surveillance Project 383 Erythromycin 365 Fluorine 57
Disinfected water 59 Escherichia coli 228 Flush cistern 77
Disinfection 156, 163, 189, 199, 219 ESIC Pehchan Card 98 Fly control measures 115
Disposal of Essential Focus group discussion 454, 565
biomedical waste 665 fatty acids 392 Folic acid 397
general waste 668 newborn care 592 Food
wastes and effluents 93 Estimates of world population 461 and nutrition 388, 389
DNA vaccines 288 Ethinyl estradiol 615 animal transmitted 251, 253
Dog tapeworm 254 Ethyl fortification 416
Domestic refrigerators 598 hexanediol 124 hygiene 423
Dose schedule of iron and folic acid 423 parathion 121 poisoning 228, 353
Double blinding 40 Evaluative study 29 preservation 404
Doubling time of world population 461 Excess of soluble salts 56 production data 413
Down’s syndrome 144 Execution of plan 477 security 428
Dracunculus medinensis 258 Ford foundation 661
Executive board 656
Drinking water 94 Foreign bodies 652
Exposure rate 34
Droplet Formal presentation methods 565
Extended sickness benefit 96
infection 261 Formalin 124, 165
Extending Public Health Services 510, 515
nuclei 154, 161 Formative influence 132
External
Drug Formulation of
resistance 315 atmosphere 45 hypothesis 39
therapy 368 environment 14 research hypothesis 456
toxicity 200 Extraintestinal amebiasis 235 Fortification of essential foods 428
Dry heat 164 Extrapulmonary tuberculosis 202, 284 Francisella tularensis 338
Duck embryo vaccine 346 Extrinsic incubation period 110 Frequency
Duodenal ulcer 644 curve 436
Duration of prophylaxis 365 F distribution table 435
Duties of PHC Medical Officer 537 measures 24
Family polygon 436
fascioloidae 252 table of qualitative data 435
E health 657 Fumes 87, 100
Ear discharge 318 Planning 536, 585, 605, 622 Fumigation 109, 156
Early latent syphilis 274 and contraception 540 Functions of
Earthquakes 690 and Population Policy 605 family 132
Easy detection of disease 176 schistosomidae 252 PHC 535
Echinococcus granulosus 254 Fasciola hepatica 252 under-fives clinic 590
Egg inoculation 172 Fasciolopsis buski 252 WHO 657
Electron microscopy 176 Fatality rate 155 Fungal infections 282
696
Fungi 12 Health High
Index
Fungus infections 302 administration and management atmospheric pressure 47
476, 489 prevalence of communicable diseases
care 532 532
G
of community 531 Hind Kushth Nivaran Sangh 269
Gambusia affinis 113 wastes 663 History of caries epidemic 677
Gandhi Memorial Leprosy Foundation economics 524 HIV
269 education 92, 116, 156, 163, 199, and kala-azar coinfection 334
Gaseous pollutants 99, 100 268, 278, 302, 506, 536, 556, testing 283
Gastrointestinal 561, 563 vaccine 287
anthrax 671 equity 551 viral load 283
tract 88 financing 528 Hodgkin’s disease 144, 357
Gender development index 523 infrastructure 7 Hookworm 257
Genetic insurance 506 Hormonal methods 611
configuration 6 legislation 506 Horrock’s test 63
constitution 145 manpower House drainage 77
Genital planning 487 Housefly 115
molluscum contagiosum 272 production 482 HPV testing 360
pediculosis 272 map 27 Human
scabies 272 organization in development index 523
ulcer 293 rural areas 499 health 106
Genital warts 272 urban areas 499 immunodeficiency virus 280
Geographic information system 21 planning 476 monkeypox 177
Geometric progression method 468 in India 477 nutrition 388
Germ theory of disease 3 Policies and Sustainable Health poverty index 523
German measles 170, 184 Systems 552 resource development 494
Gestational hypertension 367 Policy 476 Hydatid cyst 254
Giardia lamblia 228 Problems in India 532 Hydrogen sulfide 99
Giardiasis 237 promotion 9, 92, 146, 197, 358, 556, Hymenolepsis nana 256
Glaucoma 378, 379 586, 635 Hyperparasitemia 314
Global protection 589, 635 Hypertension 174, 365, 644
advisory committee on vaccine safety service Hyperthermia 314
193 development 657 Hypochlorites 165
health targets 551 planning 5 Hypoglycemia 314
magnitude 377 statistics 512, 517, 657
warming 105 status of school children 633 I
Glossina Teaching and Health Education 634
morsitans 114 team leadership 5 Ice lined refrigerator 598
palpalis 114 workers 539 Identification of cases of disease 161
Glucose 218 Heart diseases 174, 369 IEC training scheme 573
Glycated hemoglobin 373 Heat Immunization 163, 189, 197, 219,
Gonorrhea 272, 275 cramps 47 232, 328, 339, 602
Government Health Organization 498 exhaustion 46 of contacts 162, 286
Granuloma inguinale 272, 277 program 505
stroke 46
Great sanitary awakening 3 schedule 596
Helminthic infections 282
Group allocation design 39 Impaired consciousness/coma 314
Hemoglobinuria 314
Growth Implementation of National Nutrition
Hemorrhagic smallpox 175
chart 3, 586 Policy 430
Hepatitis
monitoring 586 Inactivated
A 238
rate 461 vaccine 288
Guillain-Barré syndrome 193 with hepatic coma 27
whole cell vaccine 232
Guinea worm 258 without hepatic coma 27
Incubation period 18, 157, 172, 180, 196,
B 240
216, 234-236, 241-244, 274-277, 302-
vaccination 243 304, 327, 330-334, 339-344, 348-350
H C 243 Indalone 124
H1N1 influenza 174 D 243 Indeterminate leprosy 262
in humans 174 E 244 Indian
in pigs 174 G 244 Council of Medical Research 43
Haddons matrix 375 Hepatocellular toxicity 200 Red Cross Society 692
Haemophilus influenzae 193 Heptachlor 121 Systems of Medicine and
Handflush water seal latrine 75 Herd immunity 156 Homeopathy 484
Hard ticks 119 Herpes progenitalis 272 Indications for Passive Immunization in
Hardness of water 57 Hexachlorocyclohexan 122 Emergencies 687
697
Textbook of Preventive and Social Medicine Indicators of provision of health care 8 Iodization of salt 421 M
Indirect Ionizing radiation 86, 164, 405
air-borne 166 Iron MacConkey’s
hemagglutination 236 absorption 417 broth 58
standardization 473 deficiency 415 fluid medium 58
transmission 154, 160 anemia 416 Madrid Classification 262
Induced malaria 311 nutritional anemia 426 Magnitude in India 377
Infant supplementation 417 Main causes of iodine deficiency in India
mortality rate 577 Ischemic heart disease 362 419
parasite rate 309 Isolation 158, 163, 192, 199, 264, 274, 286 Mainstreaming of AYUSH 547
Infectious disease 157 of Bordetella pertussis 190 Major
morbidity 18 of virus 185 blinding disorders 378
Infective hepatitis 153 Itch mite 119 causes of maternal mortality in India
Infectivity rate 322 Ivermectin 324 578
Influenza 153, 170 Malaria 153, 305
Infrared radiation 85 Malignant
Inguinal swelling 293 J hypertension 367
Inhalational anthrax 671 Janani Suraksha Yojana 583 pustule 349
Injectable killed whole cell vaccine 219 Japanese encephalitis 330 tertian malaria 305
Innate defense mechanisms 147 virus 331 Malnutrition 209, 532
Insect growth regulators 113 Jaundice 314 Management of
Insecticide 56, 120, 158 John Snow’s Classic Study on Cholera child with
resistance 125 Epidemic 36 acute diarrhea 223
spray 116 Jungalwalla Committee 486 dysentery 226
Inspiratory whooping 190 Juvenile delinquency 644 persistent diarrhea 226
Integrated measles 180
Child Development Services 420, 600 sick child 387
Counseling and Testing Center 290 K sterility and low fertility 606
Disease Surveillance Project 382 STI/RTI 290
Kala-azar 333
financial envelop 594 Mansonia 112
Kaposi’s sarcoma 284
Management of Childhood Illness 385 annulifera 323
Kartar Singh committee 486
Noncommunicable Disease Control Mass Blood Survey 318
Kashi Kushth Seva Sangh 270
Program 483 Maternal
Kernig’s sign 192
Rural Development Program 429 and child health 505, 539, 576, 581
Kyasanur Forest disease 338, 343
Vector Management 112, 317 deaths 467
Internal atmosphere 45 health 539
International L morbidity 577
Aircraft Regulations 328 and mortality 577
Classification of Diseases 26 Lactobacillus acidophilus 147
Larvicidals 112 mortality 577, 578
Day for Disaster Reduction 692 ratio 577, 623
Death Certificate 467 Leishmaniasis 332
Lepromatous 263 Maturation pond 80
Diabetes Federation 373 Measles 153, 170, 179, 380
Sanitary Conference 654 Lepromin test 261
Leprosy 153, 260 Measures of
Vaccination Certificate 328
Mission 269 central tendency 439
Interval scale 435
Organizations in India 269 dispersion 439
Intestinal
vaccine 268 prevention and control 217, 235
amebiasis 235
Leptospira interrogans 349 Medical
anthrax 349
Leptospirosis 348 rehabilitation 483
malaria 305
Leptotrombidium akamushi 120 Termination of Pregnancy Act 617
Intestines 196
Levels of Mefloquine 312
Intradermal
health education 568 Meningococcal meningitis 170, 191
schedule 346
test 234 noise 106 Meningococcemia 191
Intramuscular schedule 346 planning 476 Menstrual
Intrauterine devices 608 Levonorgestrel 615 induction 616
Intravenous IUD 611 regulation 616
drug users 281 Line Chart or Graph 436 Mental
rehydration 218 Live attenuated vaccine 288 disease 644
Introduction of Louse borne typhus 339 health 511, 516, 642
new pathogen 168 Low care 646
semisolids 585 activity wastes 104 Methane 105
Invasive cervical cancer 284 atmospheric pressure 47 Methods of
Investigation of contacts 162, 286 birth weight 209, 577, 581 family planning 607
and source of infection 163 Lower sewage disposal 79
Iodine 63, 165, 394 abdominal pain in females 293 surveillance 384
698 Methoxychlor 122
deficiency 418 chest wall indrawing 210
disorders 426 Lymphogranuloma venereum 272, 276 Methyl bromide 124
Microfilaria National Non-agglutinating vibrios 215
Index
density 322 AIDS Control Non-bacterial food poisoning 228
rate 322 Organization 283 Noncholera vibrios 215
Mid-upper arm circumference 412 Program 288 Noncommunicable disease 542
Mid-day Meal Program 421 anti-malarial program 312, 317 Nongonococcal urethritis 272
Mifepristone 615 Cancer Control Program 361, 483 Non-governmental organizations 692
Mild protein-energy malnutrition 415 Diabetes Control Program 374 Nonparalytic aseptic meningitis 245
Milk Disease Surveillance Network 512, 517 Nonscalpel vasectomy 618, 626
and milk products 398 Drinking Water Mission 65 Nonspecific
borne diseases 399 Family bacterial infections 170, 186
Mineral oils 113 Health Survey 627 viral infections 170
Mini nutritional assessment 639 Welfare Program 620 Normal curve 441
Minimum Filaria Control Program 325 Nosocomial infection 159, 674
needs program 479, 549 Health Nosopsyllus fasciatus 116
wage administration 430 Committees 485 Notification of diseases 465
Null hypothesis 443
Minipill 613 Planning 478
Nutrition 388, 481
Mites 119 Policy 502, 507
policy instruments 427
Mode of Programs 537, 541, 549
Status of India 425
spread 232, 235, 275 Immunization
Nutritional
transmission 161, 172, 188, 195, Day 249
anthropometry 411
216, 239, 241, 244, 247, 256, 274, Program 596 blindness 379
311, 323, 329, 334, 339-341, 344, 350 legal Services Day 142 deficiency states 413
Model registration system 466 leprosy Eradication Program 270 status 13, 148, 210, 639
Moderate protein-energy malnutrition malaria Control Program 313
415 mental Health Program 483, 647
Modified District Cancer Control Program NGOs 631 O
361 Nutrition Obesity 370, 393
Moist heat 164 Policy 424 Occult filariasis 320
Moniliasis 272 Programs 419 Occupational
Monitoring of nutrition Nutritional Anemia Prophylaxis Hazards 91
programs 429 Program 423 Health 513, 518
situation 431 Population Policy 629 Legislation 93
Monounsaturated fatty acids 391 Program for Services 506
Monovalent vaccines 250 Control of Blindness 381, 550 O-Chlor-diethylbenzamide 124
Mop up immunization 249 Maternal and Child Health 591 Ocular leprosy 380
Morphological index 266 Rural Health Mission 595 Odor elimination 75
Mortality Sample Survey 465 Onchocerca volvulus 321
indicators 7 STD Control Program 278 Onchocerciasis 379, 382
rate 159 Vector Born Disease Control Program Oral
Motivation of eligible couples 622 313 cancer 675
Motor Water Supply and Sanitation Program candidiasis 676
accidents 374 550 cholera vaccine 219
vehicle Natural Disaster 690, 684 contraceptive 367
accidents 374 Management in India 690 pills 206
emission control 102 ventilation 51 diseases 675
Movement of air 47 Nature of glucose tolerance test 373
Mudaliar committee 485 disease 8 Health Programme 483
Mukherjee committee 486 immunity 198 hygiene 149
mucosal diseases 676
Multi-drug soil 46
polio vaccine 249
resistant tuberculosis 206 Neisseria
rehydration
therapy 265 gonorrhoeae 275
salt solution 217
Multi-factorial causation of disease 3 meningitides 192, 193
solution 223
Multifactorial disorders 145 Neonatal therapy 217, 218
Multiple tube technique 58 deaths 467 Ordinal scale 435
Mumps 170, 182 mortality rate 577 Organic sulfides 99
Mushroom poisoning 228 tetanus 351 Organizational structure 383, 656
Mycobacterium Nerve tissue vaccines 345, 347 Organochlorines 122
leprae 260, 561 Nervous system 150 Organophosphorus toxicity 123
tuberculosis 195 Neurotic disorders 644 Oropharyngeal candidiasis 284
Mycoplasma pneumoniae 186 New drug development process 41 Orthotolidine
Myocardial infarction 652 Niacin 396 arsenite test 62
Nicotinic acid 396 test 62
Nitrates 57, 59 Oseltamivir 174
N
Nitrous oxide 105 Oxidation 699
Nasal swab test 672 Noise pollution 99, 106 ditch 79, 80
Nasopharyngitis 191 Nominal scale 434 pond 79
Textbook of Preventive and Social Medicine Oxides of nitrogen 99 Planning of Principles of
Ozone 62, 99, 105 health education 568 chemotherapy 199
methods 31 communication 563
Plasma glucose 314 compliance 459
P health
Plasmodium vivax 305
Painful swelling of joints 318 Pneumococcal polysaccharide vaccine education 561
Pan American Sanitary Bureau 654 186 promotion 557
Panchayati Raj 500 Pneumoconiosis 90 immunization 148
Pantothenic acid 397 Pneumocystis carinii 282 public domain 459
Pap smear 360 Pneumonia 170, 210, 211 rehydration 217
Pappataci fever 332 totality of responsibility 459
Pneumonic plague 335
Paragonimus westermani 252 Production of vaccines 600
Poecilia reticulata 113
Progestasert IUD 611
Paralytic poliomyelitis 245 Poison baiting 109 Progestin-only pill 613
Parasite demonstration 333 Polio 153 Prognostic tests 283
Paratyphoid fevers 233 eradication 248, 249 Program Against Micronutrient Malnutrition
Paroxysmal stage 190 Poliomyelitis 244 483
Pasteurella tularensis 102 Poly unsaturated fatty acids 391 Progressive
Pediatric Polyarthralgia 364 disease 645
morbidity 579 Polyarthritis 364 varicella 177
and mortality 579 Polygamy 133 Promoting consumption of vitamin A rich
mortality 579 food 422
Polynuclear aromatic hydrocarbons 57
Pediculus Promotion of mental health 92
Population
capitis 117 Protein 389
pyramid 468
corporis 117 energy malnutrition 414, 426
stabilization 503
Pelvic Protozoal infections 282
infection 610 Pork tapeworm 253
Pseudomonas
inflammatory disease 610 Post kala-azar dermal leishmaniasis 333
mallei 349
Pentachlorophenol 121 Postconceptional methods 616
pseudomallei 338
Perforation of uterus 610 Postexposure prophylaxis 291 Psychological stress 363
Performance of Family Welfare Program Postpartum Program 623, 626 Psychosomatic
483 Post-tussive Vomiting 190 diseases 353
Perinatal Potassium disorders 644
deaths 467 chloride 218 Psychotic disorders 644
mortality rate 471 permanganate 64, 165 Pubic louse 117
transmission 281 Prenatal period 577 Public
vaccine 287 Presumptive coliform count 58 Distribution System 429
Period of Prevalence of health
communicability 162, 215, 241, 247, mental illness 642 implications 54
274, 311, 323, 327, 330, 334, 342, tuberculosis infection 194 nutrition 388
344, 350 Prevention of package 529
infectivity 231 adulteration 424 software 27
Periodic interest litigation 143
blindness team 382
abstinence 607 private mix 207
deafness and hearing impairment
fluctuations 19 Pulmonary
483 anthrax 349
health check-up 92 disease in man 345
Periodontal disease 676 edema 314
fly entry 75 hypertension 367
Peritoneum 196 fly escape 75
Permanent tuberculosis 202, 368
food adulteration 429, 505 Pulse polio immunization 248
carriers 231
infection 118 Purification of
disease 645
LBW 581 pond 63
Permucosal spread 241
mosquito bites 114 tube well 63
Persistent
occupational diseases 92 water 59
diarrhea 222
radiation hazards 86 Pyrethrum 121
generalized lymphadenopathy Pyridoxine 397
syndrome 282 vitamin A deficiency 422
Personality disorders 644 Preventive vaccine 287
Pertussis 687 Primary Q
Pesticides 103 chemoprophylaxis 199
disease 645 Q fever 343
Phases in management of disasters 681
health Qualitative research methods 451
Phenoxymethylpenicillin 365
care 532, 533 Qualities of good contraceptive 606
Phthirus pubis 117
Quantitative research methods 451
Phylum arthropoda 109 center level 543
Quartan malaria 305
Place distribution 30 facilities 480
Quasi-experimental
700 Plague in India 337 hypertension 366
design 37
Plan Health Services 24 syphilis 274
studies 457
Quaternary ammonium compounds 165 Rheumatic Scrub typhus 340
Index
Quinine 314 fever 363 Second stage larva 321
heart disease 363 Secondary
recurrence 364 attack rate and attack rate 25
R
Rheumatoid arthritis 243, 644 chemoprophylaxis 199
Rabies 153, 343, 687 Riboflavin 396 health care 482, 533
in dog 343 Rickettsia hypertension 366
in man 343 orientalis 120 syphilis 274
Radioactive pollution 99, 104 prowazekii 117 Secular fluctuations 19
Rain water pipes system 78 typhi 340 Sensitivity of tuberculin test 198
Rajiv Gandhi Ridley’s Septic tank 75, 79
Gramin LPG Vitarak Yojana 70 Jopling Classification 262 Septicemic plague 336
Shramik Kalyan Yojana 97 scale 266 Serum
Rapid Rifampicin 266 alkaline phosphatase 239
Diagnostic Test 306, 313 Rimantadine 174 bilirubin 238
Household Survey 627 Ringworm 302 transaminases 238
Plasma Reagin Test 273 Rockefeller foundation 661 Severe
sand filter 60 Rodenticide 160 acute respiratory syndrome 238
Rat Role of anemia 314
bite fever 348 Civil Society 511, 517 dehydration 224
destruction 109 disposable and autodisabled syringes malaria 314
elimination 108 664 malnutrition 415
Ratio scale 435 emergency contraceptive pills 616 pneumonia 210
Rattus Local Self-government Institutions Sewage
norvegicus 107 510, 515 disinfection 79
rattus 107, 336 Routes of transmission 281 farming 79, 80
Raw sewage disposal 78 Rubella 170, 184 Sewerage system 77
Recombinant vector vaccines 288 Rural Sexual intercourse 281
Recommended Health Sexually transmitted
protein intakes for Indians 390 Scheme 538 diseases 272, 292
treatment regimens 266 Training Centers 537 infections 292
Recycling of wastes 71 Primary Health Care 480, 534 Shake test 599
Red cross 661 Shallow pit latrine 74
Reducing Shrivastav Committee 486
S
mosquito-man contact 328 Simple random sampling 442
vector population 327 Safe Single gene disorders 145
Reduction of abortion services 540 Skill development initiative scheme 98
individual exposure 105 motherhood consultant 625 Skin
noise period method 607 and mucous membranes 162
production 84 Safety of infections 318
transmission 84 mumps vaccine 183 Slaughtering of animals 89
Refuse disposal 72 smallpox vaccination 176 Slow sand filter 60
Registration of Births and Deaths Act 142 yellow fever vaccine 328 Smallpox 170, 175
Rehabilitation 10, 93, 147, 269, 590 Salmonella eradication 176
Relapsing fever 117, 341 gastroenteritis 228 Snail transmitted helminths 251
Relative bradycardia 230 infection 228 Social
Removal of typhi 231 causes of disease 134
fluorides, iron and arsenic 65 Sample registration system 465 medicine 2, 3
hardness 64 Sandfly fever 332 Socioeconomic status 133, 378
Renal malaria 305 Sanitary Sodium
Repeat bites 347 latrine 69, 74 bicarbonate 218
Reproductive tract infections 292, 594 well 54 chloride 218
Research methodology 450, 457 Sarcoptes scabiei 119 fluoride 124
Resistant hypertension 367 Saturated fatty acids 391 Soft
Respiratory Scabies 153, 304 sore 276
allergy 353 Schemes under NCCP 361 ticks 119
isolation 158 Schick test 188 Soil transmitted helminths 256
passages 162 School Solid waste 71
rate 210 Health disposal 100
system 88, 149 Program 505, 634 Source of
Restriction of conception in women 146 Service 536, 540, 633 infection 160, 187, 191, 192, 195,
Retinopathy of prematurity 36 Screening Programme 382 215, 231, 260, 273, 301
Revised Scope of Family Planning Services 605 and period of infectivity 275
Draft National Policy 507 Scorpions 118 pollution 47, 100 701
National Tuberculosis Control Screening methods 359 protein in diet 390
Programme 200 Scrotal swelling 293 water pollution 102
Textbook of Preventive and Social Medicine Special Nutrition Program 420 Syndromes under surveillance 384 Trombicula akamushi 341
Specific Synthetic Trombiculid mite 120
bacterial infections 170, 186 insecticides 113 True experimental design 37
viral infections 170, 175 peptide vaccine 288 Trypanosoma
Spectrum of Syphilis 272, 273 cruzi 118
disease 19 gambien 114
iodine deficiency disorders 419 Tsetse flies 114
T
Spermicidal methods 608 Tsutsugamushi fever 340
Spot test 421 T test 445 Tubectomy 618
Spread of infection 184 Taenia Tuberculin test 198, 202
Sputum smear examination for AFB 202 saginata 253 Tuberculoid 262
Stabilization pond 79 solium 253 Tuberculosis 170, 193
Stage of Tarapox 176 isolation 158
collapse 216 Tatera indica 336 Tunga penetrans 116
disease in man 16 Teaching methods 565 Types of
invasion 343, 348 Terminal disinfection 156 Cohort Study 34
paralysis 343 Tertiary Health Care 482 Descriptive Study 31
Staphylococcus aureus 178, 228 Tests of free chlorine 62 Drug abuse 645
Starch iodide test 62 Tetanus 153, 350, 687 Emergency Contraception 615
Starchy vegetables 402 immune globulin 351 Epidemiological Study 28
State Thermal pollution 99, 105 Evaluative Study 29
Health Directorate 499 Thiamine 396 Experimental Studies 37
Ministry of Health 499 Third Family 132
of Public Health Infrastructure 509, National Family Health Survey 627 HIV vaccines 288
514 stage larva 321 hypertension 366
Status Three types of diarrhea 222 influenza vaccines 173
epilepticus 652 Thyrotoxicosis 644 Mental Disorders 643
of AIDS vaccine 288 Tick typhus 341 radiation 86
STD 153 Tinea soil pollution 103
control on large scale 277 barbae 303 Surveillance 20, 383
syndromes 293 capitis 303 water pollutants 102
Steps of growth monitoring 588 circinata 303 Typhoid 230
Sterilization 618 corporis 303 Typical infection 155
bed scheme 626 cruris 303
Stomach poisons 124 pedis 302 U
Stop global epidemic of chronic disease unguium 303
382 Tissue culture vaccines 346 UIP plus 600
Storage and discharge of radioactive waste Total fertility rate 470, 623 Ulipristal acetate 615
104 Totally drug resistant tuberculosis 207 Ultraviolet
Strategies for Toxaphene 121, 123 light 62
Immunization 687 Toxic substances 57 radiation 85
Measles Mortality Reduction 181 Trachoma 153, 301, 379 Uncorrect refractive error 378
Polio Eradication 249 Trained dais 538 Under five
Streptococcal sore throat 170, 186 Training clinic 590
Streptococcus pneumoniae 186 infrastructure 603 mortality rate 471, 577
Strongyloides stercoralis 258 need assessment 564 Undisinfected water 59
Subcutaneous nodules 364 of eye care team 381 Units of energy 406
Subjective global assessment 639 of PHC staff 648 Universalization of Primary Education
Sub-national immunization day 249 Transmission of 481
Subunit vaccine 288 diseases 110 Unspecified viral hepatitis 27
Sulfonamides 312 infectious agents 153, 160 Upper respiratory tract 365
Sulfones 312 influenza viruses 172 Urban
Sulfur dioxide 49, 99, 100, 124 Transovarian transmission 154 Family Welfare Centres 549
Sullage disposal 81 Treatment of Malaria Scheme 318
Sulphonamides 235 hypertension 368 Primary Health Care 480, 548
Supply of laparoscopes and tubal rings malaria 312, 318 Revamping Scheme 549, 626
626 MDR-TB 207 Urethral discharge 293
Surface paralytic poliomyelitis 245 Urinary tract infections 577
infections 167 severe malaria cases 314 Uses of
water 52 vitamin A deficient child 422 catalytic converters 48
Surveillance of Trench fever 117, 340 chemoprophylaxis 315
disease 160 Trichinella spiralis 255 epidemiology 36
fever 384 Trichomonal vaginitis and urethritis 276 low beam headlights 375
702 Swimming pool hygiene 65 Trichomoniasis 272 proper glass in wind screen 375
Swine flu 174 Trichuris trichiura 257 repellents 114
standard deviation 440 Viral hepatitis 238 White coat syndrome 367
Index
Surveys 452 A 687 Whooping cough 153, 170, 190
Syringe Hub Cutter 668 B 687 Wool-Sorter’s disease 349
ventilation 50 Virus 12, 56 World
B hepatitis 272 bank assistance 382
isolation 172, 283, 344 Food Day 432
V
Visceral leishmaniasis 333, 334 Health
Vaccination 176, 339 Vision 2020 382 Assembly 656
technique 197 Vitamin 395 Organization 655
Vaccine 175, 186, 193, 240, 332, 360 A 395 Mental Health Day 648
derived polioviruses 249 deficiency 417, 426 Population Day 463
for cholera 219 B complex 396 Worm infections 251
reaction 596 B1 396 Wuchereria bancrofti 321
vial monitor 599 B12 397
Vacuum System 51 B2 396
X
Vaginal B5 397
bleeding 583 B6 397 XDR-TB 208
carcinoma 37 C 397 Xenopsylla cheopis 116
discharge 293 D 395 X-ray chest 202
ring 614 E 395 Yang and Yin principle 3
sponge 608 K 396
Varicella 170, 177 Vomiting 228
Y
zoster immunoglobulin 178
Variola 170, 175 W Yates’ correction 448
sine eruption 175 Yaws Eradication Program 304
Vasectomy 618 Waist and hip circumference 412 Yellow fever 326
VDRL test 273 Warm chain 600 in India 327
Vectors of Mlaria in India 306 Water Yuzpe regimen 615
Vegetable foods 390, 398 and food-borne infections 167, 168
Venereal diseases 272 closet 77
hardness 363
Z
Venous plasma glucose 373
Ventilation 50 pollution 99, 102 Zanamivir 174
Vibrio soluble vitamins 396 Zidovudine 291
cholerae 59, 102, 215 supply 69, 635 Zila Saksharta Samitis 626
parahaemolyticus 228 Weil’s disease 348 Zinc phosphide 109
Village Health Guide Schemes 626 Wheat Based Nutrition Program 604 Zoonosis 161, 343
703