DEPARTMENT OF COMMUNITY MEDICINE

SRI DEVARAJ URS MEDICAL COLLEGE

EPIDEMIOLOGY PROBLEMS:

Problems on Disease Frequency:

1. In a district with an estimated midyear population (MYP) of 2 lakhs, there were 40

cases of kala- azar reported during 1997. On 1st of June 1997 there were 120 registered
Leprosy cases in this district Calculate the incidence of Kalaazar and prevalence of
Leprosy.

Given Data:

Mid-Year Population of the town = 2, 00,000

No. of Kala azar cases in1997 = 40

No. of leprosy cases on July 1st 1997 = 120

Incidence of Kalaazar = No. of new cases/ Total population * 1000

= 40/200000*1000

= 0.2/ 1000 population or 2 / 10000 population

Prevalence of Leprosy = Total No. of cases/ Total population * 100

= 120/200000*1000

= 0.06% or 0.6/ 1000 population or 6 / 10000 population

2. 200 new born children were followed up till their second birthday to study the
incidence of diarrhoea. The following table shows the distribution of the children
according to the number of diarrhoeal episodes.

No. of episodes of No. of children

st
diarrhoea 1 year 2nd year
0 0 40
1 40 80
2 100 60
3 40 15
4 15 3
5 5 2
Total 200 200

Calculate the incidence of diarrhea

a) During the 1st year, b) during the 2nd year

c) Overall during the 1st & 2nd year of life.
Given Data:

Incidence of diarrhea in 1st year = No. of new cases (spells) in 1st year * 1000 / Total
children followed

= 0+40+200+120+60+25/200*1000

=445/200*1000 = 2225 spells/ 1000 children/ year

Incidence of diarrhea in 2nd year = No. of new cases (spells) in 2nd year * 1000 / Total
children followed

= 0+80+120+45+12+10/200*1000

=267/200*1000 = 1335/ 1000 children/ year

Incidence of diarrhea in 2 years = No. of new cases (spells) in 2 years * 1000/ Total
children followed

= 0+120+360+105+72+35/200*1000

=692/200*1000
 =3460/ 1000 children for 2 years

Combined annual incidence/ year = 3460/2

=1730 spells/ 1000 children / year

3. In an elementary school with an enrollment of 300 pupils, During Oct & Nov outbreak
of measles occurred and 72 children in the school had measles. The 72 pupils with
measles had a total of 92 brothers & sisters living at home. Of these siblings, 20
subsequently developed measles during the period, Oct through December

a) Compute the attack rate for Oct & Nov

b) Compute the secondary attack rate among the siblings.

Attack rate = No of New cases * 100 / No of susceptible children

= 72 *100 / 300 = 24%

Secondary attack rate

= No of Susceptible children affected * 100 / No of Susceptible children

= 20 * 100 / 92 = 21%

4. In a class room of 25 students with 15 males & 10 females, 5 males developed

Hepatitis-A, over a period of 2 weeks. During the next 6 weeks, an additional three males
& two females developed the infection.

Find the attack rate & secondary attack rates.

Attack rate = No of New cases * 100 / No of susceptible children

= 5 *100 / 25 = 20%

Secondary attack rate

= No of Susceptible children affected * 100 / No of Susceptible children

= 5 * 100 / 20 = 25%
5. Following is the data of a town for the year 1991

MYP – 30,000

No of new cases of T.B – 30

No of old cases of T.B - 270

Deaths due to T.B - 24

Calculate the incidence, prevalence, cause specific death rates & case fatality rates for
TB.

Incidence of TB = No. of new cases / MYP *1000

= 30/30000*1000 = 1/ 1000 population

Prevalence of TB = Total No. of cases (old +new) / MYP *1000

= 300/30000*1000 = 10/ 1000 population

TB specific death rate = No. of deaths due to TB/ MYP *1000

= 24/ 30,000*1000 = 0.8/1000 population

Case fatality rate = No. of deaths due to TB/ Total no of TB cases*100

= 24/ 300*100

= 8%

6. The prevalence of Pulmonary TB in a District with 5 Lakh population is estimated to

be 4 per 1000 population. In the TB register maintained by the District Health Office,
there are 501 pulmonary patients registered & receiving treatment. Can you rely on the
rates calculated from the District information system?

Prevalence of TB = 4 per 1000

So for 500000 population prevalence is

500000 * 4 / 1000 = 2000 patients.

But the number of TB patients registered and receiving treatment were 501. Hence there
is wide discrepancy in the rates calculated and registered. Hence it is not reliable

7. The mid-year population (MYP) of a town in 2000 was 7, 61,335 of which 76,100 were
in the age group of 1-4 yrs. During this year there was 700 measles cases reported in
the age group 1-4 yrs. The new cases of TB registered was 311 and the old TB cases
was 7,101 in this town. Calculate the rates for TB & Measles in this town.

Given Data:

Mid-Year Population – 7, 61,335

Population of children 1-4 yrs- 76,100

No. of measles cases reported in a year – 700

No. of new cases of TB registered – 311

No. of old TB cases in the town – 7101

Incidence of Measles = No. of new cases among 1-4 yrs / Population of 1-4 yrs *1000

= 700 /76,100*1000

= 9.19 / 1000 population

Incidence of TB = No. of new cases / MYP *1000

= 311/7, 61,335*1000

=0.4/ 1000 population

Prevalence of TB = Total No. of cases (old + new) / MYP *1000

= (7101 + 311) /7, 61,335*1000

=9.7/ 1000 population

8. An outbreak of food poisoning has been reported from the hostel of a college.
Analysis of the 48 cases reported presents the following features.40 cases have
abdominal pain / nausea / vomiting, 35 cases have salivation & prostration and 7 cases
have subnormal temperature. All cases had onset of symptoms on 3rd of November
2000. The time of food consumption was 1.00 pm.

Time of onset No of cases

2 pm 2

3 pm 7

4 pm 15

5 pm 14

6 pm 06

7 pm 04

48

a) Find the attack rate b) Draw an epidemic time curve.

b) What type of epidemic time curve is this?
c) Find the most likely agent for this outbreak.

Attack rate = Number of cases * 100 / Total population

No of cases
16
12
8
4
0
2pm 3pm 4pm 5pm 6pm 7pm

No of cases

Figure 1: Epidemic curve showing single peak

 Point source epidemic curve
Staphylococcus aureus
Analytical Epidemiology

1. A physician hypothesizes that smoking may cause lung cancer. He wishes to test the
association. He studies 35 patients with lung cancer & finds that 33 were smoking
cigarettes. 55 of the 82 patients without lung cancer were also smoking cigarettes.

a. What type of study is this?

b. Find the exposure rates among lung cancer & non- lung cancer patients
c. Estimate the risk (odds ratio). What does this mean to you?

Lung cancer Total

Present Absent

Cigarette Present 33 (a) 55 (b) 88

Smoking
Absent 2 (c) 27 (d) 29

Total 35 82 117

a. It is a case control study

b. Exposure rates among cases of lung cancer = a/a+c*100

= 33/35*100

= 94%

c. Exposure rates among non-lung cancer cases = b/b+d*100

= 55/82*100

= 67%

d. Odds Ratio = ad/bc

= 33*27/ 55*2
 = 891/110

= 8.1

Therefore Smokers have 8.1 times more chances of developing lung cancer compared
to non-smokers
2. An investigator hypothesizes that smoking is associated with coronary heart disease.
So he chooses 300 cases with CHD & 400 controls without CHD, but who had some
other disease. History of smoking was obtained from individuals in both the group. 220
cases & 100 controls reported that they were smoking.

a. Mention the type of study.

b. Find the Exposure rates (prevalence) of smoking among Heart disease
patients & those without Heart disease.
c. Estimate the extent of association between the characteristic & the outcome
(odds ratio).

Coronary Heart Disease Total

Cases Controls

Cigarette Present 220 (a) 100 (b) 320

Smoking
Absent 80 (c) 300 (d) 380

Total 300 400 700

a. It is a case control study

b. Exposure rates among cases of CHD = a/a+c*100

= 220/300*100

= 73.3%

c. Exposure rates among controls = b/b+d*100

= 100/400*100

= 25%

d. Odds Ratio = ad/bc

= 220*300/ 100*80

= 66000/8000

= 8.25
Therefore Smokers have 8.25 times more chances of developing coronary Heart
disease compared to non-smokers

3. In an attempt to measure the effect of birth weight on the subsequent growth of

children, a cohort study was carried out. 300 children with birth weight 2 kg – 2.5 kg
were followed until age one, when anthropometric measurements were made to assess
the nutritional status. A similar number of children born during the same period with
birth weight greater than 2.5 kg were also followed up. 102 children were found
malnourished at age one in the low birth weight category. 51 children were
malnourished at age one in the normal birth weight category.

a. What is the exposure factor that is being studied in this case?

b. Make a 2x2 table.
c. What is the incidence of malnutrition among the exposed & un-exposed?
d. Calculate the relative risk. What does this mean to you?
e. Calculate the attributable risk. What does this mean to you?

Answer:

a. Birth weight
b.

Outcome Total

Malnourished Normal
growth

Birth weight 2 kg to 2.5kg 102 198 300

>2.5kg 51 249 300

Total 153 447 600

Incidence of malnutrition among exposed = 102 * 1000/ 300 = 340 /1000

Incidence of malnutrition among non-exposed = 51 * 1000/ 300 = 170 / 1000

Relative risk = Incidence among exposed / Incidence among non-exposed = 340 / 170 =
2

i.e. Low birth weight children are at 2 times higher risk of being malnourished
Attributable risk = Incidence among exposed – Incidence among nonexposed * 100

Incidence among exposed

AR = (340 – 170) * 100 / 340 = 50%

i.e. 50% of malnutrition can be prevented if birth weight is improved.

4. In a prospective study, the results reveal that deaths due to lung cancer are 5/1000
among smokers & 0.5/1000 among non-smokers. Calculate the relative risk & the
attributable risk.

Incidence among smokers = 5/1000

Incidence among nonsmokers = 0.5/1000

Relative risk = Incidence among exposed / Incidence among non-exposed = 5 / 0.5 = 10

I.e. Deaths due to lung cancer among smokers are 10 times higher than in
nonsmokers.

Attributable risk = Incidence among exposed – Incidence among nonexposed * 100

Incidence among exposed

AR = (5 – 0.5) * 100 / 5 = 90%

I.e. 90% of deaths can be prevented in lung cancers if smoking is reduced.

5. In a study 7000 males aged 35 to 45 yrs, who were cigarette smokers, were followed
up for ten years. 70 developed lung cancer during this period. 3 of the 3000
non-smokers who were followed during the same period also developed lung cancer.

a) What type of study is this?

b) Find the incidence of lung cancer.
c) Estimate the risk of lung cancer among cigarette smokers in this
study.
Answer:

a. Cohort study

b.

Lung cancer Total

Yes No

Exposure Smoker 70 6930 7000

Non smoker 3 2997 3000

Total 73 9927 10000

c. Incidence of Lung cancer = Total no of new cases * 1000 / Total population

= 73 * 1000/ 10000 = 7.3/ 1000

Incidence among Exposed = 70 * 1000 / 7000 = 10 / 1000

Incidence among Non-exposed = 3 * 1000 / 3000 = 1 / 1000

Relative risk = Incidence among exposed / Incidence among non-exposed = 10 / 1 = 10

i.e. Smokers are at 10 times higher risk for Lung cancer

Attributable risk = Incidence among exposed – Incidence among nonexposed * 100

 Incidence among exposed

AR = (10 – 1) * 100 / 10 = 90 %

i.e. 90% of Lung cancer can be prevented if smoking is stopped.

6. Thalidomide, a hypnotic used during pregnancy was suspected to cause congenital
anomaly in the new born children. Hence, a study was conducted. 41 out of 46 mothers
who had delivered deformed babies gave a history of consuming Thalidomide during
pregnancy. This was compared with 300 mothers who had delivered normal babies and
10 of them had a history of Thalidomide consumption during pregnancy.

a) What type of study is this?

b) Find the exposure rates.
c) Estimate the risk of congenital anomaly among Thalidomide users.

Answer:

a. Case control study

b.

Outcome ( Deformed babies) Total

Yes No

Exposure to Yes 41 10 51
Thalidomide
No 5 290 295

46 300 346

Exposure among diseased = No of exposed with disease * 100 / No of Exposed

= 41 * 100 / 46 = 89.1%

Exposure among non-diseased = No of Non exposed with disease * 100

No of Non - exposed

= 5 * 100 / 295 = 1.69%

Odds Ratio = ad / bc = 41 * 290 / 5 * 10 = 237.8

I.e. Thalidomide exposure during pregnancy has 238 times higher risk of
delivering a deformed baby
Evaluation of screening tests:

1. In a group of 180 patients suspected to be syphilitic, both TPI & VDRL were
conducted. The results are as follows.

TPI Test ( Diagnostic Test)

Positive Negative Total
VDRL Positive 80 (a) 60 (b) 140

(Screening Test) Negative 10 (c) 30 (d) 40

Total 90 (a+c) 90 (b+d) 180

Calculate the sensitivity & specificity of VDRL test, the predictive value of the test & the
percentage of false positives & false negatives.

Sensitivity of the test = a /a+c*100

= 80/90*100 = 88.88%

Specificity of the test = d /b+d*100

= 30/90*100 = 33.33%

Predictive value of positive test = a /a+b*100

= 80/140*100 = 57.14%

Predictive value of negative test = d /c+d*100

= 30/40*100 = 75%

Percentage of false positives = b/b+d*100

= 60/90*100 = 66.67%

Percentage of false Negatives = c/a+c*100

= 10/90*100 = 11.11%
2. The table shows the results of screening test on 290 persons, as compared to a
diagnostic test. Find the sensitivity & specificity of the screening test, the predictive
value of the screening test & the percentage of false positives & false negatives.

Diagnostic Test (Reference Test)

Positive Negative Total
Screening Positive 75 (a) 50 (b) 125
Negative 15 (c) 150 (d) 165
Total 90 200 290

Sensitivity of the test = a /a+c*100

= 75/90*100 = 83.33%

Specificity of the test = d /b+d*100

= 150/200*100 = 75%

Predictive value of positive test = a /a+b*100

= 75/125*100 = 60%

Predictive value of negative test = d /c+d*100

= 150/165*100 = 90.9%

Percentage of false positives = b/b+d*100

= 50/200*100 = 25%

Percentage of false Negatives = c/a+c*100

= 15/90*100

= 16.67%
3. In a trial on 300 members of a community, a new screening method for measuring
diastolic BP is compared with the standard Sphygmomanometer method. Of the 45
persons with known diastolic hypertension, 36 have hypertension detected by the new
method. 25 of the 255 who did not have diastolic hypertension were also detected to
have hypertension by the new method. Find the sensitivity, specificity, predictive values
& percentage of false positives & false negatives for this screening test.

Gold standard ( Sphygmomanometer) Total

Positive Negative

Screening test Positive 36 25 61

Negative 9 230 239

45 255 300

4. Screening test results for detection of HIV infection by Kit A is given below compared
to the confirmatory test (Western blot). Calculate the sensitivity, specificity and the
positive predictive value of positive and negative tests of Kit A.

Gold standard ( Western blot) Total

Positive Negative

Screening test Positive 90 10 100

result by Kit A
Negative 10 90 100

100 100 200

CASE STUDIES IN INFECTIOUS DISEASES

1. Few boys is a boarding school are reported to be having head lice infestation.
How will you as a school health officer manage this situation?

Solution:

Confirm the diagnosis. Since lice infestation can spread easily Blanket treatment
should be implemented to all the inmates in the boarding school whether they are
affected or not.

Control of Lice: Lotion containing 0.5% Malathion should be applied to scalp. The
lotion should be left on for 12-24 hours when the hair can be washed. Carbaryl
powders can also be used for mass delousing.

Personal Hygiene: Regular bathing, change and launder their clothes. Clothing,
towels and sheets should be washed in hot water and soap and pressed with hot
iron.

Health education regarding personal hygiene

2. You are the medical officer in a health center. The teacher from public primary
school reports to you that many students in her class has scabies. How should
you manage the situation?

Solution:

Scabies is a contagious disease hence blanket treatment is proposed. All children in

public primary school have to be treated irrespective of being affected or not. All
children should be treated simultaneously.

Any similar cases in family or neighborhood have to be identified and treated.

Benzyl Benzoate (25%): Scrub bath should be taken with soap and water, dried using
a clean towel. Apply benzyl benzoate to whole body below neck with the help of a
brush and allow it to dry. In case of babies, head must be also included. Reapply
after 12 hrs and take a scrub bath after 12 hours of reapplication.

Personal Hygiene: The bedding and clothing of the affected children has to be
washed in boiling water and dried in hot sunlight. They should not share clothing and
bedding. Regular bathing, change and launder their clothes.

Health education regarding personal hygiene

3. A mother brings her six-year-old child with H/o a street dog bite one hour before.
There are five bite marks on the leg. How will you manage the condition as a
medical officer in the PHC?
Solution:

1. Local treatment of wound:

∙ Wash the wound thoroughly with soap under running tap.

∙ Clean the wound with alcohol or povidone iodine which will kill the remaining
viruses.
∙ If suturing is required, it should be done 24 – 48 hrs later.
∙ Local application of Anti-rabies serum is highly effective in preventing rabies
2. Antibiotics and Anti tetanus measures have to be taken

3. Anti-rabies treatment: Since there are multiple transdermal bites, it is considered

as Category III bite

∙ Passive immunization – Administer 20 IU per Kg of Human Rabies

Immunoglobulin. Half of the dose to be infiltrated around the wound and the
other half by IM in the gluteal region.
∙ Active immunization – Intramuscular Schedule: 0.5 ml of cell culture vaccines
of 6 doses on days 0, 3, 7, 14, 28 and a booster dose on day 90. Injections
have to be given in the deltoid and not in the buttock.
Intradermal Schedule: 0.1 ml 2-2-2-0-1-1 on days 0, 3, 7, 14, 28 and 90. It
consists of one dose of vaccine given each at 2 sites on 0, 3 and 7 days and
at one site on days 28 and 90.

3. Observe the animal for 10 days. If the dog is healthy on 10th day then the
treatment can be stopped

4. Immunization of dogs: All dogs should receive primary immunization 5 ml of

intramuscular injection of BPL inactivated nervous tissue vaccine at 3-4 months.
Revaccination advised after six months, and subsequently every year.

5. Control of urban rabies:

∙ Registration and licensing of all domestic dogs

∙ Restraint dogs in public places
∙ Immediate destruction of dogs bitten by rabid animals
∙ Health education of people regarding the care of dogs and prevention of
rabies
4. A mother brings her three-year-old male child to the sub-centre. The child has
vomiting and 5-7 loose stools per day since last 2 days. The health worker
notices that the child is restless, and cries without tears in its sunken eyes. How
should the health worker manage the situation?

Solution:

1. Diagnosis: Restless, irritable, no tears and sunken eye – all these symptoms point
towards a diagnosis of some dehydration. So, the child has ‘Some dehydration’.

2. Treatment: For ‘some dehydration’ treatment plan B should be followed. The child
can be managed at home under supervision

Ø Since weight of the baby is not known around 800 – 1200 ml of ORS to be
given in the first four hours. If the baby can be weighed then 75ml/kg body
weight of ORS has to be given.
Ø If the child is able to drink and willing any amount of ORS can be given
Ø Educate mother as to how to prepare ORS: give 1 tea spoon 1 – 2 minute over
4 hrs.
Ø Check from time to time for any worsening of conditions. If the child vomits,
wait for 10 minutes and then continue ORS and plain water.
Ø Re-assess the child according to symptoms and treat according to plan A, B,
or C.

3. Preventive measures: The following are the important recommendations to

prevent such attacks in future

Ø Educate the mother about proper food sanitation which includes: Food
hygiene, proper hand washing practices (after defecation, before cooking and
feeding food), adequate cooking of food and keeping the food covered
always.
Ø Also educate her about defecation to be done only in a latrine and not to
practice open air defecation; if there is no latrine, defecate at least 10 m away
from a water source.
Ø Immunization to be completed as per the schedule and fly control to be done.
5. Parents bring their 5 years old son to the urban health center with fever, cough
and fast breathing. How will you manage the situation?

Solution:

1. Diagnosis: Since the child is having fever, cough and fast breathing the ARI can
be classified as ‘Pneumonia”.
2. Treatment: Pneumonia is treated with antibiotics at home. Cotrimoxazole
(Sulphamethoxazole 100mg and Trimethoprim 20 mg) three tablets twice daily
for five days.
3. Follow up: Mother has to be explained about the danger signs in the child (not
able to drink, convulsions, abnormally sleepy, stridor in calm child) and get the child
back to health centre immediately.

4. Health education to the mothers regarding

• Compliance with treatment

• Seeking prompt care on worsening of symptoms

• Home care – steam inhalation, clearing the nose

• Continuation of breast feeding and balanced meals

• Improve living conditions

5. Measures in the community – Primary prevention

• Health promotion

- Improve living conditions – no overcrowding, proper sanitation, adequate

handwashing practices, proper disposal of masks.

- Better nutrition – EBF, Balanced meals

- Reduction of indoor air pollution – cross ventilation of houses, no smoking,

smokeless chullas

- Better MCH care

• Specific protection
 - Immunization of infants between 9 – 12 months with measles vaccine to prevent
ARI following measles. Ensure high coverage of measles immunization.

- Immunization against measles

6. An 18 years old mother delivered her first female child, under your care at the rural
health centre. The mother and the child are to be sent home. What are the preventive
and health promotive measures to be followed?
7. Four students have been diagnosed to have typhoid fever in a men's hostel over a
period of 4 months. What measure will you take to trace the source of infection,
the management of cases and prevention of such occurrences in the future?

Solution:

1. Definition – Enteric fever (Typhoid fever) is the result of systemic infection mainly
by Salmonella typhi found only in man

2. Controlling Infection

∙ Visit the hospital where the cases are admitted and verify the diagnosis by
clinical examination of the cases
∙ Extensive socio environment history of the patient will help in identifying the
source.
∙ Isolation and treatment of the patient, if already not done.
∙ T. Chloramphenicol 500mg (if sensitive) 4th hourly when febrile and 6th
hourly thereafter for 14 days. If strain is found to be resistant then
Ciprofloxacin is the drug of choice.
∙ Patients are isolated till 3 bacteriologically negative stool and urine reports
are obtained on 3 separate days.

3. Detection of the source

∙ Visit the hostel; meet the authorities, cooks and food handlers. Rule out the
direct mode of transmission through soiled hands contaminated with feces or
urine of carriers.
∙ Extensive history from the cook and food handlers includes:
a. Frequency of buying, storage and method of cleaning of vegetables
/ fruits

b. Identifying those foods that are eaten raw or cooked

c. Method of cooking

d. Storage/ refrigeration of cooked food; and that of the leftover food.

e. Serving of the food – with spoon or bare hands

f. Hand washing practices after defecation, urination and before

cooking and serving the food.

∙ Stool samples of cooks and food handlers are then collected to check for
carrier state (V2 antibodies)
∙ If positive for ‘Salmonellae’ (based on culture and serology i.e. Widal test) the
 respective individual is treated with Ampicillin, 4 – 6g/day and Probenecid
2g/day for a period of 6 weeks. If medical line of treatment doesn’t work then
Cholecystectomy can be done.

∙ Surveillance – Carriers must be prevented from handling food, milk and water
to others.
∙ Health education regarding washing of hands, better cooking practices, better
storage and serving practices to be imparted to the cooks and food handlers
in particular and hostel authorities in general.
∙ Indirect mode of transmission by ingestion of contaminated water, milk or
any other food through vectors i.e. flies must be prevented. This can be done
by keeping the food items including milk and water covered. Garbage dump
must be placed away from the place of cooking, storage and serving and
must be covered always.
∙ Samples of drinking water and milk are taken and tested for the presence of
bacilli. However, both milk and water should be boiled prior to consumption.

4. Prevent Recurrences

∙ Complete treatment of patients (preventing them from becoming carriers)

∙ Proper and adequate sanitation, health education of hostel inmates, cooks
and food handlers
∙ Immunization of inmates and cooks. (Monovalent vaccine will suffice since S.
Typhi is the main pathogen)
8. A farmer reports to you at the Health /center, with a hypo pigmented patch over
the left forearm. He also mentions about loss of sensation on the skin patch.
How will you manage the situation?

Solution:

1. Diagnosis: Leprosy is clinically characterized by

∙ Hypo pigmented patches

∙ Partial or total loss of cutaneous sensation
∙ Presence of thickened nerves
∙ Presence of acid –fast bacilli in the skin or nasal smear
For treatment purpose leprosy patients can be classified as

∙ Paucibacillary (1 – 5 skin lesions)

∙ Multibacillary ( >5 skin lesions)

Hence this is a case of Paucibacillary leprosy

2. Treatment: He should receive combined therapy

∙ Rifampicin – 600 mg once a month for 6 months, supervised

∙ Dapsone – 100 mg (1-2 mg/kg of body weight) daily for 6 months,
self-administered.
6 blister packs to be completed in 9 months.

3. Surveillance: After completion of treatment the person should be examined

once a year for a minimum of 2 years.

4. Health education:

∙ Patient and his family: Educated about the need for regular treatment to
prevent drop out , repeated examination of contacts, self-care regarding
prevention of disabilities and protection of children.
∙ General public: Public should be made aware that leprosy is not a
hereditary disease, it is curable, not all leprosy patients are infectious,
regular and adequate treatment is essential to obtain cure and prevent
disabilities, and the patient needs empathy and social support.
 ∙ Improve socio-economic conditions

6. An office clerk is suspected to suffering from pulmonary TB and is referred to

you by the health worker. His family consists of his wife and a child aged one
year. How will you manage the situation?

Solution:

1. Confirmation of diagnosis

By collecting two sputum samples one early morning and one spot sample. If
one sample is positive then the person is treated as a case of pulmonary
tuberculosis.

2. Anti-tubercular Treatment

• Start the office clerk on anti-tubercular drugs. Since it is Sputum +ve TB

the patient is started on DOTS Category 1. 2(HRZE)3 + 4(HR)3

i.e. H = INH 600mg

R = Rifampicin 300mg

Z = Pyrazinamide 1500mg

E = Ethambutol 1200 mg

Thrice a week for 2 months

• Repeat Sputum examination after 2 months of treatment. If –ve, start

continuation phase. If not, continue continuation phase for one more month.

• Sputum tested again at 5, 6, 7 months. If +ve, then considered as a

treatment failure and started on cat. II.

• Continuation phase of treatment is for 4 months with INH 600mg &

Rifampicin 300 mg thrice a week.

3. Health Education to patient

• Cough with mouth covered.

• Importance of completion of treatment, side effects of the drugs used.

• Disinfection & disposal of sputum collect in a sputum cup with 5% cresol

half filled & allow to stand for 2 hrs before disposing it into sewage system or
collect in paper hand kerchief / paper bag & burn.

4. Search for symptoms in contacts

Wife: Ask for symptoms of TB. If cough with sputum production is present then
do sputum smear examination on her and then decide on starting treatment.

Baby: Check for BCG scar

• If scar is present – No further action is required.

• If no scar – Do Mantoux test.

Mantoux –ve i.e. < 5mm – Give BCG vaccine

Mantoux reactors > 20 mm – Chemoprophylaxis with INH 5mg/kg body

for 6 months.

5. Health education to the family

• About the disease

• About free DOTS treatment and need for completion of treatment

• Screen the other family members for TB and treat them.

• Immunization with BCG if required.

6. Health education to the community

• BCG immunization

• TB disease – ways of spread, symptoms, importance of therapy.

• Create awareness about DOTS strategy of RNTCP.

10. A married business man who travels extensively to big cities, has come to your
STD clinic with painless ulcer in his genitals. What action will you take and what
advice will you give to patient.

Solution:

Business man with history of painless ulcer in his genitals. Personal history –
age, occupation and habits especially history of exposure should be asked.

It is a sexually transmitted disease. It is one of the syndrome complex for STD’s

(urethral discharge, genital ulcer, vaginal discharge and inguinal bubo)

Since 1990, WHO has recommended syndromic case management of STD’s in

patients presenting with consistently recognized signs and symptoms of STD

Investigations: VDRL, RPR, IHA, IF and microscopic examination of the scrapings.

Then treatment is given

For Syphilis:

Benzathine benzyl penicillin, 2.4 million IU by intramuscular injection, at a single

 session or Procaine benzyl penicillin, 1.2 million IU by intramuscular injection,
daily for 10 consecutive days

For Chancroid:

Ciprofloxacin, 500 mg orally, twice daily for 3 days OR Erythromycin base, 500 mg
orally, 4 times daily for 7 days OR Azithromycin, 1 g orally, as a single dose

Ø Contact tracing is done, where in his wife should be examined and investigated.
He should also be interviewed about other sexual partners.
Ø Partner treatment also should be done. Case holding and treatment remains the
mainstay of STD control
Ø Cluster screening- The man should be asked to name the other persons of either
sex who move in the same environment.
Ø Personal prophylaxis- Use of barrier methods with spermicides are
recommended for STD control. The exposed parts should be washed with soap
and water as soon after contact as possible.
Ø Heath education with the principal aim to help individuals alter their behavior in
an effort to avoid STD’s