UNIT 16 DIPHTHERIA, TETANUS AND

POLIOMYELITIS
Structure
16.1 Introduction
16.2 Diphthexia
16.2.1 The Disease-What causes it? Who gets it? How and when does it spread?
16.2.2 Symptoms and Complications
16.2.3 Prevention and Management
16.3 Tetanus
16.3.1 The Disease-What causes it? Who gets it? How and when does it spread?
16.3.2 Symptoms and Complications
16.3.3 Revention and Management
16.4 Poliomyelitis
16.4.1 The Disease-What causes it? Who gets it? How and when does it spread?
16.4.2 Symptoms and Complications
16.4.3 Prevention and Management
16.5 Let Us Sum Up
16.6 Glossary
16.7 Answers to Check Your Progress Exercises

16.1 INTRODUCTION

You have so far learnt about three common infectious diseases prevalent in our
country, namely measles, tuberculosis, and whooping cough. You would note that
these three diseases contribute to high morbidity (sickness) and mortality (death)
particularly among young children.
In this unit. you will be learning about three other equally important childhood
diseases-diphtheria, tetanus and polio. 'Ihe causes, symptoms/complications.
prevention/conwl measures for these three infectious diseases are discussed here.

Objectives
After studying this unit. you will be able to :
identify the cause and mode of spread of diphtheria, tetanus and poliomyelitis.
enumerate the symptoms and complications of diphtheria, tetanus and
poliomyelitis, and
discuss steps to manage and prevent these diseases and also educate the
community about prevention of these diseases.

16.2 DIPHTHERIA

Diphtherim is a common infectious disease in India. There are reports to indicate that
the prevalence of diphtheria (number of cases of diphtheria in the community) is on
the rise in the counuy. An analysis of admissions to Infectious diseases hospital in
Delhi indicates that about 13 per cent cases of diphtheria, among the children under
five years of age, end in deaths. The death rate due to diphtheria is also reported to
be high. Unfortunately, it is difficult to obtain accurate information about the actual
extent of diphtheria in wann climate countries like India because bacteriological
confinnation of the disease is not easily available.
16.2.1 The disease-What causes it? Who gets it? How and when Dlphtherla, Tetanus and
Pollomyolitis
does it spread?
Diphtheria is caused by Cornyebacteriwn diphtheriae, a non-motile (not moving)
organism. The organism produces a powerful toxin. Three types of diphtheria. bacilli
are differentiated.
1) Gravis : Causing serious type of disease and generaiiy accounts for about a
fourth of the cases of diphtheria.
2) Mitis : Causing milder type of infection contributing to about 65 per cent of the
cases.
3) Intermedius : This accounts for about 10 per cent of the cases.

Who gets the disease?

Age : Diphtheria is primarily a disease of children under 15 years of age. You would
rarely come across cases of diphtheria in children below the age of 6 months. The
highest number of cases are observed among preschool children i.e. 1-5 year old
children. It can also occur in unimmunised adults.
Sex : It affects both the sexes equally.
Season : Cases of diphtheria are reported in all the seasons. But, higher numbers of
cases are reported during August to October.

How does it spread?

Diphtheria spread usually by contact with a patient or a person having inapparent
infection (without any recognisable clinical sign or symptom). The transmission is
through droplet infection or infected dust.
It can also be transmitted if raw milk contaminated with discharges from the patients
is consumed. However, in India where milk is invariably boiled before consumption
transmission by milk is not likely to occur.
It is rare to contract the disease by handling articles soiled with discharges from
lesions of infected persons. The organism can sometimes enter through wounded skin
and lead to infection.
Incubation period : Usually 2 to 5 days.
Period of Communicability : The disease can spread from an infected person to
another unirnmunised person as long as the virulent bacilli are present in the
discharges of the lesions. Generally, it is communicable for about 2 weeks but never
for more than 4 weeks.
Susceptibility : Infants born to mothers who are immune do not get the disease
during the first six months of their life. Recovery from an attack of diphtheria is not
followed by long lasting immunity as in the case of measles. Prolonged active
immunity can be induced by giving diphtheria toxoid.

16.2.2 Symptoms and Complications

Diphtheria is an acute communicable disease which affects the nose, throat and
tonsils. The bacilli multiply at the site of implantation (insertion into the body), be it
throat, nose or tonsils. It produces local lesions at the site of implantation. This lesion
is characterised by formation of a patch or patches of greyish false-membrane on the
affected parts such as tonsils or larynx (voice box). It also produces an offensive and
strong odour. There will be redening and swelling of the surrounding tissues.
The throat is moderately sore when diphtheria affects tonsils, with swelling of the
ccrvical lymph glands (lymph glands in h e neck region). This may result in bull-neck
appearance.
Diphtheria affecting larynx is serious particularly in infants and children. Most often it
leads to death of the affected.
Nasal diphtheria (of nose) is usually a mild condition marked by one sided discharge
in the nose.
Common Infectbut Dherrr You should always suspect diphtheria whenever there are cases of sore throat Often.
such cases are taken lightly and treated as mild upper respiratory infection.
Administration of antibiotics, assuming that it is ordinary sore-throat delay diagnosis,
endangering the life of the patient.
Diagnosis is confirmed by examining the lesions for the presence of bacteria. Failure
to demonstrate the bacteria under microscope should not, however. be the reason for
withholding the treatment for diphtheria.
16.2.3 Prevention and Management
How to prevent diphtheria? Preventive measures are simple. Read the following
section and find out for yourself:
a) Immunlration : The only effective way of preventing the disease is by active
immunisation by diphtheria toxoid to general population. It is given as DPT or
triple antigen along with immunisation for whooping cough and tetanus. Three
intramuscular injections of 0.5 ml each at intervals of 4 to 6 weeks are given to
children at third, fourth and fifth months of life. A booster is given one year
after the third injection is given. For children over the age of six years, only DT
containing diphtheria and tetanus toxoids, is given.
b) Identification of susceptible cases : There is a test to fmd out individuals who
are susceptible to diphtheria. This test is known as Schick test. This test can also
be used for confmation of successful immunisation. The test is an intradermal
(injection into the layers of skin) test. A measured amount (0.2 ml) of Schick
test toxin is injected into the skin of the forearm. Toxin inactivated by heat is
injected into the opposite arm which is called control arm. In other words the
individual has enough antitoxin to neutralise the toxin and fight the disease. The
test is positive if red flushing (colouring) of 1 to 5 cm within 1
to 1 days of injection. The control arm shows no change. This would mean that
the person is susceptible to diphtheria.
The community, particularly the parents of young children, should be encouraged
through education to get their children immunised against diphtheria along with the
whooping cough and tetanus.
Sure prevention is better than cure. But if an individual is suffering from diphtheria,
how to manage such a patient ,Lets consider.
Management of diphtheria : In all the cases suspected of having diphtheria,
antitoxin should be administered without waiting for bacteriological confirmation.
After completion of tests for allergy to the antitoxin, intramuscular administration of
antitoxin is recommended. Penicillin and Erythromycin are effective but should be
given alongwith the antitoxin.
When there are cases of diphtheria, you should immediately take steps to arrange for
injections of antitoxins to the patients. In otherwords, these patients should be taken
to the nearest hospital at the taluq or district level. The hospital authorities will
arrange for laboratory investigations and antibiotic cover. Simultaneously, the close
contacts in the family should be investigated and kept under watch thoroughly. It
is a sound practice to administer 500-1000 units of diphtheria antitoxin to household
contacts and others who have been in recent contact with cases of diphtheria
Read Points to Remember given below, which provides a summary of diphtheria.

r Diphtheria is an acute cdmmunicable disease affecting the nose, throat and

r Diphtheria is caused by cornyebacterium diphtheria.

r D i p h w a is primarily a disease of chikiren under 15 years of age,
I Transmission of diphth-
. is through droplet infection or infected dust.

of the cervical lymph glands.

e Irnmunisation is the most effective way of preventing the disease.
20
 Diphtheria, Tetanus and
Check Your Progress Exercise 1 Puli6lnyelitis
1) Prepare a brief plan of action indicating the steps you would take to organise
treatment of diphtheria patients and the preventive measures you will take.
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16.3 TETANUS

Tetanus, commonly known as lockjaw, is an ubiquitous (common) disease occurring in

almost all the countries of the world. The rate of infection with tetanus and
consequent death rates are, however, very high in tropical countries such as India
About 5-10 per cent of all infant deaths during the first month of life can be
attributed to tetanus infection of the new born.

16.3.1 The Disease--What causes it? Who gets it? How and when
does it spread?
Tetanus is induced by a toxin produced by bacillus-Clostridium tetani. The
organism grows at the site of injury under anaerobic (lack of oxygen) conditions. The
bacillus forms spores at its terminals which are spherical in shape. Thus, the organism
appears as a drum-stick under the microscope. The spores germinate in anaerobic
conditions and the bacillus produces a potent toxin. The tetanus bacillus is a normal
inhabitant of the intestines of animals such as cattle, horses, goats etc. Contamination
with animal faeces, therefore, is one of the important causes for tetanus.

Who gets the disease?

Age : Tetanus is a disease of active age, though it affects all ages. Generally. it is
common in the age group of 5-40 years. This age group generally is predisposed to
all kinds of injuries and the risk of acquiring tetanus is higher. In India and other
,
I
tropical countries, tetanus of the new born infant is very common due to bad hygienic
practices followed during delivery particularly for cutting the umbilical cord by the
untrained traditional midwives (dais). You may be surprised to know that some
midwives apply cowdung to the umbilical cord after it is cut, in the belief that it will
help to heal the cut. This, as you can imagine, is a dangerous practice and is the
surest way of spreading tetanus. This practice should be stopped.
Sex : Generally, tetanus is more common in males than in females. However, in the
reproductive age group of 15-45 years, females are at a higher risk, particularly after
criminal abortions and deliveries conducted under primitive conditions in the rural and
tribal areas.
Socio-economicfactors : The disease is more frequent in rural areas than in urban
areas. Agricultural workers are at a greater risk of getting the disease because of their
contact with soil and animal faeces. Wide spread poverty, high illiteracy and
consequent unhygienic practices like applying all sorts of medications, sometimes even
fine sand powder on the wound without properly cleaning it, lead to tetanus infection
in low income families.

How does it spread?

Tetanus occurs in most cases after injury. The wounds may be trivial and often are
ignored or unnoticed. This is more so among labourers. Infection takes place due to
contamination of wounds with tetanus spores. The contamination may happen with
soil, dust or animal faeces. The tetanus bacilli are found in the soil.
Tetanus bf the new born occurs through infection of umbilical cord, particularly due
to unhygienic practices, adopted by unbahed birth attendants while cutting the cord. 21
Commoa ~nfcctloueD
- Tetanus may result after surgical treahnent, the spores being introduced through
improperly s e l i s e d suturing material or instruments. The tetanus spores can be
introduced through dressings of the wounds and plaster of paris used for bandaging
fractured limbs.
Incubation period : The incubation period is generally 4 to 21 days. It depends on
the character and extent of the wound. On an average, it is about 10 days. Most
cases occur within 14 days of the wound, but, sometimes it may take longer.
Period of communicability : It is not directly transmitted from man to man.
Susceptibility : Everyone is susceptible to tetanus infection. Recovery from tetanus
does not result in definite protection against the disease. Second attacks can occur.
However, prolonged immunity is induced by tetanus toxoid injection.

16.3.2 Symptoms and Complications

Tetanus is an acute disease characterised by painful muscular contractions mainly of
jaw and neck muscles. This is usually followed by spasm (contraction) of muscles of
trunk and spine (Figure 16.1). The common fmst sign suggestive of tetanus is rigidity
(tightening) of abdominal muscles. Sometimes such a rigidity is confined to the site
of injury only. It is difficult to confm the diagnosis through laboratory investigations
since the organism is rarely recovered from the site of infection.

Fig. 16.1 : Spasm of muscles of trunk and spine

Tetanus has a high fatality rate. About 40-80 per cent of the patients die. You will
appreciate how important it is to prevent it.

, 16.3.3 Prevention and Management

Discussed below are the preventive measures of Tetanus :
a) Active Immunisation : The best protection against tetanus is through routine
immunisation with tetanus toxoid. Tetanus toxoid is recommended regardless of age.
It is particularly important for workers who frequently come in contact with soil or
domestic animals and all those with greater than usual risk of traumatic injury. These
include military and police personnel. Immunisation for different individuals include:
- For Children : Pfimary course (the very fmt course of immunisation in childrcn)
of immunisation consists of 3 injections of tetanus toxoid (given as DFT) with an
interval of about 6 weeks between injections, starting at the age of 3 months. A
booster is given about one year after the third injection. Thereafter. booster dose
at intervals of 10 years is recommended.
- For Pregnunt Women : All the pregnant women should receive immunisation as
a protective m u r e against tetanus of the new born infant. Administration of
tetanus toxoid in 3 doses during the fifth, sixth months and ninth months of
pregnancy is recommended in the case of primis (first pregnancy). During the
subsequent pregnancies, one injection of tetanus toxoid is suggested.
- Temporary protection can be given to a wounded individual by an injection of
anti-tetanus serum (ATs). This should be administered only under the supervision
 Or a medical e xm and be given after a subcutaneous test dose is given. Human
I , immunoglobulins against tetanus are considered one of the best ways of protection
against tetanus.
b) Education : Education of the workqs, about the mode of transmission of the
Diphtheria, Tetanus and
Poliolnyelitio

disease is important. This would help them to take suitable preventive action like
immunisation after injury. The importance of routine immunisation aRer i n j w should
be emphasised. You should also stress on proper hygienic practices pdculsrly Pftn
injury like avoiding contact with soil, animal faeces and keeping the wound c l m
would also help in the reve en ti on of the disease. Training of Vaditional birth
anendants in proper ways of cutting the cord is essential D prevent tetanus in the new
bmn infant. You should educate the dais to use sterilised blades for cutting the cord;
to wash hands thoroughly with soap before undertaking the delivery; not to resort to
..
applying cowdung etc. to the cut portion of the umbilical cord.
Management of Tetanus : Tetanus Human Immuno globulin is given in large doses
intramuscular~yto the patients. Also tetanus antitoxin should be given inmvenously
with adequate precautions. Remember that antitoxins can cause severe allergic
reaction$ which
may lead to death. Hence these should be given after testing for such
allergic reactions. Intramuscular penicillin is also recommended. In severe cases,
artificial mechanical respiration may have to be resorted to.
Let us go through Points ro Remember and recapitulate salient features of Tetanus.

a Tetanus is caused by a toxin p

Tetanus is a disease of active age (5-40

a Its incubation period is generally 4 to 21
a Temus in most cases wcur after injury.
a The first sign suggestive of tetanus is rigidity of
Immunisalion is the best protection against tetmUS.

Check Your Progress Exercise 2

1) Indicate step-by-step the way in which a labourer working in an agriculwal field
can get tetanus.

2) What measures should be taken to prevent tetanus from occurring among the
labourers?

16.4 POLIOMYELITIS
Poliomyelitis is an acute communicable disease. It is principally an infection of
alimentary tract but affects the central nervous system leading often to paralysis. You
may have seen a number of individuals handicapped for life, as a result of an attack
of poliomyelitis in their childhood. With the introduction of immunisation,
poliomyelitis is rarely ever seen in the developed countries where the incidence of the
 direare has
approached zero. In India, however. thousvlds "
Common Infectious Diseases
poliomyelitis are reporEd even today.

16.4.1 The caum it? who gets it? and

does it spread?
Poliomyelitis is caused by a virus which can be seen only under sophistica~d
microscope. Three typcs of polio virus-type 1. type 2 and type 3 have been found
. to be respcnnible. Type 1 virus shows preponderance both during epidemic times and
non-epidemic times. Polio viruses are resistant to freezing and drying.
Who
. -
nets the disease?
I

Age : In India, it is essentially a disease of chiidhod and infancy. About 95 per cent
of the cases occur in children below the age to 5 years and, in fact, 80 per cent of
the cases are seen below the age of 3 years. The most vulnerable age is between 6
months and 3 years In contrast, in about a quarter of the cases it is found in the
group 15 yea& and above.
Sex : Males are more prone to clinical attack of poliomyelitis than females. For
every case in females there will be approximately 3 cases of polio in males.
Injury : Usually pamlytic poliomyelitis is associated with some injury or trauma snch
as injections, fractures and even surgical operations such as t0nsil~tXt0my.
Season : Seasonal variations are striking. About two thirds of the cases occur during
the months of June to September. This approximately corresponds with the monsoon
season throughout most of the country.
Standmd of living : In contrast to most of the diseases, paralytic poliomyelitis is
associated with improved living standards. This is illustrated by increased incidence
of the disease in regions where infant deaths are coming down.
How does it is spread?
Direct contact with secretions from the pharynx (throat) or faeces of infected persons
is the usual method of spread of the disease to the uninfected persons. In rare
instances milk contaminated with viruses has also been a vehicle. Epidemiologic
evidence suggests that oral to oral spread (through pharyngeal secretions) is more
important, particularly where sanitation is good, than the spread from faeces
(faecal-oral spread).
Incubation period : Usually it takes 7 to 12 days for a person to develop infection
from the time of fust exposure. It can vary, of course, between 3 days to 2 weeks.
Period of communicability : Polio virus can be demonstrated as early as 36 hours in
thmt secretions and in the faeces 72 hours after infection. This is true not only in
clinically apparent cases but also in inapparent infection (without any clinical
manifestations). The virus can persist in the throat for about one week and in the
case faeces for 3 to 6 weeks or even longer. The polio cases are most infectious from
one week to 10 days before and after the onset of symptoms.
w

Susceptibility : Generally, every individual is susceptible to poliomyelitis.

Fortunately, only a few of the infected persons develop paralysis. Second attack of
poliomyelitis are rare. Type-specific resistance of long duration is a rule both after
clinically recognisable infection or inapparent infection. In other words, petsons who
are infected with type 1 po1'i virus are resistant to type 1 polio reinfection. However,
they can be infected with either type 2 or type 3 virus. Infants born to mothers who
are immune (protected) to poliomyelitis have passive immunity which is, of course,
temporary. Pregnant women are lmown to be more susceptible to paralytic
poliomyelitis than non-pregnant women.

16.4.2 Symptom and Complications

Foliomyelitis is m acute viraI illness. Its severity varies hwn inapparent infection
(without any clinical manifestations) to a disease ending in paralysis. The symptoms
include fever, headache, upset of the gastrointestinal tract, malaise and stiffness of
neck and h k . The disease may also be accompanied by paralysis.
 Polio virus enters the body through the alimentary canal and multiplies initially in the Dlphtberla, Tetanus and
pharynx and small intestine. It may enter central nervous system through the blood Poliomyellus
stream resulting in paralysis, particularly of the lower limbs. Sometimes paralysis of
muscles of respiration and swallowing can occur which may lead to thedeath of the
patient.

II It is important for you to remember that the number of cases of inapparent infection
may be about a hundred times that of clinical cases.
Polio virus can be isolated by carrying out sophisticated investigations such as tissue
culture from samples of faeces or throat secretions early in the course of the infection.

I
Such facilities often are not available in the peripheral hospitals such as primary
health centres, taluq or district hospitals. Under these circumstances you have to
depend mostly on clinical diagnosis.

Complications of poliomyelitis : If respiratory muscles are paralysed the child can

die. Similarly if muscles of swallowing are paralysed it may threaten life. Non-
paralytic poliomyelitis may lead to aseptic meningitis. About 2-10 per cent of paralytic
cases may die.

1I
16.4.3 Prevention and Management
I eventive measure of poliomyelitis include:
a) Active Imrnunisation : With the discovery of vaccines, prevention of poliomyelitis
has become possible. Active irnmunisation of all susceptible persons against the 3
!
types of polio virus is the simplest method of prevention. All the children, who
I
are at higher risk of catching the disease, should be immunised.
1 Two methods of immunisation are available. These include:
Immunisation with (a) live polio vaccine and with (b) killed polio vaccine. Let us
discuss each one of them.
- Live Polio Vaccine : It is an oral vaccine known as Sabin Vaccine. It is prepared
from attenuated (reduced virulence) strains of the three types of polio virus
(trivalent vaccine). In other words, it is prepared 6om the virus with much less
degree of pathogenicity. The primary course of immunisation consists of 3 doses.
given by mouth, at an interval of four to eight weeks. An interval of eight weeks
between the doses is preferred. The first dose is commonly given around the age
of three months, when the first dose of DPT also is given.
Booster is given about one year after the third dose.
The advantage of oral polio vaccine (OPV) is that it produces intestinal immunity
and this prevents subsequent infection of the alimentary tract with wild strains of
polio virus. This vaccine is also relatively inexpensive. It is useful in controlling
epidemics since it produces antibodies to fight virus quickly among the
vaccinated.
- Killed Vaccine : It is inactivated vaccine given as injections. It also contains all
the three types of polio virus. It also provides protection but is less effective in
subsequent alimentary infection. In other words, it does not induce local or
intestinal immunity. Hence, mild polio viruses still can multiply in the intestinal
tract of the vaccinated individual and be a source of infection of others.
For primary immunisation, four injections are required. The first three are given at
4 to 6 weeks interval and the fourth 6-12 months after the third. The first dose
can be given at the age of 3 months. One of the major disadvantages of the killed
vaccine, particularly during epidemic of poliomyelitis, is that injections are to be
avoided in epidemic times as they are likely to precipitate paralysis. Also,
immunity is not rapidly achieved with killed vaccine as in the case of oral live
vaccine.
b) Education : The community should be educated adequately about the dangers of
the disease, the mode of spread of the disease and the advantage of immunisation.
Common Infectlous Diseases Management of poliomyelitis: There is no specific treatment for poliomyelitis.
During acute illness attention should be given to the complications of paralysis. Some
patients may require respiratory assistance.
The key points of the disease poliomyelitis are listed in the section. Points to
Remember, read them carefully.

. J',
Check Your Progress Exercise 3 -- Z

1) Prepare a flow chart of the progress of infection of poliomyelitis from its onset
to paralytic stage. 1

2) Match the following :

a) Most vulnerable age 1) Over 15 years of age

in India for poliomyelitis
b) High incidence of para- 2) 6 months to 3 years
lytic poliomyelitis
c) Age of onset of poliomyelitis 3) In areas with low infant deaths

3) State true or false. Correct the false statement.

a) Paralytic poliomyelitis has no association with trauma like injections or
tonsillectomy. (True/False)

b) In westernised countries where infant mortality is very low the incidence of

paralytic poliomyelitis in unprotected children is higher. fliuflalse)

X
.................................................................................................
c) In India, the most vulnerable age for poliomyelitis is between 5-40 years. ,
(Tme/False)
 .. - -
Diphtheria, Tetanus and
16.5 LET US SUM UP Poliomgelitis

In this unit you have learnt about three infectious diseases-diphtheria, tetanus and

Diphtheria is a common infectious disease caused by Cornybacterium diphtheria a

microorganism. It is primarily a disease of children under 15 years of age. It spreads
usually through droplet infection or infected dust. The incubation period is 2-5 days.
Diphtheria affects nose, throat and tonsils with swelling of the cervical lymph gland.
The only effective way of preventing the disease is by active immunisation.
Tetanus, commonly known as lockjaw is another acute disease characterised by
painful muscle contractions leading to rigidity of muscles. The disease is caused by a
toxin produced by tetanus bacillus. It is a disease of active age, affecting age groups
(5-40 years) who are predisposed to injuries. Tetanus in most cases occurs after injury
or through infection of umbilical cord or after surgical treatment. Immunisation of
children, pregnant women and education of people is the best protection against
tetanus toxoid.
Poliomyelitis is an acute viral illness, affecting essentially children and infants. The
disease causes paralysis and at times can also lead to death. Direct contact with
secretions of infected person is the course of spread of the disease. Active
immunisation against the polio virus is the simplest method of prevention.

16.6 GLOSSARY
Prevalence of : Number of cases of a disease at a point of
time in a community
: Test to find out whether an individual is
susceptible to diphtheria
Mascular spasm : Contraction of muscles
Anaerobic conditions : Conditions where oxygen is absent
: Traditional midwives helping in conducting
deliveries

16.7 ANSWERS TO CHECK YOUR PROGRESS

EXERCISES

Check Your Progress Exercise 1

1) You can include the following while talking about treatment and prevention :
a) Immunisation
b) Identification of the susceptible population
c) Injections of ant itoxins to cases.

Check Your Progress Exercise 2

1) a) Agricultural labourer will be in contact with the soil continuously during
different types of agricultural operations. Tetanus spores are found in soil.
b) The dangers of injuries such as cuts and wounds is more common in the case
labourer. Office going person is not exposed to the risk of the
of agIi~~lhlral
above by nature of his duties.
C) Contamination with animal faeces is one of the important causes of tetanus.
Cowdung is extensively used as organic fertilizer in agriculture. When the
agriculture labourer comes in touch with the same, he is likely to be infected.
2) a) Educate the labourers about the chance of contracting the disease because of
nature of the work which includes working with the soil. Tell them how
disease is caused.
Common .hfectlous Diseaw b) Emphasise the need for taking preventive immunisation with tetanus toxoid.
c) Arrange for active immunisation with tetanus toxoid of all the labourers
with the cooperation of the officials implementing the schemes.

1)' Fever - --
Check Your Progress Exercise 3
headache upset of gastro-intestinal tract
malaise and stiffness of neck and back
2) a, 3; b. 2; c. i
paralysis.
-
3) a) False: there is an association.
b) True
c) False; In India the most vulnerable age group is under 5 years.